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12-09-14 (4)
1505610140 REV-1500 EX (02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue Bureau Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 0 3 1 0 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 3 1 1 2 0 1 4 0 9 2 6 1 9 9 1 Decedent's Last Name Suffix Decedent's First Name MI Br e e n Pe t e r C (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ❑X 1.Original Return 2.Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 9.Litigation Proceeds Received F-1 10.Spousal Poverty Credit(Date of Death 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number The r e s a L Shade Wi x 71 7 652 8455 REGISTER OF WILLS USE ONLY First Line of Address n Wi x We n g e r & Wei d n e r - o , Second Line of Address C* ' 4 7 0 5 D u k e S t r e e t `� =bA �F L D 71 CS City or Post Office State ZIP Code _" H a r r i s b u r g P A 1 7 1 0 9 �) =� ► Correspondent's e-mail address: tISW2000@aOI.COm r rr1 Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my kr6edge ef, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which prepares has any knowledge SIGNATURE OF PER ONBLE FOR F LIQ NG RETURN DATE `71C1�rL.+'� � Jk�+�...�' \ Ad w,. r a 1 g 1 t y ADDRESS s6-7 C A,t-.a H,t l. Pit I-1o l l SIGOF PREQp RER O R T AN REPI�F�SENTATI DTE iv\ � !W/ 1 to g db ADDRESS PLEASE USE GINAL FORM ONLY Side 1 1505610140 1505610140 15.05610240 ~- r. REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Peter C. Breen RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2• 7 6 2 1 , 2 3 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. 2 6 O 0 • 1 7 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 2 O 6 4 . 9 3 7. Inter-Vivos Transfers&Miscellaneous No -Probate Property (Schedule G) a Separate Billing Requested . . . . . . . 7. 3 3 7 3 5 , 8 0 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 4 6 0 2 2 . 1 3 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 2 4 1 3 4 . 7 O 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 3 9 1 2 . 1 5 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 8 0 4 6 . 8 5 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 1 7 9 7 5 . 2 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 4 an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. 1 7 9 7 5 • 2 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 t- (a)(1.2)X.o _ 0 . O 0 15. 0 . O 0 t'` 16.,Amount of Line 14 taxable at lineal rate X .045 1 7 9 7 5 . 2 8 16. 8 0 8 . 8 9 17. Amount of Line 14 taxable O , 0 0 17. O • O O at sibling rate'X.12 18. Amount of Line 14 taxable 0 . O 0 at'collateral rate X.15 0 O O 18• 19. TAX DUE 8 0 8 8 .9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 1 REV-1500 EX(FI) Page 3 Fife Number Decedent's Complete Address: 21 14 0310 DECEDENT'S NAME Peter C. Breen STREET ADDRESS 507 Ellen Road CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 808.89 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 808.89 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 ...................................................................... ❑ ❑x b. retain the right to designate who shall use the property transferred or its income ..........I.................... ❑ 0 c. retain a reversionary interest ..................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ IZI 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... 0 ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ 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 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 p2 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-1503 EX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT .ESTATE OF FILE NUMBER Peter C. Breen 21 14 0310 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Corning, 234.457 shares @$19.3425 per share 4,534.98 (See Schedule B, Exhibit 1) 2. General Employment Enterprises, 1,571.224 shares @ .2868 per share 450.63 (See Schedule B, Exhibit 1) 3. Bonds 2,635.62 (See Schedule B, Exhibit 2) TOTAL(Also enter on Line 2,Recapitulation) $ 7,621.23 If more space is needed,insert additional sheets of the same size Sy ll1fVESTMEIVT y July 13,2014 KEVIN J BREEN 507 ELLEN RD CAMP HILL,PA 17011-2019 Dear Kevin J Breen As requested, please find the Date of Death and/or Alternate Valuation for the Estate of Peter C Breen-with Fidelity Investments. All information in the enclosed valuation report(s) is(are)based on assets in the above listed Fidelity account(s)as of the date indicated on the report(s).Valuation information is provided through a third party valuation service provider. The report does not include values for Options,Foreign Currency,or Precious Metals held in the account as of the date of death nor some accrued dividends not distributed prior to the date of death. Fidelity does not warranty the accuracy of this information for any particular purpose nor does Fidelity provide legal or tax advice. Consult with an attorney or tax professional regarding any specific legal or tax situation. FOR TRUST ACCOUNTS:Please note that if the account on the valuation is a trust registration,then a separate letter of instruction to update cost basis must be submitted. The letter must include the following three items: 1. A statement that the trust qualifies under the IRS regulation to receive'a step up 2. The percentage of the trust that should be stepped up 3. The signature of a currently acting trustee The request to update cost basis should be sent directly to: Fidelity Investments ATTN: Cost Basis 100 Crosby Pkwy,Mailzone KC I K—PR Covington,KY 41015 We hope this information is helpful. If you have any questions about account holdings or need instructions on how to transfer the ownership of the accounts not yet transferred,please visit us at Fidelity.com and search under"Change Account Registration"or call us at 800-544-0003.Fidelity Inheritor Services Representatives are available Monday through Friday from 8:00 a.m.to 6:30 p.m.Eastern time. Sincerely, Fidelity Investments Operations and Services Group A Our file: W372627-06JUL14 Enclosures: Return Envelope Date of Death Valuation Brokerage Services provided by Fidelity Brokerage Services LLC Member NYSE,SIPC Clearing,custody and settlement services by National Financial Services LLC Member NYSE,SIPC P.O.Box 770001,Cincinnati,OH 45277-0034 Schedule B, Exhibit 1 a rn io � 0.1 Q a) M H N O M Ur-)1 N 0 U Q 4-I J..) ..• '�r-1 1 � 11 O 1 ?4 Q rtS U) a) a) U a) > U . W MU) ri Q < co a) 4-4 U a) O l0 LO N (� Oa N 34 H N M oLf) N ri U O >, Ln ' rn rn (d W 1) JJ O .0 ,fid 1 •11 (n 41 O z S 4 a) V). 4-4 ri W U) Qa i--i U !Y N (d ' M 0.l U) > r U �] S-i V1 O O O x O o O o H O Ln 00 O -r-1 co N N %O O - U) N CO O (n•ri OIN O E > r m u cW M l7 :J C)1 O rt >C a •a � � \ 1~ o � U , O O Cl En O O l0 O }4 >.( U Lr) M O C4 U) U Lr) 110 O < 73 r-I N O -ri O 3 o o a° '-{ M Cd �4 O \ O :::$ O O M O -4 O O O O 00 M r-i N (� U) Lr) •• M \ a) Cl) > \ al (d O a) C r-i LL \ C4 (d M •L-) Z71 co M 1J -4 OD w x N En O La(z� M fn \ H W N P: 1J 4-4 CO o a o co 0 U H O U W O x N z a o 0 04 & W c\v � o r6 y C) >+ cn o O to O UZ cri) - W w e 44 v > rL4 •r-1 H r-I W x ri .--I N >,41 .14 o W o jj o '+� w .0 p, C7 �4 N U) N r-1 (d S I 1 H .-I O i S-i -i ;l. U) U a) ri 14 W cd 3 \ > cn\ U) li U a) 0 0 () M -ri W 0 > M 4 1~ M U C C U) Q U U Zi O Q 0 U Zi O U H O .moi 1) O i U L.n N Ln a) O O O v� N N N N to p \\\ v -, N t.0 U (1) r-1 .-i M U) �-1 M r a% ::S ri \\\ }4 W rt M O OOO rC ?4 04 Cn O 1.0 m • a) lIl • a) .0 w O O O _ 3 41 (d Q -rq O O IV ::5 (d (d J..) 4-4 Ln M aN r I a) b� ri M r m cd �-i O 0 Q 41 . rn rn Ln 0-Hz r-i �o rt �.U E a) 44-ri U) a) N M r-i < }4 0 4-) (n 23 (d (L) :� U H i N M O (d i .0 r-1 O E+ .0 O Q > 04 E H } Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 03/2014 Total Price Total Value Total Interest YTD Interest $2,612.50 $4,317.97 $1,705.47 $23.11 Bonds: 1-76 of 76 Issue `,ax: F:na: ��� :� Interest Serial # Series Denom Date Accrual Maturity Price Interest Rate Value Note C859208195EE EE $100 09/2009 04/2014 09/2039 $50.00 $1.36. 0.70% $51.361/ P5 L652396564EE EE $50 12/2009'04/2014 12/2039 $25.00 $1.28_ 1.20% $26.261 P5 L647882268EE EE $50 12/2008 04/2014 12/2038 $25.00 $1.72 1.300/o-. $26.72✓ C850770288EE EE $100 09/2008 04/2014 09/2038 $50.00 $3.96. 1.40% $53.964 L643209571EE EE $50 12/2007.04/2014 12/2037 $25.00 $5.12• 3.00% $30.124 L642421919EE EE $50 11/2007 04/2014 11/2037 $25.00 $5.20 3.00% $30.20 L642097673EE EE $50 10/2007 04/2014 10/2037 $25.00 $6.06. 3.40% $31.06 L641826036EE. EE $50 09/2007 04/2014 09/2037 $25.00 $6.14. 3.40% $31.14. C841095159EE EE $100 09/200704/2014 09/2037 $50.00 $12.28 3.40% $62.281 C836871254EE EE $100 04/2007 04/2014 04/2037 $50.00 $14.04 3.60% $64.04: C832654964EE EE $100.12/2006;04/2014 12/2036 $50.00 $14.76. 3.60% $64.76 L637616590EE EE $50 11/2006'04/2014 11/2036 $25.00. $7.48 3.60% $32.48./, L636365289EE EE $50.09/2006 04/2014 09/2036 $25.00. $7.90 3.70% $32.90 C829201164EE EE $100:08/2006.04/2014 08/2036 $50.00 $16.00 3.70%. $66.004 C826925162EE, EE $10006/2006,04/2014 06/2036 $50.00 $16.40' 3.70% $66.40 L614188001EE EE $50 12/2005 04/2014 12/2035 $25.00 $7.48 3.20% $32.48 L613670918EE EE $50 11/2005 04/2014 11/2035 $25.00 $7.56 3.20% $32.56, C809245457EE EE $100 09/2005 04/2014 09/2035 $50.00 $17.12y 3.50% $67.120 L613130295EE. EE $50 09/200504/2014 09/2035 $25.00 $8.56_ 3.50% $33.56 L608747874EE' EE $50 12/2004 04/2014 12/2034 $25.00 $6.32: 1.19% $31.32 L607447125EE EE $50 11/2004 04/2014 11/2034 $25.00 $6.34: 1.19%' $31.344 L606031519EE EE $50 09/2004 04/2014 09/2034 $25.00 $6.72 1.19% $31.72 C793713121EE. EE $100 08/200404/2014 08/2034 $50.00 $13.52 1.19% $63.52✓ C780704929EE EE $100 12/200304/2014 12/2033 $50.00 $14.44 1.19% $64.44 L600002098EE EE $50 11/2003.04/2014 11/2033 $25.00 $7.24 1.19% $32.241. C775480073EE EE $100 09/2003 04/2014 09/2033 $50.00 $15.24. 1.19%. $65.24, K106621305EE EE $75 09/2003 04/2014 09/2033 $37.50 $11.43 1.19% $48.93 L598441983EE EE $50 04/2003 04/2014 04/2033 $25.00 $8.08 0.68% $33.08 L596873123EE EE $50 12/2002 04/2014 12/2032 $25.00 $8.20. 1.19%. $33.20, C765796589EE. EE $100 12/2002 04/2014 12/2032 $50.00 $16.40 1.19%, $66.40. L625382967EE_ EE $50 10/2002 04/2014 10/2032 $25.00 $8.72 0.68% $33.72 C755955740EE EE $100 08/2002 04/2014 08/2032 $50.00 $17.56 1.19% $67.56 C745924394EE EE $10008/2002 04/2014 08/2032 $50.00 $17.56. 1.19% $67.56✓ L620919537EE EE $50'02/2002 04/2014 02/2032 $25.00 $9.44 1.19% $34.44 C740313527EE EE $100 12/2001 04/2014 12/2031 $50.00 $19.00 1.19% $69.00 L617426263EE EE $50 11/2001 04/2014 11/2031 $25.00 $9.54= 1.19'% $34.54✓ K105599111EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.19% $52.80 . C727270411EE EE $100 09/2001 04/2014 09/2031 $50.00 $20.40 1.19%- $70.40,/ K105599112EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.19% $52.80 L593694278EE EE $50 04/2001 04/2014 04/2031 $25.00 $11.16 0.68% $36.16. K105424122EE EE $75 12/2000 04/2014 12/2030 $37.50 $16.92 1.19% $54.42 L589686766EE EE $50 11/2000 04/2014 11/2030 $25.00 $11.32- 1-190/0 $36.324 L588815953EE EE $5009/2000 04/2014 09/2030 $25.00 $12.22 1.19% $37.22 1 oft Schedule B, Exhibit 2 7/15/2014 3:55 PM Calculat?d Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice C704280366EE EE $100 09/2000 04/2014 09/2030 $50.00 $24.44 1.19% $74.44V L583482831EE EE $50 12/1999.-04/2014 12/2029 $25.00 $13.30. 1.19% $38.304- L580973353EE EE $50 11/1999 04/2014 11/2029 $25.00 $13.34. 1.19% $38.34✓ L580581284EE EE $50.09/1999 04/2014 09/2029 $25.00 $14.02 1.19% $39.02 C675036588EE, EE $100 08/1999 04/2014 08/2029 $50.00 $28.12 1.19% $78.124 L571455130EE EE $50 11/1998.04/2014 11/2028 $25.00 $15.04. 