HomeMy WebLinkAbout12-16-05
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REV-1500 EX + (6-00)
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OFFICIAL USE ONLY
REV.1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
I DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
: Myers, Doris R
~TE OF DEATH (MM-DD-YEAR)
i 06-06-2005
FILE NUMBER
II
00527
05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
NUMBER
l DATE OF BIRTH (MM-DD-YEAR)
04-14-1921
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
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187-16-6203
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
4a. Future Interest Compronlse (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10 Spousal Poverty Credit (date of death between
. 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Retum Required
1 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
[!] 1. Original Retum
D 4. Limited Estate
IX] 6. Decedent Died Testate (Attach
..- copy of Will)
9. Litigation Proceeds Ree&ived
2. Supplemental Retum
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NAME
John E. Slike, Esq.
FIRM NAME (If applicable)
Saidis, Shuff, Flower & Lindsay
TELEPHONE NUMBER
(717) 737-3405
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
COMPLETE MAILING ADDRESS
2109 Market Street
Camp Hill, PA 17011
(1 ) None OFFICI~ USE O~~ y
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(2) None (--,
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(3) None C)
(4) None 0"1
(5) 304,334.76 -u
(6) None f',)
(7) None N
(8) 304,334.76
(9) 18,589.24
(10) 2,292.07
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15. Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
(11 ) 20,881.31
(12) 283,453.45
(13) 0.00
(14) 283,453.45
x .00 (15) 0.00
..~--------
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
16.Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. D
283,453.45
x .045 (16) 12,755.41
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) D Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
0.00
0.00
x .12 (17) 0.00
x .15 (18) 0.00
(19) 12,755.41
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group. Inc.
Form REV-1500 EX (Rev. 6-00:
Decedent's Complete Address:
STREET ADDRESS
1738 Creek Vista Drive
~
CITY New Cumberland
STATE P A
ZIP 17070
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
12,755.41
11,400.00
600.00
Total Credits (A + B + C)
(2)
12,000.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
755.41
755.41
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;.................................................................................. D ~
b. retain the right to designate who shall use the property transferred or its income;.................................... D ~
c. retain a reversionary interest; or.................................................................................................................. D ~
d. receive the promise for life of either payments, benefits or care?.............................................................. D ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?........... ................... ......... ........... ................................... .................................. D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... D ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?..................................................................................................................... D ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, r declare that I have examined this return, including accompanying schedules and statements. and to the best of rny knowledge and belief, it is true. correcl and
ete. Declaration of r rer other than the onal r resentative is based on all infonnation of which re rer has an knowled e.
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DATE
ADDRESS
P.O. Box 59 HNP J J
Hawaii National Park, HI 9671~__.___._(4L_c;;::. D
1738 Creek Vista Drive .r-. /'
New Cumberland, PA 17070 tiS
DATE
2109 Market Street
Camp Hill, PA 17011
ADDRESS
tes of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
ving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)].
r 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%
[72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax retum 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 twenty-one 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% [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%, 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% [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.
ESTATE OF
Myers, Doris R
PA Inheritance Tax Return
Signature of Additional Fiduciaries
FILE NUMBER
21-05-00527
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 #3
Name
Address1
Address2
City, State, Zip
Date
Mechanicsburg, PA 17050
//i:J0~-
I
Rev.1508 EX+ (8-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Myers, Doris R
FILE NUMBER
21-05-00527
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property JolnUy-owned with the rlght of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 GE Capital Assurance, long term care coverage 2,240.00
2 Travelers Life, June prorated payment 500.00
3 Travelers Life, long term care coverage 3,100.00
4 United Amercan Insurance Co., refund of premium 166.81
5 Alliance Capital mutual fund 38,012.02
see attached letter
6 Commerce Bank, CD #51075 101,211.24
see attached letter
7 M&T Bank, checking account #3363870 6.434.00
see attached letter
8 PA State Bank, money market acct. #22003420 58,656.25
see attached letter
9 jewelry - see attached list 4.550.00
10 Condo time share in Pike County, PA 12.500.00
11 MetLife Annuity contract, #073-406-840-AB 76.964.44
children are beneficiaries, see attached letter
TOTAL (Also enter on Line 5, Recapitulation)
304.334.76
(If more space is needed. additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
REV.1151 EX+ (12-991
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Myers, Doris R
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-05-00527
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
8,942.28
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State Zip
2.
