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Home My WebLink About04-01-13 � , � ; 1505610101 REV-1500 �`�O1_i°, 1� OFFICIAL USE ONLY PA Department of Revenue P�Y�vania � DEFARTMENTOFPEVENUE County�Code Year File Number Bureau of Individual Taxes iNHERITAWCE TAX RETURN PO BOX 280601 r. Harrisburg,PA 1�128-0601 RESIDENT DECEDENT � ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � � � � � � y ' DecedenYs Last Name Suffix DecedenYs First Name MI . � � � (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI � Spouse's Social Security Number � C) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE �5 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Return p 2.Supplemental Return O 3. Remainder Return(date of death prior to 12-13-82) p 4. Limited Estate p 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Retum Required , death after 12-12-82) � 6. Decedent Died Testate Q 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 O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) befinreen 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPIETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE�IRECTED T0: Name Daytime d�lephone Nurr� � - �� _ 4V � � �: � � � �� ' � '� l F��.� �.�,5�.. �� ; RW151� R�F WILLS USE�Wd�D rzrn c�� m � � � � � c� � . � � t� First line of address �� '�° ,:�� .... .. �� :: �� Q � "� .,��, , ..^��. C� ~:� 1 � 1 � A� � �� ! � v � , . � � .. :� ....� ,,,, -� n �� ° . ��°�; f � -`" Second line of address ..� --1 � rn ... ., . . .•.,:•.. :�ll�li.��.iY...�,��".°��a,,..,.� .... . . . ..... . '� \..1 � �/� � � . � 3 � � v � � � L�• ' . .� .. .... . 'ii..�.°�`JS� .+a,",�,�,s� �;:�aS ....:<.� .. . �.; � !� City or Post Office �` � State ZIP Code DATE FILED � ,�, �� f � � � � ? � � ; j � � � . .�� _�. ��.��— . ��,�� r�� : � � e.. ;� Correspondent's e-mail address: Under penalties of perjury,I declare that I have examined this retur i cluding accompa ying 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. S ATURE ERSON E PO SIBLE FOR FILING RETURN DA E .� , '�., ADDRE l a�, � -� 1�?b 11��7 � SIGNATURE OF PREPARER OTHER THAN REPRESE TATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 ` � 1505610101 1505610101 � � 15056101�5 REV-15Qq EX � � � � � � �-� 3 RECAPITULATION 1. Real Estate(Schedule A). . . ..... . ... ... . .. . . . .. .. .. . ..... . .... . .. . ... 1. �� * �� 2. Stocks and Bonds(Schedute B} . . . ..... ... .. ... . . ... . . . . . . . . . . . . . . . . .. 2. (,�• L'� 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Scheduie C) . . ... 3. �"�.(� {� 4. Mortgages and Notes Receivable(Schedule D) . . ... .. . .... . ....... . ...... 4. �i. � � . 5. Cash, Benk Deposits and Miscellaneaus Personal Property(Schedule E)... . ... 5. � � � '�'j ''��s�-� 6. Jaintly Owned Property(Schedule F) p Separate Billing Requested ....... 6. [�1 .�`j`:� : 7. inter-Vivos Transfiers&Miscellaneous Nan-Probate Praperty (Schedule G) p Separate Billing Requested.... .... 7. � �, �'� � �� ,�� 8. Tatal Gross Assets(to#a!Lines 1 through 7)...... .. ... . ... . .... ..... .... 8. � � � � � ��,� h {.,1, 9. Funera! Expenses and Administrative Costs(Schedule H)...... .. . . ... .... .. 9. � ��""'� �, � "�] t ..�, '. 10. Debts of Decedent,Mortgage Liabi{ities,and Liens{Schedule I) .. . ... . . ... ... 10. � �� `��C.�* � f : 11. Tatal Deductit�ns{total�ines 8 and 10)... . ... ..... .... . ... . ... ` . . .. . . . .. 11, � � � �_� �„� � 12. Net Value o#Estate{Line 8 minus�ine 11) .. . ... . .... . .. . .. ... . .. .. .. ... 12. � '""`7 `.,.�1 `� � °� .� 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an electian ta tax has not been made{Schedula J) .... . .. . . ... . .... . .... . . 13, �,� � � 14. Ne#Value Suk►jec#ta Tax{Line 12 minus�ine 13} .. . . .. . . ... .... . . . . . . .. . '!4. �� , `7� �� w TAX CA�CULAT!(JN-SEE ItVSTRUCTIONS�'(JR APPLICAB�E RA?ES 15. Amount af Line 14 taxabie at the spousal tax rate,or "" transfers under Sec.9116 _ :: ,,� (a)(1.2)X.0� �J � � `j j� ,�� 15. �,� �� 16. Amaunt of Line 14 taxable � at lineal�rate X.0_ � ` � � � s � 1$. , �: � �+(�'(„1� 17. Amount of Line 14 taxable : ` at sibling rate X�32 �� 37. ��,� ,� �, 18. Amount ofi Line 14 taxable � � � � � � �� , . . .,,. � _ � � � at colla�eral rate X.�5 � � 18_„ � ; � - �� t{� 19. TAXDUE .... ..... .. ..... ... ........ .... . .... ..... .... ..... ....... 19. �� 1�*�'� 20. FILL IN THE OVAL!F YOU ARE REQUESTlNG A REFUND OF AN OVERPAYMENT � Side 2 � :�5L�567,�105 1�5056],07,05 � . � REV-1500 EX Page 3 File Number Decedent's Complete Address: �) ) '�,-� C��'� DECEDE S NAM � 1� STREET ADQ l � �� ,� ��n�� S � Z'��1 Tax Paymen#s and Credits: � 1. Tax Due(Page 2,Line 19) (1) �,�� 2. CreditslPayments � �O� A.Pnor Payments B.Discount S �i �� . �� Total Credits(A+B) (2) 3. Interest c3� � �:4 a 4. If Line 2 is greater#han Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 30 to request a refund. (4) � (,, a� 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) � �, � V Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIQNS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes N a. retain the use or income of the property transferred:.......................................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ c. retain a reversionary interest;or.......................................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after 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?.............. ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa 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 9, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or#or 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 ne# 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 adop#ive parent or a stepparent o#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)l• • 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. KILL OF MICHA�L FRSDERICR DAU P�RSO�AL I�FORMAT�4� I, Michael �red�rick Dau, a resident af Pennsylv�n.i�, County of Cumberland, � declare that this is my will. My �cscial Security Number is 483�6�-0445. REVOC�TiaN OF PR�VIOUS WI�LS FIRST: T revake a�1 wi119 and codicils that I have previousl� made. r��i�aL BTgTUS S$COND: I am �arried ta Cynthia Gayle (Clark) Dau. C$ILDRE� THIRD: I have the follawinq child(ren) now living: Louisa Ann Dau, Kermit James Edward Dau, Meghan Cathleen Dau, Eli2abeth Nicole �au. FAILURE TO LE�VB FRflP�3RTX FOURTH: Yf I do not l�ave property in this will to ane or more o� the children or grandchildren wharn I have identified abo�e, my failure to do so is intentional. DL!°'INITI03�S FIFTH: As used in this will, the term "sgecific hequest" refers to a gift of sgecifically identified praperty that I leave in this will. The term �residuary estatey refers to all property sui�ject to this will that is not passed by specific bequest vr that is specifical.ly l�ft to vr becc��s a part of my residuary estate when a beneficiary af specific b�quest fails to survive me� The term "residuazy bequest" refers to a gift vf all or a gartion of my residuary estate. SFECIFIC BBQUBST t1F PROFERTY SIxTH: If my wife, Cynthia, daes not survive me, Z give equal shares of my house, contents not specifically bequ��thed, bank accounts and automabiles tv each of my youngest tw�a daughters, Meghan C. Dau and Elizabeth N. Dau, to hold and use as their own. My intentian is that Meqhan and Elizabeth have a ht�me and camforts until they are of suCh age that they should have their coliege degrees and are able to fend for themrelves. At su�h time beforehand as Meghan and 231izabeth decide, or June 30, 2�06, the house shall be put up for sale and each of my four chil.dren shall have equal share in the proceeds. If any child d�sires ta buy the house, he or she shall have si,x to twelve months to arrange financing at fair market value. However, if one of these beneficiaries does not survive me, that beneficiary's living children shall take hi.s or her share equail�r. If there are na living children, the surviving beneficiaries shall ta�e the share equally. �f there are no surviving beneficiaries, the property sh�ll go ta �my r siduary estate. , . Pa�e ].: INITI�iLS �" ' , L�' !/"� Date: .�� l " �� ,. WZLL dF MI�HAEL FREDERICR DAU To my daughter, Louisa Dau, I bequeath the followinq: the chrom� Pavoni expresso coffee maker, her Grandmother Dau's cedar chest �not cantents} , my Spanish bedroom set, �11 my gardening books, the Anniversary Waltz LLadrQ bought for her grandparents 5�th �edding anniversary, the little girl Hummel, the Talavara cruet set, and my Spanish win� barrels. To my san, Kermit Dau, I bequeath the follouring: my father's diamond rir�g, my red Pavoni expresso cof�ee maker, my red Pa�oni coffee bean qrinder, rny B�� 750 �otorcycle, my mechanicai (not woo�working) tools, the Abraham Lladro and the Fishing Boy Lladra, the antique chocalate set �rought fr�m Germany by his great- great-grandparents. Ta my grandaughter, Shalah Hall�ord, I bequeath the the following: �7er great- grandmother's collection of Spanish Niud Dolls with display case, and the green and white, dresden pZate pattern qu�lt rnade by my Grandmother Pawling. r//I/ i f`/ /// /r`/ I// /// 1!! f!! /r`/ /If f// il/ 1// 1// �r! i�i ��i ir� �� ,� r�r /,1/ ��f i l/t x " �/�� ,. �,�� ,f;'f r, . r � ;",, , � - �`_ ,r , �"� ' � Page 2 Initials: !��. �`�/ ,�f ;,�� .�..�.