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HomeMy WebLinkAbout12-02-11 (2)1505611188 REV-1500 EX(°2-1,jlFl) pennsytvania OFFICIAL USE ONLY PA Departmentof Revenue °°'""'"`N10'"`"`""` County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280801 Harrisburg, PA 17128-0801 RESIDENT DECEDENT 21 11 0688 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Binh MMDDYYYY 195 16 3398 O6 03 2011 11 05 1924 Decedent's Last Name Suffix Decedent's First Name' MI Black Viola ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Frst Name MI spouse's social security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate Q 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received D 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 Confldentlal Tax Information Should be Directed to: Name Daytime Telephone Number Elyse E• Rogers, Esquire 717 612 5801 Frst Line of Address Saidis, Sullivan & Rogers Second Line of Address 635 North 12th Street, Suite 40D City or Post Office Lemoyne State ZIP Code PA 17043 ~`~~ ,~ i--) l ~.~, ": ~tj ,- ~ ~~ Correspondent's a-mail address: er09erS(C~SSr-attOmeVS.COm REGISTER OF WILLS USE O~JI~Y n •~-- ,,. ti ~~ T t,,:..x r r--I J _ I._ L.. J t ,..3 ~ f '~,.14...~ i.. . f _.' ``' y L._.i --~? 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 the preparer other than personal representative is based nor of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS See schedule attached ~~ ~ 1 ~~A,~~ ///~d//~ ~-- ! 1 / 3 0 ~ ~ ~ ADDRESS 5 North 1 th re Suite 400 Lemoyne, A 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505611],88 1505611188 Estate of: Viola J. Black Executor Lois A. Hippensteel Scot E. Davis 1488 Brandt Avenue 1622 Woodhaven C>rive New Cumberland, PA 17070 Hummelstown, PA 17036 195-16-3398 Rev-1500 EX (FI) Decedent's Name: ~' l O l a J B l a c k 1505611288 RECAPITULATION 1. Real Estate (Schedule A) ......................................... 1, 2. Stocks and Bonds (Schedule B) .................................... 2, 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ...... 3, 4. Mortgages and Notes Receivable (Schedule D) ......................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) ....... 5, 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ...... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested ...... 7, 8. Total Gross Assets (total Lines 1 through 7) ............................ g, 9. Funeral Expenses and Administrative Costs (Schedule H) .................. g, 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 1p, 11. Total Deductions (total Lines 9 and 10) .............................. 11. 12. Net Value of Estate (Line S minus Line 11) ............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 D • D D 15. 16. Amount of line 14 taxi~ble at lineal rate X .045 D • D D 16 17. Amount of Line 14 taxable at siblingrateX.12 1,114,213.96 17. 18. Amount of Line 14 taxable at collateral rate X .1 s 2 2 7, 5 3 6. 3 8 18 19. TAX DUE .................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505611288 Decedent's Social Security Number 195 16 3398 0.00 0.00 0.00 o.oD 40,786.99 0.00 1,367,558.47 1,408,345.46 40,152.70 1,442.42 41,595.12 1,366,750.34 25,000.00 1,341,750.34 0.00 o.DD 133,705.68 34,130.46 167,836.14 O 1505611288 J Rev-1500 EX (FI) Page 3 Decedent's Complete Address: File Number ~~ ~ ~ naQu Total Credits (A+ B) (2) 166,315.78 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII In oval on Page 2, Llne ?10 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) 1 520.36 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 iincome 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 "intrust 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 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. Sect. 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. Sect. 9116(a)(1.1)(ii)]. The statue 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 alpplicable 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. Sect. 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. Sect. 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. Sect. 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 167 836.14 2. Credits/Payments A. Prior Payments 158 000.00 B. Discount 8 315.78 REV-1508 EX+(11-10) fi`,; Pennsylvania OEPARTME NT OF REVENUE INHERITANCE TAX RETURN RFCIf1 FIJT Il C/`C l~~.~T SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSAN01 PRADGQTv ~.~. FILE NUMBER: Viola J. Black 21 11 0688 Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointly owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VAOF DEATH 1 PA Department of Revenue, 2010 income tax refund 53.00 2 Transamerica Select Value Annuity Contract 27343144 40,636.32 Beneficiary: Decedent's husband Kenneth G. Black who pre-deceased Decedent - naw payable to Estate of Viola Black Per 06/30/11 letter 3 PA Unclaimed Property- PA Employees Benefit Trust Fund claims 13.24 payment check 4 PA State Employees' Retirement System Final Payment 84.43 Per 7/22/201 i letter TOTAL (Also enter on line 5, Recapitulation) I 40,786.99 If more space is needed, insert additional sheets of the same size REV -1510 E X+ f 08-09) j i1 Pennsylvania t~ 6EPARTMENT OE REVENUE INHERITANCE TAX RETURN RESIDENTDECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Viola J. Black 21 11 0688 I nis schedule must be completed and filed if the answer to any of questions 1 through 4 on oage three of the RF V_tSnn ~~ ,.ems ITEM NUM INCLUDE NAMEOFETFlANSFEIROEEOELPAITOPSH PTODECEDENT& DATE OF TRANSFER. ATTACH COPYOF DEED FOR REAL ESTATE DATE OF DEATH VALUE OF ASSET %OFDECD' INTEREST S EXCLUSION (IFAPPLICABLE) TAXABLE VALUE 1 Signatorone Money Market Account PE6- 22,933.34 100 22 933.34 063584 , 2 AMERICAN CENTY'GOVT INCOME TR 35,121.69 100 35 121 69 CUSIP: 025081506 , . Shares/Par: 3583.846 Exchange: Mutual Fund (as quoted by NASDAQ) SH TRM GOVT IN 3 COLUMBIA FDS SER TR 69,818.90 100 69 818.90 CUSIP: 19765H362 , Shares/Par: 6995.882 Exchange: Mutual Fund (as quoted by NASDAQ) SHORT TRM BD Z 4 COLUMBIA FDS SER TR I 152,090.07 100 152 090.07 CUSIP: 19765Y886 , Shares/Par: 16162.6 Exchange: Mutual Fund (as quoted by NASDAQ) CORE BD RETAIL 5 CREDIT SUISSE CQMMODITY RETURN 26,343.91 100 26 343.91 CUSIP: 225448305 , Shares/Par: 2729.938 Exchange: Mutual Fund (as quoted by NASDAQ) COMMON CL 6 EATON VANCE SER TR II 58,465.78 100 58 465 78 CUSIP: 277907101 , . Shares/Par: 9809.694 Exchange: Mutual Fuind (as quoted by NASDAQ) COM 7 EURO PAC GROWTH FD 78,042.84 100 78 042 84 CUSIP: 298706409 , . Shares/Par: 1814.106 Exchange: Mutual Fund (as quoted by Total from continuation Schedule(s) 924,741.94 TOTAL (Also enter on Line 7, Recapitulation) I 1,367, 558.47 If more space is needed, use additional sheets of paper of the same size. Estate of: Viola J. Black Schedule G -Inter-Vivos Transfers and Misc. Non-Probate Property Page 2 21 11 0688 Item Num Description of Property Date of Death Value of Asset % of Dec';. Exclusion Interest _ (if applicable) Taxable Value 7 NASDAQ) CL F-1 8 FRANKLIN INVS SACS TR 56,218.51 100 56 218 51 CUSIP: 353612823 , . Shares/Par: 6117.357 Exchange: Mutual Fund (as quoted by NASDAQ) FL RT DAILY A 9 GROWTH FD AMER INC 163,755.71 100 163 755.71 CUSIP: 399874403 , Shares/Par: 5251.947 Exchange: Mutual Fund (as quoted by NASDAQ) CL F-1 10 MERGER FD 43,381.18 100 43 381.18 CUSIP: 589509108 , Shares/Par: 2669.611 Exchange: Mutual Fund (as quoted by NASDAQ) SH BEN INT 11 NORTHERN FDS 65,638.79 100 65 638.79 CUSIP: 665162400 , Shares/Par: 4232.03 Exchange: Mutual Fund (as quoted by NASDAQ) SM CAP VALUE 12 PIMCO FDS PAC INVT MGMT SER 158,974.23 100 158 974.23 CUSIP: 693390445 , Shares/Par: 14373.8 Exchange: Mutual Fund (as quoted by NASDAQ) TOTAL RET A 13 SENTINEL GROUP FDS INC 58,701.82 100 58 701 82 CUSIP: 817270606 , . Shares/Par: 5501.576 Exchange: Mutual Fund (as quoted by NASDAQ) SENT GV SEC A TOTAL. (Carry forward to main schedule) ...... 