HomeMy WebLinkAbout05-26-15 (2) REV-1500 EX(01-10) 1505610143
PA Department of Revenue � OFFICIAL USE ONLY
p pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOx.280601 INHERITANCE TAX RETURN 2 1 15 00005
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
12 04 2014 10 29 1930
Decedent's Last Name Suffix Decedent's First Name MI
FRAZER MIRIAM L
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return 0 2. Supplemental Return 0 3.Remainder Return(date of death
prior to 12-13-82)
0 4. Limited Estate 0 4a,Future Interest Compromise 0 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
6, Decedent Died restate 7, Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
® (Attach Copy of Will) (Attach Copy of Trust)
0 9. Litigation Proceeds Received 10.Spousal Poverty Credit(date of death 11.Election to tax under Sec.9113(A)
between 12-31 l and 1-1-95) (Attach SCh.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
SAMUEL L ANDES 717 761 5361
REGISTER OF WILLS-'SE ONLY
C-) �:,- ::0 til
C O I t n
First line of address 3: ::Ij =3 o
Co
525 NORTH 12TH STREET 71 C>
-n ry I f
Second line of address ' t
C
DATE-FILED-3 =
City or Post Office State ZIP Code
LEMOYNE PA 17043 I
cn �
cv
Correspondent's e-mail address: SamuelAndes168@gmail.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAJURE OF PER N RE ONSIBLE FOR FILING RETURN TE
Gary L. Frazer
A DRESS /
1805 Letchworth Drive, Camp Hill, PA 17011
SIGNA PREPAR HER THAN REP E AT E DATE
Samuel L Andes 1
ADDR
525 North 12th Street, Lemoyne, PA 17043
Side 1
L 1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: FRAZER, MIRIAM L.
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................... 2. 4 , 294 . 68
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4. .
5• Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 17 , 374 . 87
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7. 34 , 474 . 78
8. Total Gross Assets(total Lines 1-7)....................................................................... 8. 56 , 144 . 33
9. Funeral Expenses&Administrative Costs(Schedule H)......................................... 9. 11 , 807 . 18
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)................................ 10. 783 . 77
11. Total Deductions(total Lines 9&10)...................................................................... 11. 12 , 590 . 95
12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 43 , 553 . 38
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. 43 , 553 . 38
TAX COMPUTATION-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.00 15.
16. Amount of Line 14 taxable
at lineal rate x .045 43 , 553 . 38 16. 11 959 . 90
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due..................................................................................................................... 19. 1 , 959 . 90
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
1505610243 1505610243
1
REV-1500 EX Page 3 File Number 21 - 15 - 00005
Decedent's Complete Address:
DECEDENT'S NAME
Frazer, Miriam L.
STREET ADDRESS
1055-H Allendale Road
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 1,959.90
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 1,959.90
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;........................................... O
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest;or..................................................................................................................
d. receive the promise for life of either payments,benefits or care?..............................................................
2. If death occurred after December 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?.........
4. Did decedent own an Individual Retirement Account,annuity,or other non-probate property which ❑
contains a beneficiary designation?......................................................................................................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent 172 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 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 reM are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
•The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
•The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116 1.2)[72 P.S.§9116(a)(1)].
•The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.&&9116((a)(1.3). A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wfiether by blood or adoption.
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Frazer, Miriam L. FILE NUMBER21 - 15-00005
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
8 34 shares of Prudential Financial, Inc. at$86.75 per share 86.75 2,949.50
9 11 U.S. Savings Bonds, Series EE, cashed-in in January, 2015 1,142.38
10 2 additional U.S. Savings Bonds, Series EE, cashed-in in March of 2015(no 202.80
statement from bank to confirm this transaction is available because they
were cashed-in directly with the federal agency and the proceeds were
deposited directly into the estate account, as confirmed by the attached
statement from the estate account)
TOTAL(Also enter on line 2,Recapitulation) 4,294.68
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH PENNSYLVANIAOF PERSONAL PROPERTY
INHERITANCE
RETURN TAX RETURN
RESIDENT DECEDENT
ESTATE OF Frazer, Miriam L. FILE NUMBER21 - 15-00005
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
8 Checking Account No. 34150668 with M&T Bank 12,488.11
9 Savings Account No. 15004220287179 with M&T Bank 4,486.76
10 Miscellaneous items of clothing and personal effects 400.00
TOTAL(Also enter on Line 5, Recapitulation) 17,374.87
COMMONWEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Frazer, Miriam L. FILE NUMBER
21 - 15-00005
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF EXCLUSION
NUMBER Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S (IF APPLICABLE) TAXABLE VALUE
