HomeMy WebLinkAbout11-21-14 � 1505614120 3W46478000
pennsylvania
DEPARRAEMrOFftEVENUE EX(03-14)(TP)
REV-1500 OFFICIAL USE ONLY
. County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN /I �j
PO BOX 280601 �
Harrisburg PA 17128-0601 RESIDENT DECEDENT �/� I �J��
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
03102014 04221918
DecedenYs Last Name Suffix DecedenYs First Name MI
PHILLIPS HILDA I
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name M I
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)
a7. Decedent Died Testate � 8. Decedent Maintained a Living Trust � 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
DAVID A. PHILLIPS 717-506-1222
First Line of Address
108 WINDRUSH LN
Second Line of Address
City or Post Office State ZIP Code
;-��
MECHANICSBURG PA 17055 �., '�� ,� m
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DPHILLIPS anWFDCPA ��' =� � `�
CorrespondenYs email address: ' 4 � �, ��
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REGISTER QF l'NI�CS �E O � , ! ��
REGISTER OF WILLS USE ONLY '' > `-�
DATE FILED MMDDYYYY � '"'� �
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DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
I IIIIII II'II IIIII'�III IIIII�II'I IIII)III�I II'I�IIIII"�I II'I
� 1505614120 15�5614120 � ,.�
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� 1505614220
REV-1500 EX(TP)
DecedenYs Social Security Number
DecedenYsNam�-IILDA I PHILLIPS
RECAPITULATION
1. Real Estate{Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. � ��
2. Stocks and Bonds(schedu�e B) . . . . . . . . . . . . . . . . . . . . . . . . . 2, 241523 00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , , 3. � ��
4. Mortgages and Notes Receivable(Schedule D). . . . . . . . . . . . . . . . . . 4, � Q�
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E), , , , , , 5. �26��7 ��
6. Jointly Owned Property(Schedule F) � Separate Billing Requested. . . . . 6. Q QQ
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested. . . . . 7. � ��
8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , g. �67530 00
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. 14746 ��
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). , . , . . , . . . 10. 4321 ��
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. 19067 ��
12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , �z, 34H463 ��
13. Charitable and Governmentai 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. 34H463 Q�
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- � �� �5. O ��
16. Amount of Line 14 taxable
at�inea�rate x.cf}`� 348463 00 �s. 15680 84
17. Amount of Line 14 taxable
at sibling rate X.12 � �� 17. � ��
18. Amount of Line 14 taxable
at collateral rate X.15 � 0� 18. 0 �0
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 1 'rJ6HO 84
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 retum is based on all information of which preparer has
any knowledge.
IGNA7l1RE O PE SO RE SIB E FI�.ING RETURN DATE
C.?`.. !,!�`"a'I�J
ADDRESS L
/'G� �e�t��`�� 4� �� / ����tt�4.1���G1��'� Vl� j7c.5�
SIGNATURE OF P E��THER THAN PERS`O_N RE� SPONSIBLE FOR FILING THE RETURN DATE
�, ��� C�.'� ��� /�/F�`y
ADDRESS
5006 E. Trindle Rd. , Suite 200, Mechanicsburq, PA 17055
I IIIIII II'll IIIII"III IIII'III'I IIIII'IIII IIII)IIII)�'II I�'I Side 2
� 1505614220 15�5614220 �
3W4648 7.000
REV-1500 EX(TP) Page 3 File Number 21-14-0328
Decedent's Complete Address:
DECEDENTS NAME
HILDA I PHILLIPS
STREET ADDRESS
108 WINDRUSH LN
CITY STATE ZIP
MECHANICSBURG PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 15681
2. Credits/Payments
A. Prior Payments 15200
B.Discount 784
(See instructions.) Total Credits(A+g) (2) 15984
3. Interest
(3) 0
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) 303
5. If Line 1 + Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) �
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? . . . . . . . . . . . . . . . . . . . . . . ❑ �
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : a❑ �
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.39116(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 naturai 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)J. 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 W 4671 5.000
REV-1508 EX+(OS-12)
pennsylvania SCHEDULE E
DEPARTMENTOF REVENUE CASH, BANK DEPOSITS 8 MISC.
ESIDENTDEC ENTTURN PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
HILDA I PHILLIPS 21-14-0328
Include the proceeds of litigation and the date the proceeds were received by the estate.
