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REI!. 1500 EX + l'~)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY CODE YEAR _
SOCIAL SECURITY NUMBER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
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DECEDENT'S NAME (LAST. FIRST. AND MIDDLE INITIAL)
McKEEHAN, James S.
188-12-5365
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
DATE OF DEATH (MM-DD-VEAR)
DATE OF BIRTH (MM.DD.YEAR)
----~~~~-~--_.__._-_._--,---_._------
08/11/2005
08/01/1919
REGISTER OF WILLS
- -. ---. - ----
SOCIAL SECURITY NUMBER
OJ: -Remainder Retum (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
- -. - ----.--....-- .~-----_..,~----_._--- ------ --.
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLE INITIAL)
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~ 1 Original Return
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o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after
12-12-82)
o 7. Decedent Maintained a Living Trust (Attach
copy oITrust)
o 10. Spousal Poverty Credit (date of death between
_ 12-31.,91 and 1-1:l1QJ___ ____.~._
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
Hillary A. Dean, Esquire
4. Limited Estate
6. Decedent Died Testate (Attach copy
of Will)
9. Litigation Proceeds Received
ICI (t,
00860
. ____.NUMBEFl
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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FIRM NAME (If applicable)
Martson Deardorff Williams & Otto
10 East High Street
Carlisle, PA 17013
TELEPHONE NUMBER
717/243-3341
----~-~~"-_. ._-~
-----~._--.._~_._---_._.__._--_._----._-------. ~-~._.- - ----_._--._~-"-- --
-----.._-- ---~~-~.__._~-_.._--_._-_._--
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1 )
(2)
(3)
(4)
96,658.80
None
3. Closely Held Corporation, Partnership or Sole-Proprietorship
None
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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)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
(7) 43,174.37
(8)
(9) 24,141.89
(10) 101.20
(11 )
None
(5) 47,150.13
(6) None
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(12)
13. Charitable and Govemmental Bequests/Sec 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)
(13)
\;>, ',<,:.,~..;:
186,983.30
24,243.09
162,740.21
162,740.21
(14)
SEE INSTRUCTIONS ON REVERSE SIDE 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)
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16. Amount of Line 14 taxable at lineal rate
162,740.21 x .045
(16)
17. Amount of Line 14 taxable at sibling rate
x .12
(17)
18. Amount of Line 14 taxable at collateral rate
x .15
(18)
7,323.31
19. Tax Due
(19)
20. 0
>> BE SURE TO ANSWER ALL QUesTIONS ON REVERSE SIDE AND RECHECK MATH<<
Form REV-1500 EX (Rev. 6-00)
Copyright 2000 form software only The Lackner Group, Inc.
7,323.31
Decedent's Complete Address:
STREET ADDRESS
279 Springview Road
CITY
--_._-----~-~-----
~~--- ._---_..._----~_._--- --------------
Carlisle
STATE PA
lIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
7,323.31
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + 8 + C)
(2)
0.00
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is thEOVERPAYMENT.
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 theTAX DUE.
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(3)
(4)
(5)
(5A)
(58)
0.00
7,323.31
7,323.31
Make Check
to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"'N THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.............................,............................................... ~ ;
~: ~::::~ ~h~e~~~~i~~~~s:~~;~es~~. .~~~~I. .~.~.~. ~.~~. :.~~:.~,~ .~~~~.~~.~.~~~. .~.~ .i.~. ~~.~.~~~.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'~~::::::::::: .'.'.....
d. receive the promise for life of either payments, benefits or care?...........................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?............................ ................... ........................... ....................................... 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?........ 0 ~
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.
-- - -.."----.._--------,-- - -
Under penalties of pe~ury, I declare that I have examined thiS retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Oeclaration
prepare~~her than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Michael Henry 25 Pennw~ Drive
SI~NRE~P61t~rNG RETURf.,-------ADDRESS ._~arlisl~__l ~O!.3.___ J - 2 4 ~A~ '
SIGNATURE OF PREPAREROTHER THAN REPRESENTA~ ---
Hillary A. Dean, Esquire
ADDRESS
DATE
10 East High Street
Carlisle, P A 17013
For dates 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
surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)l.
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%
[72 P.S. 99116 (a) (1.1) (ii)]. The statutedoes not exemot 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 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. 99116 (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. 99116
1.2) [72 P.S. 99116 (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. 99116 (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.
.
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
-----~-~-----~_._---_._"_.-
- ------_._~--_._--~~--~_._-.._--_._-----,-
All real prope~ 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 exchanged between a willing buyer and a wining seller, neither being compelled to buy or sell, both having
reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
FILE NUMBER
21 - 05 - 00860
ITEM
NUMBER
I
--~------------_._---- -----.._---
DESCRIPTION
VALUE AT DATE OF
DEATH
96,658.80
Residence situate at 279 Springview Road, West PennsboroTownship,Cumberland County, PA, known as
parcel No. 46-08-0585-083, being described in Deed dated January 26, 2001, and recorded in
Cumberland County, PA, Deed Book 238, Page 492, and being conveyed to James S. McKeehan. Value
is assessed value X common level ratio of 1.11.
