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08-10-12
r ,~ REV-1500 EX I°'_'°) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 2sosol INHERITANCE TAX RETURN Harrisbur PA 17128-0601 RESIDENT DECEDENT 2 1 1 2 O D 7 0 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth 0 1 1 3 2 0 1 2 MMDDYYYY 0 3 3 0 1 9 2 9 Decedent's Last Name Suffix Decedent's First Name H O P K I N S MI H A R R Y K (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLIC F ATE WITH THE REGISTER OF WILLS ILL IN APPROPRIATE OVALS BE LOW 0 1. Original Return ~ 2. Supplemental Return 3 Re i d . ma n er Return (date of death 4. Limited Estate ~ prior to 12-13-82) 4a. Future Interest Compromise (date of ~ 5 F d QX 6 D d . e eraf Estate Tax Return Required death after 12-12-82) . ece ent Died Testate (Attach Copy of Will) ~ 7. Decedent Maintained a Livin Trust (Attach Copy of Trust) g 1 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death El ~ 11 . ection to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFID N ame ENTWL TAX NFORMATION SHOULD BE DIRECTED T0: S U S A N Daytime Telephone Number ~ H A R T M A N 7 1? 2 4 9 7 7 8 0 REGISTER OF WILLS USE ONLY First line of address tv -=' 1 I R V I N E Q r•_a p~ ~~- r'~i c-- R O W _``' [ Second line of address ~, `~ n ~ ^" ~ ~~ ~-'? ,_~? ~ ~~ _ ~ ._.. ~ r,- , ~"i ~J`i .' _. (~ V.T.? t~'7 City or Post Office Cr~~~Cf "'+ `'-' ~ t Stat ~~ C A R L I S L E e ZIP Code D/tTE Fl1.ED ~:- y r ~-''~' P A 1 7 0 1 3 -~" `° r~ Correspondent's a-malt address: s u s a n a d u n c a n h a r^ t m a n l a w. c o to Under penalties of perjury, I deGare that I have examined this return, including accompanying schedules and stateme it is true, and complete. Declaration of t fe SIGNA P RSON RE ONSIBL ,~ ~ ~ ~ n P s, and to the best of m k Parer other than the personal re y R FILING RETURN PresentaOve is ~~ on all information of whidl ~ a~ belief, PfeParer has any knowledge, 5 S. MOUNTAIN ESTAT 705 S. MOUNTAIN. ESTATES 1505610140 SHIPPENSBURG SHIPPESNBUR PLEASE USE ORIGINAL FORM ONLY Side 1 L 150561D14D PA 17257 ,~ Dnr Ya ~` ~- PA 17257 1505610140 J J 15U561D24D REV-1500 EX Decedent's Social Security Number Decedent's Name: HARRY K• H O P K I N S RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 1 5 9 0 0 0. 0 0 2. Stocks and Bonds (Schedule B) ...................................... 2. 3. Closely Held Corporation, Partnership or Sole-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) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Nan-Probate Property (Schedule G) U Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 4 7 9 7 5. 2 4 1 1 8 5 8 3. 5 4 1 3 1 0 6 0. 4 8 4 5 6 6 1 9. 2 6 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 2 5 2 5 0 . 0 3 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 3 1 5 9. 0 8 11. Total Deductions (total Lines 9 and 10) ............................... 11. 2 8 4 0 9 . 1 1 12. Net Value of Estate (Line 8 minus Line 11) ..................... ..... .. 12. 4 2 8 2 1 0. 1 5 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. 4 2 8 2 1 0. 1 5 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)x.o - 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x .045 4 2 3 8 4 4. 8 7 16. 1 9 0 7 3. 0 2 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. D O 18. Amount of Line 14 taxable at collateral rate x .15 4 3 6 5. 2 8 18. 6 5 4. 7 9 19. TAX DUE ............................................ ..... .. 19. 1 9 7 2 7. 8 1 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1.505610240 1505610240 J REV-t500 EX Page 3 file Number Decedent's Complete Address: 21 12 0070 DECEDENT'S NAME HARRY K• HOPKINS STREET ADDRESS 1? GOODHART STREET CITY WALNUT BOTTOM STATE ZIP PA 17266 Tax Payments and Credits: t Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 19 , 5 0 0.0 0 B. Discount 9 8 6. 3 9 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. 5. If Line 1 + line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + g) (2) 2 0 , 4 8 6.3 9 (3) (4) 758.58 (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKs Did decedent make a transfer and: 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; .................... c. retain a reversionary interest; or ...................................................................................... 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 adequate consideration? ................. ............................................................ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? 4. Did decedent own an individual retirement account, annuity or other non-probate property, which. contains a be f' Yes No ^° a ...... ^ p ne iciary des~gnation? ........................................................................ X ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent (72 P,S. §9116 (a) (1.1) (i)]. For dates of death on or after 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)j. 