All propert 'ointl owned with ri ht of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 . �, PNC Bank Interest Checking Account, #50-0518-3208
DOD balance per bank 47, 618 .00
2_ PNC Bank Certificate of Deposit, #31800082963, 0.10�, due 6/11/14
DOD value per bank 52, 472.00
3, PNC Bank Certificate of Deposit, #31900216390, 0.35�, due 8/13/16
DOD value per bank 14, 327 . 00
4 . Susquehanna Bank Certificate of Deposit, #1308340525, DOD value 10, 127 .00
(Received $10, 147 when closed on 6/16/19 )
5, Receivable from Pennsylvania Treasury, Bureau of Unclaimed Property 1, 463.00
TOTAL(Aiso enter on line 5,Recapitulation) $ 12 6, 0 0 7 .0 0
3W46AD 1 00o If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(08-13) SCHEDULE H
pennsylvania
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
HILDA I PHILLIPS 21-14-0328
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
�. Neill Funeral Home, Inc. 10, 217.00
2. Honorarium for soloist 75.00
3. Funeral luncheon after service 621.00
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 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 9 9.0 0
5. AccountantFees:
6. Tax Return Preparer Fees: 2, 5 0 0.0 0
7. Legal ads 334 . 00
8 . Estimated final closing costs of administration of estate 500.00
TOTAL(Also enter on Line 9,Recapitulation) $ 14, 7 4 6.0 0
swasnc z.000 If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENTOF REVENUE DEBTS OF DECEDENT� �
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT �
ESTATE OF FILE NUMBER
HILDA I PHILLIPS 21-14-0328
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
�. Check number 2076 issued by decedent prior to death,
but cashed after decedent's death 500. 00
2 Final billing from Country Meadows of West Shore
(Retirement home) 3, 070. 00
3. Balance due Azizkhan Internal Medicine Assoc. 104 . 00
4 . Payment due Dr. Jeffrey A. Marks, DPM 58 . 00
5. Payment due Diamond Pharmacy for prescriptions 109. 00
6, Payment due Orology of Central PA, Inc. for December 31, 2013 visit 19 . Q Q
7 . Balance due on decedent ' s 2013 Pennsylvania income tax return 78 . 00
8 . Payment due on decedent 's amended 2013 Federal income tax return 307 .00
9. Payment due on decedent 's amended 2013 PA income tax return 61 . 00
1 0 . Payment due Camp Hill Emergency Physicians for emergency evaluation 2 Q. QO
TOTAL(Also enter on Line 10,Recapitulation) $ 4, 321. 0 0
3W46AH 1.000 If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(01-10) SCHEDULE J
pennsylvania
DEPARTMENTOF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT OECEDENT
ESTATE OF: FILE NUMBER:
HILDA I PHILLIPS 21-14-0328
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1 TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec. 9116(a)(1.2).�
1 . Richard L. Phillips Son 1/3
�.
68 Phillips Lane
Forksville, PA 18616
2. Jeffrey L. Phillipa Son 1/3
135 Northgate Dive
Camp Hill, PA 17011
3. David L. Phillips Son 1/3
108 Windrush Lane
Mechanicsburg, PA 17055
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. a
3W46AI 1.000 If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAN�N'P
OF
HILDA I. PHILLIPS
I, HILDA I. PHILLIPS of the Borough of Camp Hill, Cumberland County,
Pennsylvania, hereby revoke my prior wills and declare this to be my
will:
GIFTS
I. Personal and Household Effects: I give all my articles of
personal or household use, including automobiles, together with all
insurance relating thereto, to my husband, Vernon R. Phillips, if he
survives me by sixty days. If he does not so survive me, I give all
such property and insurance to such of my children as so survive me, to
be divided among them as they may agree or, in the absence of agreement,
as my executor may think appropriate.
My Executor may make whatever arrangements my executor deems
appropriate for storing and delivering articles of personal or household
use to the beneficiaries, and may pay the cost thereof and any related
expenses including insurance from my residuary estate.
Cash Bequests: I bequeath the sum of $17,200 to my son,
Richard L. Phillips, and the sum of $17,200 to my son, David A.
�.� � (�;�c.-��;, Page 1
ARNOLD &SLIKE, ATTORNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA 170]1
Phillips, to adjust advancements I have made during my lifetime to my
son, Jeffrey L. Phillips; provided that should my husband and I die
simultaneously and should her will contain identical cash bequests, my
gifts to my sons hereunder shall be reduced by the beguest paid to them
from my husband' s estate, so that the total that each of them receives
from both estates is $17,200.
II. Marital Deduction Trust: If my husband, Vernon R.
Phillips, survives me, I give the fractional share of my estate neces-
sary to reduce the federal estate tax falling due because of my death to
the lowest possible figure to my trustee, IN TRUST, to keep it invested
and thereafter:
A. During my husband' s lifetime:
1. The entire net income shall be paid to him, at
least quarterly; and
2. As much of the principal as my trustee may from
time to time think desirable--taking into account funds available from
other sources--for his health, support, or maintenance shall be paid to
him.
I intend my trustee to use principal liberally for my
husband to enable him to maintain insofar as possible the standard of
living to which he has been accustomed during my lifetime.
