HomeMy WebLinkAbout05-28-14 1505610143
` 'J REV-1500 IX(0241) �n
OFFICIAL USE ONLY
PA Depar6nent of Revenue pennsylvania caorny code vear File Nur�
Bureau of Individual Taxes ���*��
Po Box.2soso� INHERITANCE TAX RETURN 21 14 0233
Harrisburg,PA 1712&0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
177 24 6873 02 26 2014 04 23 1931
DecedenYs Last Name Suffix DecedenYs First Name M�
LAY OSCAR g
(If Applicable)Enter Surviving Spouse's Infortnation Below
Spouse's Last Name Suffix Spouse's First Name M�
Spouse's Soaal Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Retum � 2. Supplemental Retum � 3. Remainder Retum(Date of Deafh
Prior to 12-13-82)
� 4. Limited Estate � qa_Fuwre Irrterest Compromise
(date of d�th arter 12-�2�2) � 5. Federal Estate Tax Retum Required
� 6. ������T�e 7. Decedent Mai med a Living Tnist � 8. Total Number of Safe D
�auaa,capy orwiq � (auaa,capy a�rn,s�� eposit soxes
� 9. Lfigation Proceeds Received � 10.�12�1�J1 a�rd��-�1�j f��' � 11.Eledion to tax under Sec.9113(A)
(AUach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COYPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORYATION SHOULD BE DIRECTED TO:
Name Daydme Telephone Number
RICHARD L WEBBER JR ESQII 717 53� 7388 � �
�` � � �'*7
REGISTER�pF�II�S U�ONL•�
.�J � r �;
First Line of Address _ '`� � -! r^7
.. � � � .�'�,.r
12 6 EAST RING STREET � '' �, <:.,
�:� c�.,, 7 � �
Second Line of Address � c:_
• �j t--+ �
-rj '-'�f F--+ f"'
DATE FILE � �
City or Post Office State ZJP Code
SBIPPENSBURG PA 17257
CorrespondenYs e-mail address: rwebber(aDweiqleassceiates.com
Under penal6es of perjury,I dedare that I have examined this retum,induding accomparrying schedules and statements,and to the best of my knowledge and belief,
it is true,cortect and complete.Dedaration of preparer ottier than the personal represer�tive is based on all iMormafi�on of which preparer has arry knowledge.
SIGNA OF�SON RESPONSIBLE F FILING RETURN �
1c � E' Ricky A.LaY �
ADDRESS
35 Maple Lane,Newville,PA 17241
SIGNATURE OF PREPARER OTHER THAN REPRESENTATNE ��
� �✓L �� Richard L.Webber,Jr., Esquire �""�� �//�
ADDRESS
126 East King Street,Shippensburg, PA 17257
� Side 7 �
1505610143 1505610143
�
� 1505610243
REV-1500 EX
DecedenYs Social Security Number
°��^�'S"�^� Lay, Osca r R.
�caPiruwnoN
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stodcs and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)._....... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5_ 90,078. 57
6. JoinUy Owned Property(Schedule F� 0 Separate Billing Requested...._....... 6.
7. Inter-V'rvos Transfers&Miscellaneous�Probate Property
(Schedule G) Separate Billing Requested.......__... 7. � . 0�
8. Total Gr�s Assets(total Lines 1 through�........................................................ g. 90, 078 . 57
9. Funeral E�enses and Administrative Costs(Schedule H).................................... 9. 12, 0 74 . 61
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 14 7. 0 0
11. Total Deductions(total Lines 9 and 10)...........................................................••••• 11. 12,221. 61
12. Net Value of Estate(Line 8 minus Line 11).......................................................... �2. 77,856. 96
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to T�(Line 12 minus Line 13)............................................... �4. 77,85 6. 96
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15. 0. 0�
16. AmountofLinel4taxable �� g56. 96 �s. 3 503.56
at lineal rate X .045 � �
17. Amount of Line 14 taxable
atsibling rateX.12 0 . 00 17. 0. 00
18. Amount of Line 14 taxable
at collateral rate X.15 0. 0 0 18. �. 0 0
19. TAX DUE.................................................................••••••..__.............--•••••••••••-•--••••••• 19. 3,503.56
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 1505610243 1505610243 J
_ _ _ __ _
, REV-1500 IX Page 3 File Number 21-14-0233
Decedent's Complete Address:
DECEDENT'S NAME
Lay,Oscar R_
STREETADDRESS
35 Maple Lane
ciTY STATE ziP
Newville PA I� 17241
Tax Payments and Credits:
1_ Tax Due(Page 2,Line 19) (1) 3,503.56
2. Credits/Paymer�ts
A. Prior Payments 3,300_00
B. Discount 173.68
Total CrediLs(A +g) (2) 3,473.68
3. Interest �3�
4. If Line 2 is greater than Line 1+Line 3,enter the d'rfference. This is the OVERPAYMENT. �q�
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the d'rfference. This is the TAX DUE. (5) 29.$$
Make Check Pa able 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:...........................................••••••••••--••••••••••.............. � �
b. retain the right to designate who shall use the properly transferred or its income:.................................. � �
c. retain a reversionary interest;or............................................................................................................... � �
d. receive the promise for life of either payments,benefits or care?............................................................ � �
2. If death occumed after Dec. 12, 1982, did deoedent 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 ovm 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 tau 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 January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surv'rving spouse is 0 percent
p2 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transferto a surv'rving spouse from tax,and the statutory requirements for disdosure of assets and
filing a tax retum are still applipble even'rf the surviving spouse is the only beneficiary.
For dates of death on or after Juty 1,2000:
• The tau rate imposed on the net value of transfers irom 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 pereent[72 P.S.§9116(a)(1.2)�.
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal benefiaaries is 4.5 percent,except as noted in p2 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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-7�08 DC+(1140)
, SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERffANCETAXRETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
La ,Oscar R. 21-14-0233
Indude the proceeds of litigatim and the date ttie proceeds were received by the estate.
All P�P��Y 1a�Yowned with Ure ri¢�t M suvivorship must be disdosed on schedWe F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 2001 VW Jetta Motor Vehicle 2,500.00
2 ACNB Bank Checldng Account#122661 86,370.28
Accrued interest on Item 2 through date of death y.25
3 Adams Electric-Patronage Check#21415081 50.12
4 Adams Electric-Patronage check 470.16
5 Highmark -Refund 185.76
6 Utility Trailer 500.00
TOTAL(Also enter on Line 5,Recapitulation) 90,078.57
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form soflware onty The Ladcner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1E,10 EX+(pg-0gl
SCHEDULE G
pennsylvania lNTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lay,Oscar R. 21-14-0233
This schedule must be completed and filed if ttie answer to any nf queytions 1 thrax�h 4 m page three d the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH 76 OF DECD°S �CLUSION TAXABLE
NUMBER j}�E D 4TEnO�F TR�AIFJSFE�RSA�i4ECIi A COPYEOF THE DE�ED FOREREAL Es nJiE. VALUE OF ASSET ��REST pF APPLICABLE) VALUE
1 TE Connectivity Benefits 401(F�Plan-Valued at 0.00 0.00
�9482.82
TOTAL(Also enter on Line 7,Recapitulation) 0.00
(If more space is needed,addi�onal pages of the same size)
Copyright(c)2009 form software only The Ladcner Group,Inc. Form PA-1500 Schedule G(Rev.OS-09)
REV-1511 DC+(10-09)
, pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
IRESIDENTDEC E�R" ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Lay,Oscar R. 21-14-0233
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s)attached 2,590.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Ricky A.Lay
StreetAddress 35 Maple Lane
City Newville State PA Zio 17241
Year(s)Commission Paid 2014 4,503.93
2. Attomeys Fees Weigle�Associates,P.C. 4,503.93
3. Family Exemption: (If decedenYs address is not the same as daimanYs,attach explanation)
Claimant
Street Address
C�h/ State Zi�
Relationshio of Claimant to Deoedent
4. Probate Fees 313.50
5. AccountanYs Fees
6. Tax Retum Preparers Fees
7. Other Administrative Costs 163.25
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 12,074.61
Copyright(c)2009 form software only The Ladcner Group,Inc. Form PA-1500 Schedule H(Rev.10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
_ La�r, Oscar R. 21-14-0233
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex enses
1 Egger Funeral Home 2,590.00
H-A 2,590.00
Qther Administretive Costs
2 Cumberiand Law Joumal-Advertising 75.00
3 Valley TimesStar-Advertising 88.25
H-B7 163.25
Copyright(c)2002 form sofiware only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
eev-t;�z oc+��z-0s�
, SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERffANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lay, Oscar R. 21-14-0233
Report dehts inwrred by the dxedmt prior to deafh tliat remained uipaid at the date of death,indudmg unrei�ursed medical ezpmses
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Newville Community Ambulance 147.00
TOTAL(Also enter on Line 10,Recapitulation) 147.00
(H more space is needed,addi6onal pages of the same size)
Copyright(c)2008 form soflware only The Ladcner Group,Inc. Form PA-15d0 Schedule I(Rev.12-08)
REY-�513 DC+(Ot-10)
. � pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERfTANCE TAX RE7URN BEN EFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lay,Oscar R. 21-14-0233
RELATIONSHIP TO
NAME AND ADDRESS OF SHARE OF ESTATE OUNT OF ESTATE
NUMBER PERSONfSI RECEIVING PROPERN DECEDENT (yyords) (�$�;)
Do Na List Trust s
I� TAXABLE DISTRIBUTIONS [indude outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)
Lori BeamenderFer Daughter One-half of net 38,928.48
1489 Campus Road estate
Elizabethtown,PA 17022-8448
Randy S.Lay Son One-half of net 38,928.48
47575 Rosemary Lane estate
Park Hall,MD 20667
Total 77,856.96
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II• A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAI�N
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE
Copyright(c)2010 form soflware only The Ladcner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
., .° ...._ .. , r:, . .�.. ,.�.,.-.M,�.•, s:�, �-� ��-, ,. �.;,-... _
LAST�VII1L ANfl TESTAI�NT
f3F
�+�C�t�. ��a'
I, ���AR �i. L.�Fi', af 35 R�aple Lane, Ne�ville, Lovaer �in Tov�nship, Cumberland
County,Pennsylvania, being of sound mind, memory and disposition, do hereby r•nal;e, publish and
declare this my Last Will and Testament, hereby revoking and making void any and all Wills,
Codicils, or writings in the nature thereo�by me at any time heretofore made:
�ST: PAYMENT OF EXg'ENSES - I direct that a11 my just debts and fu.neral expenses,
including my gravemarker and all expenses of my last illness, sha.11 be paid from my residuary
estate as soon as practicable after my decease as a part of the administration of my estate.
��CdND: �SIDUE QF ES'�ATE- I give, devise and bequeath all the rest, residue and
rerrlainder of my estate, be it real, personal, or mixed, of whatsoever kind and wheresoever
situate,unto my children, CATHY S. TILDEN,RANDY S. LAY and LORI LAY. However, if a
child does not survive me, that child's shaze shall be divided equally among my children who
survive me on a per capita distriburion basis.
�= P�V��TS GIFT TO �C1�£Y LAY - I have not provided for a distribution to my
son, RICKY LAY; in this my Last Will and Testament due to the fact that I previously conveyed
real estate to him.
, F�T��� TA����+SITL�,'�'IlET� �Ql�%d 1lZY ���TH- All federal, estate a,nd other death
ta.�es that may be assessed as a consequence of my death, whether or not the assets pass under
tlus Will, s�all be paid from the residuary estate of my probate estate just as if they were my debts,
and none of those tax�es shall be charged against any beneficiary or joint owner.
PAGE ONE OF THREE
�����: ��E�IrTT'QR - I appoint my son, RICKY LAY, as Executor of my ��Jill. In the
event that he predeceases n�e or is unwilling or �na.ble to s�r��e as Ehec�tc�r, � then appcint
my daughter, CAT'HY S. TILF3EN as Executrix of my VJiil. I`Teither my E�ecutor r�or any
successor shall be required to give bond for the performance of their duties.
?,' �y'��:Y��:�� �:'�EREQF, I hereunto have signed my name to this, my Last ��Jill and
-�l
Testament, consisting of a total of three (3) pages, this � day of
r`'1 k ..._, , , 1999.
l
/v ��
. OSCA�R LAY, Testator
In our presence, the above-named Testator signed this and d�clared it to be his Will, and
now, at his request and in his presence and in the presence of each other, we sign as witnesses:
r
�. C�
�
PAGE TWO OF THREE
- _
STA� 4�F P�I�I�SYL�JANIA .
: SS
���Jl�'�'�' Q�' ��JIF'����.,�.1F?� .
I, QSC� �. L��.', havi�g been dLly qu�ed acEOrding to la�v, ackna��Iedge tY�at I
signed the foregoing instnzment as my Will and that I signed it as my free and voluntary act for
the purposes therein expressed.
�
� O CAR R. LAY, Testator
We, having been duly qualified according to law, depose and say that we were present and saw
OSCAR R. LAY, sign the faregoing instrument as his Will; that he signed it as his free and
voluntary act for the purposes therein expressed; that each of�s in his sight and hearing and at his
request signed the�ill as witnesses; and that to the best of our l:nowledge he was at the time 18
or more years of age, of sound mind and under no constraint or undue influence.
�
C�, G��
�
Subscribed, sworn to or affirmed,
and acknowledged before me by the
above-named Testator and by the
witnesses whose names appear
opposite on this �i�' day of
�_ f''7 u �. , 1999.
- _ ��' 1.! �'``'✓
- Notaty Public
r NoraRia�s�a� PAGE THREE OF THREE
RI�HARD L WEBBER,JR.,NOTARI(POBI.�
NEWVIlLE BORO.,CUi�BERLAND COUtd1Y
�'IY COMMISSION IXPIRE MAY 6 0
.�
i
A�;NB �-� .� _
__,
BAN � � - � ��,�;;
March 20,2014
Weigle&Associates
Attn: Richard L Webber Jr
126 E King St
Shippenshvrg PA 17257
RE: Estate of Oscar R Lay
Dear Mr.VVebber:
The follawing information is being peovided as per your request:
Acct_Type Account No. Balance at Accrued Qwnership Date
D.O.D. Interest to Opened/Joint
D.O.D.
Esteem 122661 �86,370.28 $2.25 Individual 1/18/85
Checkina
Account
Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. Ifyou need any additional inforcnation,please conta.ct me at(717)339-5122.
Sincerely,
fr
.�j'�,(j��� _ '(/T�.,�i,L--
;�-/�`'� vl
Barbara J W r
ACTdB B
Deposit Serr.�iees Representative II
acnb.cam�acn6b�spness.co:n-F.O.Bax 3129,Gettysburg,PA i 7325� P�one 717.334.3'E 61 •Tot#Free 1.888.334.ACi�B(2262}
04/22/2014 13:43 FAX 717 302 2250 MEMBERSNIP�BLLG I�002/006
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oab,acdwrr
� My TE Beneflts Cannection
� www.TE6eneflts-US.com
AQ08044
OSCAR R. !AY � TE Connectivity Ben�t� Center
35 MAPLE LN
NEWVILLE PA 17241-e�2a � �-877-625-0505 ,
8 a,m.to 8 p.m., Eastem time, Monday
. through Friday.
401(k) Ptan Total Ac�ount Balance by
Account Statement Source
Activity from January 7� 2014 through Ma�Ch 31, The charts below show what portion of your total
2014. account balance comes from e�ch source.
Opening Bal$nce $9�352.75
3396
Deposlts
Other Deposlts 33.18
Fees/Expenses' -15.00
aainslLosses 111.89
Closing Balance $9,482.82
67%
Vested Balance $8,462.62
Amount Porcant
Your Rate of Rsturn for tho Period 1.4% veated
�9e�ths Fsa snd Expenee Deta�l labie for e breekdown o�expeneea. 0 Before-Tax $6,388.43 100�
� � Other 3,094.38 100%
�1 ':��— . !I i t.9 • � Tot�l $9�48Z.82
/�ly "'f'',/Jlfj'P.� ��,��' � �! t_�r.
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� My TE Benefits Connection
� www.TEgeneflts-US.com
A008044
08CAR R. !AY � TE Connectivlty Bonefita Center
35 MAPLE LN
NEUWILLE PA 17241-8728 1-877-625-0505 ,
8 a.m.to 8 p.m., Eastem time, Monday
. through Friday.
401(k) Plan Total Ac�ount Balance by
Account Statement Soarce
Activity from January 1, 2014 through March 31, The charts below show what portion of your total
2014. account balance comes from eech source.
Opening Balance $8�362.75
33°�b
Deposlts
Other Oeposlts 33.78
FeeslExpenses' -'�5.00
�alne/Losses 111.89
Closing Bal�nce $8,482.82
67%
Vested Balance $g,4gZ,g2
Amount Porcant
Your Rate of Roturn fo�tho Period 1.4°� veaced
�9s�ths Fsa ene Ezpenae Detarllebia for e breekdown o�expeneea. � Before-Tax $6,368.43 10096
� � Other 3,094.38 100%
/ " Tate�l $9,48Z.8Z
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� Account Statement PaAe �
Fee and Expense petail
For the period January 1, 2414 ihrough March 31, 2014
Doscrlptlon Amount
Plan Expenses $15.00
Some of the plan's admfnistrative expenses for the period may have been paid by fees from one or
more of the plan's investment funds. These expenses are Included In the expense ratio(total annuai
operating exPense) provided in the appifcable investment fund disclosures.
Your Beneficiaries
You do not have any beneficiarieB on flle. To deslgnate a beneflcfary� visit My TE 8enefits CoRnectio�
at www.YEBeneflts-US.com.
228500038 13274•A008044
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� Account Statement Page 4
For More Information
My TE Beneflfs Connectlon at www.TEBeneflts-US.com is your best source for detalied,
peraonaliaed information about your account. The site puts everything right at your fingertips
whenever you need to check your balance, make a change, or ieam how the plan works. Usa the site
ta:
• Check your account balance.
. Change your contrlbution rate, Investment fund cholces, or transfer balances.
• Monitor your investment performance.
. Learn more about the avallable funds usinp fund detail information.
• Request a withdrawal.
• Request a Rollover Contribution Form. .
� Change your bene�iciaries.
• Leam about the plan.
Additionally, you can call the TE Connectivity Benefits Center toll free at 1-877-625-0505. Customer
Service Representatives are avallable B a.m, to 8 p.m.� East�m time, Monday through Friday. The
Web site and automated telephone system are available 24 hours a day Monday through Saturday
and after 1 p.m., Eastem time� on Sund�y.
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04/22/2014 13:44 FAX 717 302 2250 MEMBERSHIP&BLLG (�006/006
� �� TE Ret�rement Savings and Investment Plan
�,��, Quarterly Statement Notifications
�r�vestment Information Yau Need to I�now
Account Informatlon
Your total TE Retirement Savings and Investment Plan (RSIP)account balance,your vested account
balance,and the value of each of your investments are provided in the enclosed document. Review
your eecount statement carefully. You should report any diserepancies between this report and your
records to the TE Benefits Center within three months.
Fee Ynformatlon
The plan chacges administrative fees(shown as separace eccount fees)and individual fees(baaed on
specific accQUnt activiry) as shown on youc account statement and My TE Benef�ts Cannertlun.To
iearn more about specific fee information,eccess the Annua! Fee Disclosure Statement by logging into
yaur TE RSIP account via My TE Benefils Connectlon snd selecting"Plan Lnformation"from the
Savinga and Reticement menu.
Tbe Importaace of Diver�ifying Your Retirement Savings
To help achieve long-ter►�n retirement security,you should give careful consideration to the benefits of
a well-balanced and diversified investm�nt portfolio. Spreading your assets among different types of
investments can help you achieve a favorable rate of return,while minimizing your overall risk of
losing money.'I'his is because market or other economie conditions that cause one category of asse�s,
or one particular security,to perform very well often cause another asset category,or another particular
security,to pecform poorly. If you invest more th�n 20%of youc retirement savings in any one
company or industry, your savings may not be properly diversified.Althaugh diversification is not a
guarantce egainst loss, it is sn efFective strategy to help you man�ge investment risk.
[n deciding how to invest your retirement savings,you should take into account all of your assets�
including any retirement savings outside of the Plan.No single approach is right for everyone bec8use,
among other factors, individuals have different financial goals, difFerent time horizons for meeting
their goals,and different tolerances for risk.It is also important to periodically review your investment
portFolio,your investmenc objective�,and the investment options under the Plan to help ensure that you
will meet youc retirernent goals.
Foc more information about individual inves�ting and portfolio diversification,visit the Depertment of
Labo�s website at www.dol.gov/ebsa/investing.html.
Tran�fer Requests
The TE RS1P permits you to make daily trarisfers.Transfer requests processed before 4:00 p.m, Eastern
time(or market close, if earlier)will be effective on the day the reyuest is made.Trensfer requests
received after that time will be procesaed tha next business day. You may chan�e or cancel yaur
request at any time before market close by logging onto My 1"E Benefr�s Connectlon at
www.TEBene�it�-US.com or by calling the TE Benefits Center at 1-877-625-OSOS, 8 a.m.to 8 p.m.
Eastern Time, Monday through�riday. If your cornpleted request is delayed for any reason, it will be
proeessed as soon as administraNvely possible.
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RECEIPT FOR PAYMENT
-------------------
-------------------
LISA M. GRAYSON, ESQ. Receipt Date: 3/12/2014
Cumberland County - Register Of Wills Receipt Time: 15 :43 : 03
One Courthouse Square Receipt No. : 1077286
Carlisle, PA 17613
LAY OSCAR R
Estate File No. : 2014-00233
Paid By Remarks : JANA K LAY
HMW
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 210 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 30 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 5993 $313 . 50
Total Received. . . . . . . . . $313 . 50
- NEINVILLE COMM. AMBULANCE C/O PROMED SERVICES, INC.
4 W. MAIN STREET
SHIREMANSTOWN, PA 17011
1-866-678-6855
Patient Bill
Page: 1
Printed: 03/27/14 11:19
OSCAR LAY ID: Nevw-5214
35 MAPLE LN
Newville, PA 17241
DOB: 04/23/1931
�. �- • • -� � •� �' • �• � '• •� '• �� �
Patient: OSCAR LAY ID: 5214 DOB: 04/23/1931
Claim Number: 4714022�iagnosis 1) 427.5
Ins: 1)MC/Asgn 177246873A 2)BCH/Asgn ZAL102596806001A
0102/26-02/26/14 WSAA0427RH 1 A 1250.00 1 403.68 0.00 252.57 4.11 147.00 147.00
Your insurance coverage has indicated there is a deductible amount due of$147.00 for this service line.
Procedure: ALS LEVEL 1 EMERGENCY
Date first billed: 03/19/14
Patient Totals: 1250.00 403.68 0.00 252.57 4.11 147.00 147.00
Total Amount Due By Guarantor: 147.00
vwwv DETACH HERE vwwv
-------------------------------------------------------------------------------------------------
PLEASE MAKE CHECKS PAYABLE TO NEWVILLE COMM AMBULANCE
Prov Codes:WSA=Newville Ambulance
---------- To insure proper credit,please clip and mail the bottom section for each page and include with payment ---------
Guar:OSCAR LAY #: Newv-5214 Clms:47140221
Page 1 Total Due(all pages): 147.00