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Home My WebLink About96-00210 ~: '. ~, ; :' '.^.. >", " ".'/ ','. :""" '.J >,:1"'1 .," "...:~.l '.- '-! it' ~. - " '1 .,,,._'!."- ~ Register of Wills of Cumberland County, Pennsylvania Estate of SALLY H, GREEN PETITION FOR GRANT OF LETTERS No. ~/.q/p.J.IO Deceased Social Security No, 214-30-0613 poUU_r, who 10 leyoorool ego or older, oppIleo for: lCOUPLETE'A'OR 'Bo BELOW:) I:i A, Probate and Grant of Letters and avers that Petilloner Is the Executor named In the Last Will of the Decedent. dated January 31.1991. Excoplas loIlC7NI, Decodenl did nol many, woa nol divorced. end did nol have 0 chlld bom or odoplod allor oxocullon of tho doctJmonlo offored for probelo: was nol tho v1cUm ola killing end was novor adludlcatod Incompolont: N/A ~ B, Grant of Letters of Adminlstretion N/A (d,b.n_c.t.a.: pendente 1110: durante absentia: duranta m1norlloto) Petitioner. efter e proper search, has ascertained that Decedent left no Will and was survived by the following spouse (If any) and heirs: NI A I Name Relationship Re.ldence Decedent was domiciled at death in Cumberland County. Pennsylvania, with her last family or principal residence at 6 Greensprlng Lane, Sliver Spring Township. Mechanlcsburg, Cumberland County, Pennsylvania Decedent. then Sixty-siX(66)years of age. died February 23. 1996. at Harrisburg Hospital. Harrisburg. Pennsylvania Decodenl al death owned property with o.Umated value. aslollC7Nl: llfdomlclled In PAl A1lperoonal property ......,.......,....,.,............. $110.000.00 (II nol domIclled In PAl Peroonal property In Pennsylvania. . . . . . . . . . . . . . . , . . . . . . . . . .. $ (lfnol domIcllod In PAl Poroonal property In County ................,.............. $ Value ol roalaalololn Ponnsylvanla ..............,................,......................,...... $100.000,00 Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . , . .,. . . , . , . . . , , . , . . . . . . . . . . . . , . . . . . . , . . . , $ 210,000,00 Real Ealolo altualod as lollC7Nl: 6 Greon.pring Lane. Sllvar Spring Twp. Mechanlcsburg, Cumborlend County, PA ,.. $ 100,000,00 Wharefore. poUU_rla) reapectlully reque.t(a) tho probato 01 tho loal WiIl end Codlcll(a) preaontod with thla PetlUon end tho granl ollettore In tho eppropriato form 10 tho unclorelgnod: Typed or prlntod name end realdence 1 Mounlalnvtew Driva Mochanlcsburg, Pennsylvania 17055 /f-9{J-/ This i. 10 certify dUll Ihe inforln.lIillU hl'Il' H"'rn i!lo (lltrt'ld} fUplld hOI1l .111 oriHin.11 (l'rllfiu(l' of dr.nh (11I1y filed wilh me .IS Local Rcy:islrar. The origil\lll L'l'rtifililll' will hl' forwanll'tllll 1Ill" Sr,lIl' Vil.11 HI"lIJJlI~ Oflkl' for 1lt..'nnillll'11t filinH. WARNING: 1111 11I8gello dupllcalo this copy by phololtet or photograph, ,,<.., (or .hi, {cllific,II<', $2,00 __hl...Jh.tL'LL- OJ,. ___(k.\ ~_",~_llIktJ I:,~~ti\cxi,;~-r-~ 3433401 No. HI."',," N' COMWONWI!ALTII Of PfNHSYLWANlA. OEPARTMENT Of HEALTH. VITAL RICORDI CERTIFICATE OF DEATH "....., . -. 1UOl_ I. ...._~.. ,...-..-. II. tQCloIIl...u..n........ a. Fellah .. 214 - 30 - 0613 "JlCt06D1MIlu.. "':-[9"".~O 00.0 ~l F.b .. Henneaay -. - - Creon .... . ,.......1..._. Harrisburg Oau bJn _1014' .__ ---- 11=:1" --,..-- None pr nl ... ..-:~....=::r Seoretary Insuranoe QU:IOIIIIT.IMUIOMIDM........ ~...,.~ f Greenapring Dr, ~ weohanlosburl. PA 170~~ .......,........... Ray.ond HenneDIY .'. , Penney van a .or I,.!J___- ,~ .. - M" CUDber1and -.' ,,,0::"-==.. """\ilr:rr~iJ "01'upp.-r- , '.0'1::.'1:10. u~ ......._...0 ,gar at aza Way. Mechanio.bure. PA 170Dft 1"-: _II . ...- 01. II ~ .~,~ohn'a Co.etery 1I..pd.. Tlrp,. PA .oo . 011667 L 3 ~(~_""''''"'''---''''''''' ~ J) -t I=- 1--- ""0 ClINI..-_........_ W _.--.....-.._...."""'4 . ., 7;:31 P . .........._.-...-__.._ ..,_.._fA..... .. ........--..-.. j\.LVnuh~L_ f~"buL'SL\' : '1ie.f'~~u, b/leC/.o~ C-~"Ull.. I Cdto........,Uf'.tlMHrTul .-Q"jUiOiiliCiHIl;:i,ilul II _ ____ -- - . .IoU ~ ~1Il>>ClUfll ........MClflIO .'OICPt:AlA4I ...., _0 ..'" .- .........-- ONIIJI""" ...-, .....CP-.fI, .....,.__, tlI -...... - ~ rJ IJ c-"...._ rJ ~.-o;itiii,-:iI"';;;-_"_I.diii""!!- *-t'OOiiii'"rior- -...."...... ~ -" * - CIIfII'.,.."....__ ,....~n"l:.r.."J... ~;;JJ 'c&Il,."...~,.,...._.........._~__.t.."".",,""''''''''''.I__'__''''. .....................____.."'..........__..___ . .' ..... lJ '. CO "C '. -...."'Oc:..lf....""IltUII.................~OOIlI...._......."-..,_~..... 0 13 t.,..8' L III '2..Z'l"- it .....................__...._._ .........__......_..__.._ 1.1 ~ ;;;~":rtMiiiI~,i;; ;'F A nc. [J '3.,,1. ,fl,,,,b LC: Itj} .. -. "" rJ 11 - _ [J ...rJ -- -- .--- _0 ..0 .... 8 I 'IIIIOCAI. ........MC*OMII 01..........._..._..........._............-......100.&...........-.-......,..................'''''"'...... _M..............................".....-............ . .............-................-... ... I.Dtyo,o..o.,-. f.4 , '70/1 Ll.JLulIU61 .. 2l-96~2l0 ~ () Vi :u c. 7f.{') c\ do. " ~ ~ R:; -' ^ 1 '- 0\ - , ~- -" J f,J .~F ~..... :;;t < (!1 ~~ ~-' Ul .-J._ - - - - - -- - - - - - -- ~-,- --- -- .._- --- ~- .--- .- 1 I I I 1 1 1 I , I 1 I I I I I I I I I l I J ) , 1 1 l-ICllOHlu ) 1 J I I I I. 1 J I I I I I ( I I 1 REMARKS RICHARED F GREEN ~, SEAL C/O JEFFREY R BOSWELL ESQ (, " (' 7'" CHECK" 109 RECEIVEDBYI /11"1'. ,~' .,1 ,/ "hV 'I IIONAlUll 'f- , I /1'1 i REGISTER OF WILLS ~~~iS~ERL15~'I~ILL~ '/N "" ' I" '-7__._______ - - - - - -- - - -- - - -,. - - - -- -~--- -' - - - ... ..., .- '. , ~ , :l"~, ',-":~...'"'''"';,..:.----T~,~.'~.-..~'. '_f," '.'-' _: ," .",-, ',-~, '-""--,.'_"'-.. 'r:,': ,:-c,-, _.' ','''',"",'1--',', :r, "-:r'..,"'..,.,, l}/'/;i,'_';'.\'I,('m~",;",,_:.Ji'~~;O"";';P~'I"N;~'''' '~~'~~I' ;A;:i;';~>~f[;;'i,\;Y:'i"; #l\UUft ..n. r NSY.y",". "f"-'''',I'''<' ~",~~"" '-~J~i''''~'''''' "'l'" ",."." "",,,,,.,' ... .. j~f,~. \~~" "0' '1VINU.~}:':"';;;.:~t-'f.Ut~-If>~'/.'--.;:~1;:..;t0;;'; "t d"'Prfi~iNNm~' '~'INHWrANCi~ifisfm'AX\ ,_,'"'.,_" ....' ,.'. .,,,,~}f.,.. '..", ,',^'-"" ,. '" ., -,., ",., . ."" ." ,',', .. """,.', '.- ,-'.-, ,-' - .'-,'-- , ACN ASSESSMENT P:' CONTROL ~ NUMBER AMOUNT RECEIVED fROM. & JEFFREY R BOSWELL ESQUIRE 31~ N FRONT STREET POBOX 741 HARRISBURG, PA 17109-0741 Iv1 .11,/1"1.1'+ ESTAT! INfORMATION: !II ILE UMIER iii e1-1996-0210 !I NAME Of DECEDENT (LA$1l 51 GREEN SALLY H II DA1 f 'AYMENl SSN 214-30-0613 (flRSll (MI) m TOTAL AMOUNT PAID , ' , r .11,717.14 VZ , . , , ,I ~... , . I I. -, t, . ~' ~ .f ~ .-.......- 1 ._--" ---~.. .-~ __.dr- ~ - t. ,.,.. ~~r;--"~';f;;".h'\::~:r-;"ll;~~~;' i -:._,. ~:,~...___':o!';;:;'~''';,<,'~'>':''4i...........-..-...~ , , . LAST WILL AND TESTAMENT I, SALLY H. GREEN, of Levittown, Bucks County, Pennsylvania, being of full age and of sound and disposing mind and memory, do make, pUblish and declare thie as and for my Last Will and Testament, hereby revoking and making void any and all Wills and Testament or Writings in the nature by me made hereto- fore. FIRSTl I direct that my Executor pay the expenses of my last illness and my funeral expenses. SECONDl All of my household and personal effects, and other tangible personalty of like nature, including automobiles, together with insurance thereon, I give equally to my children, RICHARD F. GREEN and THOMAS C. GREEN. In the event either of my children predecease me, I direct that the share of said deceased child shall go to my surviving child. THIRDl All the rest, residue and remainder of my estate, both real and personal, which I may own or have the right to dispose of at the time of my death, I give equally to my children, RICHARD F. GREEN and THOMAS C. GREEN. In the event either of my children predecease me, I direct that the share of a deceased child shall go equally to said deceased child's children who survive me, share and share alike, per capita. FOURTHl I make, nominate and appoint my son, RICHARD F. GREEN, to be the Executor of this, my Last Will and Testament. In the event my son, RICHARD F. GREEN, shall predecease me or for any reason fail to qualify or serve as said Executor, I make, nominate and appoint my son, THOMAS C. GREEN, to serve as 1 _...,..~-,"~'y-.-~.--- --- . " ~ , Executor of this, my Will. FIFTHI In the event a Guardian need be appointed for any minor grandchildren, I appoint and nominate my son, RICHARD F. GREEN, as Guardian of the estates and of any property which passes to my son, THOMAS C. GREEN'S minor children, and I appoint and nominate my son, THOMAS C. GREEN, as Guardian of the estates and of any property which passes to my son, RICHARD F. GREEN'S minor children, and with respect to which I am authorized to appoint a Guardian and have not otherwise specifically done so. In addition to the powers given by law, I authorize the Guardianl A. To retain real or personal property even though it is unproductive. B. To use such amounts of both income and principal as the Guardian, in his sole discretion, may deem proper for the support, education and welfare of the beneficiary without leave of any Court. C. To invest in real or personal property without restriction to legal investments. SIXTHI I hereby empower my Executor to sell, at public or private sale, and convey any part of my estate, real and per- sonal, deemed advisable by him, the time, terms and conditions of sale to be determined by him. SEVENTH I No fiduciary appointed by or acting under the au- thority of this Will shall be required to give bond in any juris- diction in which he or she may act. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, which consists of three pages, this 2 \n V. . 'r,.j c '0 , rO,,. ;4 :;\.. ,'-' p~ ._~ ::.1 oU ~ 't ~ ',.1 == Gl 0 101 l"l '. I .... 0 ~ g. 01 ....~ t z o-i "... a ~ UI'tl 0 - ~IlII'l:O -- ~ -- ,,-.. 0 ~PlO ~ - t!) . co ..... ' ... UI . I ~ N ==UI'" .ri~t c . I 1::1 III \D ....o.-ll"l Ti-' -- 01 o-i-aJo-il"- ~ ......... - >< I .-I =.... ~ - ... OGlIll- ..... I ~ N - U 101 Ltl ~. E-<Ulo-i ~ 1II . UlN l')NGl-' '~ ~ Ltl.-l .a 01 101 It~ .... 0 III l') ra. : .; . .. .. '. . . .... . .. . BBPORB THB RBGlSTER OPWILLS,CUMBERLAND COUNTY ,PBNNSYL VANIA INRB: BSTATB OP SALLY H. GRBEN, : IN THB COURT OP COMMON PLBAS : CUMBERLAND COUNTY, PENNSYL V ANlA ORPHANS' COURT DIVISION DECEASED : NO. 1996-00210 ~ERTIFICATION OF NOTICE UNDER RULE 5.6 Name of Decedent: Sally H. Green, Deceased Date of Death: February 23, 1996 Will No.: None Admin. No.: 199~10 To the Register: 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-captloned (')0 CiU 3~ r,. ~. f. -J Richard F. Green, Executor 1 Mountain View Drive Mechanlcsburg, PA 17055 ~ ~ :nlli' rno 'c () :~. ~ ~~\. ~ u-;.t -'- 't. estate on June 11,1996. L <4 :..-: ~ c (, ... ~;~. -0 '", ;:; ,t, w ii> 0 ~ - 0\ Thomas C. Green 238 Dotterer Road Lenhartsville, PA 19534 ( , (. .-. , () (, ~~ Notice has now been given to all persons entltied thereto under Rule 5.6(a) with no exceptions. BOSWELL. SNYDER, TINTNER & PICCOLA By: ~~, ~ Boswell, Esquire 315 North Front Street P. O. Box 741 Harrisburg, PA 17108.{)'741 (717) 236-9377 Attorney I. D. No. 25444 Attorneys for the Estate of Sally H. Green, Deceased Dated: June 11, 1996 ~I/.UOO I.. i'l,"1 IS ~ o ~ ~f~ x2.. u..... ... ;( ... :Hi "0 "z 82 :FJ, I ~ - (I () - I ! . .BE sUR6oANsviERALlOUESTIONS ON REVERSE' SIDEAND TO RECHECK MATH... ,i i.d., p..ulli., 0' p;'i",~. -iT.;~~'t;,"i1;;';,',';O";';:-'" 'h" ",;;;;~~-i;,,~,;j;.;g ~,,~mpo" ; 9 ,;t;;.;,. .;~~d-;;~'~';"~" ,.;';o';~;:b.,;-;;t';;y Ioowl.dg" ~.d b.h;f. .j ... "", (0""" u.d .0mplNI "",10-,' 'Ii.,' "II ",01.....".',.." I.,.," "'1'",,,.,, u' ,,," .,.,;.' ",I,.. ~,;.",,,,,,,,, 1'",;,,,,,, .-""., ,100' .h. I'mo.o1 "1"'"''01''' i, i: ..,.,j o."i~.I",",OI'O' 01.10,," 1'''''0'' Iou. 0"' ''''''',;,,,, - " "Gh"UA'r6~tf.'::;" '"'Jt:;.:::/'u,,, ,-<,:,"'" 1 Mountain View Drive (JAll'- --'" ----.. J\ ',,,,,, ,,,". """".,,"', ,,' ","', Mechanicsburg, PA 17055 "A~?/27/96 . 315 N. Front Street P. O. Box 741 Ilarrisburg, PA 17168-0741 12/27/96 Ci,~,g 'f.\V~ COMMONW\AlIH o. PlhNmVANIA ot,~. MINT O. I\VINUI 01".21060 HAUlnUIO.'A 11"".oMI ll' .')., 0 NUMBIR -----..-- fitl I. Original Ro.."n o 4, llmi.od E"ale _ I 717 J 236-:9~1] _.~c,~.,~~='. :0 :nm <:In :'-.. (") ..~'o . ~ z o S ::l t:: ... :5 ... .. I. Roal E.'a'o (Schod,lo A) ( I) __.1!1,5.,!,0.O"J!!I--- .. 2, Slack. and Bond, (Schedulo B) ( 21._________0.-00----- 3, (Ia.oly Hold Slac~lPa"nonhip In.oro.1 (Scbodulo q I 3) _._._.__0...J1..0._...- 4, Marlgage. and Na'o, Receivablo (School, Ie Dl ( 4) _'___ ._..--<<LJlIL__.. .. 5. Ca.h, Ban~ Dopa,;" & MilCollan.o", Ponanal Proporlyl 5) ---- 21" lilt3,. .~.ll___..__, (Schedulo EI 6. Jainlly Ownod Praporty (Sthad,lo F) ( 6) __..-,--,-Q..-OJ!._-- 7, Tran.lo" (Schod,lo G) (Schod,lol) ( 7) _._~5.,.~55-JJi__ 8. Tolal Gro" Aue', (tolollin" \.7) 9. Funeral bpon\e\, Admini,trotive CO\", Mi"olloneou\ ( 9) Expon.o. (Schodulo HI 10. Debll, Mortgoge Liobil,ilio\, lie", ISchedule I) 11. Ta.al Ded,,,ian, (Ia'oll;n.. Q & 10) 12. Net Volue 01 e.tole (line 8 minu' line 11) 13. Charitoble and Governmental Beque\t' (Schedulo JI 14. Nel Volue SubjetllO TOll (I~~~~~!~~L ----- 15. Amounl allino Ula.ablo 016% ,ole (IS) - 195,285.64. (Include \/01...e1 from Schedulo K :>r Schedule M.l 16. Amount alline '4 tOlloblc 01 1 S~t roll' (Indud. value. from Schedule K or Schedule M.l 17. Principal tall. due (Add loll. from lint' '~and from Ii no 16.) 18. Credit' P,io' Payment' Oi\Counl P81 PQI c:::J ., n .. lAJ r'l ~ (j , ;D . ~~ OJ N .j:>, , \:'. ., ;...::c;:, enO l 8) .___222,158..,55 24,284.67 (l0)_._.2,58.8_.J~L.