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Home My WebLink About04-1198 REV-1162 EX(11-96) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004784 MOSES TERRY JAMES 50 FOX ROAD PALMYRA, PA 17078 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 $6,023.54 --STATE INFORMATION: SSN: 199-07-7247 :ILE NUMBER: 2104- 1198 DECEDENT NAME: MOSES RICHARD JAMES DATE OF PAYMENT: 12/30/2004 POSTMARK DATE: 12/30/2004 COUNTY: CUMBERLAND DATE OF DEATH: 10/02/2004 TOTAL AMOUNT PAID' $6,023.54 REMARKS: RMOSES CHECK# 1043 INITIALS' VZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS H)5.805 REV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 ~ Local Registrar P 10G85G43 No. ~ Date *ilo~ ~4:~ Rev. ~87 COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH ° VITAL RECORDS ...,.j CERTIFICATE OF DEATH ANT ! SEX ! SOCIAL SECURITY NUMBER ~ DATE OF DEATH (MCmlh, Day. YeaO 4. Ri. chaxd J. Moses I~ Ma£¢ ~ ~99- 01 - 1~47 I,.Oc.tobe~,t ~, ~004 DATE OF BIRTH ~ BIRTHPLACE (City ~ ~PI_~CE OF DEATH ~Check 0~1¥ one - see instructions o~ otller side) lWAS DECEDENT OF H~SPANIC ORIGIN? IRACE - ~e~can Ind~a~, Black. ~te.'~ COUNTY ~ DEATH CI~, ~RO, T~ ~ ~TH [ FACILITY ~ME (tf ~ ~IR~i~, ~ sheet and nu~) I No ~ Y~ O ~ yes. s~ Ce~, I (S~) Daup~n De~ry T~. M.S. Hershey Medical Center [~ ....~.~...,c ~ ,o. ~hite ~AS DECE~NT E~R IN ~ DECE~NI*S E~CAII~ ~CE~NT'S USU~ ~CUPATION I IN.TRY I U S ARMED F~CES~ ~ (~eci~ ~ ~ ~a~ , ~ m~ (~) RESI~NCE live in a ~) 1~. FAI~R'S ~ME (Fi~t M~ Last) FMOTHEffS NAME {Fffst, Mi~e, MaVen S~) , ~t I ' John Franc~ Moses 1~*. ~a' l~AC[ OF DISPOS ~ ON- N~e ' ' '" R~ LIC EE RSON ACTI~ AS S~H LICENSE NUMBER ,~ME ~e E~ UNOE~NG c. ~ ~ ) ~ST d ~n.== nc ~. ~v ~ TiME ~ iNJURY INJURY AT ~K? ~ OESCRIBE ~W iNJURY ~CURRED Ic~ETI~ OF cAusE IN~ra ~ "~ ~l I YesU UoU To ~e b~t ~ my kno~ed~, ~ath occu~ at ~e a.=, ~.-, --.- r.-- , NAME AND A~ESS ~ ~RS~ ~ COMPL A 'ME~AL ~E~ORONER ~ )ATE RLED (M~, ~y, Y~) 1'-~ty..jSOOEX(MIG) NO PROBATE REV-1500 '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C W U W C DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) Moses, Richard J. DATE OF DEATH (MM-DD-YEAR) 10/02/2004 Ui'iLY DATE OF BIRTH (MM-DD-YEAR) 09/03/1918 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A w ..., ::.:::!;w. o .", w"o ,,00 0"'-' .... .. " ~ 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (Attach copy 01 Will) o 9. litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale 01 dealh aller 12-12.a2) o 7. Decedent Maintained a Living Trust (AlIach copy of Trusl) o 10. Spousal Poverty Credit (dale ofdealh between 12-31-91 and 1-1-95) FILE NUMBER -.:l.~-'\::)~ COUNTY CODE YEAR ~~"!L~_ NUMBER SOCIAL SECURITY NUMBER 199-07-7247 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WillS SOCIAL SECURITY NUMBER o 3. Remainder Return (dale of death prior to 12-13-82) o 5. Federal Estate Tax Retum Required o 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AlIachSch0) ..., z w o z o .. '" w '" '" o o THill!!. NAME Heather D, Royer, Esquire FIRM NAME (If Applicable) Smigel, Anderson & Sacks TELEPHONE NUMBER (717) 234-2401 COMPLETE MAILING ADDRESS 4431 North Front Street Third Floor Harrisburg, PA 17110 "'1 34,419.75 1. Real Estate (Scl1edule A) 2. Stocks and Bonds (Scl1edule B) 3. Closely Held Corporation, Partnersl1ip or Sole-Proprietorsl1ip (I) (2) (3) (4) (5) (B) 6,650.96 670,92 :;;148,225.84 z o !;( ...J ::J l- ii: <C u w c::: 4. Mortgages & Notes Receivable (Scl1edule D) 5. Cash. Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Scl1edule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Scl1edule G orl) (7) (II) (12) (13) 7,321.88 140,903.96 (6) 113,806.09 (14) 140,903.96 8. Total Gross Assets (Iotal Lines 1-7) 9. Funeral Expenses & Administrative Costs (Scl1edule H) (9) (10) 6,340.68 6.340.68 10. Debts of Decedent, Mortgage liabilities. & liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for wl1ich an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !cc I-' ::J a.. :E o U ~ 15. Amount of Line 14 taxable at tl1e spousal tax rate. or transfers under Sec. 9116 (a)(1.2) x.O_ (15) 140,903.96 x.o 45 (16) x.12 (17) x .15 (18) (19) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of line 14 taxable al collateral rate 19. Tax Due 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 'Decedent's Complete Address: STREET ADDRESS -In; East Park Avenue CITY I STATEpA I ZIP 17070 New Cumberland Tax Payments and Credits: 1. Tax Due (Page Hine 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 6,340.68 6,023.54 317.02 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C ) (2) 6,340.56 TotallnteresVPenalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3. enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 0.12 5. If Une 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5) (SA) (5B) A Enter the interest on the tax due. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.................... ..................................................................... D IKI b. retain the right to designate who shall use the property transferred or its income;. .................... ..................... D IKI c. retain a reversionary interest; or......... ....................................... .............................................................. D (i] d. receive the promise for life of either payments, benefits or care? ............ ......................................................... D [iJ 2. If death occurred after December 12.1982, did decedent transfer property within one year of death without receiving adequate consideration? ....,... ........................... ......................................................................... 0 [iJ 3. Did decedent own an "in trust for or payable upon death bank account or security at his or her death? .............. D IKI 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............. ..................... .................................................................................... I!l D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparef other lhan the personal representative is ba sed on all information of which preparerhas any knowledge. SIGNATURE OF PERSON R i DATE 2- '-of) ADDRESS 4431 North Front St., Third Floor, Ha' g, PA 17110 's'i'illilliillilllillllllllillliii!'ii,illl!!i'i!lIIl1l11l11illiillllllillilliiiillilliililllllillillllllllilllllllllllllllllllllilllillllllllllllllllllllllllllllillll!lilllllllllliliWllllllllllllll llililllilllllllllll1lillllllllllllllllllllllllllllllllllllllllllllllllllllillllllllllUlllllllllllillllllllllllllllllllllilllllllllilllillililllllilllllllllll1I1111i!liillll For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)l. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax relurn 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 twenty-one years of age or younger al death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(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%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99118(a)(1.3)]. A sibling is defined. under Section 9102, as an individual who has alleast one parent in common with the decedent, whether by blood or adoption. "',"W:iW:. COMMONWEALTH OF PENNSYLVANiA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY -OWNED PROPERTY ESTATE OF FILE NUMBER Richard J. Moses It an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G, SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Terry J. Moses 50 Fox Road, Suite 1 Palmyra, PA 17078 Son B c JOINTLY -OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH I1EM FOR JOINT M'OE Include name of financial institution and \:lank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deedforjainlly-held realeslate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 2/6/0 OOmmerce Bank Cert. of Deposit #12000051 17,223.83 50% 8,611.92 (See Tab 1). CD for $17,000.00 opened 2/6/04 with funds originally held jointl w/Terry J. Moses at M&T Securities Checking Account #61746495 (See Tab 2) which originated from M&T Bank (now Allfirst) Money Fund Alternative Account #0~982-7658-1 (See Tab 3) opened 9/25/01 and held jointly w/Terry J. Mose . Therefore, decedent held only a 50% interest in the Certificate of Deposit. 