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Home My WebLink About07-20-11r 1505610140 ` ~ REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY' Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 ], 0 2 6 0 ENTER DECEDENT INFORMATION BELOW _ Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYI! 1 9 9 1 4 5 8 5 3 0 2 1 2 2 0 1 1 0 5 0 2 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI Z A W A D S K I C L A R A L (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 0 1. Original Return ® 2. Supplemental Return ® 3. Remainder Return (date of death prior to 12-13-8:?) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estai:e 1-ax Return Required death after 12-12-82) QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N & Second line of address 6 0 W E S T City or Post Office C A R L I S L E M c K N I G H T P C• P O M F R E T S T R E E T State ZIP Code REGISTER OF WILLS USE C;i'NCY :.1 r r', ~.., t ..._ ~r'~ ~ G ~ ~~'t,- ' ~~ - . ' _ : J C7 _ _~_; D" T~FLED C.':'' P A 1 7 0 1 3 a _. Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best Hof my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF,PERSON RESPONSIBLE FO LING RETURN ,.. , DATE f j ~ r~... c~ ADDRESS ,~ 220 N- COLLEGE STREET CARLISLE PA 17013 ~~ `t ~~ -{ ~ ; ~:. ; :r . ~~ ;` 7 -r SIGNATURE OF P1~tEPARER OTHER THAN REP ESENTATIVE Di~E ~' ADDRESS ~ ~ ~ ~~ `~"~` ~ ~~ f 60 WEST POMF ET STREET CARLISLE PA_17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J J 1505610240 REV-1500 E:X Decedent's Name: CLARA L • ZAWADSKI Decedent's Social Security Number 1 9 9 1 4 5 8 5 3 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. 7 0 6 5 4 . 8 6 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 9 1 9 3 . 0 3 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property ~ 2 2 9 9 6 8 4 7 (Schedule G) Separate Billing Requested ....... 7. . 8. Total Gross Assets (total Lines 1 through 7) .......... , . , . 8. 3 0 9 8 1 6 . 3 6 9. Funeral Expenses and Administrative Costs (Schedule H) ......... . ........ 9. 1 2 0 3 6 . 8 9 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .... ......... 10. 3 0 2 1 . 3 6 11. Total Deductions (total Lines 9 and 10) ...................... ......... 11. 1 5 0 5 8 . 2 5 12. Net Value of Estate (Line 8 minus Line 11) ................... ......... 12. 2 9 4 ? 5 8 . 1 1 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. 2 9 4 7 5 8 1 1 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 2 9 ~+ 7 5 8. 1 1 1 s. 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 ~~ 1505610240 Side 2 0. 0 0 1 3 2 6 4. 1 1 0. 0 0 0. 0 0 1 3 2 6 4. 1 1 1505610240 J REV-1500 EX Page 3 Y Decedent's Complete Address: File Number 21 11 0260 DECEDENT'S NAME CLARA L. ZAWADSKI _ _ _ STREET ADDRESS 220 fV. COLLEGE STREET__ __ CITY CARLISLE STATE ~ PA -ZIP 17013 Tax Payments and Credits: ~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 5, 500.00 B. Discount 289.47 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. (1) 13,264.11 Total Credits (A + B) (2) 5, 789.47 (3) (4) 0.00 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 7,474.64 Make check payable to: REGISTER ®F 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ X^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q If death occurred after Decembe 12 1982, did decedent transfer property within one year of death without receivrn adequate consi . g deration? ....................................................................................... ^ X^ 3. Did decedent own an "intrust 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? .................................................................................................. Q ^ 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-1508 EX + (6-98; + COMMONWEALTH OF PENNSYLVANIA - INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ' CLARA L. ZAWADSKI FILE NUMBER 21 11 0260 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. MORGAN STANLEY SMITH BARNEY 10,557.56 BANK DEPOSIT PROGRAM INTEREST REINVESTED ACCOUNT #56K-79644-13 FLS 2. PSECU 8.27 SAVINGS ACCOUNT 3. PSECU 27,807.56 CHECKING ACCOUNT 4. PSECU 3,767.83 MONEY MARKET ACCOUNT 5. USAA -SAVINGS ACCOUNT 28,513.64 ACCOUNT ENDING #1289 SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY TOTAL (Also enter on line 5, Recapitulation) I $ 70,654.86 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (Oi-10) pennsylvania DEPARTMENT OF REVENUE ' _ INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: 21 11 0260 If an asset was made jointly owned within one year of the decedent's date of death it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. JUANITA E. ZAWADSKI 220 N. COLLEGE STREET DAUGHTER CARLISLE, PA 17013 B. c JOINTLY-OWNED PROPERTY: 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. 