HomeMy WebLinkAbout97-01023
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I)ETITION H)H PHOUATE !lud GJ(ANT 01<' U~TTEHS
Estate 4 Ht:lll,fy C..dOAl..~~.__"'h_ No, ....llL--97-/0 ..,1.~
also klloll'lI as ___...__.. _..___. To:
-..._~- '.u__'_ I >('ct'u.\t'd,
s-;;,~i;;j,l;"l'I/"iIY Nil, '111- / 8 - I ZOQ
Ilegisler of Wills for Ihe
('0111111' IIfc.U.OI~t'JQMd ill Ihe
COIllIIIOll\\'l'alth tlll'l'llIl~ylvallill
_--o_.._.__~__.__.__..______. .
Thl' pt.'lilioll n!" tilL' t1IHll't\I).!.lIcd Il'''lll'L'ilull.\ Il'IHl'WIll~ Ihal:
Your .pl'liliolll'rt...,. WIHI i.../~ I X }'l'al'" 01 agl' Of {)Ider HlI Illl' l'~Cl'UI.r'ix.
In the I.asl will of Ihe abl'\'e deCl'delll, daled ....-_.. ..___..... ...._._._.. -.---4:'1~JI
and eodicil(,<j dllled _____. ...__._....._.._...._.._.._____.............._
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(\tall' rdnanl drrlllmtall,'l''\, l'.g. ll'llIll1l'iillioll, dt'alh tll t'\t'l'llltll, ('Ir,l
DeCl'lllll-lIl was dOllliciled al dealh ill ....._.G.-""~~e.Y'\.~"l._ . .
hn___._ lasl fa!J.jily or prilldpa' resldelli:" al -Ll.C.t(~lIr(/ ..I/',
--&r.te.H.JIJ,(.k",~/~1:I a"1Wf,&'t.m., .
(11,1 Sfl'l'l, 111I11lbl'l and IIlUIl\IjMIII~'
D~(.'CI1(JCl1t, thell ____i....J___.,. years or agc, died _'_'N.____
III -1Nt.:.t...S6f!!t.. ..1Iuir'li--..Ll/!ltillt__CUlkr
E.,,<ccPI a... folllH\''1, dC((,.'{k'lll did 1lOII1Iill'l'Y, was nol {,livoll'l'd and did flol hU\'l'lI rhihllllllll 01 ndup!l'd
lIfler exe,'ulioll of Ihe will ofll-red for probale; was 1I01lhe \'iclllll of a killillH 111111 \\U,\ lIe\'e.llIljlldk'"I'd
inl'ompctl'l1l: _'___'__. _..___..____~________''''".._
Deccndellt at dealh oWlled property wilh eslillluled vallles us follows:
(If dOllliciled ill Pa,) All pe!Solllll property
(If 1101 domiciled in Pa,) Persoual property in PeulI.lyll'allill
(If not domiciled ill Pil.) !'ersollal propeny ill COllllly
VnhJl' of real ('stalc in Pennsylvania Sf ' i
situated as follows: --'-!.!t!...Q"_~l!~I"(/._....^ IJ(~J;AA.ll!.~.LHrJ'
._-----~--~-_...._-----~--._._~.-._~._----._-,_.~._------"----
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\VHEKEHJHE, peliliollcr(s) respeClfUI.'Y. .re.'II'.)e eSI(s) Ihe..'lI.'o.haIC of Ihe IlIst. Will. 1.'.'.I.tl..CII.tll.c.'II(s)
presellled h,'rewilh alld Ihe Hrlllllof kllcrs uic~frlIIUI1;",.y ..... .... ... .~ ..__. ...
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OATIl 01' I'EnSONAI, KEI'IU~SENTATIVII:
COMIVIONWEALTlI OF l'i:NNSYLVANIA I. HH
COUNTY 0" _~l.(rH(2~llllf~..___..._..._... I
The pelillollcr(S) ahol'e-lIilllled .,,,.',,,(.\, or 11111'"1(.\' Ihllllh" .\1a1"'"1'1I1.\ 111"11' 10"'No11IM 1"'1111011111<'
ll'Ul' UlH.ll'Orrl'l'1 to the Ilt':-.[ (II Ill!' ~Ihlwkdgl.' !lfld h\'lll'l' \\1' prliliolH'lhl illld IlIutH_" I H'l'mllU I U'IH'C"t'II-
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4486587
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COMMONWEALTH OF PIiNNSV~V"NIA , DIPAH'MII~' Of' '!fAIIM I VI'AI Altomll
CERTifiCATE Of DEATH
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~ronic Technician Federal Govt. It'" ,.". ~"/( 4""''' \'I11_lpwo(.1
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lJI.Sl' \o1tl,L MiD 'l,'):f~')';\In,'. OJ' lD'i.W! C, .rONfI.8
......- .. '~r~..",+~",,jl,,,,,-;X'~,,,,,",,,,~,-,,,,-rtl'!l>;l.l-,,,,~~~,"H
I, HENRY C, .TONl\S, ofthcc Boroup,h t,f Hec.hl\\11.csburF:,
COUnty of Cwnbct'li;\ml and fit:utc cd' l'o;tfwvlvnn:L,\, boi.nf!, of sound
and (\:l.flpon1.n;~ mind, m,mo'\"Y lHH.1 '\11(\01'0 t:.nn(1t1\", r\l' mnke) I 1"\lb11!1h
and declare this 1,\Y LUQt Ian nnd '1'0!1tnl\\i'llt:, lwr.'cby l'clVol:ing
'and making v(Jid any ilI1U ull pdo1: \a1.111 1,y on at Ilny dtn,,) 1 110\:,1-
toforo made.