�� D�.te: � � �'`� � ~ ��-'�, f Will of �icbael Frederick nau RI�S I DV�RY l�S TAT`E S�VSNTH: I give my residuary estate to Cynthia Gayle �au. Hawever, if Cynthia Gayle Dau does not survive me, my residuary estate sha11 go to Louisa Ann I3au, Kermi.t Ja�s Edward Dau, M�ghan Cathleen Dau, Elizabeth Pticole Dau in equal shares; and their individual share to their children if they do not survive me. �xcv�tta�c�s �n Lr$xs EYGHTH: All personal and real property I give in a spec.ific or residuary bequest shall pass sub�ect to any encumbrances or iiens on the property, sv�vrvo�sxtp ��on � NINTH: When this will states that �. b�neficiary must survive me for the purpose of receiving a spe�ific bequest c�r residuary bequest, he or she must su=vive � by 45 days. DIVISIO� 4F BSQUBfSTS TENTH: Any specific hequest a� residuary bequest made in �his will to twv or more ben�fici�ries shall � shared equally amc�ng them, unless unequal shares are specifically indicated. PSRSONAL GUgItDIA�i ELEVENTH: I� at my death a guardian is needed to care for my nt.inor child or children, I name Meghan Cathleen Dau as guardian, If this person shall for any reason fail to +qualify or cease ta act as guardian, I name Ruth Akiens to serve as guardian. No �nd shali be required of amy gersdn�l guardian appointed unci+�r this wi11. PR4PERTY C�UA.RDYA� TWELFTH: If at my death, a guardian is needed to care for any property belonging �o �ty minor child or children, I nam� Cynthia G. Dau as property guardian. If this person for any reason do�s nat qualify or c�a�es to act as property guardia�, I na� Harlan and Rhc�nda Price to serv�e as property guardian. No bond shall be required af any property guardian agpainted under this will. PR4F8RTY MA�AGI�M�1�� TflIR�'EBNTg; All sp�cific bequests and residuary hequ�st� made in this will to Elizabeth Nicole Dau shall be helcl in a separate trust �or Elizabeth Nicole Dau until he or sh� rea�hes age 21. This trust shall be m,anaged under the trust administration prc�visic�ns set forth in this wiil. The truste� for the 8lizabeth Nicole Dau tru�t shall be Cynthia �ayle Dau. zf Cyz�thia Gayl� Dau cannot serve, the truste� shall be Harian price. Nv band shall be required of any trustee. � , � �,�'�� l.�+V �• � ^� �` , P�ge �nitia�s: Datez � � .,.i �ill of Mx�hael F�ederick �� {e} In additi�n t� ��he= p�wers gzant�d a t��stee in this will, a trust�e �hall have: (1} a�l th� p�wers generally c�nferre� an t�ust�es bv th� laws �� th� �ta�� h�vin� �u�i�d�c�i�� v�r the tru�� {2� t�� o�we�s ��nfar��d by this �il� o� the p�rsana� repres�ntativ� as to accum��at�d pr�pert� and anc�me in each tru�t� and {3} the a��thQrity t� hi�e and �av �rom trus� ass?t� the r�as�nab�� fees o� inv�stment �dvis�rs, accountan�s, �ax advis�rs, agents, att�rney� �nd a�her assi�tants t� adm�nist�r th� t�ust, manag� any �yust. asset an� ��ndle an� litiga�ion af�e�ting the trust. {f} It is m� intent that any trus� estabiish�d i,n this �ill b� administered ind�p��d�nt�y �� c�urt �upervi�i�n t� �he maximum �xt��t p�ssible unde� t�� laws of the stat� hav�n� jurisdictio� over the �rust. (g} �h� inte�est� �� any ber.�f ici�ry �� a trust �stab�ish�d �n this ��i�1 shall nQt be transfezab�e by ��l�ntary �r i�voluntar� assignment �r bv �peration �� 1aw and shall be fr.ee from the claims a� cred�t�rs and fr�m a�tach�ent, e�e�utian, ba�kruptcy, or ��her l�gal p��ces� t� the fullest �xt�nt �ermitted b� �a�. �h} Any trustee serv�ng under ��e terms �et for�h in thes� p��vision� shall be entztled t� r�asana�le c�mpensatian ��zt af trust asse�s f�r ��din�ry and ext�aardinarv servic��, and f�r all s�rvices in c�nne��i�n wi�h �he c�mplete or par�ial te�minati�n of any �rust crea�e� by �his will. (�} �h� i��ali�i�y of any trus� �r�vi�i�n �� this wiZl �h�l� n�t �f��et �he va�idi�y af the �emaininq provisi�n�. �ERS�NAL REPRE��NTATZVE SIXTEE�TH: T name Cynthi� G�y�� s my pe�s��l �epres�n�a�ive. Tf C��thia Gayle Dau for an� reason does not qualif� or ceases to act as p�rsonal repres�ntative, I name P�ieghan �ath�een Dau a� my persona� repr�senta�ive. No per�onal r�presenta�ive sh�ll be required t� po�t b�nd. PERSONAL REPRESENTATIVE"S Pa��RS SEVENTEENTH: � direc� my p�rsanal repres�ntative ta tak� al� �cti�ns legally per�is�ible �� have the pr�bat� �f my will d�ne as �impl� an� a� free �f c�urt supervis��n a� �ossib�� und�r th� la��s flf the s�ate hav�ng jurisdic�ifln over this will, in�luding �i�ing a petition i� th� appr��ri�te court f�r the �-;l � i��r ,, �. � '� r + '�;` � i �•. �,,� ��,,.;.'�- � J : � �,y � � _� _� � ,��,,, ,a J i�aqe �" Init.ial�:�� Y_ ,�� y yw,� t�,,,�, Uat�: i.� ,� f . �� .,. :..,,r:t Will of Michael �re�erick D�u �'i3URTEENTH; All speci�ic bequests and residua�y bequests made in this wiil ta Meghan Cathleen Dau shall be held in a separate trust f�r Meghan Cathleen Dau until he or she reaches age 21. This trust sha�1 be managed under the trust administration provisions set farth in this will. The trustee for the Meghan Cathleen Dau trus� shall be Cynthi� Gayl� Dau. If Cynthia Gayle Dau cannot serve, the trustee shal� be Rhc�nda and Harlan Price. Na bond shall be required of any trustee. TRUST ADMINISTRATItyN PRdVISI��3 FIFTEENTH: All trusts established in thi� will shall be managed suhject to the following pravisions: (a} Any trust income which i� nat distrihuted ta a beneficiar� by the trustee shall be ac�cumulated and added ta the principal of the tru�t administered for that beneficiary. {b} tintil a trust beneficiary reaches the age specified for final distribution of the priricip2�1, the trustee may di�trib�te some vr all of the principal or n�t income of the trust as the trustee deems necessary fc�r the child`s health, support, maintenance and education. "Education" includes, riut is not limited to, college, graduate, postgraduate and vacational studies and reasonably- related living e�penses. {c} �n de�iding whether to make a distribution to a beneficiary, the trustee may take into account the bene�iciary's other incame, resources and sources of support. (d� A trust shall t�rminate when: (I) the beneficiary reaches the age specified fc�r final dist�ibution of th�e principai {2� the beneficiary dies before the age specified for f i�al dis�ri.bution of the principal� or �3) the trust principal is e�hausted through distributions allowed under thes� provi�ians. If � trust terminates far ��ason (i), the remaining princigal and �ccumu3.ated net income of the trust shall pass to -the benef i�iary. If a trust terminates for reason {2�, the principal and accumulated net income of the trust shall pass under the beneficiary's wi31, or if there is no will, to his or her heirs. � � * � �i' �. �('� � Page Iz�,i.tials: •� � Date: � � •. wil� of Michael Freder�ck Dau independent administration of my est�te. EIGHTEENTH: I grant to my persQnal representati�e the fo11o4�ing powers, ta be exercised as he or she deems to be in the best interests of my estat�: 1) To retain �roperty without liability for loss ar deprecxation. 2} Ta dispose of property by public �r private salej or exchang�, or otherwise, and receive and administer the praceeds as a gart of my esta.te, 3} To vate st�ck, to exercis� any option ar privilege to c�nver� bond�, notes, stocks or ather s�curitie� beZonging to m� estate into �ther bonds, notes, stocks or ather secur�ties, and to e�ercise ali other rights and privilPges of a �ers�n Qs�ning similar �ropert�. �} To lease any real propert� in my esta�e. 5) To abandan, adjust, arbitrate, eomprom�se, s�e on or defend and otherwise deal with and s�ttle claims in favor of or against my estate. 6} To continue ar part�.ci.pate in any business which is a part �f my estate, and to incorporate, d�ssolve or otherwise change the form of organization of the busines5. The powers, authority and discretion � grant tQ my personal representative are �ntended to be in addition to the pawers, authority and dzs�r�tion vESted in him ar her by operation of la�a by v�rtue of his or her affice, and may be exercised as often as is deem�d necessary or advisable, without applicatian ta �r approval by any court. FAYMENT OF DEBTS NIP�ETEENTH; Except far liens and encumbrances p�acet� on praperty as security for the repayment Qf a loan or dEht, I znstruct my personal representative to pay alI de�ts and Expenses, using the follo�ing assets, in the order listed: �•sy account with Navy Federal Credit ttnion, Be3co Credit Unian, Life insurance policies from where I work and Am�r�.tas of Lineoln, NE. . PAYMENT OF TAXES TWFNTIETH: I instr�et my parsanal representative to pay all estate and inheritance taxe5 assessed against propertl in my estate Qr against my beneficiaries as provided far by the laws of Penns�lvania. il/// ///// Il//1 /!l!l ��ifr i�ir� !///l iy� - � '� � �` ; r ,,�}r�� ri,''/�l' //,.-� ;'' , r' `� _ -, -� i.�,, � � � r�, i, _ j '' Pa�e � �nitials: �! '"��- ,`�` �-Y.'.''f � 1 L�l,��.; Da�e: �i ,..�'' f ` ., . . T�iill of Mi�hael Frederick Dau I�t4 CO�tTB�T P1i4V I S�O� TWENTY--FIRST: It �ny beneficiary under this will cantests this will or any of its pravisions, any share or intezest in my estate +given �o the contesting benefieiary under this wil.l i.s revoked and shall he disposed of in the same manner as if that contesting henefi�iary had failed ta survive me and left no living children. � S I t�F1�ATURE I, �tichae{1 Frederick Dau, the testator, sign my nam+e to this instr�ment, this � � � day vf �4��^�,�,�, I9�, at t��Sf��. I declare that Z sign and egecute this instrument as mg last will, that sign it wi2lingly, anr� that I execute it as my free and voiuntary act. I c�eclare that I am 4� the age� of ma�arity or atherwise leqally empc�wered ta make a will, and under na cvnstraint ar undue influence. 4. �fr 1-. {Signt�d} KITigBSSSS We, the witnesses, sign our names to this instrument, and decl.are that the testato= willingly sign�ed and executed t�is instrument as th+e testator's last will. £ach af us, in the pre��nce of the testator, and in the pr�sence of each othe�, sign this will as witness ta the testato�'s signing. /f!/I >///I I//f/ ///i/ //I/f /!1/l ///l/ �iir� �iiii i��f i�i�f �� I//1/ ////1 ///1/ t//!/ ///// � , > � � In{� hj` .. J•� j �� ' V` �� Page� Ixi.tt�.al�: � Date. Wili of Michaei Frederick Dau To the best of aur knowledge, the testator is of the age o� majority or otherwise Iega�ly empowered to make a will, is mentally competent and under no constrai�t or undue infZuence. We dec�are under penalty of perjury that the foregoing is true and correct, th,is " �� day of �l, � c. ,c �`�_ , �9 c_�, at '�� r ` �:, +, :j � `� �. — � J-. ' f �� J ��f� �� " .Y" f.��,_ ' �� .�;1i��:�.��' ;��. � IvltileSS .#�: -�� ' � ��' � /� '. � � �._ ` f j '�" �:;� .,�C./.i-�/tf, / t � ,/� �' �;� t.• _! � Re s id inc� at: �- --- ��r°--�.!.-�y_ �..� /!�� °�;��;c_-�c;;��. �`�.� �'�'-� _ , �; , 1;, ; � f � � ��7itness #2: f� Residing at: ,� ll , ;% �`r�� _ �' Witness #3. �:--�� -��-`�--� �__ 1�--�'�-� ��-_ ,n (� � � �� , f =r � . �, / � � ! �� G��_ . .y f� _f �� Residing at. �; 1 � ,�� L�- � C �- � ;.