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HomeMy WebLinkAbout08-24-111505610140 REV-1500 Ex (~,_,~> PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year 1=ile Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 1 0 0 0 6 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 7 9 1 0 3 8 5 8 1 2 1 9 2 0 1 0 0 2 0 7 1 9 1 4 Decedent's Lasf Name Suffix Decedent's First Name MI H A L L C A T H E R I N E R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) ~ Q 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 T0: Name Daytime Telephone Number J O E L R. Z U L L I N G E R 7 1 7 2 6 4 6 0 2 9 First line of address 1 4 NORTH MA I N S T R E E T Second line of address S U I T E 2 0 0 City or Post Office State CHAMBERSBURG P A REGISTER OF WILLS USE DNLY r , ~ _: -~-n - _' -:;_ i _ -,, ;.r_~ ___ ! 7 ... ,~ _. _ :. _. ZIP Code _.___ DATE FiL~b _T ~ _ f _J r,, -r1 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 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 hasp any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DAl E i ADDRESS `" • 137 BLACK BIRD LANE SHIPPENSBURG PA 17257 NATO E OF PREPAR O THAN P SENTATIVE D -~"E ADD SS , 14 ORTH MAIN REET, SUI 200 CHAMBERSBURG PA 17201 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 REV-1500 EX 1505610240 Decedent's Name: CATHERINE R. HALL RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1 2. Stocks and Bonds (Schedule B) ...................................... 2• 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) .......................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. Decedent's Social Security Number 1 7 9 1 0 3 8 5 8 4 4 4 1 1 3.4 0 2 0 5 4. 0 0 2 8 5 0 7, 2 7 7 2 8 8 1. 4 1 5 4 7 6 5 6, 0 8 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 10) ............................... 11. 12. Net Value of Estate (Line 8 minus Line 11) ....... .............. ..... .. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) . .............. ..... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . .............. ..... .. 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.0 _ 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 5 2 7 2 8 6. 3 9 16. 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable 0 0 0 at collateral rate X .15 18. 19. TAX DUE ......................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610240 2 0 3 6 7. 1 5 2. 5 4 2 0 3 6 9. 6 9 5 2 7 ? 8 6. 3 9 5 2 7 2 8 6.3 9 0. 0 0 2 3 ~~ 2 7. 8 9 0. 0 0 0. 0 0 2 3 ;~ 2 7. 8 9 1505610240 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 11 0006 DECEDENT'S NAME CATHERINE R. HALL STREET ADDRESS Shippensburg Health Care Center _121 Walnut Bottom Road clTV Shippensburg STATE ZIP PA 17257 Tax Payments and Credits: 1 • Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 20,306.25 B. Discount 1,068.75 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) 23,727.89 Total Credits (A + B) (2) 21, 375.00 (3) (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2,352.89 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : .................................................................... .. ^ X^ b. retain the right to designate who shall use the property transferred or its income; ............................. .. ^ X^ c. retain a reversionary interest; or .............................................................................................. .. ^ X^ d. receive the promise for life of either payments, benefits or care? ..................................................... .. ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ..................................................................................... .. ^ Q 3. Did decedent own an "intrust for" or payable-upon~Jeath bank account or security at his or her death? ....... .. ^ X^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ................................................................................................ .. 