2. A.1 /31/0 Legacy Bank Cert. of Deposit #100169879 60,013.12 50% 30,006.57 (See Tab 4). CD for $60,000.00 opened 12/31/03 with funds originally held jointly w/Terry J. Moses at M&T Securiti s Checking Account #61746495 (See Tab 5) which originated from M&T Bank (now Allfirst) Money Fund Alternative Account #00982-7658-1 (See Tab 6) opened 9/25/01 and held jointly w/Terry J. Moses. Therefore, decedent held only a 50% interest in the Certificate of Deposit. ( ON ATTACH! ~ SHEE OS) TOTAL (Also enter on line 6, Recapitulation) $ - (If more space is needed, insert additional sheets of the same size) I SCHEDULE F L JOINTL Y.OWNED PROPERTY ---- --_._----~-~..~_.._. i"~,~"{-.-,-'. ~,- &~l '~" COM1flOtN,EALTH:)F PENNSYLVAniA INHERrTANCr TAX RETIJRN RESIDENT DECEDENT ESTATE OF Richard J. Moses FILE NUMBER Jf an asset was made joint within one year of1he decedenfs date of deJth, it must he reported on Schedule G. SURlflVtNG JOINT TENANT(S} N,~ME ADDRESS A. 50 Fox Road, suite 1 Palmyra, PA 17078 Terry J. Moses B. c ------- RELATiONSHIP TO DECr::C[:~r Son JOINTLY-OWNED PROPERTY: 7/19/(4 Northwest Savings Bank Cert. of Deposit 69,788.55 #2653007050. (See Tab 7). CD for $69,788.55 opened 7/19/04 with funds originally held jointly w/Terry J. Moses at Citizens Bank #6243920661 (See Tab 8) opened 1/10/04 which originated fran funds held jointly w/Te=y J. Moses at M&T Bank Checking Account #61746495 (See Tab 9) which originated fran funds held jointly w/Te=y J. Moses at M&T Securities (now Allfirst Brokerage Account) #ASQ-739189 (See Tab 10) opened 10/01/01. Therefore, decedent held only a 50% interest in the Certificate of Deposit. 7/6/0' M&T Bank Premium Interest Checking 13,996.25 Account #98276581 (See Tab 11) 7 /2/0~ Vartan National Bank Checking Account 51,248.37 50% #0001516426 (See Tab 12) Checking Account for $51,000.00 opened 7/2/04 with funds originally held jointly w/ Terry J. Moses at Integrity Bank #291900113 (See Tab 13) which originated fran funds held jointly w/Terry J. Moses at Allfirst Bank Certificate of Deposit #8-700-810-0505462 opened 3/01. * Therefo e, decedent held only a 50% interest in the Checkinq Account. * (See Tab 1 4) (cnn'INUED ON ATI'AaIED S) TOTAL (Also enler on line 6. Recapitulalion) $ LETTER ITEM FOR JOINT NUMBER TENANT DATE DESCRIPTION OF PROPERTY MADE !nclude name of Financial institution and bank account number or similar identifying n\Jmber. Attach JOINT deedforjointly.heldraalestale. DATE Of DEATH VALUE OF ASSET 3 A. 4. A. 5. A. (If more space IS needed insert additional sheets of lhe same size) " %QF DEeDS iNTEREST 50% 50% DATEOFDEAfH VALUE OF DECEDENT'S IN rER:::S r 34,894.28 6,998.13 25,624.19 ':iH~i-','T, ,~,. . .~ CGl';\~AOtjlj\jEAL1H vr PcNi~S'1'lV.~NiA I~~HERITA.NCE TAX RET'JRN RESIDENT DECEDENT SCHEDULE F JOINTL Y.OWNED PROPERTY L FilE NUMBER ESTATE OF Richard J. Moses If an asset was made joint within one year ofth-e decedent's date of death, it must be reportad on Schedute G, SURV\'JING JO',NT TENAHT(S) NAME ADDRESS r---~---_._--______ RElAflONSHIP T(; OECt:[:[~j; A. Terry J. Moses 50 Fox Road, Palmyra, PA suite 1 17078 Son B c JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DI::A fH ITEM FOR JOINT MADE !nclude name of financial institution and bank account number or similar Identifying number. Attach DAfE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deedforjoinlly-held real estate. VALUE OF ASSET INTEREST DECEDENTS IN fEPEST 6.1 A. 12/31/ 2 Three (3) U.S. Series EE Savings Bonds for $5,000.00 each (See Tab 15) 15,000.00 50% 7,500.00 Interest to date of death 342.00 50% 171.00 . TOTAL (Also enter on line 6. Recapitulation) $ 113,806.09 .' (If more space is needed, insert additional sheets of the same size) , , REV-1510 EX+ 16-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Richard J. Moses FILE NUMBER This schedule must be completed and filed if the answer to any of questions 11hrough 4 on the reverse side of the REV.1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAMEOFTHETRANSFEREE,THEIR RELATlONSHIPTOOECEOENTAND DATE OF DEATH % OF DECD's EXCLUsiON TAXABLE NUMBEF THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF AssET INTEREST IlfA?PLlCABLEI VALUE ,. AIG Annuity Contract #A0200217 (See Tab 16) 30,381.37 100 30,381.37 2. Allianz Life Insurance Company of North America Annuity - Policy #4331421 4,038.38 100 4,038.38 (See Tab 17) TOTAL (Also enter on line 7 Recapitulation) $ 34,419.75 (If more space is needed, insert additional sheets of the same size) REV.1511 EX. 112'991* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Richard J. Moses FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT I. FUNERAL EXPENSES: Zimmerman-Auer Funeral Home Funeral Luncheon Rev. Scali Ogden Honor Guard at Funeral 4,695.96 130.00 200.00 100.00 2. 3. 4. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Represenlalive{s) Social Security Number(s)fEIN Number of Personal Representative(s) SlreetAddress City State Zip Year(s) Commission Paid: 2. Attorney Fees Smigel, Anderson & Sacks, LLP 1,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant . Street Address City Stale Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Filing fee - Register of Wills - PA Inheritance Tax Retum 25.00 TOTAL (Also enter on line g, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 6,650.96 REV.1512 EX+ (12-03) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Richard J. Moses FILE NUMBER Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. West Shore EMS - Accl. #3031365A 532.23 2. PP&L - Electric bill 114.79 3. Verizon - Telephone bill 23.90 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 670.92 LAST WILL AND TESTAMENT OF RICHARD J. MOSES I, RICHARD J. MOSES, of New Cumberland, Cumberland County, Pennsylvania, being of sound mind and memory, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all wills by me heretofore made. FIRST: larder and direct that all of my just debts and funeral expenses be paid by my hcreinallcr named Executor as soon after my death as may be found convenient. SECOND: All the rest, residue and remainder of my estate, real. personal and mixed, of whatever nature and wheresoever situate, which 1 may own or have the right to dispose of at the time of my death I give, devise and bequeath to my son, TERRY 1. MOSES. THIRD: I hereby nominate, constitute and appoint my son, TERRY J. MOSES, as Executor of this, my Last Will and Testament, and I do direct that no bond shall be required of such Executor hereunder. My said Executor shall have full power at his discretion to do any and all things necessary for the complete administration of my estate, including the power to sell at public or private sale and without order of Court, any real or personal property belonging to my estate, and to compound, compromise or otherwise to settle or adjust any and all claims, charges, debts and demands, whatsoever, against or in favor of my estate, as fully as I could do if living. IN WITNESS WHEREOF, I, RICHARD J. MOSES, the above Testator have set my hand and seal to this my Last Will and Testament, which consists ofone(l) page, to which I have affixed my signature this .