HomeMy WebLinkAbout07-02-13 � ysnsbLnlos
REV-150n°"'��"�'1�1
PA dRevenue P�^�lva�a OFfIC1A1.U8EONLY � .
Burea�IndtMdualTa.ces �C,amhCade Yeer FlbN�m6er� .
INHERITAt3CE TAX RE7URN �-.—^ �_..}_2.._.._i (�
�M�r��,pqZy=g-06o1 RE3{DEkT DEGEDENT ;�� ' � (Ql i ; �V �- 1 � �
_.
ENTER D6CL°DENT INFORMATION 9E40W
Sodel Sewrlly Number Dete of Deaih MM66WYY 6aM ot Birth MMRQYYYY
......_........ ___._._._. _ a ......... ._. ...... ... ., „ ... ...
(09l20l2012 '03/12/1920 �
______._.._.__..___. ...,____ . I.--... ..... ... .. .. . . ........ {.W.... ,.._._._ .. __� ----�----..1
l7ecede�Pa Lea1:Neme Suffix DecatleM'e Fkat Name M{
. _._., _.. ,___ _ . _._..._ __ _ . _ _ _ , _ _. ._.... .. .. . .. .. _ . .. _._.�
'FIYNN ' i NEVADA
�_._.__._____._____ �.__._____,__.._._... . .._: . _ _. ... . . ..,_--.--..,,_.. ..w.__ ____„�.__. _...�
{N AppllcaWs}Enbr Survtvinp Spou��'a Mformatlon Below �. - �
;
Spouse's Lsat Neme � Suffix Spouse'a Ftrst Name � � Mi -
.. , .._,._..... . ... ....___. . ........... . .._.....,.. . ...._..� . ..._._.__ _..______.._...�_. ._.._.___._..____.,. ,__ . ._..._ _
i �._ _. _.4
..... .. .. ....... . .. ...._.. _- , _...... ! � _. . . __. _. ... .... . _.....__.. .. .._... I-
Spovae'a Soda4 Seartty Number 7E{�g RETURN MU$T BE flIED IN dUPL1CAIE WtTM TME
_,
..................._._....___.._.:..___,_...__...._._; REGiS?ER OF WiLLS
FlLL iN APPRQPRiATE OVA43 8E�8W �
f� 1.Qripinel ReWm � CI 2.Suppiamentei Retum O � & �er EteWm(Qafe of Death .
P�Ior�12-13-82) �
O 4.Gmiled Estele � G3 4a.FuWre InFerest Cas�pramFae{dete af O S. feQaro!1 Estnta Tax ReWm Re9ulred
deaN aRer 12-12-82) -
Cp 8.DxedeM Died Tsstete C} 7.Oecederft M�ntalned s Li+rkfg Tnui , &Tdal Numbsr of Sate pepodt Bones '
(AttacM1 Cop+d Wiq) {Aaach Gopy ot Tnut.) .
C7 8.Eitlpetlon Proceede Receivad O 10.3pauaat Poverty Gedlt{Qate of DeeN O 11. EleCtbn tp T6�und0r 8ea 9173{A)
Betwean 72-31-91 and 1-t^95) . (Atlech 9tl�atluN Oj
CORRESPONDENT-TNIS SEC'iION MUST BE COMPLETE6.A1.160RRE8P�iDENCE AND CONflDENTlAI TAX diFClRAMT10lI S!N?UlD BE UqtECTED'P0:
Name Daytlme T�Number�-�-�
r. . ._ v ,_.__._ .,_ _
. .� .. _ ._. .. ..._._ ..
�SANDRA F GAMBURN _ _.. n... .rv I j(570)83�3Zi8___—�� � r>'
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neo wiu.s se or��� , '
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Flrst Lina oFAdtlrees . ....... z�� .�`' .
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ss uo�a Raao � � � u; ;
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Second UneotAddress � ��'� c.:, f_, .
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Code MT8 RILE6�
..._ . .. ...,. .. ...,_..._ _._._ _.. ._ _.._. ........ . .... ...
(TUNKHANNOCK PA } 1865?
_..._...___�__.__.____ _��.__ __ _ __.. ,. .__.. .. . 1 i ., ._...._ .. .rv .W _. ._..._..�_.�
cortesporMenYs amsit addra�s: �
unaeraen■Ilkeotw+Wf�faxdareripk�havasx«nMeathisiamm,k�duNno . wt+wuesene•+st.mrMS.r�decarwud+m�wanabe�kr,
n k we�carroct sna mmpau.o.dm�tlw�a�anromsr um n»amsone�rea**•antewa Is eeeea on an�oramrnon a whld�pny�e.na em wwwiWw.
S NANf�OP (F�/$�P0N 3I,B-L�E�F.Ol�2�Flt,1ANG RETURN )DATE f
�AA.i�ll d.'Y)�t19"�n.! (p " c2� ' /43 �
,w� ss� //JV %wri� ��� � 18' ' - .
C Wr
SIONA7URE T VE 7E. . .
C �j.f!
A06RE3
83 �t,c� 5�' ,,S�s��fe a , �vn Khannnc;K �FF 18(g57
P{.EASE USE 4Rl6! PORM ONI.Y
Side 1
� 1505610105 15[i561�105 J
��
,
[ 15d5b1020S
■r�■1
REV-1508 EX(Ft} � . " ' �
6ecedeni'e Sodai Seattlry Number .
�.............._.._....__....._.._....__..,.__..._._..__.._...._..,.........�
o.cWene�N.m,: NEVADA�LYNN �
t�cApmrunan
-__._, __......._____.__..._....____..__._._._�
' 1. Roal Fstete(9chedule A). ............................................ 1.+ .
. -.�.^'-----� .,
z. stodcs and eonds{scnedWe 8} ...........:........................... 2.; 358,564.Q0
3. Cloeety Held Cur{wiatbn,Parinerahip or Sqle-Propdetorship(SChedule C) ..... 3. ' - .
4. hlatga�and Notes RecelvaWe{Schedule D}........................... 4....�. �
5. Cash,Benk Deprails and Miscelleneoua PeBOnal Property(Schedule E)...,,., 5. ; , . 905,935.00� �
8. Jo3ntly Ownad P[ope�ty{SChedt�e f} O Separate 8iiilrtg Requested ....... 5.:�� - 44,405.OD I
7. inier Vlws Ttanete�s 8 Miscelianenus NotrProbate Properiy � : ,
(SChedule G) O SepernW Billing Ret{uested........ 7. i �
8. Tcqt dross Assab(btei LMes 1 thrtsugh 7)............................�. 8.; 1,3Q8.804AU
9. Funerei Expenaee erW Administradve Cosb(Schedule H)................... 9.� . 13,889.00
to. Oebb at oeced«a,naat�ege Uebwues and uens{Scheau�e I}............... 70.; 17,408.00
11. raa�o.aucuons(mte�unea s ana t�)................................. 11.' 31,307.00
,,.._rv...__�---___.._._..._---.,..... .�._._...-----
i2. tNt Yalus of Esdib(llne 8 minus llne 11).............................. d2.� � 1,277,587.00.
13. Cheritabie and 6overtxnettt�Bequesta!'3ec 91i3 Trusts fa whieh . -
en electlon to te�t hea rrot baen mede(Schedu�e J) ........................ 13. i � � 5,800.00.
14. Nst YaW�8ubpe:t M Tu(Une 12 minus Une 13) ........................ 14.; 1�272,597.00
TA3C CA�CUtAT10N•SEE INSTRUCSIBNS FOR APPGCABLE RATES -
15. MwuM of Llne 14 fexede �
et dw apoveal tax�eta�ar � . .
,,. _ . . , _._......_. . ,.� .----- ..._...
trenffiera under Sec.8118 ,. .._.... .....,. ...... .�...1 r_�..� .
{s}(9.2}X.O,. , � S5. �
18. Amount M Llne 14 taxebla ����`"�`�""�"`�"�
at Ilnaal�ate x.0 4�` 1,272,fi97.00 I �6. 57,267,00
n. r�rwumoruneatmx�ae i�`�""�""��__.,._ �.i �„� �
ac a�d��ace x.sz j n. 1
18. Artp7unt of Llne 14 fexable � 'm�'. �'�'.� �
at CWletersl raW X.15 � ' _� 18.
