HomeMy WebLinkAbout11-14-14 1 1505610105
J REV-1500 Ext°Z-"'f9'
OFFICIAL USE ONLY
PA Department of Revenue pennsylvan9a
County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 28o6o1 i
Harrisburg,PA 17128-0601 RESIDENT DECEDENT ! 1 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
. .
.............. .
_.__................................................................................i _............_.....__............__..........._............_........._......_...._....._.._....i _-_....._......_...-.-__...- .
_..........._..__.
_..__...... .. t..._.-_..__.__....___...._.-_.-.._._-_..__...J i--.._..-._.._._..._...-_._.-_._..__..---............_..._....i
Decedent's Last Name Suffix Decedent's First Name MI
I Washington I i t Ruth ' A
t
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name. Suffix Spouse's First Name MI
_........................•...................................._............_......................._..........._.............._.............._....__._...................._._......_..i r_...................................._.._I ..................._....................................._.............._...................._......._...._............._..............._............_
l F i
! ..._................__...._.._..._......_..........._........................_....._..__.... —......._....._...._......._..............i _......-......................
; __ - --- _-- - —
Spouse's Social Security Number
.._...._..........................._......__........................................._........_............._.......__ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
....__
..........._._..._._......___.____.._...__---._._......
__...__._ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
(31D 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
_._........._.........._._...... ........_.........._......._.............._._........................_.........._._....._..............._..........._.._.._......
.. ........_._.....
....
_.............
........._..__._.---
_.._...._...__...._._._._. _. T
Rachel Reploglei(717) 770-B34 0
REGISTr-R O�WILLS USE-VNLY
M _0 C= _.,. O
rs-I C (/) :;0
1 C7
First Line of Address I� -"� rr7j ~ r ii tit
I.._.......—...._.._...__........................_....._...._........................._.......__._._..._.........._........................................._................................__.....-_-......,._.__.....__......__.._..........._................
12022 Baltimore Pike i `� cO "
CD
Second Line of Address
1 ..�
i__..............................._._....__............_......--_._..._..__.....__....._.._..........._..............__........_.................................................._......._.._.............._......_._...____...__. ) DATE FILED,
City or Post OfficeState ZIP Code
r._...._....— -........................_.........._....,........-._......._...__......_..........._..........._................................._.............._..........._..._......... ? ;......._._..-.._.� `_................................................................._............._..._. .--..............i CD _n
iEast,Berlin _- -- -— Pa 17316
-v______.....____....._.............. __ ......
Correspondent's e-mail address:
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 tru , rrect and complete.Declaration of epare'r other than the personal representative is based on all information of which preparer has any knowledge.
SIG ATU E OF PE ON Pa FO FILING ETURN DATE
X, X l L- l '{
ADDRESS
C) f3 co_,O,� 6'P_ , P/�
tZ3t b
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: Ruth Anna Washington
RECAPITULATION
.......
1. Real Estate(Schedule A). ............................................ 1. 0.00
2. Stocks and Bonds(Schedule B) .... ... ...................... .......... 2. 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3.
4. Mortgages and Notes Receivable Schedule D 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 98,438.63
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 279,635.67 i
(Schedule G) C! Separate Billing Requested....... 7
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 378,074.30
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 3,072.94
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)........ ....... % ! 4,137.56
11. Total Deductions(total Lines 9 and 10)..... ................. ........... 11. 7,210.50 !.
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. 370,863.80
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. 370,863.80
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 45 370,863.80 15. 1 16,688 87
16. Amount of Line 14 taxable
at lineal rate X.0_ 16.i
17. Amount of Line 14 taxable
at sibling rate X.12 17.'.
18. Amount of Line 14 taxable
at collateral rate X.15
19. TAX DUE ......................................................... 19.i 16,688.87
................. ...,,,.......
