HomeMy WebLinkAbout09-08-15 � J �`y� PeMnsYl�ania
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REV-1500 OFFICIHL USE ONLY
CounlyCotle Year File Numbe�
BureauonndlvidualTaxes INHERITANCETAXRETURN
aosoxzeasoi 21 15 ❑0573
Harrsbur PA m28-0601 RESIDENTDECEDENT _
ENTER DECEDENTINFORMFTION BELOW
Socidl5¢Clllity NUm�ef OaIP Of D¢dlh MMD�YYYV Date of Bltlh MM��YVYY
❑5 ❑7 2015 OS 18 1922
DecetlenPSLastName Suffx DecetlenCSFirstName MI
SHORT BERNICE G
QfApplicable�EnterSuniving Spouse'slnformaHon Below
Spouse's Last Name Suffix Spouse's First Name M�
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS 9ELOW
O 1. OriginalReNm � 2. SupP�emen�alRetum � 3. RemairMerReWrn(Oateo(tleaiM1
pnor�0 12-13-82�
� a 4eeN o1n or afler P,y�(tlate ot � 5. FUWre Interes�Compmmise(tlale of � 6. Fetleral Esla�e Tax ReWm Requiretl
20t2) tlea�hafler'1242-82)
Q �. oe�eaem o�ea res�aie � 9. Decedent Maintainetl a Llving Tmsl Q 9. Tolal Number of Safe�epost Boxes
(AVacM1 copY of wilp (At�acM1 copy o�imst) -
� t0. Liti9alion Pmceetls ReceiveE � tt Non-Pmbale Transieree Relum � 12 De(erraVElection of Spousal Trusis
(SCM1etlule F antl G Assets Only)
� t3. Business Hsse�s � 1<. Spouse is Sole 6eneGCidry
(NO�Nsf invOlv¢d)
LORRESPON�ENT�THIS SECiION MUST BE LOMPLETE�.ALL CORRESPONOENCE ANO CONFI�ENTIAL TpX INFOFMPTION SHOOLD BE DIRECTEO T0:
Name Day�ime Teiephone Number
WM D SCHRACK III 717 432 9733
First Line ot Atltlress
124 W HARRISBIJRG ST
Secantl Line of Atltlress
CityorPostOffice Sta[e ZIPCotle
DILLSBURG PA 170191268
CorrespondenPsemailadtlress: S h kl (al t t � - a
REQS� OF WILL9�lf5E Od�.YC�
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aFGIsiEROGWIlLSOSEONLv � "�
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UATEFlLEOMMODYYYT - � � � ' '�
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DATELILE06WMP �- f,�
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Side t
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15�5618403 1505618403 �ry1
l�
� 1 1505618411
' aev-�soo Ex
�ecetlenCs Social Sewrity Nvmber
o«eaeorsrvame: Short, Bernice G.
RECAPITUTATION
i. RealEs�ate(SchetluleAl. __.._.. __....... ................_.. 1.
2. SrocksanaBonas(ScheauleB).._.............. ....._.. ............__. 2. 544 ,372 • 00
3. Closely Held Corpora[ion,Partners�ip or Sole-PmprietorsM1ip(SCM1etlule G)__.,., 3.
4. MortgaqesantlNotesReceivable(Sc�etlule0) ...___. _...._..__. 4.
5. Wsh,Bank�eposits antl Miscellaneous Personal Property(Schedule E)..._..... 5. 24 •86
6. Jointly Ownetl Praperty(Schetlule Fj �..I Separate Billing Requestetl........._. 6. 6+178 • 23
]. InterVivos Transfers 8 Miscellaneoos Non-Probate Property
(SchetluleG) U Separa�e6illingReques�ed._..___ ]. 57 .702• �❑
8. Total Gross Asse[s(rotal Lines 1 [hrough])................. ......... .........._.... 8. 6 Q 8 .277 • 09
9. FunerelExpensesantlAdminisVa�iveCos�s(SchetluleH)...._._..._._.._.___.___. 9. 23.496 - 95
10. Debts of Oecetlent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 363• D O
it. TotalDetluctions(to�aiLines9antlt0).... ..._.._ _______ tt 23.859 • 95
�2. NetvaiueotEswte(LineeminusLinell) ............... _____... t2 584 .417 � 14
13. CharitableantlGavemmentalBequesis/Sec9113Tmstsforwhich
an elec�ion�o tax M1as not been made(Schedule J).........__.__........___....___.._. 13.
