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HomeMy WebLinkAbout06-08-111505610143 'J REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE Po Box.2sosol INHERITANCE TAX RETURN 21 11 0219 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 189 16 8895 O1 24 2011 10 01 1922 Decedent's Last Name Suffix Decedent's First Name MI HEISHMAN RUTH R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ^ 2. Supplemental Return ^ 3. prior to d2r13 82)n (date of death 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required ^ (date of death after 12-12-82) fi Decedent Died Testate ^ ~ (Attach Copy Hof Trniaect)a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) ^ 9. Liti ation Proceeds Received ^ 10. Spousal PovertY Credit ((date of death ^ 11. Election to tax under Sec. 9113(A) 9 between 12-31=J1 and T-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JAMES D BOGAR 717 737 8761 Al First line of address ONE WEST MAIN STREET Second line of address City or Post Office State ZIP Code SHIREMANSTOWN PA r~ REGISTER O.S USE~NLY ~Zr ~= c . ~Z~ ~~ C~ r X Ci 7~ t70 a c.~ _ . ~ t~ - DA E FILED ~'"~ C7 L T .""i 7 r-J ~~ -i tTl Correspondent's a-mail address: jbogar@bogarlaw.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 other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSQGtRESPONSIBLE FOK Plurv~ ntiurcrv -"'- (r4)A ~ Paul L. Heishman ~ f 3~ I I ADDRESS ' 103 Bucher Hill Boilin S rin s PA 17007 SIGNATURE O R ARER OTHE HAN REPRESENTATIVE DATE James D. Bogar (it ADDRESS One West Main Street, remanstown, PA Side 1 1505610143 1505610143 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF Heishman, Ruth R. FILE NUMBER 21-11-0219 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 #2 Name Address1 Address2 City, State, Zip Date Signature #3 Name Address1 Address2 City, State, Zip Date Signature #4 Name Address1 Address2 City, State, Zip Date L "i. Frances L. Heishman 203 Belaire Drive Shiremanstown PA 17011 ~ •T ~/i ~~ Joanne E.Henchbar er 15531 Ea le Tavern Lane Centreville VA 20120 p6~b3 ~I/ ~~ G ,~~ Carl A. Heishman 6 Wendover Place Brid ewater NJ 08807 6I3/~ 01 J REV-1500 EX Decedent's Name: HelShfilall, Ruth R. Decedent's Social Security Number 189 16 8895 RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous ~o~; SeparaterBpling Requested............ 7. (Schedule G) u g, Total Gross Assets (total Lines 1-7) ..................................................................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 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. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15. (a)(1.2) X .00 16. Amount of Line 14 taxable 205 478.92 16. , at lineal rate X .045 17. Amount of Line 14 taxable 0 , 0 0 17. at sibling rate X .12 18. Amount of Line 14 taxable 0 , 0 0 18. at collateral rate X .15 19. 19. Tax Due ................................................................................................................ .. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 150561243 46,921.20 95,900.00 89,960.29 232,781.49 27,302.57 27,302.57 205,478.92 205,478.92 0.00 9,246.55 0.00 0.00 9,246.55 Side 2 1505613243 1505610243 REV-1500 EX Page 3 nprprlPnt'c Cmm~lete Address: File Number 21-11-0219 DECEDENT'S NAME' ~ Heishman, Ruth R. STREET ADDRESS 203 Belaire Drive CITY STATE ZIP Shiremanstown PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 9,246.55 2. Credits/Payments A. Prior Payments 8,697.50 B. Discount 457.76 Total Credits (A + B) (2) 9,155.26 3. Interest (3) 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 91.29 Make Check Pa able to: REGISTER OF WILLS, AGENT. ~: ; T i~ ~` f ~ is . .b t.~i.=.. ...,~f~ s: m.. 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 :............................................................................... ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^^x c. retain a reversionary interest; or ............................................................................................................... ^ x d. receive the promise for life of either payments, benefits or care? ............................................................ ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^ receiving adequate consideration? .................................................................................................................... x 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death?....... ^x ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ^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. t ~•, a...#~'. ..~ ~ .?1~.~rar.k~~ j. ~M1 '~5'~' ,d -pr ~~`'; ~~~'!»r-.x.... ~. 4 ''~.`a.~'.~s. 5..::~~~-ww.;ci .~.{~:.i:F.~...~,~..-.`!F 1 .~i~~.:~..~'F~'.~..:~~.. 'E ..'~~Sc:'p . :.r. ~,i... ~-.5 For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent (72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 48500041046 REV-485 EX (1-07) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Securi or Death Certificate Number Date of Death County Code Year File Number ~18 9~ 1 6 8 8 9 5 ~~ ~~~ ~~ ~ 2 1 1 1 0 2 1 Decedent's Last Name Suffix First Name MI ~'' u t -His ma n '~ a.. ® ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE: i 203 Belaire Drive ShirFSr~anStoWil PA 17011 F NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME: JAS D. BOCJat• ESQl17-~'e CITY: STATE: ZIP CODE: , STREET ADDRESS: Sj~i T~manStOWil PA 17011 One West Ma7S1 Street AIAnnF ennaFSC eNn RFi eT1oNSHIP fIF ANYI TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: , James D Bogar, ~~cnlire [fie STREET ADDRESS: CITY: STATE: ZIP CODE: One West Main Street ~t„rFSnanstown PA 17011 b. NAME:.. RELATIONSHIP: FYant~s L. Heishman: Daughter STREET ADDRESS: CITY: STATE: ZIP CODE: i 203 Belaire Ih-iv_e_ _ Sh;~n~tvwn PA 17011 ~ I c. NAME: RELATIONSHIP: ~ Paul L. ~eisYmar>t Sou STREET ADDRESS: CITY: STATE: ZIP CODE: 103 .Bucher Hill. Boiling Sprin PA 17007 NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED i NAME: ~ Wachovia Bank j STREET ADDRESS: CITY: STATE: ZIP CODE: 320 Trindle Road Hill PA 17011 ' NAME OF PERSON MAKING LAST ENTRY DATE AN i TI~ f Q"LAST ENTRY ~ " ~ ,` ~t-~i~CaC~.J(-- v ` I DATE OF CONTRACT TO RENT BOX NUMBER OF BOX 1 TITLE UNDER WHICH BOX IS REGISTERED 260 Ruth R. Heishman NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX F a. NAME: b. NAME: } STREET ADDRESS: STREET ADDRESS: CITY; STATE: ZIP CODE: CITY: n ~ STATE: ZIP CODE: ~ NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ~ WAS A WILL IN THE BOX? ~ YES ^ NO If yes, a. Date of will: b. Name and address of personal representative, if named in the will i i NAME: 'i I 1 STREET ADDRESS: CITY: STATE: ZIP CODE: c. Name and address of attorney, if any _ -._ ~ i NAME: I STREET ADDRESS: CITY: STATE: ZIP CODE: 48500041046 48500047,046 REV-485 EX SAFE DEPOSIT BOX INVENTORY Page. of INSTRUCTIONS (1) Cash: Report total only. (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, i.e., jointly held, payable on death, etc. (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, etc: 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. (9) Return completed form to; NHERITANCE TAX DIVI ON PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ~. ITEM DESCRIPTION ~~\ ~ li,s-e-tv~©~1a~s ~ Ctl ~ ; ~1 ~~ re..c y~~sr~- ~ 1 ~ S` r.~.C~ t4(~v(t ~" l ~ - t ~ t ~ ~ t 1 t -. - l0`?tP , b L~' >3 r 2~" ~ t'-~l`k~ ' ~~ n .til~ tl4.~rrGa~ ~4~c9"~ ~-'~ I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT ND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGN E PERSON RECEIVING COP/~Y~O~F~~ SGN E DEPOSIT BOX VEN/ ~f PRt NAME~~A~N~~D((C~HECKAPPROPRIATE BO~ELO PRINT NA 55 ~~JJ~~ ~ (+C~~t,GicG?ss'.~ K ~C ~ ~ ~ ~ ~ ~ DATE CHECK APP PRINT TIT ' J' f ,,, ,, ~~ u~J gr'LC'(/ ~ - s~ tZ~'t i '~zjecutor(trix) ~] Administrator(trix) ,Y ``~uN" ~' ~,~E~~r?~ 1 ` ^ Estate Representative ^ Joint owner of safe deposit box ~, NOTE: Attach additional 8'1~" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Comdmo~wenith~ fidential tax informat onhexcept for offi9 al pu posesrmation agreemc, ~+s with Federal and local taxing authorities. The state law prohibits the Commonwealth s personnel from is osl g Rev 485 EX (1-07) Safe Deposit Box Inventory (Continued) 4. Name, Address and Relationship (if any) to Decedent, or Person(s) Present at Box Opening d. Joanne E. Henchbarger daughter 15531 Eagle Tavern Lane, Centreville, VA 20120 e. .Carl A. Heishman son 6 Wendover Place, Bridgewater, NJ 08807 Rev-1508 FCC+(6-98) SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Heishman, Ruth R. 21-11-0219 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Belco Community Credit Union -Savings Account No. 623590-S1. Date of death balance 1,097.42 $1,096.99. Accrued interest $0.43. 2 I Wachovia Bank -Checking Account No. XXXX8431. Date of death balance $3,350.91. I 3,350.99 Accrued interest $$0.08. 3 I Wachovia Bank -Checking Account No. XXXX8164. Date of death balance $3,076.31. I 3,076.34 Accrued interest $0.03. 4 Wachovia Bank -Savings Account No. XXXX6039. Date of death balance $321.20. Accrued 321.21 interest $0.01. 5 Wachovia Bank/V1/ells Fargo -IRA CD No. XXXX4971. (Part of Wells Fargo Account No. 3424 12,737.96 -4367) Date of death balance $12,737.96. This account is referred to as IRA XXXX4971 on the attached February 28, 2011 letter from Wachovia Bank and as IRA/CD No. 257410080844971 on the Estate Valuation provided by Wells Fargo Advisors. Wachovia Bank was recently acquired by Wells Fargo. 6 Wachovia Bank/Wells Fargo - (Part of Wells Fargo Account No. 3424-4367). This account is 248.79 referred to on the February 28, 2011 correspondence from Wachovia Bank as IRA No. XXXX2344 and as IRA/CD No. 257410270822344 on the Wells Fargo Advisor Estate Valuation both of which are attached hereto and incorporated herein. This is a cash sweep account with a date of death balance of $248.79. 7 Wells Fargo -Account No. 3424-4267. This is the mutual fund portion of this account. Date 23,012.37 of death value $23,012.37. 8 Coins from Safe Deposit Box -Per attached appraisal. 287.00 9 Personal Property -Sold at private sale 1,600.00 10 AARP -Medicare Refund 32.40 11 Aflac -Refund 503.75 I Total of Continuation Schedule See attached page TOTAL (Also enter on Line 5, Recapitulation) 46,921.20 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) ` Rev-1508tEX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER Heishman, Ruth R. 21-11-0219 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 12 Apria Healthcare -Refund 9 22 13 U.S. Treasury - 2010 Personal Income Tax Refund 600.00 14 Wachovia Bank -Safe deposit box refund 43.75 TOTAL (Also enter on Line 5, Recapitulation) ~ 46,921.20 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) ~BELC~ Jamey D. Bogar Attorney At Law One West Main Street Shiremanstown,Pa. 17011 February 28, 2011 Re: Estate of: Ruth R. Heishman S.S. 189-169-8895 Dear Attorney Bogar: Here is the information for the above referenced account. If you need any further information, please call me at 717 720 6414. Sincerely, ~.,'.,,.lo~ ~,A / Yvonne 3aarh~e Finance epartment ;~ 1. Name(s) in which the account was held DECEDENT ESTATE INFORMATION RUTH B HEISHMAN 2. Account number: 3. Balance as of date of death: Balance Regular Saving: S1 $1,096.99 623590 Accrued Dividends $0.43 YTD Dividends Opened $0.43 3/31 /1994 Christmas Club: S2 Money Market: S6 Checking: S4 Money Market: S15 Certificates: Balance Accrued Dividends Certficate Number YTD Dividends NA $ $ 4. Date the account was initiated: NA 5. Name(s) in which Safe Deposit Box was held: N/A 6. Date the box was initially rented: 7. Branch address at which the box is located: 8. Loan Information: A. Unsecured Loans: L14 Classic Visa Card B. Secured Loans: Balance N/A N/A Accrued Interest Per Diem Int C. Mortgage Loans: N/A $ $ $ $ $ $ $ $ 9. Miscellaneous: Facsimile Transmission VI/achovia Corporation From: Fax Number: Voice Phone: To: Company: Fax Number: 7177372086 Voice Phone: CC: Fax Notes: ATTN JAMES BOGAR, THE IRA IN QUESTION IS TIED TO A BROKERAGE ACCOUNT AND SHOULD BE SENT SEPARATELY. YOUR REQUEST HAS BEEN FORWARDED TO WACHOVIA SECURITIES FOR A RESPONSE. THANK YOU. JENNIFER STRAUB Date and time of transmission: Tuesday, March 15, 2011 8:31:08 AM Numbe;T of pages including this cover sheet: 04 A RightFAX~ Communicared Document 1- lA A 1 1 U.11 ~7I I I 1 U V 1 V 11 V/ 1 V/ L V 1 1 V V 1 ~ z V 171 1 r [~~..