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Home My WebLink About07-13-121505610140 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 1 1 1 4 0 Harrisburc , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 0 1 6 2 0 1 1 1 2 2 5 1 9 3 1 Decedent's Last Name Suffix Decedent's First Name MI S I M M O N S C A R O L I N E R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI S I M M O N S L E R O Y J Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 1 9 5 1 4 2 4 3 4 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW a 1. Original Return 4. Limited Estate Q 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 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) 3. Remainder Return (date of death prior to 12-13-E32) 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. OI CORRESPONDENT - THiS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMAL ION 511ouLU fit ulrttc:l to I u: Name Daytime Telephone Number D A V I D H S T O N E E S Q U I R E 7 1 7 7 7 4 7 4 3 5 REGISTER OF WILLS USE ONLY First line of address r 4 1 4 B R I D G E S T R E E T C7 ``~' ,.~, , ~~,~ Second line of address i ~ ~} ~-- ~ { ~ % 7 1 ~x _.. ' I.~ 4~•1 ~~ ~ , 9 City or Post Office r.~L~D State ZIP Code - -- - ~ w 'x G N E W C U M B E R L A N D P A 1 7 0 7 0 ~-,c=_ =~-~ ~:~;. pf.; ~ ` ~ n ' .t . ~~ . "~ s a-mail addres Correspondent s: D S T O N E a~ S T O N E L A W• N E T v ~~ 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, correct and complete. Gecl~ on of preparer other than the personal representative is based on all Information of which preparer has any knowledge. SIGNATI~Of' P RSO~N S-P~ IBLrE FOR FILING RETURN DATE N'" TREET NEW CUMBERLAND PA 17070 ,$I NATUR OF A ER OTHER THAN REPRESENTATIVE D~4TE /'.. ~'g . ~ 2_ 414 BRIDGE~STf~EET NEW CUMBERLAND PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 15D5610140 15056101,40 J 1505610240 REV-1500 EX Decedent's Social Security Number DecedenYsName: CAROLINE R• SIMMON$ RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1 2. Stocks and Bonds (Schedule B) .................................... .. 2. 3. Closely Held Corporation, Partnership or Soie-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 6. Jointly Owned Property (Schedule F) OX Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 1 0 6. 3 4 3 D. 2 2 6 2 3 3 4, 1 0 1 7 1 0 5. 8 5 7 9 5 7 6. 5 1 9. Funeral Expenses and Administrative Costs (Schedule H) ....... . .......... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 10) ............................... 11. 12. 13. 14. Net Value of Estate (Line 8 minus Line 11) ................... Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............. Net Value Subject to Tax (Line 12 minus Line 13) ......... ....... .... . .. .... . .. .. 12. .. 13. .. 14. TAX CALCULATION - 5EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a}(1.2) x• 0 ~ 4 0 2 2 3 4 15. 16. Amount of Line 14 taxable at lineal rate x• 0 4 5 6 2 3 3 4. 1 0 1s. 17. Amount of Line 14 taxable at sibling rate X .12 D D D 17. 18. Amount of Line 14 taxable D D D at collateral rate X .15 18 19. TAX DUE .................................................. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1 3 2 2 0. 0 7 1 3 2 2 0. 0 7 6 6 :3 5 6. 4 4 0. D 0 6 6 :3 5 6. 4 4 0. D 0 2 ~~ 0 5. D 3 0. D 0 0. D D 2 ~~ 0 5. 