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HomeMy WebLinkAbout05-19-111505610143 REV-1500 EX (01-10) '~ OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OFREYENUE PO 60X.280601 INHERITANCE TAX RETURN 21 10 1193 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 225 22 4910 11 19 2010 Decedent's Last Name HART (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Date of Birth 10 20 1919 Suffix Decedent's First Name MI MAVIS H 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 (date of death after 12-12-82) ~ 5. Federal Estate Tax Return Required © g Decedent Died Testate i l ~ ~• (AttaCher~oMaionfgin sd a Living Trust C PY T ) ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of W l ) 9. Litigation Proceeds Received ~ 10. b9tweeri12v31 ~~raerdit,~da95pf death d 1 11 ~ 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 T0: Name Daytime Telephone Number DAVID W DELUGE 717 761,-4540 First line of address 3 01 bsARKE T S TREE T Second line of address PO BOX 109 City or Post Office State ZIP Code LEMOYNE PA -- ~_..~ ....- ._r REGISTER OF W~L--~~r-djSE Oh1LY ~ ._ .• _:__. , rt r.._ 7"; ~-' .may :- ...: , ,, .,. _ ,; _ _ _ ~- = ~ ~ -= ;_ .,~; -- ~y ._ ' ~ / DATE FILED ~~ -~ t -• • , `f rn -~ Correspondent's a-mail address: dWd@JdSW.COn'1 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 OF PERSON RESPONSIBLE FOR FILING RETURN i _ ., DATE A Bolash „ .~ ADDRESS _4525~ alley Roaa d, Eng J~ PA 17 25 SIGN JJR OF PREPAR THE A REPRE ATIVE ATF / DAVID W DELUGE 301 Market Street, Lemoyne, PA Side 1 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: Hart, MaVIS H 225 22 4910 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. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 2 4 , 2 94.10 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous f~oq Probate Property uested arate Billin Re S 7 64 978 90 ............ g q ep (Schedule G) U . . , 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 115 , 2 7 2 . 7 4 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 14 , 511.8 9 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) .............................. 10. 2 90.4 7 11. Total Deductions (total Lines 9 & 10) ................................................................... 11 • 14 , 8 0 2 . 3 6 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 1 O 0 , 4 7 0 . 3 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14. 10 0 , 4 7 0 . 3 8 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 0 • 00 (a)(1.2) X .00 . 16. Amount of Line 14 taxable 0. 0 0 16. 0. 0 0 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 4 7 0. 3 8 10 0 18. 15 , 0 7 0. 5 6 , at collateral rate X .15 19. Tax Due .................................................................................................................. 19. 15 , 0 7 0 . 