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Home My WebLink About03-13-14 (3) C 1505611185 REV-1500 EX(02-11)(FI) OFFICIAL USE ONLY Bu reau of Individual Taxes Department of Revenue County Code Year File Number Bu PO BOX 280601 INHERITANCE TAX RETURN 21 13 0826 Harrisburg,PA 1 71 28-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 06122013 11031948 Decedent's Last Name Suffix Decedent's First Name M I HORN JAMES H (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI HORN BEVERLY J Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) 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 ❑ 10. Spousal Poverty Credit(Date of Death ❑ 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number VICKY ANN TRIMMER 717-620-2440 r.s REGISTER OE&VILLS USE ObW, Q . tit t First Line of Address PERSUN & HEIM, PCB w _r" "7;) Second Line of Address PO BOX 659 ' City r Post Office DATt FILED y State ZIP Code MECHANICSBURG PA 170550659 CorrespondenYse-mall address: VATRIMMER@PERSUNHEIM -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,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG RE OF PERS ESP90SIBLE FOR FILING RETURN DATE / AD RESS / ! �1 r BEVERLY( RN 1 ACAMP HILL, PA 17011 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIZ) / L PERSUN & HEIM, P .C. ATE,t �^ z ADDRESS r PO BOX 659 MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505611185 OM46473.000 1505611185 J \ -- V 1505611285 REV-1500 EX(Fl) Decedent's Social Security Number Decedent's Name: H 0 R N JAMES H RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 . 00 2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . . 2. 16,957-00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C). . . . _ 3 0 .00 4. Mortgages and Notes Receivable(Schedule D) . . . . . . 4 0 •00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) . . . , . 5, 181495 . 00 6. Jointly Owned Property(Schedule F) F-1 Separate Billing Requested . . . , 6. 0 .00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) F-1 Separate Billing Requested . . . . 7. 2 0,19 3.0 0 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . 8 55,645-00 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. 249 -00 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . 10. 0.1111 11. Total Deductions(total Lines 9 and 10). . . . _ . . . . 11. 249 -00 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . 12. 55-,396 - 00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J). . . . . . . . . . . . . . 13 0 .00 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . 14 55,396-00 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers un�er Sec.9116 (a)(1.2)X.0- 36,901- 00 15. 0. 00 16. Amount of Line 14 t viable at lineal rate X.0 4_5 18,495-00 16. 832 . 00 17. Amount of Line 14 taxable at sibling rate X.12 0 .00 17. 0.00 18. Amount of Line 14 taxable at collateral rate X.15 0.00 18. 0.110 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 832- 00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT El Side 2 1505611285 1505611285 OM4648 3.000 REV-1500 EX(F 1) Page 3 File Number Decedent's Complete Address: 21 13 0826 DECEDENTS NAME HORN JAMES H STREET ADDRESS 859 WYNNEWOOD ROAD CUMBERLAND CITE' STATE ZIP CAMP HILL PA 17011- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 832 - 00 2. Credits/Payments A.Prior Payments 777- 00 B.Discount 41-00 Total Credits(A+B) (2) 818-00 3. Interest (3) 11-00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box 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) 14 -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 . . . . . . . . . . . . . . . . . . . . . . . . ❑ a b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . ❑ ❑ c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ❑ EE 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? . ❑ 4. Did decedent own an individual retirement account,annuity,or other non-probate property,which contains a 