HomeMy WebLinkAbout 10-29-14 REV-1500 EX(oz-11)(FI) 1505610105
ns
IJJVania OFFICIAL USE ONLY
PA Department of Revenue p .xennsy County Code Year File Number
Bureau of Individual Taxes AE E�E
PO BOX 28o6oi INHERITANCE TAX RETURN
Harrisburg PA x7128-0601 RESIDENT DECEDENT 0-1 1 `—
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
[05/18/2014 04/21/1919
Decedent's Last Name Suffix Decedent's First Name MI
f
Irwin --- ----_. F
,.� Clare __ ,, I L C........
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
..__._.._.. ..-_..-_. .............. -___.. .....___............. .__._......... ........._.J ..---" .--,-....,..,. I t _....
Spouse's Social Security Number
�-------------- � THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
C@D 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)
O 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 Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
:Barbara Lane + I(717) 975-1821
t............._........ . ......._.....,.. .............. .... .........._ ....__._....._........................._ ........._............__., .... ........ _..._... ..._... _...... p _. ;
REGISTLMO&ILLS USE"O_NLY M
�:o C-D Q
CID
First Line of Address 171 -1 tz7
�r r— N
2806 Rathton Road ,.; ;:- CC
Second Line of AddressC7 z
..........-. _.... _. -.-. _. ..__......._.... ......... _......... ...._ ._. .. . . ._ DAt#FILED F---+ M
City or Post Office State ZIP Code
Camp HIII PA._� 17011 a w
Correspondent's e-mail address: miblane@yahoo.Com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all Information of which preparer has any knowledge.
SIE O�ON RESPONSIBLE FOR FILING RETURN DATE
Gig to 0 7
A05DRESS
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105 J
1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
_ Decedent's Name: Clare C. Irwin
RECAPITULATION
1. Real Estate(Schedule A). .... ... . . . ...... . .. ... . .... . .. ..... . .. . . . ... 1.
2. Stocks and Bonds(Schedule B) .... .......... . .... . .. . . ... .... . . .. .. . . 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . .. . 3.
4. Mortgages and Notes Receivable(Schedule D).... . . . .. . ... . . .. . ...... . .. 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). .. . .. . 5. 564.40
6. Jointly Owned Property(Schedule F) O Separate Billing Requested . .. . .. . 6. 577.23
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested... .. ... 7. 5,070.72
8. Total Gross Assets total Lines 1 through 7 8. 6,212.35
9. Funeral Expenses and Administrative Costs(Schedule H).. . . . . .. ... ... .. . . . 9. 11,935.25
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)... . .. .... ... .. 10. 1,198.87
11. Total Deductions(total Lines 9 and 10)... . .... . .. . .. ....... . .... . .. . ... 11. 13,134.12
12. Net Value of Estate(Line 8 minus Line 11) .... . ..... ....... . ... . . . ...... 12. -6,921.77
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. -6,921.77
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 f` .
(a)(1.2)X.0_ 15.
16. Amount of Line 14 taxable
at lineal rate X.0 45 0.00 16. 0.00
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. 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Clare C. Irwin
