HomeMy WebLinkAbout10-15-13 (2) 4
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REV-1500 EX�°'.,o, � `
o cu+�uae w+�r
PA DepartmeM af Revenue De^!�Y���'� ' nty CWa Year fBe Number
6ureau ot indw�duat 7axes INMERITANCE TAX RETURN
aa aax zsoso3 t !3 D fs''?C�
HaMStw PA x szB�o6oi RESIpEFiT DEGEDENT
ENTER D�GEDENT IHFORMA71qN BELOW
$ociai SgCUtitY Numbbr dat8 of Desth MMODVYYY Oate Of$irth ? MMDDYYYY
Q7/2712d13 07/18t1$21 '
j
Daeedent's Last Name __ . Suttix peoedenYs Ffrst� me . MI.
YO}iN MARY F2
(N AppAcabk)Entx SurvWin9 Spousa's Intormetion Balow
Spouse's Last Name Suffix Spouse's First N� e tii�
( 5pouse�n soaa�securiry Numter 7HIS RETURN MUST BE FILEp IN D pUCATE WITH THE
RE��srE� a� ���s
FII.L IN APPROPRIATE OVALS 6ELOW
(� 7,pdginal Retum Ci 2.Supplemental ReWrn p 3. Remainder Retum(date of desth �
pAOrto 12-13-82) .
p 4.limfted Estate p 4a.Future lnterest ComPranise(tlate ot O 5. Federa!Estate Tez Retum Requhed
aeath aftar 12-12-92)
� 8,pecedent DkM Testete C! 7.DeC4Went Maintaine0 a Living 7rust B. 7a4e1 Number nC Safe Deposk Boxes
{ApaGt Copy ot Wii4} {Attadt Copy M Trustj
O 9.L(tigeGOn ProcaeCS Recatv9d C,1 76.S{roueei Pmrerty Credft(date of deeth Q tt. Eiection N taat urxier Sec.91�3(A}
Datwaen 1231.91 arn11-7-95) (AttBCA Seh.O)
CORRESPOHDENT- THIS BECTION MUST BE COMPLETED.ALI.CORRESPONDENCE AND CONflDENTlq4 TAX 1 ,ORMATION SHOULp BE D4RECTEU T0:
Neme Y�me T�phw+e Numb s�� � Ri
'THOMAS E. FLOWER ( 1�}2�-�13 <-"-; � °
� _ N '�
�R6f#��LISFU$E � i"
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7a G,; .,: � ..
First lina af stldress %= ���' _n -n "�
. .. . ..... . , . . . _i � ,.
fLOWER tAW, �lC °
. . . . . . . t."f F- ' � ?
SecorM�ioe of atldrees � ` }— �
10 W. HIGH ST � / 1 �
C#y or Ppst O(firA State 2Ip Code DATE FIIED
CARUSLE PA 17013 !
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corra.paM+.,,t's e�m.0�a..:r FEOwER-t.�►w.caM
1lnder peneMms d perJury,l daclere Uwf I heae axeml�ed thia reWm,Im�Audkig a�ryinp schedules anQ elete 'nta.aM b the beat of my knowledge arM Celief,
tt ie Uue,alrtec[md eunlpete.DeqareAbn M pepPrer Wher�hen t118 peraunal reprewntatNe fe baead o�ell IM � Uon of whbh preperar hea eny knpvktlge.
SIC;FFW F RE F ,yIU�r�N+C�RETURN t7 TE
!'!V G-. '�
Ess
RUN A. Y N(SR.), EXECUTQR,6 HICKORY LAND, MECMANICSBU , PA 17055
of a rf+n.r�r�vaeseurnrn+E an
i.�" i3
ADDR
FLOWR U1W, LLC; 10 W. HIGH ST., CARUSLE,PA 17013
r�►a�oaE a�a+s�Na�Fo�a oxcr
Side 1
� 150561�101 � 15q561�101 �
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1 ],5�561Q1i]5 I
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Rer-���c o�enrg s«�a�se«,rmr r�,mt�er
oeaadsnrs Nama: MARY ROMAYNE YOHN
REGAPRUTA'SiON
t. Real Esfate(Schedule A}. .. .. . . . ... . . .. .. . .. .. . .. . ... ... . . .. . .. . ..... i. , I 200,$87.OQ
2. Stocks and Bonds(Sd�edula 8) ........... ...... .................... 2 !.
3. Closely HeW Coryoratlon,Partnershtp or Sde-Proprietorship(Schedule C) ., ... 3. � �
4. Mortgages and Notes Rsceivabie(Schedule D}.... . ...... .. ........... 4. ... ......_ .. : ..._ .:
5. Cssh,Bank peposNs and Miscallaneous Personai Properry(Schedule E).. . ,... 5, � $��3��71 ��
I . . . . .. . . . .
