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Home My WebLink About12-27-12J 1505610140 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisbur , PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 1 1 5 0 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 9 2 8 ? 7 9 4 1 0 1 9 2 0 1 1 0 4 0 6 1 9 3? Decedent's Last Name Suffix Decedent's First Name MI B A I L E Y D E L O R E S ,J (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 DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 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) QX 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 TO: Name Daytime Telephone Number M A R C U S A M c K N I G H T I I I 7 1? ~2 4 9 ~.., 3 5 3 First line of address I R W I N & Second line of address 6 0 W E S T City or Post Office C A R L I S L E Correspondent's a-mail address: r a-• REGIS WILLS I~SE ONL~I yT ("7'p r.'f ~'~'T ,~ _ ~ ;$~ rte . . "r:,~ / „ faro. ~i . f ~ f ~y ~ , ~ r ~i.. ~ ` ^ ( ~~ .,. ~~ ,"°~ ~ ,-I ~ ~ ' ,. ; ; m ;, .... ~._, '" DATE FI ED : ; .a.~ a P A 1 7 0 1 3 2 ..., .. ~..I Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF R N RESPONSIB OR F G RETURN ~ DATE ADDRESS ~ ~ ~~`' ~~ f 65 BLUE PON ROAD ~~ NEWVILLE SIGNATU Ofd ER HAN REPRESENTATIVE ~~ G DDRESS 60 WEST PO FRE STREET CARLISLE PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 M c K N I G H T P C P O M F R E T S T R E E T State ZIP Code PA 1,7241 DATE PA 1,7013 15056],0140 J h~J J 1505610240 REV-1500 EX Decedent's Social Security Number 2 0 9 2 8 7 7 9 4 Decedent's Name: D E L O R E S J• B A I. L E Y RECAPITULATION 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 and Notes Receivable (Schedule D) .......................... 4. • 1 6 2 2. 0 3 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 Non-Probate Property arate Billing Requested ....... ^ Se 7. 2 5 0 9 5 2. 6 5 p (Schedule G) 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 2 5 2 5 7 4 . 6 8 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 1 6 1 8 5. 7 1 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 9 3 3 . 4 4 11. ...... Total Deductions (total Lines 9 and 10) ........................ . 11. 1 7 1 1 9. 1 5 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12• 2 3 5 4 5 5. 5 3 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which . an election to tax has not been made (Schedule J) ...................... 13. • 14. Net Value Subiect to Tax (Line 12 minus Line 13) ...................... 14. 2 3 5 4 5 5. 5 3 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 Q Q Q 15. (a)(1.2) X -0 16. Amount of Line 14 taxable 2 3 5 4 5 5. 5 3 1 s at lineal rate X .045 . 17. Amount of Line 14 taxable Q ~ Q Q 17. at sibling rate X .12 18. Amount of Line 14 taxable Q ~ Q 0 18 at collateral rate X .15 . 19. TAX DUE .................. .......................... ... ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610240 Side 2 0. 0 0 1 0 5 9 5. 5 0 0. 0 0 o. 0 0 1 0 5 9 5. 5 0 ^ 1505610240 J J ~, Continuation of REV-1500 Inheritance Tax Return Resident Decedent DELORES J. BAILEY 21 11 1150 Decedent's Name Page 1 File Number Correspondents Name Daytime Telephone Number M A R C U S A M c K N l GH T I I I 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N & M c K N I G H T P C. Second line of address 6 0 W E S T P O M F R E T S T R E E T City or Post Office State ZIP Code C A R L I S L E P A 1 7 0 1 3 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PER O RESPONSIBLE OR FILING RETU N ~ DATE ADDRESS 61 FICKES ROAD NEWVILLE PA 17241 Name Daytime Telephone Number M A R C U S A Mc K N I GH T I I I 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N & M c K N I G H T P C. Second line of address 6 0 W E S T P O M F R E T S T R E E T City or Post Office State ZIP Code C A R L I S L E P A 1 7 0 1 3 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSO ESPONSIBLE FOR FI G RETURN DATE . ~ Z~(! ~ ADDRESS 2536 RITNER HWY LOT 105 CARLISLE PA 17015 s REV-1500 EX Page 3 Qecedent's Complete Address: File Number 21 11 1150 DECEDENT'S NAME DELORES J. BAILEY STREET ADDRESS 429 DOGWOOD CT. CITY CARLISLE STATE PA ZIP 17015 Tax Payments and Credits: 7 • Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments - B. Discount 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. (1) 10,595.50 (3) 0.00 0.00 (5) 10, 595.50 Make check payable to: REGISTER OF WILLS, AGENT '. ._.........