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Home My WebLink About95-00788 a/ale 01 Betty J. Stahle also known as PETITION .'OR PROUA TE and GRANT 0.' LETTERS :U-/Q9b>7J>1! No. To: Register of WlIIs for th~ Deceased. County of Cumber land In the Sodal Securily No. 1 90 -1 2 - 2 6 31 Commonweallh of Pennsylvania The petlllon of the undersigned respectfully represenl. thai: Your petllloner(s), who Is/are 18 years of IIge or older an Ihe execut or In Ihe last wlll of the above decedent, dated S e p t emb" r <j r and codlcll(.) dated named , 19-5-L (II ale relevanl dreunUlanccs. t.8. renundallon. dealh or execulor I etc.) Dccendenl was domiciled al death In Cumberland County, PennSy1Vallla, wllh h er IllSl family or principal resldellce at 401 Allenda Ie Wa Cam H: 11 PA 17011-8407 (Lower Allen Towns (1111 IoHetl. number and munclpalilY) Decendent,lhen 73 years of age, died September 21 ,19 95 , at Holy Spirit HosP1tal, East pennsboro Township, Cumberland Cpunty, PA Except as fol!ows, decedent did nOI marry, was nOI divorced and did not have a child born or adopled aner execution of Ihe will offered for probate; was not the victim of a kllllng and was never adjudicated Incompetent: Decendent al dealh oW".ed properlY with estimaled values as follows: (If domiciled in P.n.) All personal property $ 200,000, (If nol domiciled In Pao) Personal property In Pennsylvania $ (If not domiciled in Pao) Personal property in County $ Value of real estate in Pennsylvania $ siiuated a. follows: WHEREFORE, petllloner(s) respectfully pres en led herewllh and the grant of letters Iheron, request(s) the probate of the last wlll and codicil(s) '-~t> ~Cln ) e n l-Cll' ~/ I (les1omcntar)'i admlnls1rallon C,I.a.i administration d.b.n.c.I.B.) t !t 1l'= ~'Il -::to. "g'o a. in Haro ld r. (\ ..L:4>D1[' 11111 P^ 17011_111107 ? o,P/<"I? ?".:l. OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA } ss COUNTY OF CUMBERLAND The petilkmer(s) above-named swear(s) or affirm(s) that the stalements In the foregoing petition are Irue and correcl to the best of Ihe knowledge and belief of petllloner(s) and that as personal represen- talive(.) of Ii,e above decedent petltioner(.) will well and truly administer ~ eslate cording to law, ," ~ Sworn 10 or affirmed an.. suoscrlbed {' '" ;':t~~~'~'b'-)?I"'\"or '1 /5 -"',2 _ M R c. "TEWIS' ~~.f(, ~ 4 ~ 0- LAW O"'ICe. JON ~. 1........AYIlR 117 THllllG nIne," ..W ..."..LA..,... I I I i l~hn,t"~",,-,,~,,, ,:,;,;',' ~'::",:~/,.r,' ~ __,,~, .- .. LIIST WIIL AND TES'I'AMI:Nl' i I I I J I , J i I I, BET1"{ J, STAlIU:, of Lower Allen Township, ClIrberland County, Ipermsylvania, being of sound mind, IIleI1Dry and understanding, do hereby rmke, I 11sh and declare this as and for my Last Will and Test:aIrent hereby revoking i land Imking void any and all other wills by Ire at any time heretofore made. I , I. i I I direct that my Executor hereinafter 11BIred shall pay sll my just ldebts and funeral expenses as soon as conveniently nny be done after my decease, I I I hereby give and bequeath the SlID of ten thousand ($10,000) dollars lunto my cousin, MILDRED L. APPlE, if she survives Ire. This BI1Dunt shall not be I dUninished by any inheritance, estate or death taxes, but shall be paid in full. ! III. I I I I I I I I diminished by any inheritance, estate or death taxes, but shall be paid in full. OF BETlY J, STAHlE II. I hereby give and bequeath the sun of ten thousand ($10,000) dollars to my cousin, \-IILLIAM D. FRIO<, if he survives Ire. This BI1Dunt shall not be IV. I hereby give and bequeath the sum of five thousand ($5,000) dollars to my cousin, CYNllIIA FRIO< CASTIE, if she survives Ire. This lII1DUI1t shall not be dUninished by any inheritance, estate or death taxes, but shall be paid in full. V. I hereby give and bequeath the SlID of one thousand ($1,000) dollars lunto each of the following 11BIred children of my cousin, C. I survives Ire: IELORES, DIANE, CAROL, BETlY JEAN and KEI1lI. i Page one of four Pages ; Eugene Frick, who This BI1Dunt shall rot o .....w O""'C:I. JON ... L..,....VER 117 TIUItO UNlEtT Hew CU"'.CItL..,.O, ..... -. . I ibe diminished by any inheritance, estate or death taxes, but shall be paid in full.! ' VI. I I All the rest, residue and remainder of my estate, l<A1ether real, ! lpersonal or mixed, and wheresoever situate, I hereby give, devise and bequeath , , junto my husband, HARQlLD J. STAHlE, JR" if he survives 100 by a period of thirty , i (30) days. I VII. I I If my said husband, HAROlLD J. S'l'AHlE, JR" does not survive 100 by a I !period of thirty (30) days, then: I A. I hereby give and bequeath the Slll\ of ten thousand ($10,000) ldollars unto my cousin, WIlLWI D, FRIO<, or if he is not living, then unto his , , fe, PAT FRIO<. B, I hereby give and bequeath the SUII of ten thousand ($10,000) ldollars and all of my stock in cam Bank, unto my cousin, MILDRED L, APPIE, if she is living on the thirtieth day following my death, I C. I hereby give, devise and bequeath my house and real estate i situate at 401 Allendale Way, Lower Allen Township, CuiDerland County, Pennsylvania, unto my husband's father, HAROlLD J. STAHIE, SR., if he is living on the thirtieth day following my death, D. I hereby give and bequeath the SUII of one thousand ($1,000) ldollars unto TIiE HUMANE SOCIETY OF HARRISBURG AREA, INC. E. I hereby give and bequeath all of my clothing, jewelry, furnitur 'and household equipnent unto my husband's father, HAROlLD J. STAHLE, SR., and my attorney, JON F. LaFAVER, for further disposition as I have instructed them, or in the absence of said instructioos, as they may see fit. I F. I hereby give and bequeath the SUII of five thousand ($5,000) I dollars unto my cousin, CYNIllIA FRIO< CASTlE, if she is living on the thirtieth I Page two of four Pages d ~ 0' J L..W 0......:&. JON pr. L"""VEA al7 THIIUJ .tllnt M"W cu....altL....a.".... ,- ~ $ I I i day following my death, This bequest is in addition to the one made in , iSection III of this Will. i i ! G. I hereby give and bequeath the sun of one thousand ($1,000) I I I I dollars unto each of the following naIred children of my cousin, C, Eugene Frick,l ! are living on the thirtieth day following my death: IElDRES, DIANE, CAIDL, I I BET1Y JEAN and KEl'lli, i I I H. All the rest, residue and remainder of my estate, ~ether real, !personal or mixed, and wheresoever situate, I hereby give, devise and bequeath I las follows: i I 1. One-third (1/3) unto ST. PAUL'S LunJEMN OillRCH, New Umlberland, Permsylvania, 2. One-third (1/3) unto lAFAYE'ITE OOLLEGE in Easton, Pennsylvania. 3, One-third (1/3) to be divided equally 8IlDl1g the following four organizations: SHRINER'S HOSPITAL FOR CRIPPLED am..DREN, in Philadelphia, Permsylvaniaj MASONIC HOl-ES at Elizabethtm.n, Pennsylvania; the BENEVOIENT FOllND<\TION of the Trustees of the SUPREME OOUNCn. of the ANCIENr ACCEPTED SOJITISH RITE of FREE HASONRY ( a Massachusetts Corporation); and KNIGI-ITS TEME'UR EYE FOllND<\TION, INC., of Rhinebeck, New York. VIII, If my husband, Harolld J. Stahle, Jr" does not survive lIE, I direct that my pet dog be provided for as I have previously instructed my Executor.ÿ IX. I hereby naninate, constitute and appoint my husband, HARDLLD J. STAHlE, JR., as Executor of this, my Last Will and Testmoont. If the said lld J, Stahle, Jr. Rhould predecease tre, fail to qualify or cease to act as Page three of four Pages ~ , such, then I nominate, constitute and appoint JON F. LaFAVER, ~RF. as Executor X. No fiduciary acting under this Will shall be required to post bond in this jurisdiction or in any jurisdicticn in I-Alich he my act. IN WI'lNESS WHEREOF, I, BETlY J. STAHLE, the Testatrix, have unto this, my Last Will snd Test:anB1t, set my hand snd seal this 1 r:I. day of Septanber, A. D., 1981. ~ Q. kLt?,{SFAL) SIrnED, SF..Al.ED, PUBLISHED and DECLARED by BETlY J. STAffiE, the above d Testatrix, as and for her last Will and Testament, in the presence of us have hereunto subscribed our names as witnesses at her request, in the esence of the said Testatrix and of each other. &.AW O'''CC. .ION .... L."'.V." 117 'Hl"D STallT , ~.# ,-,eeL I I I i , I I I I. MIW ("....I.n..."o, ''', i . .. " ~, ....;....-"'" ;, ":. \t\'. . ;. ..."" ......~ ','-z\"'"-~ [, "- ""-. \ -. -, .,'-'- -'- " " "~':,,, -.-, \, ,!''''~ ",,," .,~ ~"~,;':"'~'i~:h_.:"'''~_ ,,' ':<' ;, '::' k1'! "'<",~""" ''"'\.\ \~~,. :"" ".. '\ '\ ~'" ~ - "\ :, If_';;:q~~\\~.\'\~'' ........ \ :.~ CERTIFICATION OF NOTICE UNDER RULE 5.61al Name of Decedent 1 Betty J. Stahle Date of Deathl September 21, 1995 Will NO.1 1995-00788 To the Registerl I certify that notice of beneficial interest required by Rule 5.6 (a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on October 26, 19951 liWne. Address Harolld J. Stahle 401 Allendale Way Camp Hill, PA 17011-8407 2105 York Haven Road Etters, PA Mildred L. Apple Krone Carol Goss 1291 Leidigh Drive Mechanicsburg, PA 17055 5943 Devonshire Heights Road Harrisburg, PA 17112 5903 Devonshire Heights Road Harrisburg, PA 17112 2195 County Line Road Dillsburg, PA 17019 533 S. Baltimore Street Dillsburg, PA tJ7,1l19 . ~ 7: ~;1 c/o Cynthia L. :Castle 1291 Leidigh Drive ;.', Mechanicsburg, 'PA 17055 :rJ :"10 ! C' Cynthia Frick Castle Delores smith Diane a.oyer Bettiejean McCaleb Keith A. Frick ,', .... ~ ( ,. :".. " . . ~.' . \.-'.J {J; N i..,' ~L - Thank you for your assistance In this matter, Very truly yours, ~;Lj$ Stephanie Kleinfelter ' , Estates and Trusts Pnr~~egal SKllmk;., , . cc HaroUd J, Stahle; Jr. ",-," _t '_'d f , I I r l f f t. f I I I I ~ r ,., , 'l'.t , COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND E ss: Harolld J. Stahle, Jr. b.lng duly sworn according to law, de po... a"d ..y. that h. is the Executor of th. E.tat. of Betty J. Stahle I.t. of --!&J:!~F~U.e.!l-'!:2~~!llh~. , Cumb.rl.nd County, Po" d.c....d and thot the within Is an Inv.ntary mad. by Harolld J. Stahle, J,~ , the ..Id Executor of th. entire ..tate of ..Id d.c.dent, cansl.tlng of all th. penanal prap.rty and real ..tat., .xcept rool .stat. ouhld. th. Commonwealth of Penn.ylvani., and that th. figure. appa.lt. each It.m of th. Inv.ntary r.pr...nt It'. fair valu. as of th. dot. of d.cedent'. d..th, ~ __~ L I t.J 19 96 t' ~' .,~ ..;w';"ft. ,~,i. j , E'{2, . Adm4.l; ..t., and .ub.crlb.d b.fare m., m f.';,1AL SEAl C:..:l,\ 1:0, fEIlHAVEfl. ~ PullIlc 1r2Ilr'.::~", PA DluP!llilCOUnti r~ C::;j;:..;;~~.;} B-p!rcs r.brch 8, 2000 Harolld J. Stahle, Jr. 401 Allendale Way Camp Hill, PA 17011 Addr... Oat. of ClOth 21 0' Month 1995 D.y v.., INSTRUCTIONS I, An Inv.ntary mu.t b. fiI.d within thre. month. after appointment of penan.1 repr@Silatlva, . 01 \0 2. A .uppl.m.nt Inv.ntary must be fil.d within thirty day. of di.cavery of additional .'J.e", 0, 3. Additlan.1 .h.... may be attach.d II to p.nanalty or r.alty 4. S.. Artlcl. IV, Fiduclari.. Act of 1949. ':J')~ lV Ci ~-~ 0 " (" n ~"; c: . fiE! - (Xl '.) ~_\ ) " "ill )>;:.1 ..~ c; o .t:o. =:t', ;n- O ~ a. '"j .<:: III ~ $ -d ~ w 0 .. ... " ~ '" ... .. w ;! c:: .. '"' ~ 0.. U 0 VI QI .. .. QI 0 w w QI o-i C En > .. :I: '" .. QI .. I- 0.. 0-1 o-i 0.. 0: Q- Z ... .... u. .<:: .0: ,,; ..... ~ ~ 0 0 1 u. .... III 0.. QI :I: W -< - > 0 Z '" .j.J '"' ,:. o-:l -< t'6 III QI - Z 0 0: C ~ " , VI Z . 0 0 P: . 0 '" -< ':l o-:l U ... Z W 0.. -0 '0 >. c '"' .j.J - .. III -;: .j.J 0 .. .c: QlI ..a -0 .>I U Ill' .. E ."j -; .. 0 I " it 0 P: , .... U CD Inventory 01 the real aM personal estate 01 Betty J. Stahle deceased ITEM NO, DESCRIPTION VALUE AT DATE OF DEATH 1 300 aha Balti.rrore Gas & Electric 7,932.00 2 200 aha Citicorp 3 200 sha General t-Ptora O:>rp, 14,012,00 9,562,00 1,837.60 4 40 sha General t-Ptora Class E ,-,-,,,,Ca. stock 5 10 aha General t-Ptora Class H '-'-'",..... stock 415.60 6 200 aha Green M:ultain Power Corp. 7 100 sha Hershey Foods O:>rp, 1'_',. ,~ ..' 8 800 sha MObil oil Corp. .,. " 9 799 sha me Financial O:>rp, 10 100 aha Southwestem Public Service 0:1. 11 5 aha Woodstream o:>rporation 12 100 sha Nuveen to1mi.eipa1 Value FUnd 5,276.00 6,433.00 80,248.00 22,523.81 3,138.00 0.00 969.00 13 100 aha Van Kanpen ~tt PA ~l l>1mi Trust 14 17,146.96 sha Van Kallpen Merritt PA Tax Free 15 $5,000 Allegheny COOnty Hosp. Dev, Auth. Gross Ree Rfdg Ser M 6.60~ due 7/01/96 1,662.50 293,384.49 4,917.25 Interest accrued to elate of death on ab:we item 75.90 16 $5,000 Allegheny COOnty ooB Ser C-36 6,75% due 12/01/2007 Interest accrued to elate of death on ab:we item 17 $5,000 Allegheny COOnty Sanitary Auth. SWr Rev Ser B of 1991 6.5% due 6/01/2013 Interest accrued to elate of death on ab:we item 18 $5,000 Beaver 0:> Heap BE 6250 1lJL01 (held in Dean Witter Reynolds a/e #410-022486-017) Continued 5,369.50 105,90 5,351.50 101.98 5,359.45 Page 2 Estate of: Betty J. Stahle 21-1995-0788 Item Value at Date No, Description of Death 19 $15,000 Bucks Coonty Wtr & SWr Auth O:lllection SWr Sys SWr Rev 15,625.50 Ser of 1987 7.2% due 12/01/99 Interest accroed to date of death on ab::Jve item 338.90 20 $5,000 Eastern Lebanon Cty Soh Dist GO Ser 1983 9% due 10/01/92 5,000.00 Interest accroed to date of death on ab::Jve item 217.65 21 $10,000 Hollidayeburg Area Soh Dist GOB Ser 1994 6.20% due 10,532.00 6/01/2017 Interest accroed to date of death on ab::Jve item 194,56 22 $10,000 Hollidayeburg ASD PA 6.20% due 6/01/17 (held in Halpert 10,100,00 and 00. a/c #005 68100 13) 23 $5,000 M:mroeville Hosp, Auth. Hosp Rev 1985 Ser B 7.3% due 5,144,50 10/01/2009 Interest accroed to date of death on ab::Jve item 176.30 24 $10,000 philadelphia Azpt Rev BE 6000 1S.JN15 (held in Dean 10,212.10 Witter Reynolds a/c #410-022486-017) 25 $5,000 City of Philadelphia Gas Works 12th Ser B 7.10% due 5,566.00 5/15/2005 Interest accrued to date of death on ab::Jve item 127,09 26 $5,000 Philadelphia Wtr Wstwtr 5000 02JN15 (held in Dean Witter 5,122.85 Reynolds Inc. a/c #410-022486-017) Interest accrued to date of death on ab::Jve item 0.00 27 $5,000 Woodland Hills Soh Dist GOB Rfdg Ser of 1985 7.65% due 5,000.00 8/15/93 ~ '<s 1he National Travel Club - refund on cancellation of 9.94 subscription ";1'1 1he National Travel Club - - refund on cancellation of 11.39 subscription Total $542,034.26 ! .. , Fstate of I Betty J. Stahle 21-1995-0788 stMoVIRY OF ALLOCATICNS ro BENEFICIARIES Class B Mildred L. ~le Krale cynthia Frick Castle Delores Snith Diane Boyer Carol Goss Bettiejean McCaleb Keith A. Frick 10,000.00 5,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 20,000.00 I , PA REV-lllOll EX (7-94) Pill" 2 Act 1148 to'! 1994 provide. fDr the reductlDn of the tax rate. Impoled on the net value of tranlfers to or for the u.e of the lpoule. The rate. aB pre.crlbed by the Ilalule will be: , . 3% (.03) wtll be applicable fDr ellBlee of decedenll dying on or after 7/1/94 and before 1/1/96 . 2% (.02) wtll be applicable for ellale. of decedenla dylng on or after 1/1/96 and bafore 1/1/97 . 