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 Uansfers 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) i Pennsylvania SCHEDULE A t DEPARTMENT OF REVENUE. INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT r n~ ~ ~.- .... LJINIC Vr'. HARRY K • HOPKINS FILE NUMBER: All real property owned solely or as a tenant in common must be reported at fair market value. Fair market v 2 e is defined2as the 0 ~ atOwhich 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. ITEM Attach a copy of the settlement sheet if the property has been sold. NUMBER include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE DESCRIPTION OF DEATH 1• 17 GOODHART STREET, WALNUT BOTTOM, Pq [SEE HUD SHEET ATTACHED] 159,000.00 TOTAL (Also enter on Line 1, Recapitulation.) s Ii more space is needed, use additional sheets of 15 9 , p 0 0.0 0 paper of the same size. REV-1503 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHED IlLE B STOCKS & BONDS t~ i A I t ur FILE NUMBER HARRY K• HOPKINS 21 12 0070 .All property jointlyowned with right of survivorship must be discbsed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE ~. TOTAL 9 SAVINGS BONDS ON SEPARATE SHEET ATTACHED OF DEATH 919.96 2. C485886783EE SAVINGS BOND 99.36 3• C495231456EE SAVINGS BOND 98.04 4• C495167923EE SAVINGS BOND 98.72 5• C467565968EE SAVINGS BOND 100.36 6• C425521984EE SAVINGS BOND 104.04 7• C342800988EE SAVINGS BOND 136.80 8• C310389256EE SAVINGS BOND 139.56 9- C263794964EE SAVINGS BOND 145.20 10. C276803266EE SAVINGS BOND 145.20 11• C295269063EE SAVINGS BOND 142.36 12• C266980200EE SAVINGS BOND 142.36 13- C276866362EE SAVINGS BOND 145.20 14. C310332269EE SAVINGS BOND 139.56 15• C330805896EE SAVINGS BOND 139.56 16• C394620090EE SAVINGS BOND 134.12 TOTAL (Also enter on line 2, Recapitulation) ; 3 , 2 0 5.0 0 (If more space is needed, insert additlonal sheets of the same srze) Continuation of REV-1500 Inheritance Tax Return Resident Decedent HARRY K~ HOPKINS Decedent's Name Page ~ 21 12 0070 File Number Schedule B - Stocks 8 Bonds ITEM NUMBER DESCRIPTION VALUE AT DATE 17• C342748772EE SAVINGS BOND OF DEATH 136.80 18• C360887236EE SAVINGS BOND 136.80 19• C467504572EE SAVINGS BOND 101.00 20• PRUDENTIAL MUTUAL FUND ACCOUNTS 3900015070; 3900015071; 4500242278 38,999.94 21• ORRSTOWN FINANCIAL SERVICES, INC• 601.5337 SHARES a~ 8.46 5,091.98 22• WESTMINSTER FINANCIAL ACCOUNT#3MZ-312984 678.32 SUBTOTAL SCHEDULE B 4 5 ,14 4. 8 4 GRAND TOTAL SCHEDULE B S 47,975.24 REV-1508 EX t (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF HARRY K• HOPKINS InGude the proceeds of litigation and the date the proceeds were received by the estate. All properly jointly-owned with right of survivorship must be discbssd on Schedule F ITEM . NUMBER DESCRIPTION VALUE AT DATE ~. ORRSTOWN BANK CHECKING OF DEATH ACCOUNT # 609056 52,254.85 [SEE DOD LETTER ATTACHED] 2• ORRSTOWN BANK SAVINGS ACCOUNT # 702000231 48,396.38 [SEE DOD LETTER ATTACHED] 3• SPRINT NEXTEL REFUND 4.63 4• ERIE INSURANCE GROUP REFUND 14.00 5• SALE OF 1986 FORD PICKUP TRUCK 1,000.00 6• INCOME TAX REFUND 333.00 7• UNISYS PENSION 4,500.00 8• PSECU ACCOUNT X9370678694365 [SEE DOD LETTER ATTACHED] 1,503.74 9• COMMONWEALTH OF PA REFUND 66.68 10• SALE OF PERSONAL PROPERTY 198.45 11• CREDIT ON HUD SHEET FOR COUNTY TAXES PAID [SEE HUD SHEET ATTACHED) 163.82 12• GUNS AND EQUIPMENT [SEE ATTACHED LIST] 7,523.99 13• 2002 FORD WINDSTAR PASSENGER VAN [SEE ATTACHED] 2,374.00 14. PROCEEDS FROM SALE OF GUN 250.00 (If more space is needed, insert additional sheets of the same size) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER ?1. l.a nn~ TOTAL (Also enter on line 5, Recapitulatiat} ~ s 18,583• REV-1510 EX+ (OS-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY w ~ n~ ~ yr FILE NUMBER HARRY K• HOPKINS 21 12 0070 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 DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP i0 DECEDENT AND DATE OF DEATH ~ OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST Iir APPLICABLE) VALUE ~. ERIE ANNUITY #567089 4,365.28 100.00 4,365.28 THOMAS GINNICK, SON-IN-LAW 2- METLIFE ANNUITY #0443879 24,233.74 100.00 24,233.74 KATHLEEN GINNICK, DAUGHTER 65i MICHAEL HOPKINS, SON 35i 3. METLIFE ANNUITY #0557871 102,461.46 100.00 02,461.46 KATHLEEN GINNICK, DAUGHTER 65i MICHAEL HOPKINS, SON 35i TOTAL (Also enter on Line 7 Recapitulation) ~ s 131, 0 6 0 4 8 If more space Is needed, use addltronal sheets of paper of the same s¢e. ;2EV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT CCTAT~ Ar SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS rv~r~~~ v~ HARRY K. HOPICTNC Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: t. FOGELSANGER-BRICKER FUNERAL HOME 2• TRINITY CHURCH 3• WALMART - FOOD 4• DOROTHY'S - FOOD B• ADMINISTRATIVE COSTS: t • Personal Representative Commissions: Names} of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. AttomeyFees: DUNCAN & HARTMAN, PC 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: REGISTER OF WILLS 5 Acx;ountant Fees: 6• Tax Retum Preparer Fees: ~. 