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HomeMy WebLinkAbout06-24-11 (2)~ 1505610101 REV-1500 Ex C°1.1°' ~ OFFICIAL USE ONLY enns Lvania PA Department of Revenue p Y ~`""ArME~TOFAF~E~~F County Code Year _ File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 ~ i ~ ,~{ ~ ;.~- ~ < Harrisburg, PA 1'7128-0601 RESIDENT D ECEDENT ~:~~ I _._. - `,- ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 050-30-9771 03/28/2011 01 /12/1921 Decedent's Last Name Suffix Decedent's First Name MI OSTRANDER EVA M (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 Clb 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) (~ 3. Remainder Return (daate of death prior to 12-13-82) O 5. Federal Estate Tax Return Required D 8. Total Number of Safe Deposit Boxes O 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: Name Daytime Telephone Number Andrew H. Shaw, Esquire (717) 243-7135 ..., C7 ,..:;~ First line of address 200 S. Spring Garden St Second line of address Suite 11 City or Post Office Carlisle Correspondent's a-mail address: andrewia~aShaWIaW.COm State ZIP Code PA 17013 REGISTER OF~09L~ USE ONLtY ~ ' .C 7 =-7~3 .1 r- 7 Viz C: . , ~; ~ ~: ~ : ~n t~.a ?~' DATE FILED I^v ~,) ;'T'1 rr-~C7 ~~e ~ ~~ ~! ~-, ~::7 -- ~ -., c;'~ ~~ , ...,~ ~.~ ."'7 ~•~ 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. S ATURE OF RSO ES ONSIBLE F FILING RETURN DP;fE -;~ ~ i ~ ADDRE 1116 Hillside Drive . a ~sle, PA 17013 _ SIGN RE ~F"RR A E ER THAN REPRESENTATIVE DAfE .~' ';~~~ AD RESS 200 S. Spring Garden Street, Suite 11, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY L 1505610101 Side 1 150561011 1505610105 REV-1500 EX Decedent's Social ~~ecurity Number ~eceaent's Name: Eva M. Ostrander 050-30-9771 REC APITULATION 1. Real Estate (Schedule A) ............................................ . 1. 0.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 1,505.75 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 0.00 4. Mort a es and Notes Receivable Schedule D 9 9 ( ) ......................... 4. .. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 2,807.94 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 162,453.49 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 64,565.81 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 231,332.99 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 9,053.00 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. 624.12 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 9,677.12 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 221,655.87 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 221,655.87 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 0.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate x .0 45 221,655.87 1g. 9,974.51 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17 0.00 18. Amount of Line 14 taxable 0 00 0 00 . at collateral rate X .15 18 . 19. TAX DUE ....................................................... .. 19. 9,974.51 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 REV-1500 EX Page 3 Decedent's Complete Address: 0.00 DECEDENT'S NAME Eva M. Ostrander STREET ADDRESS 4837 E. Trindle Road CITY Mechanicsburg STATE PA ZII' 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments __ B. Discount 3. Interest 498.73 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. File Number (1) Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. 9,974.51 498.73 9,475.78 9,475.78 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 :................................................................................... ....... ^ Q b. retain the right to designate who shall use the property transferred or its income : ..................................... ....... ^ Q c. retain a reversionary interest; or ................................................................................................................... ....... ^ d. receive the promise for life of either payments, benefits or care? ............................................................... ....... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ 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 is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(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. LAST WILL AND TESTAMENT OF EVA M. OSTRANDER I, Eva M. Ostrander, a resident of the Commonwealth of Pennsylvania, make, publish and declare this to be my Last Will and Testament, revoking all wills and codicils at any time heretofore made by me. I am a dependent of a person who is retired frorr~ the military service of the United States. FIRST: I direct that the expenses of my last illness and funeral, thf; e;xpenses of the administration of my estate, and all estate, inheritance and similar taxes payable; with respect to property included in my estate, whether or not passing under this will, and arty interest or penalties thereon, shall be paid out of my residuary estate, without apportionment a:nd with no right of reimbursement from any recipient of any such property. SECOND: I give all tangible personal property owned by me at the time of my death, including without limitation personal effects, clothing, jewelry, furniture, furnishings, household goods, automobiles and other vehicles, together with all insurance policies relating thereto, to my son Gary G. Ostrander, if he survives me. If Gary G. Ostrander does not survive me, then to Karen L. Ostrander if she shall survive me. If none of the aforesaid beneficiaries shall survive one, then to those of my grandchildren (Ashley N. Ostrander and Brandon O. Ostrander) who survive me, in equal shares. THIRD: I give all the rest, residue and remainder of my property and estate, both real and personal, of whatever kind and wherever located, that I own or to which I shall be in any manner entitled at the time of my death (collectively referred to as my "residuar~~ (;state"), as follows: ~ ~~ . ,,,. :~~ 4.