HomeMy WebLinkAbout11-17-10 (3) 1505610140
REV-1500 ~` ~°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Buroau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
PO BOX 280601
2 1 1~ 0 3 8 0
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date Of Death MMDDYYYY Date of Birth MMDDYYYY
1 9 2 1 4 6 4 3 4 0 3 2 6 2 0 1 0 0 3 1 9 1 9 2 5
Decedent's Last Name Suffut Decedent s First Name MI
S H R A W D E R H E N R Y L
(If Applicable) Enter Surviving Spouse's Information Befow
Spouse's Last Name Suffix Spouse's First Name ' MI
S H R A W D E R H E L E N
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE'V~I ITW THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW i
0 1. Original Retum ^ 2. Supplemental Return ^ 3. Remainder ~ etum (date of death
prior to 12-1 -82)
^ 4. Limited Estate ^ 4a. Futuro Interoat Compromise (date of ^ 5. Federal Esta} e Tax Retum Requirod
death after 12-12-82)
® 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust ~ 8. Total Numbe~ of Safe Deposit Boxes
(Attach Copy of Wiiq (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. Election to ta~ C under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attact- Sch. )
CORRESPONDENT -THIS SECTION MUST t3E GOMF'LE I tD. ALL GOKKESPONUtNGt ANO GONFIDtN I IAL I Ax RtF VKNUI I ION SHt7ULU Bt UIKtGI tU I U:
Name Daytime Telephone Number
H O W A R D B K R U G E S Q U I R E 7 1 7 2~ 4 4 1 7 8
First line of addross
1 7 1 9 N O R T H
Second line of address
City or Post Office
H A R R I S B U R G
Correspondents e-mail address: hkrugCcDpkh.com
State ZIP Code L
P A 1 7 1 0 2
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S:7
ILLS USB~NLY x
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FILED
Under penalties of perjury, I declare that I have examined this return, inducting accompanying schedules and statements, and to the best my~knowledge and belief,
it '~ true, correct and canplete. Declaration of preparer other than the personal representative is t-aaed on aN information of which prepare has any knowledge.
SIG ^ OF PERSON P NSiBLE FOR / ~ ~/D
ADDRESS
63 LITT RU OAD CAMP HILL P~A'~ 17011
N TU REP ER ER THAN REPRESENTATNE ATE
n - - ~l-,, ,?0~0
1719 N~ORTH~FRONT STREET HARRISBURG P~ 17102
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 150561014b J
~,
F R O N T S T R E E T
REV-1500 EX Deoedent's Social Security Number
Decedent's Name: HENRY L• S H R A W D E R 1 9 2 1 4 6 4 3 4
RECAPITULATION ',
1. Real Estate (Schedule A) ........................................... 1
2. Stocks and Bonds(Scheduie B) ...................................... 2•
3. Closely Heid Corporation, Partnership orSole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .......................... 4.
4 D ~ 0 D 0 . D D
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 Ng~Probate Property
ted
Billi
R
t
S
7 b 7~~ 3 3 5 7 ?
.......
eques
ng
epara
e
(Schedule G) u .
8. Total Gross Assets (total Lines 1 through 7) ........................... B. 4 ? '',2` 3 3 5 • 7 7
9.
Exp ( ) ..................
Funeral enses and Administrative Gosts Schedule H 9. ~, 4 5~~, 9 1 9 . 5 ~
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. '
11. Total Deduct[ons (total Lines 9 and 10) ......................... ...... 11. 1 4 5j 9 1 9 . 5 7
12.
..
Net Value of Estate (Line 8 minus Line 11) ....................
......
12.
3 2 61 4 1 6 • 2 0
13. Charitable and Governmental BequestslSec 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 2 6', 4 1 6 . 2 0
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 .oo_ 3 2 6 4 1 6. 2
0
15.
O.
D
0
16. Amount of Line 14 taxable
0
D
0
D.
0
D
.
at lineal rate X .0 _. 16.
17. Amount of Line 14 taxable
0
D
0
17
0.
D
D
.
at sibling rate X .12 .
18. Amount of Line 14 taxable
0. 0
D
18
D.
