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HomeMy WebLinkAbout09-27-10 1505610140 1500 EX (°'_'°' REV - 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 0 8 6 9 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 8 3 1 2 2 9 2 8 0 6 1 3 2 0 1 0 1 2 0 2 1 9 2 3 Decedent's Last Name Suffix Decedent's Fi rst Name MI F OR R E S T E R MI L D R E D V (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI FORRESTER J OHN Spouse's Social Security Number $ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW 1. Original Return 4. Limited Estate QX 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number J O E L R. Z U L L I N G E R 7 1 7 2 6 4 6 0 2 9 First line of address 1 4 NORTH MA I Second line of address S U I T E 2 0 0 City or Post Office C H A M B E R S B U R G Correspondent's a-mail address: N S T R E E T State P A ZIP Code 1 7 2 0 1 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) REGISTER dFaMILLS USE O C _ ~ _ ~Tn ~ ~__`=- i-n fU --- ~ ~; :~ ~ D FILED ~ ~ `` .~ ~ i~. 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. SIGNATUREIJF PERSON RESPONSIBLE FOR FILING..13 URN n/LTF ~ 14`~IORTH MAIN~fREET, SUIT 200 CHAMBERSBURG PA 1'201 PLEASE USE ONLY ~*~ <•_ ~ `_ ~ ~ ~..? . ~~ ..~ ~~ --~--, C~'; --;- ~ Side 1 1505610140 1505610140 "638 MUD LEVEL ROAD SHIPPENSBURG PA 17257 J 1505610240 REV-1500 EX Decedent's Social Security Number Decedents Name: MILDRED V. FORRESTER 1 8 3 1 2 2 9 2 8 RECAPITULATION 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 and Notes Receivable (Schedule D) .......................... 4. • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 5 1 3 4 7. 8 8 8. Total Gross Assets (total Lines 1 through 7) ........................... g. 5 1 3 4 7. 8 8 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 3 5 0 5. 5 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. • 11. Total Deductions (total Lines 9 and 10) ............................... 11. 1 3 5 0 5. 5 0 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 3 7 8 4 2 . 3 8 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. 3 7 8 4 2 • 3 8 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .o0 3 7 8 4 2 3 8 15. 16. Amount of Line 14 taxable at lineal rate X .0 ~ 0 ~ 16. 17. Amount of Line 14 taxable ~ 0 ~ at sibling rate X .12 17. 18. Amount of Line 14 taxable 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 Side 2 1505610240 1505610240 ~. 0 0. ~. ~. • J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0869 DECEDENT'S NAME MILDRED V. FORRESTER STREET ADDRESS 638 Mud Level Road CITY Shippensburg STATE PA ZIP 17257 Tax Payments and Credits: ~. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 0.00 Total Credits (A + B) (2) 0.00 (3) (4) 0.00 (~) 0.00 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 : ................................................................ ...... ^ Q b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^ c. retain a reversionary interest; or .......................................................................................... ...... ^ X^ 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? ................................................................................. ...... ^ Q 3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death? ... ...... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................ ...... X^ ^ 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) (i)]. 