HomeMy WebLinkAbout06-27-06 (2)
REV.1500 EX + (6-00)
*""
~ '. .
I
! OFFICiAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
--
INHERITANCE TAX RETURN FILE NUM;E; 05
~RESIDENTDECEI:)ENTu __~__ COl[~]'{C_ODE __ YEAR
I-
Z
LU
C
LU
U
LU
C
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
. Moyer, Helen_
DATE-6FDEATH(MM~DD-YEAR) '1 DATE -OF BIRTH (MM_6D_y~_n
_ 10-20-2005 _ _L~~-05-193~__.
: (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
0971
lJUMBEOR
1----....--------.---.-
SOCIAL SECURITY NUMBER
'U' __t9_0 - t f?, - g I f.o 5
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
w
....
~~Ul
UO:~
w<l.U
IOO
uO:..J
<l.lD
<l.
<(
x 1 Original Return
2. Supplemental Return
REGISTER OF WILLS
------ -----
SOCIAL SECURITY NUMBER
c=: 3. Remainder Return (date of death prior to 12.13-82)
xJ 6. Decedent Died Testate (Attach
copy of Will)
9. Litigation Proceeds Received
, 4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
1 o. rf-~~-~~I (date of death between
L_' 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
4. Limited Estate
....
z
w
c
z
o
<l.
Ul
W
0:
0:
o
U
FIRM NAME (If applicable)
, Said is, Shuff, Flower & Lindsay
TELEPHONE NUMBER
(71 7)_137 -3 4_0_~_____
2109 Market Street
Camp Hill, PA 17011
(1 )
OFFiCIAL uSE ONLY
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
z
o
i=
:3
::J
l-
ii:
<{
U
LU
0::
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
, Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) Separate Billing Requested
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
None
(2) 176.40
------.-
(3) None
---.-
(4) None
------------
(5) 20,227.19
-------------
(6) None
(7) 68,694.72
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)
(8)
89,098.31
(9)
(10)
7,385.73
---------
567.24
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
(11 ) 7,952.97
(12) 81,145.34
-- --
(13) 1,867.59
(14) 79,277.75
x .00 (15) 0.00
- --..-------
x .045 (16) 0.00
x .12 (17) 0.00
x .15 (18) 11,891.66
(19) 11,891.66
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has
not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
15. Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
z
o
i=
~
::J
a.
:!:
o
u
><
~
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
0.00
0.00
79,277.75
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Copyright 2002 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00:
Decedent's Complete Address:
[STREET ADDRESS
490~_~_~rindle_ Road
CITY Mechanicsburg
, Apt. 98
i STATE PA
I
ZIP 17050
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
11,891.66
9,600.00
505.26
Total Credits (A + B + C)
(2)
10,105.26
~1. 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. (4)
Check box on Page 1 Line 20 to request a refund
~;. 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)
1,786.40
1,786.40
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:
a. retain the use or income of the property transferred;..................................................................................
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest; or..................................................................................................................
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?................................................................................................................ ......
Yes No
x
x
x
x:
x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.........
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................................................... ......... ......... ........ ........ ............ ..... x
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
C()rT1plet"'gecla"'ti()no!Jlr~p~r~r.()thert~~.~~~rsonal representative i~.~.s_ed-"n all information of which prepar~hasanykn-"wledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
WiUiam,M. Long ~
,,~~~' 6;;,,~'mviU,"
x
875 Hawthorn Ave.
Mechanicsburg, PA 17055
DATE
trl ~ (Vi-
ADDRESS
DATE
SIGNATURE OF PREPARER H
Rdbert C. Saidis, Esq.
RESENTATIVE
ADDRESS
6/1:1/.1'"
~~-
DATE
2109 Market Street
Camp HiU, PA 17011
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)].
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 statute does 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 daltes 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.
Rev-1503 EX+ (6-98)
*'
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
All property jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 Series EE saviings bond, $100 face value, issued 103.68
1/1993
2 Series EE savings bond, $100 face value, issued 72.72
2/1996
TOTAL (Also enter on Line 2, Recapitulation) 176.40
(If more space is needed. additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule B (Rev. 6-98)
Rev-1508 EX+ (6-98)
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
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
DESCRIPTION
VALUE AT DATE
OF DEATH
1
2005 IRS, tax refund
1,216.00
2
2005 PA Dept. of Revenue tax refund
500.00
3
Auto Insurance refund
409.00
4
Com cast, refund
34.99
5
Country Meadows, refund
1,152.88
6
Members First FCU, checking acct. #111332-11
646.56
7
Members First FCU, savings acct. #111332-00
1.267.76
8
2003 Toyota Camry sedan (value based on sale price)
15,000.00
TOTAL (Also enter on Line 5, Recapitulation)
20.227.19
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
Rev-1510 EX+ (6-98)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Moyer, Helen
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.
