HomeMy WebLinkAbout06-02-10 (2)1505607121
REV-1500 EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
BureauoflndividualTaxes INHERITANCE TAX RETURN CounryCode year File Number
PO BOX 280601 ~'
Harrisbum, PA 17128-0601 RESIDENT DECEDENT 2 1 1 0 ~~~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
4 9 1 2 4 9 6 1 7 0 3 0 6 2 0 1 0 0 3 2 0 1 9 1 2
Decedent's Last Name Suffix Decedent's First Name MI
H o r n R u b y M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
0 1. Original Retum ~ 2. Supplemental Retum ~ 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)
0 6. Decedent Died Testate QX 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 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
I V O V O T T O I I I 7 1 7 2 4 3 3 3 4 1
Firm Name (If Applicable)
REGISTER OF WILLS USE ONLY
M A R T S O N L A W O F F I C E S
First line of address ~ ~ - ~,
_' ~ c
,,--
1 0 E A S T H I G H S T R E E T -'
..~
Second line of address ' "
-• i
- ~ r,~
l7ATE F1^LED
City or Post Office State ZIP Code ,~ __:. _
C A R L I S L E P A 1 7 0 1 3 ~ ..
~, ~-,
~:~- -;
Correspondent's a-mail address: I O T T O a0 M A R T S O N L A W• C O M
Under penalties of perjury, I declare that 1 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.
SIGN TORE OF PERSON RESPONS(I~LE FOR FI ~I)NG EZURN DAlE
l ~ ~ `, l~-2. ~Z~ ~r ,sue".~~~~~~~/ ~ ~D / ~ o ~ a
ADDRESS
1304 'ns ri a urt Vienna VA 22182
SIGNATURE Q R R Q SENTATIVE DATE
10 EAST HIGH STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
1505607121
Side 1
1505607121
~;j.
C_
1505607121
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 2 1 1 0
Hamsburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
4 9 1 2 4 9 6 1 7 0 3 0 6 2 0 1 0 0 3 2 0 1 9 1 2
Decedent's Last Name Suffix Decedent's First Name MI
H o r n R u b y f1
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
MI
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)
0 6. Decedent Died Testate ^X 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 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
I V O V O T T O I I I 7 1 7 2 4 3 3 3 4 1
Firm Name (If Applicable)
REGISTER OF WILLS USE ONLY
M A R T S O N L A W O F F I C E S
First line of address
1 0 E A S T H I G H S T R E E T
Second line of address
City or POSt Office State ZIP Code DATE FILED
C A R L I S L E P A 17 D 1 3
Correspondent's a-mail address: I O T T O a~ M A R T S O N L A W- C O M
Under penalties of perjury, l declare that I have examined this return, inGuding 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 representatnre is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
1304 Pinstripe Court Vienna VA 22182
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
1D EAST HIGH STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
1505607121
Side 1
1505607121 J
1505607221
REV-1500 EX Decedent's Social Security Number
Decedent's Name Ruby M• Horn 4 9 1 2 4 9 6 1 7
RECAPITULATION
1. Real estate (Schedule A) ...................................... .. 1 • '
2 2 7 3 8 6 6. 9 5
2. ................................
Stocks and Bonds (Schedule B) .
..
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. •
4. Mortgages & Notes Receivable (Schedule D) ...................... .. 4.
7 1 9 , 5 7
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... .. 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6•
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 2 8 5 3 2 8 7
(Schedule G) ^ Separate Billing Requested ..... .. 7. .
8. Total Gross Assets (total Lines 1-7) ........................ ... 8. 3 0 3 1 1 9. 3 9
9. Funeral Expenses & Administrative Costs (Schedule H) ........... ..... 9• 1 5 5 3 8 , 9 5
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ....... ..... 10. '
11. Total Deductions (total Lines 9 & 10) ..................... ...... 11. 1 5 5 3 8 , 9 5
12. Net Value of Estate (Line 8 minus Line 11) ................... ...... 12. 2 8 7 5 8 0 , 4 4
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. 2 8 7 5 8 0 . 4 4
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
0
0
0
15
(a)(1.2) X.0 .
16. Amount of Line 14 taxable 2 8 7 5 8 0 4 4
at lineal rate X .045 16.
17. Amount of Line 14 taxable Q ~ 0 17
at sibling rate X .12 .
18. Amount of Line 14 taxable 0 0 0
at collateral rate X .15 18.