STREET ADDRESS
The Bridges at Bent Creek
2100 Bent Creek Blvd.
CITY STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 0.00
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) 0.00
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.......................................................................................... ❑ N
b. retain the right to designate who shall use the property transferred or its income ............................................ ElE
c. retain a reversionary interest .............................................................................................................................. ❑ 0
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ 0
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX+(08-12)
V&pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clare C. Irwin
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. PNC Bank, North 2nd Street,Harrisburg,PA
Custodial Checking account#51-1419-87831519.56 564.40
TOTAL(Also enter on Line 5, Recapitulation) $ 564.40
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX+(oi-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clare C. Irwin
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.Barbara I Lane 2806 Rathton Road daughter
Camp Hill, PA 17011
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.-ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1, A. 12106/04 PSECLI,P.O.Box 67013,Harrisburg,PA
Account#8604951114 1,154.45 50% 577.23
TOTAL(Also enter on Line 6, Recapitulation) $ 577.23
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
vapennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clare C. Irwin
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND
NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. IRA(traditional),Northwest Savings Bank,Barbara I Lane,daughter, 1,267.68 25% 1,267.68
07/11/2014
IRA(traditional),Northwest Savings Bank,Patrick C. Irwin,son,07/11/2014 1,267.68 25% 1,267.68
IRA(traditional),Northwest Savings Bank,John F.Irwin,son,07/11/2014 1,267.68 25% 1,267.68
IRA(traditional),Northwest Savings Bank,Clare A.Frantz,daughter, 1,267.68 25% 1,267.68
07/11/2014
i
TOTAL(Also enter on Line 7, Recapitulation) $ 5,070.72
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(08-13)
pennsytvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Frank Duca Funeral Home,Expenses 9,635.00
Johnstown Tribune-Democrat,Obituary 179.25
Grandview Cemetery,grave opening _ 900.00
Our Mother of Sorrows Catholic Church,clergy 150.00
Luncheon T 921.00
Shetler Memorials,lettering 150.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 11,935.25
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsytvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Clare C. Irwin
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Pinnacle Health Medical 10.00
Synergy(home health services provider) 700.00
State Employees'Retirement System(SERS)-repayment of overpayment/month of May 2014 260.68
Apria(durable medical equipment) 26.22
Alert Pharmacy 201.97
TOTAL(Also enter on Line 10, Recapitulation) $ 1,198.87
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Clare C. Irwin
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)•]
I. Barbara I.Lane,2806 Rathton Rd.,Camp Hill,PA,17011 daughter 25%
Patrick J.Irwin,543 Maple Ct,Kill Devil Hills, NC,27948 son 25%
John F.Irwin, 1603 Woods Creek Dr.,Gamer,NC 27529 son 25%
Clare A.Frantz,4 Houston Dr.,Mechanicsburg,PA 17050 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 none
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
none
TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0
If more space is needed,use additional sheets of paper of the same size.
Performance Checking Statement IV
' ,)PNCBAN-K
PNC Bank
Primary account number:51-1419-8783
Page 1 of 3
For the period 05/14/2014 to 06/12/2014 Number of enclosures:0
A 000320 - For 24-hour banking,and transaction or
CLARE C IRWIN R interest rate information,sign on to
BARBARA I LANE VACLIST PNC Bank Online Banking at pnc.com.
2806 RATHTON RD For customer service call 1-888-PNC-BANK
CAMP HILL PA 17011-2134 Monday-Friday:7 AM-10 PM ET
Saturday&Sunday: 8 AM-5 PM ET
Para servicio en esparlol, 1-866-HOLA-PNC
111111owing? Please contact us at 1-888-PNC-BANK
IM Write to:Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Visit us at PNC.com
TDD terminal: 1-800-531-1648
For hearing impaired clients only
impowrAN'r ACCOUNT INFORMATION
The information below amends the PNC Consumer Funds Availability Policy. Please read this information and retain it with your records.
Effective June 8,2014
Longer Delays May Apply
Funds you deposit by check may be delayed for a longer period tinder the following circumstances:
We believe a check you deposited will not be paid
You deposit checks totaling more than$50,000 on any one business day
You redeposit a check that has been returned unpaid
You have overdrawn your account repeatedly in the last six months
'lliere is an emergency such as a failure of communications or computer equipment
We Will notify You of the delay in your ability to withdraw funds for any of the reasons listed,and we will tell you when the funds will be
available.In this case,funds from the deposit of checks will usually be available no later than the fifth business day after the business day of
your deposit for all purposes.
If you have questions or Would like a copy of the complete Consumer Funds Availability Policy,please visit your'locall PNC,branch or call Lis
at the Customer Service phone number listed above.
Performance Checking Clare C Irwin
Interest Checking Account Summary Barbara I Lane Vacust
Account number: 51-1419-8783
Overdraft Protection has not been established for this account.
Please contact us if you would like to set up this service.
Overdraft Coverage-Your account is currently Opted-Out.
You or your joint owner may revoke your opt-in or opt-out choice at any time.
