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10-06-10 (2)
J 1505610101 REV-1500 txca,-'o) PA Department of Revenue p~Y~aMe OFFICULL UtlE ON~.Y Bureau of individual Taxes °`""~p"`""" ~+b Code Year File Ntsttber PD Box ~ofioi INHERITANCE TAX RETURN Hamsburg, PA i~s28-o6os RESIDENT DECEDENT Z~ ~ ~ d ~ ~ Q ENTER DECEDENT INFORMATNJN BELOW Soria{ Security Number Date of Death MMDDYYYY Date of Birth MMODYYYY 162-4&8394 01 /19/2010 03/10/1914 Decedent's Last Name Suffix Decedent's First Nama MI _. _. Cookson Virginia _ _ H (ff AppQcable) Enter Surviving Spoup's-Irtfomiatton Below - Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH TIE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ~ t. Original Rstum O 2. Supplemental Retum O 3. Remainder Ratu (date of death prior ip 12.13-~j O 4. Limited Estate O 4e. Future Interest Compromise (date of O 5. Federei Estate Tax Retum Required death after 12-12-82) m 6. Decedent Died Testate t~ 7. De©edent Maintained a Living Tnrat 0 S. Total Number of $afe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) --___ CORRESPONDENT - TIg3 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTIAL TAX INFORMATION BNOULO DNtECTED TO: Name Daytime Telephone r ev __ a Carla C Malingotlirski (907) 456-6137 REOtBTBR ONC'y'f First Itne of address 2420 Lodcsley Ct Second tine of address city or Post Office Fairbanks State ZIP Code AK 99709 .~ 1 7'~ ~ ~ ~ _ a° ~- v~ ~: r-r-i ', ("', e"^~ C!'s _-CJ n-~ ~ - t--~ ~r_ ~~ =~~~ r ~.. rrr ~.~ Correspondent's e-mail addnsss: ataska24k(~acsalaska.net Under penattks of pery'ury, I dedero that i have sxanNrned this ro1um, Indudirrp acxompsrryM~p adxdWes acid statements. and to the hest Ot m' artd belief, ft is true. correct and aomPleta. Oadaratbn of proparer ottbr than iha personal roprbaerKeNve h based on all krlormatlon of which preparer any krtolMledya. 31GNATU ERSON~E3PON~16~,~ FOR FILING RETURN 1 DA Side 1 1505610101 1505610101 ~, J 1505610105 REV-1500 EX Decedent's Sociall Security Number t~enrs Name: Virginia H Cookson 162"48"8394, RECAPITULATION 1. Real Estate (Schedule A) ............................................. L ' 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 95,610.37 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) ............ . .............. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ' 15,725.86 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7,984.67 7. inter-Vivoa Transfers & Misoetleneous Non-Probate Pn~perty (Sd-edule G) O Separate BiiBng Requested........ 7. 110,939.88 8. Total Gross Asseb (total Lines 1 through 7) ............................. 8. 230,260.7$ 9. Funeral Expenses and Administratlve Costs (Schedule H) .... . .............. 9. 3,207.38 10. Debts of Decedent, Mort®age LlabUitles, and liens (Schedule 1) .............. 10. 130.37 11. Total Dsductlons (total Lines 9 and 10) ................................. 11. 3,337.75 12. Nst Vaiw of Estab (Line 8 minus Line 11) .............................. 12. ~ 226,923.03 13. Charitable and C3ovemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. ' 0.00 14. Nst Valw Sub~sct m Tax (Line 12 minus Une 13) ........................ 14. I 226,923.03 TAX CALCULATION • SEE INSTRUCTIONS FOR APPLICABLE RATES -T- I 15. Amount of Line 14 taxable ' ~ at the spousal tax rate, or , transfers under Sec. 8116 (ax1.2) X .0_ 15. i . _ . _. _ 18. Amount of Line 14 taxable at lineal rata x .0.4~ 228,923.03 16. ~ 10,211.54 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rats X .15 18. 19. TAX DUE ......................................................... 19. 10,211.54 20. FILL IN THE OPAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Sids 2 1505610105 15D56101D5 J I III REV-1500 EX Pape 3 Decedent's Complete Address: FIN Number DEC NAM Virginia H. Cookson STREETADDRESS 4905 E Trindle Road CITY Me~chanicstwrg STATE ~ PA ~ ~ ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPaymenta A. Prbr Payments - 10,211.54 e. Discount 502.48 Total Credits (A+ B) (2} I 10,049.80 3. Interest 4. tf Line 2 is greater than Line 1 + Line 3, errter the difference. This is the OVERPAYIAEN7: (3) Fill in 011 Orl Papa 2, UM 20 t0 t~eQtleft 8 refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 161.74 Make check payable to: REGISTER OF WILLS, AGENT, PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRII~TE BLOCKS 1. Did decadent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ~ ^ b. retain the right ~ desi~ate who shah use the properly transferred or its income : ............................................ ^ (] a retain a reversionary interest; or .................................... ..................................................................................... ^ 0 d. receive the promise for fife of either payments, benefits or care? ...................................................................... ^ ', 2. If death occurred after Dec. 12, 1982, did decederit transfer property within one year of death ', without receiving adequate oonsideratlon? .............................................................................................................. ^ 3. Did decedent oNm an in trust far' or e-u n-death bank account a ~ payaW po security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-globate property, which contains a beneficiary ~signation? ........................................................................................................................ ^ L ^X IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS ART 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 tp or for the u~e of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)J. 