- -' (II) ._,.1li ..6.72...8.6--- -" (121 _,_1~.5, 285.6L (13) ______--9.00 no . __i.1.::)._195, _285 . 6 L..._ x ,Qb = 11,.7.17..1:4- 0.00 (16) , . x 15 = --+._----~_.~- i\7\11,71'7,H---- z o :i .. ::l ... ::E o u )( ;( .. Inlere\l 0.00 . -....----.- .----- o..O().....__.,., ------------------. -. - + 19. II line tB j, gleoler Ir,on lin" 17. er,IN the difference all line 19. this j, the OVERPA'1MENT. gC]''':T'':1'',I,I..ta'''II..,i...L l.l'; 1,1I1l~.'.~ 1M:r:r:1aTj.),...l'lll!l!.lOj", I,l~ 20. If line 17 h srealel than line 'Po cr,'N the dilfc,,,ncc on line 20. Thi, i, the TAX DUE. A. ["Ier the inler",' on Iht' balance dl'O on line '20A B. fnhn the 10101 of linn 20 one 20A on line '208. lhi, j, the BALANCE DUE. Make Check Pay obi. !o: Rogl.to, al.WIII.,._~gont, ' IlO) IlOA) IleB1 11, 717.1~ - .-- . 8.l..l!8_ ......- 11, 80~~ Q.2.. __._.__.~._n _ \ .\ .IVotlOllh 111.111 '* COMMOtlWIAlIH 01 P1NNlYlVANIA INHIIUTANCI 'AX lIIfTUlIIN '1IIDINI DICIDINI IITATI 0' SALLY B. GREEN, DECEASED 1996-00210 1'lOpollV lolntlv-own.d wllh Righi 01 Survlvonhlp mull b. dl.c1o..d on Sch.dul. FI AII..ol..lat. .hould b. IOpall.d at '01, ma,k.1 valu. which I. d.nn.d a. tho p,lc. 01 which plOp.rty would b. ...hang.d b.rwttn a willing buV" and a wllllng..II.., n.llh.. bolng compell.d to b .. ..II, bath havlnglOa.anabl. knowl.dg. 01 th. ..I.vant lael.. ITEM NUMBER SCHEDULE A REAL ESTATE PILI NUMIU.'- . DESCRIPTION VALUE AT DATE OF DEATH I. 6 Greenspring Drive, Mechanicsburg Silver Spring Township, Cumberland County, PA, $ 105,000.00 as more fully described in the photocopy of the Deed whereby Sally B. Green took title on October 30, 1992, as recorded in Cumberland County Recorder of Deeds Office in Record Book Y, VolUllle 35, Page 963. TOTAL Alao .nlor on IIn. I, R.co Ilulollon ill mort .paCt js "oel.el, ins." additional shuh 01 10m. siZI.) S 105,000.00 . . , .. . THIS DEED, MADE THE of our Lord one 3 0 r...1f thousand day of Or /:-"/#''- in tho year nine hundrod ninoty-two (1992) BETWEEN WILLIAM Y. WALTERS I cnd PIIYI,I,IS J. WAI,TEIlS, his wife, of Silver Spring Township, Cumberland County, I'onnoylvonin, Grantor, and SALLY H. GREEN I single woman, of l.ev! ttown. Pennsylvania, Grantee: WITNESSETH, that in consideration of ----------------Eighty-six Thousand ($86,OOO.00)-------------------Dollars, in hand paid, the receipt whereof is heroby acknowlodged, the said grantor does hereby grant and convey to the said gran toe I ALL THAT CERTAIN piece or parcel of land oituatod in the Township of Silver Spring, County of Cumberland and Conllnonwoalth of Pennsylvania, more particularly bounded and described as follows: BEGINNING at a point on the southern side of Groenspring Drive North at the dividing line between Lots Nos. 71 ond 70 00 ohown on the hereinafter mentioned plan of lots: thence along said dividing line between Lots Nos. 71 and 70, South 11 degrees 58 minutos 49 oocondo West, a distance of 110 feet to a point at corner of other lando boing developed as Westfields: thence along the latter, North 78 degroos 1 minuto 11 ooconds Wost, a distance of 36 feet to a point at the dividing lino botwoon I.Ot6 Nos. 71 and 72 os shown on the hereinafter mentioned plan of loto; thence along said dividing line between Lots Nos. 71 and 72, North 11 dogrooo 50 minutes 49 seconds East, a distance of 110 feet to a point on tho llouthol'll Dido of Greenopring Drive North: thence along said Dido of GroonlllH'1 nu Dr! vo North, South 78 degrees 1 minutes 11 seconds East, a distnnco of 36 Coot to a point on the same at the dividing line betwoon Lots Noo. '11 nnd '/0 no ohown on the hereinafter mentioned plan of lots, tho plncu DC IIImINNING. BEING Lot No. 71 as shown on II curto!n ouhdivision plan of lots entitled "Final Subdivioion/l.imi tocl Plnn COl' WOlltfJoldo Phose 2" as recorded in the Office of the Recordor oC Ilundu In /11111 COI" Cumberland County, Pennsylvania. in Plan Book 56, Pogo ]3'/. \J" r: 0,)1,\ I u\) I.,> 96J .. .' t '. t " . \ HAVING erected thereon a townhouse style dwelling unit known and numbered as 6 Greenspring Drive North. BEING the same premises which Max D. Marbain and Graydon F. Lombard, Co- partners, by their deed dated July 25, 1989, and recorded in the Recorder of Deeds Office of Cumberland County, Pennsylvania I in Record Book G34, Page 85, granted and conveyed unto William Y. Walters. Phyllis J. Walters joins in this conveyance for the purpose of granting and conveying any and all interest which she has in the premises by being the wife of William Y. Walters. SAID premises are conveyed under and subject, nevertheless, to all those certain covenants, conditions and restrictions, as more fully contained in a document entitled "Declarations of Covenants, Conditions and restrictions Applicable to 'Westfields' Phases 2 and 3, in Silver Spring Township, Cumberland County, Pennsylvania", as recorded in the Recorder's Office aforesaid in Miscellaneous Record Book Volume 362, Page 897, and incorporated herein by reference thereto. ( ; I v~t'" S-~,~':'"'' lbwnShlp of ' ' Cumbo eo.. PL ~R"IEJ1818l1",".'llIIll" D:.J'" 3~1~ '-1]0 -- RobIrI P. ZJeg\If Cumb, Co. 0ItL Col."'" ,,' C0M/,\OtW/EAL1H 01' ~EN!,~:;VLV,\I'II! :-.: I)I::'~ PTM;:!'r: m REVE1'ILlf ::: /--... ------.-, -. '" "C--I.V ===-...=~'~"i.." ,\\.. l:- ,," .. "" r" -,. 'I B" 0 'I n ; ..' ii'f,I~3'"~ or' 3"12 "_~}.,; C! ,~ ,: : . 01 f,'k . w ...__...... t 1 . .~ eo. i1.:i\l~ ___'nO" .....J .... C""....h~.-I,,,J {..'., /~~ SChool Disl Cumbo eo.. PL -+'l6 R... Emte 1i'lInIfW 'llIIl ~ "Z- 3 ~( Oete ("- ''3'' Atrd. '-I- _ " Rabert Po ZJeg\If ClImb. Co. DIll. Col.--' .. . (D I"\:l = ~ --l c.:l o o c:: ~. :0 n"i rT1 ::oJ nInO -l,J 0 l.:J r- ::0 :.1 ___ Cl ;-1 :.. m '"I ;... ::0 ~.J .."") C-, '.....' ( ) -q ~-' t._ t? I.: --, r." .- ~r:lf:' -..: t::J:' I (j, ....' -" :- -0 ::3 , -l: N c.:l And the said grantor hereby covenant and agree that he will warrant specially the property hereby conveyed. , \1 ') r: . r' 064 llul'~ j vi> r.~.,t ;:; .' , . t . , : IN WITNESS WHEREOF. said grantor hnn horounto Dot hiD hand and seal the day and year first obovo writton. Signed. Sealed and Delivered in the Presence of (lAo-h~.~ ~tL tkv 10 ~ W.-4,({""'''' _tl ('-<luL'~ WII.I,I^M Y.'llill.TIms IJ? .Llc.:.... f).Mt...L/i;c) f,livtws JP'W^LTERS State of !:X~ County of On this, the de.:> doy of SO. ~ , 19 'l~, before me, the undersigned officer, porsonolly oppoorod William Y. Walters and Phyllis J. Walters known to me (or satisfactorily provon) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed same for the purposos thoroin contained. IN WITNESS WHEREOF, I herounto set my hand and official sea],.. ss. . .\,.',\tlI4H",,;, , "01 ,.. ;'\'\""1:" "t. ...-.......;-. ':.. \, .... 1"; ....."'.... ..':'..... ,... 1\:'" p.,' " , ',;"'.r'I"""'/,:{':~"'~-'l~ .... 4J~'" ....~_f::n... P It' ,>0:, 'U '" . - = u It . ,~,.~"'~:C:o,;~ ,~o'r..Jr:: .". . .. ..........) . 11". _ . . , P~f5."'!ft..;:;.-,.: 'lfi(Q,,!.t::::.~'/..:''':''' . ~. ...: . ~ :J... I.~ n.>- NOT^RY PUBLIC State of County of On this, the day of I 19 , before me, the undersigned officer, personally appeared know to me (or satisfactorily proven) to be the person whose name subscribed to the within instrument, and acknowledged that executed same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. Title of Officer. OUv.i ~ 35 r,,:,[ 965 " o .' . . . . " . , do hereby certify that the precise residence and complete post offfce address of the within named grantee is " G''-J,~Dn...... ".......,'. 1....-..c....., fl. O..-H.b..o 10 ,19q1. diff~ ,<1 Attorney for ~~.j1. COMMONWEALTH OF PENNSYLVANIA 'lu~\ ss. County of RECORDED on this 3u day of oct.. A. D.19!11::, in the Recorder's office of the said County, in Deed BookY Vol. ~ ~- , Page '/bS . Given under my hand and the seal of the said office, the date above written. ~r~ , Recorder. . \" " ,....:J.. ~. "'.:. ;r."'.'-~tl,""" .', .,..~ '" "'"'I\.''~''' :' " .........., ,.." ':J _'4 "' f! i\;r'~. . tI. I t" _.,,:..,~1.1:...-~. ,0 ,-!i/. ,.",.:"",.", ~.a.."" '.~" ' J :". '.: ~ ~ -~'ff,?~~'.~,J '.,-. -,,''':';;,,',. , <", '~'\ "'o:-'t<.r' .~...,,, /~O" . . off. ..~t'"<';" ""~.;.i '-''' - I, ," " ""': ~H.J..:,"~..,.. '.., ilJ!~'", " O'~ '.... "':I- ;, t'l''!'t'<( ".~ ~ t' ','~""'t'I,'_. '''1/ " , . . \"'-. '.. ,. I, .~ ~.... ':~. _.(}-.J,. ';t"'..};, <;....r.-,v ;,',_ .. '. ....,.,:'...' ~.r .." r~~ 0- I ". ...... ".V" .. . .. ......"....." ~\, ': . i .- .f .1oo.i. v-J .~\,\ .. . . '.. 'I."""'" 6iJlJ{ '135 I,,;" ~m 11';110111.11.'11 SCHEDULE D MORTGAGES AND NOTlS RECEIVABLE W COMMONWIAIIH 01 P1Ngy"YANIA IHH.."AH(IIAUI IN .IIIDlNI OKID ISlATI 0' SALLY B. GRBBH, DBCEASBD CAlI -"" 111ot1y.ew..4 willi tho Il,ht II Iurvl_.M, ,"..1 ... ~I..I"I~ I. l.hI4.1o ',I PI.olI Prlnl Dr T . PILI NUM.IR ITIM NUMIIR DISCRIPTION 1 Hone (II more spoc. is n..d.d, ins.rt additional sh..ts 01 sam. siz..' 1996-00210 YAWl AT DATI 0' DIATH -0- s -0- .,Yltotl.. 1111) SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY PI.a.. Print ar Typ. FILE NUM8ER 1996-00210 "~'J~~t\ ....f+lJu; COMMONWfAlfH or PlNNlnVANIA INN""A"C. fAX InUIN IIIIDIH' DICIDIH' ~STATE OF SALLY II. GREEN, DECEASED IAn ..'....,., ~Inll.,..ew,.... with lhe .'ghl .f Surwln.uhlp mUll tI. dlulo..d on Sch.dul. '1 ITEM I DESCRIPTION NUMBER VALUE AT DATE OF DEATH 1 Personal Property as per attached appraisal prepared by Claude C. Wolfe , Associates Jewelry as per attached appraisal prepared by Landis Jewelers 49.25 1,976.50 2 3 1991 Dodge Dynasty SND, VIN 1B3XC46KSMD244247 as per attached appraisal prepared by Jenkins Chrysler, Inc. 4,860.00 4 Farmers Trust Account - checking account number 1156691, as of date of death 8,561.32 5 Farmers Trust Account - checking account number 1156691 - accrued interest to date of death 5.30 5.67 6 7 8 Capital Health Care - refund paid 4/10/96 Horace Mann - refund 58.00 Blue Cross/Blue Shielid - refunds - 10 payments total 443.10 100.00 9 Federal Income Tax Refund for p.e. 12/95 10 Silver Spring Township Real Estate Tax Reimbursem nt 117.44 11 Cumberland Valley School District Tax Reimburseme t 4.21 12 Malpezzi Funeral Home - prepaid funeral account 5,422.41 S 21,603.20 (Anach additionaISV.- )C 11- ,heel' if mare Ipacell ne.ded.) i. . .....' .. ~.....,..- CLAUDE (. WOLFE & ASSOCIATES AUCTIONEERS" ESTATE APPRAISERS 113 OLD FORD DRIVE. CAMP HILL, PA 17011 717.737.0734 April 5, 1996 Appraisal for the Estate of Sally H. Green 6 Greenspring Drive, Mechanicsburg, PA 17055 LIVING ROOM Glass paneled lamp Upholstered rocker Pair of formica topped end tables Love seat . . Coffee table Pair of crystal style table lamps Beveled wall mirror Pair of sconces 2 Wall shelves 2 Figurines . . Star Barn picture Wooden plant stand Misc. plants Thomas transistor organ & bench Ironing board 2 Stools 12.00 20.00 15.00 100.00 12.00 25.00 15.00 2.00 3.00 10.00 15.00 5.00 5.00 95.00 1. 00 30.00 KITCHEN/DINING AREA Server 5.00 20.00 5.00 100.00 513.00 J~0.00 :'(\.00 ! 25.00 I L I 1(,_ 00 h JO.00 , ,', ,. - , no ~.. Table & 5 chairs Wooden trash can Whirlpool washer Kenmore dryer , Small Whirlpool refriger~tor 111,,(', coolmare lIisc. everyday dishf:s IIi sc:_ utensils lIisc. flatware Toaster . _ , , CLAUDE C. WOLFE & ASSOCIATES AUCTIONEERS" ESTATE APPRAISERS 113 OLD FORD DRIVE. CAMP HILI, PA 17011 717.737.0734 Green appraisal Page 2 KITCHEN/DINING AREA - continued Small GE b&w portable tv Electric iron Telephone . . 10.00 2.00 5.00 SITTING ROOM Wooden magazine rack Wooden chair . . . . Pair of brown recliners End table . Table lamp 3 Stack tables Child's rocker Rabbit doll Throw rug . Misc. contents of room 7.50 1.00 70.00 10.00 5.00 10.00 15.00 5.00 3.00 10.00 FLORIDA ROOM Marble top stand White stand Mauve table lamp Clock 10 Piece patio set 4 Straight chairs Ottoman . , . . Electric heater Ceramic heat"l" 3 Pictur"s Painted f:latt' Misc. contents of room 25.00 5.00 1.00 4.00 250.00 20,00 5.00 5.00 10.00 5.00 5.00 10.00 ,'.,1 CLAUDE C. WOLFE & ASSOCIATES AUC170NE,ERS" ESTATE APPRAISERS 113 OLD FORD DRIVE. CAMI' HILI, I'A 17011 717.737.()734 Green appraisal Palle 3 FRONT BEDROOH JVC am/tm/phono with turntable & 2 speakers (old) Clock. . . Sheet music Hisc. 33 1/3 records Small crystal style lamp Sango China "Rosanne" pattern, service for 8 15.00 1.00 25.00 15.00 5.00 45.00 20.00 5.00 5.00 30.00 1.00 Server . . . . . Candle holder with bowl Misc. Pictures Double bed . . Basket trash can Misc. linens Scale Trash can Concord glass domed clock BATH 15.00 1.00 1.00 10.00 REAR BEDROOH Luggage . . . Bed linens Sewing stand Eureka upright vaCUum cleaner Trash basket Humidifier 15.00 25.00 5.00 20.00 1.00 5.00 18.00 60.00 125.00 2.00 Electric sewing mn,-~d r,.~ WOOden 2 drawer file cabinet Dresser with mirror, Pair of boudOir lamps CLAUDE C. WOLFE & ASSOCIATES AUC170NEERS d ESTATE APPIUISERS 113 OLD FORD DRIVE. CAMP HILI. PA 17011 717.737.0734 Green allpraisal Palle 4 REAR BEDROOM - continued Misc. plants Octagon stand Alarm clock Double bed Chipboard stand Halogen floor lamp Computer desk with printer table (chipboard) Sears electric portable typewriter Misc. pictures " . . . . . . . . 4.00 3.00 2.00 50.00 5.00 10.00 40.00 5.00 10.00 GARAGE TV trays Clothes racks 7 Lawn chairs Wheel barrow Chaise lounge Craftsman electric weed whacker Dustbuster . . . . Misc. garden tools 4 Card table chairs Aluminum step ladder 2 Metal shelf units 2.00 5.00 15.00 5.00 15.00 15.00 6.00 5.00 10.00 5.00 12.00 4.00 2.00 10.00 1.00 10.00 25.00 I" 2 C;ar<1t:'n hoe~s Stadium seat Craftsman ~J~ctric hedge trim~@r Plastic trash can - broken Mise, hand tools llisc. contents of garage f I' I, ~- I' . _ ~ .