HomeMy WebLinkAbout08-29-13 (3) � . . a
� 1505610140
REV-1500 Ex `°2_„>`F°
OFFICIAL USE ONLY
PA Departmenlof Revenue
Bureau of Individual Taxes County Code Year File Number
Po soX 28060� INHERITANCE TAX RETURN 2 1 1 3 0 5 6 1
Harrisbum PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Securiry Number Date of Death MMODYYYY Date of Birth MMDDYYYv
0 4 1 8 2 0 1 3 0 4 1 9 1 9 2 3
DecedenYs Last Name Suffix DecedenPs First Name MI
D E R I C K B L A N C H E M
(If Applicable)Enter Surviving Spouse's Informatlon Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� t.Original Return � 2. Supplemental Return � 3.Remainder Retum(Date of Death
Prior to 72•13•82)
� 4. Limited Estate � 4a. Future Intarast Compromise(date of � 5. Federal Estate Tax Retum Required
death aRart2-12-82)
QX 6. Decedent Died Testate � 7. Decedent Maintained a Living Trust 1 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
� 9. Litigation Proceeds Received � 10.Spousal PoveRy Credit(Date of Death � 11.Election lo Tax under Sec.9113(A)
Belween 7231•91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT•iHIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE�IRECTED T0:
Name Daytime Telephone Number
B E N J A M I N J B U T L E R 7 1 7 a3 3 6 �;4 8 .�
c �w. �+++}}}---���r,�i
RE61ST OWWILLSUSSDNLV.�
� IT1 �� r-, L a �
:O y,,, �...:: �
First Line of Address '
� V) � v., .
1 0 0 7 M U M M A R 0 A D vc, " - -' '1;
Second Line of Address „� �'" -��'� '� .
} G_
,. ��_• . _ �� '
3 U I T E 1 0 1 -n �d '�"
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City or PoSt Office Stete 21P COde �� �'-'' DATE FILE� _ ��� '���
L E M 0 Y N E P A 1 7 0 4 3
CorrespondenPs e-mail address: LAWYERSna,BUTLERLAWFIRM.COM
Under penatties of perjury,I declare that I have ezamined thla retum,indudinp accompanying schedulea and statementa,antl to the best M my knowledge aM belief,
it is aue,cortect antl compbte.Decleretlon af preparer olher Man ihe peraonal repreaenta6ve is baaed on all iMOrmatlon of which preparcr has any knowledge.
SI NA E OF PERSON RE ON918LE F FILI N DATE
ADDRESS
2604 PA H RCH ROAD HARRISBURG PA 17110
SIGNATUR F PRE R T ENTATIVE DATE �_� �/ I�
7
ADDRE
1007 MUMMA ROAD, SUITE 101 LEMOYNE PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 7
� 1505610140 1505610140 J
��
' • 1505610240
�
REV-1500 EX(FI) DeeedanPs Social Security Number
oecadenes r+ame: B L A N C H E M • D E R I C K
RECAPITULATION �
1. Real Estate(Schedule A) . . . . . . . .. . . . . . .. ...... . . . .. . .. . . . . . .. . . .. . . 1. '
2. Stocks and Bonds(Schedule B) . . . . . . . .. . .. . .. . ... .. ... . . .. .. . .. . . . .. 2. 8 1 9 2 . 1 3
3. Closaly Held CorporaHOn,Partnership or Sole-Proprietorship(Schedule C) .. . . . 3. •
4. Mortgagas and Notes Receivable(Schedule D) . . . . ... .. ... . . .. .. . . . . . ..��. 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). .. . . . . 5. 1 9 2 1 8 , 0 2
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. . . .. . 6. •
7. Inter-Vivos Transfers&Miscellaneous N -Probate Property
(Schedule G) � Separete Billing Requested . .. . . . . 7. L 1 1 6 3 7 . 0 6
8. Total 6ross Asaeta(total Linas t through 7) . . .. . ... .. . .. . . .. .. . .. . . .. . 8. 1 3 9 � 4 7 . 2 1
9. Funeral Expenses and Administrative Costs(Schedule H) . .. . . . . .... . . .. . . . 9� 1 3 8 8 9 . 8� 9
10. Debts of Decedent,Mortgage Liabilities, and Liens(Schedule 1) . . . .. . .. . . . . . 10. . 4 9 . 8 1
��. Total Detluctfons(total Lines 9 and 10) . . .. .. .. .. ... . .. . . . . . .. . . . .. . . . 11. 1 3 9 3 9 . 7 0
12. Net Value ot Estate(Line 8 minus Line 11) .. . . .. .. . .. . .. . . . . .. . . . . .. . . 12. 1 2 5 1 0 7 . 5 1
13. Charitable and Govemme�tal Bequests/See 9113 Trusts tor which
an election to tax has not been made(Schedule J) . . ... .. .. . . .. .. . . .. . . . 13. •
14. Net Value SubJect to Tax(Line 12 minus Line 13) ...... .. .. . . .. . .. . .. . . 14. 1 2 5 1 0 7 . 5 1
TAX CALCULATION-SEE INSTRUC710NS FOR APPLICABLE RATES �
15. Amount of Line 14 taxable
at the spousel tax raM,or
transfers under Sec.9116
(a)(7.2)X.0 _ ` 0 . 0 � 15. � . � �
76. Amount of Line 14 taxable
at lineal rete x.oae 1 2 5 1 0 7 . 5 1 �s. 5 6 2 9 . 8 4 •
17. Amount of Line 74 taxable
at sibling rate X.12 0 • U 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 • � 0 1g. � • � 0
19. TAX DUE . .. . . . .. . . . .. . . . . . .. . . . . . . .. .. .. .. . .. .. . . . . .. .. . . . .. . . 19. S 6 2 9 . 8 4
20. FILL IN THE OVAI IF YOU ARE REQUESTING A REPUND OF AN OVERPAYMENT ❑
Slde 2
� 1505610240 15�5610240 �
REV-1500 E%(FIN Page 3 Flle Number
Decedent's Complete Address: 2i i3 0561
DECEDENTSNAME
BLANCHE M.DERICK
STREETADDRESS
132 Cazol Lane
cin srnre zia
Enola PA 17025
Tax Payments and Credits:
�. Tax Due(Page 2,Line 19) (1) 5,629.84
2. CredilslPayments
A.Prior Payments 5,000.00
B.Discount 263.1 S
Totat Credits(A+g) (y� 5,263.15
3. Interest
(3)
