HomeMy WebLinkAbout05-05-06
"~~~"''';. .-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
I-
ffi NAME
c
~ William A. Addams
3; FIRM NAME (If Applicable)
UJ
cr:
25 TELEPHONE NUMBER
o 717-243-7638
I-
Z
W
C
W
o
W
C
UJ
I-
:.:::$lIl
ocr::.::
UJQ.o
J: 00
o cr:...I
Q.al
Q.
<l:
z
o
~
<(
..J
::J
l-
e:
<(
o
w
a:
z
o
j:::
)(<1:
<1:1-
I-~
:E
o
o
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
IX! 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Atlach copy 01 Wil~
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust IAUach copy oITrust)
o 10. Spousal Poverty Credit (dale 01 death between 12-31-91 and 1-1-95)
o 3. Remainder Return (dale 01 death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Mach Sch 0)
COMPLETE MAILING ADDRESS
27 W. High St.
Carlisle,
PA 17013
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
,
(~.-'i
--,
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
r )
c.>
t._.,'..;
9. Funeral Expenses & Administrative Costs (Schedule H)
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)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
15. Amount of line 14 taxable
at the spousal tax rate
See instructions on
16. Amount of line 14 taxable
at 6% rate
17. Amount of line 14 taxable
at 15% rate
18. Tax Due
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 PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
S1GNATU~TATIVE
ADDRESS
tf
"--"
DATE
jr_ S::::-C7b
d
I C
dd
Dece ent s omplete A ress:
STREET ADDRESS 1517 McClures GaD Road
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 18)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
18,255.72
17.367.00
913.00
Total Credits (A + B + C) (2)
18,280.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3)
4. If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 19 to request a refund (4)
5. If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
24.28
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; .............................................................. 0 00
b. retain the right to designate who shall use the property transferred or its income; ................. 0 00
c. retain a reversionary interest; or .............................................................................................. 0 00
d. receive the promise for life of either payments, benefits or care? ...........................................0 00
2. If death occurred on or before December 12,1982, did decedent within two years
preceding death transfer property without receiving adequate consideration? If death occurred
after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ............................................................................................... 0 00
3. Did decedent own an "in trust for" or payable upon death bank account or security
at his or her death? ....................................................................................................................... 0 00
4. Did decedent own an individual retirement account, annuity, or other non-probate property? ..... 0 00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN
72 P .S. ~9116 (a) (1.1) (i) provided for the reduction of the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1, 1995.
72 P.S. ~9116 (a) (1.1) (ii) provided for the reduction of the rate imposed on the net value of transfers to or for the use of the surviving
spouse from 3% to 0% for dates of death on or after January 1, 1995. The statute does not exempt a transfer to a surviving spouse
from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse
is the only beneficiary.
FOR DATES OF DEATH ON OR AFTER JANUARY 1,1995 - Please answer the following question by placing an "x" in the
appropriate space.
Did the decedent create a trust or similar arrangement which is soley for the surviving spouse's benefit for his or her entire
lifetime? Yes 0 No 6a
If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second
spouse, at which time it will be fully taxable at the rate(s) applicable to the remainder beneficiary(ies). Enter the value of the trust on
Schedule J, Part II, in order to remove it from the calculation of the tax due in this estate. You may wish to file Schedule 0 in order to
make the election available under Section 9113. If the election is made, the trust or similar arrangement is taxed in the estate of the
first decedent spouse, the portion of the trust or similar arrangement which benefits the surviving spouse is taxed at the zero tax rate,
and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(ies). If you choose to make the election, you must
attach Schedule 0 to a timely-filed tax return, along with Schedule(s) K and/or M in order to show the apportionment of the trust or
similar arrangement between the surviving spouse and the remainder beneficiary(ies).
"".'M.","., '.
COMMONWEALTH OF PENNSYL VANIA
INHERITANCE TAX RETURN
R SIDENT DECEDENT
ESTATE OF
Ethel L. Kelley
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
2106 0084
ITEM
NUMBER
1.
DESCRIPTION
400 shares M& T Stock
S\~
1~5
q D ~ cd d
-AS c~dd p~},'
eM
VALUE AT DATE
OF DEATH
2,218.25
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2,218.25
""'~'''"''l'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Ethel L. Kelley
FILE NUMBER
2106 0084
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M& T checking 14,438.55
2. Sovereign Bank, checking, CD's 26,114.41
3. PNC Cumberland County Retirement check 319.62
4. Hoffman Roth Funeral Home refund 18.23
5. M& T interest check 37.92
6. Hoffman Roth prepaid funeral 7,610.50
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
48 539.23
'..""n."., '.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Ethel L. Kelley
FILE NUMBER
2106 0084
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OFTRANSFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NUMBER ATTACH A COpy OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST
(IF APPLICABLE)
1. John Hancock GPA Choice Annuity 12,045.50 100. 12,045.50
2. AIG Insurance Co. Annuity 11,367.17 100. 11,367.17
3. Jackson National Life Ins. Co. Annuity 70,171.68 100. 70,171.68
4. Nationwide Life & Annuity 26,273.48 100. 26,273.48
I
TOTAL (Also enter on line 7, Recapitulation) $ 119857.83
(If more space is needed, insert additional sheets of the same size)
.".""..,.., .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Ethel L. Kellev
FILE NUMBER
2106
0084
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman Roth 7,610.50
2. Westminister Cemetery, grave opening 1,150.00
3, Funeral meal, wake 200.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. AttomeyFees William A. Addams, Esquire, 27 W. High St., Carlisle, PA 17013 8,500.00
3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 140.00
5. Accountanfs Fees Greenawalt & Co., estimated 600.00
6. Tax Retum Prepare~s Fees
7. Sentinel, advertising 158.81
8. Cumberland Law Journal 75.00
9. Register of Wills, filing inventory and appraisement 25.00
10. Register of Wills, filing petition, estimated 25.00
TOTAL (Also enter on line 9, Recapitulation) $ 18 484.31
(If more space is needed, insert additional sheets of the same size)
...'~"n",'; '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
Ethel L ~ :ellev 21 OR 0084
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1. Harvey O. Kelley brother 1/4 residue
