HomeMy WebLinkAbout05-24-121505610143
REV-1500 Ex(°'-'°'
PA De artment of Revenue OFFICIAL USE ONLY
p Pennsylvania county toes veer File Number
Bureau of Individual Taxes evu,TMexra eaverse
Po Box.2sosot INHERITANCE TAX RETURN 21 12
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
Decedent's Last Name Suffix Decedent's First Name MI
MILLER COLETTA A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
X~ 1. Odginal Retum ~ 2. Supplemental Retum
q. Limited Estate ~ Future Interest Comppromise
~' (date of death after 12-12.82)
Decedent Died Taslate
6' (Attach COPY of Will) o~r~dennt Meir~lned a Living Truat
T' (Attach (:opY rust)
9. Litiga9on Proceeds Received
~ atq
tD.ps~°~18~?g'~i ~~a^dat{1-95)tdeeth
MI
3 Remainder Return (date or tleath
prior to 12-13-82)
5. Federal Estate Tax Return Required
S. Total Number of Sate Deposit Boxes
t t ~ (Attach Sch. O) nder Sec. 9113(A)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED. ALL
Name
MARIELLE F HAZEN ESQ
AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Daytime Telephone Number
717 540 f~i32 I ='
a-O rv 7C1
n 'T
~:~t7
~_p
_.+ ~-_1
r r-'
r -._,
;7
~`_ i`~'t
v7 ~
-T~
REGISTER OF
First line of address
2000 LINGLESTOWN ROAD
Second line of address
SUITE 202
City or Post Office
HARRISBURG
' tV
=Cr t'
G,-,
O __ -i..
T
~ _
..
n,Y
n.-
TE FILED
State ZIP Code
PA 17110
Correspondent's a-mail address:
ADDRESS
Ann Zelko
3 - )/> I Z
SIGN E OP PR PARER OTHER THAN REPRESENTATIVE DATE
~ /' `( Marietta F Hazen, Esq. h -,~~ - Jp(Z
2000 Linglestown Road, Harrisburg, PA 17110
Side 1
1505610143 15U561U143
1505610243
REV-1500 EX
Decedent's Social Security Number
o~eaem=Name- Miller, Colette A 175 20 4733
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................ . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) ....................................................... . 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 18.2 9
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 16.72
7. Inter-Vivos Transfers 8 Miscellaneous f~oq Probate Property
(Schedule G) u Separate Billing Requested............ 7, 8 , 308.77
8. Total Gross Assets (total Lines 1-7) .................................................................... . 8, 8 , 343.78
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 7 , 075.62
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 2 , 851.55
11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 9 , 92 7.17
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. -1, 583 .3 9
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) ............................................... 73.
14. Net Value Subject to lax (Line 12 minus line 13) .............................................. . 14. -1 , 583.39
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 15 O
O O
(a)(1.2) X .00 . .
16. Amount of Line 14 taxable
0
00
16
0
00
.
at lineal rate X .045 . .
17. Amount of Line 14 taxable
0 . OO
at sibling rate X .12 17. 0.00
18. Amount of Line 14 taxable
Q , 00
at collateral rate X .15 18. 0.00
19. Tax Due ................................................................................................................. . 19. 0 . OO
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-12
DECEDENT'S NAME
Miller, Colette A
STREET ADDRESS
4837 East Trindle Rd.
CITY
Mechanicsburg STATE
PA ZIP
17050
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
0.00
(1)
Total Credits (A + B) (2)
3. Interest
q, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
to: REGISTER
(3)
(4)
(5)
0.00
0.00
0.~~
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferced :............................................................................... ^ 0
b. retain the right to designate who shall use the property transferred or its income :.................................. ^
c. retain a reversionary interest; or ............................................................................................................... ^ z
d. receive the promise for life of either payments, benefits or care? ............................................................. ^ x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^
receiving adequate consideration? .................................................................................................................... x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................................. ^x ^
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 [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 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 still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A
sibling is defined under Section 9102, as an individual who has at least one parent in wmmon with the decedent, whether by blood or adoption.
Rav-1608 EXi (8-a6)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTNOF PENNSYLVANIA
INNERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Inelutle the proceeds o(litigetion end the data Iha proceeds were receivetl by the ealete.
All property )olntlyownad with the rigor IN wrvlvorMip must be dleclosetl on schedule F.