4. If Line 2 is greffier ihan Line t +Line 3,enter ihe difference.This Is the OVERPAYMENT.
FIII In oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line t+Line 3 is grealer than Line 2,enter the difference.This is the TAX DUE. , (5) 366.69
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedenl make a transfer and: Yes No
a. retain the use or income of the property transferred ...................................................................... ❑ �
b. retain the right to designate who shall use the property transierred or its income .............................. ❑ �
c. retain a reversionary Interest ..................................................................................................... ❑ �
d. receive the promise for lite of eiNer payments,benetils or care7 ....................................................... ❑ ❑X
2. If death occurred aRer December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ 0
3. Did decedent own an"in trust for or payaWe-upon-0eath bank account or secudty al his or her death7 ......... ❑X ❑
4. Did decedent own an individual retirement acroount,annuily or other non-probate property,which
contains a benefiaary designffiion?.................................................................................................. � ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
t. . . ,. ,
For dates of death on or after July 1,1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the suMving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)J.The statute does not exempt a Vansfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax relum 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 valae of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of Vansfers to or for ihe use of the decedenYs lineal benefiaaries is 4.5 percent,except as noted in p2 P.s.§s��e�a>����.
• The tax rate imposed on the net value of transfers to or for the use of the decedenPs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-19D3 F>(+(8�12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCETN(RETURN STOCKS & BONDS
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
BLANCHE M. DERICK 21 13 0561
All proparty jointly owned with Hght of survivorship must be diselosed on Sehedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 129.00 shazes Metl.ife,Inc.(ME'I)Q$35.88-See Attached 4,628.52
2. $1,000.00 Series HH Savings Bond(M9359163HH) 1,000.74
with accrued interest of$.74
3. $1,000.00 Series HH Savings Bond(M9359164HH) 1,000.74
with accrued interest of$.74
4. $500.00 Series HH Savings Bond(D6586101HH) 50037
with accrued interest of$37
5. $250.00 West Shore Lodge Bond-Certificate No. 039 265.44
with accrued interest of$15.44
6. $250.00 West Shore Lodge Bond-Certificate No.040 265.44
with accrued interest of$15.44
7. $250.00 West Shore Lodge Bond-Certificate No.041 265.44
with accrued interest of$15.44
8. $250.00 West Shore Lodge Bond-Certificate No.042 265.44
with accrued interest of S 15.44
TOTAL(Also enter on Line 2,Recapilulation) S 8 192.13
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
BLANCHE M.DERICK 21 13 0561
Include the proceeds of I'Rigation and the date the proceeds were received by the estate.
All property jointly owned wlth dght of survivorship must be distlosed on Sehedule F. �
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 2001 Lincoln Continental(approx.45,000.00 miles) 6,800.00
value based on sale dated August 2013
2. PNC Bank-Prioriry 50 Plus Interest Checking Account Na. 51-4011-1637 11,667.24
See Attached Statement
•net of checks written before death but cleazing after death*
3. 2012 1040-Refund 600.00
4. Comcast-Refund 11.23
5. Paffiot News 722
6. Erie Insurance-Refund 132.33
TOTAL(Also enter on Line 5,Recapitulation) S �g 2�g,p2
If more spece is needed, use additional sheets of paper of the same size.
-___ _...._.
REV-1$70 EX+(Ob-09)
pennsylvania SCHEDULE G
�EPARTMENTOFREVENUE INTER-VIVOSTRANSFERSAND
INNERITANCETAXRETURN MISC. NON•PROBATE PROPERTY
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
BLANCHE M.DERICK 21 13 0561
This schedule must be completed and filed N the answer to any of questbns 1 through 4 on pape ihree of fhe REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
INCLU�ETHE NAME OF TI1ElAiWSFEflEE,TNEIR RElATI0N51tlPT0�ECE�EM MlD
NUMBER THEDATEOFTRANSFER.ARACMACOPYOFTHEUEEUFONREr1LE5fATE. VALUEOFASSET INTEREST prrsrucrat� VALUE
1. Vanderbilt Securities,LLC-IRA Account No. Q80-000965 37,524.81 100.00 37,524.81
Beneficiary: Sherry Lynn Sallada(lineal)
2. Vanderbilt Securities, LLC-TOD Account No. Q81-000639 60,086.43 100.00 60,086.43
Beneficiary: Sherry Lynn Sallada(lineal)
3. The MuNal Beneficial Association,Inc. -Non-Qualified Annuity 14,025.82 100.00 14,025.82
Account No.099618
Beneficiary: Sherry Lynn Sallada(lineal)
TOTAL Also enter on Line 7,Recapitulatfon S 111 63'7.06
If more spece s needed,use additbnal sheeb of paper of Ihe sema size.
REV-}571 EX+(f0-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHEPoTANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
BLANCHE M.DERICK 21 13 0561
DeeedenPe debts must be repoited on Schedule I.
