Loading...
HomeMy WebLinkAbout08-08-08 15056051058 REV-1500 EX (os-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Numtrer Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 2so6o1 Harrislwrg, PA 17128-0601 RESIDENT DECEDENT 21 08 C~~ ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 05/15/2008 08/26/1927 Decedent's Last Name Suffix Decedent's First Name MI Clay Beverly A (If Applicable) Eller Surviving Spouse's Informaf3on Bebw Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future {nterest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will} (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Jeffrey B. Clay (717) 720-4678 ~..~ Firm Name (If Applicable) m REGISTER ~F~fY1LLS USE O~' ~ ,~ _ - C~ ~~ ~ First line of address lE 1 - ' -~ ~' ~ ' l ,:. 233 Gettysburg Pike (~ CJD ' Second line of address - ~ ~' ~i ~~ City or Post Office DAT~'~ILED Q State ZIP Code L*ti Mechanicsburg PA 17055 Correspondent's e-mail address: Under penalties of perjury, I declare that f have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of reparer other than the personal representative is based on all information of which preparer Iran any knowledge. SIGNATURE OF PE ON ICES ICING RETURN _ / DAiE , n . ADDRESS / "f/ "'~ 233 Getty Mechanics urg, PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 c~,, 15056052059 REV-1500 EX Decedent's Social Security Number Decedents Name: Beverly A Clay RECAPITULATION 1. Real estate (Schedule A) ........................................ ..... 1. 0.00 2. Stocks and Bonds (Schedule B) .................................. 2, ..... 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages & Notes Receivable (Schedule D) ........................ ..... 4. 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ... ..... 5. 26,432.58 6. Jointly Owned Property (Schedule F) Separate Billing Requested .. ..... 6. 0.00 7. Inter-~vos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested... ..... 7. 0.00 8. Total Gross Assets (total Lines 1-7) ............................... ..... 8. 26,432.58 9. Funeral Expenses & Administrative Costs (Schedule H) ................ ..... 9. 5,211.00 10. Debts of Decedent, Mortgage Liabilities, ~ Liens (Schedule I) ........... ..... 10. 14,152.82 11. Total Deductions (total Lines 9 8 10) .............................. ..... 11. 19,363.82 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. 7,068.76 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .... . .............. ..... 13. 0.00 14. Net Value Subject to tax (Line 12 minus Line 13) ................... ..... 14. 7,068.76 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0.,_ 0,00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 7,068.76 16, 318.09 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17 0.00 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18 0.00 19. TAX DUE .................................................... ..... 19. 318.09 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-150o EX Page 3 File Number Decedent's Complete Address: 21 os DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Beverly A Clay 129-20-3140 STREET ADDRESS 233 Gettysburg Pike CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19} 2. CreditslPayments A. Spousal Poverty Credit _ B. Prior Payments _ C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty 0.00 Total Credits (A + B + C) (2) Total InteresUPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 15.90 0.00 0.00 302.19 0.00 302.19 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :......................................................................................... . ^ b. retain the right to designate who shall use the property transferred or its income : ........................................... . ^ c. retain a reversionary interest; or ......................................................................................................................... . ^ d. receive the promise for life of either payments, benefits or care? ........................ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................................. . ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ............. . ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................... ........................................................................ ^ . ^x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) {i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(x)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(x)(1)], The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(x)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 318.09 0.00 0.00 15.90 0.00 REV-1508 EX+ (g-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Beverly A. Clay Indude the proceeds of litigation and the date the proceeds were received by the estate. AN property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PA State Employees Credit Union (PSECU) savings account (S-1)-account #8904038752 5.22 2. PSECU checking account (S-4)-account #8904038752 2,208.94 3. PSECU money market account-account #8904038752 18,437.36 4. Federal Stimulus Check directed deposited into PSECU checking account on June 6, 2008 300.00 5. Refund of unused health insurance premium for Highmark Blue Shield Medigap Policy paid 6/2012008 356.06 6. Prepaid Funeral Policy with Homesteaders Life Company, Certificate #-002543778 5,025.00 7. One wedding band 100.00 TOTAL (Also enter on line 5, Recapitulation) 5 I 26,432.58 (If more space is needed, insert additional sheets of the same size) Estate of Beverly A. Clay Supporting Documents for Schedule E HOMESTEADERS LIFE COMPANY A MUTUAL COMPANY This Certificate is not a contract. It is only a statement of the insurance provided by the Group Policy shown on the Certificate Schedule. The Group Policy is the only contract. In the event of any questions, the terms of the Group Policy will govern. The principal provisions of the Group Policy, which apply to this Certificate, are shown on the following pages. HOMESTEADERS LIFE COMPANY agrees to pay the face amount of the Insured's coverage under the Group Policy, as evidenced by this Certificate, to the beneficiary upon receipt of proof of the Insured's death. Payment is subject to the provisions, terms, and conditions of the Group Policy. This Certificate is issued in consideration of the enrollment form and the payment of all required premiums. PLEASE READ YOUR CERTIFICATE CAREFULLY RIGHT TO CANCEL You may cancel this Certificate by delivering or mailing a written notice or sending a telegram to HOMESTEADERS LIFE COMPANY, P.O. Box 1756, Des Moines, Iowa 50306, or to Our agent and by returning the Certificate before nudnight of the thirtieth (30) day after You receive it. Notice given by mail and return of the Certificate by mail are effective on being postmarked, properly addressed, and postage prepaid. We will refund to You all premiums and policy fees paid within ten days after we receive notice of cancellation and the returned Certificate. Return of this Certificate voids the coverage for this Certificate as provided under the Group Policy from the beginning. The parties will be in the same position as if no certificate had been issued. Signed for the Company at its Home Office 5700 Westown Parkway, West Des Moines, Iowa 50266 ~~ ~~-~~ Secretary President GROUP PERMANENT LIFE INSURANCE CERTIFICATE. ANNUAL DIVIDENDS. Definitions of frequently used words and terms are on page 5. The index is on page 2. G-93S-MO Page 1 INDEX TO CERTIFICATE PROVISIONS Page CASH OPTION ....................... .... ... ... ............. 11 CONVERSION PRIVILEGE ............... .... ... ... ... .... ...... 10 DEFINITIONS ...............................................5 DIVIDEND PROVISIONS ...... .......... .... ... ... ....... ....... 8 GENERAL PROVISIONS ........... ...... .... ... ... ... ........... 5 LOAN PRO VISIONS ................................. ........... 9 OWNERSHIP AND BENEFICIARY PROVISIONS ..... ...... ... ........... 6 PREMIUM PROVISIONS ..................... ... ... .............. 7 CERTIFICATE SCHEDULE .......................................3 TABLE OF GUARANTEED VALUES ... ...... ....... ...... ........... 4 TERMINATION ............................................. 10 Page 2 G-93S CERTIFICATE SCHEDULE GROUP POLICY NUMBER CERTIFICATE NUMBER ISSUE DATE INSURED AGE AT ISSUE CLASSIFICATION OWNER GPOl 0002543778 MARCH 17, 2008 BEVERLY A CLAY 80 STANDARD JEFFREY CLAY OWNERSHIP IS IRREVOCABLY ASSIGNED BENEFICIARY - As stated in the Enrollment Form unless changed in accordance with the provisions of the Group Policy INITIAL PLAN FACE AMOUNT SINGLE PREMIUM SINGLE PREMIUM WHOLE LIFE $5,025.00 $4,999.88 We may, on any certificate anniversary during the lifetime of the insured, increase the face amount, as determined by us. Any increase in the face amount will be added to the face amount of the last anniversary to determine the death benefit. Any increase in the face amount is not guaranteed. At no time will the face amount be, decreased. No additional premium will be charged for any increase in the face amount. G-93-11 Page 3 TABLE OF GUARANTEED VALUES CERTIFICATE NUMBER 0002543778 The calculation of these values will be made with an allowance for the lapse of time. They do not include any adjustment for dividends or loans. All values in this table are based on a single premium paid at the beginning of the first certificate year. The cash value on each certificate anniversary is determined by multiplying the face amount shown on page 3 by the appropriate cash value from the table below and dividing by 1,000. Values for all years not shown in this table will be furnished upon request. END OF CERTIFICATE GUARANTEED YEAR CASH VALUE 1 $788.63 2 $800.93 3 $812.81 4 $824.20 5 $835.09 6 $845.48 7 $855.45 8 $865.06 9 $874.42 10 $883.66 11 $892.92 12 $902.38 13 $912.28 14 $922.85 15 $934.23 16 $946.39 17 $958.93 18 $970.99 19 $980.64 20 $1,000.00 Interest rate for basis of values: 4~ Page 4 G-93 ENROLLMENT FOR - HOMESTEADERS LIFE COMPANY GROUP INSURANCE TO p,p, gOX 1756/DES MOINES, IOWA 50306/800-477-3633 PROPOSED INSURED (Please Print) ~,a v f~CUC~- (r1 ~ • ~c,,,,, (~ ~ 2C~ 1rY'~ 7 ~Q /? ~ -- ~ - ,S l ~fCy ~ Last Firsij Initial Sex Birthdate (M/D/Y) Age SS No. Residence - No. and Street City or Town State Zip Phone No. APPLICANT/OWNER (If other than Proposed Insured) _ LasJJt~~ i~ First [_~~~~q~ t Initial / Address ~'" f''ICr?,~„~i!' iiye/ f/7 /~C~S f~;srEr L:{f -.