Loading...
HomeMy WebLinkAbout03-30-12d ~' i ~.S'rATE Df //qDA H. AI+~~7PS.~v-, FILE- ~ .~/O - o/d q~ D,rJE rd AN .FRRare o+/ ~ y ~°,~re r; pc.~.3E- s~ts~ ~~'¢' TN/S /~»vr~vO.~v ScyEDc/tE T ~QE-~Y~Ei~ic.iil~u~> 1n/ THE ~1UHEX/TAr~CE TAx RET'iRi+/ ~R~/-/SOG~ S~JSr,~~TTE» rN~iPcH ~9,~~R. ~~~ ~ ~~ ~~rae x~, ~; ~. ~== ~ ~, `., _. ;_: W ~- ; ~ , ° . ,_ ~r~, ;, :~~ ~~, ~, -- ~° ~ COMMONWEALTH OF PENNSYLVANIA REV-1162 EXI11-9B) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280801 HARRISBURG, PA 1 7 1 2 8-0 601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 015761 SMALL KENNETH F 1445 VALLEY ROAD ETTERS, PA 17319 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- cola ESTATE INFORMATION: SSN: i8s-os-to37 FILE NUMBER: 21 10- 1098 DECEDENT NAME: ANDERSON VADA H DATE OF PAYMENT: 03/29/2012 POSTMARK DATE: 03/29/201 2 COUNTY: CUMBERLAND DATE OF DEATH: 10/26/2010 REMARKS: KENNETH SMALL SEAL CHECK#1010 101 ~ 531,922.60 TOTAL AMOUNT PAID: 531, 922.60 INITIALS: WZ RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS 1505610101 REV 1500 °`t°'-'°' ~ OFFICIAL USE ONLY PA Department of Revenue penmylvarria °`""~"`"`°`"`-`""` County Code Year File Number Bureau of Individual Taxes Po BOxs8D6oi INHERITANCE TAX RETURN Hanishum. PA i~i28-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY 1®q 9 I 3? ~ ~ l Decedent'snLast Ndame Suffix J /t S Date of Birth MMDDYVW g 9 1 9 0® Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ~ rrrr-r~~-rT-rm ^ Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW f• 1. Original Retum O 2. Supplemental Return O 3. Remainder Retum (date of death - prior to 12-13-82) O 4. Llmlted Estate 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O O O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 10. Spousal Poverty Credk (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 T0: Name Daytime Telephone Number / ~ 1 93 )y REGIST~ WILLS U9~1NLY ~~ ~ m First line of address ~ ~'~? r~ ~ ~ c ^ =T I /t L z Y R ~~~ ~ +~:~ .~ Second line of address °~ ~ c;_, ~ ~7 DATE FILED t City or Post Office State ZIP C de R ,, e~ rrT ®LL~3.~.1~~~ 9~L11~ Correspondent's a-mail address: under penalties of pequry I declare that I have examined this return, including accompanying schedules and statements, and to fhe best of my knowledge and belief, it is We, correct and complete. Declaration of preperer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESP~ISIBLE FOR FILING RETURN DATE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 7 1505610101 1505610101 J REV-1500 EX Decedent's Name: 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. 6. Jointly Owned Property (Schedule F) p Separate BiNing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) t= Separate Billing Requested..... ... 7. 8. Total Gross Asaets (total Lines 1 through 7) .......................... ... 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. 11. Total Deductions (total Lines 9 and 10) .............................. ... 11, 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. TAX CALCULATION - 8EE 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_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610105 Decedent's Social Security Number O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 Decedent's Complete Address: Flle Number ,-wfo - oi~9g DECEDENTS NAME VADA J-t x}n/D~SaN __ _ _ STREETADDRESS ~ yys VA~~.~c-y ~ev~v clTy ET~'Rs sPA Z1 '73l 9 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CrediLslPayments A. Prior Payments B. Discount 3. Interest ya7 Opys n ~p~4sa 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 ZO to request a refund. Total Credits (A + B) (2) (1) 3c7~ya,~8 O (4) U 5. K Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) .3 f 9o~oZ , ~o Q 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 inwme of the property transferted :.......................................................................................... ^ 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? ...................................................................... ^ I~ 2. If death occurred abler Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ [~ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent (/2 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 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are s611 applicable evenrf the surviving spouse is the only benefiaary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)j. • The tax rate im sed on the net value of transfers to or for the use of the decedents lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2rl2 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the deoedents siblings is 12 percent (72 P.S. §9116(a)(1.3)). Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood w adoption. REV-1503 EX+ (6-98) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~~ ;, SCHEDULE B STOCKS & BONDS ---- ESTATE OF FILE NUMBER VA.~A ~ 19-NDE1P.Sc>>/ v'~j/~"~109$' All property Jointty-owned with right of survivorship must Lte disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ,. S$3 cawr-,-~,v sstgrzES ,4T~T a~ as.SS ~~- /lcloYY• ~' e?, ! yD Cvrnn7a~/ S~fsyRFS /~~/Zo~ ~ 3y GS y8'S/. / y 3 33 CornrrlvN S/f~tRE3 F-RaNT/~ @ 9,39 .3z'~9. ~? ~ 7 CairlNloN .S//11RE5 /oAgF~NE ~ aZG,Rla v~a28 `f. ~ TOTAL (Also enter on line 2, Recapitulation) $ a y~ (If more space is needed, insert additional sheets of the same size) REVd508 EX ~ (497) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY __ ESTATE OF FILE NUMBER VA-~A H JI-nr~~PSo,/ o'~iv ~ oio9g• Indude the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-0wned with the right of survivorship must be disebsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 7. CN£~'K ~ T/6i ~acJ/NT'i ~NG /~j1/K t r/~tc! CdMBr<7P~19'MD~ >~+' ~' /~ 7J /a -ate -- iv 3 • 17~f~nr.D Fievrn ~7'~rrivY /i«~ I~,vg~erm~vr ~ ~ ~ ~ l ~89a2a?, ~ L/. b~V~O/3MDS FR~I T~'it-P~/o„~E .sr-oeKS aal /c1..5{f~ ~ t .S, ,~,rK Sn-/~,/FS r~cc,~vn~r ii ~s-io 9S~•ya ~ t'o, f'vR~y I TiJRE Sg«s avr ~ a2S'S3. 13 TOTAL (Also enter on line 5, Recapitulation) , ; e+7~fpr.3+~/~~ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(10.06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER VA•Dt? hR f3-ivD~SaN o~/d ~G~/y9~" Debts of decedent must be reported on Schedule L ITEM I I A. FUNERAL EXPENSES: i. f'RE~°r~io ~c'z./JYc7E'~ ~ y-~4-v9) '~'6$9z.oa o.cki CydRcJr/ /PF~~Pri~,v FAD cos~s 98.34 B. I ADMINISTRATIVE COSTS 1. Personal Representative's Commissions Name of Personal Representative(s) _ ~~`--X11~T_lt!_~ ~g'1L__.S-~!1~_1,~.~17[.,~ a ~ 9'~O Street Address ~y~ (~~LLE'Y _ _~__ _ _ City ETT~~C.S State pI~ Zip ~2~/~-_ - Year(s) Commission Paid ~L~~ ~ _ _ _ , _ __ ___ 2. Attorney Fees Q rOD 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) ©r v0 Claimant Street Address __ _ - _ City _ State Zip _ Relationship of Claimant to Decedent 4. Probate Fees 3~,~'~ 5. Accountant's Fees 6. Tax Return Preparer's Fees //VC«I/'~?~ ~~n/ P~~1//j1 /~~iQ~j~T/y~S CGyr/rM / S~/b// 7. ~ ~ 7~9 TF p DrM ~ N/ STR./tT7 /E- FXP~">l/S~"S iirrt.~0i /tlilj' E377is~~ Lhl~eK~n~G Acr~x.f.~r PR~/rTin~a~ !'~•S'o /~~Q-- ~.~x/ !~5 ~- ~cc~a/ri~ ~~v inrs~/ep,~,~c.E, ,~ ~vei--~r« 3? 8,9 8 1¢pPR/}~sA~ TOTAL (Also enter on line 9, Recapitulation) $ oja~7'/.S`. 7 ~ (It more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNEOU~~ ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER IlAOR H itND~neSvn~ ao~o-o/o9g Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ,gETt,-/1,vy rUVV~eTS gRARr~7~Nr /y1fiiIVTF~A~~ - / ,nosy ~ ~sas. ga o'!, /NETIr~Re cv-PAr mo~irT ~EDicAt GRIP ~ SI ~ ~ -~ 1 3 . Nat y SPi,ei r /-/~sP~ rAt y. C/}afP h~ltL ptrrs~eigi/s y3,9x S r1'1~7I1Cl~~ cv-pAy 12~ c~R Pr,~ysie~~~rs ~6,.~a ~, n~~-n~c,~ cv - Pi9Y N~'irRac~r Assoc. ~.a / 7• Cf}m f° 1f/LC ~~«~"~c)r I'/fySK'~/tNs to d. d! /~a.$l ~', CG1D~/T/NUING CARE /t?X q. />>Y~ 8/h~/K - CR~p, r e~~eD p,JReNi}s~s /vSBa /D, I~E1el20N !'NdNTHI y TEzCI°fitvNF ,e/~ ~~ '~ TOTAL (Also enter on line 10, Recapitulation) S I o?Q~ `l ~.$"f (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCI~IEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Vf}DA If l~nl~~San/ oZV lv -o~v9 FS 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 1 • G~oR~i~ /¢ND TEHX~E /-/lC~74 NE-~I1+~4! ~ N/6~E ~'/~ S~~ YaS~~ ~I~T a , SDNATtP9N /H/o 1l ~ n18~"Pi tY N1t.E7e .yEw; jyJECE' ~ y~ .S/, Sd y, y~ ,3, ~/f}Ncc l~f i~E'R N~.s~w %y) S/, yay, y? y ~~N~c ENO ~r ~ev.~ y ~~~~ ~~~F /y) si, v~y, y 7 II 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS (I1 more space is needed, insert additional sheets o1 the same size) ~: 0 ~_~ ~~X ~ C7O~ i ~~C~k t.~~. ~tYt.dr ~.