%� � t ` � - �� .-�, <,L� j' '.` ,� ., � � , � r, r / ? f r"' � �� ,/; t � , v �� ,�� , � , �3� , Page � Initials ��;;r, � �.'��'� .�,�..� {,.`-', pate: ,._•} �,� / / REV-1502 EX+(11-08) � pennsylvania SCH EDU LE A DEPARTMENT OF REVENUE INHERITANCE TAX REfURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER . � � �b �� _�� All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or seli,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold, ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. �� TOTAL(Also enter on Line 1, Recapitulation.) $ � �— If more space is needed,insert additional sheets of the same size. 1 � REV-1503 EX+(6-98) SCHED�ILE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 01�.- �o�'? All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. �� TOTAL(Also enter on line 2, Recapitulation) $ '—"" �--� (If more space is needed,insert additional sheets of the same size) � REV-1504EX+(1-97) SCHE�V�E � � CLOSELY HELD CORPORATION, COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP OR INHERITANCE TAX RETURN RESIDENT DECEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER ,� � � �,� _, ! Schedule C-1 or C-2(including all supporting information)must be attached for each closely-held corporation/partnership interest of the decedent,other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. �� TOTAL(Also enter on line 3, Recapitulation) $ �-- --� : (If more space is needed,insert additional sheets of the same size) REV-1505 EX+(6-98) SCNEDIJLE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE 0 FILE NUMBER � � - �D 1. Name of Corporation State on Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D.Number Business Reporting Year 3. Type of Business Product/Service 4. TYPE TOTAL NUMBER Q� ' NUMBER aF SHAFtES VALUE(}F THE ' STQCK PAR VALUE V�ting/Non-l/ating SHARES QUTSTAND[NG ' qWNE�BY TH��ECE�6htT 'D�C�C}�NT'S Sl'4�K Common $ Preferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No ` If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 7. Was there life insurance payab�e to the corporation upon the death of the decedent? . . . . . ❑Yes ❑ No If yes,Cash Surrender Value$ Net proceeds payable$ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? ❑Yes ❑ No If yes, ❑Transfer ❑ Sale Number of Shares Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....❑Yes ❑ No If yes, provide a copy of the agreement. 10.Was the decedent's stock sold? ..................................................... ❑Yes ❑ No ` If yes,provide a copy of the agreement of sale,etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ❑Yes ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 12.Did the corporation have an interest in other corporations or partnerships? . . . . . . . . . . . . . ❑Yes ❑ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • • - � • : � � A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns(Form 1120)for the year of death and 4 preceding years. C. If the corporation owned real estate,submit a list showing the complete address/es and estimated fair market value/s.If real estate appraisals have ' been secured,attach copies. D. List of principal stockholders at the date of death,number of shares held and their relationship to the decedent. E. List of officers,their salaries,bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year.List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed,insert additional sheets of the same size) REV-1506 EX+(9-00) SCNEDULE C-Z COMMONWEALTH OF PENNSYLVANIA PARTNERSHIP INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER ! C � �� 1. Name of Partnership Date Business Commenced Address ` ' Business Reporting Year City State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. Decedent was a ❑ General ❑ Limited partner. If decedent was a limited partner,provide initial investment$ 5 � �:,� � ��: �� ree�� a p �� ^,��.�� 5 . � a ° `"' :a �' -�, ae:� `�° -. � ..�,� v.a�° ,�3. .`�� s �e, '�. e .n:,��. � ��e '��,. . A. B. C. D. 6. Value of the decedent's interest$ 7. Was the Partnership indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑Yes ❑ No If yes, provide amount of indebtedness$ 8. Was there life insurance payable to the partnership upon the death of the decedent? . . . . . ❑Yes ❑ No If yes, Cash Surrender Value$ Net proceeds payable$ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ❑Yes ❑ No If yes, ❑Transfer ❑ Sale Percentage transferred/sold Transferee or Purchaser Consideration$ Date Attach a separate sheet for additional transfers and/or sales. 10.Was there a written partnership agreement in effect at the time of the decedent's death? . . . .. . ❑Yes ❑ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? . . .. . . . .. . .. . .. . . . . .. . . . .. .. . .. . . . .. .. . �Yes ❑ No If yes,provide a copy of the agreement of sale,etc. 12.Was the partnership dissotved or tiquidated after the decedent's death? . .. ... .. . . . .. .. . .. . ❑Yes ❑ No If yes,provide a breakdown of distributions received by the estate,including dates and amounts received. 13.Was the decedent related to any of the partners? . .. .. . .. . .. . .. ... . .. .. . . . . . . . . .. . .. . ❑Yes ❑ No If yes,explain 14.Did the partnership have an interest in other corporations or partnerships? . . . .. .. . .. . . . . ❑Yes ❑ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • • - � • : : � � A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns(Form 1065)for the year of death and 4 preceding years. C. If the partnership owned real estate,submit a list showing the complete address/es and estimated fair market value/s.If real estate appraisals have been secured,attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+(1-97) �� SCNEDI�ILE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER � � �� All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. l-�� . TOTAL(Also enter on line 4, Recapitulation) $ ----. (If more space is needed,insert additional sheets of the same size) REV-1508 EX+(1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS� a MISC. INHRESIDENTDE EDENTRN PERSONAL PROPERTY i ¢ ESTATE OF FILE NUMBER ' � � �y �� 3 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 �. C4�h �n-�►nGne,icLl �ns�,��ahs � . ��`�c��►�e.� �.`�(lavy �,��le�� . C�.r� U�� . 0�.�`��3�-� b`? c:h�.e�►n ��.I � 4��? ; o�-'t 1�Q � � � -� �9. � , . a � �. �n 5 C� �i�t1�- I:v� S��l:�� ' � ) . �J �✓t �b- �I , 2��` �-�-c�, � �-- �� C.at�,mt��-�- �t.� �.�►n � , � , �� 10h, ��j D, � � �,�,�,-� a�.��o� e�e,. � _ �� '�-,�.�� St�v 1 r� � ._.. � � �• �g s i��G 1 9`�`�"• `7 � � �v ��S �'�� ' r �I. �,c��, p a�. � 1�1��. � �� 5 1 `� a� �� .�a s b- ��. ��— '�1�3 . 3��" �. �I �- � ��,� � � � r�.�- � c � 1� 20) (y��.�1 �. � va � � �u. �sl 1 ��,. � C�, l�� o� � e�o�n, �i�.-� �,��-�� c�c��C�..;}� �- ��C.-- ;�12, � Jos��l� �.��`nh�,n�i o, C��-► ��F� A1Tn� � � `�c��►S , � ��.�vivi n � ��s�,, �,�a ��.�. �v�e�=�c�.��, � � ��,1� ��I`�-`p, e c� �n� «sS1��. �� p � � - TOTAL(Also enter on line 5,Recapitulation) $ ��$ � � � {' . (If more space is needed,insert additional sheets of the same size) � eStatement Page 1 of 1 � ��' . �t��.ltl�'"i � STATEMENT OF ACCOUNT ACCESS NUMBER 02186390 STATEMENT PERIOD 02/28/12 - 03/27/12 ACCOUNT NUMBER � YBWNLLSV 00000943699004 NOOOOOOP2QBVSYOAlii000MMA002 � MICHAEL F DAU 10 PLAINVIEW RD CAMP HILL, PA 17011-7928 Summary of your deposit accounts Previous Deposits/ Withdrawals/ Ending YTD Balance Credits Debits Balance Dividends . EveryDay Checking 094369970� 5708.90 $999.80 $1,063.58 $690.12 $0.12 Membership Savings 0493699004 $286.74 $1,317.19 $994.70 $609.23 $0.19 Totals $995.64 $2,311.99 $2,058.28 $1,249.35 $0.26 . Checking � EveryDay Checking- 0443699707 Joint Ovner(s): CYNTHIA G DAU � Date Transaction Detail Amount(S) Balance(S) 02-28 Beginning Balance , 708.90 02-29 Dividend 0.10 709.00 03-01 Transfer From Shares 994.70 1,703.70 03-02 Check 3212 952.76- 750.94 . 03-08 Paid io- Cmfg Life Ins CO Ad 6 D Ins Chk 2100002 3.30- 797.69 . 03 SS�Paid To - Great Lakes Student LN Chk 4200001 107.52- 640.12 03-27 Endinq Balance 690.12 Average Daily Balance -Current Cycle: $730.42 Your account earned 50.10, with an annual percentage yield earned of 0.150�, for the dividend period from 02-01-2012 through 02-29-2012 Items Paid Date Item Amountl$) Date Item AmountlS) 03-OB ACH 3.30 03-02 003212 - Check 952.76 � 03-15 ACH 107.52 Total Total Fee(s) this petiod year-to-date* Total Overdraft Fee(s)......................................50.00 520.00 *As of the first statement period that begins in January of each year. Savings Membership Savings - 0443699004 Joint Oxner(s): CYNTHIA G DAU Date Transaction Detail Amount($) BalancelS) 02-28 Beginning Balance 286.74 � 02-29 Deposit -DFAS-Cleveland Ret Net OlAfd3 1,317.11 1,603.85 � 02-29 Dividend . 0.08 1,603.93 03-01 Transfer To Checking 994.70- 609.23 � 03-27 Ending Balance 609.23 Your account earned $0.08, with an annual percentage yield earned of 0.3008, for the dividend period from 01-31-2012 throuqh 02-29-2012 2011 Year to Date Federal Income Tax Information SAVINGS DIVIDENDS 1.45 CHECKING DIVIDENDS 0.28 FINANCE CHARGE (CHK PROTECTION) 0.00 http://svr-ihs.nfcu.net:8080/uad/stmtDetails.do?statementType=A&Print=true&stmtId=23 3/28/2013 �, �` ��a��.� �-� � R ,:. - �: � ��,� Statement of Account � �� . . � , > � � Member Number �000000a20 449 Eisenhow�er Blvd • Harrisburg, PA 17111 � Statement For 03/01/Z012-03/31/2012 Page 1 of 3 RETURN SERVICE REQUESTED Belco celebrates youth in April! Every deposit s�oo32sss 1 1/2 uNQ oa-oi-�z s� of$1U or more into a Savings Safari or iilli�l�llil��l�l�i�iill�i�i��l�il�lll�i��llli�l�l��li�ill�lli�l XTSaccountfrom April 1-30equalsone entry in a drawing for an Apple iPad2! CYNTHIA G DAU 10 PLAINVIEW ROAD IGds and teens will enjoy more prize drawings, CAMP HILL PA 17011-7928 contests and special events going on during National CU Youtf�Week,April 23-28. Don't miss our Facebook party on April 25! Stop by any branch for details,or visit belco.org. Your Account Balances as of 03/3i Savings ID 0001 $554.66 Need a Loan? Holiday Club ID 0020 0.01 Checking ID 0040 �,6g2.2s Call (717) 232-3526 or apply online Account Balance Tota1 �s,z�.95 www.belCO.org . Total Dividends Paid Year-To-Date $0.43 � � � 111 Beginning Balance $554.54 Total Dividends Paid Year-To-Date$0.17 1 Total Deposits for 0.12 0 Total Withdrawals for 0.00 APY eamed 0.260%from 03/O1J2012 through 03/31/2012,based on Avg Daily Bal of$554.54 Ending Balance $554.66 Posting Transaction Balance Transaction Description 03/31 ` ; $0:12 $554.66 Deposit'DivitJend 0.25U°!o _ • � . � � 1 i 1 Beginning Balance $0.01 0 Total D�osits for 0.00 0 Total Witfidrawals for 0.00 Ending Balance $0.01 � � 1�1 Beginning Balance $655.11 Total Dividends Paid Year-To-Date$0.26 10 Total Deposits for 10,687.83 67 Total Withdrawals for -3,650.66 APY eamed 0.090%from 03/O1/2012 through 03/31/2012,based on Avg Daily Bal of$3,273.80 Ending Balance $7,692.28 �t�g Transaction Balance Transaction Descri�tion 03/01 :. $�9.99- ` $605.12 Vlridl(I�WaI C�blk C�CCI#206112102151 S1iARP SFIOPPER GRO�ERY W MIDDlErOWN PA . 