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HomeMy WebLinkAbout07-12-10 ~ ~~ Y ~ ~ ~Li -:<:~:; -~; ~ OFFICIAL USE ONL'r PA Department of Revenue pennsytvama Bureau of Individua't Taxes County Code Ye;r rile i~u:rne Po sox zSo6e~INHERITANCE TAX RETURN! 21-10-0274 Harrisburtf. PA 171zS-oGO RESIDENT DECEDENtT ENTER DECEDENT INFORMATION BELOU4' Social Security Number Date of Death MMDDYYYY Date of Birth A4FADJ'T^:'Y~ 182-01-2035 02/11 /2010 11 /27/1920 DFr..edent's Last Name Suftix Decedent's First Name ~,;, BLOSER MARTHA N {!f Appifcahle} Enter Surviving Sucuse's informatics Befcv• Spouse's Last Name Suffix. Spouse's First Name P~' N/A Spouse's Socia! Security Nur.~be= THIS RETURN MUST BE FILED IN DUPLICATE 1ry1lTH THE REGISTER OF WILD FILL IN APPROPRIATE OVALS BELOtA~ C~3 i. Original Return r~ 2. Supplemental Retum Q 3. Remainder Return idate of deal; Prior to 12-t3-ri,? Q 4. limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Reautrec loath after 12-12-F#F': t~ o. Decedent Died Testate O 7. Decedent ~Aaintained a Living Trust 0 8. Total Number of Safe Deposit riaxe:. (Attach Copy of Wi111 {Attach Copy of Ttusti Q 9. Litigation Proceeds Received O 1C. Spousal Poverty Credit (date of death Q 11. 'election to tax under Sec. 911 ,A' befv~teen ? 2-3?-9? and 1-?-951 (Aftar_h fict+. CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX -NftJRMATiON SHOULD SE DIRECTED T>~ Name Daytime Telephone Numoe ROBERT R. BLACK (717) 243-3727 »~ I REGISTER C~~NiLL5 USE O~ - .. ~_Q ~ , _.~ ' r i ~ ~ ~.. `_ ..~ First tine of address ~ ' -nom ` ~ _ 3 LANDIS & BLACK ~_ ( r'1 ' - - ~ ~ ~ ~ Second line of address ' C~ ~ !- ~ 1 36 South Hanover St. - -- ~ - ~ r`~` City or Posi Office R'FIED v ~ R - State ZIP Code - '~ - rT7t _: i - -y ., ~ _ , ~ ~~ Carlisle PA 17013 ~' ~ CorrescondesYs a-mail aeiarsm Under penalties of penury, I declare that 1 have examined this return, inGuding accompanying s:.t!edules and sfafemenls. and fo the best of itty knowfer!rae and hF~?s~; it is true, correct and complete. Gedaration of preparer other than the parsanal representative is based an alt information ofi which preparer has Dny knrnaied:- SIG(y]/~TUP,E OF PERSON REfiPONSISLE FpRpp1LING RETURN t U ~ (}fiT~_ _ -- - - At)l4.t.,~ ~_. 1 Subdivision Road, Newville, PA 17241 23 Subdivision d, Nevifvitte, PA 17244 aivrvn;uttt ~r rKtYAKtK LI1.1tK !tt,4N KEE'Kt~ENlAiIV~ _ _ V'k: tiDURESc 36 South Hanover Street, Carlisle, PA 17013 PLEASE USE flRFG><NaAI. FfliRM flIdLY Sidi . ~~Q~is~l~.i,~l~ ~~~~ta1~L~~ Y y~~~~~~~s~.y REV-15C:(; t a t' nni 1 $a fr ~..Geden. E S__.a, GL.itV 1VUmoN"' Decedent's Name: MARTHA N. BLOSER 1$2-01-2035 RECAPITUt.ATiOre 1. Real Estate (Schedule AZ .......................................... ... ?. O.OO 2. Stocks andBordsi5chaduleE~ .................. :...::....:...... ... ? O.OO 3. Closely Held Corporation, Parinershio or Sole-Proprietorship (Schedule C7 .. ... 3 O.OO 4. Mortgages and Notes Receivable {Schedule Dt ...... . ...... . ..... . .... ... 4 O.OO 5. Cash. Bank Deposits and Miscellaneous Personal Pronedv (Schedule El.... ... 5 10.376.96 8. Jointly Owned Property fSchedu(e F± Q Separate Bi!lino Reouested 6. O.OO 1. Inter-Vivos Transfers & Miscellaneous Non-Prnoate Froper~• {.Srhari~dc !_1 Q Ca~arata Rillnn Reouested_, . , ~. 70.415.37 3. Tatst Gross ' Assets ,total Lines 1 thro:;~h 7'• 4 80,792.33 9. "runerai expenses and fidministrative Coss {Schaduie Nl ................ ... 9• 8.082.66 1J. Debts of Decedent. Mortgace Liabilities. and Mans i5ci~edu!e I' .......... . .. . 1!~. 0.00 11. Total Deductions (iotal Lines 9 and 101 :....... . ..... . ..... . . . .... . . .... 1i. 8082. fib 12. Net Value of Estate iLine 8 minus Line 1il . ................ ........ .... i2. 72,709,67 13. Gharitabie and Govemmentai BeauestsiSec X11:; Trust, =c= .~;~,- art electo^ ±a tar. has not been rned° !Sc,;;c~iae Ji ......... . ....... .. ... 13. 0.00 i4. Net Value Subject to Tax Line i2 minus Line 13} .............. . . . . . . . . . 