and the date of transfer. Attach a copy of the deed for real estate. INTEREST
1 Individual Retirement Account with M&T Bank(date of 19,317.37 100% 19,317.37
death value)
2 Highmark VIP 401(k) plan account, date of death 15,157.41 100% 15,157.41
value
TOTAL(Also enter on line 7,Recapitulation) 34,474.78
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNEf��GISS&
INHERITANCE TAX RETURN ADMINUMTNE CC67S
RESIDENT DECEDENT w�v
ESTATE OF Frazer, Miriam L. FILE NUMBER21 - 15-00005
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES:
A 1 Musselman's Funeral Home 9,035.00
2 Fee paid to minister for funeral service 100.00
3 Brewhouse(reception after funeral) 673.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Years)Commission paid
2. Attorneys Fees Samuel L.Andes 1,500.00
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 Register of Wills 190.50
5. Accountant's Fees
6. Tax Return Preparer's Fees Richard S. Simpson, II, CPA(2014 income tax return) 75.00
7. Other Administrative Costs
8 Cumberland Law Journal (advertising) 75.00
TOTAL(Also enter on line 9, Recapitulation) 11,807.18
C Schedule H p
COMMONWEALTH OF PENNSYLVANIA /w����Mr�,,�`e M//++��,,,�/� «
INHERITANCE TAX RETURN A I UI is IaM VWI7 continued
RESIDENT DECEDENT
ESTATE OF Frazer, Miriam L. FILE NUMBER
21 - 15-00005
9 The Sentinel (advertising) 158.68
Page 2 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES LIENS
INHERITANCE TAX RETURN ,
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Frazer, Miriam L. 21 - 15-00005
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
8 Holy Spirit Medical Group-medical bill 136.77
9 Meadow Wood Apartments-final rent payment 622.00
10 First Choice Hairdresser 25.00
TOTAL(Also enter on Line 10,Recapitulation) 783,77
i
i
REV-1513 EX+(11-08)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA B E N E F ICIARI E S
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Frazer, Miriam L.
21 - 15-00005
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not ust Trustee(s)
ITAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
1 Gary L. Frazer Son one-third
1805 Letchworth Drive
Camp Hill, PA 17011
2 Barbara Mirarchi daughter one-third
1146 Hedgerow Lane
Harrisburg, PA 17111
3 Sharon Saytar daughter one-third
101 Sgrignoli Lane
Enola, PA 17025
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
� NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
WILL
OF
MIRIAM L. FRAZER
1, MIRIAM L. FRAZER, of the Borough of Lemoyne, Cumberland County,
ennsylvania, declare this to be my last will and revoke any will previously
ade by me.
Item I. I direct that all my just debts and funeral expenses, including
Y
gravemarker and all expenses of my last illness, and any and all taxes and
ssessments imposed by any governmental body as the result of my death,
hether on property passing under this will or otherwise, shall be paid from
y residuary estate as soon as practicable after my decease as a part of the
xpense of the administration of my estate.
Item II. I give, devise, and bequeath all my possessions and estate of
very nature and wherever situate to be divided equally among my three children,
ARBARA JEAN MIRARCHI of Verona, Virginia, GARY L. FRAZER of Camp Hill, Pennsyl-
ania, and SHARON E. FRAZER of Lemoyne, Pennsylvania, provided each shall
urvive my death by sixty ( 60 ) days.
Should my daughter, Barbara Jean*Mirar'chi predecease me,.or
e deceased on the sixty-first day following my death, I devise and bequeath
er share under this Item II of this my last will to such of her issue, per
tirpes, as shall survive my death by sixty ( 60 ) days and, in the event that
he leaves no issue so surviving my death, I devise and bequeath her share
nder this Item II of this my last will to the other persons taking under this
tem.
Miriam L. Frazer
197,7
1
Page 1 of 5 Pages f
s
Should my son, Gary L. Frazer, predecease me or be deceased
the sixty-first day following my death, I devise and bequeath his share
der this Item II of this my last will to be divided equally between
Ii
DNEY MUMMA and RANDY MUMMA, provided that each shall survive my death by
xty ( 60 ) days and, in the event that one of them shall not so survive my
ath, I devise his share under this Item II of this my last will to the
rvivor and, in the event that neither of them shall survive my death by
xty ( 60 ) days, I devise and bequeath the share of my son, Gary L. Frazer,
der this Item II of this my last will to the other persons taking under
is Item.
Should my daughter, Sharon E. Frazer, predecease me or be
ceased on the sixty-first day following my death, I devise and bequeath
r share under this Item II of this my last will to such of her issue, per
irpes, as survive my death by sixty ( 60 ) days and, in the event that she
all leave no issue so surviving me, I devise her share to the other persons
king under this Item.
Item III. Should any person entitled to a share of my estate under this
mV last will not have attained the age of twenty-one years at the time for
stribution to him or her, I devise and bequeath the share of each such person
ib my hereinafter named trustee, IN SEPARATE TRUSTS, to hold, manage, invest,
d re-invest the shares so received, and the accumulation of income thereon,
d to use and apply from time to time such portion of income and principal
thereon as my trustee may deem proper for the comfortable support, maintenance
d education of the said person, without regard to his or her parent's ability
provide such support or education, or to make payment for those purposes,
thout further responsibility, directly to such person or to such person's
rents or to any person taking care of such person. Any principal or income
Miriam L. Frazer 0
If 197
f'
Page 2 of 5 Pages
of so applied shall be distributed to such person when he or she attains
e age of twenty-one years, or, if he or she dies prior thereto, to his or
ersonal representative.