(Ir more space is needed, addkional pages M the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule E (Rev, 698)
Rev~7599 FX~ (8-99(
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OFPENNSYLVANIA
1lIHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Miller Colette A 21-12
H en aoat wo msda joint wllhln one year o/die d°eadant's tl°IS o/ dedh, ll musl l» repaNd on °eh°duls G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Mary Ann Zelko 5545 Westbury Dr. Child
Enola, PA 17025
B.
C.
In1a1T1 V l1WMCm DDl1DCOTV•
ITEM
NUMBER
LETTER
FOR JOIN
TENANT
DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT
NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR
JOINTLY-HELD REAL ESTATE.
DATE OF' DEATH
VALUE OF ASSE % OF
DECD'S
INTEREST DATE OF DEATH
DECE ENT'9 NTEREST
1 A Members 1st FCU -Acct. #124722-00 savings 33.43 50.000% 16.72
TOTAL (Also enter on Line 6, Recapitulation) I 16.72
(If more space is neetled, adtlidonal pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA•1500 Schedule F (Rev. 6-98)
Rev-1670 E%~ (B-9a)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF RENNBYLVaNIF
INHERRaNOE TR%RETURN
REBIDENl DECEDENT
ESTATE OF FILE NUMBER
Miller, Colette A 21-12
This schetlule must be compleletl and filetl if Me answer to any M questions 1 Nrough 4 Dn the reverse aitle of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
THE DATE OF TROAFNSFRERSATTACIITAOOPY of THE SEED FOOR REAEEST TE. DATE OF DEATH
VALUE OF ASSET %OF DECD'S
INTEREST EXCLUSION
(IF APPLICABLE) TAXABLE
VALUE
1 Prudential Annuity #97665232 -Beneficiary of annuity 3,765.28 100.000% 3,765.28
is decedent's daughter, Mary Ann Zelko
2 Members 1st FCU -Acct. #124722.11 checking - 3,191.45 100.000% 3,000.00 191.45
account liquidated 2/17/2012 and funds gifted to
daughter, Mary Ann Zelko
3 Members 1st FCU -Acct. #222647-05 money 4,352.04 100.000°~ 4,352.04
management -account liquidated 2/17/2012 and funds
gifted to daughter, Mary Ann Zelko
TOTAL (Also enter on Line 7, Recapitulation) ~ 8,308.77
(If more space is neede4 additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Fonn PA-1500 Schedule G (Rev. 6-98)
REV-1161 EXi n0-06)
COFN~~F~ANIA
SCHEDULE H
FUNERAL EXPENSES &
I,DMINISTROTIVF CASTS
ESTATE OF FILE NUMBER
Miller, Coletta A 21-12
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached ~ 6,735.62
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(sl Commission paid
2. Attorney's Fees Hazen Elder Law 325.00
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zio _
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 15.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 7,075.62
Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn PA-1 b00 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF ( FILE NUMBER
Miller, Colette A 21-12
DESCRIPTION AMOUNT
NUM ER
1 Funeral Expenses
Calvary Cemetery for Year Marker
45.00
2 Funeral Dinner for Family 81.89
3 Hoss's Funeral luncheon 445.38
4 Richardson Funeral Home, Enola 3,423.57
5 Stevens Mortuary, Altoona 2,740.00
H.q 8,735.82
8 Other Administrative Costs
Register of Wills, Cumberland County -filing fees for inheritance tax return
15.00
F1_g7 75.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Fortn PA-1500 Schedule H (Rev. 6-98)
Rsv~7672 EXi (72-09)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OFPENNSYLVANIA
INHERITANCE TA%RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Miller, Colette A 21-12
Report debts Incumtl by Ms tlaeatlant prior to tleaM Nat romalnad unpaltl et the date of tlsalb, Inclutlin9 unrolmburoed mWleel axpanNe.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Continuing Care RX (Country Meadows) 115.29
2 Country Meadows at Home 420.00
3 Dr. Azizkhan -medical 196.01
4 East Pennsboro Ambulance 80.00
5 Heritage Cardiology Assoc. -medical 38.35
6 Holy Spirit Hospital -medical 5.90
7 Hospice of Central PA -medical 1,850.00
8 Med Options -medical 126.28
9 Spirit Physician Services -medical 19.74
TOTAL (Also enter on Line 10, Recapitulation) I 2,851.55
(If more space is nestled, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule I (Rev. 12-OB)
REV-167J E%~t77-0a)
SCHEDULE J
coMr~~~(~D -e~ANIA
7~ €LE BENEFICIARIES
ESTATE OF FILE NUMBER
Miller, Colette A 21-12
NAME AND ADDRESS OF RELATIONSHIP TO
SHARE OF ESTATE
AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT
(Words)
($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 a 1.2
Anthony Miller Child One Third of the
115 St. Andrew's Way Residue
Ettere, PA 17319
Michael A. Miller Child One Third of the
1483 Oldmans Creek Rd. Residue
Swedesboro,NJ 08085
Mary Ann Zelko Child One Third of the
5545 Westbury Dr Residue
Enola, PA 17025
Total
Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 150 0 cover sheet as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO'iAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule J (Rev. 11.08)
LOCAL REGISTRAR'S CERTIFICATION i0F DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.110
P 18160760
Certification Number
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will he forwarded to the State Vital
Records Office for permanent filing.