-'7.Ss`_'t~ ~+©rr_ City / f State Zip SS No. Relationship to Ensured BENEFICIARY R Q U E S T E D B E N E I T S ter payment under any a the estate of the insured ants, remaining proceeds are to be paitl a beneficiary is specified above,) Sar\ Relationship to Insured 1 SINGLE PAYMENT PLAN If the insured does not sign the enrollment form, the initial face C ~ ~ ~ amount of the certificate will be equal to 1.005 times the premium . , Certificate Face Amt. $ paid for all issue ages. ^ Rider Premium $ ~, ~C>~ ^ MULTIPLE PAYMENT PLAN (The proposed insured must sign tf the following questions are both answered "no," we may issue a the enrollment form to qualify for the Multiple Payment plan.) certificate providing an immediate death benefit equal to the face Years amount. Premium Face Amt. $ OPTIONAL HEALTH HISTORY (Multiple Payment Plans) Payable 1. 1s the insured now bedridden, or currently admitted to or been Premium $ advised to enter a hospital, nursing home, hospice program, or any extended care facility; or been diagnosed as having or been DEATH BENEFITS ON THE MULTIPLE PAYMENT PLAN ARE LIMITED treated for AIDS or ARC? ^ YES ^ NO AS FOLLOWS: 2. Within the past five years has the insured been diagnosed or Years Prernium Payable treated for any of the following ailments? Less than 5 years 1st Year = 50% of Face Amt. Heart Disease Liver Disease Alcohol Abuse 2nd Year = Face Amt. Circulatory Disease Kidney Disease Drug Abuse 5 years or greater 1st Year = 35% of Face Amt. Stroke Anemia Nervous Disorder 2nd Year = 70% of Face Amt. Lung Disease Cancer ^ YES ^ NO 3rd Year = Face Amt. Diabetes If death by accident during the limited period, the face amount is payable. Payment Method ^ Monthly ^ Annually ^ Semiannually ^ Quarterly ^ Multiple Bill - (List other policies for PAC or MB) ^ Direct Bill ^ Preauthorized Collection (PAC-See Reverse) C~~Purchase Additional Insurance ^ Accumulate at Interest ^ Paid in Cash ^ Reduce Premium Dividends ~, Replacement-Will the propo ed certificate replace any existing life insurance or annuity contracts? ^ Yes ~No (If "Yes,"complete replacement papers) DECLARATIONS-To the best of my knowledge and belief, all statements and answers on this enrollment form are complete and true. It is agreed_that no insurance shall take effect until the premium has been paid and a certificate has been issued while the insured is living. ,I certify, if I am applying for insurance on behalf of the insured, that I have an insurable interest in the proposed insured's life; and have full authority to use his/her funds as premiums on the insurance applied for. i have paid. $ :~, cx~~ with thi~~enro-°ll~ment form. Signed at f~~r f, ~ ~~~t~ ~•~-. _ f~_ _, ~".~ Date _~?~4~i ~J, ~~,f~` ~' ~` State ~' ~~ ~' ~ - Signature of Apf3ficart`U06vrYer other tf~ n~roPosed Insured) Signature of Proposed Insured Agent's Statement: By my signature I certify that, to the best of my knowledge, all information contained in this enrollment form is correct, was~orded-accurately, and confirm this enrollment form was signed in my presence. ,t% ~ % ~, _ ,~ ~ _ © ~ ~ Security Option Agent's Signature ,~ ...~ Agent Number Prod. Code Mkt. Code ^ Advantage Optio GP-201-PA Copies: White -Homesteaders; White -Homesteaders; Pink -Provider; Canary -Owner DEFINITIONS WE, US, OUR means Homesteaders Life Company. YOU, YOUR means the owner of this Certificate. INSURED means the person whose life is insured by the Group Policy evidenced by a Certificate and as shown in the Schedule of Insurance. OWNER means the person(s) shown as Owner in the Enrollment Form unless changed. You may transfer Ownership or change the Beneficiary. BENEFICIARY means the person or organization named to receive the proceeds of this Certificate. A Beneficiary has no rights in the Certificate before the death of the Insured. CURRENT AGE means the Insured's age computed as of the Insured's last birthday. WRITTEN REQUEST means a request signed by You on a form provided by Us. We will accept a request not on O ur form if it contains the necessary information FACE AMOUNT means the amount stated in the Certificate Schedule. EFFECTIVE DATE means the issue date shown on the Certificate Schedule. The Certificate Anniversary, Certificate Year, and Certificate Months are computed from this date. PROCEEDS means the amount We will pay by the terms of the Certificate as provided under the Group Policy when it is surrendered by You or matures, or when the Insured dies. It includes the dividends left at interest and any paid up additional insurance bought by dividends, less any loan with interest. IN FORCE means the time duringwhich the Insured's