HomeMy WebLinkAbout06-09-15 (2) Pennsylvania 15 0 5 618 4 0 3
DEGARTMENi"REVENI=X(03-14)
REV-15010 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 21 14 725
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
489 93 5582 03 08 2014 02 03 1974
Decedent's Last Name Suffix Decedent's First Name MI
ARCOS ANGELA J
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
N1. Original Return 2. Supplemental Return 3. Remainder Return(date of death
prior to 12-13-82)
EJ4, Agricultural Exemption(date of 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
n7. Decedent Died Testate 8. Decedent Maintained a Living Trust0 9. Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
10. Litigation Proceeds Received 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
FJ 13. Business Assets 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
PAUL J ESPOSITO 717 234 4161
First Line of Address
4250 CRUMS MILL ROAD
Second Line of Address
City or Post Office State ZIP Code
HARRISBURG PA 17112
Correspondent's email address: p1eCa)goldbergkatzman.com
REGISTER OF WILLSIUSE�LY d
REGISTER OF WILLS USE ONLY ("'
DATE FILED MMDDYYYY r T1
"t =3 1 i
ry r r n
DATE FILED STAMP
Side 1
I III��I II��I'I II�II'I'II'�I� II��I VIII�I�I ��i��II I IIII
1505618403 1505618403
1505618411
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Arcos, Angela J. 489 9 3 5582
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivable(Schedule D).................................................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 585 - 36
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 585 - 36
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 785 - 40
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10.
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 785 - 40
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -200 - 04
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. -200 - 04
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.00 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 0 . 00 16. 0 . 110
17. Amount of Line 14 taxable
at sibling rate X.12 a - 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 0 0
19. TAX DUE................................................................................................................ 19. 0 . 011
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
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 knowled .
SIGNAT SON RۤPON I %R FILM RYTURN Patricia Valigorsky oarE _
V(/ 2-
ADDRESS ADDRESS
817 Tavistock Road, Mecha;Zbur A 17050
SIGNAT7 OF OPARER OT P ER THAN REPRESENTATIVE Paull Esposito DAT
9 2015
ADDRE S
4250 Crums ill Road, Harrisburg, PA 17112
I�II�I II��I�IIII��I�I�III��II�I II��I I�III'I��I II��I III I�I Side 2
1505618411 1505618411
REV-1500 EX Page 3 File Number 21-14-725
Decedent's Complete Address:
DECEDENT'S NAME
Arcos,Angela J.
STREET ADDRESS
817 Tavistock Road
CITY STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
Total Credits(A +B) (2) 0.00
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (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) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................... ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x
c. retain a reversionary interest;or............................................................................................................... ❑ ❑x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
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?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ 0
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 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 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[72 P.S.§9116(a)(1.3)]. A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1508 EX+(08.12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Arcos,Angela J. 21-14-725
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 USAA -Insurance Policy Refund. 585.36
TOTAL(Also enter on Line 5, Recapitulation) 585.36
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12)
REV-1511 EX+(08.13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENT DEC ENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Arcos,Angela J. 21-14-725
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid
2. Attorney's Fees Goldberg Katzman, P.C. 350.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zia
Relationship of Claimant to Decedent
4. Probate Fees 113.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 321.90
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 785.40
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Arcos,Angela J. 21-14-725
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Costs
1 Cumberland Law Journal-Publication fee. 75.00
2 Patriot-News-Publication fee. 246.90
H-137 321.90
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Arcos,Angela J. 21-14-725
NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENTDo Not List T 102(sl (Words) ($$$)
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Eleanor Zapperoli Trust Daughter 1/3 of all
216 S.Arlington Avenue property.
Harrisburg, PA 17109
Jack Arcos Trust Daughter 1/3 of all
216 S.Arlington Avenue property.
Harrisburg, PA 17109
Violet Perez Trust Daughter 1/3 of all
216 S.Arlington Avenue property.
Harrisburg, PA 17109
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. 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
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
LAST WILL AND TESTAMENT
OF
ANGELA J. ARCOS
I, ANGELA J. ARCOS, of 817 Tavistock Road, Mechanicsburg, Cumberland County,
Pennsylvania, 17050,being of sound and disposing mind, do hereby make,publish,and declare this
to be my Last Will and Testament, hereby revoking and making null and void all prior Wills and
Codicils made by me at any time heretofore.
