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Home My WebLink About06-22-121505610143 REV-1500 Exi°'-'°' OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Vear File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 80X.280601 INHERITANCE TAX RETURN 21 11 1274 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 208 24 3903 09 22 2011 Decedent's Last Name BUCHANAN (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW Date of Birth 09 02 1922 Suffix Decedent's First Name MI FRANCES R Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ^ 2. Supplemental Return ^ 4. Limited Estate ^ qa. Future Interest Compromise (date of death after 12-12-82) ~1 I ~ I g Decedent Died Testate (Attach Copy of Will) '^ r ~ At aoheCopy of T usd)a Living Trust ~~ ~_ 9. Litigation Proceeds Received ^ 10. between 1231 ~J1 anditl(dat0e5of death ^ 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 (Attach SonaOj nder Sec. 9113(A) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JULIE M COOPER E5Q (717)367 1370._.,_ First line of address 222 $ MARKET STREET SUI Second line of address PO BOX 267 City or Post Office State ZIP Code ELIZABETHTOWN PA 17022 Correspondent's a-mail address: 1000per@gSkdlaW.COm `L~ __NLY r REGISTER ~LS USErO ~~ ~. i _ ~ ~ . ..! 7~ ~C~_r I ~ _ ~~~' ~ ~ . ~` ~; _a: 9 - ~ ~a - ~, - ~ . DATE FILED t_r1 -~~ ,-, ~`r _:~ ; ~, O _.~ 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 belles, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSO E r1NSIBLE FOR FILING ETURN DATE '~f ,~~y~ ~/ ~ ~t Elizabeth A. Rider (D' J~~~~. ADDRESS 2143 Andrew Avenue Elizabethtown PA 17022 SIGNATURE OF PREPARE THER AN PRES - TATIVE DATE ~~ ~ ~~ Julie M. Cooper Esq. ~"~f ~-~J :.~- ADDRESS ~/ 222 S. Market S reet, Suite 201, Elizabethtown, PA Side 1 1505610143 1505610143 ~? 1 ~ ~. 150561243 REV-1500 EX oecadenrs Name. BUCHANAN, FRANCES R. REC APITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5~ sonal Property (Schedule E) ............... er Cash, Bank Deposits & Miscellaneous P 5. 6. rr ~~ Jointly Owned Property (Schedule F) LJ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous N oq-Probate Property (Schedule G) a Separate Bilking Requested............ 7. g. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .............................................. . 14. __ _ __ TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15. (a)(1.2) X .00 16. Amount of Line 14 taxable 0 , Q 0 16. at lineal rate X .045 17. Amount of Line 14 taxable 0 . 0 0 17. at sibling rate X .12 18. Amount of Line 14 taxable 1,57 , 63 6 . O1 18. at collateral rate X .15 19. Tax Due ................................................................................................................ .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Decedent's Social Security Number 208 24 3903 89,096.45 2,164.72 90,653.30 181,914.47 17,367.78 6,910.68 24,278.46 157,636.01 157,636.01 0.00 0.00 0.00 23,645.40 23,645.40 Side 2 1505610243 1505610243 ~„I REV-1500 EX Page 3 File Number 21-11-1274 r~___~.. -.ae.. r,~......le.~e AeJ rlrncc• .. ............... ~.... .r.___ . -__----- DECEDENT'S NAME BUCHANAN, FRANCES R. STREET ADDRESS 4837 Trindle Road CITY STATE 'ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 24,500.00 1,182.27 (1) Total Credits (A + B) (2) 3. Interest 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Make Check Payable to: REGISTER OF WILLS, AGENT. (3) (4) (5) 23,645.40 25,682.27 2,036.87 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 :............................................................................... ^ b. retain the right to designate who shall use the property transferred or its income :.................................. ^ L~ c. retain a reversionary interest; or ..........................................................._........................._......_............... ^ n d. receive the promise for life of either payments, benefits or care? .........................................._............... ^ LJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ......................................................