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HomeMy WebLinkAbout01-18-12 (2)1505610143 REV-1500 Ex(°'-'°' PA De artment of Revenue OFFICIAL USE ONLY p Pennsylvania county code Year File Number Bureau of Individual Taxes ~P~~~,oF~~ Po Box.28osot INHERITANCE TAX RETURN 21 11 1069 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 181 18 8236 09 27 2011 O1 19 1922 Decedent's Last Name CLARK Suffix Decedent's First Name HARRY (It Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI E MI 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required O 1. Original Return ~ 2. Supplemental Return 4. limited Estate ~ 4a. Future Interest Compromise f 82 (date of death a ter t 2-12- ) O g Decedent Died Testate (Attach Copy of Will) ~ ~ Att~cheCo aintained)a Living Trust Trust f py o 9. Litigation Proceeds Received ~ rt y 10• be~eenP2V31 9~andttdatges~fdeath 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 7AX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number WM D SCHRACK III ESQ 717 432 9733 First line of address 124 W HARRISBURG STREET Second line of address City or Post Office DILLSBURG REGISTER'O~~NILLS USf ONLY .__. D~TE1FILED • state LIF' moue PA 17191268 correspondent's e-mail address: Schracklaw@comcast.net Under penalties of perjury, I deGare that I have examined this return, inGuding accompanying schedules and statements, and to the best o1 rrh' knowledge and belief, it is true, corcect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONS443LE FOR F4L{ G RETURN DATE ~~p~~. ~ , ~~ Richard P. Clark ~` l ~ ~ ~~ ~ Z 870 Crandon Wav, Mechanicsburg, PA 17050 SIGNATURE OF PRE9Ar1}~ft OTHER THAN REPRESENTAT{VE DATE Wm. D. Schrack ill / ADDRESS 124 W. Harrisburg Street, Diitsburg, PA 17019-1268 Side 1 1505610143 1505610143 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Clark, Harry E. 21-11-1069 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Signature #2 ~~ ,~ ~~,.~ Name David S. Clark Addressl 9057 Route 75 S Addressl Cit1(, State, ZIP East Waterford PA 17021 Date ~ `3 -12 J 15D561D243 REV-1500 EX De~eaencs Name: Clark, Harry E. Decedent's Social Security Number 181 18 8236 RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 2 03 , 515.2 8 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 114 , 711.93 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous N,nq Probate Property (Schedule G) u Se ar t Billi R p a e ng equested............ 7, 9 , 232.63 8. Total Gross Assets (total Lines 1-7) ..................................................................... g. 327 , 459.84 9. Funeral Expenses ~ Administrative Costs (Schedule H) ....................................... 9. 35 ,163.51 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 4 . 2 0 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 35 ,167.71 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 2 92 , 2 92.13 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. 2 92 , 2 92.13 TAX COMPUTATION -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 15. O . O O 16. Amount of Line 14 taxable 2 92 2 92.13 at lineal rate X .045 r 1 s. 13 , 153.15 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17. 0.00 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18. 0.00 19. Tax Due .................................................................................................................. 19. 