HomeMy WebLinkAbout12-23-13 (2) 1505610140
REV-1500 EX (02-11)(FI)
PA Department of Revenue UFFICIAI USE C1N Y
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 3 0 1 0 5 8
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 9 2 7 2 0 1 3 0 3 2 3 1 9 5 3
Decedent's Last Name Suffix Decedent's First Name MI
S H 0 L L E Y K E N N E T H A
(If Applicable)Enter Surviving Spouse's Information 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
0 1.Original Return F� 2. Supplemental Return 3.Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate 4a.Future interest Compromise(date of ❑ 5.Federal Estate Tax Return Required
death after 12-12-82)
QX 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
9. Litigation Proceeds Received 10.Spousal Poverty Credit(Date of Death [] 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
G E R A L D J S H E K L E T S K I E S Q 7 1 7 7 7,4 7 3 5
C'> rn
y. GISTER OF W%l s Uti O Y
70
CO
C
r7i n Cy
First Line of Address t— N M M
r— rn W CI
4 1 4 B R I D G E S TU? c �
Second Line of Address
P - 0 B 0 X E r r`
City or Post Office State ZIP Code DATEF!LED C,0 +
N E W C U M B E R A N D P A 1 7 0 7 0
Correspondent's e-mail address: G S H E K L E T S K I a9 S T O N E L A W • N E T
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG Ajl TURF OF PERSON �PONSIS OR,Rf, RETURN
ADDRESS Y/) /ld/ .[/�J
MELANIE L . REICH 2010 KRATZERVILLE RDWINFIELD PA 17889
SIGNAT R tE THER T EP NTATIVE DATE-
ADDRESS (v�
GERALD J SHEKLETSKI ESQ 414 BRIDGE STNEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J l
J 1505610240
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent'SName: KENNETH A • SHOLLEY
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3.
4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 2 4 1 1 2 . 8 7
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6.
7. Inter-Vivos Transfers&Miscellaneous N911-Probate Property
(Schedule G) Separate Billing Requested . . . . . . . 7. 8 9 5 2 3 . 4 0
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 1 1 3 6 3 6 . 2 7
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 1 5 0 8 0 • 9 8
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 2 4 3 8 . 2 8
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 1 7 5 1 9 . 2 6
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . .
. . . . . . . 12. 9 6 1 1 7 . 0 1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. 9 6 1 1 7 . 0 1
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec. 9116
(a)(1.2)X.0 _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate x .045 9 6 1 1 7 ., 0 1 16. 4 3 2 5 . 2 7
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 4 3 2 5 - 2 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 13 01058
DECEDENT'S NAME
. KENNETH A • SHOLLEY
STREET ADDRESS
2901 CHESTERBROOK COURT
APARTMENT 101
CITY STATE ZIP
CAMP HILL P 117011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 4 ,325 - 27
2. Credits/Payments
A.Prior Payments
B.Discount 216 - 26
Total Credits(A+B) (2) 216 - 26
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0 . 00
.