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Ruth Anna Washington
STREETADDRESS
160 E South St.
CITY STATE ZIP
Carlisle pa 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 16,688.87
2. Credits/Payments
A.Prior Payments
B.Discount 834.44
Total Credits(A+B) (2) 834.44
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) 15,854.43
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.......................................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ N
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?.............................................................................................................. ❑ N
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ M
4. Did decedent own an individual retirement account,annuity or other nonprobate property,which
contains a beneficiary designation? ........................................................................................................................ N ❑
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-1502 EX+ (12-12)
i pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Ruth Anna Washington
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.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1 0.00
TOTAL(Also enter on Line 1, Recapitulation.) $ 0.00
If more space is needed,use additional sheets of paper of the same size.
REV-1503 EX+(8-12)
10 pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ruth Anna Washington
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
0.00
TOTAL(Also enter on Line 2, Recapitulation) $
If more space is needed,insert additional sheets of the same size
REV-1507 EX+(04-13)
pennsylvania SCHEDULED
' DEPARTMENT OF REVENUE MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ruth Anna Washington Estate
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
0.00
I
TOTAL(Also enter on Line 4,Recapitulation) $ 0.00
(If more space is needed,insert additional sheets of the same size.)
REV-15o8 EX+(o8-t2)
�i pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Ruth Anna Washington
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. PSECU 202202875 share acct 01 88,608.20
2 Checking 04 1,744.63
3 CD 50 8,085.80
TOTAL(Also enter on Line 5, Recapitulation) $ 98,438.63
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX+(oi-io)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Ruth Anna Washington
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.
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.
0.00
TOTAL(Also enter on Line 6, Recapitulation) $ 0.00
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
pennsytvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ruth Anna Washington
This schedule must be completed and filed if the answer to any of questions I 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. PPG Employee Svgs Plan 93,211.89 100 93,211.89
2 PPG Employee Svgs Plan 93,211,89 100 93,211.89
3 PPG Employee Svgs Plan 93,211.89 100 93,211.89
TOTAL,(Also enter on Line 7,Recapitulation) $ 279,635.67
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+ (08-13)
Pennsylvania
SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ruth Anna Washinton
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Cremation Society of Pa Inc 1,795.00
2 Sentinel 137.44
3 Cumberland Law Journal 75.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
Z. Attorney Fees:
400.00
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: 365.50
5. Accountant Fees: 300.00
6. Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 3,072.94
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
1a`"pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES &LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ruth Anna Washington Estate
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. Guardian Long Term Care Pharmacy 23.13
2 Forest Park Health Cntr 4,072.43
3 42.00
TOTAL(Also enter on Line 10,Recapitulation) $ 4,137.56
If more space is needed,insert additional sheets of the same size.
REV-1513 Ex+(01-10)
pennsytvania SCHEDULE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Ruth Anna Washington Estate
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. Ruth Anna Palmer,160 E South St,Carlislie,Pa 17013 daughter 1/3
2 Rachel Replogle,2022 Baltimore Pk,E Berlin,Pa 17316 daughter 1/3
3 Elizabeth Washington,70 E Penn St.,Carlisle,Pa 17013 daughter 1/3
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 n-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 1$
If more space is needed,use additional sheets of paper of the same size.
MAO REV(9111)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: it is illegal to duplicate this copy by photostat or photograph.
lee for this certificate, $6.00 lI)IpNN///NN'� This is to certify that the information here given
g.
correctly copied from an original Certificate of Dez
duly filed with me as Local Registrar. The origin
•o is
to certificate will be forwarded to the State Vi-
z- a Recoils Office for permanent filing.
P 20973265
-. f� fN10ti
Certification Number "' ""'N"'i) tee
`) Local Aegistrar Date Issued
Type/Print In COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
pBl.ak Ink t CERTIFICATE OF DEATH
St#U Pile Number:
1.OeCedanYs Legal Name(Finn.Mltltll.,Last.Sufnx) 2.Se% d.Social Security Number a.Dari of Death(Mo/Day/Yr)(Spell Mo)
Ruth Anna Washington Famala 202-20-2675 September 13, 2014
$a.Jae-Lest Birthday(Yrs) Sb Unper 1 Year Under 1 D# 6.D#q Of!11th(MO/Day/Year)(Spell Mon ) 7a.Blrtnp4c0(GItY arra Strb er FOrelQgnn Country)
Months Days NOYrs Minutq Penn Fenno lvess so
69 December 16, 3.924 71belrtttptac.(County) Cumberland
8a.Resleenu(Stats or Foreign country} 1811 RasidMu(Street and Number-InC1uM Apt No.j gc.Old D.cadeM cave)n a Township
Pennaylvanta 160 E. South Street 0 Yes,decadent 1111. twp.
