HomeMy WebLinkAbout12-16-11 1505610140
REV-1500 EX ~°'-'°'
PA Department of Revenue
OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg. PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 0 9 4 6
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYY
1 9 4 3 6 4 4 2 4 0 8 2 8 2 0 1 1 1 1 2 7 1 9 5 0
Decedent's Last Name Suffix Decedent's First Name MI
S T E R N E R J A M E S A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE O~~ALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
^X 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
8. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Wiil) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFID ENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
G E R A L D J S H E K L E T S K I E S Q 7 1 7 7 7 4 7 4 3 5
First line of address
4 1 4 B R I D G E S T•
Second line of address
P 0 B O X E
City or Post Office
N E W C U M. B E R L A N D
State
P A
ZIP Code
REGISTER,D WILLS USE ONLY
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OATE FILED ~. =~
1 7 0 7 0
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Correspondent's a-mail address: g S h e k 1 e t S k i a~ S t O n e 1 d W• n e t
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 prepares other than the personal representative is hated nn au infnrma4inn of which nrcn~rnr hoc ~.,,, ~...,..,iva..e
~r rtrcwN rtts ~ SIt3LE FOR FILING RETURN
- , _ -1-
DATE
ADDRESS _-
PATRICI STERNER 230 WEST ST• APT•20,WILLIAMSPORT PA 17701
SIGNATU F PAR - THAN DAT
A RESS !
GERALD J• SHEKLETSKI,ESQ• 414 BRIDGE ST•NEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedents Name: JAMES A• STERNER 1 9 4 3 6 4 4 2 4
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. 5 1 0 0 0. 0 0
2. Stocks and Bonds (Schedule B) ...................................... 2. 4 5 5 7 , 6 1
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) ...........:......... ..... 4.
5. Cash, Bank De osits and Miscellaneous Personal Pro a
P p rty (Schedule E)..
..... 5. 1 2 4 2 5 4. 9 0
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .. ..... 6.
7. Inter-Vivos Transfers & Miscellaneous N Probate Property
(Schedule G) ~ Separate Billing Requested .. ..... 7.
8. Total Gross Assets (total lines 1 through 7) ....................... .... 8. 1 7 9 8 1 2 . 5 1
9. Funeral Expenses and Administrative Costs (Schedule H) .............. .... 9. 2 2 9 2 ~ . 1 7
10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I
9 9 ( ) ......... 10.
.... 3 6 8 3 1. 7 5
11. Total Deductions (total Lines 9 and 10) ........................... .... 11. 5 9 ~ 5 8 . 9 2
12. Net Value of Estate (Line 8 minus Line 11) ........................ .... 12. 1 2 0 0 5 3. 5 9
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. 1 2 0 0 5 3 . 5 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. D. D O
16. Amount of Line 14 taxable
at lineal rate X .0 _ 0. 0 0 16. 0. 0 0
17. Amount of Line 14 taxable
at sibling rate x .12 1 2 0 0 5 3. 5 9 17. 1 4 4 0 6. 4 3
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18, Q, Q Q
19. TAX DUE .................................................. ....19. 1 4 4 0 6. 4 3
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 1505610240 J
REV-1500 EX Page 3
Decedent's Complete Address:
Flle Number
21 11 0946
DECEDENT'S NAME
JAMES A• STERNER
STREET ADDRESS
525 POPLAR CHURCH ROAD
CITY
WORMLEYSBURG STATE
PA ZIP
17043
Tax Payments and Credits:
~• Tax Due (Page 2, line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
4. If Line 2 is greater than Une 1 + Une.3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Pago~2, Llne 20 to request a refund.
(1) 14, 406.43
Total Credits (A + g) (2) 0 • 0 0
(3)
(4) D • D D
5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) 14 , 4 D 6.4 3
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ...................................................................... ^ X^
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ X^
c. retain a reversionary interest; or ................................................................................................ ^
d. receive the promise for life of either payments, benefits or care? ....................................................... ^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^
3. Did decedent own an'in trust for' or payable-upon~ieath bank account or security at his or her death? ......... ^ 0
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 ANO 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)]. 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)j.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, undE
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (01-10)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
JAMES A• STERNER 21 11 0946
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that iajointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold,
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1• ALL THAT CERTAIN PIECE OR PARCEL OF LAND, TOGETHER 51,000.00
WITH THE IMPROVEMENTS THEREON ERECTED, SITUATE IN THE
BOROUGH OF WORMLRYSBURG, CUMBERLAND COUNTY,
PENNSYLVANIA KNOWN AS 525 POPLAR CHURCH ROAD,
WORMLEYSBURG, PENNSYLVANIA. THE PROPERTY WAS SOLD
ON NOVEMBER 23, 2011, TO PAUL FACHENKO AND LARYSA
FACHENKO, HUSBAND AND WIFE. COPIES OF THE DEED AND
SETTLEMENT SHEET ARE ATTACHED.
TOTAL (Also enter on Line 1, Recapitulation.) I $ 51 , 0 0 0 0 0
If more space is needed, use additional sheets of paper of the same size.
REV-1503 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
JAMES A• STERNER 21 11 0946
All property jointlyowned wkh right of survhrorshlp must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. UNITED STATES SERIES E SAVINGS BONDS 2,193.87
2• 73 SHARES METLIFE COMMON STOCK
08/26/11 CLOSING PRICE - $31.46
08/29/11 CLOSING PRICE - $33.31
$31.46 + $33.31 = X64.77/2 = $32.38 X 73 SHARES =
$ 2,363.74
TOTAL (Also enter on line 2 Recapitulation) 15
(If more space is needed, insert additional sheets of the same size)
2,363.74
4,557.61
REV-1508 EX + (6-98)
SCHEDULE E +
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ M~~7C.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JAMES A• STERNER 21 11 0946
- Include the proceeds of litigation and the date the proceeds were received by the estate.