1..
I direct. the payrali'nt of al.l my just debtS and funer.al
fl\KpetlSeS ae !loon I1f tor lnydecens 0 I1l1 tho flll1nec:art convonisntly
be done,
2~
I give, doviso and bequeath a1.1 the ~.:e.st, res:l.due
and remsindor 0.1: my estate, rf.,al, pc.rsolllil and mixed, \~hataoovcr
and wheresoever tbe l1nme may he fJituate, to my 1:\0/0 (2) children,
to wit, my daughtut", t'!ARGARE'l' A, HURSH, and I1ty 90n, HIClIAEL L.
JONES, share and share alike, pOl.' stir.pes.
3.
For 1;11" purpose of .Cacilitl1tini; tbo settlement and
distribution oS: HiY (,Ht,.l-c., 1 Huthol'il,(' and cmpmvor nlY Executrix
or !Lxcoutor. burein(lh:cr llilll1cd, \vhicl1()ver the caso may bll, to
sell any and ,111 n,a1 (",tate \1hich I In;))' O\onJ .It the ti.tne of my
docease, at oithor public or p:dViltc snl,e, or saleH. ~lith regards
to my personal belongings Ilnd hoasoho It! f1.1J:nishinf,s, 1 dircc.cl
that I1ny itOlllS which InY children mny desire to take in kind aa
their share in my cstate, be set over and (li,f)tributo<.l to thom
in as fair .'lud llq\ll.tablo 1.1 ml.lnner as it is reasonably possible
to Llo.
it
, ,
LASTLY, 1 nominate, 00ll11t:ltLlto and Ilupoi.nt IllY dSIl!':h-
tor, HARGARlI'f A. HURSH, Ext:lcut:r'tx of 1;1110, mv Lila t \<11.11 and
'Xestarnent, and ill tht, event that my BRid d~Il{',hter Rho(Jld pre-
decease me. or should ahe bEl unable or U\will in!1'. to IJervn :I,ll
such capacity for 1!IlY reason, then in such evant I nominato.
constitute and appol.nt my eon, l>IIClJAbL L. .JUNES, Ext!cutor of
this, my Last ''';:1,11 ilnd 'l'estament, in l.er place and stead, and
in the event llla t my said son should a1.so predecease me or
should hl~ bl) unable to serve Cl!3 such Executor. for any ~ellson,
then in such tlvent 1 llom:lnate, conatitute ami uppoint TilE FIRST
BANK AND 'l'R\JSTCOC!lU'A,lY OJ" HLCilAiH CSBURG. l'btiNSYLVt\tHA, Execul;or
of this, my Las t \HU ilnd Tea tamont:.
IN WITHESB IonlEW;QF, I have her.eunto lIet my hand and
seal this .ill;!?-_ day of AUgU9t, A. D. 19[;5.
L '\b
i~ ,," .,' J ':'. _ -.J /
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Ilfnry r. .J()nes
JSEAL)
Sig~'leu, tldileu, pubHshed Imd dl.!clared by the. above-
namod 'HENRY C. JONES, as IUld for his Last ,Hll and Tee tament ,
in tbe presence of us, who have subsct:'ibed our names hereto as
witl:lesses, acebc J;'t;(jLWSt of said 1'1'>8t(l,tr,I1:, 11,\ his preacnce and
11;\ the presence of sncll ott\(~r.
~l!!,b/
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."'"''''':''' I~~t.
COMMmjW~~:lYlVANI^
UrPARfMENT 01-' flEVENtJE
OfPl 1110OO\
HAtH~1 H PA \71 \
OECWENT NAME IlA5UIRSI ,I.N[H,II(1{)lC l'jlllAII u\ll .~~~Ilik'".' ~l l4IQII'fIll WOId\
/,'/1,/1191"1-
IIf "~;A' Sl/'WI'NOSPOl/IES"",'E IlA',\ FII151 Alm""'OLI,NiI"" soc"i',ffiiiiiIi"""'BER LHIS REIUR~~~;~;~~E~I; ~~~~~'E WITH 'HE.