__.-...._....-.'_-.... r.'_ Landis jewelers 2129 MARKET STREET BOX 4B 1 CAMP HILL, PA. 17011 TElEPHONE 737.8024 INC. Jewelry Appraisal April 2, 1996 Jeffrey R. Boswell 315 North Front street P.O. Box 741 Harrisburg, PA 17106-0741 Concerning the jewelry estate pieces of the Estate of Sally It. Green, the following items have been examined and appraised. The enclosed report, in duplicate, has been undertaken to determine an approximate estate value for the items as described. Each item has been examined to the best of my ability to determine fair market value only. The procedures, wording and values would all be different if this report was undertaken for other purposes. This report or any copy does not carry with it the right of publication without prior written consent nor may it be used for any purpose by anyone other than the above named, and as such, may only be used in its ontirety and with this cover letter. The specific description of tho gems or jewelry is for the sole purpose of identification in order to determine the parameters for valuation. The description is based upon grading and other techniques and equipment available to, and used by Landis Jewelers, Inc., at the time of examination. The description may reasonably vary from other descriptions of the items listed, and may vary in the future as a result of changes and improvements in grading techniques and equipment. Unless otherwise stated, the weights of all mounted atones are estimated by formula. Many mountings restrict examination of details of the gemstone, unless specifically stated that stones were removed and graded, statements referring to color and/or internal pureness are provisional, approximate weights are determined by volumetric calculation I estimate replacement cost i8 based on assumed species, size and quality. page 1 of 3 .. , Estate of Sally Green April 2, 1996 per oz. Item 11 One assortment of costume jewelry. The group consist of approximately fifty-eight assortod pins, earrings nnd charms. All metal on these items is platod and all stones are imitation. Numerous pieces aro broken and/or incomplete. $28.00 Item 2: Cross with chain, 14kt. yellow gold. A polished crosS with initials engraved on the back. The chain is eighteen inches in length with a spring ring clasp. $21.25 Item weight - 5.0 grams. End of Report page 3 of 3 .~., ...- . . ", \'I ~~~v o Jenkin. Chry81erl IDe. Chr1Jsler. Plymouth. Dodge .,. Dodge nuclcll Roule 220 North al Route 66 Ilt:drord, PA 15522 18141623.1141 FAX 18141623-9311 3Jl/ /C;~ -r; tJ~()M l-f f'YJ"'( (b"'C.CVJj :;: h~uc. ApPIJ#IIS<;J ,q /99/ '"Dc>d~\.. D'1''''l,C' ~~ V thJ Il Ii.? 3xc ltt;.i< sinn :J't<f ,;J Lf 7 ~...J /Yldr4:/, ~ -I J9;;1.89 ),1</,,( ~~/J/_ "" I/cl.,C,/t; A -t Y..a-~~ lJi ,...",; J:lpp.....:..,J !;....J /YJ/I>"elo SeJ;-n..:. 0 1=' NI9r:J~ C)~F=I't.J u.reo C'~.... G..de ;{.... r L;--k ..s-: /r~ .114".....)4. .. law.uot..I. (11.f11 *' COMMONWfAllH O' rfNNIYlVANIA INHUITANCI we mUIN IUIDfNl DfCfDfNI SCHEDULE F JOINTLY-OWNED PROPERTY ISTATIO. SALLY B. GREEN, DBCEASBD PILI NUMIIR 1996-00210 JoInt IInonl(I)' NAME ADDRESS RELATIONSHIP TO DECIDENT A. NONE I. C. Jolntlv_noel proportVI NONE ITEM LETTER DATE NUMIEI FOR MADE DESCRIPTION OF PROPERTY TOTAL VALUE DECO'S DOLLAR VALUE OF JOINT JOINT OF ASSET % INT. DECEDENT'S INTEREST TENANT 1. TOTAL (Also In'or on linl 6, RlCopllulollon) S -0- (II moro 'POCI i. nlldld insort odditionol .hlll. of .oml .izo) ^ "':k"'~'''''~;\:'' :".~'>i,:~;"",,'A . Rly,ulo u. P..1I..,...., '* SCHEDULE G COMMONWIA~, 01 P1NIJ"IYANI. TRANSFERS IHHlllfA.'HllrJtcX I/,WRH PLEASE PRINT OR TYPE I.IIDI IDI --=..::;::':~-=-"";=;':"'-:-.~~='-:";':-=.:~'.:::~-=~~:;::c- _ - :':;',;.=:.___ .., _.;:_~. .:,,",'":":'_'_~:;';':',,"-'-_":;:;'_~*_==~:~':;::'--:-..;::;=:~ c'=~ IITATI 0' PILI NUMIIR SALLY B. GREEN, DBCEASED 1996-00210 THIS SCHIDUU MUST II COM'LIfID AND P1L1D I' THI ANSWER TO ANY O. THI QUISTIONS ON THI REVERSI SIDI 0' THI COVER SHin IS YlS. -, ---- DECD,--- r--OOlLAR YALUE ITEM DESCRI'TION 01 PROPERTY EXCLUSION TOTAL VALUE .. 01 DECEDENT'S NUMIER IneWt ItOfM 01 'h. froMItNc, lMit reIatiottahip 10 deceden', doff 01 ',ani'''. 01 ASSET -1HL- INTEREST - *-_._--- .- 1 John Alden Life Insurance Co. 60,490.46 100\ 60,490.46 Plexible Premium Retirement Deferred Annuity Contract Number: 7086675A Issued March 3, 1993 (See attach d IRS Porm 712 and Contract) 2 John Alden Life Insurance Co. 35,064.89 100\ 35,064.89 Plexible Premium Retirement Deferred Annuity Contract Number: 7086730A Issued March 19, 1993 (See attac' ed IRS porm 712 and Contract) TOTAL lAlla .nl., on IIn. 7. R.capltulallon} S 95,555.35 III mo,. Ipace il ""deJ, inltrl additional .h..,. 01 lam. &ile.J 1.11.':J,'1J8 .. lO;~l 'a30:J ~l:J 33~1 .JrtLIC 1-"lU ll'Cu'J,'Oll:J ",,-" ....... 712 I I . (rbN,Iw.. '-Iffll ~ Life InsunmCl! Sbl~m"ot ~. L OMIIllo \5U,OO,. 1lI!lort..... 01"'" TrMrury ___ I\J!pl... 11-30.9. 1Mtrft,a1.....e...lft Atnw . .. ~~r::wW' ~to be l'iled WJIb l.'mlr" SUlr$ .i!3ut'C,,[.... ~J!:=, j.'cnJl '06> .- J DftnalIlInt't Ont namt-.nd.mJ; .IniU. e4Hn1".IU\ r\lmt. ',1 l.M=odct, . ,,', MlCI.l aevu, thy uuliitc~1l)'lft urllM,b SallyH. Oleen I ~rlno....) 214.JO.0613___.I02n3/% 'TN.......s.dd.....oll...."nuconlp"1l)' 0 Alden i.1fc'JiIiWincC" (',.: ..,..-.-.. ,-.-...--.- ". U. lJox 020270 Miami,I-luri<tl .UIOZ.(JZiiJ .--.--- ..__.-\f-\~1.L~';..~*.4-.- Derened AnnullY I . OWne,'shotme. Ifd~.nlltl~O'N1_, lUu~ flU ^'~lttMr'lnamo 11c.uo.nach st-- .uc'b Wp)' ut .pp~lIU. I WV7 \A ..wJl,lWIaA. March 3" 1993 (, "'1".,("""" 708M7SA \ II I PaWl uaJpod a old1.~tI:)"I'hn \lnl1'l"t'a"~"lImr_"1 AfII(JUN 0 premium Me UuU\lCbMt) I'. I fIIal".ol ft,tfte11C..nel :U::wd P Cloc;n 1110m.. C Or<'Cll ...~ .. ....... ...."...........'.. ".' ... ... ..... . I, ".."......:":..JI~ r: ~ :,,:-i: I' ",I , , 60 490.46 .. '.--- '~ Z .~ .~~"/?/ ...,.. ",f.'//////////////////////. IS 16 17 II 19 :II 21 21 21 14 %5 U r..... aj~ wI,....:.:..:,. 1o?i"""",,, boccI'.. ""diUocW ilUtlr.""'. Otb<< br".tW'rtt, rrinel"'''' any lndClbtedMIS 1.& tM comrany \hat it dtductib\e In de1enn1nlnB nIlt p('tJCCft\1 """",,"I~"(,urIr :P)~ t.I~oI~ AJDouf'f of IGCluTNlattd d.lvldcnlb AmwDl ur p>>l.mortem dividends ~ofl"DfltnW'Af"T1TImm ~otl"t:c.~",,~.v..itl.t1bfo'l'ttftl .~..~-.... ~"".~ Vatu. of /tf'O"_lt II of d.te o( duth (1rnol pIIy.Me in unc tum) ftDUcy (I'Rlvfalom t:ODCCmill,. derttred payments or InstaJlmentJ. l'low.:tfothr-r lhan lump.r.rm 10CnJcnumt ~ AUth01Uod (cor. foutvivinJl; Sr<"use. rl...~* .n..:h' ~c.i'Y fJ( the fnauf1lna:l polley. 27 21 .....-.. . -.-- Amount.-J mtullmM\S thla af bhth. Ie' .nd name or any penon lhe duJ1ltion of 'IlIhote lire mI.)' mr.annc Ihr. tlurr.t'Ct or flIymenU. 29 ,Amo.Jol8pplied b)' tho inrursnr.e eompany.l. dngtft rr"uwlm ~ti~ 11M fJurcha~ c:.{WaJ,...:"oUh\...\J.'.:...... ..... ". .... .'. ,,'.'..,,'......... JU IJ,aftS (mor'.a1rty tIlblfl aM JI\I' of .m"~J uKd by .naulCt In wru'r'rIlnuaUmenI oef'tOnu. ~t Wu ~ b:,;\UM Ihe 'r'.n~i~r.l or ~fici'rY'or any ~~~it~ c.,ntl;~ i~~-i,\:tl,,: (:n:n(lo'ln\'~ 0 YCl, !2 Namrs of cnm,..,nifOs with ....hirh ttr.cr.rfl"nt canNld other pnUries and flfU(\unt of RIch rolieie, if Itli. Infomwllon Is dhcloy.d by your rCltonb, '1 -:0 The undl"f'iF'lC11 omurl'( 1~lC' "to\r. nftU1W ImuraDCe cClmpany ht~by ~:":;"',f1r. ill.' -th;,\ ~1~lr.........I-;~t)f;;-lt~nd -;Clrnc1 informa.tion. ---~--_. S"-'M~(J.A.~ . l..&ll"lictiuli:t . ---- ___1'~"'~2 }.:;..':.;.~'...:.~..,\ .~~.~!~~l'~~', Oa:.c. ~rec.,-..!.{"o:.&!.!.~~ ':I'.,!:! :~\-.:.!"..t)l':~ ~ " , ,-',', .,- ~ ~ l":'~:'~!i"r 'h,. f,..,..., 111;111111. II'" '.....-'d. '" "l.:',p:trfnl find \(uJirt II th4 ..,!dru'\~ It~ ,,, 1,\" imtnl,lJon: ...(~hc lU tetum ...ith ..bicb Ihlt form is rllod. 00 );'v i ~I" .:. ~, :V1ll.\.. J.~ ~~ .~.'"""" ..~,.u,., ~. ,~..~U. ;l t., .1..; .:U' .j~ . ," 1~1'1(;"nl"I,\'" ....~.:l r"'lIl,,~,..111 ~Wl~1nrnt..r tn.,ur.'r.- n,::. ~lJolrlll,.,,1 IHlat he IIL'IlI". 1m l...II." "rl~'" hUllll.Ul'Il' CNUt'OC" UlaII&S\le4lht rolle)'. by an O'hOfr'01 ~ , ....._. ..... .. ~-_'.. . .." ... ',. '1". .,.,......1. ..( .,.(' 1"~'"J""O\". p,., ,'\!11""'''. .., lloJ, :h';llIl'l'l, . f.l...\im:'~ 'lpnat\:f'I.' m.~' ~ u~t"d in li.u nf ..'rn.~IIt1 I-u:nalu,,, AM.I ut....,. ~n"" 000 UUtllUl~ ... a n....nual t1~l\Itu... ~.,J~"'L'<j,d:. B'A~';,(.!.:::':. :.~:. :'r::,',' ll.'{' .~':: fer t"': inflJmu~(,l1~:J eu. rntm I.. "1\",, ""~ 1t~ ',."'\",31 N"\'l'n,\ll. '''.... of Ihr: l:nhnd Slnlf~. I'LIY "D 1"'1011.1..... "' ,..... VI 1&1.. ....'-"'IU""""" ,....; .jo.A:.J:t t.J o)IUooo.r thAI '1"" 1:1(' lJ"I;.l':~';I'( ".;th Il)..!( 1,1"" ltft-t t.... allnQ.'w. tn figure and cobK( Ulc nllM .mouN 01 ,.., ~'""......___... ........:........... ::.. ~.h:.;._ ..:: '''''") .:..i.:;.~;.-i:l ,"n ir,l:\'j.1:,..: . ;.. t': '.'A t, '!'1. "'.:\1. \1(',,1 "''''('n,C t.:nC' I~: 7J: ,!I 1'1'" .:'''mill .1...-,._ .;__~.,"'-O. ., ...~~-- ~.......,....... ..-. ~ .-.;."..' ,:... -.... \",!" If '1"1 h.,r. L,' IIITM'r:" ("ln~r.mlf'J' ''''1' 11:'(11",('\' O(Ihc:,otlont" CM.U.lUCioUII...Jt"'~J"'.hll"l Ii"'''''''. ",,' '..11' II...,.... ..n...I.... "'.. "",,,,,L, I... 1''''0:'" ,.. ;;~... I.,.". .....1 ,.. . \ ""~"f 'n 10"'1 tI~' 1.....'\ ..."" t tilt' ,-,_p,., .' j .' 1",,- l' :I.r. al\lIu,,1 \'lr.lIliultl. nd IlltIl~'J1Il1L1.'i.f 1'"<=11111011111.1 ...._r '11 ._If. .1 U""ll ...., I,n... alii'" U~ II'" ". fl... . .", +,. in ! ""lI'IP~ "I~Il.ilJ"" el1l ~:',. HIli:)\' rOl'tt1 71i"'iN';-~I"~H 1In~n;' 1'.,'.1hl".1 1,,' T..'\" "";1.\"r"t1lt'llf In<... ., !'lllto.l.li.,,... ..I' j"'!.. 11.1......'. ,.r ""li"..~1 "l~'M.h.. 1m' ~l" 1 101~11!lll \ I : :',~, TX 'IlX \(\. ~:1!16 I',OO~ . .. ._- -- -,-..-.... .~-- TABLB OP SURRBNDBR CHARGES O:ntract y~,.. Surr'eOOer O1arge Percentaqe 1 2 3 4 5 6 7 8 9 10 'lHERI?AFrnR 9t 9 8 7 6 5 4 3 2 1 o GJaranteed Mininum Interest Rate - 4t If this ccntract is surreOOered duriIYa the first 10 contract years, we will deduct any applicable surreOOer charge. See page 5. C1le partial witlx:Jrawal in any 12 llOI1th period of as IlUch as lOt of the contract value is allC1ilE!d with no surreOOer charge. 'lhere is a surreOOer charge for other partial witlx:Jrawals rrade duriIYa the first 10 contract years. See page 5. 'lbe lIGJaranteed Mininum M:Jnthly Incare" shown below is based on (1) the rnininun guaranteed interest rates as shown above duriIYa the accunulation period; (2) the initial premium being ccntinued at the sane frequency irrlicated en the applicatien untU the annuity clate; (3) the annuity cption specified in the contract; arxl (4) the rnininun guaranteed annuity values reflected in the annuity tables in this contract. My change in the annmt or frequency of prenium payrrents, any excess interest paid by us, arxl any nore favorable annuity rates which we rray offer at the tine annuity payrrents will begin will change the stated annmt. CONTRACT DATA CONTRACT NUMBER:..... 7086675A ISSUE DATE:... March 3, 1993 ISSUE AGE:.... 63 INITIAL CONTRIBUTION: $60,000.00 INITIAL CONTRIBUTION RECEIPT DATE:........ March 3, 1993 ANNUITY DATE:. February 16, 2015 OWNER: Sally H. Green :;UARANTEED MINIMUM ~ONTHLY INCOME:...... $1,932.43 BENEPICIA1l.Y: AS STATED ON APPLICATION ESTIMATED ANNUAL PREMIUM:...... $0.00 J-5615-p(~harn"e) (39) (1/89) 2 DEFINITIONS This Is what we mean when we use these words or phrases: " "We," "us" and "our" refer to John Alden Life Insur- ance Company. "You," "your" and "yours" refer to lhe owner named on page 2. The "Annuitant" Is the person who Is to receive annuity payments, "Premium" means any payment made to us as con- sideration for the benefits of this contract. "Contract years" means the one-year periods begin- ning on the Issue date and each anniversary of the Issue date. "Calendar years" means January 1 through Decem- ber 31; the first calendar year Is from the issue date to December 31. The "issue date" refers to the Issue date shown on page 2; It determines contract years, months and anniversaries, The "annuity date" refers to the date on which we will make the first annuity payment. The scheduled annuity date Is shown on page 2; you may later change this date, "Accumulation period" refers to the time between the date we received your Initial premium and the annuity date, Other terms are defined as they occur In this conlract. GENERAL PROVISIONS Bull of contract: This contract is issued on the basis of the application and receipt of the Initial premium, EnUre conlnlct; changes: This contract, the attached application, and any endorsements make up the entire contract. All statements in the application are representations and not warranties. No agent can change this contract or waive any of its terms, Changes can be made only by written endorse- ment signed by our president, one of our vice presi- dents or our secretary, Incontestability: This contract is incontestable from Its Issue date, Non.Partlclpatlng: This contract does not pay divi- dends or share In the surplus of the company, Mllltatement of age: Before we make annuity pay- ments to you or any beneficiary, we may require proof of the payee's existence and age. If a payee's aoe Is misstated, we will make payments based on the true age; the amount payable under this contract shall be such as the stipulated pay- ments would have purchased at the correct age or ages. In the case of age correction after annuity payments start, we will: 1. In case of underpayment. pay the full amount due the payee with the next payment due with interest at 4%. J.!l6H;.p IJ9tl1,69) 2, in case of overpayment, deduct the amount due us from future payments with interest at 4%; deductions will be spread over the payment period. Ownership: The owner has all rights under this con- tract during the annuitant's lifetime, subject to: (1) the rights of any assignee of record with us; (2) the rights of any irrevocable beneficiary; (3) any restricted ownership endorsement; Non-forfeltablllty: This contract is your property; your values are for your exclusive benefit and cannot be forfeited. Beneficiary: Beneficiaries are named in the applica- tion: 1. for the owner before the annuity date; and 2, for the annuitant(s) after the annuity date, Beneficiaries may be changed at any time, Agree- ment to a beneficiary change must be made in writ- ing by: 1. the owner (before the annuity date); or 2. the annuitant (after the annuity date); or 3, any irrevocable beneficiary. Written notice of the change, signed and dated by you, must be sent to our executive office, The change will be effective on the dale you sign it. We are not liable for any action we take before we receive and file the notice at our executive office. 