D
D
at collateral rate X .15 .
19. TAX DUE ....................
........................... ...... . 19. 0 • D D
20. FILL tN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
15D561024D 150561D241p
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 10 0380
DECEDENTS NAME
HENRY L. SHRAWDER
STREET ADDRESS
63 LITTLE RUN ROAD
CITY
CAMP HILL STATE '
PA ' ZIP
17011
Tax Payments and Credits:
~• Tax Due (Page 2, Line 19) (1) 0.00
2. Credits/Payments ~
A. Prior Payments 0.00
B. Discount
Total Credits (A + B) (2) ' 0.00
3. Interest i
(3)
4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) I 0.00
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPRQI~RIATE BLOCKS
1. Did decedent make a transfer and: Y No
a. retzdn the use or income of the property transferred : ......................................................................
b. retain the right to designate who shall use the property transferred or its income; ...............................
c. retain a reversionary interest; or ................................................................................................
d. receive the promise for life of either payments, benefits or care? .......................................................
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... 0
3. Did decedent own an "in mist foi' orpayable-upon-death bank account or security at his or her death? ......... X^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a benefiaary designation? .................................................................................................. ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT A~S 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 f~r the use of the surviving spouse
3 percen# [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 require ents 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, eycdept as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j.
• 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. §91160)(1.3)). A sibling 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-1508 EX + (6-98)
SCNEDWLE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC.
IN RES~DENT DECEDEN RN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
HENRY L. SHRAWDER 21 10 0380 i
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jointly-0wned with right of survhrorship must be diubssd on Schaduk F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Traveler's Insurance Company third party settlement (personal injury action) 305,000.00
See attached invoice.
2. Traveler's Insurance Company underinsurance settlement (personal injury action) ', 100,000.00
See attached invoice.
I
TOTAL (Also enter on line 5, Recapi~latior~) I S
(If more space is needed, insert addfionai sheets of fhe same size) ~T_
- REV-1510 EX+ (OB-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OF
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
HENRY L. SHRAWDER 21 10 0380'
This schedule must be completed and filed 'rf the answer to any of questions 1 through 4 on page three of the REV-15b0 ~is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAMEDFTHETRANSFEREE,THEIRREL4TIDNSHIPTODECEDENTAND
THE DATE OF TRANSFER.ATTACHACDPYOFTHEDEEDFDRREALESTATE
DATE OF DEATH
VALUE OF ASSET
%OFDECD'S
INTEREST
~ EXCLUSION
pP~Pruc~El
TAXABLE
VALUE
1, Hartford Annuity Contract #990962401 67,335.77 100.00 0.00 67,335.77
See attached Hartford Life letter.
I
i
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~~
I
TOTAL Also enter on Line 7, Recapitulation 67 335.77
it more space Is r~eetletl, use atltliitieonal sheets of paper of the same size.
REV-1511 EX+ (10-09)
Pennsylvania SCHEDULE H
pEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RE5IDENT DECEDENT
ESTATE OF FILE NUMBER
HENRY L. SHRAWDER 21 10 0380
Decedent s debts must Ise reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoover-Boyer Funeral Home 8,011.26
2. Elizabethville Monument Company (headstone) 1,978.00
B. ADMINISTRATIVE COSTS;
t. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Addn~s
G;~y State ZIP
Year(s) Commission Paid:
2 Attorney Fees:
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address -
City StaUe ZIP
Relationship of Claimant to Decedent
4. Prorate Fees; Cumberland County Register of Wills 93.50
5 Accountant Fees:
6. Tax Return Preparer Fees:
7. Cumberland Law Joumat (advertising) 75.00
8. The Sentinel (advertising) 219.40
9. Personal Injury expenses
Attorney's Fees 135,000.01
Hershey Medical Center (obtain medical records) 284.73
UPS charges (sending medical records to adjuster) ~ 31.52
Photo copying fee (medical records) 106.73
Petition to Approve Settiement (filing fee)_ ~, 15.00
Asset Search (M.L. Ward) 45.75
Harrisburg Hospital (obtain medical records) 58.67
TOTAL (Also enter on Line 9, Recapitulationb S 145.919.57
If more space is needed, use additlonal sheets of paper of the same size.
