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Home My WebLink About08-19-14 �_ _ ae� �: �.:.�.. p�,�� _ . � � . � 1505610140 REV-1500 �` �°�.,,,�F', OFFICIAL U8E ONIY PA Department of Revenue Bureau of Indhddual Taxes CouMy Code Year File NumDer po Box 2soso� INHERITANCE TAX RETURN 2 1 1 4 0 � 3 9 6 Ha►�bu�,PA t7t2a-osot RESIDEWT DECEDENT ENTER DECEDENT INFORMATION BELOW Sccial Securdy Nurt►ber Date of Death MMDOYYYY Date of Birth MMDOWYY 0 4 D 9 2 0 Z 4 0 2 1 3 1 9 3 6 DacedenCs Last Name Sutfix DeoedeM's First Name MI L 0 T T H A R 0 L D L (N Applicable�Enter Surviving Spouse's Informatlon Below Spouse's Last Mame Suffix Spouse's First Name AAI L 0 T T H E L E N D Spouse'a Social Secu�ity Number 2 0 2 2 0 6 8 8 6 THIS RETURN MUST BE FILED IN DUPUCATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Retum � 2.Sapplementai Retum � 3.Remainder Retum(Date of� Pr(or to 12-13-82) � 4.Limited Estate � 4a.Future lnterest Cort�promiae(date of [� 5.Federal Estate Tax Retum Requtred death after 12-12-82) � 6.DeoedeM Died Testat� ❑ 7.Deoed�t Maintained a Uving Trust � 8.Total Number of Safe Oeposit Boxes (Attach Copy of 1Miq (Attach Copy of Ttusl) � 9.Litigation Proceeds Reoehred � 10.Spousat Poverty Cr�i�(Date of Death (� 11.Election to Tax ur�der Sec.9113(A) Between 12-31-91 artd 1-1-85) (Attach Schedule O) CORRESPONDENT-THIS SECT(ON MUST BE COMPLETED.ALL CORRESPONDEMCE AND CONFIDB�ITTULL TAX INFORMATION SHOULD 8E�C?ED T0: Name Daytime Teleph�Numbet :�:_ TV0 V . 4TT0 III ? 1 ? e��;3 3 � 4 �;;'� ��--` c, `°-� ;� -T:. REGIS �Iz�diLLS U8EONLY - C"? � �;�-; r.�..�,_, �� _. First Lirte of Address ,.>� � -, , ., L�:.. .�. r-� 1 0 E A S T H I G H S T R E E T ��I . ��Y[r; c' ` �; Second Line of Addrefs � City or Post OtRce State ZIP Code ��F� C A R L I S L E P A 1 7 0 1 3 Correspondent s e-mail address: IOTTO(�a MAR'I'SONLAW.COM u�er�,aroes a�uy,i aeaare n��nare exana�ed m�s rowm.�udms ao�n�anya,s xneau�es and ae��+�s.a�+d a nre nene a my�now�e ana oea�. a is we.wrrect ana oomqete.oeaera�w prepsu�er oa+er u,an nre personat representewe is based on au irt�ormsaon awnich preparer hes ary wiorMedpe. SIGNA OF PERSON RESP SIB�E FOR FIUNG RETURN pATE � �� ADORESS � 1208 WIL F OWER DRTVE WEBSTER NY b4580 SIGNATUREOF P TFWNREPRESENTATIVE �� a� 10 EAST HIGH STREET CARLTSLE PA 17013 PLEASE USE ORI�iINAL FORM ONLY Side 1 � 1505610140 15056Z0140 J � � 1505610240 REV-1500 EX(FI) DecedenYs Social Security Number oecedenes Name: H A R 0 L D L - L 0 T T RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 0 • � � 2. Stocks and Bonds(Schedule B) 2, 8 8 5 5 , 2 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. • 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4. • 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . . . . . . 5. 1 4 3 3 2 0 . 6 6 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 2 1 6 6 � . 6 6 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested . . . . . . . 7. 1 3 7 1 8 8 , 0 4 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 3 1 1 � 2 4 . 6 � 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9� 1 9 4 6 6 . 1 6 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) . . . . . . . . . . . . . 10. 5 4 1 . 8 1 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 0 � 0 7 . 9 7 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . �Z• Z 9 1 0 1 6 . 6 3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . �3• • 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. 2 9 1 � 1 6 . 6 3 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of lfne 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(�z)x.00 9 0 5 1 3 . 9 6 15. O . 0 0 16. Amount of Line 14 taxable at�inea�rate X.045 2 0 0 5 0 2 . 6 � �g, `I 0 2 2 . 6 2 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable 0 . 0 � �g. 0 . 