HomeMy WebLinkAbout06-05-13 (2) J 1505610101
REV-1500 EX(oa-io) m
OFFICIA�USE ONLY
PA Department of Fevenue pennsylvarria
Bureau of Individual Taxes `""�"`" "`°`"°` County Code Year File Number
Po aoxzso6oi INHERITANCE TAX RETURN �
Harrisburg,PA i�iz8-o6o1 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMD�YYYY Date of Birth MMDDYYYY
� o � 0���0�1� a 3 � �
Decedent's Lasl Name Suffix Decedent's First Name MI
D D L L TT�f�T�i ❑
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Su�x Spouse's First Name MI
�
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
� �� REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Return p 2. Supplemental Return p 3. Remainder Retum(date of death
priorto 12-13-82)
p 4. Limited Estate p 4a. Future Inlerest Compromise(date of p 5. Federal Estate Tax Return Required
death after 72-12-82)
� 6. Decedent Died Testate p 7. Decedent Maintained a Living Trust 0 8. Total Number o!Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy o!Tmst)
p 9. Litigation Proceeds Received p 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TA7(INFORMATION SNOULD BE DIRECTED T0:
Name Daytime Telephone Number
LLD ADIG ��
�12E 'I,�TER OF�LS �ALY -
�T.o _., .._ :,_ d
,..: .., p�) 7J
First line of address ? y r �` ~ v
� � rn m
4 Z) L /\ 6 : f!` � � %7 b
%'� O O
Second line of address �.��� ? � � � -��+7
, �_ � n
'' `� � r+�
_ =-�
Cily or Post Office State ZIP Code DAIqFILE�� � :
C H P�N�!������ .�. P ,� o � � ���..�
Correspondent's e-mail address:
UnOer penal� of rjury,I declare [I have examined ihis return,including accompanying schedules and statemenis,and to the best of my knowledge and beliet,
it is[rue rre tl co ele. dar tion of preparer other[han the Dersonal representative is basetl on all information of which preparer has any knowledge.
SIG OF P N SP SIB ORfIIING TURN DATE
� 0� �
DD
��
SI NAT E PREPARER O E T N RES NTA IVE � DATE
l�//-�
ADDR�SS � BRI,vD � f. f'i 6AD /"� GCN�V' �// � �QS S
3 PLEASE USE ORIGINA� FORM ONLY
Side 1
L 15U5610101 1505610101 J
J 1505610105
REV-1500 EX
Decedent's Social Security Number
Decetlenl's Name: ;: ,:�.
RECAPITULATION
. ��R�•��� ���
1. Real Estate(Schedule A). . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . 1 ,. # �'.
u.9 �5;,�,..c. ..
2. Stocks and Bonds(Schedule B) . . . . . . . .. r � �� ' �
2 $.����: ��
{
3. Closely Held Corporation,Partnership or Sole-Propnetorship(Schedule C) .. . . . 3 �
�, �,7����.
4. Mort a es and Notes Receivable Schedule D . . . . . . 4 ' � " �� )' '
9 9 ( ) . . . . . . . . . � ,y,.
. . . . . .. . v���$�$4��5i1"t� dX3 Yn�a
c - E
5. Cash, Bank Deposits and Miscellaneous Personal Pmperty(Schedule E). . . _ . . . 5 5 �p�
c��'�
6. Jointly Owned Property(Schedule F) p Separate Billing Requested . . . . . . . 6 .: � :�
. . , ..,' , '.
7. Inter-Vivos Transfers R Miscellaneous Non-Probate Property ��'� � �
(Schedule G) O Separate Billing Requested.. . . . . . . 7 � # 9 � g e
8. Total Gross Assets(total Lines 1 through 7). .. . .. . . . . . . . . . . . . . . . . . .. . . . 8 � � � � '� ��
9. Funeral Expenses and Administrative Costs(Scbedule H). . . . . . . . . . . . . . . . . . . 9 � ���. � � � �
��-�kkq�` ^ . . ,#
10. Debts of Decedent, Mortgage Liabilities,and Liens(SChedule I) . . . . . . . . . . . . . . 10 � °� �� :;
.�:�� � .. : � � .
