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HomeMy WebLinkAbout09-15-08 15056[]41147 REV-1500 EX (OS-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes county code Year File Number Po Box.zsosol INHERITANCE TAX RETURN Harrisburg, PA 17128-OS01 RESIDENT DECEDENT 2 1 0 8 0 0 2 5 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02 01 2008 10 31 1921 Decedent's Last Name Suffix Decedent's First Name MI EBERSaLE CLETUS F (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI EBERS~LE HELEN M Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW jX ' 1. Original Return (_~ i 4. Limited Estate ~ J X 6 Decedent Died Testate ', -- (Attach Copy of Will) ~~ i ~ 9. Litigation Proceeds Received ~ _~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGiSfER OF iii~iLLS 2. Supplemental Return '. ~ 3. Remainder Return (date of death prior to 12-13-82) 4a. Future Interest Compromise - 5. Federal Estate Tax Return Required (date of death after 12-12-82) `-- ~ Decedent Maintained a Living Trust ~ 8. Total Number of Safe De Osit Boxes (Attach Copy of Trust) p 1 ~ Spousal Poverty Credit (date of death 111. 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 TO: Name Daytime Telephone Number MARIELLE F HAZEN 717 540 4332 Finn Name (If Applicable) HAZEN ELDER LAVJ First line of address 2000 LINGLESTDWN RD. Second line of address SUITE 202 City or Post Office State ZIP Code HARRISBURG PA 17110 Correspondent's a-mail address: rv REGISTER~F~ILLS US~NLY _ - -n ~ _. - ~' _ _~~ ~ -- , r ~ r rr; _... - --.:~ ~ _ ~ ,`.... ~._ s. t ~-r _ + C3~ITE FILED ~ . Under penalties of perjury, I declare that I 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 preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE '`~~~J ~ ~/,~~p~~~ Marie E. Sheaffer ADDRESS 3405 Bedford Dr., Camp Hill, PA 17011 tIGN~~E OF PRE R~t OTHER THAN REPRESENTATIVE DATE Marielle F. Hazen 2000 Linglestown Rd., Harrisburg, PA 17110 Side 1 15056041147 15056041147 J f~~. 15056042148 REV-1500 EX Decedent's Social Security Number Decedent's Name: C I e t U S F. Ebersole RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 5 1 6 8 6 2 7 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 2 5 4 5 9 5 6 6. Jointly Owned Property (Schedule F) ~ ~ Separate Billing Requested ............. 6. 7. Probate Property Inter-Vivos Trans ers Miscellaneous N one ( ) Separate Billing Requested ............. Schedule G ~ 7. 3 4 6 2 1 0 9 1 g. Total Gross Assets (total Lines 1-7) ....................................................................... g. 4 2 3 3 5 6 7 4 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 0 0 0 12• Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 4 2 3 . 3 5 6 7 4 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. 4 2 3 3 5 6 7 4 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 (a)(1.2)x.00 423 356.79 15. 0 OO 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 16. 0 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17• 0 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 0 0 0 19. Tax Due ..................................................................................................................... 19. 0 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 15056042148 15056042148 REV-1500 EX Page 3 File Number 21-08-00251 Decedent's Complete Address: DECEDENT'S NAME Cletus F. Ebersole STREET ADDRESS 109 N. 34th St. -- -- CITY 'STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 0.00 2. CreditslPayments A. Spousal Poverty Credit g. Prior Payments C. Discount 0.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penaltyifapplicable - -- - ----- -- p. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request arefund - 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A, Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5g) ~ . ~ 0 Make Check Payable to: REGISTER OF WILLS, AGENT 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 :.................................................................................. '~ j x J b. retain the right to designate who shall use the property transferred or its income :.................................... ',~ ', x ~_ __. c. retain a reversionary interest; or .................................................................................................................. ~ x 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? ....................................................................................................................... ~ x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... x _; 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .......................... !, 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 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-7503 EX+ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Ebersole, Cletus F. 21-08-00251 All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 Delaware Investments Trend Fund A Class 51,686.27 #3-5035058701 -mutual fund account owned as tenants in common with surviving spouse, Helen Marie Ebersole. Total date of death value was $103,372.54 TOTAL (Also enter on Line 2, Recapitulation) 51,686.27 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ (6.98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Ebersole, Cletus F. 21-08-00251 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 E7(+ (6-96) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Ebersole, Cletus F. 21-08-00251 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DE RIPTI N F P PERTY INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Hartford Life non-qualified variable annuity - 49,947.43 100.000 49,947.43 Contract #712288406; Helen Marie Ebersole, surviving spouse and beneficiary 2 Transamerica non-qualified annuity -Contract 220,520.66 100.000 220,520.66 #02ARK001302; Helen Marie Ebersole, surviving spouse and beneficiary 3 Western Southern non-qualified annuity - 75,742.82 100.000 75,742.82 Contract #W0020538874; Helen Marie Ebersole, surviving spouse and beneficiary TOTAL (Also enter on Line 7, Recapitulation) (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. 346,210.91 Form PA-1500 Schedule G (Rev. 6-98) REV-1513 EX+~9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ebersole, Cletus F. 21-08-00 251 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY D D (Words) ($$$) Do otList rust els) I~ TAXABLE DISTRIBUTIONS [include outright spousal i i d f distr but ons, an trans ers under Sec. 9116(a)(1.2)] Helen Marie Ebersole Spouse one-hundred 423,356.74 Messiah Village percent of 100 Mt. Allen Dr. estate Mechanicsburg, PA 17055 Total 423,356.74 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropr iate, on Rev 1500 cove r 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 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) Delaware Investments A member of Lincoln Financial Group April 3, 2008 Hazen Elder Law Attn: Marci S. Miller 2000 Linglesto~vn Road Suite 202 Harrisburg, PA 171 10-9347 Re: Delaware Trend Fund A Class #3-5035058701 Cletus F. Ebersole And H. Marie Ebersole 00290923 204-TRANS Dear Ms. Miller: 2005 Market Street Philadelphia, PA 19103-7094 We are truly sorry to learn of the death of our shareholder, Cletus F. Ebersole. Please extend my sincere condolences to the family on behalf of Delaware Investments. Thank you for providing an original death certificate for Cletus F. Ebersole and a certified copy of the short certificate that evidences Marie E. Sheaffer as Executrix of the Estate of Cletus F. Ebersole. On February 1, 2008, Cletus F. Ebersole and H. Marie Ebersole owned 6,334.102 shares oft Delaware Trend Fund A Class. This is a mutual fund with a daily fluctuating price per share. The net a~~et-va~fiae or me runs on that day was $16.32. As such, the value of this account on February 1, 2008 was $103,372.54. .............._ ..... In order tore-register the above tenants in common account, ~e ask that you provide the following documentation: ~'" A signed letter from Marie E. Sheaffer indicating what to do with Cletus F. Ebersole's portion on the account. Her signature must be accompanied by a Medallion `STAMP' (Securities Transfer Agents Medallion Program) signature guarantee. Medallion STAMP' signature guarantees are used across the investment industry to protect shareholder accounts.from any unazrtherized activity. Yeu can obtain a Medallion `STA~LIP' signuture guarantee from a bank or brokerage firm where you maintain an account. We are unable to accept a notarized signature in place of the signature guarantee, as notarization does not provide