03/01 32.88- 572.Z4 WI�I1d1'dWBI Deblt Cdl'� #�06100149�14 GIANT 6120 MECHANICSBURG PA U3/02 2$5:03 857.27 Deposit by Chedc : 03/02 10.00 867.Z7 Deposit bY Check 03/02 20.00- $47.27 VIrIH1(�r'dWdl C,�blt Cdl'+d SIGNIAIURE DEBIT M�CIt.Pt'�s'�03/01 FOCUS dN'THE FAMILY pF 7145313400'` CO ref.2478930Z0620G213391090�,3 03/03 25.00- $22.27 Withdrawal Debit Card SIGNATURE DEBIT Merch. POSt:03J02 JOYCE MEYER MINISfRIES 636-349-0303 MO ref.24431062062083733651418 Eff.Date 03/OZ 03/03 4.23- ' 81$.04 Wilfidrawal Debit Cantl SIGNATURE DEBIT Mer+ch.Pbb'�03/02 MCDONALD"5 F15788 MECHIWY(�SURG '' PA ref.244273320627L004?524207 03/03 11.66- 806.38 Withdrawal Debit Card SIGNATURE DEBIT Merch.Post:03/02 PAPA JOHNS#0951 7177957272 PA ref. 24761972063251293010247 03J03 14.84 :791.54 Witlxlraw�l Debit C�r+d SIGNATURE DEBrI'Mench.Po�03/02�t�rr�z�aa3o19e caMP r�Pn` ref.241640T1�063835312287992 03/03 7.47- 784.07 Withdrawal Debit Card SIGNATURE DEBIT Merch. Post:03/02 U-HAUL-MECHANICSB#8115 MECHANICSBURG PA ref.2444500206320�61560776 03/04 ' 41.25- : 742.$2 Witfxlr�iwal Debit Cand #2U641875$495 e�5 wHOUES�►t.E C 3so5 Har camp H'i1 P�► : 03/04 74.71- 668.11 Withdrawal Debit Card SIGNATURE DEBIT Merch.Post:03/04 OUTBACK 3921 MECHANIC�l1RG PA ref. 24692162064000855807321 __ _ _ 03J05 16.02- ' :b52.09 V1Gd1dl"dWdl Di2blt CdtYJ#Z06516393077 VVELS MARI�T'S�58 MEGHANI(581iR PA �C� � . �� BE�CD Service Telephone Numbers Direct Inquires to: (800} 642-4482 (toll-free) • (717} 232-3526 (in Harrisburg} Member Service Telephone Hours 8:30 a.m. - 5 p.m. Monday through Friday 9 a.m. - 1 p.m. Saturday Belte Automated Services: (800� 642-4482 (toll-free}, press 1 (717) 232-3526 {in Harrisburg), press 1 Rates: www.belco.org Your Billing Rights-Keep this Notice for Future Use Comp�te this section to balance your checkbook! � This notice contains imporfantinformation aboutyour rights and responsibilities under tl�e Fair Credit Billing Act 1.Enter"ENDING BALANCE"amount from your statement................... $....................�1) Please write to us at P.O.Box 82,Harrisburg,PA 17108.Send us a copy ofyour statement Please keep all o�iginalS. 2.Enter any deposits you made that are not listed on this In Case of Errors or Questions About Your Statement statement,including ATM deposits..........................................................+$....................(2) if yau think your statement is wrong,or if you need m ore information about a transaction on + your statement,write us(on a separate sheet}at P.O.Box 82,Harrisburg,PA 17108.Write .................................................................................................................. �....................{2) to us as soon as possible.We musthear from you no later than 60 days after we sentthe first statement on v►fiich the error or problem appearetl.You can telepf�one us,but by doing ..................................................................................................................+$....................(2) so will not preserve your rights. In your le�er,give us me following information: ..................................................................................................................+$....................(2) •Your name and accountnumber. ........................................... $....................�3) •The dollar amount ofthe suspected error. 3.,4dd lines�&2.......................................... •Describe ihe error and explain,if you can,why you believe�ere is an error.If you need more information,describe�e item you are unsure about 4.In part B,list any checks you wrote that are not shown on your statement.Include ATM If you have au�orized us ta make your loan payment automaticall from your savings or withdrawals,BELLE transfers or automatic transfers.(You identify these by placing a checwng account,you can stop�e payment on any 8mountyou�ink is wrong.To stop the check mark in your register next to each check that is listing on the staternent). paymentyour letter must reach us tl�ree business days before�e automatic paymentis scheduled to ocxur. Place total on this line............................................................................... -$....................{4) Yo��R�ghts and Ou�Respor�stibti4ities Aiter We Rece�ve Your Writte�►Nottice We must acknowledge your le�er witl�in 10 days(20 days for new accounts),unless we have 5.Subtract line 4 from line 3..................................................................... $....................(5) corrected the error by 1hen.Wi�in 45 tlays(90 days on new accoun�),we m ust eirier correct the error or explain why we believe if�e stafem ent was correct The balance on line 5 should be the balance you have in your checkbook.tF you don't ARer we receive your le�er,we cannot try to collect any amount you ques�on,or report you balance,check the following: as delinquenf.We can can6nue fo bifl you for 1he amountyou quesbon,indutlmg finance charges,and we can apply any.unpaid amountagainstyaur creditlimit You tlo nathave to 1.Is your addition and subtraction correct in your register and in sections A&B? pay any questioned amountwhile we are inves�ng,butyou are sfill obligated to pay the parfs of you�Statemeflt 11'1at a�e not In qUeS60rt. 2.Does the dollar amount of your check register match the dollar amount on this ffwe find thatwe made a mistake an your statement,Xou will nothave to pay any finance statement? charges related to any ques�oned amount lfwe didntmake a mistake,you mayhave to pay finance charges antl you w�ll have to make up any missed paymenis on tt�e questioned 3.Are all deposits and withdrawals accounted for?(Including service charges or amount In either case,we vwll send you a statementaflhe amountowe you owe and the date that it is due. dividends) If you fail to pay the am ount�at we�ink you owe,we may report you as delinquent However,if our expfanabon tloes not sa�sfy you and you write to us w��m ten days tef(ing us g,Checks and withdrawals that are not on this statement 1�at you still refuse to pay,we m ust tell anyone we report you to ihat you have a quesfion aboutyour statement And,we musttell you tt�e name ofanyone we reportyou to tt�atthe mat[er nas been semed beiween us when itfinaiiv is. I chQ�k�umber AmoUnt Ifwe dan'tfollowthese rules,we can'tcollecttt�e first$50 oflhe questioned amount,even if your statementwas correct Finance Charge-Balance Computation WP,11(]UfP,111P,1111�11CP.CI'tA�(1P.�Il Vf1Ur Rrrrnrnttrtr an,,��.,...��•�..--_,...__.y_ __._._... - - —__ to the"unpaid laan balance"afler the previous aymeritwas made.This ives you the interest far ane period(day).We then mulhply�e interest for one period�day)by tl�e number of periods(days)which have elapsed since tl�e lastfinance charge was applied. The balance used to com pute the Finance Charge is the acival unpaid laan balance each Special Rule for Credit Card Purchases ff you have a problem wi�the quali of properiy or services that you purchased with a credit card,and you have tr�ed in good fai�to correctthe problem with ihe merchant,you may have the right notto pay tt�e remairnng amount due on�e property or services.There are two limitations on this right (a)You musthave made the purchase in your hame shate or,ifnotwi�in your hame sha� w�ihin 100 miles ofyour currentmailing adtlress;antl (b)The purchase price musthave been more lhan$50 These limitations do notappl ifwe own or operate 1he merchant,or ifwe mailed yau the advertisementfor�e praper�i or services.____ Total . . � � � +�,. � - Statement of Account .� - � �►.�,�..1� � ! � ,. .1 `.,k� 4 iy�.:'��4 f.3. : .i,.�f.�.:�..�1:��µ f 449 Eisenhower Blwd • Harrisburg, PA 17111 Member Number 100000U0C20 i: 3 Statement For 03/01/2012-03J31/2012 � .� Page 2 of 3 • t Corttinued from pr�vi�s pa� post� Transaction Balance Tr�saction descriptiion 03/06 20.00- 632.09 Withdrawal Debit Card SIGNATURE DEBIT Merch.Pvst:03/05 CBN DONATION 757-2263334 VA ref. 24492802065118000133823 03f 06 �CI.I`I�?- ' ,572.I�3 ��Wdl�bit�I'+d SIGNATURE DEBIT`Me�+d1.Pvb'�03/�NEW FpPE MINLSf 7`17-432-2067 PA ref. ' 243230(�Oii6�.7�D6501Q01� 03/06 10.37- 561.12 Withdr'dWal�It�t'd#206G189S5424 WQS MARKETS#58 MECHANICSBIJR PA 03/0� �10;�0- ' 351.12 W�awal Debir CarYi SI�NATURE DEBIT M+�r�.�03/0�r�ARSa�Mrn�tES m'8i�-s�a�: TX ref.241�1s7�0EiG000f1�6674�56 03/07 54Q.�0 $91.12 Deposit ACH C4MM OF PA t�D rn�:t�IEFITS ID:1031301424 CO:COMM OF PA UCD 03/07 ` 9:�9- ':8$1.13 VY�fra�wa�Debit(�ard#206�'i369727�t�aNT�2�s ca��m.�.pa 03/07 10.16- 8?0.97 Witl�drawai Debit Carrl#20fi714741042 srnntr 62�9 caMP Ht��PA 03/08 71:64- ' 799.3� IA�ra�l t)ebit Card SIGNA7I�RE DEBIT M+�.p�o�sC 03/07 F�RITAGE MEDIGLL qtCK1P 717-909-�118 PA�f.2�4506012t167�6fJU�9441495 03/08 28.22- 771.11 Witlxirawal D�it Card SIGNATURE DEBIT Merch.POSt:03/07 FIRESIDE OF NEW CUMBER NEW CUMBERLAN PA ref.243230020b7124193010091 Q3/08 1b6:63- 6i14.4$ II��C�A�I D�CdiCI SIGNArtURE DEBIT Me�k P�f�03/aY AM�RIeAN WA'�6L 8G6 2692�i,37 VA nef. 24g064�106TII9l837g3627 �3/O$ 1.$0- 602.68 1N'tthdrawal Debit Card SIGNATURE DEBIT M�ch.Post:03/07 ORC*PAYMENT FEE 800-8207496 VA ref. 24906412067719183781720 � V�,OQ � :� 7�J:lJV' � ��:��L.� Witt�drawal Debit�ard SIGNATURE�EBIT-�:M�nchr��r��L.Gk+1 ��J71-1��V11'Ir�`.rA�1..��:. 2�05�242t168�001t�100036 03/08 54.99- 497.69 1Mtald�dWd)D�It C81?C1#ZOG$iS3373Z4 BJ'S W!