Loading...
HomeMy WebLinkAbout01-15-10 (2)1 '~ 15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Hanistwrg PA 17128-0601 RESIDENT DECEDENT ~ I ~ `J ~ ~ ~ ~ -' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth f (~I 3~ X93 ~, ta' ~5,~00 ~ ~3~0 ~ 1 ~ o Decedent's Last Name Suffx Decedent's First Name MI c, Lo v ~ ~ " ,Q ~ ~~ 2T 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 ~ 1. Original Retum O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82)' O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Slafe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax un~lsr 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 SHOUL BE DIRECTED T0: Name Daytime Telephone Nunhber J v/} nrNc MA R-lN v M ~ Gr~~`~vY -~ ~ ~ a ~ o~ a-- Finn Name (If Applicable) REGISTER O USE ONUL. ~~ } --' i^'1 n ~ r : , ,, t.~~r. .,.3 First line of address ~I ~ rn {s ~ r ~' n s o ~f ~-s ~ ~ 3 s ~ ~ ~ ~ ~~~ _ ~ti " / Second line of address ~~ - ~ ~ '.:..~ t=ry ~ `~r t Offi P i State ZIP C d ~ DATE FLED ty or os ce C o e --_.___. cA~L-) dL t , P~ x'70 ! 3 - ~ as Je, ~~/ Correspondent's a-mail address: er penalties of perjury, I deGare that 1 have examined this return, including accompanying schedules and statements, and to the best of m' knowledge and belief, .#t rue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer as any knowledge. ~' SIG RE OF PERS N RESP SIBLE FO FI ING RETURN ~ DANE SI NA E OF PREPARER OTHER THAN REPRESENTATIVE /~ D E/ AoDRESS_ / S • Nl L-~' / -~' i - ~/¢ ,I° L/ .T L6.~ /~ /~- ~ 7 of / '? LY 15056051047 Side 1 1505605104'7 ~'l 1 .~ 15056052048 REV-1500 EX D ecedent's Social Security Numb er s r~ '7'- /+ ~+ Decedent's Name: ~ Q g G Itr / ~y l,~ ~/fl ~A(.J ~ e / Ip ~ j a ~ ~ 2 / RE CAPITULATION ~ 1. Real estate (Schedule A) . ........................................... . L ,' l ~ ~ C O p . ~ 0 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. 3 ~ I 1 ! ~ t ~ j 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. ~ 9 3 7 a S u ~ ! '-j / / 8. Total Gross Assets (total Lines 1-7) .................................... g, J ~ ~ ~ ' ~ ~ • ~ 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. ~ LL ''j' ~ ~ • ! ! 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...... . ......... 10. ~ ~ ~ b 11. Total Deductions (total Lines 9 & 10) ................................... 11. )1 i! I ~ ~' 6 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 Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~' / ~ J q ~ ~j j d / 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 .0_ . 15. ~ 16. Amount of Line 14 taxable at lineal rate X .0 _ .' 16. 17. ~8 Amount of Line 14 taxable Q b at sibling rate X .12 ~ I ~ ~ S ! • A ~ A ` t f Li 17. ~ l ~ i ~ ~ l . moun o ne 14 taxable at collateral rate X .15 • 18. 19. TAX DUE ......................................................... 19. J ~ ~ ! / • ~ 7 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052048 Slde 2 O 15056052D4B1 J ' REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME LL O~G~~ ~ ~ _ STREET ADDRESS _ 2~ ~ UrJ~ Q File Number o~) ~~ /a~ ~-.