HomeMy WebLinkAbout06-07-11 (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 4 7 5
Harrisbur PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 7 9 1 2 3 7 3 2 0 3 2 3 2 0 1 1 0 8 2 9 1 9 1 4
Suffix Decedent's First Name MI
Decedent's Last Name
A D A M S R O B E R T C
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
t
l R
^
2. Supplemental Return
^
3. Remainder Return (date of death
urn
e
1. Ori fina
0 9 prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required
death after 12-12-82)
intained a Living Trust
t M
d 8. Total Number of Safe Deposit Boxes
6. Decedent Died Testate ^ a
en
7. Dece
(Attach Copy of Will)
Litigation Proceeds Received
^ 9
^ (Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
^
h SchaO) nder Sec. 9113(A)
11 ~ Att
. between 12-31-91 and 1-1-95) ac
BE DIRECTED T0:
L
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIA
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ep
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D
ber
ne Num
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ime Tel
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Name
7 1 7 2 4 9 2 3 5 3
R O G E R B I R W I N ~~.,
First line of address
6 0 W E S T
Second line of address
City or Post Office
C A R L I S L E
State ZIP Code
OF WILLS U~ONLY
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Correspondent's a-mail address:
it s trueecorrect andeclomp ete.cDeclahation of p eparer other than the pe solnal representatnre is based on a information of wh ch preparer has any knowledge belief,
DATE
SI NAT E OF PERSON.R ON IBLE FO ILING RETURN j _ ` / /
ADDRESS EAST BERLIN PA 17316
384 MEADE DRIVE DArTE.
SIGNATURE REPARER OTHER THAI REPRESENTATIVE / '~ r~
ADDRESS P A 17 013
60 WEST POMFRET STREET CARLISLE
PLEASE USE ORIGINAL FORM ONLY
1505610140
P O M F R E T S T R E E T
Side 1
1505610140
~~{
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: R O B E R T C• ADAMS 1 7 9 1 2 3 7 3 2
RECAPITULATION
1. Real Estate (Schedule A) ................................... . . ...... 1. -
2. Stocks and Bonds (Schedule B) ...................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .......................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . , ..... 6.
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested ....... 7.
8. Total Gross Assets (total Lines 1 through 7) ........................... 8.
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9•
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10.
11. Total Deductions (total Lines 9 and 10) ............................... 11.
12, Net Value of Estate (Line 8 minus Line 11) ............................ 12.
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.
3 4 0 7 1. 1 8
3 0 6 7 0. 9 5
6 4 7 4 2. 1 3
6 6 2 5. 3 9
4 1 4. 8 7
7 0 4 0. 2 6
5 7 7 0 1. 8 7
5 7 7 0 1. 8 7
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)X.0 _ 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 5 7 7 0 1 8 7 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18.
19. TAX DUE ......................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
o. 0 0
2 5 9 6. 5 8
0. 0 0
0. 0 0
2 5 9 6. 5 8
Side 2
1505610240 1505610240 J
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
ROBERT C. ADAMS 21 11 0475
Decedent's Name Page 1 File Number
Correspondents
Name
R O G E R B
I R W I N
Daytime Telephone Number
7 1 7 2 4 9 2 3 5 3
First line of address
6 0 W E S T
Second line of address
City or Post Office
C A R L I S L E
Correspondent's a-mail address
P O M F R E T
S T R E E T
State ZIP Code
P A 1 7 0 1 3
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.
SI A RE OF PERSON RESRONS~E FOfj FILING RETURN , DALE
ADDRESS / '
57 DERBYSHIRE DRIVE CARLISLE PA 17013
REV-150p EX Page 3
Decedent's Complete Address:
File Number
21 11 0475
DECEDENT'S NAME
ROBERT C. ADAMS
STREET ADDRESS - -"-
384 LAKE MEADE DRIVE
-- --- -
CITY STATE I ZIP
EAST BERLIN PA 17316
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount 129.83
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.
(1) 2,596.58
Total Credits (A + s) (2) 129.83
(3)
(4) 0.00
(5)
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 : ................................................................. ..... ^ ^X
b. retain the right to designate who shall use the property transferred or its income; .......................... ..... ^ ^X
c. retain a reversionary interest; or ........................................................................................... ..... ^
d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ ^X
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................................................................. ..... ^ ^X
3. Did decedent own an "intrust for" orpayable-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? ............................................................................................. ..... ^ ^Q
2,466.75
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
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, undE
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-15Q3 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ROBERT C. ADAMS 21 11 0475
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. INVESCO VAN KAMPEN U.S. MORTGAGE FUND - CLASS A 34,071.18
FUND/ACCOUNT #1774/0000310256
TOTAL (Also enter on line 2, Recapitulation) ~ $ 34,071.1
(If more space is needed, insert additional sheets of the same size)
REV-~ 508 EX + (6-98~
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ROBERT C. ADAMS 21 11 0475
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. ORRSTOWN BANK -CHECKING ACCOUNT #146001732 19,682.35
2. ORRSTOWN BANK -SAVINGS ACCOUNT #746000429 754.67
3. OTRRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000035714 10,233.93
TOTAL (Also enter on line 5, Recapitulation) ~ $ 30
(If more space is needed, insert additional sheets 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 C. ADAMS 21 11 0475
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1, EWING FUNERAL BROTHERS
2. VFW -FUNERAL LUNCHEON
B
2.