-IDLESALE C 460 Stat CAMP HILL PA _ __ _ _ _ _ _ ___ __ _ _ _ ___ __ __ __ __ __ __ _ _ _ _ _ _ _ _ _ 03/08 ' S5.00- �32:69 IlM/�d#'1�'dW31�Cdf�S��i1�4�U1�E D�B�'f M�Ch.Pa6�03/0!NEW}IOPE MIN�St`717-4�2-2067:PA ref. 243230�2t)68123t)E'i70100�2 03/08 1b9.97- 2fi2.72 INithdrawal D�it Card#206817707G82�antr 62c�c�P t�t�u Pa : _ Q3/08 �`:00- 22Z.7"2 Ul�irttxirawal�AT�I:#000000005079 e�co co��r cu�sa��kc�►u��Pa�s0002 03/U9 16.50- 206.22 Witi�drawal Debit Card SIGNATURE DEBIT Merch.Post:03/08 ARBY'S#1172 00011726 CAMP HILL PA ref.24164072069945340286272 03/09 ' S0:0�3- .156.�2 Wldl(�dW'al d�J�TM`�0000000052�5:BBfi�COMINNNVITY CU 3500 TR�DLE ROAD CAMP'HILL PA 35t)OD2 03/09 403.14 559.36 Deposit by Chedc _ _ _ _ _ 03/09 1$:70- , :540�tf'i Witl��wal Debit Car+tl#�7000829894 ers wHOt��c�sos:t�cama�pa 03/10 b.55- 534.11 Withdrawal Debit Card SIGNAIURE DEBIT Merch.Po6t:03/OS MCDONALD"S F2449 CAMP HILL PA ref. 24427332069710046521Q�'i 03/10 74:33- ':459.7$ W�tt�rawal Debit Carri SIGNATURE DEBFi'M+erd�.P�o�+u3�os'n�ouv�r�ua�ooia��2 MC-CHAIVI(�Bl1RG PA ref.2439900207014U00�102925 03/10 13.80- 445.98 Withdrawal Debit Card SIGNATURE DEBIT Merch.POSt:03J09 TFiE OLNE GARD00014712 MECHANIGSBURG PA ref.2439900207014000041U450 03/11 ' 11.OU- . 434.9$ W�ttdrawal DebiC Card SIGNATU(�E DEBIT�I�nch.P�t 43/id MCDONALDS F15788 MECHANItSBURG PA ref.24427332Q7�OT�003BU�471Z 03/11 Z3.6$- 411.�0 Wlthdl'dW81 D@blt Cdl'd #Z07117379016 KARNS PRIME&FOOD LTD LEMOYNE PA ��03/�2 21.18- 390.12 W�drawal D�it�ird SICNATURE DEBIT M+�h.P�o�o3/it�NONG KE�AIG�6V41lA PA�+ef. _ 247'6501207101000b140296 03/13 20.28- 369.84 Wlthdl'dWal D2blt Cdl'd #20731822$1$9 CVS 01622 01622-LEMOYNE PA 03Ji4 31.56- 338.28 W�drawal Diebit Card SIGNANRE DEBTf:Merch.lros�03/��►ts o�t�i��a�o�E Pa re�. 24323002a73253233013542 03/14 23.42- 314.86 Withdrawal Debit Card #2U7419731976�'S WHOLESALE C 3805 Har Camp Hill PA 03/lfi ;' 46.74 ' `26$.12 Witl�dtaWal Debit Card#207618433706 e�5 w�at�sa�.E C 3so5 Har camp t�l PA 03/20 24.99- 243.13 Withdrawal ACH L A FITNESS�:�a92sssioo i�:1330774939 CO:L A FITNESS 0�/20 < ` �4;99- :218.14 Vlrithdl'awa!r4CH L A FITNESS rn�:s�32sssioo ID:�77�s tjo:�a FtTr�ess 03�20 96.00- 12z.14 Wltlldl'dWd)ACH L A FITN ESS TYPE:9492558100 ID: 1330774939 CO:L A FITIVESS 03/20 . 7,Sd0.00 7,622.14 De�asit;I�rnG wt�J cur�w�An�a VAU.Etr 03/20 99.54 7,522.fi0 Withdrawal Home Banldng Transfer To Loan 0014 �C��s 03/21 �482:85 8,005.45 Deposit by Chedc : ; > : J 03�21 59.33- 7,94fi.12 1MIb1dl'dWdl Deblt Cdl'C� #�0812OG37HC4 THE HOME DEPOT 4120 MECHANICSBURG PA 03/22 189:�3- 7,756.69 VY�irawal Debit�ar+d#208220�73899 n�worHE o�or 4izo Mt-cw►nn�tG pA 03/23 83.82- 7,b72.87 Withdrawal Debit Card SIGNATURE DEBIT Merch.Post:03/22 SHERWIN WILLIAMS#5167 MECHANICSBURG PA ref.2461U432U820Q4004256566 03/23 : ' 540.00 8,212.87 D!eposit;Aqi C4MM QF PA 11CD't'wE:t�CBENE�IT5It7:1031301U24 W.coM�t o�PA uen 03/23 60.�2- 8,152.85 WItI1d�dWd) DEblt Cd171 #20$3119219Z5 BJ'S WHOLESALE C 460 Stat CAMP HILL PA C13/23 ; ; g9.82- 8,053.03 1N�Id1d�l Di�blt C81'�d#20$30$6912d9 WEIS MARi�l'S�58 MC-CHANI(SBUR PA 03�23 1�8.$1- 7,�.ZZ 1N�1#;F1t��8W8I Deblt Gdf'd #ZOH�1990475�THE HOME DEPOT 4120 MECHANICSBURG PA 03J24 ; $6:75- 7,857.47 1N�Id1dl'dWdl D�It Car1d#205422�0$239 BJ5 WHOIES�ALE C 38�5 Har Camp FiA PA T .. , ,.� �"..r��, . _ M■ !ie �� M�Y u�� .�� ' .. ..�..,4 �.�.�. ...�:. . 449 Eisenhower Blvd • Harrisburg, PA 17111 Member Number �0000000c20 Statement For 03/01/2012 - 03/31/2012 Page 3 of 3 , , � , , � � �o� � Continued from previous page. Posting Transaction Balance Transaction Description a3/25 100.d0- 7,757.47 Wlthdt'dWdl at ATM #O00000007378 BELCO COMMUNITY CU 3500 TRINDLE R�AD CAMP HILL PA 350002 03J25 10.14- 7,747.37 VII�ItI1t1f8WdI De�llt CBft� #20$S11947174 WEIS MARKEfS#58 MECHANICSSt1R PA 03/25 23.64- 7,723.73 Withdrawal Debit Card #20851$055418 B�'S WHOLESALE C 3805 Har Camp Hill PA 03/26 74.31- 7,649.42 Withdrawa! Debit Card SIGNATURE DEBIT Mer+ch.Poet:03/24!-iONG KONG BUFFET ENOLA PA ref. 24765012Q850i0000144581 " z.;i�i�Q3/26 280.50 7,929.92 Deposit by Check .,J 03/26 48.97 7,978.89 WItI1df8Wd{A�dJUShTletlt D2blt Cdl'd #ZO$b2O99196G THE HOME DEPOT 4120 MECHANICSSl1RG PA 03/26 �1.79- 7,947.1� WlthdCdWdl D2blt CclCd #ZO$C17581164 WAL-MART#1886 MECHANICSBUR PA 03/27 �.45- 7,89b.65 Withdrawal Debit Card SIGNATURE DEBIT Merch.Post:03j26 SHERWIN WILLIAMS#5167 MECHANICSEiURG PA ref.24610432�6004044T59756 03/27 31.12- 7,865.53 Withdrawal Debit Card SIGNATURE DEBIT Merch. Post: Q3/2fi ISAAC'S DELI#21 MECHANICSBURG PA ref.24323002086253803011772 03/27 220.65- 7,644.88 Withdrawal Debit Card SIGNATURE DEBIT Merch.Post:03/27 COMCAST OF CENTRAL PA 800-COMCAST PA ref.24692162087000002216155 a3/2� 88.0$- 7,556.80 WlthdCdWdl D2blt CaCd #20$722517521 CARLISLE BARRAC BLDG 851 CARLISLE BARR PA 03�28 56.00- 7,500.80 VU'�thdrawal Debit Card #208810263542 e�'S INNOLESAlE C 460 Stat CAMP HILL PA 03/28 250.QQ- 7,250.80 Withdrawal Debit Card SIGNATURE DEBIT Merch. Post:03/27 NEW HOPE MINIST 717-432-2087 PA ref. 24323002088123087010022 03�28 41.32- 7,209.4$ WIf11dCdWal Deblt C8t'd #ZOH9OO$1�7OJ THE HOME DEPOT 4120 MECHANICSB(JRG PA 03/28 9.80- 7,199.b$ WlthdCdWBI D2blt CaCd #ZOHH0051bOS6 GIANT 6269 CAMP HILL PA 03/29 646.05 7,845.73 D2pOS1t ACH PA TREASURY DEPT TYPE:ANNUITANT ID:1236003133 CO:PA TREASiJRY DEPT 03/30 4b.45- 7,799.28 Wlthdl'dWdl D2blt C81'd #209012761934 GIANT 6269 CAMP HILL PA Q3 f 30 100.OQ- 7,b99.2$ Vlrlt}'idCclW81 8t ATM #ODOOOOOUHZZH BELCO COMMUNITY CU 3500 TRINDLE ROAD CAMP I-QLL PA 350002 03/30 7.2b- 7,692.OZ Wlthdl'dWal D2blt CdCd #20901934$377 WEIS MARKETS#58 MECHANICSBUR PA 03/31 0.26 7,692.28 Deposit Dividend 0.100% Overdraft Fees M-T-D Y-T-D Share-0040 Total Retum Item Fees $0.00 $0.00 Share-004Q Total Overdraft Fees 0.00 $35.00 �.�.��.�.� , CQ. �� C}�PT_ C�t}GF( NUMBER 055 �� Q072?7 60p04a XN50K ��,04„�7� , Earnings Statement �� BIEBER FLE"ET�'Et3VlCES,LLG Perirrd Ending. a3lf QJ�Qf� 32�FArR STREE'T Pay Date: Ct3/16/2012 KUTZI'UWN,F�A i953�? Ta7cable Macit�t stat�ts: Married M I C H A E 1.. F D A tJ Exemptions/Allawances; 1� P L A 1 N V I E W R C1 A D �ederal: � �AIV#P N 1 l,.C+, P A 17�11 �a: tvr� Harrisburg G; 196 Addition�!Ta�c Sacia!Securiiy Number: �CXX-XK-00�45 E�rninc�s rate hours tnis period ye�r to date +l�th�r Bene�ts and fi�gul�r 15.38t}� 4C}.{}0 6't 5.20 5,��.�4 1�1ft?�t't�#Ittt1 this }�eriod #atal tc� date ` tJvertime �'�3.03 �01 K 278.52 Holiday 24s,c38 Vac fi15,2tJ i/ac Balance -40.C►Q _�.,.;.;..��y . rr .. . v , �'-#�}�� ._ {f �`r � ' � �'��Q fi �3.31 _...... .:. � ., y..�.... u yr a� i.�..,� _......4�y� ._...._�.x Deductians St�tutary Federal income Ta�c -3�.53 44�f .06 Sc�cial S�cu€�ty Ta�c -2�.84 �92.4Ei Medic�re T�c -8.92 1 C�t,97 PA �tate Ir��c�m� 7a�c -1 f3.B9 21�.78 Harrisburg C {nc�ame T�c -6.15 69.64 �awer Ail�n income T�c -8.92" iCh0.97' PA SU{!�[�! Tax -t�.49 5.57 Qther Adp 40i K $ -24.fi1* 2?�,5� �st -1 ,tX3 11.4t} -�:.:::..:.......:..... ... _; ; :.�. ' �:�::��';; � '��+';� * Excluc�ed fr�m f�d�ral taxable w�ge� Your federal taxable wages ihis p�ricad are $59�.59 _ _ o2n�o�ton.�x- __.� . � �� r ... _ C1.A11�[�{3R Ut�PA1t1 CCtMPEi��ATiO►N��DE�EASED�iE�iBE�0�'THE UNIFt��tE�1 SE�iYlGES r ir.� ��rrr��rr��rnr�rw��-r�r i i i��r r rir�r�+ r�rr�w.�rr C�ener�llrtfo�nat�On: �u�y�ss�stSr�Ce�eemed n�ary#Ot`t�ie�fopeT�Xe��ion�f t�s�c�rm w��@ furrl�f�ta a�CI�In� ��mP�9�9@�Y. Fo+�vvard the c��feted f�rtn tc the Govemme��gen�y�wfiich the de�ce�sed w�e�loyed$#fime - i !f�� - �� rr�r ��r��r��w - irn r+�i � (� ��V Y1M�� .. � ��i �� i7� ��.�� - f1l1�� ' ` a. � � � � ��t� �� . �� +�► �; ��?�G,��,�"�.., �ompe�ion cn t�w�h�ca� � `��..°' } '� es o� �� 5, �yot,ne�,e�a�r��sd�r ss or �, ,r�nitortmfrip,�tvk'� 7. �of cba� 8. N�e�aia� � �'�'�°a'r�'` . c� � ;�� ,�..�.� , -� �.�!`��.�.�.:, �„�,�., �� , ,�',�� ;�.., �. �. do�s - _ x ��t��.�.�:, -- ---. __ _ .___. -��--�,;��ti-�, � _. � _ � _ - � �`� �;� - � .� P�urt� (To be com�tad by tt�e wi�ow ar wi+ct�c�#h��ec�se�d cx�r.} t�o ya�u ce�y ti�at y+�u re ' to the deaedent �f to#�best c��+��auwurl�c�e�nd��f#he rr��ci�e was r�c�t t�i��ed�r�c�r to�s/t�er d�h? +�WIt�C► WIDt�WE�t ANL}�f�NATED B�tEF�ARlES Q�Q#+�'R11S.�N P�►RT C. A�l C�THEAS MUST. Part C 1. t.ist��►th�r��tme,��s��curi'ty nt��t�t,�,r��a�rr�s1�►,an��ddr`ess t�: ��a '�lid�w or wi+�o�+er. �f!iQ�I�W tK Wt�CWB!'St1�YiV8S,�8�1 � G�i�d+C��d�C$�SBt��i�UdB��ti�, �i .,fYfS�B, 8nd dnd�"ld�8 S�@C�!'18fi��. YVhlG�d�5}Dx''�h8 d85C�Tldl�tll#S��. {C} �`i10 ' #�f W#i'�V�C,C�G�T d9St�!►RdBttt 0�i�8�tf t'�11�i�SUtYIN�S,f�8�'I S11NMf'fg�,�8T6t'It S�d Sta�Wt�h�na�#iral,�eP:#�t8r,4r�dQp��a��r�s�i. �d} lf r�ne vf ttie�a►ve survive�,�ist the next of tc��who n�y be c��a�of inhenting from the de+�eased � {br��l�rs,s�te�,dest�r��ts of tiec�as�d b�r��he�s ar�d�s##��s}, N�e�e��y r�tt�r Ag,e, Re�t�sh�� As�iress [�ece�d (Con�nued on ather s�fe) S'�anda�rd Form 1174 HAiIE'YOU ENCL.C)S�U A [�EATH GE�TlF1CA�'E? ��'�� . �r r��a�i.w r �...��... ...`r....�� ._.. _..._... ��-IIIIIIIIIIIII��' �'F •j � SF�1?4�E3�ck} Pa�rt D 1. !f none t�the dbove sunmres and a�n executor or adminis#rator has been appointed,t�e fo��a�rir�g staternent sh+tKdd be a��q��= �� i l we have been duly appoirned � of the estate of th�e de+�e��c1, as evider�cc�d by ��a�� certi�ate of appan�r�nt he ' admin�tration having b+�en tafcen aut in tt►e imte�est of �` -� , � • � � �- �� w � �'\ � .... ti ` , � �7 �..� � � c��,�. �� ar�d sucn appo• is sfi"!I i�futl f�roe ar�cl�fe�i. NOTE--�r�eMoe�da�en�s the�oeecubr or�dmm"�ra�ar d`tt�e�ate a#1he dec�sed.no��en�requa+�d„bu�a awrt�te enntierw;�r�g yiowur �or+e+�a�t�o��. : 2. If na admmistrator or e�:�utc�r�s been ap�ar�#e�d,w�#1 one be�ppointet�? �,.�,�*�' UESIGNATED�SEf�FtCU1AY,SURVt111NG�►PQUSE,C#�L�►►REH�FAR�I�'S►,OR!►EG�►L RE�'RESEt�iTATiVES DO NOT �.t�t P E. ALL t�TN�IRS�UST. P�art� HaVe tt�'�ur�iete�l eXpenSeS bee'c�pald? � �� ff pa�d, (8t�:�d b�l t�f the Un�'�ettaket tnUSt b@ a�tt�ched hETeto.} � �� 1Nhose mt�r�ey was us�ed to pay the fi�r�etact ex�ens�s? � Part� w�s,�wu.n�s,,��rua�ss��t�a�.�arr�.�atr..a��aa�c d�is�e�tbe uaia S1�s al�.aWd�g�#��in oaar��a�a�w�A � �. � �'i��. �C� ��I.�. 0� � ��" ��n c�s �ra� � c�� ° �� '(�,�,: � �� ;� � -� cs��i �� r `� � �� ,�� P� � � � � i �M iiH1iG}- � O�i/ � �� ) � �� _ • 1 j /� � F C� .....