HomeMy WebLinkAbout08-16-13 . �
� 15�56b0143
REV-'1500 EX{�L-s,} ���.
��'� OFFICIAL USE dNLY
PA Depertment af Revenue pennsylvania co�n�y caaa vaer File Number
BureauoflndividualTaxes 0°•�^*�"Tn"""R���
PosoX.zeflso� ENHERi3'ANGETAXRETURN 21 1g p529
Harrisburg,PA 17tP5-o66t RESIDEhST DEGEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number pate of Death Date of 6irth
04 24 2013 Q3 09 1922
DecedenPs Last Name Su�x DecedenPs First Name MI
SHAFE'ER G7,EIat7 �'
pf Applicable)Enter Surviving Spouse's Information Below
SpousO's Lest Name Suffix Spouse's First Name Mt
Spouse's Social Security Number
THIS RETURN MUST BE FILEO IN DUPLlCA7E WlTN THE
ftEG1STER OF Wti.LS
FILL IN APPftOPRIA7E OVALS BELOW
I� 1. Original Return � 2. Supplementa!Retum � 3. Remaintler Retum(oate oP peath
Priorto 12-13-82)
i� 4. timfted Estaie � 4a.�umre�n�ere.�comprom�se b, pederai EsWia Taz Retum Required
(Gateo/deathetter1252-82) ❑
�*� g becedentDiedTeafate � 7 D�ecetl80t�Yi�nt�jnet�}>Livingiru4l �_ 1 8, TofalNUmberofSafeDepostt6oxes
� (AltaehCopyof4V�1!) 1 lachc: f
� 9. LitlgationProceedsReceivetl � iO�bPtwean12�3i�1anail#Da�e��(Dealh � »,ElediontotexuntlerSBC.9113(A)
- (Atlach Schedule O)
GORRESPONDENT-TNIS SECTlON b1UST BE Ct)fdPIETED.AtL CORRESPOMUENCE AND GONFtDENTiA1 TAX INfORMATION SHOULD 8E DIRECTED TO:
Name Daytime Tec�iephane Numb„er
WM D BCHRACK III ESQ 717 43?� 973�; �, ��
� � ��
REGIS'�t$F!YQfIIS`kT$E BWLY��
2> r— C.a
r— m.�t r.,.� ��., `.'
�� ,r-�
First Line qf Address — U, .�;'. '. ' - ��� =a
12 4 W HARE2I SBURG ST `3 " Y'' _ c:` f'
;' ` ' ,.�
Second Line of Address �� ������� � ���'
„ l._� [?
'7 _i r�' �.._f
„t" O cs) C?
City or Post Office DA7E FIL�D "+i
3tate ZIP Code
DILLSSURG PA 27Q191268
Correspontlent'se•mailaddre8�: SCfll'8Ck18W�COTCOl3t.�Ct
Untler penaiGes of perjury,i deGare ihat t trave exsmined ihis reNrn,inciudi accampsnqir�g acheduias a�tl ste�+�ts,a�M the best af my knowlttlge and betiet,
I it is aue,corceci ar�tl canpiete.dedaratiorr ot preparer Wtrer zhan the persan�rep'8sentative ia based ar�aH iniartnafian oiwhich preparer has any knovneGge-
SICNA RE OF PERSOM PONS LE FpR Fl�ING RETURN DATE
, aaaR 5�,/��j�jq'^'`���- Donald L. Free � ��� .(�
3107 Meadow Lane, Harrisqurs�, PA 17109
SIGNATURE OF AREft OTHER THAN REPRESENTATIVE DATE
�/�!'��y,/f Wm.D.Schrack 11I Esq. �/ tt?+/�
AD�RE$
724 W. Harrisbur�St., Dillaburg, PA 17019-1268
Side 1
�„! 1505610143 150561[17�43 J ��`—�-j
f
I
� 1505610243
REV-1500 EX
DecedenYs Social Security Number
°°�^•^�'•Nd^a: Shaffer, Glenn F.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closety Held Corporetion,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages 8 Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 20 9, B 99. 84
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requeated............ 6.