240 Campground Road
Carlisle, PA 17013
2. Marlin F. Kelley brother 1/4 residue
1535 McClures Gap Road
Carlisle, PA 17013
3. Evelyn K. Craig sister 1/4 residue
1517 McClures Gap oad
Carlisle, PA 17013
4. Carol Kelley Hurley niece 1/16
367 Crossroad School Rd.
Newville, PA 17241
5. Steven Kelley nephew 1/16
36 March Dr.
Carlisle, Pa 17013
6. Michael Kelley nephew 1/16
257 Parkway Dr.
Carlisle, PA 17013
7. Kristine Kelley Gelbaugh niece 1/16
1420 Pine Road
Carlisle, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
n. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
II
~ ill'i!'~~:'
.:.:.:.:.:.;.
iillllllll!
f~~m~~;~
illlllillil,
,I,I~I~I~:
~ rtm:
ij~jjjj~jjji
IJ
"""'-1" -I
::~i:~':~
,:iJ.:'"1I"m
!j~~~~I: ~
,:}I,:, -<, ;u
-. j~~J!: 0;: Z
~ s;! :~B~:'$,: g
~ ~ !iiii:~:: ~
~~ 2~L~ :'01: ~
Olro
om
8l;O
I->
en
:J:
l>
;u
om
Ien
men
Ro
~6
~g
N~
<>>
iv
01
iii1[;iiI;
=!=!:;=;:!;!:
;,:.:.;.:.:.:
""
o
o
o
""
I->
'iv
0>
iv
01
o -0
r ;0
g (j
2 m
Gl ;R
--l ;0
;0 Ul
C I
Ul )>
--l ;0
2 en m
~ !='~
;u ~--
m.e.
~~
r
)>
2
o
m
o
o
o
8
o
~
><
~
::j
I
I
m
r
o
o 0
-0 C
m Ul
~ a 1j
20
Gl~
-iCD
;01->
cO>
':'1ffi
.c..~ ~
;I>-~~
8m~
8':'10
ro
)>
r
)>
2
o
m
2
!!J
-0
;0
o
o
m
m
o
Ul
2
<
m
Ul
CDa~
0;0 m
R}5;:!
CD 'ii
Ul~ !l1
?;ffi
ill I->
en
Ul
o
r
o
.e.
i
)>
o
00
~g
_2
G)-i
:~
r'n-<
<
m
~
6
o
o
o
Gl
;0
o
Ul
Ul
-0
;0
g
m
m
o
-El>en
I->
'iv
<>>
iv
01
-<
o
c:
;;0
)>
n
n
o
c:
Z
-I
:t
)>
C/)
OJ
m
m
z
n
r-
o
C/)
m
~
-I
:t
m
)>
-I
~
n
:t
m
o
n
:t
m
n
"
;;0
m
"0
;;0
m
C/)
m
z
-I
C/)
-I
:t
m
"T1
c:
r-
r-
~
r-
c:
m
o
"T1
-<
o
c:
;;0
)>
n
n
o
c:
z
:-t
=.';'1;;1
~~ii"
~ _.-0
lD:":,,:T
:-!'3g
~ <I> ~
~g-"
, <I> &
3@o
9l..3?
-<1>0>
o_~
;jo(O
;j ;j ,
~ S' ~
(})<(O
S'l}lw
..., .-+
(, ~
o (,
3 0
iii'3
a.
(J)"OQ.S:C
goo !a. en
...... rn "'" r'
::r"":::"_'"
O<l>-=:.
IX=<I>Dl
Dl ~ 0 -,
o ~;j :":"
^.j>.-
~ --.,J ~
()) <I>
Ql m
o .-+
^ 0
- ...,
z
C-
O
-.,J
0)
o
0>
I
IV
o
.j>.
-.,J
(J)
<I>
<
0'
<I>
m
"T1
o
...
::J
.Q
:.
...
(ii'
III
~
tT
o
C
..
'<
o
c
...
~
(')
(')
o
C
::J
~..
(')
o
::J
..
~
(')
..
:s:
!.
0'
::J
::J
<
11>
III
..
o
...
fA
11>
<
r;'
11>
III
:s:
11>
..
r-
;;
1Il-
-I
iil
::J
III
iD'
...
~
lQ
11>
::J
!"!'
;U -, 0 tll
@ :J 0- 0
"lj"'O =x
o Q,) (0 r-..J
~ g ~'J
2:::rg(jJ
CIl CD 2> ::r
III '" ~
3 m g
o !" 3_
a;!g~
g ~~~
(.1)0(1)(")
g.~~ ~
~~:.~
1>~~a
OQ.!!l~
'=t1:r a. jU
o 0 0 :;:J
-'cOcn
~~~~
0"'0 ~ o'
sg~~
- m -'
om'~
~g.~~
[~m~'
G)30",
!I1.m ~g
::> fO :> ""
~ ~~~
a.1Da.g
r-~oa.
o cOG/)
~~~9.
~~2.i
(') '" ~
011>0.
::> ~ <I>
~:g:
!l""
'" 0
, :E
'"
(')0'01
0"0
::>::l.X
~(1)"""J
~ 5",
.'" fO 00
:5' 5
~g~
03
; CD D)
Q oj" ~
o tT (i)'
-<I>.....
~:5" 2-
.., (C ex
III ~ (')
'O<I>~
a!~
-g. ~ g
~~~
0.0""
en ~ m
(/) ..., _.
g CD m
ij'cg 3
g:2tg
'" m '"
3 0. m
~ S $,
- " (')
[~~
(/l (') ~
gg~
~ ~ 0'
, (') ""
en:;
II> <Il
::>'0
0.0
0'(')
~ ~
a.'"
