HomeMy WebLinkAbout11-05-14 �
� 15 0 5 61412 0 3W4647 8.000
pennsylvania
�EPARTMENTOFREVENUE EX(03-14)(TP) �
REV-1500 �FICIAL USE ONLY
County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN �� c-�
PO BOX 280601 /^�)/� )
Harrisburq PA 17128-0601 RESIDENT DECEDENT t � �� �
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
02/18/14 06/14/25
Decedent's Last Name Suffix DecedenYs First Name MI
HARRIS ANNE A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Return � 2. Supplemental Return � 3. Remainder Return(date of death
prior to 12-13-82)
� 4. Agriculture Exemption(date of ❑ 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
� 7. Decedent Died Testate � 8. Decedent Maintained a Living Trust 1 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
❑ 10. Litigation Proceeds Received ❑ 11. Non-Probate Transferee Return ❑ 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
� 13. Business Assets ❑ 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MAUREEN SMITH 717-766-1430
First Line of Address
407 DARLA ROAD
Second Line of Address
rv �`
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City or Post Office State ZIP Code C —� � rn
MECHANICSBURG PA 17055 � Q �=, � �
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CorrespondenYs email address: �J �� r ���� � �+ �'-5 5 �✓ (� (���� � °���i`� � Cfl t'7
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REGISFER QF WILLS USE�NLY.:'::; --��
REGISTER OF WILLS USE ONLY � "�'�
DATE FILED MMDDYYYY — � ---= C7
� C"�1
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. �
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
I II'I�I IIIII IIIII IIIII IIII�III'I IIIII IIIII IIII IIIII"II IIII
� 1505614120 1505614120 J
�
� 1505614220
REV-1500 EX(TP)
DecedenYs Social Security Number
Decedent's NameANNE A HARRIS
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 0 ��
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2. 35HH45 00
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. 12H6Or'J 0�
6. Jointly Owned Property(Schedule F) � Separate Billing Requested. . . . . 6. 32733 ��
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedu�e G) � Separate ai��ing Requested. . . . . 7. 10995 00
8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , g. �j31 178 ��
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. 3Z44O ��
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . . . . , , , , . 10. 783 ��
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. 33223 ��
12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , �2. 49795'rj ��
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which
an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13. � ��
14. Net Value Subject to Tax(Line 12 minus Line 13), , , , , , , , , , , , , , , , 14. 497Q�j5 0�
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- � �0 15. O ��
16. Amount of Line 14 taxable '
at lineal rate X.0- � �� q g. � ��
17. Amount of Line 14 ta�ble
atsiblingratex.�z 95992 00 ��. 11519 04
18. Amount of Line 14 taxable
at co��atera� rate x.�5 401963 00 �s. 60294 45
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 71 H 13 49
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
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 person responsible for filling the return is based on all information of which preparer has
any knowledge.
SIG TURE OF PERSON RESPONSIBL OR FILIN TURN DATE
�
DRS � � • �'
.c'-Cd /�/�G�.`�S /l
SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN I DATE
T. /df��//�
ADDRESS Q
�Go�7 '/"W,til�?+� �.� or-n Ic�/s��rc� 0.� I�o`l.3
III'I IIII)IIIII IIIII IIIII IIIII II'l)III I IIIII II'll"II III Side 2
� 1505614220 1505614220 �
3W4648 7.000
REV-1500 EX(TP) Page 3
File Number
Decedent's Complete Address:
DECEDENTS NAME
ANNE A HARRIS
STREET ADDRESS
773 OAK OVAL
CITY STATE ZIP
MECHANICSBURG PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 71813
2. Credits/Payments
A. Prior Payments �
B.Discount �
(See instructions.) Total Credits(A+B) (2) �
3. Interest
(3) �
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) �
5. if Line 1 + Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 71813
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . . . . . ❑ 0
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? . . . . . ❑ �
4. Did decedent own an individual retirement account, annuity, or other non-probate property,which
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ X❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116 (a) (1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
� The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a step-parent 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 decedenYs 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 decedenYs 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.
3 W4671 5.000
, REV-1503 EX+(g_12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCETAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ANNE A HARRIS
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. US SAVINGS BONDS — SERIES HH 52, 500. 00
2 RAYMOND JAMES — ACCOUNT 15065830 306, 345. 00
TOTAL (Also enter on Line 2, Recapitulation) $ 3 5 8, 8 4 5.0 0
swasss�.000 If more space is needed, insert additional sheets of the same size
' JUL-30-2014 14:2B BAYMbND �AMES & ASSQC. 219 531 5�44 P.D2 !
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REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPAF2TMENTOF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
ANNE A HARRIS
Include the proceeds of litigation and the date the proceeds were received by the estate.
All ro ert 'ointl owned with ri ht of survivorshi must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 �, AMERICAN GENERAL LIFE ANNUITY — ACCOUNT CI256144 103, 404 . 00
2 AMERICAN GENERAL LIFE ANNUITY — ACCOUNT CI242615 19, 231.00
3 FEDERAL TAX REFUND 1, 207 .00
4 ANDERSON & PATEL ASSOCIATES, PC — REFUND OF OVERPAYMENT 200. 00
5 OHIO CASUALTY — PREMIUM REFUND 178 .00
6 PERSONAL BELONGINGS 4, 385. 00
TOTAL(Also enter on line 5,Recapitulation) $ 12 8, 6 0 5. 0 0
3W4sAD 1.00o If more space is needed,use additional sheets of paper of the same size.
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A�eriaan General Lifs Insurance ComPany . � .
P.O. Box 871, ,4marfiio, TX 79106-Q879 CHEC1t# 16588621
INTERNAL. FiEFEHENCE# 2200185206 !
. TRANSAC7'!ON 5TAT�MEN'T !
NAME: . A�tN� HARRIS Mar�h 'E7, 2�'14 �
� POLICY: CI256144
TI�ANSACTtON: DEATH Ct.AiM FROCEEDS '
OWN�R: ANN� HARRIS -
AMDt�NT (}F CH�CK $ 103,403.52
' TAKA�I.� W CUM E $ 3,�4p�,52
�
I
PLEA;E DFsTACH AND KEEP TH�S S`�'i]B FOR YOL7�t R�CO�DS
� �` ��� � ,A;r�����a�ii ��inera� �� � MA��►g�aa��ss° • � , � �vernlgf►tMaiGngAddress: �
, �.." . �.Apnuity Service Ccntee : Anaulty Sezvice C�ns�r
' . .L'i�e Companre�- ' � .,�' . 'r P O Soa 87I .. . . � 205U N Westz�S`c�et '
Ameri.c�iGeneralTafeInstn'sn�e,Com�?any' �,•� Amarillu,Texas 79105-0$7l AmariElo,TX791Db-7011 -
- Telephope; SDA.42R.499D ,
�. �Arar��mr Cu�[�r S�ra�M�n�(�r��t�ucr�o�s ori�a��5j . .. � . � . . � :
C4NTRACT NUMBER:���� C�R�UP T�ICATE NUMBER{iF ap�r7icable);
r. �.��o�n��s�n.a.xr�rTarrr: _._._.L�/��%. 1 /��-1��1 S' . � . .