Attomey's Fees
See continuation schedule{s) attached
5,500.00
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Nancy M. Dunkle
Street Address 1738 Creek Vista Drive
City New Cumberland
3,500.00
Relationship of Claimant to Decedent
State
daughter
PA
Zip
17070
4.
Probate Fees
310.00
See continuation schedule(s) attached
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
336.96
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation)
18,589.24
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
ReY-1502 EX+ (6-9S)
.
SCHEDULE H.A
FUNERAL EXPENSES
continued
COMMONWEAlTH OF PENNSYI. VANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Myers, Doris R
FILE NUMBER
21-05-00527
ITEM
NUMBER DESCRIPTION AMOUNT
1 Funeral luncheon 169.48
2 Myers-Harner Funeral Home 8,569.00
3 Nancy Wilson, soloist 100.00
4 Trinity ELC, reception 103.80
Subtotal
8.942.28
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1502 EX+ (6-9S)
.
SCHEDULE H.B2
ATTORNEY'S FEES
continued
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Myers, Doris R
FILE NUMBER
21-05-00527
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Said is, Shuff, Flower & Lindsay
5.500.00
Subtotal
5.500.00
Copyright (c) 2002 form software only The Lackner Group. Inc.
Form PA-1500 Schedule H.B2 (Rev. 6-98)
Rev-1502 EX+ (6-98)
.
SCHEDULE H.B4
PROBATE FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Myers, Doris R
FILE NUMBER
21-05-00527
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Register of Wills of Cumberland County
310.00
Subtotal
310.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B4 (Rev. 6-98)
Rev-1502 EX+ (6-98}
.
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Myers, Doris R
FILE NUMBER
21-05-00527
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Cumberland Law Journal, estate notice
75.00
2
PNC Check fee
28.08
3
The Patriot News, estate notice
233.88
Subtotal
336.96
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rev-1512 EX+ (6-98)
.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Myers, Doris R
FilE NUMBER
21-05-00527
ESTATE OF
Include unrelmbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1 Beverly Healthcare Nursing Home expenses
VALUE AT DATE
OF DEATH
1.136.41
2 Pharmerica, pharmacy bill
859.49
3 Verizon, phone bill
7.17
4 Woodlock Pines lake House Assoc.
289.00
TOTAL (Also enter on Line 10, Recapitulation)
2,292.07
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule I (Rev. 6-98)
REV.1513 EX+ (9..00)
.
SCHEDULE ..
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Myers, Doris R
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS pnclude outright spousal
aistributions, and transfers
under Sec. 9116(a)(1.2)]
FILE NUMBER
21-05-00527
RELATIONSHIP TO
DECEDENT
Do Not List Trustee/51
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
1
Nancy M. Dunkle
1738 Creek Vista Drive
New Cumberland, PA 17070
Daughter
1/3 of residue
2
Charlene M Meyers
P.O. Box 59
Hawaii National Park, HI 96718
Daughter
1/3 of residue
3
William H. Myers
615 Good Hope Road
Mechanicsburg, PA 17050
Son
1/3 of residue
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule J (Rev. 6-98)
r! M&fBank
499 Mitchell Road, MiIIsboro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
July 13.2005
Law Offices
Saidis, Shuff, Flower & Lindsay
2109 Market Street
Camp Hill, PA 17011
Re: Estate of Doris R Mvers
Social Securitv: 187-16-6203
Date of Death: June068. 2005
Dear Sir or Madam:
Per your inquiry dated July 05, 2005, please be advised that at the time of death, the above-named decedent had on deposit
with this bank the following:
I.
Type of Account
Checking Account
Account Number
33363870
Ownership (Names of)
Doris R Myers *
Nancy M Dunkle. POA
Opening Date
06/28/86
Balance on Dat~ of Death
$6,433.75
Accrued Interest
$ 0.25
Total
.A____________________________________________________________
$6.434.00
2. Type of Account Safe Deposit Box
Box Number/Location 0000801/ High/and Park
Ownership (Names of) Doris R Myers *
Nancy M Dunkle, POA *
Opening Date 02/16105
** If you have any further questions concerning this account, regarding ownership, closures and/or
reimbursement of funds, etc., please contact our Highland Park Office at 344 South 10th Street, Lemoyne, PA
,17043, or phone the branch at # 717-737-3322.