~~~xxrxelt~ D~ "' ~~ OF VADA H. ANDERSON BE IT REMEMBERED, that I, VADA H. ANDERSON, of 212 Old York Road, New Cumberland, York County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient. ITEM 2: All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment. I give, devise and bequeath unto my husband, SYLVAN J. ANDERSON, absolutely, provided he survives me for a period of thirty (30) days. ITEM 3: Should my husband, SYLVAN J. ANDERSON fail to survive me for a period of thirty (30) days, or should we die simultaneously, Ithen give, devise and bequeath my entire residuary estate as follows: (1) One-fourth (1 /4) thereof to my nephew and niece, GEORGE and JEANIE I~.ILER, or the survivor of them, per stirpes. (2) One-fourth (1/4) thereof to my nephew and niece, JONATHAN and KIMBERLY HILER, or the survivor of them, per capita. (3) ©ne-fourth (1/4) thereofto my nephew, VANCE HILER, or his survivors, -t- 1~iOS?I~QNt~' 'H ~'Q~'A •sadi~s sad `uza~~o iontnms aye io `AQf1N A1,Z~g pus ~~~A `aoaiu pus nnar~dau ~Cui o~3oaia~ (ti/i) uuno3-auo ~ucureuiaz az~W (~) 2~JJa-vio9~' TNT SfI1F OF /fT ~T SToc K C~13~x~,7 Aivo /~-x~aonr Ssoc,r (~e s~A,~s) /ni ~~>> w~tS o~g >a r~r~ ..srvcx CERTif.eA~~s ,SEiiyaG ~o.rr 1}ivo vrrx~vo~r'~,~~~. /11/rE'RES~" ~ CAta~.v7'~4~/- 6S DAys ins ,u-~a 3~S D,~ys iir a~i / ~ 7 D,/YS rNKV 3'~ $' J ~ LEs3 9e 7 D9 ys X . lbce art :. a3S.d ~ y x ''x.30, 3 y.~. 6 ~ '`~/L~ 7 9.9~ Sf~~~ l.~Pos~r ,~ iMVElvrd~y /. ~NNV~ry canrl'~'~er ~.,ie~-o ~.•rx pive -moo ~. Qci-1A~vo NdTE prgio i~ F~~c .l4y i'~v~tc ,?v~o - v1~9 Sf ~~Rri~l k~cE~rrs Fo,~ S c i/E7Jt/L ~ ,g ao/ c - O/o9~ 3/ v , ~~ r- - _ __-__ __ _ _- _., IiPfr L-PG SHi: i 3itA Tii! i)t43Y LJCii.rillYfa.ii i L:lliir~VJ1<iii r„~' ~:,1l1 + a a !aid 1 uw 1. 6 1 d~ 3;311 ea.lllltlltl~It h 11N u 6 IIIa 11 ' ~.. _ .`;f_AAl S 3=. FCT;iAil6 ~ 6AfIlFRC~Rf 1445 VALLEY RD FTTFRS PA 17319 ~pmputershare Computershare Trust Company, N.A. PO Box 4307A Providence, RI 02940-3078 ~uli~ririn i rail i ~~ rprrnllflPC h I:aRR0:1 N'!^.! h 13 !t'>~ outside t1SA- I1S tPrritruirc k ranalla 7A1 fi75 quad Hider Account Number +~-zjie i 4~ jti_Sz pie r eases:• ene erne +317) ::~ ~ ~ ~ ~ ~ ~fH ...- .. ,. Y111A/IYINpi i{:4~H! n. - +' e' ~. ' .... - IX11CS4x107SAL.CRFf.t).LCLS.0525M_3003PDD2°87/dtY16871i Cortecled ('f checked) Copy B -For Recipient Form 11t99-B -Proceeds from Broker and Barter Exchange Transactions 2010 TlaNatYakl~3ecl~aorf°naa4ts he1glietrilydto rreteerrrkltanarere servke. rywaR regriedbiearaarar4arrgigerrce paeeyvatl~raaadae~bhepoaadanpw ilia iecaretetaea6Mand the tt5 deNmrirea tl~ R tm nd been rapabd. ~ I~T~~S~ IXESTVAflAHANDERSON ETTER.S PA 17319 Accaurd Number 0013587035 Reapient's ID No. 27-6901030 Payers FederallD No. 43.19127ao OMB No. 1545-0715 tkparele:nt otrhe Traeury - Ilhnd imuemie service 1e Dale of Sale 70 CUSIP No. ~ Stomas, Gross Proceeds or Exc'ftange Bonds, etc. ~$) Reported to IRS Payer's Details 02 Dec 2010 92343V104 2,279.23 yes COMPt1TERSHARE r P.O. BOX 43010 TAXYYRHHELD~~ Descnpiion: _ NeirleoTlssuer- ____ __ _ _ __ __ _ Tran58cUai _ __~____ __--_..--.------ - -PROVIDENf~RI 02940.3010 638.18 VERIZON COIiAMl1NICATIONS INC. Sale - CO1 NOTE: rarprAersfrere wilreport dre amoum n Boz 2 b the EtS. The dil~rloe be{aieert dre grass proceeds amalm it Box 2 and the n~ proceeds You received represaMa anY fees, dfaryea, ar vviMloNig taxes f^~ ~Y ISave ~- rwm Iv~a-o trcr:ep ror your recoras) _ -.~~__. _ -__ `____°= J i iii o~i~iw i:i o iobiii~ Di UK iY1ii VI r1a11 ailuivi a%ii${a 1~Clf11Y CBVII'iltlrft,. T-...1 ni__- nl -___- _____._ -.._ ~:.. .. "s>•ru.rigti011 1 °••, •- ~ " ~r>:1I viOSSAk110Urit DedUCflOn ~edUCtlOn NtnAmamt ..... ~•,; -, ist A of Sates (s) ( Amoukrt (_) T - . .. , v ..:;•, ~ ype of Sale (fl . ~ -~-., ,.......- ~,< ; ~ uia;uih: az.3nCb?2 2 279.23 17.40 Transaction Fee 7,823.85 638.18 WdNfoldingTax Cargxdaahare Trust Company. N.0., as agent, upon wrillen request, wgl provide the name of the exeadirg broker dealer associated witlr the trarrsadion(s}. and a+dun a reasonable amount of time wit dredoee the source and amount of tamperreatiorr received Gam tlird parties in coraractlorr vddr era tramactionls), it arty. If trade tbrre is not irrcluded above, a may be av~lahle upon eritlen request. 71 UTX VZN '~ ooicmbooa ooruczE~Fr) ~~. ~« at&t 1~ IMPORTANT TAX RETURN DOCUMENT ENCLOSED r+s 000195 I~ 111'III'I1~~III'1'I'Ill~~llllelrlellllllne.rlll'~II'~I~III'1~'~ ~ Recip~nt I~NNETH F SMALL EX EST VADA H ANDERSON ~ 1445 VALLEY RD 1~ ETTERS PA 17319 ~`pmputershare Computershare Trust Comparry, N.A. P.O. Box 43078 Providence, RI 02940-3078 Within USA, US territories ti Carrada 800 351 7221 Outside USA, US territories 8 Canada 781 575 4729 www.computershare.com/att Nader Account Nurnbar 01002146670 FID '~~!1111111111 ~a~~~~~to~~~ on AivWerM paytnttrds and traNa proceeds. > Syrr~ol T Ctadp 002088102 OO1C50 W7.SAL.C.REG.DLCI5.0525f15}003/000L95N001931i 'F AT~T fnc - $ale Advi{e f 2fl1Q Tax Form 1Q99-B ^ Correcf0d ~d>ad~d) Copy B -For Recipient Form 1099-6 - Proceeds from Broker and Barter Exchange Transactions 2010 lbistsrntporMatuidenaeaanandi~fenihadbtlteYdernrltLrase9tartn. ayduaRrsgtdlsdbeeattttum,attn8lp~tce pauay aralrtrattnr8on stay tie Ywtoasd oa ~ bade inesrne it ttsabM atd 0ta 8!S deMmdrss 0rt khs not been reported. KfJJt1ETH F SMIAI.t. IX EST VADA H ANDERSON 1445 VALLEY RD Eil'ERS PA 17319 A2xxxtM Number 1002148870 Recipient's ID No. 27&901030 Payers Fedbal ID No. 43.1912740 OMB No. 1545-0715 Oepertirsnldao Traeeuy- Yitsrnl Rswnxre Sanioe ~• Date of Sale ,b 2 Stocks, Gnus Proceeds or ~ CUSIP No. goods. etc. ($} Reported tD IRS Payer's Details 02 Dec 2010 002088702 13,819.78 Yes COMPUTERSHARE P.O. BOX 43010 -- ----- -------PROVIDENCERI- TAX YYIiNFELD (;) . ~estlori' _- T7ame oTrssuet --- -- _ ~----- - Tre7rsar~ort 02940-3010 3,869.53 AT6T INC. Sale - COt NOTE: canpufeNgra rrrl report Yee amaad in cox 2 b rie 825. The 4rerence beeeeen the grow proceeds arrant a sox 2 and lls net proceeds you received nepieaenk am ~, ~0ee, ar rAhltddig uxro you may barn paid Ftxm 1099-8 (Keep ~r Your records) Summary This advice is a result of the sale of Plan and/or Direct Registration shares. Trade ShartNdlJn)ts Price Per Gross Amount Deduction Deduction Net Amount DattalT'ime ( Transaction Dtzscnptron I Sold I SharelUnit ($) I of Sales ($) I Amount ($) I Type I of Sale (i) 121021201014:06 Sale 484.000000 28b53220 13,819.76_ 58.40 TransatlionFee 9,891.83 3,889.53 NritliholtBrtgTax Congrdershae Trust Conpany. N.N., ore agent upon widen raquesC will preside the name of the executing broker dealer aesooated wiM tire frarsactiogs), and within a reasarsble amount of time wa dsdose the eourCe and anwmd at compensation received tran tlrird parses in mrrrecoion wiar the barserbon(s), d any. r trade time's not lrabded , a may be awide6le N»n written request. 71 UTX ATT ~" ao,cDyoooe 00H72E~ o?ci/v - ova 9 g i~ fi 47117 E'T' Communications -~ 1MPORTAA7 TAX RETURN DOGUME.Y i ~.:;~-L a : i 000835 111'VIII'11~~QI'1'I'III~~I~llal'1'll~l~~n"'lll'~II'~f~lll'1~'~ Recipient KENNETH F SMALL EX EST VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319 00000385166 FID :_-:_ ~.......~~11 '~' UnaAMled aft are aubisd b r~hoidlnoteas ssNmN No n aurldand oaNrwAS and aaMa preoeada. yye~. ~~ 35806A,08 amcsass,snr..c.aEn.n.~ns.aszsos ~3~ __z~e =- - - - - - -- -- -- - ` - _ ` - ` `- - ~~ ~ ~'~^•' - ^ vice / 2010 Tax form 1099-8 ^ Catrecbd (if dtecked) COPY B -For Recipient Form tt~9-B - Proroesds from Broker and Barter Exchange Transactions 2010 T~isisl~A~tmciio®iosaMYaaiga~pedtoaNiirwlReraa~SnMeee. fytwa~enpiadbN.anhn~s~rpieea~e pn~arawaraarJon rayhat~poaed ao ym f ai trrosree is faxarfls and aw 1t6 daMmMrw krd klms rrd Hsar ropawr. 11 ~FS~ IXESTVADAHANDERSON ETTERS PA 17319 Account Number 0000385188 Redpient's ID No. 27.6901030 Payers Federa110 No. 43.1912740 OMB No. 1545.0715 DeWreranldrhe Leaauy- Ytenret fLerenue Sswra ,• Dad of Sale ,b z Stocks, Grams Proceeds _ or Exd>arge CUSIP No. Bonds, etc. ($) Reported to IRS I Payer's Details OZ Dec 2(110 35906A108 309.87 Yes COMPIlrERSF~4RE ~~~ ~ , P.O. BOX 43010 TAX WITHHELD ~) ~~ - Nair is of'Is~uer 1`rartse~or~- -_ PROVNENCE RI 02940-3010 86.76 FRONTIER COMMUNICATIONS CORPORATION Sale - CO1 MOTE: Camputardrare,aNnport the emaurd h Boot 2 to the BiS. The 4iaxencs DNaeen Urel~ proceeds amount h Box 2 am the net proceeds 1Fu received repreaerge arty teas, drerges, rx,daitoMitg faxes you mry have paid r,xrn rvr~-o (tceep for your reooMS) Summary This advice is a resuk of the sale of Plan andlor Direct Registration Trade ShareslUnits Price Per Gross Amount Deduction Deduction Net Amount OateTme Transaction Destxiptton I Sold I SharelUnit (S) I of Sales (;~ I Amount (:) I type I of Sale (s) 121021201014:07 Sale 33.000000 9.390000 309.87 18.96 Transaction Fee 204.15 88.76 Wdhttolding Tax Comprderehere Trust Carperry, N.A, as agent, upon rviaen request uric provide the name or the executing broker dmlar aesadeled rMio the trarnacion(s), and„tarh a reasorreble amgmt Or fkha a,T 68de6e the SeUICe one amount of comPeraetion recaved from tldrd parties in mrarection,rilAere anlsj, it arty. f trade time is not irKluded above. ti may be available upm,rrikero requeel 71UTX FRON "~' oo,cofooos ooruczE~r=rt ~111pt1t8 Computershare Trust Corrtparty, NA. PO Box 43078 Providence, RI 02940-3078 _, 6rriiii0 iiv~ iii iwaiimins it r argrru n77 77ir frown uurssioe ii~i-. iii Terri[fxies n Ganaaa i8 ~ 5i5 z3s[ www.computershare.com(rnestnr Holder Account Number