CiS! I Original Relum 02SupplementalRetl/m 03 Rom"nd.rRelum,..oo,,,,,,,,,"'tol1lJ61'
o 4.limlled E'tale 0 4a Fulure Inler..1 Compromise 1,"00,""""'''' 11.116" D 5 Federal E'tale 'o. Relum Required
~ 6 Decedenl D,ed ,.,tale I_"""'w,", 0 1. Decedenl Maintained a living T,U'I,,,,,,,",,,,o","'" 0 8 rotal Numberol Sal. Deoo"l Bo,e'
o 9lil~'liOn PIOCOed, Received 010 Spousal Poverty C,edill"'."""""wo" 1131.91 lOll \".,,, 0 II Election 10 I.. under So< 9113(AII"""" "",'
THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO,
NAME - CQ/,IPLElH'A1l1NGAOORESS -
eH/I~l.ES E, SH/ELDS 7f[
fiRM NAME (11~phcablel AliA
TELEPHONE NUMBER
I~" - () 7-0
~
W
Q
W
td
Q
I:) , I r
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
;)'ONC.s
SOCIAL SEGURiT' f NuMBf:H
H ~ N R Y
f
FILE NUMBER
(1 ~ .3
~~~.
--(lAlf orOEATH
;). I ~..,
~(~Jllnt,)(1( '/fAIl
o
c
-------------"-~~-------_.
{;;If(;[ lllIlU!
111;~~11?97
12 Net V.lu, of E.tat. (Line 8 minus Line 11)
13 Charitable end Governmental BequestslSec 9113 Tru'~ fo, which an ,'ecion 10 ta, has not Ileen
made (Schedule JI
14. N,t V.lu. Subject to Tox (Line 12 minus line 13)
15. Amounl of line 14 taKable
allhe spousal tax rate ' I
S~e instnlcllons on reI/eM side lor applicable percentage
16. Amount of line 141axable
al6'!.rale ,~I 10,75
17, Amount 01 line 14 taxable
al 15% rate
11 1
l-i8-I;)..OO
~ C,LOU':;~,e. RJ::>
f}1 E"C-HltN } OS E IA R6,
fA 17D!"~-
1. Real ESlale (Schedule AI
2 SlockS and Bond' (Schedule B)
3. Closely Held Corpo,ation,Partnersh'p 0' SOle.P,opnetorship
z
o
~
:;)
l::
~
(.)
~
4. Mortgages & Noles Recelvabla(Schedule D)
5 Cash, Bank Depo.l~ & Miscellaneous Personal P,operty
(Schedule EI
6. Jointly Owned P,operty (Schedule F)
7. Inter-Vivos Transfers & Miscellaneou:l Non-Probate Property
(Schedule G or L)
8 Total Groll A..... (Iotall.lnes 1.1)
9 Funerel E,penses & Adm,m'lreb<e Co,~ (Schedule HI
(I)
(2)
(3)
(4)
(5)
(6)
(1)
OJ I , I 7 0,
(}..O
(}O
00
00
.2,f.?
If 0
o I
,'J,37,11oJ/,81
10. Debls of Deceden!. Mortgage Llabllil,e" & Liens (Schedule I)
II, Total Deduction. (Iotal Lines 9 & 10)
z
~
~g
....11.
~
o
16 Tax Du.
, I
/ ~ ,7 :J, 'I
/,0 :J. 7
d.8,.;l,.38
(8)
(9)
(101
11,/33
'r, ;). 7 9
2-
oD
(III
, ,,()
; .0
:::1. ,It> (p
,0 D
.06
15
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Uod" 110""'"' 01 IIonu~ I dec"18 lha" n,,' ,,,.n",'" ,h" 18'um. ,""ud"" ac<ompanyong "'''''',,'', and .""meols ,nil '0 "" "" 0' my ,"ow''''''''' and 110"" ,'" floe com'" ,nd com~'''''''""' ,,,,,,or orow
l!JJl.n.!!l!Jl!."on,' 18,,,seora'''''' 'as'" on ., mlDfmll<o ,'"h,cn ,,,Pi!illAW"ow'''''' -- -----
.st!itt~OFP,E~S NR PO~L:;7.FI~:;;:N ADDR,SS I Ktlly ct" En~I", PA /70;.5" Dm~',;?)_ft
SIGN~~WOFP~EPARt_ r: ~rHERT~)~R~5"J~ ADDRESS (" <'..IO\l.~er Rd'l "1~ChCl."'\fcsb"r~ DA;:r-- --
~C,~- _ _ Pit /10bsJ_ _f-~s~'L
19
DI\lld~'!t'1 ~ompll.!~~E~r_I!I'.:""___,___
SlIun WOIU';': //" OR t!/-IAI! Ll oST:
-_....-~,.................._.,_.~--~.,.~-~...
