HomeMy WebLinkAbout03-30-12J 1505610140
REV-1500 ~` ~°'-'°'
PA Department of Revenue OFFICIAL U8E ONLY
Buroau of Individual Taxes
Po Box 280801 INHERITANCE TAX RETURN ~~ Code Y~ FAe Number
HaMsburD, PA 1712&0801
RESIDENT DECEDENT 2 1 1 1 1 2 3 6
ENTER DECEDENT INFORMATION BELOW
Social Securihr Number Date of Death NNADDYYYY Date of Birth MAADDYYYY
2 0 4 D 1 9 9 7 4 1 1 0 5 2 0 1 1 0 9 1 1 1 9 2 1
Decedent's Last Name Suffix Decedent's First Name MI
B R E T Z M A N H I L D A M
(K AIIpIioaMe) Enbr Surviving Spouse's Infonmatlon Below
Spouse's Last Name Suffix Spouse's First Name
MI
Spouse's Social Security Number
TH13 RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1.Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prbrto 12-13-82)
^ 4. Limited Estate ^ 48. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required
death after 12-12-82)
^ 6. Dsoedent Died Testate ^ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (data of death ^ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attadt ~, O)
CORRE8PONDENT - THtS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFOENT W. TAX MIFORMATION SNOtILD BE DgtECTED T0:
Name Daytime Te
lephone Number
S U S A N J H A R T M A N 7 1 7 2 4 9 ?? 8 0
RE(iI3TER OF YVII-L.S U8E ONLY
r-.a
~a
First line of address
a.~ ~i
C?
1 I R V I N E R 0 W ~- ~~
Second line of address ~ ~
Cis ~ C _ _~ * ~~
City or Post O/Rce State ZIP Code t
~ { ~~
C A R L I S L E ~+" ~ '~'
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tinder pwwNNs a P~hMY. i dedana ttaa 1 have examined nAs ro4sn, kidudMg aooomparryinp sahedula and . and b the hat of my broMAerJp~ and twllst;
it is trw, oomacct end aompNM. Dsdarstlon or proparar athar than the personal roprosaMatlve b heed on ar hrtorrnsson a/ rMich praparsr has any
SIGNI~SURt'.'ef1PERSON R~SPONSyLE FOR F~WG RETURN ,,.x _
HES ROAD
REPRESENTATNE
ISL
1505610140
17
87
1505610140
S ROAD CARLISL
PLEASE USE ORIGINAL FORM ONLY
Sidle 1
170
1515610240
REV-1500 EX
Decedent's Social Security Number
DscedsnCSWame: HILDA M• B R E T Z M A N 2 0 4 0 1 9 9 7 4
RECAPITUUnoN
1. Real Estate (Schedub A) .... .................................... 1. •
2. Stocks and Bonds (Schedub B) ...................................... 2. •
3. Ck~sey Held Corporation, Partnership or Sob-Proprietorship (Schedub C) ..... 3. •
4. Mortgages and Notes Receivabb (Schedub D) .......................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal PropeRy (Schedub E)....... 5. 8 5 9 1 1. 5 6
t3. Jointly Owned Property (Schedub F) ^ separate Billing Requested ....... t3. 8 2 4 8 9. 2 9
7. inter-Vlvoe Transfers 8 Miscellaneous mats Property
(Schedub G) s
Ruli
7
2
2
8
7
eparate
ng Requested ....... 7. . 2 6
8. Total Oroee Assets (total Linea 1 through 7) ........................... 8. 2 4 0 6 8 8. 1 1
9. Funeral Expene~ and Administrative Costs (Schedub H) .................. 9. 8 7 5 7. 5 0
10. Debts of Decadent, Mortgage Liabilities, and Lbns (Schedub q ............. 10. 1 6 4 . 5 0
11. Total Deductions (total Linea 9 and 10) ............................... 11. 8 9 2 2 . 0 D
12. Nrat Value of Estab (Line 8 minus Line 11) ............................ 12. 2 3 1 7 6 6 . 1 1
13. Charttabis and Governmental Bsquests/Sec 9113 Trusts for which
an ebdion to tax. has not been made (Schedub J) ...................... 13. 1 0 0 0 . 0 0
14. Net Value Subject to Tax (Line 12 minor Line 13) ...................... 14. 2 3 0 ? 6 6. 1 1
TAX CALCULATION - 8EE IN8TRUCTIONB FOR APPLICABLE RATER
15. Amount of Line 14 taxabb
at the spousal tax rate, or
transfers under Sec. 9116
16. Amount of Line 14 taxabb
at lineal rate x .0 _ 0 . 0 0 16. 0. 0 0
17. Amount of Line 14 taxabb
at a~rrg rate X .12 Q. Q 0 17. Q• Q D