Q
CD 5' (J) 0) UJ
2Q"'~~~
33"T1#~
S>>atQ.... I
Ulo'3~(J)
S''''~~,5
)( g I :: S
:E 5"0<11
~~;u~g
~ejgo:~
a:"O~ ~-5
, ~!Il!2.:E
~oC';:;:
[~2.g:
9:~~a:
rE~~:5'
',<c<Ft
-m~
:1-'-(;)
!lc:~g
a ~ -g (I)
II) :=. '< m
_:=:llD_
=:e.5:~
=crg~
3'" - II>
o z3i-c
c c g !J:
a.~ g: 3
om:] c
:S~::1a
"<~cC"
00.311>
l:OO'~
.., (I) m c:
5"::1.::'-0
S~~i
3!!l.<I>""
I'D 0'-0 5
_~m-
J>> - '< c.
)(Q~21
c:g
~ X
=.....1.
~p-
II> ,
g' ;r
'" ~
"0'
e a
(') ""
<I> <l>
o.~
~~
~~
E~
3 A'
g~
;:;'3
.....'"
:;:-c
m '"
-,""
1D~
3_
~""
(I) m
]0
::l.C
moo
~'U
o
o
3
3
3:
m
<I>
o
'"
C
'"
~
3
00
m
(')
~
~
o~m -i -I'" <-.e.s: -I"1Itll
l>en< 0 (I) '" m 00 <I> <l>m;:u
;;o~m :'f cow (il0= 1>g.o
C~~ I 'OW ~ ~g "O~;;r.;
""0> 5"!.m
~OZ 0 0.... 011>_
=?: ::J I;'J ~~~ ~g:~
mO;;r.; -0 m
"'0 )> .. '" - '" '" ~a:z
l>~~ ZfO -
a & '-oQ 3"" II>
~m_ 0 0'" en 0'~3
oOOG) 0 ....01<1> CD =_CD
~G) 0, ~~~. ==g)>
't'> .e. 0, (') z[i
0>11 <D <I>
~;o W '" c: til
.e.o 01 3",
<D 0''''
W <I> -
~N
11>-
'" "
0.0
0
a.
.!1>
a..'< "C '< 2'-1
CD 0 CD 0 32':..(f)
-1::::1C
(l) -,II> II> -, '" ~ C
~. ~~ CD ~ ~: s: g
ffifjfQ;o.3""O~
~ 5'!2..g a] ~ c 'TI
5f8i@'~~-1roO
:::~;;;o.~;a~o"
- -'" -I 3
",,_,II> 0 -~ 0 I\)
Q)~5~~ '-0
"'~=:1>~5'5< 0
"'11>0",_"", -<"0
Q.O''''~;uQzroo
g-~~~~~~~(DQ)
~ a.~_3 ~ g';;o;u (D
cn-(I)II>Cl>II>~;o .
] il'3'ijl g>'" -I m to
::l. ;:0] 1ft:2 ~ 5 Q
~OOUlU5'o'''' z]!
, ~~!D~:~
g ~:tig --\
5' :-' !" III ~
< 0 Ul
'" '< 0
"' '" S 0
g en III 0 '"
0 C <1> "
Q ^ ..
(5 ~. -"' g, miil ...
=>m 0
o. ro en n
::J 0 III O-::J <1>
0> " 00-
0 :;0 a. ii' <1>
0> -1m -EI> -"' 0 ~ 0- 0.
<.n I->m ~ :Tm III
I-> O~ i--l8" <1>~ "11
~ ~' ~ -<1> 0
-:;0 0> I-> => ...,
01 ::0-1 iv 0 ~~ 3
0
01 Ulm 01 0
<0 0> ~g.3"lD
I-> 0 -m ...
::O::J!!lo
CD (0 .. X"
s: ~<CD5~
3(1)(1)...
m lJl ~ 3 o'~
-I O~ <1> <1>C::lo.
r- ~Ul~lIllD
f--- 'ii
;u !l1 OGl GJ f> ~ 8~iilO'Ill
'" Z u~ a !'T <1> -, 'tl .. i-
0 ~o "
'U. 0'" "' m 0 ~~g.~...
iji. p ,,", en 0 C
" "'-0 -0 m Ul ~ ~"O n ~
... ~a g ;0 '1:i
'" (1)0 )> 2: 8 "2: g.
a: 3 '" '" r Z
-, '" !t c 00 <1> CIl III
'" co. 2 3 O'~3.::l
~ 3'" "'
~ 0 en t;1'
0> n' "'ii' 0 ~ J!1 ""00 lQ
~ "' ;;:: 3.... <1>
!!( "' -EI>
I-> o. 0 0 m 01 -.0 ....
W " 0 0 ~ 0> ~ 3 ...
<0 2 3 0 ~ III
CD 3 oo~ ::l
0 c 0 ~~ III
3 0;. ~
t;1' "' III
J!1 0' ::j ~oo !l
" I Om
0 III I iil ~ 0'
" " m ::l
:!1 "- r 'tl ci' III
ii' 0 0 ::J
::\.lI>
0
gg>
'Ox
m~
<I> .
~~
o
~
:;:
m
g
0.
Cl>
0-
Il>
CO
2-
:;:
(l)
g
'"
'"
II>
!l
A'
?
"11
Q
II>
co
fO
iil
fO
II>
1D
til
'tJ
o
::l.
5'
~
'"
o
Cll
'"
$
~
"
ro-
Dl
en
CI)
Z
o
....