546,670.24 Estate of: Viola J. Black Schedule G -Inter-Vivos Transfers and Misc. Non-Probate Property Page 3 21 11 0688 Item Num Description of Property Date of Death Value of Asset % of Dec's Exclusion Interest (if applicable) Taxable Value 14 TEMPLETON INCOME TR 80,745.64 100' 80 745.64 CUSIP: 880208103 , Shares/Par: 5779.931 Exchange: Mutual Fund (as quoted by NASDAQ) GLOBAL BD FD A 15 WASHINGTON MUT INVS FD INC 66,809.42 100 66 809.42 CUSIP: 939330403 , Shares/Par: 2350.789 Exchange: Mutual Fund (as quoted by NASDAQ) CL F-1 Items 1-15 in Signatprone account PE-063584 POD to Viola June Bllack Revocable Trust 16 PSECU Checking Account titled: Viola June 10,300.56 100 10 300.56 Black Revocable Trust , Per 7/1/11 letter Interest on above item accrued as of 10,300.56 100 0 08 decedent's death . 17 PNC Checking Account 5004748887 titled: 2,530.99 100 2 530.99 Viola June Black Revocable Trust , Per 08!17/11 letter 18 PSECU Savings Account titled: Viola June 147.12 100 147 12 Black Revocable Trust . Per 7/1/11 letter 19 PSECU Money Market Account titled: Viola 52,060.31 100 52 060.31 June Black Revocable Trust , Per 7/1 /11 letter Interest on above item accrued as of 52,060.31 100 1 90 decedent's death . 20 PSECU CD #S50 titled: Viola June Black 105,413.43 100 105 413.43 Revocable Trust , Per 7/1/11 letter Interest on above item accrued as of 105,413.43 100 7 80 decedent's death . TOTAL. (Carry forward to main schedule) ..... . 318,017.25 Page 4 Estate of: Viola J. Black 21 11 0688 Schedule G -Inter-Vivos Transfers and Misc. Non-Probate Property Item Num Description of Property Date of Death Value of Asset % of Dec's Exclusion Interest (if applicable) Taxable Value 21 PSECU CD #S55 titled: Viola June Black 55,356.78 100 55 356 78 Revocable Trust , . Per 7/1/11 letter Interest on above item accrued as of 55,356.78 100 4 09 decedent's death . 22 Allstate Annuity Contract GA699466 in PNC 4,693.58 100 4 693.58 Investment account !004-623377 , Beneficiary: Decedent's nephew, Scot E. Davis Per 06/30/11 letter TOTAL. (Carry forward to main schedule) ...... 60,054.45 REV-1511 EX+(10-09) Pennsylvania SCHEDULE H 6EPARTMENT Of REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF Viola J. Black FILE NUMBER 21 11 0688 Decedent's debts must be reported on Schedule I ITEM . NUMBER DESCRIPTION AM OUNT A. FUNERAL EXPANSES: 1 Payments to Church/pastor for services related to funeral service 400.00 2 Musselman Funeral Home 1,138.77 3 Scot Davis, reimbursement for payment of funeral luncheon 351.05 4 Blue Ridge Memorial Gardens, scroll date of death on headstone 446.00 B• ADMINISTRATIWE COSTS: ~. Personal Representative Commissions: 28,000.00 Name(s) of Personal Representative(s~COt E. DBMS/LOTS A. Hfppensteel _ Street Address 1622 Woodhaven Dr/1488 Brandt Avenue city Humlmelstown/New Cumberland State PA zip 1703 17070 Year(s) Commission Paid: 2012 2. Attorney Fees 7, 500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State Zip _ Relationship of gaimant to Decedent a. Probate Fees: 96.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7 Cumberland County Register of Wills, additional probate fee 45.00 8 Cumberland County Register of Wills, filing fees 30.00 9 Signatorone, investment management fee 1,742.98 10 Saidis, Sullivan & Rogers, out of pocket expenses 402.40 TOTAL (Also enter on Line 9, Recapitulation) 40,152.70 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+112-08) Pennsylvania D£PARTMFNT OP RFY£NU£ INHERITANCETAX RETURN RESIDEN7DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Viola J. Black 21 11 0688 Report debts Incurred by decedent prior to death that remained unpaid at the d~ ~f ~~e, ~..,.~..a~..,......,.~_~..___~ __,.__. __ _ It more space is needed, insen additional sheets of the same size. REV-1513 EX+(01-10) ~i Pennsylvania 6FRAR1MFNf OF RFYENUE INHERITANCETAX RETURN RESIDENT DFCFn FN7 SCHEDULE J BENEFICIARIES .. ~ ~ vr~ FILE NUMBER: Viola J. Black 21 11 0688 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBE NAME AND DRESS OF PERSONS RECEIVING PROPERTY Do Not Llst Trustees OF ESTATE I TAXABLE DISTRIBUI~IONS [Inc-ude outright spousal distributions, and transfers under Sec. 9116(a)(1.2).) See schedule attached ENTER DOLLARAMOUN SFORDISTRIBUTIONSSHOWNABOVEONLINESI5THROUGHIBOFREV-1500 COVERSHEET,ASAPPROPRIATE. II NON-TAXABLE DISTRIIBUTIONS: A. SPOUSAL DISTRIf#UTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: See schedule attached 25,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I 25,000.00 If more space is needed, use additional sheets of paper of the same size. Page 2 Estate of: Viola J. Black 21 11 0688 Schedule J, Part I -Taxable Distributions Num. Name and Address of Person(s) Receiving Property Relationship to Decedent Am of E tatehare Lois A. Hippensteel Sister 222 842 79 1488 Brandt Averjue , . New Cumberland; PA 17070 Scot E. Davis Nephew 4 693 58 1622 Woodhaven' Drive , . Hummelstown, PA 17036 Arthur W. Davis Brother 222 842 79 P.O. Box 459 , . Shermans Dale , IAA 17090 Paul L. Davis Brother 222 842 79 P.O. Box 322 , . Elizabethtown, PA~ 17022 Marie L. Miller Sister 222 842 79 2610 Boas Street , Harrisburg, PA 17103 Richard W. McCurtdy Nephew 222 842 80 603 Reno Street , . New Cumberland,'PA 17070 Estate of George Qavis Brother 222 842 80 c/o Reager & Adlef, PC , . 2331 Market StreeN; Camp Hill, PA 17011 Page 3 Estate of: Viola J. Black 21 11 0688 Schedule J2 -Part B Charitable and Governmental Distributions Item Description Amount 1 St. Jude Children'$ Research Hospital 5,000.00 501 St Jude Place Memphis, TN 38145 2 Oak Orchard Community Church 10,000.00 32615 Oak Orcharid Road Millsboro, DE 1996 3 Delaware Hospice,:, Inc. 10,000.00 Delaware Hospice',Center 100 Patriots Way Milford, DE 19963 TOTAL. (Carry forward to main schedule) ...... 