The URL can be used to link to this page

Home My WebLink About05-03-06 ---I 1505"60410~b REV-1500 EX (05-04) PA Department of Revenue Bureau of Individual Taxes Dept. 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death .n :'~;:::::..W:;:f ' ";.:.fr:;,~""'t ' ~~~ii$!n g::;.~'n"f:. INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year t- I O.1tJ '<-', '--,,:-:::,'~_, ' :%U].~{':;~ File Number Q,Q .~, .9, ", I:'" .._.:~..: ~-;_~ " -.,,;-.,:,.,~...; }. :,,'-,;-:'-,.'; o.__,"",.i:.::;;. Date of Birth Decedent's Last Name 'j~ .~,:,f2~;&'j~~!Z~;0~">' Suffix it1,;~,~{:j~';:';";,,: i~dli !t'~'~'\l~i ;],.t:t ,~. 't. Decedent's First Name ,'i!l1:bIE B: MI ..<<",t:l,a, .'. ."Q,?l(u"~".:t;:g"..,~,, '.;~,W:::~':i~ '~1$i'7~ ,:::t:i:~.~~ ~'\rf)k:tj, 'Hij~g.-; ;:::;.:>;:~. ".'., L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix ~:':~':~~';) ;, ~~{~'iY~ ~g~use'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 _ 1. Original Return c::> 2. Supplemental Return <:::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required ., <:::) 4a. Future Interest Compromise (date of death after 12-12-82) c::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 10. Spousal Poverty Credit (date of death <:::) 11, Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number . '~"..",~ ~-;.'; 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received ~ 8. Total Number of Safe Deposit Boxes c::> 4. Limited Estate <::) c::> 'dtl, J~.,. rg, /3 'c' Firm Name (If Applicable) h "7 I 7 J:i; Q <1~, J .~. ,J . '; ) REGISTER .oF'WILLS USEct)NLY . _' c--...) . , T] -< , G.) First line of address " ~.~..~ ~L~"': .~... ,Q,.:R.r.l,1);~<E. .l).~ ,J)~j. ;~i;' _ .) :"7 . :0 -. i( ~:: ) Second line of address c1.' ......t,....,Q.....,Q.. ..:J::;......~.".....,I....:;~,\......:!df.r>> . 'j' , ~:;(n)g~, '.' :~;:::;:;.i.:~;; ta Correspondent's e-mail address: n Q 55 (1) /~-1>Ul.- f"; (J . br 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. SI~NAJU~~ OF PERSON RESP~SIBLE FOR FILING RETURN DATE ~t '1l..t..ljl_~' rtlA"i 3 ~~O" ADDRESS ~ # Rv' <<AR& A. 6'~-AfiO I A2J :J SIGNATURE OF PREPARER OTH R THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041046 15056041046 --' ---I 1"5.056042047 REV-1500 EX Decedent's Name: RECAPITU LATION 1. Real estate (Schedule A). .. . . . . . . . . . . . . . . . . . . .n ~ (') ~ . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or. Sole,Proprietorship (Schedule C) llo.~~~3. 4. Mortgages & Notes Receivable (Schedule D) . . . . .;.).O^~. . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) c:::> Separate Billing Requested . I). b.1.'~ 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::> Separate Billing Requested. ./).~J;!.. 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . .. . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . n.o....~~ . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - 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_ · 16. Amount of Line 14 taxable at lineal rate X.O ~ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X. 15 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056042047 [)~~~,~"t3,~~:ey~0"~\i~I~~,cuE!!~~~~8~r , t ,.',7,.~" 'J?'}> ~.j:1")$;. 3 I . ;3 :)" ~,".~ 2' ~~''1'Lt 15. 16. 17. 18. c::> 15056042047 ..--I REV-) 500 E~ Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME V:L7\ LT ~ g~-*-N E2~ 5 J fjR., ---- STREET ADDRESS 3~S Wl::?JLt '1 1) (l.. t V g- i SrpE --r:;- ~._-- CITY fv1 E Ll~ ^ N ( c-S i3 LJR~ I ZIP 55 i t\ I J7a Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payment~ A. Spousal Poverty Credit 8. Prior Payments Co Discount (1 ) J Jf 5c>.+ .3S ( S~~~g~~ tl~ M;r;;tJ.., Total Credits ( A + 8 + G ) (2) -, ~5 ~ ~ 3. InteresUPenalty if applicable D. Interest E. Penalty ------------- TotallnteresUPenalty ( D + E ) (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 difference. This is the TAX DUE. (5) 1~ '7L'1-~~ F 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) ---. A. Enter the interest on the tax due. J :3 1"7'1. 1 ;3 , 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;..... ..... ..................... ........ 0" 0........ .................... ............. .... o. D 13 b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~ c. retain a reversionary interest; or.. ......................................................... 0................0.0.. 0......... ..... ......0... 0 0.............0 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? ... ......... ............. 0......... 0.0......... .... 0""0 ......... ........... 0.................. 0.......... 0" 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. 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 three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. 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 zero (0) percent [72 P.S. 99116 (a) (1.1) (ii)]. 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 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 zero (0) percent [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 four and one-half (4.5) percent, 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 twelve (12) percent [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. REV-1503 EX + (1.97) '* SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF WftL If'/(. L ~ NzE$5 S;. J All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. ~. 3. 1-J. 5~ ~. 7. 1", CfJ {<:I. f f. }~ /3 }'t DESCRIPTION &oe 1)Aar\!1' ~~~~Ltf, LA~ G,,11WlOi\ siOt:~ CtJ~) f> D()~3~ 4 (Oo :16' ~~r", ~r1t~$~ te +n J q()~ Pl.' AIR:> c\JS). f' as 5 ~ df) J f) * ex-d.,v ;ttkc.lt., -P+<D.'5l\ ;;'\ ~~;v;J.~lld1 i /:'~(Jd Sh,;vf-' J3~J( Sl:ot; ~rf? CJA1MDA s:t;<:k C<J5JP "'7'l6~"{o:;J 3M ,Shc"fc,. co...;ft((j.4k ~':i~ Q'Ml'4tlt $To<ck C>,)51 P ~ 10"3 jJ } 6 6 & ~~d(.1 111 JYbxt. fPcJ16.. ('"OMM~^ s"'k\; cv s~p '1J.~r:J::J P16~ i. ~w -;i ~~ 6e 'Afi\cJ E(tiletr;c- CG>V\ JU'l<I' c;;'1-Gtk CrJ$) P 3~bCl1-)(j"3~-J..a:' J ; () i:~IJJP'1 f 36~..~" /n d~ v~:J..^ "" l> ~ 56(jj(I.X hCN P; J"', I ()c t CCA1.I)\\1", sh::k Cu s t~ ~ Jo & 0 )t)~ I ~Q ~-~r(f1 jie;AZ. H:X. c.. fv ~~GtC(jM~G't\ *c.tk CO~Jr>1f'3c.~/i. fjou ,~~~ He~€ Ikpc:t Ltc.. Co~1t~To~~ C\.fSoJP If.~7'''76!o?. j4 ~~C\~ M~k,. ~e~J~ $dlrl-;<."".,. ~MfP( s:t~\, CUSif>S-~JjlJ5tJ)Q W s""t~ \M~ck ~ Co. }/)c:. ColA/'(\D;n ~~~k C))$}l> S-(j<r?15~fc7 'D71~)~1 Ver~),..:. ^ C.,,vIhtV?"o:C4-t:c)o~S c~flNV\C>t sY~" SJ.p<1~Yl3YlOq. );3 'J ~ ;7lt l> ~ J... -.;:loSt... H Mee de F:' 111li(~""i j..J. v.;f(~ t,;ll4 Ctl$2 f 'tdi 1o~~1 liq3 :0 ~ I s:.h. M '" rr: J.l4Y<"" & ("Ned C4.f'TA 1 F--nJ. all:lS 11 cvs).P 5qol"~~d<( TOTAL (Also enter on line 2, Recapitulation) (If more space is needed. insert additional sheets of the same size) VALUE AT DATE OF DEATH :;2~ ~6~.O~ i (. J77, 4~ ~b.71 ~ .Oll J 71 :2tccrJ 5'0 cCfZG~ 3'1( cr* r;2 , Ob ~ j 2.l-~ 1.<ao 5, 7{;J(j, >;l5 :1'3/~g1f-..~~ )J 7.j.o '3 .~a 7) 0 )7 ,t) l> ~ ~ q~<l .IJ' j ~'3 I -r;5l-.. ~ I :1 J 5?):J .It;) $ -g1 () S~ ~.. :15 REII.l"EX'("~ *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF W,AL T~fC: L. Nf;5S., 5 ~. FILE NUMBER 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. ~. 3. 4. DESCRIPTION fit\! L: t30....k t'll!:{V 10.1" Che Loll ~ ^ c.c::., Cl .\""r-, p. 50 - ()(j r7 -I q 7 3 31.. 5 We"1~(t'l( j)ra"ve ttl q:&-~ c-Jbu ~J 7 fA Me~(,..JI ~"C(., ~<>I<~ 1). efC>~*, Prc~Y"'d"" 7~Ac.~.'<^i- (11'__ ~7?"~S-~~) "I/...f'.2.0.. ~ O'nIlAlcctb t....s 'E' 1I."S , tl " )~h_~~ a Of,1! Rb H;-"3 6J"ee1\ Ce,,^c.fc:~ Co. - f> efA;f). LY9r.",{ ~Y.f>QJ(70' VALUE AT DATE OF DEATH ~ 3~.Jo .) ITEM NUMBER 1. J E:>;7 5 (1 .,Of) t. <T<O 3.6 ~ ) If j ~':1::>. <O~ TOTAL (Also enter on line 5, Recapitulation) $ ~t.j.( 4 ~ b...b<:J (If more space is needed, insert additional sheets of the same size) 'REV-1511 EX+ (12-99) f, , _~J~.'.~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Wttl."T-E:-A. L ~ N.Es~, S R. FILE NUMBER Debts of decedent must be reported on Schedule 1. AMOUNT ITEM NUMBER A. DESCRIPTION FUNERAL EXPENSES: M'J-K:> -ft.... r; v r r; ^ V ~ \ H ..""'.. )"1<: " [~f.. :S~;G>f1' t <;ie;..s".<:It:i, cJ Wj:l t {{"'<lI,.( ~ t>b..+~t1r'~l cei't\1'u:.~+~~ r~, ~t"'~A~ ~V'60k 77c(dE.r~1 ~" 5t~c.<l. 04C;-t~.J.. Xfle t-kq'"J.:~4 c ^c.t-i<:--h (fq'~~'c11 It:Mt;tet"'' ~$~ ~tc.ke-b..) a ~ 1 \;~ G t<a-e "- ~ /1M!.. tars G, _ {C<<.~ k 1- {l1> -te rAA..t a.J. re c~~t;.1' fe.. ~ , r~f <.11 ~ prd C" e-A ;'"'nj ~ e ) 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. ~ cr83.oY> SOO "De> I1j ;$ .