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12-06-12 (2)
J 1505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 2 0 0 3 8 4 PO BOX 280601 Harrisbur , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 9 1 2 8 8 3 3 0 3 0 9 2 0 1 2 0 3 2 2 1 9 2 5 Decedent's Last Name Suffix Decedent's First Name MI C o l l i n s L o i s S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number T h e r e s a L S h a d e W i x 7 1~7 6 5 ~~ 8 4 5 5 ;~ ~ '~ c NCY I R OF WIL-t~ US A m ~ ~-, ~-~ cn a~ ~ A t-- ..t i°7 First line of address a ~ rn r,'r t~l ~ r<a c~ x ~~ W i x W e n g e r 8 W e i d n e r ~ ~ o .~ c> -rt - ' Second line of address ~ ~~ ri `'~' c' -'-t ~ ~ ~,Yt O G ~, 4 7 0 5 D u k e S t r e e t ~.~ w'7 "t' rv ~:; + n -`~ -' City or Post Office State ZIP Code v ~_~» DATE~F~ILED ~d ~ -J -*t H a r r i s b u r g P A 1 7 1 0 9 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, antl to the oesr or my xnowiecge anu oenei, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PER~ON RESP iBL~~OR FLING R~ TURNn ~~/~~AT~/~ SI J UR~E~ PPARE~TF ~THAH RAE ADDRESS 1 ~-(~ o s- lJ ~.k ~ S~-Q~~+- 1505610140 DATE r t 3 0 ~-~ / 1- MI ~ctr r `s b ~~I-~t ~:.Q I `l 1 C PLEASE USE Q I INAL FORM ONLY Side 1 1505610140 (,` ~ <~ 15^561^240 REV-1500 EX Decedent's Social Security Number 2^ 9 1 2 8 8 3 3 Decedent's Name: L D i S S• C D 11 i tl 5 RECAPITULATION 1. Real Estate (Schedule A) .. . .................. 1 • 2. Stacks and Bonds (Schedule B) ........... 2. • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ............ 4. • 8 ^ 7 9 9 , 1 5 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... . 5 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. • 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property ~ ], ^ ^ ], 5 7 7 Separate Billing Requested ..... (Schedule G) .. 7. , 8. Total Gross Assets (total Lines 1 through 7) ..... 8. 9 ^ 8 1 4 9 2 9. Funeral Expenses and Administrative Costs (Schedule H) ........ 9 9 4 4 1 . ^ 8 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule q .... ...... . 10. 11. Total Deductions (total Lines 9 and 10) ... .......... 11. 9 4 4 1 . ^ 8 12. Net Value of Estate (Line 8 minus Line 11) ... .......... .. .... 12. 8 1 3 7 3 8 4 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) 14. 8 1 3 7 3 . 8 4 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable 8 1 3 7 3 8 4 ts 3 6 6 1. 8 2 . at lineal rate x .045 . 17. Amount of Line 14 taxable ^ ^ 0 17 ^ ^ ^ at sibling rate X .12 . 18. Amount of Line 14 taxable ^ ^ ^ 18 ^ ^ ^ at collateral rate X .15 . 19 3 6 6 1 8 2 19. ......................................... TAX DUE . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15^561^240 Side 2 15^561^240 J **Duplicate Page for Co-Executor's Signature** J 1505610140 OFFICIAL USE ONLY REV-1500 ~` `°'~'°' PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO Box zao6D1 2 0 1 2 0 0 3 8 4 Harrisbu PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date nt Death NNADDYYW Dale Of Blrth p~ADDYYYY 2 D 9 1 2 8 8 3 3 0 3 0 9 2 0 1 2 0 3 2 2 1 9 2 5 Decedent's Last Name Suffix Decedent's First Name ~ C O 1 1 1 n S ~ O 1 5 $ {H AppllcabN) Ember $tlrviving 8porare's Irtfonmation Below Spouse's Lest Neme Suffix Spouse's First Name Spouse's Soaai Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE VYITH THE REGISTER OF WILLS MI © 1. Original Rstum ^ 2. Supplemental Retum ^ 3. Remainder Retum (date of death prior to 12-13-82) ^ 4. Limibd Estate ^ 4a. Future lrtNrest Compromise (dale of ^ 5. Federal Estate Tax Return Required death atterl2-12-82) ^ 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy nt W iln (Attach Copy of Tnst) ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. ElerXion to tax under Sec. 9113(A) between 12-3191 and 1-1-95) (Attach Soh. O) CORRESPONDENT - TH18 SECTION MUST BE COMPLETED. ALL CORRESPOIi~NCE AND CONFIDENf1Al. TAX SIFORItMTtON SHOULD BE DIRECTED TO: Name Daytime Telephone Number T h e r e s a L S h a d e W i x 7 1 7 6 5 2 8 4 5 5 States ZIP Code REt68TER OF YIILLL81/SE ONLY First Iine of address W i x W e n g e r ~ W e i d n e r Second Iine of address 4 7 0 5 D u k e S t r e e t City or Post Office H a r r i s b u r g DATE flLED P A 1 7 1 0 9 Correspondent's e•rnail addro9e: under perralaes a¢ perjury. I deaare that I nave examined tMs ntum, indudhg aocarnperrying sdiedrke and atalements, and b the hest or my knowledge and belief, k 6s true, corned and oompkite. Dfldaraeon OF Preperor otl~er Iran the personal reprsserde4ve is hosed on as iNOrmaaon of which preperer has arty knwAedge. SIG TIXtE OF PER RES IB OR RETURN ~~/~~ T~/ A ~ r. C CB ac- ~ - ` SIGNA OF P P R N REPRESENTATNE TE AD ESS /%y~Lt/-~`~-'..._ c~~G~G /~ .~OIoZO/~ p~joZ ,~~a tc.