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HomeMy WebLinkAbout02-0572PETITION FOR PROBATE r Estate of '~ ~'~ ~ + ~+,~`'y also known as Deceased. Social Security No. 7 ~ ~ ~ 1 - ~ 3 Z~ and GRANT OF LETTERS No. 21-02-572 To: Register of Wills or t e County of ~ in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or Q~de an the execut.t ~`~ named in the last will of the above decedent, dated ~ 1 ,~ ~ (~gc- f , 19 and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ~-~~~Y County, Pennsylvania, with h_Zr- last family or principal residence at _ ~~ ~ ~~ ,,t ~~. (list street, number and Decendent, then ~ ~ years of age, died ~ ~ f ~ ~ 2s=~ ,~- at ~` ~~ A M . Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ 31s ~ p~,a . " (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania~l $. ~7 ~ ~ ~ -- situated as follows: ~ ~ f~'~ ,, WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. C y d Fo ~e'.. ..~ y 4.n O cV C oD ~ ~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF curiB>rRLarln ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. .~ Sworn to or affirmed and subscribed ~ - r., before me this 19th day of ~~ . A f~0 ~% ~,~,4u-~~e 'ter NO. 21-02-572 Estate of ELSIE K SHIERY ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW JUNE 19 #~_ 200? in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated_ March 1st 1984 described therein be admitted to probate and filed of record as the last will of ELSIE K SHIERY and Letters TESTAMENTARY ' are hereby granted to J LYNDALE SHIERY 'stet of Wi FEES Probate, Letters, Etc.......... ~ 305.00 Short Certificates( ) .......... $ 60.00 Renunciation ................ $ JCP ~ 5.00 TOTAL $ 37~ , Qp Filed ................................... ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE r, _ . _- _ w ~- f his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 820553? No. 21-02-572 . ;4a Rer. 2107 Local Registrar AP R 16 2002 Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH WF re.E YUMOER NAME OF DECEDENT ?Fem. Malone. Laml SEX SOCML SECURITY NUMBER DATE OF DEATH,M«eh. Oay,'hrl '- Elsie K. Shier a. female a• 173 - O1 - 5325 ~• April 10, 2002 AOE ILaa BMdsy) UNDER 1 YEAA UNDER 1 D/Or DATE OF Bp1TH BmFTHPIACE 1C.ry and PIACE OF OERM /Checa Dory one -- see aNruclary on uA+N vW1 ' Mdnllae . Dap Naaee . MYUAw !Moron. OaY hw1 SYN«F«egn Caamuyl HOSPITAL. -- OTHER: 91 rn Augustl~~b ^ Norristown, PA ~ "'"^ ER'O"'p°""x ^ ~+C ,` ^ „~,~~ ~ ~ NI COUNTY of DEATH CIIY, 8080. T WP OF OEATN FAC1LrtY NAME Ix n« nuaulan. <yve slreq aro numoa~ MMS DECEDENT OF HtSPrWIC ORIGIN? MCE ~ Ame„can ndien, SycE. MA,ib. etc. Cumberland Lemoyne 44 N. Tenth Street ~ P" ,^R" '"' ~"'F`'u°'"• 1~1 white ~ . r,., ,~„ ,,e ~ w 0 DECEDENT'S USUAL OCCUPQION XINO OF BUSINESSIINWSTRY WAS DECEDENT EVERW DECEDENT'S EDUCATION Ma1RITAl STATUS-MwrrO 10. SURVIVOIG SPOUSE IGwe lanOalw«E done dernq mat U. S. ARMEDFORCEST c NerM Manrd Nramwed o x , , • . ~. maven nanwl a walaxaOlNe, m net one eFed 1 Trade Association `•• ^ No I~ ENnNnary/Sec«adwy Coe•ve p„o,ay rs°°`"" t a1 „~ 1 z1 (,.«s., ,e widowed nb• u. 1a. 12 ,~ DECEDEM'S EIa11L11eCa ADORESS(Shat. Gy/Twr.. 9ab.Zp Codef DECEDENT'S Penns lvani y Ac7uAL ,,.. slave a Did tu.^ w. arad.rrwa,ain 44 N. Tenth Street "~~r ~ ~~+ n'p ,a Lemo ne, PA 17043 °"°E'n sO" „b, Cumberland b"n""p7 ,Td.® ~E~e:a Lemoyne _ ceyaboro FRItER'S NAME IFxm. Mad W. Lam) MOTHER'S NAME Ifxm. Mdde. McWn S«rwriel ,E. Frank Zollers ,a Rose Eberhart . WFORMAIeT'S NAME (f ypaYPraru) INFORMANT'S MA0.NN) ADDRESS (SYM. Cily/town. SYN Zp Codel . J. Lyndale Shiery 4212 Isbell Street, Wheaton, MD 20906 uETHOOOFOIsPOSITION _OFDISPOSITgN pLACEOFDISPOStT10N-NeaneaCemetery.Cremwory LOCATION-CUylfawn,Stw.zapCoa CrerrWion^ Renbry b«n SYle^ • 1 ='DOrlsti0ra^ OtMr(SpeNy ^ Apri1 16, 2002 Ruling Green Memorial Park Lower Allen Twp PA 17011 ., :, D. ato. 210. OFF FOR PERSON ACTING AS SUCH LICENSE NUMBEq NAME AND ADDRESS OF FACILITY ParthemOre FH & C.$, Inc. rib. FD 013 340 L rn. ox ew Cum erland PA 17070-0431 DemPWe items 2aac when dw D.m a mr lurowleflpe, aeaN oax«red a, are tan.. aY and pb,aiwera w rrw ava4We w Tame of Mwh w s Arad Toe) p+a maYd. LICENSE NUMBER DATE SIGNED on/y Ceatae of death. (MOM.Day.wwl 27a. a]b 3 ~~ rMn aconapgleelehoo Dy IME OF DEATH A ,~~~ OQE PROIgUNCEO DEAD IM«an. Day. hear) yWS CASE REFERRED TO MEDICAL E1 INEWCOROt1ER7 ~ :.. :OU M. a . ~ ~ 11 2002 „ w.~ ` No~ aT. MITT t: Emw Ow dYeaaea, xy«r «wmpxcaboa wniNa canard uae oath. Do rr« suer 1M rrwM of gxa0 ea,<n es cardac «resgrato arrant mr k M hx A , ry , oc « an «e. pproarrnwe PMT N: Liw Dray oM cause on eeda Gle. ~ . OdW sa0nekaw wrarNYOac«uroaaira0 b gleam. but IMIIEOIATE CAUSE 6rrw r I gruel ~~•~••!a rcl raukn0 n tlr uatlm/yup cane Wen in PMT I. { .., oe e ga-- , i/ / aeeee«canolaon ~ 11 ,, ,,, -,,/ 7 IL Q ~ I K , . /J rewatrrpndeeer)-- a. '~!+ V a 2 DU (OR A A CO NCE //' a C / Li . L • Yh 0 eny, badxgbmnediwe \ IE IQ ~O@ AS A COHSE WENCE OFI: _----~~ C~ , agar. Ewer IIIIDERLYNIO !11 L' t L f «+M+ry e a A ( Y/ 1u Brat eriwW ervus I l1E ^ 0 R rot ASACOFLaEOUENCEOF7: rwaairgndeeOallAiT O. I WA$ AN AUTOPSY PERFORL/EO7 WERE AUTOPSY FOIDYeO$ AteULABLE PRgR ro MANNER OF DEATH DATE OF INJURY TIME OF 1WURY iNJURV R WORK7 DESCRIBE HOW INJt1RY OCCURRED. coetPLET1DNaFGaLUBE ,--./ IMOnea. Day. wars OF DEaON7 NwurY I.JI Noanci0e ^ AcDaa.n ^ wradxq lnarestigwaon ^ r« D No ^ Ote ^ No we ^ Ito ^' Saarasde ^ Coaab and D• Mlermnaw ^ M. PIACE OF IWURY . N home larm mnw YCI« odau OC T „~ „b . , . y, L A gN (Straw. cuyrtown, Swel Duxdtrrq, wC. ISpecxvl _ „ 3W. 301. 11FJ~Eq 1~ 1CneG «Yy «rl IPYWO PHYSICIAN IPnyacan arylyrp caaRa d down wnan andnw physC.an rocs panouncetl dean aro compgaw xem 231 To Yle bat a my taraeuYdOe, Mam oaxwnd due b tM cau.e(e) and marraer ae e4t ld SIG RE D TITLE OF C T a ......... . 'PROI/OUNCNIO AND CERTIFYNIO MIYSIC,AN IRayscun Dux: yo.ror,ncarq aeon aM cMxyarg to cause d ascot Te tlr D N f tr M LICE NUMBER DATE SXiNED 1 ~ r/t I~°~~ [',^, n e o my rww dge, Mom oecrrrM at Oae Yoe, Mle, arW piece, and dw to Ore eaYNle) and mentor as elalrad .......................... ^ ~ - 7t .I L~"'R ~ 710. ~/ ! . . 'MEDICAL EI(AMINER/CORONER ~ NAME AND ADDRESS Of PERS WHO COMPLETEOCAUSgpF OEAT (Item 271 Type «Pdnl ~y,_ - . /r {'(/yt' L,~`. `„kj " ' On Il,e buffs ayl eaaminatlon endla Irarestigation, in my opinion, death occurred at the time, date, and glue, grad due to me cauaele) and = manner as staled .................................................................................................. ^ ~ 71a. ^ /`T /Yw1/~ _/K /1J-~/~/ ~/ ~/-/~ ~ ~ Np~7 /!LA/L S 1T~ ~ t~~ ~ ~ ~ REGISTRAR'S SKaNATURE AND NUMBER W 4. O a /i4 /L-¢• /u~sL LfYYrs 4I`.r u DATE FILED (Moron. Oay. wart as ~_,, ~,~~~ --~ 3. ~ /f , e?oa wZ C ~ ~~~ C~-u=~ ~~~ ~ ~ /~ ~ ~ (~ ~ ~~ i ~ ,~ ~~~ ,~~-- z~ ~,~,. ~~;,~, G' ,~,~~-~-~- ,m ~~ ~ ~ ~~ ~~ J lJ ~ ~i~_. e'' G ~.c.~~- ~;--,ut-~~~:~~- ~ ~~~-~-,~- ~-~--~ _ ,nom ~ v,c,~--s~..~~~-~-8-~-~~-' ~-L- ~4m~ ~ ,,~ -~ ~ `~~ ~ ~~ 1,1 ~Y, •~ `" ~/~.~iC,~- -~ /UO ~~C / ~.C/I'L2•~i' ~ G?~~~?-~fYLe-Ti~E.~6Z1Lrlt-~%lyt~ e~~-r a ~~ ~~ ~Isi~e ~. ~~tr'~ry ~-~~ ~~~ ~1~ ~ ~~~5'-f~-e~~" ~`E'.m~yh~, ~hn Syc~V'cLnt~ ~~0~'3 ~u'/ ~'~ r ~/ J C[, y' G /7 I f i U C' ,~~~1q~~~; ~~ - _ , ~~ ~ ~ ~~ .. fi `~ - ~~ .~ ~ ~ J ~ ~ ~ ` ~ ~, 'C ~ `-~ O 111 ~ ~ ~ I Vf i.e. ~~ ~~ ~ ~ ~ ~, ~ ~ ~ ~ ~ ~ ' ~ ~ ~~ ~, ~ ~ , ~ ~ .~ ,~ ~~ ~~ ~ ~ ~ ~~ ~ ~ ~ J , ~ `~~ ..~ REGISTER OF WILLS OF _ COUNTY OATH OF SUBSCRIBING WITNESS codicil (each) a subscribing witness to the will presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that present and saw the testat ,sign the same and that signed as a witness at the request of testat in l~ presence and (in the presence of each other) (in the presence of the other subscribing witness(es)). Sworn to or affirmed and subscribed before _ me this day of (Name) 19 (Addr. ess) Register (NarneJ (Address) REGISTER OF WILLS OF _ COUNTY OATH OF NON-SUBSCRIBING WITNESS •_~ ~itnclra~e ~~~, i~~tu JC'~T~ ~__ ~~, ~ c~ k ~a (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that 1 r,e ~ r~ k t= familiar with the signature of ~. l S I c-: k -`'~ h ~ e e u -cadiril- testat^~ ~ of su scr' the will presented herewith and codicil that ~'hP ~ believe the signature on the will is in the handwriting of to the best of ~~__, knowledge and Sworn to or affirmed and subscribed before me this 19th day of ~ JUNE ~~ 2002 Register r^ ~~; S ~~ i amen (~/~. I ~U~f a ~.zO µ~s ~ ~ ue . l,za.~t>y ,~z. _ (Addr~ .._ lam, (Name) (~ ~"1 Zl -'- ~i~~.~ `mac ~ ~~~ 6-y-'/ (Address) ~~ July s, 2002 VIA OVERIJIGHT DELIVERY Cumberland Register of Wills Office Inheritance Tax Collections Cumberland County Courthouse 1 Courthouse Square Carlisle, Pa 17013-3387 Re: Estate of Elsie ~ Shiery, Deceased; File No. 21-02-OS72 Date of Death: 4/10/2002 Dear Sir/Madam: Enclosed is a check for $18,805.93 as payment on account of the Pennsylvania Inheritance tax on the above estate which is due 1/9/2003. Please send a receipt for this payment to: J. Lyndale Shiery 4212 Isbell Street Wheaton, NID 20906 Thank you. Very truly yours, ~ ~~~ ~~ J. Lyndale Shiery, Executor ~ ~Q ~~ ~o~ N~ - - a ~p c~ ' ? V ~ m C.... ~_ ~ iS 1 N '~ Q m ~~ p. c~ M ~ ' ~~ ~ .' ; ~ ~ Ids u ~° ~ h1 ~~~ ~~ d ' Map r~ ~ o 6 Y ~~ 4+ c dz aLLaim~ G u~z o i!J W ~ ~ ~ J R ^ 11'1 I T~ ~ U V `}+ I m ~ ~~ a *...: 'N ®~ ~ ~w ~ ~ ~ ~ ~ ~ 1 f'7 r+ / m ~ ~ :~ tl `~i ... I ~+ c~i a IV m ~ ~, ~ I _I wi ~_ E d V X W ~ ' i d W ~ -r. :~ E y c ~a ~' ~ w ~~ i y C Y C _. y = ~ r. m E a: y r y v ~' W F C i~ m Cd ~ ~ ~~ ~ ~ ~ ~ ~ i i i m ~ ~' I ... Z ~ ~' ~~ Y I ~ a: w a ~ n ~ ~. ,~ iL © 1iJ L ro ~ ~ ~ ~ ~ ~ ~ ~. ~ 8 { ~ ~ ~' ~ W m $ -'-~ ~ t'i~ ~' T H ~ ~ ~+ J a E L ~ g i i ~ m ~ N ti m (~ Vf E C of <nzi c°~I a ~ 383H 1~3d =1N31d1~3H ~' '>~w > d y ¢Z ExU n= O ado ~ I~o F (J ~ll ~~ U ~ ~ oaL ~ , 9LLq~ a L =~-LL.~ a Id U L~ U ~ r ~ 3~ ^ z - R~'A Y - ~ Jasi i. ~ a ~a 3~m~ - 'I 9a=¢ as o" m'' ~ m o ~ z°~ ~^ x ~zLL my~ ~ ~ c ~ ~ - - _ ~ d~mE~o ~ ~ ~ ~£ {O ^ L 1~ <1 i ~{ i ~~ ~ ~ ~ r ~ 1 _. ~ ~', ~ ~ ~. ~ 1 ~ m } s 4 w ~ 3 ~ _~ 1 i dl __ o ~, _ ~I ~,~- ~ ~ (` s-- ,. J j .t- ...~ j \. t i m ~ ~( ~` , ` ~ _ ~ , c n E v 1O E a a 9 a °x z H¢Z U Q ~ Q ~~, :. ah y. ~ a ~E E ~ $ I t m ~ oQ ~ 0 5~~ ~ ~ W ~ ~ a E ~ awl d ~ ~ c ~ ~~ a y 5 E d ~m~~~ ~u~ ~;`~ ~ y °t em i m r ~ ~ ~~»a- 1 8 ~ ~ m N o e O a E ~ N °s e$o ~m~_ ~ .~ ~i m ~~ ~ ~ d m o.~ y ~ C1 o ~ ,~ ~ ~ ~~ ~ ~ ~ ti a m ~ '~'1 ~ ~ ~ m _ V gO~ ;~ r r / l1 V ~ ® ~ ^' ~ •.- ,-p ~ ® T r-I ' _ =~W ~ ~.. ~aa d N ~ ~ ` ~,. ~- ~ ~ ~ 0 ~~ Si ~ m ~~ ~ ~~ r ~~ n u'I ~~ ~ N ~ m ~ ®~ ~~_ ~ X ~ ~ {1J {d d U _ ~~ l -~ ;3 ~ E W ~ _ N ~.% A ~ V "~ vi W Y A C ~~ U ~ : ; ~ O M I c ~ ~ `o ~ ZZZ ~~ O O ~ ~ ! ~; " ~ i ~ ~~NM~~a .~ ~ ~ $~ ~~~ ~~ ~~~ i~ y COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: BRIERY J LYNDALE 4212 ISBELL ST WHEATON, MD 20906 fold PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ESTATE INFORMATION: ssrv: X73-oi-5325 FILE NUMBER: 2102-0572 DECEDENT NAME: BRIERY ELSIE K DATE OF PAYMENT: 07/08/2002 POSTMARK DATE: 00/00/0000 couNTY: CUMBERLAND DATE OF DEATH: 04/ 10/2002 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~ 518,805.93 TOTAL AMOUNT PAID: REMARKS: J LYNDALE BRIERY OVERNIGHT DELIVERY NO POSTMARK CHECK# 0092 SEAL INITIALS: SK RECEIVED BY: MARY C. LEWIS 518,805.93 REGISTER OF WILLS REV-1162 EX(11-96) NO. CD 001387 REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVEIBJE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D DEPT. 280601 TAXPAYER RESPONSE HARRISBURG, PA 17128-0601 REV-1545 EX AFP (09-00) FILE N0. 21 02-0572 ACN 02134952 DATE 08-08-2002 J L BRIERY 4212 ISBELL ST WHEATON MD 20906 TYPE OF ACCOUNT EST. OF ELSIE K BRIERY ® SAVINGS S.S. N0. 173-01-5325 ^ CHECKING DATE OF DEATH 04-10-2002 ^ TRUST COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NAYPOINT BANK has provided the Depertwent with the inforwation listed below which has bean used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this inforwation is incorrect, please obtain written correction frow the financial institution, attach a copy to this ion and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Cowwonwealth of Pennsylvania. q(:estians way be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW x< * ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 100011544 Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Due Date 01-01-1971 Established 1,160.30 x 50.000 580.15 x _ b ~ ,~-5- 87.02 To insure proper credit to your account, two (2) copies of this notice oust accowpany your paywent to the Register of Wills. Make check payable to: ^Register of Wills, Agent^. NOTE: If tax paywents are wade within three C3) wonths of the decedent's date of death, you way deduct a 5% discount of the tax due. Any inheritance tax due will becowe delinquent nine (9) wonths after the date of death. PART TAXPAYER RESPONSE ^ €€€~ € ~: A. ^ The above inforwation and tax due is correct. 1. Yau way choose to rewit paywent to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you way check box ^A^ and return this notice to the Register of C 0 N E ~ Wills and an official assesswent will be issued by the PA Depertwent of Revenue. BLOCK B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return ONLY to 6e filed by the decedent's representative. s.