HomeMy WebLinkAbout04-11-14 (2) � 150561014�
REV-1500 EX (02-11)(FI)
PA Department of Revenue OFFICIAL uSE oNIY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 3 9 6 �
Harrisburq PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 7 2 1 2 0 1 3 � 5 2 6 1 9 4 6
DecedenYs Last Name Suffix DecedenYs First Name MI
C o r n m a n M e 1 v i n E
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
C o r n m a n B e t t y J
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
2 0 6 3 6 6 2 4 6 REGISTER OF WILLS
FILL IN APPROPRIATE OVALS 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 � 1'F':?Election�o Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) � (Attach�edule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENT A�INFORMATI N SH I�E DIRECTED T0:
Name �e Teleph�Nu�e�
W a y n e F - S h a d e , E s q u i r e � � � �4 � �;�2. 2` 0
� r,-
w, -t—+ ' °.'" _- _--,
� �REGISTER OF WI��§E ONLY
Q C7 �j �O —r7 'Tt
G� C � � �' � ;
First Line of Address _ � �,,� �=. rn �
5 3 W e s t P o m f r e t S t r e e t � � �o c�n � ,
Second Line of Address ° ',
� ,
_
City or Post Office StBte ZIP COde DATE FILED 'i
C a r 1 i s 1 e P A 1 7 0 1 3
Correspondent�s e-ma�i address: waynefshade(a�comcast.net
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�TUR_E OF,PERSQN���O�IBLE�NG RETURN ,D TE
,G�!.�f--1 1 l' �d ����
( /'•'�il.t�t� V C�
ADDRESS �
296 Greason Road Carlisle PA 17015
SIG T E OF PREPA HA REPRESENTATIVE �� � � �
ADDRES
53 West Pomfret Street Carlisle PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610140 150561014� J
�
� 15�561024�
REV-1500 EX(FI)
Decedenfs Social Security Number
DecedenYs Name: M e 1 v i n E • C o r n m a n
RECAPiTULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 1 3 0 6 0 0 , 0 0
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2• •
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. •
4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 7 6 3 7 2 . 7 4
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 0 • � �
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested . . . . . . . 7. 0 . 0 0
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 2 0 6 9 7 2 , 7 4
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 2 5 4 � � . 8 6
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) . . . . . . . . . . . . . 10. •
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 5 4 � � . 8 6
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 1 8 1 5 � 1 . 8 8
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13. .
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. 1 8 1 5 7 1 . 8 8
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec. 9116
(a)(�.2)x.o _ 1, 8 1 5 7 1 . 8 8 15. O . 0 0
16. Amount of Line 14 taxable
at lineal rate X _ � • 0 � 16. � . 0 0
17. Amount of Line 14 taxabie
at sibling rate X.12 0 . 0 � 17. � . � �
18. Amount of Line 14 taxable
at collateral rate X.15 0 . � 0 18. � . 0 �
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. � • � 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q
Side 2
� 1505610240 150561�240 �
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 13 960
DECEDENT'S NAME
Melvin E. Cornman
-- ------- - -- - -------
- - --__ _-- - -- _ -___ _ _____----__---- --
TREET ADDRESS -----
296 Greason Road__ ___
---- --- --------- --_ ___ _---- _ _
---- - - _ __ _
---- _____ _______---__--- _-----
ITY STATE Z�p
Carlisle PA ' 17015
Tax Payments and Credits:
�� Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments 3,000.00
B.Discount 0.00
Total Credits(A+g) �2� 3,000.00
3. Interest
4. If Line 2 is greater than Line,1 +Line 3,enter the difference.This is the OVERPAYMENT. �3�
Fill in oval on Page 2,Line 20 to request a refund. (4) 3,000.00
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 ...................................................................... ❑ Q
b. retain the right to designate who shall use the property transferred or its income ............................... ❑ XQ
c. retain a reversionary interest ..................................................................................................... ❑ �
tl. receive the promise for life of either payments,benefits or care? ....................................................... ❑ XQ
2. If death occurred after December 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... � �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ X❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary tlesignation?.................................................................................................. 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 i
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 applicabie even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in p2 P.s.§s��s(a)(�)�.