CITY
._._-----~--
/11ECIfIfNI C'S';9 W~(~
~A _=rZ1f' /70 S-6'
<j
(I) 13, 005. "'''
Tax Paymenll and Crldlll:
1 Tax Duo (Page I lire 181
2 CredllslPaymMts
A Spousal Po,My Crodlt
8, Prior Payments
C. Discount
o
----0-
" tJ
Tolal Credlls (A 18 + C I (2) 0
5
InteresVPenally If applicable
D. Inleresl ,. I 0
1', ~~naIIY 1,1 .' 0
, lolallnteresVPenalty ( 0 + E) (3)
If line 21s greater than line I + line 3, en'er Ihe difference, This Is the OVERPAYMENT,
f-~.ck box on P.g.l Lln.lg to requttt. r.fund (4)
If line 1 + II no 3'16"greater than line 2, enler the difference This Is Ihe TAX DUE, (5) ~j!l; Ob5', /Pi>
A, Enter the Inleresl on lhe lax due (SA) 0
t:, ,_, ,y) ,:-
~nler the 101.J1if Une 5,~~ This Is the BALANCE DUE, (58) ~ 13, PO 5, lP(,
Make Check ;ib'e to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1, Old decedent make e transfer and: Yee
a, retain the use or Income of the property transferred: """"""""'"'''''''''''''''''''''''''''''''''' """" 0
b. retain the right to designate who shall use the property transferred.lllts Income: ,,""""",," 0
c, retain a reversionary Interest: or,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 0
d. receive the promise for life of either payments, benefits or care? ,,,,,,,.,,. " ,,,"""" " ,,,"",""" 0
2, If death occurred on or before December 12, '982, did decedent within two years
preceding death transfer proparty without receiving adequste consideration? If death occurred
after Decembar t2, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? """',,""" "'"'' " ,"""" ," " " "",,"',,""""" ",,"",,""" ",,"""',,' ~
3, Old decedent own an "In trust for" or payable upon death bank account or security
at his or her death? "'''".,,'' """" " " " " " ",," " " " " "'" """"",,'" """,,,,,,,,,,," """"" [l;I
4, Old decedent own an Individual retirement account, annuity, or ot:1er non-probate property?", 0
o
3
4,
()
II
~
No
!Xl
~
~
o
o
~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
72 P ,S, ~9116 (a) (1,1) (I) provided for the reduction of the tax rate Imposed on the net value of transfers to or for the use of the
surviving spouse from 6% to 3% for dates of death on or after July " 1994 and before January " 1995,
72 P,S, i9116 (a) (1.1) (II) provided for the reduction of the rate Imposed on the net value of transfers to or for the use of the surviving
spouse from 3% to 0% for dates of death on or after January " 1995. The statute does not exemp! a transfer to a surviving spouse
from tax, and the statutory requirements for disclosure of assets and filing a lax return are stili applicable even If the surviving spouse
Is the only beneficiary,
FOR DATES OF DEATH ON OR AFTER JANUARY 1, 1995. Please answer the following question by placing an "x" In the
appropriate space,
Old the decedent creete a trust or similar arrangement which la solely for the surviving spouse's benefit for his or her entire
lifetime',' Yes 0 No jKI
If you answered yes 10 the above question, Ihe lax on the trust or similar arrangement Is postponed untlllhe death of the second
spouse, at which time It will be fully taxable 01 the rate(s) applicable to the remainder beneficiary(les), Enter the value of the trust on
Schedule ,I, Part II, in order to remove It from the calculation of the tax due In Ihis estate, You may wish to file Schedule 0 In order to
make the election available under Section 9113, If the election is made, the trust or similar arrangement is taxed in the estate of the
first decedent spouse, the portion of the trust or similar arrangemenl which benefits the surviving spouse Is taxed at the zero tax rate,
and the remainder Is taxed nt the rate(s) applicable to the remainder beneficiary(les) If you choose to make the election, you must
anach Schedule 0 to a timely.filed tax return, along with Schedule(s) K and/or M in order to show the apportionment of the trust or
similar arrangement between the surviving spouse and the remainder beneficlary(les).
:JOAJE.J
'~"~"""".
