HomeMy WebLinkAbout12-31-13 1505610140
REV-1500 Ex (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 3 0 7 1 2
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 3 3 1 2 0 1 3 1 0 1 8 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name MI
T H O M A S G L A D Y S V
(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
Q 1.Original Return 2.Supplemental Return F1 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 El 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone-lumber ;o
E RALPH G0DFREY , ESQ . 7` a 97`''5 91g00
�EGIST�g OF WWLS U'OApir
21 D I-"" W
First line of address m
1 0 1 1 MU MMA R OA D u c-)
Second line of address C:-• _ �rTi
c�o
S U I T 201 , '
City or Post Office State ZIP Code
> DATE E1LED
L E M O Y N E P A 1 7 0 4 3
Correspondent's e-mail address: RGODFREYOuC-WLAW.,COM
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,cog and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATUR15 OF PE SON RE .QNSIBLE FO G RETURN D TE
O
A E§S
1011 MUMMA ROAD, STE 201 LEMOYNE PA 17043
SIGNATURE OF PREPAR.�ER/OTHER THAN REPRESENTATIVE DATE/
ADDRESS
12 LILAC DRIVE MECHANICSBURG PA 17050
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610140 1505610140 J
1505610240
REV-1500 EX Decedent's Social Security Number
Decedent's Name: GLADYS V. THOMAS
RECAPITULATION
1. Real Estate(Schedule A) ........................................... 1.
2. Stocks and Bonds(Schedule B) 2. 1 0 6 0 8 6 . 5 8
......................................
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. 1 0 0 ' 0 0
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested ....... 6. 9 7 1 5 4 • 5 4
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 2 3 7 2 2 1 • 3 5
(Schedule G) ❑ Separate Billing Requested ....... 7.
8. Total Gross Assets(total Lines 1 through 7) ........................... 8. 4 4 0 5 6 2 • 4 7
9. Funeral Expenses and Administrative Costs(Schedule H) .................. 9• 6 7 1 3 • 5 9
10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule I 10. 7 0 0 • 1 7
11. Total Deductions(total Lines 9 and 10) ............................... 11. 7 4 1 3 . 7 6
12. Net Value of Estate(Line 8 minus Line 11) ............................ 12. 4 3 3 1 4 8 . 7 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. 4 3 3 1 4 8 . 7 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.00 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X.045 4 3 3 1 4 8 . 7 1 16. 1 9 4 9 1 . 6 9
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. 1 9 4 9 1 . 6 9
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
L 1505610240 1505610240 J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 13 0712
DECEDENTS NAME
GLADYS V.THOMAS
STREET ADDRESS
20 NORTH 12TH STREET
APT 219
CITY STATE ZIP
LEMOYNE PA 17043
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 19,491.69
2. CreditstPayments
A.Prior Payments 17,283.88
B.Discount 909.65
Total Credits(A+B) (2) 18,193.53
3. Interest
(3) 0.00
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) 1,298.16
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; ...................................................................... ❑ X❑
b. retain the right to designate who shall use the property transferred or its income; ............................... ❑
c. retain a reversionary interest;or ................................................................................................ ❑
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 0
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ 0
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... El X
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
containsa beneficiary designation?.................................................................................................. ❑
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
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
72 P.S.§9116(1.2)[72 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.
• a
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LAST WILL AND TESTAMENT
KNOW ALL MEN BY THESE PRESENT'S, that I, GLADYS V. THOMAS, currently
residing at Mechanicsburg, Cumberland County, Commonwealth of Pennsylvania, being in good
health and of sound and disposing memory do hereby make, declare and publish this as my Last
Will and'Testament, hereby revoking all former Wills and Codicils heretofore made by me.
FI.RST: I direct that all of my debts not barred by the statute of limitations,
expenses of my last illness, funeral expenses,costs of administration and claims allowed in the
administration of my estate shall be p aid by my Executor hereinafter named, from my estate as
soon after my decease as shall be found convenient.
SECOND: I bequeath my automobiles, household and personal effects and
other tangible personal property of like nature (not including cash or securities), together with
any existing insurance thereon, as are set forth in separate memoranda,which I shall place with my
Will,to the persons therein.designated. Any tangible personal property and other personal effects
not otherwise specifically listed in such separate memoranda shall be distributed as provided in
paragraph THIRD below.