' !9. TaX DUE............... .. .,. _ ...... ta. 6T,26T.Ot1 ,
24. Fllt IN TME OYA�IF YOU ARE REqUESTtNG A REFUNU OF AN QYERPAYMEPlT . � � �
Sida 2
� 150561Q2{t5 15�5610205 J
REY-158�EX{Fi} PeW 3 � F�a Numlm � .
DecedenYs Complete Address:
DEC E
HEVRDA FLYNN
srr�raoo�ESs
30 E MOUNT AIRY RD
CffY . � SfATE ZIP
DILLS6URG PA 17p19
Ta�c Payments and Cred�ts:
1. Ts�c Due(Pega 2,Line 19) (1) 57,267.Oq
2. GfwlitslPaymeMs
A.Ptbr Faymanis Sd,500.Od
B.DiscouM 2,863.00
Total CredBs(A+8) (2) 57,363.00
3. Interest
(3}
4. tl Llne 2�grea�t Nren Lirre 1+{,(�3,en�r the dHfererxe. Th(s is the OVERPAYMENT.
Fill In oval on Pega$Line 20 to roques!a�sfund. (4) 86.40
5. N Ur�1+L�e 3���r tlren L�ra 2,ar�r�dHfere�tce.Th�Is the TA7C DUE. (a�
Make check payable to: REGISTER OF W{LLS,AGENT.
PLEASE ANSWER THE.FOE.LQWlNG QlIES110NS SY PtJ1GIMG AN"X"]N THE APPROPFt1ATE BLflGKS
t. pW deaedent meke e tranehr and: Yes No
a. remin the uae or Inrome d the property transferred................................................................................„„.._.. ❑ ■
d. �a,e r�r m a�,a��»��.���t��re�a�u�ir�«re..............___�._..._._.._.... ❑ ■
a rem(n a r�sbnary anmresr...................................................................................................:.......................... ❑ ■
d, rocelve dw prortdee ta'Ilfe of eitlrer peyments�baneflts or care?........:............................................................. ❑ �
2. tf dae�acdArxi aRer Dec.12.1982.d(d decedent transter propet4y within one y�r of death
witlwut receh�inp adeqtmta " ?........................._. .. ❑ �
...................................................................... _........
3. pid deoeclerd own en'In Wat for'or payaWe-upon�death bank account or eacudly at his ar her dmlh7.............. ❑ �
4. pid deoedart awn an�ndlvWu�nreffireameM accouM,annuiry or oNer non-probete pmpaAy,whkh
- aMa6�a e . ' ? ..........._........_......_............................__....._....,.....................__..».._..».....,.. ❑ �
If THE ANSWER 70 ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FlLE IT AS PAR'I'OF THE REIURN.
For dakes aF�th on or ai�r July 1�1�4,end hafae Jan.1,1995,ths tax rate hnposed on B�e net value M iza�steis to or fw tt�use d the surviving spause
is 3 peraaM[72 P.S.§9116(a)(1.1)p)1•
Pa dates ot deeth on ar after Jen. 1, 1995, the taz rete imposed on the net value of trensfers W or for the use of tlie survidng spouse is O pett�nt
[72P.5.§81f8(a){1.1}(�}].Tt�e��not.e�tempt a b�sf��a survEving spouse ft�ta�ar�the stak�ary requirernents for of�ats�d
filing a tax reWm are stlil applicabie ev�it ttre surviuing spouse fs ihe on�y benefic(ary.
For datea of dealh an w afler July 1,2000;
. The��te Impqsed a�the net velue af hans(e�trom a deceased c�W 21 years af age or}ronngsr at d�th�or f�tt�uee of a r�ksrat parerd,en
adoptive perern or a stepparent of fhe chiid is o percent[r2 P.s.§s��s(a}(t.z)j.
. The fax rate fmposed on ths net value of dansieB to or for the use of the decedenYs lineal beneficieries Is 4.5 percent,except aA no0ad in(/2 P.S.§9116(a)(1)j.
. TFw ta�c ra�isnposed�the net vaE�of tr�sfers to�Ear fhe use of the decadenPs sibkings is f2 parcenk(72 P.S.§9ti6(a}(t.3)].A sit�irg is defined,
umier Seciion 9102,as an indlvidual who hai at least one paren{in common with!ha decedent,whether by bla�d or adapticn.
,
PEW{5p3p(a(&ss)
�pennsytvania SCNEDULE $ .
{�,r oErAmnerraR�vv�uE
INHERITANCETAXRE7URN STOCKS & BONDS
RESI6EM4KEDEM .
ESTATE OF FTI.E NUMBER
NEVADA FLYNN 2012-1044
AII P�Y�1��h'ow�d wtth rtght of�rvhronhip�t be dlsdased en Srheduk F. � .
- IIEM � � ^ VALUE AT DATE
NUMBER ' DE$CRIpTION � OF DEATH �
.. .... ...... . . .._...... ,.. �,...._..... . .. ...__,.:.. .. ,,..,:�-w,�,,.,.K,.� . .....r , .
i. iMORGAN S7ANtEY StufITH B1iRNEY SEGURiTIES t � 247,241 00�
2� LPLSECURITYACCOUNT#1575� � ����� ��
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� 2578 , .. ._ � 111�323.00�
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TOTAL(Alsa enter on Gne 2, Recapikulallon} � _.�.,% 358 584 4D 1?
.:, ,. . ....,.
If rtrore space is rreeded,insert addltlonal sheet9 qf the same size
� ch �
JA� K S � N�
� NATIONhL LIFE IId5UttANCE CCIMI'ANY
t Capa�ttlW!
LrMip�M7 Aa951
October 5,2012
Robert G Schultz
285 Easf Grove St
Clarks Crreen,PA 18411
� RE: Polia�Number{s) ]0031469i3- . . . _
Insured: 1Vevada Flynn
27ear Roberk G Schuitz:
Please e�ctend our oondolences to the family on the loss of Nevada Flyun. We wsnt you to lrnow
that we aze availabie for aixy questians yau may have.
Per your request the date af death value for this policy is$644,471.94,
Your sarvice needs are very impartant ta ns. If you have additional questions or cancerns,ptease
oontact our Sarvice Cesrtar at 888/565-4995,Monday tJuough Thursday, 8:U0 a,m, to 7:00 p.m.
and Friday 8:00 a.m.to 6;00 p.m. (E"I'). You may also contaet Jackson via emazl tluough
i "Cantact Us"an ou=website at www jackson.com.
Sincerely,
/1.��� ✓"`���-----
Toni Zvanar;
_.. ._. A�tP, Glaims Administration . .
Vanablb Prorlucls IasuM by Jeekean NaUonel Life InwranCe Campeny"eM dkMWRed by Jecban Msfional Ltk pplribuNis LLC.m.xwrum.80(,V595A797
• Jackson National Life•
/�� ''PorspectJve L Serles �viced& Variab/a Annuify
www.iackson.com Changed AddressT
Account No: 1003196813
Mailinp Address: . For Ovemlght Dellvery: StrBet AddrBSS:
Jeckson Nsdonel LI(e� Jacluon Nadonal Life � �
P.O.Box 24086 7 Corporsts Way � . � � �
Lanslnp,MI 98808-4088 Lensinp,MI 48961� � . P.O. BOX: . .
Prepered for: City:
JOSEPH I FLYNN TFlUST Stete: 21P:
S CAMBURN &J FLYNN TTEE Deytime Phone: � I
86 VAGO RD
TUNKHANNOCK PA 18657 Owner(s) Signature:
Owner(s) Signeture'
_ .Your Inyeslment Representative:
T�8nS8GKY0I1 COn�I/)18t%On ROBERT G SCHULTZ
October 70,.2012 285 EAST GROVE STREET
CLARKS GREEN, PA 18411
Telephone: 1-800-644-4565
Monday-Fddsy, B.00am-B.00pm Eastem 71me
BrokedDeeler.