B. On my husband' s death:
1. Any increase in death taxes or administration
expenses in his estate caused by the inclusion of a portion of this
trust in his estate for tax purposes shall be paid out of the principal
� � ,.� Page 2
ARNOLD &SLIKE� A7TQRNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA 170]1
of such portion, except to the extent that a specific reference to his
trust in his will provides for payment of such taxes and expenses from
other sources; and a written statement by his executor or administrator
of the amounts thus payable may be accepted as being correct; and
2. The balance of the then-remaining principal shall
be paid to such one or more of my descendants on such terms as he may
appoint by a will, specifically referring to this power of appointment;
or, in default of appointment or insofar as it is not effective, shall
be added to and thereafter treated as a part of the principal of the
residuary trust.
III. Residuary Trust: I give the residue of my estate, real
and personal, to my trustee, IN TRUST, to keep it invested and there-
after:
A. If my husband, Vernon R. Phillips, survives me, during
his lifetime:
1. The net income shall be paid to him in quarterly
or other convenient installments not less than quarterly; and
2. As much of the principal as my trustee may from
time to time think desirable--taking into account funds available from
other sources--for the health, support or maintenance of my husband
shall be paid to that person or shall be applied directly for those
purposes; provided that none of the principal of this trust shall be
paid to or applied for the benefit of my husband unless the principal of
the marital deduction trust has been exhausted.
B. If my husband survives me, upon his death the then-
remaining principal shall be paid to such one or more of my descendants
on such terms as my husband may appoint by a will, specifically refer-
ring to this power of appointment; or, in default of appointment or
insofar as it is not effective, shall be distributed in accordance with
paragraph C.
r ,
J . � � � Page 3
ARNOLD &SLtKE, ATTORNEYS-AT-LAW,2]09 MARKET STREE?,CAMP HILL,PA 17011
C. After my husband' s death (or mine if I survive him) ,
the then-remaining principal shall be divided into equal shares, so that
there will be one share for each child of mine who is then living or
then dead, and my trustee shall:
1 . Distribute one such share to the issue of such
deceased child per stirpes.
2. Distribute one such share to each of my children
then living.
IV. Power of Appointment: No provision of this will shall
exercise any power of appointment I may have.
V. Adopted Persons: Persons adopted during minority shall be
considered as children of their adoptive parents, and they and their
descendants shall be considered as descendants of their adoptive
parents.
TAX PROVISIONS
VI. Special Anti-Tax Provision: No income or principal shall
be distributed for the support or maintenance of a beneficiary whom a
trustee is legally obligated to support, or for the discharge of any
legal obligation of a trustee, any provision herein to the contrary
notwithstanding.
���.v Q � , -
Page 4
ARNOLD & SLIKE,ATTORNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA 17011
VII. Special Tax Election Provision: If my husband survives
me and if my executor elects to qualify only a portion of the marital
deduction trust for the marital deduction, my trustee may, in my trus-
tee' s sole discretion, divide the principal of the marital deduction '
trust into two parts and hold each part as a separate trust. One part
shall constitute the portion my executor elects to qualify for the
marital deduction, and the other part shall constitute the portion my
executor elects not to qualify for the marital deduction. The disposi-
tive, administrative and other provisions of each such separate trust
shall be identical.
VIII. Calculation and Fundin of Marital Deduction: In calcu-
lating the fractional share of my estate to be allocated to the marital
deduction trust, ( i) the unlimited marital deduction allowed by the
Economic Recovery Tax Act of 1981 shall apply to my estate, ( ii) the
fraction shall be calculated as if my executor elected to qualify the
entire marital deduction trust for the marital deduction in my estate,
(iii) the final determination for federal estate tax purposes in my
estate shall control, ( iv) the value of any property which qualified for
the marital deduction in my estate but which does not pass under this
instrument to the marital deduction trust shall be taken into considera-
tion, and (v) the fraction shall be reduced to the extent necessary to
give my estate the full benefit of all other deductions and credits
allowed in calculating the federal estate tax in my estate (but only to
,
-� � � � Page 5
ARNOLD & SLIKE, A770RNEY5-AT-LAW,2109 MARKET STAEET,CAMP HI[.L,PA 17011
the extent so doing does not increase state death taxes) . For the
purpose of computing the fractional share and making distributions to
the marital deduction trust, "my estate" shall mean my net probate
estate, but without any deduction for death taxes. No property
ineligible for the marital deduction shall be distributed to the marital
deduction trust.
IX. Survivorship: My husband shall be deemed to have survived
me if the order of our deaths is not clear.
X. Death Taxes: All federal, state and other death taxes
payable because of my death on the property forming my gross estate for
tax purposes, whether or not it passes under this will, shall be paid
out of the principal of my probate estate so that the burden thereof
falls on my residuary estate (or, to the extent my residuary estate is
insufficient, from the portion of the marital deduction trust which my
executor elects not to qualify for the marital deduction ) , and none of
those taxes shall be charged against the portion of the marital deduc-
tion trust which my executor elects to qualify for the marital deduc-
tion, any beneficiary or any outside fund. This provision shall not
apply to generation-skipping transfer taxes.