1.19% $40.04' C651001418EE„_. EE $100.08/1998 04/2014 08/2028 $50.00 . $31.96 1.19% $81.964 _ L561272893EE EE $50 11/1997.04/2014 11/2027 $25.00 „$17.18_; 1.19% $42 .184 C615087873EE' EE $100 08/1997.04/2014 08/2027 $50.00 $36.64 1.19% $86.64d' L552694640EE- EE $50 11/1996.05/2014 11/2026 $25.00 $25.00 1.12% $50.00. C579978888EE EE $100 09/1996 09/2014 09/2026 $50.00 $50.32 1.12% $100.32 L545934148EE EE o $50 03/1996 09/2014 03/2026 $25.00 ._$25.30; 1.12/o $50.304 .L540495172EE EE $50 11/1995 05/2014 11/2025 $25.00 $25.30 1.12% $50.30x/ . C537162728EE EE $100 09/1995 09/2014 09/2025 $50.00 $51.00 1.12% $101.00-4 L536430647EE EE $50.03/1995 04/2014 03/2025 $25.00. $28.08" 4.00% $53.081 L532114961EE EE o $50. 12/1994 04/2014 12/2024 $25.00 $28.6.0,.,. 4.00/o $53.60; C494384180EE EE $100 11/1994 04/2014 11/2024 $50.00• $57.56 4.00% $107.56 .C481359895EE EE $100 08/1994 04/2014 08/2024 $50.00 $58.64 4.00% $108.64. K101257912EE EE $75 12/1993 04/2014 12/2023 $37.50 $46.14. 4.00% $83.64 L516193798EE EE $50 11/1993 04/2014 11/2023 $25.00 $30.94 4.00%. $55.94' C434474774EE EE $100 10/1993 04/2014 10/2023 $50.00 $62.28 4.00% $112.28 L505950276EE EE $50 09/1993 04/2014 09/2023 $25.00 $31.32: 4.00% _ $56.32 L515176095EE: EE $50 09/1993.04/2014 09/2023 $25.00 $31.32 4.00% $56.32 , .L514786075EE EE $50 09/1993 04/2014 09/2023 $25.00 $31.32 4.00% $56.32 , L511483598EE EE $50 03/1993 04/2014 03/2023 $25.00 $32.44 4.00% $57.44J. L504804795EE EE $50 12/1992 06/2014 12/2022 $25.00 $47.60 4.00% $72.60; L503758495EE EE $50 12/199206/2014 12/2022 $25.00 $47 60. 4.00%.:_ $72.60 C394775842EE EE $100- 11/1992 05/2014 11/2022. $50.00 $95.20 4.00% $145.201 L502116476EE. _EE $50..09/1992_.09/2014 09/2022 $25.00 $49.04 4.00%: $74.04 L502628861EE EE $50%09/1992-09/2014 09/2022 $25.00 $49.04 4.00% $74.04 L503579700EE EE $50 08/1992 08/2014 08/2022 $25.00 $49.04 4.00% $74.04,x; 1499701438E EE $50 04/1992-04/2014 04/2022 $25.00 $49.04 4.000/b.''. $74.044; L497012499EE. EE $50' 12/1991 06/2014 12/2021 $25.00 $50.52 4.00% $75.52c( Totals for 76 Bonds $2,612.50.$1,705.47 $4,317.97_ Notes NI Not Issued NE Not eligible for payment P5 Includes 3 month interestl penalty MA Matured and not earning interest 2 of 2 7/15/2014 3:55 PM ""��✓ ,�. i +. �4 S-" -�C��{���f,' ,aJ'\,fNSY � �l'�► '- 4 :5 &7K'X84.�SSi.G£J';5iE516YE,4R5,+�,�,� 4so5:'. 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Q} }}}��� �} L n�nrp T V BOX 81 63✓ AKRON -01C 4432-0 ;; FIn � ��L _ 'QATING STAMP• k t` 041 200665 0.00 _;:04-0392 bQ:Z G22 R:DS rli 4 99"l rn00009'0oo l 1,0 3.,. 80499 70 h'ksit'"�'• '""s��n%�' y':�,.3�v"Ri:"ix�:.s%!� .�2L�FF?'S`s v' '�S.-x_i`_' _,jc •'i' 499 i• {�{�+� '�� � � -INTEREST CEASES 80'.YEARS „���' FROM ISSUE DATE '!f$2 12 ?342 : . 12. '!q TiK .TER CRA IG, GREEN All tD: C LAU GEN"Th B03C' 81 53 �1CRfl.N r +4i2 '.DATINAMP G-ST , 12fl _! -I 3Q4_ 00 ROS.=X �3�.D7i3�c�494 49`�0.1.2'f9 `s x:0.0;009000 r!:0 Yt3u'�,9 ?Ci i"C"l., REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Peter C. Breen 21 14 0310 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PNC Bank, 1408 North Atherton Street, State College, PA 16803 64.14 Checking Account ending 2826 (See Schedule E, Exhibit 1) Fidelity Cash 2. (see Schedule E, Exhibit 2) 1,928.59 Penn State Refund 3. (See Schedule E, Exhibit 3) 200.00 District Justice 49-3-05, State College, PA 4. Citation No. R0010514-0 Refund 151.00 (See Schedule E, Exhibit 3) 5. Refunds-$50.00, $50.00 100.00 (See Schedule E, Exhibit 3) 6. Refund -$100.00 100.00 (See Schedule E, Exhibit 4) 7. Comcast Refund 5.74 (See Schedule E, Exhibit 1) 8. Penn State Key Deposit Refund 10.00 (See Schedule E, Exhibit 5) 9. State of Maryland Treasurer's Office Refund 30.61 (See Schedule E, Exhibit 5) 10. American Chemical Society Refund 10.09 (See Schedule E, Exhibit 6) TOTAL(Also enter on Line 5,Recapitulation) $ 2,600.17 If more space is needed,use additional sheets of paper of the same size. B PWBANK Mr. &Mrs.Breen April 25,2014 — To Whom It May Concern: Please be advised,this letter reflects remaining balances in the accounts titled as Peter C Breen as of March 11, 2014. Checking Account ending 2826-$64.14 Checking Account ending 2834-$0.00 Savings Account ending 2842-$0.00 Should you require any further inquiries in regards to any of the accounts listed above,please contact me at the information listed below. Thfnk You Anelle Espinal Financial Sales Consultant NMLS#: 1036338 North Atherton Street Branch PNC Bank 1408 North Atherton Street State College,PA 16803 (P) 814-231-1702(F) 814-231-1723 arielle.espinal@pnc.com U3-U555-01-1 A member of the PNC Financial Services Group Arielle Espinal FSC North Atherton Branch of PNC BANK N.A. www.pncbank.com . Schedule E, Exhibit 1 ^3 DATE FROMDATE TO PAGE ACCOUNTNUMB St Members 1st Federal Credit Union 25/01/2014 105/31/20141 1 of 1 1 XXXXXXX394 5000 Louise Drive P.O.Box 40 Mechanicsburg PA 17055-0040 (800)237-728$ —17-1111 (717)697-5312(Hearing Impaired) iWill youri i ! r-atrmetcnrar UtaoN ----embersist.org . i ! in our 2015 Calendar? 1 �. 00 PETER BREEN ESTATE 000 0, 'yam C/O RENEEE R BREEN ADM 507 ELLEN RD KW - CAMP HILL PA 17011 e' 13294 t ACCOUNT BALANCES 1 1 GLANCE CHECKING 305.74 SAVINGS 215.17 CERTIFICATES 0.00 LOANS 0.00 CHECKING (0011) BEGINNING BALANCE: $300.00 Eff. 'Post Date Date Description Deposits Withdrawals Balance 05/15 05/15 Deposit by Check 5.74 305.74 ENDING BALANCE: $305.74 Total Deposits 5.74 . REGULAR / ! ! 1 ' "^BEGINNING'BALANCE: $151.01. Eff. Post Date Date Description OS, ML $a.�,kDeposits Withdrawals Balance 05101 05/01 Deposit by Check 1111,5 L-n-S d. ¢ 64,14 215.15 05/31 -_0531 . Deposit Dividend.0_1D0°4,-- 0.02 Annual Percentage Yield Earned 0.110%from 05/01/14 through ( a� 05/31114 ENDING.BALANCE: $215.17 Total Deposits 64.16' i SUNIMARY TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.03 0011 CHECKING 0.00 Total Year to Date Dividends Paid(includes Closed Shares) 0.03 i ' M Co- '' . . . . . N {3 U . ..N cT .. O N t(f -- m J 1 ' i4 .N U) r S: M O M V3 M t-t.•' cy N.. C p Tri.M �.' y • �13 x} 13-U Q)'. � U .. - .. .: �. tl7" S4-(0 0)4ri`U w a1 A'EO.1 co C) -4 (1) p O i1+ �4 . C) .. 00. . .. N JH E-1 0) - .',M" tn N . J-3 O t.C) ' - Cf' ..CSN.•... O . - .� U1 > . C4 ' o, O o. Cs \ p Lr) co o pp .. rO.p, .cam.: ..�... o C14 -rq ON cis .0 r v3 4r p to x: -,I U C:) C). ri rn U.. tC) M. C> CL w .. o u o \ Ca :3 O C? r-i - O D 'O O11 .-i to O N' > rn ED o' .'a a ri co 04 \ 101,0 at � � O ?C N •,� 4, w Ea CL E C> i p -- S' .: O r-1 m p CJ a.3 }�. a W. k ' (CS . a z tri a W :E cr .44 er > a1 >1 Aj s4 o ,' -i .'W o u.o •u W. IJ ?-I N. N l--t .>�r-i 14 r4- .�`� � . w U U.., z W W a-i 17.O. i ... ..i4. ` W y U U3..:' fx ", �✓ - z z Cly To 1,J'- � -_U (U -a) OO NM.. . _ri .: W O >rn < '1~..M U.. En Q U Vz O .'A C7 C.3 z.O � CJ 1-4 o e i r-I M ED'S4 M r M . r-I 1-1 r-I - N (d N 111 ri r M-M r R9 .. - 01 - - N In, O NLritD M 1J 4$ A .•ri'.. O C7 d+ (CS (15.,. J.3 QV M ri M r ON t6 }4 O O C]-p .p v' rn en > U &4 CL 'a-r-t; Z, 1-4 117 s-1 U N (o N. L>r�q to A > w H E, Schedtll.e -E', . Exhibi:t 2 DATE FROM DATE TO PAGE ACCOUNT NUMBER St Members 1st Federal Credit Union 04/16/2014 04/30/2014 1 of 2 XXXXXXX394 5000 Louise Drive P.O.Bos 40 Mechanicsburg PA 17055-0040 o (800)237-7288 , . • • • • (717)697-5312(Hearing Impaired) MEMBMSoN ww-w.memberslst.orgFEDERALMEDITUM :, •• •. •• 00 ch• PETER BREEN ESTATE C/O RENEEE R BREEN- ADM Y 507 ELLEN RD CAMP HILL PA 17011 1297x' M1 2975 ACCOUNT BALANCES AT A GLANCE CHECKING 300.00 SAVINGS 151.01 CERTIFICATES 0.00 LOANS 0.00 CHECKING (0011) BEGINNING BALANCE: $0.00 Eff. Post Date Date Description Deposits Withdrawals Balance 04/16 04/16 Deposit by Check 200.00 200.00 04/24 04/24 Deposit by Check 50.00 250.00 04/25 04/25 Deposit by Check 50.00 300.00 ENDING BALANCE: $300.00 Total Deposits. 300.00 REGULAR SAVINGS 1111 BEGINNING BALANCE: $0.00 Eff. Post — Date-* Date -Description Deposits -Withdrawals Balance 04/16 04/16 Deposit by Check 151.00 151.00 04130 04/30 Deposit Dividend 0.100% 0.01 151.01 Annual Percentage Yield Earned 0.160%from 04/16/14 through 04/30/14 ENDING BALANCE: $151.01 Total Deposits 151.01 SAVINGSSUPPLEMENTAL Itl BEGINNING BALANCE: $0.00 Eff. Post Date Date Description Deposits Withdrawals Balance 04/16 SUPPLEMENTAL SAVINGS CLOSED *This is the final statement presenting information on this product Please retain this final statement for tax reporting purposes. ENDING BALANCE: $0.00 Schedule E, Exhibit 3 tDi RODi PAiMEMBERS 1?4FMERALCRWrrUtQ0N 04/16/2014 04/30/2014 2 of 2 XXX"X394 . YTD SUMMARY TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.01 0001 SUPPLEMENTAL SAVINGS 0.00 0011 CHECKING 0.00 Total Year to Date Dividends Paid(Includes Closed Shares) 0.01 "bATE FROM DATE TO PAGE ACCOIJNTNUMSER � St Members 1st Federal Credit Union 5000 Louise Drive 06/01/2014 06/30/2014 CXX 1 of 2 XXX)O394 P.O.Box 40 Mechaiiiesburg PA 17055-0040 (800)237-7288 MEMBERS 1# (717) (Hearing Impaired) FOCUS! r�•nEniu-cemrrUNION ,,members rs1st.org Show off your photography 4`~ skills and talent by 00 participating in the Credit Union's annual calendar PETER BREEN ESTATE �OtO Contest. C/0 RENEEE R BREEN- ADM P 507 ELLEN RD CAMP HILL PA 17011 Click,for details. 25633 Dant wait in I SIGN UP TODAY! ank Online , 1 ACCOUNT BALANCES AT A GLANCE CHECKING 305.74 SAVINGS 315.19 CERTIFICATES 0.00 LOANS 0.00 CHECKING (0011) E NING ::8 GIN -BALANCE: $305.74 Eff. Post Date Date Description Deposits Withdrawals Balance ._.--Nofictivifjr�unngThis"Statenii nn-Menbd_..-_.__._... .. ___.___ ._----.- .---_--__-•.. .__. . _ ENDING BALANCE: $305.74 REGULAR SAVINGS 1111 BEGINNING.BALANCE: $215.17 Eff. Post Date Date Description Deposits Withdrawals Balance •06/11 06/11 Deposit by Check 100.00. 315.17 06/30 06/30 Deposit Dividend 0.100% 0:02 315.19 Annual Percentage Yield Earned 0.090%from 06/01/14 through 06/30/14 ENDING BALANCE: $315.19 Total Deposits 100.02-. Schedule E, Exhibit 4 st �.-DATEPROM DATE To PAGE ACCOUNT NUMtst: FMEMBErTU vmno�Vr�nExaY.car 06/01/2014 06/30/2014 2 of 2 XXXXXXX3G . • YTDSUMMARY TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.05 0011 CHECKING 0.00 Total Year to Date Dividends Paid(Includes Closed Shares) 0,05 � 7 .DMTEIFROM DATE TO PAGE ACCOUNT NUMBEFC, St Members 1stFederal Credit Union07/01/2014 07/31/2014 1 of 1 XXXXXXX394 5000 Louise Drive P.O.Boz:40 Mechanicsburg PA 17055-0040 a (800)237-7288 u (717)697-5312(Hearing Impaired) FEDERAL UNION win-A,.memberslstorgPENN STATEIF 5, 20 FOOTBALL PETER BREEN ESTATE TICKET GIVEAWAY C/O RENEEE R BREEN- ADM 507 ELLEN RD VISIT- CAMP HILL PA 17011 13217 vivvw.members 1 storg/pen ACCOUNTBALANCES AT . GLANCE CHECKING 305.74 SAVINGS 355.83 CERTIFICATES 0.00 LOANS 0.00 CHECKING (0011) BEGINNING BALANCE: $305.74 Eff. Post Date Date Description Deposits Withdrawals Balance No Activity During This Statement Period ENDING BALANCE: $305.74 REGULAR 0e00 BEGINNING BALANCE: $315.19 Eff. Post Date Date Description Deposits Withdrawals Balance 07/02 07102 Deposit by Check 10.00 325.19 07/28 07/28 Deposit by,Check 30.61 355.80 _ _07_/3_1 07/31 Deposit Dividend 0.100% __. _ 0.03 __ __ 35583.. Annual Percentage Yield Earned 0.110%from 07/01/14 through 07131/14 ENDING BALANCE: $355.83 Total Deposits 40,64.:..' : YTD SUMMARY TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.08 0011 CHECKING 0.00 Total Year to Date Dividends Paid(Includes Closed Shares) 0.08 Schedule E, Exhibit 5 PSEPennsylvania State Employees Credit Union P.O.Box 67013 Harrisburg,PA 17106-7013 800.237.7328 Member Number: 8560-- psecu.com Statement Period: 06/01/14 to 07/31/14 Direct inquiries regarding preauthorized electronic transfer or account en-ors to the above address. Page Number: Regular 1 of 1 Account Balances at a Glance Total Shares: $0.00 0505242 000013179 OPSECI 0640044 P1 P3 PETER C BREEN Total Certificates: $0.00 RENEE R BREEN Total Loans: $0.00 507 ELLEN RD CAMP HILL PA 17011-2019 �1,f1,11,1111,111�I�1�„�l�ll,�I„1�1,1111,��!