Ali property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~, PNC BANK CHECKING ACCOUNT #5001077029 88,642.29
2• ~PNC BANK SAVINGS ACCOUNT #5001114096
6,322•D6
3• AMERICHOICE REGULAR SAVINGS ACCOUNT - MEMBER NUMBER 126.10
4859
4• IBM 4D1(K) PLUS RETIREMENT PLAN 29,164.45
TOTAL (Also enter on line 5, Recapitulation) I S 12 4 , 2 5 4
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX~ (10.09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JAMES A• STERNER 21 11 0946
Decedenl'a debt: must bs reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~. SPITLER FUNERAL HOME, INC• 3,180.52
733 BROAD ST•, MONTOURSVILLE, PA 17754
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal RepresentaUve(s~
SVeet Address
City State ZIP
Year(s) Commission Pald:
2, AttomeyFees: STONE LAFAVER & SHEKLETSKI 8,900.00
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant -
Street Address
City State .ZIP
Relationship of Claimant to Decedent
4. Probate Fees: LETTERS OF ADMINISTRATION 358.50
5 Accountant Fees:
6. Tax Retum PreparerFees:
r=
7. CUMBERLAND LAW JOURNAL - LEGAL ADVERTISING 75.00
8• THE SENTINEL - LEGAL ADVERTISING 200.16
9• PENNSYLVANIA AMERICAN WATER 17.65
10• QUEST DIGANOSTICS 25.41
11• INTERNISTS OF CENTRAL PA 695.48
12• PENNSYLVANIA POWER .AND LIGHT 312.51
13• PENNSYLVANIA AMERICAN WATER 33.07
14• COMCAST 204.42
15• CONNER RICH ASSOCIATES 21.20
Z6• HERITAGE CARDIOLOGY ASSOCIATES 1,164.00
17• HOLY SPIRIT HOSPITAL 130.40
18• HORIZON HEALTHCARE SERVICES 553.61
TOTAL (Also enter on Line 9, Recapitulation) S 2 2 , 9 2 7.1?
If more space is needed, use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
JAMES A. STERNER 21 11 0946
Decedent's Name Page 1 File Number
Schedule H -Funeral Expenses 8~ Administrative Costs - B7.
ITEM
NUMBER
DESCRIPTION
AMOUNT
19• HOSPITAL TELEPHONE TELECOM SERVICE, LTD• 16.OD
20• PINNACLE HEALTH HOSPITALS 1,132.00
21• QUEST DIAGNOSTICS 25.41
22• FREDERICK LORENZO, MD 2D•21
23• T-MOBILE 34.99
24• VASCULAR ASSOCIATES 142.14
25• VERIZON 77.14
26• WEST SHORE EMS 446.70
27• INTERNISTS OF CENTRAL PENNSYLVANIA 695.48
28• SETTLEMENT CHARGES-SALE OF 525 POPLAR CHURCH ROAD, 3,9D3.09
WORMLEYSBURG, PA $27,858.17(LINE 502) LESS $47.39
(LINE 406) LESS $31.62(LINE 407)LESS $786.36
(LINE 408) LESS $20.07(LINE 409)LESS $31.16 (LINE
410)LESS $18,530.45 (HUD-1, PAGE 3 DEDUCTION TAKEN
ON SCHEDULE I, ITEM 1)LESS $4,507.33 (HUD-1, PAGE 3
DEDUCTION TAKEN ON SCHEDULE I, ITEM 2) _$ 3,9D3.09
29• HERSHEY KIDNEY SPECIALISTS, INC• 11.69
30• PENNSYLVANIA AMERICAN WATER 20.39
31• FILING FEES - INHFERITANCE TAX RETURN AND INVENTORY 30.OD
32• RESERVE FOR CLOSING EXPENSES 500.00
SUBTOTAL SCHEDULE H-B7 I 7, 0 5 5.2 4
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8~ LIENS
ESTATE OF ~ FILE NUMBER
JAMES A• STERNER 21 11 0946
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1, COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC 18,530.45
WELFARE
2• AAA CREDIT CARD (BANK OF AMERICA) ACCOUNT NUMBER 4,507.33
4264296024105451
3• DISCOVER CREDIT CARD ACCOUNT NUMBER ************1399 13,793.97
TOTAL (Also enter on Line 10, Recapitulation) I S 3 6 , 8 31 7 5
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE 7AX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
is ~ A (t ur: FILE NUMBER:
JAMES A• STERNER 21 11 0946
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llst Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outr~' ht spousal distributions and transfers under
Sec. 91 f6 (a) (1.2).]
1. PATRICIA STERNER Sibling 120,053.59
230 WEST 3RD ST•, APARTMENT 20
WILLIAMSPORT, PA 17701
I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET AS APPROPRIATE
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I 5
If more space is needed, use additional sheets of paper of the same size.
F:\DOCS\RE\DED\Sterner.lames • S25 Poplar Church Road.wpd '
~:. .
Tax Parcel #: 47-19-1590-011.