~yyL1!' ~,~cue fE6 91 12
Local Registrar Date Issued
TVpe/Print In
J
J
COMMONWEALTH OF PENNSVLVANIA•D MENT OG HEALTHVITAL RECORDS
LF RTI FICATF AF ElF4TM
eatlant'a Leal Name (First, Mitltlle, Last, suHlx) dal saeurl[y Numbs e a eM1 (MO/Day/Y.1 (spell Mal
3 s
p
9
C o l e t t a A. M i l l e r FEmale
175-2a-/ 733
Febl~.ary 26, 2012
.. Age-L.at BlrtM1a.v tv.al
oua.r v D.
n r 1 v...
Data or Bl,tn tM./D.vnaan tspall Mon<ro . Blrtnelii.
(yn ig~sta<a.r G.r.rgn c.nn<ro
x H
not
~
nn[
85 D V
Marctl 6, 1926 Te. alrtnplace tcopnHl rid
am.n=e (star. or Fore1{n c.pntM ee. Renaan« tso-eet .na Npmb.r - m¢ pea Apt No-j eant upe m a rgwnampa
Pennerylvania 4837 East 'iYindle Road v.a, ea<eaent Il..ea m _B~Pdan '1~[P ~ H.
p.
ae. R..I~eil unq)
a21d 8a. R altlance (21p CoOa) 17 Q ~N nt Ilvea wlthln Ilmlca nI dH/bare.
v
V~
9. metl Pnruai 10. MerRVl stvtuaxTlme nr Deatn Ma I a Wltlowatl
survlvlnH Spousez Name(Irwlfa, Hive name pHO. <o nrst marrlagal
,
QV
N OVnkno ~D ONev rrletl
~U
V V
12. Earner's Name (Lint, Mltlale Leat, 3uNIKl
otne
s Name P.lar [v Flra[ hlarnage (First. MlCtlle, Lxn
1
Michael Wadakh~rth Ma
Cal lahan
3A.. mmrm.nra N.me lee- ReLeonxmp m Deceaan[ lAC. mrormenra Mainng Aaaresx tscreet .na Npmbe., aH. stue. zip cpaal
Mary Artn Tellco Dangb
5545 Westbury Drive E22ola, PA 17025
¢
..... .......... ....... ...