IFILE NUMBER
21-05-0971
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECO'S TAXABLE
EXCLUSION
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1 The Hartford Annuity, contract #710011901, date 68,694.72 68,694.72
of death value - beneficiary - William M. Long
TOTAL (Also enter on Line 7, Recapitulation) 68.694.72
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule G (Rev. 6-98)
REV.1151 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
Debts of decedent must be reported on Schedule I.
I FILE NUMBER
21-05-0971
ESTATE OF
ITEM DESCRIPTION AMOUNT
NUMBEF~.
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 508.85
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid 3,000.00
See continuation schedule(s) attached
2. Attorney's Fees 3,500.00
See continuation schedule(s) attached
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 102.00
See continuation schedule(s) attached
5. Accountant's Fees
Ei. Tax Return Preparer's Fees
l. Other Administrative Costs 274.88
TOTAL (Also enter on line 9, Recapitulation) 7,385.73
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ ,:6-98)
SCHEDULE H.A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
ITEM
NUMBEFt DESCRIPTION AMOUNT
1 funeral meal, flowers, pastor donation 245.61
2 Janet Zeiters, organist 50.00
3 Obituary, Johnstown newspapers 118.24
4 Obituary, local newspaper 95.00
Subtotal
508.85
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Ftev. 6-98)
Rev-1502 EX+ (6-98)
SCHEDULE H.B1
PERSONAL REPRESENTATIVE'S
COMMISSIONS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
ITEM
NUMBEH DESCRIPTION
1 William Long
AMOUNT
3,000.00
Subtotal
3.000.00
CoPyri9ht (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B1 (Rev. 6-98)
Hev-1502 EX+ (6-98)
SCHEDULE H.82
ATTORNEY'S FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
ITEM
NUMBER DESCRIPTION
1 Said is, Shuff, Flower & Lindsay
AMOUNT
3.500.00
Subtotal
3.500.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B2 (Rev. 6-98)
Rev.1~02 EX,- (6.98)
SCHEDULE H-B4
PROBATE FEES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE: OF
ITEM
NUMBEH DESCRIPTION
1 Cumberland County Register of Wills
AMOUNT
102.00
Subtotal
102.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B4 (Rev. 6-98)
Rev-loll EX' (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
Include unreimbursed medical expenses.
ITEM
NUMBEH DESCRIPTION
1 The Bon-Ton
VALUE AT DATE
OF DEATH
30.98
2 Erie Insurance Group
248.00
3 Hamilton & Musser, tax preparation
165.00
4 Health South, therapy bill
9.48
5 Marie Huber, personal tax
11.00
6 Verizon Telephone
102.78
TOTAL (Also enter on Line 10, Recapitulation)
567.24
<If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-9B)
REV-1513 EX+ (9-00)
SCHEDULE ..
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
Moyer, Helen
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
Clistributions, and transfers
under Sec. 9116(a)(1.2)]
FILE NUMBER
21-05-0971
ESTATE OF
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
Joseph Callaway
1010 South Market ST.
Mechanicsburg, PA 17055
Nephew
1/7 of residue
Lori Callaway
1067 Second Ave.
Hellertown, PA 18055
Niece
1/7 of residue
Barbara Kotches
514 Chase Street
Park Forest, IL 60466
Niece
1/7 of residue
William M. Long
875 Hawthorn Ave.
Mechanicsburg, PA 17055
Nephew
1/7 of residue
See continuation schedule attached Continuation
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
See continuation schedule(s) attached
1,867.59
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
1,867.59
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
SCHEDULE ..
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Helen Moyer 10/20/2005
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
Randall Moyer Nephew 1/7 of residue 0.00
2454 Pin Oak Drive
York, PA 17402
Robert Moyer Nephew 1/7 of residue 0.00
3438 Station Drive
Matteson, IL 60443
Ronald Moyer Nephew 1/7 of residue 0.00
P.O. Box 47
Robinson, PA 15949
Total
1
Rev-1502 EX+ (6-98)
SCHEDULE .I.IIB
CHARITABLE AND GOVERNMENTAL
DISTRIBUTIONS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Moyer, Helen
IFILE NUMBER
21-05-0971
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Mechanicsburg Church of the Brethren, attn. Treasurer - 301 Gale Street,
Mechanicsburg, PA 17055
1,245.06
2
Robinson Church of the Brethren, attn. Treasurer - 211 High Street, Robinson, PA
15949
622.53
Subtotal
1.867.59
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J-IIB (Rev. 6-98)
~
Last Will and Testament
I, HELEN MOYER, of 11 A Hemlock Drive, Mechanicsburg, Cumberland County,
Pennsylvania 17055 do hereby make publish and declare this to be my last will and
testament, hereby revoking all wills heretofore made by me.