Address: 525 Poplar Church Road
Camp Hill, PA 17011
DEED
THIS INDENTURE made the ~"}?~ day of ~ fi! ~ r' , in the year 2011, between
PATRICIA STERNER, Administratrix of the Estate of JAMES A. STERNER, late of Wormleysburg
Borough, County of Cumberland and Commonwealth of Pennsylvania, of the first part, hereinafter called
the Grantor,
-AND-
PAUL FACHENKO and LARYSA FACHENKO, husband and wife, ofthe second part, hereinafter
called the Grantees;
WHEREAS, the said JAMES A. STERNER became in his lifetime seised, as of fee, of and in to
a certain tract of land, together with the improvements thereon erected, situate in the Borough of
Wormleysburg, County of Cumberland, and Commonwealth of Pennsylvania, and more particularly
described hereinafter; and being so thereof seised, died on August 28, 2011, intestate; and
Letters of Administration upon his estate have been duly issued by said Register of Wills on
September 7, 2011, to said PATRICIA STERNER (File No. 21-11-0946) all as in and by the records of said
Register of Wills, recourse thereunto being had, appears:
NOW THIS INDENTURE WITNESSETH, that the said Grantor, for and in consideration of the
sum of FIFTY-ONE THOUSAND and NOlI00-------($51,000.00)---------Dollars, which has been paid to
him by the said Grantees at or before the sealing and delivery hereof, receipt whereof is hereby
acknowledged, has granted, bargained, sold, aliened, released and confirmed, and by these presents does
grant, bargain, sell, alien, release and confirm unto the said Grantees,
-1-
ALL THAT CERTAIN piece or parcel of land, together with the improvements thereon erected,
situate in the Borough of Wormleysburg, County of Cumberland and Commonwealth of Pennsylvania,
bounded and described in accordance with a survey and Plan thereof, dated August 12, 1967, prepared by
Roy M. H. Benjamin, Professional Engineer, as follows:
BEGINNING at a point on the northern line of Poplar Church Road, said point being 190 feet in
an easterly direction from the northeastern corner of Poplar Church Road and Foxcroft Drive (Projected);
thence North 36 degrees 30 minutes West, 142.08 feet to a point; thence North 53 degrees 30 minutes East,
90.00 feet to a point; thence South 36 degrees 30 minutes East, 142.08 feet to a point on the northern line
of Poplar Church Road; thence along the northern line of Poplar Church Road, South 53 degrees 30 minutes
West, 90.00 feet to a point, the place of BEGINNING.
BEING the easterly SO feet of Lot No. 4 and the westerly 40 feet of Lot No. 5 on the Plan of Section
"A", Riverview, recorded in Plan Book 10, Page 12, Cumberland County Records.
HAVING THEREON ERECTED a one story brick dwelling known as No. 525 Poplar Church
Road.
BEING THE SAME PREMISES WHICH Katherine A. Junkin and Joseph B. Junkin, husband
and wife, by Deed dated July 6, 1984, and recorded August 6, 1985, in the Office of the Recorder of Deeds
of Cumberland County in Deed Book 31, Volume K, Page 376, granted and conveyed unto James A.
Sterner, deceased.
TO HAVE AND TO HOLD the said lot or piece of ground above described, with the buildings
and improvements thereon erected, hereditaments and premises hereby granted or mentioned, and intended
so to be, with the appurtenances unto the said Grantees, to and for the only proper use and behoof of the said
Grantees, forever.
-2-
And the said Grantor, for himself and his respective heirs, executors and administrators, does
covenant, promise and agree to and with the said Grantees, their heirs and assigns, that he, the said Grantor,
has not heretofore done or committed any act, matter or thing whatsoever whereby the premises hereby
granted, or any part thereof, is, are, shall or may be impeached, charged, or encumbered in title, charge,
estate or otherwise howsoever.
IN WITNESS WHEREOF, the said Grantor has hereunto set his hand and seal the day and year
first above written.
Witness
~~• ~~~M e (SEAL)
PATRICIA STERNER, Administratrix of
the Estate of JAMES A. STERNER
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF Cc~n+/,3(~~2L,/~~/~ ;
On this, the ~ day of ac~ !~' , 2011, before me a Notary Public, the undersigned
officer, personally appeared PATRICIA STERNER, Administratrix of the Estate of JAMES A. STERNER,
known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument,
and acknowledged that she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have hereto set my hand and notarial seal.
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL / -fit j~'`v~/F~~/v(~
GERALD J. SHEKLETSKI, Notary Publ~ Not Public
New Cumberland Boro.,Cumberland Co. ~'
My Commtstion Expires Nov. 9, 2014
I hereby certify that the precise address of the Grantees Is
DATE:
Attorney for
-3-
A. B. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING 8 URBAN DEVELOPMENT 1.QFHA 2.QFmHA 3. QCONV. UNINS. 4. ~VA 5. QCONV. INS.
SETTLEMENT STATEMENT 6. FILE NUMBER:
cTZO11-122 7. LOAN NUMBER:
8. MORTGAGE INS CASE NUMBER:
C. NOTE: This tam is furnished to give you a statement of actual settlement costs. Amounts paid to and by the setNemenf agent are shown.
Items marked (POCK" were paid outside the closing; they are shown here for informational purposes and are not inducted in the totals.
