HomeMy WebLinkAbout09-22-15 (2) , -
� 15�56111�1
REV-1500 EX�°z_'1, �
enns lvania OFFICRAL USE ONLY
PA Department of Revenue PEpqq,ME YFqE EN E County Code Year File Number
Bureau of Individuat Taxes INHERITANCE TAX RETURN � / / y� / / ` �
PO BOX z8o6oi �
Harrisburg,PA 1'J128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW �
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
� � b � � qac� i � l I a �l � C� b
DecedenYs Last Name Suffix DecedenYs First Name MI
m�. � Ns c � R � � � a, �" � �
(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
p 1. Original Return (� 2. Supplemental Return t� 3. Remainder Return(Date of Death
Prior to 12-13-82)
� 4. Limited Estate L� 4a. Future Interest Compromise(date of � 5. Federal F_state Tax Return Required
death after 12-12-82)
� 6. Decedent Died Testate � 7. Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
C� 9. Litigation Proceeds Received t� 10. Spousal Poverty Credit(Date of Death � 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE_D,�jRECTED T0: ��
Name Daytime�elephone Nur�r ;�� �'-�,.�
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First Line of Address ' -��
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Second Line of Address ' � ;,; c�
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City or Post Office State ZIP Code ��`��� F��-`�
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Correspondent's e-mail address: ��i cc���j, r('�AA� C_ G� �A�-'�[Y�• Gnr71
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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.
SIGNATURE OF . RSON RESPONSIB�E FOR FILING RETURN �����w����A�� DATE ��
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ADDRESS n , �_ I`
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE 7� DATE
ADDRESS ,........��.�_.�.�,�.�. .�.�._....�R_._,w._.�._...�.__.�.,�.._.�_._�.�..._,,,..,,_.._..._
_.�.�e.�.�..m. _— ..�.��____.� �,�.�._..._..�_..e,_,�.a.....�.��.....__._...��u
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 15056111�1 1505611101 J �
►
. ,
� 1505611201
REV-1500 EX
DecedenYs Social Security Number
DecedenYs Name: � � � � � � � �
.�_--------------,�_.._____�.__ ___w.___�_.�._..._._..,_....__n_.,.__..,._�- �..._�_._�...�._,._.v. .�__.w. ._.e____
RECAPITULATION
1. Real Estate(Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. � b �. U d
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. S J � �. � �
6. Jointly Owned Property(Schedule F) a;;:.�� Separate Billing Requested . . . . . . . 6. .
7. Inter-Vivos Transfers 8�Miscellaneous Non-Probate Property
(Schedule G) '::;`:r Separate Billing Requested.. . . . . . . 7. .
8. Total Gross Assets(total Lines 1 through 7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. � � J �,t( .� �
_e___. _.__.._____._...._._ _.__.. _. _---__,.e__ ._.... _ ._. . _. . __ __ .. ___...� ,..._.,_ _.,___..._ .__.�_.______..�.�._...__�__._.._
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . . . . . . . 9. � � �"I �. q �
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). . . . . . . . . . . . . . . 10. , � � �. �.y
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. �3 � O� . 02 ,
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. � ���. S�
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. 1 �p � �. � �
_� ..�._�..�.,.,_..�..,�.�.........._._�m _.�_.�..._�...�.A......_,._ ,.....w., ...._....�. ____.�.._.e_._.__._.�.__�,,�..�_._,,..,�.__.w�._�,:_.._..._�,..__ ,.....�-.e.4.�..�...o.___...��...._......
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_ . 16. .
17. Amount of Line 14 taxable • ('y
at sibling rate X .12 I Lp U y . S � 17. I "l(�. ��
18. Amount of Line 14 taxable
at collateral rate X.15 • 18. •
._ �_.
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. ( � . J S
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505611203, 15056],1201 �
�EV-1500 EX Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
- r \���� � '__ ��� '�v__��1� _ _ _ _
STREETADDRESS �
�a� `� -_--�_�� �'�" ---_
--- . _ _ __ - - - -_ _
CITY STATE ZIP
��.�` ;� C�� - � -� �
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) �� p� , �j j
2. Credits/Payments
A.Prior Payments �n
B.Discount V
Total Credits(A+B) (2) ('�
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the tlifference.This is the TAX DUE. (5) 1 � a -S s
,
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decetlent make a transfer and: Yes No
- - � - ��-- - - --- -��-- ___ . . -- ---� n �
�_� ,� _ , . ,_ �
... .�... ., _ �__ _ . .__ . _ �, .. _ ,__�_ ., ._ __, __ . __ .. ._ _ _ _ _ _ _ � �.