~ ~, (a) If Gary G. Ostrander survives me, to Gary G. Ostrander. ~; ~L `-~ ~~z ~ `1 -- :~:~ __ a ~ . ~_ r~. - -.~ rn ._ r - t (b) If Gary G. Ostrander does not survive me, my residuary estate shall_~`~~~~id ~"`' :; -~, and distributed to Karen L. Ostrander if she shall survive me. If nor~e~ ~;~~=the ~ " aforesaid beneficiaries of m residua estate shall survive me m res~.~ ua_ ~~ estate shall be aid and dist ibuted to those of m randchildren y ~' ~ ~ ~.~,+ .~3 T~ p Y g (Ailey N. ~~~.; ~~ Ostrander and Brandon O. Ostrander) who survive me, in equal shares. (c) If none of the beneficiaries described in clauses (a) and (b) above shall survive me, then I give my residuary estate to those who would take from me as if I were then to die without a will, unmarried and the absolute owner of Amy residuary estate, and a resident of the Commonwealth of Pennsylvania. FOURTH: If any property of my estate vests in absolute ownership in .a minor or incompetent, my Executor, at any time and without court authorization, may: disl:ribute the ~:~... ZYI , C1 0 C whole or any part of such prOpert to education, maintenance and su Y the beneficiary; or use the whole or a guardian, committee or other egal ref r he beneficiary; or distribute the v~ y p~a~r for the health, beneficiary under an p esentative of the beneficia hole or any part to a whom the beneficia Y gifts to minors or transfers to ~'~ °r to a custodian for th ry resides. Evidence of any such dis ors act, or to the e by the person to whom the distributio trlbution or the r person or persons with liability with respect thereto, even th n Is made shall be a full dischar e oeceipt therefor executed is a minor °ugh my Executor ma g f mY Executor from any my Executor may defer the distribution o Y be such person. If such be the beneficiary attains the age o f ei h f the whole or an neficiary for the beneficia g teen (18) years, and ma Y part °f such prOpe~Y until dies before attainin ith all of the powers described in A Y hold the same as ,a separate f g said a e rticle SIXTH hereof. If the beneficland beneficiary. g ~ any balance shall be paid and distrib uted to thf; estate oft e FIFTH: I appoint Ga shall fail to qualify for any reason as ~ G' Ostrander to be m to act for any reason as m mY Executor, or havin Y Executor. If Gary ~~. pstrander y Executor, I appoint Karen L, g qualified shall die, rc;sign or cease no Executor shall be required to file Ostrander as m jurisdiction. or furnish any bond, Buret Y Executor. I direct that y or other security in any SIXTH: I grant to m Pennsylvania Probate, Estates and F• Y Executor all powers conferred on executors under the all powers conferred upon executors lduciaries Code, as amended, or a power to retain, sell at Wherever my Executor ma ny successor thereto otherwise deal with an pkblic or private sale, exchan e Y act. I also rant to rn ~ and g ,grant options on, in ~st and IQY Executor and encumber or Y nd of prOpe~Y~ real or pledge an personal, for cash or on credit; to borrowest, and partition propert Y property to secure loans; to , Y In cash or in kind or pay any 1~, ac money disproportionate amounts of pro ert' partly in kind, and to allocaf di Y °r distribute, divide or or shares, and to determine the air val nd undivided interests in pro ert fferent kinds of property to tax basis; to determine what pro ert uation of the roe p Y among any parts, funds and c p p rty so allocated, with or without re a O of the Internal p Y shall receive basis increases g rd Revenue Code and the amount o f pursuant to Sectic-n 1022 determinations without regard to an (b) exercise all y duty o f im such increases and to powers of an absolute owner o f pro pratrtiality as between different benefic a~e such without consideration; and to em to ldrles; to p y, to compromise and release claims advice. The term. "Executor" p Y attorneys, accountants and othe with or wherever used herein shall mean the r persons for services or or administrator in office from time to ti me. executors, executor, executrix to predecease eE VENTg: I direct that for unless such beneficia purposes of this will a beneficia ry survives me by more than thin ~' shall be deemed IN WITNESS Y days. declare this instrument as m WHEREOF, I, Eva M. y last will and testament thisOstrander ' sign m name and day of publish and 200"x. 1/~i G~- Eva 1VI. Ostrander 2 ~• Y'1, c9, r? _~ The foregoing instrument was signed, published anal declared by Eva M. Ostrander ,the above-named Testatrix, to be her last will and testament in our presence, all being present at the same time, and we, at her request and in her presence and in the presence of each other, have subscribed our names as witnesses on the date above written. having an address at ~'a,~Q~.~~ ~f~ C~6~3 ~~~ I'~~ h~~ ~Ct,u~~rw~ q,v~ having an address at C a~ ~:Sle~ t7o 13 3 ACKNOWLEDGMENT AND AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA, COUNTY OF CUMBERLAND, ss. We, the Testatrix and the witnesses, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix, Eva M. Ostrander ,signed and executed said instrument as her last will and testament in the presence and hearing of the witnesses, and that she had signed willingly, and that she executed it as her free and voluntary act and deed for the purposes therein e~;pressed, and that each of the witnesses at the request of the Testatrix, in the presence and hE;at•ing of the Testatrix and each other, signed the will as witness, and that to the best of his or hear. knowledge the Testatrix was at the time at least eighteen years of age or emancipated, of sound mind and under no constraint, duress, fraud or undue influence. ~~~. ~~~ Eva M. Ostrander Testatrix ~ o~- print: lA~~e~n ~- • ~~~- Witness print: ~4h had Ka a r~ Witness Subscribed, sworn to and acknowledged before me by the said Eva M. Ostra~ier , Tes ix, and subscribed and sworn to before me by the above-named witnesses, this ~ day of , 2007. _- T Not ry Pu lic My commission expires on jl~ ~~ °Zav7 ,~ ~C)I~iVit7~V1f'E~iir a~~-i ;`s..: F°r:tva~ ~~`i..'