life is covered. MISREPRESENTATION means an omission of a fact or an untrue statement which caused Us to take action different from what Our action would have been had We known the truth. CONTEST means to claim that the Group Policy is not in force with respect to a Certificate, or to deny payment of a claimbecause the Certificate is not in force, or to claim that misrepresentation has been made. CASH VALUE means the sum of the guaranteed value of the Insured's Certificate plus the dividends left at interest and the current value of any paid up additional insurance, less any loan with interest. GENERAL PROVISION S INCONTEST- We consider statements made by You and the Insured to tie representations and ABILITY: not warranties. A copy of the enrollment form shall be attached to the certificate when issued. No statement will be used to defend a claim unless it is contained in the enrollment form and a copy has been provided to the Insured or the Insured's Iegalrepresentative. We will not contest an Insured's coverage under the Group Policy after it has been in force during the Insured's lifetime for two years from the Effective Date. G-93S-OK Page 5 MISSTATEMENT We will adjust the face amount of an Insured's Certificate if the age of such OFAGE: Insured has been misstated. The adjusted amount is whatever the premiums actually paid would buy using the correct age. INTEREST ON We will pay interest on net death proceeds. DEATH PROCEEDS; The interest included will be determined by the law of the state in which the Insured lives on the Effective Date. We will, if no state law applies: • pay interest at 2.7/i% starting 31 days after the date of death; • pay interest for no more than one year. ASSIGNMENT: We will recognize an assignment of the Insured's coverage under the Group Policy only when a copy of it signed by You is received by Us. We are not responsible for thevalidityof an assignment. Your rights and the rights of the beneficiary may be limited by the rights of an assignee. BASIS OF We compute cash values by the Net Level Premium Method. All values and net VALUE: single premiums arebased on the Commissioners 1980 Standard Ordinary Mortality Table E and interest shown on page 4. Death claims are assumed to be paid immediately. Cash values are equal to or more than required by Your state. The cash value on anypolicy anniversarywillbe equal to the present value of future benefits, if any. OWNERSHIPAND BENEFICIARYPROVISIONS RIGHTS OF THE You are the owner of the Certificate as shown in the enralhnent form. If You die OWNER: while the Insured is still living, the Insured becomes the owner, You may change the owner during the lifetime of the Insured. This must be by written request. The change is effective as of the date the request was signed. We are not liable for any payment made by Us before such request is received at Our Home Office. You may exercise any other right or elect any option in this Certificate. Your rights as owner maybe limited by the rights of an assignee. BENEFICIARY: The beneficiary is named in the enrollment form. You may change the beneficiary during the lifetime of the Insured. This must be by written request. The change is effective as of the date the request was signed. Page 6 G-93SE-MO-TD We are not liable for any payment made by Us before such request is received at Our Home Office., PAYMENT OF We will pay the proceeds: PROCEEDS: • to thebeneficiary, or • to You if living, if there is no survivingbeneficiary; or • to the estate of the Insured if no one described immediately above files a claim within 60 days after the death of the Insured. We may rely on an affidavit to determine the existence or death of any of the above. If there are two or more persons named to receive payments, We will make payment in equal shares to the survivors unless We are directed otherwise. G-93S-PA ~ Page 7 DIVIDEND PROVISIONS DIVIDENDS: Eachyear on the Group Policy anniversary We will compute the divisible surplus, if any. It will be divided among the policies as dividends. Any dividend payable to the Group Policy will be divided among the Certifcates that aze in force. The due date of the dividend, if any, will be the Group Policy anniversary and Your shaze will be allocated oneach Certificate anniversarybeginningwith the 2nd anniversary. DIVIDEND You may use the cash dividends in any of these ways: OPTIONS: • CASH. Paid to You in cash • LEFT AT INTEREST. We will apply interest each year. The rate will not be Less than 2~`i% • PAID UP ADDITIONS. Used as a net single premium at the Insured's current age to buy paid up additional insurance on the life of the Insured. This insurance also earns dividends. The mortality table and interest used will be described in the Basis of Values provision. AUTOMATIC We will use dividends to buy paid up additions unless You choose another option. DIVIDEND OPTION: WITHDRAWAL You may withdraw dividends left at interest and the current value of paid up OFDIVIDENDS: additions at any time if they are not needed as