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ �'
c. retain a reversionary interest .............................................................................................................................. ❑ .�'
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �"
2. If death occurred after Dec. 12, 1982,did decetlent 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
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 tlates 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 cn 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)(iij].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 applicabie 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 na!ural parent. an
adoptive parent or a steppar2nt of the child is 0 percent[72 P.S. §9116(a)(1.2j].
. The`ax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]
. The!ax rate imposed on the net value of transfers to or for the use of the decedenYs 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-1502 EX+ (01-10)
� �° � pennsylvania SCHEDULE A
�'���II��� DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT - �
ESTATE OF: FILE NUMBER:
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchangetl between a willing buyer and a willing seller, neither being compe�led to buy or sell, both having reasonabie kno�r�iedge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of thz settlement sheet if tne property has be2n sold.
ITEM Indude a copy of tnz deed shoviing deced2nt's interesi i'owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
�. r � �s ���a
�. f�� �� u�o ��x�
cx�c�r�sZ�� -ex e r���—
TOTAL (Also enter on Line 1, Recapitulation.) $ L--+ . Q�
If more space is needed, use additional sheets of paper of the same size.
REV-.So8 EX+(��-1^)
���� � pennsylvania �Cl�IEDULE E
oE�F�TMthTOFRE�-EN��E CASli, BANK DEPOSITS & MISC.
I""ERITA'��`TaX RET'�R" I PERSUNAL PROPERTY
RESID'eNT CECcDENT �
� � —'----- ---- ---
FSTATE 0�:------__��----='�-u-^---- -- ---�— FILE NUMBER:
Include the proceeds of Gtigation and tl�e date the procezds �aere receiv2d by thz estat2.
All Reoperty jointly oN�ned yvi+h r�iyhY af suruivorship must be distlosed on 5eheduie F.
— --- _------ -------------
T;_,., � -- -------------- �.'dLUE AT GAT�-
�.U`�IB �— �— --------------------------___ DES R�t- 'p�A--------_..__ —�—_-- OF DEATH
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o� . � �� ��'-�'� � - (�S� �v � � Q C�� . C�
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TOTAL(Also enter on Line 5, Recapitulation) $ �j j 3�j , 7�
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
� pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT �
ESTATE OP FILE NUMBER
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
AMOUNT
A. FUNERAL EXPENSES:
�. C�.��t��'►c c� a, 3 �t(� . a c�
� ��'C�'1 �.�Y�c i ��i C.�'c�S �, � C�
�G`�C�h; Qr�� �'2�
3o - �c�
B. ADMINISTRATIVE COSTS:
1. Personai Representative Commissions:
Name(s)of Personal Representative(s) \ ��C�.� C�. ��(`.) � �L�
Street Address_ � � � ` �N�11� � �"�� � '�,p� , �
- _ --— _ __ — — �
Cit� ��'r 1�_�_l� __ __ - _ _ State�� ZIP . ���� �
Year(s)Commission Paid: � � L1'� • � �
Z• Attornev fees:
3• Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City --- ------- --— _- ._ __ State ZIP
Relationship of Claimant to Decedent
4• Probate Fees:
5� Accountant Fees:
6� Tax Return Preparer Fees:
7.
TOTAL (Also enter on Line 9, Recapitulation) $ p�s C�� , q
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
� SCHEDULE I
��; ���:'' pennsytvania
oEPARrMENr oF RE�EN�E DEBTS OF DECEDENT,
mHERirnNr_e rax ReruRN MORTGAGE LIABILITIES & LIENS
RESIDEPJT D�CEDEN?
ESTATE OF FILE NUMBER
Aeport debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VAi UF AT DAT� ---
NU��iBER DESCRIPTION OF DEATr�
- � a�Qb� -- -----
�������� C; i 5 al . a�
I�.,�N �� Qc�� A�� �Ca
�N� ����' '• �6r���� � - ��Zl(Z�1 S
� . � sl���- C,�,Y t "� ��, e a�-�.� np� abl� -�cf �fi
� -- � � ��C� � jC�
� `�jC-� ���t�f��,C�
-3• �1 .��,;c1� ��, 1�,C.�/�
� N�� � i��� � ,
� -1 , C>G
TOTAL (Also enter on Line 10, Recapitulation) $ �-� 3�. a
,If more space is needed, insert additional sheets of the same slze,
4503184 02091 0028433887900000380077-0002611
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3801 PaxCon Street
Harrisburg PA 17111-1418
1-888-937-0004
mymetrobank.com
>02091 4503184 001 092140
ROBERT E MINNICH
BAD�DRESS
We're here 7 days a week, 2-1 hours a da} at 1-888-937-0004.