, ' 1PLFINANGAL,COpPORAT10N
AeLiVky'Summery Accouni/nlortnation
, : This Yeer ,..Since -..Aacount Number: ... 100379�13
Transection.; � :To Dete Inception
Total Investrtfents sp.00 m.00 Se�e.�o�.�o Type of Plen: ' Non-qudlfled
Totel Withdrewals 80.0o so,00 �,� Inception Dete: Novemb�r B,2007
Total Taxes UVithheld So.00 So.00 gp.� Totel Death Proceeds: Se46,s74.00
' Annuitent(s): NEVADA FLYNN
Value on 10/10/2012 Sess,e�4.00 Owner(s►: JOSEPH I RYNN TRUST
Your T.ransaction beiad
Date Portfolio Transactlon Type Number of Transectlon Transactlon
Units/Index Prlce Unit Values Amount
10/70/2072 JNL/WMC Monsy NlerkeL � Trsnsfer From 37,761.8642• � 10.80a6Y4 (5�8,287.�6)
70/10/2072 JNVPPM Am�rks HIOh Yid Bond Trsndsr From 7,996.0650- 76.882846 � (S12BA81.78)
70/10/2012 JNUMCM JNL 6 . Tronster From 8,087.8078- H.677867 IS70,686.48)
70/70/2072 JNVMCM Imisx 6 , � Tmnsfer From 70,957.8959- 8.698978 16108,OOB.S6)
10/70/2012 Ouarsntesd Ona Yaer Fixsd Tramfer To 2000'K 5846,874.00 .
JN4YYOU OMin�Auount B�rviw Is now�vdl�bb.Your ourMit ermunt veluw nn b�aeoawd di�th�Mt�mR. Blpn on to wwv✓.}oluon.wm to�
nWa«ro.mb�.w wvlo..
� Ths Pxpctlw L S�rlr F�wd end Wd�bls Annuiry ta le�ued by Jeclmon Natlonel LJfe Ineurence Compsny(Hane Offld:I.�nNnp,Nqch(pan)and .
dlwibu[atl byJ�oluon NatlonN Lifs DI�Mbumrs LLC,membsr FINRA Not wellable in�II abta�end Wta vedsBom mry�pply.
�� � � Jeckson Natlonsl Lifs Insursnce Compsny, 7 Corporete Way, Len�inp,MI �8967 � �
Maklns�Addltional/nvestmentsl Please meke checks payable to Jeckson Netional Life.
'If you would Ilke to direct Jadcson Netlonal Life to deposit this investment to other allocatlons than what Is currently%an Kour
policy,please indicate whlch Irnestrnerrt option(s)you would lika to choose for this deposR.
InvestmeM OpNon/►mount %or pollar Amount Investment Option %or pollar Amourrt
❑ Check here If you would Iike Jackson Netional Lifa to allocata fuNre deposits to tha Irneatmwrt optlon�s)choeen ebova.
Pleaw call our servlca caMer(B00) 788-4883 to Inquire about making ellocatlon changea to ths assets wrtMtly In your policy.
Pleese sign below to authorize tfia ellocatlon of the curreM deposit and/or it you ere elsctlng e change tfi�allocatlon for future
deposita.
Owner's Sfgnature: Joint Owner's Sfgnature:
Number:100379B973
Perspective L Series Fixed& Variab►e Annuity Holdings Summary
Portfolio Future Number of Units Unit Values Market Values
Listed by ss�et class&portfollo msnapx % AIIOCatIOn � 8t 10/10/2012 at 70/10/2012
Jeckwn NMlonal Llte � .
Ousrantssd One Yaar Fixsd � � $846,874.00
' Wslllnpton IiMnapament Compury � • � � . � � �
JNL/WMC Money Merkst 700.0 . '
Portfolio Aliocation Total Account Values
A This emount fs yourCoMrset Value s�of th�dats o(thls sutsmsnt. Th�Wlthdrawal Velue of your wnLnat may bs pwl W la�s
then�the ConhaM Vdw. Plwss s�s ths Deflnftlone secdon of your contract(or a deacripdon of how ths Cond�ct Value end
Wkbdrswel Vslus ero calaulatsd. � ' . � �
Importent Notices
Oncs s wmpl�ts or pattisl nd�mpqon hss beren msd�trom e sub•account,you wlll not be permitt�d W trensbr sny v�lus b�ck Into Lhst '
� wb-sccouM wlLhin i6 cal�ndsr dsys of Lhs rsd�mption. This rsstrictlon dos�not epply to the morroy merkst�ub-exount th�Fixad
AxouMs,Ooller Cost Av�n0��0 or the Autometlo Xebels�rcinp progrsm. �
. . �l'FE�'4Cti: rir�i4^a{i�;1ee;�:; �. ,
You have tfie right to request and receive wlthin 5 business days of the Company's r�c�pt of your roquert,the
Prospectus end contract premium peid for the product as Indicated ebove. You mey coMact.our Servlce Center
at 1-800-8444565 for ffiia informafion.
Please review your confirtnetion cerefully and notify our Service Center of eny potentlel error within 30.days.
J�C.� �.
�A� �.S �►��
NATIONAL LIFE [N$UILANCE COMYANY
� t caryaatsxy
. trakq,M1N�BiSt
Octobei 5,2012
Rnbert G Schultz
285 East Grove St
Clarks Green,PA 1$4i1
FtE: Poiicp Ntunber{s) 299'J3652�0- -
Insured: Nevada Ftynn
T7eaz Robcrt G Schuitz:
Please extend our condolences to the famiIy an the loss of Nevada Flynn. 'We want you to ICnow
that we are available for any questfons you may have.
Per your roquest the date a£death value for this policy is$79,809.05
Yaur setvice naeds are very importani to us. If you fiaue additianal questians or concernsn gltase .
contsct aur Service Center at 888/565-4995,Mondaq through Thursday, 8:00 am.to 7:00 p.m.
and Friday 8:00 a.m.to 6:00 p.m. (E'I). You may aisa contact J'mckson via emeil through
� "Contact tTs"on our webszte at wwwjsckson.cam.
Sincerely,
/C"`-' „��-----
Toni Zvonar,
.. t1VP, Ciaims Adrninis#ration
VaAabkprcduWWuqdbYdeckeanNatbnelLifelnaurent�Corryie�y�undOlsol6uisdbyJedmnNelfanallJfeL11a91bubrsLLC,mfmme.rwso.8001665�8797 � . �
. Jackson National Lif�e"
��� Perspective L Series /"-rared& Variab/e A»nurty
wwwciar.kson.com Chsaged Address?
' " Account No: 10p�365280
� (Vk�lN�Addrsss: For OvazntphS Deiiwry:
Jeckson Nationet ltfs Jsekron National Life ���#A���g' �
P.O.Box 24088 1 Corpopte Way p.0. BQX: � .
Lanein0.MI 48808-4066 Lendinp,MI A8957 �
Prepsred for:
CI#y:
JOSEPH I FI.YNN TRUST . Stete: 21P:
SANDRA GANlBURN&JQHN Fi.Y1UN TT Dayttme Phane: { }
86 VAGO R4AD
TUNKHANIVOCIC, PA 18657 Owner�s) Signature:
Owner(s3 Signeture-
_,...._......_........ _._..._..._.._..._ ........Your.inveatment Represeata#ve: . __.. . _
_---__._
Tr�insaaffon Con�rniation eaa�-r�sc�u�rz
285 EAST GROVE STREET
OGkober 77,2012 CLARKS GREEN, PA 78411
Telephone: 9-8�•644-4565
Monda�FYlday,S.00am-1�00pm Eaatem 7fma
Broker/Dealer;
( LPL FINANCIAL CORPORATION
Ac#rity Summary Account Informallon
' Thls Year . Sinae �q�ounLNamber, 340T�528tt
Tre.nsaction To Date incaption
Ta#al inveetments �p,up �o,pp g�„q�p.po Type of PIBn: Non�Taz QuallHed
To#aI WEthdrawala #o.co go.op' Sp.� inception De#e: May ta,20t0 '
Total Teuea Withhefd so.00 so.po gp.� Tatei Deeth Proceeds:i78.24o•6s
Annuitant�s►: NEVADA H FI.YNN
Value on 1Wl1/2012 #�s,2�o.ee $
C?wner{sI: Jos�Qh E FFyrm Tnrst
Your Transsct/an Dstail
Dete Partfotto Transactlon Type Number o# Transsctlan Transect!!or►
Units/Index Price Unit Valuea Amount
t011it24'!2 JNElMCM.�S - -SransF�From (B,A�.791+� 72258469 {579,248.681 -
10/f1120/R OueraMssdOneYeerftxsd � TranNarTo � � p,Dppg: $78,248,86
Perspective L Series Ffirsd 8c Varia6ta Annuity Noldfngs Summary
PortFotia Future Number of Units Unit Values Markat Valuas
I.tu�by eswt aau ee porqoJ�a menaQer °fa A110C8ti0(1 8t '[6111i2012 8t 1414112Q12
Fbrod Aceount � � .
