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HomeMy WebLinkAbout08-22-11 1505610140 REV-1500 EX ~°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN County Code Year File Number Harrisburg PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 0 6 2 5 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 7 4 1 8 2 5 1 2 0 4 0 8 2 0 1 1 0 7 0 3 1 9 1 8 Decedent's Last Name Suffix Decedent's Firs t Name MI P A R K E R R O B E R T E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name 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 O 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 ~ 5. Federal Estate Tax Return Required death after 12-12-82) QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number G E R A L D J S H E K L E T S K I E S Q 7 1 7 7 7 4 7 4 3 5 First line of address 4 1 4 B R I D G E S T Second line of address P- 0 B O X E City or Post Office N E W C U M B E RL A N D State ZIP Code P A 1 7 0 7 0 ~ ~ ~•,~_, r Correspondent's a-mail address: g S l'12 k 1 e t S k 1~ S t O n e l a W• n e t 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. SIGNA PE N RESPONSIBL-E FOR FILING RETURN _ ___ VANESSA P. SHENK 5 HILLTOP ROAD BOILING SPRINGS PA 17007 SIGNATU AN R TAT DDRESS L !" ~~/ GERALD J. SHEKLETSKI,ESQ.414 BRIDGE ST., NEW CUMBERLAND PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 15D561D14D 1505610140 J 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: R O B E R T E• PARKER 1 7 4 1 8 2 5 1 2 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 and Notes Receivable (Schedule D) ................ ....... .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 3 1 1 4 8 . 3 $ 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. $ 1 4 4 . 7 2 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. 9 3 9 $ . 6 1 8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 4 8 6 9 1 . 7 1 9. Funeral Expenses and Administrative Costs (Schedule H) ................. . 9. 1 0 1 4 1 . 2 1 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ . 10. 11. Total Deductions (total Lines 9 and 10) .............................. . 11. 1 0 1 4 1 . 2 1 12. Net Value of Estate (Line 8 minus Line 11) ........................... . 12. 3 8 5 5 0 . 5 0 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. 3 8 5 5 0 . 5 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)(t.2)x.0 - 0 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .0 _ 0. 0 0 16, 0. 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0 0 ~ 17. ~~ 0 0 18. Amount of Line 14 taxable at collateral rate x .15 3 8 5 5 0. 5 0 1 g, 5 7$ 2. 5 $ 19. TAX DUE ..................................................... 19. 5 7 8 2• 5 8 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 150561,0240 J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME ROBERT E• PARKER __ STREET ADDRESS BETHANY VILLAGE WEST 5225 WILSON LANE APT. 218 _ ___ __. CITY ____ MECHANICSBURG Tax Payments and Credits: 1 Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments ._, B. Discount 3. Interest Total Credits (A + B) (2) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 0 • 0 0 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 5 , 7 8 2 • 5 8 Make check payable to: REGISTER OF WILLS, AGENT 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; ....................... ........ ^ Q c. retain a reversionary interest; or ............................... d. receive the promise for life of either payments, benefits or care? .................. .. ........................... ........ ^ 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receivin ade uate consideration? 9 4 ................................................................................ ....... ^ 3. Did decedent own an "in trust for" 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 beneficiary designation? .......................................................................... n I-'I 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 3 percent [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 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)]. Asibling is defined, unde Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. File Number 21 11 0625 ___ __ __ ~ STATE 'ZIP _-- ;PA !17055 (1) 5, 782.58 REV-1508 EX + (6.98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESIDENTEDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER ROBERT E• PARKER 21 11 0625 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH ~. RBC WEALTH MANAGEMENT MONEY MARKET FUND ACCOUNT 23,961.50 2. (BETHANY VILLAGE REFUND I 7,144.88 3• (PATRIOT-NEWS REFUND I 42.00 TOTAL (Also enter on line 5 Recapitulation) I $ 31 14 8 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: ROBERT E• PARKER 21 11 0625 - If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) a,.VANESSA P• SHENK B. c ADDRESS 5 HILLTOP ROAD BOILING SPRINGS, PA 17007 JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. 1. A. D6-06 PNC BANK CHECKING ACCOUNT #5004893953 2• IA 106-081#5005284551VINGS ACCOUNT RELATIONSHIP TO DECEDENT NIECE OF DATE OF DEATH DATE OF DEATH DECEDENT'S VALUE OF VALUE OFASSET INTEREST DECEDENT'S INTEREST 12,192.41 50• 6,096.21 4,097.011 50• 2,048.51 TOTAL (Also enter on Line 6 Recapitulation) I $ 8,144 72 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER•VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ca ~ a i t ur FILE NUMBER ROBERT E• PARKER 21 L1 0625 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three o(the REV-1500 is yes. DESCRIPTI ITEM ON OF PROPERTY NUMBER INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION TAXABLE 1 BANKERS LIFE AND CA pF ANaLicaeLEJ VALUE . SUALTY ANNUITY 4,647.31 100•DO 0.OD 4,647.31 POLICY NUMBER 8484647 TRANSFEREE - VANESSA P• SHENK (NIECE) 2• YMCA RETIREMENT FUND ANNUITY 103.99 100.00 103.99 TRANSFEREES-VANESSA P• SHENK-1/2 (NIECE) AND CELESTE PARKER - 1/2 (NIECE) 3• BANKERS LIFE AND CASUALTY ANNUITY 4,647.31 100.00 POLICY NUMBER 8484647 TRANSFEREE - CELESTE PARKER (NIECE) TOTAL (Also enter on Line 7 Recapitulation) ~ $ If more space Is needed, use additional sheets of paper of the same size. 4,647.31 ,398.6 REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ROBERT E• PARKER 21 11 0625 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ROBERT E• HEATH FUNERAL HOME, INC• 8,686.17 61 EAST SHIRLEY STREET, MOUNT UNION, PA 17066 B. ADMINISTRATIVE COSTS: 1 • Personal Representative Commissions: Name(s) o(Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. AttomeyFees: GERALD J • SHEKLETSKI, ESQ/ 3. Family Exemption: (If decedent's address is not the same as claimanPs, attach explanation.) Claimant 4. 5. 6. ~. 8• 9- 10 If more space is needed, use additional sheets o(paper of the same size. Street Address City State Zlp Relationship of Claimant to Decedent Probate Fees: LETTERS TESTAMENTARY Accountant Fees: Tax Retum Preparer Fees: LEGAL ADVERTISING - CUMBERLAND LAW JOURNAL LEGAL ADVERTISING - THE SENTINEL FILING FEES - INHERITANCE TAX RETURN AND INVENTORY ADDITIONAL PROBATE FEE TOTAL (Also enter on Line 9, Recapitulation) ~ $ 1,000.00 130.50 75.00 189.54 30.00 30.00 0,141.2 REV-1513 EX+ (Ot-10) Pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: ROBERT E. PARKER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY [ TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. VANESSA P. SHENK 5 HILLTOP ROAD BOILING SPRINGS, PA 17001 2• CELESTE PARKER 207 PIN OAK STREET PLEASANT GAP, PA 18623 Collateral FILE NUMBER: 21 11 0625 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Collateral 23,347.62 15,202.88 CENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV 1500 COVER SHEET AS APPROPRIATE II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ If more space Is needed, use additional sheets of paper of the same size. ~e it ~tententbereb That I , 1~©~.~i ~. ~r/l,/~1~ L I , of ~J~c=G~cs~ in the County o{ti~q~j~ ~.1/rhl~Zv~~Yt~ and State of ! ~ ,being of sound mind, memory and understanding, and considering the uncertainty of life, do hereby make, publish and declare this my last ~liCl and ~egtament, hereby rewking and making void any and all f crrmer Wills by me at any time heretofore made. FIRST : I direct that all my just debts and funeral expenses be paid by my Execut ye j hereinafter named, as soon after my decease as may 6e convenient. ~ SECOND : I give, devise and bequeath `~ uroo d ~v ~ ce Uh iced /yleflrxlco~~u+n~h ~ h~.'efak ~e~ot ~vJ ~ 6e use~f ~r ~121,Q~ry .Q~e~td2a- /~ ~e ~~/n?ce. oF~AyieDest~ f~ be. d~~~dz.d -~ b~r~~ ~s~ ~~r AND LASTLY.