~ ~,.~~ -.-,. ---:? --- ~ TOTAL (Also enter on line 9, Recapitulation) $ ~ 0 I ~ ~ "5.711). (If more space is needed, insert additional sheets of t~e same size) , REV-1512 EX+ (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER WA'-TE-R L.... Nf:5S; S'A- ITEM NUMBER 1. ~. 3~ ij.~ ~~ ~~ 7 11., Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. VALUE AT DATE OF DEATH ~Zf~ll ~~ I) ;)7~.7~ 7'3<J .Of!) )D).5~ J '3J}.(j~ Lf 1 ~?i8" ], ~ V!6l:> lD..CrJ DESCRIPTION &~V; tlftje - 5k;})ed tJ\:)t5~1(~ ,- &~t:' ~..~ ~ ~06"5 CILJeTet1 )"'~JA.E ~X (;~~~.u:;+) - &b..~~t j. Q.l)6~ f~ n~~cJ,,">< ~ St<< t: 1" r:.r f"> (.1" X r;..., ~"'-7.{.\ - f..J,;} j . J W~-tShDre ~rer3~^\"J/(Ie~t:d.( S~ttllC( - BLS(;,.,t~A~<!).- S.LJ e.E'd.t.e U,,:f6J M~fl~J ;~1 ~(Jr~ (:^.r~~ ;{.) :- ~~;~;.} 5 ~~o.rR'L<~AS5~~~j [;,^i-nr.A~t~J - pb...b~t 6 rv?~Jo.~;t; f)..~;1\- }~Q3 ;s~teJ )hrJbe tltf,'s+(:...1TY.*-B - G. '-:;J ~pi\A"~ X.;...,/(l ~ H; t, } /'t' <(..cu lle r- - C~>"( bt d'~KJ C; <J.A)j a.J Uo./Ie.r- (4<1Q.^- It-uJ~Th;p - oh:brr ~ TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 3., ~ <1 (7 J~">lj REV-15i3 EX+ (9-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF w,4 L Tt.{< L N e5 5, 5P-. FILE NUMBER 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, and transfers under Sec. 9116 (a) (1.2)] 1. W~7e" L_Nets) J.r: ~..o~ If) () 0/75 ft-YI"f(\1.~ Pd\.T~"'$A. 6 b 4 -Ai1-o.. .ll)(!~ ~ ~g)7]D -P1.-o j2;p 1. to.A~~ tll') R;J? ei6.z";7 Ada. L. Srrtatn !Ji!.-{-t" Jt,Od9;^ w;(/'J 7; 5--;-0 r- - ;d - \dtoJ ~ ~~ fJ6Q"'-:,......j o~ 0.:..1. 3 . ~D01:> J)e~;(a.~i: )..c~t, ;i~cl1~ - );.~;h;1 ~ - 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 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) JOMPLETED BY ACCOlfNl ow~ERS: J. One) ~ New TOO dC5ignation and Agreement o Change in TOO Beneficiaries If changing. adding or removing B~neficiaries. plnse rest~te all current TOO Beneficiaries. Account Owner Jnd Tide: t(; r j J 11''':/ r' L. AI € ~ S Account Number: !1j [lJ [2] - ~ BJ [QI IlJ [I] t5' t'lr: "t". .c., ~ .~ .0 "\ c... o o Addition of TO 0 Beneficiary o Removal of TO 0 Beneficiary Beneficiary Designations: ~bme of UTMA Custodian Name of Beneficiary (if beneficiary is a minor) Address of Beneficiary Relationship to Owners SSN or TIN Percen tage. .-.. L it/ 'j'/ l.fi L 3 .; ~;: d J. i H.lf I- .t. c-"/ LJ,< .j'CJ ",y / J:~/- ;51. - 6 '~~I - # e t'" ,# -'"1/ W (' .J /-s i".: / ,.. .1;,-1..; /{.10 7;'ij. /.--;. 2. 3. 4. 5. 6. .Note: The toul of all perCent3gC5 must equal 100%. If the percentage column is left blank, equal percentages will be assumed. THIS QUESTION ~1UST BE COMPLETED IF MORE THAi'l ONE BENEFICIARY IS NAMED ABOVE. If any Beneficiary listed above is not living at the Death of the Account Owner, that Beneficiary's percentage of the funds, securities and assets in the Account shall (check only one box): . o Pas.s to any surviving Beneficiaries in a r:1tio based upon the surviving Beneficiaries above stated percentages (~ paragraph 11). ~ Pas.s to the estate of the Account Owner. If neither box is checked the funds. securities and assets in the Account shall pass to the estate of the Account Owner. The MLPF&S Transfer On Death Account does not provide for contingent or successor Beneficiaries. Any attempt to alter or amend this Agreement to provide for contingent or successor Beneficiaries shall render this entire Agreement null and void. . Account Owner hereby agrees to the tenns of the MLPF&S Transfer On Death Agreement and acknowledges receipt of a copy of that Agreement. THIS TRAl~SFER ON DEATH AGREEMENT MUST BE NOTARIZED. /j i?l0i 1.]!k .~:i Signature of Account Owner Signature of Account Owner Date: J)Ec.. ;l.h /f/pj/ Da te: Spousal Consent The Spousal Consent Section must be completed if ALL of the following conditions are met: (a) the Account Owner has a living spouse; (b) the Account Owner and the spouse resided in: Arizona, California. [daho, Louisiana, Nevada. New Mexico, Texas, Washington or Wisconsin, at any time during the marriage; and (c) either: (1) the spouse is not an ..