~
-<
o
c
...,
(J)
Ql
CD
II
...,
o
o
<I>
<I>
a.
m
n
::r
<I>
o
^
m
~
Ql
o
::r
<I>
a.
o
s:
OJ
Z
P
~
(11
f},
6
:j
(11
111111111111111111111111111111111111111111111111111111111111111II
~ M~~ICOmpanY
BUFFALO, N.Y. 14240
OFFICIAL CHECK
23-9711020 2886 55687 -1ID
Issued by Inlegraled Payment Systems Inc., Englewood, Colorado
Bank One. NA, Denver, Colorado
~,I$t
M'
PAY
TO THE
ORDER OF
i)1/30/06
>
Q.
o
(..)
a:
IU
~
o
....
e/)
::)
o
DATE
AUTHORIZED SIGNATURE
fi -+- [Shill or flHll L KtUUHH . H~1438..55
-V~-ffi<.\ $" s.~ M> n*un~t(lH**~~tft\fjffi~M,~.~*lat
AUTHORIZED SIGNATU . . F (Jl({" t.t:eN~U~i\nrt ~'&I..~~M'r~'~UNfWItYLS ~
NOTICE TO CUSTOMER: The ~se ot an Indemnity Bond may be r~Ulred belore lhi8 check will be replaced or refunded In the event II is 'r\lJ1~'t~U~fle~S./ 1 (10 U(.} 1 ,~... S !t 319
~
Delll1son
....
-'-
.2~~~:!!:;..Bank
Memo; Acct#167520496S\
$****~**~**1.115.48
-5420374
OFFICIAL CHECK
22-1676
960
01/30/2006
6ranch: 0167
TO THE
ORDER OF
Void If ~~mt Over
$***~**~***1~115_48
The Estate of Ethel Kelley
Drqwer. Sovereign Bank
\ NON NE~OTIABLE
1\ 1\".~STO'f~.~i?~L~,,-
AUTHORIZED SIGNATURE
..
ISSUED BY: TRAVELERS EXPRESS COMPANY, INC.
DRAWEE: ~~~,~i~p~~lt~:OUS, MN 55480
+
_overeign Bank
DETACH AND RETAIN FOR YOUR RECORDS
5420374
Memo:
Acct. 167520496B
01/30/2006
Account Holder:
Account Number:
Branch Number: 0167
$**********1,115.48
.~~~::.~~Bank
OFFIClALCHECK
0.1/30/2006
Hemo:Acct*1671016092
.**********2~225_aO .
IjraOCh, 0167 Void If Atoount Over $"''''*"-'''-'":!.22$.1I0
TO THE
ORDER OF The estate Qf Ethel Kelley.
.
:sueo BY; TRAVEl..ERs EXPRESS COMPANY INC.
P.o. BOx 9<J76.. MINN~.S. MN 55480
AAWEE: us BANK. sr,. rAUJ... UN.
+
.-
Jt"
!over~~:l:oi~
~1/30/20Q6... .it'~
CCOlIn~ Holde,.: '-4.'
IC:C;OtJnt.~~r:
r.anchNUMber: 0167
DETACH AND RETAIN FOR
'***~2.225.80
.overeign Bank
.' , . . ' . Agent for Travelers Express
OFFICIAL CHECK 5420372
22-1676
900
. ~~~~- A .
;j.~"***-'t't: oj 't. t 7,660.47' '-'-'-'\.. - CC; t #1 675:20657t:,
Lt r ~ f){:- t1~: ~) .t ~~~; -;
TO THE
ORDER OF
r i";fJ E:::. t,:~ f,"f,'. (.'..' .L,'
. , EU~I
{) J. li.3(),/2()(}e!;.
Void .if (i''''I', ~;,_t. (', . "
'11 l tJve r.
$*~~~~~~'~~'17,660~4'7
Ke II ey
Dr~wer: Sovereign Bank
>" NON NEqOTIABLE
! if !;.' ppSTO~~~,c~. ~Y.'l'
'-. " .4 ,. II ,
AUTHORIZED SIGNArURE' ,
Nt'
ISSUED BY: ;~vB~iRS EXPRESS COMPANY INC
DRAWEE: US BANK,~+6pn~~~tOllS, MN 55480
+
.overeign Bank:
DETACH AND RETAIN FOR YOUR RECORDS
MAmn-
.A~";:~T:~~~~"B auk
OFFICIAL CHECK
5420373
22-1676
9&l
Memo~ Acct;Jt1675:2()65.9J
$**~****T**5.112.66
01/30/2006
f\!,"J$nch: ('167 Void If {~mm..mt Over
TO THE
ORDER OF fhe E:?t..~t.e of Ethel Kelley
S**~.******5.112_66
ISSUED BY: TRAVELERS EXPRESS COMPANY. INC,
P,O, BOX 9476, MINNEAPOLIS, MN 55480
DRAWEE: US BANK, ST, PAUL. MN
Qrawer: Sovereign Bank
NON NEGOTIABLE
\ EUSTqM9R ,Cppr.",
, '._ ~"._'v ., f \__ ." .....~
AUTHORIZED SIGNATURE
,
"
/'\
. " 1\"""
Nt'
+
.overeign Bank
, .: ~'
DETACH AND RETAIN FOR YOUR RECORDS
5420373
Memo:
Acct#1675206591
01/30/2006
Account Holder:
Account Number:
Branch Number: 0167
$**********5,112.66
ffiontroller of ffiumherlunb QInunty
ONE COURTHOUSE SQUARE + CARLISLE, PA 17013
717-240-6185 + 697-0371, EXT 6185
532-7286, EXT 6185 + FAX: 240-6572
E-MAIL: AWHITCOMB@CCPA.NET
WEB: WWW.CCPA.NET
ALFRED 1. WHITCOMB
CONTROLLER
ROBERTJ.DAGROSA,CPA
FIRST DEPUTY CONTROLLER
MICHAEL A. CLAPSADL, CPA
SECOND DEPUTY CONTROLLER
TINA 1. POOL
ADMINlSTRA TIVE ASSISTANT
JAMES D. BOGAR
SOUCITOR
Febmary 6,2006
Evelynn K. Craig
1517 McClures Gap Road
Carlis1ePA 17013
Re: Cumberland County Pension Payout
Estate of Ethel Kelley
I have received the ''Notice of Amount Payable Upon Death of Pensioner", from our actuary,
which indicates balance owed to the Estate is $319.62 for 18 days of January 2006. There is no lump
sum balance since the amount received through December 2005 was in excess of the value at
retirement. I will request PNC Retirement Services to process a check made payable to the estate.
You should receive a payout within 10 - 14 days.