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 11 e *.� ,�7 � ^
� �
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 .� � " : 3 = ' >
13. Charitable and Govemmental Bequests/Sec 9113 Tmsts for which ""� . � ���� x
an electlon to tax has not been made(Schedule J) . .. . . . . . . . . . . . . . . . . . . . . . 13 � ` � + _ '� " �
�
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. : � r
TAX CALCULATIDN-SEE INSTRUCTIONS FOR APPLICABLE RATES � �
15. Amount of Line 14 taxable
at the spousal tax rate,or
Iransfers under Sec.9116 � _ ..M,,..,� . ,�.: �y„«, z�..., .�..�-, . ,�R..�. ��.:�:..�o����.��._.,
(a)�1.2)X.0— ;„,�t z �j" 15 : v
1 B. Amount of Line 14 taxable �" �'"���°g—� �,,�T��� � _�
at lineal�ate X D_ _�� �� � �6� fi
17. Amount of Line 14 taxable �'``�"'�'"`�'"� �
at sibling rate X.12 » � "
18. Amount of Line 14 taxable �� , � ,�� � ��
at collateral rate X.15 � �: ' ' � 18.�
zw�:�.x �:�1 ,xs,�-x3xi,a£.z�sm W„Gxw. � ..
19. TAX DUE . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . .. . .. 19. j ��. � , ...
20. FILL IN TXE OVAL IF YOU ARE REfN1ESTING A REFUND OP AN OVERPAYMENT O
Side 2
� 1505610105 1505610105 �
REV-�500 EX Page 3 Fiie Number
Decedent's Complete Address: 3 ' 4 �
�� DECEDENT'S NAME �� f �� �� D� .��� -— --
L __ _ _ __
- _ - - -
STREETADDRESS
--
. l-� �3 '7_ Cy ST --J�l)'lN,1�L �_ _7 0 A� . _ __ --_ _ _
COUNT� y�_ /"1tADo_w S _---_
- __ �^
-- __ -- --- -
- - - _
CITY _ — _____ .�I STATE � l, ZIP I �7O J D
M '�C {-� � /Vi �S � U� �T i i; i
Tax Payments and Credits: i
1. Tax Due(Page 2,Line 19)
��) ������ �7S
2. CreditslPayments
A.Prior Payments 7�� - �
B.Discount �__ r -Y( ✓ d �7__ ...7
- / Tolal Credils(A+B) (2) � ��,�' �3 —
3. Interest /
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the diflerence. This is the OVERPAYMENT.
Fill in mal on Page 2, ie 20 to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difterence.This is fhe TAX DUE. (5) _� 4�/ �j� ��
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred:.......................................................................................... ❑ �
b. retain the right to designate who shall use lhe property transferted or its income:............................................ ❑ �
c. retain a reversionary interest;or.......................................................................................................................... ❑ �p�
d. receive the promise for life of either payments,benefits or care?...................................................................... � W'
2. If death occurred after Dec. 12, 1982,did decedeM transfer property wilhin 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?.............. Q� ❑
4. Did decedent own an individual relirement account,annuity or other non-probate property,which ❑
contains a beneficiary designation? ........................................................................................................................ �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF TNE RETURN.
For dates of death on or after July t, 1994, and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the ta�c rate imoosed on the net value of Vansfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)].The statute dces not exempt a trensfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax retum are still applicable even if the surviving spouse is the only benefidary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of Vansfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(12)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent, except as noted in
72 P.S.§9116(12)[72 P.S.§9116(a)(1)1.
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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.
REVa5o8 EX+(si-1o) �
� pennsylvania � SCMEDULE �
RiT OEPAfl'MENTOFREVFNUE � yMJH� BANK DEPOSITS & MISC. `
`""ERR^"`�T�R��R" PERSONAL PROPERTY �
RESIQENT DECEDENT �
ESTATE OF: FILE NUMB�R:
---- �L� t� DADt6��/ �1�.�p�qo _
lndude the proceeds of litigatlon and the date the proceeds were received by Ux�eswte.