~ ~' ~'~-[-U~'vu'S',~ Dam/ ysrlo3 / PLEASE U$E ORK3INAL FORM ONLY aide 1 15D5610140 1505610140 REV•1500 EX Page 3 Decedent's Complete Address: File Number 20 12 00384 DECEDENT'S NAME Lois S. Collins _ __ _ STREET ADDRESS 1067 Nanroc Drive CITY Mechanicsbur STATE ~ 21P PA ' 17055 Tax Payments and Credits: ~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 3,500.00 B. Discount 183.09 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. Make check payable to: REGISTER OF WILLS, AGENT 0.00 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 : ......................... ...... ^ 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 "intrust 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 beneficiary designation? ............................................................................................ ...... ® ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + B) (2) 3,683.09 (1) 3,661.82 (3) (4) (5) 21.27 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: Lois S. Collins 20 12 00384 Include the proceeds of litigation and the dale the proceeds were received by the estate. All property jointty owned wkh right of survhrorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Pennsylvania State Employees Credit Union, P.O. Box 67013, Harrisburg, PA 17106 75,684.88 Savings Account (S1) - $708.78 Money Market (S7) - $7,780.25 Certificate (S50) - $67,195.85 (See Schedule E, Exhibit 1) 2. PNC 4,702.54 Checking Account #5112011786 - $1,088.00 Savings Account #5112052596 - $3,614.54 (See Schedule E, Exhibit 2) United Healthcare, P.O. Box 29180, Hot Springs, AR 71913 3. Refund 2.28 (See Schedule E, Exhibit 3) 4. AARP, 601 E. Street, N.W., Washington, D.C. 20049 16.00 Member Refund (See Schedule E, Exhibit 4) Erie Insurance, 100 Erie Ins. PI., Erie PA 16530 Auto Insurance Refund 5. (See Schedule E, Exhibit 5) 45.00 Commonwealth of PA, State Employees Retirement System 6. Final Settlement of the account of Dorothy M. Tifverman with the Estate of Lois 48.45 S. Collins being the beneficiary. (See Schedule E, Exhibit 6) 7. Household Goods and Personal Belongings ~ 300.00 TOTAL (Also enter on Line 5, Recapitulation) I $ If more space is needed, insert addhional sheets of paper of the same size PSEC~ Wix, Wenger & Weidner Theresa L. Shade Wix, Attorney 4705 Duke St. Harrisburg, PA 17109-0341 Re: LOIS S COLLINS, Deceased. PSECU Reference # 4312004295083 Dear Attorney Wix: 04/17/2012 The above referenced person has an account with PSECU which was opened on November 9, 2007. The Share accounts were individually held by LOIS S COLLINS. The following are the Date of Death Balances for LOIS S COLLINS's account with PSECU: Account Date of Death Balances Interest -March 1-9 $0.04 $0.58 $18.06 (S 1) -Savings (S7) -Money Market (S50) -Certificate $708.78 $7,780.25 $67,195.85 Please provide us instructions on closing the decedent's account. If you have any questions, please contact me at (717) 234-8484 or toll-free at (800) 237- 7328, press 6, extension 3120. Sincerely, ~,. a~ andy FSgle~ Member Service Representative PSECU Pennsylvania State Employees Credit Union P.O. Box 67013, Harrisburg, PA 17106-7013 • 717.234.8484 • 800.237.7328 • » psecu.com THIS CREDIT UNION IS FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY LENDER. Schedule E, Exhibit 1 ~, ,7p 1. G• L~ L IL:~'J~'v! FiS~, a I~~ ~~~ LEAI}F~fti7HE YlIAY April 18.2012 Theresa L Shade Wis Esq. Wix Wenger & Weidner 470 Duke 5t Hamsburg, PA 17109-0341 RE: Lois S Collins SSN: 209-12-8833 DOD: 03-09='012 Dear Ms. WiY: N~~, ~;~7 F. 1/2 in response to your request for 17ate of Death (SOD) balances for the customer noted above, our records show the following: Checking Account' Accotmt # ~11201178b Established: 10-27-197 LOIS S COLLINS DOD balance: $ 1,088.00 non interest bearing Savings Account Account # ~ 11205296 Established: 10-27-2004 LO1S S COLLINS DUD balance: $ 3.614.31 + 0.23 accrued interest Interest paid 01-01-2012 thru U3-09-2012 S 0.~9 YTD Please note that this atfice provides data of death balances for deposit accounts (IRAs, CI~s, Checking and Savi[ags). We do not process any financial transatlions or provide statements. If you need assistance with any of these items, please call 1-888-PNC-BANft (1-888-762-2265) or stop by your local PNC Bank branch office. Si~ucerely, National Financial Services Center PNC Bank, lv`.A. Member FDIC Page t of 2 Schedule E, Exhibit 2 United Healthcare Svs Inc PO Box 29180 Hot Springs AR 71913 Page 1 of 1 90-GO CHECK DATE 03-16-2012 CHECK NUMBER 00347539 0000000000000000002943521 03-15-12 20954543 2.28 .00 2.28 WE ARE UNABLE TO ACCOMMODATE YOUR INSURANCE NEEDS AT THIS TIME. THE CH ECK BELOW REFUNDS THE AMOUNT RECEIVED WITH YOUR ENROLLMENT FORM.IF YOU HAVE QUESTIONS, PLEASE CALL 1-888-867-5575(TTY 711). GPS '>~TAi~.>.. USD 2.28 .00 2.28 SINGLEPAY a0,3,] IOOIW 0001 00]4>il9 IIMII/f{~91-00000tW OL If110 01.00 SINOL(9AY 0001 n1WD001 p]f0 M United Healthcare Svs Inc PO Box 29180 Hot Springs AR 71913 Pay TWO AND 28/100 DOLLARS To The Order of LOIS S COLLINS - BETHANY TOWERS ~ 1067 NANROC OR MECHAMICSBURG PA 17055-4467 ~~~'I~I~II~IIII'~~~II~II~~II'~'1~~~1II~II~~If l~l~ll'~~~I'I'f ~I'~I KEYBANK NATIONAL ASSOCIATION 56.704 412 DATE 03-16-2012 CHECK N0. 