14. NetValueSubjectmTaz(Linel2minusLinel3)..............._.__...._.._.____..._ �a. 584 .417 . 14
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Hmount of Line 14 taxable
a[the spousaltaxrate,or
[ransfers under Sea 9116
(a)(12)X.00 15. 0 • 0❑
16. AmountofLinel4�axable
atlineairatex .0a5 584 .417 - 14 i6. 26 �298 . 77
1]. AmounlofLinel4�axable
alsiblingrateX.12 0 . 00 1]. 0 •0�
18. Amount of Line 1A taxable
a�collateralrale %.15 ❑. 0� 18. � - 00
19. TAXDUE ...._..._... ...._.._ __.._.._ _..__............... 19. 26 .298 . 77
20. FILL IN THE OVAL IF VOU ARE REpUESTING A REFUND OF AN OVERPAYMENT �
Untler penallies ot perjory.I Oeclare I nave evaminetl�Fis reW m,incluoing amompanying scM1etlules antl statemen6.anE to��e best ol my knowletlge and Oelrel.
it Is We,correc�antl comple�e.Declatation ot preparer o0er IM1an tM1e person responsible for Ifng IM1e reWm is bautl on all Inloima�lon ol w0ic�preparer M1as
any kncwledge.
SIG�TURE OF PER ON��SPONSI6LE FOR FlLING RETURN Linda L Stagg 9 �AiE d��b_
AD� E5�! 5����
508 Lilly Lane, Mechanicsburg, PA 17050
SIGN4TUREOFPREG ft H T N EPftESENTATNE Wm. D. Schreck III . o^TE
�� � ��./L
AODRE55
124 W Harrisburg St. Dillsburg PA 17019-1268
L II��I�I�I��IIIIII��I�I�III��II�III��II�III�I��I�I��III�II'�I Side2
1505618411 1505618411 �
REV4500 E%Page 3 File Number 214 5-00573
Decedent's Complete Atltlress:
'��DECE�ENT'S NAME
Short, Bemice G.
STREETADDRE55 �
508 Lilty Lane _ ..
CITY .. .. . .�... . STATE .. .ZIP . .
Mechanicsburg PA '17050
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) ��) Z6�Z987�
2. Credils/Payments
A. PriorPayments 2].000.00
B. Discoun� 1.314.94
TotalCreaits(A +B) 1�) Z8.3�4.9<
3- Interesl �3) . _
q_ IfLine2is9reaterthanLinel +Line3,enterihetlifference. ThlsistheOVERPAVMENT. (4) 2.0'I6.t7
Gheck box on Page Y,Line 2010 request a refuntl
5. If Line 1 +Line 3 is greater than Line 2,enter ihe tliHerence. This is[he TAX DUE. (5)
Make Check Payable to: REGISTER OF WILLS, AGENT.
.. . ,. . ._ :. . : ..
.. .. . �- ,�xt�:; .. . , , �..: ,.� . '.: . ...
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Dld decetlent make a trensfer anB. Yes No
a. retain tM1e use or income ot the property Iransferretl _.._._ __ ._. I I x I
b. re�ain the riqht[o tles gnate who shall use fhe pmpehy Uansferred or i�s inwme __ _.. x��.
c. retain a reversionary�nleresf oc .._.._. ..... ..... __ i I x
d. receive Ihe promise for life of either payments,bene0ts or care� _.. ._ . �� �x
2. If tleath occurretl afler Dec. 12, 1982, tlitl tleceden� transfer property within one year of tlea�h wi�M1OW
receivingatle9uateconsitleration9._... .__._. ._...._ ......._ ___... � �x�'.
3. Ditl tlecetlen�own an"in tmst for" or payable upon tlea�h bank accoun�or sewrity at his or her�eatM___. x�'
4. Ditl tleceden�own an intlivitlual retirement accoun�,annully,or other non-pm�ate property which ,
containsabeneficiarytlesiqnation?..... __..._ .__._. ....__. .___.. z �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,VOU MUST COMPLETE SCHEOULE G AND FILE IT AS PART OF THE RETURN.