- GLU ~ s ~-- _ _ _ _ _ __. l-~ ~4- ~` _ ~:-a f1- p _ _ _ _ _ ____ CRy STATE^ ~ 4 L!P ~ ~ /~ I Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit ~ - . _ ______ _ _____ ___ S. Prior Payments C. Discount ~ ~~ p;~p X b 3'21x3 2 J~LS '7 S i Total Credits (A + B + C ) 3. lnteresUPenalty if applicable D. Interest __ _ E. Penalty Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 + tine 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. 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. i1) ~~ s ~` (3) (4) (5A) (5B) ~ ~( ! !~~ . D ~ Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRII~TE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the propefij 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 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? ....................................................................................................... ....... ^ ^ 3. Did decedent own an "in trust for" or payable upon death bank account 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? ........................................................... ~/ ....... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS 1S YES, YOU MUST COMPLETE SCHEDULE FILE R AS BART 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)J. 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)j. 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 (O) 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(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(a}(1.3)j. 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. ,r ~ttst Yll rxnd ~esk~xmertt OF ROBERT E. CLOUSE BE IT RE~iE~iBERED. _~~- -. ROBERT E. CLOL ~E. : ~ ` ~;- -~~., _ :~ -..-~= Carlisle, Pennsylvania, being of sound mind, memory- and understanding, dolmake. pabF~t and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof made by me at any time heretofore. ITEM 1: I direct that all my just debts and funeral expenses be paid' as soon after my demise as may be convenient. ITEM 2: All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath unto my brother, JAMES A. CLOUSE, absolutely, providing he survives me for a period of thirty {30) days. ITEM 3: Should my brother, JAMES A. CLOUSE, predecease me, fail to survive me for a period of thirty (30) days, or should we die simultaneously, Ithen give,. devise and bequeath my entire residuary estate unto my two nieces, WENDY L. DEIBLER and MICHELE ti'I. ~ZORRO~'~', in equal shares. ITEM ~: 1 direct :~~~ ..~rei-•a~. ~:a-~~e~ ~~::~::::or to ~a~ alI inheritance. estate. __.:,.__._- ~.... .r~:._ ,: .•,....."~:-.- .__._re ~....:i~:~d. to ~.hich m~~ estate or the --w_=:.r ~: - r~~pem F=..ssin~ ~~ereund.r or other~.;-ise passing b~- reason of my° demise. may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes. either federal or state. on anv property required to be I have a po~~-er of appointment. i _ _. ~.- :~. .~ -~ - .~_ __.:- _ . _ __ _ .~ ~~~~ ~... CLOUSE, absolutely, providing he survives me for a period of thirty- (30) da~-s. ITEM 3: Should my brother, JAMES A. CLOUSE, predecease me, fail to survive me for a period of thirty (30) days, or should we die simultaneously, Ithen give, devise and bequeath my entire residuary estate unto my two nieces, WENDY L. DEIBLER and MICHELE M. MORROW, in equal shares. ITEM -t: I direct n~ l:er..~~-:_...~.-... ~ .~_~~-_- .: - ~.~ ---_.:_-.