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Home My WebLink About10-31-11 (2)--~ REV-1500 Ex (o,-,o> 1505610143 ,~' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes DEPARneENTOFREVENUE COUnty Code Year PO 80X.280601 File Number Harrisburg, PA 17128-0601 INHERITANCE TAX RETURN 2 ], 11 0 016 9 ENTER DECEDENT INFORMATION BELOW RESIDENT DECEDENT Social Security Number Date of Death Date of Birth 231 86 4020 02 O1 2011 06 02 1922 Decedent's Last Name Suffix Decedent's First Name MI WIRTH JOHANNA (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 FILL INAPPROPRIATE OVALS BELOW REGISTER OF WILLS ® 1. Original Retum ^ 2. Supplemental Return ^ 3. Remainder Retum (date of death ^ 4. Limited Estate prior to 12-13-82) ^ 4a. Future Interest Compromise (date of death alter 12-12-82) ^ 5. Federal Estate Tax Retum Required ® 6. Decedent Died Testate ~ Decedent Maintained a Livin Trust 0 (Attach copy or wll) ^ (Attach copy or Trust) t7 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 1 p, spousal Poverty Credit (date of death between 12-3, b, and 1-1-95) ^ 11. Election to tax under Sec. 9113(A) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX NFORMATION SHOULD BE DIRECTED T0: Name HAMILTON C DAVIS Daytime Telephone Number 717 532 5713 First line of address 20 EAST BURD STREET Second line of address SUITE 6 City or Post Office SHIPPENSBURG REGISTER OF WILLS USEt.O,~ILY L") - ~ - _ r- ,, :,-. X77 r -:.~ ` f`-r ~ r.~. . 1,~- -~..~ t~`,~ ~~ r l~ c, .~ ::`~ : ~ --- - ._~_ ~ , _, .. ~ _. ~ ~ C~ : J -- ,. , _ .. ''.i J?~~ ~-'1 ` ..'.~ .__j ' State ZIP Code DArT~~ILED -_? PA 17257 -~'~ ~- `--~~e^^~-~^~~~ Correspondent'se-mail address: hdavis@Zullinger-Davis.com Under oenattios ~t ~e,;.~,,. ~ a__~___ .~ ,~~a~ ~ ~~ave examtneo this return, including accompanying schedules and statements, and to the best of my knowledge and belief, I Is e, 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 RESPONSIB FOR FILING RETURN /.-~ J . n ~ _ ~ ~ ~. w ~ r~, r r~ PETRA S. WIRTH I ADDRESS 406 E. OLD YORK ROAD, CARLISLE, PA 1701x' SIGNATUR F PREPARER OTHER TNnu ocoocev.~r. ~~, ,... /~~~"~~'"~~` ~ Hamilton C Davis ADDRESS 20 East Burd Street, Shippensburg, PA 17257 L..._ Side 1 1505610143 1505610143 DATE J 1505610243 REV-1500 EX Decedent's Name: w i R T H J O Fi A N N A Decedent's Social Security Number , RECAPITULATION 2 3 1 8 6 4 0 2 0 1. Real Estate (Schedule A) ........................... ................................ ............................... 1. 2. Stocks and Bonds (Schedule B) ............ ................................................ ................... 2. 201, 497.98 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C) .......... 3 4. Mortgages 8 Notes Receivable {Schedule D) ................ .......................................... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5, 6. Jointly Owned Property (Sched l F 189,801.50 u e Requested ............. g, 7. Inter-Vivos Transfers & Miscell e m l aneous Non , e -Probate Pr p (Schedule G) ~ Separate Billing Requested ............. ~ 8. Total Gross Assets (total Lines 1-7) ..................... 761,993.72 ............. ..................................... e. 9. Funeral Expenses & Admini t ti 1,153,293.20 s ra ve Costs (Schedule H) .. .............. ......................... s. 30,290.46 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .. .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................ 1 , 8 61.6 5 ...................................................... 11. 12. Net Value of Estate (Line 8 i 32 , 152.11 m nus Line 11) ............................................................. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12. an election to tax has not be 1 , 12 1 , 1 4 1 . 0 9 en made (Schedule J) .......... ....................................