, Z:. FULL NAME QP UECEAS�A OWNEit{if other than abov�):Annc��uris � . .- .
. . .�Otliar�Names�psed by Dece�sed Owner(ineluding maiden name) � , . . , . . � .
• 3. IN W�AT�A.PACI�'Y OR BY WHAT TITL'E DO YQL1 CX,AItVY'S��'RbCEEDS7 �"xG G/�/�l 1� . .._.._
t
� .� a.' Fnl�Nama of Benefi�iary Clairne�t:. � �.�����.' 'CQ � �f'�'C.. /-�,���l�1 �� � �
� . . :. li;�:Da#e of Birth: '� �ra . .� - ��.c:.Sltaxe af bane�it alaimed�(percent br fiactiori amannt):•��d� /CJ �
. . . .�d. Sociat SecuritynrTaX�iayerIDNuml�er: �� ""- �:��t� r,� �� . . - ._.:
, .�, Address: , �b � �I1�"��� 1 w � , � (, ) .���'•-��.�c�'fi��'
Streot Box Number Hnzne Telsphona Number
�
. � � � ���'���i��G1�' � . . �. �. ��. .. �t a ���W ��13—��/(l
� � —�City . . State •. . Zip Code . : ���'�lephona Nuwber
f. I�t�sa.th was accidental,give date af�C�idettt and describe bow�nd wh�re accidea�t occurrecl. . � -,
4. MANlV`ETt C��PAYMENT,OR QT�iER OPII(JN,�ESIR�+D: • � .
Tf the amozint�aya�rle to you is$51i,004 or�nnre,you e�n elect to have the prnct�:ds ps[d through a Brldg�Ac�oient �-
(not ava��abae i�alE etates),a t'i�ee,inteses�benrin�p�cc�►unt i�yaur name described in tlip enclosed��tnc�ure, ��-.' " ' :
. • T�ie Bridge Ae�annt is a saf�,sec�ue pIac�ta keep your prucc.edg while ynu decide how to b�st nse t�em. ' . ' � '
.�. r,A peisonal dra�bc�ak will k►e mailed to yp� nnea paur claim has been apprAved.Xoa may accBss xlt or part of�ha
r � *�money sim,p�q by w.riting a c�ratt far.$250.U0 ax mare.Any�maunt tlaaf r�m�i�s irt the acc�unt will eontinue-to earn � .
t,�" 1rit8T'CSk. . . . • � . . . � - - • ' '- , � .
• The Brict�e Accc�uat is naY insur�ti b�WB�ederal Depnsit T�tsura�ce C�oratio�►: . � • .� -
. . Account 6�Iances�ti�e l�ability af Ameaican G�neial T3fe Insuran�Company,ant��w�resasva the right to�xedace
accflunt ba�ancss for�y payment made 3�.exror. .
. If your annuity benefit is Iess than$SR,tlOQ,�+e w3i2 send yau�ch�ck fac�te total bene�it atr�ount �
� `� ■ T�r�sig�aturc��chits Annirity Claimant Statain�nt will.be userl as yaur si�natare cetd fox�the Bz�dge Acaotu�t., •
� Totnl Distrib�tian: .. . - . . .
�lease pay the prnceecis tmuSc be$�A►0�0 or more}thrdugh the Br�dge ACcount. . , . � . .
�., �leAse by�uss#h�Bridge Account and send me one check fa�r the proCeeds payable. •
Other puyuient opfionss �
Leave pK'aueeds s►s�ope��laam�"until further»offce.(Yon m�st Still cpmplete an@ r�turn this form now to clairn
� th� proc�ects.) Yf you are x�qui�ced to begit� rnisuinnm distributio�s, we wiLl confact yoU to ttrrange tlae details. ,
G�exally� tbe aunuity proceeds wili be distributed five years from ttae data of death af f�s decedenE. Please uotify
the Tnswrer af any change in yowr ma�ing addmss:''
__. $�ustal ca�ati�uat�on(available for Il2As and nonqu�Ti&ed annuit�es onlya�
- Aimuitization �ennuity pa�tnents uptAon)�'�eaee aend annuitization quatss ta rne. � . �
If na�leclaon is mac�e,cIai�ms will 6e pafd thmugh a•single eheck.
. `Pirocauls tnay x�mai��n We cout�act far up to fevc years�o]lowing ihe ct�nq�act awrcer'�deuth.
�f►xaceeda rcma�ning in the cantract wif3 he enbjcet a�mgrket fl►�ctuadons(�a the Gasa o�v�,riable ar ind�^aced cor�tract�).
Pra�e,arls r�maininS In fixed iaferese contxact w�lt cantinu�to acccue ix�cerest us provided)m the con�cea�
ACrL,A�09(12J12) • �'sge 1
' . i
5, �'OSSESSTOT+T t)�CUN'1.'RA.CT/C�It3�CA'X�: . - t
� Z bereby cerbify that,to the best af my 3ct�owletlge,the contract/ce�ti�Zcate h�s zwt been assigned nr pletl�et9 as collateral�nnd t�at,
the cUntructJc�rtiftcate; .
(Seieet ane):
is enclose�l.
• ll is not in rny poss�ssian�and I am vz�aware of its whereabouts:I agree tl�at:should lhe,oni$ina4 come�into my possession,
I wil�xeetur�n�t to#�e Insu�r.I understand that kha or�ginal caniract ar certti�icate sl�all bscr�m�nyll and void.
