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HomeMy WebLinkAbout02-18-09J 1505607120 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes county Cotle veer Fiie Number Po Box.2aoeot INHERITANCE TAX RETURN Harrisburg, PA 77128-0601 RESIDENT DECEDENT 2 1 0 8 0 6 3 4 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 201 05 2227 05 17 2008 08 15 1922 Decedent's Last Name Suffix Decedent's First Name MI TESNO ROLAND R (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 INAPPROPRIATE OVALS BELOW X l,, 1. Original Return '~ 2. Su elemental Return p ', 3. Remainder Return (tlate of death ' prior to 12-13-62) I 4. Limited Estate I` - - L-= qa wwre mteresl Compromise 5. Federal Estate Tax Return Re wired (date of tleaU after 12-12-82) - -' Q X-' g Decedent Dietl Testate _-' (A¢ecn copy or wup ...._.. ~ Decatlent Maintained a Living Trust (Aaacn copy or rmsq ~ e. Total Number of Safe Deposit Boxes ' 9. Litigation Pfoceeds Received i, 10. Spousal Poverty Credit (date of death between 1231-91 and 1-1-95) ' 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED 70: Name Daytime Telephone Number MARIELLE F HAZEN 717 540 9332 Firm Name (If Applicable) HAZEN ELDER LAW REGISTER WILLS USE'~JJIY First line of address c~ .ra ~. ~~ ; I ~(1 2000 LINGLESTOWN RD. ;- ~' Second line of address CO r c i SUITE 202 ~ ~ ''~i ~r City or Post Office DATE~LED ^J .~~ State ZIP Code HARRISBURG PA 17110 Nm Correspondent's a-mail address: 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 a complete. De ration of preparer other than the personal representative is basetl on all inform ti hi f SIGNAT E OF R N ES ON B E FOR FILING RETURN a on o w ch preparer has any knowledge. ~ P DATE ""• John W Horn _ ~ _ C ADDREs 375 S dspring Rd., He ins, PA 17938 SIGNAT E OF PRE RER OTHER THAN REPRESENTATIVE DATE Marielle F Hazen ~ )-~ _ t_ *,~ 2000 Linglestown Rd., Harrisburg, PA 17110 Side 1 1505607120 1505607120 0 ~~ ~~~ ~ ~ ~~' ~ ~~ ~ ~~ ~~~ ~ ~~ ~~\~ ~~ PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Tesno, Roland R. 21-08-0634 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 #2 Name Donald F Tesno Addressl 372 Lexington Way Addressl City, State, Zip Littlestown, PA 77340 Date 1505607220 REV-1500 EX Decedents Name: ROiand R. TQSDO 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 8 Notes Receivable (Schedule D) ........................................._._......... ... 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) .............. .. 5. 6. Jointly Owned Property (Schedule F) ~~ Separate Billing Requested ........... .. 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) C__i, Separate Billing Requested ........... .. 7, 8. Total Gross Assets (total Lines 1-7)......._ ........................_..........._..................... __ _ g. 9. Funeral Expenses 8 Administrative Costs (Schedule N) ....................................... .. 9. 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............................. .. 10. 11. Total Deductions (total Lines 9 8 10)...._......._............_ ...........................__._..... .. 11. 12. Net Value of Estate (Line 8 minus Line 11) ...................................................._..... .. 12 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J)..._ ......................_......._..._.... .. 13, 14 Net V 1 S b' Decedent's Social Security Number 201 05 2227 99,072.00 594,175.97 49.392.92 682,640.89 46,357.53 11,626.85 57.984.38 624,656.51 629,656.51 a ue u tact to Tax (Lme 12 minus Lme 13). - -- ....._ ....................._.. ............... . 14. -- -_ 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 .00 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 2 6 0 2 9 4 3 7 17. 18. Amount of Line 14 taxable at wllateral rate X .15 3 6 4 3 6 2 1 9 18. 19. Tax Due..__..........._......_ ................................. ......... ................. . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505607220 0 .00 0. 00 31,235. 