REV-1513 EX+ (01-1 D)
Pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
HFNRY 1 RHRAWI~FR 21 10 0380
-------- --
RELATIONSHIP TO DECEDENT ~
AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSONS} RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include oufigM I dlstribulbns and transfers under
Sec. 91'T6 (a (1.2).]
1. Helen Shrawder Spousal
63 Little Run Road, Camp Hill, PA 17011 ', 100°/D residuary estate
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COV R SHEET, AS APPROPRIATE.
Ij, NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
8. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1
TOTAL taF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ! S
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT OF
HENRY L. SHRAWDER
I, HENRY L. SHRAWDER, a resident of Hampden Township,
Pennsylvania, being of sound and disposing mind, memory and understanding,
publish and declare this instrument to be my Last Will and Testament, hereby
wills by me at any time heretofore made.
0
ro
i
~~
~eby m~e,
tJ1
.t's
any and all
ITEM I: I direct my hereinafter named Executrix to pay all my just debts, funeral
expenses, administration expenses and inheritance, estate, succession or excise tars, which I owe
or may become due on account of my death, as soon as maybe convenient after my decease.
ITEM II: All the rest, residue and remainder of my estate, be it reel, personal or
mixed, of whatever nature and wheresoever situate which I may own or have the right to dispose of
at the time of my decease, I give, devise and bequeath to wife, Helen Shrawder, af!63 Little Run
Road, Camp Hill, PA 17011.
ITEM III: If my said wife should predecease me or die simultaneouslywith me,then
all the rest, residue and remainder of my estate, be it real, personal or mixed, of whatever nature and
wheresoever situate which I may own or have the right to dispose of at the tune o~ my decease, I
give, devise. and bequeath to be divided equally between my daughters:
Terry L. Harris, of 1415 Route 209, Millersburg, PA 17061
Vicky L. Lori, of 806 Pamela Lane W, Mechanicsburg, PA 17050
A. If my daughter, Terry L. Hams, should predecease me or die
simultaneously with me, then her share shall pass to my grandson, Donald Hazris, Jr.,' of State Street,
Millersburg, PA 17061.
~-,
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:.;~'
(~} I/~ ~. (SEAL)
Henry L. Shrawder
B. Ifrny daughter, Vicky L. Lori, shouldpredecease me ordee simultaneously
with me, then her share shall pass to my daughter, Terry L. Harris, or her issue per stirpes.
ITEM IV: I hereby nominate, constitute and appoint my wife, Helen Shrawder,
Executrix of this my Last Will and Testament, with full power in her discretion to do any and all
things necessary for the complete administration of my estate, without being required to file bond
for the performance of her duties, with full power to sell at public or private sale andlwithout order
of court any real or personal property belonging to my estate, and to compound, compromise or
otherwise settle or adjust any and all claims, charges, debts and demands whatsoever against or in
favor of my estate as fully as I could if living.
A. If my said wife should predecease me, die simultaneously with m$, or be unable
or unavailable to serve or complete her duties, then I nominate, constitute and appoint my daughters,
Terry L. Hams and Vicki L. Lori, CoExecutrices, with the same power and authority as given my
said wife.
B. If both my said daughters should predecease me, die simultaneously with me, or
be unable or unavailable to serve or complete their duties, then I nominate, constitute and appoint
my grandson, Donald Harris, 3r., Executor, with the same power and authority as givenmy said wife.
IN WITNESS WHEREOF, I have hereunto set my hand and seal td this my Last
Will and Testament this 12th day of October, 2007.
. (SEAL)
Henry L. Shrawder
and in the presence of each
other, we believing him to be
of sound and disposing mind,
memory and understanding,
have hereunto subscribed our
names as witnesses this 12th day of
October, 2007.
Howard B. Krug
Leon P. Haller
John W. Purcell, Jr.
