HomeMy WebLinkAbout12-01-08J 1505607121
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
Po Box 28oso1 INHERITANCE TAX RETURN
Harrisburg PA 17128-0601 RESIDENT DECEDENT 2 1 0 8 0 9 3 4
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
2 0 7 2 2 0 8 4 0 0 9 0 1 2 0 0 8 0 9 0 3 1 9 1 9
Decedent's Last Name Suffix Decedent's First Name MI
B A K E R D A L E C
(If Applicable) Enter Surviving Spouse's Information Below
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
^X 1. Original Return
4. Limited Estate
® 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
State ZIP Code
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
R O G E R B- I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3
Firm Name (If Applicable)
I R W I N &
First line of address
6 0 W E S T
Second line of address
City or Post Office
C A R L I S L E
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address:
Under penalties of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is We, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has anv knowledge.
aiv~ i vr~c ~r rtrcJUrv KtSF'UNSIBLE FOR FILING RETURN DATE
ADD SS ~ ~ ~ /i~'Zr~ by
425 KERRSVILLE ROAD CARLISLE PA 17015
SIGNATURE OE.PREPARER OTHER T~HA~},REPRESENTATIVE DATE
! rl .~
//G.-/ U
60 WEST P.4MFf~ET STREET CARLISLE PA 17013
-~' PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505607121 1505607121
M c K N I G H T
P O M F R E T S T R E E T
J
1505607221
-~~~
~;~ ~`
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: DALE C• BAKER 2 0 7 2 2 0 8 4 0
RECAPITULATION
1. Real estate (Schedule A) ........................................ 1.
2. Stocks and Bonds (Schedule B) .................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................ 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ....... 5. 8 0 7 2 9 7 7
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 2 5 2 4 2. 2 5
(Schedule G) ^ Separate Billing Requested ....... 7.
8. Total Gross Assets (total Lines 1-7) ........................... 8. 1 0 5 9 7 2, 0 2
9. Funeral Expenses & Administrative Costs (Schedule H) ......... .
.. 9. 1 3 0 9 1 1 4
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ..... ... .... 10. 2 2 0 9 , 5 7
11. Total Deductions (total Lines 9 & 10) .................... ... .... 11. 1 5 3 0 0 , 7 ],
12. Net Value of Estate (Line 8 minus Line 11) .................. .... ... 12. 9 0 6 7 1 . 3 1
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. 9 0 6 7 1 . 3 1
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.o _ 0 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate x .045 9 0 6 7 1. 3 1 16 4 0 8 0. 2 1
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. 4 0 8 0. 2 1
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505607221 1505607221 J
ADDITIONAL Personal Representatives
Estate of Dale C. Baker - SS# 207-22-0840
Under penalties of perjury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and belief,
it is true, correct and complete.
Signature ~~~.____
Name John R. Baker
Address Line 1 675 Mountain Road
Address Line 2
City, State, Zip Boiling Springs, PA 17007
Date 1 / -„z}''~'~
ADDITIONAL Personal Representatives
Estate of Dale C. Baker - SS# 207-22-0840
Under penalties of perjury, the undersigned declare that they have examined this return,
including accompanying schedules and statements, and to the best of their knowledge and belief,
it is true, correct and complete.
Signature ~ ~~, ~-~
Name Julia A. Stover
Address Line 1 175 Army Heritage Drive
Address Line 2
City, State, Zip Carlisle, PA 17013
Date / c _-a..J°_u
REV-1500 EX Page 3
Decedent's Complete Address:
Fife Number
21 08 0934
DECEDENT'S NAME
DALE C. BAKER
STREET ADDRESS
425 KERRSVILLE ROAD
CITY STATE zlp
CARLISLE PA 17015
Tax Payments and Credits:
~ Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit _
B. Prior Payments _
C. Discount
3. Interest/Penalty if applicable
D. Interest
E. Penalty
204.01
(1) 4, 080.21
Total Credits (A + B + C) (2) 204.01
Total Interest/Penalty (D + E )
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.
5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
(3)
0.00
(4) 0.00
(5) 3,876.20
(5A)
B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 3,876.20
Make Check Payable fo: 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 : ...................................................................... ^ Q
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ ^X
c. retain a reversionary interest; or ..............................................................................:................. ^
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideraiion? ....................................................................................... ^ Q
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? .................................................................................................. 0 ^
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.