8 CUMBERLAND COUNTY LAW JOURNAL - LEGAL NOTICE • NEWS CHRONICLE - LEGAL NOTICE 9• SHORT CERTIFICATE 10• FILING FEE 11- HELD IN RESERVE FILE NUMBER 21 12 TOTAL (Also enter on Line 9 Recapitulation) I s If more space ~ needed, use additanal sheets oI paper of the same size. 70 AMOUNT 11,286.86 100.00 52.60 172.82 12,282.00 373.50 75.00 88.25 4.00 15.00 800.00 25,250• REV-1512 EX+Y~2-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, ~ LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER HARRY K• HOPKINS 21 12 0070 Report debts incurred by the decedent prior to death that remained unpaid at the date of d eath, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VADF D~gDHTE ~. TIMMONS OIL CO• 357.00 2• LOCK REPLACEMENT 38.03 3• WSEMS - AMBULANCE 204.47 4• PPL -ELECTRIC BILL 64.62 5• BILGER'S GARAGE 44.70 6• DIVERSIFIED APPRAISAL SERVICES - PROPERTY APPRAISAL 350.00 7• SHED REPAIR 240.00 8• PPL 68.56 9 DONNA BROBST - TAXES 378.45 10• COHICK & ASSOCIATES - TAX PREP• 280.00 11• PPL 59.96 12• NOLT'S TRACTOR REPAIR 27.27 13• NEGLEY'S 135.20 14• PPL 49-76 15• PPL 41.74 TOTAL (Also enter on Line 10, Recapitulation) I S 3 ,15 9 0 If more space ~ needed, insert additanal sheets of the same size. , Continuation of REV-1500 Inheritance Tax Return Resident Decedent HARRY K~ HOPKINS 21 12 0070 Decedent's Name Page 2 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, 8 Liens ITEM NUMBER DESCRIPTION AMOUNT 16• PPL 41.74 17• PPL 77.63 18• NOLT'S TRACTOR REPAIR 74.61 19• MOWING & GAS 8 MISC• 117.20 20• TRASH REMOVAL 150.00 21• SETTLEMENT CHARGES - DUNCAN & HARTMAN, PC 250.00 [SEE HUD SHEET ATTACHED] 22• SCHOOL TAX - SETTLEMENT 149.88 [SEE HUD SHEET ATTACHED] SUBTOTAL SCHEDULE 1 8 61.0 6 GRAND TOTAL SCHEDULE I S 3,409.08 REV-1513 EX• (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HARRY K• HOPKINS 21 12 0070 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Nat List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Indude outright spousal distributions and transfers under Sec. 91 6 (a) (1.2}.] 1. KATHLEEN M• GINNICK Lineal 705 S• MOUNTAIN ESTATES 1/3 SHARE SHIPPENSBURG, PA 17257 2• CINDY ADAMS Lineal P•0• BOX 153 1/3 SHARE WALNUT BOTTOM, PA 17266 3• MICHAEL HOPKINS Lineal 202 LEEDS ROAD 1/3 SHARE NEWVILLE, PA 17241 I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET AS APPROPRIATE I1. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART I I -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I s If more space Is needed, use additional sheets of paper of the same size. REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: 19, 500 • 00 Discount: 9 8 5.32 Interest Table Year Days Delinquent this time period Balance Due this year Interest this period ~~Befo 981 1982 1983 1984 1985 1986 _1987 1988 throw h 1991 r 1992 __ 1993 throw h 1994 1995 throw h 1998 1999 -- 2000 ~ 2001 2002 _ ~_ 2003 2004 ~ 2005 2006 2007 2008 r 2009 _ 2010 , - TOTALS --rt----- - --- -- --i Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: v~~,+; .. a. ., _ ..~..~+~ ~. J 3 LAST WILL AND TESTAMENT I, H. KENNETH HOPKINS, of South Newton Township, Cumberland County, Penn- sylvania, declare this to be my Last Will and Testament and revoke any will or codicil previously made by me. ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the administration of m~~ estate. ITEM II: I give, devise and bequeath all of the jewelry which belonged to my wife, Joyce K. Hopkins, to my step-daughters, Phillis J. Eames and Joann M. Eames, in shares of equal value. ITEM III: I give, devise and bequeath all of my hunting equipment and guns to Michael K. Hopkins, his heirs and assigns. ITEM IV: Should either of my step-daughters, Phillis J. Eames or Joann M. Eames, be single and unmarried at the time of my death, I direct that they, either individually or jointly, shall have an option tc~ purchase my residence of which I die seized at a fair market value; said option to be exercised in writing within six (6) months of the date of my death. Should my step-daughter predecease me or die on or before the thirtieth d.~y following my death, and _~. ...c._~c.. __ =a~c___~..c .. .. .. G .~C: .1. ...C .~i. .._~..~ iC, ;3 t•:?" _r.,T" -\- racy;?^r'V .C"~. the grant of this option shall be null and void. ITEM V: I give, devise and bequeath all of the rest, residue and remainde of my estate of every nature and wheresoever situate to my children: Michael Kenneth Hopkins, Kathleen M. Ginnick, and Cindy Lou Grippin, [heir heirs and assigns, in equal shares, provided however, that the share of Cindy Lou Crippin ~' c~,~4?;;kY e . ~~ ~ ;,s 1St iC~ldbtsd"'15~r E6e .