HomeMy WebLinkAbout05-26-15 (3) pennsylvania 1505614105
DE-MENT OF REVENUE EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
................ ...................
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
'ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
........... ..................
08252014
............. ................................ ......... ........................... ...........................
Decedent's Last Name Suffix Decedent's First Name- Mi
................ .......... ............... ................... ..................... ........... ............... ............................ ............................................... ...... ......................
McClain
Marjorie
B
.......... ..........- ..................................... .................................................................
..............................-......I.-.1..............................-............................................. .......
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Ml
................. .............. ...................................................................... .............
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1 Original Return C=:) 2.Supplemental Return C=) 3. Remainder Return (date of death
prior to 12-13-82)
C=:) 4.Agriculture Exemption(date of C=) 5. Future Interest Compromise(date of 0 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
M 7. Decedent Died Testate c=) 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
C=) 10. Litigation Proceeds Received C=:) 11. Non-Probate Transferee Return C= 12. D efe rra UElection of Spousal Trusts
(Schedule F and G Assets Only)
O 13. Business Assets C=:) 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
................... ............................................. ............................................................................. ................ ................................................ .................................
,John F. Lyons, Esquire 238-4777
........... ...... .......-........... ................ ....................-................................................. .................................... ................. ...............
.............. .......................... ...................
First Line of Address
................... .............. .............. ...................................
112 Walnut Street i
........... ................. ................ .......... ........................................................... ................... .................
Second Line of Address
City or Post Office State ZIP Code
C= M
---------------- ------
Harrisburg PA 117101 -3
CD
.......... ................... ......................... ...........................-............ 1............................... j._._....................................................... ........................................
rr) rn
Correspondent's email address: jflyonslaw@msn.com
REGISTER O,FWI4S_4SE QTID(
REGISTER OF WILLS USE ONLY
PATE FILED MMDDYYYY,: 0D r_ Irr
C
a
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
1111111 HE 11111 ljlqqlll 111y1b 11111 1111111111111
4 1505614105
1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedents Name: Marjorie B. McClain
RECAPITULATION
1. Real Estate(Schedule A). ......... ..................... . .... 1.
I
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 Miscellaneous Personal Property(Schedule E)....... 5. ; 41,054.96 '.;
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property ;
(Schedule G) C=> Separate Billing Requested.. . . .. . . 7. 142,766.53
8. Total Gross Assets(total Lines 1 through 7). . .. .. .. . .. . ... . . . ... .. .. . . . . 8. 183,821.49 !,
9. Funeral Expenses and Administrative Costs(Schedule H). . ..... .. .. . . . . .. . . 9. 11,931.76
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)....... . ....... 10. 3,796.04
11, Total Deductions(total Lines 9 and 10).. ............. .... ..... .. ...... 11. 15,727.80 '.
12. Net Value of Estate(Line 8 minus Line 11) .. .. .. .. .. ... .. . . . .... . . . . .. .. 12. I 168,093.69
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which
an election to tax has not been made(Schedule J) .. . . . .. .. ... .. .. . .. ... . . 13.
14, Net Value Subject to Tax(Line 12 minus Line 13) . . . .. .. .. . .. . .. . . .. .. .. . 14. 168,093.69
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 _.... .. . ........
(a)(1.2)X.0_ 15.
16. Amount of Line 14 taxable
at lineal rate X.0 45 168,093.69 16, 7,564.21
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 1 18.
19. TAX DUE . .. .. . . . . ... . . . . . . . . . . . . .. . .. . .. . . .. .. . . . . . . . . ... . .. . .. . . 19. 7,564.21 '
............................ ....._.......
20. FILL 1N 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 knowledge.
SMNURE OF PERSON RESPONSIBLE FO FILING RETURN DATE
/sem LetCd�a` S�a y Is
ADAf SS
MD 21093
SIGNATUR T N RESPONSIBLE FOR FILING THE RETURN DST
ADORES
112 alnut Stree , risbur A 17101
Side 2
5 4 1505614205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME _
Marjorie B. McClain
STREET ADDRESS
824 Lisburn Road
Apt 301
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 7,564.21
2. Credits/Payments
A.Prior Payments 6,000.00
B.Discount 315.78
(See instructions.) Total Credits(A+B) (2) 6,315.78
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fitt 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) 1,248.43
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑
c. retain a reversionary interest .............................................................................................................................. ❑ E
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?.............................................................................................................. ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ E
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
containsa beneficiary designation? ........................................................................................................................ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S,§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 decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent 172 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,
LAST WILL AND TESTAYIEN'T
OF
MARJORIE B. McCLAIN
I, Marjorie B. McClain, of 824 Lisburn Road, Apt. 301, Camp Hill, Cumberland
County, Pennsylvania 17011, being of sound and disposing mind, memory and
understanding, do hereby make, publish and declare this as and for my Last Will and
Testament, hereby revoking any and all prior Wills and all Codicils made by me at any time
heretofore.
ITEM 1. 1 direct that all my legally valid debts, funeral and administration
expenses, and inheritance and estate taxes incurred on account of my death shall be paid
by my personal representative out of my residuary estate as soon after my death as
practicable.
ITEM 2. 1 leave to my son, Thom H. McClain, the sum of $500.00.
ITEM 3. 1 give, devise and bequeath my entire estate including the rest, residue
and remainder of my estate, whether real, personal or mixed, including automobiles,
together with all insurance policies thereon,to my daughter, Linda McGlone, provided that
my daughter survives me by thirty (30) days. In the event Linda McGlone has
predeceased me or failed to survive me by Thirty (30) days, I give, devise and bequeath
the rest, residue and remainder of my estate to my son in-law, David McGlone. In the
event that both Linda McGlone and David McGlone have predeceased me or failed to
survive me by Thirty (30) days, I give, devise and bequeath the rest, residue and remainder
of my estate to Jennifer McGlone Burke.
1
survive me by Thirty (30) days, 1 give, devise and bequeath the rest, residue and remainder
of my estate to Jennifer McGlone Burke,
ITEM 4. No fiduciary acting hereunder shall be required to post bond or enter
security in any jurisdiction.
ITEM 5. 1 nominate, constitute and appoint my daughter Linda McGlone, as
Executrix of this, my Last Will and Testament: In the!event.of=the re,hunciatiGn-;`death or
resignation or inability to act for any reason whatsoever of my daughter, Linda M'cGlone,, l
hereby nominate, constitute and appoint my son-in-law, David McGlone, as Successor
Executor of this, my Last Will and Testament.
IN WITNESS WHEREOF, I set my hand and seal to this, my Last Will and
Testament, this LA day of -' , 2012.
Lc
Marjorie . McClain
The preceding instrument, consisting of this and one ( 1) other typewritten pages,
initialed at the bottom of each page for security purposes, was on the date thereof
signed, published and declared by Marjorie B. McClain, the Testatrix herein
named, as and for her Last Will and Testament in our presence,who at her request,
in her presence and in the presence of each other, have subscribed our names as
witnesses whereof. � +.• _ /�y�
1�
Witne —
Witness
2
144
We, Marjorie B.'McClain, and141 -SA the
-Testatrix and the witnesses, respectively, whose names are signed to the foregoing,
instrument, being first duly sworn, do hereby declare to the undersigned.authority that the
Testatrix signed and executed the instrument as her Last Will and that she had signed
willingly, and that she executed it as her free and voluntary act for the purposes therein
expressed, and thateach.,of the witnesses;'i.'n-theio:re-sence;arLd-;he.ar,,Iflg-.-ofc:"-,t.-'h6i-Tes't.�tr.ix,
signed the will as witness and that to the best of their knowledge the Testatrix was at the
time eighteen (18) years of age or older, of sound mind and under no constraint or undue
Influence,
TOSGICrix I Marjorie B. McClain
L
Witness
W(tness
Sworn to and subscribed
before me this ��
day of , 2012
N41014 SEAL
"Y E W"
Nosy Peft
0900 CONTY
i�2:014
3
REV-15o8 EX+(08-12)
pennsyLvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Marjorie B. McClain 21-14-0827
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. River Source Life Insurance 25,155.85
payable to Estate of Marjorie B.McClain
2. 2008 Pontiac G6 7,000.00
appraisal attached
3. Comcast-equipment refund 260.15
4. Capital blue Cross-refund 215.27
5. 8125/2014 RiverSource Long Term Care reimbursement 3,627.00
July 18,2014 to August 17,2014
6. 10/14/2014 RvierSource Long Term Care reimbursement 234.00
August 18,2014 to August 25,2014
7, Woods at Cedar Run-resident refund prorated monthily fee 403.69
8. Miscellaneous personalty (Decedent was of advanced age and lived a simple lifestyle in a Sr.facility) 1,000.00
9. 7/14/2014 RiverSource Long Term care reirnbusernent 3,159.00
TOTAL(Also enter on Line 5, Recapitulation) $ 41,054.96
If more space Is needed,use additional sheets of paper of the same size.
