HomeMy WebLinkAbout08-29-14 J 1505610101
REV-1500 Ex(01-10)
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of individual Taxes TAX RETURN County Code Year File Number
PO BOX 280601
Harrisburg,PA 19128-0601 RESIDENT DECEDENT J T
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMODYYYY
12/02/2013 07/04/1927
Decedent's Last Name Suffix Decedent's First Name MI
MILLER ARLENE G
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
. REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
M 1.Original Return O 2.Supplemental Return O 3. Remainder Return(date of death
prior to 12-13-82)
O 4.Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
OD 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9.Litigation Proceeds Received O 10. Spousal Poverty Credit(date of death O 11. Election to lax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
THOMAS E. FLOWER (717) 243-5513 v
_ � o ,m
REGISTE- -IMLLS USE QY M
n C:)First line of address _ _ ;D I-- m CO
FLOWER LAW, LLC � 73
2 T p
Second line of address C7 p_
coo ,�., 3 ?7
10 W. HIGH STREET o C= ro
City or Post Office State ZIP Code QATEiiILED
FV O
CARLISLE PA 17013 N
e
Correspondent's e-mail address: TOM @FLOWER-LAW.COM
Under penaftles of pedury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
It is tore,correct and complete.Declaration of preparer othWAhIm the personal representative is based On all information of which preparer has any knowledge.
NATURE OF PERSON R ONSIBLE FOR F G ft TURN DATE
V, 1 -/
Ao
MARJORIE M. MOWE4& F M. KNO SE, 166 UNION HALL RD., CARLISLE, PA 17013
S OF OTHER TH EPRESENTATIVE DATE
08/12/14
ADDRESS
FLOWER LAW, LLC; 10 W. HIGH STREET; CARLISLE, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610101 1505610101 J
1505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's Name; ARLENE G. MILLER
RECAPITULATION
1. Real Estate(Schedule A). .. ... ................................... .... 1. 700,000.00
2. Stocks and Bonds(Schedule B) ....... ................ ... ..... ........ 2. 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4, Mortgages and Notes Receivable Schedule D 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 225,474.34
6. Jointly Owned Property(Schedule F) = Separate Billing Requested .. ..... 6. 0.00
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 68,389.53
8. Total Gross Assets(total Lines 1 through 7)................ ....... ...... 8. 993,863.87
9. Funeral Expenses and Administrative Costs(Schedule H)............. ..... . 9. 29,347.60
10. Debts of Decedent.Mortgage Liabilities,and Liens(Schedule 1)............. . 10. 641.89
11. Total Deductions(total Lines 9 and 10)... ..... .... ........ ... .... ...... 11. 29,989.49
12. Net Value of Estate(Line 8 minus Line 11) ......... ........... ... ...... . 12. 963,874.38
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ... ........... ... ....... 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ....................... . 14. 963,874.38
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.0_ 15.
16. Amount of Line 14 taxable
at lineal rate X.0 45 963,874.38 16, 43,374.35
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 18.
19. TAX DUE . .... ... .. .......... ..... ........... ... .............. .... 19. 43,374.35
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT t1111111)
Side 2
L 1505610105 1505610105 J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: / 7
DECEDENTS NAME
ARLENE G. MILLER
STREETADDRESS
234 DORWOOD DRIVE
CITY STATE 21P
CARLISLE PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) 0) 43,374.35
2. Credits/Payments
A Prior Payments _ _. __ ___ _ 44,5_00.00
B.Discount 2,168.72
Total Credits(A+B) (2) 46,668.72
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 3,294.37
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;........................................................................................ ❑
b. retain the right to designate who shall use the property transferred or its income;............................................ ❑
c. retain a reversionary interest:or.......................................................................................................................... ❑
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 1c❑
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ 0
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ 0
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ E ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dales of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent(72 P.S.§9116(a)(1.1)(i)).
