HomeMy WebLinkAbout05-04-15 � � , pennsylvania 15 0 5 61413 7
DEPARTMENTOFHEVENUE EX(03-14)(TP)
REV-1500 OFFICiAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po aox zso6oi INHERITANCE TAX RETURN �; � r� I�n �
Harrisburg, PA ll128-0601 RESIDENT DECEDENT �;;�I� ' � �J
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth h,9MDDYYYY
10272�12 04091926 —�
DecedenYs Last Name Suffix DecedenYs First Name MI
BAKER � MARTIN ._E __ �
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
� � �
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Return p 2. Supplementai Return � 3, Remainder Return(date of death
prior to 12-13-82)
p 4.Agriculture Exemption(date of p 5. Future interest Compromise(date of �y 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
� 7. Decedent Died Testate p 8. Decedent Maintained a Living Trust _ 9 Total Number of Safe Deposit Boxes
(Attach copy of wiil.) (Attach copy of trust.)
p 10. Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousai Trusts
(Schedule F and G Assets Only)
O 13. Business Assets O 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytirne Telephone Number
DEBRA WEBER �
First Line of Address
�`J
� C—�
7 f1ILLERS GAP ROAD � � "� r� �
Second Line of Address "�� "y; � �� p
"" � _:� e� --C c y :':7
, �_ ..._i t:a
. .,
r.... ::,�,� �..� � , i �..i
City or Post Office State ZIP Code � -'' r-a
> c:>
ENOLA PA 17025 -�" i -=� �' --i
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CorrespondenYs email address: -i N � tr1
n . F---� C1) O
REGISTER OF WILLS USE O Ct
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
�I��I�I II��I��I������I�III��II�I�I�II II��I II��'IIIII I��I I��I
� 1505614137 1505614137 J
��
� 1505614237
REV-1500 EX(TP) DecedenYs Social Security Number
�ecede�rsName: MARTIN E BAKER �
RECAPITULATION
1. Real Estate(Schedule A). . . . . .. . . . . . . . . . .. . . . . . . .. . . . . . . . . . .. . . . .. . . . 1. •
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . .. . . . . . .. . . .. . . . . . . . . .. . . 2. •
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. •
4. Mortgages and Notes Receivable(Schedule D) . . . . . .. . . . . . . . . . . . . . . . . . . . . 4. •
5. Cash, Bank Deposits and Miscelianeous Personal Property(Schedule E). . .. . . . 5. •
6. Jointly Owned Property(Schedule F) O Separate Billing Requested . . . .. . . 6. 14 ,983.57
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.. . . . . . . 7. S 6,6 9 6.71
8. Total Gross Assets(total Lines 1 through 7). . . . . . . . . . . . . . . .. . . . . . . . . .. . . 8. 71,6 8 0 .2 8
9. Funeral Expenses and Administrative Costs(Schedule H)... . . . . .. . . . .. .. . . . 9. 3,9 7 9.8 5
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I).. . . .. .. .. . . . . . 10. 3,6 7 9.6 3
11. Total Deductions(total Lines 9 and 10). .. . . . . . . . . . . . . . . . .. ... . . . . . . . . . . 11. 7,6 5 9.4 8
12. Net Value of Estate(Line 8 minus Line 11) . . . . .. . . . . . . . . . .. .. . . . . . . . . . . . 12. 6 4 ,�2� .8�
13. Charitable and Governmentai Bequests/Sec. 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . .. . .. .. . . . . 13. .
14. Net Value Subject to Tax(Line 12 minus Line 13) . .. . . . . .. . . . . .. . . . . . . . . . 14. 6 4 ,0 2�.8�
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousai tax rate,or
transfers under Sec.9116
�a)(1.2)X.0_ . 15. .