A{I property joiMly owned wtth right of wrvivorship must be disclosed on Schedule F.
I',EM VALUE A7 bATE
Nl1M6Eft DESCRIPAON '� � �
� Q A.V k -----1--_—°F°EATfi ---
1, � PNC ;,.
i C NtcK�.uG �cco�tiT # s� �3 �s�� yy � �.� �e, jy
; �
;,- _ _____--------------_._.._----------- i
� i P,v c BA� k - i
1J�10.�E f ,,+24RKCT �fCCOV,vT �E- 50� .35 (� (�j�� q � ,;� �� ��i7 �'�ti
, ;
.3 � COUN�� j� Nl�,g Do w� N��'SIUG- ��—� �
� �� �rr,�� j � �, 00� ,ag
, ;
�
� � PN C i34? O Kc�2AGE f��COUtiT �# --�
; � o r - �`G � - s�s- I .�"y� .�y
i ;
�-------- — ___ ,
,S" � .,v �i �. � F�,� �tt�� �o�� R�Fv� .�
{ � 1 I 3 0,pz�
;
� -----___--- �
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,
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;
,
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, i
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� I
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I i
� _ _______ �
TOTAL(Also enter on �ine S, Recapitulation) $ ��� / 6�./�e✓
�
REV-1514 EX+(OB-09)
/i�pennsytvania SCHEDULE G
� �EpARiMENTOFREVENUE INTER—VIVOS TRANSFERS AND
innearrnNCernxneruaN MISC. NON—PROBATE PROPERTY
. RESIDENT DECE�EM .
ESTATE OF FILE NUMBER .
�� z z�/ DA.�i GA� %��-,r3 �-�y 9 D
This schedule must be completed and filed if the answer to any of questions 1 thraugh 4 on page three of the 0.EV-1500 is yes.
ITEM DESCRSPTION OF PROPERIY DATE OF DEATH %OF DECD`S EXCLUSION TAXABLE
I41ClUDE THE Np1AE Cf ME TPANSFE0.EE,i1fEIR REU770NSHIGTD OKEDEM AN�
NUMBER n�eoahorTannsFee. annrnntoworn�eoe�oroxaeuesrare. VALUEOFASSET INTEREST prnavu�a� VALUE
i. �} L l. S'�J47� �NNu�T��
C o� -r���T ## GA /�.� 9�77b 3b,b'Y9,o 336,Sy9. a�
�. C ��v �CT $� G-a i 93 �yo $i 5gI3S7 ;158, 135 ?/
Sh�Ar��= D �� �Az�y 63`
l.� � 1-{ I L D R c/r/ �I-5 S�`o w'U
0 �J SC-H �� v l� �
i
TOTAL(Also enter on Line 7, Recapitulat�ion) $ S9y q�� , �3
if more space is needed,use additional sheets of paper of the same size.
�
Alistate�
You're in good hands.
May 20, 2013
Leo Dadigan
48 Old Farm Road
Camp Hill, PA 17011
Re: Ellen Dadigan
Contract No: GA16598776
Dear Mr. Dadigan:
We received a request to compiete IRS Form 712 for the above referenced contract. The purpose of Form
712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain
date(usually the owner's date of death or date of transfer of the contract).
Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the
following information for estate pucposes:
Date ot Death: Apri120, 2013
Annuity Value as of Date of Death: $336,849.06'
Cost Basis: $289,912.44
Named Beneficiary: Leo Dadigan, Esther Dedeo,
Janice Obermen, and
Raymond Dadtgan
'The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender
Charges.
if you have any questions, please contact me at 1-877-499-6418 Ext.24774.
Sincerely, �
i
�� k�l wA.h�i�.
� �__J�-��
Donna Rivera
Claim Representative
Allstate Life Insurance Company
L1te and Annuitv Claims
� �
Allstate.
You�e in good hands.
