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HomeMy WebLinkAbout12-02-11~. 1505610140 REV-1500 ~` ~°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN County Cade Year File Number Po Box 28oso1 2 1 1 0 0 6 1 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY 1 7 1 2 8 3 4 3 8 0 5 3 0 2 0 1 0 0 8 1 1 1 9 3 4 Decedent's Last Name Suffix Decedent's First Name MI M O O R E S R R O B E R T ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 0 1. Original Return ^ 4. Limited Estate ^ 6. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 2. Supplemental Return ^ ^ 4a. Future Interest Compromise (date of ^ death after 12-12-82) ^ 7. Decedent Maintained a Living Trust _ (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (date of death ^ between 12-31-91 and 1-1-95) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number R M A R K T H O M A S E S Q U I R E 7 1 7 7 9 6 2 1 0 0 First line of address 1 0 1 S O U T H M A R K E T S T R E E T Second line of address City or Post Office M E C R A N I C S B U R G Gor~~ondent's a-mail address: rmarkthomasCa amail.com State ZIP Code P A 1 7 0 5 5 REGISTER OF WILLS USE ONLY r_.~ C-~ _- ~~ t:::~ r a, _i'C, t,~s~ ( i, J _. --1 ',1.3 -, +- -. 'J i "i --; -~ c_, ~ --' Un r pe alties of rjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is rue, rrect a c ple .Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG E OF E SO~ R SIBLE FOR FILING RETURN DATE _ 1 n .r . 3 W T S~MPS~N/~TREET TIVE MECHANICSBURG PA 17055 ADDR S 101 SOUTH MARKET STREET MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 '~, 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: R O B E R T L• MOORE, S R 1 7 1 2 8 3 4 3 8 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 Pro a p rty (Schedule E) ....... 5. 2 0 2 9 8. 2 3 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 0 • 0 0 7. Inter-Uvos Transfers i~ Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 4 7 8 7 7 . 6 6 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 6 8 1 7 5 , 8 9 9. Funeral Expenses and Administrative Costs (Schedule H) ........... ....... 9. 1 8 6 1 2 . 9 0 10. Debts of Decedent, Mort a e Liabilities, and liens Schedule I 9 9 ( ) ....... ...... 10. 0 • 0 0 11. Total Deductions (total Lines 9 and 10) ......................... ...... 11. 1 8 6 1 2 . 9 0 12. Net Value of Estate (Line 8 minus Line 11) ...................... ...... 12. 4 9 5 6 2 . 9 9 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ ...... 13. 0 . Q Q 14. Net Value Subject to Tax (Line 12 minus Line 13) ................ ...... 14. 4 9 5 6 2 . 9 9 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.o _ 0 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 4 9 5 6 2 9 9 1s. 2 2 3 0. 3 3 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 0. Q Q 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 0• 0 0 19. TAX DUE ................................................ ......19. 2 2 5 0. 3 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 L 1505610240 1505610240 J REV-1500 EX Page 3 ©ecedent'~ Complete Address: File Number 21 10 0614 DECEDENTS NAME ROBERT L. MOORE, SR STREET ADDRESS 707 Hertzler Road CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1• Tax Due (Page 2, Line 19) (1) 2,230.33 2. Credits/Payments A. Prior Payments B. Discount Total Credits (A + g) (2) 0.00 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2,230.33 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ ^X c. retain a reversionary interest; or ................................................................................................ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ ^ 0 2. If death occurred after December 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? ......... ^ ^ Q X^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 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)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)J. • 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 isdefined, undo Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (6-98) ' ~ ~ SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESID PERSONAL PROPERTY ENT DECEDENT ESTATE OF FILE NUMBER ROBERT L. MOORE, SR 21 10 0614 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~• 993 Dodge Dakota Club Cap Pickup 2,160.00 2. 