HomeMy WebLinkAbout11-06-06
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OFFICIAL USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
~L
COUNTY CODE
~L 0125___
YEAR NUMBER
DECEDENl'S NAME (LAST, FIRST, AND MiDDLE INITIAL)
!Z EVANS ROSELLA
~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
~ 2/5/2006 1/10/1917
W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Q
B
SOCIAL SECURITY NUMBER
181-10-1046
THIS AEl\JRH MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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[X] 1. Original Retum
o 4. Limited Estete
[X] 6. Decedent Died Testate (Attach copy of 'Mil)
o 9. Liligalion Proceeds Received
D 2. Supplemental Retum 0 3. Remainder Retum (date of death prior to 12.13-82)
o 4a. Future Interest Compromise (date of death after 12.12-82) 0 5. Fedenal Eslale Tax Return Required
D 7. Decedent Maintained a Living Trust (Attach copy 01 Trust) L B. Total Number of Safe Deposit Boxes
D 10. Spousal Poverty Credit (date 0' death between 12-31-91 and 1-1-95) 0 11. EJection to tax under Sec. 9113(A) (Attach S<h 0)
THIS SECTION MUST BE COMPLETED. AL.L. CORRESPONDENCE AND CONFIDENTIAL. TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
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III
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Elizabeth P. Mullau h
FIRM NAME (If Applicable)
McNees Wallace & Nurick LLC
TELEPHONE NUMBER
717-237-5243
100 Pine Street
PO Box 1166
Harrisburg, PA 17108
1. Real Estate (Schedule A)
(1 )
(2)
OFFICIAL USE ONLY
j
4. Mortgages 8. Noles Receivable (Schedule D) (4)
5. Cash, Bank Deposils & Miscellaneous Personal Property
(Schedule E) (5)
2. Stocks and Bonds (Schedule B)
C:2
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
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6. Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedu Ie G or L)
66,033.45
B. Total Gross Assets (total Lines 1-7)
(8)
14,327.06
10,673.94
444,105.14
9. Funeral Expenses 8. Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 8. 10)
(11)
25,001. 00
419,104.14
0.00
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for y,t\ich an election to tax has nol been
made (Schedule J)
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax 0.00
Z rale. or transfers under Sec. 9116 (a)(1.2) x .0
0
i= 16. Amount of Line 14 taxable at lineal rate 419,104.14 X.o
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~ 0.00
Q. 17. Amount of Line 14 taxable at sibling rate x .12
:E
0 0.00
U 18. Amount of Line 14 taxable at collateral rate x .15
><
~ 19. Tax Due
(14)
419,104.14
(18)
0.00
18,859.69
0.00
0.00
18,859.69
L(15)
45 (16)
(17)
(19)
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
3W4645 1000
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Decedent's Com tete Address:
STREET ADDRESS
100 Mt. Allen Drive
Cumberland Count
CllY
Mechanicsbur
STATE
PA
ZIP
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
18,859.69
0.00
17,400.00
915.79
Total Credits (A + 8 + C) (2)
18,315.79
3. Interest/Penalty if applicable
D. Interest
E. Penalty
0.00
0.00
TotallnterestlPenalty (0 + E) (3)
0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
(4)
0.00
5. If Line 1 + line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
543.90
A. Enter the interest on the tax due.
(5A)
0.00
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Pa able to: REGISTER OF WILLS, AGENT
(58)
543.90
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? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? [K]
4. Did decedent own an Individual Retirement Account. annuity, or other non-probate property which
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. fXJ D
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, I declare that I have axamined this return. induding accompanying schedules and statements. and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of praparer other than the personal "'p",sentative is based on all information of which p"'parerh.s any knowledge.
