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HomeMy WebLinkAbout11-28-11J 1505610105 REV-1500 EX (oi-u) (FI) tr PA Department of Revenue pe~nn5ylfrar-ia OFFICIAL USE ONLY Bureau of Individual Taxes ~°"~`""` County Code Year File Number PO BOXz8o6oi INHERITANCE TAX RETURN Harrisburg, PA i7iz8-D6oi RESIDENT DECEDENT ~ ` l ~ ~ ~ ~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 198-14-3957 02/23/2011 07/17/1925 Decedent's Last Name Suffix Decedent's First Name MI HEALEY CATHERINE A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Mt 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 O 2. Supplemental Retum O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ROBERT B MILLER (717) 737-7617 ._ , --~ _. _ First Line of Address 815 PENNSYLVANIA AVENUE Second Line of Address City or Post Office LEMOYNE State ZIP Code PA 17043 REGISTER OF ~Al jUSE ONL~; - ~_~ ~ "~ ~', i _ m . - ) - __i , ~. DATE FILED r i •, ~ __,' -~. L, r correspondent's e-mail address; BOBMILLERCPA@COMCAST.NET Under penalties of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct and complete. Dedaration of pn3parer other than the personal representative is based on all information of which preparer has any knowledge. ATURE OF PERSON PON L OR ING RETURN DATE ice` , ~ ~ 11 /11 /2011 ' - - r~uuncaa • _. 1950 SHEEPFORD ROAD, MECHANICSBURG PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE 11/11/2011 ADDRESS 815 PENNSYLVANIA AVENUE, LEMOYNE PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 L, 1505610105 15D5610105 J REV-1`00 EX (FI) Decedent's Name: ~ HEALEY, CATHERINE Decedent's Social Security Number 198-14-3957 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 0.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 19,318.61 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 0.00 7. Inter-vvos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 249,631.27 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 268,949.88 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 12,974.60 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ......... ...... 10. 10,765.63 11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. 23,740.23 12. Net Value of testate (Line 8 minus Line 11) ........................ ...... 12. 245,209.76 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. 245,209.65 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_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 16. 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable 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 ~, 1505610205 1505610205 1505610205 11,034.43 O REV-1500 EX (F!) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME CATHERINE HEALEY STREETADDRESS 1950 SHEEPFORD ROAD CITY MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount (1) 11,034.43 Total Credits (A + B) (2) 3. Interest (3) 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 11,034.43 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 .................................................................................... ...... ^ b. retain the.right to designate who shall use the property transferred or its income ...................................... ...... ^ c. retain a reversionary interest ........................................................................................................................ ...... ^ 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" orpayable-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 lS 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(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-1502 EX+ (11-OS) ~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. If mare space is needed, insert additional sheets of the same size. REV-i5o3 EX+ (y-u) ~`' Pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCETAx RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 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 REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCIr1EDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. tir more space is needetl, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCNEDI~LE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STCICK INFORMATION REPORT RESIDENT DECEDENT ESTATE Of FILE NUMBER HEALEY, CATHERINE 2011-00279 1. Name of Corporation NOT APPLICABLE State of Incorporation N/A Address NIA Date of Incorporation Ciry N/A State Zip Code Total Number of Shareholders NIA 2. Federal Employer I.D. Number 3. Type of Business NIA 4. Business Reporting Year N/A Product/Service N/A STOCK '1Yd E T(~{'AL KtJINBEFt Of P/4R W1f:#JE Nt)1i18Ei~ OF S1S 1-+4kt1E aF ~ {foG~IllorwYoting SHARES OUTSTAG1DMfs OWNED BY THE DEt~EttT p'$ ST1;1C4(_ Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................ ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business N/A 6. Was the Corporation indebted to the decedent? ................................. ^ Yes ^ No if yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $_ Owner of the policy NIA 8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ~ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedents stock solo? .................................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • ~ •' ~ • ~ A. Detailed cak:ulations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addresses and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information reia6ng to the valuation of the decedent's stock. ^ No (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIlLE C-S PARTNERSHIP INFORMATION REPORT ESTATE QF FILE NUMBER HEALEY, CATHERINE 2011-00279 1. Name of Partnership NOT APPLICABLE Date Business Commenced Address City 2. Federal Employer I.D. Number 3. Type of Business ProducVService Business Reporting Year State Zp Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. ~~-W1kM1E PERCENT f)F INCOl1AE PEt OF SAlAFiG£ OF CT1~. AC&04iNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there I'rfe insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years ff the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferredlsold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- • ~ ~ A. Detailed calculations used in the valuation of the decedents partnership interest. B. Complete copies of financial statemerrts or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address,/es and estimated fair market values. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's paMership interest. REV-1507 EX+ (6-98) SCNEDI~LE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 Ali property jointty-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-i5o8 EX+ (u-io) '~ ~~~ '~ Pennsylvania SCNED~ILE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HEALEY, CATHERINE 2011-00279 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of wrvivorship must be disclosed on Schedule F. 1T more space is needed, use additional sheets of paper of the same size. 44~ S'i~e~o~er 8~ld +aww~wl~ ' ww. ~_ ~~-~~u~-,~ y ~~i q .~ rS ~ ~, 3 S Great service just got better. Our Gold Star Experience guarantees a host of services, like calling you by name, or we pay you. JDINT DIAINEIiS CATHERINE A HEALEY Lreso „^ 1950 SHEEPFORD RD MECHANICSBURG PA 17055 ^m~rerE.r~Eae. 2011102281 TRAM ff'FEGTNE rRyAM1ICC fCCSr DESORPTION AIMIrOUNT eA~AtiICE nwT~ or+,>= cFUwcE FuuES 0201 PREVIOUS BJILAHCE Si - SAYINGS 579 0 D203 * PREAUTHORIZED AUTO TRANSF TO MULTPL -241 6 555 8 0301 * DIRECT DEPOSIT 1056023351 987 3 654 7 ---> BENEFITS PENSION 03011 * DIRECT DEPOSIT 9949398001 159 1 670 4 ---a AETNA ffiC CT-641 HENFT PYMT 0228 DIVIDEND 1 8 670 7 ANNtIAI. PERCENTAGE RATE IS 0.30 ~ ANNUAL PERCENTAGE YIELD IS 0.30 I ANNUAL PERCENTAGE YIELD Fain IS 0. 0 0228 I NEii BALANCE 670 7 I ----- ----- RAFT AND RETURNED ITEM FEES SllENBlAR ---------------------------------- - - S1 - INGS S 1 - TOTAL FOR ------- ~ - ---- - 0 --- - ----- - I ~ THIS PERIOD ~ YEAR T -DA TOT OVE RAFT FEES ~ $ 0.00 ~ $ 0.0 - TOT I RE ITEIIi FEES ~ $ 0.00 ~ $ 0.0 0201. PREVIOUS BALANCE S2 - HOLIDAY CLUB 77 5 0203 * PREAUTHDRIZED AUTO TRANSF FROM S 1 50 0 82 5 0228 ~ DIVIDEND 9 82 7 ANNUAL PERCENTAGE RATE IS 0.30 THE AANIfAL PERCENTAGE YIELD IS 0.30 AIBIUAL PERCEN?AGE YIELD EARNED IS 0. 