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DALE C. BAKER 21 08 0934
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M&T BANK -CERTIFICATE OF DEPOSIT #31003913121528 11,321.30
2. M8~T BANK -CHECKING ACCOUNT #2673001307 337.43
3. CORNERSTONE FEDERAL CREDIT UNION -SAVINGS ACCOUNT 163.00
4. CORNERSTONE FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT 9,024.37
5. CORNERSTONE FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT ~ 9,024.82
6. CORNERSTONE FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT 9,024.82
7. CORNERSTONE FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT 30,085.45
8. CORNERSTONE FEDERAL CREDIT UNION -MONEY MARKET ACCOUNT 11,748.58
TOTAL (Also enter on line 5, Recapitulation) I $ 80 729 77
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
• • SCHEDULE G
• INTER-VIVOS TRANSFERS 8~
COM NHERITANCETAX RETURNANIA MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DALE C. BAKER 21 08 0934
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.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDFORREALESTATE VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. WESTERN-SOUTHERN LIFE 25,242.25 100. 25,242.25
ANNUITY CONTRACT W0021486811
TOTAL (Also enter on line 7 Recapitulation} ~ ~ 25 242 25
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES ~
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
DALE C. BAKER 21 08 0934
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOFFMAN-ROTH FUNERAL HOME 4,463.56
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City State Zip
Year(s) Commission Paid:
2, Attorney Fees IRWIN & McKNIGHT
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant ROGER L. BAKER
Street Address 425 KERRSVILLE ROAD
City CARLISLE State PA Zip 17015
Relationship of Claimant to Decedent SON
4. Probate Fees REGISTER OF WILLS
5. I Accountant's Fees
6. ~ Tax Return Preparers Fees PATRICIA A. ROSENDALE, CPA
7. REGISTER OF WILLS -FILING FEE
8. CUMBERLANE LAW JOURNAL -ESTATE NOTICE
9. THE SENTINEL -ESTATE NOTICE
350.00
30.00
75.00
174.58
TOTAL (Also enter on line 9, Recapitulation) I $
4,250.00
3, 500.00
248.00
13.091.14
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHED~JLE /
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
DALE C. BAKER 21 08 0934
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CHOICE CRITICAL CARE -MEDICAL 15.24
2. DILLSBURG AMBULANCE -AMBULANCE 225.00
3. PINNACLE HEALTH HOSPITALS -MEDICAL 250.00
4. COMMI~NITY LIFE TEAM EMS -AMBULANCE 116.00
5. HOLY SPIRIT HOSPITAL -MEDICAL 87.64
6. SPIRIT PHYSICIAN SERVICES -MEDICAL 30.00
7. THE STATE EMPLOYEES' RETIREMENT SYSTEM -REIMBURSEMENT OF PENSION 351.27
8. WEST SHORE EMS -AMBULANCE 97.42
9. QUANTUM IMAGING & THERAPEUTIC ASSOCIATES -MEDICAL. 569.00
10. PINNACLE HEALTH EMERGENCY -MEDICAL 234.00
11. STOKEN OPHTHALMOLOGY -MEDICAL 234.00
TOTAL (Also enter on line 10, Recapitulation) I $
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
DALE C. BAKER 21 08 0934
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 [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)j
1. ROGER L. BAKER Lineal
425 KERRSVILLE ROAD 1/3 REMAINDER
CARLISLE, PA 17015
2. JOHNNY RAY BAKER Lineal
675 MOUNTAIN ROAD 1/3 REMAINDER
BOILING SPRINGS, PA 17007
3. JULIA A. STOVER Lineal
175 ARMY HERITAGE DRIVE 1/3 REMAINDER
CARLISLE, PA 17013
I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 AS APPROPRIATE ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $
(If more space is needed, insert additional sheets of the same size)
AST WILL AND TESTAMENT
L
Pennsylvania,
I DALE C. BAKER of South Middleton Township, Cumberland County,
' Last Will and Testament, hereby expressly revoking all Wills
declare this instrument to be my
and Codicils heretofore made by me.
direct my Executrix to pay all of my debts, funeral and administrative expenses as
1. I
soon as maybe done conveniently after my decease.
Executrix to sell any realty owned by me at my death,
2. I authorize and empower my
devised herein, at either public or private sale; and to give good and
and not specifically
sufficient deeds therefor, in fee simple, as I could do if living.