ITEM I. I direct that all my legally valid debts, funeral and administrative expenses,
and debts incurred or payable because of my death, shall be paid by my Executor,hereinafter named,
from my residuary estate as soon after my death as practicable. All death taxes, including federal,
state and other death taxes, with respect to the property forming my gross estate for tax purposes,
whether or not passing under this Will, including any interest or penalty imposed thereon, shall be
considered an expense of administration of my estate, without apportionment or right of
reimbursement. Taxes on future interests may be prepaid.
ITEM II. I give and bequeath certain items of tangible personal property that are solely
owned by me at the time of-my death and that are identified in any separate writing directing
distribution thereof after my death which is dated and is signed by me at the end thereof, to those
persons designated in such separate writing who survive me. If any item of tangible personal
property is identified in more than one separate writing, I direct that, unless stated to the contrary,
the separate writing bearing the last date shall govern the disposition of such item.
J
ITEM III. I bequeath all household and personal effects, jewelry, automobiles, and
other tangible personalty of like nature, other than those listed in Item II, in equal shares, to my
Children, VIOLET ARIANNA PEREZ, JACK ANTHONY ARCOS, and ELEANOR ANN
ZAPPEROLI, if they survive me by thirty(30)days;Provided,however,that if a named child does
not so survive me,that child's share shall be divided, in equal shares,by the remaining survivors.
ITEM IV. I give,devise and bequeath all of the residue of my estate of every nature,and
wherever situate, including any property subject to any power of appointment, to my Children,
VIOLET ARIANNA PEREZ, JACK ANTHONY ARCOS, and ELEANOR ANN
ZAPPEROLI,if they survive me by thirty(3 0)days; Provided,however,that if a named child does
not so survive me,that child's share shall be divided, in equal shares, by the remaining survivors.
ITEM V. Should VIOLET ARIANNA PEREZ and ELEANOR ANN ZAPPEROLI
-(the`Beneficiary")not have attained the age of Twenty-seven (27) years.at the time for
distribution of my estate, I devise, and bequeath the share of each named Beneficiary to my
hereinafter named trustee, IN SEPARATE TRUSTS, to hold,manage, invest, and reinvest the
shares so received, and the accumulation of income thereon, and to use and apply in her absolute
discretion, from time to time such portion of income and principal thereof as it thinks proper for
the Beneficiary's comfortable support,maintenance and education without regards to any other
person's ability to provide such support or education, or to make payment for those purposes
without further responsibility to such Beneficiary or to any person taking care of the minor. Any
principal or income not so applied shall be distributed to such Beneficiary when she attains the
age of Twenty-seven(27)years, or she dies prior thereto to her personal representative.
2
ITEM VI. My son, JACK ANTHONY ARCOS, has special circumstances and
disabilities affecting him which has made him eligible for various local, state and federal benefits
and entitlements which he now receives or will receive in the future. It has not been my duty to
support JACK ANTHONY ARCOS. The amounts I am bequeathing him shall be held in trust for
and during his life. The primary purpose of this trust is to assure that JACK ANTHONY ARCOS
achieves his maximum potential and leads as full, independent and normal a life as possible. To
that end,the Trustee,in her absolute discretion, shall expend the income and principal of the trust in
ways that best further these goals and under the following terms and conditions:
1. The Trustee shall pay to said JACK ANTHONY ARCOS so much of the net
income and principal of the Trust as the Trustee, in her absolute discretion, deems
advisable for supplemental needs only, as defined below. The distribution of
income on any distribution date shall not establish a pattern for any other
distribution date. It is my express intention that no distributions of income or
principal be made for support or maintenance of said JACK ANTHONY ARCOS,
but that my Trustee may make distributions for "Supplemental Needs," as defined
below. The intent of this trust is a special needs trust and my Trustee shall provide
trust payments of such an amount as not to preclude participation in any federal,
state, local or other assistance programs. The income and principal of this trust may
therefore be used as judged necessary and appropriate as a supplement to,but not to
supplant, such federal, state, local or other assistance and to the extent the income of
this trust is not used, the trustee may accumulate the income and add it to the
principal of the trust.