13 , 153.15 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1,50561,0243 15D561D243 ,~ REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-11-1069 DECEDENT'S NAME Clark, Harry E. STREET ADDRESS Thornwaid Home CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 13,153.15 2. Credits/Payments A. Prior Payments 12,000.00 B. Discount 631.58 Total Credits (A + B) (2) 12,631.58 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request arefund - 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 521.57 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 :.................................. ^ Lz jj 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? .................................................................................................................... u LxJ 3. Did decedent own an "intrust for" or payable upon death 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 AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: . The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed en the net value of transfers to ar for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)J. A sibling is defined under Section 91 C2, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1503 EX+ (6-98) SCHEDULE B STOCKS ~ BONDS COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER _ Clark, Harry E. 21-11-1069 All property )oindyowned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 5,200 shares of 1st National Bank of Mifflintown - 5200 32 166,400.00 shares of stock 2 U. S. Savings Bonds -Series EE 37,115.28 TOTAL fAlso enter on Line 2, Recapitulation) 203,515.28 (If more space is needed, additional pages of the same size) Ccpyright (c) 2002 form software only The Lacknar Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ (8.98) COMMONUIIEALTH OF PENNSYLVANIA SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF E. FILE NUMBER 21-11-1069 Include the proceeds of Idigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on schedule F. (It more space is needed, additional pages of the same size) Copyright (c) 2402 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (8-98) SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAT( RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Clark, Harry E. 21-11-1069 I nls scneaule must ue completed and filed fi the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY NUMBER THE DATE OF RANSFER.SATTACIiTACOPY OF THE DEED FOOREREAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 First National Bank of Mifflintown -IRA #6405083 1.321.58 100.000% 1,321.58 2 First National Bank of Mifflintown -IRA #6405206 7,911.05 100.000% 7,911.05 TOTAL (Also enter on Line 7, Recapitulation) I 9,232.63 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 5-98) REV-1151 Ex+ (10-06) COM INl~~yyEA~NT DECEDN~J~RLVANIA SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Clark, Harry E. 21-11-1069 Debts of decedent must be reported on Schedule I. ITEM N M R DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s) attached 12,660.70 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Richard P. Clark David S. Clark Street Address 870 Crandon Way city Mechanicsburg state PA zip 17050 Year(s) Commission paid 2012 12,865.00 2. Attorney's Fees Wm. D. Schrack III Esq. 8,500.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees 373.