32 54,659. 32 85,889. 69 1505607220 REV-1500 EX Page 3 File Number 21-08-0634 Decedent's Complete Address: DECEDENT'S NAME Roland R. Tesno STREET ADDRESS_ _.. _. _ - _.__... __-- _ _... _. 5225 Wilson Lane - -- _- - CITY ____ _. .. 'i STATE ~ ZIP Mechanicsburg PA 17055 Tax Payments and Credits 1. Tax DUe (Pagel Line l9) (1) $5,889.84 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 51,000.00 C. Discount 2,684.21 3. InteresVPenal fa licable Total Credits (A +B+C) ty i PP (2) 53,684.21 - __- p. Interest E. Penalty __ Total InteresUPenalty (D + E) (3) 4. It Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q) Check box 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. (5) 32, 205.43 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 3 2 , 2 0 5.43 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. re ain a use or income of the property trans(erred :......................................................................... _....... _ a _, ~x ~.. c o shall use the property transferred or ds income;. h t , a n L~ ~ o retain a rever ionary i teres xJ 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 considerations._ ............................. ~I_~ ,i Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.........', ,, it x~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designalion? ........................._...._............................_....................................................... '~ x ~ ~... 1. 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. SCHEDULE B STOCKS & BONDS CpAAONWEPLTX OF PENNSYLVANW INHERRgNCE TA%RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Tesno, Roland R. 21-08-0634 All propertyJolntlyownetl with dght of survlvonthip must be tllsclosetl on Schetlule F ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 787 shares of Principal Financial Group Inc. 56 44,072.00 TOTAL (Also enter on Line 2, Recapitulation) 44,072.00 (If more space is needed, additional pages or the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1808 E%~ (6-88) COMMONWEALTH OF PENNSYLVANIN INHERITANCE TA%RETURN RESIDENT pELEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC, PERSONAL PROPERTY ESTATE OF FILE NUMBER Tesno, Roland R. 21-08-0634 InGUtle Ne proceetls of litigation and the Oate the proceetls ware receiva0 Dy the estate. All propertyJolMlyrownetl with the rlgh[ o/aurvivorahlp must be dlaclose0 on achetlule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 AARP premium refund 71.13 2 Cash 67.50 3 Citizens Bank Checking Account #610076-626-8 34,116.39 4 Donegal Insurance -Refund of Premium 13.00 5 United States Treasury -Stimulus Rebate 300.00 5 Tangible Personal Property -Jewelry 575.44 7 Citizens Bank - CCO Investments IRA -Acct. No. L7C-040207, Paid to Estate 69,758.79 8 Morgan Stanley -Allstate Annuity -Policy No. 683915 -Paid to Estate 420,087.78 9 RiverSource Life Insurance Company -Annuity -Contract No. 9920-5942848 -Paid 50,493.17 to Estate 10 Security Benefit NQ Annuity - No. 7003105333 -Paid to Estate 18,691.77 TOTAL (Also enter on Line 5, Recapitulation) 594,175.97 (If more space is neetletl, atltlitional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-~ 500 Schedule E (Rev. 6-98) Rev~151p EXi (fi-9a) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIH INHEFITANCE TP%RENRN RESIDENT pELEDENT ESTATE OF FILE NUMBER Tesno, Roland R. 21-08-0634 This schetlule must be compleletl and lletl if the answer to any of questions 1 through 4 on the reverse sitle or the REV-1500 COVER SHEET is yes. I I tM NUMBER utSCKIPTION OF PROPER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEEP FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF OECD'S INTEREST ExcwsioN (IF APPLICABLE) TAXABLE VALUE 1 Genworth Financial Annuity No. 3846895 -Edith 12,288.52 12 288 52 Tesno, sister, 50% beneficiary and Charles Horn, , . brother-in-law, 50% beneficiary 2 Morgan Stanley - MetLife Annuity -Policy No. 32,104.40 32 104.40 940167920 -Edith Tesno, sister, 50% beneficiary , and Charles Horn, brother-in-law, 50% beneficiary TOTAL (Also enter on Line 7, Recapitulation) I 44,392.92 (It more space is neetled, additional pages o! the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1161 EX~t12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ESTATE OF FILE NUMBER Tesno, Roland R. 21-08-0634 Debts oT decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. )FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: t. Personal Representative's Commissions John W Horn Donald F Tesno Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 375 S Goodspring Rd. city Hegins State PA zip 17938 Year(s) Commission paid 2009 z. Attorney's Fees Hazen Elder Law 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. ~ Probate Fees 5. I Accountant's Fees 6. Tax Return Preparer's Fees 4,047.45 21,920.00 19,500.00 252.00 7. Other Administrative Casts 438.08 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 46,157.53 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF Tesno, Roland R. LE NUMBER 21-08-0634 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Christ Church Cemetery -Grave opening 450.00 2 Myers-Harner Funeral Home 3,553.00 3 Staples -Funeral costs 44.45 H-A Subtotal 4,047.45 Other Administrative Costs 4 Cumberland Law Journal -Estate Notice 75.00 5 Davids Jewelers -Fee for appraisal of jewelry 100.00 6 Hazen Elder Law -Disbursements 30.54 7 Register of Wills -Cumberland Co. -additional short certificates 12.00 8 Register of Wills -Cumberland Co. -Filing fees for PA Inheritance Tax and 30.00 Inventory 9 Sentinel -Estate Notice 190.54 H-B7 subtotal 438.08 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev4512 E%~ (696) SCHEDULE 1 DEBTS OF DECEDENT, COAMaONWEP1TH Or RENNSVLVANN MORTGAGE LIABILITIES, & LIENS INHERITANCE Tq%RETURN RESIpENT OECE~ENT ESTATE OF Tesno, Roland R. FILE NUMBER 21 08 0634 Inclutle unrelmbursetl metlical ezpenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Bethany Village Skilled Care -Final bill 10,132.24 2 Continuing Care Rx -Pharmacy 1,428.61 3 East Pennsboro Ambulance Service 68.00 TOTAL (Also enter on Line 10, Recapitulation) I 11 828 85 (If more space is needed, atltlitional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9.00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Tesno, Roland R. 21-08-0634 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not Llet Truete s T TAVA~ICn~nTn,r„,~r-,~.~~ .. .. under Sec. 9116(a)(1.2)] Charles A. Horn, Jr. Brother-in-Law One-half (1/2) 215 Grove Dr. of the Residue Hegins, PA 17938 of the Estate Joann Tesno Miller Sister One-twelfth 170 Fairway Drive (1/12) of the Etters, PA 17319 Residue of the Estate Donald F. Tesno Brother One-twelfth 372 Lexington Way (1/12) of the Littlestown, PA 17340 Residue of the Estate Edith M. Tesno Sister One-fourth 6011 Roberts Drive (1/4) of the Mechanicsburg, PA 17055 Residue of the Estate Harold W. Tesno, Jr. Nephew One-twelfth 86 Blue Ridge Drive (1/12) of the Levittown, PA 19057 Residue of the Estate Total Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropri ate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT RFINI(_ 55enC CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET O.00 ~opyrignt (c) 1002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) Citizens Bank- July 11, 2008 CORINNE EGGERS WOODHOUSE 2000 LINGLESTOWN RS SUITE 202 HARRISBURG PA 17110 Estate of RONALD R TESNO Date of Death: May 17, 2008 SSN: 201-OS-2227 Dear Sir/Madam: 525 William Penn Place Suite 153-2618 Pittsburgh, PA 15219 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 888-999-6884 Sincerely, Pfeil, Marnie Operations Services JUL 1 4 2008 Citizens Bank° Account Number 6100766268 Account Title ROLAND R TESNO Date O ened 10/29/1984 Account T e Checkin Princi al Balance as of DOD $34116.39 Interest from Last Postin to DOD $ .00 Account Balance as of DOD $34116.39 YTD Interest to DOD $29.85 ~,~ ~"~"` o ~o ~J a ~. ~ ~~~~ ~? ~ ~ ~ a ~ y .