~-+- Q..~-~ pSp,~ ('p,,~.ly~ C. ^ The above inforwation is incorrect and/or debts and deductions were paid 6y you. You wust cowplete PART 2^ and/or PART 3^ below. - - to Ou :::;=:[~v==a:ss::::::~:::,:~;<_::~:~:~:~:~:~::~::-:~:::_.;:~~~'::~t::~:~~~~~~~~~~~~t:~::-::-:~::-s:::==:::[a:~".:.:.:: ts~:::; ::~::::[:: T If you andscate a different tax rate, please eta PAR iil~~€i€€ ' '-€~~~V€€ ~: !r~ :::: ~:::::::-:-:::::::::: ~L ~~ .Qa,. ;,,,,,,;,,;,,,,;,,,,,,,,,,,,,,,,; ....~........,...._.............. ...... ... ... relataonshap to decedent: ~ lr~.r~ :::;,::;.:::es~::~::ar:€;ii€€i€€~3r~aa5~(iaa(tii~€f€ii~t`ii~ii?tiiai'r'iwii~:~rr;€=;:r;;~;<;€ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due PART 8^ DATE PAID PAYEE OF TAX ON JOINT/TRUST ACCOUNTS (~F~} DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of ny knowledge and belief. HOME C ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE CDMNONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE FILE N0. 21 02-0572 BUREAU DF INDIVIDUAL TAXES AN D DEPT. 288681 ACN 02134953 HARRISBURG, PA 17126-6661 TAX PAYER R E S PON S E DATE 08-08-2002 REY-1543 EX AFV (09-DD7 J L SHIERY 4212 ISBELL ST WHEATON MD 20906 TYPE OF ACCOUNT EST. OF ELSIE K SHIERY ^ SAVINGS S.S. N0. 173-01-5325 ^ CHECKING DATE OF DEATH 04-10-2002 ^ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NAYPOINT BANK has provided the Departeent with the inforeation listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this inforeation is incorrect, please obtain written correction froe the financial institution, attach a copy to this fore and return it to the above address. This account is taxable in accordance with the Inheritance Tex laws of the Coanonwealth of Pennsylvania. Questions say be answered by calling (7177 787-8327. COMPLETE PART 1 BELOW ~ * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 416011453 Date 10-15-1980 7o insure proper credit to your account, two Established C2) copies of this notice ^ust accoepany your Account Balance 27,095.21 Payaent to the Register of Wills. Make check payable to: ^Register of Wflls, Agent^. Percent Taxable X 50.000 NDTE: If tax payeents are cede within three Amount Subject to Tax 13,547.61 (3) eonths of the decedent's date of death, Tax Rate X ~" / ~~ you eay deduct a SiC discount of the tax due. Any inheritance tax due will bacons delinquent Potential Tax Due 2, 032.14 nine (9) eonths after the date of death. PART TAXPAYER RESPONSE a...: .: .: ~1,~i::::: :::: :. `'`' Ei;: ~]i~:: ;~' :::: ?:: •: ! iieiiiiii i' ' 'iiii~ ~ 3iiii i ~' 'ei 'i 'Fii .:: :: ~'r'~ `~~.:.:.~:.:.3:t. :, a:~~.....~....~~~~~~iFiF' ~~' .'Fil. .... ~,.. .... il':':il' A. ^ The above inforeation and tax due is correct. 1. You eay choose to restit pay~ent to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you nay check box ^A^ and return this notice to the Register of Wills and an official assesseent will be issued by the PA Departaent of Revenue. C ONE BLOCK B. J~ The w paid wit`~h e; en sg ylvania Inh_ eritance Tax return above Asset has been or will be reported and tax ' ONLY - ^ - s representative. ~~ yip ~ ~~ to be filed by the decedent C. ^ The above inforeation is incorrect and/or debts and deductions were paid by you. You lust coXiplete PART 2^ and/or PART 3^ below. PART - - x rate ease st to our If you sndscate a dsfferent to , p y ~ ~ €s_€~€~~€€=€_€i€i~ :~~:::-..:.:-: ~:-:-~..:.,::.::~:::~ :~ ::::::..::::.:~::~:::::::-::::::::::.......:::::::::::::::::::: :::.:.::::.:.:::::.:::...:.:.:::.:.::: ~f~f€~€ € ~ relatsonshsP to decedent. a ~ ... .. ::::::::.::::::::~:::~~:::~:::::~:::::::::::::..,.:.:::_:......,.....,...,,..,.,.......:.....:.,.....,.,...,.,...,......... TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS r~'` ~°`^'' isiFS:Sic•.a'sii2iiiic2:~i~'. t`tive:i'':ii ;iii ~:c:e~ :e:~~ ~' <: ~~:iS:i.Te~:e:i~:e:i:i:i:i ~:i:iS~:e:e~:i:i:e i#!!#Y~~~~?<:;::::~ ::::::::::.::::::::::::...........:..::..........:.:.........:...:......:............:...........:...:.:.....................: LINE 1. Date E stabl a shed 1 .............:.................................... ::,w,.: s ~;,: - °~°~ } ~ ~'• ' ~~ <°~°~° °~°~°~~ 2. Account Balance 2 3. Percent Taxable 3 X :tee €f~ €€~ €€~ €~ € ~€~ €€€€€~€iiiii<< ~ii~'€~ E€~ €€~ €€€€ii~ ii€ i i~ €E~ E€€~ €€€~ jiiii~s€ € 4. ~ Amount Subject to Tax 4 ~"s~ ~i~ €i€~ ss€~ s"s€~~s~€€€~€€€~€~€ iii €€~ €€~€€i~€€€€€~s~€~~€~~~ €~~ €€"s 5. Debts and Deductions 5 - iii 6. Amount Taxable 6 _ ii5 €l~'s; 7. Tax Rate X 7 ~' 8. Tax Due 8 ~~ ~' ii PART DEBTS AND DEDUCTIONS CLAIMED 8^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID WORK C ) TAXPAYER SIGNATURE ELEPHONE NUMBER DATE Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of ny kno9Yledge and belief. HOME C ) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INBIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 ;`E; '~~, REY-15f3 ER AFP (C9-PP> J L BRIERY 4212 ISBELL ST WHEATON MD 20906 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21 02-0572 ACN 02134954 DATE 08-08-2002 TYPE OF ACCOUNT EST. OF ELSIE K BRIERY ^ savINGs S . S . N0. 173-O1-5825 ^ CHECKING DATE OF DEATH 04-10-2002 ^ TRUST COUNTY CUMBERLAND XQ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 WAYPOINT BANK has provided the Departrent with the inforration listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this inforration is incorrect, please obtain written correction from the financial institution, attach a copy to this fort and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Corronwealth of Pennsylvania. questions ray be answered by calling 0717) 787-d327. COMPLETE PART 1 BELOW * ~ ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1000012656 Data 03-08-1999 To insure proper credit to your account, two Established (2) copies of this notice rust accorpany your Account Balance 95, 699.73 Payrent to the Register of Wills. Make check payable to: ^Register of Wills, Agent^. Percent Taxable X 5 0. 0 0 0 NOTE: If tax payrents are tads within three Amount Sub3ect to Tax 47,849.87 (3) months of the decedent's date of death, Tax Rate X ~ b T S ~;}rj- You ray deduct a 5% discount of the tax due. Any inheritance tax due will becore delinquent Potential Tax Due 7, 177.48 nine C9) tenths after the date of death. PART TAXPAYER RESPONSE ^ ~:~:Ri~~!Ei€;#~~k€€~€4~€~:~~~:€€lid.!~~€s#:€i€€#Yg€~€€?ik:€€ti!~€€€t€~bt€€t:*!t~hh°Ai:~:::!b~~€:::~'~"f~iiBWi~;~~~'ei'i 3Ea~ ~:!M~_~~t~r;° A. ~ The above inforration and tax due is correct. 1. You say choose to rerit payrent to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you ray check box ••A^ and return this notice to the Register of Wills and an official assessment will be issued by the PA Dapartsent of Revenue. C ONE ~ BLOCK ONLY B. {~ The f;'' above asset has been or will be reported and tax paid with the P nsylva is Inheritance Tax return ' ~ ~ to be filed by the decedent s representative. ~y~ y.. ~..~. r ~~ C. ~ The above inforration is incorrect and/or debts and deductions were paid by you. You must complete PART 2^ and/or PART 3~ below. PART If ou indicate a dif er nt tax r to f e a lease tote our Y ~ , P Y ` ~ ii~~ii~iii'iis . . . . . . . . . . . . . iiiii~i~~ii~~° .:.:.:.:.:..:.::-:.:...::::~:::;:;:~y:;::::~:~:t~;:~::-~::::i€_'•.'€;~€;€~~:::::~;:::::::::::iii # ,~ y~ ~y . . iii€i€iiiiii~`k`~ =€+ii~A'~fC~ii~l~ii~s~ ~s~;P °='°' ' ' Soya S.~r 't'Rt~.cr ~G relationshi to decedent: P ~ ~ .. . . . . . . . . . ......................... iii'sii~s~'~ii iit~ i~it . . . . ...............................:::::::.::::::::::.:.:~::::::;:,::::::::;::;~:;s::;;:;~::~:::;: ,........... ~::::::::: i~'~~°i=''s€is~'_=:~:~:~::~:;::-:~:~:::.:~:#~:~~:-,+•~:::::::,-~s..:..::::~ ..::i~;~..:::t.k.~.,,.+:~:~::::<~::;~: i~~t~i~~ ~l?F.:3:~s1rlFi~d[Dl~it~i€=€i€~ `'s;~ ~ ii€€ T X A R - 1 ETURN COMPUTAT ON OF A 0 O T I T X N J IN TRUST ACCOUNTS ~~~' LINE 1. Date Established 1 "°""~"~""`• ra:,.~K:_.:,.:.:.:~::~:.:..:._:.,.:.:~:~ 2. A o t a n cc un B la ce 2 3. X PrcntTaabe e e x 1 3 ...,... ~;;;;~~~€€''=_'i€s€€i;i€~ ~~:a;iii<~ €€~ "s€~ €€;;€~ €€ €§€€€F;i€~ iiiisi ~€i€~ € si€=€i€€~~~ ~iiii 4. Amount Sub ect to Tax ......................:::: :::::::::::::..................:::::~:~::::::::::,::,::,;: _;::..... 5. Debts and eductio s 5 D n - ... . ..:. .... .........:................. ......... ~I:i:€ is i':ii~ iii 6. A u x mo nt Ta able 6 7. Tax at 7 X R a 8. T x Due 8 a ~ii~ ~~`:.~ €~ ~ ~ is €~ Vii= ~` ~s ~~€~i ~ '~ ~~€~ ~i~€€i~ ~ss~ss~~ €~s'ss ~' ~~€ PART DEBTS AND DEDUCTIONS CLAIMED a DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of ny knowledge and belief. HOME ( ) WORK ( ) TAXPAY R SIGNAT RE LE H N N MBER DAB -•; ,. COMMONWEALTH OF PENNSYLVANIA REV-1162 EX~11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 260601 HARRISBURG, PA 1 7 1 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 001632 BRIERY J LYNDALE 4212 ISBELL ST WHEATON, MD 20906 ACN ASSESSMENT AMOUNT CONTROL NUMBER fo10 ---°----' ESTATE INFORMATION: ssN: 173-oi-5325 FILE NUMBER: 2102-0572 DECEDENT NAME: BRIERY ELSIE K DATE OF PAYMENT: 09/ 18/2002 POSTMARK DATE: 09/15/2002 couNTY: CUMBERLAND DATE OF DEATH: 04/ 10/ 2002 101 ~ 531.08 TOTAL AMOUNT PAID: REMARKS: J LYNDALE BRIERY CHECK#1006 INITIALS: AC SEAL RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS 531.08 REGISTER OF WILLS ~~ a~ STATUS REPORT UNDER RULE 6.12 l , Name of Decedent : ~1 1 Q ~`' ~ ~c~ '« Date of Death: /tp~~ ~ ~6 2occ1-- Will No. 2(~dZ'~'~S'r7~ Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes 1/~J No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the fallowing: a. Did the personal representative file a final account with the Court? Yes No ~. b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did r.he personal representative stag an account informally to the parties in interest? Xes / No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. Date : ~ ~ r ~ ~L ~ ~~_ Signatu ~'_ .: Name ( lease type or prin Address ;-i~ r1O zeq c3ot ~ x'33 -~ 'tl 8s Tel. No. -- Capacity: Personal Representative Counsel for personal representative (MAH:rmf/AM3) ~' , ~ ~~ ~ ~ COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE: 7AX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE DR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX J LYNDALE SHIERY 4212 ISBELL ST WHEATON MD 20906 REY-1547 E% AFP (Y1-021 DATE 11-19-2002 ESTATE OF SHIERY ELSIE K DATE OF DEATH 04-10-2002 FILE NUMBER 21 02-0572 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO CDURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS -~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (01-02) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SHIERY ELSIE K FILE N0. 21 02-0572 ACN 101 DATE 11-19-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ( )CHANGED RESE;2VATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 92 , 000.00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) 39 , 362.20 credit to your account, 3. Closely Held Stock/Partnership Interest [Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule Dl (4) .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) i5) 3 ,131.06 tax payment. 6. Jointly Owned Property (Schedule F) (6)_ 302 ,988.47 7. Transfers (Schedule Gl (7)_ 1 ,129.77 8. Total Assets (g) 438, 611 .50 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 8,912.79 (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 769.88 11. Total Deductions (11) 9.682.67 12. Net Value of Tax Return (12) 428,928.83 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) [13) 5,000.00 14. Net Value of Estate Subject to Tax (14) 423,928.83 NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate [15) •00 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 413, 928.83 X 045 . 18, 626 .80 17. Amount of Line 14 at Sibling rate [17) 10,000.00 X 12 1,200.00 18. Amount of Line 14 taxable at CollaterallClass B rate (18) .00 X 15 - .00 19. Principal Tax Due (19)= 19,826.80 reY r~enrrc. DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 07-08-2002 CD001387 989.79 18,805.93 09-15-2002 CD001632 .00 31.08 TOTAL TAX CREDIT 19,826.80 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ^ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" [CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF TNIS FORM FOR INSTRUCTIONS.) REV-1500EX (B-OO) REV-1500 OFFICIAL USE ONLY COMMONWEALTH OF , PENNSYLVANIA . DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER . DEPT. 280601 ~L-.<:2.~ _ _lS"'Z.;2/ RESIDENT DECEDENT HARRISBURG, PA 17128-0601 COLMY COOE v,," ,....... DECEDENT'S NAME (LAST, FIRST, AND MIODUE INITIAL) SOCIAl SECURfIY NUt.lBER I- Z Shierv. Elsie K. 173-01-5325 w DATE OF OEATH (MM-DO- YEAR) DATE OF BIRTH (MM-DO-YEAR) THIS RETURN MUST BE FILED IN DUPUCATE WITH THE a w 04-10-2002 08-31-1910 REGISTER OF WILLS 0 w (IF APPLlCABUE) SLIRVMNG SPOUSE'S NAIiE (LAST. FIRST, AND MIOOUE INITIAL) SOCIAl SECURfIY NUt./BER a n/a w IXJ 1 Original RetLrn D 2. Supp_ Retun D 3. RemainderReI1Jn(dat8afdesthprb"\I,l12-13-82) "' "";,,, D 4. Um,ed Estate D 4a.FuturelnterestC<:m?