0 3 Side 2 150561024D 150561D240 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 11 1140 DECEDENT'S NAME CAROLINE R• SIMMONS _ STREET ADDRESS 1728 WARREN STREET CITY NEW CUMBERLAND Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits(Payments A. Prior Payments -- B, Discount Interest If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 21) to request a refund. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. STATE __ ZIP _ _ _ __ SPA 17D7D- (1) 2,805.03 Total Credits (A + B) (2) 0.0 0 (3) D • D 0 (4) D • 0 0 (5) ** 2,805.03 **SE~parate billing as shown an Sch F Make check payable to; REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTION5 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 : ................................................................. ..... ^ 0 . .. . . b, retain the right ?o designate who shall use the property transferred or its income; . . :::::; : i ::: :::::: ::: c. retain a reversionary interest; or ........................................ ... :::: ^ ^ X d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving a:iequate consideration? .................................................................................. ..... ^ 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? .... ..... ^ Q 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 tfie use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan, 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [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)j. • 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, undE 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 COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER CAROLINE R• SIMMONS 21 11 1140 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 69.78 shs $50 EE US Savings Bond #L482359585EE a $1.00 69.78 each Issue Price $25.00, Int• $44.78 2 136.56 shs $50 EE US Savings Bond #L584679531EE a9 $1.00 I 36.56 each Issue Price $25.00, Int• $11.56 TOTAL (Also enter on line 2, Recapitulation) 19i 10 6 • 3 4 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (11-10) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: CAROLINE R• SIMMONS 21 11 1140 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 Members 1st FCU-Savings Acct #3565D9-DO 30.22 TOTAL (Also enter on Line 5, Recapitulations ~ $ 3 0 • 2 2 If more space is needed, insert additional sheets of paper of the same size REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEF JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: CAROLINE R • SIMMONS 21 17, 1,1,40 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT a,. BARRY A CLAY 225 PINE VIEW ROAD SON CAMP HILL, PA 17011- r3. LEROY J I SIMMONS 1728 WARREN STREET SURVIVING SPOUSE NEW CUMBERLAND, PA 17070- c.TERRY L• CLAY ],485 HUNTLEY COURT SON YORK , PA 1,7408 JOINTLY•OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °/ OF DECEDENT'S IPJTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. a. 4ioaio9 Graystone Tower Bank-Diamond MM Acc 57,084 • D3 33 • 33 19,026.11, #1710D13127 Princ. $57,070.77, Int. $1,3.26 for a balance of $57,084.03 joist w/Leroy Simmons and Barry 0.OD Clay dated 4-08-2009 divided by 3 ** BILL BARRY CLAY SEPARATELY ** 2 C sil~ia9 Members 1st FCU-Cert. of Deposit 86,6],5.97 50• 43,307.99 #356509-41 Princ• $86,559.4]„ Int. $56.56 - joint w/Terry Clay w/date made joint Dec 10, 2010 0.00 (note this is a rollover w/original date made joint as of May ],2, 2009) ** BILL TERRY CLAY SEPARATELY ** TOTAL (Also enter on Line 6, Recapitulation) I $ 6 2 , 3 3 4 • 10 If more space is needed, use 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 