7. Inter-Vivos Transfers&Miscellaneous�oq Probate Property
(Schedule G) U Separete BIIIing Requested............ 7. 145, 668 . 94
8. Tofal Gross Asaeb(total Lines 1 through 7)........................................................ 8. 355� 568 . 78
9. Funeral Expanses and Administrative Coats(Sehedule H).................................... 9. 33, 087 . 63
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 80 . 38
11. Total Deductiona(total Lines 9 and 10)................................................................ 11. 33, 168 . O 1
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 322 , 400 . 77
13. Charitable end Govemmantal Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schadule J)............................................... 13.
14. Net Value Subjectto Tax(Line 12 minus Line 13)............................................... �q, 322 ,400 . 77
TAX COMPUTATION-SEE INSTRUCTION3 FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
trensfers under Sec.9116
(a)(1.2)X.00 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 � . �0 16. 0 . �0
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
atwi�atera�retex.75 322 � 400 . 77 1B. 48 � 360 . 12
19. TAXDUE................................................................................................................ 19. 48,360 . 12
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 1505610243 150561U243 �
REV-1500 EX Page 3 Flle Number 27-13-0529
DecedenYs Complete Addresa:
DECEDENTSNAME
Shafter, Glenn F.
STREETADDRESS
Manor Care
940 Watnut Bottom Road
CITY STATE ZIp
Carlisle PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 48,360.12
2. Credtts/Payments
A. Prior Payments 45,000.00
B. Diswunt 2,368.42
Total Credits(A +B) (2) 47,368.42
3. Interest (3)
q, If Line 2 is greater than Line 1 +�ine 3,anter the difference. This is tha OVERPAYMENT. (q)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greatar than Line 2,enter the diHerence. This is the TAX DUE. (5) 997.70
Make Check Payable to: REGISTER OF WIL_LS,AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retein the use or income of the property transferced:............................................................................... ❑x
b. retain the right to deaignate who shall use the proparty trensferred or its income:.................................. x
c. retain a reversionary interest;or............................................................................................................... x
d. receiva the promise for life of eRher payments,benefits or care7............................................................
2. If death occurced efter Dec. 12, 1982, did dacedent transfer property within one year of death without
receiving adequate eonsWareHon?.................................................................................................................... ❑ �
3. Did decedent own an`in trust fo�' or payable upon death bank account or security at his or her death?....... ❑ Q
4. DW decedant own an Individuei retirement account,annuity,or other non-probete property which
contains a beneficiary designation�.................................................................................................................. ❑: ❑
IF THE ANSWER TO ANY OF THE ABOVE CUESTIONSIS YE3,YOU AAU3T COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 7, 1994 and before Jen. 1, 1995,the tax rete imposed on the net value of trensiers to or for tha use of the surviving
spouse is 3 peraent[72 P.S.§9116(a)(1.1)(i)1.
For dates of death on or after January 1, 1995,the tau rate imposad on the net value of transfors to or for the use of the surviving apouse is 0 percent
[72 P.S.§9116(a)(7.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of
assets and filing a tax retum are still epplicable even if the surviving spouse fs the only beneficiary.
For dates M death on or after July 1,2000:
• The tax rate imposed on the net value of trensfers 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 teu rete imposed on the net value of hansfers to or for the use of the decedenPS Iineai beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)1.
. The tax rate impoaed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent p2 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.
II
Rrv-06q!E%�(77.10)
acHeou« E
pennsylvania CASH, BANK DEP03tTS, � MlSC.
�EPARTMEM OF REVENIIE
INNERITANGETA%RE7URN PERSONAL PROPERTY
RESIDENTPECEDENT
ESTATE OF FILE NUMBER
Shaffer,Glenn F. 21-13-0529
AII p��J no�a�y'aowoww�m m.nonl a:�'m r.n°f0 p mu`.f w ai`°C°sa"~we�o�:ohw ro v.