8. doirtly Owned PrvpeKy{5chedule F} O Separete BIIGng Requasted . ....., fi. � .
7. inter-Vivos Trens#azs 8 Misceiie�eous Non-Pr�ate Property
(Schedule Gy O Separake Biiltng Requested.. ... . .. 7. � 86,771.93�
9. TocN Grossnesssa{cotat 1.lnea t mraugh 7)............................ . b. 361,063.14'
0
9. Funerai Euper�es end Admintatradva Costs(Schedule H).. ... . . ... . .. ... .. . 9. � i 49,478.71 '
10. pebts W Deceden4 Mortgage L1aWIiGe6,and Lier�s(Schedule I).............. 10. � 3i 0.18
G
ti. ToMi Deductfone(fotai lines s and 1a).. . . .. .. ... ......... ...... . ...... tt. . ..i .. .. . . .. ..... .. . . 48,7$8.87.
12. Net Yalw M Eshte(Urre 8 minus Une 11).............................. 12. ' ; 312,264.27 �'.
13. ChatHa6ie e�uf Ciovemmerrtei BeQuestsiSec 9113 Tn�ts fw whk;h ... i ..... . ... ..._. .. ...
iu
an eleclion W tax has not been made(Scheduie J1 . .. ...... ... . ....... t3 , . ..i . .. ,. ,. ... . ..... .. 8.0�...
ta. N�t vuw SubJret m Taz(�ine�2 minus�i�13) ................. ....... ta. � 312,264.27
TAX CALCULATI6M-SEE IN$TRUC7iON8 FOR AFPLICABIE RATES
15. AmouM of Une 14 taxable
atthe spouse�tax rate,or
Vansfers�sWer Sec.8t18 . . . . . . . . �.
(a}(12)X.6_ 15.. yi
16. Amount of Line 14 texable
at Onea�rate X.0 4� _ 312,26427 �e. i 14�051.89 '
17. Amount ot Lirre 14 taxatde . . ' . . . .. .. ..
at sbik�g rate X.12 17. '
18. Amount of Une 74 l�able � t � �
et collateral rste X.15 � 18. i
. . . . . . . . .. i . . . . _ .... . .... .... .... ....
18. TAX UUE..... ... ....... ............................. 14�d51.89
......... .... 18. � .
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24. Fli.i fti THE C/VAi#F Ytitf ARE REQUE8TIN6 A ftEFUNO C7F AN OVERPAXMENT � O
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� 15056101�5 � 1505610105 �
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REV-t5W EX PepB 3 Flle NUm4et�. 2� ' I� '"' O V f O
Decedsnt's Comptate Address:
MARY ROMAYNE YOHN i _
_S`4REET ADORE55 .. . . .. . . .... . . ... . . ... . . .. ..
216 RIDGE HI�L ROAD :
St�VER SPRlNG TOWNSHIP
�MECHANICSBURG sTArEP 2�17050
Tax Payments and Credits:
t. Tax Due(Page 2,Line 19) (5� 14,051.$9
2. CreditalPayments 13,400.00
A.Ptior Pa}�nents —...— .
B.Discn�nt _ _ $84,99 Tot2t Credlts( e} (2} 13,$$*4.19
3. Interest ,
(3)
( A. H Ihre 2's greatar than l�1+L�se 3.�er#t�ditfe�bnce. This is the OVERPAYtAENT.
FIIi in oval on Psgs Z,Line 20 W roquest a reiund, (4)
5. 1t Line t+(,ing 3 is�eeter then lioe 2,entar the dilference.This i5 the?AX DUE. (5) _
Make check payable to: REGISTER OF WIL�S, GENT.
'�,W3°r I4+}�"�t�!�dii il 3i�.� �!�; r�^� � , �' . . . ,.._
yn; I
PLEASE ANSWER THE POtLOWING QUESTIONS BY PLAGING AN "X" 1 HE APPROPRIATE BLOCKS
i. Did decadent make a transfer and: Yes No
a. retain tla use or irunms of the ProPerty transfened:........................................................................................ � 0
b. retein the+ight ro designate who sheA use the qraPeAY t�snsferred a its income:.................. ....................... ❑ �
G. �g���;�..............._.._._........................................._.. ......................_ ...................... a o
d. recerve the prortrise Mr Iffe of eiiher peymer�s,i�enefrts w care?........................................... :....................... � 0
2. If deaM a�.urred after Oec.12,1982,dkl decedent 7grsfer property within one year ot deglh
wiShoutrecaivingadequeitecansideration?..............................._.........._..._...................._........,...,__................... ❑ �
3. D"d decedeM own en'in Uust fa"w paYab�e•uponK3eath ba�c account or seCUrity st his a he th?.............. ❑ �
4. Did dec�deM own an individual retirament account,annufij or other non-probate properry,whi
containa a beneficiary designation? ......................_..................................................................._......._................. � �
iF THE ANSWER T8 ANY OF THE ABOVE QUESTIONS IS YE5,YOU MUST CdMPi,fTE SCHED G AND FlLE IT A8 PART OF THE RETURN.