� � � }:�, .. . ... , n � � . . .: .. . �
For tlates of 4ea1M1 on or atler July 1 199a and before Jan.1,i995,the�ax rate imposetl on�ne ne�value o!iransfers Io or tor the use of the surviving spouse��
Is 3 percam p2 P.S.§9116(a)�1 111�)I.
Portla�es of deeth on oraHar January 1.1995,Ne tex ale Imposetl on Ihe netvalue o�Vansters to or Porihe use of�he survlving spouse Is 0 percent
p2P.5.§9116(a)�1.1)(ii)�. Thes�aW�edoesno(asemptat2nsferloasurvivingspausefromtezentlihastaN�oryrequlrementsfordlsclosoreofasselsana
filing a 1ax reWm are still applicable even if Ihe surviving spouse is the only beneficiary.
Por dates af dealh on ar atter July 1,200��.
• The tax ra�e imposed on�he ne�value o!Iransfers fmm a deceasetl child 21 years of age or younger at death�o or(or the use of a naNral parent,an
etlopMe parenl,ar e stapparect of�he chiltl Is 0 percent�]2 P$.§9118(e)(�2�].
• The lax ra�e imposed on the nel value oi trans(ers lo ar tor�ha use of Ihe decedenfs lineal benefciarles Is 4 5 percani,except as noletl�m�]2 P.S.§9116(a7 ry)�.
. TM1e tax rate Impasetl on�he ne�value of Vens�ers ro orfor�he use o(ihe decedan�'s sibllnqs Is 12 percenl�/2 Pb-§9116(a)(19)I� A sibllnq Is definetl.
untler Section 9102.as an IndlNdual who has at leas�one parent in cammon wAh�M1e decedenl.whether by blood ar adoplion.
Ray-050]EC��4BA2�
SCHEDULE B
�. pennsylvania STOCKS & BONDS
w oEvnalmervr oraevervuE
ERITPNCETq%RETORN
PESI�ENT pECEDENT
ESTATE OF FILE NUMBER
Short, Bernice G. 27-15-00575
ui qop.iryio��ny.ow�m wim ngm on��.mor:n'�o m�n e.a��:m..a a�sm.em.v.
ITEM CUSIP VALUEATDATE
NUMBER NUMBER �ESCRIPTION UNITVALUE OF�EATH
'I MorganStanleylnvestmentAccount 544.372.00
TOTAL(Also enter on Line 2. Recapitulationl 544,372.00
(II more space is neeaetl.aaailional oages ot tne same size)
Copyright(c)2012(orm software onty The Lackner Gmup,Ina Form PA-0500 SchedWe B(Rev.08-12)
Pey-0508E%�(OB-03)
SCHEDULE E
� pennsylvania CASH, BANK DEPOSITS, 8 MISC.
Q�' oEaaarMEr�roraeve�+ue PERSONAL PROPERN
INMERITPNCF TPXRETORN
ftE51�ENTOECEOENT
ESTATE OF FILE NUMBER �
Short, Bernice G. 21-'IS-00573
>��vn�oa me o��o�nrganoo a�a�na ee�e ma o�aa:wera r«a��ee ey me e:ia�e
�a.Mi�����y.�.e�m m.ngni m:.�,mor.niP m�.�e.ai.�io..e o�.�n.am.r.
ITEM VALUE AT DAiE
NUMBER DESCRIPTION OF DEATH
i Combinetllnsurence-premiumrefund SA7
2 Macy'sD¢partmentStore-creditaccountrefuntl 19.75
TOTAL IAlso enter on Line 5. Recapitulationl 24.86
. Qi more svaw is neetleE.atltli6onal pages ol lne same size)
Copyriqht(c)2072 form sofiware only The Lackner Gmup, Ina Form PA-1500 Schedule E(Rev.0842)
ae.nsos ez.�ai-ia�
�. pennsylvania SCHEDULE F
L�� oePnRrmeNrorReveH�e JOINTLY-OWNED PROPERTY
INHERITPNCE TAY RETpRN
RESI�ENT OECEOENT
ESTATE OF FILE NUMBER
Short, Bernice G. 21-15-00573
in�o..i w..mm.lam�.,mm o�.y..,mm.a«<e.�r.m�.m a..m,n m�.�e.,.c�n.a o�.m.em.a.