~i~~ii~ P &Vdtc~~~E ~@~i ~e~ty ~. Kis~i~r`> ~~~~~F ~-~~.~~li~ ~::arlisle Borg., ~~.~r?i~r~p~~n~i t:;a~-,~t~ r~~ Carrtmissia~ ~'x~r,;~;~ j,...,~ ~,, ~QO:~ °~4arn9ae€, ~'eas~rtsti~4~~n~ ! ;~ ~~ "•dr~~ ?r=~ °~ REV-1503 EX+ (6-98) SCHEDtlLE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Eva M. Ostrander 21-1i 1-0435 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) Computershare ~' Computershare Trust Company, N.A. -_ P.O. Box 43078 Providence, RI 02940-3078 Within USA, US territories tr Canada 800 351 7221 Outside USA, US territories 8 Canada 781 575 4729 ~_ "'"'"'""""'AUTO""3-DIGIT 170 00032010111551 1115 51 www.computershare.com/att I"~'IIII'll~'I~ll~lllll~l'I'~~lll~llll~ll"'I'I'lll~l'~II'll~ll~ ATBT Inc. is incorporated under the laws of _ HAROLD OSTRANDER the state of DE. & EVA M OSTRANDER JT TEN 1116 HILLSIDE DR Holder Account Number CARLISLE PA 17013-3500 02005808165 SSNlTIN Certified Yes Symbol T OOICSOORI RPS.DL PC I.A'T'1.191151 2R7/III551/111551/i AT&T Inc. DirectSERVICE Investment Program Statement AT&T INC. RAISES QUARTERLY DIVIDEND 2.4 PERCENT The enclosed dividend reFlects a 2.4 percent increase that was approved by the Board of Directors of AT&T Inc. on December 17, 2010. The new dividend rate is $0.43 per share. Dividend Information Record Date: 10 Jan 2011 Holder Account Number:C2005808165 Payment ~ Number of Shares Dividend Rate I Gross Dividend Tax Withheld Net Dividend Tax Type Date ~ Reinvestin Dividends g ($) ($) ($} ($) O1 Feb 2011 47.706851 0.430000 20.51 20.51 Transaction History From: 01 Jan 2011 To: 01 Feb 2011 Deduction Total Deduction ~ Net Price Per Transaction Date ~ Description Amount ($) Amount Reinvestment Shares ~ T A t $ Sh $ ($) ype moun ( ) are ( ) ~ Share Balance Balance Forward 47.706851 01 Feb 2011 Dividend Reinvestment 20.51 1.10 Fees 19.41 27.651697 0.701946 48.408797 Summary of Holdings Date: 01 Feb 2011 Class Description: DSPP -COMMON STOCK Uncertificated Shares Certificated Shares I Direct Registration ~ Reinvestment I Closing Price Total Shares Value ($) Per Share ($) 0.000000 0.000000 48.408797 48.408797 27.870000 1,349.15 124UDR A T T "~' OOIJED Holder Name: HAROLD OSTRANDER ~ptlonal Cash PUrChase Please detach this portion and mail to the address shown below. If you wish to make an optional cash purchase at this time, please make your check Holder Account Number payable to Computershare. No third party checks will be accepted. Please write your Holder Account Number and AT&T Inc. on your check. 02005808165 J NT This form should ONLY be used for ATBT Inc. The enclosed contribution will ONLY be applied to the account referenced to the right. 111'1111 IIII II'll VIII ~'I'I'IIII I'III'IIII IIII IIIIIIII IIII III Attached is a check for The plan allows for a minimum amount of $50 with a maximum amount of $120,000 per year. ATBT I 11 X11 ~ I ~ 1 IIII 1~~ III i ~rl I I I i ~ ~ I 1 Inc. invests optional cash payments every Monday. If the Monday is a non NYSE trading day the funds ~~ ~I~I ~ I II ~~III ~ I~~ I~ ~ I ~ ~ ~ ~ ~~ ~ I~~ will be invested on the next business day. Computershare P.O. Box 6006 Carol Stream, IL 60197-6006 OOOOOOOOOATT SPP1 C 2005808165 a BNY MELLON SHAREOWNER SERVICES P.O. Box 3526 So. Hackensack, NJ 07606-9226 00003367 01 MB 0.382 01 TR 00018 SQFDV101 000000 HAROLD OSTRANDER &EVA M OSTRANDER JT TEN 1116 HILLSIDE DR CARLISLE PA 17013-3500 ~IIII~IIIII~IIIIIIII~~~IIIII~II~~~~,II~IIIII~IIIII~I~III~IIIII~~ Year-To-Date Account Summary Shareholder Of: Page 1 of 1 ALCATEL-LUCENT GLOBAL BUYDIRECT PLAN STATEMENT PRINT DATE: 04/06/2011 CUSIP: 001-451-01390430 SYMBOL: ALU ACCOUNT KEY: OS;TRANDERHARO-0000 INVESTOR ID: 125076963871 FOR QUESTIONS CONCERNING YOUR ACCOUNT PLEASE CALL 1-888-582-3686 Save this Statement for Tax Pllrnn~P~ - -- ------ --- - ---- ~ -- r----- AS OF: 04/06/2011 i CARH ~ ADDITIONAL _. DIVIDENf-S NET .4MOUpIT KET VALUE $) CLOSING PRICE $) INVESTMENTS S ( INCOME TOTAL $) ITAX WITHHELD $) AMOUNT TO INVEST $) ( ~ ( _ _ O _ i _ ~ ( ~ ( ~ ( ~~ INVESTED {$) 156.60 5.8000 I TRADING FEES PAID BY ($) SERVICE FEES PAID BY ($) ~ SALE OF PLAN SHARES ($) j CERTIFICATED ~i SHARES HELD ',' SHARES HELD BY i TOTAL ~ ~ i GROSS PROCEEDS ~ TAX WITHHELD SHARES HELD BY YOU BY PLAN ,~'~~ OTHER PLAN(S) I SHARES -- i ,' , COMPANY SHAREHOLDER COMPANY SHAREHOLDERi ! 27.0000 ' I 27.0000 A -- c,urrenr Hcr~v~ry ~mormat~on RECORD DATE TRANSACTION DIVIDEND SHARES ACQUIRED ADDITIONAL ' ~ CASH ~ TOTAL ~ PAYABLE DATE ! DESCRIPTION ~ RATE OR WITHDRAWN ~ INCOME INVESTMENT ($) ' GROSS ($) ) ~ ~, ~ I __ _ __ I BUTTON ' TAX TRADING FEES PAID BY ($) [ SERVICE FEES PAID BY ($) TOTAL i CERTIFICATEDS HARIESATSHARES HEOLD D F ARES HDELDTBYI', TOTAL ITHHELD{$) COMPANY SHAREHOLDER' ~ COMPANY i SHAREHOLDER ~ NET ($) ~ HELD BY YOU BY PLANT CITHER PLAN(S) ~ SHARES ~ ~ ~ Year-To-Date Transaction Detail i TRANSACTION i CASH ~ NET I TRADING I SERVICE j AMOUNT ~ PRICE PER 'SHARES ACQUIRED SHARES HELD DATE i DESCRIPTION INVESTMENTS ($)DISTRIBUTION ($), FEES ($) !, FEES ($) I -NVESTED ($) ~ SHARE ($) OR WITHDRAWN ' BY PLAN I BALANCE FORWARD i E 27.0000 _A 4LCATEL-LUCENT :.USIP:001-451-01390430 4000UNT KEY: OSTRANDERHARO-0000 HAROLD OSTRANDER &EVA M 3STRANDER