To learn more about PNC Overdraft Solutions visit us online at pnc.com/0verdraftsolutions.
Call 1-877-588-3605,visit any branch,or Sign on to PNC Online Banking,and select the"Overdraft
Solutions"link under the Account Services section to manage both your Overdraft Coverage and Overdraft
Protection settings.
Performance Checking Statement
For ties period 05/14/2014 to 06/12/2014
11-1 For 24-hour information,sign onto PNC Bank Online Banking CLARE C IRWIN
.� a on pnc.com. Primary account number:51-1419-8783
,-Account number:51-1419-8783-continued Page 2 of 3
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
564.40 1,1:30.00 351.0 1,342.43
Average monthly Charges
balance and fees
991.67 .00
Transaction Summary
Checks paid! Check Card POS Check Card/Bankcard
withdrawals signed transactions POS PIN transactions
3 0 0
Total ATM PNC Bank Other Bank
transactions ATM transactions ATM transactions
0 {} 0
Interest Summary As of 06/12,a total of$.03 in interest was
Annual Percentage Number of days Average collected interest Paid paid this year.
Yield Earned(APYE) in interest period balance for APYE this period
{},{}t}'/, 30 i)31{;7 .00
Activity Detail
Deposits and Other Additions There was 1 Deposit or Other Addition
Date Amount Description totaling$1,130.00.
)5/30 1,130.00 Direct Deposit-\xva Belief
(IS'1'reastuy 310 XXXX\5677 10 10
Checks and Substitute Checks
-heck Date Reference Check Date Reference
camber Amount paid number number Amount paid number
10:3(1 174.84 05/28 083235943 1037 27.13 0(i/I1 0."67232,16
10361 150.00 06/12 085384995
Gap in check sequence There were 3 checks listed totaling
$351.97.
Daily Balance Detail
)ate Balance Date Balance Date Balance
)5,,1 14 564.40 05/30 1,519.5 06,/0612 1,:3.4 2.43
)5/`213 389.56 06/11 1,492.43
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MPOR'I`AAT INVESTOR INFORMATION:Brokerage and insurance products are:
int FDIC Insured--Not Bank(;uarauteed--Not a Deposit
lot Insured By Any Federal Government agency—May Gose Value
ecurities and brokerage services are provided by PNC Investments LLC',a registered broker-dealer anti irtvestrneut adviser and member FINRA and SIPC.
,itttuities and other insurance product,~are olTered by PVC Insurance Services,LLC a licensed insurance agency.
r;Ffi'•1 t,a it ilf�"
Reviewing Your Statement i', FNCBANK
Please review this statement carefully and reconcile it with your records. Call the telephone number on the upper right side of the first page
of this statement if:
• you have any questions regarding your account(s);
" your name or address is incorrect;
• you have any questions regarding interest paid to an interest-bearing account.
Balancing Your Account
Update Your Account Register
Compare: The activity detail section of your statement to your account register.
Check Off: All items in your account register that also appear on your statement. Remember to begin
with the ending date of your last statement. (An asterisk {*}will appear in the Checks
section if there is a gap in the listing of consecutive check numbers.)
Add to Your Account Register Any deposits or additions including interest payments and ATM or electronic deposits
Balance: listed on the statement that are not already entered in your register.
Subtract From Your Account Any account deductions including fees and ATM or electronic deductions listed on the
Register Balance: statement that are not already entered in your register.
Update Your Statement Information
Step 1: Step 2: check Member or
Add together Date of Deposit Amount Add together Deduction Description Amount
deposits and checks and other
other additions deductions listed
listed in your in your account
account register register but not on
but not on your your statement.
statement.
Total A
Step 3:
Enter the ending balance recorded on your statement $
Add deposits and other additions not recorded Total A+ $
Subtotal= $
Subtract checks and other deductions not recorded Total B- $
The result should equal your account register balance = $
Total 8
Verification of Direct Deposits
To verify whether a direct deposit or other transfer to your account has occurred,call us Monday-Friday:7 AM- 10 PM ET and Saturday
&Sunday:8 AM -5 PM ET at the customer service number listed on the upper right side of the first page of this statement.