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ......... .............. . 14 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABL 1 ~ 12 1 , 1 4 1 . 0 9 E RATES 15. Amount of Line 14 taxable at the spousal tax rate or , transfers under Sec. 9116 (a)(1.2) X .00 16. Amount of Line 14 taxable 15. at lineal rate X .045 1 , 121 , 141.0 9 1s. 17. Amount of Line 14 taxable 5 0 , 4 51 3 5 at sibling rate X .12 . 18. Amount of Line 14 taxable 17' at collateral rate X .15 18. 19. Tax Due ......................... ....................................................................... ..................... 1s. 50, 451.35 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERP AYMENT. Side 2 1505610243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 _ 11 _ 00169 A• Prior Payments B. Discount 3. Interest 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. 44,526.00 2,343.47 Make Check Payable to: REGISTER OF WILLS, AGENT. (3) (4) (5) 46,869.47 0 ~_ -_ 3,581.88 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred :............... Yes No b. retain the right to designate who shall use the property transferred or its income :.................................... ~ O c. retain a reversionary interest; or ............................ x 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 x receiving adequate consideration? ................. 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 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. §9196 (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 ears 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)]. • sibling Is defned under Sect nt9102 as an individual whothas at least one patient in aolmmon withphe decedet wfiether by tilood~o ado ptlon. Total Credits (A + B] (2) Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 50,451.35 SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WIRTH, JOHANNA All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER ~ DESCRIPTION 1 M&T INVESTMENT ACCOUNT, ACCOUNT NO. AYC011041 (SEE I ATTACHED VALUATION) FILE NUMBER 21-11-00169 UNIT VALUE ~ VALUE AT DATE OF DEATH 201,497.98 TOTAL (Also enter on line 2, Recapitulation) 201,497.98 SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WIRTH, JOHANNA FILE NUMBER 21 - 11 - nn~ao mciude 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. ITEM NUMBER DESCRIPTION 1 WESTERN & SOUTHERN LIFE ANNUITY CONTRACT NUMBER W0020583202 (SEE ATTACHED VALUATION) - PAYABLE TO ESTATE AS BENEFICIARY 2 M8T MTB MONEY MARKET FUND CLA, ACCOUNT NUMBER AZD325421 (SEE ATTACH VALUATION 3 HOUSING DEPOSIT REFUND FROM CUMBERLAND CROSSINGS (NOT YET RECEIVED) 4 M&T BANK CHECKING ACCOUNT NUMBER 1144391 5 M&T BANK SAVINGS ACCOUNT NUMBER 150041981883 6 ABN AMRO BANK -CHECKING ACCOUNT (EURO TO DOLLAR EXCHANGE RATE AND CONVERSION -SEE ATTACHED) 7 ING BANK -CHECKING ACCOUNT (EURO TO DOLLAR EXCHANGE RATE AND CONVERSION -SEE ATTACHED) 8 ING BANK -SAVINGS ACCOUNT (EURO TO DOLLAR EXCHANGE RATE AND CONVERSION -SEE ATTACHED) 9 MET ED REFUND 10 MISCELLANEOUS HOUSEHOLD GOODS AND PERSONAL EFFECTS 11 MISCELLANEOUS REFUNDS 12 IRS 2010 REFUND TOTAL (Also enter on Line 5, Recapitulation) VALUE AT DATE OF DEATH 80,121.50 176.76 13, 770.00 700.00 50,163.62 5,817.79 33.68 36,141.25 197.54 500.00 215.36 1, 964.00 189,801.50 COMMONWEALTH OF PENNSYLVANIA SCHEDULE G INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MI$C, NON-PROBATE PROPERTY ESTATE OF WIRTH, JOHANNA FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 20is yes. ITEM I DESCRIPTION OF PROPERTY NUMBER I Include the name of the transferee, their relationship to decedent DATE OF DEATH % OF antl the date of transfer. Attach a copy of the deed for real estate. VALUE OF ASSET DECD'S EXCLUSION ~ TAXABLE VALUE 1 I HARTFORD ANNUITY CONTRACT NUMBER 7a~,215.46 INTEREST i (IF APPLICABLE) I I f 711239491 (SEE ATTACHED VALUATION) - I ~ 741,215.46 f PAYABLE TO THREE CHILDREN IN EQUAL SHARES ~ i I 2 ~ M&T INVESTMENT -IRA ACCOUNT NUMBER 2o,~~a.2s AZE016292 (SEE ATTACHED VALUATION) - 20,778.26 PAYABLE TO THREE CHILDREN IN EQUAL SHARES ~ I TOTAL (Also enter on Ilne 7, Recapitulation) I 761,993.72 MILE H COAMAONWEALTH OF PENNSriVANW F~•'• ~ ~, ES INHERITANCE TAX RETURN ~~ ~ I J RESIDENT DECEDENT ESTATE OF WIRTH, JOHANNA Debts of decedent must be reported on Schedule I. ITEM NUMBER ~ FUNERAL EXPENSES: DESCRIPTION A• 1 CREMATION SERVICE FILE NUMBER 21-11-00169 AMOUNT 136.07 B• 'ADMINISTRATIVE COSTS: 1. ~ Personal Representative's Commissions Name of Personal Representative(s) PETRA S. WIRTH 0.00 Street Address 406 E. OLD YORK ROAD City CARLISLE State Pq Zip 17015 ' Year(s) Commission paid 2• I Attorney's Fees HAMILTON C. DAVIS, ESQUIRE 3. ~ Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 29, 500.00 Claimant Street Address I City State Zip Relationship of Claimant to Decedent 4. ~ Probate Fees 5. i Accountant's Fees STEVE CLEVER, CPA I ~ 280.00 6• ~ Tax Return Preparer's Fees 7. I Other Administrative Costs 1 I TERRY LINDSAY -HAULING 75.00 TOTAL (Also enter on line 9, Recapitulation) 30,290.46 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN Schedule H Funeral F~er~ses & Administrative Cosh oorrtinued ESTATE OF WIRTH, JOHANNA 2 ;' CHECKS DELUXE I 3 M&T -IRA COST I 4 LEGAL ADVERTISING -THE SENTINEL FILE NUMBER 21-11-00169 Page 2 of Schedule H 21.75 35.00 242.64 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WIRTH, JOHANNA FILE NUMBER 21-11-00169 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER 1 MET ED 2 CUMBERLAND CROSSINGS 3 PETRA WIRTH -REIMBURSEMENT 4 UGI 5 MET ED 6 MEDICAL ACCOUNT 7 MEDICAL ACCOUNT 8 PA DEPARTMENT OF REVENUE DESCRIPTION AMOUNT 35.10 1, 365.00 100.00 103.11 8.73 142.82 34.89 72.00 TOTAL (Also enter on Line 10, Recapitulation) 1,861.65 REV-161 FJ(+ (11-0t1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WIRTH,JOHANNA SCHEDULE) BENEFICIARIES FILE NUMBER NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I~ ITAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. X116 (a) (1.2)j ~ 21 - 11 - 00169 RELATIONSHIP TO SHARE OF ESTATE , AMOUNT OF ESTATE DECEDENT (Words) ! ($$$) Do Not Llst 7ruatee(s) 1 PETRA S. WIRTH ' ! 406 EAST OLD YORK ROAD ~ Daughter 11/3 RESIDUE & I 373,713.69 CARLISLE, PA 17013 ~ ANNUITY & IRA 2 HENRI P. WIRTH DOORNWEG 2 Son ~ 1/9 RESIDUE & i 293,903.16 2243 GS WASSENAAR ~ ANNUITY & IRA THE NETHERLANDS 003 170 511 0826 I I I Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 coverlsheet, as appropriate. ~~ NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 REV•1ti1J EX+ (9.00) COMMONWEALTH OF PENNSYLVANIA SCHEDULE J INHERITANCE TAX RETURN BENEFICIARIES continued RESIDENT DECEDENT ESTATE OF WIRTH,JOHANNA NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I, TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. X116 (a) (1.2)j 3 ANNELIES JOHANNA WING-WIRTH 53 CHARLES STREET EPPING ESSEX CM16 7 AX UK 4 REINA LUCIA VENNINK-WIRTH NIEUWLANDSE KADE 15 2935 CG OUDERKERK 5 HENRIETTE MAGRIETHA WIRTH SLOTLAAN 3004 3701 GX ZEIST I FILE NUMBER 21-11-00169 RELATIONSHIP TO DECEDENT D N ~ SHARE OF ESTATE AMOUNT OF ESTATE , (Words) o ot Llat Trustee(s) ~ ($$$) Daughter I ! 1/3 RESIDUE & i 373 713 69 i ANNUITY & IRA I , . Granddaughter I i 1/9 RESIDUE ~ 9, 905.26 Granddaughter 1/9 RESIDUE 39, 905.26 Page 2 of Schedule J Estate of Johanna Wirth Analysis of Pennsylvania Inheritance taxable residue and Schedule J amounts. The Schedule G items pass by beneficiary designation one-third to the decedent's 3 surviving children, a sum of $253,997.91 The Schedule B & E items pass under the terms of the decedent's will (and the partial disclaimer of Henri F. Wirth) one-third each to two of the children and 1/9 each to Henri F. Wirth and the decedent's granddaughters, Reina Lucia Vennink-Wirth and Henriette Magrietha Wirth. The taxable probate residue is $359,147.37. The Schedule J totals are as follows: Annelies $119,715.79 $253,997.90 $373,713.69 Petra $119,715.79 $253,997.90 $373,713.69 Henri $ 39,905.26 $253,997.90 $293,903.16 Dl $ 39,905.26 $ 39,905.26 D2 $ 39,905.26 $ 39,905.26 Total Taxable $1,121,141 As all beneficiaries are in the 4.5% Inheritance Tax Rate class, this has no impact on the Inheritance Tax liability. ~.r ~~~~ ~ ~I~~ (tm 1hf~ ~C . ~~! 