JT TEN 1116 HILLSIDE DR ~ARLISLE PA 17013-3500 Aq owner(s) must sign and date above Contact Number 7575 125076963871, r x -I v Partial Withdrawal (Continue Plan Participation) Additional Cash Investments Issue a certificate for this j ; number of shares: ~ Write the amount encbsed: I Sell this number of shares: II Make check payable to: I BNY MELLON/ALCATEL-LUCENT YOU MAY INCREASE YOUR SHARES WITH OPTIONAL CASH INVESTMENTS OF $50 Full Withdrawal (Terminate Plan Participation) UP TO $10,000 F'ER TRANSACTION ~ Issue a certificate for all full shares Deposit of Certifiic~ates and a check for fractional shares. Deposit the enclosed I ~ ~ Sell all plan shares. __! number of shares.: I 001451013904300STRANDERHARO-OOOOIR00122 REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDtlLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Eva M. Ostrander 21-11-0435 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. (If more space is needed, insert additional sheets of the same size) ~~ 9800 Fredericksburg Road '~ ~, San Antonio, Texas 78288 l.1SAA`~' Visit us at usaa.com 04462 .~8YYI.JSS195159186.01.01.521 EST OF EVA M OSTRANDER C/O GARY G OSTRANDER 1116 HILLSIDE DR CARLISLE PA 17013-3500 BALANCE ON LAST STATEMENT SUBSCRIBER ACCOUNT REFUND CHECK ISSUED ACCOUNT BALANCE AS OF 05-27-2011 EFF£GTIVf DATE t, ~ 1 STATEMENT CE-1 _ 521 110 USAA C NUMBER p 00549 83 24 2 TO UPDATE POLICIES GO TO USAA.COM OR CALL 1-800-531-8722 FOR BILLING AND PAYMENT INQUIRIES GO TO USAA.COM OR CALL 1-800-531-8722 TO REPORT A CLAIM, CALL 1-800-531-8722 MONTHLY ACTIVITY $ .00 04-28-2011 2,365.44 CR 05-27-2011 2,365.44 $ . ~00 POLICIES I3LIhIG BILLED PAYMENT PLAN OPTIONS BALANCE RE~ GU~~ LgR~pLq-V EXTfNDfD PLAN TOTALS $ .00 $ 00 $ .00 YOUR REFUND CHECK IS ATTACHED. TO FURTHER OUR MISSION OF BEING THE PROVIDER OF CHOICE FOR THE MILITARY COMMUNITY WE HAVE OPENED MEMBERSHIP TO ALL MILITARY RETIREES AND THOSE WHO HAVE HONORABLY SEPARATED. DO YOU KNOW ANYONE WHO MAY NOW BE ABLE TO ENJOY THE BENEFITS OF MEMBERSHIP? TELL THEM ABOUT US OR SHARE USAA AT IUSAA.COM/JOIN. BNY MELLON SHAREOWNER SERVICES April 11, 2011 /' 125076963871 Dormant Property in your account Shares: 0.0000 Cash Dividends: ~ 192.50 041 1-01-000004 HAROLD OSTRANDER & EVA M 1116 HILLSIDE DR CARLISLE PA 17013-3500 THE STATE OF CALIFORNIA REQUIP;ES US TO NOTIFY YOt1 THAT YOUR UNCLAIMED PROPERTY MAY BE TRANSFERRED TO THE STATE [F 1'OlJ DO NOT CONTACT US. RE: AVAYA INC. 1. There has been no activity on the accounts(s) during the past (2) years. COMMON 2. Each account listed below is in danger c-f escheating to the State of California Toll Free Phone Number: 866-222-8292 3. The California 1lnclaimed Property Law requires banks, banking organizations, and financial organizations tc- transfer funds of deposit, Response Needed By: May 11, 201 l account, shares, or other interest if it has bleen inactive for three years. Dear Shareholder: Your account with BNY Mellon, transfer agent for the company listed. above, must be updated. If you do not respond to this notice within 30 days, we will be required to surrender your property to the State of California. One or more stock certificates, statements and/or dividend checks for the above account has/have been returned from the Post Office or remains outstanding and unpaid. Pursuant to the California Unclaimed Property Law, your account may be considered dormant if an incorrect address is on our records or regular activity, such as cashing dividend checks or exercising voting rights via a proxy card, is not maintained. Please note: This rule applies to accounts with owners 'who are in possession of a physical certificate. Once the property has been surrendered, you will have to recover the property directly from the State ofC'alifornia. The recovery process can be lengthy. Even if the address listed above is correct, you must respond to prevent your property from being turned over to the State of California. To correct or confirm vour account information via the Internet please follow these simple steps: 1. Go to www.bnymellon.com/shareowner/equityaccess 2. Login to Investor ServiceDirect~~' 3. Click on the Account Name and select Manage Account Info 4. Click Account Preferences and choose Edit Account Address 5. Change your address then sabmit You will be required to enter your 12 digit Investor ID anal your 6 digit P[N. if you do not currently have a PIN, follow the prompts to create one. A confirmation number will be provided when you have completed the address change process. To correct or confirm vour account information via the Voice Response Unit please follow these simple steps: L Ca11866-222-8292 2. Say, "change address" at the main menu 3. Follow the prompts to complete the change of address process You will be required to enter your 12 digit investor [D and your 6 digit PIN. [f you do not currently have a PIN, follow the prompts to create one. A confirmation number will be provided when you have completed the address change process. Once you have corrected or confirmed your information, you will be sent a replacement dividend check or certificate automatically. 