HomeMy WebLinkAbout04-0895PETITION FOR PROBATE and GRANT OF LETTERS
Estate of -~-~rel4~ 1140Crq iqend&cK.~ p~ No.
Deceased.
Social Security No. ~0] ~ ~ gO [ ~
Register of WAils for the
Connty of C(4,~la~)¢Vla~,~/
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/arc 18 years of age or older an the execut O 1F
in the last will of the above decedent, dated ._.~..~OJO~W 2..
and codicil(s) dated
in the
named
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in ~.~v~rll0~.v' I ~ m~ ~ Cgunty., P~_~sylvania, with
h last family or principal residence at _ qO~, ~[~_l~ ~_ ~
(list s~reet, number and muncipality) J ' ' -
~ dent then ~ 'carsof~ e died ~t~t ~ ~, ~00 ~,
E~ept as follows, decedent did not ~ry, was not divorced and did not have a~ild born or adopted
alier execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent: ;~ffffl~ fid&;'b:x ~, ~d~r~ g~
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ /O~) O O o
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters
(testamentary; administration c.t. a4 administration d.b.n.c,t.a.)
theron. :~"
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA }
COUNTY OF (_ ~x Prl ~5 ~ L Pclq ~ ss
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
truc and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
before me this 4_714 ~ day of
' ~x ~ Reg~ter ~
No.
Estate of t IKkq'4L~ IIqRR~/ t¥1ccq, db( C ~ , Deceased
DECREE OF PROBATE AND G~&N'T OF LETTERS
AND NOW (.) ~. T L~ 1'5 ~- 1'7', d
?( , in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DEC~ED that the instrument(s) date& 0~7~;~ ~ t 2OCli
described therein be admitted to probate and filed of record as the last will of
and Letters Et 5 F~T~Z~
~e hereby granted to ~51~O~- 8M~% KiN ~'[b*l
FEES
Probate, Letters, Etc ..........
Short Cerdficates() .........
Renunciation ................
E 1)/~¢. b
TOTAL
Filed ..........................
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
Irene M. Mendock z Female = 201-- 18 --8710 , At:just 7 200,I
Cumberland Upper A~len Twp 908 Shef5eld Ave ~ ~.~ ~s~,, Wtute
Romem&~e~ ~¢,~ R ,,~*~ Ma ed Martin F Mendock
908 Sheffield Avenue I~.c~
Mechanicsburg, Pennsylvania 1705~/~.,~
Upper Allen
Martin F Mendock .,m. 908 Sheffield Avenue Mechanicsburg Pa 17055
RENUNCIATION
In Re Estate of
deceased.
To the Register of Wills of e bK l'b~lO~"~-/_& ~A..~ County, Pennsylvania.
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
Fc,~'r f(OCk-IA°~t. Zt~I~ ~
(Signature)
(Address)
(Signature)
of
Irene Mendock
I, Irene Mendock, of the Township of Upper Allen, County of Cumberland and
Commonwealth of Pennsylvania. being of sound mind. memory and understanding, do herewith
publish and declare this to be my Last Will and Testament, hereby revoking and declaring null and
void any and all Wills and Codicils heretofore written b) me.
ITEM L I direct that all my just debts and funeral expenses be paid as soon after my demise as
may be convenient to the proper administration of my estate.
ITEM II. 1 give, devise and bequeath thc follo~xing items of personal property to the
individuals named:
a) To my daughter, Barbara Ann Kenned>', all my jewelry and the furniture and house
hold goods owned by' me.
b) To my son, Martin A. Mendock, all the tools and equipment in the basement.
ITEM IlL l give, devise and bequeath the American General stock owned by me to the
follo'Mng:
a) 250 shares to my daughter, Barbara Ann Kennedy;
b) 200 shares to my son, Martin A. Mendock;
c) 105 shares to my granddaughter, April Kennedy;
d) 105 shares to my grandson, Kyle Kenned>'.
ITEM IV. 1 direct that my savings account shall be divided equally' between my daughter,
Barbara Ann Kenned>' and my son, Martin A. Mendock, per stirpes.
ITEM V. I then order and direct m5 hereinafter-named Executors to convert my entire estate
into cash at either public or private sale. v,n¢ne ,e in their discretion it may' be most expedient for the
proper administration of my estate, in the event of such conversion, I authorize nry said Executors to
execute a good and sufficient Warranty Deed to the purchase of any real estate of which I ma5 die
seized, in the same manner and capacity as I could if living.
ITEM VI. 1 direct that all inheritance and estate taxes be paid on the proceeds of the above
conversion and on all the rest residue and remainder of nry estate from the residue of my estate prior to
Page 1 ot'2
further distribution·
ITEM VII. 1 nominate, constitute and appoint both of my children, Barbara Ann Kennedy
and Martin A. Mendock, or the survivor of them. as Executors of this my Last '&;ill and Testament. I
direct that my Executors shall not be required to post bond other than their personal assurance for their
duties as Executors.
IN WITNESS WHEREOF. I. Irene Mendock, have hereunto subscribed my hand to this
~-'-5~ , 2001.
my Last Will and Testament. this ,~. ,~.,, day of ,' , ~
Iref~e Mendock
SIGNED, PUBLISHED and DECLARED by the above-named Irene Mendock, as and for
her Last Will and Testament in thc presence of us, who at her request and in her presence and in the
presence of each other, have signed our names as attesting witnesses hereto.
Page 2 of 2
BUREAU OF TNDZVZDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
COHHONNEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOT[CE OF INHERITANCE TAX
APPRAISEMENT, ALLONANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
RE¥-1;47 EX AFP
CHARLES J ADAHS
7702 SYCAMORE AVE
ELKINS PARK
PA 190Z7
DATE 09-20-200q
ESTATE OF ADAHS
DATE OF DEATH 10-Z0-2005
FILE NUHBER Z1 05-0895
COUNTY CUHBERLAND
ACN 101
Aaoun~ ReaA'H:ad
GEORGE R
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF MILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA~7013C:~ ='
CUT ALONG THIS LINE I~' RETAIN LONER PORTION FOR YOUR RECO~:~* ~ ':::::i
DZSALLONANCE OF DEDUCTIONS AND ASSESSHENT ~F TAX -~ ':
ESTATE OF ADAHS GEORGE R FILE NO. 21 03-0895 ACM 101 -~DATE 09-20-200q
TAX RETURN NAS: (X} ACCEPTED AS F/LED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks end Bonds (Schedule B) (2}
:5. Closely Held S*ock/PertnarshAp Interest (Schedule C) ($)
q. Mortgages/Notas RecaAvable (Schadule D)
E. Cash/Bank Deposits/MAsc. Personal Property (Schadula E)
6. JoAntly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assorts
APPROVED DEDUCTZONS AND EXEHPTZONS:
9. Funeral Expanses/Ada. Costs/MAsc. Expenses (Schedula H) (9)
10. Dab~s/Mor~gaga LAabAIAtAas/Liens (Schedule 1) (10}
11. Total Deduc~/OhS
12. Nat Valua of Tax Ra~urn
) CHANGED
9~601
.18
O0
0O
.85
25
(8)
~9~758
lz$85
1~6z038
NOTE: To insure proper
credAt to your account,
subait the upper portAon
of ~hAs form ~Ath your
tax payaant.