security for a loan. Wewill include dividends left at interest and paid up additions in the proceeds at an Insured's death, maturity, or surrender. Page 8 G-93S LOAN PROVISIONS POLICY LOANS: You may ask for a loan. The Certificate is assigned to Us while there is a loan and is the sole security for such lawn. We have the right to defer a loan for up to six months. Loans requested to pay premiums on any Policy with this company will not be deferred. We will deduct the loan with interest from the proceeds payable at the Insured's death, maturity, or surrender. If a Ioan exceeds the loan value, the coverage described in the Certificate as provided under the Group Policy will terminate. We will mail notice to both You and the assignee, if any, to the last address known to Us 31 days before the coverage as described in the Certificate as provided under the Group Policy will terminate. LOAN VALUE: The loan value is the sum of: • an amount which with interest will equal the cash value on the next Certificate Anniversary; plus • the dividends left at interest and the current value of any paid up additions; LESS • any loan with interest. REPAYMENT: You may repay the loan in full or in part at any time prior to: • maturity of the coverage under the Group Policy; or • death of the Insured. LOAN Loan interest is 8% a year. It is due at the end of each year on the Certificate INTEREST: anniversary. Interest not paid is added to the loan; interest is then due on the total amount. G-93S Page 9 TERMINATION TERMINATION A Certificate will terminate upon: OF A • the death of the Insured; CERTIFICATE: • ~~~ • surrender; • failure to pay any premium due within the grace period; • 30 days after notice of termination of eligibility for coverage of You; or • termination of the Group Policy. If termination of coverage is due to termination of eligibility or termination of the Group Policy, You may request conversion of coverage as described in the Conver- sionPrivilegeprovision. CONVERSION PRIVILEGE CONVERSION: If coverage under a Certificate ends due to termination of eligibility or termination of the Group Policy, We will issue an individual policy to the Insured. The following conditions will apply: • No evidence of insurability will be required; • Request for conversion must be received in writing; and • The first premium for the conversion policy must be paid within 31 days after the termination of coverage under the Group Policy. CONVERSION The conversionpolicywillbe: POLICY: .Any individual life insurance policy, except term insurance, You select that is currently being offered to persons of the Insured's age and class, and for the face amount being applied for at the time of conversion; • The deathbenefit of the new individual policymaynot be greater than the death benefit under the Certificate at the time of termination; • The premium for the newindividual policywillbe the usual rate for the policy chosen for the Insured's age and class at the time the Certificate was issued; • The date of the new policywilibe the date of termination of coverage under the Group Policy; however in no event will an Insured be covered under both the new policy and the Group Policy. • The cash value of the Certificate will be applied to the new policy; and • The premium due for the new policy will include the difference between the cash value of the Certificate and the cash value of the new policy. If the cash value of the new policy is Less than the cash value of the Certificate on the date it terminated, the difference will be used to purchase paid-up additions. If the Insured dies during the period after the Certificate terminates and before the end of the period in which You may exercise the conversion privilege, W e will pay the beneficiary the amount of individual coverage to which the Insured is entitled, whether or not You have applied for conversion or paid the first premium for the newpolicy. Instead of issuing a new individual policy, We may, at Our discretion, continue coverage under the Certificate. Page 10 G-93S-OK CASH OPTION SURRENDER You may surrender the coverage under the Group Policy evidenced by the OPTION: Certificate and We will pay the cash value. The value will be the net single premium at the Insured's current age for-the face amount of this Policy. The same mortality table and interest assumptions descried in the paragraph titled "Basis of Values" will be used. The amount We will pay will be the cash value plus any dividends left at interest and the current value of any paid up additional insurance, less any loan with interest. We have the right to defer payment for up to sig months. We will pay interest at 21fi% a year from the date We receive your request if payment is postponed for 31 days or more. G-93S Page 11 INQUIRIES OR COMPLAINTS REGARDING THIS GROUP POLICY MAY BE DIRECTED TO THE CONSUMER RELATIONS DEPARTMENT OF HOMESTEADERS LIFE COMPANY, P.O. BOX 1756, DES MOINES, IOWA 50306, TELEPHONE: 800-477-3633 OR 515-440-7777. GROUP PERMANENT LIFE INSURANCE CERTIFICATE. ANNUAL DIVIDENDS. G-93S-MO _ P.O. Boz 67013 (117) 234-8484 (Harrisburg) ~~ ` ~~ Harrisburg, PA 11106-7013 (800) 237-7328 (Nationwide) ~;;,~' .