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05-23-12 (2)
J REV-1500 ~lax-,a' m' PA Departrnent of Revenue P~Y~`r+~a OFFICIAL USE ONLY Bureau of Individual Taxes INHERRANCE TAX RETURN ~nry Code Year F1e Nutnbw PO Box ~8060>, ~ ( ` ~ ~ 1 d~` E Harrisburg, PA iyfi8-o6oi RESIDENT DECEDENT Sodal Severity Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~ . ~ ~o2-lovZ~L?! 0 18'091 9 1 g Decedent's Last N ame Suffuc DecedenYS Firs t Name MI / a fk~/DEkSZ~I' d ~f~IJI~ ~f _ .... . (If ApplMable) Eller SurvNfng Spouse's IrrfonnaDon Below Spouse's Last Name Suffix Spouse's Frst Name MI spouse's Sodal Sewdty Number THIS RETURN MUST BE FlLED IN DUPLICATE WfTH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Orginal Rettnn ® 2. Supplemental Retum O 3. Remainder Retum (date of death pdar io 12-1332) O 4. Limited Estate O 4a. FuWre Interest Companies (date of O 5. Federal Estate Tax Retum Required death after 72-72-82) ® B. Decedent Died Testate O 7. oeaedem Maintained a Living Trust ~, 8. Total Number of Sate Depx;X Boxes (Attach Copy of Wdl) (Attach Copy of Trust) O 9. LiBgatron Proceeds Received O 10. Spousal Poverty CredB (date of death O 17. Election to tax under Sea 9113(A) between 7231-91 and 7-1-95) (Attach Sch. O) CORRESPONDENT - TNIS SECTION YUSI SE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTIAL TAX INFDRMATiON SHOlILO BE DIRECTED TO: Name Daytime Telephate Number t~'E r/_i~:c ~' ff F. S /~ J3 L z 7 1 'j 9 3 `6 `.~. ! y $ Frst line of address y y;s ~~ L Z.~y Second line of address .. City or Post Otfice ET rERS , Correspondent's RoN-D State ZIP Code REGISTER OF WILLS USF~ILY C7 c :~ rn fJ tT, Ti 'i.~ U ~T ~ ~ rv .?v~ ;' c..t '7 Ci ~ r' ~r ~ ~ ~.:, _~ ~~ O ~~ ~. ~ r ". ~ C? i _,,...i .-~ n-t ~~ Undwlx+naltlae o(PerjM/. I deaere Met 1 have examined tl~ reaan, k~uding aomrtpenYNg adreawes all ataEerrentr. and m the best of d ie Mrs. correct and complete. Dad®atlon d papaw abler Men Me pxeanal repesentadva is based on ed inforrrmtlon d whkh weoarar ~w,aaAe~'da°~. ~. DATE anarw, ~~ yr rrtcrn~rt v, nrn i rvuv rteri¢serc~gl l V t DATE ADDRESS PLEASE USE OR161NAL FORM ONLY Side 1 1505610101 1505610101 J REV-1500 EX oe~eaenrs Nama: RECAPRULATtON ---~-.-....-. _ _-_--.~. 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. ' 3. Closely Held Coryoration, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Noes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedue E)....... 5. 6. Jointly Owned Property (Schedule F) ®Separate BiOing Requested ....... 8. 7. Inter-Vivos Transfers 8 Miscelaneous NornProbate Properly (Schedule G) Separate Bilfmg Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ................. . ........... 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilitles, and Lens (Schedule 1) .............. 10. 11. Total Deductions (total Lines 9 and 10} ............................... . . 71. 12. NM Value of Estate (Line 8 minus tine 11) .............................. 12. 13. Ghadtable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject lb Tax (line 12 minus Line 13) ........................ 14. INI~ YI.LYVLAI lW. - PGC 11~~ 15. Amount of Line 14 taxable at Me spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ t6. Amount of Line 14 taxable Decedent's Social Security Number 1`~q v~ /~37 Q ay'd9o• lS G• ~. ~v~3 71 •r~t Q p. ,,23a ylo l • 1 ~ __._~.._.___.r_~ ~ 7 ~S• 78 >~U ~ ~ •S 1 ~~i~~3•a aoS~ / '7 •~ 7 Q• _. 2vs~17•Ss? APPLICABLE RATES 15. • at lineal rete X .0 _ .. 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable ~~1t J at collateral rate X.15 p`Q,j GO ~ ~ •$. ( 18. 3C3 r6.~~ •lc 19. TAX DUE ......................................................... 19. ~,U ~. 7 O`Z .. lo.$ Z0. FILL IN TFIE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 1505610105 1505610105 ,+,' REV-1500 EX Pe9e 3 Decedent's Complete Address: File Number ,~v~o ~- c~i~9g DECEDENT'S NAME VHDq )f /~n/D~?SoN _ STREET ADDRESS I yys V~u~y R~»v cnv ETTERs sTATE ~, n~ P~ 173/ 9 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) .~ ~ ~ r loft 2. CrediLslPayments A. Prior Payments B. Discount ~ Total Credits (A + B) (2) 3. Interest yvT 7 On I J ~ r UlX~r7j v~ ,390 (3> i~79.9'a. 4. If Line 2 is greater than Line 1 + Line 3, enter the d'dfer~ce. This is the OVERPAYMENT. FHI in oval on Page 2, Llne 20 to request a refund. (4) U 5. Ii Line 1 + Line 3 is greater than Line 2, enter the di6erence. This is the TAX DUE. (5) Ja ~ 9aa r b 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: a. retain the use w income of the property transferred :.......................................................................................... b. retain the dghl to designate who shall use the Property transferred or ifs income :............................................ c. retain a reversionary interest; w .......................................................................................................................... d. receive the promise for I'rfe of either payments, benefits or care? ...................................................................... 2 H death occurred after Dec 12 1962 did decedent transfer properly within one year of death Yes No without receiving adequate consideretion? .............................................................................................................. ^ 3. Oid decedent own an "in bust for" wpayable-upon-death bank account or security at his w her death? .............. ^ 4. Did decedent own an individual retirement account, annuity wother rwn-probate property, which contains a benefidary designation? .................................................. ................................... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTNNiS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETURN. __ __ For dates of death on or after Jury 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers a or far the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [/2 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirerrrents for disclosure of assets and filing a tax return are still applicable even H the surviving spouse is the only beneficiary. Fw dates of death on w after July 1,2000: • The tax rate imposed on the rret value of transfers from a dec~sed child 21 years of age or younger at death th or for the use of a natural parent, an adoptive parent w a stepparent of the child is 0 percent (72 P.S. §9116(a)(1.2)j. • The tax rate im on the net value of transfers to or for the use of the decedents lineal beneficlaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to w fw the use of the decedent's siblings is 12 percent [/2 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 or adoption. REV-1503 EX+ (6-98) r '. SCHEpULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS IN HERITANCE TAX RET URN RESIDENT DECEDENT ESTATE OF FILE NUMBER VR9A N /fivp~neSV„/ ,~~o-- o~a9S" All property jointty-owned with Aght of survlvorshlp must be tlisclosetl on Schedule f. ' ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~ .j$3 ~OYHIMOAI S/~'A'~ES /}TAT ~ aZS~.S..S ~ J~~`/i/• ~S a, l `1t~ CcirnH7dA/ S/ft)R65 /ER/ZoN ~ 35% ~S" v $s-~, i y 3, 33 Conirnar SsttRES FR~snr7'/ELF ~' 9,..39 .s'v9 ~s? ~"7 C~MM1cN SN/!R6 /017/,~FdNE ~ o~.Rlp v~oZB`f. TOTAL (Also enter on line 2, Recapitulation) $ a1 /j/ - -- --- _ i If mo:e space is needed, insert additional sheets nt ;h2 same size) acv-+sre~.;, ~;, COfM1pNWEF1iN OE PENNSYLVANIA !NHEfLTANCE iA%RE"NRN RESQENiI~Cc'i1ENT SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. DQDCAWAI DDADCDTV ESTATE OF FILE NUMBER VADH N ~nr~~So~r Div-oia9$' Include 7te proceeds ot(idgation and the date the proceeds were received by the estate. AN property jointly-ovmad wiTh the right o(wrvivorship must 6e discWZed on Schedule F. NUMBER DESCRIPTION t' Cf~ECIG / 1'~~ /JC'l^O.'rNT, .~/ty~. f~>dlCj I`/EUl C'iJ/>"lf~'7P</41/D, .51 to -ate - ~o a. SAtc of v~~,~t~= /~-/a-,a 3. IZ~~ND FRt]M 13~`'7'r/~i/Y /i~cA~sE' ~i3r~rn~vr- ~ a~ i/ ~I. S. ~, J~tViO~1n~DS FRa+a Tz-z~°No~F sr©e,~s ~~il $ft~YK 5A/»/GS l~CCp~.INT //->S-/o FdRN~T[lKF SR~FS e`tr~// TOTAL (Also enter on line 5, Recapitulation) I S more space is needed, insert additional sheets of the sane slza) OF DEATH i~,~o $S9oZ~?, ~ !ds-~. 7 r 9S~yG4 y~ .>2S`33.13 FEV-151? EX+!10-(>SI ~- ` >~, SCHEDULE N FUNERAL EXPENSES & COASMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER VADA 1-f il-NO~s~N r~/~ `r~iD9F5' Debts of decedent must 6e reported on Schedule L .4. ~ FuNERALEXPENSES: f'~P~7°ft/D ~z~N~'Kk C`1-.2'I-~9) '~'rbss9~.aa i cHvRCt/ Rye FPr/ar/ Ftx1D Ct]5 Ts e. 1 2. 3. a. 5. 6. 7. ADMINISTRATIVE CvSTS: Personal Representadve's Commissions e~~-,„.,..~ Name of Personal Representative(s1 _1`.~NETJ>/_ F..--ri//~1L S.-'sx/ /~Q~.7/~ Streer Address _~yy~ -~JJ1LEy /p~%~JY _ ___ _ __ _. ___ _.__ n.- _-..__ City FJ-T~xS Stale r/f ZiP I7~I [.__..__ Year(s)CommissionPaitl: ~Ql~_.._. __. __ __ _ ___ __ _....... Aifomey Fees Family Ezemption: (It decedent's address is not the same as claimant's, attach ezplanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent _ _ _ _ Probate Fees AccountanPs Fees Tax Retum Preparer's Fees ~/VCGVDE7J 4//~/ PO~St'NA1 /p~R45~A'//}TRht,S CGyNM / SS /CN C3T4?~ liDvHZn/l~Rf}7/~' EX/'t'7YSF5 /~K't.JOiNC FS77y7F Cy`reKi//G AM~4uNT PR/irr/~rst PH'`!a /Kc~~- 7iyX t Ld$T SE~'c~RiTIE-~ L3d~'O /~YSUR9r/cE~ /tvVO F'vR/Yi!~/KF 1gpPRA-sslt d. G1C7 ~38.3a ~~~~~ ~ ~ OrJ G~, 00 ~/b~•J25 3?S,qB TOTAL (Also enter on line 9, Recapitulation) I $ a r~. 