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 su ving spouse is 0 percent [72 P.S. §91113 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements~or disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefdary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of Vansfers from a deceased child 21 years of age or younger at death to or for the ~ISe 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 benefiaaries is 4:5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. (1) 9,547.32 • 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. §911ti(a)(1.3)J 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+ (6-88) COMMONWEALTH OF PENNSYLVANIA INNERITANCE TAX RETURN RESIDENT DECEDENT scMEOU~e s STOCKS & BONDS ESTATE OF Fl4E NUMBER Virginia H. Cookson 2010-00108 All properly JoiMly~oYmed w<th right or suMvorehlp must be dbdosed on ScMduN F. ITEM VALUE AT DATE NUMBER DESCRIPTION Of DEATH ~• Cooper Industries PLC, 896 shares, common 38,832.64 i CBE, CUSIPgG241401081G24182100 2 Gardner Denver Inc,102 shares, common 4,384.98 GDI, CUSIP#365558105 3 Roy Dutch Shel{ PLC ADR CL A,128 shares, common 7,801.60 ROS•A, CUS{P~i365558105 4 Eaton Vance Strategic Income Fund CL A, 4998.92 shares 40, 591.15 ETSIX, CUSIP#780259206 5 Series HH US Savings Bonds, 4~ s500 ea, PQD to Carla Msatingowski 2,000.00 6 Series HH US Savings Bonds, 4~ i500 ea, PCD to Lynne Jackson 2,000.00 TOTAL (Also enter on lure 2, Rel~itulatjon) I = 95,610.37 (h more apace la needed, insect addidanal sheet of s-e same size) I REV-15~ EX+ (6-98) s~N~du~~ ^ COMMONWEALTH OF PENNSriYANIA CASH BAcN~K DEPO'SITS` ~ $ hAISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FlLE NUMBER Virginia H. Cookson 2010-00108 Indude the prooesde of IiNpattan and the date the prooeeda wero rocefved by the estate. All property ~b rrMh Hpfit of survlvoroh~ must M diesload oa ScMduN F. ITEM VALUE AT GATE m um~n 11000CIDTI/1N (1C r1FATL1 1 Cash in Wallet 2 Personal ef(e~, hcwsehold iterrta- 3 Bastk Deposit, Citibank NA South Dakota, aoct# 72474620-18550 MaganStanley SmithBamey, 214 Senate Loop, Camp Hill, PA 17011 4 Savings account, Grove City Area FCU, acct #4458 One Credit Union Way, Grove City, PA 18127 5 Undaimed Property (received June 2010) TOTAL (Also enter on line 5, Recapitulation) ; (If more space la needed, insert addftlonal sheets of the same size) ~I i 24.5fi 2oo.a0 11,093.95 a,337.a3 68.92 15,725.86 REV-1,509 EX~ (oi-10) Pennsylvania ~CN~pVL~ P OEPARTMEHT OF REVENUE 70INTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FI NUMBER: Virginia H. Cookson 201d~-00108 If sn asaat henme jointly owned within one year of t[ha decedent's data of death, R nwst be reporbd ' ~.fiadu~ Q SURYMNG JOINT TENANT(S) NAME(S) ADDRESS Rtf TIl]IVSIIIP TO DECEDENT A• Lynne C. Jackson' 82 Fairway Drive, Camp Hill, PA 17011 daug e' Carla C. Malingowski 2420 Lot4kstey Ct, Fairbanks, AK 99709 daugr,Ter C. I 70INTLY OWNfi~ PROPERTY: ITElk NUMBER ktTTtn wR TENANT kTArE NADE )0[NT DESCRIPT]QN OF PROPERTY INCLUDE NAME OF FiNANtuI INSTITUTION AND aANK ACCg1Nr NUMBER OR SIMILAR IDENiIfY[NG NUMBER. ATTACH FOR ]OINTLY REAL ESTA GATE OF DEATH VALUE OF ASSET ~ DATE Of DEATH VALUE OF DECEDENrS INTEREST 1. A. 0921105 PNC Bank Checking 11000005140164544 9,324.65 17 1,554.11 B 0921105 PNC Bank Checking 1!000005140164544 9,324.65 I h 7 i 1,554.10 A 09121/05 PNC Bank Cheddng 1<000005140164544 14,629.40 ~ 7 2,438.23 B 0921105 PNC Bank Chek4celg 11000005140164544 14,629.40 '~7 I I I I 2,438.23 TAT/tl /Alcn anhar nn I ine f Raranih datknn- ~ ~ 7,964.67 If more space fs needed, use additional sheets of paper of the same size. _, r_ _ _ p ._ REV-1510 EX;-108-09) Pennsylvania DEPARTMENT Of REVENUE u~+aarANCE rAx RETINW R~IDpIT cECi:oEr~r SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMlt~lt• Virginia H. Cookson 2010-00108 This schedule must be canoleted and filed if the ansv~xr to any of guestlons 1 through 4 on page three of the REV-1y0~ is yes. TiF~1 NUMBBt DESCRIPTION OF PROPERTY arauoE TiE NM~E ar THE TpN6R~, 7-ma RBAirolwo- to OECFDEM AND ne oAre of TPNISRaI. ATn~a A corroF TIE oE~ Foa Rb1L ESrQE. DATE OF DEATH VALUE OF ASSET 16 OF DECD'5 INTEREST CLU510N TA%ABLE VALUE i. Transamerica Life Insurance Company (Cookson Family Trust dated 53,469.94 50 ~~ 53,469.94 7-19-2002) Annt~ty death heneflt to Lynne Jackson (daughter) ', 2 Transamerica Life lnsur~ce Company (Cookson Family Trust dated 53,469.94 50 53,469.94 7-19-2002) Annuity deaBt benefit to Carla Malingowski (daughter) 3 Series HH Savings Bonds, 4 (dJ 5500 each 2,000.00 100 2,000.00 POD to Lynne Jackson (daughter) 4 Series HH Savings Bonds, ~ 5500 each 2,000.00 100 2,000.00 POD to Carla Malingowsla (daughter) ~~ 'I I i ~i, TOTAL (Also enter on Line 7, Recapitulation) ;, 110,939.88 If more space is needed, use additional sheets of paper of the same size. RF.iI-1511 E:k+ II.Q-09} pennSylvania DEPARTMENT OF REVENUE INHERITANCE TAx RETURN RESIDENT DECEDENT SCW~DULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FTLE MU ER Virginia H. Cookson 21-10-Od18 Deadant's dtbb must brt ropoKed on Sdadula I. tT>~r A. FUNERAL EXPENSES: 1' Funer~ Expenses, memorial servioe supplies and burial Mp tra+rel rekribur$errrertt, Jackson Furreral Expenses. memory service supplies and burial bap travel reimbursement, Magngowski Cemetery Pastor Organist Cremation additional fees Supplies and food B. ADMINISTRATNE COSTS: 1. Personal Representaatnre Commissions: Name(s) of Personal Representatlve(s) Street Address Cdy State ZIP Year(s) Commission Pald: 2. Attorney fees: 3. Family Exemptlon: (If decedent's address Is not the same as tlahnant's, attach explanatlon.) gaimant Street Address Gty State _ Relationship of gaimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Prep~er Fees: ~~ Adman expenses acrd tiravel reimbursement, Jackson Adman expenses and travel reimbursement, Malingowski Death notice publications Estate axount broker fees Estate tax Ming fee Z[P 405.31 269.81 175.00 200.00 75.00 157.00 173.89 0.00 327.50 327.50 0.00 0.00 46.94 786.43 123.00 125.00 15.00 TOTAL (Also enter on Line 9, Recapitulation). ;' 3,207.38 If more space is needed, use additlonai sheets of paper of the same size. REU-2512 EXr (17-OS) pennSylvania SEWEDULE I DEPARTMENT OFREYENUE DEBTS~~F DECEDENT, ~+~~ T~ ~N MORTGAGE LIABILITIES 8i LIENS RESIDENT DECEDENT ESTATE OF FILE NtfMd R Vi inia H. Cookson 2010-001 8 Report debt incurred by tM decedent prior to death that remsinad unpaid at the date of death, indudinq unralm medial expense. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• State Income taxes due for 2009 178.00 2 Refund of overpayment insurance -45.00 3 Refund of charges, assisted living -2.63 TOTAL (Also enter on Une 10, Recapitulation) I; 130.37 If more spas is needed, insert additlonal sheds of the same size. REV-1513 EX+ (O1-10) ~ Pennsylvania DEPARTMENT OF REVENUE INNERITANCE TAX RETURN RESIDENT DECE09~lT SCHEDULE ] BENEFICIARIES ESTATE OF: FILE NUMQER: Y inia H. Cookson 2110 00108 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not Lid Trudo~(~) OF ESTATE I TAXABLE DISTRIBUTIONS (Include outright spousal dLsMbutlons and transfers under Sec. 9116 (a) (1.2).] 1• Lynne C. Jackson, 82 Fairway Dr, Camp HiH PA 17011 daughter 50°10 2. Carla C. Malingowski, 2420 Locksley Ct., Fairbanks, AK 99709 daughter 50% ENTER DOLIAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 19 OF REV•1500 COVER SHEET, AS ~ NON TAXABLE DISTRIBUTi0N5 A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 8. 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. M LAST WILL AND TESTA-1VIENT OF 1TINAIMI71 8. COOF80x I, VIRGINIA N. COOKSON, of Lower Allen Townshg,l, Cumberland County, Pennsylvania, make, publish and declarel this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FZ~BT: i devise and bequeath all the rest, resi~ius and remainder of my estate of whatever nature and wherever sit~iate, including any property over which I hold power of appointment and together with any insurance policies thereon, in equal shades, to my children, •V. LYNNE JACKSON and CARLA LEE I~ALINGOWSKI, p~ovided that should any of my children predecease me, I give and'b~queath ,• such child's share unto her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such ' deceased child's share to my surviving child a8 provided herein. SEOOND: .Should any of my grandchildren not have ~! attained the age of twenty-two (22) years at the time for d~.s- tribution to him or her, I give, devise and bequeath the sh re of each such grandchild to my hereinafter named Trustee or Trtx tees, • IN SEPARATE TRIISTS, to hold, manage, irrvest and reinvest th~ hares so received, and to use and apply from time to time such portion of income and principal for the said grandchild's education (including college, trade school or other similar' training or education), as my Trustee or Trustees, in their prole discretion, deem advisable. Any income or principal not so applied shall be dish- tributed to each grandchild when he or she attains the age o~ twenty-two (22) years. In the event any of my grandchildren' predeceases me or dies prior to the termination of this Truett, I ~ give and bequeath such grandchild's share unto their issue peer stirpes by representation, and if there be a failure of same,, the. 1 interest of said grandchild in said Trust shall cease with any i income and principal being divided evenly between or ampng my other grandchildren or the separate trusts established'~ereunder for their benefit. ~' In addition to all powers granted to'~ ..law and..by..otherprovisions of this. Wills I give.. the fic~ acting hereunder the following powers, applicable to al ty, exercisable without court approval and effective u distribution, of all property: (A) To sell at public or private sale, or to ~ for any period of time, any real or personal property at~~ options for .sales, exchanges or leases, far such prices such terms (including credit, with or without security} by proper- it actual Boa, to give d upon ^. conditions as are deemed proper. This includes the powa~ to give `' legally sufficient instruments for transfer of the prope~ty and ;-. to receive the proceeds of any disposition of it. ~~ {B) To partition, subdivide, or improve real state and to enter into agreements concerning the partition, s ivi- sion, improvement, zoning or management of real estate aria to ..,impose or extinguish restrictions on real estate. ~~~ ~, (C} To compromise any claim or controversy andlty ,~ abandon any property which is of little or no value. {D} To invest in all forms of property, includ~ng stocks, common trust funds and mortgage investment funds,'~;without restriction to investments authorized for Pennsylvania fi,c~.ici- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To .exercise any option, right or privilege'~ranted in insurance policies or in other investments. {F) To exercise any election or privilege givemlby the Federal and other tax laws, including, but not necessarlxjbeing limited to, personal income, gift and estate or inheritanc~e~ tax laws. (G) To make distributions to my herein named be~lefici- aries in cash or in kind or partly in each. (H) To borrow stoney from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, andl,for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employe stock ownership plan, or any other type of qualified plan)'to the extent the plan or the law permits them to do so, and to ~*ercise any other rights which they may have under the plan, in whi~tever manner they consider advisable. ' Dlp ~: I nominate and appoint V. LYNNE JACKSON, as Trustee of the hereinabove described trusts. In the eventjof the death, resignation or inability to serve for any reason wha~- soever of the said V. LYNNE JACKSON, I nominate and appointlmy granddaughter, DEBORAR J. JACIGSON, as Trustee of the herein~bove described trusts. I direct that my Trustee shall serve wit~out bond and shall receive fair and reasonable compensation. ~~: I direct that all inheritance, estate, tr~ns- fer, succession and death taxes,. of any. kind whatsoever, wh~.ch may be payable by reason of my death, whether or not with r~spect to property passing under this Will, shall be paid out of tie principal of my residuary estate. : I nominate and appoint V. LYNNE JACKSON at~d CARLA LEE NALINGOWSRI, or the survivor thereof, Co-Execut~rixles of this, my Last Will and Testament. I direct that my Co- Executrixes, and their successors, shall not be required to ~ost security or a bond for the performance of their duties in afi~r jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand auc~ seal to this, my Last Will and Testament, this -L ~ day of y , 199? . 