3 BENEFITS AND VALUES Premium.: During the accumulation period. you may pay premiums whenever you wish. Premiums must be $25 or more; they are payable to us at our home ollice, No premiums can be paid after you reach age 70. Thlscontract will continue as a paid up annuity if no further premiums are paid. The contract value. cash surrender value and death benefit will be calculated: 1) In the same manner described In the contract lor these benellts; and 2) using the same Interest rates described In the Crediting of Interest, Guaranteed Interest and Current Interest rate provisions, Crediting ollnlerllt: Each of your premiums during the accumulation period (Including i'::ur Initial pre-. ' mlum) will earn daily Interest from the day It is received at our home ollice, In no event will the rate of Interest being earned be less than the guaranteed Interest rate. Guaranteed Interesl rate: We guarantee interest at the effective annual rate 014.0"10, The contract values shown In the table on page 9 are based on this guaranteed Interest rate, . J-H,lI-P (391 111891 Conlract values: On the dale 01 lIs receipt, the amount 01 your Initial premium is the contract value, Your contract value on any later date during the accumulation period will be: 1, the amount 01 your initial premium: piUS 2, the amount 01 each luture premium payment: plus 3, Inlerest credited: ~ 4. any withdrawals made, At least once a year we will send you a statement of your then current conlract value, Current Interest rate: After the first calendar year, we may Irom time to time declare Interest In excess of the guaranteed interest rates, This rate, once declared, shall remain In ellect for a period 01 at least 6 months, The current rate supersedes the guaran- teed interest rate, 4 Ca.h Surrenders: You may surrender this contract In full for cash at any time during the accumulation period. The amount payable will be the Contract Value If the full surrender request Is made after the . tenth contract year, In the event 01 full surrender 01 this contract during the first 10 contract years, the amount payable will be the Contract Value, less a surrender charge. - We may defer payment of cash surrender values lor not more than 6 months after receipt of the owner's request. Partial Withdrawal.: During the accumulation period you may request a partial withdrawal from the accumulation value, The request must be in writing, Each such partial withdrawal will result In a contract value reduction as of the date 01 our receipt 01 the partial withdrawal request, equal to the partial with- drawal amount received by you, plus any surrender charges. During the first 10 contract years, the Owner may make one partial withdrawal in any 12 month period of as much as 10% ofthe accumulation value without a surrender charge. However, a surrender charge will be applied to the full amount withdrawn (Includ- ing the 10% free partial withdrawal) when in any 12 month period: 1. more than 10% ofthe accumulation value is with- drawn; or 2. more than one withdrawal is made; or 3, the contract value is reduced to less than $2,000; or 4, the contract is surrendered, The partial withdrawal charge Is calculated by apply- ing the Surrender Charge Percentage shown on Page 2 to the amount of the Contract Value reduc- tion subject to the withdrawal charge, There will be no charge for partial withdrawals after the first 10 contract years, J.Y.17.P 1391 fl1P91 Death Benelll Options: If the Owner dies belore the Annuity Date, the benellciary has up to one year after the date 01 death to determine the death benefit option. The death benellt options are: a, Lump Sum Payment. If this option Is chosen, we will pay the Contract Value in a lump sum, This payment can be deferred and accumulate with interest lor up to 5 years from date 01 death; or b, Equal payments for at least five years; or c, Lile Annuity based on the life expectancy of the benellciary. " this option Is chosen, we will pay equal periodic payments for the life of the benefi- ciary as chosen; or d, Life annuity and minimum guaranteed term, " this option Is chosen, we will pay equal periodic payments during the benellclary's IIle; payments are guaranteed for a minimum term of 5,10, or 20 years, "the Annuitant(s) dies after the annuity date, we will continue the annuity payments to the beneficiary as provided under the annuity option then in effect. However, if there are joint annuitants, the contract will remain in force for the surviving annuitant. If the benel/ciary 01 the deceased payee, under an Annuity or Settlement Option dies belore all pay- ments have been made, we will pay the amount stili due in a single sum to the appropriate beneliciary, If a benel/clary dies: 1, at the time 01 or within 15 days after your death; and 2, belore death proceeds have been paid; we will pay death proceeds as though that benel/- ciary had died belore you, If no benel/ciary survives you, we will pay your estate. Minimum benellls: The paid-up annuity values, cash surrender values and amounts payable at death under this contract are not less than the minimum benefits required by the laws 01 the state in which this contract is delivered. 5 ANNUITY PROVISIONS Annuity date: The scheduled annuity date IS shown on page 2, You may elect an optional annuity date, Written request to change the annuity date must be made at least 60 days belore the scheduled annuity date. Normal ,,"Iement, life annuity: The annuity value will be used to provide a life annuity as described on the first page of this contractll: 1. the annuitant Is living on the annuity date; and 2. you have not made an alternate election, The payment amount will be determined Irom Table 1. Annuity value: The annuity value available on the annuity date to be applied towards normal sel\le- ment or an optional form 01 annuity will be deter- mined as follows: J.!SlI".p (301 (111l91 " the annuity value will be the contract value calcu- lated as described on page 4 il: a, the annuity date is at least 10 years alter the issue date 01 this contract; or b, any other annuity date is chosen and: (I) the payment period is atleastS years; and (i1) the annuity Is based on our then current single premium immediate annuity rates generally available to holders of contracts bearing this same lorm number, 2. Otherwise the annuity value will be the contract value calculated as described on page 4 reduced by the amount 01 any surrender charges calcu- lated as provided on page 2 as If a fuil surrender of this contract were to be made on the annuity date, 6 Annuity opllons: In lieu of receiving a normal settle- ment life annuity beginning on the annuity date, you may elect one of the following annuity options: Opllon 1, payments certain: We make equal payments for a set term not less than 5 years nor more than 20 years, If the payee dies during the set term, payments continue to the payee's beneficiary to the end of the term. Opllon 2, life and minimum guaranteed ferm: We make equal payments during the payee's life; payments are guaranteed for a minimum term of 5, 10, or 20 years. If the payee dies before the minimum term has expired, pay- ments continue to the payee's beneficiary to the end of the minimum term. Opllon 3, Joint and survivor annuity: We make equal payments to the payee while both the payee and his or her spouse are living; pay- ments continue to the survivor during the remaining lifetime of the survivor. Joint and 2/3 contingent survivor annuity: We make equal payments to the payee while both the payee and his or herspouse are living; full payments continue to the payee for life if the spouse dies; 2/3 of the original payment amount continues to the spouse for life if the payee dies, In addition, you may elect any other method of set- tlement allowed by us from time to time for this class of annuity contract. To elect an annuity option, you must: 1. send a written request for the annuity option to us at our home office; and 2, make such request at least 60 days before the annuity date, J.!.(.18.PI.,e9. Annuity tables: The annuity tables in this contract are to be used to determine the dollar amount of annuity payments we guarantee for each of the annuity options available, At the time annuity pay- ments under any option begin, we will pay the greater of: 1, lhese guaranteed amounts; or 2, the amounts determined at any more favorable annuity rates we then offer. Minimum payments: Annuity payments may be annual, semi-annual, quarterly or monthly, How- ever, we will not make periodic payments of less than $50; for lesser amounts due, we will change the frequency of payments. If annual payments would be less than $50, we will pay the commuted value of the benefit as a single sum: 1, to you, if living; otherwise . 2, to the beneficiary. Such payment will be full settlement; It will terminate our liability under this contract. This provision applies to payments we make to you or to any beneficiary, Annuity condlllons: Only natural persons may be payees under an annuity option. For these options, we may require proof of a payee's date of birth. The age used for these options will be the payee's age on the date of the settlement. Unless otherwise provided, no beneficiary may assign, transfer, or encumber the payments under any annuity option, To the extent permitted by law, any amount retained by us, and any payments made, will not be subject to the claims of any creditor, nor will they be subject to execution or other legal process' on behalf of any creditor of any beneficiary, 7 Age 01 Payee on Annuity Date 59 60 61 62 ANNUITY TABLES Values lor Ages Not Shown Will Be Furnished Upon Request T~BLE !..-::- N~~~~I_S~t!~c_~~!1.t.: LlIc..Annulty Amount 01 Monlhly Amounl 01 Monlhly Inslallmenls Age 01 Payee Installments Per $ 1 ,000 01 on Per S 1 ,000 of Annuity Value Annuity Dale Annuity ...alue $5,34 63 $5,83 5.45 64 5,98 5,57 65 6.13 5,70 66 630 TABLE 2 - Annuity Opllons OPTION 2. LIFE AND MINIMUM GUARANTEED TERM Monthty Installments per $1,000 of annUlly value, payable lor the number of years speCified and thereaher dUMg the Jifehme 01 the payee Age 01 Payee on Annuity Date 67 68 69 70 Amount 01 Monthly Inslallments Per $1.000 01 Annuity Value $6.48 6,67 6,87 7.09 OPTION 1 - PAYMENTS CERTAIN Monthly Install men IS, per $1,000 01 annuity value, payable dUring the number of years speCified No. of Amount 01 Years Monthly Certain Installments Age of Payee S Years 10 Years 20 Years on Certain Certain Certain Annuity Date and Llle and Life and L1fa 59 S5,32 S526 $4,99 60 5,43 536 5.06 61 5,55 5.46 5,12 62 5.67 5,57 5.19 63 5,80 5,69 5.25 64 5,94 581 5,32 65 6,08 5,94 5.38 66 6,24 607 5,45 67 6,41 622 5.51 68 6.59 6,36 5,57 69 6.78 6,52 5,62 70 6,99 6,68 5.67 5 10 11 12 13 14 15 16 17 18 19 20 S18,32 10,06 9.31 8.69 8.17 7,72 7,34 7.00 6.71 6,44 6.21 6,00 OPTION 3 - JOINT AND SURVIVOR ANNUITY Monlhly installments per $1.000 of annuity value, payable as long as either lhe payee or the payee's spouse is living, Age of Age of Spouse on Annuity Date Payee on Annuity Date 50 55 60 65 70 75 80 50 $4,17 4.27 4,36 4,43 4.49 4,53 4,56 55 $4.27 4.42 4,55 4,67 4,77 4,84 4,89 60 $4.36 4.55 4,75 4.94 5.10 5,23 5,32 65 S4.43 4,67 4,94 5.21 5.47 5.69 5,86 70 S4.49 4.77 5,10 5,47 5.86 6.23 6.54 75 $4.53 4,84 5.23 5.69 6,23 6,80 7.33 80 $4.56 4,89 5.32 5.86 6.54 7.33 8,17 OPTION 3 - JOINT AND 2/3 CONTINGENT SURVIVOR ANNUITY Monthly Installments per $1.000 of annuity value. payable while the payee and his or her spouse are both living. I Full paymenlS continue to the payee for life il the spouse dies, 213 the amount of paymenlS continues 10 the spouse for life " the payee dies. Age of Age of Spouse on AnnuIty Date Payee on Annul Oata 50 55 60 65 70 75 80 50 $4,30 $4,37 $4,44 $4.49 $4,53 $4,55 $4,57 ~ ~ ~ ~ ~ ~ ~ ~ 60 4.67 4,82 4,96 5,10 5,21 5.30 5,36 65 ~ ~ ~ ~ ~ ~ ~ 70 5,11 5,35 5.63 5.92 6.22 6.49 6.71 n ~ ~ ~ ~ ~ ~ ~ 80 S,62 5.95 6,37 6,88 7.49 8,16 8.83 The Annuity Tables are based on 4,0% interest and, where applicable, the 1983 Individual Annuity Mortality Tables, For annual, semi-annual or quarterly installments. take 11.76.5,95 or 2.99 limes the appropriate monthly Installment. J,se.ll-P 111891 8 .,~. TABLE OF MINIMUM GUARANTEED CONTRACT VALUES Contract Value for $1,000 Annual Premiums All Contract Values In this table: 1. are stated for a $1,000 Purchase Payment; 2. assume subsequent $1,000 premiums are received on the first day of each contract year thereafter; 3, are stated for the end of the contract year; 4. assume there have been no partial withdrawals; 5, are calculated at the guaranteed minimum interest rates; and 6. are to be adjusted In proportion for Purchase Payments other than $1,000, End 01 End 01 End 01 End 01 Conlrlc1 Vee. Conlrec:t Verue Conlrect Vee. Conl.e.1 Velue Conl.ecl Ve.. Conlrec:t Velue Conl...l Ve.. Conlrecl Velue 1 $ 1,040.00 11 $14,025,81 21 $33,247,97 31 $61,701.47 2 2,121,60 12 15,626,84 22 35,617,89 32 65,209,53 3 3,246.46 13 17,291.91 23 38,082.60 33 68,857,91 4 4.416,32 14 19,023.59 24 40,645,91 34 72,652.22 5 5,632.98 15 20,824,53 25 43,311.74 35 76,598,31 6 6,898,29 16 22,697,51 26 46,084,21 36 80,702,25 7 8,214,23 17 24,645.41 27 48,967,58 37 84,970,34 8 9,582,80 18 26,671,23 28 51,966,29 38 89,409,15 9 11,006,11 19 28,778,08 29 55,084,94 39 94,025,52 10 12.486,35 20 30,969,20 30 58,328,34 40 98,826,54 TABLE OF MINIMUM GUARANTEED CASH SURRENDER VALUES Cash values available upon surrender as shown in this table: End of Contract Year Cash Surrender Value 1. are stated for a $1,000 Purchase Payment; 2. assume subsequent $1,000 premiums have been received on the first day of each contract year thereafter; 3. are stated for the end of the contract year; 4, assume there have been no partial withdrawals; 5, are calculated at the guaranteed interest rates; 6, are to be adjusted in proportion for Purchase Payments other than $1,000, 1 2 3 4 5 6 7 8 9 10 $ 946,40 1,930,66 2,986.75 4,107,18 5,295,00 6,553,38 7,885.66 9,295,31 10,785,98 12,361.49 After 10 contract years, the cash surrender value is equal to the Contract Value shown above, J.!.