18. Amount of Line 14 taxabb
at collatoral rate x .15 2 3 D 7 6 6. 1 1 1 s. 3 4 6 1 4. 9 2
19. TAX DUE ............................... ................ ...... .19. 3 4 6 1 4. 9 2
Z0. FILL IN THE OVAL IF YOU ARE REQUEBTiNG A REFUND OF AN OVERPAYMENT
aide 2
L 1505610240
1505610240 J
REV-1500 EX Pepe 3
Decedent's Complete Address:
Ffle Number
21 11 1236
oECEOENrs ntarrtE
HILDA M• BRETZMAN
STREETAODRESS
540 PINE ROAD
crnr
CARLISLE PA 17012
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. q, pp~ 33, 500 • DO
B. Discount 1, ? 3 0.7 5
3. Interest
4. H Line 2 is greater than Line 1 + Line 3, enter the difference. ThLs is the OVERPAYMENT.
FIY ~ ~ on Page 2, Line 20 to request a rotund.
(1) 34,614.92
Tntal Crests (A +g) (2) 35, 230 • ?5
(3)
(4) 615.83
5. ff Une 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5) 0.0 0
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, bennt'its or care? ....................................................... ^
2. If death occurred after Decker 12,1982, did decedent transfer property within one year of death
without receiving adequate consideratlon~ .......:............
...................................................................
3. Did decedent own an 'in Dust for• or payable-upon~eath bank account or security nt his or her denth? ......... ^
4. Old decedent own an in~ridual retirernent account, annuity or other non-probate propeAy, which
contains a benetiaary designntion? .................................................................................................. ® ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE Q AND FILE R AS PART OF THE RETURN.
For dates of death on or af6er July 1,1994, and betcre Jan.1,1995, the tax rate imposed on the net v~ue 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 b or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ti)]. The statute does not exempt a transfer b a surviving spouse from tax, and the statutory requirements for diadosure of assets and
(ding a tax return are s1N ~plicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate unposed on the net value of transfers from a dece~ed child 21 years of age a younger at death to a for the use of a na4rral parent, an
adoptive parent or a stepparent of tl~e chid is 0 percent p2 P.S. §9116(aH1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) p2 P.S. §9116(ax1)].
• The tax rate imposed on the net vale of transfers to or for the use of the decedent's siblings is 12 percent 172 P.S. §9116(a)(1.3)]. A sibNng is defined, under
Section 9102, as an individual who has at least one parent in common wish the decedent, whether by blood or adoption.
REV-1508 EX + (8-98)
scHEOV~E E
COMMONVYEALTH of PENNSYWANU- CASH, BANK DEPOSITS, ~ MISC.
RESIDE~NTEDECED NTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
HILDA M• BRETZMAN 21 11 1236
~ ~ and ~ ~ were received Igr the estate.
hip mint b~ di~cbsed on Sch~duN F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~. SOVEREIGN BANK CHECKING ACCT X3381137395 25,534.92
2• M&T BANK CHECKING ACCT X1283707 2,512.09
3• SOVEREIGN BANK CD~3385D51846 10,OD0.00
4• SOVEREIGN BANK CD#1695543551 20,880.21
5• SOVEREIGN BANK CD~1695545358 10,000.00
6• CHAPEL POINTE SAVINGS ACCT 85.22
7• REFUND - CHAPEL POINTE 6,628.40
8• REFUND - CAPITAL BLUE CROSS 148.30
TOTAL (Also enter on line 5, Recapitulation) ~ t ? 5 , 7 8 9.14
(K more space tt needed. insert additlonal sheets of the same sine)
REV-1509 EX+ (01-10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERRANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
HILDA M• BRETZMAN 21 11 1236
Nan aeset waa made jolMly owned wfftlin one yeu of the decederd'e dab of death it must be reported on Schedule G.
