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HomeMy WebLinkAbout11-27-121505610143 '-' REV-1500 Ex (oz-~~> >:, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Vear File Number Bureau of Individual Taxes oEVARTMENT OF REVENUE Po Box.2aosot INHERITANCE TAX RETURN 21 12 0444 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02 21 2012 10 27 1932 Decedent's Last Name Suffix Decedent's First Name MI JARDINE J. DALE ~If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI JARDINE CAROLINE J Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Retum ^ 2. Supplemental Return ^ 3. Remainder Return (Date of Death Prior to 12-13-82) 4. Limited Estate qa. Future Interest Compromise ^ death after t2-12-82) ^ ^ (date of 5. Federal Estate Tax Return Required pp 8 Decedent Died Testate ^ ~• Attach Gopy~of~rues )a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach copy or will> ^ 9. Liti ation Proceeds Received tD. Spousal P4ven credit `Date of Death 9 ^ between 12-31 ~Jt and t-1-95) ~ t,Election to tax under Sec. 9t 13(A) (Attach Schedule O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number GEORGE F DOUGLAS III ESQ 717 ~9 633 ~ ~ REGISTER (WILLS ~ O ~ tt1 ~ n t- ~ rTt First Line of Address 2a. ~ ~ 'J 7D 354 ALEXANDER SPRING RO vz ~ ~ -~ -~ ~ ~ ~ ~ '~` Second Line of Address jaDATE FILED ~ City or Post Office State 21P Code CARLISLE PA 17015 Correspondent's a-mail address: 9douglas@salzmannhughes.com I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, Under penalties of perjury , 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. SIGNAT OF PERSON RESPO IBLE F (LING RETURN ~ DATE ~~ `~ ~,,~/~ j Caroline J. Jardine 1 I ~ ~ ~ Z- ADDRESS 685 Barnstable Rd. Carlisle PA 17015 SIGNATU E OF PREPARER OTHER THAN REPRESENTATIVE DAT ~~~ ~` L~~y~©~ 1'-d. George F Douglas, III Esq. ~ I ~ 2 ~ ~ ( Z 354 Alexander Spring Road, Suite 1, Carlisle, PA Side 1 1505610143 150561D143 J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: Jardllle, J. Dale RECAPITULATION 84,500.00 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. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7 800.00 r 7. Inter-Vivos Transfers & Miscellaneous boo; Probate Property u Separate Billing Requested............ 7. 173 , 353.97 (Schedule G) g. Total Gross Assets (total lines 1 through 7) ........................................................ 8. 2 65 , 653.97 9. .. Funeral Expenses and Administrative Costs (Schedule H) .................................... 9. 14,761.24 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............................ 10. 11. Total Deductions (total Lines 9 and 10) ............................................................... . 11. 14 , 7 61.2 4 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 2 50 , 8 92.73 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. 250 , 8 92 • 73 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 8 , 5 92.7 3 15. 0 . 0 0 (a)(1.2) X .00 16. Amount of Line l4 taxable 89,700.00 1s. 4,036.50 at lineal rate X .045 17. Amount of Line 14 taxable 2 , 6 0 0 . 0 0 17. 312.0 0 at sibling rate X .12 18. Amount of Line 14 taxable 0 . 0 0 18. 0 ' 0 0 at collateral rate X .15 19 4,348.50 19 . TAX DUE .............................................................................................................. .. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Jardine, J. Dale _ STREET ADDRESS 685 Barnstable Rd. CITY Carlisle Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3,612.38 190.12 File Number 21-12-0444 STATE ZIP pq ~ 17013 (1) 4,348.50 Total Credits (A + e) (2) 3,802.50 (3) 3. Interest 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 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. (5) 546.00 Make Check PayablSe to REGISTER OF WILLS, AGENT. ~. a;' ~,.. t..