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HomeMy WebLinkAbout07-25-11 (2)J 1505610143 REV-1500 Ex (01.11), OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 80X.280601 INHERITANCE TAX RETURN 21 10 1187 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 192 20 1198 10 23 2010 08 27 1926 Decedent's Last Name Suffix Decedent's First Name MI FISHER SHIRLEY D (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ ga. Future Interest Compromise (date of death after 12-12-82) a g Decedent Died Testate (Attach Copy of Will) ~ ~ ecedept Mainta'ned a Living Trust Attach Copy of 1lrust) 9. Litigation Proceeds Received ~ 10. Spousal P vent Credit (date of death between 12-31 ~1 and 1'-1-95) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required ~ ~3. Total Number of Safe Deposit Boxes ~ 1, Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL T'AX INFORMATION. SHOULD BEr.,~~RECTED TO: Name Daytime Tele'ph~ Number EDMUND G MYERS (; 717) 7~~ 4 5 4 Q~. -~~ n ~-rl ~ Ca ~ ~~ REGISTER Ok~~f13JUSE ~LY ~'= First line of address `~~ ~ "~ r~r ~ ~.:a C ...,.~ --_ _.~ .? 301 MARKET STREET - Second line of address i.. `~ d ~~,~ PO BOX 109 City or Post Office DATE FILED State ZIP Code LEMOYNE PA Correspondent's a-mail address: egl'1'1~dSW.COm 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 (s based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBL OR FILING RETURN DATE ~ ~rYt~ri- Susan Ann Haverstick ~ -~' ~, ~ ~ (I ADDRESS 55 Lone Oak Drive, Marysville, PA 17053 -- NATURE OF EPARER OTHER THAN REPRESENTATIVE DATE EDMUND G. MYERS ~- f ADDRESS 301 MARKET STREET, Lemoyne, PA L 1505610143 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Side 1 1505610143 ~~ J 1505610243 REV-1500 EX Decedent's Name: Fisher, Shirley D Decedent's Social Security Number 192 20 1198 RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 6, 4 8 5. 0 4 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. 42 , 4 94.84 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous I~ap; Probate Property (Schedule G) ^ Se arate Billin R t d p g eques ............ e 7. 4 61 , 94 0.16 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 510 , 920.04 9. Funeral Expenses 8 Administrative Costs (Schedule H) ....................................... 9. 17 , 4 05.82 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) .............................. 10. 8 , 3 7 2 . 0 6 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 2 5 , 7 7 7 . 8 8 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12, 4 8 5 , 14 2.16 13. Charitable and Governmental Bequests/Sec 9113 Trusts fqr which an election to tax has not been made (Schedule J) ............................................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14. 4 8 5 , 14 2.16 TAX COMPUTATION -SEE INSTRUCTIONS FQR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 15. 16. Amount of Line 14 taxable 4 8 5 14 2.16 at lineal rate X .045 r 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due ................................................................................................................. . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 0.00 21,831.40 0.00 0.00 21,831.40 Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-10-1187 DECEDENT'S NAME Fisher, Shirley D STREET ADDRESS 4837 Trindle Road CITY Mechanicsburg STATE PA ZI P 17050 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. (1) Total Credits (A + B) (2) (3) (4) (5) 21,831.40 10,526.32 11,305.08 Make Check Pa able to REGISTER OF WILLS, AGENT. r. :~ .' .. .