1% (.01) wtll be IIppllcable for ellBlal of decedenll dying on Dr aftar 1/1/97 and before 1/1/98 . SpoulOl tranafer. occurring on or aftar 1/1/98 wtll be exempl frDm Inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PlACING A CHECK MARK (II) IN THE APPROPRIATE BLOCKS. YES NO 1. Did decedent make e Iransfer and: L 'II1aIntheuooa'lncomeolthepropanylranslerred,........................................,.................,..... X b. ,etoIn the rtghlla deolgnate who ahall u,,'he p,opany Iranslerred 0' ne Income.. . . . .. . . . . . .. . .. . . . . . . . . , . . . , . . . . . . . . . .. . . X c. retain a reveraIonary Interost; or.................................... to.... II..'......... ........................ X d, rac:oIvethepromlsela'lIleofel1horpaymonlll, benoll1ao'c..e?..................,..........,............,..,........ X 2. II de.th OCCUlTed on 0' belore December 12, 1982, did decedent Wl1hln IWO Ve.,. p'ecedlng dealh Iranala, property without receMng adequalB consideration? " d.ath occurred &her Docombe, 12, 1982, did decedent lranBler prope<1y wtthln one YO" al death wtthout receiving adequal. conslderadon?............................................................................... X 3. Did dBCBdant own an '"lrUallo~ bank aceounla' hla 0' ha, death?.. .. . . ... . .. ... , ... .. .... ... , .... . .. . . . ... . .. . . .... ... 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. PAl5002 NT> .... COPrrlght FO'1'II1 Sot,..,. Only, 11... Netco,lnc.. N..PACOI ; o LAW .""'ClO N PO. '-."AVIl" t TMIlIID .""UT CUWOC."A"O. ~A. lJ\ST WIlL AND 'IESTAl-ENT OF BF:.rlY J. STAHLE I, BETlY J. STAHLE, of Lower Allen Township, CUlberland County, emsyl~, being of sound mind. IIBIXlry and Ulderst:and1ng, do hereby 1IIIke, 118h and declare this as and for my Last Will and Testament hereby revddng IIIlldng void any and all other wills by me at any time heretofore 1mde. I. I di1:ect that my Executor hereinafter named shall pay all my just debts and funeral expenses as socn as caweniently my be done after my it,.,..,,"Ae. II. I hereby give and bequeath the sun of ten thousand ($10, (00) dollars to my cousin, MIlDRED L. APPIE. if she survives ue. This 8lIDmt shall not be cilminished by any inheritance. estate or death taxes, but shall be paid :In full. III. I hereby give and bequeath the sun of ten thousand ($10,000) oollsrs to my cousin, WILT...IAM D. FlUO<, if he survives me. This 8lIDt.nt shall not be cilminished by any :Inheritance, estate or death taxes, but shall be paid in full. rJ. I hereby give and bequeath the sun of five thousand ($5,000) dollars to my cousin, C'lN1HIA FRIO< CASTlE, if she survives me. This BIID\lnt shall not '. ,. d1minished by any inheritance, estate or death taxes, but shall be paid :In full v. I hereby give and bequeath the sun of one thousand ($1,000) oollars mto each of the following named children of my cousin, C. Eugene Frick. wOO survives me: IEDRES, DIANE, CARJL, BF:.rlY JEAN and KEI'IH. This BDDUnt shall rot Page CXle of four Pages "'-~."'-"--''''"-....-- "'''-'-".",.' '<.....,'_.-'''-~~~..~''''.....,.-,-'-'_..........----~,- -,....'l",..,"_.....,'- , o ..... .r"ca. ,.. L.",..v_" "U.. DT..CT :V....IILA.....A. VI. All the rest, residue and rl!lllUnder of my estate, ~ther real, sooa1 or mixed, and wheresoever situate, I hereby give, devise and bequeath to my Imsband, HAroU..D J. STAHLE, JR., if he survives De by a period of t:h1rty (30) days. VII. If my said husband, HAIDIl.D J. STAHIE, JR., does not survive me by a iod of t:hirt:y (30) days, then: A. I hereby give and bequeath the Il\m of ten thousand ($10,000) dollars mto my cousin, WIILIAM D. FRI<K, or if he is not living, then mto his , PAT FRI(]{. , B. I hereby give and bequeath the Il\m of ten trousand ($10,000) dollars and all of my stock in CCNB Bank, mto my cousin, MILDRED ,L. APPlE, if she is living en the thirtieth day following my death. C. I hereby give, devise and bequeath my house and real estate situate at 401 Al1endale Way, I.oIver Allen Township, CulDerland O:runty, ennsy1vania, unto my husband's father, HARDII.D J. STAHLE, SR., if he is living the thirtieth day following my death. D. I hereby give and bequeath the Il\m of one thousand ($1,000) dollsrs mto 'llIE HUMANE SOCIE1Y OF HARRISBURG AREA, lliC. E. I hereby give and bequeath all of my clothing, jewelry, furni housebJld equiJll81~ mto my husband's father, 'HARDLLD J. STAHIE, SR., and my attorney, JOO,F. LaFAVER, for further disposition as I have instructed them, or in the absence of said inst:ructialS, as they may see fit. F. I hereby give and bequeath the Il\m of five thousand ($5,000) dollars mto my cousin, CYNIHIA FRICX CASTIE, if she is living en the thirtieth Page two of four Pages " ~ ~ o J L"''' .'FICI. .ION lIP. LA"'AV." 1" TMUIO nail! ..I. cu....r:.U.A.D.PA. I I day following my death. This bequest is in addit:lcn to the one made in I , I Section III of this Will. I G, I hereby give and bequeath the IlUIl of one thousand ($1,000) dollars \:alto each of the following t1BIJed children of my cousin, C. Eugene Friclt,l are living on the thirtieth day following my death: IEIDRES, DIANE, CAIm., BEr1Y JEAN and KErnI. H. All the rest, residue snd remainder of my eatate, ~ther real, sona1 or mixed, and wheresoever situate, I hereby give, devise and bequeath as follows: 1. <kle-third (1/3) mto sr. PAUL'S LUmERAN anJRCH, New <ltiberland, Peml8ylvania. 2. <kle-third (1/3) mto LAFAYETIE 0JI.lEGE in Easton, Pennsylvania. 3. <kle-third (1/3) to be divided equally BlIDl1g the following four organizat:l.onB: SHRINER'S HOSPITAL FOR CRIPPIED am..o~, in pt,il "rlptphia, Pennsylvania; MASOOIC lDES at E1izabethtom, Pennsylvania; the BENEVOI.ENl' FOum\TION of the Trustees of the SUPREl-E OJUNCIl. of the ANCIENI' Au;t;t-J.l:JJ Sa:YlTISH RI"lE of lrnEE MASrnRY ,( a MassacluJsetts .!:orporation); and KNIGlTS m1PIJIR EYE FOUNIlATIGl, INC., of Rhinebeck, New York. VIII. If my husband, Harolld J. StBhle, Jr.. does not survive me, I direct that 'my pet dog be provided for as I have previously instructed my Executor. IX. I hereby naulnate, constitute and appoint my husband, HAlUIJ) J. STAHIE, JR., as Executor of this, my Last Will and Test:anent. If the said lld J. Stahle, Jr. should predecease 112, fail to qualify or cease to act as Page three of four Pages II such, then I naninate, constitute and appoint JCN F. LaFAVER, ~ as Executor x. No ffm".fAry acting under this Will Bhall be required to peBt bond in this juriBdiction or in any jur:lsdicticn in MUch he my act. IN Wl'INESS mEREOF, I, BET1Y J. STAHIE, the Testatrix, have mto thiB, my LaBt Will Blld Te8tament, Bet my hand Blld Beal thiB 1'Ol, day of tEuber, A. D., 1981. 13.""'(; Q., k1~.(SFJ\L) , SIrnED, SE'Al.ED, PUBLISHED and IECLARED by BETlY J. ST.AHIE, the above TeBtatr:l.x, as and for he!: last Will and Testament, in the preBence of UB have hereunto subBcribed our l1BlIleB as witnesBeB at her requeBt, in the ence of the Baid Testatrix and, of each' other . "." ."111. .. Jr. L..f'AV." , '"I.. .'.111' IU......LAII_. 'A. REV-lI01EK. ("-II. SCHEDULE B STOCKS AND BONDS COMMONWEALTH OF PENNSYLVANIA . INHERITANCE TAX RETURN REalDENT DECEDENT ESTATE OF FILl! NUMBER Betty J. Stahle (All property /olnUv-owned with RighI a' Burvlvorahlp mUll be dllclal.d on Schedul. F.) ITEM NO, 21-1995-0788 DESCRIPTION VALUE AT DATE OF DEATH 1 300 sha Baltinore Gas & Electric 2 200 sha Citic:otp 3 200 sha General I-btors COrp, 4 40 she General I-btors Class E <";u1l,OIl stock 5 10 she General I-btors Class H <..;U,uLllI stock 6 200 she Green fobuntain I?c:Mer O::lrp. 7 100 sha Hershey Foo:ls COrp. 8 800 sha M:lbil Oil O::ltp. 9 799 sha m: Financial COrp. 10 100 she Salt.hwestern Public Service CO, 11 5 sha Woodstream O::lrporation 12 100 sha Nuveen M.micipal Value F\Jnd 13 100 sha Van Kanpen Merritt PA Q.Jal Muni Trust 7,932.00 14,012.00 9,562,00 1,837,60 415.60 5,276.00 6,413.00 80,248.00 22,523.81 3,138,00 0.00 969.00 14 17, J.46. 96 sha Van K.anpen Merritt PA Tax Free 15 $5, 000 Allegheny O::lunty Heap. Dev, Auth, Gross Rec Rfdg Ser M 6.60% due 7/01/96 1,662.50 293,384.49 4,917.25 Interest accrued to date of death on aIxwe item 75.90 16 $5,000 Allegheny County GOB Ser C-36 6.75% due 12/01/2007 Interest accrued to date of death on aIxwe item 5,369.50 105.90 17 $5,000 Allegheny O::lunty Sanitary Auth. Swr Rev Ser B of 1991 6.5% due 6/01/2013 5,351.50 Interest accrued to date of death on aIxwe item 101. 98 18 $5,000 Beaver O::l Hosp BE 6250 11.JL01 (held in Dean Witter ~lds a/c #410-022486-017) 5,359.45 'lbtal fran continuation (s) TOTAL Also onter on line 2, Roce Itulatlon (I' more spoca Is needed, Inson sddlUOnolsheelB 01 same size.) 73 357.45 542 012.93 $ PAl5031 NTF "" Copvrlght Farm. Soft."ar. Only, 1184 NalcCl,lnc. NI..PA031 Estate of I Betty J. Stahle Page 2 21-1995-0788 SC1IEOOlE B - - Stocks and Bonds Item Value at Date No. Description of Death 19 $15,000 Bucks O:lunty wtr & SWr Auth Cbllection SWr Sys SWr Rev 15,625,50 Ser of 1987 7.2% due 12/01/99 Interest accrued to date of death on above item 338.90 20 $5,000 Fastem Iebancn Cty Sch Dist 00 Ser 1983 9% due 10/01/92 5,000.00 Interest accrued to date of death on above item 217.65 21 $10, 000 HollidaysbJrg Area Sch Dist OOB Ser 1994 6,20% due 10,532,00 6/01/2017 Interest accrued to date of death on above item 194.56 22 $10, 000 HollidaysbJrg A9D PA 6,20% due 6/01/17 (held in Halpert 10,100.00 and Cb. ale #005 68100 13) 23 $5,000 M::lnroeville Hoop. Auth, Hoop Rev 1985 Ser B 7.3% due 5,144.50 10/01/2009 Interest accrued to date of death on above item 176,30 24 $10, 000 Philadelphia Al:pt Rev BE 6000 15JNl5 (held in Dean 10,212.10 Witter Reynolds ale #410-022486-017) 25 $5,000 City of Philadelphia Gas Works 12th Ser B 7.10% due 5,566.00 5/15/2005 Interest accrued to date of death on above item 127.09 26 $5,000 Philadelphia Wtr Wstwtr 5000 02JN15 (held in Dean Witter 5,122.85 Reynolds Inc, ale #410-022486-017) Interest accrued to date of death on above item 0.00 27 $5,000 WOodland Hills Sch Dist GOB Rfdg Ser of 1985 7,65% due 5,000.00 8/15/93 'IOmL. (Carry foxward to wain schedule) . . , , , , 73,357,45 REV- '104 U. ('-III SCHEDULE C CLOSELY HELD STOCK, PARTNERSHIP AND PROPRIETORSHIP ITEM NO, Wtillil. DEBCRIPTlON P1eue Prlnl or 0 FILE NUMBER 21-1995-0788 Iii ... I II I HI II VALUE! AT DATI! OF Dl!Alli None TOTAL A/oo anlar on Ilno 3 Roco IMoUDn S (II more IpI..lo needod, Insort oddlUonoJ 0110010 of lame Ilzo,) 0.00 PAllS041 NT"'" Cap)'rlght Farma SallwlU'. Onty. '114 Nllca,lnc:, NI4PAOoI' REV-11lO1l EX. (12-88) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATl! OF Bett J, Stahle SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER 21-1995-0788 Jolnll.nanl(a): NAME ADDRESS RELATIONSHIP TO DECEDENT JolnUy-owned property: LEnER DATl! DOU.AR VALUE OF ITEM FOR MADE DESCRIPTION OF PROPERTY TOTAL VALUE DECO'S DECEDENT'S NO. JOINT JOINT OF ASSET " INT. INTEREST TENANT None TOTAL (Also onlo, on Ilno 0, Rocaoltulallonl S 0.00 PAl6Ol1 (II moro apaco la noodod, Inso~ additional ahoots 01 alll1l8 alze,) NTF UI8A Copyright Forml 8ottw.... Only, .11" N'ko,lnc. NI4PAOllt --,,",....""~," REV-1510 EX + (2-07) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTAll! OF SCHEDULE G TRANSFERS PLEASE PRINT OR TYPE FILE NUMSER Betty J. Stahle 21-1995-0788 THIS SCH. MUST BE COMPLETED' FILED IF THE ANSWER TO ANY OF THE QUESTIONS ON THE REVERSE SIDE OF COVER SHEET IS YES. DESCRIPTION OF PROPERTY DECD, DOLLAR VALUE ITEM Includo name 01 tho Uonslareo. Ihalr EXCLUSION TOTAL VALUE % OF DECEDENT'S NO, rolollanshlD to docod.nl, dslo 01 Uonslor, OF ASSET INT, INTEREST 1 phoenix Hare Life Annuity 66,531.00 Certificate #12012580 , TOTAL (AI.. onlor Dn IIno 7, Roc".lIulollan\ S 66 531. 00 (II mora spaca Is noodod. Insort additlonalahoets olsarTlO 0120.) PA16101 NTF 1211A Copyright Fa,ml Software Only. tll84 Nelco,lnc. N,,"'PAtOI t PJloenlx Home Ure GEN~,,~L INFOR~T10N Phoenix Home Lile Mutuallnsurnnce Company P,Q, Do. 22012 All>llny. NY 1220'.2012 Notice of Payment Because of Death . ,I. ':?\:~:.f)~~J:I;~,;,~~.'I,:~.,'::\~',.'>,k~'" h ~. ~+ . DATEq~~\ -C(s AMOUNT o Supplementary Contract Issued for Surrendered or Matured Polley. o Supplementary Contract Number assigned to Matured PDllcy Number o Supplementary Contract Elected by Beneficiary. for payment purposes only. o Annully Issued to Decedent. o Beneficiary of Life Insurance under Earlier Death Claim In accordance with Income Agreement Number -,r. Lump Sum for Annuity or Contract Balance Remaining $ Commuted Value $ Death Benefit $ Principal Amount $ Interest from to $ 0 LIfe Insurance Face Amount $ Amount of Dividends $ Amount Df Loan & Loan Interest $ Net Amount Payable $ o Income ContInues Installments of $ payable Iy o UnUlthe final Guaranleed Payment due on o Until the Principal Plus Interest are exhausted. CDmmuted Value of Remaining Installments Certain at Death $ Cost on (Date of Death) atlhe premium rate then used by this company for a life annuity providing similar benefits on the life of the Survivor. o Other (Explain) VCl~\)..Q.. Q~ - t2R- ~ ~m~ ey HaS<< 2'83 . , , ~ Ph~el1ix Home Life MaIn AdmInistratIve Olllee O"e A"'e'lcan Row HarllOld. Connecllcul 06115 Stalulory Horne Olllce 99 TfClY Roact Easl Gfeenbush New York t 2061 ~ Dear Pollcyowncr: We agree to pay the benefits of this pDllcy In accordance with Us provtslDns. It Is Important to us that you are satlslled with your polley. For servfce or InfDnnaUon on ' this policy contact the agent who sold the policy or our Variable Products Operations at the foDDWIng address: Phoenix Home LIfe Mutual Insurance Company Variable Products OpemtlDns 101 Munson Street P.O, Box 942 Green1leld. Massachusetts 01302.0942 RIGHT TO CANCEL: You have a right to return this polley, If for any reason you are not saUsfied with this policy, you may return It to us 'at our home office, Matn Adm1n1stratlve Office. or Variable Products Opemtlons DlvIslon at the above address within 10 days after It Is delJvered to you for a refund of the Accumulated Value plus any charges made under this policy. The Accumulated Value WIll be detennlned as Df the nearest ValuatlDn Date coincident WIth or foDDwtng the date we received the returned policy at our Variable Products OpemUons. This policy provides for the payment of a variable payment life annuity with a 10-year period certain. The amount of each payment WIll depend on the Investment experience of the underlying sub-account(s) and w1II vmy In amount. Signed for Phoenix Home LIfe Mutual Insumnce Company at Its Main Adm1n1stratlve Office In Hartford, Connecticut. Sincerely yours. kd - Secretmy ,~ExeCUtlve Omcer FIulble Premium Variable DeCerred Annuity. All muea and beneOta provided under this pollcy are variable bued on the Investment ezperlence DC the underlylna aub-accDunt(a) DC our Separate Account and are not tuaranteed sa to dollar amount. See Part 7 Cor a description DC how the accumulated valuea prior to the Maturity Date are determined, Part 8 Cor how the variable paymenta upon maturity are determined, and Part 9 Cor a dellCrlptlon DC how the death beneOta are determined. 