HomeMy WebLinkAbout10-01-13 (3) t 150561�105
r...�,� REV-1500�«�oz.�,>��>�
PA Department of Reve�ue O�Y��ama oFFICIAL uSE ONLY
8ureau of Ind9viduat Taxes °"�"` ""°" �n� Y� Fle N��r
Po aox zsa6ar �NHERITANCE TAX RETURN ( `
Harnsbury,PA i7u8-06oi RESIpENT DECEDENT � I ' � '' � � I � '
ENTER DECEDENT INFORMATION BELOW
� Socaai Security Number... .. .. ....... Date of Death MM6DYYYV pate of Birlh ..... MA9DDYYYY
, 03/02/2p13 01/26/1927
DecedenPs Last Neme � Suffx �ecedenCs First Name MI
� 3mith ! Julia
pf Applicable)Enter Survivinp Spouse's IeMrmation Below � . . . . . . . . . . .......
Spouse s Last Name . . ... .. . 3utfiz Spouse's First Name t�k
... .. .. .. ....._ ._ ._.. .. ...... .._.
spause's social Securiry Number THIS RETURN MUST BE FII.ED IN DUPLICATE WITN THE
� REGISTEi2 Of WI��S
FILL IN APPRQpRIATE OVALS BELOW
m 1. Original Retum p 2.Supplemental Retum O 3. Remainder Ratum{Dete pf Death
Fr.a to 92-t362}
' O d.Limited Estete p 4a.Future irrierast Compmmise{data of p 5. Fede.ai Estate Taz Retum Requiretl
death aRer12-12-82)
� 8. Decedent OieG Testate O 7, Decedent Meintained a living Tmst � 9. Total Number ot Saie Deposit Boxes
{Attactr Cppy of Will} (Atiach Copy of Trusi_}
C3 9.Liftgatbn Pmceeds ftec9lvstl p 7D.Spousai paverty Credft(Date oF Deatlr O t t. Election tp 7aac under Sec.9t13(A)
Behveen 12-31-91 and i-1-95) (Atlach Schadule
CORRESPONOENT- 7HISSECTIONMUSTBECOMPLETEU.A6lCORRESPONDENCEANDCpNFIDENTIALFA%INFOR NSNOUlOBE�IECTE�ORt
Name. . ... . .. ..... ........ ... .... ... .. .. .... ... . DayUm eNur�6gr 47.p.. . �
Jane M. Alexander, Esq• (71�)r►p�d$�i�¢ �-�-+ � 7°
_ �o r "'i �"
,Gt��mtk�'u9517R�€� �
� � 7c C� `�
First Line of Addreas � n � � � 'i
... ..._. .. .. .. ... ...,.., ........ ...._ _.._ .. C? O rC ,^,;.G �
i7 � '
148 S_Bailimore Street � ,ss �, r �,�
Second tine of Address � � � G� � �
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-���P���� . ...... ....._ .._. .....Syte ZIP Code DATE FftEo
'Dillsbur9 _ _ PA 17019 _ _
� COrresporMeM's e-mait addresa:
Un�r pnnalties of p ry,I tleUaro I have exemf ihis r9[um,including aCwmpenying&Chetlules arM stataments,8ntl to ihe ba5t M my krwwletlge arq Oellef,
It is VUe�Wr�ett OOmpla . tlOn Of plg other tl18n the petean8l IgpiBSBMatiV6 i5 be68tl on e ' eti0n of whlch prepgMr hee eny k110WI0tlge.
SlGNATUR $ RE tNG RETURN P` pq-�
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ADDR
2410 y P int , East Bedin, PA 17318 503 Woodcrest Dr., Mechanicsburg, PA 17050
SIGNA OF PREP OT t AtN DATE
AD
Baltlmare St., Dil burg, PA 17 19
PLEASE U5E ORIOtNAL FtfRM 01i1.Y
8id@ 1
L5�561�1Q5 15t}561Q1�S J
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', J 1505610205
�'��.� REW1500 EX(FI)
! DectdenPs Social Securiry Number
o�r.Ne�: Julia Smith
RecnrmrunoN
1. Reaf Estate(Schedule A). ..... ................ ... ... .. .. ... .... ...... L _. ..... . ... .... . .. . .. . .. ... .. .. . ..