06/1998 MEMBERS 1ST FEDERAL CREDIT UNION 5.00 50. 2.50 SAVINGS ACCOUNT #176605-00 2. A. 06/1998 MEMBERS 1ST FEDERAL CREDIT UNION 18,381.05 50. 9,190.53 INVESTMENT SAVINGS ACCOUNT #176605-05 TOTAL (Also enter on Line 6, Recapitulation) I $ 9,193.03 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) ti pennsylvania DEPARTMENT OF REVENUE ~ - INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER CLARA L. ZAWADSKI 21 11 0260 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 EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. JOHN HANCOCK 59,745.25 100.00 59,745.25 ACCOUNT #2156286 BENEFICIARIES: SANDRA C. ZAWADSKI JUANITA E. ZAWADSKI 2. USAA 23,929.06 100.00 23,929.06 ANNUITY #008399888 BENEFICIARY: JUANITA E. ZAWADSKI 3. PROCEEDS FROM SALE OF 302 SOMERSET DRIVE, 149,294.16 100.00 3,000.00 146,294.16 SHERMANSTOWN, PA 17011 TOTAL (Also enter on Line 7, Recapitulation) I $ 229, 968.47 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09; r pennsylvania SDHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND - INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARA L. ZAWADSKI 21 11 0260 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 934.85 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2• Attorney Fees: IRWIN & McKNIGHT, P.C. 6,500.00 3• Family Exemption: (If decedent's address is not the same as claimants, attach explanation.) 3, 500.00 Claimant JUANITA E. ZAWADSK~ Street Address 220 N. COLLEGE STREET City CARLISLE State PA ZIP 17013 Relationship of Claimant to Decedent DAUGHTER 4• Probate Fees: REGISTER OF WILLS 190.50 5 Accountant Fees: 6. Tax Retum Preparer Fees: PATRICIA A. ROSENDALE, CPA 610.00 INCOME TAX RETURNS & FINAL FIDUCIARY RETURN 7. REGISTER OF WILLS -FILING FEE 30.00 8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00 9. THE SENTINEL -ESTATE NOTICE 187.54 10. NOTARY 5.00 11. REGISTER OF WILLS -SHORT CERTIFICATE 4.00 TOTAL (Also enter on Line 9, Recapitulation) $ 12,036.89 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) r pennsylvania DEPARTMENT OF REVENUE _ INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER CLARA L. ZAWADSKI 21 11 0260 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. BETRA IN HOME -NURSING CARE 150.00 2. INTERNAL REVENUE SERVICE -TAXES 1,281.00 3. USA -REIMBURSEMENT OF ANNUITY 1,446.65 4. STATE EMPLOYEES' RETIREMENT SYSTEM 143.71 REIMBURSEMENT OF PENSION PAYMENT TOTAL (Also enter on Line 10, Recapitulation) I $ 3,021.36 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) s pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT __ ESTATE OF: FILE NUMBER: CLARA L. ZAWADSKI ~~ ~ ~ n~cn ~~~~ 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. JUANITA E. ZAWADSKI Lineal 220 N. COLLEGE STREET JT ACCTS & USAA CARLISLE, PA 17013 ANNUITY/ REMAINDER 2. SANDRA C. ZAWADSKI Lineal 151 EDMUND STREET BEACONSFIELD 6162 30% OF RESIDUE WESTERN AUSTRAILIA ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 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. $ It more space is needed, use additional sheets of paper of the same size. 3Ca~t ~iCI attb ~¢g~m¢nt OF CLARA L. ZAWADSKI '~ CLARA ~• ZAWWADSKf, of Lower Allen Township, Cumberland declare this to be my last will and revoke any will revi County, Pennsylvania, p ously made by me. I. I direct that all my legal debts and funeral expenses, includin expenses of my last illness, shall be paid from m residu g my 9ravemarker and all Y ary estate as soon as practicable after my decease as a part of the expense of the administration of m estat Y e. II. I bequeath my household goods, personal effects and other tan nature (not including cash or securities), to ether Bible personalty of a like 9 with any existing insurance thereon, to my daughter, JUANITA E. ZAWADSKI, provided she shall survive me. III. I devise to my daughter, JUANITA E. ZAWADSKI, provided sh improved real estate situate in the Borough of Carlisl a shall survive me, the municipally known as 220 North Colle e, Cumberland County, Pennsylvania, 9e Street, Carlisle, Pennsylvania, and being more particularly bounded and described in Deed, dated Jul 2 199 Recorder