HomeMy WebLinkAbout01-31-111505610143
REV-1500 Ex (°'-'°'
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
Po Box.2sosol INHERITANCE TAX RETURN 21 10 00941
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
197 40 8295 09 06 2010
Decedent's Last Name
LEINAWEAVER
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Date of Birth
07 17 1927
Suffix Decedent's First Name MI
MILDRED E
Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise
f
8 ~ 5. Federal Estate Tax Return Required
(date of death a
ter 12-12-
2)
6 Decedent Died Testate
(Attach Copy of Will) ~ ~• (AttacheCoMa~of Trust a Living Trust
PY ) 8. Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received ~ 1 C• between Pov31t~Craedditl(datge5~f death ~ 11 • Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JAN M WILEY 717 432 9666
First line of address
130 W CHURCH STREET
Second line of address
City or Post Office
DILLSBURG
Correspondent's a-mail address:
State ZIP Code
PA 17019
..,
REGISTER OF W}LLS USE ONLY
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DATE-•~tt_ED
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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.
SIGNrATURE PERRSON ESPONSIBLE FOR FILING RETURN DATE
f/1 / /f . ` ~ . _,...,. r .c,.~u t-,~ Mark E_ Lpinawpavpr r ~ 1 ~ ~~ r
ADDRESS `~-/ / r
__1275 Creek Road Mechanicsbur PA 17055
SIGN URE OF PREPARER OTHER T AN REPRESENTATIVE "~-~~ ~ t ~ ~ T~ ~~ DATE
130 VHl Church Street. Dillsbura. PA 17019
Side 1
L 1505610143 1505610143 J
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Leinaweaver, Mildred E. 21-10-00941
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of
my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all
information of which preparer has any knowledge.
Signature #2 ,~y( ~1.
Name
Address1
Address2
City, State, Zip
Date
Keith E. Leinaweaver
3986 Highland Road
Millerstown, PA 17062
s
J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedents Name: Leinaweaver, Mildred E. 197 40 82 95
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 & Notes Receivable (Schedule D) ........................................................ 4.
108,292.84
5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous I~.q Probate Property
arate Billin
Requested
Se
7 9 $ ~ 62 7 . 2 9
............
g
p
(Schedule G) ^ .
g. Total Gross Assets (total Lines 1-7) ..................................................................... g.
206,920.13
12,038.27
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
1,898.36
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule 1) .............................. 10.
13,936.63
11. Total Deductions (total Lines 9 & 10) ................................................................... 11.
192,983.50
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ............................................... 13.
192,983.50
14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15
~ ' ~~
(a)(1.2) X .00 .
16. Amount of Line 14 taxable 192 , 983.50 1s. 8 , 684.2 6
at lineal rate X .045
17. Amount of Line 14 taxable
0
0 0
17
0. 0 0
.
at sibling rate X .12 .
18. Amount of Line 14 taxable
0
0 0
18
~• ~ ~
.
at collateral rate X .15 .
19. Tax Due .................................................................................................................. 19. 8 , 6 8 4.2 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-10-00941
Decedent's Complete Address:
DECEDENT'S NAME
Leinaweaver, Mildred E.
STREET ADDRESS
700 Walnut Bottom Road
CITY
Carlisle
STATE ~ ZlP
PA I 17013
Tax Payments and Credits:
(1) 8,684.26
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments 7,481.25
B. Discount 393.75
Total Credits (A + B) (2) 7,875.00
(3)
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box 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. (5) 89.26
Make Check Payab{e to: REGISTER OF WILLS, AGENT. .
~? ,. ~
~ry~' ~ ~~
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :............................................................................... ^
b. retain the right to designate who shall use the property transferred or its income :.................................. x
c. retain a reversionary interest; or ................................................~ ............................................................. ^ Q
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 ^ a
receiving adequate consideration? ............................................................................................................. .
.....
3. Did decedent own an "in trust for" or payable 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 beneficiary designation? .................................................................................................................. ~ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
.. ~~..~~
For dates`of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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)].