If you have any questions don't hesitate to call me at 717-240-6186.
5mberelY, 0
\/2-/.~
Tina L. Pool
Administrative Assistant
Enclosure
..-
ell
::)
U
..-
LLJ
~
0..
:E
LLJ
>-
..-
U
l=l
Z
<(
-I
~
LLJ
,:Q
:E
::)
U
..J
I-!
'D <(
CI ..-
CI LLJ
N l=l
~ X
<( <(
LLJ ..-
>
x
<(
....
I
I I
I
Z,
Of
..... I
.....
::)1
J:Q
.....
~
....
ell
.....
l=l
LI.
o
....
Z -I
lJJ .....
:E <(
LLJ ....
.... LLJ
<( l=l
....
ell Z
o
1-1
....
::)
,:Q
1-1
~
....
ell
1-1
l=l
NooNNCICICICI
'DClC'D'DOOCO
O\CCO\O\CCCO
..-I ..-1..-1
1'1) 1'1)1'1)
0-0-0-0-0-0-0-0-0-
J:QU....J:Q
:!: I-IUlZI-IJ:Q
..... ~lX::)lXl-I
3 ....O"O....lX
ZO":Ec/l....
Q O<[<[l-IeIl
UJ U Q.....
LI. QlX Q
XUJUlc/l
....~ <[N>U1c/l
ZC ....I-!OlXUJ
....::)N ..J..J<[lX
ZO UJlX<[..J:!:<[
::):EO-lUJLLJOc/l:!:
O<[....J:Q....lXlX c/l
:E <[Ll.Z LI.
<(UJ....X <[::)..J0u.
-IU<[ <[ 0
eIlJ:QUJ..-o..........U1
eIl<[. :EUJO::)....
OXJ:QZUJZ......Jc/l
lX<[::)O <[0
(.!)....c/lZ >U
NO
'DC
0\ CI
..-l
1'1)
00-
....
Z
LLJ
:E
>
<[
0..
....
Ll.Z
0::)
o
UJ:E
::)<[
..J
<[lX
>UJ
>
-10
<[-I
....-1
00
....lX
N
'D
'"
..-l
1'1)
Z
OZ
.....0 ~
....I-! ::)
::).... 0
J:Q::) >
I-IJ:Q
lXl-I 0
....lX ....eIl
c/l..- ell
l-!eIl l=lLLJ
QI-I UJlX
Q ....Q
UI Ul=l
:!:-I LLJ<[
....<[ ~
Z I-I~
(.!)I-I Q::)
Z(.!) 0
1-1..... UJ>-
3lX J:Q
00 Z
..J l=ll-l
-IUJ -I
OX ::)eIl
LI."-XOLLJ
....X(.!)
lX(.!)<[eIlZ
<[ZUJ <(
UJI-Il=lZX
>310U
o I-!
U1-1..:r..->
:!:-I ::)Z
....OellJ:Q<(
u......1-t
U. lXLI.
O~""""O
<[ c/l
....LLJX.....~
c/l>-0l=l0
.-I J:Q ell
I'I)LLJ eIlZ
:!:ZI-tO
>"-1-1::1:0..
lX ....eIl
<[Z~
::)1-!<[Ll.Z
Z LLJO<(
<[ .. 0.. -I
.~o..>o..
U<(..-
>UJ I-t~
J:QX-I-I::)
U-I.....O
Q .....,:Q>
UJQ3<[
::HU X >
eIl::)....<(u.
c/l ell <[""1-1
I-!c/lX ....
I-I....UJO
c/lUJ XZ
.....lXUJ....
Q UJ
lX<(O(.!)eIl
. UZ<(
",u. .....LLJ
",OZQ-I
o O~o..
.-IUJ.....<[
eIl....(.!)
:E <t ::) UJ .
lXUJ:Q~Cll:
01-10
Ll.LLJlXeIlell
X....Z.....
ell.... 11)0>
lX I-I.....l=l
I-IZQ....<
I-t c/l
UJ LLJUJX
XCll: X::) <(
....0....0'1-
0-
....
Z
::)
o
:E
<[
....
Z
UJ
:E
>
<[
Q.,
....
UI
Z
C
oUJ
.>
C I-!
UJ
U
LLJ
lX
::)
o
>
'D-ICO
0,... 0\
OCl'D
NO'"
.....NI'I)
1'I)..:r,...
.-I'D 0
......-1.-1
Nll'IO
01'1)0
0- lX
LLJ
......
ZLI.
0<[
.....
....c/l
::)>
J:Q<[
I-tQ
Cll:
....0
CIl'D
1-1
QZ
.....
IX X :
::)....UJ
OI-lU
>31-1
..-
LI.....O
Ol-!Z
c/l
ZOX
00..<[
I-ILLJ....
....Q
IX ..J
OUJ<[
0.. X 1-1
....U
LLJ UI
..JLLJQ.,
J:Q~CIl
..... c:t =
('!):E
..... UI
..J::)X
LLJO....
>
UJ 0
Xl-....
....<[
XIX
lXl-LLJ
UJ LI.
>eIlUl
OUJO::
lX
-I.....LU
-I::)c/l
00'<[
lXUJLU
lX..J
o Q.,
1-3
<[
UJ-I
Q ....
I-IXZ
U<[LU
UJ....~
Q >
..J<[
::)<[Q.,
OlX
>LLJc/l
QI-I
Ll.U1:I:
I-ILI.....
LLJo..#
I-~
<((.!)~
l=l U
>LLJ
<tX
o..U
Q
>-<[
UJO
-IlX
-I
LLJo......,
~<t.-l
(.!)CI
-I ,...
UJeIl..-l
:CLLJ
I-Cll:
LLJ::)<t
-10..
Ll.U
o LLJ
U-I
LLJ:Ec/l
I- 1-1
<t,.....J
I-..-l~
eIlll'l<(
LLJ.-IU
HOFFMAN-ROTH FUNERAL HOME, INC.
