HomeMy WebLinkAbout07-15-14 (2) J 1505610143
REV-1500 EX(02-11) lar
PA Department of Revenue OFFICIAL USE ONLY
P Pennsylvania County Code Year File Number
Bureau of Individual Taxes °EPPRTMem°F^�^^1E
PO BOX.280601 . INHERITANCE TAX RETURN 21 13 1215
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
10 25 2013 12 02 1523
Decedent's Last Name Suffix Decedent's First Name MI
ROSS ELEANOR A
(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 Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
X❑ g Decedent Died Testate 7 Decedent Mairt metl a Living Trust 1 B. Total Number of Safe Deposit 80X05
(AHarh Copy of Will ❑ (Attach Copy of crust)
❑ 9. Litigation Proceeds Received ❑ 1D.bg=al Po ert and{Datee of Death ❑ 11.Election to tax under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
LINDA J OLSEN 717 540 4332
REGISTER LL
__ S US P NLY
Ln . .
First Line of Address cn;:, -"
2000 LINGLESTOWN ROAD or" xe T
Second Line of Address
SUITE 202
C
City or Post Office State ZIP Code DATE FILED
H Rp T SBURG Rn 17120
Correspondent's e-mail address: lolsen(cDhazenelderlaw.com
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 OF PPERSO RES�PONSSIIBBLLE�FOR FILING RETURN DATE
y �G�LL2f/O� Judith G. Gould
A RESS
1048 Pebworth Rd., Magnolia, DE 19962
SIGN U OF PREPARE OTHE THAN REPRESENTATIVE DATE
Linda J. Olsen
c�ORE�s
2000 Linglestown Road, Harrisburg, PA 17110
1505610143 Side 1 1505610143 J
�t
J 1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Ross, Eleanor A.
RECAPITULATION
1. Real Estate(Schedule A)........................................................................__........... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2. 357 , 385 . 75
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. 33 , 389 . 84
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous NtProbate Property
(Schedule G) u Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 390 , 775 . 59
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 9 , 690 . 94
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 8 , 963 . 73
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 18 , 654 . 67
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 372 , 120 . 92
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. 372 , 120 . 92
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15. 0 . 00
16. Amount of Line 14 taxable
al lineal rate X .045 372 , 120 . 92 16. 16, 745 . 44
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 16, 745 . 44
20. ,FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. El
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-13-1215
Decedent's Complete Address:
DECEDENT'S NAME
Ross, Eleanor A.
STREET ADDRESS
100 Mt. Allen Dr.
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 16,745.44
2. Credits/Payments
A. Prior Payments 15,800.00
B. Discount 831.58
Total Credits(A +B) (2) 16,631.58
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) 113.86
Make Check Pa able to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;....................................____................................. ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income:..... ............-......... ❑
c. retain a reversionary interest;or............................................................................................................... F-1 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?.................................................................................................................... ❑ ❑
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary 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 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 decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)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 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 PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ross, Eleanor A. 21-13-1215
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 Morgan Stanley Act.#474-189540-235 357,385.75
TOTAL(Also enter on Line 2, Recapitulation) 357,385.75
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group,Inc. Fonn PA-1500 Schedule B(Rev.6-96)
Rev-1508 EX.(11-10)
SCHEDULE E
Pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ross, Eleanor A. 21-13-1215
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntlyowned with the night of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Bankers Life Long Term Care-reimbursements 8,526.00
2 Wells Fargo Checking#1000653216884 7,458.18
3 Wells Fargo Checking#1010230965674 17,226.20
4 PA Dept.of Revenue-refund from 2013 personal income taxes 10.00
5 Refund-CVS-Caremark 0.16
6 Reimbursement-Capital Blue 169.30
TOTAL(Also enter on Line 5, Recapitulation) 33,389.84
(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-1511 EX-(10-09)
Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENT DECED NT RETURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Ross, Eleanor A. 21-13-1215
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 240.44
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorneys Fees Hazen Elder Law 8,500.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zio
Relationshio of Claimant to Decedent
4. Probate Fees 453.50
5. Accountant's Fees
6. Tax Return Preparer's Fees 200.00
7. Other Administrative Costs 297.00
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 9,690.94
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
Ross, Eleanor A. 21-13-1215
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Chambers Hill UMC-luncheon 164.65
2 Neill Funeral Home-death certificates and newspaper obituary 75.79
H-A 240.44
Other Administrative Costs
3 Bank fees for estate checking acct. -Wells Fargo 55.00
4 Central Penn Business Journal-estate advertisement 167.00
5 Cumberland Law Journal -estate advertisement 75.00
H-B7 297.00
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ross, Eleanor A. 21-13-1215
Report debts incured 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 Alert Pharmacy Services-medical expense 174.38
2 Messiah Lifeways Beauty Salon --hair cut received before death 16.00
3 Messiah Lifeways-living facility 7,675.84
4 Messiah Lifeways-medical expenses 108.27
5 Messiah Village Employee Fund 300.00
6 Orthopedic Institute-medical expense 80.24
7 PA Dept. of Revenue-2013 personal income taxes 609.00
TOTAL(Also enter on Line 10, Recapitulation) 8,963.73
(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 BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ross, Eleanor A. 21-13-1215