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Siaterr�,enY ��}an��as ttf 4$��ftl�� �- � � �..-���=
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Date Description Debit Credit Balancc
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Interest Summary �
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Fees Summary o
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Total Overdrafr Fees Year to Date 0.00 0
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Tota Returned Item Fees Year to Date 0.00 �
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For your convenience, a summary of overdraft and retumed item fees appears on your monthly statement. Please note that the overdraft fee °,°
summary includes non-sufficient funds fees, uncollected funds fees and unavailable funds fees. The summary does not reflect refunded or waived o
items credited to your account. �
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8 Cycle Page 1 of 2
NOTE :SEE REVERSE SIDE FOR [MPORTANT INFORMATION Member FDIC
J 48500041046
REV-485 EX(05-04)
SAFE DEPOSIT
BOX INVENTORY
PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY
Social Security or Death Certificate Number Date of Death County Code Year File Number
_ _ _ . _. . _ _ _ __ .. _.. _ _..
.��� ��� -
Suffix First Name MI
. _ _ _ _ _
��J 1 I�i1(C,_Y ti I\C� -�'�1��� ; �
_ _ __ __ . _ .
__ _ . _. _. _. _.
�ADDRESS OF DECEDENT STREET: ���, J �i�_ �� CITY: ��� � STATE✓G� ZIP CODE: �
rv� �� 'C
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
NAME: `� '
�� 1 . �
STREETADDRESS: CITY: STATE: ZIP CODE:
�� - '�l ; � �° � � z
� NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING
a. NAME: RELATIONSHIP:
��CLCf�� '(��fln�C`�(1 SiS�� - 1►1 " �C��,i;
STREET ADDRESS: S ATE: ZIP CODE:
S.t� I`�'J r�'Y"��:r�K�C,.,�1 S t �(�,r I�s 1� ��-� j--�� i�
b. NAME: RELATIONSHIP:
STREET ADDRESS: CITY: STATE: ZIP CODE:
c. NAME: RELATIONSHIP:
STREET ADDRESS: CITY: STATE: ZIP CODE:
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
NAME:
�e�t��� �3c�1�-
STREET ADDRESS , , CITY: STATE: ZIP CODE:
--- -----_ __ .1���---�'Yl�xl��_St _ __(�%�1��f�� �'r�- l"�0`f�3
� NAME Oj�PERSON MAKING IAST ENTRY �DATE AND TIME OF LAST ENTRY
�`�d�C'X' '�)� ::�5,
. DATE OF CONTR�ICT,TO RENT BOX NUMBER OF BOX 1 TITLE UNDER WHIC B�OX IS REQUESTE
i 3 i `f�� �. '-�` � � r i' ,
NAME AN ADD ESS OF PERSON(S)HAVING ACCESS TO BOX
; a. NAME: b. NAME:
:�o I�r� F j��11 n iLh
STREETADDRESS: STREETADDRESS:
' ��(� S �S��" S'� ,
CITY: j � � TATE: ZIP j OD� CITY: STATE: ZIP CODE: i
� � :7
NAME AND TITLE OF EM LOYEE TAKING THE INVENTORY
�Jc � I���.d�i� ,.
WAS A WILL IN THE BOX7 ❑ YES NO If yes, a. Date of will:
b. Name and address of personal representative,if named in the will
' NAME:
STREET ADDRESS: CITY: STATE: ZIP CODE:
c. Name and address of attomey,if any
NAM E:
STREETADDRESS: CITY: STATE: ZIP CODE:
L 48500041046 48500041046 �
Page � of�_
SAFE DEPOSIT BOX INVENTORY
dSTRUCTIONS
,1) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by
name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and class of stock.
(3) Obligations of U.S.Government: Number of items,date of issue,face value, names in which registered and type of ownership,
i.e.,jointly held,payable on death,etc.