� L � j t j � s f i t t _„i (PIM;MIC tILMl�lf 81Ei ) ryi1#l�Ef i11Mi CO�! P�lt G ?1N�WITNE: ''A�i�RE�l�p � We a�+rhfy that w�are we�l ac:quainted with the abov� �'�'N� � �- ��t'f t,.� ::#�� . �nd th�tt the � signatu�{s}c�f the��{s}was{wer�}af��d in c�ur presenc�e. . -� - �'�� ''�`�� . �+�� '-�.�. �T�i�,�.�� _ c�a�� .�_�. .�� f�-c ti.i a� c�c�a u��.c��,��r��o+a a� � �� '�"�t�..c r�Z�L � tres� � {sUee3 a�akJr�} ��fit�� l�'� r�. �''�- t �1 ��11"�.� ��t�t� , P A� t '�l.� t��t : tt�ty,sta�.�wna 21P c�ee) "' (�dy, ar�d ziP cacrej —� A1 Feder�!��t�iw�r di tl�e da�"smant,drawrt to t�t t�'of the d�rt,�payn�nt Ot pp�y and��ne�es sfio�d axamp�ly�his dsin. PRtV'ACY ACT Ntt�`� The sa�s+atxxrty nu�er�the nexi o#lan cs sdr�d pur��rd 1��+e+�uUve C}�r 9�97 c�19�3. i}�t�re a�1he sa�se�t��u�rr�ber t��he n�tt t�kit��s vt'�u��ary twt �re�ly usefi�to�r i�+m since riea names and ad�ress�.s ma3►�. AS a�you sh�r�a�d�sd�s�e'�+e sop��nurt�ber c�f 1he�nct c�k'h�houtlhe� ptx��a�td I�aw�ge�t the�cst�a�sr��v�k�ttary a�d w�b�e us�c�#y�p�s af,de��ifica�on. `Et�e s��l s+�t nu�b�r t��e n�ud af kn wi�be r�ed��dent�y - N.��.w i,w..�..w�.,r.r..�..ii..r wwL.i�w+iiwr iL�«w.ir...w. "1'1.w..rlw..wd+w.i.i...wi+w....w�a.�wr+..wff twfa�A�a iw..wnw'L....w Y�.��3r.�.�i�,.,..�..+i.:..l+i.ai....1.i r�..i.. 1�+�...�..ww�. ��i�� i I�V�� DEAR �YNTHIA G DAU 12Q5Q7 Y�U MAY HQVE RECEIVED OR WILL BE RECEIVING TREASURY CHECK NUMBER 79935969 IN THE AM�UNT t7F $ �18. 4� . TNIS PAYMENT IS DUE YQU AS BENEFICIARY OF DECEASED SERVICE MEMBER DAU MICHAEL F SSN 4$364�045 . RETIRED PAY DEPARTMENT a000�� CYNTHIA G DAU A/C MICHAEL F DAU RETIDEC 1� Pl.A I NV I E1� RQAD CAMP HI�L PA 17011 -7928 �__ �....�._.._, _._�. �.�";�'`"... �t., .�-�---- ,...��,�,,,,d.w...... � _< � PRESORTED FiRST CL.ASS �� __ U,S.PQSTAGE � DEPAk�YM��T OF DE�EN�,�E Pallo DEFENSE FINANCE AND ACCOUNTING`S��E _ 1NDIANAPOLIS,�N US IV11LtTARY RETIREMENT PAY PERMIT N0.1128 PO BOX 7130 �ONDON KY 40742 7130 OFF4CIAL BUSINESS .Y,,�''�►"' �'�r' ''"�'`►"�` ��I'�` ��' � � � '� `�.. '�. °�'�. � � � � � � �. `�, `r �� `,�, � � �. ``�, � � �. . �. � � � � � � � � � � � � # � � , � � � � � � `� � � � � � � � � � � �� 4 ``�, � � . � � � '`�. � � ',�.. `,�. i �,. �. a��. � # ( # {�# ��t ;;� � � �..�►� .'� ! ! � t�t it i�I t� � �r,�,1►��.._+r._��`�� t t � i�� t I �� 1 �� ,��1��l�l�i�� r f I �l� 310 �:.�j_..:��:��.��. �.'�'=-x� �. � ��.�� _. r. - y:� � .� , ,_ . k. �� RETTRED PAY - :� . .._ � 031 ,Q33, 1$2 PAYA6L� aNL.Y DUR�NG � �� -�� .��- �,. � �`-�., ��. � :�� -� �. : LIF� 0F PAYEE ��z::.� ;�.� �' �. :�� }(NEA4{1Q45 DEFENSE f IMAt�CE ' '` ANp AC�011N1��N� SE�V�CE 852�-79435969 = �� .�` CLE1�Ei�A1�D CENI�ER ,, '-: � *•�-�={ 7�9 3 5 9 b 9 �t P�Y D 7,,�.(3'�2 P : ��- �,.;�� *oa** aoo��E-p��c� �3��a � t�G<s::�-_��i C Y N T Fi Z A G D A U � w.� � �••;. �1 C M I C M A E L F D A U RET/DEC �*****G 1 8*Q O � 1Q pi�A1NVIE�f �t?AD �y�: � _ ; CAA�i� HILL PA 1�0 1'!—l��$ v��a��v�a� � �t11�i1llil��filllil�#ll��l�i�[1�If11�i11tiF1�/1��1I1fl��l� �` r'I �' �,� , r�..�.y' � �� ...�.. _ o;-� - �*�**�618t�Q��.AR�t�CEA�TS � ,_ ..�._,.....�...,�.�..�..�., �"8� C 28t� �.OQCI�IOQ � i�8�: 799359693�" 41D5 L � . - o ^1 ` �.T ��1�.�1'� � � ,� . . � ! ��r�� v��l� � J� DEPARTM�N�'O�R�V�NU� � �r��►3�,2a I Z Joseph R.I7'Annunzio,Esquire Lat�+�ffice 4309 Linglestotvn Rd, Suite 211 Harrisburg,PA �7l 12 � Re: �state of Michael F.Dau F�le l�umber 2112-0373 �aurt of Common Pleas Dauphin Caunty Dear�.D'�C�nunzia, '�'he Deparf�nenY of Revenue received the Petition for Approval of Sett�ement Clai.ni to be filed on behaif of the above,referenced Estate�regard to�wrongfi�l death and surviva�actian. It was forwarded to t��is B�reau for t�e Common�vealth's appravat of the allocation of the proceeds�aid to set#Ie the act�ons. , Pursuant to the Petition,the 64 year o�d dec�dent died as a result af being s#ruck by a motor vehicle. The sole�eir ta dece�ent's esfate is his spause. There�ore,any proceeds paid ta se�fle the survivai action wac�ld pass to decedent's spouse ar�d�vauld be sul�ject t€�a zero percent i��heritance fax �-a#e. 72 P.S. §91 I6�a)(�.1)(ii). Accordingly,regardless of the al�ocation of�he sub,�ect}�roceeds,there would be no in�eritance tax co�sequences. Flease be advised that based upon these facts and for inheritance tax purposes only,this Department has no ob�ec�ion to the pro�osed a�ocation o�the net proceeds of this acfio�,��bS,U�0.4Q to the wrongful death clai�a and$�to the su�vival claim, Proceeds of a su�-vival action are an asset inciuded in the deeedent's estate and,although subject to the i.mpositior�of a zero percent i�eritance#ax rate iu � t�us insta�tce,they mvst be re�arted on decedent's Penvsylvania inl�ei-�tance tax return. 42 Pa.C.S,A, § 83U2; 72 P.S, §9146, �107. �osts and fees must be deducted in the same percex�tages as the proceeds are a�loeated. In re_Estate of 1Vlerrv�nan,b69 A.2d 1�59�Pa.Cmwlth. 1995). I tn,�st that this lette�•is a suffic�et�#xep�•esentatior�af the Departmetrt's pasition on tlus matter. As the�epartment has no objections to t�e Petition,an attorney from tl�e�epartmen�of Revenue�vill not be attending the hearing regarding it. Please con�act me i�you or the�ou�t has�ny c�uestions or requires anything additional fro�n this Bureau. . � Si cerely, , 1 ��! i� '��i•l}Y`_ �L�i�--� � ±/:�,.)`' ( 1 � �S nnon E.Baker Tr�st Valuation Spe�ialist Iuheritance Tax Divisia�l .. _ _ _._T-__. . ., �n ._ _ �. ___... ._ ._ . . . �� e.. � �,, , IN THE CO�'�`OF C�MIV10�T P�.EAS DALTPHIl�T C��EJ1�1'Y,PErTI�TSYLVAN3A 4RPHANS COITRT I7�l��IC�N ; IN�`�E Il�iTEREST��: : N4.�U�"�C" ��l ; i1�IICHA�L,F.DAU,A DEC�ASED � PERS4N � , ORDER APPROVING CONlPRONlfSE, SETTLEMENT AND DiSTR[BUT[ON 1 AND NOW, this �� day o€ 2Q'(2, upon consideration � af the Pef�fian �or Ap�roval a�'Wror�g�uf Dea Settlement, it is hereby ordered #hat Peti�ioner is author�zed to enter infa a settlemenf with Pro�ressive Specialty �nsurance Campany and Government Employees Ins�rance Company in a gross amaunt of $165,QOQ.QO on behalf of�he deceased. Cynthia �. Dau is authar�zed fo sign a�l Releases necessary in arder to obfain the seftlemen� praceeds. Upon rece�pt of the �xecuted Reteases, Progressive Specialfy Insurance Company and Go�ern�ent Emp[ayees Insurance Company shall forward a�l s�#tfemer�# draf#s or checks#o Pefitioner for p�roper distribu�ion. The s�ttlement proceeds shall be a[locafed as follaws: A. �"o: Cynthj� G. Dau, as surv��ir�g spouse of Michael F. Dau, $�5,ODO.OQ from , P�ogressive Insura�ce Cor�pany B. To: Cynthia G. Dau� as survi�ing spause of Michael F. Dau, $�50 000.04 f�om �avernmen# Emp(oyees I�surance Co�npany � BY THE COURT, � Judge � riJ�v �: �'...`i �Y�s:''i..:....� Z1'T""' •3 "�a.�__J _. .=� �..�� .. ,�,....,... �. o�ty nsure ate ssue rea o e ra '�_:;"" ��55��=�8�-�� LaLDOi�aDO,J t�`:�� s��`?�:�]� -C� umber 4 7 519$7 6 S -�:r Gain�# Ctaimant Date of Lass St,3te Co�e �ffte issued At PAC 1?4?I 1��f� D:atT.'1iICH.�EL ��`1? '_��13 P.� PA-Cr�SVl�P-�iRi�- i „�at3k'kX�J.�.�� *.�.1�.u�$ Y . �� rII�T�L•�TIIC}LS:�\D�tiD C�l;'�� .� .:3L�;.,C:>.. v: ' Ft;LL c�.FI�1aL SET`F'LEi�iE�'�I',BODIL�r I\T3t'R�T CL�I�i F4R�itC}I�EL.D�L' �vr� l?PCL ��°...'A'� .:r`�:_ PNC Bank, N.A. 070 ��H��r.:. .;:-.__. _-�-„_�=:-��z- ,,. �r�g>-��si�'e �p��ialt; Ir.�urar,ce ��z:pan_r �:..tT CYI��THI�D�L:•UtiL1'*��:�y�Y�%�:x:�:�*;:��:��x��*��;��*x�..��x,�%#�� 'i . T; IO PLaII�VIEt�t'RO�D `, � Tre G'+"��P H�L.L P�► �7��t1 � ,.- �r�er ��`'�, �,_� �.: G� g��; c"...:.,.--��''` h-:��:�;��;�.� s�c�:�ature ��4 ? 5 �98 ?68��' �:0�+ � 203895�: 4 23q69450��' :;:�: .. � ��.�e� � �'�� ,�A Detailed Paymen#Summ�ry ru�-�:�ti��:ti r��°;�:�Iti�� .�tic;�c�c� N{�.�T 12�899��8 c��E��IC�_�B�l�� FFEDE�.IC'.I��BtTR�. t`.� ?`�414'-O(�� laim# Qate of Loss Clate 0��i cs��:�}�lE}1t111):a[) (1:;.::.;.""�(7:j'' t)':':3};�(t1:: Field Ciaim Center: Adjuster Cade: Paymen#Type: T�ID='SS#�At#y AD,}Code 0;� Frr��F!€;ksE��:;; t1 j'; LC�`S Ctaimant Name Tota!Amount h1It�;H:�LL�'I7.=►t_; �;*}#�:r-<1'il.�)1){!.t)f) Insured Name G�'tiTH;:� D.'�l_: Pay Ta !P and Feature and Amount c:��i:�c�. D:-�� .� . -�.; �� _�� . . .... . . . In Payment Of �"t��.?Zlt�: �EL��`t�lT�Ri�TC:()`�(3. i��'LL��u1:�L�ET:L��i��(-��= ��LL CL:�i�.�S�:;.I�:ti:�.�:1;t)t�''� ��;�Kt�C}tt:'ti t�'isit beico.c�m 1\io�rT,parties invol�ed in a �EIC[,}claiin can track the pragress o#the claim,vie�rT dama,ge photos and more at geico.cam! *GEICO p�lic�holders can make a �avment, change dr��.T�rs +ar�,�ehic�tes and request additional cot=erages.� Not insured�+�ith GEIC�? 15 m�nutes could sa�re��ou 15°�o ar more on car insuranc;e. Of course,�ve're also available for�olicY or claim ser�cYice�4f7 at 1-8U0-8�1-saoa. � These oaline services are una�Tailahle tv ��lss�gned Risk polic�Tholder�. a��.�SvF�►C P;.EASE G��C�!��L�KEE�F��?��JR REC^=?4� .�,.,..o�,..w-,.�„��..._r:�....��..,-.3..,��.� .. ....:.:...... :.. ...�,,., ,, ,., . �.�..r r ; -_�,.�. � �,�,�,�. .�-.�._��v �, . �y,.-�. ....�..�_,. _....a .:;. ... ...,,.... .. _ __ _. ,_ . ---- _._ ._ ___._ . _ _. _ . __ � cQi�:��.��.�,rr�r��.o�-�:s��v��;��c:�.c�� Sa�ntc ot AmQrica � -a$ NQ. N 125$99848 � 1}:�ti.,�ililliQBLi�,1_S ,L � .. IT/1ilTFQT7�,`i!�Vi7�LV 1�.��rT l�T�llil:�'..C�58�.�f�.'1�:� �'R�:i�F1�CI�.SBtiRt�, 1`<'1 �i �i s-t�,�� Clsimant: G13t�'!Nt�1tb@1': 0"11�i42QL1#71(12t7.�1) Date: �7:;�3��c�3-,� lnsurad Name: ; ;��#7t:�i.'�F:i.(=t?�i� fsl`:�TH��I_y,�3_: ° � F��turo Syrn#�ot f�Arr�aunt: ` � ;�,. ,��r� ��s ��. �fl'��: .�^^ � � t. . � «.d�J• •i3.i�i�� 7f*'ll"XjC7C]T�'��ilel3V4l.� � !R E ( # +�F i:n 1.s+��.. �i�e+=:�x<r x -n n.x r}��n:F.�r w�i b�i s a>#*�M t)'�i-:-itC?_'•�1DiZL•D-�`14�"1`�"�Plit�i.=Sn?iD':�.�,�L'�t��li�C' L;f.)?.l.:'tK�: . Pa�r to tha Ordet af; !n Faym4r�t of: � la 1l�I��'1 tiT. a.Jiltt t_'�i�l��.�i�'.�t.��i��..'��Q��l,�)�'�3. Y �'�.T?,�.�c�'��i:tl.5�'.�i��''t'�� :�(.E.t:1..1Iht5 h L€��5.i�:tii.;)lt`1 ; �L.?V��;�}'4!'R � Meil To� ; Lr1��'UFFIC�.S C�}F T(3��EFH D. i7r�r�1,'�t;tiZI(7 ; �3U�LI:VGLE.ST(�t�13 R�:�I1.;�I.=ITE?�1 ? Hr�RRISB�:!R(:,�:� �o�3.� { � �::n.�«...•rn . .�.._��:+�:�.��nwa..M-_....e:..fz,r•a�+!r'-_....:r:-�w,m�-.•-.:.�w.....�-..�....�..�:x...; ..:...C:'^x'..,._ .-..s., � .n..:_�_�...�:..^::,t..�....,c.:�� .�.��.�.._sm�_........