The URL can be used to link to this page

Home My WebLink About05-31-12J 1505610140 REV-1500 EX (°'-'°' PA department of Revenue Bureau of Individual Taxes County Code Year File Number PO Box 2sosol INHERITANCE TAX RETURN 2 1 1 2 0 3 1 8 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 8 2 0 1 2 1 2 2 5 1 9 2 3 Decedent's Last Name Suffix Decedent's Firs t Name Mt B E L C H E R L E W I S E (If Applicable) Enter :surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH 'THE REGISTER OF WILLS 2. Supplemental Return ^ 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number S U S A N L- H I R S H M A N 7 1 7 7 6 1 1 5 6 7 First Tine of address 1 5 1 Y E L L O W Second line of address B R E E C H E S D R City or Post Office C A M P H I L L State ZIP Code 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) REGISTER OF WILLS USE Q!V{_Y C'~ `.°; C r C'~ ~• i c f',. 3~ 7,. _„_ i _.: ... ~~ ~ _..,. J "_ .. _ DATE`FILED i"3 c_~~ P A 1 7 0 1 1 Correspondent's a-mail address: HIRSHMANaSHUMAKERWILLIAMS • COM C, 7~ t'~`! -T7 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, ect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN RE OF PERSON SP NSIB OR FILING ETURN DA E_ DRESS 151 YELLOW BREECHES DRIVE CAMP HILL PA 17011 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610140 Side 1 1505610140 J k ~f ~ 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: LEWIS E• BELCHER RECAPITULATION 1 1 D D D D D, D D 1. Real Estate (Schedule A) ..................................... .... . .. 2. Stocks and Boncis (Schedule B) ................................ .... .. 2. 5 D 5 2 1 . 6 6 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) .................... .... .. 4. 4 2 7 D D 8 5 4 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E). .... .. 5. . 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . .... .. 6. 7. Inter-Vivos Transfers & Miscellaneous, Non-Probate Property (Schedule G) ^ Separate Billing Requested . .... .. 7. 4 2 1 1 2 • 9 2 8. Total Gross Assets (total Lines 1 through 7) ..................... .... .. 8. 6 1 9 6 4 3 • 1 2 9. Funeral Expense's and Administrative Costs (Schedule H) ............ .... .. 9• 1 3 2 3 D • 2 4 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... .... .. 10. 2 1 1 7 . 6 2 11. Total Deductions (total Lines 9 and '10) ......................... .... .. 11. 1 5 3 4 8 . 8 6 12. Net Value of Estate {Line 8 minus Line 11) ...................... .... .. 12. 6 D 4 2 9 5 . 2 6 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ .... .. 13. 14. Net Value Subject to Taz (Line 12 minus Line 13) ................ .... .. 14. 6 D 4 2 9 5 . 2 6 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .045 6 0 4 2 9 5 2 6 16. 2 7 1 9 3. 2 9 17. Amount of Line 14 taxable at sibling rate x:.12 D D 0 17. D. D D 18. Amount of Line 14 taxable at collateral rate X .15 ^ D D 18. 0. D D 19. TAX DUE ................................................ .... ..19. 2 7 1 9 3• 2 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVE RPAYMENT ^ Side 2 1505610240 1505610 24 0 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 12 0318 DECEDENT'S NAME LEWIS E• BELCHER _ _ _____ STREET ADDRESS 26 RIDDLE ROAD CITY STATE ZIP CAf1P HILL ', PA 17011 Tax Payments and Credits: ~~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount $1, 3 59.66 3. Interest 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 20 to request a refund. (1) $27,193.29 TotalCredits(A+B) (2) $1,359.66 (3) (4) $0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $ 25 , 833.63 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ ^X b. retain the right to designate who :shall use the property transferred or its income; ............................... ^ ^X c. retain a reversionary interest; or ................................................................................................ ^ ^X d. receive thie 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" orpayable-upon-death bank account or security at his or her death? ......... ^ ^X 4. Did decedem; own an individual retirf;ment 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."I) (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 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)]. 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-1502 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETUF;N RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF: FILE NUMBER: LEWIS E- BELCHER 21 12 0318 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of thE~ deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1• 26 RIDDLE ROAD $100,000.00 CAMP HILL, PA 17011 VALUE IS BASED ON ATTACHED APPRAISAL TOTAL (Also enter on Line 1, Recapitulation.) $ 100, 000.OD If more space is needed, use additional sheets of paper of the same size REV-1503 EX + (6-98) COMMONWEALTH OF PENN£'~YLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER LEWIS E• BELCHER 21 12 0318 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 18 - $500 HH BONDS $9,000.00 2• 127 - 5100 EE BONDS $32,622.28 2 - $100 E BONDS 3• PRUDENTIAL FINANCIAL, INC• COMMON STOCK $8,899.38 145 SHARES at $61.375 PER SHARE TOTAL (Also enter on line 2, Recapitulation) I $ 50 , 521 •66 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (11-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETUF'.N RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: LEWIS E• BELCHER 21 12 0318 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MORGAN STANLEY SMITH HARNEY $99,243.00 INVESTMENT ACCOUNT ACCOUNT MO• 724-81123-15 562 2• M&T BANK $31,553.20 POWER CHECKING ACCOUNT MO. 982D6087 3• M&T BANK 5117,876.14 POWER MONEY MARKET ACCOUNT ACCOUNT NO. 150042221'79465 4• M8T BANK 5111,122.55 RETIREMENT ACCOUNT ACCOUNT MO. 350042034.55561 5• M&T BANK 546,788.77 CERTIFICATE OF DEPOSIT ACCOUNT NO. 310039205:11184 6• 2DDD BUIC:K CENTURY 55,60D•00 VIN 2G4Wti'S5J9Y1330975 7• PRUDENTIAL ALLIANCE ACCOUNT 512,874.88 ACCOUNT N0~ 4351003066634 8• PERSONAL PROPERTY SOLID AT YARD SALE 51,950.00 TOTAL (Also enter on Line 5, Recapitulation) I $ 4 27 , D^ 8 If morE~ space is needed, insert additional sheets of paper of the same size REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER LEWIS E• BELCHER 21 12 D318 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR REIATIONSHIP TO DECEDENT AND THE DATE OFTR,4NSFER.ATiACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IiFaaauc:neLEl TAXABLE VALUE 1. PRUDENTIAL ANNUITY SERVICES; $34,370.52 10D•DD 534,370.52 CONTRACT NO• ED719634 2• PROTECTIVE LIFE INSURANCE COMPANY 57,742.4D 10D•DD 57,742.4D ANNUITY POLICY NO• G7001576D TOTAL (Also enter on Line 7, Recapitulation) $ 4 2 ,112.92 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVEPJUE INHERITANCE TAX RETUF;N RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER LEWIS E• BELCHER 21 12 0318 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. PARTHEMORE FUNERAL HOME 8~ CREMATION SERVICES, INC• $7,826.22 2• ROYER'S FLOWERS 5498.20 3• FUNERAL LUNCHEON 5600.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(sj Commission Paid: _ 2. Attorney Fees: 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation.) 53 , 500.00 Claimant AMY K • BELCHER Street Address 26 RIDDLE ROAD City CAMP HILL State PA ZIP 17011 Relationship of Claimant to Decedent D A U G H T E R 4. Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS 5505.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. THE SEPJTINEL $136.44 8- CUMBERLAND LAW JOURNAL 575.00 9• GENERAL_ ADMINISTRATIVE EXPENSES - OVERNIGHT MAIL, POSTAGE, ETC• 588.88 TOTAL (Also enter on Line 9, Recapitulation) I $ 13,230.24 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OS) pennsylvania DEPARTMENT OF REVEfJUE INHERITANCE TAX RETUF;N RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8r LIENS ESTATE OF FILE NUMBER LEWIS E- BELCHER 21 12 0318 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. FREYSINGER MOTORS $80.51 VEHICLE INSPECTION (PREPARE FOR SALE) 2• PENNSYLVANIA AMERICAN WATER $152.65 ACCOUNT NUMBER: 24-0631346-6 MARCH-APRIL-MAY 3• UGI GAS SERVICE $232.00 CUSTOMER NUMBER: 218194383508 APRIL-MAY 4• PP&L $184.45 ACCOUNT NUMBER: 44700-•72009 MARCH-APRIL-MAY 5• VERIZON $22.35 ACCOUNT NUMBER: 717 737-5469 365 93Y 6• LOWER ALLEN TOWNSHIP $108.95 SEWER/REFUSE 7• TERMINEX $95.40 CUSTOMER NUMBER: 8301292 8• OHIO CASUALTY $148.75 HOMEOWNERS INSURANCE ACCOUNT NUMBER: 85001],299264 9• PINNACLE HEALTH HOSPITALS $58.33 ACCOUNT NUMBER: 120225305 1D• BONNIE K• MILLER, TREASURER $9.80 PER CAPITA TAXES CONTROL NUMBER: 13-000960 11• BONNIE K• MILLER, TREASURER $644.43 REAL ESTATE TAXES CONTROL NUMBER: 1313000284 12. INTERNAL REVENUE SERVICE 5180.00 2011 INCOME TAXES FILED AND PAID 4/15/2012 13• P• SCOTT ARCHIBALD 5200.00 REAL ESTATE PROPERTY APPRAISAL TOTAL (Also enter on Line 10, Recapitulation) I $ 2 ,117.62 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania ~ SCHEDULE J DEPARTMENT OF REVEfJUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: LEWIS E• BELCHER 21 12 0318 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. SUSAN L• HIF;SHMAN Lineal 2'i~ of Remainder 151 YELLOW BREECHES DRIVE CAMP HILL, F'A 17D11 2• JEANNE M• DAVIS Lineal 2'S~ of Remainder 4136 BURNS F;OAD MECHANICSBURG, PA 17055 3• LINDA R• BENSON Lineal 2.5~ of Remainder 1533 BRIDGE STREET NEW CUMBERLAND, PA 17D7D 4• AMY K• BELCHER Lineal 2.5~ of Remainder 26 RIDDLE ROAD CAMP HILL, PA 17D11 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEEP, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 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, use additional sheets of paper of the same size. ~~ REGISTER OF WILLS CUMBERLANCI COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 2012- 00318 PA No . 21- 12- 0318 Estate Of: LEWISEBELCHER (First, Middle, LasU Late Of : LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY Deceased Soci a1 Security No : 185-12-9413 WHEREAS, on the 16th day of March 2012 an instrument daterd August 20th 2009 was adrrtitted to probate as the last will of LEWIS E BELCHE~R (First, Middle, Lastl late of LOWER ALLEN TOWNSH/P, CUMBERLAND County, who died on the 8th da;r of March 2012 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the .Commonwealth of Pennsylvania, hereby certify that I have th_i s day granted Letters TESTAMENTARY to: SUSAN L HIRSHMAN who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, alI of which fully appears of record in my office at CUMBERLAND COUNTY COL/RT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 16th day of March 2012. } ~ r; /~ r ',~ ~ < eg/ster / ils ! // ~._ _ 1 ! l2 e ut * *NO'TE* * ALL NAMES ABOVE, APPEAR (FIRST, MIDDLE., LAST) LAST `VILE -_. ~- _ - LEWIS E. BELCHER _:; ~~ ~ - -1 ~-~ ' Tt -~ I, LEWIS E. BELCHER of 26 Riddle Road, Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time made. 1. I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes. may. be .payable by my Estate or by'any recipient of any property, shall be paid by my Executrix out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executrix shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executrix even though on proceeds of insurance or other property not passing under this Will. 2. I hereby exercise all powers of appointment which I may have at the time of my death in favor of my Executrix, and all property subject to all such powers shall be included in my Estate. ~-. `~7 ~,.. L ~~~ _ Initial 1 3. My wife, Marian L. Belcher, having passed away on March 16, 2009, I hereby give and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, together with all policies of insurance hereon, to my children Susan L. Hirshman, Jeanne M. Davis, Linda R. Benson, and Amy K. Belcher, in equal shares, per stirpes. Should my said surviving children be unable to agree between or among themselves upon such a division of said property, alternate choice of individual items thereof shall be made by them as follows: the first choice of individual items thereof shall be made by my oldest surviving child, the second choice shall be made by my next oldest surviving child, and so on according to age until an equal or nearly equal division and distribution of said property items is completed. 