HomeMy WebLinkAbout11-20-091505607121
REV-15 0 0 EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po Box 28oso1 INHERITANCE TAX RETURN
Harrisbu PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 8 0 4
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
3 6 5 2 2 1 0 5 8 0 8 1 6 2 0 0 9 0 4 0 6 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name
MI
C O N W A Y E D I T H H
(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
D 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
® death after 12-12-82)
6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name
Daytime Telephone Number
S T E P H E N L B L O O M 7 1 7 2 4 9 2 3 5 3
Firm Name (If Applicable) ,,,_,
I R W I N &
First line of address
6 D W E S T
Second line of address
City or Post Office
C A R L I S L E
M c K N I G H T p C
P O M F R E T S T R E E T
State ZIP Code
REGIS OF WILLS ONLY =~ 1
ca ..~ -, , , ,
_.
~, ~ ~.., ., ~
=crate ~ ~ _."~
ATE FILED 1~~^' ~,_._..
P A 1 7 0 1 3
-.s
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 true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU F PERSON RESPONSIBLE FOR FILING RETURN
DAT
ADDRE ~
SIGNATURE OF PR AR ER REPRESENTATIVE
DATE
ADD S ~/ °-
~~~ ~ ,~
PLEASE USE ORIGINAL FOR ONLY
Side 1
1505607121 1505607121
REV-1500 EX Page 3
' File Number
Decedent's Complete Address: 21 09 0804
DECEDENT'S NAME
EDITH H. CONWAY
STREET ADDRESS
1414 BRADLEY DRIVE
APARTMENT G113
clrY
CARLISLE PATE ziP
17013
Tax Payments and Credits:
~• Tax Due (Page 2 Line 19)
2. Credits/Payments (1) 2, 789.11
A. Spousal Poverty Credit
B. Prior Payments 2,456.28
C. Discount 129 27
3. Interest/Penalty if applicable Total Credits (A + B + C) (2) 2, 585.55
D. Interest
E. Penalty
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT Total Interest/Penalty (D + E) (3) 0.00
Fill in oval on Page 2, Line 20 to request a refund
. (4)
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE
.
(5)
203.56
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 203.56
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 : ...................................................................... ^
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q
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? .................................................................................................. a ^
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)j.
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)j.
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-1508 EX + (6-98)
' ` SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN R SIDE TEDECEDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
EDITH H. CONWAY 21 09 0804
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER VALUE AT DATE
DESCRIPTION OF DEATH
1. ORRSTOWN BANK -CHECKING ACCOUNT #143000872 4,856.70
2. ORRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000006604 5,191.58
3. ORRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000015579 29,876.12
4. ORRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000022048 9,824.36
5. ORRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000022417 10,013.32
6. PHEASANT RUN PROPERTIES -SECURITY DEPOSIT 402.07
7. VEHICLE -SOLD 4,000.00
8 (PERSONAL PROPERTY -SETTLEMENT SHEET ATTACHED I 1,452.50
TOTAL (Also enter on line 5, Recapitulation) I $ 65,616 65
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
SCHEDULE G
INTER-VIVOS TRANSFERS &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
EDITH H. CONWAY 21 09 0804
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 % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE.
VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. NORTHWESTERN MUTUAL 1,466.78 100. 1,466.78
ANNUITY #B3353570A
BENEFICIARIES:
JEFFREY G. CONWAY
JAMES R. CONWAY
KELLI SUE CONWAY
2. LINCOLN BENEFIT LIFE COMPANY 4,923.24 100. 4,923.24
BENEFICIARY: PA DEPT OF PUBLIC. WELFARE
TOTAL (Also enter on line 7 Recapitulation) ~ $ 6 390 02
(If more space )s needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
EDITH H. CONWAY 21 09 0804
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
A• FUNERAL EXPENSES:
1.