May 20, 2019
Leo Dadigan
48 Old Farm Road
Camp Hill, PA 17011
Re: Ellen Dadigan
Contract No: GA19364051
Dear Mr. Dadigan:
We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form
712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain
date (usualiy the owner's date of death or date of transfer of the contract).
Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the
following information for estate purposes:
Date of Death: April 20, 2013
Annuity Vafue as of Date of Death: $258,135.77'
Cost Basis: $2����
Named Beneficiary: Leo Dadigan, Esther Dedeo,
Janice Obermen, �nd
Raymond Dadigan
'The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender
Charges.
If you have any questions, please contact me at 1-877-499-6418 Ext. 24774,
Sincerely, �
l. \ �.:'�.1�f��Cj_.L �,�.�y..�
Donna Rivera
Claim Representative
Allstate Lffe Insurance Compe�y
Lite and Annuity Claims
.,.. .,__,,..,... �_�_..__ �� ......... ...... .,. -- .,,, ...,. ...... � .,..,. .,.._ ._....
REV-1511 E2+ (10-09) �
� pennsylvania SCHEDULE H �
oePanTmeNroFReveNUe FUIVERAL EXPENSES AND '
`""ER„""`E T"x R�r"R" ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF �l L �N �� D ���� FIIE NUMBER�`/ �O
_ �1-�3
DecedenYs debtr must be reported on ScheAule I.
ITEM
NUMBER DESCRIPTION � AMOUNT
n. FUNERAL EXPENSES:D�OC E�SE Q l- N��ir. �f3TE Q,r y�Av�v c�y,
1.
G-�tvE M�RK�rZ. /�,vD P��cF.� E,�i 3 �0. �0
f-u.v � /t�st� �. rri�H��,v , N�=lL�,v�c kDuz�tiR � 3S y�
,5�b �'N-ST �l !.v 57�. M��H�1,��Cf g v�� f�
Sf i�t.�-� �j FoR Fl�THt'2 y�Li.v/G
Gt7v .� S Xt 0.9 2 D (�A�i /S f�, C��'�1l' N/L L �..4 l OZJ . 6�
s. A�MINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Persona�Representative(s) _
_ __
. .._. ._... _..__ _. ..
. ..___.... .
Street Address �
._ .. _.. _. ..__ ..... .
. ....___._..__... ._ ...
. .._. . ...... _..__ __.. .
Clty „ ._. . Stdte ZIP �
. . __. . _.._.._ .. ._ . . __ . .._.. .. . __ . .
Year(s)Commission Gaid:
_.._._ _ __ .. _ ._ -__.__ _._. _ .. .
� Z� Attorney Fees:
3. Famity Exemption: (If decedent's address is not the same as daimaat's,attach explanation.) .
Claimant
Street Address
.. . _._ .. .._.. __. ..... _..
... __. _._ .
.. __-__--.__.. ._.. . ...
City . ._. ._ .._ .. . _ _.._ _. ...._. ... _ . State ._._. . ZIP. _...
.._.__.._ _...._.
Relationship ofClaimant to Decedent -
. _. .... . _.. _._ .. .
4• ProbateFees: C�VIYJ �{�/2 �J,(JJ, C(J(J,UjI� ���r• �F Wl�j '733, 5�
5� Acwuntant Fees:
6� Tax Retum Preparer Fees:
'. S� C ,�c ���,'c(lls�Y— Q�s� �u,P.� r✓��}r � 3 y8.' av
c � s Pzti sro.� � �r�-m ���.s ���u�— � L �. � 3
D jA �l n eU p �`I.lJQtri�l-CY - f r.�R�� .f3�:c.� ` 3 1 .>? L
� c�j s u C,�i'� 7"E� ,.�' �i�e c�t_. Ql��ilr' �si`rlT j B4•�
TOTpL(Also enter on Line 9, RecapitulatioaJ � ��� �'�'!`
, SL
.,�:
nlocsse of Flarr�stburg
Post Office Box 365?