219 NORTH HANOVER STREET
CARLISLE, PA 17013
717-243-4511
WILLIAM E. HOFFMAN, SUPERVISOR
PAY TOTHE
ORDER OF
Evelyn K. Craig
Twenty - Eight and 23/1 00******************************** ********************************************************************
Evelyn K. Craig
MEMO:
overpayment Ethel Kelley funeral exprenses
~M&rBank
A\J(hc bankyou'lIcvt! nt:td:
6()'295/313
1/27/2006
$ **28.23
Jbul/J Ii/Lo
27683
~
.tJ
C
o
'!
<'\
DOLLARS j
f
1l
~
(j)
~
II. 0 2 7 b B j II. I: 0 j ~ j 0 2 9 5 5 I:
o 0 0 0 ~ b j 2 j b II.
Q%)
J6 USC2.2MK
GPA Choice Annuity
Transaction Confirmation
Issued by John Hancock Life Insurance Company
February 21, 2006
Prepared For:
Ethel Kelley
1517 Mcclures GAP Rd.
Carlisle PA 17013
REF 362 Ao-2-1
LINDA R JULIAS
WAYPOINT INSURANCE SERVICES, I
101 SOUTH GEORGE STREET
YORK, PA 17401
John Hancock Contact Information:
Telephone: 800-824-0335
www.johnhancockannuities.com
GPA Choice Activity Summary
Year to Date
Total Premiums
Total Withdrawals
IY~!9.~:~nF~>>rq~t&~w~~qp~J:
$0.00
$12,045.50
..::$(M)91
$10,000.00
$12,045.50
Your Account Information
Contract Number: GPQ7287262
Owner(s): Ethel Kelley
Annuitant(s): Ethel Kelley
Plan Type: Non-Qualified
Issue Date: 12/05/2001
-
-
Since Issue
-
-
-
=
=
-
-
-
-
-
-
-
-
-
Please carefully review any transactions that are reported on this statement to ensure that all instructions were acted on properly. It is
important that any errors or omissions relating to transactions, Riders and Special Programs, if applicable, be communicated to John
Hancock within 60 days of the requested transaction effective date.
-
-
-
-
Please note that the toll free telephone number for Client Services has been changed to 800-824-0335
Your Dailv Transaction Detail
Date
Guarantee Period
Transaction
Type
Tax
Year
Renewal
Date
Interest
Rate
Transaction
Amount
Payment Enhancements
01/17/06 5 Year Fixed
IT......,...:...o....'.'.'."t......i:\....'..,..,I.,...'..,..'...B.......'..a.'....'.~.'..-'.'..,",'..,..:,',:,...'..','.h.....",t.'..':...a.,.......'.',..'..',......h..,.'..'....a,".<n..:.".',c..'."....mn...',....'...'..'...,e..:.h......,'.t......~..:,'..i..:'...'.f, '::'::::;:;:;;
. :r:!-.:~.,~ .-...................................'.....-...,..'-:.:.:_:.'.:.',:.;.>:.:-:.:-:.:..:.',:-:,;,:,:,:,:,:-:-:,:,>:_:,:-:.:-:.:-:.:.;.:.:':....".....
Withdrawals
01/18/06 5 Year Fixed Death Benefit -$12,045.50
Withdrawal Charges $0.00
Taxes $0.00
Interest
$35.70
i':::;:\?::;:::"~~~7QI
M \.gOO-gVf-O~3~(d.~~"-i"'-~
~. ~~tD ... b"":. J,Q ~aoro,' ute '''0''000 Compao,
~ .'-1' P.o. Box 55106, Boston MA 02205-5106
~. d-,.>tAK~
I
Produced on 02/21/2006
Contract # GP07287262
Page 1 of 2
164
John Hancock Life Ins. Co.
Safe Access Acct. C-6
P.O. Box 790
Boston, MA 02117-0790
EVELYN K CRAIG
1517 MCCLURES GAP RD
CARLISLE PA 17013-8914
Page 1
100000893
PRIMARY
ACCOUNT NUMBER
1",111,,,111"111 J II" J 1,1,,1 J J ,I J ""I J ,1"1,,,1" '" II, J I J I
3/5/2006
STATEMENT
CLOSING DATE
TAX ID NO:
SAFE ACCESS ACCOUNT
BALANCE
LAST STATEf.~NT
NO. I
2 I
CREDITS
TOTAL lU-iOUNT
12,055.40
NO.
CHECKS &~ DEBITS
NO. I TOTAL ID-1CUNT
o I 0.00
100000893
0.00
BALA."lCE
THIS STATENENT
12,055.40
ACCOUNT TRANSACTIONS
DATE........ ... AMOUNT............ .BALANCE... DESCRIPTION
02/22 12,045.50 12,045.50 DEPOSIT-CASH
03/04 9.90 12,055.40 CREDIT-INTEREST
EFF DATE 03-05-06
RATE HISTORY
DATE..... ... .... RATE
02/22 2.500%
DATE............ RATE
DATE.... ... ..... RATE
****** CURRENT INTEREST RATE
****** INTEREST CREDITED YEAR-TO-DATE
2.500% ******
9.90 ******
YOUR JOHN HANCOCK SAFE ACCESS ACCOUNT IS COMPETITIVE WITH
MONEY MARKET ACCOUNTS. THE INTEREST RATE PAID ON THIS ACCOUNT
INCREASED TO 2.50% EFFECTIVE JANUARY 4, 2006.
********** END OF STATEMENT **********
j- % oO~ ;;lj~ '-tfl/l/
I
I
I
NOTICE: See reverse side for reconciliation of this st;:lot-.pmpnt- ::lIn...-i ;T'n't"'o......,....+-.........+- .......J:"____~..: ___
l1DJ
AIG Annuity Insurance Company
EO. Box 87]
Amarillo, Texas 79105-087]
800.424.4990
FEBRUARY 17, 2006
EVELYN CRAIG
1517 MC CL~ES GAP RD
CARLISLE, PA 17013
RE: Contract BX204959
Dear EVELYN CRAIG:
We are pleased to advise you that we completed processing your claim for annuity
benefits on February 17, 2006. In order to provide you with the benefit of
flexibility in disbursing your funds, we have opened an AIG Annuity Bridge
Account for you.
