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HomeMy WebLinkAbout05-28-10 15056051058 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes Coun Code Year File Number ty PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 21 10 0 2 8 9 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 201-18-7446 March 13, 2010 'March 28, 1923 Decedent's Last Name Suffix Decedent's First Name MI Fike _.. ... __ __ __ :Grace E _ _. _. a (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 Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) ~,~ 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust ,. 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number :Andrew C. Sheely :717-697-70 ~ . _ ~ Y, Firm Name (If Applicable) . ,,,....,.. .... ,„ .....::... ...... _._~.,.. .._... .. ~... _.~.ti... _... .~ ,. ` _ .._ _~,._~,k.....___,.~,_ .. ,..,:..... _ .. ~. ~~...... .. REGISTI~ 11tILLS UONLY ~ ~ fir' Andrew C. Sheely, Attorney at Law ~.~:~~<=~ --c i _ ~y 1Tl N r ~ . r '"~ -" ~ First line of address _. ..._ _ ~- ~ 127 South Market Street ~'C=? ~ r s ~~ ~~ ...,., ~ ....... ...... ..... Second line of address. # y,.._ -. .. ~ ....._.., ....,.:. ....... ...... ..... : ........ . u~ ~ ~~ S M1~ .~ _ ..~ ~ <. }--~-~ - ~ ~" ' ~ 4 ~ ~~ P.O. Box 95 • ; ~ c.~ City or Post Office State ZIP Code ,DATE FILED E_..._v_..___ _~ .. _~:..~.~. ~_~~.._., _ .......~.._~_..__. :Mechanicsburg =PA :17055 Correspondent's a-mail address: andreWC.Sheely@VerIZOn.net Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESP NSIBLE F R F ING RETURN V ~ ~ ` ~" ~ V Marlin B. Fike, 39 Konhaus Road, Mechanicsburg, PA 17050 SIGN E OF PR PAR O HAN RESENTATIVE M ~ATF Andrew C. Sheely, Esquire, outh Market Street, P.O. Box 95, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J REV-1500 EX Decedent's Name: F l k e~ Grace E. 15056052059 Decedent's Social Security Number ............. .............. 201-18-7446 _- ION 1. Real estate (Schedule A) . ........................................... . 1. 2. Stocks and Bonds (Schedule B) ...................................... . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 4. Mortgages 8 Notes Receivable (Schedule D) ............................ . 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ....... . 5. 6. Jointly Owned Property (Schedule F) C3 Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) t;~ Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) ..................... 8 ............... . 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ................ 10. 11. Total Deductions (total Lines 9 8~ 10) ................................... 11. 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. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers unc+~~ sec. 9116 (a)(1.2) X .0. 15. 16. Amount of Line 14 +~~~ble at lineal rate X .045 16. 17. Amount of Line 14 taxable f at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 , o 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 20,418.00 23,641.46 109,493.97 299,139.85 452,693.28 19,407.16 11,221.70 30,628.86 422, 064.42 422,064.42 18,992.89 18,992.89 15056052059 1 , REV-1500 EX Page 3 ..._.~... F~~..: .,....~: _::...:. , Decedent's Complete Address: 2~.. 