SURVMNG JOINT TENANT(S) NAME(S)
ADDRESS
TO DECEDENT
A. JOY D T
s.
c.
JOINTLY-OWNED PROPERTY:
87 E YELLOWBREECHES RD
CARLISLE PA 17015-9174
C
ITEM
NUMBER
FOR JgNT
TENANT
MADE
JgNT
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCWNT NUMBER OR SIMILAR
IDENTIfYIN6 NUMBER ATTACH DEED Fqt JgNTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENTS
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
~. A. 2010 MEMBERS FIRST 77,133.49 50• 38,566.75
CD*340396-43
2• A 2008 MEMBERS FIRST 40,944.77 50• 20,472.39
CD~340396-42
3• A 2008 MEMBERS FIRST 40,944.78 50. 20,472.39
CD~340396-41
4. A F&M TRUST 5,963.7? 50• 2,981.89
ACCT~0007127863
TOTAL (Also ante! on Una 6, Recapitul~ion) I i 8 2 , 4 9 3.4 2
It more space b needed, use additlonal sheet of paper of Mle same size.
REV-1511 EX+ (10-00)
Pennsylvania
DEPARTMENT OF REVENUE
INI#RITANCE TAX RETURN
f~sloENr oECEOENr
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
"~ ~'~ ` yr FILE NUMBER
HILDA M• BRETZMAN 21 11 1236.
Decedent'':debt swat be nporled on Schedule L
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
t. EWING BROTHERS F.H.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. AttomeyFees: DUNCAN 8 HARTMAN, P • C •
3. Famyr Exemptlon: (N decedents address b not the same as dalmants, attach explarlatlon.)
Claimant
Street Address
City Stele ZIP
Refationshtp of Clatrrlant m Decedent
4• ProbaleFees: REGISTER OF WILLS
SHORT CERTIFICATES 8 PROBATE
5. Accountant Fees:
6. Tax Retran Preparer Fees:
7. REGISTER OF WILLS - FILING FEE
8• HELD IN RESERVE
377.00
7,500.00
365.50
15.00
500.00
AMOUNT
TOTAL (Also enter on Line 9, Recapitul~ion) ~ ;
If moos space is deeded, u4e additlonal sheets of paper of Ule same sine.
,757-
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, S LIENS
`~ "" ` "r FILE NUMBER
HILDA M• BRETZMAN 2L 11 1236
Report debt Mcurred by the decedent prior to loth that rantainsd unpsid at the date of deefh, including unreimbur:ad nbdkal expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ~MILLENIUM PHARMACY
TtnAl (Also enter an lfie 10, ReCapihtladon) ~ s
144.5D
4•
H more space b needed, liaert adoYtlonal sheets of aie sine,
REV-1510 EX+ (08-09)
Pennsylvania
oEPARTMrEHr of REVENUE
KBE TAX RETINtN
DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
FILE
HILDA M• BRETZMAN 21 11 1236
This schedule moat be oonrpleled and filed N the an,trrer b any of questlorra 1 through 4 on page three of IheREV-1500 b yes.
BEM
NUIIIBER oESCRIaTION of aROPERTr
wauoeT~Nw~avn+r;mA,t~taaATia+sF~TOOr~e~Arn
7tEDATEOFTyArt$fER.ATrACNACOPYOFiF1ED~FORREALESfATE
DATEtJFDEATH
VALUE OF ASSET
%t~FpECD'S
INTEREST
EXCLUSION
pFAPRJCA~Q
TAXABLE
VALUE
t. WESTERN 8 SOUTHERN LIFE ?,129.•86 100.00 ?,129.86
IRA ANNUITY W0020190689
[SEE ATTACHED DOD LETTER]
2 WESTERN 8 SOUTHERN LIFE 19,122.57 100.00 19,122.57
IRA ANNUITY W20194473
[SEE ATTACHED DOD LETTER]
3 WESTERN & SOUTHERN LIFE 46,034.83 100.00 46,034.83
IRA ANNUITY W002069624
[SEE ATTACHED DOD LETTER]
TOTAL (Also err on Lme 7, Recapitulatlon)~~ i 72 , 2 87.2 6
M more apace b needed. uae additlonai aheeb of paper d the name aiae.