COMMONWEAL TH Of PENNSYLVANIA
INHERITANCE TAX NEHIRN
N' T
E8TATEOF H ~AJ~Y C
SCHEDULE F
JOINTLY -OWNED PROPERTY
FILE NUMBER
J,/-97-/0';.3
"In 11111 ""I midi join' wtlhln ons Y'" of tIIs dl.ldlnt's dill 01 dlflh, " mUll blllpo"1d on &chldolt 0,
SURVIVINGJDINT n,NANT(SI NAME
A, 1rI,,-h,,e.1 L. ::fane.$
8, /)')~~ artt A. HIA."'$h
c,
JOINTLY.OWNED PROPERTY:
ADDNESS
RELA nONSHIP TO DECEDENT
1110 0 rc.hc<rd st,
mec.ha.nlcsb,\'j' PA I,OSS"
&bn
I I<e/ly Ct,
12M/a, PI! /702.!:"
claujh~r
LETTEN DATE DESCRIPT'lN Of PROPERTY %Of DATE Of OEATH
ITEM fORJOlNT MADE Include n."., of nnencllllnstiltllion and bMlk account number Of almit" klentifylog number. AltOCn DATE Of DEATH DECO'S VALUE Of
NI.lAIlER TENANT JOlNT oeed lor IolnHv,1IeId real estate, VAlUE Of ASSET INTER'ST DECEDENT'S INTEReST
1. )A N/A C.hell-/(:"j ~ut, ~ 5'o7a/)3';;'1~ PNC ~~9"',3'/- Ya ~98.1B
_ 8, &>>k, N. If,
.2. r".. 'Mo SlIVIfI.1s I1cct, #: 5030o59:L09 PNC $ ~5q.. 7'1 ~8S; 09
B. Y3
BtlMK. N,,4. "/leer. .Mt flI ,j.o..1, .'19
i5~ 2~
3,' ~ A. '/1.1/13 SMIlljS ,4cc.t, ~SMoO/P31Dq7 PNC II
B. I,Q0l7.SV
13a.ltk, /.J.,+, r a.c.c.r. ',nt. tv d .O.d. 3.o~ Y3 "b~3. 5"3
(see feller fr(ll11 ~AlC (lllac/':d w ',930.58
Scheel. ~. tlbt>ye)
TOTAL (Also enter on line 6, Recapitulallonl $ I, 0:;"1. '10
-
(If more space Is needed, insert addillonal sheels of Ihe same slzol
John 1I,,"cod, MUt"U.ll Lite h~\lIri\nCl' ClJmp,lnV ,tnd Afhil,lh.d Cumpnnll!s
- -------- -.-.---.------------,-. 1
, 'JnL....JUuU'lX,l' (')(")() Cse (his torm to 'urrSj~~(~~ ~~~,~~Bi~}~r AnnLlltv Contract I
I {lv",~ ~:~~::-~ ~- for lls C...h V,llue,' .
WORI.IJWIDE SPONSOR PleJse return the Polin' IContrart wIth this r"qul'st
INFORMATION CONTROL CENTER or complete and submit the Statement at Lost :'olicy leontr,lct
JOHN HANCOCK PLACE, PO 1l0X 772 If the Policy is Lost,
BOSTON. MA 02117.0'172 Please i.omplete the Spousal Consent (regardless of marital stalus)
CUSTOMER ACCESS 1.80.0...732.5543 if surrendering funds from
roD J.8o.o..~J2.5282 Qualified Plans exceptlRA, SEP, and 4D3(bil'lans,
~Pollcy Information __.__________.__ ______.
Policy/Contract Numbe,_.J::::: C! ;2.00' Ole, Namoot Insu,ed:Jf.'II'^'V C, fiJ,vc...(
IliE.F.OII OWINC lliWRMA TTON SHOlJLfJ [~FFI rCT C1IRllrNT POliCY INroRM" TION
(?/? ) ;,,,,, . Woo
Daytime Telephone Number
I
I
...-J
:=J
~t EN Rt', C, ro"hi:J'
ame 01 wner(s)
II G~U(ARi) Sr..
xcra:re..
M.1L<:..t{ ANICS 8,,~r; ,
my ,
'j 11- 18:..1200
SOCIal 5.'Cunty or I1N No, (include Dashes)
&
I tti S' )
Stale Zip Code
;1. at,
Agency Code
(,~., .lV
Agency Territory Number
PI FASTi ~o\MF "NI:lLO.R..AI2J:llHANr.rSIl'lLII~IS SFCllON
I I I 1 I I 1 I I I 1 1 1 I I 1 I I
Owner (Only to change the name of the existing owner"
11111111111-1-.1111
SOCIal Socunty" or Tax Payor ID (Include Dashesi
I I
I I 1 I I I,LLLI
Owner Address
LL
1-1.....L1 I 1 I
I_-LJ
UII
City
'Use form 84R to transf.r actual ownership,
l!!:. Payment Provisions
Any taxes and contract surrentkr cllllrges lif applicable) will be subtractedfrom tile contract value,
Make check payable to: 0 Policy Owner ~ Other: m 1'1 Po C, A 1<: Ii T' R, H u R S II
Mail check to: 0 Policy Owner 0 Other:
p!l Agency (Form 12988 required)
Ie. Federal Income Tax Withholdlnl!
The gain from the cash surrender of a life insurance policy or annuity contract is ordinary income according to Internal
Revenue Service guidelines, so John Hancock is required to withhold federal taxes (plus state tax where applicable)
from any cash surrender payment. unless you request otherwise and provide your Social Security or Taxpayer ID (TIN)
Number, Withholding is merely a method of paying taxes which you owe .. your total tax liability is the same whether
we withhold taxes for you or not. Even if you elect not to have Federal Income Tax withheld, you are liable for the
payment of feder.! income tax on the taxable portion of your policy proceeds, If your policy is part of a tax-qualified
arrangement. we are also required to withhold from the total amount of proceeds either 20. percent or a certain amount
based on IRS tables; this withholding does not apply for a full surrender that is directly rolled over to an accepting
financial institution or if the check is made payable to the plan itself, [f you are under age 59 1/2, the surrender may be
subject to a 10% IRS penalty tax, Y0U may also be subject to tax pen.llties und,>r the estimated tax payment rules if your
payments of estimated tax and withhoiding, if any, are not adequate. Please contact your tax advisor or locallRS office
for more informa tion, .
o I IJg want Federal Income taxes withheld from any taxable gain ,1S specified:
o~, .L1u.cf'rtnwll'Jl1Jifil'd r,JiHl dir;trihl./tiMl"
~ 00 - or w ~f rn'l1r'~/.d" "/I,ll l!J:...witIlJ1P/rf
p! I Do Nat. want taxes withheld from any taxable gJll1 from this surrender. l1:giirdll'''~ 11/ f},p hn'.' 1.1l/'rkat.