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116(a)(1.1) (ii)).The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)1.A sibling is defined,under
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1502 EX+(11-08)
. pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF
ARLENE G. MILLER FILE NUMBER
21-13-1334
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM Attach a copy of the settlement sheet if the property has been sold.
NUMBER Include a copy of the deed showing decedent's interest if owned as tenant in common.
VALUE AT DATE
DESCRIPTION OF DEATH
1' FARM HOUSE ON 125 ACRES IN N.MIDDLETON TWP.,CUMBERLAND COUNTY,PA
KNOWN AS 234 DORWOOD DRIVE,CARLISLE,PA 17013;TAX PARCEL 29-07-0471-009
ASSESSED UNDER CLEAN AND GREEN AT$188,800.00;ESTIMATED VALUE$700,000.00 700,000.00
TOTAL(Also enter on Line 1, Recapitulation.) $ 700,000.00
If more space is needed,insert additional sheets of the same size.
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REV-1508 E%+Oi-TO)
}� pennsytvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC,
In"ERITANcE TAX RETVR" PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MILLER,ARLENE G. 21-13-1334
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1, ORRSTOWN BANK CHECKING ACCT.#404772 (+/-22,000) 22,765,81
2, MEMBERS 1 ST Fed.Credit Union,total funds on deposit in various certificates 174,968.13
3, M8T BANK CHECKING ACCT.#9832877980 26,080.40
4, 1997 BUICK LeSABRE AUTOMOBILE 1,660.00
TOTAL(Also enter on Line 5, Recapitulation) $ 225,474.34
If more space is needed,use additional sheets of paper of the same size.
T TYPE .STATEMENT PERIOD PAS£
98328779801 POWER CHECKING f MOV.0S-DEC.04,2013 I OF I
00 0 04341 5" MM 017
000005094 FIDS1549DO1712041312 02 000000 14200
MARLIN E MILLER
ARLENE G MILLER
234 DORWOOD DR
CARLISLE PA 17013-2142
INTEREST EARNED FOR STATEMENT PERIOD 0.19 STOMENEDGE
INTEREST PAID YEAR TO DATE 2.37
WITHHOLDING YEAR TO DATE 0.61
BEGINNING ACCOUNT SUMMARY ikl�.Tqt%RENtT-... :END
'T OA=
AMOUNT I NO. I AMOUNT NO. AMOUNT
23,228.16 if 21852.24 1 ol 0.00 1 11 0.05 0.20 26,080.55
-?POSTING-.. ACCOUNT ACTIVITY;TRANSACTION bESCDYhTION:. . , : IN T� :BALANCE'Y
DATE.
11-05-13 BEGINNING BALANCE $23,228.16
12-02-13 RETIREMENT DIS8 CKG CREDIT 2,852.24 26,080.40
12-04-13 INTEREST PAYMENT 0.20
12-04-13 FEDERAL WITHHOLDING ON INTEREST PAYMENT 0.05 26,080.55
ENDING BALANCE 026 080.55
ANNUAL PERCENTAGE YIELD EARNED 0.-00 X
SAVE MONEY ON GIFTS AND MORE AT MAJOR RETAILERS THIS HOLIDAY SEASON. FIND OUT
HOW TO GET ADDITIONAL SAVINGS BY USING YOUR H&T VISA DEBIT CARD OR "9T VISA
CREDIT CARD AT "ORE. TKAN 50 RETAILERS WHEN YOU VISIT HTB.COM/SROPPING.
FOR CUSTOMER SERVICE QUESTIONS, PLEASE CALL 1-800-724-2440. MEMBER FDIC.
COOS N12)
r DATE FROM DATE TO PAGE ACCOUNTNUMBER
St Members aI Credit Union 09/25/2013 12/31/2013 t of 4 XXXXXXX194
5000 Louise se Drive vc
P.O.Box 40
Mechanicsburg PA 17055-0040
• (800)237-7288
MEMBERS V (717)697-5312(Hearing Impaired)
es ALCREDrruan. w .membcrslst.org
ARLENE G MILLER
234 DORWOOD DRIVE
CARLISLE PA 17013
1099-INTs are not included in this statement. If you earned at least $10.00 in dividends on your
account for 2013, you will receive your 1099-I NT in a separate mailing in January 2014.
