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1505610143 REV-1500 ~"°'-'°' `'' PA De artment of Revenue y OFFICIAL USE ONLY p panne Ivanla county code veer File Numbs( Bureau of Individual Taxes 0e"a"^"'T~"r"r"~ Po Box.2aosol INHERITANCE TAX RETURN 21 11 0640 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 177 24 7428 05 02 2011 03 10 1930 Decedent's Last Name WALTERS Suffix Decedent's First Name ISABELLE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW MI M MI t. Original Retum ~ 2. Supplemental Retum ~ 3 2) (tlate of death 3. Php jp ~ r 1 2 1 4. Limited Estate ~ qa, Future Interest Compranisa (data of death aRer 2-12.82) ~ 5. Federal Estate Tax Retum Required g_ Decedent Disa Testate ~ T pecedent Main ned a Living Trust e a~ ~ ~ 8. Total Number of Safe De It Boxes ~ (Attach Copy of Wily (At ccPY N ) 9. Litigation Proceeds Received ~ t0.b~iw~eenP$v31~J7 naadit{datse5mdeath ~ 11.Electlontotaxunde~Sec.9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number AMY M MOYA 717 652 7323 First line of address LO OF SUSAN E LEDERER Second line of address 5011 LOCUST LANE City or Post Office HARRISBURG REGISTER OF WILLS US~ONLY rte, t;/1 a ~ C V State ZIP Code PA 17109 ~-' ) .tse ~ ~~ ... C7 Q b~J FILED ~w-~+ ~ ~ ~ "Ft correaponaent's e-mail address: amy@ledererlaw.com Under penalties of peryury, I dedare that 1 have examined this return, indudins~ 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 persona representatlve rs based on all infomtation of which preparer has any knowledge. ~S1 ADDRESS NATURE P ARER OTHER THAN REPRESENTATNE DATE Amy M. Moya I ~~~ ~- Z Law Offices of Susan E. Lederer, 5011 Locust Lane, Harrisburg, PA 17109 Side 1 1505610143 1505610143 J REV-1500 EX Decedents Name: WaltterS, Isabelle M. Decedent's Social Security Number 177 24 7428 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 8 Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous t~oq Probate Property (Schedule G) u Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 137,086.19 81,408.08 218,494.27 9. Funeral Expenses 8 Administrative Costs (Schedule H) .............................. ......... 9. 15 , 538.41 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ..................... ......... 10. 7 97.74 11. Total Deduetlons (total Lines 9 & 10) .......................................................... ......... 11. 16 , 33 6.15 12. Net Value of Estate (Line 8 minus Line 11) ................................................. ......... 12. 202 , 158.12 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................................... ......... t3. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................................... ......... 14. 202 , 158.12 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. 16. Amount of Line 14 taxable 202 158.12 16 at lineal rate X .045 ~ . 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due.......... .................................................. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 1505610243 0.00 9,097.12 0.00 0.00 9,097.12 REV-1500 EX Page 3 Decedent's Complete Address: Fila Number 2111-0640 DECEDENTS NAME Walters, Isabelle M. STREET ADDRESS 325 Wesley Drive CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 8,600.00 B. Discount 452.63 3. Interest (1) 9,097.12 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) 9,052.63 (3) (4) (B) 44.49 Make Check Pa able to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :............................................................................... ^ b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x c. retain a reversionary interest or ............................................................................................................... ^ ^x d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................................... ^ ^x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x 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 Rw•7808 EXa Is•se) SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INMERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Walters, Isabelle M. 21-11-0640 Include the proceeds of Irtipation end the date the proceeds were received by the estate. All property i ntlyownsd with the right of survivorship must M dieclosad on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Checking Account No. 88658007, held at MB:T Bank, titled to Isabelle M. Walters 93,637.97 2 Metlife Bank Money Market Account, held at Walnut Street Securities, Inc. in Account No. 2,054.41 33W113023, titled to Isabelle M. Walters 3 Certificate of Deposit held at Walnut Street Securities, Inc. in Account No. 33W113023, titled 40,783.60 to Isabelle M. Walters (accrued interest 3763.60) 4 Check from Highmark (refund of health insurance premium) 269.88 5 Check from Weis Markets, Inc. (refund from pharmacy) 1.87 8 Check from Nationwide Mutual Fire Insurance Company (refund of renters insurance) 146.00 7 Check from Kohl's Department Stores (refund of credit balance) 2.92 8 Check from Continuing Care Rx (refund of prescription overpayment - copy of check not 49.50 available) 9 Check from Omnicare, Inc. (prescription refund) 42.90 10 Check from Argus/Humane (prescription reimbursement) 15.45 11 Check from Delta Dental (refund of dental insurance premium) 101.79 TOTAL (Also enter on Line 5, Recapitulation) 137,086.19 (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 E (Rev. 698) Rsv-1510 EX+Is-9sl SCHEDULE G INTER-VIVOS TRANSFERS 8 MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT OECEDEN7 ESTATE OF (FILE NUMBER Walters, Isabelle M. 21-11-0640 This sdiedule must he mmpleted and filed if the ensvier to eny of queslfons 1 through 4 on the revene side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF TROANSFRERSATTACIi A COPY OF TIME OEIEO FOOREREAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECO'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Hartford Annuity, Contract No. 712590514, -held at 73,525.18 100.000% 73,525.18 Walnut Street Securities, Isabelle M. Walters, owner, Louann Zimmerman and Alan Walters, beneficiaries. On July 14, 2011, Alan Walters signed a disclaimer specifically disclaiming his interest in this annuity. A representative of Hartford indicated that the annuity would then pass directly to Louann Zimmerman; however, when Hartford reviewed the paperwork we were inforned that their policy in this situation is to distribute the funds to the Estate. Therefore, Alan Walters's 50°k interest in the annuity was made payable to the Estate of Isabelle Walters. Louann Zimmerman is the sole beneficiary of the Estate. 2 Prepaid Funeral Contract with National Guardian Life 7,882.90 100.000% 7,882.90 Insurance Company, Myers-Harner Funeral Home, beneficiary TOTAL (Also enter on Line 7, Recapitulation- ~ 81,408.08 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1 S00 Schedule G (Rev. 6-98) REV-1157 EXa (10-06) COM~~~~VANIA SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Walters, Isabelle M. 21-11-0640 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedules) attached B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) 10,852.88 Street Address City State Zio Yearfsl Commission Daid Waived 2. Attorney's Fees Law Offices of Susan E. Lederer (estimated) 4,000.00 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 Cumberland County Register of Wills 315.50 5. Accountant's Fees 6. Tax Return Preparers Fees 7. Other Administrative Costs 370.03 See continuation schedules) attached TOTAL (Also enter on line 9, Recapitulation) 15,538.41 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Walters, Isabelle M. 21-11-0640 ITEM NUMBER DESCRIPTION AMOUNT 1 Funeral Expenses Myers-Hamer Funeral Home 8,700.00 2 Slate Hill Cemetery (greve opening) 775,00 3 Gingrich Memorial (grave marker) 1,175.00 4 Red Lobster (funeral luncheon) 2p2,gg H-A 10,852.88 Other Administrative Costs S Cumberland County Register of Wills (filing fee - PA Inheritance Tax Retum and Inventory) 30.00 6 Masland 8: Garrick Advisory, Inc. (investment management fees) 87,50 7 Mileage for Executor to travel to Harrisburg from her home in Halifax for funeral, to clean out 252.53 the decedent's residence, to probate will, and to meet with the financial advisor and attorney for the Estate (455 miles X 55.5 cents a mile) H-B7 370.03 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1672 EX~112-OB) COMMONVYEA~TH OF GENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER __ Walters, Isabelle M. 21-11-0640 Report dsbta Incurred by Ms decedent prior to dsaM Met romained unpaid MMs dab of death, Indudilp unralmburwd medical expanses. (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Laekner Group, Inc. Fonn PA-7500 Schedule 1 (Rev. 12-08) Rev-~s~s ex+l~t-0el SCHEDULE J coM~q~~~~ANIA BENEFICIARIES ESTATE OF FILE NUMBER wasters, Isabeue M. 21-11-0 640 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) I • TAXABLE DISTRIBUTIONS [include outright spousal dlstnbutrons, and transfers under Sec. 9116 a 1.2 1 Louann Zimmerman Daughter 100°Ao residuary 202,158.12 P.O. Box 404 estate; 50% Halifax, PA 17032 Hartford annuity on Sch. G 2 Alan Walters Son 50% of annuity 595 Silversprings Road (disclaimed) Mechanicsburg, PA 17055 Total 202,158.12 Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sheet as a riate. II NON-TAXABLE DISTRIBUTIONS: . A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH 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. 