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HomeMy WebLinkAbout08-06-11 J 1505610101 REY-1500 Ex~°~-~°, . P Department of Revenue Bureau of Individual Taxes pennsylvania OFFICIAL USE ONLY DEPARTMENT OF REVENUE County Code Year PO BOX 280601 File Number INHERITANCE TAX RETURN Harrisburg, PA 1128-0601 ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT ~ 1 ~ 1 ~~ - ~-~` Social Security Number Date ~a~~~s~D~ of Death MMDDYYYY Date of Birth MMDDYYYY a De d ' ~a~ ~ ~ ~ ~ ~ ' ce ent s Last Name ~,a.Cs~~ S-~~v Suffix Decedent's First Name MI ~.ns ~a ~ If ` >/ ~ ( Applicable) Enter Surviving S Ouse's Infor p matron Below Spouse's Last Name S-~ ~ U ~ Suffix Spouse's First Name MI n ~ S ' ~f"L~ pouse s Social Security Number n L5 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate O prior to 12-13-82) 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O (Attach Copy of Will) 7. Decedent Maintained a Livin Trust g 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 ~ ~ ~~ ~ ~ - ~ C ~ ~ Daytime Telephone Number ~~ S ~ !1 ' - ~ 1~ S D 3 '~ ~ l~ REGISTER OF WILLS USE ONLY .... .4 First line of address ~ -- - -~ ,_`~ -- ~:.- ;~~ ,~ 3 k~ ;. Second line of address ~~ ~ ~ I _; C'~ ' _U7~ ~~' ~; _. .. - -, City or Post Office ~ ~ ~~ State ZIP Code ~~ ~ LED - t~ ': ~., -~~ 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 has any knowledge. SIGNATU E RSO ESPO FOR FILING RETURN DATE ADDRESS , `> -I Q'-~- f SIGNATURE OF PREPARER OTHER HAN REPRESENTATIVE DATE ADDRESS _ PLEASE USE ORIGINAL FORM ONLY L Side 1 1505610101 1505610101 J ~~~ J 1505610105 REV-1500 EX Decedent's Social Securit i Number Decedent's Name: RECAPITULATION 1 ~ DD• D~ .................................... 1. Real Estate (Schedule A)........ . ... • . 2. _ ~/ I ' f '~ ~,/ 2. Stocks and Bonds (Schedule B) ................................... ~, ~# -~' 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. • • • 3• . " 4. Mortgages and Notes Receivable (Schedule D) .. • • • • • • • ~ • • ~ • ~ • • • ~ • • • ~ ' ' ' ' E) l d h 4. 5. v ., .- ~ ~~ ~ ~~ ....... e u e ' Miscellaneous Personal Property (Sc 5. Cash, Bank Deposits and 6 ° `°'*~` '~' ~. -- ~'~ Se arate Billing Requested ....... 6. Jointly Owned Property (Schedule F) Q p Vivos Transfers & Miscellaneous Non-Probate Property t I . 7 ~ ~ er- n 7. (Schedule G) Q Separate Billing Requested........ . ~. ;~- ................. h 7 8. ) ............ total Lines 1 throug 8. Total Gross Assets ( - ,. (.,~ 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 10. ' s^ , ."•" 3 ~ ~ ~ e Liabilities, ( ............. ' ' ' ' and Liens Schedule I) t Mort a 10. Debts of Deceden , 9 9 1 . , . . ~.. `" ~V~~ `.~ ~~ >~V~~ ' nd10.... .................. 11. Total Deductions (total Lines 9 a • - ~ • ~ ~ ~ • ~ ~ ~ . _ - ~!~ -, ~ ~ ~ ~^ M (~ ~ Line 8 minus Line 11) ................ . . • ~ ~ • • • • 12. Net Value of Estate 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which .... 3. . ~ .