3.
4.
5.
6.
7.
8
9
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State
Year(s) Commission Paid:
AttomeyFees: IRWIN & McKNIGHT, P.C.
Family Exemption: (If decedents address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State
Relationship of Claimant to Decedent
Probate Fees: REGISTER OF WILLS
Accountant Fees:
Tax Retum Preparer Fees: PATRICIA A. ROSENDALE, CPA
REGISTER OF WILLS -FILING FEE
CUMBERLAND LAW JOURNAL -ESTATE NOTICE
THE SENTINEL -ESTATE NOTICE
141.50
425.00
30.00
75.00
198.16
TOTAL (Also enter on Line 9, Recapitulation) I $ 6.625.39
ZIP
855.73
900.00
4,000.00
ZIP
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ROBERT C. ADAMS 21 11 0475
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. CONTINUING CARE RX -MEDICAL 73.87
2. PINKER & ASSOC. -MEDICAL 41.00
3. OUTSTANDING CHECK #1140 PAYABLE TO DOTTIE BECKER 300.00
TOTAL (Also enter on Line 10, Recapitulation) I $ 414.87
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ROBERT C. ADAMS 21 11 0475
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. BARBARA L. NICKEL Lineal 28,850.94
384 MEADE DRIVE
EAST BERLIN, PA 17316
2. DOROTHY A. BECKER Lineal 28,850.93
57 DERBYSHIRE DRIVE
CARLISLE, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
I, ROBERT C. ADAMS, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,
publish and declare this to be my Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
1. I direct my Co-Executrices to pay all of my debts, funeral and administrative expenses
as soon as convenient after my decease. Furthermore, I direct that all state, inheritance,
succession and other death taxes imposed or payable by reason of my death and interest and
penalties thereon with respect to all property composing of my gross estate for death tax
purposes, whether or not such property passes under this Will, shall be paid by the Co-
Executrices of my estate.
2. My Co-Executrices may, at their discretion, compromise claims, borrow money, retain
property for such length of time as they may deem proper; lease and sell property for such prices,
on such terms, at public or private sales, as they may deem proper; and invest estate property and
income without restriction to legal investments unless otherwise provided hereunder.
3. I authorize and empower my Co-Executrices to sell any realty and/or personalty owned
by me at my death and not specifically devised or bequeathed herein, at public or private sale or
sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could
do if living. My Co-Executrices are authorized and empowered to engage in any business in
which I may be engaged at my death, for such period of time after my death as seems expedient
to said Co-Executrices.
7386
4. I give, devise and bequeath all of my estate of whatever nature and wherever situate to
my two (2) children, BARBARA L. NICKEL and DOROTHY A. BECKER, share and share
alike, the child or children of any deceased child taking the shaze their pazent would have taken if
living.
5. I nominate and appoint BARBARA L. NICKEL and DOROTHY A. BECKER to
be the Co-Executrices of this my Last Will and Testament.
6. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty
(60) days.
7. No Co-Executrix acting hereunder shall be required to post bond or enter security in
this or any other jurisdiction.
8. No beneficiary may assign, anticipate or pledge her or his interest in any income or
principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or
otherwise reach any such interest.
9. I hereby suggest that my personal representatives retain the services of Irwin &
McKnight, P.C. as attorneys in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto sef my hand and seal this ~~-""~ day of
January 2010.
n .s,2-,.?i` ~`'_ ~r~- ~ ~ (SEAL)
ROBERT C. ADAMS
2
Signed, sealed, published and declared by ROBERT C. ADAMS, the above-named
Testator, as and for his Last Will and Testament, in our presence, who, at his request, in his
presence and in the presence of each other have hereunto set our names as subscribing witnesses.
%_- ,
~""
` ~~{{~~ ~ ,;
3
ACKNOWLEDGMENT AND AFFIDAVIT
WE, ROBERT C. ADAMS, KAREN S. NOEL and SHARON L. SCHWALM, the
Testator and witnesses respectively, whose names aze signed to the foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority that the Testator signed and
executed the instrument as his Last Will and that he had signed willingly, and that he executed it
as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in
the presence and heazing of the Testator, signed the Will as a witness and that to the best of their
knowledge the Testator was, at that time, eighteen yeazs of age or older, of sound mind and under
no constraint or undue influence.