1.r ' , / _ Ji .~ Z!~ I l , ~~%• , f,/ '~ ~S .' (SEAL) VIRGIf~ A H. COORSON -- 3 . s Signed, sealed, published and declared by the a~ove- named Testatrix as and for her Last will and Testament-in,lour presence, who, at her request, in her presence and in the' presence of each other, have hereunto subscribed our names'~as attesting witnesses. Address Address f ~ r>,, f i r • ! ~~ M~ ,RUST THIS TRUST AGREEMENT' is executed in triplicate on this ~~ay o~ 7uly, 2002, by andbetweea ViRGiNiA S. CDOKSON, now of Bethany Towers, 335 Weal' Drive, #417, Mo~nicsbw~g, Cumberland:County, Pennsylvania 11055 (1-ereinaftcr called" and VIRGII~IIA H. COOli~30N, now of Bethazry Towels, 335 Wesley Drive, #417, 'csburg, Cumba~land County, Pennsylvaas.17055, LYNNE JACKSQN, now of 747 Club Road, Camp Dill, Cumberland County, Pennsylvania 17011 and CARLA hiALIIY SICI, s~rv of 13527 P'aut Cota#, Woodbridge, Y 22 h43 teach jciistly or mail ' ha+eina#~ar called "Trustee"}. ARTICLE L TRUST ESTATE 1.01. ~~ Sdtlcsc, g to establish. as imvoeable trust, hereby irncvocably transfrr, ffisign and deliver to the Trustee sad its successors, and assigns the seeds listed oa Schedule A, attached herdA sell made a part hereof. As furdies evidence o such aagignmeat, the Sdtlor has eaccuted or will execute or cease to be a~ecatod such o instruments as may be required for the purposes of completing. the asaigom4art or er of title to such ~operty to the Trustee. The Trustee accepts such transfer and assignment itself as Trustee, and u to hold, manage, invest and ieirivcat the seeds of due Tivst, to distn'bute the incame sell principal of the Trull in accordance with the pravisioas a~ ' Agx+aement. 1.02. ~' ~. The Settler and any othez person or persons, the oenaeat of tl;e Taae~ec, ~ have the rigor at any time to malre additiaen Ott the of t,~ Trust or any share thereof hereby established. All such additions shall be held„ gov and distributed by the Trustee in accordaacae with the teams and conditions of Chia AgreR~'m The Trustee, in its sole discxction, may require, as a prerequisite to accepting 'P~p~y~ tha the transferring party provide evideacc satisfactory to the Trustee that {i} the prapeity is n contaminated by say hazardous or toxic materials or substances; sell {ii} the property ' net being used and has never beta used for any activities directly or indirectly involving the ' a, use, treaameat, storage, disposal, release or discharge of any hazardous or tout or substances. 1.03. ~. The Trustee shall have the right to disclaim, in whole or is part, prior tq its acceptance by the Trustee; any iniexrsts in p~raperty for any reason, including. bat not limited to a coaceen that such property could catfse potential liability under any fCdesal, state, or local envicvnmental law. ARTICLE IL IRREVOCAEILTI['Y OFTRUST Z.01. I~evoeibililr-. Settler has beer- $dvised of the consequences of an irrevocable feast and hereby declares that this Tntst shall be irrevocable and shall not be altea~ed, amended, revoked, or Uerminated by Settlor or any other person or parsons. ARTICLE IIL LIFE INSURANCE POLICIES 3.01. If any insuunace policies are transferred into this 'Vast, the ~ Tivstee shall be vested with all right, title, and interest in and to the tcansferr~od. polices of i~smnace, and is authorixcd and empowered tD eacte+cise and enjoy, for the parposes of the Tn~ herrdn creatod and as absolute owner of such policies of ins~tunuce, all the. options, benefits, right and privileges wader such policies, including the right to bormw upon sad to pledge them fora , loan or loans. The Trastee takes alt rights, title, and interest in and tin the shave stated inatuance~ policies subject to any prior flit-dollar life icx agnean~k and assignments, wl~ioh maybe 'I is effect at the time of transfer. The insurance companies which have rued pe-licies are h~Y autho~izod and dnrected to racoguiu the Trustee as absolute owner of such policies of ~ '~, and sa fiilly entidod to all options, rights, privileges, and iat+erests under such policies, and aay recdpns, releases, and otluer insttvmetrta earecuted by the Trustee in connection wig such pahcies '~ shall be bindjag upon all paasons interested in this Trust. The Setttor hereby relinquishes all rights, tit1G, interest sad powers in such policies of insurance which Settlor may own and which sights, title, interest aadpowers-are not assignable, and will, at flu request of the Trustee, eacetartel all othex instruments reasonably required to effectuate this relinquishment. j 3.02. .The Trustee shall be under no obfigatian to pay the praniums which may become doe and payable under the provisions of any policy of insurance which may be traas~'ared or assigned to this Ti ust, or to make certain. that such premiums are paid by the transferor of such policy, or to notify attypersons of the nonpayment of sack Tx~iums, and the'I'ivstCt shall be under no respanaibility or liability of any kind in case such premiums are not paid, accept the 'T`rustee shall apply any dividends received on stub policies to the payment of premiums thereon. Upon notice at anytime during the continuance of this Trust that the premiums doe upon such policies are in default, err that premiums which. will became doe will not be pasd, either by the transferor or by any other person, the Trustee,. within its sole discretion, may apply any cash values attribatable to sash policy to the purrltaae ofpaid-up insurance err of eateaded insurance, or may borrow upon such poficy for the payment of premiums due thereon, or may accept the cash values of such policy upon the policy's forfeiture. 