1209 0014500534991,OOSTRANDERHARO-0000 BNY Mellon shareowner Services C REV-1509 EX+ (01-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI~ILE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: If an asset became jointly owned within one year of the decedent's date of death, it must be reported on ychedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIOfJSHIP TO DECEDENT A• Gary G. Ostrander 1116 Hillside Drive son Carlisle, PA 17013 B' Karen L. Ostrander C. JOINTLY OWNED PROPERTY: 1116 Hillside Drive Carlisle, PA 17013 daughter-in-law 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 % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. Orrstown Bank Account # 764000119 5,694.35 50~ 2,847.18 2. A. Orrstown Bank Account # 106001452 8,133.82 50 4,066.91 3. A. Sovereign Bank Account # 2891025075 1,984.40 50 992.20 4. A. Members 1st FCU Account # 306831-0000 140.66 50 70.33 5. A. Members 1st FCU Account # 306831-0005 21,990.86 50 10,995.43 6. AB 07/17/08 Real Estate at 1116 Hillside Drive, Carlisle, PA 402,000.00 33 132,660.00 7. A USAA Bank Account *"*7200 21,642.88 50 10,821.44 TOTAL (Also enter on Line 6, Recapitulation) I $ 162,453.49 If more space is needed, use additional sheets of paper of the same size. ~, ~ ~ ._ ~. ~++ :~ ~`< ~r; s ~, ~ era r ~ : ~~~~,?. t ~ 'r.' ~,~ View Account Information for: P'riState 0003 Accwwnt Infwrmatiwn .' Current Account Information r~~~~~.~~ 0~0~ / Eva Ostrander Other names an this account: ~: "~ ~; :_ ~; *. .:=~:d Current balance `; , 5 ~, .r ..; 5 Available balance 5, ~+~ . 35 Last statement balance , ~ ~.._ .' Date of last statement _.,_ %". ?: YTD interest _.._" PYTD interest _-. ._ Date opened - Date of last deposit , Date last overdrawn _ _ _ ___ _ _ __ __ _ i ~ A5 Ih " ~~ c F. ~' ~Lw ARK ' t,~ ~ ~~~ ~4.. ..~.. ~.1t4 ~~f1 V~MT https:/c;m.netteller.cvm~'lvgin2t~081Views/Retail/AccountInfo.aspx 413f20 l l r~~' ~ ~ Y • + N.W.Att'w~RFN. k . w n : ryn i~bM~ K.,e, ~w.Ye ati~av er 7 1/~eW TrartsactiUilS 1141': SQ Int 0042 Current Barlancem 10.588.21 ~, ii~t~ 4.tidw~°~~r`er fO,588.21 Aii Transactions View Range : ~~~r~~c ~ {~# ~,t~~r~`r aye~~ ~ ~ ~~~:~~ { .~.~ i::~~y~, ~ air l.:tia~} AU 46124/2411 ~ ~, rat :sn ~~ Deposit ~`~ ~~: 2,781.46 14,588.21 46j12j201.1 Interest Deposit 4.07 7,806.75! 4.511412011 Interest Deposit 0.49 7,806.68 i 4412 512 0 2.1 returned dir dep due to death ?,846.59' O4/18j2011 PAYMENT CITI ALiTOPAY PPD ''`~}. .; 8,180.59 44115/2011 :_ Check 1312 `°v 8,211.58 44/15/2411 ~ tn: _ Check 1316 ``~•+ 8,649.48 44/14/2411 ~. ~ 1s Check 1315 `v 15,354.48 4411412411 '~, r ~rttw~sr Deposit _ ~6,t3i)0.04 15,479.89; 44/12/2421 '~ ; ~.:3 Check 1313 `~v' 7,479.89 04114.12411 Interest Deposit 4.72 7,749.89;. 4414 8 /2 0 1 1 ",, .i. Check 1311 ,. 7,749.67 4414612411 ~ PL.:;. Check 1314 ~`°'~ 7,928.421 4410 512 4 1.1 ~ ~= Check 1314 . 8,293.92': 04j0112011. ~~ Check 1348 8,402.32 44101, 2421 AR ANN PAY DFAS-CLEVELAND 3 ~~,f)4 8 507.132 PPD , 43131/2411 "<. ~~~~:~ Check 1349 ~_._ .~_...._ ~i312 812 4 1 2 `. ,~~~ Cfteck 1.347 - 8,133.82 8,6S1.32 43/21/2411 :, f.,~:; Check 1346 ' 8,736.32 .: 4312112412 F ~.„3~ Check 1345 8,952.32; 0311712411 PAYMENT CITI AUTC}PAY PPD 12,577.2,1' 03/24`2412 Interest Deposit 4,49 12,608.20' 03/0i~%2411 AR ANh{ PAY DFAS-CLEIJELAND 374,[-4 12 647.'?1 PPD , 42117/2411 PAYMENT CITI AUTf3PAY PPD 12,233.71 0211412011 214110S9S Transf to Reward 4441 househoid repair expenses 12,264.74; Confirmation number 214114595 4211012411 Interest Deposit x,74 7.7,264.70' 0214112011 AR AhtN PAY DFAS-CLEVELAhJD 374.00 1.7 263.95; PPD , 41118/2411 PAYMENT CITI AUTQPAY PPD 4111312411 ~, .~~-+ Check 1344 1.6,889.96 16,970,95 4111012411 Interest Deposit 0.81 2.0,762.18 0 1 10 312 0 1.1 AR ANN PAY DFAS-CLEi/ELAND ~7~1.00 20 763.,37 PPD , 1211712414 PAYMENT CITI AUTt7PAY PPD 12113/2014 1213100647 Transf to Reward 4441 ZOr387,37' ~.hristmas gifts from eva 24,418.36': Coni`irmatian ns~rrtiber 1213144547 i2j121201O Interest Deposit " 3.,27 23,.418.36 12147/ ~?d14 Check 13lJ2 1 210 7/2 4 1 13 ;, ..~;. Check 1303 '' 23,417,09' 121C11~`2410 ~:ti Check 1341 ~ 27,2.56.41 12j41J201t3 AFt Ahlt~~ PAY DFAS«C'LE'~~€LA~iZy :~1.612.t28 ! ~?4.,[1!? 31,841.08' f~Lt~~s:lTcm.nect~I~~r•~.t~mr~l~~~i~~~~(l8/'~'i~v~~/R.~~~i~rEAc~c~t~n~Te~~~~~.:~i~~-z~~.~~~:~~ ~:~a`:~~i2f~ f t ~,,.11Av1.~11111LL'~ l'3.~.'vhfr~.l.lit. Lrutt.r:ta.t-.t.t:~t.~ Online Bsnking Hointe ; CusUamer Service ~ Contact Us I Log Out ~accaurst ~, TransSeyr Funds Bill Pay $e a-Buts ~ Stop Payments ~ Change Login Preferences ' Reorder Checks a~t;~s~s~rYt St.rr~ra~ar2+ ~ t~~r~~ kr;-,,~ t~~::~:'t~arrtt Account Number::2891i125(i7S ~'iU l"tl i1'! ~ i`~/ ~ It'~O I"i"t'S c't'~I C3 i'! Available Baianc<a $3,463.40 Ledger Balance Today's Deposits $U.GC~ Ledger Balance as at Today's WithdraeNats $U.OU Last Deposit Interest Accrued This Statement $U.01 Last Deposit on Interest Paid YT[) $O.is Balance La&t Statement Interest Paid Last Year $10.94 Last Statement Date Next Statement Date ~i}Sti+G'C~ jltC~IWI~:'if Date Activity Description US TREA5URY 3U3 U4/U1/2U11 ?fXS:]C SEC U40111 13122218fiD SSA 03j31/2011 CtiF..~K iQ59 03j1U/2011 SIUTERE:ST C',REDiT 03/1.(312011 w.FE~CK 1."t~56 i?3/LOf2U11 C:I~IECK 10`_i7 ~y3Jli)J2.01.1 CNECK 1J5S 03/08/2011 t'FiECK 1058 US TREr15URY 303 03/0312011 SC'>.~ SFC: 030311 :c3127.?1.i~56D 5SA 02122/2011 CHEUK:1~54 02J17j2011 CHE~~ iR53 Quick Search For A!I Available Activity ~..a_ _ ~_ Fired an ATM/Br ~~ I~rintabfe version Current: Date; 04/C13/2C?li $3,463.4U o4/UilzUn $1,479,UU U4/U1/2U 11 $2,U lU.6E U3/1012U11. U4/'.tU[?_011 ~~ Advanced 'earth >~ Download_Hi~t~?ry Deposits Withdrawals Ledger Balance $i,4'79.i)U `~.3,463.4U $16.2fi- $1,9E4,4U $U.U3 °~2,UIU.68 $4.~O- ~iU9.90- $2,OYi?.3G $2o.c"";'~ '.$4,1.35.83 $2,479.00 'b4,1.62,65 ~21Cs.24- $2,6II3.55 ~,h4E~.51 X2,893.89 ~~~ Prntablg V~[si~n Shortcut Select a Page ~ntS~lf~li~ copyright 2910 Sovereign hank. Ali rights reserved. Equal Housing Lender -Member 1=plC https://www.site-secure.com/cgi-bin/cgign.exe/sovbank/FAozNArX/,514217001372,Ac~etl:nfo 4/3/2011 v L~Fa!-: cl~^iI F':? 2_9f r`k ~, ~'~4'YY'~tii tt:= at :.`z.( .,:~-,: if:s , f _:`~; <~c;t~l,. r £.,~.^., istll ~~y?°~ ~iei~,~;,;-a::& 1CiSc~ ~.ts.. . ~~,~.:'1;:-vtib~:` ~u~;~~ r`~f>rtec' c~~t-;'~~~..a~~z x-.