2. Stocks and Bonds(Schedule B) ... . .. ... ... .. .... ... 2 . ._. . .. . .. ... . .. .. .... . .
3. Closely Held Corporetion,Partnership or SolaProprietorship(Schedule C) . ... . 3. �� �� � � ���,.
4. MoRgages and Notes ReceivaWe(Schedule D)... . .. ..... .. ........ . . q �� � � � � �.
5. Cesh,Bank Depostts and Miscellaneous Personal Property(SChedule E).. ... . 5 � � �� � 9,579.32 '�
6. JdMly Owned Property(Schedule F) O Separate Billing Requested .. ..... 6 � � � ��� ��� '
7. IntervVivos Transfers&Miscellaneous Non-Probate Properry � ������ � �� � � -� - � - �� - .....
(Schedule G) O Separete Bi1Nng Requested.... .... 7. � 63,880.13 �
8. Total Grws Assets(toWl Lines 1 through 7).... .. ......... 8. ....... ... .. .. . .... .]3,458.45 .
9. Funeral Expenses and Administrative Costs(Schedule H)......... ... .... ... g. .. 15,559.2$ .
._.... .___... .__... , ..
10. Debls of Decedent,Mortgage LiabilNies and Liens(Schedule I). .. ... ...., . 10 1,886.79 �
11. Tohl Detlucdons(toWl Lines 9 and 10).. ........... ... .... ............. 1t ., ... _.. .____ ._..17,446.07���.
12. Net Value of Estab(Line 8 minus Line 11) ...... . .. .. ... .. 12 � � 56,013.38 '�
13. Charitable and Govemmenfel Bequests/Sec 9113 Trusts for which �" �--- -��
an election to tax has not been made(Schedule J) ...... .. ..... .. . ..... .. . 13. 0.00 '�
74. Net Valua Su6Ject to Tax(Line 12 minus Line 13) . ....... . ....... .. 14. � � � �� 56,013.38 '�.
TAX CALCULATION•$EE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxabte
at the spousal tax rete,or
transfers under Sec.9116 ..... ..... .. ... . .. ..... .. _ .. ........
(a)(7.2)X A-. . .. .... . _.. . .. . ..... . .. ... ...
15
16. Amount of Line 14 taxable "...... ... .. .. ... . .. .-- .. .._... ..... .. _.. �
at lineal rate X.0 45 56,013.38 �g. 2,520.60 '
17. AmountofLinel4taxable �"���� ������� �������� ����-- -�- - ...._ .
atsiblingrete X.12 t7. ..... .-.. ......-.-. ,.��..
18. AmountotLinel4tazable .-.._.. ...__ . .._... ..._... .,..._ ..__... ....._. �
at collateral rate X.15 �, �8 '�
19. TAXDUE. ..... ... .. . .... ... .. 19. ... ._.. . ..._. _..2,520.60
. ... .... .. ... .. .. ...... ....
20. FILL IN THE OVAL IF YOU ARE RECUESTING A REFUND OF AN OVERPAYMENT
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SidB 2
1505610205 15056102D5 J
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REV•1$f70 E%(FI) Page 3 Flla Nurober
De edenFs Compiete Address:
DE OENTSNAME
Ju1ia Smfth
STR TADDRESS � � i�� � "
10 Fieldsione Road
c _� � -�— ���S�TA7E 21P���—
Ca p Hii! � FA� 17D11
Tax Payments and C�edits:
1. ax Dus(Page 2,1.i�19} (1) 2,620.60
2. reditslPayments
.Prior Paymenls �__ ,__...,�_._
piscount
----------��^ Total Crediis i A*6) (2)
3. ! terest
{3j
4. 1 Line 2 is greater dtan Line 1+Line 3,entpr the dilterence. This Is the OVERPAYMENT.
ti in rnai on Page 2,tine 20 to roquesf s refund. (4)
5. If Line i +Line�is greater than Line 2,enter the d'rfFererKe.This Is the TAX DUE (5} 2,520.64
Make check payabie io: REGiSTER OF WiLLS,AGENT.