__~_.....~ s - ~ - - -~ t 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 : ................................................................. ..... ^ 0 b. retain the right to designate who shall use the property transferred or its income; .......................... ..... ^ 0 c. retain a reversionary interest; or ........................................................................................... ..... ^ ^ 0 0 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" orpayable-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? ............................................................................................ ...... 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~- _. _. - ____ .~______.______.W_ _.____~__._ _ -_-. .. ~~- - 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) (4) 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: DELORES J. BAILEY 21 11 1150 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. F&M TRUST -CHECKING ACCOUNT #0003632369 622.03 2. PERSONAL PROPERTY 1,000.00 TOTAL (Also enter on Line 5, Recapitulation) $ 1 622.03 If more space is needed, insert additional sheets of paper of the same size f REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER DELORES J. BAILEY __ 21 11 1150 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 TO DECEDENT AND DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE) TAXABLE VALUE NUMBER THE DATE OF TRANSFER. ATTACH A COPY oFTHE DEED FOR REAL ESTATE. ( 1. NATIONAL WESTERN LIFE INSURANCE COMPANY 22,393.05 100.00 22,393.05 ANNUITY CONTRACT #01001128736 2. NATIONAL WESTERN LIFE INSURANCE COMPANY 41,604.63 100.00 41,604.63 ANNUITY CONTRACT #0101245294 3. NATIONAL WESTERN LIFE INSURANCE COMPANY 7,314.07 100.00 7,314.07 ANNUITY CONTRACT #0101152905 4. NATIONAL WESTERN LIFE INSURANCE COMPANY 7,315.52 100.00 7,315.52 ANNUITY CONTRACT #010011529006 5. NATIONAL WESTERN LIFE INSURANCE COMPANY 43,849.54 100.00 43,849.54 ANNUITY CONTRACT #01011529008 6. LIFE INSURANCE COMPANY OF THE SOUTHWEST/LSW 31,511.55 100.00 31,511.55 ANNUITY CONTRACT #681235X 7. LIFE INSURANCE COMPANY OF THE SOUTHWEST/LSW 18,999.79 100.00 18,999.79 ANNUITY CONTRACT #709637X 8. SHENANDOAH LIFE INSURANCE COMPANY 77,964.50 100.00 77,964.50 ANNUITY CONTRACT #002106853 BENEFICIARIES ON ABOVE ANNUITIES: KIMBERLY PAULUS ALECIA BAGROSKY GWENDOLYN BARRICK TOTAL (Also enter on Line 7, Recapitulation) ~ $ 250, 952.65 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER DELORES J. BAILEY 21 11 1150 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. SWING BROTHERS FUNERAL HOME, INC. 162.34 2. GREEN SPRINGS CHURCH OF GOD -CHURCH/PASTOR/ORGANIST 300.00 6 2 3 4 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees: IRWIN & McKNIGHT, P.C. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent Probate Fees: REGISTER OF WILLS 107.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 500.00 INCOME TAX RETURNS & FINAL FIDUCIARY TAX RETURN 7. REGISTER OF WILLS -FILING FEE 30.00 8. LITIGATION FEES -SEE ATTACHED 1,948.59 9. IRWIN & McKNIGHT, P.C., -ATTORNEY FEES PRIOR TO DATE OF DEATH 312.50 10. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00 11. THE SENTINEL -ESTATE NOTICE 210.78 12. NOTARY FEES 35.00 13. MINDY DEATRICK -LITIGATION PAYOUT 10,000.00 14. REGISTER OF WILLS -SHORT CERTIFICATE 4.00 TOTAL (Also enter on Line 9, Recapitulation) $ 16,185.71 ZIP 2,500.00 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE( DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER DELORES J. BAILEY _ __ 21 11 1150 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. INTERNAL REVENUE SERVICE -INCOME TAXES 473.00 2. PA DEPARTMENT OF REVENUE -INCOME TAXES 277.00 3. CARLISLE REGIONAL MEDICAL CENTER -MEDICAL 65.18 4. PP&L -ELECTRIC 49.45 5. (SOUTH MIDDLETON TOWNSHIP MUNICIPAL - WATER/SEWER I 34.00 6. SPRINT -TELEPHONE 34.81 TOTAL (Also enter on Line 10, Recapitulation) I $ 933.44 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RFRInGnIT nGrGn~niT SCHEDULE J BENEFICIARIES DELORES J. BAILEY NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. GWENDOLYN A. BARRICK 61 FICKES ROAD NEWVILLE, PA 17241 2. ALECIA K. BAGROSKY 65 BLUE POND ROAD NEWVILLE, PA 17241 3. KIMBERLY D. PAULUS 2536 RITNER HIGHWAY LOT 105 CARLISLE, PA 17015 FILE NUMBER: 21 11 1150 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Lineal 78,485.18 1/3 REMAINDER Lineal 78,485.18 1/3 REMAINDER Lineal 78, 485.17 1/3 REMAINDER ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 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. C7 -_~_ -tom ~° r= ~- ~:~M ~ ~y~~/~ ~~~~~/~ -~ ~ ~ f , ~ ' ~ / ' 1. i L/(/ I V 'Yrn ~~ _T._. 4... -+~-7 li7 ~ ~a __ 'J C_J ...+-' ~~ I L_ I, DECOKES J. BAILEY, of North Middleton Township, Cumberland County, _ Pennsylvania, declare this instrument to be my Last Will and Testament, hereby expressly _ revoking all Wills and Codicils heretofore made by me. ONE: I direct my Co-Executors to pay all of my debts, funeral and administrative expenses as soon as maybe done conveniently after my decease. Furthermore, I direct that all state, inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all properly composing of my gross estate for death tax purposes, whether or not such property passes under this will, shall be paid by the Co- Executors of my estate. TWO. My Co-Executors may, at their discretion, compromise claims, borrow money, retain property for such length of time as they may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as they may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder.. I authorize and empower my Co-Executors to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee simple, as I could do if living. My Co-Executors are authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as, seems expedient to said Co-Executors. Initial =: I specifically give, devise, and bequeath all the contents of my home located at 429 Dogwood Court, Carlisle, Pennsylvania to my daughters, GWENDOYLN A. BARRICK, ALECIA K. BAGROSKY, and II~MMBERLY D, PAULUS, to be divided as they wish. FOUR: All the~.rest, residue, and remainder of my estate of every nature and wherever situate, I give, devise, and bequeath to my daughters, GWENDOYLN A. BARRICK, ALECIA K. BAGROSKY, and KIMBERLY D. PAULUS per stirpes, which provides that the child or children of any deceased beneficiary shall take the share their parent would have taken if living. FIVE: I hereby specifically exclude my daughter, MILADY DEATRICK from any inheritance whatsoever under this my Last Will and Testament for reasons known unto her with the exception of her interest in my personal real estate located at 429 Dogwood Court, Carlisle, Pennsylvania 17013. SI_X: I appoint GWENDYOLYN A. BAR,RICK and ALECIA K. BAGROSKY,and KIMBERLY D. PAULUS to serve as Co-Executors of this my Last Will. If they have predeceased me, failed to qualify, ceased to serve, or are unable to serve, I appoint MARCUS A. McKNIGHT, III, to serve as Substitute-Executor in their place. SEVEN: No Co-Executors or Substitute Executor acting hereunder shall be required to post bond or enter security.in this or any jurisdiction. EIGHT If any person or institution entitled to share in any distribution under the terms of this my Last Will and Testament becomes an adverse party in any proceeding to contest the probate of this Last Will and Testament, such person or institution shall forfeit his, her or its entire interest inherited hereunder and all provisions in favor of such person or institution shall be declared void and of no effect. The share of such person or institution so forfeited shall be distributed as part of the residue pursuant to Paragraphs Three or Four hereof except that if such person or institution is entitled to share in the said residue, that interest shall be distributed proportionately to the other residuary distributees. Initial ~, 2 ~ WITNESS WHEREOF, I have hereunto set my hand and seal this 12th day of August 2011. 1~r~. fY ~, ~sEa~,~ DELO~J. BAII. Signed, sealed, published and declared by DECOKES J. BAILEY, 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 subscribed our names as witnesses hereto. `~:J~l~in.~ ~.~J~~ Initial~~~ ~~ 3 ACKNOWLEDGMENT A=D AFFIDAVIT WE, DECOKES J: BAILEY, KAREN S. NOEL, and SHARON L. SCHWALM, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last ~1Vi11 and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. COMMONWEALTH OF PENNSYLVANIA : SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by JOSEPHINE C. PETERS, the testator herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L. SCHWALM, witnesses, this 12th day of August 2011. COMMONWEALTH 0~ PENNSYLVANIA \ "t ~.~ `P,~-) Notarial Seal tart' ub1iC M2rtha d.. Noel, Nota~}~ Public Cgrllgt~ Qoro, Cumberland Count' MY.~nn.Pt. ,salon E__,_ x~Ireo g~4.18, 2011 ~liBFFl .@f~ a~!itl~ ~~RI~ @~~~la~ IOR ~~ I.Ot~rlpa HARON L. SCHWALM INSTRUCTIONS TO MY CO-EXECUTORS Personal property to be divided equally between by dau hters GWENDOLYN and KIMBERLY, as follows: g ~ ALECIA, ALECIA: Patio furniture, mom's bedroom suit, coffee tables and li hts Aunt Fr cedar chest, Van, multi-color recliner/couch, large wooden clothes closet in blue roo ancis' sewing machine, large Jewelry box, TV and entertainment center, microwave and refri Bold safe, basement: gold nugget earrings w/diamonds, Alaska clock, box of jewel in safe w/he ator. In it, gun and rifle. ry r name on G_WEN: Hutch/table dinette set, fiddle/guitar/brown recliner chair, brown cedar chest (Pap Bailey's) in basement, picture of mom age 50 from church, Aunt Ebb 's ni ht stan safe, Japanese jewelry box, 2 TV's in blue room and basement, refrigerator ands mall td~ new kitchen, gold nugget earrings w/o diamonds box of 'ewe able m metal wardrobe. ~ J lry in safe w/her name on it, gun, 22 and KIM: Piano, blue couch, (hide-a-bed in blue room), maroon recliner chair, 2 small chests (1 brown, 1 blue), Buick, 2 wall clocks w/Jesus on them, small jewelry box old 'ewe box, TV in mom's room, washer and dryer, box of 'ewe ' g J lry wardrobe. J lry in safe w/her name on it, metal Anything else will be divided between AI.ECIA, GWENDOLYN and KIMBERLY that is odds and ends that they feel is in their best interest My Trusts, financial investments, etc. will be divided equally between ALECIA GWENDOLYN and KIMBERLY. .TERRY BAILEY is to receive Pap's flag and desk. ~ ~ t? DE~O~i~ REg J,(~pILEy - DATE: August 1~ 2011 r 20 South Main Street ~~ PO Box 6010 Chambersburg, PA 17201 DELORES J BAILEY Page 2 of 2 October 20, 2011 .0.003632.369 CREDITS - - Date Description - - Additions ~~ 09-29 _ ..Deposit.. ..._ _ - _....._ -... _ . _ - 280.00...._ . 10-12 - ' Preauthorized.Credit __ _ _ __ 785.00 US TREASURY 303 XXSOC SEC 111012 _ _ 10-20 '.Interest Credit- ..__ .. -- _ - _ 0.24 DAILY BALANCES .- _ ......--.._.__._---....._..__..__... .. _.__._._..._.- _._. _.._ - __ ....._ .. _ _.._ ~~ Date ~ Amount Date ~ Amount Date. ..:- - , ... -,Amount , , ... , .. ... , - -- __ _._.. ------_-_-_. _ _ .__.- _--09=20___,__..___._ ~~.1~37:67-------_..-1~0--03 ~ 6,865.58 10-13 :.6;187.72.... . . -- 09-21 7,067.72 10-05 6,747.74 10-14 6,134.29 ~ ~ ~ , .. __ _. _- -- ~ -. -- ----._ __ ._-----Og~-22-_ __:.~.------ 7;23-:98 -...--------~0-06 ~..,.._..... _.---6;505:45..._.... _... ~ 0_.1..7 _ .. _.._.......2;134.29.._ . _ .. ~. 09-26. 6,995.48 10-07 5,720.45 10-18 ~ ~ ~~ ~ 1;634:29 • ~-- 09-29 7,275.48 .10..11.. ..-- ._..;5.,.590.8:1 1.Q-,19 .-... . ;, _ ~. ,~1: -7 - 09-30 6,995.58 10 X1.2 -~ ~ 6;375 8~1 _ : 10=20 ' ~ :< 622.03.' `~ ~.. . INTEREST INFORMATION Annual percentage yield earned 0.05% Interest-bearing days 30 Average balance for APY $5,8.61.59 Interest earned 50.24 OVERDRAFT/RETURN ITEM FEES Total for this period Total year-to-date .-Total. Overdraft .Fees .... ._ . _- .. -_ _ _ . -__-. ... _ _ .$.0.00_... _ ._...50.00_ - Total: Returned Item Fees _ ~... ~.: ~ 50:00 ~ ~ .. . ~ ~ ~ - - 5.0.00 Thank you for banking with F&M Trust ~~5, NATIONAL WE~.TERN LIFE INSURANCE COMPANY October 24, 2011 Alecia Bagrosky PO Box 226 Mt. Holly, PA 17065 Kimberly Paulus 2536 Ritner Hwy Carlisle, PA 17015 Gwendolyn Barrick 61 Fickes Road Newville, PA 17241 Subject: Delores Bailey annuity contracts The death of Mrs. Bailey was reported to us and we extend our sympathy in your loss. Each of you were named as a co-primary beneficiary to receive equal shares of the death benefit under each annuity. We will list each annuity separately and include the values -for each so that you may make the appropriate election individually. Non-Qualified Annuity Certificate No. 0101128736 Date of death value is $22504.18 with a tax cost basis of $22393.05. The death benefit is payable lump sum, or you may elect a payout if you prefer. Non-Qualified Annuity Certificate No. 0101245294 Date of death value is $41604.63. This annuity was a 1035 exchange from Americo Life & Annuity under which a cost basis is to be provided by the transferring company. Despite two requests for this information, we still do not have the cost basis which will result in a taxable consequence to each of you because the death benefit will be fully taxable. Enclosed is a copy of our latest request for this information. You may wish to contact Americo and ask that the information be provided. Individual Retirement Annuity No. 0101152905 Cash Value of $6948.37 payable lump sum or the Account Value of $7314.07 under a minimum 5 year fixed period payout. Benefit is taxable income to each. 850 EAST ANDERSON LANE AUSTIN, TEXAS 78752-1602 512-836-1010 AUTOMATED VOICE RESPONSE TOLL-FREE 888-695-5001 •WATS 800-531-5442 CLIENT SERVICES DIRECT WATS LINE 800-922-9422 CLAIMS 800-531-5442 WWW.NATIONALWESTERNLIFE.COM ~~ NATIONAL WESTERN ~~ ~® LIFE INSURANCE COMPANY • Re: Delores Bailey annuities Non-Qualified Annuity Certificate No. 01011529006 Cash Value of $6949.74 payable lump sum or Account Value of $7315.52 under a minimum 5 year fixed period payout. The tax cost basis is $5027.58 Immediate Annuity No. 0101152907 This annuity provided a monthly payment of $84.09 to Mrs. Bailey fora 5 year period beginning December i , 'L006 and the final payment. being made for November 1, 20.11 which terminated all payments due. Individual Retirement Annuity Certificate No. 01011529008 Cash Value of $41657.06 payable lump sum or the Account Value of $43849.54 payable under a minimum 5 year fixed period. The death benefit will be reported as fully taxable income to each of you. Claim forms are enclosed. After making your election, complete and return the applicable form(s) for the option elected. Only one original (certified) death certificate for Mrs. Bailey is required so please coordinate which beneficiary will be responsible for providing this document. We may be reached at 800-531-5442, ext. 585, with any questions. National Western Life Policy Benefit Department DK 850 EAST ANDERSON LANE AUSTIN, TEXAS 78752-1602 512-836-1010 AUTOMATED VOICE RESPONSE TOLL-FREE 888-695-5001 WATS 800-531-5442 CLIENT SERVICES DIRECT WATS LINE 800-922-9422 CLAIMS 800-531-5442 VVWV(! NATIONALWESTERNLIFE.COM E. Thomas Henefer Attorney I.D. No. 55773 111 North Sixth Street P.O. Box 679 Reading, PA 19603-0679 (610) 4782000 Attorneys for Plaintiff IN THE COYJRT OF COMMON PLEAS OF CUMBERLAND COUNTY LIFE INSURANCE COMPANY OF THE SOUTHWEST, . Plaintiff, CIVIL ACTION v. No. M1NDY DEATRICK, KIMBERLY . PAULUS, ALECIA BAGROSKY, and GWENDOLYN BARRICK, Defendants. COlV:[PLAINT Plaintiff Life Insurance Company of the Southwest ("LS~V") files this Complaint for interpleader relief against Defendants Mindy Deatrick, Kimberly Paulus, Alecia Bagrosky and Gwendolyn Warrick, and in support of its Complaint, LSW avers as follows: Parties 1. LSW is a life insurance company domiciled in Texas with its principal place of business at 15455 Dallas Pkwy., Ste. 800, Addison, TX 75001. LSW is engaged in, among other things, the sale of life insurance policies and annuities. 2. Mindy Deatrick is an adult individual residing at 147 Liberty Valley Dr., Ickesburg, Pennsylvania. 3. Kimberly Paulus is an adult individual residing at 2536 Ritner Hwy Lot 105, Carlisle, Pennsylvania. SLl 1170435v 1 101789.00007 4. Alecia Bagrosky is an adult individual residing Mt. Holly Springs, Pennsylvania. 5. Gwendolyn Barrick is an adult individual residing at 61 Fickes Road, Newville, Pennsylvania. Facts 6. At all times relevant to this action the late Delores J. Bailey resided at 287 Meadows Road, Newville, Pennsylvania. 7. Defendants Mindy Deatrick, Kimberly Paulus, Alecia Bagrosky and Gwendolyn Barrick are Delores J. Bailey's daughters. 8. Delores J. Bailey was the owner of two annuities issued by L`SViT bearing contract nuxnbers 709637X and 681235X (hereinafter, the "Annuities"). Annuity No. 709637X has a value of $18,999.79 and Annuity No. 681235X has a value of $31,511.55. The combined value of the Annuities is therefore $50,511.34. 9. True and correct copies of the Annuities (with personal identification data redacted) are attached hereto as Exhibits A and B, respectively. 10. When the Annuities were first issued, Delores J. Bailey designated the following beneficiaries in the following percentages: (a) Mindy Deatrick - 40% (b) Kimberly Paulus - 40% (c) Alecia Bagrosky -10% (d) Gwendolyn Barrick -10% 11. A true and correct copy of the original beneficiary designation (with personal identification data redacted} is attached as Exhibit C. 2 SL11170435v1 ]01789.00007 ~~ INSURANCE~COM ~~Y March 15, 2012 ALECIA K BAGROSKY PO BOX 226 MOUNT HOLLY SPRINGS PA 17065-0226 RE: DECOKES J BAILEY, deceased _ _ .._ _ __ _ -~ - - -POLICY:...-_--- 0~{ X1(76853 _ CLAIM: 0000042556 Dear ALECIA K BAGROSKY: Enclosed is the claim proceeds check .payable for this policy. The amount of the death beneftt consists of: Face Amount of Policy ~ $77,246.00 Refund of MAV Charge ~ 91.32 Settlement Interest _ 627.18 TOTAL PAYABLE 77,964.50 Minus Proceeds Payable to Other Beneficiary(ies) (51,976.34} TOTAL PAYABLE TO YOU S 25,988.16 If you have questions, please contact me at (800) 848-5433, ext. 2059. Sincerely, Cassie Bryant Life Undewriter I Enclosure(s) cc: MILLARD G ENGLE . S 140 RICE RD SHIpPENSBURG, PA 17257-9349 P.O. BOX 12847 • ROANOKE, VIRGINIA 24029 • (800) 848-5433 • fax: (540) 857-5957 • www.shenlife.com -.._, ~wing Brothers l+'uneral Home, lnc. _' 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 October 26, 2011 Alecia Bagrosky P. O. Box 226 Mount Holly Springs, PA 17065 The Funeral Service for Delores J. Bailey We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff , $1865.00 Embalming, $895.00 Dressing, Casketing, Cosmo etc. $290.00 2. FACILITIES AND SERVICES Viewing (Visitation/Wake) , $495.00 Funeral Ceremony, $495.00 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home, $275.00 Hearse (Casket Coach) $275.00 SafetyLead car/Clergy $125.00 Utility vehicle for DC filing, $125.00 FUNERAL HOME SERVICE CHARGES $4840.00 SELECTED MERCHANDISE: 20G Silver Hammertone Casket 20NG, $925.00 Acknowledgement cards , $10.00 Register Book(s) $40.00 Memorial folders , $85.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $5900.00 Cash Advances Certified Copies of the Death Certificate , $48.00 The Sentinel Obit with photo $154.34 The Valley Times Star/ShippChronicle $60.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . $262.34 Total Total Cost $6162.34 .......... ~~P~~ .~„ SUB-TOTAL $6162.34 INITIAL PAYMENT /DISCOUNT /CREDITS 5318.71 TOTAL AMOUNT DUE ~$ The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum. ~~ 1 h..fl w~ ~~8. ~ ~~fl/J~ ~~~1t~rrAl~o: ~ ~~~~`~'` ~/may. 31/ Q ~ v~ T'o 6e~L~~e„~ a..n `-~k i .Af ~~~kY` r _:1.r~w~~.. '~~ r iS~a~F~x*f~~`~,rs ~~s~.. ~'. • ' I ~5~ • R` , F ~ ~ a o . . ~ ~ . . 