��u�t�jt�a°��i��l��i�!."v8�1I'`s.',i:,� .i:; �r. ';�" � i-' , v .. . . . ti <r�'r,;(, !��..�.;�I
For d�s of d�h on a aftaz duVy i�1�94,8M)17Cf0�E.1&ti.1, 19�,�1hB 12%t2f81t11pOSCd{Nt ihC tiCf V816t8 RSf9fS 20 6P#W�1B 41SB 4{Ul8 SUtVi41tf9$FfOtlS81S
3 perceM(/2 P.S.§9tt6{aj{i.t}{i}j.
For dates of dealh on or after Jan. 1, 1995, the tex rale imposed on lhe net value of transfers to o fiw the use of the surviving sp�wse is p percent
{72 P.S.§9f18(a){1.1}{ii}].7he statute does rmt exempt a transfer to a surviving spouse from tax,and th 'staWtory requirements for disclasure of asseGS and
f��a ta�e re�n are st�I appNcaMe even if the survPviru�spou�is ihe only beneficiary.
Fa dates of deafh on or after Juty t,2000:
. The tae rate imposed on the net value ot Vansfers from a deceased child 21 years of age or young ,at death to or fa �he use of a naturel parent an
adoptAra�ent a a ot tt�cn�is o p�er�[72 P.s.§sil6(a�(�.z}�.
. Tlre tax ra0e i pn the net valus of fransfers to or for the use of the decedent's linea berrefioiaries is 4.6 percsni, except as rwted in
72 P.S.§9118(1.2 [I2 P.S.§9116(a)(1)J.
• The t�r�e�ed an tt�e�v�e of tr�.afers to ar fa tl�e use of fhe decedem's siibilings ls 92 pe t(72 P.S.§9716{a){1.3)].A sibdng is de�ir�ed,ur�r
Secdon 9102,as an��ival wtro tr�s at Ieest one parent m comman wiNt the decedeni.whether by or adoptian.
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aev�rsoz ex+�ii•oe)
pennsytvania SCHEDUI.E A `
tl6PAPTMENT OF qEVENVE REAL ESTATE
INNERRFNCE TA%RETURN
AESlQENT DECkUENi
ES7'd'fE OF FILE HUNBER
MARY ROMAYNE YQHN � 21-13-0870
AII rpi prsparty owneA eokiy or u a tanaM in comma�muet be reported a!tair marieet value.fair ma �value is defineA as t�e price at which property
wouM 6e excft0aged tretween a wilH�buyer anE a wiVling selt�rteithher bang canpeped ta buy or sNI,6oth hav � reasa�ai�e knmvkdge of the rekwant facks.
Rat propatty MN ts jpintly-ownad wkh rtpht p�survtvonhip muK be diccia on Schedula f.
Attach a copy of the settlement sheM if the property has been sdd, ,
R� Include a capy W the deed showing decedeM's lirterest if awned as Yenant tn com VALUE AT DA7E ��
NUFtBER DESCRIPTION OF DEATH
1 DWELI.ING HOUSE AND l0T 216 RIpGE HILL ROAD,SILVER SPRING TOW :HIP
CUMBERLAND CY,TAX PARCEL N0.3&18•1344-012,ASSESSED 3207,100 L.R.4.97 200,887.d4
TOTAI{Also enter an Line i ecapituiatiort.} $ 204,$87.OQ
If mpre space is neetled,insert adtlitional sheets of the same 5i .
�rc� perty Mapper
i ,i.;�.�, ;�L� ii; i ututt�. P!1
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4
v Parcel Search � �' �r�'
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1=ear �,.�re� s,:�lect:.,c' 1
F��
2 :16 RIDGE: HI�.L ROAD�
_ i�Ii�J : 3�i- 1t>- i ���,� {} 1 �
DeeC�ib�?c�k: 1?Ol �L�-0� ,`al3
�3U°� �����er: `!Ot-�N . vLEN l.! t?� Mt�,f�1�' �?