C>
C - C-> -
THIRD: To the extent that such memoranda fail to dispose of all �:sonal prgperty rte;
if no memorandum is in existence at my death; then I give all such personal r(Me - not d4os oX'
g P P �3'� r� � �, „
by separate memorandum in three equal shares to those of my children listed aFefo&5o': KARE Ste,
o
WILLIAMS,DEBORAH.A. HARBISON, and GLORIA J. PAYTON, as the g, agree. ash
nearly equal shas es as possible,provided that if they are unable to agree then th@y-shall make
selections in turn with the oldest going first ur,61 the dollar value of the items selected is as nearly
equal as possible.
FOURTH: I give, devise and bequeath the rest, residue and remainder of my estate,
whether real,personal or mixed, and of any nature whatsoever and wherever situate to my three
daughters listed as follows: KAREN S. WILLIAMS, DEBORAH A.HARBISON, and GLORIA
J. PA.YTON,in equal shares, per stirpes.
1
FIFTH: I hereby nominate, constitute, and appoint KAREN S. WILLIAMS as
Executor of this, my Last Will and Testament, without necessity for posting security regardless
of state of residence. In the event that KAREN S. WILLIAMS shall predecease me, or be
unwilling or unable to act as my Executor, as aforesaid,then I nominate, constitute and appoint
DEBORAH A. HARBISON without necessity for posting security regardless of state of
residence, as Executor of this, my Last Will and Testament. All references to the Executor
herein shall be applicable to said substitute Executor.
SIXTH: My Executor shall have, in addition to the powers and authority conferred
upon him by law, the following additional powers and authority:
1. To sell at public or private sale, exchange,transfer, partition, give options upon,
lease, mortgage, pledge or otherwise dispose of any property, real or personal, at any time
constituting a portion of my estate, and upon such terms and conditions as the Executor shall
deem wise.
2. To invest any money at any time in such bonds, stocks, notes,real estate,
mortgages, life insurance, annuities or other securities, or such property,real or personal, as the
Executor shall deem wise, without being limited by any statutes or rule of law regarding
investments by the Executor.
3. To retain, without incurring any liability, as investments, any property owned by
me at the time of my death, as long as my Executor may deem it wise, and even though such .
property is not the kind of property an Executor would purchase as an investment; and even
though to retain such property might violate sound diversification principles.
4. To cause any security or other property which may constitute a portion of my
estate to be issued,held or registered.in the Executor's own name, or in the name of a nominee,
or in such form that title will pass by delivery.
5. To consent to the reorganization, consolidation, readjustment of the financial
structure, or sale of the assets of any corporation_or other organization, the securities of which
`� 2.
constitute a portion of my estate, and to take any action with reference to such securities which.
in the opinion of the Executor is necessary to obtain the benefit of any such reorganization.,.
consolidation, readjustment or sale; to exercise any conversion privilege or subscription right
given to my Executor as owner of any securities constituting a portion of my estate resulting
from any reorganization, consolidation, readjustment, sale, conversion or subscription.
6. To pay all costs, taxes, charges and expenses in connection with the
administration of my estate, including such compensation to the Executor which shall be in
accordance with established fees throughout the period of administration of my estate.
7. To determine what is "income" and what is `'principal"hereunder, and my
Executor's decision thereon shall be final; and to purchase securities at a premium or discount,
and to apply or charge said premium or discount against income or principal as the Executor may
determine.
8. The Executor may make payments to or on behalf of any person who is the .
heneficiary hereunder but in no event, however, shall payments be made to any creditor or other
such person because of anticipation of payment by the beneficiary,and any such claim made by
way of anticipation by the beneficiary shall be of no validity or legal effect.
9. To borrow money from any person, firm or corporation, including any
corporation acting as an Executor hereunder, for the purpose of protecting and preserving or
improving my estate hereunder; to execute promissory notes or other obligations for amounts so
I
orrowed.
10. To employ legal counsel, accountants,brokers, investment advisors, custodians,
managers and other agents and employees an-A to pay reasonable compensation out of my estate
or any funds held hereunder to which said compensation is attributable.