REV-1513 EX+(01-10)
Pennsylvania SCHEDULE J
oEPAR~~oF `~~ BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
HILDA M. BRETZMAN ai. i. i. i.aa~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lbt Trus~a) OF ESTATE
I TAXABLE DISTRIBUTIONS pncwde M distributions atld trarlsfats under
Sec. 91 f6 (a (1.2).)
1. JOY TRAYER Collateral
87 EAST YELLOW BREECHES ROAD 50~ SHARE
CARLISLE, PA 17015
2• CLYDE A• TRAYER
87 EAST YELLOW BREECHES ROAD 50i SHARE
CARLISLE, PA 17015
Collateral
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1. BARNTTZ UNITED METHODIST CHURCH 1,000.00
23 CHURCH LANE
CARLISLE, PA 17015
TOTAL tJFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. i L , 0 00.0 0
ff more space is needed, use additional sheets of paper of the same size.
LAST WILL
TESTAMENT
I, HILDA M. BRETZMAN, of 540 Pine Road, Cazlisle, Dickinson Township, Pennsylvania,
being of sound and disposing mind, memory and understanding, do hereby make, publish and declare
this as and for my Last Will and Testament, hereby revoking any and all other wills and codicils
heretofore made by me.
FIRST. I direct that all my just debts and funeral expenses be paid from my estate as
soon after my death as practically and conveniently may be done.
SECOND. I direct that my remains be interred within my family's burial plot in accord
with my expressed wishes.
THIRD. I authorize my personal representative to expend funds from my estate, in such
amounts as my personal representative shall consider necessary and desirable for the purchase,
erection and inscription of a suitable mazker for my grave.
FOURTH. I bequeath One Thousand Dollars ($1,000.00) to Barnitz United Methodist
Church to be used for repairs at the local church.
FIFTH. I give, devise and bequeath all of my estate of whatever nature, be it real,
personal or mixed, and wherever situate unto JOY TRAYER and CLYDE A. TRAYER, per
stirpes.
SIXTH. I direct that any and all Inheritance, Estate and Transfer taxes imposed upon my
estate passing under my will or otherwise, shall be paid out of the principal of my residuary
estate.
SEVENTH I hereby nominate, constitute and appoint JOY TRAYER and CLYDE A.
TRAYER, or the survivor thereof, as Executor of this my Last Will and Testament. I hereby
relieve my Executor from the necessity of posting security in connection with his duties, as such,
in any jurisdiction in which he may be called upon to act insofar as I am able by law to do so. In
addition to the powers conferred by law, I authorize my Executor, in his absolute discretion, to
retain in the form received, and to sell either at public or private sale any real or personal
property owned by me at the time of my death.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
Testament, consisting of one typewritten page this y~!'h day of /~/) CL hcGl
2008.
HILDA M. BRET
Signed, sealed published and declared by the above named Testatrix (I.) as and for her Last Will
and Testament, in the presence of us, who, at her request, in her sight and presence and in the
sight and presence of each other, have hereunto subscribed our names as witnesses.
~ ~-
COMMONWEALTH OF PENNSYL MANIA
COUNTY OF CUMBERLAND
SS.
I, HILDA M. BRETZMAN, 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 instrument as my Last Will; that I signed it willingly; and that I signed it as my
free and voluntary act for the purposes therein expressed.
I-iILDA M. B TZ
,_
~,~,
JOAN D. ,1C:ai:;;;Y ~~ tary Public ~
Carlisle 8oro. ~ mbarland County
Comm' ' n Expires March 7, 2011
Sworn or affirmed to and
acknowledged before me, by
HILDA M. BRETZMAN this ~ day
of /Vt arGh ,Zoos.