<<:rnise{Cateofdta\tlaftef12-12..a2) D 5. FedeI1lIEstateTaxRel1:I11Required 0"''' wo.o IX] 6. Decedent Died Testate (Alia"""", of IM~ D 7. ,,00 Decedent Maintaned a living Trust (m<h"", ofTMlI _ 8. Total Number of Safe Deposit 80Jces o"'~ 0.'" 0. D 9. L,~_ Proceeds Received o 10. Spousal Poverty Credit (dat8 of d9dI betweell 12-31-91 n1-1-95) D 11. Election to tax L.r<Ier Sec. 9113(A) (""",,,"01 '" .... THIS SeCTION MUST Be COMPLETeD. ALL CORRESPONDeNCE AND CONFIDeNTIAL TAX INFORMATION SHOULD BE DIRECTED TO: z NAME COI.f'LETE MAIlJNG ADDRESS w 0 J. Lvndale Shierv 4212 Isbell z Street 0 0. FIRM NAME (If _I Wheaton, MD 20906 '" w '" '" TELEFHONE NUMBER 0 0 301-933-4185 1. Real E~ate (Schedule A) (1) 92,000.00 OFFICIAL USE ONLY 2. Stacks <lid Bonds (Schedule B) (2) 39,362.20 3. Closely Held Corponllion, Parlroef1lhip ex SoIe-Propr\elaShjp (3) 4. M<>19ages & Nores Receivable (Schedule D) (4) I .. 5. Cash, Bank Deposits & Miscell........ Personal Property (5) 3,131.06 Z (Schedule E) 0 6. Jointly 0M1ed Property (Schedule F) (6) 302,988.47 !;( D Sepa-ale BHIing Requesled ...J 7. b1ler-Vr/OS Tra.1Sfers & Miscella1eous Non-Probate Property (7) 1,129.77 ::J I- (Schedule G ex L) ii: 8. Total Gross _ (t"'" LInes 1 - 7) (8) 438,611. 50 <( 0 9. Fl.01erllJ Expenses & Admi_ Costs (Schedule H) (9) 8,912.79 W 0::: 10. Qebts ci Decedent, Mcrtgage liabilities, & Liens (Schedule Q (10) 769.88 11. Total Deductions (10181 Unes 9 & 10) (11) 9,682.67 12. NolValue 01 Estata (Ure8 mills Line 11) (12) 428,928.83 13. ChailabIe<lld Govenmental BequeslSlSec9113TrusIs ftrwhichlll_totaxhas no! been (13) 5,000.00 made (Schedule J) 14. Nol Value Subject to Tax (Une 12....... Une 13) (14) 423,928.83 SEE INSTRUCTIONS FOR APPUCABLE RATES Z 15. Amount of Une 14 _ at \toe spoosaIlaIl 0 !( rate, ex_ L.r<Ier See. 9116 (aX1.2) X .0_ (15) I-' 16. Amount of Une 14 taxable at lineal !lie 413,928.83 X.O 45 (16) 18,626.80 ::J D.. 17. AmountofUne14taxab1eatsiblingra 10,000.00 X .12 (17) 1,200.00 ::E 0 18. Amount of Ure 14 taxable at collateral !lie X .15 (16) 0 . ~ 19. Tax Due (19) 19,826.80 20.00 I CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT I STFPA42021F.1 > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: STREEf ADDRESS 10th Street . 44 N. CITY I STATE I ZIP Lemovne PA 17043 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credtts/Payments A. Spousal Poverty Credtt 8. Prior Payments C. Discount (1) 19,826.80 18.805.93 989.79 Total Credits (A + B + C) (2) 19,795.72 3. Interest/Penal1y if applicable D. Interest E. Penalty TotallnterestlPenai1y (0 + E) (3) 4. II Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a relund (4) 5. II Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 31. 08 A. Enter the interest on the tax due. (SA) B. Enter the total 01 Line 5 + SA. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 31.08 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 01 the property transferred; ........................................0 IX! b. retain the right to designate who shall use the property transferred or tts income; . . . . . . . . . . . . . . . . . .. 0 [ZJ c. relain a reversionary interest; or .......................................................0 IX! d. receive the promise for life 01 either payments, benefits or care? ............................... 0 [ZJ 2. II death occurred after December 12, 1982, did decedent transfer property within one year 01 death without receiving adequate consideration? .................................................. 0 IX! 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . . .. 0 IX! 4. Did decedent own an Individual Retirement Account, annui1y, or other non-probate property which contains a beneficiary designation? . . .... ... . . . . . . .. . . . ... . .. .. . . . . . .. . . . . . . . . ..... .. . . . .. IX] 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties rt peljtJy, I decla-e that I have OlI311ined this rellrn, incllXling accompanying schedules lI1d staten'onts, lI1d to the best rt my kn<>vIedge lI1d belief, ,~true, oonect lI1d oonplete. DecIa1iioo rt prepa-er atler II1lI1 the personal representalive is based 00 all i_oo rt which prepa'or has "'I knowledge. SIGNATU OF P SON RE PO SIBLE FOR FILING RETURN DATE . ADDRESS 4212 Isbell Street, Wheaton, MD 20906 SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE DATE ADDRESS For dates 01 death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value 01 transfers to or for the use 01 the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)]. For dates 01 death on or after Janual)' 1, 1995, the tax rate imposed on the net value 01 transfers to or for the use olthe surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exernot a transfer to a surviving spouse ITom tax, and the statutory requirements for disclosure 01 assets and filing a tax retum are still applicable even il 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 01 transfers from a deceased child twenty.one yeatS 01 age or younger at death to or for the use 01 a naturnl parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value 01 transfers to or for the use 01 the decedenrs lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value 01 transfers to or for the use 01 the decedent's siblings is 12% [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 wtth the decedent, whether by blood or adoption. STFPA42021F.2 REV-1502 EX + (1-97) (I> COMMONY.'EALTH Of PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Elsie K. Shiery 21-02-0572 All 11111 property owned solely or as.tenant In common must be reported at 101, mol1<et value. Fair n1lI1<et value is defined asltle price a1wrncl1 propertywould be exchanged between a willing buyer and a willing seller, neiItler being compelled to buy r:r sell, boIh having reasonable knowledge ci Itle releva1l facls. Reol property which II jolntly-owned with right oIlurvl_lp must be dIsclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Personal Residence-44 N. 10th St, Lemoyne, PA VALUE AT DATE OF DEATH 92,000.00 STF PA42021F.3 TOTAl. (Also enteron line 1, Recapitulation) $ (If more space is needed, Insert add~ional sheets of the same size) 92,000.00 REV-1503 EX" (1-97) (I) CQMMQNY.oEAlTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Elsie K. Shiery All property Jolntly-owned with tile right of survlvOI\Ihlp must be disclosed on Schtdule F. ITEM NUMBER DESCRIPTION FILE NUMBER 21-02-0572 1. 2. 3. 96 shares Robotic Vision Systems, Inc. (common) 1087.281 shares First Energy Corporation (common) 68 shares Metlife Inc. (common) VALUE AT DATE OF DEATH 141.12 36,956.68 2,264.40 STFPA42021F.4 TOTAL (Also enteron 6ne2. Recapttulation) $ (If more space is needed, insert additional sheets of the same size) 39,362.20 REV.15D4 EX. (1-97) (I) COM~LTH Of PENHS'YlVANIA IM-iERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE.PROPRIETORSHIP ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 Schedule c.l or c.2 (nc:tuding all supporting i_I must be _ for each cIoseI\'"hekI caporliim'pa1nep Interest oftl>! decedent, olhertha1 a soIe-proprielcrship. See instructions forti>! suppcrti1g i_ to be submitted for soIe-proprielcrshps. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. t-' I t.>r STFPA42021F.5 TOTAL (Also enter on line 3, Recapitulation) $ (~more space is needed, Insert additional sheets of the same size) REV.1505 EX + (1-97) (I) COMMONY.9.lTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDEtfl SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 1. Name of Corporation Address City 2. Federal Employer I.D. Number 3. Type of Business .JlA Slate Zip Code State of InCOf]lOration Date of Incorporation Total Number of Shareholders Business Reporting Yea, ProducUService 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Yoong I Non-YOOng SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENTS STOCK Common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? If yes, Position 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? DYes DNa If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy DYes DNa Annual SaIaIy $ DYes DNo Time Devoted to Business 8. Did the decedent sell or transfer stock of this company within one year prior to death orwnhin two years If the date of death was priorto 12-31-82? DYes DNo If yes, DTransfer DSaIe Number of Shares Transferee or Punchaser Consideration $ Date AIIach a sepaaIe sheet for additianaltransfers mar sales. 9. Was there a written sharehoider's agreement in effect at the time of the decedenfs death? If yes, provide a copy of the agreement 10. Was the decedenfs stock sold? DYes DNo If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissoived or liquidated after the decedenfs death? 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. DYes DNo 12. Did the corporation have an interest in other corporations or partnerships? DYes DNo If yes, report the necessary information on a separate sheet, including a Scheduie C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST .BE SUBMITTED WITH THIS SCHEDULE A. Detailed caiculations used In the valuation of the decedenfs stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding yeaIS. C. If the corporation owned real estate, submn a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shanes held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other infonnation relating to the valuation of the decedenfs stock. STFPA42021F.6 REV-1506 EX + (1-97) (J) COMM~LTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 1. Name of Partnership Address City 2. Federal Employer I.D. Number 3. Type of Business ~(Cl, Date Business Commenced Business Reporting Year Stale Zip Code Product/Service DLimned partner. If decedent was a limited partner, pf"Qvide initial investment $ 4. Decedent was a D General 5. PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedenfs interest $ 7. Was the Partnership Indebted to the decedent? DYes DNo If yes, provide amount of indebtedness $ 8. Was there iife insurance payable to the partnership upon the death of the decedent? DYes D No if yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years it the dale of death was ptiorto 12-31-ll2? DYes DNo If yes, DTlllIlsfer DSale Percentagetransferredlsold Transferee or Purchaser Consideration $ Date Altach a sepa-ale sheet for additional_ a'ldIa sales. 10. Was there a written partnership agreement in elfect at the time of the decedent's death? If yes, pf"Qvide a copy of the agreement 11. Was the decedent's partnership interest sold? DYes D No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidaled after the decedenfs death? DYes D No If yes, prQvide a breakdown of distributions received by the estate, including dates and lII10unls received. 13. Was the decedent related to any olthe partners? DYes D No If yes, explain DYes DNo 14. Did the partnership have an interest in other corporations or partnerships? DYes D No If yes, report the necessaJy information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE .. '} . .'. " ..........,'" A. Detailed calculations used in the valuation of the decedenrs partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair m8/1(et value/s. it real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedenfs partnership interest. STFPA42021F.7 REV-1S07 EX + (1-97) (I) CCNMC>NYw&\LTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIOENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Elsie K. Shiery All property JoI~ witII the right of survivorship must be disclosed on Scl1ec1ule F. ITEM . NUMBER DESCRIPTION 1. FILE NUMBER 21-02-0572 VALUE AT DATE OF DEATH tJ\f' TOTAL (Also enter on line 4, Recapitulation) $ (If more S\l3Cll is needed, insert additional sheets of the same size) S1FPA42021F.8 REV-1508 EX + {1-97} (I) COM~TH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 h:Itxlethe proceeds <i litigalia1lrod the dale the proceeds were received by the estate. All property JoIntIy-<rwned with the right of BUlVlvonhlp must be dlscloood on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Jewelry, Apparel, Furniture, Misc. household goods 1,500.00 2. Central PA Conference Tax ID 24-0826169 100.00 3. Cash/Bank Deposits 1,531.06 STFPA42021F.9 TOTAL (Also enter on fine 5, Recap~ulation) $ (If more space is needed, insert additional sheets of the same size) 3.131.06 REV.15OQ EX + (1-97) (I) COMMON'/1iEAlTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY.QWNED PROPERTY ESTATE OF Elsie K. Shiery If an asset was made joint within one year of the decedents date of death, it must be reported on Schedule G. FILE NUMBER 21-02-0572 SURVMNG JOINT TENANT(S) NAME AOORESS RELATIONSHIP TO DECEDENT A. J.Lyndale Shiery 8. c. 4212 Isbell Street Wheaton, MD 20906 Son JOINTLY -OWNED PROPERTY: 7 . 8. 9. STFPA42021F.10 lETTER ITEM FOR JOINT NUMBER TENANT 1. 2. 3. 4 . 5. 