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HomeMy WebLinkAbout08-31-0915056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~~ Q~ (') Q ~ I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 181-03-5798 11 /03/2008 07/30/1915 Decedent's Last Name Suffix Decedent's First Name MI FINKENBINDER LEE F (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 ~ 1. Original Retum 2. Supplemental Retum 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Retum Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Tnut 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 TO: Name Daytime Telephone Number SALLY WINDER h, Finn Name (If Applicable) c~ REGISTEROFUSEONLI'a '"~"~ _.~. First line of address - ;~rn W n ~ t 221 DOUBLING GAP ROAD G.-~ ~ r - Second line of address ; O ~'+ ~ . ~ ~.._ P.O. BOX 341 ~ ~ ':A ~`' DATE~7LE0 ~? i ? City or Post Office State ZIP Code IV - NEWVILLE PA 17241 Correspondent's e-mail address: Under penalties of perjury, 1 declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knwwledge and belief, it is true, cones[ and complete. DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE F PERSON RESP NSIBLE FOR FILING RETURN DATE ADDRESS . ~~~ C J _ ~~- ~-!Q" ~-~~ -- --s -- ~ - -- -- _ -- SIGNATU F P PARER j2E RE NTATI ~ DATE - ----- ADDRESS ~-r a• ~+ NIA P r ~~~, LEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 15056052059 REV-1500 EX Decedent's Social Security Number LEE F FINKENBINDER Decedent's Name: 181-03-5798 RECAPITULATION 1. Real estate (Schedule A) . .............................. . . . . ........ .. 1. 10,033.36 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. 38.98 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 10,072.34 9. Funeral Expenses 8c Administrative Costs (Schedule H) ................... .. 9. 8,090.05 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............. .. 10. 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 8,090.05 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 1,9$2.29 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. 1,982.29 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(12) x .0 45 1,982.29 15. 89.21 16. Amount of Line 14 taxable at lineal rate X .0 _ 1 g. 17. Amount of Line 14 taxable at sibling rate X .12 17- 18. Amount of Line 14 taxable at collateral rate X .15 1g, 19. TAX DUE ....................................................... .. 19. 89.21 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Flle Number Decedent's Complete Address: ii DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER LEE F FINKENBINDER 181-03-5798 - - - _ -- - - STREET ADDRESS - -- - -. --_ - -- -__ 210 BIG SPRING ROAD CITY - _ _ _ _. 1 STATE ~ ZIP NEWVILLE ~ PA 17241 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prror Payments _ C. Discount 3. Interest/Penalty 'rf applicable D. Interest E. Penalty (1) _ - _ Total Credits (A+ B + C) (2) 0.31 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 89.21 0.31 89.52 89.52 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 I'rfe 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 acxount 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? .................................................. ............................................................... ^ ....... Q IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETURN For dates of death on or after Juty 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 ex~ 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-0ne 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)]. 