19. Tax Due ............ ........................... .. ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505607221
Side 2
o. a o
1 2 9 4 1. 1 2
0. D 0
0. 0 0
1 2 9 4 1. 1 2
1505607221
F,EV-1500 EJC Page 3
Decedent's Complete Address:
File Number
21 10 0
DECEDENT'S NAME
Ruby M. Horn
__ - ---
STREETADDRESS
770 South Hanover Street
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 647.06
Total Credits (A + B + C) (2)
3. Interest/Penalty ifapplicable
D. Interest
E. Penalty
Total Interest/Penalty (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 fo: REGISTER OF WILLS, AGENT
1?.9~L1~
6~- Ub
1?ii)-l ~)fi
l2?9~1.06
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
^ No
0
a. retain the use or income of the property transferred : ................................................................. .....
^ 0
b. retain the right to designate who shall use the property transferred or its income; .......................... ..
...
^ 0
c. retain a reversionary interest; or ........................................................................................... .....
^ 0
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 ......
Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
4
.
contains a beneficiary designation? ............................................................................................ ...... 0 ^
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 fax rate imposed on the net value of transfers to or for the use of the surviving spcwe
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 fo a surviving spouse from tax, and the statutory requirements for disclosure of assets and
tiling 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(x)(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(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(x)(1.3)]. Asibling is defined, i;nder
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rub M. Horn 21 10 0
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT GAS-
NUMBER DESCRIPTION OF uEATH
1. US Bank Investment Account, Freeport, IL ~~''-~~ ~ ~ )
(See attached)
1 a. Accrued dividends on Item 1 i -' ~ ~ `'
(See attached)
TOTAL (Also enter on line 2, Recapitulation) I S » ,;ti,~, ~~~
(If more space is needed, insert additional sheets of the same size)
REV-1508,EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
FILE NUMBER
Ruby 'Vi Horn _ 21 10 0
Include the proceeds of litigation and the date the proceeds were received by the estate.
All vrope-ty jointly-owned with right of survivorship must be disclosed on Schedule F.
VAL UE A T DATE
1 TEM
NUMBER DESCRIPTION OF DEATH
1. US Bank NA,checking account # 199370715666 % ~ `>
TOTAL (Also enter on line 5, Recapltulatior,) ~ S
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Ruby M Horn 21 10 0
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, THEIRRELATIDNSHIP700ECEDENTAND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST 9r APPLiCA3LEl VALUE
1. Allianz Annuity Contract No. 1540507 28,532.87 100. Z8.~ X2.8,
Beneficiary: Ruby M. Horn Trust, Norma J. Word, Trustee, 100%
(See attached)
TOTAL (Also enter on line 7 Recapitulation) ~ $ ~ ~. ~ _ ' ~ -
(Ifmore space is needed, insert additional sheets of the same size)
REV-151; EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Ruby M. Horn 21 10 0
Debts of decedent must be reported on Schedule t.
ITEM
NUMBER DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
1, Meierhoffer Funeral Home & Crematory, St. Joseph, MO ''-.`A ~ `~`
B.
1
2.
3.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City State Zip
Year(s) Commission Paid:
Attorney Fees Martson Law Offices and Fishburn Whiton Thruman (estimated)
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
r"laimanf
12.9\I) llU
4.
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees
5 Accountant's Fees
b. Tax Return Preparer's Fees
7
Cumberland County Register of Wills, filing fee, Inheritance Tax Return I 1 ~ t)u
TOTAL (Also enter on line 9, Recapitulation) I $ I ~ ~ ; ~ y
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Rub M. Horn 21 10 0
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Ruby M. Horn, Trust dated 1/28/19931 Norma 7. Word, Trustee; Lineal 2~7.~51) -i-~
Beneficiaries: daughter, grandchildren and great-grandchildren;
See attached Trust document
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET I $
(If more space is needed, insert additional sheets of the same size)
r~tt~t i~C rx~~ C`~e~#ttmExrt
of
~~~~- ~~~
I, Ruby M. Horn of Stephenson County, Illinois, revoke all prior Wills and Codicils
and make this my Will.
FIRST: I give my entire estate, but excluding all property over which I may have
power of appointment, I give to the trustee under my Trust Declaration dated January 28,
1993, heretofore made by me to be held and administered as provided in that agreement
as in force at my death.
SECOND: I appoint Norma J. Word as executor of this Will, and request that said
executor be permitted to serve without furnishing bond. If Norma J. Word does not
survive me, refuses to act, or does not otherwise qualify, I appoint US Bank, N.A. as
executor.
I authorize but do not direct the executor to pay out of my estate passing hereunder
(to the extent it is practical) after satisfaction of the gifts made in Article FIRST, all of the
expenses of administering my estate and all estate, inheritance, transfer and succession
taxes (including interest and penalties, if any) which become due by reason of my death. I
waive on behalf of my estate any right to recover from any person any part of such taxes.
I give to my executor(s) (whomever may be acting) full power and authority to sell
at such time or times as the executor(s) may deem to be in the best interests of my estate,
such sale may be public or private and without order of any Court, and for any property,
t '
-2-
real or personal, belonging to my estate. I further authorize and direct that such sale may
be made at any time during the period of the administration of my estate and that my
executor(s) be authorized and directed to execute any deed or deeds of conveyance or any
other legal document as may be necessary to carry out said power and without providing
any bond for the sale of real estate.
Any bequest to a beneficiary hereunder, which my executor determines the
beneficiary is under a legal disability or is unable properly to administer, may be made by
the executor in any one or more of the following ways: (1) to the legal guardian or
conservator of the beneficiary; (2) to a relative or friend of the beneficiary to be expended
for the beneficiary; (3) to a custodian for a minor beneficiary under any Uniform Transfers
to Minors Act.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will
and Testament this 4`h day of November, 2002.
~-
Ruby M. Horn
We hereby certify that the foregoing instrument was on the date thereof signed,
sealed, published, and declared by Ruby M. Horn as and for her Last Will in our presence,
who, at her request and in her presence and in the presence of each other, have hereunto
subscribed our names as witnesses thereto, believing the said Ruby M. Horn at the time of
so signing to be of sound mind and memory. '
' --~1 Residing at ~-r'r'_L 1~7ts,~~}'' -1- ~-
r~ ,-~ tt
'~, Residing at ~_~ ~ nf~7 , L ,~
FIRST RE-STATEMENT OF THE RUBY M. HORN
DECLARATION OF TRUST DATED JANUARY 28, 1993
I, Ruby M. Horn, of Freeport, Stephenson County, Illinois, hereby amend and
re-state my Trust of January 28, 1993, pursuant to the right and power I have to amend said
Trust pursuant to the FOURTEENTH Clause of said Declaration of Trust. For all purposes
after the date of this First Re-statement, all terms of the Ruby M. Horn Declaration of Trust
dated January 28, 1993, are stated in this instrument, and the Trustee, and any person
dealing with the Trustee, need not refer to or examine any earlier documents including the
Declaration of Trust dated January 28, 1993. The Ruby M. Horn Trust shall be held and
managed as follows:
AMENDMENT AND REVOCATION
At any time or times while I am alive and well, and under no disability, by a duly
executed written instrument, I may amend this Declaration in any manner and may revoke
the same in part or in whole. All of my reserved powers under this Declaration, including
but not limited to the powers of amendment and revocation, are personal to me and shall
not accrue to any other person, or to any guardian or conservator, nor shall they extend to
my estate or my legal representative or to any other beneficiary.
GRANTOR'S LIFETIME
A. During my lifetime the Trustee shall pay the income from the Trust estate in
convenient installments to me or otherwise as I may from time to time direct, and also
such sums from principal as I may request at any time.
-2-
B. If at any time or times I shall be unable to manage my affairs, the Trustee may
use such sums from the income and principal of the Trust estate as the Trustee deems
necessary or advisable for my care, support and comfort, or for the care, support and
comfort of any person dependent upon me, or for any other purpose the Trustee considers
to be for my best interests, adding to principal any income not so used.
1. For the purposes of this Declaration, I shall be considered to be unable to
manage my affairs if I am under a legal disability, or by reason of illness, age
or mental or physical disability, I am unable to give prompt and intelligent
consideration to financial matters, and the determination as to my inability at
any time shall be made by Norma J. Word and my then attending physician
(or the survivor) and the Trustee may rely upon written notice of that
determination.
2. During such disability any attempt by me to exercise the rights of revocation,
amendment, withdrawal of assets or control over the Trustee shall be void and
totally without effect, this Trust being, during such period of time, irrevocable
and unamendable.
C. Additional funds, securities, and other properties, acceptable to the Trustee,
may, at any time or times, be transferred by me or any other person as additions to the
initial Trust hereunder.