ITEM -
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1. Sullivan Funeral Home 6,900.00
2. Funeral Reception 764.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personel Representetive(s)
Street Address
City State ZIP
Year(s)Canmisabn Paid:
y, Anomey Fees: Butler Law Firm 5,000.00
3. Fam1y Exemption:Q(decedenPs eddress is rwl the same as claimanPs,adach explanatlon.)
Clalmant
StreetAddress
City State ZIP
Relatlonship of Clalmant to Decedent
4. ProbateFees: 188.50
5 Accountant Fees:
6. Taz Retum Preparer Fees: 2013 1040 and PA-40;2013 1041 and PA-41 585.00
7. Cumberland Law Joumal-Estate Advertising 75.00
8. The Sentinel-Estate Advertising 210.78
9. Postage 631
]0. NotaryFee 5.00
11. Photocopies 0.80
12. Cumberland County Register of Wills-AddiHonal Short Certificates 10.00
13. Executrix Expenses 138.50
14. PNC Bank-Bank Fee 6.00
TOTAL(Alsa enter on Line 9,Recapitulffiion) S l3 889.89
If more space is rieeded,use additbnel sheeGs of paper M Me same size.
REV-1512 EX•(�2-12)
pennsylvania SCHEDULE I
DEPAFlTMEN�OFREVENUE DEBTS OF DECEDENT,
INHERRANCETAXRETURN MORT�AGE LIABILITIES&LIENS
RESIDENT DECEDEFt�
ESTATE OF FILE NUMBER
BLANCHE M.DERICK 21 13 0561
Report debh incurted by the decedent prior W death that remalned unpaid at the date of death,Including unreimbuned medical expensea.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1, Verizon 49.81
TOTAL(Also enter on Line 10,Recapitulation) S 49.81
If more space is needed, insert additional sheets of the same size.
_ _
REV-0573 EX�(Oi-00)
pennsylvania SCHEDULE J
DEP�,MENT OF R�ENUE BENEFICIARIES .
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
BLANCHE M. DERICK 21 13 0561
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not Llat Truatee(s) Of ESTATE
I TAXABLE DISTRIBUTIONS pndude outright spousal distributions and transfers under .
Sec.91 i6(a)(1.2).)
1, Sherry Lynn Sallada Lineal 125,107.51
2604 Paxton Sheet
Harrisburg,PA 17110
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If more space is needed,use additional sheets of paper ot the same size.
� ' REV-1500 Discount, Interest and Penalty Worksheet
Discount Calculation
Total Amount Paid within three calendar months of the decedenYs date of death: 5.000.00
Discount: 263.15
Interest Table
� Year Days Delinquent Balance Due Interest
this tlme period this year this period
Before 1981
1982 �
1983
1984
1985
1986
1987
� 1988 throu h 1991
1992
1893 throu h 1994
1995 throu h 1988
1999
2000
2001
200r Z -
2003
2004
2005
2006
2007
2008
2009
2010
2011 throu h 2013
TOTALS
Penalty Calculation
If the decedenYs date of death was on or before March 31, 1993, insert the applicable amount:
Total Balance Due on January 17, 1996:
Penalty:
L � ST 1!lt1LL � ND T � ST �1dI � NT
O �'
BL� RC �I � 16I. D � �t1CK
I, BLANCHE M: DERICK, of Enola, Climberland County, Pennsylvania, being of
sound and disposing mind, memory, and understanding, do hereby make, publish, and declaze
this to be my Last Will and Testament and hereby revoke all other Wills and Codicils, if any,
that I have made.
FIRST: I give and devise all of my personal jewelry to my daughter, SHERRY
LYNN SALLADA, of Harrisburg, Pennsylvania, so long as she shall�survive me by thirty (30)
days.
SECOND: I give, devise, and bequeath all the rest, residue, and remainder of my
Estate, of whatever nature and wherever situate, to my beloved husband, GILBERT N.
DERICK, so long as he survives me by thirty (30) days.
THIRD: Shoiild my husband faii to survive me by thirty (30) days or should he
� for any reason fail to take under this, my Last Will and Testament, then I give, devise, and
bequeath all the rest, residue, and remainder of my Fstate, of whatever nature and wherever
situate, to my daughter, SHERRY LYNN SALLADA;so long as she shall survive me by
thirty (30) days.
� FOURTH: Should my daughter fail to survive me by thirty (30) days, then I give,
devise, and bequeath all the rest, residue, and remainder of my Estate, of whatever nature and
wherever situate, to my grandson, CORY A:SALLADA, of Hazrisburg, Pennsylvania, so
long as he shall survive me by thirty (30) days. Should my grandson fail to survive me by
thirty (30) days, but be represented by children then living, these children shall take,per
stirpes, the shaze to which my grandson would have been entitled if then living.
FIFTH: Should my grandson not have attained the age of twenty-five (25)years
at the time of my death,�I direct that my Estate as given to my grandson in part FOURTH of
this, my Last Will and Testament; be given to my Trustee, hereinafter named, in trust for the
following uses and purposes and upon the following terms:
A. The net income of the Trust shall be paid to and be applied for my
grandson's care, maintenance, education, or support at such times as my Trustee shall
determine in his absolute discretion. Should the income&om this Trust be insufficient to
provide adequate maintenance, education, or support, my Trustee, in his sole discretion, may
invade thb principal for this purpose.
B. In the administration of the Trust, the Trustee shall have the following
powers, deemed to be supplementary to and not exciusive of, the general powers of trustees
� pursuant to law and including all powers necessary to carry the same into effect, all of which
shall be exercised in a fiduciary capacity:
1. To hold any or all of the Trust Estate in the form received.
2. To sell at public or private sale, to mortgage, pledge, or hypothecate
� or to exchange or lease (including leasg for a period eictending beyond the term of ihis Trust),
any stocks, notes, securities, real estate, minerals, and other trust property, upon such terms,
� cash or credit, or both, as he may deem advisable.
3. To invest and reinvest the Trust Fstate in investments limited to real ,
or personal properry, minerals, royalties, and leaseholds.
4. To construct, add ta, repair, or demolish {in whole or in part} anp
improvements upon any Trust praperty.
5. To participate in any rearganization, consolidation, merger, ar -
dissolution of any corporation, the stocks, bonds, or other seeurities of which may be hel8 at
any time as part of the Trust Estate and to receive and continue to hald any pzoperty which
may be allocated or disiributed to it by reasan of participation in any such reorgaaization,
merger, or dissolution. .