~ ~-~- -~ ~ J ~ ..r • snot been made (Schedule J) .................... ax ha an election tot . . 14. - - ~ ~ VV m ...... 14. Net Value Subject to Tax (Line 12 minus Line 13) ... . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers and r Sec. 9116 15 ~,.~~ '~ ~ ~ !~ ~ ~ ~; ~ ~ , ~ , a (1.2) X .0 O Amount of Line 14 taxable 16 16 r....~ s -"" ' . ~ . ~ at lineal rate X .0 - ,. ~ 17. Amount of Line 14 taxable 17 ~ `° - ~~ ' J ~ ' i .-~M at sibling rate X .12 ~` _ 18. Amount of Line 14 taxable ~ ~* at collateral rate X .15 18. -"'' ' - ~` r' "'J` ~ x ~ ;' - °`~ ~ '' "~'~~ `~ 19. TAX DUE ....................................................... 19. . . ;- 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610105 15056101051 O J REV-1502 EX+ (11-08) ~ pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE nF I~_r~l ~ . ~~~~~ FILE NUMBER n ~~v~,~ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable Real property that is jointly-owned with right of survivorship must be disclos defined as the price at which property knowledge of the relevant facts. Attach a copy of the settlement sheet if the property has been sold, ed on Schedule F. ITEM NUMBER Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE DESCRIPTION OF DEATH 1. ~ ~ lV ' ~. s~m~- l. ~l ~ ~~ ~d OD ~~ ~' `~~4~e fl~pnue bola InD2,5 TOTAL (Also enter on Line 1, Recapitulation.) $ If more space is needed, insert additional sheets of the same size. DS,`l6~- ~ sno- Cumberland County Pennsylvania TAX COLLECTOR COPY -RETURN WITH PAYMENT FOR PROPER CREDIT COULSON, CARRIER 31 RIDGE AVENUE ~ HUMER STREET 426 RIDGE AVE Acres .160 Deed: 00149-00056 ENOLA, PA 17025-2235 ENOLA TERRACE LOT 9 BLOCK E PB 1A PG 3 Residential(Under 10 Acres) Bill No: 1309 Bill Date: 3/1/11 Control No: 09002418 MAP NO: 09-14-0834-099 Payable To: DEBBIE LUPOLD, TREASURER Assessed Value: Land: 37,700 Improvement: 21,100 T'otai: 58,800 98 S ENOLA DRIVE; ROOM 101 ENOLA, PA 17025 COUNTY R/E Discount 1.90200 $109 60 Face Penalty Phone: (717) 901-9392 COUNTY LIB . 14300 $8 24 $111 84 $123.02 MUNIC. R/E .95700 $55 14 $8.41 $9.25 TAX AMOUNT DUE . $56.27 0 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII If Date Of Payment Is On $172.98 3/1/11 thru 4/30/11 $176.52 $194.17 5/1/11 thru 6/30/11 7/1/11 or Later Payable To: DEBBIE LUPOLD, TREASURER 98 S ENOLA DRIVE; ROOM 101 ENOLA, PA 17025 Phone: (717) 901-9392 MAP NO: 09-14-0834-099 Desc: 31 RIDGE AVENUE &HUMER STREET Acres .160 Deed: 00149-00056 ENOLA TERRACE LOT 9 BLOCK E PB 1A PG 3 Residential(Under 10 Acres) I IIIIII VIII VIII IIII VIII III VIII (IIII IIII IIII $1.00 FEE FOR ADDITIONAL RECEIPTS Tax Payer: COULSON, CARRIE R 426 RIDGE AVE ENOLA, PA 17025-2235 Office Hours: MONDAY THRU THURSDAY 9:00••4:00 • • • PHONE (717) 901-9392 BUI No: 1309 Bill Date: 3/1/11 Control No:09002418 Assessed Value: Land: 37,700 Improvement: 21,100 Total: 58,800 COUNTY R/E Discount 1.90200 $109 60 Face Penalty COUNTY LIB . .14300 $8 24 $111.84 $123.02 MUNIC. R/E . .95700 $55 14 $8.41 $9.25 TAX AMOUNT DUE . $56.27 $61.90 If Date Of Payment Is On $172.98 3/1/11 thru 4/30/11 6/ 52 5/1/11 thru 30/ 7/1/11 or Later TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS . ~~,~~« ~~.