00347539 150 PA~~ 2 s i i AUTHORIZED SIGNATURE ~i'000034753911' x:04 ~ 207040: 3509935 i78 L ili' Schedule E, Exhibit 3 HARP 601 E. Street, N.W. Washington, O.C. 20049. Refund issued due to overpayment of your DATE membership dues. Your membership is in 03/22/12 good standing. For additional questions call us at 1-888-687-2277 Vendor No.: 1901957 CHECK N0. 1256850 SPU Code: DATE INVOICE /CREDIT MEMO TYPE DESCRIPTION GROSS DISCOUNT NET 03/14/12 5022227540 03/14/12 1.201 -Member Refu d 16.00 16.00 THE ATTACHED CHECK IS IN PAYMENT FOR ITEMS DESCRIBED ABOVE. ~ ~ 16.00 16.00 u'0 L 25685011' x:06 L P L 2788: 3 2998 L9690n' Schedule E, Exhibit 4 REMOVE DOCUMENT ALONG THIS PERFORATION ~vv 1 ~~.~ yr rKCMiuM Ktt-UfVU DATE M0. DAY YR. Erie o6 I o5 I zo12 Insurance' 100 Erie Int. PI. Erle, PA 76530 REFUND AMOUNT $ 45.00 POLICY/ACCOUNT NO. Q061201696 AGENT NO. AA7507 AGENT NAME SHINER INSURANCE AGENCY PC CHECK NO. 2000313798 REFUND REASON FLAT CANCELLATION 000 0003898 00000000 001 001 03696 INS: D D LOIS S COLLINS 1067 NANROC DRIVE MECHANICSBURG PA 17055 AA7507 NON-NEGOTIABLE THIS REFUND CHECK HAS BEEN ISSUED TO YOU AS A RESULT OF A PREMIUM CREDIT BALANCE REMAINING ON THE CANCELLED POLICY/ACCOUNT INDICATED ON THE BELOW CHECK. IF YOUR RECORDS DO NOT AGREE, PLEASE NOTIFY YOUR AGENT. ~~, ..oe:.. ~„ DdV• eterri v cnaSTV rave nisi 11'2000313?9811' i:061iL2?88~: 329 999 65L411' Schedule E, Exhibit 5 Commonwealth of Pennsylvania State Employees' Retirement System 30 North Third Street, Suite 150 Harrisburg, Pennsylvania 17101-1716 '~` l wwwsersstate.pa.us Telephone: 1-800-633-5461 FAX: 717-787-5866 LOIS COLLINS ESTATE D L MILLER & N W COLLINS EXECS 1067 NANROC DR MECHANICSBURG PA 17055 Dear Beneficiary: May 23, 2012 ~~ ~~ ~ .. - %+"a. m' ., ~ ~F' .~Pe„ Member SSN: XXX-XX-2144 Bene. Annt. SSN: XXX-XX-8833 Beneficiary SSN/EIN: 45-6844939 A check in the lump sum benefit amount of $48.45, less Federal Withholding Tax of $0.00, will be mailed to you within one week from the date of this letter. This payment represents the designated share of 100.00% in Final Settlement of the account of Dorothy M. Tifverman, member/Lois S. Collins, beneficiary annuitant with this Retirement System. If the individual listed above was a member of the Retirement System before January 1, 1982, their contributions prior to that date were taxed as part of their gross income at that time. Therefore, no taxes are being withheld on that portion of their contributions. The difference between the amount of your payment and your share of the deceased member's non-taxable contributions, if any, is taxable for federal income tax purposes. This payment has been reported to the Internal Revenue Service. If a 1099-R form is not enclosed with this letter, you will receive one prior to January 31 of next year, with the necessary tax information regarding this payment. Under current law there are no Pennsylvania state or local taxes on any benefits paid from this system. This letter and the 1099-R form that you receive should be kept in a safe place, as you will receive the information when filing your Federal Income Tax Return. This is the only notice you will receive. There is a $5.00 charge for each request of duplicate information. Sincerely, ~%~ ,f1. y17~~ Debra G. Murphy, Director Benefit Determination Division DGM:mes Schedule E, Exhibit 6 ~OOOf,~ CDC 061 070 ', 05`812 FUND I DEPT PREP DATE 17010429 VOUCHER .836 WARR ' Fl1LTON BANK ~ ~' `~ ` ~ , `~ P °J LANCASTER, PA 11 -' VERIFICATION AVAILABLE- "POSITIVE PAY" PRpTECT O ° . ~ ~ X15 PAY ° ~ , . _ ONL a ,CTS CIS O O TO THE ORDER OF ° r D L MILLER & N W COLLINS EXECS p LOIS COLLINS ESTATE 1067 NANROC DR ~ MECHANICSBURG PA 47055 a cn 71 * ~ * ~ ~ 4839 $ ~...~. ` > i ti ,, Yw ~~ ~ -, >FI ~~ ' $5 r 66095421 ~~*~ 3 ~: ~ AtJT ~O ~ y±~ CHkCKNUM9FR .' !~k~u ° 1 '$u `d : ^'~~~ ~ 05 /2 5120 1 Q .~ ~; _ . ,;~ t, e L t . \ S y ~~'{ ~ ~~i _.. DATE ^ „.x- . ; ,,, ` ~ r 4 " _ _ ~ ! S~ Y~+ 4 -: YIN y ~ 1 VOID AFTER 180 DAYS 'r1 .:.. s ~.. - - r~ - N M . ~ IV, 1.-j Robert M:McCord TREASURER OF PENN6YLVANIA .. ~ u^6609542in' ~:03i302748~: i2i9 53847u' .. . . ~_ REV-1510 EX+ (OB-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY Lois S. Collins 20 12 00384 This schedule must be completed and filed g the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THENPMEOFTHETRANSFEREE,THEIRRELATIDNSHIPTODECEDENTAND THE DATE OF TRANSFER.ATiACHAC0PY0FTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IFAPPLICABLEJ TAXABLE VALUE 1. Allstate Life Insurance Co., P.O. Box 94212, Palatine, IL 5,015.77 100.00 5,015.77 Annuity Beneficiaries: Neal W. Collins, Son (50%) Diane L. Miller, Daughter (50%) (See Schedule G, Exhibit 1) 2. 