Page 6
ARNOLD & SLIKE, A7TORNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA 17011
XI. Tax Options: I direct my executor to exercise any options
available in determining and paying death taxes in my estate in such a
way as reasonably may be expected to achieve the greatest overall tax
savings for my family, without regard to any effect upon the size of the
marital deduction trust and without requiring adjustments between income
and principal.
ADMINISTRATIVE PROVISIONS
XII. Minor or Disabled Beneficiaries: If any income or prin-
cipal of the residuary trust is payable to a minor or to a person who
is, in my trustee' s opinion, disabled by illness or other cause, it
shall be retained by my trustee in a separate trust for that beneficiary
and thereafter:
A. As much of the income and principal of that trust as
my trustee may from time to time think desirable for the beneficiary
either shall be paid to him or her or shall be applied for his or her
benefit;
B. Any income not so distributed shall be added to prin-
cipal; and
C. When the minor attains twenty-one years of age or when
the disabled person becomes, in my trustee' s opinion, free of disabil-
ity, the then-remaining principal shall be paid to him or her. If the
beneficiary dies before that time, the then-remaining principal shall be
paid to his or her estate.
Any funds to be applied under this article either shall be
applied directly by my trustee or shall be paid to a parent or guardian
of the beneficiary or to any person or organization taking care of the
beneficiary, and my trustee shall have no further responsibility for any
funds so paid. The word "minor" shall mean a person who has not reached
twenty-one years of age.
�� � R '' ' � Page 7
ARNOLD SLIKE, ATTORNEYS-AT-LAW,2109 MARKET S7REET,CAMP HILL,PA 17011
XIII. Early Termination of Trusts: If my trustee, in my
trustee' s sole discretion, determines that it is desirable to do so, my
trustee may, without further responsibility, terminate any trust for a
minor or disabled beneficiary under the preceding articles. This may be
done by paying the then-remaining principal and income of that trust to
the beneficiary or to his or her parent or guardian or to any person or
organization taking care of him or her or, in the case of a minor, by
paying it to a custodian for the minor selected and appointed by my
trustee or by depositing it in an interest bearing account in the
minor' s name, payable to him or her at majority.
XIV. Rights in Income: Each trust hereunder shall be entitled
to a proportionate share of income accruing from the event as of which
it is to be set apart (for example, the date of my death in the case of
the marital deduction trust) , and, pending actual division, distribu-
tions of income and principal may be made directly to a trust or, sub-
ject to the terms thereof, to the beneficiaries of the trust. Except in
the case of the marital deduction trust, all income undistributed at a
beneficiary' s death shall be treated as if it had accrued thereafter.
XV. Protective Provision: No beneficiary may sell, give or
otherwise transfer his or her interest in income or principal hereunder.
No person having a claim against a beneficiary may reach any such inter-
est before actual payment to the beneficiary.
9
- � Page 8
ARNOL &SLIKE,ATTORNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA 17011
XVI. Management Provisions: I authorize my executor and my
trustee:
A. To retain and to invest in all forms of real and
personal property, without being confined to investments authorized by a
statutory list, without being required to diversify and regardless of
any principle of law limiting delegation of investment responsibility by �'
executors or trustees;
B. To compromise claims and to abandon any property
which, in my executor' s or my trustee' s opinion, is of little or no
value;
C. To sell at public or private sale, to exchange or to
lease for any period of time, any real or personal property, and to give
options for sales or leases;
D. To join in any merger, reorganization, voting-trust
plan or other concerted action of security holders, and to delegate
discretionary duties with respect thereto;
E. To borrow from anyone, even if the lender is an execu-
tor or trustee hereunder, and to pledge property as security for repay-
ment of the funds borrowed;
F. To make loans to, and to buy property from, my hus-
band' s executor or administrator;
G. To employ and to rely upon advice given by investment
counsel, to delegate discretionary authority to make changes in invest-
ments to investment counsel, and to pay investment counsel reasonable
compensation in addition to any fees otherwise payable to my executor
and my trustee;
H. To employ a custodian, to hold property unregistered
or in the name of a nominee (including the nominee of any institution
employed as custodian) , and to pay reasonable compensation to the custo-
dian in addition to any fees otherwise payable to my executor and my
trustee;
I. To hold two or more trusts hereunder as a combined
fund (allocating ratably to such trusts all receipts from, and expenses
of, the combined fund} for convenience in investment and administration;
provided that any combination of trusts for this purpose shall not alter
their status as separate trusts; and
J. To distribute in cash or in kind.
����'� � ' �� Page 9
ARNOLD & SLIKE, qTTORNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA 17011
These authorities shall extend to all property at any time held by my
executor or my trustee and shall continue in full force until the actual
distribution of all such property, except as otherwise specifically
stated. All powers, authorities, and discretion granted by this will
shall be in addition to those granted by law and shall be exercisable
without court authorization.
XVII. Executor or Trustee in Investment Business: The fact
that an executor or trustee is active in the investment business shall
not be deemed to be a conflict of interest, and purchases and sales of
investments may be made through any firm of which he is a partner,
shareholder, associate or employee.
