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HomeMy WebLinkAbout04-29-10` ~ 15056051058 ~~~~~ SOO EX (08-05) OFFICIAL usE ONLY pA DeperaneM d ftsyenue Buresu Hof IMMdual Taxes cowry Code Year FNe t4lanbar PO BO)(280501 INHERITANCE TAX RETURN _ -_. _ .. _ _ __ -_ Narrhbgrp, PA 171?d-0501 RESIDENT DECEDENT 21 09 .0783 e."T~ .><..~..~~ ~ ~.~ORIUTION BELOW Soda/ Security Number Date of Death Date of Birth _ _ _ 209-28-7711 ' 08/03/2009 ' 03N 5/1911 Decedents Last Name SuINx Decedents First Name MI ROTH _ , _ MADELINE W ._. _ . (K AppNesble) Enbr SurWvMy Spouse's IMortnation Below _ _ _ _ Spouse's Last Nanre .... ___ _ Suffix Spouse's First Name MI __ _ Spouse's Sodal Security Number _._ _.._. _ _ _ _ _ ___. THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - -- -.- REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ;~ 1. Dripinal Retum O 2. Supplemental Retum C~ 3. Remainder Retum (date d deatlr ':::. 4. //mired Estate prior to 12-13.82) q 4a. Future Interest Campramiae (dated ~ 5. Federal Estate Tax Relum RequEed death after 12-12-82) t~ 8. Decedent Died Testate (Attach Copy d WIN) O 7. Decedent Makllained a LINnp Trust 0_. 8. Total Number d Safe Deposit Boxes (Attach Copy d Tnrsq t~ 9. LJtigetlon Proceeds RaceNsd t~ 10. Spousal Poverty Credit (date d dea0r C~ 11. Eledlon to tax under Soc. 9113(A) between 12-31-91 and 1-1-95) (Attach ~. D) CORRESPONDENT - T)i1S SECTION MUST BE COMPLETED. ALL CORRESPONDtBICE AND CONFbENTI Name AI TAX SIFORMATION SHOULD BE DOIECT1eD TO: _ - Daytlme Telephone Number _ _ - BERT R. BLACK . __. _., .. __. (717) 243 3727 , Firm Name (ItAppNcable) ~, __ C"D- c~ _...._. LANDIS & BLACK _--~ "-- -- REGISTER S USE O~ ~~ , F .) '~ First Tina of address ~~ ~ ' -~ ~ ~ ~ I ' ~ c ~ . , u ~ -, 36 South Hanover Street __ 1V x_, ~~Y~~ ~ ~ ~ - ~." -.-J n ~ ~'' Seeond line d address i ~~ C'~C~~ Z" ~;~° cr -- _ _.. __ ~ . 'r _ City or Poat CNBce ' D C State 21P Code _ DATE FILEO __ "7 C) 3i Carisle _ _ PA 17013 - _ _ _. _. _ _.._. Correspondent's e-mail address: robtrblackt~embargmail.CDm n k~tue d perNalc 1 dsdre tlw I have examNrsd thle relum. tndudNg acoortpenyirp adudules and etalerrrnb, and to Mis txert d d ra ar th ~ ~ p p si~uen toe ~ w er o er tlwn the penarsl reprosentatlw fs bated on aN Inforrrwtlon d whkh prapvsr lw ed ' ADDRESS u `'' 36 South Hano et, Carlisle, A 17013 SIGNATURE OF pREpARER OTHER THAN REPRESENTATIVE DATE P USE ORIGINAL FORK ONLY 15056051058 Side 1 L 15056051058 '~~~'hl REV-1500 EX 15056052059 DeeedenYs Sodal Security Number __. .. _. DacedanYS Nsms: MADELiNE W ROTH 209-28-7711 RECIIPIT'ULATION ------.__._ ~____-__..--- _ _ ___ _ 1. Real estate (Schedule A) ............................................. 1.' 0.00 '. 2. Stocks and Bonds (Schedule B) ....................................... 2. 16,107.48 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgagee & Notes Receivable (Schedule D) ............................. 4. 5. Cash,. Bank Deposits b Miscellaneous Personal Property (Schedule E) ........ 5. 204.21 8. Jdntly Owned Property (Schedule F) C~ 3eparete Billing Requested ....... 6. __ _.._._ 8,240.01 7. Inter-Vlvoa Transfers & Miscellaneous Non~robate Property _ ... ....-._.. __ ___~. ~ ..... ,>:..,....._.. , (Schedule G) Q Separate Billing Requested........ 7. 48,942.26 e. Total Oroas Assets (total Lines 1-71 .................................... 8. . 75,493.98 9. Funeral Expenses & Administrative Casts (Schedule H) ..................... _ ___._.._.,~ ...... 9. ' .........._,__.._.__ _._„..,...F_______ _. 13,345.39 ' .. ., 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. . _ _ . _..~.m.... 2,159.97 it. Total Deduction (teal Lines 9 & 10) ................................... 11. 15,505.36 12. Net Valw of Estate (Line 8 minus Line 11) .............................. 12. 57,988.60 t3. CharitalNe and Govemmerrtal Bequests/Sec 9113 Trusts for which .. _ _..._.,_.. .. _.....,. .__. .... ........... an elsctlon to taX has not been made (Schedule J) ........................ 13. 5,000.00 14. Net Valw SubJsiet to Tax (Line 12 minus Line 13) ........................ 14.: 52,988.80 -- - TAX COMPUTATION'.-SEE INSTRUCTIW~IS FOR APPLICABLE RATES w"' 15. Amount of line 14 taxable at the spousal tax rate, or transfers under Sea 9118 ___ e. ._ .,. _ _ 18. Amount of Line 14 taxable . ` . _ . _ at Nneal rate X .0 4i5 52,988.60 - 18, 2 384.49 _.._ _..._.._. .. .,......._ ... _„ ......, .. 17. Amount of Lina 14 taxable _ at sibling rate X .12 17. 18. Amount of Line 1d taxable __,__ _ .. ._~... ,._.., ...... at collateral rete X .15 18. ' t9. TAX DUE ......................................................... 19. 2,384.49 __ _ 20. FILL IN THE OVAL ~ YOU ARE REOUESTiN(i A REFUND OF AN OVERPAYMENT ~'? 15056052059 Stds 2 L 15056052059 ~ REV 1500 FJC Page 3 3Decedent's Complete Address: .__----___...._ Filt.Npm~lar,,~_.....__...m._.. ,.. - 21 f 09 ;;0783 S DECEDENTS SOCIAL SECURITY NUMBER MADELINE W ROTH 209-28-7711 sTREETAODRess 100 E. Springville Road CITY Boiling Springs STATE PA ZIP 17007 Tax Payments and Credits: 1. Tax Due (Page 2 Una 19) (1) 2,384.49 2. CredilslPayments A. Spousal Poverty Cre<1H _ B. Prior Payments C. Distant ------_._-- ---- Total Credits (A+ B + C) (2) 3. IMerestlPenalty H applicade D. Interest E. Penally - - Total InleresNPenalty (D + E) (3) 4. H Line 2 is greater than Line 1 + Line 3, enter the rrdiererrce. This Is the OVERPAYMENT. FHI in oval on Page 2, Line ZO to ngwst a rotund. (4) 5. H Line 1 + Lino 3 is greater than Line 2, ertbr the difference. Thb is the TAX DUE. (5) 2, 384.49 A. Enter the Merest on the tax due. (~) B. F_rrter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 2,384.49 Make Check Payable to: REGISTER OF WILLS, AGENT `niA': PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes ~ a. retain the use a lncarre of the property transferred :........................................................................ ^ .................. b. retain the rind b desig-rate who shall use the property transferred a its income :............................................ ^ c. retain a revetsiorrary lntsrest; or .......................................................................................................................... d. receive the promise for IHe of eitlrer payments, Irerrefits a care9 ...................................................................... ^ ^ 2. H death occrrred after Deoemf>Br 12,1982, did decedent transfer property within ale year of death Wlthalt reCBlVlrlg t® C>Jnalderati0n~ .............................................................................................................. 3, Did decedent own an fin wst for' a payable upon death tx+Mc account a security at his a her death7 ^ ^ .............. 4, Did decedent own an Individual Refirament Account, annuity, a other narprobate property which caMains a beneftdary designation? ........................................................ © ^ ................................................................ 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 a attar July 1,1894 and before January 1, 1995, the fax rate imposed on the net value of transfers to or fa the use of the surviving spouse is three (3) pertsrtt (72 P.S. §9116 (a) (1.1) f)]• 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 N zero (0) percent (!2 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 velum are still applicable evenrf the surviving spouse is the onty benefidary. For dates of death on or after July 1,,2000: ~~ ~~mposed on the net value of transfers from a deceased child twenty-one years of age a younger at death to err for the use of a natural parent, an stepparent of the child is zero (o) percent (72 P.S. §9116(a)(1.2)). The tax rate imposed err the net value of transfers to a for the use of the decedent's lineal benefidaries is four and are-h~f (4,5) percent, except as need in l2 P.S. §9116(1.2) (72 P.S. §9116(a)(1)]. The tax rate imposed an the net value of transfers to or for the use of the decedents siblings is twelve (12) percent p2 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. REV-1503 EX+ X6.98) SCHEpULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BOTH, MADELINE W. 21-09-0783 -..--~ .....o w~„v mca) REV-1508 EX+ (a-aej COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ROTH, MADELINE W. 21-09-0783 I Include the proceeds of UUgaUon and Ule date the procecds were roeehred hY the estate. AN property Jointlyowned wkh ri8ht of surNwwhip moat be dlseloeed on 8ehedub F. REV-1$Og EX+ (oido) pennsylvania OEVAgTMENT OF REVENUE INNERiTANCE TAX RETWIN RESIDENT DECEDENT SCN~DULE F JOINTLY-0WNED PROPERTY ESTATE OF: FILE NUMBER: ROTH, MADELINE W. 21-09-0783 IE an awe t°aeanEa yolErtly owned within ana year of the decedent's date of death, R musA be sported on SehaduM 6. SURVIVING JOINT TENANT(S) NAME(S) I ADDRESS I RELATIONSHIP TO DECEDENT A• Eugene E. Roth B. C. JOINTLY OWNED PROPENTY: 100 E. Springville Road, Boiling Springs, PA 17007 ~ Son ITEM NUMBER LETIER Rxt noun DATE MADE 70BIi DE~CRIPrION OF PROPERTY INCLUDE NAME OF nNANCIAI DISTrtUT10N AND BANK ACCOUNT NuMeER oR sDmAR IDENiIFlViG NUMBER. ATTACH DEED FOR NBNRY NEID REAL STATE. DATE OF DEATH VAUIE dF ASSET x of DECEOBtiS INIBU:ST DATE of DEAiN vAUE oP DECEDENTS a(rB1EST i. A. 09/01/67 M8T Bank -Checking Account No. 434752. See attached statement 3,532.29 50°k 1, 768.15 2. A. 06/04/07 M&T Bank -Savings Account No.15004215322162. Balance-$12,947.12; Interest-.60 12,947.72 50% 6,473.86 TOTAL (Also enter on Line 6, Recapitulation) I ~ 8,240.01 If more spas is needed, use additional sheets of paper of the same size, SCHEDULE G pennsylvrania , fit DEPARTMENT OF REVENUE ~ INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ROTH, MApELINE W. 21-09-0783 This schedule must he completed and filed if the answer to any of questions i through 4 on page three of the REV•I500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY ,NCwoE THE NAHE aF THE rRANSFEREE, THEIR REUnaruHlP To oEaoEnr AND THE DATE OF TRANSFER. ATTACH A CDPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION tF aAFUCAe,Ei TAXABLE VALUE I• Met Life lns. Co. - Annuity Contract No. 073 436 623AB. See attached statement. 5,854.29 100 I 0.00 ` 5.6542! f 2 Allstate l.ite Ins. Co. -Annuity Contract No. GA272808. See attached f statement. 43,087.97 100 0.00 43.087.9'. 1 ~ I 1 I ~ i i i i I i ' i i , i i 1 ~ t { i i l i I ~ I l TOTAL (Also enter on Line 7, Recapitulation) S ~ 48.942.26 u more spaces neetletl, use additional sheets of paper of the same size. ' v. ,..k-.., v, w Pennsylvania DEPARTMENT OF REVENUE INNERRANCE TAx RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ca,iwic ur FILE NUMBER ROTH, MADELINE W. 21-09-0783 Decedent's debts must be reported on Schedule i. A. 1. 2. 8. 1. 2. 3. 4. 5. 6. ~. FUNERAL EXPENSES; HotTrnart-Roth 'Funeral Home - Sefvices Gravestone ADMINISTRATIVE COSTS: I Personal Representative Commissions: Name(s) of Personal Representative(s) _..- Robert R. Black __ --- ._. _- __. street address 60 Conway Street.. __ __ city _Carlisle, State PA ` --- - _ ZIP 17013 Year(s) Commission Paid: 2010 _ i Attorney Fees: r if~ Family Exemption; (If decedent's address is not the same as claimant's, attach explanation.) Claimant ,Eugene E. Roth _ street Address 100 E. Springville Road City Boiling Springs State PA ZIP 17007 __ ~ Relationship of Claimant to Decedent Son ___ __ Probate Fees: Aaountant Fees: Tax Return Preparer lees; Reserve for dosing and Illinu releases ~' 1.748.4' 1,304.00 1,837.00 3.,675.00 3.500.00 530.92 250.DC 500.00 TOTAL {Also enter on Line 9, Recapitutationl ~ S 13.345.3~~ N more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENF OF W. Iii " X11 . I, MAt~i~ W. RATH, of the Township.of South Middleton, Glmiberland ~Y. ~'~Ylvania, make this Will, revoking all my former wills and codicils. ~~: I direct that all my just debts, funeral thethe assts of including mY SreVe inscription, shahpaid fn~tt my estate as soon as practicable after my decease. I ~ 'the ~ herein specified to each of the following-named beneficiaries: a. To the Hoffman I~th Funeral Haa~a to be added to the Pre-Burial A~eaaeat of my son, Kenneth M. Roth, the sutra of TWO Zhousand Five Hurrared ($2,500.00) Dollars; b. Zb The samaritan Fund at the Brethren Home of Two Zhw.Sand Five Hundred ($2, 500.00) Dolla~i^ss Iteys the stun c• st ~ ZFtao~ Church of Zhe Brethren, Carlisle, Pennsylvania, the ~ousarxi Five Fiundr~ed ($2,500.00) Dollars. I Zzi: I devise and bequeath all of the residue of ~~' refute and wherever situate, in equal shares ~ ~' estate, of nazaely, Anna Mae Balser, Eugene E. Roth my five children, Phillip W. Rath, or their issue, per. stirpese M. Rath, Paul W. Roth, and ~.~V: I direct that all taxes which may be assessed in woe of my death, of whatever nature and by whatever jurisdiction 1, shall be paid frcatt my residuary estate as a part of the expense of the actninistration of my estate. .~V: I appoint 1mBERT R. BLACK, ~ , of this, my Last Wi11. bond for~th~e~fai ~~ tit ~ tOr• ~1 not be required to give perforn~x:e of his duties in any jur'isdictiari. y~(~km2'DO~ F, I have heres~nto set my hand this ~?~ day of 4,~-~ O /~E 1989. ~ ~' d / ~) ~ aline W. Roth 7~e Pal instrument, consisting of this and one other typewritten page eaicfi identified by the signature of the Ztestatrix, Madeline W. Rath was, aai the day and date thereof, sicp~ed, published and declared by Made7.fne W. Rat2x, the Z~estatrix therein na¢oed, as ar~d for her Last Will, in the presence of us, who, at her request, in her nrwca„ro and ~ the ~ of each other, have subscribed our names as witnesses thereto. ~_ .~~ N i~ 01~JNWIGAI~'fi OF PF~YLVANIA ) OCJgNt'Y OF Q~+~1D ) We, Madeline W. Rath, Robert R. Slack and ~ d wc2 v' ~ ~ • Je ~o rp~~ Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing insttnm>ent, being first duly sworn, do hereby declare to the wndersigned authority that the Testatrix signed and executed the instnao~nt as her Iast Will, and that she had signed willingly (or willingly direr-ted another to sign far her), arld that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness, and that to the best of their ln~owledge the Testatrix was at the time eighteen Years of age or older, of saluxl mind and un3er no constraint or undue influence. ~~~'~, sworn to ar~d acJQ'~aaledged before ~ by 1'~adeliile W. IZo~t'h~,'}~`1'est~aetriX~, Robert Rgl~ack and ~4~ ~~LfJe%oe by witnesses, this day of, 1989. r 'Ge~~~o- Notaty ~ lic NOTARIAL SEA! SNIRLEY W. AHLERS. NO*AkY PUBLIC CARLISLE ~., CUMBERLAND COUNTY, PA MY COMMISSION EXPIRES JULY 1t, 19sa3 .. ~ M&T Investment Group M&T securities, Inc. 285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885 September 25, 2009 Account Valuattion MADELIIVE W ROTH (deceased 8/3/09) AZD148575 >Jescnption of Security MTB Prime Institutional Fund Quantity in ValuE _snare5 nA,p- 1 8/13/09 .00 share We have received the information presented above from sources, which we believe to be accurate. However, we do not guarantee their accuracy. The price per share on valuation date is the closing price on that date. Please contact Client Solutions with any further questions, or if we may be of further assistance to you at 1-800-724-7788, Option #1. Thank you. Sincerely, ,:~~~.~~ Robin Brown ~ - - Brokerage Operations Specialist MBtT Securities, Inc. Investment and Insuren~ products; .Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Benk Guarentee • May Go Down In Value M8T Imreahnent Group" rs a aervke mark of M8T Bank invesunant advisory firma MTB In Carporadon and consists of M&T BecuriUes, Inc„ the ktvestment•related areas of M6T Bank antl Brokers a se vpatment AdWeora, Inc., and Zlrkln-Coder Investmertte, Inc. g ~~ antl Inaurance!Protluds iMe offered by M3T Becurflba, Inc. (member FINRA/SIPC), not by M8T Benk. M6T 3ec4rdkie, Irk. b Hcennetl atq en inaurettca agent and acts as agent for ktwrere. Insurance policies are obllgatlons of the insurers that issue the oolMins. ' MADELINE W BOTH Account Matlat Valve SWOk Wkte ae of 11 2009 oql Market Value ;~15.100 sb42.40 The aQQfeQate am0urtt pefd t0 all Trust BeneBOlarles Iri this dlstributlon l8 5173,4e8,23g.rr. ~ Intoraatfclt ~ M~itlrh,PUrPr.'hne