6
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City
State _,_, Zip
AMOUNT
Year(s) Commission Paid:
2. Attorney Fees IRWIN & McKNIGHT, P.C. 3,600.00
3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State _,_,_ Zip
Relationship of Claimant to Decedent
4• Probate Fees REGISTER OF WILLS 132.00
5 Accountants Fees
6. Tax Return Preparers Fees PATRICIA A. ROSENDALE
CPA
, 350.00
7. THE SENTINEL -ADVERTISE ESTATE
8•
CUMBERLAND LAW JOURNAL 198.76
9•
REGISTER OF WILLS -FILING FEE 75.00
10.
ROWE'S AUCTION SERVICE -COMMISSION 30.00
558.35
TOTAL (Also enter on line 9, Recapitulation) I $
4,944 11
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX +. (12.03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
EDITH H. CONWAY 21 09 0804
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1. L.L. BEAN -CREDIT CARD 46.95
2• (DISCOVER -CREDIT CARD I 29.18
3. (JOHNS HOPKINS -MEDICAL I 6.96
4• IMASLAND ASSOCIATES, INC. -MEDICAL I 76.00
TOTAL (Also enter on line 10, Recapitulation) I $
159 09
(If more space is needed, insert addi>JOnal sheets of the same size)
REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
r/~T ~ T~ w
SCHEDULE J
BENEFICIARIES
wir~~cv~
EDITH H. CONWAY
NUMBER
I.
1.
2.
3.
4.
II.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
JEFFREY G. CONWAY
7 MATTHEW COURT
CARLISLE, PA 17015
JAMES R. CONWAY
1505 LYONS ROAD
MT. PLEASANT, MI 48858
KELLI SUE CONWAY
2138 MORNING PARK DRIVE
KATY, TX 77494-2147
JOHN CONWAY -DECEASED -FEBRUARY 2004
FILE NUMBER
21 09 080
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
ILineal
ILineal
ILineal
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIA
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
6. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. PA DEPARTMENT OF PUBLIC WELFARE
PO BOX 8486
HARRISBURG, PA 17105-8486
DECEDENT WAS NOT RECEIVING ASSISTANCE
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
AMOUNT OR SHARE
OF ESTATE
61,98023
1/3 REMAINDER
11/3 REMAINDER
X1/3 REMAINDER
ON REV-1500 COVER SHEET
4,923.24
(If more space is needed, insert additional sheets of the same size)
24
LAST WILL AND TESTAMENT
I, EDITH H. CONWAY, of North Middleton Township, Cumberland County, Pennsylvania,
being of sound and disposing mind and memory, do hereby make, publish and declare this to be m
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Last Will and Testament, hereby revoking any and all former Wills or Codicils by me made.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and all
inheritance taxes (whether such taxes may be payable by my estate or by any recipient of an
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property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representative shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
If my spouse shall survive me by thirty (30) days, then I give, devise and bequeath all of m
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estate, both real and personal property, unto my spouse, RUSSELL G. CONWAY, absolutely.
3.
In the event my said spouse shall predecease or fail to survive me by more than thirty (30)
days, then I give, devise and bequeath all of my estate, both real and personal property, in equal
shares, unto my children, JEFFREY G. CONWAY, JOHN M. CONWAY, JAMES R. CONWAY
and KELLI SUE CONWAY, absolutely.
In the event any of my said children shall predecease or fail to survive me by more than thirty
(30) days and shall be survived by issue, then his or her share shall be held by my Trustee for said
issue and distributed to them equally as each shall attain the age of twenty (20) years. Prior to the
distribution of the principal of any share, my said Trustee shall have the sole discretion to use the
income and principal of said share for the support, maintenance and education of such issue of such
deceased children, regardless of age. To the extent that the same is permitted by law, none of the
Page 1 of 4 Pages
. ~- C'.
E.H.C.
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beneficiaries hereunder shall have any power to dispose of or to charge by wa of antici atio
Y p n any
interest given to such beneficiary; and all sums payable to such beneficiaries hereunder shall be e
fre
and clear of the debts, contracts, alienations and anticipations of the beneficiaries, and all liabilities
for levies and attachments and proceedings of whatsoever kind, at law or in a ui .