ITEM VALUE AT DATE
NUM@ER QESCRIPTION pF pEp,TH
1 Jamea Stamer-tast peyment recelved 1,Oq0.OD
2 Securi4y8enef{t-annuftypayment 312.55
3 Citlzens Bank-C.D.#$740880543 70,OQ0.89
4 ClNzer�a BanK-Checking Accourrt�i6140&78102 18,107.36
5 Citlzens Bank-Checking Accaunt#6219436710 82,122,74
6 Citlzens Bank-Checking Accaurn#6224442421 7,564.37
7 Cttizens Sank-Savings Aacount#62496S568T 516.12
6 Members ist FCU-Investment Savings Account#Zp1452-05 72,919.04
9 tYtdmbers iat FCU-regular sav9ngs account#241d52-04 10.350.08
10 Membera 1sst FCU-VISA Aecount#46720800002q017Q(contractual pledge of shares) OAO
11 Harieysville Inaurance-refund 169.19
12 NCR IM�rn>r Care-refund af unu�ed payment 2,643.75
13 Seniar Health Insurance Co.of PA 7�6•54
i1d Citizena Bank-Checking AccouM�ISidO$98225 3.9&1.21
TBTAL(Also enter an t�ne 5.Recapitulallon} 249,899.$4
Qt more spanm la needed,atlditlonal papes of t�e eame siza)
Copyright(c)201p form soflware only 7he Lackner Group,Ina Fortn PA-1400 Seheduk E(Rev. 11-10)
nav.ie�o ex.�oeau�
SCHEDULE 6
pennsyivanla lNTER-VIVOS TRANSFERS AND
DEPAHTMENT OF REi/BNUE
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIOENC OECEDEM
ESTATE OF FILE NUMBER
Shaffer,Gisn» F. 21-13-0529
ti�ia schodule musf bp wmpbtetl qM(IeC a the qnawer io eny of que6tions t iMaiyh A on pepp Urcae Mthe REV•75W ia yee.
ITEM DESCEpRIePTION dF�,qPROPERTY DATE OF DEATH x oF oECO�s �c�uswN TAXABLE
NUMBER j}{E DATE�7R4NSF�ERSAtTACN A CO�4FT7��ED Fqrt ReE.e°t E�TAiE. VAIUE QF ASSET wTEREST t�F,y.,p�,�g�� YRLUE
1 Jackson Nationai Life Inaurance Company AnnuHy 16,641.94 16,641.94
Policy#Oq8p27764A
2 Seourriy 6enefit ttfe Insunnce Campany Mnuity 129A2T.00 129A2T.00
Cpntract#p0309212
TOTA�tAlsa er�r an Llne T,Recapitu(atlon} 145,666.9d
Qf more space fa neetletl,addi6onal papes W the aamB size)
Capyright(c)2009 form soflwere only Tha Lackner Group,Inc. Fortn PA•1800 Schedula G(Rev.q&09)
REV-06H IX+�tO-0p)
pennsylvania SCHEDULE H
°EP^RT"�r�TO�R�wu� FtlNERAL EXPENSES AND
RESIDENTDECEOENTT�RN ADMINISTRATIVE COSTS
ESTATE OP FtI.E NUMBER
ShafEar,Gienn F. 21-13-0525
DecedenYs debts must be reported on Sohedule I.