or sNt shwa of MetUa. Inc. ootmtton etaek through other fen, undo etLla p Qhe 'Trust" ), hN Of arty, commbakale Or urohaaa and Sea program, u amended. A copy of the brochure deecr11t61g tlla Program h aWilaba On ~ Intenet at www.metlye.com by ..4aing Investor Reatbne and then the Sha-NatdM Servkea IMOrmation psge, a by caBng ttte number Meted above. You are Permiaed to pargra yow Trwt IrttereW only M the okarruqutoa descdbed in the brochure. Yau may aNo Inebuct that a9 (but net len than a9) W your shard d MetUa, Inc. cgnnan stock held by ~ T-uet be w8hdeawrl hom the Trust. Information re0arding your wWtdrawal dgltb may ba {ours M the Plxohne and Sea Braehun ar Dy wl9ttg the mnnber I$ted above. Investor ID 80641202 3186 IIOOB Dhddand Record Date Total Tnat Irtterv9ts 11/09,2009 24.0000 Payable Date Tex Wlthheki 12/14/2009 ,p,00 TOrttafe9c I DIsV~ lbt brt X0.74 =17.70 Net Dktributlon ~~ s17.7e st7.7e For inquiries about your account, you may visit www.bnyrrtetbn.cor7~shareovuner/iad, or c;aq 1-804849.3593. Trtrt RECIPIENTS TENT IDENTIFlCATKNV NUMBEq TOTAL ORDINARY DMOENDS QUAUFlEO OMDENDS 20Q28-7711 x rA x re'"-"----- p~TAt(NrI1FN~Eld 517.78 17.__ ~1 x 4 PAYER'S NAME -"---~ 00 BNY MELLON SNAHEOWNER SERVICES AS PAYER'S FEDERgI, IpENTIFICgTION NUMBER CUSTODIAN OF THE METLIFE POLICYHOLDER TRUST' FORM 1099-DN. M6t1,1(6 DMDENDS/DISTRIBUTIONS U.S. TAX INF0RMATiON FOR 2009 OMB N0.1846-p110 COREPIp'P RJp An annual sltarehotders~ rrteelNg to elect metnbw of ttte Bond of ~ to bs IteWl on Grp 27 ~ of oMer bwthpe is aharehokter p-opaals for coraidaiadort at ~ dead5rre for submbting 2009. A Dopy a Media, Irw.y ntbbll^a k Dsrsmber 1, ws9able hee of Charge on tx briar reMppwtth ~ ~ ueubretx will he MettYe, Inc. atq Trust a9nga under aderal aaourRi i b~wa, p) orr ttN tQ errret st www.ntel9a.com by aelecgna About MMlla, CgPorate ovemance, under Relabel links, (N) by wrlWrg to MetLYS, Inc., o% BNY Me9on Shareowrter Suvkes, PO Box 9Sa447, PitbOurgh, PA 13252.8447 or (B) try caNklg tfte number Ilsbd attoln. Thep and otlter 9EC 19fnpe b7 MettJa and !ha Trust an aho bva9abN on the Internet at www.tec.gov. Ple>3lsss Note: Important 2009 Tax Information SECURITY DESCRIPTION TRUST INTERESTS TO WHOM PAID MADEUNE W ROTH 100 E SPRINGVILIE RD 90tUNG SPRINGS PA 17007.9737 tntppeee ~ M'°~b r"p~wn'tw. ~~"°'~ ~w,rYlr « «~iw wrMw"e'bua, ,b. ~~ yar M trw e.rneku. th.r k trr net b«n Bea to • titwre lea atiyry ~'wMds tlrr w taxeyy, pige~ y,~ arroten on au 9e a Form tog «1oroA Aho, resat a on 8uwd,ee a (Form 10/0) a Scludule 1 (Earn t010A), kwarrgYas~n10010A. ~eM k °~'~trboYm j p0~iw~it ~ ~ ~' bee ~ F01111 101M1 ti bnX to Mtl Ilyy t>• Mp~pi~ br eN 1a% « OIOA ano et ere ~b angea /rl b e4 Fern 1010 «1 WeAr br how b dNamYy yyr ~~ 518818987 THE BANES YORK ~A ETON , NJ 07310 eaut 4.8howe k m W~-Be br~~ ~ ~>~YpMYK mart 6~elgp wrygold an pryb Dh,- Dkgrp k~~ ~~emant on Your Mw;on» ~ on ~. t~l~ Y~eu nnrae ~u bi1oiwew b awes wM~bnol gpr4reeblWY a~~~~ritrtmwl NNNaFam 1~~ ~~a•+Wib rlerlefr 1o/ F ~~ n1111n b ar0,r arlp,Myr Oee~nlV b NCh. A huW~nd « ame ltlee, ION, gat, sees, e~ a,y w-tQalta. 8w en aooe ©~ 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Law Offices Landis & Black 36 South Hanover Street Carlisle, Pennsylvania 17013 - Re.