~ of ~- ~0 ern ~ - ~~ ~ ~ o = ~~•$ ~ ~ m i (1\~ \~ ~ ~ v 0 €~~ ~ ~ ~, u~l~ ~\ M >~ ~ R ~~~ s~ o~ o e ~~ ~~ 1` ~ ~~-, o ~ ma ~~~~ ~ m ~ ~ ~ ~r ~o~ o W ~i a ~ p., A !V+ ~~ ~ ~ ~ ~Q~ `~°~~ ~ b ~ ~ ~~ ~ ~ ~~ ~~ 3€ ~~ a g Y I a ~~ I ~, 2 8~ ~~ J N ~ ~ ~ ~~ro s b ~~ :3 ~~ 6~ eft== a L C 6~~E2~$7 ~~~~~~ ~~~~~~~~ q~ ~~~~~r° ~=~~r~~~ .~8 ! ~'n ~,~ ~ 02/04/2009 13:00 CCG INVESTMENT SERVICES CORP a 917175404313 N0.25E D002 ~! i 6 ~ ~:~ 5 1200 Hancock Street InVe5tm2nt SerVICE:S QulnLy. MA 02169 October 37, 2008 Hazen Elder Law 2000 Lingleetown Rd. Sut~ 202 Harrisburg, PA 17110 RE: Axount Numbar: L70006167 RegMFtratbn: CITIZENS BANK REGULAR IRA F80 ROLAND R TESNO Dear Ms. Wootlhouse: 1 am writing wkh regard to your recent request for ttFe above roferenced account. Please extend our condolences to the temtly of Roland Tesno. I am providing a summary of Mr. Tesno's account in the table below as of the close of business on May 17, 2008 as you requestetl. Should you have any questions, please call oucCuatomer Service Group at 1-800-942.8300. We are available Mandey thrF>uph Friday, 8:00 a.m.'tn D:00 p.m. We will be happy to assist you. ~S~in~cere~ly, I/_ -J f,~ - Erioe Heworlh Operetions Spedelist secur¢kE Rnd mYenmeMAtlNSOry xMm trtR20 throsgtt CCD InYlstmlm XMtt1 .Dip. MCmper nnRq Arc. as xate xrCe4 mG]r70, OoAan MF oz3G]. law) 9+2-0l00. mwnna produces orhndthrough CCO Imertmenl. SpMCO [np.ln Muss[Meuttsl Insss.na h offered ihroujh CI<Issr,s F'~,nandAl Servkas IrlsunnCe ARency. m New vork, inwnnce ID Mrercd through Ckrssns Insunnu AgencyarNew Yoll(, InC CCO Investment LMUS Corp., Cttlmns Rn7nciRl xMtCes insUnEKe 4genry entl Cmzens Insunnce Agenryor New YOrk, ins sn.HiFagc oTRRS CItlxens NA. -^~ ~, R~$ ~ u aendlrounnaR uzben: NOT FDILINSURED • Np QANK GUARANTEE • NUIY LOSE VAIUF • NOTACECOSIT I • NOTINSURED BY ANY FEOERAl:L7VERNMENr AGENCY PRIME MMKT CL D EADDX.EATON VANCE 7507.029 f628 568,866.17 DNERSIF INCOME CLASS A ~~4r t ® Allstate Life Insurance Company Allstatea P.O. Box 758565 you're in good hands. Topeka, KS 66675-8565 August 25, 2008 Irrrllir~rlrrrllr~~llllrrrll~rrl HAZEN ELDER LAW 2000 LINGLESTOWN RD STE 202 HARRISBURG PA 17110 Re: Contract Number: 683916, ROLAND TESNO To Whom It May Concern: The cost basis on the above referenced contract is $340,000.00. QS f SC1U.1IC~, We appreciate your business and are pleased to have the opportunity to service your financial needs. you have additional questions, please call our toll-free Service Center number at 800-457-7617. Our service representatives are available to assist you from 7:30 AM to 5:00 PM Central Time. Sincerely, Annuity Services SEP 0 2 2008 The variable annuity, Allstate Variable Annuity- L-share, is issued by Allstate Life Insurence Company. This statement is provided on behalf of Morgan Stanley DW Inc., as principal urderwriter. The principal underwriter is not, and is not requiretl to be, a member of the Securities Investor Protection Corporation PSIPC"). Annuities are not Insured by the FDIC, nor are they tleposits or other obligations or guaranteed by the depository institugon. Variable annuities are subject to investment risk, inGutling the possible bss of the principal invested. Annuities are not protedetl by SIPC as to the loss of the principal invested. S'i.., ~r:e Num~ar r;Ot; ~.~x; °76?°! . t;..ax Plesrr br.: 7~5-2'. N,-~ ¢:~. ~ „„ August 5, 2008 Hazen Elder Law Attention: Corinne Eggers Woodhouse 2000 Linglestown Road Suite 202 Harrisburg PA 17110 Contract Owner: Roland Tesno Contract Number: 9920-5942848 Dear Corinne Eggers Woodhouse: RiverSourcee RiverSource Llfe Insurance Company 829 Ameriprise Financial Center Minneapolis, MN 55474 RiverSource Distributors, lnc. (Distributor), Member FINRA. Insurance and annuity products are issued by RiverSource Life Insurance Company. Thank you for contacting us regarding the contract listed above. Please accept our condolences for your loss. Per