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(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. OM4671 2.000 REV-1503 EX+(8-12) Pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER James H Horn 21 13 0826 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Verizon - Common - 32 shares 11056 2 AT&T - common stock - 409.944652 shares 14,280 3 AT&T - common - 29 shares 1,010 4 AT&T - common - 3 shares 105 5 12 Shares Comcast - 12 shares 506 TOTAL (Also enter on Line 2,Recapitulation) $ 16,957 2w4696 2.000 If more space is needed,insert additional sheets of the same size REV-1508 EX+(08-12) Pennsylvania SCHEDULE E DEPARrvF-WOF REVENUE CASH, BANK DEPOSITS &MISC. IDECE TAX DECEDENT PERSONAL RETURN RESIDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: James H Horn 21 13 0826 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joinfly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Ring - see attached appraisal 17,900 2 Camera Equipment - see attached appraisal 595 TOTAL(Also enter on line 5,Recapitulation) $ 18,495 2w46AD 2.000 If more space is needed,use additional sheets of paper of the same size. b REV-1510 EX+(08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER James H Horn 2113 0826 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 INOLL DETHENOMEOF THE TRANSFEREE.THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE NUMBE THE DATE OF TRANSFER ATTACHA COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE VALUE 1. Hefren-Tillotson, Inc, IRA 13,902 100.0000 0 13,902 Spouse is beneficiary 2 PSECU IRA 2,166 100.0000 0 2,166 Spouse is beneficiary 3 PNC IRA 4,125 100.0000 0 4,125 Spouse is beneficiary TOTAL(Also enter on line 7,Recapitulation)$ 20,193 If more space is needed,use additional sheets of paper of the same size. 9W46AF 2.000 REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENTOF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER James H Horn 21 13 0826 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: 1. None 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: 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: 159 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 R Novinger Jwlry Appraisal 65 2 Register of Wills 25 TOTAL(Also enter on Line 9,Recapitulation) $ 249 9w46AG 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+(01-10) SCHEDULE J pennsylvania DEPARTWENTOF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: James H Horn 21 13 0826 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).] 1. Julie Cartney Ring - see attached appraisal Inventory Value: 17,900 Daughter 17,900 2 Nathan Ritterpusch Camera Equipment - see attached appraisal Inventory Value: 595 Son 595 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. $ 0 9W46Ai 2.000 If more space is needed,use additional sheets of paper of the same size. Estate of: James H Horn 21 13 0826 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 3 Beverly J. Horn Hefren-Tillotson, Inc, IRA Inventory Value: 13,902 PNC IRA Inventory Value: 4,125 PSECU IRA Inventory Value: 2,166 100% of Residue: 16,708 Surviving Spouse 36,901 REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA r No. 2013- 00826 PA No. 21- 13- 0826 Estate Of: JAMES H HORN (First,Middle,Last) Late Of: CAMP HILL BOROUGH CUMBERLAND COUNTY 0 Deceased Social Security No: WHEREAS, on the 1st day of August 2013 an instrument dated January 17th 2005 was admitted to probate as the last will of JAMES H HORN (First,Middle,Last) late of CAMP HILL BOROUGH, CUMBERLAND County, who died on the 12th day of June 2013 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: BEVERL Y J HORN who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE, CARLISLE, PENNSYL VA NIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 1st day of August 2013. Register of Wills 0--" Deput **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) 'k (D rt Py 12 IT) JAWS-R- --HO&N,-of-AMeOcny County,Pennsylvartio,do herWy- dMare*is to be my Last Will and Testament and revoke any and all prior wills and codicils. I hereby nominate, constitute and appoint my wife,MyEnY HORN,to serve as the executrix of my estate. In the event my v&-q.