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HomeMy WebLinkAbout01-17-14 - IIt♦I I 1505610144 REV-3 500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue Bureau of individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 3 0 5 2 0 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 4 2 ? 2 0 1 3 0 4 2 ? 2 0 1 3 Decedent's Last Name Suffix Decedent's First Name MI B U R G E T T A N N E T T A 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 FXJ 1.Original Return 2.Supplemental Return E] 3.Remainder Return(date of death prior to 12-13-82) 4.Limited Estate 4a.Future Interest Compromise(date of E) 5.Federal Estate Tax Return Required death after 12-12-82) QX 6.Decedent Died Testate 7.Decedent Maintained a Living Trust — 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9.Litigation Proceeds Received E] 10.Spousal Poverty Credit(date of death ED 11.Election to tax under Sec. 9113(A) between 12-31-91 and 14-95) (Attach Son. O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTEDYO: Name Daytime Telephone Number :o rn ' D O U G L A S G M I L L E R 7 2 4 c9 c�',333?5 3 MME F W LES USE-00 I�_ .a r'r1 1? L, y First line of address -Z I R W I N & M c K N I G H T P C - o Second line of address ry i— rta 6 0 W E S T P 0 M F R E T S T R E E T ca City or Post Office State ZIP Code -DATE FILED C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: 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, $ifp^NATU OF PAR,SO� PONS,!! R FIL��ftETURN DATE J�yf 1/ `� 'JI ,r`/ ADDRESS 15 WILD ROSE LANE MECHANICSBURG PA 17050 SIG RE ,� Eijq.RER HAN REPRESENTATIVE ADDRESS/ ^ 60 WEST POMFRET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 Continuation of REV-1500 Inheritance Tax Return Resident Decedent ANNETTA A.BURCETT 21 13 0520 Decedent's Name Page 4 File Number Correspondents Name Daytime Telephone Number HC ID G[ R R 2K , xxh9 AXXN 7 1 7 2 4 9 2 3 5 3 DOUGLAS G. MILLER, ESQUIRE First line of address I R W I N & M c K N i G H T P . C Second line of address 6 0 W E S T P O M F R E T S T R E E T City or Post Office State ZIP Code C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: Under penalties of poury,I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,coned and complete.Declaration of preparer other than the personal representative is based on all information of which prepaim has any knowledge. SI URE OF PERSON RrNSI ETURN / DATE ry>r' ADaRE .N� a ( j� ,( T 3541 SPRING ROAD CARLISLE PA 17013 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: ANNETTA A- BURGETT RECAPITULATION 1, Real Estate(Schedule A) ..... . .. .. . . . 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . 2. 9 9 0 9 , 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 2 7 3 5 9 . 2 0 6. Jointly Owned Property(Schedule F) ❑ separate Billing Requested . 6. T inter-Vivos Transfers&Miscellaneous N Probate Property (Schedule G) b Separate Billing Requested . 7, 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . ... . 8. 2 3 7 2 5 9 8 0 9. Funeral Expenses and Administrative Costs(Schedule H) ... . . . . ... .. . . . .. 9. 2 8 2 4 4 . 0 0 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1 IQ. 2 5 1 . 0 4 11. Total Deductions(total Lines 9 and 10) - . ... ... .. . . . .. . .. . . . . . . lll. 2 8 4 9 5. 0 4 IZ Net Value of Estate(Line 8 minus Line 11) _ __. .....__ ... .. .__.. . 12. 2 0 8 7 6 4 . 7 6 13- Charitable and Governmental BequesWSec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . ... . . . . . . .. 11 4 0 0 0 . 0 0 14. Not Value Subject to Tax(Line 12 minus Line 13) --- 14, 2 0 4 7 6 4 . 7 6 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.O 0 . 0 0 15, 0 . a a 16. Amount of Line 14 taxable at lineal rate X 0- 0 . 0 0 16, 0 . 0 0 17- Amount of Line 14 taxable at sibling rate X.12 3 0 0 U . 0 0 IT 3 6 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 2 0 1 7 6 4 . 7 6 Is, 3 0 2 6 4 . 7 1 19. TAX DUE . . .. . . ... . . . . .. . . . . . . .. ... . . .. . . 19. 3 0 6 2 4 . 7 1 20- FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT MX Side 2 1505610240 1505610240 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 13 0520 DECEDENT'S NAME ANNETTAA. BURGETT STREET ADDRESS --- --i i ------ -----____. 3605 SPRING ROAD CITY -�--- ��-- ----� STATE ZIP i-�--! CARLISLE PA 17013 Tax Payments and Credits: I. Tax Due(Page 2,Line 19) (1) 30 624.71 2. Credits/Payments 34 000.00 A.Prior Payments B.Discount 1,531.24 Total Credits(A+B) (2) 35 531.24 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) 4,906.53 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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 ................................._........---.........._.........................,....... 171 0 d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? .................... ......... ❑ ❑X . ....................................................... 3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death? ......... ❑ [] 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ 0 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)1. 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)(11)(it)].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)1. • 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(12)[72 P.S.§9116(a)(1)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-1503 FX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE /+ p/�t.� IN14EMTANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER ANNETTA A. BURGETT 21 13 0520 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. SERIES EE SAVINGS BONDS - INVENTORY ATTACHED 9,565.76 2. 1 SHARE NATIONAL GRID 59.18 1 SHARE @ $59.18 PER SHARE _ $59.18 3. 