tTEM DESCRiPTION AMpUNT
p, FUNERAL EXPENSEB:
See continuakion schedule(s)attached 11,830.55
B, pDMIN13TRATIVE CdBTS:
t. Personai Representative's Commissions
Nama of Personal Representative(s)
Donald L. Free
Street Atldrese 3107 Mead4w Lane
Oiry HBrcisburg state PA zio 17709
Year(s)Commissian Paid 1�����
2. Attor�v's Pees Wm. D.Sohraek 111 Esq. 7,500.�
3. Famiry Exemptlon: (If decedenPs address is not the same as daimanPs,attach explanatibn}
Claimant
Street Address
Ciry 3tata Zin
Ralstior�sh�of Claimarrt ro Dacedent
4. Probate Fees 413.60
5. AccountanYs Fees
- 8. Tex Retum Preparers Rees
7. Other Adminisbstive Costs 3,343.58
See conYinuation schedule(s)attached
T07AL{Aiso orrte�an IEne 8,Rscapi#uiation) 33,08T.63
Copyright(c)2009 fortn soflware only The Lackner Group,Inc. Fortn PA-1600 Schetlule H(Rev. 10-09J I
�CHEDULE N
FllNERAL EXPENSE3 AND AQMINESTRAT(VE COST5
continued
ESTATE OF FILE NUMBER
Shaffer Glenn F. 21-13-0529
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex�nses
1 Baughman Memarial Works-grave marker 460.40
2 Cockiln Funerai Hame 1t,430.55
H-A 7 7,880.55
Ofher AdministraNve Cas�
3 Clerk of Orphans'Court-Release flling fee 3.00
d Cumberiand I.aw Joumal-estate advertisement 7SA0
5 dfits6arg8anner-estateadvertlsemeat t12.84
6 Miscellaneaus expenses incurred during pe�iod bf adminiatration(faxes,copies,posfage, 38.00
etc.}
7 PA State Empioyees Credit Unian-reimbaisement overpayment 1$4.23
8 pennsyivanla Yltal RecoMa-abtafn Death Ger�flcate far Saruh Eilen Shaffer 37.00
9 Recorder of Deeds-recording fee 52.00
10 Register af WiNs-addftlanaF Short CertMieates 15.00
17 Register of Wilis-lnherttance Tax Ratum flling fee 18.00
12 Reaerve far future administra8ve expenses 2,500.00
13 Security Benefit-relmbnrsement of overpayment 312.fi5
Copydght(c)2UO2 fortn sof(waie only 7ha Lackner Group,Ina Fortn PA�1800 5chedule H(Rev.8-98}
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Shaffer,Glenn F. 21-13-0529
ITEM
NUMBER DESCRIPTION AMOUNT
H-67 3,343.58
Copyright(c)2002 form software only The Ladcner Group,Inc. Form PA-1600 Schedule H(Rev.6-98)
Rev-1572 EXi�7t-0B)
SCNEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPAR7MEM OFREVENUE
INXERRANCETA%RE7URN MORTGAGE LIABILITIES AND LIENS
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
Shaffer, Gienn F. 27-73-0529
Raporl A�bb In<urtM by Ms tlse�dx�t PNa�d�tlh Mi+l nmelnaE unp�id N M�tl�b M M�M.Ineludlnp unnl�unMm�Eletl sxpemr.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Heardand Phartnacy of PA, LLC 80.38
TOTAL(Also enter on Line 10, Recapituladon) 80.38
pf more space la nee0e4 aCtlitlonal papes W tlie same aize)
Copyright(c)2008 fortn soRware only Tha Lackner Group, Inc. Fortn PA-1500 Schedule I(Rev. 12-08)
- . _
REV-0677 E%�(01-00)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RE7URN BENEFICIARIES
ftESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shaffer, Gienn F. 21-13-0528
RELATIONSHIP TO
NAME AND ADDRESS OF SHARE OF ESTATE MOUNT OF ESTATE
NUMBER pERSON(Sl RECEIVING PROPERTY DECEDENT �a�8� �$a$�
I TAXABLE DISTRIBUTIONS [inGude outright spousal
distnbuUons,and trensfers
under Sec.9716 a 1.2
Alexandre Dellinger Friend
157 Vine 3treet
Camp Hill, PA 17011
Donald and Patsy Free Friend
3107 Meadow Lane
Hamisburg, PA 17109
Sharon Messimer Frlend
500 N. BoIWn Ave-Apt 114
New Oxfard, PA 17350
ToWI
Enter dollar amounb for distributlons shown above on Ilnes 15 throu h 18 on Rev 1500 cover sheet as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR VNiICH AN ELECTION TO TAX IS NOT TAKEN
8.CHARITABIE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE
Copyright(c)2010 fortn soflware only The Lackner Group,Inc. Fortn PA-7500 Schedule J(Rev.01-10)
(. i
���� ��� �� �������� '
OF
GLENN F» SHAFFER
�
BE TT'REMEMBERED,that I„GI.ENN F.SHAFFER,of l 1?West Siddoasburg Road, �
Dillsburg, York Countp,Pennsylvania,being of saund mind, memory and understanding, do make,
pubTish and declare this as and for my Last Will and Testarnent,hereby revoking and making nutt and �
vaid any and all Wills and Testaments and writings in the nature thereofby me at any time heretafore
made.