0 0 at collateral rate X.15 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 9 0 2 2 • 6 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Side 2 � 1505610240 1505610240 � REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 2t t4 00396 DECEDENT'S NAME HAROLD L.LOTT - -- -- _ __-- --- STREET ADDRESS 42 Fairfield Street _ _- -------- ___ ------- -- - - -- ___. CITY STATE � ZIP Carlisle PA I 17013 Tax Payments and Credits: � Tax Due(Page 2,Line 19) (1) 9,022.62 2. Credits/Payments A.Prior Payments 7,500.00 B.Discount 394.73 Total Credits(A+g) �2� 7,894.73 3. interest (3) 4. if Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 1,127.89 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ...................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income ............................... ❑ � c. retain a reversionary interest ..................................................................................................... ❑ � d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ � 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ X❑ 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 Jan. 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)]. • 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+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCETAXRETURN STOCKS & BONDS RESiDENT DECEDENT ESTATE OF FILE NUMBER HAROLD L.LOTT 21 14 00396 Ail property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 171 shares MetLife, Inc.(CUSIP 59156R108) 8,855.24 See attached. TOTAL(Also enter on Line 2,Recapitulation) $ 8 855.24 If more space is needed, insert additional sheets of the same size REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENTDECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: HAROLD L. LOTT 21 14 00396 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Members 1 st Federal Credit Union, savings account no.207940-00 823.12 See attached. 2. Members 1 st Federal Credit Union, investment savings account no.207940-OS 85,441.06 See attached. 3. Members lst Federal Credit Union,checking account no.207940-11 28,977.02 See attached. 4. Members 1 st Federal Credit Union,certificate of deposit 207940-57 5,243.46 See attached. 5. 2012 Ford F-150 Supercab XLT 8.1 foot bed 22,000.00 Sale price of truck. 6. Construction Trailer 400.00 Sale price of trailer. 7. Titan Tiger 38 Revolver, S/N 0821715 65.00 8. Roosevelt Dime booklet(1946-1964) 8.00 9. AAA Insurance-refund due to overpayment 10.00 10. AAA Insurance-refund vehicle insurance 353.00 TOTAL(Also enter on Line 5,Recapitulation) $ 143 320.66 If more space is needed,use additional sheets of paper of the same size. _ _ REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HAROLD L.LOTT 21 14 00396 If an asset was made jointly owned within one year of the decedenYs date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Debra Reilley 1208 Wildflower Drive Daughter Webster,NY 14580 B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 07/2012 Members lst Federal Credit Union,certificate of deposit(0042) 11,562.17 50. 5,781.09 See attached. 2. A 02/2012 Members lst Federal Credit Union,certificate of deposit(0045) 1,122.93 50. 561.47 See attached. 3. A. 6/2011 Members 1 st Federal Credit Union,certificate of deposit(0053) 1,163.82 50. 581.91 See attached. 4. A. 6l2011 Members 1 st Federal Credit Union,certificate of deposit(0054) 29,47238 50. 14,736.19 See attached. TOTAL(Also enter on Line 6,Recapitulation) S 21 660.66 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER HAROLD L.LOTT 21 14 00396 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. DESCRIPTION OF PROPERTY ITEM INCLUDETHENAMEOFTHETRANSFEREE,THEIRRELATIONSHIPTODECEDENTAND DATEOFDEATH %OFDECD�S EXCLUSION TAXABLE NUMBER THEDATEOFTRANSFER.ATfACHACOPYOFTHEDEEDFORREALESTATE. VALUEOFASSET INTEREST (IFAPPLICABLE) VALUE 1. Edward Jones,Account No. 889-14033-1-6(transfer on death) 22,580.48 100.00 22,580.48 Beneficiary: Debra Reilley,daughter(100%) See attached. 