Item IV. I appoint the DAUPHIN DEPOSIT BANK AND TRUST COMPANY of
emoyne, Pennsylvania, trustee of the trust or trusts created by this my
at will. In addition to the other powers and authorities granted to my
ustee by Pennsylvania law and by the preceding paragraph of this my last
ill, I hereby give it the following special powers and authorities:
A. To retain any or all of the assets of my estate,
real or personal, without any regard to any principle of
diversification, risk, or productivity.
B. To invest and re-invest in all forms of property
without restriction to investments authorized for Pennsylvania
Fiduciaries, as it deems proper, without regard to any principle
of diverisfication, risk, or productivity.
C. To sell at public or private sale, to exchange or to
lease, for any period of time, any real or personal property
and to give options for sales, exchanges, or leases, for such
prices and upon such terms or conditions as it deems proper and
in the best interests of the beneficiary or beneficiaries of said
trusts.
D. To allocate receipts and expenses to principal or income
or partly to each as my trustee from time to time deems proper
and in the best interests of the beneficiary or beneficiaries of
said trusts.
E. To allocate receipts and expenses to principal or income
or partly to each as my trustee may from time to time deems proper
in its sole discretion.
�'. ;
Miriam L. Frazerfin--
Page 3 of 5 Pages
F. To exercise any option, right, or privilege granted
in insurance policies or in other investments.
G. My trustee may accumulate the Income from this trust
during the term thereof but may, from time to time, distribute
from current income or from accumulated income or from
principal such amounts as my trustee, in its sole discretion,
deems advisable for the education, welfare, and comfort of the
trust beneficiary.
Item V. I appoint my son, GARY L. FRAZER, executor of this my last will.
Phould my son, Gary L. Frazer, predecease me or otherwise fail to qualify
r
)r cease to serve as executor, I appoint my daughter, SHARON E. FRAZER,
?xecutrix of this my last will.
Item VI. I direct that my personal representatives, as well as their
:uccessors, shall not be required to give bond for the faithful performance
if their duties in this or any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this day. of
1111YLq-11 , 1977.
Miriam L. Frazer U
lg_Z,7
Page 4 of 5 Pages
The preceding instrument, consisting of this and four other typewritten
I ges, each identified by the signature of the testatrix, was on the date
ftereof signed, published and declared by Miriam L. Frazer, the testatrix
iberein named, as and for her last will, in the prsence of us, who at her
i quest, in her presence, and in the presence of each other, have subscribed
names as witnesses hereto.
Miriam L. Frazer Q
19 27
Page 5 of 5 Pages
• IN IN 111111111111111HE111111111111111HE111111111111
Prudential �,omputershare
Computershare
PO Box 30170
College Station,TX 77842-3170
Within USA,US territories 8 Canada 800 305 9404
Outside USA,US territories b Canada 732 512 3782
000600 www.computershare.conifinvestor
IItII��hli1fi1��111III�I11�rIlI�tI�IrI�IIIIIIIIII�llllu�ll�r
Gary Frazer
1805 letchworth drive
camp hill
PA
UNITED STATES 17011
Date 17 Dec 2014
Re: MIRIAM L FRAZER
Company Name:Prudential Financial,Inc. Account Number;**"****86.49
`DRS book-entry share ,34s ***Closing Price per Share as of 17 Dec 2014:$86.75
**Certificated Shares:0 AT.
Dear Sir or Madam:
Thank you for notifying us that the owner of the Prudential Financial stock account noted above has passed away.On behalf of Prudential and myself,I would
like to express my sincerest condolences for your loss.
I understand that this is a difficult time and the process of transferring the assets of a loved one who has passed away can seem overwhelming at times.We want
to help in any way possible and have enclosed the forms you will need to transfer the Prudential shares to a new owner.We have also included detailed
instructions,as well as a set of Frequently Asked Questions,to guide you through the process.I hope this information will be helpful as you make decisions
regarding this account.
Most of Prudential's registered shareholders received their shares as a result of Prudential's demutualization in December 2001.Although some individuals were
given shares as a result of their policy ownership;the shares are completely separate from the policy and they must be transferred to a new owner,even if you
have already claimed the policy benefits.
We understand that,in some situations,the new owner may wish to sell the shares as soon as the transfer is completed.If the new owner wishes to sell through
Computershare,it offers a voluntary sales facility for eligible shareholders to conveniently liquidate their shares.A copy of the terms of this sales facility will be
enclosed with the new account statement that will be mailed once the transfer is completed.Once the transfer is complete and the new account materials are
received,shareholders wishing to sell their shares may do so by contacting Computershare directly at the number contained within those materials.
Please do not hesitate to contact us if we can be of any help to you during this difficult time. If you have any questions regarding the transfer process,please call
800-305-9404 and select menu option 4.After the automated message,you may then press 2 to reach a Computershare representative for assistance.