_............................................................ ^^x~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ~ i X I 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which ^ contains a beneficiary designation? .................................................................................................................. ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: . The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1503 EX+ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER BuCHANAN. FRANCES R. 21-11-1274 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH MorganStanleylSmithBarney Account #54J-01144-17 as follows: 1 42 shares of AT&T 27.75 1,165.50 2 9,596.55 shares of Bank Deposit Program 1.00 9,596.55 3 150 shares of Comcast, Corp. CIA 21.02 3,153.00 4 400 shares of Hershey Co. 57.25 22,900.00 5 800 shares of PPL Corp. 28.32 22,656.00 6 600 shares of UGI Corp New 26.78 16,068.00 7 212 shares of Wellpoint, Inc. 63.95 13,557.40 TOTAL (Also enter on Line 2, Recapitulation) 89,096.45 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-7508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Rl ~CHANAN. FRANCES R. FILE NUMBER 21-11-1274 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. (If more space is needed, addmonal pages or me same si~e~ Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BUCHANAN, FRANCES R. 21-11-1274 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Elizabeth A. Rider 2143 Andrew Avenue Niece Elizabethtown, PA 17022 B. C. JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY % OF DATE OF DEATH LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF DECEDENT'S INTEREST ITEM FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSE INTEREST NUMBER TENANT JOINT JOINTLY-HELD REAL ESTATE. 1 12/08/2006 Fulton Bank Checking Account#3623-29950 181,306.60 50.000% 90,653.30 TOTAL (Also enter on Line 6, Recapitulation) I 90,653.30 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) REV-1151 EX+(10-06) COMMNHERIETANCEIAX RETURNANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER BuCHANAN. FRANCES R. 21-11-1274 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached I 11,013.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(sl Commission paid State Zip 2. Attorney's Fees Julie M. Cooper Esq. 5,700.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees See continuation schedule(s) attached 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. I Other Administrative Costs 654.78 TOTAL (Also enter on line 9, Recapitulation) I 17,367.78 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER BUCHANAN, FRANCES R. 21-11-1274 ITEM DESCRIPTION AMOUNT NUMBER Funeral Expenses 1 East Harrisburg Cemetery -funeral expenses 2,900.00 2 Musselman Funeral Home -funeral expenses 8,113.00 H-A 11,013.00 Probate Fees 3 Cumberland Law Journal -estate publication 75.00 4 Escrow for final closing costs 100.00 5 Register of Wills -Letters Testamentary 261.00 6 Register of Wills -Short Certificate 8.00 7 The Sentinel -estate publication 210.78 H-B4 654.78 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+(12-08) SCHEDULE 1 i DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BUCHANAN, FRANCES R. 21-11-1274 .,___~ ~_~._ ._......,.,r ti.,.~.e .re~o.ro.,r .,rln. r~ .warn that remained unpaid at the date of death, including unreimbursed medical expenses. (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+ (11-OSI i ~ SCHEDULE J COMMNHERITA CE TAX RETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER BUCHANAN, FRANCES R. 21-11-1274 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NAME AND ADDRESS OF DECEDENT NUMBER PERSON(Sl RECEIVING PROPERTY Do Not List Trustees (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal I. distributions, and transfers under Sec. 9116(a)(1.2)] Elizabeth A. Rider 2143 Andrew Avenue Elizabethtown, PA 17022 Niece ~ Entire Residue ~ Total ~ Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet, as a ro I NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET[ Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) WILL