IT M 1: I direct that my hereinatter namecl Executar pay ai2 my just debts, my funeral
expenses, and the ex}�nses of the administration of my estate. Witt�this direction, I authorize and `4
ernpower my Executor to expend for my fiaaeral e�cpenses and 'uxterment such amaants as it may ;
consider necessary and proper,withant regard ta any limit thxt may be prescribed by a court of law. '
In making sueh arrangements, my Executor sha11 utiliae the services of Cocklins Funeral Home in
Dilisburg, with which institutian I have campteted arrangements.
ITEM 2: I direct my Execu#or ta pay all inheritance,estate, succession, and legacy t�vices of �
whatsoever nature and kind, to which my estate, or the transfer of any propeRy passing hereunder I
or otherwise passin�by reason af my demise, may be subject, and to charge such taxes against my
residuary estate,it being my 1nCention that none of the aforesaid taxes,either federal or state, on any
praperty required ta be inaluded in my gross estate, under the pravisions of any state or federal Iaw !
now in force or hereafter enacted, shati be prorated among the persons interested in my estate to
whom such property is<>r may be transfened or to whom a�ry benefit accrues. ;
I'�E11�3: Alt the rest, residue and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be reet, persanai or mixed, includiag property over which I have a
power of appointment, I direct be divided into three equal shares to be distributed by my Executor
as follows:
1����
A. One share unto my friends, �D and SBABON MESSIMER, of 27 West
Siddansburg Raad,Diltsbnrg, Pennsylvania 17dI9, ar the sunrivor a£them;
B. One share unto my friends,DONALD anc!PATSY FREE,of 310?Meadow Land,
Hamsburg,Pennsylvania 17109, or the surv'tvor of them; and
C. One share unto my friend, ALEXANDRA DELLINGER, of 157 Vine Street,
Shiremanstown, Pennsylvania l701 l.
ITENi 4: In the event that any of ihe legatees identified herein should predecease me,I direct
that his or her particutac bequest lapse, and that the total residuar,� estate be divided between the
remaining designated beneficiaries.
ITEM 5: I nominate, canstituta and appoint mq friend, DONALD L. FREE,to serve as
Executor of this my Lasi Wilt and Testxment. In the event that I}ONAT.D L. FREE, should
preflecease me, fail to c�ualify, cease to act, or renounce probate, I appoint PATSY FREE, as
alternate Executrix Qf this my Last Will and Testament.
ITEM 6: I direct that my hereinbefore named Executor shall not be required to giva bond
far the faithful perfarmance of his duties in this or any jurisdiction.
IN WITNESS WHE1tEOF, 1 have hereunto set my hand and seal this "7`� day of
_..�1' � � . 204I.
� G���HAFF.+: �
���_����
The preceding`snstrument,cansisting ofthis and one{i)other typewritten pages,was an the
day and date thereof signed,sealed,published,and declared by the Tastator herein narned, as and for
his Last Wifl and Testament, in the presence of us, who, at his request, in his presence and in the
resan ,of ea•h o r have subscribed our name, witnesses hereto. ��
,
� —
-�� °�--��`�1���
�
� _��6��-1 0�������_;_
a
� — _
COMMOIVWEALTH OF PENNSYLVANIA .
COUNT'Y OT YORK .
� j���1�-a�-.��
We, GLENN SHAI+'FER, ��» v"V and
�--"' r-�Z„L �f- `-' "`G/�7�E�J ihe Testatar and the wimesses,respectively,whose names are
signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the
undersigned auihority that the Testatar signed and executed the instrument as his Las# Will and
Testament, and that he signed willingly, and that he executed it as Yris free and voluntary act for the
purposes therein expressed,and that each ofthe witnesses,in the presence and hearing ofthe Testator
signed the Will as w'rtnesses, and that to the best of their knowledge, the Testator was at #he time
eighteen{18}years of age ar otder, af sou� mind, and under na constraint or undue influence.