16. Amount of Line 14 taxable
at�inea�rate x .o45 64 ,020. 80 16. 2,880.94
17. Amount of Line 14 taxabie
at sibling rate X.12 • �� •
18. Amount of Line 14 taxable
at collateral rate X.15 • �$• '
19. TAXDUE . .. . .. .. . .. . .. . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . .. .. .. . .. 19. 2,88�.94
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowle
SIGNATUR O P SON R PON IB FOR FILING RETURN DATE
ADDRE � 1� \� �'l V S � �I V e�
l
SIGNAT E OF ARER OT ER AN PERSON RESPONSIBLE FOR FILING THE RETURN DATE/ �/
r,U- � ��C'� S ` s
ADDRE
305 S 32ND ST CAMP HILL PA 17011
� �I��I���I��I�IIII'���I��II�����)II�II�����II����II�I I��I I��I Side 2
1505614237 1,505614237 �
REV-1500 EX (TP) Page 3 File Number 2112—12 0 6
Decedent's Complete Address:
DECEDENT'S NAME
MARTIN E BAKER
STREETADDRESS
7 MILLERS GAP ROAD
CITY � STATE ZIP
ENOLA PA 17025
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,8 8 0 • 9 4
2. Credits/Payments
A. Prior Payments 2 3 7 • 4 2
B. Discount
(See instructions.) Total Credits(A+B) (2) 2 3 7 • 4 2
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,6 4 3 • 5 2
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred .......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ❑X
c. retain a reversionary interest .............................................................................................................................. ❑ ❑X
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ ❑X
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑X ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
�72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
. The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)).
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineai beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decetlent's siblings is 12 percent [72 P.S. §9116(a)(1.3)].A sibiing 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-1509 EX+ (02-15)
� pennsylvania SCNEDULE F
DEPARTMENTOFREVENUE �OINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ESTATE OF f1ARTIN E BAKER 2112-1206
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING]OINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. DEBRA A WEBER 7 MILLERS GAP ROAD DAUGHTER
ENOLA, PA 17�25
B. CHERYL L BAKER 121 BRIAN DR DAUGHTER
ENOLA , PA 17025
c.
70INTLY OWNED PROPERTY:
LEffE{i DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR]OINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND&4NK ACCOUNT NUMBER OR SIMILAR �ATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSEf INTEREST DECEDENT'S INTEREST
1. A/B 4692 M&T BANK ACCT # 133D3538 4 ,144 • 62 3 • 33 1,381 • 40
2 A/B 4692 f1&T BANK ACCT # 13303481 11, 550 • 62 3 • 33 3,849 • 82
3 A/B1,01,495 MEMBERS FIRST CU ACCT # 7108 29 , 259 • 97 3 • 33 9,752 • 35
SAVINGS AND CD ACCTS
TOTAL (Also enter on Line 6, Recapitulation) $ 14,983 • 57
If more space is needed, use additional sheets of paper of the same size.
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S� Sendlnquiresto: Stat@me►'�t Of ACCOUC1tS
5000 Louise Drive
PO Box 40 -"
Mechanicsburg,PA 17055 Sep 25, 2012 thru Oct 24, 2012
www.members�st.org
Main Switchboard: (B00)283-2328
EZ Call: (717)697-4372 or(800)283-4372 Account Number: 7108
� TDD: (717)697-5312 or(800)283-2328 e�.5312
TeleBranch: (800)237-7288
MEMBERS 1St Balances at a Glance:
FEDERALCREDIT UNION Checking: 0.00
5232 i av o.sso 10463-5232 SavirlgS: 4,208.84
� I��JII���III����J�I�I�L�„IIII���II���LJ�II���L��II�I��I Certificates: 25,051 . 13
MARTIN E BAKER Loans: 0.00
N 7 MILLERS GAP RD MOn2y MdIlBgElll@Ilt: O.00
ENOLA PA 17025 Swipe 5 YTD Reward: 0.00
N
o Page: 1 of 2
�
Your current Member Loyalty Rewards level is Gold.
Your aggregate balance as of October 1 st is $29,259.97.
An aaare�ate balanre Af�35,nr�n a�r,� h��ien� � �r��r�EtE
will move you to the Platinum level.
Get a free pet insurance quote! See the enclosed insert for more details.