-I do make, constitute and appoint f~'G~KQ~xL. ~~ r~~ f '" to be Ezecut ~ l~kof this my last Will and Testament. ~)n ~itneg8 3~1t)ereuf I have hereunt ubs d my name, and affixed my seal, the ,Q.r~-C..Q--r,`,~__ day of in the year one thousand nine hundred and ~ - Signed, euled, published and a~Tared by ~,~ ~ P z r r- ¢JA o,,-~ ~ the testata ,~ above named, as and for v~j j S last Wil! and Testament, in the presence of us, who have at request, subscribed our names in presence, a in the fpr`ese~nce of each Witne ~t ~r?t,~l~L t(~. (J -~:,G Witne `I 1~ 1 0 P'r p.~, Amendment to Last Will and Testament of Robert E. Parker It is my intent to change a portion of my will dated July 2 1998. I wish to change my bequeath to the Grace United Methodist Church in Mapleton Depot, PA to read that NO monies be given to them, to nullify the previous designation on $5000 to said church. The balance of any estate left when all debts and funeral expenses are paid should be divided equally between my nieces Vanessa Parker Shenk and Celeste Ann Parker,. This document was signed and declared by me, Robert E. Parker and witnessed by the individuals below on the date June 10 2010. Signed Robert E. Parker > ~ ~~ ~ ~ ~ The undersigned, at request,have been present to witness this signature. s~_ °~ I ~~ ~ ~ ~~ ~~" 1J~~#~c'~~~(~ ~~1~r~;~,~~fl~'~#~ ~-+' ~ Renaissance Place ' ~, ~tG~-, ~ ~~ 7 635 North 12th St, 2nd FL ~ ~ ~ ~ Lemoyne, PA 17043 ' Phone: 717-724-4200 Toll Free: 800-480-7497 Fax: 717-724-4239 June 2, 2011 STONE, LaFAVER & SHEKLETSKI ATTN: Jennifer Mearkle 414 Bridge St. P.O. Box E New Cumberland, PA 17070 RE: Robert E. Parker Dear Ms. Mearkle: Mr. Parker's RBC account was opened 2/25/2009 and plated as follows: Robert E. Parker 5225 Wilson Lane APT 35 Bethany Village West Mechanicsburg, PA 17055-6663. On 4/08/2011 the account was valued at $23,961.50. Regards, Robert M. Opane Vice President - Financial Advisor RBC Wealth Management RBC Wealth Management, a division of RBC Capital Markets Corporation, Member NYSE/FINRA/SIPC Asbury Communities, InC. Check Number: 0000201238 To: Estate of Robert E. Parker 33867 Check Date 05/12/2011 Invoice Number Date Description Amount Discount Paid Amount MAY092011 05!01/2011 Overpayment Refund $7,144.88 $.00 $7,144.88 $7,144.88 $.00 $7,144.88 Jun, 20. 2011 2:38PM PNC BANK 412-705-2747 No. 8509 P, 1 ~~ llaol>ws tl~E war June 20, 2011 Gerald J Shekletski, Esq. Stone Lafaver & Shekletski Attorneys at Law 414 Bridge St POBoxE New Cumberland, MD 17070 RE: Robert E Parker SSN: 174-18-2512 DOD: 04-08-2011 Dear Mr. Shekletski: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Chcckiag Account Account # 5004893953 ROBERT' E PARKER VANE$SA P SHENK DOD balance: $ 12,192.41 non interest bearing Savings Account Account # 5005284551 ROBERT E PARKER VANESSA P SHENK DOD balance: $ 4,09b.80 + 0.21 accrued interest Interest paid O 1-01-2011 thru 04-08-2011 $ 1.70 X'1'D Establishcd: 06-292006 Established: 06- l 6-2008 Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking aad Savings). We do not procesa any Snancial traosactions or provide atatementa. If you need assistance with any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Sank branch oi~ce. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC Page 1 of 2 r ~~ Jun, 20. 201 i 2.38PM PNC BANK 412-705-2747 No. 8509 P, 2 This message is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law, If the reader of this message is not the intended recipient or the employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that arty dissemination, distribution or copying of this communications is strictly prohibited If you have received this communication in error, please notes me immediately by reply or by telephone at 800-762-1775 and immediately destroy this faxed document. Page 2 of 2 yRF YMCA RETIREMENT FUND SAVINGS FOR LIFE April 20, 2011 Vanessa Shenk 5 Hilltop Rd. Boiling Spring, PA 17007-9709 Dear Mrs. Shenk: We were sorry to hear of the death of your uncle, Robert Parker. Please accept our deepest condolences in your bereavement. When Mr. Parker retired, he selected a Principal Guarantee Single Life Annuity which would pay you and your siblings the remaining balance of his