C
ROBERT C. ADAMS
N S. NOEL `~,
SHARON L. SCHWALM
COMMONWEALTH OF PENNSYLVANIA ;
. SS:
COUNTY OF CUMBERLAND _
Subscribed, sworn to and acknowledged before me by ROBERT C. ADAMS, the
Testator herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L.
SCHWALM, witnesses, this LL"~ day of January 2010.
~ .~c~
Public
Notarial Seal
Roger B. Irwin, Notary Public
Carlisle Boro, Cumberland County
IY Commission Expires pay, 3, 2012
4
April 19, 2011
Roger B. Irwin
Irwin & McKnight, P.C.
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
Fax: 249-6354
Re: Estate of Robert C. Adams
Social Security Number 179-12-3732
Date of Death 3/23/11
IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE
FOLLOWIlVG ACCOUNTS WITH ORRSTOWN BANK:
CHECKING ACCOUNT
Account No.-
Account Type-
Date Opened-
Joint Account (name/date)-.
Balance-
Accrued Interest-
SAVINGS ACCOUNT
Account No.-
Account Type-
Date Opened-
Joint Account (name/date)-
Balance-
Accrued Interest-
146001732
50+ Interest Checking
11/13/09
None- - - - -- - - - - -- -- ..
$19,682.35
$0.06
746000429
Statement Savings
11/13/09
None
$754.67 - -_ :.
$0.26
2695 Philadelphia Avenue
Chambersburg, PA 17201
1.888.ORRSTOWN
- vxxa lv~ly
B~~
- A Tradition of Excellence
CERTIFICATE OF DEPOSIT
Account No.-
Account Type-
Date Opened-
Joint Account (name/date)-
Balance-
Accrued Interest-
4000035714
12-17 Month Growth CD
11/13/09
None
$10,233.93
$2.53
Best Regards,
f~ • WC~ ~
J' 1 R. Worthington
Deposit Processing Clerk
Invesco
PERIODIC STATEMENT
January 01, 2011- March 31, 2011
>05478 6887214 OD1 008116
ROBERT C ADAMS
C/O BARBARA NICKEL
384 LAKE MEADE DR
EAST BERLIN PA 17316-9368
Your Financial Advisor:
LOGUE PATRICK T
LINCOLN INVESTMENT PLANNING
LINCOLN INVESTMENT PLANNING
4 CENTER SQ
HANOVER PA 17331-3001
PHONE: 717-633-5761
Account:. 0000310256
PORTFOLIO SUMMARY
Value on 12131110 $33,785.05
Additions $0.00
Withdrawals $0.00
Exchange In $0.00
Exchange Out $0.00
Transfer of Shares $0.00
Change in Market Value $286.13
Value on 03131111 $34,071.18
For More Information on Your Invescos"" Account:
Contact Your Financial Advisor
• Visit us online at www.invesco.com
• Talk to a Client Services Representative at
800-959-4246 from 7:00 a.m. to 6:00 p.m. CT
Tired of finding room to file these statements? Then go paperless with ease using e-delivery and get your Invesco statements, daily transaction confirmations,
tax forms, prospectuses and annual and semiannual reports online via email. You'll still receive all the same service and shareholder information you've come
expect, just with an electronic service that's all about EEEEs: environmentally friendly, economical, efficient and easy. Once you sign up, we'll email you a link t
access your documents, and you'll no longer receive paper copies by mail. To enroll, log in to your Invesco account at invesco.com/us, click on the "Service
Center" tab and select "Register for eDelivery." You can cancel the service and resume receiving paper copies at any time by going to the same Web page.
After careful consideration, the Invesco Funds Board of Trustees has approved a reorganization of our U.S. mutual fund lineup to reduce overlap and enhance
efficiency across our product offerings. This is pending shareholder approval. You are encouraged to vote your Invesco funds proxy, which was recently mailer
to shareholders. You may vote by attending the shareholder meeting in person, signing and returning your proxy card in its enclosed postage paid envelope,
calling 1 800 337 3503 or visiting invesco.com/proxy.
PORTFOLIO ALLOCATION
BY FUND
PORTFOLIO ALLOCATION
BY_INVESTMENT CATEGORY
You are 100% invested in INVESCO VAN KAMPEN U.S. MORTGAGE
FUND -CLASS A
You are 100% invested in TAXABLE FIXED-INCOME FUNDS
These Invesco funds are also available.