SAVINGS ACCOUNTS
0000 - REGULAR SAVINGS
Date Transaction Description Additions Subtractions Balance
Sep 25 Ba/ance Forward 2�7•98
Joint Owner: DEBRA A WEBER
Joint Owner: CHERYL L BAKER
Sep 30 Deposit Dividend 0.250% 0.04 208.02
Annua/ Pe�centage Yie/d Eamed 0.23U�frvm 09/O1/2012 through 09/30/20>Z
Sep 30 Deposit Transfer From Share 0004 0.82 208.84
Oct 24 Ending Ba/ance 208•�
0004-LIFE SAVINGS
Date Transaction Description Additions Subtractions Balance
Sep 25 Balan�e Fon�vard - `���""•��
Joint Owner. DEBi�A A WE6ER
Joint Owner. CHERYL L BAKER -
Sep 30 Deposit Dividend 0.250°/a 0.82 4,000.82
Annua/ Percentage Yie/d Eamed 0,250'�fi�om 09/0>/20>2 th�ough 09/30/20>2
Sep 30 Withdrawal Transfer To Share 0000 0.82- 4,000.00
Oct 24 Ending Ba/ance 4,000.00`
CERTIFICATE ACCOUNTS
0041 -48 MONTH CERT Maturity Date -Nov 29, 2012
Date Transaction Description Additions Subtractions _ Balance
Sep 25 Ba/ance Forward 24,983.37
Joint Owner: DEBRA A WEBER
Joint Owner: CHERYL L BAKER �
Sep 30 Deposit Dividend 3.300% 67.76 25,051.13
Annua/ Percentage Yie/d Eamed 3.35��from 09/0>/20�2 through 09/30/2012
Oct 24 Ending Ba/ance 25,051.13
--- Continued on following page ---
� • ' Page 1 of 2
��
_ . _. _ __. _, --. . . _._._____._.-. . _. --._ ..._ _._.. . ._.__
Q1 hereby make application for membership in the Members t n Federal Cre it Unlon,and agree to conforrc tc Its bylaws and amendments thereof,copies
01 which have been made available to me,a�d to su6scribe for at least on (1)share.Members 19'is hereby authorized to recognize any of the signa-
tures subscribed hereto in the payment oi funds or the transaction of any siness for this account and a�l sub-accounts.f acknowtedge receipt of the
Membership Account Agreement which contains al(relevant contractual o�igations for this account antl all sub-accounts.I also acknowledge receipt of
the Regulation Disclosure Pamphlet. �
' �d_ I�.-Qs � '7/D� ,
xP ma mb rsigna re � ' paie um6e
� �Lfl-l�-�S`-_ ._� �'�'� �,
Joi ner sign re ` Date '�OF#f1�T N fT�e(Far atfice use anly) �I
� �` �v e��� 7�dr�
JointOwner nature , te /J�� �/ �r �/
IC {�
Fwoflice use only Membera 1n Fe rnon ^
This application approved by the""'8oard; ''Executive Committee;or rT Membership Officer �ate:
Signed • (Person representing apprwa(application)
MBRSt 96-83 �� I'r .
REV.OS/95 �!
Book I�tumber NA.ME (ta be fi21ed fn by treasurrr) F�x �3en. c�r /� �}
Soc.5t�. �o. � � ij �`-'
7�.Q� $3��T' �ar�1.il �•
(Ia,et r��e} t t nam+�) {rnidQle name ar. itial}
�.eside�nCt ��
� P. Q. Addreas � ' '
� Pre�fo�c Asi�r� or
I chan8'e in Adctress
� Div3s�on or
� �cugr+tia � ._...rDePartm�rit.,__r__�+` TeI. Nv.�.� �
� Wiies iiret and maid� � � �G
Dat� of Eirth name ar husbandx ftztl name � � .�
� I herEby ma e appZicatton !or membersh{p fn the credst ur.iap aam�� helow,.and agrce
� tA COn�pxiri t4 �tS by3aW� an� arnendrnents thereoi, copies af �uhi.:h have tseen mad� avafl-
able to me, and Lo subs�ribe for at Ieas� ane (1) shar.e, 2t Lfie aav#n gs Jnsurance is carried
� izi Cannectton wtth my aecount, I agree, in cotisSder3�ton oi the credit vaion :eazrying such
lnsurance, t3�at.any desSgnation or change �f k�eneifeiary made hy rne shatl onty be bjndfng
upon the c�etliG unfo�3, if I have file$ w3ih th+� credit union pxiar to my death, such desfg-
nation ar ange ot ben�#icfary, in wzitir�g, sigrsed .bv mE, on the form suppifed by the
Credit•uni� and ,fn the absenre o� sa filing a designat�on bz change of heneiiclary, I agree
on beh$3f g�myself, my heigs, etc., to 3ndemnlfy and sa�*e Y�armless thp cre�ft vni�n from
aIl loss or damage t�y reason vf the payrnent ai the procee�is oi such tnsurance ta st�ch
persan as the credit reCar show to tIt�� hereta.