2647 Non-Participating TIMPLnON INVIS1lI[NT PLUS PLEXIILI PR!MIUM VARIABL! D!r!RR!D ANNUITY SCH!DUL! PAIIE . PIlIMAAY ANNUITANT I BnTY.J STAHLI 71 P!MAI.I I AGl! N#J II!X PDLICY NUMBEIII 12D12BIO .JANUARY 11, 1114 IPDLlCY DATI INITIAL PRINIUNI SBO,DOO,OO .JANUARY 11, 2D07 lMATURITY DATI CDHTINllENT ANNUITANTI NON! DlINElII BnTY .J STAHL! IIN!PlCIARIrII AI STATED IN THl! APPLlCATlDN DR AS LAT!R CHAHllID, SUBSEQUENT PIIIMIUMSI PLI!XIBL! PAYIIENT INT!RVALS I PLEXIBL! SUB-ACCDUNT rlEs DAILY IIDRTALITY AND 1!llP!NS1 RISI< rEr ON PDLICY DATil ,D034l1S (BAS!D DN AH ANNUAL RAT! Dr 1,211") IlAJLY ADNJNISTRATlV! PII: .OOO34l1S (BAS!D DN AH ANNUAL RATE DP D.12R) IlAJLY TAX r!rl 0.00Cl01I DR SUCH GR!ATER AllDUNT AS MAY I! ASSESSID AS A R!SULT DP A CHAHll! IN TAX LAWS, POLICY CHARII!S PRINIUN TAXI D.ODllS DP !ACH PRINIUN PAID. ANNUAL AIllIINISTRATlVI QWIlI!: S311 TllANSr!R CHARll! I NON! CDHTINlII!NT D!PIRR!D SALES CHARII!: srE PART. PDR A D!SCRIPTIDN or HOW THIS CHARlI! IS Dn!RNIN!D. SUB-ACCOUNT ALLOCATION SCH!DUL! T!IlPLnoN MONey MARKET SUB-ACCOUNT 1131 TI!MPLITDN 1l:ND sua-ACCOUNT 1133 T!IlPLnON STDa< SUI-&I'(;O(lNT 1132 ra.LITDN ClWlANTerD INTIIlEST ACCOUNT 1134 ra.LnON AlIET "'IDeATlDN SUI-ACCOlMT 11311 ra.LnON ZNTIIlNATIDNAL SUI-ncolNT 11311 0.00'1\ 0.00'1\ :13. DOlI O.DOlI 34. DOlI 33. DOlI 28417 SCH~DUL~ PAGE (CONTINUED) AIHlITANT: BETTY oJ STAHLE 12012BID ,POLICY NUMB~R DESCRIPTION Dr SUB-ACCOUNTS THE SUB-ACCOUNTS, MONEY MARK~T, BDNO, STDCK, AND ASSET ALLDCATIDN, INVEST IN CORRESPONDING SERIES DF THE T!l4PLETDN VARIABL~ PRDDUCTS SERUS rUND, WHOSE DBoJ~CTIV!5 ARE AS FDLLDWS, DESCRIPTIDN OF TH~ TEMPLETDN VARIABLE PRODUCTS SERIES FUND: T!l4PLETDN MONEY MARKET TENPLETDN MONEY MARKET FUND SEEKS CURRENT INCOME, STABILITY Dr PRINCIPAL, AND LIQUIDITY BY INVESTING IN IlOHEY MARKET INST~S WITH MATURITIES NOT EXCEEDING DN~ YEAR, CONSISTING PRIMARILY Dr SHORT TERN U.S. GOVERNMENT SECURITIES, CERTIFICATES OF DEPDSIT, TIME DEPDSITS, BANK~RS ACCEPTANCES, COMMERCIAL PAPER, AND REPURCHASE AGREEMENTS. TEMPLETON BDND TEMPLETON BDND FUND SEEKS HIGH CURRENT INCOME THRDUQH A rLIXIILE PDLICY DP INVESTING PRIMARILY IN DEBT SECURITIES OF COMPANIES, GOVERNMENTS AND GOVERNM~NT All!NCI!5 OF VARIDUS NATIONS THROUClHOUT TH! WRLO AND IN DEBT SECURITIES WHICH ARE CONVERTIILE INTD CO.cJH STDCK OF SUCH COMPANIES. THE DEBT SECURITIES SELECTED MAY BE RATED IN ANY CATEGORY IY STANDARD & POoR'S CORPORATIDNS ("S&P") DR MODDY'S INVESTDR SERVICE, INC, ("MODDY'S"I. AS WELL AS SECURITIES WHICH ARE UNRATED BY ANY RATING AGENCY. TEMPLETON STDCK TEMPLETDN STDCK FUND PURSUES AN INVESTMENT OBoJECTIVE or CAPITAL GRDWTH THROUGH A POLICY DF INVESTING PRIMARILY IN CO.cJH STOCKS ISSUED BY COMPANIES, LARGE AND SMALL IN VARIDUS NATIONS THROUGHOUT THE WRLO, TEMPLETON ASSET ALLOCATIDN TEMPLETON ASSET ALLDCATION FUND SEEKS A HIQH LEVEL DP TOTAL RETURN THROUGH A FLEXIBLE POLICY OF INVESTING IN STOCKS Dr COMPANIES IN ANY NATIDN, DEBT OBLIDATIDNS OF COMPANIES AND GOVERNMENTS DP ANY NATION, AND IN MONEY MARKET INSTRUMENTS, CKANaES IN THE ASSET MIX WILL IE ADoJUSTED IN AN ATTEMPT TO CAPITALIZE ON TOTAL RETURN PDTENTIAL PRODUCED BY CKANaING ECONDMIC CONDITIONS THROUGHOUT THE WORLD. TEMPLETON INTERHATIDNAL FUND SEEKS LONQ-TERII CAPITAL GRDWTH THROUGH A FLEXIILE POLICY DF INVESTING IN STOCKS AND DEBT DILIDATIONS DP COMPANIES AND GOVERNMENTS OUTSIDE THE UNITED STATES, ANY INCOME REALIZED WILL BE INCIDENTAL. ALTHDUGH THE PUND GENERALLY INVESTS IN CONMDN STOCK, IT MAY ALSD INVEST IN PRErERRED STOCKS AND CERTAIN DEBT SECURITIES SUCH AS CONVERTIBLE BDNDS WHICH ARE RATED IN ANY CATEGORY BY S&P OR IIDDDY' 5 OR WHICH ARE UNRATED BY ANY RATING AGENCY. TEMPLETON INTERHATJDNAL TEMPLETON GUARANTEED INTEREST ACCOUNT GENERAL ACCOUNT SUB-ACCOUNT, THE GUARANTEED INTEREST ACCOUNT IS NOT PART DF THE SEPARATE ACCOUNT, WE RESERVE THE RIGHT TD LIMIT CUMULATIVE DEPDSITS MADE TO THE GUARANTEED INTEREST ACCOUNT DURING ANY ONE-WEEK-PERIDD TD NO MORE THAN S2BD,OOO. IT IS ACCOUNTED FOR AS PART DF OUR GENERAL ACCOUNT. WE WILL CREDIT INTEREST DAILY ON ANY AMIlUNTS HELO LNlER THE ClUARANTEED INTEUST ACCOUNT AT SUCH RATES AS WE SHALL DETERMINE BUT IN NO EVENT WILL THE IPPECTIVE AIHlAL RATE DP INTEREST IE LESS THAN 4". ON TH! LAST WORKING DAY DP EACH CAL!NDAIt WEb( WE WILL SET TH! INTIREST RATE THAT WILL APPLY TO ANY DEPOSITS MADE TO THE GUARANTUD INTEREST ACCOUNT DlIRING THE rDLLDVING CAL!NlIAR WEb(. THAT RATE WILL R!MAIN IN EPrlCT FDR SUCH DEPOSITS. DR THEIR RESULTING ADoJUSTED DEPOSITS, PDR AN INITIAL GUARANT!I PWOO DP ONE I'ULL YEAR. UPON EXPIRY DP THE INITIAL OHI-YEAR QI'NWn'!I PERIDD. AND EACH SUBSEQUENT ONE-YIAR ClIJARANTEI PERIDD THl!RI!AFTER. THE RATE APPLICABLE PDR ANY DEPOSITS DR AlloJUSTED DEPOSITS WHOSI! ClUARANTI! PERIOD HAS aIUST ENDED SHALL BI THE lAME RATE THAT APPLIES TO N1!W DIPOSITS IlADI DlIRING THE CAL!NDAR WEb( IN WHICH THE ClUARANTI!I PI!RIDD I!XPIRI!D, SUCH RATI SHALL LIKEWISI! R!MAIN IN I!prlCT PDR SUCH ADoJUSTI!D DEPOSITS POR A SUBSEQUENT ClUARANT!I PERIOD or ONE PULL YI!AR, 2114'7T .. Table of Contents Part Schedule Pagels) BasIc Information Sub-AccDunt Fees polJcy Charges Sub-Account Allocation Schedule DescrlpUon of Sub-Accounts Table Df Contents Page 1. Deflr11UOI18.................................................. .1.2 2. About'I1t.la Policy ...........................................2 EfI'ect.tv'e Date .............................................2 PolJcy and AppIJcaUon ................................2 LImIts on Our RIght to Contest This Policy ...................................2 Required Proof of Age and Survival .............2 C1alJt1s orCrcdltors .....................................2 Misstatement of Age or Sex .........................2 Assignments ................................ ......... '0' ..3 Statement or Account .................................3 3. The Owner ......................................................3 WIlo l8 the Owtler .......................................3 What are the RIghts of the Owner............... 3 How to Change the Owner ..........................4 4. Prern1ums .......................................................4 Premium Amounts .....................................4 Net PremIum AllocaUon ..............................4 The Separate Account ................................5 6. Transfers, WIthdrawals and Lapse .................6 Transfers Among Sub-Accounts ,................5 Withdrawals and Full Sum:nder ................5 J..,apse ................................,........................6 Rules and LlmltaUons ................................6 Deferral ofPayn1cnt ....................................6 6, Expense Charges and Fees .............................7 Prem1um Tax Charge ..................................7 DlstrlbuUon Charge ....................................7 Transfer Charge .........................................7 Annual Admtntstrative Charge ....................7 Mort.alJQr lit Expense R1sk Fee .....................7 Dally'IUx Fee .............................................7 Part Pajle 7. Detenntnlng the Accumulated and AccumulatJon Un1t Valu~ .........................7 CredlUng Df Sub-Account Accumulation Unlts .................................7 This Polley's Accumulated Value ...............7 Cum:ntAccumulatlon Unit Value ..............8 Net Investnlent Factor ................................8 Valuation of Sub-Accounts .........................8 8. An.nulty Benefits ............................................8 Variable Payout LIfe AnnuIty wilD-yr. Period Certain ............................8 Calculation ofVartable Income Payments .....................................9 Arlnulty Units .............................................9 Ar1nulty Umt Value ....................................9 Assumed Investment Rate ..........................9 Payment Calculation Date .........................,9 Restrictions ................................................9 Variable Income Thble ..............................10 9. Death Benefits .............................................10 How Death Benefit is Determined .............10 SubsUtute .Annuitant ...............................11 The Beneficiary ........................................11 How to Change the Benef1ctazy .................11 10. payrnent OpUons ..........................................11 lAl LIfe AnnuIty w ISpecUled Perloct Certain ......................................12 IB) Non-Refund LlfeAnnutty .........................12 (0) Joint & SUlVlvorshlp LIfe AnnuIty ...........12 IE) Installment Refund LIfe Annuity ..............12 (F) Joint & SurvIvorshIp LIfe AnnUIty w/Speclfled Period Certain ...................12 (0) Payments for SpecUled Period .................12 IHI Payments of a Specified Amounl .............12 (I) Variable Payout LIfe AnnuIty w/l0-Year Per1Dd Certain ,....................13 (J) JDInt & Survivorship Variable PaYDut LIfe AnnuIty with 10-Year Period Certain .........................................13 Other Options .........................................13 TOll (Your) We (Our, VI) Acoumlllatecl Value AcoumIllaUoa UlIlt Annuity Annuity Vnlt AaatiJ1l Fl.zed Payout Annuity Maturity Date P8)'Dlent Date POUcy Anlllvenary Pollcy Date PoUcy Year Settlement Date 2647 Part 1: Definitions 111e owner of this poUey. Phoen1lt Home lJ(e Mutual Insurance C~mpany 111e total value of this polley's share. If any. of all sub-accounta. A standard of measurement, as descrtbcd In PaIt 7. used to measure the value of each sub-account. A contmct promising a pertodlc sertes of payments. A standard ofmeasurcment. as descrtbed In PaIt 8 used to measure the amount of each variable income payment under the varlsble payout annuity payment options. Any person to whom you assign an Interest In this polley Ifwe have notice. of the assignment in accordance with the proviSions stated In PaIt 2. An annuity providing payments which do not vary in amount after the first payment Is made. The Maturity Date shown on the Schedule Page or such changed Maturity Date as we may later agree In writing. but in no event earller than the first polley anniversary or later than the poUey anniversary nearest the annuitant's 85th birthday. It Is the due date of the first annuity payment. The Valuation Date on which a premium payment Is received at our Variable Products Operations unless It Is received after the close of the New York Stock Exchange. In which case It wUl be the next Valuation Date. The anniversary of the Polley Date. The Polley Date shown on the Schedule Page. It Is the date from which polley years and anniversartes are measured. The first policy year Is the one-year period from the Policy Date. Each succeeding poUey year Is the one-year period from the polley anniversary to the next polley anniversary. The date polley proceeds payable under a Payment Option described In Pari 10 arc appUed under the Payment Option. Unless we agree otherwise. for death benc1lIs, the Settlement Date Is the date that we receive a certl1lcd copy of the annuitant's certl1lcate of death: for proceeds payable on the MatUrity Date. It Is the Maturity Date: and for proceeds payable upon a surrender. It Is the cfI'ectlve date of the surrender. - 1 - Valuatlon Date Valuation Period Variable Payout Annuity VPO Written Requut (Written Notice) The EUeetlve Date The Polley and Appllcatlon Llmlts on Our Rliht to Contest This Pollcy Required Proof of Aie and Survival Ctalms of Creditors Al\luatment for MIsstatement of Aie or Sex 2647 For any sub-account. every day Ihe New York Stock Exchange Is open for trading and Phoenix Home Life Is open for business. For any sub-account, It Is the pertod In days beginning with the day following the last Valuation Dale of that sub.account and ending on that sub-account.s next succeeding Valuation Date. An annuity providing payments which vary In amount after the first payment Is made based on the Investment experience of the underlying sub. accounts. Our Vartable Products Operations. The address ts shown on the cover page of this polley. A request In writing In a form satisfactory to us and received by us at our VPO. Part 2: About This Policy This poUey wUl begin In elTect on the Polley Date provided the initial premium due Is paid while the annuitant Is aUve. This poUey and the written appllcatlon. a copy of which Is attached to and made a part of this poUey. are the entire contract between you and us. Any change In the terms of this polley. to be In clTect. must be signed by one of our executive officers and countersigned by our Registrar or one of our executive officers. This polley Is Issued at our Main Administrative Office In Hartford. Connecticut. Any benc1lts payable under this policy are payable at our Main Adm1nIstratlvc Office. We rely on all statements made by or for the annuitant In the written application. These statements arc considered to be representations and not warranties. We can contest the validity of this policy for any material misrepresentation of a fact. To do so, however. the misrepresentation must be contained In the written application and a copy of the application must be attached to this polley when It Is Issued. We cannot contest the vallclJty of this polley. after It has been In force during the annuitant's lifetime for one year from its Polley Date. Proof of the annultant's age must be med with us before any annuity payments wUl begin. We also have the right to require proof of the Identity, age and survival of any person entitled to any payment under this polley or upon whose life any payments depend. To the extent pelmltted by law. no amount payable under this polley will be subject to any legal process to satisfy the claims of creditors. If the age or sex of the annuitant has been misstated, any benc1lts payable wtIl be adjusted to the amount that the premium paid would have purchased based on the annuitant's correct age and sex. Any overpayments and underpayments made by us will be charged or credited agalnst future payments to be made under the polley. - 2- Al81(nmeatl Btatement of Account Who II the Owner What are the Rlptl of the Owner 2647 We wUl not be considered to have noUce of any assignment of an Interest In this polley untU we receive the original or copy of the assignment at our Variable Products Operations. In no event wUl we be responsible for Its validity. This polJc:Y may not be assigned or transferred to any person or entity such that the annuitant would not be COnsidered the holder of the contract for purposes of the distribution at death of holder rulcs under Internal Revenue Code SecUon 72. as amended by the Tax Reform Act of 1986, or the corresponding section or any new tax code. Under such secUon, as presently Interpreted. this polley would pennlt assIgnment only to the annuitant. a