2 (3) Ta retain far investment any property deposited with the Trustee hereunder. (4) To vote in person or by proxy any corporate stock or other security and to agree to or take any other action in regard to any reorganization, merger, consolidation, liquidation, bankruptcy or other procedure or proceedings affecting any stock, bond, note ar other security held by this Trust. (5) To use lawyers, real estate bmkers, accountants and any other agents, if such employment is deemed necessary or desirable, and to pay reasonable compensation far their services. (6) To compromise, settle ar adju~ nay claim or demand by or against tl~e Trust a~ to agree to any rescission or modification of any contact or agreement affecting the Trust. ('7) To renew any indebtedness, as well as to bormw money, and to secure the same by mortgaging, pledging or conveying any Property of the Trust, including the power to borrow fmm the Trustee (in ttu Trustee's individual capacity) at a reasonable rate of interest. (8) To retain any business interest transferred to the trustee, as shareholder, security holder, creditor, partner or otherwise, for any period of time whatsoever, even though the interest may constitute nit or a large portion of the trust principal; to comply with the provisions of any agreement restricting transfer of the interest; to participate in the conduct of the related business or rely upon others to do so, and to take or delegate to otlu;rs discretionary power to take any action with respect to its management and affairs which an individual could take as outri~t ou~or of the b ar the business iuteeest, including ttre vx~tiag of stack (by strparate trust or otherwise regardless of whether that sepaZate trust will extend for a term within or beyond the term of the trust) and tl~ determination of ail questions of policy; to execute and amend partnership $greements; to participate in any incorporation, reorganization, merger, consolidation, sale of assets, recapitalization, liquidation or dissolution of the business, or any change in its nature, or in auy buy-sell, stock restriction, or stock redemption agi~eements; to invest in additional stock or securities of, or make secured, unsecw~ed, or subordinated loans to, the business with trust funds; to take all appmpriate actions to prevent, identify, or respond to actual or threatened violations of any environmental law or regulation thereunder, to elect or employ with compensation, as directors, officers, employees, or agents of the business, any persons, including a trustee of any trust held under this instrument, or any director, officer, employee, or agent of a corporate trustee of any trust held under this instrument, without 5 adversely affecting the compensation to which that trustee would otherwise be entitled; m rely upon reports of certified public accountants as to the opetntions and financial condition of the business, without independent investigation; to deal with and act for the business in any capacity (including in the case of a corporate trustee any banking or trust capacity and the loaning of money out of the trustee's own funds) and to be compensated therefor; and to sell or liquidate the business or any interest in the business. - (9) To register any stock, bond or other security in the name of a nominee, without the addition of words indicating that such security is held is a fiduciary capacity, but accurate records shall be maintained showing that the stock, bond or other security is a trust asset and the Trustee shall be responsible for the acts of the nominee. (10} To set aside as a separate trust, to beheld and administered upon the same terms as those governing the remaining trust property, any interests is property, for any reason, including but not limited to a concern that such property could cause potential. liability under any federal, state, or local environmental law. B. VVturaever the Trustee is directed to distribute any trust principal m fee simple to a ' person. who is then under twenty-one (21) years of age, the Trustce shall be authorized fio hold such property in trust for such person until he becomes twenty-one {21}years of age, and in the ' meantime shall use such part of the income and the principal of the trust as the Trustee may deem necessary to provide for the proper support and education of such person in the standard of livusg to which he has become accustomed. If such person should die before becomingtwenty-one {21) years of age, the property then remaining in trust shall be distributed to the persa~nal representative of such person's estate. C. m maiaug distributicros f~ fine 'I'svst to or for the benefit of any tmnc~r or ate person under a legal disability, the Trustee need not require the appointment of a guardian, but shall be authori~od to pay ar deliver the distribution to the custodian of such person, to pay or deliver the distribution to such person without the intervention of a guardian, to pay or deliver the ~~, distribution tp the legal guardian of such person if a guardian has already been appointed, or to '~ use the distribution for the benefit of such person. D. In the distribution of the Trust and any division into sw~rate trusts and shorts, the Trusi~ee shall be authorized fio make the distribution and. division in money or in kind or in both, regardless of the basis for income tax purposes of any property distributed or divided in kind, cad the distribution and division made and the values established by the Trustee shall be binding. and conclusive on all persons taking hereunder. The Trustee may in making such chstn'butioa or division allot undivided interests in the same property to several trusts or shares. 