GRANTOR'S DEATH
A. The Trustee shall pay from the residue of the Trust all debts, funeral expenses,
costs of administration including ancillary probate (if any), costs of safeguarding and
delivering bequests, and other proper charges against my estate, all estate and inheritance
taxes assessed by reason of my death. Interest and penalties concerning any tax shall be
paid and charged in the same manner as the tax. I waive for the Trust all rights of
reimbursement for any payments made pursuant to this article.
-3-
B. Upon my death, the further administration and distribution of the Trust shall be
as follows:
1. The Trustee shall distribute $5,000.00 to each of my grandchildren living at the
time of my death. As of the date hereof, I have three grandchildren: Jennifer L. Dikkers;
Jeffrey L. Word; and Leslie Berning.
2. The Trustee shall distribute the sum of $2,000.00 to each of my great-
grandchildren living at the time of my death. As of the date hereof, I have four great-
grandchildren: Brianna R. Higgins; Mitchell C. Higgins; Benjamin Berning; and Grant
Berning.
3. The Trustee shall distribute the residue of the Trust to Norma ). Word.
4. In the event Norma J. Word should predecease me or not be living on the
thirtieth (30`h) day after my death, the residue of the Trust shall be held and administered as
follows:
(a) The Trustee shall establish a separate Trust, equal in value, for each of my
great-grandchildren living at the time of my death. The Trustee shall pay and
distribute to and expend and use for the benefit of my great-grandchildren, so much
or all of the net income and principal of the Trust estate as the Trustee determines
from time to time to be reasonably necessary for their care, support, best interests,
education (including college, post-graduate study and technical training), physical
and mental health care and assistance in entering or maintaining a recognized and
respectable business or profession, taking into consideration each great-grandchild's
other income and financial resources available for such purposes known to the
Trustee. Any excess income shall be added to principal.
(b) Each great-grandchild shall have the right, after attaining the age of 35
years, to withdraw so much or all of the Trust principal and accumulated income as
the beneficiary requests, in writing, and any requested payment shall be made to
the beneficiary or as the beneficiary directs in writing without question. These
rights of termination and withdrawal shall be a privilege which may be exercised
only voluntarily and shall not include an involuntary exercise or assignment such as
an attempted withdrawal by a Trustee in bankruptcy, creditor's committee or by
-4-
judicial order. In the alternative, each beneficiary may choose to allow his or her
Trust and Trust share to continue as to the entire Trust share of principal and
undistributed income, or any part thereof. This election to continue the Trust share
need not be evidenced in writing and shall remain in full force and effect until such
time as the beneficiary terminates his or her Trust share by direction to the Trustee
in writing. Upon the death of a beneficiary, any part of his or her Trust share not
effectively claimed by the beneficiary shall be distributed in equal shares to my then
living great-grandchildren, except that each portion otherwise distributable to a
great-grandchild of mine for whom a Trust share is then held hereunder shall be
added to that share.
-IV-
GENERAL TRUST PROVISIONS
The provisions of this article shall apply to each Trust created or directed in this
Declaration.
A. Distribution provisions:
Any income or discretionary principal payment due to any beneficiary
hereunder, which the Trustee determines the beneficiary is unable to properly
administer, shall be made in any one or more of the following ways: (1) to the
legal guardian or conservator of the beneficiary; (2) to a relative or friend of
the beneficiary, to be expended for the beneficiary; (3) to a custodian for the
beneficiary under a Uniform Transfers to Minors Act; or (4) by making direct
expenditures for the beneficiary.
2. Notwithstanding any provision, other than Paragraph D. of this Article, the
Trustee shall have the power to postpone any corpus distribution (but not the
vesting of interest) otherwise required to be made, and to postpone the
termination of a Trust, if the Trustee, in his sole but reasonably exercised
discretion, determines that, in view of my apparent overall intent, there is a
compelling reason to postpone such distribution, such as a beneficiary's
serious disability, a pending divorce, potential financial difficulty, a serious tax
disadvantage in making such distribution, or similar substantial cause. Any
such postponement may be continued from time to time, up to and including
the entire lifetime of the beneficiary.
-5-
3. Income received after the last income payment date and undistributed at the
termination of any estate or interest shall, together with any accrued income,
be paid by the Trustee as income to the persons entitled to the next successive
interest in the proportions in which they take that interest.