RiverSource Life Insurance Company
70100 Ameriprise Financial Center
Minneapolis, MN 55474
An Ameriprise Financial Company
September 29, 2014
Claim Number: 558377
Policy Number: 9300-8183989
MARJORIE B MC CLAIN.
ESTATE OF MARJORIE B MIC CLAIN
222 CHARMUTH RD
co
TIMONIUM MD 21093-5214
Dear ESTATE OF MARJORIE B MC CLAIN:
Please accept our condolences.
The attached check for $25,155.85 represents the death benefits due you under this contract.
Base plan benefits: $25,155.85
Total Payment: $25,155.85
If you have questions, please contact us Monday through Friday from 8!a.m. to 5 p.m. Central time. Thank you.
RiverSource Annuity Claims
(800) 862-7919
Insurance and annuities are Issued by RiverSource Life Insurance Company("RiverSource Life")an Amerlprlse!Financial company.RiverSource Life also act*as principal in
,he sale and distribution of Its variable annuity contracts and variable life Insurance policies,Other Informatiom regarding execution of the transaction Including the time of the
transaction will be provided upon written request.
Detach And Retain For Your Records OGLLLCAPCK(12/2006)
11L
ma)u, 4ppraisa �r
l 0
Name: LINDA MCGLONE
Address:222 CHARMUTH RD Sales Consultant:
LUTHERVILLE TIMO MD 21093 JR SAN JUAN JR,
Vehicle: 2008 PONTIAC G6 4D SEDAN GT
Mileage* 41,834 Engine: 3.51 7954-TIMONIUM CBC,MD
VIN: 1 G2ZH57N384104814 Dote:
Color: . GRAY 09/22/2014
Features Considered Conditions Asses.4;ed 29024
POWER LOCKS POWER WINDOWS Front Seats: G od Condition Rear Seats: Good Condition
SUNROOF(S) AM/FM STEREO Carpet: G od Condition Transmission: Good Condition
CD AUDIO AUXILIARY AUDIO INPUT Engine: G od Condition Front Tires: Good Condition
MONSOON SOUND AIR CONDITIONING Rear Tires: G od Condition Wheels: Good Condition
REAR DEFROSTER CRUISE CONTROL
ABS BRAKES LEATHER SEATS
POWER SEAT(S) FRONT SEAT HEATERS Carmax Car Buying Center
POWER MIRRORS ALLOY WHEELS 10130 York Road
PREMIUM PACKAGE TRACTION CONTROL
SATELLITE RADIO READY SIDE AIRBAGS Co(*eysvft, MD 21
AUTOMATIC TRANSMISSION Phone: (410) 931.7lM
OVERHEAD AIRBAGS,REAR SPOILER,SIRIUSXM TRIAL 1 Fax: (410)683-7294
AVAILABLE,ONSTAR TRIAL AVAILABLE Toll-Free(988) 289-1511
www.carmax.com
Appraisal Offer 7X00
,
This offer is valid until the close of business on 9/29/14.
If you purchase a CarMax vehicle while selling us your vehicle,
you co Id be el' iP f
in ,Ie,- or $420.00
The offer for your vehk7e not hongefor�90XYsonSdaVil�b'e�ogifelat�aipCorMtoxostores.
After 7 days,your vehicle will need to be reappraised and the offi r may change,
Comments Yourraiser
LOW MILES FOR MODEL YEAR.VEHICLE IS WELL MAINTAINED.GREAT OPTIONS ON �j FP
VEHICLE.
CarIVIax Certified Appraiser
THANKS FOR HAVING YOUR VEHICLE APPRAISED
If you would like a detailed explanation of how we determined your Appraisal 0fl11r,ask to see your Appraiser.
We'll buy your car TODAY!
'r
•We make it easy to sell your car and we'll buy your car i !;& s-
1C.e.
even if you don't buy one from us. O. sell..vs! .
-07 -f b:lj* 66ide
•The appraisal offer is good for 7 days. - it1b,-0fift is not w,' i'h e d
•When you sell to CorMax you'll save time and money E]val 4 'istrot:i8n_
and avoid the hassles of selling it yourself—costly !.
f
advertising,finding a buyer, and negotiating a price. [�,Vc(l,i t6-issued.,0,hOt6 11)f0i;_0-11 jjt,5holders
-0:Al 'keji ,and- remotes ;(:if'applicak le)
Get informed -
Ask your Sales Consultant to show you our pricing games display.
l
You'll learn how troditionol dealers can alter pricing to make customers See outer
side for important details.
feel like they're getting a good deal.
L
DATE FROM :' DATE TO PAGE ACCOUNT NUMBER.
SC Members Ist Federal Credit Union 10/01/2014 10/31/2014 1 of 2 XXXXXXX417
5000 Louise Drive
P.O.Box 40
Mechanicsburg PA 17055-0040
® (800)237-7288
MEMBERS 1" (717)697-5312(Hearing Impaired)
"DERALCREM UNION xvmv.memberslst.org
00
MARJORIE B MCCLAIN ESTATE
C/O LINDA M MCGLONE
222 CARMUTH RD
TIMONIUM MD 21093 I�
10712
"x
WITH WGAL NEWS 8'S MIKE HOSTETLER
I WINNER EACH WEEK $50 GRAND PRIZEWINNER $2,500
VISA Gift Card
Details Here: http:/Iwww.members1st,org/promotions/footbal1-challenge
ACCOUNT BALANCES AT A GLANCE
CHECKING 25,924.71
SAVINGS 5.00
CERTIFICATES 0.00
LOANS 0.00
CHECKING i0
BEGINNING BALANCE• -$7,184.87 -
Eff. Post
Date Date Description Deposits Wit Balance
10/07 10/07 Check 000051 Tracer 0000019951 C6,390.57 794.30
10/14 10/14 Deposit by Check 25,155.85 25,950.15
10/14 10/14 Deposit by Check 234.00 26,184.15
10/17 10/17 Check 000102 Tracer 0000050851 260.15 25,924.00
10/31 10/31 Deposit Dividend 0.050% 0.71 25,924.71
Annual Percentage Yield Earned 0.050%from 10/01/14 through
10/31/14
ENDING BALANCE: $25,924.71
Check# Date Amount Check# Date Amount Check# Date Amount
51 10/07 6,390.57 102* 10/17 260.15
* Indicates check out of sequence 2 Checks Cleared for 6,650.72
Total:Deposits 25,390.56 Average Daily Balance 46;647.80
Total Withdrawals. 6;650.72
-NP
CHECK.NUMBER:
30038558
GROUP I SUBGROUP ID:
00900001 -
1/07/14
ARJORIE B MCCLAIN
/OTHE ESTATE OF MARJORIE B MCCLAIN
?4 LISBURN RDAPT301
AMP HILL,PA 17011-7103
'Explanation Of Refund***
;fund Net overpay 3rd qtr:Marjorie B McClain,800339634,IS02 cx(,
T:otal Refund Amount: $215.27
;ce iw-ne, -ugwan-16 icsuai or (31uecross andior its sub5iciiariS.C;�.pital Caanjxiny',
as a r I I ii 9tldt f.V()VidfD{reltllfiO!113,f0l611 COITIP�Wli',.,S.
...D. 'ti
A-
CHECK NUMBER. 62-4
311
KJ 30038668
1/07114
PAY TO THE ORDER OF:
VOID AFTER 18,0 DAYS
MARJORIE B MCCLAIN
CHECK
C/O THE ESTATE OF MARJORIE B MCCLAIN
11-01 AMOUNT: ******+***$215.27
824 LISBURN RD APT 301
CAMP HILL PA 17011-7103
7
The Bank of New York Mellon,Philadelphia,PA
,Is 300 3A c; c;Ailv inn :k L Lnnn i_ ,)s- ci r ri
sa
RiverSource
LONG TERM CARE INSURANCE DIVISION
P:O.Box 40007
LYNCHBU RG VA 24506-9939
��0 1
000 0001187 00000000 001 002 00405 INS:0 0
MARJORIE MC CLAIN
222 CHARMUTH RD
TIMONIUM MD 21093
Page 1 of 2
A271866 Claimant:. MARJORIE B MC C'LAIN Clalrns: (888) 320-8741
Payment for Jul 18 2014 through Aug 17 2014: $3,627.00
Section A - Policy Details
09-15-2013 - 09-14-2014
Daily Benefit: $195.00
Deductible Period: 20 Days
Deductible Period Met: Nov 23 2011
Lifetime Max: 1,095 Days
Benefits Paid to Date: 985 Days
Remaining Balance: 110 Days
saai..o.oe�aseos Please detach before negotiating check
�.