° p,ar_,'~/J ,. "~ ~J :~l1i1~)~ir'sC~,rr',F:E,~ ~,~ tJ ATE. i " How to change you r account descriptions 03/28/2011 I~§" ~ `v r a ~' j Ac;tsS~tz~`~ f Iz~~~.~z~rzear~ ~ ~ ~ Av~i~.ksc.~ B~L~N~E yr~ ~avararr~~ ~ t~s~r,a~z y~ar~ Dl.vzer~aas~ 306831-S0000 REGULAR SAVINGS $135.66 $140.66 $0.09 $0.43 306831-50005 MONEY MANAGEMENT $21,990.86 $21,990.86 $18.97 $88.36 Total $22,126.52 $22,131.52 $19.06 $88.79 Please Note: YTD totals displayed above do not include dosed shares. To view YTD Totals which include dosed shams please Gick here 4.1.7 C7; i L: 1~i:1~E~' „' d IL ': tl1 8 I I 1Li~C~tJwlT a"1~.~1=•~E ~?!.~"E' ~~ ~~,~'i~~'~p75C)~ I .AVAI~~`i~3..~: ~dn4.A~+1~;~. j P~bYMENI' ~ ~tJ~'. i ~A'I"[: ...E _._ I ' ~ 1.._ _ --- N/A -° Total $0.00 $0.00 $0.00 4..... f"E'~.f4 4. n~i^.~S~i~~ N.r;piy f0. -s :rind C-,.r ~'1;i ;~'. t3!'d ~. . , , ~, ~~;; ;, . ~„ https://mlonline.memberslst.org/OnlineBanking/AccountSummary/AccountSummary.p~~ 4/3/2011 TaxDB Result Details Detailed Results for Parcel 04-21-0324-060. in the 2010 Tax Assessment Database DistrictNo 04 Parcel ID 04-21-0324-060. MapSuffix HouseNo 1116 Direction Street HILLSIDE DRIVE Ownerl OSTRANDER, EVA M & GARY G C/O & KAREN L OSTRANDER PropType R PropDesc LivArea 2875 CurLandVal 95000 CurlmpVal 307000 CurTotVal 402000 CurPrefVal Acreage .55 C1GrnStat TaxEx 1 SaleAmt 1 SateMo 07 SaleDa 21 SaleCe 20 SaleYr 08 DeedBkPage 200824760 YearBlt 1991 HF File Date 10/21/2004 HF_Approval_Status A Page 1 of 1 http://taxdb.ccpa.net/details.asp?id=04-21-0324-060.&dbselect=l 6/23/2011 JL KGV .t V .t Lr p it ~.:, t_".Ff ,I ~ r il'!/i: I.. .i ' ~ ~_,~ ' ~ tf f : ~ ~ ~ ~ l..J V R... Y A 3 4w- Mr. ~1 S C:R H '~11~ ~ ~ 9 4. L. 3 $ ~ fit' ~ 1 'y t.,']Il'..,. ~~'r j~l~~%i~ gyp' 1~.:'~ ~~!'t.~~.'~~. {...f ~fJ 31~... ~ 4 # M~i~4~ !. w~ *~~\• i~Onru' +1i7Ykaf3!?F ]711ffE~f'tllt Fra15sFATC (Y],i ra?"t}t[!f ~`f M'trA=At?{SL*di4S [~~F~Sf~ity fJPnIS ~1rt~' 1,)~ifxr~ i ~~~~~~~~~ ' ' ~ ~r?icvrrt~, Fw 1 f ! ~~!~ ih,4tdL ~FR ~~~t: ~,~islt l:; °_~. = .5t, ~ ~9 €'P~t ;~' Get more from yaur Rome page -customize it -1,.~4~ aCl`?Ci Jievd r9na`:ysis ~aiaisecc ri ntz::a+~t S?W'erl [ i~A+3nt'6'fs ... ~~s~~, :~AD;ir~aesml _ ~-°~rz~~.u ~~3,~a'a:~s Acdian What was the average IR8 tax refund in x'01 t)? Tatai Banking $1,842.86 $~.Ot~ $1,000 Add aNan-USAA Accaunt $2,000 Exrlus;ve i7eals from GM anal Mercedes•5enx $3,000 $4.OOQ ir'~ u~iC"~r?CC' ~lPCFY Ans7ry5f.5 £saiarrc.e ili7lf i t}9, (?tNfxM;I ; 4^daR$'L' . '~a+N St1r Y ljUtf! ZL PfDpxzf ty ~1l1 ~~.~~` AC,tt015 . R~"JtiT~:RS AGLOn ~~`" UaAA rdarvle<a FS~~st 1~r~hicfe5 id)C ~avertai~ ,+,aILte IRA .. •"` {;Ar X77,379.96 Action ~x^ Vi-~blr, USrat; Pair Up ~n Credit Car'c7, Irivestrnel~t~~ Fata3 insurance 577,&79.96 $G.(AA b`iew USAA'S .>.~ ~ ~ R2~7(Jrt to Member Add a Nnn-USAA Account Yiew All Save $5V wirers you quo!e antl auY auto 'rlisutance an usaa ram. t"rlrcl~+, `."!i~'~'Ic"3. C111!(`S~ Siat[tfi T1a4~e !{.§',z+'Ik 7cl ,.. A~•i. t~~fti "i..'~~~r~.~~5`. E: 4, 7r~t^6iEi €und<_~ F'!fl Qf?C,'%ii {.1<S::FS`.fTIF`(1! 1i()' ~:i t~it£` ~ :if_2 (t T~ransf'er~ ~ ivor,-i.ISAA Investment ~~t:cci+ndrlf. ti~l~ta E~ei~l~>itCtYrl~UrnE ~ t119BStr?l~f~Ya Pay Esf!4':5 Proven performance and value -that's why you should consider investing with USAA. MUTUAL FUNDS Proven performance with no sales fees Learn Mare Select a PI aducfi BROKERAGE Make online trades for as low as $5.95 Learn More COLLEGE SAYINGS 529 Keep higher education within reach Learn More tit°t° ~"`~r"~"'f=~' 1'~GiilE?f.1+~t rtr~rc ;aIS~l I`~ilt,"E' Life It1SUri3t1C~ ~fiew .All Products & Service9; Staa~ac t~,uf>re~ Renter, ~Ir,sl~rt+nCr-~ 9l'iaw All Consider the investment objectives, risks, charges and expenses of tfie USAA mutual funds and/or USAA Col{ege Savings Plan (Plan) carefully before investing. Download a sarospectus and/or Phan Description arxti https://www.usaa..com/inet/ent_home/CpHome?action=INIT&wa re~private~lobal_my_ a... 4/3/2011 REV-1.510 EX-t- (08-09 ~ pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Eva M. Ostrander 21-1 'I -0435 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, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLU>ION (IF APPLICABLE) TAXABLE VALUE 1~ USAA IRA #00470520AA 64,565.81 100 0.00 64,565.8' TOTAL (Also enter on Line 7, Recapitulation) $ I 64,565.81 If more space is needed, use additional sheets of paper of the same size. 9$00 I~rederiGksburg 1Zc~ad San Antonio, Texas '78188 USAA~ GARY G C~STRA?~iDER 111 HIi.LSIDE DR CARI_I SLE PA I U 13-3500 Annuitant Name: Eva M. Ostrander a . Imo' C:c~~~.tract Number (s) : 0047052OAA Dear Mr. Ostrander: April 28, 2:011 As requested., the proceeds were wired to your bank. A wire fee was deducted from your proceeds. The following is a summary of the transaction: COVERAGE AMC~~CJNT Accumulated Cash Value 77x814.23 Less Federal Tax - 13 , :~ 2 8 , 4 2 Less wire/Mailing Fee 20.00 Total P~yc~t~t f~4,.~65 . ~l A taxable amount of $77,814.23 was realized and will be reported as income to you. In January of next year, a 1099-R will he mailed to you for tax preparation purposes. Tf you: have 1,Aestions, please contact gas at (800) 531-8455, ext. 7-3503. You can also visit us online at usaa.com. S1nCerely, ~n Cynthia>D. Martinez, AC5 Life/Annuity ~~Claims & Benefits Advisor Life/Annuity ._ Claims & Benefits 39048 48712 - IriunPrint 1VIKT.CLT.CL?VI2 564I3-081.0 RFV-1.511 EX+ (1Q-Q9) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Eva M. Ostrander 21-11-043!5 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: i' Hoffman Roth Funeral Home & Crematory, Inc. 7,142.50 2. Cumberland Valley Memorial 230.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name{s) of Personal Representative(s) Street Address City _____ _ Year(s) Commission Paid: State ZIP 1,300.