~ L ~. i v v t • w~~ ~~~ v .~ ,~~~~ Reference ID: 3298420 Wachovia Bank Balance Confirmation Services P O Bos 40028 Roanoke, VA 24022 February 28, 2011 JAMES D BOGAR ** SUBJECT: Verification / Confirmation of Account and Balance Information provided for: Customer: RIITH R HEISHMAN (SSN# KXX-XX-8895) Date of Death: January 24, 2011 Deposit Account Information Acccunt Account Date ofDeath Average Balance Date Maturity Interest Accrued YTD Date Type Number Balance Opened Date Rate IrAerest Merest Paid Closed KTIFiCATE OF Aa~K~s~i70U~5502 $3,815.28 9/7/2005 91"7/2013 $13.64 $0.00 POSIT GAL TTI7 E: RUTH R HEISBMAN D TYLER M HEISHMAN RTIETCATEOF A~~K~~~5537 $3,815.28 9/7/2005 9/7!2013 $13.64 $0.00 POSIT GAL TITLE: RUTH R HEISHMAN D ERIN L HENCHBARGER RTIITCATE OF 3i~LK~u+Z5550 $3,815.28 417/2005 9/7/2013 $13.64 $0.00 POSIT GAL TITLE: RUTH R HEISHMAN D EMMA L HEISHMAN RTIFICATE OF ~~s.~7~~t~D~X5557 $1,907.64 9/7/2005 9!712013 $6.82 $0.00 POSIT GAL TTI'LE: Rt]TH R HEISHMAN DZACHARYIHEISHMAN RTIFTCATE OF ~~s~};,s~}~,1~5561 $1,907.64 9/7/2005 9/7/2013 $6.82 $0.00 POSIT GAL TTI'LE: RUTH R HEISHMAN D S AMUAL S HEISHMAN Page 1 of 3 . ...~... .. .~.«....~~.~i.. .. .ova. vi .ivi ~v..a_y ~ ..+izv c-si~a r[-au i. vi vv-x • u~ vvi vi..i . T'!'~,y~~ ReferenceID:3298420 IECIiING A~i~7+']+~t~7i8431 $3,350.91 1128(1992 $0.08 $0.20 2/18/2011 iGAL TITLE: RUTH R HEISHMAN .OSING BALANCE: $3318.71 IECKING AaiX7~3i8164 $3,076.31 1/7/2010 $0.03 $0.05 2!18/2011 ?GAL TTI'LE: RUTH R HEISHMAN ,OSING BALANCE: $3079.38 ?s~~~4971 $12,737.96 1/11/2006 $8.29 $0.00 ;GAL TITLE: RUTH R HEISHMAN Beneficiary Claim Form information, please call 1(866)786.4890_ 4 344 $0.00 9!2112005 $0.00 $0.00 ;GALTITLE: RUTH R HEISHMAN QS ACCOUNT IS TIED TO A BROKERAGE ACCOUNT. WE DO NOT HAVE ACCESS TO THAT INFORMATION AND IF SHOULD FOLLOW SEPARATELY. r Beneficiary Claim Form information, please call 1(866)786-4890. VINGS }s;~'X6034 X121.20 1/211950 $0.01 $0.01 2/18/2011 :GAL TTi7 E: RUTH R HEISIIMAN OSING BALANCE: $321.21 Other ACCOUIIt Information Accorart Accourrt Date of Balance Date Date Ledger Collected Type Number Opened Closed NUITY A~~KA~fi~i3811 NWORTH - For information regarding anrwitiea, please call 800.521.8884 NUITY A~CKx50~ik7~3870 ANSAMERICA-For information regarding annuities, please call 1-800-851-7555 FE DEPOSIT XXk7~."~{0260 11!3!2003 k GAL TITLE: RUTH R HEISHMAN CATION: MP HII I, 1 S TRINDLE RD MP HII.L PA 17011 Other Information or more of the requested accourris have converted to Wells Fargo Bank and a response on those accourrts will follow under separate cover. Page 2 of 3 t'a.X '1'Y'1T]5CI11551017 :~/1~/LUll t~:~l:4U AM YAIiJr r}~UUrf rax ~~tv~.c r Y~.L,~~ Reference ID: 3298420 CAP, BROKERAGE and SELF-DIRECTED IRA ACCOUNTS HAVE SEEN CONVERTED TO WACHOVIA SECURITIES. YOUR REQUEST HAS BEEN FORWARDED FOR PROCESSING and WILL BE MAILED UNDER SEPARATE COVER FOR QUESTIONS REGARDING CAP, BROKERAGE, ar SELF-DIRECTED 1RA ACCOUNTS PLEASE CALL WACHOVIA SECURITIES at i-866-87d-2717. * Date of death balance does not include aa>rued interest * If date of death occurrs on a wcekend or a holiday, date of death balance does not include any transactions that were made during that time period ~.~. ~ s~~ Jennifer Straub Servicenter Associate Phone: (540}563-7323 ae;~a By accepting this information, the recipient thereof represents and warants to Wells Fargo Bank, N.A ("Wells Fargo"), that the recipient is authmrized 6y the customer ro receive lawfully this infixmatim. I'he recipient agrees that it will not disclose this information to arty third party, unless compelled m do so by legal process, and that it will lawfully use [h>s ref°rmahoa The recipieat acknowled~s that Wells Fargo dour not represent and warrant that the infatuation is complete and accurate. The recipient fuatlter ackaowledges that the infomration may not disclose the entire relationship between costumer and tVelk Fargo. Tha utforrnation is subject to change mithnut notice to the recipient The recipient agrces to indemnify, defend, and hold Wells Fargo harmless from and against arty claim resulting from the iisclosure and use of the infonnatioa by the recipient or from the breach by the recipient of arty agreement, representation, or waranty wntained herein. Wachavia Bank and Wachovia Bank of Delaware are divisions of Wells Faro Bank, N.A Page 3 of 3 Wells Fargo Advisors, LLC One North Je$erson St Louis, MO 63103 May 4, 2011 Estate of Ruth R. Heishman c/o James D. Bogar Attorney at Law One West Main Street Shiremanstown, PA 17011 ?*, ADVISO ; , i.<~. RE: Estate of Ruth R. Heishman Dear James D. Bogar: Thank you for contacting Wells Fargo Advisors regarding the account(s) of Ruth R. Heishman. Attached is the information regarding the date of death valuation requested. If you need any further assistance, please contact an Estate Processing Specialist at 866-786-4890, weekdays 8 a.m. to 6 p.m., ET. Sincerely, ~adlra~ awe Patrick Lane Managing Director Wells Fargo Advisors, LLC '~`oget:her we'L go ~~:r __ _ -_ _ - - -'~ _ `_ __ _~ - - _ ~ F Member FINRA/SIPC .