The total amount of your claim proceeds is $11,367.17. The beginning balance
of your AIG Annuity Bridge Account is $11,367.17, as described below:
Non-Taxable Amount
Taxable Amount
Federal Tax Withheld
State Tax Withheld
$10,000.00
CS1. 367.1 n
$0.00
$0.00
$11,367.17
The taxable portion will be reported on Internal Revenue Service Form~
Your account will earn a competitive rate of interest and provide immediate
access to your funds with no monthly service charge. Interest earnings on your
AIG Anuuity Bridge Account will be reported as required by the Internal Revenue
Service.
State Street Bank and Trust will mail your new account kit shortly. The kit
will include your personalized checks and a detailed explanation of your
AIG Annuity Bridge Account.
If you should have any questions, please call 1-800-331-4631.
Sincerely,
f37J1
~ . fA ~j",. fl': ~{,.;,c.
Claims "';/101 ate, fe.- !:> ftv.:, K "{;-
I ~s w-y. "l-Lf--'-t <) '7 ()
B. M. Graves
Manager Annui ty
AIG Annuity Insurance Company
Member of Amerinl/} Imernmionol Group, ]11(.
15691
AIG ANNUITY INSURANCE COMPANY
Insurance Services - #811
P.O. Box 570
Rockland, MA 02370-0570
A1'6
AIG Annuity
Insurance Company
A Member of American International Group, Inc.
EVELYN R CRAIG
1517 MC CLURES GAP RD
CARLISLE PA 17013-8914
Page 1
2/26/2006
STATEMENT
CLOSING DATE
I.. ,III, ..III.. JJJ ,11,,11 ,I, .1,1.1",.,11,1..1",111,,, 11,.1 ,I
110742351
PRIMARY
ACCOUNT NUMBER
TAX ID NO:
BALANCE
LAST STATEMENT
0.00
No.1
2 I
CREDITS
TOTAL AMOUNT
11,373.40
NO.
CHECKS AND DEBITS
NO. I TOTAL AMOUNT
o I 0.00
110742351
BALANCE
THIS STATEMENT
11,373.40
AIG ANNUITY BRIDGE ACCOUNT
ACCOUNT TRANSACTIONS
DATE.. ........ . AMOUNT... .. ... .....BALANCE... DESCRIPTION
02/17 11,367.17 11,367.17 DEPOSIT-CASH
02/25 6.23 11,373.40 CREDIT-INTEREST
EFF DATE 02-26-06
RATE HISTORY
DATE.. ... ....... RATE
02/17 2.000%
DATE... ... ...... RATE
DATE............ RATE
****** CURRENT INTEREST RATE
****** INTEREST CREDITED YEAR-TO-DATE
2.000% ******
6.23 ******
********** END OF STATEMENT **********
NOTICE: See reverse side for reconciliation of this statement and important information.
811-11
14384
AIG ANNUITY INSURANCE COMPANY
Insurance SeNices - #811
PO. Box 570
Rockland, MA 02370-0570
AIG Annuity
Insurance Company
A Member of American International Group, Inc.
EVELYN R CRAIG
1517 MC CLURES GAP RD
CARLISLE PA 17013-8914
Page 1
3/26/2006
STATEMENT
CLOSING DATE
1",111,"111",",11"11,1,,1,1,1, III ,11,1"1,,,111,"11,,1,1
110742351
PRIMARY
ACCOUNT NUMBER
TAX ID NO:
AIG ANNUITY BRIDGE ACCOUNT
BALANCE
LAS 'I' STATEi-1ENT
11,373.40
NO. I
1 I
CREDITS
TOTAL AHOUNT
1. 88
NO.
CHECKS AND DEBITS
NO. I TOTAL AMOUNT
2 I 11,375.28
110742351
BALANCE
THIS STATEMENT
0.00
ACCOUNT TRANSACTIONS
DATE... ...... ..AMOUNT....... .... ..BALANCE. ..DESCRIPTION
03/02 11,367.17- 6.23 CK# 501
03/25 1-:88' B. 11 CREDIT-INTEREST
EFF DATE 03-26-06
03/25 8.11- 0.00 DEBIT-MIN BAL CLOSE
EFF DATE 03-26-06
RATE HISTORY
DATE......... ... RATE
02/27 2.000%
DATE.... ........ RATE
DATE... ..... .... RATE
****** CURRENT INTEREST RATE
****** INTEREST CREDITED YEAR-TO-DATE
2.000% ******
8.11 ******
********** END OF STATEMENT **********
{-o 0 O<f)).j--Lf 11D
tt/t%(P fG.
NOTICE: See reverse side for reconciliation of this statement and imoortant information.
811-11
Jackson National Life Insurance Company@
Insuring your financial future~
-
RiM
Claims Administration
March 11, 2006
Evelyn K Craig
1517 Mc Clures Gap Rd
Carlisle, P A 17013
Deceased: Ethel L Kelley
Dear Evelyn K Craig:
Thank you for your patience during our processing of this claim.
Your payment has been deposited in a Beneficiary Access Account. You will be receiving additional
information, regarding the particulars of the account, within ten business days.
The Internal Revenue Service (IRS) requires us to report payments made, so we will be sending both
you and the IRS tax form ] 099R (for Annuity benefit payments) and form 1099INT (for the interest
amounts over $600.00), in January of next year.
If you have any questions or need additional information, please contact our Service Center toll free
at 888/565-4995.
Sincerely,
~~
H. Bradley Mercer
Director
Claims Administration
m-.
;!'i;:"..'2
~'''7.?-''
Jackson National Life Insurance Company
] Corporate Way, Lansing, MI 4895]
PO Box 24068, Lansing, MI 48909-4068
Toll Free Number: 888/565-4995
Claims Administration
;)
"'~'...