` website - http://www psecu.com FOR SECURITY AND CONVENIENCE, SIGN UP FOR E-STATEMENTS THE ONLINE VERSION OF YOUR MONTHLY ACCOUNT STATEMENT. GO TO PSECUaHOME® UNDER "MY PROFILE." 7307 1 AV 0.324 ~n~~~~+u~~~nu~~~n~~~u~~~nu~~u~~nn~~u~~n~~~u~~n~ JOINT OWNER BEVERLY A CLAY 233 GETTYSBURG PIKE JEFFREY CLAY MECHANICSBURG PA 17055-5131 PaSl1N4 [SA'YE LL ~ EFFFCTIWE NavMFHTS, IJiAlld ~iftANSAGT}QN t5t~S4AIP71o>til. ~~ FINANCE FEES 4R 'T'RANSACTION . 05/01 _ UFiWiR ID O1 REGULAR SHARE BEGINNING BALANCE CHARpE CI~Agt~g Ai~btlk7 NEW BALAIJi ------ 05/31 PAYMENT: DIVIDEND 1.2401 5.22 0.01 5.23 ANNUAL PERCENTAGE YIELD EARNED 2.281 FROM 05/01/08 THROUGH 05/31/08 BASED ` ON AVERAGE DAILY'BALAMGE OF 5.22'< 05/31 ENDING BALANCE Dzu>*AEN.D YTA.;: Y~:A1~i Tai :A~tTE ; 5.23'' : ; ©- Q5, 05/01 ID 04 CHECKING BEGINNING BALANCE - 05/02 PAYMENT: DIRECT DEPOSIT US TREASURY 303 2761.91 TYPE: SDC ~ECf FD. 303103rrQ30 1107.00 3868.91 C0:! US TREASURY 3b3 ©:5/06, C.H~GK D402~#3 < 05/09 CHECK 000244 __ ' 74 44- 379:4..47 ;; 05/13 CHECK 000245 1486.35- 2308.12 05/14 CHECK 000247 56.29- 2251.83 05J16 CHECK OUp246 42.89- 2208.94 Q5/29 I CHECK OOb248 : Z81,iQ~- 192'7.84 .. 05Y31, PAY:PI~NT:: D~.IJEIIEND .U ,~~~~ `73.'79» 1854. R9 . ; . ANNUAL PERCENTAGE YIELD EARNED 0.251 FROM ;: :; 0 .. 5 ~...:: 18 5!4.61 05/01/08 THROUGH 05/31/08 BASED_ ON, AVERAGE. DAILY. BALANCE OF 2 456 37 05/31 , .. ENDING BALANCE . _ - - DIVIDEND YTD:':YEAR 'TO DATE 1854.61 ''4.41 NUIrtB~R 000243 ANOItJ~t~ NUM~:~R. ~1~#t1liNT . NUM1~:E#~ 74.44 000245 ANUI#NT NI~MB~R: l~MOUNT 000244 56.29 000247 1486.35 000246 281.10 000248 42.89 73.75 OS/O1 .I D 07 MONEY MARKET BEGINNING BALANCE ___ ____ __ __ ____ _ _________ ____ _________ 05/OZ PAYMENT; BY CH1:CK 18197 01 .:0.5/`31 PAYMENT. TIx1-rrc.-in ~,<o,,,..` 24:D.3,5 ! 184~7.~~ Department of the Treasury Internal Revenue Service Andover, MA 05501-0026 Beverly A Clay 233 Gettysburg Pike Mechanicsburg, PA 17055-5131 Notice Date: June 9, 2008 Notice Number: C P 1378 Taxpayer Identification Number: Primary: XXX-XX-3140 For assistance, you may call: 1-866-234-2942 Understanding Your, Economic Stimulus Payment Please keep a copy of this notice for your records. Dear Taxpayer: Your Economic Stimulus Payment You are entitled to an economic stimulus payment of $300.00 as provided by the Economic Stimulus Act of 2008. You can expect your payment by 6/6/08. If you do not receive it within six weeks of this notice, please contact us at the number shown above. You will not be required to report the amount of your stimulus payment as taxable income on your 2008 federal income tax return. if you receive any federal benefits or federally financed benefits, those benefits generally will not be affected by any stimulus payment you receive. What You Need To Do You do not need to do anything. If you received a refund on your 2007 federal income tax return and had it directly deposited into a bank account, we will directly deposit your stimulus payment into the same bank account. If not, your stimulus payment check will be mailed to you. If your tax refund was directly deposited into a refund anticipation loan account, your stimulus payment check will be mailed to you. How We Calculated Your Payment Your payment is based on information you submitted on your 2007 federal income tax return such as your filing status, the number of qualifying children, and your net income tax liability. The next page shows a detailed explanation of how we calculated your stimulus payment. Note: You will not be required to report the amount of your stimulus payment as taxable income on your 2008 federal income tax return. For general information, fax forms, and publications or to view "Where is My Stimulus Payment'; visit www.irs.gov www.irs.gov Catalog Number 51256M Notice '1375 (5-2006) Your Stimulus Payment Calculation + Filing Status $ 300.00 + Far qualifying children $ 0.00 - Reduction for Adjusted Gross Income Limitation $ 0.00 = Your Calculated Stimulus Payment $ 304.00 Details of Your Stimulus Payment Calculation We calculated your stimulus payment based on the following rules. Filing Status Based on your filing status, the amount of your stimulus payment is $600 or your 2007 net income tax liability, whichever is less. Nat income tax liability is your tax before credits, including the alternative minimum tax, less all non-refundable credits other than the allowable child tax credit. However, if the net income tax liability on your 2007 federal income tax return is less than $300 and you had $3,000 or more in qualifying income, the amount of your stimulus payment is $300. "Qualifying Income" refers to wages, net earnings from self-employment that is includible in taxable income, Social Security benefits, certain tier 1 Railroad Retirement benefits, certain disability compensation, disability pension or survivors' benefits received from the Department of Veterans Affairs, and nontaxable combat pay (if it was listed on your tax return). Qualifying Children The calculation is based on the number of qualifying children multiplied by $300. A child is generally considered a qualifying chid for the calculation of your 2008 stimulus payment if the child was born after December 31, 1990, and has a valid Social Security Number. The number of qualifying children shown on your 2007 federal income tax return was 0. Whom You Can Contact With Questions If you need additional information, please visit the IRS website at www.irs.govor call 1-866-234-2942. 