CAROLINE R• SIMMONS 2L 11 1140 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 RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. AttACHACOPYOFTHEDEEDFORREALESTATE DATE OF DEATH VALUE OF ASSET °fo OF DECD'S INTEREST EXCLUSION pFaPPUCae~El TAXABLE VALUE 1• Metro Bank-IRA Time Deposit 3,487.54 100.00 3,487.54 #7000170720 Princ- $3,485.57, Int• $1.97 Benef is Leroy Simmons 3 Susquehanna Bancshares Inc-IRA CD 13,6],8.31 100.00 13,618.31 #5035000001,49 Princ- $13,610.33, Int- $7.98 Benef is Leroy L• Simmons TOTAL (Also enter on Line 7, Recapitulation) I $ J, 7 ,10 5 • 8 5 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER CAROLINE R• SIMMONS 21 11 11,40 Decedent's debts must be reported on Schedule I. ITEM NUMBER A. 1• B. DESCRIPTION FUNERAL EXPENSES: Parthemore Funeral Home-funeral expenses ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) o+ Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees: David H Stone, Esquire 3, Family Exemption: ~ f decedent's address is not the same as claimant's, attach explanation.) Claimant Leroy J • Simmons StreetAd~~ess 1728 Warren Street c;~y Ne,~ Cumberland State PA z1P 17070 Relationship of Claimant to Decedent S u r v i v i n g S p o U S e 4 • Probate Fees: Register of Wills, Cumberland County 5 • Accountant Fees: 6 • Tax Return Preparer Fees: 7• I Register of Wills-filing Inh Tax Ret and Inventory 2• Reserve for closing expenses AMOUNT 9,630.57 3,000.00 136.00 323.50 30.00 100.00 TOTAL (Also enter on Line 9, Recapitulation) I $ 13 , 2 2 0 • 0 7 State ZIP If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (Ot-10) pennsylvania ~ SCHEDULE J DEPARTMENT OFREVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CAROLINE R• SIMMONS 21 11, 1140 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• LEROY L• SIMMONS Spousal 1001 RES DUE 4,022.34 1,728 WARREN STREET NEW CUMBERLAND, PA 17070 2 BARRY A• CLAY GRAYSTONE JOINT ACCT Lineal 19,026.11 225 FINEVIEW ROAD CAMP HILL, PA 17011 3 TERRY L• CLAY MEMBERS 1ST JOINT ACCT Lineal 43,307.99 1485 HUNTLEY COURT YORK, PA 1,7404 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE, II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX !S NOT TAKEN; 1• B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1• TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0 - 0 Q If more space is needed, use additional sheets of paper of the same size. A ~! ~.~ ' 1 I /T II ~i ~; 4 LAST WILL ANU ~STAt9ilQT F OTC j CAROLINE R. SIfilMONS I, CAROLINE R. SIMklONS, of the Township o,£ Fairview, County of York, i gad Commonwealth of pens~sylvt-nia, declare thin to ba my iaat wi:tl and z~evoke i aay will previously made by we. ITEM I: I devise and bequeath all. of my estate of every nature and wherever situate to my husband, LEROY J. SIMMOKS, provided he survives me by . thirty days. TTFM II: Should ~- husband, 'LERDY J. SIMMON5, tail to survive me by thirty days, I bequeath sack of my tgngible personal property as is set forth irk ' a separate unsigned memorandum, which I shall place vith mS' wi].1, tv the person i ' therein designated. XTEM II1: Should my htsbaud, LEROY J. 5ZMMONS, fail to survive me by thirty days, I devise and bequeath the residue of my estate of every nature aetd~ wherever situate as follows: i A. One-half thereof to s-y issue, per stirpes, living oa the th.trty-- i i ~~ first day following say death. i B. The remaining one~half thereof to the issue of my ]tiusband, LEROY i J. SIMMONS, per stirpes, living on the thirty-first day following my cteaCh. . <~~ 'j; -.c.3 --~ i. ~~~ .:.. _. ~;- . .. L. . 