of Deeds of Cumberland Count p Y ~~ recorded m the Office of the y, ennsylvania, m Deed Book S, Volume 34, Page 43. IV. I devise to my daughter, JUANITA E. ZAWADSKI, provided she shall survive im roved me, the P parcel of real estate situate in Lower Allen Township, Cumberland Coun Pennsylvania, municipally known as 302 Somerset Drive Shirem ~ Lot No. 14, Block "Q", Plan No. 6 of Shir anstown, Pennsylvania, being eman Manor Extension, which said Plan is recorded in the Office of the Recorder of Deeds of Cumberland County, Pennsylvania, in Plan B 35, and said real estate is more particularly bounded and ook 20, Page described in Deed, dated July 16, 1970, recorded in the Office of the Recorder of Deeds of Cumberland County, Penns Ivania ' Book S, Volume 23, Page 291. Y , m Deed V. I devise and bequeath the residue of my estate of every nature and wherever situat follows: a as A• Thirty (30%) percent thereof or Twenty-Five Thousand ($25,000.00 D whichever is less, to my daughter, SAND ) ollars, RA C. ZAWADSKI. B. The balance thereof, to my daughter, JUANITA E. ZAWADSKI. VI. I appoint my daughter, JUANITA E. ZAWADSKI, Executrix of this, my last Will. Shou daughter, JUANITA E. ZAWADSKI, fail to qualify or cease to act Id my as Executrix, I appoint Mid Penn Bank, Millersburg, Pennsylvania, as Executor of this, my last Will. VII. I direct that my Executrix, and her successors, shall not be required to post bond for faithful performance of their duties in any jurisdiction. the -2- IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~rGt day of 2004. ~'~~~~~ (SEAL) CLARA L. ZAWADSKI Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other have hereunto subscribed our names as witnesses. / , ,~ , -3- a r ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND : ss: I, CLARA L. ZAWADSKI, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~~z~ CLARA L. ZAWADSKI Sworn or affirmed to and acknowledged before me, by CLARA L. ZAWADSKI, the Testatrix, this = ~'~ay of , 2004. -- - NOTARIAL SEAL DIAIdP~IE LENIG, Notary Public Lemoyne borough Cumberland Ca. ~y Commission Expires Dec. 2i, 200h t Notary Public -4- `,~ M 7 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, -~ - and a ~ ~' the witnesses whose names are signed to the foregoing instrumen ,being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the foregoing instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was that time at least 18 years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by and ~ -C~ •~ ^ witnesses, this '~ day of 2004. Notary Public :227447 ~°"°'°~'~°-' NOTARIAL SEAL. DIANNE LENiG, Notary Public Lemoyne Borough Cumberland Co. My Commission Expires Dec. 21, 2005 -5- 111 Wall Street 3rd Floor New York, NY 10043 March 16, 2011 Law of Office Irwin & McKnight PC West Pomfret Professional Cuilding 60 West Pomfret St Carlisle PA 17013-3222 Re: Estate of Clara L Zawadski Account Number: 56K79644 Inquiry Number: 10514158 Dear Client: MorganStanley SmithBarney ~~~~~v~~ BAR 2 3 ~0~` 9RWIN & McK~1~6t~~ ~W OFFICES Thank you for your recent inquiry in regard to the aforementioned account. We would like to take this moment to express our sincerest condolences for your loss. We apologize for this delay with this matter. Enclosed is the estate evaluation you requested and calculated for the date of death provided, which is February 12, 2011. For your convenience, we have also enclosed the statement for the period in which the date requested fell. Please be advised that before the assets in the above mentioned brokerage account can be settled, the Executor/Administrator/Personal Representative must establish a new estate account. This critical step ensures proper reporting of assets under the estate's tax identification number and not the decedent's, as required by IRS regulations. We ask that you carefully review the attached listed requirements in order to establish the new estate account. As soon as it is established, the assets will be transferred from the decedent's account to the estate account, at which point the executor(s) may then act accordingly to settle the assets. Please submit all the requirements in the envelope provided for your convenience. We hope this clarifies any issues or concerns that you may have regarding this account. Please contact us directly at (877) 357-0888 with any additional questions or concerns. We look forward to servicing your investment needs. ncerely, ~~ .