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HomeMy WebLinkAbout04-08-13 1505610105 REV-1500 Exte=_ ,tFi, lvania OFFICIAL USE ONLY PA Department of Revenue P enns P F Y Bureau of Individual Taxes ,.o County Code Year File Number PO BOX28o6ot INHERITANCE TAX RETURN , Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 02/24/2011 05/20/1950 Decedent's Last Name Suffix Decedent's First Name MI O'Brien Robert F (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI O'Brien Deborah Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Cl 1. Original Return p 2. Supplemental Return p 3. Remainder Return (Date of Death Prior to 12-13-82' O 4. Limited Estate 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 1 _ 8 Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule C) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Richard L. Placey, Esq. (717) 236-9577 REIZIS)�Il OF Wll_LS U ESU Es 01d1l J First Line of Address C Placey & Wright f c:0 Second Line of Address tiF - 3621 North Front St. ry City or Post Office State ZIP Code = :}DATE FILED tmm- Harrisburg PA 17110 - =� Correspondent's e-mail address: pwiaw @epix.net Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the bes;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 t as any knowledge. GtNATURE OF RE$SQr4 RESPONSIBLE FOR FILING RETURN DATE 1f 11 ADDRESS Deborah O'Brien 27d Tracy O'Bri. Co-Adms., c/o Placey & Wright, 3621 N. Front St., Hbg. PA 17110 SIGNATURE OF PREr7. R T THAN RE NTATIVE DAT; �7 ADDRESS // Richard L. Plat PI c�Wright, 2 f p Front Street, Harrisburg, PA 17110 PLEASE USE ORIGINAL FORM ONLY Side 1 150561D1D5 1505610105 t_b 1505610205 REV 1500 EX(FI) Decedents Social Security Number Decedent's Name Robert F. O'Brien RECAPITULATION 1. Real Estate(Schedule A). . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . 1. 0.00 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . .. . . . . . . . . . . I I . . . 2. 220,419.51 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . 1 3. 0.00 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . 4. 0.00 5. Cash: Bank Deposits and Miscellaneous Personal Property(Schedule E). 5. 141,709.58 6. Jointly Owned Property(Schedule F) O Separate Billing Requested . . . 6. 0.00 7, Inter-Vivos Transfers& Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.. . . . . . 7. 28,462.89 8. Total Gross Assets (total Lines 1 through 7). .. . . . . . . .. . .. . . . . . . . . . . 8. 390,591.98 9. Funeral Expenses and Administrative Costs(Schedule H). . .. . .. . . .. . . . . . . . 9. 26,138.92 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . . . . .. . . . . . . 10. 1,449.39 11. Total Deductions(total Lines 9 and 10).. . . . . . . . . . . . . . . . . . . . . . . . . .. . 11. 27,588.31 12. Net Value of Estate(Line 8 minus Line 11) . . . . . .. . . . . . . .. . . . . . . . . . . . . . 12. 363,003.67 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13. 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . .. . . . . . . . .. . . . . . . . 14. 363,003.67 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)X .00_ 181,501.84 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 181,501.83 16, 8,167.58 17 Arnount of Line 14 taxable at sibling rate X .12 100 17, 0.00 18 Amount of Line 14 taxable at collateral rate X .15 0.00 18 0.00 19. TAX DUE . . . . . . . . 19 8,167.58 . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 Ex(F I) Page 3 File Number 21 —1 1 —0 4 5 5 Decedent's Complete Address: DECEDENT'S NAME Robert F. O'Brien STREET ADDRESS 20 Dewalt Drive CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19;, (1) 8,167.58 2. Credits/Payments A.Prior Payments 5,775.00 B.Discount 0.00 Total Credits i A+B) (2) 5,775.00 3. Interest (3) 0.00 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. (4) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,392.58* *Of the total tax, $2, 599. 