1fi, 72.709.67 TAX CAI.GtlLATl4N • SEE fN3TRU~TSdN3 FQR APPLIGABL.E R:;T:~_ 1:J. hlil i':.f[:E < {.,ilic 14 iuX:;:«::.. at ttte SC~Ci%JSBi lax r~iC. Cr. J iiCl'3iL-'fS t1rSCCr J£U. v't1*~ ~a~i1.~1 ~ li_~ s:'. 't 4: flrnnrint nY 1 ifYA ':. at lineal rate X .0 45R^ 72,709.67 1~. ii, i,Rtvuiii U~ uue iY iaAai;ro 1$. Rrnount o! Line 14 taxae~: ., .:, ..,~, : , ,..~. .. i C lu. (AX t}~tEi .. .. .... .. . . .. .. . na Lt;. t`iLL iii TtiE OvttL Yt~ 'r'Gt; irriE i~CCieii»ruTiilCa F~ nr=fiJl~sC3 t3~ Hfa v;iEiiaA~'i•~ii;~i3 3,271.94 3,271.94 u _. _ _ CJ~__..._.. ~ riEV-15GG EX Pages Fite Num~P Decede;~t's C~m~lete ~,cfc#r;rss; MARTHA N. BLO5ER { STREET ADDRES~ 1 Subdivision Road CITY _ _ __ STATE _ ZI° Newville PA 17241 Tax Pavments and Credits~~ 1. Tax Due (Page 2, Line 19} 2. Credits/Pavment< ,4. Prior Pavments 2,100.00 B. Discount _ _ 110.52 3, tatere:: 4, If Line 2 is greater than Line 1 + Line 3. enter the difference. This is the ©VERPAYMEN ~, Fill in oval on Page 2, i_ine 20 to request a refund. 5. if Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE 3,271.94 Total Credits i A + g ~ , 2a 2,210.52 {3 t4j f5) 1,061.42 Make check payable to: REGISTER OF WILLS, AGEiv~. PLEASE ANSWER THE FOLLOWING QUESTIONS SY PLACING AN "X" fN TFiE APPROPRIATE BLOCKS 1. Did decedent make a transfier and: Yes fao a. retain the use or incon~~ of the property trarsferretl :........................................•.........•..........,.....•...................... ~! ~X' -, b. retain the right to designate who shah use the property transferre~+ or its income :...........................•................ ~ ix; c. retain a reversionary interest; nr ...........................................•.................,.........................•...........•...................... ! ,` IK d. receive the promise for life of either payments. benefits or care? ......................................... ! I Ix 2. If death occurred after Dec. i 2, 1982, did decedent transfer property within one year of Beat, without receiving adepuate cansideration? .............................................................................................................. !~,' ;K 3, Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ? ~ iz ~. Did decedent own an individual retirement account, annuity or other non-probate property. whin; contains a bc-neftGiarv designation? ............................................................................................. ;X - !F THE ANS'NER TO ANY OF THE ABOVE QUESTIONS IS YES. YOU MUST COMPLETE SCHEDULE G AND FILE iT AS PART OF Ti~E RETURN• For dates of death on or after July 1, 1994. and before Jan. 1, 1995. the fax rate imposed pn the net value of transfers to pr for the use of the survivino st?oilsF 3 percent [7Z P.S. §9116 (x1(1.1 i s~`; For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the survfv!na spouse is u perce!- [72 P,S, §91i6 t,"aj (1.11 (ii}j. The statute does not exemRt a transfer to a surviving spouse from tax. and the statutory reouirements for disciesure of assets an: filing a tax return are still applicable even if the surviving spouse is the only beref!ctart. For dates of death on or after July 1.2f1C~- The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to pr for the use of a natttrai parent, az: adoptive parent pr a stepparent of 'the child is 0 percent (72 P.S. §9116(aj(1.2}f Tne tax rate imposed on ine net value of transfers to or for the use of the decedent`s ilneal beneficlares is ~.5 percent, except as norec ~r: i2 P.S. §91ia(i.2j [72 P.S. ~91it;(a}i'j; . Tr:e tax rate imposed on ttte r,Ei value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. g91ii;(ajjt.;jt. A sibling is defined, ur:d:r ~~~%tivn 9ii12. as an individual w•ho has ai ieaSf vnc G8i-gilt lir iAr~nir~?n :~r"~fh the L+eGedciif. ;rlh2ihBr b'v bvud r:r~ au"O~ilu;`. RcV-1508 EX+ (6.98j ~ SCHEDULE E BANK DEPOSITS & MISC. CASH COMMONWEALTH OF PENNSYLVANIA , INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 13LOSER, MARTHA N. 21-10-0274 InGude the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly-0wned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Adams County National Bank -Savings Account No. 9644636. See attached letter. Principal - $8,867.00; Interest-1.12 8.868.1? 