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HomeMy WebLinkAbout05-19-11 (2)1505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 2 1 1 1 0 1 3 8 Harrisbur , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 3 2 4 9 5 7 1 0 1 2 9 2 0 1 1 1 1 0 6 1 ~' 3 2 Decedent's Last Name Suffix Decedent's First Nan MI M Y E R S R O B E R T D (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DU!'LICATE WITFI THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Retum ^ ^ 4. Limited Estate ^ ^X 6. Decedent Died Testate ^ (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-$2) 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 1 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Daytime Telephone Number Name D A V I D R G E T Z E S Q 7 1 7 2 ,-~ 4 4 1, 8 2 -,, r __ REGISTER OF WILLS USE ONLY - ' , I ~ First line of address - ~ ' W I X W E N G E R & W E I D N E R ~ ~ ; Second line of address + ' ~ 5 0 8 N S E C O N D S T/ P O B 8 4 5 ~ ~~~ :. ~ ~ -~1 City or Post Office State ZIP Code DATE FILED H A R R I S B U R G P A 1 71 0 8 Correspondent's a-mail address: DGETZC WWW PALAW.COM 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 oilier rrr~r, the personal representative is based on all information of which preparer has any knowledge. SIG_ fj1~1TURE,OF PERSON RESPONSIBLE FOR FI!JPd~~ G~ ;~U?I~1 DATE '~ n, ~~~- ~- 7 .~. it ADDRESS 175 9TH ST #201 NEW YORK NY 10011 SIGNATI E~PREPARER O~hIER ThIAN R~SENTATIVE ~TEj~ p/~'( WIXvWENGER & WEIDNER, PO BOX 845 HARRISBURG PA 17108 PLEASE USE ORIGINAL FORM ONLY 1505610140 Side 1 1505610140 .~ 1505610240 REV-1500 EX Decedent's Social Security Number 2 0 3 2 4 9 5 7 1 Decedent's Name: ROBERT D. MYERS RECAPITULATION 0. 0 0 1. ...................................... Real Estate (Schedule A) ... .. 1 • 3 8 7 6 1 7.9 4 2. ................................. Stocks and Bonds (Schedule B) ... .. 2~ 0. 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 0 ' 0 0 4. Mortgages and Notes Receivable (Schedule D) ..................... ... .. 4. 1 6 5 6.4 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ... .. 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . .... .. 6. 2 5 4 6 7. 0 7 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property uested R Billi t ~ 7 . ng eq e Separa (Schedule G) .... . .. 4 1 4 7 4 1 4 1 8. Total Gross Assets (total Lines 1 through 7) ..................... .... .. 8. 9 2 4 2 4 1 5 2 9. Funeral Expenses and Administrative Costs (Schedule H) ............ .... . .. $ 8 8 1 8 3 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... .... .. 10. 11. Total Deductions (total Lines 9 and 10) ......................... .... .. 11. 3 3 1 2 3. 3 5 12. Net Value of Estate (Line 8 minus Line 11) ...................... .... .. 12. 3 8 1 6 1 8. 0 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 2 0 0 0 0 0 an election to tax has not been made (Schedule J) ................ .... .. 13. • 14. Net Value Subject to Tax (Line 12 minus Line 13) ................ .... .. 14. 3 7 9 6 1 8. 0 6 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 15. 0. 0 0 (a)(1.2) x.o _ 16. Amount of Line 14 taxable 3 7 9 6 1 8 0 6 16 1 7 0 8 2 8 1 at lineal rate X .045 . 17. Amount of Line 14 taxable 0 0 0 17 0 • 0 0 at sibling rate X .12 . 18. Amount of Line 14 taxable 0 ' 0 0 18 0 . 0 0 at collateral rate X .15 . 19 1 7 0 8 2• 8 1 19 ............................................... . TAX DUE .... . ... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 0138 DECEDENTS NAME ROBERT D. MYERS STREET ADDRESS 100 MT. ALLEN DRIVE CITY MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 16,000.00 B. Discount 842.08 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) 16,842.08 (1) 17 082.81 (3) (5) (4) 0.00 240.73 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 : ...................................................................... ^ 0 b. retain the right to designate who shall use the property transferred or its income; .............................. . ^ c. retain a reversionary interest; or ............................................................................................... . ^ d. receive the promise for life of either payments, benefits or care? ...................................................... . ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................................... . ^ ^X 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ........ . ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ................................................................................................. . ^ ^X 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 i 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(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)]. 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. REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 67 UNITED STATES SAVINGS BONDS 74,444.00 BANK STATEMENT SETTING FORTH REDEMPTION DEPOSITS ARE ATTACHED 2. VARIOUS SECURITIES HELD WITH PARENTEBEARD WEALTH MANAGEMENT 313,173.94 DOD BALANCE: $313,024.91; ACCRUED INCOME: $149.03 ITEMIZATION AND INDIVIDUAL VALUATIONS ATTACHED TOTAL (Also enter on line 2, Recapitulation) ~ $ 387.617 (If more space is needed, insert additional sheets of the same size) REV-1504 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE 0.00 TOTAL (Also enter on line (If more space is needed, insert additional sheets of the same size) REV-1507 EX + (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 All property jointly-0wned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE 0.00 TOTAL (Also enter on line 4, Recapitulation) ~ $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) SCHEDULE E + ~ COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, St MISC. INHERITANCE TAX RETURN PER50NAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly~owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. COINS REFERENCED ON SAFE DEPOSIT BOX INVENTORY 157.60 (ITEM NOS. 15 THROUGH 22) APPRAISAL ATTACHED 2. ORDINARY HOUSEHOLD GOODS ANC3 FURNISHINGS, INCLUDING 1,000.00 GRANDFATHER CLOCK (APPRAISAL ATTACHED) 3. REFUND CHECK -HOME INSTEAD SENIOR CARE 282.55 4. REFUND CHECK -HOLY SPIRIT HOSPITAL 116.25 5. REFUND CHECK - MALPEZZI FUNERAL HOME (VETERAN BENEFIT) 100.00 TOTAL (Also enter on line 5, Recapitulation) I $ 1 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ROBERT D. MYERS 21 11 0138 SCHEDULE F JOINTLY-OWNED PROPERTY If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. 