HomeMy WebLinkAbout06-15-11EX (02-11) (FI)
REV-1500
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
MARY
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
173-36-8585 11262010
Decedent's Last Name
DENNIS
1505611185
OFFICIAL USE ONLY
County Code Year File Number
INHERITANCE TAX RETURN ~ ~ I d ~ ~ ~ I
RESIDENT DECEDENT
MMDDYYYY Date of Birth MMDDYYYY
09061946
Suffix Decedent's First Name
RAYMOND
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
DENNIS
Spouse's Social Security Number
185-36-4089
FILL IN APPROPRIATE BOXES BELOW
0 1. Original Return
^ 4
. Limited Estate
0 6. Decedent Died Testate
(Attach Copy of Will)
^
9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
^ 2. Supplemental Return
^ 4a. Future Interest Compromise (date of
death after 12-12-82)
^ 7. Decedent Maintained a Living Trust
(Attach Copy of Trust.)
^ 10. Spousal Poverty Credit (Date of Death
Between 12-31-91 and 1-1-95)
^ 3. Remainder Return (Date of Death
Prior to 12-13-82)
^ 5. Federal Estate Tax Return Required
~ 8. Total Number of Safe Deposit Boxes
^ 11. Election to Tax under Sec. 9113(A)
(Attach Schedule O)
MI
A
MI
T
CORRESPONDENT - THIS SECTION MUST BIE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
ABRAM C. BERT, CPA 717-506-1222
First Line of Address
5006 E TRINDLE ROAD
Second Line of Address
SUITE 200
City or Post Office
MECHANICSBURG
State ZIP Code
PA 17050
Correspondent's e-mail address: ABERT anWFDCPA.COM
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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPO LE FOR FILING RETURN /;DATE /'
,,,... ~ f' !i'' ' c~
ADDRESS
3518 HAWTHORNS DRIVE. CAMP HILL. PA 17011-2720
SIGNATURE OF PREP ER OTHER THAN REPRESEN VE DATE
ADDRESS
5006 E TRINDLE RD. SUITE 200. MECHANLCSBURG. PA 17050-3647
PLEASE USE ORIGINAL FORM ONLY
15U5611185
Side 1
OW4847 3.000
REGISTER WILLS USE ONClY
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1505611185
J
1505611285
REV 1500 EX (FI)
Decedent's Social Security Number
Decedents Name: RAYM O N D A D E N N I S
173-36-8585
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 and Notes Receivable (Schedule D) 4
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5. 56,349.30
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6.
7. Inter-Vivos Transfers 8 Miscellaneous N on-Probate Property
(Schedule G) ~ Separate Billing Requested 7. 168,845.02
8. Total Gross Assets (total Lines 1 through 7) 8 225.194.32
9. Funeral Expenses and Administrative Costs (Schedule H). g,
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10.
11. Total Deductions (total Lines 9 and 10) , 11.
12. Net Value of Estate (Line 8 minus Line 11) 12 225,194.32
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) , . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) , 14. 225,194.32
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers un~Sec. 9116
(a>(1.2> x .o _ 225,194.32 15. 0.00
16. Amount of Line 14 taxable
at lineal rate X .0 - 16.
17. Amount of Line 14 taxable
at sibling rate X .12
1 ~
18. Amount of Line 14 taxable
at collateral rate X .15 18
19. TAX DUE 19. 0.00
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505611285 1505611285
OW4648 3.000
REV-1500 EX (FI) Page 3
Decedent's Cemnlete A-rlrirpsc~
DECEDENTS NAME
STREET ADDRESS
1 HAWTHORNE DRIVE
CITY STATE ZIP
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments _
B. Discount
3. Interest
File Number 21-10-1241
Total Credits (A + B) (2) 0,00
(3) 0 00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in box on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5> 0.00
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred ^
b. retain the right to designate who shall use the property transferred or its income ^
c. retain a reversionary interest ^
d. receive the promise for life of either payments, benefits or care? ^ 0
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . ^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ^
4. Did decedent own an individual retirement account, annuity, or other non-probate property
which
,
contains a beneficiary designation? ® ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent (72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(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)]. Asibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
(1> _ 0 00
owas~~ 2.000
REV-1508 EX+ (11-10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, ~ MISC.
PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
RAYMOND A. DENNIS 21-10-1241
Include the proceeds of litigation and the date the proceeds were n:ceived by the estate.