G. �'ViTHI�iOLDWG ELEC".['iO�T5
The disEributian(s) yau�csive frorn the Insur�ar are s�bject to fede��l income tax withh�lding ai�iless yau elect nat #a bave
wittfhalding apply. Withholding will only apply to the ta�cable portion of ynur distribution. Your xriflttwlding e�ctian will
remain in effect vntil you revoka it.Uniess yda�lect otl�erwise on page 2,we Will WxWhCitd 1Q%O o£t�le�taxable am4unt O�your
distribut�on. Spnusal benefi�iaries recerving el�gible rnllov�r distn'butions from c�ualified�lans and 4Q3(b}s�may ta�subject ta
20�mand�kory�cn�it�6holding.5`p�usal�enef�ciaries receiving disiribu#3ons�fram IItAs and nonqualifietl ann�ides are not subject
to 20% withholding. . � ,
States with a state yncflma fax eifher xeq.�tire mandatory vs�itlih�ld'u►g or atlavv valtzntxry withJ�olding, Tf your state xequir�s
marfdatory wiihholdin�,we will witl�h�Id the mundat�ry arnounr without re�ard ta yaur elscYipn balaw.Each state�etermines
their spe�ific state withholdin� re+�uireenaents and w� will fallaw �our sfate of dDmic�le witt�holding obligatFons. Stare �
�avitbholdin$may be subject to a 5% administrative default rate when state withl�old'zng is requ�te�l and na witl�hplding amount
is designatcd. Your �tate of residence m�y m�quire tiiat yonr state inCome fa7z withfaoldxng �lectiq�n he PKovided tn us on a
. specKff�state form.Shwld your sfate o�domicile re.�uire a speci�ic state witbholding fonm,yo�tr state incotne tax wat�holding
eIectiau wiTl not occur nn[il the r�tjuir�xl forrn'is receivecI by our c�ff�ce.
fiven if you �tect not ta have�ederal or state income tax witbheid,�if puu do not havg ennugh fed�r�l incnms tax wit�lteld,
� you ars�Iiabie for payment of the income ta�on the taxable portiou af the dislribvcion.You may alsa t�aubj�ct to tax penattie�
' your payme,nts of estimaEed tax and qrxthholding,if any,�nnt adequate.
��1� $
1 Q Fgdaral WithhaEding Electinn
��' J�Dt}NU�'withhold at�y fede�I income Q Y1U w3xi�hoId federal Sncnme ta�es in the amount of_. I
� . . • . x .
.�� � mxes un1ess mandated by law (cannot be less than aay mandatory withholding)
a z
� " ��� �State Wlthltolding Electlan � � Ca DD wikhhold state i�aco�ma taxes in the amount of . ' .`Yn
���� �� ❑ DD NOT witf►hald any state income�e� � (canno�be 2esm Wain a►�y mandgtory withf�olcivag)'
y Q�'m unIess naandated by]aw : • • '
� ��'�'� z Natir,e td non-res€dpnt aliens:A�paymeat ta an address outside fi�eUxiited St�tes maq l�e suhjeck to fec�eral it�come
��5'� � #ax withholdin$at a rate of 30%>nriless#1�e�ayee submi#s a�o�mpleted.IltB Paran W-SBEN(specifying the payee's
� u�� � U.S,ta�aye�r identific�[inn number)and the payment is eligible�or redufie�cl wiFhholding,
I, the nndersigneci, hez•eby make claim tn thc Deat�Benefit�aygble undex prn�visions of the cantract/cettz�xcate sad ag�e that tt�i
papers called far by �e insurer s�tall be,a part af Shis statement. Deafh CeMiPcute and CnntructlGerHf#�a#e must 6e refurned
vnith this for�m if not in t6e paesession oF the Insurer.
X ha�ve read and I understan�the fm�artant discfosure 9nfarmatian located on pages 3 and q af th�s�orm.
I further�ertify ihat the information contained in this fbrm is hve�nd carrect t+�tl�e best of�y Ycnowlec�ge. •
� �'URM�[JST BE�Tl��' I)
mG��C�'� �� c�U I� ��.� �,�/� �� ^ , ��_.�:���
Date � � � � Cl ani's Signat�ure'�
�►�� co�oP C(�.mbP�Ir�r�c� .
s����� _. _ -
On ihis � � day of ,���1 ,, -. ���' . ,ts�frnre mapereonalty ap�eared
CY'��')
�,lA.�'�� S�(Y'�`► known�W me rn� provetl to me ta be the identicai��ezsan, d�scziberl in and�wb.o
� executeci the fare,gain,�statement,and ackn��vl�tiged�execution af tl�e same as a fiee act aad deed for the purpos�t�aerein nained.
M�COri'1pa1SS�0A BX�t2� ��,,I / � � �
Notary b c
AQL�{l9(I2l12) � . Page 2
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Amertcan G�neral Li#e lnsuran�e Cornpany � � �
P.O. Box 871, AmarNlo, TX 799Q5-0871 . , CH�CK# 166t14369 �
, 1NTERNAL RE��RENCE# 220p196180
� - TRANSACTION STAt�M�NT
' {�IAME: AIV�IE I�lAR�1S M8�'Ch 3.1� 201�4 .
- POLtCY: CI2426 7 5
TRANSACTION: DEATH CI.AfM PRAC��US �
� OWN�R: Ai�N� HARRlS .
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" AMClUN7' l7F CH�CK � S . 19,231,49 �
TAXABL� LNCC7M� $ � 15,231.49 - '
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PLEA�E DETACI-I AI�D K�EP 'S�i�S STL1� FQR YOUR REC{}RI38 �
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1Vlailing Addres9:
� Ak�7�rMC�� �rQ�er�� Am�uity8arviceCenter
�.0.Box 871
° �,ife CQmpanies . . ." ,��,�o,�c��zos.og,�
Ar�rterican General L�fe In�uranc�CarnpanY ave�i$btkr�u�n$nac�res�:
Annuiry Bervice Center
xosor�w�s�►�suc�c
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ANHUETY CU1iHlANi"STATEN]EFIT INST[tUCTIQN3�1�PAf3E 5 1
CflNTRACI'NUMBLR: � �'S�� �, f GR�CIP CERT�FICA'T$DTiJMBI?R(if Appt[cttbI�}:
1. FCTLL NAMS OF DECEA�Ell AIVNUITANT(Patticipant): .f�f t� J�1�.1���}� , ,.. _.,._,.
2. FLJLL NAME CiF DBC�A.S�D DWNL�R(if nthor#.h�n aUove): J.. /.�/�(-��'' !./!��'�S' —
Other Names Usesi By DecGased Owner(inoluding maiden name)
3. ]N WZ��,.T CAPACITY OR BY WFIA'�TTTLE DD Y�U CLAIIv�'Y�PROC�E�S? �� :�f [,�j�j S( �
a. �'u�lName o��ea�Be�a�y c�ai�ant: �'���1�-C t9� �IJ t��"� 1��i�2.�.i�
b. Dat$of$ih�: �^�,•�����p� c. Share of benefit clainned(pexr�ent ar frackian amoua#): /�� /C�
T—,.� �i�� ��� g � ��
d. Social Security ar T�xpayer ID Num6er:
e. A,ddress; '7�J � y7 �)Z.�.. 1� �d . E�/7) ��� /'�7�.�C� ._.