~ of three Thousand, Fivri, ~d~ted ($3, SOQ.Otl) ~Dollara representing an amount I have already given her as a gift during my (lifetime. ITEM VI: I appoint Robert A. Eames, guardian of any property which ~pa8see either under this Will or otherwise to my stepdaughters, Phillis J. Eames and Joann M. Eames, and with respect to which I am authorized to appoint ',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 df.dtribute a share where possible to the minor or to another for r the minor's benefit. Such guardian shall have the power to use principal as well as income from time to time for the minor's support and education (includ- ing college education, both graduate-and undergraduate) without regard to his or her parent's ability to provide for such support and education, or to make payment for these purposes, without further responsibility to the minor or to the minor's parent or to any person taking care of the minor. ITEM VII: I appoint Kathleen M. Gimmick and Thamas Ginnick, her husband, ~?'~~~r as guardians of any property which passes either under this Will or otherwise to ~ minor or incompetent child of Cindy Lou Grippin and with respect to which I am authorized to appoint a guardian and have not otherwise specifically done so, pr~~vided that this appointment of a guardian shall not sunersede the right of any fiduciary in its discretion to distribute a share where passible to the minor or to another for the minor's benefit. Such guardian shall have the power to use principal as well as income from time to time for the minor's support and education (including college education, both graduate and under- graduate) without regard to his or her parent's ability to provide for such support and education, or to make payment for these purposes, without further -2- o~ tltm mtaor. ITEM VIII: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as part of the expenses of the administration of my estate. ITEM IX: I appoint Kathleen M. Ginnick and Thomas Ginnick as co-executors at this my Last Will and Testament. } '~~~'~°_~t#~rl~cE' t~lat my executors or guardians or their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and Tedds__ta__ment, written on three (3) sheets of paper, dated this ~ day of /~l~h'~t' 1986. ~° 4 ~{ 7 ! ~ S ( SEAL ) H Kenneth Hopkins .. The preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature of the testator, H. Kenneth Hopkins, was on the day and date thereof signed, published and declared by H. Kenneth Hopkins, the testator herein named, as and for his Last Will, in the presence of us, who, at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. /1 S ~~n l ~ tN residing at N~Q~~I~~IX.~ ~~ ~ ~~ ~~ residing at ~ 1rj ~J t~-r ~~ ~' ti~_ wfirslF' ~ t,!- ei~ x~: t oar . cot ~' ' P!~'~+* ta~ias -3- }~'+t 'tY E~,~ ~" s''~ ~=x + ~{~~ , a t !' ' e a. '-br~ fK n*r'~ Yak ~ 4 s1 "~'x ~"" ~ ~ r A * i e v ~ y . , 'C~i. ~ a1,./cFT~ A~''6' y~l -.JKR _ .}Vi . I i 2. • : H. Kennel Ho kips , d ~ n ~ T ` , the testator and the witnessesa respectivel whose n a are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his Last Will and Testament and that he signed willingly (or willingly directed another person to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as witnesses and that to the best of our knowledge, the testator was at that time eighteen rears or older, of sound mi luence, nd and under ~ ~1 ~ ~ s H. ennle~tLh Hopkins C.I~ Subscribed, sworn to and acknowledged, by H. Kenneth Hopkins, the es~ator and swora to before me b and ~ D , wit saes, this day of - 1986. `~ S , Notary Public / --y~ My commission expires: ` S ~~ ~ k ~~` -4- d. Prepary lacatiott 17 Ooodhart Street, Walnut Bottom, PA 17266 South Newton Township, Cumberland County Tex Parce1tY41-31-2232-007 J. Srmmary of Borrower's Tnewcdo¢a 100. Grom Amount Due 1?~om Borrower 101. Cattrut Sala price 102. Personal Property 103. Settlement charges to borrower (line 1400) 104. 103. Adjustmanb for Items paW by seller in advance 106. Cityhown texa to 107• County tortes 0726/12 to 12/31/12 108. Aasaaments to 109. School Tax to 110. Garbage Fa 111. 112. 120. Gras Amount Due From Borrower 200. Amounts Paid By Or in Behalf Of Borrower 201. Deposits or eattteat money 202. Principal amount of now loan(s) 203. _F.xisNrtg loan(s) taken nubjcct to SettWaeot ABeot Name, Addrop and Taxpayer Identification Number Zuliinget-Davis, Prnfasiottal Corpgatlon 20 East Butd Sttee4 Suite 6, P.O. Box 40 10D of Setdentera [. Settlement Dste Hatallton C• Davis, Enquire, 20 Eat Bard Stteel, 7262012 . Summary of Seller's Tntwctlea q. Groin Amount Due To Seller 403. 404. Ad usemeab for items h1 b seller in advance 40 6. Cityhown taxes to 163.82 407. Counly taxes 07/26/12 to 12/31/12 163 8: ~• ~tssasrnutts to . 409. School Tax to 410. Garbage Fa 411 . 412 . 165,344.10 420. Groan Amount Dne To Seller ! 59,163.8: 300• Reduetloru in Amount Due To Seller 13,900.00 SOI. Excess t (na ittatructiotu) 13 900 0( 302. Settlement to sdler (line 1400) 503. Etctatiog loco(s) taken nubtak to , . 250 O( 306. 210. Cityhown taxes to 211. County taxes to 212. Asaaamettts to 213. School Tax 07ro1l12 to ens ror hems unpaid by seller m raze to taxes to tents to - fax 07ro1/12 to 07/26412 149.8E 216. 315. S 16 217. . 317. 218. 318 219' . 319. 