43 SHARES SANTANDER 284.66 43 SHARES @ $6.62 PER SHARE _ $284.66 TOTAL(Also enter on Line 2,Recapitulation) $ 9,909.60 If more space is needed,insert additional sheets of the same size RE+1--1506 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE GASH, BANK DEPOSITS & MISC. INHERITANCE E TECEDEN���RN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: ANNETTA A. BURGETT 21 13 0520 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. SOVEREIGN BANK- SAVINGS AND INVESTMENT CERTIFICATE OF DEPOSIT 3,500.96 ACCOUNT#1695546984 2. ORRSTOWN BANK- CHECKING ACCOUNT#143000367 2,838.29 3. M&T BANK-CHECKING ACCOUNT#405957 17,798.89 4. M&T BANK-SAVINGS ACCOUNT#15004198225475 22,939.57 5. M&T BANK-CERTIFICATE OF DEPOSIT#31003917741140 6,000.36 6. MEMBERS 1 ST FEDERAL CREDIT UNION -SAVINGS ACCOUNT#279202-00 173.82 7. MEMBERS 1 ST FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT#279202-40 35,027.82 8. MEMBERS 1ST FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT#279202-41 5,001.78 9. MEMBERS 1ST FEDERAL CREDIT UNION-CERTIFICATE OF DEPOSIT#279202-42 6,603.29 10. MEMBERS 1ST FEDERAL CREDIT UNION-CERTIFICATE OF DEPOSIT#279202-43 6,006.15 11, MEMBERS 1ST FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT#279202-51 5,002.32 12. PERSONAL PROPERTY-APPRAISAL ATTACHED 2,465.00 13, METLIFE -ANNUITY#A2050374 11,637.31 BENEFICIARY: THE ESTATE OF ANNETTA BURGETT 14, THRIVENT INVESTMENT MANAGEMENT 6,778.00 THRIVENT MOD CONSERVATIVE ALLOC FUND A ACCOUNT#40045648 15. THRIVENT INVESTMENT MANAGEMENT 10,940.48 THRIVENT MUNICIPAL BOND FUND A ACCOUNT#7355356 16. M&T BANK- IRA#35004201000699 74,732.16 TOTAL(Also enter on Line 5,Recapitulation) $ 227 350.20 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent ANNETTA A. BURGETT 21 13 0520 Decedent's Name Page 1 File Number Schedule E -Cash, Bank Deposits, & Misc. Personal Property ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 17. 2008 CHEVROLET IMPALA 9,904.00 SUBTOTAL SCHEDULE E 9,904.00 GRAND TOTAL SCHEDULE E $ 227,350.20 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 ANNETTAA. BURGETT 21 13 0520 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 5,496.32 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Names)of Personal Representative(s) CAROLYN G. FRISCHKORN 5,053.50 Street Address 15 WILD ROSE LANE City MECHANICSBURG State PA ZIP 17050 Years)Commission Paid: 2, Attorney Fees: IRWIN & McKNIGHT, P.C. 10,850.00 1 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: REGISTER OF WILLS 233.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 375.00 FINAL FIDUCIARY TAX RETURN 7. CUMBERLAND LAW JOURNAL- ESTATE NOTICE 75.00 8. THE SENTINEL- ESTATE NOTICE 210.78 9. LAWRENCE CHEVROLET- REPAIRS TO VEHICLE 626.40 10. SOVEREIGN BANK- DATE OF DEATH VALUATION 20.00 11. NOTARY FEES 50.00 12. REGISTER OF WILLS- SHORT CERTIFICATES 25.00 13. CAROLYN FRISHKORN - REIMBURSEMENT 175.00 TOTAL(Also enter on Line 9,Recapitulation) $ 28 244.00 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent ANNETTA A. BURGETT 21 13 0520 Decedent's Name Page 2 File Number Schedule H -Funeral Expenses&Administrative Costs -61 ITEM NUMBER DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: Personal Representative Commissions: 2. Name(s)of Personal Representative(s) DENNIS R. GUTSHALL 5,053.50 Street Address 3541 SPRING ROAD City CARLISLE state PA ZIP 17013 Year(s)Commission Paid: SUBTOTAL SCHEDULE H-131 5,053.50 REV-1512 EX+(12-12) pennsylvania SCHEDULE 1 DEPARTMENT OF REVENUE DEBTS OF DECEDENT, - INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ANNETTA A. BURGETT 21 13 0520 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. CUMBERLAND GOODWILL FIRE RESCUE-AMBULANCE 172.61 2. ALERT PHARMACY SERVICES-MEDICAL 43.61 3. HOSPITALISTS OF CENTRAL PENNSYLVANIA- MEDICAL 34.82 TOTAL(Also enter on Line 10,Recapitulation) $ 251.04 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: ANNETTA A. BURGETT 21 13 0520 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE t TAXABLE DISTRIBUTIONS [Include outright spousal distdbutions and transfers under Sec.9116(a)(1.2).] 1. RUTH SHAFFER Sibling 3,000.00 2 SUNNY DRIVE HARRISBURG, PA 17112 2. WILLIAM CARL GLEIM Collateral 1/9th REMAINDER 3. GARY GUTSHALL Collateral 1/9TH REMAINDER 4. DENNIS RALPH GUTSHALL Collateral 1/9TH REMAINDER 5. VICKI GUTSHALL MINNICK Collateral 1/9TH REMAINDER 6. CAROLYN GUTSHALL FRISCHKORN Collateral 1/9TH REMAINDER 7. MARK LEON GUTSHALL Collateral 1/9TH REMAINDER ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: i. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. ST. MATTHIAS LUTHERAN CHURCH 4,000.00 CARLISLE, PA TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 130F REV-1500 COVER SHEET. $ 4,000.00 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent ANNETTAA. BURGETT 21 13 0520 Decedent's Name Page 3 File Number Schedule J - Beneficiaries -1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 8. ANDREA GUTSHALL BITTENBENDER Collateral 1/9TH REMAINDER 9. TERESA LEA GUTSHALL WEARY Collateral 1/9TH REMAINDER 10. WANDA SHAFFER Collateral 1/9TH REMAINDER LAST WILL AND TESTAMENT I, ANNETTA A. BURGETT, of Middlesex Township, Cumberland County, Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. 1. I direct my Executor or Substitute Co-Executors, as the case may be, to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore, I direct that all state, inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property composing of my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid by the Executor or Substitute Co-Executors of my estate. 2. My Executor or Substitute Co-Executors may, at his or their discretion, compromise claims, borrow money, retain property for such length of time as he or thep—may deeal;pro zq lease and sell property for such prices, on such terms, at public or private salt, 1 ortey r%ie deem proper; and invest estate property and income without restriction t§:l�a`T-',inMtmeilts� :7-1 . unless otherwise provided hereunder. u ., — m c> ; CO 3. I authorize and empower my Executor or Substitute Co-Executor, to sell a@ rea*-n and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My Executor or Substitute Co-Executors is/are authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said Executor or Substitute Co-Executors. �� 31 e 4. I give, devise and bequeath all of my estate of whatever nature and wherever situate to my husband, F. CLYDE BURGETT,providing he shall survive me by sixty(60) days. 5. Should the gift in Paragraph No. 4 not take effect, I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: a. The sum of$4,000.00 to ST. MATTHIAS LUTHERAN CHURCH at Carlisle Springs, Cumberland County, Pennsylvania; b. The sum of$3,000.00 to my two(2) sisters-in-law,ALICE GUTSHALL and RUTH SHAFFER,share and share alike,providing they are living at the time of my death; and c. All the rest,residue and remainder in equal shares, share and share alike to the following, if they survive me: (1) My nephew, WILLIAM CARL