�IGNA't''CFR.�!' af.e
' r4��3 M� A1�lC�Bli:<<� �::J� �re t untan
� 'Pf�i� app icat' n azrrrc}��ed b� hC ISoard� :x .uEiv� m�c e�"""� tiLwa��� C�ificcr
� Date: -� �l G�gned � p
Iretar y•; Executive Cornmittee 1�4€mber;o� Memb r�riip dTf3c r,
` Cro&5 aut Z ��sJ tiotfs fn each 4# t�t twa lfhes abave n�t appllcabfe. —
� ���e��, `.,,
�y�6-� 6'.� a c,��C' �i7'"'y-,
�
3/24/2015
�; _ ., ,
REV-1510 EX+(02-15)
� pennsylvania SCHEDULE G
` DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
�Nr+eRiTnrviceTnxRE-ruRrv MISC. NON—PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ESTATE OF MARTIN E BAKER 2112-1206
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 THE TRANSFEREE,THEIR RElATIONSHIP TO DECEDENT AND DATE OF DEATH �ia OF DECD�S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSE7 INTEREST (IF APPLICABLE) VALUE
i, DEBRA WEBER DAUGHTER NOVEMBER 2012 26,979 • 92 100 2 ,979 • 92
NATIONWIDE INS CO ANNUITY 16093306M
2 CHERYL L BAKER DAUGHTER NOVEMBER 2�12 26,979 • 91 100 2 ,979 • 91
NATIONWIDE INS CO ANNUITY 16093306M
3 DEBRA WEBER DAUGHTER FEBRUARY 2013 1,368 • 44 100 ,368 • 44
OFFICE OF PERSONNEL MANGMT RETIREMENT
SERVICES F3475123A
4 CHERYL L BAKER DAUGHTER FEBRUARY 2013 1,368 • 44 1�0 ,368 • 44
OFFICE OF PERSONNEL MANGMT RETIREMENT
SERVICES F3475123A
TOTAL(Also enter on Line 7, Recapitulation) $ 56,696 •71
If more space is needed,use additional sheets of paper of the same size.
❑ CORRECTED(if checked)
PAYER'S name,sireet address,city,state and ZIP code 1. Gross distribution OMB No. 9 545-0119 Distributions From Pensions,
NATIONWIDE LIFE INSURANCE COMPANY $26,979.92 ^0 f A Annuities,Retirement or
IIP INDIVIDUAL ANNUITIES 2a Taxable amount L I L Profit-Sharing Plans,IRAs,
P.O.BOX 182021 $26 979.92 Insurance Contracts,etc
COLUM8U5,OH 43218 Form 1099-R
800-848-6331 2b Taxable amount ❑ Total � ��py 2
no[determined X distributioa
PAYER's federal identification RECIPIENT'S identification 3 Capital gain(included in box 2a)4 Federal income ;exwithheld File this eopy with
number 31-4156830 number .._7614 gg 7qq.gg your state,city,or
� 5 Emplovee contributions/Desig- 6 Net unreal¢ed aaprecia[ion in loeal ineome tax
RECIPIENTS name,street address,city,state and ZIP code nated Roth con[ributions or
DEBRA WEBER insurence premiums employer's secunties return,when
7 MILLERS GAP RD required.
ENOLA,PA 17025 7 Distribution IRAlSEP/ e Other
code(s) SIMF k
4 X
9a Your percentage of total 9h l'otal employee contributions
distribution
10 Amount allocable ro IRR 11 1 st year of desig.Roth contrih. 12 State tax withheld 13 State/Payer's s;ate no. 14 State distnbution
within 5 years 829.00 _ PA/1536377U --�26 979_92-----------------
-----�---------------- - --------- -
Account number(see instructions) 15 Local tax wtthheld i 6 Name of localiry 17 Local distrihution
016093306 M --------------------- --------------------- ----------------------------
Form 1099-R wv✓w.irs.gov/form 1099r Department of the Treasury-Intemal Revenue Service
� _------ -----
_ _ - _ __._ __
_ _ _ _
' �� --i r -- - -i '_ � �...-�� �_ _; �:
� a�i18�o-�i 545-01 19
PAID �FrICE OF PERSONNEL MANAGEMENT STATEMENT OF SURVIVOR ANNUITY PAID 2013
Bt� RETIREMENT SERVICES PROGRAM Farm: 1099R Distri6ution from
b� P.O. BOX 45 Copy B - File with Federal tar. return. Pensions, Annuitier
BOYERS, PA 16017-0045
Retirement or Prai
sharing plans, IRA.