4. Should any of my children predecease me, then such predeceased child's share shall be divided and distributed equally among or between those of her children who may survive me at my death; should such predeceased child of mine leave no children of her own surviving me, such predeceased child's share of my said estate shall pass to my other surviving children, or their children, as hereinbefore provided. 5. In the settlement of my Estate, my Executrix shall possess, among others, the following powers to be executed for the best interest of the beneficiaries and in my Executrix's sole discretion: 1~~ r r ~(~ . Initial 2 (a) To sell either at public or private sale and upon such terms and conditions as my Executrix may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executrix, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executrix in this paragraph 4(a) or elsewhere in my Will. (b) To pay all costs, taxes, expenses and charges in connection with the administration of my Estate. My Executrix shall pay expenses of my last illness and funeral expenses. (c) To distribute my Estate in kind or in money. If any assets are distributed in kind, they shall be distributed at their respective value(s) on the date(s) of their distribution. (d) To retain any investments I may have at my death so long as my Executrix may deem it advisable to my Estate. -~:; ,~ t .~ ~: - . Initial 3 (e) To vary investments, when deemed desirable by my Executrix and to invest in such bonds, stocks, notes, money markets, real estate mortgages orother securities or in such other property, real or personal, as she or he shall deem wise, without being restricted to so-called "legal investments". (f) To mortgage real estate and to make leases of real estate. (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other. (h) To vote any shares of stock which form a part of the Estate and to otherwise execute all the powers incident to the ownership of such stock. (i) In the discretion of my Executrix, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. Q) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. (k) To elect such settlement options as deemed most appropriate by my Executrix with respect to any person, profit sharing or other retirement plan in which I am a participant. ~ ,~ -. ~ `~ i Initial 4 (i) To do all other acts in judgment of my Executor necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. 6. Any person who shall have died at the same time as Testator or in a common disaster with him, or under such circumstances that it is difficult or impossible to determine who died first, shall be deemed to have predeceased him. 7. I nominate, constitute and appoint my daughter, Susan L. Hirshman, to be my Executrix. In the event of the death, resignation, refusal or inability of Susan L. Hirshman to serve as my Executrix, I nominate, constitute and appoint Jeanne M. Davis to serve as Executrix. My Executrix is specifically relieved from her duty or obligation of filing any bond or bonds. IN WITNESS WHEREOF, I, the said Lewis E. Belcher, hereby set my hand to this my Last W ill, typewritten on and consisting of these five (5) sheets of paper, at the bottom of each of the preceding pages of which I also have placed my initials, on this ~4 ,day of August, 2009. _ ~ ~~~~~ Le iw s E. Belcher ;~ . o~~ ~_ Initial 5 On this ,:~-~=~ ~~ day of August, 2009, Lewis E. Belcher declared to us, the undersigned, that the foregoing instrument was his Last Will, and he requested us to act as witnesses to the same and to his signature thereon. He thereupon signed said Will in our presence, we being present at the same time. We now, at his request, in his presence, and in the presence of each of us, hereby subscribe our names as witnesses thereto and have placed our initials at the bottom of each of the preceding pages. By so doing, each of us declares tat he believes this testator to be of sound mind and memory. ~ ~ ~`~~~.. residing at 3S1 ~ 3e%c~~ ~wr ~~,.c~~,~ z ~.~G ~~ l1Sv ~ ~~~~~~ residing at %~~'~/~' ~~c~h, ~. ~' ~ L~c~~f ~~~~~ ,-l,~R.~ r/'-:.v-a residing at ~~? 1-i,~~ ~~r~~ 1~~/~~~~"-;~~t~;~, I"ra COMMONWEALTH OF PENNSYLVANIA ~~~ I _ ~_ ~1 SS. COUNTY OF ~ ~- ~h ~~~~~ ~ ~,:.. I, Lewis E. Belcher, Testator, whose name is subscribed to the attached foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed such instrument as my Last Will, and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by Lewis E. Belcher the Testator, this ;~Z-b (: ~ day of August, 2009. / ' i-, ,,. ,, j '. t. ~ t ~,' _ Lary Public ,~ My Commission Expires: ~ ~ /?" ~ t, Lewis E. etcher 223868 IKI~INAL SEAL CIMM~T~IE M CI0000101~0 NNrr hlNe tAll~ll ALtEM 1~ t~MERLM~ CNTY MX ~ E~Ir~t Myt 12, ZQ13 COMMONWEALTH OF PENNSYLVANIA COUNTY OF We, ~/ /; .... - Y SS. the witnesses whose names are signed to the attached foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Lewis E. Belcher, the testator, sign and execute such instrument as his Last Will; that such testator signed such instrument willingly and executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of such testator signed such Last Will as witnesses thereto; and that to the best of our knowledge, such testator was at that time 18 or more years of age, of sound mind and under no constraints or undue influence. worn affirm d to and subscribed before me by 6.J .~~ ~'~ :~r~ witnesses, this ~o ~ day of ugust 2009. W NESSES: ~~ ti~~ /; Notary Public My Commission Expires: ~_ ~~~~' Mn- ~z. zoos SAS-~--~-z~:_ ~~'- Second Mortgage Property Value Analysis Report File No. Belcher P. SCOTT ARCHIBALD REAL ESTATE APPRAISALS Case No. 4 Wa e • Borrower Belcher. Lewis E. 8 Marian I. Census 42-43-109 Map Ref 13-23-0545-032 _ Properly Address 26 Riddle Rd. Check one: X SF PUD ^ Co~2.4 Units City Camp Hill County Cumberland State Pa. Zip Code 17011 Phone No. n/a Loan Requested $ n/a Tenn n/a Mos. Owners Est Value $ n/a No. of Rooms No. of Bedrooms No. of Baths Family room or den: Gross Living Area GaragelCarport Porches, Patio Central Air: 7 3 1 ^X Yes ^No 1,555 Sq.Ft. None Patio ^Yes ^X No NEIGHBORHOOD Location Urban X Suburban Rural Good A .Fair Poor Built Up X Over 75% 25% to 75°k Under 25% Property Compatibility X Growth Rate ^X Fully Dev. Rapid Steady Slow General Appearance of Property X Property Values Increasing X Stable Declining Appeal to Market X DemandlSupply Shortage X In Balance Over Supply Marketing Time Under 3 Mos. X 4-6 Mos. Over 6 Mos. Present Land IJSe 65 %1 family %2-4Famity 5 % ts. _°,b Condo 30 %Commerdal_ %Industrial _ %Vacant _ % Change in Present Land Use X ~ Not Likely Likely ~ Chg From to Predominant Occupancy Owner Tenant 1 Yo Vacant SIF Price Rng $ 100,000 to $ 225,000 150,000 =Predominant Value S/F Age _ 20 to 80 Yrs. Predam. Age 40 Yrs. Note: Freddie Mac does not consider race or the radal composition of the neighborhood to be reliable appraisal factors. Comments on factors favorable or unfavorable, affecting marketability (e.g. public parks, scfaols, raise) Most amenities are located within a short commuting distance to the neighborhood. The commercial land uses within the subject neighborhood consist of various shops, stores and businesses. SUBJECT PROPERTY 1 Stories 1.5 Property Rating Year Built 1940 Units Good Avg. Fair Poor _ Type (del., duplex, semildet.) Detached Condition of Exterior (~ ~X] Design (rambler, split) Cape Ann Compatibility to Neighborhood ® ~ X sn l ^ Ext. Wall Mafl, Aluminum Roof Matt. Com shin Appeal and Marketability ,l J X Property inHUD-Identified Sp'I Flood hazard Area? ^ Yes X No Special Energy-Efficient Items NONE Comments (favorable or unfavorable inducting deferred maintenance) Gas stove, Patio. Water penetration in basement ( $8,000 -COST TO CURET, Roof is in need of replacement, chimney need repointed. Item Sub ect Pro Com raWe No.1 raMe No. 2 Com cable Nq. 3 Address 26 Riddle Rd. Cam Hill Pa. 17011 1814 Letchworth Dr. Cam Hill Pa. 17011 502 S. 20th St. Cam Hill Pa. 17011 1918 Chatham Dr. Cam HiII Pa. 17011 Prox. to Sub'. 0.54 miles W 0.78 miles W 0.66 miles W Sale Pdce n/a 94 500 $ 103 000 $ 127 920 Date of Sale Descri lion Descri lion Ad'ustment Desgi lion Ad'ustment Descri lion Ad'ustment TimeAd'ust. n/a 4/2012-94dom 6/2011-c1 csts -6 18 1/2012-c1 csts -7 67 Location Suburban Suburban Suburban Suburban SiteNiew 0.16 Acres 0.32 Acres -2 00 0.26 Acres 0.22 Acres A e 72 s 61 64 s 63 rs Condition Avera e- /Frame Avera e- !Frame Avera e- /Frame Avera e / Fr / Brk -12 00 Living Area Rm Total B-Rms. Baths Total 8-Rms. Baths Total B-Rms. Baths Total B-Rms. Baths CountATotal 7 3 1 6 3 1.00 6 3 1.00 7 2 1.50 -1,00 Gross Liv Area 1,555 S .Ft. 1 353 S .Ft. +3 03 1 353 S .Ft. +3,03 1 649 .Ft. -1 41 Air Condition _ None Central -200 None None tiara e/C n None None None 2 Car Gar. Att. -4 50 Porches, Patio Pools etc. Patio Patio Patio Deck Spedal Energy- Efficient Items None No Basement +3,00 No Basement +3,00 None Other A liances A liances liances A liances NetAd'. Total X Plus Minus $ 2 030 Plus X Minus $ -150 Plus X Minus $ -26 585 Sub Value Net=2% Grs=11° $ 96530 Net=O°%Grs=12° 102850 et=-21°,Grs=21%I$ 101335 Gen. Comments 1 have considered all of the comparables in my opi nion of the most probabale sale price of the subject property. This appraisal is for the intended user only and is not intended for any other users. The informatan shown on this report is derived from an inspection of the neightxxhood and exterior inspection of the subject property and market comparades. The estimated market value is based upon t is info aeon and the knowledge of the undersigned. This report is not to be construed as an appraisal report. /'~ Esymetg~tarket V 100,000 as of 04/26/2012 Completed By P_S T ~i~ ,--~ ~_ Title APPRAISER -RL-000060-L Signature --~~-~-+'~' °' ~ Date 04!30/2012 ATTACH CURRENT DESCRIPTIVE PHOTOGRAPHS OF SUBJECT PROPERTY AND STREET SCENE Freddie Mac Form 704 1186 Produced by ClickFORMS Software 800-622-A727 Page 1 of y P. SCOTT ARCHIBALD REAL ESTATE APPRAISALS EXTRA COMPARABLES 4-5-6 File No. Belcher Case No. 4 Wayne Borrower Belcher, Lewis E. & Marian 1. Property Address 26 Riddle Rd. City Camp Hill County Cumberland State Pa. T~pCode 17011_ LenderlClient Belcher Address Item • Su ect P e Com cable No. 4 Co arable No. 5 C arable No. 6 Address 26 Riddle Rd. Cam Hill Pa. 17011 1712 Elm St. New Cumberland Pa. 17070 Prox. to Su '. 