1 a l o' ~0 2 8 9 __ DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Grace E. Fike 201-18-7446 STREET ADDRESS 100 Mt. Allen Drive CITE' STATE ZIP Mechanicsburg PA ~ 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 18,992.89 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments _ C. Discount 949.64 Total Credits (A + B + C) (2) 18,043.25 3. Interest/Penalty if applicable - D. Interest _ E. Penalty Total InterestlPenalty (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 dfference. This is the TAX DUE. (5) 18,043.25 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :........................................................................... b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for 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 IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)). The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)). Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV•1503 EX+ (6-98} SCNEpULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT F4TATF [1F FILE NUMBER Grace E. Fike 21 ~-10-0289 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ ~ US Saving Bond, $500 Series HH, D5192918HH, value at date of death $500.00 2. US Saving Bond, $1000 Series HH, M7399650HH, value at date of death $1, 000.00 3. US Saving Bond, $1000 Series HH, M7399649HH, value at date of death $1,000.00 4. US Saving Bond, $1000 Series HH, M7399652HH, value at date of death $1,000.00 5. US Saving Bond, $1000 Series HH, M7399651HH, value at date of death $1,000.00 6. US Saving Bond, $5000 Series HH, V1459326HH, value at date of death $5,000.00 7. US Saving Bond, $5000 Series HH, V1459328HH, value at date of death $5,000.00 8. US Saving Bond, $5000 Series HH, V1459327HH, value at date of death $5,000.00 9. US Saving Bond, $1000 Series EE, M64248749EE, value at date of death $918.00 TOTAL (Also enter on line 2, Recapitulation) I $ 20,418.00 (If more space is needed, insert additional sheets of the same size) 3 SER°IES= - - = _; _ _ ~ ~~ ~= == EIS -~~ f~ ~i Q 4=~i--I II~~f 11 I~ 7 - -_ _ - _ _,.._. ._ --.. --- _ _ _ _ __ _._ _ ~_e~~.._,.~,,;.a.a.k, SE'~iES ~ =_ -- _= -- -- _. ,~ - __~__=_ ~~- _ - ~~ { .s..,..;..~~.~...~ _ 3.O~J ? 3 ~-~ 6 5 .~ - - _ _ _ _ - _ - ~~ ~ ~0~~~3-~YO~1Q611~7 SERIES ~._ - __ REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEptI~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY -_ ESTATE OF FILE NUMBER Grace E. Fike 21-10-0289 Include the proceeds of litigation and the date the proceeds were received by the estate. Ail property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1997 Buick, VIN 1 G4HP52K1 VH410188 $500.00 2. Personal property-Decedent was a resident at Messiah Village at her death and owned no personal property. $ 0.00 3. Messiah Village Refund $22,638.00 4. CNA Long term care insurance refund $32.67 5. AFLAC cancer insurance policy refund $2.33 6. AMA AAA refund $1.66 7. 2009 IRS income tax refund $287.00 8 Nationwide Auto Insurance Refund $179.80 TOTAL (Also enter on line 5, Recapitulation) $ ! 2 3 , 6 41 .4 6 (If more space is needed, insert additional sheets of the same size) ' REV-1'509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEp1~LE F JOINTLY OWNED PROPERTY JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH °o OF DECD'S GATE OF DEATH VALUE OF IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 03/05/1996 PNC Bank Certificate of Deposit Acxount #31500029630, Principal at date of death - $20,000.00, accumulated interest - $19.39 $20,019.39 50% $10,009.69 Total date of death value 2. A. 04/04!1996 PNC Bank Certificate of Deposit Account #31000032760, principal at date of death - $20,000.00, accumulated interest - $21.54 $20,021.54 .50% $10,010.77 Total date of death value 3. A. 05/07/2004 PNC Bank Certificate of Deposit Account #31100240562, principal at date of death - $25,146.68, accumulated interest - $18.96 $25,165.64 50% $12,582,82 Total date of death value 4. A. 02/18/2005 PNC Bank Certificate of Deposit Account #31900256293, principal at date of death - $11,937.45, accumulated interest - $12.46 $11,949.91 50% $5,974.95 Total date of death value 5. A. 05!10/2005 PNC Bank Certificate of Deposit Account #31500261632 Principal at date of death - $12,383.22 accumulated interest - $5,33 $12,388.55 ',i0% $6,194.27 Total date of death value 6. A. 11/25/2005 PNC Bank Certificate of Deposit Account #31400279640 Principal at date of death - $12,022.45 accumulated interest - $8.34 $12,030.79 50% $6 015.39 Total date of death value , 7. A. 01/01/1979 PNC Bank Checking Account#5070079431 Principal at date of death - $36,861.03 accumulated interest - $2.01 $36,863.04 50% $18 431 52 Total date of death value , . 8. A. 01102/2001 PNC Bank Savings Account #5001902164 Principal at date of death - $53,636.93 accumulated interest - $16.81 $53,653.74 50% $26 826 87 Total date of death value , . TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same s ize) ESTATE OF FILE NUMBER Grace E. Fike Page 1 21-10-0289 If an asset was made joint within one year of the decedent's date of death. it must be reported en Schedule REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt11LE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER Grace E. Fike Page 2 21-10-0289 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Marlin B. Fike B. C. 39 Konhaus Road, Mechanicsburg, PA 17050 Son JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY•HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °% OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST A. 11 /09/1987 Member's 1st Savings Account #2848-00 Principal at date of death - $3,411.26 accumulated interest - $ .34 $3,411.60 50% $1,705.80 Total date of death value 10. A 11/09/1987 Member's 1st Investment Savings Account #2848-05 Principal at date of death - $7,538.45 accumulated interest - $ .99 $7,539.44 50% $3,769.72 Total date of death value 11. A 03/0912009 Member's 1st Certificate of Deposit Account #2848-41 Principal at date of death - $15,928.33 accumulated interest - $16.02 $15,944.35 50% $7,972.17 Total date of death value 109,493.97 TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) • Mar, 25. i ~~ 1 D 12 : 57P~1 PAC 6ANK 412-795-7741 . . ~ 1~fi1Y March 75, 2010 Andes r Sheeiy Attorrx y st Law 12'1 S 1 ~arkc~t St Mecha ucsbmrg, PA 1 ?055 RE: CGraoe 11Eyy F1iko i* S~. i01-18-7446 bC~D: 03-13-2010 Nc.9~2i1 P, r Dear 1V.'r. shetly: Ia ~ Anse to your request for Date of Death {DOD) balances 1`ar the Amer acted above, our r~~cards show the follov~ng: Cert~ ate of DeFt-sit Accour t # 31500029630 Established: 03-(5-199 . GRACE E FIIC,~ MARLIlV' B FIKE .DDD h ~lancx: $ 20,000.00 + 19.39 accrued interest Interest paid Ol r01-2010 thru 03-13-20`10 $193.