6. A A A A DATE MADE JOINT DESCRlPTlON OF PROPERTY 1nc:Uje name of firBlCial insbt1Jion ard bar<< ac::olJ"t runberorsirrillr" ~ 1'IITiler. AttachdeedforPi~realestate. A. 9/86 Chevy Chase Bank Super Money Mkt Acct no. 080-452213-8 4/83 Chevy Chase Bank 9 month CD Acct no. 080-500024-1 5/83 Chevy Chase Bank 9 month CD Acct no. 080-500069-1 1/71 Waypoint Bank Saver's Advantage Acct no. 100011544 3/99 Waypoint Bank Cert. of Deposit Acct no. 1000012656 10/8( Waypoint Bank Cert. of Deposit Acct no. 416011453 4/72 Allfirst checking account w/int. Acct no. 00778-8682-8 1/83 A11first Fixed Rate CD Acct no. 8-700-800-0144093 6/00 Allfirst Retail Money Market Acct no. 950205763 A A A A See attached-Schedule F cont'd See attached-Schedule F cont'd See attached-Schedule F cont'd DATE OF DEATH VALUE OF ASSET 53,714.79 20,749.91 47,278.68 1,160.30 95,699.73 27,095.21 9,748.75 3,491. 79 126,117.25 33,527.20 171,893.30 15,500 %DF DECO'S INTEREST TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) DATE OF DEATH VALUE OF DECEDENTS INTEREST 50 26,857.40 50 10,374.95 50 23,639.34 50 580.15 50 47,849.87 50 13,547.60 50 4,874.38 50 1,745.90 50 63,058.63 50 16,763.60 50 85,946.65 50 7,750.00 302,988.47 REt'-1509 EX+ (6-98) . '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Elsie K. Shiery FilE NUMBER 21-02-0572 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A J. Lyndale Shiery 4212150011 Street, Wheaton, MD 20906 Son B. C. JOINTLY.OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY 'OF DATE OF DEATH ITE" FOR JOlNT MADE INCLUDE NAME OF ~INANCIAL NSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR :JATEOFDEATH DeCO'S VALUE OF NUMBER TENANT JOINT 100NTIFYING NUMBER. ATTACH OEEO FOR JOINTLY-HelD REAL ESTATE. VALue OF ASSET INTEREST DECEDENT'S INTEREST 1. A 8/1978 Series E Bond-Serial no. D202058281E 1653.60 50 826.80 2. A 9/1977 Series E Bond-Serial no. D202058166E 2224.80 50 1112.40 3. A 4/1977 Series E Bond-Serial no. D202058101E 2264.80 50 1132.40 4. A 3/1976 Series E Bond-Serial no. D2OO664Il94E 2300.40 50 1150.20 5. A 6/1975 Series E Bond-Serial no. D104782938E 2318.40 50 1159.20 6. A 2/1974 Series E Bond-Serial no. D102423709E 2374.00 50 1187.00 7. A 3/1965 Series E Bond-Serial no. D86901036E 3721.20 50 1860.60 8. A 3/1964 Series E Bond-Serial no. D85996045E 4167.40 50 2083.70 9. A 2/1963 Series E Bond-Serial no. D85083903E 4136.20 50 2068.10 10. A 9/1962 Series E Bond-Serial no. D83571957E 4161.00 50 2080.50 11. A 3/1962 Series E Bond-Serial no. D83571899E 4205.40 50 2102.70 TOTAL (Also enter on line 6. Recap.utalion) S 16,763.60 (If more space is needed. insert additional sheets of the same size) REv.. iS09 EX+ (6-98) . '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY.OWNED PROPERTY ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 If an asset was made joint within one year of the decedenfs date of death, it must be reported on Sehedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. J. LyndaJe Shiery 4212 Isbell Street Wheaton, MD 20906 Son B. C. JOINTLY-OWNED PROPERTY, LETTER DATE DESCRIPTION OF PROPERTY .OF OATEOFOEATH ITEM FOR JOlNT MADE INCLUDE NAME OF FINANCIAL flSTITUTION AND BANK ACCOUNT NUMBER OR SIMIlAR DATE OF OE,A,TH OECD.S VALUE OF NUMBER TENANT JOINT 100NTIFYNG NUMBER. ATTACH DEED FOR JOINTlY.HElD REAL ESTAtE. VALUE OF ASSET INTEREST DECEDENTSfNTEREST 1. A. 9/1972 1721.902 shares Public Service Enterprise Group (common) 78174.34 50 39087.17 2. A 6/1988 210 shares Robotic Vision Systems fnc (common) 308.70 50 154.35 3. A 5/1972 2081.476 shares Pioneer Fund A ";>..155 .~(" 50 '-II o,.,.~ 4. A 4/1973 40 shares US I><rways Group (common) 254.40 50 127.20 5. A 10/1996 Series HH Bond-Serial no. 004262559HH 500.00 50 250.00 6. A 4/1999 Series HH Bond-Serial no. 004940721 HH 500.00 50 250.00 7. A 10/1996 Series HH Bond-Serial no. MOO039936HH 1000.00 50 500.00 8. A 10/1996 Series HH Bond-Serial no. MOO039937HH 1000.00 50 500.00 9. A 6/1998 Series HH Bond-Serial no. MOO746832HH 1000.00 50 500.00 10 A 6/1998 Series HH Bond-Serial no. M00748833HH 1000.00 50 500.00 11 A 6/1998 Series HH Bond-Serial no. M00746834HH 1000.00 50 500.00 12 A 6/1998 Series HH Bond-Serial no. M06748835HH 1000.00 50 500.00 13 A 6/1998 Series HH Bond-Serial no. MOO746836HH 1000.00 50 500.00 14 A 4/1999 Series HH Bond-Serial no. M07044335HH 1000.00 50 500.00 15 A 4/1999 Series HH Bond-Serial no. M07044336HH 1000.00 50 500.00 16 A 4/1999 Series HH Bond-Serial no. M07044337HH 1000.00 50 500.00 TOTAl (Also enter on line 6. Recapitulation) $ 'l:S, 't'-l (.,. "'5 3> (If more space is needed, insert additional sheets of the same size) REV~1509 EX+ (6-98) f; '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 If an asset was made joint within one year of the decedent's date of death. it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. J. Lyndale Shlery 4212 Isbell Street Wheaton, MD 20906 Son B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH "EM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VA!.UEOF NUMBER TENANT JOINT IDENTIFYING NUMBER, ATTACH DEED FOR JOINTLY-HELO REAL ESTATE. VALUEOF,I,SSET INTEREST OECEOENTSINTEREST 1. A. 2/1971 Selies HH Bond-SeJial no. D05765527HH 500.00 50 250.00 2 A 2/1971 Selies HH Bond-Selial no. M08223222HH 1000.00 50 500.00 3 A 2/1971 Selies HH Bond-SeJiaI no. M08223223HH 1000.00 50 500.00 4 A 2/1971 Series HH Bond-SeJiaI no. M08223224HH 1000.00 50 500.00 5 A 2/1971 Selies HH Bond-Selial no. M08223225HH 1000.00 50 500.00 6 A 2/1971 Selies HH Bond-SeJiaI no. M08223226HH 1000.00 50 500.00 7 A 7/1973 Series HH Bond-SeJial no. M08342348HH 1000.00 50 500.00 8 A 7/1973 Selies HH Bond-SeJiaI no. M08342349HH 1000.00 50 500.00 9 A 7/1973 Selies HH Bond-SeJial no. M08342350HH 1000.00 50 500.00 10 A 7/1973 Selies HH Bond-SeJial no. M08342351HH 1000.00 50 500.00 11 A 7/1973 Selies HH Bond-Selial no. M08342352HH 1000.00 50 500.00 12 A 7/1973 Selies HH Bond-SeJia1 no. V01634332HH 5000.00 50 2500.00 Note: Oliginally Selies E Bonds which were rolled CHar into HH Bonds within the one year preceding the date of death. Dates shown in the date made joint column are the original purchase dates of the Selies E Bonds. TOTAL (Also enter on line 6, Recapitulalion) $ 7,750.00 (If more space is needed. insert additional sheets of ttle same size) REV.1510 EX + (1-97) (I) ,. SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMC::/f<ME6.L.TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 Th~ schedule must be canpleled and flied 'the........1o any ci q_ 111Yough 4 00 the """"'" side cithe REV-1500 COVER SHEET is l"'. DESCRIPTION OF PROFERTY %OF rTEM IN:llOE TH: WINE OF TtE TRANSFEREE. nElR R8.AnoretP TO CIEC8:I:HT Nfl TJ-E MTE DATE OF DEATli DECO'S EXCWSION TAXABlE VALUE NUMBER OF TIWS'ER. AlTH:.HAcoPY OF ThE tHO FOR REAL ESTA.1E. VALUE OF ASSET 1N'IEREST (JFAPPUCABlE) 1. Metropolitan Life Insurance Co 1,129.77 100 nla 1,129.77 Annuity TOTAL (Also enter on nne 7, Recapitulation) $ 1 129.77 (If more space is needed, insert addnional sheets of tlte same size) STFPA42021F_11 REV-1511 EX'" (1-97) (I) ca.tMOlWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS -' ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 Debts of dec8dtnt must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Parthemore Funeral Directors-facilities, staff, equipment, casket 7,891.50 2. The Iron Kettle-reception after funeral 157.18 3. Homewood Suites 241.92 B. ADMINISTRATIVE COSTS: 1. PersooaI RepresenlaIive's Corrrnissioos Naneri_Representaive(s) Social Security NLmber(s) I EIN NlI1lber ri PersooaI Represenlalivo(s) Street Address City Sllie Zip Yeajs) Canmission Pajd: 2. Altaney Fees 3. FlITlily E>iemption: (W decedenfs address is nolll1e sane as claimafs, attach expia1alion) CIaina1t Street Address Cily Sllie Zip R~ationship ri Clainml to Cecedent 4. Probate Fees 370.00 5. _sFees 6. Tax ReIIIn Prepaoer's Fees 7. Cumberland Law Journal-public notice 75.00 8 . Harrisburg Patriot News-public notice 177.19 TOTAL (Also enter on une 9, Recapitulation) $ 8 912.79 .. (If more space IS needed, Insert additional sheets of the same sIZe) STFPA42021F.12 REV~1512 EX + (1-97) (I) COMM<JNI'oE'lTH Of PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Elsie K. Shiery ALE NUMBER 21-02-0572 Indude t1nretmbursed medical experlI8L ITEM NUMBER DESCRIPTION AMOUNT 631.00 61. 03 23.85 54.00 1. 2. 3. 4. Internal Revenue Service - Tax due with Form 1040 Dr. Blacksmith medical expense Lawn Care Sewer and Trash collection Lemoyne Borough TOTAL (Also enter on line 10, Recapitulation) $ (if more space is needed, insert additional sheets of the same size) 769.88 STFPA42021F.13 REV~1513 EX + (9-00) COM~TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Elsie K. Shiery FILE NUMBER 21-02-0572 RELATIONSHIP TO DECEDENT NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Us! Tnlstee(s) I. TAXABLE DISTRIBUTIONS [include outright spousal distJibutions, and IraI1sfers under Sec. 9116 (a) (1.2)] J. Lyndale Shiery 1. 4212 Isbell St, Wheaton MD 20906 AMOUNT OR SHARE OF ESTATE Son 2. Joanne H. Shiery 12406 Atherton Dr, Wheaton MD 20906 3. Jon L. Shiery 220 Herman Ave, Lemoyne PA 17043 Granddaughter 10,000.00 Grandson 10,000.00 4. Marie Strauss 1992 Virginia Ln Norristown PA 19403 Sister 10,000.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. 8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Calvary United Methodist Church 700 Market Street, Lemoyne PA 17043 5,000.00 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert add~ional sheels of the same size) 5 000.00 SlFPA42021F.14 REV-1514 EX + (1-97) (Il COMMON\'\'EAlTH OF PENNSnVANIA INHERITANCE TAX RETURN RESIDErIT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER Elsie K. Shiery ~ \ ~ 21-02-0572 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. DWiII Dlntervivos Deed ofTrust o Other LIFE ESTATE INTEREST CALCULATION NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE OUIeDr OTerm D/Years OUIeDr OTerm a/Years OUlear OTerm a/Years OUlear OTerm a/Years 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table Interest table rate - 03 1/2% 06% 010% 3. Value of life estate (Line 1 multiplied by Line 2) ANNUITY INTEREST CALCULATION $ OVariable Rate % $ NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE OUIe or OTerm a/Years OUleor OTerm a/Years OUleor OTerm a/Years OLffear OTerm a/Years 1. Value of fund from which annuity is payable $ 2. Check appropriate block below and enter corresponding (number) Frequency of payout- OWeekly(52) OB~weekly(26) o Monthly (12) o Quarterly (4) 0 Sem~annually(2) o Annually (1) o Other ( ) 3. Amount of payout per period $ 4. Aggregate annual payment, Line 2 mu~iplied by Line 3 5. Annuity Factor (see instructions) Interest table rate 03 1/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) 7. Value of annuity -If using 31/2%, 6%,10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 $ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15, 16 and 17. (1/ more space is needed, insert additional sheets a/ the same size) STFPA42021F.15 REV-1647 EX + (9-00) .' SCHEDULE M FUTURE INTEREST COMPROMISE COMMONlN2ALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on Rev-1500 Cover Sheet) ESTATE OF Elsie K. Shiery This schedule is appropriate only for estates of decedents dying after December 12.1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest ~ts in possession and enjoyment cannot be established with certainty, Indicate below the type of instrument which created the future interest and attach a copy to the tax return, o Will 0 Trust 0 Other ~\f\ FILE NUMBER 21-02-0572 I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1- 2. 3. 4, 5. 0. For decedents dying on or after July 1, 1994, ~ a surm;ng spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedlenfs death, check the appropriate block and attach a copy of the document in which the surm;ng spouse exercises such withdrawal right, 0 Unlimited right of withdrawal 0 Limited right of withdrawal ID. Explanation of Compromise Offer: Iv. Summary of Compromise Offer: 1. Amount of Future Interest, , , ,...... , , .. , , .. , , , , ,..,., ,.." , , ., , , , , , , , , , , , ,.., , ., , , . ,. , ..,., , . $ 2, Value of Une 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Une 13 of Cover Sheet) ..""..... $ 3, Value of Une 1 passing to spouse at appropriate tax rate Check One 06%. 03%. 00% .......................... $ (also include as part of total shown on Une 15 of Cover Sheet) 4, Value of Une 1 taxable at lineal rate Check One 06%, 04.5%",...".",.....,.., .....",.... $ (also include as part of total shown on Une 16 of Cover Sheet) 5, Value of Une 1 Taxable at sibling rate (12%) (also include as part of total shown on Une 17 of Cover Sheet) .",.""" $ 6, Value of Une 1Taxable at collateral rate (15%) (also include as part of total shown on Une 18 of Cover Sheet) .."""", $ 7, Total value of Future Interest(sum of Unes 2 thru 6 must equal Une 1) . , , .. .. .. , , , , , .. .. , , , .. , , , , , , , , , $ (If more space is needed, insert addnlonal sheets of the same size) STFPA42021F.16 REV-1649 EX + (1-97) (I) SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF k FILE NUMBER Elsie K. Shiery ~\ 21-02-0572 Do not complete this schedule unless the estate is maldng the election to tax assets under SectIon 9113 (A) of thelnherilance & Estate Tax Act. If the election applies to more than one trust or similar ammgement, a separate fonn must be filed for each trust. This eIeclion applies 10 the Trust (maital, residual A, B, By-pass, Unified Credn, etc.). If a trust or similar ammgemenl meets the requirements of Section 9113 (A), and: a The trust or similar ammgement is listed on Schedule 0, lI1d b. The value of the trust or similar alllll1gemenl is entered in whole or in part as an asset on Schedule 0, then the transferors pernonal fO?lOSO"tati'Ie may specilically identift the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. if less than the entire value of the trust or similar property is included as a taxable transfer on Scheduie 0, the personal fO?lOSO"tati'Ie shall be considered to have made the eIeclion only as 10 a b:tion of the trust or simil..- arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denorninalor is equal to the totaJ value of \he trust or similar ammgement. .' COM~TH Of PENNSYlIIANA INHERITANCE TAX RET1.IRN RESIOEIIT OECEOEIIT PART A:. Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (Al trust or similar arrangement. CESCRIPTlON VHJ.E Part A Total $ PART B: Enter the description and value 01 all interests included in Part A for which the Section 9113 (Al election to tax is being made. DESCRIPTION VA/..LE Part B Total $ (If more space is needed, insert addnional sheets of \he same size) STFPA42021F.17 , t= "' t ~ i'~lk .'~ " ~ \ ,~. . .' ~ t ;~.~, .~. ~ 1 , ~' ' i \ ~"olF,~" '. ~ ~ , 1 ~" ~ .\1 ~ ..~ . 0 . i '*-~ . -~ ' "' ~ ~ . ""' ~~ ~ 1 ~ ~ r:: :' ~ ~r i .. . ~ _ ~ ~ ~ ~. ~-, Yt \ ~ ~ . 4 ~~. 4 . ' 1 ~, ~ s ,l{: '1.' . t " '>I -t' ~ ," 1 . --i~' " "c'), ,,~~ ~~ ~"f _ '-. ~'" ,,_ \ ~~. ~ ~ ~,J "'~ 'Ij; ,n) '-~ ,. La s+ hi, /I <1'-n.c J1'!'-6+a '" e-,,,--t- ~p E /:7" ~ k. ..5)/(' er'j 1-;-1( /VorTh )()"lTS+ree-T 1 'e ff1VY y,e- I ~ "It s7/v"'/1 Ill.. 170 LJ-:' D4e,t: JV)a-rc..A 11/9G'-I- - - - - -- ~--~~~. r '/YI / qCJs-. r. Z~~'u If.~ ~. ~4 ~ ~.{ ~ -1 ~ 1 ' rl'11 ~ ~ ~ t . . 1'jJ~ { c1' ~. .. .~ ~ ~ ' \ ~, ~{~ '~ ~ ~q1 ~'tjr ~~1~ , ~ ~~ ~ ~ ~ ~ -~ ~ '* y. , 1 ~ ~ ~ ~.,1 ~ r1 ~ '^'\ F -~ ?:">- d ",!.,.T," :; : r.....:o _ C' c ~ 'D ~~ -.! J. ::.il 0- I I 110 EST/MATEO s/rE VALUE ESTlMATfOREPROOUC1IONCOS1.NEW.OfIMPROVEMEN1S: Owelling 9.?ZSq.fl.@$ 85.00 '" $ 952Sq.fl.@S 12,00 GaragtlCarport ?64 Sq,R@S Total E$timaled Cosl New less Physical Depreciation 231471 OepfeciaJed Value ollmiYClvemems ''''.)s' YaJl.le 01 Sije Improvements INDICA'fEDYAlUEBYCOSTAPPROACH InM SUBJECT 4-4 N 10th 51 Address lema ne Pr(}Ximitvto Subiect Sale$Price P~sslMnaArea DataarrdJl)( Ye,m~alio.n_So.~Jce VAlUEA0JU5TMENlS Sales or Financin!l Cor.cesslons Date m SaJe/Tim! l ation LeasehoidIFeeSimole Site Vfl!W Av ~nandAQ~1Storv au olConslruclion ~ Aoe 50+f. CGndifion Av AbtmGTarle Total RQtlmCount 5 Gtoss Llvino Area Basement & finished - Rooms Btlow 111M! FtJnctlonalUtiUtv H tln lin EnerovElfIcientttems Gara~.1flli1d__., P(ll'cl1,Palio.Oeck, fire laces elc. fence Pool etc. 80920 15.00 3960 84,660 Summary Report FUtNll. 2-0701 R-4 Commen1s on Cost Approach (such as, somce 01 cost estimate, site value. square 1001 calculation and lor HUO,VAandFmHA.. lt1eestimiltdremainina tconomiclileof//lepropmty): Source of Costs: Marshall Valuation Service and Local Contractors. 25647 59233 5000 94,233 Eslimated remaini 40 ears. economic life of the dwellin is functional 25001 -$ External GOMPAAABLE NO.2 550 Walnut St. Lemo ne 0,41 miles CotolPAAABlE NO. 3 625 Pennsylvania Ave. Lemovne 0,14 miles J~:~~$f '''' -. -. . -. CGMI'ARABtENO.I 410 Maple Ava, LemoYne . ~.'" 0.85 miles NA I 94 SOO ,;-;:.:;, 93 000 95 000 103.85 ;1-; Courthouse, Realtor CPML. NA +l:~ 93.00 l{'. Courthousl!, Reallor CPML, _t-tA-..-__ DESCRIPTION Conventional Bdrms Balhs 2 , 952S.ft. Full Unfinished Stora e Kitchen Dated OHWlNo AC 5/22/01 DaM 121' Suburban FeeSim fe Acres E ual Ranch ~ 50+/- EQlJal Tolal'Bdnns: Baths 5 3 , 910SIJ.FI. Full Unfinished Stora e Private Sewer OHW/No AC Insulation NA PorchfDeck NA NA NA DESOlIPTIDN Conventional DES:CRJ!'T.1PN +H~ Insulation 1 Car DetacJ1ed Porch HP NA NA ;{.--": ~. ,~ ~L2_! Conventional +420 1/31/01 DDM 63 SuburOan Fee Sim Ie Acres E ual Ranch A, 51 E ual Total B s lhs , 2 , 1000 Sa.R. Full Unfinished ' Storae Su nor OHW/CA -2500 -2000 +2000 113101 DOM55 SubUfban FeeSim Ie .14 Acres EQual 1 Slo M so.,./- E ual TotalBdmTs Baths 6 2 , 1 OO~ SQ. Ft.' Full Part Finished FRf.5 Balh/Slor 5u nor OHW/No AC Insulation 1 C,a_rlntegral Parch HP NA NA -2000 -2500 -480 -500 +5500 '2500 +2500 N!I olal 10420 5000 Adjusted Sales Prtce of om rable 104 920 gO 000 CUmments on Sales Comparison ~1udInq UIe subjffi propMy'S compalibillly 10 lhe nelwoorhood, etc.): Sales used were all reasonabl similar 51 Ie dwelli 5 in the same nei hborhood and sub'ect to reasonabl similar amenities. Ad'ustmenls were based on markel extraction artdl 'ud ment. The indicated value ra eon Ihe above rid xlends from $90 000 to $104 920. The indicaled mMket value is estimated to be less than the UDDer end of the value ran e and at $92 000. "'" Oate,Pfice and Oala Soorce, lor prior sales wiIIlln urofa ra/sal AnaI)'Sis aI any cl.I1Jenl a!;IJeement of sale, llJllloo, or listing 01 sublect property and analysis of any Prior sales of sublett and camparables witt\in one year of the daft 1# apfl(aisa/; The sub'eet ro~ has a one car dlJtached ara e. No riorsaleswilhinone ear. INDICATED VALUE BV SALES COMPARISON APP/WAOI $ IHDlCA1'EDVALUEBYIHCOMEAPPROACH A litable Estimaletl Market Rent $ N .xGrossRlllltMullllier "'$ ll-ris appnisalls made "as Is" i_I subject 10 the repallS, alterations, inspections III conlfllions ftsteQ' below LJ sublett 10 completfon {W plans & spec' C()f1ljlions 01 .\Jl!ltalsat: ~rt is sold sub'eet to a satisfaclo lermite certiflCalion Wit" a . ed value based on clear test results. Radon certification is sUQoested. final ReconcilialiolJ: /nsumcienl marllet data was available to orocess the Income Aooroach. The Cost ADoroach is considered and used as a checlc for this raisal and ical! sets the u er limit of value. The Sales Com lIrison A roach is deemed most reliable and 'ven ealest weiQht Oennis L Stover m assistant artici ated In the re aration of this re ort. The purpose nI Ihis appraisal is to estimal,lhe market vafue otttleru!prapertylhatlsl"'subj ectOII!JJsJep<lrt.bllSedonlheaboveconditionsandlhecerlitieallon,eontIngent andlim11ingcondillans,arn:tmarke!valutdelinilionlmlares!<lledlnllleattachedfreddleMac Form 439/FNMAfarm1004B (Revlsed ~~--.J. I(WE) ESTIMATE THE MARKET VALUE, AS DEFINED, OFTHE REAL PROPERTY THAT IS THE SUBJ O~THIS REPORT, AS OF 4-10.02 iWHICH IS THE DATE OJ: INSPECTION AND THE EFFECTIVE DATE OF THIS REPORn TO BE $ 92 APPRAISER: ~ I. c-' -=- StlPERVl ,PP If R 0 Slanaturl IJ........ <:-:-0: e Nmle Dennis l. Slovef Assislant to Ihe ADoraiser Name eor e C. auser SRA Da',R,oortSioned 7-12-02 0 eR ned 7-12-02 $fatt CeniUcatlon * Slate I C # Genera/ A raiser GA: DDD233-l Or State Ueense II Slate OiS~eUeense# Freddie Mac Form 70 6(93 PAGE2DF2 Form UA2 - 'TOTAL lor Windows. allPlaisal software by a la mode, Inc. -1.800-AlAMODE SUBJECT Not Applicable COMPARABLE NO. 1 Not Applicable COfdf'ARA6tENO.2 NolApplicable COMPARABLE-NO.3 Not Applicable 92000 ~OId LJO.N. InsptclProperty Sla PA Slate Fannie Mae fOlTQ 10Q4 6-93 , .""""'. Please date, sign and mail your proxy card back as soon as possible! Annual Meeting of Stockholders ROBOTIC VISION SYSTEMS, 1Ne. April 3, 2002 ,r--... + PIIue OetIIch and Mait in the EIfWIope P1vwDId + .. ~ P_..... your "~ ~..I"ttu. .....pIe. r ], 1002'1000006 '16.000 ~ 0552'1 0'136300000 2 FOR" ~ WITHHOLD .... right ~ AuntClRfTl' _...-e..dtl)'" Iovotll-.....noma.. 1.:;'- -0"- .....0...... ........., (INSTRUC'TJON: To wilh~ ~ to \fIlM; tor etr'IlndMl:ll8f. nominee, strikie MIdI ~'. ...tn:m....,.....rigN) FOR 2. TOeoneicM'..,va.IlpOrt.~lownendD Ute Compeny'a ~ of "'_..-4#..... 10 1ncNue... ~ n...... of........ of commoR ....tn:n 75,OOQ.OCXJ let 10?.0oo.ooo. 3. To,...,u._lecIonofDelol'fll;&ToucNupD _tM~.' '. :lL~"""Ior"" ..... yar...tng~ 30, 2D02. Nomt...-: P. V. Costa F. A. DiPietro J. M. Hod\ T.Kohn M. J. Lerner H. Stem R. H. Walker L .......... ....."'" DO DO 4. Totl'u-=ta&dl......~_..,prclpMtfUlmll~1M~ PLiA8E M.vue. SICJN. DATE AND RETURN THI PROXY CARD PROMPTLY U8ING THE DCI...08ED aNVa.OPE. --- 001-000332 ELSIE K SHIERY 44 N 10TH ST LEMOYNE PA 17043-1405 _. """" -, ......nMl!,..ICLD-'CIM\.' N01'E: P..... ~~" .~ctly *! N:~~ ~.... hereorl. When Ma,.. .. bekf by Jotnt ""'aftW. both sl!.o\lld aign. 'MIen a1gnmv _ llbonley, eJllJCVtor, admiftl.,.I<<. ...... tttStonCal t'nces WYSlwyg:llllhttp://t3Dle.rmance.yanoo.coltllo !a=J&::D= J U&C==UL&::O=4&e= I U&t=U.!&::g='<U!Gs=roov YA.SootRNANCE,W Search - Finance Home - Yahoo! - Help More Info: Quote I Chart I News I Profile I Research I SEe I Msqs I Profile Month Day Year Start: --APr---G-i-c:j'o-~ End: --I\.P;--Bi"c:j -o~ @ Daily o Weekly o Monthly o Dividends Ticker Symbol: .'rob;':--II_~:_IP.~ta_.; \. '. 'Date .' ..1 Open Imgb I Low I Close I Volume ~:j;* 1O-Apr-02 1.52 [15311.42/ 1.471294,000 I 1.47 Download Spreadsheet Format * adjusted for dividends and splits, please see F AO. Questions or Comments? Copyright C 2002 Yahoo! Inc. All rights reserved.Privacv Policy - Terms of Service Historical chart data and dally updates provided by Commodity Systems Inc, ICSIl. DaIa and information is provided fa" infonnational purposes only, and is not intended for trading purposes. Neither Yahoo nor any 01 its data or content prtllliders (such as CSI) shall be liable fa" any errors or delays in the content. or fa" any actions taken in reliance thereon. 10f1 1/3/02 10:30 PM 3919 IPTIONAL CASH PAYMENT you are sending an optionaf cash payment to Llrchase additionaJ shares, specify the amount f "'-"oayment below and return this fann It. \th your ct\e.Ck or money order made ayaol6 to RrstEnergy Corp. CCOUNT 10. FirstEnergy Corp. Optional Cash Payment and Transaction Request Form CAGOF your ass s own ow is not correct, provide your COfTect address, sign. dale and rebJm this form. SEE REVERSE SIDE I GENERAL INFORMA1 If any of the following transactions ate desired, check th appropriate box, sign. date and reb.Jm this form. =:LS K SHIERY 01 SIGNA lURE o CLOSE MY PLAN ACCOUNT. send me a certificat, aU whole shares and a check for any fractional share o CLOSE MY PLAN ACCOUNT. send ma a certificate shares; sell the remaindef and send a ooe o CLOSE MY PLAN ACCOUNT. sell all shares and Sl me a ch&ck. AMOUNT $ DATE ltELSIE K SHIERY 44 NO 10TH ST LEHOYNE PA 17043-1405 o WITHDRAW whole shares from my Plan account and send me a certificate. D SELL whole shares from my Plan accour and send me a check. 1...111...111....1..1..11....11.1..111....1.1..1..1.1..11...11 o Send me a new enrollment form so that I may chang. method of participation in the Plan. TELEPHONE NO. ( ) SIGNATURE DATI AtstEnc!iY FirstEnergy Corp. Stock Investment Plan Statement of Account NAME AND ADDRESS ELSIE K SHIERY 44 NO 10TH ST LEHOYNE PA 17043-1405 ACCOUNT rD. ACCOUNT NUMBER DIVIDEND PAYMENT DATE DIVIDEND RECORD DATE ELS K SHIERY 0000520702 06/01/02 05/07/02 01 13/01/02 PlAN DIVIDEND 1WOl/02 PlAN DIVIlIEND .37500 .375000 $403.71 $407.73 $.00 $.00 $403.7 $407 .7 BAlANCE - 1,076.! $37.6750 10.716 1,087.: $34.2150 11.917 1,099.1 .----- tEnergy Corp. # Investor Services ;. Main Street, Akron. Ohio 44308.1890 ~ ASSISTANCE PLEASE CALL INVESTOR SERVICES _L-FREE: 1-800-736-3402 ,REVERSE SIDE FOR EXPLANATION OF STATEMEN HlStoncal Prices UUp.III4U'.....uJ.a.U........)..uvv...v.."'....... ........ .v_~ v___ .__ 'y__~ __u"" _u_ u " YA.HOOl~FlNANCE. Search -Finance Home - Yahoo! - Helo More Info: Quote I Chart I News I Profile I Research I SEC I MSqS I Insider Flopen I High I Low I Close F C~:!;* 11O-Apr-02 [ll36[34.25f33.29f33.99!1,778,300 I 33.20 i ADVERTISEMENT , Month Day Year Start: Apr E1"i-qo~ End: AprBiq B @ Daily o Weekly o Monthly o Dividends ....... .-;'c,'--'._'" .,.'..';0;'''.' , 'M"'<<:;';~ BDBle Ticker Symbol: fe II Get Data Download Soreadsheet Format * adjusted for dividends and splits please see F AO. Questions or Comments? Copyright C> 2002 Yahoo! Inc. All rights reserved.Privacv Policv - Terms of Service Historical chart data and daily updates provided byCommoditv Svstems Inc, rcsl), Data and information is provided for informational purposes only, and is notintended for trading purposes, Neither Yahoo nor any of its data or content providers (suchas CSI) shall be liable for any errors or delays in the content. or for any actions taken in reliance thereon. lof! 3/13/02 8:33 PM MetLife Statement of Trust Interests Feoruary.2000 Al !he time MetUfe demutuajjzes, you will be allocated shares of MetUfe, Inc. Common Stock. which will be held for you 1/1 the Melllte Policyholder Trust _ The number 01 Trust Inlerests you own is equal to the number of shares of MetUfe. Inc. Common Stock held for you In the Trust. [h.s Statement 01 Trust Interests tells you hOw many Trust Interests you will own at the time MelUfe demulualizes (in other words. flOW many shares of Metlile. Inc. Common Stock will be allocated to you and held tor you in the TruSI) _ If you want to buy more shares 01 Metlife. Inc. Common Stock to be held for you in Ihe Trusl, you should use the form printed below to submIt a Purchase Inslruction. You are only eligible to purchase additional shares if you are being allocated less than 1,000 shares. Slock can be purchased through Ihe Pun:l1ase and Sale Program on the Jimt lrading day lollowing lIIe 90th day aller Ihe dafe Melllle's demuluoCitation become. eller:tlve, Purchase InstnIctlons received belore lIIe pun:l1ase program begins will not be pro....... until the commencemenlo' fhe purchase program, If you wanl to sell Ihe shares of Metlife. Inc. Common Stock held for you in the Trust, you should use the form printed on the revers. side of this page to submit a Sell Instruction. Stock held in lIIe trust can be sold olter the IPO distribution is completed, which should be no more than 30 days alter lIIe pl.n elletlive date, Sell Instruelion. received betore the .ale program begins will not be processed untit the commencement oC the sale prognlm. All such purchases and sales will be on a commission-tree basis - AUTO ............. 