Office �# CQthofie Cerneieries Ha�sa��. Pennsylvau�ie t71Q5
PHONE 71'7l857-A804
o�e _�.Sl� ��o��rvo.�F�d��9 c�r�.a—�a 3� _a+��� sn��' aP c;
L� NI Sants Cemetery ❑Hq1Y Saviour Cemetery ❑R�unec�ion Cemetary INVOICE NUMBER �
172 AN Saints Road 3420 Susquehanna TraB 116 S.Oek Cimve Road
Elysburg.PA 17824 York. PA 774Q2 pA 17112
C1 Hoty Gross Cemetery Ll Lancaster CattqNC �l of Heaven Ceme6ery
1810 Jay SLeet 170 Chdrles Fiw�d 7313 York St�se[
Lebana�.PR 77042 Box i27 Nler,henl(�DUrg, PA 17055 .0001NG
Bausmac�, PA 17504
&onze 0ede�etl.`__...__._— -AClv�owiedgement Received---- --
Bronze Received _.--...._. .^.._ Bronze I�aiied
M Memori3ls Provided with LigM Fxtish and Oval Letter Style
�o�so: u r��ffi ❑c�v�ta n s�n n om��-SC'.f��{,_---
9oraer. ❑Rockedye ❑Frieze
Sias: U 44"x 74° ❑24'x 14" ❑24°x tY U O[her_.�_
Scro1L• G Tri Scrt�q ❑Loose �(Urri Cast i ORDEfi ENTRY
Vase: I:J Nammered Ooric ❑Lotus C7 None
Yctwen: Ll Yes I:l No
InacripRion:
ELLEN �
1922 - 2013 �
4 x��
�r, �oc-
EFORM124834
ssT oa BLLSN DADIGAN DBCD DATE�l �/� 60-1273/313
L80 S DADIGAN SSTR
PAY TO THE ( \\ _ \ � $
ORDER OF ���U(➢-�1R l`` ��W C�bbU
DOLLARS
PNC Baak, Natioaal Aesociation
Central PA
HAMPDEN 00117
MEMO �v-� o� ���� ��.�� �,r Non-Negotiable Customer Copy
NELLEPIIG 4'.r7�p'_ � .
500 EfiST MRtIY STREET f-�e � � (.�(� � L �{C.lL.1�? Tf..i�,
nEt:MRtilCSBURG.PN 17056
717-766-2990 5�� �d5t Md1R SL�'�=..:
Mecnanicapur�,
r��- �� zo�� iz�ao�oi �7171 766-299Q
�IID : xXXX%%XXXi(X40B'L
ea�i �. to � ggsy 17 C85h1er
! ermindl iP+ P0051 . .--_._.._ ...__.. .. . .__..___. . _ .
CRE�IT CRRO ��hk 3960 RAY i •i5 Gst ;.
Uj5p $fllE APr25'13 09;14AM
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TAKE CIU7
n�zo : xxxxxxxxxxxxaa9Z 6 OYZO Zp,y[:
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ea, �n : � 0 4 DUlmades 17,96
�FPro�ni c�a. � oizai3 5 Chk SOUV App 19,9�,
�ci coa. � e CUT IN HALF
rR�ns f0�903116806463898 1 Sp8cldl Re48st Q,(�t
entrv tlothod: Sw1Ped 1/3 PAN SPANAKOPIfA
no�., o»� �,,. i XiRA Open$Food Z4.99
8 Baklava 31 .�3Z
5flLE RII�UNT 3?36.42 1 R1zo9alo �,�,_
?IP HMOUNT 4892
---------- Credit 235.4<
TOiAI _--_------ Subtotal 222. 'C.