$5 YTD Accotm : # 31000032760 Establis~wtl; 0~ 4-.1 GRACE E FIKE ~ ` MARLIN 8 FTC I~Q~? ~ 1artce: $ 20,000.00 + 21.54 a~~crued interest list paid 01-01-2010 thru 03-13-2010 $193.86 Y"TD 4 Accoun : # 3 1 1 00240562 j Eactablished: OS-C 7-2004 I CIRACE E 1~`IKE N1A~LIN B FIKE DDD b~ lance: $ 25,146.68 + 18.9b accrued interest ~ ~ Interest paid 01-01-2010 thru 03-13-2010 $242.17 XTD Atxoun # 31900256293 Established: 02-1$-2005 . t~RACE E FIKE M,AIZLLN ~ FIKE T1DD bE lance: $11,937.45 + 12.46 a+~aru~ed interest .Iatoxeet paid 01=41-2Q1U three 03-13=2010 $ 32.14 YT'D ~ I'I i Page 1 of 3 . ~~+"~ r, ~~, t C' `~? 'r : ~Sp~' .PNC BANK 412-705-2747 Accm nt # 31500261632 Cl•RACE E FIKE MARL] B F DOD' mce: $12,3 83.22 + 5.33 accxu~ed xute~st Intere: t paid 0l -01-2010 thru 03-13-2010 $119.26 YTD Accou at # 314002T9b4~0 GI~4CE E FIKE MARLIN B FIKE DOD l ~~e: $12,022.45 + 8.34 accrued lnt~ra4t ~nter~ t paid 01-01-2010 tt~ru 03-13-2010 $ S 1.99 YTD Cl~~ iu~ Account . A.caou ~t # 5070079431 Flo. X21) P. 2 I i .~ i F~b~hed: 05- to-2aos Eatebliahed: 11.25-2005 Est~abli shed: 01- 01-1479 GRACE E FIVE 'MARLIN $ FIKE DOD t ~aka~ce: $ 36,861.03 + 2.01 accrued int+crest Irrteres : paid O 1-O 1-2010 tbru 03-13-2010 $22.42 YTD ~ a Aocauiat Ac~u rt # 51902164 Establisb~ed: 01- yZ-200i GRACE E FIKE • . - ~ MARLIN B FIKE T~D•~ Qlence: ~$ 53;636.93 + 16.81 accrued interest lnter+es :paid 01-01-2010 ttnv 03-13-2010 $132.72 YTD I~mresb ne®t Accvnat The de :edeYrt t~d:aed ~nv~t Account 31•SSU644. For fi~rther i~~formation, you may call the Broker ~e L~rep~mern at 1-800-?62-6111. ~u[e D ~ Bo: The ~ :edent mid safe deposit box 123 C-1~ACE E FIKE Lr~ate~ t at: ~ . Meseta i Village Brach . 939 ~Ga ~ dal ~ . Mec~ ~icsburg, PA ~ 17055-8409 , (717 6 ~1-4091 i Page 2 oi` 3 i • MAY~11-2010 12:25 From:M1ST LEND~INS SUPRT 7177955178 e MEMBERS i~` r~UrkAt. CRli[fl'1.' UNION SAVINGS ACCOUNT: Amount Number/Suffix 2848-00 Date Account Established 01/01/1962 Principal Balance at Date of Death 53,411.2E Accrued Interact to Date of Death a.34 Tdtai Principal and Acc~ved Interact 53,411.80 Name of Joint Owner Marlin Fike Otte Joint Qwnersh;p Established 11/OgJ1997 INVESTMENT SAYINGS ACCOUNT: Account Number/Suf'Poc 2x48-05 Date Account Estat>fished 10/02!1985 Principal Balance at Date of Death $7,538.45 AGcrugd interest to Date pf Death 5.09 Total Principal and Accrued Interest $7,533.44 Name of Joint ~+vner Marlin Fike Date Joint Ownership Established 11/09/1987 tRA SAYINGS ACCOUNT: Account NumberlSufYix 2848-10 Date Account Established 01!11!1982 Principal Balance at Dato of Doath 5.00 Accrued Interest to Date of Death Z.00 Total Principal and Accrued Interest 5.00 Name of Beneficiary Main Fike IRA CERTIFICATES: ACCpunt NumberlSuffix 2$48-15 Date Account Established t 0!3012009 Principal Balance at Date of Death 577,523.47 Accrued Int®rest to Gate pf Death 540.52 Total Principal and Accrued Interest 577,563.99 Name of Beneficiary Marlin Fike C,~RT_IFICATES OF DEPOSIT: Acxount NumberlSuffix 2848.41 bete Account Established 03/09/2009* PrirfGipal Balance at Date of Death 515,928.33 Acxrued Interest to Date of Dsath 516.02 Total Principal and Accrued Interest 515,944.35 Name of Joint Owner Marlin Fike "Opened by transfer of funds from 2848-00. VISA ACCOUNT: Account Number/5utfix 4672090000113779 Oats Account Established 09/15/1984 PrfnCi~l Balance at Date of Death 5.00 Name of Joint Cardhpider None To:86977065 P.1f1 BERS 1sT FEDERAL CRE IT UNIOfV 1.. ~b~ t anielle A. Kline Lending Insurance SuppOK Speualist May 11.2040 Estate of: CiRAGE E. FIKE Dabs of Death: 0311 212010 Social Security Nurnlser: 201-18-7446 5t.x.)C1 1 otri.