A-Resiaa.-(County)
Cumberland Re.Residence trip Code) 11r0 No,decederst rived within limits of Carlin le city/bora.
9.Ever In US Armed FDrces7 10.Marital Status at Time of Death O Married owatl 11.SuMving Spouse's Name(I wM+lr,glue Mme prior t4 flrrt marriage)
0 Yes M No Unknown 0 Divorced O Nwer Mended 0 Unknown
12.F&TI Name(First.Middle,UlM Suffix 13.Mother'f Name Prior t4 FIrK Marriage(First,Middle.Last)
Ray Garman Margie at Shaffer
14s.Informants Name 14b.R.IatlOnshlp to DeCatlCm 14c,Inftlrma-'s Melling Atltlress(Street MO Number,Clty,State,Zip Code)
Ruth Ann Palmer _i_ -Daughter 160 E. South Streat, Carltele, PA 17013
« _ _
S If Dlath Occurred In a Hospttali--[� tnpaDlM lilt Oeath OGcurr4d Se+new ONer Than a HOsphal: r❑MosPlee F.clllly W �]DeCetl.nt's Home
C3 01.16 rICtr Room/QYtpatlent C3 Dead On ArI LNursin Home/Lang-Timm CRR Facility C3 Other(Sp-II
SSe.F4e111ty Name(If not irutltutic, ,jI street and number) SSG.Gay er Town,ST.A,and 2JP Cptle I sbtl.County Of Deana
Forest Parte Reaith Center Carltale. FA 27013 Cumberland
m16e.M-hotl Of Disposition 0 Bunal N2 C-metlon 16b.Data of Disposition 36c.PI.Ce of Disposition(Name of cemetery,crematory,or other place)
0 Removal from State Donation Other(Speci (it t""77s) Qyt. Cremation Society of Panrisylvarila
El 111
16d.Location of Disposition(City or Town,State,and Zip) 17r. tore of F 15e Um r Person Incharge of 1-.rme- 17b.Ucense Number
Sarrtabure. Pennaylvanta 17109 FD 136940
17c.Nerve and Comptete Address of Funeral Facility C4 1V U
Cremation Society of Penna ivanta 2ne. 4100 niIII Road, Aarrtsburg, 7109
.a' SB.Decadent's Education-Check th.box Mat best deeOHbes the 19.Decedent of Hlspan)e In•check she 20, de-'s Race-Check ONE OR MORE-Co.to Indicate What
r highest degree or levet of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
0 8th trade or less Is SWnlsh/Hispanlc/Latho. Chack til.-No" ®White 0 Korean
0 No dlploms,9th-12th grade box M decedent Is not Spanlsh,/Hlapanic/Latlno. Q black or African American O Vietnamese
O Phan school graduate or GED COmpfeted ®NO,not Sp.rNsh/Hlapanic/LatinO 0 American Indian or Alaska Native 0 Other Asian
O Some college Credit,but no coat!_ 0 Yes,Mexican,Mexican American,Chino 0 Aslan Indian Q Native Hawallan
19 Associate degree(tag.AA.AS) (!Yas,Puerto Rican 0 Chinese 0 Guamanian-Chamorro
O Bachelor'$degree(O.S.SA.AS,US) C)Yea,Cuba. 0 Falpino C3 Samoan
O Master's degree(e.g.MA,MS,MEAS,MEd,MSW,MBA) 0 Yes,Other Sponlsh/Hispanic/Latino 0 Japanese O Other Pacific Islander
0 Doctorate(sI PhD,Edd)or Professional degree (SPII O Other(Specify)
e. .MD 005 DVM LLB JD
21.Decade-'s Sol- a Race SeH-Oeslgna1.-Gh.Ck ONLY ONE to indicate What the decedent Gens) eyed films.f or erre to be. 22a.DKadent'a Usual OCCupa214n-IntllutR type Of work
A White 0 Japanese 0 Samoan dont during most of working fife. DO NOT USE RETIRED.