7~.~ . `~ ! (If more space is needetl, insen additional sheets of the same size) REA1572 EX= (12-03) SCNEDIILE 1 COMMONWEALTH Of PENNSri4ANiA DEBTS OP DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABWTIES SL LIENS ~ RESIDFM DECEDENT - ESTATE OF FILE NUMBER !lA D A N it NDE7eSVn~ ~Q/a •- oio5 g Report debts brcurrad by fhe decedent prior to death vihkh remained unpaitl as of the date of death, including unrelmbursed medical expenses. REh1 NUMBER DESCRIPTION VALUE AT DATE OF DEATH t QEi'7/~}/VY r'YxJYtTs APAkTr'17ENr /311F/NTEN.9Nr4" - ! p/o,~ '~ /Saj. `~~ o`(. MED)~NL eo-PRY IYIOFF/TT N~'IED,CA[ G/P~P ..~ ~'/ 3 , Nun y SP/R/ r NvsGs rA[ ~ •a ~ ~j, CltmP /fl[L /°Hy5/e/gNS x/3.951 S; yh~Q~CyL cr..,-PAy RAJ C6~7/¢R PaySJC/i4NS '7/a„ 24 (o, ry7E"D/e~ Ca -~i9Y NEPHKaL~Y yssae. /.~ I 7• Cf}m t° NI[L E~~<aETlcr Ptrys~~'~/1/YS (06,0/ `(3. CONT////JlN6 CARE' ~2~( /~02.~'/ ~3• P,fYc 8~K - CR~o, r c!}RD PrJIZeN~sES fus8o jD, )/ER~zoN I'-+'oNTH1y TEZCI°HvA~ ,B/u l~;~o TOTAL (Also enter on line 10 Recapitulation) f I ~~'~ ~-J (tF more space ~ needed, insert addifione7 sheets of Me same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /f}D~ N f1NDERSo/I/ fro -alo9g NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~ 1 6EO~E /~fNl~ TE~1,J~E H/L6K J~/H~/ +f /vreeE ' y3, Y~3. $2 .~. ~NATM9d RNO K/m6tRCY H/t~R ~{L~n/sMErF 93, H03, Ysa 3• /ANCE H/~E~ NEPHEW `l3, ~/.>7g• $l a~ ~lilvcr ENO ~Tr IPvar p~w~N~~ vs, ya3• as "~ / 7 3, 695.0 y ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET tt NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -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) ~)_1C~_ iC~~~. ^y N.: 4 . ~~p ~7 m ~CJ Z i~r'i C G"~ j Z ~ X F r x't ~'' OOH _ ~~~{{''~~y~{~y~Hy 1 (`]' y~y ~µ~~ AW+~~.L ~~i~+ ~~~~a~ V~~~ y~ N_ i:~~ ~ L'1 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 declaze 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 maybe 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 httchanA evr v ~ *T T A wmr+.rv..~. ITEM 4: I direct my hereinafter named Executor to pay all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my estate or the transfer of any property passing hereunder or otherwise passing by reason of my demise, maybe subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 5: I appoint KENNETH SMALL, currently of 1445 Valley Road, Etters, Pennsylvania, as Executor of this my Last Will and Testament. ITEM 6: I direct that my Executor or his successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. /IN~WITNESS WHEREOF, I have hereunto set my hand and seal this ~_Sday of ~ /c~~t , 2005. COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, VADA H. ANDERSON, JAN M. WILEY, ESQUIRE and SHERRY A. FITZA~E, the Testatrix and the witnesses respectively, whose names aze signed to the attached or foregoing instrument, being first duly sworn, do hereby declaze to the undersigned authority that the Testatrix signed and executed the instrument as her Last W ill and Testament and that she had signed willingly (or willingly duected another to sign for her), and that she executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed this Last Will and Testament as witness and that to the best of their knowledge the Testatrix was at the time eighteen (18) yeazs of age or older, of sound mind and under no constraint or undue influence. ~'V'ADA H. ANDERSON ~-~-. ~~ Sworn to and subscribed avJa-c~ia9fs THE ~AtF of- ~~fr stock ~~'9 ss,~ipxES)A.vo /~.e.$a.v .S~DeX ~~~ S.yAKES~ >// o~v>J GJRS DdF ra TNT STcxK CERr~F.cAf~s BEi.v~ GosT >¢.vo vn`KNOUJK'~~/U. 6s oi9 vs /./ ,zo/a 3~S o,~vs /~v avi/ 87 O.dys ri,+,ev 3-~g-/~ t~'se 9a *~'/v ~ 9.9~ 9.?7 OAvs X • c7ocr°sr~t r,p3sa/H x'°3o, 3y4.68= ,SfIfE lJt7°~.r ,Bnx iN-/~NraRY /, /~Ni/U/TY CoNTKAcT ,Q~cNEtt,~'D 4~~r1+~ hNe -CD ~• ~iHAND NvTE ~H>.D /N Ffi~c ~Y L"cdmC aolb-o1o9~' ~ _~ V~ L<. _ _ : ,'. ~„' r';iiit•t~t~tttlPl s•tstisil,,,~attt~lis~l114r~1~i ?445 VALLEY R~ ,r..T,TLI ~V 1~/l 1/JIJ Hader Account NUmbr:: VVl/ l~}°.IiII it.-e-1 i lU T _ ! i•rNSt In? 4!8! !all m9 nqa lultl!8n! !9!I l1g1 IIHI IIN !!^' .... . s' :<} t qs; ana am win nuunn un nil Uncertified arcWmis are su6ied to whtrtwldinn faun, ccurY+4 t•nA;fn,+ -_ :-,y ~ !~ortar! F,f nc~r4v+1 r'.nn•: R For t7cr Wier! V V r.! .. `~ f Th's'sirpaSatteidotofm ald's b,ioa MriWd q Yw YNer®1 Reverse Savka. BYOU are regWrad b Sk a radon, a rregligerke psilYvuaarsftlon.otY6e trued m ~ lr~ iearc loam •td ee tRS aeumwes tint a has not Waco reported. I~Si~TN f SW11 fX EST VADA H ANDERSON 4445 VALLEY RD ETiS25 PA 1%319 Date of Sale ~0! CUSIP No. or Exchange Stocks, Bonds. etc.ISI _.. 