15642813873-2RN-3AN-S-I7-SBN-I9N-FN-OIN-OFN ® Printed on recycled paper G~C~ U.S. GOVERNMENT PRINTING OFFICE :2008: 341-836 . I GI HNW2K~ Date: 06/03/2008 This Month Gross payment amount 356.06 Net payment amount 356.06 0215534 'L ~__ '• 1 1 1 1 1 '1 1 P.O. Box 61013 (717) 234-8484 (Ha«isburg) Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide) website - http://www.psecu.com WE HAVE LiOW-RATE LOANS FOR CARS, TRUCKS, 'VANS, AND MOTORCYCLES. SAME RATE FOR NEW AND USED. APPLY AT PSECU.COM OR CALL 800.LOAN.555. 20332 1 AV 0.324 VIII'IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII BEVERLY A CLAY 233 GETTYSBURG PIKE MECHANICSBURG PA 17055-5131 JOINT OWNER JEFFREY CLAY -.~EfyBER NUtv1BER 8904XXXXXX STATEMENT PERIOD ~a» ;' -~ 06010 063008 PAGE 1 P0377NG EFFECTIVE 4 II ' bA1'E bATE H Y t Irrs, TgAN$,aGTibN dESCRIPt1DN crtErorcsdr FINANCE FEES OR TRANSACTION NEW .__._ ::._ 06/01 ~Ee+TS ID O1 REGULAR SHARE BEGINNING BALANCE CHARGE CHARfaE3 W. AMbUNT BALANCEr ' ~__. ~ ~"~ ~ ~~ 06/30 PAYMENT: DIVIDEND 1.2401 5.23 ANNUAL PERCENTAGE YIELD EARNED 2.351 FROM 0.01 06/01/08 THROUGH 06/30 5.24 /08 BASED,ON AVERAGE DAILY BALANCE OF 5.23 06/30 ENDING BALANCE BIVIDEND YTD: YEAR TO DATE 5 24 ----- _ ---------- - Os;d6 06/01 ----- ----------------- ID 04 CHECKING BEGINNING BALANCE 06/05 CHECK 000249 1854.61 05/06 i'AYMENI': DxRECT 'DEPOS'IT US' TREASURY 220 38.75- 1815.86 300.110 .2115.86 TYpEi FAX REFUliO 1Q: 3111036170 G0: US TREASURY 220 06/18 CHECK 000250 . 06/30 35 82- PAYMENT: VIA HOME BANKING TRANSFER FROM SHARE 07 12500 00 2080.04 14580 04 06/30 PAYMENT: DIVIDEND 0.2500 . . ANNUAL' PERCENTAGE YIELD 1=ARMED >0.25~ FROM 0.51 14580.55 06/ill/D8 ':THROUGH 06/30/0'& BASEb ON AVERAGE DAILY BALANCE QE' 2,472.1'7 D6f30 ENDING'.. BALANCE DIVIDEND YTD: YEAR TO DATE I'458D.55 4.92 NUMBER 000249 AMOUNT NUMBER AMOUNT NUMBER ' ' AMOUNT NUMBER AMOUNT 38.75 00tl250 35.'82 06101 ID 07 t10NEY -iARKET BEGZNNIN~G BALANCE 06/20 PAYMENT: BY CHECK 18:481,39 06/30 WITHDRAWAL VIA HOME BANKING TRANSFER TO SHA RE 04 12500 00 1 06/30 PAYMENT: DIVIDEND 2.8101 . - 6337.45 06/3 ANNUAL :PERCENTAGE YIELD EARNED 2.85 a' FROM' 42.07 06/01/08 THROUGH 05f30/ 6379.52 08< 4 ENDING BALANCE DIVIDEND YTD: YEAR TO DATE 6379'52 _...._ _ ---- ----- 135b . 07 --- ------- ------ -- ------------- TOTA ----------------------- ----------------------- --------- --------- L DIVIDEND YID: YEAR TO DATE 361.05 0101 000 065 3 '-(1 Z0332 REV-1511 EX+ (12-99) SCNEpULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF F1LE NUMBER Beverly A. Clay Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 ~ Cremation, um, memorial register, folders & acknowledgments - Malpezzi Funeral Home, Mech. PA 2,188.00 2. Grave opening - Scrubgrass Presbyterian Cemetery Association 50.00 3. Death certificates - PA Department of Health, Harrisburg Patriot News & Buffalo News 384.05 4- Memorial Service clergy -Pastor Brett Hartman, New Covenant Fellowship Church, Mech. PA 200.00 5- Memorial Service luncheon - Hoss's Steak & Seafood House, Enola, PA 259.91 s. Memorial Service - 2 musicians- William Gable, Linda Leopold,l sound-Todd Stauffer, Flowers- Royers 429.04 7- Monument -Emlenton Granite Works, 608 Main Street, Emlenton, PA 16373 1,600.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 100.00 Name of Personal Representative(s) Jeffrey B. Clay Soaal Security Number(s)IEIN Number of Personal Representative(s) 086-46-8788 Street Address 233 Gettysburg Pike city Mechanicsburg ,state PA z;p 17055 Year(s) Commission Paid: 2008 2. Attorney Fees 0.00 3. Family Exemption: (If decedent's address is not the same as daimant's, attach explanation} 0.00 Claimant Street Address Cih' State _Zip Relationship of Claimant to Decedent 4. Probate Fees 0.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7. TOTAL (Also enter on line 9, Recapitulation) I $ 5,211.00 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSriVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF F1LE NUMBER Beverly A. Clay spoon dehta incurred 6v the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. {If more space is needed, insert addfional sheets of the same size) Estate of Beverly A. Clay Supporting Documents for Schedule I ~-IIG~HMnRK. BLUE SHIELD m ~rpd..i:a.