Lan�:f tJsz� CodE; . 1 ()i
Pro��erty� Ty��e : F':
- i�t�rt��gi= : (.l .�i�
5r� 1��'IrE' FE�t?r : l `i(:)!:;
_ � �T�lX;� �?it�� ��c�tt15 : ':
,
'"`r� �'�:�,'E'_i31'1 i�; ��"!:�f?(1 �}�.iji.US '
Lani� AssE'�sec1 V�; IuE° � : 5�i1i1;;
Bui+��inc2 AsS���. ��� �i�iuz� � : '• <�f�!)() "i
' Tot<� I AssESSed V',.tilue �; : ?0 ? 1 )(;
�V� Sa1�.� Pi�ice �;>
S�� I�� D,�te �
�� Year Btailt: 195-1
('�luaticiE�ality� : SIl_l,'E�; SPP'Nt; �"��Ju
Hei:� ht iri �,I.or�f�s
Tjrp� o# '�wk211in;� : [)ET��C:H
P�in��� ry ExCericr: 3ric.k
Ba���1W>.m�er�t f'erce�r��tace� : �� OC
A�r Cont�iticrlir��� ; ��C:�
Tot�il Ror.�)n`tS ; (�i
B�c, ��oc�ms � 3
Fui' i3at}�� : 1
Ha!` Bati3 � �l
AEY•1$OB EX+(33^SO) �
pQf1115��V�111�8 /r�� �rH�QV� �
DEGppI'MENTOF NEVBNUE �,Y./1`lH� BANK DEPOSITS 8�MISC.
[NNERTI'ANGETA%RENRN pERSONAL PROPERTY
AE5t0EFff OEtE0E0ft
E5TATE OF: ��'����'
MARY ROMAYNE Y4HN i 21-13-0670
Fndude the praceeds of iitigakion and khe deke the proceeds were rece+ved the estace.
AIi P*aPehY�Of'rtiy owned wftfi ripM of wrotvorshlp muek he ffselaed ' Scbeduie P.
�M VALUE AT DATE
NUMBER DESCRIPTION OF pEATH
�. {28}$75 p�NOMINATIdN SERIES EE US SAVING5 BONDS(SEE ATTAGHED LiS7i } 5,14$.12
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y, M&T BANK CHECKING ACCT.Np.9854072692 47,645.18
g. WEIIS FARGQ 8 CQ.CERTIFICATES 4F DEPOSIT 4Q,040.St
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TOTAL(Alsa e�ter on Line 5 Recapitu{ation} $ �3,394,21
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AGGWINT tq:�.. �,_ ACCiN!!IT TYPE ? 5TA! . ENT PERIOD; '�' PA6E
9854072692 MiT SEIECT NITH INTEREST JUL.3A AU6.16�2013 1 OF 1
00 0 04319M N!1 017
000006156 FIDS1549D01708161308 0.5 000000 42263
ROMAYNE 5 YOHN
� 216 RIDGE HILL RD
MECHANICSBURG PA 17050
INTEREST EARNEO FOR STATEMENT PERIOD 0.34 NI6H $ REET-CARLISLE
INTEREST PAID YEAR TO DATE 3.11 . . . �
ACCOUNT SUMMARY
< - ':
ir<11tuWCE I �
ND. A11011pT N0. A110U11T N0. � .
49�3l9.27 .0 � .• 0. •.34 3�090.34 �
ACCOUNT ACTIVITY
; ,< '.. :. .
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� �7-16-13 lECIN11211C lALANCE , i49,3N.27
�7-1l-1 DEfOSIT 250.00 . 49i639.27
17-22�13 tNEqC IiN�IER 1136 � 15.45 49�623.l2 �
� �7-23-13 CIIEdC NIIIrER 1137 1��12.25 47�911.b7
� 87-26-1 CIIEq( IMlER 1136 2i6.39 47�645.10
'• 06-02-13 SSA TNEAS 330 7(RSOC SEC � 545.00 48.198.16
� N-�6-1 REVERSE DI�CT DEMSIi 5Y5.�0 47,645.18
` M-14-13 In l�r.eh Trr�sf�r/MSMdrvw�l 44.645.16 3,000.08
00-16-13 INTEREST PAYIIENT •.34 3,000.34
E
� �� ���E •a,000.�
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1136 07-22-13 15.45 1137 07-23-13 1,712.25 1130 - l7-26-13 266.39
. AIMIAL PE�CENTACE YIELD EANMED � 0.00 % !,
SAVE !IC ON OACK TO SCNOOL LA32C3 MNEN YW USE YOUR MiT DElI� CA�D OR MiT VIS11
CREDIT CA�D AT MNJLAR RETAILE�S IN STO�ES� ON TIIE IIEt AIO OV� TNE NIOIIE. FOR
FULL OETAIIS A10 TO START SAVINC� VISIT MTt.tON/SNOP�LIC.