>:. w .~g.~~ax s- $~,~.~.~ ~gx:w:~ ~,v ... ,. y+ ~~ g~y~' ~ti$... ~.. ?. ks~ b~ w s, .~ ,~a~ ,. a .,~~ ....~ ~. ,:,fa .:~ „.8~ ,.., . ~,~. ?sx~x`~,.?e.$~i s3.>., i$>~.. , x> ... ..„rs, wG s.a,.~`~t ~vs~~....:a°~`Y<, s~~v~a°..3 .~,,i~~ r~~.au .. spa , , v f 9 7~?~Sba, ~- fieex~ ,. .,.?£ ~'~ - y> G e 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? .................................................................................................................... x 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 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+ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Fisher, Shirley D 21-10-1187 All property jointly-owned with right of survivorship must bedisclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 Compushare -Shares owned by the Estate of Ray Fisher 59.46 4,935.18 that pass to the Estate of Shirley Fisher 2 Compushare 59.61 1,549.86 TOTAL (Also enter on Line 2, Recapitulation) 6,485.04 (It more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Fisher, Shi D FILE NUMBER 21-10-1187 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. (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 E (Rev. 6-98) Rev-1510 EX+ (8-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPER COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Fisher, Shirley D 21-10-1187 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 C OVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF TF20ANSF~ERSATTACf-I A COPY OF T~E DEIED ~oREREAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF' DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Mass Mutual Financial Group Non Qualified Annuity - 260,771.08 260,771.08 Contract No. TRN44809952 Beneficiary: Susan Haverstick 2 Mass Mutual Financial Group Non Qualified Annuity - 74,903.44 74,903.44 Contract No. TRC44763521 Beneficiary: Susan Haverstick 3 Smith Barney IRA Account No. 724-6250D-15 - 122,849.88 122,849.88 Beneficiary: Susan A. Haverstick 4 Smith Barney IRA Account No. 724-6250D-15 - DWS 3,415.76 3,415.76 Short Duration Plus Fund Beneficiary: Susan A. Haverstick TOTAL (Also enter on Line 7, Recapitulation) I 461,940.16 (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~I3,ITAjJ~ T~ R~T~RN ANIA R ID N DE ED N SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE_OOSTS ESTATE OF FILE NUMBER Fisher, Shirley D 21-10-1187 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N A. FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s) Commission rJaid 11, 518.50 2. Attorney's Fees JOHNSON DUFFIE 5,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation;) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. I Probate Fees 149.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 250.00 7. Other Administrative Costs 487.82 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 17,405.82 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 Fisher, Shirley D 21-10-1187 ITEM NUMBER DESCRIPTION AMOUNT Funeral Exuenses 1 Malpezzi Funeral Home 11,518.50 H-A 11,518.50 Other Administrative Costs 2 Cumberland County Register of Wills Office -Filing Fees for Inheritance Tax Return and 30.00 Inventory 3 Reserves: Out of pocket expenses 200.00 4 The Cumberland Law Journal -Notice of Estate Administration 75.00 5 The Patriot News -Notice of Estate Administration 182.82 H-B7 487.82 