(4) Bonds: Designate by name,amount,serial number,or other designation. (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: State name of depositor, number of book,last date appearing in book, name of bank
and branch,and balance.
(6) Jewelry,Coins,Stamps, Manuscripts,etc: List and describe as fully as possible.
(7) Deeds, Mortgages,Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible.
(8) All other contents.
(9) Return completed form to: DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT.280601
HARRISBURG,PA 17128-0601
ITEM ITEM DESCRIPTION
NO.
� ��, ���l. Q �
i, C�
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF
CORRECT AND COMPLETE TO THE BEST OF MY KNOWIEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY:
SIGNATURE SI JdRE--� P n �
������ � ����� � \ �� � � �
�v'�
PRINT NAME PRINT NA AND CHE APPROPRIATE BOX BELOW:
�� '<��,�I m �a� C ',;v r��;c.
PRINT TITLE DATE CHECK APPROPRIATE BOX:
) �`,�j�11.�.1�� ��'�` t� '���� .�Executor(trix) �Administrator(trix)
�� ?, �Estate Representative �Joint owner o(safe daposit box
NOTE:Attach additional 8'/:"x 11"sheet(s) if necessary or use duplicates of this page of form.
The Department is authorized by law,42 U.S.C.§405(c)(2)(C)(i),to require disclosure of Sociai Security numbers in connection with administering state tax laws.The Department uses the
Social Security number to identify the decedent and personal representatives of the estate.The Commonwealth may also use the information in exchange of tax information agreements
with Federal and local taxing authorities.The state law prohibits the Commonwealth's personnel from disclosin confidential tax informa6on except for official purposes.
RECEIPT FOR PAYMENT
-------------------
LISA M. GRAYSON, ESQ. Receipt Date : 11/21/2014
Cumberland County - Register Of Wills Receipt Time : 08 : 54 : 24
One Courthouse Square Receipt No . : 1079763
Carlisle, PA 17613
MINNICH ROBERT E
Estate File No . : 2014-01112
Paid By Remarks : TRACY MINNICH
CJ
- -- Receipt Distribution - - -- - -- - - -- ---- ---- -- - - -
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 60 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 10 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
- - - - - - - -
Cash $150 . 50
Total Received. . . . . . . . . $150 . 50
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Soilenbergers-Carlisle Record#: 55310
29 Westminster Dr
Cartisle,PA 17013
(717)249-8149
For: Date: OS/30/2015
TRACY GILBERT MINMCH Time: 11:16 AM
619 FRANKLIN S7'
CARLISLE,PA 17013
7179434205 Clerks Initials:JAB
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Title Number 48557795 �� PennDot-VR- Duplicate Title �0.00
VIN 2B4GH25KlSR342012 �
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Sworn and subscribed to before me on 30-May-2015. ', Totai Surcharge 0.00
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Chan�e Due_ 0.00
'~No Refunds on Service or Notary fees. W'e are not responsible
for the work the State fails to process.
Notary Seal __ __ _
Welcome to Sollenbergers-Carlisle
Your Direct Connection with PENNDOT, "Online",State&Service Fees Apply
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September 5, 2014
Tracy Minnich
619 Franklin Street
Cariisle, PA 17013
Statement of Funeral Expenses for: Robert E. Minnich
Date of Death: August 19, 2014 Account Id: 17275-200
PACKAGE:
Immediate Cremation
OPTION 6 -Cremation $ 2,390.00
t Sub Totai: $ 2,390.00
TOTAL FUNERAL HOME CHARGES: $ 2,390.00
CASH ADVANCES:
1 Certified Death Certificates at$6.00 each $ 6.00
Coroner's Fee $ 30.00
Sub Total: $ 36.00
Bank Account Check Check 13202 Sep 4, 2014 2,426.00
Total Funeral Expense: $2,426.00
Totai Payments Made: $ 2,426.00
Balance: $ 0.00
INVENTORY
REGISTER OF WILLS OF �.�?M��1�� COUNTY, PENNSYLVANIA
COv[VtONWEALTH OF PE�ViVSYLVANIA
COliNTY OF SS File Number
Personal Representative(s)of the Estate of �`1C��� Y"� �. � �i\)ti�L�l
deceased,depose(s)and say(s)that the items appearing in the following inventory include all of the personal assets wherever situate
and all of the real estate in the Common���ealth of Pennsylvania of said Decedent,that the valuation placed opposite each item of said
incentory represents its fair value as of the date of the decedent's death, and that Decedent o�vned no real estate outside of the
Common�vealth of Pennsylvania except that which appears in a memorandum at the end of this inventory.