~ r ':~ fd': r .. ~.~:-C', "3• b ..~ "i~ m.Y..S iF ~T'~~ L 1~' ~ _ ~ - -. 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 :.................................. ~ o c. retain a reversionary interest; or ............................................................................................................... d. receive the promise for life of either payments, benefits or care? ............................................................ 2. If death occurred after Dec. 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?....... ^x ^ 4. Did decedent own an individual retirement account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ^x ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ;; ~, .-T .,.tom ..:~`;r. :;. ~~.- ;_ r .~_, ..<° ._ :_ ,~_ ,` ,_. c,.,_ ,.,_ ', 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 (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-1502 EX+(01-10) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Jardine, J. Dale 21-12-0444 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which progeny would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold Include a copy of the deed showing decedent's interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Real Estate situate at Barnstable Road as Lot No. 3, West Pennsboro Township, Cumberland 47,000.00 County, PA 2 Real Estate situate at Barnstable Road as Lot No. 4, West Pennsboro Township, Cumberland 37,500.00 County, PA TOTAL (Also enter on Line 1, Recapitulation) I 84,500.00 (If more space is needed, additional pages of the same size) Copyright (c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 01-10) Rev-1509 EX+j01.10) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTHOF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER _ Jardine, J. Dale 21-12-0444 ff 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• Dennis J. Jardine 687 Barnstable Rd. Son Carlisle, PA 17015 B• Derek D. Jardine 34 Pennway Dr. Son Carlisle, PA 17015 C. David C. Jardine 4703 Enola Rd. Brother Newville, PA 17241 JOINTLY OWNED PROPERTY: ITEM NUMBER FOR JrOIN TENANT MADE JOINT DESCRIPTION OF PROPERTY (NUMBER OR SEMILARNDENTIFYWG INUMBERAA'rTACH DEEDO OR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH DECEDENT'S NTEREST 1 A,B,C 11/27N990 Hunting Cabin located at 17706 Renovo Road, 31,200.00 0.250% 7,800.00 Noyes Township, -Clinton County, PA at assessed value (see attached) TOTAL {Also enter on Line 6, Recapitulation) I 7,800.00 (If more space is needed, additional pages of the same size) Copyright (c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 01-10) SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY COMMON WEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Jardine, J. Dale 21-12-0444 This schedule must be completed and filed it the answer to any of questions t through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY HE DATE OF TRANSF~ERSATTACNTA CIOPY OF THE DEED ~OREREAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Ameriprise Brokerage Account No. 00013553359 4 021 8,447.36 100.000% 8,447.36 - Beneficiary is Caroline J. Jardine, spouse 2 Ameriprise Financial Company, Annuity Account No. 4,598.47 100.000% 4,598.47 93002380395 8 004 -Beneficiary is Caroline J. Jardine, spouse 3 Ameriprise Financial Company, Annuity Account No. 3,972.51 100.000% 3,972.51 93002380404 8 004 -Beneficiary is Caroline J. Jardine, spouse 4 Ameriprise Financial Company, Annuity Account No. 54,652.58 100.000% 54,652.58 93008055303 3 004 -Beneficiary is Caroline