-,-BEVERLY HO1Wj is-nuble-or unwilling to serve in this capacity,I hereby nominate,oonstitute and appoint my stepdaughter,JULIE CAP-TNEY, to serve as.theexecutri-t-ofmy.eggtt,-.as-if she A-beets.kitiallynominata I direct that my executrix shall serve without requirement ofbond, is to be granted the broadest powers-neognized-by4aw-and shag lie entided-to,roasonable compensation for her services. I direct that all-of-my.-debts-be-paid- a-and.-charged-tg*st the principle of my residuary estate,including the expenses of my final illness,funeral service,burial, memorial marker-andiAnguWation of my estate. The expenses of administration shall include any and all costs,of whatever kind, incurred-as my-rxecutrir,is7her-soun&ju4pneat,shall see frt. The expenses of administration shall also include any and all state and Federal taxes that-mayboMM,pay"as*tesuh t.beftwisf6i�ofe-"crd4ofmyproperty, even if property does not pass under the provisions of this ixill. I hereby bequeath--to•my- -M.]E-CARTNEY, my favorite ring. I hereby bequeath to any stepson,NATHAN FXrMRP`USC1-I, all of my camera equipment, may,from-time qo-timer--V--�4:L-�ether O-ftnr�4D My St be devised --Cifi f , estate in a particular manner and these directions shall.appear on the codicil appended to this will I re act be significant,but it is my desire they pass to these individuals for their sentimental value so that they may have them to remember me. All the rest an& emkhu-e Wd LUAW prop%—aly I-own;-of vdWever kind,I give to my beloved wife,BEVERLY HORN, should she survive me,by thirty(30)days. In the event M W pyr e,d v-v-ea s e s r wou fail a-to 9 W-*' b.7 thirty(30)days, all the rest and residue of the property I own, of whatever kind,;LL o distributed as follows: Ten percent(100kyto-each7of-nry-mmik,-MWS-W,HOPJ�and DAVID P. HORN, should they survive me-1-ty-thirty-(30)-days;... In the event that either son fails to survive me by thirty(34)days,his share shall remain as part of my estate-to be di uted-as otherwise provided herein;. The balance of my estate shalt be divided and distributed to my stepchildren, JJLIE-CARTNEY,N-AT-HAN- ,Rr TERPtJSCI#ad ADAM RITTERPUSCIL share and share alike. Being-of sound mind, and-walt the-mtent foregoing directions be legally binding,I subscribe my name. Date: / 1. C) (:4�R HORN Signed, sexK ed.an&deelar &.ih-our presence by JAMES R HORN as his Last Will and Testament. In his, and each other's,presence,we hereto subscribe our names as witnesses. Name: Name• u Address: 17 1 A Address: O WAY- �d ACKNOWLEDGEWNT COMMONWEALTH-OF-PENNSYLVANIA ) SS: COUNTY OF ALLEGHENY ) I,JAMES a.HORN,being fiM duly sworn according to 10w, do depose and say that I signed and executed the foregoing instrument as my Last Will and Testament a my free-and vohtntmy act-for-the purposes therein J S R HO1tN Ord,*the `� '` day o€ J a n.v r►r�n ,7.00 before me the undersigned authority,personally appeared James R Horn,known to me,or proven to my satihcdon,to-be them described-iirthe-f"oing mstzum W, and acknowledged that he executed the same for the"s ther My Commission expires: Notarial Seal Charles M.Jackson,Notary Public McCandless Twp.,Allegheny County My Commission Expires Oct.17,200 Member,Pennsylvania Associatirn OI Notas es t A lMAVr . COMMONWEALTH OF PENNS'Y'LVANIA ) ) SS: COUNTY OF ALLEGBENY ) We,-havintbeen-l*rst-duly sworn aceording to-law, do-depose and say that James H. Morn,in our presence,signed and executed the foregoing instrument*as his Last Will and Testament,that�he signed willingly,that-he executed it as his free and voluntary act for the purposes therein expressed,that,to the best of the