e
aoa eae
...................................... .......... .................................................. Y
If Daa[M1 Oc¢urretl 1n a Hospital:
Inpa<len[~~~~~~~~~~~~~~~~~~ IH paxM1 OCCUrretl somewhero~OLIFe~TIM1ana NOSpltal: ~~ ~~~~~MOSpice Facility ~~ ~~-[7Decetlen<'a~XVme~~~
g
y
er{enry Rwm/OUtpa<lant Oeaa on Ardvel riln{ Homa/Long-Term Care Fac
rIIH O<lier (sp clN)
1r
a2 b. Fa[Illty Neme (If not InaGtu<Inn, a(roet aria number',
ity1
Town, state, antl ZI tle tl. CnunH oG Oea[M1
Ca
l
C
l
~
1Ha
P
I1
I]
~ r
ro
yn
roxton S
ane
azdence
abur6+ PA 1
/
0
Enaph in
16a. MatM1Oa or OUpaslnnn Burial ~ Cremxlnn Ybb. pate ai Olspoaltlnn lbc. Place of Olap^altlon (Name of cemetery, crematory, nr otM1er place)
~
P
amnval Irom stvice ~ Ovnstlan
o<heNS ed March 2, 2012 Calvary CE'metery
v
=
a6e. L atmn ni olapnannn Inw p. Town, since, .na npl va. sienamr. pr Funeral ervla uc.na.. nr Pxxnn m marg. of mtxmant vb. uc.na. Npmber
Altoona, PA 16602 >Li FD 012774-L
3 F~¢
1t~
^
¢ R
`tiarcde
p
ie Elmo ral
9
z
c
o
l
13Drzle
th Ernla Drive Enola, PA 17025
~ lE.O uaen['s Etluutlnn-Chaco eha bor [ne<bast aaacrlbee the 19. Oecetlen[or HUpanlc Ongln-CM1eck [na 20. Oeceaan<'a Race-CM1eck ONE 00. MORE ra Intllcate wrier
hlg t tlegro val at achnvl cnmpletetl a[ [M1e time of tlaa<M1. bn <bes<tle tribe <aaan cetle: t conaltleree Flmself yr haraalr to
a
l
a
n
e
[
~
EtM1 [rasa ar
leaa Is sp nISIJHISp nIC/Latino
CM1eck
the
'N^"
[1~WM1Ire ~ K
r
Nv alplvms, 9th- 12th gutle box Ir tlecaeant is not spanlsh/Xiapa Ic/Latino. 0 B Incan
mxlcan
e amexe
~ V e
n
[ a
Mlgn school {ratluace nr GED completetl [XNO, n panlaM1/Hispanic/Latino
0 q can In Alaskv N ~ Ocner gslvn
v<IVa
l
tll
~ s IeR =raalt but no tlaHroe 0 Y exlcan, Mexlun American, Cnrcano ~ A an
lnalan
[] N wallan
o .n.
o A
a.{r.. o-. A:1 o y un o phln.a. o G nr Ehamo.r
,a
e
o
vp a~
s
c
R
°
'
:n a
p B
rx a.{r..(
b
r
AB as) o v
.
e can
p;
g
In
p s
,
^ ~
a
'
c¢
~M r'stleerae (e. g. MA, MS,Mn MEtl, MSW, MBA1 Vex, rspanlih/Hlspanl4Latlna ~ n : ~O<M1x PadR<IZlvnaer
O D a (e.{. ono. Eep) o m/eaaional degree Isp.dNl Dan.. (spadM
'a
mD DDS pvM L
-0
21. caaent'a single Race salt
e¢r{notion-check ONLY ONEta indicate wnac eha tleceaen<cvnxleeree M1lmzelt or M1eraxleo be. S2a.p cadem'x VauaI OCCUpvGO etypo or work
'^mcat
13 wntte Oiepane.e Os.mp.n enne aunna m.n pr wn.km
B Iira^DO NOT V3E RETIREp.
~ Black nr Arrl¢sn American O Knrean ~ Otner Paclgc IzlanJx
D A erie.n mal.n yr Al.aka N.[wa D v O p w/tint spre Eiman r2L+801LLC0a
in
n
p Aa nelan p D
e As1a O Rer sea
:x26. K ne nr Buz nessnnapa
I I
ry
O cnmese p Nacroe ww.11+n O otn.. tsp.dryl
ONllpln^ OG anion or Chamorrv AltOOna Rp6rJital
EM ZBa-2E MUET {I COMPLETED O ttP.onvunce Dry Vr Z3 eo arson ncln Dut
3 H ^ V app lu c. LI n um
Z3
a
1~'>~
IERSON WNO pRONOYNCEE OR ~/ -S O /a
CHI[TIFI{E OFATX O v
. mx slgnea (MO Dv r) A. Time of pea ~T J
~
3
/ o
/
Nl 2s. w.a Mmlcal Ex.ml a arc. d.aa o Np
. vas
CAUSE OF DEATH
2 Enter to ahvln ai. - injurlaa, or campllutlans-cna<tllrecNy cauaeG the tleatM1. D nal events sucM1 a aralvc vrrex< rvvl~t
O
r
raaplro[^ry xroat, ar venerlcul¢r Flbrlllat nn wit nu wing [M1e etl^In[V- nOT ABBREVIATE. Enter vnly
h t she DO
Vna uure
vnaline. Aatl atltlltlonal Bnei Hneceau riser to Dex
rY i O M1
IMMEDIgTE CAV3E ________ ___ ___a a. ~/V/AN \'~LeN '
(FI ontlltlon Due <o (arv sequence on:
rezult rig lnauMl b. ~ ~ vYC Q'rr~~~E [i4
nualy na<canalanna, ppa [n tnr ax a [.naeRp.nr. nn:
n+
v.