2. Baltimore Life Companies,Annuity Policy No. 01052025725 11,461.55 100.00 11,461.55 Beneficiary: Debra Reilley,daughter(]00%) See attached. 3. Baltimore Life Companies,Annuity Policy No.01052044097 12,632.05 100.00 12,632.05 Beneficiary: Debra Reilley,daughter(100%) See attached. 4. TIAA-CREF,Contract No. IG69776-7 4,689.99 100.00 4,689.99 Beneficiary: Helen D.Lott,wife(100°/a) See attached. 5. TIAA-CREF,Contract No.IG69777-5 3,387.74 100.00 3,387.74 Beneficiary: Helen D. Lott,wife(l00%) See attached. 6. T1AA-CREF,Contract No. Y009521-9 72,185.35 100.00 72,185.35 Beneficiary: Helen D.Lott,wife(100%) See attached. 7. TIAA-CREF,Contract No.&050223-0 8,619.58 100.00 8,619.58 Beneficiary: Helen D.Lott,wife(100%) See attached. 8. TIAA-CREF,Contract No. Y916329-9 1,631.30 100.00 1,631.30 Beneficiary: Helen D.Lott,wife(100%) See attached. TOTAL (Also enter on Line 7,Recapitulation) $ 137,188.04 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(08-13) pennsylvania SCHEDULE H DEPARTMENTOF REVENUE FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER f-IAROLD L. LOTT 21 14 00396 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1, Hollinger Funeral Home&Crematory,Inc. 4,343.46 2. Dickinson College-memorial service 928.14 3. Fiddlers at Mayapple-family funeral reception 215.71 4. Staples-Memorial bookmarks 44.57 5. Rowe's Print Shop-In Memory Cards 51.57 6. Obituary fees for Times-Journal,Cobleskill,NY,and The Greenville Pioneer,Greenville,NY 139.20 7. Travel expenses for Executrix to plan and attend funeral 377.88 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2, Attomey Fees: Martson Law Offices(estimated) 13,000.00 3. Family Exemp6on:(If decedenYs address is not the same as claimanYs,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: Register of Wills,Cumberland County 238.50 5 Accountant Fees: 6. Tax Retum Preparer Fees: 7. Stock Valuation Report 2.00 8. Copy of Deed 0.13 9. Additional probate 125.00 TOTAL(Also enter on Line 9,Recapitulation) $ 19 466.16 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENTOFREVENUE DEBTS OF DECEDENT� INHERITANCETAXRETURN MORTGAGE LIABILITIES 8� LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER HAROLD L.LOTT 21 14 00396 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. TIAA-CREF-prorated benefit 541.8] TOTAL(Also enter on Line 10,Recapitulation) $ 541.81 If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HAROLD L.LOTT 21 14 00396 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE � TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. Debra Reilley Lineal 21,660.66 1208 Wildflower Drive Sch. F,Items 1-4 Webster,NY 14580 2. Debra Reilley Lineal 46,674.08 1208 Wildflower Drive Sch.G,Items 1-3 Webster,NY 14580 3. Helen D. Lott Spousal 90,513.96 42 Fairfield Street Sch.G,Items 4-8 Carlisle,PA 17013 4. Debra Reilley Lineal 132,167.93 1208 Wildflower Drive Residue Webster,NY 14580 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. JI. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF HAROLD L. LOTT. I, Harold L. Lott, domiciled and resident at5 42 Fairfield Street, Carlisle, Cumberland County, Commonwealth of Pennsylvania, declare that this document is my Will and revoke all my previous Wills and Codicils. I. IDENTIFICATIONS AND DEFINITIONS I am married to Helen D. Lott. We were previously married and each have children of our former marriage. We have no children together. I have one child , a daughter, Debra R. Reilley and she is referred to in this will as my daughter. II. PAYMENT OF EXPENSES, DEBTS, AND TAXES I direct my Executor to pay medical, funeral, and