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 76^.31 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 35,163.51 Copyright (c) 2009 form software only The Laci:ner Group, Inc. Form PA-1500 Schedule N (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued :STATE OF Clark, Harry E. FILE NUMBER 21-11-1069 ITEM NUMBER DESCRIPTION AMOUNT 1 Funeral Expenses Brown Funeral Home, Inc. 12,510.70 2 Steven C. Casner - placement of base for grave marker 150.00 H-A 12,660.70 Other Administrative Costs 3 Clerk of Orphans' Court -Fiduciary Release 5.00 4 Cumberland Law Journal -Estate advertisement 75.00 5 Miscellaneous expense during period of administration 35.00 6 Patriot News West Shore Legals -Estate advertisement 134.31 7 Register of Wills -Inheritance Tax Return 15.00 8 Reserve for future administrative expense 500.00 H-B7 764.31 ~~opyright (c) 2002 form software oniy The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 t71;a (12-08) SCHEDULE 1 DEBTS OF DECEDENT, COMMONWEALTH OF PENNSYLVANIA MORTGAGE LIABILITIES, & LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Clark, Harry E. 21-11-1069 Report debts incuned by the decedent pdor to death that remained unpaid at the date of death, includinu unreimbursad medical e:oanses. Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-'1500 Schedule ! (ftev. 12-OS) (If more space is needed, additional pages of the same size) REV-1513 EX+t11-08) gyp SCHEDULE J COM,N NE~pNTN OFp,P~ RETURN~~ BENEFICIARIES ESII)EN~tDTECEDENT ESTATE OF ~ FILE NUMBER Clark, Har E. ~ 21-11-10 69 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSONfSI RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal . distributions, and transfers under Sec. 9116 a 1.2 See attached schedule Total 20,000.00 Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet, as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR wH{CH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, inc. Form PA-1500 Schedule J (Rev. 11-OS) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Harry E. Clark 09/27/2011 181-18-8236 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) i anan n. ~.iarK 2964 E. Los Altos Ct. Gilbert, AZ 85297 2 David S. Clark 9057 Route 75 S East Waterford, PA 17021 3 Richard P. Clark 870 Crandon Way Mechanicsburg, PA 17050 4 Ronald H. Clark 503 Orange Street Mifflintown, PA 17059 5 Steven M. Clark 23120 Vanguard Way Ashburn, VA 20148 6 Troy L. Clark 9 Laurel Street Lewistown, PA 17044 7 Kimberly C. Swartz 12 Cross Street Mifflintown, PA 17059 8 Linda S. Willis 2845 Penfold Lane Wake Forest, NC 27587 Grandchild 5,000.00 Child 1,300 shares common stock in First National Bank of Mifflintown and 1/4 of the residue Child 1,300 shares common stock in First National Bank of Mifflintown and 1!4 of the residue Child 1,300 shares common stock in First National Bank of Mifflintown and 1!4 of the residue Grandchild 5,000.00 Grandchild 5,000.00 Grandchild 5,000.00 Child 1,300 shares common stock in First National Bank of Mifflintown and 1!4 of the residue 1 ~nst ill ttn~'~estmuent OF HARRY E. CLARK BE IT REMEMBERED, that I, HARRY E. CLARK ,presently Country Meadows, 4837 East Trindle Road, Mechanicsburg, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that my hereinafter named Executors pay all my just debts, my funeral expenses, and the expenses of the administration of my estate. With this direction, I authorize and empower my Executors to expend for my funeral expenses and interment such amounts as may be considered necessary and proper, without regard to any limit that may he prescribed by a court of law. ITEM 2: I direct my Executors to pay all inheritance, estate, succession, and legacy taxes of whatsoever nature and kind, to which my estate, or the transfer of any property passing hereunder or otheitivise passing by reason of my demise, may be subject, and to charge such ta,~es against i7:Y r`siclt~a_~~ estate, It ~°:ng m~~ i*ntr r? ion chat none of the aforesaid ta~_es, eit!