5 6 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 Dpr_pdent's Complete Address: File Number 21-10-1193 DECEDENT'S NAME Hart, Mavis H STREET ADDRESS 4525 Valley Road CITY Enola STATE PA ZIP 17025 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 10,000.00 526.32 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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. Make Check Payable to: REGISTER OF WILLS, AGENT. (3) (4) (s) 4,544.24 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 :.................................. ^ c. retain a reversionary interest; or ............................................................................................................... ^ 0 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 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? .................................................................................................................. 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. a ~ u.. .. .. .. ... .. N . 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 defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. (1) 15,070.56 10,526.32 Total Credits (A + B) (2) Rev-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PR PERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF I FILE NUMBER Hart, Mavis H 21-10-1193 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+ (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PR PERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Hart, Mavis H 21-10-1193 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 TRANSFER.SATTACHTA CO Y OF THE DEED OR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Mass Mutual Financial Group Annuity Contract No. 41,689.71 41,689.71 ODY15327933 -Beneficiary: Kathy A. Bolash 2 Pennsylvania State Employee's Retirement System - 365.88 365.88 Final Payment 3 State Employees Retirement System -Final Pension 577.70 577.70 Payment 4 Western Southern Life Assurance Company Annuity 39,317.25 39,317.25 Contract No. W0020880136F -Beneficiary: Kathy A. Bolash 5 Gift to Kathy Bolash for the purchase of Automobile - 12,028.10 3,000.00 9,028.10 Gifted cash to Kathy Bolash on September 17, 2010 for the purchase of 2008 Chevrolet Impala Sedan. A copy of the Sales Contract is attached TOTAL (Also enter on Line 7, Recapitulation) I 90,978.64 (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 EX+ (10-06) COM INH ITAN~E T~ RET~RN ANIA RESIDEN DE EDEN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Hart, Mavis H 21-10-1193 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N MB R A, FUNERAL EXPENSES: See continuation schedule(s) attached ~ 8,972.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(sl Commission paid 2. Attorney's Fees Johnson Duffle 4,600.00 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 119.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 479.50 7. Other Administrative Costs 340.89 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 14,511.89 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 Hart, Mavis H 21-10-1193 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex en nses 1 Gingrich Memorials -Gravestone Marker 1,731.00 2 Richardson Funeral Home 7,241.00 H-A 8,972.00 Other Administrative Costs 3 Cumberland County Register of Wills Office -Filing fees for Inheritance Tax and Inventory 30.00 4 Cumberland County