6. To make or hold investments or any part of the Trust Estate in .
common or undivided interes4s with other persons, carpc�ratians, or trusts.
7. Ta demand, receive,rcceipt for, sue for, and collect anp and all
rights, money, properties, or claim4, to which this Trust may be entitled, and to compromisc,
seztle, azbitrate, or abandan any claim ox flemand in favax of or agains#this Trust.
8. To borrow fwids for this Trust in such amaunts and for such
pwposes as he shall deem for the best interest of this Trust and the benefieiary thereof, and to
purchase properry on ttae credit of this Trust, and, in eonnection with snch bonowing or such
gurchase, to sxecutc and defivex promissory notes ar other evidences of indehtedness of this
Trust and to mortgagt ar pledge all or any part af the Trust Fstate to secure paymcnt of such
, indebtedness, and to repay such indebtedness out of the Trusf Estaie.
9. To employ agents, legal caunse2, brokers, and assistaats, and to pay
� their fees and expenses as he may deem necessary or advisable ta carry out the provisions of
- this 1`rust.
� 10. To vate in person ar by proary any sl�ares af stock which may form
part of flris Trust.
� �.
11. Ta lenfl money to any person ox persons upon such terms,but with
adequa#e interest and secuzity, as he may deem advisable for the beat interests of thia Trust.
12. To elect, appoint, and remove ditectars of any cazporation, the
stock af which shall constitute Trusi properry, and to act as a directs>z and officer af any such
corporation.
13. Generally, and without limitatian by any specifia enumeratian
t1C281T1s ta manage, CASi�SO�, 4�}6Tflt8, SCCO21YCIty IIIY23tt L@lS1VC3C3 3£�� CRC�12ItgC� �C2S$s
mortgage, pled�e, pool, ar otherwise encumber and deai with the property af this Txust, for
and in bohalf of this Trust and the beneficiary thereof, to the sawe extent and with the sama
pawars that any i�ividual would have in zespect to his own praperty and&mds.
14. To act freely under all or any af the powers by this agreement given
to the Tmstee in ati matters concerning tbis Tiust, after forming his judgmem based upon ati
the circumstances of any particular situatian as ta the intarest af this Trust and the l�eneficiary
hereunder, without the necessity of obtaining the consent or permission of any person
interasted therein, or the consent or approvai of any court, and notwittstanding that he may
atsa be acting individuatly, or as mistee of other itvsts, or as agent far other persons or
corperrations interested in the same matters, or may be intesested in connection with the same
matters as stockhoider, director, or otherwise, pravided, however, that ha shall exercise such
� pawers at ail times in a fiduciary capacity primarily in the interest of the heneficiary
hereunder.
' � 15. To in�est uvst funds in interests in auy comman uvst fund or funds
now or hereafter established and being a f���P*ed by the Trustee so2eIy far the 9zxvesiment af
trust funds.
s
C. I specifically direct that my Trustee shall not be required to segregate the
shares held in Trust in some sepazate accounts prior to the termination of any Trust created
hereunder.`9hould the Trast, in the sole opinion of my Trustee, be or become too small to
warrant continuing such fund in trust, or should its administrarion be or become impractical for
any other reason, my Trustee,.in his sole discretion, may deposit the trust monies in a savings
account in a savings institution of the Trustee's choosing, payable to the beneficiary at
majoriry.
D. If the beneficiary of this hvst is the beneficiary of any life insurance
policies, any pension plans, or other contracts, the prceeeds of such policy, plan, or contract
may be added to such trust at ttie sole discretion of my Trustee. Should my beneficiary be a
minor at the time of my death; Idirect that the,proceeds of such policy, plan, or con�act shall
be added to such hvst and administered in accordance with the terms of the Tivst as set forth
herein.
E. This Trust shall terminate, and the Trustee shall pay the accumulated and
undistributed principal and income then remaining in his hands at termination to my grandson
when my grandson has atGzined the age of twenty-five (2� years. If.my grandson dies prior to
attaining the age of twenty-five (25)yeazs, then the Trust shall terminate upon my grandson's
� death and shall be distributed in accordance with Paragraph FOURTH, as if no trust had been
created.
� SIXTH: • All interest§of any beneficiary in the income or principal of this Estate,
while undistributed and in the possession of my Executor and Trustee, even though vested and
distributable, shall nof be subject to attachment, execution or sequestration for any debt,
contract, obligation or liability of any beneficiary and, furthermore, shall not be subject to
pledge, assignment, conveyance, or anticipation.
SEVENTH: All inheritance, estate, and succession taxes (including interest and any
penalties thereon)payable by reason of my death shall be paid out of and be charged generally
against the principal of my residuary estate without reimbursement from any person.
EIGHTH: In addition to all rights and powers conferred by law, I authorize and
empower my Executor and Trustee and their successors, in their absolute discretion and
without necessity of obtaining court approval:
A. To retain any of the investments composing the principal of ihis trust in
the form in which the same shall have been delivered to the Trustee whether or not the same be
in the nature and rype legal for the investment of trust funds under the laws of the
Commonwealth of Pennsylvania, including the stcek of any corporate fiduciary acting
hereunder.
B. To invest in all forms of property (including, but not by way of
limitation, real estate, akl types of stocks and bonds, and participations in common trust funds),
without being confined to investments prescribed by statute.
C. . To buy investments at a premium oi discount.
D. To hold praperty unregistered or in the name of a nominee.
� E. To give proxies, both ministerial and discretionary.
F. To compromise ciaims.
� G. To join any merger, consolidation;reorganization, voting trust
pian, or any other concerted action of security holders and to delegate diseretionary duties with
respect thereto.
H. To lend ta, and buy from, my estate:
I. To borrow and to pledge real and personal properry as'security therefar.
7. fia sell at public or private sale for cash or eredit ar partty for each, to ,
exchange, or to lease for any perio8 of tune, any reai or personat property, arnd to give options
for sales, exchanges, or leases.