J. Jardine, spouse 5 Ameriprise Financial Company, Annuity Account No. 3,473.90 100.000% 3,473.90 93102395487 4 004 -Beneficiary is Caroline J. Jardine, spouse 6 2,563.85 shares of Ameriprise Financial Company, 26,433.29 100.000% 26,433.29 Mutual Fund Account No. 01013093702 1 002 - Beneficiary is Caroline J. Jardine, spouse 7 5,137.857 shares of Ameriprise Financial Company, 71,775.86 100.000% 71,775.86 Mutual Fund Account No. 02014811356 4 002 - Beneficiary is Caroline J. Jardine, spouse TOTAL (Also enter on Line 7, Recapitulation) (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. 173,353.97 Form PA-1500 Schedule G (Rev. 08-09) REV-7151 Ex+ (10-09) SCHEDULE H COMINo N~EWRREALNTCC~~{{EOFpp,,~P~ENEETURNANIA FUNERAL EXPENSES AND HRESID~'NTDEC`EDEN ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER Jardine, J. Dale 21-12-0444 ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) 11,398.74 Street Address City State ZiD Year(s) Commission Paid 2. Attorney's Fees Salzmann Hughes, P.C. 3,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees 332.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 30.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 14,761.24 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Jardine, J. Dale 21-12-0444 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex eR Haas 1 Ewing Brothers Funeral Home, Inc. -funeral flowers funeral services 9,200.00 2 George's Flowers -funeral flowers 130.74 3 Osiris Holding of Pennsylvania, Inc. -interment charges 2,068.00 H-A 11, 398.74 Other Administrative Costs 4 Register of Wills -filing fees 30.00 H-B7 30.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) REV-151 EXf (01-10) ~E q~ E SCHEDULE J COMIN~~y~E ENT DEC DEN~RNANIA BENEFICIARIES ESTATE OF FILE NUMBER Jardine, J. Dale 21-12-0 444 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions, and transfers under Sec. 9116 a 1.2 1 Caroline J. Jardine Spouse Sch. G -all items 158,592.73 685 Barnstable Rd. Entire Residue Carlisle, PA 17015 as per Item III of the Will 2 Dennis J. Jardine Son 1/3rd Equity - 44,850.00 687 Barnstable Rd. Sch F Carlisle, PA 17015 1!2 Equity in Lots 2 8< 3 Carlisle, PA 3 Derek D. Jardine Son 1/3rd Equity - 44,850.00 34 Pennway Dr. Sch F Carlisle, PA 17015 1!2 Equity in Lots 2 8 3 Carlisle, PA 4 David C. Jardine Brother 1/3rd Equity - 2,600.00 4703 Enola Rd. Sch F Newville, PA 17241 Total 250,892.73 Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 150 0 cover sheet, as a r o riate. 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 SHEETI Copyright (c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 01-10) LAST WILL AND TESTAMEl~TT I, J. DALE JARDINE, of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, declare the following to be my last will and testament, hereby revoking any and all wills heretofore made by me. Item I. I direct my executrix hereinafter named to pay all my debts and funeral expenses. Item II. I give my two building lots 3 and 4 on Barnstable Road in West Pennsboro Township to my two sons, Dennis J. Jardine and Derek D. Jardine, in equal shares per stirpes. Item III. I give, devise and bequeath all the rest of my property, both real and personal, to my wife, CAROLINE J. JARDINE, providing she survives me by 30 days. Item IV. In the event that my wife does not so survive me, or dies in a common disaster with me, I devise and bequeath all the rest, residue and remainder of my property, both real and personal, 50% to my children and 50% to my wife, Caroline J. Jardine's, children, as follows: Caroline's children: Jennifer A. Bowman, Jimmy H. King, Jr., Jan S. Messina, and Jason D. King, the 50% share to be divided equally per stirpes. My children: Dennis J. Jardine and Derek D. Jardine, the 50% share to be divided equally per stirpes. Dale's children: Dennis J. Jardine and Derek D. Jardine, the 50% share to be divided equally per stirpes. Item V. I nominate, constitute and appoint my wife, Caroline J. Jardine, as my executrix. If she should be unable to serve, I appoint Dennis J., Jardine as substitute executor, and I direct that they should serves withou-f=- r- O rJ ~~ --C. bond. ~ ~ o r ~ %'= ; ~~ T r -- !