account that was not paid during his lifetime. The balance as of the retirement date was $7,138.84. lle received annuity payments for 29 years and 8 months at the rate of $47.55 per month. As a result, he received a total of $16,927.80 in payments, which was in excess of his balance at the retirement date. Therefore, no payments are due. However, there is a death benefit of $ 103.99 now due you and your sibling, Celeste Parker in the amount of $52.00 each. Enclosed is a Retiree Death Benefits Claim form which you will need to sign in the presence of a notary public, along with the Death Benefit Option form. Please remember to include your Social Security number which is required by the Internal Revenue Sen~ice. We will also require a certified copy of the death certificate for Robert Parker. BOARD OF TRUSTEES Eric D. Mullins Chairman Reid S. Thebault Vice Chairman /ohn A. Clymer Richard A. Coliato Harold Davis Elizabeth T. Frank Carmelite Gallo Carlos Gonzalez William A. Holby Eric K. Mann Georganne F. Perk; ns Sandra Berlin Wa1Fer G. Rainey Williams, /r. Peter D. Ziegler MANAGEMENT John M. Preis President and CF,O Generally your settlement is taxable as current income. If you elect to take a full distribution, the Victor /. Raskin Chief Investment Officer Fund will automatically withhold 20% of the taxable amount towards federal tax. IE you prefer. to Vanessa A. Bonlons roll over all or the taxable portion of your settlement into an Inherited IRA, please complete the enclosed Rollover Form for Death Ben jit Claim form. Taxes will not be withheld on the amount bein svP YMCA Reiatinns rolled over. We need an acceptance letter indicating that you are rolling over your settlement into chieflnformatio uOt~~e,:~ an Inherited IRA. Vincent M. De Sio Upon return of the r_laim form and a certified copy- of the death certificate we will issue Chief FinancialOtficer , you a settlement check. If you have any questions or need additional assistance please feel free to /amen G. Kirschner , contact our Customer Service Department at 800-738-9622, Monday through Friday, 8:45 AM_ 6:00 PIVI EST. SV$ Strategic Development John Quinones Sincerely yours, General Counsel ~ ~i~ ~ „ _ Q_ ~~r ~ +~ ~ ~ ~~ ]40 Broadway . ,,, - i • 111~~~../// Vew York, NY 10005- (197 Tel 646.458.2400 or i~IlrCela De1tr1Ch 800.RET.YMCA Vice President-Customer Service Fax 646.458.2550 info~ymcaret.org www.yretirement.org IV1-D/mmp Enc The mission of the YMCA Retirement Fund is to empower YMCA employees to achieve economic security, resulting in loyalty to the Yh(CA Movement. Incorporated under the laws of the State of New York, serving YMCAs since /uly 1, 1922. ~"` PRESIDENT'S -----~ HONOR CIRCLE Lifetime Member Jeffrey D. Johns, CLTC, MDRT Insurnrace Agent ~/A NP55~, (~kwtP ,5~~"L C~eCl~l ~S g yPn-~ P~Yoti+ ~ 5 ~ I , -~ 0~3. 37 ~~~~u s s'~~- ~,`~~- ~i v BANKE RS I For the bite at LIFE AND CASUALTY COMPANY Yaur retirement BANKERS LIFE AND CASUALTY COMPANY Annuity Claims Department- P.O. Box 1937 Carmel, Indiana x6082-1937 (800)621-3724 June 9, 2011 Ms. Vanessa Shenk 5 Hilltop Road Boiling Springs, PA 17007 9709 RE: Robert E. Parker, deceased Policy: 8484647 Dear Ms. Shenk: Please accept our sincere sympathy on the passing of your loved one. You are the beneficiary of the contract policy listed above. Based on a preliminary review, we are in need of the following items to process the claim: The Enclosed Beneficiary Claim Form and Option Form. An Original Certified Death Certificate. (Only one death certificate is necessary. We cannot accept photocopies.) The Original Annuity Policy. (If the policy is not available, please make a note of this on your claim form.) Once the documentations have been received, a Claims Adjuster will review the cases to determine that all requirements to service your claims have been met. The Claims Adjuster will then either contact you directly if additional information is needed or complete the servicing of your claims. Please contact our Customer Service Department at 1-800-654-3072 by phone or 1-317-817-4431 by fax if you have questions or require additional assistance. Sincerely, Judith Mary Kaiser Annuity Claims Assistant Bankers Life & Casualty Company (317) 817-4431 fax