196,783.62
19,108.76
1~993.98
(11)
(12)
21.102.7~
175,680.88
13.
NOTE:
ASSESSHENT OF TAX:
15. Amount of Line lq et Spousal rate
16. Amount of LAne lq taxable et LJ, neal/Cless A rata
17. Amount of LAne lq at SAblAng ra~a
18. Aaoun~ of LAne lq taxable a~ Colla~arel/Class B rate
19. PrAncA ~el Tax Due
TAX CREDZTS
PAYMENT RECETpT DISCOUNT (+)
DATE NUMBER ZNTEREST/PEN PAZD (-)
07-19-200q CDOOql8q .00
Char/tebla/Governaen~al Bequests; Non-elec~ed 9113 Trusts (Schedule J)
Nat Va[ua of Ese:ate Subjac~ to Tax
X~ an assessment Nas issued previous[y, Zines 14, 15 and/or
(13) . O0
(lq) 175,680.88
16, 17, 18 and 19 will
reflect flgures that include the total of ALL returns assessed to date.
(15} .00 X O0 = .00
([6) 175,680.88 X Off5= 7,905.6fi
(17) . O0 x 1Z = .00
(18) .00 x 15 = .00
(19)= 7,905.6q
AMOUNT PAID
7,905.6q
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
TOTAL TAX CRED/T I 7,905.6q
BALANCE OF TAX DUEl .00
INTEREST AND PEN. . O0
TOTAL DUE . O0
( ZF TOTAL DUE TS LESS THAN $1, NO PAYMENT TS REQUIRED.
ZF TOTAL DUE TS REFLECTED AS A "CREDIT' (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
RESERVATION:
PURPOSE DF
NOT[CE:
PAYHENT:
REFUND (CR):
OBJECTIONS:
ADH[N-
[STRATZVE
CORRECT[OHS=
DISCOUNT:
PENALTY:
[NTEREST:
Estates of decedents dying on or before December 12, 198Z -- if any futura interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of tho decedent after tho expiration of any estate for
1ifa or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section 21~0 of the Inheritance and Estate Tax Act, Act Z3 of 2000. (7Z P.S.
Section 91~0).
Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on the reverse side.
--Hake check or money order payable to: REGISTER OF NILES, AGENT
A refund of a tax credit, which ams not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-iS13). Applications ara available at the Office
of the Register of Hills, any of the 23 Revenue District Offices, or by calling the special Z~-hour
answering service for forms ordering: 1-800-36Z-Z050; services for taxpayers with special hearing and / or
speaking needs: 1-800-~7-30Z0 (TT only).
Any party in interest not satisfied aith the appraisement, allowance, or disalloaanca of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in ariting to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Reviae Unit, Dept. 280601, Harrisburg, PA 171Z8-0601
Phone (717) 787-6505. Sam page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1501) for an explanation of administratively correctable errors.
If any tax due is paid within three (3) calendar months after the dacadant's death, a five percent (SI) discount of
the tax paid is allowed.
The lSZ tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in tho same manner and in the the same time period as you mould appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning aith first day of delinquency~ or nine (9) months and one (l) day from the date of
death, to the date of payment. Taxes ahich became delinquent before January 1, 198Z bear interest at the rate of
six (6Z) percent per annum calculated at a daily rate of .00016~. All taxes ahich became delinquent on and after
January 1, 198Z ail1 bear interest at a rate ehich ai11 vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The appZicabla interest rates for 198Z through ZO0~ ara:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1'~ 20Z .0005~8 ~'~-1991 llZ .000301 ~ 9Z .O00Z~7
1983 Z6Z .000~38 199Z 9Z .0002~7 200Z 6X .00016~
198~ llZ .000301 1993-199~ 7Z .O0019Z ZOO3 5Z .0001~7
1985 13Z .000356 1995-1998 9Z .O00Z~7 ZO0~ ~Z .0D0110
1986 lO[ .O00Z7~ 1999 72 .000192
1987 IOZ .O00Z7~ ZOO0 7Z .00019Z
--Interest is calculated
INTEREST = BALANCE OF
as follows:
TAX UNPAID X NUHBER OF DAYS DELZNI~UENT X DALLY INTEREST FACTOR
--Any Notice issued after tho tax becomes delinquent alii reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. [f payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BU"EAU OF INDIVIDUAL TAXES
DEI~T. 280601
HARRISBURG. PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
KENNEDY BARBARA ANN
284 DOGWOOD DRIVE
HUMMElSTOWN, PA 17036
___nn_ lol.j
ESTATE INFORMATION: SSN: 201-18-8710
FILE NUMBER: 2104-0895
DECEDENT NAME: MEN DOCK IRENE MARY
DATE OF PAYMENT: 04/15/2005
POSTMARK DATE: 04/15/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 08/07/2004
NO. CD 005212
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,694.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$2,694.00
REMARKS:
CHECK# 111
~;EAL
INITIALS: CCP
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
REV.l~;oo EX (1)00)
].35 i{~
N ~?V
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'* COMMONWEALTH Of
PENNSYLVANIA
DEPARTMENT Of REVENUE
DEPT. 280601
HARRISBURG, PA 17128.{)6D1
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FILE NUMBER
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COONTYCODE YEAR
~~"lS_
NUMBER
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DECEDENT'S NAME (lAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURIIY NUMBER
~Oc.1L IVeVlel11' "nn-----F' 201---=-'-~- :r,~___
DAlE OF DEA1H (MM-DD-YEAR) DAlE Of BIRTH (MM-DD-YEAR) THIS RETURN MUS< BE FILED IN DUPUCATE WITH '!HE
't h / ol(- I lOt- 7 REGISTER OF WILLS
-(iF~) SURVIVING SPOUSE'S NAME (LAST, FIRST, A D MID E INITIAL) I' SOCIAL SECURIIY NUMBER --~--
yt{ e V\l;LO(x f<< CtVh 1'\ r- 0 'ir3 - 22- 73'--15
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[gl1.()riginalR~Um 02.SupplementalRelum o 3. Remainder Retum (dale ofde8lh Ilria" 10 12-13-82)
o 4. Umited Estate 0 4a. Future tnterestCompromise (dalltofdetalhafler12-12-82) 0 5. Federal Estate Tax Retum Required
o 6. Decedent Died Testate (AIlad1 oopy of Wil) 0 7. Decedent Maintained a living Trust (.AlIar.tl oopy of Trust) 8. Total Number of Safe Deposit Boxes
o 9. Utigation Proceeds Received 0 10. Spousal Poverty Credit (dale ofdealh blIlWeen 12-31-91 and 1-1-95) 0 11. Election to lax under Sec. 9113(A) (A1ladl Sd1 0)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDEIICE AND CONFlDEtllIAL TAX INFORIIATION SHOULD BE DIRECTED TO:
NAME 50. k' J COMPLffi MAILING ADDRESS '""
FIRMNAMEI'~~ 4 .e '^ I't e~~_ '2- ~L/ P6T-,Jooa j) V1-e
____~ \J-UV\AWl6( :;+c..H.0 '" I A
_ 0 I ~o 170 3 ~
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule 0)
(1)
(2)
(3)
(4)
{5}
o
"52.,20
10
o
1 g 20 I
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5. Cash, Bank Deposits & MisceUaneous Personal Property
(Schedule E)
6. Joindy Owned Property (Sd1edu~ FI
D Separate Billing Requested
7. lnter-VIVOS Transfers & Miscellaneous Non-Probate Property
(Sd1edu~ G 01 L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administralive Costs (Schedule H)
10. Debts of Decedent. Mortgage liabiUties, & Uens (Schedule I)
11. Total Deductions (total Unes 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmenlal Bequests/See 9113 Trusts for which an election to lax has not been
made {Schedu~ J}
(11)
(12)
(13)
10 44/
~~} ~tL/
"
5"1,\?',y
(6)
o
(7)
,',,,'
(8)
-76 1 3 1.(
(9)
'114<)
702..