2. Adams County National Bank -Checking Account No.112208. See attached letter. Principal - $459.04; Interest - .02 459.06 3. Adams County National Bank -Savings Account N0.5986621. See attached letter. Principal - $500.00; Interest - .44 500.4 4. Western National Life Insurance Co. -Annuity Payment. OXP229111 166.10 5. Bankers Life ~ Casualty Co. -Refund -Health Insurance 229 2G 6. PSERS -Retirement Payment 153.95 TOTAL (Also enter on line 5, Recapitulation) s J 10,376.96 (K more space Is needed, insert addltlonal sheets of the same size) I, pennsylvan~a ~ ~+~~iE~€~~E DEPAP,TMENT GF REVENUE j INTER-VIVOS TRANSFERS AN[~ `. INH'eRITANCE Tax aETUeN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ~ ~ ESTATE OF FILE NtlMBER BLOSER, MARTHA N. 21-10-0274 This schedule must be completed and filed if life answer tc any o. questions 1 through ~ or. page th; ee o` the REV-li0ii rs v=. iT~M NUMBER DESCRIPTION OF PROPERTY iNCiUDE THE NRA1E OF THE T0.i+r~5FEREE, THE[R RElAT10NSHIP TO DECECENT A@G THE DATE CF TRANSFER. ATTACH A COPY OF THE DEEC FOR REAL ESTATE. DATE OI- DEATH I % OF DECO'S ~ EXCLUSION ~ IAXA,°,'~' VALUE OF ASSET INTERES I iIF APPLCRBLEi I VALu C. 1• f Nationwide Annuity Contract No. 07-1152528. See attached letter. 10,044.15 , 100 ( 0.001 '001.?5 2• Westem National Life Ins. Co. -Contract No. W236657. See attached letter. ( 10,539.66 ~ ~ 100 + 0.00 ~ i i;,;;3y of 3• Westem National Life Ins. Co. -Contract No. W238790. See attached letter. I 9,906.34 ' 100 ! 0.00! 8.905 ?~ ~ 4 ~ Western National Life Ins. Co. - Contract No. XP229111. See attached letter. ~ 39,925.22 ~ I ~ 100 i' 0.00 j 35.g25.Z NOTE: All annuities had named beneficiaries being the two children and Executors of estate. See attached. TOTAL (Also enter on Line 7, Recaoitulatlon i ~ ? 717.415. (' more space rs needed, use addrticnai sheets of paper of the same s¢e, ~~~ i 5i penni~ylvar~ia ~~~E~'3~L~ DEPARTMENT OF REVENUE ~ FUNERAL EXPENSES ANi3 ~NrrERrrANCE TAX RETURrd ~ ADMINISTRATIVE COSTS RESIDENT DECEDE?rr ESTATE OF FILE NUMBER BLOSER, MARTHA N. 21-10-0274 Decedent's debts must be reported on Schedu6e . 1~Et: NUMBER. ~ DESCRIPTION i pMgU~`+' A. =FUNERALEXPENSE~: 3. ~ AJ~4ihiSTRATI'JE C.0 ?s: 1. I Personal Representative Commissions: Name(s) of Personal Representatve`s` __ __ __ 4 Street Address ~ CitY _ State ZIP __ _ _ __ Years) Commission Paid: ~ _ __ 1. i Attorney reel: 3. ~ family Exemption: (If decedent's address is not the same as claimants, attach expianation.i l Claimant U tlt-ner S. S1o~er, Jr. I __ _ _ __ f Street Address 1 Su#;d'tVisipn Road __ j city ivewviiie __ __ state P;~ zIP 1?24 I ___ neiationship of Claimant to Decedent ~O1't _. ~ ~ Probate fees: i 5 ~ Acrountant fees: !~ la(Return Prepares Fees I ~.~L 4.~3~.C a 5v0.vC, 543. Cat TOTAL {A1so enter on Line 3, Recapitulation;, S ~.JY~.~: l; mare space Is needed, use addiUOnal sheets at paper of khe same szc. Pennsylvania 4.~ CEFARTMENT OF P.EVENL~E 1NHERIfANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: BLOSER, MARTHA N. 21-10-0274 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• Wilmer S. Bloser, Jr., 1 Subdivision Road, Newville, PA 17241 Son 100°.~~ S.S.N. 173-38-6056 NOTE: Insufficient funds for the balance of the beneficiaries. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I ~ if more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF MARTHA N. BLOSER i, MARTHA N. BLOSER, of Upper Mifflin Township, Cumberland County, Pennsylvania, declare this to be my Last Will, hereby revoking all prior wills and codicils. FUNERAL EXPENSES FIRST: I direct the payment oI'my funeral expznses, i~~cluding my gravemarker, as soon as may be convenient after my death. PAYMENT OF DEATH TAXES SECOND: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of administration of my estate. DISTRIBUTION OF PERSONAL PROPERTY THIRD: All my personal effects, clothing, furniture, furnishings, jewelry, automobiles, other tangible personal property of every kind, and insurance thereon, I give to my children who do survive me fora eriod of thi them as they may agree or, if they are u able to agree as3my executormdivided among ay decide. The share of any minor child shall be selected and held by my executor for delivery to such child at termination of minority or, in the discretion of my executor, may be delivered either to the minor or to another to hold for the minor during minority and the receipt of the minor or such other person shall be a complete discharge of my executor. Any items not so disposed of shall be sold by my executor and the proceeds added to my residuary estate. BEQUESTS FOURTH: I give the sum of Twenty-five Thousand and no/00 ($25,000.00) Dollazs to my son, Wilmer S. BIoser, Jr., or his issue, this Bequest to be paid in full prior to the payment of any of the following Bequests. initials a. To The Center Evangelical Lutheran Church, 1498 Center Road, Newville, PA 17241, Three Thousand and no/00 ($3,000.00) Dollars; b. To my granddaughter, Lori A. Wickard, One Thousand and no/00 ($1,000.00) Dollars; c. To my grandson, Lonni A. Wickard, One Thousand and no/00 ($1,000.00) Dollars; d. To my granddaughter, Triiia O. Kulp, tine Thousand and no/00 ($1,000.00) Dollars; e. To my grandson, Trent 0. Wickard, One Thousand and no/00 ($1,000.00) Dollars; f. To my grandson, Wesley L. Bloser, One Thousand and no/00 ($1,000.00) Dollars; and g. To my granddaughter, Wendy L. Ott, Une Thousand and no/00 ($1,000.00) Dollars. DISTRIBUTION OF RESIDUE FIFTH: I give the rest of my estate in equal shares to my son and daughter, namely Wilmer S. Bloser, Jr. and Shirley A. Wickard or their issue, per stirpes, living on the thirty-first day following my death. ADOPTED AND AFTERBORN PERSONS SIXTH: This will shall not be modified by the birth to or adoption by me of any child under the age of 18 years, but references herein to my "children" or "issue" shall include any such child. In the construction of any device or bequest herein to any person or persons described by relationship to me or to another, any person adopted when under the age of 18 years, whether adopted before or after my death shall be considered the "child" and "issue" of his adopting parent or parents. initials PROTECTION OF BENEFICIARIES (Spendthrift Provision) SEVENTH: No interest in income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. Provided, however, any beneficiary may assign any part or all of the beneficiary's interest in my estate to any one or more of my descendants or to any one or more of the beneficiary's descendants. MINORS AND INCAPACITATED BENEFICIARIES EIGHTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, my executor as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. My executor as trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be distributed to such person upon the termination of minority or incapacity. My executor as trustee shall have the same powers as my executor. POWERS OF EXECUTOR NINTH: I confer upon my executor the right to sell or otherwise convert any real or personal property at public or private sale, at sur..h time or times, in such rr~anner, and for such price or prices, and on such terms and conditions as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, without restriction to so-called "legal investments"; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or ~-~-~ initials partly in each; and to do all other acts and things necessary or appropriate in the management, administration and distribution of my estate. APPOINTMENT OF EXECUTOR TENTH: I appoint