~~~~~'- ~~~- ~ ~~ ~ ~' • C DEBBIE LUPOLD, TREASURER 98 S ENOLA DRIVE; ROOM 101 ENOLA, PA 17025 TEMP - RETURN SERVICE REQUESTED ~ ' • .~ ~ COULSON, CARRIE R 86916-1234 426 RIDGE AVE ENOLA, PA 17025-2235 I~~~III~~~III~~~~~I~i~l~l~„I~I~~i~l~~ll~~l~l~~~l,l,ll~„I~I,I 86916-R-1234 Cumberland County Pennsylvania TAX COLLECTOR COPY -RETURN WITH PAYMENT FOR PROPER CREDIT COULSON, CARRIER 424 RIDGE AVENUE 424 RIDGE AVE Acres .170 Deed: 00215-00864 ENOLA, PA 17025-2235 LOT 8 BLK E Residential(Under 10 Acres) Payable To: DEBBIE LUPOLD, TREASURER 98 S ENOLA DRIVE; ROOM 101 ENOLA, PA 17025 Phone: (717) 901-9392 Bill No: 1308 Bill Date: 3/1/11 Control No: 09002417 MAP NO: 09-14-0834-098 Assessed Value: Land: 35,300 Improvement: 73,400 T~~tal: 108,700 Discount Face Penalty COUNTY R/E 1.90200 $202.61 $206.75 $227.43 COUNTY LIB .14300 $15.23 $15.54 $17.09 MUNIC. R/E .95700 $101.95 $104.03 $114.43 TAX AMOUNT DUE If Date Of Payment Is On $319.79 3/1 /11 thru 4/30/11 $326.32 5/1 /11 thru 6/30/11 $358.95 7/1 /11 or Later ~ ~ - Payable To: DEBBIE LUPOLD, TREASURER Office Hours: MONDAY THRU THURSDAY 9:OC--4:00 Bill No: 1308 98 S ENOLA DRIVE; ROOM 101 PHONE (717) 901-9392 Bill Date: 3/1/11 ENOLA, PA 17025 Control No:09002417 Phone: (717) 901-9392 MAP NO: 09-14-0834-098 Desc: 424 RIDGE AVENUE Acres .170 Deed: 00215-00864 LOT 8 BLK E Residential(Under 10 Acres) I (VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII $1.00 FEE FOR ADDITIONAL RECEIPTS Tax Payer: COULSON, CARRIE R Assessed Value: Land: 35,300 Improvement: 73,400 Total: 108,700 Discount Face Penalty COUNTY R/E 1.90200 $202.61 $206.75 $227.43 COUNTY LIB .14300 $15.23 $15.54 $17.09 MUNIC. R/E .95700 $101.95 $104.03 $114.43 TAX AMOUNT DUE If Date Of Payment Is On $319.79 3/1 /11 thru 4/30/11 $326.32 5/1 /11 thru 6/30/11 $358.95 7/1 /11 or Later 424 RIDGE AVE ENOLA, PA 17025-2235 ~- - •- TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS ~ • ~ - ~ - .. . ; . ~ DEBBIE LUPOLD, TREASURER 98 S ENOLA DRIVE; ROOM 101 ENOLA, PA 17025 TEMP - RETURN SERVICE REQUESTED OFFICIAL COUNTY MUNICIPAL TAX BILL 86916 - 1233 COULSON, CARRIE R 424 RIDGE AVE ENOLA, PA 17025-2235 ~~~III~~~III~~~~~I~I~I~I~~~I~I~~I~I~~II~~I~I~~~I~I~I~~II~~~ 86916-R-1233 REV-1508 EX * (1.97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE 0~ ~ n.~~ ~.ls~n SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ~e~s FILE NUMBER `. ~.,~ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F (~~~1bErs l s~ - ChECki n(~ ~ I~ol2~u`1 c~ 3. PSEC~L - Check~n~ a~,~`~ U, f~SECL~ - SQvLlu4s S~ 3~' 5, Personal Rvper~y ~oo~.ov ~o, 3~c~ K~.spec~ra- a9~o, m~ TOTAL (Also enter on line 5, Recapitulation) $ ~ (If more space is needed, insert additional sheets of the same size) ~~' ~ ~ ~, ~ ~ ~~' °~`~ ~t O MEMBERS 1St FEDERAL CREDIT UNION Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.members1st.org Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 CARRIE R COULSON C/O MICHAEL COULSON 84 FRONT STREET WEST FAIRVIEW PA 17025 StatE;ment of Accounts 1 Jan 25, 2011 thru Feb 24, 2011 Account Number: 44139 Balances at a Glance: Checking: 1, 634.47 Savings: 2, 77s . s4 CertificatE~s: o . 