HomeMy WebLinkAbout01-31-121505610101
REV-1500 Ex`°1.1°, .'~
i~#~T OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
w,ME»r of gE~E~~E
_-
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOx s8o6oi RESIDENT DECEDENT ~ ~ ~ ~ "`~ ~~'
Harrisbur , PA 1~1z8-o6oi
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
__ _ __ _.
209-12-9645 03/26/2011 11/26/1926
Decedent's Last Name Suffix Decedent's First Name MI
HERNJAK ~ MARY JANE
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social. Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
C!b 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
SHARON L CABA EX (717) 732-3204
,,.~
-_.,
First line of address
2520 LAMBS GAP ROAD
Second line of address _
City or Post Office State ZIP Code
ENOLA PA 17025
REGISTER IR~1 LS USE ONLY
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Correspondent's a-mail address:
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 OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS ~
2520 LAMBS GAP ROAD ENOLA, PA 17025
SIG E OF PREPA R OTH THAN PRESENTATIVE ATE
7 Vet'-MAIN STREET SHIREMANSTOWN, PA 17011
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
;)
J
1505610105
REV-1500 EX Decedent's Social Security Number
Decedent's Name: HERNJAK, MARY JANE 209-12-9645
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1. _ _
2. Stocks and Bonds (Schedule B) ....................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) ........................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 2,667.00
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
._._ . _ _ 4,182.36
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........
7.
109,312.52
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 116,161.88
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 8,779.87.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ....... 10.
11. Total Deductions (total Lines 9 and 10) .......................... ....... 11. ' 8,779.87
12. Net Value of Estate (Line 8 minus Line 11) ....................... ....... 12. ' 107,382.01
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
00
350
an election to tax has not been made (Schedule J) ................ ........ 13. .
14. Net Value Sub'ect to Tax Line 12 minus Line 13 14. ' 107,032.01
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 _
16. Amount of Line 14 taxable 107,032.01
at lineal rate X .0 45
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable ~ ~~ ~°~ ~ _ __ _ ~ ~-
at collateral rate X .15
15.
1s. ° 4,816.44
17.
18.
19. TAX DUE .........................................................19.'_
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
4,816.44
Side 2
1505610105 1505610105
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
CEDENT'S-NAME
MARY JANE HERNJAK
STREET ADDRESS
2520 LAMBS GAP ROAD
__.
C~ENOLA ~~ PA ! 17025
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments 6,125.00
A. Prior Payments __ __.__ ._--___
B. Discount 240.82
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval 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)
(3)
(4)
(5)
(1)
4,816.44
6,365.82
1, 549.38
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 :.................................................................................... ...... ^
b. retain the right to designate who shall use the property transferred or its income :...................................... ...... ^
c. retain a reversionary interest; or .................................................................................................................... ...... ^
d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ x^
2. If death occurred after Dec. 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? ....... ....... ^ 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 J~.ily 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percen
[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 ani
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, ai
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 ii
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, uncle
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV->.5o8 EX+ (ii-io)
SCHEDULE E
pennsylvania
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MARY JANE HERNJAK
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1, PERSONAL PROPERTY 2,500.00
2. I CREDIT - PA AMERICAN WATER COMPANY
3. ~ CREDIT -MASTER CARD
TOTAL (Also enter on Line 5, Recapitulation) $
If more space is needed, use additional sheets of paper of the same size.
33.00
134.00
2,667.00
REV-i5o9 EX+ (oi-io)
~~ ~ Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
MARY JANE HERNJAK
If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A• SHARON CABA
B.