GLEIM; (2) My husband's nephew, GARY GUTSHALL; (3) My husband's nephew,DENNIS RALPH GUTSHALL; (4) My husband's niece,VICKI GUTSHALL MINNICK; (5) My husband's niece, CAROLYN GUTSHALL FRISCHKORN; (6) My husband's nephew,MARK LEON GUTSHALL; (7) My husband's niece,ANDREA GUTSHALL BITTENBENDER; 2 (8) My husband's niece, TERESA LEA GUTSHALL WEARY; and (9) My husband's niece, WANDA SHAFFER. If any of the above-named persons should predecease me, I order and direct that the gift to such person shall lapse and the residue shall be distributed equally among those other persons who survive me. 6. I nominate and appoint my husband, F. CLYDE BURGETT, to be the Executor of this my Last Will and Testament. In the event he has predeceased me, failed to qualify or is not able or does not serve for whatever reason, I then nominate and appoint DENNIS RALPH GUTSHALL and CAROLYN GUTSHALL FISCHKORN to be the Substitute Co-Executors of this my Last Will and Testament, whereby the said Substitute Co-Executors shall have the same powers as are given to the original Executor hereunder. 7. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty (60)days. 8. No Executor or Substitute Co-Executor acting hereunder shall be required to post bond or enter security in this or any other jurisdiction. 9. No beneficiary may assign, anticipate or pledge his,her or its interest in any income or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or otherwise reach any such interest. 3 10. If any person entitled to share in any distribution under the terms of this my Last Will and Testament becomes an adverse party in any proceeding to contest the probate of this Last Will and Testament, such person shall forfeit his or her entire interest inherited hereunder and all provisions in favor of such person shall be declared void and of no effect. The share of such person so forfeited shall be distributed as part of the residue pursuant to Paragraph 5. hereof, except that if such person is entitled to share in the said residue, that interest shall be distributed proportionately to the other residuary beneficiaries. 11. I hereby suggest that my personal representative(s) retain the services of Irwin & McKnight, P.C. as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 16`s day of April 2010. Z a 19L,— (SEAL) ANNETTA A.BURGETT Signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and Testament, in our presence, who, at her request, in her presence and in the presence of each other have hereunto set our names as subscribing witnesses. 4 ACKNOWLEDGMENT AND AFFIDAVIT WE, ANNETTA A. BURGETT, KAREN S. NOEL and SHARON L. SCHWALM, the Testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to the best of their knowledge the Testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. z2" ANNETTA A. B ETT i KARtN Sr. NOEL SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA : : SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by ANNETTA A. BURGETT, the Testatrix herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L. SCHWALM,witnesses,this 16s day of April 2010. / G, 'J. N a y Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Roger B.Irvin,Notary Public Carlisle Boro,Cumberiand County My Commission Expires OcL 3,2072 5 Member,Psnnuylvanla Assoclanon Of Notaries M M d N 00 « W N Na Z IO 7 co W m W m W co co W N 0 0 O co N 1l- 1 W rh O N W O N O W O O N M d O N W ♦d" 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0 0 0 0 0 0 0 0 N A N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N O o M M M I- W W ;:, 0 � 0 N 10 O M N W r t' W W M N II- o O C _C )- 0 0 0 0 0 0 0 , 0 - O , 0 0 0 � O O O . 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N O W O O N M d d W W W W W W W W W 0) 0) 0) m m co m W m W co m m W 0) m 0) 0) W m m m 0) a « rnmm mmmmmmmmmmmmmmmmmmmmm0) m0) 0mmom NO O 0) Lo Cl) I- 0w t � 0) No O � M � N aDf= � .- aD aD aDNh u7 � O O o 0 0 0 o 0 0 , 0 0 0 0 d w w w w w w w w w mwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwww E m 7 M W M 0 o w w w w w w w w w w w w w w w w w w w w w w w MN W W 210 W W 7N W 0L W nMlO7 h00 W U00 � m 10 Z m m m 7 N 0 W O (wo W h W 1� C W 0) N R W W �0 �0 t0 W N 7 W O co 0 0) 0 7 0 0 Cl) W )0 10 N N i0 O W )!1 N 7 O o0 )0 O O I- co O m a 7 7 )0 N 7 m m N m O 1� 1- 7 Cl) • m M aN0 C N O v co N m N VW' n I r u 7 O � 7 O O Lo R � O m N 000 m N _W W N 0) CO I� _W _m m ! mNW � v m V r vmn W Cl) Cl) (0 C-4 mmm � Nm Eo0000000000000000000000000000000 0000 a 000000000 a 00000000000000000 0 1 1 1 r r , N N N N N N N N N N N N N N N N N N N N to 10 d D N •O w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w d w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w rA v C O N M 7 �0 W 1� Co 0) 0 .- N M 7 u•) W fh W 0) 0 N M 7 )0 W I- W m 0 N d . m 7 M M r I r__ N 00 L6 N ' N O d rn N Ow m d M NQ v Q m w o _ y C ` _ N O N CL CL N N min 8v TINL � rn Ito c m « � Zaoo0 C y y O y L L U `p C'C N O O N L O LJ O C C ci �Zm=ow yo M . fLa o O t') 2 y« IL m e „o_ m w. E ° a E2 axo i�o c�OF o , ,: m Ex0 0 X.- da C wrn Q Wn• p m w y m Q .c Q� f m«v a N v«roc > y C y C '> W O��n U • d- M'O CZM yd L • � CD Co m C 6 m UH `oo C » C O C y yt L E y y U U � 33� o LLi ui o awwc M__w O y y y N d N l0 Q to to 'L N @ 3 y y y.p C O 00oa N C 2 IL V 0 F O N p M V C co JAN-16-2014 09147A FROM:PROGRESS IMMANUEL PR 717 545 8787 TO:7172496384 P.3/6 THE CHECK BELOW REPRESENTS AN ADR PAYMENT To Inquire about your account,contact BNY Melton Shareowner Services . NATIONAL GRID Toll Free Number 800.455-7215 Outside the U,S. (Collect) 201-5806579 Hearing Impaired 900.231-5499 so BNY Mellon Shareowner Servlce8 is dedicated to providing YOU with the best shoreowner experience! Did you know that you could manage your portfolio online 24 hours a day, seven days a week? Simply log in to Investor ServiceDirectV(ISO)at wwm.bnXiMitoll.com/shorepmgorhsd rhsd kl #A^"1,'! urr+-� t ,�y`t.-a D ' r rZ St an . .!' .>, r n t " . .c'a. w an L -.,..•✓ .s{ �� Cl ' � dtt� � `��� t 44t'�✓"J t z t' °�;f5r�s�b4, > : 1� ' t .�'� 'Onhna,TCrvlcee nol of/bred by all fsBlom Will As a reminder, if you are currently participating in the Bank's Global BuyDIREC7'Plan, please note the Plan's reinvestment feature was suspended in order to process the optional Scrip dividend. If you elected stock but did not own enough shares(46 shares for this dividend)you will automatically be paid In cash. Additionally, only whole shares are being allocated forthe Soap,fractions will be paid In cash. All other terms and conditions of Me Global 13uyDIREC7•Pian.remain in effect. 