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 surviving spouse is 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 21 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 0 percent [72 P.S. §9116(a)(1.2)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 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 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, undE Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER MILDRED V. FORRESTER 21 10 0869 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER 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 1. Annuity Policy #L580361200, The State Life Insurance Company, a OneAmerica company, Administrator for Golden Rule Insurance Company, with no beneficiary designation, therefore it distributes to the estate 51,347.88 100.00 51,347.88 TOTAL (Also enter on Line 7, Recapitulation)I $ 51,347.88 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER MILDRED V. FORRESTER _ __ _ _ - 21 10 0869 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home, funeral services 11,758.00 B ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 2. Attorney Fees: Joel R. Zullinger 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4 5 6 7 City State ZIP Relationship of Claimant to Decedent Probate Fees: Letters - 20.00; will - 15.00; JCS fee 23.50; automation fee - 5.00; codicil 15.00; short certificate - 4.00; filing return 15.00 Accountant Fees: Tax Return Preparer Fees: 1,650.00 97.50 TOTAL (Also enter on Line 9, Recapitulation) I $ 13,505.50 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+(01-10) pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MILDRED V. FORRESTER 21 10 0869 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. John W. Forrester Spousal 638 Mud Level Road entire residue of estate Shippensburg, PA 17257 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ It more space is needed, use additional sheets of paper of the same size. I, Mildred V. Forrester, of 638 Mud Level Road, Shippensburg, ~-~ Cumberland County, Pennsylvania, being of sound and disposing mind, 1~._~ memory and understanding, do hereby declare this to be my wil_1, ~`.` hereby revoking any and all former wills and codicils thereto by me ~i l ,~~-.. rie~e~^iCr~ ~~Zade . _ _ _ , ~ 1 ~. _ _ _ __ .-. ..~ __ __ c^ `l~'' '~~~iTi.nlStr~_~~ ..~i =~Z `:1' =;~~~_~L" I~. I give, devise and bequeath the residue of my estate of every nature and wherever situate to my husband, John W.'~orrester providing he shall survive me by thirty days. III. Should my husband, John W. Forrester, predecease me or die on or before the thirtieth day following my death I give, devise and bequeath the residue of m1 estate of every nature and ~,~lherever situate to my children, namely Danny G. Forrester, Charley L. Forrester, Betty Martin and Jean Wingert, in equal shares, provided that the share of any child who predeceases me or dies on or before the thirtieth day following my death shall be distributed to said beneficiary's issue, per stirpes, living on the thirty-first day ~~~~. vim, following mfr death, and in default of any such then-living issue, f~~~. ~ - such share shall be added tc the share or shares of my other ~. ... childr~~_ . ~-_ ~._ ,. -._. 1 _- -._~,~ - -- .- - - - - - - - - - - - J ~: _. - _ - - ~ _ - .. a_ _ _~ , ~ . ~_~ __ ~ ~l ~ t _ ~_, .~. ._ ~~ _ _ _ ~ _-~ -- ~ ~ ~ Y r _ _, ,-. -- _,_ ., r _ .. - - t ti -~,%i ~_1 or ,~~l~~r-.