-ier federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 3: I give and bequeath the sum of FIVE THOUSAND DOLLARS ($5,000.00) t0 eacl7^,,1:1 <'i<I~iCi:.l'_1~dr2i1, naIl>el`~/, ~~11~vli~illTY J~'?:':~~RTZ, TROY CI~1Si~, ~Ti~/rL1'T ~ti~. CLARK, and BRIAN R. CLARK. ITEM 4: I give and bequeath all of the common stock that I own in the First National Bank of Mifflintown to my children, namely, DAVID S. CLARK, RICHARD P. CLARK, RONALD CLARK, and LINDA CLARK WILLIS; in equal shares, per stirpes. ITEM 5: All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath unto my issue, in equal share, per stirpes. ITEM 6: I nominate, constitute and appoint my sons, DAVID S. CLARK and RICHARD P. CLARK, to serve as Co-Executors of this my Last Will and Testament ITEM 7: I direct that my hereinbefore named Executors shall not be required to give bond for the faithful performance of duties in this or any jurisdiction. IN VuITNESS WHEREOF, I have hereunto set my hand and seal this day of rr `~=L--, , 2009. i ~- ~ /, HARRY E.LARK The preceding instrument, consisting of this and one (1) other typewritten page, was on the day ar_d date t?~ereof signed, sealed, published, and declared by the Testator hereir. named, as and for his L,as~ 'vViil and estarnent, in the presence o~ us, who, at his request, in his presence and in the~resence of each other, have subscribed our names as witnesses hereto. ,~ /~ ,r v rt ;i i';rJ /lam ~ ,~ ~ ~ Page -2- COMMONWEALTH OF PENNSYLVANIA ,/ % ff t ,, ,, SS. COUNTY OF YC7It1C (~/~ > r=~-'~- ~~ ``- n--~(~---- ~ ;. /` We, HARRY E. CLARK, +•'!-''~-'i •~ ~`' ~ ~/"~i'~-- r. ~J and T ~1 ~ /~ `~~~'~''=~y' ~~;} `~ 1-i'~ ' '~'•~ _ _ _ _ ,the Testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament, and that he signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator signed the Will as witnesses, and that to the best of their knowledge, the Testator was at the time eighteen (18) years of age or older, of sound mind, anti under no constraint or undue influence. / ~. HARRY E CLARK ~~ `~ ~' `` f' r',•"fit-~/L"~-C.t_it,I_~ 'I~. ~-~ '~-Y!~~ SWORN TO AND SUBSCRIBED BEFORE ME THIS ;~"~ DAY OF = 'iii .r.-: %~~ 2009. ~/" ~~ ~ , ~, i/ ~ i ' ; i ,_ _ r ~~ i C07vtMONWEALTH O~ PENNSYLVANIA 1 Notarial Seal Janet S. Gore. Notary Put:4ic i Dii!sbtxg Sao, York Coi.~nN + i ~~7 %orrxti+ss+on ~a;:.~ros :~ 25, 2t, i:,' Member, Pennsylvania Association of Nnig;i?K Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 09/2011 Total Price Total Value Tatai Interest YTD Interest $9,600.00 $37,115.28 $27,515.28 $1,074.96 Bonds: 1-99 of 99 Serial ~ Series: Oes,E.rn Issue tdext Final Issue Interest Interest Value iVote Date Accrual Maturity Price Rate R55830644EE EE $200 03/1989 03/2012 03/2019 $100.00 $208.16 4.00% $308.16 R55867098EE EE $200 04/1989 10/2011 04(2019 $100.00 $202.08 4.00% $302.08 R55903102EE EE $200 05/1989 11/2011 05/2019 $100.00 $202.08 4.00% $302.08 R55939790EE EE $200 06/1989 12/2011 06/2019 $100.00 $202.08 4.00% $302.08 R55979302EE EE $200 06/1989 12/2011 06/2019 $100.00 $202.08 4.00% $302.08 