0 0228 ~ HEtel BALANCE 82 7 1 **CONTINUED** 1 TOTAL YEAR-TD-DATE D AL -T fCRALLMYIe ~ElTwRw~ RrHpMwrw~, Ii ~'ORwYER, AILL~E asre a~w m -r F iw ~aa ~x wew~ wawa rseR T~~'~~ PjND E~CT CCt''~ t ~~~I~. ~~~ ~~~113 4 S Great service just got better. Our Gold Star Experience guarantees a host of services, like calling you by nauae, or ~e pay you. JOINT OUN~ERS CATHERINE A HEALEY '"` ° 'Ta 1950 SHEEPFORD RD MECHANICSBURG PA 17055 ~~arr~ei 2011102281 TRAM ~~ OE5C1#~TION AMMOUNT ~ ~r 814LJUNCE cl~acE ~s RAFT AND RETURNED ITEM FEES SUM~tAR - S2 - 0 IDAY UB S 2 ~ TOTAL FOR ~ 0 ~ THIS PERIOD ~ T -DA ----1 ----- ---------------i-------------------- ---~--- - ---- - --- - ----- - TOT 09E RAFT FEES ~ $ 0.00 ~ $ 0.0 TOT RET D ITEM FEES ~ $ 0.00 ~ $ 0.0 I 0201 I PREVIOUS BALANCE S3 - iilli~lTEVER CLUB gg 8 0203 I * PRFAUTHORIZED AUTO TRANSF FROM S 1 ?0 0 105 8 0228 ~ DIVIDEND 4 105 0 ANNILAL PERCENTAGE RATE IS 0.30 ANNiIi4L PERCENTAGE YIELD IS 0.30 T ANNUAL PERCENTAGE YIELD EARNED IS 0. 0 0228 NEf~1 BALANCE 105 0 RAFT AND RETURNED ITENL FEES SIAIHIfAR - S3 - LUB S 3 I ~ TOTAL FOR ~ O ~ THIS PERIOD --- ~ YEAR T -DA TOT ----------------- RAFT FEES ~ $ 0.00 --- --- ~ - ---- $ - --- 0.0 - ----- - TOT RE D ITEM FEES ~ $ 0.00 ~ $ 0.0 0201 PREVIOUS BALANCE S4 - CHECKING 2208 7 02031 * DIRECT DEPOSIT 3031036030 1193 0 2327 7 ---~ US TREASURY 303 SOC SEC 0201 PRF.AUTHORIZED iiTITHDRAUTAL 1232259884 -4?7 3 2280 4 ---> VERIZON INS PREIit 0203 * PREAUTHORIZED AUTO TRANSF FROM S 1 121 6 .2292 7 0208 PREAUTHORIZED TITITHDRAiiAL 9783397101 -14 9 2290 8 ---~ VERIZON PayaentREC 02091. DRAFT PAID 1600 -200 0 . 2270 g 0210 I DRAFT PAID 1606 -5799 3 1690 3 0223 PREAUTHORIZED iiTITHDRATiAL 0460164570 -22 1 1688 0 TOTAL YEAR-TO-MATE iCi ALL CIO ~irT1~~ TOTAL 'INAN Q IAROC YCJ~Ii-TO TC ~VIO Hi~~i, IF~WOROYEa,ii0.liE acre aura ~e -~ r 1u Fea~x wewl •aua Ti11a s ~ ~~:~ ~~~~D E~IGT ~ ~~ .~;~,~ x ~~ 5 S Great service just qot better. Our Gold Star Experience guarantees a host of services, like calling you by na0ae, or we pay you. .IOINT O~AIfYER5 iwcrnwsra~ • CATHERINE A HENLEY 1950 SHEEPFORD RD 7055 MECHAHICSBURG PA 1 ^or~E~r~Eaa~ 2011102281 7RAN ffFECTI1fE DE5C~'fION AINMOtJNT f~IAIYC[ fCL5f OALA~E pAn DATE CFIARCE RNES ---~ MIDLAND NATIONAL INSURANCE 0225 DRAFT PAID 1607 -112 0 1677 5 0228 DIVIDEND 1 4 1677 0 ANNILAI. PERCENTAGE RATE I5 0.10 I ANNUAL PERCENTAGE YIELD IS 0.10 ANNUAL PERCENTAGE YIELD EARNED IS 0. 0 0228 NEIeT BALANCE 1677 0 RAFT AND RETURNED ITEM FEES SUMMAR - S~ - CKIN S 4 ~ TOTAL FOR ~ 0 ~ ~ THI5 PERIOD ~ T -DA TOT RAFT FEES ~ $ 0.00 ( $ 0.0 TOT ----- I RE ----- D ITEM FEES ~ $ 0.00 ------------------------------------ ~ ------- - $ ---- - 0.0 --- - ----- - ------------------------ CLEARED D S ---- - --- - ----- - 1600 **** 1606 1607 1 1 1 I TOTAL DIYD YFJIR-TO-GATE CI IM[i[ -T -0JI~ iea+lurww~as ~~~ 6.71 0.00 AYH E/p~~, li >f'r OR•YER, AILLaE as~•anra ~e ~F io, i•atrwew~waawa rw `' ~ ~ `~ REV-i5og EX+ (oi-io) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F 70INTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: HEALEY, CATHERINE 2011-00279 If an asset became 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•NONE NONE NONE B. C. ]OINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR ]oINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTCTUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR)OINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % of DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. TOTAL (Also enter on Line 6, Recapitulation) I $ 0.00 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 HEALEY, CATHERINE 2011-00279 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 INCUIDE THE NAME OF THE TRANSFEREE, THEIR REU1710NSHIP 1a DECEDENT AND THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDF~tREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION pFAPPUCABLEj TAXABLE VALUE 1~ CUNA MUTUAL INSURANCE COMPANY, NON-QUALIFIED -CATHERINE 227,131.27 100 0.00 227,131.2; HEALEY, MEMBERS PREFERRED ANNUITY 2 DELEWARE INVESTMENTS, IRA, 22,500.00 100 0.00 22,500.Ot TOTAL (Also enter on Line 7, Recapitulation) ; I 249,631.27 If more space is needed, use additional sheets of paper of the same size. ~~'~~~~vc 1~`~L~~ -?a~rvare C= ~L ~ ~ ~ ~~ ~ t ~~~~ r_ Investmerltse ~ A ineml',ar of AAacc'µ;aria Grtx;O u.cw+;vx AT 02 037353 26550H193 Ass3DGT p,~ ,~ C ~~~r-ter, 1T' DMTC C/F THE ROLLOVER IRA OF CATHERINE A HEALEY C/0 MAUREEN SHEEHE 1950 SHEEPFORD RD MECHANICSBURG PA 17055-6736 I1~~~~~11111111'~~~li~lll~l~n~~lllill~~iill~~lli~llllllil~~~llll Account Services Investment Update January 1, 2011 -March 31,2011 Page 1 of 4 Your Financial Advisor MINOI L SPENCE NATIONWIDE SECURITIES LLC 5900 PARKWOOD PL PW-05-03 DUBLIN OH 43016-1216 Branch office Code 0001906 81001 53694 Account Service 800523-1918 &~e.m.-6p.mETMon.-Fri. WebSlte www.delawareinvestments.com Delaphane 800362-FUND (38631 24hours,7daysaweek Regular Mail Delawarelnvestments See Reverse forinsducaons. P.O. Box 219691 E-mail setvice~delinvest.com Kansas City, MO 64121-9691 Portfolio Summary Year to Date Retirement Account Activity Summary Fuad Name ,+, Fuad CodalAccouat No. Begiaaing Value Traditional iRA Accounts Delaware Nigh Yield Opportunities Fund A Class 137/4000010219 S22,t69.12 Subtotal 522,169.12 - RetirementTotal 522,169.12 InvestaNnW Withdrawals/ Reinvested Change in Additions Reductions Eamiags Market Value - EndiagVelue 0.00 O.DO 443.81 483.65 523,096.58 0.00 0.00 443.81 483.65 523,096.58 i .~ 0.00 0.00 443.81 483.65 $23,096.58 Yearto date Total 522,169.12 + 50.00 50.00 5443.81 5483.65 = 523,096.58 Quarter to Date Total ~z2,1ss.1z + ~o.oo ~o.oo sa43.s1 ~4e3.s5 = ~23,o9s.5a Your Personal Portfolio Rate of Return is Year to Date 4,18 % Inception • 6/19/2006 8.01 Your personal rate of return represents the performance of all the investment(s) you have selected for your portfolio, including both your Regular Investment account(s) and RetiremenYaccount(s). The calculation includes any front-end safes charges and all activity in your portfolio (such as contributions, exchanges among investment options, etc.) using daily share price in effect when the activity occurred. Due to applicable sales charges and thetiming of your investments and withdrawals your personal irnestmeM resuhs will generally not be the same as the investment returns quoted for the individual funds you have chosen. If you have questions, please call our shareholder service center at 800 523-1918 or a-mail service~delinvest.com. For accounts established priorto 1995, a January 3,1995 inception date will be used to calculate individual performance. Performance since inception is annualized. ~' (! ~ -;"~ ~? .i f-~- 1 2 6 03735310000001 I~vESTMEI~T SUMl~'IARY FOR CATHERINE HEALEY TUESDAY, MARCH 8, 2011 CUNA MUTUAL INSURANCE COMPANY: Non-Qualified -Catherine A. Healey MEMBERS Preferred Annuity Value as of 03107/11 $ 227,131.27 ... (~'. S i /.~ .~G~ G,r -> This report provides a general overview of some aspects of yow personal financial position. It is designed to provide general information and is not intended to provide specific legal, investmen; accounting, tax, or other professional advice. The information is obtained from sources believed to be reliable, but its accuracy and completeness is not guaranteed. For specific advice on these aspects of your overall financial plan, you should consult your professional advisor. Should any conflict exist between this report and any statement or confirmation provided by a product sponsor or brokerage firm, information provided by the product sponsor or brokerage fum shall prevail. Representatives are registered, securities are sold, and investment advisory services offered through CUNA Brokerage Services, Inc. (CBSI), member FINRA/SII'C, a registered brokerldealer and investment advisor, 2000 Heritage Way, Waverly, Iowa 50677, toll-free (866) 512-6109. Nondeposit investment and insurance products are not federally insured, involve investment risk, may lose value and are not obligations of or guaranteed by the financial institution. CBSI is under contract with the financial institution, through the financial services program, to make securities available to members. CUNA Brokerage Services, Inc. is a registered brokeddealer in all fifty states of the United States of America. TOTAL: $ 227,131.27 REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEPAgTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RES]DENT DECEDENT ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' MALPEZZI FUNERAL HOME 9,779 82 z GATE OF HEAVEN 1,125.00 3 FUNERAL SUIT 159.36 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: B. i 2 3 4. 