the legal protection required to complete this type of request. s/~I'he enclosed W-9 Form completed reflecting the tax identification number (TIN) for the Estate of Cletus F. Ebersole. i/ The enclosed W-9 Form completed reflecting the social security number (SSN) and birth date for H. Marie Ebersole. • There are 500.000 certificate shares that are outstanding from the account. We suggest using certified or registered mail when returning share certificates to our office. These must be returned before we can transfer the account. If you are unable to locate the shares, we suggest you contact our office at your earliest convenience. ~~~~~ £~ ° 24~~ ~~~~n~.delawareinaestments.com IlPla~niara inVPCC+MPn+c is tha marks+inn namo fnr flch~niarc ~A~n~nnm uni Nnlrlinnc Inr ~...i itc c~~hctrli ~rioc A business reply envelope has been enclosed for your convenience. If you have any questions or require assistance, please contact our Service Center between 8:00 a.m. and 7:00 p.m. Eastern Time, Monday through Friday at 1-800-523-1918. Sincerely, ~n~'~ i.isa Moore Client Service Representative Enclosure(s): W-9 Form (2) Business Reply Envelope rax 'Transmittal ~/'L F3/'LUUti :i:;i;i YM I-~AGir-~/UUt-~"ax Server Wachovia Bank N.A. Balance Confirmation Services P O Box 40028 Roanoke, VA 24022-7313 March 28, 2008 HAZEN ELDER LAW 2000 LINGLESTOWN ROAD SUITE 202 HARRISBURG, PA 17110 Reference ID: 2396070 SUBJECT: Verification /Confirmation of Account and Balance Information provided for: Customer: CLETUS F EBERSOLE (SSN# XXX-XX-0bOb) Date of Death: February 1, 2008 Deposit Account Information Accourrt Account Date of Deaih Average Date Maturity Interest Accrued YTD Date Type Number Balance Balance' Opened Date Rate Interest Interest Paid Closed J CERTIFICATE OF ?CC;'X}~}~2002 $8,661.69 1/18/2008 6/18!2008 $4.16 $13.53 DEPOSTT LEGAL TITLE: CLETUS F EBERSOLE H MARIE EBERSOLE MARIE E SHEAFFER POA CERTIFICATE OF ?s~C~CX){~y{x}C7364 $25,383.54 11/9/2007 11/9/2009 $76.02 $90.54 DEPOSIT ~tf'lt{Oa.3p3~-a:~13(ocl LEGAL TITLE: CLETUS F EBERSOLE MARIE E SHEAFFER POA-ADDED Ol/16Y1008 CERTIFICATE OF h?fA7C}p000{XX6226 $26,922.50 4/6/2004 4/6/2011 $83.75 $89.44 DEPOSIT LEGAL TITLE: CLETUS F EBERSOLE H MARIE EBERSOLE MARIE E SHEAFFER POA CERTIFICATE OF XX3LY?Di,Y}~C4626 DEPOSIT CLOSING BALANCE: $8188.40 1!1812008 CERTIFICATE OF X}LlX3OCX}00.'X4716 DEPOSIT CLOSING BALANCE: $25205.64 11!912007 ' I'o.x '1'ranami L l,al ~~~VY~ CERTIFICATE OF 3{6210 DEPOSIT CLOSING BALANCE: 525759.19 CHECKING 3+x{6090 J LEGAL TITLE: CLETUS F EBERSOLE H MARIE EBERSOLE MARIE E SHEAFFER POA .j/Gt)I C.UUfj ~ ~~ YM Yfi(l1. 2:/UU'L 1'QX iUCl'VC1 Reference ID: 2396070 911/2007 527,000.00 1/25/2008 $22.73 $0.00 'CHECKING h~4376 $22,466.31 4/8/1996 N/A LEGAL TITLE: CLETUS F EBERSOLE H MARIE EBERSOLE MARIE E SHEAFFER POA-ADDED 01/16/2008 Your request has been forwazded to the W achovia Conespandence Team to assist with address change and/or account closure. If you have any questions, please call 1-800-922- 4684. " Date of death balance dots not includc accrucd intcrest If date of death occurrs on a weekend or a holiday, date of death balance does not include any transactions that were made during that time period. j~~.IG~V~'~ ~~ Dena White Servicenter Associate Phone: (540)563-7323 pe; dw May 13 2888 21:59:43 Via Fax May 13, 2008 Corinne Eggers Woodhouse Fax:717-540-4313 Re: Hartford Annuity Contract # 712288406 Decedent: Cletus Ebersole Dear Ms. Eggers Woodhouse: Thank you for your correspondence regarding the above annuity contract. I~artfard Life The death benefit~ayabl~ under this contract is not considered "life insurance" reportable on IRS ____ Form 712, (life~suri~n~~e statement). Please find the below information in response to your request. Contract Number Owner Decedent Social Security Number Date of Death Dale of Death Value Tax Cost Basis This is a non qualified annuity. -> Hazen Elder Law The Hartford Fax Page 992 Uf 992 712288406 Cletus and H M Ebersole Cletus Ebersole XXX-XX-0606 02/01/2008 $49,947.43 $32,797.13 The Date of Death Value displayed above may include a Death Benefit Adjustment as outlined in the Annuity Contract. This figure is being provided for illustration purposes and is not equivalent to the final death benefit. The death benefit will be