-~ ~: . V J = ~ i ~- ,: 7:, l~ -? _. -i-: -% ~-- - ,:~ T ~_ ^~ "'~ T7 - l.7 e ' ~~ r- ~Yl IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~' day of ~ , 2002. ~.~~- ~ '~. tea., .~:,.' .SEAL J. Dale- ardine Signed, sealed, published and declared by the above named testator, as and for his last will and testament, who at his request, in his presence, in our presence, and in the presence of each other have J~ereunto s scribed our names as attesting witnesses: U~~,~,~tC Xn~~ COMl~10\IWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND yy~e, _ ~--t'`' and ~~` whose names are signed to the attached or oregoing instrument, being d ly qualified according to law, do depose and say that we were present and sa~v estator sign and execute the instrument as his last will, and that he signed willingly and that he executed it as his free and voluntary act for the purposes therein contained, that each of us in the hearing and sight of the testator signed the will as witnesses; and that to the best of our knowledge, the testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ., ~ c ,~ a~ ~ ~~, ~~ ~_ Sworn to and subscribed before me this ll 1 ~ day of 2002 ~.~.L,.•t~~ Notarial Seal Anne M Coz, Notary Public Carlisle 9orougn, Cumberland County My cnmmiss~en eYD~~es lutiy 14 2C0 S 1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUti~iBERLAND I, J. Dale Jardine, whose name is signed to the attached or foregoing instrument, having been duly qualified according to la~v, do hereby acknowledge that I signed and executed the instrument as my last will, that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. j. D e Jardine Sworn to and subscribed befor me this the / a day of ~ , 2002. ., Notary Notarial Seal Anne M. Cox, Notary Public Carlisle Borough, Cumberland County My commission expires July 14. 2005 05/15/2012 03:25 7172500552 511$317., TRI CUUhITY AESTR~CT Foy GEOr aE P~;~aE 01 J ~s ~~ ~~ Thanks for the information you have me on the Jardine Estate. The Dale Jardine houge is located on lot 5. Please sec if you cai~ Fgure out the owners of ].ot 2A, 3 and ~. I assume some of these may still be in the name of J. Dale and Caroline Jardine so I need to know which oneq. I am also trying to determine a value of each lot. Lot 5 was assessed at $3,500 for the laztd. Thanks and l.et l~.e know if you have any questions. George p..~. ~ r J sb Q1~. LTc~r-G~r~ 2 ~ I ~,X -- ~~ ~L ~ ~37~500~ ~-a a r a~n~ ~ ~i ~. ,~~-~~,y ~. ~~.~-~, ~ ,~,~ a o ~ - ~~~ ~-,~. - c~ o,~ao w 0 .--~ 00 '~ ~ a z b ~, fV O N 0 b a .~ a. Ci; U M O z°~ (~] O L-=]i C] ~ ~ O E-. `" v Q N ui ~ ~ w x ° o ~ w ~, ~ b m a~ 0 ~ rn ~ m Q °; ,o ~ ~ o N cX U W .-i N W C N '~ C ~ O F ~y ~ ~ ~ o -~ o ~ 0 0 0 0 0 0 ~ 0 0 0 0 0 0 ~ d~ cD N cp pp N ~ N W ri N (D N N N N (+1 N N f+1 b .~ ro 0 N a u 0 0 0 0 0 0 0 0 0 0 0 0 a in m w in m N 01 r-1 N Oi rl r-I r-I f~l r-I r-I M m m o ~ o w N x 0 0 0 0 0 0 ~n rn m o m m f~ [~ ~ `+1 m ri rn o M ~ C o ;~ o ,-~ ~ W N O a~ ~ ~ a..F-.a..E- O A ~ ~ o ~ U ~,j ` a i ~ H ~ o `" . a~ A ~ d C ~ y ~ " y H ~ 3 a i h ~C ti ~ O ~ Q ~ ~ N Q h o W t~ W ~ QCaa a O ~ h ~ o M W a w "" z~~n O ri W r-i `n p a a z a ~ d~ a N ~ U u O >. L 4' C.1 C O L c ti .