Ia mg to mec.pae
.
un
Ilmm un
. .. E a c.
t
ERLVING GVEE
pus <o (vr as a consepuence ^II:
m
~ ese or mnry m.e
Ia
tea me e.,.nta .eaw[ma a.
a.
-
y~y m
.ml uzT.
Due m Ivr s a ¢nnxaauence on:
y~ 26. Part 1L Enter neM1er bu<nat resulcrn{ In tM1e untlerlYing cvuse Hlven In Part I
ax
a meat
4 O Y
~, Dory flnaln{x avellable
e. Were elate the Gauze or tleaMi
[nc
$$$ O Ves ~ Nn
29.1/Fein 3D. DItl T^bacco Vse Cantrlbu
u
<^Dea<M1) -S. Man eat
h
~
a
oc ^r ^an
wlthln P st Year ~
t~
~
s o
prat
o H "'
a
a
at t
O P Ime or aaan
o tin
QynKFOwn
s`n..a
~mene p P
o A
aln seeadon
M p N
t p.e{n.nt. bpt pregnant wimm a2 a.w of aa.m ou
~ s tae ~ tlno[be aeterminetl
~ Not pregnant but pra[nan[C3 days tol xbePora tleacM1
k .Oaten lnlury lMV/Day/Vn (Spell MOnM1
t )
0 Un
nown IG Pregnant within Ma Paa Year 53. Time of lnlury
. Place or In)urv le.{. M1ame, canserucDOn slfe: term; xM1nnR 35. Lou[Inn of lnlury (street vna Number CI<y, state, Zlp Coael
36. lnjurye nrk 3T. li Transpvrtalnn Injury, spedN: De¢crlbe HOw lnlury OCCUrrotl:
o v o p er^
o Sn o Peaext
i.n
p Nn ~
s
o P.,a. .r o Dtnat PadNl
39..D r(en nej:
o
en
INI^g p
M1y4le
.n
TO [he b
mY kn tl{e, aeaM1 o urrctl tlue tv <ha cauu(a) antl my tea
a P
[
g
C
a
rtlo m -r. . ^mv ma
e, a.. r ma .~ ~a pm. p t o
al a m n
e
c.
a
e
.
o
w
m
o
n
p
O M
m
l
:.mmar/c n.,e.-D
na r
m aa
n..
„e/ In.aanHarion~
m . Impn,e amo .prrae acne lme
mm, .ne Ire anaa .m[ba tap n m.nnarxa
satin. tea
signa<prc m=.ren.r: oramn.r: 17~~ _
mbar: ~ l e I g D J Y L
L
ca Np
396. • tltlrosa antl Zip Cvaa era Cvmpl I g Cause of Oaa M1 ( 26
cE r/2c AO CA'x'
{a
ztc !
P l-if</PA
at
~2 <41
2
6~
t~`"~ Daa{n e1MO/Davn.l
s;l
-.`..av
..
x
~. <.t Eco
GE
Q
-
72 0112511 ~.
.Reaiarorx Deo-a Npm x m
. Raglx[rar
. Rag~xi p
I
ta
r / - ~ / ~ 9
o70 / 2
z~-
wapnxiNnn Parml<N..__11.~70 R 7/ REV -la3
o,nDlt
St san°'^,urteat°.
sooo Loulae orl~e Statement of Accounts ~
PO Box 40
Mechanicsburg, PA 17055 Feb 01, 2012 thru Mar 24, 2012
www.mamberalat.org
Main Switchboard: (717)697-1181 or (800)283-2320
EZ CaII: (717)6974372 or (800)2834372
Account Number:
370583
® TDD: (717) 697-5312 or (800) 283-2328 ext. 5312
TeleBranch: (717) 795049 or (800) 237-7288
MEMBERS ls` Balances at a Glance:
FEDERAL CREDIT UNION Checking: 4.91
Savings: 6.17
Certificates: o. 00
COLETTA A MILLER Loans: 0.00
C/O MARY A ZELKO- VA CUSTODIAL ACCOUNT Money Management: 0.03
ENOLA PA B 025 DRI VE Swipe 5 YTD Reward: 6. Do
Page: 1 of 2
Your aggregate balance as of March 1st is $53.24.
