HomeMy WebLinkAbout06-09-14 � 1505610143
REV-1500 °``°��"' '�'
OFFICIAL USE ONLY
PA Departrnent of Revenue pennsylvania co�„iy code v�r File Nunber
Bureau of Individual Taxes °�"""�'T��
Po Box.2soso� INHERITANCE TAX RETURN 21 13 1343
Hartisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Securily Number Date of Death Date of Birth
11 18 2013 10 29 1926
DecedenYs Last Name Suffix Decedent's First Name MI
FINDLEY JANINE R
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffoc Spouse's First Name M�
Spouse's Social Securily 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. P���2�3-�82��D����
4. Limited Estate � 4a.Future Irrterest Compromise � 5. Federal Esfate Tax Retum Required
� (date af death after 12-12�2)
� g DecedeMDiedTestate � 7. (Att�adi�C�y��Ti��LivingTrust 1 8. TotalNumberofSafeDepOSftBoxes
�auad,copy orwiq
� 9. LiGgaSon Proceeds Received � 10.S�P2°��'�������°t' � 11.Election in tau under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COYPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORYATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
rv
JERRY A WEIGLE 717 �32 73ff� � �
�,.. c� rn
e� -"�>�,
REG19i�Rr�F�.WILL,�SE�1 �
�'r� ;:A -- .._.; c'�
- �, �..f � ; ;..�
First Line ofAddress :' �r� `� > ��
, �:-y
12 6 EAST RING STREET ''� `�� �-, � �:; -f-i
::-� c_� --,.� � -,.Y
Second Line of Address �`7 � � �-== c�>
..� --i � rn
� DATE FI~ � �
City or P�t Office State ZJP Code
SHIPPENSBURG PA 17257
ComespondenYs e-mail address:
Under penal�es of perjury,I dedare that I have examined ihis retum,induding accanparrying schedules and siatemerHs,and to the best of my knowledge and belief,
it is true.cortect and complete.Dedaration of preparer olher ihan tlie personal represerdative is based on all information of which preparer has arry knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN � /�
�' Richard E. Findley �� �
ADDRESS
15 lan C Shi ensbu PA 17257 .,
SIGNATU OF P PAR R O R THAN REPRESENT �A� /`
� � J rry A.Weigle Esquire � —5 '
ADDRESS
126 East King Street,Shippensburg,P 17257
� Side 1 �
1505610143 1505610143
�
J 1505610243
REV-1500 EX
DecedenYs Social Security Number
o�a�,rSN�: Findley, Janine R.
�caPiTUU►noN
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks 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 Depos"its 8.Miscellaneous Personal Properly(Schedule E)............... 5. 2 9,4 4 8 . 18
6. Jointly Owned Property(Schedule� � Separate Billing Requested............ 6. 12,87�.50
7. IMer-V'rvos Transfers 8 Miscellaneous I�nn;Probate Property
(Schedule G) �J Separate Bilhng Requested............ 7.
8. Total Gross Assets(total Lines 1 through�........................................................ 8. 42,318 . 68
9. Funeral E�enses and Administrative Costs(Schedule H).................................... 9. 9,168 . 35
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 11,7 0 9. 6 9
11. Total Deductions(total Lines 9 and 10).......................................••••••••••••--••••••••••• 11. 20,878 . �4
12. Net Value of Estate(Line 8 minus Line 11).......................................................... �2. 21,440. 64
�3, 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 Tax(Line 12 minus Line 13)............................................... 14. 21,44 0. 64
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 �5 0. 0 0
(a)(1.2)X.00
16. Amount of Line 14 taxable 21,440 . 64 16. 964. 83
at lineal rate X .045
17. Amount of Line 14 taxable 0. O 0
at sibling rate X.12 0 . 0 0 17.
18. Amount of Line 14 taxable 0 . 0 0
at collateral rate X.15 0 . 0 0 7 8.
19. TAX DUE................................................................................................................ 19.
964 . 83
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
L 15U5610243 1505610243 �
REV-1500 IX Page 3 File Number 21-13-1343
Decedent's Complete Address:
DECEDENT'S NAME
Findley,Janine R.