990 Ford Taurus GI Wagon 4 Door 1,275.00 3. ehney Oil (heating oil refund) 145.05 01 Bosler Avenue emoyne, PA 17043 4. efense Finance and Accounting Service (US Military retirement pay) 1,530.78 . O. Box 7130 ondon,KY 40742 5. ationvvide Mutual Insurance Company (cancellation refund) 38.70 . O. Box 8379 anton, OH 44711 6. itizens Bank 12,557.57 ne Citizens Drive, ROP 112 iverside, RI 02915 7. entagon Federal Credit Union 1,847.29 ox 1432 lexandria, VA 22313 8. utomatic Deposit on 5/31/10 at Pentagon Fed. C.U. 99 27 ource unknown 9. entagon FCU dividend 0.57 10. 010 IRS Inc. Tax Refund 344.00 11. ersonal Furnishings 300.00 TOTAL (Also enter on line 5, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09) pcnnsylvania DEPARTMENT OF REVENUE SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT L. MOORE SR 21 10 0614 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 INCLUDETHENAMEOFTHETRANSFEREE,THEIRRELATIONSHIPTODECEDENiAND THE DATEDFTRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IFAPPlICABLE) TAXABLE VALUE 1, ashington National Insurance Co. (annuity) (Policy No. VAR0008285) 47,877.66 00.00 0.00 47,877.66 . O. Box 1982 annel, IN 46082 TOTAL (Also enter on Line 7 Recapitulation) I $ 47 877 66 If more space is needed, use additional sheets of paper of the same size. REV-1511 E?C+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ROBERT L. MOORE. SR 21 10 0614 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Malpezzi Funeral Home, 8 Market Plaza Way, Mechancisburg, PA 17055 7,137.60 B. 1 ADMINISTRATIVE COSTS: Persona! Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2 Attorney Fees: R. Mark Thomas, Esquire 3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Daryl Moore Street Address Ciiy State ZIP Relationship of Claimant to Decedent 4• ~ Probate Fees: 2,800.00 3,500.00 181.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. RSR Realtors -final rental payment on decedent's former residence (6/1/10 - 12/31/10) 4,200.00 8. Pre-authorized debit on Pentagon FCU account (creditor unknown) 6/1/10. 18.00 9. June 12 Pentagon FCU fee 0.50 10. PPL (electric bill) (3 months), 827 Hausman Rd., Allentown, PA 18104 345.19 11. Verizon (Acct# 717697-8677 840 16Y) 3 months 430.11 TOTAL (Also enter on Line 9, Recapitulation) f $ 18,612.90 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (Ot-10) • pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ROBERTI MC~ORF SR LI IV VV IY 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. Robert L. Moore, Jr. Lineal 0.20 48 Philmont Hampton, VA 23666 2. Samuel G. Moore, Sr. Lineal 0.20 10 West Beale Avenue, Apt. C Enola, PA 17025 3. Daryl W. Moore Lineal 0.20 31 West Simpson Street Mechanicsburg, PA 17055 4. Thomas D. Moore Lineal 0.20 2641 County Road 17 Corunna, IN 46730 5. Patricia E. Wagner Lineal 0.20 308 South Market Street Mechanicsburg, PA 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00 u more space Is neeoea, use aaamonal sheets of paper of the same size. 1993 Dedge Dako`.?. CL~b Cab -Private Party Pricing Report -Kelley Blue Book r«w a~ ~ Kelley Klee Lek THE TRt15TED RESOURCE -- _..,.{~.cne advertisement Fage 1 of 2 Send to Printer 1UIiiNI ;~ ' ;~~w ~d E live..without ~featur.~ #3 . ~ ~~~'~~ ~ ~ , ~ sr ? ~ x .