3-D~XT 17' ELSIE k SIaERY "" N 10TK ST lEMQVNE PA 17~3-1~05 .. co ... o ... - Ple~se be sure 'he COttec\ ;Hllire::;::; Ji!lJU.h:i ::; lhe wmdow 01 fhe enveiopf! rl yOIl :He slJlJmlfting a ptJ(chas.e Of Sale \I)SIHICl1on The allached inslrucllofl card hllJllilfies tlie !:orrecl address lor each tv~e 01 trans.action I. ..1II...1JI... .1..1..11.. ..11.1..1 11....101.. 1..1.1..11...11 - -~6'J6' PLEASE RETAIN FOR YOUR RECORDS Name ELSZE k SIIIERY Retain this number lor future reference ... Investor ID .063 ""28 5149 Number of T ruet IlIleteots 611 Seqdente Number "0069691.. PLEASE READ THE IMPORTANT INFORMATIOfC OM THE BACK OF THIS FORM AND IN THE ENCLOSED BROC"IiURE--- Use ONLY If a transacloon IS requested. Un leu you wish 10 initiate a transaction. no atlion is required. PURCHASE INSTRUCTION !Ob3 1f!24 511f'l Change 01 address (See reverse side to SEll) ELSIE k SHIERY -_.._..~----~--,_._---- Chase Mellon Shareholder Services PO Box 382200 Pittsburgh PA 15250-8200 Sianature: Iii ii1t:1rirp.s.~ Il~mll chanaedl Make clu!ol<. iR U.S. dollo... payable 'l~~--"-'""--- Mellife Purchase Program ~ 1...11.1.1...1.1.1.1.11...1..1...1.111...11...11...11...1...11 Amount Enclosed Please be Sure this address appears In the envelope window for Purchases ONlYI Minimulnlnvestment $2S0~OOTexcept-as j deSCribed in the enclosed brochure) J 0000101 102 1I0b3'f1l24S1'f'l 'I ttJS10nCal rnces ....t'~,.__._._----_...-_.- "Y.ABoO!,RNANCE .m Search -Finance Home - Yahoo! - Helo More Info: Quote I Chart I News I Profile I Research I SEC I Msas I Insider ADVERTISEMENT Month Day Year Start:Apr .. 6iqdo~ End:-APr.6 i-q ~ @ Daily o Weekly o Monthly o Dividends --......."......,~_'-'-'. "TO> -ii."- Ticker Symbol: met II. Get Data ~.,"" "'- ' .:" ..' .- .-....,..,...-'''.-.-,-.;.., ..'i::-"--':,::'.','_...'_':'i-:,,:."','-': .,.<.,.;.,;.,.--:'.....:",.....,.,".-'..:,-,...,.....--.,....'--'. ,....,..-',..,,"-.,-.....-..........--.:.:.. .-.. Paying FI Open I High I Low I Close I Volume I ~:!;* I I I"" I I .. I" , i 10-Apr-02 ; 32.77 ,33.42: 32.66: 33.30,1,757,600! 33.30, Download Spreadsheet Format * adjusted for dividends and splits please see F AQ. WE LIVE WHEREYOU LIVE.... Ouestions or Comments? Copyright Cl2OO2 Yahoo! Inc. All rights resefVBd.Privacv F:oiic)' -Terms oi Service Histaical chart data and daily updates provided byComrno_gj..tL~~!D.s.Jlli:--'--(Q...~ Data and infamation is prOllided for informalional ptJrpose& only, and is notintended for trading ptJrposes. Neither Yahoo nor any of its data or content providers (suchas CSI) shall be 1_ for any errors or delays in the content. or for any actions tal<en in reliance thereon. lofl 3/13/02 9:37 PM ?- ~ c~ l7t~ f\~~-n<t <'~~ ~7\cJ t'-~\v 4\tc/u<...--' ~ " ~7 6LC:~~ ~ Account number Account balance Account status .!J Number of related accounts 3 l~ulff.Jt~t_ti4 rRe I ated account deta i I ! Account description ISUPER MONEY MARJ<ET I Account relat !onship IJNT OR FIRST 1~...JIijj I~~f~~~ . ._"', ;r>t'<_",., Chevy Chase Bank Aspen Hill Branch Branch # 3 13641 Connecticut Avenue Wheaton MD 20906 " r Accoun t i den t i fica t i on , Type /9 MOtlfH CD (B21 Status II nact i ve PacklOff code 1999999/522~R Balance I 20.749.91 rAccount standi -Account ownership ( Date opened 04/07183 'n IELSIEK SHIERV OR ---. I Issue date 04112/02 IJ LVNOALE SHI ERY I 101/12/03 '--'.-'.' .. , I Matur i ty date I r Interest data Interest rate Payment method Paymen t eye I e Transfer account \NlA Penal ty (in days)\ 90 I 2.100 ICompound i ng lQuarterly r IRA info Plan type "Must" WID I 100/00/0000 l~.~~'''~ . . ..._^-~~-$;,:" "May" WID 100/00/0000 Chevy Chase Bank Aspen Hill Branch Branch # 3 13641 Connecticut Avenue Wheaton MD 20906 rAccount i dent i f i cat ion I Type 119 MONTH CD (B2) Status Ilnactive PacklOff code 19_99999/522RR Balance I 47.791. 62 A~gum t s t alldl ng-- Date opened 05/10/83 Issue date - i Maturity date 102114/03 Account ownership IELSIE KSHI~_OR IJ LVNDALE SHIERV Interest data Interest rate I 2.350 Payment method ICompounding Payment cycle lQuarterly Transfer account IN/A Penalty (in days)1 r IRA info Plan type "Must" WID I 100/00/0000 1_ "May" WID 100/00/0000 Chevy Chase Bank Aspen Hill Branch Branch # 3 13641 Connecticut Avenue Wheaton MD 20906 " .' : 080 ~52213 8 DDA . . !~ i I I i i Type of account ISUPER MONEY. MARKET (80) i I i i [Balance CU....e.. bala.ce [, I. Funds on Hold I ..., i "j lOC avai lable j I I Available balaace I I .. I ----------------- I 00 li ne allOun t .. I ReI acct balances .. I P..acessing balaace I 53.881.79 .00 i:, , 53.881. 79: I I' I I r I ! i I I I 53.881.79, "';"';;;';<i;-- '~;"!'''''''~+ - ",," -=-..-.<> ,,', ... I~ IUtI~1 Status Ilnact ive Pack/Off Code L /522RR .00: ,Account ownership ! laslEK SHIERV IIJ lVNDAlE SHIERV II I .00 Relationship account I. l 2 mnths avg balance .00 Service charge waive IWAIVE FIRST CYClE I~ -"'ij',*",, '''Jt'''''''-'"'Oo -'''"';;'-''''' ~~'>;:'i"i ~o I~---; I--..,.~ I~;j .<".."..,-~''''''<<;';''''';-~.. Chevy Chase Bank Aspen Hi/lBranch Branch # 3 13641 Connecticut Avenue Wheaton MD 20906 "V1WayRqlnJ LOOK FOR US. WE'LL GET YOU THERE. /" P.O. Box 178. Harrisburg. Pennsylvania 17105-1711 Member FDlC ELSIE K SHIERY J lYNDAlE SHIERY 44 N 10TH ST lEHOYNE PA 17043-1405 STATEMENT DATE 4/30/02 5614 PAGE . . T RAN SAC T ION A C C 0 U N T S U H H A R Y . . ACCOUNT TYPE OF ACCOUNT: INTEREST PAID ANNUAL PERCENTAGE YIELD DAYS IN CYCLE YEAR TO DATE EARNED (APYE) 0100011544 SAVER'S ADVANTAGE 2.44 1.24 S 30 --. ACCOUNT 1000012656 0416011453 . . I N V EST N E N T A C C 0 U N T SUN N A R Y . . TYPE OF ACCOUNT: INTEREST PAID YEAR TO DATE AVERAGE INTEREST RATE CERTIFICATE OF OEPOSIT 716.93 2.28000 S CERT.JfICATE_OF DEfpSlit;,,"K~,::';:;,~;.. ..~20000 S DATE 413 0102 TYPE OF ACCOUNT: SAVER'S AOVANl PREVIOUS BALANCE DE 1.160.26 INTEREST 1.18 ACTIVITY DESCRIPTI INTEREST EARNED . ltin9 checks, 11s with just a $ online at ayment is! ..-.. SAVER'S ADVANTAGE 0100011544 I AVERAGE BALANCE 1.160.26 ENDING BALANCE 95,645.96 26,647.10 ENDING BALANCE 1.161.44 BALANCE 1.161.44 Customer Service Toll-Free 1-866-WAYPOINT (1-866-929-7646) . In York Area 717/815-4500 .-- I.. DDA009LE SCHUBEPC Waypoint Bank SAVINGS - Account Inquiry 6/19/02 13:42:39 Account Number 100011544 Account Type A SAVER'S ADVANTAGE -- BALANCES .vai1a01e 1,162.66 Collected 1,162.66 Current 1,162.66 Accrd Int .71 Pend W/H .00 Close Out 1,163.37 Tot Holds .00 Short Name SHIERY ELSIE K Branch Number 001 MAIN OFFICE S COD E S ~~g~~~~~~t~~e A 1 ~RS ADVAN Chg/Waive C Charge Waive Rsn NSF/OD Opt E No Chg/NoNtc UNC Opt TIN Cert OD Limit Spc Attn Employee C 0 U N T E R S Int Type 11 1.2400% Lst 13M Lite Cycle Cd MT Cycle Code M NSF Items 0 0 Officer NULL CHAR FI OD Items 0 0 User Cds JTO UNC Items 0 0 Auto CIs 999 Days F3=Exit F4=Field Help F5=Inquiry Fee F7=History F8=Memo Post F9=Title Inq FI0=Options F12=Previous F13=NSF/OD Hist F14=Add Note F15=ALLView ~t~ ~~e~e~ II Last ctivity Last Overdraft Last Statement Last Maint Last Deposit Amount 5/31/02 5/09/00 3/07/02 1,032 C Certified o $0 N ALERTS (1:') como ::;tm ,.-., r-~ . TD003001 SC;::HUBEPC Account Number Product Type -"'""'ranch Number Avall Int Cur Bal Accrued Penalty Pend W/H Close Out Hold Arnt YTD Int YTD Fed YTD St Last Ren Per Diem Waypoint Bank Certificate Inquiry 1000012656 501 20 M No-Penalty 010 WEST SHORE Short Name 6/19/02 13:43:33 SHIERY, ELSIE K .00 95,645.96 113.51 .00 .00 95,759.47 .00 902.14 .00 .00 95,645.96 5.97459 F3=Exit F4=Field Help F7=History FI0=Inquiry Options F12=Previous (c) ,-- ,-- a e aturity Interest Interest Index Status Pen Type GL Type Spc Attn Officer 1 Officer 2 Serial Nbr Term Period Type Fixed 501 20 Month Penalt o Open 12 Penalty Free Ct 01 GL Type 01 NULL CHAR FIELD t: NULL CHAR FIELD t: F8=Display Holds/Alerts F9=Tit1e Inq F14=Add Note F15=ALLView 1998 ALLTEL Information Services, Inc. , .. - TD003001 SCHUBEPC Waypoint Bank Certificate Inquiry 6/19/02 13:43:07 Account Number Product Type r-'>:anch Number 416011453 C20 20 Month CD 030 CAMP HILL MALL Short Name SHIERY ELSIE K Avall lnt .00 rlg a e Cur Bal 27,398.47 Ori 10 15 1980 aturity Term 20M Accrued 8.88 Nxt 02 15/2004 Interest Period 1M Penalty .00 Lst 06/15/2002 Interest Type Fixed Pend W/H .00 Nxt 06/30/2002 Index C20 20 Month Certif Close Out 27,407.35 1st 06/15/2002 Status G Grace Period Hold Amt .00 1st 10/18/2000 Pen Type 04 180 Days SimplE YTD Int 751.37 1st Maint 04/08/2002 G1 Type 01 GL Type 01 YTD Fed .00 Cust Contact 05/02/1995 Spc Attn YTD St .00 Redeemed Officer 1 NULL CHAR FIELD t 1ast Ren 27,398.47 Officer 2 NULL CHAR FIELD t Per Diem 2.22190 Serial Nbr F3=Exit F4=Field Help F7=History FIO=Inquiry Options F12=previous (c) F8=Display Holds/Alerts F9=Title Inq F14=Add Note F15=ALLView 1998 ALLTEL Information Services, Inc. ~ ~ " ~\~\~ CUSTOMER PROFILE MPCPPR 136/19/132 11 :51:26 PAGE 1 OF 2 ELSIE K SHIERY AKA ~ ADR 4212 ISBELL ST ADR ADR ADDED: 131/83 ACTIVE TIN: 173-131-5325 CERT: CERTIFIED-W9 DOB: 138/31/19113 HOME: 717-737-66113 MD 21391364222 USA WORK: X NUMBER OF ACCOUNTS: ~ WHEATON RCK 131313131300001300~8a~2&iRtiSHPWI'J: lIlT,> (JTWROS) _ RMM 131313131313130013~~lZ!l?7i63i(""ONEY FUNI},ALT.' (JTWROS) RSV 001313131387131353136113678 STMT SAVINGS (JTWROS) mo 00000138"10080001'4'41393 CD 24 - 35 MOS (JTWROS) NORM AFB 1313 lilB~~04\'/2ar.72f/ NORM AFB 131 3 ~9.I'!I;N~,0$,~8100 PURG AFB 013 CLSD: 136/28/013 ACT! AFB 01 3 OPEN: . 01/137/83 KEY 1ST LETTERS OF SCREEN OR X PROFILE PERSONL LOCATE NAME(S) CMRCIAL SELECT MAl LI NG BALANCE CNTACTS CALLS OSSMENU PNEXT NEXT TO CUST/ACCT, JUMP CODE: C/WITH SIGNERS ACCESS ------- PSCREEN F1~HELP PRESS ENTER TO CONTINUE. TOTAL$ RELATED PPREV SPECIAL RPORTS ADD ALERT OTHER SRVICES COMMNTS OOPS ~ CUSTOMER ACCOUNT BALANCES . 'PAGE 1 OF 2 ELSIE K SHIERY AVAIL BALANCE 04/12 02 ,0;748.7 E CURR 04/12/132 A~iE9:;;~~?"CURR 04/12/02 NOT AVAIL CURRENT BALANCE 04/12/02 0.00 CURRENT BALANCE .. ~~~~~~~~~--- OR X NEXT TO CUST/ACCT . PRESS ENTER JUMP: TOTAL$ C/WITH SIGNERS RELATED ACCESS ------- PPREV PSCREEN F1=HELP .~ RCK RETAIL CHECKING --- ~'?78136828 f RMM RETAIL f1biiiE'fHARKET _ ~5763' RSV RETAIL SAVINGS _ 00000087005313610678 HYD CERTIFICATE ACCOUNT 00000087008100933189 HYD CERTIFICATE ACCOUNT 000000870088891'44093 KEY 1ST LETT.EftS OF'SCREEN PROFILE PERSONL LOCATE NAHE(S) CMRCIAL SELECT MAl LI NG CNTACTS OSSHENU ~ - A BALANCE CALLS PNEXT A \\5r.-4 }1,,-<~ (EJ~ cA 1J MPCBLN ADDED: 01/83 ACTIVE CURR LEDGER BAL 04/12/02 9..748.-75 LEDGER BAL 04/12/02 126 , 11 7 . 25 LEDGER BAL 04{12/02 NOT AVAIL SRVICES COHMNTS OOPS 4 hu\ 0 1.- 04/12{02 13:47:22 12 HTH AVERAGE 04/11/02 9,709.04 12 MTH AVERAGE 04{11{02 113,622.66 30 DAY AVERAGE NOT AVAIL MATURITY DATE 04/12/02 04/07/04 MATURITY DATE 04/12/02 01 {07/03 TO CONTI NUE . SPECIAL ALERT RPORTS OTHER ADD vings Bond Calculator 04$0 z. - 0<;r~ ~~ ';~i:~i~~~;~I~ D202058281E 08/1978 E D202058166E 09/1977 E D20205810lE 04/1977 E D200664094E 03/1976 E DlO4782938E 06/1975 E Dl02423709E 02/1974 E D86901036E 03/1965 E D85996045E 03/1964 E D85083903E 02/1963 E D83571957E 09/1962 E D83571899E 03/1962 E lylta~l '0!=r~ $500 $375.00 500 375.00 500 375.00 500 375.00 500 . 375.00 500 375.00 500 375.00 500 375.00 500 375.00 500 375.00 500 375.00 NI Not Issued NE Not Eligible for Payment P5 Includes 3-month interest penalty ME Matured (Exchangeable for HH) MN Matured (Not Exchangeable for HH) lofl $1,278.60 $1,653.60 1,849.80 2,224.80 1,889.80 2,264.80 1,925.40 2,300.40 1,943.40 2,318AO 1,999.00 2,374.00 3,346.20 3,721.20 3,792.40 4,167.40 3,761.20 4,136.20 3,786.00 4,161.00 3,830.40 4,205.40 . 4.00% 6.00% 4.00% 4.00% 4.00% 4.00% .00% 4.00% 4.00% ,t.. l,( '0 ~ 1) ~)( }~ ) f'. ?OD 6/13/023:15 P: ,0', ":,1 'I,!I" Public Debt on I i n c Account Number: 2 173015325010 Bond Serial Number Entered: M 07 044 337 HH Page 1 of2 The information you see is only for the account on which the bond serial number entered appears. If all your bonds are not listed on this account, they may appear on a separate account because they have a different inscription. You must provide a bond serial number to view each separate account. Bond Serial Number I De~e.rr~.