IOINTLY OWNED PROPERTY:
2520 LAMBS GAP ROAD, ENOLA PA 17025 ~ DAUGHTER
ITEM
NUMBER LETTER
FOR IOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. M&T BANK CLASSIC CHECKING ACCOUNT 2675020578 8,364.71 50% 4,182.36
TOTAL (Also enter on Line 6, Recapitulation) $ 4,182.36
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
. pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
www~~~wrr~ INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
MARY JANE HERNJAK
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
NI IMRFR THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. ~ JACKSON NATIONAL LIFE INS CO ANNUITY 009294838A
109,315.52 ~ 100
109,312,52
TOTAL (Also enter on Line 7, Recapitulation) $ 109,312.52
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
MARY JANE HERNJAK
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' WAKE 796.70
2 GAS 50.00
3 FUNERAL EXPENSES 870.83
a PACKING MATERIAL 28.00
B. ADMINISTRATIVE COSTS:
1, Personal Representative Commissions:
Name(s) of Personal Representative(s) SHARON CABA
Street Address 2520 LAMBS GAP ROAD__-. ____--.__
ENOLA _ _ State PA ZIP 17025
__ ___.-
ity .-------- ------ ---
Year(s) Commission Paid: _2011
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
4.
5.
6.
7.
s
9
10
11
12
City State _
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
APARTMENT CLENINGIMOVING VAN
JEWLERY APPRAISAL
POSTAGE
NEWSPAPER ADVERTISMENT OF ESTATE
PHARMACY
ASSISTED LIVING RENT
ZIP
6,000.00
95.50
150.00
260.00
30.00
20.00
240.00
96.33
142.51
TOTAL (Also enter on Line 9, Recapitulation) $ 8,779.87
If more space is needed, use additional sheets of paper of the same size.
REV-1513 EX+ (01-10)
r ~ Pennsylvania SCHEDULE ~
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
ESTATE OF: FILE NUMBER:
MARY JANE HERNJAK
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. KELSEY HERNJAK, 1276 SUMMIT WAY, MECHANICSBURG PA 17050 GRANDAUGHTER 2000.00
2. SHARON CABA, 2620 LAMBS GAP ROAD, ENOLA PA 17025 DAUGHTER 33.33%
3. CYNTHIA PETROSKI, 2511 VANCE DRIVE, MT AIRY MD 21771 DAUGHTER 33.33%
4. DAVID HERNJAK, 1276 SUMMIT WAY, MECHANICSBURG PA 17050 SON 33.33%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
HOLY SPIRIT HOSPITAL 50.00
2. ~ BRIDGES I 300.00
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 350.00
If more space is needed, use additional sheets of paper of the same size.
REGISTER OF WILLS
CUMBERLAND COUNTY
PENNSYL\/ANIA
CERTIFICATE OF
GRANT OF LETTERS
No . 201 ~ - 00480 PA IVo . 21- 1 1- 0480
Estate Of : MARY JANE HERNJAK
(First, Middle, Lastl
Late Of: CUMBERLAND COUNTYHIP
Deceased
Social Security No : 209- 92-9645
WHEREAS', on the 14th day of April 2011 an instrument dated
October nth 2000 was admitted to probate as the last will of
MARY JANE HERNJAK
(Firs!, Middle. I asl/
late of S/EVER SPR/NG TOWNSH/P, CUMBERLAND County,
who died on the 26th day of March 2011 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THFRE.FORE, I, GLENDA EARNER STRASBAUGH _, Register of Wills in and
fo_r CUMBERLAND County, i.n the Commonwealth of Pennsylvania, hereby
certify that I' have this day granted Letters TESTAMENTARY to:
SHARON L CABA
whr~ has duly qualified as EXECUTOR(R/X)
and has agreed to administer the estate according to law, all of which
f u 1.1 y appears of record in my of.fi ce a t CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 94th day of April 209 9.
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RegrsteF of Wrl/s
T Deputy
* *1VOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
LAST WILL AND TESTAMENT r-~
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MARY JANE HERNJAK ~'° `^r ~ _ -
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I, Mary Jane Hernjak, now or formerly of Camp Hill, Cumberland County:, ~ ~=_
,_
Pennsylvania, being of sound and disposing mind and memory, do make, publish and
declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by
me at any time made.
ITEM I: I direct that all inheritance and estate taxes becoming due by
reason of my death, whether such taxes may be payable by my Estate or by any recipient
of any property, shall be paid by my Executor out of the property passing under this Will,
which is not specifically devised or bequeathed, as an expense and cost of administration
of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for
any such tax paid by my Executor even though on proceeds of insurance or other
property not passing under this Will.