1.0 3N8 (CT 2071-122.PFD/CT2011-122/70)
D. NAME ANO ADDRESS OF BORROWER:
Paul Fachenko and
Larysa FadTenko, husband and wife E. NAME AND ADDRESS OF SELLER:
Estate of James A. Sterner
525 Poplar Church Rd
Camp Hill, PA 17011 F. NAME AND ADDRESS OF LENDER:
G. PROPERTY LOCATION:
525 Poplar Church Road
Camp Hill, PA 17011 H. SETTLEMENT AGENT:
CT Land Services Company I. SETTLEMENT DATE:
November 23
2011
Cumberland County, Pennsylvania PLACE OF SETTLEMENT
300 North Second Street, Suite 701
Harrisburg, PA 17101 ,
J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER:
101. Contract Sales Price 51,000.00 401. Contract Sales Pdce 51,000.00
102. Personal Pro a 402. Personal Pro
103. Settlement Cha es to BoROwer Line 1400 1,495.28 403.
104. 404.
105. 405.
Ad ustments For Items Paid B Seller in advance Ad us(7nents For items Paid B Seller in advance
106. CI /Town Taxes 11!23/11 to 01/01!12 47.38 408. Ci /Town Taxes 11/23/11 to 01/01/12 47.39
107. Coun Taxes 11!23!11 to 01101112 31.62 407. Coun Taxes 11/23/11 to 01/01/12 31.62
108. School Taxes 11/23/11 to 07101!12 786.36 408. School Taxes 11/23/11 to 07!01112 786.36
109. Pro-rated Refuse Fees 11/23!11 to 01/01112 20.77 409. Pro-rated Refuse Fees 11123/11 to 01107!12 20.77
110. Pro-rated Sewer Fees 11/23/11 to 01/01/12 31.16 410. Pro-rated Sewer Fees 11/23/11 to 01/01/72 31.16
111. 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 53,412.58 420. GROSS AMOUNT DUE TO SELLER 51,917.30
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER:
201. De sit or earnest mono 501. Excess D sit See Insbvlxiorts
202. Pdna I Amount of New Loans 502. Settlement Cha es to Seller Line 1400 27,858.17
203. Existln loans taken sub'ect to 503. Existin loan s taken sub act to
204. 504. Payoff First Mortgage
205. 505. Pa ff Send Mo e
206. 506.
207. 507.
208. 508.
209. 509.
Ad ustments For Items Un aid 8 Seller
210. Ci !town Taxes to
211. Coun Taxes to Ad'ustments For Items Un aid 8 Seller
510. CI /Town Taxes to
511. Coun Taxes to
212. School Taxes to 512. School Taxes to
213. 513.
274. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAID BY~OR 80RROWER
300. CASH AT SETTLEMENT FROM/TO BORROWER: 520. TOTAL REDUCTION AMOUNT DUE SELLER
800. CASH AT SETTLEMENT TOIFROM SELLER: 27,858.17
301. Gross Amount Due From Borrower Line 120
302. Less Amount Paid B /For Borrower (Line 220) 53,412.58
( 601. Gross Amount Due To Seller Line 420
602. Less Reductlons Due Seller Line 520) 51,917.30
( 27,858.1
303. CASH (X FROM) ( TO) BORROWER
By siankn narv2NMk Nela.,u.,,x,e.;....a,...:e...a......~r__~__,_. _._____._ 53,412.58
._~___ .... 603. CASH (X TO) ( FROM) SELLER 24,059.13
SuDStBUb Form 10995:
SELLER'S TAX ID SOLICRATN)N: THE INFORMATION IN BLOCKS E, G. H, I AND ON LINES 101, 408, d07 antl 408 LS IMPORTANT TAX INFORMATION AND IS BEING FURNISHED TO THE INTERNAL REVENUE
SERVICE. IF Y'Oll ARE REQUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY OR OTHER SANCTK)N AMY BE IMPOSED ON YOU IF 7H18 REM IS REQUBiED TO BE REPORTED AND THE IRS DE7ERMrE$
THAT R MAS NOT BEEN REPORTED. YOU ARE REQUIRED BY UW TO PROVIDE THE SETTLEMENT AGENT W RH YOUR CORRECT TAXPAYER IDENTIFICATION NUMBER. IF YOU W NOT PROVIDE THE
SETTLEMENT AGENT W RH YOUR CORRECT TAXPAYER IDEMIFlCATION NUMBER, YOU MAY BE SUBJECT TO CML OR CRMNNAL PENALTIES IMPOSED BY IAW.
Fa sabe w exchanges d terteln real estate, tM person roaporuiDb M dosarg a reel sstab transaction moat rspM Me real estsb praseds to tra ktamel Revenue Service and muM fumalt trlb Stebmenl to you. To
determine tl'ATU have t0 report 8re SaN a exchange d your main bong on your tax realm, see tlta 2071 Schedub D (Porto 1040) instructlone. K the reel BNeta was not ya,r main holrl9, repprt trle trenaacllon an Form
4797, Selea d Buakssa Property. Form 8252, InsbNmsnt Sale Income, anlVa ScDatlub D (Form 1040), CapBM Gabs antl Loseea. You may Dave k recapWre (pay Dock( a1 a pM M • Fadxal nlortW W wbeky 8 Y tie
disposetlg p~y a) Vou reuivsd • ken provitletl /yarn IDs proceetls of a 9ualiMtl mtMge(p lwntl a you receivetl a nartgege aed8 certiflpete; b) Your original mortgage ban wee provMSO alter 1890. and: c You soM or
Home. your howls al a gek during Me first 9 years albr you received tDe Federal mortgage subsitly. Thn wiN irwreeae your lax. Sea Form 8828, RerapWro of Federal Mortgage Subsidy, ano Pub. 523, Ssakg Your
If you have ake9dy paid trre reel 98teb la% for tM period that indutles the seb Date, subtract NB amounts on Llnas 408, 407 d 40H irom the amount alreatly paitl to oebrmke your tletlucDDle real esate tax. But a you have
atreatly detlllaled the real esate tax k a prior year, generally report 81k anqun) as kcgne on Ne'Olher klxame' Xne of Form 1040. For more inlormalbn, see PuD. 523.