~S-~c~Lt~ c'~,~L1a.t1(JI1 ~.E'~Or~ Prepared for the accounts of RUTH R. HEISHMAN Togefiher we'll gc~ far aaA~` The Federal Estate Tax is an excise tax. on the right to transfer T~.32'Gpert;y rt% death. The gross estate includes all assets owned at death. This includes: assets held in individual names, the appropriate share of assets owned as tenants in common, one-half of the jointly held property where the joint tenants are husband and wife, and all of jointly- heldproperty where joint tenants are not married to each other - subject to the surviving tenant's ability to prove contribution to the purchase of the property. Life insurance death benefits are included in the gross estate if the insured was the owner of the policy or if the death benefit was payable to the estate of the insured. The Estate Valuation Report provides the value of assets including: Equities, Municipal Bonds, Mutual Funds, Savings Bonds, Corporate and Government Bonds, GNMAs, FNMAs, FHLMCs, CMOs, Unit Investment Trusts (UITs), U.S. Treasuries and Savings Bonds (E, EE, H and HH). Notes regarding Alternate Valuation Date: All assets are included in the gross estate at their "fair market value" on the Date of Death or if the executor elects, their value six months after date of death, which is referred to as the Alternate Valuation Date. The election between the Date of Death and the Alternate Valuation Date exists to allow the tax burden on an estate to reflect the value of that estate as accurately as possible. For example, the value of an estate can change dramatically during a six-month period of time depending on stock market conditions. This fluctuation can dramatically affect the amount of estate taxes owed. If the Alternate Valuation Date is elected, assets are revalued as of that date. Assets sold or distributed during the six-month period between the Date of Death and Alternate Date are valued at the date of the sale or distribution. Assets remaining are valued on the date six months after the Date of Death. The Alternate Valuation Date can only be used if it results in a reduced tax burden on an estate. When requesting an Alternate Date evaluation, it is possible that not all of the asset values have changed, and you will notice that accruals do not continue to accumulate after the Date of Death. According to IRS Regulation?.0.2032-1, a.ny item in an estate that can change in value for any reason other than the simple passage of time can be re-evaluated on the Alternate Valuation Date. Anything else -accruals, for erarnple, which would only change because more time has elapsed -keep their Date of Death value. Accruals are simply cash owed to the decedent the day he died. Therefore, if you re-evaluate the value of this cash sir, months later, it will still be worth the same amount. The value of accruals is unchanged between the Date of Death and the Alternate Valuation Date. Investment items that do not represent cash, however, are re-valued on the Alternate Date because their worth may have changed. Stock, for instance, can change iri vahze with the fortunes of the company and could potentially be worth something much different six months later. It is, therefore, re- evaluatedfor the Alternate Valuation Date. T-Bills, E and EE Bonds are bought at a discount and rise during the course of their lifetime to their face value. This increase is steady, predictable, and represents accrued interest. Therefore, Alternate Valuation Date reports will show the same value for these securities as Date of Death reports. Terminology Date of Death: If that date falls on a holiday or weekend, then the previous and following market dates are used in determining value in the estate. Valuation Date: Date of the historical quotes requested, usually the same as the date of death. Alternate Valuation Date: Date six months after the date of death. Can only be used if estate tax burden is reduced. Security Description: Issuer name, CUSIP number, and other informational messages relating to the holding. CUSIP Number: Unique identifiers assigned to every publicly traded security in North America. While such identifiers as ticker symbols can be duplicated across different exchanges and change with a company's name, CUSIPs change much less frequently and their re-use is tightly controlled by strict rules. The word "CUSIP" comes from the name of the group that created them, the Committee for Uniform Securities Identification Procedure, a committee of the American Banking Association. Shares or Par: For stocks, the number of shares or units held. For bonds, the face amount (par). If the quantity is unavailable, the information provided is based upon one share of stock or X1,000 par for bonds. High/Ask, Low/Bid, Mean: The mean price is calculated as an average of the high and low on the valuation date when available. If these prices are not available, such as on holidays or weekends, the mean price is the inversely weighted average of the high and low on the nearest trading dates before and after, when these prices are available within one week of the valuation date. If actual trades are not available, the nearest bid and ask prices are substituted. Securities traded on a Canadian exchange are reported with Canadian prices and an exchange rate. The value of the security is reported in U.S. Dollars. Security Value: For stocks, the number of shares times the mean price. For bonds, the par value times the mean price, divided by 100. .This Estate V,~ltat iori ~R~Po.rt priJVidas historical securities Pricing as of a particular Date of.D~a~h,whichyru°~a~re s~~ci~ed. ;. , Wells ~'argod~ls'ors,.