11-08) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OP INDIVIDUAL TAXES DEPT. 280807 HARR158UR0, PA 17128.0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX~11-961 NO, CD 014733 ZIMMERMAN LOUANN PO BOX 404 HALIFAX, PA 17032 ACN ASSESSMENT AMOUNT CONTROL NUMBER ESTATE INFORMATION: SSN: 177-247428 FILE NUMBER: 21 1 1 -0640 DECEDENT NAME: WALTERS ISABELLE M DATE OF PAYMENT: 07/ 19/ 201 1 POSTMARK DATE: 07/18/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 05/02/2011 101 ~ $ 8, 600.00 TOTAL AMOUNT PAID: REMARKS:. RECEIPT TO ATTY SEAL CHECK# 98 INITIALS: WZ RECEIVED BY: S 8, 600.00 GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER Last Will and Testament of Isabelle M. Walters ~~ ;1 ~ ~,f ~t ~. , ~:_ ~~ I, Isabelle M. Walters, a resident of Mechanicsburg, Cumberland County, Pennsylvania, revoke any prior wills and codicils made by me and declare this to be my will. Article One Family information The members of my immediate family are: Name Relationship Date of Birth Larry Lee Walters Son January 12, 1950 Louann Zimmerman Daughter July 26, 1953 Alan Victor Walters Son June 2, 1962 References in my will to "my children" are to the children listed above. References to "my descendants" are to my children and their descendants. I have intentionally not named Larry -Lee Walters as a primary beneficiary of my will because I have provided substantaal financial support to him during my lifetime. I have intentionally not named Alan Victor Walters as a primary beneficiary of my will, not for any lack of affection, but because he received a substantial inherixance from his father. Page 1 of 15 Article Two Specific and General Gifts Section 2.01 Disposition of Tangible Personal. Property I give all my tangible personal. property, together with any insurance policies covering such property and claims under such policies in accordance with a "Memorandum for Distribution of Personal Property" or other similar writing directing the disposition of such property, which shall be signed by me. It is my intent that such writing qualifies to distribute my tangible personal possessions under applicable state law. Section 2.02 Contingent Distribution of Tangible Personal Property Any tangible personal property not disposed of by a written memorandum, or if I choose not to leave a written memorandum, I give such property not disposed of to my children in shazes of substantially equal value, to be divided among my children as they, and such other person as my Executor may select to represent any child of mine believed by my Executor to be incapable of acting in his or her own best interests, shall agree. In case my children and such other person do not agree upon the division of such property within a reasonable time not to exceed 6 months after my death, my Executor shall make the division. My Executor, whose decision shall be final and binding, may use a lottery or rotation system to determine the order of selection and distribution of any such property, or may otherwise allocate and distribute the same. As an alternative, my Executor may sell any such property and distribute the net proceeds equally among my living children. My Executor shall incur no liability to any party for any decision made by my Executor with respect to either the division or sale of my tangible personal property, and any decision made by my Executor shall be final and binding on all of my beneficiaries. Section 2.03 Definition of Tangible Personal Property For purposes of this Article, my tangible personal property shall include but not be limited to my household furnishings, appliances and fixtures, works of art, motor vehicles, pictures, collectibles, personal wearing apparel and jewelry, books, sporting goods, and hobby paraphernalia. Page 2 of 15 Section 2.04 Ademption If property to be distributed under this Article becomes part of my probate estate in any manner after my death, then the gift shall not adeem on account of not being a part of my probate estate at my death, and my Executor shall distribute the property as a specific gift in accordance with this Article. If property to be distributed under this Article is not part of my probate estate upon my death and does not subsequently become part of my probate estate, then the specific gift made in this Article shall be considered null and void, without any legal or binding effect. Section 2.05 Encumbrances and Incidental Expenses of Tangible Personal Property Property being distributed under this Article shall be distributed subject to any mortgages and other encumbrances on the property so distributed. However, my Executor shall pay, as an administration expense, the reasonable expenses of storing, insuring, packing, transporting and otherwise caring for my tangible personal property until actual delivery of each article of property to the appropriate beneficiary. Article Three My Residuary Estate Section 3.01 Definition of My Residuary Estate All the remainder of my estate, including property referred to above that is not effectively disposed of, shall be referred to in my will as my "residuary estate." Section 3.02 Disposition of My Residuary Estate My residuary estate is to be distributed outright to Louann Zimmerman. If Louann Zimmerman predeceases me, her share shall be distributed to Alan Victor Walters. Page 3 of 15 Article Four Remote Contingent Distribution If, at any time, there is no person or entity qualified to receive final distribution of my estate or any part of it, then any such portion of my estate with respect to which such failure of qualified recipients has occurred shall be distributed to the Care Assurance Fund at Bethany Village, 325 Wesley Drive, Mechanicsburg, Pennsylvania. Article Five Designation and Succession Fiduciaries Section 5.01 Executors I nominate Louann Zimmerman to act as Executor of my estate. If Louann Zimmerman is for any reason unable to serve, I nominate Alan Victor Walters as my Executor. Article Six Powers of My Fiduciaries Section 6.01 Grant of Powers My fiduciaries may perform every act reasonably necessary to administer my estate and any trust established under my will. Specifically, my fiduciaries may exercise the following powers: They may hold, retain, invest, reinvest and manage real or' personal property, including interests in any form of business entity and policies of life, health and disability insurance, without diversification as to kind, amount or risk of non-productivity and without limitation by statute or rule of law. They may partition, sell, exchange, grant, convey, deliver, assign, transfer, lease, option, mortgage, pledge, abandon, borrow, loan, contract, distribute in cash or kind or partly in each at fair market value on the date of Page 4 of 15 distribution, without requiring pro rata distribution of specific assets and without requiring pro rata allocation of the tax bases of such assets. They may hold in nominee form, continue businesses, carry out agreements, and deal with themselves, other fiduciaries and business organizations in which my fiduciaries may have an interest. They may establish reserves, release powers, and abandon, settle