StreetorBnxNumber ..�. Hoate Tele�honcTlnmber
� e r�N re.? �� � a�.��" c7��� 9�3-� �9 r�
��Y �St�tc ZlpCade ��v�r WerkTelepbopaNumber
� Z�deafh was acczdenta(,give data of acczd�zt and desatl6e how a�nd.wh�re acciclont occurred.
a �
4. MANNER OP PAYMENT,OR QTHER�PTION,DESIEt�D: f
If tf�e�moubk a uble ta au�ls$50 nOQ or more ou ean etect tu havs t.�e xoceeds aid throu a�rld �;Aecount not �
i� Y Y � ,Y ,p P S� � ( �
ava�lable in�a�1�ntes),a iree,interest baaring account in your name descr98ed fn#be encloaed brochure. i
• The I3xidge Accaut�t is a safe,aecur�place fo keep your praceeds while you decids how ta aest use them. ;
• A persoual dra$bpqk will be axai�ed#o you once yot�olaim has beeu appFoveci.You map access uil or parB of the money !
simpiy by writin�a dt�foz$250.U0 ar ruore. Any a�nQunt tbat renaains itt fhe account wll►continuo to eaxn�ernst. �
• •T7se Bridge Account is not insured by the Federal Dapnsi�ins�rrunce Corppra�Ion. �
• Aaeount balanecs arce ihe ti�b9lity of American General.Life lnsnrar�.ce Comparry,and we xaserve th��g�to reduce acaoUnt �
balances for an�paymenfm�de 3�errdr.
� • I£your annuity hene�it is less tlxau$SR,000,we wall sand you a uhook for the total bauef'it atrqx�at.
• The sigaature on#his A�Ui#y Claimanr Statement will bc usec[as yawr sigaafure aard far thd Bridgc Accour�#.
Taial Dietr�bution:
s
�'[casv pAy thc proceads(must be$50,000 or more)thron$h aBridge.9�oeoant.
✓ Piease Irypass tlze Brid�e Accaunt and seud nae one cTaeck far#tce prac�eds payabYa. �
i
Other payment opttons: �
}
Leave praceeds ss"open c�aim�°'un#it�urther not�ce.(You must still comptete and ret�un th9�form now t�claim the
ptuucecds.}��you are r�quia�ed to begini minimum distri6utfons,we w111 c�n,€act yon fa a�xange th�details.(3enaraily,tha
annuity proc�eeds wi11 he distr,ibut,�d flve years�'i'om the d�tte a�deak�t A�t��doc,�dent. Please nntify the Insurer of a►�y
ch�nnge in your mailing address.'��
_ .._ _.. S�ausal con#inuatinn(availabte fnr IltAs�►nd 1►onc�ual�ed aamuities pniy}z
� A�nnuitize►tion(annaity��yments ophon)—Plaase send an�uitlzaiion quutes to ma,
�f no e�ect�an is made,claiuuis win be paid throngi�a sYngte chcck.
�Proceed$may remain in fhe con#rt�at for up ta five year.�follow�tg#h$eontraot ownar'�death.
Z�'rooeeds re�ainiag itt the comr�ct wili be sabject to market f�ctuations(in thc case nfvaria6le or indexed contra�ts).
Proceeds remaining xn fixdsl interest CQntructs wifl continue to aca,rua 3�erest as provided in fi�a contract �
AOL 409(GIA3) � Page 1
I
. � ..
` 5. POSS�SSIOT+X O�'CONTRACT/CIIt�'ICA3"E:
I hareloy cet�ifsy#hat,to th�best of my knowledge,t�e contract/aeztl#icate has not been assigned oz'pledg0d as collatemml and that the
coutract/certiScste:
(B�Iect cmc): :
is enc�osed.
�S na#jn npy passession a►id I am uQawarn of�ts whereabants.1 agree thst shaold tlte original+Gome intn my possession,I ;
vvill xetar,n It to the Inaursr.I understaad that the nrig�inal contract rnr certi�cate Shall beconte nu3l and void. !
i
6. WI�'�HQLD}NG�LECTIONS: I
T1r� distr7butiou(s} yan rec�ive firom the Insurer a�re subjac� to federai incame tax witi�holding unless yau elect nat to have
withlioldin�g gpply.Withholding wilf onty spp�y ta tl�e taxable portion of your ciistr3bution.Your withholci�ng election will rem�ain in
wffcct unt�l yqu ra�vokc xt.Un[ess yau elect othprwise on page 2,we wlll w�it[�he�Id 10°/�of the taxabI�atnount of your dista'Ibution.
Spousal beneficiaries iecazviwg gligible Xo�tnver distn'butions frnm qu$lified pians and�03(b}a msy be subject to �0°10 mandatnry
wifbhoiding.Spousal benefciaries reaeiving d�stributiQns fram iRAs and nonqualified annuxtles are not subject to 2U°10 wit6hoIdIng.
States wlth s state iwaaxr�e fttx�ither req�ir�mandatory withholdir�g ox allaw uo�untary wiFhXzolding.Tfyour state requix�s mand�tnry i
witbhalding,we will wit�hold the rnandatary arnalmt witt►out ragard ta y�ur slectinn below.�ach state dotermines their speci�Zc s#ata I
wi#hholding requirements�d we wiill fiolIow your atate o£domicile wt�holding obligations.Sfiata withholding may be nubject to s
5%adm�a�stratiue default xate when state wit�haidin$is requ�ated and na wifhholding amount ia designated.Your state o£xestdenca
may rec�u�re tbat yow state iaaome#ax w�thl�olding eiection be pronided#o us on a speafic s#a#a�oz�i.Should your state nf domictle
req�ite a sp���s����oldiag form,your s#eto incomc t�wi.t�bolding e.��ction will�aot oeeur untit the rac�uired form i�received
by aur o�ics.
�ven if you e�ect not to have federaE or 9kate incame�wilth�Ze�d,or#fyau da�ant have enough fCderal ittcome tax withheld,yo�are
liable far�pa�yment of tl�e fncnme taac on the t�abla gortion a�the distrihation.Yflu�+'atso be subject to taJc penalfies if your
" payments of estimated tax aad withhalding,if any,aie aot adequate. ,
;
Fsderal Wikhhaid[ng Electian
❑ TtD NUx�w�ithhald any federat ine�nc t�es uc�ess CT D(l withhuld federal iacomu ia�es in tite amnunt nf ___.%
�uandated by law (cennot b��ess thau any mandatazy withholding) .