XVIII. Trustees: I apppoint my sons, Richard L. Phillips,
David A. Phillips, and Jeffrey L. Phillips, trustees of any trusts
created herein, and I direct that:
A. My individual trustees may, by written instru-
ment, appoint one or more of them to exercise his powers as a trustee.
B. My trustees may, at any time by written instru-
ment, appoint a corporation with fiduciary powers as a co-trustee of one
or more trusts hereunder and may enter into a binding agreement with it
regarding its compensation.
C. Any individual trustee may resign at any time
without court approval.
--,� � ' Page �0
ARNOLD & SLIKE, ATiORNEYS-AT-LAW,2109 MARKET STREET,CAMP HILL,PA]7011
, �
Executors: I appoint my husband, Vernon R. Phillips, and
my son, David A. Phillips, as Co-executors of this, my Last Will and
Testament, and I direct that:
D. My executor may, at any time by written instru-
ment, appoint a corporation with fiduciary powers as a co-executor or as
agent or custodian for the executor and may enter into a binding agree-
ment with it regarding its compensation.
E. Either of my individual executors may resign at
any time without court approval.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this,
� �
the � day of ;�f�;�.-��.-��:�.�;�.,•_.� . 19 8 8.
�C.��La..� � . (SEAL)
Hilda I . Phi ips
In our presence the above-named testatrix signed this and declared it to
be her will, and now at her request, in her presence, and in the pres-
ence of each other, we sign as witnesses:
`-f � ,
�_
; -;S i�-- .� / � 7
� J7(.il � ''./ �'.f ,� 1 /�I,-'� !� �� y�r.r.
Name Addre��s s
' �?�'l,t � �/...�'-�1-.1C.r �� '�,.(�,�C;. � / ' ••L,,.,�'..�I . ',�
�� •
Name Address
Page 11
ARNOLD & SLIRE,ATTORNEYS-AT-LAW,2109 MARKET STREET,CAMP H1LL,PA 17011
i
I
COP'iPZONWEALTH OF PENNSYLVANIA)
. ss.
COUNiY OF CUMBERLAND)
WE, the undersigned, the testatrix and the �aitnesses, respectively,
whose names are signed to the foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the testatrix
signed and executed the instrument as her Last 64i11 and Testament and
that she signed willingly (or willingly directed another to sign for
her) , and that she executed it as her free �aill and voluntary act for
the purposes therein express�d, and that each of the witnesses, in the
presence and hearing of the testatrix signed the will as witnesses and
that to the best of their knowledge the testatrix was at that time
eighteen years of age or older, of sound mind, and under no constraint
or undue influence.
, �//, � .
Testatrix
--7��i'�'1•u� l�, �^ ���c
4�Iitriess
!A �'� i ti
, � r
�
' tness
�
Su scribed, sworn to and acknowledged before me by the testat�' x,
and subs ribed nd sworn to be ore me by both witnesses, this �_
day o f C(;rx,�el , 19 8 �
�lX.e;c.a..���✓
Notary Public
NUTRRIAL;�EAL
TN-L�rsh, ,J. 'wt,;�},U"' ^
��_!��, ly�ta.ry Rublic
i.-;��� i-;;�?, r,� �:urr,berla��{;cun!Y
���iy �amn�i�ssion rxF,ires Juiy 3, 1932
ARNOGD &SLIKE,ATTORNEYS•AT-LAW,2109 MARKET STREET,CAMP HILL,PA 11011
Total B anking Statement � C������ti 4 /���0 4�� .�N� PN C BANK
PNC Bank C�R>/,�'/cq-r�S �p /,,i:�vriT
Primary account number:50-0518-3208
Page 1 of 3
For!hs pariod 02/15/2014 to 03/14/Z014 Number of enclosures:0
001153 For 24hour banking,and transaction or
� HI LDA I PH I L L I P$ �interest rate information,sign on to
108 WINDRUSH LN PNC BankOnline Banking at pnc.00m.
MECHANICSBURG PA 17055-9235 'a Forcustomerservicecall1-888-PNC-BANK
Monday-Friday:7 AM-10 PM ET
Saturday&Sunday: 8 AM-5 PM ET
Para servicio en espaRol, 7-866-HOLA-PNC
Moving? Please contad us at 1-888-PNC-BANK
� Write to:Customer Service
PO Box 609
Pittsburgh PA 15230-9738
�Visit us at PNC.com
� TDD terminal:1-800-531-1648
For hearmg impaaed clients orily
Relationship Qverview
Bank Dsposit Accounts
Description Account Number Deposit Balance
Interest Checking 50-051&3208 47,118.01
Certif`icate(s)Of Deposit Total of 2 66,'192.01
Total Deposiis 118,910.02
Perfo�mance Checldng Hilda I Phillips
Interest Checldng Account Summa�y
Acoount numbor: 50-0518-3208
Ovordratt Protoctlon has not been established for this account.
Please contact us if you would like to set up this service.