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
D.N.t List
I• TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
Kim D. George Child One-third of the
409 Middletown Rd. Residue.
Hummelstown, PA 17036
Judith G.Gould Child One-third of the
1048 Pebworth Rd. Residue.
Magnolia, DE 19962
Sherry L.Thompson Child One-third of the
127 Fieldstone Dr. Residue.
Carlisle, PA 17015
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as approp mate.
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)
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
No. 2013- 01215 PA No. 21- 13- 1215
Estate Of: ELEANORA ROSS
/Firs(,Middle,Levu
Late Of: UPPER A L L EN TO WNSHIP
CUMBERLAND COUNTY
0 Deceased
Social Security No:
WHEREAS, on the 14th day of November 2013 an instrument dated
March 9th 2009 was admitted to probate as the last will of
ELEANOR A ROSS
IRW,Mieek Levu
late of UPPER ALLEN TOWNSHIP, CUMBERLAND County,
who died on the 25th day of October 2013 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARYto:
JUDITH G GOULD
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURTHOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 14th day of November 2013.
Rg(^ 'ayz
Deq t
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
LAST WILL AND TESTAMENT
OF
ELEANOR A. ROSS
I, ELEANOR A. ROSS, now domiciled in Dauphin County, Pennsylvania, declare this
to be my Last Will and Testament. I revoke all other wills and codicils that I may have
previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate
shall be paid by my Executor from the principal of my residuary estate as soon as practicable
after my death.
Article II
All inheritance, estate, and succession taxes (including interest and penalties thereon, but
not including any generation skipping tax) payable by reason of my death shall be paid out of
and be charged generally against the principal of my residuary estate without reimbursement
from any person. This provision is not a waiver of any right which my Executor has to claim
reimbursement for any such taxes which become payable as the result of any property over
which I have the power of appointment.
Article III
I give, devise and bequeath my tangible personal property in accordance with any
memorandum I have handwritten or signed, located with my will or with my valuable papers and
found within 30 days of the probate of my will. Gifts may only be to persons who survive me or
to organizations which exist at my death, and if there is a conflict, the memorandum having the
latest date shall govern. To the extent no such memorandum is found, or all of my tangible
personal property is not disposed of pursuant thereto, my tangible personal property shall be
added to my residuary estate and pass under Article IV hereof.
Article IV
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath IN EQUAL SHARES to my children, JUDITH G. GOULD,
of Magnolia, Delaware, SHERRY L. THOMPSON, of Carlisle, Pennsylvania and HIM D.
GEORGE, of Harrisburg, Pennsylvania, per stirpes. If a beneficiary fails to survive me by
thirty (30) days, but leaves descendants who survive me by thirty (30) days, those descendants
shall receive, per stirpes, the share the beneficiary would have received had he or she survived
me by thirty (30) days. The share of any deceased child who does not have living issue shall be
divided and distributed to my remaining children,per stirpes.
Article V
I nominate, constitute and appoint my daughter, JUDITH G. GOULD, as Executrix of
my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any
reason whatsoever of my Executrix, I nominate, constitute and appoint my daughter, SHERRY
L. THOMPSON, as successor Executrix of my Last Will and Testament. I direct that my ,
Executrix or successor Executrix be permitted to serve without bond. In addition to those powers
granted by law, I grant them power to distribute in cash or in kind, in like or in unlike shares, and
to file any qualified disclaimer I could have filed if living. My Executrix or successor Executrix
shall receive reasonable compensation for services rendered to my estate.
2
Article VI
In addition to the powers conferred by law, I authorize my Executrix or successor
Executrix, in her absolute discretion:
(a) to retain in the form received and to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any
beneficiary,
(f) to file any federal income tax return for any year for which I have not filed such
return prior to my death,
(g) to make distributions in cash or in kind, or in both, and to determine the value of
any such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by
my Executrix or successor Executrix; and to pay from my estate reasonable compensation for all
their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have
an interest in at time of my death, and
3
(j) to receive reasonable compensation in accordance with their standard schedule of
fees in effect while their services are performed.