OF FRANCES R. BUCHANAN I, FRANCES R. BUCHANAN of Cumberland County, Pennsylvania, do make this my Last Will and Testament, hereby revoking all Wills and Codicils at any time heretofore made by me. FIRST: Tangible Personal Property. Distribution. I give my tangible personal property to my niece, ELIZABETH A. RIDER, per stirpes and not per capita. SECOND: Residue. I give the residue of my estate to my niece, ELIZABETH A. RIDER, per stirpes and not per capita. THIRD: Spendthrift Provision. While in the hands of my executor, and until actually paid over or delivered to the persons entitled thereto, the interest of beneficiaries in the income or principal of my estate shall not be subject to assignment, pledge, attachment, or the claims of creditors. FOURTH: Powers of Fiduciaries. In addition to the powers conferred by law, my executor shall have the following powers to be exercised in such executor's absolute discretion: to retain for distribution in kind, without duty of diversification, all property owned by me at my death, or to sell all or any part of such property, upon such terms as my executor deems advisable; to hold any proceeds and other cash uninvested or to invest in all forms of property, without restriction to so-called "authorized" or "legal" investments and without regard to diversification; to exchange or lease for any period of time any real or personal property and to give options for sales, exchanges, and leases; to exercise all rights of security holders; to compromise any claim or controversy without court approval; to delegate discretionary powers; Page 1 of 4 to employ investment counsel, custodians of trust property, brokers, agents, accountants and attorneys and to act without independent investigation upon their recommendations; and to make distributions in cash or in kind at current values, in undivided interests or non-pro rata shares. FIFTH: Payment of Taxes. All estate, inheritance, and succession taxes, including interest and penalties, payable with respect to property included in my gross estate, including any property not forming part of my testamentary estate, shall be paid from the principal of my residuary estate, at such times and in such manner as my executor deems advisable, without apportionment or right of reimbursement. SIXTH: Appointment of Executor. A. Appointment. I appoint my niece, ELIZABETH A. RIDER, as the executor of this my Will. B. No Bond Required. Under no circumstances shall any personal representative appointed hereunder or otherwise be required to post bond in any jurisdiction. SEVENTH: Headings. The bold headings used throughout this Will are for convenience only. I do not intend such headings to be used in the construction and interpretation of this Will. EIGHTH: Number of Pages. This Will consists of 4 pages. 1';~~ VviTiJESS my hand this ~ ~~ day of -~ ~ ~~~~ , ~Ou^7. ~G C'-~{ t c:,r.,~ °~` ,~ ~K)c,~.n-Z._~ =~..:s.~~, (SEAL) FRANCES R. BUCHANAN Signed, published and declared by the above named Testatrix, FRANCES R. BUCHANAN, as the Testatrix's last Will in the presence of us who at the Testatrix's request, in Page 2 of 4 the Testatrix's presence and in the presence of each other have hereunto subscribed our names as witnesses. ~_- J Name ~ ~ ~ '=~ ., ,~1~ ~~ ~ ~~~ ~ '~ .. ~ti ~~ Address ~J I \ `~ J Name ~ S Address Page 3 of 4 AFFIDAVIT OF WITNESSES COMMONWEALTH OF PENNSYLVANIA ) /~ ) SS: COUNTY OF ~(,t~ ~~' I~.-~ `~~. ) We, FRANCES R. BUCHANAN, ~~,) ~~r~,~-,~ ~'' ~~ 4.