B. The laws of the State of Illinois shall govern the validity and interpretation of the
provisions of this Declaration. The situs of each Trust shall be the State of Illinois, which
situs may be changed at any time by the written declaration of the then acting Trustee.
C. The interests of beneficiaries in principal or income shall not be subject to the
claims of any creditor, any spouse for alimony or support, or others, or to legal process,
and may not be voluntarily or involuntarily alienated or encumbered. This provision shall
not limit the exercise of any power of appointment.
D. No Trust created hereby shall continue for more than twenty-one (21) years after
the death of the last to die of myself and the beneficiaries in being at my death. Any
property still held in Trust at the expiration of that period shall immediately be distributed
to the persons then entitled to receive or have the benefit of the income therefrom in the
proportions in which they are entitled thereto, or if their interests are indefinite, then in
equal shares.
E. The Trustee shall hold, manage, care for and protect the Trust property, shall
have all powers and duties provided for Trustees by the statutes and the laws of the State of
Illinois except as modified herein, and shall specifically have the following powers:
To retain any property, including real estate or stock of any corporate Trustee,
originally constituting the Trust or subsequently added thereto, although not of
a type, quality or diversification considered proper for Trust investments.
2. To cause any property, real or personal belonging to the Trust to be held or
registered in the Trustee's name or in the name of a nominee or in such other
form as the Trustee deems best without disclosing the Trust relationship.
-6-
3. To deal with, purchase assets from, or make loans to, the fiduciary of any Trust
made by me or a Trust or est d to retain any property so purdchaseld.
Declaration has an interest, a
4. To establish out of income and credie~ooprincipal reasonable reserves for
depreciation, obsolescence and dep
S. To hold the several trusthema aomn onduv ded'intderests tolthe several trusts,
proportionately among g
and make joint investments of the funds belonging to them.
6, The Trustee may at any time receive, as Trust assets, the proceeds of any
pension or profit-sharing plan, in in helex stence and operation of thert usts for
Revenue Code, and shall continue t
the purpose of receiving such installments.
7. Except as otherwise specifically directed in this instrument, the Trustee shall
have full authority and discretion in the selection of properties, without regard
to whether of low basis or high basis for income tax }purposes, for the funding
of trusts, satisfaction of bequests, or for sale to achieve liquidersonal or
distribution or debt satisfaction, and shall have no liability, p
otherwise, to any person whatsoever for the exercise of such discretion. The
Trustee shall have no obligatia resulrt of supch exerc~sestments or other
compensating allowances as
g. The Trustee shall make such elections under the tax laws as the Trustee deems
advisable, without regard to the relative interests of the beneficiaries. The
Trustee may allocate income (such as capital gains or loss} and expenses
between principal and income for tax and other purposes, in the Trustee's
reasonable discretion. No adjustment shall be made between principal and
income or in the relative interests of tmade b fltherTrustee or by the executor
effect of elections under the tax laws Y
of my Last Will and Testament.
g. To maintain and keep any residential real estate I may occupy as my
residence, whether an asset in Trust or not.
10. Any Trustee may resign by giving written notice, specifying the effective date
of the resignation to the beneficiaries to whom the Trustee is to or may
distribute the income at the time of giving notice.
F. The Trustee is authorized and empowered to permit any beneficiary of the Trust
to enjoy the use and benefit of any residential real estate, and any household goods,
-~-
chattel, or other tangible personal property used in connection with such real estate which
the Trustee may receive in kind, and the Trustee shall not be liable for any consumption,
damage, injury to, or loss of any such property so used, or for holding any such non-
productive or wasting assets.
G. If the Trustee determines that continuation of any Trust being administered is
contrary to the best interests of the beneficiaries thereof by reason of (1) legislation, or (2)
unforeseen changes or circumstances, or (3) because the value of the Trust's assets are at
such a level, in the sole judgment of the Trustee, as to make continued administration
thereof financially burdensome and uneconomical, then the Trustee in his sole discretion
may terminate such Trust and distribute the principal thereof, together with undistributed
income, to the persons then entitled to receive the income therefrom, or to have it
accumulated for their benefit in the same shares as those in which such income is then
being distributed to, or accumulated for, them.
-V-
THE TRUSTEE
A. I will be the initial Trustee. At my death, or at any time I am unable or
unwilling to serve as Trustee, Norma ). Word of Freeport, Illinois shall be the Trustee
hereunder. In the event Norma J. Word fails to qualify or act as Trustee, I name US Bank,
N.A. as successor Trustee.