Insurance cantracti
PAYER's Federal ID. No. Receipients ID No. (Survivor) Account Number (Retirement Ciaim no.) 1. Gross distri6ution ,
� > 52-6083699 196-38-7614 F3475123A 1368.44 �
o �
N °' �
� 5. Employees Contributions, 2a. Taxable amount
� = Designated Roth contributions PAID DEBRA A WEBER 1368.44 �
r a or insurance premiums
w 'z -�� 7 MILLERS GAP RD
� `- 0.00 � ENOLA PA 17025 4. Federal Income Tax withheld �
� 0.00
- � -- 7. Distri6utian Code�s)
Q� i, II
� - 4 DEATH BENEFIT i
�
IL - 12. State taz witF�hcld 13. State/Payer's state r�ONE �
y ��' 96. Total Employee Contri6utions
U '- - - - - - - - - - - - - - - - - - - - - - - - - - - - �I
� - NONE '
LL E `c i
E
- I
r O
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_ `i�,����'��a4�ti:�.��fca Achiever Annuity- - _ _ - -
, �•,-�
- _ . i�F... _ �e�:_�I3AKER - _ - � _z�.�=. _
... . � F: _s����Gf�P FtD . . , -_ _ -.� ,y,:��:>�..._ . -
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. : �:`�-�$}��: e�_R i 7025-i 008 � _ . _ .- ;:_.. .
•- . .. _- . -- . . = -. _ �-'
- - ti �
z��p��lr����tment Professional: ' �
�}��!��C;ii�HER L hULTQl�iS3
4�=��5��lNANC1AL C�RPORATiON -
. .. _.£i��E�i 32TH�T _ ,. _ _._..,__:_..._....�._.�.:-v...... . .
-- -: -. LEP�lOY�lE PA 1.7043 . . . . . > .-� .- . . ..
: - -. -_ .. . . ....-...................................•---......_......................................................._...... .........................:....... .:;::::�-.., .. , �. ., . -
�e�kra�t I�sue Date:10/46%2009 - : - -` --
�ian Type:IRA
Art��ifant:MART.IN.E BAKER
......................................................................................................................................................................
How to Contaot Us: - -
www.nationwide.camliogin
Nationwide tifie Insurance Company
P O Box 182Q24
Columbus OH 432�8-2021
Custamer Service:
1-60Q-848-6331
Hearing Impaired:
1-BOQ-23S-3035
24 hr.Automated lnformatian Line:
1-800-848-633�
' -AAIDQ If f0 ' .01fi�93306 �026Z{1171585£! - P9g�'1 013 '
OODOt1001.,0000D:10301f41fl5261B97852 � � � -
00600017
, t 5.�:..•�va f a. . - ��;�•-�uucyuistnnution- .- - -- " NW Policyutsfr.i�u_i;-: `_ -,.. :-C:��.:-. :::�.��y :�.;�� i=i;°< _ �
�'��� ��°n����ement = _ � - _ . � ;� ���������1��� _-= -- -
.
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' ' . ' R6R��.1I.���31-,201-2 . -- .--, �.:�-�' ._- - � . .�.:��-� ���.. .� ��.�f�4z;�-. ��- .. � - - -_ . -. _
�
c���.$�_�::�._�����rnber: 01-60�330f�=�-�:. :�-:-- � _= __ - -_ -. � .