�� ,� ��, . „i�;t5 ,�, ,m�:;;,:�t„4�Fw'e��i',,,��;l�,si�s�l�?,?�Rn�'11�1s�,�+Mtu.lt�°��.;;��sr,!'R;h�tikld�°����ist�13.1��1;�'I�dl'.�',"�Inxi��tt4d,i�"�1i�i���i�I��r ,�ir�+�a,�;��'�4's§�a����ii��l{r��t�k�",!
PI.EASE ANSWER THE FOLLOWING QUESTIONS BY PLAGING AN "X" 4N TNE APPROPRlA7E 8lOGKS
t. Did decedent make a Uao-ster end: Yes Na
a. retain the use or incoma ot the property transferred......._................._............,.._...._..........,................._......... ❑ �
G. retain the right ro designate who shall use the property trensferced or its income ............................................ ❑ �
c. retain a reversionary intarest.............................................................................................................................. ❑ �
d. receive the Promise for Iife of etlher payments,benefits or care?...................................................................... ❑ �
2. ff dealh occurted after Dec,12,1982,did decedeM hansfer property within ane year of dsath
without receiving adequate cartsideratron?.............................._....................................................................:......... ❑ �
3. Did decedent own an"in trust fat'flr aaya6le-�pon-death bank account w security a!his nr f�r daat�?............_ � ❑
4. Oid decedent own an individual retirement account,annuity or other�oo�probate property,wh�h
contains a benefieiary desigoatbn? ....................................................._._.............................................................. � ❑
IF T ANSWER TQ ANY Of THE ABOVE QUESTfONS!S YES,YOUt MUST C�IPI>�.ET3E{Sy}C�H,�E{sD�{ULyE��)G A'�pNDpgF�I}�L�gE fT AySv,��P,ryAR'T 8F TrSH;�UeE�»x(RE7,U�1RN.
t „ �1��. ,.t�e� ��,� r�.�.� dd��ti;1�a14���5�,�[�a4�14A9�i�w� v��t it ::�Yi,�,��.�uk.�U�i��t��d'+iflYi�=rif.'.t���irflC.f�3�i4H��.tYCi+tf9Ui���il�HSnlUk�t��lYN3�KnNUV�t�!"'�;fi�Vi{�if�'
for da s of death ar ar after July 1,1994,and 6efore Jan.t,1995,tl�e tax ra#e imposed an the net vaive of transfers ta or for the use of the surviving spouse
is 3 perI nt[72 P.S.§9118{a)(7,1)(i)]_
Fw da�s of death on w after Jan. t, 1995, t�e tax rate impased on the net value of iransfers to a#a ihe use of the surviving spause is 0 percent
[72 P.S.§9116{a)(1.1�(ii)].The statute does not exempt a lransfer to a surviving spouse trom tax,and the statutqry requirements 4or discbsure of assets and
fi�ing a t x retum are stilf applicable even if the surviving spouse is the only beneficiary.
Fa dat of death on a after July 1,2000:
• The tex rete imposed on the net value ot Uansfers irom a deceased ohild 21 yeare of age or younger at death to or for the use of a natural parent,an
ad " e pareM or a stepparenf of the child is 0 percent[72 P.S.§9116(a}(12}j.
. The x rate imposed an ths ne#value of transfere io or frn the use of the decedenYs Iineai beneficieries is 4.5 percent,except as noted in(72 P.S.§9116(a)(1)].
• 17re x reie imposed on the net vaiue of transters to or for the use of the decedenPs siMings is 12 percenl[72 P.S.§9116(a)(1.3)].A sibling is defined,
und r Sec6on 9td2,es an individuat who has at Ieast one psrent in mmmon with the decedent,whether by blood or adopfion.