220. Total 1lfd By/For Borrower 16,049.88 520. Total Redaction Amorat Due Eklkr 300. Cash At 9ettlemaot 1PFos/fs Borrewer 16,299.8E 608. Coh At 9etdemnt To/From Seller 301. Otoas Amomrt due if'om borrower (Una 120) 165,344.10 601. Oroaa Amount due to xller (line 420) 1 302. Lean amamtn paid by/for borrower (lira 220) ( 16,049.88 59,163.Bi 602. Las t+eductiaoa in amt. due seller (line 320) ( 16 299 303. Cab ®1~Fom ^ To Borrower = 149,294.22 , .8E t~ Cab XD To ^ From Selkr S 142,863.94 I hne eanYb%nviawad tM ttUD•lt ht Strr~ett and b Ma toot o(ap asd taYaf a is • ere. and atataaar of a6 nealpra sad dbbuaas,ata arde m aaNly thr teiw . mr porn i-.e i attW saaleaa.t _ ~ Q ~ >~ ~ ~°h~ , 3_ At- a of Fat H. Kau>eth Hopktas ' rwa~ Bortoamr Hanuhoo C. Davis, far Exchgrl,inda S. Nolt S ' ' OJIO1/t 0 c14 er of Est of H. Kenneth Hopkim CI TL6sfLN y AG1:Kf CER7II+ICATlON n. t rw~w q . r.. r Kowr d W. arena l e.w r • rr.a • Sellerh Taxpayer 1dad0eatla N ~ Sagetbtba sad Certlllutfoa vo.. ~tw. r w a. taa~r a~ _ ~ j~A ~sw~ a..aaaeea A ~ ~ ~ '' ~ a ~,, y. wrN +e.."a rr~:r h wrmne j~ry, 1 oaa i ~!i ~' 4~aaaYa~wf~ '~~ °~ ~ a1r SYe~lwtlelo~>ernr~. Yr ~y U~1r~ frr ~ ~1Y • a~fr i~p~ 6a ~~ni 4avMafe. a~ Mlui i err W Yip~~1Prv AiuU~ w: lIW It U.1 CCO~iwris 10a1 M FIUD - 13/91 Selkr'a S' Date RFSPA, FIB 1303.: i D • 1 3191 RESPA, HB 4305.2 ..u wsr cargs ~e Pe10. 1110 t>f001~ lptitbtt~bllOw will ~ elpns qr]t~ )'Or ttM u1001~7! ~°~ PW~4. aom + tIClt, I141eallne r 11CCtlele is opened to pey tlhx .Ido;peled expene,: ~~ ~~ r4+~lb. aur6+d fhcl6sC 12 month, atlet {teeln~ 11etr: Yorr elxrow etxoeet peyseet w111 be S Peyce ~• PK ~~Poh A^tkiPehd Dre Deh EeMweled Aleoeet 08/02/2012 08:29 7175309537 SOUTHAMPTON TOWNSHIP PAGE 03/05 1UU:Z !+'ord Wmndstar Passenger Limited Minivan. 7'cade In Values -Kelley Blue Book ra~r~ of3 ZIP eoDt;17tb7 I Sign In for 51pn up) home ~ car values ~ cars for sale ( car reviews ( kbb top picks ~ research tools i Popula-et K8t3.com 16 CoolaL Can Undo 516... ~~wlwaeNt f Mane > Car Values > Ferd > VOatdtlar Pao;ettfer > 200Y > 5tyle > Optldtc s ~ FOttl 1=:t ~ IM1Atltl6tar Passenger ~ i 2002 ge Umlkcd hNnlvan You r Blue Book' Value Show Used Gar Prlen , Pike Par NeM l:u 2002 Ford Winds~ar Passenger sgle~urrl~oed roilwvanp ~dk oonn~e ia,a~ style I nn - ~ reaga:140006- anenae ~w, dusee~ Trade-In Value Private Party Value ', ~ wMn trd/ty M rt a doaleldrlP i ; ~dbl ~ fl10 tll' yeleeer ~ arPlint RdDart i Excellent Sz,~z4 Very Good Sx,574 $z,~~a ~ Fair ~~..~4 TaNO Condition Gkriz Instant Trade-In Offer Own it? Lwe it? TeU Us. get the other , i .. ~ i i write s review v>tues valid unit Be the first to know 08„~ ~1 when values change tdtow this car aWamw7rknt Welpful resources from kbb.com YYr1te s Review Chedt Spces Sell Your Cer Own K? laMe R9 Td ux. ~ Know your qr held! ~ Ux Our Tkfr a Taelt. and ouC 3 out of 4 car seats aren't used cort'e~c~tly. whraa:~ ~+r ~+ Search Cars for Sate ~ Get a Used Car Report near Shippansburg (Ford -[] ' whtdtxar Get Cu fiFametlcn You Need tm TMe m0~ Ford Belh~e You euy :conch Reartlr Vlesrad tys I rh saved Caix caVO ~.1r ~ ; ~ A http://www.kbb.com/ford/windstar-passenger/2002-ford~windstar passengex/limited-miniva... 8/1/2012 Prudential 00004291 Your Representative PRUCO SECURITIES LLC JASON R MILLER (717) 975-8150 Your SSN/Tin#: ON FILE H KENNETH HOPKINS 17 GOODHART ST WALNUT BOTTOM PA 17266 Your Accounts 3900015070 3900015071 4500242278 Page 1 of 9 Non-Retirement Non-Retirement Non-Retirement Mutual Fund Statement -January 1, 2011 to December 31, 2011 Your Portfolio as of December 31, 201'1 $38,899.94 Summary of Non-Retirement Investments Opening Balance - Additions Subtractions Investment Results Closing Balance Dividends Capital Gains Personal Performance" $37,051.96 $0.00 $0.00 +$1,947.98 $38,999.94 $216.19 $3.67 +5.26 $37,607.91 $0.00 $0.00 +$1, 392.03 $38,999.94 $833.89 $3.67 +3.70 Tax Exempt 53% f ' Calculated uatng adollar-weighted rate of return method for the period(s) listed. Results are based on your specific activity and may not reflect overall fund performance. Standardized fund performance is available by specking with your linancinl professional or by visiting www.prudential.com. Note: There are other petsonnl performance formulas that may yield different figures, and past performance is not indicative of future reauka. Reminder: Read the enclosed newsletter for more While we make every attempt to ensue that your ; information on the cost basis changes that will be effective statement is accurate, errors may inadvertently occur. for shares acquired on or after Jan 1, 2012 on Please review your statement thoroughly and contact us if non-retirement accounts and for more details on the tax you find any information you believe to be inaccurate. If forms you may receive, we do not hear from you in 30 days, we will assume that ali information is correct. 4th Qtr Year-to-Date Investment Allocation Oct 01, 2011 to Dec 37, 2011 Jan 01.2011 to Dec 31, 2011 Det2~lled Transaction Activity Page 3 of 9 transaction Sales Charges Date Description Dollar Amount Shares This = Share To h a res / Transaction X Price - O n e d Taxes W/H 03/25/11 DIVIDEND -REINVEST 04/25/11 05 DIVIDEND -REINVEST $62.89 $64 59 4.470 $14.07 1,337.436 /25/11 06/24/11 DIVIDEND-REINVEST DIVIDEND -REINVEST . $65.64 4.574 4.555 $14.12 $14 41 1,342.010 07/29/11 DIVtOEND -REINVEST $70.35 4.842 . $14.53 1,346.565 ~ 1 351 407 08/31!11 09 DIVIDEND -REINVEST $76.62 $67 67 5.266 $14.55 , . 