5. 6. ~. B s ~o Attorney Fees: 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 Probate Fees: Accountant Fees: Tax Return Preparer Fees: 2010 INCOME TAX REGISTER OF WILLS AT&T, VERIZON ZIP TOTAL (Also enter on Line 9, Recapitulation) ~ $ If mare space is needed, use additional sheets of paper of the same size. State ZIP 1,500.00 260.00 123.50 26.92 12,974.60 r i , . , ~ ~ry ~:! Q7x L } d ti ~ ~~ ~ tb_ z, - .- , ~~ ~ k r ,.w - ~. - - _ ' ., hh . J •~,:< ~~ - 3 ~. r,~ 1 a . 4 T f xL . _ .~li~2iIEl.~ `~T;~~.D ~~' a - . -... .tvuI _ .D ..1~ . tt E..µ~~~ _L - ~, _~ J - ~. ._ - a~ yy .1' , ~i 1. y ~4 ~' 1T .~ j h~ ~S. 1 ~ ~ , ~I~ ~ ~r~q~iA'I~Ieale~ . ~~ r ~ - ~~' c ;~,,h ~-~e~p7ac,e~l.~r~~s~~~d'°~a,~i11 con~i~t~e t~ ~ssi~i~ti~o~ in-eve.~ .. -,. ~~~~~,aj~' ,.. - , ,ale-ate uzstY~?n~s`n r ~~ ~ ,~ _ ~.,ard to rt~~~ srat~ngan~ = , . I~jk"I;~)FT ~ E4zY"I _~, LS; F ~I_[LtI1~~ i~L~l~)~1(Jf~Z ~t ~ / F'C~~P~1 _ ~ ~ ~~ el'f' y , p , r~r Y ~', " :~~.'"u~:4: ~~ ~"nL ~~'IN~~~t'~'rl~~~'~~itJ~,~'~~G~1~ ~ -. ~'x7 ~ 8 ~ '{' l ' y ~'~'i-c,' ~ ` a t °~t its ,~. _ z ~. ~ i I y I r _ ' i f7E Sf ref ~C• ~ ~~_ . 7~~~~ _ :S'~Ei"~ ti.:TID ` 1~:~~~-.a,~ _. ~= ~~- ~~~ ;~ `s' .. ~ ~ ~ Yaw N- E F.S ~ -~d e- ^, ~,; b~~~z-8~p: . ~~ ~~ 's sue: ~~,52~~:~Q© ~ 6 ~ h~~~1~8 -~y~ a,~ ~ _ >9=~ J tom' :. ~ ,p _ ~ ,~n o=. - ~~~6 ~)s~,N `n '~pi'~f A,~~T .~Vx~~~~ C k~ { lt~J ~. a ' ~~ ''NN ~ ~ - ~ '~I,? D~ ~~ F~ ikD~.4I*~eED~ Rl ~l~.k'~Y~~f ~N f~ T(>~ ~ ~` ~ y . .~~ :~ eC) •~,~l~'~Iv(iTSA~TA~CCOtJ~I1'T~3U~?~~7HCt~~Gi~~~ti: ~ ~ L ~ a~ " I '" of _ p ' "~ ' ~~ . ~ ~~ -. ~ . . . ~ e . ~. ~ . ' s ~ ..~ ~ ;~ atr'i o~ . " 1 ~ ~ a ... , ~.= `~` .~ - , ~ ~Y2 L ~~ y ,~ ~~ r r ~~ y ~ ~1.Gp-6~6;~. 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RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: Cumberland County - Register Of Wills Receipt Time: One Courthouse Square Receipt No.: Carlisle, PA 17613 HEALEY CATHERINE A 3/01%2011 14:52:07 1064621 - - - k Estate File No.: 2011-00279 Paid By Remarks: MAUREEN E SHEEHE DB ------------------- ----- Receipt Distribution ----- -----r-- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL 60.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 15.00 20.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN JCS FEE AUTOMATION FEE 23.50 5.00 ------- BUREAU OF RECEIPTS CUMBERLAND COUNTY & CNTR GENERAL M.D FUN Check# 6594 --------- $123.50 Total Received..... .... $123.50 c-- REV-1512 EX+ (12-08) ~ ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 Report debts inwrred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed mediewl pY~o~~e~ ,~ nwic aNa~c io neeueu, inser~ a00iClOfldl Sr182L5 OI Th@ S8 R1@ SIZ2. ~.- p ~~ .,.--~ r~>1~..~...c~-I~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 MAUREEN SHEEHE 1950 SHEEPFORD ROAD MECHANICSBURG, PA 17055 p ~ f Form PB-01 R'ESID"ENT # UNIT " STMT. DATE 50106 443 03131/2011 RESIDENT S Mrs. CATHERINE A. HEALEY TOTAL.AMOUNT DUE $0.00 DATE DUE 04!30/2011 DATE _ DESERIPTION RATE Units. CHQFi<GES CI3fl71TS BALANCE Balance Forward 10,040.53 03/21/2011 PAYMENT RECEIVED -THANK YOU!!! 10,040.53 0.00 RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 50106 0.00 0.00 0.00 0.00 0.00 $0.00 RGJIUCIV 1 rvt~rolC iV1rS. l:A~l-ri1+:K11V ~; A. Hk.ALl:Y Form PB-01 'lease make check payable to Messiah Village. 1 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! REV-1513 EX+ (01-10) ~;~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ] BENEFICIARIES -~G ~ ESTATE OF: FILE NUMBER: HEALEY, CATHERINE 2011-00279 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• Karen Healey 5349 Long Shadow Ct, Westlake Village CA 913762 DAUGHTER 45360.57 2 Joanne Page 960 Jubilee Ln, Hershey PA 17033 DAUGHTER 45360.56 3 Maureen Sheehe 1950 Sheepford Rd, Mechancisburg PA 17055 DAUGHTER 45360.56 4 John Healey Jr 34 Meadowbrook Ct, New Cumberland PA 17070 SON 45360.57 5 Elizabeth Murray 12 Pocono Dr, Mechanicsburg PA 17055 DAUGHTER 45360.56 6 Karen Healey 5349 Long Shadow Ct, Westlake Village CA 913762 DAUGHTER 4619.32 7 Joanne Page 960 Jubilee Ln, Hershey PA 17033 DAUGHTER 4619.31 8 Maureen Sheehe 1950 Sheepford Rd, Mechancisburg PA 17055 DAUGHTER 4619.32 9 John Healey Jr 34 Meadowbrook Ct, New Cumberland PA 17070 SON 4619.31 10 Elizabeth Murray 12 Pocono Dr, Mechanicsburg PA 17055 DAUGHTER 4619.32 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE, II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1• NONE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. NONE 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. Offca'Use Only: _ ;941 1 1 0331 086 S C~`-~ ~~``\' .,, ~,'<~ ~C~~~~~~C Z 2~ ` 1 ~- 0~2 ~9 S~Z I CUNA MUTUAL GROUP CUNA Mutual Insurance Sociefy April 7, 2011 Ms Maureen Sheehe 1950 Sheepford Road Mechanicsburg PA 17055 Re: Insured Certificate/Policy Claim Dear Ms. Sheehe: Catherine A Healey 000060130214 110331086 The documents have been received to complete the claim settlement for Ms. Healey. Your request for EFT could not be processed since a void check did not accompany your claim form. I am sorry for any inconvenience this may have caused. The claim check will be sent under separate cover and may be presented and cashed at your financial institution. Payment information can be found on the enclosed Statement of Values. We consider it a privilege to serve our members through this insurance program, and we are glad we could help you during this difficult period. If you have any questions, please call me at 1-800- 798-6600, Ext. 2440. Our office hours are from 7:30 a.m. to 5 p.m., Central time, Monday through Friday. Sincerely, Jolene White, FLMI, ACS, ALHC, AAPA Claim Specialist 3JW Enclosure cc: 08874 Emmor E Boslet, CFP 2000 Heritage Way ^ Waverly, IA 50677-9202 Business: 800/798-6600 VoicelTDD: 319/352-4090 ^ Fax: 608/236-8030 ^ Web Site: eservice.cunamutual.com T STATEMENT OF VALUES Claim # 110331086 Insured: Catherine A Healey Type: ANNUITY BENEFITS DEDUCTIONS Amount of Insurance or Annuity ....... $226,802.82 Policy Loan ....................................... $0.00 Term Insurance Additions ................. $0.00 Interest on Policy Loan..................... $0.00 Accidental Death Benefit .................. $0.00 Premium ........................................... $0.00 Paid-Up Additions ............................. $0.00 Miscellaneous Deductions................ $0.00 Dividend Accumulations ................... $0.00 Total Deductions ............................ $0.00 Interest on Accumulations'' .............. $0.00 Regular Dividend .............................. $0.00 Termination Dividend $0 00 SUMMARY ........................ . Premium Refund ............................... $0.00 NET BENEFIT.................................. $226,802.82 Advance Premium Deposit ............... $0.00 INTEREST **.................................... $1,050.35 Interest on Advance Premiums ........ $0.00 Miscellaneous Benefit ....................... TOTAL BENEFIT........................ $227,853.17 Total Benefits .................................. $226,802.82 " Interest on accumulations while the policy was in effect will be reported to the policyowner on Form 1099-I ** Interest on net benefit is reportable as taxable interest to the benetl'iciary(ies). SETTLEMENT BENEFICIARY: Special Remarks SETTLEMENT BENEFICIARY: Special Remarks Ms Karen L Healey Benefit: $45, 360.57 Federa! Withholding: $0.00 State Withholding: $0.00 Paid to Assignee: $0.00 Net Payment: $45, 570.64 By Check Policy: 000060130214 **'` Taxable Interest: **** Taxable Income: $210.07 $13, 960.57 Ms Joanne M Page Benefrt: $45, 360.56 Federal Withholding: $1, 396.06 State Withholding: $0.00 Paid to Assignee: $0.00 Net Payment: $44,174.57 EFT -Electronic Funds Transfer 't"'k Taxable Interest: '~*** Taxable Income: 3JW "` Interest amount reportable on Form 1099-I as taxable interest to the beneficiary(ies). '""' Amount of distribution that will be reported as income to the beneficiary(ies) on Form 1099-R. Printed: 4/7/2011 Form 01-3448 $210.07 $13, 960.56 r Insured: Catherine A Healey STATEMENT OF VALUES Claim # 110331086 Policy: 000060130214 SETTLEMENT BENEFICIARY: Ms Maureen E Sheehe Benefit: $45, 360.56 Federal f~thholding: $4,188.17 State ~thho/ding: $428.59 Paid to Assignee: $0.00 Net Payment: $40, 953.87 Special Remarks: By Check SETTLEMENT BENEFICIARY: Mr John J Healey Benefit: $45, 360.57 Federal ~thho/ding: $2,094.09 State t~fhho/ding: $428.59 Paid to Assignee: $0.00 Net Payment: $43,047.96 Special Remarks: EFT -Electronic Funds Transfer SETTLEMENT BENEFICIARY: Ms Elizabeth A Murray Benefit: Federal Withholding: State ~thho/ding: Paid to Assignee: Net Payment: Special Remarks: By Check $45, 360.56 $1,396.06 $0.00 $0.00 $44,174.57 *** Taxable Interest: **** Taxable Income: s.fw ""` Interest amount reportable on Form 1099-I as taxable interest to the beneficiary(ies). "" Amount of distribution that will be reported as income to the beneficiary(ies) on Fonn 1099-R. Printed: 4/7/2011 Form 01-3446 Type: ANNUITY *** Taxable Interest: **** Taxable Income: $210.07 $13, 960.56 *"`* Taxable Interest: **** Taxable Income: $210.07 $13, 960.57 $210.07 $13, 960.56 Beneficiaries Karen L. Healey 179-44-8962 , 5349 Long Shadow Ct Westlake Village, CA 913762 , DOB 9/19/51 Joanne M. Page 210-44-7165 960 Jubilee Ln Hershey, PA 17033 DOB 1/8/53 Maureen E. Sheehe 191-46-4760 1950 Sheepford Rd Mechanicsburg, PA 17055 DOB 8/24/54 John J. Healey Jr. 162-48-2400 34 Meadowbrook Ct New Cumberland, PA 17070 DOB 12/8/55 Elizabeth A. Murray 194-52-9299 12 Pocono Dr. Mechanicsburg, PA 17055 DOB 9/10!58 REV-1513 EX+ (01-10) ~ ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES ~P~ 2 ESTATE OF: FILE NUMBER: HEALEY, CATHERINE 2011-00279 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).j 1. 11 Maureen Sheehe 1950 Sheepford Rd, Mechanicsburg PA 17055 DAUGHTER 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• NONE B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. NONE 19318.61 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. _T- REV-1514 EX+ (4-09) .: Pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box 2$0601 Harrislwrg PA i~]28-o6oi SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (CHECK BOX 4 ON REV-t5oo COVER SHEET) ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 This schedule should be used for all single-life, joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single-life calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other ..... MAME <F lIFE TENANT DATE OF 638TH . 1DATE QF''D~ATH ,. :,. Ll~~i~'iS PAYABLE NOT APPLICABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable .........................................$ 2. Actuarial factor per appropriate table ............................................... . Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line i multiplied by Line 2) ....................................$ NAME OF LIFE A!~lU3TA~IT DATE OF BfRTIf D~ DEATH ~ LS RAYA8L1: NOT APPLICABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ...........................................$ 2. Check appropriate block below and enter corresponding number ................ . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (See instructions.) ................................................ . 7. Value of annuity - If using 3.5, 6, or SO%, or if variable rate and period payout is at end of period, calculation is Line 4 x Line 5 x Line 6 ..... . .....................$ If using variable rate and period payout is at beginning of period, calculation is (Line 4 x Line 5 x Line 6) + Line 3 ...............................................$ NOTE: The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size. i __ REV-1644 EX+ (01-10) ~ pennSylvania INHERITANCE TAX ` DEVARTMfNT OF REVENUE SCHEDULE L INHERITANCE TAX RETURN REMAINDER PREPAYMENT RESIDENT DECEDENT OR INVASION OF TRUST CORPUS I. ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 This schedule is appropriate only for estates of decedents dying on or before Dec. 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). II. REMAINDER PREPAYMENT: A. Election to Prepay Filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on Date or Annuitant(s) of Election NOT APPLICABLE Term of Years Income or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate ........................... $ __ 2. Stocks and Bonds ...................... $ 3. Closely Held Stock/Partnership ............. $ 4. Mortgages and Notes .................... $ 5. Cash/Misc. Personal Property .............. $ 6. Total from Schedule L-1 ........ . ......... ............ . ...............$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ....................... $ 2. Unpaid Bequests ....................... $ 3. Value of Non Includable Assets ............. $ 4. Total from Schedule L-2 ............. . .... ............................$ E. Total Value of Trust Assets (Line C-6 minus Line D-4 ) ...........................$ F. Remainder Factor ........................ ............................ G. Taxable Remainder Value (Multiply Line E by Line F) .......................... . .$ (Also enter on Line 7, Recapitulation) III. i INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) B. Name(s) of Life Tenant{s) Date of Birth Age on Date or Annuitant(s) Corpus Consumed C. Corpus Consumed ............................................. . ......$ D. Remainder Factor ................................................... . E. Taxable Value of Corpus Consumed (Multiply Line C by tine D) ................... .$ (Also enter on Line 7, Recapitulation) Term of Years Income or Annuity is Payable REV-1645 EX+ (i1-09) ~ _ Pennsylvania INHERITANCE TAX SCHEDULE L-1 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -ASSETS- I. ESTATE OF FILE NUMBER 1-aE+AL.~y, CATNE.'~~E Gall- vv~9 II. ITEM NO. DESCRIPTION VALUE A. Real Estate (Please describe.) NUNS Total Value of Real Estate $ (Include on Section II, Line C-1 on Schedule L.) B. Stocks and Bonds (Please list.) ~t~N~ Total Value of Stocks and Bonds $ (Include on Section II, Line C-2 on Schedule L.) C. Closely Held Stock/Partnership -Please list. (Attach Schedule C-1 and/or C-2.} 1 ~~`~G Total Value of Closely Held/Partnership $ (Include on Section II, Line C-3 on Schedule L.) D. Mortgages and Notes (Please list.) NONE Tota{ Value of Mortgages and Notes $ (Include on Section II, Line C-4 on Schedule L.) E. Cash and Miscellaneous Personal Prope se list.) rt y (Plea ~! ~ t I~D~~C Total Value of Cash/Miscellaneous Personal Property $ (Include on Section II, Line C-5 on Schedule L.) [II. TOTAL (Also enter on Section II, Line C-6 on Schedule L.) $ If more space is needed, attach additional sheets of paper of the same size. "T __ _ ____. _ ___ REV-1646 EX+ (11-09) Pennsylvania INHERITANCE TAX SCHEDULE L-2 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION RESIDENT DECEDENT -CREDITS- I. ESTATE OF FILE NUMBER ~i Ep ~ Ey ~ (,A7 NCR { ~ ~ a,t~ ~ ~ - C)U.?7 II. TTEM NO. DESCRIPTION AMOUNT A. Unpaid Liabilities Claimed against Original Estate and Payable from Assets Reported on Schedule L-1 (please list) No~~ Total Unpaid Liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests Payable from Assets Reported on Schedule L-1 (please list) N~~'~ Total Unpaid Bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of Assets Reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are Not Included for Tax Purposes or that Do Not Form a Part of the Trust. Calculation as follows: ~~~ ~ Total Non Includable Assets $ (include on Section II, Line D-3 on Schedule L) [II. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ If more space is needed, attach additional sheets of paper of the same size. ~_ - REV-1647 EX+ (02-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE {Check Box 4a on REV-s50o~ ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 This schedule is appropriate only for estates of decedents who died after Dec. 12, 1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. rl Will n Trust f'i Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1, NOT APPLICABLE 2. 3. 4. 5. II. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate box below and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: NOT APPLICABLE IV. Summary of Compromise Offer: 1. Amount of future interest ....................................................... $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) ........ $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ^ 6%, ^ 3°/0, ^ 0% .................... $ (Also include as part of total shown on Line 15 of REV-1500.} 4. Value of Line 1 taxable at lineal rate Check one. ^ 6%, ^ 4.5% .......................... $ (Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) ........ $ 6. Value of Line 1 taxable at collateral rate (15%) (Also include as part of total shown on Line 18 of REV-1500.) ........ $ 7. Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) ....................... $ If more space is needed, use additional sheets of paper of the same size. REV-1648 EX (02-09) pennsytvania ~.yi DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box 28o6oi Harrisburg PA 17128 ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable assets total from Line 8 (cover sheet) ...... ..... 1 . ................................... 2. Insurance proceeds on life of decedent .......N, ~~.... h-.`. ~~ ~ `- ~... 2. 3. Retirement benefits ................................................................ 3. 4. Joint assets with spouse .............................................................. 4. 5. PA Lottery winnings ................................ 5. ................................. 6a. Other nontaxable assets: List and attach schedule if necessary .. _6a,_ _ ,;; 6b. 6c. 6d. ~":a 6. SUBTOTAL (Lines 6a, b, c, d) .......................................................... 6. 7. Total gross assets (Add Lines 1 thru 6} ................................................... 7. 8. Total actual liabilities ................................................................ 8. 9. Net value of estate (Subtract Line 8 from Line 7) ............................................ 9. If Line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part 11. Income: 11. I TAX YEAR: 19 a. Spouse ............. la. b. Decedent ........... 1b. c. Joint .............. lc. d. Tax-exempt income .... ld. e Other income not listed above ........ , le. f. Total lf. 4. Average joint exemption income calculation 4a. Add joint exemption income from above: (lf) 0.00 + (2f) _ 2. I TAX YEAR: 19 2a. 2b. 2c. 2d. 2e. 0.00 2f 0.00 + (3f)_ 3. I TAX YEAR: 19 3a. 3b. 3ci 3d. 3e. 0.00 3f. 0.00 = f~ 3 4b. Average joint exemption income ........................................................ _ If Jine 4(b) is greater than $40,Op0=STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less 2. Multiply by credit percentage (see instructions) 3. This is the amount of the Resident Spousa{ Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet . ................................ . 4. For nonresidents, enter the ratio of the decedents gross estate in PA to the value of the decedent`s gross estate ................................................... . 5. Multiply Line 3 by Line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet.......... . SCHEDULE N SPOUSAL POVERTY CREDIT FOR DATES OF DEATH 01/01/92 TO 12/31/94 1. ~ , 2. 3. 4. 5. 0.00 0.00 0.00 0.00 REV-1649 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI/LE O ELECTION UNDER SEC.9113(A~ (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER HEALEY, CATHERINE 2011-00279 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the NOT APPLIr:ARI F Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may spec'rficafly identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or sim- ilarproperty treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election onty as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. Part A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which Dass to the decedent's Hart li: Inter the description and value of all interests included in Part A for which the Section 9113(A) election to tax is being made. _ _ _ __ __ _ -- _ _ LOCAL REGITRARy ~o ~°I~~C~-`~IO~V ~' ~~AT~ WARNING: It is illegal tee a~~tg~lic~~,~ ~~~~~ =r~~~A~ ~aIF ~:1~~~~~„~~~t tst` r~l~~t~g~~~~q. ~t:~e tiyr this certifieate, ~C~.00 ,~. r,~ l,i~- (.az tta.~ t?,t~l)~)~iat)er. nc°'e +_r?~~n Is _. '.,, c,(,~,Icc~ r(<);,i :)n t. i~~in~it ~ ertifie;(te of L~caU~ ~,it:h filet; ~~°i11~ (~~~ ~Ir. L(>~a~ Regisir~r. 'll)e ori~*inal ~r~(i)i~:a(c toil( '?~ ?i)~~-<,.(rclecl t<) the State. i tial ~r°~t)rcls z)I~'ace `<u f>ermar)ent filing. P 17 2 9 6 4 0 2 __ ~~ ___~~a~f~___ Certification Number i ri l l?e~:~istr:.(r I)<tte Issued H105-113 REV 11200A COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ryPERMANENfN CERTIFICATE OF DEATH ~* INH (See instnacttons and examples on reverse) eiL Fn C rl IYRFR t. Nuns d Oewdnl (Fkn, niche, aft stAPoc) 2 Sex 3. Sodal SewrBy Nlnba 0. Dne of Deem (Momh, mY. Y~ A Heale Female 1QA - 14 - 3957 Feb 23 2011 S Ags (lau alranel? Unmr 1 under 1 8. Des d BM , m 7. ~ end sra « 8e. Paw d Dea87 Check aro MaMb DaW Hpae eaeaee H c odrr~. 1925 Scranton, PA July 17 ^ ^ R ^ D s ^ ^ 85 , Ya. m«- DOA Nanllg Home eamxa ER I Ou~esenl PSdM ,r~.mm eb. Caurdy d Dalh Bc Ciy, Bern, Twp. d Dean p ~ Btl. Pacify Nema (II ref iwnulion, Pw Sb9e1 and numbu) 9. Wu Dewdui d Hepenk Oripn? oPNO ^ Vas f D. Raoc Anrdc.n Indlan, Blerk wMa, et Cumberland East Pennsboro Twp Holy Spirit Hospital Medcer~Puem ~, .w> ( e it. DewauKslawl dwakmre mend pa. ooadwa Madetl. 15. Surv~4g SPaw (R wife. ghe maiden nema) M uwC t2. Wa Dewdem rra b me 13. Dewmnya Bmwsm (Spsay aiv INghaN greM rmpaarg 1/. Iclmawok wnaaaaewerarbwy u.s.AmraFawa? ~ /~~J , ~ Eamanry/sxmd.ry(alzf Corge(t<«s«) l d d OWil j;gre ^ Yea ®No r~ we 12 Wl 78. Dewdam'e Mairq Addrase (SSen, dyr bwn, sera, nP code) Decedents ""'"' `~itla`w 'Te' ~" Did Detedera Pennsylvania +Neln a n~. ~ va& Dewa.m u~ad b iJ~s Allen Tw,. 100 Mt . Allen Drive ? CtIInberland ,?d. ^ hanicsb PA 17055 17b'QOany ~ ~ c3yreae 1& FemMa Name (Piro, nidtlle, rst ud8a) f 9. Momefs Name (Pau, nidda, maiden s«reme) Matthew Thomas C.oolican Barbara K. Messett za. MomrM's Name (fwd / PrkrQ zoo. Moored'. Ma.p Amress (.nest mY r bvm, era. 24 cam) Maureen Sheehe 1950 Sh ford Road Mechanicsburg, PA 17055 21a Metlbd d Dapreim r ^ Crartlan ^ Ddu/m 21 b. Der d DapmRicn (Malin, mY• YaA 27a Prw d D"wpoegion (Name d cemetery, aatnaY or odrr Bawl 27d lxatla+(Cirylbwn, stale, rip mm) k~C Buhl ^ R.n,oN hnn sad ~ wa cr.nriorr « Dorrrbn Autlbdxetl ^ p,,,,, r sv Mean Fxrlhwrc««l.rr ^ v«^ Ne ~ Feb 28 201 rVaZY , Gate of Heaven Cemete>_y Mechanicsburg, PA B.rNw t)wneae (« .. nrd0 27a sgwan d 22b. Ixae. Numbu 22c Name antl Aadmsa d Faddy 8 Market Plaza way - ~_ FD-138630 Mal zzi Funeral Herne Mechanicsb PA 17055 CaIIIPIea 23ac day whNl wm'iykq 29a TO mebatdmylonekdge, exaranma 5ne, deM and Paw srrd. (Sgnabas andtlm) 23o. licence NarMr 23c. Dar Sigrrd (Mmm, my,ymr) m ware. n tar d dam wlaY cafes d man 8wrw 2428 mwf M oorrpletM q' Paean 2/. TYre d DeuA Z8. Der Pranols¢M Dead (Mmm, day, year) 28. Wes Casa flafaed b Me8Ca1 Eaaiilu /Came la a Raem Diner men Cremalun a DarBm? ~( ^ wro warrrr mom. ~ ( v j p A ~ M. ~ 23 ZJ I l va No ChuSE OF Dealt/ (t;aa Instrea:tforu aeM enmWaa) ApaosereN inarval: DO N0T emu erenr such a cardiac emat Oren b Dam wooed sr meth ne -mu d'r«11 8wd Y l F E t m a Ma P Part II: Enw Dino ' but rot reuYtlng a me unmryiq caws given n Pad 1 26 Did Tobacco Ua Cmerse b Dam? ^ Y bea ^ P y . Ism Z u . n u area, Mdur , a coap c . a 19BhgI.tDiole- B aM r a. m a w w e m tlr sB dapY. Dal mN r«paebry aneet a veddplr awiam wefpM doelrq . a m y ®No ^ UNlnown ~ {r u ` ,, ~ _, ~ ~ , ~, . p w'"ma`Yidaml~ a. /'-fizhoA.~l~/l3? `\~CA l~~l.