All ro a ointl owned with H ht of survivorshi must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 ~. PENNSYLVANIA STATE EMPLOYEES CREDIT UNION
ACCOUNT # 0173XXXXXX
REGULAR SHARES 5,482.13
VACATION SHARES 788.85
CHRISTMAS SHARES 24.92
CHECKING 6,463.49
MONEY MARKET 10,229.53
2 PENNSYLVANIA STATE EMPLOYEES CREDIT UNION
ACCOUNT # 1173XXXXXX
REGULAR SHARES 1,679.13
CHRISTMAS CHARES 0.01
CHECKING 10.33
3 AMERIPRISE FINANCIAL - ACCOUNT # 0020 1447 7810 5 002 31,670.91
RVS TAX EXEMPT HIGH-INCOME FUND
TOTAL (Also enter on line 5, Recapitulation) S ~ 5 6, 3 4 9 3 0
ow46AD 2.000 If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX + (08-09) SCHEDULE G
pen nsylvan is
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
r~~c ryumtsltlrc
RAYMOND A. DENNIS 21-10-1241
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIP11ON OF PROPERTY
ITEM IWCLIAETFEN4MEOFTHETRANSFEREE,ThEIRRELATIONSHPTOOECEDENfMp DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE
NUMBE THeowTEOF TRO~ER. nTrncHncoPV of THE oEEO FoR REAL EsrnTE. VALUE OF ASSET INTEREST IF APPLJCABLE VALUE
1, ROTH IRA ACCOUNT #8517-7901-203 44,619.18 100 0.00 44,619.18
AMERICAN FUNDS - AMERICAN MUTUA
FUND - B
SPOUSE IS BENEFICIARY
2. ROTH IRA ACCOUNT #8517-7901-208 40,739.60 100 0.00 40,739.60
AMERICAN FUNDS - THE BOND FUND F
AMERICA - B
SPOUSE IS BENEFICIARY
3. ROTH IRA ACCOUNT #8517-7901-211 43,951.29 100 0.00 43,951.29
AMERICAN FUNDS - AMERICAN BALANCED
FUND - B
SPOUSE IS BENEFICIARY
4 DEFERRED COMPENSATION PROGRAM 457 13,959.22 100 0.00 13,959.22
PLAN - COMMONWELTH OF PENNSYLVA I
SPOUSE IS BENEFICIARY
5 SEP-IRA ACCOUNT #2802-5783 7,379.70 100 0.00 7,379.70
CHARLES SCHWAB - AMERICAN CENTU Y
REALESTATE FUND INV CL
SPOUSE IS BENEFICIARY
6 ROTH CONTRIBUTORY IRA ACCOUNT 18,196.03 100 0.00 18,196.03
NUMBER #2802-5782
CHARLES SCHWAB - PERKINS MID CA
VALUE FD CL T
SPOUSE IS BENEFICIARY
TOTAL (Also enter on line 7, Recapitulation) $ I 16 8 , 8 4 5 0 2
If more space is needed, use additional sheets of paper of the same size.
OW46AF 1.000
REV-1513 EX+ (01-10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ta~f+i t vr: FILE NUMBER:
RAYMOND A. DENNZS 21-10-1241
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. MARY T. DENNIS SPOUSE 225,194.32
1.
3518 HAWTHORNE DRIVE
CAMP HILL, PA 17011-2720
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET AS APPROPRIATE
(I~ NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
1
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ~ ;
OW46AI 1.000 If more space is needed, use additional sheets of paper of the same size.
REGISTER OF WILLS
CUMBERLAND COUNTY
PENNSYLVANIA
CERTIFICATE OF
GRANT OF LETTERS
No . 2010- 01241 PA No . 21- 10- 1241
Estate Of : RA YMOND ,4 nFlVnn_c
rrrrst, ronvu~e, Lastl
Late Of : HAMPDEN TOWNSH/P
CUMBERLAND COUNTY
Deceased
Social Securi ty No : 173-36-8585
WHEREAS, on the 17th day of December 2010 an instrument dated
October 19th 2004 was admitted to probate as the last will of
RA YMOND A DENN/S
rrusr, mioaie, Lastl
late of HAMPDEN TOWNSH/P, CUMBERLAND County,
who died on the 26th day of November 2010 and
WHEREAS, a true copy of the wi 11 as probated i s annexed hereto .
THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi 11 s in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
MARY THERESA DENN/S
who has duly qualified as EXECUTOR(R/Xl
and has agreed to administer the estate according to law, all of which
fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE,
CARL/SLE, PENNS YL VAN/A.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 17th day of December 2010.
.~
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Register of Wills
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* *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
LAST WILL AND TESTAMENT
OF
RAYMOND A. DENNIS
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I, Raymond A. Dennis, now or formerly of 3518 Hawthorne Drive, Cam
P
Hill, Cumberland County, Pennsylvania, being of sound and dis osin mi
p g nd and memory,
do make, publish and declare this to be my Last Will and Testament here
by revoking all
Wills and Codicils by me at any time made.