knowledge,information and belief of each of us, years of age or older, of sound mind and under no constraint or undue influence and that we,in the presence and hearing of James-iF signed :fo=c15o!U-16--inauu en t as witnesses. Sworn and subscribed before me,the undersigned authority,this day of /yilxj 2? + 200x• Notary Public My Commission expires: Notarial Seal Charles M.Jackson,Notary Public McCandless Twp.,Allegheny County My C.ornmission Expires Oct.17,2005 kt n tho,Pennsylvania hmociation O`Noteriaz &mputershare Computershare venzon PO Box 43078 Providence,RI 02940-3078 IMPORTANT TAX RETURN DOCUMENT ENCLOSED Within USA,US territories 8 Canada 800 6312355 Outside USA,US territories ti Canada 781 575 3994 """AUTO"3-DIGIT 170 000096/0037450 037450 www.computershare.com/verizon III'1'II1IIIIIIIIIIIIIrllulrllll'll'llu1lll loll III Jill 1111'1'I' Recipient JAMES H HORN 859 WYNNEWOOD RD Holder Account Number CAMP HILL PA 17011-1644 C0000662062 I N D Record Date 10 Oct 2012 Check Number 0005075302 SSNf11N Certified Yes 001CS0005.130mL e-PG I.VZN.D3333 48494/0374501037450! Verizon Communications Inc. - Combined Dividend Payment 12012 Tax Form 1099-DIV Corrected(if checked) Account Number C0000662062 Form 1099-DIV-Dividends and Distributions 2012 Copy B-For Recipient Recipient's ID No.ending in ""-"-5502 Payer's Federal ID No. 23.2259884 This Is Important tax Information and Is being furnished to the Internal Revenue Service.If you are required to file a return,a negligence OMB No. 1545-0110 penalty or other sanction may be imposed on you H this Income is taxable and the IRS determines that It has not been reported. Department of Ore Treasury-hxemat Revenue Servloa Recipient JAMES H HORN 859 WYNNEWOOD RD CAMP HILL PA 17011-1644 �qt ma Total Ordinary P Qualified 3 Nondividend a FEDERAL INCOME rForeign Tax 7 Foreign County a Cash Ligtidatiort Payer's Details Dividends($) Dividends($) Distributions($) TAX 1NITHHELD(S) Paid($) a U.S.Possession D�stri.($) 64.48 64.48 0.00 0.00 0.00 VERIZON COMMUNICATIONS INC. C/O COMPUTERSHARE P.O.BOX 43010 PROVIDENCE RI 02940-3010 Form 1099-DIV (Keep for your records) Dividend Confirmation Payment Date I Class Description I Participating I Dividend I Gross I Deduction I Deduction I Net Shares/Units Rate Dividend($) Amount($) Type Dividend($) 01 Feb 2012 COMMON 32 $0.50000 16.00 0.00 N/A 16.00 01 May 2012 COMMON 32 $0.50000 16.00 0.00 N/A 16.00 01 Aug 2012 COMMON 32 $0.50000 16.00 0.00 NIA 16.00 01 Nov 2012 COMMON 32 $0.51500 16.48, 0.00 N/A 16.48 Year-To-Date Paid 64.48 0.00 64.48 ® 4 6 U T X V Z N + \0ICD70006/R 00RX6A-PP•(F2) &Imputershare at&t Computershare Trust Company,N.A. PO Box 43078 Providence,RI 02940-3078 IMPORTANT TAX RETURN DOCUMENT ENCLOSED Within USA,US territories 8 Canada 800 351 7221 Outside USA,US territories 6 Canada 781 575 4729 -..AUT0"3-DIGIT 170 00046610125839 125839 www.computershare.com/att _ III'I'II'lllllllllll�l'II"I'llll'11'11"'III"I'I"II11'Ill�l�i� AT&T Inc.is incorporated under the laws of the State of DE. JAMES H HORN 859 WYNNEWOOD RD CAMP HILL PA 17011-1644 9� � Holder Account Number v\, �� C3003075248 SNMN Certified Yes S \ 001CS008I_rps.DLTX PG2.ATr.002501_296/125839f251677 ....................................................................................................................................................................................................................................................................................................................................................................................................... .. 