+ p ~p m g o "~ o ~ ° x m ~ rn ~' N v a o z d ~ O E ., N •. ~ m z z u z + w" ~ v a -~ ~ 0 o c _ x ° C C H H „ ~ ° ~ i c z u T -~ o v N A u N .C s~ . . " A b N a ~ vm a~ ° " a o o - " ~ C o a rn v " v ° ~ o O1 ~ m p~ a c~ H .~ ro ~ a H ~ , N .; 7 4 .-. -. i u ~ ro ~ -. i c ,-a o 'i ro ~D 1 ~ W H ~ z ^' z x ~ ~ ~ a u° a a° u CL > A > - ,y o v a~ a~ ro v u o v N F ., ~Ha aw Ana zm ni ao ~ , Page ot'Ci From: SDLifeEventsCommunicationCenterjCURP{AMPF Sent by: 5andeep R Poman/Corp;A,MPF To: Scott MBechtold/Field{AMPF@AMPF Date: Friday, htarch 02, 2012 10:20Af~1 Subject: 14930464 2 001 J D JARDINE DEATH SETTLEP9ENT REQUIREMENTS PLS DO NOT DELETE. Company March 3, 3(.)13 CAROL[IYE J JARDINE 68~ I3AR?VST.AI3LE RD CARLISLE:, PA 1 %0l7-;~~'_ RiverSource Life Insurance Ameriprise Financial Company 7Q100 Ameriprise Financial Cenier Minneapolis; MN 55474 [ 4~~304h•~ =1 On [ C)ear CARC)I.I NIA J ,EAR D WE: ~~4`e have received noti>ication of.I U JARDIitiL•'s death. Please accept our condolences on your las>. 11te deceased's name is associated with. the fullot~ring accounts..Acantnt values as of 03!21/3012 are listed below. AI tlx estd of this letter, you will find a list of beue[i. iaries shot~-n in our initial revic;ty of the accounts. Account Information 114utual Funds ~caxint iVwlihcr Q~ri~er~llip (}1013(~93?O3 100'_...Individual -T'C)D 0301481 l3S6 ~ (X)3 Individual -'EOD Annuities - ['ust 19R~ ~cc~unt_itiuniher Uwner~i>p 9300?_;8()3G~ S 00=[ Individual 93002380404 8 tH)4 lndividuul 9300805j303 3 ()().) Individu<d 93I0339i487 4 00~' IR:a -beneficiary designated Ametiprisc Brokcragr :lccuunt _~ccgunt.i~urn(~r Ou-~itcrsh_ip 0(?OI ~i53359 4 031 indis•iciual - TOD ~Iu tua t Funds as{c .f ~ t }l~ V r l..~ts ~„ ~~cciunt Iv'i)_nsher Tnt tl Valt)c~#.of charec ~czt ~ alue Pct Shari: OI0130937()2 l ir)_ 5?h,-13?.?9 ?,S(~3.8~(1 x;10.3[ L, ...„... /,....,{.. ..,...:1 I ., .a. ., ~..•. ,•evin~cC ~~nrrt l,InIO,IT]1;111n~IChP1'htl R-nsf/(~%2~Inbuxl/A ~i'~~. ll}(~07... ~/2 ~.~..(~~. ~7 Pa~e2at6 02()1-18 l J 356 •} ()L2 `~? I .?75,8b 1.1.3 ~.R>? S 1 3.9' Annuities - Pvst 19SS .Account Nunlher Tor;d Value 9'ipf}23^i(1?91 J l)t)4. ~-l,i~)y.~k7 93(x123804(.)4 8 (>!?4 53,9 ~ ?.~ 1 93()()8()5130.( 3 tx'~l 5.°,4,65258 931(323954K7 4 001 S x.473.1+(i Ameriprise Brol:era~e Account Account Number Total Value (x)013553319 4 (iZ 1 58,4•(7.3(, 7r Acct Name:AJneripnse &okerage Accoun[, J DALE JARDINE TOD Acct No:000 1 3553359 02 1 Asaet Name Ticker Broad Mqt. Nalme CASH CASH EQUNALENTS fA~KESSON CORPORATION MCK LARGE CAP STOCK ~uantiry 314.36 100.00 Account Total: The state of death r aluc,s provided are for catatc tax putposes a!td are not a vaiue to be paid. Aecilunt• may be suh_ject to mark each product. Ylease note that the calue~ indicated for any Life instu•ance products with rho insured deceased reflect the grass and nut the crush vahtc. V1ILIeS indicated for Life Insurance prc,ducts with only the owner deceased reflect the cash value as of ally proprietary rnutnal funds inelude accrued elividends us applicable. Values provided t"or brokerage produets are manually I estimates only. The prices used. to provide values are estimates ubtain.:d from outside sources believed to be reliable. Amerip. values as a sen•ice to its clients. Actual valuc;~ used in prep:iration of ta.z returns or for planning purposes shouftl be ceri.fied t advisors. Account Disposition Acanutt disposition is b:lsed on how alt account is owrtcd (the ownership type). The folknviug information will help you and 1LSCd t0 Se[Cle Chr: ai:CiH31?fs. Disposition for Individual - 7'OD ownership Upon the death of the owner, all accounts registered a:individual-transfer on death pass to the Wanted beneficiaries. Althnu~l of the estate for distriburiim, we understand they should be included for inherit:mce and/or estate tiix purposes. llisposition fi-r Indi~~idual ownership Upon the death of the owner and annuitant, account proceeds tti-piailly pass to the. named beneficiaries. tf no beneficiary is n: detault beneficaarv provision the proceed. will be paid according to the beneficiary default langua41~. 