B. Every successor Trustee shall have all the powers given the originally named
Trustee. No successor Trustee shall be personally liable for any act or omission of any
predecessor.
-8-
6. Every successor Trustee shall have all the powers given the originally named
Trustee. No successor Trustee shall be personally liable for any act or omission of any
predecessor.
C. No Trustee shall be required to give bond or surety, or be appointed by, or
account for the administration of any Trust to any court.
D. The successor Trustee shall render an account of his receipts and disbursements
at least annually to each adult income beneficiary. The Trustee shall be reimbursed for all
reasonable expenses incurred in the management and protection of the Trust and any
successor corporate Trustee shall receive fair compensation, which shall be charged
against income or principal, or part to each, in the Trustee's reasonable discretion.
-VI-
TESTIMONIUM
IN WITNESS WHEREOF, I have signed this Declaration on November 4, 2002.
Ruby M.- orn
STATE OF ILLINOIS )
SS.
STEPHENSON COUNTY )
I, the undersigned, a Notary Public in and for said County, in the State aforesaid, do
hereby certify that Ruby M. Horn personally known to me to be the same person whose
name is subscribed to the foregoing instrument, appeared before me this day in person and
acknowledged that she signed, sealed and delivered the said instrument as her free and
voluntary act, for the uses and purposes therein set forth.
Given under my hand and Notarial Seal, this 4`h day of November, 2002.
. ..F., .~__.-_ ~
,~`,;/ ;_
NOT>.1Y Pt!~l.~G. ,'~',~'~- ~~'~ 'f.!_!,~~.~~5 N tart' PUbI IC
by ~;~', 'i?i C'~-~ ~''1•i!iv3
Cate of Deat'n: 03/06/2010
Valuation Cate: 03/06/2010
Processing Cate: 03/10/2010
Estate Valuation
Es*_a*_e of: R:by Hcrn
Account: R:by Horn .nat #C90C072935C0
Report :ype: Date o` Ceath
C7;ayer of Securities: 14
Bile IC: Ruby Horn
Mean ar.d/or i~~ and ~.... Security
Shares Security
High/Ask Low/Bid Adj~ustmer.ts Accruals Va_ce
cr ?ar Descrioticn
1) '.0097.61 FIRST AMERN FDS INC (31946V203)
GOVT CBLIG C
2) 50000 FECERAL HOME LN BKS (3133XGLE2)
Government/Agency (Dealer Quotations)
D'TD: 08/11/2006 Mat: 09/10/2010 5.125$ 102
62500 102.59375 A/B
.
03/05/2010 102.56250 Mkt
03/08/2010 102.595939
Int: 09/10/2009 to 03/06/2010
3) 626.325 EATON VANCE SPL INVT TR (277905808)
LGCAP VALUE A
Mutual Furd (as quoted by NASDAQ) 17.17000 Mkt
03/05/2010 17.170000
q) 529.075 FIRST AMERN INVT FDS INC (318530268)
REAL EST SEC Y
Mutual Fund (as quoted by NASDAQ) 1q,96000 Mkt
03/05/2010 14.960000
5) 1688.059 FIRST AMERN INVT FDS INC (31853P743)
INTL SEL CL Y
Mutual Fund (as quoted by NASDAQ)
9.95000
Mkt
03/05/2010 9.950000
6) 911.083 FIRST AMERN INVT FDS INC (31853P693)
QUANT LC COR Y
Mutual Fund (as quoted by NASDAQ) 19.61000 Mkt
03/05/2010 19.610000
7) 391.496 PRICE T ROWE GROWTH STK FD INC (741479208)
ADVISOR CLASS
Mutual Fund (as quoted by NASDAQ) 27,66000 Mkt
03/05/2010 27.660000
g) 79.075 ROWE T PRICE MID-CAP GROWTH FD (779556208)
ADVISOR CL
Mutual Fund (as quoted by NASDAQ) 49.32000 Mkt
03/05/2010 99.320000
9) 199.431 ROWE T PRICE MID CAP VALUE FD (77957Y309)
MIDCP VAL ADV
Mutual Fund (as quoted by NASDAQ) 21.34000 Mkt
03/05/2010 21.340000
1C) 559.353 AMERICAN CENTY INTL BD FD (025092108)
INTL BD FD INV
Mutual Fund (as quoted by NASDAQ) 14.09000 Mkt
03/05/2010 14.090000
11) 1590.106 CRECTT SUISSE COMMODITY RETURN (225448305)
COMMON CL
Mutual Fund (as quoted by NASDAQ) 8.33000 Mkt
03/05/2010 8.330000
12J 4679.427 FIRST AMERN INVT FDS INC (318530797)
SHRTRM INSTL Y
Mutual Fund (as quoted by NASDAQ) i0.OlOCO Mkt
03/05/2010 10.O1CC00
1C,097.61
51,292.97
1,252.79
10,754.00
7,900.00
15,108.13
9,061.34
10,829.50
3,899.98
4,C21.12
7,391.28
_3,245.59
46,941.C4
gage 1
Iris reo~rt was orod:ced wi*_h EstateVal, a product c. Estate Valuations ~ Pricing Systems, In.. If you have H:estians,
elease ccr.tact EVP Systems at !919) 313-6300 or www.evpsys.cem. (Revis_or ~.C.4)
{ !