0.90 miles E Sale Price n/a $ 107 923 $ $ Date of Sale DesCri lion Desai Bon Ad'ustment Desai Bon Ad'ustment Descd tan Ad'ustment Time Ad'ust. n!a 9/2011-97dom Location Suburban Suburban SiteNiew 0.16 Acres 0.22 Acres A e 72 65 rs Conditon Avera e- /Fra me Avera e- / Fr / Brk -2 00 Living Area Rm Total B-Rms. Baths Total B•Rms. Baths Total 8-Rms. Baths Thal B-Rms. Baths Count 8 Total 7 3 1 7 4 2.00 -2,000 Gross Liv Area 1 555 S .Ft. 1 430 S .Ft. +1 87 .FL .Ft. Air Condition None Central -2 00 Gara elCa rt None None Porches, PaBo Pcols etc. Patio Patio, Screen Por -1,50 Spedal Energy- Efficient Items None None Other A liances A liances Net Ad'. Tolal Plus X Minus $ -5 625 X Plus Minus $ 0 X Plus Minus $ 0 Sub Value Net-5% Grs:9°~ $ 102 298 Net:Q% Grs:0°k $ 0 Net:0% Grs:0% $ 0 Gen. Comments Freddie Mac Forrn 704 1186 Produced by CIIckFORMS Software 800-622-8727 Page 2 of 9 P. SCOTT ARCHIBALD REAL ESTATE APPRAISALS SKETCH ADDENDUM File No. Belcher Case No. 4 Wayne Borrower Belcher Lewis E. & Marian I. Property Address 26 Riddle Rd. City Camp Hill County Cumberland State Pa. Zip Code 17011 LendedClient Belcher Address 32' Second Floor Bedroom I [,4rea: 41 fi Its 3a~ 15' 6" r Family 11' D/A Kitchen Bedroom Firs# Fi~or N [Area: 11:38 Bath Living ~~ Bedroom 7 5' -~, ~r f -17$ 8-!F Aar Fber' r 4.00. !!~5 hlp6f" .. _ - '4161h F kA x '- ~ kQx 1.(R+.~, 97,8.. . ~4R Ipl~ 21 R' 1z r zt 7-x .1.QL°- ;8s ~, - ia~- +srt= -'. [.:.tpr 6'-ic,. . tax ~~- - ~' iS7_. Secoeb F tnor z t00 ~ •tb Produced by ClickFORMS Software 800-622-8727 Page 3 of ! SUSAN L. HIRSHMAN, Executrix Estate of Lewis E. Belcher 151 Yellow Breeches Drive Green Lane Farms Camp Hill, PA 17011 717-761-1567 March 30, 2012 Treasury Retail Securities Site 90 Hennepin Avenue Minneapolis, MN 55401-1804 RE: Estate of Lewis E. Belcher 185-12-9413 Ladies and Gentlemen: Pursuant to my telephone conversation with and instructions received from Dave in your office this date, please find enclosed Form PD F 1522 E -Special Form of Request for Payment of US Savings and Retirement Securities where Use of a Detached Request is Authorized, along with the additional following Bonds and documents: 1. Eighteen (18) $500 HH United States Savings Bonds, each signed by the Executrix for the Estate of Lewis E. Belcher, each being listed on Form 1522. 2. Death Certificate of Lewis E. Belcher. 3. Death Certificate of Marian L. Belcher. 4. Short Certificate issued by Cumberland County, Pennsylvania granting Letters Testamentary to the undersigned. PLEASE RETURN ALL OF THE ORIGINAL DEATH CERTIFICATES AND SHORT CERTIFICATE TO: Susan Hirshman, Executrix 151 Yellow Breeches Drive Camp Hill, PA 17011 If you have any questions regarding this transaction, please do not hesitate to contact me at (717) 761-1567. a5 . ~~~ Susan L. Hirshman, Executrix l=or official use only:.,: Customer. Name Customer No: PD F 1522E SPECIAL FORM OF REQUEST FOR PAYMENT OF OMB No. 1535-0004 Department of the Treasury UNITED STATES SAVINGS AND RETIREMENT Bureau of the Public Debt SECURITIES WHERE USE OF A DETACHED FOR OFFICIAL USE ONLY (Revised July 2011) REQUEST IS AUTHORIZED TRANSFER MONTH & YEAR _/_ Vislt us on the Web at FISCAL AGENT CODE vww.creasurvoirect.aov ISSUE DATE ;' SERIAL NUMBER ISSUE DATE SERIAL. NUMBER ISSUE DATE SERIAL NUMBER 02/04 D6556681HH 02/04 D6556684HH 02/04 D6556688HH 02/04 D6556680HH 02104 D6556683HH 02/04 D6556687HH 02!04 ~ D6556679HH 02/04 D6556682HH 02/04 D6556686HH 02/04 D6556685HH 02/04 D6556689HH 06/04 ~ D6698921HH (A you n@@O more space, aIIBGl7 @IUI@I a ~[/ r Jaw. a Nwm ancca v. rorw, ... v r,.nvav....~.) 2. REQUEST FOR PAYMENT I request that the described bonds be redeemed and payment be made in the form of ^x a check. ^ direct deposit. ^ To the extent of: (Complete this line only if partial redemption and reissue of the remainder is desired or if the signer is entitled only to a portion of the bonds listed. See Item 2 in the Instructions.) 1'~ / / _ d~'~w~ S ~e l~~jer ~57~ 45-6814838 (Social Security Number of Payee) OR (Employer Identification Number of Payee) 3. DELIVERY INSTRUCTIONS (Read Item 3 in the Instructions before completing this section and complete only Item 3A or 36.) A. Please mail my redemption check to: Estate of Lewis E. Belcher, c/o Susan L. Hirshman, Executrix 151 Yellow Breeches Drive Camp Hill PA 17011 (Number and Street, Rural Route, or P.O. Box) (City) (State) (ZIP Code) B. Please deposit my funds directly, as authorized below: (Name/Names on the Account) Type of Account: ^ Checking ^ Savings (Depositor's Account No.) Bank Routing No.: (Financial Institution's Name) (Phone No.) 1. DESCRIPTION OF BONDS 1 am the owner ar person entitled to payment of the securities described below, which bear the name(s) of LEWIS E. BELCHER OR MARIAN L. BELCHER PDF3500E Department of the Treasury Bureau of the Public Debt CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1552 E ISSUE DATE DACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 123-45-6789], names, inGudin middle names or initials, and addresses on the bonds 06/04 500 D6698922HH Lewis E. Belcher, 26 Riddle Road, Camp Hill, PA 17011 06104 500 D6698923HH SS185-12-9413 or Marian L. Belcher OW04 500 D6698924HH :06/04 500 D6698925HH 06104 500 D6698926HH 06104 500 D669892THH (Signature) 4. SIGNATURE ~.~ Sign Here• i~~ ~i~t ~ f1/lS/l/!'T2h ~ Signature) ,(~ ~TPrint Name) Home Address ~ ~ g ptuy 1~ree~h~eS I.~f ~ susan~irs~n~.na~ 1+~Sn.~or-'>I ( tuber d Street, Rural Route, or P.0. Box) (E-mail Address) ~m i~/I ~A /7oi~ `7/7~761-~Sb7 City) (State) (ZIP Code) (Daytime Telephone Number) Sign Here: (Print Name) Home Address -'~ (Number and Street, Rural Route, or P.0. Box) Address) ,~a~- ~:f~, I CERTIFY that 'mil (~~i ~} ~~ l~- /~" I r:S n nor (1 ,whose identity is known or was (Name of Person V1fiol!A'~~ppeared) ~} jj~~ proven to me, personally appeared before me this ~ V ~ day of ~ (.,{,/~~ ~ V ~ a" , nn (MonthNear) { ~ 1 at ' ,and signed this form. //I ~ ~ / ~ ~S'~~l)~ (City/State) '`f ;" . _ ~n f li7 ~n n i,,., ~ / i ~.. _,./~ (~r ~_ ,. institution's signatur¢~I (Notary certification is NOT acceptable.) I CERTIFY that of Person Who proven to me, personally appeared at , (City/State) (City /State /ZIP Code) ared) - day of ned this form. whose identity is known or was (Month/Year) (Slari'ature and-Title ~. , ACCEPTABLE CERTIFICATIONS: Financial institution's official seal or stamp (such as corporate seal, signature guaranteed stamp,or medallion stamp). Brokers must use a medallion stamp.. (Notary certification is NOT acceptable.) of Financial (City /State !ZIP Code) 2 PDF1522E RESERVED FOR IDENTIFICATION NOTATIONS Customer Account Number ^ and Date Established: [~ Identified by (Signature and Address): ^ Document(s) -Description: >~r_s>~h~r~~ ~~ ~ u ~ZS ~,~' INSTRUCTIONS TO CERTIFYING OFFICER Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or she is personally known to you. Place an adequate notation above or on a separate record, showing exactly how identification was established. A notation is adequate if it is suffiaently detailed to permit, at a later date, a determination of the exact identification actually used. You and the organization will be held fully responsible for the adequacy of the identification. The signatures to the request must be executed.in your presence. Fully complete and sign the certification form provided for your use for each signature you witness. If you are an empbyee (rather than an officer) authorized to certify signatures, insert the words "Authorized Signature' in the space provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization. INSTRUCTIONS USE OF FORM -Use this form to request payment of United States Savings Bonds, Savings Notes, Retirement Plan Bonds, and Individual Retirement Bonds. WHO MAY COMPLETE -This form may be completed by the owner, coowner, surviving beneficiary, or legal representative of the estate of a deceased or incompetent owner, persons entitled to the estate of a deceased registrant, or such other persons who may be entitled to payment under the regulations governing United States Savings Bonds. A minor may sign this form if, in the opinion of the certifying officer, he or she is of suffiaent competency to understand the nature of the transaction. (See "CERTIFICATION" below.) An incompetent person may not sign this form. COMPLETION OF FORM -Print clearly in ink or type all information requested. ITEM 1. DESCRIPTION OF BONDS -Provide the name(s) of the person(s) shown in the inscription of the bonds for which payment is requested. Describe the bonds by issue date and serial number. If you need more space, attach either a PD F 3500, a plain sheet of paper, or a photocopy. ITEM 2. REQUEST FOR PAYMENT Mark the appropriate box to indicate whether you want to be paid by check or direct deposit. If the signer is entitled to a distributive share of the listed bonds or if partial redemption of bonds and reissue of the remainder is desired, that fact must be shown on the line provided. Check the box "to the extent of and insert "$ (face amount) and reissue of the remainder." If such bonds have not reached final maturity partial redemption at the current redemption value will be made in amounts corresponding to authorized denominations and the remainder will be reissued showing the original issue date(s). If such bonds have reached final maturity, partial redemption is not permitted and, in this event, full payment will be made. The payee's Taxpayer Identification Number must be provided. Furnish the Social Security Number if the payee is an individual. If an estate is involved and IRS has assigned an Employer Identification Number, provide that number. Please verify account information for accuracy and legibility to avoid a delay in deposit. ITEM 3. DELIyER.Y INSTRtlCTlQNS If payment is to be made by check, furnish in Item 3A the name and address where the check is to be mailed. For payment by direct deposit, complete Item 36. Fumish the name(s) on the account, the account number, the type of account, and the financial institution's name, the routing/transit number which identifies the institution, and the institution's phone number. You may need to contact the financial institution to obtain the routing number. ITEM 4. SIGNATURE -The person(s) requesting payment of the bonds must sign the form in ink, print his or her name, and provide his or her address, daytime telephone number, and if applicable, a-mail address. If the name of a person requesting payment has been changed by marriage or in any other legal manner from the name in the inscription of the bonds, the signature to the request for payment must show both names and the manner in which the change was made; for example. "Miss Mary T. Jones now by marriage Mrs. Marv T. Smith." (See "CERTIFICATION" below.l P[1F1577F ~i° o~ ~ z ~ N ¢ ~ N O a < ~ N ~ ~ hj ~ ~ W N o azU~ T a~ CV o ~ ~ * ~ z; ~~ U ~ ~ O J O ~ M Q ~O W ~O Z N a ~. H M C S u1 O O 4'1 M'rl O GO -~ i+ rr LL O O ~ O Q O~ N . q Wv ry • q F- N OL Z H •• ,~ ,~ (Jf ~ O 'p ~ eD Q -r n ~ V1 Q O UZ q I~+~d 00 V > N ~= U l0 N ~a a~ ~o G z a :< H z ~ .~ O C.~ _ cry Q F- z N c M ~ ~ ~g ~~ ~~ ~~ W H F- X N .'ri W W = A 2 V ~ OC W W W U v1 m a J oe Writ rs~=OJ J J W J J H ~ ~Q}0. OC 3N.+Z W WO~Q ~ J N .-r V O I ~ II Q a 0 a ._ .