STREETADDRESS
151an Court
CITY STATE ZIP
Shippensburg PA 17257
Ta�c Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 964.83
2. Credits/Payments
A. Prior Payments 906.57
B. Discount 47.71
Total Cred'its(A +B) (2) 954-2$
3. Interest �3�
4, If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,eMer the difference. This is the TAX DUE. (5) �O.rJrJ
Make Check Payable to: REGISTER OF WILLS, AGENT.
.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X"IN THE APPROPRIATE BLOCKS
1. Did deoedent make a transfer and: Yes No
a. retain the use or income of the property transferred:.....................................••••••••••••....................•••....... � �
b. retain the rigM to designate who shall use the properly transferred or its income:.................................. � �
c. retain a reversionary interest;or............................................................................................................... x
d. receive the promise for life of e'dher payments,benefits or care?............................................................ � �
2. If death occurted after Dec. 12, 1982, did deceder�t transfer property within one year of death without � �
receivingadequate consideration?.................................................................................................................... x
3. Did decedent own an°in trust for or payable upon death bank accour�t or security at his or her death?....... � �x
4. Did decedent ovm an individual retirement account,annuity,or other non-probate property which � �
containsa benefiaary designa6on?............................................................................................••••.................. X
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 ta�c 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
[72 P.S.§9116(a)(1.1)(ii)]. The statute dces not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disdosure of assets and
filing a tax retum are still appl'�cable even if the surviving spouse is the onty benefiaary.
For dates of death on or after July 1,2000:
• The ta�c rate imposed on the net value of Uansfers irom a deceased child 21 years of age or younger at death to or for the use of a naiural 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 transfiers to or for the use of the decedenYs lineal benefiaaries is 4.5 percent,except as noied in[72 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 p2 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 ihe decedent,whether by blood or adoption.
Rav-7508 DC+(11-70)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, 8� MISC.
DEPARTMENTOFREVENUE pERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Findley,Janine R. 21-13-1343
Indude the proceeds of litiga[im and the date tt�e poceeds were receiwed by the estate.
a�nron�r i��r-���u�r�ne or�a:n�P mu�be a�aoaed on scn�re F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cash money in lockbox 20.000.00
2 CRPCEN-Pension fund France 211.61
3 First National Bank of Hermitage,PA-Certificate of Deposit#5145905 2,594.93
4 Highmark-Refund �'83
5 M8T Bank Checking Account 9862431518 4,073.92
6 MST Bank Savings Account 15004237978600 2,756.79
7 News-Chronicle-Refund 70.10
TOTAL(Also enter on Line 5,Recapitulation) 29,448.18
(If more space is needed,addfional pages of the same size)
Copyright(c)2010 form soflware only The Ladcner Group,Inc. Form PA-1500 Schedule E(Rev.11-10)
Rev-1509 DC+(07-70)
pennsylvania SCHEDULE F
DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY
INHERffANCE TAX RERIRN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Findle ,Janine R. 21-13-1343
H an asaet was made jdM wiUrn one year d the deceda�Ys date of death,it rtiust be reported on sched�le G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Richard E. Findley 15 lan Court Son
Shippensburg, PA 17257
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %�F DATE OF DEATH
��M LETTER DATE INCLUDE NAME OF FINANCIAL INST1TU110N AND BANK ACCOUNT DATE OF DEATH DECD'S DECE ENTS INTEREST
NUMBER FOR JOIN MADE NUMBER OR SIMIL4R IDENTIFYING NUMBER ATfACH DEED FOR ALUE OF ASS �NTEREST
TENANT JOINT JOINTLY-HELD REAL ESTATE.
1 A 05h 2/2006 2006 Chevrolet Equinox LT Sport Utility- 7,847.00 50.00Oyo 3.923.50
(57847.00-in Richard E.Findley(son)and
Janine R.Findley's names)
2 A 06/30/2011 2017 Chevrolet Colorado Extended Cab LT 17,894.00 50.000•� 8,947.00
Pickup Truck-(517894.00-in Richard E.