FO11 CUSTOIIER SERVICE alIESTIONS� �LEASE CALL 1-600-724-2440. �
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PMA accou�t 1512049972 i 1u1y 1, 67 3-July 37,2613� Page i of b
� ����� Welfs Fargo� PMA Package
Questionx7 P ' se[antact us:
W�sFugo i�rBankingTsim�^
Availaale24h rsaday,7dsysaweek
Phone: 1 742-4932, TlY: 1-806600-4833
.. 5panish: 1-8 ��-727-2932
Chinese: 1 2�-2288
Online:well rgo.com
Wrife:Wells rgo Bank,NA.
t7056461 AV 6.388 17{SOfi P.6.BOx 6 �.
rdi���I����q�I�nPqr�piupryi����qh�d����nllli�61� Portland,oR b��2a-c�s
� MARY ROMAYME YOHN �'��
MARCIP{A YOtiN SR POA .JUIY$�r �1�
218 RtDGE HiLI.RD
MECMANICSBUC2G PA 17050-1748 Total arw t $40,001J6 $
last mon $4p,000.91 �
Change in $6.85 c
'Change in ': 0.00% _
Tatal(iabi i ies: 50,40 �
Last mont $O.Q6 Z
Change in $0.00 z
� Change in t 0.0096 Z
z
Qualifying iance: 340,00�.76 Z
Deposit Ba �ce: 540,001.78 Z
z
tonants p� z
z
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 8
PMA•Premi �..hecld�g Account. . . . . . . . . . . . . . . .3 $
� 5avlrn3s and �iremant Savings. . . . . . . . . . . . ... . & �
Certificateso posit. . . . . . . . . . . . . . . . . . . . . . .5 �
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Calculated Value of Your Paper Savings Bond(s) I Page 1 of 1
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Calculated Value of Your Paper Savings Bon��(s)
Calculator Resuits for Redemption Date 09/2013
Total Price Totai Value Total Interest YTD Interest
975.00 5 748.12 4 773.12 0.00
Bonds: 1-26 of 26
Issue Next Final Issue Interest
Serial # Series Denom pate Accrual Maturity Price Inte st Rate Vaiue Note
K34985554EE EE $75 12/1982 I12/2012 $37.50 $1 .74' ;210.24 MA
K34981950EE EE $75 11/1982 11/2012 $37.50 $1 .74' �210.24 MA
K28997107EE EE $75 10/1982 10/2012 $37.50 $1 .85 ;220.35 MA
K28993192EE EE $75 10/1982 __ 10/2012 $37.50 $i _ .85 ;220.35 MA
K28989270EE EE $75 09/1982 09/2012 $37.50 $1 .85 i220.35 MA
K28985628EE EE $75 08/1982 08/2012 $37.50 $1 .S5 ;220.35 MA
K28981952EE EE $75 07/1982 07/2012 $37.50 $1 .85I 5220.35' MA
K23028004EE EE $75 06/1982I 06/2012 $37.50 $1 .85' ;220.35I MA
K23023981EE EE $75 05/1982 OS/2012 $37.50 $1 .85 #220.35 MA
K23019951EE EE $75 04/1982 04/2012 $37.50 $1 .85 5220.35 MA
K23014745EE' EE $75-03/1982' 03/2012 $37.50 $1 .85 #22035 MA
K21402905EE EE $75 02/1982 02/2012 $37.50 $1 .85 ;220.35 MA
K21398758EE EE $75 0]/1982 O1/2012 $37.50 $1 .85' ;220.35 MA
K19891112EE EE $75 O1/1981 O1/2011 $37.50 $1 .66' ;230.16 MA
K19895877EE EE $75 02/1981 _ 02/2011 $37.50 $1 .66' ;230.16 MA
K19900907EE EE $75 03/1981' ' 03/2011 $37.50 $1 .66 ;230.16 MA
K20721939EE EE $75 04/1981 04/2011 $37.50 $1 .66 ;230.16 MA
K20726838EE EE $75 OS/1981 OS/2011, $37.50 $1 .85 5220.35 MA
K20731405EE EE $75 06/1981 06/2011 $37.50 $1 .85 ;220.35 MA
K20735904EE EE $75 07/1981 07/2011 $37.50 $1 .85 ;220.35 MA
K20740678EE EE $75 OS/1981 08/2011 $37.50 $1 .85I ;220.35 MA
K20745444EE EE $75 09/1981 09/2011 $37.50 $1 .85 ;220.35 MA
K21381787EE EE $75 10/1981 10/2011 $37.50 $1 .85 �220.35 MA
K21385995EE EE $75 10/1981 10/2011 $37.50 $1 .85 �220.35 MA
K21390103EE EE $75 11/1981 11/2011 $37.50 $1 .85 5220.35 MA
K21394471EE EE $75 12/1981 12/2011 $37.50 $1 .85! ;220.35 MA
Totals for 26 Bonds I 975.00 4 7 .12' S 748.12'
NoYes I
NI Not Issued
NE Not eligible for payment
P5 Includes 3 month interest penalty
MA Matured and not earnin interest
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http://www.treasurydirect.gov/BGSBCPrice . � 9/16/2013