ITEM II: I hereby exercise all powers of appointment which I may have at
the time of my death in favor of my Executor, and all property subject to all such powers
shall be included in my Estate.
ITEM III: I give and bequeath all my household furniture and furnishings,
automok~iles, books, pictures, jewelry, china, linen, silverware, wearing apparel, and all
other like articles of household or personal use and adornment to my husband, George J.
Hernjak., if he survives me, or if my husband does not survive me, to my children, per
stirpes, Sharon L. Caba, now or formerly of 2620 Lambs Gap Road, Enola, Pennsylvania,
Cynthia A. Petroski, now or formerly of 2511 Vance Drive, Mount Airy, Maryland, and
David P,. Hernjak, now or formerly of 25 Cherish Drive, Camp Hill, Pennsylvania, to be
distributed to them in equal shares by my Executor.
ITEM IV: I give, devise and bequeath all of the rest, residue and remainder
of my property, real, personal and mixed, to my husband, George J. Hernjak, if he
survives me, or if my husband does not survive me, to my children, per stirpes, Sharon L.
Caba, Cynthia A. Petroski, and David A. Hernjak, to be distributed to them in equal
shares by my Executor.
ITEM V: In the settlement of my Estate, my Executor shall possess, among
others, the following powers to be executed for the best interest of the beneficiaries:
(a) To sell, either at public or private sale and upon such terms and
conditions as my Executor may deem advantageous to my Estate, any or
all real or personal estate or interest therein, whether owned by me
severally or in conjunction with other persons or acquired after my death by
my Executor, and to consummate said sale or sales by sufficient deeds or
other instruments to the purchaser or purchasers, conveying a fee simple
title, free and clear of all trust and without obligation or liability of the
purchaser or purchasers to see to the application of the purchase money or
Page 2 of 8
to make inquiry into the validity of said sale or sales; also, to make, execute,
acknowledge and deliver any and all deeds, assignments, options or other
writings which may be necessary or desirable in carrying out any of the
powers conferred upon my Executor in this Paragraph V (a) or elsewhere in
my Will.
(b) To pay all costs, taxes, expenses and charges in connection with
the administration of my Estate. My Executor shall pay expenses of my last
illness and funeral expenses.
(c) To distribute my Estate in kind or in money. If any assets are
distributed in kind, they shall be distributed at their respective value(s) on
the date(s) of their distribution.
(d) To retain any investments I may have at my death so long as my
Executor may deem it advisable to my Estate so to do.
(e) To vary investments, when deemed desirable by my Executor
and to invest in such bonds, stocks, notes, money markets, real estate
mortgages or other securities or in such other property, real or personal, as
he shall deem wise, without being restricted to so-called "legal
investments."
(f) To mortgage real estate and to make leases of real estate.
Page 3 of 8
(g) To borrow money from any party to pay indebtedness of mine or
of my Estate, expenses of administration or inheritance, legacy, estate and
other taxes.
(h) To vote any shares of stock which form a part of the Estate and
to otherwise exercise all the powers incident to the ownership of such stock.
(i) In the discretion of my Executor, to unite with other owners of
similar property in carrying out any plans for the reorganization of any
corporation or company whose securities form a part of the Estate.
(j) To distribute my personal property directly to the Guardian of the
person of any minor beneficiaries hereunder.
(k) To elect such settlement options as deemed most appropriate by
my Executor with respect to any pension, profit sharing or other retirement
plan in which I am a participant.
(I) To do all other acts in the judgment of my Executor necessary or
desirable for the proper and advantageous management, investment and
distribution of my Estate.
ITEM VI: Any person who shall have died at the same time as Testatrix or
in a common disaster with her, or under such circumstances that it is difficult or
impossible to determine who died first, shall be deemed to have predeceased her.
ITEM VII: I nominate, constitute and appoint my husband, George J.