ITEM I: I direct that all inheritance and estate taxes becomin due b
9 y
reason of my death, whether such taxes may be payable by my Estate orb an reci ie
Y Y p nt
of any property, shall be paid by my Executor out of the propert assin un
Y p g der this Will,
which is not specifically devised or bequeathed, as an expense and cost of a
dmmistration
of my Estate. My Executor shall have no duty or obligation to obtain reim
bursement for
any such tax paid by my Executor even though on proceeds of insurance or
other
property not passing under this Will.
ITEM II: I hereby exercise all powers of appointment which I ma have at
Y
the time of my death in favor of my Executor, and all propert sub'ect to
Y 1 all such powers
shall be included in my Estate.
ITEM III: I give and bequeath all my household furniture and furnishin s
9,
automobiles, books, pictures, jewelry, china, linen, silverware, wearin a arel
9 pp ,and all
other like articles of household or personal use and adornment to my wife, Ma Ther
ry esa
Dennis, a/k/a Mary T. Dennis, if she survives me, or if my wife does not survive me
,to my
children, James J. Dennis, now or formerly of 2140 Coyote Creek Lane Issa u
q ah,
Washington 98027 and Shelley A. Dennis, also known as Shelley A. Bo usch now
9 or
formerly of 1370 Stonegate Drive, Downingtown, PA, to be distributed to them in e
qua)
shares by my Executor, per stirpes. In the event that either of my aforesaid children shall
predecease me, then that child's share shall go to his/her children, per stirpes. At the
present time, I have two (2) grandchildren, namely, Nathan Dennis, now or former) of
Y
2140 Coyote Creek Lane, Issaquah, Washington 98027, and Alie Bo usch now or
9 ,
formerly of 1370 Stonegate Drive, Downingtown, PA.
ITEM IV: I give, devise and bequeath all of the rest, residue and remainder
of my property, real, personal and mixed, to my wife, Mary Theresa Dennis, a/k/a Ma T
ry
Dennis, if she survives me, or if my wife does not survive me, to my said children to b
e
distributed to them in equal shares by my Executor, per stirpes. In the event that either of
my aforesaid children shall predecease me, then that child's share shall go to his/her
children, aforementioned, per stirpes.
ITEM V: In tl~e sEttlement cf w;y Estate, my Executor sha!! possess, among
others, the following powers to be executed for the best interest of the
beneficiaries:
(a) To sell, either at public or private sale and upon such terms and
conditions as my Executor may deem advantageous to my Estate, any or
all real or personal estate or interest therein, whether owned by me
Page2of8
severally or in conjunction with other persons or acquired after my death by
my Executor, and to consummate said sale or sales by sufficient deeds or
other instruments to the purchaser or purchasers, conveying a fee simple
title, free and clear of all trust and without obligation or liability of the
purchaser or purchasers to see to the application of the purchase money or
to make inquiry into the validity of said sale or sales; also, 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 Executor in this Paragraph V (a) or elsewhere in
my Will.
(b) To pay all costs, taxes, expenses and charges in connection with
the administration of my Estate. My Executor shall pay expenses of my last
illness and funeral expenses.
(c) To distribute my Estate in kind or in money. If any assets are
distributed in kind, they shall be distributed at their respective value(s) on
the date(s) of their distribution.
(d) To retain any investments I may have at my death so long as my
Executor may deem it advisable to my Estate so to do.
(e) To vary investments, when deemed desirable by my Executor
and to invest in such bonds, stocks, notes, money markets, real estate
mortgages or other securities or in such other property, real or personal, as
Page 3 of 8
he shall deem wise, without being restricted to so-called "legal
investments."
(f) To mortgage real estate and to make leases of real estate.
(g) To borrow money from any party to pay indebtedness of mine or
of my Estate, expenses of administration or inheritance, legacy, estate and
other taxes.
(h) To vote any shares of stock which form a part of the Estate and
to otherwise exercise all the powers incident to the ownership of such stock.
(i) In the discretion of my Executor, to unite with other owners of
similar property in carrying out any plans for the reorganization of any
corporation or company whose securities form a part of the Estate.
(j) To distribute my personal property directly to the Guardian of the
person of any minor beneficiaries hereunder.
(k) To elect such settlement options as deemed most appropriate by
my Executor with respect to any pension, profit sharing or other retirement
plan in which I am a participant.
(I) To do all other acts in the judgment of my Executor necessary or
desirable for the proper and advantageous management, investment and
distribution of my Estate.
Page 4 of 8
ITEM VI: Any person who shall have died at the same time as Testator or
in a common disaster with him, or under such circumstances that it is difficult or
impossible to determine who died first, shall be deemed to have predeceased him.