~~~~-~~ • '~`~ and J 1 L~~~ ~~ • ~~ ! ~~ ,Testatrix and witnesses, respectively, whose names are si` ned to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as the Testatrix's last Will and that the Testatrix signed willingly, and that the Testatrix executed it as the Testatrix's free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witnesses and that to the best of his or her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint or undue influence. TESTATRIX ~) Frances R. Buchanan W1~f~ESSES ! ~', ~ _ , ,_ ~ , i f" ~' J Subscribed, sworn and acknowledged before me by Frances R. Buchanan, the Testatrix nd subscribed and sworn to before and +'~~~~' a ~~ -~ ,witnesses, this 9 ~C;~" day of , 2007. Notary Public MY COMMISSION EXPIRES: 92188 COMMONWEALTH OF PENNSYLVANIA Notarial SCI Paulkte Pattl Thomas, Notary Public City Of hlartisburg. Dauphin County My Cornrnission E~ires March 24, 2011 Membar, Pennsylvania Assoclatlorl of N4tarl4s Page4of4 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: RIDER ELIZABETH A 2143 ANDREW AVENUE ELIZABETHTOWN, PA 17022 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX(11-96) N0. CD 015338 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold ESTATE INFORMATION: ssN: 2os-24-sso3 FILE NUMBER: 21 1 1-1274 DECEDENT NAME: BUCHANAN FRANCES R DATE OF PAYMENT: 12/16/201 1 POSTMARK DATE: 12/1 5/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 09/22/201 1 101 ~ 524, 500.00 TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTY SEAL CHECK# 310 INITIALS: HEA RECEIVED BY: 524,500.00 GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER 7r1~ Floor Came H~li, P~? 1 i0ll rel "_~ i i ~~J 1300 December 19, 2011 Julie M. Cooper GSK&D Attorneys at Law PO Box 67 Elizabethtown PA 17022 RE: 54J-G1144-17 date of death values September 22, 2011 Dear Ms. Cooper: MorganStanley Smith~arney As instructed the following are the values on Frances Rider Buchanan's account as of 9/22/11: Amount Description Price Value 9,596.55 Bank de osit pro ram 1.00 9,596.55 42 AT & T I nc 27.75 1,165.50 150 Comcast Corp CIA 21.02 3,153.00 400 Hershe Compan 57.25 22,900.00 800 PPL Corp 28.32 22,656.00 600 UGI Corp new 26.78 16,068.00 212 Wellpoint Inc 63.95 13,557.40 Total 89,096.45 Should you require any other information please don't hesitate to let us know. Sincerely. a~ ,.~ 's;:~- ;,,.:;. .. ~ ___ ,• -s_~~_..Qebra A. Koons Registered Marketing Associate The Keystone Group Encl: a/s The information herein has been obtained from sources we believe to be reliable, but we do not guarantee its accuracy or completeness. nn„~„~„ c.~„iP„ c.,~~i, R~~.,P„ r r ~ nn..mtiP~ cirr r ~ i7 I-- ; ~ 1 ~ i„~ ~ 4 _ a c Y a - ~~-LB LISTENING IS JUST THE BEGINNING.° December 22, 2011 Gingrich, Smith, Klingensmith & Dolan Attorneys at Law 222 South Market Street P.O. Box 267 Elizabethtown, PA 17022 Dear Ms. Cooper, RE: Frances Rider Buchanan, deceased September 22, 2011 In response to your recent inquiry concerning the accounts maintained in the name of the decedent, please be advised that the following account was open at the date of death: Checking #3623-29950 Date of death balance $181,306.60, opened 12/8/06, joint with Elizabeth A. Rider If you have any other questions, please feel free to contact me at (717) 327-2497. Sincerely, „, Joshaa A_. Groff Credit Confirmation Processor 1.800.FULTON.4 fultonbank.com Fulton Bank, N.A. Member FDIC. Member of the Fulton Financial Family. ..-~ ~ ~ ~~Il 4~ 6 THE BANK OF MARION '`~' ~~-~,sl i~ 12816 MARION, VIRGINIA PRIN. INCOME ACCT. MARION, VA SL' P1~~•J-U Ell ~ 7 , 2011 6& 184/514 01100337 PAY TO THE ORDER OF ).'P,~111C~~J R PU I;fiN~~N $ 650.00 - ~I I~ }' Uf ,VIII I I~;, ~; ~ ~. 1 t'f /i ,~° ; ~ ~ ~ ~! ~ +'° I~ ~,,,I 1 I DOLLARS 1,,~' -_ INCOZiL /110133 FRANCES P. BUCIiANAN ACCOUNT VOUR ENOORSEM ENT ON THIS CHECK ACKNOWLEDGES PAYMENT FOR ABOVE APPROVED TRUST FUNDS ~ -r~ ~~~ ~~ ~ l~s~ THE BANK OF MARION - ASSISTANT TRUST OFEIC ER 11'00 ~ 28 1611' 0;0 5 L40 L849~: O L Iti 00 3 3 ?11' ~GHNWZK, Prescription Drug Plan Premium Refund DATE 10/04/2011 *TWENTY-SIX AND 21/100 DOLLARS* ~3~~6~2 AMOUNT 26.21 PAY THE ESTATE OF FRANCES R BUCHANAN TO THE ORDER OF 2143 ANDREW AVE nay urn APT 219 ^~""°RI:EO51cNnTUaE ELIZABETHTOWN PA 17022 11'036665211' x:0360?6150: 6 20 54 5 2 58Lu' -- _- T - - ;~ _; - Country Meadows Associates waonov~a sank, N.A. 194444 830 Cherry Drive 3-50 Hershey PA 17033 3~0 DATE CHECK NO. AMOUNT 11 /03/2011 194444 $1,488.51 **'` Pay ONE THOUSAND FOUR HUNDRED EIGHTY-EIGHT AND 51/100 DOLLARS TO THE ORDER of ESTATE OF FRANCES BUCHANAN C/O ELIZABETH RIDER 2143 ANDREW AVENUE __ ~ ~~, J ~ ELIZABETHTOWN, PA 17022 gl" 11'0 L9444411' x:0 3 1000 50 3: 20 L4 20 L 2?088511'