("'~PI~9' I1'S~1 9 , ' John Alden Ute Insurance Company Home 0II\C8: SL Loult Pari<, MN Ellecullve Oftlce: P.O, eox 020270, Miami, FL 33102-0270 " SlOCk Company ~~y ENDORSEMENT DEATH BENEFIT OPTIONS The contract to which this Endorsement Is attached is amended by the addition of the following language: If the Owner dies before the Annuity Date, the beneficiary has up to sixty days after the date of death to determine the death benefit option. If no election Is made within 60 days of the death of the Owner, we wlll pay a lump sum benefit. If the beneficiary selects an option other than Lump sum Payment, the beneficiary will have up to one year to begin taking distribution. If the beneficiary defers distribution for up to one year, Interest credited on the proceeds wlll not be less than the Guaranteed Minimum Interest Rate of 4.00/0. John Alden LIfe Insurance Company ~ Secretary , ...~. .. ..... MAR 0 11993 APPLICATION FOR FLEXIBLE PREMIUM RETIREMENT DEFERRED ANNUITY Pleaso prinla" In'9LJllatior t J~~ ....,,.. i'1k. \01/ PARTICULARS RELATING TO THE BENEFICIARV 11~IIlflLi#:~~:':N\ ['l'(.Uhvo Ollf(~ PO nIl. 0;'0210. M..lIIu. rl JJ10}-{hllO PARTICULARS RELATING TO THE ANNUITANT (a) Full nome of proposed annUItant (print - lust nilfnc flrsl) 2eJI.I.1_-':Lj).R..EC~,L_.._ . (b) Se" 0 Male ~ Female 2, (a) Dale of birth -~.1bL'3.Q 1.4."'lh 0",. "',I' 3 SOCial Security Nurnwr ~/_t{.,::'30.~ Oft, IS (h) Age c..a 4 ta) Residence address Strl'et fa_. G12eetJ5 f-I":"'N'J.D 12 ,'11"'- Clt/'1~~A"Ir,J!'c.~,e -'A ZIP'/ "70 s-:s- (b) Business address, SlIeet City Sfale ZIp PARTICULARS RELATING TO THE OWNER OFTHE CONTRACT 5, Is the contracl being applied for, and to be owned by, Ule annuilant? ~ Ves 0 No (If no. comp'e,e 6 and 71 6. (a) Full name 01 proposed owner (prinl - fllsl name fllsl) (b) Relationship 10 Ihe annullant (c) Socral Socunly number 7, (a) Residence address: Streel ___....,______...._ Clly ____...___ State_ZIp (b) Business address Slreel City _ Slate ___ Zrp__.___. (PIIIlI, alln.1"'os In full and slale 'elalionr~~~~~~d ar'llullant) - ::r:;.." 1I~'S'~:,1Lo 12 rumary honoltc18ry(ies) 10 be __ _____._____.. "'-h"..e d. f...Orl2...ee.N..S_lLD._-B:.~_lf-=-5L 'J??I3S .C. j],Rt!'lSN-I:5l1:r\_S':..~3:21 if Itving; otl1l!IWl5e St'~~nd.1fY hcnnflclary(ics) .." ._-~.._-- ----.---.-- ._-----~~-- --. - --------~---._._------ PARTICULARS RELATING TO THE PLAN 13 litl Plall ~f)phcd for o "[',SION 0 PROFlT,SHARING o Io<'f::',{ji4 Pt AN 0 PUOllC EDUCATIONAL o INDIVIDUAL RETIREMENT INSTITUTION ""',UITY ONON,PROFlTORGANIZATION , p5(O'''ER I'!J.OfJ.r~ er; tI- 14 AnnUity ODllons (life annuity wrll be provldeo" no olher option.s requeslep I OLlie annuity o Life 8nnUlly Wllh rnlnimum guaranteed term of ~- _______ Years 15, 1001 20) . o Joult ;:no survivor annully on the lives of the an.,uilanl and his or he spouse; select annuily percentage 10 conlinue to annUltanl's spouse; =: 100% 066,213% 15 Will thiS annully ,eplace or change any exisllng life lnsuranceor annllily?:::J Ves 'lI1l No (If yes. give name o~m~y and plan 01 lile If'15Ufancc &~nnUlty.) :J: == ,.,. ;;1::0 . '......, .-...-.-----........::Q-l>o/Tl- , C'")o -.--.-----------(.)--::i.- f "..... --"-.-,... '....-..':ta-<n<_ ::Jl: ~..... 16 SpeClal..:.t.:llcsts _ rn'" ~ 00 B. M.lIl notices Ie ~ ReslPence 0 Bllsmess 0 Olher (snecllYI To 1110 ''''51 (" '-'y knowledgeano belief, thestal~enli""ndanswe's In thIS ^pr"c;~:lon arc true and complelo. I agroe thny shall be the baSIS lor ;In\, i.HlOUlty Issued as a resul1 of lhis application 9 Inlll.1l prClnllJl11 submllled With thiS applIcation s(,4ooo (mad!"' payahh~ to John Alden life) 10 ESlil.1' 'J fHclIllum for contract 10 he Issued UFI(:t>f this appllC.l1lon 5 _ _0____. _. _ (S25 mllUlIllllll) To he paid 0 Anllually o S,'f1l1-anllually o Quarterly o MOlltllly 11 Srlh'(~llt'.d :lIlr:,/l~Y (jalr' 2/ ;:?P/S- , '.. UnCI'r IH.'rl.-l ~ ._'~ of perJury. I cer11fy that Ihe SOCial Security numbers !ltlll." n on to- ~ 1"rl1l arU~lhe c ecl rm(p~r Identlhcallon number D,""j"~~ ,?t_g,'1.. d"yr:t.d.-., 1993 C ly - SI"le b _ , J 1 71. ~ Sl~' .' .re' p~sed annUItant (age 15 Of over) '>.- . .f" (II P'OP()S(~ff OWrlp.r If OU1111 1t~i1n ilhn'.-,' Iid~ ;I, J-~ SH111alll!P of hu:ns,_'{j a~]I'll! TABLE OP SURRENDER CHARGES a::ntract Vp;:tr surreOOer amge Pel'"r"Pntaae 1 2 3 4 5 6 7 8 9 10 'llIERFAFl'ER 9% 9 8 7 6 5 4 3 2 1 o Q.Ial:aI1teed Mi:rUnun Interest Rate - 4% If this cxntract is surrenderEd cl1.1rirYil the first 10 caltract years, \Oe will deduct any cq;p1icable surrerxler charge. See page 5. One partial wit1x1xawal in any 12 nonth pericxi of as nuch as 10% of the caltract value is alla..ed with no surrerxler charge. '!here is a surrerxler charge for other partial wit1x1xawals nade cl1.1rirYil the first 10 caltract years. see page 5. 'lbe "Q.Ial:aI1teed Mi:rUnun M:s1th1y Incare" shcMn below is based en (1) the mininun guarantee:l interest rates as shcMn aboVe cl1.1rirYil the accunulatien pericxi; (2) the initial prenium being cxntinued at the sane frequency indicated en the applicatien until the anmdty date; (3) the anmdty option specified in the cxntract; am (4) the mininum guarantee:l anmdty values reflected in the anmdty tables in this caltract. Arrf cl1atY;je in the annmt or frequency of prenium payrrents, any excess interest paid by us, am any rrore favorable anmrlty rates which \Oe nay offer at the t:lIre anmdty payrrents will begin will change the stated annmt. CONTRACT DATA CONTRACT NUMBER:..... 7086730A ISSUE DATE:... March 19, 1993 ISSUE AGE:.... 63 ANNUITANT: Sally H. Green INITIAL CONTRIBUTION: $33,640.97 INITIAL CONTRIBUTION RECBIPT DATE:........ March 19, 1993 ANNUITY DATE:. February 16, 2015 OWNER: Sally H. Green BENEPICIARY: AS STATED ON APPLICATION GUARANTEED MINIMUM MONTHLY INCOME:...... $1,083.48 ESTIMATED ANNUAL pREMIUM:...... $0.00 J-56lS-p(Schedule) (39) (1/89) 2 , \ . I . - ~ .-'- -~ _ _r .... _'" DEFINITIONS This is what we mean when we use these words or phrases: . "We," "us" and "our" refer to John Alden Life Insur- ance Company, "You," "your" and "yours" refer to the owner named on page 2, The "Annuitant" is the person who is to receive annuity payments, "Premium" means any payment made to us as con- sideration for the benefits of this contract. "Contract years" means the one-year periods begin- ning on the issue date and each anniversary of the issue date. "Calendar years" means January 1 through Decem- ber 31; the first calendar year is from the issue date to December 31, The "issue date" refers to the Issue date shown on page 2; it determines contract years, months and anniversaries, The "annuity date" refers to the date on which we will make the first annuity payment. The scheduled annuity date Is shown on page 2; you may later change this date, "Accumulation period" refers to the time between the date we received your initial premium and the annuity date. (1lher terms are defined as they occur in this contract. GENERAL PROVISIONS Basis of contract This contract is Issued on the basis of the application and receipt of the Initial premium, Entire contract; changes: This contract, the allached application. and any endorsements make up the entire contract. All statements In the application are representations and not warranties. No agent can change this contract or waive any of its terms, Changes can be made only by written endorse- ment signed by our president, one of our vice presi- dents or our secretary. Incontestability: This contract is incontestable from Its issue date, Non-Participating: This contract does not pay divi- dends or share In the surplus of the company, Mlaatatement of age: Before we make annuity pay- ments to you or any beneficiary, we may require proof of the payee's existence and age, If a payee's age Is misstated, we will make payments based on the true age; the amount payable under this contract shall be such as the stipulated pay- ments would have purchased at the correct age or ages, In the case of age correction after annuity payments start, we will: 1, In case of underpayment. pay the full amount due the payee with the next payment due with interest at 4%, J.!'I61r..1l f3Qll1'P(j 2. in case of overpayment, deduct the amount due us from future payments with Interest at 4%; deductions will be spread over the payment period. Ownership: The owner has all rights under this con- tract during the annuitant's lifetime, subject to: (1) the rights of any assignee of record with us; (2) the rights of any irrevocable beneficiary; (3) any restricted ownership endorsement; Non-lorlellabillly: This contract is your property; your values are for your exclusive benefit and cannot be forfeited, Beneficiary: Beneficiaries are named in the applica- tion: 1, lor the owner before the annuity date; and 2, for the annuitant(s) after the annuity date, Beneficiaries may be changed at any time, Agree- mentto a beneficiary change must be made in writ- ing by: 1, the owner (before the annuity date); or 2. the annuitant (after the annuity date); or 3. any irrevocable beneficiary, Written notice 01 the change, signed and dated by you, must be sent to our executive ollice, The change will be ellective on the date you sign it We are not liable lor any action we take before we receive and file the notice at our executive ollice, 3 Ca.h Surrendel1: You may surrender this contract In full for cash at any time during lhe accumulation period. The amount payable will be the Contract Value lithe full surrender request is made alter lhe , tenth contract year, In the event 01 lull surrender 01 this contract during the first 10 contract years, the amount payable will be the Contract Value, less a surrender charge, - We may deler payment 01 cash surrender values lor not more than 6 months alter receipt olthe owner's request. Partial Withdrawals: During the accumulation period you may request a partial withdrawal Irom the accumulation value. The request must be in writing, Each such partial withdrawal will result In a contract value reduction as of the date 01 our receipt 01 the partial withdrawal request, equal to the partial with- drawal amount received by you, plus any surrender charges. During the first 10 contract years, the Owner may make one partial withdrawal in any 12 month period of as much as 10% of the accumulation value without a surrender charge. However, a surrender charge will be applied to the lull amount withdrawn (includ- ing the 10% free partial withdrawal) when in any 12 month period: 1. more than 10% olthe accumulation value is with- drawn; or 2. more than one withdrawal is made; or 3. the contract value is reduced to less than $2,000; or 4, the contract is surrendered, The partial withdrawal charge is calculated byapply- ing the Surrender Charge Percentage shown on Page 2 to the amount 01 the Contract Value reduc- tion subject to the withdrawal charge. There will be no charge lor partial withdrawals alter the IIrst 10 contract years, .I.