~-.,_- =_~... succession and legacy tales e: ~:• ~~.__~ ~- :-~._-~ _ ._.:_.:- _- _. ___.~ _- __,. transfer of and- propem- passing 1-.reu::;:;r ~~- ~~:...--.-~.== ~ :.> ~._ ~~ re:2s,~r: ~~ . r-3` ~; . ~ ~: ~~.s.. may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state.. on an~~ propert~~ required to be included in my gross estate. under the pro~~isions ~~f a~~ s.r e ~,~ `.::era. . _. _ .- -_ -~. or hereafter enacted, shall be prorated among the persons ir.teres:e,:::-: ---:: ~_,~:::~ -,~~::-:_~- such property is or may be transferred or to ~~-hom am~ benefit accries. ITEM 5: I appoint my brother, JAMES A. CLOL-SE. as Elecut`~- ~~f the -::~. Last Will and Testament. Should my brother predecease me, fail to qualit<. cease to act. or 1 renounce probate, I then appoint my niece, WENDY L. DEIBLER, as Executrix of this my Last Will and Testament. ITEM 6: I direct that my Executor or his successor shall not be required to give bond for the faithful performance of their duties in an~~ jurisdiction. ITEM 7: My Personal Representatives shall have the follow°ing powers in addition to those vested in them by Law and by other provisions of this, my Last Will and Testament, exercisable without court approval, and effective until distribution of all property: 1. To retain any or all of the assets of my estate, real or personal, without restriction to investments authorized for Pennsylvania fiduciaries, as they from time to time may deem proper, without regard to any principal of diversification or risk. 2. To invest in all forms of property without restriction to investments authorized for Pennsylvania fiduciaries, as they from time to tame may deem proper, without regard to any principal of diversification or risk. 3. To sell at public or private sale. to exchange, or to lease for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms or conditions as they from time to time may deem proper. 4. To allocate receipts and expenses to principal or income or partly to each as they from time to time may deem proper. 5. To borrow money from persons or institutions, themselves included, and to mortgage or pledge any or all real or personal property as they in their sole discretion shall choose, without regard to the diapositive provisions of this instrument. 6. To compromise any claim or controversy asserted by or against my estate or trust estate. 7. To make distribution in cash or in kind or partly in cash and partly in kind, and in such manner as they may determine, and at valuations finally to be fixed by them. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 13`h da~~ of Januan ?009. '~ L%~.7` r- . ~ ' ~,'~,~,-(SEAL) t~-1T~E~S- ~ 1 ~_- -^- J; *-'".~ ~ conditions as they from time to time may deem proper. 4. To allocate receipts and expenses to principal or income or partly to each as they from time to time may deem proper. 5. To borrow money from persons or institutions, themselves included, and to mortgage or pledge any or all real or personal property as they in their sole discretion shall choose. without regard to the dispositi~•e pro~~isions of this instrument. E. To compromise and- claim or controversy asserted b`. or against my _ _ . _~:..ti.