175 9TH AVE #201 NEW YORK, NY 10011 RELATIONSHIP TO DECEDENT ADDRESS SURVIVING JOINT TENANT(S) NAME(S) A. REBECCA S. MYERS B. C. JOINTLY-OWNED PROPERTY: DAUGHTER ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °1 OF DECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 12/2000 M&T BANK CHECKING ACCOUNT XXXX247 49,912.38 50. 24,956.19 DOD BALANCE: $49,912.38 A. 1/30/08 PSECU SAVINGS ACCOUNT (S1) 954.96 50. 477.48 DOD BALANCE: $954.64; ACCRUED INT: $.32 A. 1/30/08 PSECU CHECKING ACCOUNT (S4) 66.80 50. 33.40 DOD BALANCE: $66.09; ACCRUED INT: $.01 TOTAL (Also enter on Line 6, Recapitulation) I $ 25,467.07 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 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. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE,THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER. ATTACH A COPY OFTHE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IF APPLICABLE TAXABLE VALUE 1. TOTAL (Also enter on Line 7, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MALPEZZI FUNERAL HOME, HARRISBURG, PA 13,383.12 2. CHESTNUT HILL CEMETERY (GRAVE OPENING) 1,000.00 3. MESSIAH VILLAGE CATERING, MECHANICSBURG, PA (LUNCHEON) 579.43 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2 AttomeyFees: WIX, WENGER & WEIDNER (ESTIMATED) 7,500.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 423.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PARENTEBEARD 450.00 7. CUMBERLAND LAW JOURNAL (ADVERTISING) 75.00 8. THE SENTINEL (ADVERTISING) 240.64 9. MOBILE MERCHANTS/GOLD MINE (APPRAISAL) 26.50 10. REBECCA S. MYERS -REIMBURSEMENT FOR MISCELLANEOUS 247.44 OUT OF POCKET COSTS, INCLUDING POSTAGE, GAS, TOLLS, ETC. 11. THE CLOCK DOCTOR (GRANDFATHER CLOCK APPRAISAL) 50.00 12. PARENTEBEARD -MANAGEMENT FEE 265.89 TOTAL (Also enter on Line 9, Recapitulation) $ 24,241.52 If more space is needed, use additional sheets of paper of the same size REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT D. MYERS 21 11 0138 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PSECU VISA LOAN (L9) 69.54 2. PAUL DALBEY, DPM (MEDICAL BILL) 43.00 3. VERIZON (PHONE BILL) 8.35 4. SERS REIMBURSEMENT 53.48 5. CREDO (PHONE BILL) 42.00 6. MESSIAH VILLAGE, MECHANICSBURG, PA (NURSING HOME CARE) 8,416.26 7. MESSIAH LUTHERAN CHURCH -DECEDENT OBLIGATION FOR FLOWERS 96.00 8. ALERT PHARMACY (MEDICAL BILL) 153.20 TOTAL (Also enter on Line 10, Recapitulation) I $ g 881.83 If more space is needed, insert additional sheets of the same size. REV-1513 EX+(Ot-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT L ESTATE OF: FILE NUMBER: ROBERT D. MYERS 21 11 0138 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. 9116 (a) (1.2).] 1. ROBERT MYERS Lineal 118,050.33 68 BROOKFIELD ROAD LITITZ, PA 17543 2. JOHN MYERS Lineal 118,050.33 219 SECOND STREET, 5C NEW YORK, NY 10009 3. REBECCA S. MYERS Lineal 143,517.40 175 9TH AVENUE #201 NEW YORK, NY 10011 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. MESSIAH LUTHERAN CHURCH 901 NORTH 6TH STREET HARRISBURG, PA 17102 2,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. .. LAST WILL AND TESTAMENT OF ROBERT D. MYERS I, Robert D. Myers, of Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. ITEM 11: I hereby exercise all powers of appointment which I may have at the time of my death in favor of my residuary estate, and all property subject to all such powers shall be included in my Estate. ITEM III: I give and bequeath all my household furniture and furnishings, automobiles, books, pictures, jewelry, china, linen, silverware, wearing apparel and all other like articles of household or personal use and adornment to my spouse, Mary A. Myers, if she survives me, or, if my spouse does not survive me, to my then living children, to be divided among them in as equal shares as practicable, as they may agree. In the event my children fail to agree on the division of such items, my Executor shall Page 1 of 7 determine the distribution of such items and her decision shall be final. Any undistributed items shall be sold and the proceeds added to the residue of my estate. ITEM IV: If my spouse does not survive me, I give, devise and bequeath the sum of Two Thousand Dollars ($2,000.00) to the Endowment Fund of Messiah Lutheran Church of Harrisburg, Pennsylvania, or its successor. V: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, to my spouse, Mary A. Myers, if she survives me. If my spouse does not survive me, then I give, devise and bequeath all of the rest, residue and remainder of my property in equal shares to my children or their issue, perstirpes, subject to the provisions set forth in Item VI herein. Provided, however, that any distribution made to my children or their issue shall be adjusted to account for any indebtedness owed to me by them at the time of my death. Such indebtedness shall be determined, without interest, by my Executor by reference to a Book of Account which I have maintained and kept at my desk at my residence, or such other place made known to my Executor, and shall be offset against the amounts the indebted child, or persons claiming through the indebted child, would otherwise be entitled to receive. IT M VI: For purposes of this Will, the term "issue" shall be deemed to exclude each and every one of the children born of the union of my son, Robert P. Myers and Ann Helen Cannon (also known as Ann Helen Myers), it being my express intent that such child or children not receive any distribution as an heir or beneficiary of my estate. ~Q,L: In the settlement of my Estate, my Executor shall possess, among others, the following powers to be executed for the best interest of the beneficiaries: Page 2 of 7 (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 atl real or personal estate or interest therein, whether owned by me 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 VII(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 marpetsp, Ir~yeal