Register of Wills Office -Additional Probate Fees 60.00 5 The Cumberland Law Journal -Notice of Estate Administration 75.00 6 The Patriot News Co. -Notice of Estate Administration 175.89 H-B7 340.89 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Hart, Mavis H 21-10-1193 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule 1 (Rev. 12-08) (If more space is needed, additional pages of the same size) REV-1513 EX+ (11-08) COM IN~ ES~DE~EDECEDEN~R~ANIA SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Hart, Mavis H ~ 21-10-11 93 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions, and transfers under Sec. 9116 a 1.2 Kathy A Bolash Niece 1/2 of Residue of 4525 Valley Road Estate Enola, PA 17025 Robert S Bolash, Sr. Nephew 1/2 of Residue of 4525 Valley Road Estate Enola, PA 17025 Tota I Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 150 0 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO 1'Ax IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART It -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) ESTATE OF MA VIS H. HAR T SCHEDULE OF EXHIBITS EXHIBIT A Last Will and Testament for Mavis H. Hart signed and dated September 17, 2004 EXHIBIT B Date of Death Valuation Letter and Susquehanna Bank Summary of Account for the Month of November 17 through December 1 S, 2010. EXHIBIT C Receipt for the Purchase of Personal Property EXHIBIT D Mass Mutual Annuity Contract No. ~DY1532;~933 EXHIBIT E Western Southern Life Assurance Company Annuity EXHIBIT F Receipt for the transfer of the automobile 442308 L J ;~-~...a ~ ~ . X ~ c....J r'~~ ~ 77 ~~~ i....~ ~~ Fy`? C,j, ") ~ "`J ~ 'S`7 ~~ OF _ ~ ~ . - ~ 1VIA VIS H. HART I, MAVIS H. HART, of Enola, Cumberland County, Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void any and all former Wills made by me. ARTICLE I direct my Executrix to pay all the expenses of my last illness, my funeral and burial and of the administration of my estate as soon as practical after my decease. ARTICLE II direct my Executrix to pay ali inheritance, ,transfer, estate and similar taxes (including interest and penalties) assessed or payable by reason of my death on any property or interest in property which is included in my estate for the purpose of computing taxes. My Executrix shat( not require any beneficiary under this Wil( to reimburse my estate for taxes paid on property passing under the terms of this Will. ARTICLE Ill I bequeath my household and personal effects any other tangible property of a like nature (not including cash and securities) together with any existing insurance thereon, to ROBERT S. BOLASH, SR. and KATHY A. BOLASH. Should ROBERT.S. BOLASH, SR. or KATHY A. BOLASH predecease me, I bequeath such items of tangible personalty and the insurance thereon to the survivor of them. ...Y`~1 .....