Far Paperwork RetlucBOn Act Noscs, see Me 2077 Instruatlons fa Fomre 1099, 1098, 5498, and W-G2.
Departrnent of me Treasury - klemal Revenue Service
UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE NUMBER SF10WN BELOW ON THIS STATEMENT LS MY CORRECT TAXPAYER IDEMIFK;ATION NUMBER.
selbre slgname selbr. slgn.kro seams' rtek,re
TaxIDISSN: 9 Seller's SI~aWre
TexIDISSN: TaxID/$SN: TaxIDSSN:
Pace 2
L. SETTLEMENT CHARGES
700. TOTAL COMMISSION Based on Price $ 51,000.00 @ 3.5000 % 1,785.00 PAID FROM PAID FROM
Dlvisiorl 0 Ommission ~iine T00) aS FOifOwS: BORROWERS SELLERS
701! 1 785.00 to Keller Williams of Central PA East FUNDS AT FUNDS AT
702. t0 SETTLEMENT SETTLEMENT
703. Commission Paid at Settlement 1 785.00
704. Brokers Fee to Keller Williams of Central PA East 250.00
800. ITEMS PAYABLE IN CONNECTION MATH LOAN
801. Loan Ori inatlon Fee % to
802.1oan Discount % to
803. Appraisal Fee to
804. Credit Re rt to
805. lender's Ins ectlon Fea to
808. Mo age Ins. App. Fee to
80T. Assumptlon Fee to
808.
809.
810.
811.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to (dl $ /day ( days %)
902. MIP otlns. for Life oan for months to
903. Hazard Insurance Premium for 1.0 ors to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard Insurance months er month
1002. Mo a Insurance months $ er month
1003. Cf !town Taxes months $ er month
1004. Coun Taxes months $ er month
1005. School Taxes months ~ $ per month
1006. months er month
1007. months $ er month
1008. r to Ad ustment months $ per month
1100. TITLE CHARGES
1101. Settlement or Closi Fee to
1102. Abstract or Title Search to
1103. Titl xaminatlon to CT Land Services Com an 50.00
1104. Title Insurance Binder to
1105. Document Pr oration to CT Land Services Com an
1106. Note Fees to Nota 10.00
1107. Attorneys Fees to Stone LaFaver & Shekletski POC Seller
includes above item numbers:
1108. Title Insurance to First American Title Insurance Com n ENH Reissue 508.28
includes above item numbers:
1109. Lender's verage
1110. er's verage 51,000.00 508.28
1111. ndorsemenls 100 300 900 CT Land Services Company
1112. losing Protection Latter CT Land Services ompany
1113. utter, Wire and Email Fees to CT Land Services Company 55.00
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recordin Fees: Deed $ 62.00; Mortgage $ Releases $ 62.00
1202, i n a tam s: Deed 510.00 ~ Mo a e 510.00
1203. State Tax/Stam s: Revenue Stam 510.00; Mo a e 510.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Surve to
1302. Pest 1 n to
1303. Tax Certification to CT Land Services Com an 10.00
1304. DOG Processin 8 Retention Fee to CT Land Services Com an 50.00
1305. See addict disb. exhibit to 25,553.17
1400. TOTAL SETTLEMENT CHARGES Enter on Linea 103. Section J and 502, Section K 1,495.28 27,858.17
Certified to be a true copy.
The undersigned hereby acknowledge receipt of a completed copy of pages 182 of this statement $ any attachments referred to herein.
I HAVE CAREFULLY REVIEWED THE HUD-1 SETTLEMENT STATEMENT AND TO THE BEST OF MY KNOWLEDGE AND BELIEF,17 IS ATRUE ANO
ACCURATE STATEME OF ALL RECEIPTS AND DISBURSEMENTS MADE ON MY ACCOUNT OR BY ME IN THIS TRANSACTION. I FURTHER CERTIFY
THAT I HAVE RECEI D COP OFT HUD 1 SETTLEMENT STATEMENT.
Borrower Seller Estate of a A. Sterner
PaulFachenko
BY:
Larysa Fach nko /
TO THE BEST OF MY KNOWLEDGE, HE HUD-1 SETTLEMENT STATEMENT W I HAVE P D ACCURATE A COUNT OF THE
FUNDS WHICH WERE RECEIVED AND HAVE BEEN OR WILL BE DISBUR Y SIGNE ASP T OF THIS
TRANSACTION.
T La mpany, Settl t t
WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENT N TE S OR IMILAR FORM. PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FORD LS SEE: T ODE SECTI 001 8 SECTION 1010.