3
r
2. While the trust is in existence, it shall be for the primary benefit of JACK
ANTHONY ARCOS, however, my Trustee is directed to consider the
remaindermen of the trust and use her best efforts to preserve the trust's assets for
distritubution to the remaindermen. The foregoing sentence is in no way intended to
limit the sole and absolute discretion of the trustee with respect to such distributions
or to give any remainderman any right to challenge any distribution made by the
trustee in the exercise of such discretion. Rather, said sentence is intended to aid the
trustee and any Court or administrative agency in properly interpreting my intent in
establishing this trust, namely, that the needs of JACK ANTHONY ARCOS be
provided for only to the extent that governmental benefits and entitlements and
other resources are either unavailable, inadequate, or have been exhausted. It is
recommended that my Trustee consult legal counsel so that expenditures my Trustee
makes out of this trust in no way effect benefits which JACK ANTHONY ARCOS
is receiving through any federal, state or local governmental program.
3. As used in this instrument "Supplemental Needs" include (but are not
limited to) items such as travel and vacation, recreation, socializing, clothing
beyond what is required for maintenance, visiting, companionship, memberships,
subscriptions to magazines and newspapers, small irregular amounts of spending
money, guardianship fees, vocational rehabilitation (if not available from other
sources), counseling and guidance, reimbursements for time and expense of a
companion, legal representation, items which Medicaid and. other government
programs do not cover or have denied payment or reimbursement for (e.g.,
4
wheelchair, communication devices), and other expenditures used to provide
dignity, purpose, optimism and joy to the beneficiary.
4. On the death of said JACK ANTHONY ARCOS, the then remaining
principal and undistributed income shall be paid to his then living issue,per stirpes.
If no issue of his are then living, said principal and income shall be distributed to my
then living issue,per stirpes, as designated under my Will.
ITEM VII. I hereby appoint PATRICIA VALIGORSKY,to serve as the executor
(the"Executor") of this, my Last Will and Testament.
ITEM VIII. I hereby appoint KAREN E. HASSLER to serve as the trustee (my
"Trustees") of any Trust created hereunder.
ITEM IX. I hereby designate and appoint KAREN E. HASSLER and ROBERT J.
RUSANOWSKY to serve as Guardians of the person and the property of my minor daughter,
ELEANOR ANN ZAPPEROLI.
ITEM X. I hereby excuse those persons named in or appointed pursuant to this Will as
Executor, Trustee or Guardian, from the necessity of posting any bond or other security for the
faithful performance of their respective duties in any jurisdiction.
ITEM XI. The interest of the Beneficiaries hereunder shall not be subject to anticipation
or voluntary or involuntary alienation.
5
r y
ITEM XII. My Executor and Trustees shall have the following powers in addition to
those invested in them by law and by other provision of my Will applicable to all property,whether
principal or income, exercisable without court approval, and effective until distribution of all
property:
A. To retain any or all assets, real, personal or mixed, without regard to any
principle of diversification, risk or productivity.
B. To invest in all forms of property without restriction to investments
authorized for Pennsylvania fiduciaries or executors.
C. To sell at public or private sale,to exchange,mortgage or lease for any period
of time, and to repair, alter or improve any real or personal property, and to give options for
sales, exchanges, or leases,for such prices and upon such terms and conditions as they deem
proper.
D. To compromise any claim or controversy.
E. To make distribution hereunder in cash, in kind, or partly in cash and partly
in kind.
F. To make any distribution hereunder for the benefit of minor beneficiaries or
others, who, in their opinion, are incapacitated through illness, age, or other cause, directly
to the beneficiary thereof, to the natural or legal guardian or the person who has custody of
such beneficiary,or to apply any such distribution directly to the benefit of such beneficiary.
The receipt of such persons to whom payment is made or entrusted shall be a complete
discharge of the fiduciary in respect thereof.
G. In general,to exercise all powers in the management of any funds which any
individual could exercise in the management of similar property owned in his own right
6
upon such terms and conditions as to them may seem best, and to execute and deliver all
instruments and to do all acts which they deem necessary or proper to carry out the purpose
of this Will.