administrative expenses and all taxes payable by reason of my death, before any division of my estate. My Executor shall not attempt to have any part of such taxes apportioned among the recipients of property includible in determining the amount of such taxes. Proceeds on insurance on my life up to the maximum allowable as an exemption from Pennsylvania lnheritance Tax and distributions from pension and profit sharing plans exempt from federal estate tax, all of which are payable to any beneficiary (other than my estate), shall not be used to pay debts, taxes, expenses of administration or other charges against my estates. _ III. SPOUSE SURVIVING If my wife survives me, I devise, bequeath to my daughter, Debra L. Reilley, all my personal property including, but not limited to, my truck and firearms and the contents of the safe in my shed, together with any bank accounts, credit union accounts and certificates of deposit solely in my name. My wife shall receive a the balance of my estate and I have placed her name on all my insurance accounts and pensions to insure she is cared for after my passing. IV. � SPOUSE FAILING TO SURVIVE � If my wife does not survive me I leave my entire estate to my daughter Debra. �`, VI. FIDUCIARIES Executor: I nominate and appoint my daughter Debra L. Reilley as Executrix of my estate to serve without bond. VII. MISCELLANEOUS Survival Defined: No person shall be deemed to have survived me or to be living at my death if he shall die within thirty (30) days after my death. In testimony of which 1 now sign this Will, in the presence of witnesses whose names will appear below, and request that they witness my signature and attest to the execution of this Will, this 8`" day of May, 2012 at 1237 Holly Pike, Carlisle, Cumberland County, Pennsylvania. AROLD L. LOTT HAROLD L. LOTT., in our presence, signed this instrument. Before he signed it, he declared to us that it was his Will and requested that we act as witnesses to its execution. We believe him to be of sound mind, possessing testamentary capacity, and not subject to undue influence, fraud, or coercion. We now, in his presence, and in the presence of each other, sign below as witnesses, all on this 8TH day of May, 2012, at 1237 Holly Pike, Carlisle, Cumberland County, Pennsylvania. n , ,y�..�1 � r'i � � ,�� . - :'l�'� � � �°" residing at 1237 Holly Pike, Carlisle, PA 17013 �.-' 2�.2��,�,�,Y;�C?- ;y k�,o�3oa ,` _ residing at 20� Hoy Road, Carlisle, PA 17013 COMMONWEALTH OF PENNSYLVANIA : : ss COUNTY OF CUMBERLAND : We, Joseph D. Buckley and Elizabeth Stoneberger, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as his Last Will: that he signed willingly and for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen (18) or more years of age, of sound mind, and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by Joseph D. Buckley and Elizabeth Stoneberger, witnesses, this 8�' day of .N�a}v�012. � � ,.--� �: . f '4 ,;�� '^ /` .I 1 'v ,; `t=�--�t�.a}-�L.� � '� �1�-� otary P blic .�...��....,�— NOTARIAL SEAL KAREN KAY BUCKIEY Notary Publk M�OIETON TWP,CUMBERIAND CNTY tAy Co�xnbsion Expirea Jun 23,2013 Estate Valuation - 15629.1 Date of Death: 09/09/2014 Estate of: Harold L. Lott `✓aluation Date: 04/09/2014 Account: MetLife stock Processing Date: 05/08/2019 Report Type: Date of Death rlumber of Securities: 1 File ID: 15629.1.1ott.metlife Shares Security P�ean and/or Div and Int Security or Par Description High/Ask Low/Bid Adjustments Accruals Value 1) 171 METLIFE INC (59156R108; MET) COM New York Stock Exchange 09/09/2014 52.38000 51.19000 H/L 51.785000 8,855.29 Total value: 58,855.29 Total Accrual: 50.00 Total: $8,655.29 Page 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing 5ystems, Inc. If you have questions, please contact EVP Systems at (B18) 313-6300 or www.evpsys.com. (Revision 7.3.1) 5c� � � , �-�C'M I St � MEMBERS lst FEDERALCREDTT UMON REGULAR SAVINGS ACCOUNT: Account Number/Suffix 207940-00 Date Account Established 08/01/2001 Principal Balance at Date of Death $823.10 Accrued Interest to Date of Death $0.02 � �.