~ 1993 Dodge Dakota Club Cab Pickup BLUE BOOK® PRIVATE PARTY VALUE Condition Excellent Good Value $2,935 $2,685 ~" Fair $2,160 (Selected) Vehicle Highlights Mileage: 141,191 Engine: V6, 3.9 Liter Transmission: Manual, 5-Spd Drivetrain: 4WD ' Selected Equipment Standard AM/FM Stereo Steel Wheels i Optional Air Conditioning ------- advertisement ~.m Dodge Dakota Internet Price Build & Price wit " - Incentives View Inventory ~~_ " Get a Brochure Find a Dealer +~ Presented by: ~~~ Blue Book Private Party Value ad~v^er^ti~se~m^-e~n(t'~^^~~ .,:: ~, WetCOm~ t8 your ~OCt~~'i~f't'I ~0~~~' dt;'dIBPS ~. i-~--- - r ;~_. `.l ~ http://www.kbb.com/used-cars/dodge/dakota-club-cab/1993/private-party-value/pricing-re... 7/ 15/2010 Close Window 1993 Dodge Da'~ora Club Cab -Private Party Pricing Report -Kelley B'ue Book Page 2 of 2 u visible defects, • Cgmple:e and verifiable service records. Less than 5°~: of all used vehicles fall into this category. GOOCI ~j"~,~, $2,685 • Free of any major defects. • Clean title history, the paints, body, and interior have only minor (if any) blemishes, and there are no major mechanical problems. • Little or no rust on this vehicle. • Tires match and have substantial tread wear [eft. + A "goad" vehicle wi!( need some reconditioning to be sold at retail. Most consumer owned vehicles fall into this category. Falr (Selected) ~~ ., $2,160 • Some mechanical or cosmetic defects and needs servicing but is still in reasonable running condition. • Clean title history, the paint, body and/or interior need work performed by a professional. • Tires may need to be replaced. • There may be some repairable rust damage. Poor ~..~ NSA • Severe mechanical and/or cosmetic defects and is in pcor running condition. • May have problems that cannot be readily fixed such as a damaged frame or a rusted-through body, • Branded title {salvage, flood, etc.) or unsubstantiated mileage. Kelley Blue Baok does net attempt to report a value on a "pcor" vehicle because the value of these vesicles varies greatly. A vehicle in poor condition may require an independent appraisal to determine its value. * Pennsylvania 07/15/2010 http://www.kbb.com/used-cars/dodge/dakota-club-cab/ 1993/private-party-value/pricing-re... 7/15/2010 1990 Ford Taurr.~s -Private Par±y Pricing Report -Kelley Blue Book Fage 1 of 2 ' . ~ .~~G~ T~~ ~ ~ l C~ ~'~~' C~ .~ ~- ~e1~~y Buy Bank THETRLt5TED RESUiJRGE ' ~ ~~ Send to Printer advertisement 1990 Ford Taurus GL Wagon 4D BLUE BOOK® PRIVATE PARTY VALUE ~~ ~ Condition ~,~~'~= ~~ Excellent Gooa ~'' l=air (Selected) Value $2,o2s $~.,soo $1,275 advertisement I _. ~ i Appt~l TOf~ay - ~C1C grew I'af~5 on auta leans Vehicle Highlights ,-. ~? Mileage: 134,597 Engine: V6, 3.0 Liter Transmission: Automatic Drivetrain: _.. __ FWD Selected Equipment Standard Air Conditioning Power Door Locks AM/FM Stereo Power Steering Tilt wheel Cassette Power Windows Cruise Control Steel wheels _... _. Blue Book Private Party Value Kelley Blue Book Private Party Value is the amount a buyer can expect to pay when buying a used car from a private party. The Private Party Value assumes the vehicle is sold "As Is" and carries no warranty (other than any remaining factory warranty). The final sale price may vary depending on the vehicle's actual condition and local market conditions. This value may also be used to derive Fair Market Value for insurance and vehicle donation purposes. _ _. Vehicle Condition Ratings Excellent $ ~~~• ~~ ors new, is in excellent mechanical condition and needs no raconditi3 Z~_~~5 ~ PJever had any paint er body overk and is free of ru=.t. o Clean title history and avill pass a smog and safety Inspection. o Encino compartment is clean, with no fluid leaks and Is free of any wear or visible defects. Close Window http://www.kbb.com/used-cars/ford/taurus/1990/private-party-value/pricing-report?conditi... 