~ _---~-. _-. _~:- ,- - . --~. ~- ~artl~- in cash and partly .._-<,~- .~ .,- - ,, = - ~ -- ~, -:-~-, :-,at determine. and at ...._......._ :...w .~ ce ~x.d ~ ~ them. - IN WITNESS WHEREOF, I have hereunto set my hand and seal this 13`n ~~~- C4 JaI?'~a:-~- ~~nA. «'IT~ESS: ~_ .i' ~. ~~ ~ t ~.` ,. ~ -~r, --, ~~~ , . -~,?-- ,__ ; :;%, „~ (SEAL) ROBERT E. CLOUSE 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF YORK SS We, ROBERT E. CLOUSE, DAVID J. LENOX, ESQUIRE and MARCY K. RENSHAW, the Testator and the witnesses respectively. whose names are signed to the attached or foregoing instrument, being first duly sworn. do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament and that he had signed willingly (or willingly directed another to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of'the Testator, signed this Last Will and Testament as witness and that to the best of their knowledge the Testator was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. -, RO$F.,~ZT E. C,,,L~-O-~U"~SE ': WITNESS _ F ~ ~,. % WI ESS Sv~~orn to and subscribed before me this 13`h day of January, 2009. ~~ _ ~~ ~n ~ ~'~ ~r~ NOTARY PUBLIC MY COMMISSION EXPIRES: COT~isl0ivlf°eR!: i _ r-, - ;: G+vS YLVA.NIA N.::a ~a Seal S. Dawn GlaCtefter, Nc3su)I Ptt~i~ D~isburp BQrO, Y~ Cou17 2009 i nny Commiss-on ~' "~~' ----~ Member, Pen~sylvenie Asaoclatfon of Notarfaa ' REV-1502 EX+ (i1-08) ~ Pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE - --- ESTATE OF ~ FILE NUMBER ~a~~~ T ~~. LL a cc.S ~ ~~ _ a y - ~ a y~ All reel property owned solely or as a tenant m common must be reported at fair market value. Fair market value is deFlned 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 facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a mpy 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 common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION >.. 3~ ~~ G - k'' oN c?v ~~ ~T e~ Lis z..E~ P~ ~ 7 ~ t-,3 ~J a 4~, d~ v ~~ TOTAL (Also enter on Line 1, Recapitulation.) I $ If more space is needed, insert additional sheets of the same size. REV-1 Wli EX+ (8.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEI~t~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY I ESTATE OF FILE NUMBER _ ~'.4~f~z~ ~ , C~ c~ctsL ~ l o y /rya Include the proceeds of litigation and the date the proceeds were received by the estate. All proaerty Jointly-owned with right of survivorship must be disclosed on Schedule F. • REV-1510 EX+ (08-09} ~ Pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERTfANtETAXRENRN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBE$ Phis schedule must be completed and filed if the answer to any of quest(ons 1 through 4 on page three of the REV-1500 is yes, ITEM ~, DESCRIPTION OF PROPERTY INCLUDE THE NAME of THE TRANSFEREE, iHE1R RELATIONSHIP TO DECEDENT AND DATE OF DEATH 9b OF DECD'S EXdLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPUCABLE) VALUE Vh ~ ~/ ~. Io~j So~,~3~vP~J -- Ivujs:~a.~3 'A/f/N/o ~ ~ 4 ~1 yf.z b '3 6 .Zyl S>Q b ~vo ~o ~--' /~y si o. ~ $' ' _ ~,~~ 3~35Z .-_--. '07,91~.~1 o ? 