SIGNA nJRE OF PERSON RESPONSIBLE FOR FILING REWRN
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Yes
No
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DATE
,
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Dillsburg, PA 17019
DATE
17108
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.!3 9916 (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. S 9116 (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 retum are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or afIer 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. 139116(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. S 9116(1.2) [72 P.S. S 9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. 9 9116(a)(1.3)]. A sibling is defined. under Section 9102. as an
individual who has at least one parent in common with the decedent. whether by blood or adoption,
3W4646 1.000
REV.1503 EX + (&-98)
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SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
ROSELLA B. EVANS
21 06 0125
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUv18ER
1.157 Shares
BP PLC
DESCRIPTION
VALUE AT DAlE
OF DEATH
10,945.26
2 438.938 Shares
Thrivent Investment High Yield
Fund Class A
2,225.42
3 U.S. Savings Bonds - Bonds owned
jointly by decedent and her spouse
who died in November 2005.
See attached bond listing and
February valuation information.
32,655.60
3W46961.000
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
45,826.28
REV.1508 EX . (6-98)
COMMONVVEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
ROSELLA B. EVANS
FILE NUMBER
21 06 0125
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jolntlv-owned with the right of lurvlvol'1lhlp must be dlsclaNd on Schedule F.
ITEM
NUMBER
cescRIPTlON
VALUE AT DATE
OF DEATH
1
Adams County National Bank
Checking Account No. 1604880
Interest accrued to 2/5/2006
See attached bank letter
116,614.07
55.90
THE FOLLOWING ACCOUNTS WERE HELD
BY THE DECEDENT WITH CITIZENS
BANK; SEE ATTACHED VALUATION
INFORMATION:
2
Citizens Bank Checking Account No.
6208348343
2,689.39
3
Citizens Bank Checking Account No.
6100745740
13,289.74
4
Citizens Bank Circle Money Market
No. 6101190076
94,061. 36
THE FOLLOWING ACCOUNTS WERE HELD
BY THE DECEDENT WITH MEMBERS FIRST
CREDIT UNION; SEE ATTACHED
VALUATION INFORMATION:
5
Members First Certificate of
Deposit No. 47
Interest accrued to 2/5/2006
29,572.85
16.17
6
Members First Certificate of
Deposit No. 46
Interest accrued to 2/5/2006
29,543.81
13.82
7
Members First Certificate of
Deposit No. 48
Interest accrued to 2/5/2006
31,008.93
11.55
8
Members First Certificates of
Deposit No. 45
Interest accrued to 2/5/2006
4,701.45
2.20
9
Members First Regular Savings
Accoun t
25.00
Total from continuation schedules
10,639.17
3W46AD 1.000
TOTAL (Also enter on line 5 Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
332,245.41
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Estate of: ROSELLA B. EVANS
181-10-1046
Schedule E (Page 2)
Item
No. Description
Value at Date
of Death
MISCELLANEOUS ITEMS, REFUNDS:
10 Social Security - Per a notice
from Social Security, the decedent
was due $2,006.20 (additional
benefits from November 2005 to
January 2006 due to death of
decedent's spouse in November
2005).
2,006.20
11 Thrivent - Nursing Home Insurance
Refund
745.27
12 Estate of Kenneth Evans - The
decedent was the sole beneficiary
of Mr. Evans' Estate. No formal
administration was necessary as
that all assets were held jointly
or had a beneficiary designation.
Mr. Evans was due an additional
$7,887.70 from Social Security.
According to Social Security,
there was a discrepancy in the
amount Mr. Evans received from
April 1977 through his death which
amounted to $7,887.70. The error
was discovered after he died and
while social security was
adjusting the decedent's benefit
due to her husband's death.
Since the decedent is the sole
beneficiary of Mr. Evans' Estate,
we are reporting this amount in
her estate.
7,887.70
Total (Carry forward to main schedule)
10,639.17
REV-1510 EX. (6-98)
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SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYL VANIA
INHERITANCE TAX RETURN
RESIDENT" DECEDENT
ESTATE OF
ROSELLA B. EVANS
FILE NUMBER
21 06 0125
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 PROPERlY
ITEM II'U.I.DE Tt€ """"E OF Tt€ TRANSFEREE, TI-E.R RELATlONSHP TO DECEDENT NoO
NUMBER n-E DATE OF _. ATTJlCHAcoPY OF THO DEED FOR REAl. ESTATE.
1. Citizens Bank Individual
Retirement Account No.