An aggregate balance of $2,500 and having 3 products
will place you in the Silver MLR level.
Celebrate National Credit Union Youth Week with us!
See the enclosed insert for more details.
cH~c~rN~ acc+~u~u
0091 - CHEt9'Ktb1G
Date jrahsacelon Deecrfotitm Additions Statrtractions Balance
Feb 01 Balance Fonwni _ 4.91
FebA7 Deposit Members 1st Online Transfer From Share 600 1,094.00 1,099.91
Feb 14 Check1028Trecerb0 0 131 5 24 0 ~~14rd0- 4.91
Mar 24 Entling Balance ' 4.91
,. , .CHECK SUMMARY .
h
~
C'ty Ainouht fJa~B
ry
x ChetYit ,# Ar~t3t~t Date
,
001 .~ t)0 ~ , FeH 14
~
s. ~ ~.
~p / v
D t R Tuna- ` ' ' cr~ tl n Additions..... S ~ ~ . lions Balance
Feb 01 /price id ~ ~ 6.12
Feb 01 t5epositACH JC~[A BEt~EF 'A 1,094.00 1,100.12
ID 31110~H~10$GX?: XXVA 8
~IpoL~t@~ 1Hi 1sY~n
li
he Tra NEF
ar,To are Q~ .'.
~ 1,894.00-
Mar,01
~
"
An~aiPar~~~ ~0 2Irrafrom
Mar'Y4
Ei
~1
`
°"
~t29f~fbrtf lfb2/29/2 0.05 0.17
17
5
~
~h~
e
~
rc ~ ,
,. >,~-m.:w .. .t z,
~~- <~ - `5fiictlonQYUob ' ~~` , . ~ Mldltib~ ; St~bt+actfons Balance
Fe~~ ~rilti
°Mdir ~t4 ~Ii"i~lA¢~alartcer
" ~
~ 0.03
ll. D3
~ .d
~,
,~
~.
h
~ Y ~
--- Continued on following Page ---
$t canalnrJwraslo.
5000 Louise Drive Statement of Accounts ~
PO Boz 40
Mechanicsburg, PA 17055 Feb 01, 2012 thru Mar 24, 2012
vnsw.membarslst.org
Main Switchboard: (717) 697-1161 or (800) 283-2328
FS CeII: (717)697-4372 or (800)2631372
Account Number: 222647
® TDD: (717) 697-5312 or (800) 283-2328 ezt. 5312
TeleBnnch: (717) 79511049 or (800) 237-7288
MEMBERS 1St Balances at a Glance:
FEDERAL CREDIT UNION Checking: o . 00
Savings: s.oo
Certificates: o . 00
COLETTA A M ILLER Loans: o . 00
5545 WESTBURY DRIVE Money Management: 0.73
IN CARE OF MARY ANN ZELKO
ENOLA PA 17025
Swipe 5 YTD
Reward:
o. 00
Page: 1 of 1
Your aggregate balance as of March 1st is $53.24.
An aggregate balance of $2,500 and having 3 products
will place you in the Silver MLR level.
Celebrate National Credit Union Youth Week with ds!
See the enclosed Insert for more details.
MEMBERS 1st
FEDERAL CREDIT l1NtON
COLETTA A MILLER
MARY ANN ZELKO
5545 VYESTBURY DRIVE
IN CARE OF MARY ANN ZELKO
ENOLA PA 17025
Sentl Inquir9s to:
5000 Loulae DrNe
PO Boa 40
f4echanicsbum, PA 17066
www.memberatstorg
Msin Swachboertl: (7171697-1161 or 16001263.2326
F2 call: (717) B97 4372 or (800) 263.4372
TOD: (7171687312 or (800) 263.2328 eat 6112
7eleararleh: (777179641048 or (800) 237-7288
Statement of Accounts
Feb 01, 2012 thru Feb 29, 2012
Account Number: 124722
Baknces at a Glance
Checking: 32.18
Savings: 5.00
CertiFlcates: 0.00
Loans: 0.00
Money Management: 0.00
Swipe 5 YTD Reward: 1.70
Page: 1 of 2
Your current Member Loyalty Rewards level is Silver
and your aggregate balance as of February 1 is
58,774.16. An aggregate balance of 575,000.00 and
having 3 products will move you to the Gold level.