�usrantsed One Yspr flxsd . . 679,2W.68
JF6+��2YOU bnMi A000uM S�rvvlus h�ww avaqabk.Your ainx�t eaaunt VaWai un bs sww�d W th�Mtsm�i. �r on te www.�aokwn.awn ta �
rpi�tr br t�h eHw arvW. � '
ThW Pa�ryfwUw L 9�rla FwM snd Vsdabls Annuiry to IuuW by Jeckaon Natlunel Life In�urence Company(Home Otfic+:lanNnp,Midfle�n)end
� di�tdbutsd by Jedroun N�tlonM Ufs Dl�edbutoro ILC,mqmber FINRA Not evellebin in NI eteroe end ebts vsHetlone mry�pp1y, �
.lsckaa�Natlonsl�tte Intursnca Compaey, i Ccrporate Wsy, Lamtnp.MI �8961 � .
�t+�akftto Addtttanal lnvesfm8itfsT Ptsese make cheeks peyable tu Jackson Natiansl Life.
1f you would ifka to direct Jeckson Natlanal Life to depo�it this invustmant to othar allncetions thsn what is currendy on your
pollcy,pteasa indTcate which tnyestmatrt opUonis}yon wauld Iika to chaoss fo►thls deposit
Invastment Ootlon mount %or poll�ar Am.._ount Invastment O,ption °/n or Da41sr AmJUrrk
� Chxk hare If yau would Iike Jedcsan Natlonat Llfe m allocete future dapositts to ths Irrvestrne�rt optlon(s)chosan ebove.
Plasse call our aervics center f8001788-48�i To inqulre abput making alixatlan ehanges to the asssLs cum�ntly In your policy.
F4aasa sign treiaw#o sutlwrize the atlo�tlon of tlta wment depas€t andla�If yau are elaetl�a char�e ther allocstion hsr fimue
deposits.
tiw�a�'s Signature: Jdn;Ownar's Signature:
Mumbee:lt}07365280
Parspect�ve i Sarias Ffxed& Y�riabl�a Annuity Notdings Summary
Portfolio Future Number of Units Unit Values Merket Valuos
u*L°dbY,.�.t�..•a�p°�ce�rom.""aK °IoAilacation at 70l'f1t2412 . at 70T1112072
(nvsshnent piWslon � � . ' .
JNL/MCM JNL 6 t00A � 0.0000 72.2634B9
��� ��r
Portfolio Allocation . �oa�o 7otal Accaunt Value� 579,2ao:5s
S ThIM�mount is your Contrqct Valus es of ths date of this etetement. 7he Withdrewel Velur uf your ccMnce mpy bs squai W loa�
.then YM CcaVact Vsiw. Ptmes�sse ths Dsflnitlons axtion af ynur caMruct fnr a descriptlpn of how ths Contraat Valua and
1NNtfdrawat�VMtususctrletdatad. . �
. important Notices
Otucs a comp#Me or pprNa!rodw�pUon its�r F»m mads hom a subwecouni,you will�rot bs parmithd to transfar a�iy v�ue bs�c Intci tbat
�ub-wcour�t With(n 1B wiendar days oi the redsmptfon. This restria8on does not epp�y to the maney merkat sub-sacoun;LM Ffxed
AccouMS,Dollar Cort Av�npingl or ths Automadc Rabnlancinp proqram. � .
Yaa have the righ#to requeat and reca(ve w�ithin 5 6usiness deya of tfie Campeny's racaFpt af yaur request#he
ProspeCtus end cantrect pramium paid for the product as Indicated above: Yoo may contect our Service Center
et 1-800�6449685 for thia lnfortnatlon.
Pleese r,eview yaur conflrmatian cerefulfy and notify our Service Center of eny potentiel emar wiffiin 80 days.
�G.h �
Form 7089-H coaRecT�fn�n��l ,o,o.,m.mwe� oMe nb. �saso++e Distributfons From
r�veae�»,w.e.aa.e,mr,.w..�a ae ooa. /� Penslons, Mnufties,
WItANNOTON�1`RI�TAePAYOHFOR M .78 n7 O 1 L RltlF1IY1N1t Or :.
LJNCOWPINANCLILOROUPIM - � ' LTaabNamowt Li ProlitSharing. �
wi��r.xrmr�oN�iT�aooi Plans, IRAs,
Form 1099-R �nsurenoo
� � . ffiTwds�mant ToW ('i011uHCtl� 61C.. .
na ea.rm�.a X mr�ama, X
PAYER'8 hGid IhMlbatlon iunY�r RECI%EM'e MreMwtlom m�br 7 GqW Odn(��� 9 F�MeI Inoam bx wlWr�d 6��� �
In bm�YW . �a.+oP+bp�wuum•«
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THEEBfATEOFNRYNN . �nrnqoydeaeourillw e� X
BANORA FLYNN OAMBURN,IXECIl�OR 4 %
e!VAOO RD ' Y�Yau P��u9a ol totN Elatnbullan 9b Tald�rWeYe�omtrWUlkro
TUNIQMNNOCK PA��� .
% $
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FW'IIl yOO�R � . CORRECTED('rf checked) ,oro.,m„��,e�, � oMe rio. �sasmia Dlstributions�From
PAVEH'8 m�,.InM Wdn�,aMy,rW and 7lP aods Pensions, Mnuitles,
WILMNOTONTRUBTABPAYORFOR. �0�1� . �R�tiromsnt or .
LINCOIN FINFNONL f3ROUP IRA P����
3 Tmbl�unw�t
W'�ANO°N�°E1�' Form 1099-R Plans, IR�,
ffiTaahle�mant � ToW ' �IIiUfBI1C� �
' iwl daNminad X Wadibutlan X � Ci011�8Cti� 6tC. .
PAVEH'81d��WwAAO�tlan nu�iwr RECIREM'8 kmtlAO�m nu�ber a C�pIW peln(kMutlaE 1 Psderd kaan�Wc wIMMd e BMvI�•m+�"
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RECIPIENI'8�wnti rnM�Edna(IM.4L nal�al4'�M'N�d LP aatl� a NN unrsdivd yp�eoietlon 7 datrNwtlm oode(W IwV e qher '
i�«�dor.r...b,m..
THE E81'ATF OF NRYNN � `,�qi X �
BAWtiAFLYNNCAM@lkiN�IXEOUfOR 4 - g % - �
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TUNWIANNOCK PA 78867
% 6
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_____________'_ '________"'_' ______"_______
FiN YY�mPY wW�Y���4 ab.� .
�NwmM bz Mm,rMn�WNd ww�`'•�. . � Depertment of the Tr�sury-Intxnd Fevsnw Servka
Form 1099-R cow�ECreo p�cnec�a� ,o,,,;s�rewe� Distributlons From
OMB No. 1546-0116�
PAYER'Bnnr,MnNWOiw,ally,.m.nanrooe. � Penslons, MnulBes,
WILMNOTON7RUBTABPAVORFOR 3443.78 �O��. � Rl1�f91110flt Of �
+�nNn��R�TUPIM . 2�Taxeblsxnwnl ProfltSharing
wiu,+ria�roNce�aeua000i Fortn 1098-R Plens, IRAs,
mT�wa.�m row Insurence
. � � nmamrmn.a X aetna�n«i X Contfacts� sta�
PAYER'B IMs�d M�Albatlan nmbar REOIPIENi'8 M�ntlAOWm rw�b�r 9 Capital pdn(Indudsd s FedsrY kwan�tex wItlY�Nd 0 emM'��W+�
• in bm�4eI �w�leubn�«
m
� 61�860Q2B9 � . .
RECIflEM'8 n�m�WM Wdr�r(M.M+��J�opP�NW end LP ootls !NM unndiatl ePProol�tlon �a.��aa IRN �OCrr
: T/{E EBfATE OF N FLYNN � In amployafe aeoutltlw �
; BANDRAFLVIMlGMBURN�IXWUfOR , . . .4 ewstt �( . % .
. BOVN00RD WVarpeiwnb7s'WtoWdMAWtlan YbTaW�rtplo�MOaMWUAain
� TUNKHANNOCKPA18867 �
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' 128WS ta�t wlhhW ti 61�ivPM'�IO N�OS'ro. M&W Mltlbutlan '
MoaMnlnWf�N�InMolmy 117MyMfMdwO.RWfoM�llb. _"'_'__"_____ � __________ .