or contest claims. They may employ attorneys, accountants, custodians of the trust assets, and other agents or assistants as deemed .advisable to act with or without discretionary powers and compensate them and pay their expenses from income or principal or both. Section 6.02 Fiduciaries' Powers Act In addition to all of the above powers, my fiduciaries may, without prior authority from any court, exercise all powers conferred by this Will or by common law or by any fiduciary powers act or other statute of the Commonwealth of Pennsylvania or any other jurisdiction whose law applies to this Will. My Executor shall have absolute discretion in exercising these powers. Except as specifically limited by this Will, these powers shall extend to all property held by my fiduciaries until the actual distribution of the property. Section 6.03 Alternative Distribution Methods My fiduciaries may make any payment provided for under my will or under the terms of any trust established under my will as follows: Directly to the beneficiary; ]n any form allowed by applicable state law for gifts or transfers to minors or persons under a disability; To the beneficiary's guardian, agent under a durable power of attorney or caregiver for the benefit of the beneficiary; or By direct payment of the beneficiary's expenses, made in a manner consistent with the proper exercise of the fiduciary's duties hereunder. A receipt by the recipient for any such distribution shall fully discharge the fiduciary. Page 5 of 15 Article Seven Administrative Provisions Section 7.01 No Court Proceedings Any trust established under my will shall be administcrcd expeditiously consistent with its provisions, free of judicial intervention, and without order, approval or action of any court. It shall be subject only to the jurisdiction of a court being invoked by the Trustee or by other interested parties. Proceedings to seek instructions or court determinations shall be initiated in the court having original jurisdiction over matters relating to the construction and administration of trusts. Seeking instructions or court determination shall not thereafter subject the trust to the continuing jurisdiction of the court. Section 7.02 No Bond I direct that no fiduciary shall be required to give any bond in any jurisdiction, and if, notwithstanding this direction, any law, statute, or rule of court requires any bond, no sureties be required. Section 7.03 Fiduciary Compensation An individual serving as a fiduciary under my will shall be entitled to fair and reasonable compensation for the services he or she renders as a fiduciary, unless the fiduciary waives such compensation. Any corporate fiduciary shall be compensated by agreement with my Executor or, in the absence of such agreement, in accordance with the corporate fiduciary's published fee schedule in effect at the time the services aze rendered. A fiduciary may be reimbursed for reasonable costs and expenses incurred in carrying out its duties undex this agreement. Section 7.04 Self Dealing A fiduciary who is a descendant of mine may engage in acts of self-dealing, even though state law restricts acts of self-dealing. Unless expressly prohibited by another provision of my will, a descendant of mine who is serving as a fiduciary may enter into transactions on behalf of my estate in which that fiduciary is personally interested so long as the terms of such transaction are fair to my estate. For example, such a fiduciary may purchase property from my estate at its fair market value without court approval. Page 6 of 15 Section 7.05 Spendthrift Trust Provision This will, and all Trusts created hereunder, are intended to qualify as Spendthrift Trusts. In addition, all interests in this will, or in any Trust hereunder, are intended for the personal protection and welfare of Grantor's named beneficiaries, and no beneficiary shall be allowed to voluntarily or involuntarily assign or anticipate his or her interest in the income or principal of this will or any Trust hereunder, and no beneficiary's creditors, nor a spouse or former spouse of any beneficiary, shall be allowed to attach or otherwise reach any such interest before actual payment to the beneficiary. If any beneficiary shall become the subject of a judgment or court order, then during the period in which such judgment or court order remains in effect, such beneficiary shall only be permitted to receive distributions from any Trust created for the benefit of such beneficiary at the discretion of the Trustees. This limitation as to the right of a beneficiary to receive a distribution shall apply notwithstanding any provisions within the trust for such beneficiary which authorize distributions for the health, education, support or maintenance of such beneficiary. In addition, if any beneficiary shall become the subject of a judgment or court order, and such beneficiary is only entitled to discretionary distributions from a Trust created for their benefit, it shall not be an abuse of discretion by the Trustees to withhold distributions to such beneficiary while such judgment or court order is in effect. If the Trustees determine that a beneficiary would not benefit as greatly from any outright distribution of Trust income or principal because of the availability of the distribution to the beneficiary's creditors, the Trustees shall instead expend those amounts for the benefit of the beneficiary. This direction is intended to enable the Trustees to give the beneficiary the maximum possible benefit and enjoyment of all of the Trust income and principal to which the beneficiary is entitled. Nothing contained in this Section shall restrict in any way the exercise of any power of appointment granted in this agreement. Section 7.06 Distributions to Incapacitated Persons and Persons Under Twenty-Five If my Executor is directed to distribute any share of my probate estate to any beneficiary who is under the age of 25 yeazs or is in the opinion of my Executor, under any form of incapacity that renders such beneficiary unable to administer distributions properly when the distribution is to be made, my Executor may as Trustee, in my Executor's discretion, continue to hold such beneficiary's share as a separate trust until the beneficiary reaches the age of 25 or overcomes the incapacity. My Executor shall then distribute such beneficiary's trust to him or her. Page 7 of 15 While any trust is being held under this Section, the fiduciary may distribute to, or apply for the benefit of the beneficiary for whom the trust is held such amounts of the net income and principal as the fiduciary may determine to be necessary or advisable for such beneficiary's health, education, maintenance and support. Any undistributed income shall be accumulated and added to principal. Upon the death of such beneficiary before that time, the fiduciary shall distribute the trust, including any accrued and undistributed income, to my then living descendants, per 5tirpes. If I have no then living descendants the property shall be distributed under the provisions of Article Four of my will. Section 7.07 Maximum Term for Trusts Notwithstanding any other provision of my will, unless sooner terminated under other provisions hereof, any trust established under my will shall terminate 21 yeazs after the last to die of me, my descendants and the descendants of my maternal and paternal grandpazents living at the time of my death. At that time, the remaining trust property shall vest in and be distributed to those persons . then entitled to mandatory distributions of net income of the trust and in the same proportions. If none of the beneficiaries are entitled to mandatory distribution of net income, to the beneficiaries then eligible to receive discretionary distributions of net income of the trust in equal shazes per capita. Section 7.08 Representative of a Beneficiary The guardian of the person of a beneficiary may act for such beneficiary for all purposes under my will or may receive information on behalf of such beneficiary. Article Eight Tax Provisions Section 8.0'1 Payment of Death Taxes All estate, inheritance and succession taxes payable by reason of my death, whether or not such property passes under my will shall be paid as set forth in this Section. Page 8 of 15 (a) Payment from Residue Except as otherwise provided in this Section or elsewhere in this agreement, my Executor shall provide for payment of all such taxes from my residuary estate as an administrative expense without apportionment and shall not seek contribution toward or recovery of any such payments from any individual. However for the purposes of this Section, such taxes shall not include any additional estate tax imposed by Section 2031(c)(5)(C), Section 2032A(c) or Suction 205?