~ I day of . i , " " '-' ,2001. ,,- ') .. '/.1 ;::::."-':~-;- '"c. (8 EAL) Richard J. Moses Signed, sealed, published and declared by the abovc named Testator as and for his Last Will and Testament, in the presence of us, who at his request and in his prcsence and in the presence Df each other have hercunto subscribed our names as witnesses. //("", I //' ,:.:. !::" /( ,/ I jt , c- f'\, '~l , .f i . (_L"-\./ '':'[ .,';"...- -' , /.. 2 1130 Carlisle Rd Camp Hill PA 17070 November 18, 2004 Dear Sir or Madam: This letter is to serve as notification that the certificate of deposit number 120000517 held jointly by Richard Moses and Terty Moses was opened on 02-06-2004 for the amount of $ 17,000.00 On 10-02- 04 the certificate of the same number was worth $17223.83. On today's date 11-18-04 the certificate was closed with a balance of 17,264.85. Cedar Cliff . . . . . . . . . . . . . . . . . . . . . . . !l:1 M&fBank Manufacturers and Traders Trust Company, 344 South 10th Street, Lemoyne, PA 17043 7177373322 FA.X717 737 6498 November 23, 2004 To Whom it may Concern: Re; Bank Accounts This letter serves as formal notice that as of July 6, 200 I all accounts with M&T Bank/Allfirst Bank were titled in the names of Richard J Moses and Terry J Moses. Beatrice 0 Moses had been deceased since October 20, 1995 but Mr Moses didn't, nor was he required from the bank to remove her name from the accounts. He and his son finally on the date noted above came to our branch and made the name changes. For a period of time after the names were changed, the statements kept arriving and showed no record of the changes. This was finally resolved and as of December 2003, the bank statement showed the proper titled of the accounts with Richard and Terry listed. Should you have any further questions, please feel free to call me at the above number. a~ David A Brown Select Banker m1M&fBank ACCOUNT<NO~ ACCOUNT TYI?E '. 61746495 M&T SELECT WITH INTEREST STATEMENT PERIOD JAN.29-FEB.27,2Q04 1 OF 1 00 0 06113M NM 017 -- 3688 RICHARD J MOSES TERRY J MOSES 101 E PARK AVE NEW CUMBERLAND PA 17070-1653 INTEREST PAID YEAR TO DATE 43.30 HIGHLAND PARK BEGINNING :DEPOSITS&- O'l;'HER CURRENT ENDINO: BALANCE OTHERADOITlONS ""00"0 ">T" · _:"'~"';;''':';''~C'1'ION''' INTERESTPlJ: BA:LAN'CE NO. AMOUNT NO. AMOUNT NO. AMOUNT 31,393. 00 0 0.00 5 31,393. 00 1 7.07 7.07 0.00 ACCOUNT SUMMARY POSTING -- :: ;~SA.cHbN'n~s~k:t~T1:6N DErosITS':INTERES:T CHECKS: &; O'l'HER DAILY DATll: &':"OTHER ADDITIONS: St1B'I'RACUONS .BALANCE 01-29-04 BEGINNING BALANCE $31,393.00 01-29-04 CHECK NUMBER 2463 'evO",," '1'1 13(,~./f~ 86.98 31,306.02 02-02-04 CHECK NUMBER 2464 Iv'< "'~~I" 41. 38 31,264.64 02~O9-04 CHECK NUMBER 2466 3,264.64 02-09-04 CHECK NUMBER :2465 17,OOO...?.f 02-09-04 CHECK NUMBER 2451 11,000.00 0 .00 02-27-04 INTEREST PAYMENT 7.07 02-27-04 CLOSEOUT 7 .07 O. 00 ENDING BALANCE $0.00 ACCOUNT ACTIVITY CasCt$~AIb s~y 2451 02-09-04 2465 02-09-04 11,000.00 17,000.00 2463* 01-29-04 2466 02-09-04 86.98 3,264.64 2464 02-02-04 41. 38 ANNUAL PERCENTAGE YIELD EARNED:c O. 7S " ONE CARD, MANY ACCOUNTS. WITH YOUR M&T CHECK CARD OR ATM CARD, YOU CAN NOW ACCESS UP TO: 4 CHECKING ACCOUNTS, 4 STATEMENT SAVINGS OR MONEY MARKET ACCOUNTS AND 2 LINES OF CREDIT AT THE ATM. NOW THERE IS JUST ONE CARD TO CARRY AND JUST ONE PERSONAL IDENTIFICATION NUMBER TO REMEMBER. TO LINK VIRTUALLY ALL OF YOUR ACCOUNTS TO JUST ONE CARD, SIMPLY VISIT ANY M&T BANK BRANCH OR CALL THE M&T TELEPHONE BANKING CENTER AT 1-800-724-2440. ~ M&I'Bank Manufacturers and Traders Trust Company, 344 South 10th Street, Lemoyne, PA 17043 717 737 3322 FAX 717 737 6498 November 23,2004 To Whom it may Concern: Re; Bank Accounts This letter serves as formal notice that as of July 6, 200 I all accounts with M&T Bank/Allfirst Bank were titled in the names of Richard J Moses and Terry J Moses. Beatrice 0 Moses had been deceased since October 20, 1995 but Mr Moses didn't, nor was he required from the bank to remove her name from the accounts. He and his son finally on the date noted above came to our branch and made the name changes. For a period of time after the names were changed, the statements kept arriving and showed no record of the changes. This was finally resolved and as of December 2003, the bank statement showed the proper titled of the accounts with Richard and Terry listed. Should you have any further questions, please feel free to call me at the above number. a~ David A Brown Select Banker iii allflrst RICHARD J MOSES TERRY J MOSES 101 E PARK AVE NEW CUMBERLAND PA 17070-1653 1."111,,,111,,,1.,,111111,,,11,11,,,1,1,,,11,11111,,,111,1,,1 Page 1 of 3 The Money Fund Alternative September 2"5, 2001 thru October 25. 2001 -. ,.., .., allfirst.com " 24-"oor Customer Service 1-800-5334630 Richard J ~.OS.$ Terry J Mos.s Acd No l.Ji.J::i8~~/btiu~1 Activity Summery Annual percentage yield earned Avg. daily ledger balance Avg. daily collected balance Interest earned this statement Interest paid this statement Interest paid this year Days covered by this statement 2.33~ $87,467.21 $87,461.69 $171. 07 $171.07 $2,612.91 31 Balance on 09/24 Deposits and additions Belence on 10/25 $86,286.47 1,755.07 $88,041.54 Deposits end eddltlons Date Description Amount 10/03 ACH CREDIT US TREASURY 303 sac SEC 199077247A SSA 3031036030RICHARD J MOSES 20012746282918 10/25 INTEREST PAID $1,584.00 171.07 $1,755.07 End of Dey Ledger Belence Account balances are updated in the section below on days when transactions posted to this account. Date SI!lance Date Balance Date Balance 09/24 $86,286.47 10/03 $87,870.47 10/25 $88,041. 54 001892 0014-98317539017 050 iii allflrst The annual percentage yield earned reflects the amount of interest earned on the account during the statement period and the average daily balance in the account for that period. The interest rate paid will fluctuate according to money market conditions. Balancing your chackbook. Look on the back of your first statement page for a fast and easy way to balance your checkbook. What your icons mean o Customer Service e Credit to your account OO~892 0014-98317539017 050 o Important reminder e Charge to your account ~ Other banks. ATM transaction P6ge 3 of 3 For questions about your statement or change of address information, please see page 2. . Legacy Bank November 18,2004 2600 Commerce Drive P.O. Box 60947 Harrisburg, PA 17106-0947 Phone: 717-441-3400 Fax: 717-441-3410 Toll-Free 1-800-436-2124 Terry 1. Moses 50 Fox Rd. Palmyra, P A 17078 Dear Terry, Per your request, I am providing information regarding CD # 100169879. This account was opened 12/30/03 in the amount of $60,000.00 in the names of Richard Moses OR Terry J. Moses. The value of this account on 1012/04 was $60,000.00 plus accrued interest of$13.12. The value this date is $60,000.00 plus accrued interest of$55.76. If you need anything further, please contact me. Sincerely, r, .