(10)
14. Net Value Subject 10 Tax (Line 12 minus line 13)
(14)
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SEE INS1RUC1IONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Une 14 taxable at the spousal tax
rate, Of transfers under Sec. 9116 (a)(1.2)
___ x.O ___ (15)
x .0 'l_5' (16)
Z(,"tt./
59 'i,4
_not
16. Amount of Une 14 taxable at ~neal rate
17. P.mo\.Int of Line 14 taxable at sibling rate
x .12 (17)
18. Amount of Une 14 taxable at callateral rata
x .15 (18)
19. Tax Due
(19)
Z (" 1<{
200
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address:
STREETAODRESS Q01f_ S'het iP(J A~_~
CITY
ZIP 170c
L
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CrednS/Payments
A. Spousal Poverty Cnedn
B. Prior Payments
C. Discount
(1)
2,0>'14
TolaICredits(A+B+C) (2)
o
3
InterestJPenalty if applicable
D.lnterest
E. Penalty
(3)
(4)
(5)
(SA)
o
4.
- --- ~ TotallnterestlPenalty ( D + E)
If Line 2 is greater than Line 1 + Line 3. enter the difference. Th~ is the OVERPAYMENT.
Check box on Page 1 Une 20 to request a refund
5.
If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE.
20'1Y
A. Enter the interest on the tax due.
o
B. Enter the tolal of Line 5 + SA. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
2Gcr~
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. relain the use or inDOme of the property transfenred;.......................................................................................... 0 I)!I'
b. relain the right to designate who shall use the property transferred or its income; ............................................ 0 ~
c. retain a reversionary interest; or.............,............................................................................................................ 0 ~
d. receive the promise for life of enher payments. benefits or care? ...................................................................... 0 C8l
2. If death occurned after December 12. 1982. did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 lEI
3. Did decedent own an "in trusf fo( or payable upon death bank a<:GOunt or security at his or her death? .............. 0 I)S'l
4. Did decedent own an IndIvidual Ret.ement Account, annuity. or alher non-probale property which
conlains a beneficiary designation? ...... ................. ........ . .. .... .. ....... ........ .... ..... .. ...... .... ..... . ~ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Underpena/liesof~, I declare.thatlhlMexaminedlMretum, indI.dng~scheduleS and~ and to lhebesl:of mykncMtedge and belief. it is lrue. correct and compIei:l.
DedarationofprepnrotheflhanlhB personal representadve is baSed on alllntlrmation ofwhich preparer has any knowledge.
SIGNATUR OF PERSON RESPONSIBLE FOR FILING RETURN
.~
DATE
nL/= l?:,-Q S=
---- ----
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADDRESS
For dates of death on or after July 1. 1994 and before January 1. 1995. the lax rale imposed on the nelvalue of translers 10 or for the use of the surviving spouse is 3%
[72 P.S. 99116 (a) (1.1) (i)l
For dales of death on or after January '. 1995. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse ~ 0% [72 P.S. 99116 (a) (1.1) (ii)).
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneliciary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. 99116(a)(1.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineai beneficiaries is 4.5%. except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(0)(1 )).
The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is 12% [72 P.S. 99116(a)(1.3)). A sibling is defined. under Section 9102. as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1SQ'2 EX'" [6-98)
.
COMMONWEALTH OF PENNSYLVANIA
lNHERlTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
Z/~O<(-Ok15~
ESTATE OF
rVei1L
FILE NUMBER
M.
MeVl..Joe)L
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller. neither being compelled \0 buy or sell, both having reasonable Knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F,
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
'1{j..-....J.--
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
o
REV-1S03 EX+ (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE B
STOCKS & BONDS
2-/-1)(1- OfCf5-
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
76 L{ shave s
VALUE AT DATE
OF DEATH
DESCRIPTION
AWlenca" rh.f-efAAftOrta.( &OUpt!N:
52) 120
TOTAL (Also enter on line 2, Recapitulation) $ 5 2- I \ 2. 0
(If more space is needed, lnsert additional sheets of the same size)
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-"
Matt Lowry
EdwardJones
Man::h Hi, 2005
Historical Quote
Symbol
De,eription/T ype
Date
Value
Ale:
AMERICAN INTL GROUP INC COM
Adjusted Closing Price
08/06/2004
568.2200
Page'
This information is for lax and eslale purposes only and while believed accurale, is 001 guaranleed. Ther. is no warranty
ttlat any trades were or WOUld nave been executed at tnese prices on tne elates given.
1\J 39\1d
W1S3ANI S3NOr Q~\1MQ3
8LrEE~L8881
5r:r0 ~00G/9T/E0
"
REV-150B EX+ (6-98)
'.
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
l / - 0 V - 0 3' "1 .,-
FILE NUMBER
ESTATE OF
TVtVle.
j{;{
tv( e V\ dorJ(
Include the proceeds of Iltigation and the date the proceeds were received by the estate.
All property Jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
M q.!
&Vl~ Chn([\Vlj
Au,o(..lVlr /j.~5'-J<-jot..f30
~)L'2-&.OO
L JeWC-IVj 1- Fun/I; tLL~e ( fo .spoLLse)
3 IDols "l- ~(pvYle VI.. t I", bet Se. V1II.e!ll +
( fo Sf 0 uSe )
if AUf'(s+- SdVI VljS ACUJU V\ r tt-z loo<Z>6 Il"i~ '\ D I
()
o
I !.v I qi5
TOTAL (Also enter on line 5, Recapitulation) S
(If more space is needed, Insert additional sheets of the same sIZe)
(%\201
~ M&I'Bank
E ACCOUNT NO.
35440430
ACCOUNT TYPE
STATEMENT PERIOO PAGE
AUG.12-SEP.IO}2004 1 OF 1
RELATIONSHIP CHECKING WITH INTEREST
00
o 06117M NM 017
/"
1772
IRENE M MENDOCK
908 SHEFFIELD AVE
MECHANICSBURG PA 17055-5745
INTEREST PAID yEAR TO DAlE
u.92
nEC:HANICSBUHG
BEGINNING ... .. PEPOSUSl ... ..... ..... OTHER ... CURRENT . ..ENPING ...