(f) of the Internal Revenue Code or any other compazable taxes imposed by any other taxing authority. Nor shall such taxes include any generation-skipping transfer tax, other than a direct skip. (b) Property Passing Outside of My Will Except as to Qualified Retirement Benefits, all such taxes imposed with respect to property included in my gross estate for purposes of such taxes and passing other than by my will shall be apportioned among the persons and entities benefited in the proportion that the taxable value of the property or interest beazs to the total taxable value of the property and interests received by all persons benefited. The values as finally determined in the respective tax proceedings shall be the values used for the apportionment of the respective taxes. Section 8.02 Tax Elections In exercising any permitted elections regarding taxes, my fiduciaries may make such decisions as they deem to be appropriate in all the circumstances and my fiduciaries shall be under no duty to make any compensatory adjustment as a consequence of any such election. My Executor may also execute such joint tax returns and pay such taxes or interest and deal with any tax refunds, interest, or credits as it shall deem necessary or advisable, whether in the interest of the other joint tax payer or in the interest of my estate. Page 9 of 15 Article Nine Definitions and General Provisions Section 9.01 Definitions For purposes of my will and for the purposes of any trust established under my will, the following definitions shall apply: (a) Adopted and Afterborn persons A legally adopted person in any .generation and his or her descendants, including adopted descendants, shall have the same rights and be treated in the same manner under this agreement as natural children of the adopting parent, provided such person is legally adopted prior to attaining the age of 18 years. (b) Descendants The term "descendants" shall include a person's lineal descendants of all generations. (c) Education The term "education" shall include, but not be limited to: • Enrollment at private elementary, junior and senior high schools, including boazding schools; • Undergraduate and graduate study in any field at a college or university; • Specialized, vocational or professional training or instruction at any institution, including private instruction; or • Any other curriculum, institution or activity that my Trustee, in its sole and absolute discretion, deems useful for developing the abilities and interest of the beneficiary including, without limitation, athletic training, musical instruction, theatrical training, the arts and travel. Education shall also include distributions made by my Trustee for expenses such as tuition, room and board, fees, books and supplies, tutoring, transportation, and reasonable allowance for living expenses. Page 10 of 15 (d) Internal Revenue Code References to the "Interaal Revenue Code" or "Code" or to provisions thereof are to the Internal Revenue Code of 1486. References to the "Regulations" or "Regs" aze to the Treasury Regulations under the Internal Revenue Code. If by the time in question a particular provision of the Internal Revenue Code has been renumbered, or the Internal Revenue Code has been superseded by a subsequent federal tax law, the reference shall be deemed to be made to the renumbered provision or to the corresponding provision of the subsequent law, unless to do so would clearly be contrary to my intent as expressed in this agreement. A similar rule shall apply to references to the Regulations. (e} Per Stirpes Whenever a distribution is to be made to a person's descendants per stirpes, the distribution shall be divided into as many shares as there are then living children of such person and deceased children of such person who left then living descendants. Each then living child shall receive one shaze and the shaze of each deceased child shall be divided among such child's then living descendants in the same manner: (fl Qualified Retirement Accounts "Qualified Retirement Benefits" means any qualified retirement plan, individual retirement account ("IRA") or other retirement arrangement subject to the "minimum distribution rules" of Seetion 401(a)(9) of the Code, or other comparable provisions of law (g) Shall and May Unless otherwise specifically provided in this agreement or by the context in which used, I use the word "shall" in this agreement as a command, directive or requirement, and the word "may" in this agreement as allowing or permitting, but not requiring, the taking or omission of any action. (h) Other Definitions Except as otherwise provided in my will, terms shall be as defined in the Pennsylvatua Probate, Estates and Fiduciaries Code as amended after the date of my will and after my death. Page 11 of 15 Section 9.02 Contest Provision If, after receiving a copy of this paragraph, any person shall in any manner, directly or indirectly, attempt to contest or oppose the validity of my will, including any codicils thereto, or commences, continues or prosecutes any legal proceedings to set my will aside, then such person shall forfeit his or her share, cease to have any right or interest in my estate, and shall for the purposes of my will be deemed to have predeceased me. Section 9.03 Survivorship Presumption If any other beneficiary shall be living at my death, but die within 30 days thereafter, then such beneficiary shall be deemed to have predeceased me for all purposes of my will. Section 9.04 General Provisions The following general matters of construction shall apply to the provisions of my will: (a) Governing State Law My will shall be governed, construed and administered according to the laws of the Commonwealth of Pennsylvania as from time to time amended. Questions of administration of any trust established under my will shall be determined by the laws of the situs of administration of such trust. (b) Gender, Number, Captions Words denoting the masculine or feminine gender shall be construed to mean or include the opposite gender, and the singulaz form shall be construed to include the plural and the plural the singular, as the context requires or admits. The captions of Articles, Sections, and subsections used in my will are for reference purposes only and shall have no effect on the interpretation of my will. (c) Notices Unless otherwise provided, whenever my will provides for notice, such notice shall be in writing and shall be•effective when personally delivered and receipt of delivery received, or when mailed postage prepaid by certified mail, return receipt requested, to the last known address of the party requiring notice. Page 12 of 1 S (d) Severabilifiy The validity or unenforceability of any provision of my will shall not affect the validity or enforceability of any other provision of my will. If a court of competent jurisdiction determines that any provision is invalid, the remaining provisions of my will shall be interpreted and construed as if any invalid provision had never been included in my will. I, Isabe a M. Walters, having signed this Will in the presence of ~°F~'s r~c~~+i r'.~n1 and , E'~ a who attested it at my request on this day, 2007 at Mechanicsburg, Pennsylvania, declare this to be my Last Will and Testament. ~..~ .~~7~ GL~~e Isabelle M. Walters, Testatrix Page 13 of 15 The above and foregoing Will of Isabelle M. Walters was declazed by Isabelle M. Walters in our view and presence to be her Wi11 and was signed and subscribed by the said Isabelle M. Walters in our view and presence and at her request and in the view and presence of Isabelle M. Walters and in the view and presence of each other, we, the undexsigned, wi a~s ~ed and attested the due execution of the Will of Isabelle M. Walters on this day, ~CJG~~ i t , 2007. ~~ /~~ residing at /~6o m~ i~cPa~xc rc~ k~ ~'~ ~ ~` residin at g ~a~ ~, s~u~~ ~~' ~ l ~ ~ PENNSYLVANIA SELF PROVING AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND ) I, Isabelle M. Walters, the testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the ir~strunlent as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by Isabelle M. Walters, the testatrix, this day, Q C~li~- ~ i , 2007. 