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-1502 EX+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER LEE F. FINKENBINDER All real property owned solety or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. iTEM Include a copy of the deed showing decedent's interest if owned as tenant in rnmmon. VALUE AT DATE NUMBER OF DEATH DESCRIPTION i. ~ Real estate located in Hopewell Township, Cumberland County, PA, in which decedent had a life estate interest as shown by deed recorded in Cumberland Cty Recorder of Deeds Book 123, Page 421.Copy of deed is attached. Valuation of real estate is the assessed value of 67,460 multiplied by the Common Level Ratio of 1.26 which equals $84,999.60. Using the Nov. 2008 annual AFR from IRS Publication 1457 at the rate of 3.57% and Table S for the nearest percentage, the life estate interest for age 93 (that of the decedent) yields an int- erest of .11804 which when multiplied by the value of the real estate gives a value of $10,033.36 10,033.36 TOTAL (Also enter on Line 1, Recapitulation.) I $ 10,033.36 If more space is needed, insert additional sheets of the same size. s ' ~~~re~ RDaERr A. trFcc~R RECORDEp OF DEEDS CU-~BERLANp COUNTY-Pq ~95 ~W 1~ ~ ~ `~~ Tax parcel no. 11-30-0612-004'' T H I S D S S D MADE this ~~~ day of / r4--r in the year nineteen hundred and ninety-five (199 5 BSTWSHN LSB F. FINKSNBINDSR, xidow and single xoman, of 117 Green Ridge Lane, Nexville, Cumberland County, Pennsylvania, Grantor, AND SETH A. FINKSNBINDSR and FAY R. FINBSNBINDSR, husband snd wife, of 675 Ridge Road, Shippansburg, Pennsylvania, an undivided one-half interest, and CYNTBIA BARLfiT'PA, single woman, of Box 2010, Sdgartoxn, Naesachuaetts, a oae-halt interest, the said one-half interests to be held as ,joint tenants xith right of survivorship and not as tenants in common, Grantees. WITNSSSSTH, that in consideration of the sum of ONS DOLLAR is 1.00), in hand paid, the receipt whereof, is hereby acknowledged, the said Grantor does grant and Canvey in fee simple Lo said Oranteea, their heirs end sa:igna, as their interests appear above, ALL that certain real estate or tract of farm land situate in the Toanahip of Hopexell in the County of Cumberland and State of Pennsylvania, and bounded and limited as follows: BEGINNING at a point in the Ridge Road on line of land now or formerly of John Wonders; thence by same North l8 degrees Weat 23 perches to s point; thence by leads now or formerly of George Commerer South 83 degrees West 32.2 parches to a poet; thence by the same and land now or formerly of Joe. Chamberlain South 73.25 degrees West 1D2.5 perches to a post; thence by same South 1T degrees East 49.8 perches to a post ar stake in the Ridge Road; thence by the same North 64 degrees East 140 perches, more or leas, to the place of BEGINNING. CONTAINING 33 acres and 61 perches. LESS 'the following tracts previously conveyed: (1) Tract containing 1.OI9 acres conveyed by deed from Lee fi. Finkenbinder and Simon R. Finkenbinder, her husband, to Clarence L. Chamberlin and Velma C., Chamberlin, his wife, e~~z i23 racy 42~ .. ~i ~,3_ 66~~ .. _.. ?012009 12:39:42 PM ~ CUMBERLAND COUNTY ./' inst.# 199512803 - Pano i of 7 dated August 12, 1969 and recorded in Cumberland County Deed Book "I", Volume 23 at Page 468; and (2~ Tract containing 3.S6b acres conveyed by deed from Simon R. Finkenbinder and Lee F. Finkenbinder, his wife, to Seth R. Finkenbinder and Fay R. Finkenbinder, his wife, dated October 6, 1976 and recorded in Cumberland County Deed Book "V", Volume 26, at Page 556. BEING TB8 REMAINING PORTION OF REAL BSTATE WHICH LEE F. FINKENBINDER and SIMON R. FINKENBINDER. hat husband and RUTH F. GRAHAM, widow, by deed dated June 24, 1985 and recorded in the office of the Recorder of Deeds in and for Cumberland County in Deed Book Volute G-23, Psge 925, granted and conveyed to LES F. PINKBNBINDER and SIMON R. FINKENBINDER. The said SIMON R. FINKRNBINDER having died on August 3, 1992, title to the same remained vested by operation oY law solely in his surviving spouse, LEE F. FINKENBINDER, widow and single woman,. who is the Grantor herein. RESERVING AND SUBJECT TO A LIFE SSTATH in the Grantor, GEE F. FINKENBINDER, widow and single woman, whereby she shall have exclusive possession of the above-described tract of real estate and improvements for her natural lifetime. AND the said Grantor will warrant generally the property hereby conveyed. THIS IS A CONVEYANCE FROM PARENT TO CHILDREN AND IS THEREFORE EXEHPT BAON P$NNSYLVANIA REALTY TRANSPBR TAX. IN WITNESS WHEREOF, the said Crantor hsa hereunto set her hand and seal the day and year first above written. WITNESS: ,E~~ /~ - / y y1 ~ ~~ o2~ii2:~L".