estate mortgages or other securities or in such other roe real or personal, as he shalt deem wise, without being restricted to so-called "legal investments." (fl 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 n uwhose securities form a part of the Estate.ny corporation or compa y Page 3 of 7 (j) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. (k) To elect such settlement optiony as deemed ofi t shar~priatoe bother Executor with respect to an pension, p 9 retirement plan in which I am a participant. (I) To dobael for the a roper and advantageous managements nvestment desira p and distribution of my Estate. ITF~M VIII: Any person, other than my spouse, Mary A. Myers, who shall have died at the same time as me, or in a common disaster with me, or who shall fail to survive me by ninety (90) days, shall be deemed to have predeceased me. If my spouse shall have died at the same time as me, or in a common disaster with me, or under such circumstances that it is difficult or impossible to determine who died first, this Will shall be construed as if, and I shall have been deemed to have predeceased my spouse. IT MIX: If at any time any minor child or legally incompetent person shall be entitled to receive any assets hereunder, I hereby nominate, constitute and appoint my Executor to act as Guardian of the assets payable to such person. Said Guardian may receive and administer all assets authorized by law and shall have full authority to use such assets, both principal and income, in any manner said Guardian shall deem advisable for the best interest of such person, including college, university, post-graduate or other education, without securing court order. Said Guardian shall have all the rights and privileges as to the Guardianship and the assets thereof as are herein granted to my Executor as to my Estate and the assets therein. ~FM X: I nominate, constitute and appoint my spouse, Mary A. Myers, to be my Executor. In the event of the death, resignation, refusal or inability of Mary A. Myers to serve as my Executor, I nominate, constitute and appoint my daughter, Rebecca S. Myers, to serve as Executor in her place. My Executor and Guardian are specifically relieved from the duty or obligation of filPage 4 of 7d or bonds. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consis'tin~g "of this, the next two pages, and the preceding four pages this r ~~ day of s3Q~~r~~ 2001. Robe D. Myers SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testator, Robert D. Myers, as and for his Will, in the presence of us, who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses in attestation thereof. ,~ / ~/ . Address ~~ Address ~~C l J~6~- ~Gv ~?.~ ~ 70~ ,yu~, Address o2 ~ ~ 7 ~ ~ C/( cj Page5of7 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF •'CJP~ F`-' ` ~ I, Robert D. Myers, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. S orn to or affirmed and acknowledged before me by Robert D. Myers, the Testator, this ~ day of ~~a''n~-s ~ , 2001. .- Rob D. Myers, Testator t ~ - -; ry Publi ~ ~' y Commission Expires: ~', (SEAL) Notarial Seal Denise B Williamson, Notary Public Harrisburg, Dauphin County My Commission Expves May 1, 2G0=~ j Member, PennsylvaniaASSOCiatior:^~ •~• _~ - Page 6 of 7 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF ~~Prilr~,i We, i 1 0 ~~c ~~~ ~ ~ ~a ~ ~ ~ and ~Qn~ ~ d u ~ ,the witnesses whose names are signe 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 sub cribed to before me by `Cl'~~s (.. Ll%~ta ~ YY ;~ I and Tan,+<c~ ~uP.ec iti++ witnesses, this ~~ day of I~ W' Hess Witness r fitness P(I.e~Eary Public My Commission Expires: (SEAL) F:\dbw\W ills\Myers\Robert - W ill.doc Notarial Seal Denise B Williamson, Notary Public Harrisburg, Dauphin County My Commission Expires May 1, 2004 Page 7 of 7 Member, Pennsylvania Associat~or of ~Ictar yes ~ ~~ __._________ SAFE DEPOSIT BOX INVENTORY __ _____ __ _ INSTRUCTIONS (1) CASH: REPORT TOTAL ONLY. ~V (2) STOCKS: LIST IN DETAIL EVERY COMMON OR PREFERRED CERTIFICATE, WARRANT OR OTHER RIGHTS FOUND IN BOX. STOCKS ARE TO BE DESIGNATED BY NAME OF COMPANY, CERTIFICATE NUMBER, DATE OF CERTIFICATE, NAME IN WHICH STOCK IS REGISTERED, AND NUMBER OF SHARES AND CLASS OF STOCK. (3) OBLIGATIONS OF U.S. GOVERNMENT: NUMBER OF ITEMS, DATE OF ISSUE, FACE VALUE, NAMES IN WHICH REGISTERED AND TYPE OF OWNERSHIP, ie.. JOINTLY HELD, PAYABLE ON DEATH, ECT. (4) BONDS: DESIGNATE BY NAME, AMOUNT, SERIAL NUMBER, OR OTHER DESIGNATION. (BEARER BONDS) (5) BANK AND SAVINGS AND LOAN PASSBOOKS: STATE NAME OF DEPOSITOR, NUMBER OF BOOK, LAST DATE APPEARING IN BOOK, NAME OF BANK AND BRANCH, AND BALANCE. (6) JEWELRY, COINS, STAMPS, MANUSCRIPTS, ECT: LIST AND DESCRIBE AS FULLY AS POSSIBLE. (7) DEEDS, MORTGAGES, CURRENT INSURANCE POLICIES OR OTHER EVIDENCES OF INDEBTEDNESS: LIST AND DESCRIBE AS FULLY AS POSSIBLE. (8) ALL OTHER CONTENTS. __~_~~._ ITEM NOI ~._~ ITEM DESCRIPTION _.:- ~ --! _)~.~~}}~L~~_.~~ t! .~'~.t~N~'~_~~ Svc ~ t _ L.,,.. ,~ e[-c~ -~~ ~~_3~ c~ti' =~~ I(~~~~y ~~ .~LZ'~ cr - 1 _ ,•• rr - ~ . ~~~1C`~ ~__ ~_-'r!Lw._l4~_.~~~`~~L?_._ . ~__~r~ifLt' ~--n.G'cl,t y. a - - ,Lj i~11 ~~ .L) ._.y?i i __.{~~f ~~ ~1"7W_ ` _. ~: ~~_L''iVC`~tY~.~~.'L-~ /-~~ h~ ~~;_~~ ~~ / ~{ l 1 ~ ~ ~ 1 ~ ~ ~~t k~'t'~ ,~ ~'~5u', ~ ' ~r".-..e ~~~~~ i """___777 Y _""' 1, ~ ~ ~ r i~ ~~~ f`}3 ~ ~ 1rc a ,~_ rr~ __ ~. __. ~` ~s_.__ ~_ _~_! ! .~.. ~~ _~('i~Lj_._~ts-)_`~ cJ~Ck` ~-'~.S_. hu~%~.y cf.~Lr"'r~_ _.I. _. ~~1]~~.~J j~~J 1 ~:?m`~1.._.~ n~4~.~G~E! ~(° !' ~'Y G±~ ~C 1146-vim TCl~tici.~- J_I cal<e=ti-"a''~~ ry L% ~'1r~- I l i _~~ 1_'~ ~- ~Y'~ ~ lL.. (4~~.~~ .`s.'-L.._.__.1.A01~ L`-:.~~.1 ~'. ......'_F~L~'=J.V•~- ~~C1 ~-'n ~ C.. ~ 1 -.~_ ~ ~' K~! I ___ I _ __ __ nn cc.. _ ~._ (/ _-t ~~. ~' ~ ' _` ly< ~`~'17-~.!1s_- ~_."_~i..ll~_~-~G~_.._ -_nr~ -- ' " ~ct~~..___ c {~~.~ ,., ~",T ~~j f l ~' ~~-- ' '~, r ~1 L _ _ ~. `{ _ - - - - __ ~~,~~ ~c r~ 111 C I~ ~ E~ l,i- C~ c ~Y j~ _ ._ ~~ - _ ~ - / - I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: RECORD IS CORRECT AND COMPLETE TO THE BEST OF MY j KNOWLEDGE AND BELIEF. .~_.__...___---__- -_-------- ----------_ - _ ..--------------.---_ _.~_r_,_M ._______.____.___ _ _ ___~._____ __ __._ ____ _ _-__ _ -. _ -- ____.