your request the date of death balance was $50,493.17. The cost basis is $45,346.72. The following information is required to initiate a claim: • A Death Claim Statement form completed by the co-executors of the Roland Tesno Estate as beneficiary. Be sure to provide complete information and fill in all sections of ~thy enclosed form, paying particular attention to the Taxpayer Identification Number and Certification section. Please note that the beneficiary signature must be notarized any beneficiary is deceased, please provide a copy of the death certificate. -•~A Certified Death Certificate with raised or color-coded seal./ ~~/~ fhe contract, if available. If the contract has been lost or destroyed, please note it on the Death Claim Statement form. • A completed IRS form W-9. This form is enclosed. Short Certificate with raised or color-coded court seal. If you would like to have the original death certificate returned, please write the name and address of the recipient on the back of the certificate or on an attached note. If this information is not included, we will not be able to return the death certificate. If you have any questions or further service needs, please call Client Services at (800) 333-3437. Representatives are available Monday through Friday from 8 a.m. to 7 p.m., Central time. Sincerely, Betty Bolin Client Services Encl. I (~~ AUG 0 8 2008 © 2007 RiverSource Life Insurance Company. All rights reserved. 64918(8/07) securitybenefitcom 800.888.2467 =~t~ SECURITY BENEFIT° /l~~ June 26, 2008 HAZEN ELDER LAW ATTN CORINNE EGGERS WOODHOUSE 2000 LINGLESTOWN RD STE 202 HARRISBURG PA 17110 Re: Contract Number: 7003105333, ROLAND R. TESNO Dear Ms. Eggers Woodhouse: We are in receipt of your request for additional information regarding the referenced account. This account is aNon-qualified Annuity that was issued on August 10, 2006. This account has the following registration: Owner: Roland R. Tesno Annuitant: Roland R. Tesno Primary Beneficiary: The Estate of Roland R. Tesno The account value as of the date of death, May 17, 2008, was $18,691.77. The current account value as of June 25, 2008 was $18,791.98. The cumulative earnings as of May 17, 2008 were $1,546.37. We have forward the death notification letter and Proof of Death form under separate cover. If you have any questions regarding this letter, or if we may assist you with other questions or information, please contact our Customer Center at 1-800-888-2461. Our Customer Center associates are available from 7:00 am - 6:00 pm Central Standard Time. Sincerely, -c~e¢arr /~2~ Vanessa Rials Client Service Specialist IV Service Operations Security Benefit A3051 JUL O 1 1008 One Security Benefit Place • Topeka, Kansas 66636-0001 i',4 V/ZVVB 4:ZJ :3tS YM _\~4/ %+ Genworth Financial July 30, 2008 (ir:IV W Vit"1'11 HAZEN ELDER LAW 2000 LINGLESTOWN ROAD STE 202 HARRISBURG PA 17110 RE: Annuity No.: 3846895 Decedent: ROLAND R TESNO Dear Ms. Corinne Woodhouse YAGC L VP' Z GenwaM life and Annuity hsurance Company P.O. Baz 6158 Lynchburg, VA 24505fi158 888 322.4629 Tdl Free 434 848.5440 Fax We are in receipt of your request, for the value of this contract as of the date of death of Roland R Tesno. As of May 17, 20118, the value was $12,288.52. Although we have determined this dffie of death value at your request, you should seek the advice of a tax advisor concerning what amount, if any,.is to be included in Roland .R Tesno's estate with regard to this particular annuity contract. ' Genworth Life Insurance Company is not responsible for any tax consequences, which may or may not occur as a result of our submission of this information. The contract does not contain any provisions that would allow the right to advance, commute, or otherwise receive unscheduled payments. Should you have any questions or concerns, please feel free to call 888 322.4629, Monday -Friday 9:00 a.m. to 5:00 p.m. Eastern Time. Sincerely, Annuity Claims