BALANCE .... OTHER.ADPUlONS .... CHECKS "PAlO SUBtRACTlONs. lNTEREST.PO . BALANCE
NO. I AMOUNT NO.1 AMOUNT NO. I AMOUNT
1,226.54 01 0.00 01 0.00 o 1 0.00 0.10 IJ226.64
ACCOUNT SUMMARY
POSTING ....... ........... PEPOSITS, INTEREST CHECKS l.OTHER PAILY
pATE ..... ..... . 'TRANSACTION PESClllPTlON / l OTHER APPITIONS SUBTRACTIONS ... BALANCE ...
08-12-04 BEGINNING 8ALANCE $1,226.54
09-10-04 INTEREST PAYMENT 0.10 1.1226.64
ENPING BALANCE $1...226.64
ACCOUNT ACTIVITY
ANNUAL PERCENTAGE YIELP EARNEP = 0.09 %
DOO
?\
y d--~ .
\\ ---\
LOO8A(1J03)
~--'1
IN ACCT. Tr-e.rLt. Jl\. 'N\ f)~ --l ",r. 01
WJTH I 1 '\:.I VU~
'6,t194'+1.8 lO'i'<3-11 d-1fYir(l/1Qt..<M
DATE AMOUNT/CODE BALANCE TELLER NO.
04MAYOO ****$265.00 D ***$8340.64 272 024161
19
20
121
,
I' 22
23
124
2
3
01JUNOO
07 JULCl(l
07AUGOO
*****$50.44
****$200.00
I ***$8391.08
D *....$8591.08
NO.
GOO 000000
272 022428
272 007509
272 022-:1.28
163 ,.'
16:3 '.~;.i ;5::':;',;:;
NU\"';Y' ;\-7j-**$:Cl.OC.OO ..... ***$4513..28 102 ~)1Lc ,-'"It.:;
****$622'8~***$9213'88
****$5(:'{) ~ iX, D ***$t:;'~? i 3.88
.:4 ......:...d:/.,-'r' ;';f\ P "'<l:-;r>~~""" C-\:'
~*ft~~~VVa'~V U **.~vl~~.~U
***$6000..0u -i,", ~k-iHt$4113.88
PLEASE INFORM US OF ANY
CHANGE OF ADDRESS
iD: ~i ;c,t,S",. {.[' r Yo.! t t.;: ~;~,,~.:" 50
***$2500.00
*****$45.00
D *""$7068.50
D ***$7113.50
4
5
6
:~SSE.F"OC;
+.:.;-*:+'i-,.:C;,-::;',
';;d'c?l- ~,'7~, 1:;3 ':::-:.
000 000000
272 022428
000 000000
_'::L-;::~E.2<,":::"'c;
272 022285
~ ' ~
i..-~..j
21'!..;-.LS"6
7
8
04DCTCC
,'-."
"*'*$545'00[i***$8058'50
~.' '. <.I.:'::{',i", .,"-,.:'" 7' ,.. ,,,," _ ;:;:<;.~;.:;.' :::::r"
'~***-+"-..I''''-'~'''"'''.'- ,~**..$:-_,,-,-.i'-..}_<"""./
~~ct-1ii.*'~.,*!~,<:' \::C, :: :If'*'~*,37~'8. 5;)
""'**7.,*:f:f:-. b::'L ~~'*~.;-i,8~-~,:;L" '12;
"~..-ft' c~--1-,-::':- :'''' (,
~, **1i':!~:,<:J",,-
,
-'-"'....
.,' '..-."""
'_,'':'''-+0i.:!
9
10
11
. -.'....- '-'<";:'l;..i~_
*->.t":*$~7:>'"
',-',-'"
.-:):)UC(~
12
13
14
OlOfCnO
04JAN01
08JANOl
J..''::
15
16
17
18
L 02N{\;~~:) 1
Allfirst Bank
NO",:JCE- This book should be presented at this bank, at least once in eac;h year so that it may be posted,
the ,Interest entered and the balance shown. In makmg withdrawals, always present your passbook-we
declme to pay unless you do.
CODES: D - Deposit W - Withdrawal J -Interest
\.-
;-.( :~i;:: ::.;,~) 1
"--;~,_--'.'!(..:_Vi-;
'.' --.. "--
,,, ,c. v;";:-\'..-')
"=;'--:":'~:'-
:"'-=:"1"', '
-' '~,,-~, .,,-~,~-
IN ACCT.
WITH
\'\.~\f'€~~
NO.
DATE.
AMOUNT/CODE
TELLER NO
2 C('Z>d qcQ8'l 1L-(156^.7~ cJ-{q~
3 I - 3 3<:>o.caD (S o.s::,-:7 6 0'-{9'fS
14 t--'\("tV\-M.\<}t;C,'lvJl\)Qn-\\\1i\ 1')052.1<6 5~'-lUl-/
! :J.-5-bL/ 3bO~ J535.;).7~ 5S7I..P
73-4'Ot.f vYJ. ~ J55Sl.1g 5gl/~lf
8 ~,?,\.O'-\ ct.o \ 55LD \ . 'ilS 'S?,41O'1
,: L\-1.\'(j...\ '5lJ2',oO L0 \lo,(L~.'i,') 5~L\1O,\
1 1 I.r It-D't
12
()t...i DO t,
\5 .!55. \'>,,5 4'1<390
F PL_EAS,E INYOR~ U? OF AN,!
CHANGE OF ADDRESS
Il..Pf~15.,,1
./'
poO
13
14
15
16
17
19
4J
18
20
21
22
23
24
Allfirst Bank
~~T"mi~~;\~;h~~t~,~~~ ~~~ull~:ebfl~e~~;t:go~n~hil~ b~~~i~~ 1~~t~d~~~~I~n :~~y~e~~e~~~~ayto~rmpals:~og~s'ewd,
=- e o pay un ess you do ' -
CODES: D - Deposit W - Withdrawal I - Interest
I
'---~~..._-
04/15/2005 09:51
71 75554004
ALLFIRST HUMMELSTOWN
PAGE 02
STFT 1 THF TRANSACTION STMT FORMAT 05{04{15 10.22.49
STMT CO 96 OP EBRN MS 50852 ACTION COMPLETE
ACTI9N COlD
PROD CODE RSV ACCT 21000001196907 SHORT NAME MENDOCK IREG
CURR CODE PAGE 3 SEARCH FROM 103{08{04 THRU 104/11/01
ACTN POST EFFECTIVE CHECK NUMBER TRAN AMOUNT D/C BALANCE
TRACE ID DESCRIPTION
11/01 2.98 C 16,975.47
I-GEN104110100000001 INTEREST PAYMENT GENERATED
11{01 306611497 16,975.47 D .00
MOWBKP99 PAYOFf ACCOUNT 1 PAY ACCRUED INTEREST
~AN/)TRADERS TRUSTCOfolIWft'
~ BeASTMAINSTREET
........ fUMoIF' RTOWN, PA l1D.'111
PF: 1.HELP 3-PLVL 6-INQ 7-SB a-SF 9-ASUM 11-CUTO -STSM
-
RECEIVED TIME APR,15. 10:40AM
PRINT TIME APR. 15. 10:41AM
71 755541211214
ALLFIRST HUMMELSTOWN
.,1 .
t)MbViY<1 . ~~
'fYu~
L ) L '1 N~ KIA )1'1 B H-
rY) zt T g~IK
r~~}t 5-b~~ LfOO3;
RECEIVED TIME APR. 15, IO:40AM
PRINT TIME APR,15, 10:41AM
PAGE 1211
REV-1510 EX+ (6-98)
..