U no election is made, taxes will automatically be withheld according to IRS Regulations,
I 1 I
u
I I
State
I I I
Zip Code
UJLLLili
Area Code
I I-I I IJ.
Daytime Phone
I1III111111111111111111111111111111111111111111111111111111I1111111I1111111I11111111111111111111111111111111111111111111111111111111111111111111111111111I1111111111I1I111
'I'
14'
Form 17484 10195 Ed,
-'-~"Tr"-' ...
...,-...-.-.
- '--~r'-.'-- -
~,' __, -woo... _ _._., ~.._.---
-.. --
~ Mutual Life Insufance Company
John Hancock Place
Boston, Mass 02117
OWNER
HENRY C JONES
ANNUITANT
HENRY C JONES
ANNUITY NUMBER
V0200546
INDIVIDUAL ANNUITY WITH FIXED AND VARIABLE OPTIONS
The John Hancock Mutual Life Insufance Company agrees to pfovlde the benefits, fights and privileges
as stated In this contract.
If the contract Is In fOfce on the Date of Maturity, we will pay an Annuity to the Annuitant, until
otherwise dlfected by the Ownof, The vaflable and fixed portions of each Annuity payment will be
determined In accordance with the "Conversion" pfovlslon of this contract. The vaflable portion may
Increase or decrease depending upon the Investment experience of the Subaccounts In which the Net
Premiums afe Invested, Annuity payments will be payable at monthly Intefvals fOf a peflod of 10 yeafs
and as long thereafter as the Annuitant lives,
By written notice, the Owner may elect the Date of Matufity at any time before the Pfovislonal Date of
Maturity, provided the Date elected is: (I) not latef than the Annuitant's 85th blfthday without our prior
approval; (II) at least 31 days after the wfltten notice; and (Iii) at least six montho after the date the first
premium Is applied to the contract. If no othef election Is made, the Date of Maturity will be the
Pfovlslonal Date of Maturity,
A Death Benefit will be pal/able If the Annuitant's death OCCUfS befofe the Date of Matufity and before
the Surrender Date, as stated In the "Death Benefit" and othef cant fact pfovlslons,
We are Issuing this contract In consldefatlon of the application and the payment of pfem!ums.
The Cant fact Specifications on page 3 and the conditions and pfovlslons on this and the following pages
are part of the contract,
10 Day Right to Cancel - This contl'act may be returned by delivering or mailing It within 10 days after
Its receipt to the Company at Boston. Massachusetts. or to the agent or agency office through which it
was d'lllivered. with a written request for cancellation, Immediately on such delivery Of mailing and such
written request. the contract shall be deemed void from the beginning and a refund will be made within
10 days, The amount refunded will be the sum of (i) the Accumulated Value at the end of the Valuation
Period during which we receive 'the contract and (II) the sum of ali charges made with respect to the
contract,
~.~lh~
8-cL-
Secretary
Combination FlxedlVafiabla Annuity - monthly annuity payable to Annuitant beginning on the Date of
Maturity fOf a guaranteed peflod of 10 years and thefeaftef 10f IIle, i
Nonpaftlclpatlng
Initial pfemlum Is shown on page 3,
All benefits. paymellts and values under this contract which are based on the Investment experience of
a Separate Account are variable and nat guaranteed as to fixed dollar amount,
Form 90-70P
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COMMONI'/EM TH Of PENNSYI.VA"'A
INHERITANCE TAX RE TURN
R. .NT r
ESTATE OF
HCII)/()' C. .:To1J ES
SCHEDULE J
BENEFICIARIES
-
-
NUMBER
I,
~-
FILE NUMBER
J./- f'7- /Oo?,)
NAME AND ADDRESS OF PERSON(SJ RECEIVING PROPERTY
TAXABLE DISTRiBUTIONS (include OUlfighl SpOusal dislrib,liions)
-0--
RELA TIONSHIP TO DECEDENT
Do Hot LI'f Trull..(.,
AMOUNT OR SHA~-
OF ESTATE
,.
fl)o.rJo.rd 1/.. flu.l's4
I ke.lly Cf.. E"no)ec, P/1 17,,;)S'
/11 j c.ha.e.1 /... .T" l1eS
1/(" Orcko.r'd 5f,. l"rlec,ho.n,e.Sbl-\W/, PA-
. J /70S5'
Y2..
c1Cl.(o\3h~,.
.1.
Y7..
Sc> \II
.'IE. COl", ^""",rn""" -au,"" SHOll!< ''''' '" l.., " "_17." "''''''''IE. '" "'" "'><'0,", ..."