CHECKNO,
.... 51-4
.RiverSource 6930235901 11
LONG TERM CARE INSURANCE DIVISIONDATE OF EHE-CK
P:O.Box 40007 08/25/14
LYNCHBURG VA 24506-909
PAY EXACTLY*****THREE THOUSAND SIX HUNDRED TWENTY SEVEN DOLLARS AND NO CENTS
PAY TO THE ORDER OP MARJORIE MC CLAIN VOID AFTER 180 DAYS
222 CHARMUTH RD
.TIMONIUM MD 21093 .. CHECKAMt5UNT
$3,627.00
91004137948 A271866
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RiverSource
LONG TERM CARE INSURANCE DIVISION
P.O.Box 40007
LYNCHBURG VA 24506-9939
�01 000 0001063 00000000 001002 00388 INS:0 0
1311 1 1 1121111 1 1 1 111 1 11 111 111 111 111 111 111 111
MARJORIE MC CLAIN
222 CHARMUTH RD
TIMONIUM MD 21093
Page 1 of 2
A271866 Claimant MARJORIE B MC CLAIN Clalm�c: (888)320-8741
Payment for Jun 8 2014 through Jul 17 2014: $3,159.00
Section A Policy Details
09-15-2013 09-14-2014
Daily Benefit: $195.00
Deductible Period: 20 Days
Deductible Period Met: Nov 23 2011
Lifetime Max: 1,095 Days
Benefits Paid to Date: 954 Days
Remaining Balance: 141 Days
15931 v.0.09 10-25-N Please detach before negotiating check
-IIECK NO. 51-44
6930233547
RiverSource 119
LONG TERM CARE INSURANCE DIVISION DATE OF CiTECK
P.O.Box 40007 /'I 4
LYNCHBURG VA 24506.9939
PAY EXACTLY***** THREE THOUSAND ONE HUNDRED FIFTY NINE DOLLARS AND NO CENTS
PAY TO THE ORDER OF MARJORIE MC CLAIN VOID AFTER 160 DAYS
222 CHARMUTH RD CHECKAMOIITN71�
TIMONIUM MD 21-093
$3,159.00
X
-604137948 A271866
aA
A4
A
�ink of A st tur
America,NA
ORD,CONNECTICUT
.. ... .... .. .
111I693023354 ?111 1:01190041, S11: 00000699390
REV-1510 EX+(02.15)
�r pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FXLE NUMBER
Marjorie B. McClain 21-14-0627
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 %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER, ATTACH A COPY Of THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICA8LF VALUE
I. Ameriprise Financial 4,601.87 100 4,601.87
mutual fund acct.no.02014329836.002(see attached letter)
Beneficiary:Linda McGlone,Daughter
Ameriprise Mutual Fund
2, 80,228,29 80,228.29
Acct no.0206512295-002(see attached letter)
Beneficiary:Linda McGlone,Daughter
3 Ameriprise Deferred Annuity 16,332,77 16,332,77
acct no.9300686697004(see attached letter)
Beneficiary:Linda McGlone,Daughter
4, Ameriprise Deferred Annuity 16,51285 16,512.85
acct no,93006846700004(see attached letter)
Beneficiary:Linda McGlone,Daughter
5 Ameriprise Deferred Annuity 25,090.75 25,090.75
acct no.9300818398-004(see attached letter)
Beneficiary:Linda McGlone,Daughter
TOTAL(Also enter on Line 7, Recapitulation) $ 142,766.53
If more space is needed,use additional sheets of paper of the same size.
09/08/14 18;03 HPFAXAMERIPRISE 7175259484 Page 1
Ameriprise Financial
25 S. 3516 Street
Amerlprise $w Camp Nils$ PA 17011
Financial Phone (717) 525.9481
Fax (717) 525-9484
Fax
To: John Lyons From: Ron Leuschen
Fax: 238-4793 Phone:
Date: 9/812014 Pages: 3 including cover
❑ Urgent ' Per Your Request ❑ For Review ❑ Please Reply
Comments:
This communication and all attachments are confidential and may be legally privileged.If you are not the intended recipient,
(i)please do not read or disclose any content to others,(ii)please notify the sender by reply(e-mail or fax)immediately,and
(iii)please destroy this document.Failure to follow this process may be unlawful and subject to prosecution.Thank you for
your cooperation.
uyIua/ 14 ia,us H1-TAAAMtMl1lJF{i�t /1 /5259484 Page 2
Ameripr:ise
Financial
Account Summary for the Estate jSettlernent of Marjorie B McClain, Client ID '16322244
1)Type of investment: Mutual Fund
Product Name,Mutual Fund
Total Account Value(as of pate of Death): $,4,$01.87
Account Number:02014329836 002
Account Registration:Marjorie B Me Clain Tod
Beneficiary Designation:
PRIMARY BENEFICIARY
LINDA MC GLONE DAUGHTER 100.00%
How the accounts)proceeds will be settled:
We will transfer assets In this account to an account for the beneficiary(les).
Important Details about this account:
N/A
2)Type of Investment:Mutual Fund
Product Name:Mutual Fund
Total Account Value(as of Date of Death):00,228.29
Account Number:02015121295 002
Account Registration:Marjorie B Mc Clain To}d
i
Beneficiary Designation:
PRIMARY BENEFICIARY
LINDA MC GLONE DAUGHTER 100,00%
How the account(s)proceeds will be settled:
We will transfer assets In this account to an account for the bene>tciary(ies).
Important Details about this account:
N/A
3)Type of investment: Long Term Care insurance
Product Name:Long Term Care insurance
Total Account Value(as of Date of Death):Date of death value is unavailable
Account Number:91004137948 004
Account Registration:Marjorie B Mc Clain
Beneficiary Designation:
nation:
How the account(s)proceeds will be settled:
i
}
vaivv, it iv.va I I I OG3y4254 rage 6
We will update the account ownership to the person who completes the bond in lieu paperwork.
Important Details about this account:
This account does not require settlement,
4)Type of Investment: Deferred Annuity-Beneficlary
Product Name: Deferred Annuity-Beneficiary
Total Account Value(as of Date of Death):$;16,332.77
Account Number:93006846697 004
Account Registration:Marjorie 8 Mc Clain
Beneficiary Designation:
PRIMARY BENEFICIARY
LINDA MC GLOME DAUGHTER 140.00%
How the account(s)proceeds will be settled:
We will distribute proceeds to the beneficiary.
Important Details about this account:
N/A
5)Type of Investment: Deferred Annuity-Beneficiary
Product Name: Deferred Annuity-Beneficiary
Total Account Value(as of Date of Death):$16,512.85
Account Number:93006846700 004
Account Registration: Marjorie B Mc Clain
i
Beneficiary Designation:
PRIMARY BENEFICIARY
LINDA MC GLONE DAUGHTER 100.00%
i
How the account(s)proceeds will be settled:
We will distribute proceeds to the beneficiary.
Important Details about this account:
N/A
6)Type of investment: Deferred Annuity-Successor annuitant possible
Product Name: Deferred Annuity-Successor'annuitant possible
Total Account Value(as of Date of death);$25,090.75
Account Number:93008183989 004
Account Registration:Madorle B Mc Clain
Beneficiary Designation:
c
I
REV-1511 EX+ (02-15)
Q7pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Marjorie B. McClain 21-14-0827
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Cocklin Funeral Home 6,390.57
2. Blair Mountain B&B(funeral luncheon) 1,066.78
3. Flowers(reimbursement to Linda McGlone-items for memorial service at Woods at Cedar Run) 413.09
4. Pastoral Service fee 150.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
1,250.00
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: 375.00
5. Accountant Fees:
6. Tax Return Preparer Fees:
7. NTW#581 Vehicle Repair&Inspection 164.04
8. Ed's Garage: vehicle repairs to make roadworthy 804.30
9. Margret McCarthy 1 week shelter Decedant,s dog 250.00
10. Country Inn&Suites Executrix 4 nights loding for funeral arrangements and Apartment cleanout,etc 553.53
11. Travel expenses from MD to Pa re funeral arrangements,viewiing,atty consults&estate admin 514.45
TOTAL (Also enter on Line 9, Recapitulation) $ 11,931.76
If more space is needed,use additional sheets of paper of the same size.