Qgiaekor African Amfrican 0 Nonan 0 Other Pacific Islander Glass Producer
p 0AmMn't
erican Indian or Alaska Nail- 0 Vteamaae C3 Do "o-Not Sure
Q Asian l`ID Other Asian CI Refused 22b.Kind of Suslness/Intltry
us
0 Chinas! 0 Nacw Hawaiian O Other(Specify)
0 Filipino 0 Guamanian or Chamorro PPG
nvA"231.-"Is MUST se EBRAPUITED II 2 .Data Pronouncad Def MO U r) nature o ersch Pronouneinii Death my when applicable) 23c.Ucense Num r
ByPERSONDWHO PRONOUNCES OR L,__ •J +.s^ 1p ['w. "'��
231.Oats Site (Mo 24.Time yt OaatniIG� J .Kf.V 'y/,'_,S `�a•-e / Q/(� ,( �y"'t,�" i�e^�,
QQ d (: 00 Am zs.Wax MMeWdicallEE%alminorr o••r/Coroner contacted?n•s,+ 0-y.. Go-'N.
CAUSE OF DEATH , Approximate
26.Part 1.enter the chain of events--ill-li ss.Injuries,or compllcatbns-that directly caused the death.DO NOT enter terminal events such as cardiae!weal 1 Interval:
respiratory errasC or ventricular fibrillation without showing the ecology. DO NOT ABBREVIATE. Enter my one cause on a line.Add additional lines N necessary. 1 Onset to Death
IMMEDIATE CAUSE --»-------> a. O r
(Finest disease Or cen!inch see to(ora}a consaquenCq Of): i
1
resulting In death) ,
Se4uentially list conditions, Due to(Or as.consequCMa Of): /
If any,keeling to the cause
listed on line a. the the C. 1
UNDERLYING CAUSE Due to(or as a consequent.of): r
(disease or Iniurythat /
i.e.,ed the evs-s resuhing d.
q In death)LAST. Due to(or as s consequenes of):
O 26.Pon i6 Enter otherbut not resulting in the underlying Gus.*duan In Part 1. 27.W.s an autopsyperf.rmed7
Q Yet
28.Vwn autopsy nndings.-liable
to complete the cau�se�oS.derxh7
C3 Va.
N.
29.St.larv�c�al.: 30.Old Tob- UN Contribute-Oath? g1.Ma 01 Death
4,snot pregnant-)thin past year O Y" 0 P +rural 0 Homicide
0 Praline-at lima Of death O nknOwn NO 0 Accident Ci Pandlna Investlgatlon
b p Not
pregnant,but Prenant-lthtn 42 days Of death O Suicide O Could not be determin.d
O Not pregnant.but P.:no.%43 days to i year before deathof Injury(MO/Day/Yr)(Spell Month)
a2.Data
C3 Unknown If pregnant within the past year 33. me of Injury
��-�y 34.Place Of Injury(..g.home:construction site;farm;school)hoOl) 35.tocatiOn OT Injury'street and Nvm ,City,County,Slate,Zip GOtl.)
^•fSo.1 cry at Wr. 111,11 T1--1-IN.-ap 'c 38.Describe HOW Injury Occ."M
0 Yes O Orvar/Operator 0 Pedestrian
O HP (D Passenger C7 Other(Specify)
39a. Mr-physician,certN{ad nurse@t�d.
oMr,metllcal exsmin.r/co--I(Check only onq):
Cartlrydng only-TO the hart t my ,death accurretl due eo CM cwle(sj and mannan afetal.