25,000.00 ~ ;o ¢ N _ w ~ m ~ H D U O .7i N; ~ ~~ ~ ~ ~ 119 ~ ~ ~ R Q ~ Q ~ ~ a ;H m ;. Q:4 3 w ~ :¢: ~ _ ~, n T- 1 t7 , J. D F. ~ 1 O ~ a, ~ ~ ~ a ~ yt i a ,> Q '~ ~u}i D °~ `~ ~* !w O ~' : : * - . .¢ w ~¢ * E '~ ` i ¢ * _. iH ~T E£9LE0 ~ ~ w E-- _ _ O, ~ - f~' _ M >- ~ n o - Z ~ - - <w > ~ o W ti ~ - F-. m W ~ Q = W - a~ > ~ - . ~ ~O -,W m U ~ MW~ p > Z - Ov U~~~ j- '- ~oZCO Q Q ~ 0]OQ~ - 'z'a z O ~ o ~omU ¢w~ (Y1 I- Q ¢ OZm?~ = °~ ` w J W J ;Z ;~ 'J ¢ ~j ~g> L ao 1111111111111111111 " 3 2 0 11 lllll IIIII 111 0 0 0 11111 0 1111111111111111111111111111111 11 0 0 5 3 0 0 N J rY1 L!l ~' .-a ru a ~' J N n.~ O 1Y1 .-i rfi O :' c~ Q' C~- .-a N S c0 Ti~vSA,.MERICA w LIFE INSURANCE COMPANY Transamerica Life Insurance Company 4333 Edgewood Road NE PD Box 3183 Cedar Rapids, Iowa 52406-3183 June .30, 2011 Kenneth G Black c/o Elyse E Rogers 635 N 12th St Suite 400 Lemoyne PA 17043 RE: Annuity Number(s) 27343144 Dear Kenneth G Black: We have received notification, Viola J Black, annuitant of the above listed non-qualified tax deferred annuity is deceased. Our office wishes to extend sincere condolences for your los:;. The following is the current information on this annuity: Annuitant: Owner:: Primary Beneficiary: Annuity Policy Date: Full Value as of 06/30/2011: Full Value as of 06/03/2011: Viola J Black Viola J Black Kenneth G Blacl~: 100 February 17, 2000 $40,725.27 $40,636.32 The attached document reflects the options available to the beneficiary lusted above. The full value as of the date of death is for tax purposes only and is not a guaranteed death benefit amount. Operations performed on an automatic basis when applicable have been terminated, such as; Systematic Payouts or Automatic Billing. The attached document contains general tax information based on Transamerica Life Insurance Company's interpretation and should not be relied. upon for your personal tax planning. If you have questions concerning the direct tax consequences when selecting an option, you may wish to consult a tax advisor. Member of the AEGON. Group D nw Da~Lnu ANNBITY FIN ANCtAI - INTER~d ED4ARv SERVICE AWARD ~ ..POST-SALE `SERVICE 'Awa RD " °; .,sons. -,-an-n~3 __ _ - -- PROPERTY DESCRIPTION PropertylHolderln#ormationl Pco e _ p rty.1D : , :4353769 (Ai Gnginal Owner's Name (B) Gnginal Owners Address as Reportec BLACK VIOLP, J RT 4 BOX 147 MILLSBORO DE 19966- (Cj Hostler Reporting Funds (Dj Last TransacLOn Date PENNSYLVANIA EMPLOYElKS BENEFIT TRUST FUND 03/16/1993 (E; Holder Atltlress and Contact (F) Type of Funds Reported 150 S 43RD ST STE 1 CLAIMS PAYMENT CHECK HARRISBURG PA 17111 (G) Certificate. Fol~cy or Check Number R LASHLEY 528310 717-565-7311 (Hj Amount Reported 13.24 Total Shaires Claimed 0.0000 Total Gash Claimed 13.24 RETURN CLAIM FORM AND DOCUMENTATION TO: ioo6soo6o Bureau of Unclaimed Property ~ F?.O. 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O ~ y m ~ IQ 0 Z Z C C C ~ 7 O O d U U ~ Q¢ ~ Estate Valuation Date of Death: 06/03/2011 Valuation Date: 06/03/2011 Processing Date: 08/21/2011 Shares Security or Par Description High/Ask Low/Bid 1) 3!i83.846 AMERICIyN CENTY GOVT INCOME TR (025081506) SH TRM (GOVT IN Mutual !Fund {as quoted by NASDAQ) Estate of: Viola Black Account: Signatorone Report Type: Date of Death Number of Securities: 14 File ID: Black, Viola Estate Sinatorone Mean and/or Div and Int Security Adjustments Accruals Value 06/03/2,011 9.80000 Mkt 9.800000 35,121.69 2) 6995.682 COLUMBIA FDS SER TR (19765H362) SHORT TYtM BD Z Mutual Fund (as quoted by NASDAQ) 06/03/2011 9.98000 Mkt '3. 980000 69, 818.90 3) ].6162.6 COLUMBIA FDS SER TR I (19765Y886) CORE BD RETAIL Mutual Fund (as quoted by NASDAQ) 06/03/2p11 9.41000 Mkt !3 . 410000 152 , 090.07 4) 27'29.939 CREDIT SUISSE COMMODITY RETURN (225448305) COMMON QL Mutual Fund (as quoted by NASDAQ) 06/03/2011 9.65000 Mkt 9.650000 26,343.91 5) 9809.694 EATON VANCE SER TR II (277907101) COM Mutual Fund (as quoted by NASDAQ) 06/03/2011 5.96000 Mkt 5.960000 58,465.78 6) 1814.106 EURO PAQ GROWTH FD (298706409) CL F-1 Mutual Fund (as quoted by NASDAQ) 06/03/2011 43.02000 Mkt 43. 020000 78,042.84 7) 6117.357 FRANKLItG INVS SEC5 TR (353612823) FL RT DAILY A Mutual $'und (as quoted by NASDAQ) 06/03/2p11 9.19000 Mkt 9.190000 56,216.51 8} 5251.947 GROWTH FD AMER INC (399874403) CL F-1 Mutual Fund (as quoted by NASDAQ) 06/03/2011 31.18000 Mkt 31.180000 163,755.71 9) 2669.611 MERGER ND (589509106) SH BEN ANT Mutual Nund (as quoted by NASDAQ) 06/03/2011 16.25000 Mkt 16.250000 43,381.18 10) 4232,03 NORTHERN FDS (665162400) SM CAP ~ALUE Mutual Nund {as quoted by NASDAQ) 06/03/2011 15.51000 Mkt 15.510000 65,638.79 11) 14373.8 PIMCO FDS PAC ZNVT MGMT SER (693390445) TOTAL RET A Mutual Fund (as quoted by NASDAQ) 06/03/2011 11.06000 MY.t 11. 060000 158,974.23 12) 5501.576 SENTINEL GROUP FDS INC (817270606) SENT GV SEC A Mutual Fund (as quoted by NASDAQ) 06/03/2011 10.67000 MY.t 10.670000 58,701.82 Page 1 This report was p roduced with EstateVal, a product of Estate Valuations & Pricing Systcsms, Inc. If you have questions, please contact EVP Systems at (618) 313-6300 or www.evpsys.com. (Rc=_vision 7 .1.0) Date of Death: 06/03/2011 Valuation Date: 06/03/2011 Processing Date: 08/21/2011 Shares Security or Par Description 13) 5779.931 TEMPLETON INCOME TR (680208103) GLOBAL BD FD A MutuaY Fund (as quoted by NASDAQ) 06/03/2011 14) 2350.789 WASHINGTON MUT INVS FD INC (939330403 CL F-1 Mutual Fund (as quoted by NASDAQ) 06/03/2011 Total Value: Total Accrual: Total: $1,114,108.49 Estate of: Viola Black Account: Signatorone Report Type: Date of Death Number of Securities: 19 File ID: B1acY„ Viola Estate Sinatorone M[:an and/or Div and Int Security High/Ask Low/Bid Atijustments Accruals Value 13.97000 Mkt 13.970000 28.42000 Mkt 28.420000 80,745.64 66,809.42 $1,114,108.49 $0.00 Page 2 This report was produced with EstateVal, a product of Estate valuations & Pricing Systems, Inc. If you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.1.0) T _ _ _ N~~, '~, ~C'' '~i;~4A(U~ PNC BANK No,'8'3 F. ?~'~ ~~ :~ TMF war August 17, 2011 Elyse E Rogers Esq. Saidis Sullivan & ~togers 63 5 N 12~' St Ste 4100 Lemoyne, PA 17043 RE: Viola J Black SSN: 195-1i6-3398 DOD: 06-OB-2011 Dear Ms. Rogers: In response to your, request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checking Account Accou~at # 50047481887 Established: 08-15-2006 VIOLA JUNE BLAC.YC TRT VIOLA. BLACK TTEE LOIS A HIPPENSTEEL TTEE S DAVIS TTEE URTAD 01/28/2005 DOD balance: $ 2,30.99 non interest bearing Investment Account The decedent maintained Investrnent Account # 4623377. For further information, you may call the Brokerage De~partm~nt at 1-800-762-6111. Please note tlxat this o~fice provides date of death balances for deposit accourrts (IRAs, CDs, Checking and Savings). We dv not process sny financial transactions or provide statements. If you .deed assistance with any of these items, pldase call 1-888-PI~TC-B1~1VIG (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC D.