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs sibiings 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-1502 EX+(12-12)
pennsylvania SCH�DULE A
DEPARTMENT OF REVENUE
REAL ESTAT�
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Melvin E. Cornman 21 13 960
All real property owned solely or as a tenant in common must be reported a�t fair marke4 value.Fair market value is defined as the price at which property
would be exchangetl between a willing buyer and a willing seller,neither being compelied to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Inclutle a copy of the tleed showing decedent's interest if ownetl as tenant in common. VALUE AT DATE
NUMBER OFDEATH
DESCRIPTION
1. Undivided one-half interest as tenant in common in that certain lot of ground 130,600.00
known and numbered as 656 Alexander Spring Road, Carlisle, Dickinson
Township, Cumberland County, PA, with improvements thereon erected, and mor
particularly bounded and described in Cumberland County Deed Book 254, Page
3401, valued in accordance with the assessed value for real estate
tax purposes, listed in memorandum form as a nontaxable transfer to the
surviving spouse of the decedent
TOTAL(Also enter on Line 1,Recapitulation,) $ 130,600.00
If more space is needed,use addition��l sheets of paper of the same size.
REV-1508 EX+(08-12)
pennsylvania SCH�DULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAI_ PROPERTY
ESTATE OF: FILE NUMBER:
Melvin E. Cornman 21 13 960
Include the proceeds of litigation and the�iate 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 DESCRIF'TION OF DEATH
�, 2010 evro et Si vera o 1500 pic -up truc,k 22, 5 .00
2. 1997 Chevrolet Corvette automobile 15,000.00
3. 1969 Chevrolet Corvette automobile 15,000.00
4. Aluminum trailer 3,000.00
5. Special construction trailer 250.00
6. M&T Investment Group, account# 311571(08, one-•half interest in the principal 21,066.74
remainder of the Morrell E. Cornman Trust
TOTAL(Also enter on Line 5,Recapitulation) $ 76,372.74
If more space is needed, use additi�mai sheets of paper of the same size.
REV-1509 EX+(01-10)
pennsylvania SCHE:DUL� F
DEPARTMENTOFREVENUE ,101NTLY-OW'NED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Melvin E. Cornman 21 13 960
If an asset was made jointly owned within one year of thc decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADURESS RELATIONSHIP TO DECEDENT
A. Betty J. Cornman 296 Greason Roac� Wi ow
Carlisle, PA 1701 S
B.
c.
JOINTLY•OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTL"-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 11/28/85 Undivided one-half interest as tenant by the entirety 0.00
in that certain lot of ground knowr�and numbered as
296 Greason Road, Carlisle, West l?ennsboro
Township, Cumberland County, �'ennsylvania, with
improvements thereon erected and more
particularly bounded and described in Cumberland
County Deed Book 31-P-920, with an assessed
value for real estate tax purposes oi'$252,400,
listed in memorandum form as a r�antaxable transfer
� to the widow of the decedent as surviving tenant by
the entirety.
2. A 4/5/OS Undivided one-half interest as joint tenant with right
of survivorship in PNC Bank check:ing account
# 5112024122 with a date of death balance of
$6,099.29, listed in memorandum f�rm as a
nontaxable transfer to the widow of�the decedent
as surviving joint tenant.
3. A 3/23/09 Undivided one-half interest as joint tenant with right
of survivorship in PNC Bank savin�,s account
# 5005820465 with a date of death balance of
$20,586.721isted in memorandum form as a.
nontaxable transfer to the widow of'the decedent
as surviving joint tenant.
TOTAL(Also enter on Line 6,Recapitulation) $ 0.00
If more space is needed,use adciitional sheets of paper of the same size.
_
_
REV-1510 EX+(08-09)
pennsylvania SCH�I�ULE G
DEPARTMENTOFREVENUE INTER-VIVOS 1'RANSFERS AND
INHERITANCETAXRETURN MISC. NON-PRO�BATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Melvin E. Cornman 21 13 960
This schedule must be completed and filed if the answer to�any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD�S EXCLUSION TAXABLE
NUMBER THEDATEOFTRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. VALUEOFASSET INTEREST (IFAPPLICABLE) VALUE
�, F&M Trust ompany, IRA account wit a ate o�'
death balance of$85,079.601isted in memorandum
form as a nontaxable transfer to the surviving spoixse
of the decedent as designated beneficiary.
2. PNC Bank, IRA, account# 55010210723, formerly
Pennsylvania State Bank account# 9150004294, `�vith a
date of death balance of$221,144.41 listed in
memorandum form as a nontaxable transfer to the
surviving spouse of the decedent as designated
beneficiary.