¢su.rk ud wa~.sur,~wa P.O. Box 890171 Camp Hill PA 1 7089-01 7 1 I~~~111~~~1II~~~~I~I~~I~I~~IJ~~~~II~~IL~~~ll~~ll~~~ll~~ll~~l BEVERLY CLAY 233 GETTYSBURG PIKE MECHANICSBURG PA 17055-5131 Member Covers a Period ID Number Be innin Endin 100678615001 B 06/01 /08 07/31 /08 P.O. Box 382102 Pittsburgh PA 15250-8102 {nvoice 03-1-2939 Date Group 05/05/08 06605481 Company Code Billing ID 01 900046052 Account Status Previous Balance 2 81.10 Payments Received CR (281.10 ) Adjustments o . 0 0 Coverage: MedigapBlue - Plan E Prior Balance Due 0.00 Individual Coverage Period Premium 2 81.10 Total Balance Due 281.10 Look for important information in this space on future bills. We will provide updates on your benefits, health tips and other information. If you have any questions about your coverage, please contact our Member Services department. The address and telephone number appear on the reverse side of this statement. To ensure proper credit to your account, always include your Billing ID on your payment. See reverse side for important information. East Pennsboro Ambulance Service, Inc. Post O~ce Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Tax Number 23-2464545 BILL TO C1ay,Beverly C/O Jeffery Clay 233 Gettysburg Pike Mechanicsburg,PA 17055 I TRIP NUMBER I PATIENT NAME ADDRESS: ADDRESS: PICKUP: TAKEN TO:. DESCRIPTION: Invoice DATE INVOICE # 5/15/2008 08-1076 Beverly Clay 233 Gettysburg Pike Mechanicsburg,PA 17055 Holy Spirit Hospital Manor Care West Stretcher 08-15464 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 5/13/2008 Stretcher Transport -One Way 70.00 70.00 5/13/2008 Van Rate Mileage -Per Loaded Mile 3 1.25 3.75 For your convenience, we now accept Mastercard, Visa and Discover. Card Type: Name on card: Credit Card Number ---- ---- ---- ---- Ezpiration:_ / _ Amount to be charged: S I agree to pay the above total amount according to card issuer agreement. TOTAL DUE Signature• Comments: Payment due upon receipt. Medicare and most insurances do not cover this service. Unpaid accou~s will be sent to a collection agency alter 90 days. $73.75 . .. .. , i`I. :...1 L..i !; i. 11: l... ! I"~1......i ii"~ i :: ... .:. ..1 ~'IP•!i":1`'..__ { :.. (I•:'(,,,(,,, ( l...4•~t~'4e-' i"l 1. i..s...., i't°I ,. .I. r c:).L: ~~ _l t4. ..i,.i '~! i5 ; ~. f~ `'y`I11'~;._. .... C:11f~.4. i ~.~ r+ f t:.~ ~r'~•~~.~ f.<:}... ti. ~ ~~ k~::... r` 4:... h~{' i=ii.::'1 .1: ~:: 1:'i''t 1•~'I:ai~~: i.~f...i~~t''} .. !::• / ": r.•r i.l ...~ ., s `~ ~ i V~~t I i'S ~P: C:. •.a n r ~ } {±,.,, t:!._,:: ~?l,., r:~r::.e:,r::..l..+, tI I°t4 I 1 4 ~:..i. :4. t 1~°i...' .. p; :'. ~c.iLl!:~~.ai::.•..7t:.. .t. •~ i...l.[{ .! t...i:;f~ E°4f'( i::.(''ti.:)r I'ff._ l_I.{. .y::,t ..,:..;'..Lt~.,~~:~~~~~f~ r~~c:ir~: i.:=i..l'•1~'r v ,i•f:-r~~f:~4~~f:::Y~ c..,:'. r , .. ... .... ~ ... -..3 . ,~ .• '-}' + - ~ ~ Beverly A Cfay(19445)/Melissa A Davis PA-C/296188 Location: Manor Care 03/10/2008 SNF Subsequent Care Level III 04/01/2008 SNF Subsequent Care Level II 05/23/2008 Medicare adjustment Adjustment from Medicare 05/23/2008 Medicare Payment from Medicare 05/30/2008 Blue Shield Payment from Highmark Blue Shield-Security 65 05/30/2008 Transfer from Insurance As participating physicians, we have agreed to accept assignment for your recent services, provided all DEDUCTIBLE amounts are paid by you within 60 days from the date of this notice. This statement reflects your DEDUCTIBLE liability. $105.00 1.00 $105.00 $0.00 $85.00 1.00 $85.00 $0.00 #108857 ($58.53) $0.00 #108857 ($76.52) $0.00 #335764 ($19.13) $0.00 #335764 ($35.82) $35.82 $0.00 $35.82 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $35.82 $0.00 $35.82 Susquehanna Internal Medicine'` 890 Poplar Church Road Suite 508 "Camp Hi{I, PA 17011 " (717) 761-3875 MCHS CAMP HILL 1700 MARKET STREET CAMP HILL PA 17011 717-737551 Resident: BEVERLY CLAY Resident Number: 00583-2208 Statement Dater 07/01/2008 ins Detail BALANCE FORWARD 06/03!2008 REVERSE PAYMENT 06/03/2008 REVERSE PAYMENT 03!01/2008 ROOM & BOARD CHARGES MAR 1-31 2008 04/01/2008 ROOM 8< BOARD CHARGES APR 1-30 2008 05/01/2008 ROOM 8 BOARD CHARGES MAY 1-12 2008 03/01/2008 AIR FLUIDIZED BED RENTAL 03/01/2008 PRIVATE PORTION MAR 1-31 2008 04/01/2008 AIR FLUIDIZED BED RENTAL 04/01/2008 PRIVATE PORTION APR 1-30 2008 05/01/2008 AIR FLUIDIZED BED RENTAL 05/01/2008 INTERMIT INCONTINENT-DAILY FEE 05/01/2008 PRIVATE PORTION MAY 1-4 2008 05/05/2008 PRIVATE PORTION MAY 5-12 2008 31 30 5 5 -$378.19 $4,255.05 -$4,255.05 $7,440.00 $7,440.00 $2,880.00 $93.00 -$1,418.35 $90.00 X1,418.35 $15.00 $20.45 -$624.08 X416.08 Your account is due upon receipt, please remit payment. REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Beverly A. Clay RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE i TAXABLE DISTRIBUTIONS [ndude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~ • William R. Clay, 22064 East Jamison Place, Aurora, CO 80016 Son 33.33% 2• Jeffrey B. Clay, 233 Gettysburg Pike, Mechanicsburg, PA 17055 Son 33.33% 3• Frederick H. CIay,1074 Walck Road, North Tonawanda, NY 14120 Son 33.34% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROU GH 18, AS APPROPRIATE, ON RE V-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I S (If more space is needed, insert additional sheets of the same size)