0 ^ 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. REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER CATHERINE R. HALL 21 11 0006 All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Investment Account #50 00 1013 0 02, Orrstown Financial Advisors, consisting of 444,113.40 assets as shown on attached date of death valuation TOTAL (Also enter on line 2, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER CATHERINE R. HALL 21 11 0006 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Genworth Financial, refund of unearned premium 1,540.00 2. U.S. Treasury, 2010 income tax refund 452.00 3. PA Department of Revenue, 2010 income tax refund 62.00 TOTAL (Also enter on line 5, Recapitulation) I $ 2 054.00 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEF JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: CATHERINE R. HALL 21 11 0006 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. Maxine E. Mohn e. C JOINTLY-OWNED PROPERTY: 137 Black Bird Lane Shippensburg, PA 17257 daughter ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTERESI 1, A. 5/08 Checking Account #103007920, Orrstown Bank, 57,214.54 50. 28,607.27 including interest accrued to date of death TOTAL (Also enter on Line 6, Recapitulation) I $ 2$,607.27 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER CATHERINE R. HALL 21 11 0006 This schedule must be completed and filed if the answerto any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDETHENAMEOFTHETRANSFEREE,THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER,ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION pFnPPUCns~e) TAXABLE VALUE 1. Annuity Contract#W0020814491, Western-Southern Life 72,881.41 100.00 72,881.41 Assurance, named beneficiary Maxine Mohn TOTAL (Also enter on Line 7 Recapitulation) I $ 72 881 41 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER CATHERINE R. HALL 21 11 0006 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home, funeral services 11,232.65 2. Spring Hill Cemetery Association, grave opening 600.00 3. Meal after funeral 250.00 B, 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: Joel R. Zullinger 3, Family Exemption: (If decedent's address is not the same as claimants, attach explanation.) Claimant Street Address 4 5 6 7 City State ZIP Relationship of Claimant to Decedent Probate Fees: Register of Wills -Letters 410.00; will 15.00; JCS fee 23.50; automation 5.00; short certificates 16.00; filing return 15.00 Accountant Fees: Tax Return Preparer Fees: Preparation of personal income tax returns 7,500.00 484.50 300.00 TOTAL (Also enter on Line 9, Recapitulation) ~ $ 15 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OS) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER CATHERINE R. HALL 21 11 0006 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 Chambersburg Imaging, balance due 2.54 TOTAL (Also enter on Line 10, Recapitulation) ~ $ 2 54 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CATHERINE R. HALL 21 11 0006 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. Maxine Elizabeth Mohn Lineal 137 Black Bird Lane residue of estate Shippensburg, PA 17257 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 TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. Jan. ~. ~0 ~~ ~ ti r,'v ZU'__I ~GE~~'-DA'VI` '~C r-~ <<< ~. . _~; - . `.~{~ _ - ,~.~~ .~ - --: m i ~,~ w ,' -' ~ LAST WILL AND. TESTAMENT ---~ _ - --; ~. r T, Gatheri.ne R. Hall, of Southampton Township, Franklin County, Pennsylvania,. .being of. sound and disposing mind, memory and understanding, do her.eby.d,eclare. this to be my wi11, hereby .r.evoking any and all Former wi.11s and. codicils thereto by .me heretofo.xe made. FIRST T d~..rect ...that .all my just ..debts and funeral e:Xpenses , including a11. expenses o£ my last it l.ness , . sha ll. be paid from my . .estate .a s. soon as practicab.~.e after my. decease, as a part of the exp.ense~ of .the administxat~..on of my .estate. ' 5 E.COND I give,..devisee and..be.que ath. the ..resi:due of my estate of .every nature and wherever. s.i:tuate . to my husband, ~7ohn Henry Hall, providing he shall survive .me. by thirty. days. THIRD 3h.ould my ..husband p.re.decease' me or . die on or . before . the thixty-f~ir.st. day fol].ou~ing my..death, I give, devise and, bequeath the residue of my. e.s:tate of..eveacy nature ,and .whenever situate to my daughter, Maxine El.izabetti Moh'n; pz-~o ided , .that . should my . said Page :.l of a Fi.:ver-:P~~e V~i;l1 Received Time Jan. 3. 10:59AM ~dn, _. L~~' ~,~rid L.,_'_.1G"_h.