00 Loans: 22, 772.05 Money Nlanagement: o . 00 Swipe 5 YTD Reward: o . 00 Page: 1 of 2 Your aggregate balance as of February 1st is $11,921.23. An aggregate balance of $2,500 and having 3 products will place you in the Silver MLR level. Ready to take control of your financial future? You're ready to try MoneyCoach. See the enclosed insert for more details. CHECKING ACCOUNTS 0011 -CHECKING Date Transaction Descri tion Jan 25 Balance Forward Additions Subtractions Balance Jan 26 Check 000115 Tracer 0001175222 1,818.47 Feb 01 Check 000110 Tracer 0001164044 20.00- 1,798.47 EFF 1/31 50.00- 1,748..47 Feb 23 Withdrawal Feb 24 Ending Balance 114. 00- 1,634.47 1, 634.47 Check # CHECK SUMMARY Amount Date 000110 50.00 Feb 01 Check # Amount Date * Asterisk next to number indicates skip in number sequence 000115'` 20.00 Jan 26 2 Checks Cleared for 70. 00 SAVINGS ACCOUNTS 0000 - REGULAR SAVINGS Date Jan 25 Transaction Descri tion Balance Forward Additions. Subtractions Balance Jan 31 Deposit Dividend 0.250% Annual Percentage Yield Earned 0. 250% from 01/01/2019 through 01/31/2011 Feb 04 Deposit ACH HOLY SPIRIT HOSP TYPE: BATCH ID: 2231512747 CO: HOLY SPIRIT HO 0.26 709.66 1,308. s4 1,308.90 2,018.56 Feb 15 Feb 18 SP Withdrawal Transfer To Loan 0010 Deposit ACH HOLY SPIRIT HOSP TYPE: BATCH ID: 2231512747 CO: HOLY SPIRIT H 479.47- 1,237.55 1,539.09 2,776.64 Feb 24 OSP Ending Balance 2, 776 . s4 - - - Continued on following page - - - STATEMENT OF ACCOUNT flora ~~t~.r~r~I:=tf ditaPrpa.. CARRIE R COULSON 426 RIDGE AVE ENOLA PA 17025-2235265 EFFECTIVE DATE TRANSACTION DESC121PTION ........... STATEbI ' T PERIOD F' T O O1/O1/11 01/31/11 PAYMENT,6,CREOIT3 OR FJNANCE FEES OR TRANSACTION D~81T8 CHARGt CHARGES AMOUNT NEW BALANCE Ol/OJ. ID 01/31 OJ. R.EGTJT~AR SHAPE Beginning Belanc:e Payment: Dividend 0.400a 27.84 Annual Percentage Yield Earned 0.42% from Based on Average Dail B l O1/O1/11 through 010/31/11 27 85 01/31 y a ance of 27.84 Ending Balance Dividend YTD: Year to Date 27.85 _________ _________________________ 0.01 O1/O1 ID __________ _ 04 CHECKING Beginning Balance -__------ 01/31 01/31 Withdrawal JAN DORMANT FEE 58 36 Ending Balance 2.00- 56.36 Dividend YTD: Year to Date 56.36 --------- --------- ------------- --------- -------------- __________________ 00 ________ ----- Total Dividend YTD: Year to Date ---------------- _______ 0.01 393, 918 REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~i . ~r~~..ls©~ ~~~~~ FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: cr~ma~n ~n . ~~l~~~n, ~ u~~~ ~~ e ~ ~~~`s ~©od. - G ~t I ~;~ B• ADMINISTRATIVE COSTS: ~ • Personal Representative's Commissions Name of Personal Representative(s) _ _ __ treet Address -- City _ _ _ - __ - - _ _ - - State Zip ___ - ear(s) Commission Paid: 2• Attorney Fees 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant -__- __-_ __ treet Address __ __ _ City _ _ - _- State Zip Relationship of Claimant to Decedent __. -- - 4• Probate Fees 5• Accountant's Fees 6• Tax Return Preparer's Fees 7. AMOUNT ~a,~s.~ 495,aD 15D,6D ADD 6D 3U 13~ 13a.a1 O ._.. 33a.sp -D - -D - TOTAL (Also enter on line 9, Recapitulation) I $ ~~ ~~' ~~~ (If more space is needed, insert additional sheets of the same size) SCHEDl~LE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT -nT ~ ~~ .. SCNEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ~1~11C Vr ~ ~ '(` ~ ~~ , l~b~ ~~J l~ V FILE NUMBER ~~ N Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, inclucling unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE t. ~~~\1n~ ~~~ OF DEATH 1~1 v ~ ~~ l ~ ~','~ ~1 ~,. ~ fnidu~~s~ FLnancial Swviees ,~ - TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~,3,6DI~.b~1 4b~36 "~' 09/01/2011 09;28 ®` E-~ i ~~~ ~~ W N W ~u W m i~ U O V ~` 1I ^\ O ~~ O O -0 i r.,l r. ; n u r r ~ ONN , ~'r /++ I ' G v N l -. J. lA ~ 1 1•~ N O ' Midwesfi Loan Services (FAX)90b 483 4385 P. 001/001 M'~ J. ~ IJ O ~.• r ~ b M ~ J• ~ ~ 1•~ @ I i C s' rJJ ti t*7 rf r. I h III V'I J ~ ~~~ ~ O r tii W ~ 'b ' ' . , 1 O O 4 'J 'J ~ f -q Ip r N f.,i N N N /p N -'n v ~ I ~ N j.~i '"~ I :~ 'O ~ " p• ~ 1 INI ^ N ~ N ~\' K u ~ v G' \ \ t l ~ •~~ ~ 11 • ~p Win r es \ , r , " ~' " IP Ia ~ ~ .. F -~ r „ ~ ! \ \ \ ~ to r .• ~ ~ H 17 Ul H ~ ~. ro ~p i N 1 J~ VJ Ltu Cn \m o\ ~.t r+ ti ' -., 4" ~~~u~ ~ rn ~ m ~~ r ~ .,, N a ~, ~ . Wu,bM ,. r ~. ., .. [A CL fn Vi r " ~~ ' ' -~ N n ~ rI trf d T A D ~ ~ ~ r,, '+v w 'd ~C ~; y Ja .d r~ N M N ~ o \ ?- rJ~ N n r ~-. m G \ .~ ~ ~ 0 . 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Fi L, ~" s" '" x J ' vl A I a + I n J `a ' " Mow % o m ~ ~ ~ "1 . . ~ ~t V ~ I N ' v' r -~ N O i7 Vl 47 .ti 9 y. b Ii N I I r; ~I ' 'Ilwp M IiJ M ^~~ ~~ eay c~ n ~' H v•r 'ti71 o o ~ VI I ~~ r W ,I,i ' . ~01 C? r n y w •tJ !+ wO,y y n C r N J pe ~ ~ C7° M u n M r I I 4 • LL W u ~, v. ,., ~ C11 V N 1 , T7 ~ ~ W L3 L ~,I w p O J N r ~ 'C'1 '11 C7 41 -1 u~ ~, F• W h M ~ I ' • r~ '~ ~ 0 • J. ~~ GI N', ~ N Ih i ` ly, ~ N O '~ r VI to w O VI " I b CS. Q, Q. ti7 (1• Lt u ~p hi Il X11 -• f~~//)~ ~ , i r ~ 2• y ~ ' ~ J • Qt h O /'a f ,•I IT ~ ~ V' Ca I I ~ ' ~ \ 1~ rr r7 h I•I ~ , G W N u ~ \ N N O v ~ ~ ~ ~ lu C,~ I W U ' 1 ~ W n n ~ W O I 1,•, \ N N W A \ ` '~\ 10\ ,p w~G C ~-' rr 1.. n -~ Y-' 1"r \r r r c4 .