9i~'31 /° °7° TOTAL (Also enter on Line 7, Recapitulation) $ ~ ~ ~ ~~ i~f$'~"' If more space is needed, use additional sheets of paper of the same size. 0i/14/2010 1~;59 717-783-3467 INHERITANCE TA}C PAGE 03105 . JAM-~,~-2©13 94:0? FROf•!: TC:171';'~83~46'7 P.2~5 AIIiSnY Life Insurance Company of Narih America PC Box 38060 ~i~dir, ~ asaaao0do 80018541 w~~~ p ~!-NN~'JI'I'Y OPTION AG + EM~1'~T Policy Numbs: tlnnuitanl E~at+u: Owner Name; Settiemern Bt"~ct+ve Debo: option Chosca: O~.~tal Amount of Prou3orla PayracAt Mode: Nand raymart T7~tc: Final P+cy~tpd D~ 4380953 Today's Datec Novar~ar 2, Zfl09 RU'TFf i~ G'1.QUS~„ DL'C~SFI~ TAMES A CL4USB ~~ly ls. 7oaa Instalt~ewc for a Guarantood Period 39'7.905.39 Maathly N'avensber 1 S. ~Ot)9 .ham 1 S, 20 ] 9 Corttio~t Ownsr; pATRICL~ M CLOUSE l+syrnertx Amasa~ 5999, i 9 Gunrasrtaad pCeiod; 10 YB.4R$ tTndcr the provi~o,~s ot: your polioy. you l~,svo alroreu the ab~ovadaeanUed opetoo. $aoh tnatallmont wiJ! ootxsi~t at?part ~ncipal arA pgtt ius~st. R i6 ~mdcrataod that blecticm of this annuity optiaa wsivte all sfp~tc to subrr~it pncn-lum or maicQ adttitianal wi6hciisw$1g, No furt~r adju~ettt in intarest will be made. . Facaapt tOr the Compsny'c obligalaons w!~ raapect io payment parsuaat to tha aeztuity option selectod b3- you, sal atharpz+ovisiooa otthn policy terminate once paymmu bagLas, Tha+~-oda aF payntieut a iced and wanot be ohat,ged. VViI~ the elec~ien oPt!':i:: annuity option, quarterly ardlor ttnnua; ~ will ao ianger genante. The selrtcNon of thin annuity option is . irrovcratbiQ, unsfc;gt~blb, Aod na~n iransi~rob]s. Should ~ owncx die batome Rho final payr~omt dais„ paytncata will camir~e to ba>~ iu tine soma rnartrsr as praviousiy alectert to the ccmdngptt c~woer, or sa am~u-dad. Maureen A, Phttltpe /b YR ~, S"~ 7 / )f ~/~ Q yam. ,7F Gary C, $hojw~i RreeldAht And COQ l ~' w~; ?~ 1. F' ,~' 9 ~' ~F ~.~, ,+.~' 0 01i1ai201fi 12:59 71l-7S3-3467 JAN-13-zQZO 0907 FRa'1: INF~RITAN~E TAX rD :171'77$33467 PAGE ~2r 05 F.3~5 • A~lanz Liae In~uranre Company of North ~~~~~ Ametlt,a ~0 6ax 88060 ~oQJ~5a JBa ~s~o A~1rl"UY'T"~ t7PT~aN AGREEII~ENT • 1?a74oy Wumber: 4942636 T'oday'a Date: Novambar 2, 2409 RBYI3F.D Axsauitmit Nst'r-a: ROBERT 8 CLOUSF., DECEASET~ thu»er Noma TAI+atE3 A CLOUSE 3e~ttlcrnent Sl'feative L`-aate: Mey 3, 20{19 (httian G'hoseti: It~tallttteats for d Gueeafltard Period ()rigiswaJ Amou,7t of Ptvccads: 5119,061.42 Payaxient'I~ode: hianthly Paymoat A.maunt; 51,256.38 Next Paynra,t Date: Nov~nber 3, 20(>y Ci<uarantaed period: I0 `Y~AR5 Firuil Payrnert Data: May 5, 20l! Gmtin~mtt t>wma: AA'IRTGir4 M SrL0U513 SI~tJ'SL T 04,0096 Under the proviaians of your policy, You stave chaaen the ebove•dssctil~ad annuity option, each instal{me7nt alll odnsist of peat priacippl and part it~tete6t, It is tinder$tood t1~Rt eleotion• o°thlz arutuiry option waiver all right¢ tQ zubrnit prvrnittm ar rttalce additional withdrAwals. No 19trth+e adjustment sat intat~t will ix~ made. ~xoept for the Conopaay's ob!l,gatior~s with re~spret to paymerrt pursuant w :he annuity ppti4rr seiecssd by yau, all athcr pron+taiuns of the policy ternilr,~po onoo payn~t bcgms. Tha model oP ptymont is Frxtd and Cannot ba o}tMtt~exi. With tha aloction of thin atu~wity option, gt{aricrly tt--id/or arutual etaorrrtents wilt ao long 1+'enacato. Tha selection a£'ttus acuity Option, is irtevarslble, uncssigrtablt, and norytransi'brab{e. Shauid the owner dic b~orethc tins! payment data, paytncstts will continuo W ba paid itt the seine tamer as prs~viausly slxxed to the aorttin~ owner arms a~ton~ded. ~' nt Matr+e~A~. ~hNPs • ,~t~ Gary C, Bhojwa . r • Pnesidt~t and CEO ~,r pp .