IIMb1100P1MWIJ0A __---___'--__— "—_'_
.�Py `. toMwi�WoaWNtaIRRwltlin6Ywn 16lmYtm�wlW�Nd 1BNem�oibodiry 171m.IdWlbWm �
For Reclpia�Ys Records --------------- -------------- ---------------
Ti Irlamdlon Y ONro*+mYMda wwx.npw
M IM�mI Hwanw e.Ma.. DepartmeM of the Treeeury•IrMxnel Revenue Ssrvbe
(lap�aY�rer ..1 . . .
_ ] � _ ; �-^ � �:_.. � �--' j. v; �� • �:_—^
PAVER'S nems,�ttes[addrw,dty,Karo and 21P eoEa ❑ CORflECTFD(If cMCkaJ1 �G� � � .
METLIFE INSURANCE CO OF CONNECTICUT 1 Groadiehibuclon Distribuvone From Panslone,
PO BOX 14592 $3,472.03 'ZQ� '2 p ofit+Shering PI n�IPAs,
DES M�INES� IA 5�.306-.3592 2sTa��bleemount
- . Ineuranca Contracte,�etc.
� � S3,472.�3 FORM 7099-R
26 Taeble emaum noe Toul
. debrmirod � ainde��o� � Copy B �
�PO��Ltl�hwam��
on your M1dsni ua '
PAVER'8 hEwN WenNHUtlon rwmbs flECNIENT'S Wentlflutlon wmbar 3 Capl W gain Ilncl Wetl in box Iel C FWn�I invan�wx wlthMltl N�.If tM�io�m
06-0566090 •"•-'"- •�w•�•�u�•
flECIPIENT'S wme,eVeat addren Iintlutlinp�pt.no1,ciry,St.and 21P coEe 6 Empoyx aan�i�Wi�bn�o�N�.Ommlum� e�����6M.q.s�ilui In anpeyk� m W�M��
box 4,�tteoh Nq
� . oWY m Your nturn.
7 Dirtributlon cade ey,�p� . 8 OtMr �����alnp
ote07 4 ❑ 0� Innrn�IlLVmu�Bnviw.
E TATE OF NEVADA FLYNN ea Vour parcenuge o!rotal 8b Tottl emplayas eontrihutloro
8 VAGO ROAD ai.n�e�no� %
TUNKHANNOCK, PA 18657 ,oso.�ao..w�mn.w „su�.mww..�.a�. �xs�.e.amnwn�,
PA/10841450
13 L«N tu[wlNlald 14 Name of lowlity 16 lx�d4MWtion �
AwoumnumGrloptlonell . ' . .
T678625933
Form 1099-R - . Departrnent of tha Treasury-Internel Revenue Servfce
PAYER'9 nun�.mwt�tltlnw.dtY���+d 2W oaa� ❑ COflREGTED Of checkadl
METIIFE INS�IRANCE CO OF CONNECTICUT �o�e.+aimiwno� OMB Ne.1646-0118 Dbtdbueons From Pamiona
PO BOX 145y2 $3,472.03 Annukk�, Rstircmsnt or
DES MOINES IA 50306-3592 2eT�xaWeamount 201 � P��itShs�iny Plana,IRAe,
7-800-515-1 b75 Inauranca Contrecn,etc.
. $3,472.�3 FORM 1098-R � �
. Yb TaxabN uno�+l+t not Tottl '
' tlatermirotl � � tlMWbution � COpy C .
For hapYntY
PAVEX'8 FedvY Wr�tlNenlen numG RECIPIENi'9 kntllleatlon nurnbar . 3 CwItM gsin(IncludeE in!on L) 4 FaMN ineom�oa wMIrM ��
06-0566090 "•-"•- e e��.,wn�°w"�`
PECIPIENT'S n+m�.wrt tlMw pnrAUtllnp apt.rol,dty,BL uM 2U'eotle 6 Emqoyas ooninw�bm a�s.pumbn e w�u��wa pp.dnbn n �i�� .
nom ��� Rnromr S�rvb�.
7 Dbhlbutim catle 8 Other �
4 e�` %
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86 VAGO ROAD DittrlbuNOn o�
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� ' 13 LxY bx wiMhelA 74 Name of locallty 16 LoaY dbtAbutlm � .
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T678625933
Form1099-R � ._,.,,.. Departmen.t.,of,theTreasury-lnternal,RevenueSeryice.._,_
.......... .. ...... ....._..... .... .... ..... ..._. .._._ .......
, �
PAYEfl'S mma.�trMt atldrm.Nry.�bb rd 2W coM ❑ COIIRECTED nt clrckWl ' . ' � �
METLIFE INSURANCE CO OF CONNECTIGUT 7 Grou dhhibutl,on OMB No.1616-0i1B DbMbutiom From Psmlons,
PO BOX 74592 $3,472.03 AM+�d.•.MUnm�nt or
DES MOINES, IA 50306-3692 2�7 2 ProtKSh�dnp PIam.IMe.
z.r«.ae.mo�.rt , IraunncaContracts,sta.
. $3,472.�3 PORM 7099-R � - �
� � �Taz�d�vnount not ❑ Tottl . ❑ L.�Y.j .
� � � aatmn�n.d , einnnunon w.w.oaw .
PAYER'9 Fetlerd IMrttiflenlan num RECIPIEHf'S IGeMiNCatlen manMr 9 C�plttl 9aln Ilnclutlad In boz 4�1 4.FWnI Mwom�bt wM1Muk . wIM Y��bb.
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PECIPIENT'S nrM.nnst adtlnw Ihidudi qt.rol.dty:St.rM 21G coM �uI n��.wMn .
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ai.o-iMrtlon p�
TUNKHANNOCK, PA 18657 1o9ensxuiwimMm il5tna/Payannwno. 126twdWlbWion
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�ORfI 'IOJJ-R � nwnnrtmwn�nf the T..aen�._i..........i o_..._..._ r__..�"'
;�R�,� oF I�=YIO�� T�ES � enns Lvania
. ro sox :aoco� Pennsylvania lnheritance Tax .� p y
xARRISlUR6 PA 17128-06a1 Information Notice DEPARTMENTOFREVENUE .
�[rnrs o�weuec u�aa
And Taxpayer Response pl�e N0.sno
ACN 12154662
DATE 10/02/2012
Type of Acbount
Estate of NEVADA H FLYNN Savings
Checking
Date of Death 09-20-2012' Trust
SANDRA F CAMBURN County YORK Certificate
30 E MOUNT AIRY RD �
� DILLSBURG PA 17019-9567 � � � � �
METRO DANK proVicled the department with the information below indicating that at the death of the
above-named decedent ou were a 'oint owner or beneficia of the account identified.
Account No.513109603 Remk Payment and Forms to:
Date Established 0&22-1999 REGISTER OF WILLS
Account Balance �59,526.98 45 NORTH GEORGE STREET
Percent Taxable X 50
YORK PA 17401-1240
Amount SubJect to Tax $29,763.49
Tax Rate X 0.150 NOTE`: If tax payments are made within.three moMhs of the
Potential Tax Due $4,464.52 decedent's date of death,deduct a 5 peroent discount on the tax
With 5�o Discount(Tax x 0.95) $(see NOTE') due. Any inheritance fax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below.
�
/+ �No tax Is due. I am the spouse of the deceased or I am the p.grent of a decedent who was
21 years old or younger at date of death.
Proceed to Sfep 2 on reverse. Do not cheGc any other boxes and d'�sregarti the amount
shown above as Potential Tax Due.
g �The information is The above informaiion is correct, no deduotions are being taken,and payrTrent will be sent
_ Qoereet. . . _ _ _-with my response:_ __ _
Proceed to Step 2 on.reverse. Do not check any other boxes.
� �The tex rate is incorrect. � 4.5°/, I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased.
(Select correct tax rete at
right,and comptete Part � �p� I am a sibling of the deceased.
3 on reverse.)
� � 15% All other relationships (including nona). , .
p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. -
iisted. Complete Part 2 and part 3 as appropriate on the back of this/orm.
E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Retum filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes:
Please sign and date the back of the form when finished.
lUREAU OF INDIVIDWL TA%ES � �� pennsylvania . �
. ro sax zeaso� Pennsylvania lnheritance Tax
FLIRRISBURG PA 17128-0601 - � .� IflfOffTl3tl0f1 NOtIC2 � � DEPARTMENT OF REVENUE
KY-INl OI YeaFKft l0�-IIl
And Taxpayer Response Fi�E No.sno
ACN 12154663
DATE 10/02/2012
Type of AccouM
Estate of NEVADA H FLYNN Savings
Checking
Date of Death 09-20-2012 Trust
SANDRA F CAMBURN . � . . - � CountyYORK � �� CBRiflCate
30� E MOUNT AIRY RD � � � � �
DILLSBURG PA 17019-9567
METRO BANK provided the department with the information below indicating that at the death of the .
above-named decedent ou were a`oint owner or beneficia of the account identified.