-i rY~ ru rL 0 l O O a r1'1 Investor Relations -Prudential Financial -Historical Price Lookup investor Relations > Historical Price Lookup Historical Price Lookup Stock Quote ~ Sta:k Chart ~ Historical Price Lookup ~ Inv~estmen[ Calculator Symbol PRU (Common Stock) Lookup Date March :{08!!2012' Lode Up -'.. Results Date Requested 03/08/12 Closing Price ;61.880 Volume 2,566,974 Split Adjustment Factor 1.0000:1 ~~ Open $61.220 ~~ h ~ ~~ ~j~ Day's High $61.970 ~, . Day's Low $60.780 http:/iwww.investor.prudential.com%p'~oe~ s..zhhnl?c=129695&p~rol-... Print This Page !,. ~ Receive E-:nail Alerts ~j ( 3' ~ ~i`'~VI J NOTE: The Cbsing Price, Day's High, Day's Low, and Day's Volume have Veen adjusted to account for any stock spliLS and/or dividends which may have occurred for [his security since the date shown above. The Actual Price 5 not adjusted for splits or dividends. The SpfR Adjustment Factor is a cumulative factor which encapsulates all spfts slice the date shown above. The cbsing price above s not necessarily indicative of future price performance. 1 of 2 4/17/2012 2:30 PM Page 1 of 2 Prudential ~omputershare OD2562 11~111~~111111111"1111'III'II'111'11"1111"""I'I'Il'Illlllll' SUSAN L HIRSHMAN EX EST LEWIS E BELCHER 26 RIDDLE RD CAMP HILL PA 17011 Computershare Tnlst Company, N.A. PO Box 43033 Providence, RI 02940-3033 Within USA, US territories & Canada 800 305 9404 Outside USA, US territories 8 Canada 732 512 3782 www. computershare.com/investor p~I1 MFIDN MCI YI~~~IWIIINIYIIIIIf~II ,~s , _ Pxuder~fi~~ Fi~ari~i~h ~(~Cr ~ ~ , ~, t ~ _ ~ ~ ,. ~ _,,~ ~~ r Trade Date: 02 Apr 2012 14:01 (Time) Settlement Date: 05 Apr 2012 Cost Basis Method: FIFO ShareslUnits Price per I Gross Amount I Trading BankinglVNire Taxes Other Net Amount Sold SharelUnit (USD) of Sale (USD) Fees (USD) Fees (USD) I Withheld (USD) Fees (I~SD) ( of Sale (USD) 145.000000 64.483989 9,350.18 22.60 0.00 0.00 0.00 9,327.58 Covered Transaction Total: 0.000000 Noncovered Transaction Total: 145.000000 Covered ShareslUnits Covered Cost I Covered Short Term Covered Long Term Overall Covered Sold Basis (USD) GainlLoss (USD) I GainlLoss (USD) GainlLoss (USD) 0.000000 NIA N/A NIA N/A PLEASE SEE REVERSE SIDE FOR IMPORTANT DISCLOSURES AND DEFINITIONS 1 LTR PRU '~' 001CD70003 us.ltr.csal.il_3744/002562J0025621i MorganStanley SmithBarney March 21, 2012 h~~Ilh~dlh~~~~Jb~dldLdL~~~~Id~~~11~~L61L~~dLI 'OB1MS17100066601.724562 LEWIS E BELCHER, DECD 26 RIDDLE ROAD CAMP HILL PA 17011-6021 The Keystone Group Financial Advisor 717-730-1806 www.smithbarney.c:om ACCOUNT NUMBER 72481123-15 562 IMPORTANT NOTICE THIRD PARTY FUNDS DISTRIBUTION CONFIRMATION PLEASE RETAIN FOR YOUR RECORDS. As a service to you, this is a confirmation that funds have been distributed from your account to a third party. Our records indicate the following disbursement of funds was made on March 21, 2012 to: AMOUNT ISSUED TO: $99,243.00 ESTATE OF LEWIS E BELCHER 26 RIDDLE RD CAMP HILL PA 17011 If the information is incorrect, please contact your Branch Manager immediately at 717-730-1800. We appreciate your business. WEST SHORE OFC CTR • 214 SENATE AVE-7 FL • CAMP HILL, PA 17011 Morgan Stanley Smitb Barnry LLC. Member SIPC. ~ NIBt~' I~~~~~c ACCOUNT N0. ACCOUNT TYPE 98206087 POWER CHECKING 00 0 06113M NN 017 STATEMENT PERIOD PAGE FEB.29-MAR.28,2012 1 OF 1 12197 I.EWIS E BELCHER 7.6 RIDDLE RD (:AIMP HILL PA 17011-6021 INTEREST EARNED FOR STATEMENT PERIOD 0.70 HIGHLAND PARK INTEREST PAID YEAR TO DATE 3.27 ACCf111NT CIIMMARV BEGINNING BALANCE DEPOSI S & OTHER ADDITIONS CHECKS PAID OTHER SUBTRACTIONS CURRENT INTEREST PD ENDING BALANCE N0. AMOUNT NO. AMOUNT NO. AMOUNT 30,144.80 2 2,656.40 7 31,801. 0 1 1,000.70 0.70 0.00 A f`!`~1111J T A !` T T V T T V POSTING DATE TRANSACTION DESC IPTION SITS,INTEREST & OTHER ADDITIONS CHECKS & OTHER SUBTRACTIONS DAILY BALANCE 02-29-12 BEGINNING BA~_ANCE 530,144.80 03-02-12 DEPOSIT 1,500.00 03-02-12 US TREASURY .i03 XXSOC SEC 1,156.40 32,801.20 03-05-12 CHECK NUMBER 1238 116.44 32,684.76 03-07-12 CHECK NUMBER 1239 45.34 32,639.42 03-08-12 CHECK NUMBER 1242 715.96 03-08-12 CHECK NUMBER 1241 370.26 31,553.20 03-09-12 CHECK NUMBER 1237 5.82 31,547.38 03-12-12 CHECK NUMBER 1240 116.00 31,431.38 03-16-12 CHECK NUMBER 0055 30,431.38 1,000.00 03-26-12 INTEREST PAYMENT 0.70 03-26-12 CLOSEOUT 1,000.70 0.00 ENDING BALANCE 50.00 _ CHECKS PAID SUMMARY 55 03-16-12 30,431.38 1237* 03-09-12 5.82 1238 03-05-12 116.44 1239 03-07-12 45.34 1240 03-12-12 116.00 1241 03-08-12 370.26 1242 03-08-12 715.96 ANNUAL PERCENTAGE YIELD EARNED = 0.04 WARM UP WITH SPECIAL SAVINGS THIS SPRING AT POPULAR RETAILERS WHEN YOU USE YOUR H&T CHECK CARD OR M&T VISA CREDIT CARD IN STORES, ON THE NEB AND OVER THE PHONE. VISIT MTB.COM/SHOPPING TO TAKE ADVANTAGE OF GREAT DEALS ON SPRING SAVINGS TODAY! w~i&T ~3aut~.~~c ACCOUiPII' NO. ACCOUNT TYPE STATEMENT PERIOD PAGE 15004222179465 POMER MONEY MARKET DEC.10-MAR.09,2012 1 OF 1 00 0 06113M NM 017 42364 LE:WIS E BELCHER 2E~ RIDDLE RD GIMP HILL PA 17011-6021 INTEREST EARNED FOR STATEMENT PERIOD 70.26 HIGHLAND PARK INTEREST PAID YEAR TO IDATE 70.26 erCflllNT CIIMMORV BEGINNING BALANCE D POSITS 8 OTHER ADDITIONS NIT RAMALS i. HER SUBTRACTIaNS CUR iNTEREST PAID ENDING BALANCE N0. AMOUNT N0. AMOUNT 56,877.65 1 60,955.36 0 0.00 70.26 117,903.27 OCCOl1NT Af'TTVTTY POSTING DATE TRANSACT ON DESCRIPT ON DEPOSITS,INTERES. OTHER ADDITIONS NYDRAMALS 8 OTHER SUBTRACTIONS DAILY BALANCE 12-10-11 BEGINNING BALANCE 556,877.65 01-09-12 DEPOSIT 60,955.36 117,833.01 01-11-12 INTEREST PAYMENT 14.06 117,847.07 02-10-12 INTEREST PAYMENT 29.07 117,876.14 03-09-12 INTEREST PAYMENT 27.13 117,903.27 ENDING BALANCE 5117,903.27 ANNUAL PERCENTAGE YIELD EARNED = 0.29 ~ M&TBank GF289(8/10) WIP TRANSACTION DEBIT OrrRlfiiNA~~7itdv COST CENTER EMPLOYEE NUMBER AUTHORIZATION DATE ACCOUNT # CUSTOMER NAME (PRINT) DESCRIPTION: ~ PARTIAL WITHDRAWAL ~ CLOSING WITHDRAWAL Original -Processing Work Copy -Branch CUSTOMER SIGNATURE: ~ 2 1 8 0 7 8 7 - • SEQ. NO. m L00?A (6!071 ~~ One M & T Plaza, Buffalo, New York 14240 Highland Park March 30, 2012 s~o LEWIS E BELCHER 26 RIDDLE RD CAMP HILL PA 17011-6021 Re: Retirement Account Closing Notice Account ~ 350042.0345551 Dear Lewis E Belcher, We are writing to confirm that on 03/29/12 our Re ire nt account was closed or transferred. At that time, the balance was $111,122.55. If you are receiving scheduled distributions, the a ove account has been closed and internally transferred to another Individual Retirement Account in your plan 1:0 accommodate your next distribution. We'd like to remind you that M&T Bank is committed to providing you with solutions to all your financial needs. To find out more about the many ways we can help you with those needs, simply stop by any M&T Bank office or call the M&T Telephone Banking Center at 716-626-1900 or 1-800-829-1924. Or if you'd like, visit the M&T website at www.mandtbank.com. Thank you for banking with M&T Bank. Sincerely, iU~.ehae~2 N . Tread yen Michael N. T'radyer EM?CCL A7_R.RS1 M&T One M & T Plus, Buffalo, New York 14]40 Highland Park March 16, 2012 293 LEWIS E BELCHER 26 RIDDLE RD CAMP HILL PA 17011-6021 Re: CD Account Closing Notice Account # 3 1 0039205 1 1 1 84 Dear Lewis E Belcher, °~ % Ct~~,Z ~~' -f - - We are writing to confirm that on 03/16/12, your CD account was closed or transferred. At that time, the balance was $46,788..77. We'd like to remind you that M&T Bank is committed to providing you with solutions to all your financial needs. To find out more about the many ways we can help you with those needs, simply stop by any MBtT Bank office or call the M&T Telephone Banking Center at 716-626-1900 or 1-800-724-3222. Or if you'd like, visit the M&T we~site at www.mandtbank.com. Thank you for banking with M&T Bank. Sincerely, M~chaeP N. 7~rrdyen Michael N. Tradyer Ous~om ~~dar~ ~0 ~s~d Oar I:'rices ~ ~(elley flue ~... ~pa~e ~. o~ 5 car values ~ cars for sate ( car reviews ~ kbb t. advertisement Home > Car Values > Buidc > Century > 2000 > Options > Condition > I ~suick ~ a C e Custom Sedan 4D n 2000 Buick Century u _ __ _ ___ 1999 2000 2001 Style: Custom Sedan 4D - r .....~,~.,.....~...~ y View all 2 photos Mileage: 15,165 c ------ __ r- ~ ...-__, r- .______ _ ---- pricing photos ; ~ specs ~ ~ kbb expert review ; ± consumer reviews ' ratings ,compare i; li ~~ See Trade-In/Sell Values $5,838 Find Deals Near You see local deals ~; Verify Condition '• ___.._ __ Very Good $5,613 Free VIN Check Enter VIN (optional) go Good ~ ~; $ 5, 513 ~ , No VIN? No Problem! '. Fair ~ _ __ __. _ . _ $4,938 lased Car Prices Suggested Retail PrlVate Part/ Excellent get yours now Recently Viewed Cars ~ http://www.kbb.com/buick/century/2000-buick~entury/custom-sed... 3/15/2012 edit options ;change style Prudential Alliance Account Services The Prudential Insurance Company of America P.O. Box 41582 Philadelphia, PA 19176 ADDRESS SERVICE REQUESTED ESTATE OF LEWIS E BELCHER C/O SUSAN HIRSHMAN, EXECUTRIX 151 YELLOW BREECHES DRIVE CAMP HILL PA 17011 7 ACCOUNT INFORMATION Balance Last Statement 512,861.13 Balance This Statement 50.00 SUMMARY + CREDITS $13.75 - CHECKS and DEBITS $12,874.88 ENDING BALANCE $0.00 RATE HISTORY CURRENT INTEREST RATE 3_0ppo,(, INTEREST CREDITED YEAR-TO-DATE $109.55 ACCOUNT TRANSACTIONS DATE DESCRIPTION 04/13 CREDIT-INTEREST 04/13 DEBIT-GUST REQ CLOSE Prudential ALLIANCE ACCOUNT Statement Closing Date: Account Number: CUSTOMER SERVICE 4/13/2012 4351003066634 Contact Information: Prudential Alliance Account Services The Prudential Insurance Company of America P.O. BOX 41582 Philadelphia, PA 19176 Internet: www.prudential.com Phone: 1-877-255-4262 8:00 AM to 8:00 PM, Eastern Time, M-F Access to your Account Information is also available 24 hours a day 7 days a week. Please have your Account Number (located above) available when calling Toll-Free. AMOUNT $13.75 $12,874.88 SEE REVERSE SIDE FOR IMPORTANT REMINDER AND UPDATED TERMS AND CONDITIONS BALANCE $12,874.88 $0.00 803-1 Page 1 i OOOOOOi55 Prudential - Prudential Annuities Llfs, Assurance Corporation Check Statement Annuity Servipe Centsr P.O. Box 13888 Philadelphia, PA 19178 Date: MARCH 26 2012 ,3s,e,z9z• Owner: LEWI S E BELCHER SUSAN L HIRSHMAN 151 YELLOW BREECHES DRIVE Annuitant: LEWIS E BELCHER CAMP HILL PA 17011 Contract ~: Eo719634 . ~~ Product: AS LifeVestll Market Type: Non Qualified Page 1 of 1 Thank you for your patience while we completed your request for death benefits from the contract listed above. The table below provides a breakdown of how we determined the net check amount. Taxable amounts are reported to you and the Internal Revenue Service. The federal taxable amount of your payment is $ 4128.37. The state taxable amount is $ 4128.37. We have presented this information based on our understanding, of tax law. You may wish to consult your tax adviser if you have any tax questions. Because each situation is unique, neither the Company nor its representatives can provide tax advice. Financial Breakdown Information GROSS FUND WITHDRAWL AMT 8592.63 FEDERAL TAX WITHHOLDING 825.67 ~ NET AMOUNT OF CHECK 7766.96 (VPAS d0890941 e e ~ ~ ~ ~,, - ;,~ i~k ,'.,?,~:~ ~A `..~~. ~~k~+~~o:~?. i~ :.. t; a i:t'N:r', ~- 4 r,~$ :'fit asy: ****,k,t****5EVE~i Ti40Ug~~SE N 1 1F l ~ ~ F r ~ ~' ~ r f .,. ~ - til tit. ji 4 it ~,1, ., f l i .. ti-ST^^ ~~ 4 ~ FM `~1~ i. l~ ~T` ~: oro~ of• SUSAN L H I RSHMAN**~**~**** ~ ~`aik,k,~~E~~k ~ ?: a ~~ ~~ ~; +; • 151 YELLOW BREf`CHEF.QRIVE~*##*~*?~~ltikitall7lt ,~{, ~ .~~ ~ ~w, .; ;~ , CAMP HILL PA 17011.. ~'4~ xr, ~~ ~;~ .~y~ t ,.,~. ~~ •,~ ~. ' , i• , Y71R{C ~f ~ y x' ...__. ~S~01i1 FrYlaiJocYtl~ddl~ '. ,Pi k „f 4 :~ .. ~+ r' a•138i~>,2924n' ~:03~t3t00225~:20?99 5008 3 384~~' -c8 1 .