1,356.673 /30!11 DIVIDEND-REINVEST . $69 55 4.613 $14.67 1,361.286 ~ 10!31/11 11/29/11 DIVIDEND-REINVEST SPECIAL DISTRIBUTION-REINVEST . $63.45 4.696 4.310 $14.81 $14.72 1,365.982 1 370 292 ~ 11/30/11 DIVIDEND-REINVEST $3.67 $66 06 0.249 $14.74 , . 1,370.541 12/30/11 DIVIDEND -REINVEST . $67 96 4.485 $14.73 1,375.026_ 12/31/11 Closing Share Balance . 4.543 $14.96 1,379.569 1,379.569 Additional Account Information Non-Retirement Accou t Add n i tional Information ~ Account Fund Name 2011 2011 ~ Open Date Dividends Capital Gains 3900015070 Pru Jen Blend A 3900015071 Pru Jen Growth A 02/03/1995 $18.72 $0.00 4500242278 Pru National Muni A 06/26/1998 $0.00 $0.00 02/03/1995 $815.17 $3.67 $833.89 $3.67 To help reduce the ma~ing costa of your mutual funds, please oontact us if any of the above addresses should be changed or deleted -- Thank You. Please oal! us, toll-free, at t-800-225-1852 Monday through Friday, between 8:00 a.m. and 6:00 p.m. Eastern time. a a 0 n V N 1,I1 O °w m ~, A N N o N 0 ~ ~ 0 A' ~_ ~~ m c a ~, C A a 0 ~i ~: 0 r k ~~~ - ~x ~ ~ m~ - o o°~ - ~O~ ao r om ~ O~y f.. ' ' N z .. is _ - ~ o Hex ~~ _ o H~ N o~ _ Oy~x ~, rte. ~-i H y ~ o v ~ o ~ N ~ v ~ _ -_ 1-~ r] c O ~O O ~ W x ~"~ O W b b N 01 r 0 0 0 0 N W _ np~ ~ ~ n ~a'C3~ _ • ~. 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N_ N N NN O? ~p d N~ N C ~ 7 fA ~ O N ~ n a ~ ~ o ~ ~ ~ ~ ~ ~ ~. ~ ~ Q ~ ~ ~ `.~ u~' ~ ~' g m t~ ~ m ~, ~ c ~ ~.~ cQ~'m ~l g ~ ~~~ ~ ~ ~ ~ ~ w o m n r7i v y ~• w ~ c m g... y ~ ix m i 7Si'~' m ~ _ s ~ ~ ~ Off 7 (D 3' ~ ~ 2 -1 p a+ t0 Ul ~ c~_i_ T c ~ 2 ~ ~ ~ ~ `~ ~ ~ ~ ~ o ~ 3 ~ 3 ~ ~ ~~~~ m ~ ~- ~ _ o ~ H p D ~ ~ 3 • ~n ai ~i w 3 o ~ ~ ~ 3 m ~ ~ D ?~ om. ~ ~ n ~~• N ~~ O 3 ~ ~ m ~ ~ ~ A ~ ~~~~ ~ ~_. .g ~~ L. ~ j. V N ~ .0•., d i ~ O ! O ~ O O r i ~ ~. 0 .O ~--on }oon~ n m •~~ ~~ o~ ~7~. 3 e O d ao ~ ~ 2 ~ ~~~pp voZ Orn'~~ ~ iA i O~ ~ ~~ N O no-- n,rn ~ O ~ A ~ ~ c a ~ o '^ 3 -« ~ °z ~ ~ G y N ~ ~ Z N N /D O ~ ~ g g o ro rp • ~ I~ Z Z A D ~ ry C C ~• ~3 m v m obi ti a ~ 1 N _ N y~ ~ /D ~D ~ ~ ~ .~ N V w N °o o° g~T `~ ~ ~ w N ~ ~ ~ w w p~ pp A N N N m O O p Z $ ~ ~ 3a `n ir€ I~' ~I~I o ~sIL o~o~ o V ,~pO d O ~. ~~~ ~~ ~e O ~'r--. } a ~ ~a "~ 0o m O ~ w" ~ '~ ~ v. O O S d ~ O X O . • ? ~ ~ ~ ~ J N g w ~ J 00 O ~O 3 A a v A O o N o y r w N O HARRY KENNETH HOPKINS #21-12-0070 SCHEDULE B -STOCKS & BONDS ATTACHMENT Serial Number Value C437954679EE $ 101.68 C437891354EE 102.68 C425587888EE 103.36 C410710533EE 104.76 C394681548EE 105.80 0367468951 EE 134.12 C527367907EE gg.gg C515431063EE 89.44 0527306421 EE 89.44 Total $919.96 02/02/2012 Orrstown Bank Page: 1 Branch: 6 Savings Bond Ltst Teller: 106 Serial Number Denominstton Issue Date Value Int_ C485886783EE 100 10/1994 99.36 $49.36 C495231456EE 100 02/1995 98.04 $48.04 0495167923 EE 100 12/ 1994 98.72 $48.72 C467565968EE $100 07/1994 100.36 50.36 C425521984EE $100 08/ 1993 ~ 104.04 54.04 C342800988EE 100 06/1992 136.80 86.80 C310389256EE 100 11/1991 139.56 * C263794964EE 100 09/1990 145.20 89.56 * C276803266EE $100 12/1990 95.20 C295269063EE $l 00 07/ 1991 $142.36 95.20 C266980200EE $100 04/1991 $142.36 92.36 * C276866362EE $100 02/1991 145.20 $95.20 C310332269EE 100 09/1991 139.56 89.56 C330805896EE 100 01/1992 139.56 89.56 C394620090EE 100 01/1993 134.12 * C342748772EE $100 04/1992 136.80 84.12 * C360887236EE 100 08/1992 136.80. 86.80 * 86.80 C467504572EE 100 _ 05/ 1994 101.00 * -~~37q~~E 51.00_ ~ C437891354EE $100 102%199 $10 68~_ _R___.. ~__ S T.68 *_ __ __ . ~C425587888EE $ I00 10/1993 $103.36 52.68 * ~q C410710533EE $100 06/1993 $104.76 3.36 * C394681548EE $100 03/1993 $54.76 0367468951 EE $100 11/1992 $ i ~4'g2 $55.80 C527367907EE 100 09/1995 gg.68 $84.12 * C515431063EE 100 05/1995 89.44 38.68 * 1 ~ 0527306421 EE 100 07/1995 89.44 39.44 * 39.44 Pre-January 1990 Bonds: 0 $0.00 $0.00 January 1990 and Later Bonds: 27 $3205.00 $1855.00 Total Bonds: 27 $3205.00 $1855.00 N/E =Not yet eligible for redemption February I3, 20I'? Duncan ~~,1lartrnan, P.C. Attorneys at Law Susan J. Hartman, Esquire One Irvine Row Carlisle, P.4 17013 Fax: 249-78dd Rc_ Estate of Harry Kenneth Hopkins Social Security Number 211-22-6846 Date of Death 1/13/2012 I"[' IS I-IERF.QY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THF_. hOLLOWING ,ACCOUNTS WITH ORRSTOWN DANK: C'tlls'C'IiING SIC("""OZINT Account No. 60906 Account Type- Sd+ Interest Checking Image Date Opened- 10/!5/1983 Joint Account (narnc,~date)- No Balance- $52,254.85 Accrued Interest- $0.93 SCI VI~'V GS ;1 CCU Z~'NT Account No.- 702000231 Account Type- Statement Savings Date Opened- ?/211996 . Joint Account (name/date)- No Balance- $48,396.38 Accrued Interest- $1,9y 7GJ5 F'h lady: Vphia ,avetlur. Chan t~ersbr,rg, PF, f ~ x'(19 1.888.ORRSTOWN iliJ ~JSIL•z1'. ~ G~'~'_~i7i.:P:"5. ~±/ ~":2 VRRSTOWN six A Tra[litiat of Cxcelle~u~ sal/-•~~ ~~~;~/~nst7~ ~~~x Account N~~.