~ \r M\ \ r ` j ,p• N Oe~ I ` -+ ~. r. r c" ~ ~' -~ -- . ,+ H N N N w H bd k '"~ ~ ' ' I p v N ~ u r na I-. N AI n, ~, N \ r ~" ' ~„ '~ I ~ , 4J ~ I M , ~ '~ ~ M UI If1 W w N N ~ ' ~ ~ O q N W ^ 0 r N ~ N N N N N b In 1.. ~ -+ N b 'Jf O {-I ~ , I p ,~.. ' ~ r 1 - 1 ~ t11 r p N VI pI ~ ~ hl I L7 : i 'y M -~ , ~ ~ I J- W '~ A 'F' i` W --, m m N N III 1J1 N w ° O N 1L1 Id ' M ~• ' 7 (i, N N L' ~; •• I '-' I }, ' ~ '' V ~ V Ih A y w ' I I y I C~ 4 r I U~ O I ~' b N r J N '~ ID ~ N J.. m Ln ~ ~ m 1p N ~ ~ I UI ' 17 4' ; O~ ~.., N Q~ y y ~ C+ ~I Vt 1., N M N yj J t ~ ~ r I ' U M N Iv V r ~ ~ W ~ N C) ~~1 O ~: LD I I N ,y ' I H ~ ' ~ i M y i w n ~ oI a. AI • r U I ~ . w W w N N ~, O J- Ja W W W ~" a, v. a. w o, AI N w, ' ° ~~ I y C r K 4 U 1p 1p Ip .] .J Ip ' 4~ W w (" l W (~ t1 O , nl I ' ~, y Ipm In ~ 6 p p b m V m ~,. 'J y ' tir d I.i , + y 1 1 I ~~' C) ~ ~. `•, ., ' I I v ~ I ~ \ \ r r r l u ,., 1~ ~ I r.. .. I ' W V1 n U1 ^ Cn J os ~ w W ~D Ip IQ " J) N ' ~ I 1 ' I (n u u 4 q O N ~. Ih f t i , N 'O -. I N ~ I u n ~ ~ M Cn Ip IJ ~ ~ I b 1 , ~ ~' ; I -~ '~ ~ I~ ~ N ~ ~ N N ~ r r r r M i ~ n M I 6J ~ r o o -+ ., o ° m 0~ r I~ ~ ~ to ~p ~ I . I I I ,~ i.t y, W F. ~O , ~ u f:l G.1 N ~ N ~. ~ VI ' LC I I V I , tit 1 p Ip r-1 /~ q ~ ~ ~ h ~• ^ y ~ . ~ •~~ 1 b I N a y '0 , w I N N n r f.. N C' ~ I I ' I p ~ ~,,,, ~ ~ V' OI ~ IA Ip ~ ~ w~ H n G Uj A~ ~ w ,h Ip O [D 1C] m • p I j ° N , ~ a ° J~ w .J u u lu J; w I u ,La I c ~ w ~, w r„ ~ ~ ~ i I I I .. r l ° ~ I , W s. , ~p ~ , I ' Ln ~ ~ .. h RI 'O U h !tf I ~ ~ ~ n n ~3 .' ~' ~ O a o ° ~ o ° - '~ i i 'u ~' I , u u ~ , ° o ° ° ° ° a C ' ~ i ~,~ ~ ~ ° o 0 0 0 " ° ~ pJ , , iJ tl~ I I ~ ' U ~a ; In \ \ 1 , ' ' ~.~ ' v -" ~~ N N I x. r , ~ td y RI In ~ ' r~ ' ~ N tit I 1C 1D Ip V 1 ~ .~ St Send Inquires to: 5000 Louise Drive PO Box 40 MEI~tBERS tie Mechanicsburg, PA 17055 FlUt..\L CREUIT UM1TON www.members1st.org Main Switchboard: (717) 697-1161 or {800) 283-2328 EZ Calf: (717) 697-4372 or (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 Jan 25, 2011 thru Feb 24, 2011 Account Number: 44139 Page: 2 of 2 LOAN ACCOUNTS 0010 - BUSINESS/INVESTMENT RE Jan 25 ~ ~w"" `""' Amount Interest Fees Balance Forward Princi al ta+~cE Feb 15 Payments Transfer From Share 0000 23,138.72 Feb 24 Ending Balance 479.47- 112.80 0.00 366. 67- 2, 772.05 Annual Percentage Rate 5.740% Daily Rate .015726% 2010 /nterest Paid 22, 772.05 421.49 YTD SUMMARIES TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0011 CHECKING 0.26 0010 BUSOINESS/ NVESTMEIVIT RE 0.00 227.38 Total Year To Date Dividends Paid NOTE: Total includes closed shares 0.2E' Total Year To Date Interest Paid NOTE: Total includes closed loans 227' 3F3 Add Your Photo For Security Your personal safety and financial security are top priorities at Members increased scams and fraudulent activity throughout the entire count w1st. As a result of encouraging members to have their photos added to their account records. Whe branch offices, you may be asked b one of rY, a are strongly member identification program will assist in our fraud deterre allow us to take your~photo.oThis identity theft prevention program to the next level. We are experienc n tives and will take our attempted fraudulent activities and as a result, we need to