R60192024EE EE $200 07/1989 01/2012 07/2019 $100.00 $202.08 4.00% $302.08 R60635017EE EE $200 08/1989 02/2012 08/2019 $100.00 $202.08 4.00% $302.08 R50116230EE EE $200 12/1988 12/2011 12/2018 $100.00 $208.16 4.00% $308.16 R50079186EE EE $200 11/1988 11/2011 11/2018 $100.00 $208.16 4.00% $308.16 R50041937EE EE $200 10/1988 10/2011 10/2018 $100.00 $208.16 4.00% $308.16 R48288302EE EE $200 09/1988 03/2012 09/2018 $100.00 $214.32 4.00% $314.32 R46214538EE EE $200 08/1988 02/2012 08/2018 $100.00 $214.32 4.00% $314.32 R46176782EE EE $200 07/1988 01/2012 07/2018 $100.00 $214.32 4.00% $314.32 R46140088EE EE $200 07/1988 01/2012 07/2018 $100.00 $214.32 4.00% $314.32 R43606176EE EE 3200 06/1988 12/2011 06/2018 $100.00 $214.32 4.00% $314.32 R43575061EE EE $200 05/1988 11/2011 05/2018 $100.00 $214.32 4.00% $314.32 R43544607EE EE $200 04/1988 10/2011 04/2018 $100.00 $214.32 4.00% $314.32 R43513995EE EE 5200 03/1988 03/2012 03/2018 $100.00 $220.64 4.00% $320.64 R43483093EE EE $200 02/1988 02/2012 02/2018 $100.00 $220.64 4.00% $320.64 R42772397EE EE $200 01/1988 01/2012 01/2018 $100.00 $220.64 4.00% $320.64 R42741389EE EE $200 12/1987 12/2011 12/2017 $100.00 $220.64 4.00°!0 $320.64 R42710300EE EE $200 11/1987 I1/2011 11/2017 $100.00 $220.64 4.00% $320.64 R42678994EE EE 4200 10/1987 10/2011 10/2017 3100.00 $220.64 4.00% $320.64 R42647505EE EE 5200 C9i19S7 03/2012 09/2017 $1CC.00 $227.04 4.00% $327.04 R42615915EE EE $200 08/1987 02/2012 08/2017 $100.00 $227.04 4.00% $327.04 R42312130EE EE $200 07/1987 01/2012 07/2017 $100.00 $227.04 4.00°!0 $327.04 R42280146EE EE $200 07/1987 01/2012 07/2017 $100.00 $227.04 4.00% $327.04 R35592020EE EE $200 06/1987 12/2011 06/2017 $100.00 $227.04 4.00% $327.04 R35563935EE EE X200 05/1987 1iJ2011 05i20i7 $100.00 $227.04 4.00% $327.©4 R3492~,542EE c"C ~2i;~0 04'/i9$7 ZO/ZC1i 04,20i? $i'J0.U'C $227.04 4.OG''io $327.04 R34897020EE EE 5L'JO 03/I9b7 03/2012 03/2017 $100.00 $233.60 4.00% $333.60 R33044090EE EE $200 02/1987 02/2012 02/2017 $100.00 $233.60 4.00% $333.60 R33016200EE EE $200 01/1987 01/2012 01/2017 $100.00 $233.60 4.00% $333.60 R33831860EE EE 5200 12/1986 12(2011 12/2016 $100.00 $233.60 4.00% $333.60 R33090080EE EE $200 11/19$6 11/2011 11/2016 $10C.OC $233.60 4.00% $333.60 R33080384EE EE 500 10/19$6 10/2011 10/X16 $100.00 $270.96 4.00% $370.96 R33070365EE EE- 5200 09/19$6 03/2012 09/2016 $lOC.00 $278.40 4.00% .$378.40 R32532388EE EE $200 08/1986 02/2012 08/2016 $100.00 $278.40 4.00% $378.40 R32522390EE EE $200 08/1986 02/2012 08/2016 $100.00 $278.40 4.00% $378.40 R31248450EE EE 4200 07/1986 01/2012 07/2016 $100.00 $278.40 4.00% $378.40 R31239096EE EE a2C'J 06/1980 12/2011 06/2016 $100.OC $278.40 4.OC% $378.4G R31230788EC EE <~2~)0 05/1986 1t/Zi~lt 05/2016 S~OO.GO $278.40 4.OG°./o $378.40. R29974873EE EE X200 04(1986 10/2011 04/2016 $100.r)!? $278.40 4.00% $378.40 R29703097EE EE ~;Z(i~0 03/1986 03/2012 03/2016 $100.00 $286.00 4.00% $386.00 R29695052EE EE 52110 02/1986 02/2012 02/2016 $100.00 $286.00 4.00% $386.00 R29683194EE EE $210 01/1986 01/2012 01/2016 $100.00 $286.00 4.00% $386.00 hitp://www.treasurvdirec[.~~r~~ ' ~~ ~RCi'rice 1 Oi ;?.?