�m � Total Principai and Accrued Interest �-�C�`• ' Name of Joint Owner one INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix 207940-05 Date Account Established 08/01/2001 Principal Balance at Date of Death $85,437.27 � Accrued Interest to Date of Death $3.79 ` C ��''� Total Principal and Accrued Interest ��C.1�• ' Name of Joint Owner one CHECKING ACCOUNT: Account Number/Suffix 207940-11 Date Account Estabiished 08/01/2001 Principal Balance at Date of Death $28,976.70 � 1�� Accrued Interest to Date of Death $0.32 � ��, � , `�� Total Principal and Accrued Interest �" Name of Joint Owner one CERTIFICATE OF DEPOSIT: Account Number/Suffix 20T940-42' Date Account Established 10/09/2013 Principal Balance at Date of Death $11,559.64 Accrued Interest to Date of Death $2.53 -�� Total Principal and Accrued Interest �,L�. �, Name of Joint Owner e ra ei y Date Joint Added 07/09/2012 ''Rollover from CD 207940-47 opened 07/09/2012. MEMBERS 1ST FED RAL CREDIT UNION � Tessa L Klugh Lending Insurance Support Specialist May 14, 2014 Estate of: HAROLD L LOTT Date of Death: 04/09/2014 Social Security Number: 077-28-6722 �jC�1. � � _�`i`tl� � ' -7J �C�-�, F , ��r-� I 5000 Louise Drive • P.O. Box 40 • Mechanicsburg, Pennsylvania 17055 • (800) 283-2328 • wwwmemberslst.org St � MEMBERS lst FEDERAL CREDTT IJiVION CERTIFICATE OF DEPOSIT: Account Number/Suffix 207940-45* Date Account Established 02/05/2012 Principal Balance at Date of Death $1,122.83 Accrued Interest to Date of Death $0.10 1 ,, Totai Principal and Accrued Interest �� , �� +� �'�'l � Name of Joint Owner ebra Reilly Date Joint Added 02/05/2012 `Rollover from CD 207940-61 opened 11/05/2010. CERTIFICATE OF DEPOSIT: Account Number/Suffix 207940-53" Date Account Established 01/02/2013 Principal Balance at Date of Death $1,163.56 Accrued Interest to Date of Death $0.26 ( � Total Principal and Accrued Interest L�� h, � � �-rC M � Name of Joint Owner ebra Reiliy Date Joint Added 06/0 512 0 1 1 'Rollover from CD 207940-41 opened 06/05/2011. CERTIFICATE OF DEPOSIT: Account Number/Suffix 207940-54* Date Account Established 01/03/2013 Principal Balance at Date of Death $29,465.92 Accrued Interest to Date of Death $6.46 �� Total Principal and Accrued Interest �;�-�. � � Name of Joint Owner Debra Reiily Date Joint Added 06/06/2011 `Roliover from CD 207940-43 opened 06/6/2011. CERTIFICATE OF DEPOSIT: Account Number/Suffix 207940-57* Date Account Established 01/21/2013 Principal Balance at Date of Death $5,242.31 � Accrued Interest to Date of Death $1.15_ i- Z�' ,�r-� Total Principal and Accrued Interest �-�C r' � E , Name of Joint Owner None *Rollover from CD 207940-44 opened 10/22/2011. MEMBERS 1ST FEDERAL CREDIT UNION `.J.?J�1Q_ Tessa L Klugh Lending Insurance Support Specialist May 14, 2014 Estate of: HAROLD L LOTT Date of Death: 04/09/2014 Social Security Number: 077-28-6722 ��e� C � -��-e,� � ��,�h. �_ , �-4-em� � - y 5000 Louise Drive • P.O. Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wwwmemberslst.org _ TM1`�. w �� p�en�s�r�varna . DEPARTMEN7 OF RpVE►yUE t�UA�AU OE 1Np7VZOUAl TAXE5 June 23, Zq14 Edward Jvnes stonehedge Sq, Ste 1 950 Wa{nut Bottom Rd Cariisle, Pa X7015 Re: Estate of: Harold L Lott Sociai Security Number. 