SURVIVINGJOINTTENANT(SINAME A�DRESS RELATIONSHIPTODECEDENT
A. Linda L. Stagg 508 Lilly Lane Daughter
Mechanicsburg, PA 17050-3727
B. Richard D. Stagg 508 Lilly Lane Son-in-Law
Mechanics6urg, PA 170503727
C.
JOINTLV OWNED PROPERTY:
DESCftIPTIONOFPROPERTY ��p onrsoroenrw
ITEM FOR,JOINT MADE HurneERo sEMun�oENrrrwcnume npnrrncNKo eo�oa OATEOFDEATH DECD'S oECEOEHrsir�ireacsr
NUMBER TENANT JOINT �oirvnv-��emeeuesrnre. VAWEOFASSE INTEREST
1 AANDB 05/11/2009 PNCBank-checkingaccount#5005807762 18,55315 33.300% 6,778.23
TOTAL(Also enter on Line 6. Recapitulation) 6,17825
�it more space�s neeeee,aeea�onai oaees oi me ume s�ze)
Copyright(c)2010 fortn sottwa2 only The Lackner Group,Ina Form PA-1500 Schedule F(Rev.0140)
ne.nsia ex.ioe ov�
SCHEDULE G
� pennsylvania lNTER-VIVOS TRANSFERS AND
'�'�� �E�A�'TME��o"`E�`�"E MISC. NON-PROBATE PROPERTY
INHERRPNCETA%REtURN
RESIOENT OECF�FNT
ESTATE OF FILE NUMBER
Short, Bernice G. 21-15-00573
1n�..scnaame m�:i ce�ompie�ea a�e niea n ma a�..e�m a�v��wa:eo�:i�nro�en a o�vaee mrea onne aev-+soo��i rei.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH °b ov o[cos esc�osiorv TA%ABLE
NUMBER TMELOPE�OFTRANSFENSPTfPGNFLOMOFTXEOEE�F�OPREALESTATE. �/(��UEQFAS$ET INTEREST (�FPVPLICP6LE1 VAWE
7 Tronsamerica Annuiry Contract 0200SS50179 57.702.00 57.702.00
TOTAL(Also enter on Line 7,Recaoilulation) 57,702.00
(II mwe space Is neetleq aaCifional pages o(tM1e same size)
Copyright(c)2009 fortn soflware onty T�e Lackner Group,Inc. Form PA4500 Schetlule G(Rev.OB-09)
nev+sn ex.loe ia�
q�. pennsylvania SCHEDULE H
t'+7' oEP^ATME�*oFaE�E��F FUNERAL EXPENSES AND
���ER"p"`E��R"�R" qDMINISTRATIVE COSTS
RESIDENi OECEDENT
ESTATE OF FILE NUMBER
Short, Bernice G. 21-15-00573
Decetlent's debts must be reportetl on Schedule I.
ITEM DESCRIPTION AMOUNT
M
q. FONERALEXPENSES:
_ See continuation schetlule(s)attached 10,449.71
B. ADMINISTRATIVE COSTS:
1. PersonalRepresenta�ive'sCommissions
Name of Peroonal Representa[ive(s)
5[reetAdtlress
Ciry Stace _ Zio
Year(s)Commission Pald
z. Atmmey s Fees Wm. D. Schrack Iil 6,000.00
3. Famiy Exemption: �If decedenfs address is not the same as claimanPs,attach explanation) 3,500.00
Qaimant
Street Atldress
City State 2io
Relationshio ot Claimant�o�ecetlen[
4. Pmba�e Fees 670.50
5. AccounlanfsFees �
6. Tax Retum PreOarers Fees
]. Other Administretive Costs 2�93�.�4
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 23,496.95
Copyright(c)2013 farm software ontyThe Lackner Gmup, Ina Form PA-0500 ScheEule H(Rev.OB-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FIIE NUMBER
Short, Bernice G. 21-15-00573
ITEM
NUMBER DESCRIPTION AMOUNT
F �n rai xo n <
1 Bible Baptist Church-use of facilities tortuneral 300.00
2 DanFrancis-vocalist 75.00
3 DonWingek-organist 75.00
4 LawrenceBlack-videographer 75.00
5 Malpeui Funeral Home 9.774.11