~ccount Owner; (2) QB the. spouse is not the sole Beneficiary of the assets of the Account Spousal consent may be revoked by providing MLPF8cS a written revocation. In order for this revocation of spousal consent to be effective, it must be delivered to \ MLPF&S prior to the Account Owner's death. MLPF&S reserves the right to add to the list of states above in the evenc..any other state shall adopt a system of com- munity or marital property. Signature of Spouse _1----1_ Date Name of Spouse (primed) Address of Spouse ACKNOWLEDGMENT STATE OF P A COUNTI OF LU rn BER-L-A IV D \ , \ The foregoing instrument was acknowledged before me this \ ~ NNbtary ?ublic ......2.\ 107.. -' ~ ~ - 0/ M~~y Commission Expires \ \ ..., 1\\HHflHI,JI.. "e.-I"' C"M 1}'!-O tX. ~\ ayor ".I;'!2 ~" \ DC' "- ,j ~""",..,: '\.. ;.;) J ~ . .:..,. ..:~. ;; -:", ", r:......~~. "<... 1" r'-) <',~ ,.... ':'":,' " ~.... .\ ,To . '. .,' . ,. ",*., ~ {~:~t:, ,~;,V).:;;;''S~~,c':; ';'. ~... '. '. . .fI" "'" .........'..,,' .."" . '.' .J '", ...,.... ~'f "'" <; /' f-l ~ge 3 ' , . in the year ( q q ~ , by LAST WILL AND TESTAMENT I, WALTER L. NESS, of Lower Allen Township, County of Cumberland and State of Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all former wills, codicils and other testamentary dis- positions by me at any time heretofore made. 1 . I direct my executor, hereinafter named, to pay as soon as practicable after my decease all my just debts and the expenses of my last illness and burial. 2 . I give and bequeath the sum of Four Thousand ($4,000.00) Dollars unto my sister-in-law, Mrs. Ada L. Brown, if she survives me. 3 . I give, devise and bequeath all the rest, residue and remainder of my estate, whatsoever and wheresoever situate unto my son, Dr. Walter L. Ness, Jr. 4. Should my said son, Dr. Walter L. Ness, Jr. predecease me without leaving issue surviving me, then and in that event, I dispose of my estate as follows: # A. I give and bequeath the sum of Two Thousand ($2,000.00) Dollars unto each of my following named nieces and nephews if they survive me: Mrs. Louise Shiffer, Robert Reinsel, Randall Almony, Richard Almony, Robert Almony, Elma Almony Mertz, Carolyn Almony Noll, Iris Almony Thomas, and Jean Almony Wujnovich, Charles T. Ness, Dean Ness and Francis Kibler. B. I give and bequeath the sum of Two Thousand ($2,000.00) Dollars unto each of my wife's following named nieces and nephews if they stlrvive me: Patricia Dundore Nau, Joan Marie Hood, and Jack Dundore. Should my- estate be insufficient to pay in full all of the pecuniary legacies hexeinhefore set forth in this item 4 of my Will, then and in that eventl the said pecuniary leg- acies shall be pro-rated among the legatees who survive me. C. I give, devise and bequeath all the rest, residue and remainder of my estate unto the Endowment Fund of Grace United Methodist Church, State Street, Harrisburg, Pennsylvania and the Fund for Education of Lebanon Valley College, and Care Assurance Endownment Fund of Bethany Village, equally, share and share alike. 5 . I nominate, constitute and appoint my son, Dr. Walter -' L. Ness, Jr.> executor of this my Last Will and Testament. Should my said son fail to qualify or cease to act as executor, I hereby appoint my nephew, Randall Almony, executor of this my Last Will. 6 . I direct that my personal representative, as well as his successor, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF> I, WALTER L. NESS, the Tcistator, have hereunto set my "hand arid seal to this my Last Will and Testament this KfJr.* day of October, 1990. ... /Jfdt;.t: k~ (S E A L ) Signed, sealed, published and declared by the above named Walter L. Ness as and for his Last Will and Testament in the presence of us, who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto. ~.>t ~ -L-~ ~lA.t~ k1 OAl1 ~:ethanY Village T 325 Wesley Drive Mechanicsburg, PA 17055 eXHIBiT Statement Date Due Date ACCOUNT NUMBER 04/10/2006 Upon Receipt 415 $1,489.00 - 7.0. AMOUNT PAID $ 1} L/8 /. q1 Please make check payable to BETHANY SKILLED NURSING MR. WALTER L NESS c/o WALTER NESS, JR. AV. RUI BARBOSA 664 APTO.1002 RIO DE JANEIRO, RJ, BRAZIL, 22250-020 Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055 t~AY Q 1 2006 120 ?