Sincerely,
~C~
Nancy Clagett
Records Management
Wachovia Securities, LLC
Eberly & DeRuri Financial Consulting Group
of Wachovia Securities
Three Lemoyne Drive
Lemoyne, PA 17043
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Tel 717 975-8424
Toll Free 866 837-3186
Fax 717 975-8426
July 7,2005
John E. Slike
Saidis, Shuff, Flower & Lindsay
2109 Market Street
Camp Hill, PA 17011
WACHOVIA. SECU'RITIEs
Re: Doris R. Myers, D.O.D. 6/6/05
Dear Mr. Slike:
This letter is in response to your letter of July 5th for information regarding the accounts of Doris
R Myers.
We are currently listed as the broker of record for one account for Doris R. Myers held at
Alliance Bernstein Funds.
The information that you requested is as follows:
The assets at Alliance Bernstein are one mutual fund: Growth and Income B shares. The NA V
for the date of death was $3.66 per share. The account value on date of death was $ 38,012.02
for share balance of 10,385.798 shares.
Prior to any new activity in this account, the new account application will need to be completed
and sent to Alliance Bernstein along with a signed letter of authorization from all of the persons
listed on the short certificate indicating what is to be done with account. They also require a
short certificate dated within 60 days. If you have any questions on the Alliance Bernstein
application, please call their service area; toll free at the number listed on the application. You
may make copies as needed.
Please let me know if I can be of further assistance to you.
e ay
ministrative Assistant
PRJ/prj
Enc: Alliance Bernstein Account Application
CC: Charlene Meyers
Membef NYSE,i $IPC
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Commerce
_Bank~
October 22, 2005
OCT 2 5 2005
Saidis, Shuff, Flower & Lindsay
2109 Market St
Camp Hill, PA 17011
RE: Estate of: Doris R Myers
Social Security #: 187-16-6203
Date of Death: June 6, 2005
Dear Sirs:
In reference to the letter regarding the above mentioned
Estate, we would like to inform you of the information that
we have researched and found.
Type: Time Deposit
Account #: 51075
Date Opened: 10/12/04
Primary Owner: Doris R Myers
Power of Attorney: Nancy Dunkle
Date of Death Balance: $101,211.24
Accrued Interest: $160.28
Principal Balance: $101,050.96
If there are any questions or additional information that
is needed, please feel free to contact me at (717) 795-7118
ext. 3151.
Sincerely,
~dQ ~ ~~
Wanda J Morris
Senior crF Specialist
Commerce Bank / Harrisburg, N.A.
P.O. Box 8599
100 Senate Avenue
Camp Hill, Pennsylvania 17001-8599
.
Jewelry of Doris R. Myers
Item Value
14k gold Tennis Bracelet $750.00
Diamond 3/4c solitare ring, 14k gold $750.00
14k gold bracelet with 3 1/4c diamonds $250.00
1/2c diamond 14k gold necklace $500.00
Ladies diamond 14k gold engagement rina with 1/2c and 4-2pt diamonds $750.00
Ladies white gold watch with diamond band, 12-3pt diamonds $650.00
14k white gold diamond heart necklace, 20-1pt diamonds $550.00
14k aold bracelet with 8 14k gold charms $350.00
$4,550.00
"--.-- --<,"" ---','-. --._. --- ----.--- .-., .--......
I
PO Box 40007, Lynchburg, VA 24506-9939
June 7, 2005
The Estate Of Doris Myers
C/O Nancy Dunkle
1738 Creek Vista Dr.
New Cumberland Pa 17070
CLAIMANT:
POLICY NO.:
CLAIM NO.:
Doris Myers
HFN6353622
A065995
Dear Ms. Dunkle:
Please accept our condolences on your recent loss.
The final benefit check is being sent under separate c~2~ent is for the period
May 05, 2005 through June 05, 2005 in the amount 0 $2,240.00. .
Please let us know if we can be of further service to you during this difficult time.
We are ready to assist you. If you have questions, please contact us:
· Toll free at: (800) 876-4582: we are available Monday tt>.rough Friday from 6:00
A.M. to 5:00 P.M. (Pacific Time).