In Case of Errors or Questions About Your Electronic Transfers
Telephone us at the customer service number listed on the upper right side of the first page of this statement or write us at PNC Bank Check
Card Services,500 First Avenue,4th Floor,Mailstop P7-PFSC-04-M,Pittsburgh,PA 15219 as soon as you can,if you think your statement
or receipt is wrong or if you need more information about a transfer on the statement or receipt.We must hear from you no later than 60
days after we sent you the FIRST statement on which the error or problem appeared.
(1)Tell us your name and account number(if any).
(2)Describe the error or the transfer you are unsure about,and explain as clearly as you can why you believe it is an error or why you
need more information.
(3)"Cell us the dollar amount of the suspected error.
We will investigate your complaint and will correct any error promptly. If we take more than 10 business days to do this,we will
provisionally credit your account for the amount you think is in error,so that you will have use of the money during the time it
takes us to complete our investigation.
Member FDIC =1 Equal Housing Lender 91
PNDMLT01-JO B31754-N40-YNNNNN-002-000682
U '
Pennsylvania State Employees Credit Unions
P.O. Box 67013 Harrisburg, PA 17106-7013
800.237.7328
PSECIUm Member Number: 8604*'****
psecu.com Statement Period: 05/01/14 to 05/31/14
Direct inquiries regarding preauthorized electronic page Number: Regular 1 of 2
transfer or account errors to the above address.
Account Balances at a Glance
Total Shares: $1,564.32
38948 1 AV 0.381 00.703 00.092 T206 P1 213 Total Certificates: $0.00
,, CLARE C IRWIN Total Loans: $0.00
BARBA
2806 RA H ONN RD ----- - -- -"- --
CAMP HILL, PA 17011-2134
IIIIIIII'I'1111'1111111"'1'1'11/'1111"11'lll'lllllll'1'llllllll
001134 06 013999 001 D S2 SAP: 1,2,3,4
s
y,6*
piFt Waima .
Enroll in e-Statements. Log in >>My Money.
YEAR TO DATE INFORMATION
Description Amount
Total Dividends Year to Date $1.38
SHARES
Posting Effective Transaction New
Date Date Transaction Description Amount Balance
REGULAR SHARE ID 01
05/01 Beginning Balance 297.40
05/21 Withdrawal via Home Banking Transfer To Share 04 -250.00 47.40
05/21 Withdrawal via Home Banking Transfer To Share 04 -40.00 7.40
05/31 Payment: Dividend 0.150% 0.02 7.42
Annual Percentage Yield Earned 0.120%from 05/01/14 through 05/31/14
Based on Average Daily Balance of 194.50
05/31 Ending Balance 7.42
Dividend YTD: Year to Date 0.51
CHECKING ID 04
05/01 Beginning Balance 1,723.95
05/02 Payment: Direct Deposit SSA TREAS 310 1,447.00 3,170.95
05/02 TYPE: XXSOC SEC ID:9031736026
05/02 CO: SSA TREAS 310
05/04 Withdrawal POS#10359537 -9.81 3,161.14
05/04 POS GIANT 6005 6560 CARLISLE PK S
05/04 MECHANICSBURG PA
05/06 Check 001149 -2,444.31 716.83
05/21 Payment:via Home Banking Transfer From Share 01 250.00 966.83
05/21 Payment:via Home Banking Transfer From Share 07 140.22 1,107.05
05/21 Payment:via Home Banking Transfer From Share 01 40.00 1,147.05
05/21 Withdrawal Check Card -14.25 1,132.80
05/20 2433239GX05E75RM4 5968 760 THE TRIBUNE DEMOCR 814-5325000 PA
Y��
(R) Pennsylvania State Employees Credit Union Member Name: CLARE C IRWIN
P.O. Box 67013 Harrisburg, PA 17106-7013 a Member Number: 8604""
800.237.7328
PSIECiLi. psecu.com Statement Period: 05/01/14 to 05/31/14
Page Number: Regular 2 of 2
Posting Effective Transaction New
Date Date Transaction Description Amount Balance
05/21 Withdrawal Check Card -179.25 953.55
05/20 2433239GX05E75RLW 5968 760 THE TRIBUNE DEMOCR 814-5325000 PA
05/22 Withdrawal Check Card -48.45 905.10
05/21 2433239GY05EAI H4K 5968 760 THE TRIBUNE DEIVIOCR 814-5325000 PA