Tax 13,32
PaYment �35.42
cusroneR coav -------17 Check I;loseti---- _
--APr25'13 12:SiPM -
Thank You
P'ease Come Agafn
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RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date : 4/29/2013
Cumberland County - Register Of Wills Receipt Time: 11 : 38 : i,=:
One Courthouse Square Receipt No . : 107396c
Carlisle, PA 17013
DADIGAN ELLEN
Estate File No . : 2013-00490
Paid By Remarks: RJ DADIGAN
HMW
- -- - - - - - - - -- - - - - - - - Receipt Distribution - - - - - - - - - - --- - - -
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 610 . 00 CUMBERI,AND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COLTNTX GENERAL FUN
SHORT CERTIFICATE 50 . 00 CUMBERLAND COUNTY GENERAL FUN
JC6 FEE 23 . 50 BUREAU OF H.ECSIPTS & CNTR M.D
AUTOMATION FEE S . 00 CUMBERI,PSdD COUNTY GENERAL FI7AS
INVENTORY 15 . 00 CUMBERI,AND COUNTX GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERI,AND COUNTY GENERAL FUN
- -------------—
Check# 2867 $733 . 50
Total Received. . . . . . . . . $733 . 50
. __ ---- -—----- ---
.,
R.J.DAD!(iAN 2�7
A L.DADI(iAN eoainrz�ia
PH.717-887-3602
137 BRINDLE RD. _ � �-�
MECHANICSBURG,PA 7T055
DA1E
PRYT0IHE Register of Witls �
� ORDER OF _ _ __ . � ��7) �
, __.__.__ _ ._._-
� -1�'wY`�CC�� .��_� DOLlARS /� �`:
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HARFISBUPG.PA 1]11a2990 j
F°_".�IQ,��._.�ST147�:-- __ __ -- . _ __-u�-,o"t�
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�: 23i38iii6�: 04508219i3��• 67
Your New Benefit Amount �_�=�-�
� "�'�' ,�/� � �.�Ti;
BENEFICIARY'S NAME: ELLEN DADI , �
Your Social Securih- benefits will increase by 1.7 percent in 2013 because ��f a nse in ttie cost
�f'living. You can use this letter when you need proof of your benefit amount to receive food.
•ent,ar energy assistance; bank loans; or for other business. Saving this IeCter could save vou
hi inconvenience of making a trip to a local office and waiting in line to obtain a new document.
How Much Will,t GetAnd When'?
� Your monthly amount (before deductions) is $I.�F52.9t?
� 'The amount we deduct for Medicare medic�t insurance is - �j�� ����
I:If�ou did n�t have Medicare as of Nov. 15, 2012 -
or if someoiie else pays your premium, we show $0.00.}
� The amount we dt>.duct for your Medicare prescription drug plan is $� ����
(If you did not elect withholding as of Nov. 1, 2012, we show $0.0�.) �
� The amount we deduct for vc�limtary Eederal tax withholding is ��} ����
I lf you did not elect voluntary tax withhoiding as of �
Nov. 15. 2012, we show $U.00.)
• After we take any other deductions, you wil[ receive � ��_��x O�p
on .lan. 3. 20f? --
If yoi.i disagree evith any of these amounts, you must write to us within 60 days Yrom [he date
�ou receive this letter. We w��uld be happy to review the amounts.
You may receivc your benefits through direct deposit, a Direct Express'"' card or an Electronic
I�ransfer Accouut. lf you sti11 receive a check, please remember that you must s�✓itch to an
,lectronic payment by March (, 20I3. For more inf`ormation, please visit www.godirect.org o;�
�a11 1-800-333-1795.
rVhat If I Have Questions?