(y! __ p ~QXV I~ '~ 2s.ttFemaa: Nd pegnua wpha Pan Yes Dw b (« a e wreaprnw og: P ~ ^ Pregrd r rrr d dam en wnaiare, a ° ' b' rate "~- ^ r woes rrd m a a. Enr DNOelxvixi cAUSe Dw a (a a . wrewlrnae ofl: ~ n'1~/r ~ ~ Nd gapwq bIA gagrlra wsNn e2 aaya d mein yy~~a.yy inn Mrew m. , c ^ N ewmb rwiwMA d.em) tASf. Due to (a tl a wrwa0lrrrw oQ: d We7we. W pregnant 43 days b 1 year boors deun a. ' ^ unaow*I r pregnen wino me pan year 3oe. Wa m Aubpay Son Ware Aw;ey Finipe 37. d Deem 32a. Dad d Injury (March, dry, year) 32D. Dacdm flow kMel' Oewmed 32c Place d Injury: Horre, Farm. Stran, Fecbry, Perlomrd'! Avaiabls Prlorr Canttietbn d Dales a Dean NWxn ^HmirJm Oise BuiGng, eY. (Bpetlfy) ^ N ^ Y ^ N ^ A~aarv ^ ~9lmeaswam ~. Tm of Iriury 32e. Injury n Wren 321 n Trenapafatlm Injury (SPx/y1 32g. L«aam daiury (Slreal. tilt' /lam. err) Ya o a a ^ Suiim ^ Caad Nd oe Dalemurtl M ^ Yes ^ No ^ Dr'war/Oiler°I°r ^ Paseergar ^ Petlennen Omx ~ Sper,rj- 33a C«tl8sr Ideaak aNy arl 33b. Siryueee and 7ia d G `~ • Da+nYra plryakW (Pfryaben andykq wwe a d.ar wlrn aberr dysidan nos tsmouriwd dam and mnlwra lam 23) To err a.namy anorMdpa,rwnowemear.mwwa(q aM mrm«uamlyd---------------- -'--------------_ ^ - Pmrrrwrlnp arrd oYtllyinr P IPMeidan Dom Dmcrndnp mein end wMybg b wuae d deem) enm dm r e m m d a ea rm m w a ~ 33t. Licerne NlaMar 33tl. Dad Slgrro (Mode, mY.Yar) ~ «ewr. a r awua(a). mrarra. a - a. . oa.an r TanrlydmYlmow ega.ea o • a.ael FsrarrfCorwrr ----------------- M4~it~~~ 2 23 )I pr me boa d asamiamn andf «Inwetlgamn, In my opalon, mrh oeeurree H me lime, Oar, and Paw, and due b me eau.a(a) atl m.nrw a stated. ^ 3+. Noma ere Arbrees d P•rem woo conpleW cave d Dam (mrri 2>) Typa / PrLa ^ 35. c sign.ea. Manbar ill / i ?i i~ 3s r Frd IMadh, dry, yrrrl I fi \ y i $ ~uLa.~ cy!: M '~ `~ ,~ V .a .you ` 4~ c ; ~~ e' ~ . o , Diepoamm Peron Na. 0567563 COMMONWEALTH OF PENNSYLVPN~~ COUNTY OF CUMBERLAND estate of CATHERINEA HEALEY SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 2nd day of March, Two Thousand and Eleven, Letters TESTAMENTARY in common form were granted by the Register of said County, on the late of LOWER ALLEN TOINNSH/P /First, Middle, Last) in said county, deceased, to MAUREEN E SHEEHE (First, Middle, LasU and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 28th day of February Two Thousand and Eleven. File No. PA File No. Date of Death S.S. # 2011- 00279 21- 1 1- 0279 2/23/201 1 198-14-3957 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL COMMONWEALTH OF PENNSYLV/~N~o COUNTY OF CUMBERLAND SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 2nd day of March, Two Thousand and Eleven, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of GATHER/NEA HEALEY late of LOWER ALLEN TOWNSH/P (First, Middle, Lastl in said county, deceased, to MAUREEN E SHEEHE /First, Midd/e, Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 28th day of February Two Thousand and Eleven. File No. PA File No. Date of Death S.S. # 201 1- 00279 21- 1 1- 02 79 2/23/2011 198-14-3957 Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL COMMONWEALTH OF PENNSYLVAN~o COUNTY OF CUMBERLAND SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 2nd day of March, Two Thousand and Eleven, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of CATHERINE A HEALEY late of LOWER ALLEN TOWNSH/P (First, Middle, Last) in said county, deceased, to MAUREEN E SHEEHE (First, Middle, Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office a t CARLISLE, PENNSYLVANIA, this 28th day of February Two Thousand and Eleven. File No. 2011-00279 PA File No. 21- 11- 0279 Date of Death 2/23/2011 S . S . # 198-14-3957 Regis ter f i//s Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL COMMONWEALTH OF PENNSYLVQti~o COUNTY OF CUMBERLAND SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 2nd day of March, Two Thousand and Eleven, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate o f CA THER/NE A HEALEY late of LOWER ALLEN TO WNSH/P /First, Midd/e, Lastl in said county, deceased, to MAUREEN E SHEEHE /First, Middle, Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 28th day of February Two Thousand and Eleven. File No. PA File No. Date of Death S.S. # 201 ~ - 002 79 21- 11- D279 2/23/2011 198-14-3957 C ~~ ,~ ~ .~ ~-, uy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL Y REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 201 1- 00279 PA No . 21- 1 1- 0279 Estate Of : CA THERINE A HEALEY /First Midd/e, Last) Late Of : LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY Deceased Social Security No: 198-14-3957 WHEREAS, on the 2nd day of March 2011 an instrument dated December 8th 1997 was admitted to probate as the last will of CA THERINE A HEALEY (First, Middle, Last) late of LOWER ALLEN TOWNSH/P, CUMBERLAND County, who died on the 23rd day of February 2011 and WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi11s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: MA UREEN E SHEEHE who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to Iaw, alI of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 2nd day of March 2011. ~ ~ '' eglster of /71s ~% Drury **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) n =-~- ~ - __ G C'Z ~ , =_~ ~'_•~ ~ J " '~ I I "'i C. 7 ~:~ ~ ~ LAST WILL AND TESTAMENT = cf7 r~ `~ __` ~. --, _ t_ r--- `' .i '-. ~.~ Q CATHERINE A. HEADY . c: . I, CATHERINE A. HEALEY of Lewisberry, Pennsylvania, decla*e this to be my Last Will and revoke any Will or Codicil previcpusly made by me. ~ ITEM I: I direct that all expenses of my last illness and f~neral, including my gravemarker and perpetual care, shall be pa~,d from my residuary estate as soon as practicable after my decease as apart of the expense of the administration of my estate. ITEM II: I devise and bequeath all of my estate of every~!nature and wherever situate to my husband, JOHN J. HEALEY, pro~ic~ing that he shall survive me by thirty (30) days. fol~:o eve~y childr ~i ~~ ~~~~~-. _ ~ .v~ .~„_ ITEM TII: Should my husband, JOHN J. HEALEY, ease me or die on or before the thirtieth (30th) da~° ing my death, I devise and bequeath all of my estate of nature and wherever situate in five equal shares to my 1. Karen L. Healey 2. Joanne M. Page - _ - - _ _ 3. Maureen E. Sheehey i 4. John J. Healey, Jr. 5. Elizabeth A. Murray I I In the event that any of our five named children fails to survive me for a period of thirty (30) days then their share under phis paragraph shall go, per stirges, to such of their children who are living on the thirtieth (30th) day following my death Band, in the event, that any of my children shall fail to surviv me for a period of thirty (30) days and leave no issue surviv nq for a period of thirty (30) days then their share shall Lapse and be divided equally between the remaining beneficiaries under this paragraph. ITEM IV: I direct that all taxes that may be assessed in aon equence of my death, of whatever nature and by whatever jurijsd ction imposed, shall be paid from my residuary estate as a part o the expense. of the administration of my estate, without appo~t onment. ITEM V: I hereby authorize and empower my /Executrix, hereinafter named, to sell any of the real or 1 property which I may own at the time of my death, as he/s~e shall, in his/her sole discretion, deem appropriate for the be$t interest of my estate and my beneficiaries, upon r ~ ~ ~_~~ -~ ~ , q: _,~ ___ _ __ _ .. ,., .. ~ , : ,... u. . ,...,.,.. ;., .:-<~, .. . ., . ,~. ~ ~ ..•,,~ u, .... . . whatever terms and conditions he/she deems to be appropriate, and to execute, acknowledge, and deliver all proper writings, deeds of conveyance and transfers thereof. ITEM VI: I appoint MAUREEN E. SHEEHEY, Guardian of any pzoperty which passes either under this Will or otherwise to a minor and with respect to which I am authorized to appoint a Guardian and have not otherwise specifically done so, provided that this appointment of a Guardian shall not supersede the right of any fiduciary in its discretion to distribute a share where possible to the minor or to another for the minor's benefit. Such Guardian shall have the power to use principal as well as income from time to time for the minor's support and education (including college education, both graduate and undergraduate) without regard to the ability of any other person to provide for such support and education, or to make payments for these purposes, without further responsibility, to the minor or to any person taking care of the minor. ITEM VII: Wherever the word "minor" is used herein, it sihall mean any person under the age of twenty-one (21) years. ITEM VIII: T appoint my husband, JOHN J. HEALEY, Execiutor of this, my Last Will. Should my husband, JOHN J. ~ ~4. ` 1+~ ~ ~ , i~ /~~~ ° 'f _ ~ ,. ~ 4 ~ ' ~ ~°; ~ i t x - w ? F r ~. ni 1 #,:,4, 't Y g it i w,y'~ ~~~ 1~ ~~t,"~k-~4r .era. ~~ ~ 'til ~ r '1« i ~HEAL~Y, fail to qualify or cease to act as Executrix, I appoint my daughter, MAUREEN E. SHEEHEY, Executrix of this, my Last Will. ITEM IX: I direct that any specifically named Executor or specifically named substitwte shall not be required to give bond for the faithful performance of his duties in any jurisdiction. ~N WITNESS WHEREOF, I have hereunto set m hand this d '~ da of Y Y Decerrjber, 1997. '~ CATHERINE A. HEAL ~:.;, t . L , y a`~= ~,- ~~ The preceding instrument, consisting of this and six (6) other typewritten pages, identified by the signature of the Testatrix, CATHERINE A. HEALEY, was on the day and date thereof signed, published and declared by CATHERINE A. HEALEY, the Testatrix therein named, as and for her Last Will, in the presence of us, who, at her request and in her presence and in the presence of each other, have subscribed our names as witnesses hereto. _ I~ ~t~~. , ~ I~,C~I.UL C.rj o f ---- ;( ~~~ ~. of r (M.