non-Indlvldual. or a trust or other entity as agent for the annuitant. We will furnish you. at least annually, a statement of the Accumulated Value of this polley In each of the sub-accounts. We wUl also furnish you a statement of the Investments held by each sub-account. Part S: The Owner The owner Is the person named as owner In the application, unless later changed as prOvided In this policy. Ownership may not be changed to any person or entity such that the annuitant would not be considered the holder of the contract for purposes of the distribution at death of holder rules under Internal Revenue Code Section 72. as amended by the Tax Reform Act of 19S6. or the corresponding section of any new tax or code. Under such section, as presently Interpreted. this polley would permit ownership only by the annuitant. a non-individual. or a trust or other entity as agent for the annuitant. The annuitant wUl be the owner. Ifno other person or entity Is named as owner. You control this polley durtng the annultant's lifetime but not untU this polley begins In foi'ce. Unless you and we agree otherwise, you may cxerclse all rights provided under this polley without the consent of anyone else. Your rights Include the right to: a. Receive any amounts payable under this policy during the annuitant's lifetime. b. Change the owner for the Interest of any owner subject to the rcstrtctlons stated In this part. c. Change the premium amount and payment Intervals. See Part 4. d. Change the sub-account al1ocaUon schedule for premium payments. See Pari 4. e. Transfer accumulated values between and among the various sub-accounts. See Pari 5. f. Make withdrawals from the various sub-accounts or fully surrender the polley for Its surrender value. See Part 5. g. Select an annuity payment option for amounts payable upon a withdrawal or full surrender. h. Select an alternative annuity payment option to commence on the Maturity Date. See Part S. -3- '. How to ChanCe the Owner I. Change Ihe beneficiary of Ihe death benefit. See Part 9. J. Assign. subject to the restrlcllons slaled In Part 2, release. or surrender any Interest In Ihls polley. See Parts 2 and 5. You may exercise these rights only whUe the annuitant Is alive. Your exercise of any rights wlll. to the extent thereof, assign. release. or surrender the Interest of the annuitant and all beneficiaries and owners under this polley. To change the owner you must submit a wrttten requcst satisfactory to us. Part 4: Premiums and Allocations to Sub-Accounts Premium Amounts The initial premium Is due on the Policy Date. The annuitant must be alive when the Initial premium Is paid. Thereafter. the premium amount and payment Intervals are as shown on the Schedule Page unless later changed as described below. All premiums arc payable In advance at our Variable Products Operations, except that the InItlsl premium may be paid to an authorized agent of ours for forwarding to our Variable Products Operations. No benefit associated with any such premium wUl be provlded unW It Is actually received by us at our Vartable Products Operations. You may vary the amount and payment Intervals for subscquent premiums, and additional premium payments may be made within the follOWing limits: a. Each premium payment must at least equal $25. b. No more than $1.000.000 In total premiums may be paid on this polley unless we agree otherwise. c. The premium payment Intervals may be changed to annual. semi-annual. quarterly, monthly. flexible, or any other arrangement agreed to by us. We reserve the rlght to waive any or aU of the above limits. Net Premium Allocation The net premium Is equal to the premium paid. less the applicable premium tax If any which Is assessable at the time of payment of the premium. As of the Policy Date, the premium tax for your policy. If any, Is as shown on the Schedule Page. The net premium wUl be applied on the Payment Date to the vartous sub.accounls In accordance with the allocation schedule elected In the appUcation. The number of Accumulation Units credited to each sub-account will be determined by dividing the net premium applied to that sub-account by the Accumulation Unit Value of that sub-account on the Payment Date. Any Accumulation Units credited to a sub-account wUl bear the same Payment Date as the net premium applied to creale such Accumulation UnJt. You may change the allocation schedule with respect to subsequent or additional premium payments by wrttten notice rued with us. We reserve the rtght to waive Ihe requirement of written notice. 2647 - 4 . The Separate Accaunt Tranlfera Amona Suh-Aceounu WtthdrawaJa and Full Surrender 2647 The values under this poUey are based on the amount and number of premium payments made. the polley charges and the Investment experience of the lJub- accountls) to which the premium payments are allocated by you. The sub- accounts are part of the Phoenix Home We Variable Accumulation Account (VA Account) and they Invest In Mutual Funds which have d1fTerlng Investment objectives as shown on the Schedule Page. We have the right to add additional sub-accounts subject to approval by the SecuriUes and Exchange Commission and. wherc required. by the Insurance supen'lsory official of the state where this polley was delivered. Subject to the terms of this polley, you may transfer the polley's Accumulated Value between and among the various sub-accounts. The VA Account Is a Separate Account estabUshed by our company under New York Law and Is registered as a unlt Investment trust under the Investment Company Act of 1940. All Income. gains and losses. realized and unrealized, of the VA Account are credited to or charged against the amounts placed In the VA Account without reference to other Income. gains and losses of our General Account. The assets of the VA Account are owned solely by us and we are not a trustee with respect to such assets. We use the assets of the VA Account to buy shares of the Fund Identified .on the Schedule Page of this polley according to your most recent aUocaUon Instruction on rue with us at our VPO. The Fund Is registered under the 1940 Act as an open end. diversified management Investment company. The Fund has separate Series that correspond to the sub-accounts of the VA Account. Assets of each sub-account are Invcsled In shares of the corresponding Fund Sertes. Part 5: Transfers, Withdrawals, and Lapse You may transfer all or a portion of the Accumulated Value of this polley among one or more of the sub-accounts. You can make at least six transfers per polley year. We reserve the right to require that such transfers be made by written request and to llmit the number of additional transfers made dunng a polley year. A transfer charge will be Imposed as shown on the Schedule Page. Any such charge will be deducted from the sub-accounts from which the amounts are to be transferred In the same proportion as the amounts to be transferred to each sub-account bear to the total amount transferred. The Accumulated Value of each sub-account will be determined on the Valuation Date that coincides with the date of transfer. Any new Units credited to a sub-account as a result of any transfer shall bear the same Payment Date as the Units released to elTectuate such transfer You may withdraw In cash the Accumulated Value of this polley. less any appllcable contingent deferred sales charge. In whole or In part any time prior to the Maturity Date. Such withdrawals must be by wrilten rcquest In a form satisfactory to us and must Include such tax withholding information as we may reasonably require. The withdrawal wUl be accompllshed by the surrender and release of Accumulation Units credited to the sub-accountls) from which the withdrawal Is to be made In such amount as required to elTectuate such withdrawal. Including any contingent deferred sales charge applicable to such withdrawal. If as the result of a withdrawal. no Accumulated Value remains under this polley. the polley wUl be deemed fully surrendered and of no further value or effect. The Accumulated Value of each sub-account will be determined on the Valuation Date that coincides with the date of the withdrawal. - 5- Lap.. Rule. and Llmltatlon. Deferral o(Payment 2847 Mer the first policy year, and each year thereafter. an amount up to 10% of the Accumulated Value of this policy as of the end of the prtor polley year may be withdrawn free of any contingent deferred sales charge. Any amount withdrawn durtng the first policy year or In excess of such 10% during later poUey years will be subject to the following contingent deferred sales charge. expressed as a percentage of the amount withdrawn: Age of Deposit In Complete Years from Payment Dnte Unit Released was Credited o 1 2 3 4 5 6 and over Contingent Deferred Sales Charge 6% 5% 4% 3% 2% 1% 0% In no event. however. will the total of all contingent deferred sales charges applied under this polley exceed 9% of the total premiums paid on this poUey. You may elcct to apply the amount withdrawn or surrendered to the various payment options deSCribed In Part 10. If on any Valuation Date the Accumulated Value of this polley becomes zero. the polley will lmmedatc1y termtnate and lapse without value. We wUl mati to you, at your most recent post office address on me with us at our VPO, a written notice oflapsc within 30 days after any such Valuation Date. The Accumulation Units released for transfer or withdrawal will be determined on a First-In, First-Out lFIFO) basis based on Payment Date. No transfers. withdrawals. or full surrender may be made after commencement of an annuity on the Maturity Date or with respect to any funds applled under a Payment Option. Transfers, withdrawals. payment of the proceeds due at maturity or a request for a full surrender will usually be processed within 7 days. However, we may postpone the processing of any such transactions for any of the following rcasons (as provided under Investment Company Act of 1940): la) when the New York Stock Exchange Is closed, other than customary weekend and holiday closings: (b) when trading on the exchange Is restricted by the Securities and Exchange Commission: lc) when the Securities and Exchange Commission declares that an emergcney exists as a result of which disposal of securities In the Fund Is not reasonably practicable to determtne the value of the Accumulation Units In the sub-accounts: or ld) when a governmental body having Jurisdiction over the account by order permits such suspension. Rules and regulations of the Securities and Exchange Commission. If any. are appllcable and wUl govern as to whether conditions descrtbed In (b) or lc) or ld) exisl. -6- Pnlmlum Tu Charao DlItrlbntlon ChaJto Tranlfer Char.e Annual Admlnlltratlve ChaJte MortRUty and Expense RlIk Feo Dally AdmInlstratlve Fee Dally Tal: Fee Credltlnit of Sub-Aceount Accumlllatlon Vnlts Determination of Thls Polley's Accumulated Value 2647 Part 6: Expense Charge. and Fees Charges to cover expenses Incurred by us In the distribution and administration of this policy are made In the manner described below. A prcmlum tax, If any, Is asse8Sed against each premium payment In such amount which as of the policy date Is as shown on the Schedule Page. We further reserve the right to deduct from the Accumulated Value any premium tax Imposed upon annulUzatlon on the Maturity Date or the elecUon of a Payment Option. A charge to cover expenses Incurred In the distribution of this polley arc taken In the form of a contingent deferred sales charge as described In Part 5 which Is applled to any withdrawals or full surrender made within the six- year period following the Payment date of the Accumulation Units released to elTectuate such withdrawal or surrender. A transfer charge as shown on the Schedule Page Is Imposed on Transfers. A portion of the administrative expense Incurred by us Is assessed In the form of an annual charge as shown on the Schedule Page. We reserve the right to lower such charge. Such charge will be deducted at the end of each polley year from the total Accumulated Value of this polley with each sub-account beartng a pro-rata sharc of such expense based on the proportionate Accumulated Value of each of the sub-accounts. By agreement with us. you may. Instead, elect to pay this charge to us In cash. The mortality and expense risk assumed by us Is taken In the form of a dally fee agalnst each sub-account In such amount as shown on the Schedule Page. We reserve the right to lower such fee. A portton of the administrative expense Incurred by us Is assessed In the form of a daUy fee as shown on the schedule page. A daUy tax fee. If any. Is taken by us In the form of a daUy fee against each sub- account In such amount as shown on the Schedule Page. Part 7: Determining the Accumulation Unit Values When a premium payment Is received by us. we wUl apply the premium paid less the applicable premium tax on the Payment Date to credit Accumulation Units to one or more sub-accounts under this polley In accordance with the most recent allocation schedule on file with us. The number of Accumulation Units credlld to each sub-account wllJ be determined by dlvlding the premium. net of any applicable premium taxes, applied to that sub-account by the then current Accumulation Unit Value of that sub-account. The AccumulaUon Unit Value of each sub-account on a Valuation Date Is determined at the end of that day. The Accumulated Value of a sub-account at any time prtor to the Maturity Date Is determined by multiplying the total number of units under this polley for that sub-account by the current Accumulation Unit Value of that sub-account. - 7- Determlnatlon of the Current AccWDulaUon Unit Value Determlnatlon of the Net IDvCltment Factor The Valuation of Sub-Aceounta Variable Payout LUe Annuity WIth lo-Year Perlocl Certain (Ps)"ment Option I) 2647 The total Accumulated Value under this policy equals the sum of the Accumulated Values of each orthc sub-accounts. The Accumulallon Untt Value of each sub-account was set by us on the first Valuation Date under the sub-account. The current Accumulation Unit Value of a sub-account on any subsequent Valuation Date Is determined by mulllplylng the Accumulation Untt Value of the sub-account on the immediately preceding Valuation Date by the Net Investment Factor for that sub-account for the Valuation peliodJust ended. The Net Investment Factor for a sub-account Is determined by the Investment performance of the assets underlying the sub-account for the Valuation Pertod Just ended. The Net Investment Factor of a sub-account for any Valuation Period Is equal to 1.?0ooooo plus the applicable net Investment rate for the pertod. The net Investment rate Is determined by: a. taking the sum of the accrued net Investment Income and capital gains and losses. realized or unrcaUzcd, of the sub-account for the Valuation Period: and b. for each calendar day In the Valuation Period subtracting an amount equal to the moliallty and expense risk fee plus the dally administrative fee and dally tax fee. 