ITEM VII: I nominate, constitute and appoint my wife, Mary Theresa
Dennis, a/k/a Mary T. Dennis, to be my Executrix (herein referred to as "Executor"). In
the event of the death, resignation, refusal or inability of my wife, Mary Theresa Dennis,
a/k/a Mary T. Dennis, to serve as my Executrix, [nominate, constitute and appoint my
children, James J. Dennis and Shelley A. Dennis, also known as Shelley A. Bogusch, to
serve as Co-Executors. My Executor(s) are specifically relieved from their duty or
obligation of filing any bond or bonds.
IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will
and Testament, consisting of this, the next three (3) pages and the preceding four (4)
pages this day of , 2004.
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ymond A. Dennis
Page 5 of 8
SIGNED, SEALED, PUBLISHED AND DECLARED by the above named
Testator, Raymond A. Dennis, as and for his Will, in the presence of us who
request, in his presence and in the presence of each other, have hereunto subscribe t his
names as witnesses m attestation thereof. dour
i~;~k.
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5115 East Trindle Road
~~ `. Mechanicsburg, PA 17050
r
72 South Pin Oak Drive
Boiling Springs, PA 17007
Page 6 of 8
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA :
COUNTY OF CUMBERLAND SS.:
I, Raymond A. Dennis, the Testator whose name is signed to the attached
or foregoing instrument, having been duly qualified according to law, do hereb
acknowledge that I signed and executed the instrument as my Last Will; and that I si ned
it willingly and as my free and voluntary act for the purposes therein expressed. g
Sworn to or affirmed and acknowledged before me by Raymond A. Dennis,
the Testator, this /9~ day of Q 2004.
.,
~' ~ ~
` ~.
N ublic
My Commission Expires:
(SEAL)
NOTARIAL SEAL
CONNIE R. SHULTZ, Notary Public
Mechanicsburg Boro., Cumberland County
My Commission Expires August 19, 2006
Page 7 of 8
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.:
COUNTY OF CUMBERLAND
We, Margaret A. Fenstermacher and Robyn A. Cronin, the witnesses
whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw the Testator sign and
execute the instrument as his Last Will; that the Testator signed willingly and executed it
as his free and voluntary act for the purposes therein expressed; that each subscribing
witness, in the hearing and sight of the Testator, signed the Will as a witness; and that to
the best of our knowledge, the Testator was at that time 18 or more years of age, of
sound mind and under no constraint or undue influence.
Sworn to or affirmed and subscribed to before me by Margaret A.
Fenstermacher and Robyn A. Cronin, witnesses, this /9~ day of C~C~,t~~ 2004.
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Witness
to Public
My Commission Expires:
(SE,4L)
NOTARIAL SEAL
CONNIE R. SHULTZ, Notary Public
Mechanicsburg Boro., Cumberland County
My Commission Expires August 19, 2406
Page8of8
American Funds'
COREY EAYSHORE
MML 11WESTORS sERVrCES 1NC
100 CORPORATE CENTER DR
STE 201
CAMP HILL PA 17011-1758
Re: American 11~lutual Fund - .6
The Bond Fund of America - B
American Balanced 1~ and - B
Account #8517-7901-203/208/211
CBOT CUST ROTH iRA CONY
RAYMOND A OEN~i~S/DEC'D
Dear Mr. Bayshore:
May 26, 20I I
We recently received your inquiry regarding the balance of the accotrn
t referenced below.
'1"he table below reflects the share balance, per share net asset valve
date ~'equested: ~NAV), and total valve of the account on the
Date Account number Share balance
1lMrC/tn .._._ __
11/26/10 8517-7901-20$
1I~6/10 8517-7901-211
~~r~n Funds Servke COT~Y
Pos! Ottica dpx 2280
Norfolk, Yrrginia 23501-22x0
am~ftanfunds.com
1,849.$83
3,304.104
2,549.378
NA V per share
$ 24..12
12.33
17.24
Total value
$44,619.18
40,739.0
43,951.29 ~~
Please note that closed funds within an account may afl'cct our abiti
the date requested. ty to provide an accurate account value on
Mutual fund share prices vary with the fluctuations of Fnanciai market
found in the fn~cial a share prices. The prices of the funds are
P ges of most m~politan newspapers under American Funds in the Mutual F
listings, unds
if you have any questions, please contact us at 800/42 l -Ol 80. You can r
1~onday through Friday ,ten $ a.m, and 8 p.m. Eastern time. You each one of our service representatives
visiting our websitp at www,~ericanfunds.com. may also obtain account information by
We appreciate the oppo~unity to be a part ofyour client's investment r
p ogram.
Cordially,
~I.mericat~ Funds Service Company
Statement On Demand
for Plan 98978-O1
Commonwealth of Pennsylvania Deferred Compensation Program457 Plan
for the period: 26-Nov-2010 to 25-Dec-2010
RAYMOND DENNIS
3518 HAWTHORNE DRIVE
CAMP HILL,PA17011
Your Account At A Glance
Beginning Balance Total Total
as of Deposits Withdrawals/ Dividends
26-Nov-2010 Expenses
$ I ;,059.22 c0.00 -$ I . I h $0.00
Activity By Contribution Source
Contribution Source Beginning Deposits Withdrawals/
Balance Expenses/
as of
26-Nov-2010 Transfers
f;MPLOYEF; Bf:h'ORE $13,959.22 $0
00
TAX .