Please visit our website at www.socialserurity.gov for more inforniation and a va�ietv of'online =
+ervices.lou also can call 1-500-772-1213 arid speak tn a representative from 7 a.m. unt�} i p.m.,
vlonday through Friday. Reu�rded information and servrces are auailable� 24 hours a day. (��u-fines are
�usiest early in the week,early in the month,as wel(as dtuing the week between Christrnas and New
t'�r s t�ay; it is best co call at other times. lf you arc deaf or hard of h�ring,cal l oiu 1'I`Y nwnber, �
l-fifx1-325-0778. I f you are ou�iide the United States, you can contact any U.S.embassy or consulate
>ffice. Plea�e have vour Social Security claiin number available when you call or visit and include it on
my letter yau send to Soci<il SeciUiry. If you are inside the United States,and need assistance of anv kind
iou also can visit vom•local c��cc "
st�rrt�: s�i;
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tatement Date: OSl06173 � . � Diamond Pharmacv
ustomer Number: 47773 , � W��AW� ' 645 Kolter Drive
acility ID: �Myygq ��r���- �����y�f3:�.� Indiana, PA 7570�
uxtomer Group: P 152 ��' �'�YM��1T Qfsl ' (800)882-6337 pnc�ne
Salance Forvrard ��� iTAT1��1+P�NT � (724)349-1111 toi�free
:,i :+����aa�+i'V�SY RetUrn tdG�'tL
81�C169 L"Y[M
_ $90.37
'ayments ...._. _-
. . .. _ CheckDate 'i � ......-.. ..t���r.k�Nurriber I Amount
; ___ _ _I-- . _ __. _.
;
_
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lew Activity
� _ . .. . -------- ----- -
Date Rx No Unng N�ame � Qty price lns.Pay qrtH. Pat.Pay Amt.
noice-IN00035s �----------� -��--- I -
DADIGAN,ELLEN
04/05/13 3123'72 RX- :i �-neSULFSOI.N OM(3lML 60 $36.48 $18.64 copay $18.44
04/O$!13 3t2386 OTC ' '. �iAMWOPHFI�6 OM(.SI)PP� �p �07 S�00
OMOS/t3 312397 W(- �i�.�',hllOf2PER SUP 25MG 70 $34.97 y2fi.50 mpay $8�47
04A5/13 318100 RX-. P.��:'��zsun250MGT���,BS 14 5370 y1.88 cqpaY yiB2
04/18/13 320443 OTC fCi�GEVAC SUP h)MG 5 $125 $Q00 $�.g5
04/18l13 320449 RX-I ,'.'l.)I.OSE SOLiOGM/15 473 511.93 55.99 copaY $5.94
i0U0355268 Totala ��ef��� g __ _
Topl aqe+d-IM00035!i268 f87.0H ^-552.41 S3q.67
Tot i:��l': .iM600355:�68 S6.Y! 50.00 56.22
7 :il� R1000355268'� 593.30 $52.41 fqp,gg
tafemeM Tofels
Todl 3i�e'd.:iptement :87.08 . 552.47 S34b7
Toh 1'�I": -Slatamend f6.22 S0.0p f8.22
T :�. .IilatxmeM E91.70 552.41 540.89
......_ -� Page t Balance Due:5131.26
1-30 Days O/Due 31-60 Days DIl u: 61•90 tlays O/Uue Over 90 Daya OlDue
340.89 590.37 $].00 50.00
Paymi i U ie�Upon Repaipt Please pay 9ala�e Due. To pay using your MastarCartl or V sa, please ra11
1 ;C i l82-6337. Pharmary Houre:MorWaY-Fritlav B a.m.-5 p.m.&SatuMav 9 a.m.-2 o.m.
EST OF ELLEN DADUiAM DECD 1 O2
LEO 8 DADIQAN EXTW
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GIMPHILL,PA77011-28pq ._S_. � ,�3 ... r � tte
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REV-1513 E%+ (O1-lOj j i
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� pennsytvania SCHEDULE 1 �
�EPAflTMENT OFREVENUE
1NHERRAfYCE TAX RETURfJ BENEFICIARIES
RESiDEM DECEDENi
ESTATE OF: FILE NUMBER:
ELLEN .�A D 1 G-� p
RELATIONSHIP TO DECEDENT AMOUM OR SHARE
NUMBER NAME AND ADDRE55 OF PERSON(S)RECE[VING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRtBUTI0N5[Include outright spousal distributions and transfers under
Sec 9116(a)(11).]