~ , i_ ,~c Barbara Sariano Personal Banking Specialist 717-441-3400, exU18 www.thelegacybank.com ~M&rBank Manufacturers and Traders Trust Company, 344 South 10th Street, Lemoyne, PA 17043 717 737 3322 FAX 7177376498 November 23, 2004 To Whom it may Concern: Re; Bank Accounts This letter serves as formal notice that as of July 6, 2001 all accounts with M&T Bank/Allfirst Bank were titled in the names of Richard J Moses and Terry J Moses. Beatrice 0 Moses had been deceased since October 20, 1995 but Mr Moses didn't, nor was he required from the bank to remove her name from the accounts. He and his son finally on the date noted above came to our branch and made the name changes. For a period of time after the names were changed, the statements kept arriving and showed no record of the changes. This was finally resolved and as of December 2003, the bank statement showed the proper titled of the accounts with Richard and Terry listed. Should you have any further questions, please feel free to call me at the above number. UG1=--- David A Brown Select Banker f!:1M&fBank STATEME:NTPERiOP PAGE: ... DEC.27-JAN.28,2004 1 OF 2 ACCOUNT NO. ... ACCOUNT TYPE; 61746495 M&T SELECT WITH INTEREST 00 0 06113M NM 017 1170 RICHARD J MOSES TERRY J MOSES 101 E PARK AVE NEW CUMBERLAND FA 17070-1653 INTEREST PAID YEAR TO DATE 36.23 HIGHLAND PARK BEGINNING DE:POSIl'S &.: OTHER CURRENT ~INO: 'BALANCE OTHER-ADD IT tONS CHECKS. PAID> <.- SUBTRACTIONS INTERESTPD BALANCE. NO. I AMOUNT NO. AMOUNT NO. I AMOUNT 76,986. 70 2 89,315.54 16 134,945.47 0 0.00 36.23 Jl 393. 00 ACCOUNT SUMMARY POSTING ... DEpOSITS/INTEREST CHECKS.&.OtHER DAILY DATE T~SACTIONDESCRIPTrON & . OTHER ADD1TIONS SUBTRAC'l'10NS BALAN'CE 12~27-03 BEGINNING BALANCE $76,986. 70 12-30-03 CHECK NUMBER 2555 3,774 .00 12-30-03 CHECK NUMBER 2543 364 .70 12-30-03 CHECK NUMBER 2556 212 .00 72,636 .00 01-02-04 CHECK NUMBER 2558 60,000. 00 01-02-04 CHECK NUMBER 2557 487. 07 12,148. 93 01-05-04 M&T SECURITIES BROKERAGE 79,364.85 01-05-04 CHECK NUMBER 2559 82 .00 91,43l. 78 01-08-04 CHECK NUMBER 2452 373. 00 91,058. 78 01-09-04 DEPOSIT 9,950.69 01-09-04 CHECK NUMBER 2453 79.28 100,930. 19 01-13-04; .CJ:I~C!< NUMBER 2454 ~~O 31,930. 19 01-22~04 CHECK NUMBER 2458 96.62 01-22-04 CHECK NUMBER 2461 22. 27 01-22-04 CHECK NUMBER 2459 U. n 31,799. 59 01-23~04 CHECK NUMBER 2455 20 .9S 01-23-04 CHECK NUMBER 2457 14 .73 31,763. 91 01-26-04 CHECK NUMBER 2460 380 .64 01-26-04 CHECK NUMBER 2456 26 .50 31,356 .77 01-28-04 INTEREST PAYMENT 36.23 31,393 .00 ENDING BALANCE $31,393.00 ACCOUNT ACTIVITY CHECKS .l?AID SUMMARY 2452 01-08~04 373 .00 2453 01~09-04 79 .28 2454 01-13-04 69,000 .00 2455 01-23-04 20 .95 2456 01-26-04 26 . 50 2457 01-23-04 14 .73 2458 01-22-04 " .62 2459 01-22-04 U. n 2460 01-26-04 380. 64 2461 01-22-04 22 .27 2543* 12~30~03 364 .70 2555* 12-30-03 3,774 .00 2556 12-3C-03 212 .00 2557 01-02-04 487. 07 2558 01-02-04 60,000 .00 2559 0'1-05-04 82 .00 ~ M&fBank Manufacturers and Traders Trust Company, 344 South 10th Street, Lemoyne, PA 17043 7177373322 FAx717 737 6498 November 23, 2004 To Whom it may Concern: Re; Bank Accounts This letter serves as formal notice that as of July 6, 200 I all accounts with M&T Bank/Allfirst Bank were titled in the names of Richard J Moses and Terry J Moses. Beatrice 0 Moses had been deceased since October 20, 1995 but Mr Moses didn't, nor was he required from the bank to remove her name from the accounts. He and his son finally on the date noted above came to our branch and made the name changes. For a period of time after the names were changed, the statements kept arriving and showed no record of the changes. This was finally resolved and as of December 2003, the bank statement showed the proper titled of the accounts with Richard and Terry listed. Should you have any further questions, please feel free to call me at the above number. a~ David A Brown Select Banker iii allflrst RICHARD J MOSES TERRY J MOSES 101 E PARK AVE NEW CUMBERLAND PA 17070-1653 1,"111...111...1...111...,,,11,11",1,1,,,11,11""1,111,1,,1 Page 1 of 3 The Money Fund Alternative Seplember 25. 2001 thru October 25, 2001 RiChard J MOs.s Terry J Moses Acct No I.Jv~184!~/btiti-l G aufirst.com ., 24-hour Customer Service 1-800-533-4630 Activity Summary Annual percentage yield earned Avg. daily ledger balance Avg. daily collected balance Interest earned this statement Interest paid this statement Interest paid this year Days covered by this statement 2.33X $87,467.21 $87,461.69 $171.07 $171. 07 $2,612.91 31 8alance on 09/24 Deposits and additions Balance on 10/25 $86,286.47 1,755.07 $88,041. 54 Deposits and additions Date Description Amount 10/03 ACH CREDIT US TREASURY 303 SOC SEC 199077247A SSA 3031036030RICHARD J MOSES 20012746282918 10/25 INTEREST PAID $1,584.00 171. 07 $1,755.07 End of Day Ledger Balance Account balances are updated in the section below on days when transactions posted to this account. D/Jte Balance Date B,lance Date BaJ/Jnce 09/24 $86,286.47 10/03 $87,870.47 10/25 $88,041.54 001892 OOi4-98317539017 050 iii allftrst The annual percentage yield earned reflects the amount of interest earned on the account during the statement period and the average daily balance in the account for that period. The interest rate paid will fluctuate according to money market conditions. Balancing your checkbook. Look on the back of your first statement page for a fast and easy way to balance your checkbook. What your icons mean o Customer Service e Credit to your account 001892 0014.98317539017 050 o Important reminder e Charge to your account ~ Other banks' A TM transaction Pagt! 3 of 3 For questions about your statement or change of address information, please see page 2. N N SA~i'l f\1 ::"'_]:'-,i November 17, 2004 Re: Richard Moses CD To Whom It May Concern: This letter is to inform you that Certificate # 2653007050 originally held in joint ownership of Richard Moses or Terry Moses was opened with an original balance of $69,788.55. In addition, the balance of said Certificate of Deposit was $69,788.55 on both October 02, 2004 and November 17, 2004. Please feel free to contact our office should you need additional information concerning this Certificate. Sincerely, ~ . D~~~~~~C:/~' 'Manager REVOCABLE TRUST AGREEMENT Account Number: 2653007043 SECTION 1 [X] One Trustee for one or two Beneficiaries without the right of survivorship. D Co-Trustee with the right of survivorship for one or two Beneficiaries without the right of survivorship. Successor Trustee: SECTION 2 Beneficiary's designated age: This trust, subject to the right of revocation shall continue: [X] until the grantor or both of the grantors dies; D until as each beneficiary reaches the above designated age, the trust shall then terminate at that time, but only as to such beneficiary and his pro-rata share shall then belong and be distributed by the trustee to such beneficiary; D for the life of the grantor and thereafter until the beneficiary reaches the above designated age, the trust shall then terminate at that time, but only as to such beneficiary and hls pro-rata share shall then belong and be distributed by the trustee to such beneficiary. SECTION 3 Between: Northwest Savings Bank and Trustee{s) for the Beneflciary(ies). This Revocable Trust Agreement is only valid for the above designated Account Number which has been established at Northwest Savings Bank by the Trustee(s) for the Beneficiary(ies) as all named on the signature card for as long as the funds remain on deposit at Northwest Savings Bank. The funds in the deposit indicated on the signature card, together with the earnings thereon, and any future additions thereto are conveyed to the trustee( s) as indicated for the benefit of the beneficiary or beneficiaries as indicated. The conditions of said trust