~J Lw ~ t ~+ f n ~ ~ ~ ~:t' Kn;~~~f'. 'r .ice, }~ "1.a. ~J1~'14~20~@ 22:59 717-783-3467 INI-ERITANC~ TA:~ PAGE @1105 J~V-23-2610 04:~~ FRpMr Tt7:17177833467 P.4~5 Lifie trrsuran~ce Compsu+y of North ~~~~ f^~ n z r ~ ~~~ ~/ PQ Box S~BU pilli6, N 554$9~Q1360 M I C 11 1~A Ad ~ y [ ~/ \~ ~j ~ ~ QUVf~7O~~~ ANNU'I'Z'~' t~PTII~N ACR,~~11~11YT 'Fbifcy+Ns,:mbar 2$50447 Today's Data; November 2, Zop9 REVISED Annuitant Nana 12.dS6R7' ~ CLOt.!SE, DECEASED Uwntr Hama: JAMES A CLOUSE Settietnatt fEfl'tative Aata: May 5, zaa9 Opsfon Choces~: Inmusilmcnis far a C3wrranteod pcriOd Osigina7 Aman~zn of Froceedy: SSQ,03Z.b2 Payrnapd Moda: Mon~thiy Paytnaat Amour+t: S91S1.$1 Next payment Data: November 5, 2009 G'tiaraateed period; S YiEiARS Final Payznatt Date: May 3, 2014 Comingent t~utner; PATRTCIA M CLQUSE SPOUSE i40.1109~ Under ilia provisions o£yaur p'oiiay, yaa haw chasm the aborrade:cribad axmuity option. ~ w~sailauat wiII oonaiat of D~ ~cipal aad part iat~t.tt is urydr:rotood t},wi dadion of thifa ennu9tty aptfoa. waivcx~ ail tv submit pq~nlum or make additioiwl withdta~r+als. Na furllhor e~justrnens in islt3re~t will bo t~da, Frxccps for tlac Cc+mpaay'a obtigatiaae wisdi raspoct to paymcrtt pussuaat to the iatlmiity Optiaa ael octod by you, of 1 othtr pravi~ions of the policy t+Grmistate otwea peym~ begis~. "1'he mod! of paysaant io Axed and cannot be~chax:ged. '1~iih tba electlat of Chia aansutiy option, tiuwrtGrly and/or snma,i statcrneni~ will ran re~ger ganarate. '~ selection a#'thJs annuisy option is Crrav~ersible, ussasaignsblo, ^xdnnz:.•trsnsfenbla . Should the owner die before the £inali payn~ant datr, pe:ymonta wit'. oantiave so hr paid in rhm ~aYre manr~r as pravios~y clo~vd to the CC:rrtirt,gC~t ownsr, ar a@ am«ss$e~l, ~'~`~ ,~, ~- ~~, ,~, ~ ;~. ~~yy ~, ~'• 7°rs" N9saureers A. Philip' , pry ~^ ;~,~ ~~',~,J ~~r~ w' ,~ I Gsry C. Bisojwz~nf f~9ald@flt ~~ Cf:~ /; Y ~~~yir k~~P^. ~~ .« ~tT~, ». ~j sfdi ~.:~Fr.. 0 ~1ln4f2010 i2: 59 71i-783-3467 ii'JFERITANG£ Tra?C PAGc. 051'05 ,.~.-a.-a,;~-ce~~r~ ~~t:~tt r+ttil'1: TD~~.7~?7B334b? P.5~5 x13/zo~,o ~ :13 PM A.11i~ylZ Lit9 ~> '+'17241257 ~a~ye z a~f 2 A1liarrz Ule Insurance Company of NatKh Arnstieua PQ Box cDQQO Mlnnsapolls, MIV 65459-0l38ri 80taNJ~t942 October 20, 2008 JAMES CRUSE a8o uNl41V HALL ROAD CARLlSLi: PA 17013 ileac Bene~dery: ~i~ ~c ~ We sent you tktia it~tter because you aro the named beneficiary of Aobert Clouso. Please mccept our sincero ayrnpaihy bn yaur lose. Listed below is irrforrr~tion nv+~d to file $ Clt9irl'I for benefits oR th. fixed! annuity +cor~q^aot. R~afer ~ the enolased brochure for answers to our moat fregwntly asked quasfiorts. Pavt~rt t~ians Choose otw of the optiar-e irn Sacl6on IV on the de~rn form. t',tantr~et Inbrrn~-toet Contract Annuitization Min~murn Cash Qualified or Nurnbor Yalue out Period Vetu Non ualif ed 118 30. t N 1 ra.,cy ra,+ru w~ ^rracr~o oy