'$1.16
Total $ 13,959.22 $0.00 -$1.16
Activity By Investment Option
Total Change In Ending Balance
Value as of
25-Dec-2010
$701.17 $14,663.2
Dividends Change In Ending
Value Balance
as of
25-Dec-2010
$0.00 $705.17 $14.((3.23
$0.00 $705.17 $14,(;63.23
Investment
Option Beginning
Balance Deposits Transfers Withdrawals/ Dividends Change Ending Unit/Shares
as of Ex enses
p
In Value
Balance
as of
26-Nov-2010 as of 25-Dec-2010
ZS-Dec-2010
Stock Index $13
959
22
I~ and ,
. $0.00 $0.00
-$1.16
$0.00 $ 705
17
$14
663
23
. .
. 726.98
Total $ 13,959.22 $0.00 $0.00 -$ I.16
$0.00 $705.17
$14.663,23
Page I of I 94978-01-3361220
~~~~~e~scxwAs
Account Statement
Retain for Your Records
Simplified Employee Plan Statement Period: December 1, 2010 to December 31, 2010
Account Number: 2802-5783 Page 1 of 3
Cut paper clutter. Last Statement: November 30, 2010
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31/12-PNCL2107-004662-SML-17011272000 817731 '2-3-4
RAYMOND A DENNIS
CHARLES SCHWAB & CO INC CUST
SEP-IRA
3518 HAWTHORNS DR
CAMP HILL PA 17011-2720
Account Value Summary
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_~_
-- ~ ~~
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~~~' N ~~.
~.~~_ ~~
Cash 8 Sweep Money Market Funds $ 0.00
Total Investments Long $ 0.00
Total Investments Short $ 0.00
Total Account Value $ 0.00
Income Summary
Change in Account Value
Starting Account Value $ 7,379.70
a
Transactions & Income ~~
$ (7,528 28) ,~
Income Reinvested $ 0.00 ._
Chan a in Value of Investments ,
$ 148.58
Ending Account Value $ 0.00 '~"~
Year-to-Date Change in Value Since 1/1/10 $ (6,061.74) ~=
~~
Rat+E Summary ..r
Value Adv Money Fd SWVXX 0.01
Sch Investor Money Fund 0.01
~~
Description This Period Year to Date
Cash Dividends
68.14
Total Income 0.00 68.14
Transaction Detail
$@tt/e Trade
Date Date Transaction Description Quantity Price Total
Cash, Money Market, and Deposit Accounts Activity
12/09 12/09 Journaled Funds JOTRANSFR 7028025533 (164.14)
12/10 12/10 Joumaled Funds JOTRANSFR 7028025533 (1.00)
Investments Activity
12/09 12/09 Journaled Shares AMERICAN CENTURY REAL (412.7320) 17.8400
ESTATE FUND INV CL: REACX
Please see "Endnotes For Your Account" section for an explanation of the endnote codes and symbols on this statement.
V
A
01
01
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92010 Charles Schwab & Co., Inc. All rights reserved. Member SIPC. C512440-02 (0001-0386) STP10479R2-04 (02/10)
Charles scxwAB
Roth Contributory IRA
Account Number: 2802-5782
31!12-PNCL2107-004661-SML-17011272000 817727 '2-3-4
RAYMOND A DENNIS
CHARLES SCHWAB & CO INC CUST
ROTH CONTRIBUTORY IRA
3518 HAWTHORNS DRIVE
CAMP HILL PA 1 701 1-2720
Account Value Summary
Last Statement: November 30, 2010
~_ g
~_
A
o
=- _ -'
.__
Cash & Sweep Money Market Funds $ 0.00
Total Investments Long $ 0.00
Total Investments Short $ 0.00
Total Account Value $ 0.00
Income
hange in Account Value ~_
.:~'
~_
Starting Account Value $ 18,196.03
Transactions & Income $ (18,480.84)
Income Reinvested $ 0.00
Chan a in Value of Investments $ 284.81
~
Ending Account Value $ 0.00 _
'---
Year-to-Date Change in Value Since 1/1/10 $ (15,682.52)
Rate Summary .~
--
Value Adv Money Fd SWVXX 0.01
Sch Investor Money Fund 0 01 % ~~
..~..