�1��,1,111,�1,11111 Use Bill Payer Service Instead! >>psecu.com/biUpayer YEAR TO DATE INFORMATION Description Amount Total Dividends Year to Date $1.02 SHARES Posting Effective Transaction New Date Date Transaction Description Amount Balance REGULAR SHARE ID 01 06/01 Beginning Balance 0.00 07/21 Withdrawal Adjustment Account Adjustment: 10.09 10.09 07/21 DC1 AMERICAN CHEMICAL SOCI 800-333-9511 D 07/21 DATE 07/18/14 7407280JR8AFF3Z3B 8699 07/21 Withdrawal Transfer -10.09. 0.00 07/21 To BREEN,KEVIN J XXXXXX XXX Share 01 07/21 ID 01 REGULAR SHARE Closed Ending Balance - 0.00 Dividend YTD:Year to Date 0.29 scoots-000 Schedule E, Exhibit 6 REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Peter C. Breen 21 14 0310 If an asset was made jointly owned within one year of the decedents date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Renee Breen 507 Ellen Road Mother Camp Hill, PA 17011 B. Kevin Breen 507 Ellen Road Father Camp Hill, PA 17011 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. 9/16/04 PSECILI Savings 298.07 50, 149.04 Savings(Sl) (See Schedule F, Exhibit 1) PSECU Checking 2. A. 9/16/09 Checking (S4) 2,337.01 50, 1,168.51 (See Schedule F, Exhibit 1) 3. B. Bonds 1,316.85 50. 658.43 (See Schedule F, Exhibit 2) 4. A. Bonds 128.54 50. 64.27 (See Schedule F, Exhibit 3) 5. A/B Bonds 74.04 33.3 24,68 (See Schedule F, Exhibit 3) TOTAL(Also enter on Line 6,Recapitulation) $ 2,064.93 If more space is needed,use additional sheets of paper of the same size. PSECO 04/17/2014 Renee R.Breen 507 Ellen Rd. Camp Hill,Pa 17011 _ Re:PETER CBREEN,Deceased. PSECU Reference#5546501781887 Dear Ms.Breen: The above referenced person has an account with PSECU which was opened on September 16,2009. The Share accounts were jointly held by PETER C BREEN and RENEE R.BREEN.The Visa is jointly held with KEVIN J.BREEN. The following are the Date of Death Balances for PETER C BREEN's account with PSECU: Account Date of Death Balances Interest—March 1- 11th. Savings (SI) $ 298.07 $0.01 Checking (S4) �$ 2337.01 $0.07 Loans: Visa Loan (L9) $223.24 .Please provide us instructions on closing the decedent's account. The joint owner needs to close the decedent's account with.PSECU at the earliest convenience. If the Estate has sufficient funds to payoff the decedent's Visa loan,please remit a check,made payable to PSECU. If there are not sufficient funds to payoff these loans,please submit a letter of insolvency along with supporting documentation such as a final inheritance tax return and financial accounting. If you have any questions,please contact our department toll-free at(800)237-7328,press 6,extension 3120 or email accountservicesnae,psecu.com. Sincerely, ana Willard Member Service Representative PSECU Schedule F, Exhlrbt 1 P. O. BOX 67013 HARRISBURG, PA 1 71 06-701 3 800.237.7328 >>psecu.com THIS CREDIT UNION IS FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION.EQUAL OPPORTUNITY LENDER. t' C alculatsd Value of Your Paper Savings Bond(s) http://www.treasurydirect.aov/BC/SBCPrice Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 03/2014 Total Price Total Value Total Interest YTD Interest $2,612.50 $4,317.97 $1,705.47 $23.11 Bonds: 1-76 of 76 Serial # Series Denom Is"'e �'`"` "' "` Interest Interest Value Note Date Accrual Maturity Price Rate C859208195EE. EE $100 09/200904/2014 09/2039 $50.00 $1.364 0.70% $51.36 P5 L652396564EE EE $50 12/200904/2014 12/2039 $25.00 $1.28 1.20% $26.28 P5 L64788226SEE EE $50 12/2008 04/2014 12/2038 $25.00 $1.72 1.30% $26.72' C850770288EE EE $100 09/2008 04/2014 09/2038 $50.00 $3.96. 1.400% $53.96 L643209571EE EE $50.12/2007 04/2014 12/2037 $25.00 $5.12' 3.00%: $30.12 L642421919EE EE $50 11/2007 04/2014 11/2037 $25.00 $5.20 3.00% $30.20! L642097673EE ' EE $50 10/2007 04/2014 10/2037 $25.00 $6.06 3.40% $31.06,/ L641826036EE EE $50 09/2007 04/2014 09/2037 $25.00: $6.14 3.40% $31.14 C841095159EE EE $100 09/200704/2014 09/2037 $50.00 $12.28: 3.40% $62.28 C836871254EE EE $100 04/2007 04/2014 04/2037 $50.00 $14.04. 3.60%- $64.04: C832654964EE EE $100 12/2006 04/2014 12/2036 $50.00 $14.76 3.60%' $64.76! L637616590EE EE $50 11/2006'04/2014 04/2014 11/2036 $25.00 $7.48, 3.60% $32.48 L636365289EE EE $50 09/2006104/2014 09/2036 $25.00. $7.90 3.70% $32.90,1 C829201164EE EE $100^08/2006_04/2014 08/2036 $50.00 $16.00 3.70%. $66.00 C826925162EE, EE $10006/2006.04/2014 06/2036 $50.00 $16.40; 3.70% $66.40 L614188001EE EE $50 12/2005 04/2014 12/2035 $25.00 $7.48 3.20% $32.48 L61367091SEE EE $50 11/2005 04/2014 11/2035 $25.00 $7.56 3.20% $32.56 C809245457EE EE $100 09/2005 04/2014 09/2035 $50.00_ $17.12_ 3.50% $67.12 L613130295EE EE $50 09/2005 04/2014 09/2035 $25.00 $8.56 3.50% $33.56-1. L608747874EE' EE $50 12/2004 04/2014 12/2034 $25.00 $6.32: 1.19% $31.321 L607447125EE EE $50 11/200404/2014 11/2034 $25.00 $6.34: 1.19%: $31.34 L606031519EE EE $50 09/2004 04/2014 09/2034 $25.00 $6.72. 1.19% $31.72:! C793713121EE. EE $100 08/2004 04/2014 08/2034 $50.00 $13.52 1.19% $63.52 C780704929EE EE $100 12/2003 04/2014 12/2033 $50.00 $14.44 1.19% $64.44,(. L600002098EE EE $50 11/2003 04/2014 11/2033 $25.00 $7.24 1.19% $32.24 C775480073EE EE $100 09/2003 04/2014 09/2033 $50.00 $15.24. .1..19.%. _$65.24 K106621305EE EE $75 09/2003 04/2014 09/2033 $37.50" $11.43, 1.19% $48.931 L598441983EE- EE $50 04/2003 04/2014 04/2033 $25.00 $8.08 0.68% $33.08) L596873123EE EE $50.12/2002 04/2014 12/2032 $25.00 $8.20. 1.19%. $33.20 C765796589EE EE $100 12/2002 04/2014 12/2032 $50.00 $16.40 1.19% $66.40✓ L625382967EE. EE $50 10/2002 04/2014 10/2032 $25.00 $8.72 0.68% $33.721 C755955740EE EE $100 08/2002 04/2014 08/2032 $50.00 $17.56 1.19% $67.56, 0 6 C745924394EE EE $1008/2002 04/2014 08/2032 $50.00 $17.51.19% $67.56 L620919537EE EE $50 02/2002 04/2014 02/2032 $25.00 $9.44 1.19% $34.441. C740313527EE EE $100 12/2001 04/2014 12/2031 $50.00 $19.00 1.19% $69.004 L617426263EE EE $50 11/2001 04/2014 11/2031 $25.00 $9.54 1.190/o $34.54 K105599111EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.19% $52.80 C727270411EE EE $100 09/2001 04/2014 09/2031 $50.00 $20.40 1.19%• $70.40 K105599112EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.19% $52.801 L593694278EE EE $50 04/2001 04/2014 04/2031 $25.00 $11.16 0.68% $36.161 K105424122EE EE $75 12/2000 04/2014 12/2030 $3750 $16.92- 1.19% $54.421., L589686766EE EE $50 11/2000 04/2014 11/2030 $25.00 $11.32 1.19% $36.32 •L588815953EE EE $50 09/2000 04/2014 09/2030 $25.00 $12.22 1.19% $37.22! Schedule F, Exhibit 2 1 of 2 7/15/2014 3:55 PM Calculat?d Value of Your Paper Savings Bond(s) http://www.treasurydirect.aov/BC/SBCPrice C704280366EE EE $100 09/2000 04/2014 09/2030 $50.00 $24.44._ - 1.19%.- . $74.44 L583482831EE EE $50 12/1999 04/2014 12/2029 $25.00 $13.30. 1.19% $38.30 L580973353EE EE $50 11/1999 04/2014 11/2029 $25.00 $13.34._ 1.19% $38.34 L580581284EE EE $50.09/1999 04/2014 09/2029 $25.00 $14.02 1.19% $39.02✓ C675036588EE EE $100.08/1999 04/2014 08/2029 $50.00• $28.1.2 1.19% $78.12 L571455130EE EE $50 11/1998 04/2014 11/2028 $25.00 $15.04. 1.19% $40.04 C651001418EE EE $100 08/1998 04/2014 08/2028 $50.00 $31.96 1.19% $81.96, 1-561272893EE EE $50 11/1997,04/2014 11/2027 $25.00 $17.18-,. 1.191%. $42.18 C615087873EE' EE $100 08/1997 04/2014 08/2027 $50.00 $36.64 1.19% $86.64 L552694640EE EE $50 11/1996 05/2014 11/2026 $25.00 $25.00 1.12% $50.00 C579978888EE EE $100 09/1996 09/2014 09/2026 $50.00 $50.32 1.12% $100.32 L545934148EE EE $50.03/1996. 09/2014 03/2026 $25.00 $25.30: 1.12% $50.30 L540495172EE EE $50 11/1995 05/2014 11/2025 $25.00 $25.30 1.12% $50.30 C53716272SEE EE $100 09/1995 09/2014 09/2025 $50.00 $51.00 1.12% $101.00 L536430647EE EE $50.03/1995 04/2014 03/2025 $25.00 $28.08 4.00% $53.08 L532114961EE EE $50. 12/1994 04/2014 12/2024 $25.00 $28.60, 4.00% $53.60✓ C494384180EE EE $100 11/1994 04/2014 11/2024 $50.00 $57.56: 4.00% $107.56 C481359895EE EE $100 08/1994 04/2014 08/2024 $50.00 $58.641 4.00% $108.64, K101257912EE EE $75 12/1993 04/2014 12/2023 $37.50 $46.14_ 4.00% $83.64✓ L516193798EE EE $50 11/1993 04/2014 11/2023 $25.00 $30.94 4.00%. $55.94• C434474774EE EE $100 10/1993 04/2014 10/2023 $50.00 $62.28 4.00% $112.28, L505950276EE EE $50 09/1993 04/2014 09/2023 $25.00 $31.32 4.00% $56.32✓ L515176095EE EE $50 09/1993.04/2014 09/2023 $25.00 $31.32 4.00%._ $56.32 L514786075EE EE $50 09/1993.04/2014 09/2023 $25.00 $31.32 4.00% $56.32 L511483598EE_ _EE $50 03/1993 04/2014 03/2023 $25.00 $32.44 4.00% $57.44 L504804795EE. EE $50 12/1992 06/2014 12/2022 $25.00 $47.60 4.00% $72.60,(, L503758495EE. EE $50 12/1992.06/2014 12/2022 $25.00 $47.60__ 4.00%1 $72.60 _ C394775842EE EE $100.11/1992.05/2014 11/2022 $50.00 $95.20' 4.00% $145.20^ L502116476EE .EE $50.09/1992 09/2014 09/2022 $25.00 $49.04 4.00% $74.04 L502628861EE EE $50__09/1992 09/2014 09/2022 $25.00 $49.04 4.00% $74.04 L503579700EE EE $50 08/1992 08/2014 08/2022 $25.00 $49.04 4.00%.. $74.04. 1499701438E EE $50 04/1992 04/2014 04/2022 $25.00 $49.04 4.00%' _ $74.04 L497012499EE EE $50' 12/1991 06/2014 12/2021 $25.00 $50.52 4.00% $75.52 Totals for 76 Bonds $2,612.50 $1,705.47 $4,317.97 Notes NI Not Issued NE Not eligible for payment P5 Includes 3 month interest penalty MA Matured and not earning interest 2 of 2 7/15/2014 3:55 PM ZEE I to Y— y JIScI���V/ fe �A .ted FIT$RE@T tEASE5t3f�YEARS `,. �:.. v.��_ F d55U SATE..i ` 4805 PATRIOT.BOND �iTr� 2007 ' I rr PETER":CRAIG GREEN ���i����� RB"'P ITT` yp1 • �7 V 5D7 ''ELLEN RD:' CAMP HILL PA 17011 .2019: N nim WW.��� Ao l,lltll.11llitri.ltllrir� l�nirllit�ti�jnrtrn�rirlil ;OR_ =KEVIN BREE na t r7 ,'r090Cit1407M51A 07240-39940000 1ii4071 �- -'� 1a642421919�a " vim.._ • . lto000 a0 L064 2-1,219 19',9+ ,; i-:.gam MTr -sem= ;i;,A� i�, �i1.r�` ,;� a' LlRaW'1 - INTEREST'LEASES 36-YEA RS� _ *: * 4805-. 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ELLEN ROAD ][� ►^.}J CAMP; HILL -, A 1701.1 2019 . �I1 1!� 1l kll1E"I ,1 11� I ILI 111 Illltl 141 121111 t t7 t11 x, t1R` KE1fZh1 GREEN �43Of1II261 OQ00 040A000 12394,�f12D, � ' 05321+{4-9fr1 ' 'T, i'.r.+�"r, .,.�ci'•'=sr.+. { ' -141910 v1 ' CPPyoy.rybR x:00009000 �:0 ?0,53 21 L4'.96 Ltl''t `.� .c J. ry'::asj., fi f t Y Y:�I i N t �. • i 6 6 i �.R.t ;w:ati`' �Y �ir!.r!i�r,;,'�1 ,.,���►q~~,.� t. ,� _��.��� JANR § -a 1ti .s iNTEF2 EST C<AS.S �., i" d_ `its# L 5� t f ,? ,.i -?, .Y '� tL'c, 6 �c3t � #"[3 m .� t� .,f Yr � s✓ ��. aS.e M � -; t k'7�.:hFi�, !\'.�7�#.{ YL�u.}�y�� 'F. ',Y r + J . , 3 -T�w���.��?G �•' '� mtawft AGiNT; -- .. Lx ;j*�yl+ ,}\)�-��cII ) - f x �r ...DATINGS AMP Y1N Ar7}�'� M.}+Yyt{� h., .y.. r +t - r_. •* � �rf 12 �"v 9K� � #:030091300' .'00 2 80-10:1 2 5 1 ?:9 ` ; <` � � :wl��`�/:.�;.��° 1/ 1 V V S•1( � V � � _ � � ! 1 1 �M��V/lr!�� �` '��h•`,"`•+_'iVI ' '�;.as�.>3�.-+'-:a}''� r.�� -w ,gar. 4� •-•. �.^s ';.x4 +9 x -YAE•! q. Ra.t-m a .S"N / -a-'. :r '. s# ��s* '' l , t'� Y'" x ♦y a r�✓� ! ,` 04TERES.T CEdSffS SG�Y'E'A t S Q}i t d ,s,•.,� - a. li6l#.ISS315�AT5 .0 ". . � 1 ei R B13, � ° �147 - � sC;3 u ` Rk- C���-�` ���� (L ( }•.nY ryJ/Frnw.uy f����Y�a���� �„ ��'�_ flD_��00��';�0 �' ' `*' •LO5059502�76+�• _ ���' ��� M•;%�":'. •�"•�,.:���•:�`V�!i��` 1/ i Y 11 •1 1 � •n „11' _ � : # 1, ! 1 1 �y`w`�aV�..�,,�.�� e` ��``��' '�S.:.