Wilmer S. Bloser, Jr. and Shirley A. Wickard, or the survivor thereof, executors of my will. WAIVER OF BOND ELEVENTH: I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. INTERCHANGEABILITY OF LANGUAGE TWELFTH: Words used in the singular may be read to include the plural or the plural maybe read as the singular. Similarly, the masculine form may be read to include the feminine and neuter; the feminine may be read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine. HEADINGS THIRTEENTH: The headings used on the various paragraphs of this will are included for convenience only and shall have no legal significance. I have signed this will this 1 ~ da of . y ~~~-~~~ , 2008. ~'YI ~ ~ 23 .L ~. ~~ Martha N. Bloser ~~ Witness .~.~ Witn ACKNOWLEDGMENT and AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) , SS. COUNTY OF CUMBERLAND ) I, Martha N. Bloser, the testatrix in, and W ~~-N~~ ~ ~" 1 L ~~~ i and ~ ~~ ~ L y ~ ~ L j (~~~' i 1 ,the witnesses to the last will, the attached or foregoing instrument, who have signed the instrument, having been duly qualified according to law do depose and say: (a) that I, the testatrix, do hereby acknowledge that I signed and executed the instrument as my last will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the testatrix sign and execute the instrument as her last will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the will as a witness and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Martha N. Bloser, Testatrix ~~~~~ .ei ~~ Witness ~7 CUMMUNtVEALTH OF PENNSYLVANIA ~ "Y~-1°"~ ~ c ~~ ` Notarial Seal Witness `-J Robert R. Black, Notary Publlc Carlisle eoro, Cumberland County My Commission Expires Sept. 28, 2009 //~ ~ ~1, /" l ~~~i~.l/ C. Notary Public /` ~~~~~~~ COL:~~IY NATIONAL BAND Apri12, 2010 Landis & Black Law Offices 36 S Hanover St Carlisle PA. 1701.3 Re: Estate of Martha N Bloser Dear Mr. Black: The following information is being provided as per youl• request: Acct. Type Account No. Account Accrued Otimership Date Principal on Interest to Opened D.O.D. D.O.D. Savings. 9644636 $8,867.00 $1.12 Individual 10/13/77 Checking 112208 $459.04 $.02 Individual 11/19/84 Savings 5986621 $500.00 $.44 Individual 11/29/01 Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5116. Sincerely, ~auo Q. ~. Lois A Kime Deposit Services PO Boy 3129, GeTrYSSURC, PA 17325 I rrioce 717.334.3161 I Toi.i. Face 888.334.2262 I ~wvwacnb.com i ~uc.~ r~~1Y13/bU~S r-111 Wt1oM~;idC Finsncia ~. ~ l7or ~8Z021 +roiurnnoa art ads-~02i 18tionY/ids.CCrn March 2.2010 Harold Joseph Besha•N M & T Socurities 552$ CaNisle Pike Mechanicsburg, PA 1+'050•ZA13 Rs: Nationr~teo Annuity Contract Number: oT•11S2S78 Contract Owner end Annuitant: Martha N. Bloscr Dear PAr. Beaha~nr_ We appreciate your inquiry, This letter is a follaw~-up providing date of death value information regeested far annuity contract t1Y•T15z;sztr, Mr, Beshttw, as of February 11, 2010, the contract value of this annuityvns X10,044,15, We are Here if you need us. PleaBe oontaet our annuity Senric9 Conter sit ~•gOp.g21.8084, Monday through Friday, S:bO a.m, to 8:00 p,m, Eastern Tune if you have any quostions or need additional contract information, Sincerely. Serviop Management Nationwide Financial ~~9 04/23/2916 13:45 6863426966 WNL VALIC I¢Ivuz/002 PAGE 02 ~N~STER_,,~.~ NATIC?NA.~ ---.-.. I. ife In ~ ~irct n c~ 1~ciRax871 ~'°mPa ny A~~t~rillcr, Texas /910.1 f1P71 i H0(1.4;!A.~44Q Aprl] 23, 2010 Edward Taylor (717)243-5907 Re: ~4nbtuity Contract W236G57, VV238790 & x'22911 I Deceased Martha Bloser Dear Mr. Taylor: Thank you far yotar recent inquiry regarding the above referenced like to take ~tlvls opportunity to respond to your request, annuity contract. We would The accu><x~ulated value of contract W236G57 as of 02/11/2010, the date of death, is $10 The accumulated value of contract VV238790 as of 02/l ] 12010, the date of death, is $9 9539.66. The accumulated value of contract XPZ29111 as of 02/11%2010, the date of death, is $39 06.34. ,925,22. Mr. Taylor, we appreciate the opporhi,ruity to assist you, Should you have any uestiorts contact our Client Care Center at i-S00-4244990. q ,please Sincerely, ~~~~~ Becki Gataviz Annuity Claims Department ~ 5T5(1.1 r'1 j/'~j +/'Z ~ ~iIESTERN~ ~ NATI.