• Estate of.• Madeline W Roth _ _ Social Security 209-28-7711 - Date ofDeath: Au.¢ust 03 2009 Phone (888)502-4349 Pax (302) 9342955 August 27, 2009 Dear Sir or Madam: Per your inquiry datdd August 21, 2009, please be advised that at the time of death, the above-named decedent had on deposit with this bank) the following: l • 7,~pe ofAcCount Chec~EirtgAccount Account Number 434752 Ownership,(Names on Madeline WRoth* Opening Date Eugene E Roth* 9/Ol/tS7 Closed 8/25/09 Balance on Date of Death $ 3,532.29 Accrued Interest $ 0 ~ Total ---------..-.------ -- --.--- - ._ $ 3 532.29 - -----~ 2• Type ofAccbunt Savings Account Account Number 15004215322162 Ownership (Names oj7 Madeline WRoth* OP~~gDate Eugene ERoth* 6/04/07 Closed 8/25/09 Balance on Date ofDeath $12,947,12 Accrued Interest $ 0.60 Total •- --------- ----- --•- __.__..---_.--- $12,94872 Please be advised, there was no safe deposit box found for the above decedent, above, you believe them are additional accounts not referenced ~ °p0D reviewing the information name of any possible joint account holder. For any additional inn utntatl ~ oo ~ aboveroaaouotms, ~~~ ~g ownership and any chahges, closures and/or reimbursement of fltnds, eta, please rnntact our Boiling Springs Office # 717-241-7790. Singly, Trade Hare Adjusgnent Services • Metropolitan Life Insurance Company ~ ~ P.0. Box 10342 Des Moines IA 5030&0342 Statement of Value of Annuity Contract 1. Name and address of Insurance COmDanv MetLife Metropolkan Life Insurance Company, One Madison Avenue, New York, NY 10010 2. Name of Annuitant MADELINE ROTH 5. Contract Number 073 436 623 AB 8. Owner's Name (Attach copy of Application) MADELINE ROTH' 11. Name(s) of Beneficiary ANNA M BELSER EUGENE E ROTH DALE M ROTH PAUL W ROTH PHILLIP W ROTH of Annuitant's Death 8/3/2009 6. Type of Annuity VARIABLE DEFERRED 9. Assignee's Nam (Attach copy of assignment) N/A 12. Description of Contract NON QUALIFIED 13. Value of annuity contract on date of death of Annuitant This represents the death benefit as follows: Accumulations Value on Date of Death $5,854.29 Cost Basis/Retum of Payments Interest $4,494.44 Total Payout $ 14. Mow payable: One Sum X i See Remarks 4. Annuitant's So 209 28 7711 7. Date of Issue 10/27h999 10. Date As N/A 15. Remarks EACH BENEFICIARY WILL NEED TO COMPLETE ONE OF THE ENCLOSED CLAIMANT STATEMENTS September 23, 2009 /~ ~~ ~~~ ~ ¢ie ---~-~~; ~'°~ 's Annuity Representative Post Issue Processing .- Allstate Life Insurance Company P.O. Box 94212 Palatine, IL 600944212 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 September 23, 2009 Robert R Black Landis & Black 36 S. Hanover Street Carlisle, PA 1701'3 Re: Madeline W. Roth Contract No: GA272608 Dear Mr. Black: Alistate~ You're in good hands. 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, it is not reportable on IRS Form 712. I can, however, provide the following informagon for estate purposes: Date of Death: Annuity Value as of Date of Death: Cost Basis: Named Beneficiary: August 3, 2009 $ 43,087.97* $ 28,621.83 Anna M. Belser, Eugene E. Roth, Dale M. Roth, Paul W. Roth, & Phillip W. Roth *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. 86184. Sincerely, Donna Gray Sr. Claim Examiner