2005 Honda Accord 8,000.00 100.00 3,000.00 5,000.00 Transferred to granddaughter, Katana Lanier Herman on December 16, 2011 (See Schedule G, Exhibit 2) TOTAL (Also enter on Line 7, Recapitulation) ~ $ 10,015.77 If more space is needed, use additional sheets of paper of the same size. Allstate You're in good hands. April 16, 2012 Theresa L. Shade Wix Wix, Wenger & Weidner Attorneys at Law 4705 Duke Street Harrisburg, PA 17108 Re: Lois S. Collins Contract No: GA109089 Dear Ms. Wix We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the' contract). Because this contract is an annuity, it is not reportable on IRS Form 712. t can, however, provide the following information for estate purposes: Date of Death: Annuity Value as of Date of Death Cost Basis: Named Beneficiary: March 9, 2012 $ 5,015.77 $ 5,000.00 Neal W. Collins and Diane L. Miller 'The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. 28122. Sincerely, ~ ~ Q~ .1 ~ l%a' Ted Nelson Claim Representative Allstate Life Insurance Company Schedule G, Life and Annuity Claims Exhibit 1 P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523 2005 Honda Accord DX Sedan ... 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Recently Viewed Cars My Saved Cars save car New Cars You Might Like __ 2013 Honda Accord "°"' view Schedule G, Exhibit 2 __ _ __http://www.kbb.com/honda/accord/2005-honda-accord/dx-sedan-4d/?vehicleid=846&inte... 11/15/2012 advertisement why ads? 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 Lois S. Collins 20 12 00384 Decedents debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Auer Cremation Services, 4100 Jonestown Rd., Harrisburg, PA 17109 415.11 (See Schedule H, Exhibit 1) 2. Food for Funeral and Memorial Services 339.55 (See Schedule H, Exhibit 2) 3. Pealer's Flower Shop, 3720 Trindle Rd., Camp Hill, PA 17011 143.05 Flower spray for funeral (See Schedule H, Exhibit 3) B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: WAIVED Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: p AttomeyFees: Theresa L. Shade Wix, Esq., Wix, Wenger & Weidner 2,625.00 3, Family Exemption: (If decedents address is not the same as claimant's, attach explanation.) 3, 500.00 claimant Diane L. Miller Street Address 1067 Nanroc Drive city Mechanicsburg State PA zIP 17055 Relationship of Claimant to Decedent Daughter 285.00 4. Probate Fees: 5 Accountant Fees: 6. Tax Retum Preparer Fees: 7. The Sentinel, P.O. Box 540, Waterloo, IA 50704 221.40 Estate Advertising (See Schedule H, Exhibit 4) 8. Cumberland County Law Journal, 32 South Bedford St., Carlisle, PA 17013 75.00 Estate Advertising (See Schedule H, Exhibit 5) 9. Neal Collins, Co-Executor -Expenses relating to Probate of Estate Mileage from Gallipolis, OH to Harrisburg-773.4 miles rd. trip @ 55.5 per mile-$429.24 557.76 Hampton Inn Hotel -Bedford, PA $128.52 (See Schedule H, Exhibit 6) TOTAL (Also enter on Line 9, Recapitulation) S 9.441.08 If more space is needed, use additional sheets of paper of the same size Continuation of REV-1500 Inheritance Tax Return Resident Decedent Lois S. Collins 20 12 00384 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses 8~ Administrative Costs - A. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 4. Charles Yocum 112.00 Organist for Memorial Service 5. St. John's Lutheran Church, Shiremanstown, PA 200.00 Memorial Service SUBTOTAL SCHEDULE H-A ~ 312.00 Continuation of REV-1500 Inheritance Tax Return Resident Decedent Lois S. Collins 20 12 00384 Decedent's Name Page 2 File Number Schedule H -Funeral Expenses & Administrative Costs - B7. ITEM NUMBER DESCRIPTION AMOUNT 10. Space Mart Storage Unit, 4751 Wesport Dr., Mechanicsburg, PA 17055 881.92 Storage unit rental March 2012 through October 2012 - $110.24 per month (See Schedule H, Exhibit 7) 11. Diane Miller, Co-Executor 6.25 Mailing to Decedent's Relatives (See Schedule H, Exhibit 8) 12. Cumberland County Register of Wills 30.00 Inheritance Tax and Inventory Filing Fee 12. Wix, Wenger & Weidner, 4705 Duke Street, Harrisburg, PA 49.04 Postage & Photocopies SUBTOTAL SCHEDULE H-B7 ~ 967.21 ~~~~~~IONSER`'`~~ AVER CREMATION SERVICES OF PENNSYLVANIA, INC. •~p ~G• 4100 Jonestown Road • Harrisburg, PA 17109 • 1-800-720-8221 • Fax 717-541-9943 • Shawn E. Carper, Supervisor p~~'1VSriYAN1A' Mar 9, 2012 Mrs. Diane Miller 1067 Nanroc Drive Mechanicsburg, PA 17055 Lois S. Collins - Deceased SPECIAL CHARGES X Direct Cremation Nationwide Guarantee Program Worldwide Travel Protection TOTAL SPECIAL CHARGES PROFESSIONAL SERVICES X Services of Funeral Director & Staff Other Preparation of the-Body Facilities & Staff for Memorial Service Staff & Equipment for Memorial Service Witnessing the Cremation Private Family Viewing/Witnessing Cremation Packaging And Forwarding Cremated Remains Personal Delivery of Cremated Remains Scattering of Cremated Remains Medical Documents/Courier Fee TOTAL PROFESSIONAL SERVICES AUTOMOTIVE EQUIPMENT X Removal Vehicle Lead Car/Clergy Car Family Car Service Vehicle TOTAL AUTOMOTIVE EQUIPMENT $1,595.00 Included 120288 SVP-5 $1,595.00 $0.00 Included $0.00 Schedule H, Exhibit 1 MERCHANDISE