~~~~~ ~'ed Annuity ApptBcat~on ~`i~~VNL Flex 5 O VVNIL Flex 2 1 f' K3 ~ h S t} i' C3 d1 t1. H ~.' G !ri ',? i3 Tk ~ ~'~ f~:°4Y?~%~wi6t3lAri44vti "%'lt'r9".A~t%..t?7r7<.T;tl~^ „'~.f arrnr, OWNER (All~7tPotlgyhctder ccPrresjp+ondence will be sent to this address.) ~ • r/.~riiF7Lf w !!!- ~1f1r41~:~} n.. !,, r-ti.. r~/', f+(amE1- . AddreBS. t~laritai Status: . y SSN• • /$ Z~ 20J.J1:7 ' ~ fl t Daytime Pttvne: 7r7-?1 ~F ~„ .iGiiv i ulrvnex t~pnonar. Pion-t~ualtfied Annuities anly.) ---- - Name: Sex: Cfioose One Age• DOB• Marital Status: -- SSN:. _ t)avtirne Phony,- ANNUITANT' (1f different from !ha Owner.) Upon the death of the Annuitant, owner •may designate a new Annuitant if no deskJnatlon is made within 30 days of the death of the Annuitant. the Owner wi8 become the Annuitant. , f+lamB: _._. _ Ssx: f:h~nam C_1r,_o At.o• ----- nnT~. J Address: 'Daytfine.Phone; v SSN: . Relationship to Owner: +1W1J'CA~Q t1CAiLCtr/AOV nr_e`s..a.tw.... _--._..------ - _--- --- - - _...~....~.. «.....-......ar.. w.~ ~ M~..tW fYfIK to P~iuT OT VMfM~s i1IfVlYing.(Oln[ dWigr be~pf~~s I~riRliry t3enettCfi{y O If you do not wan! the Joint Ownel t~ ba the Prtwm~y Seneftdary, check here and Hams Beneficiary below. . Banafldary: Name: jfl~~lC!' ~.~ ~~~_ Re~shffx ~ t -,..,-:_..~...~ ~~~- r ovllviTCil~Ty: ivame: Relat#onship: 1 INTERE RATE (Interest is credited and oom nded dagy to achieve the annual rate. To a a this retie, the premium must be left for s fug year without any wtthdrawa~. j The min mum guaranteed !Merest rate ta~ the life of your policy is _2.Ot3 9',. :... -~ F rw w:wiwi Hain v-1 u In n iiuHi rf6tiljum f3 ~_'j~;~-'~I tpr _~_ y{~~g~, PURCHASE PAYMENT . Policyr rlutr,bac ~23$79Q Rolfcy hate: r l =c7.~ - % • •._.___- .. - . fnpfat Premium Payment: $ -115 ~,~,-.~tA gnnuny Dater , ~ p a~.. PLAN TYPE (requitedj: uagfied O tlualified .; -~- • . Tax-QTmff}!ed Plans: TracGtional iRA Ct SEP #RA O Roth fITA O 4II4 {Corfsora#e Afartj ,C~ tQther: _ w rocx weer: u Inlual t:ortinnunon for rax Teat O Transfer ^ Rogover ^ Roth IRA Conversion Y>~r SItiNATURE3 Checks must be made payab#a to Wsstem National Life insurance Comparry. ~ Do you have any existing qfe insuranoa pagcies or annuity contracts? '~Yss p No . ,... --..... ....:.,•r~'g',~ ~r.~lca-yn aT,y v~uns ire stsurance or anrtwty cotttraCt iSBUed~ an~COrnpartyt ~fes Q No (If Yes. complete the ~ Ana You an alive duty service member of the united States Amted Forces? ^ Yea ~-No © ! underBtand this annufty is not fedewagy insured. 1 Have read and understand the Important rllcr~tncr~rac rr,natnrt ,~„ 14,,, ,,,,,„,,._ „~ ,,,,., t~ erWpne~iion, i represent that au statements and answers In it~4 appNcation are complete acid true on behalf of me and arty~persoR who Nma~y/Jd] aim any Intere~fst~/under this potlicy. ~ • (~ xl~4~i.~i .~~.w.^~.s~.Vil.~nw 1 t//iJ it /a._ t. i ~ z Joint Owner's Signature (lf appgcabla) z Signed at (c>h-Istate~ ~s St~tyr~a _ 7~l ~v ~ V •.~.....v.s ..... r.`uW-VTNaMe1VT\ __. ~ _ _ _____ _ ~ To the best of my knowledge the applicant has an existing qfe ~surartce pogcy or arirxrity cantracL L!n'es ^ No ~ Y'~ have any reason to begeve this annuity wilt replace, dtsoontinue ar change any existing life insuranas or annu Rs agent, have you campged w)th all State Re lacement ~ ~ i'k' p Regufa$onS and eomoleted all rAClulrwA StatA RoMnrnme.»t fnan,e.9 r•~ way oy ' rang finis Corm, t Ca titer 1 have truly and accurately recorded het+eirt the InfOrmatbn prpvided by the appUcant ....~. u . r., u ~... a . .. •. s Uce Aueni's Signature ,,,,,,__,,.,,,,,_, ~ _ - t r.yw w~ .wn~a ailu itiuu WG7 Donald C. IGltian State t.ic.