_.._.,...W....-.._�-ir�...._vv._...�-.___u.�!-�w•-.«.._..s�. -,-.vt"..-+c_:.N35Ki-.y".v--%aF-'::'v+.+.�.—r,?'.x-.-�....f�.-.«.aau..�.a .�-.t...r-o-.�..ri-.. ��' � C 5899848��' �.0 � i900445�: C30DC�000 �9 �9 �,t►• ��.�1v��, � � �;��r,,:�r�,�,��;��: _�:1}�.�:i�:�.��,�_-�.4,.�°_� ��;__,�a+;: - - _. �{ � ��-, � s '` �� f _ - it1�f t��'[ir�. �� v�:�� '. '��s4's��FS�r �'� ± �i _ ��Q �.��f�!��T:��ti�F� R��';, C,�#�'` ' ` �ii�L� � .��1 J il!i1`i?'V1J�'.11\L7r �� i.r.L, a � �� 0 .�4 Q a 0 0 P O O O a O n 0 a 0 0 0 0 0 a ��, a a m �a 0 � r e� !`t r"'y ^. �^'! � f`"' � � a.i .t nc' L� l E .�L% � �J�4� �.�.. � `�' C�_�\]((�� V/� �� REV-1509 EX+(1-97) � SCHEDULE F : COMMONWEALTHOFPENNSYLVANIA JOINTLY-OWNED PROPERTY � INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER . � r �� If an asset was made joint within one year of the decedent's date of death,R must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT a. ci l��, \►� ��1-� �ny 1�,v� � � v � 'f�. a, � � � S c� n � c � �c�,�„ ��11, �}- )�C�l) ��, B. ��'�'�a�'� ��5,a�r�C,C. ��.�. S��J,�. � �. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number.Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL(Also enter on line 6,Recapitulation) $ (If more space is needed,insert additional sheets of the same size) REV-1510 EX+ (08-09) � enns lvania SCHEDULE G p y DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER � ��) �-� b� 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 INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER. ATfACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE �. 1�� ,r'�I�n��ilS � �. ��"�. � � �..��r�1n�,r�' �� '�� .a �.��.-�� fi� C ,� �. � �, �� .(�,�1 �i,�ie-�.('�Y1 C�+ �1��'t�m j�-� �! _� �� 1� �(� � �0� 1 S �'7�. /� rn A m�,a j�,�� *-1Ci��, 1(n �:��11,� � TOTAL(Also enter on Line 7, Recapitulation) $ � � � � If more space is needed,use additional sheets of paper of the same size, � _� C�C'�M�1C?NiWEAC'�"�1 QF PE�VEi�YL.Y1�A � � STATE Et1AAPl.DYEES"RETiREMENT Sll'`STEM �NQRTFI TH�RD STREE7,SU1TE 150 � � HARRISBURG,�'A 1T101-1�16 �� : ,,��' , 1-800-f33-5�61 : www.�ers.St�te.p�a.us s REL.E��E AND��MN�FICAT'IC��1 AFFI�AVIT FC)RNI� Tt'�►OBTAI��►1 D�CEr4SED MEMBER'S RET'1REMENT AND/O�t DEATH BEt�EFITS Member'� �Jame: MICHAE�. DA�J �Jlemk�er'S S�N: X�CX-�tX-�045 _ _._--- State t�f ��T��'C�'�.�' ��S�:�'�t��, _� -- . �r� � 3 � s ��'�'s ��+��...�-.J'�..�� GOU�ty�# ��t-��' �c�.�� : I �-�` �'t�►�1C�. 'la - �,.. certi that 1 am the named �rsonal � _ .... . . fY � _f�-fi�am�} _ _ ___ _ represent�tiv�f4r or ben�ficiary t�f the ak�v�-n�m�d dec�a�ed nn�mber ("M�mber"� �f the Pennsylvania State Employees` Re�rement�y�tem ("�ERS"), and that in cQnsideratia►n o#the tvtat sum af�62.55, I discharge and forever release S��S fror�fur�her I�a�ility ft�r p��ment of any ben��its which h�v�accrc�et� �s a r�sult ofi Member's death. I further c+�rti#y tt�the be�t t�#my know��+dge, in�t�rmatic�n �,r�d belie#th�t at the time of Member's d��th Member was not n�med as plaintiff 4r def+endant in any d�vorce prc�ceeding fiied in a�y court withi�the�ommonweaith af Penn�ylvania and that Memb��"�assets wer� not subj�ct t��q�itable d��tr�butic�n incident to a diu�rce proceedin�fil+ed 4r pendinc� in �.Pennsylvania caurt. 1 further certify that 1 shall �t a11 times ��reafter�eep�ERS ir��mni#ied an� held harmless agair�st any and all � claims, d�bts, and liabilities whach m�y�rise as �result�f th� pa�ment of retirement or death benefits from Member's account. 1 understand that�ecti�n 5954 of the State Empfoyees` Retir�ment Cc�de �rovides that any person who kn�wingly makes�ny fals�st�tem�nts c�r f�ls�fi�s or permits to be#alsified any rec�rd or r��ords�f SERS in an attempt to de#raud SERS is guilty r�f a misdemeanor c�#th+e s�cond degree (such a crime subjects tt�e guilty person to a�ine and/or imprisonment). , '� � . ��.�i , � � � � D e s�gnat �f Affiant � t� �,. �� r�� worn ta and subscribed �►efore me thi� Affiant's Address ' � _��day of �o�► 2� ,1 --� • c-.r.._.. _ � .�.- }��' ;,;��' Notary ubfic � My Cc�mmissic�n Expires: c��a�o��vu�A�.s�o��s��.`�'�c�� f�ICHAEL R.GARA�1�1, �#c�ta�Publi� Lemoyne Boro. 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G ross Distribution Amount: 15, 5 7 6 . 17 Total Taxable Amount: 15, 5 7 6 . 17 Less Federal Income Tax: 3, 115 .23 Net Check Amount: $ 12, 4 6 0 . 94 TOTAL: $ 15, 5 7 6 . 17 DETACH THIS CONFIRMATION AND RETAIN FOR YOUR RECORDS. PLEASE CASH PROMPTLY. � `� �n�e.��e. °� 1� �, � The Haddad Group 1»0 Pond Road Suire'0� Allento�vn,PA 18104 , � direct 610�98 6�1� fax t;1Q 39�Gt�>�' toll free 866�62'll2 � MorganStanley � A SmithBa�rney ugust 24, 2012 Mrs. Dau 10 Planview Road Camp Hill, PA 17011 Re: Michael Dau, Deceased, Bieber 401 K Dear Mrs. Dau, Please accept our most sincere condolences on the passing of your husband. We are keeping you and your family in our thoughts and prayers. I understand you are attempting to process a rollover of your husband's 401k. Enclosed is the appropriate paperwork to be completed and signed. You can choose to take the entire account as a lump sum distribution(approx. $15,000) but please note that this will be 100%taxable at your current income tax rate. To Process a Lump Sum Distribution: Complete only the"Death Benefit Form", sign and return to me for processing. You can also choose a rollover of the funds into an IRA in your name which will avoid all income tax consequences. To Process a Rollover: Complete and sign all three forms to the best of your ability and return to me for processing. I would be happy to speak with you to discuss these forms and answer any questions you might have regarding your options. Feel free to call me at 610-398-6508. Sincerely, ;��.�� ,�-✓- -�,,t��--��'� ��. The Haddad Group Al Haddad, CIMA�, Senior Vice President, Wealth Advisor Kristin L. Jones, Financial Advisor Tammy Nederostek, Senior Client Service Associate A1 Haddad,CIMA• Kristin L.Jones Tammy Nederostek Wealth Advisor Financial Advisor Senior Client Service Associate Senior Vice President kristin.l.jones�mssb.com cammy.nederosrek�a mssb.com alfred.haddad�mssb.com Mnro�n Cr�nlr..Cmirti RornPV T T C' iVtrmhrr.�iPC' REV-1511 EX+(10-06) SCHEDIJLE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. �--- � � a�n�.mor�. fi�i�n�2 r�.,� c��e., � �J� �� B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) ______ _ _ __ __ Street Address __ __________ City State Zip _ Year(s)Commission Paid: ____ 2. Attorney Fees 3. Family Exemption: f decedenYs address is not the ame as claimanYs,attach explanation) � �, Claimant �`� � �. ��O�'� - �-- ---- -------- -------- Street Address ��Q,)R1��'Q,U�.�r-i�- - - — -- --- - City 1 � State�Zip ��l� Relationship of Claimant to Decedent �� ! � S — ------- � 4. Probate Fees � �� ._ . � 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL(Also enter on line 9, Recapitulation) $� � (If more space is needed,insert additional sheets of the same size) � � r�/� � f A Famil �'radition Of �arin `� � � �- Y � ----� -----' � PAR�'H�l�i�flR� �u�i��.i ��1�� & �r��n�.�i�n ��rv�ces, I��c. Mrs.Cynthia G.Dau 3/14/2012 10 Plainview Road Camp Hill,PA 17011 ;i i� I�ridgc Street We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way E>�,} g��` �?l 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 \�� Cun�bei�land. PA 1?07O when making the funeral arrangements. �-i�) �'�-�-77�'1 �� ;.�->��, Terms � Due Date Account# ��°��,��,�,.partl�ct��re.co�1; j Net 30 4/13/2012_ � 2012020.31 � _ �_ ----� i Description ; Amount i _ a !SERVICES&MERCHANDISE '� � ; i �Direct Cremation ! 2,320.00 ;Memorial Service 595.00 ��isitation/Viewing I 450.00 � �i�:?i�;;rt ��. Partl�e»�ore, j Leather Prestige Stationery Set � 195.00 ;�}�.�i��i�r i White Cultured Marble Urn ', 203.00 , � � �Total Services and Merchandise � 3,763.00 j �.r`[�1�i't .�. T�lIrtllEIl1UTE. � I � � '?�::1'��1>O1' �� i CASH ADVANCE ITEMS ' �':��1i�Ii �l. P�li'tii�ii�OP�, `� �`�' Death Notice,Harrisburg Patriot ' 312.47 '. 15 Certified Copies of Death Certificate 90.00 � �>>-_i�� R. Pa1-t11e�11o�'�. �Clergy Honorarium � I50.00 � P��-\eed Coordinator, CPC Flowers 75.00 �� Dauphin County Coroner Fee,Cremation Authorization 30.00 Total Cash Advances 657.47 F�, � �� , '1 � � ', ! i'rofzssic�nal ti�leinbel-sl�ips: � 1� � �-�Q , \FD:�• PFD.�� , � ��`T . � , :)C'FDA•CCrDA (.}�j� � ; � � � � I � (nl<;nul<<�nd r1Mrr ul(fu ' GC''�LDEN i ; ' �TL� i ' ��Rt�/c' }r�u I�nn�i'. � � � l'��u��lc' Sr�u �I�(��! i � I � i ' Total $4,420.4� �I Payments/Credits $o.00 ��_-� _ � Balance Due $4,420.4� ' - � �a ---- : _ �. ---� .,��-�,, : � �_ � _ __ � � .� �_ �� P�g��4� - 1. n �e�i��--- � �t� � �� RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 3/28/2012 Cumberland County - Register Of Wills Receipt Time : 12 : 30 : 13 One Courthouse S quare Receipt No. : 1069290 Carlisle, PA 17613 DAU MICHAEL FREDERICK Estate File No. : 2012-00373 Paid By Remarks : CYNTHIA G DAU DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20 . 00 CUMBERLAND COUNTY GENER.AL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 20 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash $83 . 50 Total Received. . . . . . . . . $83 . 50 �-1�. � REV-1512 EX+(12-03) SCHEDt�LE 1 COMMONWEALTN OF PENNSYLVANIA DEBTS OF DECEDENT� INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF .— FILE NUMBER `�1 G a�.l I�' e� �� - '� i � !�� .. �.v�, �.�) c�0� ►� 2 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death,inciuding unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. �,m ��den�e� �rrn�e.. I�a�l- � � �.,-� r�.�� `� 1 �� .�� 1 1 �, � TOTAL(Also enter on line 10,Recapitulation) $ 1� I �,��. � l (If more space is needed,insert additional sheets of the same size) Loan Statement CENLAR� PO Box 77404 Statement Date: 03/01/12 ��,,,�„�,a� Ewing,NJ 08628 Account Number: 0037410529 STATEMENT ENCLOSED Payment Due Date: 04/Ol/12 - �- . . . i (Balances � { 036�942 �00022116 09CLST 0953400 WP 1AF041.img Principal Balance'` $139,254.51 � MICHAEL F DAU i Escrow Balance $1,886.99 i CYNTHIA G DAU Year-to-Date � 10 PLAINVIEW ROAD Interest Paid $537.40 CAMP HILL PA 17011-7928 � Taxes Paid $0,00 Payment (nformation ��I�I��ul��l�ll�l��f��ll"'I��II'��'��'1�1�'�i�ll�l�lII�II i interest Rate 4.6250% Current Payment $952.76 Past Due Amount Unpaid Late Charges ( Other Fees Total Amount Due $952.7fi Property Address: 10 PLAlNV1EW 'This is not a payoff amount CAMP HILL, PA 17011 Website:www.loanadministration.com Transaction Activity Since Las# Statement Transaction Due Trans Eff 7otal Optional Description Date Date Date Received Principai tnterest Escrow Insurance Unapplied Fees PAYMT-THANK YOU 03/12 03/01/12 a3/01/12 S952.76 S179.49 S537.40 S235.87 Important Messages Need to contact us? 