(~h?FA~.obtains this histor`acal c~atafrom Estate Valuations . r. an~ P,ricin~'~vsterxis,.)ric:, a company not related to WFA,y!rTlazc~l ire #urn:cozn~iles flits lYifor37latioXl'~~'~T~T anttrli~:e1'af.,sources; While ~~ ~ ~ _ r we deem plus Yn~orzi3a~~,ox~ to he z~elial~~e, we ~. '. ,r x: ~ ~ k da ilot warrar3ty-or;x„1'tlaran~a~ its accurac~T. W~`A-assutxie5 no t:-espnnsabtl~ty~fo~ the _~. '~~ Accrued Dividend: If an equity is ex-dividend for a cash distribution on or before the valuation date but is of record after the valuation date, the dividend is included in the valuation report and is added to the security value. If the date of death is on or after the record date and the dividend is payable after that date, the accrued dividend is listed separately on the report and added to the portfolio's total value. Accrued Interest: Interest is accrued for bonds from and including the last payable date up to but not including the date of death. Interest accruals are calculated on a 30/360-day basis for corporate, government agency, and municipal bonds. An actual day basis is used for U.S. Treasury Bonds and Notes. It is assumed that Interest is paid semi-annually and coupon dates fall at six-month intervals corresponding to the maturity date. Stock Dividend (Div.) Dates: "E" denotes the date the dividend was declared. "R" represents the date of record. "P" is the payable date. Bond Interest (Int.) Dates: "F" denotes the date current period interest began accruing and "T" the date to which interest due has been calculated. r3ccurac~ r~r: cor~~leteia,~~s +~~;~he}u~formatiarT ~~ you pro~rz~e~.,~iz1u~'di~~'Y ~ ~~~~~e ~f J3eath end tl~ spe~fi~ e~u~s~.~ h'L~~ ~~e valued. T31exe}vvl~l ic~7~ }~s ass~~~s tric~ucledln ?: ~~ tale ~stat~~or ~~>~>~a~~at~, alrx~au~-~as~s, ~ r ,~ ~vhz>~l ar~~x~~t 11ste~ dia~~~~?~rt~~;l~s ! 4 l,ry 1 c,..•~ 3 J ~ , ~ ser~ce,ls n#3~t ~i~o"~a~i~t~tllt~~e~a~ dr tsx ~c~+nce~ Ya1t~s~:~~~~s~.su~~';url~l:your. tam, -: l.r ~ y , p~c~fessxarialta~i~.a't~tar~i°y tt~'dz~s~us~ ~sYata ~ ~ # c settl~inen~~a~d Pny~.e~~~1~sra.att~rS - r - , INVESTMENTANDINSURANCEPRODUCTS: NOTINSUAEDBYFDIC NOBANKGUARANTEE MAYLOSEVALUE Wells Fargo Advisors is the trade name used by two separate, registered broker-dealers: Wells Fargo Advisors, LLC and VNe11s Fargo Financial Network, LLC. P~Temoers SIF'C, ron=nark a"iliates of Welts Fargo & Company. Wells : argo Advisors does no± provide tax or legal advice. Please consult with your own tax and legal advisors before taking any action that would have tax or legal corsequerces. :_; zUiO Wells Fargc Advisors, LLC. Ail rights reserved. ECG-23u1U4 051G-C:414 58699''' RevOr Estate Valuation RUTH R HEISHMAN Date of Death: 01/29/2011 Valuation Date: 01/24/2011 Processing Date: 05/04/2011 Shares Security or Par Description High/Ask Low/Bid 1) 248.79 Cash (CASH) IRA/CD 257910270822394 2) 10365.931 FRANKLIN CUSTODIAN FDS INC (353996300) INCOME FD CL A Mutual Fund (as quoted by NASDAQ) 01/24/2011 3) 12737.96 IRA/CD 257410080844971 (CASH2) 48-60 MO FIX Accrual Total Value: Total Accrual: Total: $35,753.11 Portfolio Endnotes Titled: RUTH R HEISHMAN WFBNA CUSTODIAN TRAD IRA 203 BELAIRE DR SHIREMANSTOWN PA 17011 Account was opened on 09/28/2005. Estate of: RUTH R HEISHMAN Account: 34294367 / 257410270622349 Report Type: Date of Death Number of Securities: 3 File ID: 3429-4367 Mean and/or Div and Int Security Adjustments Accruals Value 2.22000 Mkt 2.220000 0.00 23,012.37 12,737.96 2.78 $35,750.33 $2.78 Page 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. if you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.2.0) Bill Rowe i ~ _ X11 NorEh Old 5tonehouse Road Carlisle, PA 17015 ____ , US SILVER DOLLARS VALUE - _ -_ __ 1878 S -_ 1891 ri ~- 1921 _ _ __~ ~i^ 1922 -~" - ---~-- 1922 -`~-~' 1923 S ~"'~ MERVIN'S US COINS dollar Silver 192.1 5 --- _ Ctuarter_- Dime - ~_ 1948 1948 ,,,~ -- ~,.~-- - - Penny --- 1948 ~ ~~ FRAN`S US COINS Silver dollar 1923 ,2- ~' Silver dollar Halfdollar 1923 1944 2-~-~~-- t~ ° ~ Quarter Dime ~~ 1944 _ ~ ~' ,~- -~"' Nickel 1944 j `'"` Nicke( 1943 ~ -~ Benny steel' penny _1944 1943 , Penny 1906 Penny 1908 4 CANADIAN 5 cents 1942 _ _ one cent 1930 georgivs vi d:g:omn:rex f:d:ind:imp. one penny 1944 three pence 19`w ' ©,~' georgivs vi d:g:omn:rex ~^' two shilling `__ __ 1944 _ C.vc~ S one shilling 1944 sixpence 1944 ,. p ~~..." CANADIAN 2 dollar bill Ottawa 2 jan 1937 _ 50 cents 1932 _ 25 cents _ 194A ~ C. ~ 1925 ~ _ one cent __ ! 1912 one cent 1932 1 cent 194'0 1 cent 1942 __ 1 cent ____ - ------ 1945 _ ~ a- 2- ~- Fran Heishman .__-- 203 Belaire Dr Shiremanstown,_PA 1701 1 V~ cy~ ~- V ~-cam ~ ~~ ~-- V ~~~~~~` ~ _ ~ ~-~lc ~ l ~ ~-,.~ l~S~ `~ ~ ©~-~~ S~ ~~ ~ n ~.-. .~ t ~`~ tf ~2z,~ ~Z~ G~ u~~~ ,~ ~ ~,,~ ,,/ ~ 1 ! ~ ~~~ (CSC ~' ~ ~~ ~iiC_ `7~~ ~ it Rev-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF (FILE NUMBER Hpichman_ Ruth R. 21-11-0219 If an asset was made joint within one year of the decedent's date of death, it must be reportetl on scnetlwe ~. SURVIVING JOINT TENANT(S) NAME A. Frances L. Heishman B. C JOINTLY OWNED PROPERTY: ADDRESS 203 Befaire Drive Shiremanstown, PA 17011 RELATIONSHIP TO DECEDENT Daughter DESCRIPTION OF PROPERTY % OF ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSE INTEREST TENANT JOINT JOINTLY-HELD REAL ESTATE. 1 A 3!1011999 Real Estate - AI that certain piece or parcel of land having thereon erected a dwelling house being known and numbered as 203 Belaire Drive, Shiremanstown, Pennsylvania 17011. The property was acquired by Ruth R. Heishman, single person, and Frances L. Heishman, single person, as joint tenants with the right of survivorship, by Deed dated March 10, 1999 and recorded March 11, 1999 in the Cumberland County Recorder of Deeds Office in Deed Book 195, Page 687. A copy of said Deed is attached hereto and incorporated herein. The county assessed value of the real estate is $191,800.00. The common level ratio is 1.00. The total assessed value is $191,800. TOTAL (Also enter on Line 6, Recapitulation) 191,800.00 ~ 50. DATE OF DEATH VALUE OF DECEDENT'S INTEREST 95,900.00 95,900.00 (If more space is needed, additional pages of the same size) Form PA-1500 Schedule F (Rev. 6-9`') Copyright (c) 2002 form software only The Lackner Group, Inc. ~6~'~ ~ Tax Parcel No. 48-23-055'7-160 THI5 DEED, MADE 171E 1C716~. day of N~~'d~'-- in the year one thousand nine hundred ninety-nine (1999) BEIy RUTH R. HEISHMAN, single person, of Shiremanstown, Cumberland County, Pennsylvania, Grantor, and RUTH R. HEISHMAN, single person, and FRANCES L. HEISHMAN, single personb th ofiShiremanstown~ the right of survivorship, Cumberland County, Pennsylvania, Grantees: .