are: (1) trustee(s) is (are) authorized to hold, manage, pledge, invest and re-invest said funds in their sole discretion, or at the discretion of anyone of them acting unless it is indicated on the signature card that more than one signature is required in all matters related to this trust (excepting revocation); (2) the undersigned grantor(s), or any of them, reserve the right to revoke said trust in part or in full at any time and any partial or complete withdrawal by the original trustee(s) or anyone of them, jf they or he be both or one of the grantors shall be a revocation by the grantor to the extent of such withdrawal, but no other revocation shall be valid unless written notice by all or any of such grantors is given to the Institution; (3) in the event of the death, resignation, remova!, or incompetence of all said trustees, the above designated successor trustee is appointed, or in the event no successor trustee is named herein or the successor dies, resigns, is removed, becomes incompetent, or fails to act, Northwest Savings Bank is authorized to appoint a successor trustee, and such successor trustee shall have the same powers of the original trustee; (4) this trust shall continue as indicated above in Section 2; (5) the pro-rata share that each beneficiary will receive upon the termination of the trust as to such beneficiary (as designated above in Section 2), shall be determined by dividing the amount of the trust funds then existing by the number of beneficiaries then living as to whom such pro-rata distribution has not previously been made. If any beneficiary should die prior to the grantor(s) dying or reaching the age specified above (see Section 2), his pro-rata beneficial interest in the trust funds shall terminate at that time and such funds shall continue to be trust funds subject to all of the other terms of the trust agreement. In the event that the last surviving beneficiary shall die before the grantor(s) die{s) or before reaching the age specified above (see Section 2), the trust shall then terminate and the funds shall revert to the sole ownership of the grantor or grantors then surviving or the estate of the last survivor of said grantors; (6) the Institution in which such funds are invested is authorized to pay the same or to act in any respect affecting said account before or atter the termination of this trust upon the signature of any of the trustees, or successor trustee duly appointed, unless it is indicated on the signature card that more than one signature is required in all matters related to this trust (excepting revocation) and the Institution has no responsibility to follow the application of funds. In this instrument, except as otherwise indicated, the singular includes the plural and the masculine includes the feminine and neuter. Northwest Savings Bank is not offering tax advice, and recommends that the customer review this Revocable Trust Agreement with a lawyer or an accountant. j cr:/ /Gr0:: / . I ) /) jj)'7 Date Grantor "I- 25-02-046 ITEM 29856l0(9812) I Date NORTHWEST SAVINGS BANK SIGNATURE CARD 2653007050 07-17-04 Account Number: Date Account Opened: JOINT WITH RIGHT OF SURVIVORSHIP PERMANENT Ownership: TERRY JAMES MOSES 50 FOX RD SUITE 1 PALMYRA, PA 17078 Tax ID/SSN: 181-42-7542 000-000-0000 Day Phone: Evening Phone: 717..838-2242 Employer: 07-19-1951 SELF Mother's Maiden Name: DOB: Dr. License State & No: PA 14821944 07/20/05 Name 2: RICHARD MOSES Tax ID/SSN: 199-07-7247 Address: 00000 00-00-0000 Dr. License State & No: DOB: Trust Beneficiary Name 1: Name 2: DOS: DOS: Custodian Minor Name: Tax ID/SSN: 000-00-0000 Address: 00000 DOS: 00-00-0000 The undersigned acknowledge(s) receipt of the Northwest Savings Bank New Account Disclosure Booklet and agree(s) to the terms of the following disclosures contained therein: Deposit Account Agreement, Funds Availability Disclosure, Electronic Funds Transfer Disclosure and Protecting the Privacy of Customer Information. The undersigned also acknowledge(s) receipt of the Truth in Savlngs Disclosure. If this is a Certificate of DeposiVPassbook Savings, the undersigned acknowledge(s) receipt of the certificate/passbook. TAX CERTIFICATION I The undersigned certify, under penalties of perjury, that I am a U.S. person (including a U.S. resident alien); I that the tax identification number shown next to my name is my correct number, or I am waiting for a number I to be issued to me; and I am not subject to Internal Revenue Service (IRS) backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. NOTE: The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Check the box next to your signature only if the IRS has informed you that you are subject to backup withholding. D I am subject to backup withholding. Signature J?u/!I / j.' /j '/ v. -~ /j/lw/2i! ' Signature f D I am subject to backup withholding. D I am subject to backup withholding. Signature Signature D I am subject to backup withholding. 2653007043 Account Number: REVOCABLE TRUST Ownership: NORTHWEST SAVINGS BANK SIGNATURE CARD Date Account Opened: 07-17-04 PERMANENT TERRY JAMES MOSES 50 FOX RD SUITE 1 PALMYRA, PA 17078 Tax ID/SSN: 181-42-7542 000-000-0000 Day Phone: Evening Phone: 717-838-2242 Employer: 07-19-1951 SELF Mother's Maiden Name: DOB: Dr. license State & No: PA 14821944 07/20/05 Name 2: Tax ID/SSN: Address: 00000 00-00-0000 Dr. License State & No: DOB: Trust Beneficiary TIM J MOSES 03-20-95 Name 1: Name 2: DOB: DOB: Custodian Minor Name: Tax ID/SSN: 000-00-0000 Address: 00000 DOB: 00-00-0000 The undersigned acknowledge(s) receipt of the Northwest Savings Bank New Account Disclosure Booklet and agree(s) to the terms of the following disclosures contained therein: Deposit Account Agreement, Funds Availability Disclosure, Electronic Funds Transfer Disclosure and Protecting the Privacy of Customer Information. The undersigned also acknowledge(s) receipt of the Truth in Savings Disclosure. If this is a Certificate of Deposit/Passbook Savings, the undersigned acknowledge(s) receipt of the certificate/passbook. TAX CERTIFICATION The undersigned certify, under penalties of perjury, that I am a U.S. person (including a U.S. resident alien); that the tax identification number shown next to my name is my correct number, or I am waiting for a number to be issued to me; and I am not subject to Internal Revenue Service (IRS) backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notjfied by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (C) the IRS has notified me that I am no longer subject to backup withholding. NOTE: The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Check the box next to your signature only if the IRS has informed you that you are subject to backup withholding. /' (~ .,/VV ~ j D I am subject to backup withholding. .X Signature Signature D I am subject to backup withholding. D I am subject to backup withholding. Signature Signature o I am subject to backup withholding. November 18, 2004 Dear Sir or Ma'am: I am writing on behalf of Terry J. Moses. Account #6243920661 was titled in both his name and his father's name, Richard J. Moses. The initial deposit was for $69,000 on January 10, 2004. As of July 15, 2004 when the account was closed, the total interest earned was $788.55. Enclosed I have included the supporting documentation. Any other questions please feel free to contact me. Sincerely, l~i^..tI! /.7t/ ~1 /,'If} /l ;~...-' i ? / , )..,;hV:.