~n~erest'[ Beneficiary IIssue~~te - .. -..---'-- ----... 110 96 1418.08 .iI _n I ---,-_...~---- .. ----~ 10499 u 1446.43 .. .. J ---..".--. -.-.-.-- -....... "--.- 12 01 139~.8~ j no .. .---- . ... .. . . .-"_.,,, 110~6. 1836.16 il .' ----. I .. . .. ----.-...-" .. -..- -.-..,. , I~~~'~~ t.. 10 96 . .. -----,,-~ ~.__m._..___. . .....---_. 06 98 1850.00 L --.- .. ~-_._..__. .'. ... I 106' 98' .1850'.00 J I.. .. L... _e_' . ... . ..-.- .__.~.__.. 10698' 1850.~~. II . ---". .. ...- -.-'''. -'-.-.. --- I069~ 1850.00 ..!I. I . . , . J85~.0~ .J e98 . -_... .. . . un -.--.- .. 04 99 1892.86 'I -"'- .. l .-,,--..... .-----,"-- .. ---- . .-.. 104 99 1892.85 I --~"---I 5Cb 'ID04262-559-HHJ ID04940721 Illi) /n 05765 527HH j /(PX) [M ~~9~"II~ 1~06.0~9~~~_~ .~. 1M 06 746 832 HH " _ ... ....... ....-......{ '1M 06 746 833 HHJ' l.. ........u.....__.... 1M 06 746 834.~. J 1M 06 746 835 HH ,( I . IM06 746836 HH j 1M ~07 044335IiH 1 1M 07 044 336 HH / lof2 3/26/02 10,50 AM H1H Internet Services: Current Holdings btlpS:l/WWWS.J.pUUIJ\;U'I;;Ul.....(&,;>.e;v.' "Co' Y....--.- , I 1892.86 1785.64 I 1785.64 I 1785.64 1785.64 I I 1785.62 I , i I I I dOU 1M 07 044 337 HH 10499 l~ 08223 222 HH ~2 01 1M 08 223 223 HH 112 01 1M 08 223 224 HH ,1112 01 [M08 223 225HH112 01 1M 08223226 HH /112 01 .. I I L_____ 1 1M 08 342 348 HH 1103 02 1M 08 342 349 HH /103 02 1835.76 , I 1835.76 I 1<1 '!11!1 'to \.\, 11IJ Updated September 17. 200 J 20f2 3/26/02 10:50 AI '111"..t,,('[',. Public Debt on I i n e Account Number: 2 173015325010 Page 2 of2 Bond Serial Number Entered: M 06 039 936 HH The information you see is only for the account on which the bond serial number entered appears. If all your bonds are not listed on this account, they may appear on a separate account because they have a different inscription. You must provide a bond serial number to view each separate account. ~ iBo~d-Serial N~~ber II~~~~'I)~t~ Defe~~edInt;~~~tr . I. . ..... .. . .. 1. .. '.. .. . ..... .1 1M 08 342 350 HH /103 02 1835.76 I !.. .. . ._1 ... I ..... I 1M 08 342 351 HH /103 02 --1835.76 i I. .____...__._._ ..._ .. .____..____.1.. __.___ ..____.L IM08 342 ~52~H <10~~2 1~35. 76[ IV 01634 332 HH .103,02. 14178.80.-' Beneficiary I .- .1 l.Tpdared September 17. 2001 lofl coiJV'l ~ ~ Z}J) 3/26/02 11 :02 M Public Service Enterprise Group Incorporated Enterprise Direct - Dividend Reinvestment and Stock Purchase Plan Statement of Account ~.o PSEG Public Service Enterpri.. Group Incorponlted P.O. Box 1171 New.rk, NJ 07101-1171 1~13 &IlRl-IfIC- BAb\llCr=:--- ~ ~ -.- -->_.-~. ,'.~ 1 ;U9;6841 _._._-~.'- _. - -_._~- 03[30/01 PLAN DIVIDEND 874.63 41.9040 20.8722 1.640.5563 06[29/01 PLAN DIVIDEND 885.90 48.7211 18.1831 1,658.7394 09/28/01 PLAN DIVIDEND 895.72 41.4594 21.6048 1.680,3442 12/31/01 PLAN DIVIDEND 907.39 42.2877 21. 4575 1.701.8017 .---... DIVIDENDS ~...$-- TAXES YllTl!!!ELfI___ COUMSSlONS 3,563.64 2.05 IMPORT ANTI Please retain this statement for your income tax records. Fold and Detach I and Detach Here Voluntary Contribution - Purchase Additional Shares Return thls stub with your.'-It to acquire -- -- of Check EncIo.... for: $ Common StocIc. We __the _ _ _ cIaya before en I_bnent Dete. The Inveab_ Dates are the 15111 and the _ Number: 0000250908 .... bualnesa dey of each month. You may .....at from $50 to a __ of $125,000 .... calendar year. Make the check payable _ID: ELS K SHIERY 01 to 'Publlc ServIce Enlerprloe Group Inc.'. 51 ,au Return this stub and check to: Public ServIce En.......... Group Inc. P.O. Box 18406 -rk, NJ 07191-8406 Mailing to any other acldre.. could delay your In_ ~ ELSIE K SHIERY AND J LYNDALE SHIERY JT TEN 44 N 10TH ST LEMOYNE PA 17043-1405 I. ..111...111....1..1..11....11.1..111....1.1..1..1.1..11 C1.c1wnl,;at rnl,;cs WYSlwyg:t/16/Dnp:.rllaOU:.1Jru:lflcc.yanuu.l:UIUlu: a_IX. U-- 1 VO(.l,;~VL./X.U--""tOX.C- J Voc.l-"1JL./x'!>-UUl:.;)-pc:g "'YASoO!FlNANCE~ Search - Finance Home - Yahoo! - Help More Info: Quote I Chart I News I Profile I Research I SEC I Msos I Profile Month Day Year @ Daily El i-l-~-O'-~ 0 Weekly Start: -P;P;---, . o Monthly End:-Aj;r" EI :}]..:3 0 Dividends Ticker Symbol: " peg "'-II_~!l[)a~_ Aren't Life's Little Mome State Fann is Here for Your Family. I..... Date.lopenj Highl Low Close Volume ! IO-Apr.OZ I44A4 145.44144.38 145.40 1358,400 STATE FARM 44.851 ..6.. ...... Adj. Close* Download Snreadsheet Format · adjusted for dividends and splits, please see F AO. INSURANCE @ I CLICK HERE I Questions or Comments? Copyright iC>2002Yahool Inc, All rights reslll\'llCl.PrivacY Policy - Terms of Service Historical chart data and daily updates prtllAded by Commodity Systems Inc, (CSIl, [)ala and intamalioo is pr<Nide:I for .duo.._ pu<poseS only, and is not intended for trading purposes. Neither Yahoo nor any cI its data or content prcMders (such as CSI) shall be liable for any enors or ~ in !he content, or for any actia1s taken in reliance there,,,," lofl 1/4/02 12.06 AM ~ ~ T Ple_ mork YOU' .. ~ vot.... In th1e .......... r Please date, sign and mail your proxy card back as soon as possible! Annual Meeting of Stockholders ROBOTIC VISION SYSTEMS, INC. April 3, 2002 + PlAN oetach ilIld Mail In the EIWeklpe Pn:IvkMd + 1 10029000006 210.000 ./'tr::u"c, 05529 0936300001 0 fOR"lIOI'ftNe& WITHHOLD IIQd lit ~ (e3<<:IIIpt AUTMORITY .. rrwta.d to ht to we. for.. nomlneM ";-O~ TI OlrecfOra: (INSTRUCllOH:' To wIhftDtt 1Mbority to ..... Jor .ry1ndMduaf nomiMe. .".. sucb nl;IIftinen ...,. tram tM ftIt lit right) HoInl.I:o...... P. V. Coata F. A. DiPietro J.M.Ha/l T.Kohn M. J. Lerner H.Stem R. H. W~k.r FOR 2. lO~andww.upon.~lDlIIfMIndO the CompMy'e cerntk:Ue ~ IncofponUOft to ~. Ute .uthoIttM Dumbftr 01 aNi,.. of COInnlCIn 1iII:ldl1tom 75.000.00o >>1l1O,OOO.OOO. 3. To ndytM...... at 0.10.-& To.... UP 0 _ the ConIpMy'. II lFr r.......... for die fI8oaI~endIng-~3D,2002. L IGf4NST ABSTAIN DO DO .. To tNn.ad'" otberbnlMM..~ Pf'OI*"'" c:orM MfonI1M ~ PLEASE MARK. SIGN. DAlE AND REtURN THE PROXY CARD PROMPTLY USING THE ENCLOSED ENVELOPE. 002-000333 ELSIE K SHIERY & J LYNDALE SHIERY JT TEN 1+4 N 10TH ST LEMOYNE PA 17043-1405 r---.. -~ s..u.~. F feLa.JClW1'L'I' NOTE; Plea.. sign llIdCfIy.. name appe.... hereon. When eft.....,. Hid by Joint..".,..., both .hould.;gp. When IlivnlllG _ &Romey. execu\Of. ~QlOI'. "... Dolc 0.." .' ~ --" ~ Q- "Y1s..8.00!RNANCE. Search - Finance Home - Yahoo' - Helo , ~ _ ,_" " ''-' - ,~"~" l 'c\ - " ,r. ....'.f, --" .,l" ,. !,^:;'~. ,',! _ I. J..; n,r ~~I(Qffi~':m.~:'\.t':?'j;:>.~ ~ ~~C~'1.vi;J~!-:::~~, n..,.~.....-~~...' -,.,-;>n r'''C More Info: Quote I Chart I News I Profile I Research I SEC I Msos I Profile Month Day Year @ Daily Start: ' Apr G [Ig~ o Weekly o Monthly End: Apr G CI9J3 o Dividends I Ticker Symbol:, robv II Get Data I,~l'~ . .1 Open I High j Low I Close Volume ~~;* I 11O-Apr-02j 1.5211.531 1.421 1.471294,000 f1A7i Download 80readsheet Format * adjusted for dividends and splits, please see F AQ, Questions or Comments? Ccpyright C 2002 Yahoo! Inc, All rights reserved. PrivacY Polley - Terms of Service Historical chart data and daily updates provided by Commoditv Svstems Inc. (CSI\. Data and informatioo is pl'Ollided for infuonlB!io.l8I purposes only, and is not inte<1de:l for trading purposes, NeiIhef Yahoo nor any of its data or content providers (such as CSI) shall be liable for any errors or delays in the content, or for any actions taken in reliance thenean. lofl 1/3/02 10:30 PM m.e!,~~~~~~, G) Call Us Retirement Accounts Call Account Statement December 31, z001 1-800-225-6292 1-800-622-0176 ... _. 0101,'-1.10% tDOlI; _ 1..11.'-'" f) II Your Representative 8CK CONWAY Bill 8223-0041-0006 IFG NETWORK SECURITIES, INC. 3424 PEACHTREE ROAD SUITE 1900 A TLANT A. GA 30326 Visit us on-line Pa! 1 of www.pioneerfunds.com ELSIE K SHIERY & J LYNDALE SHIERY JT TEN WRO SURVSHP 44 NORTH 10TH S'l' LEMOYNE, PA 17043-1405 Total v..... its_"~r:31y2OD1 $80,889.10 Check out the winter issue of Pioneer News. which accompanies this statement. You'll find information about new savings opportunities for retirement plans, including Pioneer's innovative Uni-K. the first 401 (k) plan designed specifically for self-employed individuals. The newsletter also provides information about year-end tax-related mailings from Pioneer. For more information about retirement plans, call your financial advisor. or contact the Pioneer Retirement Plans Account Information line at 1-800-622-0176. For information about your account or Pioneer funds. call your advisor or Pioneer at 1-800-225-6292. You can also visit our web site at: www.pioneertunds.com. We wish you a happy. healthy and prosperous 2oo2! Regular Account Summary Acct. No,. 001-0730668719 J"_1.2I01-DICOIlI""31.2IIl Assa. CaIogory _N_ r an ncome PIONEER fUND-CLASS A keOllDt N..... AAlolido.. Be i.llia V.... ... V..-....o_ w_ C......inV..... V..-ID-O_ ... V.......o_ . Tol81 Value 001-07306687t9 SOO.924.95 $0.00 $0.00 -$10.035.85 "--"""'nt o.u_ Totals October 1 2001. December 31 21107 $0.00 $0.00 $6.989.98 $73.899.12 Regular .Aci;QUc1'JtOitehJt~?:Inr:t4ctivi,ty.'.,.. ... . SlIlI,88II.1 SlIlI,88II;1 .......,.---.....,.,..-.....,'.'.., ....'.... . ......'.--". ,,--..... ,,'..,'. ..':... ..... ' . .. . .-- .. ,.", ..:..-.:::,':'::....::."......,:.....,:'..,'........,'::....'.:.:'...'..:...:':..:::'...,..:,','.'.'..... . . "-1,_._.....'31.. PIONEER FUND-CLASS A - Overview Account Intormation Account No. Accouat Open Oate Owner ELSI~ K SHIERY & J lYNOAlE SHIERY JT TEN WRO SURVSHP 44 NORTH 10TH ST LEMOYNE, P A 11043.1405 Earnings Summary Dividends Shon Term Capital Gains Long T enn Capital Gains 001-0730668119 05/ll4119n Other lnlormetion Sbarn: OA Deposit 2.078.877 OistritutionOptions ONiuen~Shurt T ~m Capital Gilins LonQ-Term Capital GaIns AceDuat Fe_res Telephone Exchange Telephone Redemption Year-tn-Data Tran.aelion Aelivily Dollar Share Amount .;:- Price $ 40\.26 $61.63 $ 39.84 $102.79 $ 41.58 $61. 75 $ 33.61 $1;11.88 $ 38.40 $106.30 $ 38.65 $ 31.11 = Number Total Share' of Shares Owned Ion. 111S4.m 1.547 ' 2,055.884 2.472 2.tIS8:S 1.837 '. 2.1160.193 15.934 2.016.121 2.750 : . 2 G18.a71 .. . " 2 Date 01 D:lI2:W 1 06/25,\11 09r.mn 11121J\11 121211111 17lJ1A11 Transaction Oescriotion a..i.AiA. Balnee OMOEND REINVESTEO $0.03 OMDEND REINVESTED $O.D5 OMOEND REINVESTED $0.03 LONG TERM CG REINVEST $0.297 DMDEND REINVESTED $0.0512 E 8_ ~ IIIII1II _ _1_'-'.''".1' _ .- 1..';10"___ Paid Year- To-Date $332.47 $0.00 $611.88 RelnVest/ASlmies Reinvest Total Account Value $.tO B2-tJa .,10 ......"'......., ..,....\;;:) WYSlwyg:tIY/nnp"Jlt8ole.nnance.yanoo.comJo {a=<f&O== 1 U&C=U.l&O'=4~e'= 1 V&t=V.l&g'=a&S""P10dx . 'YA.SootFlNANCE. Search - Finance Home - Yahoo! - Help More Info: Quote I Chart I News I Profile I Profile Month Day Year Start:-A;;r-G J3 -O~ End:-AP;-'-G-iCjo~ @ Daily o Weekly o Monthly o Dividends Ticker Symbol: piod"ll (3~~pa~. ,. Date.. I Open I High I Low I Close I vOlume~ !IO-Apr-02j39.47 f41.88f39A7139.47/ 0/ 39.47 Download Spreadsheet Format * adjusted for dividends and splits, please see F AQ. Questions or Comments? CopyrightCl2002 Yahoo! Inc. All rights reser'lled.Privacy Policy - Terms of Service Historical chart data and daily updates provided by Commodity Systems Inc. rcsn. Data and infamation is provided for infamational pulpClSell ooly, and is not intended for trading purposes. Neither Yahoo nor any of its data or content providers (such as CSI) shall be liable for any errors or delays in the content, or for any actioos taken in reliance thereoo. lofl 1/3/02 11 :40 PM " --- US AIRWAYS GROUP, INC. 2002 ANNUAL MEETING OF STOCKHOLDERS WEDNESDAY, MAY 15, 2002 9;30 A.M. ELSIE K SHIERY & J lYNDAlE SHIERY JT TEN 44 N TENTH ST lEMOYNE PA 17043-1405 ~ To vole your shares: . Mark, sign and date the proxy card below . Detach the proxy card . Return the proxy card in the postage-paid envelope provided T DETACH PROXY CARD HERE T ~ Marfl:. Sip, Date iRd Allum 111. Pro" Card I'romplIy lJst.g Ute EDdosed Errrefotle. 00 Votes must be iAdicatld (x) II. 81m 81' Blul ink. G~' BIlAIIllllf lllllE&TllllS RECOMMEIIDS A VOn: FOil ITEMS 1 ANO 2 . 1. Election of Directors fQftallnorninees 0 liSted below wmtttOlD AUJ1IOR(T't 10 volll 0 lor all nominees listed below "EXCEmotfS o Nonllnees: M.J. DeVito, P.M. George, RL Johnson, R. LeButln. J.G. Medlin, Jr., H.M. Merriman, T.H. O'Brien, H. Ocnoa.Brillembourg. R.B. PIiorj. D.M. Si'1lel, R.w. Smith, S.M. WoW (INSTRUCTIONS: T. _ for an nom_ _ilia. ../lai. specifted nom_, marl< Il1e "Exceptions" lImt.... wrile thai nominee'. name in Il1e space pIOIided below.) . Exceptions FOR AGAIm AlSTAUI 2. Ratification of the selection of KPMG LLP as auditors, 000 000 To Change your address, please mark this box. o BOARD OF DIRECTORS RECOMMENDS A VOTE AGAINST ITEM 3. 3. StOCkholder proposaj concerning cumulative voting. ELSIE K SHIERY & ~ LYNOALE ~~ SHIERY JT TEN 44 N TENTH ST LENOYHE PA 17043-1405 3897 2002 000074930 I NOTE: Please siqn as Ililme iijlpllillS IlSfton../oIn1 0Wf\IKS snoutd ad\ s~. Wt\el1 SIgIllIIQ M; 1J\101n~ execuIOf.admll1lslralot.lruSleeOl"goardiall,pleasegiYefulllilleassuch Data Share Owner Sign here Co-Owner Sign hen:! I I fil,SlUHl,;al rnCl;;S "'~t'''''''''"'''''''''''''''''''''''J-'''''''''-''- -.