IN WITNESS WHEREOF, I, ELEANOR A. ROSS, hereby set my hand to this my Last
Will and Testament, on C> 72009, at Harrisburg, Pennsylvania.
ELEAN RO A. ROSS
In our presence, the above-named ELEANOR A. ROSS signed this and declared this to
be her Last Will and Testament and now at her request, in her presence, and in the presence of
each other, we sign as witnesses.
Name Address
` 2000 Linglestown Rd., Suite 202, Harrisburg, PA 17110
2000 Linglestown Rd., Suite 202, Harrisburg, PA 17110
I, ELEANOR A. ROSS, Testatrix, who signed the foregoing instrument, having been
duly qualified according to law, acknowledge that I signed and executed this instrument as my
Will, and that I signed it willingly as my free and voluntary act for the purposes therein
expressed.
Sworn to or affirmed and
Acknowledged before me by
ELEANOR A. ROSS, the Testatrix
on /)'Apc,6 c] 12009. /Y
Notary Public ELEANOR A. ROSS
COMMONWERLTH OF pENNSYLVgNIq
Notarial Seal
Malissa M.Kain,No
Susquehanna 7w �FuWb
MY Commission P,Dauphin County
F-�cpires Aug.11,2p10
4
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the Testatrix sign and execute
this instrument as her Will; that she signed and executed it willingly as her free and voluntary act
for the purposes therein expressed; that each of us in her sight and hearing signed the Will as
witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or
more of age, of sound mind, and under no constraint or undue influence.
Sworn to or affirmed and
Subscribed to before me
by fY111RP,l Il F
A114 CIA 1-1�
and fn� ,j P_ 1]�P N.c, fitness
witnessed, on &94ci7 2009.
P Q �
Witn
Notary Public
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Melissa M.K7 Notary Public
Susquehanna Twp.,Dauphin County
My Commission Expires Aug.11,2010
5
HAZEN FIRER LAW Estate Planning • Elder Law • Special Needs Planning
2000 Linglestown Road TW (717) 54011332
Suite 202 FAx: (717)54011313
Harrisburg, PA 17110 www.HazenElderLaw.com
December 18, 2013
Alz
Department of Revenue
Safe Deposit Box Unit
PO Box 280601
Harrisburg, PA 17128-0601
RE: Estate of Eleanor A. Ross
File No.: 2113-1215
To Whom It May Concern:
Enclosed please find the Safe Deposit Box Inventory which was taken in the
above-referenced estate.
Sincerely,
a"� 4'�s IJ4A'V�
Corinne Eggers Woodhouse
Paralegal
Enclosure
cc: Nancy V-BaIdwin
REV-085 EX(45-04) 48500041046
SAFE DEPOSIT
B oX INV ENTORY PLEASE USE ORIGINAL FORM ONLY
Social Security or Death CerSficate Number Date of Death County Code Year File Number
1012512013 21 13 1215
becedenrs Last Name Suffix First Name .. . . .... MI
Ross Eleanor
A
ADDRESS OF DECEDENT STREET. CITY: STATE: ZIP LADE: i
100 Mt.Allen Dr, Mechanicsburg FAA 17055
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
"AmE`Judith G.Gould
STREET ADDRESS: CITY: STATE: ZIP CODE:
1048 Pebworth Rd. Ma nolia DE 18962
NAME ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING
a. NAME: RELATIONSHIP:
Judith G Gould daughter/Executrix
STREET ADDRESS: CITY: STATE: ZIP CODE:
1048 Pebworth Rd Magnolia DE 19962
b. NAME: RELATIONSHIP:
STREET ADDRESS: CITY: STAGE: ZIP CODE:
c. NAME: RELATIONSHIP:
STREET ADDRESS: CITY: STATE: ZIP CODE:
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
i
NAME:
Wells Fargo Bank
STREETADDRESS: CITY: STATE: ZIP CODE:
1085 E Park Dr. Harrisburg PA+ 17111
• NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LA
ENTgY
Judith G. Gould /—��— 3 t3a 4�. Lis cwt
DATE OF CONTRACT TO RENT BOX NUMBER OF BOX t TILE UNDER WHICH BOX IS REQUESTED
NAME AND/A/DOR E/SSfSOJFF PERSON(S)HAVING ACCESS TO BOX
b. NAME:
STREE RESS- STREETADDRESS:
f bl�liPp� nili0 DE 19
CITY: ,J/ STATE: ZIP CODE: CITY: STATE; ZIP CODE:
NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
Ckelsa�- �etl Cis-to�e..;� s�t�
WAS A WILL IN THE BOX? pKS 0 NO If yes, a. Date of will:
b. Name and address of personal representative,B named in the wilt
NAM�, fd r -
„�
E�-.-�a �,7 l'outd .