11. To carry on any business owned or controlled by me at my death for whatever
period of time my Executor shall think proper, and my Executor shall have the power to do any
-- - /-`Z 3
0
e
and all things my Executor deems necessary or appropriate, including the power to close out,
liquidate or sell the business at such time and upon such terms as my Executor shall deem best.
12. To do all other acts in my Executor's judgment necessary or desirable,for the
proper and advantageous management, investment and distribution of my estate.
SEVENTH: I direct that all transfer and inheritance taxes, state or federal, assessed
because of my death, on funds or property or insurance proceeds to which such taxes are-
attributable pass under this Will, shall be paid out of my residuary estate, except that my
Executor shall deduct from the share of any beneficiary the pro-rata portion of Pennsylvania
inheritance or other death taxes attributable to any non-probate property he or she receives as a
result of my death. I also direct that my Executor pay, or provide for payment of all such taxes at
such time, or times, and in such manner as my Executor deems best.
IN WITNESS WHEREOF, I, GLADYS V. THOMAS,the Testator to this; my Last Will
and Testament, typewniren on four sheets of paper which I have identified at the bottom of each.
page by my initials, hereunto set m,,.-hand and seal the �� $'_ 4- of
C► In 2006.
GLADYS V. TAOMAS
The preceding instrument consisting of this and three other typewritten pages, each identified by
the signature of the Testator, GLADYS V.THOMAS, this day and date thereof signed,
published and declared by GLADYS V. THOMAS, the Testator therein named, as and for her
Last Will, in the presence of us who, at her request, in her presence, and in the presence of each
other have su?scribed our names as witnesses.
Lt .1 L Gr t� "S
. ��'
71 4
A
COMMONWEALTH OF.PENNSYLVANIA
SS
COUNTY OF
I, GLADYS V. THOMAS, Testator,whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law,do hereby acknowledge that I signed and
executed the instrument as my Last Will;that I signed it willingly; and that I signed it as my free and
voluntary act for the purposes therein expressed.
GLADYS V. OMAS
Sworn or affirmed to and acknowledged before me by GLADYS V. THOMAS,Testator,the
day of ,�,��,�. ,2006.
(SEAL) otary Public
FLEmoYNE OTARIAL SEAL
ID H RADCUFF
otary Public
UGH,CUMBERLAND COUNTY ion Expires Jun 29.2008
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF
and CIA 1L G7. C-7/ C 616, ,the
witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according
to law,do depose and say that we were present and saw Testator sign and execute the instrument as her
Last Will;that she signed willingly and that she executed it as her free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and
that to the best of it knowledge- he Testator was at that time eighteen or more years of age,of sound
mind a unbar to c stra.int o Yndue influence. 9
/6 118ua"ei
Sworn or affirmed to and subscribed to before me by �i7 i9iL/ J. .�D and
Cig1,e- 67, (/���'c; witnesses,this //day of ir'•�2r�/ , 2006.
rA
(SEAL) r✓��4 // '�
Notary Public
NOTARIAL SEAL `
DAVID H RADCLIFF
Notary Public
LEMOYNE BOROUGH,CUMBERLAND COUNTY
MY Commission Expires Jun 29,2008
5
REV-1503 EX+(6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GLADYS V. THOMAS 21 13 0712
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Columbia Property Trust, Inc. (FKA Wells REIT II, Inc.) 106,086.58
Shares: 14,4729310 @$7.33 per share
(See Exhibit A)
TOTAL(Also enter on line 2,Recapitulation) S 106 086.58
(If more space is needed,insert additional sheets of the same size)
REV-1508 EX+(11-10)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN CASH, BANK DEPOSITS, & MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
GLADYS V. THOMAS 21 13 0712
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. Misc furniture and clothing 100.00
TOTAL(Also enter on Line 5,Recapitulation) $ 100.00
If more space is needed,insert additional sheets of paper of the same size
REV-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
GLADYS V.THOMAS 21 13 0712
If an asset was made jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.Karen S.Williams 12 Lilac Drive Daughter
Mechanicsburg, PA 17050
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER,ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 11/2012 Ally;Acct No.2129397218;See Exhibit B 190,448.55 50. 95,224.28
Money in account was owned jointly since 3/2006. Attach