TOTAL. (Also enter on Line 7,Recapitulation) $ 0.00
If more space is needed,use aclditional sheets of paper of the same size.
REV-1511 EX+(08-13)
pennsylvania SCHE:DUL� H
DEPARTMENTOFREVENUE FUNERAL IEXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Melvin E. Cornman 21 13 960
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
�, Hoffman-Roth Funeral Home 11,151.5�
2. Letort Cemetery, grave plot 600.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) _
Street Address
City _ State ZIP
Year(s)Commission Paid: _
2, Attomey Fees: Wayrie F. Shade, Esquire 9,0OO.00
3, Family Exemption:(If decedenfs address is not the same as claimanYs,attach explanation.) 3,5��.��
Claimant Betty J. Cornman _
StreetAddress 296 Greason Road _
c;�y Carlisle _ state PA ZiP 17015
Relationship of Claimant to Decedent wife _
4. Probate Fees: Register of Wills of Cumberla:nd County, PA 328.SC
5 Accountant Fees:
6. Tax Return Preparer Fees: �
�. Register of Wills, file Renunciations lO.00
8. Cumberland Law Journal, advertise Letters of Administration 75.00
9. The Sentinel, advertise Letters of Adm.i�listration 210.78
10. Register of Wills, filing Disclaimers lO.00
11. Register of Wills, filing inheritance taa return 15.00
12. Register of Wills, reserve for filing Acc��unt, etc. SOO.00
70TAL(Also enter on Line 9,Recapitulation) $ 25,400.8E
If more space is needed,use aclditional sheets of paper of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENf=FICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Melvin E. Cornman 21 13 960
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PRO?ERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Inclutle outright spousal distributions and�ransfers untler
Sec.9116(a)(1.2).j
�. Betty J. Cornman Spousal 181,571.8F
296 Greason Road
Carlisle, PA 17015
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOb'E 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 ELEC710N TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1,
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUI"IONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needetl,use�idditional sheets of paper of the same size.
REV-1500 Discount, InterE�st and Penalty Worksheet
Discount Calculation
Total Amount Paid within three calendar months of the decede:nYs date of death: _ 3,000.00
Discount: 0.00
Interest Table
Year Days Delinquent , Balance Due� Interest
this time period ' this year this period
�Before 1981
^1982 '
1983 ----_
--- —
-- _____--
' 1984
'�1985 -------- .
' 1986
1987
1988 through 1991
' 1992
---—
' 1993 through 1994
1995 through 1998
1999 ' � i
2000 ''
' 2001
' 2002 ----
2003 '
!, 2004
'~2005 '
2006
' 2007
' 2008
' 2009 ------
' 2010 -
� 2011 through 2014 � __ __
' TOTALS �
Penalty Calculation
If the decedent's date of death was on or before March 31, 19!a3, insert the applicable amount:
Total Balance Due on January 17, 1996:
Penalty:
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<_., � Miteage:z�t��x>
Trade-tn VaEue
Excellent
$2Q,781
very Good
520,431
Good
$19,631
Fair
$17,531
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Wayne Shade
Betty Cornman Vehicles and T�ailers values as follows
NADA guide
19G9 Chevrolet Corvette VIN#1946795715236.With 64000 miles in approximately$15000.00
in its not running not drivable condition.
1997 Chevrolet Corvette VIN#1glyyzz64v5103748.With 44510 miles approximately Is$15000.00.
Trai(ers valued by compared local sale prices
Aluminum car trailer VIN#4gfa417z49c113297 is approximately$3000.00
Specia) purpose constructed trailer VIN#sw12641pa is approximatefy$250.00
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�Lj�\ LAST WILL AND TESTAMENT •
OF
'MORRELL E.CORNMAN
I, MORRELL E. COR)VMAN, of Dickinson Township (maiting address: 656
Alexander Spring Road,Carlisie,Pennsyivania 17013),Cumberland County,Pennsylvania,
being of sound and disposing mind,memory and understanding,do hereby make,publish and
declare this as and for my Last Will and Testamcnt hereby revoking and making void any and a�l
Wills by me at any ame heretofore made.
]. I direct my hereinafter named Executors to pay all of my just debts and funcral
expenses as soon after my death as may be found convenient to do so. I direct that my funerat
services be conducted by Hoffman-Roth Fnnerul Home, 219 North Hanover Suee[,Carlisle,
8ennsytvania,and that my body be intened on my burial lot located in Kutz's Church Cemetery
in Middlesex Township,Cumberland County,Pennsylvania.