..� 0Pronourising G Certlfj. - th. XvAildg.,death occurred at the time,date,and piece,and due W the causes)and manner stated.
t� 0 Medical ExamiMr/Coro -O %ammatbn and/or invascgatio.,in my bolnion,plain o.,tccu st the time,date,and piece,and due to the uu�sss�(s)/and manse t�i
Signature of unmet. /�"'�=-� Tltb of ClRMler: ��{r ', ^ License Number: G"�.�-fOv sem`
39b.N me,Agtlro. and Zip Od era n mpleting Caw!of Death(IW'm 26j 39c.Dire 5) nW(MO OayJYr)
Ca "7"Ati
40.Ra it tri a District NYm .r 41 41. eg i$FgnitYre 42.RegistraY Oeste( �D'tay 1
43.Amendments a
Otsppskion Psrmk No.
�108""!� ! REv0�7n012
LPennsylvania State Employees Credit Union
PSECI , P.O.Box 67013 Harrisburg,PA 17106-7013 Member Number: 0202******
800.237.7328
psecu.com Statement Period: 09/01114 to 09/30114
Direct inquiries regarding preauthorized electronic
transfer or account errors to the above address. Page Number: Regular 1 of 3
Account Balances at a Glance
Total Shares: $0.00
Total Certificates: $0.00
RUTH A WASHINGTON Total Loans: $0.00
160 E SOUTH ST
CARLISLE PA 17013-3428
for Purchases&
A 909%VIS Cash Advances.
No Annual Fee.
Annual Percentage Rote
YEAR TO DATE INFORMATION
Description Amount
Total Dividends Year to Date $182.95
SHARES
Posting Effective Transaction New
Date Date Transaction Description Amount Balance
REGULAR SHARES ID 01
09/01 Beginning Balance 87,478.20
09/03 Payment:Direct Deposit SSA TREAS 310 1,128.00 88,606.20
09/03 TYPE:XXSOC SEC ID:9031736042
09/03 CO:SSA TREAS 310
09/23 Payment:Direct Deposit CMFG LIFE INS CO 2.00 88,608.20
09/23 TYPE:ADD PYMT ID:001ADDISAP
09/23 DATA:6355042207 CO:CMFG LIFE INS CO
09/23 Payment:Transfer From Share 50 8,090.19 96,698.39
09/23 Payment:Dividend 8.00 96,706.39
Annual Percentage Yield Earned 0.150%from 09/01/14 through 09/30/14
Based on Average Daily Balance of 64,902.68
09/23 Payment:Transfer From Share 04 1,744.82 98,451.21
09/23 Withdrawal By Check -98,451.21 0.00
09/25 ID 01 REGULAR SHARES Closed
Ending Balance 0.00
Dividend YTD:Year to Date 127.97
CHECKING ID 04
09/01 Beginning Balance 11,676.54
09/02 Payment:Direct Deposit PPG INDUSTRIES 61.22 11,737.76
09/02 TYPE:PAYROLL ID:2256193407
09/02 CO:PPG INDUSTRIES
09/04 Check 002216 -30.13 11,707.63
09/04 Check 002215 -9,945.00 1,762.63
09/08 Check 002214 -18.00 1,744.63
LPennsylvania
State Employees Credit Union Member Name: RUTH AwasHlNcroN
EP.O.Box 67013 Harrisburg,PA 17106-7013
" 800.237.7328 Member Number: 0202"'
psecu.com Statement Period: 09/01/14 to 09/30/14
Page Number: Regular 2 of 3
Posting Effective Transaction New
Date Date Transaction Description Amount Balance
09/23 Payment:Dividend 0.19 1,744.82
Annual Percentage Yield Earned 0.100%from 09/01/14 through 09/30/14
Based on Average Daily Balance of 2,279.07
09/23 Withdrawal Transfer To Share 01 -1,744.82 0.00
09/25 ID 04 CHECKING Closed
Ending Balance 0.00
Dividend YTD:Year to Date 2.31
CLEARED DRAFT RECAP
Draft# Date Amount Draft# Date Amount Draft# Date Amount
2214 09/08 18.00 2215 09/04 9,945.00 2216 09/04 30.13
'Indicates a break in check sequence.