~~ /, U or gan i rector MSSB CAC i t Solutions VP/ddd ~~ Morgan Stanley Smith Barney LLC. Member SIPC. ^ Date of Dear_h: 02/12/2011 Valuation Date: 02/12/2011 Processing Date: 05/15/2011 Shares Security or Par Description 1) 10557.56 Bank Deposit Program (BDP) Total Value: Total Accrual: Total: $10,557.56 Estate Valuation High/Ask Low/Bid Estate of: Clara L Zawadski Account: 56K79694 Report Type: Date of Death Number. of Securities: 1 File ID: 56K79699 Mean and/or Div and Int Security Adjustments Accruals Value 10,557.56 $10,557.56 $J.00 Page 1 Please be aware of the following important information: The attached valuation provides you with the value of the assets of the estate shown on page 1 of this document held through Morgan Stanley Smith Barney LLC, member SIPC (MSSB) as of the date shown on page 1 of this document. The valuation is provided to you using software by Estata Valuations and Pricing Systems, Inc. (EVP), a separate company that is not part of MSSB. MSSB provides the EVP service to you at cost. The references to EVP shou_d in no way be considered to be an endorsement of EVP by MSSB. The purpose of this valuation is solely to assist you in preparing required estate (Form 706) and gift tax returns for submission to the Internal Revenue Service. This report is not an official account statement and while it may contain data regarding income, liabilities, capital gains and losses, it is not an official tax statement. Please refer to th= original statement for current account information and any Form 1099's and related materials. All data is believed to be re'_iable, however, it is not guaranteed for accuracy, or completeness. MSSB and its affiliates do not provide tax or lega_ advice. To the extent that this material or any attachment concerns tax matters, it is not intended to be used and cannot_ be used by a taxpayer for the purpose of avoiding penalties that may be imposed by law. 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II, m p =` ~ D ~ ~ ~ r- O ~ ~ N '~ c ~ zv ~o ~~ _z Z Z G7 ~ ~ m p m m N --- D n ~o --i ~ m O 0 ~ D N ~ c ~ ' q1 ~ -~1 W ~ ~ ~ ~ ~ r~. .7 b ~ ~ ~ ~~o v fD ~ ~ b ~ O ~ O ~ ~ Gl ~ '"~ ~ i. a ~ n' ~ ~ o ~' (Q ~ ~ ~ ~ ~ ~ ~ ~ y "~ c°i a, 3 O ~ O d n O = ~ ti ~ ~ < cD CD r« ry: O ~ ~' ~ ~'~= ~ o ~' a 3 ~ `~ °' m ~ Qb ~ ~ ,,. a ~: o ~ o ~ ° C ~ ~ ~ rn Q. ~~~ c°i~c`o `~ ~ m u?i = ~ ~ oa °c a -ci ~ r '~ ~~o ~ ~ ~ ~ cD ~I ' °a ~ ~. ~~ sv ~~ ~ y M ° ° ~ ~ tv ~ ~ ti ~ rn <D ~a ~. ° ~~ ~ c ~. ~ n C ~ ~ ~o c ~, a v 0 o ~ Q ~ rn ~~ ~fi ~ ~ O. ~~-. o ~, ~ ~ sv b 0 cp ~ va ~ o Q1 (np ~ ~ ~, o ~ ry 0 0 0 cD 0 O_ rn ~+ 0 r--l- ~ ~ T~ ^^W ~.1~ r ~n a ~ - ~. ~~ a ~ ~D n ~ ~ a ~_ ~ ~ ~ I p.~. L C ~ ~ rh N n ~ 0 c 3 Q ~D cn rn V co A ~ ~ ~ W ~ W r ~w V1 W _ USAA i :7 USAA ~~ 4/13/2011 3;30;32 PM PAGE 2!002 Fax Server USAA FEDERAL SAVINGS BANK Estate of Clara L Zawadski C/0 Irwin & McKnight, P.C. West Pomfret Professional Bldg 60 W Pomfret St Carlisle, PA 17013-3222 Attn: Roger B Irwin Reference: Estate of Clara L Zawadski April 13, 2011 Dear Mr. Irwin, As you requested, we're providing the balance of Clara L Zawadski's account on the day of her death. Account Type Account Ending in Interest Accrued Balance Savings 1289 $10.93 $28,513.64 This account was established on May 3; 2006. No change in ownership or registration has been made since the account was established. This account is held individually by Clara L Zawadski with no beneficiary designation. Mrs. Zawadski held no other accounts with USAA Federal Savings Bank. If you have questions, please call a member service representative at (800} 531-1045. Sincerely, jd~avLw Ma~.a~ Joann Macias Account Services Specialist USAA Federal Savings Bank USAA I'~cdar~l Savings Da.rtk USAA Savings Dank 10750 I~IcDrriuull Ftrrway 1773 Huw:utl Hu3ltrs Pkwy Slr. 190N L.SAA Rrlu~<Uivtt Sravicrs, Lic. Sw Antonio, TX ?8288-0~~4 L1s Vegas, NV 39109 1~~750 McDermott Freeway 1,800:1 531-22G5 (210) ~I SG-8000 (300) 922-909? S;ut Antonio, TX ',8283-0553 FDIC INSURED FDIC LVSLREL) (SOQi 531-?741. PSEC~ March 9, 2011 Account # 0199X~~:~~X ROGER B IRWIN WEST POMFRET PROF BLDG 60 WEST POMFRET ST CARLISLE, PA 17p13-3222 Dear MR. IRWIN: F.