7/ 15/2010 1990 Ford Taurus -Private Party Pricing Report -Kelley Blue Book Page 2 of 2 • Complete and verifiable service records. Less than 5% of a!I used vehicles fall into this category. Good • Free of any major defects. • Clean title history, the paints, body, and interior have only minor (if any) blemishes, and there are no major mechanical problems. • Little or no rust on this vehicle. • Tires match and have substantial tread wear left. • A "good" vehicle will need some reconditioning to be sold at retail. Most consumer owned vehicles fall into this category. Fair (Selected) ~~~ $1,275 • Some mechanical or cosmetic defects and needs servicing but is still in reasonable running condition. • Clean title history, the paint, body and/or interior need work performed by a professional. • Tires may need to be replaced. • There may be some repairable rust damage. Poor ~Q, N /p • Severe mechanical and/or cosmetic defects and is in poor running condition. + May have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. • Branded title {salvag" Flood, etc.) or unsubstantiated mileage. Kelley Blue Bock does not attempt to report a value on a "poor" vehicle because the value of these vehicles varies greatly. A vehicle in poor condition may reGuirc an independent aapraisal to determine its value. * Pennsylvania 07/15/2010 http://www.kbb.com/used-cars/ford/taurus/ 1990/private-party-value/pricing-report?conditi... 7/15/2010 BEHNEY OIL DELIVERY SERVICE 501 BOSLER AVENUE LEMOYNE, PA 17043- 1815 July 22, 2010 Robert Moore 707 Hertzler Road Mechanicsburg, PA 17055 Dear Mr. Moore, As you requested, we removed you from Automatic delivery today. As a result, it will be your responsibility to kee}~ an eye on the level of fuel in the tank and call us if you need a delivery. Enclosed you will find a check for $ 145.05 which will close your budget account. If you have any questions, please contact us at (717)763-1.844. Thank yvu fcr your patronage and please accept our condolences. Sincerely, Andrea Magee Office Manager BEHNEY OIL '; I ~ooo~ V 027,555,592 PAYABLEyONLY DURING ~~:~~~ ~ i LIFE OF PAYEE ~'~ Q Check No. ~ 1712XAEA8343$ DEFENSE FINANCE AND ACCOUNTING SERVICE 8522-798391.12 ?`~ CLEVEI AND C N E TER 79839112 JUL 19,2010 P;,y <<, * 00062-00062 ~~ ~~ rhea-cl~rro( ******~`***MIXED AP.DC 430 DARYL tl h100RE rr' ~t~ A/C ROBERT L MOORE RET/DEC ~~ex 707 HERTZLER RD ~**~*1530*78 MECHANICSBURG PA 17055-6124 ~ui~~~u~i~~un~~~n~i~n~~uui~~~i~~~~~n~C~n~~n~~~i~~~~ VOID AFTER ONE YEAR 14 ~ ~3 ~~ $****1530DOLLAR78CENTS iP8 5;2 28n^ x:000000 5 ~8~: ? 9~ 3 9 L L 2 Lu' ~ LO ? 10 01503 ROBERT L MOORE 707 HERTZLER ROAD MECHANICSBURG PA 17055-6124 m 0 0 m 0 0 Policy Number: 58378 923896 Refund Amount: $ -;::38.70 Check Number:- 58363651 Check Issued: 07-21-2010 This refund was issued for the following reason(s): CANCELLATION CREDIT REFUND. If you have any questions, please contact your Nationwide representative. Agent Name: GL JACKSON Agent Phone Number: 717-691=1 100 Agent Number: 0030315 Detach Stub Before Cashing And Keep For Your Record ~. -_ -"t--'~.i`C9'i.tl4Gif': ia^Kilv.:.'~E-'e '~' ...-, .~i.~- ~ - -~,.~__'3ts ,t~1 ^'„ir~ r i~~~,. ! ~ ~ '~f _. ~ Casey ~ - ~~ ~5. g~ ~n ? 6 14i :'" '+S :TSi`lrs.:'...- ~ :~.:,~. ~y f-~4./ ~k- ~~ -_ I~XR~.•~"- NATIONWIDE MUTUAL INSURANCE COMPANY P.O. Box 8379,Canton OH - NatiOnwlde' 58363651 44711 -a3~9 001503 -~ Insurance Check No: 7a-12s2 Date: 07-21-2.010 Policy Number: 58376 923896 72a PAY '*THIRTY EIGHT .AND 70/100 DOLLARS*****************************************************************+******** EXACTLY; ~~~~~i~~~-~~~~~~~~~~Y~~~~~ni~~~~~~n~n~~~u~~~~~~t~~~~su~~~~~ ROBERT:L MOORf 707 HERTZLER. ROAD PaY MECHAN`I CSBURG $:::38.70 To The PA 17055-6124 Order. ~} Void If Not Cashed Within 90 Days .''This isfull payment unless otharvvise indicated on stub.' scar ryJPMorgan Chase~Bank, NA. "" ~~ Feat i U rborn, MI"' Detail ,y or e~~i Authorized Signature li'S836365LIi' ~:0724L2927~: LL5826ii' ROBERT L MOORE 707 HERTZLER ROAD MECHANICSBURG PA 17055-6124 i~~ "' PENFED PENTAGON FEDERAL CREDIT UNION February 21, 2011 R. Mark Thomas Attorney at Law 101 South Market Street Mechanicsburg, PA 17055 Dear Mr. Thomas: PO Box 247009, Omaha, NE 68124-7009 800.247.5626 PenFed.org Re: Robert L. Moore Re File #: 250238 Please find below the date of death values for Mr. Moore's accounts per your request: Account Number Principal Balance Dividend Accrued Total DOD Balance 250238-01-1 $1,846.99 $.30 $ 1,847.29 The share savings account 250238-01-1 is individually owned. If you have any questions, please call us toll-free