t.u�n�si� rui�G�ai nu��ic, enc' Acct: Contract # 389
MEMORANDUM OF SERVIC,E
[SERVICES OF: Marjorie B. McClain DATE:
(A) Services:
Memorial Folders $55.00
Cultured Marble Urn with Personilazation $412.00
Rental Casket $895.00
Cremation Service Option 1 $4,260.00
Total (A) $5,622.00
(B) Cash Advance Items:
Certified Copies $72.00
Newspaper Notice- Harrisburg $311.20
Newspaper Notice-Carlisle $355.37
Coroner Authoization $30.00
Total (B) $768.57
a
Total mount $6,390.57
Less Amount Paid $0.00
Due $6,390.57
Blair Mountain Bed & Breakfast Invoice
231 West Ridge Road _
Dillsburg, Pa 17019 Dat<_ Invoice#
8/27/2014 1192
Bill To
Linda McGlone
222 Charmuth Rd.
Timonium,MD 21093
P.O. No. Terms Project
8/29/2014
Quantity Description Rate Amount
1 Garden Room (NO Charge for extra bed) 129.00 129.00T
Hotel Tax 3.00% 3.87
1 Antique Tea Room 129.00 129.00T
Hotel Tax 3.00% 3.87
1 Reception for Mother's Funeral Sat.August 30th,from 12:30 to 3:30 PM 165.09 165.09T
40 Catering 12.00 480.00T
Any tip or gratuity for services rendered.9/620 96.00 96.00T
Sales Tax 6.00% 59.95
y� \
, n u
Total $1,066.78
Order: 72936 Clerk: 325 Sale Date: 08/26/2014 Time: 13:53
Delivery Date: 08/29/2014 DOW: FRI Store: 52
Delivery Code: SOUTH General
Delivery Address: MARJORIE MCCLAIN
COCKLIN
30 N CHESTNUT ST
DILLSBURG, PA 17019
BY 3
I IIIIII IIID/I I I II III I I II/III
wire: This order is filled!/ This is a change of order!! CLK:O
PN Qty. Description Designer Amount
46 1 P/EURO HAND TIE $46.99 f
HANTIED BOUQ 4 RED ROSE IN CENTER 8 WHITE
ROSES BB BOW & RIBBON WRAP? TRISHA WILL CALL
WITH COLOR OF RIBBON
Amount $46.99
08/29 Phone $0.00
Delivery $0.00
SubTotal $46.99
Coupon $0.00
Discount $4.70
Tax $2.54
— / Occasion: .1 Register Seq: REG#1 Total $44.83
D
R �.
Customer: CASH nn ; v,
LINDA MCGLONE
Ph (717)752-8003 Wk III IIIIII III I it II I II III
Order:
72931 Clerk: 325 Sale Date: 0;8/26/2014 Time: 13:55
Delivery Date: 08/29/2014 DOW: FRI Store: 52
Delivery Code: SOUTH General
Delivery Address: MARJORIE MCCLAIN
COCKLIN
30 N CHESTNUT ST
DILLSBURG, PA 17019
BY 3
III I IIIII I I I IIIII Ii it 1111 1111
wire: This order is filledll This /s a change of orderll CLK:O
PN Qty, Description Designer Amount
22 1 CASKET SPRAY $200.00
4369 --PINK CARNS PURPLES BB GARDEN LOOKING
Amount $200.00
08/29 Phone $0.00
Delivery $0.00
SubTotal $200.00
I Coupon $0:00
- Discount $20.00
Tax $10.80
Occasion: 1 Register Seq: REG#1 Total $190.80
C
A
R
D
Customer: CASH
LINDA MCGLONE
Ph (717)752-8003 Wk IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Order: 72933 Clerk: 325 ' Sale Dater 08/26/2014 Time: 13:52 _
Delivery Date: 08/29/2014 DOW: FRI Store: 52 _
Delivery Code: SOUTH General
Delivery Address: MARJORIE MCCLAIN
COCKLIN
30 N CHESTNUT ST
DILLSBURG, PA 17019
BY 3
111111 IIID VIII VIII VIII/III/III
Wire: This order is filledll This is a change of orderll CLK:O
PN Qty, Description Designer Amount
i
20 2 Funeral Urn $75.00
2 MATCHING URN ARRGT TO MATCH THE CASKET SPRAY--
PINK CARNS PURPLES BB GARDEN LOOKING
Amount $150.00
08/29 Phone $0.00
Delivery $0.00
SubTotal $150.00
Coupon $0.00
Discount $15.00
Tax $8.10
Occasion: 1 Register Seq: REG #1 : Total $143.10
C
A
R
D
Customer: CASH
LINDA MCGLONE
Ph (717)752-8003 Wk I IIIIII VIII VIII 1111111 11I1 IN
Order: 72940 Clerk: 325 Sale Date: 08/26/2014 Time: 13:50
Delivery Date: 08/29/2014 DOW: FRI Store: 52
Delivery Code: SOUTH General
Delivery Address: MARJORI� MCCLAIN
COCKLIN
30 N CHESTNUT ST
DILLSBURG, PA 17019
BY 3 I
I III I VIII(VIII III (IIII IIII IIII
Wire: This order is filled!/ Thls is a change of orderil CLK:O
PN Qty, Description Designer Amount
4312 1 Nature in Bloom Small Cross $35.99
i
DONE IN SILKS MATCHING THE FUNERAL FLOWERS
Amount $35.99
08/29 Phone $0.00
Delivery _ $0.00
SubTotal $35,99
Coupon $0.00
Discount $3.60
Tax $1.95
Occasion: 1 Register Seq: REG*1 Total $34.34
C
A
R
D
Customer; ;CASH .�
LINDA MCGLONE
Ph (717)752-8003 Wk I IIIIII(IIII(IIII IIII III I IIII If II
PATE FROM �. :DATE TO J
St Members 1st Federal Credit Union 09/01/2014 09/30/2014 1 of 2 XXXXXXX528
5000 Louise Drive _
P.O.Box 40
Mechanicsburg PA 17055-0040
" (800)237.7288
MEMBERS 1'' (717)697-5312(Hearing Impaired)
MERALCREDtT UMON www.members l st.org PENN
STATE
3 FOOTBALL
MARJORIE 6 MCCLAIN 'TICKET GIVEAWAY
824 LISBURN ROAD APT 301 ! K
CAMP HILL PA 17011
14e b- • • -
B. . A GLANCE'
Your aggrebaie:balance a of September 1st is$21;941 02. . . "
An aggregate balance bf.$2,500 and having 3 prodlfcts will piace,you:in the Si.Iver:MLR I.eyeL
CHECKING 0,00
SAVINGS 0.00
CERTIFICATES 0.00
LOANS 0.00
;CHECKING-(0011)
BEGINNING BALANCE $4,.000;00 . :
Eff. Post
Date Date Description Deposits Withdrawals Balance
09/01 09/02 Check 005507 Tracer 0000318920 0W-PUrS 413.07 3,586.93
09/02 09/03 Check 005509 Tracer 0000504098 p OLS�V{c,\ 150.00 3,436.93
09/11 09/11 Withdrawal Fee 3.95 3,432.98
Bill Pay Service Fee
09/13 09/13 Deposit 3.95 3,436.93
09/13 09/13 Withdrawal 3,261.93 175.00
09/13 09/13 Withdrawal 175.00 0.00
09/13 CHECKING CLOSED
*This is the final statement presenting information on this product
Please retain this final statement for tax reporting purposes,
ENDING BALANCE: $0.00
Check# Date Amount Check# Date Amount Check# Date Amount
5507 09/02 413.07 5509* 09rr5!63.0" 150.00
* Indicates check out of sequence 2 Checks Cleared f
Total Deposits 3,95:::__: 7otaP:Withdrawals. '4:,003:95
Joint Owner LINDA MMCGLONE.
REGULAK SAVINGS (00 00)
NI
• .. .: : _. .-: .. :° ��...316,992.66
. . . ,. .. ,, BEGIN NG BALANCE :_
Eff. Post
Date Date Description Deposits Withdrawals Balance
09/04 09/04 Withdrawal 948.36 16,044.30
09/13 09/13 Withdrawal 16,039.30 5.00
09/13 09/13 Deposit Dividend 0.54 5.54
�Z�BW -AVACS
'qlW— TIRES-SERVICE,BRAKES-BATTERIES
4D NATL TIRE & BAT # 581 FINAL BILL -INVOICE** Page 1
1.705 YORK ROAD Invoice# 78947404 - RI
jUTHERVILLE MD 21093 Order Num 52798193 - WI
(410) 828-9295 Date/Time In. . . . . . . . 09/30/14 17 :43 : 36
Date/Time Promised. , 10/01/14 18 : 14 : 59
2008 PONTIAC G6
Tag: EBM4047 St : PA Mileage : 41865
Engine :- VIN# 1G2ZH57N384104814
-------------------------------------------------------------------------------
�ustomer: 34589693 PO# : Ship To:
4C GLONE, LINDA
222 CHARMUTH RD
=HERVILLE MD 21093
opening Salesperson 32008529 Home# 410-491-4429 Work#
Tmail : dmcglone@comcast .net
-------------------------------------------------------------------------------
Item Number Item Description Qty Price Each Extended
--------------------------------------------------------------------------------
qA WHEEL ALIGNMENT 1 89 . 99 89 . 99
6 Months / 6000 Mile
12991173 BEKKERMAN, LEONID
. EC60K RECOMMEND 60, 000 MILE SERVICE 1
PA Price Adjustment 1-
�Cwc SERVICE WARRANTY CREDIT 1- 9 . 00 9 . 00-
VISA Visa 89 . 04-
CARD NUMBER 9422 APPR 03631C
IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK
rO OUR STORE MANAGER, ALFRED HARTLEY
D,T (410) 828-9295
Special Credit :
We use both flat rate and hourly rate to calculate charges. All parts are new unless otherwise Total Charges . . 89 . 99
specified U=Used or R=Rebuilt. Total Credits . . 9 . 00-
Sub-Total . . . .. . . 80 . 99
New Tire Fees" . 00
Shop Fees (*) 8 . 10
All Taxes . . . .. . . . 05-
Payments. . . . . . . 89 . 04-
Mauntacturer Special Adjustment Policy Programs;
Federal law requires manufacturers to furnish the National Highway Traffic Safety Administration INM.T.S.A.)with bulletins describing any Net Amount . . . . .