____-_. SIGNAT F~ SIGNATURE _ .__. ___ r _ , ~._ , ~- PRINT NAME_ _ _~ ~__ _ ____ ~____ ___.__. __.~_.____.~PRINT_NAME AND CHECK APPROPRIATE BOX BELOW:___ _ _____._ __..._ 1~ /~~ - _ __ . _ __ _ __ ' ~ _.._ . __..~ -_.._~1.~_ M__-- - ._ . ....._. -- - --- - ___..-__ PRINT TITLE _ __ ~CHE K APPROPRIATE BOX: _ _ _ _ _ ~/ ~~L c-~ l~~-'' f !EXECUTOR(TRIX) ~ _ ~ ~ ±ADMINISTRATOR(TRIX) I ~ ESTATE REPRESENTATIVE i JOINT OWNER OF ~___ ..~___.___ __._._...._. _ ___.____.______.__ _,_.__._..___ SAFE DEPOSIT BOX.' NOTE: ATTACH ADDITIONAL 81/2" x 11" SHEET(S) IF NECESSARY OR USE DUPLICATES OF THIS PAGE OF FORM. 1'47 ._._____.____a_.__._____.,_______ _._,~. __ _.....,__._______.___.__.___.___ _... SAFE DEPOSIT BOX ~ PLEASE PRINT OR TYPE .... ,~..~... r.... MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS 1,_ CO.UNTYpCODE_, ~.~_ _ _-e__._ ~2., FILE NUMBER _~~.r a_w,_:w: ~ ._~ 3..SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER 21 21-11-0138 203-24-9571 _ ___ , 4. DECEDENT'S NAME (LAST FIRST- MLDDLE)_, __ ~~_ _. ~_ __ _ r_ 5. DATE OF DEATH Myers, Robert D. _ /29/11` __.._.___. DECEDENTS ADDRESS . _ _ _: :~ . ~ .~~: ,.-;._._Y ~: ~.m; ;~~ :: ~ ~ STATE fZIP CODE ___ , _ _ . .._ _ __ ___ __ _ 100 Mount Allen Drive - -. . ...___ __~ _ _ _ _ ;Mechanicsburg ~r----- -- ~ _ ' iRA 17055 ~ __ .__ ___-_r__.__.___._____._ __.___,_._.._ __,___,__.____.___ _._._ _____ 7. ATTORNEY NAME _ __-.--._---.____.. _.__.._ __. _ . _ _ _. _ , __ _. _.___-___.______ ._.,_ __~____.~,___w.._.__ .____~__. __. ti. ___.._~,.____________ . ____._.... __ ____ _____. _ _ '~ David R. Getz __ _, STREETADDRESS CITY w STATE ZIP CODE _„_, __.,______ _._ _ __., _.__.. __ ._ .._...~... _._ _.,._____ _..__,,._.._.__m_.._. __ . _ .__. ...___ 508 N. 2nd Street Harrisburg _. ..._ ______e__.__.__~.._. ,_ ._ .. __.._. ~_.._~._...~..__._..,._ .___ ~._..._.~ ~ _~____^..__.,~~ _..,,_, ._.~.w.__ ~.__.__ _. ._ _ ___._.__ ~ I?A . , j 17101 . 8. NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OFpERSON(S) PRESENT AT THE -, , BOX OPENING .. RELATIONSHIP . _ ~F~tz~,~..~ _~`~~~~,~ ___ _ _ T __ ~--~~t- Lx~~:~-lam, _ i _ _ , STREETADD R ESS - ~ :: : A w , CIT Y _ STATE .`y ZIP . C OD E~ r .__.,. ... . __. . y ~j~ ~/ _ __ ( , / -- ~ ~~ / .~ ~~~ ,f"~:._ ~ r~4~C Ctl-k `~'~.h,`.__.,~~ _.......r._ ~ ., --s ~~ __.. ~ _ ~ ~ ) / ^ . ~ ~ ~~-._._i,.._l-.= -~1~.~. _T. B. NAME ... _.. . _ .. ,_...__... ., ..:.__-„ . _. . ... __.. RELATIONSHIP_ __ ._ .. ..: -__... __. .-. . _~__ .. `~ .._ .- -._. _ -__- - _ _ ..,_A... - ~ . _. _ - - _ - __ _ .. ~ _. _ .: CITY STATE ZIP CODE ~____..____ ~-- - ____,____. _ , . ,~..._.___.,._,_.__.. ___._..~_.__._.,._~_..__._„~.___.__~.~- C. NAME..... _ _ __ .. __. __ ~. _ i._,.___..______~..,.___.___._ _,___.___._._. RELATIONSHIP _ ~.,.__ _...__~_._.____. ,._. __ .._. TREET ADDRESS S _ _ ~ : i : CIN :: Y ~ STATE ZIP CODE _, ....._ _ _._ _. _ __ _ ___, _. ___ _ ._ ._ _._ ..._ __ . __ _ , _.. __. _ . __ ..~. . _ _. ____ _ . ~ _ _. _ .~. _._ , 9. NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE-THE SAFE DEPOSIT BOX IS LOCATED M 8~ T Bank _ __ _._____-_ w__ - _ STREET . _ _ __ _._. _ .__ _.... _, _ _....: _ .. -. _ _ . _..._- .~ CITY____ -_._ . _ - --,.___ , __ . _ ._ STATE ___ ZIP .CODE ~ _ _ _ 1200 Market Street ;Lemoyne _ _ ~ PA ;17043 !. 12. DATE OF CONTRACT TO RENT BOX _. ,_ 13 NUMBER OF BOX , _ 14 TITLE UNDER WHICH BOX IS REGISTERED _ _ _ _ _ __ C,,~~ _____.___ __. ..___._ _s2 __ _ ___ r., .. _ r .___~_~._r __,_._ _ ~__-._ , _ . _, _ _ .- _ 15. NAME AND ADDRESS OF PERSON(S) HAVING ACCESS :TO BOX A. NAME _. n_ _ _ - --- ._ s_.R __ _. ~. _ , B NAME r STREET ADDRESS. _ ___ _ _ _..___._._. _ _____. __..._.._ ,_ __ ___.._ __ . _ _ STREET ADDRESS__- _ _ . ... _ _ ; _ _ _. ___ ___ __,_.__ .__.___._______._ ____.. CITY _ _ STATE _ -._ __ ZIP CODE _ . _ __ __ ,_?__r__. - .,CITY ....__.._._ ._ _.. _._ _.. . __ __ ..;STATE . _ZIP, CODE _ _ .. . 16_ NAME AND TITLE OF INDIVIDUAL TAKING INVENTORY _ _ 17. WAS A WILL IN THE BOX? YES NO A. DATE OF WILL : _. : B. NAME AND ADDRESS OF PERSONAL REPRESENTATIVE S, IF NAMED IN THE'WILL _._..._.._ ... . .. STREET ADDRESS ~ ~~~ _ ._ __ _ ____, ~_ _ -_ ._ n__, ; __ CITY STATE ~~ZIP CODE ~ - _ .____.~_..__ __..__.___.v__._._________ . --.~~._,._____ ._,__ ~ .~,....w._..__ _.. C. NAME AND ADDRESS OF ATTORNEY, IF ANY (NAME). _ . ___;_ _. STREET ADDRESS _ .. _ __ ....._...... .._..._...w_ :_CITY._. __ _, _.. _ ____.__. _._.,STATE_._ ZIP_CODE_._' L 1 f s o ~ h '~ ~ ~ ;, ~ y ° a ~ ~ az ~. ~ ~ ~ ~, w / ~ ~ , ~~ O~ ~ 'j~l i~ K ~~' V y F H y '~ ,~ ~~ ~++ -y ~ ^y~ , i ~. z ~ ~ \I v ~~~ ~~ W m t z - z ~ ~ ~~ vWi O E vUWi ° _ ~~ ~~ V _ U_ _ L1" ~~' ~ W ~ J m Q w U W 7 y ~. ~ 1~ O cn J O F- w ti In "" W S !O ~ L. ~, ~ y~~ Z ~ J ~_ ~ Z~ m W ~ 1-' ~ ~ '~ ~ ~ '~ ~ 1 -J' y~ U -J- .'~- ~ ~1 `~ a Q ~ ~,n ~~`~ ~J v ~ m O ~ ~-.~ ~~~ M ~ i .~- W Y Z ~ ~ P ~ > ~ ~,a ~ ~ -~ -~ ~ V z ~ } ~ O ~ ~ J ~ ~ ~ ~j ~~ ~n to '~ ~~ ~ ~. ~` w ~ Z ~ } v r~ ~ c~ ;Y~ .~ a > a f o y ~ ~, :, ` ~" ~ ~~~ ~ .v ~- ~ ~ ~ r ~ ~ ~ ~ ~ ~ •:~ ~t W w ~ J O FW{ y CC LL N ~ `'~ W \ ~ ~ ~r 1 = Jr ~ ~/~: ~ y ~/^~ V I z O a ~ ~ ~ j J U (K ~ ~ nJ ...~1 1J r /t ~1 yl J ~~1 ^ F- 67 Y N ~ X UI a m V\1 Z ~ ~ ~w O Q ~O QF ~H V ~ J. V ,v ~ ~ :q:'y' K w f ~. ~~ 1~ " v, ,,n ~` ~` ~~ fZ W ~ ~ /~ p,_ ~~ , i REV-1502 EX+ (01-10) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ROBERT D. MYERS 21 11 0138 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION NONE 0.00 TOTAL (Also enter on Line 1, Recapitulation.) I $ 0.00 If more space is needed, use additional sheets of paper of the same size. For official use only: Customer Name Customer No. PD F 1522E SPECIAL FORM OF REQUEST FOR PAYMENT OF oMe No. 1535-000 Department of the Treasury UNITED STATES SAVINGS AND RETIREMENT Bureau of the Public Debt SECURITIES WHERE USE OF A DETACHED FOR OFFICIAL USE ONLY (Revised May 2009) REQUEST IS AUTHORIZED TRANSFER MpNTH & YEAR _/_ Visit us on the Web at FISCAL AGENT CODE www.treasurydirecL qov IMPORTANT: "Follow instructions in filling out this form. Youcshould,be aware thatthe making of.anyifalse, fictitious, orfraudulentclaim or tatement to he United.States'isFa crime that is punishable:by fine::and/or imprisonment. iPRINT IN;INK OR'TYPE ALLiNFORMATION 1. DESCRIPTION OF BONDS I am the owner or person entitled to payment of the securities described below, which bear the name(s) of Robert D. Myers; POD Mary A Myers ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER 01/02 V0021564081 01/02 V0030040461 01/02 V0030040451 01/02 V0021564091 01/02 V0030040441 07/98 D4753529HH 01/02 V0021564101 07198 D4753530HH 07!98 D4753531HH 07198 D4753532HH 07!98 D4753533HH 07198 D4753534HH to yvu urcu nwr c aNo~. c, .