~,.~n 1 ~,f 7 i - _ _ __ PSEC~k July 1.201 1 Law Office of Saidis, Sullivan 8 Rogers Attn: Elyse E. Rogers 635 North ]2`~' St, Suite 400 Lemoyne, P'a 17043 Re: Viola J. Black, Deceased. Account #0195163398 Dear Ms. Rogers The account was opened on June 1, 1999. The account is a Living Trust Account, with Viola Blacl< as Trustee, Lois A. Hippensteel as Trustee and Scot Davis as Trustee. There are no loans on this account. The following are the Date of Death Balances for Ms. Black's account with PSECU: Account Date of Death Balances Interest -June 151- June 3rd Savings (S 1) $ 147.12 $0.00 Checking (S4) $10,300.56 $0.08 Mone}~ Market (S7) $52,060.31 $1.90 CD # S50 (S50) $105,413.43 $7.80 CD# S55 (S55) $55,356.78 $4.09 if you have any questions, please contact me at (717) 234-8484 or toll-free at (800) 237-7328, then press 6, extension 3120. Sincerely, Dana Willard Service Advisor PSECU Pennsylvania State Employees Credit Union P.O. Box 6'7013, Harrisburg, PA 17106-7013 • 717.234.8484 • 800.237.7328 • » psecu.com THIS CREDIT UN10N IS FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY LENDER. A=1l~state M You're in good hands. June 30, 2011 Elyse E. Rogers Law`Offices of Saldis, Sullivan & Rogers 635North 12th Street, Suite 400 Lerr~oyne, PA 17443 Sent'Via-Email to erogers@ssr-attorneys.com Re: Viola J Black Contract No: GA699466 "Dear; Ms. Rogers: V1le received a request to complete IRS Form 71.2 forthe above referenced contract. The;,purpose of~Focm 712 is to provide a'n estate or donor with the value of a life insurance contractor itsproceeds as of a certain date (usually'the owvner'sdate of death or date oftransfer of the contract). Because :this conf~ract is an annuity, it is not reportable on IRS Form 712. I cari, however, provide the 'following informatipn for estate purposes: Date of Death: June 3, 2011 - ---- Annuity Value as of Date of Death: $ 4,693.58* _ Cost Basis: $ 3,000.00 Named Beneficiary: Scott Davis *The.actual amournt paid may differ due to Market Value Adjustments and/or any applicable Surrender ..Charges. If you`have any qu&stions, please contact me at 1-877-499-6418 Ext. 25112. Sincerely, Steven ~Arbitman Senior Claim Examiner Allstate.Life Insurance Company Life and Annuity Claims P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523 i ~~1~~ ~'~`~Illlll ~Il~~ ~~E~~Il~Il~~IlIl~ OF I ~lIOLA JUNE BIL4CK I, '1rI0I~~1 J~tTNE BLACI2, of 1VIillsboro, Delaware, County, Pennsylvania; do hereby make, publish and declare this to be my Last «'"ill and Testament, hey°eby revolting all T~iTills and Codicils by me heretofore made. IT i M L Family Information. I am a widow, having I been married to KENNETH GORDON BLACK. I have no children. My intended ~ beneficiaries include my siblings, ARTHUR Vi'. DA~TIS, GEORGE S. D AV ' I IS, PAUL ,' DAMS, LOIS HIPPENSTEEL, MARIE 112ILLER and the issue of my deceased sister°, N1~OMI 1`~/IcCURDY. IT I\~ II: Death Taxes. I direct that all inheritance ~ and. estate taxes.. becoming due by reason of my death, whether payable by m 5 estate or by any recipient of any property, shall be paid b~~ the Executor out of the residue of my estate, as an expense and cost of administration of my estate, except that no taxes shall be charged against any gift qualif~ring f'or tL-:e marital or• J char•ii;able deduction in my estate. The Executor shall have no duty or obligation to obtain reimbu~°sement for anST such t,ax so paid, even though on proceeds of insurance or oth~~:• proper°ty not passing undei° this Will. i ITE~ ~ III: ---~--- Debts anal Final Ext~enses. I direct. the Executor to pay i;he expenses of my last illness illy le~~ balls enforceable debts; and my funeral expenses from the residue of my estate as an expense and cost of administration of my estate. Page 1 ~~ / ~ i ITEM IV: Tangible Personal Pi•o~~~erty. (a) «'ritten List. I may leave a written list in my safe deposit box oi° elsewhere disposing of certain ii,ems of my tangible personal propert>>. The Executol° shall dispose of items of mfr personal property- as specified in the «rritten list. If nn writt:en lisT. is found in my safe deposit bc~x or elsewhere and properly identified by the Executor within this°ty (3Cl) da~rs after the probate of my ~~rill, it. s~~all be presumed' that there is no othe.i• statement or• list. Any subsequentl~% discover°ed list shall be ignored. ~) I give any property of the type described in this Item and not set forth in a written list to my siblings, and to the then living issue of m~- deceased siblings, to be divided among them aS they shall agree. Should there be no agreement, the Executor shall divide this property= between them in as nearly equal portions as the Executor, in the discretion of the Executor, deems appropriate, having due regard to the personal preferences of the beneficiaries. The Executor shall represent any minors in the ditiTisi.on of t;his property. If the Executor thinks any property to which a minor child would become entitled is unsuitable for the child's use, the pzoperty shall be sold a.nd the proceeds sl2all be added to the share of my residuary estate held for t;hc benefit: of• t;~~at. child. The Executor may deliver any property to which a minor is entitled and. which is not sold. to the person with whom. t;he child resides or v~rho has the car°e or control of hin7 (vrithout bond). and the receipt of that person shall be a complete release of'the Executor. ITEM ~': P~esidue. I give the residue of my estate, not disposed of in the preceding portions of this Fill, t;o the then acting Trustee of the Pale :~ y~°. i C% `'I01L~ JUNE BLACK TRUST, as Trustees; IN TR.LTST, to be administered and distributed in accox•dance with an Agreement. of Trust. executed by me, LOIS HIPPENSTEEL and SCOT E. DAB%IS, ;~s Trustees and b~- me as Grantor, on the ~S5 ~ clay of ~t~,~-~~..~-~ ,~~(j~. I coi7firm and ratif ~ this A re ~'- 5 g ement. of Trust; as amea~ded by me fi°om ~in~e to time. in every respect. IT M VI: Administrative Powers. In addition to the powers granted at law, the Executor shall possess the following; powers; each of v,Thich shall be construed broadl~T and may be exercised without court approval, but in a fiduciax•~° capacity onl3~: (a) Retain Investments. To retain any investments I have at my death; including specifically those consisting of stock of any bank even if I have named that bank as the Executor. (b j Varv Investments. To vary investments and to invest in bonds, sto~lis, notes, real estate mortgages or other securities or in othe~° prop~rt~~, x•eal or personal, without being restx•icted to so-called "legal investments", and. without being limited by any statute ol° rule of law regarding investments by fiduciaries. (cj Division o!'Assets. In order to divide the principal of my estate or make distributions, the Executor is authorized to distribute personal property and real property partly or wholly