6 _ _ _. E. If at any time after Settler's death the total fair market value of the assets of any frost established ar tci be established 1~~ is sv small that #Ite corporate Tr+rs~ee's Brutal foe for administering the trust would be equal to or less that the minimum annual fee set forth in the Trustee's regularly published fee schedule, then the Trustee in its discretion shall be authorized to terminate such trust or to decide not to establish such trust, and in such event the property then held in or to be distributed to such trust shall be distributed to the persons who are then or would be entitled to the income of such trust. If the amount of income to be received by such persons is to be determined in the discretion of the Trustee, then the Trustee shall distribute the property among such of the persons to whom the Trustee is authorized to distribute income, and in sucb proportions, as the Trustee in its discretion shall determine. F. The Trustee shall be authorized to lend or borrow, including the right to lend to or borrow from the Senior's estate, at an adequate rate. of interest and with adequate security and... upon such terms. and conditions as the Tnistee she11 deem fair and equitable. G. The Trustee shall be authorized to sell or purchase, at the fair market value as determined by the Trustee, any property to or from Settler's estate, or any trust created by Settler', during life <x by will, evert tltcwgh the same perm or corporation may be acting as executor of Settler's estate or as trustee of any other such mists and as the Trustee of this Trust. H. The Trustee shall have discretion to determine whether items should be charged or credited to income or principal or allocated between income and principal as the Trustee may deem equitable and fair under all the circwnstances, including the power to amortize or fail to amortize any part or all of any premium or discoun, to treat any part or all of the profit resulting from the maturity or sale of any asset, whether purchased at a pn~nium or at a discount, as income or principal or apportion the same between income and principal, to apportion the sales price of any asset between income and principal, to treat any dividend or other distribution on any investment as income or principal or to apportion the same between income or principal, to charge anp expense against income oz principal or apportion the same, and to provide or fail to provide a reasonable reserve against depreciation or obsolescence on any asset subject to depreciation or obsolescence, all as the Trustee may reasonably deem equitable and just under alI of the circumstances. 5.02. ~~ Trustee. ant ~ authority and power carder this Tnust is vested in two (2) or more Trustees or Co-TnrsDees, the authority and powers are to be jointly by the Trustees or Co-Trustees. A majority of the Trustees or Co-Trustees may exercise any authority or power granted under this Trust Agreement or granted by law, and may act on behalf of the Trust. Any attempt by one such Trustee to act for the Trust on other than ministerial acts shall be void. The action of o~ such Trustee on behalf of the Trust may be (but need not be) validated by s subsequent ratiScation of the act by a majority of the Trustees or Co-Tn>stees. 7 ARTICLE VI. SPENDTHRIFT PROVISION h.01. Genera! Provision. No beneficiary shall have the power to anticipate, encumber or transfer his interest in the Tn~st Estate in any manner other than by the valid exercise of a Power of Appointment. No part of the Trust Estate shall be liable for or charged with any debts, contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditd-r of a beneficiary. ARTICLE VIL CONSTRUCTION OP` TRUST 7.01. Choice. of Law. This Trust shall be administered and interpreted in accordance with the laws of the Comanonwealth of Pennsylvania. ?.02. Wig. Unless otherwise stated, all references in this Trust to section and eha~pter numbers arc to those of the Internal Revenue Code of 1986, as amended, or corresponding provisions of any subsequent federal tax laws applicable to this Trust. 7.03. Oar Terp~. Unless the context otherwise requires, the use of one or mare genders in the text includes all other genders, and the use of either the singular or the plural in the text includes both the singular and the plural. 7.04. Ca~ioa~ The captions set forth in this Agreement at the b'8 of the various divisions hereof att far convenience of reference only and shall not be deemed to define or limit I the provisions hereof or to affect in any way their construction and application. 7.OS. Sites of Trust. The Trust shall have its legal situs in Cumberland County, Pennsylvania. ARTICLE VIII. COMPENSATION OF TRUSTEE AND APPO1lhiTMENT OF SUCCESSOR TRUSTEE 8.01. C aneasstion The Trustee shall receive as its compensation for the services performed laneunder that sum of money, based on as hourly charge or percentage rate, which the Trustee normally and customarily charges for performing similar services during the time which iR ~I, performs these services. 8.42. ~tesoval of Trastee. Senior may remove the Trustee, at anytime or times, with or without cause, upon thirty (30) days written rmtice given to the current Trustee. Upon the death of the Settlor, a majority of the current beneficiaries may remove the Trustee, at any time or times, with or without cause, upon thirty (30) days written notice given to the Trustce. Upon the 8 removal of the Trustee, a successor Trustee shall. be appointed in accordance with the terms set forth in Paragraph 8.03. 8.03. ~.gpointanent of Successo,~ sru tee(sl. The Trine may resign at any time upon thirty (30) days written notice given to the Settlor if Settlor is living, or in the event of Settlor's death, upon thirty (30) days written notice given to the current beneficiary or beneficiaries (including a beneficiary's natural or legal guardian or legal representative), hereunder. Upon the death, resignation, removal or incapacity of the Trustee, a successor trustee tray be appointed by the Settlor during Settior's lifetime, or, after Settlor's death, by a majority of the current income beneficiaries. Unless otherwise designated, the successor trustees shall be LYNNE JACKSON and CARLA MALINGOWSKI, or the survivor(s) of them, to act jointly or individually. Any ', successor trustee thus appointed, or, if the Trustee shall merge with or be consolidated with another corporate fiduciary, then such corporate fiduciary, shall succeed to all the duties and to all the powers, including discretionary powers, herein granted to the Trustee.. ARTICLE IX. PERPETUITIES CLAUSE 9.01. ~~ Provision. Notwithstanding anything to the contrary in this Trust, each disposition I have made here, legal or equitable, to the extent it can be referred in its postponement of becoming a vested interest to a duration measured by some life or lives in beingi at the time of my death is definitely to vest in interest, although not necessarily in possession, not', laterthattwenty-one (21) years after sash lives (and any period of gestation involved); or, to the '~ .extent it cannot be refen~ed in any such postponemen to such lives, is to so vest not later than twenty-one (21) years from the time of my death. ARTICLE X. ACQUISITION OF UNITED STATES TREASURY BONDS ELIGIBLE FOR TAX PAYMEIYT,• PAYMENT 4F TAXES, FiJl*TEItAi. EXPENSES, AND EXPENSES OF ADMINISTRATION 10.01. AA~q~~i~+~n of Bonds. The Trustee may, at any time, without the prior approval or direction of the Settlor and whether or not the Settlor is able to manage Settlor's own ailairs, acquire United States Treasury Bonds selling at a discount, which bonds are redeemable at their par value plus accrued interest thereon for the purposes of applying the proceeds to the payment of the United States estate tax on the Settlor's estate; and the Trustee may borrow from any lmxler, including itself, with or without security,. to so acquire these bonds. l0.OZ. Payment of United States Eat#e T:x by Boad Redemption. The Settlor directs that any United States Treasury Bonds which may be redeemed at their par value plus accrued interest thereon for the purpose of applying the proceeds to the payment of the United 9 Mates estate tax imposed on the Settlor's estate, and which are held by the Trustee, shall, to the extent of the amount determined to be required for payment of the estate tax, be distributed. to the legal representative of the Settlor's estate to be used by the legal representative ahead of any other assets and to the fullest extent possible to pay the estate tax. 10.43. Payment of Death Taxes send Other Esbte Settlement Costa. After the Trustee has complied with paragraph 10.02, above, and ascertained from the legal representative that all such bonds have been redeemed in payment of the United States estate tax, the Trustee shall also' ascertain from the legal representative whether the legal representative has sufficient assets to pay the remaining legacy, succession, inheritance, transfer, estate and other death taxes or duties rexcept the additional estate tax imposed by Section 2032(c), or corresponding provisions of the !r-temal Revenue Code of 1986 applicable to the Settlor's estate and imposing the tax) levied or asseseed against the Settler's estate (ia~uding all ~ and penalties tom), ail of why faxes, interest and penalties are hereafter referred to as the death taxes, interest and penalties. ff "rhe legal representative advises the Trustee that insufficient funds exist. to pay all the death taxes, interest and penalties, the Trustee shall then pay to the legal representative from the trust nvperty, an amount equal to all the death taxes, interest and penalties in excess of the funds available to the legal representative for this purposes, which payments are to be made without ~,portionment. In making the payments, the Trustee shall use only those assets or their proceeds .xhieh are includable in the Settlor's gross estate for purposes of the United States estate tax and shall not impair the marital portion without first exhausting the entire non-marital portion. If the Executor of the Settlor's estate, in such Executor's sole discretion, shall determine that appropriate assets of Settlor's estate are not available in sufficient amount to pay (1) the S~ttlor's funeral expenses, and (2) expenses of administering the Settlor's estate, the Trustee shall, upon the request of the Executor of the Settlor's estate, contribute from the principal of the trust estate the amount of such deficiency; and in connection with any such action the Trustee shall rely , upon the written statement of the Executor of the Settlor's estate as to the validity and correctness of the amounts of any such expenses, and shall furnish funds to such Executor so as to enable such Executor to discharge the same, or to drscilarge any part of all thereof itself by making petymem directly to the person entitled or claiming to be entitled to receive payment thereof. No consideration need be required by the Trustee from the Executor of Settlor's estate for any disbursement made by the Trustee pursuant hereto, nor shall there be any obligation upon such Executor to repay to the Trustee any of the funds disbursed by it hereunder, and all amounts ehsba~ed by the Trustee pursuant to the uutl3arity l>ereby con£err~ad upon it shall be disbiu~ed without any right in or duty upon the Trustee to seek or obtain contribution or reimbursement fran any person or property on account of such payment. The Trustee shall not be responsible for the application of any funds delivered by it to the Executor of the Settloi's estate pursuant to the authority herein granted, nor shall the Trustee be subject to liability to any beneficiary hereunder on account of any payment made by it pursuant to the provisions hereof. 