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REV-i5o8Ex+(o8-12}
�pennsylvanie SCN�Oi�LE E
DEPARTMENT OF REVENt1E CASH, BANK DEPOSiTS 8c MISC.
�'. INHERITANCE TAN RETURN pERSONAL PROPERTY
RESIDEtiT DELEOQiT
ATE bF; FII.E NUhIBER:
J tia Smith 2113-0312
Inciude the proceeds af iitigatbn and the date tfie proceeds were received by the estate.
All properly jWndy owned wlth Aght of survivorship must be dlsclased on Schedule F.
REM VAIUE AT 4ATE
N MBER DESCRIPTiON OF DEATN
1. M&T Bank personal cFrecking aawunt no.79824994 6,802.59
z, aiifirst Bank now M&T Bank—personai checking acxount no 950266263 @aiance as of 1/26/13) 327.58
I3, M&T Bank CD#31003913919907 1,003.25
Iq, Net proceeds ftom public sale 6/27113 1,445.90
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T07AL(Also enter on Line 5, Recapitulation) 5 9,579.32
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REV-1510 Ex+ (OB-09)
pennsylvarria SCHEDULE G
'�� DEPRHTMENTOfFEVENUE INTER-VIVOS TRANSFERS AND
`""ERR""cET^"RE"'"" MISC. NON-PROBATE PROPERTY
� 0.ESIDENT DECEDEFLr
E5 ATE OF FILE NUMBER
Ju ia Smith 2113-0312
This schedule must be completed anG filed if the answer to any of questions 1 through 4 on page three of the AEVd500 is yes.
� M DESCAIPTION OF PROPERTY
NU BER ���TMEK''"EaTxem�ns�n�E,Meiaxeunoxsn�vrooeceoemnNO DA7EOFDEATH %OFDECD'S EXCLUSION TAXABLE
iHE DATE OF 1MNSFER.AIIACM A COPY Of iryE�EEO PoR AE,1L ESTATE. VALUE OF ASSET INTEREST (IF AFPLICqBIf) VALUE
Jackson National Life Insurance Company Policy No.1000959495
Beneficiaries:JayA.Smith,Mitchell Smitli,Michelle L.Kunkel 43,543.10 100 43,543.i0
JaGcson National Life Insurance Company Policy No.1000959479
Beneficiaries:Jay A.Smith,Mitchell Smith,Michelle L Kunkel 4,087.95 100 4,087.95
USG Annuity&Life Company Policy No.US 063476 �6,249.08 100 16,249.08
Beneficiaries:Michelle L.Kunkel
TOTAL(Also enter on Line 7,Recapitulation) � 63,880.13
If more space is needed,use additional sheets of paper of the same size.
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a�lvasu ex+�to•os�
pennsytvania SCNEC►Ut�E H
oeonRr�enr oF xevenue FUNERAL EXPENSES AND
iN"c�T^r�c�rnX t�rvu+ ADMIhISTRATIYE C4STS
'� RE$lDEM DECBDENT
E ATE OF FILE NUMBER
J Iia Smith 2113-0312
DecadenPS dehts must be reported on&hedule I.
IIEM
UMBER DESCRIFTtON AMOUM
n. FUNERALEXPENSES:
i' Malpeai Funerai Home-funeral expense 8,392.32
St.John l.utl�eran Church—tur�eral lur�chson 150.98
Roiling Grcen Cemetery Camp�Y—apen 9rave 1,495.p0
Rolling Green Cemetery Company—grave stone 1,782.40
ADMiNiSTRATIVE COS75:
1. perspnai Representative Commissions:
Name(s)of personal Representative(s) None Claimed �_�
Street Address T^^_____,�_,��__
Ciry �Skate..,_,,,_ZtP_�._,,._.