--, • WI7NESSETH,that in consideration of One and No/100 Dollars ($1.00), in hand paid, the receipt whereof is hereby acknowl- edged, the said Grantor does hereby grant and convey t:o the said Grantees, their heirs and assigns: ALL TKAT CERTAIN piece or parcel of land situate in Lower Allen Township, Cumberland County, Pennsylvania, bounded and described as follows, to wit: BEGINNING at a point on the northern line of Belaire Drive said point being at the dividing line between Lots Nos. 1 and 2 on the hereinafter mentioned Plan of Lots; thence continuing along the northern line of Belaire Drive, South 66 degrees 36 minutes 00 seconds West, one hundred twenty-four and sixty-four ohe- hundredths (124.64) feet to a point on the eastern line of Maple Avenue; thence continuing along the eastern line of Maple Avenue, North 23 degrees 24 minutes 00 seconds West, one hundred fifteen and zero one-hundredths (115.00) feet to a point; thence North 66 degrees 36 minutes 00 seconds East, .one hundred twenty-four and sixty-Pour one-hundredths (124.64) feet to a point at the divid- ing line between Lots Nos. 1 and 2 on said plan; thence along said dividing line, South 23 degrees 24 minutes 00 seconds East, U~Ln lad ~•i.. AU~t one hundred fifteen and zero one-hundredths (115.00) feet to a point on the northern line of eelaire Drive, the place of BEGINNING. BEING Lot No. 1, Block "R", on Plan No. 5 of Shireman Manor Extension, said Plan being recorded in the Cumberland County Recorder of Deeds Office in Plan Book 20, Page 75. HAVING ERECTED THEREON a brick and .aluminum dwelling house with attached garage, being known and numbered as 203 Belaire Drive, Shiremanstown, Pennsylvania. BEING the same premises which Clyde E. D'e Barr and Sandra J. De Barr, husband and wife, by deed dated August 13, 1973 and re- corded November 26, 1965 in the Cumberland County Recanted and Deeds Office in Deed Book P Volume 31, Paqe 616, q conveyed unto Ervin L. Heishman and Ruth R. Heishman, husband and wife. .The said Ervin L. Heishman died June 27, 1987, whereupon full and complete title to the within described real estate became vested solely in Ruth R. Heishman, the Grantor herein. UNDER AND SUBJECT, NEVERTHELESS, to a 20 foot drainage easement along the eastern property line, said easement being wore fully shown on Plan No. 5 aforesaid, and to restrictions as set forth in the Cumberland County Recorder of Deeds Office in Miscella- neous Book 167, Page 435 and to amended restrictions as set forth in Miscellaneous Book 159, Page 685. THIS conveyance is a transfer from parent to parent and child and is, therefore, exempt from the payment of realty transfer taxes. AND the said Grantor hereby covenants and agrees that she will warrant specially the property hereby conveyed. IN WITNESS WIIF,REOF,said Grantor has hereunto set her hand and seal the day and year first above written. 9{~ned, Sealed aid Defivercd }n tfie Prnence of ~~ C L'/.G7/.C (iI /~4FY~'~~'y~ (SEAL) : f/ RUTH R. HEISHMAN ~ocm i3~ r.:t 68~i COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this, the 1(~I~ day of r~~f C~l 1999 , before me, ' the undersigned officer, personalty appeared RUTH R:. BEISHMAN, known to me {or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and offici ~ytu +i~"` seal. ' •,a,:-i:r.;.e::._ _ ::•,7'•. n' b, i!• rn o r Public ~ -- ~~~ ~'~;~• ~ ~. _.r 111 .:: y ;~~ ~~~w:.. L, .. r~ ~, My Commission Expires. >~f.,,~ .,;~j•:~,~~~.•,`•• • ~ _ ... r-1 Noterid Sedala.y i~ i ; ~ ~ { ~ Pao 7Wp, ~Cama c . a ,^ t ` ' My Cammhilon ExpVes /prll 6. 1M`t t C: 1:1 . r^~ " ~ OJ I do hereby certify that the precise residence and complete post office address of the within named grantees is 203 Belaire Drive, Shiremanstown, Pennsylvania 17011. yua.Y~ck. lp , 19 ~ ~ m' do +~/ Ja es D. B ga , Esquire N.T.S. Attorney/A en for Gxantees COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND tt RECORDED on this I, day of Gna~e~~ , I9 ~ , in the Reco der's Office of the said County, in Deed Book V1'S" Page `~,rj iven under..,,~~.nX_ ~nd.the seal of the said office, the date above writt~3r' r *~' ~'t . °.::~lti•* ^~~n~Ev~;x'k.* ~~j~ , Recorder. 't51~.,~' -`'dam ~:a.:w:MSr'c~. •. `' ~~- ,..: _ _ BOOK S.9J`' P~~Ct ~~ ,~--~ l axllti Kesult lletalls ra~cicii Tlara;lP~ Rac„lrc fnr Parcel 4~-23-0557-160. in the 2010 Tax Assessment Database DistrictNo 48 Parcel ID 48-23-0557-160. MapSuffix HouseNo 203 Direction Street BELAIRE DRIVE Owner! HEISI3MAN, RUTH R & FRANCES L C/O PropType R PropDesc LivArea 1682 CurLandVal 55000 CurImpVal 136800 CurTotVal 191800 CurPrefVal Acreage .33 C1GrnStat TaxEx 1 SaleAmt 1 SaleMo 03 SaleDa 11 SaleCe 19 SaleYr 99 DeedBkPage 00195-00687 YearBlt 1972 HF File Date 11/12/2004 HF Approval_Status A http://taxdb.ccpa.net/details.asp?id=48-23-0557-160.&dbselect=l 4/11!2011 Rev-1510 tJC+ (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF 21-11-0219 Heishman, Ruth R. This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY INCLUDE NAME OF TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND TE DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST (I EXCLUSION F APPLICABLE) TAXABLE VALUE NUMBER . THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTA 1 Genworth Financial -Annuity No. TN4073811. The 74,644.61 74,644.61 Decedent's four (4) children are the named beneficiaries of this Annuity. 2 Wachovia Bank -Certificate of Deposit No. 3,828.92 3,828.92 XXXXX5502. Date of death balance $3,815.28. Accrued Interest $13.64. The POD beneficiary of this Certificate of Deposit is Tyler M. Heishman. 3 Wachovia Bank -Certificate of Deposit No. 3,828.92 3,828.92 XXXXX5537. Date of death balance $3,815.28. Accrued Interest $13.64. The POD beneficiary of this Certificate of Deposit is Erin L. Henchbarger. 