- ��}�: ����E���:��€v€�tica Achiever=Ar�nuity�._. - - ._ : - , . --� ; - _� -
:- �.. _ �a� ��a���a�c€y reasons you can coritinue�to-have�can�id�t��$in Pa�sBe���r�d�."��t���t-�t.��;�°��i����f ���
•�- ; -�
��tar����es��.���a/�ohtidence today. -:� - :: . . . . _, . , . _
___n._ - ,_�������� �ummary � ,.� �_
- .� __._ -- �uarter-TaOate _ ��,�e��+a•t��t�: Es�cm�€�rc�`�e���u4�
�;;s�;=;;;' :-���i�rn€rtg f�ate 10/0112012 t?t/Qfl�f��� �ElI�fi1�Qi3g
= � _��g6��ii�C��iteaot Yalu• $54,899.33-_ �§0��?74.�Q -_:__ :::_:�::-:_:_ �.00
; : .:Pt�rciiBse P�yt�eents $:00 ��p ����5£3+b.7�
- : :..�4i4i�cica�v�ls/E.tAurges ($5�;9a8.�3"s�_�.: (�5�,�5��3� ~ -�.�6,�8+�.��)
----_- - ' ._h�et Inveatrtjent-flesuits' l$1:039.SQ1� $3.F6���. . - ;8.2da.96
-...._�ndi�g��astract Yatue as oi 12/31/2012 =�AO=. $.a� .- K -.- �.O(�
;. _____-z °Rhis is the nnt nmount oE investrnent gaine or tosnes during each periad._Yhene r�aulia in.�ude the de@uc�on o!ch�rges ae��yi�lne�io
poui.pr�apecfue.
. . .- _ Pioase.r�aie�lh�intormaUon ln thie statementcarelully. lnaccuraciea or dincrepancles at,ciuld tse prompBy repot9�d tatfatioii+�id�!n
._ ,,,. vorrl6ng. .Pleaea be advised ihaf any oral eommunica5aa ahould be re-Confirmed fn wRting. You may coestac2 our Cua4omer�ervi�a
Canf�r at the=teJephone number or maiRng address.ifated atlhe fcp ot this stotement. �
1laB°�abie �ccounf Summary
. 4
_ lcsvnatment Beginning-oi-Quartar Quarter-To-Oete End-o�-Quarler �nd•o!•Qaael�r
_ - _ Option Value Paymente Wlthdrawala Unit YaEue Uni1s OwtRec! Vatue
JPlSASP FR71`SVC $11,402.43 .OQQ00 .d000Q $.00
,, NYY,t�YlT MPlY MKT i �.00 (j53,959.83] .00000 .0004D �.00
_ PIMGO VIT FORGNBOUNHOG ADV $43,696.80 ,DOQ00 .00QQO �.0�
Total ;54,998.33 S.00 (�53,959.83) �AO
- Purchase PaymentslCredits from 0�/01I2012 thr�ugh 12/31/2012
Trartseation Inveslmsnt Option Ooltar Unit Eursd or Grodi�ed
_ _Date Type Amount Vatue Units Rate
NO TRAN6ACTIONS
Saurce 05:Tr�nafer
�ifhcirawals/Charges from 01/01/2012 through �2I31I2Q12
� q e
Yean�sciEon Invseiment Opllon Dolfar Uni4 Fund
_ [}ate Type {eoures� d�maunt Vetcae UniF�
. 11R7/12 BURREMDEFi NW NVIT MNY MKT I(06) (�26,479.91� 9.96339 �2782.67991)
. Taxe� �7,573.98
, Net Amount $i 9,A05.53
AAID(3- H !3 ' 99fi093306 - 0202tl1�1385e �Pago2 n1�
ODDDDOQtAI(IR00030l64}i5361a97d53 � � � � - - ' � Q���a
_-. .._. . . . .. ...-.�J ... .....�� • .....•.F- �o_u.. sa_��� .- ' _ _ �..�:s.,._-sc.rrt: .v�:"v"ru i� - tc f�e_ � - .
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. . �'f3��� -��'�r'�e�L��: - -
" -- `����=����_����e�ent - ' - _ - - - - - ����:�� ; �-
� ��:���-��3'�;:201� _ - - .r -.. . - .. - . � , - => -
- ��°��������l�:mber:�0'I-609330�::._ ___ : : _ - . _ _: -, _ � -_- :
: . '�E����8��_�►�erica Achiever Annuit� - - _ ;_ . -- -� . : --- _ .. - . � _ _. . -,
- - � �it�i����afs�Ch�rge��frorn���/0�12a�����i�c��t�������������,` -:�.- � _ _ . . - - _ =
- _ . . - . - - .. _ 4 . _ . . � . .