+ _} , ..; ~- _:..c ~~ ~`.'y? _:~~ c ARTICLE IV " 1 give, devise- and bequeath all the rest, residue and remainder of my. E:statP of every .nature and wherever situate to ROBERT S. BOLASH, SR. and KATHY A. BOLASH in equal shares. Should any such person predecease me, then the entire residue of my estate shall go to the survivor of them. Should both of them predecease me, then the entire residue of my estate shall be distributed to the children of ROBERT S. BOLASH, SR. and KATHY A. BOLASH in equal shares. ARTICLE V nominate and appoint KATHY A. BOLASH, as Executrix of this my Last Will and Testament, and require that said Executrix serve without bond. In the event that the above named Executrix shall, for any reason, fail to qualify, or having qualified, fail to complete the administration of my estate, I nominate and appoint ROBERT S. BOLASH, SR. as Executor of this my Last Will and Testament. - IN WITNESS WHEREOF, I hereunto set my hand and seal this ~ day of 2004: w '~d~~`'~~ ~ C~i~ (SEAL) MAV I S H. HART Signed., sealed, published and declared by the above-named Testatrix as and for her .Last . Will and Testament in the presence of us, who, at her request, in her presence and in the presence of each other have hereunto subscribed our mes as itne es. . ~ ;. ;. •, ACKNOWLEDGMENT' COMMONWEALTH OF PENNSYLVANIA ... .. COUNTY OF CUMBERLAND I, MAVIS H. HART, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Wil( and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. MAVIS H. HART Sworn or affirmed to and acknowledged before me, by Mavis H. Hart, the Testatrix, this ~ ~~'day of `~~,~ X2004. _ ~NO TARiAL SEAL DIANN~ LENICp Notary Public Letnoyne Borougi~ Cumberland Co. My Commission E~~ires Dec. 2i, 2Q(l5. r Notary Public AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA : ` ~:~s:~~ COUNTY OF CUMBERLAND We ~~.::;,, ~ '~~ ; '~~, ";...~~.... .and ~ t~~...~`~~ 1'~ _ ~~ ...:s.~ ,~.-r... the witnesses whose names are signed to_the foregoing .instrument, being duly qualified~ccording to law, do depose and say that we were present and saw the Testatrix sign and execute the foregoing instrument as her Last Will and Testament; that she signed willingly and that she executed it as .her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was at that time at least 18 years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed to and subscribed to before me by ~ .~ and _~~_~~„~~.~., '~~ _ ---~r.~~ ti,,,L,.~ , witnesses, this '~~-ay of ~~,r.._.~~.rc.2004. ~ NOTARIAL SEAL CI~NNE LENlG, Notary Public t_ernoyne Borough .Cumberland Ca. ~iy Commission Expires Qec. 21, 200a ~ ~L~ ~`~ ; Notary Pubr ~ ~~, :234657 12/31/2010 JOHNSON DUFFIE LAW OFFICES ATTN: DANA L. WIESEMAN PO BOX 109 LEMOYNE, PA 17043-0109 RE: Mavis H. Hart Estate DOD: 11/19/10 SS#: x;XX-XX-4910 ~~`~~ c~~~a~~ Susquehanna Bancshares, Inc. 26 North Cedar Street ' P.O. Box 1000 Lititz, PA 17543-7000 Tel 1.800.311.3182 Fax 717.625.4478 1'o Whom It May Concern: In response to your letter of December 20, 2010, here is the above customer account information as of November 19, 2010. Account # 1 • Account Title: Mavis H Hart • Account Type/# Ckg/146004534 • Date Opened /Maturity 7/19/04 • Interest Rate: .15% • Account Balance*: 20,050.93 • Accrued Interest: .17 • YTD Interest: 27.40 *Account balance does not include accrued interest. Account #2 Account #3 Mavis