,d,
Notary blic
MpNVVEA1,TFt pP PENNSYLVANIA
NOTAR!Al. SEAL
JOAN D. RD:~'~lS, Matary Pubic
Carlisle $oro., Cur°~; ~rla^d Cau~;y
Commission Expires March 1, 2011
COMMONWEALTH OFPENNSYLT~ANL4
COUNTY OF CUMBERLAND
:SS.
We, vl//LLJLt M ~' • ~ ~~ ~ and ~?}~~ ~~ ~,j v,(,~,y~e 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 (I.) sign and execute the instrument as
her Last Will; that she signed willingly and that she executed as her free and voluntary act for the
purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the
will as witnesses; and that to the best of our knowledge, the Testatrix was at that time eighteen
(18) or more years of age, of sound mind and under no constraint or undue influence.
Sworn or affirmed to and
subscribed before m by
wl ~,~~c~r ~#- pv~~ ^' and
this ~ day of l~/r~ ~'l , with 2008.
//r
Notary blic
!ACTH QF PEP1iVSYLVANIA
NOTARIAL SEAL
,iOAN D. A0~41S, Notary Public
Cate goro„ Curn?;e:land County
Commission Expires March 7, 2011
~~~i~~
Western & Southern Life
A member of Western & Southern Financial Group
JOY TRAYER
87 E YELLOWBREECHES RD
CARLISLE PA 17015
Dear HILDA BRETZMAN:
Annuity Operations
Po Bon 2915
Cincinnati, OH 45201 2918
toll free 500.926.1702
fan 513.629.1799
March 13, 2012
Thank you for your request for information on the annuity contract. I hope the
following contract information is helpful to you.
Annuitant: RALPH BRETZMAN
Owner. HILDA BRETZMAN
WestemSouthem Life Assurance Company Contract Number.
W0020696241
Date of Death Value (11-05-2011): $46034.83
The quoted value information is as of 3-13-2012.
If you have any questions, please call our Annuity Operations Department at
1-800-926-1702. A representative will be happy to help you.
Sincerely,
Jessica Heizer
Annuity Operations Department
ocos3~-os~o
Western-Southern Lice Assurance Company
Western &
Southern Life
A member of Western b Southern Financial Group
JOY TRAYER
87 E YELLOWBREECHES RD
CARLISLE, PA 17015
Dear Ms. Trayer.
Mnuity Operatlone
Po box 2918
Cincktnatl, OH 45201 2918
toll free ~.928.171Y2
fax 513.629.1799
March 13, 2012
Thank you for your request for information on the annuity contract. I hope the
following contract information is helpful to you.
Annuitant: HILDA BRETZMAN
Owner: HILDA BRETZMAN
Western-Southern Life Assurance Company Contract Number:
W0020194473
Date of Death Value (11-05-2011): $19,122.57
The quoted value information is as of 03-13-2012.
If you have any questions, please call our Annuity Operations Department at
1-800-92&1702. A representative will be happy to help you.
Sincerely,
..
Jessica Heizer
Annuity Operations Department
t~0331-080
Western-Southern life Assu-ance Company
Western &
Southern Life
A member of Western d~ Southern Flnancial Group
JOY TRAYER
87 E YELLOWBREECHES RD
CARLISLE, PA 17015
Dear Ms. Trayer.
Annuity ~perationa
Po Box 29,8
CincMnati, OH 45201-2918
cat rree X0.926.1702
fax 513.629.1799
March 13, 2012
Thank you for your naquest for information on the annuity contract. I hope the
following contract information is helpful to you.
Annuitant: HILDA BRETZMAN
Owner. HILDA BRETZMAN
Westem-Southern Life Assurance Company Contract Number.
W0020190689
Date of Death Value (11-05-2011): $7,129.86
The quoted value information is as of 03-13-2012.
If you have any questions, please call our Annuity Operations Department at
1-800-926-1702. A representative will be happy to help you.