" __ _'-,' :Y��esct�ori' :. _ - : . -- inveafinen O`fiots "� -`� ' -- ,_. �.__ ..-�ie#�s • ..itnit` Furod �.- - -. __. _ _ _
�; P
= �[e: �-.-. : - �_ TYPs (soa[aeJ ._ ,��. �Sc�c��anF, � -.5 Valuo _:. U�ite .
- - .-• - - — . . .._. .... ---- . ,
. . _.
" '" �-'3�t�s7/t2 WIT'HDRAWAL NWNVITMNY MKT7 06
'•--- ( ) f�2&,9Y9 92) 9.98339 (27�12.�9Q8�)
:- . . :. _ � Taxen._:_ _ .- :-:: _- . .-. ..._• _.:�7;573:9g _.-- . .
- - . � . � .Net Amounl_;�, .._-._ �t:9;�0��4:-: :;: : -
�as�itm;06:Tran�P�r _ �- :... :: - _. -
-�r�sf�r� from �1/41/2012 throt�gh �2f��/2a1� � _ . , � - - -
- . . _. '. . - _ ' - .. _ �=.- . 4 5. ' _
- � - Tr�nsaotion . Invaatment Qption Dollar Unie � Fund or Credi�ec! ,
• - �Oata Typs (eoures) � ' -`�mourrt `Vetus. llnit,a Rats ' - '
- • - - tift7192- TRANSEER-fAOM JNSASPFRTYSVC_.(4&), . (=t1,t75.8s7 2U.9922�._ _,(532,379B�
� - PIMCO WT FORGNgI?ttNHOf AOV(06) '�(�2,783.9� 13.09616 (3281.95118)
91P2T/t2 TRANSFER•TO � NW NViT MNY MKT l-(6fi) �53,968.83 9.96338 5404.96053
Souroe 06:Ttanefer
�or Yo�ar I�formation
The t 21.i1/12 a000unt befanca(Fair Market Value)trom your Individual R�tirament Aawunt(IRAy,Ia baing furniahed to the Internai Revenue
Ssrvios(�Rs3- - - .
' --� To follow your contraot 6atsnces,our intecnet eile,rta6onwlde.comfiogin and eur eutometsd Annuity Intorn�atlen&yntem,i-800-8a6-6331,
are availatrle 24 houre a dsy,7 daya a week for your convenience.
- - - - Our Annuity Serviee Cenie►Repreeentativea are availabk Mnnday thraugh fridny 8:00 a.m.to 8:Q0 p.m.Eanisro Tim�. P{eeoe rsvtew ths
- - � Informetion in this alatemant oarefuily_ Any questione or correctiona muet be ropo�iad to Netlonwiote imm�distety to assure�roper ceedltlng
to rour contract. -
Annuitlee: �
`ere NOT ineured by ths FQfC or any ledera!povernmenE agenoy - '
'are NOT dspoaib or.obligatlona.of,gueanteed by,.oc intured hy,your dopoeitorjr Ine54utlon or�►ny of i�c.aKliat�f �
'involve inveetmant d�k,lnctudiog posefble toee of value.
�
-•- Unit�/alue�and Units are diaplayed to Ave(5}deelma!placea. However,all axounting is actualiy oalcutated!o e,ight(B)plaoee.
5
The atated Credited Inlerest Rate lt determfned on ths beait ot vedous facters,Induding a Ba6e Rate thatwiil rtet change for tho perlod
�- Indicated by the 8ese Rate E�iratlon Dals and/ot Matudry Oafe. Atthough the Base aat�w18 not changs Ier the du�ation indlcated,
• ths actuai CredNed tnhr�ai rct�may ba grsater or lea�Ihan th�Base Rats depending on 1)ihe alacBon or tem�innAan o0 an optional
rider,and/or 2)any othe�appitoable lealuro that ls descrihed in 1hs Co.ntracL Refer lo�your contraol,dat�page and enq Rider
Transactiort Surritnary eectlon that may be fncludetl on thie slatemen!tor turther detaila.