~~ ~,.~ .................... ................~- - ~ 2. REQUEST FOR PAYMENT ^ a check. I request that the described bonds be redeemed and payment be made in the form of 0 direct deposit. ^ To the extent of: (Complete this line only if partial redemption and reissue of the remainder is desired or if the signer is only entitled to a portion of the bonds listed. See Item 2 in the Instructions.) (Social Security Number of Payee) 27-7064799 OR (Employer Identification Number of Payee) 3. DELIVERY INSTRUCTIONS (Read Item 3 in the Instructions before completing this section and complete only Item 3A or38.) A. Please mail my redemption check to: (Name) (Number and Street or Rural Route) (City) (State) (cir uooe) B. Please deposit my funds directly, as authorized below: Estate of Robert D. Myers/Rebecca S. Myers (Na 7042530993 Ames on the Account) Type of Account: 0 Checking ^ Savings (Depositor's Account No.) Bank Routing No.: 031000053 Charles Schwab (717) 393-9721 (Financial Institution's Name) (Phone No.) Continuation of description ofi bonds in Item 1: ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER 07198 D4753535HH 07/98 D4753536HH I ~ ~ 07/98 ~ D4753537HH 07/98 D4753538HH 07/98 D4753539HH 07/98 ~ D4753540HH 07/98 04753541 HH 07/98 D4753542HH 07/98 D4753543HH 07/98 D4753544HH 07/98 D4753545HH 07/98 D4753546HH 07/98 D4753547HH 07/98 D4753548HH 07/98 D4753549HH 07/98 D4753550HH 07/98 04753551 HH 07/98 D4753552HH 07!98 D4753553HH 07/98 D4753554HH 07/98 D4753555HH 07/98 D4753556HH 10/98 D4830339HH 10/98 D4830340HH 10/98 D4830341HH 10/98 D4830342HH 10!98 D4830343HH 10/98 D4830344HH 10/98 D4830345HH 10/98 D4830346HH 10/98 D4830347HH 10/98 D4830348HH 10/98 D4830349HH 10/98 D4830350HH 10/98 D4830351HH 10/98 D4830352HH 10/98 D4830353HH 10/98 D4830354HH 10/98 D4830355HH 10/98 D4830356HH 10/98 D4830357HH 10/98 D4830358HH 10/98 D4830359HH 10/98 D4830360HH 10/98 D4830361HH 10/98 D4830362HH 10/98 D4830363HH 10198 D4830364HH 10/98 D4830365HH 10/98 D4830366HH 10/98 D4830367HH 10/98 D4830368HH 05/99 D4987571HH 05199 D4987572HH 05/99 D4987570HH (If you need more space, use a continuation sheet and attach if fo this form.) PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the United States. The furnishing of a social security number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109). The purpose of requesting the information is to enable the Bureau of the Public Debt and its agents to issue securities, process transactions, make payments, identity owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information Public Debt may be unable to process transactions. Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to distribution or payment; agents and contractors to administer the public debt; agencies or entities for debt collection or to obtain current addresses for payment; agencies through approved computer. matches; Congressional offices In response to art inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation. We estimate it will take you about 15 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form fo the above address; send to correct address shown in "WHERE TO SEND" in the instructions. 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(752--~~ ~~ 2 tL N Ch N N rn N a C O w co y 0 e~ '~ 3 .~ a ... m m ~ Q. U U p~ O ~ Q r+ ~ N 3 m V' CO N r" Q7 CrJ O ~ O ~' ~ ~ L 3~ O N N ~ ~ ~ ~ ~ O ~ O ~ N ~ cn r M ~ Q7 U ~ = O m ~ U~ ~ o ~ m c ~ N cn E~ w o a~ ~ ~ L ` Q ~ n' ~ ftr o ~ U (,~ ~ ~' 'O m m ~ ~ ~ N ... O ~~ V ~ C h NJ O n. m ~ O Q U ~ ~ ~ (D ti 30 ~ ~ w . U ~ m o ~ ~y O a ~ C m O O> O N m ~ ` coi " = N ~ o o ma Q ~ ~ m Q 3 y O • N N~ T y '6 O~ ~ O O a m ~ '00 0I ~ '~~ , O m Q „ _, ~ a ~a~~ ~~ ` w~ Qm~ .0.. O N >., "" ~ ~ U t4 m ~ -a O ~ v ~O O d ~ ~ cep ~ V m ~ ~ 3 V C O O c m ~. d ?~ m ~ i6 ~ a c m ~ N ~ rn 1O o ~ :+ c `o ~ ~ `a ~ b ~ ~ ~ a ca ` ~ ¢ y ~ o H rn ~ m O v ro a s m C C O C ~~ G ~ > I- ~ ~ y m ~ .,~ ti.. O N ~ O ? O V Y O O v' O ~ v m CO y ,~ 4 m N O ~ ~ j i N ~ O LL w m ~ ~ . ~ C 0 W (p C] 5 .-+ ~ 'a > ~ c m E ~ .C 'a X d m ~ G O ~ ~ ~ ~ ~ ~ ~ ~ ~ m ~ ' ~ ~ ~ ~ m ~ ~ ~ p > v w m ~ ~- N ¢ ~ 7 O N ' •.~ 7 > m ~ ~+~ C C 7 'a ~ ~ m m ~ 'q 7 O (0 y ~ ~ .n L ~ ~ m h ~ `~ N N (G ~ h m ""' ~ Q F~O~ J t/1 W J Q a ~ v ~ w w Q ~ N Q ~ 0 -z>O-VW n ~ ~ ~~ t0 t~ ~ . r-~, ON~1^~a21 1111•_ ~~ ~ ~ fQ ~~ COn~ 3 h ^_ '~~ ^~~•s! ~~ ~ s~ ~ ~~ J Q ~ O ___ " ' "~D A~ ___ ` _'~'~' _•_ ___ ___ ___ •___ ___ ___ _•• ___ ~ ~ ~`J U_ ~ ~ ~ Z ~ -~ -~, \,,, ~. W z ~~ .. o \~ v ..i J l_ 4. v ` `~ Z O a o ~ ~~ e , 4J ~ 4 ~ `~ ~ : ; r z a ~~ f6 a... ~~ ~' a Y a C H i Mervin Brubaker Mervin Brubaker 633 Willow Way Mechanicsburg PA 17055 Phone 717-697-0120 E-mail MBrub15926@aol.com Generic Clock Appraisal: Bob Myers Estate: The case is about 8 feet tall made of walnut. It has a broken arch.The hood is detachable. The finish is not restored nor is it well kept having been in a nursing care environment for several years and has surface wear to show for the experience.The door latch does not work. The case appears to be about a mid 1800 vintage. The movement is a black forest, part wooden and part metal.The frame of the clock move- ment is wooden.Thegears are cut of brass.The wooden case has brass bushes while the ihafts are iron.lt has a single bell strike to mark the hours.The movement was awag-on-the- walland was adapted to fit in the case, some times referred to as a marriage in the trade. Value: $750.00 Yours truly' ~VJervin Brubaker National Watch & Clock Collectors, Inc.. #0074932 Member for 30 years Antique clock restoration and repair< 30 years ,~ ~... ,_., '~Efi.-a:~tl~,~c IN~T=.4~ S=NIC~~ C~R_ 5002 LENKER ST. MECHANICSBURG, PA i705C PH.(717) 731-9984 Faimew OFia 60-295-313 2/2/2011 'AY f0 THE ORDER OF Bob Myers ~' "282.55 Two Hundred Eighty-Two and 55/100""•*~~~.