05/30 Payment: Direct Deposit PA TREASURY DEPT 651.70 1,656.80
05/30 TYPE:ANNUITANT ID: 1236003133
05/30 DATA:A7005141437015032
05/30 CO: PA TREASURY DEPT
05/31 Payment: Dividend 0.100% 0.10 1,556.90
Annual Percentage Yield Earned 0.100%from 05101/14 through 05/31/14
Based on Average Daily Balance of 1,175.76
05/31 Ending Balance 1,556.90
Dividend YTD: Year to Date 0.87
CLEARED DRAFT RECAP
Draft# Date Amount Draft# Date Amount Draft# Date Amount
1149 05/06 2,444.31
*Indicates a break in check sequence,
MONEY MARKET ID 07
05/01 Beginning Balance 140.22
05/21 Withdrawal via Home Banking Transfer To Share 04 -140.22 0.00
05/31 Ending Balance 0.00
Dividend YTD: Year to Date 0.00
Balancing Worksheet
A. Complete this section to balance your checkbook. B. Checks and withdrawals that are not on this statement
1. Enter"ENDING BALANCE"amount from your statement ..........$
2. Enter any deposits you made that are not listed an this Check Number Amount
Statement Include ATM deposits .... . ... ... .._...................+$ (2)
+$ -----------
(2)
................. .......__...................1$ (2)
3. Add lines I&2.... ............... ...................... $ (3)
4. In part B.list any checks you wrote that are not shown on your statement. Include
ATM withdrawals,SST transfers,online banking transfers, or auto transfers- (You
identify these by placing a check mark in your register next to each check that is
listed on the statement.)
Place total on this fine......__........... .......... (4)
5. Subtract line 4 from line 3 __.............._........... ........... $ (5)
The balance on line 5 should be the balance you have in your checkbook.If you don't
balance,check the following:
1. Is your addition and subtraction correct in your register and
in sections A and B?
2. Does the dollar amount of your check register match the
dollar amount an this statement?
3 Are all deposits and withdrawals accounted for? Total
Important Information
Your Billing Rights-Keep this Notice for Future Use The"unpaid loan balance"used to calculate finance charges is the balance after credits are
This notice contains important information about your rights and responsibilities under the Fair subtracted and advances or other charges are added.
Credit Billing Act, Visa"Loans:You can avoid paying finance charges by paying the new balance of purchases
Please write to us at P.O. Box 67013, Harrisburg, PA 17106-7013. Send us a copy of your each month within 25 days of your statement closing date. Otherwise, the new balance of
statement.Please keep all originals. purchases and subsequent charges from the date they are posted to your account are subject
to finance charges.Cash advances are always subject to finance charges from the day they
In Case of Errors or Questions About Your Bill are posted to your account.
It you think your bill is wrong,or if you need more information about a transaction on your bill,
write us(on a separate sheet)at P.O. Box 67013, Harrisburg, PA 17106.7013,as soon as Purchases: We calculate your finance charges by multiplying the average adjusted daily-
possible.We must hear from you no later than 60 days after we sent the first bill on which the balance,including now purchases,for the billing cycle by the monthly periodic purchase rate.
error or problem appeared.You can telephone us,but doing so will not preserve your rights, Advances.We calculate your finance charges on cash advances by multiplying the average
In your loiter,give us the following information: adjusted daily balance for cash advances during the billing cycle by the monthly periodic
• Your name and account number, advance rate.