II, NON-TAXABLE DISTRIBUTIONS:
A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
"
,.
B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
.
TOTAL OF PART II. ENTER TOTAL NON. TAXABLE DISTRIBUTIONS ON liNt 13 OF RtV 1500 COVER SHEET $
----- -~~
(If more space is nlleded, rnsen additIOnal sheets of the same ~Ize)
'-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
/ S j,J J - /v
IUREAU OF INOIVIOUAL TA~r:$
INtf:RHANC:E TAM InVlSlON
PEPT, 21D60t
HARRJSIUNO, IIA 171Z8~06'1
c
NOTICE OF INHERITANCE TAX
APPRAISENENT. ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
11- 02 -1998
JONES
11-28-1997
21 97"1023
CUMBERLAND
101
L_~A.~U!!rR.!.It~~ J
MAKE CHECK PAYABLE AND REMIT PAYMENT TO,
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE. PA 17013
CUT ALONG THIS LINE ... RETAI~ LOWER PORTION FOR YOUR RECORDS ~
RiV: i54j" iif"AFP-ii19":9'fi-NOYici--OF-YNHiiiii'AifcE-YAX- APjiiiA'iiiiiiNT";-AL.LOWANCE-oi---n-n----- - ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
liENRY C FILE NO, 21 97-1023 ACN 101
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
CHARLES E SHIELDS III
6 CLOUSER RD
MECHANICSBURG
PA 17055
ESTATE OF
.JONES
TAX RETURN WAS, (X I ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VAlUE OF RETURN BASED ON, ORIGINAL RETURN
1, Real Eltate (Schedule A)
2. stock. and Bondi (Schedule B)
5. Clo..ly Held stock/Partnership Inter.at fSchedule C)
4. Harty_g../Hot.. Receivable (Sohedule D)
S. C..h/8ank Deposits/HI.o. Paraonal Property ($Qhadule E)
,. Joln'Uy Owned Property (Schedule F)
7. Transfars (Schedule OJ
8. Total A..~tl
APPROVED DEDUCTIONS AND EXEMPTIONS,
9. Funeral Expen.../AdM. Coats/Hilc. E~p.n..1 ISchedule N)
10. Dlbtl/Nortue.1 Lilbilitiel/Lienl (Schedule I)
11. Total Deductions
12. Nat Value of Tax Return
15. Charitable/Govern..nt.l Bequa.ts; Non-elected 9113 Trust.
14. Net Value of Eltate Subject to Te.
(9)
(10 I
(lJ
(2)
(3)
(4)
(5)
(6)
(7)
) CHANGED
91.170,20
,00
,00
.00
16.729,26
1,027,40
128.238,01
(8)
11,133.21
9.279.00
(11)
(12)
(13)
(141
(Schedul. J)
*
UY.ISH UA" l..."l
HENRY
C
l)ATE 11- 02-199B
NOTE: To insure proper
cr.dlt to your aocount,
.ubltH the upper portiun
of this for. "tin your
tax paYMant.
237.164.8'7
:>0,41:> :>1
216.752,66
.00
216,752,66
If .n ........nt w.. i..u.d pr.viou.ly, lin.. 14, 15 .nd/or 16, 17 .nd 18 will
r.fl.ct figur.. th.t includ. the total of abb r.turn. .......d to d.t.,
ASSESSMENT OF TAX'
15. AMount of Linl 14 at Spoulel rate 115)
1', AMount of Line 14 t.~.bl. at Lin..l/ClaDs A rat. (16)
17. AMount of Line 14 taxable .t Collateral/Class Brat. (17)
18. 'rlno!pal Tax Du.
NOTE:
TAX CREDITS'
PAYNENT
DATE
OB-27-199B
RECEIPT
NUNIER
AA296598
DISCOUNT (+1
INTEREST/PEN PAID (-)
,00
,00
216."152,66
,00
X ,00:
X ,06:
X ,15.
(181
ANOUNT PAID
13.005.66
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN,
TOTAL DUE
.00
13.005,66
,00
13.005.66
13,005,66
,00
.00
.00
. IF PAID AFTER DATE INDICATED. SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS loESS THAN U, NO PAYNENT IS REIlUIRED,
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YDU NAY BE OUE
A REFUND, SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
I
I
'9;_\
'<iIlVI.,
GI..,
CVIi,
, '
RESERVATION I E,t.t.. of decldents dying on or blfore Doo.~.r 12, 1982 -- !f any future lnterl.t In thl ..t.t. il trenlflrrld
In po....don or enjoy..nt to ell" I (coUeteraU benefiolart.. of the deaed..,t "ftlr ttM> IlCplntlon of MY ..t.t. far
11flor for v..r., thet COIlIlon\IHIIUh hlrlby Ixpr...h "I.lrIlIU the right to epprlhl and ...... tren.flr 1nti,dtenel hit..
It the II.,ful (;111' e (coUetareU reb on eny luch future 'ntlr,.t.