at 1-800-247-5626. Si_ ay, ~, rica A. Rinehart Estate Account Specialist II Omaha Service Center ~e CONSECOo Conseco Services LLC Annuity Claims Department 11825 N Pennsylvania Street P.O. Box 1982 Carmel IN 46082 866-588-2255 June 21, 2010 Daryl Moore 707 Hertzler Rd Mechanicsburg PA 17055 RE: Robert Moore, deceased Policy No. VAR0008285 Company: Washington National Insurance Company Claimant: Daryl Moore Dear Mr. Moore, We have been advised of_Mr.Moore's passing and wish to express our condolences. Our records reflect that the above addressee may be a Claimant for the referenced contract(s). Submission of a Claim Form does not guarantee payment of any claim, nor is it an admission of liability, or waiver of any rights or defenses, by the Company. Further, the Company reserves~the right to require additional documentation to validate the existence of a claim and to ensure that claim benefits are distributed according to the terms of the Contract. Please provide the following documents and any other documents required by the Company. Upon receipt of properly executed documents, we will begin reviewing the claim(s). 1) A certified death certificate which reflects the manner and/or cause of death. • If there is more than one Claimant or contract, only one death certificate is required. • If any Claimant named in this contract is deceased, a certified copy of the death certificate of such deceased, Claimant must be provided. 2) The enclosed Claim Form executed by the Claimant or individual(s) authorized to act on behalf of the Claimant. The Claimant's Social Security Number or Tax Identification Number must be provided. A witness signature is required. If there is more than one Claimant, a separate Claim Form must be submitted for each. • If the Claim Form is executed by someone other than the named Claimant, documentation supporting said individual(s)' authority to act on behalf of the Claimant must be provided. 3) The original annuity contract(s) and-any checkbook(s). • If the contract(s) and/or "Checkbook(s)" are not returned (subject to special rule for Spousal Claimant), the signature on the claim form certifies that it/they have been lost or destroyed. If found later, the Claimant agrees to deliver them to the Company without claim. • If you are a Spousal Claimant and elect a spousal continuation as settlement of the claim(s), retain the original contract(s) for your records. 4) Other applicable forms (a) required by the Federal and/or State government, (b) required by the settlement method elected on the claim form, and/or (c) any other requirements requested herein or in the enclosed Claim Settlement Requirements. Prior to completing the Claim Form, please read carefully all instructions contained herein and review the enclosed Claim Settlement Requirements to determine if additional documentation is required. Failure to provide all required properly executed documentation may result in delay of settlement of the claim(s). Neither the Company nor it's representatives provide tax or legal advice. We recomrnend that you consult an independent tax and/or legal advisor regarding your particular situation prior to submitting your claim. The tax qualified status, the named Claimant's portion of the lump sum death benefit, and cost basis (if applicable) for each contract are provided below. Contract No. Tax Status Lump Sum Death Benefit Amount Cost Basis* VAR0008285 Non Qualified $47,877.66 $45,778.51 *Cost Basis is the amount on which income taxes have previously been paid Any Lump Sum Death Benefit amount pRid that is greater than Cost Basis will be considered taxable income. If you should have any questions please call 800-544-0467. Sincerely, Traceyll~ichols, ACS, AAPA, AIAA, AIPC Annuity Adjuster II Washington National Insurance Company Enclosure CHECK NU. ` 00045-17491 WASHINGTON NATIONAL i mP INSURAN'CE COMPANY I 21825 N. 