(? I I R28301094EE EE $200 12/1985 12/2011 12/2015 $100.00 $286.00 4.00% $386.00 R28293021EE EE $200 11/1985 11/2011 11/2015 $100.00 $286.00 4.00% $386.00 R50189932EE EE $200 02(1989 02(2012 02/2019 $100.00 $208.16 4.00% $308.16 R50159210EE EE $200 01/1989 01/2012 01/2019 $100.00 $208.16 4.00% $308.16 R28284956EE EE $200 10/1985 10/2011 10/2015 $100.00 $286.00 4.00% $386.00 R22997134EE EE $200 02/1985 02/2012 02/2015 $100.00 $301.60 4.00% $401.60 R21943106EE EE $200 01/1985 01/2012 01/2015 $100.00 $301.60 4.00% $401.60 R21936866EE EE $200 12/1984 12(2011 12(2014 $100.00 $301.60 4.00% $401.60 R23003266EE EE $200 03/1985 03/2012 03/2015 $100.00 $301.60 4.00°/0 $401.60 R20794774EE EE $200 11/1984 11/2011 11/2014 $100.00 $301.60 4.00°!0 $401.60 R2078860SEE EE $200 10/1984 10/2011 10/2014 $100.00 $301.60 4.00% $401.60 R23989701EE EE $200 09/1985 03/2012 09/2015 $100.00 $293.68 4.00% $393.68 R20782303EE EE $200 09/1984 03/2012 09/2014 $100.00 $309.60 4.00% $409.60 R18138115EE EE $200 08/1984 02/2012 08/2014 $100.00 $309.60 4.00°!0 $409.60 R23459530EE EE $200 08/1985 02/2012 08/2015 $100.00 $293.68 4.00% $393.68 R23451429EE EE $200 08/1985 02/2012 08/2015 $100.00 $293.68 4.00% $393.68 R23263391EE EE $200 04/1985 10/2011 04(2015 $100.00 $293.68 4.00% $393.68 R23439519EE EE $200 07/1985 01/2012 07/2015 $100.00 $293.68 4.00°l0 $393.68 R23432146EE EE $200 06/1985 12/2011 06/2015 $100.00 $293.68 4.00°10 $393.68 823269422 EE $200 05/1985 11/2011 05/2015 $100.00 $293.68 4.00% $393.68 R16866292EE EE $200 06(1984 12/2011 06/2014 $100.00 $309.60 4.00% $409.60 R18132001EE EE $200 07(1984 01/2012 07/2014 $100.00 $309.60 4.00% $409.60 R18144457EE EE $200 08/1984 02/2012 08/2014 $100.00 $309.60 4.00% $409.60 R16768326EE EE $200 02/1984 02/2012 02/2014 $100.00 $317.76 4.00% $417.76 R16861238EE EE $200 05/1984 11/2011 05/2014 $100.00 $309.60 4.00% $409.60 816856284 EE $200 04/1984 10/2011 04/2014 $100.00 $309.60 4.00% $409.60 R16320347EE EE $200 12/1983 12/2011 12/2013 $100.00 $317.76 4.00% $417.76 R16625313EE EE $200 01/1984 01/2012 01(2014 $100.00 $317.76 4.00% $417.76 816773262 EE $200 03/1984 03/2012 03/2014 $100.00 $317.76 4.00% $417.76 R16315457EE EE $200 11/1983 11/2011 11/2013 $100.00 $317.76 4.00% $417.76 R160171364EE EE $200 10/1983 10(2011 10/2013 $100.00 $317.76 4.00% $417.76 R16060292EE EE $200 09/1983 03/2012 09/2013 $100.00 $326.16 4.00% $426.16 R16065365EE EE $200 09/1983 03/2012 09/2013 3100.00 5326.16 4.00% $426.15 R13119312EE EE 5200 OS/19S3 02/201.2 OS/2013 5100.00 5326.16 4.00% $426.16 R13114765EE EE 5200 07/1983 01/2012 07/2013 $100.00 $326.16 4.00 % $426.16 R13110722EE EE $200 06/1983 12/2011 06/2013 $100.00 $326.16 4.00% $426.16 R13106926EE EE $200 05/1983 11(2011 05(2013 $100.00 $326.16 4.00°!0 $426.16 R13103237EE EE 4200 04/1983 10/2011 04/2013 $100.00 $340.96 1.42% $440.96 I R11745494EE EE 57.00 C3/19S3 03/2012 03/2013 5100.G0 $3=14.08 1.85% $444.05 ~ R11741798EE EE $200 02(1953 02/2012 02/2013 $100.00 $428.32 4.00% $528.32 R11738021EE EE 5200 01/1953 01/2012 01/2013 $100.00 $428.32 4.00% $528.32 R11734384EE EE $200 12/1982 12/2011 12(2012 $100.00 $428.32 4.00% $528.32 i R11730659EE EE $200 11/1982 11/2011 11/2012 $100.00 $428,32 4.00% $528.32 R11288935EE EE $200 10/1982 10/2011 10/2012 $100.00 $453.68 4.00% $553.68 ~ R11285255EE EE 5200 10/1982 10/2011 10/2012 5100.00 $453.68 4.00 % >553.68 R11281537EE CE 5200 09(1982 03/""2012 09(2012 5100.00 $464.72 4.00% $5b4.72 ` R11277985EE EE $200 08/1982 02/2012 08/2012 $100.00 $464.72 4.00% $564.72 C36555432EE EE $100 07/1982 01/2012 07/2012 $50.00 $232.36 4.00% $282.36 C36534738EE EE $100 06/1982 12/2011 06/2012 $50.00 $232.36 4.00% $282.36 C34625462EE EE x100 04/1982 10/2011 04/2012 $50.00 $232.36 4.00% $282.36 