'nETA1N FOR tlO't}R REi:01}Oii -------- .... WWWWWROM-0090 ON!, SHAREHOLDER OF - TRANSACTION DESCRIPTION - - NATIONAL GRID DIVIDEND tNVBI tD CUSS ACCOUNTKEY TYPE OF SECURITY RECORD DATE- PAYABLE DATE RATE PER ADS 806718e20656 00145503927430 aURGETT—ANNEA0000 AOR 1 1211 Oti1012012 1 $I.OB6700o CERTIFICATED ADS eOOK•ENTRY ADS GROSS DIVIDEND US TAX WITHMELD FOREIGNTOVNnTHHET.d AIDE FEE NETONIDENO 0 1.0000 $1.10 $0.00 50.00 SO1 $1.10 USTA%iNRHHELDYTO FO REIGNTAFAINHELDYrD AOR FEES Y@ NET OMOEND PAID YTD DROSS DIIMENDYTO TA%IONU ER please d�lash oMS reiatn $0.00 $4.00 $0.00 $1,10 31.10 ON FILE thta fmmtm WVr,emrds. , PLEASE DETACH BELOW CHECKNUMBER: 79196994 91� u NGG Historical Prices I National Grid Transco,PLC Nati Stock-Yaho... http://finance.yahoo.com/q/hp?s=NGG&"- 3&b=27&c=20l3&d=03_ Home Mail News Sports Finance Weather Games Groups Answers Solvent Flickir Mobile I More Mail National Grid ple(NGG) -NYSE Ar Role. AddloPortfoilo, Ulas �1_5 64.06 -0.12(0,19%) 9:3MM EST-Nasdaq Real Time Peter Historical Prices Got Historical Prim foi F_j Set Date Ran" S Daily Start Delete Elf.Jinn 1,2010 r Weekly End parts:FApT,V7 201371 Monthly r Dividends Only, Prima Date Open High Low Close volume Adi Cli Apr26.2013 62.34 62.56 62.31 62.39 423,700 59.18 Closer Prim inflatable for tkineend.and sp#tsr Download to Spreadsheet currency in VSD. Ad Topics That Might Interest You... 1, Best Stocks to Buy 6,Stocks to Buy Now Z High-Yield Dividend arp, 6, Penny Stocks mBuy u Hot Penny Stock Picks zpei Stocks mWatch « 10 Best Mutual Funds u, Dividend Income Funds � pmmmck m` / p+*,-mw*m^ww-nxm"-Sewnwm°a,vxmCC! ABC News Network Quotes are real-time for NASDAQ,NYSE,and NYSE Ai See aim delay broes for other inforrealintended for loading ourposes, mmwm Neither Yahoo!nor any m/ocleo is liable for any ^*wmow any actors taken i^reliance on'ommw"o centered^in' mo°w.00mo Yahoo/ue,you agree hot*/°u*m»vw*w/mwwiwvrol»,em mo Time comomxu,mammu ounces owmmknemmm"*our wmmm"nm»*,You myymstmm,,o vmmat on«off of 1/16/20149:35/QN | JAN-16-2014 09:528 FROM:PROGRESS IMMANUEL PR 717 545 8787 TC:7172496354 P.4/6 Direct Registration Account Statement ° "Haft Questions: U.S.telephone number:888A10.7458,Outside U.S.:651.453.2128 For online account Information,please visit www.adr.com/shareholder February 7,2013 Account Summary Banco Santander, S.A.American Depositary Receipts Adcount 0. 7000418115 Direct Registration Information F CLYDE BURGETT B CUSIP Number: 059641-1105 ANNETTA A BURGETT JT TEN Broker I Dealer Firm Name: 9806 SPRING ROAD Broker/Dealer Account Number: CARLISLE PA 17013.877 Broker/Dealer Participant Number. Transfer Agent Account Number: 7000418115 Account Value Market Value Date 2!6/2013 Market Value Price $7.93 Total Market Value $340.99 Share Balances Year-to-Date Amounts Service Charges Paid by You $0.00 Direct Registration 43.000 Commissions Paid by You $0.00 Certificate(s) 0.000 Federal Tax Withheld $0.00 Global Invest Direct Program 0.000 Nonresident Alien Tex Withheld $0.00 Total Shares 43.000 State Tax Withhold $0.00 Transaeflon or Transaction- -- - Prileper Gross service Brokerage NetAmounY Number of freer aa. ra on Settlement Oeto T share Amount Che a Co solo shares Balance DRWARD_._ Stock Dividend $0.00 $0.000 1.000 This statement represents the Banco Santander ADS$Issued to you as a result of your scrip election.A check fai:cash In lieu or fractional ADS Is attached.It you did not receive a statement then you are only entitled tocash In lieu of fractional ADSs. The shares represented by this statement are fully paid and non-assessable. This statement Is a record of addressee rights at the time of Issuance. Delivery of this statement of itself convoys no rights to the recipient. This statement Is neither a negotiable Instrument nor a securlry. A full copy of any rights, privileges, restrictions,and conditions which may be attached to the securities covered by this statement can be obtained by writing to the Secretary of the Company. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII •ZB0 91 607159361111 JYIYIYIYa1e M i 11� a �u, . SAN Historical Prices I Banco Santander,S.A. Sponsored Stock-Yaho... http://finance.yahoo.com/q/hp?s=SAN&a=03&b=27&c=2013&d=03... Home Mail News Sports Firlartce Weather Games Groups Answers Screen Flickr Mobile I More Mail E+;TRADE- No-FEE t t ATM ACCESS (OPEN AN ACCOUNT, r.,awr:rouaaar ao %� Trade Now -Banco Santander,S.A.(SAN) -NYSE * Follow Add to Portfolio Like {32 9.23 +0.17(l.81%) 10:37AM EST-Nasdaq Real Time Price Historical Prices Get Historical Prices far. Set Date Range � f Daily Start Date: Apr K' 2013 !Eg.Jan t,2010 r Weekly End Date: Apr 1 V7 ' 013 r Monthly r Dividends Only I,.Ge[Frices First I Previous I Next I Last Prices Date Open High Low close Volume Pdj Close- Apr 26,2013 7.08 7.14 7.06 7.14 3.687,800 6.62 -Close price adjusted for dividends and splits. First I Previous I Nett I Last Al Download to Spreadsheet Currency in LSD. Ad Topics That Might Interest You... 1. Best Stocks to Buy 5. 10 Best Mutual Funds 2. High-Veld Dividend ETFs S. Stocks to Buy Now 3. Hot Penny Stock Picks 7. Penny Stocks to Buy 4. Best Penny Stocks to Buy 8. Penny Stocks to Watch Feedback eds Privacy-Aboutour Ada-Terms-seed Feedback-Yahoo!-ABC News Network Quotes are real-time for NASDAQ,NYSE,and NYSE MKT See also delay times for other eshanges.All information provided as is for informational purposes only,not intended for trading purposes or adobe.Nei her Yahoo'nor any of independent providers is liable for any informational errors,incompleteness,or delays,or for any scions taken in reliance on information contained herein.By accessing the Yahoo'site you agree not to redistribute he information found[herein.Real Time continuous streaming quotes are available through our premium service.You may turn sthearring quotes on or off of 2 1/16/2014 10:38 AM Savereigri 4o Santander, b Court Ordered Processing\Decedents- MAl-MB3-02-10 - P. O.Box 841005 - Boston,MA 02284 s May 31, 2013 5 Law Offices s Irwin & McKnight, P.C. 60 W. Pomfret St. Carlisle, PA 17013-3222 RE: Estate of Annetta A. Burgett Date of Death: April 27, 2013 = Dear Mr. Irwin: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. Please feel free to contact me if I can be of any further assistance. Very truly yours, Linda Spavento Team Leader z 617-514-5189 fi R 0 tl a c u a a pyfi R 'v Sovereign Bank ESTATE OF Annetta A Burgett SOCIAL SECURITY#: 159-24-8001 DATE OF DEATH: April 27, 2013 Account#: 1695546984 Type: Save& Invest CD Open date: 6/4/2010 In the name of: F Clyde Burgett or Annetta A Burgett Date of Death Balance: $3,500.96 Int.