2. T give,devise and bequeath my house snd land known as 656 Alexander Spring Road • .
in Diekinsort Township,Cumberland County,Pennsylvania,to my wife,Mildred V.Cornman,
. so long as shc shall live,and during her lif�tune she shall be responsible for payin e real estate
taxes and carrying fue�insurance with extended coverage with reasonable limits of iliry for the
benefi[of my estate and co keep the propeny in a reasonable state of rep t r death the
same shall pass in enjoyment to the remaindermen who are my ewo c ' n,Me v ornman .
and Clover A.�Haycock,cheir hetts and assigns,as equal tenants i
3. All of the rest,residue and remainder of my esta al, nal and mixed,and
wheresoever the same may be situate,I give,devise and ueath ers 1Yust Company and
its successors, 1 West C-Tigh Saeet,Carlisie,Pennsyl , t,t ive and co invest che
same,and to pay the income arising therefrom at r ar interv lea nually to or for the
benefit of my wife,Miidred V.Cornman,so long hc shall li and at her.death said trust '
shall termina[e and the principal thereof s 's betwcen my son,Mclvin E.
Comman and my daughter Clover A.Ei ock,pmvid e them be then living,but should
eicher of them be deceased then the sh uch deceas hild of mine woutd have received shall •
pass to such of his or her issue as shall th livirtg sdrpes,and if either child shall have no
then living issue the share that child or that ch e would have received shall pass entirely to
the other child,or the other child's issue.
4. I hereby nomina[e,consdeu[e and appoint my said wife,Mildred V.Comman,and my
said cwo chiJdren,Melvin E.Comman and Clover A.Haycock,as co-Executors of this my Last
Will and Tes[ament but shoutd any of them fait to qualify or cease serving as soch,I direct that the
one or more so qualifying and serving shall be sufficient,und T further direct that none of them
shall be required to post any bond to secure the faithful performance of his or her duties in the
Commonwealth of Pennsylvania or in any other jurisdicdon.
IN WITNESS WHEREOF,T have hereunto set my hand and seal to this my Last Will and
Tescament written o0 one(1}page,this 29th day of December. ,1988.
. 0'�-�'� �, �'�'r�($gp[,)'
orrell E.Comman
Signed,sealed,published and declared by MORRELIL E.CORNMAN,the Testator above
named,as and for his Last Will and Testament,in our presence,who,in his presence,at his
request,and in the presence of each other, have hereunto subscribed our names as attesang
witnesses.
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Mar, 27, 2014 2;05PM PNC Bank No, 8986 P, 1 _ .
'��� . .
� � March 27,2014
, Wa�ae F Shade,Esq . � �
53 W Pozn�eY St '
Carlisle,PA 17013 �
RE: Name: Melvin�Cornman . •
• $Sl�: 195-38-9715 '
AOD: 07�21-2013 � ..
. Dear Sir/Madam: .
In response to your request for Date of Death(DOT�)balances for the customer noted above,our
records show the follo�aring: �
Checki�ng Account
� Account# 5112024122 Established: 0405-2005 �
MEL'VII�T E CORNMAN° .
� B�rr�r coR�►rr
' DOD balance: $6,09929+0.00 acerued inte�cest
Tnterest paid 01-01-2013 ttu�07-2X-2013 $U.00 YTD
Saviwga Acconnt
.A,ccount# .�005820465 Bstablishsd: 03-23-2009
B��r coRn�x �
MELVIIJ E CORN"MAN
DOD balance: $20,586.59+0.13 accrued intezest
Interest paid Ol-01-2013 thru 07-21-20I3 $9.11 Y'TD
IRA Account
' Accouat# 55010210723 Established: OS-28-2006
' .... � MELVIl�i E CORNlM+A1V ,
DOD balance: $220,936.69+207.72 accrued interest
boterest paid 01-01-2013 thn107-21-2013 $ 1,636.49 'Y'Tll
For benefici�ary information,please call 1-888-762-4.727.
Pa$e 1 of 2 '
03/2z/2014 2:24PM [Job No. 6261] I�0001
Mar. 27. 2014 2:05PM PNC Bank No, 8986 P. 2
' ... � ., � _ . ,�,.
�. Please note that this office pro�►ic�s�e of death balances for deposit accounts(IltAs,CUs,CL�king and
Sa�vings). We do n�ot process aby�i�ua�acxal tra�nsactiwr►s ox pro�vide statemebis. Ifyou nced assis�nce�arith
' a�uy of these items,please call 1-88S-PNGBAt�TT�(1-888 762 2265)or stop by your 1oca1 PI�TC Bank branct� .
ot�'ice.
SincereIy, .
Natioaal Financial Services Center �
_ PNC Baxakk,N.A.
• Member FDIC
7'�is message Ys ir�ter,ded for the ure of the indivfdr�al or�erittty to which it is adabMessed cmd may
�� contarn inforination t�iat is privilegec� conf:dential and exempt fror,:drsclosure wrder appl'icable law.
�f the reaaier of this message is not the inrerrded recfp�ent or t�ie empl'oyee or agent responsible for
deliver�ng this m8ssage �o t�e intended rec�pient,you are hereby nori,f�ed that any d�ssemination, �
� distr�but�on or co,pytng of this commun�cations is strictly prohibited if you have received this
cornmuntcation in error,please notify me immediately by reply or by telephone at 800�762-1775 aond
, immedia7ely rXestroy this fcaed documer,t. .
,_, . . .
� Page 2 o�f 2
03/2T/2014 2:25PM [Job No. 6261] �0002
��r
�V1UW,(l��ti�ust��������9.con�
�����
Wayne F Shade
Attorney At Law
53 West Pomfret Street
Cariisle, Peni�syivania 17013
Dear Mr. Shade:
Per your request, Mr. Melvin E Cornman's IRA was transferred to his spouse (Betty J. Cornman) on
December 2, 2013. The value of the certificate on date of death was$85,079.60.
If you have any further questions, you may cail me at 717-261-3597.
Sincer�ly,
\�"_ ��i . ,�i. _. �`{�it,r.
� ,,
F
Brenda Hege
CD/IRA Clerl<
717-264-6116 888-264-611& P.O.Box 6010 Chambersburg,PA 17201-6014
FINANCfAL SOLUTlONS ... FROM PEOPtE Y011 KNOW
(Page 1 oP 5)
............ . _. . „ _ . .---------^_- ^,�_—�^"r^— -»_----•------...._._.... . ,
� ' �NSYLVANIA STATE BANK �'
Traditional IRA 1 NoR� �o�S�
Alication `"���� � � cp,RUSi.E, PA 17013
pp '�r (717j243-3189 ,
Pleasc print or�ypc. (Cuscodian's name,address and phone number above)
� IRA WN�E/ R lNGFORMATION n n
,
Nwne. �.Y...� �i ��,n a, j ry}�IRA Account IVumber ."�1��,..!1����4�.,
Address�.. �. X�S��. ... .. .���.51:�i.... Y�......�����........... +,,,... ........... ................................
Social Secunty Number(3SN) � �; � ��.�............................�....Date of Birth..�'�'.�Q��'�:.!tf......Gender: �Male � Female �
Duytime Phone IYusnber..��7....� �.�..�Z...............&mail(optional).......................,...............,.................................................................
,
� CONTRlBUTION INFORMATtON �--
A.General Contrlb o`n Info a �+�j�� B.Conlributian Type:(Se(ecr one)
Account Num r. ❑RegulcvlSpousal ❑Roltover from a Traditionul 1RA or SiMPLE JRA '
�j A�j . . ....6r.�!...'T,..
Amourtt$,...�..!....a.....r�. .���...,.... 0 Cutch-Up(uge SO and oldcr) Rollover from an Eligible Retirement Plan �
�
Cont�ibutIon Dute...'�..'.�.......................... �Simplified Employee Pension(SfiP) 'rect Rollover from an Eligible Retirement Plan ;
Tux Year..............`............... ................... ❑Recheracterizadon ❑Trensfer from a Traditional IRA or SIMPLE IRA f
Fee$.............".'...................,.................... .
�� DESIGNATiON OF BENEFICIARY °-- --
�� At the time of my dealh,the primary benefici�vies numed below wiU receive my IRA ossets. iF ail of my primary beneficiuries die before me,the
contingent beneficiaries named below will receive my IRA asxe�s. In the event a beneficiary dies before mc,such beneficiary's shsre will be
rcalloc:ated on a pro-rata basis to Ihe other beneficiacies that share the deceused beneficiury's classification as a primary or contingent beneficiary.If
all of the beneficiaries die before me,my[RA a�.cet,�wi11 be paid to my estace.If no percent�ges ure assigned to beneficiarirs,the beneftciuries will
share equapy.!f the percentage totnl for euch beneficiary classificaaon dces not equal l0U percen[,any remnining percentage will be divided oqually
among thc bcneflciuries within such cIass.This designation revokes and superccdes all earlier beneficiary designadons which may apply ro ihis iRA.
A.Prtmary Beneticiary
• SSN ar Taxpayer Relationship Beneficiary '
P tage nme of Benefciary ldentificution Number to 1RA Owner Dute of Bin �
.�5..,� .....��::k�....�.Qr!�i'vt.(�!qn................................. . .�.'�.a..S��!� .1N.t'.�:.......... ...1:x�r1..��#.�i.
...............� ........................................................,....................................... ......,................................ ............................. ............................. �
Total10096 ...................................................................................,............ ....................................... ..........,........:........ ...,.........................
B.Condugent Beneliciary
SSN or Taxpayer Relationship Baneficiary
Percentage , Nome nf eneficiar ldentificntion Nurtber / to IRA Owner Dat�of irth
...��...� ....... ��:�n..�-��... ..r..n.r�r:u�,�. ... .....�q�...�...�3� . �ir.:�.. �.a ��.
....�...� ........:�i.c.l�'�� .t�... ..r�l.�►��!�i�.'t::,.. ....���...:G�...:0��6 ..:,i.�� . �i'r.'�fcr:��iQ. .....
Tota110096 ................................................................................................ ....................................... .............�....._. ..............�............ �
� SPQUSAL CONSENT C-- - . ----.—
n - -� ---_.._
.�.� .......................... I Am Macrled.!undastand chat if I designate u primary beneficiaty osher tbttn my spoux,my spouse must consent by signing
L y (IRA Owaec IAip016) ��OW.
.......................... i Am Not Marrled.1 understand ihat if[marry in the fulure,t must complele a new Designation of Beneficiary form,which :
(IRAOwner Inillala) includes 1he spovss►1 consent documentation.
[am the spouse of the IRA owner.8ecause of the significanl consequences associated witt�giving up my interest in thc IRA,the custodian hns not
provided me with legal or tox udvice,but hus advixed me to seck tau or le�ul advice. I ncknowledge that t have received a fair and reusonable
disclosure oC the IRA owner's ussets or proprrty anJ any financial obliga[ions for a communiry property state.in thc event 1 have a legal incerest in
the IRA acsets,I hereby give to the 1RA owner xuch intercst in�he assets held in this IRA and consen�[o the beneficiary designndon set fortb in
Section 3 of this form.
Sign�au�e of Spouse.........................................................DAte.................�S,gnature of Witncss(if requiredj...,..................,............ .Da�e..........
--; SIGNATURES��_--_.�.- .::-���----..- - ...� __ _, ;
�� i certify that the inforrnation provided by me on this Applicution is accurate,and that 1 have received u copy of IRS Form 5305-A,ledlvidual 1
,,� Retlrement Custodrol Accnunt,a Disclosure Statement,and a Fnancia!Disclosuce. 1 agrce to be bound by the tetms and condidons found in the
Agrecment,Disclosure Slntement,Fnancial Disctnsure,and amendments thereto. [ussume sole responsibiliry for all consequences t�elating to my
actions conceming this 1RA.i understand that!may rovoke this IRA on or before seven(7)days after the date of establishment.I have not teceived �
Lny wx ur legaf advice from the cus[odiun,�ad I will seek che advice of my own tax r essional to ensurc my compliance with reluted laws.
(relense and agree to hotd the IRA custodian harmless ngainst any und a!1 clni or 'sing my actions.
�x .�,n�.P�...�.��..�.�:�•............................3;r.8--o.`.�X ....�.. ...........,,..�.�.,....,�..., ,.......... ......I�
... . ......... ........ .
Signnture of IRA Owner Unte Si u of Cust au
tq Coq�-putodba 7ad CopY•IA4 AdmlaiproNaa ProNd�r 9rd Cop�r�INA 4�nar Eu}�r3�,"01il3�tY�Bin�at 5ytqmt�loe..�.pao0.MN Form IM�i�831 8er.Sfl/lOQt
�. ', . , i ,