Sf�Ee Wltith4[dtng�fecfIan
❑ DU�UT withkxold�ay stabe incoatte tax�y unless 0 DO withl�old stat,�inGorae taxes in the amounh oF %
mandated by law (eannoi he Ress tban any man�i$tozp wit6b.oldi�n,�)
Notiee to non-re�ident a!€ens.A payment to an acEciress rnitside the United States may ba subjsct to�ederal in�eome tax
wzthha�ding at a rate of 30%, unless the payee subraits a compl�ed IR5 �arm W-BBEN {spac[�ing the payee's U,S. I
tax�ayer identlflca#ia�n�znber)and the paymcat�is eligfblc for reduced withho�c�ing.
T,t�o undersignec�hereby make c�aim ia the,De,at#��eneflt payable und�r prov�sin�.s of tha contraet/cartific�te and agree that all�apers calted fo� �
by ihe�nsuirer shall b$a part nfthis stutement.IJeatL Cert[flcate and Confrac�lCerti�icate must be r�tarned w�tlh t�tis foxm it'not in tb� �
possesaion�f tlte f�surer. p
E
T have read aud I un�lerstand the�im�wrtsnt disclasure iufarmaHon located an pagee 3 and a a�'th9s for�u.
T fu�th�r cortify t1�Ethe ire�oxmation caztta�lned in this form ix true and r�uect to the b�st of tny knu�vvltxige.
�'ORM MUST BE NOTA,RiZED
� �� 1�-f �` ' ✓����
Date f Cl��s�iQneturi.,�t.��---
. � � ri" -
STAT�OF v✓vi. �,F' � c� COUN2'Y OF
On thia c��� day af � �d�� ,be�ore me peusonally agpeare:d
(xear)
�.�t.0 P'�[.� �.,_„X�►`�""`--~" lanown to me or�raved tn ma to be thc idanticsl person dsscrib�d;in
and who axeauted tha foragoing stateruent,a:ad ar�mowledged;the�ecurian of the sgm s a frea aat aud dee for tlae purp4se th�rein.
named. " - -
My commissiou expires L�.� � �� -
. N°�' ��na V N -
Na7AR1AL�AC �
. ' QFi�H1'f.R.t�phHMAN,�'1o1ery p'abll0
' � I�ta�den't4up.,Cumbarland Cnunty ;
• .A.GL+309(G113) � � My Ci0ml�l�Cn�q1lres M�y►21?���l
. �
REV-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMEM OF REVENUE
INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ANNE A HARRIS
If an asset became jointly owned within one year of the decedenYs date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
f{, MAUREEN SMITH 407 DARLA ROAD, MECHANICSBURG, PA 17055 NIECE
B.
C.
JOINTLY OWNED PROPERTY:
�-reR DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FORJOIM MADE INCLUDE P1AME OF FINANCIAL INSTITUTIONAND BANKACCOUM NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TEW+M JOINT IDEMIFI'INGN.MBER.ATfACHDEEDFORJOIMLYHELDREALESTATE. VALUEOFASSET INTEREST DECEDENTSINTEREST
1. A. 8/18/2008 PNC BANK, INTEREST CHECKING
ACCOUNT 50-0529-9569 3, 429. 00 50. 00 1, 714 .50
2 A 8/18/2008 PNC BANK, PREMIUM MONEY MARKET
ACCOUNT 50-0529-5517 62, 037 . 00 50. 00 31, 018 .50
TOTAL(Also enter on Line 6,Recapitulation) $ 3 2, 7 3 3. 0 0
3W46AE 1.000 If more space is needed, use additional sheets of paper of the same size.
Tot� Bankin� Sta�e�nexa.�G . p pl��`�A�iOlK
PN�Bank
Prirnaryac�ount n�rmb�r:50-0529-9569
Page 1 of 4
�'a�tftp period Q�/74/�Q7A,to 03/73/��74 Number ofenalosures:4
0010�8 • • ��or 24-hour banlcinc�,and transaction or
�� MAUREEN SMI7H interesk rate informatian,sign an to
407 �AR L.A RD PNC Bank Online Banking a#pna,corn.
MECHANTCSBURG PA 17055-6658 '1"r Forc��stom�reervicecall1-888-PNC-BANK
� Mond2y-Friday:7 AM-'[p PM ET
Saturday&5unday: 8 AM-5!'M E1'
P2ra seivicio en es�af�ol, 1-g6S-H�LA-PNC
Mauin�� Please cantact us ak 7-888-PfUGSANI<
�Write to:CUstomeT 5eivice
PO Box 609
f'ittsburgh PA 15230-973$ �
�Visit us at PNC.com
� 'fDl7 terminal:9-800-537-1648 i
For hearing impaired clicn�i only '
l
RelatNonsh�p Overview . .
Bank DEeposit Acc�unt�
Dascrit�tion ' • Accou�t Number [7eposit Balance
TntErest Checkiu�r 5()-0529-95�i9 2,5�:1,9fi
Premium]U1one}�Marlcet 5U-0529-55x7 30,50�.19 4
'�otd1 Z)epusiis • $3�Q'1,6.15 ;
i
Pe�rforrr�an+�e Check�ng . . M���ee�sm�cE,
�nEerest C[�eckiug AGeaun�Su�nNnary
AcoaN�nt numher:50-0529-9589
bverdra/t Pratec#Rou Provided By; XXSCXXX�a517
�verc�rat't Govrerage-Yaur accasan#ls currentlyQpted-��t�
You or your joint owner may revolca your o(�C-in or ont-out ciloiae at anytime.
Ta learn more ahout PNC Ovardraft Solutlons vislC ue onllne at pnc.com/overdraftsolutions.
Call 1-by7-588-3605,visit any hranch,or sign on to pNC Online Bankiny,and aalectthe"Overdraft
Solutlons"link undertE�e Acoount Servlces sectlon to manage boCh your Overdraft Coverage and Overdraft
Protection ssrtings,
Balance Sum�marl� . , .