-.- '. AkE�t? li ID 016083306 .020Zflt 715858 _ - ' P�g�3 sS�
�Co3twi00000,tott9ltssot�9'lts� . - � .: .- . - - -� - - - � 000p0019 �
REV-1511 EX+ (02-15)
i pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX REfURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ESTATE OF MARTIN E BAKER 2112-12�6
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1� NEILL FUNERAL HOME 548 • 35
DAUPHIN COUNTY HONOR GUARD 200 • 00
AMERICAN LEGION POST 1001 - RECEPTION 2,396 • 50
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State __ZIP_._._
Year(s)Commission Paid:
Z. Attorney Fees:
3. family Exemption: (If decedent's address is not the same as claimanYs,attach explanation.)
Claimant
Street Address
City State____ZIP,....
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer fees: 8 3 5• �D
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 3,9 7 9 • 8 5
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+ (02-15)
� pennsylvania SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
iNHeRCTArvice rax R�uRN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ESTATE OF MARTIN E BAKER 2112-1206
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
i. PERSCRIPTIONS AND MEDICATION 64 • 89
2 JEWISH HOME OF GREATER HARRISBURG 3,614 •74
TOTAL(Also enter on Line 10, Recapitulation) $ 3,679 • 63
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+ (02-15)
� pennsylvania SCHEDULE )
` ` DEPARTMENTOFREVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ESTATE OF MARTIN E BAKER 2112-1206
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec.9116(a) (1.2).]
1. DEBRA A WEBER DAUGHTER 50i
7 MILLERS GAP ROAD
ENOLA, PA 17025
2 CHERYL L BAKER DAUGHTER 50i
121 BRIAN DR
ENOLA, PA 17025
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAK,EN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
_. - �—�ST WII�L AND TESTAMENT
of �.
MARTIN E. BAKER
1, Martin E. Balter, of Swatara Township, Daupi�in Coun�y, Penn--
sy3.vania, being of sound and disposin� mind, memory and understanding,
hereby make, publish and declare this as and far my LAS�' WILL AND T$S`I`-
AMFsNT, hereby revoking all other Wills and codicils, heretQfore made
bY me.
I�.�, I . I direct the payment of my debts and expenses of my Iast
i�lness and funeral frotn my estate as soon after my death as conveni-
�ntl.y may be done.
ITEM II_ I then direct that:
A_ One-hal� {lj2) of the balance of my estate, rea1, personal
and mixed, shall be given to my older daughterr Debra �,. Weber_ -In
the event tha� Debra A. Weber predeceases my yaunger daughter, Debra
A. Weber� s one-half (lj2) of the bal-ance my estate shall be given to
•my granddaughters, Tracy Weber and Wendy Weber, and any future
grandchiidren. share and share alike_
B. One-half (1/2) of the balance of my estate, real, persanal
and mixed, shall be given to my younger daughter, Cheryl L��. Baker. In
the event that Cheryl L. Baker predeceases my alder daughter, CheYyl
L. Bakerts one-haif (I/2) of the balance o� my estate shall be given
to my granddaughter, Kacey Baker, and any future grandchildren� share
and share alike.
ITEM III . I direct that no execntor or other fiduciary na�ned,
nominated or appointed in this, my LAST WILL AND TESTAM$NT, shall be
required to post any band ar give any security of any type for any
purpose whatsaever, any law or rule of court of the Commonwealth af
Pennsylvania or any other jurisdiction to the contrar� notwith=
standing.
I'i`EM IV_ Finally, I nominate, constitute and appoint Debra A.
Weber and Cheryl L. Baker, my daughters, E�cecutrixes of this, my LAST
WILL AND TFSTAMENT.
IN WITNFSS WHEREOF, I have hereunto set my hand and seal to this,
my LAST WILL AND TSSTAMENT, consisting of one E1) page typewritten,
which bears my signature for the purpose of identification, this
day of f��Q x�f!p , 19 9 b.
c � )
�
1 �
�R .
Signed, sealed, gubiished and dec3ared by the above named Test-
ator, MAR'TI}�T F; gAgFsg, as and for his LAST WILL A�1D TFSTAMF�NT, in the
sight and presence of us� w�io at his request, in his sight and
presence and in the sight and presence of each other, have hereunto
subscribed our n.ames as witnesses_
b�_���� � - � t�...� �33 3 /� ���1� �'�uirt! �D
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