1 AT&T Inc. DirectSERVICE Investment Program Statement Dividend Information Record Date: 10 Oct 2012 Holder Account Number:C3003075248 Payment Number of Shares Dividend Rate Gross Dividend Tax Withheld Tax Type Net Dividend Date I Reinvesting Dividends I ($) I ($) ($) I I ($) 01 Nov 2012 404.914858 0.440000 178.16 178.16 Transaction History From:01 Jan 2012 To:01 Nov 2012 Deduction Deduction Net Price Per Transaction Total Date I Description I Amount($) Amount ( I I I Shares I Reinvestment ($) Type Amount($) Share($) Share Balance Balance Forward 389.327856 01 Feb 2012 Dividend Reinvestment 171.30 2.57 Fees 168.73 29.436963 5.731909 395.059765 01 May 2012 Dividend Reinvestment 173.83 2.52 Fees 171.31 32.757612 5.229624 400.289389 01 Aug 2012 Dividend Reinvestment 176.13 2.46 Fees 173.67 37.546464 4.625469 404.914858 01 Nov 2012 Dividend Reinvestment 178.16 2.50 Fees 175.66 34.923893 5.029794 409.944652 Summary of Holdings Date:01 Nov 2012 Class Description:DSPP-COMMON STOCK Uncertifcated Shares Closing Price Value Certificated Shares I I Total Shares I I ($) Per Share Direct Registration � Reinvestment ($) 0.000000 0.000000 409.944652 409.944652 35.090000 14,384.96 1 2 4 U D R A T T 02CS40036 001JED .. ................................................................I.............. ..........................................._.......................................................................................................... .. .._................................. ................................ ...__ _.............__.. Holder Name:JAMES H HORN Optional Cash Purchase Please detach this portion and mail to the address shown below. If you wish to make an optional cash purchase at this time,please make your check Holder Account Number 6imputershare at&t Computershare 43078 PO Box 43078 Providence,RI 02940-3078 IMPORTANT TAX RETURN DOCUMENT ENCLOSED Within USA,US territories&Canada 800 351 7221 Outside USA,US territories&Canada 781 575 4729 ''•'""--"AUTO"3-DIGIT 170 000188/0067670 067670 www.computershare.com/att I11�1�11�11111Il11lllhllnl'1111'11'llnrlllnlJnllllrlll�lrlr Recipient JAMES HENRY HORN 859 WYNNEWOOD RD Holder Account Number CAMP HILL PA 17011 C0006470548 I N D Record Date 10 Oct 2012 Check Number 0015357173 SSN/TIN Certified Yes 001 CS0078.DomLngEgs_PGLATT.151022_7/067670/067670C k AT&T Inc. - Combined Dividend Payment/2012 Tax Form 1099-DIV ` ❑ Corrected(If checked) Account Number C0008470548 Form 1099-DIV-Dividends and Distributions 2012 Copy B-For Recipient Recipient's ID No.ending in "*-"-5502 Payer's Federal ID No. 43.1301883 This Is important tax information and is being famished to the internal Revenue Service.If you are required to file a return a negligence OMB No. 1545.0110 penalty or other sanction may be imposed on you if this Income is taxable and the IRS determines that it has not been reported. Department of Ox>Treasury-hxemal Revenue Service Recipient JAMES HENRY HORN / 859 WYNNEWOOD RD CAMP HILL PA 17011 O to Total Ordinary to Qualified 3 Nondividend 1 4j FEDERAL INCOME a Foreign Tax L!j Foreign Country a Cash Liquidation Payer's Details Dividends($) Dividends($) Distributions($) TAX WITHHELD(S) Paid($) or U.S.Powssion Dili.($) 51.04 51.04 0.00 0.00 0.00 AT&T INC. C/O COMPUTERSHARE P.O.BOX 43010 PROVIDENCE RI 02940-3010 Form 1099-DIV (Keep for your records) Confirmation of Dividends Paid in Cash Payment Date Class Description Participating Dividend Gross Deduction Deduction Net Shares I Rate I Dividend($) I Amount($) Type Dividend($) 01 Feb 2012 COMMON 29 $0.44000 12.76 0.00 N/A 12.76 01 May 2012 COMMON 29 $0.44000 12.76 0.00 WA 12.76 01 Aug 2012 COMMON 29 $0.44000 12.76 0.00 NIA 12.76 01 Nov 2012 COMMON 29 $0.44000 12.76 0.00 NIA 12.76 Year-To-Date Paid 51.04 0.00 51.04 4 6 U T X A T T + OORMA-PPJAMU) 002CS70003 ' i GImputersham at&t Computershare _ PO Box 43078 Providence,RI 02940-3078 IMPORTANT TAX RETURN DOCUMENT ENCL OSED Within USA,US territories ti Canada 800 351 7221 Outside USA,US territories&Canada 781 575 4729 k"""""'AUTO"3-DIGIT 170 00004010015620 015 6 2 0 www.computershare.com/att IIIrIJIJIIIIIIIIIIIIJInI'1111'11'11n1111nlrinl111'lllrlrll Recipient JAMES H HORN 859 WYNNEWOOD RD Holder Account Number CAMP