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-OS) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Fisher, Shirle D 21-10-1187 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. (If 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) ,. COM INWE ANNT DECEDN~N$,RNANIA SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Fisher, Shirle D ~ 21-10-11 87 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 Susan Ann Haverstick Daughter Entire Estate 55 Lone Oak Drive Marysville, PA 17053 Tota I Enter dollar amounts for distributions shown above on lines 15 throu 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 T~Ax IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -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 SHIRLEY D. FISHER SCHEDULE OF EXHIBITS EXHIBIT A Last Will and Testament for Shirley D. Fisher signed and dated December 17, 1992. EXHIBIT B Date of Death Valuation for PNC Checking Ac°count. EXHIBIT C Morgan Stanley/Smith Barney FMA Account No. 724-71933-16 EXHIBIT D Mass Mutual Non Qualified Annuity Contract No. TRN44809952 EXHIBIT E Mass Mutual Non Qualified Annuity Contract No. TRN44763521 451157 a 1~ • ~ ~~ t11 ~ ~ ~ Z r ~ ~ r~.y .- . rt.~ ~.n ~ ~ ~ n ~~, c~ ~ ~ _-- m ~~~ ~ N OF ~ ~ ~ -~ ~~ ~~ SHIRLEY D. FISHER N ~ O -..a I, SHIRLEY D. FISHER, of the Borough of Mechanicsburg, County of Cumberland, and ~orrimomvealth of Penns;~lvania, being of sound and disl?orng mi.~!d, memory and unders±anding,~ do hereby make, publish and declaze this as and for my Last Will and Testament, hereby revoking all other Wills heretofore made by me. ARTICLE I I direct the payment of my legal debts and the expenses of my last illness and disposition of my remains from my estate as soon after my death as conveniently may be done. All of the foregoing shall be considered expenses of the administration of my estate. ARTICLE II I bequeath all of my tangible personal property (excluding cash or securities), together with any existing insurance thereon, to my husband, RAY P. FISHER, if he survives me for a period of thirty (30) days. If he does not so survive me, ,I bequeath .said tangible personal property to my daughter, SUSAN ANN HAVERSTICK. If both my husband and my daughter are not then living, I bequeath said tangible personal property to my grandson, CHRISTOPHER J. HAVERSTICK. - ARTICLE III I devise and bequeath all of the residue of my estate to my husband, RAY P. FISHER, if he survives me by a period of thirty (30) days. If he does not so survive me, I devise and bequeath all of the residue of my estate in equal shares. to my daughter, SUSAN ANN HAVERSTICK. If both my husband _^~~; _° ~-,~. __ ,.,~ ._,_ z:y+ ~-_ -~ .. . ~: --, --r- ,.~ `~.} ~~ - - ; - -- -- >: r 7.~. _. ~T .. ~~ ~-~ z and my daughter are not then living, I bequeath said tangible personal :property to my grandson, CHRISTOPHER J. HAVERSTICK. ARTICLE IV I appoint my husband, RAY P. FISHER, Executor of this my last Will. In the event of his inability or unwillingness to act or continue to ~ act as Executor, I appoint my daughter, SUSAN ANN HAVERSTICK, Executrix. ARTICLE V I direct that my Executor, or his successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction in which they may be called upon. to act, insofar as I am able by law to do so. IN WITNESS WHEREOF, I hereunto set my hand and seal this J'~'L-day of December, 1992. ~ ~ p - ~ `~~ - (SEAL) .