'PENNSYGYANIA:$7., CARHEL, IN 46032 THE BANK OF NEH YORK HELLON ~ PHILADELPHIA, PA 62-4 311 I s i PAY fORTY-SEVEN THOUSAND, EIGHT HUNDRED SEVENTY-SEVEN AND 66/.100 -----•----------------------------------'~_ DATE CHECK AMOUNT To DARrL MOORS 07/23/2010 ****'**47,877.66 I THE 707 HERTZLER RD ~ ORDER MECHANICSBURG, PA 17055 .. ,. OF ...........::•::r::: ..,....,.: ~ r .. 1 ~. "'' i ~.~ k Y W 97 J VOID AFTER 180:DAYS AUTHORIZED SIGNATURE ~ ,_ 1 ~~'00045 L7~,9 Lii' x:03 L L00047~: 2~~~969 9 2 L~i• WASHINGTON NATIONAL INSURANCE COMPANY 11825 N. PENNSYLVANIA ST., CARMEL, IN 4.6032 PAYEE: DARYL MOORS PROCEEDS ON ROBERT MOORS SR .... 0 /2 /2010 004 1 4 1 VENDOR#: POL/ACT#: VAR0008285 TOTAL~'~ ~ 877.66 wNlc /oloPa/ 5026/ R. MARK THOMAS Attorney at Law 101 South Market Street Mechanicsburg, Pennsylvania 17055-3851 Telephone: (717) 796-2100 Telefax: (717) 796-3600 April 1, 2011 William Rothman, Partner rj~,/~~,71f.1~ RSR REALTORS, LLC ~~ ~ ~ ~~~ 3 Lemoyne Drive, Suite 100 ~ y ~~/ Lemoyne, PA 17043 Re: 707 Hertzler Road, Mechanicsburg, PA 17055 Estate of Robert L. Moore, Sr. Dear Mr. Rothman: Pursuant to our recent conversation, enclosed is a check in the amount of $2,100.00 which represents all funds due and owing from the Estate of Robert L. Moore, Sr. Along with this letter, Daryl Moore, his son, is dropping off all the keys to 707 Hertzler Road. Thank you for your consideration. Very truly yours, GZ~6~ R. Mark Thomas RMT/jlm Enclosures " 11V1a e ' 8 Market Plaza Way • Mechanicsburg, PA 17055 p ~~~ Michael J. Malpezzi, Owner Phoner 697.4696 FUNERAL-HOME Jeremy J. Shartzer, Funeral Director ., W STATEMENT OF FUNERAL GOODS AND SERVICES SEL~;CTED Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reason in writing below. If you selected a funeral that may require embalming, such as a funeral viewing, you tray have to pay for embalming. You do not have to pay for enilnhn- ing you did not approve if you selected arrangements s/uch as direct cremation or immediate burial. If we charged for embalming, we will explain why below. For the Service of ,~,~~iL i /~ " /.~?„~~ tr ,~~ Date of Death .~G .1 D -~ J'~~ Charge to: ~„(~ct'11 ~L G262/t ~~" /~"~::" _'v .iS''.~ /;.~ :r/ L~/'G ~L Name" - - Address A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES Services of Funeral DirectoriStaff ...... $.{.~'' Embalming .....................$ Other preparation of body /' City Other clothing Cremation urn , . $ ~-~ -~-'~ ....... (Description) ~, !.~/~ !/ii',~~G',~7~..ur-/ OTHER SUB-TOTAL OF PROFESSIONAL SERVICES ..........AI $ 2. FACILITIES AND SERVICES Use of facilities and services for viewing (Visitation/Vl~ake) ......... $ Use of facilities and services ~~ for funeral ceremony ............ Use of facilities and services for Memorial Service $ ~'"' Use of equipment and services for graveside service ............. $, Other use.of facilities SUBTOTAL OF FACILITIES/EQUIPMENT ...........A2 $ 3• AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home Local ,;......~ :............ Hearse (Casket Coach) ..... $ Local ................... ...... $/j'r' Limousine Local . .................. ...... $ ..-..+. Family car ..~-.. Local ....... ~ ........... . .: $ . Flower car or floral disposition n Local ....... ~ Lead car/clergy car ~.~ Local ................... .. .... $ Car for pallbearers _ TOTAL MERCHANDISE SELECTED .................B $ ~.~ C. SPECIAL CHARGES: Forwarding of remains to (Funeral Home) Receiving of remains from (Funeral Home) lmmediate Burial ................: $ Direct Cremation ................ $ SUB-TOTAL OF SPECIAL CHARGES ................C $ D. CASH ADVANCED Opening Grave .............. .... $ ..-~ Cemetery Equipment .......... .... $ "` Lot and Deed .............. .... $ -^" Newspaper Notices-Local ....... .... $ ~2,'"~ "" Newspaper Notices-0ut-of-town .. $ ~ ?~ "" Telephone & Telegrams ..' ...... .... $ Airfare ............'........ .... $ Clergy/Mass Offering .......... .... $_~L~ J Pallbearers ................. .... Certified Copies of the Death .... .... $ ~ 2..y " Certificate .................. .... $ Police Escon ................ .... $ - Flowers .................... .... $~ Va ult Service Charge ........... .... $ ~ $ PP~~ E!e ctric Utilities Electric Service For: ROBERT L MOORE 707 HERTZLER RA MECFIANICSBURG PA 17055 Questions about this bill? Please contact us by Ju123 at X-800-342-5775 -- (1-800-DIAL-PPL) ,, or write to: Customer Service 827 Hausman Rd. Allentown, PA 18104-9392 www.pplelectric.com Electric Use This graph shows your electric use aver the last 13 months. Types of Meter Readings: Actual . Adjusted Estimated Customer 0 iii ., ..__ ... pp •. :.. ~,. Summary Page Page l :-:-YaitirB3li'i~c~ . `ia6~iK`> 20210-82004 :eastl'- ~>o~:~ Balance as of Jul Z, 2010 $0.00 Chargge~s: TotaCPPL ELECTRIC UTILITIES Charges $28.42 Total DOMINION ENERGY SOLUTIONS Charges $75.79 Total Charges $104.21 Account Balance $104.21 72 60 48 36 24 12 a KWH -Average Per Day JASONDJFMAMJJ 2009 Months 2010 Meter Reading information Meter #57899807 Tul 1 Actual 1289 Jun 2 Actual 12081 29 Da s KWH Billed 80F Average -Jul 2009 201,0 Teemmp~erature 69F 75F KWH Per Day 61 28 Yearly Use: Total Aver Use Mon' Aug 2008 - Ju12009 20665 1 Aug 2009 -Jul 2010 17645 1 Other important information on back ~ Accouct I ~ r e f Amount Due 71;' 691- ~ 840 ~ L ~ 5248.20 Vetizdln News: $99.99/mo. FiOS Triple Play Get FiOS N Prime HD, Internet speeds up to 15/5 Mbps & home phone for $99.99/mo. w~lh NO TERM CONTRACT REQUIRED. Plus, you can get:: mos. FREE 01 HBO® and Cinemax®. Call 1-888--5-".0-7911 to order by 1/15/11 and install by 3/15/11. Subj. to avail, faxes, terms & tees. Fast Speed & Peace Of Mind Right now when you switch to Verizon FiC ~, you'll get blazing last speeds - up to 1515 Mbps - ~or only $49.99/mo. with a 1-yr agmt! Have peac ~ of mind knowing that you can cancel within 30 da ~s with no early termination fee. Call 1-888-474-i 514 to order today. Subj. to avail, taxes, terms & fees. Get More, Save More Call 1-888-251-964410 make sure you re getting the best Verizon services at the best value -from phone and Intemet, to N and money- sa!~ing bundles. Together we'll evaluate your current servi~:es, and find ways to save you even murc. Want Automatic Payment? Enroll below or at Verizon.com to authori!e lour financial institution to deduct the amount of your nonthly bill from the account associated with your enclosed check and send payment directly to Verizon. To disc~minue Automatic Payment, call Verizon. Please <el:p a copy of this authorization. Accau~t~ ~n;armatjt~ M Statexruer-: ::a.v: 11r?'? ': ROBE!iTl '~1o~7!iE Phcrte: ~ ' 6~i7-86r. Aca;our[ Surnmanr Previous I a n: $185.74 No Payme-I Fec:i~~ed _. $.00 Balance F ~rward 5785.74 Neva Ch~v grrs _ _. Current A. ~ !try __ $47.74 _ _- Taxes, Ft;~- aria Other . ~ $14.72 Total Nev; Charges due / tietember is 10 562.46 Amoutll Iaue Question u ab~uutyorr viii or se-il~:;~ View your : l~s in detail ~, l ~ ~ nor ~.cor ~ + Enter your ' : n digit nurrr, ~ 7 697 t followingl,nlrarcountc~: u;r. Use Quick r; odrs! - Ems 4?AY (47; 1 Customer, ~+,iih {lisabilit„ f reach u: r $248.20 -~P )1 6 : '.I 'UN (1-800-837-4966). s. I~ i . s ed for the three digits fit , t 19 3,u (4225) for balance. ' a1 1 h [ - l r4 -6006. ~ Please rea urn ~ e nit slip wilt payment. To enrol! in Automatic Payment (Sign and dale below) F :oust Numt~ l 7 S 7 -3E 77 840 16Y p,ietre Charge~c tie. D : 1 i 2010 ^ F rnmunt Due: 4.48.20 111910 ay signing above I verily that I have reviewed and N' :~:.E~~ ch rick pay::.: i ~ 'er Ton accepted the terms and conditlons at - verizon.com/autopayterms to automaVc bit. payment ~~0yry 00030249 01 AV 0.335 VPf.,32611 0115 XX ROBERT L MOORE 707 HERTZLER RD MECHANICBG PA 17055-612t I~Illlrl~hll~lrlll~~I~I~rLlnl~llr~lhl~~lll~lnlllllllr lilllr~l I'I~II~~I',1'll~r~llltrl;lfl .irrlr i I II'll~~~ll~lllrlrlll~lll~ L:=izori I ;lox 280 ac Icla:clluAU._rrr l~uz- ri 1097170697867784060281]:7,190CI:1~C1600[ C0:68.~ it{.i [1111: ~II?~820300000 I ^1~111^ INI•111':1111111stf1~'il".hllTfl~1~'88'-fEIP,T If7il 1'I ~...~. _..