CERTIFICATES
Trans Post Fees or Transaction New
Date Date Transaction Description Charges Amount Balance
ID 50 24 MONTH CERTIFICATE
09/01 Beginning Balance 0-..8,085.80
09/23 Payment:Dividend 4.39 8,090.19
Annual Percentage Yield Earned 0.900%from 09/01/14 through 09/22/14
09/23 Withdrawal Transfer To Share 01 -8,090.19 0.00
09/23 ID 50 24 MONTH CERTIFICATE Closed
Ending Balance 0.00
24 MONTH CERTIFICATE is Closed
Dividend YTD:Year to Date 52.67
LOANS
Trans Post Payments,Credits Finance Fees or Transaction New
Date Date Transaction Description or Debits Charge Charges Amount Balance
ID 01 PSL LOAN (Open End)
"'ANNUAL PERCENTAGE RATE 12.900%'"" Periodic Rate(Daily).035342%
09/01 Beginning Balance 0.00
09/25 ID 01 PSL LOAN Closed
Ending Balance 0.00
Credit Limit:$0.00 Available Credit:$0.00
Interest Charged YTD 0.00
"The balance used to compute interest is the unpaid balance each day after payments and credits to that balance have
been subtracted and any additions to the balance have been made.
VOVA
I FINANCIAL- Voya U.S.Retirement Services
PPG Plan Administration
P.O.Box 24747
Jacksonville,FL 32241-4747
Tel:(888)774.4011
October 22,2014
Rachel Replogle
2022 Baltimore Pike
East Berlin,PA 17316
RE: PPG Employee Savings Plan Account
Dear Ms.Replogle;
We are sorry to learn of the death of Ruth A,Washington. On behalf of PPG and Voya,we
express our sympathy to you and your family.
Our records indicate that you are a named beneficiary of the proceeds payable from the PPG
Employee Savings Plan. An account has been established in your name, and a transfer in the
amount of$93,211.89 was processed today. A Password has been established and is being
mailed to your address under separate cover.
The following information pertains to your distribution options as a non-spousal beneficiary:
Under the Plan,you are required to take a final distribution of your beneficiary account no later
than 6 months from the date that the funds are transferred to the beneficiary.
I. Effective January 1,2007,non-spousal beneficiaries are permitted to rollover the taxable
portion of their account balance to an inherited IRA.
2. You may elect to take cash distribution,paid to you directly. If you elect a cash distribution,
a mandatory 20%federal income tax withholding will be applied to the taxable portion of the
distribution. In addition,if applicable,we are required to withhold any mandatory state tax.
Please read the enclosed Special Taal Notice Regarding Plan Payments prior to requesting your
payment. You may also want to consult a professional tax advisor prior to requesting a payment
from the PPG Employee Savings Plan.
If you have any additional questions or concerns, please feel free to contact the PPG Industries
Plan Information Line at 1-888-774-4011.
Sincerely,
Voya Retirement Services
PPG Industries Plan Administration Unit C3 L
Voya,
FINANCIAL"' Voya U.S.Retirement Services
PPG Plan Administration
P.O.Box 24747
Jacksonville,FL 32241-4747
Tel:(888)774.4011
October 22,2014
Elizabeth Washington
70 E Penn Street
Carlisle,PA 17013
RE: PPG Employee Savings Plan Account
MAr'Ms.Washington;
We are sorry to learn of the death of Ruth A Washington. On behalf of PPG and Voya,we
express our sympathy to you and your family.
Our records indicate that you are a named beneficiary of the proceeds payable from the PPG
Employee Savings Plan. An account has been established in your name,and a transfer in the
amount of$93,211.89 was processed today. A Password has been established and is being
mailed to your address under separate cover.
The following information pertains.to your distribution options as a non-spousal beneficiary:
Under the Plan,you are required to take a final distribution of your beneficiary account no later
than 6 months from the date that the funds are transferred to the beneficiary.
1. Effective January 1,2007,non-spousal beneficiaries are permitted to rollover the taxable
portion of their account balance to an inherited IRA.