Again,please accept our sincere condolences.
Sincerely,
f�'IIGl. rAl;b /'Yl
Margaret M.Foran
'hief Governance Officer,
Ace President and Corporate Secretary
DRS book-entry shares-a recordkeeping option for you to record your ownership electronically on the books of the company.
"Shares for which a physical stock certificate has been issued.
"Account value subject to market fluctuation.
001 CS0003.d.fmix.051246 5079/000600/002996 01DAVA
f omputershare
HOW to Complete this Form Seethe enclosed Frequently Asked.Questions(FAQs),for more information
The enclosed Transfer Request form is required to transfer the shares of stock to a new owner. The remaining instructions and FAQs are included to
provide additional information that you may find helpful.
Online Option:The online Computershare Transfer Wizard can walk you through the transfer process and allows you to print the completed transfer
forms.All you need is the 11-character account number(e.g.,C1234567890)which is found on account statements or dividend checks.Please visit
Computershare's secure website,www.transfermystock.com,for an easy and automated tool to help get your transfer on its way.
If you prefer to use the enclosed form,the following steps will assist you in simplifying the process:
Step 1: Complete the Transfer Request Form
The instructions following the Transfer Request form provide information on which sections you need to complete.You will also find a FAQ sheet that
provides answers to commonly asked questions.If you are transferring to more than one new owner,simply make a copy of the New Holder/Recipient
Information page of the Transfer Request form and complete one form for each new owner.
Step 2: Stock Certificates
You only need to complete this step if the attached letter shows there are shares in certificate form for this account. If so, please return the original stock
certificates for any shares that you with to transfer,along with the completed Transfer Request form.When mailing stock certificates,we recommend that
you use registered or certified mail,or some other trackable delivery method such as overnight express mail.
If you cannot locate the certificate,you will first have to replace the certificate by paying for replacement insurance and processing.Please call us at
800-305-9404,select option 4 and then option 2 to discuss your situation and get information about next steps.
Step 3: IRS Form W-9—Certifying Your Tax Identification Number
The new owner should sign and date section 9 of the Transfer Request form to certify the tax identification number for the new account. If the new owner is
unable to provide tax certification at this time,we will send a Form W-9(Request for Taxpayer Identification Number and Certification)once the transfer is
processed.Note that Computershare is required to withhold taxes from dividend or sales checks, or other payments,until the appropriate tax certification is
received in good order.
Step 4: State Tax Agency Requirements
Depending upon the decedent's state of legal residence,you will need to fulfill one of the following requirements:
1) Inheritance Tax Waiver Form: Less than half of US states require an inheritance tax waiver form.These states are listed in the FAQs found in
this package. If the decedent's state of residence(as of date of death)is on this list,you will need to contact that state to obtain the required
inheritance tax waiver form.
2) Affidavit of Domicile: If the decedent's state of residence(as of date of death)is not listed,then all you will need to complete is the enclosed
Affidavit of Domicile.Remember to have the Affidavit notarized by a valid Notary Public official.Note: If the state is not listed, but your financial
institution is willing to affix their Inheritance Tax Waiver stamp next to the authorized signature on the Transfer Request form,you will not need to
complete the Affidavit of Domicile.
Step 5: Sign the Form and Obtain Medallion Signature Guarantee from your financial institution
All surviving registered holders(if applicable),or a legally authorized representative,must sign section 7 of this form and obtain a Medallion Signature
Guarantee.The authorized representative must indicate his or her capacity next to the signature on the form(e.g.,John Smith,Executor).Please check
with your bank or financial institution concerning the requirements and process for signing and obtaining the Medallion Signature Guarantee Stamp.Note:If
the value of the shares you are transferring exceeds$14 million,please contact us for additional requirements.
Step 6: Send the completed forms to Computershare as follows:
Regular,Certified or Registered Mail: Overnight Mail:
Computershare Computershare
P.O.Box 43033 250 Royall Street
Providence,RI 02940-3033 Canton,MA 02021
It is important that you follow the steps above to ensure that the transfer can be completed as requested. Please submit only the requested documents,
and please note that we are unable to return documents that are submitted.
A statement will be sent to the new owner upon completion of the transfer. Please note that the statement of holdings cannot be sent to a third party.If
your transfer cannot be processed due to missing or incomplete documentation,we will contact you in writing for more information.