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REVd.510 EX+(08-09)
�������;� SCHEDU�E G
OEOFPTMFNi OF NEVENUE INTER-VIVOS TRANSFERS AND �
rN�wrnrxe rnx aeruw+ MISC. NON—PR06ATE PROPERTY '
RfS[OENTOECEDENi ,
Esrar�oF ��e nu�efR
MARY ROMAYNE YOHN 21-13•0870
fiis uheduk must be compieted and flled af the answer W any of questions i through 4 an pag �hrec af the REV-350�is yes.
�M 4ESCRIPRON OP PROPER'fY DATE OF pEA � %OF pKD'S EXClUSiON TNfA9lE
NUM9ER �ha�.��mn�nmo��wa%ua��m�.� VALUEOFASS �' INTEREST �v VALUE
1. TRAN$pp�RICA GARITAL BUltDER ANNUITY CONTRACT i
#02TC9009471,PAYABLE 1/2 to SON,MARtIN A.YOHN,and 112 to
DAUGHTER,CAROLYN L.ULRICH gg,771, aqp 66,771.93
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TQSAi(Also enter on Line 7, apitufatipn) # 86,771.93
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T,� . _ T� � � �T��� AdministrativeO/f'ite:
V 0 I\I 0 I\/1 H � 4333 Edgewood Road NE
1\�11�I S�1r1L
� LIF� INSURANCE COMPANY � CedazRapida,IA52499
�rt����ransamericaann�ides.com
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September 25, 2013
CAROLYN L ULRICH
402 COCKLIN ST
MECHANICSBURG PA 17055
REs ]►aauity Numper(s) 02TC8009471 i
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Dear Claimant:
We have received notification of the death of Ro yne S Yohn. We
extend our sincere condolences to you for your 1 s . The information ,
in this letter is being provided to assist you i '' submitting death
claim paperwork. Our records reflect the follow g information
regarding this annuity:
Annuitant: Romayne S Yohn
Owner: Romayne S Yohn �
Claimant: Carolyn L Ulrich 50� i
Annuity value: $66, 771 .93 as of 07-27-20
Annuity type: Non-Qualified
Tax 2aformatioa
This letter includes general tax information tha ' should not be relied
upon for personal tax planning. Transamerica Li � Insurance Company
does not give legal, tax, or accounting advice. ou may want to
consult your attorney, tax advisor, or accountan jwith questions
regarding the direct tax consequences when selec �ng an option.
Oeaeral Iafosmatioa i
Please be advised automatic operations such as S 'stematic Payouts and
Automatic Payments have been stopped.
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� �I'R.��N5A,��IERICA ; ��"�;S"°""°��":
-0333&lgowovd Road NE
�i LIPB INSURANCE COMPANY j CedaFRaP'd9.IA$Za94
( y^•^�rr�nsameri�aarLnLities,com
September 25, 2013
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MARLIN A YOHN
6 HICKORY LN
MECFiAAITCSBURG PA 17055
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A8: J►nauity �hsmber{s} 0�3'C8009471 i
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Dear Claimant: �
We have received notificaCion af the death of Ro yne S Yahn. We
extend our sincere condalences to yau for your 1 ' s . The information
in this letter is being provided ta assist you i subrnitting death
elaim paperwork. Our recarcls reflect tha follow g informatian
regarding this annuity:
Annuitant: Romayne S Yphn �
4wner: Romayne S Yohn �
Claimant: Marlin A Yohn 50$ �
Annui�y value: $66,771.93 as of 0?-27-20�
Aiuiuity type: Non-Qu�lified �
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Taa xaEormatioa �
This letter includes general tax information tha shauld not be relied
upon for personal tax planning. Transamerica Li e Insurance Company
daes not give legal, ta�c, or accounting aclvice, Yau may wartt to
consult your attprney, t�x advisor, or account with questions
regarding the direct tax consequences when sele ing an aption.