(CT2011-122 / CT2011-122114 I
HUD-1, Page 3
Borrowers): Paul Fachenko and Larysa Fachenko,
husband and wife
Sellerys): Estate of James A. Sterner
525 Poplar Church Rd
Camp Hill, PA 17011
Settlement Agent: CT Land Services Company
(717)236-5263
Place of Settlement: 300 North Second Street, Suite 701
Harrisburg, PA 17101
Settlement Date: November 23, 2011
Property Location: 525 Poplar Church Road
Camp Hill, PA 17011
Cumberland County, Pennsylvania
Additional Adjustments For Items Paid By Seller In Advance (Borrower Debit)
Description Amount FromlThroutth Prorated Amount
Pro-rated Refuse Fees 49.00 10/01/11 through 12/31/11 20.77
Total Line 1091409 20.77
Pro-rated Sewer Fees 73.50 10/01/11 through 12!31!11 31.16
Total Line 1101410 31.16
Additional Disbursements
Payee/Description NotelRef No. Borrower Seller
Alma Berresford, Tax Collector 1,432.53
2011 School Taxes
Alma Berresford, Tax Collector 813.36
2011 County/Borough Taxes
American Infosource as Agent for Bank of America 4,507.33
Statement of Claim
Department of Public Welfare 18,530.45
DPW Claim CIS # 210257299
Borough of Wormleysburg 269.50
Final Refuse /Sewer Fees
Total Additional Disbursements shown on Line 1305 $ 0.00 $ 25,553.17
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and
accurate statement of all receipts and disbursements made on my account or by me in this Uansaction. I further certify
that I have received a copy of the HUD-1 Settlement Statement.
~~'
Paul Fachenko ~~.,,~ ~ ~
Larysa F ch ko ~~~~'~~
Estate of Sterner
BY:
To the best of my knowledge, the HUD-1 Settlement Statement which I have prepared is a true and accurate account of
the funds which were received and have been or will be disbursed by the undersigned as part of the settlement of this
transaction. ~------~
es t;ompany ~/
ett! ent
WARNING: It Is a crime to knowingly make false atatementa to the United States on this or any similar form. Penakies upon conviction can
Include a fine and Impriaanment. For details sea: Title 18 U.S. Code Sactlon 1001 and Section 1010.
(CT 2011-122.PFD/CT2011-122/9)
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 08/2011
Total Price Total Value Total Interest YTD Interest
$375 00 $2,193 87 $1,818.87 $0.00
Bonds: 1-20 of 20
Serial # Series Denom Issue
Date Next Final
Accrua{ Maturity
Q6314633469E E $25, 12/1978 . 12/2008
Q6305784828E E $25 11/1978 ; 11/2008
Q6408609823E E $25 06/1980 '. 06/2010
Q6405754823E E $25 05/1980 05/2010.
!Q6405347336E E $25 04/1980 04/2010,
Q6396121470E E $25 01/1980 . 01/2010,
Q6397976198E E $25, 02/1980 ... 02/2010.
Q6400897490E E $25 03J1980 ; 03/2010.
Q6280875909E E $25. 10/1979 ; .10/2009
Q6393716133E E $25 11/1979 ; '11/2009
Q6394510124E E $25. 12/1979 ,12/2009.
Q6366200466E E '. $25 07/1979 07/2009,
Q6370338527E E $25 08/1979 . 08/2009
Q6372690858E E $25, 09/1979 09/2009.
Q6337498261E E $25: 04/1979 , ;04/2009
Q6352981436E E $25 05/1979 05/2009
Q6359735468E E $25 06/1979 06/2009
Q6321339505E E $25 01/1979 : 01/2009,
Q6328885175E E $25 02/1979 , 02/2009
Q6330452926E E $25 03/1979 , 03/2009
Totals for 20 Bonds
Issue Interest
Interest
Price Rate
$18.75 $89.52:
$18.75' $89.23
$18.75 $93.00
$18.75 $93.00
$18.75 $91.87
$18.75 $91.87
$18.75: $91.87
$18.75 _ $91.87,
$18.75 $90.84
$18.75 $91.87
$18.75 $91.87
$18.75 $90.84
$18.75 $90.84
$18.75. $90.84:
$18.75 $89.53,
$18.75 $90.58..,
$18..75 $90.84
$18.75: $89.53
$18.75 $89.53.
$18.75 $89.53
$375.00 $1,818.87
Value
$108.27. MA
$107.98 MA
$111.75 MA
$111.75 MA
$110.62 MA
$110.62. MA
$110.62 MA
$110.62 MA
$109.59 MA
$110.62 MA
$110.62 MA
$109.59 MA
$109.59 MA
$109.59 _MA
$108.28 MA
$109.33 MA
$109.59 MA
$108.28 MA
$108.28 MA
$108.28: MA
2,193.87
Notes
NI Not Issued
NE Not eligible for payment
P5 Includes 3 month in~erest penalty
MA Matured and not ear:iin interest
it ~`~
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MetLife
BNY Mellon Shareowner Services
P.O. Box 358420
Pittsburgh, PA 15252-8420
Account Registration:
0000090 02 SP 0.640 ~'SNGLY Tl 0 4066 17070-018099 COl B1MAI - 23
~'I~II~~~~~'I~'IL(II111111~~~111~~1~~~1~11'I„Illll~l~lr~~~ll~l~
PATRICIA STERNER ADM EST JAMES A
STERNER
ATTN GERALD SHEKLETSKI
414 BRIDGE ST PO BOX E
NEW CUMBERLAND PA 17070
Date: 10/21/2011
Fr~r information concerning this statement, please call BNY Mellon Shareowner Services,
MetLife, Inc,'s Transfer Agent, tall free at 1-Et)Ci-f~~~-359J
Trust Interests (Shares) 73.0000
CUSIP Number 59156R10
Transaction Date 10/19/2011
Transaction Advice Number 0019277854
Investor ID 1251 6630 2709
This Transaction Advice is your record of the indicated Trust Interests being credited to an account on the books
of the referenced transfer agent. The Transaction Advice should be kept with your important documents as a ~
record of your ownership of these securities. These Trust Interests are transferable only as permitted under The
MetLife Policyholder Trust.