COMMONI/VEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISe. NON-PROBATE PROPERTY
2-/ -0 '1-0 lr
rVe "It' VLt
jIL{..e- IA cL 0 d L
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER
1.
L.
DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AN 0
'i'r!E DATE OF 'iRANSFER. ATTACH A COPY OF THE DEEO FOR REAL ESTATE.
DATE OF DEATH % OF DECO'S EXCLUSION
VALUE OF ASSET INTEREST (IF APPLICABLE)
TAXABLE
VALUE
T (Me(ev> L j' Fe ..LI1SUVZH1 c..e 1000
+Vt/.h~ey;e.J tv /t{{LVJUl r. 1-4e vu:'-odC.
_ 'Sf 0 uS L -'bel1e fraV<1
~ /1-0 11-00'-1 J
fl\lc- IV\VfSt-W1e Vl+ S rrvl- -'1..
1'2,'- 'd "132S:~
A \ M fD s G YI'J uc.<-\LLV1~e
C + II I.' ~ v0t€.kdex)<:..
+(CLh":> 1Je.ryed 0 V"lt(r,1 lit ,...
'6/2-4/ 0 ~ Sfuu s.e. - &neftclavj
100
1000
- 0
100
51 :>2-$:'3
- 0
~
TOTAL (Also enter on line 7 Recapitulation) $
()
(If more space is needed, insert additional sheets of the same size)
TravelersLife&Annuity 'J""
Amemberof CltJqroup
00008 04264
~ife and Health Serv;ce Center
PO Box 990020
Hartford CT 06199-0020
1-800-334-4298
I NSVR)\NcE:
00008
Fa829Y9D
MARTIN MENDOCK
908 SHEFFIELD AVE
MECHANICSBURG PA 17055
DATE:
POLICY NUMBER:
CHECK NUMBER:
AMOUNT:
INSURED:
09/20/2004
2717545
119-890 L 40453965
$1000.00
IRENE M MENDOCK
Attached is our check representing the insurance amounts payable
under this claim.
Amount of Insurance
Loan Payoff
Premium Adjustment
Interest Paid
Federal Tax Withholding
State Tax Withholding
$
$
$
$
$
$
1000.00
0.00
0.00
0.00
0.00
0.00
00.00)
Beneficiary's Share of Proceeds
$
If you have any questions please contact your Travelers Life & Annuity
representative, or call our Life and Health Service Center toll free
at 1-800-334-4298, Monday through Friday from 8:00 a.m. to 6:00 p.m.
Eastern Time.
CY0400
o PNC1NVESTMENTS
Member NASD and SIPC
TRADE
CONFIRMATION
dE-i;JA#~ 1
SETTLEMENT DATE: 08/27/04
FINANCIAL CONSULTANT: J202
SCOTT CARTER
PNCINVESTMENTS
TWO PNC PLAZA
620 LIBERTY AVENUE
PITTSBURGH PA 15222
(717) 534-3402
5O:ill1fOO1.951OZ111-4115
HILLIARD LYONS CUST FOR
IRENE M MENDOCK IRA
908 SHEFFIELD AVE
MECHANICSBURG PA 17055-5745
Ilulllll.IIIIII,I.I..I.IIII.I.I.ul.IIII.I.lllulll
PNC Investments is pleased to confirm the following sale transaction.
Thank you for the trust and confidence you have placed in us.
TRADE DATE SECURITY DESCRIPTION SYMBOL SOLD PRICE PRINCIPAL
08/24/04 AIM FDS GRP BALANCED AMBLX 226.1290 23.5500 $5,325.34
FD CL A SHS
I TRANSACTION AMOUNT $5,325.34
ACCOUNT NUMBER: 61225487
ACCOUNT TYPE: CASH ACCOUNT
CUSIP / SECURITY NUMBER: 008879744
Capacity:
AS AGENT FOR YOU ON THE OVER-THE-COUNTER MARKET.
WE WILL FURNISH THE NAME OF THE OTHER PARTY AND THE TIME OF EXECUTION ON REQUEST.
Special remarks for this transaction:
UNSOLICITED
;;;
i
;;
ProcessmgDaw: ~~4
fiNe Investments may recClTl'l'lel'ld securities WhIch are l,I'lder.Mitten or sold by PNe II"I\IeS1rnenIS or its affilal8$ or may recorrmend mutual fu\ds whitt! lire ............-1 nr
...............A.~"...' D~lr ,~_.............. A~"" ~H;"A"'''
TR4N5AtvlERICA TRADITIOf'.:5
Ht'xlbi~' !'r::l1llul1l Vanai)l<: .\:111iJl:\
TRA~SAMERICA LIFE
INSURANCE COMPAI\'Y
Mcmlx:r nr [he ~EGON. (,roup
CONFIRlvtATION
09/02/2004
MAR TIN MENDOCK
908 SHEFFIELD AVE
MECHANICSBURG PA 17055
CARTER SCOTT W
PNC
09/02/2004 PREMIUM PAYMENT
ASSET ALLOC MOD G (
5,300.52 )
.^'
1. 216723
4356.3901
"
--- t
MGRAA
37429.8022
1.21 723
----..--
Fixed Account Options
Accumulation Value
Total Accumulation Value
$
45,541.70
NOTE: Please review this confirmation carefully and report any discrepancies to us immediately. Transamerica Life Insurance Company will
not be responsible for any errors or omissions which you fail to report to us within 30 days from the date of this confirmation.