~~ Prudential Prudential Annuities Life Assurance Corporation Check Statement Annuity Service Center P.O. Box L3688 Philadelphia, PA 19176 Date • MARCH 26 201 Z 1381612917 JEANNE MARIE DAVIS Owner: LEWIS E BELCHER 413b BURNS ROAD MECHANICSBURG PA 17055 Annuitant: LEWIS E BELCHER Contract #: E0719634 Product: AS LifeVestli Market Type: Non Qualified Page 1 of 1 Thank you for your patience while we completed your request for death benefits from the contract listed above. The table below provides a breakdown of how we determined the net check amount. Taxable amounts are reported to you and the Internal Revenue Service. The federal taxable amount of your payment is $ 4128.37. The state taxable amount is $ 4128.37. We have presented this information based on our understanding of tax law. You may wish to consult your tax adviser if you have any tax questions. Because each situation is unique, neither the Company nor its representatives can provide tax advice. Financial Breakdown Information GROSS FUND WITHDRAWL AMT 8592.63 FEDERAL TAX WITHHOLDING 825.67 NET AMOUNT OF CHECi( 7766.96 (VPAS d089094) ~t FeCF nc-reru o rnonc ~rz0~"eS.r +tE.'c(e7L r~-7gi`a~~ a 3 , ~~~flTft~'ii~F +~'x;3~ ~~~ /~~` ~ Prudential Annuities Llte Assurance Corporation 1381612917 Prudential Annuity Service Center Wachovia Bank of Delaware, N.A. P.Q Box 73688 Wilmington, DE 79803 62-22 Philadelphia, PA 19778 31 1 Pay: **********SEVEN THOUSAND SEVEN HUNDRED SIXTY-SIX c~:Fs~„:c:cst>r:~>•c:;:;*;t:t:;>r:c:c:r~~r:t*t:~ic~c>•rAND 96/100 DOLLARS To the order or: JEANNE MAR! E DAVIS**************>ti*747rf**** 4 i 36 BURNS ROAD~**********~:**:~::*7t~:><c:r~r>*c>!c* MECHANICSBURG PA 17055 I MAR 26 2012 ~ $:c*~c**7766.96 Please cash within t80 days Dollars Cents ~~ asuaeR coivTi~oLL ___ _.__. _.__. _. __._.____. _..._._._______ __. ______. __._.___ . _. =~.Scwnpr Features lr.~.yg~i~etaiis.on Gatk~A____._. __..C~._._._____. Contract No. ii^ L38 i6 i 2917ii• x:031 i00 2 25~: 207995008338tii~' N O ~ ~ N W W 2 S - 'O ~O V U - C1 •1.. N J J +~ •- C W W N ~F- ~ m m ~ > •- W W M N f0 S In N 01 ~ d U - - ~- J .~, Q: 3 3 n C (/1 Q W W O V1 O ~J ~ J J ~W Q Z Y U -• d ~ ~ ~ ~ IIU ~ ~o u +~ +~ ~ u +~ ~ L •- i. 7 N +-+ C C C O L f0 ; C O L• 10 D O }~ U ~ ~ ~~~~ ti ~~ 'I c 0 g. U •py •~ m ~ m N A , W ~ J n O w m y O! : ~ ~ ~ a ~~~a O aZm`° O m N x g m ~g m m ~~ ~ C Q t aaaa O ti ~~ W Q wa ZF- o O N Z cn ZwJ W U' Q: opcw H~ mmc ~Q.L OD ~ m¢ v NOM mZM3 ao~--~Ll~ W ~Jr-Z ~, o .- ~ ~: ~ ~. ~_ ~ w ~ ~ o •- o p~ ~~,~ '- V f0 ~ L (A O~1 d p~ L~ a+ U ~~'O ~p N tC ~ ~ Er Xcx d O c,> ,A, O N ~ ~ ~ ~.- ~ ~ ~ ~ ~ i ~c ...a~0 N ~ ~ ~ ~ ~ Y ~R=C C op N~ OL ~ d ~O =NC 3 ~P +. ~ U io ~ aj U ~ ~~ a3 O tn` ~ ~ ~3 c _ a~~~ Qo ~. ~ a~ ~ ~ o ~~ov o }• ~ = ~ ~ ~ ~° ,~ `°N x ~ a+Y - C ~~ yc~oN0 CaCd t x~':r C~ ar ~~ ~ ~ ~ ~y 'V'' NO ~L~O'O ~ ~ OF-` .C d . yX p• O C7 M C U~ ~ 3V0 ~ 4 ~. N acid O~ ~~]~ O ~ Ov> 00 ~~ ~y0•-C p '~ ~y X' l0 ~`m O~IOCC _ ~ ~ ~ Y~ .DO~ i ~ ~O j ~ N ~ X I-= F- O.~.c ~ C 0 -'~., ~O C a MM~ fW ~V U C ~~~ co cn m ~ NlD ~~r H az_ J p ~ = w ~.~-. U 3 LL 3 ~ oaF- 2 ~ Z LL J Q fn d'G oo~ C~A~Z 000000162 Prudential Prudential Annuities U1e Assurance Corporallon Check Statement Annuity Service Center p.0. Box 13686 Philadelphia, PA 19176 Date: MARCH 26 2012 1381612931 AMY K BELCHER Owner: LEWIS E BELCHER 25 ESSEX ROAD CAMP HILL PA 17011 Annuitant: LEWIS E BELCHER Contract #: E0719634 Product: AS LifeVestll Market Type: Non Qualified Page 1 of 1 ~{ you haue`any ge(estll~ns;:Riease contact ih9 AnnuftFes;Serv/cs'Cenfer at 1.888-778-2888. Thank you for your patience while we completed your request for death benefits from the contract listed above. The table below provides a breakdown of how we determined the net check amount. Taxable amounts are reported to you and the Internal Revenue Service. The federal taxable amount of your payment is $ 4128.37. The state taxable amount is $ 4128.37. We have presented this information based on our understanding of tax law. You may wish to consult your tax adviser if you have any tax questions. Because each situation is unique, neither the Company nor its representatives can provide tax advice. 1'InanCla/ t3l'eaKpOWn InTOI'n1 GROSS FUND WITHDRAWL AMT 8592.63 FEDERAL TAX WITHHOLDING 825.67 NET AMOUNT OF CHECK 7766.96 (\/D D C .-Inf2Q(lQil1 P_L.FASE..DFTOC_t~~l-lFClf_- KF_FP STGTFAAEN7 FC]A RFC(]Rf].S ___ .__ _.. C-'0?19034 Prudential Owner: LEWIS E. BELCHER Annuity Contract No: E0719634 Annuitant: LEWIS E. BELCHER Subject to Terms and Conditions of section titled "Beneficiary", the following beneficiary(ies) are hereby designated: BENEFICIARY PROVISION The proceeds that arise from the Owner's death will be payable as follows: Class 2 25.0% SUSAN L. HIRSHMAN, Daughter. 2:5.0% JEANNE M. DAMS, Daughter. __. ~_ 25.0% LINDA R. BENSON, Daughter. 25.0% AMY K. BELCHER, Daughter. Class 1 100.0% Estate Endorsed or Acknowledged for the Company by: Joseph Emanuel Secretary Date: July 24, 2009 Attest Prudential Annuities, Inc. and Prudential Annuities Life Assurance Corporation are both Prudential Financial companies. Prudential Annuities Life Assurance Corporation is solely responsible for its financial condition and contractual obligations. A- RELATIONCH 001 PAGESofS 02184 7317677 003177 004734 00003/00003 Protective Life Insurance Company Life and Annuity Administration Post Off~e Box 830712 Birmingham, Alabama 35283-0712 866-749-4567 • Facsimt. ° 205-268-3684 March 28, 2012 Susan L Hirshman 151 Yellow Breeches Drive Camp Hill, PA 17011 Re: Protective Life Insurance Company Policy Number: 670015760 Insured: Lewis E Belcher, deceased To Whom It May Concern: This letter serves as confirmation that the pending death-claim has been processed. Under separate cover, a check in the amount of $1,742.04, will be mailed to you. This check will represent the full and final settlement of all claims under the terms and provisions of the above referenced policy. Thank you for sending the Certified Death Certificate. We have made a copy of the Death Certificate for our records and returning the original to you. If you have any questions, please contact me at 866-749-4567, extension 5669. Sincerely, ~~ ~ ~~~ Pat Greathouse Customer Service Associate IV Providing Services For: Protective Life Insurance Company /Protective Life and Annuity Insurance Company HumanaDental Insurance Company /Reliance Standard Life Insurance Company /Commonwealth Annuity and Life Insurance Company SunAmerica C.ife Insurance Company / Molina Healthcare Insurance Company /Anthem Life Insurance Company of Indiana John Hancock Life Insurance Company (U.S.A.) /First UNUM Life Insurance Company / UNUM Standard Insurance (.'ompany / Aetna Life Insurance Company / (NG Life Insurance and Annuity Company ••~ '' M d~ ~' N ' O ~ ~ ~-i u: 01 ; N ~) ~ ~ ~' '~ Ti ' O ~ n ~ !~ 'i-1 r-i ''' O ~ ' N O ('~ !w's 01 ~' ~ O M a 'o a a o ~ o -~ 'o ;; ~o >.:' ~ '"' o ''o :~ ;, ~+ v ,.: ~.. ~ ,, a '~ a o ~<: O ~ ,, a '!',', w w ~:: N ~~ C M ..a ~"~ 7r V ~ p, J a o W ~[~1~ cdv ~ U ~ a loa vxiama u~ ~ ,~~ ~o a e ~_ u+ ! U ~ WW E >N '.L'0~7 ~.€ °'~r. > W00x x~x w o ~ Q E.a . ~ ,~ W .a ~c o N Y a O ~"~ ~~~ y O V ~~ v a s as ~n r+ v ~ m Q ~ ~ a m a a. Z ~ ... A 0 o ~;"' Protective Life Insurance Company P.U. 13u.~ 2C~OG 1.3inninglwm..Vabawia 35202 SUSAN L HIRSHMAN 1~1 YELLOW BREECHES DR C MP HILL PA 17011 INCOME TAX INFORMATION Police No. ....... G7o015760 'Car m No... . ... . XXX-XX-8970 Weer oc'rssue ...... 02/28/94 Sucrender,Maturity, or Exchange Calculation Date .... 03/27/ 12 The information below is furnished for your convenience in connection with the recent surrender or Section 1035 exchange of your life insurance or endowment contract or in connection with a surrender, loan, partial a•itltdrawal or Section 1035 exchange of your annuity contract. This information wilt also be reported by us on Fortn 10998 at the end of the year 1. Total Amount Distributed (includes net cash value, any dividends and/or coupons, refunded unearned loan interest, refunded premiums) , , , , , , , , , $ 2. Total Imesttnent in the Contract (includes base premiums paid and coupon and/or dividend interest already reported to IRS, less prior distributions and any unrepaid loans) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , $ 3. Amount Includable in Gross Income ......................... $ -1. Loan Amount (only applicable in 1035 exchanges) ................. $ j. Amount Includable in Gross Income in Connection With A 1035 Exchange . . $ 6. Federal Income Tax Wit13l3e1d ............................. $ 7. State Income Tax Witl3held ............................. $ 8. Subject to [RS Premature Distribution Penalt<~ ................... . 9. This Form is Being Prepared in Connection With A 103 Exchange...... . lt). Tax Qualified Plan .................................. . 1.935.60 .00 1.935.60 .00 .00 193.56 .00 N/A NO YES * Polic}owner is considered the recipient for income tax reporting purposes. Consult ~~our tax ads iser or attorne} regarding the use of this information in .'our income tax returns. ACQUISITION ADMINISTRATION DEPARTMENT 03/28/2012 F-1088-R Protective Life Insurance Company . ~' Li:~ and Annuity Administration Post Office Box 830712 Birmingham, Alabama 35283-0712 866-749-4567 • Facsimile 205-268-3684 March 28, 2012 Jeanne M Davis 4136 Burns Road Mechanicsburg, PA 17055 Re: Protective Life Insurance Company Policy Number: 670015760 Insured: Lewis E Belcher, deceased To Whom It May Concern: This letter serves as confirmation that the pending death-claim has been processed. Under separate cover, a check in the amount of $1,742.04, will be mailed to you. This check will represent the full and final settlement of all claims under the terms and provisions of the above referenced policy. If you have any questions, please contact me at 866-749-4567, extension 5669. Sincerely, ~~~~.~~- Pat Greathouse Customer Service Associate IV Providing Services For: Protective Life Insurance Company /Protective Life and Annuity Insurance Company HumanaDental Insurance Company !Reliance Standard Life Insurance Company /Commonwealth Annuiry and Life Insurance Company SunAmerica Life Insurance Company J Molina Healthcare Insurance Company /Anthem Life Insurance Company of Indiana John Hancock Life Insurance Company {U.S.A.) /First UNUM Life Insurance Company / UNUM Standard Insurance Company / Aetna Life Insurance Company / ING Life Insurance and Annuity Company PROTECTIVE LIFE INSURANCE COMPANY ,. -i~CO. BOX 2606 ` BIRMINGHAM, AL 35202 JEANNE M DAVIS 4136 BURNS RD MECHANICSBURG, PA 17055 Protective Life Insurance Company P.O. Bos 2006 Birmingham, AL 35202 POLICY DISBURSEMENT ACCOUNT IM ....:.::;:. cu~TE ::.::::: :. ~~~. . -03/29/12 06591236 The attached check is in payment for the item described above. '----------------"-------DETACHAIONG.O.OLT.EDLINEANDCASHIMMEDIATELY --- --------- .--r----.----..---_-. THE BACK OF THIS DOCUMENT CUNTAINS AN AjETIFICIAL WATERMARK- HOLD AT AN ANGLE TO VIEW _. ' CHECK. VOID !F NOT PRE$ENTED_ 81-373 Protective Life Insurance Company GHEGK IvO. "' WITHIN 90 DAYS FRONT DATE' 622 P.O. Boa 2606 Birmingham, AG 35203 x65.91236 POLICY DISBURSEMENT ACCOUNT- PAY ONE THOUSAND SEVEN HUNDRED FORTY-TWO DOLLARS FOUR CENTS 1 GATE CHECK AMOUNT .03/29/12 ******1,7.4.2..04 Tv/f0 5lGNATUR=_SRSQUIRED WHEN AMOUNT tS OVER$25,OOD:~ _ W _- REGIONS BANK , . - ;. ~ - - ~ UTHORIZEO~SIGNAFURE... li~f~ ~ 5 ~ ~ ~ ~ ~u, 4'Q ~, ~' ~'0 ~ 7 ~ 5+~ QQ ~OQCl4 ~ ~Qsi' Pc~'~;etycr Life Insurance Company • P.O. Box 2606 Birrnin~am.:~labama 35202 JEANNE M DAVIS 4136 BURNS RD MECHANICSBURG PA 17055 INCOME TAX INFORMATION Policy No. ....... G 700 i 5760 Tax tD No... ... XXX-XX-8693 Date of Issue ...... 