�.'C:`,�r_-_•1�� gyp ,,b. .. nrng�'���-f—m rites^--ytr � �WNSS cv� Iwo "N6:`� "� �L1KL-_i+La�: ,' y al .dF h.- ' r ',•(`„' � ! <. .,�z�'� `� "t.w��"•��` ` �.�[�s»c� ' �E�" r � ,�. _ HxE�i�sY�c� ss�;bus sAl i yy soc wcMr ro no `r3 y �--.:.. Sty��s�•a Y h a E'r+ „sr rs •rar. '_ yE�s. ��' F� ,may}.SAS fq���t A'teK _ ��1. ..!"z..lt�.: +•y��4_ ., 'E�. � YJ- � � & � s t . •�'� .+.v Tl—:W tRATG,`lBR CPxNIL ! K l— . .N' M Lr d� fT d� V"� Y t �3• M3. U f 'A yy��, \ ,i_ s�. -.'�' ��-..�. �eC# -+o�-"�` '� � I. � ..��"',.\. v"„�•� ..p• X°fie, �. t' —Y Y F '. r� ?_.•':•ar`t'y ...•.sr"'•.^� ✓ii,, 1! 1 V V C'1 I V 1 ! 1 1 -' teas'-.,�",. „!�i�. is .0��.` �V/' SERIES EE � :INTEREST CEASES 30 YEARS _ _ - FROM ISSUE DATE t �+a 6 1 - 1 07 ELL' CAM ILLt-P441 fry ''� X �y •� '_ 7 ._ nyetS L502b288blEE 1:0000 9000 71:0 3 r`= 10'S0 2P. 28$6 l+l' Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice C704280366EE EE $100 09/2000.04/2014 09/2030 $50.00 $24.44. 1.19% $74.44 L583482831EE EE $50 12/1999 04/2014 12/2029 $25.00 $13.30 1.19% $38.30 L580973353EE EE $50 11/1999 04/2014 11/2029 $25.00 $13.34_ 1.19% $38.34: L580581284EE EE $50.09/1999 04/2014 09/2029 $25.00 $14.02 1.19% $39.02 C675036588EE. EE„ $100.08/1999 04/2014 08/2029 $50.00 $28.12 1.19% $78.12 L571455130EE EE $50 11/1998 04/2014 11/2028 $25.00 $.15.0.4. 1.19%... $40.04 C651001418EE_ EE $100'08/1998 04/2014 08/2028 $50.00 . $31.96 1.19%' $81.96 561272893EE EE „L_ _ $50 11/1997.1,04/2014 11/2027 $25.00. $17.18. _1.19%__ C615087873EE EE $100 08/1997.04/2014 08/2027 $50.00 $36.64 1.19% . $86.64: L552694640EE EE $50 1.1/.1996105/2014 11/2026 $25.00 $25:00 1.12% $50.00 C579978888EE EE $100 09/1996 09/2014 09/2026 $50.00 $50.32 _ 1.12% . $100.32 i. L545934148EE EE $50'.03/1996 09/2014 03/2026 $25.00 $25.30; .1.12% $50.30 L540495172EE EE $50 11/1995 05/2014 11/2025 $25.00 $25.30 1.120/a $50.30 C537162728EE EE $100 09/1995 09/2014 09/2025 $50.00 $51.00 1.12% $101.00 L536430647EE EE $50.03/1995 04/2014 03/2025 $25.00 $28.08 4.00% $53.08 L532114961EE . EE $50. 12/1994 04/2014 12/2024 $25.00 $28.60. 4.00%' $53.60: C494384180EE: EE $100 11/1994 04/2014 11/2024 $50.00 $57.56: 4.00% $1.07.56 .C481359895EE EE $100 08/1994 04/2014 08/2024 $50.00 $58;64; .4.00%.. $108.64 K101257912EE EE $75.12/1993 04/2014 12/2023 $37.50 $46.14 4.00% $83.64 L516193798EE EE $50 11/1993 04/2014 11/2023 $25.00 $30.94 4.00%.- $55.94v C434474774EE EE $100- 10/1993 04/2014 10/2023 $50.00 $62.28 4.00% $112.28: 1-505950276EE EE $50.09/1993 04/2014 09/2023 $25.00 $31.32: 4.00% $56.32 L515176095EE; EE $50 09/1993 04/2014 09/2023 $25.00.. $31.32 4.00%q.. $56.32 L514786075EE EE $50109/1993.04/2014 09/2023 $25.00 $31.32 4.00% $56.32. L511483598EE EE $50:03/1993 04/2014 03/2023 $25.00 $32.44 4.00% $57.44' L504804795EE EE $50 12/1992 06/2014 12/2022 $25.00 $47.60 4.00% $72.60 L503758495EE. EE . $50 12/1992.06/2014 12/2022 $25.00_ $47.60 4.00%: $72.60:✓, C394775842EE EE 11/1992.05/2014 11/2022 $50.0 _ $145.20„: % L502116476EE EE ..$_ o f ' eRoe` nor L502628861EE EE �50�09/199209/2014 09/2022 $25.00. $49.04 4.00/ $74.04 -te 6 L503579700EE EE $50,08/1992,08/2014 08/2022 $25.00 $49.04 4.00% $74.04. 1499701438E6 EE $50 04' /1992:04/2014 04/2022 $25.00 $49.04 4.00% . $74.04 L497012499EE. EE $50' 12/1991 06/2014 12/2021 $25.00 $50.52 4.00% $75.52 Totals for 76 Bonds. $2,612.50. $1,705.47 $4,317.97 Notes NI Not Issued NE Not eligible for payment P5 Includes 3 month interest penalty MA Matured and not earning interest Schedule F, Exhibit 3. 2 of 2 7/15/2014 3:55 PM Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 03/2014 Total Price Total Value Total Interest YTD Interest $2,612.50 $4,317.97 $1,705.47 $23.11 Bonds: 1-76 of 76 Issue- ` rInterest al I�s�� Interest Value Note Serial # Series Denom Date Accrual Maturity Price Rate C859208195EE EE $100 09/2009^04/2014 09/2039 $50.00 $1.36' 0.700/o: $51.36 P5 L652396564EE EE $50 12/2009'04/2014 12/2039 $25.00 $1.28 1.20%' $26.28` P5 L647882268EE EE $50 12/2008 04/2014 12/2038 $25.00 $1.72 1.30% $26.72 C85077028SEE EE $100 09/2008 04/2014 09/2038 $50.00 $3.96: 1.40%' L643209571EE EE $53.96 _ $50.12/2007.04/2014 12/2037 $25.00 $5.12' 3.00%: $30.12: L642421919EEEE $50.11/2007 04/2014 11/2037 $25.00 $5.20' 3.00% $30.20 L642097673EE'_ EE10-/200.-7-..04/2014 _ T - ..1..... $50 10/2007 04/2014 10/2037 $25.00 $6.06; 3.40%. $306' L641826036EE. EE $50 09/2007;04/2014 09/2037 $25.00• $6.14 3.40_% $31.14. C841095159EE' EE $100 _09/200704/2014 09/2037 $50.00 $12.28;. 3.40% $62.28 C836871254EE EE $100 04/2007 04/2014 04/2037 $50.00 $14.04 3.60%. $64.04: _ C832654964EE EE $100.12/2006:04/2014 12/2036 $50.00 $14.76; 3.60%' $64.76. L637616590EE- EE $50 11/200604/2014 11/2036 $25.00 $7.48: 3.60% $32.48 L636365289EE: EE $50'09/2006:04/2014 09/2036 $25.00. $7.90: 3.70% $32.90 C829201164EE� EE $100'08/2006.04/2014 08/2036 $50.00 $16.00 3.70% $66.00 C826925162EE: EE $100'06/2006.04/2014 06/2036 $50.00 $16.40 3.70%, $66.40 L614188001EE EE $50 12/2005 04/2014 12/2035 $25.00 $7.48 3.20% $32.48: L613670918EE EE $50 11/2005 04/2014 11/2035 $25.00 . $7.56 3.20% $32.56. C809245457EE EE $100 09/200504/2014 09/2035 $50.00, $17.12' 3.50% $67.12 L613130295EE EE $50 09/2005.04/2014 09/2035 $25.00. $8.56 3.50%_- $33.56 L608747874EE' EE $50 12/2004 04/2014 12/2034 $25.00' $6.32: 1.19% $31.32 L607447125EE EE $50 1]./2004 04/2014 11/2034 $25.00 $6.34: 1.19%' $31.34 L606031519EE EE $50 09/2004.04/2014 09/2034 $25.00 $6.72: 1.19% $31.72 C793713121EE. EE $100.08/200404/2014 08/2034 $50.00 $13.52 1.19% $63.52 C780704929EE EE $100 12/2003 04/2014 12/2033 $50.00. $14.44: 1.199/b $64.44. L600002098EE EE $50 11/2003'04/2014 11/2033 $25.00 $7.24 1.19% $32.24 C775480073EE EE $100 09/2003 04/2014 09/2033 $50.00 $15.24. 1.19%. $65.24_ K106621305EE EE $75 09/2003 04/2014 09/2033 $37.50 $11.43: 1.19% $48.93- L598441983EE EE $50 04/2003 04/2014 04/2033 $25.00 $8.08, 0.68%- $33.08 L596873123EE EE $50 12/2002 04/2014 12/2032 $25.00 $8.20. 1.19%. $33.20 C765796589EE* EE $100 12/2002 04/2014 12/2032 $50.00 $16.401 1.19%. $66.40 L625382967EE. EE $50 10/2002 04/2014 10/2032 $25.00 $8.72, 0.68%. $33.72 C755955740EE: EE $100 08/2002 04/2014 08/2032 $50.00 $17.56 1.19% $67.56 C745924394EE EE $100 08/2002 04/2014 08/2032 $50.00 $17.56 1.19% $67.56 L620919537EE EE $50'02/2002 04/2014 02/2032 $25.00 $9.44 1.19% $34.44 C740313527EE EE $100 12/200104/2014 12/2031 $50.00 $19.00 1.19% $69.00 L617426263EE EE $50 11/2001 04/2014 11/2031 $25.00 $9.54: 1.19% $34.54 K105599111EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30: 1.19% $52.80• C727270411EE EE $100 09/2001 04/2014 09/2031 $50.00 $20.40' 1.19%, $70.40 K105599112EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.19% $52.80 L593694278EE EE $50 04/2001.04/2014 04/2031 $25.00 $11.16 0.689/b $36.16 K105424122EE EE $75 12/2000.04/2014 12/2030 $37.50 $16.92. 1.19% $54.42 L589686766EE' EE $50 11/2000 04/2014 11/2030 $25.00 $11.327 1.19%ry $36.32 L588815953EE EE $50 09/2000 04/2014 09/2030 $25.00 $12.22' 1.19% $37.22 1 oft 7/15/2014 3:55 PM 1m as l `/F�.r. ��. y� /[1 t 51 2 Y' i 7t11j!-iFi 1 . ? �7MiClifr Q r`a rz^� ti, Y, "=3: ;V 'W ( y }r INTEREST GiSES SO YEARS ?�^` l +t ��q ,¢?-: �#4�.-i.'� t t d 3• a t �' a i <r ^T 5 4 2 a liN Ixt�.. i �' .-� ��._E.+ �' SO.0 SECYEMP ID KO! 'Y 7 }t r `� ,t ) ! ��r � �_3� -.x }•�Zr� Y. */33•'` L .; r -r./. a,ry er7-fci-''{� �. -_ iR.D'�tiA .i -' "Lt• a 3. F1'�.n... ^� 1 "T ' al.-x'35�7 .�` + r� 4- •\ b.? :\,�\aM �T.y�£+ � I t rd. ! � � s� tiL�'u J313�1y 1�T1��? DATING STAt1P "+ �: �.��� �e�� � c��.'y1m. s��.:P?t'�t f-_y,,, ji,, t � 7.-' ,, S..t� _r! �.�c `y�•y: `> �'y r�� � S'` �r. ` 4511A 7ff W���. � '�[� ,� I yt' #-.• ;-. v R�4 4 - :r..l r l a t _"1"` y„I �.. g a 20;5 ---- ------------------------------------------ w U P 1 0 M) S 40 sR s EE m �awp; � INTEREST CEASES SO YEARS Aaaa�4 to FIR WISSUE DATE c✓ a r t ,� - r .•i �'�•2 t J� mufm ...� .: Ls'il4t €F...i_° ;:'£� €:1.h"�. ` Yr '' . �`� 1�`�g•- q{,35�,. s- •. '4 r} �SS�D�AGEI!yy:��T'G•,rye 't', i - w,•y - f •Sn �. ; �.. J Yi Sw S..'6'sf' i Y Y �.f �k - S X :�.�.D.. r` 3 (• 4 ' :t �AYIN SYAMP- - L50 �584,95EE ¢\ ' : 0000900071:03: .�w+r. `k\��',_�.A�-Y!gfi'-'li•� rWF a\!1 1 Y N :�/( -- -- 0. G 0 1 -l N.�����•""\VLrr'.^,i ii,�� ���. P-°c<:�. �L;g,r•L,.�'.'.'r;a>':.:c- .., y�r��.-q�',y `. ;-y'j �v �y.�-j•. t `��• ... �7y�y- .:..'t ,P..r.���� �,,.if a lRc�finSalr. s SERIES 1E E` Y -y; At14 ~{ ' y�, ftv�;�F � 'IN T.EREST CEASES SO-.YEARS -' - s FROM ISSUE DATE '- -<s „/ e 5th t E'LLN;:11RB qq rRB-�y'MINN, CAMP I;ILL�i 05 31U`�!s } ' I$lssuitTdfil rsai I 'SEP• 2.1.y11-1991 p��r -_-{�-+.�. � p� n •Q r� G C f DMII�GP� ! ,.r �:•'y+; .. E=U-1 U i t't'f 'I� G� /i '• E7i-L r• - jt _RDSQ'`°1!�9Z-CC104. _-,�_;_ 2620.00-�': - :_::° i35t?2 161476E . Q 4. $ S ry✓lfrSm.wy - y E-1- '1:0000 9000 71:0 3 " 70 50 2 1It 4 ?r3 - A t�G^AaEdYR:.itt7.rt{•Q¢;�'Afihdb.ES.'A REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Peter C. Breen 21 14 0310 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 INCLUDE THE NAME OF THETRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OFDECD'S. EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. The Royce Funds, P.O. Box 219012, Kansas City, MO 64121 2,010.36 100.00 2,010.36 Roth IRA Fund 264 Beneficiary: Kevin Breen - Father-50% Benefciary: Renee Breen - Mother-50% (See Schedule G, Exhibit 1) 2. The Royce Funds, P.O. Box 219012, Kansas City, MO 64121 2,035.77 100.00 2,035.77 Roth IRA Fund 277 Beneficiary: Kevin Breen - Father-50% Beneficiary: Renee Breen -Mother-50% (See Schedule G, Exhibit 1) The Royce Funds, P.O. Box 219012, Kansas City, MO 64121 Rother IRA Fund 291 Beneficiary: Kevin Breen - Father-50% 3. Beneficiary: Renee Breen -Mother- 50% 2,124.41 100.00 2,124.41 (See Schedule G, Exhibit 1) 4. The Royce Runds, P.O. Box 219012, Kansas City, MO 64121 27,402.34 100.00 27,402.34 UTMA Account Beneficiary: The Estate of Peter Breen (See Schedule G, Exhibit 1) 5. Bonds- Payable on death to Kevin J. Breen - Father 162.92 100.00 162.92 (See Schedule G, Exhibit 2) TOTAL (Also enter on Line 7,Recapitulation) $ 33 735.80 If more space is needed,use additional sheets of paper of the same size. A -3 E laeRoy� 'LIDCJS '::CRdM1'!I`,D TO S!d SUER CON4PANJI-S,f2}4`O"i"fSU TO VAUIE PO Box 219012•Kansas City,MO 64121-9012 July 18,2014 RENEE R BREEN 507 ELLEN RD CAMP HILL PA 17011-2019 REFERENCE: 12786429 State Street Bank&Trust Co Cust Roth IRA Contrib Peter Craig Breen Renee R Breen Cust Peter Craig Breen UTMA PA Dear Ms.Breen: We are writing in regard to the above referenced account. As a procedural safeguard,a temporary Stop Transfer restriction has been placed on the account. An account with a Stop Transfer restriction is blocked from redemption and transfer requests until the appropriate documentation has been received to remove the restriction. The following information is in response to the inquiry regarding the Estate of Pete:Craig Breen: The date of death value for Peter Craig Breen's account on March 11, 2014,was as follows: Fund Account Shares Net Asset Value Value (NAY) 264 xxx9579 120.093 $16.74 $2,010.36 277 xxx9579 202.564 $10.05 $2,035.77 291 xxx9579 157.714 $13.47 $2,124.41 260 xxx7505 1,857.788 $14.75 $27,402.37 The account value is calculated by multiplying the number of shares held by the Net Asset Value(NAV). Please note,we have enclosed the submitted documents,as requested. If you have any further questions,please feel free to contact our office at 1-800-841-1180. You may also contact us at the above address. Sincerely, Shareholder Services Representative Enclosure(s): Original Document Business Reply Envelope Schedule G, Exhibit 1 P.O.Box 219012•Kansas City,MO 