~ Shirley D, sher Signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and ~ent`in the presence of us; who at her request, in her presence and in the presence of each other have ~ ~~~~¢ n subscribed our dames as witnesses. d~ i s~ ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA . ss: COUNTY OF CUAr1EEIZLAND . I, Shirley D. Fisher, 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 Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. - .,~~~ hirley D. ' ~ er ` Sworn or affirmed to and acknowledged before me, by Shirley D. Fisher, the Testatrix, this ~~ day of December, 1992. ~ ~ Notary :Public NOTARIAL SEAL DIANt~E LEAIIG~ NOTARY PU6LIC lEMOYNE BORd. CUMBERk,ANU.CO. ~iY COMMISSION EXPIRES DEC. 21, 1993 `~1 r `~. ~~ -.~". -r-.~ _-„__, ., .. r. ~ ~„ .. ~...-r AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA .. ss: COUNTY OF CUMBERLAND We, ~ ,-CZ ~~"~J'~`' and ~' ~ . t~~~..r~',-~. the witnesses whose names are signed to the foregoing instrument, being duly qualified according 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 tha.± she executed it ~s 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 least 18 years of age, of sound mind and under no constraint or undue influence.:- ~~.`fi ~,lA~PR ..~ ~~~~ x ~~~ Sworn to or affirmed to and subscribed to before me by ~ - ~ ~,~ f~~ and `~"~ ~ ~'~1.~.. ,witnesses, this ~~~day of December, 1992. ~_ Notary Public ~:, NOTARIAL SEAL DIANNE LE~iIG. NOTARY Pt18LIC LEMOYPJE BORO. CU~tBERLAfiiD CO. MY CrJ~1NfISSiON E%PIRES DEC. 21. 1993 3 ~.~ '' _ ~ '~_ _i, ~ ~ - ~ ~. `~ 1. r-^- 2 -^z~-~ _, _ `,~~ -_ -.'~^^ ~ -. -....`".°"--~r~-..-...--ate -- ,-,.. ,- . Jan, 25. 2011 11:28AM PNC BANK 412-705-2747 No. 8007 P. 1/2 _ .. QPNC January 25, 2011 Dana L Wiesman Johnson Duf~ie Stewart & Weidner Attorneys at Law 301 Market St P O Box 109 Lemoyne, FA. 17043-0109 RE: Shirley D Fisher SSN: 192-20-1198 DOD: 10-23-2010 Dear Sir/Madam: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checiang Account .. . Account # 5002006097 Established: 09-15-1999 SI3IRLEY D FISHER DOD balance: $ 7,810.12 + 0.03 accrued interest Interest paid 01-01-2010 thru 10-23-2010 $ 3.45 YTD Please note that this off ce provides date of death balances for deposit accounts (I-RAs, Cns, Checking and Savings). We do not process any financial tra~asactions or provide statements. If you need assistance with any of these items, please calf I-SSS-PNC-BANK {1-888-762-2265) or stop by your local PNC Bank branch off ce. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC Page 1 of 2 ~, n ^" o~ ' ~ M M ~ C ""' n ~~~ ~ y .~ a `~o~ ~, ~ ~s 5 ~~ a 4a ~~ d y b '~ O o:. 0 V ~ ~ i ~ , ~ Ln ~' C ~ ~ ~ c=--~~ (/) C a~ ~ o ~ ~~ ~ ~ 0 j ~ M y ~ * a~ IN 0 a M~1.SSMtltllc11 FINANCIAL GROUP" `.l,t...t.i;t~.'!;. ',1~,iu.tl f t!: I:',.t:r.tit,~: l , .~+i+.t~;~ ,u;u .tl~;~;i,t:.~, 11•rm.'~.it! ~,I•\ tiI ! i +-!!!itll ~~ ~~ ,~ ut.t~~n:un:al . um SHIRLEY D FISHER 55 LONE OAK DR MARYSVILLE PA 17053-9751 QlldI'teCly Stcitetllerlt For the :Period Of: 07iU 1.%201 U - 09/30/2010 Cj•~ec~its ty Date: +~; 93 5, j? Owner: Sl-I[RLGY D FISHER Joint Owner: iV/A Annuitant: SHIRLEY D ~1SHER Cin~tr~4ct ~: "f RN44$09I52 lss>`ie Date: 12/20/2p05 Plan Type: 1~1on-Qualified Contract Values - For this Quarter Year to Date From Issue Date Beginning Balance $259,623.96 $257,362.26 N!A Payments $0.00 $0.00 $307,734.26 W ithdrawalsOO $0.00 $0.00 $8,030.00 Investment Performance !O $1,147.12 $3,408.82. $38,933.18- Ending Balance $260,771.08 Total Death Benefit $260,771.08 Cash Sur•ender ValueOO $249,017.91 lOlnvestrnent Performance includes applicat~le credits and charges for contract riders chosen. 