41r 9.1.i '~ CLr:ir'Jfr.CE: (iV ISJOI JS~ Payefs~Federal lD No. 43-1912740 oMe No. pus-lots pepaNre,aof the Treawry- Mtemal Revenue Soma Gross Proceeds Remrfed to lR.S t es FEDERAL WCOME ~ Description: TAX WRNNFI D (SI s3a.te E: Corv~azewil repalSre amauMin es you received represmis anY fees, drergea Name of Issuer ~iomputershare '~" Computershare Trust Company, N.A. wl Fnx e'di5.. Providenre, RI U2940~f?"' Transaction VERIZON COMMUNICATIONS INL'. Sale-CM f IRS.The 1ti8erercabelween thegross proceeds enou,t'm Box 2 and the net proceeds aldmg tines yw may here paid. Payer's Details ~~ COMPUTERSHARF P.O. BOX 43010 PROVIDENCE RI °' +-_-' nee ,ur iu„.,. ,.:.:,., - - -' -" ^-~rluction Net Amount .. "- ,.:, lV/ iyEi6 Of 5016 (E) ._..._.__._ .. __ _ _-., -~.: ~ ;::::: ee 1,623.66 638.18 Withholding Taz CanpWersha2TruslConpary, N.A., as alpM, Won vrtitten request. vdX prrnide the Wane of See,ecuting broker tlealer asea9aled wBh th transaUUion(sl. 8rM rdthin a reasonable amam(n(linv, W@I di.-,dose the s~.~me aM amamt of cony,emetion received hen tlSrd parties in cormection mlh the transaction(s), it anY. Irtratle Sine rs not ir,dutled above, d may De availaNe upon vrcitlen n;yues'i 71UTX V Z N '~" aq+coTCgaa ooNxzelFrl ~~~~ fj Communications r-- ..--- _._ _ _ _ 1 _. ...I i!1 ltl,~l i'~'tltlfliti''i'tililirtf'i'IOOeiite'iil"~itttt(1( 1445 VALLEY RD ~a Uncertified accourds are suhpw e., Wx :(u.!:..,::~ r_:.__ _..__. .... __.__. __.___.-q end„y~'~,f't~ II~~RIRR, RRpR~t~R,R,~1'R~p 1C'ai:'~1~1f'N,IIN,1111 ' 11a~,t!Rl,I'IMttRRI MN NII ua,l' aaauonrw OUICSUOUZSAL.C.REG.D.LCISASYSUS 30ULIIq)a)SNUUa35/i =-1J Cortected ('rfcttedced) Copy B -For Recipient Form 1099-8 -Proceeds from Broker and Barter Exchange Transactions 2010 Ttis-s irpuYwlui/ansrion and i btig Frrriatredbfls brWrW Revaee Saviea. Ryeu are ragrdred b Ne a refum a negligence ~~ paoRvriraadoneq~4 ilgosed onyw RitrY ircome ktax~leand Rte RtS rlNmnirw Mk Rhos not been reported. ' I~NIk fH F SMALL EX E5T VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319 _- Dale of Sale " CUSIP No. z _ Stocks, Gross Proceeds w Exchange Bonds, etc. ($) Reponed to IRS 02 Dec 2010 35906A108 309.67 Yes FEOE_R_A~_NiFOME __ '---Descd _ ._ -_.. _.. _. __- _ TAX WrtNFIELD Ii) I. _ Nar~oftsstie'r---_.-_..-_ ..Transaction---- 66.76 FRONTIER COMMUNICATIONS CORPORATION Sale-C01 E: Comprlerehare vriM rePOrtRU anwum in Boat roRteIRS. The diRermce between thegmss proceeds amoumheoa2antl the net pmceetls you recerred repeseMS any fees, Maigas, or wiRdgldsIg taxes you may have Paid. Account Number 0000365166 Redpient's ID No. 27-6901030 Payets Federal ID No. 4 3 7 912740 OMB No. 1545-0715 DaVaMwntditn T~easwy-Inremel Rewemre Servae Payer's Details COMPUTERSHARE ', _... __. - - - PRO 02940- 0 01 ~~~~~~ ~~~~-o tneep rw your recoras) Summary Thi< adviro is a wcnH „r }Hn min ni Oren endfnr rvi.e.~l DeniNrsC.... ~6.....e ~- "` - iss Amourd I Deduction Deduction ( Net Amount _:.__ ,,,, , ,,,, ,,, ~~i I ;,; Sales ($) Amount (SI TYPe of Sale ($) -. - _ __ _ --- ;... _ ...-_,,.,,,,...., i. iv0000 309.87 18.96 Transaction Fee 204.15 86.76 Wthhdding Tax Comgdershare Trust Company, NA., es agent, upon writlen request, vriN Dravida the name olthe eaeatirg broker dLwkr assodaletl wdh Ne tr~sadiaps), aM vwlhin a reasonable amount orbme wdl disclose the source aM amount of wmpensaeon nax;ived from third parties m cormeceon with the trensactian(s), R any. R trade time le nolinduded above, k maY be availehle upon wdRen request ^ 71 UTX tpmputershare CDmputershare Trust Company, N.A. Ndrter Account Number FRON '~ aofo-vi~9~' OUtCD1000e OUHx2E{FT) ;blll-UfD94" at&t IMPORTANT TAX RETURN DOCUMENT ENGi%S ooalgs ~- III'llll'tgllll'I'1'Illllllllrlelellllllrra"ill'lll'llllll'll'l Rer~pient KENNETH F SMALL EX EST VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319 Holder Account Number 01002146670 FID _ .. ,,,. ...., exlu atilt 11 g iafi '~' UncerBNed aeeourrts are wbJaet to rvithhoNBrg taxes SSN/TIN Cartl6ed No on divMend payments and sales proceeds. Symbol T CusiP 002088102 W lC'SIX~O'ISAI_GREG.D.LCIS.052305_3003N00195)OW7951i Arn.T ~,,~- .Sale Advice / 2010 Tax Form 1099-B Canecbd (d q,egred) Copy B -For Recipient Porm 1t199-8 -Proceeds from Broker and Barter Exchange Transactions 2010 7U's's iAwtaranxiionratlonad is txang hmkhW tithe Ndernal RwvarxreSavka. 8you are raquxedb 0M a reWm,a negrrgenre peaty aetllxmrKtlan may rae errpesed m you tthe hworn rstuWk and tlN 0ZS aemmaiNa tlln thu notr>err rrgoraed. IU=NNETH F SMALL EX EST VADA H ANDERSON 1445 VALLEY RD ETfERS PA 17319 Account Number 1002146670 RedpleM's ID No. 27-6901030 Payels Federal lD No. 43.1912740 OMB No. 1545-0715 DeparXrwM d the Tiea.:airy - YXema Rererxre service ,. ~~ ~ S 9 n CUSIP No. ~ Stocks, Gross Proceeds ~ Pa er's Details or Exchan a Bonds, etc. $) Reported to IRS y 02 Dec 2010 002088702 13,819.76 Yes COMPUTERSHARE __ _ocrxRU 1NCOIIE ] _ _ P.O.80X 43010 _Description: _._. NameiiT Issuer _.. _ __.