K: To allacate azry property received or charge incurr�l to principai or
income or pazkty ta each, without being obiiged to apgly che usuai rules of tivst accaunting.
L: Ta exercise any option permitted by law which tliey believe ta be
advantag�us ffam the viewpoint af averall tax rednctions, inclnding, without limitmtion of tt►e
foregaing,power and authority to claim administsatian ar other expenses oither as income t�
deductions or inheritance or estate tax deductions, withoat regard to whether they were paid
from principat ar income and without requiring adjustments between principal and income far
� any resulring effect on income or estate taxes, and a deduction of such e�t,•nses for income tax
purpases shall be given effect in compncing the respectiva shares of all persons interested in
my estate or the trusts set forth herein, aven than$h the effect is to increase the share of one
baneficiary or class af bene5ciari�herennder at the expense af another; and to iriake such
, adjustments, if any, between beneficiaries with respect thereto as they deem appropziate in
view af the nature of the transaction and the amounts invalved.
M. When pezmitted under the Internal Revenne lavrs af the United States, or
�`� of any state, tp join with my spouse in �Ling a jaint income tax retum without requiring my
.3\
spouse to indemnify my estate against liability for the tax attributable to my spous'e's income,
a�to consent to any gifts mada by my spouse during my lifetime being treate�as having been
(� made one-half by me far the purpose of federal laws relating to gift tax.
N. To distributa in cash oi in kind or partly in each. _ •--
The powers granted hereunder shall be exezcisable with respect to all real and personal
praperty, inciuding, but nat limited to, income and principai held for minozs or disabled .
beneficiaries at.any time hel'd by the Trustee and shall continue in full force, even after the
termination of any trvst hereunder, until the actual distribution of all property. All powers,
authorities and discretion granted hera shall be in adrlitian to those gramed by law and shat2 be
exercisabte without leave of court. Hawever, nat6i:ng here3n shall be interpreted or canstrued
to encouzage, authorize, empower, or permit tha T7rustee or Executor to act or cause anyone to
act in a manner cantrary to ar inconsistent with accepted standards of portfalio diversification
and risk management. _
NIAiTH: I nominate, constitute, and appoint the follawing persons:
A. My husband, GILBERT N. DERICK, as Execu#or of this,mp I,ast VJill
and'T`estament. In the evenz of�tl�e renunciation, death, resignatian, ar inability of my husband
to act for what�ver reasan in this capacity, then T nominate, constitute, and appoint my
daugptez, SHERRY LYNN SAI.LADA, as Executrix of this, my Last Will and Testament.
B. My san-in law, DONAI.D SALLADA, of�Iazrisburg, Peunsylvania as
• Trustee of the Trust described herein. In the event of the renunciation, fleath, resignation or
inability of my son-in-law to act for whatever reason in tb'rs capacity, then I nominate,
constitute, and agpoint my uephew, BARRY DERICK, of Enala, Pen�sytvania as Trustee.
� I direct that no representative named abave shall be required to post security for the
faithful performa�nce itf his dt�ties in any jurisdiction insofar as T azn able by law ta relieve
him af snch obligation. Any of my representatives shall be entitled ta reasonable compensatio�
for the performance o£the dudes set farkh here.
�
IN WITNESS OVHEREOF, I have hereunto set my hand and seal this !2� day of
S'+�j , 2001, on this, the ninth of nine fypewritten pages. I have also signed the
le8-hand margin of Ehe first eight of these pages for purposes of identification only.
�
LANCHE M. DERICK
SIGNED, PUBLISIiED, and DECLARED by the Testatrix, BLANCHE M. DERICK,
as her Last Will and Testament, in the presence of us, who at her request, in her presence, and
in the presence of each other, have hereunto subscribed our names as witnesses.
4pW�.r1G.�.,�w.r S14 A�terl✓�••J �.• .
9�'1tt 6ww►��b�+�f. '�il� I�oSS�
-�
J�b�n ,C�rt.c�o.u, o�a�c..P
At //A71C1/i��Q/Yl. �//T � /�/v
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of C�mberland
I, BLANCHE M. DERICK, Testatrix, whose name is signed to the attached
instrument, having been duly qualified according to law, do hereby acl�owledge that I signed
and executed the inshument as my Last Will and Testament; that I signbd it willingly; and that
I signed it as my free and voluntary act for the purposes therein expressed.
.
���rl'ZC/�.e_ //l • ��L/�l.t/�
ANC�IE M. DERICK
Swom or affumed to and subscribed before me by BLANCHE M. DERICK, the
Testatrix, this �_day of� , 2001.
Notary Pub1
Ndetid Sed
e�v�i �'e„o,`�'"°m"��
►�y co��ea occ 2��,20'�
�MertDer�Peir�syNaNeA�odetlondNOl�les
AFFIDAVIT
Commonwealth of Pennsylvania
County of Cumberland
We, Debra K. Wallet and �honC�[x"U, 1�t.��, , the witnesses whose names
aze sigied to the attached in.cr,,,ment, being duly qualified according to law, depose and say
that we were present and saw the Testatrix sign and execute the instrument as her Last Will
and Testament; that she executed it as her free and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the Testatrix signed the VJill as witnesses;
and that, to the best of our l�owledge, the Testatrix was at that time 18 years of age or older,
of sound mind,-aa�uader-ae sonstraint or undue influence.
�C�' .�d.c., �
b,A.un,.'k.�.�,war-
Swom or afSrmed to and subscribed to before me by'�h,r-� k, � �o,.���
and���an� , witnesses, this J�day of ..�l.�l�y , 2001.