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Payments Qualified Written Requests Tax Bills IMPORTANT DRAFTING PO Box 986 PO Box 77423 6053 S.Fashion Square Drive INFORMATION:IF YOUH PAYMENTS �000602'-Newark,NJ 07184-0986 Ewing,NJ 08628 Suite 200 ARE AUTOMATICALLY DRAFTED Murray,UT 84107 FROM YOUR CHECKING OR Insurance Collections All Other Correspondence SAVINGS ACCOUNT,THE DRAFT WILL OCCUR ON YOUR SCHEOULED PO BoX 202028 PO Box 77407 PO BOX 77404 DRAFT DATE PROVtDED YOUR Florence,SC 29502-2028 Ewing,NJ 08628 Ewing,NJ 08628 LOAN IS CURRENT OR PREPAID FAX 843-413-7133 FAX 609-538-4017 FAX 609-538-4005 TWO DAYS PRIOR TO YOUR SCHEDULED DRAFT DATE. Website:www.loanadministratian.com Customer Service/Pay By Phone:1-800-223-6527 � sco3oa-000 E-mail:customerserviceQloanadministration.com --� � 1 �� REV-1513 EX+(11-08) � pennsylvania SCH E DU LE � DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BEN EFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER 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[Inc{ude outright spousal distributions and transfers under Sec. 2116(a)(1.2).] 1. ��.� 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 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. �v 1 ��/ _ B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ � '�'�'—� If more space is needed,insert additional sheets of the same size. REV-1514 EX+(12-03) SCHEDULE K LIFE ESTATE, ANNUITY COMMONWEALTH OF PENNSYLVANIA & TERM CERTAIN INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4 on REV-1500 Cover Sheet ESTATE OF ,_ FILE NUMBER �, �� This schedule is to be used for all single life,joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, ' and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ❑ Will ❑ Intervivos Deed of Trust ❑ Other , . . � _ _ _ : NA�I�{S)�F LI��1`�NANT(S) DA�'�E}�B1C�TH : �EAAE�T AGE�T' . 'TERM C�F'Y�1nk�S DA'T��1F DEATH I.IFE ESTATE I�F�AYABLE ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ : 2. Actuarial factor per appropriate table . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interest table rate—❑ 3 1/2% ❑6% ❑ 10% ❑Variable Rate % 3. Value of life estate(Line 1 multiplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ . . , � .I�IM��i)4F t.1�E ANNUI'('ANT(S� ' QATE t�F B(RTH NEAREST�IGE�tt TER�!�}��A�S aAT�t?F DEATH AN�IUITY IS PAYJ�t�� ❑ Life or ❑Term of Years � Life or ❑Term of Years ❑ Life or ❑Term of Years ❑ Life or ❑Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) . . . . . . . . . . . . . . . . . . . . . . . . . . Frequency of payout—❑ Weekly(52) ❑ Bi-weekly(26) ❑ Monthly(12) ❑ Quarterly(4) ❑ Semi-annually(2) ❑ Annually(1) ❑ Other( ) 3. Amount of payout per period . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Annuity Factor(see instructions) Interest table rate—❑3 1/2% ❑ 6% ❑ 10% ❑Variable Rate % 6. Adjustment Factor(see instructions) . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Value of annuity— If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period,calculation is: (Line 4 x Line 5 x Line 6)+Line 3 . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ NOTE:The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return.The resulting life or annuity interest(s)should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed,insert additional sheets of the same size) REV-1644EX+��o4� INHERITANCE TAX SCNEDULE L COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT �J��l I\J� IN RESIDENTE ECEDENT N OR INVASION OF TRUST PRINCIPAL FILE NUMBER !%^�/� 1 W� "—� I. ESTATE OF �-- � (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II, REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wlls on . (Date) B. Name(s)of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Stocks and Bonds . . . . . . . . . . . . . . . . . . . . . . . . . .$ ��' " 3. Closely Held Stock/Partnership . . . . . . . . . . . . . . .$ 4. Mortgages and Notes . . . . . . . . . . . . . . . . . . . . . . .$ 5. Cash/Misc. Personal Property . . . . . . . . . . . . . . . .$ 6. Total from Schedule L-1 . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities . . . . . . . . . . . . . . . . . . . . . . . . . . .$ �-. 2. Unpaid Bequests . . . . . . . . . . . . . . . . . . . . . . . . . . .$ '� 3. Value of Unincludable Assets . . . . . . . . . . . . . . . . .$ 4. Total from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$ E. Total Value of trust assets(Line C-6 minus Line D-4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$ F. Remainder factor(see Table I or Table II in Instruction Booklet) . . . . . . . . . . . . . . . . . . . . . . . .. G. Taxable Remainder value(Line E x Line F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$ (Also enter on Line 7, Recapitulation) . nI, INVASION OF CORPUS: A. Invasion of corpus (Month, Day,Year) B. Name(s)of Life Tenant(s) Date of Birth Age on date Term of,years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ D. Remainder factor(see Table I or Table II in Instruction Booklet) . . . . . . . . . . . . . . . . . . . . . . . . . E. Taxable value of corpus consumed (Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (Also enter on Line 7, Recapitulation) Aev-��a5 ex+ t�.s5� INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION �j INMERITANCE TAX RETURN `�/��—��✓ RESIDENT DECEDENT —ASSETS- FILE NUMBER ��—� I. Estote of � (Last Name) (First Name) (Middle Initiol) 11. Item No. Deacription Value A. Real Estate (please describe) :� Total value of reai estate $ (include on Section II, Line C-1 on Schedule L) B. Stocks and Bonds (please list} �� : Total value of stocks and bonds $ (include on Section (I, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) �� Totol value of Closely Held/Partnership $ (include on Section II, Line C-3 on Schedule L) D. Mortgages and Notes (please list) ��`-�____ Total value of Mortgages ond Notes $ (include on Section II, Line C-4 on Schedule L) E. Cash end Miscelleneous Personal Property (please list) � � � � � � Total value of Cash/Misc. Pers. Property $ (include on Section II, Line G5 on Schedule L) 111. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ `� '"' (If more space is needed, ottach additioncl 8'/s x 11 sheets.) REV-1646 EX+ �3.e4� INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA , INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION l � RESIDENT DECEDENT —CREDITS— FILE NUMBER �D/�� D��J I. Estate of (Last Name) (First Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) ;_ � 1 \. Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: � � � Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ —' , (If more space is needed, attach additional 8'/s x 1 1 sheets.) REV-1647 EX+(9-00} SCI�EDIJLE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER � � 1 � � �4 �oJ�=bb�'�� This Schedule is appropriate only for estates of decedents dying after December 12,1982. This schedule is to be used for al uture interes here the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ❑ Will ❑ Trust ❑ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a sunriving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death,check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ❑ Unlimited right of withdrawal ❑ Limited right of withdrawal III. Explanation of Compromise Offer: ) , � IV. Summary of Compromise Offer: 1. Amount of Future Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Value of Line 1 exempt from tax as amount passing to charities,etc. (also include as part of total shown on Line 13 of Cover Sheet) . . . . . .$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . . .$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . .$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate(12%) (also include as part of total shown on Line 17 of Cover Sheet) . . . . . .$ 6. Value of Line 1 taxable at collateral rate(15%) (also include as part of total shown on Line 18 of Cover Sheet) . . . . . .$ � � 7. Total value of Future Interest(sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . .$� (If more space is needed,insert additional sheets of the same size) , . REV-1649 EX+(1-97) SCHEDULE 0 COMMONWEALTH OF PENNSYLVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN SPOUSAL DISTRIBUTIONS RESIDENT DECEDENT ESTATE OF �---- FILE NUMBER '�. � , � � �—' �� Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A)of the Inheritance 8�Estate ax Act. If the election applies to more than one trust or similar arrangement,a separate form must be filed for each trust. This election applies to the Trust(marital,residual A,B,By-pass,Unified Credit,etc.). If a trust or similar arrangement meets the requirements of Section 9113(A),and: a.The trust or similar arrangement is listed on Schedule 0,and b.The value of the trust or similar arrangement is eniered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust(all or a fractional portion or percentage)to be included in the election to have such trust or similar property treated as a taxable transfer in this estate.If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0,the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement,The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0,The denominator is equal to the total value of the trust or similar arran ement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location,which pass to the decedent's survivin s ouse under a Section 9113 A trust or similar arran ement. DESCRIPTION VALUE � l Part A Total $ PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made. DESCRIPTION VALUE � , 1 ., Part B Total —"��..� $ (If more space is needed,insert additional sheets of the same size) � � � .:� . _ -� .�; �, � �� . ` t j�� . � / �-�� ` � �,; � � �� i i �' ,,.�-� -�'f i � f; � ��