91 is due as a result of litigation. No net interest was produced. Pursuant to 72 P. S. 9143 no delinquent interest is due. Make check 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 ........................................................................................ F 0 b. retain the right to designate who shall use the property transferred or its income ........................................... 0 c. retain a reversionary interest ............................................................................................................................. d. receive the promise for life of either payments,benefits or care?...................................................I........... ...... 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?......................................................._..................................................... 3 Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. F 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 Juiy 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 deceoent's siblings is 12 percent [72 P.S. §9116(a)(13)].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-i503 EX+(8-12) lal pennsylvania SCHEDULE B DEPARTMENT OF REVENUE_ INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT F. O'BRIEN 21-11-0455 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1" Ameritrade Account 907219130 220,419.50 i i I I i i i i� i TOTAL (Also enter on Line Z Reca itulaton)i 5 220,419.51 P If more space is needed, insert additional sheets of the same size REV-i5o8 EX+(08-12) IFpennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAf RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ROBERT F. O'BRIEN 21-11-0455 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. M&T Bank Checking Account 9846828482 704.83 2. M&T Bank Savings Account 15004200901575 3,779.61 3. Cash on Hand 15,300.00 I 4. 1999 Ford Escort(insurance pay-out) 2,800.00 5. 2000 Chevrolet Astro Van 3,500.00 6. The Hartford-policy cancellation/premium refund 26.39 7. Q-Ray Bracelet-refund 47.30 8. Miscellaneous Disc Jockey Equipment including speakers, mixers, amplifiers and lighting 500.00 9. i Erie Insurance-survival claim (see PA Department of Revenue 1128/13 letter attached. 115,551.45 (Funds received March 8, 2013) 10. Miscellaneous Personal Effects No Value I f i II I TOTAL (Also enter on Line 5, Recapitulation) 142,209.58 I=more space Is needed, use additional sheets of paper of the same size. REV-1510 EX+ (03-09� pennsylvania SCHEDULE G DEPARTMEN-D=REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TA> RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT F. O'BRIEN 21-11-0455 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. DESCRIPTION OF PROPERTY ITEM mauD=THE NAME of THE TPLANSFEREE,THEIR RELATIONSHIP To DECEDENT AND DATE OF DEATH OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST (IF APPUCAB_E VALUE I Anneritrade IRA 908948990. Beneficiary daughter,Tracey O'Brien. 28,462.89 100 28,462.89 Transferred on February 24, 2011. I I � I I i I I i i i I TOTAL(Also enter on Line 7, Recapitulation) $ 28,462.89 If more space is needed, use additional sheets of paper of the same size. RED 151 1 E7+ (1G-09 jl,' pennsylvania SCHEDULE H LQDEPARTM=NT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TA>::RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT F. O'BRIEN 21-11-0455 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hetrick-Bitner Funeral Home, Inc. 4,217.32 i I B. ADMINISTRATIVE COSTS: i 1. Personal Representative Commissions: 0.00 Name(s)of Personal Representative(s) I Stree:Address City _ Stale ZIP 1'ear(s)Commission Paid: I 2. Attorney Fees: 15,000.00 3. ' Family Exemption: (If decedent's address Is not the same as claimant's,attach explanation.) 