Are you always on the go? Get our mobile banking app today! See the enclosed insert for more details.
CHECKING ACCOUNTS
0011 -CHECKING
Dats Trensectlon Daedotfon Additlorro SuMraetlons Balance
Feb 01 Balance Forward 88.47
Feb 01 Deposit Transfer From Share 0000 83.48 151.85
Feb 01 DeposO Transfer From Share 0000 164.42 318.37
Feb 03 Deposfl Transfer From Share 0000 1,234.00 1,650.37
Feb 07 Deposit Members 1st Online Transfer E0. 02106/12 3,900.00 5,450.37
From MILLER,COLETTA XXXXXXX)00t Share 0005
Feb 07 Check 003805 Tracer 0001136341 10.00- 5,440.37
Feb 10 Check 003807 Tracer 0001124169 2,160.00- 9,280.37
Feb 11 Deposit by Check 3,088.13 6,376.60
Feb 13 Check 003808 Tracer 0002512065 120.55- 6,265.96
Feb 14 Check 003006 Tracer 0001131317 3,084.50- 3,191.45
Feb 17 Withdrawal Members 1st Online Transfer 3,190.00- 1.45
To ZELKO,MARY A XXXXX)COCXX Share 0005
Feb 28 DeposB Members 1st Online Transfer 2.30 3.75
From MILLER.COLETTA XXXXXXX)O(X Share 0000
Feb 28 Deposit Members 1st Online Transfer From Share 0000 28.43 32.18
Feb 29 ErMing Balance 32.18
Cheek # Amount Date
00380b 10.00 Feb 07
003805 3,084.50 Feb 14
4 Checks Cleared for 55,353.05
CHECK SUMMARY
Cheek # Amount Date
003807 2.180.00 Feb 10
003808 120.55 Feb t3
WITHDRAWALS AND OTHER CHARGES
Dabs Amount Daeriotlon Date Amourrt Daserl~on
Feb 17 3,190.00 Withdrewal Members 1st Online
Transfer
- Cominuetl on fo0owirp pope -
st Send lnrJUires OD:
60001.oulse Dnve AAaln SvAtchboertl: (7171697-1181 or (8001283.2328 Feb 01, 2012 thru Feb 29, 2012
Po t9ox 40 F1 tau: pn) 697 4372 or (9901293.437x Account Number: 124722
M9tIDFA1M1•• MaeMnicsWre, PA 17066 TDD: (717) 697.6312 or (800) 283.23x8 ext 6912
www.mambaraletorg TalaBranch: (71717966048 or (800) 237-7288 Page: 2 of 2
1 Nlthdrawals and OMer Charges for 53,190.00
DEPOSITS AND OTHER CREDITS
Date Amount Descriotlon Date Amount Descriotlon
Feb Oi 63.48 Deposk Transfer From Share 0000 Feb 11 3,096.13 Deposit by Check
Feb 01 164.42 Deposit Transfer From Share 0000 Feb 28 2.30 Deposit Members 1st Online
Transfer
Feb 03 1,234.00 Deposit Transfer From Share 0000 Feb 28 28.43 Deposit Members 1st Online
Transfer From Share 0000
Feb 07 3,900.00 Deposit Members 1st Online
Transfer Eff. 02/06/12
7 Deposits and Other Credits for 58,488.78
SAVINGS ACCOUNTS
0000 - REGULAR SAVINGS
Date Trarrsactbn DeseAodon Addkiorre Subtracdona Balance
Feb 01 Balance Forwent 33.43
Feb 01 Deposit ACH BENEFIT PAYMENTS 83.18 96.81
TYPE: DEPOSIT ID: 9186063000 DATA: BPP0458UAVJMC CO: BENEFIT PAYMENT"S
Feb 01 Withdrawal Trensfer To Share 0011 63.46- 33.43
Feb Oi Deposk ACH RETIREMENT 164.42 197.85
TYPE: PENSION ID: t166265706 CO: RETIREMENT
Feb 01 Withdrawal Transfer To Share OOi 1 164.42- 33.43
Feb 03 Deposit ACH XXSOC SEC 1,234.00 1,287.43
ID: 3031036030 CO: XXSOC SEC
Feb 03 VMlhdrewal Transfer To Share 0011 1,234.00- X8.43
Feb 28 Withdrawal Members 1st Online Transfer To Share 0011 28.43- 5.00
Feb 29 Endirg Relents 5.00
0005 -MONEY MANAGEMENT
Date Transaction Descdotbn Addklons Subtractlona Balance
Feb O7 Balance Forward p,pp
Fab 29 Ernling Belarrce 0.00
YTD SUMMARIES
TOTAL DIVIDENDS PAID
0000 REGULAR SAVINGS $0.00
0005 MONEY MANAGEMENT $0.00
0011 CHECKING $p.pp
Total Year to Date Dividends Paid 0.00
NOTE: Total includes dosed shares
~~ ~'rud~ntiai
Mazy Ann Zelko
5545 Westbury Dr
Enola, PA 17025
Dear Ms. Zelko:
Thank you for your inquiry on the above contract.