~~ ~'_%7 /' ~~ /.s" . Tb S8A1, LSE F. FINKENBINDER es~;r 123 F~cE 422 20/2009 12:39:42 PM CUMBERLAND COUNTY Inst.# 199512803 - Pace 2 of . REV-1509 EX+ (698) scNEOU~ F COMMONWEALTH OF PENNSYLVANIA ,~O~~y-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ---- ESTATE OF FILE NUMBER LEE F. FINKENBINDER If an asset was made john within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. SETH FINKENBINDER ~ 677 RIDGE ROAD, NEVVBURG, PA 17240 ~ SON B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FlNANCIAL INSTITUTION AND BANK ACCOUNT NUM3ER OR SIMLAR IDENTIFYING NUM3ER. ATTACH DEED FOR JOINTLY+ELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECDS INTEREST DATE OF DEATH VALUE Cf DECEDENT'S INTEREST ~ ~ A. ORRSTOWN BANK, CHECKING ACCT NO 514926 29.13 50 14.57 2 . q. MEMBERS 1ST FCU, SAVINGS ACCT NO 65135 48.82 50 24.41 O ~ TOTAL (Also enter on line 6, Recapitulation) ~ ; 38.98 (If more space is needed, insert additional sheets of the same size) dRRS /RRSTOWNBANK A T~ikon of Excellence P.O. Box 250 Shippensburg, PA 17257 Return Service Requested I~~~111~~~1~.l~l~l~l~l~~~il~l~~l~~~l~~lit~~l~il.~~I~~~Iil~l~~l 001040 0.4804 AV 0.324 TR00004 Lee F Finkenbinder Seth R Finkenbinder 671 Ridge Road Shippensburg PA 17257-9732 Building? Buying? Remodeling? We can help! 1.888.ORRSTOWN - orrstown.com Date 12/05/08 Page 1 Primary Account 514926 Rnclasures C S S C K I N G A C C O U N T S Account Title Lee F Finkenbinder Seth R Finkenbinder - - g~P~ t'heo.1~~„~a _ .Check. Safekeeping Account Number 514926 Statement Dates 11/06/08 thr u 12/07/08 Previous Balance 29.13 - Days In The Statement Period 32 Deposits/Credits .00 Average Ledger 29.13 Checks/Debits .00 Average Collected 29.13 Service Fee .00 Interest Paid .00 Current Balance 29.13 Daily Balance Information Date .8alaace lI/06 29.13 THANK YOU FOR BANKING WITH ORRSTOWN BANK N O~ n N n .-i Sendlnquiresto: / ~~ f /Z- Statement of Accounts 5000 Coulee Drive (,. PO Box 40 '"°~''°"i~~ ~" 10~ Nov 25 , 2008 thru Dec 24, 2008 wrw memberslst.org Maln swlc~neo~d: (moo) 2a9292a ez ca8: (7,7) ss7-~7i w (moo) ze3~72 Account Number : fi5135 _ TDD: (717) 697-5312 or (800) 289 2328 ext. 53,2 _ ®1 Tebt3rench: (800) 297-7288 Balances at a Glance M~.~~S ~st Checking : 0.00 FEnERALCREDIT UNION Savings: '48.82 10554 1 Av 0.324 ,IIl,,,I„LLI„L,~iI I 10554-10554 ll Certificates: ,,III,„I„i LI,„I„iL l L I _ 0.00 „ LEE F FINKENBIND , „ , , ~ ER Loans: 0.00 _ 117 GREEN RIDGE LN Money Management: 0.00 s NEWV(LLE PA 17241-9484 $WIPe ~J YTD Reward : 0. ~ " Page : 1 of 1 _ Your aggregate balance as of December 1st is $48.82. An aggregate balance of $2,500 and having 3 products ___ _ _ _ _ _ _ _ _ _ ..will place .you in the. Silver MLR ieveL__ _ 1099-TNT's are not included in this statement. ff you earned at least $10 in dividends on your account for 2008, you will receive your 1099-INT in a separate mailing in early January 2009. 1099-INT information will also be available on Members 1st online in early January. SAVINGS ACCOUNTS 00 -REGULAR SAVINGS Date Treutsadiort DescxiQtion Additions Subtractions Balance Nnv 25 Ba~rae Forward 48.77 Joint Owner: SETH R FINKENBINDER Nov 30 Deposit Dividend 1.000% 0.05 48.82 ~4renua/ Pisit:>artt~s Yid Earned 0.9910X horn 11/O1/2YJ'JIQf1B 6nnt~h 1 f/3U/ZU019 Dec 24 End Ba(ance 48.82 YTD SUMMARIES TOTAL DMDENDS PA(D 00 REGULAR SAVINGS 1.94 Total Year To Date Interest Paid ~ 0.00 NOTE: Total includes closed loans Add Your Photo For Security Your personal safety and financial security are top priorities at Members 1st. As a result of increased scams and fraudulent activity throughout the entire country, we are strongly encouraging