is a statement Exhibit F showing joint ownership in 2006
2 A 8/2007 Integrity Bank;Acct. No. 201018749 64.06 50. 32.03
See Exhibit C
3. A 3/2006 PSECLI;Acct No.8220514130 3,796.46 50. 1,898.23
Savings, Checking and Money Market
See Exhibit D
TOTAL(Also enter on Line 6,Recapitulation) $ 97 154.54
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
GLADYS V. THOMAS 21 13 0712
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 %OFDECD'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. Protective Life Insurance Company Annuity 17,305.40 100.00 0.00 17,305.40
Contract No. FK0755269
See Exhibit E
2. ING Annuity&Life Insurance Co. 219,915.95 100.00 0.00 219,915.95
Contract No. C103801-OX
TOTAL Also enter on Line 7,Recapitulation) $ 237 221.35
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
GLADYS V. THOMAS 21 13 0712
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Athens Marble&Granite 160.00
2. Funeral meal and flowers 801.79
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees: Cipriani&Werner, P.C. 5,000.00
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: Cumberland County Register of Wills 508.50
5 Accountant Fees:
6. Tau Return Preparer Fees:
7. Cumberland Law Journal Estate Notice 75.00
8. The Sentinel - Estate Notice 168.30
TOTAL(Also enter on Line 9,Recapitulation) $ 6,713.59
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES,&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GLADYS V. THOMAS 21 13 0712
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. Citi Credit Card Debt 176.21
2. Verizon 58.72
3. Holy Spirit Hospital Hospital 184.05
4. Holtgate Podiatry, PLLC 30.98
5. Genesis Rehabilitation Services 94.74
6. Internists of Central PA 155.47
TOTAL(Also enter on Line 10,Recapitulation) $ 700.17
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:
GLADYS V. THOMAS 21 13 0712
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.9116(a)(1.2).]
1. Karen S.Williams Lineal 209,152.59
12 Lilac Drive
Mechanicsburg, PA 17050
2. Deborah A. Harbison Lineal 111,998.06
3572 Twenty Mile Way
Loveland, OH 45140
3. Gloria J. Payton Lineal 111,998.06
23-60 Rice Avenue
Hamilton, Ont L9C7S3
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.
EXIIIBIT A
. 4 --
wo I Is Capital, lnc:
July 12, 2013
Cipriani&Wemer
Attention: E.Ralph Godfrey
1011 Mumma Road, Suite 201
Lemoyne,PA 17043-1145
Re: Columbia Property Trust,Inc. (f/k/a Wells REIT 11,Inc.)
Dear Mr. Godfrey: -
On June 30, 2013,we received a request for a death valuation as of March 31, 2013 on behalf of shareholder,
Gladys V. Thomas. Since Columbia Property Trust,Inc. ("Columbia")is not a publicly traded investment,the
estimated date of death valuation is based on the terms and conditions of the Share Redemption Program(SRP).
For your reference,below is some important background information on the SRP for Columbia.
Redemption Information
Based on the most recent prospectus and SEC filings for Columbia,the price to be paid for any eligible shares
redeemed through the SRP in cases of death, qualifying disability, or qualification for federal assistance for
confinement to.a long-term care facility is the most recent estimated per-share value. This redemption price is
adjusted as appropriate for any stock'dividends, splits, aggregate distributions per share or any net sale proceeds
and other special distributions.
As discussed in the most recent prospectus and SEC filings for Columbia and the.Columbia SRP,the aggregate
dollar amount for all redemptions and the number of shares redeemed under the SRP are subject to certain
limitations. Please note that the Board of Directors can amend,suspend,or terminate the SRP at any
time upon 30 days' notice.
Should you wish to review the details of the SRP further,we encourage you to read the latest Amended and
Restated Share Redemption Program that has been filed with the Securities and Exchange Commission(SEC).
Please note,this important information may also be found on the Columbia website,
www.ColumbiaPropertyTrust.com,under the"Investor Relations"tab.
Wells Capital,Inc.is affiliated with Wells Real Estate Funds,Inc.and Wells Investment Securities,Inc.—Member FDaWSIPC.As of February 28,
2013,Columbia Property Trust,Inc.(Yk/a Wells REIT II,Inc.)became self-advised and is no longer externally advised by Wells Real Estate Funds,
Inc.or its subsidiaries.Affiliates of Wells Real Estate Funds,Inc.continue to provide certain support services to Columbia Property Trust,Inc.under
temporary contractual agreements.