GLE���
��--��
� ���
SWC?RN TO AND SUBSCRTBED
BE�'ORE ME T�TIS �� I}AY
OF x ���� ,2401.
�
iLL� � '
OTA Y B C
Notarial Seal �
Janet S.gdn�e,Nohary public �
�Y�ommissl ga%vork�c�iY
art Fxperes 4et.2�,pppz
Membcy,N@nnsyNanl,�p.sstx,ictipnntNOtatles
�
� 48500�41046
REV-4&5 EX(OS-D4)
SAFE DEPC?S1T
BOXiNVENTQRY
PA Depatlment oi Revanue PLEA$E USE ORIi31NAl FORM ONLY
Sodai Security or S}eait�CeNficate Number Date of Deaih Cauniy Code Year File Number
189-18-7452 04/24l2013 21 13 0529
DecedenPS Last Name Suffix First Name Mt
Shaffer Glenn F
�ADORESS QF DECEOENT STREET: � � � CITV: STATE: ZIP CODE:
94Q Walnut Bottom f2oad Carlisie PA 17013
NAIdE ANO ADQRESS OF PERSON RE4UESTIN4 TNE OPENING OF THE 3AFE DEP4SiT 80X
� NAME: D0113ICI L. FYB2
_.—.,._—__.__ ____.. .' ____ __ _
S7REE7 ApDRESS: CITV: STATE: 21P CODE:
3107 Meadaw �ane Nanisbur PA 17109
� NAME,ADORESS ANO RELATIQNSHIP(IF ANY)TO OECEDENT,OF PER$6H(Sj PRESENT AT THE 80X OPENING
a. NAME: RELATIpNSHIP:
Donald L. Free Executor
STftEET ADDRESS: CITY: STATE; ZIP G06E:
3107 Meadow�ane Harrisburg PA 17019
b. NAME'. RELATIpN3HlP:
Wm. D. Schrack, III Attom�
—---- — _ _
STftEc'T ADDRESS: CITY: STATE: XIP C06E: �
124 W. Harrisburg Street __ _ Dillsburq PA 17019
c. NAME � REIATIONSHIP:
STREETADORESS� C�Tl': STATE: ZIPCODE:
NAME ANb AODRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BO%IS LOCATED
NAME:
Citizens Bank
----__ _-----__..--____ _ �--
STREETApORESS: pTV: STATE: ZIPCODE:
4 S. Baltimore Street Dillsbur PA 17p19
. FFAME QP PfRS4N MAKING LAST EN7RY 0t�TE AND TlME 4�LAST ENTRY �
� + SCa/�C¢G� _ !vt<L �'(^:,,¢2Ce�� `�+ 3ot o�o(.j
; DATE OF CONTRACT TO RENT BOX NUMBER OF BOX 1 TIT E UNDER NICH BpX IS REQUES7ED
� ao .c� za5 , �
NAbiE AND ADDRESS OF PERSON(3}HAVINCi ACCESS T6 BOX
a. NAME� b. NAME: �
Glenn F. Shaffer __�. �_
STftEETADDRESS: STREETAODRESS:
117 W. Siddonsburg Road
CITY' � STATE: 21P CODE; CITY: STATE: ZIP CODE:
Dillsbur PA 17019
NAME ANb TRLE OF EMPIOYEE TAKtNG THE INVENTORY
WAS A WILL IN THE BOX? ❑ YES ❑ NO If yes, a. Date of wilt:
6. Name and addrees ot parsonai represaotatWe,if rtamad{n the wil! �
NAME:
Removed during Wili Seatah
STREET ADDRESS: CITY: STATE: 21P CODE:
� . a Name and addresa of attamey,it any r
NAME:
, —_..__--._.�__ ___..�_ _. .— _.
STREET A4DRESS: CtTY: S7ATE: 2IP C6DE:
: . .. . .. .. . ... ... . .... . ...... . . . . . . . . . . . .