I verify that the statements made in this Inven- �� �C,� �, ��",���^\��
rory are true and correct. I understand that false state-
ments herein are made subject to the penalties of
18 Pa.C.S. S 4904 relating to uns�vorn falsification to
authorities.
Attorney-- (Name) (Suprei7ie Coitrt LD. No.)
(.Address)
(Tele�hone)
DF i c OF D�ATH LAST RESIDENCE DECEDENT'S SOC.SEC NO
�� - 1 �'t - � 1 �I a3 0 5 - �'` ,�. r�.r� Q� - ����(3 �
FIGURES NNST BE TOTALED
a�.�.� ��`\/ (�,- , �— ".—�._._. _ � L�i i �u � �
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i �
(Attach additioital slteets as needed)
�,oTAL: S � ,
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative indude the value of each
item,but such fipures should not be extended into the total of the Inventory. (See?0 Pn. C.S.§3301(6))
Fornt RW-09 rev. 10.13.06
Jackson National Life Insurance Company A� K S �N�
PO Box 1207 Jacksonville IL 62651-1207
Phone 800-323-8764 Fax 803-333-4938 NATIONAL LIFE INSUAANCE COMPANY
Apri14,2014
THE ESTATE OF EDWINA J MINNICH
C/O ROBERT E MINNICH
230 S 8TH ST
LEMOYNE PA 17043-1813
Policy Number: 5610086
Insured's Name:EDWINA J MINNICH
Correspondence Number: 02036080
Dear Mr.Minnich:
We recently received information from the United States Social Security Administration("SSA")regarding a notice
of death for Edwina J Minnich as of December 27,2008.Our sincere condolences go to the family for their loss.If
the information we received from the SSA is incorrect please contact our office at the phone number located at the
top of this page.Additionally,contacting our office will not correct the SSA's records,so we recommend you
contact them also if the information is incorrect.
In order to proceed with our review of the claim,we require the following items to be submitted:
• The enclosed Claimants Statement completed and signed by the named beneficiary. If the beneficiary
has had a change in name,we require a copy of the applicable marriage license,divorce decree or similar
legal documents.
• Heirship Affidavit-Please complete this form identifying the heirs of the insured. All responders must
complete and sign the form.
Please review Page 1 of the Claimant Statement which also explains other documents that may be required.
Providing the Claimant Statement is not an admission of liability on the part of the Company.
We will promptly review and evaluate the claim upon receipt of the required documents. If you have any questions,
please call our office at 800-323-8764,Monday through Friday from 730 AM to 4:30 PM Central Standard Time.
Sincerely,
Mickey C.
Claims Services
Enclosure(s): Life Claimant Slatement No RAA
HEIRSHIP AFFIDAVIT
Fax Send' Image page �
Date & Time : DEC-13-2014 03:41AM SAT
Model Name : B1265dnf Laser MFP
Machine Serial Number : JLRH7S1
No Name/Number Start Time Time Mode Page Result.
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CLAIMANT STATEMENT
� � � �
l.Name of Deceased(Last,First Middle) 2.Last 4 digits of Deceased's Social
m 1 1`.1 N�i C•� �1 U�j�i� � , Security No: 1 G,�
1 1
3.If the Deceased was known by any other n es,such as maiden name,hyphenated name,nickname,derivative
form of first and/or middle name or an alias,please provide them below.
4.Policy Number(s) � � I o O� � 5.If policy is lost or not available,please explain:
�
6.Deceased's Date of Death 7.Cause of Death 8. Natural❑ Accidental
p� ❑ Suicide❑ Homicide
� � � -1 " t�� �� �- A ❑ Pendin
9. Claimant Name(Last,First,Middle). If trust,please list trust name and complete Trustee Certification section.
m��N rv",c� �,1�c � -
10. Street Address ' 11.City 12. State and Zip 13.Daytime
Phone Number
C��q �-,�aNk1r, � sr C�a��'�S�,Q, pA . �-��r 3 ���_ �.-f3 - ao,s
14.Date of Birth 15. Social Security or Tax ID Number 16.Relationship to Deceased
�� - a�- (�� S'�s'r�. � n� L�
17.I am filing this claim as: an individual who is named as a beneficiary under the policy
❑a Trustee of a Trust which is named as a beneficiary under the policy
,�an Executor of Estate which is named as a beneficiary under the policy
❑ Other
18.Are you a U.S.Citizen? Yes No
If"No" lease list coun of citizenshi
19. Policies subject to Viatical / Life Settlement transactions - Are you a viatical settlement
provider, life settlement provider, the receiver or conservator of viatical or life settlement �Yes
company, a viatical or life financing entity, trustee, agent, securities intermediary or other
representative of a viatical or life settlement provider; or an individual or entity which invested in ❑No
this olic as a viatical or life settlement?