Sincerely,
Jessica Heiner
Annuity Operations Department
cc~33~-oa~o
Westem-Southern Life Assurance Company
MEMBERS i*
SAYINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Prncpal and Acxrued Interest
Name of Joint Owner
Date Joint Ownership Established
CERTIFICATES OF DEPOSIT:
Acxxwnt Number/Sufibc
Date Aocount Established
Principal Balance at Date of Death
Accrued .Interest to Date of Death
Total Principal and Acxrued Interest
Name of Joint Owner
Date Joint Ownership Established
340386-00
10/1/2008
$6.97
$.00
$6.97
Joy D. Trayer
10/01/2008
340398.41
05/04/2010•
$40,936.97
$7.81
$40,944.78
Joy D. Trayer
05/04/2010
340398-42
05/04/2010"
$40,936.96
$7.81
$40,944.77
Joy D. Trayer
05/04/2010
'Rollover from certificate 340396-40, originally established 10/01/2008.
"Roibver from certificate 340396-40, originally established 10/01/2008.
CERTIFIC3 OF DEPOSR:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Aodved interest to Date of Death
Total Prndpal and Accrued Interest
Name of Joint Owner
Date Joint Ownership Established
340386-43
11/01/2010
$77,12o.so,
$12.59
$77,133.49
Joy D. Trayer
05/04/2010
EM ERS 1 ~ FEDE CRE9~N~ ION
Danielle A. Kline
Lending Insurance Support Specialist
January 20, 2012
Estab of: HILDA IIA. BRETZMAN
Dab ~ Dsath:11/05/2011
Soctal Security Number. 204-01-8874
5000 Louise Drive P.Q Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 • wwwmemberslsGOrg
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Sovereign Bank
ESTATE OF Hilda M. Bretzman
SOCIAL SECURITY #: 204-01-9974
DATE OF DEATH: November 5, 2011
Account #: 3381137395 Type: Checking Open date: 1/2/2004
In the name of: Hilda M Bretzman (Joy D Trayer POA)
Date of Death Balance: $35,079.81
Int.(YTD) from 1/1/2011 to 10/13/2011 $19.22
Accrued interest to date of death: $1.69
Other Info: Account closed on 12/15/2011 for $1,472.11.
Account #: 1695543551 Type: CD Open date: 7/7/2008
In the name of: Hilda M Bretzman (Joy D Trayer POA)
Date of Death Balance: $21,440.58
Int.(Y1'D) from 1/1/2011 to 10/31./2011 $299,67
Accrued interest to date of death: $6.95
Other Info: Account closed on 11/30/2011 for $21,470.39.
Account #: 1695545358 Type: CD Open date: 1/21/2009
In the name of: Hilda M Bretzman (Joy D Trayer POA)
Date of Death Balance: $10,000.00
Int.(YTD) from 1/1/2011 to 10/31/2011 $110.84
Accrued interest to date of death: $2,37
Other Info: Account closed on 12/01/2011 for $10,000.00.
Account #: 3385051846 Type: CD Open date: 4/8/2002
In the name of: Hilda M Bretzman or Ralph W Bretzman
Date of Death Balance: $10,000.00
Int.(YTD) from 1/1/2011 to 10/31/2011 $341.23
Accrued interest to date of death: $7,84
Other Imo: Account closed on 12/01/2011 for $10,000.00.
Account #: 3385029719 Type: CD Open date: 9/4/2001
In the name of: Hilda M Bretzman or Ralph W Bretzman
Date of Death Balance: Account closed pnor to death
Int.(YTD from to
Accrued interest to date of death:
Other Info: Account closed on 05!04!2010.
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REV-1500 Discount, Interest and Penalty Worksheet
Discount Calculation
Total Amount Paid within three calendar months of the decedents date of death: 33, 500.00
Discount 1, 7 3 0 • ? 5
Interest Table
Year Days Delinquent
this time period Balance Due
this year Inten3st
this period
Before 1981
1882
1983
1984
1985
1986
1987
1988 thro h 1991
1982
1893 thro h 1894
1896 thro h 1898
.1888
2000
2001
2002
2003
2004
2005
2006
2007
2008
2008
2010
TOTALS
Penalty Calculation
If the decedents date of death was on or before March 31, 1993, insert the applicable amount
Total Balance Due on January 17, 1996:
Penalty: