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1505610143
REV-1500 Ex (oz OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENTO REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 12 0726
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
502 30 8261 06 27 2012 04 08 1933
Decedent's Last Name Suffix Decedent's First Name MI
RASMUSSEN ADIS A
(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 ❑ 5. Federal Estate Tax Return Required
❑ (date of death after 12-12-82)
x❑ B Decedent Died Testate ❑ 7. DecedeptoMaint Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach py Trust)
❑ 9. Litigation Proceeds Received ❑ 10. bgtweeni2ver%~re liitjDatte of Death ❑ 11. Election to tax under Sec. 9113(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 717 249 6333
( TER OF`WILLAS NLY
=3 C'>
M ~
First Line of Address
354 ALEXANDER SPRING RO Cf)
M_' C>
Second Line of Address :.a
DATE VILE ) 1
City or Post Office State ZIP Code a tom) {n
CARLISLE PA 17015 co
Correspondent's e-mail address: gdouglas@salzmannhughes.com
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 PERSON RESPONSIBLE FOR FILING RETURN DATE
`~Yniwj: John E. Eng a
ADDRESS
907 Castlerock Way, Mcdonough, GA 30253
SIGNATURE OF PREPARER OTHER THAN REPRE ENTATIVE DAT
G George F Douglas, III Esq. 1
ADDR SS
354 Alexander Spring Road, Suite 1, Carlisle, PA
Side 1
1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Rasmussen, Adis A. 502 30 8261
RECAPITULATION
1. Real Estate (Schedule A) 1.
2. 24,994.92
2. Stocks and Bonds (Schedule B)
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. 28,457.96
6. Jointly Owned Property (Schedule F) ❑ Separate Billing Requested............ 6. 103,804. 96
7. Inter-Vivos Transfers & Miscellaneous -Probate Property
(Schedule G) Separate Billing Requested............ 7. 8,705.59
8. Total Gross Assets (total Lines 1 through 7) 8. 165,963. 43
9. Funeral Expenses and Administrative Costs (Schedule H) 9. 271 735 . 88
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule 1) 10. 1 , 430 . 30
11. Total Deductions (total Lines 9 and 10) 11. 29, 166. 18
12. Net Value of Estate (Line 8 minus Line 11) 12. 136, 797 .25
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. 136,797.25
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 0.00
(a)(1.2) X.00 15.
16. Amount of Line 14 taxable 136, 797 .25 16. 6,158.88
at lineal rate X .045
17. Amount of Line 14 taxable 0.00 17. 0.00
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15 0.00 18. 0.00
19. TAX DUE 19. 6,155.88
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-12-0726
Decedent's Complete Address:
DECEDENT'S NAME
Rasmussen, Adis A.
STREET ADDRESS
801 N. Hanover Street
CITY STATE __tilP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 6,155.88
2. Credits/Payments
A. Prior Payments 6,000.00
B. Discount 307.79
Total Credits (A + B) (2) 6,307.79
3. Interest (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 151.91
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)
Make Check Pa Payable to: REGISTER OF WILLS, AGENT.
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 ❑ lxl
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? ❑ ❑x
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑
4. Did decedent own an individual retirement account, annuity, or other non-probate property which
contains a 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.
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-1503 EX+ (6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 456.862 shares of Oppenheimer Global Fund Class A; 54.71 24,994.92
Account No. 003303300138303
TOTAL (Also enter on Line 2, Recapitulation) 24,994.92
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98)
Rev-1508 EX+(11-10)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-46 1,578.54
Accrued interest on Item 1 through date of death 0.90
2 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-47 1,029.64
Accrued interest on Item 2 through date of death 0.44
3 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-48 514.81
Accrued interest on Item 3 through date of death 0.22
4 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-49 514.81
Accrued interest on Item 4 through date of death 0.22
5 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-50 6,177.96
Accrued interest on Item 5 through date of death 2.64
6 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-51 5,148.29
Accrued interest on Item 6 through date of death 2.20
7 Members 1st Federal Credit Union, Certificate of Deposit No. 29586-52 514.46
Accrued interest on Item 7 through date of death 0.22
8 Members 1st Federal Credit Union, Checking Account No. 29586-11 1,746.53
9 Members 1st Federal Credit Union, Savings Account No. 29586-00 1,486.67
Total of Continuation Schedule See attached page
TOTAL (Also enter on Line 5, Recapitulation) 28,457.96
(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 E (Rev. 11-10)
Rev-1508 EX+(11-10)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN continued
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Accrued interest on Item 9 through date of death 0.26
10 Bank of America NA - refund of credit 3.00
11 Commonwealth of Pennsylvania - return of unclaimed property, MetLife dividend 13.52
12 The Church of God Home, Inc. - refund of credit 8,605.33
13 USAA - refund of unused insurance premium 1,117.30
TOTAL (Also enter on Line 5, Recapitulation) 28,457.96
Copyright (c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 11-10)
Rev-1509 EX+(01-10)
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
If 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. Betty Jo Eng 907 Castlerock Way Daughter
Mcdonough, GA 30253
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY % OF DATE OF DEATH
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S DECEDEVALUE OF
NT'S INTEREST
NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSE INTEREST
TENANT JOINT JOINTLY-HELD REAL ESTATE.
1 A 01/01/1975 PNC Bank, Checking Account No. 207,609.92 50.000% 103,804.96
5140189784
TOTAL (Also enter on Line 6, Recapitulation) 103,804.96
(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)
Rev-1510 EX+ (08-09)
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
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 DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE ONAME F TRANSFER. A COPY OF THE DEIED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Allstate Life Insurance Company, Annuity Contract 8,705.59 100.000% 8,705.59
No. GA16881281 -decedent's children are the
beneficiaries: Betty Jo Rasmussen Eng, Ronald
Richard Rasmussen, Jr. and Mary Ellen Rasmussen-
Flores
TOTAL (Also enter on Line 7, Recapitulation) 8,705.59
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 08-09)
REV-1151 EX+ (10-09)
SCHEDULE H
COMMONWR~ ALTCHFq~PENNgUYLVANIA FUNERAL EXPENSES AND
IN RESIDENTEDECEDENTRN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 21,232.72
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s) Commission Paid
2. Attornev's Fees Salzmann Hughes, P.C. 5,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ZiD
RelationshiD of Claimant to Decedent
4. Probate Fees 377.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 1,125.66
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 27,735.88
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
Rasmussen, Adis A. 21-12-0726
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 CTOF, Carlisle Barricks Church - Carlisle, PA funeral services 1,000.00
2 Ewing Brothers Funeral Home - Carlisle, PA funeral services 2,921.52
3 John and Betty Jo Eng - reimbursement for funeral travel 4,365.00
4 Laura Douglas - Carlisle, PA catering service for funeral luncheon 500.00
5 Mary Flores - funeral expenses and travel 5,825.92
6 Ralph Knuream - Carlisle, PA organ music for funeral services 150.00
7 Rev. Tim Sadler - Carlisle, PA funeral services 300.00
8 Rick Halac - Carlisle, PA videographer for recording funeral service for absent family 75.00
members
9 Ronald Richard Rasmussen, Jr. - reimbursement for funeral travel 4,420.05
10 Rosehill Memorial Park - setting the monument grave marker 120.00
11 St. Paul's Lutheran Church - Carlisle, PA funeral services 1,000.00
12 Thompson-Larson Funeral Home - balance due for funeral services in North Dakota 555.23
H-A 21,232.72
Other Administrative Costs
13 Register of Wills - filing fees 30.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
ITEM
NUMBER DESCRIPTION AMOUNT
14 Salzmann Hughes, P.C. - reimbursement for probate expenses reimbursement for payment 75.00
to Cumberland Law Journal for legal advertising
15 Salzmann Hughes, P.C. - closing costs and final fees for income tax preparation, postage 800.00
and miscellaneous contingencies in order to administer the estate
16 Salzmann Hughes, P.C. - reimbursement for Fed Ex mailing 20.50
17 The Sentinel - Legal advertising 200.16
H-67 1,125.66
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+ (12-08)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES AND LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rasmussen, Adis A. 21-12-0726
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 Alert Pharmacy Services, Inc. - balance due on account for prescription drugs 23.70
2 Defense Finance and Accounting Service - reimbursement for overpayment of monthly USA 1,395.40
Annuity payments after death
3 Philhaven - balance due on account 11.20
TOTAL (Also enter on Line 10, Recapitulation) 1,430.30
(if more space is needed, additional pages of the same size)
Copyright (c) 2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+ (01-10)
C~{E~F g SCHEDULE J
COMMORNEWE~ N TCEEEETJURNANIA BENEFICIARIES
ESTATE OF r~ T FILE NUMBER
Rasmussen, Adis A. 21-12-0726
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words)
Do Not Lust Trustee(s) I~ TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
1 Barbara Ann Rasmussen Gulden Daughter
predeceased the Testatrix on 1/1/2011 - leaving
no issue
2 Betty Jo Eng Daughter Schedule F 114,802.39
907 Castlerock Way 1/3rd Sch G
Mcdonough, GA 30253 113rd Residue
3 Ronald Richard Rasmussen, Jr. Son 1/3rd Sch G 10,997.43
635 Paisley Dr. 1/3rd Residue
Colorado Springs, CO 80906
4 Mary Ellen Rasmussen-Flores Daughter 113rd Sch G 10,997.43
P.O. Box 333 1/3rd Residue
865 Main St.
Clio, CA 96106
Total 136,797.25
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate.
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 SHEET
Copyright (c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 01-10)
LAST WILL AND TESTAMENT
OF
ADIS ANN RASMUSSEN
I, ADIS ANN RASMUSSEN , a legal resident of the City of CARLISLE,
County of CUMBERLAND, State of PENNSYLVANIA, being of sound and disposing
mind and memory, and not acting under duress, coercion or undue influence
of any person whomsoever, do hereby make, publish and declare this instrument
as my Last Will and Testament, hereby revoking all wills and codicils to
wills previously made by me.
ARTICLE I
I direct that all estate, inheritance and other death taxes payable
by reason of my death on any property included in my estate for tax purposes
shall be paid out of my residuary estate as an expense of administration,
without contribution from any person, and without apportionment.
ARTICLE II
My children now living are BETTY JO RASMUSSEN ENG, born February 18,
1953, BARBARA ANN RASMUSSEN, born June 19, 1954, RONALD RICHARD RASMUSSEN, JR.
born April 26, 1958 and MARY ELLEN RASMUSSEN, born October 17, 1961. I intend
the provisions of my will to apply to such children as well as any children
subsequently born to or legally adopted by me. My personal representatives
and trustees (subsequently called my executor or executrix, or trustee)
may rely on such dates of birth for any purpose.
ARTICLE III C)
7DO
G _T
I give all my tangible personal property together with any insurance
policies and claims under such policies on such property, except such property _ F,
used in any business in which I may have an interest, to my children who
survive me in shares of substantially equal value, to be divided among
them as they, and such other person as my personal representative may select CjC:
to represent any child of mine believed by my personal representative to
be incapable of acting in his own best interest, shall agree. In case
my children and such other person do not agree within six months after A o Q
my death as to the division among them, my personal representative shall
make the division. Notwithstanding the foregoing, should my personal representative,
in his sole judgment, determine that it would not be in the best interest
of my children to receive possession of any item of such property, such
as an automobile, my personal representative may sell such item and add
the proceeds to my residuary estate.
ARTICLE IV
I give, devise and bequeath all of the rest, residue and remainder
of my estate and property of which I may be seized or possessed or to which
I may be entitled at the time of my death, of whatsoever nature and wheresoever
situated, be it real, personal or mixed, including lapsed legacies and
any property over which I may have power of appointment, forever and in
fee simple, in equal shares to my children but if any of my children
shall not survive me then to the issue of such child or children who shall
survive me such issue to take per stirpes.
PAGE ONE OF FOUR PAGES
r-W7
s
ARTICLE V
In the event my children nor the issue of my children do not survive
me, then I give, devise, and bequeath all my property be it real, personal
or mixed, of whatsoever nature and wheresoever situated, forever and in
fee simple, to my son-in-law, JOHN EDWARD ENG, provided he shall survive
me.
ARTICLE VI
I hereby appoint my son-in-law, JOHN EDWARD ENG, as Executor of this
my Last Will and Testament. In the event that he shall predecease me
or shall for any reason refuse or be unable to serve or continue serving
as Executor hereof, then I hereby appoint my daughter, BETTY JO RASMUSSEN,
as Alternate Executrix.
ARTICLE VII
I direct that no executor, executrix, guardian or conservator, or
any successor, shall be required to give any bond in any jurisdiction
and that if, notwithstanding this direction, any bond is required by any
law, statute or rule or court, no sureties be required. I desire that
bond be waived to the full extent permitted by law.
ARTICLE VIII
In administering my estate, my executor or executrix (as the case
Y may be) may exercise the following powers: hold, retain, invest, reinvest
and manage without diversification as to kind, amount or risk of nonproductivity
in realty or personalty and without limitation by statute or rule or law;
partition, sell, exchange, grant, convey, deliver, assign, transfer, lease,
option, mortgage, pledge, abandon, borrow, loan, contract, distribute
in cash or kind or partly in each at fair market value on the date of
distribution and without requiring pro rata distribution of specific
assets, hold in nominee form, continue businesses, carry out agreements,
deal with itself, other fiduciaries and business organizations in which
fiduciaries may have an interest, establish reserves, release powers,
and abandon, settle or contest claims.
In addition, if I die domiciled in Colorado, or if the situs of administration
is in Colorado, my fiduciaries may also exercise all the powers in the
Colorado Fiduciaries Powers Act, as amended after the date of my will
and after my death. If I do not die domiciled in Colorado or if the situs
of administration of my will is outside Colorado my fiduciaries may also
exercise all the powers in the Colorado Fiduciaries Powers Act which I
incorporate in my will as the Act exists on the date of my will.
ARTICLE IX
In the event that I shall die leaving a minor child or children surviving
me, I hereby appoint my daughter, BETTY JO RASMUSSEN ENG as Guardian of
the person and property of each minor child of mine who shall survive
me, during his or her minority. In the event that she shall predecease
me or shall for any reason refuse or be unable to serve or to continue
serving as Guardian, then I appoint my son-in-law, JOHN EDWARD ENG as
Alternate Guardian, with the same powers and authority.
PAGE TWO OF FOUR PAGES
s~
ARTICLE X
Adopted Children: A child adopted by any person and the descendants
by blood or adoption of such child shall be considered descendants of
such person and of such person's ancestors if the adoption is by legal
proceeding while the child is under twenty-one years.
ARTICLE XI
Unless the context requires otherwise, words denoting the singular
may be construed as denoting the plural, wandswofds one of g he pluralbeaconstrued
construed as denoting the singular, and
as denoting such other gender as is appropriate.
ARTICLE XII
Wherever in this my Last Will and Testament it is provided that any
person shall benefit hereunder if such person shall survive me, such person
shall be deemed not to have survived meoifahetor s e shall dieIeithein
within sixty (60) days after my death, a common disaster
diedcircumstances that it is difficult
ussuch
dewith termmne which of under
or impossible to
IN WITNESS WHEREOF, I sign, seal, publish and declare this as my Last
Will and Testament in the presence of the persons witnessing it at my request
this a~ r day of 1\ n 19 at ?ro
Signature of Testatrix
The foregoing instrument, consisting of four typewritten pages, was this
199, signed, sealed, published, and declared
by day of a
by the said 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 subscribed our names as witnesses thereto.
WITNESSES: ADDRESSES:
p~ 5d- r1-
y
PAGE THREE OF FOUR PAGES
We, 144 Rnn QSNussen. and
S the testatrix and the witnesses, respectively,
whose names are signed to the attached or foregoing instrument, being first
duly sworn, do declare that the foregoing instrument was signed, published
and declared by the testatrix, as and for her Last Will and Testament, in the
presence of the witnesses, who at her request and in her presence, and in the
presence of each other, have subscribed their names to this instrument as
attesting witnesses on the day and year last above written; and that the
testatrix executed the foregoing instrument as her free and voluntary act for
the purposes therein expressed; and that to the best of our knowledge, opinion
and belief the testatrix was at the time eighteen years of age or older, of
sound and disposing mind and memory and under no constraint or undue influence.
"rteaKU""Jgnature of Testatrix
Signature of Witness
Signature of Witness
..i Signature of Witness
State of Colorado )
ss
County of El Paso )
Subscribed, sworn to and acknowledged before me by ; f,, ~q'3 r*LksseV
the testatrix, and subscribed and sworn to b fore me by
~l~n~ E• Gu euLt andi~,r~ witnessessgp-~ ay
of lg?f.
NOTARY PUBLIC
My Commission Expires: I,1id-Ig
PAGE FOUR OF FOUR PAGES
OppenheimerFunds
OppenheimerFunds Services
AugUSt 8, 2012 A Division of OppenheimerFunds, Inc.
P.O. Box 5270
Denver, CO 80217-5270
www.oppenheimerfunds.com
GEORGE F DOUGLAS
SALZMANN HUGHES PC
354 ALEXANDER SPRING RD STE 1
CARLISLE PA 17015
Dear Mr. Douglas:
We received your request for information concerning Adis Ann Rasmussen's
OppenheimerFunds account. Please extend our condolences to the Rasmussen family for their
loss.
As of June 27, 2012, the total dollar value of account number 003303300138303 was
$24,994.92, based on 456.862 shares and a share price of $54.71 per share at Net Asset Value.
We hope you find this helpful. If you have any questions, please email us via the "Contact Us"
section of our website, www.oppenheimerfunds.com, or call us at 1-800-CALL-OPP (225-5677).
We are available Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern Time.
Sincerely,
Carly Riffel
OppenheimerFunds, Inc.