otDBon
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SHARON E SAYTAR 179-44-8934 Redemption Date: 01/17/2015
101SGRIGNOLI LANE
ENOLA PA 17025-0000 Transaction Number: 6113017974
Serial Number Series Denom Issue Issue Price Interest Earned Redemption
Date Value
030369341352 EE $50.00 03/ 1988 $25.00 $65.26 $90.26
030408598702 EE $50.00 12/ 1988 $25:00 $63.50 $88.50
Total Total Total
Price Interest Value
Total number of bonds redeemed: 2
�+
Highland Park Office
344 South 10th Street
Lemoyne, PA 17043
(717)737-3322
40
Savings Bond. Rp icon +moi
U.S. � B
b:•
pt
SHARON E SAYTAR 179-44-8934 Redemption Date: 01/15/2015
101 SGRIGNOLI LANE
ENOLA PA 17025-0000 Transaction Number: 6113015973
Serial Number Series Denom Issue Issue Price Interest Earned Redemption
Date. Value
00435673469 EE $50.00 10/ 1989 $25.00 $60.06 $85.06,
0281100243 EE $50.00 09/ 1986 $25.00 $81.54 $106.54
0338735919 EE $50.00 06/ 1987 $25.00 $68.90 $93.90
107695324 EE $50.00 11 / 1982 $25.00 $115.16 $140.16
133905074 EE $50.00 08/ 1983 $25.00 $90.32 $115.32
161773694 EE $50.00 05/ 1984 $25.00 $90.32 $115.32
188451216 EE $50.00 03/ 1985 $25.00 $88.06 $113.06
222730559 EE $50.00 12/ 1985 $25.00 $85.84 .$110.84
50471798318 EE $50.00 07/ 1990 $25.00 $58.40 $83.40
Total Total Total
Price Interest Value
jj
_x Wwl'!RIM
Total number of bonds redeemed: 9
s
Highland Park Office
344 South 10th Street
Lemoyne, PA 17043
(717) 737-3322
FOR INQUIRIES CALL: (800)724-2440
ACCOUNT TYPE
MYCHOICE PLUS CHECKING
00 0 06113M NM 017
ACCOUNT NUMBER STATEMENT PERIOD
000004282 FIDS1549D01704071504 02 000000
P 9864255964 MAR.07-APR.07,2015
z
ESTATE OF MIRIAM L FRAZER BEGINNING BALANCE _ $8,410.16
�.
s GARY L FRAZER,ADMIN DEPOSITS&CREDITS 207.75
1805 LETCHWORTH DR LESS CHECKS&DEBITS 79.95
CAMP HILL PA 17011-5934 LESS SERVICE c4mt es 0.00
tC3Nt3;.�tA1 AICIr $8,537.96
INTEREST EARNED FOR STATEMENT PERIOD $0.00 HIGHLAND PARK
ACCOUNT SUMMARY
BEGINNING DEPOSITS&OTHER CHECKS PAID OTHER DEBITS(-) CURRENT ENDING
BALANCE CREDITS + INTEREST PD BALANCE
NO. I AMOUNT NO. F AMOUNT NO. AMOUNT
$8,410.16 2 1 $207.75 1 $75.00 1 $4.95 $0.00 $8,537.96
ACCOUNT ACTIVITY
POSTING TRANSACTION DESCRIPTION DEPOSITS&OTHER WITHDRAWALS& DAILY
DATE CREDITS W OTHER DEBITS BALANCE
03/07/2015 BEGINNING BALANCE $8,410.16
03/18/2015 APA TREAS 310 MISC PAY, ; $202.80 8,612.96
03/25/2015 CHECK NUMBER 0106 $75.00 8,537.96
04/07/2015 WAIVE ADD-ON FEE:CHKS/SAFE DEPOSIT BOX 4.95
04/07/2015 M&T ADD-ON FEE:CHKS/SAFE DEPOSIT BOX 4.95 8,537.96
ENDING BALANCE $8,537.96
CHECKS PAID SUMMARY
CHECK NO. DATE AMOUNT CHECK NO. DATE AMOUNT CHECK NO. DATE AMOUNT
106 03/25/15 75.00
WHEN WAS YOUR LAST MORTGAGE CHECK-UP?WHETHER YOU OWN A HOME OR ARE THINKING
ABOUT BUYING ONE, NOW IS A GOOD TIME TO TALK TO AN M&T MORTGAGE EXPERT ABOUT
YOUR HOME FINANCING NEEDS.CALL 1-888-253-1023 TODAY.
2015 M&T BANK. NMLS#381076.ALL LOANS SUBJECT TO CREDIT AND PROPERTY APPROVAL.
THIS IS NOT A COMMITMENT TO MAKE A MORTGAGE LOAN.OTHER TERMS AND CONDITIONS MAY
APPLY.
PAGE 1 OF 1
.008(6/12)
f
M&T Bank
NOV.22-DEC.19:2014
00 0 06113M NM 017
000000 P
MIRIAM L FRAZER
1055 H ALLENDALE RD
MECHANICSBURG PA 17055
SELECTED ACCOUNT SUMMARY
. ... ... ... ............... IIT Sl:EI!i#21 :.. ..:.:::.. :
-:::::#k1ETl�•._:::. .-:::::::-.f#ALhIIICE:=::;:�: :�>
M&T SELECT WITH INTEREST 000000034150668 2.00 12,488.21
RELATIONSHIP SAVINGS 015004220287179 0.90 4,486.76
TOTAL DEPOSITS 16 974.97
M&T SELECT WITH INTEREST MIRIAM L FRAZER
ACCOUNT NO. 34150668 HIGHLAND PARK
INTEREST EARNED FOR STATEMENT PERIOD $0.09
ACCOUNT SUMMARY
!? 'SITS: ;: : : z:>::::>::::>:.:::::;;;;;::»::-
;::;: ..d__._.&tk7H............ ._..::..:..