201E values are withdrawn ft•om a Lung'Cenn Guarantee account, a contingent defer•ed sales charge (CDSC) and a market value adjustment (1V1VA), also known as an [nterest Rate Factor adjushment, may apply. The MVA may increase or decrease the Contt'act Value. Rcl;istered ERIK M. V'ATTEIZ. Representative: MORGAN STANLEY 1NSURANCF_. SERVICES, INC. Rate of Return 1 1 NORTH 3RD S•I'. 2ND 1~L HARRIS[3URG PA 17101 ~"i~ar-'fo-Dote: + 1.32`%, Since Contract Purchase: - 2.92`%, Annuity Service {800) 272-2216, Monday through Friday ~ Phase visit www.massrnutual.tom/asc for further details. Centel : 4:00 a.m. - 8;00 p.m. F,astern time Ch~~tu~r.c nttrv nJ~t~ri-t rep-r~~-tlcttt' irtJnrnutti~ut oft acx~otutt cu/uc•.~', unit f~ttltre.~•. •%u~ttl~t~°t.f~t•tuattc~w.° tort!/~e~~yorttt selc~c'lc~tl !r-cttt.rrri~tit~tt.v hy' vrsltitt~r: Internrt Sitc: tivww.tnaastnutual.cotttr'asc MassM~~~ttlal TRI~NSITIONS SELEtC'T~1~' V,1R1,~13I~[: ;~NNUf~[`Y NATTER ERIKM. TRM44805952 10/03/2010 Page 1 of 6 .M aN ~IMutual Ms~tiarhusetL~ Mutu;Q Life Insurance Company ;and aCCllialcs, Springlicld M11A Ul I l t-UfIUI www.m;usmutual.cum Quarterly Statemen SHIRLEY D FISHER 55 LONE OAK DR MARYSVILLE PA 17053-9751 For the Period Uf 07/01 /2010 - 09/30/20 •.~. ':i::::~ :::''..ii:.~' ::.: ~(}wn.~ lP ~ ~e~ anti<:~:~:: ..:~ SH:II~LI~:IF: I~:F~[~hI6.R:::~`::>:.. ~ .... :.:~~ ~~~.::. ....:..~~....:ar~ ..........::..:.. ~:...:.:.:..:.., .....:....:..:::......,...........::.....:...:...:.. _::..::.......::..: <:::: .. ,..:a~n:::~Jwne 1 ...:..::.::.. P . :...:....,..:.....:.:.:.~:..:...: Anne Pant;:.::::::::::;: ~;:::>::: ~ :::::: ....:..:. S ~IIRI.:~Y l~ .~~~ ~-[:~[~.,....:::...:...:.....'.. ~tam~t~~U~~~L .... .............................:.:...:................:.......................... ..~.....:..:., :...::.::::...::::..P~~~..~q~~t ~~:::::<~:~'~`~~s:R:t~c~n~:C`ustum: ~~st~..:..:~,`: r~ue.. Date .................... ..... ,`. ..~ .......... .....,.... :. :~:::.;:::.:::<~:.: .....~....~.. .e,..:..:.. ~Utl.:.. VII:L~tCt~.:...:.,;....;::.;~~..: ~.::.. .:: :..: For This Quarter Year To Date From Issue Date Beginning Balance $74,347.45 $73,290.42 N/A Payments $U.UO $O.OU $106,355.38 Withdrawals $U.UU $U.OU $22,995.54 Investment Performance* $555.99 $1,613.1)2 $8,456.4.0- Bnding Balance $74,903,44 Total Death Benefit $74,903.44 * Investment I'erformanec includes applicable credits and charges for contract/certificate features chosen under the "transitions Custom Plan. Starling in Apri12012, you will receive a persistency credit based on your contract/certi6cate value at that time. Rc~istcred L:R1K M. VA'fT1sR Representative: MORGAN S'1'ANL1sY INStJRANCG SI:RVIClsS, INC. 11 NUR'f}[ 31tll S'['. ZNI) ILL IIARRISBIJR(i PA 17101 :lnnuit3• Service (800) 272-2216, Monday through I'riday Center: 8:OU a.m. - 8:00 p.m. I'sastern time Owners may obtain tep-ro-cline ittfvrntcttiort on ctecount valcces, tacit valcces, fte~ed perfvrmarece and perfvrnc selected tra~esactioics by visiti~eg: Internet tiite: www.massmutua-l.com/asc NATTER ERIK M. TRC44763521 10/OL'1010 0006053 MassMutual TRAM S ITI OI~1 S'~ VARIABLE ANNU lT1' Rata of Return Year-To-Dote: + 2. I ~'% Since Contract Purchase: - I.-t')% Please visit www.massmutual.camlasc for filrther details. Page 1 of 8 31 16-Ut -UO-01 01992.000'1-000©401