Findley(son)and Janine R.Findley's names)
TOTAL(Also enter on Line 6, Recapitulation) �2•$70•50
(If more space is needed,addfional pages of the same size)
Copyright(c)2010 form soflware only The Ladcner Group,Inc. Form PA-1500 Schedule F(Rev.01-10)
REV-1511 EX+(70-09) SCHEDULE H
pennsylvania
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
'�so NTDEC E`H"'R" ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Findle ,Janine R. 21-13-7343
Decedent's debts must be reporF.ed on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
q, FUNERAL EXPENSES:
See continuation schedule(s)attached 2,400.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
C�y State Zio
Year(s)Commission Paid
Z. Attome�s Fees Weigle 8�Associates,P.C. 2,785.00
3, Family Exemption: (If decedenYs address is not the same as daimanYs,attach explanation) 3,500.00
Claimant
Street Address
Cihl State Ziu
Relationshi�of Claimant to Decedent
4. Probate Fees 178.50
5. AccountanYs Fees
6. Tax Retum Preparers Fees
7. Other Administrative Costs 304.85
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 9,168.35
Copyright(c)2009 form soRware 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
Findle ,Janine R. 21-13-1343
NUM ER DESCRIPTION AMOUNT
Funeral F�c eo nses
1 wlliam F.Sellers Funeral Home,Inc. 2,400.00
H-A 2,400.00
�her Administrative Costs
2 Cumberland Law Joumal-Advertising 75.00
3 Miscellaneous Administrative Costs-postage,letters,etc. 50.00
4 News Chronicle-Advertising 774.85
5 Register of�Ils-Recording Fee for Release 5.00
H-B7 304.85
Copyright(c)2002 form software ony The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-,s�z oc+c�z-0s�
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERfTANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Findle ,Janine R. 21-13-1343
Report debts inwrred by tlx decedmt prior to death tl�at remained uipaid aR the date d dwth,indudmg unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Menno Haven,Inc. 540'79
2 Pa.Dept of Public Welfare-Medical Assistance 11,168.90
TOTAL(Also enter on Line 10,Recapitulation) 71,709.69
(If more space is needed,addfional pages of the same size)
Copyright(c)2008 form soflware only The Ladcner Group,Inc. Form PA-1500 Schedule 1(Rev.12-08)
REV-1513 DC+(Ot-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Findley,Janine R. 21-13-1343
RELATIONSHIP TO
NAME AND ADDRESS OF SHARE OF ESTATE OUNT OF ESTATE
NUMBER PERSON(Sl RECEMNG PROPERTY DECEDENT (W/ords) ($$S)
Do Nat Liat T s
I� TAXABLE DISTRIBUTIONS [indude outright spousal
distributions,and transfers
under Sec.9116 a)1.2
Richard E.Findley Son One Hundred Per 34,216.17
15 lan Court Cent
Shippensburg,PA 17257
Total 34,216.17
Erder 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 TAKEN
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 soRware only The Ladcner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
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LAST tiVIT,L AND TESTAMEN�" `
�� �
t
a Camberlana County, ;,
I,JANINE R. FI�DLEY,presentl�residin�at 15 Iau Court, ShiPPe�bur�, �lisl� and �
memor�� and ctispo�ition, do here'�y maF�e, p
Penasylvania 17257, being of saund mind, Q and making voidi all wilts by me at an�time
�ec4are this m��Last Will and.Tes�ent,hereby revokin�
here�ofore made_ ••
FIR��'. I order an� direet the payrnent of ail m�� legally enforceable deb�s and fiineral
ekpenses�soon�as may be convenient after my decease.
SECO�'�. � �ive, c�evise and bequeaih all my estate, r�, personal and mi��ed, whatsoe�er
- - C�j�j�j} �. 1�il�fllL��, p��S�Ittiy i�luiri� aa
= RI
and ��heresoever sit�a.te, to my belo�ed son,
�S Iau Coud t,Sluppensb�rg,Penns�lva�ia 17��7.