02/28/94 Surrender,Maturity, or Exchange Calculation Date .. . . 03/27/ t 2 The information below is furnished for your convenience in connection with the recent surrender or Section 1035 exchange of your life insurance or endowment contract or in connection with a surrender, loan, partial withdrawal or Section 1035 exchange of your annuity contract. This information will also be reported by us on Form 1099R at the end of the year 1. Total Amount Distributed (includes net cash value, any dividends and/or coupons, refunded unearned loan interest, refunded premiums) .. , , , , , ... $ 1 , 935.60 2. Total Im•estment in the Contract (includes base premiums paid and coupon and/or dividend interest already reported to IRS, less prior distributions and any unrepaid loans) ................................... $ . 00 3. Amount Includable in Gross Income ......................... $ 1 , 935.60 4. Loan Amount (only applicable in 1035 exchanges) ................. $ .00 5. Amount Includable in Gross Income in Connection With A 1035 Exchange .. $ .00 6. Federal Income Tax Withheld ............................. $ 1'93.56 7. State Income Tax Withheld „ ................... ......... $ .00 8. Subject to IRS Pre-nature Distribution Penalty .................... N/A 9. This Form is Being Prepared in Connection With A 1035 Exchange....... NO l0. Tax Qualified Plan ................................... Y E S * Policyowner is considered the recipient for income tax reporting purposes. Consult your tax adviser or attorney regarding the use of this information in }'our income tax returns. ACQUISITION ADMINIsTRATlON DEPARTMENT 03/28/2012 F-1088-R - Protective Life Insurance Company Life and Annuity Administration Post Office Box 830712 Birmingham, Alabama 35283-0712 866-749-4567 • Facsimile 205-268-3684 March 28, 2012 Linda R Benson 1533 Bridge Street New Cumberland, PA 17070 Re: Protective Life Insurance Company Policy Number: 670015760 Insured: Lewis E Belcher, deceased To Whom It May Concern: This letter serves as confirmation that the pending death-claim has been processed. iJnder separate cover, a check in the amount of $1,742.04, will be mailed to you. This check will represent the full and final settlement of all claims under the terms and provisions of the above referenced policy. If you have any questions, please contact me at 866-749-4567, extension 5669. Sincerely, ~~ Pat Greathouse Customer Service Associate IV Providing Services For: Protective Life Insurance Company /Protective Life and Annuity Insurance Company HumanaDental Insurance Company /Reliance Standard Life Insurance Company /Commonwealth Annuity and Life Insurance Company SunAmerica Life Insurance Company / Molina Healthcare Insurance Company /Anthem Life Insurance Company of Indiana John Hancock Life Insurance Company (U.S.A.) /First UNUM Life Insurance Company / UNUM Standard Insurance Company / Aetna Life Insurance Company / ING Life Insurance and Annuity Company i, - Protective Life Insurance Company P.U. Box 2606 Birniingham, Alabama 35202 LINDA R BENSON 1533 BRIDGE STREET NEW CUMBERLAND PA 17070 INCOME TAX INFORMATION Policy No. ....... G70015760 Tax ID No..... xxx-xx-4595 Date of Issue ...... 02/2$/94 Surrender,Ma[urity, or Exchange Calculation Date .. . . 03/27/ 12 The information below is furnished for your convenience in connection with the recent surrender or Section 1035 exchange of your life insurance or endowment contract or in connection with a surrender, loan, partial withdrawal or Section 1035 exchange of your annuity contract. This information will also be reported by us on Form 1099R at the end of the year 1. Total Amount Distributed (includes net cash value, any dividends and/or coupons, refunded unearned loan interest, refunded premiums) , , , , , , , , , , $ 1 , 935.60 2. Total Investment in the Contract (includes base premiums paid and coupon and/or dividend interest already reported to IRS, less prior distributions and anyunrepaidloans),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$ .00 3. Amount Includable in Gross Income ......................... $ 1 , 935.60 4. Loan Amount (only applicable in 1035 exchanges) ................. $ .00 5. Amount Includable in Gross [ncome in Connection With A 1035 Exchange .. $ .00 6. Federal Income Tax Withheld ............................. $ 193 , 56 7. State Income Tax Withheld ............................. $ .00 8. Subject to IRS Pretnature Distribution Penalty .................... N/A 9. This Form is Being Prepared in Connection With A L035 Exchange....... NO 10. Tax Qualified Plan ................................... YES * Policyo~vner is considered the recipient for income tax reporting purposes. Consult your tax adviser or attorney regarding the use of this information in your income tax returns. ACQUISITION ADMfNISTRATION DEPARTMENT 03/28/2012 F-1088-R PROTECTIVE LIFE INSURANCE COMPANY P.O. BOX 2606 BIRMINGHAM, AL 35202 AMY K WELCHER 25 ESSEX ROAD CAMP HILL, PA 17011 Protective Life Insurance Company P.O. Box 2606 Birmingham, AL 35202 POLICY DISBURSEMENT ACCOUNT j GATE ,;CHECK' N6. , 03/29/12 06591237 le attached check is in payment for the item described above. ---------~ ~----~------~-DETACH Alr1NG nf1TTFD IINF 4Nf1 C4SN IMMFr114TFIV ------------•---~__ _ __ _ _ _ a q Protective Life Insurance Company P.O. Boz 2606 k3imtinghant. Al.ib~ma 35282 AMY K BELCHER 25 ESSEX ROAD CAMP HILL PA 17011 Policy No. ....... 670015760 Tax ID No.. ... XXX-XX-4447 Date of Issue ...... 02/28/94 Sun ender,Maturity, or Exchange Calculation Date .... 03/27/ 12 INCOME TAX INFORMATION The information belnic- is hirriished for your convenience in connection with the recent surrender or Section 1035 exchange of your life insurance or endowment contract or in connection c~•ith a surrender, loan. partial withdrawal or Section 1035 exchange of your annuity contract. This information will also be reported by us on Forn 1099R at the end of the year 1. Total Amount Distributed (includes net cash value. any dividends and/or coupons, refunded unearned loan interest, refunded premiums) , , , , , , , , , , $ 2. Total Investment in the Contract (includes base premiums paid and coupon and/or dividend interest already reported to IRS, less prior distributions and any unrepaid loans) , , , , , , , , , , , , , , , , , , , , ,,, , , ,, , ,,, ,, $ 3. Amount Includable in Gross Income ......................... $ -t. Loan Amount (only applicable in 1035 exchanges) ................. $ 5. Arttount Includable in Gross Income in Connection With A 1035 Exchange .. $ 6. Federal Inco-ne Tax Withheld ............................. $ 7. Sate Incocne Tax Withheld .............................. $ 8. Subject to IRS Premature Distribution Penalty ................... . 9. This Fortn is Being Prepared in Connection With A 1035 Exchange...... . 10. Tax Qualified Plan .................................. . 1.935.60 .00 1.935.60 .00 .00 193.56 .00 N/A NO YES * Policyowner is considered the recipient for income tax reporting purposes. Consult your tax adviser or attorney regarding the use of this information in your income tax returns. ACQUISITION ADMINI TRATION DEPARTMENT F-1088-R 03/2/201 2 /) R j Protective Life Insurance Company Pt't}ti~C$1lE', r/h.. Life and Health Insurance Administration Post Office Box 12686 Binnirigliam. AL 35202-6686 POLICY NO: 670015760 INSURED'S NAME: Lewis E Belcher B TEA~~ OWNER NAME: Lewis E Belcher CHANGE OF BENEFICIARY I (we) hereby request that all previous beneficiary designations and directions for settlement of this policy be cancelled and that the proceeds of said policy upon the death of the insured be paid, in one sum, unless otherwise providf:d herein or in said policy, as follows: PRIMARY BENEFICIARY: (Print full names and relationship to Insured) Name Address Relationship PercentaSe Trust Date, If Applicable SUSAN L. HIRSHMAN 151 Yellow Breeches Dr. Daughter 257 Camp Hill, PA 17011 JEANNE M. DAVIS r Daughter 257 g, PA 17055 Mechanicsbu LINDA R. BENSON 1533 Bridge Street Daughter 257 New Cumberland, PA 17070 AMY K. BELCHER Ro s Daughter 257 PA 17011 Hill Camp if more than one primary beneficiary is named, use percentages to indicate how proceeds are to be paid. If there are no percentages indicated, payment will be in equal shares to the surviving primary beneficiary(s). If there are no surviving primary beneficiary(s) ,then the proceeds will be paid to the contingent beneficiary(s). If a beneficiary is a minor at the time of death of the insured, it may be necessary to delay the payment of the death benefit until a court appoints a guardian of the estate of the minor. Before naming a minor as beneficiary, we recommend you consult an attorney about options, such as creating and naming a trust, making a designation sander your state's Uniform Transfer to Minor's Act.. or other beneficiary designations. CONTINGENT BENEFICIARY: (Print full names and relationship to Insured) Name Address Relationship Percenta st Date If A licable O 0 If more than one contingent beneficiary is named, use percentages to indicate how proceeds are to be paid. If there are no percentages indicated, payment will be in equal shares to the surviving contingent beneficiary(s) . If there are no surviving contingent beneficiary(s) ,then the proceeds will be paid to the executors, administrators, or assigns of the owner. DAY COMMON DISASTER CLAUSE IS REQUESTED (Maximum of 30 days): If any beneficiary shal I die simultaneously with the Insured or not be living on the ~' day following the death of the Insured, payment shall be made to the beneficiary(s) as if such beneficiary so dying had not survived the Insured. Request for Change of Beneficiary Page 1 of 2 SEE PAGE 2 for Signature Lines and Signature Requirements CUSTOMER #: 7375469 L E & MARIAN L WELCHER 26 RIDDLE ROAD CAMP HILL, PA 17011 HOME:717-737-5469 CONT:N/A BUS : c>~ r,r. 554197 f *INVOICE* PAGE 1 COLOR YEAR MAKEfMODEt ---' _ - VIN ••.• • ••••.•• •. ltCEl BEIGE DEL. DATE 00 BUICK CENTURY PROD,-DATE. 1NARR. EXP. 2G4WY55J9Y1330975 P PROMISED PO NO. RP 08JUN00 D : 17:00 13MAR12 R:OOPEN ED READY - OPTIONS: STK:B1055 13MAR12 13MAR12 L1Nr; UYCVllr; TECH TYPE HOURS A VEHICLE,EMISSIOI~TS EXEMPTION NCESIE VEHICLE EMISSIONS EXEMPTION 206 CRAVER,,RALPH LiC#: A_ CPNC PARTS: 0.00 LABOR: ,,20.00 .OTHER.: 0:00 T07 fREVSINGER MOTORS i 1537 @QT,REET NEw cunBfk aND. Pa 17070 717 774-7055 Term ID: 002 Ref p: 0U2 ~ Sale t XXXXXXXXXXXX13~3 ~c VISA Fntrv Method: 5aiped 03~14i12 13;49:09 Im a; 0002 ~r C«k;12S840 Aaarud; Online Batch: 000171 total; S 80.51 c~stoner cove THAW( YOU! PLERSE C01'IE AGAIN! ESIE STICKER # LM2 3061952 EXP 3/13 PSI STICKER # AI2'3762156 EXP 3/13 TIRES FRONT 10/32 REAR 10/32 BRAKES FRONT 8/32B REAR 5/32R B PA STATE SAFETY INSPECTION NCMA04 PA STATE SAFETY INSPECTION 206 CRAVER,RALPH LIC#: A CPNC. 21.0 0 PARTS: 0.00 LABOR: 21.00 OTHER: 0.00 TOTAL LINE B: 21.0 D 21.00 C 3750'!MILE SERVLCE: QUAKER. STATE r REPLACE'ENGINE OIL, OIZ FILTER,. -& . DRAIN PLUG GASKET (IF NEEDED), CHECK TIRES & SET TIRE PRESSURE' , CHECK AND TOP OFF FLUIDa, CHECK LIGHTS; 'WIPERS, BELTS; & HOSES. NCMA01 3750 MILE SERVICE: QUAKER STATE / REPLACE ENGINE OIL, OIL FILTER,' & DRAIN PLUG GASKET (IF NEEDED), CHECK TIRES & SET TIRE 1?RE$SURE, CHECK AND TOP OFF FLUIDS, CHECK LIGHTS, WIPERS, BELTS, & HOSES. 