-7rartsaetidn .. _.__.- - --.-_----PROVIDENCE RI- TAX YYITFIHELD (SI 02940-3010 3,889.53 A78T INC. Sale-COI NOTE: CallpWershere rriX report ne amoum in BOx2lo tlra IRS. The dixetence 6elweenXregrocs proceeds azemnln 9ox2a~therlet proceeds you receive0 repesenls any kes, rlgrges, a witlthddig axes you may have prod. Form 1099-B (Keep for your records} Summary This advice is a resuR of the sale of Plan andlor Direct Registration shares. Trade I (SharesNnfts ~ Price Per ~ Gross Amount I Deduction Deduction ~ Net Amount Transaction Description Date/Time Sold Sharelllnit (;) of Sales ($) Amount (;) Type of Sale ($) 12/021201014:06 Safe 484.000000 28.553220 13,819.76. 58.40 TrensaactionFce 9,891.83 3,889.53 Withholding Tax Campulershare Trust Comparry, NA., as agent, upon wdUan request vdX pmride the name of dra executing Mdcar dueler associated with the trensadion(s), end vnmin a masonabk emWnl of tine rdl discbse the source antl amount of conpensalion received from third parses in romectnn with the barreacXon(s), if arty. X aerie time is not included above, X maY be available upon wdXan request 71UTX ~pmputershare Computershare Trust Company, N.A. P.O.Bax 43078 Providence, RI 02940-3078 'vvriiiiu ii3ix. ii$irviiiu6rs it ianarin Hair .iii i7ii uucsitie u5ia, iii terrimries v ianada /G 15/D 4/09 www.computershare.com/att A T T ""I" OOiCD]000a OOHX2E {FTi ~.CJ/!~ -~IcKI~ FOCITI 199-8 Proceeds From Bri to Date of sale or exchange tb CUSIP No. 12110!2010 92857W20 I z st«as, Bonds, etc. U.S. INFORMATION RETURN 2284.49 ,FOR 2010 1 I ~ .r,L:DV B fc: I OMtl. Flo Statement for o-m - s: srnra+ .ar..vnr inn pFPI (1177Fr1~ ~ Oro55protee!aSleaaCOmmis- t±) ? S Bartering I4 emeau x~cosE rax amwso I7 Descdptlon - 5 No. or snares excnaerge~ , a c~ .r:::a: _. ..:.....: ;.c. ,..... _ - .~..,.:..,.,,~., e~,e,~.,r.e.w..~.:a~.u...........w,...... ~,.. The Bank of New York rawutrra~ra-vtw,vnuruu )O(}rJ(X1030 I 480 Washington Blvd 00145192857W20 I_- 1 Jersey City NJ 07310 ro KENNETH F SMALL EX UW VADA H WHOM gNrIFRC~IN 1445 VALLEY RD I weyw.brrymeNon.comishareownerliad ETTERS PA 17319-9703 13-5160382 PoRM to»$ CORRECTED DUPLICATE if checked PO Box 1630 Manchester, CT 06045 002312901 A60.380"AUTO H52 xi~i?i~_eiy IIIII'111'11"IIIII'ieire~er a ,•.'.. .. _ _.-, _..,.-.. KENNETH F SMALL EX UW VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319-9703 a °a m >~ ~_ s ~~I at&t IMPORTANT TAX RETURN DOCUMENT ENCLOSED 036688 III'VIII'II~~~~1'I'I'III~~I~IIrlrirll~l~~umlll'~11i~~~Iil'I~'~ Reapient KENNETH F SMALL EX EST VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319-9703 ^ ~«- Aoceull Nunber. 01002377094 Ra~yier[s N) ND. ~~ ~ ®Saks price 7o ftS ~ Sales price kss commissions and option pmmiums Issuer Name: AT&T Inc. Payers DetaNs COMPUTERSFiARE P.O. BOX 43010 PROVIDENCE RI 029403010 Payers Federal ID Number: 43.1912740 I~ used D IH1e IX 2 Jalee pots Q a l:Da[ IX a rCUCKAL II7I:NIIIC ~ rvesn sale o II UIeQ{ea, type IX sak or acquislion socks, bonds, a0rer basis (S) TAX WITHHELD (SI kiss disalklwed ba+nslb, 3,5,and gain ar bss ~mP~ ezldlarloe elc (SI 8 may be blank Yea sale of p shares of CONRJON STOCK (CUSIP: 0O206R102) sold ~ 529.30 x129 JW 2071 and total(rlg 52,007.70 will be reported to tbe IRS as follows: 29 Jul 2(177 2,607.70 730.16 ® 89 of R9 Shares Sold SEE REVERSE SIDE FOR INSTRUCTIONS AND DESCRIPTIONS NOTE: The Payer will report the anaunt in cdurm 2 to the IRS. The difference between the gross proceeds amain( in column 2 and tl1e net proceeds you received represents any fees. d7arges, or wiTttholdirg faxes you may have paid. Copy B - Far Recipient (Keep fa yea records) Department of dx7 Treasury -Internal Revenue Servos This is important tax information and Ia being famished to the Internal Revenue Service. H you are requhed to fde a rehan, a rtegNgertce penalty or other sanction may be imposed an you H this income is taxable and the IRS detemtbtes that k has not beer) reported 1000TX 01CLDA ''" OOICSWII.DOMLT B_DPLSX.ATf.lI3910 22711N3668aq? p~dlb-olc~l`~ ragelotz tomputershare + Computershare P.O. Box 43078 Providence, fll 02940-3078 Wdhin USA, US terdtaries 8 Canada 800 3517221 Outside USA, US territories 8 Canada 781 575 4729 www.computershare.coMatt Holder Account Number Company ID 01002377094 ATT ~ ~I ~ .t:! ONB No. - 7515A715 ap~~_p/C~' Pagelof3 1/, ver~Lln IMPORTANT TAX RETURN DOCUMENT ENCLOSED 009364 III'~1II'il~~~~l'I'i'Ill~~l~llrl'I'll~l~~""'111'~11'~~~III'I~'~ Rettipient KENNETH F SMALL IX EST VADA H ANDERSON 1445 VALLEY RD ETTERS PA 17319 ^ Canect9d (tf tS7edced) Account Number: 00013587035 Recipienrs ID