~~n'.f" r''l, f~ fl'. Death Benelll Options: II the Owner dies belore the Annuity Date. the beneficiary has up to one year alter the date of death to determine the death benelit option, The death benefit options arc: a, Lump Sum Payment. II this option Is chosen, we will pay the Contract Value in a lump sum. This payment can be delerred and accumulate with interest lor up to 5 years Irom date of death; or b, Equal payments for at least five years; or c, Life Annuity based on the IIle expectancy 01 the benellclary. II this option Is chosen, we will pay equal periodic payments lor the IIle of the benell- ciary as chosen; or d, L1le annuity and minimum guaranteed term, II this option Is chosen, we will pay equal periodic payments during the benellclary's lite; payments are guaranteed lor a minimum term 015, 10, or 20 years. II the Annultant(s) dies alter the annuity date, we will continue the annuity payments to the beneficiary as provided under the annuity option then in ellect. However, II there are joint annuitants, the contract will remain in lorce for the surviving annuitant. lithe beneficiary 01 the deceased payee, under an Annuity or Settlement Option dies belore ail pay- ments have been made, we will pay the amount still due in a single sum to the appropriate beneficiary, II a beneliciary dies: 1, at the time 01 or within 15 days after your death; and 2, belore death proceeds have been paid; we will pay death proceeds as though that benefi- ciary had died belore you, II no beneficiary survives you, we will pay your estate, Minimum benellls: The paid-up annuity values, cash surrender values and amounts payable at death under this contract are not less than the minimum benelits required by the laws 01 the state in which this contract is delivered, 5 ., Annuity options: In lieu of receiving a normal settle- ment life annuity beginning on the annuity date, you may elect one of the following annuity options: Opflon 1, paymenfs certain: We make equal payments for a set term not less than 5 years nor more than 20 years, If the payee dies during the set term, payments continue to the payee's beneficiary to the end 01 the term, Option 2, life and minimum guaranteed term: We make equal payments during the payee's life: payments are guaranteed for a minimum term of 5, 10, or 20 years, If the payee dies before the minimum term has expired, pay- ments continue to the payee's beneficiary to the end of the minimum term, Option 3, Joint and survivor annuity: We make equal payments to the payee while both the payee and his or her spouse are living; pay- ments continue to the survivor during the remaining lifetime of the survivor, Joint and 2/3 contingent survivor annuity: We make equal payments to the payee while both the payee and his or her spouse are living; full payments continue to the payee for life if the spouse dies; 2/3 of the original payment amount continues to the spouse for life if the payee dies, In addition, you may elect any other method of set- tlement aliowed by us from time to time for this class of annuity contract. To elect an annuity option, you must: 1, send a written request for the annuity option to us at our home Office; and 2, make such request at least 60 days before the annuity date. J.!l618.P 1~lfl<j, Annuity tables: The annuity tables in this contract are to be used to determine the doliar amount of annuity payments we guarantee for each of the annuity options available, At the time annuity pay- ments under any option begin, we will pay the greater of: 1, these guaranteed amounts; or 2, the amounts determined at any more favorable annuity rates we then offer, Minimum payments: Annuity payments may be annual, semi-annual, quarterly or monthly. How- ever, we will not make periodic payments of less than $50; for lesser amounts due, we wili change the frequency of payments. If annual payments would be less than $50, we will pay the commuted value of the benefit as a single sum: 1, to you, if living; otherwise 2. to the beneficiary, Such payment will be fuli settlement; it wili terminate our liability under this contract. This provision applies to payments we make to you or to any beneficiary. Annuity conditions: Only natural persons may be payees under an annuity option, For these options, we may require proof of a payee's date of birth, The age used for these options will be the payee's age on the date of the settlement. Unless otherwise provided, no beneficiary may assign, transfer, or encumber the payments under any annuity option, To the extent permitted by law, any amount retained by us, and any payments made, will not be subject to the claims of any creditor, nor will they be subject to execution or other legal process on behalf of any creditor of any beneficiary, 7 Age of Payee on Annuity Dale 59 60 61 62 ANNUITY TABLES Values for Ages Not Shown Will Be Furnished Upon Request ._ ,...,_,. _.T"B.LE.!..=.~orma!.~~l!lemenl . tIte ~~,!ully___._ Amount of Monthly Amount 01 Monthly Installments Age 01 Payee Installments Per $ 1 ,000 of on Per $ 1 ,000 01 Annuity Value Annuity Date Annully Value $5,34 63 $583 5.45 64 5,98 557 65 6,13 5.70 66 6,30 TABLE 2 - Annuity Opllons OPTION 2 . LIFE AND MINIMUM GUARANTEED TERM Monlhly Installments per $1,000 01 annUIty value, payable 'or the number 01 years specl"ed and thereaher dunng the "Ietlme 01 the payee Age 01 Payee on Annuity Date 67 68 69 70 Amount 01 Monthly Installment. Per $1.000 01 Annuity Value $6,48 6.67 6,87 7,09 OPTION 1. PAYMENTS CERTAIN Monthly Install men Is, per S 1,000 01 annuity value, payable dunng the number 0' years SpeCI"ed No. 01 Amount 01 Age of Payee 5 Years 10 Vears 20 Vears Vears Monthly on Certain Certain Certain Certain Installments Annuity Dale and Lite and Llle and Llle 5 $18,32 59 $5.32 $526 $4.99 10 10.06 60 5.43 5,36 5,06 11 9,31 61 5,55 5.46 5,12 12 8,69 62 5.67 5,57 5,19 13 8,17 63 5,80 5.69 5.25 14 7,72 64 5.94 5,81 5,32 15 7.34 65 6.08 5.94 5.38 16 7,00 66 6,24 6,07 5.45 17 6.71 67 6.41 6.22 5,51 18 6.44 68 6.59 6,36 5.57 19 6,21 69 6,78 6,52 5,62 20 6.00 70 6.99 6.68 5,67 OPTION 3. JOINT AND SURVIVOR ANNUITY Monthly installments per $1.000 0' annuity value, payable as long as either the payee or the payee's spouse is living. Age 01 Age 01 Spouse on Annuity Dete Payee on Annuity Dale 50 55 60 65 70 75 80 50 $4,17 4.27 4,36 4,43 4.49 4,53 4,56 55 $4.27 4.42 4.55 4,67 4,77 4,84 4,89 60 $4.36 4,55 4,75 4,94 5.10 5,23 5,32 65 $4.43 4,67 4,94 5.21 5.47 5.69 5,86 70 $4.49 4.77 5,10 5.47 5,86 6,23 6.54 75 $4,53 4,84 5,23 5.69 6.23 6,80 7.33 80 $4,56 4,89 5,32 5,86 6,54 7,33 8.17 OPTION 3 - JOINT AN 0 2/3 CONTINGENT SURVIVOR ANNUITY Monthly Installments per $1.000 01 annuity value. payable while the payee and his or her spouse are bolh living. Full payments continue to the payee lor hIe lithe spouse dies, 2J3 the amount 01 payments continues 10 the spouse lor hIe lithe payee dies. Age 01 Age 01 Spouse on Annuity Dale Payee on Annul~ Date 50 55 60 65 70 75 80 50 $4,30 $4,37 $4,44 $4.49 $4.53 $4,55 $4,57 ~ ~ ~ ~ ~ ~ ~ W 60 4.67 4,82 4,96 5.10 5.21 5.30 5,36 65 ~ ~ ~ ~ ~ ~ ~ 70 5,11 5.35 5.63 5,92 6.22 6.49 6,71 ro ~ ~ ~ ~ ~ ~ ~ 80 5.62 5.95 6,37 6.88 7.49 8.16 8.83 The Annuily Tables are based on 4.0% inleresl and. where applicable. Ihe 1983 Individual Annuity Mortality Tables. For annual. semi-annual or quarterly inslallmenls. lake 11,76. 5,95 or 2.99 limes Ihe appropriale monthly Inslallment. 8 'J.50t8-P(1/89) TABLE OF MINIMUM GUARANTEED CONTRACT VALUES Contract Value for $1,000 Annual Premiums All Contract Values In this table: 1. are stated for a $1,000 Purchase Payment; 2. assume subsequent $1,000 premiums are received on the first day of each contract year thereafter; 3. are stated for the end of the contract year; 4, assume there have been no partial withdrawals; 5. are calculated at the guaranteed minimum interest rates; and 6, are to be adjusted in proportion for Purchase Payments other than $1,000. End 01 End 01 End of End of ConIr8cl V..r Con\racl V.lue Conlrecl Ve.. Conlracl Value Conlrect Ve.. ConlrBCt V.rue Conlrect V... Contract Vllue 1 $ 1,040,00 11 $14,025,81 21 $33,247.97 31 $61,701.47 2 2,121.60 12 15,626,84 22 35,617.89 32 65,209,53 3 3,246.46 13 17,291.91 23 38,082,60 33 68,857.91 4 4,416.32 14 19,023,59 24 40,645.91 34 72,652,22 5 5,632.98 15 20,824,53 25 43,311.74 35 76,598,31 6 6,898.29 16 22,697.51 26 46,084,21 36 80,702,25 7 8,214.23 17 24,645.41 27 48,967,58 37 84,970.34 8 9,582,80 18 26,671.23 28 51,966,29 38 89,409.15 g 11,006,11 19 28,778.08 29 55,084,94 39 94,025.52 10 12,486,35 20 30,969,20 30 58,328,34 40 98,826,54 TABLE OF MINIMUM GUARANTEED CASH SURRENDER VALUES Cash values available upon surrender as shown in this table: End of Contract Year Cash Surrender Value 1, are stated for a $1,000 Purchase Payment; 2, assume subsequent $1,000 premiums have been received on the first day of each contract year thereafter; 3, are stated for the end of the contract year; 4, assume there have been no partial withdrawals; 5. are calculated at the guaranteed interest rates; 6, are to be adjusted in proportion for Purchase Payments other than $1,000, 1 2 3 4 5 6 7 8 9 10 $ 946.40 1,930.66 2,986,75 4,107,18 5.295,00 6,553,38 7.885,66 9,295,31 10.785,98 12,361.49 After 10 contract years, the cash surrender value is equal to the Contract Value shown above. ".l:H. r ,'10, /" ~~ 9 I ~ " 'I John Alden UI. InaurMCe Compeny Home oHlce: Sl. louis Psrle, MN Exocul;ve oHice: P.O, Box 020270. Mi4ml. Fl33102-0270 A Slock Company Individual Retirement Annuity Endorsement This endorsement is a part 01 the contract to which it Is attached, The contract Is amended by the addition 01 the following provisions: Owneflhlp: The entire Interest In this contract will be for the exclusive benefit of the annuitant or his or her beneficiaries. The owner must be the annuitant. "You" or "your" means the owner/annuitant. Premium.: During the accumulation period, you may make premium payments whenever you wish, However, no premium payments can be made after the close of the taxable year In which you attain age 70~. The minimum premium amount for any subsequent purChase payment shall be $50; however, we may either accept the additional future payments or terminate the contract by payment In cash of the present value of the paid up benefit if no premiums have been received for two full consecutive contract years, and the paid up annuity benefit at maturity would be less than $20 per month, Premium Umltl/Exceu Premium.: No premium payments may be made under this contract unless this contract is an Individual Retirement Annuity which meets the requirements of Section 408(b) ofthe Internal Revenue Code for the taxable year of the Owner for or during which the premium is paid. Premiums must be paid In cash; and: (a) must not exceed $2,000 per year (or the lesser of $30,000 or 15% of compensation per year In the case of a simplified employee pension as defined in Section 408(k) of the Internal Revenue Code), In the case of a spousal IRA, the maximum premium payment to all IRA's for any year shall not exceed $2,250, of which no more than $2,000 can be contributed to either spouse's IRA; or (b) must be paid with funds which qualify as a rollover premium payment under Sections 402(a)(5), 402(a)(7), 403(a)(4), 403(b)(8), 405(d)(3), 408(d)(3) or 409(b)(3)(C) of the Intemal Revenue Code, Compensation means wages, salaries, professional fees, or other amounts derived from or received for personal service actually rendered (Including, but not limited to commissions paid salesmen, compensation for services on the basis of a percentage of profits, commissions on insurance premiums, tips, and bonuses) and includes earned income, as defined In section 401 (c)(2) (reduced by the deduction the self employed individual takes for premium payments made to a Keogh plan). Compensation does not include amounts derived from or received as earnings or profits from property (including, but not limited to, interest and dividends) or amounts not includible in gross income. Compensation also does not include any amount received as a penSion or annuity or as deferred compensation. The term "compensation" shall include any amount Includible in the individual's gross income under section 71 with respect to a divorce or separation instrument described in subparagraph (A) of section 71 (b)(2), J.{l617.