4 Wachovia Bank -Certificate of Deposit No. 3,828.92 3,828.92 XXXXX5550. Date of death balance $3,815.28. Accrued Interest $13.64. The POD beneficiary of this Certificate of Deposit is Emma L. Heishman. 5 Wachovia Bank -Certificate of Deposit No. 1,914.46 1,914.46 XXXXX5557. Date of death balance $1,907.64. Accrued Interest $6.82. The POD beneficiary of this Certificate of Deposit is Zachary f. Heishman. 6 Wachovia Bank -Certificate of Deposit No. 1,914.46 1,914.46 XXXXX5561. Date of death balance $1,907.64. Accrued Interest $6.82. The POD beneficiary of this Certificate of Deposit is Samual S. Heishman. TOTAL (Also enter on Line 7, Recapitulation) I 89,960.29 (If more space is needed, additional pages of the same size) Form PA-1500 Schedule G (Rev. 6-9P1 Copyright (c) 2002 form software only The Lackner Group, Inc. .\ ~!. :~ f t~~ Genworth Financial March 4, 2011 James D. Boger Attorney At Law One West Main St Shiremanst 17011 Delivers also via fax: 17-737-086 Re: Deceased: Ruth R. Heishman Contract Number. TN4073811 Claim Number: LV2011 DC001241 Dear Sir or Madam: Genworth Life & Annuity Insuranra Company FO Box4~014 Lynchburg, Vq pg5~6-4014 BQO 635.Bp56 genworth-c4m Please accept. our condolences an the death of Ruth R. Heishman. The designated beneficiaries of the above referenced annuity are Frances L. Heishman, Paul Heishman, Joanne E. Henchbarger, and Carol A. Heishman. There are various settlement options available. Please see the enclosed Deferred Annuity Glairn Fvrm explaining these options and requirements for each option. We request th9t each beneficiary complete the form indicating the option elected and return it tv us as soon as possible, A certified raised seal death certificate is also required. • We were first notified ofi the death on 03!02/2011. Funds in separate accounts have been moved into the Money Market Fund as shown vn the contract data pages. • The assets will remain in the Money Market fund un#il due proof of death and any required forms are received. • ~ The amount of the claim will be calculated as of the first valuation day as of which we have received proof of death and required documents. Wa also request that each beneficiary review the enclosed information regarding the Secure Access Account. Secure Access is a lump sum payment option. Certain states require that the beneficiary affirmatively elect Secure Access as their option. Please see the Deferred Annuity Claim Farm for additional details and instructions on how to properly complete the Settlement Option section of the Form. The value of the contract as of the date of death, 07/24/2011 is $ 74,644.61. Please let us know if you have any questions concerning any of these options, You may contact us at 800 635.8056, Monday -Friday 8:30 a.m. to 5:00 p.m. Eastern Time. Sincerely, Claim Representative/crh Enclosures CC: Wachovia Ins Agency Inc Attn: Jay Thomas Ravlish 6416 Carlisle Pike 2100 Mechanicsburg, PA 17050 rax Transmission ~/ l~/ Lull ~ : ~l ; ~u P,ri rA~~. li oue: r dx ~~i v~r Facsimile Transmission Wachovia Corporation From: Fax Number: Voice Phone: To: Company: Fax Number: 7177372086 Voice Phone: CC: Fax Notes: ATTN JAMES BOGAR, THE IRA IN QUESTION IS TIED TO A BROKERAGE ACCOUNT AND SHOULD BE SENT SEPARATELY. YOUR REQUEST HAS BEEN FORWARDED TO WACHOVIA SECURITIES FOR A RESPONSE. THANK YOU. JENNIFER STRAUB Date and time of transmission: Tuesday, March 15, 2011 8:31:08 AM Numbe,T of pages including this cover sheet: 04 A RightFAX® Communicated Document r~.x 1ralzsmission ~il~iz~ll ~:~1:4u AM L~AI.?!r ~iuu~ rax server ~'~~ Wachovia Bank Balance Confirniafion Services P O Bos 40028 Roanoke, VA 24022 February 28, 2D 11 JAMES D BOGAR ** Reference ID: 3298420 SUBJECT: Verification / Confirmation of Account and Balance Information provided for: Customer: RIITH R HEISHMAN (SSN# XXX-XX-8895) Date of Death: January Z4, 2011 Deposit Account Information Accouirt Account Date cf Death Avernge Balance Date Maturity Interest Accrued YTD Date Type Number Balance Opened Date Rate IrAerest Irrterest Paid Closed ERTIFiCATE OF 502 $3,815.28 9/7!2005 9/7/2013 $13.64 $0.00 EPOSIT EGAL TITLE: RUTH R HEISHMAN ~D TYLER M HEISHMAN ERTIFICATE OF 537 $3,815.28 9/7/2005 9/712013 $13.64 $0.00 EPOSIT EGAL TITLE: RUTH R HEISHMAN ~D ERIN L HENCHBARGER ERTIFICATE OF SSO EPOSIT EGAL TITI E: RUTH R HEISHMAN ~D EMMA L HIISHMAN $3,815.28 9/7P2005 9/7/2013 $13.64 $0.00 ERTIFICATEOF 557 $1,907.64 9Y7l2005 9/7/2013 $6.82 $0.00 EPOSIT EGAL TITLE: RUTH R HEISHMAN ~D ZACHARY I HEISHMAN ERTIFICATE OF ' 561 $1,907.64 9/712005 9M/2013 $6.82 $0.00 EPOSIT EGAL TITLE: RUTH R HEISHMAN 7D SAMUAL S HEISHMAN Page t of 3 Fax ~1~ransmi~5ion 3/15/2011 8:31:40 AM PAGE :~/UU4 rax Server Reference ID: 3298420 ~~'~ HECKING }~~'7L8431 $3,350.91 1/28/1992 $0.08 $0.20 2/18/2011 EGAL TITT E: RLTI'H R HEISHMAN EASING BALANCE: $3318.71 LIECKING ~+'70,'30L'7~"7~8164 $3,076.31 It7/2010 $0.03 $0.05 2/18/2011 EGAL TITLE: RUTH R HEISHMAN EASING BALANCE: $3079.38 :A ~LaLtt7~4971 $12,737.96 1/11J2006 $8.29 $0.00 EGAL TITLE: RUTH R HEISHMAN ~rBeneficiary Chun Form information, please call 1(866)786890. :.A 344 $0.00 9/21/2005 $0.00 $0.00 EGAL TTI7 E: RU'T'H A HEISIiMAN IIS ACCOUNT IS TIED TO A BROKERAGE ACCOUNT. WE DO NOT HAVE ACCESS TO THAT INFORMATION AND IF SHOULD FOLLOW SEPARATELY. ~rBeneficiary Chun Form information, please call 1(866)786-4840. WINGS h~~6039 $321.20 1/2/1950 $0.01 $0.01 2/18/2011 EGAL Ti1'I.E: RUTH R HEISHMAN LASING BALANCE: $321.21 Other Account Information Account Accourrt Date of Balance Date Date Led~r Collected Type Number Opened Closed ~VNUTI'Y AaCKJOO~D0;3811 ENWORTH - For information regarding annuities, please call 800.521.8884 NNiIl'I'Y 870 RANSAMERICA -For information regarding annuities, please call 1-800-851-7555 aFE DEPOSIT I~0260 11/3/2003 OX EGAL TITLE: RUTH R HEISHMAN OCATION: AMP HILL 205 TRINDLE RD AMP HILL PA 17011 