- `I~ BAR 10 2 011 a ~~ LAW OFFICES The following is the status of CLARA L ZAWADSKI's account with PSECU as of the date of death. Joint Owner's Name NONE Date of Death 02.12.2011 Date of Birth 05.02.1923 Share Description Open date Balance Accrued Dividend S O1 Regular Shares 07.17.1998 $ 8.27 $0.00 S 04 Checking 07.17.1998 27,807.56 0.85 S 07 Money Market 12.11.2006 3,767.83 0.51 The dividend earned from January 1, 2011 through the date of death was $5.08. The decedent had no loans with us. We do not have safe deposit boxes for our members. The check for the proceeds will be sent under separate cover. If you have any questions, please ca11234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, ` // i ~ c.M-~a, ~d- r 1viCaC.iG Faire Member Service Representative Finance Support Unit. Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990 • 717.234.8484 • 800.237.7328 Mailing Address: PO. Box 67013, Harrisburg, PA 17106-7013 • 71 7.777.2100 (TDD) • 800.472.1967 (TDD) psecu.com This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender MEMBERS 1st FEDERAL CREDIT iJNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established Estate of: CLARA L. ZAWADSKI Date of Death: 02/12/2011 Social Security Number: 199-14-5853 176605-00 06/17/1998 $5.00 $.00 $5.00 Juanita E. Zawadski 06/17/1998 176605-11 06/17/1998 $. .00 $0.00 J~ ita E. Zawadski 6/17/1998 176605-05 05/12/1999 $18, 379.11 $1.94 $18,381.05 Juanita E. Zawadski 05/22/2007 M BERS 1ST FEDERAL CREDIT UNION n~.1~~ .1~~.~ o Danielle A. Kline Lending Insurance Support Specialist March 3, 2011 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org ._ the future is yours Prepared For: 050014 SH NAS1P003 CLARA L ZAWADSKI 220 NORTH COLLEGE STREET CARLISLE PA 17013 Your Financial Representative: Sherri H Phillips Morgan Stanley Smith Barney 11 North 3Rd Street, 2nd Floor PO Box 12057 Harrisburg PA 17101 For Questions about your Contract: 1-800-344-1029 www.jhannuities.com Yvur Account ~ ~,~ ~ ~ = ~ Venture Vantage Quarterly Statement Issued by John Hancock Life Insurance Company (U.S.A. For the period of January 01 -March 31, 2011 to Date Since I Value as of December 31, 2010 $52,499.96 Total Premiums $0.00 $59,745.25 Total Payment Enhancements $0.00 $2,987.27 Total Withdrawals $0.00 $0.00 Chan a in Value $2,698.56 Value as of Marsh 31, 2ti11 x55,198.52 Surrender Value as of March 31, 2011*: 555,158.52 Death Benefit Value as of March 31, 2011: x59,745.25 *Amount payable upon total withdrawal calculated as Closing Balance, less surrender charges and outstanding loan balance if applicable. Your Investment Allocation Your Account Information Account Number: 2156286 Owner: Clara L Zawadski Annuitant: Clara L Zawadski p Plan Type: Non-Qualified Inception Date: 02/16/2000 ~~ ~~ Your portfolio currently contains the following investments. For specific information on each investment, visit www.jhannuities.com today. z° ~U 0 .. y A x' ,~ 0 N ° -" C to O a r. oNO o~ ~~ 20% T. Rowe Price Equity-Income ~, - 20% T. Rowe Price Blue Chip Growth ~ , _ 20% T. Rowe Price Science 8'< Technology A ° .. - 20% Davis Fundamental Value - 20% UBS Large Cap 100% Total Value g W John Hancock Annuities Service Center P.O. Box 9505, Portsmouth, NH 03802-9505 Produced on: 03/31/2011 Account # 2156286 Page 1 of 2 ~} 9800 Fredericksburg Road San Antonio, Texas 78288 USAA® JUANITA ZAWADSKI March 11, 2011 220 N COLLEGE ST CARLISLE PA 17013-2304 Reference: Policy Information Attached Dear M s. 7.awadski, Enclosed are the documents required to file a claim. When you are ready, please call Sandra Graham at 1-800-~31-8455 extn 7-3274 to walk you through these documents. We value your business and look forward to continuing to serve your financial needs. Thank you, USAA Life Insurance Company 38942 - 48712 • InunPrint MKT.CLT.CLMA 56412-0708 << JUANITA ZAWADSKI Page Number 2 March 11, 2011 Name of Policy: Single Premium Deferred Annuity II USAA Number: 008399888 Policy Number: 6724897874 Beneficiary: JUANITA ZAWADSKI Accumulated value: $23,929.06 Total benefits available: 523,929.06 Fax the Following L?ocuments to 1-877-435-7099: • Claimant's statement • Annuity Insurance Claim Settlement Request Form • Completed application/request form • Tax Withholding Election Form Recommendations: We recommend that you meet immediate financial obligations and place your remaining proceeds into aloes-risk account to give you the time needed for long-term planning. We have allotted time with a financial advisor at no cost to you. During your appointment, your advisor will answer your questions, provide guidance, address any concerns and review your finar_:ial plan, Options: Single Premium Immediate Annuity (SPIA) - If a settlement option that provides