{' / Ll :..:]~",- Heather Nelson Sale and Service Representative Page J of I Command ===> STIl 11/18/04 11:48:07 ACCOUNT INFORMATION Account 00006243920661 Ctl2 060 Ctl3 000 Ctl4 000 Ctl1 01 Prod Type 804 GUARANTEED MM CD 6 MONTH RICHARD J MOSES TERRY J MOSES 101 E PARK AVE NEW CUMBERLAND PA New Balance Cust Nbr TIN Short Name Branch 290 TERMINATED 17070 Avail Bal Current Bal Closing Bal ColI Bal Holds Pledges 0.00 Dt Opened 01/10/04 Dt Last Dr 07/15/04 Dt Last Cr 01/10/04 Dt Last Mnt 00/00/00 ----- MATURITY ------ Period D Iner 182 Annv Day 12 DIy Accr Unrdm Accr 1 Accrd lnt Prin Dist 0 proj Accrd Auto Renew 2 Redep lnt Nxt Mat Dt 01/10/2005 YTD Int PF5-Redisp PF12-Help PF14-S/H Inq BALANCES 0.00 0.00 0.00 0.00 0.00 0.00 -- - - - DRS / CRS 69788.55 11.36 0.00 0.00 INTEREST - - -- 0.000000 0.000000 0.00 0.00 788.55 199-07-7247 MOSES RICHARD Officer Last Dr Last Cr Drs Tdy Crs Tdy PF1-Fwd PF4-Hist http://branchpJatform/touchpoint/3270/emuI3270.htm o o 1 1/18/2004 Page 1 of 1 ACCOUNT HISTORY INFORMATION Account 00006243920661 Ct12 060 Ct13 000 Ct14 000 Ctl1 01 Prod Type 804 GUARANTEED MM CD 6 MONTH Name RICHARD J MOSES 11/18/04 11,48,30 Command ===? STI2 SEQ BATCH TRAN AMOUNT / SVC CHRG/ RATE DATE DESCRIPTION TAX/RA 126.82 C 05/10/04 01 INTEREST EARNED 131. 29 C 06/10/04 01 INTEREST EARNED 127.30 C 07/10/04 01 INTEREST EARNED 8.50 C 07/12/04 01 INTEREST EARNED 1.980000 07/12/04 INT RT CHG 2.230000 1.980000 07/12/04 REN 071204 TRM D 182 11.36 C 07/15/04 69788.55 D 07/15/04 07728 90290 0360 07729 90290 0302 PF1-Fwd PF2-Bkwd PF12-Help PA2-Prompt STPCI2S1 ST0047 I, LAST PAGE LAST http://branchplatfonn/touchpoint/3270/ cmul~ 2 7 O. htm II/] 8/2004 ~ M&rBank Manufacturers and Traders Trust Company, 344 South 10th Street, Lemoyne, PA 17043 7177373322 FAX717 737 6498 November 23, 2004 To Whom it may Concern: Re; Bank Accounts This letter serves as formal notice that as of July 6, 200 I all accounts with M&T BanklAllfirst Bank were titled in the names of Richard J Moses and Terry J Moses. Beatrice 0 Moses had been deceased since October 20,1995 but Mr Moses didn't, nor was he required from the bank to remove her name from the accounts. He and his son finally on the date noted above came to our branch and made the name changes. For a period of time after the names were changed, the statements kept arriving and showed no record of the changes. This was finally resolved and as of December 2003, the bank statement showed the proper titled of the accounts with Richard and Terry listed. Should you have any further questions, please feel free to call me at the above number. a~ David A Brown Select Banker m1M&fBank ACCOUNT NO.. ACCOuN'tTYPE ...... 61746495 M&T SELECT WITH INTEREST S'tJl..'fE:M:ENTEERIOD JUL.29-AUG.28,2003 1 OF 2 00 0 06113M NM 017 1226 RICHARD J MOSES OR BEATRICE 0 MOSES 101 E PARK AVE NEW CUMBERLAND PA 17070-1653 INTEREST PAID Y'E1\R TO DATE B4.41 HIGHLAND PARK .-BEGINNING': ._ : DEpOSITS..&- .... .~..~.._"".... OtHER CORReNT ENPING BArANcr: OTHER:ADDr'I'tONS SUBTRACTIONS .~Wrms.~ro B:M,l\~CE. NO. 1 AMOUNT NO. AMOUNT NO. AMOUNT 3,638.33 11 813,057.00 10 3,567.41 0 0.00 124.30 88,252.22 ACCOUNT SUMMARY POS"UNG 'l'RANstcnOlJ .. DEpOSITS, INTEREST cHECKS-&_OTHER DAIL:l;: '''ATE DESCRIPT:tON &:aTHBR ADDITIONS StrB'l'RAC.riONS BALANC 07-29-03 BEGINNING BALANCE $3,638. 33 07-29-03 CHECK NUMBER 2515 C .' ..r'",~ 817 .,' 2,82l. 33 07-31-03 CHECK NUMBER 2516 ""JAI1"'VI ~ 119 .40 2,70l. 93 08-01-03 INTEREST PAYMENT ~I.\ 0 .02 2,701. S5 08-04-03 DEPOSIT ~ ( 88,057. 00 .' 08-04.-03 CHECK NUMBER 2518 Y'MOI1 i"{v.,,,1 355 .n 90,403. .2 08-11-03 CHECK NUMBER 2522 400. 00 08-11-03 CHECK NUMBER 2520 f'\Tri"~i,1Ivc 567 .42 08-11-03 CHECK NUMBER 2519 0vt -r 'f 425. 00 89,011. 40 08-14-03 CHECK NUMBER 2521 PI ' I -fl ,,~ 143 .41 88,867. 99 08-22-03 CHECK NUMBER 2523 78 .80 88,789. 19 08-25-03 CHECK NUMBER 2524 568 .25 88,220. 94 08-28-03 INTEREST PAYMENT 124.28 08-28-03 CHECK NUMBER 2525 93 .00 88,252.22 ENDING BALANCE $88,252.22 ACCOUNT ACTIVITY CHECKS PArD SUMMARY 2515 2519 2522 2525 07-29-03 08-11-03 08-11-03 08-28-03 817.00 425.00 400.00 93.00 2516 2520 2523 07~31-03 08~11-03 08~22-03 119.40 567.42 78.80 2518* 2521 2524 08-04-03 08-14-03 08-25-03 355.13 143.41 568.25 ANNUAL PERCENTAGE YIELD EARNED 2.03 % o ~ 1-4 ! ot: ~ ~ II 01 ex> ~ 01 ~ " III <( ;.: .. ... 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"'.. 0 \3 zz - -- C ,n 0 CC Il> o~ ::I'" E ~ ~ 00 Il> ~<;! ,," ro "" ~8 c(c( tii ~ M&rBank Manufacturers and Traders Trust Company, 344 South 10th Street, Lemoyne, PA 17043 717 737 3322 FAX 717 737 6498 November 23, 2004 To: Whom it may Concern Re: Date of Death Balance This letter is the accurate date of death balance for account number 98276581. As of October 2, 2004 the balance in the above referenced account was $13,996.25 a~ DAVIO A. g'tCD"",J t-1 ~-r g<..k.. %.7 vartan - - vartan national bank November 18, 2004 the I'8g/on'B pl'8m/.' bus/n... bank Terry J. Moses Richard J. Moses Account 1516426 This account was opened on July 2, 2004, business day July 6, 2004, with a check for $51,000.00. On October 2,2004 it's balance was $51,248.37 with $59.67 in accrued but not credited interest. Today, the balance is $51, 462.71. Beverly Eisenacher . ~4 ~LLc Headquarters. 3601 Vartan Way, Harrisburg, PA 17110. (717) 657.7727. www.vartanbank.com TERRY J MOSES RICHARD MOSES 50 FOX ROAD SUITE 1 PALMYRA PA 17078 Checking PRIVILEGED CHECKING Beginning Rate ACCOUNT NUMBER 0291900113 PREVXOUS ST~ BALANCE AS or 09/07/03 ........................ PLUS 2 DEPOSITS AND OTHER CREDITS ................... LESS 0 CHECKS AND OTHER DEBITS ...................... CURRENT STATEMENT BALANCE AS OF 09/20/03 ......................... NUMBER OF DAYS IN THIS STATEMENT PERIOD 13 Page: 1 Enclosures: 1 Statement Date: 09/20/2003 Account Number: 291900113 CYCLE-013 1.00000 .00 70,007.20 .00 70,007.20 . Account Transactions DATE DESCRIPTION 09/08 DEPOSIT 09/20 INTEREST PAYMENT DEBITS . Balance Bv Date 09/07 .00 09/08 69,982.27 09/20 70,007.20 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 52-2389022 24.93 *** INTEREST EARNED THIS STATEMENT PERIOD DAYS IN PERIOD ......................... INTEREST EARNED ........................ ANNUAL PERCENTAGE YIELD EARNED (APY) .... *** 13 24.93 1.01% CREDITS 69,982.27 24. 93 ~ - ) OlD ~... p,;((f-"orc~ eJ .~ -:1::03" ~rl n..V S" (J)rkw2d 1_ftJJ,.a,/ "!10M,; INCh' -fY'Clvl I i11e~ ",HJ,-/JUCA- ,/;). ," OJ '/('" to V(Jff~.~......'lnregtlty. '.. . ~:.tU,..:.._. v liifTEGRIi'Y BANK CAMp. HILL BRANCH 3345 Marl<at SlrHt as Hili PA 17011 CONSUMER SIGNATURE CARD ACCOUNT'lYPE P ( ,'1/ t. K ,.. ACCOUNTNUMBERdJ. q/9 do I J 1 ACCOUNT MAIUNG ADDRESS NUMBER OF SIGNATURES REQUIRED / f1ofnxl<d S'u,'tel Palmyra.. PI} /'7(l'lf O /) TAXPAYER ID NUMBER) (;'/_11 ,_ 15U'l re.rr'l:J.fYl4St.!' !{.. d, ZtJ. _ la n J~ ~~~ f<.,-rhnr77 ({lOseS ACCOUNTOWNERSHIP ~ . O{'I , AGREEMENT. By your lignature you agl1l8 that the account Is :zg~iJi; ou:~lmer Oepoa<< ACCO~U Tlme Oopos<< Agreement. All terms dellned In l!lol ogreemont apply here, You acknowtodge recalpt of that agl1l8ment; our Pl1vacy Nob; the Truth In Savings disclosure; tho foe schedule; ~ your OCCDUnt Is a choclclng aCODun~ the disclosure about your ability to withdraw fundI; the disclosure and fee 8chedule for elactronlc fundI transfers (~contracted); and any addenda 10 those documents, You hava road and agl1l8d 10 those documenls, i5-~-~---- X . PAYABLE ON DEATH BENEFlCIARY(IESI ACCOUNT l1TLE Dale Date Oala 9~~1L 7lJJJ IF YOU TELEPHONE US OR IN OTHER CIRCUMSTANCES. ;Chard (Y70St5 Nema: SSN: Phone: Phone: Job: OOB: Type 10: 10#: Other. THE INFORMA~ BELOW ~~BE USED T.1 CONFIRM YOUR ID 'me: ~f;.