2. You may elect to take cash distribution,paid to you directly. If you elect a cash distribution,
a mandatory 20%federal income tax withholding will be applied to the taxable portion of the
distribution. In addition,if applicable,we are required to withhold any mandatory state tax.
Please read the enclosed Special Tax Notice Regarding Plan Payments prior to requesting your
payment. You may also want-to consult a professional tax advisor prior to requesting a payment
from the PPG Employee Savings Pian.
If you have any additional questions or concerns,please feel free to contact the PPG Industries
Plan Information Line at 1-888-7744011.
Sincerely,
Voya Retirement Services
PPG Industries Plan Administration Unit
Voy� Voya U.S.Retirement Services
PPG Plan Administration
P.O,Box 24747
Jadcsonville,FL 32241-4747
Tel:(888)774.4011
October 22,2014
Ruth Palmer
160 E South Street
Carlisle,PA 17013
RE: PPG Employee Savings Plan Account
Dear Ms.Palmer,
We are sorry to learn of the death of Ruth A Washington. On behalf of PPG and Voya,we
express our sympathy to you and your family.
Our records indicate that you are a named beneficiary of the proceeds payable from the PPG
Employee Savings Plan. An account has been established in your name, and a transfer in the
amount of$93,211.89 was processed today. A Password has been established and is being
mailed to your address under separate cover.
The following information pertains to your distribution options as a non-spousal beneficiary:
Under the Plan,you are required to take a final distribution of your beneficiary account'no later
than 6 months from the date that the funds are transferred to the beneficiary.
1. Effective January 1,2007,non-spousal beneficiaries are permitted to rollover the taxable
portion of their account balance to an inherited IRA.
2. You may elect to take cash distribution,paid to you directly. If you elect a cash distribution,
a mandatory 20%federal income tax withholding will be applied to the taxable portion of the
distribution. In addition, if applieable,we are required to withhold any mandatory state tax.
Please read the enclosed Special Tax Notice Regarding Plan Payments prior to requesting your
payment. You may also want to consult a professional tax advisor prior to requesting a payment
from the PPG Employee Savings Plan.
If you have any additional questions or concerns,please feel free to contact the PPG Industries
Plan Information Line at 1-888-774-4011.
Sincerely,
Voya Retirement Services
PPG Industries Plan Administration Unit
iAlrr%m IIIUU*Ll 100
Employee Savings Plan
Beneficiary Account Transfer
OW13
RUTH PALMER
160 E SOUTH STREET TRANSACTION DATE: 10212014
CARLISLE, PA 17013
This statement confirms the amount transferred to an account in the PPG Employee Savings Plan on your behalf.
Investment Fund Transfer Amount(s)
PPG Stock Fund $93,211,89
Total: $93,211.89
Source Name Transfer Amount(s)
Company Contributions $93,211.89
Total: $93,211.89
Your account access information will be sent to you under separate cover.
Please review and keep this notice for your records. If you have any questions about this notice,call the PPG Plan Information Une at 1-888-7744011 or to obtain addition
plan or account Information,access your account at httpsJ/PPG.voyapians.com.Customer Service Associates are available Monday through Friday,8 a.m.to 8 p.m.Ea!
Time,except on New York Stock Exchange holidays.
PPG EMPLOYEE SAVINGS PLAN
MULTIPLE BENEFICIARY STATEMENT
Deceased: Ruth Washington Date of Death: 13-SEP-2014
1. NAME Rachel Replogle
RELATIONSHIP daughter
SOCIAL SECURITY# t -1 `t• k 9 S I DATE OF BIRTH
ADDRESS a6 -. a Q AL L r i m o Rlls_ 1K-
2. NAME Elizabeth Washington
RELATIONSHIP daughter
SOCIAL SECURITY# of 1 G a.7' DATE OF BIRTH - a q ! 4 5 '7
ADDRESS 7 O C` e N N R
3. NAME Ruth Palmer
RELATIONSHIP daughter
SOCIAL SECURITY# 1 5 zy y 0 DATE OF BIRTH
ADDRESS 1 Cc a t S o d /� S C � /4- fi' e 77�i � 013