No. 27.6901030 Reported t ®~s ~ to IRS J ^ ~ ~ ~ ~nissions and option premiunr• Issuer Name: Verizan Communications Inc. Paye/s Derails COMPUTFRSHARE P.O. BOX 43010 PROVIDENCE RI 02940.3010 Payefs Federal ID Number:43-1912740 U Dale d ro Dols d z Saps price A s Costa a FEDERAL INCOME s Wash sale a If checked, a Typed 7 sap or aco;sr3m sbda, ttards, .that hasa (S) TAX WITHHELD (5) loss disallowed ~ 1q 3.S,and gain or loss Desa~rxm excharae etc (S) 8 may be blank Your sak d70 shores of COMMON STOCK (GUSH: 92343V104) sold ~ S37.0T5617 on 14 Ju12011 and totaling 52,595.31 will be reported to the IRS as follows: t4 J;i 2011 2,595.31 0.00 ® 70 d 70 Shares Sold SEE REVERSE SIDE FOR INSTRUCTIONS AND DESCRIPTIONS NOTE: The Payer will report the amount in column 2 to the iRS. The ddference between the gross proceeds amount in column 2 and the net proceeds you received represents any fees, charges, or withholding taxes you may have paid. Copy B - Fa Reapient (Keep for your records) Department of the Treasury - Internal Revenue Service This is important tax information and is being famished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed an you if this income is taxable and the IRS determines that it has not been reported, 1000TX orc~on ~omputershare Computershare PO Box 43078 Providence, AI 02940-3076 Within USA, US territories & Canada 800 631 2355 Outside USA, US lenitories & Canada 781 575 3994 www.computershare.com/verizon Holder Account Number Company ID 00013587035 VZN OMB No. 7545-0775 001(50a21.DOMLT a rWi.F.%.V~rJ.INYtSJ 1i0fitflXwifiM11F ~a~a-O~o98 Asbury Communities, Inc. Description Amount Check Number. 0000206290 Check Dale 08/25/2011 Discount Paid Amount $.00 $88,922.00 To: Estate of Vada Anderson 34214 Invoice Number Date AUG242017 08/11/2011 Standard Entrance Fee $88,922.00 $88,922.00 $.00 $88,922.00 Total Banking Statement a,~io-o~~ "~°=`` PNCBANK YNC Bank ~. at. n«b+ t voanoto co >tzrosno~s oootes VADA ANDERSON DECD 325 MESLEY DR APT 3121 NECHANICSSURG PA 17055-3501 Primary account number 51-4000-1307 Page 1 of 4 Number of encbsuses: 0 For 24-hour banking, and transaction or ~' interest rate information, sign on [o PNC Bank Onlitre Banking at pnc.com. a For customer service call 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday: 8 AM - 5 PM ET Para servicio en espaflol, 1-866-HOLA-PNC ^IoritpT Phase tooted us at 1-888-PNC-BANK ® Wrketo:c~st~merservice -.._ - _ - - PODSx - -_ __ _. Pittsburgh PA 15230-9738 V isit us at pnc.com ® TDD terminal: l-800-531-1648 Ea txara,g aapaaed ct3enb Daly be9cniplbn Interest Checking Premium Money Market Tots) Depoaita Oaeaunt rUanasr 51-400(1.1807 51-3005-8537 Important Information on Federal Deposit Insurance Coverage (FDIC) Depo9it Balance 6,215.71 .00 6,215.71 Get acquainted with recent FDIC changes: ' On July 10, 2010, the basic amount of FDIC deposit insurance 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 _ ___~rovide unlimited FDIC insurance coverage for funds held in noninterest-bearing transaction accounts (checking} at insured banks. This temporary category will. remain ih effect through December 31, 2012. For more information on FDIC or to learn more about how to maximize coverage, visit www.FDlC.gov or call toll-free at 1-877-ASK-FDIC (1-877-275-3342). Hearinst imaaired line t-800-925-4618. ~Ott9r~ftt a1A~1g t ~Y~M~Bf y Axoum number: 51-4000-7307 Overdrsn Protectbn Provided BY: Ca'rkaot PIrC tw uahpMM O~~eiralt rrotsoUen Veda Anderson Balanos SusnmarY Beplnninq Dapoalts and Cheoks aMl other balance otMradditlon9 daductlons 7,900.66 1,582.79 9,217.74 Average mo~dhty balance 6,678.99 Endlnp aaaue 6,215.71 Charyea and Toes 20.00 WJnMI TM VIM9eM uan uuuuun, non nnnnnn •y Total Banking Statement ,~o/O- U~49R ~. u.. n«ba ~'afo9n9~s a ~snsri9~o For 24hour information, si0n on to PNC Bank Onlltre Banlung VADA ANDERSON DECD on pncwm. Primary aocourrtnumber: 57-4000-1307 Accosmt ntaaber: 51.4000.1907 - conlinaed Page 2 of 4 Nltefa9t ~ As of 12N3, a total of 57.39 in imerest was Mnua{ PerpMaga Number of days Avarega wifacted Interest Paitl Pad this year. Yleltl Earned (APYE) in iMeroat period balance for APYE this period 0.017. 30 6,678.99 .05 D9po9its and Other eons There were 2 Depositsand Other Addltlons Date amount Description totaling 5'I.i33J9. 11/16 1,53Y.74 Reverse Corporate ACH Debit Effective I1-15-10 lY/OS .05 Interest Payment ...:.... 