Please read the important information on the back of this form and in the Purchase and Sale Brochure.
if you wish to request a purchase or sale transaction, detach coupon at the perforation and complete the applicable side of the form.
PLEASE BE SURE THIS ADDRESS APPEARS IN THE ENVELOPE WINDOW FOR PURCHASES ONLY
Purchase Instructions 1251 6630 2709 Change of Address:
(See reverse side to SELL)
PATRICIA STERNER ADM EST JAMES A
BNY Mellon Shareowner Services
P.O. Box 382200
Pittsburgh, PA 15250-8200
~niii~~~~n~~ii~~~~~~~in~n~rn~~~~iu~~~n~~irn~~n~~~uO
4016 01 0000090 0000179
The MetLife Policyholder Trust ("Trust")
Transfer Transaction Advice
RETAIN 'd'HIS D(3CUMEPJT FUR YL7lIR RECI'~RGS
Signature
(if address is being changed)
Make check in U.S dollars, payable to
MetLife Purchase Program
Amount Enclosed
Minimum investment 5250 (except as
described in the Purchase and Sale Brochure)
0000101 102 125166302709 7
Print
Investor Relations
Historical Price Lookup
Symbol
MET (Common Stock)
Select Date
August 26 ~:`!; 2011 Look Up Price
Results
Date Requested 08/26/11
Closing Price 331.46
Volume 9,929,300
Split Adjustment Factor 1:1
Open $31.15
Day's High $31.92
Day's Low 330.42
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Designed and powered by Dow Jones Client Solutions
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Intraday data is at least 20-minutes delayed. All times are ET.
Historical and current end-of-day data provided by Interactive Data Pricing and Reference Data.
Privacy Policy
Print
Investor Relations
Historical Price Lookup
Symbol
MET (Common Stock)
Select Date
August - 29
Results
2011 Look Up Price
Date Requested 08/29/11
Closing Price $33.31
Volume 7,685,900
Split Adjustment Factor 1:1
Open X32.09
Day's Nigh $33.46
Day's Low X32.09
Copyright $~ 200II MarketWatch, Inc. All rights reserved. Please see our Terms of Use.
Designed and powered by Dow Jones Client Solutions
Intraday data providetl by Interactive Data Real Time Services and subject to the Terms of Use.
Intraday data is at least 20-minutes delayed. AU times are ET
Historical and current end-of-day data provided by Interactive Data Pricing and Reference Data.
Privacy Policy
~ep.lb. 1U11 lU:3lAM NNC SANK
~~~
l,FAttt#Vi THE 1NAY
September 1 b, 2011
. Gerald J Sheklctslci Esq.
Stone Lafaver & Shekletski
414 bridge St
PQ$axE
New Cumberland, PA 17071
RE: James A Sterner
SSN: 194-36-4424
DOD; 08-28-ZOl 1
Dear Mr. Shekletski:
No. 3377 P. 1/2
In response to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
Checking Account
Account # 5001077029 Established: 12-04-1997
JAMES A STERNER
DOD balance: $ 88,b42.29 non interest bearing
Savings Account
Account # 5001114096 Established: 12-04-1997
JAMES A STERNER
13OD balance: $ 6,321.87 + 0.19 accrued interest
Interest paid 01-01-2011 thru 08-28-2011$1.72 YTD
please note that this office provides date of death balances far deposit accounts (mtAs, CDs, Ghecki:og and
Savings). R'e do not process any $n9ncial transactions or provide statemen#s. If you need assistance with
auy of these items, please ca111-888-k'NC-BANK (1-888-762-2265) or stop by yow local PxG Bank breach
office.
Sincerely,
National Financial Services Center
PNC Bank, N.A,
Member FDIC
Page i of 2
yep, ib, LUII IU,31jAM
f'NC SANK
No. 3377 P. 2/2
This message is imended for the use of the individr~al or entity to which it is addressed and may
contain information that is privileged confidential and exempt from disclosure under applicable law.
If the reader of this message is not the intended recipient or the employee or agem responsible for
delivering this message to the intended recipient, you are hereby notified that any dissemination,
distribution or copying of this communications is strictly prohibited. If you have received this
Communication in error, please notify me immediately by reply or by telephone at $00-762-I77S and
immediately destroy this, faxed document.
Page 2 o:f 2
~ AmeriChoice
FEDERAL CREDIT UNION
Building Relationships For Life
October 6, 2011
Stone LaFaver &Shekletski
Attorneys At Law
Post Office Box E
New Cumberland, PA 17070
Re: Estate of James A. Sterner
Attorney Shekletski,
The decedent has one member number 4859 titled James A. Sterner. This account includes only
a Regular Savings (suffix O1) -opened 9/18/1978. The date of death balance was $126.10. This
small account earns $0.03 dividends monthly.
Please feel free to contact me directly with any questions you may have.
Sincerely,
~2 ~ ~.~
Bonnie R. Seagraves
Operations Specialist
Phone (717) 591-1282
Fax (717) 697-3713
Email bsea aves americhoice.ora
Main Office: 2175 Bumble Bee Hollow Road • Mechanicsburg, PA 17055 • Phone: (717) 697-3474 • Fax: (717) 697-3713
Website: www.americhoice.org ~~
~~ ~
LENDER CREDIT UNIONS'
~ ~~ ~
~~~ ~~ ~ ~~
~ ~ ~ ~~ i
~ ~~ ~~~
~- ~ ~ ~~~
~~~~~ ~ ~
~~ ~~ ~ . ~~
IBM BENEFITS STATEMENT
Employee Name: James A Sterner
IBM Serial Number: 687113
Group Universal Life insurance
This is an optional insurance plan offered to IBM employees. It is not an iBM sponsored
benefit plan. Contact Prudential Insurance at 1-877-448-5778 to verify if the deceased
held a Group Universal Life Insurance policy.