036504307 EE $100 04(1982 10/2011 04/2012 $50.00 $232.36 4.00% $282.36 C34593688EE EE 5100 OZ/19S2 02/2012 02/2012 $50.00' $238.04: 4.00% $288.04 ((( C34572201EE EE $100 O1/19S2 01/2012 01/2012 $50.00 $238.04 4.00% $288.04 ~ Totals fior 9 9 Bonds $9,600.00 $27,515.28 $37,115.28 Notz~_ I ~1ii Not Issued iVE Not eligio(e ror payment i f I PS Includes 3 month interest penalty ~ MA Matured and not earning interest i,,r~:/!ww~w.treasur~~direct. ~:~~~iz;~„~r3C,t,;-; ., I(~~~-,~~trl OjMijflinlown PO BOX 96 MIFFLINTOWN PA 17059 RESPONSE TO ACCOUNT INQUIRY TO: WM D SCHRACK III, LAti'~' OFFICE DECEDENT: HAP.RY E CLAP~K DATE OF DEATH: 09/27/2011 SOCIAL SECURITY#: 181-18-8236 We held account (sl in which this decedent had an interest at the time of his/her death as follows: i COUNT OWNER(S): HAP~RY E CLARK I Typ ccount: CHECKING Account #: 5500160 Principal ce at D.O.D: $41,525.44 Interest Rate: 00% Original Openi e:12/01/1981 Interest t D: $ 2.97 _. ACCOUNT O'~VNER(S): H E CLARK eficiaries: David S.Clark, Richard Clark, Ronald H Clark, Linda S ' Willis ~ 1Vpe Ol Account: IRA Accou-it fit`: 64OJO83 t Principal Balance at D.O.D: S 1321.58 merest Rate: 2.7000 % . Original Opening Date: 07/11/200 t to D.O.D: $ 1.96 ~ ~. ACCOU\~T OV~'NER(S -ABBY E CLARK Beueliciaries: id S.Clark, Richard ' P Clark, Ronald rk, Linda S Willis ~ Type of Acc t: IRA Account #: 6405106 "114Ct7' i~ni2i?iCi z>_ ir.V.i;:~~ i" i i nc 1 .v_ ~:a~ ~~ t>` av; L. Jf?(ll1°I i ~~ Or' nal Opening Date: 01/22/2008 Interest to ll.0_D: $ 5.58 Penalty is waived on withdrawal of decedent's fund before maturity: Safe Deposit Box: ti'PC ulrncial Corp. stock or~ther securities: r` -Ye J ~+k_L4Llei_!~ ``? /I ~~~ f'.k~T Ll±~<-FljL~,r_"'t:~ ~L~t_! ~f.`lr °~ /,' No ~~~~1 ~C.tf ~.~ ;~ ~i ~; ~~ "~ ~-// LAW OFFICE OF WM. D. SCHxACK III ' 124 WEST HARRISBURG STREET • DILLSBURG, PA 17019-1268 Telephone 717-432-9733 E-mail: Telefax 717-432-1053 SchracklawCcomcast.net October 21, 2011 Attention: Decedent Account Information 1" National Bank of Mifllintowtr Yost Office Box 96 Miftlintown, YA 17059 ite: Social Security #: Date of Death: To Whom It May Concern: estate of Harry E. Clark 181-18-8236 September 27, 2011 "hhis Letter will inform you t}rat I represent the Court appointed Co-Executors of the Last Will and TesL-unent of the above-noted decedent. hound among ttie decedent's possessions were documents that indicate his sLltus as an irn~estor in 1"National Bank of Mifflintown. Yle~~se review your rccorcls, and respond to me setting forth the following: .~. ivomenclature of t11e account; I3. Account cumber; C. Account balance, as of September 27, 201 l; and D. If a joint account, the date made joint. Supporting the request is a Short Certificate of Letters Testamentary that was issued by the Register of Wills of York County, Pennsylvania on October 12, 2011, as well as a Letter of instruction authorization provided by die Co-Executors, requesting your assistu~ce. If a Safety Deposit Box exists in the decedent's name, please verify that fact, also. Sincerely, . D_ SCHRACK III %~ ~` ;:: r. - : -;~i ~_ H ~:+;` ,. ~. L. ~i~~'i'' C!V'~ ~~~~ L~fitll~t3 T'tiE W~4Y November 3, 2011 William D Schrack III Esq. 124 W I~amsburg St Dillsburg, PA 17019-1268 RE: Harry E Clark SSN: 181-18-8236 DOD: 09-Z7-2011 Dear Mr. Schrack: ~jo, ~~099 P. lit In response to your request far Date of Death (DOD) balances fox the customer noted above, our records show the