6140792827
Interest accrued to 2/5/2006
Beneficiary: Kathy Eurich
2 Citizens Bank Individual
Retirement Account No.
6248349814
Interest accrued to 2/5/2006
Beneficiary - Kathy Eurich
3 Thrivent Financial for
Lutherans Annuity No. B3185364;
Beneficiary - Kathy Eurich; see
attached valuation information
4 Thrivent Financial for
Lutherans Annuity No. B2834806;
Beneficiary - Kathy Eurich; See
attached valuation information
5 U.S. Savings Bonds - Held by
decedent and payable on death
to Kathy Eurich; See attached
listing and valuation
information
DATE OF DEATH
VALUE OF ASSET
% OF DECO'S
INTEREST
1,787.80 100.0000
3.11 100.0000
1,868.30 100.0000
5.53 100.0000
16,372.25 100.0000
37,044.46 100.0000
8,952.00 100.0000
3W46AF 1.000
(If more space is needed. insert additional sheets of the same size)
TOTAL (Also enter on line 7, Recapitulation) $
EXCLUSION
(IF APPUCABLEl
0.00
0.00
0.00
0.00
0.00
TAXABLE
VALUE
1,787.80
3.11
1,868.30
5.53
16,372.25
37,044.46
8,952.00
66 033.45
REV-IS11 EX. (12-99)
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COMMONWEALTH OF PENNSYLVANIA
INt-ERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ROSELLA B. EVANS
ITEM
NUMBER
A.
1.
B.
1.
2.
FUNERAl.. EXPENSES:
Cocklin Funeral Home, Inc.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative{s)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of decedent must be reported on Schedule I.
DESCRIPTION
Street Address
Social Security Number{s) I EIN Number of Personal Representative(s)
City
Year(s) Commission Paid:
State
Zip
Attorney Fees McNees Wallace & Nurick LLC (Estimated)
Claimant
Street Address
City
Relationship of Claimant to Decedent
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
3W46AG 1.000
State
Zip
4.
Central Penn Business Journal
Legal Advertising
Total from continuation schedules
FilE NUMBER
21 06 0125
TOT AL (Also enter on line 9. Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$
AMOUNT
9,564.48
4,000.00
414 . 00
97.00
251.58
14 327.06
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Estate of: ROSELLA B. EVANS
Schedule H Part 7 (Page 2)
2
Cumberland County Register of
Wills
Filing Fee re inheritance tax
return and inventory
3
Cumberland Law Journal
Legal Advertising
4 McNees Wallace & Nurick LLC
Costs Advanced as follows:
Duplicating
Postage
Misc. Filing
Fee
Toll Calls
Short Cert.
$22.20
29.08
15.00
1.30
4.00
5
McNees Wallace & Nurick LLC
Reserve for closing costs re
duplicating, postage, etc.
Total (Carry forward to main schedule)
e
181-10-1046
30.00
75.00
71.58
75.00
251.58
REV-1512 EX + (12-03)
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COMMONINEAL TH OF PENNSYLVANIA
INI-ERITANCE TAX REiVRN
RESIDENT DECEDENT
ESTATE OF
ROSELLA B. EVANS
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
21 06 0125
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unrelmbursed medical expenses.
ITEM
NUMBER
1.