calculated on all contracts associated with this client the day we receive the certified death certificate. Once the death benefit is calculated, the benefit amount remains invested and is subject to market fluctuation until complete settlement instructions are received. If you have any questions or concerns, please feel free to contact your investment professional, or one of our annuity specialists by calling 1-800-862-6668, Monday through Thursday from 8 a.m. to 7 p.rn. and Friday from 9:15 a.m. to 6 p.m., Eastern Standard Time. We will be happy to assist you. Thank you for the opportunity to help provide for your financial needs. Sincerely, Hartford Llfs Insurance Companies A. Taylor 200 Hopmeadow Street Slms6ury, CT 06089 Investment Product Services Toll free 1 800 862 6668 ICS-Death Benefit Contract Change Team Investment Product 3ervlces Hartford Life Insurance Company Malling Addrrss: P.O. box 5085 Hartford, CT 06102-5085 www.hartfordlnvestor.com May 13 ZeBB 21:58:32 Via Fax -> Hazen Elder Law The Hartford Fax .~ ;~x~:f©~rc~ .~~~~ Fax Cover Page Paye BB1 Of 8BZ To: Corrine Eggers Woodhouse Fax Number: 7175404313 Company: Name: Allison Taylor Company: Investment Products Address: 175 Addison Road City: Windsor, CT 06095 Phone: 860-547-5000 Date: OS/13/08 09:49:56 PM Subject: 712288406 Cletus Ebersole Total Pages: 2 This electronic communication, including attachments, is for the exclusive use of addressee and may contain proprietary, confidential and/or privileged information. If you are not the intended recipient, any use, copying, disclosure, dissemination or distribution is strictly prohibited. If you are not the intended redpient, please notify sender immediately by phone, destroy this communication and all copies. Memo: Allison Taylor Contract Management DSCC Night Team Ext: 36131 T~vS~~CA ®LIFE INSURANCE COMPANY Transamerica Life Insurance Company 4333 Edgewood Road NE PO Box 3183 Cedar Rapids, Iowa 52406-3183 April 9, 2008 Marci S Miller Hazen Elder Law 2000 Linglestown Road Suite 202 Harrisburg PA 17110 RE: Annuity Number(s) 02ARK001302 Dear Marci S Miller: ~~ --~..., .., . m~..~.::,.., C' I; AA a.. ¢_' ~+ Gtiils~ ~ ~= Y~ e ~; Thank you for the recent inquiry on the above listed non-qualified annuity for Cletus F Ebersole (deceased). The full accumulated value of this annuity as of February 1, 2008 was $220,520.66. The following is the Pre-Tefra and Post Tefra information for this non-qualified annuity: Pre-Tefra Principal: $ 0.00 Post Tefra Principal: $197,874.17 Tax Deferred Interest Earned as of April 7, 2008: $ 23,816.95 Full Accumulated Value as of April 7, 2008: $221,691.12 The following is the current information on this annuity: Annuitant: Cletus F Ebersole Owner(s): Cletus F Ebersole Bra.m~ry Benefic? ary (-ies) : Helen 1~4ar:~~ ~bers~la Contingent Beneficiary(-ies): Estate of Cletus F Ebersole Our records indicate that there have been no ownership changes made to this annuity since its inception on February 5, 2003. Please find enclosed annuitization application. The annuitization application contains a summary of the annuitization options available. If Helen Marie Ebersole decides to take a settlement option, please read and complete both sides of the application in their entirety. This form-may be faxed to our home office at 1-877-355-4385. Member of the `EGON. Group ./ Da~yaa Onigac FINANCIAL ANNWTY ', _-(~ ~NTERtdEDIARY - SFRVICE ANJARD - { POST+SALE ` 'z?SERVICE AWARD ~~'~' 20~pS ~~ 2006 ~~ Please be aware that if Helen Marie Ebersole chooses a settlement option, the payments are made to the annuitant but taxable to the owner. Once a settlement option is chosen and the payments begin, neither the payment amount nor the payment option can be changed. This letter contains general tax information based on our company's interpretations and should not be relied upon for Helen Marie Ebersole's personal tax planning. She may wish to consult her own tax advisor to discuss her financial situation. Transamerica Life Insurance Company is a member of the Insurance Marketplace Standards Association (IMSA), an organization committed to high ethical marketplace standards in the sale and service of individual life insurance and annuities. If you have any questions or concerns, you may call our