. 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)]. A
sibling is def+ned under 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)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Leinaweaver, Mildred E. 21-10-00941
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
(If more space is needed, additional pages of the same size)
Rev-1510 EX+ (8-98)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Leinaweaver, Mildred E. 21-10-00941
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
THE DATE OF TRANSFERSATTACN A COPY OF TIOHE DEED FOR REAL ESTATDE. DATE OF DEATH
VALUE OF ASSET °rb OF DECD'S
INTEREST EXCLUSION
(IF APPLICABLE) TAXABLE
VALUE
1 American Progressive Annuity Policy Number: 53,250.77 53,250.77
OA5097526:
2 Bankers Life and Casualty Co. Annuity Contract No.: 10,863.02 10,863.02
7899288:
3 Dearborn National Annuity Contract Number: 18,732.59 18,732.59
P00000052047
4 Jackson National Roth IRA Contract Number: 7,486.02 7,486.02
1001702951:
5 Minnesota Life Annuity Contract #1353382: 8,294.89 8,294.89
TOTAL (Also enter on Line 7, Recapitulation) ( 98,627.29
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98)
REV-1151 EXt (10-06)
COM INH~R,ITAN~EDT~ R~T~RN ANIA
R sIDEN DEcc;;EDttN
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Leinaweaver, Mildred E. 21-10-00941
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N M E
A. FUNERAL EXPENSES:
See continuation schedule(s) attached ~ 1,033.27
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City
Year(sl Commission raid
State Zip
2. Attorney's Fees The Wiley Group, PC 10,300.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees The Register of Wills: 327.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 377.50
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 12,038.27
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Leinaweaver, Mildred E. 21-10-00941
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Malpezzi Funeral Home: 1,033.27
H-A 1,033.27
Qther Administrative Costs
2 Cumberland Law Journal (advertise): 75.00
3 Register of Wills (filing fee): 30.00
4 The Sentinel (advertise): 272.50
H-B7 377.50
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+ (12-08)
SCHEDULE i
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Leinaweaver, Mildred E.
FILE NUMBER
21-10-00941
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
Ali more space Is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+ (11-08)
,..
COMMO GQ~reLnir~FCrax RFNS~RLN ANIA
SCHEDULE J
BENEFICIARIES
ESTATE OF
Leinaweaver, Mildred E.
NAME AND ADDRESS OF
NUMBER PERSON(Sl RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 Keith E. Leinaweaver
3986 Highland Road
Millerstown, PA 17062
2 Mark E. Leinaweaver
1275 Creek Road
Mechanicsburg, PA 17055
FILE NUMBER
21-10-00941
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
DECEDENT (Words) ($$$)
n.. l.l..~ 1 :e• T.v.clnnlcl
Son ~ ~ 96,732.79
Son ~ ~ 96,732.79
I ~ Total ~ 193,465.58
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
~~~t ill ttrt~ Cle~t~tmrrtt
OF
MILDRED E. LEINAWEAVER
BE IT REMEMBERED, that I, MILDRED E. LEINAWEAVER, of
1212 Peffer Road, Mechanicsburg, Cumberland Ccunty,
Pennsylvania, being of sound mind, memory and understanding,
do make, publish and declare this as and for my Jast Wiil and
Testament, hereby revoking and making null and void any ar~d
all Wills and Testaments and writings in the nature thereof
made by me at any time heretofore.
ITEM 1: I direct that all my just debts and funeral
expenses be paid as soon after my demise as may be
convenient.
ITEM 2: All the rest, residue and remainder of my
estate, of whatsoever nature and wheresoever situate, whcti~er
it be real, personal or mixed, including property over which
I have a power of appcintment, T give, devise and bequeath
unto my two sons, MARK E, LEINAWEAVER and KEITH E.
LEINAWEAVER, in equal shares, per stirpes.
ITEM 3: I direct my hereinafter named Co-Executors to
pay all inheritance, estate, succession and legacy taxes of
whatsoever nature and kind, to which my estate or the
transfer of any property passing hereunder or otherwise
passing by reason of my demise, may be subject a11d to charge
such taxes against my residuary estate, it being my intention
that none of the aforesaid taxes, either federal or state, on
~nl~`~'N E S S
-i'~ (~-~ _~~~-~ G • y~-'P.~stc<1et~~ ( SEAL )
MILDRED E. LEINAWEAVER
-1-
any property required tc be included in my gross estate,
under the provis:ions of any state or federal1aw now in force
or hereafter enacted, shall be prorated among the persons
interested in my estate to whom such property is or may be
transferred or to whom an•~~ benefit accrues.
ITEM 4: I appoint my two sons, MARK E. LEINAWEAVER and
KEITH E. LEINAWEAVER, as Cc-Executors of this my Last Will
and Testament.
ITEM 5: I direct that my Co-Executors shall not be
required to give bond for the .faithful per~ormance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this ~ Q f{., day of
/1'x/4 R ~ H 2003 .