~ of m estate of every nature and wherever situate to my wife,
`~ 3. I devise and bequeath all Y
~~ she shall survive me by sixty (60) days.
`v EVELYN M. BAKER; providing
hould the gift in Paragraph No. 3 not take effect, I give my Grandfather clock to my
4. S
AKER, with the direct that it be kept in the Baker family and I glue my old
son, ROGER L. B
watch to my son, JOHN R. BAKER•
've devise and bequeath all the rest, residue and remainder of my estate to ROGER
5. I gl ,
JOHN R. BAKER and JULIA A. STOVER, share and share alike, the child or
L. BAKER,
deceased child or stepchild taking the share their parent would have taken if
children of any
living.
M. BAKER to be the Executrix of this my Last Will
fi. I nominate and appoint EVELYN
. h without bond. Should she die before my death, renounce
and Testament; she is to serve as suc
in any of my estate unadministered, I nominate and
or refuse to serve for any reason, or die leav g
BAKER and JULIA A. STOVER as substitute Co-
appoint ROGER L. BAKER, JOHN R•
' out bond, with the same powers as are given herein to my
Executors, also to serve as such with
Executrix.
ersonal representative retain the services of Irwin,
~. I hereby suggest that my p
i ht & Hughes as attorneys in the settlement of my estate.
Iv1cKn g ,;r
y
I have hereunto set my hand and seal this_r--- da o
IN WITNESS WIiERE~F'
July, 2003.
~ ~ ti (SEAL)
~1 ~.. ~Cs
DALE C• BAKER
DALE C. BAKER> the above-named Testator,
Signed, sealed, published and declared by resence
staYnent, in the presence of us, who, at his request, in his p
as and for his Last Will and Te es as witnesses hereto.
and in the presence of each other have subscribed our nam
(~1 '
1 t
1.4C.
~/
2
ACKNOWLEDGEMENT AND AFFIDA VIT
WE, DALE C. BAKER, SHARON L. SCHWALM and KAMEore oinCOinstNrument,
the testator and witnesses respectively, whose names are au honto that t e testator signed and
being first duly sworn, do hereby declare to the undersigned Y
xecuted the instrument as his Last Will and that he had signed willingly, and ththe witnessesain
e
as his free and voluntary act for the purpose herein expressed, and that each o
the resence and hearing of the testator, signed the Will as a witness and that nd mindeand under
p
knowledge the testator was, at that time, eighteen years of age or older, o sou
no constraint or undue influence.
DALE C. BAKER
a` f >'i R
HARON L. SCH t,ivi
L ~~. ~~.
KAMELA S. C RNMAN
COMMONWEALTH OF PENNSYLVANIA SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by DA WALM andRKAMELA S.
and subscribed and sworn to before me by SHARON L, SCH
CORNMAN, witnesses, this 31 yf day of July, 2003.
~':
No ary Public
Notarial Seal
Roger B. Irwin, Notary Public
Carlisle Boro, Cumberland Caunty
My Commission Expires Oct. 3, 2004
Member, Pennsylvania AtlaoClstlpn of NAtrari0e
3
Q MST' Bank
499 Mitchell Street, Millsboro, DE 19966
September 15, 2008
Law Offices
Irwin 8s McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
RE: Estate of Dale Baker
Date of Death: September 1, 2008
Social Security Number: 207-22-0840
Dear Mr. Irwin:
In response to your request, please be advised that at the time of death,. the above-
named decedent had on deposit with this bank the following accounts.
1. Account Type ..........:................ Certificate of Deposit
Account Number .....:................. 31003913121528
Ownership (Names off .............. Dale Baker
Opening Date ...........................01 / 09 / 06
Balance on Date of Death..........$11,301.98
Accrued Interest $ 19 32
Total ....................................... $11, 321.30
2. Account Type ........................... Checking Account
Account Number ....................... 2673001307
Ownership (Names off .............. Dale Baker, Evelyn Baker
Opening Date ...........................09 / O 1 / 67
Balance on Date of Death..........$337.41
Accrued Interest $ 0 02
Total ....................................... $337.43
• Page 2 September 15, 2008
The above named decedent did not have a safe deposit box.
If upon reviewing the information above, you believe there are additional
accounts not referenced, please provide us with an account number and/or the
name of any possible joint account holder. For any additional information on
the above accounts, including ownership and any changes, closures and/or
reimbursement of funds, please contact our Stonehedge Branch at 960 Walnut
Bottom Road, Carlisle, PA 17013, or # 717-240-4524.