JC8408
If the Transaction Date reHects a non-business day, the Value of Uniu'Unit Value reflected is as ohhe close of the next business day
'>'>I''1Q ~J.....,
o Life Investors Insurance Compan)' of America
o Monumental Life Insurance: Company
o Peoples Benefit Life Insurance Company
o Transamerica Financial Life Insurance Company
q,. Transamerica Life Insurance and Annuity Company
[!J Trans.america Life Insurance Company
o Transamerica Occidental Life insurance Company
o Western Reserve Life Assurance Company of OhIO
VARIABLE ANNuITY
SYSTEMATIC PAYOUT OPTION FORM
(
j
'-
(
Financial Markets Group
P.O. Box 3183, Cedar Rapids, IA 52406-3183
4333 Edgewood Rd. NE, Ceaar R.pids, IA 52499
"'
1. POLICY INFORMATION
Service Office:
Overnight Mailing Address:
3. PAYOUT FREQUENCY
(
l
If Joint Owner, only one Owner may receive Systematic Payout
Oprion (SPO). One SPO per conlr.a.
j~J1~TLAI E._/l4t~poc.K
Policy Owner
_[,,-OO,OT-1/ .._
Policy Number
Systematic payouudistrib~~n:
o Inil!:uc or )i\ Change existing instructions
2 . OISTRIBUTION OPTIONS
o Free amount available
o Annualized specified amount of S or % I
(If the amount of pcrcemagcgivenequals the policy "'free amount""
the Insurance Company will ddault to scrring up' yo-,J!"poljcy for I
,.,your annual free amount.)'", I
*ltlll-l1MUM REQUIRED DlSTRIBlITION omONS./)
...."..... . .-J'-- I
Qu.I,fiedoPI.ns___"....... .....,. ...... . I
I. Year for which distribution is being t3k~O{)~ ~ ,
2. Value 01 IRA as of prey;ous year end S g t~1 s-:- ?jl
Relationship of Benefici.ry to Owner ~t17 ~ :
Beneficiary Date of Birth I-fa -I ,). I
"Unless odlerwisc indicated in special InslJUcrions area,
distribution(,) will be applied proportionate to current allocations." I
Complete lor 403(b) Plans...Prior 10 age 75, you can choose either 01 I
the folJowing policy value optioru upon which to calculate your I
paymcnt amount. Once you have anained agc 75, your payment must I
be based upon your "Full Policy Value.'
o Full Policy Value 0 Post 12/31/86 Value Only I
No 40J(b) distribution, permitted if under age 59~. .
I
I
I
c
Date Owner is ro receiye firstp~ymen<. '7 - /,? - ,;l.oo;L..) c
(fhc carlicsr a payrocnt may begin IS 30 days !tom the policydate.) .... ~
I-
,
I
I
I Direct deposit or check options:
: D..Scm!oAnnual
rXAnn.:;j-""j .
li~lfS~~irect deposit., Y/?u must complet:, direct 'deJX!sit
authorizarion below.)
Dir~ct deposit options:
o Monthly $50.00 Minimum. IP.id by direct deposit only.)
o Qu.rtcrly $50.00 Minimum. (Paid by direct deposit only.)
,~
~
('
(:
1:
"
',.:
4. OIRECT OEPOSIT AUTHORIZATION
v
.'.
You must anach a voided check or an encoded savings withdrawal .~
slip or the direct deposit cannor be ser up. c::
o Checking 0 Sayings
co
--c..c
Financiallnscitution
1::
0..
Telephone Number
Address
City
Srale
Zip
A.BAffransitlRouring Number
Account Number
5 .INtOME"TAX'WITHHOLDfNli-'" ..... -. -. .. ___0 -'.. _.._- ..---
BE CERTAIN TO READ INfOIUMTION CONCERNL.~G Ff.OERAlI\ND STATE
INCOME TAX WITHHOLDING ON RlVER.SE SIDE Of FORM. U nOl checked
nothi.ng, will be withheld.
o Yes, I want to have Federal Income Tax withheld from my policy
distriburion.
6. SPECIAL INSTRUCTIONS
See Reverse Side for Important Infonnation.
15
8UJ 1114 10103
7. REQUIRED SIGNATURES
By signing this fann I acknowledge I hal'c read the information on
the reverse side of the form, and that I understand any distribution
requested will be subject to applicable policy penalties. Under
penalty of perjury, I certify that the number shown on this form is my
cor:rcct Taxpayer ID Number. 1 :1m not subject to b3Ck~up
withholding, and I am a U.S. pmoo (including a U.S. resident alien).
In addition, l{}~.Fcdt.ral Tn penalty may be imposed on
withdrawals front th~ anDuity if the contract Owner is under age
59'11. Please consult your t:lX advisor {or details on these mattClS.
Unless we have been notified of a community or marital propcr1Y
intert$! in this policy. we will rely on our good faith belief that no
such interest exists and will assume no responsibility for inquiry. The
policy ownct agrees to indmmify aDd hold the Insurance Company
hannless. from the consequences of accepting this transaction.
~~~~ 8-~V-J.Di-
Signature of OWl1crffrustcc Date
Of3-d-.J..- 23tS-
Social Security Number I Tax Idenrification Number
A,...,) ,.
_r...2!JL ~.! Y
Phone Number
~,fo 7' (,
b s'l.k
Signature of Joint Owner
Date
Socia] Security Number I T41X ldentificarion Number
Phone Nummc
10-/5-/ f"02cf'
Ownec~s Date 01 Birth
Joint Owner', Date 01 Birth
Full Policy Value
Full POb')' V31uc is me 5:lme as your Annuity Purchase Value, which at any rime
is your total prc:miwn plus accrued imcrest.1ess previous disbursements.
Notice Concerning Federal and. State Income Tax Widiliolding
You ha.ve tl\e option of h~ving Fedcml Inrome T:u: withheld on
disttiburions from }"Our policy. AJternarivdy. you may deer to not luve
Feder:U Income Tax withheld. If )"OU elect not to have withh.otd.in~. this
election moy be: revoked by you :II :my time in me future. otherwise the
dec:rioD rem:1.ins in effect umil revoked by you.
If you cicCi not to withhold your policy dislrihurion(s)J or i{ you do not
have: enough Feder.:d Inc:ome TIlX withheld from your poticy distribution,
you may he responsible (or payment of estimated taX. You may incur
penalties under the estimated t:DC rules if your withholding:md l:stim;lted
fa'( p.3yments ace not sufficient. .
For a qualified mmuity, w"hholmng will :l.pply to the full amoUl'lt
distributed. For a non-quaJjfjcd annuit),. however, withholding will apply
only to the :unount of gain included in the discribution; tnerdOfe, tn
liotbiliry may be l'aJculated on an amount other thaii me full;unoulu
remo\'Cd from a non-qualifj~d tulnuity. Federal Income Tax wiU be
withheld al a rate at 10% of the taxable amount, unless you specify
otherwise. If you wish to ha.ve: a larger amount withheld, note the
percentage in writing on the front side of this fonn.
rE you, the: annuiry owner, ace a resident of a slate [hat requires mancbtory
withholding, you are electing to also withhold for state income taxes
when you dect to have Federal Income Taxes withheld,
In order Co correctly report the distribution to the IRS, the
Insuranc:e Company needs the owner's social security number and
date: of birth for all distributions. Be sure to complece Ihe social
security number and date of birth section on the frOnt of chis form. The
Insurance Company will nor be ahle to process your requesl until this
in{onnation is received.
Distributions from a deferred annuity may be subject to a tax
penalty, imposed by the Fedet31 Government, equal to 10% o{ the
'taxable a'mount "distributed. This ('3X penalty is not appHClble if the
individu'" receiving th~ moncy iS:lt least 59~ yean oJd. Thece is no (:IX
penalty jf your en.titc annuity CORmlct is o:changcd (or .mother annwty
contr.1cr or i{ you convert your emire policy into a life option guaranteed
payment annuity. For ta.."C purposes, dismbutions from non-qu:1lified
deferred annuities will bc first 3 di:lo1riburion of accrued interest earnings.