HILL PA 17011 C2008566081 I N D Record Date 10 Oct 2012 \ SSNMN Certified Yes 001 CS0078.17omLngAdvFgs_PG I.ATT.133300_17/015620f015620fi M Inc. - Combined'Dividend Advice 12012 Tax Form 1099-DIV ❑ Corrected(if checked) Account Number C2008566081 Form 1099-DIV-Dividends and Distributions 2012 Copy B-For Recipient Recipient's ID No.ending in *"-"-5502 Payer's Federal ID No. 43.1301883 This is important tax information and Is being furnished to the Internal Revenue Service.If you are required to file a return,a negligence OMB No. 1545-0110 penalty or other sanction may be imposed on you H this Income Is taxable and the IRS determines that it has not been reported. DepaMieM of Ox;Treasury-Memal Revenue Senloe Recipient JAMES H HORN 859 WYNNEWOOD RD CAMP HILL PA 17011 is Total Ordinary to Qualified Nondividend a FEDERAL INCOME 6 Foreign Tax 7 Foreign Country a Cash Liquidation Dividends($) Dividends($)[Distributions($) TAX WITHHELD(f) Paid($) or US.Possession Distil.($)I Payer's Details 5.28 5.28 0.00 0.00 0.00 AT&T INC. C/O COMPUTERSHARE P.O.BOX 43010 PROVIDENCE RI 02940-3010 Form 1099-DIV (Keep for your records) Confirmation of Dividends Paid in Cash Payment Date Class Description Participating Dividend Gross Deduction Deduction Net Shares I Rate I Dividend($) I Amount($) I Type I Dividend($) 01 Feb 2012 COMMON 3 $0.44000 1.32 0.00 NIA 1.32 01 May 2012 COMMON 3 $0.44000 1.32 0.00 NIA 1.32 01 Aug 2012 COMMON 3 $0.44000 1.32 0.00 N/A 1.32 01 Nov 2012 COMMON 3 $0.44000 1.32 0.00 N/A 1.32 Year-To-Date Paid 5.28 0.00 5.28 Comcast® �.�'� Comcast Corporation Clads-A Common Stock Account Information Record-Date Share Information Current Dividend Summary Total Dividends Year-to-Date Account Number 3500394204 DR res 0 6-ed ross Dividend $1.95 Gross Dividends $7,20 Record Date 10/03/12 ertificate ares 8.000 Tax Withheld $0.00 Fed Tax Withheld $0.00 Payable Date 10/24/12 Plan ares . o State Tax Withheld $0.00 State Tax Withheld $0.00 Rate Per Share $0.1625000 Total Record-Date Shares 12.000 NRA Tax Withheld $0.00 NRA Tax Withheld $O.OD Paid in Cash 12.000 Net Dividend $1.95 Net Dividends $7.20 Reinvested 0.000 Paid in Cash $1.95 Reinvested $0.00 For online account information,please visit www.shareowneronline.comlComcast If you have any questions,please call Shareowner Services: Toll-free:888-883-8903 (j Outside of the US:651-554-3873 �! TDD:6514504114 Is your account current?It's important to update your address with Shareowner Services,cash all your dividend checks,and vote your proxy. By state law,after a given length of time, returned mail,uncashed checks and inactive accounts can be considered abandoned property and may be turned over to the state of your last known address. Retain for tax purposes YEAR: 2012 DIVIDENDS AND DISTRIBUTIONS OMB No.1545-0110 FORM-1099-DIV View your tax documents,and more while signed into your account at: f'Y +P ber' ` REPORTED 13Y,i}11w10,482"., `' www.shareowneronline.com/Comcast Comcast Corporation WELLS FARGO BANK,N.A. • New users:enroll by selecting Sign Up Now!Select Authentication ID,and Class A Common Stock P.O.BOX 64854 then check I do not have my Authentication ID. 27-0000798 CMC1 ST.PAUL MN 55164-0854 • Tax information is also available on our automated phone system at = Account°umber° : Reciptepts-lD rtbHr 888-883-8903 3500394204 518-54-5502 • Investment Plan Participants:Total dividends reported may include -_ company paid brokerage commission and/or discounts on purchases. To1a1 orr0na 1b' ed dfvk#errcts" $7.20 $7.20 JAMES H HORN Taal"per attbutkut 4k sp.5e07 859 WYNNEWOOD RD $0.00 $0.00 CAMP HILL PA 17011-1644 2;», " Section Itf9aitr" t ailledtbteu y$q, p $0.00 $0.00 S. Ptstdivklend dis#ributkls " `4 `Federal income tax'ythtetd $0.00 Copy B For Recipient:This is important tax information and is being furnished to the Internal tAt, 5teta Tax Witlihekt fS Stata atsd t3 'State ID Revenue Service.K you