ACCOUNT
Your current Member Loyalty Rewards level is Titanium. Your aggregate balance as of December 1st is$174,968.12.
CHECKING �. 0.00
SAVINGS 74.11
CERTIFICATES 174,901.48
LOANS 0.00
REGULAR SAVINGS rrrr
BALANCE: $73.35
Eff. Post
Date Date Description Deposits Withdrawals Balance
09130 09/30 Deposit Dividend 0.150% 0.01 73.36
Annual Percentage Yield Earned 0.170%from 09/01/13 through
09/30/13
10/04 10/11 Deposit Transfer From Share 0047 25,043.66 25,117.02
10/11 10/11 Withdrawal Transfer To Share 0058 25,043.66 73.36
10/31 10/31 Deposit Dividend 0.150% 0.73 74.09
Annual Percentage Yield Earned 0.150%from 10/01/13 through
10/31/13
1122 11/22 Deposit 15.98 90.07
Deposit 15.98-Coin Counter
11122 1122 Withdrawal 15.98 74.09
11/30 11/30 Deposit Dividend 0.150% 0.01 74.10
Annual Percentage Yield Earned 0.160%from 11/01/13 through
11/30/13
12/31 12/31 Deposit Dividend 0.150% 0.01 74.11
Annual Percentage Yield Earned 0.160%from 12/01/13 through
12/31/13
ENDING BALANCE: $74.11
ota Deposds 15 06040� o aT al Wthdrawa s'c �`
Y k 25,059.64:
- `a. -u"ft ✓ 4 A`
's<
.MEMBERS V _ DATE TO PAGE ACCOUNT NUMBER
FFlIF.RALCMZTWON 09/25/2013 12/31/20131 20f4 I XXXXXXX194
MONTH r , .
Eff. Post
'BEGINNING BALANCE:. $25,035.7¢?
=
Date Date Description Deposits Withdrawals Balance
09130 09/30 Deposit Dividend 0.350% 7.20 25,042.94
Annual Percentage Yield Earned 0.350%from 09/01/13 through
09/30/13
10/04 10/04 Deposit Dividend 0.350% 0.72 25,043.66
Annual Percentage Yield Earned 0.350%from 10/01/13 through
10/03/13
10/04 10/04 Renewed at 0.350%to mature 04/04/14 25,043.66
10104 10/11 Withdrawal Transfer To Share 0000 25,043.66 0.00
10104 6 MONTH CERT CLOSED
'This is the final statement presenting information on this product
Please retain this final statement for tax reporting purposes.