64121-9012•1-800-841-1180•wwwcroycefunds.com Calculated Value of Your Paper Savings Bond(s) Page 1 of 1 Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 03/2014 Total Price Total Value Total Interest YTD Interest 50.00 $64.04 $14.04 $0.60 Bonds: 1-1 of 1 Issue Next Final Issue Interest Serial # Series Denom Date Accrual Maturity Price Interest Rate Value Note C836841254w EE $100;04/2007.04/2014' 04/2037! $50 00! $14.04- 3.60%i$64.04f Totals for 1 Bonds;$50.001 $14.04 $64.04y. Notes NI Not Issued NE Not eligible for payment P5 ;Includes 3 monthinterest penalty MA ;Matured and not earning interest http://www.treasurydirect.gov/BC/SBCPrice Schedule G, Exhibit 2 10/9/2014 C alculaxi�d Value of Your Paper Savings Bond(s) http://www.treasurydirect.cov/BC/SBCPrice Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 03/2014 Total Price Total Value Total Interest YTD Interest $2,612.50 $4,317.97 $1,705.47 $23.11 Bonds: 1-76 of 76 Issua `,, Interest Cxt F0rz: I5�::� Interest Value Note Serial # Series Denom Date Accrual Maturity Price Rate C859208195EE EE $100 09/2009 04/2014 09/2039 $50.00 $1.36 0.70% $51.36 P5 L652396564EE EE $50 12/2009 04/2014 12/2039 $25.00 $1.28 1.20% $26.28 P5 L64788226SEE EE $50 12/2008 04/2014 12/2038 $25.00 $1.72 1.300/0 $26.72 C850770288EE EE $100 09/2008 04/2014 09/2038 $50.00 $3.96 1.40% $53.96 L643209571EE EE $50 12/2007 04/2014 12/2037 $25.00 $5.12 3.00% $30.12 L642421919EE EE $50 11/2007 04/2014 11/2037 $25.00 $5.20 3.00% $30.20 L642097673EE EE $50 10/2007 04/2014 10/2037 $25.00 $6.06 3.40% $31.06: L641826036EE EE $50 09/2007 04/2014 09/2037 $25.00 $6.14 3.40% $31.14 C841095159EE EE $100 09/2007 04/2014 09/2037 $50.00 $12.28 3.40% $62.28 C832654964EE EE $100.12/2006 04/2014 12/2036 $50.00 $14.76 3.60% $64.76 L637616590EE EE $50 11/2006 04/2014 11/2036 $25.00 $7.48. 3.60% $32.48 L636365289EE EE $50 09/2006 04/2014 09/2036 $25.00 $7.90 3.70% $32.90 C829201164EE EE $100 08/2006 04/2014 08/2036 $50.00 $16.00 3.70%. $66.00 C826925162EE EE $100 06/2006 04/2014 06/2036 $50.00 $16.40 3.70% $66.40 L614188001EE EE $50 12/2005 04/2014 12/2035 $25.00 $7.48 3.20% $32.48,f L613670918EE EE $50 11/2005 04/2014 11/2035 $25.00 $7.56 3.20% $32.56 C809245457EE EE $100 09/2005 04/2014 09/2035 $50.00 $17.12 3.50% $67..12 L613130295EE EE $50 09/2005 04/2014 09/2035 $25.00 $8.56 3.50% $33.56 L608747874EE EE $50 12/2004 04/2014 12/2034 $25.00 $6.32 1.19% $31.32 L607447125EE EE $50 11/200404/2014 11/2034 $25.00 $6.34 1.19%: $31.34 L606031519EE EE $50 09/2004 04/2014 09/2034 $25.00 $6.72. 1.19% $31.72 C793713121EE. EE $100 08/2004 04/2014 08/2034 $50.00 $13.52 1.19% $63.52 C780704929EE EE $100 12/2003 04/2014 12/2033 $50.00 $14.44_ 1.19% $64.44. L600002098EE EE $50 11/2003 04/2014 11/2033 $25.00 $7.24 1.19% $32.24 C775480073EE EE $100 09/2003 04/2014 09/2033 $50.00 $15.24 1.19% $65.24 K106621305EE EE $75 09/2003 04/2014 09/2033 $37.50 $11.43 1.19% $48.93 L598441983EE EE $50 04/2003 04/2014 04/2033 $25.00 $8.08 0.68% $33.08 L596873123EE EE $50 12/2002 04/2014 12/2032 $25.00 $8.20 1.19%. $33.20 C765796589EE EE $100 12/2002 04/2014 12/2032 $50.00 $16.40 1.19% $66.40 L625382967EE EE $50 10/2002 04/2014 10/2032 $25.00 $8.72 0.68% $33.72 C755955740EE EE $100 08/200204/2014 08/2032 $50.00 $17.56 1.19% $67.56 C745924394EE EE $100 08/2002 04/2014 08/2032 $50.00 $17.56 1.19% $67.56 L620919537EE EE $50 02/2002 04/2014 02/2032 $25.00 $9.44 1.19% $34.44 C740313527EE EE $100 12/2001 04/2014 12/2031 $50.00 $19.00 1.19% $69.00 L617426263EE EE $50 11/2001 04/2014 11/2031 $25.00 $9.54 1.19% $34.54 K105599111EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.19% $52.80 C727270411EE EE $100 09/2001 04/2014 09/2031 $50.00 $20.40 1.19% $70.40 K105599112EE EE $75 09/2001 04/2014 09/2031 $37.50 $15.30 1.190% $52.80 L593694278EE EE $50 04/2001 04/2014 04/2031 $25.00 $11.16 0.68% $36.16 K105424122EE EE $75 12/2000 04/2014 12/2030 $37.50 $16.92 1.19% $54.42 L589686766EE EE $50 11/2000 04/2014 11/2030 $25.00 $11.32 1.19% $36.32 L588815953EE EE $50 09/2000 04/2014 09/2030 $25.00 $12.22 1.19% $37.22 1 of 2 7/15/2014 3:55 PM C alculatPd Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice C704280366EE EE $100 09/2000 04/2014 09/2030 $50.00 $24.44 - 1.19%. $74.44' L583482831EE EE $50 12/1.999.04/2014 12/2029 $25.00, $13.30,: 1.19% $38.30 L580973353EE EE $50 11/1999 04/2014 11/2029 $25.00 $13.34• 1.19% $38.34 L580581284EE EE $50.09/1999 04/2014 09/2029 $25.00 $14.02 1.19% $39.02. C675036588EE EE $100 08/1999 04/2014 08/2029 $50.00 $28.12 .1.19% $78.12 L571455130EE. EE $50 11/1998.04/2014 11/2028 $25.00 $15.0.4. 1.19%.._ $40.04 C651001418EE. . EE $100.08/1998 04/2014 08/2028 $50.00 . $31.96 ..1.19% _ $81.96 L561272893EE EE o $50 11/1997 04/2014 11/2027 $25.00 $17.18: 1.19/o. $42.18 C615087873EE' EE $100 08/1997 04/2014 08/2027 $50.00 $36.64 1.19% $86.64 L552694640EE EE $50 11/1996 05/2014 11/2026 $25.00 $25.00: 1.12% $50.00 C579978888EE EE $100 09/1996 09/2014 09/2026 $50.00 $50.32 1.12% $100.32 L545934148EE EE $50!.O3/199609/2014 03/2026 $25.00 $25.30: 1.120/o $50.30 L540495172EE EE $50 11/1995 05/2014 11/2025 $25.00 $25.30 1.120/4 $50.30 C537162728EE EE $100 09/1995 09/2014 09/2025 $50.00 $51.00 1.12% $101.00 L536430647EE EE $50.03/1995 04/2014 03/2025 $25.00. $28.08.-. 4.00% $53.08 L532114961EE1. I EE. 1. $50. 12/199.4.104/2014 12/2024 $25.00 .$28:60. 4.00% $53.601 C494384180EE., ..EE $100 .11/1.994 04/2014 11/2024 $50.00 $57.56: 4.00%: $107.56_ C481359895EE EE $100 08/1994 04/2014 08/2024 $50.00 $58.64__ 4..00% K101257912EE EE $75 12/1993 04/2014 12/2023 $37.50 $46.14. 4.00%._ $83.64 L516193798EE EE $50 11/1993 04/2014 11/2023 $25.00 $30.94 4.00%. $55.94 C434474774EE EE $100- 10/1993 04/2014 10/2023 $50.00 $62.28 4.00% $112.28: 1-505950276EE EE $50.09/1993 04/2014 09/2023 $25.00 $31.32.: 4.00%, $56.32, L515176095EE: EE $50 09/1993 04/2014 09/2023 $25.00.. $31.32 4.00%.. $56.32 L514786075EE EE $50 09/1993.04/2014 09/2023 $25.00 $31.32 4.00% $56.32. L511483598EE EE $50_03/1993 04/2014 03/2023 $25.00 $32.44 4.00% $57.44 L504804795EE EE $50 12/1992 06/2014 12/2022 $25.00 $47.60 4.00% $72.60 L503758495EE, EE $50 12/1992,06/2014 12/2022 $25.00 $47.60 4.00%q'__ $72.60. . .._ C394775842EE EE $10011/1992 05/2014 11/2022 $50.00• $95.20; 4.00% $145.20 L502116476EE.. EE $50_._09/1992 .09/2014 09/2022 $25.00 $.49.04 4.00%.:. . $74.04.._ L502628861EE, EE $50.09/1992 09/2014 09/2022 $25.00• $49.04 4.00% $74.04 L503579700EE EE $50.08/1992:08/2014 08/2022 $25.00 $49.04 4.00%". _ $74.04. 1499701438E EE $50 04/1992 04/2014 04/2022 $25.00.. $49.04 4.00% $74.04' .. L497012499EE EE $50. 12/1991 06/2014 12/2021 $25.00 $50.52 4.00%. $75.52 Totals for 76 Bonds $2,612.50 $1,705.47 $4,317.97 Notes NI Not Issued NE Not eligible for payment P5 Includes 3 month interest penalty MA Matured and not earning interest 2 of 2 7/15/2014 3:55 PM 4Sydsk iii" 1 1 Y Y:1 `.N r', `4 dr 1 3® ry�� k;.r -►ria 1S x ? ,wk lF7ERE57 cPhs'>^t3acit5 rs� ��+ � ''{+ r'�x♦�Fi20M 1��tYE��iY�i��� �r 0 t:.;� 1+:: PATRIOTSOND Y J �14y ; 277 2T a f >, '20 �T/PETER CBREEN t. t. Fes-•-.,^' ?,- ♦ d ,i i. _ f F I j Y i y- �i �Y0� Kzffl . t 507 ELLEN 22C1f1D +� Y zt _ CAIMP'. HILL PA ` 1 7D13=2019 >t bifill�t.111111ittIII ii lfiilrlil �ralllt.' s w �! � Y i �`: ...wr ,. tv.: ',_A..• �' 1 • -5 l 4y.fa+`*' .t�� L�'iM � r�-'i 06D KEVIN .!SBF EN at. � 14SCU411fl702086A=031 $#t12B30a720 0# SQA 231 +} b$ i � I25 �/"� 1t�Y�{�JT''��g'v�fJ �`'"�'���.i.?�!�u it U ``�. ''`4 t '3C [ rat ne r �� ✓L4 ".✓ !,. 1 W 3 iJ, # ,�i lr. i r:Ofloo900oqi�nL ►v `.:��4;i�w.> v H 1 u Y:1 1 a Y = t /1 �` W/✓NN?r" %° lih' F ti a��� il�v` z Fir f �'a° t G'�.�,•��� •"�� ,:�.:.�..;i � �r G�r Iw��R€s�c�as€s's+.�T�� ,, y E^ �?�"..`L�yr �'f� .r � a ie �r c zy y � } � > t 2U4 72 _4805 PATRIQT I�QND .� aI s, -.s.a+. t; r �Y �w ...• p;✓ �` r - n'r�t4.-.�� *� .�..5'� s7��µ �' . ryry'+PETER CRAIG BREEN414 � y » tx M LEN ROAD L"-J x �A7 E . r CAMP HILL - ,` P'A' :7.7`(2:32, 2A19 urrw� tl; It �kir.� ��nm a Pt38 KEVIN J ;GREE# L c=t ' ` = 14SCObt2b 080.0132A 031000(1530000 ObiIO�G3 �y w082 ','"+�''�.7.k2 � ".ArI 009000"71'04° ;: ° .310`&`2.69.2.5'i6 2a'• R t . ±n. EKti/'"u` �';��� "'.,` •.F:r. p 1 4 Y:'1 f _ Y [ t t /1 '�.��'A`V/a"'"_ � ��fi�� "` 204 72 48,05- PATRIOT BUND : 12< 20x5 ` �'s33 r a, ;i PSTER: :BREEN u h E-MAIL 'TO KEVIN-BREENM s5a-7 ELLEN RD o v {as CAMP HILL f r.t PA 17811 2019 t 5 DATtM ES/Mk � �+'t..%w, .-� f< •r�tr - -.w' ��i 1-.t'l.t c.� 1t_1 it '- - tt ,L a .� 1 ,yet J 'a; �i��Nturlllik�fi�lli�Illtrl;7iit�ui�fllil�illi�i�aai #i11f1 ii eQD 'KEVIN BREEfiI .. , , '- .♦ t.,.. - f = D90C12Ub-053.2�88A .0724039.940000.,126. 06 J. 3' ; s � '061418800I { i f }`F. .i a"�♦'st���i � -i'G�,�,�^r�'a`�r .,` - .r 'i� �k�Y aro 1 k REV-1511 EX+(08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL L EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Peter C. Breen 21 14 0310 Decedent's debts must be reported on Schedule t. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Malpezzi Funeral Home, 8 Market Plaza Way, Mechanicsburg, PA 17055 15,750.48 (See Schedule H, Exhibit 1) Decedent passed away while on a trip to Italy 2. Gingrich Memorials, 5243 Simpson Ferry Rd., Mechanicsburg, PA 17050 4,275.00 (See Schedule H, Exhibit 2) 3. St. Michael's Lutheran Church Cemetery Assoc., Klingerstown, PA 850.00 Burial Plot (See Schedule H, Exhibit 3) B. ADMINISTRATIVE COSTS: WAIVED 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: Theresa L. Shade Wix, Esq., Wix, Wenger&Weidner 875.00 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: Cumberland County Register of Wills 133.50 5 Accountant Fees: 6. Tax Return Preparer Fees: 7. The Cumberland County Journal 75.00 Estate Advertising (See Schedule H, Exhibit 9) 8. The Sentinel 211.78 Estate Adverting (See Schedule H, Exhibit 10) 9. Cumberland County Register of Wills, One Courthouse Sq., Carlisle, PA 17013 25.00 Short Certificates (See Schedule H, Exhibit 11) TOTAL(Also enter on Line 9,Recapitulation) $ 24 134.70 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent Peter C. Breen 21 14 0310 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses&Administrative Costs -A. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 4. Woodring's Floral Gardens, 145 S. Allen St., State College, PA 16801 221.49 Flowers for Penn State Memorial Service (See Schedule H, Exhibit 4) 5. Koch Funeral Home, 2401 South Atherton St., State College, PA 16801 90.00 Register Books for Memorial Service (See Schedule H, Exhibit 4) 6. Payments to the following individuals were made for their participation at the funeral service: a. Rev. Kathryn Johnston - Pastor-$500.00 750.00 b. Rev. Myrtle McCall - Pastor-$100.00 c. Ellen Hunt-Organist-$100.00 d, Gary Weber-Vocalist-$50.00 (See Schedule H, Exhibit 5) 7. Building use donation to Mechanicsburg Presybertian Church for funeral service 500.00 (See Schedule H, Exhibit 6) 8. Building use donation to St. Michael's Lutheran Church for funeral luncheon 250.00 (See Schedule H, Exhibit 7) 9. Funeral Luncheon 100.00 (See Schedule H, Exhibit 8) SUBTOTAL SCHEDULE H-A 1,911.49 Continuation of REV-1500 Inheritance Tax Returh Resident Decedent Peter C. Breen 21 14 0310 Decedent's Name Page 2 File Number Schedule H -Funeral Expenses&Administrative Costs -67. ITEM NUMBER DESCRIPTION AMOUNT 10. Wix, Wenger&Weidner, 4705 Duke Street, Harrisburg, PA 17109 27.45 Photocopying SUBTOTAL SCHEDULE H-B7 27.45 1 alpezzi Fane' ral Hine 8 Market Plaza Way (717)697-469 Mechanicsburg,PA 17055 www.MnlpezziFuneralHome.com Jeremy J.Shartzer,FD Michael J:Malpezzi,Owner,FD Kyle C.Knipe,FD April 22,2014 Kevin J.Breen 507 Ellen Road Camp Hill,PA 17011 This is the final statement for the funeral services of Peter Craig Breen We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way. PROFESSIONAL SERVICES: Services,Facilities and Cremation $4,330.00 Out of town transportation to airport . $240.00 Out of town transportation to cemetery $90.00 FUNERAL HOME SERVICE CHARGES $4,660.00 SELECTED MERCHANDISE: 12 ga.Regular Steel Urn Vault $295.00 Cherry Cremation Urn $495.00 325 Custom Memorial Folders $125.00 THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE THAT YOU HAVE SELECTED $5,575.00 CASH ADVANCES: At the time funeral arrangements were made, we advanced certain payments to others as an accomodation. The following is an accounting of those charges. Opening Grave $200.00 Newspaper Notices-Patriot $547.72 Flowers $360.40 Worldwide Flight Services Terminal Service Fee $40.00 Humanitas Funeral Home $9,247.36 International Wire Transfer Processing Fee $110.