Hernjak, to be my Executor (herein referred to as "Executor"}. In the event of the death,
Page 4 of 8
resignation, refusal or inability of George J. Hernjak to serve as my Executor, I nominate,
constitute and appoint my children, Sharon L. Caba, Cynthia A. Petroski, and David A.
Hernjak, to serve together as Executors. My Executor(s) are specifically relieved from
their duty or obligation of filing any bond or bonds.
IN WITNESS WHEREOF, 1 have set my hand and seal to this my Last Will
and Testament, consisting of this, the next three (3) pages and the preceding five (5)
pages this '' l;y day of r ~~~~~:~r~~~.~~/.~.. , 2000.
. ~ .,
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Page5of8
SIGNED, SEALED, PUBLISHED AND DECLARED by the above named
Testator, Mary Jane Hernjak, as and for her Will, in the presence of us, who, at her
request, in her presence and in the presence of each other, have hereunto subscribed
our names as witnesses in attestation thereof.
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Page 6 of 8
1521 Penn Street
Harrisburg, PA 17102
5115 East Trindle Road
Mechanicsburg, PA 17050
5115 East Trindle Road
Mechanicsburg, PA 17055
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS.:
We, Mark K. Emery, John R. Fenstermacher and Margaret A.
Fenstermacher, the witnesses whose names are signed to the attached or foregoing
instrument, being 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.
Sworn to or affirmed and subscribed to before me by Mark K. Emery, John
R. Fenstermacher and Margaret A. Fenstermacher, witnesses, this ~~. day of C~_to1~c~
2000.
~___--~-
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Wit ess
i'
Wit, ess
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Witness_ _._
f
t Public
My Commission Expires:
(SEAL) -`~~ ~-~
i~OTARIAL SEAL. Public
CONNIE R. SHULTL, Notary
Mechanicsburg, Cumberland County i
M Com!-~Issi^~n Er-giros Ate. 1S__3. 202 -~
Page8of8
/~1 &T Bank _ ~.
ACCOUNT N0. ACCOUNT TYPE
2675020578 CLASSIC CHECKING
00 0 06113M NM I17
r.. ~.
C / I ~~) i L c` t--
~~
MARY JANE HERNJAK
SHARON CABA
2520 LAMBS GAP RD
ENOLA PA 17025
INTEREST EARNED FOR STATEMENT PERIOD
12510
0.00
s ~+r.n~ t-iT 011 MM A D V
HIGHLAND PARK
r-~..+.. .. .. .. ~ ~... _. .._ .
OTHER
CURRENT
ENDING
BEGINNING
BALANCE DEPOSITS '&
-OTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE
N0. AMOUNT N0. AMOUNT
36
447
15 4 NO. AMOUNT
3 637.38
0.00
3,279.97
8,364.71 0 0.00 .
,
~ r~T T\,TTV
M V V \/ V ~~ ~ n v
INTEREST
DEPOSITS
CHECKS & OTHER
DAILY
POSTING
DATE TRANSACTION DESCRIPTION ,
&'OTHER ADDITIONS SUBTRACTIONS BALANCE
58,364.71
03-24-11 BEGINNING BALANCE i
2,000.00 6,364.71
03-28-11 CHECK NUMBER 3810
04-04-11 CHECK NUMBER 3813 100.00
04-04-11 CHECK NUMBER 3816 28.00
638.87
04-04-11 CHECK NUMBER 3815
04-04-11 BARCLAY CARD US CREDITCARD 000000000003812 511.98 5,085.86
50.00 5,035.86
04-05-11 CHECK NUMBER 3811
870.83 ~
04-08-11 CHECK NUMBER 3817
150.00 4,015.03
04-08-11 CHECK NUMBER 3818
110.00 3,905.03
04-11-11 CHECK NUMBER 3761
04-12-11 CHECK NUMBER 3819 57.83
04-12-11 CHECK NUMBER 3820 50.00
20.00 3,777.20
04-12-11 CHECK NUMBER 3763
30.00 3,747.20
04-13-11 CHECK NUMBER 3762
95.50 3,651.70
04-15-11 CHECK NUMBER 3764
04-18-11 In Branch Transfier/Withdrawal 10.00 3,641.70
96.33 3,545.37
04-19-11 CHECK NUMBER 3765
04-20-1I CHECK NUMBER 3814 150.00
115.40 3,279.97
04-20-11 CMS MEDICARE PREMIUMS
53,279.97
ENDING BALANCE
CHECKS PAID SUMMARY