STREET ADDRESS: CITY: STATE: ? Zip E:
c. Name ana aff��4ress of atto ey,tr/ann
NAME , �
I SE PA t
111�1LL[tj�f�S} trlYt Lff Sfj/fF20Z— j� : r 70
STREET ADDRESS:,/ CITY: STATE: ZIP CODE:
L„ 48500041046 48500041046
S:
REV-485 EX SAFE DEPOSIT BOX INVENTORYa9B Of
INSTRUCTIONS
(1) Cash:Report total only.
(2) Stocks:List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to�ba designated by
name of company,Certificate number,date of certificate,name In which stock is registered,and number of sharestand 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,
Le.,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:State 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 Billy as possible.
(8) All other contents.
(9) Return Completed form to: DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT.280601
HARRISBURG,PA 17128.0601
ITEM
NO. ITEM DESCRIPTION
f r
Or to Maq id Y)
qP f
Jr r3r r
a oad 1 race
9 SQ ` rs b a de e5a r era 3�dnk
f f 7G r r
dr z V rI
k F` � 1t 1 r lb s
io e b -
1 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 SIG TYRE
PRINT NAME E CHECK PROPRIATFyeoxeEWW: -
e tsae Q. C3�1� v Q/
(PRa�TRLE p r' g2.y DATE CHECK APP e x
OPRIATESO
I S�Wter tS�(1es tstrVI� 12—�2—�3 L xeca«tux) ❑Administratw(rdx)
Y'e�t"'✓v+ R 'yt_ ❑Estate Repras V. 0 Joinl owner of safe dePWt bW
NOTE:Attach additional 81/21 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 g2j(C)6),to require disclosure of Social Security numbers in connection with admwstedng state tax la",T*Department uses th
Social Sealrily number M Weatiy the decedent and personal representatives of the estate,The Commomvealth may also use the information In exchange of lax information agreements
with Federal and local laying Gull o flies.The stall law pM*b the Commonwealth's personnel f um disclosing confidential tax information except for offida(pulp
)
Date of Entry
Month Day Year
ENTRY INTO SAFE DEPOSIT BOX
COMMONVt1:ALT14 OFPENNSYLVAtdA TO-REMOVE A Wli l.OR 1 a -
1PN2TMB4f DFREVENUE CEMETERY DEED
DEPT.280501
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Safe Deposit
Box Surrender
Agreement
In accordance with the Bank's Safe De x Lease Terms,
you surrender Safe Djosit Box No. .
(the"Box's and 'd keys to it(or certify that the
combination is 1,and you certify
that all property contained in the Box has been removed
and is now in your possession or that of another person
legally entitled to possession.You acknowledge that the
Bank has fully discharged all of its obligations under the
Agreement between you and the Bank and you release the
Bank from any and all claims of any kind whatsoever arising
under or in connection with the Agreement or the Box.
Wells Fargo° Essential Checking
Ac.uunt nurnoer: 1010230963674 ® September 27,2013 -October 25,2013 ILI Page 1 of 3 ) 0
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ELEANOR A ROSS Avoiloble by phone 24 hours a day,7 days o week:
JUDITH G GOULD PDA 1-800-TO-WELLS (1-800-869-3557)
1048 PEBWORTH RD TTY: 1-800-877-4833
MAGNOLIA DE 19962-1853 Eo esponol: 1-877-727 2932
1-800-288-2288 l6 am to 7 pm PT,M-F;
(1nGre: rae!Islargacnm
Write: Wells Fargo Bank,N.A.(345)
P.O.Box 5995
Portland,OR 97228-6995
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You and Wells Fargo Account options
Thank you for being a loyal Wells Fargo customer.We value your truss in our A checkmnrk in the bor mawntesyoulmm these
company and look forward to continuing to serve you with your financial needs. convenient servl<e5 wi[0 yourZ,cmunr. Goto z
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You could go to Super Bowl XLVIII in NY/NJ,courtesy of Visa!