7. . ~ .. .H •~ ,r ~ Y, _ ri ~, ~* o ~ '~ •'• t ~ O • ,.Y ~11.;' ;e~ ~~ ~ •ic . . .. ~ . ~ ~; • l • ~' • • • • • O ~ I l.1. • r •~ .~ ZI ~. r t~ ~ • ' s O f , R ' ~• ~ ,,[;. I~.. ~. .ate. O ~ p..+ ~:' 1 ~'~'..~.-.~ i K ~ f" .owC ' ~ ~ H O • b~z~;pr'u ; o +~ ~ ~ , ~ ~ QZ ~ ~ a pZj p'1--~ C7 .. F~~',; by . ft .Q•1 O O ^ r ~1 rf f Vt.~~ ~ .. 4 W ~.~i~J .. (1 IRUITIN ~ McIQVIGHT WEST POMFRET PROFESSIONAL BUILDING 60 WEST POMFRET STREET CARLISLE, PENNSYLVANIA 17013-3222 MS DECOKES BAILEY Matter No. 7485-1 Estate Planning Fees: 10/ 19/ 11 MAM TraveUmeeting with Delores and family 10/19/11 MAM Telephone call with family Telephone call with Attorney Maxwell Hours: Total fees: Payments & Adjustments: 10/ 14/ 11 Payment -Thank you. Total payments & adjustments: Billing Summary Previous balance $1,012.50 Payments & adjustments 1,012.50 CR Current fees & expenses 312.50 Total now due $312.SQ` Due date 11/21/11 October 31, 2011 7485-1 Hours/Rate 1.00 $250.00/hr 0.25 $250.00/hr 1.25 $250.00 $62.50 1 0 $1,012.50 CR $1,012.50 CR ACCOUNTS DUE BEYOND 90 DAYS ARE CHARGED INTEREST AT THE RATE OF 18% PER ANNUM IR ~ McIQVIGHT WEST OMFRET PROFESSIONAL BUILDING 60 W ST POMFRET STREET CARLISLE, PENNSYLVANIA 17013-3222 MS DECOKES BAILEY Matter No. 7485-1 Estate Planning Late Payment Charge Fees unpaid over 90 days $312.50 Expenses unpaid over 90 days 0.00 Late charges unpaid over 90 days 9.3 8 Total unpaid over 90 days $321.88 Late payment charge of 1.50% $4.83 Billing Summary Previous balance $331 26 Payments & adjustments . 0 00 Late payment charge . 4.83 Current fees & expenses 0.00 Total now due $336.09 Due date 06/21 / 12 ACCOUNTS DUE BEYOND 90 DAYS ARE CHARGED INTEREST AT THE RATE OF 18% PER ANNUM May 31, 2012 7485-1 FOR YOUR CONVENIENCE WE ACCEPT VISA, MASTERCARD AND DEBIT CARD PAYMENTS .a IRVITII~T ~~ McKNIGHT, P. C. WEST P~MFRET PROFESSIONAL BUILDING 60 WEST POMFRET STREET CARLISLE, PENNSYLVANIA 17013-3222 ALECIA BAGROSKY GWEN BARRICK December 13, 2012 KIMBERLY PAULUS 7485-1 Matter No. 7485-1 Estate Fees: Hours/Rate 11 /2 7/ 12 MAM Telephone call with attorney 0.20 $50.00 $250.00/hr 11/28/12 MAM Prepar'ation/Settlement Conference 2.50 $625.00 $250.00/hr 11/29/12 MAM Prepare Release 1.00 $250.00 $250.00/hr 11/29/12 MAM Review/revise Release 0.50 $125.00 $250.00/hr 12/10/12 MAM Conference with clients Letters to attorneys 1.25 $312.50 $250.00/hr 12/12/12 MAM Letter and telephone call to Katie Maxwell Es , q. 0.50 $125.00 $250.00/hr Hours: 5.95 Total fees: $1,487.50 Matter No.~7485-1 Estate ®" ' ` Billing Summary December 13, 2012 Page 2 Previous balance $0.00 Payments & adjustments 0.00 Current fees & expenses 1 487.50 Total now due $1,487.50 Due date 01 /03/ 13 ACCOUNTS DUE BEYOND 90 DAYS ARE CHARGED INTEREST AT THE RATE OF 18% PER ANNUM FOR YOUR CONVENIENCE WE ACCEPT VISA, MASTERCARD AND DEBIT CARD PAYMENTS IRT~ITIN ~ McIQVIGHT, P. C. WEST POMFRET PROFESSIONAL BUILDING 60 WEST POMFRET STREET CARLISLE, PENNSYLVANIA 17013-3222 ALECIA BAGROSKY GWEN BARRICK KIMBERLY PAULUS Matter No. 7485-1 Estate December 19, 2012 7485-1 Fees: Hours/Rate 12/17/12 MAM Letter to Attorney Maxwell, Letter to Attorney 0.50 $125 00 Henefer $250.00/hr . Telephone call with Attorney Henefer Hours: 0.50 Total fees: $125.00 Payments & Adjustments: 12/14/12 Payment -Thank you. $675.00 CR Total payments & adjustments: $675.00 CR Billing Summary Previous balance $1,487.50 Payments & adjustments 675.00 CR Current fees & expenses 125.00 Total now due $937.50 Due date 01/09/13 ACCOUNTS DUE BEYOND 90 DAYS ARE CHARGED INTEREST AT THE RATE OF 18% PER ANNUM FOR YOUR CONVENIENCE WE ACCEPT VISA, MASTERCARD MUTUAL RELEASE This MUTUAL RELEASE is entered into b ~~ C ~~ ~ ~ ~ 2012 Y the parties this ~ day of ~~e---~; by and between ALECIA K. BAGROSKY, GWENDOLYN A BARRICK AND KIMBERLY D. PAULUS, Co-Executors of the Estate of DECOKES