'If any; and c. dividing the result of la) and (b) by the Accumulated Value of the sub- account at the beginning of the Valuation Period. The values of the assets In each sub-account w1l1 be calculated In accordance with applicable law and accepted procedures. Part 8: Annuity Benefits Unless you elect an allemative annuity payment option as described In Part 10 on or before the Maturity Date. the Accumulated Value of this polley on the Maturity Date will automatically be applied to provide you a 10-year period cerialn variable payout monthly Ufe annuity based on the annuitant's Ufe under Payment Option I as described below. Unless otherwise changed, any annuity payments falling due after the annuitant's death durtng the period certain will be paid to the beneficiary. If the amount to be applied on the Maturity Date Is less than $2,000 or would result In monthly payments of less than $20, we shall have the right to pay such amount to you In one lump sum In lleu of providing such annuity. We also have the light to change the annuity payment frequency to annual If the monthl)' annuity payment would otherwise be less than $20. The first monthly Income payment Is due on the Maturity Date. Future payments wUl be due on the same day of the month as the first payment Is due. or If such date docs not fall within a month then the first ValuaUon Date to occur In the following month. Payments will continue during the Ufetlme of the annuitant. or. If later. the end of the IO-year period certain starting with the date the first payment Is due. -8- CalculatlOD of Variable IDcolDe P8)'Dlenu Annuity Vnlu Annuity Vnlt Value Assumed IDveltment Rate Payment Calculation Date Restrietlons 2647 The Variable Income Table below shows the minimum amount of the first monthly payment for each $1,000 applled. The minimum first payments shown are based on the 1983 Table annuity table projected to the year 2000 with Projection Scale Q, and with projection Scale Q thereafter. and an effective annual interest rate of 4-1/2%. The actual payments will be based on the monthly payment rates we are using when the flrat payment Is due. They wUl not be lellS than shown In the table. In determining the first payment, the amounts held under this opUon In each sub-account of the Separate Account are mulUplled by the rates we are ustng for this option on the first Payment Calculation Date. The Orst payment equals the total of such figures determined for each sub-account. Future payments are measured by Annuity Units and are determined by multiplytng the Annuity Units In each sub-account with assets under this option by the Annuity Unit Value for each sub-account on the Payment Calculation Date that applies. The payment will equal the Bum of the amounts provided by each such sub-account. The number of Annuity Units In each sub-account with assets under this option Is equal to the portion of the first payment provided by that sub-accounl divlded by the Annuity Unit Value for that sub-account on the first Payment Calculation Date. All Annuity Unit Values In each sub-account of the Separate .Account were sel at $1.?0ooooo on the Orst Valuallon Date selected by us. The value on any date thereafter Is equal to lal the Net Investment Factor for that sub-account for the Valuation Pertod divided by lbl the sum of 1.?0ooooo and the rate of Interest for the number of days In the Valuallon Period, based on an elTecUve annual rate of Interest equal to the Assumed Investment Rate, and multiplied by Icl the corresponding Annuity Unit Value on the preceding Valuation Date. The Assumed Investment Rate of 4-1/2% per year Is the annual interest rate assumed In determining the first payment. The amount of each subsequent payment from each sub-account of the Separate Account will depend on the relationship between the Assumed Investment Rate and the actual Investment performance of that sub-account. If a 4-1/2% rate would result In a Orst variable payment larger than that permitted under applicable state law, we will select a lower rate which will comply with that law. Payments are calculated on a Payment Calculation Date. That date Is the earliest Valuation Date which Is not more than 10 days before the due date of the payment. No withdrawals. partial or full surrenders. transfers. or additional premium payments may be made as regards any assets held under this option. - 9- '. Variable Ineome Table Mlntmum Monthly Payment Rate for First Payment for Each $1000 Applied. Based on 4-1/2% Assumed Investment Rate. Adlusted Me. lsIIlA Female 40 4.31 4.14 45 4.51 4.2S 50 4.76 4.47 55 5.09 4.73 60 5.52 5.07 65 S.lO 5,53 70 6.83 6.17 75 7.69 7.00 60 S.62 S.OI 85 9.46 9.04 · Age on birthday nearest due date of the first payment. Monthly payment mtes for ages not shown wUl be furnished on request. How the neath BeneOt III Determined 2647 Part 9: Death Benefits In the event of the annultant.s death, we will pay to the beneficiary upon our receipt of due proof of that annuitant.s death at our Variable Products Operations death benefit determined as follows: A. Death before Maturtty Date - If the annuitant dies beforc the Maturity Date. the death benefit will equal the greater of III the sum of all premium payments made under this policy less any prior partial withdrawals or (2) the Accumulated Value of this polley on the date of our receipt of a certified copy of the certificate of death. In lieu of recelvlng the death benc1lt In a lump sum cash payment. the beneficiary may elect certain alternative payment opUons as described below. No deducUon Is made for sales or other expenses, other than premium taxes, upon such election. B. Death on or after Maturity Date - If the annuitant dies on or after the Maturtty Date, any death benefit wUl be determined In accordance with the provisions of the applicable payment option elected by you. If the annuitant dies before the Maturtty Date. the beneClclary of any death benefit then payable may elect to apply his or her respective share of the death benefit under the Payment Options descrtbed In Part 10, subject to the following limitations. These limitations arc Imposed to satisfy the annuity contract definition requirements of the Internal Revenue Code of 1986. The benc1lciary's election shall be lI~ted to the follOwing options: a. an Option A Ufe annuity on the life of such beneficiary with a specified period cerlaln of at least 5 years but not beyond the Ufe expcctancy of such beneficiary; or rb. an Option B Ufe annuity on the life of such benc1lclary; or c. an Option E Installment refund life annuity providing for a rcCund period of at least 5 years but not beyond the Ufe expectaney of such benc1lclsry; or - 10- Substitute Annuitant The BeneOelary Bow to Chan&e the BeneBclary 2647 . d. an Option 0 Installment payout providing for payments for a speclfled period of at least 5 years but not beyond the life expectancy of such beneficlary; or e. an Option H Installment payout providing for payment of a specified amount for a pertod of at least 5 years but not beyond the life expectancy of such benefiCiary: or f. an Option I variable payout monthly life annuity with a period certain of 10 years, or the life expectaney of such beneficiary If shorter. We reserve the right to extend the options olTered or further restrict the options offered to the extent consistent with futurc changes In the Internal Revenue Code and any regulations or rullngs under such Code. If the annuitant dies before the Maturity Date and the annuitant's spouse Is the beneficiary, In lieu of any of the above settlements, he or she may elect to continue this policy on his or her Ufe as the subsUtute annuitant as If no death had occurred. We shall have the right to first require return of the polley to us so that we may amend It to rc1lect this change. Unless othelWlse provided, any death benc1lt or Income payment that falls due after the annuitant's death wl11 be payable In equal shares to such prtmary beneficiaries as are then liVing. But If none Is then living, payment will be made In equal sharcs to such contingent beneficiaries as arc then llvtng. But If no beneficlary Is then living. payment wlU be made to the executor or admlnlstmtor of the survivor of the annuitant and all benc1lclartes. Unless othelWlse stated. the relationship of a beneficiary Is the relationship to the annuitant. At any time prior to death of the annuitant. you may change the beneficiary by written notice signed by you and med with us at our VPO. When we receive It. the change wUI relate back and take elTect as of the date It was signed by you. However. the change will be subject to any payments made or actions taken by us before we received the notice at ourVPO. Part 10: Payment Options The election of a payment option must be In a written form satisfactory to us. We reserve the right to requtre that the election of a payment option be In the form of a supplementary contmct dlstrtbuted by us refiectlng the terms of the payment option elected. We have the right to require proof of age and sex of any person on whose life payments depend, as well as proof of the continued survival of any such person. We further have the right to requtre that the amount applled on the Settlement Date to any payment option elected at least equal $2.000 'and result In a monthly payment of at least $20. Options I (Vartable Payout Life Annultyl and J (Variable Payout Joint LIfe Annultyl are not available for partial withdrawals. As regards the election of a payment option by the benefiCiary of any death benefit payable under this policy, limited as described In Part 9. the term "annuitant" as used below shall refer to such beneficiary. - 11 - .' Option A . Life Annuity with Specified Period Certain Option B . Non-Refund Life Annuity Option D . Joint and Survivonhlp Life Annuity Option E . Installment Refund Life Annuity Option F - Joint and Survivonhlp Life Annuity with Speclfled Period Certain Option G . Payments for a Specified Period Option H . Payments of . Specmed Amount 2647 The guaronteed annully poyment rates under the fixed payout payment options below will be based on the annullant's age and sex. and wUl be no less favorable than the following: Under Options A. B. D. E and F rotes are based on the a.49 Annully Table projected to 1985 with Projection Scale B, and with Projection Scale B thereafter. We use an Interest rate of 3-3/6% for 5 and 10 year certain periods under Option A. for the 10 year certain pertod under Option F. and for Option E: an Interest rate of 3-1/4% for the 20 year cerialn period under Options A and F: an Interest rate of 3-1/2% under Options Band D. Under Options a and H the guaranteed Interest rate Is 3%. If our rates In elTect on the Settlement Date are more favorable. we will use those rates. A Ilxcd payout annully payable monthly while the annuitant Is llvtng or. If later, the end of the specified period certain. The period certain may be specified as 5. 10, or 20 years. The pertod certain must be elected at the time that this option Is elected. A fixed payout annuity payable monthly while the annuitant Is llvtng and ending wllh the last due preceding the date of the annultant's death. A fixed payout annully payable monthly while the annullant and the designated Joint annuitant are living, and continuing thereafter during the Ufetlme of the survivor. The amount to be continued to the survivor may be 100% or 50% of the Joint annuity payment, as specified at the time this option Is elected. The designated Joint annuitant must be designated at the time this option Is elected and must have an adjusted age of at least 40. The adjusted age Is the person's age on his or her birthday nearest the Settlement Date. A fixed payout annuity payable monthly while the annuitant Is llvtng or, If later, the date the annuity payments made under this option total an amount which rcfunds the entire amount applied under this option. If the annuitant Is not living when the final payment falls due. that payment wl1l be limited to the amount which needs to be added to the payments already made to equal the entire amount applied under this option. A fixcd payout annuity payable monthly while either the annuitant or designated JOint annuitant Is llvtng. or If later, the end ofthe specified period certain. The pcrlod cerialn specified may be 10 or 20 years. Thc period certain must be specified at the tlme this optlon Is elected. The deSignated Joint annuitant must be designated at the time this option Is elected and must have an adjusted age of at least 40 ycars. Thc adjusled age Is the person's age on his or her birthday nearest thc settlemcnt date. Equal Income Installments for a specified period of years are paid whether the payee llves or dies. The period certain specified must bc In whole number of years from 5 to 30. Equal Income Installmenls of a specified amount are paid until the prtnclpal sum remaining under this option from the amount applied Is less than the amount of the Installment. When that happens. the princIpal sum remaining will be paid as a final payment. The amount specified must provtde for payments for a period of at least 5 years. - 12. \. Optlonl- Varlable Payout We Annult,' with IG-Teu Period certain Optlon J - Jolat 8arvlvonhlp Variable paJOUt We AnDult,' with IG-Teu period certain Other OptlODl 2647 As described In PariS. this opUon provides a vartable payout monthly annuity based on the Ufe of the payee WIth variable monthly Income payments that are not guaranteed as to dollar amount and will vary based on the Investment expertence of the sub.accounts of the Separate Account to whtch such proceeds are applied on the Settlement Date. The flrsl payment Is due on the Settlement Dale. Unless another Payment Option has been elected. lhls option w11l automatically apply to any polley proceeds payable on the Maturity Date. This opUon provides a variable payout monthly Ufe and annuity whUe the annuitant and the deslgnaled Joint annuitant are 1tvIng, and contlnulng thereafter during the life of the survivor or. If laler. the end or the 10-year period certain. The designated Joint annuitant musl be designated at the Ume this opUon Is elecled and must have an adjusted age of at least 40. The a~usted age Is the person's age on his or her birthday nearest the Settlement Dale. The variable Income payments arc not guaranteed as to dollar amount and wiD vary based on the Investmenl experience of the sub.accounts of the Separate Account to which such proceeds are applled under this option. The payments wUl be made In the same manner and under lhe same lerms as provided for variable Income paymenls under Option