}S C~II&r- Please detach and return this portion with your remittance to the address above. Comments PreBiII 0 - 30 31 - 60 61 - 90 > 90 BALANCE DUE I $o.oo__df , --_.__.--~----~_.._--~ $0.00 $1,489.00 $0.00 $0.00 $1,489.00 Balance Forward $1,489.00 TOTAL BALANCE DUE: $1,489.00 FACILITY NAME I BETHANY SKILLED NURSING RESIDENT NAME MR. WALTER L NESS ACCOUNT NUMBER 415 o ~ ~ o 0 OiO W W w!Ql ......... ......... .........:..... I\.) 0 oitb o 00 m! ~ s: s:l~ z ~ ~ ~~~ ~ ~ ~ ~ 1-5, -.of AX" X" i !:to 9 0 0'0:0 -. m m mi::3 ~ "8"8"81 Ul Ul UlI ;:+ ;:+ ;:+ i -0 -0 -01 0001 OQ. OQ. ao. i m ID ID1 3 3 3! -..t W o o o ~ ~ (Q o o it:? ~!~ 0; Ul o!~' o O!t:? ~~:~ WI\.): tb ~ ~I s: s:it:? ~ ~i~ ~ ~:~, 'A 'Al!:t. ~ ~lg "8 "8 j ~ ~l a a'1 ~~j w wi 3 31 (Xl p ~ (1J I~ j:'- :0.. i~ !~ I~ d c: ::0 () s: )> s: o ~ rn --< )> o o o c: ~ --t :d )> :2: C/) :l> o --t -- o ~ C/) O~ Wi OJ ii) d! 0) ~!~ i"'" iM: lCO 1::3 Z oj 0 m Wi OJ -.of dl co d 001 Q ~ 1m .- jttl jo.. i Olio Oli:r -..t i ro jn i"" 12: Ie: 13 !O" 'ro I~ -olt:? :t> i tb 01 C/) mi ~ ~!~. 010' ,,! ::J ::01 ~; m I 21 m! i i ~ I ! I i i i i I I i d c:: ::0 o s: ~ :d ~ :2: ~ o -; -- o :2: (f) ~ ~ m ::0 r Z m (J) (J) o () (J) o )> \ti n ~ n 0 ~ c: ~ ~ ,.... \.b z c: "- 3 -i 0" CD - :'1 co -.....J tY tV W (J1 0 tV ~ ..., -..t I~ w W t:? .... ~ 0 0 ~ 0 0 ro en (j) g Q.) -:.... tv 0 0 ., (') en lO :~ ::T' 0 0 0 0 1* 0 0 0 ~ f'0 0 -I 0 0 Q) ~ ~ ill r0- Il ., 3: (') ::T I'T1 ~. ~lo w ::tJ ~ "(i_,. .' ~ :::a ~:_,i..-':\.,__ I\.) i ro CJ1 01"'0 0 f'0 0 . :0 (tl 0 r- .... gl~ 0 r-; \.) ~ Q) :J') E7\tI tAc] 4 WEST SHORE EMS - BLS 205 GRANOVIEW AVE SUITE 211 CAMP Hill, PA 17011 Phone #: (800) 367-0512 Federal Tax 10: 23-2463002 fA WEST SHORE PATIENT NAME: WALTER NESS INSURANCE: MEDICARE B CAREFIRST 178015988A UH5912N7 PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: 16237 WCS 139950W NONE 02/20/2006 03:30 PM HOLY SPIRIT HOSPITAL HOLY SPIRIT HOSPITAL BETHANY VillAGE 139950W WALTER NESS 325 WESLEY DR MECHANICSBURG, PA 17055 REASON(S) FOR TRANSPORT Pneumonia INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT Stretcher One Way Transport A0999 1.0 82.98 82.98 Transport Van Mileage A0999 6.0 3.09 18.54 ~ l ~53 efi C> j.. 5 r;, '3/ d 0& Total Charges 101.52 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~ $101.52 RE""URNED CHECK FEE - $31.00 t.,,-HI8JT io Account #: 230894 Please Pay: $41.88 WALTER L NESS ID# 230894/JAMES R HARTY MD 01/13/2006 OFFICE / OUTPATIENT VISIT ESTABLISHED PATIENT EXP PROBL 02/01/2006 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE 02/01/2006 PAYMENT FROM MEDICARE 02/10/2006 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR DEDUCTIBLE WHICH IS NOT --> COVERED BY YOUR INSURANCE BALANCE TICKET #BVC001751 "j ~ i~ r", ct( .~f1 11 ( \ } <lb ..... ......... .. ........... ......... .. . ..... ..... ... --..... ... . ... ... ..... . . . ............................. . .-. . ..... .... .. . "'n.',__'" .__...... ......_........ . ..... ..... ... n.............. _ _ .n.. .'.._ _. n n_......... "._ ....... j~mmmmmmmmmmmmmmmmm~mmmmmmmmmOj~~~B*~r{ttmM~$~~~~l:~Q~g~l~g~~~j~~~Q~~jll:!lmmmmmmmm!m~:mm: .. PROMPT PAYMENT WOULD BE GREATLY APPRECIATED. Make Checks Payable To: CONNER RICH ASSOCIATES PLEASE DO NOT SEND CASH THROUGH THE MAIL EG1521-32 Due Date: 03/07/06 i~~I~~I~~j'i' ,~~li'llliilillflllli 65 00 65 00 0 00 -17 37 0 00 -5 75 0 00 -41 88 41 88 00 41 88 ..... ..I~~~~jll!~~~~~~jll~:I;llj:.lj .::::'.':':'::' :~~~~~li~tjll~~I.t~~jjll!ijll!1 ;~I~M~~.j~~~I..;.j!I!I.~!I...I::..!i~llj:I!.::j~ 41 88 00 41 88 For Billing Questions Call (717)-7618331 PAGE 1 OF 1 1=~t+J8fT 7 Melanie DeMartyn, MA, ATR-BC, LPC i~eg;~tereJ Art TheY'ap;~t, L;cen~eJ ProFe~~;ona) Coun~e'oY' 110 Cumbel'lcmd P~l'kw~y, Suite #5 Mech~nic5bul'g, PA 17055 717-795-1166 E-Mail: art-therapy@paonline.com February 2006 RE: Walter Ness Art Therapy February 1 1 hour February 22 1 hour Total Service: 2 hours Art Therapy @ $60.00/ hour Total Due: $120 r?~ ~ /)')D-u)G J de;o~ t. '{fZ4~ ~ fl/~ 00 L.{) L.{) 0'1 L.{) L.{) 0'1 L.{)L.{) N c..o N c..o I'- 0 I"- 0 c..o .......... c..o .......... 0 0 M M .......... .......... r-l ~ ...--l 00 ...--l 00 00 00 ~ ~ 0 ~ L.{) L.{) 0 ~ L.{) L.{) Z 0 Z 0 U U ~ ~ ~ I- ~ I- ........ Z 1-1 Z en W CO W => => cr 00 c..o c..o cr 00 Z mm i 1-0 0 Z mm 1-1 zo 0 1-1 ~ ~~ ai ::::> N N ~ . ~~ W 0..........0.......... W 0 U...--ll-O 0 (/)0 M 0 1-1.......... ..........-~, 0 W ?- 0M ~ W I- U Z U z: 1.0 .......... W 0 c..o 1-1 W 0 0 I- ~ W WO 00 0 I- ~ w WO 00 0 OO~ l- => 00 0 OO~ l- => 00 00 00 N ZZ<( I- ~ 00 N ZZ<( I- ~ 00 .......... <( 1-1 <( 00 .......... <( 1-1 <( 00 ...--l X~~ :E > ...--l X~~ :E > 0 <(~W a:::l LOLO 0 <(~W CO LOLO .......... I-W3 => .......... I-W3 => M a:::l0 (/) M COO V) -1:E~ ~:E~ <(=> V) <(=> V) ZULJ.... W ZULJ.... W 0 0 X 0 0 X W V)LJ.... <( U W (/)LJ.... <( I- ~Oo... I- ..........U I- ~Oo... I- <( W 1-1 0... .......... <( W 1-1 0 0... >- I 0 0... 0 o....>-I 0 I-V) 1-1 >- I-V) 1-1 ~ c..oZ Z <( I-Z ~ c..o Z Z <( ~ 0=>3 0... Z=> ~ 0=>3 0... ........ 000 Z U:E 1-1 000 Z en NUl- => NUl- => ~t1fB1T ~ I- 0... 0... '\S" <(o(j ~ ~ \r7 ~ <) W >- (/) W t> ~ CO a:::l >- ~ CO '- ~ => M <( => M ~ ~t:> V) 0\ L.{) ~o V) m ~ <( L.{) L.{) 01-1 <( L.{) "- W I ~o ~ W I '""-' ~ ...--l o I'- ~LJ.... ~ ...--l \P c I- ...--l ~...--l I I- ...--l wo * 0\ WO 1 . => I'- (/) . => I'- ~Z...--l c..o W<( V) >- ~Z...--l 1..0 WW 0 Z 0... ~<( WW 0 ~> N <( =>0 ~> N ~<(<( 0 c..o .-lLI') IV) ~<(<( 0 c..o 1-1 0... W ~ 0::' I-W 1-1 0... W :E-I ~ WZ=> Z :E~ ~ w . ........ I-OCO o(jO W 1-1 .:E-I WI- .-l V) (/) W ...--l .:E~ WI- ~:E-I ~w (V) <(~U V)3(/)1'- ~:E~ .-lW ('1) =>........ I-~ ...--l 31-11-1 W >- '--/ =>1-1 I-~ ...--l WII 1-1 3Z =>0<( WII 1-1 1-1 1->- <( f-WOw 1-1 1->- 2 (V) 0- ~ (j')L.{)I 0{/) 1-1 Z z(V)o... ~ ZO\:E a:::l---1 ---1 (/)NU 20---10 zm:E CO~ .-l om<( O=> f- WNW O.-lOI om<( O=> I- \ COMU r-:>LJ.... U ZL.{):E :EU:Co... a:::l...--l U r-:>LJ.... U r\. If changing, adding or removing B~nefidaries. ple3Se restate ill current TOO Beneficiaries. Account Owner and Tide: t(; r J 1 II-='; / L - it! € ~ S Accoum Number: I1t [l] (l] - @) ~ IQ) [2J II] l;" 0; ~- .~ ~ .~ .... a d- jOMPLETED BY ACCOUNT OWNERS: ..J( One) 1JI New TOO designation and Agreement o Change in TOO Beneficiaries o Addition of TO 0 Beneficiary o Removal of TOO Beneficiary Beneficiary Designations: Name of UTMA Custodian Name of Beneficiary (if beneficiary is a minor) Address of Beneficiary Rebtionship to Owners SSN or TIN Percen tage- ........ 1 '/ 1.,Al7f S ~k - d <.I.. 5" j-(J~ f.. ,t. C"/ V',< ~.CJ ,...y I g'~/- :3.2 - 6 '~~j . U/~/-- #.c-r#;//J//(' J/-S <,-I ~.. h"'-i /C.'6 ; -; 2. 3. 4. 5. 6. -Note: The toul of all percentages must equal 100%. If the percentage column is left blank, equal percentages will be assumed. THIS QUESTION ~lUST BE COMPLETED IF MORE THAt~ ONE BENEFICIARY IS NA1Y1ED ABOVE. [f any Beneficiary listed above is not living at the Death of the Account Owner. that Beneficiary's percentage of the funds, securities and assets in the Account shall (check only one box): o Pass to any surviving Beneficiaries in a r:ltio based upon the surviving Beneficiaries above stated percentages (see paragraph II). " Pass to the estate of the Account Owner. If neither box is checked the funds. securities and assets in the Account shall pass to the estate of the Account Owner. The MLPF&S Transfer On Death Account does not provide for contingent or successor Beneficiaries. Any attempt to alter or amend this Agreement to provide for contingent or successor Beneficiaries shall render thi.s entire Agreement null and void. . Account Owner hereby agrees to the tenns of the MLPF&S Transfer On Death Agreement and acknowledges receipt of a copy of that Agreement. THIS TRANSFER ON DEATH AGREEMENT MUST BE NOTARIZED. /) i?/0i 1-7!L .~a Signature of Account Owner Signature of Account Owner Date: )JEt:.. ;i. h / fly Y/ Date: Spousal Consent The Spousal Consent Section must be completed if ALL of the following conditions are met: (a) the Account Owner has a living spouse; (b) the Account Owner and the spouse resided in: Arizona, California. Idaho, Louisiana, Nevada, New Mexico, Te.:us, Washington or Wisconsin, at any time during the marriage; and (c) either: (t) the spouse is not an .