~e Drive YU. l~wc 4U M4c)f~Incabur~, Prru~sylvarii~ '17(155 (F3nt1) 2fi3 2:~2K • wwwmcrnbcrs'lst.c~r~ REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA fNHERITANCE TAX RETURN RESIDENT DECEDENT SCMEI~IIILE 6 INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Grace E. Fike 21-10-0289 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. ITEM NUMBE DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE ~. Member's 1st IRA Certificate #2848-15 -value at date of death $77,563.99 100% $77,563.4 2. MONY Flexible Payment Variable Annuity, Contract #2VA0025777 $157,964.95 100% $157,964, 3. Transamerica Non-qualified tax deferred Annuity Number 02MFB001183 $29,330.37 100% $29,330.? 4. Allstate Annuity Contract #GA0682794 $34,280.54 100% $34,280.5 TOTAL (Also enter on line 7 Recapitulation) ; I 299,139.85 (If more space is needed, insert additional sheets of the same size) • Ma r. 31. 201 ~ 12 : 47PM 3/31/2010 10:47:00 AM PAGE 2/pQ2 lNo. 559brveP, 2 P9 a ~` ~ AlEstate Life Insurance Company P.O. Box 94212 I'alttine, IL 60094-4212. ~ ~ ~ ~ ~ ~~ w . Telephone: (877) 499-6418 YaE)'r~ Ih gad h~t'~s. Facsimile: ($66) 635523 Mnrclr 31, 2010 Kathy Harris PNC Invesfimetrt Services 1400 Camp Ilill Shopping. Mall Camp Hi11, .FA 17011 Re: Grace E. Tike Contract No: G;A0682794 Dear Ms. Harris: VIA, FAX- 717-533-8032 We received a request to complete IRS Form 712 for the above rrferenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a eertaiir dale (usually thie owner`s date of Berth 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 inforrmtion for estate pluposcs: Date of Deatb: March I3, 2010 Annuity Vahic as of Tate of T7eath: $ 34280.54* Cast Bass: $ 25,000.00 Named Beneficiary: Marlin Filoe 'The ad.ual amount paid may differ due to Market Value Adjusfimenls and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. $6173. Sincerely, We~y Navuro/ bg Sr. Claim Fxaminex • FAp r. 26. 2~~? 0 3.09PM T ~r~ ~ LIpE ~Nft)RAl~1CE COMtANY 4/26/2010 11:57:32 AM PAGE 2/pp~ iNo_ ~~116zw~P_ 2 Triaasmerie~ Li#e Iaatu aace Company 4333 Edrewood Road NE I't? Box 3183 C,cd:r R'pid~, Iowa 52406.31E3 Apri 1 2 6, 2 010 Kathy Harris Via Facsimile 717-533-8032 RE: ~anuity or(s) 02~001~.$3 Dear Kathy Harris: Qur office has received your request concerning the above listed non- qualified tax deferred annuity. A Form 712 is not issued On tax defezzed annuit~.es. The taxable portion of this policy wzl], be reported an a Farm 1099-R as taxable to the beneficiary upon receipt of the funds. The value as of March 13, 2010, the date of death for Grace E Fike is $29,330.37. Any additional questions regarding this annuity can be dixected to the Annuity Service Center at 1-800-553-5957. A Transamerica Life ' Insurance Company representative will gladly assist you w~.th any questions you may have regarding this annuity and help you meet your financial goals, SincereJ.y, Kelsey Huber Claims Transamexica~zife Insurance Company Member of tle rM Group From: Subject: Date: To: Return-Path: Return-Receipt-To: Received: Received: Received : X-Originating-Ip: Message-Id: Mime-Version: X-Mimeole: Content-Type: Content-Class: Importance: Priority: X-Priority: Sensitivity: Thread-Topic: Thread-Index: X-Ironport-Anti-Spam-Filtered: X-Ironport-Anti-Spam-Result: X-Ironport-Av: X-Ms-Has-Attach: X-Ms-Tnef-Correlator: Original-Recipient: X-Originalarrivaltirne: RE: Contract: 2VA0025777 Annuitant: Grace Fike, Deceased Dear Mr. Sheely: "Amie, Valerie" <Valerie.Amie@ axa-equitable.com> MONY LIFE INSURANCE COMPANY OF AMERICA -CLAIMS May 19, 2010 1:29:47 PM EDT <andrewc.sheely@verizon. neb Valerie.Amie@axa-equitable.com "Amie, Valerie" <Valerie.Amie@axa-equitable.com> from i52mrp04.equitable.com ([unknown] [141.191.20.139]) by vms169131.mailsrvcs.net (Sun Java(tm) System Messaging Server 7u2-7.02 32bit (built Apr 16 2009)) with ESMTP id <OL2000HTWGLQOY26@vms169131.mailsrvcs.net> for andrewc.