Other Illi'ormation ne or more of the requested accourrls have converted to Wells Fargo Barilc and a response on those acccurds will follow under separate cover. Page 2 of 3 Fax Transmission 3/15/2011 8:31:40 AM PAGE 4/004 Fax Server ~~~~ Reference ID: 3298420 CAP, BROKERAGE and SELF-DIRECTED IRA ACCOUNTS HAVE BEEN CONVERTED TO WACHOVIA SECURITIES. YOUR REQUEST HAS BEEN FORWARDED FOR PROCESSING and WILL BE MAII.ED UNDER SEPARATE COVER FOR QUESTIONS REGARDING CAP, BROKERAGE, or SELF-DIRECTED IRA ACCOUNTS PLEASE CALL WACHOVIA SECURITIES at 1-S66-S74-2717. * Date of death balance does notinclude a«xued interest * If date of death occurs on a weela;nd or a holiday, date of death balance does not include any transactions that were made during that time period . ~ s+~~ Jennifer Straub Servieenter Associate Phone: (540)563-7323 ja;ja BY aooepting this information, the recipient thereof represanb and warrants to Wells Fargo Bank, N.A ("Wells Fargo"), that the recipient is authorized by the customer to receive lawfidly this infi~mratim. The recipient agrees that it will not disclose this information to arty third party, unless compelled Oo do so by legal process, and that it will ]awfiilly use this information The recipient aclvwwledges [hat Wells Fargo does not represent and warrant [hat the information is complete and accurate. The recipient further aclmowledges that the information may not disclose the entire relationship between customer and Welk Fargo. The information is subject to change without notice to the racipiertt The recipient agrees b indemnify, d~'end, and hold Walls Fargo hamiless from and against arty clavn resulting from the disclosure and use of the information by the recipient or firm the breach by the recipient of arty ageement, representation, or waaanty contained herein Wachavia Bank and Wachovia Bank of Delaware are divisions of Wells Fargr Bank, N.A Page 3 of 3 REV-1151 EX+(10-06) COM INHEWRITANCE TAX RETURNANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Heishman, Ruth R. 21-11-0219 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached ~ 13,715.38 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(sl Commission oaid 2, Attorney's Fees Bogar 8c Hipp Law Offices 12,180.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees 343.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,063.69 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 27,302.57 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-~~; SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Heishman, Ruth R. 21-11-0219 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Barbara Lee -Minister's honorarium for funeral 400.00 2 Hoffman Roth Funeral Home -Funeral bill 9,725.30 3 Sunnyside -Funeral luncheon 614.08 4 Westminster Cemetery 2,976.00 H-A 13,715.38 5 Other Administrative Costs Bonnie Miller, Treasurer - 2010 Per Capita Tax 9.80 6 Connor Rich Associates -Medical bill 85.51 7 Metro Bank -Return check fee 12.00 8 Moffat Heart and Vascular Group -Medical bill 66.82 9 Quantum Imaging and Therapeutic Associates -Medical bill 8.77 10 RESERVES: -Costs to conclude administration of Estate including filing fees for PA 850.00 Inheritance Tax Return and Inventory, 2011 Personal Income Tax Returns and payment of taxes and Fiduciary Income Tax Returns 11 U.S. Postal Service -Certified mail to Wells Fargo Advisors 5.79 12 Wells Fargo -Estate valuation fee 25.00 H-B7 1,063.69 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6 ~~;j SCHEDULE J COMIN~ERIETANCE~~RETURNANIA T DECEDENT BENEFICIARIES RESIDEN ESTATE OF FILE NUMBER Heishman, Ruth R. 21-11-0219 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Tr ste I TAXABLE DISTRIBUTIONS [include outright spousal ~ distributions, and transfers under Sec. 9116 a 1.2 Carl A. Heishman Son Twenty-five 6 Wendover Place percent of rest, Bridgewater, NJ 08807 residue and remainder Frances L. Heishman Daughter Twenty-five 203 Belaire Drive percent of rest, Shiremanstown, PA 17011 residue and remainder Paul L. Heishman Son Twenty-five 103 Bucher Hill percent of rest, Boiling Springs, PA 17007 residue and remainder Joanne E. Henchbarger Daughter Twenty-five 15531 Eagle Tavern Lane percent of rest, Centreville, VA 20120 residue and remainder Total Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) cp - __, _. ~; ,' ~~x ~i11 ~zn~ ~P~t ~zmP ~~~-r r~ _; ;/ ~ _. ` OF ~ =, ~ c? _ .~ RUTH R. HEISAMAN `:' I, RUTH R. HEISHMAN, of Lower Allen Township, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate, of whatever nature and wherever situate unto my children, FRANCES L. HEISHMAN, PAUL L. HEISHMAN, JOANNE E. HENCHBARGER and CARL A. HEISHMAN, or their issue, per stirpes, in equal shares. SECOND: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all .property, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivision, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for ~~ investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. THIRD: I direct that all inheritance, estate, transfer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the princi- pal of my residuary estate. FOURTH: All interests hereunder, whether principal or income, which undistributed and in the possession of the fiduci- aries acting hereunder, even though vested or distributable, shall '~ not be subject to attachment, execution or sequestration for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, convey- ance or anticipation. FIFTH: I nominate and appoint my children, FRANCES L. HEISHMAN, PRUL L. HEISHMAN, JOANNE E. HENCHBARGER and CARL A. HEISHMAN, or the survivor thereof, Co-Executors of this, my Last 2 Will and Testament. I direct that my Executor or Executrix, as the case may be, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this ~~day of ~~4-~~-ti , 1987. /~`-~f%~L~Z,~~rrc/' ( SEAL ) Ruth R. Heishman Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address ~~ ~~ Address 3