(YTD) from 1/1/2013 to 4/27/2013 $0.00 Accrued interest to date of death: $0.00 Otherinfo: Account#: 2891032608 Type: Checking Open date: 3/29/1990 In the name of. F Clyde Burgett or Annetta A Burgett Date of Death Balance: $0.00 Int.(YTD) from to Accrued interest to date of death: Other Info: closed 3/8/12 for$12,541.65 Page 1 of 1 5 13/13 Deposit iaquir F; C]:; e k� " t Y Page Q] of 15 09 :53 : 15 ° � CIF number: APRIL B024345 ^Anne£ a A '-u y Phone: (H) (717) 243-0442 Birth date: 3605 SprIng Road (B) (000) 000-0000 4/20/1929 Carlisle PA 17013 Tax ID number: 204-30-6237 Br#: 043 Account type: 50+ Interest Check Messages Internet Banking Account number: 143000367 1 of 1 Available Balance: 2,:8318::'2;9_ >% Date last active: 4/17/13 Collected balance: 2, 838 .29 Last Dep: 4/17/13 10 . 93 Current balance: 2, 838.29 Date last overdrawn: 0/00/00 Yesterday' s bal : 2, 838 .29 Date opened: %310/.043;, Last stmt balance: 2, 838 .29 Date last statement: 4/25/13 Avg collected bal : 2, 838 .29 Date last contact : 9/30/03 Avg ledger balance: 2, 838.29 Closing balance: 2, 838 . 31 Interest rate: . 010000% Accrued interest: . 02 Stmt/Service chg/Int cycle: 25 Service charge: Yes Automatic NSF fee: Yes SC Waive expiration: 0/00/00 Statement/passbook code: Statement Service charge code: 11 More. . . F1=Addl functions F2=Image F3=Exit F4=Sweep Inquiry F5=History F6=Messages F8=Maintenance F24=More Keys /May.' 3�0. 2013 2:22PM No. 2401 P. 1/1 v Thrivent Investment Management' PO Box 219348,KOM$City,MO 64121.9348 A subsidiary of Thriven[Financial for Lutherans' Thriventoom•800-THRIVENT(6068474836) Appleton,WI•Minneapolis,MN Member PINRA and SIPC. May 30,2013 Attn Mike FAX#717-254.6349 RE: 00723425 THRIVENT MOD CONSERVATWB ALLOC FUND-A ACCOUNT NUMBER:XXXXXXX5648 FRANK CLYDE BURGETT& ANNETTAA BURGETT JTWROS POA. Dear Mike: We have received your request for information.In the table below we have listed the account(s)for the above-referenced indivldual(s). Any shares and balances of the mutual funds listed reflect values as of the date quoted.A mutual fund account balance is based on the net asset value share prices as of specific dates;values mayfluctuate on a dailybasis. AsOfApdl27,2013 Fund Name Account Number of Price Per Balance Number Shares Share NTMOD CONSE IV 40045648 583.30$ $11.62 $6,778.00 CONSERVATE ALLOCFUND-A THRTVENT MUNICIPAL BOND 7355356 919.368 $11.90 $10,940.48 FUND-A If you have any questions,please call us at 800.847-4836. Sincerely, Ko Bil Her Mutual Fund Representative MetLife Investors USA Insurance Company P.O. Box 295 01168 Q T/rQQ �,"",� Des Moines, IA 50306-0295 Meftil ■ e-,n.-sue+ ;. ESTATE OFANBURGETT 60 W POMFRET ST CARLISLE, PA 17013 1 Date: 06-17-2013 Customer Service: 1-800-343-8496 Check No: 061502665 Contract No: A2050374 Claim Proceeds Gross Payment 11,637.31 RECEIVED JUN 2 1 2013 IRWIN&McKNIGH t LAW OFFICES z Bethany Hopper Sr. Annuity Representative-Post Issue Processing MetLife�nnuity Operations and Services Help us stay connected: Please keep us updated with respect to all who are associated with this contract,including the owner,the annuitant,and any beneficiaries. Make sure that we have the following information for all persons or entities: name,address, phone number,date of birth,and social security or tax identification number. Changes may be submitted to the address provided above,by calling our Customer Service Center at the phone number provided above,or by contacting your Representative. Kevin M.Wickard 140 Pleasant Hall Road Carlisle, PA 17013 (717) 241-5341 May 13, 2013 Estate of F. Clyde and Annetta Burgett 3605 Spring Road Carlisle, PA 17013 I, the undersigned appraiser, have personally inspected the articles listed on the attached summary. To the best of my knowledge, the values stated are true and correct as of May 13, 2013. I have found most items to be in good condition and have taken into account both physical and functional depreciation in arriving at conclusion of value. I further certify that I have no personal interest in the property and that neither my employment nor compensation is contingent upon the valuation of this property. In my opinion the fair market value of the items contained in the Burgett Estate as of May 13, 2013 is $2,465.00 Respectfully submitted, nn Kevin M.Wickard f*Vft PRIMARY OWNER: F. Clyde Burkett MEMBERS V "° o FMERALCRMrr UMON REGULAR SAVINGS ACCOUNT: Account Number/Suffix 279202-00 Date Account Established 01/31/2008 Principal Balance at Date of Death $173.80 a' !'! Accrued Interest to Date of Death $0.02 Total Principal and Accrued Interest $173.82 Total Interest 1/1/13 to 4/27/13 $0.11 Name of Joint Owner Annetta A Burgett Date Joint Added 01/31/2006 CERTIFICATE OF DEPOSIT: Account Number/Suffix 279202-40 279202-41 Date Account Established 08/06/2012 09/17/2007 Principal Balance at Date of Death $35,001.64 $5,000.00 Accrued Interest to Date of Death $26.18 $1.78 Total Principal and Accrued Interest $35,027.82 $5,001.78 Total Interest 1/1/13 to 4/27/13 $116.78 $7.94 Name of Joint Owner Annetta A. Burgett Annetta A. Burgett Date Joint Added 08/06/2012 09/17/2007 CERTIFICATE OF DEPOSIT: Account Number/Suffix 279202-42* Date Account Established 11/01/2012 Principal Balance at Date of Death $6,600.00 Accrued Interest to Date of Death $3.29 Total Principal and Accrued Interest $6,603.29 Total Interest 1/1/13 to 4/27/13 $14.67 Name of Joint Owner Annetta A Burgett Date Join Added 12/_03/2009 *Rollover from CD 279202-49 opened 12/03/2009- CERTIFICATE OF DEPOSIT: Account Number/Suffix 279202-43 279202-51 Date Account Established 07/1012008 05/12/2010 Principal Balance at Date of Death $6,000.00 $5,000.00 Accrued Interest to Date of Death $6.15 $2.32 Total Principal and Accrued Interest $6,006.15 $5,002.32 Total Interest 1/1113 to 