ENDING BALANCE: $0.00
17-
'o Deposits 7.92 Total With als•draw 25,043.66 -
MONTH rr
_BEGINNING BALANCE:' 5254l57.83_
Eff. Post
Date Date Description Deposits Withdrawals Balance
09/30 09/30 Deposit Dividend 0.350% 7.21 25,065.04
Annual Percentage Yield Earned 0.350%from 09/01/13 through
09/30/13
10/31 10/31 Deposit Dividend 0.350% 7.45 25,072.49
Annual Percentage Yield Earned 0.350%from 10/01/13 through
10/31/13
11/30 11/30 Deposit Dividend 0.350% 7.21 25,079.70
Annual Percentage Yield Earned 0.350%from 11/01/13 through
11/30/13
12/31 12/31 Deposit Dividend 0.350% 7.46 25,087.16
Annual Percentage Yield Earned 0.350%from 12/01/13 through
12/31/13
ENDING BALANCE: $25,087.16
r Tota eposrts 29.33 - 'Ma unity Date - 01/28114
MONTH rr
BEGINNING BALANCE: $5Q000.00
Eff. Post
Date Date Description Deposits Withdrawals Balance
09/30 09/30 Deposit Dividend 0.650% 26.71 50,026.71
Annual Percentage Yield Earned 0.650%from 09/01/13 through
09/30/13
09/30 09/30 Withdrawal by Check 26.71 50,000.00
10/01 10/01 CHK#852738 DIVIDEND W/D 09/30/13 50,000.00
10/31 10/31 Deposit Dividend 0.650% 27.60 50,027.60
Annual Percentage Yield Earned 0.650%from 10/01/13 through
10/31/13
10/31 10/31 Withdrawal by Check 27.60 50,000.00
11/01 11/01 CHK#861042 DIVIDEND W/D 10/31/13 50,000.00
11/30 11/30 Deposit Dividend 0.650% 26.71 50,026.71
Annual Percentage Yield Earned 0.650%from 11/01113 through
11/30/13
11/30 11/30 Withdrawal by Check 26.71 50,000.00
12/02 12/02 CHK#868901 DIVIDEND W/D 11/30113 50,000.00
12/31 12/31 Deposit Dividend 0.650% 27.60 50,027.60
�' EMBERS 1" 's
•!Mr EALMEDIT ON 09/25/2013 12/31/2013 3of4 XXXXXXX194
Elf. Post
Date Date Description Deposits Withdrawals Balance
Annual Percentage Yield Earned 0.650%from 12/01/13 through
12/31/13
12/31 12/31 Withdrawal by Check 27.60 50,000.00
ENDING BALANCE: $50,000.00
o a Deposits - 108.6 - ot8 ithdrawa s
�Jvlaturity.Date . 07/16114
MONTH rr
BEGINNING BALANCE: _ - $74,770.66
Eff. Post
Date Date Description Deposits Withdrawals Balance
09/30 09/30 Deposit Dividend 0.650% 39.95 74,810.61
Annual Percentage Yield Earned 0.650%from 09/01/13 through
09/30/13
09/30 09/30 Withdrawal by Check 39.95 74,770.66
10/01 10/01 CHK#852739 DIVIDEND W/D 09/30/13 74,770.66
10/31 10/31 Deposit Dividend 0.650% 41.28 74,811.94
Annual Percentage Yield Earned 0.650%from 10/01/13 through
10/31/13
10/31 10/31 Withdrawal by Check 41.28 74,770.66
11101 11/01 CHK#861043 DIVIDEND W/D 10/31/13 74,770.66
11/30 11/30 Deposit Dividend 0.650% 39.95 74,810.61
Annual Percentage Yield Earned 0.650%from 11/01/13 through
11/30/13
11/30 11/30 Withdrawal by Check 39.95 74,770.66
12/02 12102 CHK#868902 DIVIDEND W/D 11/30/13 74,770.66
12/31 12/31 Deposit Dividend 0.650% 41.28 74,811.94
Annual Percentage Yield Earned 0.650%from 12/01/13 through
12/31/13
12/31 12131 Withdrawal by Check 41.28 74,770.66
ENDING BALANCE: $74,770.66
ota Deposits 162.46 Total Withdrawals 16046
Maturity:Date; 07/16/14
MONTH (00 58)
BEGINNING BALANCE: $0.0.0
Eff. Post
Date Date Description Deposits Withdrawals Balance
10/11 10/11 Deposit Transfer From Share 0000 25,043.66 25,043.66
10/31 10/31 Deposit Dividend 0.350% 5.04 25,048.70
Annual Percentage Yield Earned 0.350%from 10/11/13 through
10/31/13
10/31 10/31 Withdrawal by Check 5.04 25,043.66
11/01 11/01 CHK#861044 DIVIDEND W/D 10/31/13 25,043.66
11130 11/30 Deposit Dividend 0.350% 7.20 25,050.86
Annual Percentage Yield Earned 0.350%from 11/01/13 through
11/30/13
11/30 11/30 Withdrawal by Check 7.20 25,043.66
12/02 12/02 CHK#868903 DIVIDEND W/D 11/30/13 25,043.66
12/31 12/31 Deposit Dividend 0.350% 7.44 25,051.10
Annual Percentage Yield Earned 0.350%from 12/01/13 through
12/31/13
12/31 12/31 Withdrawal by Check 7.44 25,043.66
ENDING BALANCE: $25,043.66
st
DATE FROM DATE TO PAGE ACCOUNTNUMBER 7
'MEMBERS'lit;
FFDERALCREDIT 09/25/2013 112/31/20131 4of4 1 XXXXX_XX194
fk�a�"s. r �j M �Y ',r •ray�c � i{ ,r,s^i r. a•r. < <
�.TotalrDeposiLs t'T ,,y re ' 25063 34. TotaI�VJ{htlrawals �,"fl f .,:�' pt` "�T g 19 68)} .