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES $10,505.48 CONTRACT PRICE $16,080.48 HISTORY: 03/28/2014 Discount Compassionate Discount(Transportation) $330.00 .04/22/2014 Payment Renee R.Breen $15,448.12 TOTAL AMOUNT DUE $302.36 If you have any questions or concerns regarding this bill,please call our office at(717)697-4696. Schedule H, Exhibit 1 17^.-f j.4..}..�;�y,����:�,w'^��h.,.\�t'tai »,'�fj•'.74�1eC: -"h+ -4i ��4Tj. ,� :�,a' �,. • S�iOF�'l3N$Kt1i:,CaCIX}DS Anti?573R;1�SF.L^E `,. Cbuges ale arty for those Items ilial you seleaedPor,drat ue requval Rwe are requued'1ry baa pr by a'mr aery ar:aeraAtory to use artyitrmd;ak will,' ., Mlain the mson in writing below.. ' If you srlemd a funeral that may require embalming,such as a funeral viewing,you may have to pay for embalming.You do not have to pay for embalm- ing you did not approve if }seteaed such as disea cremation or immediate burial.It we charged far embalming,we-m explain whp beMw. Fut the Service of T�•�oi Date of DnfL jf�AMI. Cbargetm t(e.n:,. + a+.. (`SG s67 'F//en /2.rwl C, p A'('I. IPA i 7ea[1 Name Address City State . A.CHARGE FOR SUMC'FS SELECTED: Od=dung . f.#ROF'EMONAL SERNCFS Saviors of Fwxenl D'irmor/Soff......f� Bunn...................�t —A . ............. .........'-'... TOTAL MER(7LA mm SELECTED.................B S SHU SUR•TOTAL OF PROFESSIONAL SERVICES.........At fI)M C.SFFCLAL CHARGES: . 2 FACUM AND StRVM Fonvmding of remains to tise of fadtaies and Senices for view3n8(ViistatiaJWAkd.........f wt - (Funeral Home) Use of facilities and services Recc v*of remains fmm for funeral aremary ............S Use of facilities and m km for (Flineni Home) _ Memorial Service ..".:..........$ Immediate Smut......:.....,.....t Use of opdpmem and aenkes DirectCmmiloa..................S ',I ' for gavnside cervix.............$_wtS_ - ........0 S�A Cnher use of facilities - - .SUR-TOTAL OF SPECIAL CHARGES ..t...... D.=AN . .......................:SJ^r1 OpatGig Cmvr ..............:...t SUR•TDm OF FA� ....:.....A2 f rut Ctmewry Equ)purent ..............S 3.AUTOManVE EQUIPMENT to and Deed ...................t Vebide to tnamfer rew'uu to Funeral Home Newspaper Naiaes-Ow-c town...... Loral .........................f r,a1 - TelepborK&Taeg.uns ..........:..f Hearse,(Casks Lmch) .........Sr_. Loral ..........................f Ckngghdass Offering ......:.......f _ Umous m - Pallbearers .................:...t Cod ..........................t corefied Copies of she bath ....I...$ Family Car :..CentT,= ......................f Lori .........................t Poria Esmt.................". f Flower car or floral disposition i Flowers........................ Lod .........................f r_s^.�— - Vaub Savtte S Lad addergy ar ..4....{.. local . .................t,+r•+� 14.,,LytY4 f Local .........................t . Gawcias.)c..$OtaofmSBTOTAL OF ADVANCES 1 s ; ......................D S`l ,r,�y. SWIWAL OF AUTOMOTIVE EQUMONT........A3 f— _ We dirge you for our rh=in oU ming' TOTAL OF 12OFMONAL SEIM{ES, (sprdfY oub odusnxs mar me madaed+rp} . FAC]ZHES AND AUTOMOTIVE EQUEPMFNT-..._............."................A S S 22S R.CHARGE FOR MERC 0ANDTSESEL ECTL'D: SUMMARY OF CHARGES A Prefcdoml Savims,Facilities and . Caslra.........................S a+,\ Fqugxmem•and AmomohT - t} � .....................1�2 B.Merchandise .....................f, -+AG Other Receptacle.............. t -C Special Chm m.....:............S ..ct c"E 'D.Cash Advanxa ..................f 4S- .t'4 outer burial magma .....:.......s ZSr TOTAL OF AIL.SECTIONS.....".;...............$11.6mi Z . PAID AT TIME OF OPRIOR TO . ARRANGEMENTS.k��afvF�e�iScaat�... �.$� � Ad w4edgmtem olds............S BALANCE DUE .......t t V• 2 Register book(s)...........:......f IREASONTR= G� Memory folders..:...............f�1L. .�.f Perm ands '....................t - V any law,xaoaerY,or a--y-T-h—haWreT—the Puedsasc . .. madcer of the he Ik* quirearent is ;-.. '$urrat,afathurg ;:....::a•r.. ,. ,x..:%aF' _. _ ,... c ..�V��—]- Jager that I have eaaacoed the items of goods and savica selected above and fomd dm to be correct and according to the am ngem=I bane requested.I admowbcdge ,axipt Of a copy of this StImcm of Funeral Goods and Services Selected I represent that I have atdfident funder available for payment of the ash poke for tire goods and services srleacd i also agile to .ke paym=cf s K,WK-/Z whhiq J& dapsi agree to be pmdy and severally liable with else Wen signs bdow.A-lam dtarw of / P.moochm ao ntin�g to !2 per year will be applied d the unpaid balance begireft_e days -6om rite dam'of this agew enc I wI also pay to the Funeral Director erg reasonable oras paid by the Funeral Dineew m collet amwms I owe under Ibis ageeman . '!hose mazs may include anomcys'fees,noun cA¢s and ohs costs Any additlwal serviors or madandise ordered or nequcaed,Am the date of this ageemem,will be P-/dta ageaoeru and the tort thereof will be reflected on the foal bill w sacement (sun f -�. !—jfc •� / 6j� Ali r�7` 20+y (Sal) - fFmchaser) - > o rv».,t—wo.4 Dere-Amdam svrms tm�t naaov ww®t oar. rocs ceoaa farm'-600 Revised 1/04 2-022.54 ME11�0 %LS ' $trice �9�� Drawing Drawing.Sent to Gust. Approved 5243 Simpson Perry Road,Mechanicsburg,PA 17050 Found.8y5 Fouad. Ordered (717)766=5622•Fax Qf7)76Cr8007 Vendor _Acic# wwuvgingrichmemorials.com, Grave flosition Verified Cremation SOLD TO: _LttVti? (j1'tAf R� Date of Order "t• �'� f q � i f Cal", t'i i P A . Cemetery. �"� 9 -.Ltlillrr.'4, Cemetery Location : l ri1)t t ct Z"�A_=r. Phone t s D Cell Center Over Graves' Sec.!Lot # Email Approx. Date of Completion n; it; •. ;= r� Lettering 2 1st' Sty. #1Y : "Alt f #1t` Y x;*st1►^.:`i � ( �vttd Y ,aTt } r1 JS}C�4��s • Yz T tk 181*�v�� �t+1•}:� rt ,- 7j a+�a k• t � [' R li }V 11zi(ti 1 Type Prt.��� Material r i C e? ;' i i '�,'i t� Additional Lettering: Size 'f X T'i�, X - Top S t ' i o Finish El Back X Base Sized 1 X lb X� Finish P. -� �I * 1ti y Description A VL r NAL � �t Location on Cemetery YY1(3; E .VasePhoto ❑ Other Agreement:A SW deposit.is required to commencement of work. COSTS: n Agree to pay stated balance upon erection regardless of labor troubles or shipments or any other good reasons.This order or Memorial $ �l r contract cannotbe cancelled by customer unless agreed by both parties.The article herein mentioned shall.remain the property of t James R.Gingrich Memorials unb'I paid in full and they reserve the right to remove the same is hot paid as stated. Foundation $ I agree to.carefully proofread all names and dates for accuracy and accept full responsibility for any errors or omissions.THERE Cemetery Fees $ WILL BE AN ADDITIONAL CHARGE FOR ANY LETTERING ADDED TO THIS MEMORIAL AFTER ERECTED ON THE CEMETERY f; t •` t1ZA� $ 1 further agree,to pay the.balance stated for the work performed under this contract within thirty(30)days of receipt of the final invoice and further agree that interest shall accrue at the rate of one and one=haH percent(135%)per month on the unpaid balance• $ owed to James R.Gingrich Memorials not paid within thirty(30)days of the invoice date.In.addition thereto,I agree if it becomes ` $ necessaryforJames Ft.Gingdch to institute legal proceeding to collect any funds due from me for my account being past due thirty t (30)days,to pay all sts andZmeys fees incurred by James R.Gingrich Memorials to collect She same.• TOTAL $ "'f _" Memorialist P" __ _-� " C1" �.-.�-,�r DEPOSIT _ c 7 . rc� r.--, Schedule ,H, Exhibit Customer Balance Due $ (1 further agree that the above narnes,spelling,and dates are correct) - Upon Completion St.Michael's Lutheran Curch Cemetery Association invoice No. 032014-2 Klingerstown, Pennsylvania CIO Mike Troutman, 204 Green Acres Lane,Herrmdon PA 17830 INVOICE irrorm r��rr_imr�oi��r��ir..vu�nrim� Customer Misc J Blame Peter Breen (Care of Kevin and Renee Breen) Date 3/28/2014 Address 507 Ellen Road Order No, � City Camp Hill State :PA ZIP :.17011 Rep Phone POB Qty description Unit Price TOTAL 1 Burial Lot for Peter Breen(1 Cremation Um) $ 850.00 $ 850.00 I � I � I • i Paid in full-Check#6719 to: �St.Michael's Lutheran Church Cemetery Association SubTotal ! $ 850.00 Shipping Payment Check Tax'Rate(s) ! I Comments #6719(3/24/14) TOTAL �850.00� Name Kevin J.&Renee R. Breen f CC# Expires Please keep this receipt with your important papers, as this serves as a legal deed. Thank You! Schedule H, Exhibit 3 ❑ A 1 R FUNERAL 11 PREVIOUS CUSTOMER# NAME OF DECEASED OR DESCRIPTION BALANCE 0 AMOUNT RECEIVED ACCT.# t WL ADJ. . tJv BALANCE DUE RECEIVED r ( r N0._-� FROM n n I DATE KdCh.Fttt!@1"aI Horne. eel BY _ 2401 SOUTH ATHERTO?4'STREET 1 # STATE COLLEGE, P;A'.16801: /Q Thank You! 5 wOODRING'S FLORALGARDENS 145 S.ALLEN ST: ' ; STATE',COLLEGE PA 16601 a. :::(800) 627-6737 Macle:;'POS :.Reg•Id.:• W4',Store #: 001' - Payment Type`: Credi`.t Card 'Tak Trans;Number .01552655 Date/Time:_03j182014 D5:.25pm.• Salesperson::0361-LISA H • Delivery:Method: Taken. =_ oty Description'- 'rice 1 PAIR .OF�ALTAR VASES ;150.00: ] • FRESH ARRANGEMENT FO .>- ;54.00 CANDLE,`• 1 DELiVERY.CHARGE 8.95 . l.c:C-, Sv►�teca�2.r: t . Sub:Total 208.95 . Tai:Amount.,.'.' %_12 54. . Total' $US): 2214949x" h1bit 4 Schedule `H, Ex Check#6724-04/09/2014 ^; Q, https;/Aiomebank.psecu.com/Checklmages/PrintCheck.aspx?FNA... Check #0724 04109/20,14'. $500 00 MnN J.BREEN 6124 RENEE M BREEN . 6�J-Sit�`231� r CAMP HILL„RA 1701 t Y Pay the �a Order of 00%0 ea. e rs el EMPLOYEEs Otter U"N LF ' i3� 1.1L is 014 so 201257:# . f a R� r •r wry . a 'S');63J.301846<'a tf 1 � .•ca a= . s _ . trb Rank glib.. -#'31 � ' ► c f� y� A yy,���f �/yy $a;:--2054-0"SSV-�. r�:L�$ - aE n e t rr '' � r * e schedule. H, .;Exhibit' 5. I of 1 9/22/2014 12:30 PM Check#6723 -04/03/2014 https://homebank.psecu.com/CheckImages/PrintCheck.aspx?FNA.-.. ` Check #6723 - 04/03/2014 $10.0.00 Malt J.BREEN 6723 RENEE R.BREEN 607 ELLEN ISD sa8ti1123t3 CAMP HILI,PA 17011 Date P v the to order o ~ CO PSECCip 10 y 231381L161. 04 50ci2065711" x723 r_ �:. -n _ . I of 1 9/22/2014 12:00 PM Check#6722-04/04/2014 https://homebank.psecu.com/Checklmages/PrintCheck.aspx?FNA:.. Check #6722 - 04/04/20.14, -. .$1,00.00._ 6722 WT ELLW ROAD 6 iBlxiltlli CWP MU,PAIIM.1 JAO 'Oki T Date Pay to the EPSWf"ISSUMPAM104M P&MMAMA EilP�.C�'YMs�MW MON F'U3' 2313a.11161' 0450920r.S ?B. 6722 I of 1 9/22/2014 12:29 PM Check#6720-04/02/2014 j ' Blips//home, an psecu corn/Checklma&'es/PrintCheck.aspx?FNA.:.- Check #6720 04/02/20.1.4 :- ',$50 00 . _ <.'f.F'+•HEE4�!�!1�.'f•rrr{'�"!'.k:N '�a•v1'.,.. ...'.d.. tl+n�.---- �' SSM}r KEVIN J,.BREEN 6720 REMEE�R.BRE SW MENROAD EN ' aso` Pay to Old Otylor of ' �� V VRsT 7 ,r. r,,...:K• '... � �I1� ���i7 LY.i.