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 41109 - 01
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred ...................................................................... ❑ IR
b. retain the right to designate who shall use the property transferred or its income ............................... ❑
c. retain a reversionary interest ..................................................................................................... El d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ IR
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ ❑X
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑9 ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 surviving spouse is
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)].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 return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 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 transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in p2 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's 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-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
KENNETH A . SHOLLEY 21 13 01058
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CITIZENS BANK CHECKING ACCOUNT NUMBER 6100788040 121272 . 23
2. FISHER AUTO PARTS 401 (K) PLAN 91570 . 40
PLAN NUMBER 010020
3 • CAMP HILL APARTMENT ASSOCIATES 930 .73
SECURITY DEPOSIT REFUND
4 • BJ ' S WHOLESALE CLUB FINAL PAYCHECK 530 - 51
5 • CIGNA HEALTH AND LIKE REFUND CHECK - AMBULANCE SERVICE 809 . 00
TOTAL(Also enter on Line 5,Recapitulation) $ 241112 - 87
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KENNETH A . SHOLLEY 21 13 01058
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. PRUDENTIAL ANNUITIES CONTRACT NUMBER 71,401 . 74 100 . 00 711401 . 74
E0780807
TRANSFEREE-MELANIE L . REICH, DAUGHTER
2 . BJ ' S WHOLESALE CLUB 18,121 . 66 100 . 00 18,121 . 66
401 (K) SAVINGS PLAN
TRANSFEREES:
MELANIE L . REICH, DAUGHTER 1/311
MICHELLE L - SHOLLEY-CIAGETT,
DAUGHTER 1/3 AND MATTHEW L • SHOLLEY,
SON , 1/3
TOTAL (Also enter on Line 7,Recapitulation) $ 891523 - 40
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KENNETH A . SHOLLEY 21 13 01058
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. PARTHEMORE FUNERAL HOME & CREMATION SERVICES, INC - 51671 . 69
1303 BRIDGE ST - , NEW CUMBERLAND, PA 17070
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. AttomeyFees: STONE LAFAVER & SHEKLETSKI 51000 - 00
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: LETTERS TESTAMENTARY 263 • 50
5 Accountant Fees:
6. Tax Return PreparerFees:
7. CATHOLIC CEMETERIES — INTERMENT 865 . 00
8 • 1-800—GOT—JUNK/APARTMENT CLEANING/TRASH REMOVAL 775 . 00
9 • THE SENTINEL — LEGAL ADVERTISING 189 . 54
10 • CUMBERLAND LAW JOURNAL — LEGAL ADVERTISING 75 . 00
11 • CAMP HILL APARTMENT ASSOCIATES — OCTOBER, 2013 RENT 11037 . 09
12 • CARECENTRIX 25 . 00
13 • COMCAST 66 . 25
14 • EAST PENNSBORO AMBULANCE SERVICE, INC . 809 . 00
15 • JACKSON SIEGELBAUM GASTROENTEROLOGY 9 . 16
16 • LIBERTY MUTUAL GROUP 6 . 88
17 • PPL 15 . 94
18 • PPL 90 . 49
TOTAL(Also enter on Line 9,Recapitulation) $ 151080 - 98
If more space is needed,use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
KENNETH A. SHOLLEY 21 13 01058
Decedent's Name Page 1 File Number
Schedule H - Funeral Expenses &Administrative Costs - B7.
ITEM
NUMBER DESCRIPTION AMOUNT
19 • CITIZENS BANK - CHECK PRINTING FEE 47 . 44
20 • CITIZENS BANK ESTATE ACCOUNT MAINTENANCE FEE 4 . 00
21 - FILING FEES - INHERITANCE TAX RETURN AND INVENTORY 30 . 00
22 - RESERVE FOR CLOSING EXPENSES 100 . 00
SUBTOTAL SCHEDULE H-137 181 - 44
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
KENNETH A . SHOLLEY 21 13 01058
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. BJ ' S 401(K) SAVINGS PLAN LOAN BALANCE 21438 . 28
TOTAL(Also enter on Line 10,Recapitulation) $ 21438 - 28
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
KENNETH A . SHOLLEY 21 13 01058
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec.Tin%(a)(1.2).1 SCHED. G, ITEM 1
1. MELANIE L . REICH Lineal 1 /3 SCHED. c. , -
2010 KRATZERVILLE ROAD ITEM 2
WINFIELDI PA 17889 RESIDUE OF ESTATE
2 - MICHELLE L . SHOLLEY-CIAGETT Lineal
1120 GREINER ST. 1 /3 SCHED. G.
LEBANON, PA 17042 ITEM 2
3 - MATTHEW L . SHOLLEY Lineal
527 BALTIMORE ST - 1 2ND FLOOR 1 /3 SCHED. G,
HANOVERI PA 17331 ITEM 2
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. $
If more space is needed,use additional sheets of paper of the same size.