~~~~>,~,.,~~~~~,~~,~~~~~~~,~,.~~,~~~..**~~.,~~~~~~.~~„-~~~~~*.~~~~,~.,,-,~.~,»*,.~ DOLLARS Bob Myers 100 Mt. Allen Dr. Rm: 1 Mechariicsburg, PA 17055 MEMO i / f ~ ' f` /` ~~~ AUTHORIZED SIGNATURE II°OOb59211' o:03b30?955~: HOME INSTEACo SENIOR CbRE Bob Myers 94435550611' U a 0 v 0 r U aJ N 1592 2/2/2011 282.55 Checking 282.55 Holy Spirit Hospital 503 North 21st Street Camp Hill, PA 17011-2288 PNC BANK `CHECK 60-1273 3T3- 247466 CHECK t)ATE PAY THIS AMOUNT 02/03/11 """"'"*$116.25 VOID AFTER 90 DAYS PAY One hundred sixteen and 25/100 Dollars TO THE ORDER OF' ROBERT D MYERS 175 NORTH AVE~t201 NEW YORK NY 10011 ~/ /Pir.~,a,~ ~~ue~-~r w,lcc SECURITY FEATURES INCLUDED. DETAILS ON BACK. 11'24746611' ~:03L3~2738~: 5L400 2 9 9 5 911' Malpezzi Funeral Home PNC BANK, NATIONAL ASSOCIATION 17 S 4 2 8 Market Plaza Way Cumberland Parkway Mechanicsburg, PA 1055 60-1273/313 (717) 697-4696 3/24/2011 )THE of Rebecca Myers ~ ~ **100.00 Hundred and 00/100**~,~**,~,~~~******~~*~***~,~~*,~***~~*,~**~:~***„~*~*****,~,~******~****,~***,~**~**,~*~***~**,~**~*~ DOLLARS B , Rebecca Myers 175 9th Avenue, #201 New York, NY 10011 - -~ ,`.Veteran ~..~.~~.~?~~~-- _-- "" l~'OL7942u' ~:03~3L2738~: 5~~204409411' ~ M&T Banlc 1200 Market Street, Lemoyne, PA 17043 717 731 1730 xnx 717 761 6497 03/08/2011 Robert D Myers has a joint checking account with M&T bank. The account number is 62716247. The date of death balance was $49,912.38. The joint account holders name on the is Rebecca S Myers. If you have any questions please ca11717-731-1730. Sincerely, Torrin W Cavanaugh, RB 1 y~nti wl ~s~r wY~.~ cLE~t' vp~~cC) IZ'1ti1z~c PSE(~k Wix, Wenger & Weidner Attorneys at Law 508 North Second St, PO Box 845 Harrisburg, PA 17108-0845 Attn: Denise B Williamson, Paralegal Re: Robert D Myers, Deceased. PSECU Account # 0203249571 Dear Ms. Williamson: January 11, 2010 The account was opened on September 30, 1991. The Share accounts were held jointly by Robert D and Mary A Myers. On January 30, 2008 Mr. Myers removed Mary and added Rebecca to his account as a joint owner. A copy of the Change of Ownership form is included. The Personal Service loan and Visa loan were held solely by Robert Myers. The following are the Date of Death Balances for Mr. Myers' account with PSECU: Account Date of Death Balances Savings (S 1) $ 945.64 Vacation (S2) $ 0.00 Checking (S4) $ 66.09 Interest -January 1-29 $ 0.32 $ 0.00 $ 0.01 Loans: Personal Service Loan (L1) Visa Loan (L9) $ 0.00 $ 69.54 If the Estate has sufficient funds to payoff Mr. Myers' Visa loan, please remit a check, made payable to PSECU. If there are not sufficient funds to payoff the loan, please provide PSECU with a letter stating this fact. The funds in the account will be release to the joint owner Rebecca upon request. If you have any questions, please contact me at (717) 234-8484 or toll-free at (800) 237- 7328, then press 6, extension 3120. S'r erely, 1~~ - " _~ Ci/~-~ Roxahn Myers Service Advisor PSECU Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990 • 717234.8484 • 800.237.7328 Mailing Address: P.O. Box 67013, Harrisburg, PA 1 71 06-701 3 • 717.777.2100 (TDD) • 800.472.1967 (TDD) psecu.com This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender Authorization to Change Account Ownership ~~ ~~ d>~ ~~ p~~C Changing/l3el~oving Joint Owner(s,~ d ~ ~ ---J 41 ~~~rrr Important Account Security Information -Please read before continu`in`g. 1~},~C(. (~EbCt.E'af ~"(}iP~S I acknowledge that it may 6e in my best interest to restrict access to my account from the person(s) that have been replaced or removed as joint owner(s). I understand That I should change my Personal Identification Number (PiN) and should obtain any checks, ATM, orVisa®cards still in es oho t se persons. I also understand that I should replace these services if I am unable to regain possession of the checks and/or cards. Please ry~~~ hc~~t my services in accordance with my instructions set forth below. I release the credit union from any liability fa: ;nauthorized withdrawals by ATfr - resulting from my failure to replace these services. d A -t e~ ~ 20~a A $1 entrance fee will be charged. If change is due to death, the~g will be waived. Please send a copg of th eath Certificate or obituary. MembarName: c;i+'~6l.YJt~.9.itl;~t'~ (2ol,e/~'~. 1'4/~AccountNumber; o20~"c~'-1-~/~7~ Members Home Address : P'~2,CCtal1 ~(')~ ~ !'m116~fi. ~~ . f 00 /"(~' ~F61e,. ~ r ~'l Q~.~z t ~~t ~ I ZoSS z - ~ Member's Home Phone Number: {'l7 } 7 9.~-!a 3S Member's Work Phone Number: (_) I am: ~ Replacing Current Joint Owner{sj ~jZ] Removing Joint Owner(s) All (oint owners to be listed on the account must complete information below. RC~cv- - S, My :ir3 - d ,a~~~-e~ - ~- Joint Owner Name (print) Relatto ship to Member Ct7 b - ~ r l0 si ~ tt>a .S'rn.e Address. if differentfrom member's ~' Joint Owner Name (print) Relationship Eo Member fa a~~1.954 . f 75~~J~ ~~R7-- - - - -~~3~ ~~z Date of Birth .Social Security Number Daytime Phone Number Dote of Birth Persona! Identification Number Foy the security of your account, please select a new PIN: Your account P!N can 6e any four numbers you wish. You will nee Ft to access your account when you contact PSECU. Self Service Telephone Transfer ^ I authorize SST transfers from my account io the following accounts: em e s amean ccount um er em e s amean ccount um er ^ Please cancel SST transfers from my account to the following accounts: Member'sNamean Account Number Mem6ersNameandAccountNumber A choice must be made in each of the following sections to ensure the security of your account. Checking All joint owners must be at least 12 years old. Checks will be ordered in the style you currently are using. If you were originally charged for this check style, you will be charged again. Please allow hvo weeks to receive your checks. ^ I do not have checking service. ~,I have obtained all checks from previous joint owners}. There is no need to replace checks. ^ I have not obtained all checks from previous joint owner(s). Piease close my existing checking service and open a new checking service on this account. The last check written was # _ on _/_/__ for $ ^ I have recorded new imprint information on