ITEM XIII. Any person who shall have died at the same time as me, or in a common
disaster with me,or under such circumstances that it is difficult or impossible to determine who died
first, shall be deemed to have predeceased me.
IN WITNESS WHEREOF, I have hereunto set my had and seal to this, my Last Will and
Testament, consisting of seven(7)typewritten pages, this/ day of ��Gs �� , 2013.
(SEAL)
ANGELA J.ARCOS
7
L
We,the undersigned, hereby certify that the foregoing Will was signed, sealed, published
and declared by the above-named Testatrix, ANGELA J. ARCOS, as and for her Last Will and
Testament, in the presence of us, who at her request and in her presence and in the presence of each
other,have hereunto set our hands and seals the day and year above written, and we certify that at
the time of the execution thereof, the said Testatrix was of sound and disposing mind and memory.
residing at
residing at
Ze
COMMONWEALTH OF PENNSYLVANIA
SS..
COUNTY OF DAUPHIN
We, ANGELA J. ARCOS, the Testatrix, and J4 .1 934./? and
f:A 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 that each of
the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the
best of his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound
mind and under no constraint or undue influence.
C
ANGE J.ARCOS
WI ,S
WITNESS
8
Subscribed, sworn to and acknowledged before me by the Testatrix,ANGELA J. ARC-(O-S,
and subscribed and sworn to before me by C,m and
witnesses, this�day of UC, 11�1, 2013.
Notary PubliZ
(SEAL) COMMONWEAIXH OF PENNSYLVANIA
Notarial Seat
Shirley M.Erb,Notary Public
Lower Paxton Twp., Dec.S0,uphin n
tY
M Commission Expires
r4EMQEm RENNSYLVANIA
IA no" NpTARIES
9
STATEMENT CE-1 84 110
USAA
9800 Fredericksburg Road _ =__ NUMBER D
'e, ` San Antonio, Texas 78288
-
9 6
2 06
US"US" Visit us at usaa.com 01621
04462.14KH4.JSS934320605.02.01.B4
TO UPDATE POLICIES GO TO
USAA.COM OR CALL
1-800-531-8722
EST OF ANGELA J ARCOS FOR BILLING AND PAYMENT
C/O PATRICIA E VALIGORSKY INQUIRIES GO TO USAA.COM OR CALL
817 TAVISTOCK RD 1-800-531-8722
MECHANICSBURG PA 17050-5007 TO REPORT A CLAIM, CALL
1-800-531-8722
:>::::
... ::..,....:.,:::. It+tONTHI:y'S <ACI I't�Z IY. < >:<; ;: .;<. ::;: »: :>::: : > : ._.:. ..`<: .. ;:< :: ::: : .::
BALANCE ON LAST STATEMENT $ 321.52
NO PAYMENTS RECEIVED BY CLOSING DATE
SUBSCRIBER ACCOUNT 03-28-2014 417.19-CR
EFUN C D 04-11-2014 5 .3
AA AUTO POLICY 7106 6 INAC ATO
POLICY CANCELLATION CREDIT 01-27-2014 220.21 CR
USAA VPP POLICY 91C INACTIVE
POLICY CANCELLATION CREDIT 01-27-2014 87.00 CR
USAA RENTERS POLICY REN 004 INACTIVE
POLICY CANCELLATION CREDIT 01-27-2014 182.48 CR
ACCOUNT BALANCE AS OF 04-11-2014 $ .00
-----------------
:..:.
YMENT . . : ON5
.:Y___ ::=: _ _=-`:: P3.�th1 OFT _.
1:=_ :::• -:: LA1dC 3 ECaU[ .t 11TH v_ XT£ t3Ed3 ? tPE
=EFFFCi�...t�AT - _ . :.:BA I?
11-30-2013 USAA AUTO POLICY 7106 6 INACTIVE: AUTO $ .00 $ .00 $ .00
11-30-2013 USAA VPP POLICY 91C INACTIVE $ .00 $ .00 $ .00
11-30-2013 USAA RENTERS POLICY REN 004 INACTIVE $ .00 $ .00 $ .00
TOTALS $ .00 $ .00 $ .00
YOUR REFUND CHECK IS ATTACHED.
a OM4462 REFUND CHECK # 4865965