Prudential Annuities
A Business o(Pmden[ial Financial, Inc.
P.O. Box 7960
Philadelphia, PA 19176
(888) 778-2888 TTY- (800) 654-7637
www.pruden[iatcom
Re: Colette A Miller
Contract Number: 97665232
April 16, 2012
The value of contract #97665232 as of February 26i1', 2012 was: $3,765.28
If you have any questions, please call the Prudential Annuity Service Center at f,888) 778-2888. The
Service Center is open Monday through Thursday between 8:00 a.m. and 7:00 p.m. and Friday between
8:00 a.m. and 6:00 a.m. Eastern time. If you are using a telecommunications device for the hearing
impaired, you may call (800) 654-7637, Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern
time.
Sincerely,
Annuity Service Center
Prudential Financial
Variable annuities are issued by Pruco Life Insurance Company (in New York, by Pruco Life Insurance Company of New ]ersey). Both companies
are located in Newark, Nl. Variable annuities are distributed by Prudential Annuities Distributors, Inc., Shelton, CT. Raced annuities are issued by
The Prudential Insurance Company of America. All are Prudential Financial companies and each is solely restansible for its own ^nancial condition
and contractual obligations.
(Page 1 of 1 ]
a , -, r
~,
{~j~~`~°
N
~R~~~~~
~ os
. ~ a
i+ u
~;
~~
~S ~ ~>`a
~ix~
.,, ' ,,a; i~~ ~.P
'F+F~~P' ^ '; '~~~
C'~F'~~~
~ ~~ ;:22
q~~~
~,A`~ ~
l~~~i ~
,., t^
~~~;~~FiIA~'~~ ~'~,' Y PP
a
rn
x
q'
a
o
o
= r
N
r
a
a
r
~+
'mod
N
c~
~ O
O "~
P~i r-
.-
Od p~.,
~ ~, bA
~~ ~
a N
O
O "x+
N
a.
c
0
O `~ cn
~o~o
0 0 o p~,
~U~ ~
~`~~~
x~ ~u
~O
a~
p
U
O
[-'
i
~~ L.AW Estate Planning • Elder Law • Special Needs Planning
2000 Linglestown Road Tec: (717) 540-4332
Suite 202 eax: (717) 540-4313
Harrisburg, PA 17110 www.HazenElderLaw.com
CERTIFIED MAIL
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Cazlisle, PA 17013-3387
May 23, 2012
Re: Estate of Coletta A. Miller
Date of Death: 02/26/2012
Social Security No.: 175-20-4733
Inheritance Tax Return
To: The Register of Wills:
-~
-~
~ ~ ~\l
~
~ ~~ ~. r'i Z~~7
i~~ ~
b
. -~ N
r r:~i~~
z
o c .> -o
n
y N `
N
Enclosed for filing please find the original and one copy oi'the above-referenced
Inheritance Tax Return, along with a copy of the first page of the Inheritance Tax Return.
Please date stamp the first page of the return and return it to my office in the enclosed
self-addressed envelope.
Also enclosed is a check for the filing fee in the amount of $15.00.
If you have any questions or require any additional information, please do not
hesitate to contact me.
Sincerely,
~~ ~~
Corinne Eggers Woodhouse
Paralegal
Enclosures
cc: Mazy Ann Zelko