_Description This Period
Year to Date
Deposit Accounts Interest
0.06
(Total Income 0.06
Transaction Detail
0.70
0.70
Settle Trade
Date Date Transaction Descri tion Quanti
Cash, Money Market, and Deposit Accounts Activity Price Total
12/09 12/09 Bank InterestX~Z BANK INT 111610-120810
12/09 12/09 Joumaled Funds JOTRANSFR 7028025536 0.06
12/10 12/10 Joumaled Funds JOTRANSFR 7028025536 (9,345.28)
Investments Activity
12/08 12/07 Stock Merger
PERKINS MID CAP VALUE FD 412.7680
CL T: JMM1Z
(1.06)
Please see "Endnotes For Your Account" section for an explanation of the endnote codes and symbols on this statement.
92010 Charles Schwab & Co., Inc. All rights reserved. Member SIPC. CS12440-02 (0001-03$6) STP10479122-04 (02/10)
PNCL2107-004661 817727
Account Statement
Retain for Your Records
Statement Period: December 1, 2010 to December 31, 2010
Page 1 of 3
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P.U. Box 67013 (/ I /) 234-8484 (Horrisburg)
Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide)
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0401 000 000 1 043746 2198258
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PAGE 1
MEMBER NUMBER I PAYMENT DU= DATE TOTAL AMOUNT PAST DUE ~
NEW BALANCE • CURRENT AMOUNT DUE MINIMUM PAYMENT
. __
0173XXXXXX 0~/25/11.~ 0.00 0.00
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00000411 2 AV 0.460
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RAYMOND A DENNIS
3518 HAWTHORNE DR
CAMP HILL PA 17011-2720
1000901733002068585
PSECU AMOUNT OF PAYMENT ENCLOSED
PO BOX 67010
f0 REPORT A OST OR STni FN aRn• CALL OUR BUSINESS NUMBERS LISTED AT THE TOP OF EACH STATEMENT PAGE
-ROM 7 AM - 5 PM MONDAY TO FRIDAY AND 8 AM TO 12 PM SATURDAY, OTHERWISE CALL 800-556-5678
MEMBER NUMBER I STATEMENT DATE j PAYMENT DUE DATE CREDIT LIMIT .. W _
1 - ! i .._. _ _ _ BALANCE I
0173XXXXXX 12/31/10. 01/25/11 0.00 0.00
-SUMMARY OF ACCOUNT ACTIVITY--
I PREVIOUS BALANCE 50.00 i
I PAYMENTS 50.00 I
I OTHER CREDITS 50.00 II
I PURCHASE 50.00 II
I CASH ADVANCE 50.00 it
I PAST DUE AMOUNT S0.00 II
I FEES CHARGED S0.00 II
I INTEREST CHARGED
I ---------- 50.00 II
--------~
I NEW BALANCE
I --
----------I
50.00 I
CREDIT LIMIT I
50.00 I
I AVAILABLE CREDIT 50.00 I
I STATEMENT CLOSING DATE I
I 12/31/10 I
I DAYS IN BILLING CYCLE 31 I
LOST OR STOLEN CREDIT CARD
800-237-7328
R ASE BEFORE A
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BALANCE - -~ ---_~ ....`•,•
I AVAILABt.E
0.00 0.00
----------------PAYMENT INFORMATION-------_____
I NEW BALANCE 50.00 I
I MINIMUM PAYMENT DUE 50.00 I
PAYMENT DUE DATE 01/25/11 I
LATE PAYMENT WARNING; IF WE DO NOT RECEIVE I
YOUR MINIMUM PAYMENT BY THE DATE LISTED ABOVE, I
YOU MAY HAVE TO PAY A LATE FEE OF UP TO 520.00 I
------------------------------------------------I
ID 09 SUSPENDED VISA LOAN
POST TRAN REFERENCE DESCRIPTION
AMOUNT
FEES
TOTAL FEES FOR THIS PERIOD 0.00
INTEREST CHARGED
INTEREST CHARGE ON PURCHASES 0.00
INTEREST CHARGE ON CASH ADVANCES 0.00
TOTAL INTEREST FOR THIS PERIOD 0.00
---------2010 TOTALS YEAR-TO-DATE------______
I FEES CHARGED YTD 50.00 I
I INTEREST CHARGED YTD S0.00 I
-----------------------------
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Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide)
websit~ ~ http://wwvlr.~se~r~.~csn~
0402 000 000 1 043746 219825'
PAGE 2
` w MEMBER NUMBER ~ PAYMENT DUE DATE I TOTAL AMOUNT PAST DUE '
NEW BALANCE • CURRENT AMOUNT DUE MINIMUM PAYMENT
_ _. _. . .