for regular periodic payments is selected, IRS regulations require that such payments begin within one year from the date of death. If you choose this option, please call for an application. Lump Sum -Interest earned is taxable in the year paid. The IRS requires that we withhold 10 percent of the interest earnings for Federal income tax. The total amount of interest earned as of today is $13,929.06. If you do not want the tax withheld, complete and return the enclosed Tax Election Withholding Form. Note: • Financial advice provided by USAA Financial Planning Services Insurance Agency, Inc. (known as USAA Financial Insurance Agency in California), a registered investment adviser and insurance agency, and its wholly owned subsidiary. Previous editions are obsolete form HUD-1 (3/ri5) rat Handbook 4305.2 A. Set~lement Statement U.S. Department of Housing and Urban Development B. Type of LOan r)MR Annrnv,l nln '7~n~ n~aG 1. ^'"~° ~ ^FmHA 3. ^Conv. Unins. 6. File Number 7. Loan Number 8. Mortgage Insurance Case Number 4. ^VA 5. ^Conv.lns. CL10064 is orm Is umis e o glue you a s a amen o a ua se amen cos s. moun s pal o an y e se amen agen are s own. C. NOt@: Items marked "(p.o.c.)" were paid outside the Uosing; they are shown here for Information purposes and are not inGUded in the totals. TItIeEXpfeSS Settlement System WARNING: It is a crime to knowingly make false statements to the United Stales on this or any other similar form Penalties upon . conviction can inGude a fine and im risonment. For details sae: Title 1 t3 U. S. Code Section 1001 and Section 1010. Pflnted O7/19I2O1 O at 12:16 VS D. NAME OF BORROWER: Loyetta R. Quinn ADDRESS: 35 S. 18th Street, Camp Hill Pa. 17011 E. NAME OF SELLER: Clara L. Zawadski by her POA Juanita E. Zawadski --- _ ADDRESS: 302 Somerset Drive Shiremanstown PA 17011 '~ `l ~ - ~ r)<. S"8s 3 ~ F. NAME OF LENDER: Cash -- ADDRESS. G. PROPERTY ADDRESS: 302 Somerset Drive, Shiremanstown, PA 17011 -- LowerAllen Township H. SETTLEMENT AGENT: Cornerstone Land Transfer, Inc., Telephone: 717-730-9664 Fax: 717-730-9665 PLACE OF SETTLEMENT: 4705 E. Trindle Road, Mechanicsburg, PA 17050 I. SETTLEMENT DATE: 07/20/2010 J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER 101. Contract sales price 155 000.00 401. Contract sales rice _ 155 000 00 102. Personal Property 402. Personal Pro art . 103. Settlement char es to borrower line 1400 2 745.75 403. 104. 404. 105. 405. Ad'ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance 106. City/town taxes 07120110 to 12131110 296.42 406. Cit /town taxes 07/20/10 to 12131/10 296.42 107. Count taxes 407. Count taxes 108. School taxes 07120110 to 06130/11 " 1 697.62 408. School taxes 07120110 to 06130111 1 697.62 109. SewerlRefuse 07120110 to 09130110 79.44 409. Sewer/Refuse 07120110 to 09130110 79 44 110. 410. . 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 159819.23 420. GROSS AMOUNT DUE TO SELLER 1ST 073 48 200. AMOUNTS PAID BY OR ON BEHALF OF BOR ROWER . 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201. Deposit or earnest money 1 000.00 501. Excess De osit see instructions __ 202. Principal amount of new loans 502. Settlement char es to seller line 1400 7 779 32 203. Existin loans taken sub°ect to 503. Existin loans taken sub'ect to _ . 204. 504. Pa off of First Mort a e Loan __ 205. 505. __ 206. 506. 207. 507. -- 208. 508. -- 209. 509. -- Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 210. City/town taxes 510. Cit /town taxes _ 211. County taxes 511. Count taxes 212. School taxes 512. School taxes 213. 513. -- 214. 514. -- 215. 515. --- 216. 516. -- 217. 517. 218. 518. 219. 519. -- 220. TOTAL PAID BY/FOR BORROWER 1 000.00 ' 520. TOTAL REDUCTION AMOUNT DUE SELLER 7 779 32 300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLE . R 301. Gross amount due from borrower line 120 159 819.23 601. Gross amount due to seller line 420 157 073.48 302. Less amounts aid b /for borrower line 220 1 000.00 602. Less reduction amount due seller line 520 __ 7 779.32 303. CASH FROM BORROWER 158 819.23 603. CASH TO SELLER __.149,294:16 SUBSTITUTE FORM 1099 SELLER STATEMENT: The information contained herein is important tax information and is being fumishad to the Internal Revenue Service. If you are required to file a return, a negligence penally or other sanction will be imposed on you it this item is required to be reported and the IRS determines Nat it has not been reported. The Contract Sales