11/lY 1,665.00 Direct Payment -Reversal US Trrasury 809 XXXXX1087A 11/15 1,53Y.74 Corporate ACH Cash C&D Asbury Comm 162 870 Other Dsalactions pate Amount lY/OS Y0.00 Da~7y Balance Deita7 pate Balaxe 11/04 7,900.66 71/]2 6,235.66 Dexriptlon Calculated Service Charge Type Hd Date Balance Date 11/15 4,702.9Y 12/08 11/16 6,235.66 Balance 6,215.71 i rears were i ~:niine or Electronic i3anking Oedudlonstotalirtg 53,f87J4. There was 1 Other Deduction tofalirg Sso.N. l~9M MAN ~ Serrdae Charge Explanation Aowaat MPe AocouM number Balance type As of Balance ~e axourrts were reviewed to meet LtenY Checkog XX XXXX 1307 This Cycle Avg Balance lY/04 6,679.66 [he balance requirements of your Senor Premium Plan Axoum. Since balance requirements were not met ifiis morRh, a 520.00 fee was deduced from this atwoum. Premwim Monet Market Aoootmt Summary vada Anderson Dena _ Aaount number. 51-3005-8537 OverdraR Protection Provided By: Cmtfae! PtIC >ta eels6ieM Oearrale Probotlos Bagimdrq Dspoaffs ant Checks and other ErMinp balarKe other addffions deduQbns balance 95,640.46 .00 95,640.46 .00 Averepe monthly Charges balance ant fees 95,068.16 .00 hetereet Sunrrary Amwal Perce~daga Number of days Averogs collected Interest Pald Yield Earned iAPYE) In Interest peno0 Delaue for APYE this parted O.OOY. 11 95,640.46 .00 As of 1211D3, a total of 5378.31 in imerest was paid this year. FOBMl6afl Free Checking Account Statement a°i°-°~°9~' For w Ptttrpa ~famnou m >tzxsrso~s For 24hour informatan, sign on to PNC Bank Online Banking EST OF VADA H ANDERSON DECD on pnc.oom. Primary aocoun[ number: 50-0448.5562 Accoumt snmber: 50-0448.5562 _ ~~~ Page 2 of 3 AcR111ifty D~ftail DtMotaita and Olh~r Additiono There overe 5 Deposits and OtherAdd'aiorw Date Amount Dexnplion totaling;a6.1O4.6O. 11/29 772.22 Deposit Reference No 520587805 12/06 177.00 Deposit Reference No 52647980E 12/10 12,019.94 ~ Deposit Reference No 525252085 - Q//AO3ij iRe»t /E~/ieCF SAL~F 12/14 6,215.71 Transfer From Sub Account 0000005140001807 12/16 11,719.6E Deposit Reference No 522710989 Chatmlta and Snbalipde gNdta Cbeok Date Reratenoe number Amoum paid number 1001 1,503.82 12/14 5YYS744Yi There b ~ chedt u~ toca8 l~,6oa.oa. Date Balance 11/27 95,878.89 11/29 96,151.11 Date 12/06 12/10 Balance Dafe Balatrce 96,328.11 12/14 178,059.94 108,348.05 12/16 724,779.57 FOgM165n ~o~.f~a ~, ~u,~iort ~E~vieE AUCTIONEERS & APPRAISERS 208 CREEKWOOD DRNE • CAMP HILL, PA 17011 PHONE (717) 737-0000 November 12, 2010 Fee for Appraisal for Ken Smith 150.00 Thank you Michael Costea Au-1759-L Auction Management and Appraisal Service Antiques appraised, purchased, sold on consignment ,~jia- dit~9S ~o~a ~. v~uef~ort cSs~veE AUCTIONEERS & APPRAISERS 208 CREEKWOOD DRIYE • CAMP HN.L, PA 17611 PHONE (717) 737-0000 November 12, 2010 Appraisal for Ken Small: 1 Modem Curio with Arched doors 175.00 2 Mahogany Breakfront with Curved glass door 250.00 3 Mahogany sideboard 125.00 4 Reproduction ice box stand 35.00 4 Vintage Gone with the wind lamp 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 table 150.00 7 Vintage Gone with the wind lamp electrified ]25.00 8 Single Mahogany bed 75.00 9 Vintage square Oak china cabinet 200.00 10 Small Mahogany stand 35.00 11 Modern pole lamp 25.00 12 Upholstered Modern chair with Queen Ann feet 85.00 13 Vintage rectangulaz White mazble top table 175.00 14 Vintage Brown Rectangulaz mazble top table 150.00 15 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 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 Auehlon Management and Appraisal Service Antiques appraised, purchased, sold on consignment ~-fio - oio~~ `~~ ` ~ ~~j ~~ ~ A Family Traditi(~n Of Caring' .~"'~-, PARTHEMORE Funeral Home & Cremation Services, Inc. Mrs. Vaaa H. Anderson 212 Old York Road New (,5tmberland, PA 17070 i30J Bride Street P.U. Bos -i ~ I \ew Cumberland. PA 17070 1-:'1' ~3-7i3i i Fat I ---l-~~d6 «~c~:parthemore.com Gilbert ~3~. Parthemore, Founder Gilbert J. Parthemore. Supers isor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre Veed Coordinator CPC Professional Memberships: NFDA•PFDA DCFD.4 • CCFDA ~w..n,bre~n~N.k Cr t ULE n,u e„t~• ~~~, n,~,,,,: rn,~ N~~~~i~~ ~t,,, r,,.,~, ~,.~ ~~ -~ .. ~ ~a~€,a~ } 17129!2008 We sincerely appreciate the confidence you have placed in us and will continue m assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, facilities, antomotlve equipment and merchandise that you selected when making the funeral arrangements. Terms Due Date Account # __ Net 30 1/28/2009 2008111.0 Description Amount SERVICES & MERCHANDISE Traditional Funeral Service 5,595.00 Wildflower Stationery Set 135.00 Total Services and Merchandise 5,730.00 CASH ADVANCE ITEMS Dea[h Notice, Harrisburg Patriot 199.89 10 Certified Copies of Death Certificate 60.00 (2) Clergy Honoraria 200.00 Organist Honorarium 125.00 Flowers, Casket Sptay 200.00 Total Cash Advances - 784.89 ~~~ p ~ s ~ ~`c~t Ir - ~~l ~ ~'~.~ ~ _ r~ o ~ g Total $6,514.89 Payments/Credits $o.oo Balance Due $6.514.89 '~1~CU.rs 1 t `/. 