following: Certificate of Deposit Account # 11020033902 Established: 01-16-2007 1-IA1tRY E CLARK DOD balance: $ 15,000.00 +;,865.37 accrued interest interest paid Ol -01-2411 ihru 09-27-2011 $ 0.00 Y'I'D Account fi 11020033903 Established: 07-25-2007 HARRY E CLARK DOD balance: $ 14,500.00 + 2,926.17 accrued interest Interest paid 01-01-2011 thru 09-27-2011 $ 0.00 YTb Savings Account Accauztt ~# 5005822858 Established: 07-10-2008 HARRY E CLARK DOD balance: $ 36,894.48 -r 0.47 accrued interest Interest paid 01-O1-2011 thru 09-27-2411 $ 1.48 YTD Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and Savings). R'e do not process ratty financial transactions or provide statements. If you need assistance with ~ any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, ~J National Financial Services Center PNC Bank, N.A. Member FDIC Page 1 of 2 OjMiJJ7inrown PO BOY 96 MIFFLINTOWN PA 1709 RESPONSE TO ACCOUNT INQUIRY TO: WM D SCHRACK III, LA~V OFFICE DECEDENT: HARTZY E CLAP.IL DATE OF DEATH: 09/27/2011 SOCIAL SECURITY#: 181-18-8236 We held accou an m eyes a e ime o ?~C~OUNT OWNER(S): HARRY E CLARK T~°pe of Account: CHECKING Principal Balance at D.O.D: $41,525.44 riainal Opening Date:12/0l/1981 Account #: 55001(0 Interest Rate: 0.1000% Interest to DOD: $ 2.97 ACCOUNT OWNER(S): HARRY E CLARK Beneficiaries: David S.Clark, Richard P Clark, Ronald H Clark, Linda S ' Willis ~ Tvpe of-Account: IRA Accow~t #: 6405083 Principal Balance at D.O.D: S 1321.58 L~terest Rate: 2.7000 °l° ~ ~ Original Opening Date: 07/11/2005 Interest to D.O.D: $ 1.96 ACCOU\~T OWNER(S) HARRY' E CLARK Beneficiaries: David S.C1ark, Richard P Clark, Ronald H Clark, Linda S Willis i Tvpe of Account: IRA Account #: 6405106 1 7J~ri2iFilC iJ_v.fi_ ~_ . i i ; n`r , i_ ;~C .,;~ t> ,' G.,2(1~1(l~c, ~ Original Opening llate: 01122/2008 Interest to ll.O.D: $ S.SB Penalty is waived on withdrawal of decedent's fZU1d before maturity: ~ 1'es J No Safe Deposit Box: ~4'es ~ No _ - . First Community Financial Corp_ stock or ther securities: Yes No /~~J`""`"~' `~~~ Trust Dept. Accounts: Yes N~ ~`J ~~"~ ~~`` ~ ~ ~~~~~''hG .y. t. %E_ ZrLY.R. r`i , =~ ~ G-h.C~'.211,_~i ._.i tnr~t-L-/; y_'t_- ~ / , ' ~ Of MifJlinlorvn PO BOX 96 MIFFLINTOWN PA 17059 RESPONSE TO ACCOUNT INQUIRY TO: WM D SCHRACK III, LAW OFFICE DECEDENT: HARRY E CLARK DATE OF DEATH: 09/27/2011 SOCIAL SECURITY#: 181-18-8236 We held account (sl in which this decedent had an intPrect at the t;me of h;c/her rlPath ae fnll~..,o• CC UNT OWNER(S): HARRY E CLARK Type of Accou Account #: 5500160 Principal Balance at D.O.D: $41,525. t Rate: 0.1000% Original Opening Date:12/01/1981 Interest to D ACCOUNT OWNER(S): HARRY E CLARK Beneficiaries: David S.Clark, Richard ` P Clark, Ronald H Clark, Linda S Willis Type of Account: IRA Account #: 6405083 f Principal Baiance at D.O.D: $ 1321.58 Interest Rate: 2.7000 '% . Original Opening Date: 07/1 1/200 Interest to D.O.D: $ 1.96 ACCOUNT OWNER(S) HARRY E CLARK Beneficiaries: David S.Clark, Rlchai-cI P Clark, Ronald H Clark, Linda S Willis ~ Type of'Account: IRA Account #: 6405106 ;~ „ I 1'i IIIClp2i1 ~zt72ill~:c « ..v.i;: ,"-> i i.iiJ ~ t-~`C...,+ a>.~+._, ~. 2!~!1ll0/ Original Opening Date: 01/22;2008 ~ Interest to D.O.D: $ 5.58 Pe alto is waived on withdrawal of decedent's fund before maturity: ~ Yes ~ No a e _ ~-__ First Community Financial Corp. stock or other secur~ ~ ~ ~ es~ No ?~ ~" " Trust Dept. Accounts: Yes uta~ ~~`` ~ ~- ,~ i~