-rn�,a� �. �a.a�
Notary Publi �—
Namde�S.N
My��M.L.oper�Pu61b
�oa.�
,�� a
_ __ _
GOMMQNWFALTH OF PFNNSriVANIA flEV-11B2 EX(11-96)
�EPARTI�AENT OF qEV@lUF
BUPEAL OF INOMOUAL TA%ES
�' DEPf.]BO801
MMfl158UR0.VA t]1280601
PENNSYLVANIA
RECEIVED FFiOM: INHERITANCE AIVD ESTATE TAX
� OFFICIAL RECEIPT NO. CD 017874
SALLADA SHERRY LYNN
2604 PAXTON CHURCH ROAD
HARRISBURG, PA 17110
ACN
ASSESSMENT AMdUNT
CONTROL
NUMBER
'..._"' �aa _y.� —
101 j 95,000.00
ESTATE INFORMATION: SsN: ie7-�e-a3at �
FILE NUMBER: 2113-OB61 (
DECEDEMT NAME: DERICK BL,ANCHE M �
DATEOFPAYMENT: 07/15/20T3 �
P05TMARK-.DATE: 07/15 J2013 �
CouNTY: CUMBERLAND' �
DATE OF DEATH: 04/18/2013 �
I
TOTAL AMOUNT PAID: S5,000.00
REMARKS: SHERRY LYNN SALLADA
CH.ECK# 1133
INITIALS: D61
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGI6TER OF WILLS
� TAXPAYER .
1 48500�41046
�J REV�aS ex�osoa�
SAFE DEPOSIT
BOXINVENTORY
PADepaMieMWRsvanue PLEASE USE OR161NAL FORM ONLY
Sodal Secuifty w Death CeNficete Number Date of D�th Counly Code Year Flle Number
--- ---- -- � --- — --- —� j ------- �—'.
i187-18-4331 � 04/18/2013 21 ! 13 � 0561 �
_ __ _ � __.____ . __ � �--' �-_--� �----�
�Decedenfs Last Name �� � � ��- � �SuHix Flrst Name � MI
. . _._.._. .. .. ._._... .. . ...--- . _._.._..
-- .... ...-, .---_-'-.._ .._._... .. _-----
DERICK _ � i � (^BIANCHE � M
� --- ----- �-----' —J
-------------______-_-___--_---
�ADDRE33 OF DECEDENT STREET. CfTY: . 3TATE ZIP CODE j
132 CAROL LANE ENOLA PA 17025
NAME AND ADORE38 OF PER30N REGUESTING THE OPENIN6 OF THE SAFE OEPOSR BOX �
NP'"�E: SHERRY LYNN SALLADA
STREETA�ORESS: CITY: STATE ZIPCODE
2604 PAXTON CHURCH ROAD HARRISBURG PA 17110 !
• NAME,ADDRESS AND RELA710NSHIP(IF ANI�TO DECEDENT,OF PERSON(S)PRESENT AT THE 80%OPENWG �
� a. NAME: RELATION8HIP: I
BENJAMINJBUTLER ATTORNEY �
srn�rnoor�ss: aTV: S7ATE: ZIPCADE �
1007 MUMMA ROAD, SUITE 101 LEMOYNE PA 17043 �
- b. NAME: � RELATION9HIP: .
SHERRY LYNN SALLADA EXECUTRIX/DAUGHTER i
STREETADDRE55: CIT^. STATE: ZIPCADE: �
2604 PAXTON CHURCH ROAD HARRISBURG PA 17110 � ,
. c. NAME: RELqT10N5HiP: �
� i
STREETADDRESS: CIT': . 3TATE ZIPCADE I
NAME ANO ADDRESS OF FINANCIAL INSTRUTION WHERE THE SAFE DEPOSR 80X IS LOCATED j
i- NAME: �
� PNC-BANK
� STftEETADDRES3: CITY: STA7E: ZIPCODE
235 N. ENOLA ROAD ENOLA PA 17025
� NAME��OF PERSON MAKIN�U�ST ENTRV plaALn L � . D e�,c k DATE AND TIME OF LABT ENTRY$ � 'L 0 )� I
U
� . DATE F ONfRACT TO RENT BOX • NUMBER OF BO% 1 7TfLE UNDER WMICX BO%18 RECUESTED (
2 I 1 q C t N 297 BLANCHE M DERICK
NAME AND ADDRE88 OF PERSON(8)HAVINO ACCESS M 80X
s. NAME 6. NAME:
; BLANCHE M DERICK I
�STREETADDRESS: � � STREEfADDRE3S: �
132 CAROL LANE �
! CRY: STATE LP CODE: CRY: STA7E: ZIP CODE: j
ENOLA PA 17025
NAME AND TRLE OP EMPLOYEE TAKIN6 TME INVENTORY h a �
WAS A WILL IN THE BOX1 � YES ❑ NO If yas, e.oats or w�n: 07/12/2001 � �
' b. Nams and eddnss ot penaul roprsssMatNe,tl romed In Ihs wlll �
NAME:
' SHERRY LYNN SALLADA
9TREEf ADDRESS: CITY: STATE: ZIP CODB �
2604 PAXTON CHURCH ROAD HARRISBURG PA 17170 I
,' e. Nkn�md sddnss of ottom�y,H any
NAME: '
BENJAMIN J. BUTLER I
� STREETADDRES3: CRY: STATE LPCODE: �
____ 1007 MUMMA ROAD, SUITE 101 ._____.___._LEMOYNE _ PA , 17043 �
� 48500041046 48500041046 J
� � �
R�-��� SAFE DEPOSIT BOX INVENTORY Page 2 or 2
INSTRUCTIONS
��� casn:aePortarei onry.
(2) Stoeks:List In defell every common w preferred certificate,wartent a other rights found In baoc.Slocks ere lo be designeted by
name of compatry,cerGflcete number,date of certlficate,name in whkh stodc is registered,and number of sherea end class M stock.