are required to file a return,a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. $0.00 N/A totstz 1 III 111111 1111111111 1111 1111 11111111 1111 IN III III 1 IN `ZCMC1 USA15 3191 IYIY,YIY* K NOVII3GEP. JIwELRY DESIG 1200 Market Street Lemoyne PA 17043 P#717.972.0553 August 14,2013 Beverly Horn 859 Wynnwood Rd Camp Hill,PA 17011 Dear Beverly Horn, At your request I examined the jewelry you submitted and have provided an opinion of the approximate Replacement Value at the retail market level for insurance purposes. There is 1 item in this report and it is valid only in its entirety. The final figure excludes local sales tax. You may wish to take this into consideration when using the report. The value conclusions are subject to limiting conditions that are set forth in the body of the report. My opinion, to the best of my knowledge and experience,is that the replacement value of the jewelry is approximately$17,900.00. Photographs are included with the original report for your reference. I suggest that you keep your copy of this report in a safe place. This report was prepared in accordance with the Uniform Standards of Professional Appraisal Practice (USPAP). Please call if I can be of any further assistance. Sincerely, Kristin Novinger,GG K Novinger Jewelry Design,LLC 8/132013 Hom:318 I M Visit us on the web at wwNv.fii>ieartphotoiiic.ei.)lnz Date CUSTOMER INFORMATION Name Address City state Zip phone# r 3 Drivers License## State Description r 1 �'r Value fJi ,f'd iX21 r.'� rt! /!% {!� A iul7 i✓i�' rJ��,re" 4. > 810e /fir --.1(.;Ar0n *7— 5. --N/?�-J/ b /V;, t�dfi 10. t/e� �,>1I; l3lr,9 ifT'w ifC.tl /V,� 12. 14, l S. 16. 17, Customer:Signature Total 4,the above signed.agree to all terms and conditions of fine Art Photo,Inc. 1 do hereby assure that all listed equipment is solely owned by nic in its entirety:and no liens or licnholders exist and in exchange for above agreed payment relinquish all rights to said equipment. Consignments arc subject to a 20%sales commission. A PK1.•chnfiM Agrnempn♦ � ,� 171ther Pennsylvania State Employees Credit Union P.O. Box 67013 Harrisburg, PA 17106-7013 Member Number: 9964****** PSECLI 800.237.7328 psecu.com Statement Period: 06/27/13 to 07/31/13 Direct inquiries regarding preauthorized electronic Page Number: Regular 1 of 1 transfer or account errors to the above address. Account Balances at a Glance Total Shares: $0.00 63863 1 AV 0.360 00.460 00.041 T208 P1 19 Total Certificates: $0.00 BEVERLY J HORN Total Loans: $0.00 AS BENEF OF JAMES H HORN 859 WYNNEWOOD RD CAMP HILL, PA 17011-1644 nIII�IIIIEI��nhl�lly"Ill�l��l�l�llllhlllll�lnullllll�ll�l 000869 08 013217 001 D S1 SAP: 1,2,3,4 0 E� ., ANNUAL FEE .�®/O INACTIVITY FEE VISA ' � BALANCE TRANSFER FEE OUR _ APR psecu.com/visa (from us) ■ANNUAL PERCENTAGE RATE YEAR TO DATE INFORMATION Description Amount Total Nontaxable Dividends Year to Date $3.67 SHARES Posting Effective Transaction New Date Date Transaction Description Amount Balance REGULAR SHARE ID 01 Additional Joint Owner(s): JAMES H HORN 06/27 Beginning Balance 0.00 07/26 ID 01 REGULAR SHARE Closed Ending Balance 0.00 Dividend YTD: Year to Date 0.00 CERTIFICATES Trans Post Fees or Transaction New Date Date Transaction Description Charges Amount Balance ID 52 BENE 60 .MTH IRA CERT 07/01 Beginning Balance 2,166.09 07/22 Payment: Dividend 3.08 7 Annual Percentage Yield Earned 2.500%from 07/01/13 through 07/21/13 07/22 Withdrawal By Check Death -2,169.17 0.00 07/22 ID 52 BENE 60 MTH IRA CERT Closed Ending Balance 0.00 BENE 60 MTH IRA CERT is Closed Nontaxable Dividends Year to Date 3.67 ellen.laubach @pnc.com Member of The PNC Financial Services Group PNC IRA Number 7700014289 1400 Camp Hilt Shopping Matt Camp Hill Pennsylvania 17011 Business Phone (717)783-0551 !CAMP HILL PA 17011 (717 )737-1085 Distribution Reason I direct the Custodian/Trustee to distribute funds from my IRA for the following reason: ❑ 1. Early(premature)distribution,no known exception to section 72(t)of the Code,applies.