defects in their vehicles.You may obtain copies of these bulletins from either the manufaturer orN.H.T.S.A. In addition,certain consumer . 00
publications or organizations publish this Information,which may be available for a fee or for free. PLEASE PAY A13OVE AMOUNT .
THANK YOU! Closer: 32001313
I have received: the goods and services as represented on this invoice. If this is a credit card
purchase I agre" ;"to pay and comply with the cardholders agreement with the issuer. *This charge
represents costs and profits to the vehicle repair facility for miscellaneous Shop Supply or
Waste Disposal.
Customer Signature
PLEASE SEE REVERSE SIDE FOR WARRANTY,TERMS,CONDITIONS AND OTHER IMPORTANT INFORMATION CUSTOMER COPY
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State of Maryland
Motor Vehicle Inspection Report 7 j
OWNER 1A �:af L STATION NO.
E- E NO.
ADDRESS (1�
DAT_
Y.I.N. ODOMETER
MAKE
r`---� -f -MODEL r YEAR
(02) -STEERING (05)-FUEL SYSTEM (14)-GLAZING (26)-EMISSIONS
P F R P F R P F R P F R
Steering Wheel Tank Driver Door Window Catalytic Converter 7
Column Cap r Mechanism Fuel Filler
Lash Tubing
Windshield Positive Crankcase
Travel Accelerator r Damage or Glazing Air Injection
Linkage: (06). EXHAUST SYSTEM Indicate Window F Gas Recirculation
Tie Rods r P F R (15)- WIPERS Evaporative Emissions
Drag Link Muffler P F R REQUIRED READINGS:
Pitman Arm
Any Piping Arms/Blades TOE:
Idler Arm Manifold- Park Position BALL JOINTS OR KING PINS
Rack&Pinion j Controls
Steering Box (07)- "'
Power Steering BUMPERS
,
P F R 16). HOOD/CATCHES LU LL
? —1 --- "
(6) ALIGNMENT Front P] F R-
P F R' Rear Indicate Location RU RL
see req. rdng&, (08)- FENDERS 17)-DOOR HANDLE LATCHES
I P F R
F R
Toe In/Out I P JF DRUMS & Discs
Rear.Wheel Alignm4entZ Circle Rej. LF PF LR RR Indicate Location
(C) SUSPENSION (10)- LIGHTS (18)- FLOOR/TRUNK PANS LF RF —.7
(
P F R P F R P I F R X
Ball Joints or King Pinjs, Turn Signal-seif cancel Indicate Location F777-
see required rcadin6s� P LR:
L (19)-SPEEDOMETER/ODOMETER
Hazard
Struts
C
Wheel Bearings Brake Warning Operation/Legibility_ PADS OR NINGS
Springs/Shackles'' High Beam Indicator
Torsion Bars ....... Stop (21)- DRIVERS SEAT LF RF
Stabilizer Tail I P I.F I R
Control Arm Park Mounting&Operation
Shocks Side Marker
(22)-SAFETY BELTS LR FIR
Reflector
(03) - BRAKES P _F R
Tag
P F R HEADLIGHTS
Dash
Road Test(@ 20 mph) Rear 1969
Clearance
Hydraulic System Ll Ri
ID Lamp (23) - MOTOR MOUNTS
Master Cylinder
Adjusters
Wheel Cylinders Fog/AUX Height/Aim Indicate Location
Drum/Disc-see req.rdngs. L2
Headlights-see req.rcings
(24)-GEAR SHIFT INDICATOR
Lining/Pads-see req.icings
Obstruction L/R 1/2 L P,LF-LR
Booster System _
Parking Brake (11)- ELECTRICAL SYSTEM Position INSPECTORS
Mech. Components P F R (25) - UNIVERSAL& CV JOINTS ADDITIONAL COMMENTS
(04) -WHEELS/TIRES Horn-- -- I-- P:ff.FR
Switches/Wiring Z'
Universal 7
P F R
Neutral Safely Switches
I - - 1- - Constant Velocity
LF -1 11 1 i
Battery
FIF Z
—3) . MIRRORS
LR
IRR P F R
Interior
7
11erlor
�
INSPECTOR: WORK ORDER NO. �W� C
REINSPECTION OF DEFECTS ONLY IF RE-TURNED WITHIN 30 DAYS AND WITH!N 1000 MILES.A PRORATED INS P EC710N'FEE.MAY BE CHARGED.
P=PASSED F=FAILED R=REPAIRED
COURTYARD" Courtyard by Marriott 4921 Gettysburg Road
Harrisburg West Mechanicsburg,Pa 17055
AMrrioft ''Mechanicsburg
T 71,7.766.9006
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25Aug14 Room Charge 165.30
25Aug14 Occupancy Sales Tax 4,96
25Aug14 State Occupancy Tax 9.92
26Aug14 Room Charge 165.30
26Aug14 Occupancy Sales Tax 4,96
26Aug14 State Occupancy Tax 9,92
27Aug14 Visa 360,36
Card#: VIXXXXXXXXXXXX94226AXXX
Amount: 360.36 Auth:050580 Signature on
File
This card was electronically swiped on 25Aug14
Balance: 0.00
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INNS SUITES
Linda Mcglone Room No. 204
222 Charmuth Rd Arrival 09-02-111
Timonium MD 21093 Departure 09-04-14
United States Page No. 1 of 1
Folio No.
INFORMATION INVOICEConf. No.
80306989
Membershlp No. Cashier No. 9908
A/R Number
Group Code
Company Name 09-04-14 04:57:41 AM EST
Date Text Charges Credits
09-02-14 Room 80.10
09-02-14 State Tax 6% 4,81
09-02-14 Local Tax 3% 2.40
09-03.14 Room 80.110
09-03.14 State Tax 6% 4,131
09-03.14 Local Tax 3% 2.40
Total 174.62 0.00
Balance 174.62
Club Carlson: A faster way to a free night stay at over i1000 Carlson hotels worldwide.
Enroll and learn mare at the front desk or at clubcarlson.com
Thank You For Staying With!Us
I agree that my liability for this bill Is not waived and agree to be held personally responsible In the event that the Indicated person,company or
association falls to pay for any portion or the full amount of these charges.
Guest Signature
Country Inn&Suites Harrisburg West
4943 Gettysburg Road
Mechanicsburg,PA 17055
Telephone: (717)796-0300/Fax:(717)796-0800
Email: cx—hawp@countryinns.coin
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ACCOUNT SUMMARY :...._ ...
a.:�....w PAXM.9NT.*.1NF RMAT1pN
M.:.Wl,nau.:V.ca::waaT'ws+%.n..wH:.v:kr '.• 'deu.1:4:,M'i'.�t.3..3r..ai,r,-4"i.W.tN1a:.vn.4u_,.ti:x1eUR..ntic.w'w vi.21'iai--\'�:-v^ue.�'..:e1.-.,..:.......ru..x-X.�.v..
Account Number: d1JJ1kVftWJ0kJgft New Balance $40"
Previous Balance qqLV&qW Payment Due Date 10/09/1
Payment,Credits �,�, Mlnimum Payment Due $225:0(
Purchases , tate Payment Warning: if we do not reoolve your minimum payment
Cash Advances $0.00 by the date listed above,you may have to pay a late fee of up to$36,00
Balance Transfersand your APR's will be subject to Increase to a maximum Penalty APR
$4,00 of 29,9 %,
Fees Charged $0,00 Minlmum Payment Warning: if you make only the minimum payment
Interest Charged +$117.59 each pprlod,you will pay more in Interest tend It will take you longer to
New Balance -"" pay off your balance, For example:
Opening/Closing Date 08/13114.09/12/14
Credit Access Line If you melte no You will pay off fire And you will end up
additional charges ueing balance shown on paying an estimated
Available Credit (OM this;oard and each this statement In total of...