We recommend you seck the advice of a competent tax consuhant
concerning any <lppJic:ilblc tax penalties prior to taking a
distribution from your annui.ty.
Income Tax Withholding
Definition of Federal Backup Withholding:
The Insur:mce Company m.:LY pay tt\e policyholder (owner) interest,
dividends or certain other payments. The ponion of a p.3yment received
from the Insurance Comp:my that is subject to federal income tax truly ~
be subject to a 28% Backup Withholding tnX.
To Avoid B:lC1rup Withboldin1l' I) Ci,'O your com:ct T .:<poyer
Identincation Number (llN). 2) Certify your TIN when required. 3)
Repon all t3X3.blc interest and dio.idends on aut returns..
Vou Wdl be Subject to Backup Withholding iI: J) Vou do not provide your
TIN to the tnsurance Comp:my. 2) The IRS notifies the: lnsur:mce
Company that you furnished an incorr~c:t TIN. J) You :Ire notified by the:
IRS that you are subject to backup witbholding/due to nol reporting all
inleTt!St or dividends on your tax return (for interest and dilliJmd
accounts ollly)}. 4) You do not cenify to the Insumnc:c: Company th:ll you
are not subject to backup withholding under #3 in this pllt:!gr.tph. ({or
inteTest and dividend a<,ounts opened afteT 1983 only). S) Thiny-day
grac:e periods apply to both sun-up and stopping though a shaner grace
period can be elected. This applies to grace periods as they are: used in #2,
13 and #4 above.
1/\
REV.1511 EX+ (12-99)
..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
:Iy-eV\e vtt NevtcLocJe.-
FILE NUMBER
'2-/ - 0 '1-0 8- ? s-
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A
DESCRIPTION
FUNERAL EXPENSES:
lvlue.v'S fUliH'.xcd !fame - Co SKe.-t I VlelUll1~ I BtLVta.(
J().'ta .;.-JAVt4-- ~es+(wx~ - rt.lVIe.VOJ Lu./ltc.v..e..oV\
Flov.!e.vs fOY FUVlucd
MVe.VtIS\\V<..7 o{ GVCLViro F LeH~vs
Apprcu SQ.( (e....e.. - House
B. ADMINISTRATIVE COSTS:
1.
Personal Representative's Commissions
Name o.f Personal Represen\at\\Je(s)
Social .Security Number{s}fE1N Number of Personal Representative(sj
StreelAddress
Ci~
State_Zip
Year(s) Commission Paid:
2. Allorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, allach explanation)
Claimant
Street Address
Ci~
State _Zip
Relationship of Claimant to Decedent
4.
Probate Fees
5.
Accountant's Fees
6.
Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space IS needed, Insert additIOnal sheets of the same size)
AMOUNT
'i? <-17/
I .
?J5&
22...0
/~3
2-50
o
ZCPS
o
o
Q,745
,
JUICE & JAVA Restaurant Cafe'
5258 SIMPSON FERRY ROAD
MECHANICSBURG, P A 17055
(717) 691-9000
Bill 10
Misc.
Description
Marsala Wine Chicken wI Asiago
Wild Rice
Gounnet Wrap Platter Tray(s)
Specialty Sandwiches Smoked Turkey, Mediterranean, Classic
Club, Albacore Tuoa, Balsamic Marinated Roast Beef, & Grilled
Chicken on SlUldried tomato rolls
Traditional Greek salad platter complete with feta, kalamatas &
homemade Greek dressing. (Serves 10-12) Complete with a
compliment of artesian breads.
Homemade chocolate chunk cookies
Disposables
Louisiana Potato chips Free
Delivery & Set-up Free
Dave's discOWlt 20%
PA STATE SALES TAX
Invoice
Date
Invoice #
8/1 0/2004
1797
Qty Rate Amount
25 8.95 223.75T
20 0.95 19.00T
6 5.95 35.70T
5 6.29 31.45T
46.95 46.95T
35 1.29 45.15T
35 0.50 17.50T
0.00 O.OOT
0.00 D.
-83.90 -83.90T
6.00% 20.14
r~~J
r f~f1
~/J~ 04
Total
$355.74
3 "'IJ...
,., .....
~~
MARTIN F. MEN DOCK 3007
IRENE M. MENDOCK /, ~
908 SHEFF.lELO ,(VENUE P' . 6O'Il73/313
MECHAN\~?BUR~, PAnOSS: O"e ~ IftP4 106
~;,!:~:l.(:lrJ) ~ .... rJefi O#/R-- flJ~~ .'. $841 t~/ri
f- /J~18,ij .<MIIA rJ,;)/";U;J.kv''''3~J/~~~
e PNCBAN< .:.r"""""" }
~l:~~,~t~~(A 040~~J~~ilY ., '~ . J'.),
Fo;l,&;.k-~,f0~fdlVfk t ~~.~-P7;~
1:0 iH 3 l.2 B81: 5 ~ 1,00 I, 255511' 3007 ,"00008 I, n ~ u
<ll~,*.",_,,,.~
'1 BOYD L. MYERS, JR., Supervisor
37 E. MAIN STREET
MECHANICSBURG, PENNSYLVANIA 17055
(717) 766-3421
or crematory to use any items, we will
fig. You do not have to pay for embalming
embalming, we ~l ex~ain ~y beJqw.
'ate of Death \:5.... f (- U'>O'1
r- M..c~1-I ~.
S1:ate
Services of Funeral Director/Staff .
Embalming
Other preparation of body
.:~C:
I~
I
I
1_
Cremation urn . .
(Description)
OTHER ~ 1_
~V,L l
.I-~,..4 (~dP'~-~C (1IJ
TOTAL MERCHANDISE SELECTED,...,.......,..,., B I~ ,-
C. SPECIAL CHARGES,
Forwarding of remains to
~
SUB. TOTAL OF PROFESSIONAL SERVICES.
2. FACILITIES AND SERVICES
Use of facilities <1nd services for
viewing (Visitation/Wake). .
Use of facilities and services
for funeral ceremony .
Use of facilities and services for
Memorial Service
Use of equipment and services
for graveside service.
Other use of facilities
AI u:;,J:.
--:-? L-
...~
.. .ICJ-..
4J1.t c."-
I~I....
I
CI~
(Funeral Home)
Receiving of remains from
I
(Funeral Home)
Immediate Buriid .
Direct Cremation.
. ..J
I
I
SUB.TOTAL OF SPECIAL CHARGES
D. CASH ADVANCED
Opening Grave
Cemetery Equipment. .
Lot and Deed.
Newspaper Notices-Local
Newspaper Notices~Out.of-town. .
Telephone & Telegrams
Airfare
Clerg}'~ Offering. .
Pallbearers.
Certified Copies of t~ DeatUJ.
Certificate ...J.t.,.~.~....
Police Escort .
Flowers
Vault Service C~.
"'4~"
I~
r;7
A21U
SUB. TOTAL OF FACILITIES/EQUIPMENT.
o AUTOMOTIVE EQUIPMENT
~~~~/~ .t~. t.r~~~kr .r~~a.i~~ .t~ .~u.~e.r~l. ~
Hearse (C<1sket Coach)
Local.