Yo $..
Proceeds Payable to:
Policy Number:
Claim Number:
Policy Information:
Policy Benefit:
Loan Payoff:
Premium Due:
Beneficiary Information:
Benefit Paid:
Interest Paid:
Mise Interest Paid:
Premium Refund:
Foreign Withholding:
Federal Withholding:
State Withholding:
Check Amount:
Evelyn K Craig
0058977820
0600004302
$70,171.68
$0.00
$0.00
$70,171.68
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$70,171.68
~
Jackson National Life Insurance Company. .
Insuring your financial future~ ~
Jackson National Life Insurance Company
1 Corporate Way, Lansing, Ml 48951
PO Box 24068, Lansing, MI 48909-4068
--
Imm'lunm
I
Transaction Confirmation
February 10, 2006
Contract Number: 07-1119809
Life comes at you fast. Believe it or not, so does
retirement. Be prepared by contacting your Investment
Professional for a financial assessment.
Contract Value is $.00
Customer
ETHEL L KELLEY
1517 MCCLURES GAP RD
CARLISLE PA 17013-8914
Your Investment Profesaional
M T SECURITIES
APPLETREE BUSINESS PARK
2875 UNION ROAD SUITE 30 33
CHEEKTOWAGA NY 14227
Account Information
Con1ract Number:
lsaue Date:
Annuitant:
Plan Type:
07-1119809
1212012002
ETHEL L KELLEY,OEC'O
NON-QUALIFIED ANNUITY
Nationwide Ufe and Annuity
POBox 182021
Columbus OH 43218-2021
24 hr. Automated Information Une:
Customer Service:
Hearing Impaired:
Internet:
(800) 848-6331
(800) 321-9332
(800) 238-3035
www.nwservicecenter.com
Account Summary I
---
~
~
-
-
-
Beginning Contract Value on 01/01/2006:
Purchase Payments
Withdrawa!slCharges
Annuity Performance
Ending Contract Value as of 02110/2006:
$26,163.64
$.00
{ $2o,273.46}
$109.84
$.00
---
---
-
---
~
-
-
Withdrawals/Charges on 02/10/2006
I
-
==
---
~
-
---
~
Transaction
Dollar Amount
Date
Type
02110106 SURRENDER
( $26,273.48)
.
o
~
8
'"
:s
?
RRS2N 00 FI 071119809
00000oo1 00000oo1 00002717 00004126
070HOO055055
Page 1 of 1
00004126
10644
Page 1
Nationwide Secure Access
insurance Services - #937
P.O. Box 570
Rockland, MA 02370-0570
EVELYN K GRAIG
1517 MCCLUNES GAP.RD
CARLISLE PA 17013-8914
2/28/2006
STATEMENT
CLOSING DATE
I.. .111... 111......11.,11,1..1.1.1... ..11,1..1.. .111... 11..1.1
220091468
PRIMARY
ACCOUNT NUMBER
TAX ID NO:
0.00
CREDITS
NO. I TOTAL 1U/..oUNT
2 I 26,302.90
NO.
CHECKS AND DEBITS
t.;o. I TOTAL Al'vl0UNT
o I 0.00
220091468
BALANCE
THIS STATEMENT
26,302.90
SECURE ACCOUNT
BALANCE
LAST STATEMENT
ACCOUNT TRANSACTIONS
DATE.. ..... .... AMOUNT............ .BALANCE.. . DESCRIPTION
02/13 26,273.48 26,273.48 DEPOSIT-CASH EFF 02-10
164123990
02/28 29.42 26,302.90 CREDIT-INTEREST
****** CURRENT INTEREST RATE
****** INTEREST CREDITED YEAR-TO-DATE
2.150% ******
29.42 ******
ACCESS TO YOUR ACCOUNT INFORMATION IS NOW AVAILABLE 24 HRS A DAY
7 DAYS A WEEK. PLEASE HAVE YOUR ACCOUNT # AND CUSTOMER SERVICE
CODE (LOCATED ON THE REVERSE SIDE OF THIS STATEMENT) AVAILABLE
WHEN CALLING TOLL-FREE 1-800-331-4631.
********** END OF STATEMENT **********
NOTICE: See reverse side for reconciliation of this statement and important information.
937-22
('
INVENTORY
Estate of Ethel L. Kelley
No. 2106
0084
, Deceased
Date of Death 1/18/2006
Social Security No. 186-28-3544
also known as
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no
real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. INJe
verify that the statements made in this inventory are true and correct. INJe understand that false statements herein made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal Representative:
Name of
Attorney: William A. Addams
J.D. No.: 06265
Evelyn K. Craig
1517 McClures Gap Road, Carlisle 17013
Dated April 2006
Address: 27 W. High St.
Carlisle,
Telephone: 717-243-7638
PA 17013
Description
Value
M& T checking
14,438.55
Sovereign Bank, checking, CD's
26,114.41
PNC - Cumberland County Retirement check
319.62
Hoffman Roth Funeral Home refund
18.23
M& T stock 400 shares
2,218.25
M& T interest check
i\_,'
37.92
Total
(Attach Additional Sheets if necessary)
IS :2 lid
c-
, 1 . ~ l r, ,1 fl-/
,\\l.;J )Ju":'
170,615.31
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylva[1ia may. at the election of the personal representative,
include the value of each item, but such figures should not be extended into. theJ9Jal btthe JpIJ8ntqry,.
RW-4 :.J:Ud...i'..J ,,-,:,_:~',-,,,~i~
tJ
~
Continuation of Inventory
Ethel L. Kelley
2106
0084
Paqe 1
Description of Inventory
Description
Hoffman Roth - prepaid funeral bill
Value
7,610.50
John Hancock GPA Choice Annuity
12,045.50
AIG Insurance Co. Annuity
11,367.17
Jackson National Life Ins. Co. Annuity
70,171.68
Nationwide Life & Annuity
26,273.48
Subtotal $
127,468.33
Grand Total $
170,615.31