The Right Way to Invest
1DOC# 205665508
St
MEMBERS 1St
FEDERAL CREDIT UNION
SAVINGS ACCOUNT:
Account Number/Suffix 29586-00
Date Account Established 06/30/1982
Principal Balance at Date of Death $1,486.67
Accrued Interest to Date of Death $.26
Total Principal and Accrued Interest $1,486.93
Name of Joint Owner None
CHECKING ACCOUNT:
Account Number/Suffix 29586-11
Date Account Established 05/16/1984
Principal Balance at Date of Death $1,746.53
Accrued Interest to Date of Death $.00
Total Principal and Accrued Interest $1,746.53
Name of Joint Owner None
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 29586-46 29586-47 29586-48
Date Account Established 03/05/2010* 04114/2010** 04/14/2010***
Principal Balance at Date of Death $1,578.54 $1,029.64 $514.81
Accrued interest to Date of Death $.90 $.44 $.22
Total Principal and Accrued Interest $1,579.44 $1,030.08 $515.03
Name of Joint Owner None None None
*Rollover from certificate 29586-44, originally established 04/01/2009.
**Rollover from certificate 29586-43, originally established 09/11/2008.
-Rollover from certificate 29586-43, originally established 09/11/2008.
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 29586-49 29586-50 29586-51
Date Account Established 04/14/2010* 04/14/2010** 04/14/2010***
Principal Balance at Date of Death $514.81 $6,177.96 $5,148.29
Accrued Interest to Date of Death $.22 $2.64 $2.20
Total Principal and Accrued Interest $515.03 $6,180.60 $5,150.49
Name of Joint Owner None None None
*Rollover from certificate 29586-43, originally established 09/11/2008.
**Rollover from certificate 29586-43, originally established 09/11/2008.
-Rollover from certificate 29586-43, originally established 09/11/2008.
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 29586-52
Date Account Established 05/28/2010*
Principal Balance at Date of Death $514.46
Accrued Interest to Date of Death $.22
Total Principal and Accrued Interest $514.68
Name of Joint Owner None
*Opened by transfer of funds from 29586-11.
b~E R S 1sT FEDERAL CgEDIT NIO
Danielle A. Kline
Lending Insurance Support Specialist
July 18, 2012
Estate of: ADIS A. RASMUSSEN
Date of Death: 06/27/2012
Social Security Number: 502-30-8261
5000 Louise Drive • P.O. Box 40 • Mechanicsburg, Pennsylvania 17055 • (800) 283-2328 • www.memberslst.org
Jul, 16. 2012 1:04PN1 PNC No. 0874 P. 2
1&21PN'C
July 16, 2012
George 1: Douglas 111, Esquire
Attorney at Law
354 Alexander Spring Rd Ste 1
Carlisle PA 17015
RE: Adis A RasrnusseTi
SSN: 502-30-8261
DOD: 06/27/2012
Dear Sir/Madam:
In response to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
Checking Account Established: 01/0111975
Account # 51401897$4
ADIS A RASMUSSEN
SETT Y J ENG
DOD balance: $207,608.69 + 1,23 accrued interest
interest Paid 01-01-2012 thru 06-27-2012 $5.49 YTD
Investment Account
The decedent maintained Investment Account 1776866. For further information, you may call the
Brokerage Department at 1-800-762-6111. Per PNC broker - this housed the Allstate
Annuity. Nothing else in account.
Safe Deposit Box
The decedent maintained safe deposit box 040-176-Z43
located at:
Carlisle Branch
105 Noble Blvd
Carlisle PA 17013
(717) 243-6021
Page 1 of 2
7/20/2012 9:44:48 AM PAGE 2/013 Fax Server
U40
`OLIN. in good hands.
July 20, 2012
Mr. George F. Douglas, III, Esquire
Salzmann Hughes, P.C.
354 Alexander Spring Rd. Suite #1
Carlisle, PA 17015
Via Facsimile #1-717-249-7334
Re: Adis A. Rasmussen
Contract No: GA16881281
Dear Ms. Gulden:
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. 1 can, however, provide the
following information for estate purposes:
Date of Death: June 27, 2012
Annuity Value as of Date of Death: $ 8,705.59`
Cost Basis: $ 0.00
Named Beneficiary: Barbara Rasmussen Gulden (pre-deceased)
Contract Default "spouse; if not living, then,
children; if not living, then the Estate of Adis A.
Rasmussen"
*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. 24522.
Sincerely,
Lin Breckler
Sr. Claim Examiner
Allstate Life Insurance Company
Life and Annuity Claims
P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523