c:escRIPTlON
VALUE AT DATE
Of DEATH
Messiah Village
Final Nursing Home Charges
6,246.94
2 PA Department of Revenue
Tax Due re 2005 state income tax
return
108.00
3 United States Treasury
Tax Due re 2005 federal income tax
due
2,194.00
4 United States Treasury
Tax Due re 2006 U.S. Individual
Income Tax Return (ESTIMATED)
2,125.00
3W46AH 2.000
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
10 673.94
REV-1513 EX+ (9-00)
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SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ROSELLA BEVANS
NUMBER
I
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [indude outright spousal distributions. and transfers
under Sec. 9116 (a) (1.2)]
Kathy Eurich
23 Impala Drive
Dillsburq, PA 17019
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
FILE NUMBER
21 06 0125
AMOUNT OR SHARE
OF ESTATE
Daughter
419,104.14
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
" NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
3W46All.000
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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)
$
0.00
B)(1l1B11 ^
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ESTATE OF ROSELLA B. EVANS
PENNSYLVANIA INHERITANCE TAX RETURN
TABLE OF CONTENTS (EXHIBITS)
A. Miscellaneous Documents
1. Table of Contents - Exhibits
2. Copy - Letters Testamentary issued by Cumberland County Register of Wills to
Kathy J. Eurich and copy of decedent's will dated January 3, 2006
3. Copy - Pennsylvania Department of Revenue Official Receipt
B. Schedule B- Stocks and Bonds; Savings Bond Information
C. Schedule E - Cash, Bank Deposits & Misc. Personal Property
1. Adams County National Bank
2. Citizens Bank (Also Schedule G, Item 1,2)
3. Members First Credit Union
D. Schedule G -Inter-vivos Transfers & Misc. Non-Probate Property
1. Thrivent Financial
2. U.S. Savings Bonds
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STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
~state of ROSELLA BEVANS
Register for the Probate of Wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 8th day of February, Two Thousand and Six,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
, late of UPPER ALLEN TOWNSHIP
(First, Middle, Last!
in said countYr deceased, to KATHY J EURICH
(First, Middle, Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 16th day of May
Two Thousand and Six.
File No. 2006-00125
FA File No. 21-06-0125
Da te of Dea th 2/05/2006
$.S. # 181-10-1046
~ '--1~/f,Wi~~
~D.~ut~
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
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lliust Ifill emu i!Lesmmrut
OF
ROSELLA B. EVANS
BE IT REMEMBERED, that I, ROSELLA B. EVANS, of 23 Impala Drive,
DilIsburg, Pennsylvania, being of sound mind, memory and understanding, do make,
publish and declare this as and for my Last Will and Testament, hereby revoking and
making null and void any and all Wills and Testaments and writings in the nature thereof
made by me at any time heretofore,
ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after
my demise as may be convenient.
ITEM 2: All the rest, residue and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be real, personal or mixed, including property over which
I have a power of appointment, I give, devise and bequeath unto to my daughter, KATHY
J. EURICH.
ITEM 3: I direct my hereinafter named Executor to pay all inheritance, estate,
succession and legacy taxes of whatsoever nature and kind, to which my estate or the
transfer of any property passing hereunder or otherwise passing by reason of my demise,
may be subject and to charge such taxes against my residuary estate, it being my intention
that none of the aforesaid taxes, either federal or state, on any property required to be
included in my gross estate, under the provisions of any state or federal law now in force
or hereafter enacted, shall be prorated among the persons interested in my estate to whom
such property is or may be transferred or to whom any benefit accrues.
ITEM 4: I appoint, my daughter, KATHY J. EURICH, as Executrix of this my
Last Will and Testament,
WITNESS:
~
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ROSELLA B. EVANS
~:;ii~:
(SEAL)
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~: I direct that my Executrix shall not be required to give bond for,the
faithful performance of their duties in any jurisdiction. .
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ay
of ~t1rlf ,20014-.
~;;.~::::
r{f~e ~
(SEAL)
ROSELLA B. EVANS
2
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COMMONWEALTH OF PENNSYLVANIA
: SS
COUNTY OF YORK
We, ROSELLA B. EVANS, JAN M. WILEY, ESQUIRE and MARCY K.
RENSHAW, the Testatrix and the witnesses respectively, whose names are signed to the
attached or foregoing instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the instrument as her Last Will
and Testament and that she had signed willingly (or willingly directed another to sign for
her), and that she executed it as her free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the presence and hearing of the Testatrix,
signed this ~t Will and Testament as witness and that to the best of their knowledge the
Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no
constraint or undue influence.
\1~13 ~
~2t~~
WI ES
Sworn to and subscribed
before me this~ day of
~LJL~'200k.