1. L. �D S, ��} 1���� �S O N) SO N o�s v
� k pL D F-�J/1M 2 01�� I
Cf��l O t//t � �'A / 7 o I/
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3 �T•'j•v � C1- L. D$� C�AvG/�tdL� D,AUGNTt� o� S,
� I y ��ST �� �,� Sf I
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y � Ay�oN� �7�" DADIG�N�soN� s d � � s �
� 3 7 �� (iu,D�c ��
M�cN�Nics�u,e � �.� / 7aSs
ENTER DOLLAR AMOUPITS FOR DISiRIBUTI0N5 SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV4500 COVER SHEET,AS APPROPRIA?E.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECiION 9113 FOR WHICH AN ELEC7ION TO TAX IS NOT TAKEN:
1.
N�� I
B. CHARITABIE AND GOVERNMENTAL DISTRIBUT[ONS:
i.
! - /�
� i
I �
i �
� �
I I
TOTAL Of PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ;
Pa. O.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF CUMBF�v L AN 1� COUN7'Y, PENNSYLVANIA
Name of Decedent: �L�- L � �� � � �T�/U
Date of Death: LI - � � - � 3 File Number��'�G % 7 6
Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
1. State whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . . . Yes ❑No
2. If the answer is No, state when the personal representative
reasonably believes that the administration will be complete:
3. If the answer to No. 1 is YES, state the following:
a. Did the personal representative file a final account with the Court? . . . . . . . ❑Yes �No
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account �
informally to the parties in interest? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .L�1Yes ❑No
d. Copies of receipts, releases,joinders and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans' Court and may be att ed to t ' re
`
Drtre � (�/
Si ure ofPersan Filing[his, rm
Capacity: ❑PersonalItepresentative ❑Counsel
Nrtme of Persan Fifing Niis Fonn
Address
Te(ephone
Form RW-l0 mv. /OJ3.06
INVENTORY
REGISTER OF WILLS OF C' UN1�3E1?Lf���cotnvTY, ]'EN'iVSYLVANIA
COMNIONWEALTHOFPEMVSYLVANIA �!`��� J/QO
WUNTY OF � SS File umber 7 7
Personai Representative(s)of the Estate of ����� �� � � ��
deceased,depose(s)and say(s)that the items appeazing in the following inventory include all oY the personal assets wherever situate
and all of the real estate in the Commonwealth of Pennsylvania of said Decedent,that the valuation placed opposite each item of said
inventory represents its fair value as of the date of the decedenYs death, and that Decedent owned no real estate outside of the
Commonwealth of Pennsylvania except that which appears in a memocandum at the end of thzs inventory.
I verify that the statements made in this Inven-
rory are true and correct. I understand that false state-
ments herein are made subject to the penalties of
18 Pa.C.S. § 4904 relating to unswom falsification to
authocities.
Attorney-- (.N'nme) (Supreme Cour[LD. No.)
(Address)
(Telephone) �
DATE OF DEPTH LAST RESIOENCE `" O vM r�J.Y iv)�:� f+ 'Dp v� j OECEDENT'S 50Q SEQ N0.
- � m -/ y�3 ? E: �N � = d n�Ecr��� � /�'aSa /s - /6- Col� /
/�� T �LL FIGURES MUST BE TOTALED ��(�rJ�`�
pNc L' ANK CNEcKING f3CC#� 51137s �� yy `
------- _---- �
__-- --- ----- �'l��'7�`{
�NC 31�� K /�'10NEy MKT, �Iec� Sov3s 666 � 9 � ,
-------- ___.__ _ _ _-
_ ____ _ --
C0U /LTRY /1iIEf} 17Gu7S /UU(�S).VG- I�DM � o�(�� oQ(o, at�
I� c� FUN1>
Pti � B � aKF2 ��� /�c� #- o � � -so� - s� s 5��. yy
.--------------------------- —
�v �iL � Futi �� � No�� R �FV� � 130, 0�
. :� , e . �
(AKach additinnal sheets as needed) /� ,/ ��—�4/�'�
TOTAL: 0.00
NOTE: The Memorandum of real estare outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value o(each
i[em,but such figwas should not be extended into the total ofthe Inventory. (See 20 Pn C.S§3301(b)J
Fonn RW-09 rev /0.13.06
_ _ _. ._ _ ....._