~heely@verizon.net; Wed, 19 May 2010 12:29:50 -0500 (CDT) from w51fmp41.axa-financial.intraxa ([10.76.146.97]) by i52mrp04- int.equitable.com with ESMTP; Wed, 19 May 2010 13:29:50 -0400 from W5IFMPC4M2.axa-financial.intraxa ([10.76.146.29]) by w51fmp41.axa- financial.intraxa with Microsoft SMTPSVC(6.0.3790.4675); Wed, 19 May 2010 13:29:50 -0400 [ 141.191.20.139] <F735BCCBE2B1964CB8D4CA523026912101 E19E6A@W51 FMPC4M2.axa- financial.intraxa> 1.0 Produced By Microsoft Exchange V6.5 multipart/alternative; boundary="Boundary_(ID_Uv6kELX3FsQ2xeweYWLa7w)" urn:content-classes:message high Urgent 1 Company-Confidential MONY LIFE INSURANCE COMPANY OF AMERICA -CLAIMS Acr3eOD8yc+T4MA8SRuOS1 UCxOG6ag== true AmQFALu880sKTJJh/2dsb2JhbACRZoxODr5lAoJzghsE E=Sophos;i="4.53,264,1272859200"; d="scan'208,217";a="38870882" rfc822;andrewc. sheely @verizon. net 19 May 2010 17:29:50.0058 (UTC) FILETIME=[E26F94A0:01 CAF778] As requested in your recent correspondence dated May 18, 2010, the date of death .value as of March 13, 2010 (Date of Death) is $157, 964.95. Thank you, Valerie Amie -Key Contact-Claims MONY,an AXA Financial Company 100 Madison St., Syracuse, NY 13221 800 Line 800-659-1058 Phone 315-477-2560 Fax 315-477-4357 Email Valerie.Amie(a7~CA~Equitable.com REV-f 511 EX+ (10-09} ~ pennsylvan~a DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Grace E. Fike 21-10-0289 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Malpezzi Funeral Home $16,426.65 2~ Grave opening - Trindle Spring Cemetary Association $800.00 3. Funeral Luncheon $88.11 e. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 0.00 Name(s) of Personal Representative(s) Marlin B. Fike street Address 39 Konhaus Road ~;ty _Mechanicsburg state PA zIP 17050 Year(s) Commission Paid: 2. Attorney Fees: Andrew C. Sheely, Esquire $1,150.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address _ City _ State ZIP Relationship of Claimant to Decedent 4• Probate Fees: $153.00 5. Accountant Fees: 6. Tax Return Preparer Fees: $148.00 ~. Postage $26.40 8. Filing Fee - Register of Wills $15.00 s. Reserves to conclude Estate administration $600.00 TOTAL (Also enter on Line 9, Recapitulation) I ~ 19, 407.16 If more space is needed, use additional sheets of paper of the same size. J I 1~ MARLIN B. FIKE 39 KONHAUS ROAD MECHANICSBURC, PA 17050125 Pay to the Order of_ 5405 80-1273/313 © tQ oat Datc d~.t a,~, ~G+tGYrV ~ ~ ~ g ~ Zt K ~ ~t_ n ~~ -~'-rE~~ ~. s.ou,try F..tur~. o tars ~ D.t.ti, .n 9.Ck- ®s~~ ~ V~~ PNC Bank, N A. Q40 Central PA r For ~t~~ ~-et . ~ o?'v~ / ~~ G~ CL ~ ~,~ ^~' ~:0 3 L 3 L 2? 38~: 50 ?00 2 6 4 3~i' S 40 5 Hagand Clarke VJ ~ --3 ~r ~ . o p ~~~.~ .~ N ' ~• , ~ ~ O ~ r-* ~ ~ M"'~ T~ ~ ~ ~' ~ ~ ~ ~ n' ~ ~ vv V1 ~ ~ V Gay _. , ~~ ~ ~ ~ ~~~ ~ o~ '`~ ~ o o ~, a ~Nl °~ ~ ~w ~ ~ ~ ,.... N ~ ~ ~ i , -~ p p . O p ~ ~ - ~ r ~ t~ n m O m CC G ii; ~ z 1 ~~ Q ~ O ~ (~ JV , z o z N D , ,~; ~ ~ r.. ~ .. t, ..7 ' ~ _ ~ ~ ~ :'S .,r ~ O ~ wrv ice. .'"+. D tr_. : A Y+ v , ' rn .