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The share of any of my said children who shall predecease or fail to survive me b more than
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thirty (30) days and shall not be survived by issue shall be distributed to my remainin children in
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accordance with the terms hereof.
4.
I nominate, constitute and appoint my spouse, RUSSELL G. CONWAY, as Executor of m
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estate. In the event he shall be unable or unwilling to serve in such capacity, then I appoint m son
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JEFFREY G. CONWAY, to act in such capacity. In the further event he shall be unable or unwillin
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to serve in such capacity, then I appoint my daughter, KELLI SUE CONWAY, to act in such
capacity.
5.
I nominate, constitute and appoint my son, JEFFREY G. CONWAY, as Trustee under the
terms of this Last Will and Testament. In the event he shall be unable or unwilling to serve in such
capacity, then I appoint my daughter, KELLI SUE CONWAY, to act in such capacity.
6.
I direct that neither my personal representative nor my Trustee shall be required to file a bond
to secure the faithful performance of their duties in any jurisdiction.
7.
I authorize and empower my personal representative and Trustee, in their sole and absolute
discretion, to purchase or otherwise acquire and retain any investments of which I die seized or an
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real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dis ose of
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or grant options in regard to any or all property of any kind forming a part of my estate for such
terms and such prices as they may deem advisable; to borrow money for any purposes connected
with the protection and preservation of my estate; to mortgage or pledge any real or personal pro e
P rtY
forming a part of my estate or to join in or secure the partition of same; to compromise any claims or
Page 2 of 4 Pages
~~
E.H.C.
demands of my estate against others or of others against my estate; to make distribution in kind d
an
to cause any share to be composed of cash, property or undivided fractional shares in ro e
P P ttY
different in kind from any other share; to employ agents, attorneys and proxies and to dele ate to
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them such power as my personal representative and Trustee consider desirable and to a reasonable
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compensation for such services a.s may be rendered by such agents, attorneys and proxies; and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my personal representative shall have the power to conduct an invento of an
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safe deposit box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 20th day of September,
2000.
' (SEAL)
Edith H. Conway
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and
for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testatrix and of each other.
~_~% ~ ~ ~
Page 3 of 4 Pages
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND SS.
I, EDITH H. CONWAY, Testatrix, whose name is signed to the attached or fore oin
instrument, having been duly qualified according to law, do hereby acknowledge that I si ed ang
executed the instrument as my Last Will; that I signed it willingly; and that I si ed it as m fr d
voluntary act for the purposes therein expressed. ~ Y ee and
,~~
Edith H. Conway
Sworn or affirmed to and acknowledged before me by EDITH H. CONWAY, the Testatrix
this 20th day of September, 2000.
No ary Public
COMMONWEALTH OF PENNSYLVANIA Notarial Notary Public
Sharon E. Bloom,
North Middleton Twp., Cumberland County
S S . My Commission Expires Aug. 5, 2002
COUNTY OF CUMBERLAND ~ Memt~er, Pennsylvania Association of Notaries
We, ~~"~ ~1~ rl ~ ~ ~~ U
~ and ~ ~5~~ ~ ~, ~n r,Ja.
the witnesses whose names are signed to the attached or foregoing instrument, being duly ualified
according to law, do depose and say that we were present and saw EDITH H. CONWAY the
Testatrix, sign and execute the instrument as her Last Will; that the Testatrix signed willin 1 ~ and
that the Testatrix executed it as her free and voluntary act for the purposes therein expressed that
each of us, in the hearing and sight of the Testatrix, signed the Will as witnesses; and that to the best
of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no
constra.~nt or undue influence.
c
Address
r
~-~ -.~- ! . U -7
Address ~~~~ ,~~~~~~_ ..
' 70 ~
Sworn or affirmed to and subscribed before a this 20th day of September, 2000.
No, Public
C:\SLB1Estate Planning\10175.1w-will.doc Notarial Seal
Sharon E. Bloom, Notary Public
North Middleton Twp . Cumbe„and Coun
Page 4 of 4 Pages My Commission Expires Aug. s, 2t>02 b
Member, Pennsylvania Association of Notaries
, r. uu~~ uuu
.Date September 21, 2009
To: Trwin & McKnight, P.C.
West Pomfret professional Building
60 West Pomfret St.
Carlisle, PA 17013 3222
AttentYOn: Stephen .L Bloom
From: Shirley Wescott
On~stown Bank
PO :QOM 250
Shippensburg, Pa 17257
Re; Estate of Edith H Conway
Date of death :August 16, 2009
77 East King Street
Shlppensburg, PA 17257
JT IS I~EREBY CLCRTIFIED Th~AT THE A130 vE N~J~YfE'D D.FCED
FOLLOWING ACCDYINTS H~ITH ORRSTO yYNBANK.• ENT. 01V THE ~iBOYE DATA, I~A.,D THE
CHECKING ACCOL~~'
Account # Title of Account
Dip= Pn- nc.~.iLl. Accrued_Interest Y'i'p interest DOD
143000872 Edith H Conway 05/25/2007 $4854.57 $ ~ Ba~•
. _.13 $6.04 $4856.70
SA TlI1VGS ACCOUNT
Account # Title of Account Date opened ~Princi a1 A
N A --~... ccrued Interest
CERTIFICATE. n~ DFpOSIT
Account # Title of Account
*4000006604 Edith H Conwa Date ~yned
-~
7/01/OS
P-' n- c-'~
A~'o~ Tnter'est
YTD Intr
DOD 8~
*(Jc~ey G Conway POA added 6/14/p~ $5156.42
_ $5.16 5135.52
$S1 519 58
4000015579 Edith H Conway 03/ 1, 3/07 $29552.1 S
$23
94
4000022048 Edith H Conway
12/20/07 . $755.71 $29876.12
.
4000022417 Edith H Conway $9820.00 $4,36 $230.97 $9824.36
01/04/08
$10000.00
$13.32 ~
$269.54
$ l 0013.32
9'/21/09 TIME
•Edith H Conway
DEPOSIT f V V 4 r V U 4
INQUIRY ~ 13:44:39
D.~,te ~'
Fi®ld description C024648
~ 4 0 0 0 0 0 6 60 4 T
7~'O1/09 Interest Rate Changed Values.
3/17/09 Include on Statement To; y ~ ~ 02.720000
3/17/09
1/11/08 Add to Lead Acct
Officer To: 113000872 D
6/14/07
6/14/07
ADDITIONAL NAME 1
ADDITIONAL NAME 2 To:
To: CARAM
Jeffrey G Conwa POA
y
6/19/07
6/19/07 PRIMARY CIF NUMBER
PRIMARY SHORT NAME To:
To: C024648
6/14/07
DLT X-REF CIF# To:
~ To; CONWAY EDITH H
6/19/07 DLT X-REF RELATIONSH To:
7/07/05 To: NEW ACCT
Enter=Return F10=CIF Maintenance Bottom
F20=Fold/Unfold
r-------~~~-..
R o wE ~ s Luc
TI4~N sERVI c~H 79L
CE ~
Bill Rowe (AU 1538L) 2505 Ritner Highway Carlisle, PA 17015
249-1978 697-4794 249-2677 Dave Rowe (AU 2295L)
Auction Is Action Call "Rowe" F'or Satisfaction
SELLERS NAME ~ Q l.f~tZ [.(~(~-
r~ ~/y~ j~ ,~ ~ DATE
ADDRESS 1 l ~ l C~ f ~ ~~ WC.C ~~t" ~ 1''" ~~ ~ ~ ~ t~:~ /~(, / 5~
PHONE
~~ ~~
OTHER ` _ AUCTIONEER % ~ ~
AUCTION DATE/LOCATION ` ~f.~
CLERK %
DESCRIPTION OF MERCHANDISE ~ ~ ~ ~
~'~,(~ uz ~ ~tfy C ~.
~~
r
-•-
S~~os ~ .v
~.1~.0 - ~. ~~- - ~ ~ t .vim, ~ d 4
,~
~ ~.:~5 i- .. , ~..