#: . Licensed Agent (Print name] Agent: . W-~44-8 I05-12X WH1TEfYELLOW -Home Office Copy PINK-Agency Copy GOLD-Agent Copy.. • " - - i i al ~~ ~ .»...___ 4~._ ~~ ~>~ •^'•"' irrsoaAnc~~ CoiirUr'ArY••~ Deferred Annuity Appt~cation utc ~~ ~ 3l15 P.^1l:LML A•~:oc .~t.~`i~t~1 ~~G~v 1: ,-.T Atrt w. ... ~~~Ii9~ -.~ ~ .fL J ItiA f OWNER] ( II Policyholder c~irrespondence will ire seat to this address.) NalrK: I~(l'~ 2~7'~/L~ it,C ~~..< I-F7 r•- 17 _ Address: v Marital Status: t~ ssN:~~~.-row v20~ti" Daytime Phone: ~f ]'-'~7~_~-,~'~fT.S~ ~w:•: ~ :,..~icn wyuonar. hon.yuaiffied Annnitles only.) ___, -- Name: Marital Status: Sex: ~~ ~: DU6'~._. ANNUITANT (if different from the Owner.) Upon the death of the Annuitant, Owner may designate a new Annuitant. If no designation is made within 30 days of the death of the Annuitant, the Owmer will become the Annuitant. Name: ----~-------~'-_.._'-.____ c_... Address: _.___ =_... ,--~.'^aa• wn: DaYtbrie Phone: SSN: Retationsliip b Owner. c>vvwtcrrc acuerv+..,, . ........... .._ _ .. _ _ __ ....._ ..... • ,........^.^., ~.vn - la trlf 1Y~nt Ot olath Of Owner survlvin _ _ _. _ - .~_.-..- _._._ O if you do not want the Joint to be the Prima t3en~fic 9 Joint Owmr becomes Nrirrlary Beneficiary. rY iary, check here and name Bettefk:iary below. eetetlaary' Narrre• ~ „~ p. rwQ ~Y 12etationshi --^^-~y....~..vaa.w..~.y: rrrrrrre: _ lull 1 ~tr_rf ['tom Relationship: ~IirI11 CiJ4~'C°1? __._..._... _ _ _ IYTG~CI.~ w for a full Year'vtitltoitt any withdrawals.) Th minimum aanY to achieve the annual rate. To ' ve this rate, the W guaranteed interest rate for the life of your policy is ...~,°~. - - - : ~ .. ~....r...-.W.p{yll ib _ •.v~ 'rb r01' _>~L.year(s). WIDf!u~QCeaV^^Rf,~ _ N ,z, Z U POD' "`nnb~' ~W--Z~-3-6657 p,~.~,,Y~,a,~e: PLAN TYPI_' (tCitu i Nn6f e~1e1aGT~s.,t n r+...,,.a,,.. rY~~l ~. tax-Qualified Plaits: o Tr.rcfitionai iRl1 o sEP rRA l7 Roth lii~- D 40, cCwporate Pmn) D 403(4) TSA o Other: Check one: D In~+ai Conblbution far Tax Year D Transfer O Rotlaver Q Rotfi IRA Gahversion Year ~^ ~'1. V.w.V v/Ii3t.A1 1nU$r De made paY~Je ~ AiG An.v lbv i -_.........-.. »..~_.,._T..... DO you have .^' 1 ~~ ~' ex kle ir+sirance poGaes or annuity rontrails? Yes O No WiA this aranrdy replace or change any existing fife insurance or annuity contrail in this or env other cAmx3an~n #~v..a n „It i +^~r~ati0 InIS amm~ty is not tederatty irtstmed. On bray of myseY and any person who rrwy clalrn any interest under this of~ and answers in this are Mete and true. i have read and understand the ~ i represent aPPNr~tiort_ trtrpatent disclosures located on the X ~l ~~~7'.17-~.~i2 E~~. LOwnar's S+Bnahrre ~ Signed at {c~ty/state):~S.l..,~ . X Joirrt Ownec's Signature {if applicable) tlcal.,~.~ ,~ ..:. t~.:::.j. -. ! .a.i t..ciu -i To the best of my lutowled~ the applicant tree an exLstirg Iile krsurance D4 You have alry reason to believe the annu' A~ or annuity rontracf. ~ O No ~[ L y,,,~~,,~~ w.... ~Y aAAiied fa[ trill reoiace of nhanrx. env a..;:ra..,. I:r ,..~..,~.,_,. _ .-,1: _ N Grit .i .II~VIr/6y, l ^la~ atta~9d a _ _ _.a ...~ ...~~....,~...... .........~ s K+ / W lJ 14t! ropy beach d~dosure statement and a Get of companies involved and indicated cost basis: sal. ~rr~n _,r.-r~„fI uoerrsea nAent's Signature t ~ Agency Name and Number ) ~" !Q h State lic.~: Licensed Anent tPrint nam~ol Agent: +~ 105-12X WHiTEIYE~LaNy-Home Olrioe Coi~Y PINK,At~en~y COPY GOLD l~gent Copy HOI ,.~ , ,. _ «.,._ ~~~ ~ ~ ~ ~o`° AawiUn,'rerns 7Q1~2-1;ir +~re+r~e~i Annuity Application ~Fiexibie Premium C] Single Premium OWNER` ;All Policyholdericorrespondence wil! be sent to this address.) .,~ti r~-ci__ ,,~«+,.~t;,~ Hge: i~_ uut~: ~s -~ s-+~df ~ Address: ft31 S1 ! O Marital Status: ~(~~`~ SSN:1~-' J~CJ'~„~"" ._..__.__-_ ~ 1~~( ! ~ --- Daytime Phone- ~~~ 7~~/~-~~~rr-: ,• JOINT OWNER (Optional. Non-Qualified Annuities only.) Name: Sex: Age: DOB: . . , .__ -~., vayirn-rx rntyne: ___._ ANNUITANT (if different from the Owner.