-\ecount Owner; (2) QR the, spouse is not the sole Beneficiary of the assetS of the Account. Spousal consent may be revoked by providing MLPF&S a written revocation. [n order for this revocation of spousal consent to be effective, it must be delivered to I, MLPF&$ prior to the Account Owner's darn. MLPF&S reserves the right to add to the list of states above in the event-any other state shall adopt a system of com- munity or marital property. Signature of Spouse _'---1_ Date Name of Spouse (printed) Address of Spouse ACKNOWLEDGMENT STATE OF PA COUNTY OF c...u ffl BC12L-A IV i) ~~J,\\ \\ ~ :d~.;J6J~I::}; .l>E:<:E N\ &:ft- ',i ,..' ~..l ~,. ;';J' -.~:- .'.';, , ;; ..'\ ,"''''':: ..<0..... l>.. ,',' .....,..... ,..~:.... , .J....1i~..... .... ..' ~).. '\ ',. h, ",. {)'./, "';' ':, }. i.:~'" ...'$ , v.J.': >>~~;. ':'./r~' ,. .-;'" ,:-. .....: t". . , '.~, 0- .~. " =\..... ~ :.It tt . .: .,~ ~"" : -.... f.:' %0 :}::, , , . ~.. ~. ;,.; '.' I , /J~"'''''''' .-,. ,,'. " "'" <: / II ~ge 3 ,.'. . in the year ( q q ~ , by \ The foregoing instrument was acknowledged before me this \ \ / /1 ...I . . NNbtary ?ublic -.i, /0< -';). ~ - 01 My.\y Commission Expires \ \ \ FC: COFFEE, RICHARD KAI PRC ACCT: 872-35021 WALTER L NESS TOO BENEFICIARIES ON FILE 5225 WILSON LN # 104 MECHANICSBURG PA 17055 .00 .00 1.52C PAY CSH SETB SETD 2/28/06 FF: N PRV YR: SEC # 00123 M 079J5 M 08780 M 139XO M 228E2 M 31607 M 35C10 M 35955 M 36780 M 46J71 M 48654 M 79B06 M 94SK9 C 97M76 C 97M76 M 974YO C 974YO M 05/04/03 SEC SYMBOL ABT BP BLS CEG DLM GE HSP HNZ HD MHS MRK VZ 94SK9 FIDBX FIDBX MBCPX MBCPX CUSTOMER ACCOUNT ASSETS (717)697-3935 17/ 03 o .00 1.52C .00 218184 218,112.00 .00 .00 08:06 03/06/06 PG 1 COB 03/03/06 FC: 8145 TYPE: CMA 328,457.28 .00 .00 .'00 16,750.00 .00 .00 .00 POS/PGS: UNPRC 12/05 INT: MCSH INTC FME SMA MCAL TeAL UPDATE: N 315,625 348,075 ---- DESCRIPTION ---- ABBOTT LABS BP PLC BELLSOUTH CORP CONSTELLATION ENERGY DEL MONTE FOODS CO GENERAL ELECTRIC HOSPIRA INC HEINZ H J CO PV 25CT HOME DEPOT INC MEDCO HEALTH SOLUTIO MERCK&CO INC VERIZON COMMUNICATNS ML BANK DEPOSIT PROG J HANCOCK FINANCIAL J HANCOCK FINANCIAL ML BALANCED CAPITAL ML BALANCED CAPITAL SPON <END> 360,737 - QUANTITY - 600 264 1,800 300 66 1,200 60 150 800 24 200 800 16,750 .7460 3,336 .0810 493 ACCT T-VAL RAFND STFND C-MNY C-OTH BCORT "I/ANo MFA CURR PX 43.7800 67.1500 31.4600 57.2500 10.6000 33.0600 40.5100 38.2300 42.2000 58.0500 35.1900 33.5800 1.0000 19.1000 19.1000 25.5200 25.5200 cl o~I~1 , f\ (i VALUE -- 26,268 17,727 56,628 17,175 699 39,672 2,430 5,734 33,760 1,393 7,038 26", 864 16,750 14 63,717 2 12,581 Senior Checking Plan Account Statement PNC Bank ~ PNCBANK For the period 02107/2006 to 03/08/2006 Primary account number: 50-0097-7973 Page 1 of 2 Number of enclosures: 0 u WALTER L NESS 5225 WILSON LN APT 104 MECHANICSBURG PA 17055-6663 Q For 24-hour banking, and transaction or interest rate information, sign-on to tt Account link<<l by Web on pncbank.com. For customer service call1-888-PNC-BANK between the hours of 6 AM and Midnight ET. Para servicio en espafiol, 1-866-HOLA-PNC Moving? Please contact us at 1-888-PNC-BANK I2!SI Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 8 Visit us at pncbank.com I) TOO terminal: 1-800-531-1648 For hearing impaired clients only For a limited time you can earn 10,000 Visa Extras Bonus Points when you enroll your PNC Bank Visa@ Check Card in Visa Extras. Rewarding yourself. Easy as PNC (8M) . See branch or pncbank.com for offer details. Senior Checking Plan Regular Checking Account Summary Account number: 50-0097-7973 Walter l Ness Balance Sanlmary Beginning balance 4,750.35 Deposits and other additions 2,253.16 Checks and other deductions 6,197.47 Ending balance Please see the Activity Detail section for additional information. 