afun`4
M
»� ."„ �",• ��{��.^CS '�f.:.M.�?li.k'��•�'.°�'{r04/1�'�/1�.k� ,����,�(dree���,y'"."k_,'±��`�������� ,� a< �� �� �
YTD SUMMARY
TOTAL DIVIDENDS PAID
0000 REGULAR SAVINGS 5.44
0047 6 MONTH CERT 43.66
0055 6 MONTH CERT 87!16
0056 11 MONTH CERT 122.87
0057 11 MONTH CERT 183.76
0058 6 MONTH CERT 19.68
Total Year to Date Dividends Paid(Includes Closed Shares) 874.97
z ,
Retirement Plan Statement
T ItMe �RETttELAJI D.,EIO�I s — 7' LM 23 3
01-01- 'Ap
INDIVIDUAL RETIREMENT ACCOUNT M&T
TELEPHONE BANKING CTR
M&T BANK AS TRUSTEE FOR PO BOX 767
BUFFALO, NY 14240
0011105 40802288 800-829-1924
4345 27:765
ARLENE G MILLER
234 DORWOOD DR
CARLISLE PA 17013
`14
UANKFIDWUMBER 16-0538020 BIRTNDA
DAT NSACT10NiDE3RIP1`(ON AMOUNT LANE
ACCOUNT NO 35-004110112329 ACCOUNT TYPE SELECT -12MO RATE 0 .200
MATURING 08-25-14 REGULAR IRA
01-01-13 BEGINNING BALANCE 47,313.29
08-25-13 INTEREST 76.86 47,390. 15
08-25-13 ACCOUNT RENEWED
12-02-13 TAX WITHHELD-NORMAL W/D 503. 33- 46 ,886 .82
12-02-13 PAYOUT DISTRIBUTION 2,852.24- 44,034.58
12-31-13 INTEREST 32. 72 44, 067.30
ACCRUED INTEREST AS OF 12-31-13 0.24
N
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a
8
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g
PLAN SUMMARY
BEGIN PLAN BAL 47,313.29 DISBURSEMENTS 2,852.24
PLUS DEPOSITS . 00 FED TAX WITHHELD 503. 33
NET INTEREST 109.58 ST TAX WITHHELD .00
LESS DEDUCTIONS 3,355 .57
TOTAL PLAN VALUE 44,067. 30
2013 IRA CONTRIBUTION INFORMATION
THIS INFORMATION ,IS BEING FURNISHED TO
THE INTERNAL REVENUE SERVICE
BOX 1 - IRA CONTRIBUTIONS IN 2013 OR 2014 FOR 2013 0.00
BOX 2 - 2013 ROLLOVER CONTRIBUTIONS 0 .00
BOX 5 - FAIR MARKET VALUE OF PLAN AT END OF 2013 44 ,067.54
BOX 7 - IRA
L007(11113)
F "IVA Aviva Life and Annuity Company
811 5th Av enue
PO Box 4905
Des Moines IA 50306-4905
(800)551-5268
ARLENE G MILLER M&T SECURITIES INC
234 DORWOOD DR ACCT KIMBERLY HEAVNER
CARLISLE PA 17013 285 DELAWARE.AVE STE 2000
BUFFALO, NY 14202
Phone: 800-350-9285
Interest To.You..