J. BAILEY and beneficiaries of certain Insurance Policies and annuities of DECOKES J. BAILEY D and MINDY S. DEATRICK, daughter of Delores J. Bailey and sister of the a eceased individuals. bove named WHEREAS, MINDY S. DEATRICK received by gift an ownership interest in the real estate located at 429 Dogwood Court, Carlisle, PA 17015, and WHEREAS, thereafter DECOKES J. BAILEY named ALECIA K. BAGROSKY GWENDOLYN A. BARRICK and KIMBERLY D, PAULUS, Co-Executors and beneficiaries of her estate and certain life insurance policies and annuities includin Monumen Life Insurance Policy 220015380 and Life Insurance Company of the Southwest g tal numbered 709637X and 681235X annuities NOW, therefore, intending to be legally bound the parties agree as follows: 1. The Estate of DECOKES J. BAILEY and ALECIA K. BAGROSKY, GWENDOLYN A. BARRICK and KIMBERLY D. PAULUS do release any claim with respect to the real estate situated at 429 Dogwood Court, Carlisle, PA 17015, which was conveyed to MINDY S. DEATRICK and her husband LARRY D. DEATRICK on July 2, 2010, including but not limited to any claim for reimbursement for inheritance tax paid by the estate. 2. MINDY S. DEATRICK does hereby withdraw her claims and objections to the Estate of Delores J. Bailey and all beneficiary designations on all her policies of insurance and insurance annuities including, but not limited to Monumental Life Insurance Policy 220015380 and Life Insurance Company of the Southwest Annuities numbered 709637X and 681235X. ALECIA K. BAGROSKY will inform her employer, Pennsy Supply, by written communication, that any and all disputes she has with MINDY S. DEATRICK have been fully resolved, and that their relationship is such that it will not negatively affect her abilit as an employee of Pennsy Supply, to interact with MINDY S. DEATRICK in the course of such employment. 3. The parties will sign all documents required to implement this MUTUAL RELEASE AGREEMENT. 4. In consideration of the Mutual Agreement and Release made by the parties. The Estate of Delores J. Bailey will pay to MINDY S. DEATRICK the sum of Ten Thousand and no/100 ($10,000.00) Dollars on or before December 21, 2012. 5. This Mutual Release is binding upon the parties, the Estate of Delores J. Bailey, their heirs and assigns. In the event of any litigation arising out of, or relating to this Mutual Release the prevailing party shall be entitled to recover from the non-prevailing party all costs and expenses incurred by the prevailing in such proceeding including, but not limited to, reasonable attorney fees. Intending to be legally bound the parties enter their hands and seals the date set forth below: The Estate of Delores J. Bailey And the Undersigned Individuals: ~. (SEAL) ALECIA . BAGR SKY ~" AL) GWENDOL A. BARRICK Witnessed: HIMBERLY D. PAULUS ~ L) IND S. + CK COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS: ~~ ~~~~~ On this ~ day of leer. 2012, before me the unsigned officer, a notary public, personally appeared, ALECIA K. BAGROSKY, GWENDOLYN A. BARRICK and KIMBERLY D. PAULUS, known to me (or satisfactorily proven) to be the same person whose names appear above, and they acknowledge that they execute this Release for the purposes herein contained. COMMONWEALTH OF PENNSYLVANIA Notarial Seal Karen 5. Noel, Notary Public CarNsle Bono, Cumberland County My Commission Expires Dec 8, 2015 MEMBER, PENNSYLVANIA ASSOQATION OF NOTARIES COMMONWEALTH OF PENNSYLVANIA : COUNTY OF CUMBERLAND SS: cl ~ce~ber On this _~~ day of peer. 2012, before me the unsigned officer, a notary public, personally appeared, MINDY S. DEATRICK, known to me (or satisfactorily proven) to be the same person whose name appears above, and she acknowledge that she execute this Release for the purposes herein contained. ~ ~-Pi No ar ublic COMMONWEALTii OF PENNSYLVANIA Notarial Seal Mary M. Price, Notary Pubiie Carlisle Bono, Cumberland County My Commission Expires Aug. 1$, 2015 MEMBER, PENNSYLVANIA ASSUUA7ION 4r NOTARIES