1 FES -$ P~ 3: 07 LAST WILL AND TESTAMENT Cf~RK QF OF QRPHAN`S COURT CUMBERl.A1~lD CO„ PA JOHANNA WIRTH I, JOHANNA WIRTH, of South Middleton Township, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and revoke any Will or Codicil previously made by me. ITEM I: I direct that all my just debts (except as may be barred by a Statute of Limitations) and my funeral expenses (including my gravemarker and expenses of my last illness) shall be paid from my residuary estate as soon as practicable after my decease as a part of the administration of my estate. ITEM II: I bequeath those articles of my household furniture and furnishings and those articles of my personal effects and personal property as I have or may set forth in a separate memorandum (which is or will be signed by me, dated and make specific reference to this Will and memorandum, which I shall place with my Will or deposit with my attorney), to the persons therein designated. ITEM lII : I give and bequeath all my tangible personal property, including but not limited to, any and all automobiles and other motor vehicles, household goods and furniture and furnishings, china, silverware, jewelry, ornaments, works of art, books, pictures, wearing apparel and personal effects, but excluding cash on hand and tangible evidences of intangible personal property and excluding any items bequeathed by ITEM II above, together with any policies of insurance applicable thereto including any prepaid premiums thereon, to such of my children as °~ under the Pennsylvania Uniform Transfers to Minors Act. Provided, however, that this appointment shall not supersede the right of any fiduciary to distribute a share where possible to the minor or to another for the minor's benefit. ITEM VIII: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as part of the expenses of the administration of my estate. ITEM 1X: I appoint my daughter, PETRA S. WIRTH, Executrix of this my Last Will. Should she fail to qualify or cease to act as Executrix, I appoint my son-in-law, BRUCE K. STORMS, Substitute Executor of this my Last Will. ITEM X: I direct that my Executrix, custodian, or their successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ITEM XI: The interests of the beneficiaries hereunder shall not be subject to anticipation or to voluntary or involuntary alienation. ITEM XII: FUNERAL AND BURIAL DIRECTIONS. I direct that my funeral and the disposition of my remains be carried out in accordance with the instructions that I have discussed with my Executrix, which may be reduced to writing and a copy of which may be attached hereto. It is my intention that my instructions and this statement shall be a statement of "contrary intent" and the sole authority concerning my funeral and the disposition of my remains and that no person (including my spouse, if any) shall have any authority contrary to these instructions, either under common law or under the provisions of Section 305 of the 3 Pennsylvania Probate, Estates and Fiduciaries Code. IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and Testament, written on five (5) sheets of paper, dated this ~ ~ day of AT~~ , 2009. (SEAL) JOHANNA The preceding instrument, consisting of this and four (4) other typewritten pages, each identified by the signature or initials of the Testatrix, was on the