STONE. LAFAV ER SHEKLETSKI
ATTORNEYS AT LAW
414 BRIDGE STREET
NEW CUMBERLAND PA 17070
I
i
LAST WILL AND TESTAMENT
i
OF
KENNETH A. SHOLLEY
i
I, KENNETH A. SHOLLEY, of Lower Allen Township, Cumberland County,
i
I Pennsylvania, declare this to be my last will and revoke any will
previously made by me .
i
_lr,f'i i i dii-ect th--L my Executrix hereinafter n, m•2d shall pair
i
all my just debts and funeral expenses as soon as conveniently may be
I
done after my decease from the residue of my estate .
ITEM II : I devise and bequeath all of my estate of every nature
and wherever situate to my daughter, MELANIE L. REICH, or to her issue,
per stirpes .
I
I
ITEM III : I appoint my daughter, MELANIE L. REICH, Executrix of
it this my last will . Should my daughter, MELANIE L. REICH, fail to
Iqualify or cease to act as Executrix, I appoint GERALD J. SHEKLETSKI,
II
Executor of this my last will .
ITEM IV: I appoint my Executrix and her successors guardian of any
property which passes, either under this will or otherwise, to a minor
and with respect to which I am authorized to appoint a guardian and have
it not otherwise specifically done so, provided that this appointment of a
II guardian shall not supersede the right of any fiduciary in its
I
discretion to distribute a share where possible to the minor or to
I
another for the minor ' s benefit . Such guardian shall have the power to
'I
i use principal as well as income from time to 'Lime for the minor ' s
Page 1 of 4
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support and education (including college education, both graduate and i
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undergraduate) without regard to his or her parent ' s ability to provide
i
for such support and education, or to make payment for these purposes,
I I
without further responsibility, to the minor or to the minor ' s parent or {
I
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to any person taking care of the minor.
ITEM V: No fiduciary acting hereunder shall be required to post
I
bond or enter security for the faithful performance of his or her duties I
in any jurisdiction.
I
ITEM V_I : I have made no provision in this my Last Will for my ti
f
daughter, MICHELE L. SHOLLEY, nor my son, MATTHEW L. SHOLLEY, as I do
not wish them to receive any share of my estate .
IN WITNESS WHEREOF, I, KENNETH A. SHOLLEY, have hereunto set my i
hand and seal this day of 2011 .
rv� l
KENNETH A. SHOLLEY
f I
SIGNED, SEALED, PUBLISHED and DECLARED by KENNETH A. SHOLLEY, the
t
I
1Z taLor about named, as and for his Last 'Rill and Testa�m;ent, and in tt:°_
I
I '
presence of us, who at his request, in his presence and in the presence
' of each other, have subscribed our names as witnesses .
i
414 Bridge St . , New Cumberland, PA
Witness Address
-- \ 414 Bridge St . , New Cumberland, PA
Witness Address
I
Page 2 of 4
f�
COMMONWEALTH OF PENNSYLVANIA:
. SS .
COUNTY OF CUMBERLAND
i
I, KENNETH A. SHOLLEY, the Testator whose name is signed to the
attached or foregoing instrument, having been duly qualified according
i
i
to law do hereby acknowledge that I signed and executed this instrument
I
as my last will; that I signed it willingly and that I signed it as my
free and voluntary act for the purpcses therein contained.
KENNETH A. SHOLLEY
1
Sworn to or affirmed to and acknowledged before me by KENNETH A. j
SHOLLEY, the Testator, this day of � � '�� 2011 .
" Notary Public
-f PENNSYLVANIA
i SFn"�
j FewC : ,LE, Notary PuhGc
' ,. C timberland Co.
a. ` �;ires Jul 7
y 012
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Page 3 of 4
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COMMONWEALTH OF PENNSYLVANIA
I '
SS :
COUNTY OF CUMBERLAND
We, and
w
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testator sign and execute the instrument as his
last will; that Testator signed willingly and that he executed it as his
free and voluntary act for the purposes therein expressed; that each of
us in the hearing and sight of the Testator signed the will as
witnesses; that to the best of our knowledge, the Testator was at that
time eighteen or more years of age, of sound mind and under no
i
constraint or undue influence .