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No purchase or obligation necessary to enter or will
Activity summary -- --- l.;caunt numbe,, 1010230965674
Beginning balance on 9;27 $14,OC6.50 ELEANOR A ROSS
Depo5its!,Addmons 17,x2550 JUDITH G GOULD PDA
Withdrawals/Subtractions - 9.585.>o Pennsylvania account terms and con:u!/uns ny:r;y
Ending balance on 10125 $17,226 20 1 o Direct Deposit and AVtOrn6][Payments,se
-- Routing Number(RTNI: 031000103
Overdraft Protection
This account is riot currently covered by Overdraft Prntecnon. If you would like more mfivmation naya,dinu Ovenlran Protection and eligibi0ty Al re,;.er'men
please call the numb',hied an your statement of visit you,Wells i a,go store.
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Account 11,151.11
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Checking/Savings Account History
Tax Responsible Customer ri_,-A NO" A 11[i. Sole Owner
Additional Customers JUDI 111 U Power Of Attorney(Joint or)
',:;1A Power Of Attorney(Joint or)
Ledger Balance $7,44227
Available Balance $7,44227
Check
Date Description Number Amount Balance
11/12/13 Monthly Service Fee Reversal 20.00 7442,27
11/12/13 Monthly Service Fee 20.00 7422.27
11112/13 Interest Payment +0.09 744127
11106113 Check 1691 16.00 7442.18
11V/13 Soo Sao Admin Dth Alert Xxxxx I 512d Ssa Date Of Death'1 02513*customer
Ssn'047142815-aMOLin R00000091003653140102 7458.18
11101/13 Wflb Nor Reclaims 1330500274 Us Treasury Reclaim Pymhs I'm 1 V01/13norsieclam 972.0D 7458.18
043241612d Sea 1000000091003957451399
11101/13 Ssa Trees 310 Xxsoc Sao 110113 Xxxxx1612d Ssa Eleanor A Ross 9031736026 +972.00 8430.18
043241612d Sao 300000091003653140101
:Check
10121113 Check 16.90 16930 7515.18
10/21!13 Wthdr2wal Made In A Branch/store 6362 75 7684,48
10116/13 Check 1689 250.12 14047,23
10/09/13 Monthly Service Fee Reversal +20.00 14297,35
10109/13 Monthly Service Fee 2000 14277.35
10/09/13 Interest Payment +0.09 14297,35
10/03/13 Ssa Tress 310 Xxsoc Sac 100313 XxxxxIS1 2d San Eleanor A Ross 9031736039
041241612d Ssa R00000091004352374491 +972.00 14297.26
09;23/13 Deposit +6362.75 13325,26
0920113 Check
1685 45.00 3962.51
09/18/13 Check 1686 2000 7007,51
09/18/13 Check 1683 236.48 7027.51
09/17/13 Check
1684 169,30 7233,99
09/11/13 Monthly Service Fee Reversal +20.00 7433-29
09/11113 Monthly Service Fee 20,00 7413.29
09111113 Interest Payment 0.06 7433.29
09/05113 Check. 1682 342,67 743323
09/03/13 Ssa Tress 310 Xxsoc Sec 090313 Xxxxx1612d Ssa Eleanor A Ross 9031736026
043241612d Ssa 800000091003850630661 +972.00 7775,90
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https://iic-siteI.sal osandservi cc.G\,clIsf-,ir(.,o.com i'svp/acc(iLiiitHi stow]nit.clo 1 1/19/2013
Wealth Management
One Liberty Place
1650 Markrr Street,42nd Fl
Phiiadeiphia,PA 19103
tel 215 854 6000
fax ze 8 23
Morgan Stanley
colt free 80000 3 31414
December,9 2013
Hazen Elder Law
Attn: Corinne Eggers Woodhouse
200 Linglestown Road
Suite 202
Harrisburg, PA 17110
RE: Eleanor A Ross
Morgan Stanley Account Date of Death information
Dear Corinne,
I have enclosed the information you requested regarding Eleanor Ross Morgan Stanley account.
1. Account number :474-189540-235
2. Ownership of the account: Eleanor A Ross
3. Value as of October 25, 2013,the date of death : see attached
4. Account type : Individual
5. Interest/dividends earned from Jan 1, 2013 through October 25,2013: see attached
In order to open an estate account I will need the paperwork that was forwarded to Judith G Gould
completed and returned to me. If a new set of paperwork needs to be mailed, please let me know.
If you have any questions or need any additional information, please do not hesitate to contact me.
Sincer f
L' da DI Mic
Senior Registered Associate
to Savage Schaeffer Group
�s+ L�C 1 v 20113 f
Morpan Seanlcy Smith Barney LLC.Member$IPC. ------------°°"--------