�D. In. the event my said son, Richard E. Findley, shauid predecease me or
n.
i� nat living on the si�ieth (b0� da� follo«Fing my death, I then ��'e, de��ise aud bequeath r�� saic�
estate as follo;�s:
dda ahter, �'RACY S. HALi�SI�A, presen�y
�. On�-haif (;/Z) share t� my � �' ensbur Pennsylvania 17257, on a p�r
residing at 1�65 Lindsay Lot Road, Shipp g�
stir�es distributio�basis_
� = andson,THOMAS D. FINDLEY,presently res�ding
B. One-half(/a} share to m� gr �vanfa 17201, an a per stdrpes
at 8Q�7 F€�rt�c�ord.Road, Chambersbur�, Pennsy
distributEOn ba�is.
�t m son, Ri�IARD �. FIl\'DLE�', to be
�OL�RTH. I nomina�e; �nstitute anc� appo Y
LR
�e Ex�cutor of this my Last �ill and Testanaen�; ��I�SKAa�anld tTHO���S D���1�DI��Y, or�th� '
I tben nominate, canstitute and appoint TRAC�' �. II=
�ivor thereofZ to be the Ca-Executors of this my I,as��i11 and Testamen�
FTF"I`�I-
I direct that n�� personai re�a'zsenta�ve(s} shail not be required to ��'e bond for
the�aiYhfu�perfarmance of their duties in any juriscliction.
have hereunt,a,Yset my hand and seal to this my
h�,s
II� WI`��SS �VI-�REOF, I, 3a�ine R. �'intile , . 2a01_
Last�Vill and Test�nent,written on one a�e_�as � ��'of J�.,,�-��-�-�.% �
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Wc[Gis.. P�..43KIN5 � ASSOCIATES —.AT?Or"iivEYS AT LAW — iZ`o �ASg �tiG STREET — SHIPPE'NSSURG. PA 1725�7-1397
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This inst�urrient was by.the Testatnx,:on die date hereof_ signed, p�blished and d�e�acx�� of each other,
her Last RTill and Testa.ment, in our presence, who at �er request and m tt�e gre
we believing her to be of sound and disFosu�g m�� �d �emory, h�we hereunto subscribed our
names as�itnesses.
f��,�l�,���`
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CO��NWEALT'�I OF PE�1N'SYLV<AN�A : �S
COUI�fiTY OF C��MBERLAND =
I, Jan�ne R Findle�, the persan u��iose name is signed to the foregoing instrument, having been
cluly qualified accordin�to la�a,do herebv ackno�Tiedge that I sig�eci and exeeuted the instrument as my
Last Wil1; that � signed it v��illingfy, and-that I si�ned it as ffig free aud volunta� act for the purposes
therein expressed. -
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Swom or a$irmed to and ackno`vled�ed b�fore
me by 3�anine� FindYe , the
this ��� �Y Q� r���+'�v � �2Q0
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N{3TARiA�S��F
.�Ercy A�teigte,I�Ia#ary�ut�c
Shippens�,PA Curnbe�and Cr�r.utty .
G�rtsmission Fx 'res�tx,'�r Ct7
VYEI6LE�. PERKINS &�ASSOCfATES —ATTORNEYS AT LAW — SZ6 �AST Mt`��'� `�TRE� — Si34PPE4vSBURG, PR 17257-i397
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COL�3T�OF CI���iBERLEINI�
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the wiinesses whose names are signed to�e foregoi.n.� instrnmen� being duly c�ualified accordina to
- law, do depose and sa��that nre were present and sa�v Ja�ine R Fis3dTe�, the Testa.tr�x, si� and.exec te
the in�trument as her Last A,ill; t�at she signed �rillin�y and. that she execirted it as �er free d
�aoluntary act for the putposes therei�expressed; tha�each of us in the hearing anc� si��of the Y"esta x,
signed the��xill as��itnesses; and that to the best of ou�kno��ed�e the Testatr��vas a�the fime ei�ht �
(18}or more years of age and of sound mind and under no constraint ar uridue influenc�e.
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�f �anmission F�r�L?ctc,t�et A7 2dt32
4y,r���g�, p=RK}{15 & ASSOCIATES — ATTOR�4cY5 AT L.4'tY — iZ6 EAST iCF�t6 STR��T — SH�3'�PEI�HS�URG. P?, t7Z57-1397
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REV.ae7 Ex+ �s-85�
' Date of Entry
ENTRY INTO SAFE DEPOSIT BOX Mo�th pay y��
COMMONWEALTH OF PENNSYlVANIA TO REMOVE A WILL OR /� p(D I�
DEPARTMENT OF REVENUE CEMETERY DEED
POST OFFICE BOX 8327
HARRISBURG,PA 17105-8327 Please Print or Type
MUSfi BE COMPLEfED BY REPRFSENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPO5IT BOX IS LOGATED AND RETURNED TO ABOVE ADDRE55.
DECEDENT' NAME(Last, First,Middle) SOCIAL SECURITY NUMBER DATE OF DEATH
. � C{/7�/�e- �
/ �c�v i �'i �oi.3_
RESS OF DKEDENT
S eet Address
C�tY State Zip Code
I �ouY� o�'!� ��s��� � ����s�
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
Name
' I - !r j� �r�/7 c/%.
Street Address City State Zip Code
/� ,Za�? L o U rT
. NAME AND ADDRESS OF FlNANCIAL INSTRUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
Name of Finanaal Institution ,?u��C
«
- r I67 � ��/�YZ /`-�-�L.0 j � '�i�— ��v�-/ /
Street Address C' State Zip Code
NUMBER OF SAFE DEPOSIT BOX : TRLE OR NAME(S)UNDER WHICH BOX IS REGISTERED
'�J� �iG�1c�r� � �%�/� G!f'IC1 �G'c/'1/��7e � Z, cl��i
WAS THERE A WILL IN THE BOX? �
� �t h /� i
LVJYES ❑NO !f yes a.Da�e oF will: �e�' �C/�/
M°"N' �Y Yaa
b. Name and address of personal representafive(s),iF�wmed in the wilt:
Name ��C{'1C[� t f/l��i�y
la.� �Gu�� �l�r er�S�Ic,I�' -�ce� /703� .
Street Addreu Cify State Zip Code
Nome
Street Address Cty State Zip Code
c. Name and addrcss of attorney,if anyn: `
Name �e l� �°L /T �]��/d'12 y$ C!T �C[t.�J.
Cl ? " T!� T 11 V � �7,��J
Street Address i St ate Zip Co de
Name
Street Address City State Zip Code
I certify under penolty of perjury that the above record is correct and complete to t6e best of my lu�owledge and belief.
$ignature ' Date
cCy �` � j/�� /_3
Prinf Nome � Title
��� .l �-��� �' . �� � h, ��
' � 48500041U46
REV-485 IX(OS-04)
SAFE DEPOSIT
BOX INVENTORY �
PA Departrr�ent of Reverwe PLEASE USE ORiGiNAL FORM ONLY
Social Secxiriry or Death Certificate Number Date of Death County Code Year Fle Number
._._.� _ _�� �
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j / ; �Vov iF, a��3 ��3. �a6�.3 -v�3�3
Decedent's Last Name Suffix First Name MI
� (� ` ; �
��i�n�/l� I � � ; �a�!ne_.�os�---------- ---_; �___.�
�ADDRESS OF DECEDEPiT STREET CffY: STATE: � ZIP CODE�
�
�E AN��_Q�SrS�F P�RS�N�QeESTING THE OPENING OF THE SAFE DEPOSIT BOX �
� ���7,�.0�-r ��r� .S�-►i,o� nS.d /Y .r Y' illo�i Jr� �
STREETADD SS � CffY: STATE: ZIPCODE
• NAME,ADDRESS AND RELATIONSHIP(IF AN1�TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING �
� a NAME- REIATIONSHIP: SDY7 �
; �C/�rc/ F��c/% �' CaUyf �sl►�s � .�ctr �c�
STREETA�RESS: CITY: STATE: ZIP E �
�
� b. NAME: RELATIONSIi1P: �
�
� STREETADDRESS: CfTY: STATE: Z1PC0�: �
�
a NAME: RELATIONSHIP. �
�
STREET ADDRESS: . CITY: STATE: ZIP CODE: �
4
NAME AND ADDRESS OF FlNANCIAL INSTfTUTION WHERE iHE SAFE DEPOSR BOX IS LOCATED
� NAME
�t:�-1-J3an K.
STREETADDRESS: _CITY: STAy� ZIPCODE:
� 1iUc��n �- i r- f�L i 7 `/
. NAAlE,(�PERSON IIAAIMIG LAST ENTRY DATE AND E OF LAST ENTRY �
Y��C'�'1 O(�'�/ � `�- �C, f 1/�O V a�C) a d l3 �e►?'1 O�� i.CJ r /�
: D�ATE;OF CONTRACT'f0 RENT BOX • NUAI6ER OF BOX 1 T/�IT�LE UNDER WHICH BOX IS REQUESTED
--/`'�� I �� � Fa�C�' �Of � �
NAME AND ADDRE OF PERSON(S)HAVING ACCESS TO BOX
a NAME:/C ,�Q/� � }—/n /�1, n. ruune. ✓r�hine � f�l/)C%�il �-
Srtx��.� .T4� �OU�� Srn�/�RE�a/7 L"OVt'T—T— !
CfTY• TATE: ZIP CODE: CIiY: ST : ZIP CODE:
�h�� ei�s,�u� i1 5 �S r` en s�c.cY a 17
NAYIE AND OF EMPLO TNONG THE INVENTORY
�ncl� (,j n � - f��e./a �`dns h�' � �'lker �+7 n
WAS A WILL IN THE BOX1 YES ❑ NO If yes, a Date of wilt: � � Lr s"'f h ���
b. N�ne and address of personal re�resentative,if named in the w�ll �
NAME:
��n ha�� �= �,%�cl%v S h,�p��s}��,, f�� �7�
STREETADDRESS: n - C STATE: ZIPCODE: �
� l S Tr�n ( 'Ct.l/� �
c. Name and address of attomey,if a�ry/
NAME: ��` � �/] T /� �
�'�- ��t.�S/��'%G7�S `C.. .
STREETADDRESS: /��P ��OS� /�-�� ��Ye� C���/f7 f7Cj'ISCJU/� STAT� ZIP CODE
_ _ t'Q �7d S7
L 48500041046 48500041046 �
-
' R�-�� SAFE DEPOSIT BOX INVENTORY Page of
INSTRUCTIONS
(1) Cash:Report total only.
(2) Stocks:List in deta0 every common or preferced certiBpte,warrant or other rights found in box.Stodcs are to be designated by
name of oompany,certificate number,date of certificate,name in which stodc is registered,and number of shares and dass of stodc.
(3) Obliga6ons of U.S.Govemment:Number of items,date of issue,face value,names in which registered and type of ownership,
i.e_,jantly held,payable on death,etc.
(4) Bonds:Desgnate by name,amount,serial number;or other designation.(Bearer Bonds)
(5) Bank and Savings and Loan Passbooks:State name of depositor,number of book,last date appearing in book,rtame of bank
and branch,and balance_
(6) Jewelry,Coins,Stamps,Manuscripts,etc:List and describe as fu11y as possible.
(� Deeds,Mortgages,Current Insurance Policies or other evidences of indebtedness:List and describe as fully as possible.
(8) AII other co�rtents.
(9) Return completed form to: DEPARTMEN7 OF REVENUE
INHERITANCE TAX DMSI�i
DEPT.280601
HARRISBURG,PA 17128-0601
RE1VA
NO. (TEM DESCRIPTION
�' uran � ��� �' � �a��C c�
�e_
� ri9er�`L'of'I creYle�'cy � r C G � 7!� 5�9
�n1� a es � �- Df���� e�f,��r'C� vf O!�
- u f� i4 �r/ 3 �?Db�. -�
� l�o 's. 03� �ea �d a �
S �s � 9 3_5"� -°°
S �!� tS� � �/G .��a . I-�c.� f � y . oQ .
Cas I l�'f -1' j� . U v
i CERT�Y UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEMNG COPY OF
CORRECT AND CO i.ETE TO THE BEST OF INY IO�IOWLEDGE AND BEUEF SAFE DEPOSIT BOX INVENTORY:
5��,�,� � ��,
C � C_ '� � ���'
PRINT NAME PRINT NA�AE AND CHECK APPROPRIATE BOX BEL W:
�incclL Lln � �` . �'�� �; f"t.� e.
��'tTT� DATE CF�CKAPPROPRIATEBOX
�e la-{y�onsh i p �a r�lC� ��c�, ❑„��TM��
ia-��-/3 p�R�� ❑.�t�����x
NOTE:Attach additional 8'l:°x 11°sheet(s)if necessary or use duplicates of this page of fortn.
The Oeparhment is aulhor¢ed by lax,42 U_S.C.§405(cx2KC�.�o requie dxdosue of Sodal Seauily ruur�bers in came�on w�h ad�istering sfate t�haws.The Depar6r�ent uses 1he
Sodal Security rwmber�idenlify tlie deced�t and persaral re�xesenfatrves of Ihe e.smte.The Carmomnrealih may atso use Ihe ofama6a�n end�ange of taz'rdom�afion a�re�s
w�h Federal�d bcal ta�drg aiUariG�s.The state law proh�bits tlie Cambnwealth's persar�el fiom d�g oa�ential tax ir�omration exoept for offi'aal purpos�s.
.
. .
` S`TA7EM�N7' 1'E.RI00 :<: �A�:
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00 0 06825M NM 017
000005529 FIDS1549D017110713i1 02 0010W 14664
�, JANINE R FINDLEY
• S 15 I AN CT
SNIPPENSBUR6 PA 17257-8206
>- -
;:: -<: S�l.�GT�T3 AGCQ1l:I�T SllMMARY , `
pCCp�(T ACCOUNT INTEREST EARNED MATIIRITY ENDZ!!G
TypE NUMBER YEAR-TO-DATE DATE BALANCE
M8T CLASSIC CHECKIN6 M/INTEREST 000009862431518 0.04 4,631.42
RELATIONSHIP SAVI116S 015004231978600 0.10 2,156.69
TOTAL DEPOSITS 6,�88.11
;A�GOl1tIT::>. JANINE R FIl�I.EY
M&T CLASSIC CHECKING W/INTERES7 I �i��� : :
ACCOUNT N0. 9862431518 NALNUT BOTTOM
INTEREST EAttlIED FOR STATEMENT PERIOD 0.03
ACCOUNT SUMMARY
��GIfIN� ;,"�tEP0.�I3'S &: 4iH i! � ; E�R
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O�AER...�DE�iD/lS 1'.ilEC1ES P#ifl � 5LBT3UETi0N� �NTfRES� PD =: B�a it+E`� : <
N0. Al�OUlIT NO. Al10UNT NO. AMOUNT
4,354.87 1 834.00 1 557.49 0 0.00 0.04 4,631.42
ACCOUNT ACTIVITY
. .. .. - ��fDS�TS;�ERES7 �fIF�14�:S 4}i1M�R #)J�i.L1t
P�7It�. . . . _
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>-_�I�IE . -: : > - 3Ri1ir5!►G?�flliz��SEitIPTIQN 8�:-�QTfIFJ�:�IDDI�IOI�M ;_:St�7ifAC7i0NS�_ <-� BwLAi�iCE
10-08-13 BE6IlNING BALANCE 54,354.87
10-10-13 CHECK NU!ffiER 0103 557.49 3,797.38
11-01-13 SSA TREAS 310 X�(SOC SEC 834.00 4,631.38
11-07-13 INTEREST PAYMENT 0.04 4,631.42
ENDING BALANCE 54,631:42
rHECKS PAiD=StM�MU�RY-
103 10-10-13 557.49
AIi1l/AL PERCENTA6E YIELD EARlIED = 0.00 %
LOC78(6'i�
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� �7ATENEt1i::P£RTt1D= �#GE
OCT.08—NOV.07,2013 2 OF 2
�� JANINE R FINDLEY
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SAVE MONEY ON 6IFTS AND MORE AT MAJOR RETAILERS TFiIS HOLIDAY SEASON. FIND OUT
HOM TO 6ET ADDITIONAL SAVIN6S BY USING YOUR M8T VISA DEBIT CARD OR M8T VISA
CREDIT CARD AT MORE THAN 50 RETAILERS MHEN YOU VISIT MTB.COM/SHOPPIN6.
� FOR CUSTOMER SERVICE QUESTIdiS, PLEASE CALL 1-800-724-2440. MEIffiER FDIC.
AGCOUNI : JANINE R FII�LEY
RELATIONSHIP SAVINGS ;�I�t€. ___
ACCOUlIT N0. 15004231978600 MALNUT gOTTOM
INTEREST EARNED FOR STATEMENT PERIOD 0.03
ACCOUNT SUMMARY
�cz�Nri+G ;- D�zt�: � �t�t���Ait�.s �;.a�#i�� cu�R�IS Et��
SXLJItICE ` OZHER ADIII7IOIiS� > ':'- St�Z#tACTIDNS < INTERE�T,FAib `:_$ALIINCE
� N0. AlIOUNT N0. AlIOUNT
2,156.66 0 0.00 0 0.00 0.03 2,156.69
ACCOUNT ACTIVITY
FQS7�.: ' �S
�Z :,INT�1tEST it/ARAMAf:S $ qT� #1A�LY
i11�7E- : ��AETSON:Il�ES�[f1PT2�1 _: �=>Q7HEfl �DDiTZl1fIS ----=:SliHTiU�3201�15- $ALAi�ICE
10-08-13 BE6INNIN6 BALANCE 52,156.66
11-07-13 INTEREST PAYMENT 0.03 2,156.69
EpDIM6 BALANCE 52,156.69
AlNUAL PERCENTA6E YIELD EARNED = 0.01 %
** E1� OF STATEMENT **
�acrs(snz�
�;�
. + -..-
TM Pa e. 1
Cus�omzr: ?233� 0���3/2013
JANINE R F`I�3DLEY
15 IAl� C�'
SHIPP�NSBURG PA 17257-8206
FIRST NA��dl'�AL BAN� TeZep�one:800-555-5455
4140 E S�A'�`'E S`�
HERMIT�IGE, PA 161�8
_______-----
--------------------------
9 NIO F�XIBLE Certificate 5145905
Oraginal Iss�.e Date: 04/03/2000 Interest Rate= 20d0 0
Original Issue Value. 2,000.00 Maturity Date: 10/03f2013
�ast Renewa� l�ate: uij�3 j�ui.s �ierae: � i�iv���.s�
L�st Renewai Vaiue: 2,589.08 �3alagce as of Ol/03/2013 : 2,589.48
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Your certifica�e matured on O1/03/2013_ The certificate has reaewed and �he new
matu?�ity date is 10/03/2013. Interest will be credited to your certiiicate
sema-anuually. -
I� YOII HAVF Aj�R�:A1�Y NIAD�; OT�IER ARRANGEMENTS FOR `IHIS ACCOUNT WITH YOUR
PERSONAL BANR�R; KINDLY DISREGARD THjS NOTICE. FIRST NATIONAL BANK HAS
MANY SOLUTIONS TO MAXI�+IIZE YOUR EARNINGS POfiENTIAL_ IF YOII WOIILD LIRE TO
MAKE CHANGES TO YOIIR ACCODNT, PLEASE CALL OR VISIT YOUR LOCAf BRANCH
WITHIN TEN DAYS �ROM TH� DATE OF THIS NOTICE.
The interest rate for the renewed certificate is .2000 �
wa�h an aninual perce�.tage yield of .20 0.
• xza�e P.O EDX 43
� �� � � jpHfaS3O44T{PA 15907-Q098 Certi,�cate o.�.�e�os�t
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Rate lnforr�allwr'�6e Beleres[�a1_�Y°�
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