20. Claimant Name(Last,First,Middle). If trust,please list trust name and complete Trustee Certification section.
21. Street Address 22.City 23. State and Zip 24.Daytime
Phone Number
25.Date of Birth 26. Social Security or Tax ID Number 27.Relationship to Deceased
28. I am filing this claim as: ❑an individual who is named as a beneficiary under the policy
❑a Trustee of a Trust which is named as a beneficiary under the polic}�
❑ an Executor of Estate which is named as a beneficiary under the policy'
❑Other
29.Are you a U.S. Citizen? ❑Yes ❑No
If"No" lease list coun of citizenshi
30. Policies subject to Viatical / Life Settlement transacrions - Are you a viatical settlement
provider, life settlement provider, the receiver or conservator of viatical or life settlement ❑Yes
company, a viatical or life financing entity, trustee, agent, securities intermediary or other
representative of a viatical or life settlement provider;or an individual or entity which invested in ❑No
this olic as a viatical or life settlement?
YOUR SIGNATURE IS REQUIRED ON THE NEXT PAGE.
CL G012F Life Claimant Statement No RAA 02/13/2014 Page 3
CLAIMANT STATEMENT
'The policy may contain one or more settlement options, such as Interest Payments, Installments for a Specified
Amount, Life Annuity, Life Annuity with Period Certain, and/or Joint Life and Survivorship Annuity. You may
choose to receive a lump sum payment or another settlement option available in the policy under which a claim is
made. For more information,refer to the optional methods of policy settlement provision in the policy or contact us
at the mailing address noted on the front of the claim form.
If you wish to select a settlement option,please indicate your settlement selection by name (not by number) on the
line below after you have carefully reviewed the options available in the policy. Availability of settlement options
are subject to the terms of the policy.If you do not choose a settlement option,we will send a lump sum settlement to
you.
Name of Settlement O tion from Polic
To help fight the funding of terrorism and money-laundering activiries, the U.S. govemment has passed the USA
PATRIOT Act,which requires banks, including our processing agent bank,to obtain,verify and record information
that identifies persons who engage in certain transactions with or through a bank. This means that we will need to
verify the name, residential or street address (no P.O. Boxes), daxe of birth and social security number or other ta�c
identification number of all account owners.
A valid claim will include interest due and payable from the date of death at a rate of 10%if we do not pay the claim
within 31 days from the latest of 1)the date that we receive proof of death,2)the date we receive sufficient
information to determine our liability and the appropriate beneficiary(ies)entitled to the proceeds;or 3)the date that
an le al im ediments are resolved.
This information is being collected on this form versus IRS form W-9 and will be used for supplying information to
the Internal Revenue Service(IRS). Under penalty of perjury,I certify that 1)the tax ID number above is correct(or
I am waiting for a number to be issued to me), 2) I am not subject to backup withholding because (a) I am exempt
from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a
result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to
backup withholding, and 3) I am a U.S.person(including a U.S. resident alien). Please cross through item 2 if you
have been notified by the IRS that you are subject to backup withholding because you have failed to report all
interest and dividends on our tax retum.
I/We do hereby make claim to said insurance, declare that the answers recorded above are complete and true, and
agree that the furnishing of this and any supplemental forms do not constitute an admission by the Company that
there was any insurance in force on the life in question,nor a waiver of its rights or defenses.
For Residents of New York: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information, or
conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act,which is a crime,and shall also be subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim for each such violation.
For Residents of All Other States: See the Fraud Information section of this claim form.
The Internal Revenue Service does not require your consent to any provision of this document other
than the certifications required to avoid backup withholding.
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Signa re f Claimant and Title Date
Signature of Second Claimant,if any,and Title Date
CL G012F Life Claimant Statement No RAA 02/13/2014 Page 4