1 fi r ~ Isabelle M. Walters, Testatrix No y ublic corns,norv+rr-.atz'~i Qr PGf4NSY~VAt~Eila~ t~ctzutai ,seat Ja;~Slisie ht. hninde_'`~:, tdt~fiery Fubiic Pa e 14 of 15 ~~' ~'' ~"~'•- Datrpiron Couniy g PAy Cwnrniaion lr~n,. iros OcL 25, 2010 Pnemher, ?~annayi~ a.. ~ ~saoclaticn of Motsri3s COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND (~~ j We, ~is ~2c~bc?/-fsaJ and ~`1""yl'~ ~ ~~ ~, the witnesses whose names are signed to the attached or foregoing instrument, eing duly qualified according to law, do depose and say that we were present and saw the testatrix sign and execute the instrument as her Last Will; that the testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testatrix signed the will as a witness; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind, and under no constraint or undue influence. Witness ~ , ., Witnes No ublic COMMGN4JEALTi~ Or PENN5YLV4N(f, EJOtariai Seal ~' Jacquekne M. Mintle~, Notary Public Lower Paxton Twp-, :thin Cotr, Ay MY Ccmmisuort Expires; Oct. 2B, 2010 Member, Penn:yivania P,saoclctlon of Ptotariss Page 15 of 15 IN RE: ESTATE OF In the Office of the Register of Wills ISABELLE M. WALTERS, deceased Clerk of Courts of Common Pleas Orphans' FILE N0.21-11-0640 Court Division, Cumberland County, Pennsylvania DISCLAIMER WHEREAS, ISABELLE M. WALTERS died on May 2, 2011 a resident of Cumberland County, Lower Allen Township, Pennsylvania. WHEREAS, ISABELLE M. WALTERS, during her lifetime executed a Last Will and Testament on October 11, 2007; and WHEREAS, LOUANN ZIMMERMAN became the Executrix of the Estate of ISABELLE M. WALTERS by Grant of Letters issued by the Cumberland County Register of Willson June 3, 2011; WHEREAS, ISABELLE M. WALTERS held anon-qualified annuity with The Hartford, Account Number 712590514, Contract Number 000012058/712590514, managed by Masland and Barrick, Inc. with Walnut Street Securities, Inc.; WHEREAS, LOUANN ZIMMERMAN and ALAN WALTERS were the designated beneficiaries of The Hartford Annuity, Account Number 712590514, Contract Number 000012058/?12590514; WHEREAS, less than nine (9) months have elapsed since the date of death of ISABELLE M. WALTERS and the undersigned Disclaimant has not accepted The Hartford Annuity, Account Number 712590514, Contract Number 000012058/712590514 nor has he exercised any control as beneficial owner over any such property or any interest therein; -1- WHEREAS, the Disclaimant acknowledges that the effect of the execution of this Disclaimer is that the property that otherwise may have been distributed to him will now pass to LOUANN ZIMMERMAN. NOW, THEREFORE, I, ALAN WALTERS, an adult beneficiary residing at 595 Silversprings Road, Mechanicsburg, Pennsylvania, do hereby exercise the rights granted to me in the Pennsylvania Probate, Estate and Fiduciaries Code, 20 Pa. C.S.A. 6201 et seq., to DISCLAIM certain of my interests as a beneficiary of The Hartford Annuity, Account Number 712590514, Contract Number 000012058/712590514. 2. I understand that as a result of this Disclaimer I will have no right, title or beneficial interest in this asset. IN WITNESS WHEREOF, intending to be legally bound hereby, I have hereunto set my hand this L~ day of t/// 1 r/ , 2011. WITNESS: ~: .~4 ~~ ~~ ~~~~~~ -~ AN WALTERS -2- ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN ss On this, O~ ~ ~~ 2011, before me a notary public, the undersized officer, personally appeared ALAN WALTERS, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. (SEAL) NOTARIY PUBLIC COMMONWEAL9}I OF PENNMVANIq ~ Mlnde~ Notary Publk TM'P., Dwphin County On Otk 25 1014 Mert168r. Pennsvlyany,~dadon Notd-Ies -3- 5~~~~ E, 1ac..., ~ ©11-1I&T~~arik 499 Mitchelt Road, Millsboro, DE 19966 Adjustment Services Phone 888-5024349 Fax (302) 934-2955 July 5, 2011 Susan E Lederer Law Offices 5011 Locust Lane Harrisburg, PA 17109 Re: Estate of Isabelle M Walters Social Security: 177-24-7428 Date of Death: May 2, 2011 Dear Sir or Madam: Per your inquiry on June 22, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 88658007 Isabell M Walters Loua~ut V Zimmerman (POA) OSllBr/9 $93.637.97 $ .00 For any addttional iniormauon on the above amounts, including ownership and any changes, closures and/or rebnbutsement of foods, place ®h the Hampden lice at iP117-255.2293. We wen nnable to laente any sate deposit boz Por the above-mmtioaed decedent This letter does not indade any amounts in which the decmced may Katie been listed as Power of Attorney, Custodian of Uniform Ttac~'ers, Reptrsmtaflve Payee, or Ttvstee ands s Wtittm Agreement sincerely. Tammy Spencer Adjustment Services _° n5e4l'zb11 13:37 7177617524 MASLAND AND BARRICK PAGE 01/06 MASLAND & BA~t.~CZ~, ZNC. 3600 T[tINDLE ROAD CAMP 1~.L,1~A 17011 (71?) 761-6606 FAX (717) 7617524 www.maslandandbarrick.com FAX COVER SHEET nLEA.s>; DELIVER DATE 5-042011 TO -Susan E. Leder+cr, Attorney at Law COMPANY Lederalr 1~aW FAX NO 652-7340 THIS IS PAGE 1 OF 6)?A(3ES kROM Danette M. Howarth, Office Manager dhowarth aC~aslandand arrick.com ICE: LsabeUe Walters Susaa, please fund attached a date of death snapshot of Isabelle Walter's investments. With respect to her Hartford 1~ fixed al;><z~uity, tlae primary beneficiaries are LouAnn Zimmerman, 50%, and Alan Walters, SO%. There are no contingent beneficiaries listed. Her brokerage account (#33W-113023) is individually owned; tllerefo>•e, no bcne~.cxaries listed. We will handle the death claims upon notification from the Executor(s) and proper documentation. Atzy questions...please let ma lrnow. Securities ot~m~d through Walnut Street Securities, lnc. Member FTNRA1511'C Ma5land & Barrick Advisory, lac and Walnut Such 5couritics are unaffiliated entities. wri ';~ y:. ~ • r•~.'. .~I ~ rt T~ '~ ~ ~L~ri 4,~:'C.1 C ~..: io l ~;.. _ ' ~:1 ~ m = •i.:~•. •; l rr~y~yv Z.... f y~~ I y g~~~=~rj.~j ~ dog ~;:,; ~~ ~ ;~. ~;,.,., ~ pm ,: F, ,.tea`' ~. J ~ ~. ~ .' 1-.; }~ •r',' VV O v',',l:,~k ~~ +•~'S .~i~;~t 1~ lam' ~ '~ M1I a ` , +Y' ~; : ~•' - P.'i~wAV. r N Qp;^%~~i;, g',.I C '+ ~. ; ~' .fin. ,,,,.,,..,,,.j . ,.d.'. 3 i,r t e to .:..' .: _;f: ~ ' ~ "+ '~' ~ ~ ;{, p$p ~ Mli ` ~ y@~ i Q .'''1 ~ IP 'TI v,:. 11 ~. . 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Rqm~ ~~~~d ~g'~lp w g ~~pQ 7~a.y~ ~' e ~ ~ Li n wppp ~ @~~ ~. ~~~ C c W a5.~~~0~ _awe g`rt „~ 5~~~~v ~m ~rT a~ C ~ n 4 S~ m~ W~ ~~ d ,~~,p em~,,m3~.pw~~.9<~~ o~~ ~A~ nw~'a6 'ice-o7 gS.N ~Qm m~~~Sa~~~~ 3~0 w~~a '~ mw m~Q~. mz~.o3~$`a ~~~ ~.tn R'~~a~ aa~ s~3 .~5~,$~W gurd ~~a s~i.~°~c~,~ ~~ WAS s °~§esp+n ~~~ ~w" ~~0~76~® g 4, p~~ a~~'~~~ ~ s ~ ~g ~~ ~°-~~~Z~~aryP o~~ m ~ SZ ~W ~~..~a W ~m v~ ~~ ~$~'~5~~~ ~~z o~ a ~~ $a m e o ~ ~' H ro m ~ ~ '~ ~ ~' a 'Q ~_ ~ q'~, o ~ o ~~~ a ~' a ~ w ~ a a Ci H G N Y x_ G x x~ X a ~ N a m ~ m" t7 m Cp 7 e° 9 c w aN 4 J O ~. N N a h a 7J 7 N n O v ~C Sw 9 ~ ~~ m m e K N A 'a 90/90 3Jtld 7k7I~RItlH QMi QNtl~StlW b7.G/T.g1JU JR:Fi TTAZ/bL1/CA __ _ ___ 90/l0 3JHd ~i~I2f~ QNt7 QNH~IS'VW 4Z5LI9LLiL LE~F.T. iiGi7.IbG/Cp ~HMN2K. Date: 05/17/2011 S~ ~~~ E, i -~, y This Month Gross payment amount 269.98 Net payment amount 269.98 p354066 .. ...y 3l•S^'..~r..~....~~c.s~....m...i !~' ~i'.~'Li1"^'.'" • YIiT~~O'JG'.q~ r{]'. 'r Yk W>- \ P N -__. ibi#S 2+M1S-~rdiiN ` $''tvS:ia~ ~K1sci... - e~ ~~~n vdy`d~i ~. ~Irv1°, v.~~tz:7bw'~~.?~. :n _. ~~- ,-~~+_~_~ ~ __._~;~_ 0354066 1GHI~ti'~K® -- Direct Pay Central .Regwn DATE' AMOUNT.: Premium Refund- 05/17/2011 269.98 :..~~ :., *TWO HUNDRED SIXTY-:N~NE~AND 98/I00•AOLLARS* PAY THE ESTATE ~OF ISABELLE M;~ WALTERS '` ~ ~ ~ - ~ ~~ TO THE ~~ OADEA OF PO BOX 404 rr ~leC~ l~r~ HALIFAX PA 17032 l~A«„t,~ ii'0354066u' ~:0 360 76 1 50~: 620545z58in' __ _ _ Sc~e<i;,,l~ t_, I~ S --' 1 6 40 4 3 9--' .