X Register Book $45.00 X Memorial Cards 150 @$105.00 X Thank You Cards 2 @ $24.00 X Remembrance Package $120.00 Cremation Container X Cardboard Container Urn Burial Vault Veterans Flag Case Grave/Memorial Marker TOTAL MERCHANDISE CASH ADVANCED ITEMS 6~ Tax $2.70 $0.00 6e Tax $6.30 $37.10 6~ Tax $1.44 $0.00 6~ Tax $7.20 $127.20 Grave Opening Cemetery Equipment X Patriot Newspapers Newspaper Vault Service Charge Clergy Church/Organist/Soloist Flowers X Crematory Charge X Cumberland County Coroner Cremation Approval X 12 Certified Copies of Death Certificate TOTAL CASH ADVANCED ITEMS SUMMARY OF CHARGES Special Charges $1,595.00 Professional Services $0.00 Automotive Equipment $0.00 Merchandise $164.30 Cash Advanced Items $153.81 SUB TOTAL CREDITS AMOUNT PREPAID Date TOTAL AMOUNT PAID Date BALANCE DUE $1,913.11 -$900.00 Dec 7, 1996 -$695.00 $318.11 Mar 12. 2012 -$318.11 $0.00 $56.81 Included $25.00 $72.00 $164.30 $153.81 THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES ,.., _ _ __ __ . _. (COMPANY I (ADDRESS) Received from ~. _.1, ~ ~~ No. ,, ^ _ ___.._ h f; ~ J ~ ..._ __._..____._ _.._.__.~ -.___. _ _ ~_ L,,~;~.,_ - - -.-._-_,_ _ ~ Dollars LAST BALANCE $ `_' ~' r. ;~i f Payment,;.- `~'~ '~ ,`, "~ For `;~:~,~,L,~*'.., -~~ AFEWLANCE $ ~f'`` , ;z Date ~ _j. By ....-:~;.:_~,'~" J G G~OCG.~ CHARGE SALES INVOICE GIANT FOOD STORES, LLC ~ ~ „~ ~ ~ ,~ MARTIN'S FOOD MARKETS ~'~-~ Please a from this invoice. Store. ~ '~~ ~ )Y~1 P y + Date ~ TERMS: NET 10 DAYS ~~ ~~ ~~ ~ M . Payments axompanlsd by remittance copy of this Inwlee should be mulled to: ~ / Customer ~ ~~ ~-- Ahold Financial Servic .\ f Account No. 3213 Paysphere Circle ~'~ Profit N~on-Pro_f__it Chicagp, IL_6067~4, .~ ~'~---, t t r r a~ J L- y . ~ - Name /! Address (Street) (City) P.O. No. _ (State) (Zip Code) x t6M~'-x~° ~" z }"E ~-.- .. ~6 ,~. ~ ~ n m~ g~1~l~ ~{+"; ;i "54~+~`~# „f i x ~. c xil ~a~+i~ k R3,~` -~4", i i ~`~. 9an ~.u f~ 'I`i-. r i~ ~ . , ~., .v}, .. Y ~ ail a'~~ 't E$: *~. ,`vc ..'{,x ~v ~3„ e _ ~~~~.,`e; .. i.. Shopper's Name Printed ;~,,t~.~,: -C r ,~ 2-- Customer Signature t', ,', ,r~~.~; , ,<; - ~~ TOTAL Yellow - Rer~ttance Copy f JPink -General OY + $124.97 - Ahold 155.60 - Weis Total: $280.57 58.98 (Ahold) Grand Total: $339.55 ~oia - siore ~opY , Schedule H, Exhibit 2 !~~ Pealer's Flower Shop --~ ~~ 3720 TRINDLE RD CAMP HILL, PA 17011 ~• 717-737-4506 www.pealers.com Date: 03/10/2012 Terminal: 3 Time: 03:14:56 PM Session: 6284 o Janice Order Number: 250155 Oty Description Price 1 Spray onEasel, to look $ 125.00 just like s33-4513 but to include some yellow and some butterflies, likes stargazer ~ lilies, orchids, snaps ~ and tulips, nc tarns ~ -a ~ ~, pl ease Sub Total: $ 125.00 Delivery Charges: $ 9.95 Sales Tax $ 8.10 total Amount Due: $ 143.05 Check Tendered: $ 143.05 Change Due: $ 0.00 Send flowers....Just Because! Print Date: 03/10/2012 Print Time: 03:15:03 PM Schedule H, Exhibit 3 ~~,- S~IS~~z~ t y~5v The Sentinel WIX WENGER a WEIDNER ATTY www.cumberlink.com 4705 DUKE STREET ~~~ HARRISBURG, PA 17109 71752-8455 AD NUMBER PAGE NO. 408638 1 of 1 BILL DATE SALESPERSON 04/26/12 wolfc _ START DATE _ STOP DATE 04/12/12 04/26/12 I 408838 I NOTICE LETTERS TESTAMENTARY IN THE I 10 PUBLIC NOTICES 140 ' 2 cols I Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $212.40 TOTAL AD CHARGE $212.40 3 M081LE SITE M082 $2.00 3 PROOF OF PUBLICATION 01 PRF $7.00 Purchase order Est.LoisCollins PAY THIS AMOUNT $221.40 $265.68• "AFTER 05/21/12 Thank you for advertising with The Sentinel! Deadline for in-column legal ads is 4:00 p.m. two business days prior to date of insertion. For questions, call (717) 240-7130. THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 Schedule H, Exhibit 4 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2663 May 4, 2012 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Theresa L. Shade Wix, Esquire RE: Lois S. Collins Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: April 20, April 27, and May 4, 2012 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof-Request $ 0.00 Payment received $ 75.00 Total Amount Du® $ 0.00 Becky H. Morgenthal, Executive Director Schedule H, Exhibit 5 i __- ';. ~ ~- ~ --- 'c, ~'/ ~ 2 Schedule H, Exhibit 6 ~d !~f ~C ~__. _. wAvoar C O N R A D .'~"~~ ~ ® q~~~ ~ Horvievrooo ~ ~ U H I LTO N nstoain~ .~„~~.,~~~..,. Hilton txx~etE7A~ .....,. ®Garaeninn c7/omaw wrres HOME Hdton p,e...,o„ - ~...~..e. •-•••........ Grand Vacations n HHONORS Space Mart -Mechanicsburg 4751 Westport Dr Mechanicsburg, PA 17055 717-790-9100 Past Due Notice Tenant Diane Miller Companc Address 1067 Nanroc Drive cih, state, zip Mechaicsburg PA 17055 Date of Notice March 21, 2012 Unit Number C170 Dear Tenant: I f pay rr~em !.as not been forwarded, then you are hereby notified that you are past due in the payment under your tease agreement number 3705 of November I5. 