--- -~-_.__._._--- --- --.- ------- --_.._---_._----.._-~~---. -----------------------------.- --- -.----
-----------------.-----_._~--_._--
TOTAL (Also enter on Line 1, Recapitulation)
96,658.80
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
---~'-"-----------'-------- --.-------______________ n_._______.._________ ______
. ----------- --------.-----.- -..----..'---------...-- --
FILE NUMBER
21 - 05 - 00860
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
NUMBER
1
--..--- .-.-.-.---..--~..---.__. ---..---- -- ----- .- ---- __'_______u__ _ __ __n ____ _ __ ___...______
Citizens Bank checking account #610073-149-9
VALUE AT DATE OF
DEATH
21,364.86
DESCRIPTION
2
Citizens Bank CD #6140-720982
5,869.60
3
Citizens Bank CD #6140-857651
2,354.11
4
2004 Chevrolet S 10 pickup truck, Kelley Blue Book value
17,230.00
5
P A Turnpike Commission, refund of insurance premium
132.62
6
P A State Employees Retirement System, benefit
183.94
7
Register of Wills, refund of fees
15.00
TOTAL (Also enter on Line 5, Recapitulation)
47,150.13
*'
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
FILE NUMBER
21 - 05 - 00860
ITEM
NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH % OF
InClude the name of the transferee. their relationship to decedent and the date of transfer. VALU 0 S T. DECO'S EXCLUSION TAXABLE VALUE
Attach a copy of the deed for real estate. E F AS E INTEREST (IF APPLICABLE)
-~-------_.~-~-~---_.._---_._--
Symetra Annuity AN0971207: Beneficiary, Michael Henry,
grandson, 100%
43,032.46i 100%
0.00
43,032.46
2
Citizens Bank IRA #6140888751: Beneficiary, Michael
Henry, grandson, 100%
141.91 100%
0.00
141.91
TOTAL (Also enter on line 7, Recapitulation)
43,174.37
.
SCHEDULEH
FUNERAL EXPENSES &
ADMINSTRATlVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
------ ------------------.------ .------- ------------
FILE NUMBER
21 - 05 - 00860
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
"- -- -----_.._._-_.~----~ -------- --.--- --,._-----------
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Hoffman-Roth Funeral Home, Carlisle, PA
7,625.05
B.
ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Michael Henry
Social Security Number(s) I EIN Number of Personal Representative(s):
203-50-4172
Street Address 25 Pennway Drive
City Carlisle State P A Zip 17013
Year(s) Commission paid 2006
Attorney's Fees Martson Deardorff Williams & Otto (estimated)
7,600.00
2.
7,900.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Cumberland County Register of Wills
334.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Certified mailing, Department of Public Welfare
4.42
2
Register of Wills, filing fee, Inheritance Tax return
15.00
Total of Continuation Schedule(s)
663.42
TOTAL (Also enter on line 9, Recapitulation)
24,141.89
.
SchectE H
FmeraI Expenses &
~CosIscontinued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
3
Register of Wills, filing fee, Will Petition
------~._------ ---_.__._-~-----_._.._-_._. - - -_._--'--~---'----------'-'--- -- - - ---._--
FILE NUMBER
21 - 05 - 00860
4
Register of Wills, Citation issue
5
Landex Title search
6
Register of Wills, Short Certificates
7
The Sentinel, advertising Letters Testamentary
8
Cumberland Law Journal, advertising Letters Testamentary
9
Nationwide Insurance, homeowners insurance pending disposition of real estate
10
Recorder of Deeds, filing fee
11
Martson Deardorff Williams & Otto, reserve for miscellaneous filing fees and costs
Page 2 of Schedule H
30.00
20.00
0.63
4.00
144.29
75.00
51.00
38.50
300.00
*'
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
- ---_..._._--~.._~-----_._-- ---.-- -_._.~---_._-----_._--
FILE NUMBER
21 - 05 - 00860
Include unreimbursed medical expenses.
ITEM
NUMBER
1
---.--------.. ---------------- ---...-----.------------
DESCRIPTION
AMOUNT
Outstanding check on date of death, Citizens Bank checking #6100731499
68.20
2
Andorra Radiology Assoc., P.C., account payable
33.00
TOTAL (Also enter on Line 10, Recapitulation)
101.20
REV-1513 EX. (9-00)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
McKEEHAN, James S.