6 kev. BrianWebb-honorsrium 75.00
7 Rev. RonBerrus-honorerium 75.00
H-A 1o,449A7
Other Atlministrative Costs
8 Cumbedand County Law Journal-estale ativertisement 75.00
9 IRS-estimated payment for year 2015 2,000.00
10 Miscellaneous expenses incurretl tluring period of atlministrotion 50.00
11 PA Department of Revenue-estimated paymen[s for 20t5 600.00
72 The Patriot News-esta[e advertisement Zi2.34
H-B7 2,937.34
Copyright(c)20021ortn sokware only The Latkner Gmup,Ina Fortn PA-0500 Schetlule H(Rev.6-98)
ea.-�sz ex.��zaz�
SCHEDULE 1
� pennsylvania DEBTS OF DECEDENT,
"] DEPARTMENT OF REVENl1E
,„„Ea„qH�Er�aE.,,q„ MORTGAGE LIABILITIES AND LIENS
aEsioeHl oeceoErvr
ES7A7E OF FILE NUMBER
Short, Bernite G. 21-15-00573
a.aon amu mcvnea W m.e.o.e.m enor w a..m mn r.m.m.e.�w�a.i m.a.ie or a..m.mcmoma��reime�a.e v»nm.i e.pz�.e�.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF�FATH
i ABWEDonorServices-hanorpletlge 150.00
2 Betty Short 30.00
3 Bible Baptist Church-pledge for 3 months 150.00
4 George's Cleaners 33.00
TOTAL(Also enter on Line 10,Recapitula6on) 363.00
(It more soace Is neeEeE.aatli6onal pages ol Ine same size)
Copyright(c)2012 form sotlware only The lackner Group,Ina Form PA-1500 Schedule I(Rev. 12-72)
FEV45ll FJP(01-00)
�j pennsylvania SCNEDULE J
�»� oeaavrmeHrovaevervue
���ER�T^��ET^xAET�R� BENEFICIARIES
xesmer�roECEoervr
ESTATE OF FILE NUM6ER
Short, Bernice G. 21-15-00573
RELATIONSHIP TO
NUMBER NAMEHNDA��RESSOF DECEOENT SHAREOFESTATE AMOUNTOPESTATE
PERSONISIRECEIVINGPROPERTY (Wortls) ($$$)
I TAXABLEDISTRIBUTIONS �inclutleouVightspousal
tlisVibu[ions.antl transfers
vnderSec.9116a L2
Doris M.Alamo Daughter 1/3 of resitluary
3005 Valley View Way estate
Lansdale,PA 79446
Don R. Short Son 1/3 of resitluary
629 Wrights Cove Drive estate
Lottsburg,VA 23517-2372
Linda L.Stagg Daughter 1/3 of residuary
508 Lilly Lane estate
Mechanicsburg,PA 77050
Total
Enter tloilar amounts fortlistributions shown above on lines 15 ihrou h iB on Rev 150o wver sheet as a ro nate.
NON-TAXABLE DISTRIBUTIONS'.
II. A,SPOUSALDISTRIBUTIONSUNDERSECTION9113FORWHIGHANELECTIONTOTA%ISNOTTAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TA%ABLE DISTRIBUTIONS ON LINE 130F REV-1500 COVER SHEET
Copynght(c)2010 fortn sokxare onlyThe Lackner Group, Inc Portn PA.1500 Schetlule J(Rev.01-10)
OF
I BERNICE G. SHORT I
BE IT REMEMBERED, that I,BERNICE G. SHORT, anreinaiiied wido�v, prescnrly of
1910 Rosbury Coua, Mcchauicsburg, Cumbcrland Counry, Penusylvnnia, licing of sound mind,
memory and undcrseanding, do makc, publish and dcdacc d�is as and I�n- nry� Lnst Will :ind ��,
Tcsnmcnt,licceby cevoking 2nd makin�null znd void any aud all Wills and 7cs[amen[s ancl�vii8n,�s
in du naturc durcof by mc �t any time liece[oforc madc I
ITEM 1: I di�ec[Lhanny hercin�ftcr nnmed Executtix pay all my ju,ct dcht�, my funcr�l !