Year(57 Commi55itln Pald:___—..—___�._'__"__—_.'_._'____"_'____
2. � Attorney fees:
z,soa.00
3. Famity Expmption:(If decedenPs address is nat the same as ciaimant's,attacfi expianatlon.j
Qaimant NOn4'Cf21mBd
Strept AddreSS ,v,
Gry ._._.-- ----sta.e_tta_`_
Reie6anship p4 Ciaimant ta Decedent_.�,�,_
4. probate Faes: 103_60
5. Accountant Fees:
6. Tax Retum Preparer Fees: �
� Register of Wilis-short certiGcates 24.Q0
�. Register of Wi�s-fiNng lnheritance Ta�c and inventory 30.00
Narurrql Alexarider-wifness fee 25.Otl
i . Notary fees 45.50
t . Reserved for flktig release 15.00
TQTAL(Aiso ertter on line 4,Recapituiation} ; 15,559.2$
tf more space is needed,use addiEionai sheets af paper ot;he same srze.
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REN•1512 EX+ i12-OB)
' j pennsytvania SCHEDULE I
oEP^aTNENTOFaE�ENUE DEBTS OF DECEDENT,
iNHEn�T^ncE T^X a�ruR" I�IORTCiACaE lIABIlITIES&IIENS
a�s[oErn t�€c�rr
E ATE Of FIGE NUMSER
Julia Smith 2113-0312
R�wrt debts incurred by#�e decedent prior M daaM ihat rcmaFned unpaid at the datc of dea�,i�dudiny anreimbunced medini expenaes.
ITEM VALUE AT DATE
UMBER F}ESCRIPTION OF DEATH
Y Bormie K.F,�,Treasurer—2412 per capita tax 4.9d
I 2. PinnacleNe�th Hospitats—expense of last�Inass 375.d0
3. Sarah M.l�ynch,D.M.O.,P.C.-expense af last illness 12d.&6
Id. Bank of Amarica—credit card-deM of decEdeM 73.71
5. Pennsylvania American Water—debt of decedent 92.85
I &. PPl Elechic UBlities—debt of decedent $37.58
Checks hpnored after date of deatl�:
I7. Capital Blue Cross Insurance-Premium due 169.3p
I8. NephrologyASSOCiate 5.$0
9. PPL EU Electrio Service 207.00
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TOiAL(Also enter on Line 10, Recapitulatinn) $ ��8g6.79
If more space is needed,insert additipnal sheets af Me same size,
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REN-1513 EX+(01-10)
'pennsylvania SCHEDULE 3
. OEPpRTMENT OF PEVENOE BENEFICIARIES
INHERIUNCE TR%RETURN
RESIUENT OECEOENT
E ATE OF: � FlIE NUM681i:
J lia Smith 2113-0312
REtATIQNSHIP TO DECEOENT AMOUNT 4R SHARE
MBER NAME AN6 A06RE55 4F FERSQN{5}RECEIVIN6 PROPERTY 6o qot I.ist Trustte{s) QF ESTATE
I TAXABLE D[5T12i0UII0N5[Indude wtrlght spousa�distributions and trensfers under
Sec.41i6(a)(1.2).�
1. Jay A.Smith Son 50°lo a#residue
2410 Stoney Paint Road,East Bedin,PA 17916
2. h�tcheii�.S�th So� 50%of residue
. 503 Woodcrest Ddve,Mechanicsburg,PA 17050
ENTER bOLUR AMOUNTS FOR DISTIUBUTIONS SHOWN ABOVE ON UNES 15 THRpUGH 18 OF REV-1500 COVER SHEET,AS APPROPAIATE,
u NON-TAI(A81E 6ISTRIBUTIONS
A. SPOUSAL DISTRIBUTSONS UNDER SECfION 9113 i0R WHICH AN ELECTIQN TO 7AX IS NOT 7AKEN:
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B. CHARttA6LE AND GOVERNMENTAL DISTRIBUTIONS;
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TOTAL OF PAR7 II-ENTER T4TAL N4N TAXA8I.E DISTRFBUTfONS ON ISNE 13�REV-550�COVfit SHEET. �
if more space is needed,use additlonal sheets of paper of the same size.