FILE NUMBER
21 - 05 - 00860
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Michael Henry
25 Pennway Drive
Carlisle, PA 17013
RELATIONSHIP TO
DECEDENT
DQJtQlU.tTrust~1
AMOUNT OR SHARE
OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
Grandson
One-fourth of estate
residue + vehicle
($17,000) + real estate
($96,658.80)
2 Kelley Henry
279 Springview Road
Carlisle, PA 17013
Granddaughter
One-half of estate
residue
3 Sharon Liberator
271 Springview Road
Carlisle, PA 17013
Daughter
One-fouth of estate
residue
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheE1t
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
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LAST WILL AND TESTAMENT
I, JAMES S. McKEEHAN, of West Pennsboro Township, Cumberland
County, Pennsylvania, being of sound and disposing mind and
memory, do hereby make, publish and declare this to be my Last
Will and Testament, hereby revoking any and all former Wills or
Codicils by me made.
1.
I direct that all my just debts,
funeral expenses,
testamentary expenses and all inheritance taxes shall be paid
from my residuary estate as soon as practicable after my decease
and as part of the administration of my estate.
2.
I give and devise to my grandson, MICHAEL HENRY, the truck
which I may own at the time of my death, and my tract of mountain
land consisting of approximately twenty (20) acres, situate in
Perry County, Pennsylvania, said devises to be absolutely.
3.
I give and devise the house in which I presently reside,
~ogether with all outbuildings appurtenant thereto, and all
contents of said dwelling and outbuildings, to my said grandson,
MICHAEL HENRY, absol utel y.
The land which shall be appurtenant
to this devise shall consist of approximately two (2) acres. The
eastern line thereof shall begin at the end of a board fence
located on
the
southern line of my property and shall extend
northwardly
the northern property 1 ine.
to
Said devise shall
also be subject to the right-of-way set forth in the following
paragraph.
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4.
I give and devise the dwelling, outbuildings and land
appurtenant thereto, in which my daughter, SHARON K. LIBERATOR,
presently resides, unto my granddaughter, KELLY HENRY, under and
subject to a life estate in the said SHARON K. LIBERATOR to
reside therein for the remainder of her natural life, or as long
as she shall so desire.
In the event the said SHARON K.
LIBERATOR shall remove from said premises, this life estate shall
terminate and ti t1e shall vest entirely in said KELLY HENRY.
During her occupancy of said premises, SHARON K. LIBERATOR shall
pay all taxes, insurance and maintenance costs for the premises.
She shall also maintain said premises in good state of repair.
The land included in this devise shall be the remaining part of
the premises presently owned by me situate east of the property
line described in the prior paragraph and shall also include a
fifty (50)
foot perpetual right-of-way along the northern
property line of my premises extending from Springview Road to
--.....
the property herein devised.
Said right-of-way shall be for the
purposes of ingress, egress and regress to and from said premises
and shall be perpetually appurtenant to the premises herein
devised.
5.
All the rest, residue and remainder of my estate I direct
shall be divided as follows:
One-fourth (1/4) thereof unto
""". e
,~ tIS SHARON K. LIBERATOR; one-fourth (1/4) thereof unto MICHAEL HENRY;
t")
and the remaining one-hal f (1/2) thereof unto KELLY HENRY. In
determining the residuary share of the residuary legatees, I
-2-
'"-
direct that my Executor shall include in the computation thereof
any property which shall pass outside the operation of this Will
and by operation of law: i. e. any property which I may own
jointly with any of said residuary legatees and is included in my
estate for inheritance tax purposes.
It is my intention by
making this provision that the residuary estate shall include
said assets in order to equitably divide the residuary estate.
6.
I hereby nominate, constitute and appoint my said grandson,
MICHAEL HENRY, as Executor of this Last Will and Testament.
7.
I direct that my Executor shall not be required to file a
bond to secure the fai thful performance of his duties in any
jurisdiction.
8.
To the extent that the same is permitted by law, none of the
beneficiaries hereunder shall have any power to dispose of or to
by way of anticipation any interest given to such
all sums payable to such beneficiaries hereunder
shall be free and clear of the debts, contracts, alienations and
anticipations of the beneficiaries, and all liabilities for
levies and attachments and proceedings of whatsoever kind, at law
or in equity.
9.
I authorize and empower my personal representative, in his
sole and absolute discretion, to purchase or otherwise acquire
and retain any investments of which I die seized or any real or
-3-
. .-. ........-.#.-.. ..... -_...~... .~_. ....... --._- -.---
personal property of any nature: to sell, lease, pledge,
mortgage, transfer, exchange, dispose of or grant options in
regard to any or all property of any kind forming a part of my
estate for such terms and such prices as they may deem advisable:
to borrow money for any purposes connected wi th the protection
and preservation of my estate: to mortgage or pledge any real or
personal property forming a part of my estate or to join in or
secure the partition of same: to compromise any claims or demands
of my estate against others or of others against my estate: to
make distribution in kind and to cause any share to be composed
of cash, property or undivided fractional shares in property
different in kind from any other share: and to execute and
deliver such instruments as may be necessary to carry out any of
these powers.