Jill M. Wineka
Nicho]e M. Staley O'Gorman
Lisa A. Rynard
~j} ~~ Law Offices ~~
f~~~C~G, ~.%~ ~ C~~G'~I~GP/I~
1719 North Front Street
Harrisburg, Pennsylvania 17102-2305
Telephone (717) 234-4178
Fax (717) 233-1149
July 12, 2010
Estate of Henry L. Shrawder
c/o Helen Shrawder
63 Little Run Road
Camp Hill, PA 17011
Re: S08121-36061
Hershey
(717)533-3836
yohn W. Purcell (1924-2009)
Jose h Nissle I
P Y
(1910-1982)
FOR PROFESSIONAL SERVICES RENDERED
TOTAL AMOUNT COLLECTED: (Traveler's Underinsurance) ', $ 305,000.00
LESS ATTORNEY'S FEES: (331!3% OF $305,000) I, (101,666.67)
~I
i
TOTAL AMOUNT DUE CLIENT I $203,333.33
Howard B. Krug
Leon P. Haller
John W. Purcell, Jr.
Jill M. Wineka
Nichole M. Staley O`Gorman
Lisa A. Rynard
Law Offices
~ir~~c~ ~~ ~' ~~~~
1719 North Front Street
Harrisburg, Pennsylvania 17102-2305
Telephone (717) 234-4178
Fax (717) 233-1149
July 12, 2010
Estate of Henry L. Shrawder
c/o Helen Shrawder
63 Little Run Road
Camp Hill, PA 17011
Re: S08121-36061
Hershey
(71~ 533-3836
~lohn W. Purcell (192420D9)
Joseph Nissleyl
(1910-1982)
FOR PROFESSIONAL SERVICES RENDERED
TOTAL AMOUNT COLLECTED: (Traveler's Third Party Insurance)
LESS ATTORNEY'S FEES: (33 1/3% OF $100,000)
LESS COSTS ADVANCED:
$ 100,000.00
(33,333.34)
Date Item Amoun
4/21!2010 Cumberland County Legal Journal Advertising (75.00) ~,
4/28/2010 Harrisburg. Hospital medical records (58.67)
5/7/2010 Overnigh shipping fee for sending medicals to adjuster (31.52)
5/18/2010 Copying fee (Hershey records) to send to adjuster (106.73)
5/19/2010 The Sentinel -Advertising Estate Notice (219.44) !
6R/2010
Hershey Medical Center medical records ,
(284,70'
7/8/2010 Filing Fee for Petition to Approve Settlement (15.00)
7/9/2010 Order history re: search of M.L. Ward assets (8,50)
7/12/2010 Order history re: search of M.L. Ward assets (37 25')
(836.80)
TOTAL AMOUNT REMAINING
PLUS REFUND OF RETAINER
TOTAL AMOUNT DUE CLIENT
$65,829.86
$100.00
$65,929.86
t7 2818 22:38:46 Via Fax
September 17, 2010
Howard Krug
Fax: 717-234-0409
Re: Hartford Amiuity Contract # 990962401
Deoedent: Henry Shrawder
Dear ~Ir. Krug:
Thank you for your correspondence regarding the above annuity contract.
Har~fprd Life
The death benefit payable under this contract is not considered "life insurance" reportable on IRS
Form 712, (life insurance statement). Please find the below information in response to ypur
request.
Contract Number 990962401
Owner Henry Shrawder
Decedent Henry Shrawder
Social Security Number XXX-XX-6434
Date ofDeatl~ March 26, 2010
Cash Yalue on the date of death $67,155.28
Death Benefu Value on the dale of death's $67,335.'T7
This policy was established on April 18, 2000 with 534,308.95.
'The Death Brnefit Value on the date of death displayed above may include s Death $enefit Adjustmerdt ~s outlined
in the Annuity ContraM. This figure is being provided for illustration putposes and is not equivalrnt tb the finsl
death benefit The death benefit ticill be calculated on all contracts associated vt•ith this client the day wb teceive the
certified desth certificate, Once the death brnefit is calculated, the benefit amount remains invested and is subject to
market fluctuation until complete settlement instructions are received,
If you have any questions or concerns; please feel free to contact your investment professional,
or one of our annuity specialists by calling 1-800-862-6668, Monday through Thursday From 8
a.m. to 7 p.m. and Friday from 9:15 a.m. to 6 p.m., Eastern Standard Time, We will be 1lappy to
assist you. Thank you for the opportunity to help provide for your financial needs.