customer service line. Our toll free customer service line, 1-800-553-5957, is available Central Time from 7:00 AM to 5:30 PM Monday-Thursday and Friday 7:00 AM to 4:30 PM. Sincerely, ~~ ~~~ Brandie Butz Customer Care Group Transamerica Life Insurance Company Enclosure(s): Annuitization Form Postage Paid Return Envelope HF'N. lk~ ~17~1~ 1 ~ ~ :~b rK WbL HUll 51J b~'~ l ('~'~ I U '~l (l (~4tJ4.31J f-', l'1/k~b Western-Southern Life"' o4~o9i~ao~ RE: CLETUS EBERSOLE(DECEASED) 109 N 34TH 5T CAMP HILL PA 17011-2705 FAX #717-540-4313 Subject: Annuity Contract W0020538874 Westem-Southern Life Assurance Company bear Ms. Miller: Thank you for contacting the Westem-Southern Life Assurance Company about the above annuity. have enclosed the death claim paperwork including a letter stating Mrs. Ebersofe's options as well as requirements. Below is the information you requested: 1. This is the only account number involved with the above client 2. Cletus was the owner and H_ Marie Ebersole was join# owner. 3. Value as of February 1, 2008 was $75, 742.82 4. Cost Basis $50,650.41 taxable as of February 1, 2008 $25,092.41 5. This is Nan-Qualified- If you have questions, please call our Annuity Operations Department at 1-800-926- 1702. A representative wil! be happy to assist you. Sincerely, r, ~ ~ ~..~~_ ANG~ A ILSQN Annuity Administrator Annuity Operations Department X016 Member, Western & Southern Financiat Group Mnuity Operations Group. ts0 Box 2918. Cincinnati, Ohio .45201-2918 Phone (800) 926-1702 + Fax {513) 629-1799 LAST WILL AND TESTAMENT OF CLETUSF.EBERSOLE I, CLETUS F. EBERSOLE, now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Article III I give, devise and bequeath my tangible personal property to my wife, HELEN MARIE EBERSOLE. In the event HELEN MARIE EBERSOLE predeceases me or fails to survive me by thirty (30) days, then I give, devise and bequeath my tangible personal property in accordance with any memorandum I have handwritten or signed, located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. To the extent no such memorandum is found, or all of my tangible personal property is not disposed of pursuant thereto, my tangible personal property shall be added to my residuary estate and pass under Article IV hereof. Article IV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath to my wife, HELEN MARIE EBERSOLE, of Cumberland County, Pennsylvania. In the event that HELEN MARIE EBERSOLE predeceases me or fails to survive me by thirty (30) days, I give, devise, and bequeath as follows: A. TWENTY THOUSAND ($20,000.00) DOLLARS to my friend, CANDACE A. SVETZ, of Clairton, Pennsylvania. In the event that CANDACE A. SVETZ fails to survive my death by thirty (30) days, then her share shall be distributed to her daughter, KAREN L. TRUAX, per stirpes; B. TWENTY THOUSAND ($20,000.00) DOLLARS to my friend, KAREN L. TRUAX, of Pittsburgh, Pennsylvania, per stirpes; C. FIVE THOUSAND ($5,000.00) DOLLARS to my friend, R. LAMAR GILCHRIST, of Camp Hill, Pennsylvania, per capita; D. TWENTY THOUSAND ($20,000.00) DOLLARS to my friend, VICKI ROUDABUSH, of Martinsburg, Pennsylvania. In the event that VICKI ROUDABUSH fails to 2 survive my death by thirty (30) days, then her share shall be distributed to her parents, HARRY and GENEVIEVE ROUDABUSH, of Martinsburg, Pennsylvania, per capita; E. TWENTY THOUSAND ($20,000.00) DOLLARS to my sister-in-law, CHARLOTTE STONE, of Horseheads, New York. In the event that CHARLOTTE STONE fails to survive my death by thirty (30) days, then her share shall be distributed to her husband, RICHARD STONE, per capita; F. TEN THOUSAND ($10,000.00) DOLLARS to my friend, H. DAN STURM, of Enola, Pennsylvania, per stirpes; G. SIXTY THOUSAND ($60,000.00) DOLLARS to my friend, MARIE E. SHEAFFER, of Camp Hill, Pennsylvania, per capita; H. TEN THOUSAND ($10,000.00) DOLLARS to my friend, CARLA FRISCH, of Joppa, Maryland, per stirpes; and I. THIRTY THOUSAND ($30,000.00) DOLLARS to my friend, KATHY BROOK, of Dillsburg, Pennsylvania. In the event that KATHY BROOK fails to survive my death by thirty (30) days, then her share shall be distributed to her husband, RUSSELL BROOK, per stirpes. All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath in three equal shares to the NATIONAL VETERANS LEGAL SERVICES PROGRAM, of P.O. Box 65762, Washington, DC 20035, the DISABLED AMERICAN VETERANS, of P.O. Box 14301, Cincinnati, Ohio 45250-0301 and the SALVATION ARMY, of 1122 Green Street, Harrisburg, Pennsylvania 17105. 