-JH~VTJ "~ ( (-~~r-~LLL daughter predecease me or . die on oz b:efo.re . the .thirtieth .day following my death, T give,. devise and be.que.ath the residue of my estate of. every na.tuxe and wherever. siay;ate to my grandchildren, namely, Gregory Lee Mohn, Jeffrey Lynnr~^.ohri and Stephen Edward T Mohn, in equal. shares. Should any of my sand grandchildren p.r.ed.ecease me or. die on or. before the .thirty-first day following my .death, such share .shall be distributed to .their issue, per stirpes, living at the time of my .death, and in ~def.ault of any . such then-Living issue, to my .other grari.dchi.l.dreri Living at. the. time of my..de.ath . FOURTH Any fiduciary. under this will. .shall have :the following powers in addition to those Vested in them by law .and by .other provisions of my will applicable to all property, whether principal or income, including property he.].d for minors, e.xercisab.le without Court approval, and effective until actual. distribution of all property: A. To retain .any and all of. the ,as,sets of my .estate, .real or personal, without .regard to any principle of diversification of risk. B. To invest .in all forms of 'prop'erty, including .stock, common trust funds and mortgage investnlerit funds without restriction to investments authori.z.ed for.Pennsy.lvania fiduciaries, as ..they deem proper, without regard to any principle of diversification of risk. C. To .sell at .p.ubl:ic 'oz pr.iwa.te. sale, to exchange or. to Page 2 of a Five-Page Will Received Tlme Jan. 3. 10:59AM Jdn~ ~ Ll,~ ~ l ~iV L ~~_ ~~GEIQ.-~A~.., 'C I I J~~~ ~LL L ~'i ~, f~~ L .lease, for any peziod of time,: .any rea]. or personal propexty, .and to give options for sales,: exchanges or leases, for such p~:ices and . upon such tezms or condi tio.ns as. they. deem pro.pex. D. To al~.:ocate receipts and.rexpenses. to principal or income 'or partly to. each 'as. they from time 'ba time. think p~:ope.r. E. To. compromise any claim or controvezsy. F. To distribute in cash• or in kind or partly each. G. To. hold property .in. their names without :designation of any fiduciarycap.acity ox in ..the name' of anominee or un.registere:d. Fz~Tx I. direct 'that all taxes: that may. be ;assessed ,in canseq,uence of my..death, of whatever. nature and. by .whatevver .juri.sdictian imposed, ..shall. be paid from my .res.iduary..estate ,as 'a part of .the expense of ..the. administration of my..estate. SIXTH I' appo.i.nt my. husband, .John ~Tenry. Hall, .as executor of. this 'my will. Should my .husband p.re.decease' me', 'fail to qualify or .cease to .act, I appoint my. daughter, Maxine ~Eliz.abeth Mohn:, .as. ex.e.cutrix of ..this my will. Sh.ou.ld. both my husband and. d.augh.ter pr.ede.cease me, fail to qualify ox . cease . to act, Z appoint my gran.dchild.ren, Gregory .Lee Mohn, Jeffrey Lynn Mohri, and .Stephen Edward Mohn, co--e.xecutorx of this my will. Page. 3 .of a Five-Pa.ge Will Received Time Jan. 3. 1Q:59AM Jan. 3. 2011 ,~BAtr ZU~Lii~GER-DAMS G 117-530-22~ ua %~d,~' -. SEVENTH No. bond. shall be requi.r.ed of any fiduciary. hereunder in any jurisdiction. N r IIv WITNESS WHEREOF, I. have. hereunto .set my. hand .and ,seal to .this, my. last wi11 a.nd..testament,. consi'sfing of five typewritten pages, .the first three of which. bear mg signature in the margin for the purpose of identification, this .G ~ day of ~~1 ~~ L1..L - 19 ~. Si.gn.ed, se~a.led, published and ..declared . by . the above-named testatrix, as :and for her last wi11 .and,.testamerit in .our presence, who in her presence, at .her re.q.ue.st and -in the p.res:ence of.e.ach .other have hexeunto .s.et .our hands as :attesting wi.tnes.se~s. ,.~ ~ L~A~~~ JYct, ~, Addr.es's' -- -- - A res s~ We ,. Catherine R. Hall , ..~..~a ~e'J ~ , ,Z.u %7~`~ ~'c i , .and -~ - L P~~SC~ ~(. ~~;~ k~~ ld e ~ ~ , the testatrix .and ..the witnesses , resp:e,ctively, whose names "are. signed to the attached or foregoing instrument, being first . duly . sworn, do hereby declare to the undersigned authority that .the. .testatrix. signed and. executed the instrument as her last wilh and. that. she had. signed willingly (or willingly directed another to sign for her), and that she. exe.c.uted it as her f.r.ee a.nd. voluntary act .for ..the purposes therein exp.res.sed, and. that ..each of . the . witnesae's, in ..the pr.esen.ce and Page 4 of a Five--gage Will Received Time Jan. 3. 