�ordnft Co�ongo-Your account is currentlyQptod-Out.
You or your joint owner may revoke your opt-in or opt-out choice at any time.
To learn more about PNC Overdrak Solutiona visit us online at pnc.com/overdraftaolu[ions.
Call 1-677-588-3605,visit any branch,or Sign on to PNC Online Banking,and select the"Overdraft
Solutions"linlc un�aTlhs/lccount Seevices aectea�re to manage both youe Overdraft Coyersee and Overdraft
Protection settings.
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
45,865.08 8,442.59 7,189.66 47,118.01
Averege monthly Charges
balance and fees
43,821.06 .00
1'ransaction Summa�y
Checks paid/ Check Card POS Check Card/Bankcard
withdrawals signed trensactions POS PIN trensactions
5 0 p
Total ATM PNC Bank Other Bank
transactions ATM transactions ATM transactions
0 0 0
�ti
PN DMLT01-JOB70377-N40-NNNNNN-002-002263
Tota1 Banking Statement
For the period 02/15/2074 to 03/14/2014
�For 24hour information,sign on to PNC Bank Online Banking HILDA I PHILLIPS
on pnc.com. Primary account number:50-0518-3208
Account number:50-051&3208-continued Page 2 of 3
Interest Summary As of 03/74,a total of$1.OZ in interest was
paid this year.
Annual Percentage Number of days Average collected Interest Paid
Yield Earned(APYE) in interest period balance forAPYE this period
0.01% 28 43,625.95 .34
AC�YI� �@�1�
Deposits and Olher Additions
There were 3 Deposits and Other Additions
Date Amount Description tOt811f1Q�,�Z.Ss.
0�/03 2,879.00 Du-ect Deposit-Xxsoc Sec
SSA Treas 310 XX�XX7811D
03/U6 5,563.25 Deposit Reference No. 054763003
03,!14 .34 Interest Payment
Checks and Substih�te Checks
Check Date Reference Check Date Reference
number Amount paid number number Amount paid number
?072 500.00 02/24 089654390 2075 534.44 03/07 086553966
2073 5,488.80 02/20 os5sg22sa 2076 500.00 03/13 oss427oo5
20'74 166.42 0�/10 ossss�725
*Gap in check sequence There were 5 checks listed totaling
$7,189.68.
Daily Balance Dalail
Date Balance Date Balance Date Balance
02/15 45,865.08 03/03 42,755.28 03/10 47.617.6'7
02/20 40,376.28 03/06 48,318.53 03/13 47,117.6'1
02/24 39,876.28 03/07 47,784.09 03/14 47,118.01
Invest in your own future.
Open a PNC Investments Individual Retirement Account("IRA")today for a smart way to help prepare for retirement.Making small,periodic
contributions to an IRA throughout the year is a positive step toward reaching your retirement goals.Whether you need help with retirement
planning,setting up a PNC Investments IRA or discussing distribution options for a 401(k)from a previous employer,a PNC Investments
Financial Advisor is only a phone call away.Stop by any PNC branch or call 1-855-PNC-INVEST today.
IMPORTANT INVESTOR INFORMATION:Brokerage and insurance products are:
Not FDIC Insured—Not Bank Guaranteed —Not a Deposit
Not Insured By Any Federal Government Agency—May Lose Value
Securiues and brokerage services are provided by PNC Investments LLC,a registered broker-dealer and investment adviser and member FINRA and SIPC.
Annuities and other insurance products are offered by PNC Insurance Services,LLC a licensed insurance agency.
If you have a 40l(k)from a former,job,you may have several options to consider;each may have different costs,payment options and other features. Consult
your legal or tax adviser for more information.
Cer 'df'icates vf Deposit
Hilda 1 Phillips
Investment Description Maturity date Interest Original or Current
number rate renewal value value
�1$00082963 C�Month(s)Fixed Rate �6/11/2014 .10 0 52,454.59 52,468.09
319U021639U �6 Month(s)Fixed Rate Q8/03/2016 0.35 % 14,293.33 14,323.92
Total curreM valw 66,792.01
.�
Sus.�uehanna O�cial 110 8 3 8 4 4 2
MEMO: C�SING OF CD 1308340525
BRANCH: 1105
ORIGINATOR: PKEL 12 2 3 2 8
TIME: 11:11:03
CKA141T: $*****10, 146.89
DATE: 6/16/14
FEEAMT: $***********.00
� � TOTAL: $*****10, 146.89
..�l��J ��. �O c°'<
. �
`� l�.0 j ti
TO: THE ESTATE OF HILDA I PHILLIPS
NON-NEGOTIABLE
��P�1\ICBANK
040
HAMPOEN (117)
4242 CARLISLE PIKE
CAMP HILL, PA, 17011
Cashbox 04
Busin�te JUN 1_
Calendar Date JUN 16, 2014
nP� i 11;21
Transaction Number 00061
Account Type Checking/Savings
Account Number XXXXXX3208
Transaction Amount � 10,146,89
Check Amount $ 10,146.89
Su s +Cl u�/-/��vn��- �J/�ti�< �./�, �.2 o Lr F_a .s
This devosit nr oevment is accevted subiect to
uerification and to the rules and reeulations of
this benk. DevnsSts mav not be aueilabte for
immediete withdrewai. Receivt should be held
until uerified with your stetement.