Price described on line 401 above constitutes the Gross Proceeds of this transaction. You are required by law to provide the settlement agent (Fed. Tax ID No: 251751821) with your correct taxpayer Identification number. If you do not provide your correct taxpayer identification number, you may be subject to cavil or criminal penalties imposed Dy law. Under penalties of perjury, I certify that the number shown on this statement is my cored taxpayer identification number TIN: - / - - SELLER(S) SIGNATURE(S): _ ~ SELLER(S) NEW MAILING ADDRESS: --- SELLER(S) PHONE NUMBERS. (H) w, -- form Hu0-FIINAL r HandbPAGE 2 U.S. ~EPARTh'.ENT OF HOUSING AND URBAN DEVELOPMENT File Number: CL10064 SE'I~TLEMENT STATEMENT TitleExpress Settlement System Printed n7llv~n~n of ~•~~,a vc L. Jt 1 1 LtMtN I Gt1AKGE5 700. TOTAL SALES/BROKER'S COMMISSION based on rice $155 000.00 = PAID FROM BORROWER'S PAID FROM ' ' Division of commission (line 700) as follows: FUNDS AT SELLER S ~ F N 701. $ to SETTLEMENT U DS AT 702. $ to SETTLEMENT 703. Commission paid at Settlement - 704. Auctioneer fee to Robert R. Rowe 3 875.00 800. ITEMS PAYABLE IN CONNECTION WITH LOAN --- 801. Loan Origination Fee % --- 802. Loan Discount % -- 803. Appraisal Fee -- 804. Credit Report --- 805. Lender's Inspection Fee -- 806. Mortgaqe Application Fee --- 807. Assumption Fee -- 808. 809. - 810. - 811. --- 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From to $ /da 902. Mortgaqe Insurance Premium for to 903. Hazard Insurance Premium for to --- 904. 905. - 1000. RESERVES DEPOSITED WITH LENDER FOR 1001. Hazard Insurance mo. Imo 1002. Mortgaqe Insurance mo. ~ $ /mo 1003. Cily Property Tax mo. Imo 1004. County Property Tax mo. $ /mo 1005. School taxes mo. $ Imo 1009. Aggregate Analysis Adjustment 0.00 1100. TITLE CHARGES 0.00 --- 1101. Settlement or closing fee - 1102. Abstract or title search 1103. Title examination -- 1104. Title insurance binder -- 1105. Document Preparation 1106. Notary Fees to Irwin & McKni ht P.C. ' 15.00 1107. Attorney s fees to Irwin & McKnight, P.C. _ 475.00 (includes above items No: - 1108. Title Insurance to Cornerstone Land Transfer A ent for FNTIC 1 133.75 (includes above items No: 1109. Lender's Policy --- 1110. Owner's Policy 155,000.00 -1,133.75 1111. --- 1112. --- 1113. -- 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES - 1201. Recording Fees Deed $ 62.00 •Mortgaqe $ • Release $ 62.00 1202. City/County tax/stamps Deed $1,550.00 •Mortgaqe $ 1 550.00 _ 1203. State Tax/stamps Deed $1,550.00 ~ Mortgage $ __ 1 550.00 1204. - 1205. -- 1300. ADDITIONAL SETTLEMENT CHARGES ~- 1301. Survey 1302. Pest Inspection -- 1304. Reimb for tax cart - Ctylfw to Cornerstone Land Transfer A ant for FNTIC 10.00 1305. 2010 School tax to Jud Prowell _ 1 756.37 1306. SewerlRefuse (JAS) to Lower Allen Townshi Sewer Authori _ 97.95 1400. TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section K 2 745.75 __ 7,779.32 HUD CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowletlge antl belief, it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I fu er certify that I have received a copy of the HUD-1 Settlement Statement. L :I ~ /ye u l ra awe s i y er uanl a awes i WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION trarl6action. I have caused or will cause the f ds to be disbursed ~n accordance with this sl IemenL CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: tom`///'- ~~~0//~ U.S. CODE SECTION 1001 AND SECTION 1010. SETTLEMENT AGENT DATE. r ~ ~ ~ . ~ ~ 219 North Hanover Street Carlisle, Pennsylvania 17013 t r `~ 717.243.4511 ' ~ - toll free 1.866.451.4511 fax 717.243.3723 ~~- www.hoffmanroth.com /' ~ FUNERAL HOME ~ CREMATORY, INC. infoQhoffmanroth.com Juanita Zawadski 220 North College Street Carlisle, PA 17013 February 23, 2011 Statement of Funeral Expenses for: Clara L. Zawadski Date of Death: February 12, 2011 ~ Account Id: 16167-044 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,550.00 Sub Total: $ 4,550.00 MERCHANDISE: Casket: Whitmire II $ 2,400.00 Sub Total: $ 2,400.00 TOTAL FUNERAL HOME CHARGES: ~ $ 6,950.00 CASH ADVANCES: 10 Certified Death Certificates at $ 6.00 each $ 60.00 Newspaper Notice -Sentinel $ 160.68 Newspaper. Notice -Patriot $ 270.17 Clergy $ 100.00 Flowers ~ $ 159.00 Hairdresser $ 40.00 Newspaper Notice -Wilkes Barre Times Leader ~ $ 60.00 Add'tl Death Certs 5 $ 30.00 Organist ~ $ 125.00 Alter Servers 3 @ 10 ~ $ 30.00 Sub Total: $ 1,034.85 Total