1^ all other cases where the proceeds become part c>f the owner's eat;Ite fur distribution. IarIZI2It.F:D ANN['IT~' tif3TICE: If the beneftciary(s) wishl plan, we must rccei~•c~ written notice of this election within 60 Jays of our receipt of complete reyuirentenrs from any individt value will remain iuvestexl in the separate aca:nntt until ~;•e receive a a?mpleted claim. (f there are multiple beneficiaries, racl separately rind each hens tic:iary's share will remain invested in the separate account until it is c:ktitned. The benefici:IrieS bear llisposition for IR_i -beneficiary designated ok•nersitip The deceased was the annuiL;nt on at h~ast unc annuity account previouslc listed. L'~pou the death of the annuitant, account pry benefciaries ^alnc:d at the. ti.nte of death. lt' no beucfici:u•v was desizna[e1J the. proceeds hc:axne part of the estate for distribut I`TC)TCGL: J.f the bcuet;ciary(s) svilx to elect an annuity payment plan, we must rc: eive written notice of this election within >^.~..,..»..,~r,~,-..,;I I ari,:icnrr~rt~nna.c c~nrn/clrttt)5/mail03/she~h(1$.nst7(cc2~Inbox)/A.~F615Ot)$?... >/2/201.2 I3c:ncficiary Inf(-I•tn~iti(i!t~ 1~'~ Tia:c the fti5ktuti~ iiii, }~eaePici:~ries on t'ecord t~~r the deceased"~ accounts. Account \umbcr: t)IOt ;Oq.;?t}'' k (.H)~ t)esi;nation: PI2l:~'I~R1' B[Nf:FICTARt" CAROLINi~. J J:aI~C)ftif: SPOI.~SF IOO.OO~~c SI:i:'i:}NC)ARY f3FNLF[C(ARI' i.I~`kti<;_ L.AGVFt[_ C1-T[I_I)REN IN I=(Z4.;,<1L SHARES !O().(}O~;c :lccuant '~umhcr: 0^_0 f-18 i k ~~6 4 (N}? llesil;natiun: PR11,t.~I21' 43I3NEPTCI:~I2Y C:Al2OLlNG .I J:~Rf:)INE ~~"iF1~: 100.E}0°~~~ 5l:t.'ONI)AR1` I3RtiEI~I(:I.1RY` 1:)I:ti'~1S J J:\RCr(tiF SON 17[.REK [) JARDfNF: SON I~QI~r1LLY, C}R "I'EiI~: SI~RVTVOR Account Numkscr: 93C)02340~9~ 5 O<kl llcsiRiurtion: PRt~IAR'Y I3FNLFIC'IAR1' C':'~RC)i,iNE .t JARI)!NE SPO[.rSI; 100.005~~. tiI.:C'(.)NrJARi` f3FtiI;T~TCTARY" l.a ~ [l~ICi, LAGi'I~UI. CHILURf ~ [;V` EQUAL. S4-4AR.ES 1UO.OO~ic 1:)GNN IS .1 J.~~RDINT?. SON \ccc~uut !~urnbcr: ~;r(}O?3504(kk fi (N)4 I)csil;nation: P4tI;G1ARY 13[:NEI~ICT.aRY' {.'AROLINI; I .1.<1RDlNt. 5P0[JSE 100.0()<<, SGC'OtiT).-,RY I3fN[;rTC'IARY !_.1V[NG. L:IGVFIJf.. CHIi.I)RI?ti IN I:QL~AI_ SIT.ARLS 1(}O.C}O~r [)6Nti 1S J J ARI:)INI: SON hEI:IK I) JARf)lNL•: SON ;account Nu~nher: 93i}(}8(1Sz0:: 3 (H}-[ Dcsi~;nat4vn: PRT:~tAR~` I3ENI:FfC1.=1R~' (:AR(:)L.[N[ J Jr~I2t)INF SPOUSC 10(}.(}070 SI('OtiI)ARY I3F tit.-:Fk(~ IARY L[VlNG. LAGi'I~l..i_ C4ilI..DIZI~N [y [QL~AJ_ SfiARL•S 1(}O,OO~r [F~ A C'H[LI:~ IS DICIiASID: Fi1S OR HF'K SIiARE: TO 13r FA[D TO HIS OR HI:R I"I~'ING, I.ACG'FI.1I. Cl-f[[_DRI: ~v IN E<11J.-1L SH,4IlF:S Account ?\untbcr: ~):tlt}_'~3)~•3S7=k C)0-I I)csi,;nation: PRT:~t<<1RY [it-:tiT[~[C'k:3RY C'.AI2OL.[NIs J JARI:)[NTi SPOC`SG L00.00 ~~ SI•:C'OivL?aRY f3ESwEf~ICIr\RI` LfVINC.;, L:~~L I~t.'I. CH[L.f)RIN' l.N IiQU:\I. Sli,\1RfsS 100.O0~-b I)I:~:Ns;IS .I :IARI)['~;T S()N I)C?RTK i~.t.\i21)IAF: SC)N rlrcount Nunrbrr•: (N}C)f.~~53.i7<a,I O'' I llesirnatio-r: PR11~t:~R.l' BI:\P:F~TCIAR}- C:-~kC)T._[NI=,1 J.-,RI)Iti£~: «LI~I~: IOO.IH)~:( ht[t~~;:/it~.eh,•-n;iil l.advisarorn~ass.corn/i1rn0~/niai103/sbechil $.nst%(~"r:2~(nbox)/A ~F615(JU87... x/2/201.?