. . , 8eglnning Depnsfts ond Checks and other �ndSng
balance , other addilfons deduotlons balance _
, 3,f37..$7 :L,05492 2,1(i�.r�3 2,5�I.9G
. averaga monthly Cheraes .
balai3oe ahd feas
?,52,O.SG A�
Trar�sac�[on Sumnc�ary
. Checks pald/ Check Card POS Cheak Card/Bankoard
' withdrawals signed transactions POS PIN transactlons
� 8 � 0 '
Tofal ATM PNC 6ank Other Bank
� transactlons AiM transaotlohs � nTM transactions
0 U 0 '
' R �
.��
PNbMLT09-J(�837782-P140-�1NNf�N N-D02-44 7967
'�'ota�. Ba�n.kirig St�.te�nean.t
For tite psrivd��/'�4/Z074 to OSl1$/7q74
I�I For 24-hour informaYion,sic�n Qn to PNC Bank Ontine Bantcfpg �+AAUR�EN SM1TH
�on pnc.com. Primary aGcotmt numher 50-0529-9569
Account number:50-0529-9569-cantinued Page 2 of 4
�����eS#������,�. As of 03J73,�to#al of$.08 in interest was •
Annual E'ercentage Number of days Averaga coi3eatea tnteresf Pald P��d this ye�r.
Yield Earned(APYE} tn lnierest perlod balance forAPYE this parlod
o.a7� 2a 2,52a.rs .oi
{�.ctiy+►��y �3eta�1
De�►asits ar�cf O#her Additions Tl�ere were 3 Depasitsand t3therAddikiens
oata Amdunt �ascrlpilon toEaling$1,p�i4.2Z.
()i/08 5�.�1 llu•cctDcpaslt-Deposit
}3cXlC�ll.l�:i}`A71e111S�1.���3iX.�}i.�134b`�
Oa�O'7 1,UOO.fJU 'I'el()40U0].1�()2 U(17.2'15•iuisEer T�'roui�1.��<Z.�i51`7
()3f lii .01 IuCerest PaytneuE
Ghec�ts ar�c� Subs�tilute Ci�ecl��
Cneck llate Refereoce Check Date Refetenca
numher Amounf paid numbar numbar Aritoubt �aid nUmbar
�(1`(t� 7�.00 02��� U3GG�D4a0 7Y�3 �0$.5�} ()�`�% 08G658397
1l 0'�j' 1fi2.55 U�/25 u529u3z�2
�Gap in cltecksaquenoe Ti�ere were 3 checics lisced totalinc�
$6�E6.05.
Online and Eleatw�anic B�r�king D�ductions Tl�ere were 5 Oniine or�IonCronio Banking
�ate Amount o�scription Dede�ctionstotalinc�$'�,5l8.08.
02,/18 12�ri(l Papxa��nl,k-Cat�eck Cl�eckpayxnt PNC I14U
D`�`�0 52.3'7 Payiuent,E-Cfaeck Psyn�ents Verlao2a Fln3iicia 1I01
0`�$U 88�.00 Direct Payment•-Sk:�1.e,.i�c:z�l:s Mesxialx Hom�;asos
U`�`�$ 54 91 Direct Payment-Reversal
Benr[ic Pa}'mcnty��,�,'L.�'1.11Y1�i8002
U�/05 �OU.00 Tv��1�Auto T�ansfei•1'0 5fl()!i`�95517
1)aily �al�uce Detai[
Date Balance bate Balaltce Date Balance bate �alancs
02 14 3,G31,8'7 0;�/�Ci �,�t8().4!i 03/U3 Y,9�X�ri U�f 13 2,K21.9G
�� �zf�-��----� 02/�'7 �.1,�3`�7..95 ° 03/U5 1,5�1.y�i
"�9�?r6�"—� ��%�8 y,rifi7.'1� OS/07 `K;i`ti7..95
r�"` `�`� ��
invest in you�-orvn luturc, ' �
Open�+1'NC lnvestmants Tn�ividual Retirement Account("TTZ.4")tod�y for a sm�►rt way to help prep.�re for rzkirement.Mak.ing sznall,�eziodic
c�ntribution�to�in IRA throughout tI►e yaar is a positive slep towarci reeching yoitr retirentent goals.Whet��er you xteed hel�tivith retiremant
plannix�g,setting np�+PNC Investments]RA or discnssing distribution oprions For a 401(k)from a previaus employer,r PNC Invesfinents
l�iaan.ezal Advisor is o�zly a pk�one c:ill away.Stop by any 1'NC branch ar ca111-85S-PNGINV�S'1'today.
ll141'O1tTANT ll�'V�STOR INI�'DR�!'�ATION:I3rokerage ui�cl i�i�urs�y�ce proc�ucts are:
Not�FA�C Insux•eei--Nc�t I3ank Gu:��-unteec� --�V'ot a Deposxt.
Nut Tnsu�•eci li�An��I`ede�•al Govea^a�ment Ag�ncy--May�.,c►sc'Valu�
Securities and.Uroker.�ge sexvices are providecl by PI3C Investrnen[s LLC,n re�isEered Uroker-ciealer and investrnent adviser and rne��ibar FlT(�t�and SIPC.
Annttities and uther insurance pro�iiicts;�re offered by P1�TC Insurc�r�ce Services,T,Y1C"a license�i insttrance a�ency,
(f you liavz a 401(k) la�om a former job,yau[ncjy]tcjve severcil optiqns to consider;eacl�may have di#fera�if casts,paym.ent aptions and other feaftiees. C�nv�tlt
yoizr legal or tax�dviser fnr more infvrniatiori.
.�fl���
To�tax Faxxl.zin� St�.te�.en� - -� - L�P�NCBA`Nl<
For#he perFod a2l'A4/2U11L to O�/�312014
(ol For 24-hour infqrmatian,sign on#o p1VC Banknnlino eanking MAUfi��N S}V11TN • �
�'nn pl�c.com; �•. ... .• .. .. . . . .. .• . ry
, E'rima aocount numhar:50-4529�95&9 �
Accoant munber:50-05�9-0569-continued Page 3 of 4 , , � . ,_ . .. ,
Pr+emiu�m Mo��ey 111�arke�k�AccouMwt St�mmary Maureen Srt�ith .. . � � •
Aacotu�t Inulnber:50-0529-55'i7 ' - . ' '
puerdratt Covera�e-Yaur account is current(ytl,�ted-ar�t. � �
You or your�oint owner may revoke your opt-in or o�t-oiat choica at any time.'� • �
To]earn rnoreahout PNC Overdraft Salutions vislt us online at pnc.com(overdraftsohltioh9,
Call 1-877-588-3605,visitany branch,oYSignohto PNC Onllne BahkiRy,end selestthe"OverdrafC
Solutlons"link undertheAcoount5ervlcessecrionta manage botftyour Overdraft Covaraye and Pvardr�fc
Protectlan settlnye,
����ItCe sillmm�E'�/
pegin�ing Deposits and Rheoks and other Endiitg
balanca otheradditfnns deduoti4ns balance
�i2,�?37.00 �67.19 32,OOU.4p 30,5��.19 •
� AVeI'age moftthly Charge5
balance al�d f9es
��5,3�;3.59 .00
Transaa#ivn SiEmimary
Checks pald/ CHeok Card POS Check Card/Bankcard �
withdrawats signed transactlens POS P1tV transac#inns
1 o c� .