806.04 Average monthly balance 727.94 Charges and fees .00 Transaction Summary Checks paid/ withdrawals Check Card POS signed transactions Check Card/Bankcard POS PIN transactions 11 o o Total ATM transactions PNC Bank ATM transactions Other Bank ATM transactions o o o Activity Detail Deposits and Other Adcrdions Date Amount Description 03/01 1,091.52 Direct Deposit - Pension BenefitsXXXXXXXXX~~2908 165.76 Deposit Reference No. 026640260 41.88 Deposit Reference No. 026847025 954.00 Direct Deposit ~ Soc Sec US Treasury 303 XXXX-~5988A There were 4 Deposits and Other Additions totaling $2.253.16. O~/Ol 03/02 03/03 FORM953R-1005 Senior Checking Plan Account Statement 8 For 24-hour information, sign-on to Account link @ by Web on pncbank.com. Account nwnber: 50-0097-7973 - continued Checks and Substitute Checks Check Date number Amount paid 1143 258.88 02/10 1144 60.00 02/09 1145 144.4 7 02/07 1146 1,900.00 02/08 1147 106.00 02/13 1148 2,000.00 02/07 * Gap in check sequence Reference number Check number For the period 02107/2006 to 03/08/2006 WALTER L NESS Primary account number: 50-0097-7973 Page 2 of 2 Date Reference Amount paid number 180.00 02/13 025585762 41.88 ~;~ 024446840 130.00 026889813 101.52 03/07 025770051 1,274.72 ~8 027415009 There were 11 checks listed totaling $6.197A7. Balance 806.04 Daily Balance Detail Date Balance 02/07 2,605.88 02/08 705.88 02/09 645.88 Date 02/10 02/13 03/01 024152440 1149 024805864 Cc/')r~i! R;~,~ ~>-; 1'tj~to 1151 * 025529225 6~Jt.i.'( V" fed j(ett.. Ch . m2 026486352 k]e-it S~, r. ENts- 94-5 lJ.li$ 026281343 ~ 1 . t -. . 1155 * 027076198 n:s.J~I.t.,.\ ~~~ 1d'\. - (U"7. J rt.e.1v;Cj ) Balance 387.00 101.00 1,358.28 Date 03/02 03/03 03/07 Balance 1,400.16 2,354.16 2,122.64 Date 03/08 '~enior Checkillg Plan ACColmt Statement '\.J C Bank ~ PNCBANK For the period 03/09/2006 to 04/07/2006 Primary account number: 50-0097-7973 Page 1 of 2 Number of enclosures: 0 WALTER L NESS 5225 WILSON LN APT 104 MECHANICSBURG PA 17055-6663 ~ For 24-hollr banking, and transaction or ~ interest rate information, sign-on to 1t Account Link@ by Web on pncbank.com. For customer service call1-888-PNC-BANK between the hours of 6 AM and Midnight ET. Para servicio en espanol, 1-866-HOLA-PNC Moving? Please contact LIS at 1-888-PNC-BANK [!5] Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 ~ Visit us at pncbank.com ~ I TOO terminal: 1-800-531-1648 For hearing impaired djent~ only or information on exciting offers and promotions for our free Online Bill Payment service, stop .y any PNC Bank office, visit pncbank.com, or call 1-800-PNC-BANK for further details. teniar Checking Plan iegular Checking Account Summary .r:count number: 50-0097-7973 Walter L Ness ] 20.00 Ending balance 1,749.G6 Please see the Activity Detail section for additional information. lalance Summary Beginning b<Jlance SOt>. C}iJ Deposits and other additions 1,063.G2 Checks and other deductions Average monthly balance 98!1.<-j7 Charges and fees .00 transaction Summary Checks paidl withdrawals Check Card pas signed transactions Check Card/Bankcard pas PIN transactions o o Total ATM transactions PNC Bank ATM transactions Other Bank ATM transactions () o o 'ctivity Detail Jeposits and Other Additions 3/31 Amount De<;cription 1,Ofd.62 Direct Deposit - Pension Beneflts XXXXXXXXXXX3598 There was 1 Deposit or Other Addition totaling $1.063.62. ;'ltp :hecks and Substitute Checks heck Date umber Amount paId ~~ 120.no 0;1/13 r Reference number 026579277 ~ jYf ~ J4A 4 ~J)<;> jr1" rt~ f} There is 1 check listed totaling $120.00. FORM953R-1005 Senior Checking Plan Account Statement Q For 24-hour information, sign-on to Account Link @ by Web on pncbank.com. Account number: 50-0097-7973 - continued Daily Balance Detail Date Balance 03/09 806.04 For the period 03/09/2006 to 04/07/2006 WALTER L NESS Primary account number: 50-0097-7973 Page 2 of 2 Date 03/13 Balance 686.04 Date 03/31 Balance 1,749.66 Are you Renting? Take a look around. 'Vhat would it take to replace your valuables? Learn about Renters Insurance today. Visit rentersins.com/pnc Product not available in FL, NC and NJ. Need to know what's on your credit report? Get Unlimited access to your credit reports & scores, 24 hour notice of changes to your credit plus $25,000 in identity theft insurance. It's safe & secure. Visit pncbank.com/ creditreport RfiI-1510E':".oI, *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER 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 OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE ATTACH A COpy OF THE DEED FOR REAL EST ATE. NUMBER VALUE OF ASSET INTEREST (IF APPLICABLE) 1. TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size)