(Includes rollover distributions,distribution due to medical expenses, health insurance premiums,higher education expenses,or first time home purchase expenses if participant is under age 59 1/2.) ❑ 2. Early(premature)distribution,exception applies. ❑ 3. Permanent Disability. (If you are disabled within the meaning of section 72(m)(7)of the Internal Revenue Code.) ❑ 4. Death. (If you are a Beneficiary of this account and can furnish a certified copy of the Death Certificate.) ❑ 5. Prohibited Transaction. ❑ 6. Revocation. ® 7. Normal Distribution. (If you are the Participant and age 59 1/2 or older.) ❑ 8. Removal of Excess/Nondeductible Contribution plus earnings before tax filing deadline.(earnings taxable in year contribution was made) Amount of excess/nondeductible contribution $ In which year was the contribution made? Is the contribution plus earnings being removed in the same year? ❑ Yes ❑ No ❑ 9. Removal of Excess Contributions(principal only)after tax filing deadline. ❑ 10. Transfer Incident To Divorce or legal separation. (Documentation required.) ❑ 11. Conversion to a Roth IRA. ❑ 12. Recharacterization(of contribution)to a Roth IRA. ❑ 13. Rollover of a"conduit"IRA paid directly to the Trustee of Employer's Plan. Amount • Method of Until I furnish written instructions to the contrary,I direct the Custodian or Trustee to distribute the following amount in the manner described below: Date Payment(s)To Begin: 06/26/2013 $ 4,124.76 Amount Requested Distribution To Be.Made: ® Single Payment ❑Monthly -$ 412.47 Less Withholding ❑ Quarterly ❑Annually ❑ Other 5 3,712.29 Net Amount Method Of Payment(s): ®Credit to my PNC ❑Checking ®Savings Account# 1012593784 ABA Routing# 043000096 ❑Check ❑In Kind to my PNC Trust Account# Additional Instructions for PNC Trust Accounts: Distribute: ❑ Number of Shares of Security(name) or ❑From Money Market Account Special Instructions: 75700037342 Withholding Withholding I elect(check one): ® to have Federal income tax withheld at the rate of 10.00% of the amount withdrawn. ❑ not to have Federal income tax withheld. (Must have US residence address on file) I understand that I am still liable for the payment of Federal income tax on the taxable amount. I also understand that I may be subject to tax penalties under the estimated tax.payment rules, if my payments of estimated tax and withholding,if any, are not adequate. Signatures I certify hat I am the proper a to receive payment(s)from this IRA,and that all information provided b me is true and accurate.I acknowledge that I have fY P P PrtY P Y g read the Notice of Withholding on the reverse side of this form and have completed the Withholding Election above.I further certify that no tax advice has been given to me by the Custodian or Trustee and that all decisions regarding this withdrawal are my own. I understand that distributions are reported to the IRS. I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I hereby indemnify the Custodian or Trustee and hold it harmless from any liabilities,claims,taxes,causes of action,etc., to which I may be subjected as a result of this withdrawal. Signature of Participant or Payee Date PNC Use Only Market Branch Name Branch# Employee NameMumber Telephone Number Date 040 32ND STREET 0000106 ELLEN S LAUBACH 1-888-PNC-IRAs 106/26/2013 EFORM1 08 31 9-0702 Customer Copy v .0 �.+ ! i I E �C A! �. cc A-w I + ao 10 I o QI 66 cn o , a cn at Owl C �V ° �;, S i � • i 1 � I � � � �, i � � I r,�� ( ; I= a cu a- m ! y !° g I. aim z cc N , ` .I lzlio It ! cv CD 0 OoIU io, i L L co cc lE+ Olri —i I ±, . Oi + ' � I ^( � Ilavi LD (DI Lo o ii il1i � OO'Z _� ; ` i y �l IIM� , � �� I �� ► ` ( + I � lili f { , co Co c��°'�� ° :' i ' �*` ! ' (ti �o'c:3,_+ ; .; fir• ( ( j `� , , `�= 1 ��; ( € I ' � � I � , ;. , ( � � i , !. � , ao !o+ a, o