077-28-6722 � File Number: 2114-p396 Dear Sirs: The Department issues this waiver fer th� following security held in beneficiary Pormat by the decedent. The se�urity will be subject to Pennsylvania inheritance tax. The Department wi(I issue an information notice to Che transferee of the potentiaf Pennsylvania inheritance tax due for this asset. A capy of this waiver is to be used by you to �otify the transfer agent that the reparting requirements of Section 641�. vf the Probate Estates and Fiduciaries Code (Title z0, Chapter 64, Pennsytvania Consolidated Statutes), have been satisfied. Name of Gompany: Edward ]ones Type vf Account(s): Capitial Stock ID Number(s) 2 Account eatance(s): $22,580.48 Sinc�rely, Amber Heimbach Inheritance Tax Dlvlsion ' De�artment pf Rever�i.�e � PO EiOx 7,80601� HBrrisburg, PA Z712£3 � 717.7�7.6677 � www.revenue,5tal;e.pa.t,�5 � ��t h �` - ' ��{iYl I U' Form 712 Life Insurance Statement (Rev.April 2006) OMB No. 1545-0022 Department of the Treasury Internal Revenue Service DeCBd@f1t—IIISUf@d (fo be filed by the executor with Form 706,United States Estate(and Generation-Skipping Transfer)Tax Return,or Form 706-NA,United States Estate(and Generation-Skipping Transfer)Tax Return,Estate of nonresident not a citizen of the United States.) 1 Decedent's first name and middle initial 2 DecedenYs last name 3 Decedent's social security number 4 Date of death H C'�Y G 1 C� �-- �...o� (if known) O�'�''�.� ��O�1..2. y ��N 5 Name and address of insurance company �c �hmU�e �-�f-e u�s�uanc � EZe�1 C2wn �lvci pw�c� s M��Us C'�� ?,111�- 6 Type of policy 7 Policy nu er n�, ' � 0 IU52oZ5�-ZS 8 Owner's nam . If decedent is not owner, 9 Date issued 10 Assignor's name.Attach copy of 11 Date assigned attach copy of application. assignment. 5 /� /o � N�R 12 Value of the policy at the 13 Amount of premium (see instructions) 14 Name of beneficiaries _ time of assignment _ `�, j � i60D.06 S�n J1e Qtemui �E'b'�c^- �G1e FZ�..:.� 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 15 $ `�� 5 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 16 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . �� $ 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 $ 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . 19 $ 20 Interest on indebtedness (line 19) accrued to date of death. . . . . . . . . . . . . 20 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 21 $ 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 22 $ 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . 23 $ 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . 24 $ l\�1�1 .55 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . 25 $ 26 Policy provisions concerning deferred payments or installments. � P� � , ` � � `=`. `� �� '�� Note.If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of ;��,��'� a. the insurance policy. ��, � � ��,� x ��:��• -------------------------------------------------------—--------------—----------—-----------------------— �c* , � ��. � ��^� 1 F Y,�^��„k irR. a��R 'fl' t�`�„�'Ny�.�� ..; ..._'_.'.'_..'_.."......................... '.._....._"._..__'_._.....__.."_..-."_________._._.__..' t� �3+34'$�: w�.^f��kk.L�., ia� __'__'_..' 27 Amount of installments . . . . . . . . . . . . . . . . . . . . . . . . 27 $ 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. �,'��'� �� .___.__'.._'_..._."'..___.__.'..__.'_".___._'__'_._.'.. _..'....................."._.._.__.____-__._._._......__. „, �°-�� ?. 4�}�y, Y�'��b��i� ��i Y i'° E hd'�K., "__'_______"'""'"""'"""""""'"'"..._""""'_'""__"' "'"_'"_'"'""""""_'""""'"""""'""'"""""'_"""""""'"'""""' �'v 29 Amount applied by the insurance company as a single premium representing the purchase of -=�'��- - ti z�� -� - instailment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 29 30 Basis (mortality table and rate of interest) used by insurer in valuing instaliment benefits. --------------------------------------------------------------------------------------------------------..__...