10 IN WITNESS WHEREOF, the Settlar and Trustees} have hereunto set their hands and seals as of the day and year first above written. WITNESS: ~z COMMONWEALTH OF PENNSYLVANIA U` ~ ~ ~.1~ (SEAL) VIRy~- t~~ H. COOKSON, SET'I'LOR SS: COUNTY OF CUMBERLAND On this, the ~ day of July, 2002, before me, a Notary Public, the undersigned officer personally appeared VIRGINIA H. COOKSON, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within Trust Agreement, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, T have set my hand an cial Seal. Notary Public My Commission Expires: t~lotww sew ~ ~0. CUn~d My Conx~+rssbn E Jaet. 20 11 The foregoing Trust Agreement was delivered, and is hereby accepted, at Lemoyne, .Pennsylvania, on July ~, 2042. WI1`NESS: r' VIRGI ~I. COOKSON, TRUSTEEi . ~sEA~.h LY dA N, TRUSTEE ~-- CARLA SKI, TRUSTEE 12 SCHEDULE"A" SCHEDULE REFERRED TO IN THE ANNEXED TRUST AGREEMENT DATED: JULY I ~ , 2042 FROM VIRGIIVIA H. COOKSON, SETTLOR TO VIRGII~tIA A. COOKSON, LYNNE JACKSON, and CARLA MALINGOWSKi, TRUSTEE(S) PROPERTY DESCRIPTION: ', 13 Final Expstaes Vlrglnia H. Cookson 2010-00108 Furwral and t>ecedsnt's Funeral Admin Admin Dsbts Expenses Probate Attorndy Other Total Sch H Sch I Pa Dept of Rev, 09 tax 178.00 178.00 Crestview Cemetery 175.00 175.00 175.00 175.00 Organist 75.00 75.00 75.00 75.00 Pastor 200.00 200.00 200.00 200.00 Register of wills 277.50 277.50 277.50 277.50 Auer Cremation 157.00 157.00 157.00 ' 157.00 SSPC memorial service food 111.30 111.30 111.30 111 30 Gates, Halbruner, Hatch attorneys . for trust 162.00 162.00 162.00', 162.00 Register of wills Debbie Jackson 62.59 62.59 62.59 ' 62.59 Lynne Jackson reimbursement 452.25 452.25 405.31 46.94 452.25 Carla Malingowski reimbursement 1,056.24 1,056.24 269.81 788.43 1,056.24 Refund, Country Meadows (2.63) (2.83) ~, _ Refund, insurance (45.00) (45,00) 2,859.25 2,728.88 130.37 Additional: Gates, Halbruner, Hatch attorneys 40.50 40.50 40.50 ' 40.50 Cumberland Law Journal 75.00 75.00 75.00 75.00 Paxton Herald 48.00 48.00 48.00 48.00 Estate account broker fee 125.00 125.00 125.00 125.00 James Boger, attorney (will) 125.00 125.00 125.00 ', 125.00 Register of wills, probate fee 50.00 50.00 50.00 ' 50.00 Estate tax filing fee 15.00 15.00 15.00 15.00 3,337.75 3,207.38 130.37 1,456.01 327.50 327. 1,096.37 3,207.38 3,337.75 ~~ Probst fees letters 210.00 will 15.00 short oerti}icates 24.00 JCS fee 23.50 ' auto fee 5.00 . Paid Feb 2010 277:50 add'1 per Uc 9115 50.00 327.50 Estate tax filing fee 15.Q0 ~® • incudes burial trip expenses from funeral to burial site (456 miles round trip), funeral supplies, executor travel, postage ••incudes travel from Alaska to Pennyslvania (air and auto rental) for funeral and estate executor matters, burial site trip, and misc supplies 214 Senatc Ave 7th Floor Camp Hill, PA 1701 I tel 717 730 1800 fax 717 730 1894 toll free 800 237 1700 Date of Death Valuation Estate of Virginia H. Cookson As of 01/19/2010 3vmboflCUSIP Description GDI GARDNER DENVER INC ROSA "*" ROYAL DUTCH SHELL PLC ADR CBE "'" COOPER INDUSTRIES PLC CASH ACCOUNT BALANCE ~ ETSIX EATON VANCE STRATEGIC INCOME #BDP BANK DEPOSIT PROGRAM Totals Quantity 102.Q0 128.00 896.00 4,998.91 11,093.95 ~' L 42.99 ~ ~~, 60.95 43.34 8.12 11,093.95 Total Value 4,384.980 .7,801.800 38,832.640 40,591.150 11,093.950 102,704.220 Morgan Stanley Smith Barney LLC and its affiliates do not provide tax or legal advice. To the extent that this; terial or any attachment concerns tax matters, it is not intended to be used and cannot be used by a taxpayex for the of avoiding penalties that may be imposed by law. Any such taxpayer should seek advice based on the taxpayer's 'cuhlr circumstances from an independent tax advisor. The information set forth was obtained from sources believed to be reliable, but we do not guarantee its accuraey or completeness. Past performance is no guarantee of future results. Morgan Stanley Smith Barney LLC. Member SIPC. MorganStanley SmithBarney SNE {NfoRMAT1C>N HEREiN ~ HAS SEAL. C-BTAINE© l:ROM SOURCES WI'E gEIiEVE~ TO BE REtIABIE, BUT 00 NOT ~lARANTEI* iTS ACCURACY OR COMPtJET~t+~SS- Morgan SranleySmirh Barney LLC. Member SIPC. 25-0970727 ~,,;,,r 08!31110 GROVE CITY AREA FCU 1 CREDIT UNION WAY GROVE CITY PA 16127 TEL: 724-458-7520 STATEMENT PERIOD 10/01/09 08/31/10 CN/ACCOUNT# 1/ 4458.0 VIRGINIA H. COOKSON C10 LYNNE JACKSON SOC^SEC-NUM 747 COUNTRY CLUB ROAD +a+_+*_+4r+ CAMP HILL PA 17011 TRAN TRAM TRANSACTION CHK k TRAM INT/INS ACCOUNT ', NUM DATE TYPE AMOUNT AMOUNT BALANCE Share $ 1 PRIMARY SHARE Beq Bal: 4,315.64 40191 10/01/09 DIVIDEND 10.88 9,326.52 10101/09 TERM: 92 DAYS AVERAGE DAILY BALANCE: 4,315.64 ~' 327 01/O1/10 DIVIDEND 10.91 9,337.43 191432 03/02/10 DEPOSIT 1,872.16 6,209.59 191437 03/02/10 WITHDRAWAL 3,104.80 3,109.79 191439 03102/10 WITHDRAWAL 3,109.79 0.00 Div Paid YTD 10.91 Last Div Rate 1.00008 Tot Div Paid YTD 10.91 Finance Charge YTD 0.00 PG 1 ~tANSA11~iERICA LIPB INSUASNCB COIL?ANY ~/0[eaLe C.OtapeII7 4333! ~d8errood B:oad NB pQ . 3183 Cedatapide, Iowa 52406-3183 February 3, 2010 Carla C Malingowski 2420 Locksley Ct Fairbanks AR 99709. (`~ ~~~ oaf s~ ,F~r ~~~ ~-, `jam°n R=: 7-aniiity ~usber(s) OZp800Z039s h liear c>ar~ia -c- r~rngows~~ : _ _, . _ , _ A check for $53,469,94, representing tie full and final d~'th benefit payment for the above lsted`non-qualfied'tax deferred. uity, has been sent to you. Next January, you will receive a Form 1 99'-R reporting this distribution as follows: Gross Distribution: $53,469.94 X ~1e Taxable Portion: $ 969.94 Federal Withholding: $ 0.00 State Withholding: $ 0.00 .Transamerica Life Insurance Co snot give legal, tapc or mpany doe .accounting advice: You may wish to consult your own attorriMey, accountant, or tax advisor with questions or specific poinlt~ of interest to you. Any additional questions regarding this annuity can be directed to the Annuity Service Center at 1-800-238-4.311. A Transamerica Life: Insurance Company representative will gladly assist you wit any questions you may have regarding this annuity and help you Meet your financial goals. Sincerely, C~-U ~„~ Amy Jacob Transamerica Life Insurance Company Claims Member of the r.Gconp