~:0 3 1309 1 2 3~: 4 2 68 2 20 1--' IIIIC(illl~~~ll~l[i~li(~Il~ll DD493 s~ ~ r~~ ~ , r --~-- 15ABELLE M WALTERS C/0 LOUANN ZIMMERMAN PO BOX 404 HALIFAX PA 17032-0404 s m e 0 0 v N m e 0 0 s Policy Number: 5837H0818506 Refund Amount: $ *'~ 146.00 Check Number,. Check Issued: 58436214 05-12-2011 This refund was issued for the tollowing reason(s): If you have any questions, please contact your Nationwide representative. Agent Name: GL JACKSON Agent Phone Number: 717-691-1100 Agent Number: 0030315 Detach Stub Before Cashing And Keep For Your Record TO:VERIFY:P~IJiFiC~ j' NATIONWIDE. MUTUAL FIRE INSURANCE COMPANY '- Nationwide' Check N : 58436214" 'Y4-T292 ~ P.O. Box 8378,Canton-ON 0004g~;' Insurance' O -Date: 05-12 201":1 44711-8379 " ~ ", . ~ ~=~~ -.. - 'PdlcyNumber:: 724 ` ..5837H08165D6 , N < ~ ,. .~. '`PAY «"ONE" HUNDRED FORTY SIX AND 00/100 DOI~.A~S~rrarx*«`r~ia`it+ww«*r««irxrx**«nw-+w:,e++rit+e,etxrt*'rrw+rsx+trtr**x*xrxrrx*ew „~ ':EXACTLY::..- ,. ,~ `~, : : ~; , ~ _;., . .: .,: •. IILIrIIJ~1.161La11;61,ad IIIILa~J11e,iIIl rLllll~~a+1111 .. '' ~~~. 1 SABI:1_LE M WALTERS" ~, ~_ `' C/0 LOUANN'ZIMMERMAN K? ;. ~,:. ;. ': PaY PO BOX":.404 .: . .. . ~ X146.00`: .$,c , To The .. HAL I F pX -.~ _ ; . _ ;Order ~.: , .77032 040`4 PA ` ' ~ ~ ~ . ~ ~ Yatd U Not;;Cashed.Wtthln~9o Days . ,. ,, ( Thf fNLpayment unless ofhenNse ` ~~`•M ~ -'iMm'We CAae Btn14 N.A. .n.m r ~ ~ ` ~ '~ :~ ~ ~`? ,, ti *'^ ~ ~~ neturo Authodzed &I ~ ~„ .t ~ . : ~ g _ ISABELLE M WALTERS C/0 LOUANN ZIMMERMAN PO BOX 404 HALIFAX PA 17032-0404 u'S84362L41+' r:0724i2927~: ;L582611^ ~.-~m 7 T'HIN'G ;12-. TIMES A: Pic~oeci ': mercharndise ;, '.., . Omnicare, Inc. -National A/P -859-392-3653 I INVOICE NUMBER/COMMENT I INVOICE DATE BVA100053890 REF 1047 ~ 07/14/11 '. For questions repardinq this refund please call 877 372 2279 Ext 306 GROSS AMOUNT I DISCOUNT I NET AMOUNT 92.90 0.00; 42.90 c`'`~ ~~;~ ,~ ~~ ~~ Copy CHECK N0. VENDOR NUMBER CHECK DATE TOTAL GROSS TOTAL DISCOUN T CHECK AMOUNT .101.500552 999295991 07/27/11 .$42.90 $0.00 $42.90 ~ ~ ~ . ' ~ ~ ~ aoe 07/27/ 1 OMNICARE INC SunTrust Bank s4.7g 1600 RiverCenter II Sevierville, TN 611 No. 101500552 100 East RiverCenter Bhrd. Covington KY 41011 VOID AFTER 120 DAYS DATE .0 7 . 2 7 Z.,. 0 1 ' 4 M M D D Y Y Y Y PAY FORTY TWO AND 90/100 DOLLARS**~++*~~k~***.t*+r,r~+*a*t+*+***~*+**w~~++t*~**«* i~ SG2.90 TO THE ORDER OF Amourne Over 55D.D00 ReQUrse Sewnd Sgrotun ~~ ~~ Estate of Isabelle Walters PER clo Louanne Zimmerman PO Box 404 iaz Halifax PA 17032 PER AVi1gRITFD 8KiW1NRE u'0 LO L 500 55 2n• x:06 i X00?90~: 70 L9006 266~~" __ _ A RGUSTM HUMANA LV.320.0006.004.HUMANA INS CO.DMR P.O. BOX 14601 LEXINGTON, KY 40512 Address Service Requested MB O1 000106 55133 8 6 A ~~ IIIII~"mlrl{il~lh{nlh~~{~{~h~ll{~I1111Ph11{{~{{~Id~{I~ WALTERS ISABELLE M 5225 WILSON LN MECHANICSBURG, PA 17055-6663 Claim Summary for this Period Amount Submitted $15.20 Allowed by Plan $15.45 Deductible $0.00 Copay $0.00 Paid Amount $15.45 Prescription Claim Activity through 07/01/2011 Expfanat~on of ~overag Plan Information Page 1 of 2 LV.320.0006.004.HUMANA INS CO.DMR Member Name/ID WALTERS ISABELLE M H54589741 Date Amount Allowed Pai Filled Drug Description Submitted by Plan Deduct Copay Amout 01/12/11 TAMSULOSIN HCL 0.4 MG CAP $15.20 $15.45 $0.00 $0.00 _$15.4 Check Issued 1099696 $15.4 ~ '~~. DETACH THIS CDNFIRMATlON AND RETAIN FDR YOUR RECORDS BEfORE CASHING OR DEPOSITING CHECK. A-RGUSTM Pay to the order of: WALTERS ISABELLE M Reimbursement Check \ ~-: 36-1870/1012 -''`.'~ Check No. Check Date Dollars Cent 1099696 July 15, 2011 ***************** $15.45 VOID AFTER 180 DAYS FIFTEEN AND 45/100 DOLLARS ***** COMMERCE BANK, NA KANSAS C{TY, 5T..1USEPH iM,~~"w AUTHO IGNATURE 11'000 7.09969611' ~: LO L 2 >r8704~: ~430000>46 >,u' __- _ ._._. c~~z.C-. I ~~-~=~'~ Unbn Bank of Cdifarnia CNECKNUMBER d DELT/~ DENTAL' AARP Dental Insurance Plan ~ Fi~CI"atesc~a~TO4 6.3913 Administrative Trust Fund Dena Dental Inavratttt Company premium Refund Account 6m+•~~+216 VOID IF OVER {2,560.00 Delta Dental Insuran GB COm pang DATE VOID IF NOT CA6NE0 WITHIN 1B6 DAYS 100 First Street 11/1012011 ~ ~~s**101.79 San Francisco, CA 94105 CAY EXACTLY ********a******************ONE HUNDRED ONE & .79 DOLLARS TO THE ORDER OF ISABELLE WALTERS C/0 LOUANN ZIMMERMAN P 0 BOX 4tt4 HALIFAX PA 17032 ~~~IIL2~IIL~~~~III~IL111~~~16~211~~~11~~26~~11 Delta Dental Insurance Co. ~~.~~ ~ ll'00000639 1311' ~: i 2 L000497~: 7000 i65039n' ~L'M ~~TAL° AARP Dental Insurance Plan Administrative Trust Fund Delis DentalInsuran6eCompany premium Refund Account Delta Dental Insurance Company 100 First Street San Francisco, CA 84105 V~ ~I `~ ~ ~ 1' ;ice /r. ~/ ~l 1 Delta Denta! insurance Company is a proud provider to 1`7['1~~L Health Care ~~~ Options° ___ _,~ _ -- - 05I04/2011 13:37 7177617524 MASLAND AND BARRICK PAGE 01/06 MASLAND & BA,XtRICI~, INC. 3600 TRINDLE ROAD CAMP HIZ.L, PA 17011 {?17) ?61-6606 FAX (717) 961-7524 www.maslandaadbarrick.com FAX COVER SHEET PLEASE DE1.IY&1~ DATE 5-042011 TO Susan E. Lederer, Attorney at Law COMPANY Lcdtrex 1.aw FAX NO 652-7340 THIS IS PAC3rE l OF 6 PAQES k"RONI Daaette M. Howarth, Office Manager dhowarthCc~tnaslattdandbatrickcom RE: ~sabeUe Waters Susan., please find attached a date of death snapshot of Isabelle Walter's investments. With respect to her Hatt,#'ord Fixed annuity, the primary beneficiaries are LouAnn Zimmerman, 50%, and Alan Walters, 50%. There are no contingent beneficiaries listed. Her brokerage account {#33W-113023) is individually owned; therefore, no beneficiaries listed. We will handle the death claiztts upon notification from the Executor(s) and propez documentation, .Any questions...please let me know. Securities 0#fered through V/alnut Street 3ecurides, Inc. Member FINRA/5A'C Masland & Garrick /I.dvisoxy, tnc and Walnut Street Securities are unaffiliated entities. o ~~'~'~, , ~ ~1 ~ .~ y , y .~ ! ~ ~ ~ a n ~ ~ _ rl . ~` ~: . . r~ r v. aS r ~ 'J S ~ N 7 H w am. ~. k 01 r I iiaa Ll 7- 7F _ m ~1 ~'' ' T ~ e ssa~~i i ~~:: = Y • +; ~. 's2. yam: ~ . ~.: m ~ m i ~.:'~ 1t ~ ~ t ~r } ' w ..'PPP C~, F ] LLLT~~.. .i: ;I 4 l . pp i STS. F~~'~ '~ ~~~ ~ '•'; ~ ~~ ~ ~ : W O :.. . ~y p ~ .4; , ~ . ~ ~i. ~'. ~ py ~ 1 ~ s ~ ~: aY 'y ~ ~ ~ $ ? ~/~ n u fir '!' ~Y _i: '~i. ' - G P , ~ i:4'i ~r4 :: ~ Y.S'W .) 4 ~ V i: ~ '~ wr r'~;f ; ;' r. _ _ .:>: ' r ; .~ 0 011 T. , G . i4~ 1 r Y y ~ . . ~ N ~ ' r'• 3 tT ~ p. i CI i~:. i.-.. ~i ~. {N .:~. ~ ~ ~~ 9 g '1~ ' -pml q... :. T Yp v.: I. rl • ' .~ ' ~ d ~~: ; , w $}~ p~Ll y•I•~ ~ ~ ~ R'C. 7 a " ~'' . ~ ., ~;r ~ 98/66 33tld 71~I21~JtlS QNti QNtl~StlW tl5LZ9LLiL L£~£T TTOZ/b0/S0 ~~. '~~,'~'+ ~ m~~ii a S .~. ~ ~ ~. ._ ~~~:~.~~ - ~~'~ ~{~ ray ~...:; ;~ ` m O :: ;<~,' 77 a`_,iy, V ~ Or ~.., ' ., ~•.' , fY . 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QMiISIiW bZSLS9LLtL LE ~£Z ITOZ/b0/90 C 3 a 0 O a n M L M ~~.~ ~ ~~~~~~a ~ ~~~ ~~a~'~a'~a~~~ ~~a ~~~;~~~~~~ a~~ ~~'~aid~ar5~~~a~.~g o~~ ~~p~~3$~~a~w ~~~ ~,~a~~~~m~~~ ~ ~~a ~~~~ C~ ~ ~ "~ O C ~ ~ ~-~ ~~ ~~~°~~~x ~ ~ ~~~ ~ 4 ~ ~~~~~ ~~ ~~~~~~~~~a$ `~~,~$~" ~~~ ~ma4~~~~ ~o G ~ ~ .~ ~~~ ~g ~~P ~ ~o ~ ;~ m~~ c~~'~~~e ~$w d~ ~~~pT~~~~ Sap ~aa55~~1Y~ ~l o ~ ~' 4~~ ~~~~ g ~~~ ~rz m '~ ~ 7 a~ ~ ~ W ~ d Y~ d~ ~~ ~ ~~ ~~ ~~~~~~~q ~~a 7d~ ~" ~,~3'~~e~' ooh' roves a$ ~~g;~ ~~~ '" _ m ~ ~ ~~ ~~x ~~~gcg °~ mWw~~~a3 ~Bw ~g ~~~" ~.~~ ~ ~~~ y~R e a !~ ry~~ ~~+~0 ~ e o _ ~ °' a® rt~ R ~ m ~ O. ~_~ qQe G ~-, d n x n xGx g~ X y X 0 d N C") 91 a ~. r ~, 0 ri a 0 0 .~ a N N 1 w N nt 0 ~~ s~ ~~ 1 /w ee tJ~ N n ... 1D N 7 n .~ 90/90 3~tid N~I~21tlH QNd QNtl~StlW bZ5Lt9LLtL LE~Et itOZ/b0/50 S P ~ ~~.. ^ ~ n ~ 4. ~ O 3 1A s ~ ~ °' ~ '~ ~ ~ ~ ~ ~ r®F ~' tD r n a a m ~ r* n ~ 3 ~ - ~„ ~,; h !s. n m ,.~. ~ :' ~ a ~ n •~+ .. , ~ o ~ ~ ~ ~ ~ ~ ~ ~ a 'a _ -~ N 1 q S Q $ ~' .•F ~ o a K .~. ~ a~ ~. ~ Q ~ ~ O a .~ ~ Q p ? v 7 + /w 6 r J O C n r m O n M Z ' y n 5 90/Z0 39tid 7rJI2R1tlS QNtl ~ltflStlW bZ5LT9LLTL LE ~EI ST0l/ti0/50 PREFU~VDED`:FUNERAL .AGREEMENT Sc~.~,~,.1~ ~~ l~~ J~ AGREEMENT NUMBER ri , For the benefitot ~ ~ ~. `~~11~ ~~ e v S ~'1 ~~ ~ ~ 7y~ ~G ~.~ ,:. ~ . r Fur~et~ ~ ietit){t~nreti=. ;..~' . ~' .s So'c~al Se~utry Numbed:; STATEMENT OF GOODS AND SERVICE& ~f,_, Y_ ~~~ . . ~ ...,,~ .~. .~ ~`~ F~~,~ ~~: _ _ ~ ~. _ _ -_ - .. - .. ' r 4 !,i I y-r :Yt 65,.6t`ty f;Ya~;:q''' ~L^ x,... yr },..+~ 'F/' r di ~.i r. fxK." ~Y°. t ~~.~1t~ ~1N#30LLN!$i~1'[~~+~t1R1~~1r~kG1G" ~g2 • ` ~ '~ ~~r' • I C r ~ ~yr1 xt a -r .4 .kt'i ` :~ , , x1 7d 1t~l~fg , • I ,: iVatrbtiatG • w .. -~ry(.~ Yy~sy~ kX n{ i-. :r . j,:.. . ~ - ,{ ~Ja r~ /. Y, ~ y~ f'r°4y5 ~2 J":,'^~i ' <~ '~' `~~t~~t ~'+Nir~ ~ K ~~~ - ~~_ ...'J v ~~ r ~ ' .! lL i T ., :] ~~'y ~yi%yr'1 ~.. l . P'.