expcnses, and the expcnses of the administcntion of my es[ate. Widt thfs direction, 1 aut6ori_c nnd
empower my LxecuCrix m expend for my funeral expenscs and ii�[e�mcnt such amounts as she m,i}� �
(
co¢sider necessary and proper, wic6out cega�d to any limi[t6ae inay 6c prescrihed l�}' :� court of I.w. ���`��
ITEM 2: I direct my 6xecutcix m pay nll inheti(2nec, es[a[c �ucce�si��n, nnd Ie.�acy
[ases of wh2csoever natuce and kind, to mh[ch my estate, or the uans(er o( any properry ��assinr �;� �
l�eceunder nr oehecwise passing by reason o(my dem[se, may be subject, and ro d�ar�.c snch tasc
i
a�ainst my ssiduary escate, it bcing my inte�tion that none of the afomsaid ca�e,�, eCthcr (edcral or I�
\
s[aee, on any prope[cv required to be inctuded in iny gross eseate, undcr che prcnSsions nf nnp stare -
�
oc federzl law now iu fo�ce or hemafeec enacred, shall be pcoLated amonh d�e pe�cons SnteresYed in ��
\
my esta[c [o whom such properry ix or may i�� ciana(crrecl or tC wlic.m any ��ci.e(it�ca'.�ce- "'�
ryI� .
IITEM 3: I give, devise, and beqaeath all d�c rese, residue and remainder o[my �
� es[aCe, of whatsocvet na�uce, and whcccsocver situa[e, whecher i� be renl, pecnnnL or mited, �
Iincluding pcopecty ovec which 1 may tiavc a powcr of appointmci�c, vnto my i�suc LINDA L. I
� STAGG, DON R. SAORT, and DORIS M. ALAMQ in eqaal sliares, Ucr stirrycs.
IITEM 4: In the event r6at any of my chitdren s6ould predcceace me, 1 direct thar
� the sltam o£such decc.vccd ch[Id be distribuecd Co his on c�r ehildren who smvivc, �n cyual �6�res.
I
� �
�
I'1�M 5: I nominace, cons[i[ure utd appoint my daughtei, LINDA L. STAGG, ns
ExecutrCx of[his my Last Will and Tes[amen�,direcnng ehat shc not Ue required �o Five hond for dic �
fai�hful pe�form�nee of duties in this o[ anp jurisdiceion.
( llV WITNESS WHEREOP, I have hemun[o sct my hand and scal dus , G ` ��
da�
I of ��..��J .✓� - , 2009.
i
�i �' � �
� i�.�e i,�� . . .f�'.. _
BERNICE G. SHORT���—
The preceding inscmment, consiscing of dlis and onc (1) odicr typewric[en p��c, �vas on du
day and da[e thercof sig�ed, sealed, published, a�d dcdared by the Testat-ria hcrcin n�mrd, ns and
(or her Last Will 2nd Testumen[, in the presence of us, wlio, at her mquest, [n her presencc nrn1 in
fne presence,of cach oeher, have subsccibed our names as wimesses 6ercro.
; � � , , n
,
-��( _�� OF ,L C���_.. ��� - I
---\ _7"�- -! .--
! ���ip l� � ;' j , / �r� ''�" �� l' + � I
� , l�.ai i . 'l� ���,lis:�.—
I
�,���-
�
�
i ,I
, :
�I� COMMONWEALTH OF PENNSYLVANIA .
I SS.
�� COUNTY OP YORK : / /
/� /, � �/%�
�
�We, BERNICE � /S��HORT, �'/q9qj� ,/-� C�C(�CJJ and
��- lUl1.LP� ,thc 7'cs�aciix aiid[he�oimesscs,respcc[ively,
�
�ndiose Ames ace sigeed co d:c attacltcd or foregoing i!ts[mment, being fii�_=C duLy s�vom, .In hereby
declace m t6c undecsigned autho�ity ihat che Testatxix signed and execuced ehc insrrumen[ ns licr
Last Will and Tes[ament, and thai she signed willingly, and that she esecuted it as hcr fi�ec und
volun[ary aa for thc purposes dierein expressed, and dme cacl�of flte wimcsscs, in d�c prescnce nnd
heacing of[he Tcstatrix signed dZe Wi1L as wienesscs, and [Liat m t6e bese of[he[r knowlcdpe, t6e
Tes[a[cix was at ihc time ei�h[eea (IS) years ofage or oldeq ofsound mind, nnd undcr no consb�aint
or uiidue influenca �
:,� � .._ u;..., �'� �'��:�i�c_
BERNIC�G. SHORT
;l i,
, � f .' � � �
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June 16, 2015 � �
Williazn b Schrack T1T Esq.