~~ I; ~m . Name: \...$N: ~ - SSN: Phone: (H) '3;_. JJ Phone: Phone: (W) Phone: Job: Job: OOB: 7 -&. - ~ I OOB: . Type 10: e ill Type 10: 10#: I 'f' {'1l./f.{ 10#: Ol/ler. Other. (H) (W) 077 TlNlBACKUPWITHHOLDlNOCERTlFICATlON: jl'1/_ / J { _ T7c..-/ /, Taxi_on Number. / D '1 /J 7"<- ~ Under peneiIloa of(l8ljUly.1 C8IIIft thai tho number shown above Is my conac:\ laxpoIyarlden1lftceUon number end thai (c:hac:k appropriate box): ilJ/r am not auIljocl to backup wIlhhoIdIng. because I am exampt ~ backup~. 0( _ I have no! been no1IfIecI by the Inlemal Revenue _thai 1 am .ubloc:I to backupwllhholdlng II a result of /aU... 10 report aI_ ..._.... becauao the IRS has notIIIed me thai I em no longer 8UbJoc:I1O bacltup wilhholdil1g. C I am aubJed 10 backup wllhhoIding. 2,"A;::t/~ (Signature of U,S. person) 'O~te 0/~ /j 3 ~~ ~~~ ~ cN2t '((1, ,*,20 /21. . LhOO.. 4RIl tJ3/J/f?f? . . E~< 'i\.-\P ""'" !lee/II O~9/90011J. PPT.CONSUMER SIGNATURE CARD 00005000/20002820 Printe<l6l1812D03 4:27 PM Cl 2001 Klrchman Corporation I . -~_.'_.. ~--:. .- .~.. ......,j "---. ". -...,. ll~' 131 . .'\ p~. .'3 _7-). -ry{ ::;"n.;"": , ,- ,~ · DITE ~ HCS-- $ Sf; Our} fnj~ PI' ~ () / & {J ---. fv~ DOIWS (D gg::::. ~/h- . l Integrity 8 A N K TERRY J MOSES RICHARD MOSES 50 FOX ROAD SUITE 1 PALMYRA PA 17078 TERRY J. MOSES RICHARD MOSES 60 FOX AD. SUITE 1 PALMYRA, PA 17078 ./" i PAYTOTHEORD' I h fi<1 0",& . , . ~~~T ~~_.- fOR 1:0:1 n ~8 78 71: Current Date: November 23, 2004 . Account Number: Capture Date: Item Number: Posted Date: Posted Item Number: Amount: Record Type: 291900113 July 07, 2004 30004132673 July 07, 2004 189000009 $51,000.00 Debit o 2Cj ~1:j00 I. BII"O ~31 ~ 021873514.4 D7072004 031000040-PRB-PHILA ENT=3818 T~C=3864 PT.=11 , #r: II allfirst RICHARD J MOS E S OR BEATRICE OMOSES 101 E PARKAVE NEW CUMBERLAND PA 17070-1653 1.1111111I11I11I 111I1 II.... 1I11.1I...l.lllllI.II," ,"11I,1.. I Slwlv CO I V\ VZ) II t:;{ ~'-t -r- Vt}vVl i-I ~ (J "2- 'to ~-2.-03 P.J,e lofJ Certificate of Deposit J'lUIary I~ 2fX)2 dUll JUM ..IJ 2CXJ2 R_J_ orBeallfc:eO _ A<:cl No 8-700-BIQ.OSOS462 fa --... G 2/HIoIr Fixed Rall! CD C_S...... 1-1100.533-4630 A~SImlBY Interest nlte Inll!rest paid this stall!ment Inll!rest paid this year Tenn (months) Maturity dall! 2.18X Beginning balance $1.913.51 Depo.siU andaddldons $1.913.51 CImlll:VlIIUe 15 09/0112003 $55.375.59 1,913.51 $57.289.10 DEPOSits anlI..dI:I...... 0",. tHsctfpt/od AmcNJnt 06.<)1 INTEREST CREDIT $1.913.51 $1.913.51 Due 10 a change by the Maryland legislature. which Is elli!ctlve June 3Olh,2OD2, the dme period for an account 10 be Inactive before kls ,u""ndered 10 the Stall! of Maryland has been changed Ii"om 5 yea.. lD 4yea.., Elli!ctlve June 3Olh. 2003, this Inactivity period will reduce 10 3yea... This appUes only 10 accounlS opened through a Maryland b..nch. The A11fi..tBank Rules for Consumer Depo.skA<:counlS ore revised elli!ctlve June 3Olh. 200210 rellectthls new change. 013710 002l>98J177199430Sll ... *~ PD F 5263 Department of the Treasury Bureau of the Public Debt (Revised March 1999) PLEASE FOLLOW THE INSTRUCTtONS ON THE BACK. PAINT IN CAPITAL LETTERS. SCANNABLE FORM - DO NOT WRITE OUTSIDE BOXES. .' ... ORDER FOR SERIES EE U.S. SAVINGS BONDS OMS No. 1535.0084 Previous Editions Usable 1. FULL NAME OF OWNER OR FIRST-NAMED COOWNER Name R I C. 4 f} K 1) -J fY} 0 S cS Social Security Number 1 '7 '1 - 0 7 - 7 (), if 7 2. NAME OF PERSON TO RECEIVE BONDS IF OTHER THAN THE OWNER OR FIRST-NAMED COOWNER ABOVE Mall to: ~ ~:.l 3. ADDRESS WHERE BONDS ARE TO BE MAILED 101 f ?II{(!C I~J [ (NUMBER AND STREET, RURAL ROUTE, OR POST OFFICE BOX) AJfvJ e UIl6(elf-lJ/) (CITY OR TOWN) ~ I;~ATE) t7070 (ZIP CODE) D beneficiary: Namel f KKY :r trJOSCS coowner 4. COOWNER OR BENEFICIARY (Optional) The following person Is to be named as ... (Coownershlp will be assumed if neither or both blocks are checked.) 5. BONDS ORDERED Denom. Quantity Issue Price Total Issue Price FOR AGENT USE ONLY $ 50 X$ 25,00 =$ 0 0 . $ 75 X$ 37,50 =$ ~ . $ 100 X$ 50.00 =$ 0 0 C.C.# 535' . DEe 31 2002 $ 200 X$ 100.00 =$ 0 0 . AUf/RST iANK $ 500 X$ 250.00 =$ 0 0 . $ 1,000 X$ 500,00 =$ 0 0 lS5015944. . $ 5,000 X$ 2,500.00 =$ } /::000 0 0 $ 10.000 .3 X$ 5.000,00 =$ 0 0 TOTAL ISSUE PRICE OF PURCHASE $ /5.000 AFFIXED AGENT STAMP CERTIFIES THAT TOTAL AMOUNT OF PURCHASE IS CORRECT 6. DATE PURCHASE ORDER AND PAYMENT PRESENTED TO AGENT / d- 3 I OL (MO,) (DAY) (YR.) 7. 7IG.~?RE i.' Ii. AY? I ~_ / /VVV'~ i /....,/ PURCHASER'S 5 NATURE IF YOU NEED A GIFT CERTIFICATE, PLEASE ASK THE PERSON ACCEPTING THIS FORM TO PROVIDE ONE TO YOU. ~C~ASE~AME, IF ~R THAN ")(j tox '0 STREET ADDRESS (If not shown above) CITY STATE ZIP CODE ... 5263 0399 SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE CUST~ER RECEIPT ... , Savings Bond Calculator Page I of I Value As Of Savinc 110/2004 1IIIli!l~.11 Imliillll.m CALCU Bond Info Series I EE Bonds Denomination Serial Number Issue Date If $15,000 II E Results # Bonds 1 Total Price $2,500,00 Total Interest $114,00 Total Value $2,614.00 YTD In' $58.1 Serial Number Issue Date Series Denom Issue Price Interest Value Interest Next Final Rate Accrual Maturit: 12/2002 EE $5,000 $2,500.00 $114.00 $2,614.00 2.84% 11/2004 12/203: Le,end Note Description NI Not Issued NE Not Eligible for Payment P5 Includes 3-month interest penalty MA Matured and Not Earning Interest Please rate this service. (Please print and/or save this page before submitting your survey) Service Excellent Good Fair Poor Savings Bond Calculator r r r r -.. http://wwws.publicdebt.treas.gov/BC/SBCPrice 02/02/2005 ~ AlMllAR\\1AifY AlG Annuity Insurance Company A Stocl< Company 205 East 10th Avenl1e Amarillo. Texas 79101-3546 Telephone: 800.424.4990 November 18, 2004 Terry J. Moses 10 I Park Ave. New Cumberland, PA 17070 Re: Deceased: Contract #: Beneficiary: Richard Moses A0200217 Terry J. Moses Dear Sir or Madam: We have received your request to defer payment of the death proceeds for the referenced contract up to five years from the date of death of Richard Moses. Please be advised of the following important information regarding your open claim. . The contract will remain in the name of the deceased. The beneficiary does not become the owner of the contract. . Beneficiary rights: o The beneficiary may withdraw all or a portion of the proceeds from the contract at anytime during the five- year period. . The IRS requires that the beneficiary take receipt of the full amount ofthe proceeds by the fifth anniversary of the date of death of the contract owner if the policy is non-qualified, or by December 31" of the fifth year following the date of death if the policy is qualified. . Any distribution will be reported to the IRS via IRS Form 1099-R. By January 31" of the year following a distribution, the beneficiary will receive a copy of this form for tax purposes. . If multiple beneficiaries have selected tbe open claim option for this contract, each must withdraw the same amount ofthe proceeds at the same time. Each beneficiary must complete and submit a Claim Distribution form. A withdrawal form and return envelope are enclosed for your convenience. o The beneficiary may not name new beneficiaries for the contract. Upon the death of the beneficiary, the remaining proceeds shall be paid to the beneficiary's estate. . If multiple beneficiaries exist, the death of each beneficiary will result in payment of the beneficiary's remaining portion to the beneficiary's estate. o To receive important contract information, the beneficiary must advise the company of any and all address changes. Should you have any questions or require further assistance, please contact our Client Care Center by using our toll free number of 1-800-424-4990. Sincerely, g.'1y).