~RQPO;S\ED INSURED/ANN4JtTANT ~sMale ~- Female ,,,~~p-_ ~s rT ~~;~ ~ ~ _ ~~ FirstName p ryt tasthlame hiSneNumber X Soc Sedun um er -Age DateofBrrttr 'OWNER `= Com lete on if other tharq~Iftsur+et}rAlnnuit~rtt-'~ rr, ~ ~;~: ",~ - ~;' ..~ _ , "~~ ', i'-~ ' ' ' '.1 A'.: ~ ~ > b ;3*S, r r.~ y 3r ~ n ~ r:i '~.a. r.r ~ ~Y .:-~ y Y " ,. " -'." k .' •_ 1.,C,~t.3 ~ n tl Zr t"i nit E' r ~r~ ~ -~ ., i!i.~~~ ..~ ~ Lja u ~ t -~ t ,~ First Name M! list Name, ~ SQCial Se lYrprrker ">,`- ,~-.. - ~? ,`Relationship to Insured -- ~ MAILING ADDRESS ^-{NSUREDiANNU1TANT W. NER (YV.heretnsend-information about.this.Policy) J -'S~ ~- r 1 7s `.i.A , .. r , _ ~.. 1 ~w.t _ A isr e. t " ~ } ~ t . . , Street Address Clry: '_.: , .State ~ Lp '~~ ~11 Y~~~°''C~ Lc6.~;. r. .:, w~.. {a r -L ° .: '~4Y~ ~y~'NI 3?tkJ "r<" '.u'X` -e~'i r~l r • ` ' :Funeral Price $ ~' ~7' '~„ -.~'~a'de~,Ar~#otiht~$`~•"~" l •,?'"^ ' C.~ B < "p~rrauattntet''~~rafabieon~ aa~f1~ ^ch;arteriy . Single Pay Life F~ble Anna $:~1 ~ ~~_ ° =~ ~ ~_*~~~- ~ Mu4f+ Slay Li#e [~'1 Yeah -- , • ~'' AkYY'~~~~dt ~C~'1~ Ye9r - t . _ , " "F,~ ~` . -. iradialPxemium,. ~+-; Multi.:PayPremrum ~TatalE~xsmiurxt,Arsaounttw,tt~l~ C]`~"' 9,M~-trsxeMatlnl~DirectPacxor ^Nlortthiy~rect' ~}i :.'~ ~.:A". m '~.,.5, .. ^~F •.~ 3 ~~sztti«kY'R) S ~ -~..py~s `i31°.u jnl''.` c l ;~~~~ 1 ~~'~W f+»F .:~ ` `Y 5 r ~•- }43 {r;r+ Hx.,. . ,k.~' n~ Y ~,J ttv a y~ e.., ,, s~ - r a r, __ ~ 7, '}, ~v 'ro "; ~T+, `^pi 9 1. §YiAFSI•~ E E' k ~~ < '. ter. J.:1'~:' r 1 `Are'you currently on oXj+g~rtl'hd5j~~ta1~ dricxJflfii"#ti ~ FitJlrsmg~l'~Tth~°ot~1C~n~t~TrtSioarer#~cility't= h , ~' ' r p"YE3 d NC 2.1Jtiting;the-pas'rtwo years-have'ya:7r~been ad~'i5~r a medical professronai to:hav~`artysurgu~l procedure that _ ri •~ ~ r ... ; - `hasnotbeen-performed7; -~,~-:.,:i°~.',s. ~r°,...,~ ~~+:; ~~:.. ` x .. ~s - ~ .z ,h• a1rrESpNC 3. During~the pasttwo.years:have you-been.treated or:are you being treated by:amedicat professional for any of - f the following diseases or disorders: ~ - • . • _ ., ^YES [J VO Congestnte•Heast Failure Immune 5ystem.Disorder.- Chrat~c Obstructive Pulmonary (lung).Disease ~ Amputation {caused try disease) ..Heart Disease , Grdmsis of the Liver Emphysema ... ; ,Stroke ; ~ .. ~.. _` ._- thug Ar 7~fcbFi0tj7e f5endeiicy ~ " `Alzhetrri~F`~{ia ,~ _ ...... ,:. _ Gancer(other than shin) ,.I~drtey fa~lure~ firtcltxx~l!~gdiays~s) _ ;:.I~abeticCortre/Insulin~Shock: ;. '. - - If the health question is: not artsvrered rsr answered '",Yes".aritl you arezbpplying #or a~+laltt Pay Pian,~a Pohcy vith`limited death ben= .: _efits Burin 'the. earl. earsv~nll be issued•''The ull death. berrefrt rs . aid fior accidehtahdeath,, . `: ~~ ' .~::;-, .. 'r - .:..:.. ., ..._, -;,.. :F.Fgit'R' t yid-.+ crt;, ~~::: , r as„i .. '.. ~; e ~{. ~ji ~ . t Vi\"riYfJ.. + a ,• ~ : :: fir'.. :VVtltten ~NWn '~.~, -- ~NGL isdirected'`ta~pay an-amount not to exceed th~•deatiibenefit t~f;the Policy to the-Funeral: Pcovtder nari~ed below, if ariy, upon ,: :receipt of proof thaT-funeratmerchandrse at~servicesftave:.been proi~ded ~Jrt the:event that~N,CaL:-rescinds or'decltnes..to.i5sue:the: Policy, i-also assign to the:i=uneralProwder('t the.t7ght~tiJ receroe th~~premiurrt paid upon receiptofiproof that funeral merch`andise- ` '-and services have been-pmvided,:{2) the nghtto compromise clatms.aatd (3)_the~rtght;to agree~to rescission. 4} ~ ~ Y C~ 1 a G~ ~c n+C>~~ ~~(~~ i -1~ )~„ t.• ~C"'..~" ~:"~ ~`~'.1~-• :f5 ~l '~~ Y j~i'[) . 17~. Nine of Funeral Prtrv/der Street-Address, ,Cay - State Zip - ^~ .'- Name o1:P.rimary Beneficiary' !. StreetAddress > - , ~1'T - - - x,State :Zip. Relationship to Msured,. . t r r ..:. .: ;: ~,r "xf~m %~si ~.,, s r• ~ r r; ./ ~r^. ~:'~ F~`.bryt`rE. "~x'rk£~ r .~ ...,~-.. ~~". j ~-s :.,:~T~ •:: 7o4he bestof my knowledge and belief, Theabove;inform8tibn is true and complete i~,nderstartd that no insurance wilt baeffective until this-farm is:apl5roved and tl=te Policy-is-issued°whtte the~ansured;is-ttvtng, a~ata`IktCfrize N~L~to share=:my rtonpub4ic personal .; `information with :any Funeral Provii3er:with-whortt 1;h~ve a:l~Gefunded:FUneraiAgreemerat. if t.am the Owner for insurance on the-life' of the~Proposed~lnsuted;; I certrfy,that Irhav~any+nsur~bfe'interest iii his or het`hfe~ ': :.. { acknowtedge:that i_have -~e~adthe~rautf warning;st~tetrletit;on tNa l~$f page:ot<thls~form. ° _ Signed at ~ ~ -. State -, ..:; -... Signature ni'Pro7p~osed.lnsuredlAnmuitan~ty~ Dale -. ~: ~ Signature< : a :{Required N'otherr than Insured)< Date `' . ... _ - /y,-~`.:~n x,~.,; ~'-~,~-'rr'::1 ~''s~~n~~ ~ _ ~ r~it~~ L~,{t..Y3Z~y^~3 ~ 't ~ f^'~'TrK„.R'-.d~ x~:" .~t+r,+:' 'J ~~` r ..t~ ` t that.any i miation recorded on this form #s~l`e and accurate3o:tne best: bf my knowledge. ent(s).Signature. Ag_ ;.Agent. (s)printed- - _ .:NGLAgent# : - -,:Agent State-Ucense# %_ ,., .. .. _ _. ,.- .. ,,,r..- : r ,-. ,. -.- .-- - • Agent(s) Signature .: ,: •;;iAgerrt Name(s~ Pnrrted _, - NGL.Agent#, - Agent'State License# %::~ m ~:. a -e ~"'"i7~ -`.,Y.. -_ i a~* ,a7>F~'xx ~ .. ~; .s psi ~ zy~,.vr.. ' '~ / +1~ a^ -s, ~' ; ~rt .; x .r - t+'e r~~ ` r t •r+k a _F r F '4"` t '~' ' r 2? r ts*t bi+ "vii r qc nv, ~: ° rn ~ ~e^'t 'iS'S r Yy 5 .t .~N ~ h ~SL~- r .. +'~~~1'IY"t71-c .c, r .i. s.j:->. cr A 6N3a~~ roe M k~>...vw .x ~SB WItt~{ ,+.r v!/.r .~ ~Mas...ikrr T# ;ta~~-'J'.~'X uTa~j~`s~""~ra3`- x i Insured:~~-~-:~~1\f= 1.~a1-1~. Agent:~u~cr~ ~ ~ ~; i~~rGC' ~' ' l Y. Ti P A S r~'1~ ~~ Fti?~C3G~ABLE A~$IGN1V1~1`~~ `~ ~ ~' ,~` ~~ ~ 'X~ ~ '' .. ~ ... Assignment of Ownership, Death Benefit and Rescission Rights: The Owner hereby irrevocably assigns to the Funeral Provider named in the Direction for Payment of Proceeds all incidents of ownership-of the Policy, the right to receive all or part of the death benefit payable under the Policy upon receipt of proof that the funeral merchandise and services have been provided, and, if the Insurer, for any reason either rescinds or declines to issue a Policy, all-rights; including the following: (1) the right to receive the premium paid (upon receipt of proof that the funeral merchandise and ervices have beeri,provided), (2) the right to compromise claims and (3) the right to agree to rescission.. The Owner acknowledges that by making the assignment irrevocable it cannot be canceled.: This assignment does not affect the right of the Owner to cancel the Policy under the Right to Cancel provision.. By making this assignment irrevocable, the Owner "also acknowledges the following; _. ' 1. The assignment of death'benefit.proceeds is permanertfand cannot be'changed by the Owner 2.. The Owner has waived all rights.under the Policy to surrender for cash, to obtain a loan, to change the Owner or - beneficiary,;or to receive a:refund for any premium paid. 3. "The Owner remains responsible for the payment of all insurance premiums when due. >tt is understood.and agreed that this irrevocable assignment in noway inhibits the Owner or the next of kin of the Insured from hereafter selecting another Funeral Provider to perform funeral services and provide funeral merchandise in connection with the funeral of the Insured. The Insurer is not a party to this :assignment and .the sole responsibility of the Insurer is to pay the death `,6enefitproceedapursuant to the terms of.the Policy as amended by this assignment. ' - Imfnediate'Transfer (For purposes of-Medicaid~Eligibility QNLY) =•I hereby elect to make this irrevocable assignmenteffective immediately. I understand that by making this election I give up all rights to cancel the Policy and receive a return of premium under -the `R~i'/ght to Canceel/provision of the Policy.. To m/v7ake an immediate transfer election please /iniitial rrh''ere~ 1 ' ~r!` ~rC2'!r<~7 ~ ~ttart~I ir•G.tl~r ~ / mat 1 L~.~ /'iJ f~ $Jgneture 01Owner / Date .L J '» y .tars mv"Ms`~+""z x~, ~> .ytr.a'" r5}c;' ~ o ~ 1 ~ t l~ '- ~~x i ~ x:.. ~'"".J .n sx ~ L y -.: ~ , t Na#` ~arhS ., z. ;,a.~~i tt E^ A - ~ ~£. M 4 ~ t x ~,` ~ '~'r--,kV+r-rpt'.~ ~ _ n .i 'ts~.,,~a ar*}yyr~t~ a s . , , m~3 ..~ , > r,. s~ t, mss.. s'~i- 2w.~ m <a. : A ~ ~ s M a , s J > > ,.A: ~.W+ -,s " ~n-• 6 .+,3' s ,, y-y i~r . A .r '~,l? f 'F i 4r i>+ s ~.r 1 1 ~"'.k''St`"' '`.t > ~'^' ~ st'> Wks •,,, r5 4~:,~~:J '~ .A . .t~1 ~~: ~s~.