�1e�sral Iaforaatioa
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Please be advised automatic operatians such as stematic Payouts and
Automatic Pa�cnents have been stopped.
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REV4511 E%+(10-09j I
�pennsylvania SCHEDULE H
DEVAXTMENTOF0.EVENUE FUNERAL EXPENSES AND
INNERRRNCETNIRFNRN ADMINISTRATIVE COSTS
RESIDEM OKEDEM
ESTATE OF FILE NUM9ER
MARY ROMAYNE YOHN i 21-13-0870
Dacedant's dabb mud ba reported on Schedule I.
�M AMOUNT
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
1' MALPEZZI FUNERAL HOME,FUNERAI SERVICES 8 MERCHANDISE � 11,739.64
MEMORIAL DINNER(49 GUESTS) 619.00
e. ADMINISTRATIVE COSTS:
1. Personat Representative Commissions: 13,026.00
Name(s)of Personal RepresenWtive(s) MARLIN A.YOHN, SR.
StreetAddress 8 HICKORY LANE
�ny MECHANICSBURG __ State PA p ��055 _
Year(s)Commission Paid: .... . ... . . . .. . . .
13,026.00
2• Attomey fees:
3. Family Exempdon: (If decedent's address is nat the same as claimant's,attach ezplanation.)
tlaiman[ . _ ... .. . .. .. ... . .
Street Address . .. . . ..._ .
... __._ . . __ . . . ... . .
City.. .. . ......... . .. .. . . . .. Stdte . IP .. .. ... . .
Relationship of qaimant to Decedent .._ _... . .... .. . ... . . . . . . . . .
a. vrobate Fees: 403.50
5. AccounWnt Fees:
6. Tax Retum Preparer Fees:
7• PUBLICATION OF ESTATE NOTICES,CLJ($75.00)&SENTINEI($189.54) 264.54
a. LAWNS UNLIMITED,MOWING AND TRIMMING 800.00
a. SCOTT FOGLE,CHIMNEY REPAIR 1,850.00
�o. PARVIN,PAVING 8 SEALING DRIVEWAY 6,600.00
��. PPL 150.03
�z. CONTINUATION SHEET TOTAL
TOTAL(Also enter on L �9, Rewpitulation) ;. 48,478.71 �
If more space is needed,use additlonal sheets of paper of Me sam �ize.
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REV-1512 EX+(12-OB) !
pennsylvania SCHEDULE I
DEVRPTMENT pF NEVENUE DEBTS OF DECEDENT, i
(NNEpR�NCETAX RENRN MORTGAGE LIABILI'RES &LIENS
0.ESIDEM DECEDEM
ESTATE Of FILE NUMBER
MARY ROMAYNE YOHN i 21-13-0870
Raport debts Incurred by the dendmt prlor to death tha!remained unpaid at the data of death,in udhg unroimburaad madiul ezpenses.
ITEM VALUE AT DATE
NUMBER DESCR[PTION OF DEATM
1 WEST SHORE EMS,AMBULANCE SERVICE 256.92
2. VERIZON 38.93
3. PA AMERICAN WATER I 14.31
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TOTAL(Also enter on Line 1 ,�Recapitulation) ; 310.16
If more space is needed,insert addidonal sheets of the same siz
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REV4513 EX+(0140) � �I
pennsylvania SCHEDULE 7
OEPRRTMENTOiPEVENUE BENEFICIARIES '. I
INHEItIf�NCE TA%0.ElUiW
ilES[OENf DECEOEM
����; FILE NUMBER:
MARY ROMAYNE YOHN 21-13-0870
RELAT[ONSH ;�.TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADD0.E55 OF PERSON(S)RECEIVING PROPERN Do Not LI ITrustaa(s) OF ESTATE
I TAXABLE DISiRiBIlfI0N5[Indu�outright spousal disUibutions and hansfers under
Sec.9116(a)(1.2).]
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i. Catherine L.Ulrich,402 Cocklin St.,Mechanicsburg,PA 17055 daughter ; 1/2 residue
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2. MaAin A.Yohn,Sr.,6 Hickory Lane,Mechanicsburg,PA 17055 son i 1/2 residue
3. Marlin A.Yohn,Jr.,330 Capital Hill Rd.,Dillsburg,PA 17019 grandson $5,000
4. Mry E.Wehel,2156 Canterbury Dr.,Mechanicsburg,PA U055 grenddaug r $5,000
5. Sper�cer B.Ulrigh,334 Hogestown Rd.,Mechanicsburg,PA 17050 grandson $5,000
6. Chandra Ulrich,504 Spring Run Drive,Mechanicsburg,PA 17055 granddaugh r $5,000
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ENTER DOLIAR AMOUNTS WR DiSTRIBUTI0N5 SHOWN ABOVE ON UNES IS 7HRW6H 18 OF REV-1 � COVER SHEET,AS APPRO%UAlE.