members to have their photos added to their account records. When visiting our branch offices, you may be asked by one of our Associates to allow us to take your photo. This member identification program will assist in our fraud deterrence initiatives and will take our identity theft prevention program to the next levet. We are experiencing an increasing number of attempted fraudulent activities and as a result, we need to be able to verify your identity immediately upon retrieving your accourrt information. In addition to having your photo in our files, you may be required to show additional forms of identification based on the type of transaction you are seeking. This is for your protection and securityt and we appreciate your ongoing cooperation and understanding. REV-1511 EX+ (12-99) scNEOU~ x COMMONWEALTH of PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER LEE F. FINKENBINDER Debts of decedent must be reported on ScFredule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' EGGER FUNERAL HOME, funeral account 7,196.00 LISA'S FLOWERS, casket spray 37.05 FIRST UNITED PRESBYTERIAN CHURCH, felbwship fdk)wing funeral 82.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representatve(s) Social Security Number(s)lEIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (ff decedent's address is not the same as claimant's, attach explanation) Claimant Street Address Cfff' State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip Zip 750.00 25.00 TOTAL (Also enter on line 9, Recapftulation) 15 8,090.05 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (11-OS) Pennsylvania SCHEDULE ~ INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER LEE F. FI NKENBINDER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and bansfers under Sec. 9116 (a) (1.2).J 1. RD, SHIPPENSBURG, PA 17257 SETH FINKENBINDER, 677 RIDGE SON 50% 2. / CYNTHIA BARLETTA Zd ~ 2 l90 ~ G~ ; DAUGHTER 50% Ml1C~rotrrtli~s ~ PIA 1'!0 SS ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ If more space is needed, insert additional sheets of the same size. REV-1514 EX+ (4-09) Pennsylvania DEPARTMENT OF REVENUE Bureau d Individual Taxes PO B°oc z8a6o1 Harrisburg PA 171z8-06o1 SCNEp1~LE K LIFE ESTATE, ANNUITY & TERM CERTAIN (CH@CK BOX 4 ON REV-><5ao COVER SFffET) -- ESTATE OF FILE NUMBER LEE F. FINKENBINDER 21- This schedule should be used for all single-life, joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single-life calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest and attach a wpy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ®Other • NAME OF LIFE TENANT DATE OF BIRTH NEARgT Aim AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE LEE F. FINKENBINDER 07/30/1915 93 ®life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable .........................................$ 84,999.60 2. Actuarial factor per appropriate table ................................................ 0.11804 Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 3. Value of I'rfe estate (Line i multiplied by Line 2) ....................................$ 10.033.36 NAME OF LIFE ANNUIRANT • DATE OF BIRTH • NEAREST A6E AT DATE OF DEATH T0W OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ...........................................$ 2. Check appropriate block below and enter corresponding number ................ . Frequency of payout - ^ Weekty (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3.5% ^ 6°k ^ 10°k ^ Variable Rate 6. Adjustment Factor (See instructions.} ................................................ . 7. Value o+f annuity - If using 3.5, 6, or 10°k, or if variable rate and period payout is at end of period, calculation is Line 4 x Line 5 x Line 6 ...........................$ If using variable rate and period payout is at beginning of period, calculation is (Line 4 x Line 5 x Line 6) + Line 3 ...............................................$ NOTE: The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size.