I as al\Justed for. mtes based on the Joint lives covered under this option. This payment option Is available for payment to you of any proceeds that become payable under the poliey on Us Maturity Date or upon a full surrender and for the beneficiary of any death benefit thal becomes payable under the poliey. We may olTer other payment options or altemaUve versions of the options Usted above. - 13- .' POLICY AMENDMENT . This amendment Is Issued as II part of the polley to which It Is attached. The following Pari 111s added after Pari 10 entiUed "Payment Options". Part 11: Table of Payment Option Amounts The tables that follow show the guaranteed mlntmum installment amounts for each $1,000 applled. The actual payments w1ll be based on the monthly payment rates we are using when the first payment Is due. They w1ll not be leas than the amounts shown In the tables. Amounts for payment frequencies. periods or ages not shown w1ll be furnished upon request. The term "age" as uacd In the tables refers to the adjusted age. Under OpUons A. Band E, the adjusted age Is defined as follows: W For surrender values, the age of the payee on the payee's btrthday nearest to the polley anniversary nearest the date of surrender. (B) For desth proceeds, the age of the payee on the payee's btrthday nearest the effective date of the payment option elected. Under Option D and F the ac\Justed age Is the age on the btrthday nearest to the polley anniversary nearest the date ofsurrcnder. Option A & E -lJ(e Annuity with Spectlled Period Certain: Installment Refund LIfe Annuity Age lnstallment Refund 10 Years certaln 20 Years Certain of , Payee Male Female Male Female Male Female 10 $3.0S $3.03 $3.0S $2.99 $3.00 $2.94 15 3.14 3.09 3.15 3.04 3.07 3.00 20 3.22 3.16 3.24 3.11 3.15 3.07 25 3.33 3.24 3.24 3.20 3.25 3.15 30 3.45 3.35 3.47 3.30 3.3S 3.25 35 3.61 3.4S 3.64 3.43 3.55 3.3S 40 3.80 3.64 3.66 3.80 3.74 3.54 45 4.05 3.S5 4.14 3.82 3.99 3.74 50 4.36 4.12 4.50 4.10 4.2S 3.99 55 4.76 4.47 4.95 4.47 4.61 4.31 50 5.2S 4.93 5.54 4.96 4.97 4.67 65 5.97 5.54 6.30 5.83 5.29 5.06 70 6.91 6.39 7.24 6.50 5.43 5.31 75 S.21 7.57 8.26 7.56 5.44 5.40 80 10.04 9.26 9.12 8.80 5.46 5.46 S5 12.61 11.68 9.60 9.31 5.46 5.46 R657 - 1. OpUon B - Non-Refund LIfe Annuity Age Of ~ 10 15 20 25 30 35 40 46 50 55 60 6lS 70 75 SO S6 Male .3.17 3.24 3.32 3.42 3.56 3.73 3.95 4.24 4.62 5.12 6.79 6.75 S.I5 10.26 13.54 1S.72 Female .3,12 3.1S 3.25 3.34 3.44 3.68 3.75 3.9S 4.2S 4,68 6.24 6.04 7.22 9.03 11.68 16.54 OpUon D&F'- Joint and Survivorship lJ(e AnnUity With 10-year Pertod Certain: Joint and Survivor We Annuity Age or Age of Insured Age of Age of Insured other Other Annuitant Male Annuitant Female F 55 60 6lS M 55 60 65 40 $3.62 $3.64 $3.65 40 $3.72 $3.77 $3.80 45 3.80 3.83 3.86 45 3.S9 3.97 4.03 50 4.00 4.07 4.12 50 4.06 4.19 4.31 55 4.22 4.34 4.44 55 4.22 4.43 4.61 60 4.43 4.64 4.S2 80 4.34 4.64 4.93 6lS 4.61 4.93 5.23 65 4.44 4.82 5.23 70 4.75 5,lS 6,63 70 4.50 4.95 5.4S 76 4.86 5.36 5.96 75 4.64 5.03 5.S5 R657 -2- .' OpUon 0 - Payments for a Specified Period Number of Annual Monthly Years Instalbnent Installment 15 .211.99 $17.91' 6 179.22 15.14 7 1155.63 13.16 8 138.31 11.68 9 124.69 10.153 10 113.82 9.61 11 104.93 8.86 12 97.154 8.24 13 91.29 7.71 14 815,915 7.28 115 81.33 6.87 16 77.29 6.153 17 73.74 6.23 18 70.59 5.96 19 67.7S 5.73 20 65.26 5.51 25 515.78 4.71 30 49.53 4.18 Option 1- Variable Payment lJ(e Annuity with 10-year Perted Certaln: Monthly Income per $1,000 - Based on 4.5% Interest. 10-Year Certaln and LIfe Annuity, and the 1963 lAM Table ProJeeted to Year 2000 with Project/on Scale 0 and with Continued MortalJty Improvement Thereafter, .Age or Payee 40 45 50 55 60 65 70 75 60 S5 R657 Male $4.31 4.51 4.76 5.09 5.52 6.10 6.83 7.69 8.62 9.46 -3- Female $4.14 4.28 4.47 4.73 5.07 5.33 6.17 7,00 8.01 9,04 OpUon J- Joint Survivor Variable payment We Annuity with 10-year Pertod Certain: Month]y Income per .1.000 . Balled on 4.5'16 Interest, 10-ycar Certain and We Annuity. and the 1983 lAM Table ProJecled to Year 2000 with ProJectlon Scale 0 and wllh Continued MortaUty Improvement Thereafter, /tie of Age of Insured Age of Age or Insured Other Other Annultant Male Annuitant Female F 65 60 65 M 55 60 65 40 ....08 ....10 ....11 40 ....16 ....20 "4.23 45 4.18 4.21 4.24 45 4.25 4.32 4.37 150 4.31 4.36 4.40 150 4.35 4.44 4.53 55 4.44 4.52 4.59 55 4.44 4.58 4.71 60 4.58 4.70 4.S2 60 4.52 4.70 4.90 65 4.71 4.90 5.07 65 4.59 4.S2 5.07 70 4.83 5.08 5.34 70 4.64 4.91 5.23 75 4.93 5.24 5.60 75 4.68 4.98 5.35 Phoenix Home We Mutuallnsumnce Company k.d~ Secretary ~ f - n. f R657 - 4- POLICY AMENDMENT This amendment Is Issued as pari of the polley to which Ills attached. DeOnltlona The definitions In Part I are amended to add or modify the following terms: Annuitant - On or prtor to the Maturtty Date, the term "annuitant" as used In this polley refers to the PrImary Annuitant as shown on the Schedule Page, whUe such primary annuitant Is IIvtng, and then the Contingent Annuitant. If any. as designated on the written application for this polley or as later changed by you as indicated below, provided such contingent annuitant Is living at the death of the primary annuitant. Mer the Maturity Date, the term "annuitant" shall mean the annuitant under this polley detennined as of the Maturity Date. Annuitant's Beneficiary. The benc1lclary entitled to receive payment of any amounts payable under this poll~ upon death of the annuitant. Owner's Beneficiary - The beneficiary entitled to receive payment of any amounts payable under this policy upon death of the owner. Maturtty Date. The Maturity Date shown on the Schedule Page or such changed Maturity Date as may result from death of the primary annuitant or as we may later agree In writing. Unless we agree otherwise. the M3turity Date may be no earlier than the first polley anniversary nor later than the policy anniversary nearest the annuitant's S5th birthday. If a contingent annuitant becomes the annuitant as the result of death of the primary annuitant prtor to the Maturity Date. unless you and we agrcc otherwise, the Maturity Date wUl change to the polley anniversary nearest the contingent annultant's S5th birthday. Assllnmentll The provision entitled "Assignments" In Part 2 Is amended to delete the restrictions contained In the last two sentences of such provision. The rcvtscd provision shaU read as follows: We wUl not be considered to have notice of any assignment of an Interest In this polley unLU we receive the original or copy of the assignment at our Home Office. In no event will we be responsible for its vaUdlty. Ownershlp The provtslon entitled 'Who Is the Owner" In Pari 3 Is amended to read as follows: The owner Is the person named as owner In the application. unless later changed as provided In this polley. However. a husband and wife may be designated as Joint owners. In the event of such designation of Joint owners, upon death of the first of the JOint owners to die. ownership of this polley will vcst entirely In the survlvtngjolnt owner. The annuitant wUl be the owner If no other person Is named as owner. R665 1 AnDulty BeDeDw The last sentence of the first paragraph of Part. S Is amended to read as follows: Bow the Death BeneDt .. DetennlDed Any annuity payments falltng due after the annullant's death during thc period certain will be paid to the Annuitant's Beneficiary. The first paragraph of the provision entitled "How the Death Bencllt 18 Determined" In Part 9. including clauses A. and B.. 18 amended to read . as follows: Death of OWner. If the owner Is not the annuitant and dies prior to the Maturity Date, and there 18 no surviving Joint owner, upon our receipt of due proof of the owner's death. we will fully surrender th1s polley and pay the cash surrender value of this polley to the Owner's Beneficiary. The distribution of this payment must occur within 5 years of the death of the owner or. alternatively. occur over a period not extending beyond the life (or life expectaneyl of the Owner's Beneficiary. provided the distribution bcglns within 1 yeur of the owner's death. If the owner Is nol the annullant and dies on or after the Maturity Date. we wUl pay any remaining annuity payments to the Owner's Beneficiary under the payment option In effect on the owner's death. If the owner and the annuitant are the same. then the rules stated below for death of the annuitant shall apply. Death of Annuitant - If the annullant dies before the Maturity Date and there Is no surviving contingent annuitant. upon our rccclpt ofdue proof of the annuitant's death, we will pay to the Annuitant's Benc1lclary: For death occurring during the first 6.year period following the Polley Date. a death benefit equal to the greater of (1) the sum of all premium payments made under this polley less any prtor partJal wtthdrawals. or (21 the Accumulated Value of this Polley; For death occurring during any subsequent 6-year pcriod following the first. a death benc1lt equal to the greater of III the death benc1lt that would havc been payable at the end of the Immediately preceding 6.year period. plus any premtum payments made and less any partial wtthdrawals since such date, or (21 the Accumulated Value of this polley. If the annullant dies on or after the Maturity Date, except as may otherwise be provided under the terms of any supplementary contract between the owner and us refiectlng the terms of the payment option elected, we wUl pay to the Annuitant's BenefiCiary any annuity paymenls falling due during any period certain applicable under the payment option In elTect on the annuitant's death. The first sentence of the second paragraph of the provtslon entitled "How the Death Benefit Is Determined" Is amended to permit both Owner's and Annuitant's beneficiaries to elect among the Payment Options as follows: ROOS 2 .. The benenclary of any death benefit payable upon death 0' either. the owner or the annuitant may elect to apply such proceeds under any of the Payment Options descrIbed In Part 10. subject to the following limitations. Sub.tltute Annultaat The folloWIng new provlslon Is added at the end of Part 9: At any time prtor to death of the pnmary annuitant. you may designate or change the contingent annuitant by nUng with us at our Investment Products Dlvlslon a WrItten notice as to the name. date of birth. and address of the contingent annuitant. The provision entitled "Subsutute Annuitant" In Part 9 Is amended to read as follows: The Benellelary If the annuitant Is the owner and dies before the Maturtty Date and the Annuitant's Beneficiary Is the annullant's spouse. then In lieu of any of the above settlements, the Annultant's Benenclary may elect to continue this policy as the subslltute annullant and new owner as If no death had occurred. We shall have the rtght to nrst require return of the polley to us so that we may amend It to refiect this change. The provision entitled 'The Benenclary" In Part 9 Is amended to read as follows: The Annuitant's Benenclary shall be as stated In the appllcallon for this polley, unless later changed as provIded under the terms of this polley. Any death benent payable to the Annuitant's Beneficiary wUl be paid to the owner or the owner's estate If the Annuitant's Benenclary Is not llvtng when such death boneO! becomes payable. The Owner's BenenClary shall be as stated In the appllcallon for this policy, unless later changed as provlded under the terms of this polley. Any death beneO! payable to the Owner's Benenclary wUl be paid to the owner's estate If the Owner's Benc1lclary Is not living when such death bonc1lt becomes payable. Unless otherwise stated. the deslgnallon of an Annullant's Benenclary by fami1la1 relationship rather than by name shall be understood to refer to the relationshIp to the pnmary annullant as shown on the Schedule Page of the policy. LikeWise. the desIgnation of an Owner's Benenclary by familial relaUonshlp shall be understood to refer to the relationship to tlle primary annuitant. Bow to Chanle the Beaeflclary The provision entitled "How to Change the Benenclary" In Part 9 Is amended to read as follows: At any time prior to the earliest of death of the owner or death of the last of the annuitant's under this policy. you may change the Owner's BenefiCiary or the Annuitant's Benenclsry. The change must be made by WrItten notice signed by you and rued with us at our Investment Producls Division. When we receive It, the change wUl relate back and take effect as of the date It was signed by you. However the change wUl be subject to any payment made or actions taken by us before we received the notice at our Investment Products Division. R665 3 Option It. VUIIhIIl'QOat AIUlull7 ..or A BpeolAed Perlod I The following Payment Option K IS added as an avaUable 8ltemaUve payment opUon to Part 10 of the polley. ThIs option provides variable payout monthly Income tn&taUments for a speclfled pertod of time. whether the payee Uves or dies. The pertod certain speclfled must be in whole number. of years from 6 to 30. However. the pertod certain selected by the beneflctal)' of any death benefit under thJs polley may not extend beyond the Ufe cxpectaney of such benc1lclBry. Payments wW be made on the same basis as deacrtbed for variable Income payments under Option I. except that: t. paymenla will not extend beyond the spec1fled period. regardlCSII of whether the payee Uvea or dtcs: and 2. the mtnImum first payment will be based on the Assumed Interest Rate of 4-1/2% and the specified period (no annuity table wUl be used). Installment payments wW vary with the Investment experience of the sub-accounts of the separate account and may be eIther higher or lower than the first installment. Effect on other PoUeT ProYlaIODI Any provtslons contained In the polley relating to endorsement shall be deemed satisfied or waived as to this amendment. Phoenix Home lJ(e Mutual Insurance Company k.!L~ R66S . Registrar 4 . . VARIABLE ANNUITY AMENDMENT This amendment Is Issued as part of the policy Identified below. Pollc~' Number: Annuitant: The policy Is amended to Include a Guaranteed Interest Account among the sub-accounts to which premiums may be allocated or accumulaled value Iransferred. The Guaranteed Interest Account Is accounted for In our General Account and Is not part of the Separate Accounl. DeOnltlons As used In this rider. the following definitions shall apply: Adjusted Deposit - Any Deposit to the Guaranteed Interest Account. ns adjusted to Include any Interest credited on and any polley charlles or withdrawals deducted from such Deposll while held under such sub- account. Deposit - Any net premium or transferred amount applied to the Guaranteed Interest Accounl. Guaranteed Interest Account We will credit Interest dally on any amounts held under the Guaranteed Inlerest Accounl at such rates as we