Sincerely,
Hartford Life ~nsunnec Cnmpanics
1 Griffin Road,lJbrth
Windsor. CT i#b 95.1512
A. Taylor Toll Free 1 8~ ~62 6665
Investment Pr duct Senrices
Investment Product Scrviccs
_ _ __
__ r
-> ?172348489 The Hartford Fax Page B82 Of BB2
ICS Annuity Benefit Services Team t~tauin~ Addrc~s, P.O. Box suss
Hartford, CT Q6102.5085
Hartford Life and Annuity Insurance Company online larttordli~e eom
Hou 82 2818 16:28:38 Via Fax -> 7172348489 The Hartford Fax Page 882 !1f 882
(rage 1 or 1)
Apr 28 2818 18.27:46 Via Fax -> The Hartford Fax Page 883 Of q83
~I
Th~rtgs to Kno'+~v for Annuity Contract Number 990962401
April 20, 2010
Coutnot Otvsur; Henry Slatwder
Deoedezn: Henry 3hrtwder R~t}R~
R•oipient oEProo••de: $alsn 5hrawdsr
Contract Typa; Firod Product
Plea Types Nan-Qualified
/, Pleue note, the iafotmttian provided it for the above oontsaot end the speoifia outlined here may na apply to other
rcntracta o«ned by the decedeak
• Bubmiaaion of Baaafit Oation $l~ction Inatructiona
Host-queli$ed eantrneta - must be received is good order within 60 days of receipt of due proof of death in ordex to evotid fan
imm•diat• tucabl• •vnt
Qualified contracts - moat be received in good order by 12131 of the yea following death, If an election is not made, the
defualt will be Life Bxpetnaaoy,
*:*IMPORTANT :VOTE, CALCULATION OF DEATH BENEFIT***
For Variable Convacu: The guaranteed death benefh will be calculated for all individual annuity
contracts aerociated with the decedent upon receipt of due proof of death",
The calculated benefit amount, if any, will be invested into the investmmzt option(s) it accordance with the last invaatma$St
insrntetions rsedvsd. ?hie will rnult in the guaranteed death bensfit invsstsd in tl:s same manner as a subssquem prsntiiu~n
paymaslt. During tba time period batvraan our receipt of dua proof of death and recaipf of complsts~ in ~opd
order, benefit option election inertructlonr, the entire calculated benefit amount ~clll be aubJect to marlte~
fluctuations.
Duo prootoiduth hu eotytt bean roeelvad.
For Filed ContrecU: The detthbenefit ~r>71 be determined es of the date the due proof cf death' end brneft eptien
election ere recet4td in good order.
• D~at}i Bene[1tAdlmtment
If Spousal Continuation Opdoa (if available) is elected the deerk benefit adjustment will be processed as follows
^ The oasaireat's account value ~rltl not bs stepped up to tho Death Benaf"rt Ye1ue. IE a death beuefh adjustment ruse
applied prior to the e]eotiatl of this option, this emourrt wt71 be zemoved.
^ The eomtrect's accoatnt value maybe stepped up to the Death Brnefit Valtu, if applicabia
® Not Applioab;a,
• For 8nouetl Hsnsllclarlea only - Ot>tional Withdrawal Honeflt Ridora
^ Cmz-sact has The Iiartford's Lifetime Foundation x.ider
^ Com':mot hoe the Herd'cad'r Prittoipal First Benefit 9tep^up
® The oonmot doer not have The Hartford's Lifetime Foundation Rider or The Htaford'r Principal First Benefit
stop-up
Hertford Life moagly reoomrnende that you consult with your tax advisor for ashy queationa p~teining to dietr~but~ons pf
benefit proooeda from en annuity oontraot
• Due proof is a ees'tified (rained acct) dedtlt certificate (long form) or cry other grcof of death acceptable to
Hertford Lif..
Plesse keep this letformation for you rocord4
84/28/2918 18:28 AM ~,
~' Deo: 106027566 Page: 1/i
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