[ (3911000 ,P,l:;"') If your premium payments for any year exceed the ~aximum amount you are legally entitled to deduct under the Internal Revenue Code, you may request a refund of the excess amount if: 1, you send your request to our executive office with written proof that an excess premium payment was made; and 2, we received your request and proof in time to make the refund before your tax return deadline (including any extensions) for the year In which the excess premium payment was made, We will then refund the amount of the excess premium payment from your last premium payment(s) received that year. No interest will be credited on the amount refunded, and no surrender charge will be Imposed, Annuity Dale: The scheduled annuity date Is shown on Page 2. You may elect an optional annuity date; however, the entire annuity value must be or begin to be distributed to you no later than the first day of April following the calendar year In which you attain age 7017. Written request to change the annuity date must be made at least 60 days before the scheduled annuity date, Annuity payments: Your entire interest (value of the annuity) will be distributed or commence to be distributed no later than the first day of April following the calendar year in which you attain age 7017 (required beginning date), in equal or substantially equal amounts, over: (a) your life, or your life and the lIle of your designated beneficiary; or (b) a periOd not extending beyond your Ille expectancy, or the joint and last survivor expectancy of you and your designated beneficiary. MinImum amounts 10 be distributed: If your entire interest is to be distributed In other than a lump sum, then the amount to be distributed each year (commencing with the required beginning date and each year thereafter) must be at least an amount equal to the quotient obtained by dividing your entire Interest by your life expectancy or joint and last survivor expectancy of you and your designated beneficiary, Life expectancy and joint and last survivor expectancy are computed by use of the return multiples contained In section 1,72-9 of the Income Tax Regulations, For purposes of this computation, your lIle expectancy may be recalculated no more frequentiy than annually, However, the life expectancy of a nonspouse beneficiary may not be recalculated. Proceeds payable al death: If you die before the entire Interest Is distributed, Ihe following distribution provisions shall apply: (a) If you die after distribution of your Interest has commenced, the remaining portion of such Interest will continue to be distributed at least as rapidly as under the method of distribution being used prior to your death, (b) If you die before distribution of your interest commences, your entire Interest will be distributed in accordance with one of the following four provisions: (1) Your entire interest will be paid within five (5) years after the date of your death, (2) If your interest Is payable to a beneficiary designated by you and you have not elected (1) above, then the entire interest will be distributed in substantially equal installments over the lIle or life expectancy of the designated beneficiary commencing no later than one year after the date of your death. The designated beneficiary may elect at any time to receive greater payments, (3) If your spouse Is not the designated beneficiary, you must elect a method of distribution that assures at least 50% of the present value of the amount available for distribution will be paid within your life expectancy, (4) If your designated beneficiary Is your surviving spouse, the spouse may elect within the five year periOd commencing with your date of death to receive equal or substantially equal payments over the life or life expectancy of the surviving spouse commencing at any date prior to the date on which you WOuld have attained age 70':. The surviving spouse may accelerate these payments at any time, i.e., increase the frequency or amount of such payments, J-(l617.E 139} 10 '8A IP,l11'il . . " (5) If the designated beneficiary Is your surviving spouse, the spouse may treat the contract as his or her own Individual retirement arrangement (IRA). This election will be deemed to have been made II such surviving spouse: makes a regular IRA premium payment to the contract: or makes a rollover to or from such contract; or falls to elect any of the above three provisions. (c) For purposes of the above, payments will be calculated by use of the return multiples specified In section 1.72-9 of the regulations. Life expectancy of a surviving spouse may be recalculated annually. In the case of any other designated beneficiary, life expectancy will be calculated at the time payment first commences and payments for any 12-consecutlve month period will be based on such life expectancy minus the number of whole years passed since distribution first commenced, Non-forfellablllty: This contract Is non-transferable, and your entire interest Is non-forfeitable, In accor- dance with the appllceble provisions of the Intemal Revenue Code. Aallgnment The Individual Retirement Annuity may not be: 1. sold; or 2. assigned; or 3. pledged to any person or entity: a. as collateral for a loan; or b. as security for the performance of an obligation; or c. for any other purpose. The Individual Retirement Annuity Is not transferable, except to your former spouse under a qualified domastlc relations order. Refund of premium.: Any refund of premium (other than those attributable to excess premiums) will be applied before the close of the calendar year following the year of the refund toward the payment of future premiums or the purchase of additional benefits. In the event of conflict between this endorsement and the contract, the provisions of this endorsement will govem. John Alden Ufe Insurance Company ~~ Secretary J-0617.E (39110/88 lPaQt!3) , ' , John Alden Ufe Insurance Company Home Olfice: 51. Loull Pari<, MN Execullve Office: P.O. Box 020270, Miami. FL 33102-4270 A Slock Company ~:y ENDORSEMENT DEATH BENEFIT OPTIONS The contract to which this Endorsement is attached Is amended by the addition of the following language: If the Owner dies before the Annuity Date, the beneficiary has up to sixty days after the date of death to determine the death benefit option. If no election Is made within 60 days of the death of the Owner, we will pay a lump sum benefit. If the beneficiary selects an option other than Lump Sum Payment, the beneficiary will have up to one year to begin taking distribution. If the beneficiary defers distribution for up to one year, interest credited on the proceeds will not be less than the Guaranteed Minimum Interest Rate of 4,00/0. John Aiden Life Insurance Company ~ Secretary ,,.,-r"'''''''''', 11!~4!f(~~:~, ~~)V MAR 0 ~JqQi APPLICA Tlort.FOR FLEXIBLE PREMIUM RETIREMENT DEFERR~ lI'fmUITY Ploasc print nil intorm.{!tion. Usn hlack ink O 3 (' ." , ., , R .......- . .,"to' PO Om omno Mhlml n. 33102.0:,.,0 PARTICULARS RELATING TO THE ANNUITANT 1. (a) Fullnomo ul pruposed annuitant (print - lusl name first) 5f111'1 tI.Jlecw ----. _._- (h) Sex: r..'J Male ~ Female 2 (a) Dale oltll,llI (h) Age . b,i,_ ~J 1.(.,30 ',',~'It. \)d, ~",\' ;J. 3 Social ScclJIlly Numbe' I.J .~.3t?::..~~_I.3. 4 (a) Bl1SH1tmcc nc.1l1fCSS Sl,cel fo(l,e-e.eN"jpr.bv~._Il.e/l!'e- cl,l1eekwtdbu.o,.lC __fft_ Zip. / .7Q.s":S" , (b) BUSiness address rt Stlcet _ -.,.--' Clly Slalc _Zip PARTICULARS RELATING TO THE OWNER OF THE CONTRACT 5. Is 1l1e conllacl being applied for. and 10 be owned by. the annuilant? plJ. Yes D No (11 no. comp/cle 6 alld 71 6 (a) Full name 01 proposed owner (pnnt - first name Ilrst) - _._~._...__.-._-_..._---------- (b) Relallonshlp 10 lhe annullanl (C) Social Secullly number 7. (a) ReSidence address ._~,01.) Street C.ty Slale ___ ZiP . -' . (bl BtlSlllP5S ndCICSS Stlt~el -- -----.- ....------------ ----. C,ly .. __ State _' ZiP ._+n~__ -- ~ ReSidence 0 BUSiness 0 Olher (speel1y) 8. M,III nollcc!.10 9 11lI1lill pH~I111tll1l SUbl111lll:>d with thiS appllcntlon S . (madp p.lyablp 10 John Alden life) 10 Fst"llall~O 1('cll"II1~-l PIl>IllHII1l lor contract 10 he 155U('d Wl(lt;1 tillS ;lppllcatu In S o tS25111l1'111HlI111 To bl' p.llt! Ll/4.lH1llally ;-1 ~:, 1111 ;W"ll;IIly U Ollar101y :JMol1tt. 11 ';<.I"""'~ "", ',"':' ;-/ ?o1S- PARTICULARS RELATING TO THE BENEFICIARY (pont all flames If1 full and state relationship to proposed nnnwlant ) It, I? Pfll1l"ry bel1cllcoary(les) to h?".._~~_~~""-It., ~ '1(,'GtlJ'I,eJ r (JlIe'etJ".S8n-,--~---~.'f_.~I. . rnl?S (.. ,Or,e-e,ef'J.I.S/r.'::>,_.5.:~ ~7?:Y If IIvll1g, ottlpIWI~;e ~;l~col1dafY hcneftclary(lcs) ~- ___n______ ----~ .~---------_._- - PARTICULARS RELATING TO THE PLAN 13 (;1) Pl,lll applied fOf [J I'LN~;ION D PROFlT-SHAlHNG i-I KF(\G" PLAN 0 PURI.!r. fDUr.A lIONAl J!> INDIVIDUAL RElIREMENT INSTITUTION ANNLJI1Y DNON.PIlOF'T OIlGANllATION D omEn ' 14, Annully opllons (hie annuily wlil he plovided II 110 olheo optlOl1 IS ,eQuesled ) D Lile annuity [J life annuity with minimum guaranteed term 01 __ _ Years 15, to u' 201 . [J JOIl" and survIVor annuity on the lives of the ilnnUlI(tIlt and tus 01 her spouse; select annuity percenlage to conlllluc to :lIlIllJltant's spouse. D 100% D 66-2/3% 1 ~ Will this annuity replace or change any existing hfe Insurance or anlllllty? D Yes ~o (If yes, give name 01 company and plan 01 hIe inswancc Jr-a~mJlty.) --------..------------. H', Sp""lillll'qlll,sIS 1'4~-~;;'~ AsAP -(~~,~..7'o ~ .~..... 1 0 111l'11I:~il 'II Illy I..nowledge and behel, the slalernents and an5wcr5 III lI1l'j l..pplll':;illl11l ilf(l true and complete I ag'et~ t!ley shall be the til',1:, 101 illlY OI1llllJlly Issued as a resull of thiS applicatIon LJI1l:1~t pI11l.Il\It':; 01 pe'lury.l certify IIlal tile SOCial SeclIflty tHuntJIltS :,I,ow" .,11 """ 101111 a,e I"" co"cclla.payer IIl""'J"""" 1I1111l!>'" 0,11.'>1 (1..1.. . .'./"., ~1I1S_:<-(," day 01 Nt-, 19 V Li'~~71;;j ? '. .J<t~" 7/ ~(-'1V ~;H;I1;II'I't' 01 pfO){)~pd annuItant (ilqe 15 01 (I"'I~l) ~~";"'~'l'" ,,I PIIIIIU:,I": OWI'j'! Ilotll1'llh.I'; ;11',;1'..' /0d1tL- 1/, ;p AtrnK- '~I':!lal1PI ullln'''~''i1 ;lll~"'~ jI~.nl'l ROpOrt To Ih. bell of your knowlodgo,ll roplacomont or change of any olllllng Inluranco or annully In any way Involvod In Iho Iran18cllen? o Ves 99-NO, (II "yes; submit wllh this npphcahon all IOformation required by stale rcgulnhon and company.'ulcs,1 Salesperson's name ~,It_,-..7~"/';!~ Salesperson'. code no. _€I. tP 10 Y'i Salesperson's b~slness a~e...s07P~~~-I-h 33()7-~ Iht/-r/i; - I 70 ( I Finn Name~,e. "'J~-~--~- Ollicecode; -------- J.!>62',A 1391 Enclosures: ;;031' ) Check for~}~ ~:::;;ayabl~.fohn Alden Life Insurance Company) ReplacemenVcomparison forms Other RemarkS: 1!t.('J~ OJ "#. .I1-"U.. A.';,I'/,t:::> wl,fA.. a /I-",-~~~<. .~--ifrn'" ~ -IA,,-;d":,. J .I; -TM.-;Z<'u -h..-. "'-I I,.). -;A.I Mrr::;r--" -. ~~A.6J- -7A"-r (7/7) 7~ l' -79 7/ Mailing Instrucllons: (Contracts Will not be mailed direct to the owner, They will be mailed to salesperson's business address shown above unless olherwlse requested,) . Prinl names of agents Interested in Ihis application f:i:th.tt:E2>Lfl~(7N~ Agent code dt) , "'I 2-0"'1'1 Share / a~ ot;?", Agent code -- Share I certify that I havo reViewed IhlS ilpphcation. determined that all questions are answered IlIlIy. cOlOpletely and accuralely as supplied by Ihe apphcant, and recorded lull details as requirod, Agenl'sSlgnalure _&~.,g.~ 9Z I \ \tel '1- ~~\-\ ~G . td30 3f1SS11:lljUU\O'J 03"\3~3~ . . ". . llv-UnUt v.... SCHEDULE H fUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES ~:i;!- CoMMOHWIAl1H O' 'IHHlYlYAHIA IHHUI1AHCf lA)( lnUIH lUIOIH1 DICIDfHT Plea.. PrInt ar Type a flL SALLY B. GREEN, DECEASED ITEM NUMBER A. Funeral bpense.. 1. 1996-00210 AMOUNT DESCRIPTION Gingrich Memorials - grave marker Ck. 1106 paid 10/24/96 75.00 5,422.41 Malpezzi Funeral Bome B. AdmInIstrative Casll: 1. 2, 3. 4, C. 1. 2, 3. 4, 5. 6, 7. a, WAIVED Penonol Repr..entative Commi..ions Richard F. Green_ - Sodal Security Number 01 Personal Representative: 201-40-7517 Vear Cammi..ions paid Attorney Fees _ Boswell, Snyder, Tintner Iio piccola 8,850.00 Family exemption - NONE Claimant Address 01 Claimant at dotedent', death Slreet Addre.. Cily Relatian,hip State Zip Code probale Fee, _ advanced by Boswell, Snyder, Tintner Iio piccola - Ck. 16 paid 5/23/96 MIscellaneous Exp.ns.., Boswell, Snyder, Tintner Iio piccola - disbursements for cORies~ postage, fax, travel, etc. Ck. 16 paid 5123/'J6 Landis Jewelers, Inc. - jewelry appraisal - Ck. 11 paid 5/23/96 Dauphin Deposit Bank and Trust Co. - service charge Dauphin Deposit Bank and Trust Co. - service charge Dauphin Deposit Bank and Trust Co. - deluxe checks 293.00 23.85 15.00 6.00 1.00 17.24 67.30 The patriot News Co. - advertising - Ck. 120 paid 7/11/96 Cumberland County Law Journal - advertising - Ck. I 21 paid 7/11/96 60.00 ------- TOTAL (Also enter on line 9. Recapitulation) S 24,284.67 (II more space i. needed, in.ert additional sh.ets 01 .ame .111,) December 27,1996 Jeffrey R. Boswell, Esquire BOSWELL, SNYDER, TINTNER & PICCOLA 315 North Front Street P. O. Box 741 Harrisburg, PA 17108.()741 RE: Estate of Sally H. Green, Deceased Dear Jeff: I am the Executor of the Estate of Sally H. Green. As one of the two sons, I am also a beneficiary of the Estate. I recognize that I am entitled to be paid an executor's commission for my work In the administration of this estate. However, I have decided to waive this payment of the executor's fee or executor's commission. You have explalned that I am entitled to this executor's fee or executor's commission. I authorize you to state my walver on the Pennsylvania Inheritance Tax Return. Sincerely, /~f~ Richard F. Green, Executor RFG:clh ., . 1I\l-III,,,.P'" ,,~:~'91\ ...~s.,.; Cl)MMONWUllH Of "NN"'.....N'... UIHUltlHCI W InUIN IUIOIH' OtCfOINI SCHEDULE I DEBTS OF DECEDENT, MORTGAGE L1ABLlTIES AND LIENS PI.a.. Print ar Typ. fiLE NUMBER 1996-00210 ESTATE Of SALLY H. GREEN, DECEASED ITEM DESCRIPTION NUMBER 1, Andrew , Patel Associates Ck. . 3 paid 5/23/96 2. A. Z. Ritzman Ck. . 4 paid 5/23/96 3. A. Z. Ritzman Ck. . 5 paid 5/23/96 4. Kilmore Eye Assoc. Ck. '7 paid 5/23/96 5. Moffitt, Pease , Lim Ck. . 8 paid 5/23/96 6. A. Z. Ritzman Ck. '9 paid 5/23/96 7. G1amm Anesthesia Ck. '10 paid 5/23/96 8. P P , L Ck. '11 paid 5/23/96 9. United Water PA Ck. '12 paid 5/23/96 10. York Waste Disposal Ck. '13 paid 5/23/96 11. Suburban Cable Co. Ck. '14 paid 5/23/96 12. Debra Bashore Wiest - Tax Collector Ck. . 15 paid 5/23/96 13. Capital Health System Ck. '16 paid 5/23/96 14. Bell Atlantic Ck. '17 paid 5/23/96 15. Andrew' Patel Assoc. Ck. '20 paid 6/19/96 AMOUNT 173.93 10.35 13.46 14.54 51.98 19.46 16.54 227.18 24. Bl 35.04 2.10 230.46 65.11 88.78 42.88 TOTAL (Also onlor on IIno 10, Rocopllulotlon) {II more spac. is ne.d.d, inlert additional ,h..ts or same size.' $ 2,588.19 1 -.. ., SCHEDULE I (continued) Bell Atlantic Ck. # 18 paid 6/19/96 49.58 PP&L Ck. # 19 paid 6/19/96 17.56 United Water PA Ck. # 101 paid 7122196 32.17 PP&L Ck. # 102 paid 7122/96 19.77 Pinnacle Health Ck. # 104 paid 9/26/96 170.88 American Hcprt Association 10.00 Metropolitan Life annuity - reclaim 310.53 Metropolitan Life annuity supplement - reclaim 20.13 Silver Spring Township Sewer - paid 6/28/96 132.00 Pinnacle Health Ck. # 105 736.00 Kunkel Surgical Group Ck. # 108 pald 11/19/96 72.95 -'--;v,~.". ""_" >._-~~"~ "z,.' "'_~': ~:. ':'~'~~~~.'