shall determine but In no event will the elTectlve annual rate of Interest be less than 4%. At leasl once n month. we will set the Interest rate that WIll apply to any Deposits made to the Guaranleed Interest Account. That rate will remain In effect for such Deposits. or their resulting Adjusted Deposits. for an Initial guarantee period of one full year. Upon expiry of the Initial one-year guarantee period. and each subsequent one-year guaranlee period thereaner, the rate applicable for any Deposits or Adjusted Deposlls whose guarantee period has just ended shall be the same rale thut applies to new Deposits made during the guarantee period. Such rate shall likewise remain In effect for such Adjusted Deposlls for a subsequent guarantee period of one full year. Not Premium Allocation The section entitled "Net Premium Allocation" Is amended to provide thut the value of the Guaranteed Interest Account will be accounted for In the form of Adjusted Deposlls and not Units. The amount deposited to the Guaranteed Interest Account as the result of a premium payment will equal the amount of any net premium applied on the Paymenl Date to that sub-account. Any Deposits credited to the Guaranteed Interest Account as the result of a premium payment will bear the same Payment Date as the net premium applied to create such Deposit. Interest Included as part of an Adjusted Deposit shall bear the same Payment Date as the Deposit. Transfe1'8 Amoni Sub-Accounts The section entitled 'Transfers among Sub-Accounts" Is amended to provide that you can make only one transfer per polley year from the Guaranteed Interest Account. Transfers from the Guaranteed Interest Account will be effectuated by us on the Valuation Date which the transfer request Is received by us. The amount that may be transferred from the Guaranteed Interest Account at anyone time cannot exceed the higher of $1000 or 25% of the value of this polley In such sub-account. R 717 I Any Units held under a sub-account of Ihe Separate Account or Adjusted Deposlls held under Ihe Guaranleed Interest Account as the result of any transfer shall bear the same Payment Date as the Unlls or Adjusted Deposlls released to elTectuale such transfer. WlthdrawaIa and Full Surrender The sectlon enlltled "Withdrawals and Full Surrender" Is amended to provtde that any portion of the accumulated value withdrawn from the Guaranteed Interest Account will be taken by the release of Adjusted Deposlls In the amount needed to elTectuate such withdrawal, Including any contlngent deferred sales charge applicable to such withdrawal. The pertod on which the contlngent deferred sales charge will be based. as regards any portion withdrawn from the Guaranteed Interest Account. will be measured from the Payment Dale of the Adjusted Deposit released to elTectuate such withdrawal. Rules and Llmltatlons The secllon entllled "Rules and Llmllatlons" Is amended to pr0\1de that the Adjusted Deposits released for transfer or withdrawal from the Guaranteed Inlerest Account will be determined on a LasHn. Flrst.Out (LIFO) basis based on the date the Deposit was Inlllally made to such sub-account. Delay Due To lmposslbWty The Secllon enlllled "Delay Due to Impossibility" Is amended to pro\1de that we may defer payment of a withdrawal from the Guaranteed Inlerest Account for up to six months from the date the request Is received by us. If payment Is delayed 30 days or more. we will add Inlerest at an annual rate of 4%. Effect on Other pollcy Provisions In determining the accumulated value or the policy. the value of the Guaranleed Interesl Account Is exprcssed In Adjusted Deposits and not Units. Any nct premium or Iransfers allocated to the Guaranteed Interest Accounl are used to credit Deposits to such sub-account and nol Units. The accumulaled value of the Guaranteed lnteresl Account equals the sum or the Adjusted Deposlls. Ir any. held under such sub. accounl. The total accumulaled value of the policy will Include the accumulated value of the Guaranteed Interest Account. In addltlon to lhe total value of all Units outstanding 10 the credit of this policy. The provisions com'emlng the Mortality and Expense Risk Charges and Investment Management Charge do not apply 10 Ihe Guaranteed Interest Account. Waiver of Endorsement Any pro\'lslons of the polley relating to endorsement shall be deemed satlsfied or wall'ed as to this amendmenl. Phoenix Mutual Life Insurance Company k- :!..~~ /', ( 1/ ~ , l~ _I (1 .~bv\...Wrl ~ . . R7,I'1 .. 2 " ~ TEMPLETON INVESTMENT PLUS ~ APPLICATION FOR FLEXIBLE PREMIUM VARIABLE DEFERRED ANNUITY CONTRACT TO THE PHOENIX MUTUAL LIFE INSURANCE COMPANY For Home Office Use Only: COnlrect Number I ^-t:" I '1 )-'7:(" Pleasa make check payable to Phoenlk Mutual Life. Send check and appllcallon to: Phoenlk Mutual Ule Insurance Company, Variable Products Operallons, 100 Bright Meadow Boulavard. P. O. BOk 1900. Enlleld. CT 06083.1900 PLUSH PRINT PART I. CONTRACT INFORMATION 1. Prim Annullant ma not be cor rallon or trust ......'___Lull J3Q.11" .::r. .stA lEX us. CITlZlN 81RTliDATI ^ _ I " _ 2.:z.. 141 AT LAST BIRTHDAV 71 Male F male Ves 0 No -,... .....IUPOA...~.._C/lr.cw.,.._n>~1 AI 1"11 rJ 17 AnI AL1.e!!d"l.. l...!)"'1J vAmp n, . r-A - 01/ 2. Conllngent Annuhant . ' HAUl',"" Ydl:N InIIIl.lMI) sa u.s. CITIZEN eIRTMDATE! Male 0 Female 0 Ves 0 No ADORESS FOR UA~No.. s...... or,. County, S,*I.. ZIP Code) AGE AT LAST 8lRTMDAY SOCIAl. SICU\ITY NUUlEA 3. Annullanrs Benefld~ PR.UAIlV /lll~~ /1 d .Y si:a.h.1:L.-J' ~. ... . =~~7=~:"~~;J::r ~~~::{;.'~' __......""'. _.n>~1 ~F~~ANT 1'/0// IRlLAT1ClNSHlP TO AHtUTAHT 4. ...... . e II o.vner Is other than P An....ilant as Pri Annultant wll be o.vner. Joint Ownersh allowed belWeM 0 s. a. NO.1 TAXPf\YER I.D. NO. AllOIU!-........""'._.n>Co<loI IJ.) _. :- :"J ;, '- Al~TO~AHT ,.:. ,.:;) I .' - I~~?,,~AHT ~. -:-:- 0 c. 1_ 6. Conlract Speclllcallons ., ~ , a' Initial Purchase Paymenl $ ~Q. oCJ D Minimum Inlllal purchase payment for Non Tak.Oualllled perliilnallnvestment plans ekcept Check'()'Matlc Is $1,000 ($25 for Tak Quallned, Employer Sponsored or Check.O.Matlc plans.) Subsequent payments muet $25 0 more. b. Remlndar Notlcae (BIlling) Requeeted 0 Ves 0 No (If yes, complele the Information balow) c. Subsequent purchase paymenls shall be lIeklble unless otherwise noled as follows: Monthly Check'().Matlc $ Monthly $ Quarterl $ Saml.Annual $ Annual S REWNOIR HCmCEalHamtJ ACDRUS (No.. sr-t. CIfy. 1&Me. ZIp CoOeI 5. Owne~s Benellcf PR.UAIlV Must be com leted when Owner Is other than the Annultanl AllOIU!__""'._.ZIpCo<loI CONT1NGENT ADDAES5(No... h'Mt. Cltr...... ~ CGdII d. Maturity Dale shall be the policy anniversary nearestlhe Annuitant's attalnmenl of age 85 for Non Tax.Quallfled Plans (age 70 1/2 lor Tax Quallfled Plans) unlssa earlier age noted as follows e. 0 Check here II $35 Annual Admlnlstrallve Charge Ie to be paid In cash. rather than deducted eutomatlcally from sub.eccount(s) on poll~ anniversary. I. Sub-Account AJlocatJon Instructions. Use lull %'a. Written authorization Is required to change an allocaUon schedule. III Templeton Aaael Allocation 33 y~ 0 Templeton Bond ,.. J{J Templeton Slock S' 0 Templeton Money Marl<at_% o Guarantaed Interest Account % HIT........, _'" 7. Plan Type 0 Tek.auallned Plan fComDlele Part 11.1 C8' Non Tax-ouallned oorsonsllnvestment Dlan e. 0 Please send me a Slalement 01 AddllIonel'nlormellon. 9. WlU the annuity applied for replsce any eklstlng Insurance or annuities? 0 Ves 0 No (II "yes., subml1lull details, Indudlng name of company, plan and amount, date Issued and reasons for replacement; also replacemen material If required.) If "yes" any purchase payment amounts will ba tamporarlly applied enllrely 10 the Templeton Money Marl<et sub-account until termlnallon c . the Right 10 Cancel period provided In the policy and then aulomatlcally reallocated to the above designated sub-account(s) If by the end c the Right to Cancel period Ihe policy has not been retumed to the company's Investmant Products Division lor a refund. -. ........ ...... " . ~ 10. Telephone Transler ~ Ves _ No lithe contract Owner checks the 'Ves" box. Phoenix Mut Is orlzed to honor telephone Instructions I,om the Owner to.transfer contract values among the sub.accounts. By Initialing this box. _ the Owner also gives the Registered Representative aUlhorily to Inlnsle, contract values among the sub.accounts. lithe contract Owner checks the 'No' box. only the Owner may authorize a transler. by sUbmllling a Change Authorization form to the Investmenl Products Division. Telephone Iransfers are subject to the terms and provisions In the Contract and Prospectus. Including the provision that Phoenix Mutual will not be liable lor any loss, Injury or damage Incurred as a result 01 acting upon. and nellher will it be responsible for the authentlclly 01. any telephone Instructions. Phoenix Mutual reserves the right to discontinue the Telephone Transler privilege at any time. but you will be notllled In writing at the address last on file with the Investmenl PrOducts Division. lithe privilege Is discontinued. Illhe Owner does nol check either the ..V.... or "No" box, it will be ..Iumad that the Owner II not Ilectlng the Telephone Trenller privilege. We will not revoke any authorization. unless the Owner lubmlls a requeat In wrlllng 10 the Investment PrOduct. Dlvlslonl. PART II. TAX-OUALIFIED PLAN INFORMATION 1. Individual Retirement Annully o Regular Contributory o Rollover FROM: TlIJC Vear to which contribution applies: :; Qualified Pension Plan o Transfer C Existing IRA o Simplified Employee Psn.ion . SEP nRA Complete IRS Form 5305 _ SEP The Annuitant, as proposed owner 01 the policy, acknowledges receipt of a current Phoenix Mutual IRA disclosure statement. 2. 0 TlIJC Shellered 403(b) Annuity NOTE: Tha employer must sign this application cerlllylng Ihat a salary reduction agreement Ie In place balWeen the sponsoring organization and the employee. this contraet Is designed lor salary reduction contributions only. No other Employer or Employee contributions may be made. Complete Forms PT 319H Statement by Employer. 3. 0 Corporate 0 Keogh 0 401 (K) 4. 0 Deferred Compensation Section 457 Plan NOTE: Complete Form PT 352 A. Panslon Trust Qualified Submission NOTE: Complete Form OL 1340 C Statement by Employer PART III. MISCELLANEOUS INSTRUCTIONS' COMMENTS Any policy Issued hereunder In the state 01 Missouri or Oklahoma shall be considered a Missouri or OlIlahoma contract respectively and lis terms, Including those concerning the receiving of Inlormetlon by the agent. shall be construed In accordance wilh the laws 01 the stete 01 Missouri or Oklahoma respeCllvely. PART IV. APPLICANT SIGNATURE AND CERTIFICATION On the date 01 this application, the Undersigned applicant paid to tha agent named hereunder $ on account 0' the premium for annuity applied for. I declare that the statements In the application ara true and complete to the best of my knowledge and bellel. I further agree that this appllcallon shall be the basis 01 and a part 01 the policy; thetthls appllcallon and policy will consUlule the enllre contract; thai a current prospectus discussing the policy and The Templeton Vartable Producte Series Fund has been received by me; that Ihe policy shall not take effect untlllte date of Issue; and that the agent laking this application has no authority to make, mOdify, alter. or discharge any contract hereby epplled for. Under penalty of pe~ury, I certify (1) that the number shown on this form Is my correct taxpayer :dentlficatlon number and (2) that I am not subject to backup withholding either because I have no been noUlled by the Internal Revenue Service (IRS) thai I am subject to backup withholding as a result 01 a failure 10 reporl alllnteresl or dividends. or the IRS has noUfied me thaI I am no longer subject to backup wllhholdlng. II you have been noUlled by 100 IRS that you are currenlly subject to backup wllhholdlng, strike out phrase (2) above and Inltlallhe deletion. THE ACCUMULATED VALUE AND CONTRACTUAL PAYMENTS OF THE PDLlCV APPLIED FOR WILL BE BASED ON THE INVESTMENT EXPERIENCE OF THE APPLICABLE SUB.ACCOUNTS. EXCEPT FOR THE GUARANTEED INTEREST ACCOUNT. THIS VALUE IS VARIABLE AND IS NOT GUARANTEED AS TO FIXEO i~~~:~ ~a?!:J1t~~!i~~~ W1ll1ESS IAoeNTl this /_~ day al::r"'u~A ~'<{ J9?~ SIGNATURe OF OWNER IIF OTHeR THAN PRIMARY ANNUITANT) SIGNATURE OF APPLICANT 19 OTHER nuN OWNER PART V. AGENT'S STATEMENT Thle replacement Is meant to be a tax-Iree exchange under Section 1035. 0 Ves ~ No Will this contract replace any eXIsUng Insurance or annuity? 0 Ves Qr No (If "Yee", please give partlculll1l below) Thl! ~ent herebY. certifies that he 'she hll5 truly and accuratelv recorded on the appllcaUon the Information supplied by the proposed annullant: and tha e 'she Is qualified and authortzed to diseuse the contiact herein applied fdr. I - I :3 . .,~ eNTS SlGNATUA OATe N'JlHT, DROKaR NAIll AHa I. D. NO. (Pttue Pnrt FuI NMw) 1t IACKI" D!Al.ER HAMI AND ADDRESS klJj"rl ~. MA6/~pd 71!J'17/ 1N~~e AGENCY'S NAMe AND AODAl!SI (I'''' ....n atJow_1 "lTt:J~!f..1 ~d~ -+- C!.ll "AHaH ""'",e "UIANO ~l'.J'!.,,' ... ml'M'-"M.P ~.IOt:t"'.r.-/4... . . . REV-Iat t EX. (1-11) SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELlANEOUS EXPENSES Pl.... Prlnt ar Type FlU! NUMBER 21-1995-0788 . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT OECEDENT I!8TATE OF Bett J. Stahle ITEM NO. A. FunoraJ Expanaaa: DESCRIPTION AMOUNT 1 Parthenore F\lneral Hare, Inc. -- funeral expense 2 Receptioo following merrorial service 3 Rolling Green Cemetery - - p.u:chase of ll'ausoleum Portion of Expense Paid After Death 2,67S.11 208.61 2,157.00 B. Admlnlalra1lv. Coata: 1. Poraanal R.p......nllllve Commlsslan. Social Secu~1y Number ar Pel1lDnal R.present.lIve: Year Commission. paid 0.00 2. Anarney F_ 12,940.00 3,500.00 3. Famly Exell1lllon C1Il1mantHazolld J. stahle. Jr. Rel.lIon.hlpHusband Address ar Claimant al deee~enr. de.lh streetAddress 401 Allendale Way C11y 0lIlp Hill state PA ZIp Code 17011-S407 4. Problte F_ 375.00 C. Mlac.""n..u"l!xplIn...: 1 OJmberland O:lunty Register of Wills - Sh:>rt Certificates, JCP Fee and C11arge of Extra Pages 2 OJmberland O:lunty Law Jouznal - Lega11\dvertisarent 3 'lhe Sentinel - Lega11\dvertisarent 4 Freeman Real FBtate - Awraisal Fee 5 OJmberland O:lunty Register of Wills - Filing Fee for Inventozy of Real and Personal Estate and for the Pennsylvania Inheritance Tax Retum 29.00 40.00 58.76 275.00 25.00 TOTAL AI.. enlor an line D. R nulallon S (II ma,. _.. II nMded, Inaarl.ddlUanal ah..ta of oem. ....., 22 286.48 PAlaU1 NT' 11.. COPvrJOhl Form. Bonwarl Only, 1014 N.lco,lnCo N14PA1t 1 ~.:._ ~~'_<'~-""~';'NH:<-'< .:~~,~~~f:c?r~;1(;., REV:"" EX. (1-17) . COMMONWEALTH OF PENNSYLVANIA INIWIITAHCl! TAlC RET\IRN RESIDENT DeCl!Dl!HT E8TA're OF SCHEDULE J BENEFICIARIES FlU! NUMBER Bet ITI!M NO. J. Stahle NAMI! AND ADORESB OF BENEFICIARY Rl!LAllOHSHIP 21-1995-0788 AMOUNT OR BIWII! OF EBTA're A. T...bIe Bequ8l1l: See Schedule attached ITI!M NO. NAMI! AND ADORI!8B OF Bl!NI!FICIARY AMOUNT OR lIHARl! OF I!STA're B. Chll1table IIIld Govllnmontal Bequ8l1l: None TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS AlIO enl8r on lna 13 R la1Ion (If more 1plI08 Ie ..