,WI NESS: ~
~,~ ~~p ~~ ~a `~
_ ~' -' Lt.C.~Lcr,.f' C . d-~iws. SEAL )
MILDRED E. LEINAWEAVER
-2-
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF YORK
We, MILDRED E. LEINAWEAVER, JAN M. WILEY, ESQUIRE
and SHAWNA L. VARNER, 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 her Last Will and
Testament and that she had signed willingly (or willingly
directed another to sign for her), and that she executed
it as her free and voluntary act for the purposes therein
expressed, and that each of the witnesses, in the
presence and hearing of the Testatrix, signed this Last
Will and Testament as witness and that to the best of
their knowledge the Testatrix was at the time eighteen
(18) years of age or older, of sound mind and under no
constraint or undue influence.
~o
DRED E. LEINAWEAVER
f'1~1. (,,,J
I`B' ESS
WITNESS
Sworn to and subscribed
before me this I9~~day of
~Q/Z.~ 2003.
NOTARY PUBLIC '
MY COMMISSION EXPIRES:
Noterlai Seal
$. Dawn Glad'eise~ Notary Public
Dillsburg 3or: park COUnty
My Commies or~ Exp~ios N,ay 1 2005
Member, Pennsyivarna,~ssoc~ation of Notaries
October 21, 2010
The Wiley Group
130 W. Church St
Suite 101
Dillsburg, PA 17019
To Whom It May Concern:
RE: Mildred E. Leinaweaver
In reference to the above customer, our records show the enclosed information to be
accurate of today's date. If I may be of any further assistance, please contact me.
Sincerely,
~~ ~,~~~
Tricia Ganoe
Deposit Operations Manager
717-261-3624
717-264-6116 888-264-61.16. P.O. Box 6010
_ FINA-N,CIAL~$O.LU`tIONS... FROM
Chambersburg, PA 17201-6010
PEOPLE Y:OU KNOW
Dearborn ~ NatIOnalTM
~.,
October 5, 2010
The Wiley Group
C/O Jan M. Wiley
130 W. Church Street
Suite 101
Dillsburg, PA 17019 -~=
Re: Contract # P00000052047 , ~t~
~ ~~
Mildred E. Leinaweaver, Annuitant/Decedent ~~.
Dear Ms. Wiley: ~~'
;~;,
Thank you for your recent inquiry. The date of death value of the above referenced annuity is ..
59 as of 9/6/10. The total interest accrued until date of death is $732.59. This contract
732
$18
.
,
was established 7/14/08 and was owned by Mildred E. Leinaweaver. Enclosed you will find
Yti~ '~~ ~
the death claim paperwork along with a return envelope for your convince. #~~`=a
please contact our office.
If you need further assistance `.,.
r y ~~
, ~~ ~'~
~}~ ;
'
incerely,
;:
;~ i
,,, ..
.,:,
~` ~~
A-
,
r,
~~, ~. ,,
~'.. ~'~.., i .
;.\;,~ ~a
Teaira Anderson
Individual Customer Service 3- y~''
1.800.538.0379 x '
xh
:i
CC: Michael J. Clinton
P.O. Box 655443, Dallas; Texas 75265 a Toli Free: 800.538.0379 ~i Fax: 972.480.0642
:;u.ts and services ;narketQd under ~ne C~ea+born tvatinna': ° ~sar;d a.,d the star loge are unde .s'rtien andor provided cy Fcii ~earo~ -' , ;;? ,~ r?^ce Company,
;,~o;r~ners ~soJe ~ ~ ~n a~~ states (excluding NeYr „ ~,, ; .~: ,,r~~~ o, oiu~nbia. the ;.n tec S.a:es t;rgin islands. ~~e Sr4tis~'1ir ,,~ ', :~:,~,r^
Minnesota Life Insurance Company
A Securian Company
400 Robert Street North
St. Paul, MN 55101-2098
www.minnesotalife.com
651.665.3500
October 1, 2010
THE WILEY GROUP
ATTN JAN WILEY
130 W CHURCH ST, SUITE 101
DILLSBURG PA 17019
RE: Non-Qualified Annuity -contract # 1353382
Mildred E. Leinaweaver -deceased
Dear Ms. Wiley,
Please extend our company's condolences to the family of Ms. Leinaweaver for their loss.
MINNESOTA LIFE
On March 1, 2004, Ms. Leinaweaver elected a life only annuity option and began receiving variable
monthly annuity income. The listed beneficiaries are Mark Leinaweaver and Keith Leinaweaver. As
beneficiaries, their settlement options are as follows:
1. Commuted Value: Each beneficiary may receive his portion of the cash value as a lump sum
distribution. Because this is a variable annuity, the value will fluctuate each day depending on the
performance of the Index 500 sub-account, until the date of distribution.