AccountNo.538132242 Remft Paymentand Formsta
Date Estabilshed 03-12-2008 REGISTER OF WILLS
Account Balance $pg,pg4,qg 45 NORTH GEORGE STREET
YORK PA 17401•1240
Percent Taxable X 50
Amount Subject to Tax $74,64224
Tax Rate X 0.150 NOTE": If tax payments are made within three months of the
Potential Tax Due $2,196.34 decedenYs date of death, deduct a 5 percent discount on the tax
With 5�o Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due wiil become delinquent nine months
after the date of death.
PA� Step 1 : Please check the appropriate.boxes below.
1
A �No tax is due. I am the spouse of the dsceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed to Step 2 on reverse. Do not check any other 6oxes and disregard the amount
shown above as Potential Tax Due. .
g �The inform�on is_.�_ ThQ�bQve_In�orm�tion,is.conect,,po deductions are being taken�and_payment will be seM
correct. with my response. �
Proceed to Step 2 on reverse. Da not check anyother boxes.
� �The tax rate is incortect. � 4.5% I am a lineal beneficlary(parent;child, g[andchild,etc.) of the deceased.
(Select correct tau rete at
right, and complete Part � �p�, I am a sibling of the deceased.
3 on reverse.)
� 15% . All other relationships (induding none). , . . . . � �
p �Changes or deductions The information above is incorrect and/or debts and deductions were paid.
listed. Complete Part 2 and part 3 as appropriate on the back of this form.
E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax
inheritance tax form Return filed by the estate representative.
REV-1500. Proceed to SYep 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
REV-f6o8IX+(o8-fz) � .
�pennsylvania SCNEDULE E
DEPMIM@lTOFIiEVENUE CASH, BANK DEPOSITS &MISC.
�+X�*�T��w+ PERSONAL PROPERTY
�s�oErrr oecm�xr
ESTATE OF: FILE NUMBER:
NEVADA FLYNN 2012-1044
Indude tlre praeeds of Iitlgatbn and the daM the proceeds were receNed by the estete. - . �
All proprty�olptly ownqd wkh righL ot curvivonhip must ba disda�ad on Sd�eduk F.
.. �M VALUE AT DATE
NUMBER DESCRIPTION OFDEA7H� .
. ...... . . ...... . .. ....... . . . . ......... .. .__ ._. . ., .
� ; WACKSON NATIONAL LIFE ANNUITY POLICY#1003796913 � 649,472.00 ,
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2 , �JACKSON NATIONAL IIFE ANNUITY POLICY#1007365280 l 79 809 00�
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LINCOLN PINANCIAL IRA#20130115 � �� �
3 ` ; 004900087087 € 3,444.00�
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jAMERIPRISE FINANCIAL ACCOUNT#000258284324133 4 u L } ,9.,A�����i� 41,274.00�
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+ 5 �METL.IFEANNUITYCONTRACT#8625933 j 3,472.00 �
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m �� i ;i ANNUITY#930022304594004 N* f 2,355.00 u
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� ANNUITY#930078582556004 '• 119,421.00 g
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' 7 � AMERIPRISE FINANCIAL 403b ACCOUNT#931039749839004 � 6 688.00�
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TOTAL(Alsa enter on Llne 5, Recapitulatlon) � s 905 935 00'i, -
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REV-�5o9IX+(oi-1o) � .
�pennsylvan9a SCNBD!!LE F
oeremnexrorneveaue ]OINTLY—OWNED PROPERTY
1NH�lITApQ TAX RENRN � � �
RESiDeR OCCEDEt1T
ESTATE OF: FtLE NUMBER:
NEVADA FLYNN Z��2"�044
I/an ewt Wwme�olMly owned withln one ymr of tfie dacedeM's date o}desth,k murt ba roporbd on Sdfadula G.
SURVIVIN6 JOINT THJANT(5)NAME(S) ADDRE55 • . �� RHATIONSFIIP TO DECEDENT �
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70INTLY OWNED PROPERTY:
LLmL9t p�7E DBCRIPRON OF PROPERTY M UF OYC1E OF 0lA1M
[IBt PoR70V/f IMOE 016AIDENNIEdFFIIUNOAL[167SI11flONMIDBANKA0C0U1RM1MBE0.0RAMWVt NOEOF06OH DC�MS VAWEOF
� M1MB9t.IR17,W D�W0.10MM1Y NfiD PFAL 6TRfE. . V E ➢rt&6T ➢!1!qlST
�• A' p5/l?19g ME7ROBANKCHECbNGACCWNT#513109603 59,527.00 �'_—bOi 29,763.00
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2 t f 03�17J08 � �MEIROBANKCHECKINGACCOUNT#53813Y142 ; 29,284.00 50� 14,642.00
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� TOTAL(Also enter on L1ne 6, RecepRuiatlon) �^� � , . 44 405.00�i
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REV-1511 E%+(10-09J , �
�pennsylvania SCHEDULE H
DEMFTMEXTOFPEVlNIIE FUNERAL EXPENSES AND
[NHERifAN�TrI%RENRN A�DMINISTRATIVE COSTS � �
PBIDENT DE�EM -
ESTATE OF FILE NUMBER
NEVADA FLYNN 2012-1044
Dacedent'a debb muat be rcported on Schedula I. � �
ifEM
NUMBFR � DESCRIPTION . AMOUNT �
A. F,I��RAL..FdSP.�NSE�;_.,,_..�___.._. . . _. _.._7 �,,,�,�.�,x r , p,,�„�
i. __ , z
€COCKLIN FUNERAL HOME � 6 773.00
�.
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; 30 CHESTNUT ST,DILLSBURG PA 17019 � ��.�;�.��iYe.e_.�
_.� �_ ,� �.., ;� .�; _
ROLLING _ ..,..__.._. . .m
GREEN CEMEfERY � 1 772.00 .
.; , �: ,-"-_.__._. .:, ,. .._... ,... , , °,""�,��«,.,�;.�:.
' 7811 CARLISLE RD,CAMP HILL PA 17011 5910 = "
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B. ADMINIS�RATtVE CASTS:
��.nuamr u xin-rxu�
-1. Perwnel RepBSeMative Commissl0re:
r
Name(s)of Personal Representative(s) ,�„�� ��t�,*�:
SkeetAddress '
q�y State_ZIP � . -
Year(s)Cammission Paid: . � .
� � � � ��,��..��.
� 3 460 00'!
z. attomey Fees: � �,���,M�?,
3. Family&emptlon:(If decedent's address Is not the same as daimant's,attach ezplanadon.) ?i,�,.��:,nm�,ry-,�» ;�.,.�, � . ��..
qalmaM
Street Address .
qty State_ZIP �
Reletlonship of qalment to Decedent .
. � i',..wrwm»mw,�;n�e+�.ws�i,:.�.::��+�"�
� 894.00;..
a. ambete r�ees: . ,;,��.n�:•.N���.,-�,:;:x
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5. � RaauMaM Fces: � . �F 865.Q0 i�
t»�:��, � .,,a,�.����
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6, lbz Retum Preparer Fas: � � . � 335 00 r
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TOTAL(Also enter on Line 9,Recapitulatlon) � 13 899.00�
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- . . _ _ _
REV-1512 EX+(12•13) �
�pennsylvania SCHEDULE I
�'���+� DEBTS OF DECEDENT,
INNHUTMICFTW(PETURN MORTGAGE LIABILITIES & LIENS -
RlSIDBlf DEC�@ff
ESTATE OF FILE NUMBER
NEVADA FLYNN 2012-1044
Raport dabb Marrad by tlw dacadent prior to da�th tlut ramalnad unpeid et!he deta M dealh,Includinq unralmbunad m�did axp�ma�. -
IfAd .. - � VALUE AT DATE �
NUMBER � DESCRIP'fION OFDEATH
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1• €MESSIAH LIFEWAYS � 14 750 00 :
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2 �ALERT PHARMACY � �{{ ry�,pryy 373 00`�
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US TREA3URY RECLAMATION(RETURN SOCIAL SECURITY CHECIQ �w �.� 2 160.00� '`�
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� TOTAL(Alm enter on LJne 10,Recapkuladon) Q� 17,408.00"-.