-. IIlHIt eddIIIonal_ olllllll8 ...., . 0.00 PAtSt3t NT' mOll Cap)'ftght 'onll.lo'twu.OnIy. ,.... N.Ico, tne. N14PA1J1 REV-1llolD EX. (BIDe) . . SCHEDULE 0 mANSFERS TO SURVIVING SPOUSE COMMONWEALTH OF PENN8YLVANIA INHERITANCE TAX RETURN RESIDIEHT DECEDENT ESTATl! OF FlI. Number Betty J. Stahle 21-1995-0788 PART A: En1er the deecttpllon .nd valu. 01 111 Inl.....I8. bolh IIll.bIe .nd non-tu.bIe, n>glldlllsl 01 1De.1Ion, (net 01 daductlolll) which pili to \he dec:8denr. aurvMng apoUIO by will, Inlll1l1C'f, oper.lIon 01 law, or otherwlM. 0IIcr1 lion 01 I1amI Amount 1 See Schedule attached Pill A TolII: Enl"'lll1Ount .hown on lha 1tu1.lIon .hoet In tho ~llnlonnaUon _on. 574 831.69 Election To Subject Property To Tex Under Section 2113(A) As A Taxable Transfer By This Decedent If. trust oralrrMlllITangemonl ",,",II the roqull1llllOnl8 01 SOctlon 2113(1.). and: a. Tho trust or a1m1lllllTangemont I. noted on SChadule 0, and b. Tho valu. 01 the trust or a1nilllllTangemont Is .nl.red In whale or In pill as an ...11I on Sch.dule 0, th.n the lranolOlO(. p.....nal ropreoenl.dve may .peclncaUy Idonllfy Ih.lnlS1 (111 or .lrllCtlonal ponlon or porcenlago) to be Included In the olllCtlon 10 hava ouch truS\ or oImI1ll property Ireal.d as a laxabl.lranafor In this BS\.t.. If loss Ihan tho .nllr. valu. 01 \he 1nlS\ or BInilIl property Is Included as a tlllabl.lr.n.'... on SChodule 0, tho penlOnal ropr...nl.lIv. .hlll be conafdorod to h.v. made the oIoctIon only II to a Iroctlon 01 tho truS\ or .1mII1lIITang.mont. Tho nu",",alor ollhl.lreedon Is .quallo lhe lll10unt ollh. tru.t or olrrMlllITangmonllnclUd.d II a tllloble IIIOt on SChadule O. Tho denomln.lor I. .quallo tho 10lal valu. 01 the tru.t or .lnilllllT.ngemonL ELECTION: Do you elect under SacUon 2113(1.) to Ir..la. a taxabl. \ran.I.r In \hI. ..tata alf or a porUon ola tru.lor .Imllar arrangemenl o....tad tor \h. .01. UM 01 thl. _nl'a aurvlvlng apou.. during \h. .urvlvlng opou.... .nU.. IIf.Um.? YES D NO [1!!] Slgn.tura 0.1. Nota: .f the election applln to more than one trult or similar arrangemlnt. then. Iepllrate form mUlt be sIgned and tiled. Part B: Enler the dooa1pllon .nd valu. 01 oIllntor...., both IIll.bIB and non-tlll.bIe. roglldloss olloc.lIon, (n.t 01 d.duc1lono) which pUllo the dec:8denr.aurvMng OPOUIO lor which a SOCIIon 2113 (A) oIoctIon I. being mad.. o 1 lion 01 horns Amount None PIllBTolII 0.00 PAlMI! NT' '021 Cop)'rlaht For",. Soft.at. Oflly, 11111 H.lco.lne. N.IPA411 . . Page 2 21-1995-0788 Estate of I Betty J. Stahle samooIE 0, PARI' A -- Transfers to SUrviving Spouse Item No. Descriptien J\no.m.t 1 Residue of Estate Calculatien : Gross Estate fran line 1 of FoIlll 706 $1,123,062.54 less: Schedule E - Joint J\ssets $ 509,025.37 Deductions on Schedule J 5,043 .72 Deducitions Taken en Fbrm 1041 14,161.76 specific Bequests 20,000.00 508,300.69 Schedule I Assets 614,761.85 66,531.00 Total Residue $ 508,300.69 2 Item 1 en Schedule G 66,531.00 'IOmL. (Carry forward to main schedule) . . . . . . 574,831.69 " . , /5-(".,), .F REV-1547 EX AFP (12-95)*, ' COMMONWEALTH Of PENNSYLVANIA ~~'RTHEHT OF REVENUE aURLAU OF INDIVIDUAL 'AMES DEPT. 28D6Dl HARRISBURG, Pi 17128-0601 ACN 101 NOTICE OF INNERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 10-07-96 STATE OF FILE NO. DATE OF DEATH 09-02-95 COUNTY CUMBERLAND NOTE. TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS FORM WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS. MAKE CHECK PAYABLE TO "REGISTER OF WILLS, AGENT" REMIT PAVMENT TO: RICHARD R LEFEVER MCNEES ETAL PO BOX 1166 HBG PA 17108 REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE. PA 17013 Allount Ra..lU.d CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv=is4"'i"ix-Aj:ji-rri:9sT"iii:ii"ici--oF-YNHiifii'iiNc'E"'i"liit"iiPPRiiisiHE'iir-;-ALi."owiiNcE-iili---m--m------ DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX BETTV J FILE NO. 21 95-0788 ACN 101 TAX RETURN WAS. I ACCEPTED AS FILED Xl CHANGED SEE ESTATE OF STAHLE DATE ATTACHED 10-07-96 NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. R..l Eat.i. (Schedul. A) (1) 2. stock. ~d Bond. (Schedule BJ (2) 5. Clo..ly Hald stock/Partner.hlp Int.r.at (Schedule C) (3) 4. Hartg.gel/Not.. Receivable (Schedule OJ (4) 5. Cash/Bank Dapollt./Hllc. Parlonal Property (Schedul. E) (5) 6. Jolntl~ Owned Propert~ ISchedul. Fl (6) 7."fran.fara (Schedule OJ (7) a. Total A...t. .00 542,012.93 .00 .00 5.493.24 .00 66.531. 00 leI 614,037.17 APPROVED DEDUCTIONS AND EXEHPTIONS: 9. Fun.ral Expan.../Ad.. COltl/HiIC. EMpan... (Schedule HI (9) 10. Dabt./Hortgaga ~labl1ltie./Llan. (Schadula I) (10) 11. Total Daductlon. 12. Hat Value of TeM Raturn 1S. Charit.ble/Oovarnnantal Oaqua.t. (Schadula J) 14. Hat Value of e.t.ta Subjact to Tax 22.286.48 .00 Ill) C121 CISl U41 ???R~ 7R 591.750.69 .00 591,750.69 If an assessment was issued previouslY, lines reflect figures that include the total of ~ ASSESSHENT OF TAX: 15. A~ount of Lin. 14 .t Spou.al rata (IS) 16. AMount of Lin. 14 taxabla at Lina.I/CI... A rat. (16) 17. AMount of Lina 14 taxabla .t Coll.taral/CI... Brat. (17) 18. Principal TaM Du. 14, 15 and/or 16, 17 and 18 will returns assessed to date. NOTE: 571.750.69 X .00. .00 X .06. 20.000.00 X .15. ue) .00 .00 3.000.00 3.000.00 TAX CREDITS: PAYMENT DATE 06-18-96 DISCOUNT C_I INTEREST (-I 11. 86- RECEIPT NUltBER AA112944 AMOUNT PAID 3.000.00 INTEREST IS CHARGED FROM 06-19-96 TO 10-15-96 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 2.988.14 11.86 .35 12.21 . IF PAID AFTER OATE INOICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN fl. NO PAYMENT IS REQUIREO. IF TOTAL OUE IS REFLECTED AS A "CREon" ICRI, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I . c..-- N (; R " c , r.....' c:~ '<T I t; ',.:1 :' I ..) illU. :; Ct: . 1'" ,~ UU PURPOSE OF NOTlCEI To fulfill the r.quln..nt. 0' hcUon tlU Cb) of the Inh.rltlll\C' Md [I.... ,.. "ct, Act II. of 1"1. 112 P.I. SecUon !l4S). PAYHEHT I D.tach tM top portion of this Holln end ,utMllt with vour p,v..nt to the R.aht., of Willi printed on the nv.tI. lid.. u "aka check Dr ~v ordu p.yabl. tal REGISTER OF HILU, AOEHT. All ,Iynnt. r.c.lved .h.ll b. appli.d first to MY Int.r..t which 'IV b. due with MY n..lnd.,. applltd to the t.l. REFUND ICA)I A ,..fund of It.. cr.dlt "V be r.qua.t.d by CGa91.tlnt ~ -Application 'or R.fund of Ptnn'vlv~l. InMrlt.nc. Md bl.t. r.... (RfY-un). AppllnUont .t. .v.lllbl. .t tM Dfflu of the A....'.r of WUh. any of tM 21 R.y~ DI.trlct Dfflc.. or fro. tM Dep.rt.~t'. Z4-hour an....rlng ..rvle. ~.r' 'or lor.. orderlntl In P~.ylvlnl. l-aaO-'6Z-ZDSO, out.ld. PInn,vlv,"l, end within loc.1 H.rrl.bUrg .r.. (717) ,a'-la9., TDDI (717) 7n-Un CHa.rlne 11III.lrad Only). OBJECTIONSI Anv p.rtv In Int.r..t not ..tl.,I.d with the ........nt of t.. ., .hown on thl. notlc. .'W Dbjact wIthin .I.tv (60) daVia' rlcalpt of thl. Hotlc. bVI uwrlU.., prot..t to thl P' Dep.rt.."t 0' Anenue, Bo.rd of Appe.ls, D.,t. 281011, "rrhburg, P' 17ua-url, OR --ellctlng to haY' the ..tt.r d.t.r.ln.d .t eudlt 0' thl per.on.1 repr..ent.tlve, OR --appell to the Orphan.- Court. ADHIH- ISlA.nVE CORREcnOHSI Factu.1 .rror. dl.cov.rad on thl. .......lnt .hould b. .ddre..1d In ..rltlng tal P' Departlent of R.venue, BurelU 0' Individual Tau., ATTNI Po.t A.......nt Ani... Unit, DlPt. 280601, Hsrrhbur., P' 17121'0601, Phone (17) 787-6505. S.e p.g. S of the bookl.t "In.tructlon. for IntMrlt....c. T.. R.turn for I Ruld",t O.cedent.. (REV-ISOlJ for en I.planatlon of acbIlnhtratlv.h corractabl. Irrort. PENAL TVI TM 1511: t.. ......tv non-p.rtlolpatlon p.n.ltv It cll~t.d on the tohl of thl taM and Int.rnt .......d, Ilnd not p.ld bafor. Janulrv 18, 1996, the flr.t dlv I,t.r the .nd of the tl. .-n..tv plrlod. Thl. non-p.rtlclp.tlon penaltv I. app..labl. In the .... .ann.r end In the the .... tl.. p.rlad .. you would .pp..1 tha tl. and Inter..t thlt h.. b.en .......d .. Indlc.t.d on this notice. INTEREST I For dat.. of de.th on or eft.r 10-S-91, pann.vlvanl. E.tet. Ta. ba..d on the fed.ral E.t.t. l.. r.turn bleoa.. d.llnquant .t th. ..plratlon of nlna (0') .onth. 'r~ the data 0' d..th. For data. 0' death prior to 10-S091, Pann'Ylvanl. t.t.tl 'I. b...d on the Fld.rll f.tat. 'I. raturn beeOH. d.lInquent .t thl I.plratlon of .Ight.ln (la) ""th. fro. th. dlt. of dnth. la... which b.c... d.llnqu.nt b.for. Janu.rv 1, l,ar b.ar Int.r..t .t the tet. of .1. C6~) p.tcant p.r ~ c.lculat.d .t . delly t.tl of .0001'4. All tl..' which blc.a. d.llnqu.nt on or .ft.r Janu.ry 1, 1'1' will b..t Int.r..t at I r.t. which will v.ry 'ro. cllend.r y..r to callnd.r y..r with th.t r.ta announc.d by th. p. O.p.rt_ant of R.venue. Thl .ppllcabl. Intlr..t rat.. for 1912 through 1996 ar.l YI.r Int.r..t Rat. Ualh Int"..t F.ctar Y..r Int.r..t R.t. U.lly Inten.t Fector 1982 ..X .000541 1987 'X .000247 1985 lOX .OOOUI 198a-I991 llX .000301 19a. llX .ODOSOI 1992 'X .000U7 1985 UX .000356 1993-19'M 7X .000191 I... lOX .000274 1995-1996 .X .000247 --Int.r..t I. cllcul.tld .. follo"'1 INTEREST. BALANCE OF TAX UNPAID X HUNBER OF DAYB DELINQUENT X DAILY INTEREST FACTOR --Any Notice luuact .fler the tl. blco_., delinquent will r.fI.ct an Int.r..t c.lcul.tion to flft.." US) d.va b.yond thl d.t. of the ......-.nt. If p.y.ant I. .Id. aftlr the Int.r..t coaputltlon dlt. ahawn on the Hotlel, additional lnt.r..t au.t be c.lcul.ted. -.. -'. ~-- .'"'--- .-~... ",,"""1"" " *' INHERITANCE TAX EXPLANATION OF CHANGES . COMMONWEAltH Of PENNSYlVANIA DEPARTMENT Of REVENUE .UR....U OP INDIVIDUAL TAXIS DEPT. 210601 HARRISBURG, PA 17121.Q601 AM fiLE NUMIER AtN 5CHIDULI ITlM NO. EXPLANATION OF CHANGES H ~ ThlLvalue .of...the..estate. baa.. beeD~ adjusted_aa_the. .reault__of_the..correction--- of an error in arithmetic. ".~- .. - - ...__._~. --.--...-.. .~. .... _.'-~ .... +-- --.-.--... - - --_.~ ---~_. ....-......- -.".., .~.~ ... ~~,,-_.._- -- "-_.__...-.-,-----~._..- - --------..------ _i... +__..'__.+__~._.__...._~_.. ___......~.~.____.".".. ._.__...___.__" _..._.__ ----.".". ..-.------~-, --.-. ...~. .____..._._"_ri.~".--'~---"-----'-'-_..' ---.~-.- r_,"'" _,..__ ~_..p",__.__,_~_._,_"4_ --.---.---.-.~--~-. -- . .'~'.'''.'-'---' ---- .----.--~ -., .._-.~ p- ..". ...--.- --,",-'~ --,,_....-..-_._~---~._. --- - -..-- _.....-.- +.~_4'_.__~____ __...-.__.__~._.__.__--'_ ~.~~.~..._- - _~_m+__'____'~ .p' ..~---.-, _......-....~.. ~_._-~-_.----- ----.--..,..--- - -..'---. ,_._...._,___....~.-...._--~-.----_..--~-.,.......-._-~........-~._._-~_,....________.~......__..___....,......__..,M ---.---.... _.~'.~ ..~....__.-_..._---"" ,~,__,,,,~_,,,,____~,,_,,,,___,,,_-------:-~_w__~"'___'_'_______~_'____---------"""'--------~__._w_..~_.____.__ .-~ ) .;:. . . ..' . ..... .... .' '.' . .-.. ._".._____.......-....-......---'-.....--c---.....-..~.--~~..."'----. ...~.__~__.c.___,___--._......-.--~.--.-:--~---~.._.---...~-~ -_......-_....__...--~. _.......-----~......._...---_."---.~_......_..- ---_...~_..._.....-.~-,....---"'-~.._...-..----_..~:....- . , .'. -- ' .,---_~~___________....__---.-_.------~--_.- ...._~~... __ __......__.~,,. ~__.-______........-~-,.....--:-----_.-----------_.~_.o ~ _..... _._.._._~~_~.-._~_.~._----'.._....~._-...-".-w,-;,.~ .~.._~___~__ -,--~~----.--_.....,;.."...--"-~..........- ----------..,...---.------'--..- --..-~---.-- .~.__.p---_._----------.~-_....- _..-,---~--_.._--~_.._._.._- -,,-_._----_.__._~..._..~--,-_.._.------------~._~.~ .._-----" .~_ ~._._...__.<."._..___.._._ .c,~._~"'..___~.. ~_' ",___~..__.'.' _..w_. -.- .....- --.---- . .- --~---.,...--------...~..--.--~~.-------.-----~......~-. .J .'''__. _.._.'" ..... _. ~._.-o.__ ~...__... _c ,.. ......... ..."n.'.' >_ _'. __",' ,.--_...__.._ ..,....."... w....~ --..-..-,....."." ..'" __ __,,~.~_...~ _-0'-_.0--- ~.-----_.~.~. "~..~-- --_...... ...-.--.----.- .,-....-...".. ".~.__.. ,---~..._-~.~.... ,.,-....-.-" ___~.._ _________.._ ___. ..._~..~" __~ _+ _____. _,~_... ...___~ .'V .....w....___.__y.__ n____ ..----.--. ---.-.--"-' ~-------_..--..-_._-- ..-"-" ~ .~._- >~ ~.._._---_.-_. ~.~ ~_.~--..- -~ --.-,......-..-----" - ... _.-~--~--"...~~~'_. ,.__.__..-._.~_._----------._~---------_._-~- -.. ---_.-~--_.~.. ._-_._~.. . _ ._._~__..,~_..__._~>_~ '~'_'".""~' .._~..,~~___,-__ ...,;u~..,.___....__~_,.._.. ~~----~-----,~~-~-------.-._----- - .-- _. ~J" ,,+_~ ...v_..~__~_.___ --.-----,.,~ '<-'" ,,..~,_.~._._'~A"" _.__~~....~."...____.' ~ ---...--~..-~..-..-.----.,--.. .--- - , __~___...~., __,," ~., _ _.___.~_..._.._.___... _._~._._ ~_ _.._._...~.""-+ .._ <~.'''' ~.___."..~."_ ..____...., _ . ..__---'.>>W..__ ,_",~_'__'_ ~._._.___.4._P____ --....-.-" ..." " _.._..,... .._,__",~ ,.,..__.^._~"...~.. _" _.+". A,__ __....._.____ - ,...-..~.-~-".~-.. ~_.-..-_..-....-.-..---~ TAX EXAMINER, Shpf 1 n Mpg-nnnpll PAGE /S~~,i .f? BUREAU OF INOIVIOUAL TAXES INHERITANCE TAX DIVISION DEPT. ZlO6U HARRISIURG, Pi 17121.0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER & - an.,.. n '" CU.NI RICHARD R LEFEVER MCNEES ETAL PO BOX 1166 HBG PA 17108 DA', 0:. ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-03-97 STAHLE 09-21-95 21 95-0788 CUMBERLAND 202 A.ount R..! tied J BETTY MAKE CHECK PAYABLE AND REMIT PAYMENT TOI REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 HOTEl To 1n8\l.... p......r cNdlt to your accOU'\t, aubIIlt the upper portion of thla fONl with your tax pe)'ltM1t. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR FILES ~ REV:'iirEX--AFP"Tiz:'-96r--"-iii"Niifii:i'-iii:-IiETERii'iifAf'iiiti-liifli-lissEsiiHENT---------------------------- OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER .. ESTATE OF STAHLE BETTY J FILE NO.21 95-0788 ACN 202 ESTATE TAX DETERMINATION DATE 03-03-97 1. Cr.dit For Stet. D.eth Tex.. e. V.rifi.d .00 2. P.nn.ylvenie Inh.ritenc. Tex A......d (Excluding Di.count end/or Int.r..t) 3.000.00 3. .00 Inh.ritenc. Tex A......d by Oth.r stet.. or T.rritori.. of the Unit.d Stet.. (Excluding Di.count end/or Int.r.st) 4. Totel Inh.ritenc. Tex A...ss.d 3.000.00 5. P.nn.ylvenie E.tete Tex Du. .00 6. Amount of Penn.ylvenie Estete Tex Previously Ass....d Besed on F.d.rel E.tate Tex R.turn .00 7. .00 Additionel P.nn.ylvanie E.tat. Tex Du. TAX CREDITS 1 PAYMENT DATE ECEIPT UMBIijl '" DISCOUNT (+) INTEREST (-) AMOUNT PAID r, o '" 0 " ~-: ":1 J <=> ~ , , "" ,-'" . :':'-: . ,.... ~ 6 ~ 0\ 5 TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 _IF PAID AFTER THIS DATE. SEE REVERSE SIDE IIF TOTAL DUE IS LESS THAN .1. NO PAYHENT IS REQUIRED FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTEO AS A "CREOn" CCRI. YOU HAY 8! OUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)