be able to ver an increasing number of immediately upon retrieving your account information. fY Your identity In addition to having your photo in our files identification based on the t ,you may be required to show additional forms of security and we a yPe of transaction you are seeking. This is for your protection and ppreciate your ongoing cooperation and understanding. . , 1 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA S~NE~V~E INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ~CTATC ne tJ N NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under ~~. Sec. 9116 (a) (1.2)] '~ ~ ~ ~ flUe~ u~2 ~~1~, . i ~l ~,S FILE ~JUMBER RELATIONSHIP TO DECE N Do Not List Trustee(s) spouse AMOUNT OR SHARE OF ESTATE DU°1u ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE ON R - II NON-TAXABLE DISTRIBUTIONS: ~ EV 1500 COVER SHEET A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING ti1ADE 1. I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1500 EX Page 3 Decedent's Complete Address: File Number CEDENT'S~ NAM STR~ETAD[}6~E~S c~ ----- ~~-+ ~ ---- ---------- ESTATE - i i ZIP I Tax Payments and Credits: 1. 'Tax Due (Page 2, Line 19) 2. Credits/Payments i4. Prior Payments __ E3. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FEII in oval on Page 2, Line 20 to request a refund. 5. It' Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) Total Credits (A + B) (2) (3) (4) (5) V __.. .. .,..r ~ - ~..,.~. Make check payable to: REGISTER OF WILLS, AGEf~JT. . - rt~ ;~ PLEASEANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred :............................................ No b. retain the right to desi Hate who sh """"' ^ 9 all use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or........... d. receive the promise for life of either a m ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~"" p y ents, 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? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ ^~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES YOU MUST COMPLETE SCHEDULE G AND FILE IT AS P ~~ ` ~ `~~ x~- ~ ART OF THE RETURN. or dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value percent [72 P.S. §9116 (a) (1.1) (i)j. of transfers to or for the use of the surviving spouse is or 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 survivin souse is '2 P.S. §9116 (a) (1.1) (ii)j. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for digscl sure 0 Percent ping a tax return are still applicable even if the surviving spouse is the only beneficiary. of assets and or 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 adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. parent, an 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, exce t as 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j. p noted in The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3 . A siblin is deft Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. )j g ned, under