Witness
Witness
I
I Sworn to or affirmed to and acknowledged before me by
and
witnesses, this f day of 2011 .
Y
Notary Public
�i CO.,NIONVVEAJH OF PENNSYLVAN;A
t,,10TAR!AL SEAL
11;JNiFER A tAEAF3KLE, Nc)Wry Public
iNew Cumberland Boro. Cumberland Co.
Page 4 of 4 my Comrnicsion F-spires July 7, ?01^
(I
.'� One Citizens Drive
ROP112
Riverside, RI 02915
October 18, 2013
Stone LaFaver&Shekletski
Attn Gerald J Shekletski, Esq
414 Bridge St
PO Box E
New Cumberland PA 17070
Estate of Kenneth A Sholley
Date of Death: Sep 27, 2013
SSN: 174-38-3401
Dear Sir/Madam:
In accordance with your request, the attached information sheet has been provided in the above decedent's
name as of his/her date of death.
As per your request,the decedent did have a credit card with our institution. A copy of your request has
been forwarded to our Credit Card Department, please contact them at 1-800-571-8213 with any
questions you have about this account. For all other inquiries, please call 1-877-579-2667.
Si14s ��c
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r
Deced ent Acco t rocessing
REF#: 613669
Citizens' : n .Account Number 6100788040
Account Title Kenneth A Sholley
Date Opened 2/13/1987
Account Type Checking
Principal Balance as of DOD $12272.23
Interest from Last Posting to DOD $ .00
Account Balance as of DOD $12272.23
YTD Interest to DOD $ .00
Prudential Retirement
The Prudential Insurance Company of America
Prudential
30 Scranton Office Park
Scranton,PA 18507-1789
1-877-778-2100
www.retirenient.prodential.com
Estate of Kenneth A Sholley Plan Number: 010020
Stone. LaFaver and Shekletski Sub-Plan Number: 000001
414 Bridge Street PO Box E Reference Number: 01002083401
New Cumberland. PA 17070 Account Owner: Kenneth A Sholley.
November 20, 2013
Dear Mr. Sholley:
• Our records indicate that the September 27,2013 account balance for Kenneth Sholley in the
Fisher Auto Parts 401(k)Plan was $9570.40.
Thank you for allowing Prudential the opportunity to serve your retirement needs. If you have
any questions or require assistance; please contact our office at 1-877-778-2100.
Sincerely;
Chris Roling
Disbursement Specialist
Fax server 10/15/2013 9: 47: 42 AM PAGE Z/002 r'ax server
Prudential Prudential Annuities
A Business of Prudential Financial,Inc.
P.O.Box 7960
Philadelphia,PA 19176
(800)513-0805
Kevin S Kleinfelter Contract Number: E0780807
150 Tice Lane
P 0 Box 235 October 15, 2013
Cornwall,PA 17016
Dear Mr.Kleinfelter:
Thank you for your recent inquiry concerning the value of your Premier X Series.
As of September 27, 2013, the Contract Fund Value was:
Investment Option Value
AST JP Morgan Strat Opp $15,386.16
AST Academic Strategies Asset Alloc Port $16.157.21
AST Balanced Asset Allocation Portfolio $16,964.03
AST First Trust Balanced Target Portfolio $17.680.18
AST Investment Grade Bond Portfolio $5,214.16
Total Contract Fund Value $71,401.74
Your satisfaction is important to us. If you have questions, please contact your internal
wholesaler or our Annuities Service Center at (800) 513-0805. Representatives are available to
assist you Monday through Thursday between 8 a.m.and 7 p.m.,and Friday between 8 a.m. and
6 p.m. Eastern time.
Thank you for choosing to do business with Prudential Annuities.