P.O.Box 219073 Kansas City,MO 64121-9073 Tel:800-557-4830 Fax:770-243-8198 www.ColumbiaPropertyTrust.com
TA-CS-20i3-01-24-0398
i
Wells Capita'I, Inc. k
? \
Valuation Information.
On November 8, 2012,the Board of Directors for Columbia published an estimated value of$7.33 per share*.
As a result,the estimated valuation for Gladys V. Thomas Columbia account is based upon this most recent
estimated value of$7.33 per share.
Below is the date of death estimated account value you requested:
Investor Name Account Number
Gladys V. Thomas 3601-1000974242 14,472.9310 . $106,086.58
In regards to items 1 through 6 on your request for account level information, we have enclosed a copy of the
client's 2013 quarterly statements. Also, we can confirm that there have been no changes to the registration of
the account for the past two years and Ms. Thomas's account is still open and active. In regards to question 7,
there are no named beneficiaries listed on her account.
If you have any questions,please contact a Client Services Specialist Monday through Friday at.800-557-4830.
*The independent third party based their estimate on the net asset value of the portfolio of Columbia as of September,30 2012,and
took into consideration certain assets and liabilities of Columbia as of that date. This valuation is considered only an estimate and is
based on a number of assumptions and estimates which may not be accurate or complete.
Sincerely;
Wells Capital,Inc.
Client Services
client.services @ wel lsref.com
Wells Capital,Inc.is affiliated with Wells Real Estate Funds,Inc.and Wells Investment Securities,Inc.—Member FDMA/SIPC.As of February 28,
2013,Columbia Property Trust,Inc.(f/k/a Wells REIT 11,Inc.)became self-advised and is no longer externally advised by Wells Real Estate Funds,
Inc.or its subsidiaries.Affiliates of Wells Real Estate Funds,Inc.continue to provide certain support services to Columbia Property Trust,Inc.under
temporary contractual agreements.
P.O.Box 219073 Kansas City,MO 64121-9073 Tel:800-557-4830 Fax:770-243-8198 www.ColumbiaPropertyTrust.com
TA-CS-2013-01-24-0398
EXHIBIT B
ally
P.O. Box 951
Horsham, PA 19044
07/30/2013
E. Ralph Godfrey
1011 Mumma Road Suite 101
Lemoyne, PA 17043-1145
RE: Estate of Gladys V Thomas
Dear: E. Ralph Godfrey
In response to your inquiry, the above-named decedent had the following account(s)with Ally Bank:
>ti` ape�b1;�Account ,s r A000]At Title•�`m���-,'�''���a �ccoUnt�Ylir�lbef�'`"� `" � alan�e'ztbll� "��"`��4 t' t
Money Market Gladys V Thomas 2129397218 Principal: 190,448.55
Karen S Williams Interest: 65.20
The principal balance(s) listed above represents the account balance, including any interest earned on
the account(s)up to the last statement cycle date. The interest amount(s) represent the accrued interest
from the last interest posting up to but not including the date of death of the account holder.
Questions?
We're here to help, anytime. Just call 877-247-ALLY(2559)24 hours a day, 7 days a week.You can
press"0"to reach a Customer Care Associate immediately. Or go to allybank.com.
Sincerely,
.61ovn
Susan W. Green
Ally Bank Deposit Executive
Member FDIC
EXHIBIT C
July 10, 2013
CIPRIANI &.WERNER Ill�egrlty
1011 Iv1 .MMA ROAD,.SUITE 201 , B .A 'N , K
LEMOYNE,'PA 17043 4145
Re: Estate of. Gladys V. Thomas
Social Security#: 407-30-0331
Date of Death: 03/31/2013
Dear Mss. E. Ralph Godfrey
I am writing in regards to the letter in which you sent inquiring about accounts
that Mss. Thomas held at Integrity Bank.
Mss. Thomas held a Joint High Yield Checking Account 201018749 with A.