�' GSE �wti i�" oo * PEHi�f5Wt1�1�11�S#'A'6E i . PC ' For --- U. A - , r ", .#/y���/+��.� �/G{ ./•y��.^��..��y{ try;�{- __ G..� .�.MLt•i.F't i � �.i ii.,�SL,V. ii�R .�� '..w� .6:.•��.Z.,.�� ... - #. k C=�M, i C=o ca 1 of 1' 9/22/2014 11:57 AM Check#6725-04/02/2014 https:Hhorriebank.psecu.com/CheckImages/PrintCheck.aspx?FNA... Check #6725 - 04/02/201.4 -;$500:-00 =...,.J,. EN 6725 RENEE.fL BREEN WT ELLEN ROAD a�err�r3 CAMP HIU„PA 17011 acs POtier of �"s .tiny�V, �.�1v� C, $ . o -00 ., PSECEDWIMMUR0,PA 17110-2M nu For l 2.3 L3B I1191 01*5092065.70 G ? 2G C O m =Z 4 n CZ 7 f Schedule H, Exhibit 6 ! of 1 9/22/2014 11:59 AM Check#5728-04/02/2014 — a h,ttps://horhebank.psecu.cam/Checklmages/PrintCheck.aspx?FNA... Check #6728 - 04/02/2014 - $250-.00 F;RIII4 m 6726 Ba 604111013 so El I E ROAD LF ��� �° rder of PEf*JSYWANtA STATE �ca�R ¢.1�i1�rt�a2 For 1', !` rn ., CO �ao— X22 f Schedule H, .Exhibit 7 1.of 1 9/22/2014 11:58 AM Check#6729-04/04/2014 2+3 https://homebank,psecu.com/ChecklmagestPrintCheck.aspx?FNA... Check #6729 - 04/04/2014 -_:$100..00. . w.�. 6729 RENEE YL BRcs���r3 SVMLS(ROAD CAW HU,PA MIM 2'.1 Date Pay to the Order of PSE(D .For 23138 I i Lr*t* 045 39 20rms70 67 29 .1 WIN Sam— >v3130sso7 Mid Pdnn tink #002 - 0042320786 . i i Schedule H, Exhibit 8 1 of 1 9/22/2014 12:01 PM CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(717)249-2663 May 16, 2014 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Theresa L. Shade Wix; Esquire RE: Peter C. Breen Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: May 2, May 9, and May 16, 2014 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director Schedule H, Exhibit 9 fhe Sentinel WIX WENGER&WEIDNER ATTY AD NUMBER M PAGE NO. www.cumbertin-k.com 4705 DUKE STREET - 429956 1 of 1 HARRISBURG,PA 17104-0341 BIL 717-652-8455 L DATE SALESPERSON -. . cr,Mrst> SHFPEr�suP. FW courm 05/04/14 wolfs START DATE.. STOP DATE 04/19/14 05/03/14 AD NUMBER-- _..__.. ___...._ AD,IlESGRIP310N CLASS' . LINES- 429956. j NOTICE LETTERS OF ADMINISTRATION O 10 PUBLIC NOTICES'_ 138 '"2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL-LEGAL 3 LGL $201.78 TOTAL AD CHARGE $201.78 3 MOBILE SITE MOB2 $3.00 3 PROOF OF PUBLICATION 01PRF $7.00 Purchase Order Est.PeterBreen PAY THIS AMOUNT $211:78 $254.14* *AFTER 05129/14 Lee Enterprises no longer accepts credit card payments sent via e-mail Emails containing credit card numbers will be blacked. .Please use the coupon below to send credit card payment to our lockbox. THE SENTINEL You may also send the coupon to a secure fax at 319-291-4014. c/o LEE NEWSPAPERS Thank you for advertising with The Sentinel! Deadline for PO BOX 540 in-column legal ads is 4:00 p.m.two business days prior to WATERLOO IA 50704-0540 date of insertion. For questions,call(717)240-7130.. Return this portion wfih your payment Legal _ ❑ Check# Credit Card Ad Number t 424956 THE SENTINEL c/o LEE NEWSPAPERS ❑ ❑ ❑ ® ❑ °:91= Billing Date - 05/04/14 PO BOX 540 WATERLOO IA 50704-0540 , Acct#: Amount Due $ 211.78 Date:. o Yvt4 Name-on credit card �r3C�O�QiI?;: signature Please make checks payable to: THE SENTINEL Y xOW202 THE SENTINEL �' � W I X WENGER&WEIDNER ATTY c/o LEE NEWSPAPEi2S 4705 DUKE STREET PO BOX 742548 - HARRISBURG,PA 17109-0341 CINCINNATI OH 45274-2548 i�LLi�l �tiJL ( I��iLLLi, L (LJ�1Lr(L1(1I1Ioil Scheduler H, Exhibit 10 21540200000.0042995600.00000000000002541400000211787 E- 9 RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ: Receipt Date: 4/17/-2014 Cumberland County - Register Of . Wills Receipt Time : 12 :43 : 07 One Courthouse Square Receipt No. : 1077705 Carlisle, PA 17d13 ! BREEN PETER CRAIG Estate File No. : 2014-00310 Paid By Remarks: RENEE R BREEN WZ ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE .25 . 00 CUMBERLAND COUNTY GENERAL FUN Check# 6757 --------$25. 00 Total Received. . . . . . . . ,$25 .00 r 4 Schedule H, Exhibit 11. REV-1512 EX+(12-12) pennsylvania SCHEDULE DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Peter C. Breen 21 14 0310 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. Mount Nittany Physician Group, P.O. Box 6005, Hermitage, PA 16148 147.50 Medical Bill (See Schedule I, Exhibit 1) Centre Lifel-ink EMS, P.O. Box 293, State College, PA 16804 Medical Bill 2. (See Schedule I, Exhibit 2) 100.00 Mount Nittany Physician Group, P.O. Box 6005, Hermitage, PA 16148 3. Medical Bill 6.75 (See Schedule I, Exhibit 3) 4. Centre Emergency Medical Association 60.78 Medical Bill (See Schedule I, Exhibit 4) Mount Nittany Medical Center, P.O. Box 1259, State College, PA 16804 Medical Bill 5. (See Schedule I, Exhibit 5) 250.00 Rehab After Work, 1440 Russell Road, Paoli, PA 19301 6. Medical Bill 70.50 (See Schedule I, Exhibit 6) 7. PSECU, P.O. Box 67013, Harrisburg, PA 17106 111.62 Visa ($223.34- 1/2 joint account) (See Schedule I, Exhibit 7) Internal Revenue Service, P.O. Box 37008, Hartford, CT 06176 Federal Taxes 8. (See Schedule I, Exhibit 8) 2,348.00 Pennsylvania Department of Revenue 9. State taxes 102.00 (See Schedule I, Exhibit 9) 10. Hotel Savio, Cesena, Italy 330.00 Outstanding bill (See Schedule I, Exhibit 10) Fracassi Worldwide Shipping Shipping of Decedent's belongings from Italy 11, (See Schedule I, Exhibit 11) 385.00 TOTAL(Also enter on Line 10,Recapitulation) $ 3,912.15 If more space is needed, insert additional sheets of the same size. YNYIENT NAMh TAI I.rN I N Umt$rlrl. PETER BREEN. 2396970 No Usual Provider Spec DATE CPT DESCRIPTION CHARGESPA)(MFNTS AD.TUT,,,.,, NET DUE Provider: PASQUARIELLO, RICK D Voucher: 512198650 03/02/2014 99222 INITIAL 'HOSPITAL CARE, 230. 00 03/18/2014 0992108763 BLUE SHIELD PAYMENT 0.00 03/18/2014 0992108763 BLUE SHIELD CONTRACTUAL 82 .50 03/18/2014 0992108763 BLUE SHIELD TRANSFER 147.50 THIS BALANCE HAS BEEN APPLIED TO YOUR DEDUCTIBLE. PLEASE REMIT PAYMENT. yt; 3 3, Total Amount Due $147.50 PkYkiqT IS DUEAVONIRECEIP T.'�'" `7 MOUNT NITTANY PHYSICIAN GROUP PO BOX 6005 HERMITAGE, PA 16148-1005 STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION Schedule I, Exhibit 1 Centre WeL,ink EMS Inc. PO BOX 293 STATE COLLEGE,PA 16804-0293 (814)237-8163 Ext.3 Patient Name: BREEN,PETER Patidnt SSN: XXX-XX-0000 Run Number: 14-1278 Date of Call: 3/2/2014 t 1 El`s Time of Call: 01:28 Caller: From: 10 VAIRO BLVD To: Mount Nittany Medical Center PETER BREEN Primary payor: Highmark 10 VAIRO BLVD APT 30C _ -- -... _ ******6286 STATE COLLEGE,PA 16801 Secondary payor: Bill Patient Payment Description Check# Quantity Unit Price Date Amount ALS Emergency 1 1,004.25 I,004.25 Mileage 5 13.40 67.00 r Highmark PLEASE PAY THIS AMOUNT $1,071.25 ct- t. As w o—S �c^R �eZ'--'0A. Schedule I, Exhibit 2 PATIENT NAME P�TIENT NUMBER YOUR PROVIDER E BEEN 2_396970 No Usual Provider S ec DATE CPT DESCRIPTION CHARGES P^YMENTS� I NET DUE Provider: EATON; JEFFREY G Voucher: 512370750 03/03/2014 93010, ELECTROCARDIOGRAM REPOR 22. 00 04/03/2014 0992123.753 'BLUE SHIELD PAYMENT. . .. 12 .75 04/03/2014 0992123753, BLUE 'SHIELD CONTRACTUAL-. 7.00- 04/03/'2014 0992123753 BLUE. SHIELD TRANSFER 2.25 THIS HAS ;BEEN APPLIED .TO YOUR COINSURANCE RESPONSIBILITY.. .PLEASE REMIT PAYMENT. Provider: GILBER.T, 'JEF.FERY A Voucher: 512351340 03/02/2014 93010 ELECTROCARDIOGRAM REPOR 22.00 04/03/2014 0992123753 BLUE .SHIELD PAYMENT' : 12 .75 04/03./2014 0992123753 BLUE. SHIELD' CONTRACTUAL 7.00 04/03/2014 0992123753 BLUE ,.SHIELD.'.TRANSFER 2.25 THIS HAS BEEN APPLIED. TO YOUR COINSURANCE RESPONSIBILITY. PLEASE REMIT PAYMENT. . Voucher.:. 5.12374580 03/02/2014 93010. •ELECTROCARDIOGRAM REPOR 22. 00 04/03j2014 '69921237.53 BLUE SHIELD .PAYMENT 1 .75 04/03/2014 0992123753 BLUE S'HIELD`-CONTRACTUAL 7 .00 04/03./2014 099.2123753 BLUE SHIELDTRANSFER 2.25 THIS HAS. -BEEN.-APPLIED-TO YOUR COINSURANCE RESPONSIBILITY.. , :PLEASE REMIT PAYMENT. Total Amount Due W $6.75 PAYN=IS DUE:UPON•RECEIPT.: MOUNT'NITTANY PHYSICIAN GROUP PO BOX 6005 = TA1-6148-1005 • - , . . HERMITAGE, PA .STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION j0 1uxcad OOI fird iii ani `i'eaf� puapo. u 1VA 1=1 UOTIZ) oid o 4cioz1S�i � inoA q�Eai noe rs •r.+'.� T:'f..TTnTI»' r-A .0-mA nnk cnrnn'1nnnn TTT-0 C1TTn7TTJ(VrTn-) '9'TTTVTTICTTfrm gmmndyX, 1av,.)od-T0-1n0 Schedule I, Exhibit .3 may . 'GENTRE EMERGENCY MEDICAL , / ASSOC Page 1 of 2 Statement Date: 4/10/14 Thank you for choosing CENTRE EMERGENCY Responsible Party: BREEN,-PETER Account Number: . 1591"538611 MEDICAL ASSOC for your health care needs.. . Due Date: Upon Receipt REQUEST FOR PAYMENT Summary of Account �_� ::: uti.�,avaaita itcaaayc. Total Charges $ 525.00 Insurance Payments -$ 155.72 Thank,you for;;-Using ou'r seN cies_ Your insurance has.':: Insurance Adjustments $ 308.50 .:app lied our-charges o.your deductible:, The.baiance:iiue is Patient Payments $0.00 your.responsibility. :' Account Adjustments $ 0.00 pjease:' a ie payment in;full"using a.:paymenf metl odaisteri AMOUNT YOU OWE $.60.78toahe;teft on statement.. Your prompt payment is appreciated! Please see the following page for transaction details. Thank you for-yourproinpt:attention.; .:; Please,. awareifiat�biilin rna refiectthe.su ervisin Pay-meet,tnsuraht% �Billing tnformatiora 9 y p 9. :. ..., . ian's nam physic a if:you were heated by.a..physician Pay by credit card online' ass�s#ant - �:. visa anytime,day or txightt: - wvvtnpeyaur h'ea lth.co m . Pay by credit car,f;via phoiie;87747'2143;'.-4 . Gertrfiecr;safe and'secure credd card processing: .Visd us at www-PerY66rHe4b cam to update insurance,address view.your a courrt or send.a:.: ; .message to our bilking office ID9591'S3r8611 Access:.key JR97BN To contact the:billin='office- le .4<•. :: : 0,4:80 9 P ase ca-800-399-2993 fUlondey'througfFriday8 30am to pm. Schedule I, Exhibit 4 . L CHECK CARD USING FOR PAYMENT MOUNT NITTANY MA STERCARD DISCOVER "+? VISA MOUNT NITTANY MEDICAL CENTER IL Iy CARD NUMBER AMOUNT EO.Box 1259 MEDICAL CENTER State College,PA 16804.1254 SIGNATURE EXP.DATE 9111-6732 - RETURN SERVICE REQUESTED STATEMENT DATE PAYTHIS AMOUNT ACCT.# 06/09/14 942.00 V00023043340 )05472 0101 PATIENT NAME PETER BREEN PAYMENTS AND CHARGES RECEIVED AFTER ADMISSION DATE: 03/02/14 DATE OF THIS STATEMENT WILL BE SHOW AMOUNT DISCHARGE DATE: 03/03/14 PAGE: 1 of 1 REFLECTED ON THE NEXT STATEMENT. PAID HERE f 651334 li�>111i1i1111111111111311111111,lilt 1111111111111111111fill 1111 {=sEl=1�II;�II�f��il��lt�i�lc� dill it<>�i�E11�it���llr�i11�13�� PETER BREEN MOUNT NITTANY MEDICAL CENTER 507 ELLEN ROAD PO BOX 382804 CAMP HILL, PA 17011-2019 PITTSBURGH, PA 15251-8804 9111-6732'T36OGGFWWO00118 ❑Please check box H above address is incorrect or insurance IIVI Information has changed,and indicate change(s)on reverse side. PLEASE.DETACH AND RETURN TOP PORTION WITH YOUR PAYMEN- ACTIVITY DATE DESCRIPTION AMOUNT 200 INTENSIVE .CARE GENERAL j 2690.00 250 .PHARMACY GENERAL { - 4.25 300 LABORATORY GENERAL 2 - 56.00 301 LABORATORY CHEMISTRY 13 - 1600.00 305 LAB HEMATOLOGY 3 - 243.00 306 LAB BACTERIOLOGY/MICROBIO -182.00 450 EMERGENCY ROOM GENERAL, -1720.00 636 DRUG SPEC ID DETAIL CODING 7 -286.75 0 730 EKG/ECG GENERAL 3 - 624.00 987 PROF FEES HOSPITAL VISIT 692.00 a 03/26/14 PAYMNT FEDERAL BLUE CROSS; BC RCF -9016.00 04/10/14 ADJUST FEDERAL BLUE CROSS; BCFED 1860.00 CONTRACTUAL ADJ 0.00 04/23/14 PAYMNT FEDERAL BLUE CROSS; BC RCP 9016.00 04/23/14 PAYMNT 'FEDERAL BLUE CROSS; BC RCP -9016.00 Billed charges to date: 8098.00 Receipts to date: 9016.00 Adjustments to date: -1860.00 Refunds to date: 0.00 Total due: 942.00 Estimated insurance due: 942.00 YOUR INSURANCE CARRIER HAS PROCESSED YOUR CLAIM. PLEASE CALL 1-888-255-6192 TO DISCUSS YOUR .BALANCE DUE GUARANTOR ACCOUNT NUMBER PETER BREEN. V00023043340 TOTAL 8096.00 TOTAL CREDITS -7156.00 TOTAL DUE 942.00 INSURANCE COVERAGE POLICY NUMBER . BC FEDERAL BLUE CROSS 858996286 MOUNT NITTA-NY MEDICAL CENTER Schedule I, Exhibit 5 �pj gra 9111-6732*T36OGGFWWO0011$ ����R 1a lA �o Explanation E of Benefits THIS IS NO a A BILL Federal Employee Program. yt_ ..s. w *f pblue.arg CAPITAL BLUE CROSS HARRISBURG, P.A. 17177 C80O) 344-5446 86- 1 . KEVIN J BREEN 507 ELLEN RD CAMP HILL PA 17011-2019 I EXPLANATION OF BENEFITS AT A GLANCE 1 1We Sent Check To: PROVIDER OF SERVICE I ID Number: R58996286 I I Claim Number: 14D732938202 , (Patient Name: PETER BREEN I C1aim, Paid On: 04/23/2014 I •Claim Received On: 04/14/2014 (Dates of Service: 03/02/2014 - 03/02/2014 1 Claim Processed On: 04/21/2014 IYou Owe the Provider: 5250.00 Provider: MOUNT NITTANY MEDICAL CENTER Dates of Service: 03/02/2014 - 03/02/2014 Type: PREFERRED PROVIDER Type of Service I Submitted I Plan IRemarkl DeductlCoinsurancel Medicare/ I What IYou Owe the 1 Char-ges I Allowance I. Codesi I Or Copay 10ther Ins. I We Paid I Provider MEDICAL CARE 1 2,690.001 9,266.001 110 1 1 250.001 1 9,016.001 250.00 I I 1 625 1 I . 