Total ATM PNG Bank Othsr�ank
transactians ATM transaations A7M transa�ti4ns .
0 0 p ' � .. . .
• -- '
j����,�� �����r,�, As of 03/13,a Yotal of,i's�6.1 D in interest was
Annual Parcentags Numperof days Average aollected Interest ea�d . t��1d fhi�year. .
Yleld�arned(APY�► In lnterest period balance(or APYE thls parf04 . . • . �
0.10% �8 �5,383.59 • 3.44 .
Ac�vit� D+etail . :
Deposirts and Other Ildditions Therewara 3�epnsiCs and OtherAdditions (
Date Amount oescrlptlon totaling��s7'.1J. �
03/4� 6�3.'75 Direct DeposiY-Apa'T i�eas 87U Hi�.��1.�3 . �
OS/05 40�:U(S 'I�vhAuto TransFer�'rom 500r�ggrgg .
OgfIB 8,44 Tntere�tPayiuenC �
Other Oedtr�t"ror�� There were Z Other Deduotions totaling �
bata Artlount Dascrlptlon ��■��Q•�p' , �
U?�?'7 31,DOO.Oq 'Wltl�dratval Refcrence No. 05UOfi59U8 � - ,
U3/D7 1,000.00 'Te10�4D0U11`�f)2 U0�2 Transfer�To X�f�XXX9569 . �
Da�My Bafar�ae Detarl
Pata 6alahce Pate Balance • Data &a[ance �
U`� 14 S 0� .00 03/U9 3�.,r04.'15 0�/07 30,50�.75
02/27 31,03 .00 63f05 8:1,500.'75 03/]a 3Q,5Q�1.19 . • . . ..
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RiVDM1..T01-JqB3978 2-N40-NNNNNf�-002-001988
REV-1510 EX+(08-09) SCHEDULE G
pennsylvania
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ANNE A HARRIS
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLIAETFEf�kMEOFhfTW1NSFEREE,THEIRRELATIONSHIPTODECEDENTAND DATEOFDEATH %OFDECD�S �CLUSION TAXABLE
NUMBE TI-EDA7EOFTWV35FER.ATfACHACAPYOFTHEDEEDFORREALESTATE. VALUEOFASSET INTEREST IFAPPLICABLE VALUE
� 129 SH PRUDENTIAL (PRU)
TRANSFERRED ON DATE OF DEATH 2/18/14
TO BRETT STEEL, NEWPHEW 10,995.00 100 10,995.00
TOTAL(Also enter on line 7,Recapitulation)$ lo,995.00
If more space is needed,use additional sheets of paper of the same size.
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REV-1511 EX+(08-13) SCHEDULE H
pennsylvania
DEPARTMENTOF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ANNE A HARRIS
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
�, MALPEZZI FUNERAL HOME 12, 314 . 00
2 INDIANA FUNERAL AND BURIAL EXPENSES 1, 137 . 00
3 L'KOSTE VILLA CATERING 1, 045. 00
B. ADMINISTRATIVE COSTS:
1. Personai Representative Commissions: 12, 9 7 7 . 0 0
Name(s)of Personal Representative(sJ"IAUREEN SMITH
Street Address 4 0 7 DARLA ROAD
City MECHANICSBURG State PA ZIP 17055
Year(s)Commission Paid: 2 014
2. Attorney Fees:
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach e�lanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 4 3 4 . 0 0
5. Accountant Fees:
6. Tax Return Preparer Fees: 3, 9 0 0. 0 0
7. POSTAGE 431. 00
8 SIMPLE FILINGS — EIN 177 . 00
9 SHORT CERTIFICATES 25. 00
TOTAL(Also enter on Line 9,Recapitulation) $ 32, 4 4 0. 0 0
swasA�z.000 If more space is needed, use additional sheets of paper of the same size.
1��1�e,��� �'����°c�l����
8 Market Plaza Way � „ . (717)697-4696
Mechanicsb�rg,PA 17055 wW'wMalpezzi�uneral�iome,cortx
�eremy J.Shartzex,BD Michael 7.1V1alpezz3,O�vne��.�+U 7tyle C.I�nipe,l+�
�eb;ruazy 26,2034 •
IVZauree� Smitla ;
4Q'�Dar�a Road �
Mecb.anicsb�.tr�,PA 17QS5
T
This is the final statemenfi for the�era�sexvices of Axzz�e A.Harris
W e sincexely ap�xeciate the coz�fidenoe yau have placed in us and will continue to assistyou i�n.every way. f
PRO�`�SSIONAT�S��2VxC�S: , �
�'unezal Ceretriahy $SS4,00
Hearse(Caslcet Coach) $42S,QQ
but p£tOwn.transpartation(to BWI Airport) $150.00
ForwazdingRamainstoBurnsl�unaralHome ' $3,OSO.Ob
T+'Y71V�RAL HOME SER'VTCF CA�#�tGES $�€,175 00
S���CTED ML+`RCAANDTS�+:
Steel Casket $3,325.a0
Air Tray • $150.4Q
Prayer catds $4D.00
THE COST OT`OT3R S�R'V�C�S,�Q�TII'NA�NT,AND M�RCHAi+iDT�
TFIAT YOCJ HAVE SE��CTEA $'7,690.00 ;
CASI�ADVA1�iC�S:
�It the tirne funeral arrangements were made,we rsdvanced certarfz�ayments to ot�ters cts an accomodation, f
The following is an accourrtrr�g of those charge.r. �
Cer�ifted Death Certi�icates $120.00 � '
I;
Newspaper Notices-Patriot . $285.17 4
Newspaper�Iotiaes-North�est�ndzaxaa Tixnes $23837 ,
Clergy Of�exing�Father Ogde�c $1,OOOAQ �
Clar�y Offerin�-Father Mischler � $200.00 3
Organzst $125A0
Caator $75,00 3
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F'lowers-lndiana . $195.88
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REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENTOF REVENUE DEBTS OF DECEDENT�
INHERITANCETAXRETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ANNE A HARRIS
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 DF�4TH
1. HOLY SPIRIT HOSPITAL 150. 00
2 PPL 63. 00
3 MESSIAH VILLAGE 570. 00
TOTAL(Also enter on Line 10,Recapitulation) $ 7 8 3. 0 0
3W46AH 1.000 If more space is needed, insert additional sheets of the same size.