NOT~~r1tI"r~
MY COMMISSION EXPIRES:
Ol'
NolMIl_
8. c.n0l0ll0lllr.~_
llIIlug...., yootc Ca.riIy
MyOcmniollan ~ May 17,2llI>>
_,I'onnoylvlnla_nol_
3
3
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF INOIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG, PA 17128-0601
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REV-1162 EX(11-961
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ESTATE OF ROSELLA BEVANS
KATHY J EURICH
23 IMPALA DRIVE
DILLSBURG, PA 17019
u______ told
ESTATE INFORMATION: SSN: 1 81 -1 0-1 046
FILE NUMBER: 2106-0125
DECEDENT NAME: EV ANS ROSELLA B
DATE OF PAYMENT: 05/01/2006
POSTMARK DATE: 04/28/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 02/05/2006
NO. CD 006636
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $17,400.00
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TOTAL AMOUNT PAID:
$17,400.00
REMARKS: PAID BY MCNEES WALLACE &
NURICK EST OF ROSELLA EVANS
CHECK#107
SEAL
INITIALS: GFS
RECEIVED BY:
TAXPAYER
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
EXHIBIT B
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EXHIBIT C
e
J~ ADAMS COUNlY
NATIONAL BANK
e
February 24,2006
McNees, Wallace & Nurick, LLC
Attorneys at Law
PO Box 1166
Harrisburg, P A 17108
Re: Estate of Rosella B. Evans
Dear Ms. Eshelman:
The following information is being provided as per your request:
Acct. Type Account Account Accrued Ownership Date Date Joint
No. Principal on Interest to Opened
D.O.D. D.O.D.
Checking 1604880 $116,614.07 $55.90 Individual 5-12-03 N/A
Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5116.
Sincerely,
1h~ K~
Lois Kime
Deposit Services
e
e
05/01/2006
14:50
NO.310 li002
~~ Citizens Bank'
525 William Penn Place
Suite 153-2618
Pittsburgh, PA 15219
May 1,2006
M:xNees Wallace & Nurick
100 Pine S1reet
PO BOX 1166
HARRISBURGPA 17108-1166
Estate of ROSELLA B EVANS
Date of Death: Feb 05, 2006
SSN: 181-10-1046
Dear SirlMadam:
In accordance with your request, the attached infonnation sheet has been provided in the above decedent's
name as ofhislher date of death.
For lL or LC accounts, contact our loan Department at 1-800~708-6680. For all other inquiries, please
call 1-888-999-6884
Sincerely,
Barbara Richards
Operations Services
gl5/01/2006
e
e
14:50
NO.310 Gl003
i ~
I
, I
~~ Citizens Bank'~
Account Number 6100745740
Account Title ROSELLA B EVANS
Date Opened 6/6/1966
Account Type Checking
Principal Balance as oiDOD $13289.74
Interest from Last Posting to nOD
Account Balance as of Don $13289.74
YfD Interest to DOD $6.30
e
e
05/01/2006
14:50
NO.310 [;1004
I '
, I
= Citizens Bank->
Account Number 6101190016
Account Title ROSELLA B EVANS
Date ()Pened 1/15/2002
Account Tvoe Checking;
Principal Balance as afDOD $94061.36
Interest from Last Posting to DOD
Account Balance as of DOD . $94061.36
YTD Interest to DOD $322.21
05/131/2006
e
e
14:50
NO.310 (;lee5
I~ Citizens Bank'
Account Number 6208348343
Account Title ROSELLA B EVANS
Date-Opened 8/14/2004
Account Type Checking
Principal Balance as ofDOD $2689.39
Interest from Last Postin~ to DOD
Account Balance as of Don $2689.39
YTD Interest to DOD $3.10
e
135/01/21305
14:50
~~ Citizens Bank ·
Account Number
Account Title
Date ened
Account T e
Princi at Balance as of DOD
Interest from Last Postin to DOD
Account Balance as ofDOD
YTD Interest to DOD
e
NO.310 D005
05/~1/2006
It
e
14:50
NO. 310 [i)8137
~~ Citizens Bank~
Account Number 6248349814
Account Title ROSELLA B BY ANS
Date Opened 1219/2005
Account Type Time Deposits ORA)
Principal Balance as of DOn $1868.30
Interest from Last Posting to DOD is.S3
AccoUilt Balailce as ofDOD $1873.83
YTD Interest to DOD $7.94
e
e
MEMBERS 1st
FEDERAL CREDIT UNION
REGULAR 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
Interest Earned from 1/1/06 to Date of Death
Name of Joint Owner