Cate cF Ceath: C3/06/2010
Valuation Cate: 03/06/2010
Prccessir.q Cate: 03/10/2010
Scares Security
or Par Cescr~pticn High/Ask Low/9id
131 4066.326 FIRST AMERN INVT FCS INC (318929577)
TOTAL 3ET HD Y
Mutual Fur.d (as quoted by NASDAQ)
03/05/2010
14) 3738.319 PIMCO FCS PAC INVT MGMT SER (693390700)
TOTAL RETRN PT
Mutual Fund (as quoted by NASDAQ)
03/05/2010
Total Value:
Total Accrual:
Total: 5273,866.95
Estate of: Ruby 3orn
Account: Rub~r Horn Trust 4090007293500
3epcrt Type: Cate of Death
Number of Securities: 14
File iD: Ruby Horn
Mean ar.d/or C_v anal Int Securi*_y
Adjustments Accruals VaL:e
10.23000 Mkt
10.230000
10.99000 Mkt
10.990000
41,598.51
91,084.11
5272,614.17
51,252.79
Page 2
retort •~as produced with Esta*_eVa1, a product of Estate Valuations & Pric~_ng Systems, =~. .f you have guesticr.s,
~~ please rontac*_ EVP Systems at ;819) 313-6300 or www.evpsys.com. iRevls~c.^, '.0.9)
815 235 8603
Aliianz Life Insura~~.~- may, ~_:~ ~~' l~"'~'~~ ,
PO Box 59060
iy l' ~c ~~ ve a~ES , L~ S ~ 5 ~ A 4 ~1
800(954-1962
March 09, 2010
RUB Y N(K4RrV TRC/S ~ Q TL3 ~'"-' ~= ~ ~'~' '
CIO 1304 PINSTRIPE LOUT
VIENNA VA 22182
Dear Trustee(s):
03:24:58 p.m. 05-20-2010
~-llianz ili
We sent you this letter because the trust is the named beneficiary of Ruby Hom.
Please accept our sincet~ sympathy an your loss. Listed Referito the enclosed eded
to file a claim for benefits on the fixed annuity contract(s).
brochure for answers to our most frequently asked questions.
4 /4
Payment Options
Choose one of the options in Section IV on the claim farm.
Contract Information
!Contract ~ Annuitization Minimum Cash Qualified or
Number Value Pa out Period Value Non ualified
1540507 $37,500.25 five ears $28,532.87 Non ualified
Policy values are affected by wifhdrawals, partial surrenders, loans and market value adjustments;
as a result, values quoted in tfiis letter may increase or decrease and are not guaranteed.
Claim Requirements
^ Fixed Annuity Clairn Form completed for the trust and signed by the appropriate
trustee(s)
^ Employer Identification Number (ElN) for the Trust -please visit the IRS website
at www.irs.gov or call 1-800-829-4933 for instructions and/or farms to obtain the EIN
^ Copy of the First/Title and Signature pages of the Trust Agreement for the
trustee/successor trustee designation, and any other pages that may fist
trustee(successorlrustee information
^ Trust Affidavit signed by the appropriate trustee(s)
^ Copy of the Certified death certificate (on(y one copy is required for the deceased)
Once we receive your claim requirements, allow 15 business days for processing.
Should you have any questions, please contact us at 800-950-1962.
Sincerely,
Annuity Claims
. ,,~crr s ,~.
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