- ~9oao~ 13ox "J'ype- ;x 1 d D~~te Opened- 4/30/l 991 Joust ACI:UUIlt (t-ame,/date)- Thomas L. Ginnick, 4/3U/] 991 .____.___ Rental nmount- $40Od -- - ~ ~x ue atc- -- - _--_-___ Best Regards, Jyll R. Worthington Deposit Processing Clerk PSF(~k Duncan & Hartman, P.C. Attorneys at Law Susan Hartman, Attorney 1 Irvine Row Carlisle, PA 17013 Re: H KENNETH HOPKINS, Deceased. PSECU Reference # 9370678694365 Dear Attorney Hartman: The above referenced person has an account with PSECU which was opened on February 3, 1987. The Share accounts were individually held by H KENNETH HOPKINS. 04/18/2012 The following are the Date of Death Balances for H KENNETH HOPKINS's account with PSECU: Account Date of Death Balances Interest -January 1-13 (S1) -Savings (S4) -Money Handler $1,344.84 $157.85 $ 0.12 $ 0.01 The account has been closed per your request. A check totaling the share balance (s) will be mailed to your office. If you have any questions, please contact me at (717) 234-8484 or toll-free at (800) 237- 7328, press 6, extension 3120. Sincerely, hand F 1J y gley . Member Service Representative PSECU Pennsylvania State Employees Credit Union P.O. Ebx 67013, Harrisburg, PA 17106.7013 • 717.234.8484 • 800.237.7328 • » psecu.com iHiS CREDIT UNION IS FEDERAIIY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY (ENDER. p~-as F~r'z ~ ~~-~-,s ~~ S~ mod' ~~-- - f~~ ~- _ _ ~ ~~ `~- _ __ ~'1~tbp~C~ __ ~.~c.~- _ t~_ _ _ -----____ - r _ 1...t_-h1b~S (~~~-~_~'SukS _ l ~ ~3oCf . _ ___ ,_ - ~ ~.~ _- ____ __ .__ 7 _.- - ----- ----- _ _ p~ ------- __ h~ .~`-- -~------ - - t- - - _ ~- _- - - _ _ __ _ S ~132.Yo-t/ - _ . - - _ _ t ~ '~bWr~c(~fSf'£(,~. ~l'0 ~vynP gZd~3 `1Z ,~~~~NrM,ls~,~ l _ __ ._ __-- ~< -,..~--~!'~ l n ~------ ---- - - - -- __ -- .- 2Z _~ o L ~' - _ __ _ _ - ---__ - - q lfk ~~ f [.D _ z 5' _ Z ~ 6 S2 S 3 Z . _ -- _ __ ~~__ ~/f-~e-L c ~ _ ' -_ _ __- _- ~~ `3~ G4.v£~. -- - 3.36_... Leo yoo3T _ - I .~~ _~'thct-F~s~r~~e _ 3d -3d G~ _ _`!`~ 3°- ___ ____ _r 3_ as-q'-C_. j ~' wr-rt lf~,~'t~- c~ ~ ~~»~a~~f~~~ 3~t - 3o r~.K. 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Box 14592 Des Moines IA 50306 MetLife January 26, 2012 Jeffrey Swope 1725 Oregon Pike Suite 203 Lancaster PA 17601 C~ ~ ~~ [~ I~ ~~~ ~' JAN ~ U 10'~I U II RE: METLIFE INSURANCE COMPANY OF CONNECTICUT CONTRACT 0443879 OWNER H KENNETH HOPKINS Dear Mr. Swope: We are writing to provide you with important information regarding the above contract. The Internal Revenue Service requires we furnish the date of death value for Individual Retirement Annuities (IRAs) on which a death claim has been filed in case this value is needed for income tax purposes. In most cases, the executor/administrator of the decedent's estate will not need the date of death fair market value for income tax purposes. The date of death valuation will only be necessary for income tax purposes if one or more of the decedent's IRAs contain nondeductible contributions and, in addition, the decedent received an IRA distribution in the year of death. This is to inform you that the value of the IRA contract as of the date of death, January 13, 2012, was $24,233.74 . If you have any questions, please contact your representative or call our Customer Service Center at 1-800-874-1225 (Broker Dealer Channel), Monday through Friday between 9:00 a.m. and 6:00 p.m., ET. Sincer Tara .Johnson Sr. Annuity Representative -Post Issue Processing MetLife Annuity Operations and Services Holdings by Investor Kenneth Hopkins Mr Jeffrey Swope Combined Account Portfolio 17 Goodhart St 172S Oregon Plke Date: 01/20/2012 Watnut Bottom, PA 17266 Suite 203 Created: 01/23/2012 Lancaster, PA 17601 717-735-0220 Kenneth Hopkins Acct Name: H KENNETH HOPKINS 17 GOODHART ST WALNUT BOTTOM PA 17266 Acct No:00000443879 AcctType:IRA Individually Estabi(shed Asset Name Ticker AssetType Mgt. Name a-,andty Price ($), ;~ . Value (5) PIONEER IBBOTSON MODERATE NON-CLASSIFIED MetLife of 21,086.88 1.17 24,647.51 ALLOCATION - Connecticui Account Total: 524,647.51 Acct Name:H KENNETH HOPKINS 17 GOODHART ST WALNUT BOTTOM PA 17266 Acct No:00000557871 AcctType:General Asset.Name `" 7lcker AssetType Mgt Name ~ !IQuagtity, ~ ,Pilce'4~) Vaiue ~s); PIONEER tBBOTSON MODERATE US STOCKS ALLOCATION MetLife of . 90,678.07 1:17.. 