3,500.00 Claimant Deborah O'Brien Street Address 20 Dewalt Drive city Mechanicsburg State PA zip 17050 Relationship of Claimant to Decedent Surviving Spouse I 4. Probate Fees: 142.50 5. Accoun_ant Fees 6, Tax Retirn Preparer Fees: 7 Cumberland Law Journal-estate advertising 75.00 8. The Patriot-News Company-estate advertising 151.10 I 9. PA Department of Revenue-PA41 3/1/11-2/28/12 11.00 10. M&T Bank Charge 42.00 11. Reserve for future costs,taxes and expenses 3,000.00 TOTAL (Also enter on Line 9, Recapitulation) $ 26,138.92 If more space is needed, use additional sneets of paper o`the same size. REV-1512 EX+{12-12) IDpennsylvania SCHEDULE I DEPARTMENT OFREVENUE DEBTS OF DECEDENT, INHERITANCE TAX,RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT F. O'BRIEN 22-11-0455 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 Bank of America-credit card debt 1,260.57 I 2. Verizon -debt of decedent 41.56 3. AT&T Mobility-debt of decedent 66.99 4. Dish Network-debt of decedent 80.27 I i I I I TOTAL(Also enter on Line 10, Recapitulation) $ 1,449.39 If more space is needed, insert additional sheet=_of the same size. REV-1513 EX, (01-10) pennsylvania SCHEDULE ] DEPARTMENT O-REVENUE INHERITANCE TAX,RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF, FILE NUMBER: ROBERT F. O'BRIE_N__ 21-11-0455 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a) (1.2).] 1. Tracy L. O'Brien. 2250 Pine Lane Bushkill, PA 18324 Daughter One-Half Residue i i i I i I I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPdIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1 Deborah O'Brien One-Half Residue I I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. , II i TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S I`more space is needed, use additional sheets of paper of the same size. v H85000HlOHL �� SAFE DEPOSIT '!N' BOX INVENTORY PA Depanrnent o'Revenue PLEASE USE OR113INAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Yea- File Numoer 4 4 2 2 7 6`" 0 2 2 4 2 0 1 1 2 . 0 1 . 1 0'. 0,,. 4' 5 5., Decedent s Last Name Suffix First Name IJII O B R I E N R 0 B, E R, T F. ®ADDRESS OF DECEDENT STREET CITY: SKATE ZIP CODE 20 Dewalt Drive Mechanicsburg PA 17050 NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME Richard L. Placey-,- _Esquire STREET A3621 North Front Street Harrisburg PA –1711 CODE –17110 0 NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT. OF PERSONS)PRESENT AT THE BOX,OPENING a. NAM= RELATIONSHIP: Tracy -L_. _O_'_Br_ieri -- -- -- Daughter STREET ADDRESS CITY ;;TAT= ZIP CODE 65 Sidorick Lane East Stroudsburg I?A 18302 b. NAME RELATIONSHIP. Deryck Henry Attorney for Estate STREET ADDRESS CITY: STATE ZIP CODE: 5621 North Front Street Harrisburg 1?A 17110 c. NAME RELATIONSHIP. Richrd L. Placey Attorney for Estate STREE'ADDRESS CITY AT= ZIP CODE: 3621 North Front Street Harrisburg PA 17110 NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME ---– M&T Bank STREET ADDRESS. CITY STATE ZIP CODE. 6 )60 Carlislp 'l MP(-hanjc._shii-rq_ DA 17050 NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY *Robert O ' Brien June 17 , 2009_ 1 : 04 PM 13DATE OF CONTRACT TO RENT BOX NUMBER OF BOX 1 TITLE UNDER WHICH BOX IS REGISTERED 06/17/ 1994 177 Robert O ' Brien NAME AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX a. NAME b. NAME: ----- — - Robert F. O ' Brien STREET ADDRESS STREETADDRESS: 13 Dewalt Drive CITY STATE ZIP CODE CITY ATE ZIP CODE: Mechanicsuurq, PA 17055 NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY Richard L. Placey, Esquire; Attorney for Estate WAS A WILL IN THE BOX? ❑ YES �N' NO If yes. a. Date of will: b. Name and address of personal representative, if named in the will NAME STREE1 ADDRESS C17Y ;,_ATE ZIP CODE c. Name and address of attorney, if any NAMe STRE-_AD C:TY ATE ZIP CODE *Boa entered ?March 30 , 2011 by Deborah O ' Brien with bank representative to search for V,'_ll only. �850DD4y046 485DOO�il0�6 SAFE hr^ P S eK BOX F N V N NST RUCTIONS _ (1) Cash (2) Stocks: _Isl Ir detail e,Yery common o 1,1eteifec, ,erhficatn rear ant ��IhE:r ngh!s found In bon Stoat arc- t;. �_tnr3ted by name of VVW,';l ;W I raisrd rmc! n �u _ � r .. of stoci; (3) Obligations of U.S Government: Number of IteniS date of tssur If -ectistered ownershiti nlnlh nr--,Ir! or. death etc (4) Bonds: Deslc)nate ov name, amount serial number or ether cle;lgnati�r !Bearer Bonds (5) Bank and Savings and Loan Passbooks: Staler name o4. depn,Aor number 01 'M01, ,rat date aupeannq m boot:_ name of bani� and branch, and ba ance (G) Jewelry. Coins, Stamps, Manuscripts, etc' -!St and drscnbe as, hilly a�. po sibiE (7) Deeds. Mortgages Current Insurance Policies or other evidences of indebtedness ._ISt and describe as fill; as possihle (8) All other contents. (9) Return completed form to DEPARTMENT; CN RE rJ.JE INHERITANCE TAY DIVISION PO BOY 2Y,0601 HARRISBURG PA 1 7 1 26-0601 ITEM ITEM DESCRIPTION NO 1 . ', Cash $ 15 , 300 . 00 2 . Miscellaneous expired homeowner policies , marriage and birth certs . 3 . ', 2000 Chevrolet SW VIN 1GNDM19W3YB111135 Title 4 . 1999 Ford Sedan VIN VAFP10P4XW174952 Title I i I i I � i I I i I I I I CERTIFY UNDER PENALTY OF,PERJURY T�T THEA80VE RECORD IS S N RECEIVING COPY OF ~ CORRECT AND COMPLETE TOAHF BEST OF,i Y K4NKO L DG AND BELIEF SAFE DEPOSIT BOX INVENTORY__ SIGNATURE SIGNATURE -'PP,INT NAh,9c AND:;H=CY,APPRO°RIAr-BOA Bp-.O`/s . Iichrd L . Placey, Esquire Tracy L. O ' Brien & Deryck Henry PFIIN-'FW DATE �..^HcCr'.a.p°P'.PRIrrT;.BOX Attorney for Estate 4/22/11 rIEXe,rro(m>. K]Adm srntw;,X Esrale rePr somat,e ❑ Jo"!owner o'sate j NOTE: Attach additional 8'/:" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department Is authorized b• lay 4 'J_S C �',405(c)(2)(C)(i; to reaulre disclosure of Sccial Securit: numbers Ir connection with adnimistermc state tar nwr. Tae Deca-mient ase- !ne Soca'Securio;numbe-to identi;lht,decedent and Dersonal reDresentatwes of the estate The�ommonw.ealtri rr�i,,a sc use the Informatlor, m exchanc)-o`ta, ,ntormatlor aoreemenr with Fedem r r c lora'faxmG autmri I„- one state iavr rronyt the commonwealth Dersonlle:�froni daDlosin0 confidential tax informatior except fD'ofilcla DurDO5e5. Ell zm In �- ,w NIP : c6i cv; k[I LO Lf) In c"I 7F LC) LL LL L'I. CL I (L C cr, F U5 IF) U5 75 Ili z z z z z = m L, LL W W LD L" LL q c� L; 1,— L IN ; U W L; -I T C 7 T (7� ©M&T'Bank ACCOUNT NO. ACCOUNT TYPE STATEMENT PERIOD PAGE 9846826482 M&T CLASSIC CHECKING W/INTEREST FEB.-!---MAR-10,20-1 i OF 1 00 0 G4342M NM 017 21218 ROBERT F OBRIEN 20 DEWALT DR MECHANICSBURG PA 17050 INTEREST EARNED FOR STATEMENT PERIOD 0.00 CARLISLE PIKE INTEREST PAID YEAR TO DATE 0.02 ACCOUNT SUMMARY BEGINNING DEPOSITS. & - OTHER CURRENT ENDING BALANCE OTHER ADDITIONS CHECKS PAID' SUBTRACTIONS INTEREST PD BALANCE NO. AMOUNT NO. AMOUNT NO. AMOUNT 468.84 339.00 3 337.29 1 10.87 0.00 459.68 ACCOUNT ACTIVITY POSTING DEPOSLTS,INTEREST CHECKS' & OTHER DALLY' DATE TRANS-ACTION DESCRIPTION & OTHER ADI21TIONS SUBTRACTIONS BALANCE 02-11-11 BEGINNING BALANCE $468.84 02-14-11 DEPOSIT 93.00 561.84 02-15-11 DELUXE CHECK. CHECK/ACC. 10.87 550.97 02-16-11 CHECK NUMBER _781 92.14 458.83 02-23-11 DEPOSIT 60.00 518.83 02-24-11 DEPOSIT 186.00 704.83 03-07-11 CHECK NUMBER 1783 165.1 