124 W Harrisburg St � �
Dillsburg,PA 17019-1265
TtE: Bemice G Short
SSN: 235-23-6726
DOD: OS-07-2015 .
Dear Mr. Sckuack: � �
Tn response to your request for Datc of Death(DOD)balanccs for 4�e customer noted abovc,our
cecords ;how[he following: �
(;hcclang Account -
Acwmmt# 5005807762 EstaUlislied: OS-11-
2009
HERNfCB G SHORT
LTNbA L STAGG
RICHnRD D STwGG .
DOD balance: $ 18,55'3.19+0.06 accruzd intecest _
Interest paid Ol-01-2015 thru OS-07-201� $ 0.60 YTD �
Please note that this office provides date of death balances for deposit accounis(IRAs,CDs,C1�ecF;ing snd
Savings). Ne do no[process any�Cmanciat hansuc0uns or�rovidc statemeuts. If you need assistnncewith
any of thcse items,please call 1-8S8-PNC-BAA'IC(1-586-762-2265)or stop by your]ocal PNC Hank bravc6
ofFica
Sincei�ely,
National Financial Services Center �
PNC Bank,N.A. ( `. ,\
Member FDTC �/
This messa�e is intended for the use of the individval or entity!o ivhich it is crddressed arid map
contain i��formation that is privi]eged, confidenrial m�d exemptfrmn disdosm�e m,der app&coble 7mv.
If the reader of this nursage is not the inlended recipieru or tlie empioyee or agent respGruiblz far
deiiverniglkis message to the irvzenderl rec7piei�t,yau are hereby no��ed qra!any dissemination,
distribution or capying of this co�mnuntcadons is strictly prohibtted. If yau have rnceived thrs
commm�icatio�s irs error,please notify me iminediately by reply or by telepl:one at 800-761-1775 arid
innnediately destroy this jtixed documemt
Page 1 of 1
� Transamerica Lile Insurance Company
4333 Etlgewaod Roatl NE
� �TRANSAMERICA" c�aa,aap�asiowasza�s
LIFE INSUFANCE COMPANY WWW,�1dpSdfllEliC3.COi9
June 16, 2015
Linda L Stagg
506 Lilly Lane
Mechanicsburg PA 17050
RE: Annuity Number(s) 02005550179
Dear Linda L Stagg:
A check for $93, 823 . 21, representing the � full and final death benefit
payment £or this annuity policy, has been mailed to you under separate
cover. You will receive a Tax Form 1099-R next January reportinq U�i.s
distributior, as follows : -
Gross Distribution: $57, 922 . 69
Taxable Portion: $92, 725 . 69
Federal Tax Withholding: $12, 817 . 71
State Tax Withholding: S 1, 281 . 77
The Company does not give legal, tax, or accounting advi_ce . You may
want to consult your attorney, tax advisor, or accountant with
questions .
For cuestions regarding this letter, please contact your financial
professional or call us at 800-553-5957 and press 3 for the Claims
department hlonday through Thursday between 8 : 00 a.m. and G : 30 p.m. ar
Friday between fl : 00 z.m. and 5 : 30 p.r. ET.
Best regards,
Administrative Services �
Claims
mp
LAW OFFICE OF
WM. D. SCHRACK III
124 WEST HARRISBURG STREET
DILLSBURG, PA 17019-12G8
Tcicphonc 717-432-)733 E-mail
"L'cicfax 717-132-10�3 Schxackla�v�comcastnet
Septeinber2, 2015
� � a �
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R0g1SYCT Of Wi1L5 `� � " �
Cumberland County Court House ' � .
One Courthouse Square . .- -.� � . ...�
Carlisle, PA 17013-3387 � �
5 ci
N '- T
Re: Estate of Bernice G. Short �� o �� �
D/D: May 7, 2015 � `D
File #: 21-15-00573
To Whom It May Concern:
You will find enclosed herewith two completed copies of an REV4500 presented
for filing, accompanied by an additional face page. Kindly accept the Return as
presented,time-stamp the extra face page and return that to me in the envclope provided.
Thank you for your assistance.
Sincerely,
/
WM. D. SCHRACK III
WDS/jsg
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