1. I direct my personal representative to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease. I direct that
all inheritance ta.'{es imposed or payable by reason of my death and interest
and penalties thereon with respect to all property,,h.rhether or not such
property passes under this Wilyshall be paid by my personal representative
out of my estate.
2. I authorize and empower my personal representative to sell any realty and/or
personalty owned by me at my death and not specifically devised or
bequeathed herein, at public or private sale or sales and to give good and
sufficient deeds and/or bills of sale therefore, in fee simple, as I could if
living. My representative is authorized and empowered to engage in any
business in which I may be engaged at my death, for such period of time after
my death as seems expedient to said representative.
3. I give, devise and bequeath all of my estate of whatever nature and wherever
situate as follows:
~ 10% to Mechanicsburg Church of the Brethren, Gale Street,
~ Mechanicsburg, Pennsylvania, for general purposes;
\!:)5% to Robinson Church of the Brethren, Robinson, Pennsylvania, for
general purposes;
~~TO Lori Callaway, my Royal Dalton "Bride and "Affection" figurines;
.... To Barbara Kotches, my Hummel "Spring Dance" figurine;
, 0 Patricia McConnell, four items of her choosing of my remaining
Hummel and Royal Dalton collections;
~ To Donna Long, everything in the china closet; and all the
~ Rest, residue and remainder to Robert A. Moyer, Ronald N. Moyer,
!'A\ William M. Long, Barbara Kotches,. Randy W. Moyer, Lori Callaway And
,-1; Joseph Callaway, share and share alIke.
R. If any of my beneficiaries have predeceased me, then their share I give,
devise and bequeath to their children, share and share alike, or if such
deceased beneficiary has no surviving children, then the gift to such
beneficiary shall lapse and become a part of my residuary estate.
4. I nominate and appoint William M. Long to be the personal representative of
my estate, to serve without bond. Ifhe cannot or does not serve, then I appoint
, Randy Moyer to be the substitute representative, also without bond.
Ch. ..,"",,41' ....'.,;...:>.;...t1.(
. . "',[ .'\:. r'f. ."~'
/.1;, .,,:1, ..C'
o "'4.1 ~
-;.,.-,-",
IN :3. ~ WHEREOF, I have hereunto set my hand and seal this
,2003.
\
I (
th day of
<7.LLJ~/
HELEN MOYER
ACKNOWLEDGEMENT
I, HELEN MOYER, the testatrix, whose name is signed to the foregoing instrument, do
hereby declare to the undersigned authority that I signed and executed the instrument as
my last will and I signed willingly, and that I executed it as my free and voluntary act for
the purpose herein expressed.
, -/P-J ~
. LEN MOYER
Commonwealth of Pennsylvania
:ss:
County of Cumberland
Subscribed, sworn to and aCknOW~efOre me by HELEN MOYER the testatrix
heremthisLthdayof ( ,2003.
\
-r
NOTARIAL SEAL
PAMELA F. HDFFMAN, NOTARY PUBLIC
MONROE TWP., CUMBERLANO COUNTY
MY COMMISSION EXPIRES JUNE 7, 2004
S\f.- Rl ~S
it
BQ1\JDS
I~
18
I OJ
I~
III<....~
lru
1-
ILn
ILn
I
;"11
~"I,.*-.J
,,(. .a~
~ ~ f-J N
F '
f.'4-"::~
~ f':~... .,
L ;om
....y ,l>, m
....
....,
o
IJ1
iJ'l
:~1_..1
· rt
w
00'
-..J
W
-+=
ru
I-
Lr1
U1
fT1
rTl
."
-
- i.tl
~)-n
c~ 0; ;;0'
~-o: s:l>Q, \
~ ~cn
~' H'~1j-
~..... --~ :r I
~\C. "'C '"'" '
-a "'Ulr""
'.w._<"
:hI'"
:ll:~
I~D
Ii 1I1
I~ Ln
,~ -~
I~ -""
!~ ru
i~
I~ ....