9TONEa ~roNE Page l of 4 _. ,,~-~ .. ~~ i A~tA/r»Ys e! Lew " 414 0~1dQs 9ireet "' <a I '4~~ .~ r..:. New CUrr,t~erWw. Ps. ~) : ~-, X7070 ~~ !I I 4; ITEM IV: I appoint my eycecutor and his successors guardian of i ! any property which passes either under this Will or otherwise, t0 a ainor and} With respect to Khich I a:n authorised to appoint a guardian and have not otherwise specifically done so, provided that this appointment of a guardian shall not supersede the right of any fiduciary in its discretion to distribute a share -~here possible to the minor or to another far the minor's benefit. ~ Such guardian shall havt the power to use principal as Well a$ income fxoap j '~ ties to`time for the minor's support end education (including college educe- ' lion, both graduate and undergraduAte) Without regard to his or. hez~ parent's ability to provide foc such support and education, or to make payment Eor these purposes, vrithout further responsibilfty, to the minor or to the minor's ! parent or to any person taking care of the minor. i ISM V: I appoint my husband, 1.EROX J. SIIiMONS, Executor of this my i last ails. Should m9 husband, LgROY J. STIKMOHS, fail to qualify or cease to act as my Executor, I appoint mp son, TERRY L. CLAY, and my hsaband's ! dauShtar, CANSTANCB 1. SIl~i0N5, Cn--Executers of this aiy last wi7.l and teatamentl ITEM VY: I dixect Chac my Executor or Guardian or their succesaor$ shall not be required to give bond fox the faithful performance of Chair duties; in any jurisdiction, i IN WITNESS W~REOF,.I, CAROY.YNL R. SIPII~igNS, Teataerix, have hereunto ! set mp hand and seal this ~ 7~ day of ~ ~-p r~~ , 1989. '~ CAROC:INB ~. SIMMONS ! ~Y'OMi ~ fiTONt Atton~.v se uw 414 Sridps StMe P ~ e ~ p£ 4 w... C.~.e..,.na, P.. g j ,~o~o ~~ I~ i I ;.. SIGNED,. SEALED, PUBLISHED and DECLARgD by CAROLINE R. SIMMONS, the Testatrix above nat#ed, a8 and for her Last iJill and ?estament, and in the pre- sence of us, oho at has requeot, in her presence and in the presence of each i other, have subscribed ovr names as witaesee®. ~tn ..5~ ~r~,~m~$ Flitnese COIMlONWEA,L11i OF PENNSYLVANIA.: :SS: CoUNT7 OP CIDiBgRLAND ,A.ddr as ,? , d xtc~.~~F~' fir' .. Ada ~ ~ `~` I,, CARO'LZNL :R. SIl'Il'fONS, the Teecacrix whose netaoe is signed co the .. attached or foregoing iD.etrument, having been duly qualified according to law do hereby acknowledge that Y aign@d and executed th~.a instcumen't as my last will; that 1 signed it wi111ng1y and that I Signed it ss ~y free and voluntary act for the purposes therein contained. u ~~~ Ct. .~. Il /,~ , . CAROLING R. SII~tONS Sworn to or affirmed to and acknowledged before mP by CAR(~I.xNE R. SIt~'(ONS, Che Testatrix, this ay of 1989. otary Public sTV..e a ero~ ~-se.,,..v. ee ~+.~ 414 srwpe Sveef N.M. o~„b.~.~.a. r.. ~oo~o I' i i i „~ DELINDA M. RITCHIE.SMOTARY PDBIIC 1 '. ~ CUK$ERl.AND BOR4. CUMS£RLAkD CO. ~' COyIM[SSION EXPIRES MARCH 29. 