I� NONdAXABLE DISfRIBURONS
A. SPOUSML DI57RIBUf[ONS UNDER SECf10N 9113 FOR WNICH AN ELECTION TO TA7(IS NOT TAKE �
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8. CHARITABLE AND GOVERNMENTAL DISTRIBUf10N5:
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TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTION$ON LINE 13 OF REV•15 � COVER SHEET. ;
If more space is needed,use additlonal sheets of paper of Me sam ��ize.
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I�AST WILL AND ?'ESTAME
OF
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MARY ROMAYNE FOHN I
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I, MARY ROMAYNE YOHN, of 216 Ridge H I' Road, Mechanicsburg,
Cumberland County, Pennsylvania, being of sound and disp ; ing mind, memory and
understanding, do make, publish and declare this as and for m Last Wili and Testament,
hereby revoking and making void any and all former Wills, icils, or writings in the
nature thereof, by me at any time heretofore made.
FIRST: I hereby order and direct my Executrix or Executor,
hereinafter named, to pay all my just debts, funeral expense testamentary expenses
and all Inheritance, Estate, Transfer and Succession Tax '; as soon as may be
conveniently done after my death, out of my residuary estate. �
SECOND: I give, devise and bequeath all my estate, be it•real; .
personal or mixed, of whatsoever kind and wherescever situat 'to my husband,'GLENN
U. YOHN, provided he survives me by thirty (30) days.
THIRD: In the e��ent that my husband, G fNN U. YOHN, fails ko
survive me by thirty (30) days, and should my net estate a r payment of taxes and
expenses, be equal to or in excess of One Hundred ($100,000. 0) Dollars, I give to each
of my grandchildren, the sum of Five Thousand ($5,000.00) Dol rs.
FOURTH: All the rest, residue and remainde of my estate, be it real,
personal or mixed, of whatsoever kind and wheresoever s' 'ate, I hereby give and
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bequeath to my children, MARLIN A. YOHN, SR. and CAROLY! LEE ULRICH, in equal
shares, per stirpes. '
LASTLY: I nominate, constitute and appoi� my son, MARLIN A.
YOHN, SR., as Executor. In the event that MARLIN A. YOH , SR. shall be unable to
serve as Executrix for any reason, I appoint my daughter, CA LYN LEE ULRICH, as
Executrix. No Executor or Executrix shall be required to file ond in this or any other
jurisdiction.
IN V1fiTNESS WHEREOF, I have hereunto set my and and seal this
1 �1 day of , 2008.
. ry Romayne ; n _
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SIGNED, SEALED, PUBUSH�D and '
DECLARED in the presence of:
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COMMONWEALTH OF PENNSYLVANIA : ss
COUNTY OF CUMBERLAND �
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I, MARY ROMAYNE YOHN, Testatrix, whose name is� 'igned t laWe do che eby
foregoing instrument, having been duly qual�ed acco ' g
adcnowled9e that I signed and executed the instrument as m Last Will; that I signed it
willingly; and that I signed it as my free and voluntary a for the purposes therein
expressed.
RY ROMAYNE YOHN,
Swom or affirmed to,�nd ac�ka°of�9� b re me, by ; , 2008.
the Testatrix, this� y
ary ma '�e Yo , estat ' c
No IPu lic
MERlEIE J.W�RI�IE1! �MOTIYFY PI�LB
MIY �NM�40iC
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CQMMONWEA�TW OF PENNSYLVRNIA :
: ss
COUNTY OF CUMBERtAND :
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We and _,,,_ � ,
the witne whose names are sign ta the attached ar f oing instrument, being
dufy qual' according to law, do depose and say that were present and saw
Testatrix sign and execute the instrument as her Last Will; t t she signed wiilingiy and
that she executed it as his free and votuntary sct for the purp s therein expressed; that
each of us in the hearing and sight of the Testatrix signed th sll as witnesses; and that
- to the best of aur knowledge the l'estatrix was at that time or more years of age, of
sound mind and under no constraint or undue infi4uence.
Sworn ar a�rmed to and subscribed to before me by �_
and i���this )�� d of ,
2008.
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No � ry !ic
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MY CGMI�SS E%PlF�S JIN� 2019
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