IN WITNESS WHEREOF,
this flv( day of
J }I'J
I have hereunto,,~~t my hand and seal
','. .
, 1990-,.,\ '0 ) "-
','\ ,\ ,/
{i'Wt':i,~~ .J J) )( /Cufi.-..n./ (SEAL)
\~e~s. McKeehan
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named
Testator, as and for his Last Will and Testament, in the presence
of us, who at his request, have hereunto subscribed our names as
witnesses thereto, in the presence of said Testator and of each
other.
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COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
I, James S. McKeehan, Testator, whose name is signed to the
attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will: that I signed it
willingly: and that I signed it as my free and voluntary act for
the purposes therein expressed. j
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Sworn or affirmed to and acknowledged before me by James S.
McKeehan, the Testator, thiS.:4-,d day of --1)''''-'1 ,1990.
/'5 ) /'ti~-HL ,yf I) i..~k<...j./
Notary Public (J
COMMONWEALTH OF PENNSYLVANIA
)
: 55.
)
COUNTY OF CUMBERLAND
We, ;.::4,u,...lL/)7 ~:r-v ?i...~ ;</~"- 4'. /<1J-Z.,~,j
the witne'sses whose name~ are signed to the attached or f~regoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw the Testator sign and execute
the instrument as his Last Will: that the Testator signed
willingly and that the Testator executed it as his free and
voluntary act for the purposes therein expressed: that each of
us, in the hearing and sight of the Testator, signed the Will as
witnesses: and that to the best of our knowledge the Testator was
at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
.~5d~r~~:k..:-A 'n 1, .;i~~5iL~j
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Address
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of
Sworn or affirmed to and subscribed before me this ft./- day
, 1990
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Notary Public 0
~~ Citizens Bank
Account Number
Account Title
Date 0 ened
Account T e
Princi al Balance as of DOn
Interest from Last Postin to DOD
Account Balance as of DOD
YTD Interest to DOD
6100731499
JAMES MCKEEHAN
6/6/1966
Checkin
$21364.86
$.00
$21364.86
$43.65
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if .-.-,.
.:)
_.<~.-;~ _--L_ I
~~ Citizens Bank
Account Number
Account Title
Date 0 ened
Account T e
Princi al Balance as of DOD
Interest from Last Postin to DOD
Account Balance as of DOD
YTD Interest to DOD
/""", (/(/">"' /
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C C f.-.(clv, _ C!- L- _'I:> / ' 2.
6140720982
JAMES MCKEEHAN
12/23/1997
Time De osits
$5858.52
$11.08
$5869.60
$129.73
~~ Citizens Bank
Account Number
Account Title
Date a ened
Account T e
Princi al Balance as of DaD
Interest from Last Postin to DaD
Account Balance as of DaD
YTD Interest to DaD
JfT&ctlJ ~L
.-
'f .f
c
/1
P'''-Y' <- .3
6140857651
JAMES MCKEEHAN
3/5/2005
Time De osits
$111.jl ~ 3~2. ~b
$ .01 I. ~rS"
$141.~ ..:J3.s-'/.11
~
SYM~TRA_
FINA"~CIAL
November 7, 2005
Martson Deardorff Williams & Otto
10 East High Street
Carlisle, P A 17013
RE: Symetra Annuity AN097 I 207 for James S McKeehan, Deceased
Dear Victoria LOtto:
The information on the above-mentioned annuity was as follows:
Date of Death Value August 11,2005
Initial Annuity Investment March 7, 1995
$43,032.46
$44,441.08
If you have any questions, please call us at 1-877-SYMETRA or 1-877-796-3872. Press option
2 for Retirement Services and then option 3 for the IRAlNQ Department to speak to a
representative.
Sincerely,
Individual Retirement Plans
Retirement Services
Symetra Insurance Company
/ . If (
5,. /t'[lulL. C I
/J
I
/~- /'. r I
r
pII Symetra Life Insurance Company. Retirement Services. 777 108th Avenue NE, Suite 1200. Bellevue, WA 98004-5135. wwwsymetra.com
~fil Mailing Address: PO Box 3882. Seattle, WA 98124-3882. Phone 1-800-796-3872. TTY/TDD 1-800-833-6388
'J_-':" 2, 2,:S
~~ Citizens Bank
Account Number
Account Title
Date 0 ened
Account T e
Princi al Balance as ofDOD
Interest from Last Postin to DOD
Account Balance as of DOD
YTD Interest to DOD
6140888751
JAMES MCKEEHAN
10/1111988
Time De osits (IRA)
$141.91
$.01
$141.92
$2.76
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