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REV-1513 IX+(01d0) � - .
�pennsylvania SCHEDULE J
OEP�qTMENTOFPfVFt111E - pENEFICIARLES
INHEAl1'AN�TAX RETURN
RgtDB/T DE�EM .
ESTATE OF: FILE NUMBER:
NEVADA FLYNN 2012-1044
�unonsHiv io o�oerr anourrr oR srwnF
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIV[NG PROPERtt Do Not Lirt TrupN(�) � Of 6TATE , � �
� I TAXABLE DISTRIBlJfI0N5[Indude autrigM spouul distributlons and t2risfers under � . � � . �
Sec.9116(a)(1.2).] . � �
..-. • • •.. - •.... .. . LMW"'RYF x.WS'v. p�;
1. ;WINIFRED FLYNN 640 RIFE RD EAST BERLIN PA 17316 DAUGHTER I � 1/8�
_ �._ .. _�_� ._ _.____..�_ . ._ � _ _.._ ��.��a���,�<,._a.�
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� 2. jGLENN J PLYNN 14761 SR 104 MARNILLE NY 13111 � SON ��� � 1/8 j
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3 jSANDRA F CAMBURN,86 VAGO RD TUNIo-IANNOCK PA 18657 �DAUGHTER 1/8�
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4., iJOANNE FL_. ... ._.. _ �_ .. .. 4 .__m._.�._.____ ��:�4� <�R FY�
` YNN 16815 MILLTOWN LANDING RD,BRANDYWINE MD 'DAUGHTER ' 1!8�
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5 i �VALERIE FLYNN LE1MS,414 GREENBRIER AVE,RONCEVERTE NY DAUGHTER _ �; 1/8��,
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6. ;JOHN FLYNN 74 SALT RD CONSTANTIA NY 13044 SON � 1/8�
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� 7 ;pANIEL FLYNN 2980 GR4NDVIEW DR,YORK HAVEN PA 17370 � �SON 1/8 `
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8 . ;CHRISTINE F MONROY 30 E MOUNT AIRY RD,DILLSBURG PA 17019' i DAUGHTER � 1/8�
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ENTER DOLU4R AMWNSS FOR DISTRIBUfI0N5 SHOWN ABOVE ON lINES IS THRWGH 18 OP REV-1500 COVER SHEET,AS APPROPRiATE. .
n NON-TA%ABLE DISTRIBURONS . .
A. SPOUSAL DLSIRIBURONS UNDER SECfION 9113�FOR WHICH AN ELECTION TO TAX IS N0T TAKEN: �
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�B. CHARITABLE AND GOVERNMENfAL D15iRIBUTIONS: . .. � � �
.. . . . . .. . . ,�...,.,:. �
;DILLSBURG PUBLIC LIBRARY i � 3000
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175 S BALTIMORE ST,DILLSBURG PA 17019 � x '
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�MESSIAH LIFEWAYS ENDOWMENT FUND `' � 2000 r;
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100 MOUNT ALLEN DR,MECHANICSBURG PA 17055
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TOTAL OF PART II-ENTER TOTAI NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE7 ¢i. M1uf Y � � � � 5000 �F�
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P
�EGISTER OF WILLS OF CUMBERLAND COUNTI, PENNSYI:VAN
�f Decedenk Nsvada H.FIYnn
`Deeth: 08/20/2012 File Number. 21-12-0144
3tters Gran�d: tiA/26/Y012
Register.
,thet N�of Esmte Adm�f�daHon required by Pa.O.G. ftuie 5.8(a}of ttre drph8ns'Court Rules
ved on or maildd to the talluwing beneflclarles of the ebavo-capdoned estaie on ,
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Sandra Flarnn Cembum 86 Vaga Road,fiunkhannoak,PA 18867
DOlsbury Pubile Library 17 S.Bsllimore Street, Dlllsburg,PA 17019
D�niei Rabett Fiymn 2880 Grat�ew DrNe,York Haven,PA 173T0
61enn Jay Plynn 14T61 State Routa 104, Martvlile, NY 18/11
John Jweph Flynn 74 8a1t Raad,Cvnstanda, NY 1304+t
WEttlttsd Agntta Elynn 60 Rtfe Road,f�i B�iltt,PA 17318
Vaterie Fynn Lawis(Wibsr� 414 Cireenbrter Avenue;RonceverEs,WC/ 24970
Messiah Vlllrge Endawmsn!Fand 100 AAt Allen Drive,Mechwnlcsburg,PA 17i1�
Chrkstins flynn INonroy 30 E.Mauttt lliry Road,Allisburg,PA 57419
Joanns Fynn Newlin 16816 MlMftown Lending Road, Brandywtns, MD 206w
has how been given to aii persons entltled ttiereta under Pe. O.C. Rute 5.8(a}e�ceept:
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OF
NEVADA H. FLYNN
BE 1T REMEMBERED, that I, NEVADA H. FLYNN, of 30 East Mount Airy Road,
liillsburg, York Counry, Pennsylvania, being of sound mind, memory and understanding, do make,
publish and declare this as and for my Last Will and Testament, hereby revoldng and making null and
void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore
made.
ITEM 1: DEBT . I direct that my hereinafter named Executor pay all my just debts,
my funeral expenses, and the expenses of the administration of my estate. With this direction, I
authorize and empower my Executor to expend for my funeral expenses and interment such amounts
as he may consider necessary and proper, without regard to any limit that may be prescribed by a
court of law.
ITEM 2: TA3�S. I direct my Executor to pay all inheritance, estate, succession, and
legacy taxes of whatsoever nature and kind, to which my estate, or the transfer of any property
passing hereunder or otherwise passing by reason of my demise, may be subject, and to charge such
taxes against my residuary estate. It is my intention that none of the aforesaid ta�ces, either federal
or state, on any property required to be included in my gross estate,under the provisions of any state
or federal law now in force or hereafter enacted, shall be prorated among the persons interested in
my estate to whom such property is or may.be transferred or to whom any benefit accrues.
ITEM 3: SPECIFIC BEOUEST.
A. I give and bequeath the sum of Five Thousand Dollars ($5,000.00) to the ST.
ELIZABETH ANN SETON ROMAN CATHOLIC CHURCH, Mechanicsburg,
Pennsylvania,to be utilized without limitation. In the event my spouses predeceases
me and a bequest for Five Thousand Dollars ($5,000.00)was made to St. Elizabeth
Ann Seton Roman Catholic Church, the foregoing bequest shall lapse.
_ .
B. I give and bequeath the sum of Three Thousand Dollars($3,000.00)to the Dillsburg
Public Library of Dillsburg, Pennsylvania, to utilize without limitadon.
C. I give and bequeath the sum of Two Thousand Dollars ($2,000.00) to Messiah
Village of Mechanicsburg, Pennsylvania, directing that the sum become part of the
endowment fund of Messiah Village.
TTEM 4: ARTICLES. I give and bequeath unto my spouse, JOSEPH I. FLYNN, if
he survives me, and if he shall not survive me, to my children who survive me, any and all fumiture
and fumishings,household goods and supplies,jewelry,and all other articles ofpersonal or household
use and adomment to me belonging at the time of my death, together with any automobiles which I
then own and together also with all policies of insurance on any of the foregoing articles of personal
property.
ITEM 5: EXEMPTION EOUIVALENT TRUST If my spouse, Joseph I. Flynn,
survives me (I direct that for the purpose of this paragraph of my Will, he shall be deemed to have
survived me uniess it appears unmistakably that he predeceased me), I devise and bequeath unto my
Tnzstees, JOHN J. Fi.YNN and SANDRA F. CAMBURN, property with the value equal to the
exemption equivalent permitted my estate under the federal estate tax provisions of the Intemal
Revenue Code of 1954, as amended, and enforced at the time of my demise, which property may be
transferred free of tax using the estate tax credit as provided for in IRC §2010 or other pertinent
sections. It is my intention to fund this Trust with the largest amount of property which could pass
from my estate to this Trust free of federal estate tax by utilizing the unified credit exemption
equivalent. The Trust hereby created shall be known as the NEVADA H. Fi.YNN TRUST.