� REV-1513EX+(01-10) SCHEDULE J
pennsylvania
DEPARTMENTOF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ANNE A HARRIS
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 JULIE MACONEGHEY, 415 LUZERNE ST, SCRANTON, PA 18505 NIECE 1� OOO. OO
1.
2 ANNE MOSER, 321 N EVERETT AVE, SCRANTON, PA 18504 NIECE l� OOO. OO
3 COLLEEN COGGINS, 575 LORELIE DR, SCHAUMBURG, IL 60193 NIECE 1� OOO. OO
4 ANNE MARIE HUMPHREY
915 ROCK SPRING RD, NAPERVILLE, IL 60565 NIECE 1, 000.00
5 JOHN COGGINS
1104 N CAMPANIA CT, ST AUGUSTINE, FL 32092 NEPHEW 1, 000. 00
6 MICHAEL COGGINS
1903 BEECH ST, APT 315, VALPARAISO, IN 96383 j�]Ej�gF,jn] l� QQQ. QQ
7 PATRICIA LETNAUNCHYN
1017 TERRANOVA WAY, ST AUGUSTINE, FL 32092 NIECE 1, 000. 00
8 IRENE KOESTER
4705B CHARLES RD, MECHANICSBURG, PA 17070 SISTER 81, 630. 00
9 MAUREEN SMITH, 407 DARLA RD, MECHANICSBURG, PA 17055 NIECE H1, 630. 00
1Q KATHIE STEEL, 51 E ENGLE DR, VALPARAISO, IN 96383 NIECE 81, 629. 00
11 JACK LAHEY, 1864 SUNCHASE CT, JACKSONVILLE, FL 32246 NEPHEW 81, 629. 00
12 ROBERT WILLIAMS
1670 MEADOW GLEN DR, LANSDALE, PA 19446 NEPHEW 81, 629. 00
13 BRETT STEEL, 51 E ENGLE DR, VALPARAISO, IN 46383 NEPHEW ZO� 99S. 00
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 DISTRIBUl10NS 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.
3 W 46AI 1.000
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A�iNE HARRIS
LAW OFF{CES
BR�NSER, WAGNER & ZIMMERMAN
6 EAST MAIN STREET-SECQAID FL.00R
' P,q. BOX 323
� PALMYF2A, PENNSYLVAht1A 17ti78
(7 S 7) 838-6348
WILL
UF �
A1VNE HARRIS
�, ANNE HARRIS, a/k/a ANNE A. HARRZS, currently of Upper Allen
Tawnship, Gumberland County, Pennsytvania, declare this to be my Last Will and
Testament, hereby revoking any and all prior Wills and Codicils made by me.
I. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable after my demise.
II. Ti direct that all estate and inheritance taxes that may be assessed in consequence
of my death, shall be paid out of the pzincipal ofmy general estate to the same effect as if
said taxes were exp�nses of administration and all property includable in my taxable
estate whether or not passing underr this Will sha11 be free and clear thereo£
II�. I bequeath the sum of One Thousand Dollars ($14�0) unto each of the following
individuals who survives me, namely, J'ulie Maconeghey, Anne Moser, Colleen Cazrol,
Anne Marie Humphrey, John Caggins, William Coggins, Michael Coggins and Patricia
Letnaunchyn.
IV. All the rest, residue and remainder of my estate, ofwhatever nature and wherever
situate, including property over which I hold a power of appoinhnent, I devise and '
bequeath equatiy unto the following individuals who survive, namely, Irene Koester,
Maureen Smith, Ka#hie Steel;3ack Lahey and Robert Williarns.
V. I appoint my niece, Maureen Smith, Executri�� of this my Will. In the event that
she fa�ls 4a quaiify or eeases to aet as Executrix, I appoint my niece, Patricia -
Letnaunchyn,Executrix of this my Will.
VI. T direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
�- -1- � _ � ��1.Q�
.�— -��
��4�f�� ��REDF, I,AI�NE HARRIS, herewith set my hand to this my
� �'�1L t�;gewritten on two 2) sheets of paper including the attestation clause and
�i�at� of wiinesses, this � day of.�e.��p�,1� 2009.
,� R..... . ���� / (SEAL)
ANIv'E HARRIS
Signed by ANNE IIARRIS, by her declared ta be her WiII in our presence, who
have he eunto subscribed our names as witnesses in her presence and at her request,
this �day of ���cy�t , 2009.
- residing at - " P l;
� _ . _ J� ��
residing at ��y�L l?,�'�
-2-
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COMMI�NWE,ALTH �JF PENNSYLVANIA: :
C4LTNTY OF LEBANON : -
WE, ANNE HARRIS, GERA.LD J. BRINSER and (,�2� �� ���'S
!/ �
the testatrix and the witnesses, respectively, whose names ar�ned to the attached or
foregtiing instrument, being first duly a�£irnaed, do hereby declare to the undersigned
authority that the tesfiatrix signed and executed the instrument as her Last Will and that
she signed willingly {or willingly directed another to sign for her), and that she executed
it as her free and-.�oluntary act for the purposes therein expressed, and that each� o�the
witnesses, in the presence and hearing of the testatrix, signed the WiII as witnesses and
that to the best of our knowledge the iesiafrix was at 2hat tzme eighteen years of age or
older, of sound mind and und�r no constraint or undue influence.
�'����;�_ ( ?�,�.-�,:� r '�'
ANNE HARRIS �
t�'` � ,��2'��
WITNESS �
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W,YTN�SS
Subscribed, sworn or a�rmed and acknowledged before me by ANNE HARRIS,
the testatrix, GERALD J. BRTNSER and f�Q�iy :�. '�--�r.�'�
witnesses, this � day af���'I , 20Q9. �-� �
i�t9 � ��)
otary Public �
COMSW47t3WEALT!-i OF PEhEf��YLVAt+ItA
h10ThR1AL SEAL
WENDY L Ci�AVdFORQ,Notary Pufalic
Ft3{iilj��a�C3f0.��2�1��1G11 COUfI�!
f�y Goinmissior���pires Se tember 10,2009 ,
-3-