(3) Obligetlons of U.3.Govemment:Number of items,date ot issue,face valua,names In whlch registered and lype af ownership,
i.e.,jointly held,payebie on death,eta
(4) Bonds:Designete by name,amount,sarial number,or other designetlon.(Bearer Bonds)
(S) Bank and Savinga a�d Loan Passbooks:State name o(depositor,number of book,last date appesring in book,name ot bank
and branch,and balence. �
(6) Jewelry,Colna,Slamps,Manuscrlpts,ete:lisl and deseribe es tuly es possible. �
(7) Deada,Mortgagas,Current Insuranea Policles or other evldenees o(Indebtedness:Lis[and describe es fuly as possible.
(8) AII otAer wntents.
(9) Ratum eomplatad form to: DEPAit7MEN70F REVENUE �
INHERRANCE TA%DMSION �
DEPT.2B0801
HARRISBUR6,PA 17128-OBOt
RE� ffEM DESCRIP710N
NO.
N one
2 , Dh{
3 . � anL
y � �n�
tila��
� N Q �e
7 ec � -h� 132 C�arot n,�� (o�q oet.l
►�(.+L.; fi Ii�L �stu.....c� r+.l.m�^-{
a %iq
� I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PER80N RECFJVIN6 COPY OF
CORRECT ANG GOMPLETE TO THE BE8T OF MY KNOWLEDGE ANO BELIEF. SAfE DEPOSIT BOX INVENTORY:
RE SI E
NT RINT EAND qCAPP PoATEBOXBAOW:
SHERRY L N SA LADA SHERRY N S LLADA
PRINT1iRE DATE CHECI(APPROPRIA7EBO7C �
lol/.�/� 6d E..a�� O nam,�.n.wn.n�>
EXECUTRIX/DAUGHTER �E,�unw�+ ❑.wa�oMwa�.a.�wro.
NOTE:Attaeh addiUonal 8'h'x 11"sheet(s)if necessary or uea duplleates of this page of Mrtn.
The Dapeihnent ie miMwAmd by IaM 42 U.S.C.§405(e)C�I�7@,M requ6e dfedosue dSodal SacuNy numben In mrieNmwitl�eNnWetm6�g alate tax lawt The DepeiNiaM uaes tle
3odal SauAb rnrmhx ro ider�tlly Ihe de�edent end Pmmrel representatF�as M Ihe eamla.The Cmv�rxeeAh mey also uae Ihe hdametlon h exd�aige d tmc hlormetlon epreenrenh
wqh Fedard end bcd eutliMlea.The aleh la,v Iha Conenanv,eeMHe han coMdenl�l Imc informe8m far WRdel
tET Historica}Prices�MetLife,Inc. Common Stock Stock-Yahoo! ... http://finance.yahoo.com/q/hp?s=MET&a=03&b=18&c=2013&d=0...
Homa Mell News SpoRS � Flrence WBethar Caamea Grolqa Anawen Flkkr Moro
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DETACH AT PERFORATION BEFORE DEPOSITING CHECK � REMITTANCE ADVICE
P'riori�v �0 Plus Account Staternent �PNCBAIVK
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Primaryaccountnumber.57-4011-1637 , �
Page 1 of 4
For t6ar perfod 8$t13M013 to 0511At2473 Number of enc3asures:6 � � � -
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� BLANCHE M DERICK �interestroteinfatmation,signonto
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ENOLA PA 17025-18p$ 'a Porcustomerservicecail1-988-PNGBANK
Monday-Friday: 7 AM-1tl PM ET
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'riority�50 Plus Account Statement
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For tM p�rtoi 04M3/2073 to OS/14M2013
]For 24hour information,sign on to PNC Bank ONine Banking BLANCHE M OERICK - ,
3 on pnc.com. , . Primary axount numher.57+1017-7637 .,
Mcount mm�ber:51-4011-1687-con�inued � Page 2 of 4 �
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�Yposits and. K.Additions . ... ___. . . . . ,. Therewere4DepositsandOtherAddkions � �
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i/Ol .��� 00 D'u'ec[Deposit-Pn Pmts/Bg � .,
Uspbec-Bedilehem 1.286181mg/18121� �
i/06 . 7.22 Check Cazd Credit'Ihe Patriot-News Ez PA 717-2558150 PA -
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i/14 10� In[eres[Paymen[
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hack Date Refelancs Check Data Rafaranca
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494 65.00 04/16 uase7oor,9 4447 * 24.00 04/22 oa6sayss4
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tanking/Ch�al[Card Ylrehdrawab and Purchases
at. nmo�M o.scr�puon Therewas t CheckCardBankcard PIN POS
4/16 50.90 POS Purchase Giant 6268 Enola PA purohase totaling$60A0.
4/29 18.56 7418 Recurru�g Check Caz-d Comcast Of Cennal PA
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Yl/1S 11,889.92 04/22 11,567.57 05/02 11,417.91 05/14 11,425.29
M/15 11,742.14 04/29 11,554.21 05/O6 11,425.19
kl/16 11,626.24 05/Ol 11,644.21 05/07 11,425.18
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'rior�t� 50 Plus Account Statement '
B PN�BAI�IK
. For th�perbd 04/73M2013 To OSM4/2073
�For 24hour information,sign on to PNC BankOnline Banking � BLANCHE M DERICK � � � �� �
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... .. : .- . �.
on pnc.com. Primary accounc number:57-4011-7637
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� Eri�Insurance 105°`�°�Y
Exchange Mail Date: 08/09/2013
Member • Erie In�urane�Oroup
100 Erie Im.PI. • Erle,PA 16530
Final Statement of Policy Balance.
Named Insured
BLANCHE M DERICK
2604 PAXTON CHURCH RD Policyhoider Name: BLANCHE M DERICK
HARRISBURG PA 17110-9643 � Policy Number: Q071601175
� "' Policy Type: Private Passenger Auto
a��aesoa Balance Pr(or to Cancellation: $320.67
'�7685 Cancellation Credit: $453.00 CR
Final Balance: $132.33 CR
Due Date:
,�:
" Refund Check to follow wkhin 15 days
You were previously notified that the above-referenced policy would terminate or terminated effective
08/07/2013.