Cash Access tine qp" month you pay.., about...
Available for Cash 1p_W Only the minimum I, aw
Past Due Amount $0,00 payment
Balance over the Credit Access Line $0,00 $367 *owl*
(Savings=$8,861}
if you would like Information about credit counselln Ices,call
1.866497.2886, 1�` t»-
YOUR MSSAAES -.. .
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We hope you enjoy all the benefits your card has to offer and we appreclate;your buelness,Your annual membiDrehip foo In the amount of
$59,00 will be billed on 11/01/2014:There Is a transaction fee for each balance transfer and cash advance In the amount of 3.00%or$5.00
minimum per balance transfer and 6.00%or$10,00 minimum par cash advance, Please oee the Annual Renowal Notice section of your
statement disclosures for more Information,
S�UTNWESTaAl,INES RA lD REWARDS
+2X Pts for Southwest and AlrTran purchases 0 For more Information about your rewards program call
+2X Points for Partner purchases 11,105 1.800.792.0001 or visit www.ohase,00m/southwest.To
+Points earned on purchases 1 414 make Southwest flight reaervallone call
Total Rapid Rewards transf,to Southwest 2,519 1`800'1-FLY-SWA.
Earn 2 Rapid Rewards@ Points per$1 spent on flights purchased directly through Southwest Airlines@ or AlrTran@ Airways and on
participating Rapid Rewards and A+Rewards Hotel and Rental Car partner(purchases.Escape faster by earning 1 Rapid Rewards Point on
all other purchases:
ACCOUNT ACTIVITY - - - -
Date of
Transaction Merchant Name or Transaotioni Description $Amount
PAYMENTS AND OTHER CREDITS
09/04 Payment Thank You-Bill Pay Service V -800.00
PURCHASES
08/17 VON
��
08/22 rn f..fi k p tet
08/25 BAKERS RESTAURANT DILLSBURQ PA � �n' fro �++w�Y� 7 142,81
08/27 COURTYARD BY MARRIOTT HAR MECHANICSOUR4 PA to 377-83
08/27 BLAIR MOUNTAIN BED&BREA DILLSBURG PA- .. 1,066.78
CV11A 10%
0000001 FI&333390 4 000 N Z 12 14/09H2 Pag9 1 o12 01866 MAMA 66431) 28610000040606643001
0468
REV-1512 EX+(02-15)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Marjorie B. McClain 21-14-0827
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. Comcast 601.15
2. 2013 Lower Allen Township Per Capita Tax 30.50
3. 2014 Lower Allen Township Per Capita Tax 11.00
4. Spartan Pharmacy-medications 1,889.73
5. Members 1 st Visa 948.16
6. AAA Credit Card#xxxx xxxx xxxx 6574 172.04
6. AT&T 143.46
7.
TOTAL(Also enter on Line 10, Recapitulation) $ 3,796.04 .
If more space is needed,insert additional sheets of the same size.
-(comcastm Account Number 09547 260774.01.8
Billing Date 10/07/14
Unpaid Balance $261.15- Due Now
New Charges $340.00-Due 11/01/14,
Total Amount Due $601.15
Contact us:G www.comcast.com 1.888.931.1379 Page 1 of 2
MARJORIE MCCLAIN
Previous Balance 261.15
For service at: Payments- received by 10/07/14 0.00
824 LISBURN RD APT 301
CAMP HILL PA 17011-7103 Unpaid Balance - Due Now 261.15
New Charges- Due by 11/01/14 340.00
News from Comcast see below for more Information
Tota!Amount"Due- - $601.15
We regret losing you as one of our subscribers. Our records
indicate that the final balance shown above is now due.Your
prompt payment is appreciated.Any outstanding equipment t • ' !
must be returned to our office within 7 days. Please call us at
1-600-COMOAST any time should you wish to reconnect your Other Charges &Credits 340,00
a
service. Total New"Charges_:. $340:04 0
Hearing/Speech Impaired Call 711
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Ce
Cmc
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Detach and enclose this coupon with your payment.Please write your account number on your check or money order.Do not send cash,
Ccomicast. Account Number 09547 260774.01-8
Payment Due by Due Now
PO BOX 985
TOLEDO OH 43697-0985 Total Amount Due $601.15
MB 01 001214 92626 E 6 A Amount Enclosed $
(III((+I+IiiIIIIIIII'IIIIIIIIII'II'I'II'I'I'I"I'IIII'lll"'lll'II Make checks payable to Comcast
MARJORIE MCCLAIN
LINDA
222 CHARMUTH ROAD (I(( (IIII(I(11(I+nllll+Inlllll+Il(I(II+I(i+(l�((+�I(I+(II�+(II
TIMONIUM MD 21093-5214 COMCAST CABLE
P 0 BOX 3006
SOUTHEASTERN PA 19398-3006
09547 Rkn774 n1, A c nLni i c
170 W_ _ ll 1 FUJI L
04/23/14 AC17
-lours: Mon-Thur 8am-10pm EST
INT[RNAT IONAL
Fri 8am-5pm EST CLIENT: Cumberland County TheA wriaunv ofCrcdit
and CoOmtivn Ynf.ionila
Sat 8am-12pm EST ID NUMBER: B0179530 A4mibn
phone: 800-900-1370 TOTAL BALANCE DUE: $30.50
REQUEST FOR PAYMENT
=ailure to contact our office leads us to believe that you do not have intentions of resolving your just debt.
f you are unable to pay in full, settlements and/or payment arrangements may be available. We will do our best to work
vith you.
Dlease contact our office today, or go online to account.pen ncredit.com. or send payment in full in the enclosed envelope.
this letter is from a debt collection agency. This is an attempt to collect a debt. Any information obtained will be used for
.hat purpose.
SERVICE RENDERED SERVICE DATE ACCOUNT NUMBER BALANCE
2013 CNTY&TWP PER CAPITA TAX 2013/00/00 723618113 $30,50
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IFPAYINGBY VISA,MASTERCARD OR DISCOVER,FILL OUT BELOW
P- 0 Box 1259, Department 91047 ❑VISA ❑MAffM8CARD� ❑DISCOVER
Oaks, PA 19456 �w
CHANGE SERVICE REQUESTED 90.NATNE ANOUH
111111111111111111111111111111 111111111111111111
Visit http://account.pennoredit.com to pay your bill online,
ayments received by check will be electronically deposited, unless you pay by non-consumer type check.You may opt out of this program by paying with a money
rder or a travelers check. In the unlikely event your check(payment)Is returned unpaid,we may elect to electronically(or by paper draft)re-present your check
)ayment)up to two more times.You also understand and agree that we may collect a return processing charge by the same means,in an amount not to exceed
Iat as permitted by state law. ID NUMBER: B0179530 03/05/14
11111��1111�1�11�11"�IIIIIII�I�I�I�III�IIIII�III�I�IIII11111'III 91203.5633 PENN CREDIT
MC CLAIN MARJORIE 916 S 14th ST
10"N
824 LISBURN RD APT 301 PO BOX 988
CAMP -HICL' PA 17011=7103 HARRISBURG PA 17108-0988
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII III�IIIIIIIIIIII111111
91203-NEW-5633
TAXPAYER'S COPY
BONNIE K MILLER,TREASURER KEEP THIS PORTION FOR YOUR RECORDS
2233 GETTYSBURG ROAD
CAMP HILL,PA 17011.7302
TEMP -RETURN SERVICE REQUESTED
REMINDER NOTICE
002378*'****...******AUTO**S-DIGIT 17011
MARJORIE MC CLAIN I illlli VIII illi illlll Ilill illi illi/IIID lili Ilii illi
824 LISBURN RD APT 301
CAMP HILL PA 17011-7103
................. .......... ....... .............. .......................... ......... ...... ......
'ayable To: Office Hours: MONJUES&THURS 9.4 Bill No: 6181
BONNIE K MILLER,TREASURER CLOSED WED,FRI AND ALL HOLIDAYS Bill Date: 03101/2013
2233 GETTYSBURG ROAD BMILLER@LATWP.ORG Control No:13.032966
CAMP HILL,PA 17011-7302
PHONE(717)737-6671 occ
i ilii//lilll iii/lilil hill liiil illi/Viii lilll Iii) Discount Face Penalty
COUNTY PC $4.90 $6.00 $6.60
1$1.00 FEE FOR ADDITIONAL RECEIPTS
Tax Payer:
MARJORIE MC CLAIN TAX AMOUNT DUE $4.90 $5.00 $6.60
824 LISBURN RD APT 301 If Date of Payment Is on 3/1/13 thru 4/30/13 6/1/13 thru 6/30/13 7/1113 or Late
CAMP HILL PA 17011-7103
REMINDER NOTICE
............. ......... ......... ....... ........ ...................... ...................... ................. .........