1 1 1 PRESCRIPTION DRUG 1 291.001 1 634 1 1 ( I 1 DIAGNOSTIC LAB TEST 1 56.001 1 634 1 DIAGNOSTIC LAB TEST 1 1,600.001 1 634 1 1 1 1 1 DIAGNOSTIC LAB TEST 1 243.001 1 634 1 ! 1 1 1 DIAGNOSTIC LAB TEST 1 182.001 1 634 1 1 1 1 1 MEDICAL CARE 1 1,720.001 1634 1 1 1 1 1 DIAGNOSTIC TEST 1 624.001 1 634 1 1 1 1 1 MEDICAL CARE 1 692.001 1 634 1 1 1 1 1 TOTALS: 1 81098.001 9,266.001 1 0.001 250.001 0.001 9,016.001 250.00 EXPLANATION- OF REMARK CODES 110--BECAUSE OF AN AGREEMENT BETWEEN THE LOCAL BLUE' CROSS AND BLUE SHIELD PLAN AND THE PROVIDER OF SERVICE, THE, REQUIRED PRECERTIFICATION HAS BEEN OBTAINED FOR YOU. FOR THIS REASON, YOUR BENEFITS HAVE NOT BEEN REDUCED ON THI§-CCAIM. 625--OUR NEGOTIATED DISCOUNTS WITH THIS PROVIDER ARE USUALLY LOWER THAN THE SUBMITTED CHARGES (PROVIDER'S ACTUAL CHARGES). HOWEVER, IN SOME CASES, .OUR NEGOTIATED AMOUNT IS HIGHER.THAN OUR ALLOWABLE CHARGE (PROVIDER'S ACTUAL CHARGE LESS ANY NCINCOVERED CHARGES). ALTHOUGH OUR PAYMENT ON THIS CLAIM IS BASED ON THE HIGHER NEGOTIATED AMOUNT, ANY APPLICABLE COINSURANCE IS CALCULATED ON THE LOWER AMOUNT (OUR ALLOWABLE CHARGES). YOU ARE NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN OUR NEGOTIATED AMOUNT AND OUR ALLOWABLE CHARGE. Continued On Next Page .. - CON0020-CUT(7/12) TE PROC. DIAG. DESCRIPTION PROVIDER CHARGE CREDIT SUBTOTAL CODE. CODE } (0184989)`_PETER BREEN 03/05/2014 90791 303.90 EVAL, NON-MD LUTES, MA, M. 200.00 200.00 03/05/2014 COPAYMENT CASH 10.50 189.50 03/1912014 BLUE SHIELD RECON ADJUSTMENT, #992101573 03/05 119.00 70.50 03/19/2014 CHARGE EXCEEDS FEE.SCHED MAX ALLOWABLE OR LUTES, MA, M. .00 70.50 CONTRACTED%LEGISLATED FEE ARRANGEMT.5119.00 03/19/2014 DEDUCTIBLE AMOUNT $81.00 992101573 03/05 LUTES, MA, M. .00 70.50 SUB.-TOTAL 70.50 .............: ...... ..... ............... ............... ......... ................................... Please pay this-amount....'........> 70.50 L. t THANK YOU FOR REMITTING PAYMENT .PROMPTLY. DUE FROM PATIENT ►►►►►r $70.50 MAKE CHECKS PAYABLE TO REHAB AFTER WORK OR LIFE COUNSELING QUESTIONS? CALL THE BILLING DEPT. AT 610,.644.6464, OPTION 8 0 - 30 days 31 - 60 days 61 - 90 days aver 91 .days. .00 .00 .00 .. 70.50 REHAB `AFTER WORK' 1440 RUSSELL ROAD PAOLI., PA 19301-1236 41458•T3Mow4809001333". ID!(qllmlQll➢6!!!�®®�®®Il�11111®®�ll��I Schedule. I," Exh1bbit 6 tL* 04!17/2014 Renee R Breen . '. 507 Ellen Rd.' Camp Hill;Pa 17011 Re:PETER C-WEN,Deceased. PSECU Reference:''5546501781887 Dear Ms.Breen: The above referenced person has an account with PSECU which was opened on September 16,2009_ The Share accounts were jointly held by PETER C BREEN and RENEE R.BREEN.The Visa is jointly held with KEVIN J_BREEN,, The following are.the Date ofDeath Balances for PETER C.BREEN's account with PSECU: Account Date,ofDeath'Balances Interest—March 1. 11th Savings (Sl) S 298.07 SO-01 Checking (S4) S. 2337.01 $0.07 Loans: Visa Loan (L9) $22_'j.24'::. Please provide us instructions on closing the decedents account: The joint owner needs to close the decedents.account with PSECU at the earliest convenience. If the Estate has sufficient funds to payoff the.decedent's Visa loan.please remit a,check;made payable to PSECU. If there are not sufficient fi.,nds to payoff these loans;please sub-it a letter of insolvency along with supporting documentation such as a final inheritance tai;return and financial accounting. If you have any questions;please contact,our department toll-free at(800)213 ,=7328,press 6,extension 3120 or email accountservices@gsecu.com. �---�Sincerely; ; j'�✓ '..�:./.' ice'.. 'Dana Willard Member Service Representative PSECU P. O. BOX 67013 .HARRISSLIRG, P '. _.?10.6,-7013 800.217.7=8 »Psecu.com . THIS'CREDIT UNION IS-FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADNINISTRATLON.EQUAL OPPORTUNITY LENDER. Schedule I Exhibit, 7 KEWJN J.BREEN `'1 0 V fie. ti .vw1 6753 RENEE R.BREEN ; 507 ELLEN ROAD 60 s11111313 I CAMEL till.,PA 17011 (711T) -7.77-S739 Date Pav to the 011-3 5?-CJ—,5 �`�-T'-� ��r I V �-1.:3.y `t cc i�;.��, -�`�,r��;�a�� 'f'�n•-� �u.�� e.,�.t1�-u.,.� •Dollars 8 0�. PENNSYLVANIA STATE EMIPLA CREDR UNION W4RRISBUt1RGRG,PA X7'110-299090 For A 0 LI- 7 a - 4l8 F,5-- `-jam-^ 1: 23 1391 L L6.11: 04509 2065711' 6X53 Department of the Treasury Internal Revenue Service (99) 2013 Form 1040-V Payment Voucher ► Use this voucher when making a payment with Form 1040. ► Do not staple this voucher or your payment to Form 1040. ► Make your check or money order payable to the'United States Treasury: Enter the amount211 3 4 8 I- Write your social security number(SSI)on your check or money order. lof our payment........ REV 03/03/54 TTW 1555 PETER C BREEN . INTERNAL REVENUE SERVICE 507 ELLEN ROAD P.O . BOX 37008 CAMP HILL PA .17011 HARTFORD, CT 06176-7008 204724805 KP BREE 30 0 201312 610 Schedule I, Exhibit 8 01 ^41N J.BREEN ,cENEE R.BREEN 6754 '507 ELLEN ROAD 66811112313 CAMP HILL,PA 17011 (,IL -237-s L3 �� 1 tZl_ ��l�j Z) Date Pay to the Order of 2e-"nv-�3.f1y L'v��G� 1�M' as ►'1eva Li my--mm-A $ /O o2. Cc cc ollars �PSE � ON For 1: 23138111 PIC 04509 206S ?no 6754 { anuana 2 2 0 L'C a}o�uaw�eda4 eIueAlfsuuad ayl of olqufted AIN 0 3 S f1 l N 3 W l S V d 3 Q e d japio Aauow jo 3139yo mpyu -I l I H d W`i13 aVON N3113 LOS 00'2011 $ 555E-SQS-L2L N313d N33NG lN(IOWV IN3WAVd 2602T600ET X18 909h-2L-t1O2 nnu suvoi��n3a SSS L - >:.. L Schedule -I, Exhibit 9 i Page 1 of 1 TRANSACTION DETAILS Members Ist Federal Credit Union 5000 LOUISE DRIVE MECHANICSBURG,PA 17055, USA Today's Date: March 18,2014 8:59 AM EDT IMPORTANT NOTICE:Members lst Federal Credit Union relies on the information that you provide us to transfer funds to a bank account.Please ensure that all transaction details you have provided to us,including the account number,bank details and currency of the Recipient's account,are accurate prior to completing your transaction.If the account number or bank details are incorrect,money may be sent to the wrong bank account and may not be recovered. SENDER: KEVIN J BREEN 507 ELLEN ROAD CAMP HILL,PA 17011 RECIPIENT: HOTEL SAVIO VIALE 4 NOVEMBRE 21 CESENA FC,47522,ITA ConE-ration Code: 6333163 Date Available: March 3l,2014 (Funds maybe available sooner) Transfer.Amount: USD 290.00 Transfer Fees: +USD 40.00 Transfer Taxes: +USD 0.00 Total: USD, 330.00 Total to Recipient: USD 290.00 Recipient may receive less due to fees charged by the Recipient's bank and foreign taxes. You have a right to dispute errors in your transaction.If you think there is an error,contact us within 180 days of the date we-advised you that funds i would be made available to the receiver at 800-283-2328 EXT 5243 or EFTServices@membersIst.org.You can also contact us for a written ` explanation of your rights. Subject to applicable law,you can cancel for a full refund within 30 minutes of payment,unless the funds have been deposited into the Recipient's bank account. For questions on your transaction,please contact us at: Members 1st Federal Credit Union 5000 LOUISE DRIVE,MECHANICSBURG,PA 17055,USA 800283-2328 EXT 5243 EFTServices(c�,members lst.org For questions or complaints about Members I st Federal Credit Union,contact: Consumer Financial Protection Bureau 855-411-2372 855-729-2372 07YfrDD) www.consumerfinance.gov Additional Terms: Date available refers to the latest date on which the funds should be available to Recipient.In certain countries or at certain banks due to local practices in crediting Recipient bank accounts,or due to other factors beyond our control,the date available reflects that delivery may take longer in these circumstances.However,in most cases,funds are available sooner. Schedule I, Exhibit 10 3/18/2014 -:1 Page 1 of 1 TRANSACTION DETAILS Members 1st Federal Credit Union 5000 LOUISE DRIVE MECHANICSBURG,PA 17055, USA Today's Date: April 15,2014 9:13 AM EDT IMPORTANT NOTICE:Members 1st Federal Credit Union relies on the information that you provide us to transfer funds to a bank account.Please ensure that all transaction details you have provided to us,including the account number,bank details and currency of the Recipient's account,are accurate prior to completing your transaction.If the account number or bank details are incorrect,money may be sent to the wrong bank account and may not be recovered. SENDER:. RENEE R BREEN 507 ELLEN ROAD CAMP HILL,PA 17011 RECIPIENT: FRACASSI WORLDWIDE SHIPPING S.R.L. VIA SANTO SPIRITO 11 FLORENCE,50125,ITA Confirmation Code: 6413050 Date Available: . April 28,2014 (Funds may be available sooner) Transfer Amount: USD 345.00 Transfer Fees: +USD 40.00 Transfer Taxes: +USD 0.00 Total: USD 385.00 . Total to Recipient: USD 345.00 Recipient may receive less due to fees charged by the Recipient's bank and foreign taxes. You have a right to dispute errors in your transaction.If you think there is an error,contact us within 180 days of the date we advised you that funds would be made available to the receiver at 800-283-2328 EXT 5243 or EFTServices@memberslst.org.You can also contact us for a written explanation of your rights. Subject to on law,you can cancel for a full refund within 30 minutes of payment,unless the funds have been deposited into the Recipient's bank account. For questions on your transaction,please contact us at: Members 1 st Federal Credit Union 5000 LOUISE DRIVE,MECHANICSBURG,PA 17055,USA 800-283-2328 EXT 5243 EFTServices@members l st.org For questions or complaints about Members 1 st Federal Credit Union,contact: Consumer Financial Protection Bureau 855-411-2372 855-729-2372(TTY/fDD) www.r,onsumerfinanr,e.gov Additional Terms: Date available refers to the latest date on which the funds should be available to Recipient.In certain countries or at certain banks due to local practices in crediting Recipient bank accounts,or due to other factors beyond our control,the date available reflects that delivery may take longer in these circumstances.However,in most cases,funds are available sooner. Schedule I, Exhibit 11 . 4/15/2014 REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Peter C. Breen 21 14 0310 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE ] TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. Renee Breen - Mother Lineal 50% „ 507 Ellen Road, Camp Hill, PA 17011 2. Kevin Breen - Father Lineal 50% 507 Ellen Road, Camp Hill, PA 17011 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. ]], 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 11 -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.