49
....:
-444 4 <.> ;:.: :.:>;:;;:•::.; <.;.>;:;.:;-;:.�:: :.: ;<.:::<.:•.> :<.::.:.::;:;.:::<;;.:•:;::.:;;.::.:>;<:::.;>•:::,..:.::. aN'iF'I�ST'Pia- ..:::: .NIDE...�•:
NO. AMOUNT NO. AMOUNT O AMOUNT
$12,880.86 1 $1343.00 5 $1,675.96 2 1 $59.791 $0,10T $12,488.21
ACCOUNT ACTIVITY
po
::::: 1!ls^iIIC13i3N::D) tl It+f::;_:......:_::> ... ..... :... ;. . ::.. ::::• ::..:. ::. ::.:.-MAW
.:.:.. .. ... ..:::::.:.
:::::::zCt2FAI ::: ::::::
:..... .:....:z:>s;::: >:;:> :;::::;:::;::=>:::>: :::>:: <>; :»::.::::>»:::s»>;:< >z :::;:. :: #T#1
�t.131i7&: 13AAi5hl:E=:< :z:
11/22/2014 BEGINNING BALANCE $12,880.86
11/24/2014 CHECK NUMBER 6403 $50.00 12,830.86
11/25/2014 CHECK NUMBER 6404 50.00 12,780.86
12/02/2014 LibertyMutuallns INSPayment 000000000006406 34.00
12/02/2014 VERIZON FINANCIA PAYMENTS 000000000006407 25.79 12,721.07
12/03/2014 SSA TREAS 310 XXSOC SEC $1,343.00
12103/2014 CHECK NUMBER 6405 400.00
12/03/2014 CHECK NUMBER 6409 135.96
12/03/2014 CHECK NUMBER 6410 1,040.00 12,488.11
12/19/2014 INTEREST PAYMENT 0.10 12,488.21
ENDING BALANCE $12,488.21
PAGE 1 OF 2
M&T Bank
NOV.22-DEC.19,2014
MIRIAM L FRAZER
CHECKS PAID SUMMARY
>;...........................::........,......... :.. ...,..... ..-...........:... ... :.........::::::: :::::::....::...:...:.:.::. --. ...... . . .. ......: - . ::::::................
.
_ ........_....AMC)UNT::::: >:::C�i�:N.t3:::::�:;:�:�1A7�:��:>::::<:::>:;::: :�:}kihl NT::: :•>::1ii --Ad s:::-:>:-13X:. ::�:<_::::>:s:�>:->:�<:::iditlil011
6403 11/24/14 50.00 6404 11/25/14 50.00 6405 12/03/14 400.00
6409' 12/03/14 135.96 6410 12/03/14 1,040.00
ANNUAL PERCENTAGE YIELD EARNED=0.00%
APPLE PAY IS HERE!
PAY FOR PURCHASES WITH A SINGLE TOUCH AT THOUSANDS OF STORES NATIONWIDE.ADD
YOUR M&T CREDIT AND DEBIT CARDS TO APPLE PAY TODAYI LEARN MORE AT
MTB.COM/DIGITALWALLET.
RELATIONSHIP SAVINGS = ��! :: MIRIAM L FRAZER
ACCOUNT NO. 15004220287179 MECHANICSBURG
INTEREST EARNED FOR STATEMENT PERIOD $0.06
ACCOUNT SUMMARY
I.
?s» DEi�OS 113 OTHER < :=>: s ?:>fNFr.HD AW i . .:8=:=:=«>:i::: ::>::::::: :: #I EI+1 ......... ..
�3'> >> = >: ;<:;>: . z:: ::::::::: ::?1~fi4hU4N
..... ..L3A�GiAAI�' ..CR>rt>•ITS::�<::::: �>�::�::;: ::: �:�0' 'b`:::: TERI~$�'. ..
NO. AMOUNT NO. AMOUNT
$4,486.69 0 $0.00 0 $0.00 $0.07 $4,486.76
ACCOUNT ACTIVITY
S
>::
::.;;:; .•. . :-:�:;:<=>:-;:::::;::;;-:.;::::.>:>;:<-:� 1!1^.aA4:`l cil�:.Ci��E�tIl�1:t(?�f:::;:->;;;;:-:»:<.:::•::;::-:-:� .... >;:::-:;.;.,;: .- . . ....::.:•.;;:-:::.: - : »:-:_:-:«:
:.:_:;<DhTE:.:;_:� <-::; ::•>:•;:;-::-:-:: ;:»:-:;:-:;;:;:;:;->:;-:»:::.::::.::..::;:;;.::<-:;:�;:�::;:::-:<.:;:>;::;-::�;:;;;::<;;:-;:-�: :;:;-:;:CftlWflt:3� -..:;-::;:.::•;�k'�'19th:�3r�'�8: . ::::;.::�.�::EtA#�N!DE.::�::.::•.