-._ ii. ~t ,./' + ° r,re dumber Account Number Date Due Page + ~ ~ ~ ~~ ~ ~+ , 5,, 7-86 r 7 717 697-8677 840 16Y 12/16/10 2 of 3 ~` ~~E'aN~;~IDI'1 Carr ent N ' IVlty Included on this portion of your bill is approximately $3.47 for PA taxes on utilities Curs nt Cha r es 11/ _. 1?~1,5 ~ :rizon Local P x:r ~ .; 34.99 171"~ 1 t/1Ei I+~n-Published Nur:, : 3.50 i'i"~ 12itEt:rardianplan 9.25 Current Cha t es Subtotal 547.74 Cum 3n [ Fit :i city Total $47.74 TaxES, Fer::t and Other Charges Taxe: , Cover r rrxntal Surcharge:; and FeQ^, Federal Excise Ear 1.34 FA State and Luca: ~;e;as 1 ax 2.87 leiecommunicatic~:, -eia, ~~erdice .08 L911 1.25 Verizrro Surrh•arges and Other Charges and Credits PA Interstate Gross f~cco;l`is 1 ax Surcha.c .35 t ate payment cha I;;c 2.28 Federal Subscribe i re Charge 5.80 Federal Universal ;e r,;ce ' se .75 Total T.3xe:., Fees and Dther Charges $14.72 Reference IL' DVIFOL7697 Rest ltrrme 11: of Charges Regul 3tiuns r:+auire Verizan to g: pup your charges as ;h~ - rn be low to make it clear which charges yoc nusi itay to avoid susp Isjon of your local :~eruice. Easic inr;iur;es ci7ar,;;::~ fcr iccai ~Iling, aF !icabla tax and tees. Non- iasic cl~erges include, but ar,; not limited to, 6aiie D, inside wire maim :nance regiona! and long- ;listance calling, intern- service, DIRECN and applicable tax and fec;s. f+on-paument c; a: y pas+d due basic charg s could esult in suspensi:7n of your basic local ;e , icE; a11er you receive a sr,pa: ate written statem,:nl. Fast Uue tins Totals Basic, 3; .43 1~ Ei! 50.12 Non--~ 3asic ! 413.31 4~ 7 _ _ -- 198.08 Tots! _- - 1!35.7 4 . _ _- 6F 41 - -248.20 Correspondence Go to verizon.comlcontacius or mail to PO Box 33078, St. Petersburg, FL 33733 Ques bons~t:orrespondence If you r eve a big problem or complaint, plea: call or write u ae . re your bill is due. You m~ y else cbt:;m rate schedule, g!t an explanation of char e: :n your bill, and learn h ~w to verity the accuracy of ycu ball ty contacting us ':': 1 300-f137-4966 or at PO E ox 9000 ~~nnapolis, MD 27401--3000. Payrrient by' Check 1Nhen y ou pay t y check, you authorize .cs either to use inform,:ti, frorn your check to make a one-time electronic fund h anster from your accou: t c to process this transaction as a check. If you wish to ba exc:uded from the e r ct iic fund transfer process, please call 1-888-500--535E. Bankruptcy ilntormaUon Ir yea ere or were subject to a bankruptcy prxeeding, this st: !ei nt may include amounts for pre-bankruptcy service. Any such pre-bankrupt % t .arises are fee your inform~.tto ~ only and you should not pay any pre--bankruptcy am .,nts. Please direct ail cprrsponder~ce concerning banks;prey to PO Box 3037, B wr igton, IL 61702. Late 'ayrnent Charges To avoii a late payment charge, pay the; Total Oue on page 1 ny I :comber 16, 2010. Far N, data and wireless servces, the late payment charge i~ 7. ik or $5, whichever is greater. For all other services, the Uate payment he: ;e is 1.2590 . VPC32611 030249 0002 GY RM Service Providers Verizon Pennsylvania provides local, regional calling and other voice services, unless otherwise indicated. FiOS is a registered mark of Verizon Trademark Services LLC. ~II4e . I~r111 fwlA Phone Number Account Number Date Due Page 717-697-8677 717 697-8677 840 16Y 12/16/10 3 of 3 ver~n Need-to-Know Information Payment by Check When you pay by check, you authorize us either to use information from your check to make aone-time electronic fund transfer from ; your account or to process this transaction as a check. If you wish to _ _ be excluded from the electronic fund transfer process, please call 1-888-500-5358. ~ '~•~ `'"~ '= New 855 Toll Free NPA Begins October 9, 2010 The FCC has authorized use of the 855 NPA for toll free services, in addition to the existing 800, 888, 877, and 866 NPAs. Beginning October 9, 2010, it you order new or additional toll free services, you may be assigned a toll free number beginning in 855. 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