0173XXXXXX O1/2!~~/11 , _ ._
.. .00 0.00 i
0.00 0.00
PSECU AMOUNT OF PAYMENT ENCLOSED
PO BOX 67010
RAYMOND A DENNIS
1000901733002068585
70 REPORT A LOST OR STnI Fnl roan- ;ALL OUR BUSINESS NUMBERS LISTED AT THE TOP OF EACH STATEMENT PAGE
FROM 7 AM - 5 PM MONDAY TO FRIDAY A,ND 8 AM TO 12 PM SATURDAY, OTHERWISE CALL 800-556-5678 CREASE BEFORE A
DETACHING HERE
MEMBER NUMBER j STATEMENT DA fE j PAYMENT DUE PATE CREDIT LIMIT .-. ~- V A W AL P L W UN Di
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x_..._ ....... ;._ . _ ..._ t ! '~ HALANCE
_ .. _ . _ ...... ~_ .:. i_ ~ . ... LANCE .a - .. _ .. _. i . AVAII.A91.E
0173XXXXXX 12/31/:L0 01/25/11
INTEREST CHARGE CALCULATION
YOUR ANNUAL PERCENTAGE RATE CAPR) IS THE ANNUAL INTEREST RATE ON YOUR ACCOUNT.
ANNUAL PERCENTAGE BAL SUBJECT TO
TYPE OF BALANCE RATE CAPR) INTEREST RATE INTEREST CHARGE
PURCHASES 9.9001 0.00 0.00
CASH ADVANCES 9.900% 0.00 0.00
ID 09 SUSPENDED VISA LOAN CLOSED ON 12/01/10
YTD FINANCE CHARGE: YEAR TO DATE
0.00
~~
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RAYMOND A DENNIS
P.O. Box 610 i 3 (711) 234-8484 (Harrisburg)
Harrisburg, PA 1110b-1013 {800) 231.1328 {Naiiorrwide)
website - http://N,N,M,,psecu.com
043746 21982
IMPORTANT
TAX RETURN DOCUMENT
ENCLOSED
JOINT OWNER
MARY T DENNIS
0173XXXXXX
120110123110
PAGE 3
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12101 I - -, ,....~,.~w, re'11C!:1757~1. -. .~,.:•,,..,...:: FIN/WCE
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12/02 REGULAR SHARES BEGINNING
BALAN
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12/02 PAYMENT: TRANSFER FROM SHARE 03 5482.13
x2
~~~ PAYMENT TRANSFER FROM SHARE 02 24.92 5507.05
; l~.~fiHDRAWAI. TR~I~~~R
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ANNUAL PERCENTAGE YIELD EARNED 0.401 FROM 12/01/10 THROU ~ + ~~ ~ ~ ~~~ Q~.....`
GH 12/31/10
BASED ON AVERAGE DAILY
12/07 BALANCE OF 177.65
P/~YMENT TRANSFER FROM SHARE 07
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DIVIDEND YTD: YEAR TO DATE
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ANNUAL PERCENTAGE YIELD EARNED 0.461 FROM~12/O1/10 THROUGH
BASED ON AVERAGE DAILY
12/31/10
~ 11....4.....,:
12/07 BALA~lCE OF 25,45
WITHDRAWAL TRANSFER TO SHARE O1
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12101 ID 03 CHRISTMAS SHARES BEGINNING BALANCE
12/02 WITHDRAWAL TRANSFER TO SHARE O1
1.2/07 ID 03 CHRiST61ee cuanr~. ... ____
12/02
12/02
12/02
12/07
ELECTRONIC BILL 0010 FOR 543...97 ~~
WAS SENT TO PENNSYLVANIA-AME
WITHDRAWAL TRANSFER
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6419.52- 4,3.97
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Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide)
`~r~f~s~te - {~ttp~:f~~nrw.~s~~uFcc~r~~
0403 000 000 1 043746 2198261
IMPORTANT
TAX RETURN DOCUMENT
ENCLOSED
JOINT gNNER
MARY T DENNIS
F~;~ Yh~OND A DENNIS
;,
--- CONTINUED ON FOLLOWING PAGE --- ~~
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P.Q. Box 61013 {» ~) 234-8484 (Harrisburg)
Harrisburg, PA 1110b-7013 (600) 231-1328 (Nafionwide)
websit~e - http://wWN,,Psecu,com
043746 21982
IMPORTANT
TAX RETURN DOCUMENT
ENCLOSED
JOINT OWNER
MARY T DENNIS
RAYMOND A DENNIS
2010 TOTALS YEAR-TO-DATE
0173XXXXXX
120110123110
PAGE 5
TOTAL DIVIDEND YTD. YEAR TO DATE ---
80.56
P.O. Box 61013 (717) 234:=8484 (Harrisburg)
Harrisburg, PA 17106-7013 {800) 237:-~73Z8; (Nationwide)
`~ ~ebsi~~ - htfp~ffw.p~~~~u.~on7
'• ~ ~ ~ •~ ~
PLEASE NOTE: BASED_ON IRS CRITERIA
THIS ACCOUNT DID NOT RECEIVE AN
IMPORTANT TAX RETURN` DOCUMEAIT •
00003003 1 AV 0.335
I~~~Iil~~~lll~~~~~~ll~~~ll~~l~ll~~~l~~l~lll~~~~~~lll~~l~il~~~l
RAYMOND A DENNIS
C/0 MARY T DENNIS
3518 HAWTHORNE DR
CAMP HILL PA 17011-2720
JOINT OWNER
1173XXXXXX
120110123110
~ PAGE 1
12/01 ID O1 REGULAR SHARES BEGINNING BALANCE
12/02 PAYMENT: DIVIDEND
ANNUAL PERCENTAGE YIELD EARNED 0 44% FROM
:... ...