275978 ..00
12/02/2005
$25.00
$.00
$25.00
$.00
None
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
AccNed Interest to Date of Death
Total Principal and Accrued Interest
Interest Earned from 1/1/06 to Date of Death
Name of Joint Owner
275978 -45
12/0212005
$4,701.45
$2.20
$4,703.65
$19.19
None
275978 -46
12/13/2005
$29,543.81
$13.82
$29,557.63
$120.58
None
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Interest Earned from 1/1/06 to Date of Death
Name of Joint Owner
275978 -47
12/13/2005
$29,572.85
$16.17
$29,589.02
$140.97
None
275978 -48
12/20/2005
$31,008.93
$11.55
$31,020.48
$100.84
None
~B~RS 1ST ~DERAL CREDIT UNION
;car d a)~
enise A. Wolfe /
Insurance Services Supervisor
March 10,2006
Estate of: ROSELLA B. EVANS
Date of Death: February 5,2006
Social Security Number: 181-10-1046
5000 Louise Drive · P.O. Box 40 . Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 · www.members1st.org
b~lllBl~ D
e
\P Thrivent Financial
for LutheransnA
e
Death Benefit Information
Annuity Contract: B3185364
Deceased: Rosella BEvans
Date of Death: 02105/2006
Date Prepared: 02/08/2006
Claim Number: 361704
Death Benefit
Cost Basis
Taxable Gain
Enhanced Benefit
$
$
$
11,000.00
5,372.25
0.00
Total Death Benefit
$
16,372.25
Beneficiary Designation
Primary: Kathy J Eurich, Children Born/Adopted
First Contingent: Janelle L Elliott, Grandchild, David W Eurich, Grandchild
Special Messages
1. IMPORTANT TAX REQUIREMENTS: Each beneficiary will be subject to federal income tax
withholding for their share of the taxable gain. Each beneficiary needs to complete the substitute
W-4P section on the Claimant's Statement. If NO withholding is desired, the first section in the
substitute W-4P should be checked. If the beneficiary DOES want withholding, the appropriate
section should be completed.
2. To assist the beneficiary in selecting a distribution method, you should refer to Non-qualified Tax
Chart No.3. This chart can be printed from InfoSource, Customer Service, Claims, Death Claims
Tax Charts.
e
\J1 Thrivent financial
for Lutheransm
e
Death Benefit Information
Annuity Contract: B2834806
Deceased: Rosella 8 Evans
Date of Death: 02/05/2006
Date Prepared: 02/08/2006
Claim Number: 361704
Death Benefit
Cost Basis
Taxable Gain
Enhanced Benefit
$
$
$
20,000.00
17,044.46
0.00
Total Death Benefit
$
37,044.46
Beneficiary Designation
Primary: Kathy J Eurich, Children 8orn/Adopted
First Contingent: Janelle L Elliott, Grandchild, David W Eurich, Grandchild
Special Messages
1. IMPORTANT TAX REQUIREMENTS: Each beneficiary will be subject to federal income tax
withholding for their share of the taxable gain. Each beneficiary needs to complete the substitute
r.--..~
W:4P section on the Clatm~nMt~!ement. If NO withholding is desired, the first section in the
substitute W-4P should be checked. If the beneficiary DOES want withholding, the appropriate
section should be completed.
2. To assist the beneficiary in selecting a distribution method, you should refer to Non-qualified Tax
Chart No.3. This chart can be printed from InfoSource, Customer Service, Claims, Death Claims
Tax Charts.
2
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\-;t'
"-
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
, Deceased
No. 2006-00125
Date of Death 2/5/2006
Social Security No. 181-10-1046
Estate of Rosella B. Evans
known as
Kathv J. Eurich
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 of the Commonwealth of Pennsylvania except that which appears in a memorandum at
the end of this inventory. l!We verify that the statements made in this Inventory are true and correct. l!We understand that false
statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of
Attorney: Elizabeth P. Mullaugh, Esquire
I.D. No.: 76397
p~nal Re. preSenjtive:.