in kind, and to allocate specific assets among beneficiaries so long as the total market ~~~alue of each share is not; affected by the division; distribution oi° allocation in kind. The Executor is authorized to make, join in and consummate partitions of lands, voluntarily or involuntarily , inc]uding Page 3 ~~ _ (~~; _ ~ giving of mutual deeds; or other o1~ligations, with as wide powers a.. an individual owner in fee simple. (d'~,j Sell Asset. To sell eit;he~° at public or pri~;~ate sale any or all real cjr personal propel°t.y severally or i.n conjunction vc=ith other persons,'ancl to consummate sa.le(s) by deed(s) ol° other instrument(s) i to the pL~~°chaser(s), convey=ing a fee simple title. No purchaser shall be obligated to see to the application of the purchase moneST or to make inquiry= into the ~=aliclit5= of any. sale. The Executoi° is authorized to make, execute, acknowledge and deli~Ter deeds, assignments, options or othez• writings as necessary or convenient to carry out the powers conferred', upon the Executor. (e) Encumber Real Estate. To mortgage real estate, and to make leases of real estate. (f) Borrow Monez=. To borrow money from any person, including the Executor, to pay indebtedness of'mine or of my estate, expenses of administration or inheritance, legacy; estate and other taxes, and'to assign and pledge assets of my estate. (g) Pa -Costs. To pay all costs, taxes, expenses and charges in connect~,on with the administration. of m3' estate. Ch) Distributions VG'ithout Court Order°. To make distributions of income and of principal to the proper beneficiaries. dul°ing t;he .administration of my estate, with or without court order; in such manner and in such amounts as my Executor deems prudent and appropriate. Page 4 ~~~ I (i) Tote Stock. To exe:r•cise voting rights with respect to securities which form a part oj~ my estate, and to exercise all the powers incident, to the ownership of securities. (jj Reorganize. To tuiite with other owners of property similar to property in my estate to carry out. any plans fol° the reorganization of any company whose securities form a part of n1v estate. (kj Disclaim. To disclaim any interest in property which would devolve to me or n7y estate by whatever means; including but not limited to the follo~Ting means: as beneficial-y unde~° a will, as an appointee .under the exercise of a power of appointment, as a person entitled to take by intestacy, as a donee of an inter vivos ti ansfer, and as a donee under athird-party beneficiary contract. (lj Tax Returns. To prepare, execute and file t.ax returns of any t`Tpe r~quirecl by applicable law, and to make all tax elections authorized by la~~. {m) Allocate Ext~enses. To allocate administl°ative expenses to income or to principal, as the Executor deems appropriate. However, no allocation to income shall be made if the effect:. of the allocation zs to cause a reduction in the amount of any estate tax marit;a] deduction or estate tax charitable deduction. (n) Emnlov Advisors. To employ custodians of property, investment or business advisors, accountants anal attorneys as the Executor deems appropriate, and to compensate these persons from Page 5 'jI `~ assets of nay estate; v~~ithout affecting the compensation to which the Executor is entitled. (o) Ad~iust. Basis. To make any adjustment. to basis authorized by law, including, }.gut not limited to increasing the basis of any property included in my estate; uThether~ or not. passing under this Fill, by allocating any amount by which the bases of assets may be increased.. The Executor shall be under no duty and shall not be required tp allocate basis increase exclusively, primarily, or at all to assets which pass as part of my probate estate as opposed to other property fpr which a basis adjustment is allowable. The Executor shall allocate basis increase e uitabl b ~ g ~ y among those beneficiaries receivin property a~ a result of my death; but shall not lie liable to any person, nor subject to remo~Tal or surcharge, for any reasonable a.ll'ocation of basis increase. (pj Compromise Claims. To compromise claims. (q) Other gets. To do all other acts in the Executor's judgment deemed necessary or desirable far the proper and advantageclus management, investment; and distribution of the estate. ! j ITEl~I ~%IL Survival. Any per son who has died within thirty (30j days oj' niy death, or under such circumstances that the order of our deaths cannot be established by proo:[', shall be deemed to have 1>>redeceased me. ITEIy~ VIII: EYecut;ors. I make the following p~°ovisions with respect. to Executors: Page 6 ~!_ (a) I appoint: mt~ sisier, LOIS HIPPENSTEEL and my nephe~•, SCOT E. DgVIS; tc, be t;hE Co-Executors, hrein collectively re.ferz•ecl to as 'Executor,:. (b) The Executor shall have the right to receive reasonable compensation foi° services rendered and reimbursement for reasonable expenses. (c) No Executor shall be liable or accountable for any loss that maj- i+esult fiom the good. faith exercise of the authority granted in this ~fiill. (d) The Executor is specifically relieved from the duty of filing bond'' or entering security. . IN ~~,%ITNESS u'HEREOF, I have set my hand and seal to this, my Last ~~'ill and Testament, consisting of'this and the preceding six (6) pages, at the i end of each page df uThich I have also set; my initials for greater security and better identif~.cation this ~-~ day of ~~~,~ , ~~ C3. -~ _J i ,~ ~-- ~~ ~~ ~~ISEAL) ~%IOLA THE B ~ C - We; the undersigned, herebj- certify that the foregoing ~~ill was signed, sealed.; published and declared. by the above-named Testatrix as and for her Last ~~ill and Testament:, in the. presence of us, ~=ho; at: her request and in her• presence and in the presence of each other; have hereunto set: our hands and seals the day and veai• first above ~~~i•itt.en, and we certify that at the time of she e3.ecution thereof, the said 't'estatrix was of'souncl and disposing mind and memor~~. ~ . ~ (~ ~, ~. ~ , r~~~„ :, n.~ (SEAL) F~esiding at _ ~~ ~~ ~ ~,~' ~ _~~1?lr~ ~; .~ , , • ,, ,; ''~ ~~. ~;U.~U' (SEi~Lj Residing at. i ~~ ~~ ~~ ~ ~ ~ r, ~ '/ ~ ~ ~ ~ (SEAL] Residing at ~~( -~ ~.C~,,~ ~~, ~ ' ~ ~ 1 _ -- - - _~_ i ACINO~~'LEDGNIE tiTT I COMMONti~TEALTH OF PENNSYL~ ~~1:I~?I_g ~ C O U1tirT~ O F ~;.~w~e.~,~-..~~t ~ SS I, VIOLA JUNE BLACIi; Testatrix, Those name is signed to the attached or foregoing instrument, having been duly qualified according to law, do i hereby acl~novcTledge that I signed and executed the instrument as mi- Last ~~'ill and I Testament; that I signed it. willingly; 'and. that I signed it as my free and voluntary act for the pul•po~es therein ehpressecl. ~f ;' (SEAL] VIO ACNE BLAG Sworn to and subscri d before me thisp~~'~ day of uo ~ ~ / j '~ ~ h Notary P~. lic My Commission Fapi.res: (SEALI C.OMM~NWEAl.7H OF PENNSYLVANIA I~^;aRIC.'