day and date thereof signed, published and declared by the Testatrix therein named, as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the presence of each other have subscribed our names as witnesses hereto. ' residing at S f ~q l~ ~, ~~~~ n//JJ . residing at I'C Q/`t 4 COMMONWEALTH OF PENNSYLVANIA . ss. COUNTY OF CUMBERLAND .. ~ ~ ~,ll I, JOHANNA WIRTH, the Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge abet I sgaed"and ~ " executed the instrument as my Last Will; and that I signed it willingly and as my free and~oluntary ' act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by JOA W1RTH, the Testa ,this _(~ day of 2009. ~ ~ c~nuL1>~ Vh ~t(~6-l~l~ Nd[ary Publi ~~~. ~tI L~ • (SEAL) JO A WIRTH COMMONWEALTH OF PENNSYLVANIA Ntarial Seal Artpeta M. Schaeffer, Notary Public ShIPPertsbug Boro, Cumberland County ~ C~'vnission E~ires May 15, 2011 Member, Pennsylvania Aasool~tlon (7} Notofit'K COMMONWEALTH OLF.P,ENNS~Y/LVANIA . ~.~,~i~P.! Ir~r1LJ : ss. COUNTY OF We, t`1~ i ~ n l' l~ar~ and'~~A'~l ~ ~ l C ,the witnesses whose names are signed to the attached or foregoing uishument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness; and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. .~~ Sworn to or ed and su cribed to before me b h~i ~0l1 iS and ~ witnesses, this day of ~ , 2009. NlStary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Artgela M. Schaeffer, Notary PubUc Shlppensburg eoro, CumbeAand County My Commissbn E~Ires May 15, 2011 Member, Pennsylvania Association of Notaries ~ M&T Investment Group M&T Securities, Inc. ' 285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885 February 28, 2011 Johanna Wirth ~ AYC011041 - P~,vz ~- ~, I,'~ ~ / Date of Death: 02/01/2011 ~` ~~~ Description of Security Quantity in Price per share on Shares 02/01/2011 MTB MONEY MARKET FUND INSTL CL 10,520.87 $1.00 LS V VALUE EQUITY FUND 820.275 Low: $14.23 High: $14.23 Close: $14.23 ALPINE GLOBAL PREMIER PPTYS FD COM SHS OF BEN INT 360 Low: $6.97 High: $7.02 Close: $7.01 ARTIO GLOBAL HIGH INCOME FUND CLASS I 302.644 Low: $10.42 High: $10.42 Close: $10.42 DREYFL7S 1NTERNATIONAL B OND FUND CLASS I 589.688 Low: $16.48 High: $16.48 Close: $16.48 GUINNESS ATKINSON CHINA AND HONG KONG 36.414 Low: $39.27 High: $39.27 Close: $39.27 HARBOR INTERNATIONAL FUND INSTIT'UIONAL CLASS 132.904 L°~'~ $62.72 High: $62.72 Close: $62.72 ING CLARION GLOBAL REAL ESTAT , E INCOME FD COM 168 Low: $8.10 High: $8.20 Close: $8.15 Investment and Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Bank Guarantee • May Go Down In Value M&T Investment Groups" is a service mark of M&T Bank Corporation and consists of M&T Securities, Inc., the investment-related areas of M&T Bank and investment advisory firms MTB Investment Advisors, Inc., and Zirkin-Cutler Investments, Inc. Brokerage services and insurance products are offered by M&T Securities, Inc. (member FINRA/SIPC), not by M&T Bank. M&T Securities, Inc. is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states. 0 ~ M&T Investment Group M&T Securities, Inc. 285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885 T ROWS PRICE INSTITUTIONAL LARGE 317.549 Low: $17 09 CAP GROWTH FUND . High: $17.09 Close: $17.09 LAZARD EMERGING MARKETS 188.073 Low: $20 98 PORTFOLIO . High: $20.98 Close: $20.98 MFS EMERGING MARKETS DEBT FUND 415.267 Low: $14 40 CLASS I . High: $14.40 Close: $14.40 MTB SMALL-CAP GROWTH FUND 227.253 Low: $17 11 CLASS I . High: $17.11 Close: $17.11 MTB SHORT TERM CORPORATE BOND 2,560.242 Low: $10 26 FUND CLASS I . High: $10.26 Close: $10.26 MTB MID-CAP GROWTH FUND CLASS I 346.999 Low: $15.30 High: $15.30 Close: $15.30 MTB LARGE-CAP VALUE FUND CLASS I 841.735 Low: $10.93 High: $10.93 . Close: $10.93 MTB LARGE- CAP GROWTH FUND 1,055.845 Low: $9 11 CLASS I . High: $9.11 Close: $9.11 MTB INTERNATIONL EQUITY FUND 1,309.086 