{t~A~, ; 'n i. ~ ~ Y, F ~~Y as t ~• ~ N ~ ~ ..i . ., <:.. ., .~.,.. a.~r...,. ~.~. .--. ,.>..~'~ ^t.m > ~1ng ~.,... ..... ,FaYx -+Yz r ^ Monthly Electronic Funds 11~ansfer - Date of month to initiate payment (dates available are ist I request -and authorize NGL io make monthly withdrawals throu h 28th select one: against the financial institution account specified at right or Bank Name ) any account subsequently named by me, and such bank(s) to process these withdrawals as 'rf I had signed .Bank .Routing/ABA # them, for the purpose of collecting. premiums under this Account # -plan. If the said account is replaced by.an account in ^ Checking ^ Savings .another bank, this request and authorization shall also .apply to such other-bank. if using a checking account; please_include'a:`voitl check. (Signature as a appears on bank records) Forsavings account, please contact.the bankao verify EFT is.allowed and verify correct routing.and.accountmsmber. (Date) ^~ Morrthly Credit Card Authorization (NotAn-Annuity) I authorize the premiums due to be remitted monthly to NGL through my credit card account indicated at right. This authority will remain In full force and effect until I ---revoke this authorization by written notification to NGL. (Account Number) - (6cp. Date) (Cardholder Signature) Select one onl : (cardnoider address) y ^ VISA ^ MasterCard -, rrv--aiu (rage ~ 05/08 MYERS-HARP+tER FUNEl2AG HOME, INC. 1903 MARKET STREET CAMPHiLL, PENNSYLVANIA 17011 717.737.9961 LOCALLY OWNED AND OPERATEp May 20, 2011 Ms Louann Zimmerman P 0 Box 404 Halifax PA 17032 Services for Isabelle M. Walters May 5, 2011 Total: Received check from Insurance Company: Total: Non-guaranteed items not under original contract: Opening Grave (Additional) Certified Copies (Increase) Obituary (Refund) Burial Vault (Additional) ROBERT R.RARNER SUPERVISOR PUSTi;I R. BAKER FCENERAL DIRECTOR $ 8,700.00 $ 7 8-'~3T.3~ $ 70.00 66.00 65.00 746.10 Balance Due: $ 817.10 l~ ~~ d,j ~l x. ~~ ~o t~L ..... -.r ._~~,.ailCSie MYPR.S-HARIVER FUNERAL HOME. INC. 1983 MARKET STREET CAMP Hrt.L, PENNSYLVANIA 470{1 717.777-996k hUCALLY OWNEll AND OI'ERATEU May 19. 2011 National Guardian Life Insurance Company P 0 Box 1191 2 East Gilman Street Madison WI 53701-1191 Services for Isabelle M. Walters May 5, 2011 Charges for Services Selected Professional Services Use of Facilities Automotive Equipment Charges for Merchandise Selected Casket Liner Cash Advanced Opening Grave (additional) Newspaper NoticeJLocal Clergy Certified Copies Flowers Hair Dresser Total: $ 4,990.00 $ 2,210.00 750.00 $ 70.00 235.00 125.00 90.00 185.00 45.00 Rh BERT H. RARXER SC~rERYISOR U U1119 R. BA6FN FL'NF0.Al DIRECTOR $ 4,990.00 $ 2,960.00 $ 750.00 $ $ ~ _ _, ~ ~ ~- - - Lvlyers-darner Funeral Home, Inc. 7903 MARKET STREET CAMP HELL, PENNSYLVANIA 17011 Hobert H. Harper. Supervisor phone: (717) 737-9967 Dustin R. Bt3kt)r, Funeral Dirt;ctOr STATEMENT OF FUNERAL GOOllS AND 5IsRVTCES SELECTED Clwrga an nnl!- I'or these items that yvat selnmi m that arc rrquirrJ, If xc arc raquircd 1?v Iwv or by a centtten• nr cremamn• to rue mlr iunu. xc ?cill explain in retiring belmv. If yvu selected a funrnl that mar rcyuire enthalnting, such :tx a fitnenl with vicN•ing. vrou mar have to pay Inr rmhalntiug. litu Jx nor have ro }xry fix embalming!nu JiJ nvr aipmcr it [vu ulac[cd atr:mgrm-ryn~ts wa'h es a direct franarinn nr inunnlime burial. IF??e charged (nr cmb:thninr, aac Dill replain shy lxduw. Fnr the $rnice of -F-S0. b ~l ~~ ~ ~, ~~S Derr nt Dea ~- ~ ^~O ~ba~rtn:L.cx~-C..nn z;N.,t,.z~-,>v~,,n PQP~~x yby 1~IG1~: ~ . Namv AdJnu Cin' titan A CFIAI(Gt POR 55RVICES SELECTED: I. I'k(1FFtiSIONr11. SFkVICYS s Srn'iea nl imenJ C)irreturlSµtT ....... ~ F F~tll,alinin ........................ ; : S ` Drha preparation of hvJr Pnving a\" (.~,cmvudog)~ .......... .. i A hG laslrt Plaacnirnr ......... . ...... .. $ ynfi ( - 5 _,_ FACILITIES AND SERVICES hx• aF Facilities and service lire ~~` ~~- """~~~--- aicwin}: (ViainvivntWxkc7 ~,, Ux of ixiliries and w'n'ifi> fur timeral ctrunuua' ................. Ux• of lacilitie anJ %cn•ice for ~icmvrial Serria+e ................. l!sr vi v ui ,man and erv" I' SC0.'I'O'1'AL OF PAOF'FSSIONAL SERVICES .....Ai S,.t~. Crcmarivn urn ...................... S - IUawTiprion) l!m V:uJr ..... ~ ....................5 _~ IDe<riptinnl S~ (ITHL•'li 5 ~-a TOTAL TfLRCHANDISI; Sti.L'(,7EU ....... R '~1~, ~ G SPECIAL CHARGES: Ivfwarding vl rcuctina m `> S S _ (Funeral Hvmrl 1f 14~ RaecivinR of remains floor 5,~ \ (Funeral Homcl S ..... 5 _ Immedimc Burial ' i • ............. D rect Crcnt:nim, ..... S 9 I ices nr a gra?'axiJr sen•itc ................... $ltKi~. (hhcr ux• nF fteilifics (Slier Atra .... ... .. 5 1 I'rcpmuivn klw,m .............. •,.5 5 SLrB-TOTAL OP FACiLI'I'7l:'S/tQI;IPMFM .... A2 9~~ S $ ~_ Sl1R-TOTAL OF AU7.OMOTAB/F;QLrlPh1ENT .. A3 {L(\G~' 3. Al!TOAiOTTVF. EQOIPMRTVT \2hidc u, aa?ukr remain m Funeral Honrc '"~~ l.frul ..................... • ...... S f-s1L,~ Hcarw (C,ukcs Coaah) I.ucal ............................ S ~G~- Flusacr car m (lord di% itinn f Ln[al ............................5 If1t..~ fraJ eatllleig\' t'ni I.ncal ............................5)~ '1'OTU. OF PROFESSIONAL SERViCL• 5, FACILI'1'IFS Af+3~Al. , yiQT1VE I O ~ ~ EQCIP~IEf .... ..1. ..~V`.t1Gsf....`..~. A S - B. CHARGE FOR MERCHANDISE S)7,EC1'!; Ca%krr ....... .. ..................5~ 00 I DcMrip ~vnl~G _'r„' TT C7t~hcrll epode ...................._ j !Desariprinni _ SCB-TUTAL OF SPF.CNL CHARGES ............ C 5 D. CASH AIIVANCED: Opeeing Gnat ..... .............. ... NarsPalxT Nmiae-I fxnl ........... . • . ~fN~PJpI'r NnrIG•-(~Ut-uliUN•n .. .. . .. Airfare ......... 5 (,lelgribla%5 U1lerlllg .............. . .. C Certil' C:vpic% of rhr ncath Ccrtilicam r~ Fc C b CID Oa ~0 .....ach .. Flnsw~n ... . ......... .. ...5 • ~{' O D ... 5~ 4Sub krvia (:barge ............... ... S UrF, nice . • ...................... ... $ __ . Soloist .......................... ... S Altar $crs•ices ..................... _ ... S __ Coroner Fee ..................... ... S _ Al'ilagr,, .......................... I1~v~aOC~Set ...5 5~ _S St;A-TOTAL DF AIrvANCES ..... • .. • ........... D 5 ~_m \Ve chagk yvu for our ttn•icn in nhtaining: !r/+rr'iMSrnb )rArnnm dun ,nr urnlrrl-nil sT:biMARY or• cTT.ARCrs rl. Pn?fr%>ialal Services. F•acilirias anJ Fyuipmnu. end Aummvtirc i h ~ ~O ~ yu pment ........• ......... R. hit•rrhandisc ................. .........5 t ......... S~~• L. Special Charges ............... ......... S D. ('aslt Adrencrs ................ _~ o ......... $~~ • ~ TDTAL OF ALL Sk;CTIUNS . , Q ~i 1~. ...................... S _L2.)_a! PAID AT TRIE OP OR PR10R TO ARRANGEAIGNTS .... ..... • ... .......... ~ .. 5 BAI.ANCF. nLIL• ............ ...................... s REASON FOR Ff:Id'f'1A/L'1MfNG II env lawaav, ccnleltr)1 Ur crcm910O' fttlUltemC111X h:wt• n'(IUIRYI the purchase of auy ul the inns listed alxm the Llw or nquimmem is cxpLfiued heluN•. 1 agree rho I ha?'c rxamincJ the ilcnu vfgufxls and scn•ica seltrnd abtrve and titund them m be mrnct and actvrding tv nc~ arrengcntcnn !have requastcJ. I acknnaeleJge nceipr nl a u,py of this Sntenten oFFunrnl GmnLs and $rrvias Sdaeted. l rtP that l havcsulYicirm 1'unJs axtilahlc lire payment ol'thc rash price Iwr nc~ goods and srrviara %rln'n•J. I al c m make Payment nfS, within ~_ dots. (agree rv he inindy:uul mnc•rally liable pith anvnne elx why signs hdnw. .4 leer rhm~ge v1 5_ per month antoundng m 5 ~Olj~ For ~~ar Ndll Ix applied m nc~ unFtid balance beginning b p . Jacs from nc~ dare of this agrmnrnt. I wJl ulm pav tv the Funeral Uirccrnr all mappable u,xis paid by nc~ Funeral Director rn collect amrnmts 1 ulec under J,i% agreement. Thule cnsns mar indudeumrnrvs Ina.cnurttnasundothermsw. Anvasidiixrnalaen~itcaorrm-rehandisenrdercdorrcquaredahrrrheda,refihixugn•.menravillbecon%idercdparrofthia agrccmnu anJ the cn%I ihrnvl'will he rcflcaed nn [he linal bill or sumu,rnl. 11'nrchascrl Ili,nbu%a'n ILiaYnaed Funeral Dimtvrl n n O •rhurialcnnrainer ........ .........5a~~ u ` ~ 1~19C1~ Acknux'lulgrmnn urJs ....... ........5 _ kcgister M,ukr.f ............. .. • ..... S Mrmon InWcn ............. • ....... S _ I'rrn•cr umLs ................. ..... .. S __ lenipnfar?' grate IllarkaT ... .... ... .. ... 5~_~ Burial dnthiug .............. ........ 5 Other durhing _, _S ~ S