Sincerely,
Annuities Service Center
Annuities are issued by The Prudential Insurance Company of America and Pruco Life Insurance Company(in New York,by Pruco
Life Insurance Company of New Jersey), all located in Newark, NJ, or by Prudential Annuities Life Assurance Corporation,
Shelton,CT. Annuities are distributed by Prudential Annuities Distributes.Inc.,Shelton,CT. All are Prudential Financial,Inc.
companies and each is solely responsible for its own financial condition and contractual obligations.
CFECCContV a1112012
PS W - Plan Sponsor Webstation Page I of 4
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BJ's Wholesale Club,Inc.401(k) 401(it)Savings Plan Statement
Savings Plan for Hourly Employees
KENNETH A SHOLLEY 9 Customer Service:(800)835-5095
2901 CHESTERBROOK COURT#101 S Fidelity Investments Institutional
CAMP HILL,PA 17011- Operations Company,Inc.
82 Devonshire Street
Boston,MA 02109
Statement Period:09/27/2013 to 11/06/2013
Beginning Balance $18,121.66
Employer Contributions $28.70
Change in Market Value $419.06
Ending Balance $18,569.42
Additional Information
Vested Balance $18,569.42
Outstanding Loan Balance $2,438.28
Loans are an asset of your account but are not included in your ending balance or reflected in your asset
allocation.
Your Personal Rate of Return _
This Period 2.3
Your Personal Rate of Return is calculated with a time-weighted formula,widely used by financial
analysts to calculate investment earnings.It reflects the results of your investment selections as well as
any activity in the plan accounts)shown.There are other Personal Rate of Return formulas used that
may yield different results.Remember that past performance is no guarantee of future results.
Statement Period:09/27/2013 to 1110612013
■ Stock Investments($13,170.57),70.92%
• Short Term Investments($3,189.49),17.17%
M Bond Investments($2,209,36),11.89%
Your account is allocated among the asset classes specified above as of 11/06/2013.Percentages and
totals may not be exact due to rounding.
The Additional Fund Information section lists the underlying allocation of your blended funds.
Statement Period:09/27/2013 to 11/06/2013
This section displays the value of your account for the period,in both shares and dollars.
Shares/Units Shares/Units Price Price Market Value Market Value
Investment as of as of as of as of as of as of
09/26/2013 11/0612013 09/26/2013 11/06/2013 09/2612013 11/062013
Stock Investments $9,576.75 $9,914.67
FID Diversifd Intl 103.338 103.498 $34.86 $35.75 $3,602.37 $3,700.06
Mgrs/c Mid Cap SRV 121.642 121.823 $30.96 $32.30 $3,766.04 $3,934.88
Royce PA Mutual INV 155.189 155.189 $14.23 $14.69 $2,208.34 $2,279.73
Blended Fund Investments* $5,710.21 $5,814.11
FID Freedom 2020 369.832 370.562 $15.44 $15.69 $5,710.21 $5,814.11
Short Term Investments $2,834.70 $2,840.64
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Vang Prime MM Inst 2,834.700 2,840.640 $1.00 $1.00 $2,834.70 $2,840.64
Account Totals $18,121.66 $18,569.42
Remember that a dividend payment to fund shareholders reduces the share price of the fund,so a
decrease in the share price for the statement period does not necessarily reflect lower fund performance.
'You have invested a portion of your account in Blended Funds.Blended Funds generally invest in a
mixture of stocks,bonds and short-term investments,blending long-term growth from stocks with income
from dividends and interest.Please refer to the Additional Fund Information section to see how your
blended funds are allocated across the three asset classes.
Please refer to NetBenefits and other Plan information,such as your SPO,for a description of your right to
direct investments under the Plan.For Information on any plan restrictions or limitations on those rights visit
NetBenefits and dick on'Plan Information".
To help achieve long-term retirement security,you should give careful consideration to the benefits of a
well-balanced and diversified investment portfolio.Spreading your assets among different types of .
investments can help you achieve a favorable rate of return,while minimizing your overall risk of losing
money.This is because market or other economic conditions that cause one category of assets,or one
particular security,to perform very well often cause another asset category,or another particular security,
.. to perform poorly.If you invest more than 20%of your retirement savings in any one company or
Industry,your savings may not be property diversified.Although diversification is not a guarantee against
loss,it is an effective strategy to help you manage investment risk.