� 4850�041046 485p0041046 J
REV-485EX SAFE DEPOSIT BOX INVENTORY Page of
INSTRUCTIONS
(1) Cash:Report total only.
(2) Stocks: List in detail every common or preferred certiflcate,warrant or other rights found in box.Stocks are to 6e designatetl by
name of company,certifcate number,date of certificate,name in which stock is registered,and number of shares and class o(stock.
(3) Obllgatlons of U.S.Government: Number of items,date of issue,tace value,names in which registered and type of ownership,
i.e.,jointly held,payable on death,etc.
(4) Bonds: Designate by name,amount,serial number,or other designatioa(Bearer Bonds)
(5) Bank and Savings and Loan Passbooks:State name of depositor,number of book,las[data appeanng in book,name of bank
and branch,antl balance.
(6) Jewelry,Coins,Stamps, Manuscripts,etc:List and describe as fully as possible. .
(7� Deeds, Mortgages,Current Insuronce Poilcles or other evidences of indebtedness: List and describe as fuliy as possible.
(8) All other contents.
(9) Ratum Gompleted fofm t0: DEPARTMENT OF REVENUE
INNERITANCE TA%DIVISION
�EPT.280601
HARRISBURG,PA 17128-0601
ITEM ITEM DESCRIPTION
NO.
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I CERTIFV UNDER PENALTV OF PERJURV TXAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF
CORRECT AND COM LETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. S E DEPOSIT BOX INVENTORY:
SIGNATURE SIG TURE
PRINT NAM �/ �
� �� � PRINT AM AND CHECK APPR P IA E BOX BELOW:
1 S
PRINTTI � DATE CHECKAPPROPRIPTEBO%:
,` ��/�/ 7 Execwor(mx) �qaministra�oqmx)
� � v��/.���J �l `/� �ESlata RapresantaWe �Joinl ownB�ol safa EBposi!Ooa
NOTE:Attach additional 8'l:"x 11"sheet(s) if necessary or use duplicates of this page of form.
7he Department is authorize0 by law,42 U.S.C.§405(c�(2�(C)(i),W require disdosure of Saial Securiry numbers in connection with aEminislenng state taz laws.The DeparMent uses the
Social Secunry number W identify ihe tlecedent and personal represenUtives of the estate.The CanmonwealN may also use Ihe information in exfhange of tax informauon agreemenls
vrith Fetleral and tocal tanin auMorities.The state law rohibiLS the Commonwealth's nnel from disclosim m�fidentlal tax intormatlon ezce t fa offidal u ses.
Account Number 6140890543
Account Title Glenn F. Shaffer, Sarah E. Shaffer Decd
Date O ened 10l12/1987
Account T e Time De osits
Princi al Balance as of DOD $10,000.00
Interest from Last Post�ng to DOD $ ,g9
Account Balance as of DOD $10,000.89
YTD Interest to DOD $g,29
*Already held jointly when it converted from Mellon Bank in 2002
\J
Ae�orn2t Number 610067b102
Account Title Glenn F. Shaffer
Date dpened 2!1 I/1971
Accaunt T e Checking
Princi al Balance as oCDOD $18,107.31
Interest from J,ast Postin to DOD $ .OS
Acco�int Ba(ance as ofDOD � $1$,10736
YTI7 Tnterest to DOD $1.47
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Account Number 6219436710
Account Titie Glenn F. Shaffer
Date O ened 3/25/2008
Account T e Checkin
Princi al Balance as of DOD $82,121.17
Interest from I..ast Postin to DOD $1.57
Account Balance as of DOD $82,122.74
YTD Interest to DOD $26.75
V
Account Number 6224442421
AccoLmt Title Glenn F. Shaffer
Date Opened 4/14/2009
Account T e Checkin
Princi al Balance as of DOD $7,560.34
Interest from Last P�stin to DOD $ .03
Account Balance as of DOD $7,56037
YTD [nterest to DOD $ .49
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Account Number 6249055687
Account Title Glenn F. Shaffer
Date O ened 1/8/2007
Account T e Savin s
Princi a] Balance as of DOD $516.12
Interest from Last Postin to DOD $ .00
Account Balance as of DOD $516.12
YTD Interest to DOD $ .03
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MEMBERS 1"
FEIIHRALCREDR UMON
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 201452-00
Date Account Established 02/01/2001
Principal Balance at Date of Death $10,349.10
Accrued Interest to Date of Death 3�98
Total Principal and Accrued Interest $10,350.08
Name of Joint Owner None
INVESTMENT SAVINGS ACCOUNT:
Account Number/Suffix 201452-05
Date Account Established 08/15/2002 �
Principal Balance at Date of Death $72,907.55
Accrued Interest to Date of Death $11.49
Total Principal and Accrued Interest $72,919.04
Name of Joint Owner None
VISA ACCOUNT:
Account Number/Suffiz 4672090000200170"
Date Account Established O6/09/2004
Principal Balance at Date of Death $.00
Name of Joint Owner Cardholder None
•Contractual Pledge of Shares.