----•-------------------- 31 Were there any transfers of the policy within the three years prior to the death of the decedent? . . . ❑ Yes No 32 Date of assignment or transfer: / / Month Day Year 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . . . . ❑ Yes � No 34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by him/her at the date of death? . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes � No 35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records. ----� ---------- --- ----- --------- ------------------- --------------------------�-------------------- -------------------------- ------------------------ ----------------------- ------------ ------- --------------- ----------------------------------- ----- The undersigned officer of the above-named insurance company(or appropriate federal agency or retirement system official)hereby certifies that thls statement sets forth true and correct in on 5 Z�C r Y\c� P t�`>��f Signature ► Title ►��r� Ce��,-,� ' Date of Certification ► For Paperwork R c ion Notice, see page 3. Cat.No.ioi�oV Form 712 (Rev.a-2oos) �ch. �-► ��.� � Form 7 1 2 (Rev.April 2006) Life Insurance Statement OMB No. 1545-0022 Department of the Treasury Internal Revenue Service DeC2d@flt-111SU1'ed (To be filed by the executor with Form 706,United States Estate(and Generation-Skipping Transfer)Tax Return,or Form 706-NA,United States Estate(and Generation-Skipping Transfer)Tax Return,Estate of nonresident not a citizen of the United States.) 1 Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number 4 Date of death 1lcrrr�icl l. t.._o�'1' (ifknown) O��' - ZY�-Co�-LZ '� �q �l� 5 Name and address of insurance company 6c�firno�e C,�Fe �r�s�r�ce IOO�S �ec� �R� b\vd Owtn ,t�Us, �G� 2��1� 6 Type of policy 7 Policy number An o�aszo4�lo��- 8 Owner's name. If decedent is not owner, 9 Date issued 10 Assignor's name.Attach copy of 11 Date assigned attach copy of application. assignment. Z � Z� ��3 ��{ 12 Value of the policy at the 13 Amount of premium (see instructions) 14 Name of beneficiaries time of assignment �IZC�00,G6 Svc�c�tA � - � 17ebr�.�. R �� 15 Face amount of policy . . . . . . . . . . . . . . . . . . . . . . . . . 15 $ �- Z , v S 16 Indemnity benefits . . . . . . . . . . . . . . . . . . . . . . . . . . �s 17 Additional insurance . . . . . . . . . . . . . . . . . . . . . . . . . �7 $ 18 Other benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 $ 19 Principal of any indebtedness to the company that is deductibie in determining net proceeds , 19 $ 20 Interest on indebtedness (line 19) accrued to date of death. . . . . . . . . . . . . 20 21 Amount of accumulated dividends . . . . . . . . . . . . . . . . . . . . . 21 $ 22 Amount of post-mortem dividends . . . . . . . . . . . . . . . . . . . . . 22 $ 23 Amount of returned premium . . . . . . . . . . . . . . . . . . . . . . 23 $ 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . 24 $ `2 �32.US 25 Value of proceeds as of date of death (if not payable in one sum) . . . . . . . . . . 25 $ 26 Policy provisions concerning deferred payments or installments. ;��°�r� v��'��a�� ,�� Note.If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of x �� ,? t ��` the insurance policy. �� t �. � � � ��.. ---------- ----- -- -------- -- - ------- - ----------- -- --- - ------ - — ------------ -. ... � ' �� . ��:��`�� u � �,, - ------------- ----- ------- - ------- - �- ------- --- . _.....------ - - - ---------- - . ----. ��`v``�»��'�`�'��s,.�„�``�.�;� 27 Amount of installments , , , , , , , , , , , , , , , , , , , , , , , , 2� $ 28 Date of birth,sex, and name of any person the duration of whose life may measure the number of payments. ��^'��r�a��"��, c � . -------------------•-�----------------------------- ----------------------------------------------------------- �� `,�` ,�� ,;�`�� --------•—�-•-------- -------------- - r�,��`' `j , a - -—-----—------------ -----•- ----------------- ----------------------- � � 29 Amount applied by the insurance company as a single premium representing the purchase of ��'��-. _`�.