60 ~ Yoo, a`T a~~a-U~~9~- ~~~~ A Family Tradition Of Caring® ~'~' PARTHEMORE Funeral Home & Cremation Services, Inc. November 23, 2010 1303 Bridge Street P.O. Box 431 New Cumberland, PA 17070 (71'1774-7721 tF~a?~4-scab www.partbemore.com Gilbert W. Parthemore. Founder Gilbert J. Parthemore. supervisor Stephen K Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC The Estate of Vada H. Anderson c/o Mr. Kenneth F. Small 1445 Valley Road Etters, PA 17319 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 Death Notice, Harrisburg $ 367.07 $ 350.00 Certified Death Certrficates 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 Whfte Dress -0- 132.00 Subtotals: $1024.07 $1107.00 Difference: Total Refund Enclosed: Professional Memberships: NFDA•PFDA DCFDA•CCFDA ~~ The Rufe You Krtm¢ The People You Trust ($ 82.93) $82.93 Please call if you have any questions. Thank you. klc !z~, ~'• - rY ~ ~` ~ - - K1 lil. al~lo -via9$ Comments _ YOUR DESIGNATED AMOUNT WILL BE PAID BY ELECTRONIC FUNDS WITHDRAWAL FROM YOUR BANK Balance Forward $1,532.74 11/15/10 -11/15/10 ACH Payment 11/10 Check #ACH $1,532.74 11!15/10 - 11/15/10 ACH Payment 11/10 Check #ACH - RET $(1,532.74) 10/18110 -10!19/10 Transportation 2 $18.75 $33.50 11/30/10 - 11/30/10 Monthly Fee (1) $(62.42) TOTAL BALANCE DUE: $1,503.82 ~I~ send a ~nec~, Apr ~m~l+ ~~ ~ ~ ~ D ~ a, ~ FACILITY NAME RESIDENT NAME ACCOUNT NUMBER BETHANY COURT APARTMENTS MRS. VADA H ANDERSON 2134 J 48500041046 ob/0-!J/09$ REV-085 EX (1-07} SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE OR161NAL FORM ONLY Sodal Seauity or Death Certificate Number Date of Dea[h County Code Year File Number _.. , . _ -. ~9 -Oq l O 39' 1 O Zco 2-0 ~ O Decedent's Last Name Suffix First Name ~ MI A +~ c1 s e. r S G n ~( C( c~ A- (-~ ©ADDRESS OF DECEDENT STREET: CrjTY: STATE: ZIP CODE: n n .- ~ .. _..r /1 , 1 _ ~_} _ '1 .. -~ new.. NAME AND ADDRESSS1'' ,O,F PE^RSON REOtN:STNIG THE OPENNG OF THE SAFE OEPOSR BOX NAM~111'1.~~'K -Y ~(L~~ STREET ADDRESS: , r ~ e ~ r n ~MT~'- TO DECEDENT. OF PERSON(S) PRESENT A7 THE BOX OPENING a, ~(~ REL4T10 SHIP: STREET ADDRESS _. - /7--,G R_--r-~~ - (?~~I~IP CODE: ':. - l ~~.c ~5_ t). ~1 \~e~ ~Q e__ Ly_".LLB., >' 3 ~J b. NAME: RELATIONSHIP: STREET ADDRESS: clTr: STATE: ZIP CODE: c NAME: RELATIONSHIP: sTREETnoDRESS: an: STATE: ZIP CODE: NAPE AND ADDRESS OF FNIANCIAI R1STiTUTiON WHERE THE SAFE DEPOSR BOX IS LOCATED lJG ~_ OF DATE QF CQNTRACT TO RENT HOX OF IS ® NAME AND ADDRESS OF PERSON(S) HAWNG ACCESS TO BOX a. NAME: b. NAME: S7 E TADD ES ~ ST 7AD9RE8 ,CITIY:_ ~~ ) n ~ STAT§: ,ZIP CODE: CITys .~ STATE:_ ~jIP CODE: OF WAS A WILL IN THE SOX? U YES x)10 N yes, a. Date of will: ~; b. Nama and address of pereonal reprosentalWe, N named In iha will NAME STREET ADDRESS: CITY: STATE: ZIP CODE: j c. Name and address of attomsy, H any ~ NAME: STREET ADDRESS: - CITY: STATE: ZIP CODE: 48500041046 48500041046 J ~o/v' aio9S REV-485 EX SAFE DEPOSIT BOX INVENTORY Page of INSTRUCTIONS (1j Cash: Report total only. (2) Stocks: List in tletail every common or preferred certificate, wanant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and nurnber of shares and class of stock. (3) Obligations of U.S. Government: Numher 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. numher 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. I (Tj Deeds, Mortgages, Curcent Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. ' (8) All other contents. (g) Retum completed form to: OEPARFMErST OF RE+JENUE INHERITANCE TAX DMSION PO SOX 26D501 }iARRlgetlRCx, PA S i 128-0561 ' REM `• i No. --_ - ® ITEM DESCRIPTION -- -~-'~ ~ , BOO ~1J~,-GtCS'~t~~y' a~C~t-~m~~ .- ---- -- ----- /~~. _t~_l~tk'~G~[~E- --=~~~'e~K- ~aDo.+--~_~n ~_ _ -L~(a`~~xt.~Q: --- _t~C~-yf.L, ~f~.~S.~~ r ~rr~~~- GCP1f1~~-~? ' - -- - ---- I - --- -- 1 CERTI UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CO C OOMPL 70 THE BEST MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT t30X INVENTORY: 51 T ) / 516NAT RE ~ -- ~ PRI AME p \VS lA/~l'.Lt ~ / ~ `^ DATE t,CL7r~C„A (y--Lf`- to ~~(~ PRI AME AND CHECK APPROPRIATE 80%BELOW- CHECK APPROPRIATE BOX. ~ExeCUlogViz) ^AtlminisVatrn(Mz) ^ Fatale Representatlve ^ Joint owner of safe tlePesit box NOTE: Attach additional 8'/:° x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized bylaw, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connecfien wib administedng state tax laws. The Department uses the Social Security number to identify the decedent and personal representatNes of the estate. The Comrtronwealth may also use the infortnatlon h exchange of tax information agreements wiN Federel and local fazing authad6es. The state law prohibits the CommomvealN's personnel firm discbsing confidential tax ilrfonnation except for offidal pu sea.