Funeral Expense: $ 7,984.85 Total Payments Made: $ 6,950.00 Payments Made: Funeral Directors Life Check 167276 Feb 23, 2011 6,908.54 PreNeed Discount Discount Cont vs PreN Feb 23, 2011 41.46 Balance: Please return this portion with your Remittance. ~ Amount Enclosed ~a L. Zawadski °ce ID#: 16167-044 SERVING OUR COMMUNITY SINCE 1 907 • ~~ ~~ BETRA I Home - 1026 Ritner ighway Carlisle, PA 17013 717-258-3881 BILL TO Clara Zawadski 220 N. College St. Carlisle Pa, Pa 17013 DESCRIPTION HOME HEALTH AIDE HOME HEALTH AIDE HOME HEALTH AIDE ~~ mN z HOURS 2 2 2 --- w ~~~ zm z w ~ RATE 25.00 25.00 25.00 Invoice DATE INVOICE# 2/28/2011 4009 PATIENT NAME Clara, Zawadski SERVICED AMOUNT 2/3/2011 50.00 2/7/2011 5 0.00 2/ 10/2011 5 0.00 oc w d w R ,~ t• Patricia A. . March 4, 2011 Certified Public Hcc.A ~ 701'5 255 Hickory Rd. • Carlisle P 3184 Telephone or fax: (717) 243 e-mail: rosendaleC~comcast.net Irwin & McKnight PC 60 W. Pomfret St. Carlisle PA 17013 T~payer: Clara L. Zawadski Gentlemen: tax returns for the above taxpayer. Please take a few Enclosed are 2010 Federal and State income filin instructions: minutes to review these returns and note the following g electronically. Be sure to pay the balance of $1,281 to Federal Return -The return will be filed A ril 18, 2011. Use the enclosed coupon and mail the the United States Treasury no later than p payment to: Internal Revenue Service p, O. Box 37008 Hartford CT 06176-0008 si n Form 8879 and return it to me as soon as possible. Please ask the executor to g . _ eturn will be filed electronically. No tax is due with this return. Pennsylvania Return The r Form PA-8879 and return it to me as soon as possib e Please ask the executor to sign s for our files. Please call me if you have any questions I have included a copy of the return y about these returns Rnsendale CPA, LLC ,sours truly, ~-~ ~~ c.` Patricia A. Rosendale, CPA and Burden Estimate Statement See Reverse Side "Notice to Account Owners'" Copv ~i ,~ OMB N0: 1510-0043 wn~n wr~n~l 19ATC. oi~o ins - ~EPOSEI' ~....,...,,-.. -- ---- -. --. -- FROM: ELECTRONIC FUNDS TRANSFER DEFENSE FINANCE AND ACCOUNTING FEDERAL RECURRING PAYMENTS SERVICE -CLEVELAND C E N T E R P.O. BOX 998017 CLEVELAND OH 44199-8017 NOTICE OF RECLAMATION , DATE: 201 10223 P 11 A94 RECIPIENT AND/OR BENEFICIARY NAME CLAIM NUMBER DATE OF DEATH ZAWADSKI CLARA L 199-14-5853 20110212 AGENCY DATE OF AND/OR TRACE PAYMENT TYPE OF NUMBER TYPE OF ACCOUNT DEPOSITOR ACCOUNT NUMBER AMOUNT PAYMENT 20110301 USA ANNTY 041036007016882 C 0450028881 1446.65 ~~ '1 .,~ 0 1 7i ~~ AMOUNT OF PAYMENTS RECEIVED WITHIN 45 DAYS OUTSTANDING TOTAL 1446.65 NOTICE TO ACCOUNT OWNERS FROM THE GOVERNMENT The Government has received information that that the person named on this notice is deceased. The purpose of this notice is to inform you that by law entitlement to Government benefits for this person ended at death. Therefore, the Government must recover all payments made after the date of death. If there has been an error and this person is not deceased, or if the date of death is wrong, this notice explains how to correct the mistake. If you do not understand this notice, please get help from either your financi al institution or the Gov ernment agency that was making payments. PAYMENTS TO THIS PERSON HAVE BEEN STOPPED Your financial institution has been asked to return the payments shown on this notice to the Government because they were issued in error. The Government has asked your financial institution to send this notice to you, the account owner. Your financial institution must notify you if it has taken action to recover these funds from the account. Contact your financial institution immediately if you do not understand its actions. If the Government is unable to collect from the financial institution the full amount of the payments made after death, you may be contacted by the agency which made the payments. IF THE PERSON IS NOT DECEASED If the person is not deceased, immediately contact both your financial institution and the agency that made the payments to correct the error. The Government regrets any inconvenience this error may cause. Your financial institu- tion can correct the collection action if it is given satisfactory proof that the person is alive. NOTE: YOU MUST CONTACT THE AGENCY THAT MADE THE PAYMENTS- BECAUSE THIS ERROR HAS STOPPED FURTHER PAYMENTS. ONLY THE AGENCY CAN RESTART THE PAYMENTS. NOTICE TO ACCOUNT OWNERS