HomeMy WebLinkAbout07-10-14 (2) _
� 1505610143
REV-1500 �``02-"'
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania co�ncY code Year File Number
Bureau of Individual Taxes �P�TMENTOFREVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 13 1140
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 09 2013 12 21 1936
DecedenYs Last Name Suffix DecedenYs First Name MI
SMITH SR WILLIAM S
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Return � 2. Supplemental Return � 3. Remainder Return(Date of Death
Prior to 12-13-82)
� 4. Limited Estate � 4a.Future Interesc Compromise � 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
� 6 Decedent Died Testate � Decedent Maintained a Living Trust � 8. Total Number of Safe De osit Boxes
(Attach Copy of Will) ❑ (Attach Copy of Trust) P
� 9. Litigation Proceeds Received � 10.S ousai Pover�Credit�Date of Deacr, � ��.Election to tax under Sec.9113(A)
b�tween 1231- 1 and -1-95) (Att2Ch SCh2duIB O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JESSICA F GREENE ESQ 717 697 3223
REGISTE WILLS USE�NLY
� �,C.. :S�
First Line of Address `b � �- �
�i-�n-�..� r,,_ _;. `
555 GETTYSBURG PIKE ��` -- �� ��
� � ��
�.• Q t '1
Second Line of Address L7f-,
STE C100 O�� � � �
::� - -,-
,:_��
� ��iFILED 'p -. rr�
City or Post Office State ZIP Code �.. � �
MECHANICSBURG PA 17055 "' T'
CorrespondenYs e-mail address: JessicaCD_keystoneelderlaw.com
Under penalties of perjury,I declare that I have examined this return,inGuding 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.
ATURE OF PER O ONSIBLE FOR FILING RETURN DATE
�.—�, Dana L.Smith "1� �� �y
ADDRESS
2443 North 5th Street, Harrisburg, PA 17110
SIGNATURE OF PREPARER THER THAN REPRESENTATIVE DATE
���(�� , -�/�.ItLf�� Jessica F. Greene, Esquire � 'q'I'�
A RESS
555 Gettysburg Pike , Mechanicsburg, PA
Side 1 \
� 1505610143 1505610143 J v
�
� 1505610243
REV-1500 EX
DecedenYs Social Security Number
DecedenPSNama: Sllllth� William S. S1'.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. 2 , 0 7 7 . 6�
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. 2 'rJ ,350 . 45
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous -Probate Property
(Schedule G) Separate Billing Requested............ 7. 130 , 871 . 25
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8, 15 H ,2 9 9 . 3 0
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 19� 94 9. 88
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule i)............................ 10. 6,2 65 . 17
11. Total Deductions(total Lines 9 and 10)................................................................ ��. 2 G,215 . � 'rJ
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 132 , �84 . 25
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. 132 , 084 . 25
TAX COMPUTATION-SEE INSTRUCTI�NS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 �5 � . ��
(a)(1.2)X.00
16. Amount of Line 14 taxable 132 , 084 . 25 16. 5 , 943 . 7 9
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE................................................................................................................ 19. 5 , 943 . 7 9
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. �
Side 2
� 15U5610243 150561�243 J
REV-1500 EX Page 3 File Number 21-13-1140
Decedent's Complete Address:
DECEDENT'S NAME
Smith,William S. Sr.
STREETADDRESS
700 Walnut Bottom Road
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 5,943.79
2. Credits/Payments
A. Prior Payments 1,792.56
B. Discount 94.35
Total Credits(A +g) (2) 1,886.91
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,enter the difference. This is the TAX DUE. (5) l�,Qrjs.$$
Make Check Pa able to: REGISTER OF WILLS AGENT.
� �� rm���� �e,
"��� k� ���;i��b��
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 property transferred or its income:.................................. ❑ 0
c. retain a reversionary interest;or............................................................................................................... ❑ ❑x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ 0
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... 0 ❑
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑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 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 January 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 retum 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 decedenYs 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 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-1503 EX+(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSVLVANIA
INHERITANCE TAX RETURN
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
Smith,William S. Sr. 21-13-1140
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 42 shares of Met Life Stock 46.18 1,939.56
2 Savings bond E Series 138.04
TOTAL(Also enter on Line 2, Recapitulation) 2,077.60
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.6-98)
Rev-1508 EX+(��_�0)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OFREVENUE
INHERITANCETAXRETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,William S. Sr. 21-13-1140
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Members First Credit Union Checking Account 5,255.08
2 Members First Credit Union Regular Savings Account 1,418.34
3 Santander Bank CD 5,366.37
4 Santander Bank Money Market 5,038.62
5 Santander Checking Account 6,890.66
6 Bankers Life and Casualty Co. Refund 512.13
7 Omnicare Insurance Refund 419.25
8 United States Treasury Personal Income Tax Refund from 2013 450.00
TOTAL(Also enter on Line 5, Recapitulation) 25,350.45
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1510 EX+(08-08)
SCHEDULE G
pennsylvania lNTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,William S. Sr. 21-13-1140
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.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFERSATTACFITA CO Y OF TIHE DEIED F�OREREAL ESTATE. VALUE OF ASSET INTEREST ��F APPLICABLE) VALUE
1 American General Annuity Contract XXXX3687 26,845.76 26,845.76
2 American General Annuity Co�tract XXXX5499 68,011.58 68,011.58
3 American National Annuity Contract XXXXXX-9893 35,600.63 35,600.63
4 Central Pennsylvania Teamsters Pension Fund 300.00 300.00
5 Savings Bonds EE Series, Pay On Death to daughter, 113.28 113.28
Dana L.Smith
TOTAL(Also enter on Line 7, Recaaitulation) 130,871.25
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX+�70-08) gCHEDULE H
pennsylvania
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,William S.Sr. 21-13-1140
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
q, FUNERAL EXPENSES:
See continuation schedule(s)attached 5,799.04
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Dana L. Smith
Street Address 2443 North 5th Street
city Harrisburg state PA zio 17110
Year(s)Commission Paid 5,471.00
2. Attorney's Fees Keystone Elder Law P.C. 8,082.00
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zi�
Relationshio of Claimant to Decedent
4. Probate Fees 203.50
See continuation schedule(s)attached
5. AccountanYs Fees 95.00
6. Tax Return Preparer's Fees
7. Other Administrative Costs 299.34
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 19,949.88
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
__ _
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Smith,William S. Sr. 21-13-1140
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex en nses
1 Flowers for Funeral 201.40
2 Meal for Funeral Reception 117.64
3 Saloon-Peterson Funeral Home for cost of funeral 5,480.00
H-A 5,799.04
Probate Fees
4 Register of Wilis Additional Probate Fee 30.00
5 Register of Wills Fee For Two Additional Short Certificates 10.00
6 Register of Wills Probate Fee 163.50
H-B4 203.50
Other Administrative Costs
7 Cumberland Law Journal Legal Notice publication 75.00
8 Ordering Checks for Estate Fee through Walmart 14.80
9 Santander Bank Fee for date of death balance request 20.00
10 Sentinel Legal Notice for Publishing Estate 189.54
H-67 299.34
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+�72-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OFREVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,William S. Sr. 21-13-1140
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cumberland Goodwill Fire Rescue EMS $2•28
2 Forest Park Health Center 6,048.00
3 Guardian LTC Pharmacy 134.89
TOTAL(Also enter on Line 10, Recapitulation) 6,265.17
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX+�01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BEN EFICIARI ES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Smith,William S. Sr. 21-13-1140
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$)
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Seq.9116 a 1.2
Dana L.Smith Daughter 79,250.55
2443 N.5th Street
Harrisburg, PA 17110
William Scott Smith Son 52,833.70
147 W. Louther Street
Apt.4
Carlisle, PA 17013
Total 132,084.25
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 TAKEN
B.CHARITABLE AND GOVERNMENTAt DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
Personal income Tax e-Services Center Page 1 of 1
Penalty and interest Calculations
CALCULATION DATES-
7/9/2014 TO 7/10/2014
TAX DEFICIENCY $ 4,056.88
CALCULATED INTEREST $ 0.33
BALANCE AS OF 7/10/2014 $ 4,057.21
Start Over
https://www.doreservices.state.pa.us/pitservices/Default.aspx 7/9/2014
s '
' , ,. .. �'; ;� �,
� ca-' "f�1 � .'
� � e°:7 5�7 �.:?
� '�„ _,,,} 3 �,� —q�
._; °
.�;-3 s "'._,a
.�
3 t-�.3 ' ,�
�� � 4�:� @
�v�. �:,1
� ` . �. , c"e?
� � ° n
: --'j I '+
< -� 7}
� �^�3. r < -,. � � . �C.� �.
��.,..� �' . ��.� � T..;�
� � tt.� �
'�,± {.:-.� �
�.�t��.J� ������ �b`\ �Y ��d�7�.l�S SilV..JL.a r���t
E . . ... . . ....... . ... ......... .... . . ... . .
`��
�'✓ ��i.�s��a1,sL�� I �D �������JI..� ��n
T, VvILLI,�111�1 S:. SSv�iTI-I, SR.., h���fin� nty le�;stI t•es'€dence ��t {i0{} I� ';treet, `C`.arlisle, i'e����syh�ai�ia,
17�1�, dc� herehy declare t}iis i� be mtir Last V�ill aild "1"estar��ent, ret=c��in� alf c�tl�er Wills �s�d t;:oc�icils
h�:rclota.re�nacle by me.
1 declare tiiat I a��z uriciai�Ted and that I 11a�e tlic Cc�lla���ii�� iwo (�) chiidr�n barn to �t��; l�ana L.
5n�it�i�t�� Vtlilliam S. �mith,J�•.
� ��'�I1�'1��`dE: I dir�ct th�.t a11 rny�7aiid debt� a��d t��� e��ens�s a£my' last illn�ss and funeral
�e paid f�a�n ln}r estate a� saon as }�racticable af�er m}�cieatl�.
� ITE1►r1 T'W+C�. I bive anc� beque:ath all �f my tan�ibtc �erson�l���•opert�to ni}• residuary hcirs
��►�cier Item Fa�xr, bcta«,�as fc�Ilc��us:
E1. �ll[ itesns tyl�t���i�le�er5on�zl �ropert:}� s13aC1 b�in���i�ttUried a�zci valued aL a lair tn�tkei value.
I�. I nYay leave a Memorar�ctttin listin�;same of'the ite�77s of,my tan�ible persc�rzal p�•aperty�1vl�it;f�
I wisla certai�i��rs�r�s to IZauc a��d r�c�uest ilaat:m�r wisl�es as sut f�rtl� in tl�►e n��:an�rai�du�z� bc
ohserv�d' hy rrty Per�c�nal R.e�t•escnt�.fii��e:. 11n;y it�tt�s ot tRZ��;E�alc �ersc�n�I' ��•c�l�ei�t�� a�crt st�
cte�i�;«�tec� shall be dividcc� an�dist�'il�tite�i amc�ng�azy r�sidua�:v heirs as�c�llows'
1. Eac��c��n�y l��i�•s may selcct on�it�n�, in rot�ti�atY, in or�i�r c�cterrrii�aecl �y Ic�t, until suclz
�in�� at �,uhicl�tlYe ilems cl�c�s��by eaclx heir re�clY such}�czr's pr�►pc7��tionrtt�; sliar�c�f t11�
total ��alt�c� o:E my est�7te, o�• until sucla tit�le a� e�ch hGix° �isl�c:s tc� rnat�e raca furtl��c•
selectic���s.
1
, , . ., �' .
Z. Ar�y items not seIected shall be sol� and the net procesds added ta the residue af my
estate.
3. Ta tlie extent my heirs aze unable tu a�ree, the deeision as to what may canstitute "ane
item"fnr purposes of this seleet�on shall be made by my Persanal Representative{s},
4. Any dispt�tes conceming this method of allacatian shali be resalved by my Persanal
Representative(s}in my AersQnal Representative's sale discrction.
5. To the extent my Personal Representative is unahle to resc�lve a dispute amnng two or
more of my heirs�oncerning the in-kind distribution of any af my persona� pro�erty, I
direci my Persanal Repres�ntalive tc� sell the disputed property and the net proceeds
there from be added tv the residue of my estate.
iTEM THREE: I give and devise any interest I may flwn in any real property to�ether wi#h the
znsurance thereo�to my residuary heirs under Item Four,betaw. My Persanal Representative may either
distribute any real property at its then fair naazket�a1ue ta nne or mv� of zrty residuary heirs under and
in acec�rdance with Item Fow below,nr may se11 any such real prvperty and th� net proceeds there frc�m
be added fa the res`rdue of my estate.
ITEIVI FaUR: I geve, bet�ueaCh and devise all the r�sidue of my estate, af whatsoever naCure
and wheresae�er situate, to my children as follaws: G� ��,��,�
111`�"� >r� ,
i. Ta my daughter, DANA L. SMITH, I give�xRy�cercent N59%) of the residue �f my
estate. Tn the e�ent my daughter fttils ta survive me, this gifc shall lapse and I give her
share t�my xemainin�beneficiaries und�r this.�m Four,per sti es. `�� S�r
2. To my san, V►jILLIAM S. SMITH,JR., I give�g�ercent���@9��c�f th�resicfue of my
estate. In the event my san fails to survive me,this �ifl shall lapse and I git�e his share
to my remaining beneficiazies uader this Itcm Faur,per stirpes,
ITEM FIYE: I appoint, my brother, JDI-iN H. SM�TII, Personal Represezatative of►his my
'Will. In the event mq brother is unable or unwilling to act or cantinue to act as my I'ersonal
Rep�°esentativc,I appoint my daughter,DANA L. SMITH, as Fexsonal Represeniative of this my Will.
2
_ ___ ____. _ _
-
, z
e�" , . . � .
ITEM SIX: I appoinL my duiy app�inted Pers�nal Itepresentative(s} Trustee(s} of the
'I'rust(s}crea#ed p�rsuant to Item Fir+c,above.
�TEM SEVEN: No bond shall h� required of any fiduciary hereunder in any jurisdict'ran. No
fiduciary hereunder shall�a.�e any liability for any mistake or snc�r of judgrnent made in good£aith.
TTEM EYGHT: I auth�rize my Personal Repres�r�tative(s) and Trustee(s) w exercise the
fvllvweng powers it��ddition tA thoss gi�ven by law,to t3e exercised in their sc�le discretian:
A. Ta retain any or aIl vf the assets of my estate,withvut regard to any principle of
diversification,risk ar producti�vity;
II. To invest in ali ft�rms of property without restriction ta invest�nents authorixed for any type af
fiduciary;
C. Ta compramise any claim or conbrs��ersy;
D. To Ioan�noney to or buy property from my estate;
C. To bo�raw maney fram any persan, including any Executar or Truste�, and to martga�;e or
pledg�any real or persr�nal I�P�Y:
F. Ta sell at public or pri�ate sale, ta exchange nr ta lease fnr any period of time, any real ar
�ersan�l �roperty, and tc� girre aptions for sales, exchan�es or le�ses, aIl for such prices and
upon such terms and conditions as they deem praper;
G. Tc�atlacate receipts and expenses ta princigal or incona�vr partly to each as tl�ey deem proper,
H. To repair,alter or improve any real or personal praperty=
I. 'I`a distribute in cash or in kind or partly in each at val�atians fixed by them>
3. Ta kesp reason�ble�mounts of cash in a barik wunvested if deemed ad�vissbie far the pratectian
of ti�e principal;
I�. Ta subscribe fvr or#o�xercise options for stacks,bands or other inr�estmer�ls;to,�oin in any plan
of lease, martgage, merger, consolirlation, reorganiaation, forec�osure ar v�ting m�st and to
degosit securities thereunder, and to generally exercise a11 the cights of security holders or
ernployees of any ec�r�oratic�n;
L, To register securities in the name of a nominee ar in such manner that title shall pass by
a������y;
M. To add to the principal af any �rust cneateci by this instrez�xient any real vr personal F�P�Y
received fraxaa any persc�n by Dced,Will ar in any Qthex manner;
N. To ex�rcise all power, authority and discrefion �iv�n by this instrument af�er the tez�ainatiflz� of
any tr�t cre�ted herein until the same is fu11y distribut�;d;
p. 'fo use their sole discretivn in deciding wh�th�r stocl� dividends on stock they hold in frust
should be apportiQned to principal ar incame, except stock dividends of re�ulated investment
cornpanies wha.ch shall be added ta principal;
P. TQ CO�'21'I]lll��� f�'1� SS5�t5 fl�81]}r trust estate created by this Will in any onc oz mor� cc�mman
funds for gr�ater canvcni�ice and flexibility;
3
� � ` , ' , . .. �
Q. To ernploy agents, accountan#s,engineers and suct�ather persvns, professional ar oiherwnse,as
may be necessary for the prdper adrninistration of this estate or trust and to pay their
compensation frarn such funds_, and
R. To disclaim alI c�r any interest in a pro��rty passing to me vr my estate.
ITEM NTNE: I realize that Personal Re�tresentatives are given discretion by law to mak�
varinus elections which aff'ect the incQme and estate t�es payable by estates and $eneficiaries, as well
as the relative shares of beneficiaries, such as taking administration expenses as deductions far eith�r
estate nr incame tax p�,irpases, setecting aprions#'or the payment of employee death benefits, electing to
take a qualified terminabie interest as part of'the mazital deduccion� seiectian� alternate valuation dates,
post�orrin� t�►e payrr�ent of taaces, fiIin�jpint inevme tax or gift taac re#urns and redeeming ccarporatc
stock. The decisions made by my ficluciaries in any o�these matters shail t�e binding upon, a»d nat
subject to questian �y, any �ffected persons. I rely upan rny fiduciaries tc� take inia cc�nsideratian the
totai income and estate taxes payable by reason af their decisions including those payable by my
survivors, and they are authorizec� in their discretion, but not required, to rnake adjustments k�etween
inaorne and principal as a resuit thereof.
ITEM TEN: I direct that atl estate, inheritance and other ta�ces in ihe nature thereof,
togetlx.ez�rith any interest and penalties thereo�n,becozning payable because of my death with respecC to
the prvperty constituting my grass estate for death tax purposes, whether or not such gr.operty passes
under this rny Last Wil� and Testament, shall be paid from the ptincipal o�my residuary estate, and no
person receiving or having a benefciat interest in any such prnperty, ivl��#��er ur�der this n�y Last Wi11
and Testament or otherwise, shall at any time be required to coniribute to or refund any park thereo�';
PR4VIDED, however, that this direction shall not apply to ttae taxes fln any property included in my
�state solely becaus� o�a power af appoi�tment ther�over which I possess but have nof exercised or an
any qualiSed terminabie interest ar to any generation-skipping transfer taxes.
ITEM EI.E'�EN: If any bene�eiary,persan ar eniity in any manner, directly or indirectly,
contests oz attacks th.is W��1 a�any of its pravisians, or abjects tc�the accounts or actions ofmy fiduciaries,
without prabable c�use, suc� beneficiary, person ar entity shall pay ail costs, including but not limited�+o
attomeys fees,arising in connection with sueh contest, attack or objection incu�ced by my estate, such trust
�
_ __ _ _
or such fiduciary personally, In the event that such beneficiary, person or en�i�yr does nnt prevail in such
acfion, any s�are or interest in my estate ar such trust which would oth�rwise pass to such beneficiary,
person, entity or remainderman under this'Vl�iil sha[I be revoked and the pmpercy consisting af such share
shall be dispased of in the ma�ner provided lterein as if that contestin�persan ar eniily had predecea.�ed be
without surviving issue.
ITEM TWFLVE: Should any flf ihe provisions of my Will be fvr any reason declared
invalid, sueh invalidity shall tvat a#�ect any of the other provisians af this Will and all invaiid provisinns
shall be�►►hc�tly disre�arded iz�interpreting this Will.
ITEM THIItTEEN; This Will shall be cUxtstrued, re�ulated and gave�ned by and in
accorda�rtce with the laws af tr�e Cnmrnonwealth of Peru�sylvania.
Il'�T'WiTNESS WHERE4F,T ha.ve at Carlis�e,Pennsyl�vania,nn December 23,2Q1D, set rny hand
and seal to this my Last Will and Testament cansisting of six�5)pages plus any ack�.awledgemen#,
affidavit and certificatian pa�es.
I
�'��1���� ----- ���'c ��`
� [SEAL
WILLIAM S. SMITH.SR.
s
, ,
SIGNEII, SEAT ED,PUBLTSHET3 AND DECLARED BY"1UILLIAM S. SMITH,SR., the above named
Testator, as and far lus Last �'ill t�nd Testament, in the presence ot us, who, at his request and in his
presence,and zn the presence of each other,have hereunto subseribed ot�r narnes as witnesses.
'1 r -`"
� �` �nt � '
� f\` "[h(}/�� � er
� .J w..a�
[I�SS �^ �11LtT� S
� `�'�`-.^_
SSS Gettysb Pike.Mecbaniesbur .� PA l7dSS 555 Gettysburg_,Pike,IVlechanicsbvre,PA 17US5
b
ACKN4'�4rLEDGEMENT
COMM4N'WEALTH O�PT'NNSYLVANIA .
. S�:
C�UNTY OT'�CUI'v�BERLAND .
I, WILLIAM S. SMITH, SR, the Testatar whose name is signed to the attached or faregoing
instirument,having b�n duly qualified accarding to law,do hereby acknovvled�e that T si�ned and executed
the instnumern as my Last Wi�I, aztd #hat I signed it willingly artd as my free and �olun#�y act for the
A�P�ses therein�xpressed.
��,('�r,c...-%� �:d�,l.��'� ��'
� WILLIAM S. SMITH,SR.
�worn to or affirmed and acknowiedged befare me, by WILLIAM 5. SM�T'H, SR., the Testator on
Decerni�er 23,24�0.
� r
q J..
PA Att mey
�
. , . r _
� AFFI.DAVIT
COMMONWEA�,TH QF PCNNSYLVANIA .
: SS:
COI3NTY()T�CL�TviBERLAND
I, Robert P. Grubb, a ivitness whose name is signed tv the attached vr foregoing instrument,
b�ing duly sworn and qua[ified accord'mg ta law, do depose and say that I was present and saw the
Testator sign and e�cecute the ins�uzx�eni as his Last Witl;tliat he had signed wil[ingly and exec:uted it as
his free and va�ux�tary act for the purposes therein expressed; that each subscribing witness in the
hearing and sight of the Testator, signed the Wil� as Witness; and that to the best of my knowledge the
Testatar was at that time ei�teen(18} y�azs of age or otder, of saund mind and under na canstraints or
undue inflaence.
--�.._,�.
Witn�ss
Swom to or affumed arid acknowledged before me, by Ratlert P. Grubb, a Witness on
l�ecember 23,2010.
�� ,��
' or PA AtCOrney
8
'.
4 � J 4
AFFIDAViT
C�DMIVIQNWEAGTH O�F PENI�SYLVANIA .
:5S:
COUNTY QP CUMI�ERLAND .
I,Jessica L. Fist�er, a witness whose name is sign�d ta the aitached or fvregoing instnament,
being duly sworn and c�ualified accvrding to law, do dep�se axid say that I was present and saw the
Testatar sign and ex�cute the instrument as his Last VViI1;that he had signe� wiliing�y and �xecuted it as
his free and vattzntary act far the pw�oses thezein expressed, fihat each subscribing witness in the
heazin�and sight t�t the '�esta#ar, signed the Wiil as Wiiness; atjd that to the best t�f my knowle�ige the
Testator was at that tinne ei�.hteen (18) years of a�e or aid�r, of sound mind anc� under na canstxair�ts or
undue influence.
.. ,
u3�. .�(1�'�'�t�-�,,
Wi ess
} , }
n t� _��__�ny n
- � .
��
cERTr���T�orr
+C�MM�NWEAL'�'H[}F PENi�1SYLVANIA .
, SS:
COUNTY OF CUMBERLAND .
�n Dece;mber 23, 2010, before me the undersigned ofticer, personally appear�d Jessica L.
Fisher, Esyuire (Pennsylvania Supreme Court Ii) No. 310Q1.Sj, knawn tca me nr satisfactorily pmven to
be a mernber of the bar of the�ighest caw�t Qf Penrisylvania and certi�ed that she was personaliy present
when the foregoin�acknowledgem�m a�d affidavit(s}were signed by the Testatar and witnesses.
IN WITNESS HERE4F,T hereunto se#me hand and official seal.
'���:;� ��'7 "��c�..��
Notary Public
N07ARIA!SEAE.
MApCiA!4i PfE861T
Notary Pubtic
� W'PER ALLEN TWP.,CttlNBERLAStD COUPiYY
3�t Comntl�Expinaa Jun 4,201!
. ;. .
- ' ' • .
������ ���1'1L�.�C�1��.�!��� ��
�����1�� �a �����q ��n
This informal lei#er of instructian ta rny family anti �'ersc�nat Re�resentative serves ta
cvnr�ey my persanal wishes conceming distribution of selected personat effects. In any situatinn
where the provisions af tkiis I�tter may be deemed to be incc�nsistent with or cantrary to tlie terrns
of nny Wilt, ar other formal Estate Plan,uing Dacuments, it is my desire and intent that the
pmvisians of my l�ill and other farmal Estate Pla�nning irEStruments shall ga�em and be
cQntralling since I do not intend that this letter sl�all serve in any respect as a Wili nor shall the
terms of this tetter override the provisions of a Will or a Tnist executed by me whether it was
signed prior or suhsequent to the date af this letter.
Distribution of Perspmal Prape�rty
IIescrfntion af Pro_�ertv Beneficiarv
l. 1.
2. Z.
3. 3.
4. 4.
5. 5.
b. 6.
'7. 7.
8. 8.
9. 9.
10. 14.
I1. ll.
I2. 12.
yo
, .. ,
. �� r • y i
D�scri�tion of Pronert�v Beneficiarv
13. 13.
14. 14.
I5. I5.
16. 16.
17. 17.
18. 18.
19. l9.
20. 20.
21. 21.
�z. z�.
23. 23.
24. 24.
2S. Z5.
4ther Dircchans Ta�y�amily:
11
_ _ __ __
7/9/2014 MET Historical Prices� MetLife,Inc.Cortxrbn StockStock-Yahoo! Finance
F't�i77r, ?;1< z�E�<... i . .- 'v4'e�t�Fr ,�m��� a�w �=e; „ �F . �;, 149r,�:=
,Sigri��id � Mail
Finance Home Nty Portfolio Market Data Yahoo Originals Business&Finance Personal Finance CNBC
Enter Symbol i � .;: Wed,Jul 9,2014,32Rpm�T-US Markets dose in 32 inns Report an Issue
Dow t0.46%Nasdaq tp.59% ��
_ '' CC3MM171�IC3�EE E�'T�' '��� '
Trade ot+��,�rt nCCOtuvr
MetLife,Inc.(MET) - Nvse *Foiiow
�J6.2$ t0.29(0.5 x
Introducing Following.
Historical Priees Follow Ticker by clicking the�.Theywill appear Get Ffistorical Prices for., Gffl
in the site navigation with real-time prices and
will be available on Yahoo Finance Nbbile _
Set Date Range
Q Daily
Start Date: Oct � 9 2013 Eg.Jan 1,2010 Q Weekly
End Date: Nov � !9 2013 Q�nthly
Q Dividends Oniy
Get Prices
First�Previous�Ne#�Last
� _._ __ �
� Prices
E
Date Open High Low Close Volume Adj Close'
Nov 8,2013 47.84 50.66 47.60 50.14 12,493,800 49.50
Nov7,2013 48.12 48.84 47.56 47.59 5,628,400 46.98
Nov6,2013 48.01 48.42 47.57 47.96 6,221,900 47.35
Nov6,2013 0.275 Dividend
Nov5,2013 47.99 48.24 47.71 48.07 4,435,100 47.18
Nov4,2013 47.45 48.07 47,31 48,07 6,272,800 47.18
Nov1,2013 47.42 47.81 47.11 47.32 6,489,900 46.45
Oct 31,2013 47.24 48.29 47.00 47.31 10,198,100 46.44
Oct 30,2013 49.30 49.40 48.59 49.00 4,343,600 48.10
Oct 29,2013 48.72 49.25 48.60 49.20 4,848,900 48.29
Oct 28,2013 48.65 48.76 4825 48.59 4,695,100 47.69
Oct 25,2013 48.71 49.06 48.48 48.63 4,896,000 47.73
Oct 24,2013 48.29 48.63 47.92 48.57 5,439,500 47.67
Oct 23,2013 48.86 48.96 47.95 4826 5,796,900 47.37
Oct 22,2013 49.66 49.81 49.00 49.16 5,455,700 48.25
Oct 21,2013 49.52 49.63 49.18 49.58 3,453,700 48.66
Oct 18,2013 49.53 49.67 48.81 49.45 5,030,600 48.54
Oct 17,2013 49.03 49.58 48.77 49.28 5,937,200 48.37
Oct 16,2013 48.84 49.57 48.60 49.30 5,065,200 48.39
Oct 15,2013 48.59 48.94 48.30 48.34 3,931,900 47.45
Oct 14,2013 48.40 48.89 47.96 48.67 4,117,300 47.77
Oct 11,2013 47.94 48.75 47.78 48.74 5,085,600 47.84
Oct 10,2013 47.15 48.11 47.12 48.11 5,394,500 47.22
Oct 9,2013 46.53 46.61 45.75 46.38 6,089,300 45.52
`Gose price adjusted for dividends and splds.
First�Previous�Ne��Last
r'�1 Download to Spreadsheet
Currencyin USD.
http:/�nance.yahoo.com/q/hp?s=M ET&a=098�b=98�c=20138�d=108e=98��2013&g=d 1/2
rage t or z
• �omputershare +
�� ' � Computershare Trust Company,N,A.
PO Box 43006
� Providence,RI 02940-3006
� Within USA,USterritories&Canada 800 649 3593
� IMPORTANT TAX RETURN DOCUMENT ENCLOSED outside usA,us temtories s��anada zot sso ss�a
Hearing Impaired(TDD) 201 680 6611
� 0 0 0 4 5 9 www.computershare.comlinvestor
� ��I��I��������I����I����������I1���'����t�"I�I���1111111'I��II��
= Recipient
� WILLIAM SMITH
— 2443 N 5TH ST
= HARRISBURG PA 17110-1910
= Holder Account Number
�
C0051234758 ���
Reported � � Sales price Ticker Symbol MET
to IRS � gaies price less commissions and option premiums CUSIP 59156R108
PLEASE SEE REVERSE$IDE FOR IMPORTANT UISCLOSURES AND INSTRUCTIONS SSNITIN Certified Yes
2014 Tax Form 1Q99-B 1 MetLife Policyholder Trust Sales Advice
� Corrected(rf chec:ked) Copy B- For Recipient Account Number 005123475s
Form 1099•B-Proceeds from Broker and Barter E�cchange Transactions 2014 RecipienYs ID No.ending in ••=��-as�a
Payer's Federal ID No. 43-1912740
This is importanttax infomwtion and is being fumished tothe Irdertwl Revanue Service.IFyou are required to file a ietum,a negligence OMB No. 1545•0715
Pe�Y or ofher sanction may be inposed on you'rf this income is�xable and the IRS detertnines that it has nd been reported.
Depaztment ot the Treasury-In1em�Revenue Service
WILLIAM SMITH
Recipient 2q43 N 5TH ST
HARRISBURG PA 17110-1910
�a Date of Sale �d Stock or �e Quantlty Za Stocks, 4 FEDERAL INCOME � Check if
or Exchange other symbol sold bonds,etc.($) TAX WITHHELD(S) Noncoveredl Payer's Details
Securit
08 Jan 2014 MET 42.000000 2,268.97 0.00 � COMPUTERSHARE
�3 �4 State i5 PO BOX 43006
Desaiption State identification State tax PROVIDENCE RI
no. Withheld($) 02940-3006
42.000000 shares sold @ 54.02 METLIFE INC
NOTE:The Payer will report the amount in column 2a to the IRS.The diflerence between the repoRable proceeds in cdumn 2a and the net
praceeds you received represents withholding taxes and nonstandard service fees or charges you may have paid.
Form 1099-B (Keep for your records)
Trade Date: 08 Jan 2014 Settlement Date: 13 Jan 2014 Cost Basis Method: FIFO
Opening ShareslUnits Price per Gross Amount Taxes Net Amount Closing
Balance I Sold I SharelUnit(USD) of Sale(USD) Withheld(USD) of Sale(USD) Balance
42.000000 42.000000 54.023000 2,268.97 0.00 2,268•97 0.000000
YOUR ACCOUNT HAS BEEN CLOSED ANO YOU ARE NO LONGER ELIGIBLE TO PARTICIPATE IN THE RURCHASE AND SALE PROGRAM. THE ATTACHED CHECK REPRESENTS
THE FULL VALUE OF YOUR ACCOUNL
� 1 LGLT MET � 't'
001CD70008 01K1RA
us.lgl.c.4dysal.il 4878/000459/000459/i
., .t*fi � *�'�w''" ,r�� � �,,. �"'t ,��" '�# �s �aa., s� ' '. �",�d�x 'n.:.+"".
��,�'� �` '� .. �, 7 `3 ,�"'�, e � .�.X' � �...»� �..�.,.t-a.�.�"�� �rr�� °' ��<;t ?.�K'"m.� v3 r.,, �> �`'� ^'' �,�`��«.
s?a�4� �g^' � �,P•+, � . ..w..,.�, ,�. r � .��.
`� »� �� .rs"� � Y , � . . � r , r a- -i
��� �€ � �� ` . . �... � � c.. �.a�7��$�a, ��, r��gz�a.� �.t.i.�'. .f �m� '. �;,,�> ��, . y �. �. � --°'�, s�,.
a� �.,.J.:s�' "`^^a �aw'�..�,-i 3 � � � € � r�,, 1 6 z''b,�c L 5 . n v�' s .3 t :�r"z �,,, � +�y.
'� `'k� ,a-^�y��°�a� s �4 . F �� �� �t.�� .�.s� a u� i '�z e�� �5 a �.,t 1,���Sn� . ', �'" S
�� t � '� ��� "�` ��-�-��'r�.�,. a.�"'��.b�aba���°.-���-..a�'e�:„� '�,�:��'' - �. ,
�*- y �,-°"� � � �r.
�'"� �,�'� � •� .� �,`z� a x� �� a'4�* 'r r .i ys�s i �� �.�� �'�.,.� ��"'� .y, ! - ��t,:
�b E� :;,rg3� _;�,'�' �„,�.�.,�..�•m�°�.��c�b m,�i �� �mF'+.:�.����,.�� -��a ,� ,�,�,, � �i�*€
�a ��.", � � ��ka� .,y $��
�d� r�� � '�u;' �`�,,` �r'�.�" ��� I....��,
�6 b . .� � -��z`'uy '�, ,�."���
a ����� � +-�r _ ���- H• ,�� � � � �,�s w` . "H fa .�.�'�n� w':
S4�� £ ..-,,,dl�., 4a� �� K ad .r�*.n
� 3����'�'� ���4� ��',�� � g� �a' �.s-��r,� 2� ��y�s cr k^��+ ���
�g$ } ��T��l�. +�..�...� ' ,, � '�'P i,.�"'s , ;s �'� � �`# `�'��t ����,�"h�����-���''s
��F�"� � .�."��s�. -d.'�^ ��- ��'� "°'� : r'�r ��i�r r 3 ���S � ,
� so :�." � �' ,�z
',���t �e C z i , x�- � y��� �t'�*;, " �: ''�v2&� � tu.?�,�' .��.� � y�'" � �7��:..
. ���, � oy�_r-.� -t �„, ,� -�� � �� p n r � '�", t � a "°
r
9 t 1 p '4 -�� «»��z �.t � ��� ' ���..
� ;°�",'"^' � .
wz i �' �.' �„ � �, t � t
c r`3 j� a.. R^t ��,�y�,��g s s'. y �� � s ���� ��
{'`�°� d t��J F€ 1`i.C+ } 4 ��t3..T" �-p;'����4�� h� dC. v� � 3
f ( � �
t`�� ��Ed zi[ � '��`� �a�� �'���� �-�M3�`.�' �� .:����r�.�'�� �`€��.�a L , � zx`',��"�� �R.�
!j i"�&� � � �'^A��'�9 F Y F°i°��.. �F'+a, i�. $ .�
� c. wo�,_.2,7< .���.,� .�� � y� 1 � a,• �.�x,�.zn� ��� r ..� "F`-�-"*,a<„ gd �
...'� /i��'k,����4� l�^�r���'� 5�� �..c x � �,� §4ii-e:�''.:, � 3�� � ��;.�'^.34.+..,�s*' �,Y% :�a'.�C��y.
,€p ' 3'��. �2��,- . a°�,»� F�''"`�.�. �-� �'it d" ��i✓' i.��..�.s. '�"'.�s� f, �,.,�. ����a. ' �t...,��
� t � ���A� � �r�,� � �� ,��y^r�. , �` �� `� ��._ ����� ��,�+�t,��` x .,.. ' �, ��'�
.,,
x; �§- �"k��� ����€a ��s•'�:'a�.16'� . ,�. r .,,,���, . �,��,��. t`o�^���.�* ,��...'�`"°�,p'�s'�� :�
�� ` e �,7"` ^t�3.� u�'�-�`'.-sa'z .�c. -.t�?.` .�a��a.z�..sst.v`�tL.'�;,`'t„�sr �: ^'a�,.. "� . .
. i � r '��,,� ...�.y_ .,x. ' ��..� y *�;»�',,.._'Y".:;a`�"„�".'°"°" - �� ,.�,.0 .�e _::_.s c...w.. t ,'°', ^»,��c i S%
�� � � � r o- `e°"F��°Ay,� _�a �`45+�`���'"�r'".a...s�'�i..�"a.'��' r�.�.a'"a.'�+�c�'.$`YV�a.� �- � ��.� � �.�� ���. a.� i o�� ����
� 4 S �ji
$�b§' .�.,.-,'�r. r e ....�.�,.,.�..�.a�a:�.,m,�d.c *�..; s�n.�'.�....�` '�z���� ...�',k °�;y � ��^,��"�.
m ..�:'� �'�-�-�ri°�� � �m,�.
��� . . .� � ' �...v...,�,.ww, roi F f�v { � J�.
Q.».,a..� , . . .
Y� n r .
€� -1 n i '-� �.�-: t�.�`,@'�.5�»"��.�.a��,��.m�� `�f'����'.�.C`� �"°� .*,f eC;'e�.b* ',a t 1 q�
� x i
�'�:�' t � �� � �. � �j s, u�� *...�fb..v.J� - ��s ,t
g 3�. !+ �g""e,? � �s b�3��: (',�r .e q & i�t � : 3 S �'i r P s� Z s
t
1
w,. y.�.."y�..+d 3! ' ti 7 �'
„�.-. m...°�, .,_.. ,.,. .'� .�..: � � `� 1 A � �Z _
ff � �� t ;,. '.t � \ f� S�` _
�_ � +' �t � $ � E �{
S
R
.'4YJ`�. �.7 ��t yy�.S"#�.,� s �A
7 1 j�{ M
si.;- �; � 3 + h�5�r„��a.r es.�
'„9� '" q., s
�k P 'fr �r
1
= :� �
hF- k 1
'F � � }
� t � i � 4 � �y �
$ . l:c �h.`' .i � � ������9f� �
:J. F ��>,yv,�s,v�*
}-..-. � . ` ._ '" :,- .:_ " _
'a. . ..�, 'I
��'
f,- _
y� ..,� . ,. �
H'y > �, . .
; �a i
g ._ � ... , � �
� .,3.. � +4 ��
�. �
'-v "�.n+:�` h_�a,, m�`.,�, � ,y,.,<..:w...,,, t::...r �. ��'� "3 �`5L*�,?�S i„-.>z��, x�, • ...'v-'y`" - ' ���a
��
�*err r��+ Q M �
��.._.,, Z � � �- O
...,,� lf> �--
N
�,� � N
�'.< L � � N
7 � r' a
� ++ O N fa
"'. �0 +��+ O O �
� � N N
� � �
Q � _ � O O ��
� O
�-' �ULL NL � N
a a' N O N �'O a
N
� ` � �I'� .a 1A �a
11. C� d c- ,� � N•�� �
_ � O y �- >,-� � C
0 N � � � O �U
d O �•�i Z�� X
� �
Z � L w U `
N
O
0 0 �C�a
� I� � � � N L
01 I� O � '��i ,�'p.c0
�- � � N � (p � U
CO �Z �o�
� � = • a�
cr o m = �, �o
� � �i. C C N � `p
� � a � � ��•`
� �w a a
T,C � �
C�(, � p_� �fQ
G� �, Q7� C N'�
3 �. C O O �
�y.I 1 :
L � Z N � @ O
U'a � ��
O � W��h �,V
N � O> 00 ��� � fl-
LL � r"' N � 'a w V� �
� G� � I� C O.S ��N
� � � � �Z-p .n
.�r � •N ��•�
�.0+ � = X'Q I���
> W �rn .n
_ �_. . �°O� Z'
G� V � o ' �,�c
> Q � � "� co �.°n
= y ao � �Z��
v � � L • � a�2
L
a � �o� �
� L L
Uin o 0 0
y � c �w
� � ��'_'_�
C� d f� � 3 �NNm
7 a+ � � '���� 7 c
y � � � O,c v� y m
N 0 O O � `.�.�V
U � 3 3W
d W • �ww c
� � W � L �
E � W � O O�
� � �
Z � cfl � v� cn�
N � �,N N N
�' � U
� � � .-� N N
'L � o, a cn cn N
y � Y � � N�
c
� N � 000�
o c� ���
� � � "
0 N �� �a: .
f!l (p ,*" � •
G� �-'
�� W W F-
� �
� � N �
N
� p = � N w
m Z'; > m �
�
St
�
MEMBERS 1St
FEDERAL CREDIT UNION
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 413565-00
Date Account Established 03/23/2011
Principal Balance at Date of Death $1,418.29
Accrued Interest to Date of Death $0.05
Total Principal and Accrued Interest $1,418.34
Name of Joint Owner None
CHECKING ACCOUNT:
Account Number/Suffix 413565-11
Date Account Established 03/23/2011
Principal Balance at Date of Death $5,255.02
Accrued Interest to Date of Death $0.06
Total Principal and Accrued Interest $5,255.08
Name of Joint Owner None
MEMBERS 1ST FEDERA CREDIT UNION
�.J
Tessa L Klugh
Lending Insurance Support Specialist
January 15, 2014
Estate of: WILLIAM S SMITH
Date of Death: 10/09/2013
��cia! �scurit�� Ram�er: 165-28-9978
�,: ._ ,.
5000 Louise Drive • P.O. Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wwwmemberslst.org
Santander
ESTATE OF William S. Smith
SOCIAL SECURITY#: 165-28-8978
DATE OF DEATH: October 9, 2013
Account#: 1671000463 Type: Checking Open date: 7/30/2001
In the name of: William S Smith - (Dana L Smith- POA)
Date of Death Balance: $6,890.63
Int.(YTD) from 1/1/2013 to 9/30/2013 $1.09
Accrued interest to date of death: $0.03
Other info: Account closed 11/12/2013 - $6,561.65 - (Dana added as POA 1/19/2011)
Account#: 1674065140 Type: Money Market Open date: 7/6/2010
In the name of: William S Smith- (Dana L Smith- POA)
Date of Death Balance: $5,038.26
Int.(YTD) from 1/1/2013 to 9/30/2013 $7.56
Accrued interest to date of death: $0.36
Other Info: Account closed 11/12/2013 - $5,039.09 - (Dana added as POA 1/19/2011)
Account#: 1675550352 Type: CD Open date: 7/6/2010
In the name of: William S Smith
Date of Death Balance: $5,365.78
Int.(YTD) from 1/1/2013 to 9/30/2013 $68.39
Accrued interest to date of death: $0.59
Other Info: Account closed 11/12/2013 - $5,367.50
Page 1 of 1
.. -� :' 1' . ' .. . r� �
� : M �:
' �� �
� �N �
OQ ''; �rl
O , �
O� � V'� �
ZO� '� ;'�I.+,; LLJ.'k � .
' Y,O1 f!i at =*
' �� `p £J.k �`
�:O � !:` ,K.':
, .
; :L�Q� <>:K-
O . � ,.� ;
, � .K �
z.
A:,�, , � �..�
� � O
eu ' ;i�
,;.. �
, �
�' , �
o., �
r� � �
�a . � °
1 o.a ; ... p , $ >' �
� :.zu�, � ;, � N ' �
� ID t . , Q\ 'i t!1
� ;:, .. :: p eM
w.r � (�
. ,:.�Ha . t�.::; \ Q�
. .. � ���. � . _ �
�. � � ,
1 �
� �
1. _ i
1
�;i.:�:a.,.
" y: '.
, :��:'. �:: 4�:.:� !
.:.?. �- :�:! ■•
, l �
� _ �'
i � F N j l
+ � �Q � ❑
j � .. H�O i O
� H � ; �
� •-
3 1- � � :.. ��[� ��� i � � ri .
Z � W� j a
Q � M W
[ ' �' " � J i�a i 1Y1
� ' p M: ~y ' i �
3: . . V p 3=� � .�
�: O LL f-� !
i �- N: � ;! O M m , ' �
i �` J .<.� T . W Z N) ' _ .
� Q w Q�9OC i �
� Z ; �' F-V I �
� � �< ::: +�i' :; N�� .; C�
� ,<.7 "V 'Q ': WN � O
;o 'y ' �, ` 68Z00 i �
, z ` , � , � Q'
; a = � � o
,� `> � �
� �. � � o
`y W ::.
� '_ ; o ,;� O .
W �
G.
� � � �
.
,lY.l "'__ �' ."�" ,:`;: ���{
1 ..� ��'N .' 4J '�� � .':i
m � < � °W 4
u. o=a°u. � ` ;
; ; i--�oo
,: �
¢ �
� (�]}��� € �
f �N.`:J .. ... . . . .. . ,
_ ,_.. ,
,e.�.`�:
-- � � -
�E= y, a'.� ..
,it� '�' �
�: � :
� �;., �
� ��y �
� �; � �
- .
a -
,
�� ,d`'_"'.�� '_ Q : *: .. .. .
*�
�� �. _ � . . . .�a'
�. .,�` z
�
� � . � � ` � � �
� -� f
, o ,
�_� * ; , .
�; � x , ' �
o #`} =j j�
w k � '¢ �
. �:
,' ' -� ? [.D
* � �p
. ,_ *: ti
� �i
} * �
� 0 * w w. Q
* a a:
�� ;,° � Q'
.��.
: c�o H � * $ �
� # ao ❑
�� �..� .� � .. # : .. . . . �
v! - *
� Z a �'
1-�'��. , p' *'. ■•
� x.
� t!)`. � �. ❑
Q'
�. N
_ �. O
-�7 ❑
�- �
O: � .a
� ;:'k . � � a,,..,�� - � .-�
w .V�` . . - , C.0
O' �, ❑
,� "y ��
_tr,: ,,
u?,>.: ,-�'' ,
$
• . .- . �,. . , . .. � .
. Q- ��� ` � .-�
L+ � ': 8 '^
� �":O � O' ' f.�1
� CA'y� � ;
U � �''�� �. � �� rf1
� � �'-� �' o` 1 [D
ki�7 t� ��.Q � : �
� �
Q � � � �" �,:_ �: � .�a
,� � � G ; . . H � � � .> �, �
� s�,� . �.: ��Cn,�`� .-a
� O> N C) 4] ' JF'=�
W tL. ���m �
,. � � � =QZ�
::.� � ;; Q :: F`ZMfY
� .. a' �" �ON�:S
O
-. -� x;::: ;:,.
: � �
�,�; o(�� ,F=-
`. � ; �;?:; �,
Y� �.,• -
_ �-- -
s � .�T��� �' y � ���„�,:..�;�t P S'f 0, '! 1 � ,8�� ,��"�,`"�s�
� ��k 4�:���������:�������.��n �` � . �f a��
�c� ,�� ���.. > <-
h4� . F Y�.d�zc. � . : . � . .s.
��w. �h f. c =.� ' ��, ,,f ;?';. w�I�''u�'�'��„3€) �'ibP�a�� C��'Y;: P�[() �'a;ll3ta �►��999��
�s �. �<:� � ��€3�'�'�:s>5i�i��� �:s����3�� � �3d��.}2�314'!�b�4'#
f„►�,�
���� :� ��
:;� #�oy 7 {srs��3�F��aa��1�`£�#si€�ier£�3���i::E�s3E�#�#:���'si��:,f�lsif.F��s�1
Y .,�'� , ��e� : ��3 �}A��i� �t��7'�i PER .R��'
�a' ' ��w:€��.�y� � ��7I'f�i ��C�3 �1 nry
u<� i � � , . . �t
. R w5'Y' • . . : ,��,f.,r'�A:.�� :Y �`3�.� w7 's � .. . �it:k'7!' �,�4�V��VV
�'f < �,f��<�����.;�?v �?� ����� '#g`€'�
t3, 'l atO d�TE�t TiF}�YERR
�,�.
'�4�'e� ' 1 >S SS�iJ }>- .^a
K�F�,� � �„��'—#�'��.�s t 3 �5:��r���'�yy..;s,�;.r r"���;
`�.-Y�. , r:�-�:� �.
�" �..�h c�' � .: ... . r�`���5,,;`����'���;t-z-,k�,� �,$#�w�'�y�}��y,
.�� ,. . , %isq,�.;�'��f11..�.er-fi�'ri.y�'�t a.±t��F:?d;�;:g}�.v::�
./. ac� 4.re:"L'�3#.3 sr°�.�£�F�.�"�3�3 ;%�'f � ��'s:��,ri�t 1 't� r�'Hs�4�`i4
i ��'€ (C:�t�:,afi..� 3'v��r�.,�r,'i`�T�� s=�+���E��.ys �;,y
<,,._
.�:�-7+r�"��` � .. . � ��' �i::.,.�r tL' _ � .r: . , ��:��
a
;�. ��6 �;..�-::�..„,..-'-- ......,�.,...,-. . r.�:i�..+:<.
,..._: c .. . :
>,x; ,:>.,<�a�s gPl:j���s.si;ii�€`� � �€��s. 2'7 ��'��� ?��Ee f��ti5s�
� � ��-,��v`�-
�� ��c�
����
zc�
' � £ � .. -� ;r"E,i',.� -. f p � �s v -� �� - �' - r � t k!S " .�
��t�r� ` � �` � " ' § '�:� ` " �`` , ��T+tt30�,'..�t� � ���.tt� � ` Gt��CK. �, ���� � � ;
r�:d1�. � �4
r
���"t��, ,����"���;17G��"��8����?�� r ,' � '�65$���7 s �.2���
P� ,�t�x $7�f�1��?t8�a`��, '���`'���'�#�-C�87'T OAs O�c����S. � , �, ��
" ^
� j R ' ��p ( �.5 h � �'�. $.
�� � d � � FM� � �
� a ,� � ti E� h�ioC��"t1iFt D l�81�1�ec8 � �
^ .�.� ,i!im�nrc e�u�rm�;-.�` �: ° ,
,
� � ' ��4�t 7'1���#'�N�t�", `� �
'��`� �,��'�'�� `�����r� 1�I�T'�` ,. +���� r����:�3� ��'�Z,I.�i��` ��� � ' � � Nk � � ���� � .
' ? ` �a: � � ,� A " r„ �,;� � < ,� �,�'r
v� �
,,;
i��. �^ }�- @y/�(e� y�pp yt }�t.��r ;
".yS�[�"�L1�f•��t'�'��A #�����4'FY6Gk 4r#�R VqF�� �.' �� t �������� ``: �,'�^�^��k*�
� y�,���r+t�ik�F
�
cr��rt �r�a`r��7�e�`ta� rt�u� s{g���,xes ��auxr�a i � �� � ��{�.,
�� ti �� , if irver �a�'�D�QC�.4�� � , ��; � ��� �
V�IC3,�4F`F�EF# 18Q,.�?�X`f�S = �` �-
� � e � � �
i-M i '' ��k�.`d����. usY��/,� 4 '�: �. � � k � � t
*p T i �z p3
���'� � svf , t . : - x '�+ y L�
�,�.�� _ � �1��+ a .� '�" ^���: � ,;�$ �' .� �` r" ��, p,i„�.� �r'R��: 5������'.�L'�'u .
,� �.� �w � . �. �t' . � �� .' � tR �"'°�&5 5 �b�p� ..
��F�«'" �,t� ,r������������ �� ��. ,������M#,������;� � x�� ���;� r} � �% ti.��;��: ` o � zi ,� '��i`���'`��
� n a" �fr� _ � i' � „�`�r t'���X,��,k �,�a,, j � .�S ,�� �� r, * R aY r�y �S4�j�„ � g.
�q " -,�y :'g�` J'r" �' �.�r v��'s�� &� �'4. �'"� �:.�.„�,,�'r',. � .� �, t s � .�-R..� ��,� g� ra � �„k �,�� � ��`.�����,�` �'� z���� .xr ��r�
�rs �.a ,�,��r�.Yr§`5�:�. � v�""�'���:.. z�;���-. *� _,r� '�3.,:``�C S � � � � ..� �� r � v��:. �. � . �:. zd<<, � ..,d4�s,
'� ��R a. �. �3 ,� � � �w, 9 �;�� � t�- & �u��`�= # ya"� y �" �,. ."dkA ' �9e�:
,e,� �#vl�a «� '� �a�, �s° � ,� r�re�. �' �+�
- . .� :s:,.�.�.� �:"��-� �#;��<,��s'"�"�,, ��' �w����lz',�,e , .�3� z.. ��. �`t -'� �� � F
F ,_�s
. �,�,:�.�.4�5......,..�.�*. ��. .�t;�:.,.'� .«�.. ,��,�. �..,a� �;:. �..�x�' ?,i'.a�S,,, ��-�€ .� Z 'fmk �� 3 �
. . � . . . �,:.�s , ,•.•�>,� w� ��.�.f'k°`�',��..,::���,x:�
rr� �6557'4� 7a�� �;D3 � �i703S l�: CI3aCl95D03 ?n•
Amsrican G�nerai Life Insurance Company
P.O. Bnx 871, Amarilto. TX 7&S05-CI$77 GHEGK# 36587467
.INT£RNAi REFER£NCE# 22E}6198378
T�A�SACTlt1lU �T"ATEMEN't"
NAt4lEE: WILLIAM SfVflTH March 'f 8; �014
PCJUCY: XP2�3687
TRA9VSACTION; D�ATH Ct,AIIVI PROCEEDS
C?WNER; Wt�L1AM SMITH
FEQER;�L V11`ITHHOLI}ING TA?C � 34�.29 —
AMOUNT t�F +CHE�K $ 13,08(�.59
. . . �E'tllriG7�:4 '�i�Ytii��.�i;. �, ' �:r„M^`.'� � �.. � �' ���� }� � e �a
�Tp��•,,� �'� A,��a! h i l W�� ��j�4a�� �`: �
� � � . ,.r.7 _�� q ���� , 'a.� `���� �� E ��d'�� € ��.
. ' ' - : , . .. ��`-',s�� �, ���,���3 - ,�a.99� o E '`3 �"�..
-- . � � '��'��� ������������.. ��
........_.. .._......_....,, . . ... .. ... .. ,,,///'''))) �
_ ^ .._.�__ . �� .3�5 64�.
'�\ . � j9}� �'�
� � -� �G��C�S e�-- .�`
� � �� n` �
��.i 'n` yy(�'Y' � . � .
1 / . �`���V �� � .
" /� � K J , /`/� . ^ � . .
�� Y � Li.., � �` � �� ' � �
� / .'—
. � ��:� �x � �
� � ���
� ._� I � � �
� �, � �
�� �����,�
�J'/���G��- .A }��JQ�r`J
�'•"' •�� / 3 .
�� `���•�`�.. .�..�- �
�� � � � �r �����. � �
. ; : ,n. z ��y �,y 5< r�,�" �
> �?�?�`j�'E3'+�F"�'�,`�'�`�I�E'i}P' Z'I��a� Y»�^�`������ �E�� ���� �.! 1E G
:` ,�._ r , � ., � m.. ... .. , xa ��.��
� � c �
�,s , ,; � .,✓,s u� . .�;� �.� �, �
� M:M��s, .� ��-
�Y��� � �.�;���r��� �'r ������`"�� 'A :�� �'� ���`.r�kN���n t� �� ��. �M.r�` �tJ��4 ���!'!�.'�{�'�"�,�� s a���� d ����� r+�,x ss
� h
�£4I`��t�'ls�����q ; ,«dzy ���!�`a�� �arj*: �� � £ �1�5 `��,`3��-���`�� r�fia����8 �'�.t'"�� � c,��3�9,� ,
' .P�3 �Glaf 8?t,`,�F�$�YNn, T� Z"���{����& Y �
a �. � �,�� ;r° ,,; �,
� -�`+ aY' s �� � `B�ti'7r�C04�-`Y�f78t-�oP�D9t�d�dK� � ��
' M�1Ktt4p�rAE(.ili+�l�R�.-; , t
; ; , l�
' -� � ' .: ' �. < �� Y,
- � � 'e • , . ^ . . .:w `�
: ' . `� �'�� ��i�` I��Q��{ "h '
,, �, , i
' �*� '���I��"'�' '�� ��'�t�3��� ���I���2,$1) .F�F't`� TH��� ��+� ����.0(} �t3L�RS s��a�s�
z ;� f
.: .
f �w �� ��:�.:.�
„ ` ° � � 3� �53�� ��
; . ;
****�+v**JVOT'�tiCI;I� B�fit)�� C�1��1� b�t��' ; �
�F���'14 ��'������1`t 4 '� ¢ �"uua sign��u�e� eequ�red ` ��^, ,�:; �a� � �
3 yy 3 ��y�y K �'
�t �:� � � t l�{�����,Y����47W W�� t F � �' �.�� 9 s
��� ���"� ��� '�i.i��J �.
.,
� Rl 4� �'
� � � Z�
+� ����r �i��}�{��2.�� ��9�.�T � �� � ..
4�g�C ���� �Y�.��S^�t! ; l �t ... �� �/ �f, �� �'f` . Y �q�y.' � �` q� { .
�,R�.1� a }f'�f�tr�sBl���� ��1�� � � ° � ��•�����M�� � � � s ,�„��
�.�t �'-�� o , � � a��� . � .s 1$' . a.� �'
� t a 3 �K' : �v t� � 2�, � m�,: avr x s i t�-�' Y",�� r
.:: � � � �"x � �� �. ',.. -� ' ;s �'� �� �� '" k ���a � � � r ��`��`�r� � .
. . � '� � . .,�- t e
-'� , , I�t� r �" •W,�. . 9 ''1 �;q"� . s� I e +' �:� 4� a v Z�'Y r�. �
_ R (
<
�£z� . �� - , ., ,�'c�,,. = k. .� 3 � � - ��t '¢ Y� i
� t�.M 'a' ,. ,_�.�_. �..:��,..,.... ' .�aka '- F � 5"�`rx-r,r .., , m�a�e f�`� '��i� ��f��
.., �� � �: „ . ,`� ,,
..,_ - .;,_ , ��.
� . . .,, , ,«., - ,�. . ... . . . ""13 �r ,�.�..
►�� i 6 �8 ��, �8�• �:a � i ioo 3 � ��: o�009 soo � ����
American' Generaf Life 'Insurar�ce Company
P.Q. $ox 87`I. Arnariilo, TX �9105-D871 GHECK# 16587478
1NTERI�+IAL REFERENCE/t 2200196391 ,
TRANS�4CTtC)N STATEMENT
t�AME; '+tt�{LLlAM S�`i�;ITH �aFCri ��t �a��
PC?LfCti': XV215499
'f RANSACTfUN: > DEATH CtAlit%1 RROCEEDS
01/UNER. WILLIAIVI SMITH
FEDERAL W1fiHHC�Lt]fNG TA�t � 852.75 -
:AM{3UNT QF CHF�K �v 33,153.U4
y-`
�'.', _\ 3 �a Y 3 .�r a� },� � �� 3 �� g � . 7��L
TA:3�ABLE 1:h1��i�1E ` � �°����&� r� �� ��
� � F,r � � �� ,
����� m ���, ��s �
� �
�
��� �:��
._ .___�.� _ � � � �_ -
� � V
�;� � �- � ��'���-
� �
�
1 � ��
�� ,� � � �-� � C� `���� � � �
� � . c�� (c ►
� �
� , ��; ��
� ��� �C �
.��� � � 3 ��� ���
� � P —�- � � , �
3 LI,G�S° �q� �--��5 C� C-E-1,�c;� � k- ��c.
�
� �az �° � ��' ��U,�
, , � �,� � ���� �`� ^��
n� � �� � � � � �
� :r� s. .. �..� � � a �� �.� r r°�y�' E��� .��t��S
��. t'�a��„�;�u���1� �i�� ����: ��: �,�,�;5���� ���� �t � � � ���
� , '� N ,k�>+a 4����c���� ....�� �.
ri .. . ... . . , . . .. _ � i
,.__...�.�
.��—�
�w� � �
������
AMERlCAN NAl10NA�lNSURAN�E COM17P�NY ,�„�,�,_,�_,�„��„TM,r.� .
�.IF�61ti�tJRANC�ANC)ANNUITY C�.AIMS[D�PARTM�N3'� ��T�����—���
i'c.)f1C?;C 1045fi.;f�RlNGFIFt...f�,MC)F5'30R-��6�,TFI..:;�'Of}l f?5-737?i°AX:(?.$'•)53£3-di757
.T,tnL1aN l�l, ?(1l�
F:��i'S�i'QNE EL,T�ER L,AW PC
A�rf`I�1: �3F,CI�T STAP�R
,55 G�TTYSBiTRK PIICE SUIT.F_, C;-100
!bi�;(:H�,NI�;:;BiJRG PA ?7075
�;lairri C'887852 Will'za��i Smith :�ar�tr•act �A,R€_r,'>E:;��;,
�.�e�r 11�1s. Starr:
T��n�yo�a for yoiir inquiry,
T'l�e dat� of death value(October 9, 2��13� afth�y z�c�n�qualzfi��i a�1r,�uty ci�ntr�ct i�:
ContxaGt Va:lue: $35,600.63
�ost Ba.sis; $29,194,44
IFyo�.� have any further questions please let us knc�w.
Six�cerely,
�har�;.,Zajaclr
�ENIOR CLAIIVIS SPECIA.LIST
_ ` � -�, � �..���-�-
�� �� � �
��
���
�1..�.s�- � ��--j 1�3� �3�.— �+ � ��a�
>
�u��� . a�� - �.,�����a� �- - � , gS . �3� ��-��f.�
a �
, ,,���, �-� - �.�.°..- ..�.�..�._.---
�
� �j�� �t�� . ��_
� ?���t�C:� - ��
� ��� �
�s..,--`�II K�,,..riiF � : 9�` .Y t�s��P �� c°-ra�f���� v� _ y�,�' �?it y �`� . �� . ..
`�"�T���»� � �� dt �'�i y� � �`"� �`'�,���s��� 7 r ' �.��'Y�.
�a�r�'i,s'�'fa s.PAr�3 ��.�e ��d�.\ �� `��,w �� . ��`,� !r'�"� �' �.� y � ...
�a�� wa3� eg. � �s ` .� �,., ��r � ����z+�S _ °+kt.� '�",�s�`�„ v,.,*:�S'�ca�n�r � � ��� X u..
� � ,����.+ .� �. T" c�� .,��= � -�tr�' ,,,�,. � ���-*5 ras.� . -
� ` � s��a� �� ��» �
�» , �,� � '
� �� ���� �
, �; . ;, � �4� � r � s �� " . � '�,.��,g�� �,,� s�: �� Y �ar�,��;��.
� x. � o � v : ... � r� . �'�,, i
�;� �a'.�m �� �`�r �;���,�� . ��; ""�"�`�°�'`����`§���� ��'?a�p;+'
. � ... a v�- �?� �� �� � , S r isK,��r�Y u�� �k���`��; .�.4 ,;� �,�'.,..
s . 4`, '°�� S r�" �x.�'�`a�J� �" � ��,�s���,��
� �Rx �� a =�,�� $ �"R �1c ���' ����'.��r t � r�ct ����y :.�a�`�`X�� �M'�'��E.
? -C �.�.��� f. �.����'i�r {��',.'�^t'��s�k�c h4�` �, h '�jsf � F�^� r.'i�1 �
. ���['�r �1 "�}�y�j� � ". � . y �
U��7+°ip�V��FiGi '1�����14�4•��� � ����",�s'��`� �'�.'�,b e .��a a ;� ��
- �. � �y A Y 7� � rat x. r ��
. ��e++i��'�.Qi��Mr�r�`�.����� � a i rr�� "��,��s'"4��;�'
;, _ �y
� � �� ����R)��� 3 ��:' "� x ':� �f�y�F b : '�i4� '..�4e�.� q��(�,�.y"
. . �. . � � �, g , +d - .cYb'�+"�k 3 ,.
��.. ��.�j�i`�����17��l4!/�� •"I�JF � : A fC '?� zg �2 ��:�b�'M�
� � .5,' �' f .� � �
. ,�n..� L�(i P �' y �'.�`� �' y���
, � '� ;- £ � .� c^����� �h5�s
. _ .. . ,. �,.,�,"�5$ ��1t` E�`
: ,
..... � .. � �o-� ��� ��
� ��x��y
" ^; � ��� ��,�
� 3�
- x H i 7,r p Y � � �
e�ril l{),Z�k�� �� ��
;
, ���F
�,�--
'ti�i�Iiar�S. �n�iih
cto t�ana Szni�24�3 t+i..�t��tz�:er.
�axr�is�ur,g,PA 1"7X I�
S�temeitt D�G�arg�s fot�Serv���s�e�dered.
P�r F�rm G`I�rge�:
See f�r��"st�l b�lo�v-Fe�l�t G0:04
���'c�r�s listet�b�ia�-peuns�r'l�+�ia 3 j.t#Q
�;;
K��:
�'i�tal fee $ 9�.00 �
���
�r ;
, ���'
r�
r�
� s,
,
��
' q�(�� -
: �. -
..k.L:;°�.
fj ��_ ��
� ...�.�:�� . � � - .
���;_ .
�� � ��
.�
�,� �;
�3�
, . ���... �"� � ..,...� . . " 2
&=`'
... .. �`�, .
�
.. . �.. . .. � . .. � fr{;�
. � � �'. � .: ,
.. . .. . � .:,. a :. �'....,. .. :x���`�ia�`£�`'�.�' � X$..,;: A g .;.k "xF N."} �� § _
„ . �+,..:.., .,..�;e J.
:. ::.. .. . ..�: ,.,_.. >• k ...
.. ,. __... _. .,... - .�F :.,': > �z
. _ , ,. _ _
- � _ : ,: _ ;
_ , x�
:., , . .. . , . :: .t,
; _ ; .. . , �
,�
_ _ �
.
,.. - � ,
���.��}t�.�.� �a-;�� �#��
��. Sm���.��. �,,y,� �����
�3�7�t�i St . . , .. .
�a�.�isbur�,.pA 1711Q �-• � �0� CkF�� :
_ �x .
4� r
Payto(6e �.�0!l d�l �'CYl� Ti'� I $ ���w.. `�--�Q`
o �-10 � � ,a.,,....
_� u.�r� � c�nr �
s��x�,���r
4Qt EnolaRa�d
Enola.P/i t7A�5
� o�� ���.��.
Fer ��t�' � -°- -��
�: 2 3 L3 7 269 L�: 290 106 2 L0 5i�'O L06
�111Ni�#t$.��i��.Sr.E�t 11 13 ��$
t7��a L.�►t�ith.�''er.R�p.
�Q��� 6D-7268l2373
H��,�P,�1�1�D � .
__ _
������� '�� ����
Pa�to.Ihe -�1._ ��..i'1C,1. � � �l'11�'Y1 I $ ,
° t � � 14~l ��
r�� �u:��t�re� �.�.r�� C� `�i�o,� e ��
s�t��►d��
qp�Enola Rpad
Enota.PA,A?5125
�r �������� i���t� �������..�� ....
. . . , . �
�. 2 3 l 3 ? 269 1�. 290 L06 2 LO 5it'0 L08
� --� �
� �- : �
� � � ; o
� -� -+ I N � � � .
�. � 'Li � b� p X � ' CO I � .�
n .-� � _. C'� 7C' W T� .z. G7 5
�� . -D C� [v "D [.!� � cn z 3 t[] O O CA 3 c� -n ,--r 7� � . �h fu W � CD j � i m :t 'rJ --s c�
., ?� c� 'O J� O J -�- J O W • • tD W C7 -ti _. � � ��,O -t i O i r E � � g tn �.
fA 3 -�� fD (n S fD --a G= i Z T.' � —'T
� -na cz� � � ` -S Jo�av�i ! � °' � .
� �. � r+ Q7Sr-� r7 Z [D � 57� (�D NQ� ��Ttr+ NCD h i D �� `f �0 � .
JL. -> CD (U . ._ O J h i „n I tQ N C Z �
co ci. cn � �a ,� � o� � � �� cn o° � N °- o a �
cu c7 c, co o, �' J o z cn m �-+ a � w � i -�i,�c-'o ��c
y cv rv � ; o, -�
Qa. �n. c �'� w n' o � � . � i � c'c� � �.w -c+ c°n m
� . 0! d q+ I •- ' _'N F � r�+
�
� � p I `� O D � � w .
' A �7 0.� U'�(C] C'.
1 3 � O � O �
. � -J -J N 00 �1 O i � � Q r+ .
� .,f -J . . . . � � � j r+ t
-� �
� � ii= cAD co tt7 � � � c � i
� � i
Vp! O�i � � O £ O
7r 7r a• 'z £ � _. j � _. _. .A � _, � _.
(D O £ �
�G 'v o --� crr � -� tn r- f c7 r r r � �. T �
o -� c �� o w c ca a o ca co m � � c�
� � o �� �. .-r �-+ x o' -n TDWTD � - Ar -- Tc�� vcnd cnz,
� -, �-a -�,�. � rn w ,�- � � -f.� v � � s o � � c :. Q ca � - �o -o - w •c �
�� o �-1,r+ <o •� -, o n� o cn r+ ro c� cc ro -< cn co � -, Q ,+ = co cu -.w c m
cn s ro cn �-r u. o m �o co � -s i � - i �-+ .+ • � cn c� --• cn .
cv cu �� �a -�,¢ o cu � ,+ o v: c� n ' w o c n w �-r+ ao -�:
� w � c � cn -,� -i s c'�� r- �-c�� r- -� � c� cn � � co m r cn ;
� < �-+ � o ,--r � cn� cn r-+ w � co o, cn � cn m -� a Q cn � � �-
cv o - -�. c� co cu T � �, � cn m --• �, w ro x
�� � n ca� cn a� �,-• cu cv -, --� o� x c� -� c a�
�� �� � D � �G � � rr:� �• �• � �-r i� �� `�• rv
. ... .. . . r- --�
� O • � O V7 „r, w N V1 VI (D C3� Cn � r+
�� � • � aa � c°�
�� ° ti
�
.�. cn , .�
��
= Ct ('� Cn '7 N -+ -� tV N W ESi C3"� OQ ^J
� �- � � CO G W CD O G W CD CU ' CD OO
w rn cn cn co co co co rn c� cn c�+ ca
�
. ____
��'�
n_�_� 1�J l`�(I�
__ --"''��-.
��� .�.;:;,� '��.��� �Ey.�`� k�.�.-��'��.xy�� �. �:
�- �¢--• .
_ �, _ . ,. � . .._. I.
. . ... �.r`. .. - . .._r _... _.
OCT 9„ 2013
FAMILY OF WILLIAM S. SMITH
°/a DANA SMITH
2443 N. 5 TH ST'REET
HARRISBURG,PA
FUNERAL SERVICE FOR MR. WILLIAM S. SMITH..
FULL SERVICE 3195.00
RENTAL STEEL CASKET 840.00
CLERGY 100.00
CERTIFIED COPIES 120.00
NEWSPAPER NOTIVE 300.00
CORONER 30.00
CREMATION SERVICE 595.00 �� �� S
CEMETERY 300.00 \����\ �
TOTAL DUE $5480.00
�
William S. Smith, Sr. , Estate �
Dana L. Smith, Per. Rep, 60-7265/2313
2443 N. Sth St. 101
Harrisburg, PA 17110 onTSNovember 14, 2013
�
� n�ro Saloom-peterson Funernal Home, Inc.
g THEORDEROF d� ,r'480.00
�e •P
, Five Thousand Four Hundred Ei ht and 00/100-----
� DOLLARS � �`�
° � Santander'
Santander Bank,N.A.
MEMO Funeral bill
. .-�' �����
�. 23L372691�: �
2 9 0 10 6 2 10 5 ii' -����
oioi
s��r��
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date : 10/28/2013
Cumberland County - Register Of Wills Receipt Time : 14 : 32 : 54
One Courthouse S uare Receipt No. : 1076049
Carlisle, PA 17�13
SMITH WILLAIM S SR
Estate File No . : 2013-01140
Paid By Remarks : KEYSTONE ELDER LAW
CJ
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 25 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 1719 $163 . 50
Total Received. . . . . . . . . $163 . 50
11/14/13 WaI mart Checl6-E�ery Day Low Prices!
.�_2 ' lmartcom Checks and Accessories
���[!l.�.�� d#"4,.i..{iL:,�� OrderStatus � GoriG3ctUs
_.._.._............. ... _.... _.,._.._,
See Ati Cate�aries Search search forproducts ^J ' "` Mty Carf(Q)
Thank You
Thank you for your order!
Your order number is 40-65023180.Soon we will send you an email order confirmation that will include the order number and order details.Please save Lhis number
untli you receive your order.You may also want to print this page for future reference.
Order Sumriary
ProductSubtoWl: $8.46
Shipping and Handling: #5.50
Sales Tax: $0.84
O�r To,t�ai: $�14.8'�:
� t�. � �� �� 1'Q�
y�� ������ `z�` 6b•7369i2913
-�`�Lt�r P�1�..���i .
�� ����-- �4�= ������F��
�-€��t�a�� _
i�; - �.�r��� ��.�:: P.e.,
�, i�s.3o
1
. �y �. � (� �~�MN��^�.
yy f 'n+��{p��� '}'
" � .�dW ��Y�Y�" �^ �V���
l 'i, Y
' ��dr
� ��n1��5�'0�5 � � �
� J
,,, � �. ��x�se�n�n� �
'z�� c�ie,ck� ;�t Fee ������. ._ fi��i - �
. �� � �.. . �:�� �-_ ,
r°�! �3 3� 3�'7 ?6 9 L�; 2 9 0 L 0 6 2 L CI�14+0 L 0 5
. � . � •.., ..`.. � . ..., } ...` ♦
� � �
� y � f'0 i
�_ ".��.� .�' �' ; � -J�- �" � '
-- , � � ELDER LAW P.C.
www.keystoneelderlaw.com
December 6, 2013
Cumberland County Bar Association
Cumberland Law Journal
32 South Bedford Street
Carlisle, PA 17013
RE: Publication of Estate Notice for the
Estate of William S. Smith, Sr.,(deceased)
a/k/a William Steward Smith
To Whom It May Concern:
Kindly publish the attached estate notice in the next three (3) issues of the Cumberland Law
Journal. Enclosed is a check in�he amount of$75.00 as payment of your publication fee: Kindly
provide to my office a certified Proof of Publication.
Should you have any questions please contact my office. Thank you for your prompt attention to
this matter.
Sincerely,
KEYSTONE ELDER LAW P.C.
�, T � ���
Jessica F. Greene, Esq.
Enclosure: Es� ,. , ;
1Y1���1��i` ��� ,�Sa�'.�Sr� �`i•13 ��,�.
$� ��1��`�'. t�$j�.
24q�1�['a#tf-�t' : 60 7PG972$'�?3
F���ris6�r�,l���'ra K 9;�. � D�: . 2D L ' �'' �
�,.�.�-'� ....� �#��C�5�.l��; �
F�to the ����,,�,.���L1��T�u�?r,,, I � 7 5.00
OMet ot
��u��.�� ��d 00�10i�-.---��-- -- �-�-�-�� -�-- Du�ars $ �.,��
�,�n�nd�t ���
E`�rxola�AA a��7.�.�r
PO�.Le:�?�.-1�-N�.3��ie , ?,u����k-���.
� �}- - - ��..�..�,�'����
�. 2'3 i 3 7 c�6q'l�:' 290 L06 2 L0 5�i''D 10 7
��.k� .. ,,, . . . > .:� ,�n.: _ .._r.,:.3.: ..- : _ .,. : r.,,.. .. . .:. . .. �_.��t.a�ra� .� , .., b.�.,,,,.w.:�:�:�,� .
555 Gettysburg Pike,Suite C-100 • Mechanicsburg,PA 17055 • Phone: 717.697.3223 • F�: 717.691.80'70
� �� ��� ����
555 Gettysburg Pike, Suite C-100
Mechanicsburg, PA 17055
Phone: 717-697-3223
Fax: 717-691-8070
Facsimile Cover Sheet
Santander/Sovereign Bank Fax# (717)243-5907
17 W High St
Carlisle, PA 17013
Re: WILLIAM S. SMITH, SR., Deceased
SSN#:xxx-xx-8978
DOB: December 21, 1936
Address: 2443 N. Sth St., Harrisburg, PA 17110
January 3, 2014
To whom this may concern:
Your customer, William S. Smith, Sr. a/k/a William S. Smith, died on October 9ih, 2013.
Jessica F. Greene from Keystone Elder Law P.C. is the attorney for the Estate. Dana L. Smith
has been appointed as Personal Representative for the Estate.
We are aware that Mr. Smith held accounts with your financial institution. Please inform
us of the date of death balances of all accounts, whether he held a safe deposit box with vour
bankaswellast'-- - ., ".. -
an Authorizatior. 410
Wi1Nam S.�mith, Sr. Est i�-�3
for your records. Dana L. �rtr�i#h, Per. Rep. soa269/2313
2443 N 5th St � 20��
Marrisburg,PA 1711D CHEC!:SAfE�
Sincerely,
Keystone Elder I � `� �� , �Q, ��
Pay to ihe �(�f l�
. Order of : ��
8 '.�"`..�
�
, �
• Sat�tancler
401 Enola Road
Becki Starr, Lega �„o�a,PA 170�5 �-}�-�Ac1 r'+�.
Attachments: 4 �p�y�x�,a�C�. A�c�, ` ; n �
������ ��` � m�"
r rl �_\� �
For C �.
�: 231372691�: 2901062L05��'O l L0
v��
��Sentine� KEYSTONE ELDER LAW,P.C. AD NUMBER PAGE NO.
www.cumberlink.com 555GETTYSBURGPIKE 427176 1 of1
MECHANICSBURG, PA 17055-8070
���' BILL DATE __ SALESPERSON
717-697-3223
er,ausi� ���e�nise;;ec �earawr,rrv 12/23/13 wolfc
START DATE STOP DATE
12/09/13 12/23/13
AD NUMBER AD DESCRIPTION CLASS LINES
427176 NOTICE LETTERS TESTAMENTARY ON THE 10 PUBLIC NOTICES 34 * 2 cols
Publication Insertions Rate Net Amount Gross Amount
3 THE SENTINEL-LEGAL 3 LGL $180.54
TOTAL AD CHARGE $180.54
3 PROOF OF PUBLICATION 01PRF $7.00
3 MOBILE SITE M082 $2.00
��
: � ���
� �
�\�\ �
\�
�V
ti
PurchaseOrder Est. W.S. Smith PAY THIS AMOUNT $189.54 $227.45*
*AFTER 01/17/14
Lee Enterprises no longer accepts credit card payments sent via e-mait. -----
�.�: . . ' • •�1 L_ LI"1"J 1'11_"' .._.. 14� .........�..
: �r�tr���,��'��� 11.�� ' SENTINEL
� ` ���.��'�:�`'�';�p: ` �d� EE NEWSPAPERS
���th� � soaassn:�t�- �OX 540
i�arris�iurg,F�A t71�T�`` - , � ERLOO IA 50704-0540
� +`�J 2O� CHEC.�:SAFE'
P���o�he___�h� ��'�1 �i� � I $ `�y. S�
- ° ;_ ` �� j�
''r"���fS """"„"' --
'��C�tand�r B `.•�• umber 427176
6ole�Pk 7025 ---- --
ig Date 12/23/13
� � t �(� '� �un4 Due $ 189.54
ftlI 2 q 00. ��£'iY�i�4 i,�_ '��0;., �,�` ( --
�; . � �.;���'_-�' �
23L3 ? 2�,9 ��`. 290 �:Q6 � 1,, Su�0 �09 � no�r�t
���s�a $ ` °��.�j.`�J�-
Please make checks payable to: THE SENTINEL
�" °0°129 THE SENTINEL
�`� KEYSTONE EIDER LAW, P.C.
c/o LEE NEWSPAPERS
555 GETTYSBURG PIKE PO BOX 742548
MECHANICSBURG, PA 17055-8070 CINCINNATI OH 45274-2548
����������������������������������������������������������u��
215402000�00�427176000OOQ0000�0000227450�000189543
;}�'1E�5E°R�i���+�.�T�� #.!`�Y. £' "� Y v�� '�: • �. •
= j
+"� r 3,�r�_�' � `s • �- �
; ' x • <r, s
' � y. ' ,..: .��
.�.vi�a.'�•.�.-k:� � 'y��
Curnb�ri�r�� Got�dwill Fire Rescue EMS
Billing Office 13-216960 11/13/2013 $82.28
PO Box 726
New Cumberland, PA 17070-0726
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Date of Service: 10/4/2013 15:14 Please visit our website to provide insurance or make payment, and
Patient Name: SMITH,WILLtAM S.
for additional payment options and frequently asked questions:
From: Carlisle Regional Medical Center www.ambulancebillingoffice.com
To: FOREST PARK HEALTH CENTER
• • .
**Final Notice** If we do not receive payment within 10 days,your account may be referred to collection Contact our o�ce
to make payment arrangements This service is not covered by most insurance carriers.
10/04/13 Stretcher Van One-Way Transpoi A0130 1.0 80.00 80.00
10/04/13 Mileage S0209 1.3 1.75 2.28
Tota/ 82.28 � 0.00 _0.00
William S. Smith, Sr. , Estate �_����13 102
Dana L. Smith, Per. Rep.
2443 N. 5th St. DATE December S, 2013
Harrisburg, PA 17110
� PAYTO Cumberland Goodwill Fire Rescue EMS � � 82.28
g THE ORDER OF
} Eighty—two and 28/100----------- --------------DOLLnas 8 ��
� -----
� � Santander'
Santander Bank,N.A.
MEMO ambulance bill _�
�
'�: 2 3 L 3 7 269 1�: 290 �06 Z l0 5��'0 LO 2
, � �
r=
� � �
#�., f1 f F t . . -
�:�"`a , �n ,�a>� �y,`-�'���1 y1�y 3,�y� d �� . y, �"�,X"�``.p�"-Sr�w` x.� s- s • �- �
r���`� �JI�(�
�"��� '�R."� ?�C .1���'Qltll�.i��t� �lA VC�� � ����+`��� �zk� �.i �� lr.s.:;( �4UIM1L11 1r11'G,'i 4 ,{:r,
ne�essa `� "b�
�y,.p1��'s�c�lf us at 897 214 6Q�8:= ��{,'��.���
�� � 13-216960 $ 82.28
� vlsa � ascpy,ea
r��
Credit Card: ❑MASTERCARD ❑VISA ❑AMERICAN EXPRESS ❑DISCOVER Amount Paid:
Pt: SMIT'H,WILLIAM S.
Piease make any corrections to address below.
'
Electronic Check Deduction �- �
��� DANA SMITH
Please send a voided check OR provide information below: --�•••-.•-- ----
CUMBERLAND CROSSINGS
1 LONGSDORF WAY
CARLISLE, PA 17013-7623
*Returned checks—You will be responsible for all incurred bank fees permissible under state law.
�----,--,
STATEMENT
Forest Park Health Center Resident: Smith, William (23155)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2014
(888)880-7090
ALL TRANSACTIONS PROCESSED AFTER Dec 31, 2013
WILL APPEAR ON YOUR NEXT STATEMENT
Dana Smith
2443 N 5th Street
Harrisburg, PA 17110
Amount Due $0.00
PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amo�nt Enclosed $
Forest Park Health Center Resident: Smith, William (23155)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2014
(888) 880-7090
Effective
Date Description Units Unit Amount Amount
BALANCE FORWARD $6,048.00
12/10/2013 Payment-#104 ($6,048.00)
BALANCE DUE $0.00
QUESTIONS REGARDING BILL?
PLEASE CALL 888-880-7090/NIKKI EXT 807
Nikki.ppbilling@guardianeldercare.net
WE ACCEPT
MOST MAJOR CREDIT CARDS
(SEE BACK OF BILL)
PAYMENT IN FULL IS DUE BY THE 15th OF THE MONTH
Please make check payable to facility listed above in upper left or complete credit card payment information on back of this form.
This is an attempt to collect debt.Any informaaon provided will be used for that purpose.
. ,,�
Guardian LTC Pharmacy ��� �r���� ?�� '���.�`��,�.,,,. ����:���'�`,
(814)503-7400 -- � -
123 Brubaker Road CUSTOMER NO.: 9989
Brockway,PA 15824 PAGE: �
United States DATE: 11/1/2013
REMIT TO ADDRESS:
SOLD SMITH,WILLIAM
TO: 24q3 N 5TH STREET Guardian LTC Pharmacy
HARRISBURG,PA 17110 123 Brubaker Road
Brockway,PA 15824
USA
`---------
S'x—^e p:�. �4�T' ..�-.',t'^ . . .–.. :., _� .-� ._ '
F :;a�� . n� '¢x '>.'� �' _"a�� �x{:a. ---'�,�;
,x
� z��F�7` cs,�v �v�'��yit��4�` � ��+[�';ti��� �'�t,��1��' ; ° ��'`*��'�a��� ��d��ia:ni '�E`,ti�'i,(`4�.�" � � �
�` 7�
_:� _..'_'�:�._,___"t��_..�.�._sY.::;.� z�_.._ ..s.c .._r:t.�:.___.�.- .: �n �w�. �°.�" � C � Ar �:��yA#1����) i�i i�..r'r
t�-v_�.,...:___�_,�..�.._�''4�___..� �:��&�::.. ._.. -�.��:..,-
I I N000025300 � 9/30/2013 � I N � 10/30/2013 85.99
,I N000026297 10/31/2013 I N ' 11/30/2013 48.90
� i
i j
I �
i
I j
i �
�
! �
i �
i
I ;
i �
�
( William S. Smith, Sr. , Estate �_����13 103
Dana L. Smith, Per. Rep.
2443 N. 5th St. DATE December 5, 2013
Harrisburg, PA 17110
� —I � 134.89
� PAY TO ('
g THE ORDER OF ,,,.�,�......
� DOLLARS f o,,,,,,..,,
;
One hundred thirty-four and 89/100----------------- "'°'
� � Santander'
.
Santander Bank,N.A. `, _n ���( n � :_�
MEMO
final bill ''�1., �k' �
� �: 23L37 269 L�: 290 L062L05�i'OL03
�ra�
i I
� I
;
;
I f
i
� ;
�
IN-invoice PY-Applied Receipt UC-Unapplied Cash Please pay amount showing. Total: 134.89
DB-Debit Note ED-Eamed Discount RF-Refund
CR-Gedit Note n�-na��$�e�� Credit Limlt: 0.00
I IT-Interest Payable PI-Prepayment
Credit Available: 0.00
i 1 -30 DAYS O/DUE 31 -60 DAYS O/DUE � 61 -90 DAYS O/DUE —� OVER 90 DAYS O/DUE
85.99 0.00 I 0.00 i 0.00
I— ----- --- --------- ' ----------- -------- --------- ---------_..