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�'c����.1� `t�e�t�:rtxe��tf
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JlfLIA SMITH
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II,Julia Smith,of tht Tawnship of Lower Al2en,County of Cumberland and Commonweaith of
Penns�ivania,bcing of saund mind,memory and understaziding,do herewith publish and declare this to
Fe mv...zst Witl and Testamant,hereby revoking and declaring null and void any and all Wills and
Codiais her+;tofore written by me.
ITEM I. I direct that all my just debts and funeral expenses be paid as suon after my demise as
may b cunvenient to the proper administration of my eskata.
ItTEM II. I oider and direct my hereinefter-naased Execeatazs to convert my entire estate into
cash at eiiher pubfic or private sate,whenever in ttseir discretion it may be most expedient for the proptr
admini tration of my esYate. In the event af such conversion,C auth�rriu my said Executors to execute a
good sufficiern Watrairty Deed ta tha purchaser of any real estate af wkuch I may die seiud,in the
same anner and capacity as I could if 3iving.
TEbi III.I direa that ail inharitanae arid exute taxes bc paid on the proceeds of the akwve
convers on and on ali the rest residue and remainder of my estate from the residue af my estate prior to
further istribution.
1TEM IV.I then give,devise,and bequeech atl the rest,residue,and remainder of my esiate
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enaludi the pruceads of the above-mentioned conversion zn equsl shares to my two(2}sons,Jsy A.
Smith d Mitchtii L.Smith,per stirpes snd not per capita,
� S fiave not given eny of my estate to my daughter,Mickelle L.Sprucebank as I was
�+er?mni}, tn i�ar rinrinn mv lifnfimo
I EM V, i nominate,constitute and sppoint my two{2}sons,Jay A.Smith and Mitcheil L.
Smith,a the sur�ivor of tl�ent,as Execu!c�rs of this my Last W':t!and Ttstament. ?direc?that m,v
Exuu2o shalk not be required Yo past bond other than their personal assurance for iheir dutias as
Executor .
I W7TNES5'WHEREQF,I,Jutis Smith,have herevnto subscribed my hand to ihis my Last
Will and�astament,this�Y,Aday af r r�,r M,��p`i,��,/ 2004.
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', Ji a S_m�th
ISIGNED,PUBLISHED and DECLARED by the above-named Ju6a Smith,aa and for her Last
Will d Tzstamen[in the presence of us,who at her request and in her presence and in the presence of
each o er,have signed our names as attesting wimesses hereto.
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ACCUUNT N�Q ACCOUNT 7YPE STATEMENT �PERIOD �� PqiSEV==�
� ,.
�_ 7982v°4t F4#T SttECT MZTH ZHTEREST� MAR.O1-MAR.28�2013 1 OF 1
00 0 06113N NM 017
OOi7U('2P�OE FiD�'�';a9D01i(!328130302000000 �Z�y�
�� JU�IA 5MITN
[0°_i GIELDSTONE RD
;AP1P HILL PA 17011-8441
INTERfiST IEARNED f'OR STATEMEHT PERIOD p.03 N2GNLAND PARK
INTEREST PAIp YE0.R "'0 DATE 0.14
,_ ACCflUFlT SUMMARY
G lMING - DEPQS TS & ' � ..:' ... H . �� q .
BALANCB :OTHER ADCIITI �. �NELKS P ID :�.�. $U ?RAC7I RESiI' E �.
R MQ. pMqR(f Np. AlIOUFIT NO. AXOI1tYT
5,b36.34 2 1,2§4. 0 5.80 4 6,869.06 9.6q 6.g6
ACCOUNT ACTIVITY
- ; s
€, .�.-OATE . _�._._,.TRAXSAG'T QK6E�� �� PTZd1 ���: ���: { GT R�lt�T'f ���At'T 6Al,:.�.