The dollar amount of the suspected error. The average adjusted daily balance is calculated by averaging the adjusted daily balances
Describe the error and explain,If you can,why you believe there Is an error.It you during the billing cycle.To calculate the adjusted daily balance each day,we followed these
need more information,describe the item you are unsure about, steps;
You do not have to pay any amount in question while we are investigating,but you are still We take the outstanding balance(all amounts you owe)at the start of the day.Then,in the
obligated to pay the parts of your bill that are not in question. While we investigate your sequence In which amounts are posted to your account,we add the amounts of all debits
question, we cannot report you as delinquent or take any action to collect the amount you and subtract the amounts of all credits which post to your account that day.After applying
question. payments and credits, we subtract the amount of any unpaid finance charges or late
charges.Then we also subtract the amount of any cash advance transaction that posts to
Special Rule for Credit Card Purchases your account on that day of in any previous day in the billing cycle. The result is the
If you have a problem with the quality of goods or services that you purchased with a credit adjusted daily balance for that day.
card,and you have tried in good faith to correct the problem with the merchant,you may not Note:Cash advance transactions which are posted to your account are not Included in the
have to pay the remaining amount due on the goods or services.You have this protection only average adjusted daily balance calculation, and are therefore not subject to the monthly
when the purchase price was more than$50 and the purchase was made in your home state periodic rate for purchases.The average adjusted daily balance is calculated separately for
or within 100 miles of your mailing address.(If we own or operate the merchant,or if we cash advance transactions and is subject to the cash advance monthly periodic rate.
mailed you the advertisement for the property or services, all purchases are covered
regardless of amount or location of purchase.) Additional Important Information: Material contained in the Payment Information table is
Finance Charges-Balance Computation provided for informational purposes and is subject to change based upon your account
Personal Service Loans and Home Equity Loans.We calculate the finance charge for one activity. A credit balance remairting on your Visa account longer than 60 days wig be
day by multiplying the"unpaid loan balance'by the daily periodic rate on your statement.We transferred to your Regular Share account.
then calculate the sum of the finance charges for each day between payments.If the amount
of the payment or credit is not sufficient to pay the entire calculated finance charge, the
remaining"unpaid"finance charges carry over to the next payment or credit.
PSECU Telephone Numbers
Direct Inquiries to: Member Service Telephone Hours
800.237.7328 8 a.m.—9 p.m. (ET)Monday through Friday
9 a.m.—5 p.m. Saturday
TDD:
Rate Line: 800.472.1967 (Nationwide)- 717.777.2100 (in Harrisburg)
800.237.7328
Self Service Telephone:
800.435.6500(Nationwide)
This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender. LENDER
MEL ORT EST
SAVINGS BANK
Where people make the difference.
100 LIBERTY STREET R. O. BOX 128 WARREN, RENNSYLVANIA 16365
July 31, 2014
Barbara I Lane
2806 Rathton Rd
Camp Hill, PA 17011
RE: Clare C Irwin
Barbara I Lane,
Enclosed is the information you had requested on the IRA (individual retirement
account) of Clare C Irwin. As of 7/22/2014 the balance and interest are as listed
below.
XX)0=6257 balance $5,067.22 interest $3.51 total value $5,070.73
If you have any questions or you need further information please call our toll
free number (1-888-588-3071).
Sincerely,
tny Szymczyk -
IRA Department
Northwest Direct: 1-877-672-5678 www,northwestsavingsbank.com
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LEL60Z
Synergy Homecare of Mid Pennsylvania Invoice
453 Lincoln St., Suite 110
Date Invoice
Carlisle PA 17013 #
717-243-5473 5/13/2014 C1704
Bill To
Clare Irwin
2100 Bent Creek Blvd
IZN1200
Mechanicsburg,PA 17050
P.O. No. Terms Project
Due on receipt
Quantity Description Rate Amount
2 Service:05/05/2014-Amber Cleck 25,00 50.00
2 Service:05/05/2014-Amy Bingaman 25.00 50.00
2 Service:05/06/2014-Whitney Geesaman 25.00 50.00
2 Service:05/06/2014-Rachel Denne 25.00 50.00
2 Service:05/07/2014-AmvBingaman 25.00 50.00
2 Service:05/07/2014-Rachel Denne 25.00 50.00
2 Service:05/08/2014-Amber Cleck 25.00 50.00
2 Service:05/08/2014-Rachel Denne 25.00 50.00
2 Service:05/09/2014-Whitney Geesaman 25.00 50.00
2 Service:05/09/2014-Charlotte Daniels 25.00 50.00
2 Service:05/10/2014-Tammy McKelvey 25,00 50.00
2 Service:05/10/2014-Charlotte Daniels ?5.00 50.00
2 Service:05/11/2014-Amy Bingaman 25.00 50.00
2 Service:05/11/2014-Charlotte Daniels 25.00 50.00
I lave a great week!