Low: $9 43 CLASS I . High: $9.43 - Close: $9.43 MTB INCOME F[TND CLASS I 4,298.06 Low: $9.90 High: $9.90 Close: $9.90 Investment and Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Bank Guarantee • May Go Down In Value M&T Investment Group' is a service mark of M&T Bank Corporation and consists of M&T Securities, Inc., the investment-related areas of M&T Bank and investment advisory firms MT8 Investment Advisors, Inc., and Zirkin-Cutler Investments, Inc. Brokerage services and insurance products are offered by M&T Securities, Inc. (member FINRA/SIPC), not by M&T Bank. M&T Securities, Inc. is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states. ~ M&T Investment Group M&T Securities, Inc. 285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885 MAINSTAY EPOCH GLOBAL EQUITY 130.975 Low: $15 21 YIELD FUND CLASS I . High: $15.21 Close: $15.21 MASTERS SELECT INTERNATIONAL 266.197 Low: $15 69 ~~ . High: $15.69 Close: $15.69 MORGAN STANLEY FOCUS GROWTH 137.036 Low: $38 31 FUND CLASS I . High: $38.31 Close: $38.31 RS GLOBAL NATURAL RESOURCES 72.847 Low: $38 80 FUND CLASSY . High: $38.80 Close: $38.80 RIDGEWORTH SEIX FLOATING RATE 1,265.940 Low: $9 05 HIGH INCOME FUND CLASS I . High: $9.05 Close: $9.05 SPDR SER TR S&P DIVID ETF 18 Low: $52.32 High: $52.89 Close: $52.68 We have received the information presented above from sources, which we believe to be accurate. However, we do not guarantee their accuracy. The stock price per share on valuation date is the closing price on that date. The mutual fund price per share is the low/nav price on that date. Previous business day price is used if DOD falls on a weekend or holiday. Please contact Client Solutions with any further questions, or if we may be of further assistance to you at 1-800-724-7788, Option #1. Thank you. Si t;rely, • • Graf ~~ erage Operations Specialist M&T Securities, Inc. Investment and Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Bank Guarantee • May Go Down In Value M&T Investment Group' is a service mark of M&T Bank Corporation and consists of M$T Securities, Inc., the investment-related areas of M&T Bank and investment advisory firms MTB Investment Advisors, Inc., and Zrkin-Cutler Investments, Inc. Brokerage services and insurance products are offered by M&T Securities, Inc. (member FINRA/SIPC), not by M&T Bank. M$T Securities, Inc. is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states. ~J Pershing AN AFFEJATE OFTHE EAN}; OF NEW YO]U: MELLON One Pershing Plaza, Jersey City, NJ 07399 Pershing L(C, member FINRA, NYSE, SIPC ESTATE OF JOHANNA WIRTH PETRA WIRTH, EXECUTOR 406 E. OLD YORK ROAD CARLISLE PA 17015-0000 DATE DESCRIPTION 03/02/2011 THIRD-PARTY AS PER YOUR REQUEST FROM ACCOUNT OF JOHANNA WIRTH NET AMOUNT 1 of 1 AYC-011041-1 $201,497.98 0300956497 AMOUNT 201,497.98 201,497.98 . ............ .................( ......................................................................... (Detach Here} .................... - III ........................................................................................................ ~ M&T Securities, Inc. 285 Delaware Avenue, Suite 2000 Buffalo, NY 14202 f~o~r~`~1. ~`~ . J$v~ `~ t ~~ Page: 1820 0512 Account Number: Amount Paid: Issuing Bank Acct: PAYMENT SUMMARY CHECK NunneER: 4010034335 CHECK DATE: 03/02 /2011 Mar, 7. 