Karen S. Williams. It was opened on 06/17/2006 and It was later changed to a 50+Free
Interest checking account as of statement dated 8/20/2007.
This 50+checking became a single owner account under the name of Karen S.
Williams as of statement dated 05/20/2013. The Annual Percentage Rate of interest for
this account was 0.18%. .
The date of death balance on 03/31/2013 was $64.06,there was no interest
accrued. I am also including the last 3 statements for this account.
If I can assist you further, please feel free to contact me at(717)920-4900 ext. 233
orjlara@integritybankonline.com
Sincerely,
uan C. Lara
Integrity Bank—Camp Hill
Customer Service Representative
3345 Market Street, Camp Hill,PA 17011 •Phone:717-920-4900.877-I-HAVEIT•Fax:717-920-4904^www.integrttybankonhne.com
EXHIBIT D
PSECO 06/28/2013
Cipriani&Werner
E. Ralph Godfrey,Attorney
1011 Mumma Rd., Suite 201
Lemoyne,PA 17043-1145
Re: GL ADYS V THOMAS,Deceased.
PSECU Reference#7688104784738
Dear Attorney Godfrey:
The above referenced person has an account with PSECU which was opened on
March 13, 2006.The Share accounts were jointly held by Gladys V.Thomas and Karen S.
Williams. Ms.Williams has been a joint owner since this account was opened.
The following are the Date of Death Balances for GLADYS V THOMAS's account with
PSECU:
Account Date of Death Balances Interest-March 1-31
Shares:
(Sl) Savings $5.00 $0.00
(S4)Checking $2,215.10 $0.17
(S7)Money Market $1,576.36 $0.46
PSECU pays interest on the last day of the month so the interest amounts shown above are
included in the DOD balances.
The joint owner needs to close the decedent's account with PSECU at the earliest
convenience.
If you have any questions,please contact me at(717)234-8484 or toll-free at(800) 237-
7328,press 6, extension 3120.
Sincerely,
��and`y Fa�ey
Member Service Representative
PSECU
Pennsylvania State Employees Credit Union
1 Credit Union Place, P.O. Box 67013, Harrisburg, PA 17106-7013 •800.237.7328 • >>psecu.com
THIS CREDIT UNION 15 FEDERALLY INSURED BYTHE NATIONAL CREDIT UNION ADMINISTRATION.EQUAL OPPORTUNITY LENDER.
EXHIBIT .E
Protective Life Insurance Company Protective ARk,
1707 North Randall Road,Suite 310 Life Insurance Company
Elgin,IL 60123-9409
Cipriani & Werner
Attn: E Ralph Godfrey
1011 Mumma Road - Suite 201
Lemoyne, PA 17043
Gladys V Thomas, Deceased July 11, 2013
Contract No. FK0755269
Claim No. CL 069037
Dear Mr. Godfrey
Please accept this letter in response to the recent correspondence
received by my department.
"Below please find the information requested:
1. Gladys V Thomas was the sole account holder.
2 . This was a Tax Sheltered Annuity 100% taxable.
3. Account No. FK0755269
4 . Date of Death Value $17,305.40
5. Interest accrues at a rate of 4.5%.
6. No Transactions after date of death.
7 . Beneficiaries - Deborah Harbison, Gloria Payton, Karen Williams
all per stirpes.
9. No loans are outstanding.
If you have any questions, please feel free to contact the Claims
Department at 1-888-397-8485. We will be glad to assist you in any
way possible.
aSie y,
her McMahan
xaminer
Enclosure
Paw
FORD INTEREST ADVANTAGE Note: 9071628601
For the period: 6116316.6-03/31706
Me Silver Gold Platinum
#BWNCHJJ ***3-DIGIT 335
84749460739773673# Under $15,000 to Over _
M662005 0073690 1 AT 0308 09231 S Beginning $15,000 $49,999.99 550,000 =_
Iii I_hal llnlluil��I�I�I,uh�ImahI1IIun.IldIIIIIIII�I Monday Rate Rate Rate
02/27/06 5:05 5.20 5:35
GLADYS V THOMAS& �G S 03106/06 5:09, . 5.24 5:39
KAREN.S WILLIAMS JT TEN 03/13/06 5:14 5.29 5.44
312 ROYAL PALM WAY / L/ f�34608
SPRING'HILFL 03/20/06 5.18 5.33 548
L
�D OD 073690 03/27/06 5.21, 5.36
HAVE YOU CHECKED THE RATES THAT YOU ARE EARNING ON YOUR FIA LATELY?