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation,) Claimant Street Address City __ State Relationship of Claimant to Decedent 4, 5. 6. 7. Probate Fees: Accountant Fees: Tax Return Preparer Fees: ZIP 380.50 TOTAL (Also enter on Line 9, Recapitulation) I $ 9,053.00 If more space is needed, use additional sheets of paper of the same size. t._.' ~~I~~~', i t~~1 i5y4uc~~~~tE.,a E ~...~ d f.7 ~:'~~3 lit ~' f.%~t'"tt3..~~;3 .~'+~~; r ~ a.. ., is ~:7.?~x:>~' ; tC~~' ~T'Ott ~ t1: rat.., Gary Ostrander 1116 Hillside Drive Carlisle, PA 17013 April 14, 2011 Statement of Funeral Expenses far: Eva M. Ostrander Date of Death: March 28, 2011 Account id: 1 Ei208-079 .....~_. PACKAGE: ~~ Package to set individual casts of funeral expenses ccc $ 3,730.00 Sub Total: $ 3,7;30.00 MERCHANDISE; Casket: Hyacinth $ 2,975.00 Sub Total: $ 2,975.00 TOTAL FUNERAL HOME CHARGES: $ __M._.~ 6,705.00 CASH ADVANCES: 10 Certified Death Certificates at $ 6.00 each $ fi0.00 Newspaper Notice -Sentinel $ 78.50 Clergy $ 100.00 Flowers $ 159.00 Hairdresser $ 40.00 Sub Total: $ 437.50 Total Funeral Expense: $ 7,142.50 Total Payments Made: $ 7,142.50 Payments Made: Gary Ostrander Check 1312 Mar 31, 2011 437.50 Grary Ostrander Check 1316 Apr 14, 2011 6,705.00 Balance: ~____~ O.aa Please return this portion with your Remittance. $ Amount Enclosed Eva M. Ostrander Service lD#: 16208-079 .:..7 .,.. ;'~. ty! 4 f~`~ >..? ...~1 L.j ~4a ~ « ~. ~ ,''ay~1 ~'Y i au~ i'`i ~~ . A 1~ t ;3 y y ~~ f REV-1517_ EX~- (I2-08) r, pennsylvania SCHEDULE I DEPARTMENT Of REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Eva M. Ostrander 21-11-043~~ Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. ,~.i (g~1tg i ;'97 -f dW,te.PPil ~Lit)Fjs3 ''?'i ~.I pi (p~' 2: tii~~'~,1C~iY,? 7~~I~J `5 ~~'~~, ~~ :1t1~E000 66DE~OO OOD~000 92+~~`~l~~~~'~ :''[ 1~~i~~~~~ ~~-k~ aR~~n~~ uo suo~san.~}xu~~ }unu+tud ~~~7tio~ puv y~o;~d .. ~. a Cv tlt "C3 GJ r-t • f"`~ ~. Q ~ ~ Cam? Ua ~ ~. ~ ~ ~'- a awuuw ~ ~ ~ ~ ~ ~ ~. ..~ ~=* ~ ~ C 0 : ' ~ f'7 ` K 6:. 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' ^ Auto/Travel ^ Education ^ Medical/Dental ^ Business ^ Entertainment ^ Savings ^ Charities ^ Food ^ Taxes ^ Clothing ^ Home ^ Utilities ^ Dependent Care ^ Insurance ^ Other For enhanced security your account number has been blocked out on this copy Memo _ -- DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT Stretcher One Way Trans Member T2005 1.0 96.06 96.06 Transport Van Mileage S0209 3.3 3.74 12.34 / r ~ ..Y7 ~ ~~ S ~ ~ ` ~ ~ s t 7 ,r ' Total Chari~es 108.40 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 ~~~~Slm: ~~~~~ THIS AIVIOi,..JI~IT -~ !N~'OICE DUE i.,ll~0 ~~~;~I~° ~. ~~-~` I,Q~~I~r~ ~~s~r~ ~~~ _ ~~-~ ~~~ $108.40 -- PATIENT NAME: OSTRANDER, EVA M CALL NUMBER: 215348W AMOUNT PAID: 03/24/2011 111111'OI~TAI'~~` tV1ESS~OS; THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL ASSISTANCE. WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA. 17011 NOT NEGOTIABLE .~..........r... f / TrackYour Expenses... ^ Auto/Travel ^ Education ^ Medical/Dental ^ Business i ~ Entertainment ^ Savings Charities ^ Food ^ Taxes ^ Clothing I ~ Home ^ Utilities ^ Dependent Care ^ Insurance Cl Other For enhanced security your account number has been blocked out on this copy TAX DEDUCTIBLE ITEM ~- Memo -- -~.~.~.~•~.~.~.~.~.~.~. f,. \.~.~.~.i-.~•~•~; NOT NEGOTIABLE Please Remit Payment To: ,:~ ~-= S~^~ia1 `Event Emergency Medical Services Ir Billing Office P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@arnbulancebillingoffice.com Date of Service: 3/12/2011 10:18 Patient Name: OSTRANDER, EVA M. From: FOREST PARK HEALTH CENTER To: COUNTRY MEADOWS ASSISTED LIV/MECH Please visit our website i.v provide insurance or make payment, and for additional payment= options and frequently asked questions: www.ambulanc~billingoff~ice.com This type of service is not covered by ambulance memberships, Medicare, Medicaid and most secondary insurances is your responsibility. ~1 a 3/12/11 Wheelchair Van Transport A0130 1.0 60.00 60.00 3112/11 Mileage S0209 18.2 2.50 45.50 Total 105.50 0.00 0.00 ? ~ =~ I .~ .~~~ ..r 1 '~ .3~ ,_ y, n~ ~ ~ _„ r DETACH AND RETURN BOTTOM PORTTnN wTTH YC~IIR PAYMENT Iii Yaur Home Care 19 South Hanover St. Suite 108 Carlisle, PA 17013 Bill To: Eva Ostrander ci o Karen Ostrander 1116 Hillside Drive Carlisle PA 17013 ^ nvt~ i c e Invoice #: 10019001 Invoice Date: 3/28/2011 "DON'T STA Y HOME WITHOUT US!" Description Hours/Qty Rate Amount Care Service: 03/21/11 -Bobbie Jo Guyer 6:30 A - 4:00 P 9.5 17.50 166.25 Care Service: 03/23/11 -Tracy Slaybaugh 9:00 A - 12:00 P 3 17.50 52.50 n ~' ~_ b ~~ ~ `~ ~~ i'' ~~I~~ Thank you for choosing IN YOUR HOME CARE! Total $218.75 Phone # Fax # E-Mail 717-243-5080 717-243-6950 infoC~inyourhomecares.com Payments/Credits $o.oo Balance Due $218.75 DUE UPON RECEIPT { o, ,~ QUANTUM IMAGING AND THERAPEUTIC ASSOCIATES 629D LOWTHER ROAD LEWISBERRY, PA 17339 (877}932-5955 bent : Acct #: 331205 O.STRANDER, EVA M 4837 E TRINDLE RD RM 304 MECHANIGSBURG,PA 17050 sponsible party: OSTRANDER, EVA M 483? E TRINDLE RD RM 304 MECHANICSBURG, PA 17050 v-c. Date Proc. Code Proc. Description Charge Balance Physician f17/2011 '71020 Insurance Payment: Insurance Payment: /23/2fl11 71020 Insurance Payment: Insurance Payment: CHEST 2 VIEWS PA & LATERAL $45.00 04/20/2011 of $8.62 Adjustment: $34,22 05/09/2011 of $0.00 CHEST 2 VIEWS PA & LATERAL $45.00 04/2512011 of $8.62 Adjustment: $34.22 05/13/201"1 of $0.00 $2.16 Stephenson, Jonathan D $2.16 Harris, Brian /24/2011 71010 CHEST SINGLE VIEW FRONTAL 536.00 insurance Payment: 04/25/2011 of $7.02 Adjustment: $27.23 Insurance Payment: 05/13/2011 of $0.00 /251.?.011 70491 Insurance Payment: Insurance Payment: !25/2011 71260 Insurance Payment: Insurance Payment: $1..,...75 Licata, Paul CT SOFT TISSUE NECK W/ CONTR. $281.00 04/28/2011 of $54.45 Adjustment: $212.94 05/16/2011 of $0.00 CT THORAX W/COIvTTRAST $2.75.00 04128/2011 of $49.34 Adjustment: $213.33 05/16/2.011 of $0.00 $13.61 Potok, Paul S 4>12.33 Potok, Paul S Print Date: 06116/2011", ~, ._ r .. y ' ;~ _~.._~_a._ ~ ._ _.