~1i, ~e- Ut.~v~sc. Q. ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS. I, CATHERINE A. HEALEY, the Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirlIm~~ed and acknowledged before me by CATHERINE A. HEALEY, Testatrix thisX,~ay of December, 1997. NOTARIAL SEAL BRUCE D. FOREMAN, Notary Public City of Harrisburgh, Dauphin County M Commission Ex fires Se t. 25, tass CATHERINE A. HEALEY Notary Public 6 ~.., ~~~~ ~~ °`~~+ {r* 4•nf ri ~~(~~ ~~~~- s ~,~~ ,~ 4 ', ~*'~'-~ ':any ~';'~,-;j 4L ~~` - ~, ~~ + a ~~ _ n'Y V~yt 'K ;4 } ~` q~, t _ yt f "S y` t F, r .~ " w ~ ~.. ra ' , : ~ 4 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF DAUPHIN WE, the undersigned witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix, sign and execute the instrument as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness; and that to the best of our knowledge, the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed before me by the undersigned witnesses, this~~ay of December, 1997. ~, ~~wt~ ~. ~~~ Witness Witness Notary Public N07ARIAL SEAL BRUCE p. FOREMAN, Notary Public City of Harrisburgh, Dauphin County M Commission Ex Tres Se t. 25, 1999 7 M ty 4 ! M I? ~. . 1'(4[ f t ~Z~ h" I '~ ? ~ ~ n ~` ' _ RA 1 , ~ . z y s. T tY 3 ! -i , ,, . ~: ~`: r sti .' . .. ~ ,. ~ - ... ~ _ _ _ _ 1 L' S".1 Gl RE : Ap1ENDAiENTS TO SUPR~IE COURT OI:Pki.AATS' COURT RULES PER CURIAM: NO. 103 SUPREME COURT RULES DOCKET NO. 1 O R D E R AND NUW, this 3Gth day of April, 1y92, the Supreme Court Orphans' Court Rules are amended as follows: 1. New Rule 5.6 requiring the giving of notice to beneficiaries and intestate heirs is adopted as set forth in Attachment A hereto. Rule 5.6 shall apply to decedents dying on or after July 1, 1992; 2. Rule 6.5 requiring a personal representative's account to be filed with the Register of wills is repealed and Rule 6.6 requiring the fi)_ing of all fiduciary accounts with the Clerk of the Orphans' Court is amended as set forth in Attachment B hereto. These changes shall be effective on the date of this Order; and 3. Existing Rule 6.12 requiring the filing of status reports by a personal representative is repealed and new Rule 6.12 is adopted in its place as set forth in Attachment C hereto. These changes shall apply to decedents dying on or after July 1, 1992. TRUE COPY FROM RECORD Attest: May 1, 1992 ATRICIA. J NSON Assistant Chief Clerk, Supreme Court of Pennsylvania. az~ PART 11. ORPHAN'S COURT RULES .[231 P,4. COD1= PART 11j Amendment to OrPl,ans' Court Rule 5.6 and ,4dop- tlon of Rule 5.7; No. 213 SupretnE Cour4 Rules Doc. No. 1 Per Curium: Order Now, this 23rd day of December, 1998, upon the recommendation of the Orphans' Court Procedural Rules Committee; the proposal having been published for adop- tion at 2,5 Pa. Bulletin 2802-2804 (July 16, 1995) and 26 Pa. Bulletin 4079 (August 24, 1996): ll !s Ordered pursuant to Article V, Section 10 oC the Constitution of Pennsylvania that Orphans' Court Rule 5.6 is amended and new Rule 5.7 is adopted, all in the Collowing form, and shall apply to decedents dying on or after January 1, 1999. Rule 5.6 as adopted on April 30, 1992 shall continue to apply to decedents dying on or aRer July 1, 1992 and before the date of adoption of these amendments. This Order shall be processed in accordance with Pa. R.J.A. 103(b), and shall be effective January 1, 1999. Annex A TITLE 231. It1ILES OF CIVIL PRL)CIEDURE PART [I. ORPfiANS COURT RULES RULE 5. NOTICE Rule 5.6. Notice to Beneficiaries and Intestate Heirs. (al Requinenunt of notice. Within three (3) months after the grant of letters, the personal representative t.o whom original letters have been granted or [his ] the personal representative's counsel shall send a written notice of estate administration in (substantially ] the form [prescribed to ]sat forth in Rule 5.7. (1) every person, corporation, association, entity ®r other party named in decedent's will as an outrigltt beneficiary whether individually or as a class member; (2) the decedent's spouse and children, whether or rtnt they arc named in, or have an interest under, the will; (3) where there is an intc~tacy in whole or in part, to every person entitled to inherit as en intestate heir under Chapter 21 of the Probate, Estate end Fiduciaries Code; [ {2) ] (4) the appointed guardian of the cst<1[e. p~rrnt or Icgal custodian of any bencfici~ry wlto is a minor chitct under the age of eighteen (l8) years; [ (3) ] (5) the appointed guardiin of the cst.~tc nr, irr the absence of• such appointment, the institution or person with custody of any beneficiary who i9 an adjudi- cated [mental incompetent ] incapscitated person; [ (4)) (S) the Attorney General on beha]C of any chari- table beneficiary whese interest exceeds $25,000 or which will not be paid in full; [ (5) ] (7) the Attorney Ceneral on behalf of any gov- ernmental beneficiary; [ or In default of tine other heirs of the estate; (6) ] (8) the tn,stee of any trust whidi is a beneficiary; and ( (7) the spouse, children or ocher intestate heirs of the decedent as determined under Chapter 21 of the Probate Estates and Fiduciaries Code. ] (9) such other per3ona and in such manner as ~rnay be required by any local rule of court. [ (b) Contents of police. The notice ehalI contain the following information: (1) the date and place of decedent's death; (2) whether decedent died testate or 'intestate; (3) the county in which original letters were granted; (4) the names, addresses and telephone numb@ra of ail appointed personal representatives and ttretr counsel; and (5) a copy of the. will or a description of f)re beneficiary's interest in the estate. ] _' (b) De~ni(inn of BeneTciar)c "Beneficiary^ shall be deemed to include any person who may have an interest by virtue of tare Pennsylvania anti-lapse stntute, 20 Pa.C.S. 6 2514. (c) Manner of police. Notice sljall be given by personal service or by first-class, prepaid mail to each [party ] person and entity entitled to notice under subdivi- sion ta)(l)-t9) whose address is known or reasonab)y available to the personal representative. (d) Ccrii~cnfion o~ unties. Within ten (10) days aRer giving lire notice required by subdivision (a) of this Rule, the personal representative or (his ] the personal representative'8 counsel shall file with the Register or Clerk [his, her or its ] a certification in [ eubatan- tinily ] the [attached ] from set forth in Rule ti.7(b) that notice has been given as required by this Rule. No fee shall lx charged by the Register or Clerk for tiling the certification requirccl by [ pan-agraph (d) ]this eubdivi- ~ion. (e) Failurr to file certiJicntion. U n the failure by the pcrsnnnl representative or [his ] ~he personal repre- sentative's cnun~cl to file the certif+cation on a timely Imsis, the ttr`gistcr shall, attar ten (10) days prior written notice to the delinquent [fiduciary ] personal repre- sentative and hig counsel, notify the Court oC such dr•.linqucncy [ e+long with a request that the Court conduct n hearing to determine whether sanctlona shut) be unposed upon the delinquent personal representative or his counsel }. Oft-icinl Notc: The 1998 amendment to su'bdivieion (c) is not intended to limit the inherent power of the Court t~ impose sanctions upon a delinquent perconnl representative or counsel. (f) EJr'ect of notice. This Rule Ahall not alter, dirninia;7 cr confer [additional aubst.antiv~ ri;ghta upon Amy lraneficiary ]coating rig3~ts. (g) Copies of rcclz. The Regist.