~,~ise to .aid ~~eneficiar- ~~aid trustee s~~~~_? . _ ~n the -~ trustee`s .sole discretion and without order of ccurt, use principal as well as income from time to time as may appear to be necessary for the Beneficiary' s welfare, comfort, medical care, recreation, support and education, without responsibi lity to the beneficiary or to any person taking care of the beneficiary; and the remaining balance in the hands of said trustee shall be distributed to said beneficiary when the beneficiary attains the age of twenty-three years. If such beneficiary dies prior to attaining the age of twenty-three years, said trustee is authorized in the trustee's Page 2 d~.seretion to pay part or a1 1 ~~f ~ ~e oeneficiary ` s fur~eral expenses and the remaining balance in the hands of said trustee shall be distributed to the beneficiary's personal representative. In the event the funds held by the trustee for any beneficiary become in the opinion of the trustee too small for proper and efficient administration, the trustee, in the trustee's sole discretion, may ~~~.,,~ deposit such funds in a savings account in the name of the ... ~ beneficiary . :-..... ~. ,:~~. ,~ '~J . ~~ -~ _. __ ._ ,. ~ -- - _ _ -- -1 - ~. _ _ _ .w; - - ~~ __ ~. - , r-s - -. ~ _ - ~ - ,- R , .. :_ - 4~; a ~,.' ~i ~ '.. _. _ _ _. 1.~ l_. ~ ~ ~ ~ _ L_. __ ~ I l Y' ~ ~ ~~ . l ' I._ ~_: ~. ~ _ti ! `~ ~ !_ ~ J...%1~ 1, ! v _ i '.,.i _ ~c ~ ! ~' ~ ~ ~~ ~- ~ ~ ., ., - -, --~~ .~~tai11 alp,- any ~.l ~ ~f the ~ssGts ~,f :~~v ~stat~ real or ~" ,` personal, without regard to ,and; principle of diversification of risk . B. To invest in all forms of property including stock, common trust funds and mortgage investment funds without restriction to investments authorized for Pennsylvania fiduciaries as they deem proper, without regard to any principle of diversification of risk. C. To sell at public or private sale, to exchange or to lease for any period of time any real or personal Page 3 property a~ ~d t o give options fcr sales , ex ci-?anges or leases, for such prices and upon such terms or conditions as they deem proper. D. To allocate receipts and expenses to principal or income or partly to each as they from time to time think proper. E. To compromise any claim or controversy. ~._ F. To distribute in cash or in kind or partly in each. ,tom. G. To izold property in their names without designation of . ~ a-i~,% f i disci aryl capaci t~~ or ~ n the name of a nom nee or ~~. `_~'~,:~ -~.~nregistered . ,:::~. ,_. ~_. '~~' _ _ ,_ _ - - - - - - - .- r ,~ - - Cc ~~ ~. ~ --- ~ _ _ ~ -_ . - _ -.. v ,~ ,, ~.. _ _ R . ~. ~~ i7 a i _ .,., .- _ - ' _. ~~ _ :. ~'~TTt "~ _ '~ - ~ ~_ Q' . a ?~ _ _ S ~ c r ~ .~ ~ a ~. ~, _ - -- _~ ._ __ - h.- f- ~ "1 ~ _ :; ~~ .the aQTt'iiir strati or ~f mLL- estate . r' ~~,~` ~~. ~'~_ VII . The interest of the beneficiaries hereunder shall not be subject to anticipation or to voluntary or involuntary alienation; and the principal and income shall be paid by the tr~.~stee or guardian directly to or for the use of the beneficiary entitled thereto, without regard to any assignment, order, attachment or claim whatever. Page 4 ~l ~ ! .!. . I appoint my husband, John W . Forrester as executor of this my will. Should my husband, John W. Forrester predecease me, fail to qualify or cease to act, I appoint Orrstown Bank, with principal offices located in Shippensburg, Pennsylvania, as executor of this my will. .