206; GRAVER, RALPH. LIC#: A CPNC 14.50 14 50 1 PF47 OIL FILTER `` 6.95 6..95. . 6.9'$ 9 QS5W30 QUAKER STATE 5W30 1/2 QT CONVENTIONAL 1.50 1.50 13 50 PARTS; 20.45 LABOR: 14,50 OTHER: O. DO TOTAL LINE C: . 34.95 TECH FOUND'THE INTAKE GASKETS LEAKING, INTERNALLY AND EXTERNALLY (MAJOR LEAK). ENGINE OIL IS LEAKING INTO THE COOLING SYSTEM AND CAUSING DAMAGE TO THE_HOSES AS WELL AS G~N'Y`AMINATTNG THE COOLING AND HEATING SYSTEM COMPONENTS., APPRC~X F.GTTM~T1+! C7Sn nn _ cocas n„ WARRANTY DISCLAIMER: ALL PARTS AND ACCESSORIES ARE SOLD AND ALL REPAIRS ARE HE D WARRANTIES EXPRESS RANID A'~IAIPL S BV SL ClESCRIPTION' TOTALS , IED NCLUD NG ANY IMPL ED WARRANTIES OF MERCHANT LABOR ABILITY AND FITNESS FOR A PARTICULAR PURPOSE, AND NEITHER ASSUMES NOR H IZ H AMOUNT 5 5 . 5 O SAL A O AT I YIL E H PARTS AMOUNT E OF P TS OR PRODUC TS OR HE REPAIR. THE ONL WARRAN~ ES ON PARTS AND ALL PARTS 2 0 . 4 5 OR E ~R ~ R Y GAS OIL LURE G NA pAR S DISTR BUTOR AND ONLY SUCH MANUFACTURER OR D STRFBUTOR SHALL BE ARE NEW UNLESS , , 0 . 0 0 LIABLE FOR PERFORMANCE UNDER SUCH WARRANTIES. CUSTOMER SHALL NOT BE ENTITLED TO RECOVER FROM THE DEALERSHIP ANY CONSEQUENTIAL DAMAGES, DAMAGES TO PROPERTY pTHERWISE SUBLET AMOUNT O . 0 0 , DAMAGES FOR LOSS OF USE, LOSS OF TIME, LOSS OF PROFIT OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES. INDICATED. MISC. CHARGES ` 0 0 D ey si nin below, 9 9 you acknowledge that you were notified of and authorized the D TOTAL CHARGES 7 5 . 9 5 ealership to perform the serviceslrepairs itemized in this Invoice and that you received LESS INSURANCE (or had the opportunity to inspect) any replaced parts as requested by you. The vehicle D . D 0 is betas returned to ou in exchan a for our a ment of the Amount Due. SALES TAX 4.56 DATE CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAY THIS AMOUNT 8 0.51 . LRdIE'I~AP ®2006 ADP (03/091 SERVICE INVOICE TYPE 2 - 2SI2C - 'AS-IS' - PENNSYLVANIA „9,6>Z8p8]_AMFR ~nDV customer account ~'nforRnation For Service To: L E Belcher 26 Riddle Rcl Account Number: 24-0631346-6 Premise Number: 24-0373071 Billing Period & Meter Information Billing Date: Mar 08, 2012 Billing Period: Feb 02 to Mar 05 (32 days) Next reading on/about: Apr 03. 2012 Rate Type: Residential Meter readings in current billing period: Meter Number N043260724 is a 5/8-inch meter. Present-actual 436800 Last-actual 432300 Gallons used 4500 Bltl/ng sumrr~ar~w ----------Prior Balance---------------__-__- Prior Water Balance Prior Balance Ottrer Payments prior to Mar 08, 2012. Thanks! Total prior balance, Mar 08, 2012 -__--Current Water Charges--_-_ Service Charge Water Volume ($.009101 x 4,500) Total water charges, Mar 08, 2012 _____Other Current Charges---___ Customer Protection Water Une Total other charges, Mar 08, 2012 _____AMOUNT DUE -______~___ ~a ,~~i -~ Water Usage Comparison Monthly usage in hundred gallons. 5 i i :i r- $44.69 $5.50 -50.19 .00 13.75 40.95 54.70 5.50 5.50 s a $60.20 Messages to you from Pennsylvania American Water Any portion of the water charges which is not paid as of 4/02/12 will be subject to a 1.50% penalty. "Approximately 4.57 percent, or $2.49, of State taxes are included in your current bill. "Effective November 11, 2011, the Distribution System Improvement Charge (DSIC) decreased lrom 5.44% to 0.00%. This charge funds the replacement of wafer distribution fatalities. Have you recently changed your primary phone number? If you have, please update your account information online using My H2O Online at www.amwater.com/myh2o or call us at the number below so that we can update our records. Customer Service & Emergencies 1-800-565-7292 (24 Hours) For Hearing Impaired Customers TDD 1-800-300-6202 {24 Hours) Visit us online at: www.pennsylvaniaamwater.com RAWt00AW486t 0009431000943 NCDLGI TAVO6 15 A1M 13088 2 M A M J J A S O N D J F M 2 0 a p a u u u e c o e a e a 0 1 r r y n I g p t v c n b r 2 Customer Account Information For Service Ta: L E Belcher 26 Riddle li;d Account Number: 24-063134fa-Ei Premise Number. 24-0373071 Billing Period & Meter Information Billing Date: Apr 06, 2012 Billing Period: Mar 05 to Apr 03 (29 days) Next reading on/about: Mlay 04, 2012 Rate Type: Residential Billing ~ummcr~r ---------Prior Balance---_--------------- Prior Water Balance Prior Balance Other Payments prior to AF r O6, 2012. Thanks! Total prior balance, Apr 06, 2012 --------Current WatF~r Charges------- Servioe Charge Water Volume ($.OOf ~ 101 x 3, 900) DSI - PAWC Charge 0.32% Total water charges, Apr Oti, 2012 _---------Other Current Charges------- Meter readings in current billing period: Customer Protection Water Line Meter Number N043260724 is a 5/8-inch meter. Total other charges, Apr 06, 2012 Present-actual 440 700 Last-actual 436800 -----AMOUNT DUE ----------_____ Gallons used 3900 ~ '~. I $54.70 $5.50 -60.20 .00 13.75 35.49 .16 49.40 5.50 5.50 $54.90 Messages to you from Pennsylvania American Water * Any portion of the water charges which is not paid as of 5/01/12 will be subject to a 1.50% penalty. * Approximately 4.57 percent, or $2.25, of State taxes are included in your current bill. *Effective April 1, 2012, the Distribution System Improvement Charge (DSI~:,) increased from 0.00% to 0.32%. This charge funds the replacement of water distribution facilities. * Have you recently changed your primary phone number? If you have, ple,~se update your account information onlin using My H2O Online at www.amwater.com/myh2o or call us at the numbe,~ below so that we can update our records. Customer Service & Emergencies 1-800-565-7292 (24 Hours) For Hearing Impaired Customers TDD 1-800-300-6202 (24 Hours) Visit us online at: www.pennsylvaniaamwater.com RAW t00AM7091 0038871003887 NCDNUe TAV03 12 AtM tt824 2 A M J J A S O N D J F M A 22 ~ t y n~ g p i v c n ~ a r 2 Customer account information For Service Tai: L E Becher 26 Riddle Rd Account Number: 24-0631346-6 Premise Number: 24-0373071 Billing Period & Meter Information Billing Date: May '10, 2012 Billing Period: Apr 03 to May 07 (34 days) Next reading on/about: Jun 07, 2012 Rate Type: Residential Meter readings in current billing period: Meter Number N043260724 is a 5/8-inch meter Present-actual 442 7 00 Last-actual 440700 Gallons used 2000 Water Usage Comparison ~ ~ Monthty usage in hundred 4 P_. 3 6* P_. f. fv 2 M J J A S-0 N-0 J F M` A M 2 0 a u u u e c o e a e a a 0 ~ Y n ~ g p t v, c n b r ~. y 1 2 Q951~,~ $49.40 $5.50 -54.90 .00 13.75 18.20 _ .10 32.05 _ 5.50 5.50 II 537.551 L Messages to you from Pennsylvania American Water ' Any portion of the water charges which is not paid as of 6/04/12 will be subject to a f.50% penalty. ` rox~mate/y 4.57 percent, or $1.46, of State taxes are included in your current bill. `E active April 1, 2012, the Distribution System Improvement Charge (DSlC) increased from 0.00 % to 0.32%.. This charge funds the replacement of water distribution fadtities. `Have you recent)y changed your primary phone number? tr you have, please update your account information online using My H2O Online at www.amwafercom/myh2o or call us at the number bebw so that we can update our records. Customer Service & Emergencies 1-800-565-7292 (24 Hours) For Hearing Impaired Customers TDD~1-800-300-6202 (24 Hours) Visit us online at: www.pennsylvaniaamwater.com RAW 100AM7671 Bfrl/ny~ ~'r:rmma~ ---Prior Balance-------------- Prior Water Balance Prior Ba/anoe Other Payments prior to May 10, 2012. Thanks! Total prior balance, May 10, 2012 -------Current Water Charges-------_ Service Charge Water Volume ($ 009101 x 2,000) DSl - PAWC Charge 0.32% Tota! water charges, May 10, 2012 ------Other Current Cfiarges------ Customer Protection Water Line Total other charges, May 10, 2012 ---_--AMOUNT DUE ------------ ooo99nooos9~ NcoRa~ rava5 rs A1M 29501 A CU D) j ' i m ~ ~> Gl M ' ~ ~J O a= .~ ~ O N ~ T N ^ H n N ~r- S C d N fa m 3 ~¢ 1 O1 n n 7!' o -~ N twY 1a Gr. O~ V fki tt3 t.:.. O eOn CD r Qf CA71 A W N~ O Km C _d m ^ O O O aa~ m ~~ m r~+~ G ?~ ~~ 01 7 O !A h '+ !OD O ~7 O -+ G -~ o ^ O g d C d p~ W N' 0 ?i O C1 m 7 c w m N m A n T ^ O C p M ~. g $e ~ 7 6A 0 0 N A A t7 ~A C~ ~ '~ n. KR ~ j„ a~ mom„ - ~ ,~ w _ y.. ~ C ~ X Op C Ql ~ ~ ~, u [~`d 17 xJr.,~ S o U ~ l~ ~ ~ ~i~~p ( ~ ~ ~+ ~ tN W ' Ip . r r G } ~~ ~{ { p .Nj V W -n e ~ ~ ,-•, horn o ^' C• ~ Ip x:~ ~~2~ s°r*+ ii c ~m ~oci. {:o c'> m ~ ' mm ~' ~ 3 ~ ~m ~ ~ o ::~• f7 N ~ W ~ ~ ;~ O ~ ~ ~ OCU N ~ N ~ or '? -' ~ .. V _ m a ' q -` ~ ~ ~ N y O [- ~p ~, O ` _ ~9 ~ ~ N f} 0 n ~ ca ~ 0 cn a c m o r~ ~ ~ d m ~ S a G s d d 3 N -1 Cm--1'oOOf)27C3 s ~'3~~,aui m~Q ~y C >~ ~C~CC33~ C ~~~ y 7 7~C 27~ .~+ ?t0 '"" !C A C'~ A '~N ~ 01n~~'~~~~~ a a~;~~mmW~ ~ ~ C O N tp N ~ ? ~ O ~a03 ~' .~1~. a ~ 6T1 O ~~ ~~ Mni t y ~J Ci UC1f Ai .i ~'~ '~i "~'Ar1 Hi ~ dy O; C i i "~ ^~ is i .~ i ooo 01 i WAVE ~' m W ON: t i No. s` r ° _ ~ i Of ONOVCO i o' 'sao~aoin O .A -r QI V C71 i Q ~ ~ m .. 'sa~' ID ,b N d s, s ; ~ W N m ~ v `~' ~ o~~ ~ N `~' y ~ i r y ~ O 0 ( / N \ / i ~ ~ / i _: ~' k .., + M M tl1 ~ ~ ,_. o o O ~nf { 6 000813 U 2 H = opt f[iric[ Billsl1gg Summary for Service to: LE-MS~LCHER 26 RIDDLE RD CAMP HILL PA t7011 Rate Classiflcatlon: Residential Heating Bitiirrg Period: 03!27/2012 to 04/26/2012 (30 days} Remote Device Read Quastlonsl' Cali 800-276-2722 or mite to UGI at PO BOX 13009 Reading, PA 19612-3009 `Your current UGI charges include State taxes totaling about S 1.96. Past Btll iMornratlon - Uq Utllity ~~ The account baMance on your last 'll was ...__.._..... S 116.00 Thank you for your payment of _____..__.._...._..____. -11 &00 218194383508 Your balance as of 05/01/2012 .......,_.._........_.._....... ~~~if Current Bill IMormatlon - UGI UtlUty Customer Charge .__......__....___.........._.,__........._...._. Commodity Charge { 34 CCF at 50.58853)) ._........_. Distribution Charges {First 34 CCF at 50.40294) ... 8.55 20.01 13.70 PA State Tax Su arge .__....______._..__......_........... Total Current Charges - UGI Utility ___..___ .._.....-- _...... -0.16 mod Budget ~ilinp Arrwunt .__........_..___...._........__........... U61 Utility charges owed this bili ____..__....__,..._....____ 116.00 . ............___..,......._......___ ~ 1.1 Total Amount Due, Please Pay by Due Date (05/22/2012) ._........__..__......_.._.... :11 Average txF Per Oay Mebr IMorraatlon - Ns~ Read Dots May Z9, 2012 10.90 Meter Number Prwious Readisp Present Reading CCF Used 9.81 10790F3 2824 (remote} 2858 (remob} 34 8.72 7.63 Msssayss from UGI t ^Your current price to canpare is S 0.60244 lCCF. ^Your total annual usage is 982 CCF. Your average monthly usage is 81 ^Your annual budget y~r began with September 2011. ~q~'~ To date you have been billed S 816.00 To date you have used S 1,039.21 ^ Help prevent pipeline damage, accidents and service disruptions. Coil 811 before you dig. • New look. Easier to find what you need. Ysit the new wwvvugi.cornl Be sure m dick on 'Energy Savers' for more ways to save energy and money. • Save time. Save the planet Sign up to view and pay your UGI bills online at vrww.ugi.com. Last This Average Year Year CCF/day 2.30 1.13 If you pay at a payment agent please take your entire bill. Nbke check payable to UG1. Daily temperature 53°F 53°F Keep this part for your records. Important iMormation is on the back of this bill. AMJJA80NDJFMA 2011 Morrtha 2012 0 ~E a, c c o~ ~d ~ d ~n >a \~ l ~QJ^ G.