In deciding how to Invest your retirement savings,you should take into account all of your assets,including
any retirement savings outside of the Plan.No single approach is right for everyone because,among other
factors,individuals have different financial goals,different time horizons for meeting their goals,and
different tolerances for risk.It is also important to periodically review your investment portfolio,your
investment objectives,and the investment options under the Plan to help ensure that your retirement
savings will meet your retirement goals.Visit the Department of Labor website
http:/Avww.dol.gov/ebsaAnvesting.html for information on Individual investing and diversification.
Some of the administrative services performed for the Plan were underwritten from the total operating
expenses of the Plan's investment options.
As of 11/072013 '
This section displays the funds In which your future contributions will be Invested.
Your Current Investment Elections as of 111072013
Ail Eligible Sources
EMPLOYEE SOURCES
Investment Option Current
%
Stock Investments
FID DIVERSIFD INTL 20%
MGRS/C MID CAP SRV 20%
'ROYCE PA MUTUAL INV 20%
Blended Fund Investments'
FID FREEDOM 2020' 20%
Short Term Investments
VANG PRIME MM INST 20%
Total 100%
EMPLOYER MATCH
Investment Option Current
%
Stock Investments
FID DIVERSIFD INTL 20%
MGRS/C MID CAP SRV 20%
Blended Fund Investments'
FID FREEDOM 2020 40%
Short Term Investments
YANG PRIME MM INST 20%
Total 100%
EMPLOYER MATCH VESTED
Investment Option Current
%
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Stock Investments
FID DIVERSIFD INTL 20%
MGRS/C MID CAP SRV 20%
Blended Fund Investments'
FID FREEDOM 2020 40%
Short Term Investments
VANG PRIME MM INST 20%
Total 100%
ONEC
Investment Option Current
Blended Fund Investments'
FID FREEDOM 2020 100%
Total 100%
Statement Period:0927/2013 to 11/062013
Contributions Employee
Sources Employer Sources
Period to date $0.00 $28.70
Inception to Date $9,431.88 55,895.37
Vested Percent 100% 100%
Total Account Balance $10,072.88 58,496.54
Total Vested Balance 510,072.88 $8,496.54
Statement Period:0927/2013 to 11/062013
Use this section as a summary of transactions that occurred in your account during the statement period.
Activity Mgrs/c Mid Cap Vang Prime MM Royce PA Mutual
SRV tnst INV FID DiversHd Intl
Beginning Balance $3,766.04 S2.834.70 52,208.34 $3,602.37
Employer Contributions S5.74 $5.74 $0.00 55.74
Change In Market Value 516310 $0.20 571.39 S91.95
Ending Balance $3,934.88 $2,840.64 $2,279.73 $3,700.06
Activity FID Freedom
2020 Total
Beginning Balance 55,710.21 $18,121.66
Employer Contributions $11.48 528.70
Change in Market Value S92.42 5419.06
Ending Balance $5,814.11 518,569.42
Statement Period:09272013 to 11/062013
Use this section to verify that Fidelity's records of your information are up-to-date.
Loan Loan Loan Balance on Principal Paid Balance on Interest Paid
ID# Date Amount 09262013 This Period 11/062013 This Period
LOAN 1 09/132010 $5,000.00 S2,414.11 -$24.17 $2,438.28 S0.00
Total $5,000.00 52,414.11 -S24.17 S2,438.28 50.00
As of 11/07/2013
Use this section to determine the asset allocation of your blended investments.
Blended Investment Stocks Bonds Short Term
FID Freedom 2020 56.00% 38.00% 6.00%
Blended investments generally invest in more than one asset class.The blended investment asset
allocation above reflects the stated neutral mix or,if not available,the asset mix reported by Morningstar,
Inc.for mutual funds or by investment managers for non-mutual funds.
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