the right. ^ I have obtained all checks from previous joint owner(s). However, I wish to change my imprint information. Please order me new checks starting with # I have recorded the new imprint information on the right. Check imprint • Please complete Please print the information you wanton your checks, i.e. name(s), telephone number, address, etc. Maximum imprint Isfive lines. Piease destroy any checks in your possession. If you have any electronic debits or credits on your account, please contact this credit union for instructions on further actions. ATM All individuals listed on the account must be at least 12 years of d io order an ATM card in their name. Please allow five days to receive your new card. If you ore requesting new ATM card(s), please complete the ATM PIN information at the bottom of this form. ^ I do not have ATM service. I have in my possession the ATM card(s) issued on my account, and I am not concerned with unauthorized access to my account. Please delete the 2^dcard. ^ The joint owner removed from my account was authorized to use my ATM service. Please close the existing ATM card(s) and issue new card(s) in the name(s) indicated below: first cord name Print second card Home (must be faint owner) ^ Please issue o second ATM cord on my account in the name indicated be[bw: Print second card name (must be faint owner) Complote your PINs -Select PINS that are not easily identified with you. Write your PINS in the spaces provided. P oe n your PINs on file. Please do not use the letters "Q" or "Z" as part of your PIN. Please do not use the following combing rs: 0 through 0009 or 9999. NOTE: We cannot issue a Visa card without a PIN. You will need this PIN to make cash advances at an ATM. r- lf you wish to add your joint owner as co-applicant on your line of credit, call 800.237.7328 nationwlda or 717.234.8484 in Harrisburg. ' Personal Service loan line of Credit ^ I do not have a PSL. Please remove the co-applicant from my PSL line of credit. I understand that if I complete a now LOANLINER°, PSECU will evaluate my ability to maintain the existing line of credit on my account. If t do not qualify individually for the fine of credit, I understand PSECU will convert my line of credit to a closed-end loan and both myself and the co-applicani will remain irdividirally and jointly responsible for paying the entire amount owed on the loon. ^ I am not concerned with unauthorized access to my PSL line of credit. Please leave my PSL as it exists now. Visas -Please allow ten days to receive your new card(s) Note: An additional cardholder who is not a co-applicant is not entitled to Visa account information. ^ I do not have a Visa Capitol Card. ^ The joint owner removed from my account was authorized to use my Visa service. Please close the existing Visa card{s) on my account and issue new card{s) in the name(s) indicated below. IF you want to change your PIN, enter the new PIN on the bottom of the front page. Print -first card name Print -second card name (if name is other than o co-applicant on your line of credit, the co-appticanl must sign below to authorae this card} ^ Please remove the co-applicant from my Visa line' of credit and close my existing Visa card(s). I understand that if I complete a new LOANLINERM, PSECU will evaluate my ability to malntaln the existing line of credit on my account. If I do not qualify individually for the line of credit, I understand PSECU will convert my line of credit to a closed-end loan and both myself and the co-applicant will remain on the loan and will remain individually and jointly responsible for paying the entire amount owed on the loan. I have my PSECU Visa cord(s) in my possession and I am not concerned with unauthorized access to my Viso and will hold PSECU harmless if my account is accessed by any former owners}. Please delete the 2"d card. Signatures -Member, all joint owners and co-applicants must sign I understand that PSECU will close my current account to terminate the Joint Ownership Agreement that exists between the former account owners and PSECU, and will use the same account number to establish a new account and Jolnt Ownership Agreement in the names of the owners whose signatures appear below. I understand a $1 membership fee will be taken when the account is re-opened. I understand that in the absence of any instruction to restrict account acce3?; to'my accouni; f.nccg~t full responsibility for the activity on my account and will hold PSECU harmless if my account is accessed by any former owner(s). We agree to 6e bound by tho terms and conditions of the Visa Service Agreement, including any modifications made to the agreements from time fo time by PSECU. Any negative balance created by the use of the ATM card shall bear interest at the highest unsecured loan rate offered by PSECU until paid in full. Ail owners agree to be liable for any negative balances, Including fees and costs, created by the actions of any joint owner, in any jointly held account. I, and al joint ow a rev to be bound by Fhe agreements set forth on this authorization form and to the bylaws, rules and regulations of PSECU in effect from time to fim . {S qg\~,`e~ pelow.) i a ab~-rsoVn',~ssoclation, firm, corporation, credit bureau or personnel office to furnish informofian, including credit reports, concerning me or my affairs upon rege~,t f lt~' edit Union. l understand that f have the right to request, in writing, the nature and scope of the credit union's investigation. ` `T~tle~`Internol Revenue Service does not require your consent Eo any provision of this document other than the cerlificotions required to ovoid backup withholding. Mem ers :gnature x_~, , ~ ,tflr '~'~ct~,r.n~ Joint Owners Signature X r•., e....u~,....