~ ~ = ~ ~a ~ '1 ~ D ~ z 1 ~ 0 v o D ~ n ~' m ~ ~ ~ W ~F~ W C .. •' 'c. ~ ,A W ~ ~ ~' : .' t 1 ~ ii: _, - .. p -. CTI /' ~'VEISER' S MARI~:ET - 805 Main Street, Akron, PA 17501 - 859-2765 .itz - PO Box 95, Akron, PA 17501 - 626-0271 Main Street, Mechanicsburg, PA 17055 - 697-94-'84 ~1 ('O ~ ~ `(1 ;SS ity Description Price Amount < vYl ~~B ~ 1 .~... / -9 [, V~~~ ~~~ Tax Total Please Pay From This Invoice No Statements Will Be Sent laims and Returned Goods MUST Be Accompanied By This Bill WEISER' S MARI~:ET Akron - 805 Main Street, Akron, PA 17501 - 859-2765 Lititz - PO Box 95, Akron, PA 17501 - 626-0271 714 W. Main Street, Mechanicsburg, PA 17055 - 697-9484 DATE SOLD TO ,,,_ ~~ ADDRESS ____---- --~ H~ Block 4953 CARLISLE PIKE MECHANICSBURG, PA Office: 3702`l (717)737-0714 Professional: #000042 THOMAS CHASE Client: GRACE FIKE Tax Pr~eparatian 148,00 Total 148.00 Check #5413 Tendered 148.00 Change Due O.OC Employee No. 000042 Thank You for choosing H~ Block far your tax services. 4/2/11110 9:23:23 PM 7417895 REV-1.512 EX+ (12-0$) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF Grace E. Fike FILE NUMBER 21-10-0289 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (9-00) SCNEpULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Grace E. Fike 21-10-0289 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. Sherry D. Stoner, 37 Konhaus Road, Mechanicsburg, PA 17050 Granddaughter $5,000 cash 2. Deborah L. Smith, 700 Whisler Road, Etters, PA 17319 Granddaughter $5,000 cash 3. Marlin B. Fike, 39 Konhaus Road, Mechanicsburg, PA 17050 Son Rest, Residue & Remainder ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROU GH 18, AS APPROPRIATE, ON RE V-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I ~ (If more space is needed, insert additional sheets of the same size) O' ~,. ~. w.~..........,,.a .. LL'~~ ~.~~ Y~ ~ ~.L.~ 1'~1V !J rl L i J ~i. ~ 1~ 1 V ~ ~ l'.l1 L~ ~ . ~~ .L L~,G Y, G1~AC~ E. l~'1K~, of the Township of Silv+~r Spring, ~ouYtty of ~uu~berl.and s.rxu 5tat~: of Pennsylve.nia, being of pound and dis~~oairxg tnixx~, menivey and utidersts.Yxciirxg, cir~~ ms.~Ce, publish ~r~d de.c pare thi8 my ~.as t W~.11 anr3 'x'es tament, hereby revo~.irYg and nia~ ~.ng void a1~y anr~ all prier Willa by nae at any time heretofore raa.d~ p . 1. T direct thr~ payment ©f all. nay just debts and futxeral ' exp yi~sr~s as soon after my decease a,a the same can be convenientl~r i~©rl 3 . ~. I give anc~ bec~ueatlZ the $uxn of Five T~iousand {$~, 00~. On) i~o"1 Le.xs to each of m-y ~randch~.ldren, who are living at: the tfine of ;~y c~ece~t8e. 3. Y give, devis+~ atic~ bequeath dll. the rest, resid~~e. and rem i~.nder of my ~s tote , real , per: sonal and. mimed, whatsoever and whe: ~esoever situate , to any son, MA~,,I~~€ B . FII~;, absolutely anti i-c:c -xzcli t Tonal ly . ~ ~r .. M LASTLY', 1 nominate, canstitt~te s.nd s.p}aaint mfr ,ion, NYA.RLrN 13. ~'IitL, YrxeC~.ttor of t~iis pry :~.as t ~1ii: ~.r~t,i ~as Camen::, IN WITN~5S WYi:f:;F~E';OF', I ha~re h~~e.ur-to set my l~ancY at~d seF:l tY~is ~ ciay of YriBrch, ~. Yi. , 195.5. .~ ..r - -- -- . (SEAL) race e - - Si~ ned, sealeu publ3.shed aizd ciecl~.recf. by the ~xbove named, ~~ Cl, L . I`r~.~; , as ~.~~,~ fvr Yier Last Will anc `Ies tamc~nt, in tha prE se~YCe n~ us, who have subseribad our names hereto as ~a~.tneases, at the request o~ said testatrix, ~.~~. he~rp-prese~c~ce arxd in the ~rE~3C13C:E of each vCi~er. .~~_