2011 1:06PM ZULLINGER-DAVIS PC Western & Southern Lx:fe A member of Western & Southern Financial Group ZULLINGER-DAVIS HAMILTON C DAVIS 14 NORTH MAIN ST STE 200 CHAMBERSBURG PA 17201 Dear Mr. Davis: No, 8728 P, 1 Annuity Operations PO Box 2918 Clnclnnati, OH 45201-2918 toll free 800.92fi.1702 fax 513.629.1799 March 3, 2011 Thank you for your request for information on the annuity contract. I hope the following contract information is helpful to you. Annuitant: JOHANNA WIRTH Owner: JOHANNA WIRTH Westem-Southem Life Assurance Company Contract Number: W0020583202 Contract Value: $80,121.50 The quoted value information is as of 2/1/11, the reported date of death. If you have any questions, please call our Annuity Operations Department at 1-800-926-1702. A representative will be happy to help you. Sincerely, . ~ ~~~ ~~~ ~~. Lois Craft Annuity Operations Department DC0331-0810 Westem-Southem Life Assurance Company Johanna Wirth Estate Schedule E -Items 6,7 & 8 are converted from EUROS to DOLLARS at the date of death exchange rate of 1.36452 as follows: Item EUROS RATE DOLLARS 6 4263.86 1.36452 5817.79 7 24.68 1.36452 33.68 8 26486.42 1.36452 36141.25 ~ M&T Investment Group M&T Securities, Inc. 285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885 February 28, 2011 Johanna Wirth 7 AZD325421 '~' Date of Death: 02/01/2011 Description of Security Quantity in Shares Price per share on 02/01/2011 MTB MONEY MARKET FUND CL A 176.79 $1.00 We have received the information presented above from sources, which we believe to be accurate. However, we do not guarantee their accuracy. The stock price per share on valuation date is the closing price on that date. The mutual fund price per share is the low/nav price on that date. Previous business day price is used if DOD falls on a weekend or holiday. Please contact Client Solutions with any further questions, or if we may be of further assistance to you at 1-800-724-7788, Option #1. Thank you. Sincerely, Brokerage Operations Specialist M&T Securities, Inc. Investment and Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Bank Guarantee • May Go Down In Value M&T Investment Group`" is a service mark of M&T Bank Corporation and consists of M&T Securities, Inc., the investment-related areas of M&T Bank and investment advisory firms MTB Investment Advisors, Inc., and Zirkin-Cutler Investments, Inc. Brokerage services and insurance products are offered by M&T Securities, Inc. (member FINRA/SIPC), not by M&T Bank. M&T Securities, Inc. is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states. I~1 M&T Investment Group M&T Securities, Inc. 285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885 February 28, 2011 Johanna Wirth AZE016292 - LYE Date of Death: 02/01/2011 Description of Security Quantity in Shares Price per share on 02/01/2011 CASH 127.92 $1.00 MFS TOTAL RETURN FUND CLASS A 1,436.046 Low: $14.38 High: $14.38 Close: $14.38 We have received the information presented above from sources, which we believe to be accurate. However, we do not guarantee their accuracy. The stock price per share on valuation date is the closing price on that date. The mutual fund price per share is the low/nav price on that date. Previous business day price is used if DOD falls on a weekend or holiday. Please contact Client Solutions with any further questions, or if we may be of further assistance to you at 1-800-724-7788, Option #1. Thank you. Sincerely, ~arles Graf Brokerage Operations Specialist M&T Securities, Inc. Investment and Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Bank Guarantee • May Go Down In Value M&T Investment Group" is a service mark of M&T Bank Corporation and consists of M&T Securities, Inc., the investment-related areas of M&T Bank and investment advisory firms MTB Investment Advisors, Inc., and Zirkin-Cutler Investments, Inc. Brokerage services and insurance products are offered by M&T Securities, Inc. (member FINRA/SIPC), hot by M&T Bank. M&T Securities, Inc. is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states. Mar 63 2811 17:80:41 EST FROM: F2M/17832682868 March 3, 2011 Law Offices of Zullinger-Davis Care of Hamilton Davis Fax 7175305222 Re: Hartford Annuity Contract # 711239491 Decedent: Johanna Wirth Dear Attny Hamilton Davis: Thank you for your correspondence regarding the above annuity contract. ~lartford :C~ife The