Cumberland County Pennsylvania REMINDER NOTICE
F111,FIR Vil 0 IT11 317 k 115013 11=4EW11:1 k flu fiV443 go]NU441111yll--IAN IFTIM sxiloillnTiln�IrSITIA-TTI IN 11120 a 171
TAX COLLECTOR COPY- RETURN WITH PAYMENT FOR PROPER CREDIT] Bill No: 6181
Bill Date: 03/01/2013
MARJORIE MC CLAIN Office Hours: MONJUES&THURS 9.4 Control No: 13-032966
824 LISBURN RD APT 301 CLOSED WED,FRI AND ALL HOLIDAYS
CAMP HILL PA 17011-7103 SMILLER@LATWP.ORG
Payable To: OCC
BONNIE K MILLER,TREASURER Discount Face Penalty
2233 GETTYSBURG ROAD.
CAMP HILL,PA 17011-7302 COUNTY PC" $4.90 $6.00 $6.60
PHONE(717)737-6671liliili hill illi lilill illll11111 illi ilii/illll iliiilli 1
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TAX AMOUNT DUE $4.90 $5.00
If Date of Payment Is on 3/1/13 thru 4/30/13 6/1/13 thru 6/30/13 7/1/13 or Laterl
WEST SHORE • •
LOWER ALLIM"TOWNSHIP
TAX:OFFICE
BonnieK. Mille,Tax Collector
2233'Gettysburg Road
Camp.:Hill, PA .17011 7302
Phone. (717)737-5671
Fax: 717�`975-2292'
Ema h`timiller.@Iatwp org,
: .Important Information
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MEMBERS 111 �� ti a➢ , k
*FEDERAL CREDIT UNION C}�
MARJORIE B MCCLAIN O`/p
Statement Closing Date:
Account Number:### ########2488 Q�� October 01, 2014
Summary of Account Activity(` Payment information
Previous _
Balance _ \\ $ 948.36) NewyBalance ti u $�0.00�
Payments - '� .3 Total Minimum Payment Due $0.00
Other Credits - 0.00 payment Due Date 10/26/14
Other Debits + 0.00
Purchases + 0.00 Late Payment Warning: IF WE DO NOT RECEIVE YOUR
MINIMUM PAYMENT BY THE DATE LISTED ABOVE,YOU MAY
Cash Advances + 0.00 HAVE TO PAY A LATE FEE UP TO$25 AND YOUR APR'S MAY BE
Fees Charged + 0.00 INCREASED UP TO THE PENALTY APR OF 18.00%.
Interest Charge + 0.00 71
NEW BALANCE $0.00 Contact information
Credit Limit $11,500.00 Customer Service:(800)283-2328 Ext:6035 _•._._.
Available Credit 0.00
Report Lost or Stolen Card:(866)839-3485
Available Cash 0.00 /�6, Please send Billing Inquiries and Correspondence to:
Amount Disputed 0.00 `� MEMBER SERVICE
Statement Closing Date 10/01/14 PO BOX 30495 TAMPA,FL 33630-3495
Days in Billing Cycle 30 Visit us on the web at:
www.members1st.org
Please Mail Your Payments to:
PO BOX 2109 MECHANICSBURG PA 17055-1719
. Im_portant News
TO REPORT A LOST OR STOLEN CARD_PLEASE___ _CALL_ MEMBERS 1ST FCU AT 800-283-2328 866-260-0868 OR _AFTERHOUR5—+.TO`—
OBTAIN ACCOUNT INFORMATION 24 HOURS A DAY CALL 800-299-9842,OR ACCESS ONLINE AT EZCARDINFO.COM.
Transactions
Trans Date Post Date Plan Name Reference Number Description Amount
Payments,Adjustments and Other
09/04 09/05 K5 PAYMENT-THANK YOU 948.36-
TOTAL PAYMENTS OR ADJUSTMENTS $ 948.36-
Fees
48.36-Fees
TOTAL FEES FOR THIS PERIOD $ 0.00
_ NOTICE:CONTINUED OIJ PAGE 3
Page 1 of 3 5144 VD-*
PLEASE DETACH COUPON AND RETURN PAYMENT USING THE ENCLOSED ENVELOPE•ALLOW UP TO T DAYS FOR RECEIPT
MEMBERS 1ST FEDERAL CU St -Account Number]
5000 L DRIVE MEMBERS 1St # 2488
MECHANICSBURG PA 17055-4899
FEDERAL CREDIT UNION Check box to indicate
name/address change F
on back of this coupon
Total Minimum AMOUNT OF PAYMENT ENCLOSED
Closing Date New BalanceI ymerit Due Date
..Payment Due. Ra
10/01/14 $0.00 $0.00 10/26/14 $
■
MAKE CHECK PAYABLE TO:
MARJORIE B MCCLAIN = N
824 LISBURN RD APT 301 = N I...IiI���IILI��I�I��IIL���IIIfIILI�IIIII��IL�JJI�JILI
CAMP HILL PA 17011.7103 MEh1BERS'IST FCU
PO BOX 2109
MECHANICSBURG PA 17055-1719
III iil1i111111c1fill III III .
SPARTAN PHARMACY
94331 AB 0.406 9433 244 3526 BROWNSVILLE ROAD
**************ALL FOR AADC 170 ,}( PITTSBURGH,PA 15227 Statement Date
MARJORIE MCCLAIN "\
824 LISBURN RD APT 301 \v 07/31/2014
CAMP HILL,PA 17011.7103 �(r tv4�"
N� 5. Ilk
Account Number
A,
001988
Amount Due
$1,889.73
PLEASE RETURN TOP PORTION WITH YOUR PAYMENT AND KEEP BOTTOM PORTION FOR YOUR RECORDS
SPARTAN PHARMACY STATEMENT Pa e 1 or 2
3526 BROWNSVILLE ROAD SPARTAN Statement Date Account Number
PITTSBURGH,PA 15227 P H A R 1A A C 't
07/3112014 001988
412.884.5650
DATE Rx NUMBER QTY DESCRIPTION AMOUNT SALES TAX ITEM TOTAL
PATIENT:MARJORIE MCCLAIN
07/01/2014 2106961404 30 Rf#04 Qty=0030 MIRTAZAPINE 15 MG TABLE 7.02 .00 7.02
07/01/2014 2107691100 30 Qty=0030 CITALOPRAM HBR 20 MG TABLET 4.19 .00 4.19
07/01/2014 2107707000 30 Qty=0030 OMEPRAZOLE DR 20 MG CAPSULE 4.75 .00 4.75
07/01/2014 2107707100 30 Qty=0030 FUROSEMIDE 20 MG TABLET 1.61 .00 1.61
07/01/2014 2107707200 120 Qty=0120 DELZICOL DR 400 MG CAPSULE 143.41 .00 143.41
07/01/2014 2107707300 60 Qty=0060 ACETAMINOPHEN 326MG TABLET 2.99 .00 2.99
07/01/2014 2107707400 60 Qty=0060 AMIODARONE HCL 200 MG TAB 7.96 .00 7.96
07/01/2014 2107707500 1 Qty=0001 COMBIVENT RESPIMAT INHAL SP 131.69 .00 131.69
07/01/2014 2107707600 1 Qty=0001 IPRAT-ALBUT 0.5.3(2.5)MG/3 10.00 .00 10.00
07/01/2014 2107707700 60 Qty=0060 METOPROLOL SUCC ER 25 MG TA 25.58 • .00 25.58
07/01/2014 2107707800 527 Qty=0527 POLYETHYLENE GLYCOL 3350 PO 14.88 .00 14.88
07/01/2014 2107707900 10 Qty=0010 NOVOLOG 100U/ML VIAL 92.85 .00 92.85
07/0112014 2107708100 14 Qty=0014 PREDNISONE 5 MG TABLET 2.13 t .00 2.13
07/01/2014 2107708200 60 Qty=0060 SENEXON-S TABLET 5.68 .00 5.68
07/01/2014 2400401300 60 Qty=0060 HYDROCODON-APAP 5-325 9.33 .00 9.33
07/03/2014 2107724500 100 Qty=0100 MONOJECT 1/2 ML SAFETY SYR 30.79 .00 30.79
07/09/2014 2107757100 30 Qty=0030 FUROSEMIDE 40 MG TABLET 2.66 .00 2.66
07/1112014 2107763000 1 Qty=0001 BACITRACIN ZINC OINTMENT 5.68 .00 5.68
07/12/2014 2107440902 30 Rf#02 Qty=0030 CLOPMOGREL 75 MG TABLE 39.36 .00 39.36
07/12/2014 2107596501 30 Rf#0I Qty=0030 VITAMIN D 2,000 UNIT SO 2.99 .00 2.99
07/12/2014 2107763100 60 Qty=0060 AMLODIPINE BESYLATE 5 MG TA 4.66 .00 4.66
07/12/2014 2107777400 14 Qty=0014 AMOX TR-IC CLV 500.125 MG TA 11.58 .00 11.58
07/19/2014 2106577607 90 Rf#07 Qty=0090 HYDRALAZINE 50 MG TABLE 20.30 .00 20.30
07/19/2014 2107638201 30 Rf#01 Qty=0030 ISOSORBIDE MN ER 120 MG 16.09 .00 16.09
07/20/2014 2107828100 8 Qty=0008 FUROSEMIDE 40 MG TABLET 2.03 .00 2.03
07/23/2014 2107848100 30 Qty=0030 PANTOPRAZOLE SOD DR 40 MG T 6.56 .00 6.56
07/24/2014 2107757000 30 Qty=0030 AMIODARONE HCL 200 MG TAB 4.88 .00 4.88
PAYMENT DUE UPON RECEIPT
YTD Medical
Over 30 Over$0 0".'90 over 120 Ear, 0
AMOUNTDUE
Previous sale nee� Charges This Month + Finance Charges e
- Total Charges- - Payments&Cr
e, _
RX4A SPARTAN2 2 V><7 208338GRP 9433 08022014144237 2 44
r
MARJORIE MCCLAIN
Account Number:4264 2960 2402 6674
July 18-August 19, 2014
ocount Information:
ww.aaanetaccess,com Kim= miss=
I
fall billing Inquiries to: New Balance Total........................................................................$125.00
72.04 Previous Balance...........................$118.00
AA Financial Services Current Payment Due.............. ..,,,.......,,,..,,,.... 28,00 Payments and Other Credits....................0.00
,0.Box 982235 Past Due Amount............................................. Purchases and Adjustments..................26.50
1 Paso,TX 79998.2235
Fees Charged..................................................26.00
!ail payments to: Total Minimum Payment Due...........................................................,53,00 Interest Charged...............................................2,54
AA Financial Services Payment..Due...Date. ...... ............................9f 14/14.