>>'~~'_..~"~~':':<>,,:L~~Z.:~-'_:-Y~~-7 ... .., , 1I't.\IIU" fU11 *' (OMMONW'ALI" Of "NNltLVANIA IHMflITANClIA. .'NIN "IlMN1 DleIDlN' SCHEDULE J BENEFICIARIES L ISTATI OP SALLY B. GREBH, DECEASED FILE NUMBER ITlM NUMBER NAME AND ADDRESS OF BENEFICIARV RELATIONSHIP 1996-00210 AMOUNT OR SHARE OF ESTATE A. Ta.ablo BoquOIl1: 1. Richard F. Green 1 Mountain View Drive Mechanicsburq, PA 17055 Son SOl of residuary 2 Thomas C. Green 238 Dotterer Road Lenhartsville, PA Son SOl of residuary 19534 ITEM NUMBER NAME AND ADDRESS OF BENEFICIARV AMOUNT OR SHARE OF ESTATE B, Charilablo and Gavornmonlal SoquOIh: I. NONE TOTAL CH,\RITABLE AND GOVERNMENTAL BEQUESTS (AI.o onlor on line 13, Recapilulalion) (If more .paco I. n"dod, InlOrt additional .h".. 01 .amo .1.0) S -0- Inventory of the reel end personal eslate 01 SALLY II. GREEN deceDsed Real Estate - 6 Greenspring Drive, Mechanicsburg, Silver Spring Township, Cumberland County, PA Personal Property Jewelry 1991 Dodge Dynasty SND - VIN 1B3XC46KSMD244247 Farmers Trust Account - checking account number' 1156691 Farmers Trust Account - checking account number 1156691 (interest) Capital Health Care - refund Horace Mann - refund Blue Cross/Blue Shield - refunds - 10 payments total Federal Income Tax Refund for p.e. 12/95 Silver Spring Township Real Estate Tax Reimbursement Cumberland ~alley School District Tax Reimbursement Malpezzi Funeral Home - prepaid funeral account John Alden Life Insurance Co. Flexible Premium Retirement Deferred Annuity, Contract Number 7086675A issued March 3, 1993 John Alden Life Insurance Co. Flexible Premium Retirement Deferred Annuity, Contract Number 7086730A issued March 19, 1993 .... N 5~ o.!!1 N .':li? co 0 .:? ~;: -=x: ) . 0 }; ..- .- ~)C) - .J '? 1""\ ~' .- '" ::1 C,.) ,] 07:,; Q _h_ 0.., 'J) ~Q) ~ ,~ ..0 r:~ a:: a:: 0 05,000 00 1,976 50 49 25 4,860 00 8,561 32 5 30 5 67 58 00 443 10 100 00 117 44 4 21 5,422 41 60,490 46 35,06 ,89 22,158 55 I COMMONWEALTH Of PENNSYLVANIA ) COUNTY Of CUMBERLAND J III being duly ,___._ eccardln9 to 'ew, dapo,"' end ley' thet ho "iJL.tbc_____..__._ ExeCll.tOJ:._______---- 01 tho ElIeto 01 _.--Bally" r.rt>t>n, Dc"nRAnrl lete 01 __l>-i;Lycr. Spring.. Township ___.._---..-, Cumberlend County, Pe., deceesed end thlt the within" en Invontory meda by _.-!!!m-. -. .-- - --.-.--, tho uld-EXccut.Or 01 the entlro utete 01 uid decodent, con,l,tln9 01 ell the penonel prop.rty end reel utete, except reel utete ouhlde the Commonweelth 01 Penn'ylvenle, end thet the fi9uru appa,lte oech item 01 the 'nventary repruent It'l felr velue 01 of the deto of decodent'l doeth. R~t:d.~,,~cn-.___. -~-- -- --_._._._._~---_._---_._---_._--- Sworn to end lublcribed beforo me, x- /!.JJlJ- - <,~/ /..::::. Eucutor . Admhhl,.t r December 30, 1996 .. Ri~ard F. Green, Executor 1 Mountain View Road ~f.~...(_~ N01I,mAl S[l\l SARAH (, ^?I'IUW, 1"'\01 Y Puhllc MyCOITilHI\,iunr\.p:r." O"c. 13, 1'1'1K HOI il,lJllrg, Pi\ uGi,pllin CQunly . Addr.u Mechan1csburg, PA 17055 ....--.--------- Dete of Deeth 23rd Day February Month 1996 v.., INSTRUCTIONS I. An invontory mull be fIIod within threo month 1 efler eppolntmont of penonel repruentettve. 2. A lupplement invontory mull bo filed within thirty dey' of discovery of edditlenel e"eh. 3. Additlonol ,huh mey be ettechod 01 to penonelty or roelty 4. See Article IV, Fiducleriu Act of 1949. ~ .... .d III III C ~ .~ rz:l & e Eo< .,; III E tll rz:l Ul I:: .. Cl ~ ~ < rz:l .... .. ~ Ul C \.l .. N lL ... U 0 <I'l .. .. Cl I 0 Ul Ul UI C II' t' Cl J: ~ II :. l- lL E I I Z ... -' u. \.l ..; ~ -' ~ 0 III lL .. 0 u. ~ l7\ W 0 <( ~ -;.. r"(\ l7\ > Z ~ U\ - ~ ~ Z 0 c .... c: ~ <I'l Z . UI 0 0 ~ =1 u 'tl Z Ul <( ~\ III ... lL -0 c: Iol .. III - -;: go lIol 0 .. lIol JJ UI .. E Iol III -0 '" - Cl4 ~ ~ 0 .. ~ 0 ..J U u: DO /s -1()~ / BUREAU OF INDIVIDUAL TAXES lHUlMI1AHC[ lAX DIVISION OlPI, 110611 HAR'UIURO, Pi HllI-OUI COHHONWEALTH OF PENNSVLVANIA DEPARTHENT OF REVENUE /~ I~p L/ NOTICE Df INItERITANCE TAX APPRAISEHEN1. AllDWANCE DR DISAllDWANCE DF DEDUC11DNS AND ASSESSHENT OF TAX '''_Lh,,,.''III.tll JEFFREV R BOSWELL ESQ 315 N FRONT ST PO BOX 741 HBG PA 17108 DATE ESTATE OF DATE OF DEATH FILE NUHB!R COUNT V ACN 04-21-97 GREEN 02-23-96 21 96-0210 CUHBERLAND 101 SALL V H A.aunt R."ltt.d HAKE CHECK PAVABLE AND REHIT PAVHENT TO: REGISTER OF WILLS CUHBERLAND CO COURT HOUSE CARLISLE. PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .. iiiV:iS4j-EX-"FP-iii3':97Y-iioYicr-OF-YNHEii'ii'AiicE-YAX-AJiiiilA'isEHE'iir-,--"Li:oiiAiicE-iili----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF GREEN SALLV H FILE NO. 21 96-0210 ACN 101 DATE 04-21-97 TAX RETURN WAS' (X I ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN I. Rool E.toto (Schodule Al (II 2, stock. end Bond. (Schodulo BI (21 3. Clo..1~ Hald stock/Partnership Int.r..t (Schadula C) (3) 4. Hortg.gal/Hat.. Recaivable (Schedule OJ (41 5. Ca.h/Bank Deposita/Hile. Parlonal Property (Schedule E) (5) 6. JointlY awnod Proporty (Schodulo FI (6) 7. Transfara (Schedule OJ (7) a. Total AI.at. ) CHANGED HOTEl To inJure proper credit to your account, sub"it the upper portian of this for. with your talC pay..ant. 105.000,00 .00 .00 .00 21.603.20 ,DO 95.555,35 lal 222/158.55 APPROVED DEDUCTIONS AND EXEHPTIONS: 9. Funeral Expanlal/Ad... COlta'Hlle. Expan... ISchadula H) 19) 10. Oobt./Hortgogo llebllltlo./llon. (Schodulo I) 1101 II. Totel Doductlon. 12. Hat Valua of TaK Raturn 15. Charitabla/Covarn.antal Baqu..t. ISchadula J) 14. Net Velue 01 E.toto Subjoct to Tex 24/284.67 2.588,19 1111 U21 U31 U4) ?1t.A'? A6 195.285,64 ,DO 195.285.64 If an assessmant was issuad praviously, linas 14, 15 and/or 16, 17 and 18 will reflact figures that includa the total of ALL raturns assess ad to date. ASSESSHENT OF TAX: 1S. A.ount of Lina 14 at Spou.al rata 11S) 16. A.ount of llno 14 texoble ot llnool/Clo.. A rete (161 17. A.aunt of Llna 14 t.~.bla at Collataral/CI... 8 rata 117) la, Prlnclpel Tex Duo TAX CREDITS: PAYHENT DATE 12-31-96 12-31-96 NOTE I ,DO X .00. 195.285.64 X ,06. .00 X .15. ua) .00 11.717.14 ,DO 11.717,14 RECEIPT NUHBER AA185019 AA185020 DISCOUNT (t) INTEREST/PEN PAID (-I 87.88- 22,10- 87.88 11.717.14 AHGUNT PAID INTEREST IS CHARGED THROUGH 05-06-97 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORH TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 11.695.04 22,10 .69 22.79 . IF PAID AFTER DATE INDICATED. SEE REVERSE FDR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL GUE IS lESS TNAN .1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI. YDU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRH FDR INSTRUCTIDNS,) . .".,- - --.-'- . ~ Of:' .~~ If' L/~ ~ t,.. N N 0< '2 " ~~~( .,. ., rJ r;) we.: a: r- 9' ,. 2~ 00 AUERVATlOHI Eltetn af dee...,t. dying an ar before Dee"'r 12, 1'82 -- If .", future Int.r..t In the ..tlt. It tnn.f.rred In panl..lon or MjOyunt to C.... . CeoUater.l) beMflc1arln of thtl dlud.nt eft.r the .xplr.tlon of MY' ..tet. for Ilf' or far y.ar., the coeeanwealth her.bY' .xpr...I, r'l.rv.. the right to appr.i.. .nd II.el. trMlf.r InherltMe. T...I .t the lawful CI.II . Ceall.t.r.l' r.t. on ."y .uch future Int.r..t. P\IIPOU OF NOTICEI To fulfill thl r.qulr.aent. of Section 2140 of the Inherlt."ce and E.t.te Tlx Act, Act 21 of 1"5. e72 P.$. Section .1U). PAVlEMTI OIit.ch thl tap portion of thl. Notice and .ubelt with )'our pI".nt to the A.gltt.r of "lilt printed an the nVI,., tlM. .....-e check or IKIM)' order ply.tll. tal REGISTER OF MILLS, AGENT RfRIrID (CA)I A nfW'lCl of _ tax credit, which .... not r.quelted on the Tax Rlturn, uy be rlqUelted by CMPllt1nt ." "appllc.tlon far Refund of PennnlvWlI. Inheritance and E.tat. Tax" CREV-1315). Applications Irl .v.llabl. It the Offlc. of the Reght.r of WIlIt, ."y of the ZS Revenu. Dhtrlct OUlcn, or bY' ceiling the .p.elel 2"-hoUr Inlverlng I.rvlc. nuebers for for.. ord.rlng, In PennsYlvanle 1.IOO-S62-20S0, outlld. pennlylvanl. ~ within loc.l Harrisburg .r.. (717) 717.10'4, TODI (717) 77Z-ZZSZ CHe.rlng Iapllr.d OnIY'I. OIJECTIONSI Any plrty In int.r..t not s.tlsfl.d with the .ppr.II..ent, allowanc. or dl.allowanc. of deduction., or "I'S.-.nt of t.. (Including dlscQW\t or Int.r..U .. .hown on thlt Notice Milt object within Ilxty (601 d.y. of nc.lpt of thlt Notice bY'1 \ \, .....rltt., prahlt to the Pi Oepart.ent of A.venue, lo.rd of App...., Dept. 2110Z1, Harrisburg, P' 17nl"1021, OR ...I.ctlon to hev. the ..tt.r d.t.r.lned at Mldlt of the .cc~t of the person" repr..entetiv., OR .-...,..1 to the Orphan." Court. AlIIIIN UTR'IIVE CORREC1IDHS' f~tUlI .rrar. dl.cov.red an thl. .I......nt .hoUld be Iddrel..d In writing tal PA Dep.rt.ent of R.venue, lur.su of Indlvlo.al lax.., A1THI POlt '."I.aent R.vl.. Unit, Dept. 280601, H.rrllburg, PA 171ZI-0601 PhoM (717) 7.,.6505. S.. PatS 5 of the baa....t "In.tructlonl for Inharltanc. Tlx Aaturn for a A..ldent Decedent" IREV-lSOI) far en axpllnlltlan of IIdIlnhtntlv.b cornetab" arror.. DISCOtIIl I If any t.x due I_ p.ld ..Ithln thr.. (5) c.l.nd.r aonthl .ftar the d.c.dent-. d..th, . 'Iv. percent ISXI discount of the t.x p.ld II .Ilowed. The lSX te. eene_tY' nan-p.rtlclp.tlan penalty Is caeput~ on the total of the t.x end Int.r..t .11...ed, end not p.ld before Janu.ry 11, 1996, the flr.t daY' aft.r the end of the t.. lIM.ty p.rlod. Thl. nan-participation penalty It 8PPI.labl. In the .... .enner and In the the .... tI.. p.rlod .. you would app..1 the tIX end Int.rnt thlt he. bill" ......ed .. Indlceted on thlt notln. , I i I PDlAlTYl INTEREST I Int.rnt I. charged beglnnlnt with flr.t day of ddlnquency, or nine (9) .anths end OM (I) daY' froal the d.t. of de.th, to the d.t. of papent. T.... which bee... delinquent tMfar. Jenuan 1, 19lZ beer Int.r..t at the nt. of .Ix (6X) percent par annue c.lculated .t . d.lly rat. of .000164. All t,MI. which tMc... d.llnquent on end .ft.r January 1, 1,IZ will ba.r Int.r'lt .t a rat. which ..Ill vlry fro. c.lender yl.r to c.lend.r y..r with thet r.t. announced b)' the P' Depart.ent of Rlvenue. The 1IPP11cllbl. Intere.t nt.. for 1982 through 1997 .r'l !!!! Int.r..t RIte O.lly Int.r..t Factor !!!!' Int.rl.t A.t. U.lly Int.n.t factor 191Z ZOX .0005" 1917 OX .000Z47 191] I6X .000411 1911-1991 IIX .GOnOl 191" IIX .GOnOI 199' 92 .00Ol47 1915 lSX .OOnS6 1995.19'" 7X .GODI9Z 1916 lOX .GOOU" 1995.I997 OX .00Ol47 ".Int.r..t I_ calculated .. faUow" INTEREST a BALANCE OF TAX UNPAID X HUKBER OF DAYS DELINQUENT X DAILY INTEREST FACTDR ".Any Hatlce I..ued .ft.r lha t.. blcoaes dlllnquent will refl.ct en Int.r..t calcul.tlon to flft.... 115) dly. beYond the d.te of the a,,'''lInt. If PI~t I_ .ade .ftar the Int.rnt caaput.tlon d.t. .hown on the Hatlc., IKIdltlOMI Inter..t Milt be calcul.ted. STATUS REPORT UNDER RULE 6.12 Name of Decedent: Estate of Sally H. Green, Deceased Date of Death: 02/23/96 PA No.. 2196-0210 Will No. Admin. No. 1996-00210 pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No X . b. The separate orphans' Court No. (if any) for the personal representative's account is: N/A c. Did the personal representative state an account informally to the parties in interest? Yes X No Family Settlement Agreement signed June 2, 1997 d. copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the orphans' Court and may be attached to this report. Si9~~ Date: 03/27/98 Jeffrev R. Boswell. Esquire Name (Please type or print) Boswell, Tintner, piccola & Wickersham 315 N. Front st.. P. O. Box 741 Address Harrisburg, PA 17108-0741 (717) 236-9377 Te l, No. \I'l \.-.... N ,.... N Capacity: personal Representative ~ Counsel for personal representative (HAH:rmf'iAM3): ~ .. ..J(.1 .. .~. JRD/Juoe 30, 1992/17858 REGISTER OF WILLS Cumberland County Courthouse One Courlhouse Square Carlisle, PA 17013 NOTICE PURSUANT TO RULE 6.12 PENNSYLVAMA SUPREME COURT ORPHANS' COURT RULES To: Personal Representative COumd: JEFFREY H. HOSWELL, ESQ., RE: Estate or SALI.Y H. GHEEN ,Deceased, Lale or SILVEH SPRING TWP Estate No.: 21-1996-0210 Date or Decedent's Dealh: 2-26-96 Pursuant to Rule 6.12, the above named personal representative or the above named attorney, if ,applicable, within two (2) years of the decedent's death, and annually thereafter until administration is completed, is required to file with the Register of Wills a Status Report as required by Rule 6.12, in substantially the prescribed form, showing the date by which the personal representative, or attorney, as applicable, reasonably bdieves administration will be ClImpleted. The purpose of this Notice is to advise )'OIl that unless the requisite Status Report is filed with the Register of Wills or Clerk of the Orphans' Court. u appropriate, within ten (10) calendar days after the date of this Notice that the Register of Wills II required to DOtify the Orphans' COurt Division, COurt of COmmon Pleas of such ddinquency and to request that said COurt conduct a hearing to determine whether sanctiom should be imposed upon the dellDquCDt personal representative and the ddlnquent personal representative's coumd, if any. MconI1ngIy, If the requisite Status Report is not filed by 3~30 , 19~hou are hereby ................... ..'''''..- ~~. Coo. . "",,,_ .'" ",. '.12. ~ Date: 3-17-98 \..Q1~;C.~p.vt.vn nl..tJ Deputy egister of Wills r r Distribution to Estate File .." ',',~:-"t:. lof~" '-". ,,"I', .... ~i~' .t._~ WiL:';"'~i" A ...W .. L. . ',I..t.' ': . ...-~ ..