11/22/2014 BEGINNING BALANCE $4,486.69
12/19/2014 INTEREST PAYMENT ;$0.07 '4,486.76
ENDING BALANCE $4,486.76
ANNUAL PERCENTAGE YIELD EARNED=0.01%
PAGE 2 OF 2
Retirement Plan Stateme-n:
;# . .
01-01-14 to 12-31-14 !21
INDIVIDUAL RETIREMENT ACCOUNT M&T
TELEPHONE BANKING CTR
M&T BANK AS TRUSTEE FOR PO BOX 767
BUFFALO, NY 14240
800-829-1924
Yr 6113 26,586
MIRIAM L FRAZER
1055 H ALLENDALE RD
MECHANICSBURG PA 17055
16-0538020
ACCRUED INTEREST AS OF 12-31-14 0. 11
m
a
N
O
O
O
O
H
O
m
O
O
1
F
H
N
m
K
C
LL
N
O
N
O
m
•
5
e
a
PLAN SUMMARY
BEGIN PLAN BAL 20,551 .81 DISBURSEMENTS 1 ,247.40
PLUS DEPOSITS . 00 FED TAX WITHHELD .00
NET INTEREST 42. 30 ST TAX WITHHELD . 00
LESS DEDUCTIONS 1 ,247.40
TOTAL PLAN VALUE 19, 346 . 71
2014 IRA CONTRIBUTION INFORMATION
THIS INFORMATION IS BEING FURNISHED TO
THE INTERNAL REVENUE SERVICE
BOX 1 - IRA CONTRIBUTIONS IN 2014 OR 2015 FOR 2014 0 . 00
BOX 2 - 2014 ROLLOVER CONTRIBUTIONS 0 . 00
BOX 5 - FAIR MARKET VALUE OF PLAN AT END OF 2014 19,346 .82
BOX 7 - IRA
BOX 12A - REQUIRED MINIMUM DISTRIBUTION BY 12-31-15
BOX 12B - REQUIRED MINIMUM DISTRIBUTION AMOUNT 1 , 307.21
X007(11/14) i
Retirement Plan Staternw,
01-01-14 to 12-31-14 1
INDIVIDUAL RETIREMENT ACCOUNT M&T
TELEPHONE BANKING CTR
M&T BANK AS TRUSTEE FOR PO BOX 767
BUFFALO, NY 14240
000010062 JOB11580 800-829-1924
6113 26,585
MIRIAM L FRAZER
1055 H ALLENDALE RD
MECHANICSBURG PA 17055
16-0538020
ACCOUNT NO 35-004110093967 ACCOUNT TYPE SELECT —18MO RATE 0 .200
MATURING 10-03-15 REGULAR IRA
01-01-14 BEGINNING BALANCE 20,551 .81
01-03-14 PAYOUT DISTRIBUTION 113.40— 20,438.41
g 02-05-14 PAYOUT DISTRIBUTION 113.40— 20,325.01
03-05-14 PAYOUT DISTRIBUTION 113.40— 20,211 .61
04-03-14 INTEREST 12. 96 20,224.57
04-03-14 ACCOUNT RENEWED
04-04-14 PAYOUT DISTRIBUTION 113.40— 20, 111 . 17
05-05-14 PAYOUT DISTRIBUTION 113.40— 19,997. 77
N 06-05-14 PAYOUT DISTRIBUTION 113.40— 19,884 .37
07-03-14 PAYOUT DISTRIBUTION 113.40— 19, 770 . 97
LL 08-05-14 PAYOUT DISTRIBUTION 113.40— 19,657.57
s 09-05-14 PAYOUT DISTRIBUTION 113.40— 19,544. 17
10-0.3-14 PAYOUT DISTRIBUTION 113.40— 19,430 . 77
11=05=-1?4 IP.,;AYOUT,c. DI,S:TR!BU,TjON` 113.40— 1,9-,317.P37�.
12-05-14 PAYOUT DISTRIBUTION 113.40— 19;20397r
12-05-14 PAYOUT DISTRIBUTION 113.40 19, 317. 37
12-31-14 INTEREST 29. 34 19,346 . 71
yY
"J
*** CONTINUED NEXT FORM ***
L007(ivia)
KI;11K1✓1V1bIV 1 lil;lv!✓r 11 11v r uK1Vlf',11uN
Statement
� !IGHMMK.
October 1,2014-December 31,2014
>00001 5021604 001 092036 651742
MIRIAM L FRAZER
1055 H ALLENDALE RD
APT H
MECHANICSBURG PA 170554458 Status: TERMINATED
Account Information
The IRS has increased the annual 401(k)plan contribution limits for 2015.You may now contribute up to$18,000 for the year.If you
will be age 50 or older during 2015,you can also contribute an additional$6,000,for a total of$24,000.To increase your contributions,
log in to your plan website and click on the plan name in the"What do I have?"box.Then select"Change your contributions"in the
Quick Links box on the right.