H Hart CD/10007094674 7/28/09 / 7/28/11 closed 11/16/10 15,15 8.5 8 total balance 101.91 2010 interest ® There is no safe deposit box in the name of the decedent. ^ There is a safe deposit box # 0 in the name of the decedent located at the branch name. Kathy Bolash was named general POA in 2005. Alternate was Robert A. Bolash, Sr. ' Susquehanna MAV I S < H HART 4525 VALLEY RD ENOLA PA 17025 Page 1 146004534 225-22-4910 Follow us on Twitter to help local food banks this Yloliday season. #Tweet2Feed @SusquehannaBank, November 15 - DE~cember 31 For more information visit www.susquehanna.net/tweet2feed »» S U M M A R Y O F A C C O U N T S «« ACCOUNT NUMBER ENDT_NG BALANCE 146004534 RELATIONSHIP CHECKING ~ .00 Date 12/15/10 Primary Acct # 01 Enclosure: »»»» »» »»»» C H E C K I N G A C C O U N T S <:«« ««««««« < ACCOUNT TITLE: RELATIONSHIP CHECKING Account Number Previous Balance Deposits/Credits 4 Checks/Debits Service Charge Interest Paid Ending Balance MAVIS H HART 146004534 22,141.64 .00 22,143.30 .00 1.66 .00 Number of Enclosures 0 Statement Dates 11/17/10 thru 12/15/10 Days in Statement: Period 29 Average Ledger 13,901.42 Average Collected 13,901.42 Interest Earned 1.66 Annual PercentagE: Yield Earned 0.150 2010 Interest Paid 29.06 DEPOSITS AND CREDITS Date Description 12/07 Closing Entry:Accrued int paid WITHDRAWALS AND DEBITS Date Description 11/18 KMART POP 165 PURCHASE 9043509123 ENOL PA 11/19 KMART POP 166 PURCHASE 9043509123 ENOL PA 12/07 Closing entry - zero balance Amount 1.66 Amount 58.84- 31.87- 20, 052 . 59- Reference 9510000951 Reference 0629801774 6643972670 9510000951 SUMMARY BY CHECK NUMBER Date Check No Amount Reference Date Check No Amount Reference 11/18 165 -See above- 0629801774 11/18 167 2,000.00 0076275280 11/19 166 -See above- 6643972670 * Indicates Skip in Check Numbers Sus uehanna MAVIS H HART 4525 VALLEY RD ENOLA PA 17025 RELATIONSHIP CHECKING Date Balance 11/17 22,141.64 11/18 20, 082.80 If you have questions regar~ SUSQUEHANNA BANK, 9 E. Main (800)311-3182; OR visit our Date 12/15/10 Page 2 Primary Acct # 146004534 Ol 225-22-4910 Enclosures 146004534 (ContinuE~d) SUMMARY OF DAILY BALANCES Date Balance 11/19 20,050.93 12/07 .00 ding your account(s), please cont~~ct us at: Street, P.O. Box 1000, Lititz, P~~ 17543; Web site at www.susquehanna.net. Member FDIC « .._ . .i . i ai':: :: _ ~ x i- ~• :: • _ .'i -" ! • _ ? i i i s c f'' :i {./ I i_ • ~'• . r E:.t {,_x :..., ` iyf_ :i ...: a :.... s.:_.. ! :' : S : . ~......« } ~ i 'S r i..::..? .... .... ...« .« « _ .... •Ci r- ~ ... r...l ~ i«.Ei ~. r ~ ~ 3.._# I.~'i. -t __ 'i ~ f ~_ 3 sy~y, 7~ r •f 'i :! ~ I i M :.~ F i:'•t F ': :.~ :... __ .. . .... •.. .. wx i« ..»r F` i ..... Y.«. ...: f : ••~Y .__ L C 6. ... ... .. ... .... ._ w .« - « My ~ 3•^ :, ~ .. .. ~ .. ; i i+ i a f ., . i ••. 3::. =...- S': Y F:::~ L.. 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( { _.. :»i {':~ ~ 3 `::_ ~°. ~ _ :". ~..~ ..~ ~... i..` •-. r : i.......: .i. ~ 4 4.: ~""~ ? .'» s...? l~•E -_.: F S : . ~ ~:::_ €: = :.... --- f~~t. ~:... ....._. r~ ;;: ~ »..i . } ~~ t ..»_ s i ~.:.