. SEAL CYN7Hir ~ , .. r: '~rnary Public Camp Hd~ go,,, ~umbenand County My Commission Expires February 3, 2D08 AFFIUAti IT COM11~I01~'4~''EALTH GI' PENNSYL~_~NIA ) ~~, CCiUI~?T~~ OF I ~; i SS: ~~ ~ ;, , ,: ~. { . anal L L ,~,~ (5 ,the ~%itnesses whose vain es are signed to the attached or~fos•egoing instrument, being duly qualified according I b to law, do depose and. say that we were present anal sav,= Testatrix, V IULA JU1~E BLACK sign and execute the instrument as her Last ~~i%ill and Testament; ghat; T estatrix s].gned willingly and that she executed said til'ill as her free and voluntary act for the purposes thererin expressed; that each of us in the hearing and sight of the Testatrix signed the Vi'ill as Witnesses; and that; to the best of our knowledge the Testatrix was at that tune eighteen (18) or more years of age, of sound :mind and under no constraint or uz~adue influence. ,, ~ .~ ~Titness «Titness ~ _ __ Savor:n to and su~bscri ed before me this-~~'~ da,,~= of ~ ~1 ~~-ne SS_,_ 205 ~~.~~`-f' '~`-~'i ~'--'~---c•;--, ~ 1~--~-.ice--L. 'J i~Ota]'}' ~U 11C My Commission Expires: (SEAL} COMMONWEgL-rH Op PENNSYLVANIA CYNTHIA~TRU EL No ary public Camp Hill 9oro., Cumberland County My Commission Expires Februan~ 3, 20D8 ~c~~~cC~,~~c~ ~~~°c~c~~nc~R~~ ~~ ~~°~u~~ VIOLA JUNE BLACK REVOCABLE TRUST AGREEMENT OF TRUST made thisa ~ day of ~ 20 ~ by VIOLA JUNE BLACK, of Millsboro, Delaware, as Grantor, (the "Grantor"), and VIOLA JUNE BILACK, LOIS HIPPENSTEEL and SCOT E. DAVIS as Trustees (collectively the'"Trustee"). WITNESSETH: WI~EREAS, Grantor is the owner of certain assets (the "Trust Property") descr~.bed on Schedule "A", attached to this Agreement; and WI~EREAS, Grantor desires to establish a Trust f:or the active management anid control of the Trust Property during the lifetime of Grantor and after Grantor's death. NO!W, THEREFORE, in consideration of the covenants in this Agreement, Grantor and Trustee agree as follows: AR'~''ICLE I: Establishment of Trust. Grantor will transfer and convey to Trustee the Trust Property. Trustee agrees to hold and administer the Trust Property and any additions to the Trust Property, as Trustee, IN TRUST NEVERTHELESS, for the uses and purposes set forth in this Agreement. ARTICLE II: Family Information. Grantor is a widow, having been marx•ied to KENNETH CORDON BLACK. Grantor has no children. __ _ _ Grantor's intended beneficiaries include her siblings, ARTHUR W. DAVIS, GEC>RGE S. DA~~IS, PAUL DAVIS, LOIS HIPPENSTEEL, NCARIE MILLER and the issue of Grantor's deceased sister, NAOMI McCURDY. AI~.TICLE III: During Grantor's Lifetime. During the lifetime of Grantor: (a) Income to Grantor. Trustee shall manage and invest the Trust, co~lect the income and pay over the net income in convenient installm~'nts to Grantor during Grantor's lifetime. (b)' Unlimited Principal to Grantor. During the lifetime of Grantor, !Trustee shall pay to Grantor so much, even if all, of the principal''~~of the Trust as Grantor may from time to time request in writing. (c) Principal for Needs. Trustee may also expend so much of the principal of the Trust as may be necessary and/or advisable to supplemelnt Grantor's income in order to provide support and maintenance, including medical, hospital, nursing and nursing home care for tlhe Grantor. ARTICLE IV: Death of Grantor. Upon and after the death of Grantor: (a) Payments to Estate. Trustee shall pay over to the Executor of Grantor's estate so much of the principal as shall be required to pay all inheritance and estate taxes, funeral and -2- administrative costs which may be incurred with respect to Grantor's estate. (1~) Charitable Gifts. Thereafter, the Trustee shall make the folldwing distributions: (i} The sum of FIVE THOUSAND DOLLARS 05,000) to ST. JUDE CHILDREN'S RESEARCH I3IOSPITAL, Memphis, Tennessee; (ii) The sum of TEN THOUSAND DOLLARS 0'10,000) to OAK ORCHARD COMMUNITY CHURCH, Olak Orchard, Delaware, in loving memory of Reverend aid Mrs. Duke; and (iii) The sum of TEN THOUSAND DOLLARS 0'10,000) to DELAWARE HOSPICE, INC., Georgetown, Delaware. (c) Distribution of Balance. The Trustee shall. divide the remaining assets of the Trust into as many siblings of Grantor as are then living and siblings of Grantor who are then deceased but are represenlted by then living issue. The Trustee shall distribute one (1) share to each living sibling of Grantor and shall distribute one (1) share to lthe then living issue, per stirpes, of each deceased sibling of Grantor. ARTICLE V: Additions to Trust. Grantor, or any other person, from time to time, with the consent of Trustee, may make insurance policies -3- on the life of Grantor subject to the terms of this Agreement, or give or otherwise transfer any other property, real, personal or mixed, to Trustee, to be administered and distributed in accordance with the provisions of this Agreement. AI~,TICLE VI Spendthrift Clause. No part of the income or principal of the ,property held under any Trust created under this Agreement shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary prior to actual receipt by the beneficiary of the income and/or the principal. Trustee shall pay the net income and the principal to the beneficiaries specified in this Agreement, as their interests may appear, wi~,hout regard to any attempted anticipation, pledging or assignment by any beneficialry, and without regard to any claim thereto or attempted levy, attachment, seizure or other process against the beneficiary. ARi'TICLE VII: Administrative Provisions. Trustee shall possess, among ethers, the following powers, each of which shall be construed broadly and mad be exercised without court approval, but in a fiduciary capacity only: (a) Retain Investments. To retain any investments Grantor has at her death, including specifically those consisting of stock of any bank even if Grantor has named that bank as the Trustee. (b) Vary Investments. To vary investments and to invest in such bonds, stocks, notes, real estate mortgages or securities or in such other property, real or personal, without being restricted to so-called "legal investments," and without being limited to any statute or rule of law regarding investments by fiduciaries. An institutional Trustee -4- shall have the power to invest in and vote securities with the management of mutual funds affiliated with that Trustee. (c) Division of Assets. In order to divide the principal of a Trust or for any other purpose, including final distributions, Trustee is authorized to divide and distribute personal property and real property partly or wholly in kind, and to allocate specific assets among beneficiaries and Trusts created hereunder so long as the total market value of any share is not affected by the division, distribution or allocation in kind. The Trustee is authorized to make, join in and consummate partitions of lands, voluntarily or involuntarily, including