3761 04-11-11 110.00 3762 04-13-11 30.00 3763 04-12-11 20.00
3764 04-15-11 95.50 3765 04-19-11 96.33 3810* 03-28-11 2,000.00
3811 04-05-11 50.00 3813* 04-04-11 100.00 3814 04-20-11 150.00
3815 04-04-11 638.87 3816 04-04-11 28.00 3817 04-OS-11 870.83
3818 04-08-11 150.00 3819 04-12-11 57.83 3820 04-12-11 50.00
STATEMENT PERIOD PAGE
MAR.24-APR.22,2011 1 OF 6
3
LG08A (6/07)
Quarterly Statement
For the Period of 01 /01 /2011 to 03/31 /2011
www.~ackson. com
Prepared for:
MARY JANE HERNJAK
2520 LAMBS GAP RD
ENOLA PA 17025
Activity Summary
This Year Since
Quarter To Date Issue Date
Beginning Value $1o~,13a.ss
Totallnvestments $o.oo $o.oo $1zz,o55.23
Total Withdrawals $o.oo $o.oo $a,ooo.oo
Total Tax Withheld $o.oo $o.oo ~aoo.oo
Net Change $z,1~~ss
VValue on 3/31/11 $1os,31z.52
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Your Representative:
STEPHEN M STACKHOUSE
77 CEDAR AVE
HERSHEY PA 17033-1419
Broker/Dealer:
National Planning Corporation
Contract Information as of 03/31/2011
Contract Number:
Type of Plan:
Inception Date:
Annuitant(s):
Owners}:
009294838A
Nonqualified
9/11/06
MARY JANE HERNJAK
MARY JANE HERNJAK
Benefits
Death Benefit: $133,625.22
Glossary on last page. See prospectus and your contract for more information on optional benefits added to your contract by rider or endorsement.
Remember, your contract: is a valuable asset. Canceling or replacing your contract could result in adverse tax consequences. You should also consult
your tax advisor before engaging in either of these transactions. If you have any service questions regarding your contract, please call your financial
representative or a Customer Service Representative at 1-800/644-4565.
Performance changes over time. Please visit www.lackson.com for daily performance updates. Any other information required by Exchange Act Rule
10b-10(a) shall be furnished upon request.
The Perspective L Series Fixed and Variable Annuity (VA210G Not available in all states. State variations may apply.) is issued by
Jackson National Life insurance Company, Lansing, MI. Jackson National Life Distributors LLC, member FINRA.
1 Corporate Way, Lansing MI 48951
Please include your contract number on your check when sending additional premium.
Questions about your statement or contract?
Jackson Service Center, P.O. Box 24068, Lansing, MI 48909-4068;
Contact your representative indicated above. > '`., or; Express mail: Jackson Service Center, 1 Corporate Way
Lansing, MI 48951
I^ ~ 24-hour automated service: 1-800/644-4565
a.' Visit us online at www.jackson.com
~„ , Service representatives available Mon. -Fri. Sam - 8pm ET
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RECEIPT FOR PAYMENT
GLENDA FARMER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17613
HERNJAK MARY JANE
Estate File No.: 2011-00480
Paid By Remarks: SHARON CABA
DB
------------------------ Receipt Distribution
Receipt Date: 4/13/2011
Receipt Time: 1"3:54:33
Receipt No.: 1065?.29
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Fee/Tax Description Payment Amount Payee Name
PETITION LT:RS TEST 30.00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 10.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 12.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION :E'EE 5.00
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ACCOUMi' PAGE
000002675020578 4 OF 6
MARY JANE HERNJAK ~s++s 3 7 6 S
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