Sincerely,
Charlene Warrington, Records Management
1-888-502-4349
CORNERSTONE
F e d e r a l C r e cl i t U n i o n
P.O. Box 1181, 5 East Gate Drive, Carlisle, PA 17015
Telephone (7 17) 249- 166 I FAX (717) 249-8208
Member founded -Service based vvvvw.cornerstonefcu.coop
September 19, 2008
Irwin & McKnight
Attn: Roger B Irwin
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pa 17013
RE: Estate of Dale C. Baker
Roger,
~~~ ~~ , ~ .
~#2N11(V & CvlchiVil;N
~_A!N ~EF!rFc
At the time of his death, Dale C. Baker was a single owner of a savings, money market and a four
certificate of deposits. Listed below is the information requested per your letter dated 9/10108:
1) Dale C. Baker, single owner
2) Savings and Money Market accounts were established on 11124/2006 and all four certificates of
deposits were established on 7/30/2008.
3) Not Applicable
4) Not Applicable
5) Interest accrued for: Savings account - $4.27, CD 10 - $24.37, CD 11 - $24.82, CD 12 - $24.82, CD13 -
$85.45 and Money Marker account - $358.47.
6) Date of Death balances for: Savings account - $183.00, CD 10 - $9,024.37, CD 11 - $9,024.82, CD 12 -
$9,024.82, CD13 - $30,085.45 and Money Marker account - $11,748.58
If you require any additional information, please do not hesitate to contact me at 717-249-1661 ext 240.
Sincerely,
~/
.~
Donna J. Mickey
Financial Services Administrator
MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED TO $ I OO,000 BY THE NATIONAL CREDIT UNION ADMINISTRATION
Western-Southern Life"
11 /04/2008
DALE C BAKER
C/O IRWIN & MCKNIGHT
60 WEST POMFRET STREET
CARLISLE PA 17013
~~;
~~~
Subject: Annuity Contracts W0021486811, V000201848'i 6 - Gaie C. Baker
Western-Southern Life Assurance Company
Dear Mr. Irwin:
Thank you for contacting the Western-Southern Life Assurance Company about the
above listed annuities.
We have received your correspondence informing Western-Southern of the death of
Dale C. Baker. We have sent the appropriate paperwork to the beneficiaries at the
addresses that you provided to us. The following is the information that you requested:
-The registered owner of both annuities is Dale C. Baker. i`..
-The contract date for contract W0020184816 is 05/04/2004. l`?~~~' ~
-The contract date for contract W0021486811 is 01/12/2006. ~. ,~ ~i~
~ t~ ~i/
-Contract W0020184816 was surrendered on 06/20/2008."~~ ~~~`~ ~
-The accrued interest for contract W0021486811 for 2008 is $17.10.
-The date of death value for contract W0021486811 is $24,625.15.
if you have questions, please call your sales representative or our Annuity Operation s
Department at 1-800-926-1702. A representative will be happy to assist you.
Sincerely,
,~
~1
~~
JOSEPH KLOTZ
Annuity Administrator
Annuity Operations Department
F016
Member, Western & Southern Financial Group®
Annuity Operations Group • PO Box 2918 • Cincinnati, Ohio • 45201-2918
Phone (800} 926-1702 • Fax (513} 629-1799
Hoffman-Roth Funeral Home & Crematory, Inc.
219 North Hanover Street
' ~ Carlisle, PA 1.7013
(717)243-4511
September 16, 2008
Roger Irwin Attorney
RE: Dale C. Baker
60 West Pomfret Street
Carlisle, PA 17013
The Funeral Service for Dale C. Baker 15417-199
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS .AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, ACJTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
OUR SERVICE:
Traditional Funeral Ser~~ice Package $4150.00
FUNERAL HOME SERVICE CHARGES $4150.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED _ $4150.00
Cash Advances
Newspaper Obituary Notice- Sentinel , _ $106.56
Certified Copies of Death Certificates , _ $48.00
Flowers. $159.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES . $313.56
Total
Total Cost , $4463.56
TOTAL AMOUNT DUE $4463.Sfi
This statement is net and payable in full within 30 days of receipt.
------------------------------------------------------
Please return this portion with your Remittance
$ Amount Enclosed Service ID' # 15417-199
Dale C. Baker