~X. i\ C __; -~.''1"~ ~:.i. ~ ~ = c! 1 ! _J c ~ C~iyt 1.C ~ Cf ~ i ?_ 11'„- ~ 1_ CZ i C 1. ~ 1: _ I~ ° r ° t:!'_~' ~ ~ r' -± T1 a i~l 1 _ C ~ `,1~~ i 'Y I~ °~, ~ ti G a~~.~# ,~~" ~'C_~, ~` ~`~ ~ . ~ __ ._ i._. _ . ~ '.J - __ c_ -~ i ~ I~'~ ~ ~ _ Lei ._ _ C'. _ ~_ ._ _ _ _ _ ._"t,'~,~, L - L i ~ ~ v ~ ~_ ._ ._ L .' ~ i ! ~~..: ~ ~ i_ % ` 2 =~ i~,% - !- ~ i J. ~ _ ~~. - J ~..l i ,.. _~. _ ` ~^.~. ~~ g - =-1 _. ~' r _ ~ _ _ r;'i~: i ~' ~' C '~ o ~ _. Q ~ x~. ~ ~ .L _ i=: c'ti L i L, i 1 fi. h Z ~, ~ , ~~ ~ ~ ~%; ~~ ~ ~~! ~°~~/" 1....t,~" ~~..-, --- - ~~'~~j ... r _ f.' f ~ ~ w.f--__.~- i~~ ;- ~,-~ S EAL ) Signed, sealed, published and declared by the above-named testatrix as and for her last will and testament in our presence, who in her presence, at her request and in the presence of each other have hereunto set our hands as attesting witnesses. ~~"" ~~ c~ ~~ ~ ~ -,_ .- ,~, J f Page 5 a__CG __ _~ the testatrix and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as he-r last will and testament and that she executed it as her free and voluntar1T act for the purposes therein expressed and `hat each of the witnesses, in the presence and hearing of the said testatrix gi gI-~ed ~` }„_ -ai ~ as 'tii tnesseS and tO the .Jest of ti].e1r ~IiO"vd~ edge Bald s1Cri7~?~ "f~~as ~.t ti~at tliii~ _1gllteel`1 y°ars r;,f Cie ~~~ ~~1-der O~ s C' ~. ? ~~ ':.i ^:1 i.. ~i'; i ~_ 1~ ~~ U I i c.:,.. = ±~ i7 C ~: C n S t ~ ,,..1 i i t ~ ~ ~.~ i ! ~ i~. 2 ~. i`l. f ! i l e r~ ~ ~ ~~ ~ul~~s~~ribe~._z swor_~ ~ o and acknc~~~,fledged before me by the above-named signer and subscribed and sworn to before me by the above-named witnesses this _ day of .._ _ . _. ~ ~~. ` Notar fiP7abli~ COMMONVvEAL"I"rI O!~ PENNSYLVANIA Notarial Sea( Teresa .P. l~urkholder, Notary Public Shippensb~ar~ ~oro~ Cumberland C©unty zVly Comrr.~ssaot~ Expires Aug. 6, 2068 ~`~I°fl"l~~r. '~rar;ric~;t~lc.'t;a, ucS~~f:igii,7'} !lf Nrf~i'ISS Page 6 JI?~ - ~ ~ ! ~~~LO~~~st~r , rGd D~C~m~^er' ~ X005 ~QDIC~L I, MILDRED ~7. ~'ORRESTER, of 638 Mud Level Road, Shippensburg, Pennsylvania, being of sound and disposing mind, memory and t.:~ understanding; do hereby declare this to be a codicil'~o my ~.~11 ;:~:. -=.__ ~, dated ~~7arch 3 , 2005. ~-~, ~.; ~ ~-~ _ - , ~ :.i .~ _ f •-; - ~~ ~_ ,^~ r- f ~~' ~i _ _ ~.. ~ lJ ~`~ ~ ~ Cn'. ~~ ~t g Z G!. p 1 i _~~ ~ I ~ `: f i~ i`~ _ ti- a ~ ~ L ~'~-~ ,._ ,- ~' _. i 1 ! ..L !~. 1-.~ ~ ~i ~ ~ ~ ~~ ''-~ `~1-=~- -ll _ _ _ - - - _ ~~ n; i -~ 1~' - i `I ' -~_ r1 "i~ ~ l._ .~.1.`~ ~_L a~t_k ~1d,~d~~.~.C` ~ :~~ ~~~~Ct ~i1C~"~. !_ ~1!'_~ ~r.) _':~,,?'-i 1~~~ jam, r_.. `~Iij.J~t_!. l~U~._C)~: '~ I appoint _nv husband, Join ~v . ~~ orrester as ~ecutor of this my ~~,~ill . Shoup. my husband, John W. Forrester predecease me, tail to qualify or cease to act, I appoint my children jointl-~ and severally, namely Danny G. Forrester, Charley L. Forrester, Bette Martin and Jean Wingert." II. In all other respects I hereby ratify, confirm and republish my will dated March 3, 2005 together with this codicil as and for my will. IN WITNESS WFiErZEOr~, T have hereunto set my hand and seal this ~''` ~` day of ,~'~ ~ , ~,~~~:,~_ 2 ~_ n .-f~~'~ ~' ,~` `kf ~ f ~ ii ~ f.~;~~ ~ -~ ~ S SAL ) ,. Signed, sealed, published and testatri~~ as and for her last will a ~;,~ho ~ ?