Cot�imon��►eattl� �r�f Pcynns��lvania Sheet � of �
I1�>m���c�n�� t����r�C,� 000035 0598 5000029593
Pennsylvania Treasury - Bureau of Unclaimed Property Payment
CLAIM # 77996612
Property ID Holder Name Description Amount
11015022 CENTERLINE CAPITAL GROU DIVIDENDS 172.00
Total: 172.00
�
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�---� NOTE: Direct payment inquiries to:
PAYEE INFORMATION:
* PHILLIPS HILDA ESTATE OF PA Unclaimed Property 1.800.222.2046
108 WINDRUSH LN P.O. Box 1837
MECHANICSBURG PA 17055-9235 Harrisburg, PA 17105-1837
FOLD ON PERFORATION,THEN DETACH CAREFULLY
t
P1::'vitiSYL�'ANlrl
TR�A��.TR�
LII�C'[.,11lA�lf';t? PROPk;RTY
September 03, 2014
Phillips David
108 Windrush Lane
Mechanicsburg, PA 17055
Re: Claim ID 77996600
Dear Mr. Phillips:
I write to you about the following property(or properties) for which you have filed a claim:
Property ID: 9397878
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 56.19
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 9397879
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 41.65
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 9397880
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 62.88
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 9397881
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 50.81
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 9397882
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 62.72
Rob McCord,Treasurer� Pennsylvania Treasury � P.O. Box 1837 � Harrisburg, PA 17105-1837 � 800-222-2046
www.patreasury.gov
Mr. Phillips
September 03, 2014
Page 2
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 9397883
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 57.62
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 9397884
Property Type: MINER.AL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 33.70
Owner(s) of Record: Phillips Vernon Dr
2440 Lincoln St, Camp Hill,PA 17011-3637
Property ID: 9397885
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 35.42
Owner(s) of Record: Phillips Vernon Dr
2440 Lincoln St, Camp Hill, PA 170ll-3637
Property ID: 9397886
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 46.50
Owner(s) of Record: Phillips Vernon Dr
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 10535454
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 81.63
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 10535455
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 90.66
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 10535456
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 62.36
Mr. Phillips
September 03, 2014
Page 3
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 11578700
Property Type: MINER.AL &ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 81.24
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 11578701
Property Type: MINERAL & ROYALTY PROCEEDS
Holder: Plains Marketing Lp
Claim Amount: $ 74.64
Owner(s) of Record: Phillips Vernon
2440 Lincoln St, Camp Hiil, PA 17011-3637
Property ID: 12083892
Property Type: DIVIDENDS
Holder: Alcatel Lucent
Claim Amount: $ 13.77
Owner(s) of Record: Phillips Vernon R
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 12083893
Property Type: STOCK UNDELIVERABLE
Holder: Alcatel Lucent
Claim Amount: $ 71.49
Owner(s) of Record: Phillips Vernon R
2440 Lincoln St, Camp Hill, PA 17011-3637
Property ID: 12484825
Property Type: DIVIDENDS
Holder: Avaya Inc
Claim Amount: $ 367.50
Owner(s) of Record: Phillips Vernon R
2440 Lincoln St, Camp Hill, PA 17011-3637
To ensure that property is returned only to its rightful owner, we carry out a thorough review
during which we look at various types of evidence. In the case of your claim, we need the
following:
• Completed, signed, and notarized Affidavit and Indemnification Agreement.
Please submit this evidence to the Bureau of Unclaimed Property, P.O. Box 1837,
Harrisburg, PA 17105-1837, along with a copy of this letter. We will then resume work on
your claim.
Mr. Phillips
� September 03, 2014
Page 4
We ask for your patience during the claims process. As much as we would like to return
your property immediately, it may take up to 8 weeks, sometimes longer to complete the
appropriate research, verification, and approvals that are necessary to prove entitlement and
prevent fraud. In the meantime, if you have any questions,please call the Bureau of
Unclaimed Property at 1-800-222-2046 from 7:30 a.m. to 4:30 p.m. Eastern Time; or call me
directly at 800-222-2046 Ext 484 from 8:30-5:00.
If you have filed your claim online at www.patreasur��ov,you may log in to check the status
of your claim.
Thank you for contacting the Pennsylvania Treasury. It is our pleasure to serve you. I
encourage you to explore www.patreasur��to learn how Treasury can help you earn,
learn and invest.
Sincerely,
Diane Cangioli
Claims Examiner
dcangioli@patreasury.gov
800-222-2046 Ext 484
8:30-5:00
ennsylvania Treasury- Bureau of Unclaimed Property Page 7 of 10 +
r�sss�oa
�
�
Robert M.McCord
State Treasttrer �
P}:NNS1'LVANIA �
..........................