~r shall deliver a copy of [ this Ftula ] Ru9oo ti.(3 and 6.7 to each personal repre- sentative and counsel at the time letters are gn~nted. O~cIa1 Dote: It is cot lire Ir,i.ertiora ref the IZuIe #o rrqulrr notice beyond the degree of conamrl~aainl#y entitling a person W inherit under Chanter 21 oY PART 11. ORPHAPIS' COURT t=S(~Lt=S [231 PA. CODR P{+RT flJ Amendment to Orphans' Court t1,~es 14.1-14.4; No. 214 Supreme Court Rums Ijoc. hfo. 1 Order Per Curicm: Mow, this 23rd day of I3etember, 199A, upon Lhe recommendation of the Orph;tns' Court Procedurnl Ru3e$ Committee the piroposal having been published for ndop= lion at 25 Pn. Bulletin 5505 (Decemtrer 2, 1995): Jt Is Ordered pursuant to Article V, Section 10 of the Constitution oC Pennsylvania that Rules 14.1-I~S.9 era amended, all in the following Corm. This Order shall be processed in accordance with Pn.R..).A. I03(b), and shall be effective JanuAry !, 1999. Annex A TITLE 231. RULES OF CIViI, I'ROCFOi1iRE PART Ii. ORPHAIY9' COURT RULES Amendments to Orphans' Court Rulca l~t.l-id.9 Rule l4. ([iVCOMPETEIV'TS' ESTA'I')ES GUARDIANSHIP OF [NCAPACI'I'ATEI3 PERS01dS Rule 19.1. Local rules. The practice Rod procedure with rc~rect to (incompe- tents' estates [ incapacitated persons' shall he as #§~e Pe•obaie, Eatat-sa and F3duciarl~eo Code. (~diior's N~~tz: T),a form of Notice and CerdScetiea following Rule 6.6 is rescinded and new Rule 6.7 is adopted to r°place the form of Notice and CertSfica'aon. Rule 5.7 is printed in regular t,,ype to enhance readabilit-yJ Rttle S.~ Form of srotlca and cEgtiY9ca~t3ori of rtotlca 3a banaficiatxd2a and Int~stats hal.~: (a) Form o/Notict to B~ne~rinrice and Jntestafx Heim. prescribed by local rules, which shaft not be inconsistent with [Rules 14.2 and 14.3 hereof ] Rz.les 14.2-14.b. Pule I9.2 is repealed and rapiacEd svi2lr the foJosv i ng. 13u1e fl4.2. Adjudication of incapacity and appolnk- went of a guardian of il-ie person and/or estate of an incapacitated person. A ~titiion to ac>,judicate incapacity shall meet all requirements set forth mt 20 Pm.C.B. $ 6511. A cltd- tion end notice in the form set forth in Rude 14.5 shrel! b•e attached to and served with a petition. The {Srocedure for determination of incamismcity enol for vrppointrnent cif m guaetiiian shall rare:et ail reraanis^E+- menta set (o r2i~ Ai 20 Pa.GS. ~$ 6612 errd 6512.1. Rule td.3. [Adjudication of co~petency ] Re,~•i2w hearing. A petition (to adjudicate that a p~raor+ pr~evl~ously Adjud;~ed incompetent has become competent ]for a review hearing shall set forth: (1) the date of the adjudication of [ Incompetency incapacity; (2) the name and address of the guardian; (3) if the [ incompetent ]incapacitated person has (rren a patient in a mental hospital, the name of such institution, the date of [his ]admission, and the data of discharge: PENNSYLVAVfA ©ULl_ETiN, VOL. 29, NO. 3, JA`IUARY tfi, t'~99 Il~'IPOR~'ANT ~ OTICE 1 vYOTi~i O ~~ ~ r^'~ ~ ~ ~i111'4~1~.~1T1J i i~.t'i~1~1'~~ - -- - - _ _- THIS NOTICE DOES NOT ti1EAN TI-I.aT YOU WILL RECEIVE ANY ~IONE~" OR PROPERTY FROI'v1 THIS ESTATE OR OTHERWISE T3'7zether you will receive any money or property tia•ill be determined wholly or partly by the decedent's will. If the decedent died tivithout a will, whether you mill receive any money or property will be determined by the intestacy lativs of Pennsylvania. BEFORE THE REGISTER OF WILLS, COUNTY OF , PENNS~ZVANL~ IN RE: ESTATE OF ,Deceased File Number T0: (Beneficiart) (Address) Please take notice of the death of the Decedent and the grant of Letters to the personal representative(s) named below. The Decedent died on the day of , a resident of County, PA. The Decedent died: testate (with a will) or intestate (without a will). You may have a beneficial interest in the estate as follows: (If additional space is needed, use separate sheet) The name(s), address(es) and telephone number(s) of all personal representatives appointed are: NAME ADDRESS TEI,EPI-TONE If the Decedent died testate, the will has been filed with Office of the Register of ~T/ills of County. If the Decedent died intestate, a Petition for the Grant of Letters of Administration was filed with the Office of the Register of Wills of County. The Register's address is ,and telephone number is A copy of the Will or Petition may be obtained by contacting the Register of Wills and paying the charges for duplication. Date Signa!ure ojPerson Filing !Iris Form Narne ojPerson Firing this Form Capacity: D Personal Representative Address O Counsel for Personal Representative Telephone C~R~IFICATION Off' NOTICE UN~~'R Pa. O.C. Rule ~.~{a) REGISTER OF WILLS COINTY. PEN:~'SYLVANIA Name of Decedent: Date of Death: Date Letters Granted: File Number: To the Register: Y certify that Notice of Estate Administration required by Pa. O.C. Rule ~.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Name: Address: (If more space is needed, attach separate sheet.) Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) except: Dace Signature ojPerson Filing this Form Capacity: ^ Personal Representative O Counszl ,Nome ojPerson Filing this Form Address Talephate Form RW-08 rvv !(1 I i !IF PULE 6 . S FILIh WITH THi? REGISTER OF WILLS (Repealed) RULE 5.6 FILING 6dITH THE CLERIC OF THE ORPHANS' COURT Fiduciaries accounts. The accour>t of a personal representative, trustee, guardian of the estate of a minor or incompetent and custodian under the Uniform Gifts to Minors Act shall be filed with the Clerk of the Orphans' Court. ATTACH~LENT C PULE 6.12 STATUS RF,PORT BY PERSONAL REPRESENTATIVE (a} Report of uncompleted administration. If administration of an estate has not been completed within two years of the decedent's death, the personal representative or counsel shall file at such time, and annually thereafter until the administration is completed, a report with the Register of Wills showing the date by which the personal representative or counsel reasonably believes administration will be completed. (b) Report of completed administration. Upon completion of the administration of an estate, the personal representative or his, her or its counsel shall file with the Register of Wills a report showing: (1) completion of administration of the estate; (2) whether a formal account was filed with the Orphans' Court; (3) whethei a complete account was informally stated to all parties in interest; (4) whether final distribution has been completed; and (5) whether approvals of the account, receipts, joinders and releases have been filed with the C].erk of the Orphans' Court. (c) Fonn of report.. The report required by this Rule shall be in substantially the prescribed form. (d) No fee. No fee shall be charged for filing the report required by this Rule. (e) Copy of rule. Upon the grant of letters, the Register shall give a copy of this Rule to each personal representative and his, her or its counsel. (f) Failure to file a report. Aftez at least ten (10) days prior notice to a delinquent personal representative and counsel, the Clerk of the Orphans' Court shall inform the Court of the failure to file the .report required by this Rule with a request that the Court conduct a hearing to determine what sanctions, if any, should be imposed. Pa. ®.C. Rule 6.12 STATUS REP~i-.T ~GISTER OF ~~ILLS OF COUNTY, PE~?iSYLVAtiTI.A Name of Decedent: Date of Death: File Number: Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete:.................... [~ Yes Q No 2. If the answeris No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is YES, state the following: a. Did the personal representative file a foal account with the Court? ....... QYes ~No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account u7formally to the parties in interest? ............:. .........:........ ! I'es No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts maybe filed with the Cleric of the Orphans' Court and may be attached to this report. Sigieature ojPerson Filing this Form Capacity: QPersonal Representative QCounsel Nmne of Persai Filing this Form Addrzss Tzlephone