~:1 ~•: '::.. .... s :.._ .._ .~.. i ..._ ~~i a r Massachusetts Mutual Life Insurance Company and affiliates Springfield MA 01111-0001 ~f-1.IJIJJ~.L~L ~. FINANCIAL BRO.OP• January 4, 2011 "'*M356**" KATHY A BOLASH 4525 VALLEY ROAD ENOLA PA 17025 Dear Ms.''Bolash: Re: Contract No(s). ODY15327933; Annuitant - Mavis H Hart; Issuing Company - CM Life Insurance Co (referred to herein as "MassMutual") Enclosed please find a check representing your full settlement of the above referenced policy. Transaction Date: January 4, 2011 Valuation Date: ~ December 30, 2010 Total of Funds: $41;689:71 Policy Interest* $17.37 Net Proceeds $41,707.08 In this transaction the Company has acted as principal and as agent for this Annuity product. *Interest has been calculated at 3.00% from the valuation date to January 5, 2011. If you have any questions, please contact your claim examiner Kim Fournier at (800) 767-1000 ext. 21388 or contact~me directly at ext. 22606. Sincerely, ~A~~ j~. . Laura Ritchie Operation Support Analyst USIG Policyholders Services and Claims Enclosure: 1 WESTERN-SOUTHERN LIFE ASSURAN ~. CE COMPANY CINCINNATI OHIO bzJ bLJ STATEMENT OF DEATH CLAIM SETTLEMENT INFORCE DEPT MAVIS H HART 1-26-2011 , MAIL TO 980 ~_ 5157 MAVIS H HART _ PAYEE W0020880136F _ CHECK #OC 07126824 HAS BEEN ISSUED FOR $39,317.25 I THE CLAIM ON THE ANNUITY LISTED ABOVE HAS BEEN APPROVED AND A.CHECK FOR YOUR SETTLEMENT AMOUNT IS ATTACHED BELOW . WESTERN-SOUTHERN LIFE WILL NOTIFY THE IRS THAT THE TAXABLE ,AMOUNT O 0 ~ ` F THIS PAYMENT IS $7,597.76 ~ FOR THE 2. 11 TAX YEAR. IF YOU HAVE ANY QUESTIONS, CALL A WESTER N-SOUTHERN LIFE REPRESENTATIVE ~ AT (800) 926-1702. ~ AMOUNT OF CONTRACT ,- $39,317.25 ~ ~~ i ~ . 1 ~~ - ~~ .~ L TOTAL PAYABLE THIS CONTRACT~~ $39,317:25 .. . .. .. ~ ~ 1 AMOUNT OF THIS CHECK i I ` $39,317.25 _r r ~ i • - Detach the check below. _ '~ •,sgNOOZN• ego ~- ~ • ~• • s- a =• •• ~ -•- ' ® ~ w~'~T ~ S ~ EE S ~: r ~ '~''~ f ~+ i hi '~ ~ BANK OF AMERICA 51-,x1119 yy1N CONTRACT ID DIST ~~ T ' ~~~ ~ DSOR, CT ~~1~ - 126824 _W0~208.80136F 980' ~ ~~ aY tof~heiotrder of ~ ~ 5 - , EXACTLY * * * * * 3 9., 317 * M [ ~ ~ U~ iy ti~'.• i a 3 ~ ~. ~DOL~LA~t } ~~AND"~2 ~"RfCENT L~1 ~~, RH~7 ~~~~~~~ ~ 1, ~ r 4 ~~ ~; y ~%: . •. 31 a ,3~7r r T• 4w 4 ~r°r . ' ~ e ur ~ 9.~ z~ ~' ~ ~ `'t r '` BOLASH~ ;~,h ~ KATHY ~;;~ ~ I ,~~ ~ ~ ~ 4525 VALLEY '"~ ~., ~. ~'~;~ ~ }`~ ENOLA PA 17025,E .~, r~ .~ ~~ k r ~:v~„f > ~~'07 L 268 24ii' ~:0 ~ 1900445: 68083ii' , FROf~I :IJORLEY f~IOTORS INC. - FAX N0. :7177326219 FE=b. 10 2011 11:02Af'I P1 ~ (~ ~•. J ~• • • l LJ - ~. _ .rET/11#1^ r~i >~i~~~M~w to:r. VEHiCL•1: C118H PURCHASE GOHITAACT ^^ Vf7LtL. t itilV f VT~3''~71~V. ~ ~ Su~quehttnna Ave. ,~ E~ofe Aoad • Erlo!>i, PA i702~ - / ~ ~ / G / ~~ (7i ~ 132.2051 ~'` ~ • t~LlwSt: Blrrt~ Y'ortp~lr FORT+iE ~LLOwM14 {TIKE(T,,.~OOl1Et~i T1 I C +1 ~ ~ // ~~~1 JJ- p/ o«t~v.tSuamca..aor~aw~l_ dT~,c a t ~~ osy w YE+w wI~ a~ofs T~ sa~.res .-n to +.+o.IE COLOR IaaEAt3E TOH ~LIVEAEPb-IORABOUT • ~ ~ , TAKDE iN u~FORW17'1QN • C~1 ~~ ~. to ~ ~ ~ ~ S ~. `~ ~ >~K rENC.