10:59AM f a n. ~ O i '~~ y :. t~ r,'d ~ U'~~_ I ~ ~~~ G E R- ~~ A d? ~ C i i l -'~ ~ C~ -; ~<< 1'0. ~'~Ci~ J, 6 hearing of -the .testatrix. signed. the will as witnesses and to the .best of, their knowledge, the. testatrix was at. that time. eighteen .years of age or o.l,der, of. sound mind and. under no constraint or undue influence. SubsCr.ibed, sworn to and .acknowledged before me by .the .ab.ove-named .testatrix and s.ub.scrib.ecl, and sworn to. befoxe me by the above=named witnes.se's, this 'loc`i daY~ of ~ r~.,~ri~e~ ~. 19 ~7 . ~ n~:. ~. Notary Public VELDA M. SEASE, Notary PUb11C Shippensburg, Cumberland Co., Pb. My Commission Expires April 16, 199{7 Page 5 of a F.iye=Page Yn7i7,1 Received Time Jan, 3. 10:59AM ~~./u~o1Gl~/' Wi:tnes:s JRPJ-07-2011(FRI) 15;16 P. 002/002 CHARLENE FEUCHTENBERGER, FIDUCIARY OFFICCR ORRSTOiAN FYNANCIAL ADVISORS 77 EAST KING STREET, SHIPPENSBURG, PA 17257 Estate of: ESTATE OF CATn eRiNE R. HALL D3CC oY Death: 12/19/2010 Account: 50 00 1013 0 02 Valuation Dace: 12/19/2010 ReporC Type: Date of Death Procesfling bate: 01/0'1/2011 Number OE uecurities: 7 File :L D: C. HALL 1013 bean and/or Div and Int SoCUrlty 9haros r ear Security Doscripclon High/Ask Low/pid Adjustments Accruals value o 11 100000 COLUMBUS BK d TR CO GA (19BBBZE201 Financial Timea Interaetlve Data DTD: 10/15/2009 Ndt: 10/19/2011 1.02 12/17/2010 12/20/2010 Int: 10/15/2010 to 12/19/2010 2) 371p.575 FEDERATED INCOME TR 1314199100) INuTL SHRS Mutual Fund las quoted by NASDAQ} 12!17/2010 3) 5345.595 FEDERATED TOTAL RETURN S6RS 13142BQ1011 TOTE RET INSTL Mutual Fund (as quoted by NASDAQ) 12/1.7/2010 q) 40000 PARKNAY BST HAR~COOD IIGTS IL (70153RGT9) Financial Times intaractlve Data DTD: 09/07/2010 Mat: 09/09/2013 1.5'd 12/17/2010 12/20/2010 Int: 12/0/2010 to 12/19/2010 5) 10224.948 ROME T PRICE "u1fDRT TERM BD FD (71957P105) COM Mutual Fund las quoted by NASDAQ) 12/17/2010 61 6895.839 VANGUARD FIXED INCOME SECS FD 1922031836) STRM INVGRA AD Mutual Eund (as quoted by NASDAQ) 12/17/2010 7} 3673.77 VANGUARD FIXED INCOML~ SECS FD {922031869) INI'L eubT SECS Mutual Fund {as quoted by NASDAQ) 12/17/2010 Total ValuC: Total Accrual: Total: Cg12,120.fi9 101.03125 A/B 101.01660 Ml:t 101.023925 10.55000 Mkt 10.550000 11.11000 Mkt 11.110000 100.46875 A/B 100.48300 Mkt 100.475875 4.89000 Mkc 4.A40000 10.77000 MkC 1o.77oaoo 13.14000 Mkt 13.190000 101,023.93 320.OD 39,146.57 59,389.56 40,190.35 20.00 49,gBB.75 74,268.19 48,273.34 5411,780.69 9340.00 Portfolio EndnoCes OD DAILY DEC: TOTAL SHS: 31,989.29 COST: 1.00 MKT VALUE: 31,989.29 ACCRUED INTEREST: S3.d2 Pagc 1 This YOpOrt was produced with Estateval, a product of Estato valuations S Pricing Systems, Inc. If you nave questions, p1©asc ConCact EvP Systems at (810) 313-6300 or www.evpsys.COm, !Revision 7.1.1) Received Time Jan. 7. 3:24PM JRN-07-20111FRI) 1,29 1,..)RRSTOWN ~~ A Trndit~ron of Excellence Joel R. Zullinger, Esq. Zullinger-Davis Law Offices 14 North Main Street Suite 200 Chamber. sburg, PA 17201 Fax 264-1884 January 7, 2011 Re: Estate of Catherine R. Hall Social Security Number 179-10-3858 Date of Death October 26, 2010 1T IS ,HERERBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE FOLLOWING ACCOUNT WITH ORI2STOWN BANK.• CHECKING ACCOUNT Account No. -- Account 1~pe - Date Opened. - Joint Account (name/date) Balance - Accrued Interest - 103007920 50+ Interest Check 5/8/08 Maxine E. Mohn 8/8/08 $57,203.57 $10.97 In,~ormation on Trust accounts will be r~rovided under separate comer. F. OO1i001 77 Eest King Street PO. Box 250 Shippensburg, PA 17257 1.888.ORRSTOWN Best Regards, Vicki L. Gullixon Customer Service Specialist Received T I m e Jan. 7. 2 : 46 PM ,~,wv,r.®rrst®w~.~®sza Western & Southern Life A member of Western & Southern rinancial Group JOEL ZULLINGER ESQ 14 NORTH MAIN ST STE 200 CHAMBERSBURG PA 17201 Dear Mr. Zullinger: Annuity Operations PO Box 2918 Cincinnati, OH 45201-2918 toll free 800.926.1702 fax 513.629.1799 February 4, 2011 Thank you for your request for information on the annuity contract. I hope the following contract information is helpful to you. Annuitant: CATHERINE HALL Owner: CATHERINE HALL Western-Southern Life Assurance Company Contract Number: W0020814491 Current Interest Rate: Contract Value: $72,881.41 Surrender Value: The quoted value information is as of 12/19/10. if you i lave a~ y questions, please caii uur Annuity Operations vepar'tment ai 1-800-926-1702. A representative will be happy to help you. Sincerely, ~" ~` Lois Craft Annuity Operations Department DC0331-0810 Western-Southern Life Assurance Company