3 Article V I nominate, constitute and appoint my friend, MARIE E. SHEAFFER, of Cumberland County, Pennsylvania as Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executrix, I nominate, constitute and appoint my friend, H. DAN STURM, as successor Executor of my Last Will and Testament. I direct that my Executrix or successor Executor be permitted to serve without bond. In addition to those powers granted by law, I grant them power to distribute in cash or in kind, in like or in unlike shares, and to file any qualified disclaimer I could have filed if living. My Executrix or successor Executor shall receive reasonable compensation for services rendered to my estate. Article VI In addition to the powers conferred by law, I authorize my Executrix and successor Executor, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file any federal income tax return for any year for which I have not filed such return prior to my death, 4 (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executrix or successor Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, CLETUS F. EBERSOLE, hereby set my hand to this my Last Will and Testament, on ~ ~ ~~ - b , 2008, at Harrisburg, Pennsylvania. CLETUS . EBERSOLE In our presence, the above-named CLETUS F. EBERSOLE signed this and declared this to be his Last Will and Testament and now at his request, in his presence, and in the presence of each other, we sign as witnesses. Name Address o~OCl7 G~' S!r llh l~ ~ ~--- !O /l - / } /~ /~/t~i ADO ~ a,.~ ~ / /~V 5 I, CLETUS F. EBERSOLE, Testator, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and Acknowledged before me by CLETUS F. EBERSOLE, the Testator on J-(~n ~~ ~ LS- , 2008. Not y Pub is .--- CLETUS F.EBERS LE COMMONWEALTH OF PENNSYLVANIA Notarial Seal Marielle F. Hazen, Notary Public Susquehanna Twp., Dauphin County My Commission Expires Sept. 23, 2010 We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testator sign and execute this instrument as his Will; that he signed and executed it willingly as his free and voluntary act for the purposes therein expressed; that each of us in his sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that he was at that time eighteen (18) years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and Subscribed to before me by iN) A~gl^.l S, vY1 /LL EiQ and ~n n oo tau s-e witnesses, on , 2008. Notar Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Marielle F. Hazen, Notary Public Susquehanna 'Ihvp., Daupfun County My Commission Expires Sept. 23, 2010 6 Witness a~ Witness lr-- _-- _ ":, W A N a '! f ~ .. Q~ 11 y (V~ 4 a - ~~ ~'6 ~ ~50311Nn ~1 ru Q' 0 a 0 0 O V"I m 0 0 xp o a ~ °~ ~ ~ ° a y ~ ~ Y. ~ ~ N ~ L .a ON A p C ~ '>. O ~ ~ N 0 o ~~ U ~ M ~ a. M M CCA~ Q~o~o ~~U or O~ ~~Q o ~ _ L ~ ~ ~ ~a~~om ~ NFU ~ ~ '~ E m '~ Wa~~cca V~UOU I~~~N ~~ LAW An Estate Planning and Elder Law Firm 2000 Linglestown Road, Suite 202 wwwHazenElderLaw.com Harrisburg, PA 17110 Tet: (71'~ 540-4332 Marielle F. Hazen, CF.LA* Fax: (717) 540-4313 Marci S. Miller, Associate September 12 2008 ~ - , o cn ;r,-' ~ CERTIFIED MAIL - , ~-; ~ r rs ~v ~ ~ :, - - ` ` , ::7 _ Register of Wills _, ;; ~; _ c, ~---r; Cumberland County Courthouse ;~,~:~, ~ , t=-> One Courthouse Square ; >°~ = ' Carlisle, PA 17013-3387 ~"' w Re: Estate of Cletus F. Ebersole File No.: 21-08-00251 To: The Register of Wills: Enclosed for filing please find the original and one copy of the above-referenced Inheritance Tax Return and Inventory, along with a copy of the first page of the Inheritance Tax Return. Please date stamp the first page of the return and a copy of the Inventory and return them to my office in the enclosed self-addressed envelope. Also enclosed is a check for the filing fee in the amount of $30.00. If you have any questions or require any additional information, please do not hesitate to contact me. Sincerely, ~~ } d Z'c.u'~-~P ~/~~ ~_.tx;~c~-gyp Corinne Eggers Woodhouse Paralegal Enclosures cc: Marie Shaeffer *Certified Elder Law Attorney by the National Elder Law Foundation as authorized by the Pennsyluarria Supreme Court