..... ~., .' 'J
~( . ,'..-GL-< v...-.J_
:/ '-
Address: McNees Wallace & Nurick LLC
100 Pine Street, P.O. Box 1166
Harrisburg, PA 17108
Telephone: (717) 237-5243
Dated:
II / I / , 2006
, f
Description
Value
SEE ATTACHED
$ 378,071.69
Total: $ 378,071.69
(Attach Additional Sheets if necessary}
NOTE: The M?morandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the
value of each Item, but such fIgures should not be extended into the total of the Inventory.
Estate of ROSELLA B. EVANS
Estate Inventory
Valued as of Date of Death
Cash & Cash Equivalents
Adams County National Bank
Checking Account No. 1604880 $ 116,614.07
Interest at Date of Death 55.90
Citizens Bank Checking Account
No. 6208348343 2,689.39
Citizens Bank Checking Account
No. 6100745740 13,289.74
Citizens Bank Circle Money
Market No. 6101190076 94,061.36
Members First Certificate of
Deposit No. 47 29,572.85
Interest at Date of Death 16.17
Members First Certificate of
Deposit No. 46 29,543.81
Interest at Date of Death 13.82
Members First Certificate of
Deposit No. 48 31,008.93
Interest at Date of Death 11.55
Members First Certificates of
Deposit No. 45 4,701.45
Interest at Date of Death 2.20
Members First Regular Savings
Account 25.00
Total Cash & Cash Equivalents $ 321,606.24
No. of
Shares Stocks
157 BP PLC $ 10,945.26
Total Stocks 10,945.26
Par
Value Bonds, Debentures & T -Bills
Page 1
Estate Inventory
Par
Value
Bonds, Debentures & T -Bills
U.S. Savings Bonds - Bonds
owned jointly by decedent and
her spouse who died in
November 2005.
Total Bonds, Debentures & T -Bills
Miscellaneous
Social Security - Per a notice
from Social Security, the
decedent was due $2,006.20
(additional benefits from
November 2005 to January 2006
due to death of decedent's
spouse in November 2005).
Thrivent - Nursing Home
Insurance Refund
Estate of Kenneth Evans - The
decedent was the sole
beneficiary of Mr. Evan's
Estate. No formal
administration was necessary
as that all assets were held
jointly or had a beneficiary
designation.
Mr. Evans was due an
additional $7,887.70 from
Social Security. According to
Social Security, there was a
discrepancy in the amount Mr.
Evans received from April 1977
through his death which
amounted to $7,887.70. The
error was discovered after he
died and while social security
was adjusting the decedent's
benefit due to her husband's
death.
Since the decedent is the sole
beneficiary of Mr. Evan's
Estate, we are reporting this
amount in her estate.
Total Miscellaneous
Page 2
$
32,655.60
$
2,006.20
745.27
7,887.70
$
32,655.60
10,639.17
No. of
Shares
438.938
Mutual Funds
Estate Inventory
Thrivent Investment High Yield
Fund Class A
Total Mutual Funds
Total Inventory
Page 3
$
2.225.42
$
2,225.42
$
378,071.69
COMMONWEALTH OF PENNSYLVANIA
DEPARTMEfH OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
EURICH KATHY J
23 IMPALA DRIVE
DILLSBURG, PA 17019
u____u fold
ESTATE INFORMATION: SSN: 1 8 1 - 1 0-1 046
FILE NUMBER: 2106-0125
DECEDENT NAME: EV ANS ROSELLA B
DA TE OF PAYMENT: 11/06/2006
POSTMARK DATE: 11/01/2006
COUNTY: CUMBERLAND
DA TE OF DEATH: 02/05/2006
NO. CD 007391
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $543.90
I
I
1
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS:
CHECI(# 111
SEAL
INITIALS: CJ
RECEIVED BY:
REGISTER OF WILLS
$543.90
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
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