~ i ~,a ~ 1n ti~J ~ O C jQ~ ~~°~ f0 ~ C ~ w 1 ~ ~~~~ ,r . .;::. . . ,. I•~ 0 '~ On1 VY Vl m ... w m 0 L v N 4J o-' N ~ ~ _u ~ ~ ~ ~' w w 3 ~ J ~ ~ a ~ v a +° ~_ ~ ~ ~ m ~ U d O L a ysjvV W W L m ~`o s v H N O N M ri O. Q O .D f0 O 0 m O d L .~ ,'~ JWJ 1~C dmOZ ^ G7 u V1Dd ~ C • ~~ CC~ 7 {A~NU G~ ~D d' L °i 3 Y O1 a N U ~ H rn~ ~j O N i y •- ~a ?p 3 ~~~ ~ r p_LL vii ~~ o O L d~ ~ ~ ~~ ~ o ~ ~°E V ~'' ~ 67 a ai =os c ~~~ f~A ~ U \ ro L m ,,, m ~>d ~ a, w L a ava ~ N d ,r C f0 ~ (D O 3 ~~ +r f0 f0 y ? ~ ~ ~ T C y ~ ~ N ~~ ~ ~~ ^ TO ~ aE ~ R s~o~ yr ~ N_ u 3 ~ ~L H 01 O t! l 508500 ~/ p _7~ r C 0 p u 7 7 ~~ in0 In ~ p ~ T d j >_ O. ~, • ~j p ~, H f0 -- O +' `0 ~ ~ C q- . N ~ C C r ._ 0~= C C Q D C u 0 mOE ~w O Oa0 u~ ~ a~ N~ ~c -oo _> v~ ~ ~~ ~ Q~~ 3- O ~ N~ O ~ ~' ~ O E ~ ~ O C u~ C L C C C N ~ 0 00 p 3 f U 00 ~ >.!nN ~~d T~C OON oo~'o Qia a, ~ m ~ ~ m CSC '~~~ ~~d ~ ~ a 7+L+Tt_O o=m~a H c In~,a,v a i ... ~°ro~; ~o > f°u~aa ~ O ~ `~ ~ ~ ~ a`,~~ c oa ia i e°0~o3 ~'f6 i G 3a' ' o m~ ° c~ > ~~ ~- v~~ ~ • • • fOf1 N ry N ~ 11'1 Q ~4M~1) Aep gad •8ny D 2 0 w Q a LL Q; ~ O tC C ++ C L h w A~ ~ O~ 4J~ O m N ~ O Ql p ~ -_t1yDi C~EC C [~ S~ ` p• O 7 3 O. vfEfoO n fO ~ ~ a~ 0 2 c u ~-7 ~ ~ ~"' n d [D O rod UUaOQ n ~i 0 d ti V a~ L ~ d -` ~ z c z 3 _ 0 o a mNUQ LL LL ~ m ' • ~ 00 m ^ ~ l0 M l 0 l O -n `° v ~ ~ N e ~i ~ O d n ~ m ~ ~ a a L 3 Y N ei r-i ~ M m ~ ~ ~ ~~ ` L ~ ~ ~ M T ~ 1 ~ ~-`I f6 N N ~ 0l O O • ~ LL 0 (~O ~ l 0 m c • ~ L • ~ Q Q T N r 0 Y u t C O O w C c ,E as s O .-, d m d ~£ a, c~ O '' ~d ~d ~a >a 'cr N f0 a~a~ ~ M~J ~ O c jQd ~ ~~°$ o G1 = Cp LL U $.~~~ ~:....~~ .•. '•r ' ~ ~ ~' c 0 O M M C N N ~ ~ ~ ~ Cl m f0 L U N ~ N ~ ~ frf U ~' obi _ tL ~ O a ~ d C ~ ~~ c_~~gg ~°~ m m U ~I!, a` VI .~ v _~ W L O N N OD m u :° H N rl O N .~-i T c~ L O ro 0 C 0 m c O N e-i ~ ~. =oa ~ v ~°;~ n E ymO= ^ Cl uvs~a. '~ c ~z3~~ d ~~NV ~>°- M N ~ 3 ~ Y a aci '> U VI 01',~ ~p O N a.. N 0J - ~a 7~ N moo? A ~° _ aa'i m +, QLL ~Np N l0 ~ i..~ 0 O L N '"~ ~ ~ .:. in ~- m IN ~ ,-~~ ~ v m -o ~ c ~ ~ tlD ~ V \ f6 i M N m ~>3 ~ L a d ~°' a ~ N N i. C fC ~ >j O ~ co f0 ~ ~'• f0 oc >~ c v ~ ~ N i ~ a ~ `e' ~~ ~ T c _ O d ~ ~ R1 t~ o GJ j~ ~ ~ N ~ ' ,n QI m -~ -L-a~o ~,< <E5~ II Iill I I I INI I IIII~ I Ill II II I IIII II II III II ~~ 3 T ~ C ~ ~'' 7 ON00 O~ OCp~,~ ~~ ~ Q.J ~~ +~ ~ ~ ? u~ p ~ T+ ` C } p ~+ c~ OJ C "" w ~ ~ N o ccooE C ro y C C0 y a o = o ~u ~ a, Qc > ` ~ ~t +~ c o o a--•- 3 a, afOi ~t ~ m= ~~~ ~0 ov t v - N~ ~ ~ ~ E N N C U•p C t p 3 m c C V - d yL u 4! ~+ U 00 _ OG~'i~ ~ ~ p O V f0 ~ ` p ~ + ~ fD ~ 00 t!i ~N ~ a a~ d ~ ~~ C Cm ~ ~- ~~ ~~~ ~a ~~ctO~ G/ = C ~ d f6 ~` N ~ ~ ~ ~ VI ~ d~~ oaa i '"f° °c$3 u ~ ~~oa+ ~aci3 aio°~a i ' =. WY'O. ~ C 3 N ~ yLO ~ v 3da> ~`v°+o m~~,'a~ d. lynn~) tieo ~a ~~d Z O H a i LL amp '° c ±' a, n~~o ~ m ~' O.~ N N p~~''aO c Udri ~~~~ ~ln ~p n. ~~ cLEc N a-~ sm~ ~ m o= o o.v.~~ ~Ynnaci m'o o~ u°~o"'oQ n .--1 H O ~ d ~ u N Lena. ~, z c c 0 t ~ ca ~o ?~ Z~a~ O a ~ mNua LL LL M M OD tD • a~Y 00 ~~~ l0 M ~ ~ • ° ~ a i v N 01 ~ ~ - u m ~ m ~ ~ a a 3 Y N ei e-i r-1 ' O 01 • O O M N N N N L 1. ° • a a - H N • • N N ~ ~ ei O ~-i a-1 ` 0 ri ri O O ~ ~p O O N N Q C ~ N N L • ~ Q "' f~0 t~0 . . ~ ~ fOn N N N O Y1 O a ~~ Cv o~ ~d a~ fl. •> a t6 O J ^ CL a Td ~ ~ (w.~JN a0-+ c yam E ~~~~ ~ ~~ yc DOLL C1 v.=1~~ e ,, • ':: -- ~~~ _- ~~~ "~i C O m t U aN-I ~ ~ _U ~ a~'i w ~ o ~ N ~ a ~~ C ~ ~~ m m U 0 L a m v W L n N ~. a m U N O N M a--1 O 3 O .D f0 O 0 m C O N ~ ~~ =od ~~ ~~tiJJ ~ OmpS ^ N vv~~a y c ~ cSQ~ c %fJN~ c~ ~ t 3 a~ fl . -- N C N ++ " ~ .~. crf Gl O ~- C ~- C~ v O _.. O p 0 p~,~ 7 G/ 00 0 O~ O T ~p O ~ ~O j, in ~ ~ ~'n0 rnJ d ++ ~ N ~p>• ~''y~Ql~ d p• Q~ N p p ~ y ~~ C cow V1N ~pOE Ny ~c ~'-OO ~ a° ° ~ aE ~~ - ~~ 3- ^f'if O 0 ,cN R O ~'~ ` 3 O U 7 L to v' OO r .. O ° '~~ yF- c°1~ y °o c O C t 0Oo3~ . o.LL r; N co ~ ai O v a i ~ ~ " 0 ~ ~ ,n dori w ~~~ ~ O O uO ~ O ~'=~ t 0-O -md 0 ~`~'iiC Cm ~~~ ~~ m a+ 00~'C cv+~~ °' n e4 N ~aroa C d 0 ._ ~~-+c`-°E ~ ~,"' i~O a C ~ = „o •Q '~'~~ V ~ boa °`~ °_`° °' ~ U~ ~`~ Q 0 ~ ~ ~ ~' ~- = m ? ;n OO ~n ~ • ~n ~ O NNO m N Clti Ci~~ oON= t ~ v +' ~ ~~u~ ma m c ~ ~ ,'•, ~ ~ oA m a ai a t °' oo ~ ~~ ~ .y -o ~ c ~ ~ ° L' ~ •~m NL ~ ~ ~~ ~' N 3aa> o '~-~C ~LRo ot a i,' ioc ~ N O m~~•o~-a >~3 y W U O ~ ~ • • v cJ.~0' ~ O . a a~ ~. d ~ C co 7 ? ~ ~~ L Q~ T f6 OC ~-:~ N ~ N ~~ ~ ~~ ~ O~ _ ~O ~ a ~ ~ Ri ~~~ ~ U dL N O (WV1~I) A~ gad 'H^tl D 2 O N Q C a LL ° ' ~ •° o - ~~~ c ~ ~'H~ • { /1 ~ N ~yr a \Ufl.O A i a 'p M rn `O~ O Y~1 ~M O ~ ~ m~ eel c~ O ++NO ~N C i CQ N N caa ~~~~ CN ~ C t= mo=~ ~ O- u •%1 ~ : ~'n 1~ N - >. ~ y,, c0 O m~ O 3 N C~UoOQ e 0 ®i G ~u m~ a, cd Oa n ri a-i 0 a ~ °' ~z c -.~ W o ~ZV aci mNC)Q T t 0 Y v O r C O c 0 O C c r O a d Z ~ ~ N ~ ^ ~ ~ r-1 ~ ~ ~ ~ lD M 'ct M i e N 'O ri O N n ~ ~ m "' ~ ~ ~ a a 3 Y N ei N N M M R ~ ~ ~ T N ei a -i e -1 f 6 i O ~ a N N Q- O O ~ Q M N N T co ~ m ~ ~ ~ ~ M N N~-1 e0i Ill O ~ ~n ~ M i N O N N 6 A ~ N ~ ~~~ ~ r N _ o N ~ a _ ~, ~ p~~ ~ ~ ~. E ~ s E ~ _ ~ ~m~ v7 ~ Y3 ~ ~ ~ ~ f5 0 2 ~ ^ ~ ~ ~ ~ ~ ~ _ ~ ~ E O ~ ~ ~ ~ ~ ~ ~ S y( Q n. Q ~ d. m I ~ q ~ ~ ~ ~ g ~ ~ ~ ~ ~ a~ o; c`os ai ~w a`~ eo of ~ '~ _ ~ a~ ~n ~ ~ ~ ~ ~ g ca~ ~ vi _ ~ ~ ~ 8SE c~ ~~•E _i ~ O ~ ~~0 GC-~~ ~ ~ ~-a ~ ~g ~ ~~~ ~,~~ ~ ~~W ~,' o~ a.=~~ a0i~ eyi ~ ~zS.iG d ~ a E~~~^g ~ N~~~N ~a •c t~ tp m Q o4c i s ~ ~? O /0 ~ C d O O U N ~ 'i E rf j ~ ~ tO ~ y ~ w ~ .°.3 m ~ O ~ rn f ~ oaa~x~ =~c~ d Z ~c GLL~~zm~ ~?~~~ S c~ E o ~i c7t~~~E~ ii c7,°~~~ ~~ I ~ O I ~ o a ~* o d ~ w ~ opp ~ - CO o c0 ~ a0 Myy }r _ ~ ~ y r ~ `o ~°n ~ ,S o n ~' ~~8 3 ~ ~~ ~.~ .~ ~ ~ b '~ •a, ~ C ((~~ L lO l0 ~ c ~ •~ N ~ := ~. c ~' °~' T ~ O v >W~~ ~a~ $ ~.Fg'cn ,°'„ E ~ o x g ~~~ m c y ~ a s =oo m 6 ~ ~ " E^» a p i° 3 o c ~ C ~ y T U w ~ ~ A ~ m ~ ~ E E `o $' ~ c m ~ ~ c ~ E «+ S'S ~ 8E 3 O ~ 'g c w~~Sia o ~ N O ". .C " -o '" o a~ ~, ma `~ `° a~ ~ o 0 ~,Q U =O . V 3 ~ ~ U ~ ~ o Q ~a~oa ~~ ~ O -o W y f w J ~ ~ ~ ~ u~ = O ~ C >+ a o ~ ~ y ~ .~ ~ ~ ~ ° ~ ~ ^' O Q a. W N ~ ~ ~ ~ Soon, j ~ o Z¢~ n~ ~ o \ c oo~~ ~ r ~ ~O° ~ ~ \ ~ i ~ ~` ~ c i v o 0 E ~~ ~ ~ a _ W yam, J uj a ,~ i~=o O . Qc~~a m ° ~MUJ 0 ~ au N ~ \ ~ ~ y ' OM r b J , O ~ S ~ ° mmJQ J _ ~ ~Hz ^ ~i ~' d O + ~' a 70ZW 2 ,I. V O •~ W D ~ N ~ W ~ > NHVI ~aw ~[ - + m o ~ a ~ ~ \ ~~~~ ° a 3 W ~ 34-3u. arvWw V1~N~ O ~ O~ ~ p I ~ c f- ~ ~ v O O 00 ~-1 ri 4 O ~i I ~I ~~ ~~_ ~~ ~-~ ~~ o, o0 o~ ~ ~i r-I '\-I ~~ ~~ 00 ma G14- ~Q 0 v r 3 1-~ ~ O r F- b •suoi;do ~(ed ~tse3 ano;noge;no pui~ o; ao s. XINIW2l31-008-I Iles 'anoge pa;ou `~agwnu aau. ~a,c ~~•- ~ ~ O O ~ ~ ~'" : ~ ~ O m a O N Z E m W Q d ~ `_ r ~ W p. ~ a o Q. 7 H N 1 i J Y %l S D oX z ~ ~ v X W rn~ ~ n X ~ c Z O '- Z m =Z Z u~ E O E ®~ ~p~ii ~ ~y ~o ~oo~~ F-O dU d~ ~ ~~ r N m ~ H T ~ T O_ G G T (/1 W d O ~ Q y J ~O r W J- ya do W D 2 ~ M = w ~ 0 ~ o e ~. UQd= J ~N e ~ ~ W t0 m N U - ~Z JO Q z.1 g e-.1 ~ - 02 o m ~ U ~ ~n In f A r-1 ~. f-:O °v ri'~ ui ~`~ <~ d °v rE to y ~ ~ ~. .N a.. .~ A, iJ L .Q ~:Z...Z.. Q O ^'I rr~ Y ^` ~`..`.`+~ W ~' ~+ W O Q. ~ ~ ~ ;+~~ ~ ~_~ ~ ~c • - g :~ V ~ "~ N ~ ~ v /~ y ~ ~ ~ ~ N ~ O a~ .s ~ U W O O X ~ ~ d~ ~" ~} ~ ~ ~ H Z .~ v at?u s a ~- ~ m Q ~ : ~~~ s ~ ~ E i V • :~s ~ 0 ~ a~+ ~ F ~ ~ ~ N ~E 0 O p O U ~ G) .~ a p p ~o~ c ~p d ~ N J ~~ p O 2 •~:.,a ~ u f W J U ~iJ /~ ~ ' 6F~ _: s t ___ ~ - ;, , o: _ r E T Q °, R 1 E t m m J m ~ m ~ m ~ O ~ a ~ 7 1 ~ m a 1 J I T ~ a i n c ~ ~ t L N " ` e~ T i O ' N ~ N \ ~ i ~ ~ i \ o ~ 9 ~ m m ~ O m . T ~ m , U m i m t m ~ ® ~ o ~ ~t r ~; r ~~ W ~~ ~~ ~~ o~ ~~ ~~- 0 a O 0 ~ *~' z U~ JN Q m ~ r- ~.. o ~ ~m m C v 'C ~ 3 ~ ~~ m~~ ~~ ~~ ~~ __ ~ o e c~ ~ O g s a ~ $M U Q~i e'3rQ 01 ..~ N~a ~ ~ a ~3 ~'~~ ~ _ 03 g ,fir, 3 ~ ~ can z a ~ ~~ o~~ ~~ s s~~ ~ ~ 3 a • o Q O ~ ~ ~~~ ~ ~ ~ ; ~ ~ _.. a ~ v ~ W ~~ t ~ , : ~oM~e 3n v,a~ m ~ c o~ = ~~ y ~.~ W ~~_.°_ ~ J .~ ~_ L•Va C ~ L Y~% o v 3 : < : ~ ~ ~ .;: . ;~; a ~ ~, y~. ~ o ~-s~~r` U - .,~m~ °°ox H a ~.=m=m Yn=EQ' v ~ Q ~U W ~~ad~ _7e ll I B~~ II I N~~~~ I N I~~~ I~ I I~~~~~~~~~I~~~1~ ygZggZLl004B 8ZZ000 3 a w .~ i ~o ~ uj ~ .~ O 7 LL ;~ ~ ~~ E «+ W ~ a ' W ~ °~ ~ W ~ ~ ~. • r•Q ~~~..~ > p ~ ~ O ~ O x V N __ ~ ~ O O t S ~- O c '3 ~ W ~ ~ ,~ ~ p ~~ am ~ ~ _ cC~ ~ `Q c ~ ~ ~ V ~ C~ , ~ V N •~ ~ ~ 3 ~~ ~ ~~ ~ ~ o t~ J a 'C ~ ~ O O ~ p ~CO ... ~~ ~~ ~~ o f~ M M o ~O 1plM) M ~ P M M N 4- ~ ~ H ~ a ~ m d V ~ ~ y W ~°-aaa~ d a a i~~ c ~' ~ o a ~vl~ m ~ ~ stO ~ O m r.. ` ~ O ~ o ~~ =ate ~~ O pa g S ~ M ~~~ ~ N ~ O v ~ ~jj C ~ ~ ~ Iii U F ~ [ C/1 ~~[ ° I.t3 ~ w M o, . N N_ . ~o a J z= ~ L ~ ~ ~a _ a W I`' •- ~ .. t ~ H H W ~ J~ d ~ ~ ~. ~ E C V °~ Z' oa ~ ~ E ~ ~ ~ V ~ ~NMtt ~c~iV a ~ v~ Q a c c c c ~` 3397 ~~ ~Q Z p~ O 2 « m m V } O J J ~WjQ '~aO = LL ~Wg W3~ ~ W J Z O J ~Um 0 s ~7i, ZS o M 8 O Ip EF3 tR I r N ~_ 0 g Z o` ar W m W J Q ~ W ~ ~ o ~ ~ U ~ w c SF. ~ o LL U 30 = d i Z O a 0 a ~ v O O O n.> ~ > ~ ~ ~ U U ~ W wp~ ~~~~ ~~~ ~ ~ 0 ° ~ ~ ~c } na J rF W W = C ~ r Z ~ ~ 0 _ ~ ~ m a a Joa c ~ ~ m W J ~ ~ ~oa ~ ~w~a ~ d F-~c iU ~_ ~~ „a ~ 12 5 ESTATE OF LEWIS E BELCHER DATE ~A~ron-~bh ~ ~ ~.~1Ct' ~fL"~S.~i~.C' I~~fiv~{ ORDER OF Y11 ~- ~~ 3 DOL ACtS B ~ mom; I!~ i1 lrlOU ~~liK ~ayiYaaPrtor.. ~,E\i~' 0 - ------- ~:O ~~~ ~` ~~ 858 4 i406~'0 L 25 Payable To: BONNIE K MILLER, TREASURER Office Hours: MON,TUES 8 THURS 9-4 FRI AND ALL HOLIDAYS CLOSED WED BiN No: Bill Date: 330 3/1/12 2233 GETTYSBURG ROAD , ORG BMILLER~LATWP Control No:1313000284 CAMP HILL, PA 1 701 1-7302 . PHONE (T77) 737671 MAP NO: 13-23-Ob45-032. Dssc: 26 RIDDLE ROAD Atxes 0.16 HIGHLAND PARK LOT 5J E F ADDITIONAL RECEIPTS Tax Payer:. ~ .. EIELCHER. LEWIS E 8 MARIAN L 28 RIDDLE ROAD CAMP HILL, PA 7701,-802, Assessed Value: Land: 33,100 Improvement: 121,000 Tota1:154,100 ;,, p Face Penally 1.902 X8724 5293.10 X22.41 .143 521.60 522.04 524.24 TwplBarn: 1.23 5'185.75 0.41 561.92 5189.54 583.18 5208.49 569.50 ~. . J ~ 1 526.00 0.41 561.92 5z6.oo 583.18 52s.oo 569-50 if Data Of Payment Is On :6µA3 3/1/12 tfxu 4/30/12 5667.04 5/1112 thru 6!30!12 5720.14 7/1!12 or Later TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS ~~~ ~~ BONNIE K MILLER, TREASURER 2233 GETTYSBURG ROAD CAMP HILL, PA 17011-7302 TEMP - RETURN SERVICE REQUESTED OFFICIAL COUNTY MUNICIPAL TAX BILL Iiduul.,I.,u.Diu,ly.lul,l~l...lwil~ullll~lr,l,.l.l.~l, 87„0-szs ~ ~~ BELCHER, LEIdIS E 8 MARIAN L g {{"~ 26 RIDDLE ROAD ° CAMP HILL, PA 17011-6021 _~ ~., 3~ 18113 12 ESTATE OF LEWIS E BELCHER //~J DATE P09tDEROF ~~~.7~/,~V4•n U B ~r i~JC @. ~ ~' 1~~. ~C ~.~4~J1~ _~~(~~~ °~'" // nor LARS 8 ' U 1~~ wye~arn~oeo. ~p /~S-/~-9~/~ ,~• ~•:0 3 L 30 29 5 5~: 985844 1406~~'O ~ 20 ia~l Revenue Servicery cam, 2011 .Form 1040-V Payment Voucher a this voucher when making a payment with Form 1040. not staple this voudier or your payment Ea Fomt 1040. ke your check or money order payable to the 'United States Treawry.' Enter the amount ~ 18 0 to your social security number (SSM on your ctiedc or Haney order. of Uf ent ....... . REV otno-tz no 1858 W_IS E BELCHER INTERNAL REVENUE SERVICE RIDDLE ROAD PO BOX 37008 MP HILL PA 17011 HARTFOf~D CT 06176-0008 ],85129413 !IW BELL 30 0 20111 610 -- - - INVOICE Date: 04!30/2012 Prepared for: Belcher Property Appraised: Belcher, Lewis E. 8 Marian I. 26 Riddle Rd. Camp Hilt, Pa. 17011 File No. Belcher Case No. 4 Wayne Appraisal Fee $_ 200.00 Paid in Full $ (200.00) $ $ $ Total Amount Due: $ 0.00 Please make checks payable to: P. Scott Archibald 4454 Dunmore Dr. Harrisburg, Pa. 17112 Producetl by GIICKFpFiMS Software tlW-6"[""[-t3/ZI