death benefit payable under this contract is not considered "life insurance" reportable on IRS Form 712, (life insurance statement). Please find the below information in response to your request. Contract Number 711239491 Owner Johanna Wirth Decedent Johanna Wirth Social Security Number XXX-XX-4020 Date of Death February 1, 2011 Cash Yalue on the date of death X741,215.46 Death Benefit Yalue on the date of death ~ $741,215.46 *The Death Benefit Value on the date of death displayed above may include a Death Benefit Adjustment as outlined in the Annuity Contract. This figure is being provided for illustration purposes and is not equivalent to the fmal death benefit The death benefit will be calculated on all contracts associated with this client the day we receive the certified death certificate. Once the death benefit is calculated, the benefit amount remains invested and is subject to market fluctuation until complete settlement instructions are received. If you have any questions or concerns, please feel free to contact your investment professional, or one of our annuity specialists by calling 1-800-862-6668, Monday through Thursday from 8 a.m. to 7 p.m. and Friday from 9:15 a.m. to 6 p.m., Eastern Standard Time. We will be happy to assist you. Thank you for the opportunity to help provide for your financial needs. Sincerely, Rebecca Girard Investment Product Services ICS Annuity Benefit Services Team Hartford Life Insurance Company MSGit 77292336-687-1 PAGE 992 OF 96Z Hartford Life Insurance Companies 1 Grin Road North Windsor, CT 06095 - 1512 Toll Free 1 800 862 6668 Invesunent Product Services Mailing Address: P.O. Box 5085 Hartford, CT 06102.5085 online.hsrtfordlife.com filar MAR._24._201^l~z~l_~39P~fi~~F~QM; FZM/1~506e66976 • : • Annuity Contract A,ece~~ -Painter Friendly N0. 127 P. 2 nSGit 147667z9~6B7'1 PAG1; 6B2 OF 6ez Page I of 1 ~' a ~~~ • The Director Variable Annuity , ,. ~ . ~,~ Seriea:7 • ,•nnirt~xi~~°~u ~ Contract DeEail • t3en~ral Inform8tian Retum to_Contraot Q_etail • Conkraet Number: 711289491 • Purchase Date; October 1, 2002 ConVact Type: Weriable - Johanna Wirth ~ Plan Type: Non Qual~ed ice ~~e Qr Owner Name: Johanna Wirth Carlisle, PA 17013 Annuitant: Johanna Wirth Flnanclal Proieaslonal Kimberly J Heavr,er M & T Sec Ino ' 100 S Spring Gordon St • Carlisle, PA 17013 • 717 - 218 - 5426 • lnvestment choices a5 of March x3, 2017 •Investme~t Cholce • Future Rate/No. tlnlt Contributio Investment ~/, of ' - • Abbreviation n Units Value Allocatlon~ Choice Contract Hartford CapitAl value Value"" Appreciation Ht,S 11,79A,350 13.973679 r,, Fund • X164,666.36 22,3% Fxed Accumulation - ioo oo% . 3% Minirnum $575 ,195.37 77.7% ' Tofal $740,061.73 -Due to roundin®totals may • ~ ~ 7o eaourgtely allooate, your Premluln Payments to the seleoted funds, our eystem may ne ed to apply a percentage that Is n of e whole percentage. When requesting a charge to Future Contribution Allocati ons or upon en investment Choice Transfer/Contract Reallocation, whole perccntepes must continue to be Indicated. ' ~ Due to rounding totals may not equal 1o0~iG htipy://finanoialproPossional.hartPordinvestox.com/cab/CozttractHalanoes2A,CTION=Prizit,,, 03/24•/207.1! C .~ ~~~ ,~ O • O N ~. m Ci m ~ r C N m O Q ~ m ~z~ ~ N mon ~ ~ O 7 ~ ~m~ e N_ O ct M Ol Ol Ql M ~'- ~ Mpp ~ lD ~d~Na~o rri m °o,°~nu'"~iry ~ O ~ N s o ~, ~ '" C o ~ ~ ~ ^ W ~ ~ ~ v ~ A L~~ C N N C ~ jp N 7 _ ~ ~ O u p~ c¢ ter.. c a~~ Z ~ , .' y C ~ 6! ~ ~~CJ U DU aH~ °0 0 a O r 0 A a N O r-1 ~ rl N _ o _ O E o o x r~i F' ~ = ~+ A N o o o = O °; = "' ~ O _ ~~ ~ = z x o ~ ~ ~ O~ a v z o Q "' O~ CJ O ANz O H __ ~ ~ (~ ~ C a' O IJ. Z O _ ~ ~ ~ . U ~ ~ V * ~-i~-~ e1' ~ Y' O x ~ o O O O o °o, l °o 0 0 c e ~ ~~ ~ N ~ ~ ~ '~ ~ ~D J ~ '7 QN1 Ol 01 b~ rv o m 67 O M ~ N N ~ ~ C 'a H a 0 d D v O T ~ ~ C C OO ~y„ G ~ fL~ V ~G 0 d rn 0 d