HIGHER BALANCES EARN HIGHER RATES
UP T0. 515,.000 5.21%
$15,000 TO $50,000 5.36%
OVER $50,000 5.51%
opening;Balance Investments Interest Redemptions Other Charges ClomIg:Balance
00 $100,000.00 $294.15 5-00 $:00 x$100.29415 H$
Date - Type of Activity Amount Balance Information *•
01/04106 INVESTMENT BY MAIL 1,000:00 1;000:00 Current:Rates-and Note
01/31/06 INTEREST 3.71 11003.71 Information amavailable
02/28/06 INTEREST 3.83 1;007.54 24 hours a day
03%13/06 INVESTMENT BY MAIL 99,000.00 100,007:54 Service Agents are available
03/31/06 INTEREST 286.61 100,294.15 8:30.a:m:-7:00 p.m.EST
M ,
onday=?Friday
Call: 1.-800-462-2614.:
TOO.Users .
Call: 1-800'-258=9668
Foreign Service Employees
Call' 11312-444-7558-,.To order enrollment packages
Call:::1.=800-5 80=4778'
To wire funds to FIA
use ABA routing number.
- 0710=00'152.,
Monthlystttenients are
available upon request
Year Interest this Period Total Interest Year-to-Date Tax Withheld
Summary of
Interest Invested 2006 $2 9 4. 15 $294. 15 5 .0 0
DetW
HM
Additional Investment Form
Make checks payable to: Checks Enclosed.
Ford Interest Advantage
Investments must be drawn in
Note: 9071628601 U.S. Dollars on a U.S.Bank.
Investments made by check
cannot be redeemed for ten TOtal
business days after-the check
is first credited to the note. Investment must total at least$50.00
Mail check(s)and this form to:
GLADYS V THOMAS &
Ford Interest'Advantage
The Northern Trust Company
PO Box 75935
Chicago, IL 60675-5935
9071628601
FORD 74834 P NNN
FORD INTEREST ADVANTAGE Note: 9071628601
(� FordCredit For the period: 01/01/12-02/29/12
Silver Gold Platinum
#BWNCHJJ
#4749451339773676# Under $15,000 to Over
MDG2005 0018116 1 MB 0404 09231 S Beginning $15,000 $49,999.99 $501000
In�llln�llinni�l�lluu�llnull�llnl�luu�ll��hl�l�l�l Monday Rate Rate Rate
01/30/12 1.05 1.15 1.25
GLADYS V THOMAS& 02/06/12 1.05 1.15 1.25
KAREN S WILLIAMS JT TEN 02/13/12 1.05 1.15 1.25
12 LILAC DR 02/20/12 1.05 1.15 1.25
MECHANIOSBURG PA 17050-3136 018116 02/27/12 1.05 1.15 1.25
OUR FIA WEB SITE HAS MOVED - PLEASE BOOKMARK OUR NEW WEB ADDRESS
FORDCREDIT.COM/INVESTOR-CENTER/INTEREST-ADVANTAGE
MAIL ALL INVESTMENTS TO PO BOX 75935, CHICAGO, IL 60675-5935 ONLY.
AS A REMINDER, INVESTMENTS BY CHECK ARE SUBJECT TO A
TEN BUSINESS DAY HOLD BEFORE THE FUNDS ARE AVAILABLE TO YOU. 1.
1pening Balance Investments Interest Redemptions Other Charges Closing Balance
$240,759.70 $.00 $494.62 $10,000.00 $.00 $231,254.32 _
Dafe Type of Activity _ Amount Balance Information -
01/31/12 INTEREST 255.60 241,015.30 current Rates and Note
02/29/12 ACH DEBIT FORD TRANSFER PP#9071628601 10,000.00- 231,015.30 Information are available
02/29/12 INTEREST 239.02 231,254.32 24 hours a day C
Service Agents are available
8:30 a.m.-7:00 p.m. EST
Monday-Friday C
Call: 1-800-462-2614
TDD Users
Call: 1-800-258-9668
Foreign Service Employees
Call: 1-312-444-7558
To order enrollment packages
Call: 1-800-580-4778
To wire funds to FIA
Use ABA routing number
0710-00152
Monthly statements are
available upon request
Year Interest this Period Total Interest Year-to-Date Tax Withheld
Summary of
Interest Invested 2012 $494.62 $4 9 4.6 2 $ .00
DETACH HERE
FordCredit Additional Investment Form Ford Interest Advantage
Make checks payable to: Checks Enclosed
Ford Interest Advantage $
Investments must be drawn in
Note: 9071628601 U.S. Dollars on a U.S.Bank.