Your life Insurance statement is a good way to keep Cash values in life insurance always grow tax-deferred.
track of your contract's transaction activity,to see how It's an efficient way to put compound interest to work for
your premiums are allocated and to review the interest you;you earn interest on your money, interest on the
rate credited to your account. We have created this money you would otherwise have paid in taxes, and,of
new format to make it easier for you to understand all course, interest on your interest gained. For long-tern
of this information, savings,few other financial vehicles offer this Gear
advantage.
ANNUAL LIFE INSURANCE STATEMENT
08124/2008 THROUGH 08/23/2009
Insured: ARLENE G MILLER Product Name: WEALTH TRANSFER ADVANTAGE
Contract Number: 30WT504437 Contract Date: 08/24/2005
issue State: PA
Summary of Values&Benefits
Your Cash Value as of 08/23/2008 was$25,190.09
Death Benefit as of 08/23/2009 Contract Value as of 08123/2009:
Base Death Benefit before Loan: $37,906.00 Cash Value $25,354.94
Outstanding Loan 0.00 Surrender Charge 999.99
Net Death Benefit after Loan: 37,906.00 Outstanding Loan 0.00
Surrender Value* 24,354.95
*The Surrender Value is guaranteed to be no less than the Principal as long as the Cumulative Premium Balance
equals or exceeds the No-Lapse Guarantee Premium. Otherwise,the Surrender value will be the Cash value minus
the Surrender Charge and Outstanding Loan balance,if any.
Coverage is guaranteed until the maturity date of the contract under guaranteed and non-guaranteed interest credits
and mortality and expense charges as tong as the Cumulative Premium Balance equals or exceeds the No-Lapse
Guarantee Premium.Otherwise,the contract will remain in force as long as the Surrender Value is positive.The
minimum guaranteed death benefit is the face amount shown in your contract The face amount will be adjusted with
requested changes in face amount, and reduced pro-rata in the event of a partial surrender.
Principal: 25,000.00
Cumulative Premium Balance: 25,000.00
No-Lapse Guarantee Premium: 25,000.00
This contract is a modified endowment contract(MEC)and, as such, gains in the contract are taxable as income
when withdrawals or loans are made. In addition, a 10%penalty tax is imposed if such distributions are made before
the insured has attained age 59'!2. For more details on the tax implications of a MEC,you should consult with a
legal and tax advisor.
AMOSA094US Page 1 of 5 Contract Number 30WT504437
REV-1511 EX+(10-09)
7pennsy[vania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ARLENE G. MILLER 21-13-1334
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. EWING BROTHERS FUNERAL HOME,PROFESSIONAL SERVICES 6,507.08
2. EWING BROTHERS FUNERAL HOME,EOUPMENT 890.00
3, EWING BROTHERS FUNERAL HOME,MERCHANDISE 2,385.00
4. EWING BROTHERS FUNERAL HOME,CASH ADVANCES 607.08
S. CUMBERLAND VALLEY MEMORIAL GARDENS,GRAVE OPENING&INTERMENT 75100
6. CLERGY HONORARIUM 150.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Names)of Personal Representative(s)
Street Address
CRY State ZIP
Year(S)Commission Paid:
2. Attorney Fees: 7,500.00
3. Family Exemption:(i£decedent's address is not the same as daimant's,attach explanation,)
Claimant
Street Address
City .. _. . . State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 503.50
5. Accountant Fees:
6. Tax Return Preparer Fees:
7, PUBLICATION OF ESTATE NOTICES:CLIMB.LAW JOURNAL($75)&THE SENTINEL($190.54) 265.54
B. PPL
319.92
9. ERIE INSURANCE,FIRE&HAZARD POLICY PREMIUM 1,373.00
10. CHECK PRINTING FEE 26.90
11. H&R BLOCK,2013 INCOME TAX PREP 103.00
12. CONTINUATION SHEET TOTAL 7,963.58
TOTAL(Also enter on Line 9, Recapitulation) $ 29,347.60
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SCHEDULE H
CONTINUATION SHEET
ESTATE OF ARLENE G. MILLER FILE NO. 21-13-1334
12.A. 2014 County/Local Real Estate Tax 561.00
B. Furnace repairs 384.99
C. 2014-15 School Real Estate Tax 2,132.63
D. Plumbing repairs• 4,884.96
Continuation sheet total: 7,963.58
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle,PA 17013
(717)243-2421
December 8,2013
Faye M. Knouse
519 Garland Dr.
Carlisle, PA 17013
The Funeral Service for Arlene G. Miller
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
Professional Services
Basic Services of PA L.F.D. 1,200.00
Basic Use of Facility 250.00
Documentation Prep/Recording 375.00
FD/Staff Supervision View/Visit/Service 375.00
Facility/Equip View/Visit/Service 375.00
FD/Staff for Interment Service 150.00
Total Professional Services ----2,725.00 -
Equipment
Transfer Deceased to Funeral Home 295.00
Hearse Usage 295.00
Safety/Lead Vehicle 150.00
Utility Vehicle
150.00
Total Equipment ------ ---------- 89000----
Merchandise
Dakota Poplar Casket 2,250.00
Register Book
40.00
Memorial Folders 85.00
Thank You Notes
10.00
Total Merchandise Selected -----------------Z, —5.-do-----
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO
OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
Cash Advances
The Sentinel Obituary w.Photo 328.08
The Valley Times Star 60.00
Death Certificates
Flowers . 60.00
159.00
Total Cash Advances -------------------50'7368-----
SALES TAX 0.00
SUB-TOTAL 6,607.08
INITIAL PAYMENT/DISCOUNT/CREDITS 100.00 w�9a� LF'r
TOTAL AMOUNT DUE 6,507.OS C .�.✓.� (05t�/�;
REV-1512 Ex+(12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE DE EDENT URN MORTGAGE LIABILITIES & LIENS
RESfDEM DECEDENT ESTATE OF
ARLENE G. MILLER ESTATE FILE NUMBER
21-13-1334
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1. THORNWALD HOME
412.18
2 PPL 55.03
3. MILLENIUM PHARMACY
37.85
4. DIRECT TV
5.29
5. CENTURYLINK,PHONE SERVICE 131.54
TOTAL(Also enter on Line 10, Recapitulation) $ 641.89
insert itio
If more space is needed, addnal sheets of the same size.
REV-1513 EX+(01-10)
�q
pennsylvania SCHEDULE ]
DEPARTMENT Of REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ARLENE G. MILLER 21-13-1334
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
1. MICHAEL E.MILLER, 1035 LONGS GAP RD,CARLISLE,PA 17013 SON 25%
2. DAVID M.G. MILLER, 1192 ROYAL LINKS DR, MT.PLEASANT,SC SON 25%
3. FAYE M.KNOUSE,519 GARLAND DR,CARLISLE, PA 17013 DAUGHTER 25%
4. MARJORIE M. MOWERY, 166 UNION HALL RD,CARLISLE, PA 17013 DAUGHTER 25%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
OF
ARLENE G. MILLER
I,ARLENE G. MILLER of 234 Dorwood Drive, Carlisle, Cumberland
County, Pennsylvania, 17013, being of sound and disposing mind, memory and
understanding, do make, publish and declare this as and for my Last Will and
Testament, hereby revoking and making void any and all former Wills, Codicils, or
writings in the nature thereof, by me at any time heretofore made.