Phone# Total $700.00
717-243-5473
COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM S�
HARRISBURG REGIONAL COUNSELING CENTER
30 NORTH TFIIRD STREET', ROOM 319 S
HARRISBURG, PA 17101
TELEPHONE:(717)783-9065
FAX:(717)783-9599
'rOLLFREE: 1-800-633-5461
www.sers.state.pa.us
July 22, 2014
Estate of Clare Irwin Invoice# 30444
C/O Barbara Lane
2806 Rathton Rd
Camp Hill PA 17011
RE: Clare Irwin
SS#:
Dear Ms. Lane:
We have been informed of the death of Clare Irwin a retired member of this System. We wish to
extend our condolences to you at this time.
Since Ms. Irwin died 5/18/14 and the May check was not returned to our office, this account has
been overpaid in the amount of$260.68 for the period from 5/19/14—5/30/14. It will therefore
be necessary for our office to be reimbursed for$260.68 to liquidate this overpayment.
The reimbursement should be made payable to The State Employees' Retirement System,and
mailed with the enclosed copy of this letter to the address shown above.
If yod have not already done so,we will need a certified copy or an original death certificate
for our file. If you cannot permanently spare the originals, please submit them with a note to ask
us to return them. We will return the originals to you within 5 working days.
Upon receipt of the reimbursement, this account will be closed. There are no further benefits to
be paid from this System.
Should you have any questions concerning this matter,please do not hesitate to contact me at the
above address or by telephone at(717)783-9065 or 1-800-633-5461.
Thank you for your cooperation.
Sincerely,
Linda Dolan,Administrative Assistant
Harrisburg Regional Counseling Center
Enclosure
Past 0.0 $0.00
Cu"ont 0.0 $26.22
F., .!.I Amount 0.0 $2612
'APRIA'
The Apria Great Escapes Program is a national
program that allows our patients to travel
"If comfortably and conveniently while on oxygen
or other therapies.
Please contact your local branch at(717)761-0830 for
d more Information.
Date of,' ' . I
ServIcs Invoice Daicription
PREVIOUS BALANCE
06105/2014 00000989 PATIENT RESPONSIBILITY PER INSURANCE
Current Insurance Information on file:
Primary. SELF PAY PRIMARY ONLY Amount bu'e�-�,
$26.22
KWWJt3M 3028-APRMTMT"20082-28eoI0381-P;5208121-1.151;34855492-1:1
Thank you for using Aorta Healthcare.We appreciate your business.VI
You are responsible to notity Aorta of changes in Insurance coverage or disoontin
Failure to provide accurate insurance Information may resuft in the mspon
Accredited by The Joint Commission
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D. C. NOKES,JR.
ATTORNEY AT LAW
2.43 ADAMS STREET
JOHNSTOWN,PENNSYLVANIA 15901-2002
814535-6288
FAX V4-02309
LAST WILL AND TESTAMENT
Of
CLARF. C IRWIN
I, CLARE C. IRWIN, of the Borough of Westmont, County of Cambria, and State of
Pennsylvania, being of sound mind and memory, do make, publish and declare this as and
for my Last Will and Testament, hereby revoking all former Wills by me at any time
heretofore made.
FIRST: I direct that my debts and funeral expenses be paid by my Executor as soon
after my death as conveniently may be done.
SECOND: I give, devise and bequeath to the person or persons identified in any
J
written statement which is signed by me, and attached to my Will,whether prepared at the
time of making this Will or at a subsequent time, certain items of tangible personal
property described therein. This provision authorizing reference to such a separate
agreement does not necessarily mean that such a statement has been made by me in
connection with the making of this Will.