~E I D w0 YII.EAOE GGL l~RiCE OF VEHICLE ~ s ~~ ~ ~• ~=%~7'~-. ~Y'~ ~ '~,. W Jam' ~ • h ! ~ ~ TAALIE IN ALLOW/1NC1: _ rALANCE OWED ON !'AADE IN , NET TiiAnE IN At-irOWw~ICE _ Tom, yOvi ~tiGl.wlO t!*~Gf.t wt K AEA+N1~i[ri ~i ~i *W MN-!~O OrW1Qt O~ • tiE~ous YECrI•lEG-l a[rtAOraTron srG r~E.Ortt OR *q! Or•QfMAi. vwt.u+4nol. ~ afM10A TO iT~•OEUVE11t TO TILE OEw- NI OA tf r•M* pl ACCE7~lf OA •O'r G . . {.iAtIG K ~ TMEi i1AYE AEEli ItI/OY~D D1M IElS~D Vrfli MATS 11%dal.~ip/KS l~ MKiApI • Ouu1.t r+ . . w~a~-~rr~r iNFO~ru-ri~ ~I w,..~.. w~„ ^ piSCLAIIrER Of .IIrAAAANTIES 1 W+pE#tiTAND THAT TOLE ~TNE pfA~E~) Sx• • rwt?ssr.r olaculM AL.L wT1ES_ EIT11Ea E1V1tE58 OII Itu+uED. tNCt.uDlnlp AMY • t~Y'LIED WAM1MiTd OF M~nc~1A+~TAti11,1-r ort FIYN~ FOA A rA1tTltf,1W1 RrM'OSF. A~/O TW-T YpU MiE1TIlEA ARSLM~E NOit AUTMgAIii ANY OTNiR ri1180r1 TO ~$$Iy~E FOIL rOU A*1r LMNt.rTY Mt CZ+r~~GYlolr tarcTN THE sA1.E vi TnE• vEr~Crt, ,LxGE-r As GTrEMltlnt`3E p110VIDE0 W tltlwli'WG fr YOU IN Ai~t AYi'ACfMIFJ~it TAD THIS Cpw Y~MG't OR M w OOGWlNT OELIVAIIaED TI? t~1E t+MFE~t rME VtilMCLE IS OELlVA11RD . ^ "AS 15' 711E tlAO#Op 1/tchl{CLE IS SOLD -ws IS': MffTtiQUi I-t~iY WAR1bwTY EITNEp ~ ' ~rRx E111 RESS C+it IMPLIED TNS t~RpM~A 1MILL tiFAR Tt~E iiNT iRE E>tfKeliSf. OF AE• 0 t~111fIIP1[3 t']R CORREGTM/G•~/IY OEfEGTS TNA# Paf,BENzLr t=iciST'pR TNJ1T WV GC.Ci1111N THE VEHICLE. . DOCUltEKTARY sE£ ~ . DI5CL45uRESTAlWBMT GON~RACTUAt L15t:DYE-sIGLESW+tr} . I • tt.>=1taE~ a fE TiIAT10M F T/IE NIF17111~tAT10N Yp(~ SEE ON THE rrlliOpW FOiHA FOR THIS VE141CLf IS PAAT Of ~~ ~ TrNS C17WTgAGT iNFOR~AATiOiN ON TriE Wt+10pW tFQRht 01iEJ1~tIDES ANT CG'NTgA1~T TOTwi COwTRACT MICE ~ PIiOVISiONS IN THE CdMTaACT OF 6N.f. • /v IF J CANCEL TW$ IMUgCMASl: CONTMCT OA gEFUSE TO ~~~ ~~~ .,~ ACCEPT DSLIYERY Of. TFIE VEHICLE Of~DERfrD. EXCEPT ustTASSOwNICFsoR:r~-aEw .wS PEAIr11TTED 9Y U1~W, 1 WtLI. AT YOUR OPTIpN, FOAI^EIT. • wS D~awG S i • pct: twt ~ ~~~ _ E ~ _ 1 wGCEPT THE ABDv~ CONDITIONS (Cusjt. hlit~ls) x. • • ~~ THE CONTRACT PRICE OF 'rttE IdIOTOR VEHICLE CANNpT 6f= INCREASED AfTEA TkiS CONTRACT t4A5 BEER ACCEPTED sY 7HE DEw4Eii OR THE AUTKOWZEO DEJLL$A REPRESENT~ITIVE UNLESS TN~ lNCRfeJ-SE t$ pUl: TO THE PASSAGE pF A l.AW OA REGU4ATION OF ~T~+E C~w~ED STATES OA THE COAINOs/WE~LLTN WFNCN. iiSgl.NilES• ADDITION OF NEW EQUIPMENT TQ GEATAIN VEFltCI_E$: CHANGES IN TfIAriSP~oATAT10N DA EXISTING,TwIC RATES: pR, Iw 7tfE CASE OF FOREIGN Ir<ADE YEr+sCLES. IS DUE TO A RE-EVI-LUATIO~ QF THE ~tTEO STA7`E5 DOLIAA w+-i-ve; THE CUAAENCY OF TNIw GOLiNTRY OF A~IANUfAGTURB. , Tats CONTRACT tS NpT 81NfltN3 UPON EITHER THE DEALER OR TFit3 PURCHASER UNTIL SIGNED Br AN AUTMOflIZEG DEALER pEl'RE- SENTATIyg. YOU, Ti•4E BUYER YAY CANCEL THIS GpNTRACT A'ND RECEIVE R FULL REFUND ANY TIDE BEFORE RECEIPT, OF A COPY~OF TMS CONTRACT SIGNED $Y AN AUTHOWZEQ DEALER REPRESENT/1TIVE 8`I' CtitviNG WA1TTl=N NOTICE pF.CANCELtAI"IDN 70 THE DE~-I.ER. 1 CEATiFY THAT 1 AEt•OF LfG~1k O RAND wGKNOWLEDGE RECEsaT OF A COPY of tMIS CONTRACT. r S:9r-stax. al Vahlc{a Pu.tc t aL - aat~ 3 ` / a - /d S-Qlutur~ of ALtitloria~d CttlaNr Raprsse~tatiw X ~ iaata ~ y`~°/