:. ....
:::
...,..~ ~a.a- r 7awrrr +7f7,f1i1FC Yom'..
• ;:.
• .
12/02 WITHDRAWAL BY CHECK
12/02 ID Ol REGULAR SHARES CLOSED
DIVIDEND YTD:_YEAR TO DATE
FINANCE
CHARC3E
1679.13
0.02 1679.15
L2/O1/10 THROUGH 12'131/10
~,•O . ~r~ 1'89.48
1689.49- 0.00
6.15
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12/01 ID 03 CHRISTMAS SHARES BEGINNING
BALANCE
I~1fl~ .
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12/01 ID __
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04 CHECKING BEGINNING BALANCE -~_ -
12/02
_, WITHDRAWAL TRANSFER TO SHARE O1 0.33
1.~~~.2 ID •
~~ ~#fE~C~[~ CL~15D.....
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TOTAL DIVIDEND YTD
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: YEAR TO DATE 6.15
... :...
oioi o00 000 2 ~: ..:.......... : ;....
003003 4003003
Confirmation
Ameriprise Fnancial Services. Inc.
70100 Ameriprise Financial Center
Minneapolis MN 55474
www.ameriprise.com ~ (800) 862-7919
~I~"~'~I'I~~'~I'..~.III.~1~.~I..II'~~~II~~I'~~I...II'~It"II1..~
o Mary T Dennis
° 3518 Hawthorne Drive
A '!F Camp Hill PA 17011-2720
Ameriprise
Financial
Account number:
0020 1447 7810 5 002
Owner: Mary T Dennis
Your financial advisor
Michael Brittain
(717) 441-4801
_ ~'~~ ilk iw~ ~~`~''
Date/Transaction Class Amount Price Shares
December 21, 2010
Ownership Transfer A
From Tax-Exempt High Income Fund
Account 0000 0011 5523 5393 7 002
7,705.819
This transaction was executed by American Enterprise Investment Services, Inc. ("AEIS") as Agent for you and for the mutual
fund purchased or redeemed. This transaction was executed directly between AEIS and Columbia and not through a specific
market center. Other information regarding the execution of the transaction including the date and time of the transaction
will be furnished upon written request. Your account type is cash. Settlement date is the business day following the date of
the transaction. Prices are rounded to the nearest one tenth of a cent. Sales charge amount is included in the price.
Many mutual fund companies offer sales load discounts to customers that have invested over a certain dollar amount.
These discounts may be calculated based on your current purchase or on your aggregate holdings, and may also include the
holdings of your family or household members. To ensure that you are obtaining all available discounts, you should talk
with your broker or financial advisor, or check the fund's prospectus or website. Please read important explanations and
disclosures on last pages of confirmation.
Total Shares - Class A 7,705.819 Divs Yr-to-Date - Class A $0.00
Value per Share - Class A $4.110 Taxes Withheld Yr-to-Date $0.00
Value of Shares - Class A $31,670.91
Dividends Accrued - Class A $20.77
Account Value $31,691.68
Member: Fnancial Industry Regulatory Authority (FlNRA) Securities Investor Protection Corp. (SIPC) Please review your
statement carefully. If you notice an error, please notify us immediately. Failure to notify us within 30 days will constitute
your acceptance of the content. You may direct any questions to your financial advisor or service office. ®2007 Ameriprise
Financial, Inc. All rights reserved.
Page i of i
i~M~~~w~~~~~t~u
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I , GL ENDA EARNER STRA SBA UGH
Register for the Probate of Wi 11 s and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 17th day of December, Two Thousand and Ten,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
estate of RA YMOND A DENNIS 1 a to of HAMPDEN TOWNSHIP
(First, Middle, Lastl
in said county, deceased, to MARY THERESA DENN/S
(First, Middle, Lastl
and that same has not since been revoked .
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office a t CARLISLE, PENNSYLVANIA, this 17th day of December
Two Thousand and Ten .
File No. 2010- 01241
PA File No. 21- 10- 1241
Date of Death 11/26/2010
S . S . # 173-36-8585
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL