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Home My WebLink About07-09-14 (2) � 1505610143 REV-1500 EX`oz_„> �, OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes �EPARTMEFf�OFREVENUE Po Box.2soso� INHERITANCE TAX RETURN 21 14 O 10 9 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Sociai Security Number Date of Death Date of Birth 12 21 2013 05 20 1930 DecedenYs Last Name Suffix DecedenYs First Name MI LEEDY LETHA E (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. Supplementai Return � 3. Remainder Return(Date of Death Priorto 12-13-82) � 4. Limited Estate � 4a. Future Interest Compromise � 5. Federal Estate Tax Return Required (date of death after 12-12-82) � g Decedent Died Testate � � (AttacheCo aintained a Living Trust �- 8. Total Number of Safe De OSIt BOxES (Attach Copy of Will) py of Trust) P � 9. Litigation Proceeds Received � �p, Spousal Povert Credit(Date of Death 11.Election to tax under Sec.9113 A between 12-31�J1 and 1-1-95) � (Attach Schedule O) ( ) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JERRY A WEIGLE ESQUIRE 717 532 7388 REGISTER O�WILLS USE"O�ILY �--- •-,; w��t First Line of Address �� - ; `�`� S!'�7 r`.; �' s C,., f7l�_c_.i t" �T� ;,;J 126 EAST KING STREET � �" _ F' ' : 4 � r � r.j SecondLineofAddress �U'-'' � ��} C:1�-, —, � ,�,., C'3 C: �'-� �'? `� fi� C3t__ F':» `�: C� City or Post Office State ZIP Code DA�E F1 ED G,3 '.�:'rt C✓7 C'� '�� SHIPPENSBURG PA 17257 c.� � CorrespondenYs e-mail address: Under penalties of perjury,I deciare that I have examined this return,including accompanying schedules and statements,and to the best of my knowiedge and belief, it is true,correct and compiete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE / Gary L. Leedy �� I�� ADDRESS 557 Britton Road Shi ensbur PA 57 SIGNAT OF PREPARER OTHER THAN RE RE N I E DATE � Jerry A.Weigle Esquire —g��G ADDRESS 126 East King Street, Shippensbur , A Side 1 � 1505610143 15�5610143 � PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Signature#2 � Name Ja nee C.Leed AddreSS1 100 South Fayette Street AddresS2 2nd Floor City, State,Zip Shippensburg,PA 17257 Date 1'�� 1505610243 REV-1500 EX DecedenYs Social Security Number DecedenYsName: L@@CI�/, Letha E. RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 51 , 0�0 . �� 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 Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 116, 973 . 13 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous I�q-Probate Property (Schedule G) U Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1 through 7)........................................................ 8. 167 , 973 . 13 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 22 , 634 . 90 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 3 , 005 . 48 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 2 S� 64 0 . 3$ 12. Net Value of Estate(Line 8 minus Line 11).......................................................... �2. 142 , 332 . 75 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)............................................... �4. 142 , 332 . 75 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 15. O . 0 O (a)(1.2)X.00 - 16. Amount of Line 14 taxable 142 332 . 75 16. E) 404 . 97 at lineal rate X .045 � � 17. Amount of Line 14 taxable 0 . �0 17. 0 . �0 at sibling rate X.12 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE................................................................................................................ 19. 6, 404 . 97 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21-14-0109 Decedent's Complete Address: DECEDENT'S NAME Leedy, Letha E. STREET ADDRESS 557 Britton Road CITY STATE ZIP Shippensburg PA 17257 Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) 6,404.97 2. Credits/Payments A. Prior Payments 6,000.00 B. Discount 315.79 Total Credits(A +B) (2) 6,315.79 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) $9.�$ Make Check Payable to REGISTER OF WILLS, AGENT ,�, , � ��, �' �f, � � � � �� .;��°� � � , . . . . ,�, ...,, . �. , �,..��';.,�, 4 .......�. � ;s,._..... .. .....:�.� ,��x��: .. ...�ec„�,.�.;s„� . .� ,W.,., xr,.. .�,..��.. _..',.,� ,,,,,��..,. ,��..a_o.._....,,�'�6.� 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:.................................. ❑ � c. retain a reversionary interest;or............................................................................................................... ❑ � d. receive the promise for life of either payments,benefits or care?............................................................ ❑ � 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.................................................................................................................... � � 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ 0 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.............................................................................................................:.... ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. �� ta � � � ... ., ..,,,.,a.� .,�.. . ,.,,.,.,....«_ . , ,.�a,.�..,��»,��. .a..... �„x ,u.��'��''�.,�r��.,.�. „� „ .,,....;� ...-...�..s.�..«.�.,. ..��, „�,�,�: '�..,.�..� .�..R.nAis.'�. ,,,...�:.,��, �z:, .�:..�..,. 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 return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the 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 decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)�. A sibling is de5ned, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-1502 EX+(01-10) - SCHEDULE A pennsylvania REAL ESTATE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as lhe price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold Include a copy of the deed showing decedenPs interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Residence at 557 Britton Road-Shippensburg,Southampton Township,Cumberland County 51,000.00 TOTAL(Also enter on Line 1, Recapitulation) 51,000.00 (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 A(Rev.01-10) Rev-1508 EX+(11-10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OFREVENUE p E RS O NAL P RO P E RTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 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 U.S.Treasury-2013 federal income tax refund 140.52 2 Checks on hand at date of death-inciuding October and November social security checks 2,738.05 ($2,276.00); November SKF pension check($288.75);2012 federal income tax refund check ($146.00);and various certificate of deposit interest checks($27.30) 3 M&T Bank Certificate of Deposit 5933 10,000.00 Accrued interest on Item 3 through date of death 0.27 4 M &T Bank Certificate of Deposit 5967 10,000.00 Accrued interest on Item 4 through date of death 0.44 5 M&T Bank Checking Account 6677 19,868.34 6 M &T Bank Checking Account 6677-automatic debits from account from date of death to -180.00 closing,transferred to savings account 7 M &T Bank Checking Account 6677-credit to account after date of death reversing a prior 20.84 charge Accrued interest on Item 7 through date of death 0.17 8 M &T Bank Savings Account 0851 17,591.66 9 M&T Bank Savings Account 0851 -automatic credits to account after date of death 180.00 transferred from checking account Accrued interest on Item 9 through date of death 0.30 10 M &T Bank Savings Account 6606 56,610.15 Total of Continuation Schedule See attached page TOTAL(Also enter on Line 5, Recapitulation) 116,973.13 (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-1508 EX+(11-10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCETAXRETURN PERSONAL PROPERTY RESIDENT DECEDENT � continued ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Accrued interest on Item 10 through date of death 2.39 TOTAL(Also enter on Line 5, Recapitulation) 116,973.13 Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10) REV-1511 EX+�10•09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE F U N E RAL EXP E N S E S AN D INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER q, FUNERLlL EXPENSES: See continuation schedule(s) attached 9,695.90 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Ziq Year(s)Commission Paid 2. Attorney's Fees Weigie 8�Associates, P.C. 8,469.00 3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) 3,500.00 Claimant Gary L. Leedy Street Address 557 Britton Road city Shippensburg state PA zio 17257 Relationshi�of Claimant to Decedent SpOUSe 4. Probate Fees Register of Wilts, Cumberland County 313.50 5. AccountanYs Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 656.50 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 22,634.90 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 Leedy, Letha E. 21-14-0109 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Fisher's Fiorist 185.50 2 Fogelsanger-Bricker Funeral Home 9,175.40 3 Parklawns Memorial Gardens 335.00 H-A 9,695.90 Other Administrative Costs 4 Cumberland Law Journal -advertising Letters of Administration 75.00 5 Linda K. Klein-notary fee 22.00 6 M&T Bank-drilling open safe deposit box 150.00 7 News Chronicle-advertising Letters of Administration 129.50 8 Register of Wills,Cumberland County-payment in advance for filing of PA Inheritance Tax 15.00 Return 9 Register of Wills,Cumberland County-cost of filing Family Settlement Agreement 75.00 10 Register of Wills, Cumberland County-2 Short Certificates 10.00 11 Register of Wills,Cumberland County-1 Short Certificate 5.00 12 Sailhamer Real Estate-market analysis 125.00 13 Weigle&Associates, P.C. -reimbursement for postage,xerox copies,and long distance 50.00 telephone calls Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 ITEM NUMBER DESCRIPTION AMOUNT H-B7 656.50 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX+(�2.08) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 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 Chambersburg Hospital 1,218.92 2 Chambersburg Imaging Associates 3.81 3 Fayetteville Volunteer Fire 153.00 4 Shippensburg Area EMS 215.02 5 Southampton Township 43.74 6 Summit Physician Services 94.02 7 Vivian F. Coy,Tax Collector 293.51 8 West Shore EMS 983.46 TOTAL(Also enter on Line 10, Recapitulation) 3,005.48 (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-OS) REV-1513 EX+�01-10) pennsylvania SCHEDULE J DEPARTMENT OFREVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Leedy, Letha E. 21-14-0109 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not List Trustee s I� TAXABLE DISTRIBUTIONS [inciude outright spousal distributions,and transfers under Sec.9116 a 1.2 1 Gary L. Leedy Son One-half 71,166.37 557 Britton Road Shippensburg, PA 17257 2 Jaynee C. Leedy Daughter One-half 71,166.38 100 South Fayette Street 2nd Floor Shippensburg, PA 17257 Tota) 142,332.75 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 GOVERNMENTAL 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) °-°-�---�, Sailhamer Real Estate, Inc. �94 E. I�iu�St� �}11��K'IlS}Jlll•g, I'a 1i25� Off ic�c�(i I i)532-6O�9/F�1 (i 1 i�530-�181 www.sailhamer.com/info(a(a�sailhamer.com January 14,2014 Gary L. Leedy 557 Britton Road Shippensburg, PA ]7257 Mr. Leedy; This analysis has not been performed in accordance with the uniform standards of protessional practice which requires valuers to act as unbiased,disinterested third parties with impartiality,objectivity and independence and without accommodation of personal interest; it is not to be construed as an appraisal and may not be used as such for any purpose. In response to your request for a comparable market analysis of real estate of the Est of Letha E.Leedy and located at 557 Britton Road, Shippensburg, PA, Southampton Township, Cumberland County, I am sending you my estimation of current market value. The property is known as 557 Britton Road, Shippensburg, PA 17257 being more fully described in Deed Book Q17, Page 452,Tax ID#39-11-0310-031, containing 54/100 acre.The property is improved with a 1&1/2 story cement block dwelling with metal roof.The first floor offers kitchen, living room, bath and three bedrooms.The second level offers a partially finished room and balance of area is unfinished storage area. The heating system is an oil fired hot air furnace that is currently not working. The occupant is cunently heating dwelling with a kerosene space heater. The electric system is an older style fuse box(60 AMP). Domestic hot water is delivered by an electric water heater in the basement. The basement floor is of concrete. There is a drilled well and on-lot septic system of unknown type/design. The property appears to be in poor to fair condition with a number of repairs needed. I would suggest a current value of between Forly-Seven Thousand Dollars($47,000.00)to Fifty- Five Thousand Dollars($55,000.00). Sincerely; � ��"K� on Sailhamer Real Estate Broker � p M�s� 499 Mitchell Road,Millsboro,DE 19966 Adjustment Services Phone 888-502-4349 F ax (302)934-2955 February 13,2014 Weigle & Associates, P.C. Attorneys at Law 126 East King Street Shippensburg,PA 17257-1397 Re: Estate of Letha E.Leedv Social Securitv: 168-24-3198 Date of Death: December 21,2013 Dear Sir or Madam: Per your inquiry on February 07, 2014, please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type ofAccount CheckingAccount Account Number 67346677 Ownership(Names ofJ Letha E.Leedy Opening Date 09/28/1985 Balance on Date of Death $ 19,868.34 Accrued Interest $ .17 ___._.___.._____.---.---...___--__.___...--------------..._._-------- Total $19,868.51 2. Type ofAccount Savings Accaunt Account Number 15004208570851 Ownership(Names o� Letha E.Leedy Opening Date 11/06/1987 Balance on Date ofDeath ,S' 17,591.66 Accrued Interest $ .30 -------------------------------------------------------------- Total $17,591.96 3. TypeofAccount SavingsAccount Account Number 21000001216606 Ownership(Names ofJ Letha E.Leedy Opening Date OS/24/1976 Balance on Date of Death $ 56,61 D.1 S Accrued Interest $ 2.39 __--...------...._........_.._...._..---..........__----.._......___..,.........__------------- Total $56,612.54 3. Type ofAccount Certificate ofDeposit Account Number 31003914465967 Ownership(Names o� Letha E.Leedy Opening Date 01/30/1995 Balance on Date ofDeath $ 10,000.00 Accrued Interest $ .44 ------------------------------------------------------------------- Total $10,000.44 4. Type ofAccount Certificate ofDeposit Account Number 31003914465933 Ownership(Names o� Letha E.Leedy Opening Date 01/06/1995 Balance on Date of Death $ 10,000.00 Accrued Interest $ .27 _�-------......___.........................._.._..._..__....__.----_�_._____-- Total $10,000.27 5. Type ofAccount Safe Deposit Bax Boz Number/Location 749/King Street Ownership(Names o� Letha E.Leedy Opening Date 07/01/1950 For any additional information on the above accounts,including ownership and any c6anges,closures and/or reimbursement of funds, please call the Walaut Bottom at 717-532-2414. We were unable to locate any safe deposit boz for t6e above-menHoned decedent. This letter does not include any accounts in whic6 the deceased may have been 6sbed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement SIriCeT'01y, Valarie Meroer Adjustrnent Services _ _ _ _ .___.__...—� t � �;8500�41046 REV-485 EX(05-04) -� SAFE DEPOSIT BOX INVENTORY . PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Number __... _. _ _ .. _ _ _ __ 168-24-3198 12-21-2013 21 14 0109 Decedent's Last Name Suffix First Name MI LeedY _ _.. _ Letha _ E __ _ _ __. _.. _ ___. _ _ __ �ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE: 557 Britton Road Shi ensbur PA 1 2 NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX "AME' Jerrv A. Weigle, Esquire , STREETADDRESS: CITY: STATE: ZIPCODE: ' 126 East Kin Street Shi ensbur ' � NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING ' a. NAME: RELATIONSHIP: Jerry A. Weigle, Esquire Attorne� fnr the EstatP STREETADDRESS: CITY: STATE: ZIP CODE: 126 East King Street Shippensbur� PA 17 57 b. NAME: RELATIONSHIP: Gary L. Leedy Co-Execu�or of �he F.GtatP � STREET ADDRESS: CITY: STATE: ZIP CODE: 557 Britton Road Shippensburg PA 172�7 c. NAME: RELATIONSHIP: Jaynee C. Leedy Co-Exer_utnr af the Estate STREETADDRESS: CITY: STATE: ZIP CODE: 100 South Fayette Street, 2nd Floor SHi ensb ' NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED ' NAME: M & T Bank ' STREET ADDRESS: CIN: STATE: ZIP CODE: 35-39 East Kin Street Shi ensbur NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY Jerr A. Wei le Es uire 5-29-2014 10:10 a.m. ' : DATE OF CONTRACT TO RENT BOX NUMBER OF BOX 1 TITLE UNDER WHICH BOX IS REQUESTED Unknown 749 Letha E. Leedy NAME AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX a. NAME: b. NAME: ' _ Letha E. Leed� STREETADD��S�,� Britton Road STREETADDRESS: / CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE: ' Shippensbur , PA 17257 NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ' Jerry A. Wei le, Es uire - Attorne for -- WAS A WILL W THE BOX? ❑ YES � NO If yes, a. Date of will: b. Name and address of personal representative,if named in the w11i NAME: .._ STREETADDRESS: CITY: STATE: ZIP CODE: c. Name and address of attorney,if any NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: __. _ ___ _ _ _ _ __ _ � 48500041�46 48500041046 � k REV-485EX SAFE �EPE3Si� E3Q�� f�i�fEf�i��Y Page 2 of 2 INSTRUCTIONS (1) Cash: Report total oniy. (2) Stocks:List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and class of stock. (3) Obligations of U.S.Government: Number of items,date of issue,face value,names in which registered and type of ownership, i.e.,jointly held,payable on death,etc. (4) Bonds: Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:5tate name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Coins,Stamps,Manuscripts,etc: List and describe as fully as possible. (7) Deeds,Mortgages,Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 HARRISBURG,PA 17128-0601 ITEM REM DESCRIPTION NO. 7 Deed of Conve ance - Ambrose B. Leed and Etta B. Leed to Harrison L. Leed a d Letha E. Leedy, Cumberland County Deed Book Q 17, 452 7 Deed of Conve ance - same rantors/ rantees as above - Deed Book V 18 367 7 Satisfied Bond - Harrison and Letha Leed to eo es National Bank � Metropolitan Life Insurance Company Polic 18 163 263 - Letha E. Leed insured 7 Metropolitan Life Insurance Company Policy 726 431 436 A - Gary L. Leedy insur d 7 Amalgamated Life Insurance Com an Polic 168-24-3198 - Letha E. Leed insured 7 Washington Natinal Insurance Eolicy 726130 - Gar L. Leed insured 8 Military Service Release - Harrison L. Leedy 8 Smallpox vaccination receipt - Harrison L. Leedy 8 Release of Contractor Lien and related .documents 8 Home insurance olic - Harrison & Letha Leed ex ired 5-24-67 7 Satisfied Peoples Natia�al Bank mortgage and related documents - Harrison & Letha Leed 8 Old estate settlement documents - E. Beatrice Keefer estate 8 Park Lawns Cemeter deed I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNATURE � SIGNATURE PRINT NAME PRINT NAME AND CHECK APPROPRIATE BOX BELOW: Jerr A. Wei le, Es uire PRINTTITLE DATE CHECKAPPROPRIATE BOX: , Attorney for Estate 6-3-14 ❑�ecutor(trix) �Administrator(trix) �Estate Representative �Joint owner of safe deposit box NOTE:Attach additional 8'/�'x 11"sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law,42 U.S.C.§405(c)(2)(C)(i),to require disclosure of Social Security numbers in connection with administering state tax laws.The Department uses the 5ocial Security number to identify the decedent and personal representatives of the estate.The Commonwealth may also use the infortnation in exchange of fax information agreements with Federal and local taxing authorities.The state law prohibits the Commonwealth's personnel from disclosing confidentia�tax information except for official purposes. � � � 3rn � �. � m`� `° m n� D cu y � � c � � v�i c° c� �°— o � �� n. D � °� m � �' � �� N � �� v � n