a~/o- o1d9S Form 1099-B Proceeds From Broker and Barter Exchange Transactions 1a Data of Sala or exchange 1b C1181P No. 12/10/2010 92857W20 2 stocks, Bonds, Kc. U.S. INFO 2284.49 FOR 2010 Copy B for ol~. nlo. ;_,;_,_ ~ !?r,~dt?ients - StahmeM for Reclpkv[ts of Proceeds from Broker and R RRe-}nr ~.sr!v _SnI<r. Tr~1?c irt~rsn_ REPORTED °`~' p1OC°a0s "" Comm"' sions and option premiums TO ~,_, S Bartering 6 No. of shares exchanged TOTAL, ~ 1 ~ 1284 45 i iRO j ~ X I u,~~. p~~~taas INCelta T/at 1mr1MRa 7 Description 638.66 VODAFONE GROUP PLC C Classes of stock exchanged ~ BROKER`S nary, address, ZiP ~JC: and =~~z: ai ACCOUNT KEY RBCi16~ITS idaNlflcation nlanber an file ANDERSON-VADAHOF00 XXXXX1030 00145192857W20 v~oM KENNETH F SMALL EX UW VADA H pA~ ANDERSON 1445 VALLEY RD ETTERS PA 17319-9703 ~ toes-B ~ CORRECTED ~ DUPLICATE if checked BNY Mellon Shareowner Services ]?O Box 1630 Manchester, CT 06045 idenUPieaUOe~ ruav[~e The Bank of New York Mellon 480 Washington Blvd Jersey City NJ 07310 (800)233-5601 x~rMr.brlyrrleNaori.caNshareowner/fed 13-5160382 0623728 O7 AB 0.300 AUTO Ft5 2 3722 17319 'ttill't11~tt"/tlt"'tltt'1'It'1/t'II111It1'1 tI11'IIIIIIIII" KENNETH F SMALL EX UW VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319-9703 P23tS2 s3 8 w a C at&t IMPORTANT TAX RETURN DOCUMENT ENCLOSED 036688 III'{III'll{) {{I'i'1'lllr~l{lleteldl{I{{en.'lit'{II'{{{111' I{'{ Recipient KENNETH F SMALL EX EST VADA. I# A":~~ux; 1445 VALLEY RO ETTERS PA 17319-9703 Aaxaa#lhsrrber:01002S77094 ,Zo/t~ - 0/098 Yage 1 otz ~pmputerrshare Computershare P.O. Box 43078 Providence, AI 02940-3078 V~ithin USA, US territories ti Canada 800 3517221 Outside USA, U5 territories ti Canada 781 575 4729 vrww.comprtershare.com/att Holder Account Number Comparry ID C1~2377094 ATT I~IIIIIIl 1ZadPkr><s ID No. ~~ ~®~~ to ~ ~ Sales pica less pxnm~ebns and option prernYm~s Issrrarltame: AT&T Inc. COMPUTERStIP~RE P.O. BOX 43010 PROVIDENCE R! 02940.3010 Payers Federal lD Nran6er:43.1912740 iklket Dale d Saks Priced Cast a FEDERAL INCOMES Wash sek a q d>edred, e 7 0l a ~ sate a as~im Zsbda. bards. ae~er tarsis (~ 4 TAX WRNHELD (f} loss drsaNow~ed Yaes 1!43:5; and ~n ~ nrricnoe. ~ iSl _ _ 8 nrey be Yar sale of 89 shares of COIIIrON STOCK tCUS~: 002068102) sold ~ 529.30 on 29 .hd 2011 and tofa0np !'1,807.70 vr91 be roporbd Po the NtS as 1o0ovus: 29,h12011 2.807.70 730.16 ® 89 of 89 Shares Sob _ _ .:~ uSsz S~iDE FOR INSTRUCTIONS AJr1D DESCRIPTIONS FinTe_ T;~ p... _ . „~; ......a rua as;v:, ~t :n :~+;,;~; Z t0 ~ a tRS. The drfferenoe between the gross prooaeds arr-ount in colurrxt 2 and the net proceeds -_._,_.. C:1 ii;~ ___..-_ _vi ~__ _, _._. ~`_b, a3i niiiii i+nLn y.i~d7C['.S yalrrtBy tTa~/e p81d. Copy B .For Redplent (Keep far your records) Departrtrerd of the Tremor - Internal Revenue Service This is important tax irikrmation and is Ming famished to the httiemal Reventre Service. H you are required to file a return, a negligence penalty ~.: or atiter sanction may M imposed on you N this lrtcolne is taxable and the roc .~+~n;;i +~,~ ;_- ta; i==;--a -:, -- nw ae~: 1000TX o,~ ooicsaosr.oon~rr synbx.~rcrz~ia~rrua+ ^ ~db~ - _ _ _ _ _ _ 6M8 Mo. - - 1515-0715 '3~ '~_ >~ v~er~~vn IMPORTANT TAX RETURN DOCUMENT ENCLOSED 009364 I11'~11191~~~~1't'I'Ill~~l~lldfl,11~1~'fffultl'~11'~f~llt'1~'~ 1~N1~TH F SMALL EX EST VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319 ^ ~~ Account Number:000135a7035 Recipierrrs 10 No. 27-W01630 Reported l ®~ P'~ td IRS J ~ ~ plioe less camn6~ions ad option premiums Issuer Name: Verfzon Communications Inc. Payers COMPUTERSHARE P.O. BOX 43010 PROVIDENCE R102940~3010 Payers Federal IDNumber: 43-7912740 to pate Ol Deb of 2 Sebs price d 3 COST Or a FFnFRi 1Nr:AYF 5 we5h 5816 8 If dlfllked, a Type a 9 sale or aoquis~an sioda, ~ elher basis (~ TAX lN1TNHELD (S) bss disatlowed trmeg 1a 3,5 alyd geld or kss ~P~ exclrarge a may be blank Yar aerie ar70 sfrefes dCOMMOM STOCK (tom: 92343V104i sold ~ 537.075817 err 14 Jut 2041 and totaling S2,595.31 wi5 be reported to the IRS as follows: 74 Jut 2017 2.595.31 O.QO ® 70 X70 Shares Sdd 3EE REVERSE SIDE FOR INSTRUCTIONS AND DESCRIPTIONS NOTE: The Payer will report the amount in cdumn 2 to the IRS. The difference between the gnus proceeds amount in cdtartn 2 and the net proceeds you received represents any fees, dlarges, or withholding taxes you may have pad. Copy 8 • For Reapielrt (Keep for your records) Dep~artrrrent of the Tr~stay - Internal Revenue Service This Is important tax irlformationandistlefig firrMshad to th~hltem8l Revenue Service. If you are required m file a return, a negligence penalty or other sanction may be imposed on you ff this Income is taxable and the IRS determines that it has not been reported. 