M M RS tsT FEDERAL CREDIT ON
�� �. ���
Danielle A. Kline
Lending insurance Support Specialist
May 16,2013
EsWte of:GLENN F.SHAFFER
Date of Death:04/24/2013
Social Security Number:169-18•7452
5000 Louise Drive • P.O.Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wwwmemberslst.org
Account Nwnber 6140890225
Accoimt Title Glenn F. Shaffer
Date O ened 1 lll7/1989
Account T e Time De osits (IRA)
Principal Balance as of DOD $3,980.18
Interest from Last Posting to DOD $1.03
Account Balance as of DOD $3,981.21
YTD Llterest to DOD $15.66
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�AC K S � N'M
NAT[ONAL LIFE [NSUAAIVCE COMPANY
Claims A&ninistration .
Proceeds Payable to: Estate of Glenn F Shaffer
Policy Number: 008021764A
Claim Number: 201305230000202
Policv Information.
Policy Benefit: $16,652.85
Loan Payoff: - $0.00
Premium Due: $0.00
BeneGciarv Information:
Benefit Paid: $16,652.85
Interest Paid: $0.00
Misc Interest Paid: $0.00
Premium Refund: $0.00
Foreign Withholding: $0.00
Federal Withholding: $8.35
State Withholding: $2.56
Distribution Amount: $16,641.94
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,, Jackson National Life Insurance Company
l Corporate Way, Lansing, MI 48951
800/644-4565
. . . -. . � .
'. SECURITY BENEFIT UFE INS. CO. uMe 6nNK,N.A. 0008032270 i
� One SW Securiry Benefit Pl1ce 36oi Mitchell
; Topeka;KS 66636-0001 St,doseph,M0.64507
.. � . . , 36-190JI1012 - � ,. �
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: � . - � . . ' � �
Date June 14,'2Q13 Pay Am6uM_"5129,027.46`•` �
I Pay ""ONE HUNDRED TWENTY-NINE THOUSAND TWENTY-SEVEN�AND�46/100�US DOLLAFS"" � � � �
I
To The Not valid after 180 Days' ;
Order Of ESTATE OF GLENN F SHAFFER j
' 124 W HARRISBURG ST '
� DILLSBURG PA 17019 ' I
T,,�,�_,c�,�.� .�.G�. !
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�---------. _ .-`--- --- ---..__—_._-_� �esea,�nrv.n,resin�wealoeww:onemc�------------------ ---..;,..
�r00080 3 2 2?Ou� �: LO i 2 L90 L 7�: x� 50080�0646M
,�i V
_. � SECURITY BENEFIT"
��� life Insurence Company
Check Date: June 14 2013 Cheek Num: 0008032270 LH
CONTRACT NO 00309212 � � �
REFEAENCE NO. '
OWNER GLENN F SHAFFER '
ANNUITANT GLENN F SFiAFFER - '
� PAYEE ESTATE OF GLENN F SHAFPER ,
t
OEATH HENEFIT - DEATH ' �
PROCESS DATE 06/13/2013 ' �
CHECK AMOUNT $ 129,027.46
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