2. Continue Pa, ments: Each beneficiary would receive his portion of the variable payment each month
with a final payment on February 1, 2015. Again, because this is a variable annuity, the monthly
payment amount will fluctuate depending on the performance of the Index 500 sub-account.
Please have each beneficiary complete an enclosed form electing an option and return it to us. I have
enclosed a return envelope for your convenience. If you would rather fax the claim forms to us, our fax
number is 651-665-7942. In addition, I am returning the certified death certificate for your records.
This is tl~e only annuity that Ms. Leinaweaver had at Minnesota Life. The cash value as of her date of
death was $8,294.89.
Information in this letter should not be considered tax advice. You should consult your tax advisor
regarding your own tax situation. If you have any questions regarding this claim or the completion of
the form, please feel free to contact our office. We can be reached at {800) 362-3141.
cerely,
G~~1
Sarah Brenny
Customer Service Technician
Annuity Services
Enclosures
C: 3022-942
a~ ~ ~~
BANKERS LIFE AND CASUALTY COMPANY
Home Office: 222 Merchandise Mart Plaza • Chicago, II{inois 60654-2001
(312) 396-6000
ANNUITANT MiLDRED LEINAWEAVER 80 FEMALE AGE AND SEX
POLICY NUMBER 7899288 SEPTEMBER 12, 2008 DATE OF ISSUE
SINGLE PREMIUM $10,000.00 SEPTEMBER 12, 2018 DATE INCOME BEGINS
In this policy:
You or Your refers to the Annuitant named in the Schedule on page 2 of this policy.
We, Us or Our refers to Bankers Life and Casualty Company.
Owner refers to the Owner or joint Owners of this policy. The Owner may be someone other than the Annuitant
See WHO OWNS AND CONTROLS YOUR POLICY on page 11 of this policy.
MONTHLY INCOME BENEFIT
We will pay You the Monthly Income if You are alive on the Date Income Begins. The Monthly Income amourr
will be determined by the cash amount placed under the payment plan chosen. See HOW WE PAY POLIO
BENEFITS on pages 6 through 10 of this policy. The Date Income Begins is as shown in the Schedule or as later
changed.
The Monthly Income payments are subject to the provisions of this policy.
DEATH OF ANNUITANT
We will pay the Death Value to Your Beneficiary if You die before the Date Income Begins. The Death Value
is the greater of:
1. The Cash Value of this policy on Your date of death rr~inus any payments made by Us after Your date ofi
death under this policy; or
2. The Single Premium, including any premium increases, minus any Withdrawals.
We will pay the Death Value in one sum, unless otherwise agreed. This payment is subject to the provisions
of this policy. See DEATH OF OWNER BEFORE DATE INCOME BEGINS on page 5 of this policy.
THIRTY DAY RIGHT TO RETURN THIS POLICY
If the Owner is not satisfied with this policy, he or she may return it to Us within 30 days after getting it. The
Owner may return it to Us by mail or to the agent who sold it. We will then refund any premium paid. This policy will
then be void.
THIS POLICY AND THE DATE IT BEGINS
This policy is a legal contract between the Owner and Us. It consists of this and the following pages. READ
THIS POLICY CAREFULLY. See the POLICY GUIDE on page 1A of this policy.
This policy begins on the Date of issue shown in the Schedule.
Signed for Us at Our Administrative Office on the Date of Issue.
Secretary ~ ~ ~ President
e
Examen by
SINGLE PREMIUM DEFERRED ANNUITY POLICY
IF YOU ARE ALIVE ON THE DATE INCOME BEGINS WE WILL PAY THE MONTHLY INCOME - IF YOU D!E
BEFORE SUCH DATE WE WILL PAY THE DEATH VALUE -SINGLE PREMIUM IS DUE ON THE DATE OFISSUE -
SINGLE PREMIUM INCREASES ALLOWED DURING THE FIRST 180 DAYS -THIS POLICY DOES NOT PAY
DIVIDENDS.