} Upon the death of the Annuitant, Owner may designate a new Annuitant. If no designation is made within 30 days of the death of the Annuitant, the Owner will become the Annuitar? Name: Sex: Age: DOB: Address: Daytime Phone: ~~~• Relationship to Owner. OWNER'S BENEFICIARY DESIGNATION - In the event of death of Owner, surviving Joint Owner becomes Primary Beneficiary. Q N you da not want the Joint Owner to be the Primary 6eneficiarv. check horn areri n~m~ a~..fl~,-lam,,: s,.,,....- Primary Beneficiary: Name: ~ ~ ~ - ~~77-- ~.h Relationship: Contingerrt Beneficiary: Name: i! a Relationship: ,~rrr-rte.-r+T w.a+... .~ ~ .. ... _ ~- - ~ -' '-' ' "' • • - ~^ ••~• ~~• ~~ ~•~~~•~ a++~.+-~-lrrN~u„~~~ ~duy w ac;rneve zne annua- rate. I oiachieve this rate, the premium must be left for a full year wifhout any withdravkals.) The Interest Rate on the (InitiaUSingle) Premium is ~d© ~~ for ~ year(s). r r Policy Number: XP ~ ~ ~^ ~ ~ ~ Policy Date; __~ " ~ ; Initial i~`emium Payment: ~ ~r`sy t'~~~ ~,,,,,,;+„ n,tn. ,~,,,,r, 1!",i t PLAN TYPE (required): (,Non-Qualified 0 Qualified Tax-Qualified Plans: O Traditional IRA O SEP IRA ^ Roth IRA D 401 (Corporate Plan) O 403(b) TSA O Other. ~~ I acknowledge on ~ ~$- ~ I received annuity policy _ X 1- Z Zg' / ~1 Date n_r:_ . Boa. ,~umaer Gheck one: D Initial Contrihlitinn fnr TaY vPar rl Trn..~i..- n n..„_.._~ r-.n_._ .. .. ...________. ~ .._.._._ . .......... .. ... vv..,w o.vn r ca. SIGNATURES Checks must be made payable to AIG Annuity Insurance Company. Witt)his annuity replace or be exchanged for e~dsting life insurance or annuitses? O Yes ~~to i a~ t"1 .1.. ~..~ w~.... _ ._ . .. - - .__.._.~ _..._.. ., ,.~......... ... w..u v..w. 1 understand this annuity is not federally insured. On behalf of myself and any person who may daim any interest under this policy, 1 represent that all statements and answers in this application are complete and true. I have read and understand the importan# disdosures located an the revzrse Hof this dpplicatian. _ X l~i,~~i l~~ sc ~`. 1 l1v, /~' _ `~'l')_ ,,./ ~s-~ /mil' -- ,_ ._._ . ~ ~~,,,,v~„er•s ~tgnature {lt applicable? -- Signed at (ctylstate):_ (~~C:lt51Ei t t'~ on (date): ~ ~°~O~ REPRESENTATNE INFORMATION j/ TO the t?P.Cf of my knrnn,lar}nc and hcticf +hic Ann,:....h,..• n .t...,., ~,1r .. _ _ -_ r ment is involve I have ttached a copy of each disdosure statement and a ~listvof companies involved and indicatedacost basisrwlues. sr - y! irAnmfl 6ncnt.c Cin.,~t...... - 'r"+ ~ _ X state uc.#: Licensed Agent (Print name) Agent: ~~,'-~1.[_~ F$DA (C~-00-A WHITE - Pnlir_vhnlrior!'nnv vcr , n,e, u___ ...n__ ..__ _.. .._ PR3~3fi~6~~~~ ~~~a~~~~ iATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY APPI.iCATION FOR '.D. Box 182008 1NDNIDUAL SllVGLE DEFERRED ANNUITY _ .-+ rtr:ru a r-i' r31V~ti['TJ- 4~~ li ~:?"11 ti fL 4 f+'1 f i~ ~ r~~ . t= -~ ~ - _ DORESS ~_7"~I CD ~ i ~,~ ~ SOC. SEGO )TY/STAT"FJZIP l ~tC.U-•-y 1 uX -~ /,~ i 1 d' `i i DATE OF BIRTH I i k~ f / f `7o~C.y MM DD YYYY a'~'NI~TT_~-NT: 1;~1A ~• ~~~ SEX i ff M 3t~- Mf%IAIg1D ISSOi AjC Zr.'f ~DR~ SOC. SEC. # :l7~YlS 1~A f hJL1Y DATE OF BIRCH i 1 / o- // M ) MM DD YYYY ~ UI?VT C)~1'iLTER: ____ SEX ~] M (~ ~ ~ v "~pome old a~ m tlb n.t. vx. rw ula v i DRESS SOC. SEC. # 1'lY/S t A l rJLtY DACE OF BIRTH / / MM DD YYYY ONTIitiIGEh'T OWNER: 4DDRESS ftY/STATFJLII', SAX [~ h~ n F SOC. SEC. # DATE OFBIRTH / / MM DD YYYY --- - -- rQt4'TLTiGEN'I' AIViViJITANT: ___. __ SEX [-~ M (~ P MuitriYm issue w=! W DATE OF BIRTH / / SOC. SEC. # MM DD YYYY BENEFICIARY: twlwk percentates only. Mlut eg1n11009G.) Relationship $irthciate ~ ~....,,,._. t-•._.,.._,.,,.,. h_.,. r...tt wr..._., n .... ~:....« txtz Att.,...,a..._ a.. A.._...,....« S~_., P,. ? t., • si ar+.+...n.-~- 1~ ^ ~~~ 1„_' t[./17C~ -1. -~7~ -~Q~,_ tZ3-~•ldX7n t 0 0 ~ ^fYA•Ti) A r"'1•'i`1/QC f..... ....t•i.... +.....r i.n nt....sn Ala 1 1 SD A ~ h..«x tD A .._ n....7: [:_ 1 FHL-711 PV 3/2001 (AO) (3/2()01)