By this notice, we are confirming that your policy is cancelled, and any coverage provided therein will
terminate or terminated on 08/07/2013.
Additional premium payments will not resuit in the reinstatement of this policy.
Contact your Agent if you need assistance in obtaining replacement coverage.
ERIE Agent
Agent Number AA7685
STROCK INSURANCE AGENCY
401 S 32ND ST
CAMP HILL, PA 17011-5137
(717)737-5405
PCOpp7
Blanche M. Derick
DoD Values as of 4/18/2013
Vanderbitt Secunties, LLC
IRA Account#Q80-000965
Securi T e Securi tD Ciosin Quanti Hi h low Mean Total
Cash & Cash E uivalents FDAXX 1,052.95 $1.00 $1,00 $1.Q00 1,052.98
Common 8tocks/ETFs EXG A85 $9.36 $9.26 $9.310 1,722.35
Pre#erreds ANTPRD 304 $25.29 $25.13 $25.210 7,563.00
Preferreds SFIPRF 400 $24.00 $23.80 $23.900 8,560.00
Units 25537M100 1,708.48 $6.76 $6.76 $6.760 11,549.32
Units D4M 1,260.40 $5.06 $A.96 $5.045 6,406.40
$87,524.81
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Blanche M. Derick
DoD Values as of 4/18/2013
Vanderbilt Securities, LLC
TOD Account#Q81-000639
Security ID Closing Quantity High Low Closing Price Closing Market Value
DEX 341 $12.25 $12.15 $12.20 $4,160.20
DHF 1,500.00 $4.42 $4.41 $4.41 $6,615.00
DHY 1,000.00 $3.32 $3.29 $3.31 $3,310.00
EXG 500 $936 $9.26 $9.28 $4,640.00
HTY 400 $12.56 $1236 $1236 $4,944.00
HYF 3,000.00 $2.21 $2.18 $2.20 $6,600.00
IID 305 $9.89 $9.78 $9.80 $2,989.00
IRR 400 $10.40 $10.25 $10.29 $4,116.00
KCAP 700 $10.01 $9.70 $9.73 $6,811.00
AHTPRD 200 $25.29 $25.13 $25.14 $5,028.00
NRFPRA 200 $25.56 $25.39 $25.40 $5,080.00
NRFPRB 200 $24.98 $24.90 $24.94 $4,988.00
TAYCP 400 $26.15 $26.15 $26.15 $10,460.00
DOM 1,200.00 $5.05 $4.96 $4.97 $5,964.00
DX 900 $10.29 $10.15 $10.19 $9,171.00
Money Market 0 $0.00 $0.00 $0.00 $0.00
Value of Securities $84,876.20
Matgin Balance ($24,789.77)
Total Account Value $60,086.43
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' Fa[m 117, AeV iB97 Hay 21. ^<613 ,
THEi M,tJ".7' UAI; B. EN�`� I��CIAL ASS`O' CIATTON
Tcnow all Men by th�se Presents,
That I, SHERRY SALLADA 2G04 PAXTON CFI[IRCH RD �[ARItISBUR6 PA I7120 for and in consideratian of
the sum of}�NNUITY AMOUNT OF FOURTEEN TliQUSAND TWENIY FIVE DOI.LARS 82Ca1 f$I4 Q25 82j
to in hand paid by The Mutual Benefieial Association,Incorporated,a corporation of the State af Delaware,at and before the
sealing and dolivery horeof, tha receipt whereof I da herahy aetmawiedge, and for ather good causts and vaivabte
considerations, and more especiatly for any claims or demands due to me as beneficiary under She palicy oP BLANCHE
DERICK: MY MdTHER by the said Association in Class ".ANNUITY " by which as such boneficiary t am entitled ta the
sum of FUtlRTEEN THOt)SAN4 1'WENTY FIVE DOLlAftS $2� {$i4 425 $2) have remised, reteased,
quitclaimed do forever dischuge the said The Mutual Beneficial Association, Incorparated, its successors and assigns and
every one of them, and of and from alf, and all manner of action and actions, aause and causas of action and actions, suits,
dehts,sum or sums of monay,accounts, contracts,agreementc,pramises,judgmenu,olaims and demands whatsoever in taw
or eryuity or ntherwise]�exsoever whir,h against The Mutual$enefioial Association, Inearporated, I evar had, now have, or
which, I,my heirs,exeeutors, or administrators hereafter can,shall,or may hava, for upon,or by reason of any matter,caase,
ar thiag whatsaever,fram the beginaing of the world to the day afthe date nf tfiese presents.
Witness my hand and seal this o'ZS'� - day of �--�,�N �. 20�_
�{h 00.��1�,
� ignaturo of Baneficiary) ~
, ERRY SALLADA
STATB UF �Q„r.t�as�4 V,qN�R }
ss.
Cauntyof �t.spn�,ZRtftl�.t33 }
S,�}�g$y,g�,j,Ql��_._persexially appaared.bafore mo the undersigned,a dulu cammiss'soned Natary Pohlic(ac.dxsticc-ofthe
Fexr}for the above named State and County, residing in the State of Q£_tau�r �ysa,,,�q
l-.uinA fJt�„{,�,�a.� County, who, in dua form of law acknowiedged tho foregoing release to be N b�
awn act and deed to the end that the same might be recorded as such.
Wimess my hand and /a+ o �rA�+t,i A-t..- seal this�S"�'�" day o€ �l vN� A.D, •�,ta �3
(SEAL] f�=�L�Stis_�l��.R�.- �1
COMMDM1IWEALTHOfiPENp�1jf1NIA Nota bticr�.twtic�ai.Vew�
NOTARIAI.SEAL
CFiERYL 1_FERCilISZ1N.N8f0ry Pt�AC A
BO��W��Gu���h' Mycqmmissionexpires }�AR�c.. {�r�Ql�
My Commkssion Expites lyixN 6.2018