Investments made by check
cannot be redeemed for ten Total
business days after the check
Is first credited to the note. Investment must total at least$50.00
Mail check(s)and this form to:
GLADYS V THOMAS & -
Is eFord Interest Advantage
The Northern Trust Company
PO Box 75935
Chicago, IL 60675-5935
9071628601
fordcredit.com/interestadvantage FORD 18221 P NNN
FORD INTEREST ADVANTAGE Note: 9071628601
( I FORD CREDIT For the period: 04 101112-06/30112
Silver Gold Platinum
*BWNCHJJ Under $15,000 to over
#4749491339773672#
MDG2005 0057109 1 MB 0404 09231 S Beginning $15,000 $49,999.99 $50,000
ull�,ullluulrl,�I,rn,l�u,rll,ll„I,lun,llul,lrl,l,l Monday Rate Rate. Rate
05/28/12 1.00 1.05 1.10
GLADYS V THOMAS& 06/04/12 1.00 1:05 1.10
KAREN S WILLIAMS JT TEN 06/11/12 1.00 1.05 1..10
12 LILAC DR 06118/12 1.00 1.05 1.10
MECHANICSBURG PA 17050-3136 057109 06/25/12 1.00 1.05 1.10
EFFECTIVE MAY 17, 2012 WEB BROWSER FIREFOX 3.5 WILL NO LONGER
SUPPORT ONLINE ACCESS TO FORD INTEREST ADVANTAGE DATA AT
WWW.FORDCREDIT.COM/INVESTOR-CENTER/INTEREST-ADVANTAGE _
WEB BROWSERS SUPPORTED INCLUDE:
FI.REFOX 12, 13, OR 14; INTERNET EXPLORER 7, 8, OR 9 AND OTHERS
Opening Balance Investments Interest Redemptions Other Charges Closing Balance
$231,487.47 $41.93 $425.76 $231,955.16 $.00 _ $.00
Date Type of Activity Amount Balance Information
04/30/12 INTEREST 209.29 231,696.76 current Rates and Note
05/31/12 INTEREST 216.47 231,913.23 Information are available
06/07/12 ACH DEBIT FORD TRANSFER PP#9071628601 231,913.23- 0.00 24 hours a day
06/13/12 INTEREST CREDIT ADJUSTMENT, RAS#9071628601 41.93 41.93 Service Agents are available
06/14/12 CLOSING REDEMPTION 41.93- 0.00 8:30 a.m.-7:00 p.m.EST
. Monday-Friday
Call: 1-800-462-2614
TDD Users
Call: 1-800-258-9668
Foreign Service Employees
Call: 1-312-444-7558
To order enrollment packages
Call: 1-800-580-4778
To wire funds to FIA
Use ABA routing number
0710-00152
Monthly statements are
available upon request
Year Interest this Period Total Interest Year-to-Date Tax Withheld
Summary of
Interest Invested 2012 $425.76 $1 , 19 5.4 6 $ .00
DETACH HERE
I FORD CREDIT Additional Investment Form Ford Interest Advantage
Make checks payable to: Checks Enclosed
Ford Interest Advantage $
Investments must be drawn in
Note: 9071628601 U.S. Dollars on a U.S. Bank.
Investments made by check
cannot be redeemed for ten Total
business days after the check
is first credited to the note. investment must total at least$50.00
Mail check(s)and this form to:
GLADYS V THOMAS &
Ford Interest Advantage
The Northern Trust Company
PO Box 75935
Chicago, IL 60675-5935
9071628601
fordcredit.corn/interestadvantage FORD 57597 P NNN