II~
IILn
I '. OJ
I =
i .
i
I
1':'{ 0
rr;c;~
'r'N
~ rf\=-"~
'"
! r;:s-' 0
'<~.~e,
~:.~ -"OJ.:
:i:;J ;'12:\
-:..I
ru
I-
W
-1
Ln
00
rT1
IT1
.......
\0
o
0'"
...,.....
.qt"';-
,.;..'
o
(.N
N
(S!
;~
-t..
fu-
~-
e~
~
~-
\~
J,~
f~
l&
t;
($
I.
~ ::.,
W'
,~
~..
~
,;~
t~
j::
~
i~
~~
.~
Ie
.-
~~:-i.t
t;
l~
,-
r~
~
@
I-
I,'"
~
t?
~
~
!~
;.r,.
~
(~
~.
: -otl:l
:->,-
: t:l
- (j)
=- ...,. t:l
-....,
:- ...,.
::.. 0
-lJ1
I
N
'"
....,
lJ1
::~
k\ I
-;::.~
y.
,"
;,.
n
,
,
zW
;;;~
.,," .
:o:ri~
0.... ",....
3: n ...,
~~ ~
~~CJ)
~ to> t'!'j
....0
"'...
~~ i}
L""'-..J ';.
"
"
~
."1
~,
~~
0/
u;
\J"I
-...j
N',
...,.
Vl
-...j
\J"I
CXl
0'"1'1
"N:::O'- 'JI
~ I tr" \ -
~f\.) t"~
~\.C -c I _..
~ I i-(
;",-+'
"'. -'I
SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: HELEN MOYER
Date of Death: 10/20/2005
Social Security Number: 190-28-8165
fvlm
MEMBERS 1st
FEDERAL CREDIT UNION
111332 -00
10/12/1989
$1,267.21
$.55
$1,264.76
. None
111332 -11
02/18/1995
$646.56
$.00
$646.56
None
4j,MBERS 1ST F~,DERAL CREDIT UNION
1u~ d t04
enise A. Wolfe v;-
Insurance Services Supervisor
November 29,2005
5000 Louise Drive . Po. Box 40 . Mechamcsburg, Pennsylvama 17055 . (717) 697-1161 . www.members1st.org
Guide Edition:
Wednesday, November 02, 2005
Eastern Used Car Guide - October Stock #:
Vehicle Description:
2003 TOYOTA
CAMRY-4 CYL. Sedan 4D LE
$18,970
14150
VIN: 4T1BE32K.X3U162060
MSRP:
Mileage:
Weight: 3086
Base Retail $15,825
Base Trade-In $13,425
Base Loan $12,100
Accessory Equipment:
Alum! Alloy Wheels
Power Seat
Retail
$325
$200
Trade
$275
$175
Loan
$275
$175
Accessory Total-Retail $525
Accessory Total-Trade $450
Accessory Total-Loan $450
Mileage Total $1,050
Total N cial Used Car Guide Values
Retail $17,400 Trade-In $14,925 Loan $13,600
N.A.D.A. Official Used Car Guide@ Company Copyright @ NADASC 2000
N
N
f-->
m
W
N
o
f-->
Hartford Life
December 12,2005
William Long
875 Hawthorn Ave
Mechanicsburg P A 17055
Re: Hartford Annuity Contract # 710011901
Decedent: Helen Moyer
Dear Mr. Long:
Thank you for your correspondence regarding the above annuity contract.
The death benefit payable under this contract is not considered "life insurance" reportable
on IRS Form 712, (life insurance statement). Please find the below information in
response to your request.
Contract Number:
Owner:
Owner's SSN#:
Deceased:
Date of Death:
)><:Date of Death Value:
Tax Cost Basis, (if applicable)
Alternate Date of Death Value:
If you have any other questions or concerns, please feel free to contact your investment
professional, or one of our annuity specialists by calling 1-800-862-6668, Monday
through Thursday from 8 a.m. to 7 p.m., Friday from 8 a.m. to 6 p.m., and on Saturday
from 9 a.m. to 2 p.m. Eastern time. We will be happy to assist you. Thank you for the
opportunity to help provide for your financial needs.
710011901
Helen Moyer
190-28-8165
Helen Moyer
October 20, 2005
$68,694.72
$0.00
Sincerely,
Danielle Murphy
Investment Product Services
Contract Management
Hartford Life and Annuity Insurance Company
Hartford Life Insurance Companies
200 Hopmeadow Street
Simsbury, CT 06089
Toll Free I 800 8626668
Investment Product Services
Mailing Address: P.O. Box 5085
Hartford. CT 06102-5085
on lin e. b.artfo rdli fe.com