1000TX e,rxon ~~~ _ Odd 9 $' Page 1 of 3 ~,omputershare Computershare PO Box 43078 Providence, fll 02940-3078 Within USA, US territories b Canada 800 631 2355 Outside USA, US territories & Canada 781 575 3994 www.computershare.com/verizon Holder Account Number Company ID 00013587035 VZN k: ~ ~~~~~ OYB No. 1S4S-0715 OOICS0021.DOMLT B DPLfiX.V7N.IF0'157 2iaR'rt•MIOiR4Nllf ~o~a - oio9~' ~f/RriAL /~EC~Ei~s ~.~ SC/~6'DUGE E Asbury Communities, Inc. To: Estate of Vada Anderson 34214 Check Number: Check Date 0000206290 082512011 invoice Number Date Description Amount AUG242011 08/112011 Standard Entrance Fee 388,922.00 Discount s.oa Paid Amount sfta,9zz.oa tas,9zz.ao 3.00 388,srz.oo Total Banking Statement PNC Bank For tM perfoi 11/N/Zb/D i>o 14/OS/Z~i• ~U/a-O/09S" 000189 ~~ VADA ANDERSON DECD - 325 itESLEY-DR APT 3121 (IECHANiCSDUR(i PA 17ai55-3541 ~. PNCBANK Primary account number. 51-4000-1307 Page 1 of 4 Number of enclosures: 0 For 24hour banking, and trarteadion or interest rate informatbn, sign on to PNC BankOnllne Banking at pnc.com. 'IQ Foralstomerservicecall1~88-PNC-BANK Monday - Friday: 7 AM -10 PM ET Saturday & Sunday: 8 AM - 5 PM ET Para servk:io en espafbl, 1-866-HOLA-PNC Pbase contact ua at 1-888-PNC-BANK ~"~" aomoant Nnnlber Daposk t3alana Interest Checking 51-4000-13Q7 6,215.71 Pt+emir~ Money Market 51S30ff5-85?f 7 .00 Total Dapowts 6,X15.71 Important Information on Federal Deposit Insurance Coverage (FDIC) t3et acquainted with recent FDIC changes: On July 10, 2010, the basic amount of FDIC deposit fnsurance coverage permanently increased from $100,000 to $250,000 per depositor, per institution. Beginning December 31, 2010, the FDIC will implement a new temporary insurance category to provide unlimited f=DIC insurance cavgr~lge for funds held in .riont~ttere~-~arlr~ #I•ansa~#lon _ ~ accouftts •(check}'~t Fnstrred barlks. Th(s temporary category wi(i remain in effect through December 31, 2012. For more information on FDIC or to learn more about how #o maximize coverage, visit www.FDlC.gov or call tolhfree at 1-877-ASK-FDIC (1-877-275-3342). Hearing impaired line 1-800--925-4618. Iwar~ Clil~eliriwy A~o~wt ~sry Aoaourk number. 51-4000-1307 Overdraft Protectbn Provided By: e..e..r F1MC is eeW6a.r OoaAralt Fnteaw~ t36pfnNnp Deposns and Checks and oihar Mlanw other addNions dedudlons 7,900.66 1,532.79 8,X17.74 Avanlpa monthly balance ss7sss Veda Anden~on Decd Elldirg balance Charges and Has X0.00 DWrIaM TM 1/1D91CfM ~IAff •lauuuW nnn Mnnlsw Total Baukiug Statement For 24hour informatbn, sign on to PNC Bank Online Banking on pncoom. Accormt smsben 514000-1307 - eontinaed ~r Mnual Percentage Number of days Average eolleeled Idrnd Pskl Yield timed (APYE) In Intend period belong Tor APYE this period o.oix 3o s,s7s.99 .05 step Dt~Nits a^d Otl~ Aditls>rrs Date Amount Deecrlption 11/16 1,532.74 Reverse Corporate ACH Debit Etiectlve I1-15-10 12/03 .05 Interest Payment .~ Tnare were 2 ;mine w Electronic Banking "~"` ~ • ~ ~NtplrwWif~""~~?..w =~ Deductions totaling #S,7f7J~. 1112 1,665.00 Direct Payment -Reversal.... USTreastay 303 XXXXX1037A 11/15 1,532.74 Corporate ACH Cash G&D Asbury Comm 162 810 OIhM s Gate Amount DeecApnon 12/03 20.00 Calculated Servke Charge Type I3d D~air ~ Dttila7 Dab Balance Date Balance Date Balance `lit/04 7,900.66 11/15 4,702.92 12/03 6,215.71 tl/12 6235.66 11/16 6,235.66 ~1~ M.AN - E~o~ d~ar~ E~w~ien ,iAenmii ~ Asooent num6~r Balance typo as of Balanw These accounts were roviewed to meet XX xXXX 1307 Tlvs Cyr3e Avg Balance 12/04. 6,679.66 the balance requirement of your Senior Premium Plan Aomunt Since balance requ)roments were not met this month, a 520.00 fee was deducted from this aooourrt. Aocourrt number. 57005-8537 Oven4raR ProteQiwrPravided By: CesMaet lNC ee sefa6isk oeerirar! ~rataatls~ iFetra»~.eNtl ii~wrs.,•..,~.~. VADAANDERSON DECD Primary account number. 51-4000-1307 Page 2 of 4 Vada Anderoon Decd aai~ -oio98' As of 12103, a total of =i.i~ in interest was paid this year.. Thera were 2 Depos(ts and Other Addkbna totaling si,is2Jf. Thera was 1 Other Dedtretion totagtig ~rN. t7spiwdrg Dtposks srd checks and other Ending 6alanc+ afMraddkions daduct(ons balance 95.840.46 .00 95,640.46 .00 Avewge monthly Charges balance and foes 35,068.16 .00 Annwl Pareerrtage Yield Eamed (APYE) O.OOX NumWrofdays Avenlpcdlected in Interest period balance for APYE 11 95,640.46 infanst Pald this period .00 As of f 2103, a total of ~iTfit in btterest was paid this year. wlarrean Free Checking Account Statement ~~~ ^ ~~~ 9 ~ F.. ~. ~...