1993 Page 3 of 4 COirB'iONIiEA1.TH Op PEi3NSYI.VANYA :ss: COUN1tY OF CUFIHERLAND ~ .., 6` 5ie, ~ and lcu,, ~ J (~' ~ ~ ~ the W3tnesaea >Phoae napes, are signed to the attached or Foregoing instrument, tiTONC Lt tiTON! Attv+ya rt Law 474 9/Id~ 6tr'*at Nsw CyrytpMlpnd. Ps. 1T4~o being duly qualified adcording to law, depose and say that.we xere preseAt and = saw Testatrix sign and execute the instrument as her last Will; that Testatrixt Qigned willingly and that she esecuted it as ber free and voluntary act for the purposes therein eapresaed; that each of us in the hearing and sfght of # the Testatria signed the will as witnesses; that to the .best of our knowledge, the Testatria~ was at that tine eighteen or Wore gears of age, of sound mind and under no constraint or undue influence. - 1 _~ ~ ~. ~ ~'~ Wi.txta s s ' 1 StwrA to or affiruted to and acknowledged before me by ~++'', ,~L~id~1~t~1~ ~ ~ and ~~ U U1 ~~'!'~~ ~ Q~f ~ ,_,_, tai the s s s s , '' this ~ day of 1989. Notary public idOTAR1a4 SEAL OEI.INIM M. RITCNIE. tIOjAR~ PUBLIC MfN CU~16fRlANn BORO. ClJMBERt.AND CO. ' MY ~OMr+l1$$ION tY~i':fS M.sRCH ?9. 1993 Page 4 of 4 jj i Calculate the Value of Your Paper Savings Bond(s) ~C"E'Ca S U 1"~~11'G'C ~ Page 1 of 1 tlncne LCIJ-viA ;al Trn1: C.aic~.dite the Value ..^,f Your pgippr iavtr+gs pond(s) Calculate the Value of Your Paper Savings Bond(s) SAVINGS BOND CALCULATOR '' Value as of: 10.2011 l)P~0.~E ~' t:.., Serles: Denomination: Bond Serial Number: Issue Date: EE Bonds 50 CALCULATE 'MOW TO SAVE YOUR INVENTORYI Ct~arlculator Results for Redemption Date 10/2011 a~it'Ir '' "~ E`~~ Total Price Total Value Total Interest $50.00 8106.34 556.34 Instructions -" - ~-~ -~I I' ~w to ~ ~<. Lh a:~~nos 8o'td I "alcula[or ! Notes Description ~ NI Not [ssuetl ', NE Not eligible for payment DS Intludes ~ month Interest penalty MA Matured and not earning interest ' VTD Interest ¢3.22 Bonds: L-2 of 2 Serial # Series Uenom Issue Next Final Issue Interest Aate Accrual Maturity Prke Interest pate Value Note L584679.531 FE EE SSD 05/2000 11!2011 OSj203q $25.00 SLt.Sfi 1.77% ;36.58 ~.-a:,MJVF ~'._ 14A2:7595ASEE EE 550 10/1991 04/7012 10/2021 (25.00 544.78 4.001 ¢8918 et:o-~u,e ~ 1LCU''A'E 1f'OTti°o BO^!C Survey _. How would you rate this tool? '.. _' Excellent ' .-~ Good 'Pair POOr SUgM27 ' ~r« irrn of t~.ttor r'.atir,+r h<-1I 1_ ti & r,uin:~ :cr• ~ EClya.v !f I erra~ Norir s ~ W!•hsne 'e rr "+: ^. r, r. Conti /S.i.;;S511`.LkY,Y `Y.tra :Z rd 1v I_i S Denartm rt of tt It'N~~•+rv t "s•au of i1~ N ~`I~ ~~rfPS http://www.treasurydirect.gov/BClSBCPrice 12/2/2011 MEMBERS 1~ FEDERAL CREDIT [JNION PRIMARY OWNER: Caroline Simmons Leroy Simmons REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CERTIFICATES OF DEPOSIT: ,~ 356509-00 05/12/2009 $30.22 $.00 $30.22 None Account Number/Suffix ~ 356509-41 Date Account Established 12l10/2010* Principal Balance at Date of Death $86,559.41 Accrued Interest to Date of Death $56.56 Total Principal and Accrued Interest $86,615.97 Name of Joint Owner Terry Clay Date Joint Ownership Established 12/10/2010 *Roflover from certificate 356509-40, originally established 05/12/2009. **Rollover from certificate 200236-41, originally established 12!03/2009. VISA ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Name of Joint Cardholder *Contractual Pledge of Shares. 4672090000353557 12/30/2009 $-11.81 Leroy Simmons 200236-00 1 212 9/2 0 0 0 $11,105.57 $1.14 11,106.71 Caroline Simmons 12/29/2000 200236-44 07/03/2011 ** $124,033.09 $63.21 $124,096.30 Caroline Simmons 07/03/2011 M BERS 1ST FEIDE~RA~L C DIT UN ~~~ ~ ' ~~ Danielle A. Kline Lending Insurance Support Specialist November 8, 2011 Estate of: CAROLINE SIMMONS Date of Death: 10/16/2011 Social Security Number: 168-24.4270 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org ~4~ pRAYSTONE TOWSR -- BANK November 9, 2011 Stone LaFaver & Shekletski Attn: David H Stone 414 Bridge Street, PO Box E New Cumberland, PA 17070 RE: Estate of Caroline RSimmons - SSN 168-24-4270 -Date of Death 10/16/11 Mr. Stone: Please see below for account information: ~'~' Diamond Money Market -Acct 1710013127 Date of Death Value: $57084.03 (Current Balance $57070.77 + Accrued Interest $13.26) Date Opened: 04/08/09 Date Closed: 10/25/11 Owner(s): Caroline Simmons, Leroy Simmons, Barry Ctay 36 Month Certificate of Deposit -Acct 300004882 Date of Death Value: $46766.72 (Current Balance $46668.32 + Accrued Interest $98.40) Dated Opened: 05/22/07 Owner(s): Caroline Simmons, Leroy Simmons 36 Month Certificate of Deposit -Acct 3000049624 Date of Death Value: $45502.44 (Current Balance $45439.80 + Accrued Interest $62.64) Dated Opened: 06/01/07 Owner(s): Caroline Simmons, Leroy Simmons 36 Month Certificate of Deposit -Acct 3000117573 Date of Death Value: $33209.18 (Current Balance $33182.27 + Accrued Interest $26.91) Dated Opened: 07/08/09 Owner(s): Caroline Simmons, Leroy Simmons 36 Month Certificate of Deposit -Acct 3000119106 Date of Death Value: $24747.90 (Current Balance $24745.89 + Accrued Interest $2.01) Dated Opened: 07(17/09 Owner(s): Caroline Simmons, Leroy Simmons 60 Month Rate Riser Certificate of Deposit -Acct 3000159216 Date of Death Value: $35650.81 (Current Balance $35626.90+ Accrued Interest $23.91) Dated Opened: 09/07/10 Owner(s): Caroline Simmons, Leroy Simmons Caroline R Simmons held no other accounts with Graystone Tower Bank, including safe deposit boxes. Should you have any questions, please contact me at 717-728-2678. Thank you. Sincer ly,_., /~ %J ti G Staci Wright Deposit Operations Analyst Graystone Bank, a Division of Graystone Tower Bank 1826 Good Hope Road Enola, PA 17025-1233 METRO BANK November S0, 2011 Stone, LaFaver & Shetleski 414 Bridge St New Cumberland PA 17070 3801 Paxton Street 888.937.0004 Harrisburg, PA 17111 mymetrobank.com RE: Estate of: Caroline R. Simmons Tax Identification Number: 168-24-4270 Date of Death: October 16, 2011 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type: IRA Time Deposit Account Number: 7000170720 Date Opened: 08/10/2009 Date Closed:ll/07/2011 Primary Owner: Caroline R. Simmons Principal Balance: $3485.57 Accrued Interest: $1.97 Date of Death Balance: $3487.55 Please feel free to contact me at (717) 412-6122 if I may be of further assistance. Sincerely, Diana Reynolds Metro Bank Support Associate/Deposit Services Susquehanna November 9, 2011 STONE LAFAVER & SI-IEKLETSKI 414 BBRIDGE STREET PO BOX E NEW CUMBERLAND PA 17070 RE: Caroline R Simmons Estate DOD: 10! 16/ 11 SS#: XXX-XX-4270 Tracking # 248503 Tc W}tom It May Ccncern: Susquehanna Sancshares,lnc. 26 North Cedar Street P.O. Box 1000 Lititr, PA 17543-7000 Tel 1.800.311.3182 Fax 717.625.4478 In response to your letter of November 4, 2011, here is the above customer account information as of October 16, 2011. • Account Title: • Account Type/# • Date Opened /Maturity • Interest Rate: • Account Balance*: • Accrued Interest: Caroline R Simmons IRACD 503500000149 1 /29/07 1.19% $13,610.33 $7.98 • YTD Interest: $127.25 *Account balance does not include accrued interest. ® There is no safe deposit box in the name of the decedent. Leroy J Simmons IRA beneficiary. If I can be of further assistance, please feel free to call. Sincerely, .~ _~ ,..L ?~~ i~~ `~T1• Dawn M Berrier Deposit Research -Reporting Department Lead 1-717-625-6546 DMB/aem