~ ~~e ~^ presence, at her request otl~e~~ 'lci-ie ~~eseuntc set ou_ ha~~ds ~~s i ,~ ~~ ~ ~, ~~ ~~. ` f declared by the above-named nd testament in our presence, and in the presence of each f _..._... .. _ .. -. ,, ~ - ..,~ - ~, --~~_, - --- T~~ E _ -- - - - ;chose names are sinned to ~~he attaohed or foregoi na instr~_~ment, being fii.r,st dul~s sworn, do herebzr declare to tree undersigned authorittiT that the testatrix signed and executed the instrument as her last ~aill and testament and that she executed i t as her free and -voluntary act for the purposes therein expressed and that each of the witnesses , in the presence and hearing of the said testatrix signed the will as witnesses and to the best of their knowledge Page 2 said signer was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~F } ~,~- l Testat~`lx ,_ '~_~ ~~ ~~ '~~ ~ ~ Tnlitness 1 --- -- Tn~itness Subscribed, sworn to and acknowledged bef o~~e me :c~~,; r_he abo~~~re -named signer and subsc~ ~ ::~~ ~ ~._nd s~-,~o ~~n ~~o be~oze -ne ~~'/ ~.he ~~ ~ -- abo~~,e-Darned ;witnesses this _ `_ dad,; o~ . ,. _. Page 3 ~~ ONEAMERICA~ The State Life Insurance Company a ONEAMERICA~" company An administrator for Golden Rule Insurance Company One American Square, P.O. Box 6008 Indianapolis, IN 46206-6008 September 7, 2010 ESTATE OF MILDRED V. FORRESTER C/O JOEL R. ZULLINGER 14 NORTH MAIN ST, SUITE 200 CHAMBERSBURG PA 17201 Owner: Mildred V. Forrester Policy: L580361200 Claim: GS201006085 Dear Mr. Zullinger: We have received the Letters of Administration you submitted naming John W. Forrester, as Executor of the Estate of Mildred V. Forester. We have also received an authorization of release of information by the Executor. Per your request, the date of death value of the above annuity is $51,347.88. The following documents are required to complete the processing of your claim Claimant's Statement -This statement must be completed by the Executor of the Estate of Mildred V. Forrester.. A notarized signature is required on Page 2. If the agent/broker signs in the notary space, notarization is not necessary. IRS W-4P Form (enclosed) Non-Qualified Plans and IRA's- Federal Income Tax will be withheld at a flat 10% rate on any non-periodic payments the beneficiary receives unless the beneficiary chooses not to elect withholdings by checking box # 1 on the enclosed form. If the beneficiary elects a flat dollar amount, the withholding amount will be 10% plus the flat dollar amount stated on the W-4P Form. If the beneficiary would like an additional amount withheld, please state. The withholding amount will be 10% plus the additional amount stated on the W-4P Form. A return envelope is enclosed for your convenience. If you have any questions or concerns, please call the Individual Resource Center toll-free at 1-800-275- 5101. Sincerely, Individual Claims Dept Enclosure(s): W-4P Withholding Certificate for Pension Claimants Statement -Death Claim ~;~_ Y, ... ; , ~" ~.. ,~P ~. . --~ _~a - ;~ '~ -: x,EZ, •~ s '' ` _ '~'; _~. s e •~F i_ t'~. f b. CV - {~__ {~ ` t ~ ~ „ ~ ` _ _.- _. _, ~~ f _.. _. i.1.. ~ . _,' cz.. C, , .. ,_ r _~.. ~ti ~ tvM_. _ .~~ N w ~ ; C ' ~ - , '3 C.1.. . U ~... L -. 3~ ~ ~ W / // V! ~ W o ~ N -~ ~ ~ W N T o }, Q U N cY1 Z ~ ~ ~ cn ~, cd O ...I ~ ~ ~ G rr~ -J ~ ~ ~ 3 0 ~ ~ z ~ U N ~ a N ~ ord ~ d- ~ /~ li ~_ ~ N J ~ rl ~ ~ 1-- r--~I ~ •~ W U "-~ ,.fl o ~ O N ~ U ctf ~ P~ U .-i V •• O r~ '~ ~'; ~~ ,~ '~ ,F ' ~ 1 - y ~ ~ ' , - ~ tS 3. ~ ~, 5 1 4 ' l ^t r f t 3 ~ ~!~ ~ ~ ~~ ~~ti cF 1:. ,} *~ ~ #~ i - - - `~ t ' ` ~ , ~y ~ 4K L