03-07---1 CHECK NUMBER 1782 60.06 459.68 ENDING BALANCE $459.68 CHECKS PAID SUMMARY - - 1781 02-16-11 92.14 1782 03-07-11 60.00 1783 03-07-1_ 185.15 ANNUAL PERCENTAGE YIELD EARNED = 0.00 0 WARM UP WITH SPECIAL SAVINGS THIS SPRING AT POPULAR RETAILERS WHEN YOU USE YOUR M&T CHECK CARD OR M&T VISA CREDIT CARD IN STORES, ON THE WEB AND OVER THE PHONE. PICK UP A COUPON BOOK AT YOUR LOCAL M&T BRANCH, OR VISIT MTB.COM/SHOPPING FOR GREAT DEALS ON SPRING SAVINGS. IF YOU PAY WITH YOUR M&T CHECK CARD, BE SURE TO SELECT :OR ASK, TO USE YOUR CARD AS; "CREDIT". pM&T Bank ACCOUNT NO. ACCOUNT TYPE STATEMENT PERIOD PAGE 15004200901575 M&T PERSONA:., SAVINGS DEC.22-MAP.,21,2011 OF 00 0 04342N. NM 017 16364 ROBERT F OBRIEN 20 DEWALT DR MECHANICSBURG PA 17050 INTEREST EARNED FOR STATEMENT PERIOD 0.46 CARLISLE, PIKE INTEREST PAID YEAR TO DATE 0.46 ACCOUNT SUMMARY ^BEGINNING- DEPOSITS & WITHDRAWALS & OTHER CURRENT -ENDING BALANCE OTHER ADDITIONS 1 11 SUBTRACTIONS INTEREST PAID BALANCE NO, AMOUNT NO. AMOUNT ,779.31 0 F 0.00 U r 0.00 0.46 3,779.77 ACCOUNT ACTIVITY _ POSTING DEPOSITS,INTEREST W/DRAWALS & OTHER DAILY DATE TRANSACTION DESCRIPTION & OTHER ADDTTTONS SUBTRACTIONS BALANCE 12-22-10 BEGINNING BALANCE $3,779.31 01-21-11 INTEREST PAYMENT C.16 3,779.47 02-18-11 INTEREST PAYMENT 0.14 3,779.61 03-21-11 INTEREST PAYMENT U.i6 3,779.77 ENDING BALANCE $3,779.77 ANNUAL PERCENTAGE YIELD EARNED = 0.04 EFFECTIVE DUNE 22, 2011 THE FEE FOR EACH WITHDRAWAL FROM YOUR SAVINGS OR MONEY MARKET ACCOUNT IN EXCESS OF 4 PER MONTHLY SERVICE CHARGE CYCLE WILL BE $5. THIS FEE WILL BE CHARGED REGARD,;.,ESS OF THE BALANCE IN YOUR ACCOUNT, AND IS IN ADDITION TO ANY FEE FOR ANY ELECTRONIC FUND TRANSFER SERVICE; WE MAKE AVAILABLE. A WITHDRAWAL INCLUDES, AMONG OTHER THINGS, A WITHDRAWAL MADE BY A CHECK, AT A TEL;�ER, BY USING AN ELECTRONIC BANKING CARD TO TRANSFER FUNDS TO ANOTHER DEPOSIT ACCOUNT WITH US, OBTAIN CAST. OR PAY THE PURCHASE PRICE OF GOODS OR SERVICES, OR BY TRANSFER 111ADE BY TELEPHONE TO ANOTHER DFP'JS';T ACCOUNT WITH US. ennsyLvania PARTMEN7 0" REVENUE J 31 D,,:;r�ck Escl-Lire Lyaw office Froiil StTcet Pik 1 '11 Re: E-SLaw oi"I"tobtrL O,Britn rile , 21 1 1-(.)455 Court of Corn-rnar- Pit"s Cal 11,DC; iand Cuunt-�, Dear'Ar. Hem:, The Department of Revenue Las received the Petition for APPrOva' Of'Settlel-n-en' C'Ll" to oe filtc unbehalf of tilt above-rtEcrenced Estate in regard to a "7ongRa AM aid survival action- It has bum fwwardk to ilk Bureau for ihP- Co-,mmonweahh's appToval of the flocation of Aw proceeds paid w Sealc tit,, actions. pus.&jo to Pwition, the 60 year old atucacm died as a rt-SUIZ c-' a im-,Loy ve-,L-c"t 10cedew is suTvi\!e,by--ns wif�- uid daughter, Please be advised that, based upon One Ids an for inht-'i-tanct -,-a), pul-poses ur�l j% Aw Df.,pay-=cn-, ha-- no chjectioi-,jo the p-To posed aRocabon of the net proc-teds, o�this to the wrongful Laih claim and 51 15,551.45 to the survival Claim. Proceeds of a sul-A�"a", acuoli are an asset mcluaed, a-.Che decedent's estate and are subj�;ct to Lbe imposition o-FPc=isy1vania i-mernanct tax- 42 Pa-C.S.A. ,,,^302: 72 P.S. c.91106, NOT Cost and Dos ram! be Cindumed in the smne penunngus as the proceeds are Alocat.cd. In re Estate of 669 f12d 1059 (PS CM&A 1905) 1 -._:at this lctttj ib a sufi-lu.on-, lepresell'a-uon ME Wparunwa's posillun on As MaKy, K At lkparununi has no oQCUMS to the MKOK an a"rwy hum the Dcparnncnt o1 Revenue nol, a-Li-ndin, g an,, heatmz rogarding lt. Fk;asc cornact me Qyu or To Court tab any yusnun; oT require LL�dnional frorn tilts Bureau. fialli or, Baku 5u WdWoun: Taxes i PC) Box 2BO501 Hamsburn PA 1722S 7:73ET5824 1 T LU il F t: Ul 30 0 > id I rl cc N PC z Yr cc V uj 45 725 Ca to I fp > CL C, CL in o