rrrax+rswars. parns~ at/rrM>r7sr3, lQaRa ~QQ tt+ttM~rsr tlprill ae(r'uet'manta: eta q result, rafuws quata~d in th+a /ilfar tn~ty ir-or~a or dtaor~st- area tla not ~eaarantaad, xe Ann~utt~ Claim norm Q +Cppy of the oBrtified death oertlfit~tte;only ores copy Ir roq,:irad for ~ aeco.aed) Qrtca wrr radiivo your claim requiramer~, apow 13 business datys for processing. Sk:auid you have anY queadons, daass carnact wa at O40-x50,1862. sincerely, Annuity Cl~timt rc9"w .'J ,~;'~,~ ~4j Q REV-1511 EX+ (10-09) s Pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER 1Qo13 ~~T ~. eLnus s ~i o y ~ o~~. Decedent's debts must be reported on Schedule I. TTCM NUMI A. 1 B. 1 FUNERAL EXPENSES: FvNE2R ~ ~I2 ~eTZri. 7 0 ,~ ` 6 S OSi2ts M oN~M t~ 4/~'6AN~Si~ St~VO1S1' lfog, Oc) ~~~Gy -30 , o .~_ kN iG-H T' s o ~ e ° ~ U M g~ 5 r~ A ~-a- a2>:~+T ~Fz ~ ,) c~ ~ s v o - - Lu~c~g~ ~ ,~ ! ~ ~_o Lc~ a oc~: ADMINISTRATIVE COSTS: 2. Attorney Fees: l 3. Family Exemption: {If decedent's address is not the same as claimant's, attach explanation.) Claimant .....-- - _ ..__. ~.~ ~`~ ~ _S. . _ .~ _~ L Q t.L Street Address .. -- __ ... ~ ..lo _ o...._ CJ ~_l._a ~ .._.._1'~' /_} L L- /C.aJ~ _D_.. City _..-- ---- . _~./~~L~_~__~.~._ _ . State ~ ZIP,~~ ~ ~-~_ Relationship of Claimant to Decedent _ ~ ~ ~_~- fir`"' 4, Probate Fees: S. Accountant fees: 6. Tax Return Preparer Fees: ~. f } D1/ f.+2-Tr S 5!K E ~ S (r ~ r<1 ~ ~ ~ ti- ~ ~'_ T~~S Personal Representative Commissions: Name(s) of Personal Representative(s) v A M ~-f.,... ~ _ L'. L p ~$ Street Address .Z (r ~ U n1.1-+~,.~ f..f ~ ~L ~.p~ ,j) ? City _ ._ - -------- - . -C /1- RLi Ji t- ~ _ State ...P~ ZiP _1 .7d f J. Year(s) Commission Paid: ____ . _ . _. yo t'~._ 2~~ 7 l0 8~ 9~- O ~ ~ ' ~ ~ TOTAL {Also enter on Line 9, Recapitulation) I $ ! ~ ~_~ ~~r ~ 3 if more space is needed, use additional sheets of paper of the same site. . ,, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY';;~V ~ 6 20©~~ PENNSYLVANIA ORPHAN'S COURT DIVISION ESTATE OF ROBERT E. CLOUSE NO. d ~ d ~~ OF 2009 In Re :Estate of Orphan's Court Division Robert E. Clouse Deceased No. ~ 1- o ~ - l d ~'~--- Decree NOW, this ~ ~ day of /lS , 2009, the within petition having been presented, read, and considered, it is hereby decreed that James A. Clouse, with whom the deceased, Robert E. Clouse, resided at the time of his death, be and is entitled to a family exemption. THE COURT J. ,r.. r~~ti, ~~iC31~1 RECORD '`':v ;~shoro9, ! he-~sunto :r~~ and the weal •;aas"# a! Carlisle, PA c~ ' C O ..c3 , y ~3 _.i~ ~ ~ ~ `ty . _ ~ ~ -~ -, """" ' --r ~ _ ~ ~ _.- r' ... . -_ ~ ~ -p , s ._, ~-~ .:~. ~.i ~ ~ N w ~ .~ _u , , ~~ i%via1~ REV-1512 EX+ (12-08) ~ Pennsylvania DEPARTMENT Of REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT .SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE QF FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH i. f~MBLLt} lvc£ U~-2F/MR,»2.5~~ ~~. o a oZ.: p~~ L ~~~q7 ~' ~ ce.:~/u~~ f ~ /j 3 • v ~ . ~ d u s ~ ~ Pi2~ P~4 R A'~'~ a ~•J ~ S'} t~~ v ~~ p fiY/L Sl f-7-C.. ~r-/L.A r .f' PL 2 'TT .J~ ~ £Gr i T~ J'~! AiL~lnf ~' C~ 2PS L. € A frc.~ ~. ~/~ p p d . ©C7 FR.a M o T"~ t- ~- ~jvo eA-slt ~ ,/ rte-/i.