~.. r....,.r, ..e Date Joint Owners Signature Send Completed form io: PSECU, PO Box 67013, Harrisburg, PA i 7106 W-9 FORM -INTERNAL REVENUE SERVICE TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number, (2) I am not subject to backup withholding because: (a) I am exempt From backup wihtholding, or (b) i have not been notified by the Internal Revenue Service (lR5) that I am su6jed io backup withholding as a failure to report ail interest dividends, or (c)-the !RS hes ^oiified ma that ! om na longer su6jed to backup withholding, and{3) I om a U.S. person (Inducting e 11.5. resident alien). Instructions: Cross out item (2) above 'd you have been notified by the IRS that you are curcently su6jed to backup withholding because you have failed to report all interest and dividends an your tax return. Cross out item (3) and complete the appropriate W-8 if you are not a U.S. person (a non-resident alien or a foreign entity not su6jed to backup withholding). Checking Agreement I/VJe hereby request PSECU to provide access to my MoneyHandler/ Checking Shares by check. I understand that checking is a credit related service and I outhorae PSECU fo obtain a credit report on any users of thls checking account. PSECU is authorized to honor checks executed by any one of the individuals listed as owners on this account. Ownership of the checking account shall be determined by my membership application and Joint Ownership Agreement, if applicable. t agrao chat the use of this account constit!~tes acceptance of the terms and conditions of this agreement. Should PSECU receive any check in an amount in excess of the available balance in the account, it may, at Its sole option and without regard to which of us issued the check, either pay the check and add the excess to the Personal Service Loan of any of us or withdraw sufficient funds from any other shore balances owned by me/us, or decline to pay the check. The exercise by PSECU of any overdraft option to o PSl constitutes authorization fo any of the signeeslo advance funds from my/our Personal Service Loon regardless of whether the joins account holder is also a party to the Personal Service Loan. In the event of non-payment of a check by reason of insufficient funds or upon request by me/us, PSECU shalt incur no liability and I/we agree to indemnify and hold PSECU harmless from any damages Incurred in connection therewith. PSECU may impose charges in connection with checking accounts in accordance with its policy as adoptod from time to time. In the event f/we Issue apost-doted check, PSECU shall not be liable For premature payment unless I have previously notified PSECU in writing of the issuance of the check. PSECU shall not be liable for payina a stale item or an Item tmorinted Joint Ownership Agreement - (*Not Transferable) The Pennsylvania State Employees Credit Union (PSECU) is hereby authorized to recognize any of the signatures subscribed hereto in the payment of funds or the transaction of any business for this account. The joint owners of this account, hereby agree with each other and with PSECU that a:l sums now paid in on shares, including certificates (excluding IRA), or heretofore and hereafter paid in on shares by any or all of said owners to their credit as such joint owners with all accumulations thereon, are and shall be owned by ahem jointly, with right of survivorship and be subject to the withdrawal or receipt of any of them, and payment to any of them err the survivor or survivors shall be valid and discharge PSECU from any liability far such payment. Any or all of said owners may pledge all or any part of Regular Shares in this account as collateral security to o loan or loans. All owners agree to 6e liable for any negative balances, Including fees and costs, created by the actions of any joint owner, in any jolnily held account. The right of authodry of PSECU under this agreement shall not be changed or terminated by said owners, or any of them except by written notice to PSECU which shall not affect transactions theretofore mode. U.SA. Patriot Act Identity Verlficotton Notice: Important Information about procedures For opening a new account: To help oar government fight the tending of terrorism and slap money-I law requires all ftnanrial instiluttons, Including PSECU, to obtain, verity, identifies each person who opens an account. What this means for you: When you opcn an account, we will as< for youinname, oar dress, dote of birth, Taxpayer IdenlHication Number (TIIV) (usually your Social Secr.rily Number} and other intom:ation m Mal~ezZi Funeral Home 8 Market Plaza Way Mechanicsburg, PA 17055 Jeremy www. (717)697-4696 Michael J. Malpezzi, Owner, FD February 24, 2011 Rebecca S. Myers 175 9th Avenue, #201 New York, NY 10011 The Funeral Service for Robert D. Myers c,"~ ~` Kyle C. Knipe, FD 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. THF. FOLLOWING IS AN TTEMI"LED STATF,MENT OF ZHE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELEC.TF,D WHEN MAKING TI-IE FL~IERAL ARRANGEMEN"fS. 1. PROFESSIONAL SERVICES: Services of Funeral Director/Staff $4,625.00 FiINERAL HO>V1E SERVICE-CHARGES $4,625.00 SELECTED MERCHANDISE: Solid Cherry Casket $5,30G.00 Sentinel Vault $1,425.00 Acknowledgement cards $10.00 On Freedom's Wing Register Package $235.00 Laminated Obituaries $60.00 THE COST OF OUR SERVICES, EQUIPMENT, .4ND \9ERCHAND(SE THAT YOU HAVE SELEC'fI~,D $11,655.00 AT THE TIME FU'VERAL ARRANGEMENTS W ERE MA1:)E. ~l~E .ADVANCED CER'TAIi~ PAYMENTS TO OTHERS AS AN ACCOMMOI)-47'ION. TI',E f'Z)LI..OWING IS A*d Ai;C~~L~I`!"fINf} FOR "fIiOS E CFIARGES- CASH ADVANCES: Cemetery Equipment $225.00 Certified Death Certificates $60.00 Newspaper Notices -Patriot $51 1._i2 Newspaper Notices -Hanover $165.00 ClergyiMass Offering $150.00 Military Honor Guard $]00.00 Flowers $296.80 Monument Engraving $220.00 TOTAL CASH ABi'ANC'1.` :3Ni? SI'E~t'1?±L t;l;~:~d2i;~;4 $1,728.12 SUI3-TO"I AI. .a 13.38)3./12 (hl [ n F-.~- $1).00 <<.lI'1.~., r~:ti`1~,€_ti-I'~'I~~tSC'C3t~?~,'T:."1~.I~:I~i':`ti T(~'F,~1., fi!ti30LN a' Dt!r= $13,3&3.12 1~essiah ~Tiila e Catering Service Fe~rua-~ ~~h , 7_ Tire:~.Z.Q~ Contact: Rebecca Nlyuee #201 address. 17~ g York, 10011 New York, New prgani~,ation: Service Type: buffet Service Time: 12:00 Room: multipurpose room Luncheon Buffet mot and c®i~ be~era~es Coffee service ~` c~~ ~.cco~nt # to be billed: Final Count: Cost per ~'erso~c: ; ...: Suh Totai: 574.43 Tax: ~ Less Deposit: ~ Room Charge: ~ Amount Due: 579.43 Please make cheeks payable ter: Il~essiah ~~illage 104 Mt. Allen Drive l~echaniesburg, Fa 17055 uest/BiII ~a~~t: Telephone; (817)470-9b 17