My Trustees shall keep the corpus of the Trust invested and shall distribute the income and
principal of the Trust as follows:
A. During my spouse's lifetime the entire net income shall be paid to my spouse in at lea st
quarter annual paymenta
B. In addition to the income, my spouse shall have the power to direct the Trustees to
pay to him or apply for his use the principal of the Trust in each calendar year
including the year in which my death occurs,in an amount not in excess of the geater
of Five Thousand Dollars($5,000.00)or five percent(5%)of the aggregate value of
2 �
�
I
the principal of the Trust on the last day of the calendar year for which payment may
be directed. Such power shall not be cumuiative, but shall expire on the last day of
each calendar year. This shall be exercised by an instrument in writing, subscribed by
my spouse, or his duly authorized agent, and delivered to the Trustees.
C. I authorize my Trustees,acting solely and without consultation with my spouse;who
is also a Co-Trustee, in my Trustees' sole discretion, at any time, and from time to
time, to pay or apply to or for the use of my spouse such portion of the principal of
this Trust, even to the point of completely exl�aasting the same, as they may deem
advisable to provide for the proper health, mainienance and support of my spouse.
In determining the amount of principal to be so disbursed,my Trustees shall take into
consideration any income which my spouse may have from any other source, and the
Trustees'discretion shall be conclusive as to the advisability of any such disbursement
and the same shall not be subject to judicial review.
D. In regard to the administration of this Trust, I direct that my Trustees shall have no
duties or powers concern the administration, investment, filing oFtax retums or any
other power involved in the administration of this Trust, except as specifically
outlined above, while my spouse is living; however, upon my spouse's death, I then
direct my Trustees to assume full powers and duties as Trustees of this Trust.
E. Upon my spouse's death,all principal and the net income,together will all accrued and
accumulated but undisbursed income, shall be disbursed as hereinafter directed,in the
same mazmer as the ultimate disposition ofthe residuary estate,in an attempt to divide
the estate into as nearly equal shares as practicable.
ITEM 6: POWER�•
A. No Trustee or Executor who is beneficiary hereunder shall ever participate in:
1) The exercise of, or decision not to exercise, any discredonary power to pay
income or principal to, or to apply income or principal for the benefit of any
bene8ciary [including discretion to allocate funds among a groixp of
beneficiaries and discretion to accumulate income];
2) The deternunation of whether any beneficiary is disabled;
3
I
3) The decision of when to pay death ta�ces on any future interest;
4) The decision to terminate any Trust hereunder;
5) The exercise of discretion to allocate receipts or expenses between principal
and income;
6) The decision of whether to use expenses as income or estate tax deductions;
7) � The decision to make payment to aid in the settlement of my estate; or
8) The selection of the property to be allocated to the marital deduction Trust.
B. Except as just stated, the words "My Trustees" shall refer to all those acdng as
Trustees;
C. "My Executors" shall refer to all those acting as Executors; and
D. Any Trustee or Executor may resign at any time without court approval.
ITEM 7: RESIDUARY GIFT. I give, devise and bequeath all the rest, residue and
remainder of my estate, real, personal or mixed, of whatsoever nature and wheresoever situate, to
which.I may be legally or equitably entitled at my decease, to my spouse who survives me, and if
my spouse should fail to survive me,I then give, devise and bequeath all of my estate unto my issue,
namely,WII�TIFRED AGNUS FLYNN,GLENN JAY FLYNN,SANDRA FLYNN CAMBURN,
JOANNE FLYNN NEWLIN,VALERIE FLYNN WEBER,JOHN JOSEPH FLYNN,DAN�L
ROBERT FI,YNN, C7iRISTINE FLYNN MONROY, in equal shazea, per stirpes.
TTEM 8: ULTIMATE DISTRIBUTION. In the event that any of the beneficiaries
designated in Item 6 hereof should predecease me without leaving issue surviving, I direct that the
share of such beneficiary lapse, and that the balance be divided among the remaining children named
in Item 6 in appropriate shares. In the event that any of the beneficiaries should die leaving issue
surviving, I direct that the shaze of such deceased beneficiary be disuibuted to his issue, in equal
shares.
ITEM 9: BENEFICIARY LES S THAN THgtTY YEARS. In the event any beneficiary
should be less than thirty (30) years of age at the time of my death, I give the share of such
beneficiary unto my Trustee hereinafter named, IN TRUST, NEVERT�LESS, for the following
uses and purposes:
4
A. My Trustee shall hold and administer said Trust property, collect the income
there&om, and expend or apply the net income as hereinafter d'uected. During the
administration of my estate, the income earned by the property included in this trust
shall be considered income of this Trust and subject to distribution as hereinafter
provided for other income of this Trust.
B. My Trustee shall pay and/or use for the benefit of said beneSciary or their lineal
descendants so much of the net income as deemed necessary for their support,
maintenance, and education, and any income not so used shali be accumulated and
added to the corpus of this Trust.
C. My Trustee shall have the power in his discretion to encroach upon the corpus of the
Trust estate in such amounts and at such times as he may deem necessary in order to
provide for the support, maintenance, caze; and education of said beneficiary.
D. All of the net income may be paid to or for the benefit of the beneficiary at least semi-
annually.
E. When the oldest child attains the age of twenty-two (22) years, the principal of the
Trust shall be divided into as many shares as are hereinbefore mentioned living
children. Upon attaining that age,that child shall have the right to withdraw principal
from this Trust in the following manner:
(1) Twenty-Five Per Cent (25%) of the then value of the principal upon the age
of twenty-two (22) years, at his or her request;
(2) Fifty Per Cent(50%)of the balance of the remaining principal upon attaining
the age of twenty-five(25)years; and
(3) The entire balance of his or her shaze upon attaining the age of thirty (30)
years.
Such rights of withdrawal shall be cumulative, and may be exercised in whole or in part,from
time to time, after that right accrues.
10: TRUSTEE OF ASSETS. I appoint the surviving spouse ofany ofmy children
who predecease me as Trustee of assets left to the issue of my deceased child, empowering that
spouse to implement the preservation and distribution set forth in Item 8 hereof. In the event that no
5
__ _
These authoriries shall extend to all real and personal property at any time held by my
Executor or my Trustees,and shall continue in full force until the actual distribution of such property
is accomplished. All powers, authorities and discretions granted by this Will shall be in addition to
those granted by law and shall be exercisable without leave of court.
M 15: WII,L CONfEST. I direct that any beneficiary of this my Last Will and
Testament who asserts a contest of that Will shall be deemed to have immediately forfeited his or her
share of my estate, and direct the Executors hereafter named to distribute the residue of the estate
in equal shares among those of my children enumerated who survive me, and who are not involved
in the challenge.
ITEM 16: EXECUTORS. Lastly, I nominate, constitute and appoint my spouse,
JOSEPH L FLYIVN to serve as Executor of this my Last Will and Testament. If my spouse should
fail to survive me, or be unable to qualify, or cease to act, or renounce probate, I then appoint my
son, JOHN J. FLYIVN, and my daughter, SANDRA F. CAMBURN, to serve as altemate
Executors of this my Last Will and Testament.
1TEM 17: URETY. I direct that my hereinbefore named Executor shall not be required
to give bond for the faithful performance of his duties in this or any jurisdiction.
IN R'ITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and
Testament, this��day of �y���-..� , 1999.
;�;1,���,L ��� ���
NE�ADA H. FLYNN
The preceding instniment, consisdng of this and six(6) other typewritten pages, was on the
day and date thereof signed, sealed,published, and declared by the Testatrix herein named,as and for
her Last Will and Testament, in the ptesence of us, who, at her request, in her presence and in the
presence of each other, have subscribed our names as witnesses hereta
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COMMONWEALTH OF PENNSYLVANL�, .
COUNTY OF .
We NEVADA/H�j.FLYN , �yi�l�lJ,', .L.� �9"v£��
and (ti�A� %/J ,�/GL1��.6� , the Testatrix and the
wimesses, respectively, whose names are signed to the attached or foregoing instrument, being Srst
duly swom,do hereby declare to the undersigned authority that the Testauix signed and executed the
insttument as her Last Will and Testament, and that she signed willingly, and that she executed it as
her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the
presence and hearing of the Testatrix signed the Will as witnesses, and that to the best o£their
knowledge, the Testatrix was at the time eighteen (18) years of age or older, of sound mind, and
under no constraint or undue influence.
��'i�t.�[.�� /"`• %xY��/
NEVADA H. FLYNN �
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SWORN TO AND SUBSCRIBED
BEFORE ME �HIS�t,l�DAY
OF �'^� , 1999.
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