FIRST: I hereby order and direct my Executrix or Executor, hereinafter
named, to pay all my just debts, funeral expenses, testamentary expenses and all
Inheritance, Estate, Transfer and Succession Taxes, as soon as may be conveniently
done after my death, out of my residuary estate:
SECOND: I give, devise and bequeath my entire estate of whatever nature. .,. _ ..
and wherever situate to my children, MARJORIEM. MOWERY, FAYE M.
KNOUSE, MICHAEL E. MILLER, and,DAVID M.G. MILLER,in equal.'
shares per stirpes. Should any of my children predecease me and leave children as of
the date of my death, I direct that the share of my deceased child shall be paid to or
for the benefit of that child's surviving children in equal shares per stirpes. Should
any of my children die without issue, that child's share shall be paid in equal shares to
my other children.
THIRD: Should any grandchild of mine inherit directly from me, I direct
that that grandchild's share of my estate be paid in Trust to that child's surviving
parent for the maintenance, support, medical expenses or educational expenses of said
child, with the authority to invade principal for these purposes, and that income from
said Trust be paid to or for the benefit of said child after the age of 18, and that any
unexpended income or principal of said Trust be paid outright to said grandchild
upon attaining the age of twenty-two (22).
LASTLY: I nominate, constitute and appoint my daughters, MARJORIE
M. MOWERY and FAYE M. KNOUSE, acting jointly, to be my Executrixes, of
this my Last Will and Testament. Should either of my daughters not survive me by a
period of at least thirty (30) days or be unable or unwilling to act as such, the other
may act solely as Executrix. No Executor or Executrix shall be required to file bond
in this or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of 12011.
Arlene G. Miller
SIGNED, SEALED, PUBLISHED and
DECLARED in'die presence of'
COMMONWEALTH OF PENNSYLVANIA
ss
COUNTY OF CUMBERLAND
On this, the a`� day of November, 2011, before me I+l-Okhg- t tai L�-
notarTpublic, the undersigned officer, personally appeared James D. Flower,
Jr., of Flower Law, LLC, known to me (or satisfactorily proven) to be a member of
the bar of the highest Court of said state, Supreme Court ID Number 27742, and a
subscribing witness to the within instrument, and certified that he was personally
present when Arlene G. Miller, the Testatrix, signed the attached or foregoing
instrument, having been duly qualified according to law, and having acknowledged to
said attorney that she signed and executed the instrument as her last Will, that she
signed it willingly, and that she signed it as her free will and voluntary act for.the
purposes therein expressed.
a, In witness whereof, Lhereunto set my hand and official seal.
Arlene G. Miller, Testatrix
Notary Public
COMMONWEALTHOOF - lIy1,VANIA
NOTARIAL SEAL
THOMAS E.FLOWER,Notary Public
Carlisle Boro.,Cumberland County
My Commission Expires October 26,2014
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
On this, the aq may of November, 2011, before me'IGerrAz, 6, {zap
notary public, the undersigned officer, personally appeared James D. Flower,
Jr., of Flower Law, LLC, known to me (or satisfactorily proven) to be a member of
the bar of the highest Court of said state, Supreme Court ID Number 27742, and a
subscribing witness to the within inst.rr-ument, and certified that he was personally
present when he and �q-wW L , F^ c'
-6wR , whose names are signed to the
attached instrument, being duly qualified according to law, did depose and say that
they were present and saw Testatrix sign and execute the instrument as her Last Will;
that she signed willingly and that she executed it as her free and voluntary act for the
purposes therein expressed; that each witness in the hearing and sight of the Testatrix
signed the Will as witnesses; and that to the best of their knowledge the Testatrix was
at that time 18 or more years of age, of sound mind and under no constraint or undue
influence.
In witness whereof, I hereunto set my hand and official seal.
Witness
C.�
Witness
Notary Public
COMMONWEALTH OF PENNSYLVANIA
NOT SEAL
THOMAS E.FLOWER,Notary Public
Carlisle Boro.,Cumberland County
M Commission Expires October 26,2014