LA-03D Page 1 843J
~~
~~~
BANKERS BENEFITNOW ACCOUNT
P.O. BOX 570
ROCKLAND, MA 02370-0570
RETURN SERVICE REQUESTED
000191
MARK E_ LEINA~JEAVER
1275 CREEK ROAD
MECHANICSBURG PA 17055
~~t~~~~~~~~~i~t~~~~i~~i~i~~~~~~t~~~~~~~~~t~~~~ n ~~~~~~~~~~ n
~:0 ~ L0000 28:0 LO L 0 2 200 5 59 5011' X90
~ 5 x/31. SI f~ !'vIGU-k /~i naurPa L~
5 N3I S ~ ~u ~~j~-h I.~-i ~uJeQV~/
1(~~ 8'(~3~~ a
~,1VIER.IG.AN
PRO GRE S SPITE
LIfE & HEALTH INSURANCE COMPANY OF NEW YORK
October 12, 2010
ESTATE OF MILDRED E LEINAWEAVER
C/O THE WILEY GROUP
ATTN: JAN M WII,EY, ESQUIRE
130 W CHURCH ST, SUITE 101
DILLSBURG, PA 17019
Re: Insured: Mildred E Leinaweaver
Policy Number: OA5097526
Dear Estate of Mildred E Leinaweaver:
PO Box 81709
Lincoln, NE 68501
Thank you for your recent inquiry regarding the above numbered policy. Please find the
requested information below:
• Accumulated Value as of 09/06/2010: $53,250.77
• Surrender Value as of 09/06/2010: $50,231.45
• Cost Basis: $40,100.00
• Owner: Mildred E Leinaweaver
• Issue Date: O 1 / 14/2005
• The forms and instructions for filing a claim are being sent under separate cover.
If you have any questions, please call our office at 866-626-0199, Monday through Friday from
8:00 AM - 5:00 PM eastern time.
Sincerely,
Client Services
3 W/RCA01212
BCJNUS MAX ANNUITY
Statement Date: November 4, 2008
For the period November 4, 2007 to November 4, 2008
www.~nl. com
Prepared for:
Mildred E Leinaweaver
1212 Peffer Rd
Mechanicsburg PA 17055
Phone: (717) 245-0524
$M
.NATIONAL LIFE INSURANCE COMPANY
Your Representative:
MICHAEL J CLINTON
710 LONGS GAP RD
CARLISLE PA 17013-8527
Activity Summary Account Information
Beginning Period Accumulated Value $7,129.43
+Interest Earned for Period $242.40
Contract Number:
Annuity Type:
Issue Date:
Owner(s~:
Annuitant(s):
1001702951
Roth IRA
November 04, 2005
Mildred E Leinaweaver
Mildred E Leinaweaver
Ending Period Accumulated Value $7,371.83
A partial withdrawal or full withdrawal from the Contract may be subject to an Excess Interest Adjustment (Market Value Adjustment in some states) as
specified in your Contract. The EIA (MVA) may result in an increase or decrease in the Withdrawal Value in accordance with the terms of the Contract.
Withdrawals may be subject to withdrawal charges and ordinary income taxation and, if taken prior to age 59 1/2, may be subject to a 10% federal tax
penalty. Contact your tax advisor prior to making withdrawa{s. Please see your Contract for definitions and additional information.
The average interest rate credited to your Accumulated Value for the statement period was 3.40%. Each of your premium payments, along with the interest
previously accrued on the premium (if any), is treated as a separate payment into your Contract. The applicable interest rate depends on the effective
date(s) of your premium payment(s). Therefore, it is possible for each of your premium payments to earn a different interest rate.
lY2FDB8F OW Ol ~~~- SZ 100170"t551 1712E~~1 11/05/2009 REVF.(T FPM
For ease in making additional premium payments ($1000.04 minimum), please tear off this portion and submit with your payment.
Contribution availability may vary by state. Please read your contract or contact our Service Center to confirm your contribution availability.
MAKE CHECK PAYABLE TO: Jackson National Life Insurance Company
Please include Contract number on check.
Owner Contract Number
Mildred E Leinaweaver 1001702951
Jackson National Life Insurance Company
PO Box 24068
Lansing MI 489-09-4068
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Amount
Enclosed:
For proper crediting Tax Year
of your IRA
contribution please
enter the tax year.
02 01307 004 1001702951 D001DD000 4
_ _ __ THE__ORIGINAL DOCUME_N7_HA_S A_REFLE_CTIVE_WATER_MA_RK_ON_TH_E BACK. HOLD AT A_N A_NGLE TO VIEW WHEN CHECKING THE ENDORSEMENT. _ __ _ _ _._ - Foio r
DETACH THIS CONFIRMATION AND RETAIN FOR YOUR RECORDS BEFORE CASHING OR DEPOSITING CHECK.
JACKSON NATIONAL LIFE INSURANCE COMPANY
PAYEE MARK E LEINA~}'EAVE R CHECK DATE 11/03/2010
DESCRIPTION OF ITEMS PAID BY ATTACHED CHECK
CLAIM PAYMENT
Policy Number:
Net Payment Amount:
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1001702951
CHECK NO. 0047376198
X3,893.01 -' '~~
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Jackson National Life Insurance Company
1 Corporate Way
Lansing, MI 48951
1-877-JNL-2Y0 U
(1-877-565-2968)
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