giving of mutual deeds or other obligations, with as wide powers as an individual owner in fee simple. (d) Sell Assets. To sell either at public or private sale any or all real or personal property severally or in conjunction with other persons, and to consummate said sale(s) by deed(s) or other instrument(s) to the purchaser(s), conveying a fee simply title. No purchaser shall be obligated to see to the application of -the purchase money, or, to make inquiry into the validity of sale(s). T:he Trustee is authorized to make, execute, acknowledge and deliver deeds, assignments, options or other writings as necessary or convenient to carry out the powers conferred upon Trustee. (e) Encumber Real Estate. To mortgage real estate, and to make leases of real estate. -5- (f) Borrow Money. To borrow mone3~ from a:ny person, including Trustee, to pay indebtedness of a Trust and taxes, and to assign and pledge assets of Grantor's estate or any Trust therefor. (g) Pav Costs. To pay all costs, taxes, expenses and charges in connection with the administration of a Trust, including a reasonable compensation to agents. (l) Distributions Without Court Order. To make distributions of income and of principal to the proper beneficiaries, with or twithout court. order, in such manner and in such amounts as the Trustee deems prudent and appropriate. (i) Vote Stock. To exercise voting rights with respect to securities which form a part of any Trust established u~.nder this Agreement, and to exercise all the powers incident to the ownership of securities. (j) Reorganize. To unite with other owners of property similar to property subject to this Agreement to carry out plans for the reorganilzation of any company whose securities are subject to this Agreement. (k) Disclaim. To disclaim any interest in property which would devolve to Grantor or these Trusts by whatever :means, including but not limited to the following means: as beneficiary under a will, as an appointee under the exercise of a power of appointment, as a person entitled to take by intestacy, as a donee of an inter vivos transfer, and as a donee under athird-party beneficiar;;~ contract. -6- (1) Tax Returns. To prepare, execute and file tax returns of any type required by applicable law, and to make all ta.x elections authorized by law. (m) Employ Advisors. To employ custodians of property, investment or business advisors, accountants and attorneys Trustee deems apipropriate, and to compensate these persons from assets of any Trust under this Agreement, without affecting the compensation to which the Trustee is entitled. The power to employ under this provision', shall be deemed to include the power to engage the services of entities affiliated with a Trustee. (n) Divide Trusts. To divide any Trust into two or more separate '~'1'rusts so that the inclusion ratio for purposes of the generatioin-skipping transfer tax shall be either zero or one, in order that an election under Section 2652(a)(3) of the Interna Revenue Code may be made with respect to one of the separate Trusts, or for any other reason. (o) Allocate Expenses. To allocate administrative expenses to income'or to principal, as the Trustee deems appropriate. However, no allocation to income shall be made if the effect of the allocation is to cause a ra~duction in the amount of any estate tax marital deduction or estate tax'' charitable deduction. (p) Retain Insurance. To retain and to purchase insurance and/or annuity contracts on or for the life of any beneficiary or any person in which a beneficiary has an insurable interest, and to pay the premiums from assets of this Trust. -7- (q) To Purchase Assets. To purchase assets fi~om, or make loans to, the estate of the Grantor. All assets must be purchased at fair market values at the time of purchase. Any loan rraust be adequately secured and must bear interest at a rate prevailing at the time of tl~e loan. The Trustee shall incur no liability fox purchasing assets frgm the estate of the Grantor, even if the property is not the kind in v~hich Trustee is authorized by law to invest trust funds. (r) Other Acts. To do all other acts in its judgment deemed necessar~r or desirable for the proper and advantageous management, investment and distribution of the Trusts. ARfTICLE VIII: Payment on Behalf of Beneficiary. The Trustee is authorized to distribute principal and/or income in .any one or more of the following ways z!f the Trustee, in the discretion of the Trustee, considers the beneficiary unable to apply distributions to the beneficiary's own best interests, or if the beneficiary its under a legal disability: (a) To Beneficiary. Directly to the beneficiary; (b)' To Guardian or Conservator. To the legal guardian or conservator of such beneficiary; (c) To Custodian. To the Trustee, or to another person selected b~ the Trustee, as custodian under the Pennsylvania Uniform Transfers'to Minors Act as to a beneficiary under the age of twenty- five (25) years; -8- (d) To a Relative. To a relative of the beneficiary=, to be expended by that relative for the benefit of the beneficiary; or (e) Direct Expenditure. By directly applying distributions for the benefit of the beneficiary. A~.TICLE I~: Accountings. The Trustee, on an annual basis, shall provide each income beneficiary who has attained. the age of eighteen (18) years, and'the Guardian of the person of any income beneficiary who has not attained the age of eighteen (18) years, statements showing transactions in each Tru~;t establisheed for the benefit of that beneficiary. The beneficiary, or the Guardian of the person of that beneficiary, may waive this right to receive an annual accounting. The Trustee may, at any time, settle any account, or questions concerning the 'administration of any Trust established hereunder, by agreement with the then clurrent income beneficiaries of the Trust, if legally competent, or if not legally competent, in the Trustee's discretion, then with the Guardian of the person of such beneficiary, the legally competent spouse of such beneficiary, or the oldest legally competent relative of such beneficiary who would take a portion of the estate of the be~ieficiary were the beneficiary to die at that time intestate under the laws of the Commonwealth of Pennsylvania. Any agreement made hereunder shall bind all persons who may ever have an interest in such Trust, and shall constitute a release and discharge of the Trustee with respect to transactions disclosed in said Agreement. Nothing herein shall be construed to preclude the Trustee from seeking a judicial settlement of any account. AF~,TICLE ~: Survival. Any person who shall have died at the same time as Grantor, or under such circumstances that t:he order of deaths cannot be established by proof, or within thirty (30) days of Grantor's death, shall be deemed to have predeceased Grantor. -9- ARTICLE ~I: Revocability. This Agreement of Trust is revocable, and may be modified or amended by written instrument executed by Grantor and delivered to Trustee. AT-~,TICLE III: Trustees. Grantor makes the following provisions with respect to Trustees: (a)' Successor Trustees. After Grantor's incapacity or death, LOIS HI~PENSTEEL and SCOT E. DAVIS, or the survivor of them, shall con$inue to serve as Co-Trustees. Each person serving as a sole Trustee sihall have the right to appoint the person(s) which serve as successor Trustee, but the successor Trustee must be a :member of Grantor's family. (b) Trustee Actions. Grantor as Trustee shall have the power to act indlependently of any other Trustee, but all other persons serving as Trustee must act unanimously. (c) Method of Appointment and Removal. Each appointment or removal of a Trustee shall be in writing and shall be filed with the court in the jurisdiction which is the situs of the Trust. The written instrument shall be signed by the person having the power to make the appointmlent or removal. (d) Delegation. Any Trustee may delegate investment and related rr~anagement functions to the other Trustee, provided the other Trustee accepts delegation in writing. To the extent accepted, the delegating Trustee shall be relieved of responsibility for the -10- _. ~ r investment decisions of the Trustee to whom investment and related management functions were delegated. (e) Acceptance of Office. A Trustee shall be deemed to have accepted the office of Trustee as to Trust property only to the extent it accepts that property by written instrument delivered to the Executor of Grantor's estate. Should a Trustee refuse to accept. property from Grantor's'Executor, the Executor shall have the power to select another person to serve as Trustee, or to divide any Trust created by this Agreement (pursuant to the powers granted in ARTICLE VII(n)) so as to permit one person (or persons) to serve as Trustee with respect to some Trust property and another person (or persons) to serve as Trustee with respect to other Trust property. (f) Standard of Care. The Trustee shall not bey liable or accountablle for any loss that may result from the good faith exercise of the authority granted in this Agreement. (g) Dutv to Investigate. In the absence of actual knowledge of a breach of trust, or information concerning a possible breach of trust that would cause a reasonable person to inquire, a successor Trustee is under no duty to examine the accounts and records of any predecessor Trustee, or to inquire into the acts or omissions of such predecessor, is not liable for any failure to seek redress for any act or omission of such predecessor, shall have responsibility only for property vcThich is actually delivered to such successor by such predecessor and shall have all of the powers conferred upon a Trustee hereunder. -11- (h) Compensation. The Trustee shall have the right to receive reasonable compensation for services rendered and reimbursement for reasonable expenses. (i) Security. The Trustee is specifically relieved from the duty of ffling bond or entering security. A~t,TICLE VIII: Situs. The initial situs of this Trust shall be Millsboro, Delaware. The Trustee may determine, from time to time, to change the situs of any Tnzst established under this Agreement. However, no change in situs shall be effective until written notice shall have been provided to the income beneficiary of tie Trust. III WITNESS WHEREOF, VIOLA JUNE BLACK has hereunto offered her hand and seal as Grantor and Trustee and LOIS HIPPENSTEEL and SCOT E. DAVIS has offered his hand and seal as Trustee all on the day and year first above written. S GRAN OR: ` {SEAL) V~itnes VIOLA JU BLA.CK EAL) EAL) Witness - .~~ (SEAL) VIOL E BLACK -12- COMMONWEALTH OF PENNSYLVANIA SS: COI7NTY OF : On this, the ~~"-day o , 20 OS ,before me, a :Notary Public, the undersigned of~'icer, personally appea d VIOLA JUNE BLACK and LOiS HIPPENSTEEL and SCOT E. DAVIS, known to me (or satisfactorily proven) to be the persons whpse names are subscribed to the within instrwnent, and acknowledged ghat they executed the same for the purposes therein contained. IN WETNESS WHEREOF, I hereunto set my hand a.nd notarial seal. I(~ Notar Public My Commission Expires: (SEAL) CUMMONWEALTFi OF' PENNSYLVANIA NOTARIAL :>EAL CYNTHIA J RULE, (Votary Public Camp Hill Boro., Cumberland County My Commission. Expires February 3, 2008 COMMONWEALT Ii OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 260601 HARRISBURG. PA 1 7 1 28-0601 RECEfVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014908 HIPPENS~TEEL LOTS 1488 BRANDY AVENUE NEW CUIUIBERLAND, PA 17070 ~a~a ESTATE INFORMATION: Ssty: i 95-~ 6-3398 FILE NUMBER: ~1 1 1 -0688 DECEDENT NAME: LACK VIOLA JUNE DATE OF PAYMENT: 08/30/201 1 POSTMARK DATE: 08/29/201 1 couNTY: CUMBERLAND DATE OF DEATH: 46/03/201 1 REMARKS: RECEIPT TO ATTY ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ S 158, 000.00 REV-1162 EX111-96) TOTAL AMOUNT PAID: CHECK#137 INITIALS: WZ SEAL RECEIVED BY: S 158,000.00 GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER Law Offices of SAIDIS, SULLIVAN & ROGERS A PROFESSIONAL CORPORATION 635 NORTH 12TH STREET, SUITE 400 CARLISLE OFFICE: ROBERT C. SAIDIS LEMOYNE, PENNSYLVANIA 17043 26 WEST HIGH STREET DANIEL L. SULLIVAN TELEPHONE: (717) 612-5800 - FACSIMILIE (717) 612-5805 CARLISLE, PA 17013 ELYSE E. ROGERS EMAIL: attorney~ssr-attorneys.com TELEPHONE: (717)243-6222 JOHN A. FEICHTEL www.ssr-attorneys.com FACSIMILE: (717)243-6486 DEAN E. REYNOSA TODD F. TRUNTZ Of Counsel MARYLOU MATAS JOHN E. SLIKE JASON E. KELSO JOHN B. LAMPI STEPHEN L. GROSE December 1, 2011 REPLY TO LEMOYNE 717-612-5801 erol;ers@ssr-attorne vs.com Register of Wills of Cumberland County One Courthouse Square Carlisle, PA 17013 Re: Estate of Viola J. Black ~© ~~.. :.,-' ~, Date of Death: June 3, 2011 ;~~' r ~ r; File No. 2011-0688 ~' ~ r'' ' -~ ~ F" G!1 ~ i tV , . ~ 7 - Dear Sir/Madam: ~ ~~~ -~ =' , ~ Cw - ~ Enclosed herewith please find the following: .-~'-~ -' ~ 4;~ c.- 1. Pennsylvania Inheritance Tax Return (in duplicate); 2. Check in the amount of $1,520.36 representing the inheritance tax due; 3. Inventory; and 4 Check in the amount of $30 for your filing fees. Please time stamp and return the enclosed extra copy of this letter. Aself- addressed stamped envelope is enclosed for your use. If you have any questions or require additional information, please do not hesitate to contact me. cjr Enclosures cc: Lois A. Hippensteel Scot E. Davis Sincerely yours, ~. J Elyse E. Rogers s ~} __ `~~-: Ct ~ ~ OI Q-N ~N ~m ~ U °°O a r ~' 0 ~ N ~ `"' ~ N O f0 N _ `" to I,'~ j i :y C..,) d N o- a r ti 0 0 0 0 r 0 0 t` M ~ o~ ~° T 0 n. ~- N~ 0 1 .~~ ~i .~ ~~ ~~u ©~,.~ ~~ 0 b t." Cd ~ ~ O ~ ~ ~ U ~i L ~ O !. . T '^ O V{ ~ ^~ ~ W O ~ N~'~ Q ova ~ ~ ~ o ~ O ~ , ,--~ , ~ 2 ~ U ~ ~ 'y ~ : ~ ~,' ~ :~ ~° rxOU O H