.0,Box 15019 New Balance Total $172.04
7Hmington,DE 19886.5019 Late Payment Warning:If we do-not receive your Total Minimum Paymint.by
ustomer Service: the date listed above,you may have to pay a late fee of up to$35.00 end Total Credit Line..........................$19,900.00
800.807.3068 your APRs may be increased up to the Penalty APR of 29.99%. Total Credit Available...................$19,727.96
Total Minimum Payment Warning:If you make only the Total Minimum Cash Credit Line............................$6,000,00
..800.346.3178 TTY) Payment each period,you will pay more in interest and it will take you longer Portion of Credit Available
to pay off your balance. For example: for Cash ..$6,000.00
Statement Closing Date...................8/19/14
Days in Billing Cycle ..................................33
Only the Total 7 months $182.40
Minimum Payment ,��
If you would like information about credit counseling services,call
1-866.300.5238 min=....... ...
i
MEMO=ce
Transaction Posting Reference Account
Date oats Description Numbirr Number Amount Total
Purchases and Adjustments
07/21 07/23 SHEETZ 00005272 MECHANICSBURGPA 431'i 6574 26.50
$26,50.
Fees
08/14 08/14 LATE FEE FOR PAYMENT DUE 08/14 0144 25.00
TOTAL FEES FOR THIS PERIOD $25.00
i
1
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I
I
I
MARJORIE B. MCCLAIN Page: 1 of 4
.;
at&t 824 LISBURN RD APT 301 Bill Cycle Date; 08/12/14•-09/11/14
CAMP HILL, PA 170114103 Account: 464011066902
Visit us online at: www.att.com
Wireless Statement
Previous Balarnee $143 4:6. ;±jt?r J'!2 r nc.)nt
Payment -Thank '( ul' $2869.ZCR :"
Adjustments 5'18.4:0
Add a line today.
i3aEancea t'8t7U.�309.0735 . ...:��tt.cornJaaltoctay o an AT&T store
New.Ch.arlos $:127 92
Requires 20 mo.0%APR eligible+nsiallinenr aprasmenl,rlualified Credit and wireless service
Total Amount Due $�?� �� plan.Tax dile at sale.if wireless sve is cancelled,device balance is due.Neev device
atter i year requires 12 imtaiiments,eligihlo trade-in and reiv purchase.Other charges and
iestriclions apply.Se.att.com/naxt or a store for details.
Amount D.ue:in Full-by, Oct Q6 201:4;
p
v ltern
Service Page Total. No. Description
1. One Time Direct Debit posted 08/27 .143,46CR
A&ouint Charges $46.82 2. Payment posted 09/13 143.46CR
Total Payments 286.92CR
Wireless 581.11)
717 307-8581 $35.21 2 3. Returned Check 09/04 143:46
717 319.0.482 $45.89: 2 Total.Payments.& Adjustments 143.46GFt
Total-New Charges $1:27.92.
....... _._.... ....._................... ..... ._
t Account Charges.
Other Charges and Credits
__....._.....-..._......... ---- ... _ ...... . __.-...._......----
One-Time Charges
Date Descri aeon
1. 08/27 Restoral Fee 40:00
Surcharges and Other Fees
2. Federal;tIrlIversal Service Charge 1.98
3. State Gross Receipts Surcharge 2.20
Total Surcharges and Other Fees 4,1$
Now to'.ctintact Us>
F,'or questions about yo:iir act unt: 1 800.331SQ0
or 611 from your tett phone
For Deaf/Hard of meal rng TTY:1:966 241-6.56T
Visit us online at'W.WWAtt corn_
3�'6"For Important.Information about your bill, please
Ys
section (Page 3�.
see the News You Can Use
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D, TE T 0 PAGE ACCOUNT NUMBER
St Members 1 st Federal Credit Union 11/01/2014 11/30/2014 1 of 2 XXXXXXX417
5000 Louise Drive
P.O.Box 40
Mechanicsburg PA 17055-0040
® (800)237-7288
op-
EMBERS V (717)697-5312(Hearing Impaired) St
FFDERALCREDrr UNION www.memberslst.org VISAO
a
00
gift Card
IB MCCLAIN ESTATE
C/O LIThe perfect gift.
C/0 LINDA M MCGLONE
222 CARMUTH RD
TIMONIUM MD 21093
11037 www.memberslst.Org
CHECKING 21,148.64
SAVINGS 5.00
CERTIFICATES 0.00
LOANS 0.00
00
BEGINNING BALANCE:-_ $25,924.71
Eff. Post
Date Date Description �� Deposits Withdrawals Balance
11/10 11/10 Check 000101 Tracer 0000029902 +A 172.04 25,752.67
11/15 11/15 Deposit by Check 4,210.00 29,962.67
11/17 11/17 Check 000105 Tracer 6932612145 - fie'^"` 0 30.50 29,932.17
Processed Check-02 Central Credi TYPE: CHECKPAYMT ID:
9232470030 DATA: 1
11/18 11/18 Check 000103 Tracer 0000054860 - V-YI-%A SVIOV-t ��S 1"r`�'� 11.00 29,921.17
11/18 11/18 Check 000104 Tracer 0000029908 - Sipe1-r-k-uV% Pwwrm^a c`( 933.90 28,987.27
11/26 11/26 Check 000106 Tracer 0000052036 - LirNd,a 1M-GlwA, ( SA+M 5 c Lwb) r X79 28,942.48
11/26 11/26 Check 000107 Tracer 0000052035 - �� QASCtk✓Cfwi11S ooas orJ� 205-50 28,736.98
11/26 11/26 Check 000108 Tracer 0000052b34 - t^�^c.^ 1A`6rtvvA- (5*g 1,589.42 27,147.56
11/26 11/26 Check 000111 Tracer 0000041108 �`S s��-r W`its 6,000.00 21,147.56
11/30 11/30 Deposit Dividend 0.050% 1.,08 - 21,_148.64
Annual Percentage Yield Earned 0.050%from 11/01/14 through
11/30/14
ENDING BALANCE: $21,148.64
Check# Date Amount Check# Date Amount Check# Date Amount
101 11/10 172.04 103* 11/18 11.00 104 11/18 933.90
105 11/17 30.50 106 11/26 44.79 107 11/26 205.50
108 11/26 1,589.42 111* 11/26 6,000.00
* Indicates check out of sequence 8 Checks Cleared for 8,987.15
Total Deposits 4,211.08 Average Daily Balance 26,319.31
TotalWithdrawals. 8,987.15
REV-1513 EX+(02-15)
pennsylvania SCHEDULE ]
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Marjorie B. McClain
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(5)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, Thom McClain Son $500.00
2. Linda McGlone Daughter 100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, $
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