PIJRt'OSElIf
NOTICE I
To fu.' .11 the requlr...nts of S.ctlon 2140 of thl Inherltenol end Estate 18X Act, Act 21 of 1995. (n P.S.
SMtt.n 9140).
Jltech thl top porUon of thia Hotlce end tub.1t ",Hh your plVllllnt to the Rltlllltlr of Wllh printed on the rlv.r.. .1..
u"oke chIck or- loml)l order payoble to: REGISTER OF MILLS I AGENT
PAVttE"'1
."
'REFUND (CAli A refund of III te)! credit, which was not requested Dr! the Tax Return, lIa'l be requuted by oO.flletlng en "ApplJcatlon
for Ref~ of P.nnl)'1vanJa Inh.rltano. and Estate TIl)(ff (REV-1313J. AppHcatAon. arlll .v.llllbl. .t th8 Office
of the R8gltt81' of Willi, IIny of the 23 R8vlllnue Dhtrlct Offlc8s, or by call1ol1 the Ipecl"l 24-hour
Ilfl....rlna ..rvic. nUllb8rs for forll' ordering: In Pennsylvania lRaOO~36ZR2050, outsldlll Penn.ylvl!ll1l11 and
within 10c.l Harrisburg or.a (117) 187.8094, TOO. (717) 172-2252 Ottoarlna IIIPalud OnlY),
OBJECTIONS I Any p.rt)' In Intere.t not .,tl.fled with the apprai....nt, allowanc8 or dl.allOMenee of deductions, or .......-ot
of t.lI: (including dltcount or Inter.stl Ill. shown on thts Notice ..ust olljoct within .ixtv (60) da)'1l of receipt of
this Notice bYI
~.wr1tt.n prot..t to the PI.. O.Pllrt.lllnt of R.Vlllnu", Bo"rd of Applllals, Dept. 281021, Ilarr!sburg, PA 17128-1021, OR
uell11ClUon to have the lIaU.r d.terlllnllld at audit of the account of the p.r.onal repre..nhtlve/ OR
R.~pllln1 to the Orphens' Court.
ADHIM
ISTRATlVE
CORREcnONS I
DISCOUNT l
Factual error. dl.oov.red on this as......nt .hould be addr....d in writing tOI PI.. Oepart..nt of Rev*"U.,
lur..u ot Individual TaKllls, ATTNI Pott A.le....nl Revt.w Unit, Oept. 1.80601, llarr1tburg, PI.. 17128-0601
PhoM (717) 787.6505. See p.ge S of the booklet "Instr'uotions for InherItllnce TrI)( Roturn tor a ReshMnt
necedent" (REV-1S0l) for an .KplDnatioo of adllioistratlvelY corr.etable errors.
If .n~ tel< due II paid within three (ll cal.ndar Month!i aHor the d.e.dent'. death, . flv. p.rc.nii (5:1.) dlsoount of
the teK paid it allow.d.
PEMAlTVl
Thl 15:1. t.x 811n8.ty non-participation p.nolty I. oOllPut.d on the tot"l of the ta)( and Int.relt .......d, end not
Plld btlforlll J.nua"~ 1ft, 1996, the flr.t day /'Ifter the .od of the ta)( DIlnestv periOd. This "onRpartielpaUno
pena1t~ 11 ",pealable In the .... eanner and In the the .allle tillle period a. ~ou would appeal the tax and Inhr..t
that ha. be'" ,..u.ed a. indicattd on this notice.
JM'rEREST t
Int.re.t I. charg.d b.ginnlng with f1rst dav of d.llnquency, or nine (9) Month' and one (1) day frOll the date of
death, to the date of pay..nt. 111)(.' which bec... delinquent bnfore January 1, 1982 blar Intere,t at the rat. of
.IK (6:1.) Plrc.nt per "nRUlII calClulat.d at 0 dlllh rllte of .000164. All taK'" which becn.. d.Unq,,"nt on and .Her
Jlnulry 1, 1982 Nlll bear Interest at 8 rate whiClh w111 vary frOM oalend"r year to Clalendar veal' with that rate
ennounCllld by the PI.. Depart.ent of R.venu.. The applicable inter.st rates for 1982 through 1998 arel
t!!!; 1nt.rellt Rate Dallv Int.rest Factor X!!r Int.rest Rat. Dalh Interlll.t Factor
19a2 ZO% .000548 1987 9% .0"0247
1983 16i:" .000458 1988-1991 111: .000501
19&4 11i:" .000301 1992 9% .000247
1985 15% .000356 1993-1lJ94 n .000192
1986 10% .000274 1995.1998 9;: .000247
.RIntere.t 11 calculated ., foll(1tlll
INTBREST . BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
-~An)' Hotlo. I.sued .fter the taK becOll8s delinquent will reflect .n intere~t CI~lculation to flftellln (15) ~.y.
b_YO'ld the dllt. of the .....III.nt. If pav..nt ,h, 1Il8de flft.r tho \nterest cOllPut.Unn date shown on the
HoUce, additional inter..t' lIust be CI.lcul.te~l.