MY BALANCE
Begihn,ng iBa[an�ce r,13149
Change This Period -$974.08
�ding l3alar, a $15;WIr
Vested Balance $15,157.41
PERSONALIZED RATE OF RETURN
Statement Period 0.34%
Year To Date 1.29%
12 Months 1.29%
3 Years 1.66%
MY CONTRIBUTION SUMMARY
C
antribud Vested:...:. >: Vested 1�1"erra
This Pers 04:. Percent Bal
atiice Percent
_. .:. , :..... 1213014,
'ost 86 After Tax $0.00 100% $2,977.53 N/A
imployer Match $0.00 100% $6,216.32 N/A
're-87 After-Tax $0.00 100% $5,963.56 N/A
I'OT L515 41.
our total after tax contributions to date are$0.00
ease verify this financial information and call your plan's toll-free number with any questions within 30 days of receipt. If we do not hear from you,we
ill assume?the information on this statement is correct. Any corrections will be reflected on a subsequent statement.
PAGE 1 OF 2
For information visit us on the web at
I Iflllll IIIIIIIII II��I III I��I www.myhighmark.net or call
1-855-694-4446
1021 00001 5021604 000002 000002 00001/00001
Account Information
October 1,2014-December 31,2014 MIRIAM L FRAZER
MY ACTIVITY SUMMARY
Begilp ingContrgirutwins. VviithJ14 4114 hanged DMdendsf. Etttlirig
Balance '` and O@ir and Oitlter Transfers !=a#ningsl Balace'
credits- � t?ebtts Gatnl�.oss ;;
BlackRock LifePath Index RET $0.48 $0.00 $0.04 $0.00 $0.00 $0.44
Van Shrt Trm Bnd Ind Inst Plus $16,131.01 $0.00 $1,030.92 $0.00 $56.88 $15,156.97
�3 tai Clotkv'
Period-To-Date $16,131.49 $0.00 $1,030.96 $0.00 $56.88 $15,157.41
Have you named a beneficiary?Your beneficiary is the person who will inherit your retirement plan account,so it's important that this information is on
file and up to date.Be sure to name a beneficiary for each plan you participate in.
ADMIN&PLAN EXPENSES
All or a portion o the plan'sadministrative expenses may have been id
so a a exp paid E610etfses Paid from the annual operating expenses of the plans investment options.
" Administrative expenses include preparation and distribution of plan
information materials,and recordkeeping,legal,and accounting services.
TOTAL _ To the extent your account was charged for a portion of these expenses or
any individual transaction fees during this quarter,they are reflected here.
MY INVESTMENT SUMMARY
B_ nnin. Itndi- Btitd�nhdin
eintrtg -lit
share Price Share Balance Market Value.. share Perim Share Balance Market Wks
_...... _ .. ..._...:. . _ :._.. :..: _._. ...._ ..: ?AZ44:010103�t .01.4. . .. _.: �3313a1}. g133af10�t
BlackRock LifePath Index RET $13.0903 0.037 $0.48 $13.2631 0.033 $0.44
Van Shrt Trm Bnd Ind Inst Plus $10.4900 1,537.751 $16,131.01 $10.4800 1,446.276 $15,156.97
1J#Al� � $ 5,1b-41
----_..._ ... ... __.�.. . ... .......- .._. ... - -- ..
1.49
Important Information about Your Plan
To help achieve long-term retirement security,you should give careful consideration to the benefits of a well-balanced and diversified investment
portfolio.Spreading your assets among different types of investments can help you achieve a favorable rate of return,while minimizing your overall risk
of losing money.This is because market or other economic conditions that cause one category of assets,or one particular security,to perform very well
often cause another asset category,or another particular security,to perform poorly.If you invest more than 20%of your retirement savings in any one
company or industry,your savings may not be properly diversified.Although diversification is not a guarantee against loss,it is an effective strategy to
help you manage investment risk.
In deciding how to invest your retirement savings,you should take into account all of your assets,including any retirement savings outside of the Plan.
No single approach is right for everyone because,among other factors,individuals have different financial goals,different time'horizons for meeting their
goals,and different tolerances for risk.
It is also important to periodically review your investment portfolio,your investment objectives,and the investment options under the Plan to help
ensure that your retirement savings will meet your retirement goals.
For more information on individual investing and diversification,please see the Department of Labor website at.www.dol.gov/ebsa/investing.html
fou are free to direct the sale of your plan investments and reinvest the proceeds in the plan's other investment options in whole dollars or percentage
ncrements,except to the extent restricted by the manager of a particular investment option or under securities and other applicable laws.All
nvestment options under the plan are available to you.To obtain more information about the plan's current investment options,visit your plan's website
x speak with a Service Representative available by calling your plan's toll-free number(contact details are listed at the bottom of your statement).
'lease read each investment's prospectus,fund fact sheet or offering statement carefully before making any investment decisions.
PAGE 2OF2
For information visit us on the web at
www.myhighmark.net or call
1-855-694-4446