~ B.M. Graves Annuity Claims Manager Enclosures: AlGA 410 and Return Envelope AlGA Open Confirm .. t. -_ ,-"r.'..~ ,j.I'\fi.,':, '._ _ i' Allianz Life Insurance C~mpany of North America PO Box 59060 Minneapolis, MN 55459[0060 800/950-1962 i , '\ij,,)-:(-,?v. /v :0< "" I Allianz (ill) November 3, 2004 TERRY MOSES FAX: 717-737-649 Re: RICHARD MO ES, deceased Policy Number' 4331421 Dear MR MOSES: , We are sorry to he r of your recent loss. Please accept our ~ncere sympathies, I The above referen Etel policy has been annuitized. The annuity payments have been temporarily suspen ed. As the named beneficiary, you are 6(1titled to receive the remaining guarant .d payments. Once the claim form is rec~ived and approved, the annual payments 0 $4,038.38 will continue to you effective ~ay 9, 2005. until the last , payment date of My 9. 2005. ! I Please complete th enclosed Continuina Annuitv Ootion Set::ement Claim Form. Attach 0 ertlfieddeath certificate (must have raised state *eal), and if available. a dated obituary. PI ase refer to the Specia/lnstructions SectJ/:m for any specific requirements nece sary to process your claim. I I , Please give this m possible. Thank y Uer your prompt attention and submit you! claim form as soon as lI, and again please accept our condolencus. I Sincerely. Pam Streifel Claims Examiner I i If you are a~ IlIInols'ij.". khmt: Part 919 of the. Rules of the Illinois Depa1ment of Insurance governing . claIms practICes requor " that our company advise you thaI you mayexpr<tss any concerns wdh the illinoIS Department of Insuran fl. It maintains a consumer division al100 W Ran~olph Street, Suite 15-100, Chicago, illinois 60606 Md at 320 West Washlngtoo Street, Springfield, IIIJnois 62767. i ! " , , , , l'd oo~,~SS~E:S~ ---'----'--.. - -- _._~-_..-._---- 3~I1Z~UlllU Wd~S:S ~OO~ vO ^O~ Allianz Life Insurance Company of North America PO Box 59060 Minneapolis, MN 55459-0060 800/950-1962 Allianz @Y December 6, 2004 TERRY J MOSES 101 EAST PARK AVE NEW CUMBERLAND, P A 17070 Re: RlCHARD J MOSES, deceased Policy Number: 4331421 Dear TERRY J MOSES: Thank you for providing the necessary information for processing the claim on the above referenced policy. Please accept our sincere sympathies to you and your family. Enclosed is the Settlement for Annuity Benefit that specifies the terms under the option you have chosen. Please read the agreement over carefully and store it in a place of safekeeping. All future correspondence and payments will be sent to: TERRY J MOSES 101 EAST PARK AVE NEW CUMBERLAND, P A 17070 If you have any questions after you have reviewed the agreement, please don't hesitate to contact your agent or call me at 800-950-1962. We appreciate your business. Sincerely, Idm~ Pam Streifel Policyholder Claims Allianz Life Insurance Company of North America PO Box 59060 Minneapolis, MN 55459-0060 800/950-1962 Allianz @) ANNUITY OPTION AGREEMENT Policy Number: 4331421 Annuitant Name: T oday's Date: December 6, 2004 REVISED RICHARD J MOSES, DECEASED TERRY J MOSES Owner Name: Settlement Effective Date: Option Chosen: Amount of Original Proceeds: Payment Mode: Next Payment Date: Final Payment Date: Contingent Owner: May 9, 2000 Installments for a Guaranteed Period $22,800.26 Annual Payment Amount: $4,038.38 May 9, 2005 May 9, 2005 PATRICIA K MOSES SPOUSE 100.00% Under the provisions of your policy, you have chosen the above-described annuity option. Each installment will consist of part principal and part interest. It is understood that election of this annuity option waives all rights to submit premium or make additional withdrawals. No further adjustment in interest will be made. Except for the Company's obligations with respect to payment pursuant to the annuity option selected by you, all other provisions of the policy terminate once payment begins. The mode of payment is fixed and cannot be changed. With the election of this annuity option, quarterly and/or annual statements will no longer generate. The selection of this annuity option is irreversible, unassignable, and non-transferable once the first benefit payment has been cashed or deposited. Should the owner die before the final payment date, payments will continue to be paid in the same manner as previously elected to the contingent owner, or as amended. ~~ ~4~b Suzanne J. Pepin Senior Vice President, Secretary, and Chief Legal Officer Charles Kavitsky President COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX BUREAU OF IHDIVIDUA")~\~n nr:cr!:E rl.APPRAISEHEHT, ALLOIIANCE DR OISALLDIIANCE INtERITANCE TAX DIVISIDIf,---~J "..J"_,~, ,-..11,..)_ '__,1 OF DEDUCTIONS AND ASSESsttENT OF TAX PO lOX 210601 HARRISBURG PA 17128-0601 ?nt!.n~.. 9 C\~ t . 02 ~ .. 2., Ii ,2.. DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-25-2005 MOSES 10-02-2004 21 04-1198 CUMBERLAND 101 AIoount _ntH r. I cP'! \f....,-_' .;\ HEATHER ~~Po9J~:f~i)URT SMIGEL Er~L 4431 N FRONT ST 3RD F HBG PA 17110 *' REY-1547 EX AFP (03-05) RICHARD J MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS UNE ~ RETAIN LOWER PORTION FOR YOUR RECORDS 4IJ , 11"'_\'!f.,.yt.WfJ.'l'lfJ'!'lI'&'.'Il1n1M.tII!".!MftItWJM!r.'IW.l'll\fl1l~~.ycr.!IV'JM!I!'.Mt'...~.......... ... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MOSES RICHARD J FILE NO. 21 04-1198 ACN 101 DATE 04-25-2005 TAX RETURN liAS: I X) ACCEPTED AS FILED I ) C_ED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. R..l E.tata ISchadula A) 2. Stack. _ Band. lSc:haclula B) !Ii. Closely Held stock/Partnership Interest (Schedule CJ 4. Hort_aINota. Ra...lvabla I_la D) S. CaahlB_ _db,"lac. Par_l proparty I_la E) 6. Jointly _ Praparty ISchaclula Fl 7. Transfars lSchlKlul. en 8. Total As.t. 11) (2) (3) (4) IS) (6) (7) .00 .00 .00 .00 .00 113.806.09 34.419.75 (8) NOTE: insure pr...r creel! t to your 1lCC0000t, _It _ _r porUon of thl fo~ with your t_ t. 148,225.84 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral ExPen_S/AcIIt. Costs/HIsc. ExPenses (Schedule H) (9) 10. Dabts/Hort_ LlabllIUaa/LI.,s IS_clula I) lID) t;70. 92 i 11. Total _Uons 11ll J 7.3?1 88 12. N.t Val... of T_ Raturn (12) ~40,903. 96 13. Charltabls/Bo..rnasntal Bequosts; Non-.lact.d 9113 Trusts ISchaclul. J) (13) .00 14. Hat Val... of E.tat. Subj...t to T_ 114) l40,903.96 NOTE: I~ an ........nt w.. issued previouslY. lines 14. 15 end,or 16. 17. 18 land 19 will re1'lect ~igur.s tha1: inc1ud. the tatel of Ab.b. return. assessed to date'l ASSESSMENT OF TAX: : IS. Mount of U... 14 at Spousal rat. 115) .00 X 00 = I .00 16. Mount of U... 14 t_abl. at Ll....lIClass A ~t. 116> 140,903.96 X 045 ~ 17. Mount of Ll... 14 at Sibling ~ta (17) .00 X 12 = I .00 18. AIoount of Ll... 14 t_la at Collat.~lIClass B rata (18) .00 X 15 "----1 .00 19. Prlnd..al T_ _ 119)= . 6,340.68 6,650.96 IUlBER CD004784 INTEREST/PEH PAID 1-) 317 . 03 A_ PAID 6,023.54 DATE 12-30-2004 ~ TOTAL TAX CREDIT BALANCE OF TAX DUE IMTEREST AND PEN. TOTAL DUE ,6,340.57 I .11 .00 .11 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCUUTIDIl OF ADDITIDIlAL INTEREST. I IF TOTAL DUE IS LESS THAN tl, ND PAYIlENT IS REWIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR)! YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOHN FOR ~NSTRUCTIDNS.)