201 I, ,for unit number C 170. You are currently past due for the Total Due amount shown below and calculated as follows: Charge Date Description Amount 03.15/2012 Rent 104.00 6.24 0.00 110.24 03'2U/2012 Late Fee 20.00 0.00 0.00 20.00 Total Due 130.24 Please remit payment within 7 days from date of this notice to avoid further charges. Sincerely. Manager Schedule H, Exhibit 7 4~' . , r 'L r, O H y~ T ro ~~ m n !!!~~~''' N n ~j. ~ N • ~Y{. n ::fi~rr m n M ~ ~ ~~.5 . .~ 'i 7 ~ ~ a ~ ~ m ~ ° m N ~ n x n ~ s ~ m ~ 3 ~ ~ o ~ ~ 7 m ~ n n ~ N ~ Lt ry ~ 7 n ¢ ~ r- ~ N O ~ d K b 0 a w R 7 A+ G h r r 0 N ~4 a n R N v Y N w a n 0 O rt N N N -~ ~ b 4 W ~ yg _. a ~ 't ~' ~ 5, ~ ~ A t-+ f7 ~ I a f't T Av, f ~ ~ CG,~. r r '° r~+ A Ch ~ N ~~ to '~? p e,y- W c a o ~ ~ ~ ~ ~ ~ ~ oo°`~ ~ ~ Q fD ~ , ~ ~ ~, r ~ ® A' ~~ m ~ ;D' A~ iD ~ tp ~ ~p R M N ~ ~ Q r gyp ~ _~ .~. ~ w N o4 ~ .' -,] ~ r m /~, N. 'D ~• ~ a 7 Y ~ tJ~ ~~ r r ~ ~ ..] p r ~ ~ o H ~ ~ ~ e ~ ~ ~ d_ 6 m ~~~ ~ ~ ~, ~? B ~ ~ 'Tt 'd ~ O ~ ~ N K x ~~ _ R ew ~ d N a y n rf rn a~ 3 m a Z~ G7 r a n ~ ,~ ~,. m N N o ~ G ,.~ .r, A~ ~' m q.n> ~ o°. G ~ ~' fn a~~ ymm~ oooa ff o a. ~ n ~, Y~LrtS u~ pOC~7i ~+ d o cu r- ~, p N ~ 'j> ~ ~ a~ ~ ~ O Y' X ~ p A% W p ~ t. D ~'' ~ tJ N N ~ ~ O p O G r H r N tJ m rf oor°R N v+ ~"> p S+ N W ,o- ~ ro ~~~ ~ W ~p0'o 6~O p0 m 0 / .o aoNO ~~oa~ct fl a ~noosr ~ ~ ~ m N ~r N 7 ~ ~ O au P~ ' V Space Mart - Mechanicsburg 4751 Westport Dr Mechanicsburg, PA 17055 717-790-9100 5:. Payment Receipt Date Printed July 1 i 2012 Tenant Diane Miller , Payment Date July 11, 2012 1:11 PM Company Unit C170 wddress 1067 Nanroc Drive Available Credit 0.00 City, sate, zip Mechaicsburg PA 17055 Current Balauce 0.00 Paid Thru September 14, 201 2 Receipt Number 59618 By AM Date 07 15 1 Unit DesCri tion C170 Rent 7 15-8/19 Char a Discount Tax Total Pa t Method 08/15/12 C170 Rent 8/15-9/19 109.00 0.00 6.29 110.29 109 00 0 00 110.23 Check 09/15/12 C170 Rent 9/15-10/19 . . 6.29 110.29 109.00 0 00 6 24 1 110.29 Check . . 10.29 0.01 Check Taxes 12 98 Payment (less tax) 208.00 Payment Subtotal 220.98 Credits Applied 0.00 Refunds Applied 0 00 Total Applied to Account 220.98 Current Account Balance 0.00 Paid ey Check 061273313 Paid Thru Date September 19, 2012 No returns, refunds or exchanges on merchandise "LIKE" Space Mart Self Storage Mechanicsburg to stay up to date on auctions, yard sales and contests! { 1' No returns, refunds or exchanges on merchandise EFORM724934 EST OF LOIS 3 COLLIN3 DECD DIANE L MILLER CO-EXTRX PAY TO THE ,LQ~~ rn ~~ ORDER OF ~+ DATE ~~~i~~.2. 60-1273/313 $ oL+~ ~ ~ ~ DOLLARS PNC Baa]c, National Association Central PA WINDSOR PARR 00115 ,~/ Non-Negotiable Customer Copy MEMO C' I ~"b ~~ O~ ~ °~7~ C ~0020o-o~os PAPER FOR GL TICKETS AND CONVENIENCE CHECKS ~_ Mechanicsburg Main Post Office MECHANICSBURG, Pennsylvania 170559998 4134870055 -0096 03/20/2012 (800>275-8777 10:19:58 AM - Sales Receipt Product Sale Unit Final pescription Oty Price Price Other 65c Wedding 7 $0.65 $4.55 Cake PSA ARVADA CO 80004 Zone-7 $1.70 First-class Large Env 4.40 oz. Issue PVI: $1 70 ~~1~ ~~rn~ Total:C~~l ~~, ~ (~~. m~-rn. ~:~/1Ce ~o $6.25 Paid b G~ aF.'~~~'~, ~ Cash ~rs-r. l~EUn~ndti~, FK. f; ~ $20.00 Change Due: -$13.75 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx BRIGHTEN SOMEONE'S MAILBOX. Greeting cards available for purchase at select Post Offices. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Order stamps at usps.com/shop or call 1-800-Stamp24. Go to usps.com/clicknship to print shipping labels with postage. For other information call 1-800-ASK-LISPS. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Get your mail when and where you want it with a secure Post Office Box. Sign up for a box online at usps.com/poboxes. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Billq: 1000403618506 Clerk: 06 All sales final on stamps and postage RefuAds for guaranteed services only Thank you for your business xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxXxxxxxxxxxxxxxxxxxXxxxXxxxxxxxxxXxxXxx HELP US SERVE YOU BETTER Go to: https://postalexperience.com/Pos TELL US ABOUT YOUR RECENT POSTAL EXPERIENCE YOUR OPINION COUNTS xxxxxxxxxxxx*xxxxxxxxxxitxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Customer Copy Schedule H, Exhibit 8 REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT EST NUMBER 1. 1. 2. 3. 4. 5. 6. SCHEDULE J BENEFICIARIES NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] Diane L. Miller 1067 Nanroc Drive, Mechanicsburg, PA 17055 Neal Collins 102 Adelaide Drive, Gallipolis, OH 45631 Katana Miller - In Trust (Age 28) 1067 Nanroc Drive, Mechanicsburg, PA 17055 Karina Miller - In Trust (Age 26) 1067 Nanroc Drive, Mechanicsburg, PA 17055 Kyra Collins - In Trust (Age 7) 102 Adelaide Drive, Gallipolis, OH 45631 Danika Collins - In Trust (Age 2) 102 Adelaide Drive, Gallipolis, OH 45631 FILE NUMBER: 20 12 00< RELATIONSHIP TO DECEDEN Do Not List Trustee(s) Lineal Lineal Lineal Lineal Lineal Lineal 20,347.41 20,347.40 13, 919.75 8, 919.76 8,919.76 8.919.76 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. AMOUNT OR SHARE OF ESTATE LAST WILL AND TESTAMENT ~o '~ = T, ~~~ ^, _- - OF - ;~~:~ -~ - . T. LOTS S. COLLINS . -, :~~ U r _: I, Lois S. Collins, presently residing in Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils previously made by me. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though such tax was paid on proceeds of insurance or other property not passing under this Will. If the assets not specifically devised or bequeathed are not adequate for the payment of all such taxes, then the recipients of the property specifically devised and bequeathed shall each pay a pro rata portion of any such tax based upon the valuation of the property received by each such recipient as finally determined for Federal Estate Tax purposes, or if no such determination is made, then for applicable State Inheritance Tax purposes. ITEM II: I hereby exercise all powers of appointment which I may have at the time of my death in favor of my Executor, and all property subject to all such powers of appointment shall be included in my estate. ITEM III: I hereby give, devise and bequeath my estate, whether real, personal or mixed, of whatsoever nature or kind and wherever located as follows: a) Twenty-five percent (25%) of my estate I give, devise and bequeath unto my daughter, Diane L. Miller; b) Twenty-five percent (25%) of my estate I give, devise and bequeath unto my son. Neal W. Collins; c) Twelve and one-half percent (12'/z%) of my estate I give, devise and bequeath unto my granddaughter, Katana L. Miller; Page 1 of 5 d) Twelve and one-half percent (12'/2%) of my estate I give, devise and bequeath unto my granddaughter, Karina L. Miller; e) Twelve and one-half percent (12'/z%) of my estate I give, devise and bequeath unto my granddaughter, Kyra M. Collins; and f) Twelve and one-half percent (12'/z%) of my estate I give, devise and bequeath unto my granddaughter, Baby Collins, who is expected to be born in April 2010. ITEM IV: Regarding any and all property I bequeath unto my grandchildren who have not attained the age of thirty (30), I hereby give, devise and bequeath said property, whether real, personal or mixed, of whatsoever nature or kind and wherever located, unto my Trustees to be used for the benefit of said grandchildren, in trust, and to be administered in accordance with the provisions set forth herein. a) I hereby appoint my daughter, Diane L. Miller, as Trustee for her children, Katana L. Miller Herman and Karina L. Miller. b) I hereby appoint my son, Neal W. Collins, as Trustee for his child, Kyra M. Collins and any other children fathered by Neal who are beneficiaries under my Will. c) It is my intention that a separate account be maintained for the property bequeathed to each beneficiary. d) The Trustees shall have, hold, manage, invest and reinvest the principal of the trust for the benefit of each beneficiary, and during the continued existence of the trust, pay to or for each beneficiary's benefit, in not less frequent than quarterly installments, so much of the net income of said trust as, in the sole discretion of the Trustees, may be necessary to maintain the beneficiary in the proper station in life, including proper support, maintenance, medical, hospital, nursing and nursing home care; any unused income shall be accumulated. e) In the event that a beneficiary should desire to continue their education once they graduate from high school, my Trustees shall use any unpaid accumulated income and the principal of the trust to pay any and all bills to continue said education. These expenses may include, but are not limited to, tuition charges of any college, university, post-graduate school or trade school. In addition, the Trustees shall use the income and principal of the trust to pay all reasonable and necessary expenses for room and board, books and supplies, and travel expenses. PAGE 2 OF 5 PAGES f) In the event that any beneficiary does not wish to continue their education upon their graduation from high school, or in the event that they do not graduate from high school, my Trustees, in their sole discretion, may continue to use the income from the trust for the maintenance of said beneficiary. g) Upon the thirtieth (30th) birthday of each beneficiary, my Trustees shall pay to them all remaining unused income and all of the principal remaining in the trust. h) If, at the establishment of said trust, a beneficiary has already attained an age at which a distribution would have been made, the portion which would have been distributed at such prior age shall be paid to them immediately. i) No part of the income or principal of the property held under the trust established hereunder shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary prior to her actual receipt thereof. The Trustees shall pay over the net income and the principal to