�' 03-01-13 BEBZNqIN6 B�ILANCE �5�630.34
� 03-tl1-'13 SSA TREAS ':t6 }ptSOt SEC 1,220.90
03-01-��:3 °AkC AAV;1E�'t 47.75 6�802.59
gj 03-05-13 CAF"ITAIBLUEI:ROSS IN5. PREN 164.30 6.633.29
� 03-06-LL3 CHECK NUM9E1! 4364 5.80 6�fr27.49
u 03-14-53 JACKSUt! aUTI:OMAL ZNS PYXT 24.50 6,6b1.49
03-21-13 PPL EU E�EC SVC 2p7.00 6�444.99
0E-22-�3 INTEREST PAI'MENT 0.04
'� 4E-22-53 cIOSEGUT b�445.03 9.96
g ENDINC BALANCE �O.Otl
� �. ' � . . . CtlECKS PA26 StMMARY � .. . . . . . . .
4364 03-06-1i 5.s0
AMKIAL PERLENTABE YIELD EARNED = O.pO %
LET NDRE OF YWR PERSOIMLITY SHON DY ENNANCINB YOIIR MR7 CNECK CAitD NITN TNE
PIC7U�RE OR DE$I6N OF MpIM CNpICE. VI5IT MTl.COM/CUSTOIICARD TO VIEM OUR 6ALLERY,
EXPlq1tF OUR 2NTERACTIVE OEMOMltTRATION 700Lr ANp 6Ef 5lARTED.
t�E QF 7F� {Y,iSTON CAIlD OESZp1 SERVZCE IS 41AJEGT TO PA06RAI1 TEICfS i CqW2T26M5�
2HRGH 6tJIDEL2NES AID A i7.95 IMA6E SET-UP PEE FOR EACN Y�iN.Y A�►pOYED tUSTOM
[ARD LIESI6N. FOR CAROS NAVINC TNE SAME MlllER� MIE FEE NLLL BE CNAR6ED P'ER
APPRUVED Ct137QM DESIGII, RE6AMMI.ESS OF TNE INNlER OF CARDS ISSUED. REPLACEMEM
CANDS MStt !p7 SNCUR TNZS FEE If TNE CU570M DESICM RENAZNS VNCi1MlCED,
itw�a�r�
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fr m ihe auct'ron of my gcods and property sold an the above da#e. I acc t aIl rey�t�sibilify�for providing
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(Selfsr`s Signa#waj
_ _ _ .
� S�°. '220'3 8: 57AM �ACKSON NATIO�vAI � �N0. 811 � '�P. 2
JAC., ��� � N
�, NAT[ONAL LIFE IN'SUAANCE COMPANX
sepcemtxr 11, 2013 Yaur r�c�r�ve:
7ANE M AL@L4NDF'�R T1bfOTHX C HIC3GINS
148 SOUTH BAT.'I�ORE ST 680 HARVES'r DR
P 0 BO%421 FIARRISBL7RG,PA 17111-56'76
p]IJ.SBCJItG PA 17019 � �,� �x
Paliay Numbs►�s): 100085'9478
10008�4�5
Insu�od Manw: Julte�mith
Dear Jane M Alcxaader:
ple�se extend our concbl�c�W the f�mily of 7ulia Smith. 'We are available�or eny questSons yon maY
hava
Listed beiow mre the value aa of Mazch 1.2013 for the above murtio�ed polacies:
1000959479 -54,087.95 & 1,000959495 - $43,543.10
Your�vice necds are vexy impottent to us.Tf you have additional questions or concarns,please
contact aa 5ervice Cmter et(886) 565-4995,Monday thmugh�'hursday, 5:00 a.m.to 7:00 p.m. aad
Priday 8:00 a.m.ta 6:00 p.m. (6'f).Xou may also coatsct Jackson vis wpail tluough „Contact LTs" on
ouc webeite 8t wavwjackeon.com.