____,._._.., - -...._,,.. This report has been Rep~~duced from the Original Reproduced Thursday, June 16, 2011 03:25:53 PM Page 1 of 1 .,, _.~ .... ,... y ~. 4.:i ... ~FFITT HEART & VASCULAR GROUP 06/03/11 14640Li X000 NORTH FRONT STREET ~ Y ~ '~ ~ ~~~ ~ , ' WORMLEYSBURG, PA 17043 . : _... ... ..... ._M :: k .. . ~. ,.; ;~a . ,. ~ Forwarding Service Requested MC VISA ~ Disc Security _ Card~~ ~_ C4de Sign . ~ Exp /~ 45236 EVA OSTRANDER 4537 E TRINDLE ROAD MOFFITT' HEART & VASCULAR. (1ROUP COUNTRY MEADOWS 1000 NORTH FRONT STREET MECHANI:CSBURG PA 17050-3680 WORMLEYSBURG, PA 17043 ~ ~-f~'ri 1 i a y.w r ~ 4 ~ AA.X .t 2C F r a i~` 1F f i t''a`~S M, . _ a 4 .r r~. ;'+.~f~ br ~k " r r~~~ ~~~ ~.. ~~"~;P [ j,~t ;tr rc ~.:`?"~ ~k.4~~~1~r m.,,.~ .~P~,.~ ~,a 1 ~` ~`rr~+, ~`~~t'f ' Plea:se Pair -Amount I3ue Now From Patient- See Red Box Thank You! ! ! ~'~'~~ ' ~~)~` Thank you for y;aur prompt g'ayment. Please call 717-731--8315 with any ~'~'"~ C )~C : C ~C ~)~C X X 7: 7~ ~)~C ~ 7F '"~ )~C'}ti )~t )ti 9~C ~C )~?~ ~C ~t'!~f )~C ~C )~f ?~ )~f ~ )~C ~' ~C ~C ~C '~C ?~C ~C 7~C }C ~f ~~t'3~f )At 1~C ~C )~[ )~C ~f ~ ?~C :'C ~::~C :~C )~' 'Y~C )~C 7F :C 7~C 7~C `iC ~' 7~C 3~C C ~C )~ 2~C ?~C 7~C'~f 3`C )ti 7~C ~C ~C ~C )4 Insurance Charges ending to Prv : 160.00 Ins Pay/Adj against Its pending 53.46 -93.1$ 13.36 OZ/10/il 1 8 L HOSPITAL INITIAL CARE 2 99222 427.31 160.00 03/23/11: . Medicare Payment I05.13 03/23/11 Accept Assign. Adj. -28.59 04/26/11. TRICARE FOit Payment 0.40 26.2$' 02/11/11 1 $ L HOSPITAL SUBSEQUENT CARE 99232 427,31 $0,00 03/23/lI Medicare Payment 55.02 03/23/11 Accept Assign AdJ• -11.23 04/26/11 TRI~ARE FOR Payment '0.00 13.75~~ 02/14/11 1 $ L HOSPITAL SUBSEQUENT CARE 99232 427.31 80.UO 04/01/11 Medicare Payment 55.02 04/01/11 Accept .Assign Adj. ~1.1 .23 05/1$/11 TRICARE FOR Payment . . 0.00 I3.7.5'~ ~y ..,. ` x~ mow, ,~, _. ,., - .. _ ^p, , y ~ ~; u ~, ~ ~Y v. '~ ~..- y ~~ , , m r. . ~.,, ,,,~ ~ ~- ~,~ . , > ~.. r t@ '+.:., ~ _ ~ a L-~The 'PLEASE PAY . , .. _ti., ~, .,,,q `4CS'rkr .~~~ includes un~aid c~y--v~"'~co-ins. ~o Please make payment. ~.:..o 00/00/40 , 0.00 =~,~3: 40.03 ' 0.00 0.00 0.00 13.3b 0..00 67.14 .._ . ~OOOINaRTHAFRON'TVATRU~~R ..GROUP ~- r ~ y' ss'.r'~`~ '~~j` S EET ~ 3~ r~ ~y ~ .~ ~~ ,~,fi ~- k~a_~ ~'u.~ W©RMLEYSBURG, PA17043. ;' ~..~ ~.~5~:~~' ~ Ph: (717)-731-0101 PAT~~ 1--EVA M OSTRANDER PRV~~ $--PAWLUSH, DAVID, Mi), FACC Ac~t~~: X46405 zka.~e: 06/03/11 Page 1 of ~: . w v, g \ ra ES EXPLAINED BELOW "~`~~ "`'` Thank you dues t i ons . for your prompt payment. Please call 717- 731-8315 with .any '~ ""' Insurance Charges pending to Prv: Ins Pay/Adj against Ins pendin 240.00 1 g 08.48 -104.41 27.11 02/10/11 03/23/11 1 8 L HOSPITAL INITIAL CARE 2 99222 427.31 160.00 03/23/11 Medicare Payment Accept Assign Adj. 105.13 04/26/11 TRICARE FOR Payment _28.59 0.00 26.28; 02/11/11 03/23/11 1 8 L HOSPITAL SUBSEQUENT CARE 99232 427.31 80.00 03/23/11 Medicare Payment Accept Assign Adj. 55.02. 04/26/11 TRICARE FOR Payment -11.23 O.OC) 13.75~~ L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. SATE LAST PAID AMOUNT • - ~ • _ ~ ~ • - . ~ • - ~ ~ . 00/00/00 0.00 40.03 0.00 0.00 0.00 ~ ~ 0.00 27.11 ~ - • .. :.. - 0.00 67.14 MOFFITT HEART & VASCULAR GROUP 1ECK 1000 NORTH FRONT STREET ~ I ` ~' ' ~ DYABLE To: WORMLEYSBURG, PA 17043 40.03 ~~ ~~ PAT~~ 1-EVA M OSTRANDER PRV~~ 8-PAWLUSH, DAVID, MD, FACC Acct~~171464050101 Date: 05/06/11 Page 1 of 1 GRAHAM MEDICAL CLINfC, PC 100 S. HIGH STREET NEWVILLE PA 17241 EVA M 4STRANDER 1116 HILLSIDE DRIVE CARLISLE, PA 17013 Statement Tax I D : 232173798 Phone # : {717)776-3114 Date : 06J01 J2011 Page : 1 Patient : EVA M QSTRANDER Account # : 20893 this amount : ~_-~ $30 29 Please a . p y ` ._._..__ ______J ~ . ~ ~ ~~' ^T Insurance Patient Date Code Description Provider Diagnosis Location Amount Balance Balance Balance Forward: 0.00 0.00 02/1 "li 11 99304 INITIAL NH VISIT, DETAILED ~ JAT 290,21 FP 100.00 17.4~i 04/27/11 MCCK Medicare Check -69.86 04!27!11 j MCDD ~ Medicare Deductible 17.46' 04/27/11 ~ MCDS ` Medicare Disallowance ! -12.68 05/16/11 ~ INDN Insurance Denial ~ t 17.46* 03/11/11 j 99308 SUB NH VISIT,EXPANDED GKR 1 486 FP 75.00 12.83 (?4/21/11 ~ MCCK Medicare Check ~ -51.33 ~ 04/21f11 ~ MCDD Medicare Deductible ( 12.83' 04/21/11 MCDS Medicare Disallowance ~ -10.84 05/16111 i INDN Insurance Denial ~ _ ~ i 12.83* k s 's I t ~ ~ 1 I j i ~ ; I i i i ~ a ~ ____ _ _ _ _. ____ .. _ __ ___ ___ __ . __ _ _ __. _ _ _ _ __________ __ ._. __- ~_ __-- - -_ _-- _ - - _ _-_______ Current ; $30.29 Past Due : $0.00 Total amount : ~ $0.00 $30,29 ----..__~_.____~~_-_.--- -------------..._ ~~-- - -- - ----- -_-.~-~R _~_. _ v i-__-. Please pay this amount : $30,29 Your insurance carrier has rarocessed this claim and the balance is now your responsibility. Please remit promptly or contact our office to make payment arrangements. informatlrxr only (Deductible 8 berried) REV-1513 EX+ (01-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: Eva M. Ostrander 21-11-0435 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. Gary G. Ostrander, 1116 Hillside Drive, Carlisle, PA 17013 son 157789.49 2. Karen L. Ostrander, 1116 Hillside Drive, Carlisle, PA 17013 daughter-in-law 60360.3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II 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. 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.