IBM 401(k) Plus Plan
James was participating in the IBM 401(k) Plus Plan (the "401(k) Plan"). The balance of
this account as of September 15, 2011 was $29,164.45. The account balance changes
daily based on the investment gains and losses of the investment options chosen by the
participant. The account balance will remain invested in the current investment options
until the beneficiary changes the investment allocation after a beneficiary account is
established.
James did not designate a beneficiary for this 401 {k) Plan balance and was not married
at the time of his death. The 401(k) Plan provides that the beneficiary is determined in
the following order:
• Surviving children, in equal shares;
• If no surviving children, surviving parents, in equal shares; and
• If no surviving children or parents, estate.
In order to verify the beneficiary, the Beneficiary Affidavit must be completed and
returned.
Once the 401(k) Plan receives all documents required to verify the beneficiary a
separate account will be established for each beneficiary under the 401(k) Plan. The
beneficiary account(s) initially will be invested in the same investment options that the
participant had chosen prior to his death. Once the account is established, each
beneficiary will receive a letter from the 401(k) Plan with instructions on how to access
the beneficiary account. At that time, the beneficiaries will be able to manage their own
accounts, including making investment allocation changes and requesting a distribution
from the 401(k) Plan. Please be sure to review the brochure called Additional
Information about Your IBM Benefifs to understand what the options are under the
401(k) Plan.
3.IM-8-701A.102
In order for the beneficiary account to be established, please submit the following:
• a certified copy of James's death certificate, indicating the manner of death,
• a completed, signed and notarized Beneficiary Affidavit,
If the estate is the beneficiary, we will also require the following:
• a certified copy of the Letters Testamentary or Letters of Administration,
• the estate's tax identification number
Please send all forms to:
Tom Sumner
Program Administrator, Survivor Services
IBM Employee Services Center
5411 Page Rd. /
Durham, NC 27703
3.IM-B-701A.103
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
September 20, 2011
STATEMENT OF CLAIM SUMMARY
NAME Estate of STERNER, JAMES
ID 210 257 299
MEDICAL GLASS 3 CLASS 5.1 '-TOTAL
INPATIENT .00 .00 .00
OUTPATIENT 7,218.85 11,311.60 18,530.45
LONG TERM CARE .00 .00 .00
DRUG .00 .00 .00
REIMBURSEMENT TO DPW 7,218.85 11,311.60 18,530.45
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
servi es
t
4150 OLSON MEMORIAL HIGHWAY, SUITE 20O
MINNEAPOLIS, MINNESOTA 5542?-4811
TELEPHONE 763-852-8620
FAx 877-326-8784
TOLL.-FREE 877-326-1536
November 04, 2011
Account No
************1399
Dear Sir or Madam:
Unpaid Balance
$13793.97
Hours (CT)
Reference No
7675190
7:OOam-9:OOpmM-TH
7:OOam-S:OOpmF
8:OOam-12:OOpmS
Our company represents Discover Bank. We have learned that JAMES STERNER, who was a valued customer, has passed
away. Please accept condolences from our client and our company.
As indicated above, there is an unpaid balance on this account. Please accept this letter as a Notice of Claim on behalf of
our client.
This letter is sent to you solely in your capacity as personal representative of the Estate of JAMES STERNER. It is our client's
policy that you are not personally liable for the balance. Please call our office toll free at 1-877-326-1536 to discuss
resolution of this matter and payment on this account. If you are not the personal representative, please contact us with
the name and address of the personal representative or attorney who is handling the estate.
Cordially,
DCM Services, LLC
*IMPORTANT NOTICE*
Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion
thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice
that you dispute the validity of this debt or any portion thereof, this office will obtain verification of the debt or a copy of a
judgment and mail you a copy of such judgment or verification. If you request of this office in writing within 30 days after
receiving this notice this office will provide you with the name and address of the original creditor, if different from the
current creditor.
This company is a debt collector. We are attempting to collect a debt and any information obtained will be used for that
purpose. Calls may be monitored or recorded for quality assurance purposes.
NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION -Side 1 of 2-
I~~IIINnINNII~II~~II~III~I~II~I~ "'Detach Lower Portion and Retum with Payment'"'
DCM Services, LLC
4150 OLSON MEMORIAL HWY STE 200 Reference #: 7675190 Client ID: DISC31
• MINNEAPOLIS MN 55422-4811 Unpaid Balance: $13793.97
ADDRESS SERVICE REQUESTED Checks Payable to: Discover Bank
IIIINIIIN~IIIININNIIMIINI~NINIIINIINNII~IINIIIINIIIIIII~INN~ININIIIIIIIINIIIIIIII Amount Enclosed: $
November 04, 2011
#BWNJGZF
#1651730818144299#
The Estate of JAMES STERNER
GERALD J SHEKLET3KI
414 BRIDGE ST
NEId CUMBERLAND PA 17070-1927
t ssn - ~ so
DCM Services - Payment Processing
PO Box 9317
Minneapolis MN 55440-9317
~~~~~u~~~u~u~i~n~~~u~~i~nn~~nn~~~u~~n~~~~n~~~~u~~
7675190 1399
ass»-aos~-~9o