105,990.69 Connecticut Account Total: $105,990.69 Acct Name: H K HOPKINS 17 GOODHART ST WALNUT BOTTOM, PA 17266-9711 Acct No:8020701 AectType:Prtvale Annuity Rep. No;163730 Account Total: $0.00 IrnestorTotal: S130,638.20 Incomplete If presented wllhout accompanying dlsGosure pages Page 1 of 2 Erie Family Life ANNUAL STATEMENT OF POLICY VAL ~-. Insurance® UES STATEMENT PERIOD: JANUARY 01, 2011 -DECEMBER 31, 2011 :Y y~ k, f 1. OWNER: H K HOPKINS ANNUITANT: H K HOPKINS POLICY NUMBER 567089 PRODUCT NAME FLEX PREMIUM DEFERRED ANNUITY TAX QUALIFICATION NON-QUALIFIED ANNUITY DATE OF ISSUE FEBRUARY 10, 2003 THANK YOU FOR CHOOSING ERIE FAMILY LIFE AS A PARTNER IN BUILDING YOUR SECURE FINANCIAL FUTURE. IF YOU HAVE ANY ADDITIONAL INSURANCE NEEDS, PLEASE CONTACT YOUR AGENT OR OUR OFFICE AT THE NUMBER LISTED AT THE BOTTOM OF THE PAGE. If applicable, IRS forms 1099 and 5498 will show account number EE567089 for this contract. c131~ ~# ACCUMULATION VALUE AS OF DECEMBER 31, 2010 $4,197.39 SURRENDER VALUE AS OF DECEMBER 31, 2010 $4,197.39 PREMIUM RECEIVED DURING CURRENT PERIOD $0.00 ROLLOVER/TRANSFER/1035/RECHAR/CONVERSION $0.00 INTEREST CREDITED FOR CURRENT PERIOD $167.89 GROSS DISBURSEMENTS (INCLUDING SURRENDER CHARGES, FEES AND WITHHOLDING) $0.00 ACCUMULATION VALUE AS OF END OF DECEMBER 31, 2011 $4,365 28 SURRENDER VALUE AS OF DECEMBER 31, 2011 _ ~;~:--~ ~~ . +. ~ As of 01/12/2012, the rate credited to new deposits is 4.000. Interest rates are determined by current and historical financial market conditions and are adjusted by Erie Family Life as necessary. Agent name: CARL L. CRAMER INSURANCE LLC 833 W KING ST SHIPPENSBURG, PA 17257-9201 (717) 530-8600 IF 14/E CAN BE OF ANY ASSISTANCE, PLEASE CALL YOUR AGENT OR CALL US AT 1-800-45g.pg11 OPTION 3. Member Erie Insurance Group • Service Center • P.O. Box 83026, Lincoln, NE 68501 • Toll free 1-80058-0811 • Fax 866.567.1219 • www.erieinsarw~e com EMENTS NO ACTIVITY FOR THIS PERIOD inGude express mail/wire transfers of funds at owner's request. TOTAL 567089 48500041046 REV-485 EX (OS-04) SAFE DEPOSIT BOX INVENTORY PA Depaltnent of Revenue PLEASE USE ORI~i1NAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Number 211-22-6846 01/13!2012 21 12 0070 Decedent's Last Name Suffix First Name Mi HOPKINS HARRY K © ADDRESS OF DECEDENT STREET: CITY: STAT 17 GOODHART STREET WALNUT BOTTOM E: PA ZIP CODE: 17266 NAME AND ADDRESB OF PERSON REQUEBTING THE OPENING OF THE SAFE DEPOSIT BOX NEE' KATHLEEN M. GINNICK STREETADDRESS: 705 SOUTH MOUNTAIN ESTATES ---- - -- CITY: SHIPPENSBURG STATE: PA ZIP CODE: 17257 • NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: KATHLEEN M. GINNICK DAUGHTER/ EXEC UTRIX STREET ADDRESS CITY: __ STATE: ZIP CODE: 705 SOUTH MOUNTAIN ESTATES SHIPPENSBURG PA 17257 b. NAME:- RELATIONSHIP: __ --- -__ - - __ _ STREET ADDRESS: CITY: STATE: ZIP CODE: _ - _ ____ ~' NAM ~ RELATIONSHIP: _ _- - . STREET ADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCULL IN8TrfUTION WHERE THE SAFE DEPOSfi BOX 18 LOCATED NAME: ORRSTOWN BANK STREET ADDRESS: 121 LURGAN AVENUE __ __ CITY: SHIPP __ STATE: ZIP CODE: ENSBURG PA 17257 PERSON MAKING ENTRY DATE AN TIME LAST ENTRY in ~ ~ ~ ~ / d GATE OF C T TO RENT BOX • NUMBER ~ 80X 1 Tfi'LE UNDER WHICH BOX IS REQUESTED 30 i 9 ti/ 4 O d.2- tnn ~s NAME AND RES'S OF PERSON(S) HAVING ACCESi TO BOX a. NAM~..~ I n~ s ~.. hn~ ck- ~ n ~~ S ~`AgpRESS ~~~~~ ~ ~~ STREET ADO S3: cl4Y~~ 4 vP cooE: cl ~ J t - -- s ~~ THE INVENTORY /t /~ WAS A WILL 1 THE BOX9 ^ YES NO H y«, a. Dah of wip: b. Name and addrasa ~ paraonal nepnaantaflw, H Hamad In tM wip NAME: STREET ADDRESS: e. Name and addrsaa of attorr~ H any NAME: STREET ADDRESS: L 48500041046 CITY: CITY: !f ZIPS~ C~~OD~~E~~ • a !t~!'S2. 7 STATE: ZIP CODE: STATE: ZIP CODE: 48500041046 J r REV-485 EX SAFE DEPOSIT BOX INVENTORY Page °f INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) ObHgaNons of U.S. Gowmmsnt: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and 3avinys and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) feeds, Mortgages, Currant Insuranw Policies or othsr evidences of Indebtedness: List and describe as fully as possible. (8) All other contents. (9) Retum completed form to: DEPARTMENT OF REVENUE INHERRANCE TAx DIVISION DEPT. 2e0801 HARRISBURG, PA 17128.0801 ITEM NO. REM DESCRIPTION __ __ I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PER RECEMNG COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOtIYLEDGE AND BELIEF. SAFE EPOSIT BOX INVENTORIF ~~~ /l / [l[-~ ~HLti { ~S-/~ PRINT NAI`E AND CHEt~C TE BOX BELOW: PRINT TITIE ,Q GATE CHEq(APPROPRIATE BOX: . ~ /\. ~xecvbr(tris) ^ A~strtMwttroi) 3 ~ ,3 ~ Z ^ EatMrt R~prp~iv+ ~ Jdnt owr,., d ~. d•oo.a m. NOTE: Attach additional 8'/:' x 11' ah4ret(s) if essary or uss duplicates of this page of form. S Oepartrnent is au~orized by law, a2 U.S.C. §405 (cX2KCX7. m require ire d Soda) Soprgy rxxnbers in cprlecfbn with adrrrtisMrng state tax laMrs. The Departmerd uses the Scarify rxxrlber to identity the decedent and personal repraserltatives of the estate. Tire CorrxnonweaMh ~, also use Cie iniamatian in exchange of tax nfarnlation agreerrlenls with Federal and kcal authorities. The state law the CarnmonweaMh's howl dsclosing CantidenWai tax inforrrlatian exosd for official otroasas _ __ ~. VERIFICATION The undersigned, hereby verifies that Notice of my proposed safe deposit box entry and inventory on March 13, 2012 has been delivered to the PA Dept. of Revenue via United States Postal Service in accordance with 72 P.S. section 9193. This verification is made subject to the penalties of 18 Pa.C.S.section 4904 pertaining to unsworn falsification to authorities. Ka Teen M. Gmni ,Executrix nv~ ~ C~ ~ '~-~ ~ i ~ ~~ ~~ l..