4/27/13 $27.46 $10.33 Name of Joint Owner Annetta A Burgett Annetta A Burgett Date Joint Added 07110/2008 05/12/2010 MEMBERS IT FEDERAL CREDIT UNION Tessa L Klugh Lending Insurance Support Specialist May 9, 2013 Estate of: ANNETTA A BURKETT Date of Death: 04/27/2013 ' Social Security Number: 159-24-8001 5000 Louise Drive • P.O.Box 40 * Mechanicsburg,Pennsylvania 17055 * (800) 283-2328 * www.memberslst.org p M&TBank 499 Mitchell Road,Millsboro,DE 19966 Adjustment Services Phone 888-502-4349 F a (302)934-2955 May 14,2013 Law Offices RECEIVED Irwin & McKnight, P.C. West Pomfret Professional Building MAY 1_.7 2013 60 West Pomfret Street Carlisle, PA 17013-3222 IMM i McKUGHT LAW ONUS Re: Estate of Aiineita A.Burgett ; Social Security: 159-24-8001 Date of Death: Apri 127, 2013 Dear Sir or Madam: Per your inquiry on May 07,2013,please be advised that at.the time of death,the above-named decedent had on deposit with this bank the following: 1. Type ofAccount Checking Account Account Number 405957 Ownership(Names qn AnneitaA.Burgett F. Clyde Burgett Carolyn M Frischkorn(POA) Opening Date 0910111967 Balance on Date of Death $17,798.84 Accruedlnterest $ .05 Total $17,798.89 2. Type of Account Savings Account _ Account Number 15004198225475 Ownership(Names q)) Carolyn MFrischkorn(POA) Annetta A.Burgett F. Clyde Burgett Opening Date 0412312002 Balance on Date of Death $22,939.16 Accruedlnterest $ .41 Total $22,939.57 3. Type ofAccount Certificate of Deposit Account Number 31003917741140 Ownership(Names of Carolyn M.Frischkorn(POA) AnnettaA:Burgett `R'Clyde`Burgett Opening Date 0113112007 Balance on Date of Death $6,000.00 Accrued Interest $ .36 Total $6 000.36 For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds, please call the}Tigh Street Carlisle at 717-2404536. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Valarie Mercer Adjustment Services 4. Type of Account Individual Retirement A ccount Account Number 35004201000699 Ownership(Names ot) F. Clyde Burgett Opening Date 1010212006 Balance on Date of Death $74,729.49. Accruedlnterest $ 2.67 Total $74,732.16 LM M&T Bank IRA DISTRIBUTION TO BENEFICIARY FORM AND AFFIDAVIT ❑TRAD ❑ROTH ❑SEP.PLAN (FOR OUAUFIED PLANS COMPLErE rORM B"94) Name F. CLYDE BURGETT Date of Birth 04/20/1929 social security tt 204-30-6237 Data of Death• 04/17/2013 •Attach death certificate L4.jfflft , _ fR -1 Name THE ESTATE OF AARfg�A% phone (711 249-2353 Data,f Binh' Mailing Address 60 WEST PON M T STREET Relationship to Depositor ESTATE Percentage of Plan 1002 City,state,zip CARLISLE PA 17013 Customer Modification Legal Address(it different am noting address) Customer Identification- city.state,zip Current Employer or Nature,of Self•Employmenrl SSO or Estate Tx to# 46-6807783 *Not applicable If the beneficiary is not an individual,such as the estate or a trust. **Two forms of Identification are required If customer is now to M&T Bank and an If not an IndMdual,allach appropriate Legal documentation. Inherited IRA Beneficiary or Transfer to Spouse Account Is being established. SECTION A: OWNER DIED ON OR AFTER THE REQUIRED BEGINNING DATE(April I of the year after owner attained age 7014) 1. If the beneficiary IS an Individual or qualified trust,select one of the following: a) ❑ Lump Sum-Distribute account In a single lump sum b) ❑ Inherited IRA-Single Life Expectancy-Make periodic distributions based on single life expectancy of the beneficiary's or owner's remaining single life expectancy c) ❑ Transfer To Spouse-Designate entire account as spouse's own(Available only if the spouse Is named sale beneficiary). d) ❑ Spouse Rollover-Rollover spouse's interest in account to spouse's own IRA (Available whether or not the spouse Is named as safe beneficiary) 2. If the beneficiary IS NOT an individual or qualified trust,or if NO beneficiary is named,select one of the following: a) ❑ Lump Sum-Distribute account In A single lump sum b) ❑ Inherited IRA-Single Ufa Expectancy-Make distributions periodically over the owner's remaining single life expectancy SECTION B: OWNER DIED BEFORE THE REQUIRED BEGINNING DATE(April 1 of the year after owner attained age 70%) 1. If the beneficiary IS an individual or qualified trust,select one of the following: a) ❑ Lump Sum-Distribute account in a single lump sum b) ❑ Inherited IRA-Single Life Expectancy-Make distributions periodically based on single life expectancy of the beneficiary's remaining single life expectancy c) ❑ Inherited IRA-Five Year Rule-Distribute entire account by December 31 of the year containing the fifth anniversary of the IRA owner's death d) ❑ Transfer to Spouse-Designate entire account as spouse's own(Available only if the spouse is named sale beneficiary). a) ❑ Spouse Rollover-Rollover spouse's Interest In account to spouse's own IRA (Available whether or not the spouse Is named as sale beneficiary) 2. If the beneficiary IS NOT an individual or qualified trust,or if NO beneficiary is named,select one of the following: a) ❑ Lump Sum-Distribute account In a single lump sum b) ❑ Inherited IRA-Five Year Rule-Distribute entire account by December 31 of the year containing the fifth anniversary of the IRA owner's death 24-5 A". Amounts distributed from your IRA may be taxable as Income to you In the year received.These distributions are subject to federal income tax withholding at 10%unless you elect not to have tax withheld.If you elect not to have withholding apply to your payments,or If you do not have enough federal income tax withheld from your payments you may be responsible for payments of estimated tax.You may Incur penalties under the estimated tax rules If your withholding and estimated payments are not sufficient. must check one and only one of the following boxes: I elect not to have any federal income tax withheld from the distribution(s) I elect to have %of each distribution withheld as federal income tax.