I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen-
tative of the merchandise, goods and or property and have good title and the right to sell and that they are free
from all encumbrances. agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. gree to hold harmless the Auctioneers against any claims of the nature referred to in
his agreement.
i-
J 7~+ l - ,f
AUCTION S GNATU SELLERS SIGNATURE
-__~-_
Total Sales (Clerking Tickets Attached) ~ _ ~ ~ ~ ~- ~~
Less Sale Expense:
~~
1 % Commission Auctioneer ~ ~ ~~
% Commission Clerks ~
OTHER: t..Z. ~~ ~~,._. ~ ~ ---
C
~~~4~
•~ ~----
TOTAL SALE EXPENSE DEDUCTED ~ `yam=' -
IS
SELLERS NET $ ~' L-}- -
Lincoln Benefit Life Company
P.O. Box 94212
Palatine, IL 60094-4212
Telephone: (877) 499-6418
Facsimile: (866) 635-4523
September 24, 2009
Stephen L. Bloom
50 West Pomfret Street
Carlisle, PA 17013-3222
Re: Edith Hilda Conway (owner/annuitant)
Contract No: LBF 1228570
Dear Mr. Bloom:
OAT 1 9 ZOOy
IR~WN & McKNtGH~
yaw o~c~s
We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form
712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain
date (usually the owner's date of death or date of transfer of the contract).
Because this contract is an annuity contract, it is not reportable on IRS Form 712. I can, however, provide
the following information for estate purposes:
LINCtJLN BENEFIT LIFE
A N A L L S T A T E C G M P A N Y
RECEIVED
Date of Death: August 16, 2009
Annuity Value as of Date of Death: $4,923.24* ' J
Named Beneficiary: PA Dept. of Public Welfare -- ~ I~lYA~~
Contract Date: May 19, 2007
*This value is an illustration for estate purposes only. It does not represent a cash value or a lump sum
withdrawal offer.
Enclosed i th certificate you provided with the claim documents since this does not belong to our
contr . _Please se d us a certified copy of death certificate for Edith Conway.
If you have any questions, please contact me at 1-877-499-6418 Ext. 86760.
Sincerely,
Theresa Parsons
Sr. Claim Representative
Northwestern Mutual°
720 East Wisconsin Avenue
Milwaukee, WI 53202
LIFE BENEFITS DIVISION
STATEMENT BY INSURER -DEATH OF PAYEE
Treasury Department Form 772 Not Applicable
INSURED (ANNUITANT) DECEASED PAYEE
Russell G Conway Edith H Conway
POLICY (CONTRACT) NO. PAYEE'S DATE OF DEATH (MM/DD/YYYY)
B3353570B 8/19/2009
POLICY (CONTRACT) INFORMATION
death of Insured on
~ . I~OIIC Orl inall y DATE (MM/DD/YYYY)
y g y payable b reason of maturity on 06/25/1990
DATE (MM/DD/YYYY)
surrender on
DATE (MM/DD/YYYY)
2. Settlement Option (Description):
Joint and Survivor Life Income Plan
Elected by Russell G Conway Date 06/25/1990
3. Value of any remaining benefits $ 1,466.78 (MM/DD/YYYY)
4. Successor payee designated by Russell G Conway Date 06/25/1990
(MM/DD/YYYY)
5. The deceased a ee did have the ri ht to chap a or revoke the successor a ee.
IMMEDIATE ANNUITY INFORMATION
1. Annuity applied for by Date
2. Type of annuity (Description): (MM/DD/YYYY)
3. Value of any remaining benefits $
4. Successor payee designated by
Date
(MM/DD/YYYY)
5. The deceased a ee did have the ri ht to chap a or revoke the successor a ee.
REMARKS:
The undersigned officer of The Northwestern Mutual Life Insurance Company hereby certifies that this statement sets
forth correct and true information.
Date of ~,~----r~
Certification October 28, 2009 Signature ~ `~`-'"
(MM/DD/YYYY) VICE PRESIDENT OF LIFE BENEFITS
15-0163(1203)
WORD 8-LS