Sincmrdy,
`/��� � �
Toui Klus,
A.VP,(laime Adtninis�ation
cc: TIlvipTHY C HIC3(�IN'S
t•�se�c.�
i c�o�.w�.v,r.��[as�sz
7'0ll�w Nnm6er: �5
Email et(�omaGresJ�m:Oa�Wedelbe Is www ja�ieso�e.00m
C J/CLBWF
4 aE iR �� Mp� �lltl E11Q
_ _ _
�NG �
May 2, 2013
JANE ALEXANDER
148 S BALTIMORE ST
DILLSBURG PA 17019
ING USA Annuity and Life Insurance Company
Decedent:Julia Smith
Contract Number: 063476
Claim Code: 03010
Dear Mrs. Alexander,
Thank you for your recent inquiry regarding the annuity contract listed above. Please fmd
the contract information below.
IJeath Benefit Value $16,249.08 as of3/2/2013
If you have questions regarding this information,please contact our Customer Contact
CenEer, auailable Monday—Thursday, 8:30 a.m. to 630 pm., Eastern Time, and Friday,
8:30 a.m. to 5:30 p.m., Eastem Time. Ca11800-369-5303 and press 3 to identify yourself
as a beneficiazy. When prompted, enter the five digit Claim Code above and press #.
Your call will be addressed by a claims specialist.
Sincerely,
Customer Service
ING
Annuities iasuedby ING L7SAAnnuiy wd Lifelnsuronce Co�my
/0016m
ll�alpezzi Funeral Home
$Mar�ket PSaza Way (719}647-4696
Mec icsbu ,PA t 7055 www.Mal zziFuneralHome.com
Jerem J.Shartzeq FD Michael J.Malpezzi,pwneq FD Kyle C.Knipe,FU
�arch 18,2d13
itcheil L. Smith
03 Woodcrest Drive
echanicsburg, PA 1'7050
his is the final statement for the funeral services of Julia A Smith
e sincerely appreciate the confidence yau have placed in us and wi!!continue to assisi you in every wsy.
PROFESSC4NAL SERVICES:
Services of Funera!Director/Staff $5,475.00
FUtYERAL ROME SERYICE CHACtGES SS,A75.tki
9E[,ECTED MERCHANDISE:
Stee!CaskeY $2,675.00
Rase RagistorPackagc $145.06
THE CCIST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE
THAT YOU HAVE SELECTED 58,295.Op
CASH ADVANCES:
At the time funeral arrangemenrs were made, we advaneed certain payments ta others as an accomodation.
The fo!lowing is an accounting of thosa charges.
Certified Death Certificates $6U.00
Newspaper Notices-Pakriot $24'7.42
Clergy $150.00
f3rganist $125.00
Ctergy $75.00
Flowers $439.90
TOTAL CASH AIiVANCES AtY[}SPECIAL CFIARGES $1,491.32
SUB-TdTAL $9,39232
INITIAL PAYMENT I DISCOUNT 1 CREDITS �4.00
TOTAL AMOUNT DUE 8Y Apri13,2013 59,392.32
�
Ifyou have any questians or cancerns regazding this bili, please call our o�ce st(717�697-469b.
I
__ . _ _ _ _ _ ..
St. �ohn's �utheran Church
' 44 West Main Street
' SHIREMANSTOWN, PENNSYLVANIA 17011-6326
Office Phone: (717) 761-5121 • Fax: (717) 761-4110
E-mail: churchC�Pstjohns1787.org
Web Site: www.stjohns1787.org
(Church:5-7 South Ebery Avenue,Shiremanstown, Pennsylvania)
SENIOR PASTOR ASSOCIATE PASTOR
The Rev.Michael L.SeHrled The Hev.Serah M.Keithdtz
Phone(71�763-9090 . Phone(717)5026374
March 15, 2013
To whom it may concern:
Mitchetl L. Smith reimbursed St. John's Lutheran Church $150.96 for the funeral luncheon of
Julia Smith.
+�� c � �l
Beth C Bard
Administrative Assistant
Member Congregetion•E.L.C.A.
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