the parties herein designated, as their interest may appear, without regard to any attempted anticipation (except as specifically provided in this Will), pledging or assignment by any beneficiary under a trust, and without regard to any claim thereto or attempted levy, attachment, seizure or other process against said beneficiary. ITEM V: In addition to such other powers as my Executor may be granted by law, or under previous portions of this Will, they shall have the following powers: a) To retain investments I may have at my death so long as my Executor may deem it advisable to my estate or to do so. b) To vary investments, when deemed desirable by my Executor, then to invest in such bonds, stocks, notes, real estate mortgages, or other securities, or in such other property, real or personal, as they shall deem wise, without being restricted to so-called "legal investments". c) In order to effect a division of the principal of my estate or of any trust or for any other purpose, including any final distribution, my Executor is authorized to make said divisions or distributions of the personalty and realty partly or wholly in kind. If such division or distribution is made in kind, said assets are required to be divided or distributed at their respective values on the date or dates of their division or distribution. PAGE 3 OF 5 PAGES d) To sell either at public or private sale and upon such terms and conditions as the Executor may deem advantageous to the estate, any or all real or personal estate or interest therein owned by the estate or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trusts and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable, in carrying out any of the powers conferred upon my Executor in this paragraph or elsewhere in my Will. e) To mortgage real estate, and to make leases of real estate. f) To borrow money from any party, to pay indebtedness of mine or of my estate, expenses of administration or inheritance, legacy, estate and other taxes. g) To pay all costs, taxes, expenses and charges in connection with the administration of my estate. My Executor shall pay the expenses of my last illness and all funeral expenses. h) To vote any shares of stock which form a part of the estate, and to otherwise exercise all the powers incident to the ownership of such stock. i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the estate. ITEM VI: Any person who shall have died at the same time as Testatrix, or in a common disaster with her, or under such circumstances that it is difficult or impossible to determine who died first, or who shall have died less than thirty (30) days after the death of Testatrix, shall be deemed to have predeceased her. ITEM VII: I hereby nominate, constitute and appoint my daughter, Diane L. Miller, and my son, Neai W. Collins. as Co-Executors of this my Last Will and PAGE 4 OF 5 PAGES Testament. My Co-Executors are specifically relieved from the duty or obligation of the filing of any bond or bonds in this or any other jurisdiction. ITEM VIII: Where appropriate throughout this my Last Will and Testament, all references herein to the singular or the masculine shall include the plural or the feminine, respectively. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament, consisting of this page and the preceding four (4) pages , this 3~ day of ~~'``'`'`'``~ 2010. Loi S. Collins We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence and in the presence of each other, have hereunto set our hands and seals the day and year above written, and we certify that at the time of the execution thereof, the said Testatrix was of sound and disposing mind and memory. c ~ 'tom ~ (SEAL) Residing at_~~~D ~-G-°L I',~ (` 7/ l l \~-~ ~ ~ W~SG (SEAL) Residing ~e ~Q 0 ~s-4-~ ~~ 2yu.~ fir, s 6<-~..~G . ~'~9 ! rl// I Residing PAGE 5 OF 5 PAGES ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF DAUPHIN I, Lois S. Collins, the Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by Lois S. Collins, the Testatrix, this 3~- day of F~br,x.w~~ , 2010. _~°r-~~ Lois S.. Collins Testatrix ~Y Notary Pub Ic My Commisslon Expires. COMMON WEALTH OF'PENNMVANIA NOTARIAL SEAL AFFIDAVIT GAYE CRIST, Notary Public City of Hamsburg, Dauphm Counly MY Commission Expires April 18.2013 COMMONWEALTH OF PENNSYLVANIA ) COU OF DAUPHIN ) /~ and ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testatrix, signed the Will as a witness; and that, to the best of our knowledge, the Testatrix was at that time 18 or more ye rs of age, of sound mind and under no constraint or undue influence. l~J~--~ worn to or(a~Irmpend annd subscribed to before me by ~~~~~ (~ - (~I~ and ,witnesses, this 3 ~ day of Frbr~- ~ , 2010. ~ ~,1-~-~ Witness Witness Witness ~ /tea Notary Pu is My Commission Expires: CGMW:7KW _nLTr. :3~ PENNSYLVANIA NOTARIAL SEAL GAYE CRIST, Notary Public City of Harrisburg, Dauphm Counly My Commission Expires April 18, 2013 j