� ��.�=f installment benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 29 $ 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits. ---------------- -------- -----------------------�- -...------�----- ------------- -------- ----- -------- ------------- -------------- 31 Were there any transfers of the policy within the three years prior to the death of the decedent? . . . ❑ Yes No 32 Date of assignment or transfer: / / Month Day Year 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . . . . ❑ Yes � No 34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by him/her at the date of death? , , , , , , , , , , , , , , , , , , , , , , , , , ❑ Yes � No 35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records. -------——-------------------—---------—-------------------------------------------------------—------...---------—---------------------- --------------•------------ -------——------------------------- --------------------------------------—-------------------------------—--- The undersigned officer of the above-named insurance company(or appropriate federal agency or retirement system official)hereby certifies that this statement sets forth true and correct information. S�Ri�t ��L'� P�ey�c�e� Ge�e�c�. co��s�� !%I�� Signature ► � Title ► c.,�, i.�.tp �..�c et c�� Date of Certification ► For Paperwork etion Ac Notice,see page 3. Cac.No.iol7ov Form 712 (Rev.a-2oos) L�� V � ��l� � `°-.� TIAA - CREF '.� SUBSTITUTE FORM 712 FINANCIAL SERVICES FORTHE(iREATERa00D' 1'njS StatCIllellt Fla3 beell pI�CpAI'C(� aS il SUbStltUtC fOC U.S. Treasury Department Form 712 which does not apply to our annuity contracts or certificates since they have no life insurance features. Name of First Annuitant Date of Birth Date of Death Harold L Lott 2/13/1936 4/9/2014 Name of Second Annuitant Date of Birth Date of Death N/A N/A N/A Name of Decedent Date of Birth Date of Death Harold L Lott 2/13/1936 4/9/2014 VALUE OF CONTRACT/CERTIFICATE AT DECEDENT'S DEATH Contract/Certificate Issue Date of the Date of Death Remaining Number Contract/ Value of the Investment in the Certiticate Contract/ Contract/ Certificate Certificate TIAA No.: IG69776-7 7/1/2010 $4,68999 $0.00 TIAA No.:IG69777-5 7/1/2010 $3,387.74 $0.00 CREF No.:Y009521-9 7/1/2010 $72,185.35 $0.00 CREF No.:Y050223-0 7/1/2010 $8,619.58 $0.00 CREF No.: Y916329-9 7/1/2010 $1,631.30 $0.00 Notes: The Federal Estate Tax Value (Date of Death Value) of an annuity at death is what it would cost the surviving annuitant or beneficiary to replace the continuing benefits. The value is calculated as of the date of death and therefore does not change. The value does not represent the cash entitlement a beneficiary is due and is used solely for estate tax purposes. TIAA-CREF follows accepted industry standards and procedures in determining the value of payout annuities for the estate of a deceased annuitant. The Remaining Investment in the Contract/Certificate represents any remaining after-tax contributions in the Contract or Certificate owned by the annuitant. The Remaining Investment in the Contract/Certificate is non-taxable to the surviving annuitant or beneficiary when it is paid. The undersigned Beneficiary Services Representative of TIAA-CREF hereby certifies that this statement sets forth correct and true information. Signature Title Date Bene acia Services Team Beneficiary Services Team July l, 2014 TIAA-CREF Individual&Institutional Services,LLC Member F[NRA,SIPC. Headquarters: 730 Third Avenue,New York,New York 10017-3206 Tel: 212-490-9000 5ch, C�, ��m`� � `� - g