/ TARGET MATURITY FUNDS
/ ALLOCATION SOLUTIONS
/ INTERNATIONAL/GLOBAL EQUITY FUNDS
/ DOMESTIC EQUITY FUNDS
/ TAX-FREE FIXED-INCOME FUNDS
/ SECTOR EQUITY FUNDS
/ ALTERNATIVE FUNDS
Important: This account statement reflects financial transactions for the period indicated. Carefully review all of the information to verify the
accuracy of the transactions. Please notify us immediately if there is an error. If you fail to notify us of an error within 30 days of this statement,
'you will be deemed to have ratified each transaction.
..~.-,o ~oe~.,,. ,,,,,~« ,,.,,,,o. ,,,,,,,,,,,,,,,,,,~
Invesco
PERIODIC STATEMENT
January 01, 2011 -March 31, 2011
Page 2 of 3
As part of the Energy Improvement and Extension Act of 2008, mutual fund companies will be required to provide cost basis reporting to the Internal
Revenue Service (IRS) and to taxpayers for mutual fund shares purchased after January 1, 2012. Invesco is already preparing to comply with the new
requirements, which will compliment the cost basis services currently offered by your fund. We will continue to periodically share information related to the
cost basis changes in your future statements.
PORTFOLIO BREAKDOWN
Fund Name
Fund Symbol
Value on Additions Withdrawals Net Transfer Change in Value on
12131110 Exchanges of Shares Market Value 03131111
Non-Retirement Accounts __
INVESCO VAN KAMPEN US. MORTGAGE FUND -CLASS A
VKMGX
$33,785.05 $0.00 $0.00 $0.00 $0.00 $286.13 $34,071.18
Total Non-Retirement Accounts
$0.00 $0.00 $0.00 $0.00 $286.13 $34,071.18
Totals:
$33,785.05 $0.00 $0.00 $0.00 $0.00 $286.13 $34,071.18
INDIVIDUAL ACCOUNT TRANSACTIONS
Non-Retirement Accounts
INVESCO VAN KAMPEN U.S. MORTGAGE FUND - CLASS A FundlAccount: 177410000310256
ROBERT C ADAMS
Post Trade Transaction Dollar Share Transaction Ending
Date Date Description Amount Price Shares Shares
Value on 12131110 $33,785.05 $13.00 2,598.850
01131111 01/31111 DIVIDEND REINVEST @NAV $90.52 $13.00 6.963 2,605.813
02128/11 02128111 DIVIDEND REINVEST @NAV $91.28 $13.02 7.011 2,612.824
03131111 03131/11 DIVIDEND REINVEST @NAV $104.47 $13.00 8.036 2,620.860
Value on 03131111 $34,071.18 $13.00 2,620.860
PERIOD-TO-DATE INCOME SUMMARY
Fund Name Dividends and Long Term
ST Capital Gains Capital Gains
INVESCO VAN ICAMPEN U.S. MORTGAGE FUND - CLASS A $286.27 $0.00
Period-to-Date Total $286.27 $0.00
ACCOUNT OPTIONS
Fund Name Telephone Redemption Dividends Systematic Automatic Automatic
Telephone Exchange Capital Gains Withdrawal Investments Exchange
INVESCO VAN KAMPEN U.S. MORTGAGE FUND - CLASS A Yes Reinvest No No No
Yes Reinvest
05478 6887214 010957 021086 00002/00002
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
March 27, 2011
Barbara L. Nickel !3
384 Lake Meade Drive ,~ ~
East Berlin, PA 17316 ~~~ z p ~ ~
~/~~c
The Funeral Service for Mr. Robert C. Adams
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff , $1840.00
Embalming, $875.00
Dressing, Casketing, Cosmo etc. $290.00
2. FACILITIES AND SERVICES
One day service viewing/funeral $890.00
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home, $275.00
Hearse (Casket Coach) $250.00
Lead car/Clergy $125.00
Utility vehicle for DC filing, $125.00
FUNERAL HOME SERVICE CHARGES $4670.00
SELECTED MERCHANDISE:
Acknowledgement cards, $10.00
Register Book(s) $40.00
Memorial folders , $75.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED $4795.00
Cash Advances
Opening Grave XTRA for SAT PM $375.00
Clergy/Nfass Offering, $100.00
Certified Copies of the Death Certificate , $18.00
Flowers . $159.00
The Sentinel Obit with Photo $213.55
The Chambersburg Public Opinion, $152.50
The Honor Guard , $50.00
Video Tribute , $75.00
The Patriot News Obit with Photo , $377.00
Organist (Kenneth Walker) , $100.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES . $1620.05
Total
Total Cost $6415.05
SUB-TOTAL $6415.05 _ ~~` _ ~~~
INITIAL PAYMENT /DISCOUNT /CREDITS 5459.32 -'~`'~~J
TOTAL AMOUNT DUE $955.73
The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum. 1 a ~_ « - ~Q,(Fs~,'l ~a~,,,,,'r~ ~C
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