~+ ,,,~,~.~. a ,sr~srs.,. ® For 24hour information, sign on to PNC Bank OnBne Banking EST OF YADA H ANDERSON DECD ~3 on pnc.cam. Primary aocouM number. 500448-5562 Accord ~~ 50~04485li62 _ cont~od Page 2 of 3 s ~ ~~ tti Thera vtrere 5 Deposits and OtherAdditions Date Mount DeeeAptbn Lotaling ~.N4~. 11/29 772.22 Deposit Reference No 520587805 12/06 177.00 Deposit Reference No 526479303 12/10 12,019.94 Deposit Reference No 525252085 - 171C1~~/ ~ ~Ro~ /EJ1~~tFS~1<< 12/14 6,215.71 Transfer From Sub Account 0000005140001307 12/16 11,719.63 Deposit Reference No 522710939 I~ttdns asd CINOI~s CMCk Data RKerena number Mount paid number 1001 1,503.82 12/14 52xs7a45e, ~,, p~ . 11/27 valance 95,378.89 Date 12/06 t'7alanca Dab t3ahnce 96,328.11 12/14 113,059.94 11/29 96,151.11 12/10 108,348.05 12/16 124,779.57 FOAM18aA ~vio-oiv9g P~,~rigl ~~c~Prs fog Sc~~.~r~z~ ~~ ~JJr~-- O/o9 B" ~o~a ~ I2 ~E~vie~ AUCTIONEERS ~ APPRAISERS 208 CREEKWOOD DRIVE • CM1P HILL, PA 17011 PHONE (7171787-0000 November 12, 2010 Fee for Appraisal for Ken Smith 150.00 Thank you ~~u~~ GfCi-' u~ Michael Costae Au-1759-L Auctiam Management and Appraisal Service Antiques appraised, plurchased, Bold on oonsignmeat C~O~£Q'4. ~ IZ ~£'LULLrE AUCTIONEERS & APPRAISERS 208 CREEKINOOD DRNE • CANS HILL, PA 17011 PHONE (717) 787-0000 November 12, 2010 Appraisal for Ken Small: 1 Modern Curio with Arched doors 175.00 2 Mahogany Breakfi~ont with Curved glass door 250.00 3 Mahogany sideboard 125.00 4 Reproduction ice box stand 35.00 4 Vintage Gone with the wind amp electrified 125.00 5 Vintage rocker made from spinning wheel 75.00 6 Six Chippendale style chair and dining table 225.00 7 Mahogany games Gable 150.00 7 Vintage Gone with the wind lamp electrified 125.00 8 Single Mahogany bed 75.00 9 Vintage square Oak china cabinet 200.00 10 Small Mahogany stand 35.00 11 Modern pale lamp. 25.00 12 Upholstered Modern chair with Queen Ann feet 85.00 13 Vintage n,.ctangular White marble top table 175.00 14 Vintage Brown Rectangular marble top table - 150.00 I S Mahogany Gov. Winthrop desk with Bookcase top 350.00 15 Walnut desk chair 25.00 16 Occasional chair with claw feet ~ 35.00 Total 2,440.00 ~jjp - oiv9g Appraised to the best of my Knowledge as an Appraiser and Auctioneer with 30 Years Experience. Appraised by Photos supplied by Ken Small Michael Costea Au-1759-L Auction Management and Appraisal Service Antiques appraised, pnurliased, sold on conaig~ment pt's ~~~ A Family Tradition Of Caring® EMORE Funeral Home & Cremation Services, Inc. Mrs. Veda H. Anderson 12/29!2008 212 Old York Road New Cmnberland, PA 17070 1303 Bridge Street P.Q. Bax 431 New Cumberland, PA 17070 (7t7)774-7721 (Fa:K) 774-5546 v~ticlv.parthemore.com Gilbert W. Parthemore, Founder .Gilbert J. Parthemore, Supervisor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC Professional Memberships: NFDA•PFDA DCFDA•CCFDA G ~~rk ~~L The Rule }bu KrroH; - Tlrc Pcop/c }iut Trvrsf We sincerely appreciate the confidence you have placed is us and will continue to assist you in every way we can. Please feel flee to intact. us if you have any questions is regard to this statement T!w following is an itemized statement of the services, facilities, automotive equipmart and merchandise that you selected when making the funeral arrangements- Terms Due Date Accotrrrt # Net 30 1!28/2009 2008111.0 Description Amourtt SERVICES Bc MERCHANDLSE Traditional l§meral Service 5,595.00 Wildflower Stationery Set 135.00 Total Services and Merchandise 5,730.00 CASH ADVANCE ITEMS Death Notice, Harrisburg Patriot 199.89 10 Certified Copies of Death Certificate 60.00 (2) Clergy Honoraria 200.00 anist Honorarium Or 125.00 g Flowers, Casloet Spray 200.00 Total Cash Advances 784.89 ~~. t °~~~ ~z ,~ _a ~- ~ pis ~~ l ~ ~,-- o~r~°g~ Y Total s6slas9 Paymer~ts/Ceedits to.oo Balance Due $6,514.89 7t~,.r, I t N. b0 ~ Yoo. ~`~ avi~- viv9S `~~ I ~~/ (~/ ` A Fam11y Tradition Of Canng ~ `' , P __ PARTHEMORE .Funeral. Home & Cremation Services,. Inc. November 23, 2010 1303 Bridge Street The Estate of Vada H. Anderson P.o. BaX ail do Mr. Kenneth F. Small New Cumberland, PA 17070 1445 Valley Road (7l7) 774-7721 EtterS, PA 17319 4554s "cavvw emore.com Dear Mr. Small; The following items were either not funded or not guaranteed in the pre- arrangements for Vada H. Anderson: Actual