� TREASURY �
UNCLAIMED PROPERTY
Property ID's:9387876,8387878,9397880,9397881,9397882,8387883,8397884,9397885,8397888,10535454,10535455.
10535458,11578700,11578701,12083892,12083893,12484825
AFFIDAVIT AND INDEMNIFICATICIN AGREEMENT �
INSTRUCTIONS:
•This affidavit must be signed in the presence oi a notary.
•The person(s)signing the aHidavit is/are the claimant(s}.
.IVaJI� lI t�f� � i
YOUR NAME(S): ���� ,
YOURADDRESS: l�� t�tJl/G/' r�'�'�"` ^'� �C.�a.i�C���c�� �
BEING first duly swom,the above ciaimant(s)deposes and represents as follows:
THAT I/we have made a ctaim for unclaimed property held by the Treasury Oepartment;
THAT Ilwe am/are unable to present to the Treasury Department,as proof ot entltlement to Unclaimed Property,the �
following origfnal iniormation because such property hes besn lost,stolen,destroyed,mispfaced,or never received and '
Cleiment,his/her heirs,essigns or successors have not received or anjoyed any benefit irom the properly or proceeda •
therefrom; '
PrapeRy Id Property Description Holder `
9397878 Mineral 8 Royalty Proceeds Plains Marketing Lp
9397879 Mineral 8�Royalty Procesds Plains Marketing Lp ;
9397880 Mineral 8 Royal Proceeds Plains Marketing Lp
9397881 Mineral 8�Royalty Proceeds Plains Marketing Lp '
9397882 Mineral 8 Royalty Proceeds Plains Marketing Lp
8397883 Mineral 8�Royalty Proceeds Plains Ma�lceting Lp '
839T884 Mineral 8�Royafty Proceeds Plains Marketing Lp
9397885 Minerel 8 Ro al Proceeds Plains Marketin L �
9397888 Mineral 8�Ro al Proceeds Plains Ma�lcetin L ;
10535454 Minersi&Ro al Proceeds Plains Marketin L
10535455 Mineral8 Ro al Proceeds Plains Merketin L �
10535456 Mineral&Ro al Proceeds Piains Marketin L !
1157'8700 Minera!8 Ro al Proceeds Piains Merketin L
11578701 Minera!8�Ro al Proceeds Piains Marlcetin L �
12Q83892 Dividends Icetel Lucent
12083893 Stock Undeliverable icate{Lucent ,
12484825 Dividands va e Inc
In exchange for payment by the Treasury Department oi the above claim,IMre agree to indemniy,seve,defend,and
keep harmless the Treasury Department,its employees end representatives,irom and against all claims,demands,
actions,or suits egainst them,and irom ell losses,dameges,liabilitiss,costs end fees arising out of or in any way
connected with the payment of the claim,regardless of eny gr�ss negligence or willfut misconduct of the Treasury ,
Department.This includes a clalm for property to any third person claiming an ownership interest in the property.or who
may corne into poasession of the orfginal security.
THAT Uwe agree that this Affidavit and Indemnifrcation Agreement shall be construed in accordance with the laws of the
Commonwealth of Pennsylvania;and �
THAT I/we ecknowledge and understand that any talse information andlor documentation supplied with the Gaim will
�
https://www.patreasury.gov/unclaimed/C1aimForm.asp 6/17/2014
Pennsylvania Treasury- Bureau of Unclaimed Property Page$of 10 �
subje e/us to prosecution under 18 Pe,C.S.§4904,relating to unswom fatsification to authorities;the conviction of
whic o d s j�e/u a prison term oi up to two years and e fine of up to$5,000.
X X
Signature ot Ciaimant Signeture of Additional Claimant(s) �
BEFORE ME,the undersignBd euthoriry,on this day personally appeared �
known to me to be the person whose name is subscribed to the foregoing ins rument,and acknowledg d so he/she�
executed the ame tor the purposes and co�ideration therein expres and SUBSCRIBEO AND SWORN TO ME this
the day ot �7td�qn_ A.p.20
NQ7ARY(���yyEqLTH pF pENNSyLypNlp � � ,
�� Notary Signature: '
C]ndy].Hawe{I,Notmy PubOt ,
Hen�pdPn�wp.,Cunbe�larw0o�n�qr Printed Name oi Notary;
Caronlssl0�► 2014 .
My Commission Expires: -, .
IMPORTANT NOTICE TO THE NOTARY PUBLIC:All blanks on this tortn must be completed prior to notarization or �
the form will be wnsidered incomplete end prooessing of tha claim mey be delayed.Additionally,in accordence with the �
Notary Public I.aw(57 P.S.§147 et seq.),a notary public may not act if he/she has a direct or financial interest in the
Gaim.
https://www.patreasury.gov/unclaimed/C1aimForm.asp 6/17/2014
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