THIRD: As to the balance of my worldly Estate, and all the property, real, personal
or mixed, of which I shall the seized and possessed, I give, devise and bequeath unto my
beloved children, BARBARA I. LANE, of Camp Hill, Pennsylvania, PATRICK J. IRWIN, of Kill
Devil Hills, North Carolina, JOHN F. IRWIN, of Johnstown, Pennsylvania, and CLARE A.
FRANTZ, of Mechanicsburg,Pennsylvania,to share and share alike. Should any of my
children predecease me,then his or her share in my estate shall pass to his or her children,
per stirpes, and should any of them predecease me without issue, his or her share shall
pass to the survivor or survivors of them.
FORM Should any of the beneficiaries referenced in the third paragraph above
be minors, I give, devise and bequeath their share in trust, until they reach the age of 21
years,and I hereby appoint the surviving parent of any minor beneficiary as Trustee of the
share of said minor beneficiary. I authorize said Trustee,in his sole discretion, to consume
the principal of said minor's estates for the health, education,maintenance and support of
said minors.
i
a FIFTH: In addition to the powers granted him or her by law,my Trustee hereunder,
shall have the right and power to retain in trust any property transferred to or accepted by
him from my Executor or from other sources; to transfer and hold trust property in the
name of a nominee or nominees satisfactory to him; to compromise claims and
controversies; to vote and give proxies in respect to stock or other securities forming part
of the trust,and join In plans of reorganization,merger,consolidation or exchange thereof,
to exercise subscription rights and to pay and charge principal or Income of the trust with
sums which may arise therefrom,as he,in his sole discretion,deems propel,to sell, assign,
lease,transfer,and pledge trust property upon such terms and for such prices,as he,in his
sole discretion,deems proper,without the consent of any court.
SIXTH: I appoint my son, JOHN F. IRWIN, executor of this, my Last Will and
Testament to serve without bond.In the event that he should predecease me or be unable to
serve as said executor, then I nominate, constitute and appoint my daughter, BARBARA I.
LANE,to serve as alternate executor,to serve without bond.
nATIS Ur'FENNNILVANIA
} SS:
COUNTY OF CAMBRIA }
I, CLARE C. IRWIN, testator, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I
signed and executed the instrument as my Last Will and Testament; that I signed it
willingly; and that I signed it as my free and voluntary act for the purposes therein
expressed.
Sworn or affirmed to and acknowledged before me by CLARE C.IRWIN,the Testator,
this day of January,2001.
(SEAL)
Clare C.Irwin
G1mr..;i,'I o
. y G .,,;)n ..i'rir ,r:h... ^i i Notary Public
STATE OF PENNSYLVANIA }
} SS:
COUNTY OF CAMBRIA }
We, D. C. Nokes, Jr. and Catherine E. Vitale, the witnesses whose names are signed
to the attached or foregoing instrument, being duly qualified according to law, do depose
and say that we were present and saw testator sign and execute the instrument as her
Last Will and Testament; that CLARE C. IRWIN signed willingly and that CLARE C. IRWIN
executed it as her free and voluntary act for the purposes therein expressed; that each of
us in the hearing and sight of the testator signed the Will as witnesses, that to the best of
our knowledge, the testator was at that time 18 or more years of age, of sound mind and
under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me by U. 0. Nokes, Jr. and (.nlhadflo
E.Vitale,witnesses,this ay of January,2001.
D. Nokes,Jr.
9
Catherine E.Vitale
Notary Public
`�h%nips PA,ial4p,i'1rt.uV�' iir'
l
.. k.-'`x... `"'..iu., ^a_5_.:�,�,..,._.. .�._.: —c _...
IN WITNESS WHEREOF, I have hereunto set my hand and seal this .1f day of
January,2001.
SEAL
Clare C. Irwin
Signed, sealed, published and declared by the above named Testator, CLARE C.
IRWIN, as and for her Last Will and Testament, in the presence of us, who at her request
and in her presence and in the presence of each other, have hereunto subscribed our
names as witnesses thereto.
D..G Nokes,Jr.
Catherine E. Vitale~
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