Cost As Funded Gitbext W. Parthemore, Founder` CSt6ext J: Parthemore, K Pacthemore, GFSP Bruce R Parthemore, Pre-Need Coordinator, CPC Professional Memberships: NFDA • PFDA DCFDA • CCFDA G ~d~ TAe Rule Yau Know The People You Trust Death Notice, Harrisburg $ 367.07 $ 350.00 Certified Death Certificates 120.00 60.00 Hairdresser (Refused) -0- 40.00 Clergy Honorarium 200.00 200.00 Organist 125.00 125.00 Flowers, Casket Spray 212.00 200.00 White Dress -0- .132.00 Subtotals: $1024.07 $1107.00 Difference: ($ 82.93) Total Refund Enclosed: 9182.93 Please call if you have any questions. Thank you. klc ~ ~~ , =. _ _. ~ ,. i ~ ~~~ a~~~-- o~o9$ /~iPRri~z /2~cEif'TS ~d~ SCH~I /JGE Z ~I~ -0/09 S Comments YOUR DESIGNATED AMOUNT WILL BE PAID BY ELECTRONIC FUNDS WITHDRAWAL FROM YOUR BANK Balance Fonnrard $1,532.74 11/15110 - 1 1/1 5/10 ACH Payment 11/10 Check #ACH $1,532.74 11M5l10 -11/15/10 ACH Payment 11/10 Check #ACH - RET $(1,532.74) 10/18110 - 10!19110 Transportation 2 $16.75 $33.50 11/30110 - 11/30/10 Monthly Fee (1) $(62.42) TOTAL BALANCE DUE: 31,503.82 ~~e send, a cr,ec~. ~vr p~me~~ ~,~ ~6' 1 D ~a' FACILITY NAME RESIDENT NAME ACCOUNT NUMBER BETHANY COURT APARTMENTS MRS. VADA H ANDERSON 2134 J 48500041046 REV-485 EX (t-07) SAFE DEPOSIT BOX INVENTORY PA DepaAlllerlt of Revenue PLEASE USE ORIGINAL FORM ONLY Social Severity or Dealh Certificate Number Date of Deaih County Code Year File Number ~ ~`i ~0`'i e l O'3~` '1 O Z~ 20 ~ O x ,_ , ._ _ _~. Decedent's Last Name Suffix First Name ~ MI _ . . __~._v__ _ _~.___. © ADDRESS OF DECEDENT STREET: CITY SATE: ZIP CODE: ~ ~ f 1 iD~ n ..: a- 110.1; , ~. . ~'L, , ~ ..~ /1 ~ '7 /`~~ NAME AND ADDRESS OF PERSON RECtIEStr[!G THE OF THE SAFE DEPOSR BOX """~ lC~t1 KIrLV~ ~- ~ ELI l (( ~ 5 ~ ~al~ 7~i.1 ~~/~ ~~ATE: ~~cOpG1 ~ NIUrE. ADOR£SS AND Itf3AT10MSi1P ~# ANY) TO OECEDEItT, at= PERSON(S- PRESENT AT THE BOX OPENING a n~~ ~ ~r~QQ RELA SHIP: ee~ ° STREET ADDRESS: ~_ _ b. NAME: . STATE: RELATIONSHIP: IPCODE: STREET ADDRESS: CITY: STATE: ZIP CODE: G NAklE: RELATIONSHIP: STREET ~~- CITY: STATE: IIAiE ANk1 ADDRESS OF FiIANCUIL ~7TiUF10N WHERE THE SAFE DEPOSIT BOX IS LOCATED ZIP CODE: CC : T9TE: ~- ZIP COD Nal?t OF PERSON L~T ~ ~ F t DATE l~ _TO RENT BOX NUMB OX I ~~ DATE AND ME OF T ENTRY 1 T ~U~E~t WNI~~Y~i EGISTERED ~I•~ ' NAME aND aooRESS of r~RSON~61 wwlNC accESr To Box a. NAME: IJ~t~de~Y, ~ a>_y- ~~ b. NAME: nl..~V-~.~. ~ S r~.~l - A~e,l~- • ST A~OD ES ~ J ST~F..ET. ,ADQRES (L.'l.l~~- STA ZIP CODE: ~~ ~ 7~A- ~ s CI ~ STATE: ~ (-4e ~~ P CDOE: NAME.A,ND TITLE.OF EMPLOYEE TAKING THE INVENTORY ,„ _ ,~ ?~ WA8 A WILL IN THE BOX4 U YE8 j~ f IO If yss, a. Data of wNl: b. Name and address of personal raprosentative, H named in the will NAME: STREET ADDRESS: CITY: STATE: ZIPCOOE: a name arq addlYaa or attomay, K any NAME: STREET ADDRESS: 48500041046 CITY: STATE: ZIP CODE: 48500D41046 J ad~v- a.~9g SAFE DEPOSIT BnX INVENTt7RY Pa9~ --- _ Df REV-485 EX INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stack is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) Atl other contents. } (9) Rehrm completed form to: DEt~ARTMENT OF REVENUE s WHERITANCE TAX DMStON (?O SOX 280601 HARRiS6l1RG, PA 17128-0601 ITEi f;10. ITEIJ DESCRIPTION ~ -- ~n~'tc.c.~'~-c-(~~b~vrz~- - is&~.cf~ ~~~~G i/[f_~'I~-l-eot:~5 Cd' ~7--U ! ___ _ . ,. Ftrr~ ~- ,d©o -~ ,U~, ,ttit.~~.b.u-~ cat•t ,Cax-~, a~.~ ~ ~~ ~~OJZ Jt-t N it L'~-l~u~- ]~A l~'~" Lt Q t : ~ ----- ' ~S "' _`~' '~ ~., - r~ '+FC~t~~~t'lr'rrl~a,e nyt}-t~C ~Q~S . --- e - { I CERTI UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CO C COMP TO THE BEST MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF - SAFE DEPOSIT BOX INVENTORY: 51 I SKiNAT RE ~'L{7- PRI~ ~ ~~'a~ - PRI AND CHECK APPROPRIATE BOX Bq.OW: PF~{~JT TITHE ' " ~ ~ ` ~ / ~! t ~/ \ DATE ~~`~~~(, f`}-LJ\"" CHECK APPROPRIATE 90X ~m~~~~~~ ~Executor(trix) ^Adrtdmstrata(V6c) ^ EstaOS RepresentaWa ^ Joint owner of safe deposit box NOTE: Attach additional 8'h" x 11" sheets) if necessary or use duplicates of this page of form. The Deparhnent is authorized by law. 42 U.S.C. §405 (cK2)(C)(i), to require dire d Stxaal Setauilyy numtlas in txmrledion wflh admrclisteairg state talc laws. The DeperUnerlt uses Ule Sodal Security number b identity the decedent and persalal lepresenmtitres of the estate. The Cammonvrealtll may aim use the in(orma6on n h f exc ange o felt inftxmatbn agreements with Federal and bcal ~ autlwrl7ias. The slam law the Cammonweagfl's Fran txxddentiN tax irlmrrllation extxpt for olfiaal ~~,~~~` ~ ~ ~q~i~~ ~ ~o~~ \o~~