(You must elect a percentage greater than 10%.) ❑ I elect to have a fixed dollar amount of $ from each distribution withheld as federal income tax. Copy to Pension services a Customer BA469 law)W 2008 Chevrolet Impala LT Sedan 4D Trade In Values-Kelley Blue Book http://www.kbb.corWchevrolet/irnpala/2008-chevrolet-impala/It-sedan... QZIPCODE:17015 I Sign in(or Sign up) home I car values I cars for sale I car reviews I kbb top picks research tools Popular at KBB.com The 40 mpg Cars of 2013 advensemeot My ads? Home>Car Values>Chevrolet>Impala>2008 >Style>Options>IT Sedan 4D Chevrolet Impala 2008 Go Your Blue Book°Value Show Used Car Prices I Price Your Next Car 2008 Chevrolet Impala style: LTSedan4D edit options i check specs Mileage: 30000 Change Like this car Trade-In Value Private Party Value when trading in at a dealership when selling the car yourself Q Print Report Excellent $9,904 Shop for your next car ""`ck? Very Good $9,754 Good Instant Trade-In Offer Gee ehe offer $9,279 Fair $8,229 Own it? Love it?Tell Us. write a review Verify Condition Track this car's values Values valid until Sell your current car Place an ad 08101/2013 ad,aaement Why aria? (updated weekly) Helpful Resources from KBB.com New Cars You Might Like Apply for Financing Get Selling Advice Check Local Prices Lock in your loan,then See the pros and cons See what people near you shop for your next car. of different ways to sell, are asking for their cars. 2014 Chevrolet Impala T� View Cars for Sale Get a Used Car Report near Carlisle 2014 Kla Cadenza 2008 Chevrolet Impala Get the Information You Need on This 2008 Chevrolet Before You Buy 47 for Sale Near You View Enter VI/V(opb'ona/f Go 2014 Mazda MAZDA6 sue . Recently Viewed Cars I My Saved d Cam Save car View 1 of 3 7/26/2013 11:41 AM FUNERAL HOME & CREMATORY, INC. Carolyn Frischkorn May 23, 2013 15 Wild Rose Lane Mechanicsburg, PA 17050 Statement of Funeral Expenses for: Annetta Agnes Burgett Date of Death: April 27, 2013 Account Id: 16868-109 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,850.00 Sub Total: $ 4,850.00 TOTAL FUNERAL HOME CHARGES: $ 4,850.00 CASH ADVANCES: 30 Certified Death Certificates at$6.00 each $ 180.00 Newspaper Notice-Sentinel $ 167.32 Clergy $ 100.00 Flowers $ 159.00 Hairdresser $ 40.00 Sub Total: $ 646.32 Total Funeral Expense: $ 5,496.32 Payments Made: Balance: $ 5,496.32 MAY-7-2013 12:12P FROM:PROGRESS IMMANUEL PR 717 545 8787 70:71724%354 P.1 F. Clyde and Annetta Burgett Estate 3605 Spring Road Carlisle, PA 17103 FAX COVER SHEET TO: Karen FROM: Carolyn Frischkorn & Dennis Gutshall FAX NUMBER: ay 9 - 4 3 Sy DATE: May 7, 2013 COMPANY: Irwin & McKnight TOTAL# OF PAGES 10 (including the cover sheet) Karen, Attached is the paperwork concerning my uncle's car repair and inspection. The cost of the repair from the accident was $1,847.92. (I attached the insurance paperwork from D.L Dravie and Assocaites) Lawrence Chevrolet has,received a check from the insurance company for $1,347.92. `Clyde has'a;$600AO.deduatiblewhich'will need tobepaid. ' ' Also, the car was inspected and needed a "away bar" repaired to pass inspection and the t3tal of the inspection with the repair is $T26 40.; If you would please ie'`d":Lawrence Che'vrolet,'6446 Carlisle Pike, Mechanicsburg;PA. 17080, a:cheek'foi;$626.40;.we would appreciate it, then we will be able to obtain the car from them. Thank you, Carolyn Frischkorn &Dennis Gutshall Contact Information Carolyn's Denny's Phone: 791.9761 249.4788 Cell Phone: 717.497-8830 717-448.4316 Work: 545-8711 241-9222 MAY-7-2013 12:53P FROM:PROGRESS IMMANUEL PR 717 545 8767 TO:71724%354 P.5 Ljjnj! 6445 Carlisle Pike Mechanicsburg, PA 17050 Phone (717) 766.0284 CH www.lawrencechevy.com OY EP Q AMMOR NVORM tLATE INVO N . -COS: :Z. SHAYdN C: MCNERTNEY. 11 : '' - -4c.::5' 03' 1;4•.. CVC5430391 .."Ism re a1aEN 8n4 MIIE«ae aowa BraaK N0. CNd BURGV'f .00 2tJE/: 664988 ' 3605 SPRING RD rE«Rrr IMo oE- -PAW - mu rn WWII CARLISLE, PA 17013-8737 CNEVROL / PAiA, ' LMPALA.:L'T _` r,=05/12. 11'_ 4 90 . 2 G law T 5 8 N 0 8 9 2 4 9 8 3 0 BE'LLNO OE«EP NQ P,ROWCT ON M1a +.. P. ,aN0. NO.NO. RO,bRE 05/02/13. REPRINT#:Je: NEB71.�;243 1075 0DISAPPEARING. ' QQ At , ,•......... ....... a' r: ;es �: .. ';' •.; .- ,rr s� ' � � •� 4 6 r DISCLAIMER OF WARRANTIES t; " FARTS 3T7 The only warranties, If any, applying to " ' y, ,S C5,' 10 t `" ' the part(s) and/or service are those -.; h JG3{�; e10QRFUIL 'PROIX' CV 0 4 JtiTvlL - 19 2g.` offered by the manufacturer.The Bening Cf(ARQES.. rtx .... ..:. a_.<:•. d. :,; dealer hereby expressly disclaims all : . 3 :.w tc, ,• J. warranties, either expressed or implied, W including any Implied warranties of ;=f.'.';,:_,; ECQ,1( NAAT. O S' OR lo- merchantability or illness for a particular RAf(Sfl.s ON FOSH'T69395 PkUS TAX purpose, and neither assumes or aulho- '` •:,::. :,; Nzes'any other person to assume for It p; any Ilebllity In connection with the sale of JOB# 5 JOURNAL PREFIX CVCS JM#: 5 T:OTTA4 '" ' '9 'Pb this perils)and/or service.Buyer shall not • r �> - L,• be entitled to recover f the selling :. ......,..............................................:.....:' dealer any consequential damages. L (9 •949A' 7 i ",' of "see loss of pert, damages for loss .........................................................r,:r 9 ..i. p Income,or any other Incidental damages. AxkttNxMrka4a�«YF�Tr««.rr OTAL LABOR > 10 ;45 r LPgRIS 33,79 ..,�,. .: . .. .. • TO SUBL 00 TA1 ET... - 1 IMPORTANT INS CK O #........... « T 7 L O:A . , . Q4QD' : DISCO r tSe 1.6,700: ► ONARCrF`( ) ^' a T 7 J)lb pEC @S 0 8 4"f DgTE. t w T O ? �re►ww " �i twrtrr« t]�tr�'y�$' � t d @',+{0 ro v a A''SUav �' ' E�OING:-. SERVICE $, ,. t wAN R MP.LL y ri . 11 IAIIK Y011 lE COKTA L/( ENCE. • L E >AAP 0 t @ +° I ; N ''MaGOEIN WILEME ovr Q�3pOG20 pQ whkle If Imwn p a , :, - ':.•;.. ;.• . it to to ,lu neMCr.our '..:• 9oAy shop ProfgePorale am ready"help. , _ y." eame 4n for a }m pR MOA an all tower and nlw r/��«eba i "'+ • and 14 ymm"kids loerar�q �?:, • a' S.. ,flit" ., .• ` IIMe mml Phase cell(717)766-0204 SAG oI P CUST'NERCOPY ( ENO OR (p"NV.OICE'J" .OB;78aM.':. for an appd"Not, MAY-7-2013 12:14P FROM:PROGRESS IMMANUEL PR 717 S45 8787 TO:7172495354 P.3 7 6445 Carlisle pike L Mechanicsburg, PA 17050 Phone (717) 766-0284 C�`IEIVEZOI T www.iawroncechivycom cu HOH r o H :0'$ 2,.:z. IA. - x �fi: :, 'a ":'z. - 5 p 1 3' CVCB429845 S u {y t ro yt ,�- -::P':.s ti '.CY, !l.{80tiNVH (JGEXHp Np .EffyE,(QH CARL- Gum Hf4ClF{t0. F:cGL° DE $i1R ET`I ' =. ':.•. ,. g,..,0 G G t,r . T 66#983 3G05 SPRING RC H"" e+oos� oRUVe ,a a sy,i i78 `HEuRt) 8i�'xMf?ALA' Y RALA_;CT :aaz, , Yr4s t36' 11CARLISLE, PA 2 7013-8737 " ➢ ' 2 fi 8 1 t} ..4:: IwTS tt089 498 3 0. .*'. +.Y$ y�' t,6. :.x.• •F ,{ '(' ..r. ,!0. ` RM. 34 e H a o s 444°C fs#. fJp SA}#RFAIMI;,'. .� : ez" Y a,- a - .•, ,ir^r ` , NY�lA6 3rF!i1�Nitlk�i'Ma;;k*" Yh #-'Mv!##,Mr MY k'ifh•FFi1�iH'rtr;R: ..w'^ -.- �xi, : 'r DISCLAIMER OF WARRANTIES The on warranties, If any, applying to ;1 .r, ,.yF * r 1AE "x { h w Ta t ' the part(s) and/or aertnoa are those � ' *-: . offered by the manufacturer.fia setting tG Ci4 M ,, i tflS fit ( .) � * A� G 0 G tF ,s dealer hereby expressly disclaims all OTAL 5pa1� at a:lpv p TOTAL M $@ p . °' {r ' :gyp werrantle8, ellher expressed or Implied, :z 3 { f TOTAL Jt"Including any Implied warranties of �b' merchantability or Ntness for a particular �3YkA ,;u,i RA s , ,,. • ;.` UL INVpIC ,� ; c. purpose, and neither assumes or autho ... > ;iy rizes any other pstson to assume for It r Y s O*A (tRYEY`.ptpNNEtO1G HO1OttS ; `'�' s , 'anY liability in connection with the sale of AE��PO fihYIGa,Y SIT E'Yt><! 1tiH0T x this part(s)and/or servtea.Buyer shell not R COIT;SEp Td A 41USfidO ... be entitled to recover from the selling E Gp ACT. LaAhI IVCP.;I'WILL 9EUPPY T6 HELP *'•,,, dealer any consequential damages, = ::, _ .. . ` : - . �< ,• ;damages to property, damages for lose of use, loss of time, loss of profits or Income,or any other InGdemal damages. 'YW'-: `:C :0..y'.,'- � j� •t �'+4 ' MAY-7-2013 12:12P FROM:PROGRESS IMMANUEL PR 717 545 8787 TO:7172496354 P.2 L 6445 Carlisle Pike Lawrence Mechanicsburg, PA 17050 Phone (717) 766-0284 C MVROLET www.lawrencechevy.com � . Nal G Rk, 16$ 5019429845 „I. ',: :, .: LAS flA' ceXaeNO. ° .,. ]3• CL<YDV OUACe `; ;�: 1r0b, r 1E�oe •S1 20`4 $�1�k/ wusa 3605 5PRING RD r�fl MAaer eo �euvE DAre pEyvem Mpee CARLISLE, PA 17013-8737 UtI CHE�f�OLET -I PAI.A.LT/.SM04 4rT` VEXICL61.0. p. �EWNQ p6Al6fl NQ ffl6pY4TpNDATE 2 G 1 W T 5 8 N 0 8 9 2 4 9 8 3 0 ,_: •.. 5: 'oa61N2pB P.pN6 a B ..-•..._... y- .r_ . . - i + A - i _re.•�t - r"•.. .�i "p•�,...'..,:. .,. .. . , ?� .:� ._,A DISCLAIMER OF WARRANTIES ,t )14 f.2. �' .E-1 - •-1 rc.YiC yY.\ L::r.. •• •A.. }A9 .jd'•i 3 .:, ...2. .i`!. \ �}�:.:Ir''pl The only warranties, H any, applying to T P`: a�. .,. T . . ..._ ;.. . the pert(s) and/or service are those °° .1 offered the manufacturer.The selling P QEO° I) N V R:''. H Pi"11EATkED AN..,.,... . by 9 i:>'S ';% .;.g dealer hereby expressly disclaims all werre itles, either expressed or Implied, PAR75 : .f 4f .FR NUM�Bg R a.: r D�SLRIPTION .....................UNIT b'3X '`" including any Implied warranties of 1 95 8160".�'�i 26950360 tIS 0 tlDV, 252 50 2 2 5 merchantability or fitness for a particular 't , 59025�47U . 990?5047 95110 FA5G . 20-17 43r ' purpose, and neither assumes or autho- I +U: , ', ' TQTA4 ¢ has rizes an other person to assume'for H PART'. Y �aO'O & {7PpCI $• ......... .. " • n} airy liability In connection with the sale of 0X97 :,; to 0.000 /UNIT` , ' c; •w6 dD this perils)and/or service.Buyer shall not D 0[( be entitled to recover 1rom:the selling 3 ':'•1' dealer any consequential TOfAhS:..:.::.:..:.......:-_.•..-_..._.:....._..........._ ..:... r;':, i. d damages, �Y ).A80R, damages to property, damages for lose Ws* ` . ; - • .+ of use loss of time, loss of profits or ;;N. PARTS . . 5. ;: 5 P � sr.�,g• r•'' , Income,or any other Incidental damages. 7 �` ,rLaigs• • < .................... 7fIBN 1:T0�AL.' . ':,' .'859 ts'. IMPOnTANT NIT. NER AS NEEDED. :•.,•, ;:. , " ED FRO BUMPER, RIGHT FENDER, REAR UNP R ER° ' A: t ?-a PAINT AND RTA ��-•NIT v S'?6�;� 3Q �S :;70L }l YOU atTr d4!,i n, JO 2 JOURNAL PREFIX .(VCS '0 2 7 A N`4 0TAL • 8 4q�. gy V MM5 Z .., MMAGE IN LA 13e011r " LtN�t♦FORMA,Z eA(L F 6URGETI 717.497.9494. 0 01 39 DOW V1 a;` _ .. ' .. .. I:+t'tn'• nwl p yaw whlde It hahhp a 11"Is under the meander• our :':d:,f7.• ::f i ' .,.Y'- i'-W'�.y 000 Shop Prafaelanah are •:.7 rr _ n?' y ready to help. ".P:,v "�•':,` I:� ,Y '. ji„) CrrM In for }lE9 F0)mar8 an all n4or and Mnar ra Ira `';k po ? : ..+i: ', :� SIN hsrp your.shlck(aaMlnp 3'�s`.e ;' :..�4'. _•F . .. :e:r .',., . , , r' Ilk,nni �Y fd+•' n.( y rti 'li'd + , Piave mil(717)766-02M O11670ME9 OAV ,' (CONTINUEG,ON.N�XTPAQAI 02#Pm � tar an aPP�tlnmt. aramua,m _..__. _.Y.. .. -.«..... © Mli�mpany RETURN ITEM NOTICE Manu' cturers and Traders Trust'Ce 9uf lo, New York 74240 405957 F CLYDE BURGETT 05-06-13 ANNETTA A BURGETT 3605 SPRING RD CARLISLE PA 17013-8737 ITEM SEQUENCE NUMBER AMOUNT ACTION NUMBER 3926 175.00 ITEM RETURNED - ACCOUNT CLOSED 008003426443 CI INSURANCE, INC. M�►- 1 C�1e�IG ; Acct If you have any questions regar, representative or M@T's QuickL i' Buffalo Area - (716) 626-1900 � � 40 170 t3(} OF 1 \J LIM Isiah Please'Remit Payman[To _ , ,-Cumberland Goodwlllflre Rescue EMS Billing Office 13-141156 n86.48 PO Box 726 New Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: Info @ambulancebillingoffice.cem Date of Service: 4/10/2013 18:15 Please visit our website to provide insurance or make payment, and Patient Name: BURGETT,ANNETTA for additional payment options and frequently asked questions: From: Carlisle Regional Medical Center www.ambulancebillingoffice.com To: CHURCH OF GOD HOME • This type ofservice is not covered by ambulance memberships, Medicare, Medicaid and most secondary insurances. Payment is your responsibility. ..-_c_ - _ . o- �, . . "�',.�''_ ;. � YS)�axN\ Pii�iu`1ti° ::,({, 4/10/13 Stretcher Van One-Way Transpo A0130 1.0 80.00 80.00 4/10/13 Mileage S0209 3.7 1.75 6.48 Total 86.48 0.00 0.00 Please Remit Payment To: r.� , ,_ , _ •. ,Cumberland Goodwill Fire Rescue EMS Billing Office 13-142010 4/23/2013 PO Box 726 New Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: Info @ambulancebillingoifce.com Date of Servioe: 4/12/2013 14:10 Please visit our website to provide insurance or make payment, and Patient Name: BURGETT,ANNETTA for additional payment options and frequently asked questions: From Carlisle Regional Medical Center www.ambulancebillingoffice.com To: CHURCH OF GOD HOME IMPORTANT-MESSAGE: This type of service is not covered by ambulance memberships, Medicare, Medicaid and most secondary insurances .Payment is your responsibility. o 4/12/13 Stretcher Van One-Way Transpo A0130 1.0 80.00 80.00 4112/13 Mileage S0209 3.5 1.75 6.13 Total 86.13 0.00 0.00 U u u u U u u U u u u U u u - ; m m n M H m O . r-. . N . 1p M M 41 n . d. Ill . Ill . 0\ r. 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