· By mail at: P.O. Box 40007, Lynchburg, V A 24506-9939
· By Fax at: 888-557-5526.
Please be sure to include the claim number on the documents. Please allow 48
hours for faxes to show in our system.
Thank you for choosing General Electric Capital Assurance Company for your long term
care Insurance.
Sincerely,
Brijesh Nayyar
Customer Service Specialist
Claims Services, General Electric Capital Assurance Company
Affiliated companies: General Electric Capital Assurance Company - GE Capital Life Assurance Company of New York
.
.
METROPOLITAN LIFE INSURANCE COMPANY
PO BOX 17700
DENVER CO 80217-0700
MetLife@
JOHN E SUKE
C/O SAIDIS SHUFF FLOWER & lINDSA Y
2109 MARKET ST
CAMP HILL PA 17011
RE ANNUITY DEATH CLAIM
DECEASED DORIS R MYERS
CONTRACT 073 406 840 AS
Dear Mr Slike
This is in response to your call to our toll free number requesting the date of death value
for the above contract.
Contract 073 406 840 AS is non-qualified and all monies over the cost basis are
c taxable in the year received. The date of death valueas of J~6,2005 is
$76,964.44. The current value is $76,980.84.
If you have any questions, please feel free to call our toll-free number at 1-800-638-7732.
One of our Customer Service Consultants will be happy to assist you.
Sincerely
~~~
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Michael Herriman
Annuity Death Claim Unit
Annuity Operations-Tulsa
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XCELLENCE
Sili4e
August 24, 2005
John Slike, Esquire
2106 Market Street
Camp Hill, PA 17011
Dear Attorney Slike:
All of the Woodloch family was sorry to hear of the loss of Mrs. Myers.
As requested, I have researched the approximate value of similar Time Segments to that of
Time Segment 23, Unit 2 (Memorial Day). This information may help Yo~valu~.the unit.
a Time Segment #11 sold for $12,500.00 in 2002.
As you can see, the above Time Segment sold in 2002. This is the most current sale we
have record of and the closest to compare Mrs. Myers' Time Segment to. I hope this
information will give you some parameters to work with.
If you have any questions, please don't hesitate to contact me.
Sincerely,
.~~~
Brandie White
Administrative Assistant
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cc: Charlene Meyers
AN AW,4,.RD,WINNTNG RE~ORT & CHAMPIONSHIP GOLF COURSE
RR 1 Box 280, Hawley, PA 18428~9757 (0 570.685.8000 ~ $00.572.6658
www.woodloch.com
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lersLife&Annui(
A member of atlqroup
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LOXG TBRX CARE DIVISION
P.O.Box 8021
SAX RAFAEL CA 94912-8021
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000000048 9460091024 1
1 REGUI.AR MAIl.
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DORIS R MYERS
1738 CREEK VISTA DRIVE
NEW CUMBERLAND PA 17070-2213
A065996
CLA IMANT NAtvE: ()(R IS R MYERS
Payment for May
2005 through May 31 2005
Total dollars paid to date: $ 23,393.54
Total dollars remaining: $ 49,606.46
Your claim is scheduled for reimbursement review on or about 07/26/05.
Invoices must be received on or before 07/20/05 for timely benefit processing.
Nursing Home Facility = $ 3,100.00
Excluded Amount $2,629.00 Reason: Exceeds Daily Max.
CKat231o.1f.O) Please detach before neqotiatinQ check
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umted amerIcan Insurance company
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3700 SOUTH STONEBRIDGE DRIVE . POST OFFICE BOX 8080 . MCKINNEY, TEXAS 75070
Date 06/20/2005
Estate of Doris R Myers
1738 Creek Vista Dr
New Cumberlnd PA 17070
Policy 574521804
Check No 265558
Dear Sir or Madam:
We are concerned to learn of the death of our Insured.
Attached is the refund of monies paid beyond the date of death for policy number 574521804.
Sincerely,
Ann Braswell, Vice President
Policy Service
Detach This Portion At Dotted Line Before Depositing Check
62DU
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LC3G TBRII CARE DIVISIOI'
P.O.Box 802~
SAI RAFAEL CA 949~2-802~
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000000024 9460093521 1 1 REGULAR MAIL
I.. .111.. .111. ..I.. .111.... .1.1. .1.1.. .11. .11...11.1. .1. .11..1
THE ESTATE OF DORIS HYERS
1738 CREEK VISTA DRIVE
NEW CUMBERLAND PA 17070-2213
o PNCRAN<
A065996
CLAIMANT NME: OCRIS R MYERS
~;4 L fJA 1/)'Y)<r~4J T oV LT (!
040 t
CAMP HILL (102) 0
2101 MARKET STREET .
CAMP HILL PA 17011\~ .
Cashbox 01 \ ~ \
* Depos it Check
11:32 AUG 122005
Account Number
Tran Amount
5003871365
$500.00
Payment for Jun
2005 through Jun 5 2005
Sequence Number 00105
W/S 10 WWSH1021
Batch 401
ClaWZ3 10.tloO:l
t is accepted subject to
This deposit or paymen les and regulations of
verification and :0 the r~ot be available for
this bank. .oepos1tsl ma~eceiPt should be held
i ..ed i ate W 1 thdrawa .
until verified with your statnent.
Please detach before negotiating check
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SAIDIS,
SHUFF &
MAS LAND
AITORNEYS.A T.U W
2109 Market Street
Camp Hill, PA
LAST WILL AND TESTAMENT
OF
DORIS R. MYERS
I, DORIS R. MYERS, of the Borough of Camp Hill, Cumberland
County, Pennsylvania, declare this to be my Last Will and
Testament, hereby revoking any will previously made by me.
I - I direct the payment of all my just debts and funeral
expenses out of my estate as soon as may be practical after my
death.
II - I bequeath certain articles of my tangible personal
property in accordance with a written list made by me during my
lifetime. In absence of a list or designation on such list, my
tangible personal property shall be divided among my living
children or sold as my Executors shall determine.
III - I direct that my deceased husband's brother, G. BOYD
MYERS, shall have the right to be interred in our burial lot in
R.olling Green Cemetery, Lower Allen Township, Cumberland County,
Pennsylvania, next to his mother, Lucille M. Myers.
IV - I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate
unto my three children, CHARLENE M. MEYERS, NANCY M. DUNKLE and
WILLIAM H. MYERS, the share of a deceased child to be paid to his
(Jj 1r'l711 e
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SAIDIS,
SHUFF &
MAS LAND
ATIORNEYSoAToLAW
or her issue per stirpes.
v - I appoint my children, CHARLENE M. MEYERS, NANCY M.
DUNKLE and WILLIAM H. MYERS, as Executors of this, my Last Will
and Testament. My Executors shall not be required to post bond
in this or any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on
this, the ,;2?"~/~
/1 /.
day of 7U---Z:'i?rvr-rz:.--Jr--
, 1998.
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DORI SR. MYERS /
( SEAL )
Signed, sealed, published and declared by DORIS R. MYERS, Testa-
trix therein named, on this and one (1) other sheet of paper as
and for her Last Will and Testament, in our presence, who, in her
presence, at her request, and in the presence of each other, have
hereunto subscribed our names as attesting witnesses.
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Yfl'l/k ,-Cl .?~
If' Name
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" I Name
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Address'
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, Address
2109 Markel Street j
Camp Hill, P A
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SAID IS,
SHUFF &
MASLAND
ATIURNEYSoAToLAW
2109 Market Street
Camp Hill, P A
COMMONWEALTH OF PENNSYLVANIA)
COUNTY
SS.
OF
CUMBERLAND)
WE, the undersigned, the Testatrix and the witnesses,
respectively, whose names are signed to the foregoing instru-
ment, being first duly sworn, do hereby declare to the under-
signed authority that the Testatrix signed and executed the
instrument as her Last Will and Testament and that she signed
willingly (or willingly directed another to sign for her), and
that she executed it as her free will 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
witnesses and that to the best of their knowledge the Testatrix
was at that time eighteen years of age or older, of sound mind,
and under no constraint or undue influence.
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TestatriX
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() ;/ Witness
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// wi tness ·
Subscribed, sworn to and acknowledged before me by the
testatrix, and subscribed and sworn to before me by both wit-
nesses, this ,;;(:3rd day of Ve,ve,'))be-.-- 1998.
Notarial Seal .
Jo Smith, Notary Public
Camp Hill Boro, CU":1berland Coun6b
My Commission Expires May 6, 20
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otary Public