- .-._ . ___. " "YA.aOO!~,RNANCE .w Search -Finance Home - Yahoo! - Help More Info: Quote ADVERTISEMENT Month Day Year Start: Apr El J.g..23l End: Apr E1..i2J..23l Ticker Symbol: . uawgq .11 Get Data Payinl @ Daily o Weekly o Monthly o Dividends , ",'--,,'--"; ~-' ,".' , FI Open r;/ Low I aose Volume III-Apr-OZ! 6.371 6.3715.941 6.081637,4001 IIO-Apr-OZ f6.301 6.3916.031 6.36 1 610,400 ! Adj. aose* , 6.08 : I i 6.361 -..>:.',....,J'>.:......., WE LIVE WHERE YOU .. LIVE'IM,': Download Soreadsheet Format * adjusted for dividends and splits olease see F AQ. Questions or Comments? Copyright C 2002 Yahoo! Inc. All rights reserved,Privacv Policv - Terms of Service Historical chart data and daily updates provided byCommoditv Systems Inc. !CSIl. Data and infonnation is provided for infonnalional purposes only, and is notintended for trading purposes. Neither Yahoo nor any of its data or content providers (suchas CSI) shall be liable for any errors or delays in the content, or for any actions taken in reliance thereon. lof! 3/13/02 9:35 PM MetLife . ALL TNOUIRt~S SHOULO BE OIRECTED ~ METROPQlITIAN u..EE INSURANCE r1'lMPANY e..Jl.. IllIX ~ TULSA OK 74121-2053 If you have questions about your paymelll~, "au, 1-800-635-7775 ANNT 10: 000584734RB DAn llE ~ liRQSS PAYMENT FEDERAL 1M SIAn: IM ~ PAYMENT .wtI II llZ. 1 1 1 1 1 ...llQ ...llQ 12g 77 Metropolitan LIfe Insurance Company 129 77 JAY LYNDALE SHIERY ~212 ISRELL ST SILVER SPRING, MD 20906-4222 ----------------------------------------------- For cIIange of address. cut on dotted line and forward completed form to: Metropolitan Ufe Insunlnce Company This is change of address only; Does P.O. Box 22053 not affect my current Direct Deposit Tulsa. OK 74121-2053 Send me a new Direct Deposit form Send future checks to new address My new address is: (Please PriotJ Name Street City, State Zipcode Social Security Number Signature My legal address fif other than aboveJ: Street City, State Zipcode ANNT 10 000584734RB ,-VI" SQIl _I) Detach stub before castling Form 1040 Department of the Treasury - Internal Revenue Service 2001 1(99) U.S. Individual Income Tax Return IRS use only - Do not write or staple in this space. For the year Jan 1 - Dee 31, 2001, or other tax year beginning ,2001, endlno ,20 OMB No. 1545.0074- label Your First Name MI Last Name Your Social Security Number (See il1structions.) El 5 i e K, Sh i e rv 173-01-5325 II a Joint Return. Spouse's First Name MI last Name Spouse's Sodal Security Number Use the IRS label. Otherwise, Home Address (number and street). If You Have a P.O. Box, See Instructions. ApartmenlNo. .. Important! .. please print or type. 44 North 10th Street You must enter your social City, Town or Posl Office. If You Have a Foreign Address. See Il1structions. Slate ZIP Code security number(s) above. Presidential Lemovne, PA 17043 Election Campaign (See instructions.) Filing Status ~ Note: Checking 'Yes' will not change your tax or reduce your refund. Do OU, or our spouse if filin a 'oint return, want $3 to go to this fund? 1 X Single 2 Married filing joint return (even jf only one had income) 3 Married filing separate return. Enter spouse's SSN above & fuJl name here. ~ 4 Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this child's name here. .. Qualif in widow(er) with dependent child ear spouse died'" ). (See instructions.) 6a X Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, do not check box 6a. , ... . . . . . . . . . . . . . .. ...... ......... . . . .' . . .. . .. No Check only one box. 5 c Dependents: (2) Dependent's social security number (3) Dependent's relationship to you } No. of boxes checked on .. 6a and6h.... No. of your .. children on (4) if 6cwho: chil~ai~7i~h~ld . lived lal( credit with you. (see ir'lstrs) . did not ~~~ ~~~rv~~e orsep..ration (seelnstrs)... 1 Exemptions b Souse. (1) First name Last name If more than six dependents, see instructions. Dependents on 6c not entered above. Add numbers .1 11 entered on d Total number of exemptions claimed. lines above . .. 7 Wages, salaries, tips, etc. Attach Form(s) W.2 . 7 Income 8a Taxable interest. Attach Schedule B if required. 8a 27,349, .........1...,1.. Attach Forms b Tax~exempt interest. Do not include on line 8a. ... 8b ... W-2 and W.2G 9 Ordinary dividends. Attach Schedule B if required. 9 5,48l. here. Also attach Form(s) 1099.R if 10 Taxable refunds, credits, or offsets of state and local income taxes (see instructions). . 10 tax was withheld. 11 Alimony received. 11 12 Business income or (loss). Attach Schedule C or C-EZ . .........~tJ 12 If you did not 13 Capita! gall1 or {loss). Attach Schedule D if required. If not required, check here. . 13 612, get a W.2, see instructions. 14 Other gains or (losses). Attach Form 4797. . 14 15a Total IRA distributions..... ~ I b Taxable amount (see instrs). . 15b 16a Total pensions & annuities. 16a b Taxable amount (see instrs). 16b 3,800, 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . 17 Enclose, but do 18 Farm income or (loss). Attach Schedule F.. 18 not attach, any 19 Unemployment compensation. 19 payment. Also, 20a Social security benefits.. ~I 12,720, I b Taxable amount (see instrs) 20b 10,812, please use Form 1040-V, 21 Otl1erincome 21 22 Add the amoo~sintlW fa;:-r~ht wj~mn fo-;-line--;"7 thr-;uah-21. This is ~oo;;~aTincome~ ~ ~-;. 22 48,054, 23 IRA deduction (see instructions). 23 ... Adjusted 24 Student loan interest deduction (see instructions) . 24 Gross 25 Archer MSA deduction. Attach Form 8853. 25 . Income ; 26 Moving expenses. Attach Form 3903. 26 ; 27 One-half of self-employment tax. Attach Schedule SE. 27 28 Self-employed health insurance deduction (see instructions) 28 )\ 29 Self-employed SEP, SIMPLE, and qualified plans. 29 , 30 Penalty on early withdrawal of savings. 30 9, 'i 31 a Alimony paid b RecIpient's SSN. .. 31 a 32 Add lines 23 through 31a.. 32 9, 33 Subtract line 32 from line 22. This is your adiusted aross income .. 33 48,045. BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. FDIAQ112L 12110/01 Form l04D (2001) Porm 1040 (2001) Tax and Credits Standard Deduction for - . People who checked any box on line 35a or 35b or who can be claimed as a dependent, see instructions. . All others: Single: $4,550 Head of household, $6,650 Married filing jointly or QualifYing wldow(er), $7,600 Married filing separately, 3,800 Other Taxes Payments If you have a qualifying child, attach Schedule ErG, FDIAQ1l2L 12110101 Refund Direct deposit? See instructions and fill in 68b, 68c, and 68d. Amount You Owe Third Party Designee Sign Here Joint return? See instructions. .. Keep a copy fm your records. Paid Preparer's Use Only Elsie K. Shier 34 Amount from line 33 (adjusted gross income) '.' . .. .... ................ 35a Check if; 0 You were 65/older, DBlind; 0 Spouse was 65folder, Add the number of boxes checked above and enter the total here. b (f you are married filing separately and your spouse itemizes deductions, or you were a dual-status alien, see instructions and check here. 36 Itemized deductions (from Schedule A) Qr your standard deduction (see left margin). . . 37 Subtract line 36 from line 34. 38 If llne 34 is $99,725 or less, multiply $2,900 by the total number of exemptions claimed on line 6d. If line 34 is over $99,725, see the worksheet in the instructions. . .. . . . . . . . . . . 39 Taxable income. Subtract line 38 from line 37. If line 38 is more than line 37, enter -0-. 40 Tax (see instrs). Check If any tax is from a 0 Form(s) 8814 b 0 Form 4972 . 41 Alternative minimum tax (see instructions). Attach Form 6251 42 Add lines 40 and 41 . 43 Foreign tax credit. Attach Form 1116 if required. 44 CredIt for child and dependent care expenses. Attach Form 2441. 45 Credit for the elderly or the disabled. Attach Schedule R 46 Education credits. Attach Form 8863.. 47 Rate reduction credit, See the worksheet. . 48 Child tax credit (see instructions). 49 Adoption credit. Attach Form 8839. . . . . . .. . . . , . . 50 Other credits from a 8 Form 3800 b 0 Form 8396 c 0 Form 8801 d Form (specify) 51 Add lines 43 through 50. These are your total credits . 52 Subtract line 51 from line 42. If line 51 tS more than line 42, enter -0-. . 53 Self -employment tax. Attach Schedule SE. . 54 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137. 55 Tax on qualified plans, including IRAs, and other tax-favored accounts. Attach Form 5329 if required. 56 Advance earned income credit payments from Formes) W-2. 57 Household employment taxes. Attach Schedule H . 58 Add Imes 52.57. This is our total tax.. 59 Federal income tax withheld from Forms W-2 and 1099. 60 2001 estimated tax payments and amount applied from 2000 return. . 61 a Earned income credit (EIC) , b Nontaxable earned income. 61 b 62 Excess socia! security and RRTA tax withheld (see instrs). . 63 Additional child tax credit. Attach Form 8812. 64 Amount paid with request for extension to file (see instructions). 65 Other payments. Check if from..... a DForm 2439 b 0 Form 4136. 66 Add lines 59, 60, 61a, and 62 through 65. These are your total a ments. 61 If line 66 is more than line 58, subtract line 58 from line 66. ThiS IS the amount you overpaid. 68a Amount of line 67 you want refunded to you. ~ b Routing number. ~ d Account number. . 69 Amount of line 67 you want applied to our 2002 estimated tax. ... 69 70 Amount you owe. Subtract line 66 from line 58. For details on how to pay, see Instructions. . 71 Estimated tax enalt > Also include on line 70. 71 Do you want to allow another person to discuss this return With the IRS (see instructions)Z . Yes. Complete the following, Designee's Phone Persona) Identification Name ~Preparer No. ~ Number (PIN) ~ Under pen;;lllies 01 perjury, I declare that I have e~amined this return and accompanying schedules and statements, and to the best of my knowledge and bel!ef, they are true, correct. and complete. Declaration of preparer {other than \all.payar) IS based on all intormation of which preparer has any knowledge. [j Biind ~ 35a 173-01-5325 34 Pa e 2 48,045, 36 5,650. 37 42,395. 38 2,900. 39 39,495. 40 7,431. 41 .. 42 7,431. 43 44 45 46 47 48 49 50 51 .. 52 53 54 55 56 57 .. 58 7,431. 7,431. 59 60 61 a 1,800. 5,000. No 62 63 64 65 "66 67 68a 6,800. ~ c Type: 0 Checking .. o Savings Date YourOccupalion Day1ime Phone Numoer Your Sig Retired Spouse's Occupation Date SDOuse's ~ Preparer"s ..... Signature'" Oe-- -.a.- Firm'sName Youn Bra h & Co. P.C. (or yours If 110..' , self-employed),,,, 12501 Pros eri t Dr. Ste. ~!~C~~~ar"ld Si 1 ver S ri n , MD 20904 Preparer's SSN or PTIN Check it self.employed ...).. t CI- .., 'f'" 3vy Y 250 "N 52 -1593339 PM" No. (301) 680 - 0040 Form 1040 (2001) LAWRENCE G. COX, D.O. & JAMES E. BLACKSMITH, D.O. 522 LOCUST ROAD NEW JUM6ER~.0 PA 17070 17171 932-4050 TAX 10 ~ 25-1786967 ELSIE K SHIERY 44 N l~TH STREET LEMOYNE PA 17043 DATE ~ATIENT ~~~ PRCC CODE TRANSACTIGN DESCRIPTION ~,6/22101 ELSIE 99214 OFC E&M ESTAB MOD-HI 25 MIN CHECK PAYMENT FRCM MEDICARE TRANSFER FROM INS MCARE TO INS BS TRANSFER FROM INS BSPA TO PATIENT 01/11/02 ELSIE 99213 OFC E&M ESTAB LOW-MeD 15MIN CHECK PAYMENT FROM MEDICARE TRANSFER FROM INS MCARE TO INS BS MEDICARE ADJUSTMENT TRANSFER FROM INS BSPA TO PATIENT ACCOUNT ~: 1924 AGING: CURRENT 61.03 31 - 60 .00 61 - 90 .00 .. PAYMENT DUE UPON RECEIPT . THA~lK YOU .. FUTURE APPOINTMENTS: ELSIE ~4/11/02 11:15 ROUTINE VISIT CHARGES CHARGES 113.03 65.00 53.00 CRED ITS 52.00 .00 .00 CREDITS 52.00 .00 .00 4.97 '-"0; .~i(j PAGE 1 04101102 ACCOUNT ~ 1924 BALANCE 13.00 48.03 BALANCE 61.03 <INSURANCE PE~IDIN6: .00 PATIENT BAlANCE: 61.03 91 - 120 .00 121 - UP .00 Trapp Lawn Care 65 Cold Springs Road Dillsburg, PA 17019 George H. Trapp, Owner Shiery Residence Mrs. Shiery 44 N. 10th Street Lemoyne, PA 17043 DATE SER VICE CHARGE CO:APr-0 h;l .'3" Mowrrrim x. \.014 $22.50 16-Apr-02 Mowrrrim -;;}. '=>. ~e:, $22.50 24-Apr-02 Mowrrrim $22.50 Subtotal $67.50 $4.05 $71.55 Tax: Total: Thank You. i~~~-' Phone: (717)432-3672 BOROUGH OF LEMOYNE 665 MARKET STREET, LEMOYNE, PA 17043 PHONE: 737-6843 ~ iVj/ ~ EMOYllE, PA 17043 Pe(i~Jd r-3.nge: 10d-')!(h -ill/ .JiUc ~I EFU~E '. . SEWER .l95 458 63' . efuse Sewer . 34.00 20.00 34.00 20.00 PREVIOUS BALANCE PAYMENTS PAST DUE PENALTY INTEREST OTHER CHARGES SPECIAL CHARGES SERVICE CHARGE ~ , . July 5, 2002 VIA OVERNIGHT DELIVERY Cumberland Register of Wills Office Inheritance Tax Collections Cumberland County Courthouse 1 Courthouse Square Carlisle, Pa 17013-3387 Re; Estate of Elsie K. Shiery, Deceased; File No. 21-02-0572 Date of Death: 4/10/2002 Dear SirlMadam: Enclosed is a check for $18,805.93 as payment on account of the Pennsylvania Inheritance tax on the above estate which is due 119/2003. Please send a receipt for this payment to: J. Lyndale Shiery 4212 Isbell Street Wheaton, MD 20906 Thank you. Very truly yours, :r: ~~~ Sl,O J. Lyndale Shiery, Executor (WCI:.24729.I)