- i ~-~ l"- \ . a TOTAL {Aiso enter on Line 10, Recapituiation} I; If more space is needed, insert additional sheets of the same size. ~. - NOTICE OF INHERITANCE TAX Pennsylvania ~ BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (12-09) PD BOX 280601 FY-RRISBURG PA 17128-0601 DATE 12-21-2009 ESTATE OF (LOUSE RUTN L DATE OF DEATH 06-03-2009 FILE NUMBER 21 09-0621 COUNTY CUMBERLAND JOANNE MARINO MCGREENY ACN 101 137 S WEST ST APPEAL DATE: 02-19-2010 CAR L I S L E PA 17 013 (See reverse side under Objections ) Anount Reatitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HdUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV--1547 - E?C AFB --E12-09) NOTICE Of INHERITANCE TAX A~PRAISEMENT, ~ttLOWANCE DR - DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: (LOUSE RUTN LFILE N0.:21 04-0621 ACN: 101 DATE: 12-21-2009 TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) C1) .00 NOTE: To ensure proper 2 Stocks and Bonds (Schedule B) (21 .00 credit to your account, . 0 0 submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule C) C3) . of this form with your 4. Mortgages/Notes Receivable (Schedule D) C4) .00 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) 6,87 5.06 6. Jointly Owned Property (Schedule F) C6) .00 7. Transfers (Schedule G) C7) 97, 000.00 t l A T CB) 103.875.06 8. sse s ota APPROV ED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. CostslMisc. Expenses (Schedule H) C9) 7.1 3 1.31 10. Debts/Mortgage Liabilities/liens (Schedule I) C10) 22 1.88 11. Total Deductions C11) 7,353.19 (12) 96:521.87 12. Net Value of Tax Return 13. Cheri#able/Governmental Bequests; Non-elected 9113 Trusts CSchedul® J) C13) .00 14 lue of Estate Sub3ect to Tax t V N C14) 96,521.87 . e a NOTE: If an assesssent was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will _ _ _ref~ect_-~altce~ that include the total of AFL . re#urns assessed t~-4a~s_ - - ASSESS MENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .DO X DO = .00 16. amount of Line 14 taxable at Lineal/Class A rate C16) 96 .521 _ 87 X 045 ` 4, 343.48 17. Amount of Line 14 at Sibling rate C17) .Od X 12 = .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 a .00 19. Principal Tax Due C19)= 4,343.48 TAX CREDITS: P DATE T RNUMBER I INTEREST/PEN PAID (-) I AMOUNT PAID I PAYMENT MUST BE MADE BY 03-03-2010*. TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE 4,343.48 INTEREST AND PEN. .00 TOTAL DUE 4,343.48 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. REV-1513 EX+ (i1-08) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF ~j D ~ ~ ~ ~ ~ ` e L J ~ ~, ~ FILE NUMBER /`- v~/L D ~- /~~, 4 ~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SNARE OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).) 1. ANn/;,~ 1 ~ #~- y-,3 ~' a q ss ` ~32o~i tT~-r.- ~/av, s a a, a A M T t~ CLO ~t S L 'T~ ~ E t AN~v ~ r~--T~ ~f 9' y~ z!o 3 ~. ~Q2o~ ~ ~'1... Tn ToNf tr c.t..o .~ s ~ ~ ~ ~ , S" ~ ° , ~ 3 s~/V A/J i ~ ~ .z ~~a ~ ~ ~ ~j rZu , tt-~ vc., ~ [.~ ~~ ~ `/ 3 , S ~ ~ TiM fa c~ ..~--.r ~ 2007 CtfR~ lL~/t ~~' o, u~ . ( ' 9 a~ d,, ~ j ~ 3 ;~ I3 n.o Tt~*2~ TAM r S ~- d M ~rtfizA 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. ~ = 'l 7/ If more space is needed, Insert additional sheets of the same size.