Limousine
lool.
Family car
loc;l.l.
Flower car or floral disposition L
Local, ....~
Lead car/c~&y. car J
Local. . . .,IJ,..- <fi"(I<f,fL: .,
Car for pall earers
Local.
Out of town transponation .
s:G "L
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SUB. TOTAL OF AUTOMOTIVE EQUIPMENT.. .
TOTAL OF PROFESSIONAL SERVICES,
FACILITIES AND AUTOMOTIVE
EQUIPMENT
DI~ ~
SUB.TOTAL OF ADVANCES..
A3 ,:YfLL We charge you for our services in obtaining:
(specify cash advances that are marked-up)
.~ r or r{;;,
A~lnj:' v/v_
" . SUMMARY OF CHARGES
A. Profe5siom.l Services, f;l.cilities and
Equipment, and Automotive
Equipment.
B. Merchandise.
C. Special Charges
D. Cash Advances.
. TOTAL OF ALL SECTIONS..
PAID AT TIME OF OR PRIOR TO
ARRANGEMENTS.
BALANCE DUE,
REASON
B, CHARGE FOR MERCHANDIS1tELECTED' .~
Caske! ..,..<:;...,l't~ ........ I~
(Description) .1, u "'- ,.t.s:c..
Other Receptade
(Description)
1_
O b I t' ItG'2-~.:t.
utcr uria con ;1.l1JtL . . . .,' :;. . .L"
(De5cription) J-e~ .o...e...
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,
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Acknowledgement card~
Register book(s) .
Me.mory folders
Prayer cards.
Temporary grave marker.
Burial clotbing .
I-
i
I agrcl: that I have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I acknowledge
receipt of a copy of this Statement of Funeral Goods an~~icpJi.'Ete.d. 1 represe atj have 5ufficient fund5 'Avai\able for p'Ayment of the cash price for the goods
Jnd services selected. I also agrei tQ..Cltike payment o~ wi i 0 days. I agree to. be joil1tly and severally liable with a~7else who
signs below. A late charge of .) 'f/J per month amounting to . per year will be applied to the unpaid balance beginning days
from lhe date of this agreement. 1 w' I also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I owe under this agreement.
Those costS may include attar ey , ees, court costs and othe costs. Any additional services or merchandise ordered or requested after t date of this agreemerlt will
be considered part f t~i5 7.gr t ..nct the cost r of b reflected on the final bill or statement.
{Sea
(Seal)
(Purchaser)
WHIT~_FlIneralDjrector
REV-1512 EX+ (12-03)
~.~R.
~
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
2-/ -()
5-
COMMONWI;::ALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
::trtM
FILE NUMBER
M
~illd.D 61L-
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including uoreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF OEATH
itll S c...
fxuJo
l11eJt ad B ,-/1 :>
r2.efXl\ v 1>; /l
{j(/i./
5'r
1.
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
fen.
REV-1513 EX+ (9-00)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
lYelt1€.
M
HeftcLcJut..
2.--/-0
FILE NUMBER
NUMBER
I
NAME AND ADDRESS DF PERSONIS) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
See 9116 lal 11211
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
AMOUNT OR SHARE
OF ESTATE
J><<uqhHv-
:5ttVIoUVa i<eVlV\€-dj )..."1 ( '5Ml'e ~
2'64 1>ocl (JJooc( Dr, ve A I &-
l-fuVV1vYlif~1vwl'1 ,f~70y., .sc<.NIV\~S Acc.t
~~vhV\ A. NeV\docJ- 22ct S~laVe5
Iq 5 f1atlouJtxoo IL lX\ ve. ';:A..~ ViOl s A-c.<- t-
Rafvoc..lC tJc., J
Z~(31
bw"dd=q~
Apr; / J.<e. f1 Y1ed:J
Z8~ Vbqwood Jr\~
~u.ww-.e.(sfolJ-l11 fAc
GXClndSOh 1,03C,
~ L }<e.V1I11e.dy-'"
1- L( 7)oq woOJt'Dv;)
UW\/Vla'(sfo'-<.ll1 l/~o '3(.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
50 VI
J~18?L.
g <1 &>7
I
(~-)&22
?") <( 6 7
DeLl") \II tev
I '2.2.. S ha.ves
AI&-
GVCl..lI1.ddauJl1+ev
'6) '32-'3>
/22 Sf-.ay-es
AIG-
G nlV1ci 50 VI
~323
II
NON.TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
In RE: Estate of Irene Mary Mendock
Alk/aJ Irene Mary Brinkerhoff
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND
COUNTY PENNSYLVANIA
ORPHANS COURT DIVISION
NO.21-04-0895
INVENTORY OF ESTATE
Personal Property:
Costume Jewelry and Furniture -
Household Goods
Tools and Equipment
Stock:
Savings Account
Checking Account
PNC Investment IRA
Travelers Life Insurance
Real Estate
908 Sheffield Avenue
Mechanicsburg, P A
Owned jointly and in possession of Spouse
Martin F. Mendock
Owned jointly and in possession of Spouse
Martin F. Mendock
Owned jointly and in possession of Spouse
Martin F. Mendock
660 Shares of American General Stock
Which is now American International Group
764 Shares at
68.22 a share at DOD
TOTAL VALUE - $52,120.00
Allfirst Account #21000001196907
$16,975
M & T Bank Account #35440430
$1226
$5325
Husband named beneficiary
$1000
Husband named beneficiary
Owned with Husband who currently still resides
there. $128,000
;.)
r""":l
j
I certify to the best of my knowledge that this is a complete list of the inventory
of the Estate ofIrene Mary Mendock.
Q~
B bara A. Kennedy
Executrix
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 7/05/2006
KENNEDY BARBARA ANN
284 DOGWOOD DRIVE
HUMMELSTOWN, PA 17036
RE: Estate of MENDOCK IRENE MARY
File Number: 2004-00895
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
8/07/2006
please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
..... .. /J
{~/ ~N~R'.,
OI,~Jo>-V~~,)i;'~
,. /!
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
~,
Register of Wills of Cumberland County
ST A TUS REPORT UNDER RULE 6.12
N,me ofDe"den"ZY"e ~ e 11(!."!tI1en deck..
Date of Death: AWjLL6 r 7 j2-0Dtj
L/-6Y -08'15
Estate No.:
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
I. State ~\;>:1her adm. inistration of the estate is complete:
Yes W No 0
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete:
3. If the answer to No. I is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes GY No 0
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the person~)Ypresentative state an account informally tlO the parties in
interest? Yes l1' No D
c. Copies of receipts, releases, joinders and approval of formal or informal
accounts may be filed with the Clerk ofthe Orphans' Court and may be
attached to this report.
Date: 7.;l ~- ()~
I /1
d--i.Gftl.A-tL
ignature
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Name
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oj) I" I ve j kl.Uf1 i11 t" (S fe l.'..l/cff
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2~4
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Address
117 5uG - 01 gO
Telephone No.
Capacity: B'Personal Representative
o Counsel for personal representative
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