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Home My WebLink About10-31-11 (2)1505610143 -J REV 1500 Ex (ot-to) ~~ OFFICIAL USE ONLY File Number ~ County Code Year pA Department of Revenue ~ nnn~sy~vaniaE 0 5 3 0 INHERITANCE TAX RETURN 21 11 Bureau of Individual Taxes Po Box.2sosol RESIDENT DECEDENT Harrisburg, PA 17128"0601 Date of Birth ENTER DECEDENT INFORMATION BELO Date of Death Social Security Number 12 23 1932 07 18 2010 MI 18 5 2 6 07 2 4 Decedent's First Name Suffix A Decedent's Last Name BETTY 1„~SSICK MI (If Applicable) Enter Surviving Spouse's Information Below Suffix Spouse's First Name Spouse's Last Name Spouse's Social Security Number THIS RETURN MUST BIER OF yV~l-LS TE WITH THE REGIS FILL IN APPROPRIATE OVALS BELOW ^ 2 Supplemental Return 1. Original Retum 4a. Future Interest Comppromise ^ 4. Limited Estate ^ (date of rrdl1~~eath,a~1fat tear 12-12-82) ^ ~ • Atlac~h r%oMPY ~~ TNS )a Living Trust Decedent D ~ VVillj to X^ 8' (Attach Copy Q rtv Cred' date of death ^ 10. ~B8~1Z~~191 and T-1-95) -- 9. Litigation Proceeds Received CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND conrtucn ~ ~^~ayt~me Telephone Number Name (717) 761 4540 EDMUND G ivjyERS SE (SI~Y First line of address 301 MARKET STREET Second line of address p0 BOX 109 City or Post Office LEMOYNE schedules and statements, and to the is based on all Information of which pl st of my knowledge anu w„~,, Irer has any knowledge. DATE ~~I2~~~ Sue A (luarterson OF PREPARER OTHER THAN REPRESENTATIVE EDMUND G. MYERS 0_ ylw ^ 3' prior to 12r13e82) (date of death ^ 5. Federal Estate Tax Retum Required 0 8. Total Number of Safe Deposit Boxes 11.Election to tax under Sec. 9113(A) ^ (Attach Sch. O) . _.._..... ne n~RFCTED TO: dsw.com Correspondent's e-mail address: e9mL~,l Under penalties of perjury, I declare that I have examined this return, including) it is true, correct and complete. DeGaratio~n of prepQ reu Ner than the persona ADDRESS 301 MARKET STREET, Lemo ne, PA 17043 Side 1 1505610143 REGISTER OF WILLS U ~„ -, ~; c~ ' 'T" -~ '~ '~ --~ -t7 : , _; ^ ~ _ _ .- ~;: , ~ _ .. ._. '. i ~__ .,. ' _ State ZIP Code ' pA 17043 DATE 1111 ~ 150561D143 J 150561D243 REV-1500 EX pecedenYsNeme: nnESSicic, Be0•Y A 1. RECAPITULATION 1. Real Estate (Schedule A) ................................................................................ 2. ................................ .• . ... 2. Stocks and Bonds (Schedule B) ................................. 3. 3. Closely Held Corporation, Partnership or Sole-Propnetorship (Schedule C)......... 4. 4. Mortgages & Notes Receivable (Schedule D) ......................••••••••••••••••••••••••"""" 5. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... Schedule F) ^ Separate Billing Requested............ 6• 6. Jointly Owned Property 7. Inter-Vivos Transfers & Miscellaneous -Probate Prope Separate Billing Requested............ 7. (Schedule G) 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. ........... 9. 9 Funeral Expenses & Administrative Costs (Schedule H) ............................ Mortgage Liabilities, & Liens (Schedule I) .............................. f Decedent 10. , 10. Debts o ........ ............ 11. 11. Total Deductions (total Lines 9 & 10) ............................................... ...................... .. • 12. Net Value of Estate (Line 8 minus Line 1 ...•••••••••••••••••••••~~"' ' "' ts/Sec 9113 Trusts for which 12. 13. Charitable and Governmental Beques t been made (Schedule J)........•..••••••• •• 13 an election to tax has no 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or 15. transfers under Sec. 9116 (a)(1.2) X .00 16. Amount of Line 14 taxable ]. 8 9 , 9 9 9.0 4 1 s. at lineal rate X .045 0 . 0 0 17. Amount of Line 14 taxable 17. at sibling rate X .12 Amount of Line 14 taxable 0 . 0 0 18. 18. at collateral rate X .15 19. 19. Tax Due .................................................................................... Decedent's Social Security Number 185 26 0724 149,200.00 727.38 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 20,799.67 16,071.68 22,987.18 209,785.91 13,942.60 5,844.27 19,786.87 189,999.04 189,999.04 0.00 8,549.96 0.00 0.00 8,549.96 1505610243 J 1505610243 Rev-1502 EX+111-08) NSYLVANIA SCHEDULE A REAL ESTATE COMMO EN~nAN~C ~APX~RETURN _~..,nMnPC.EOENr I ru F AIUMBER 21-11-05~'0 ESTATE OF A pe would be MESSICK, Be Red et tair market v olusell,eboth Kevingalreesoneble knowledge of theWelevant f8cts. owned solel or as s teneaand a will n9 seller ~e ~e wing comPel~ to buy must be disclosed on schedule F. All real properly y exchanged between a vRe 9properH which is Jointly-owned with right of survivorship Attach a copy of the settlement sheet Ir the properly has been sold Include a copy of the deed showing decedents Interest N owned es tenant in common. VALUE AT DATE OF DEATH ITEM DESCRIPTION 149,200.00 NUMBER Hill, Pa 17011 -Assessed Value 1 Residence located at 17 Hunter line, Camp 149,200.00 TOTAL (Also enter on Line 1, Recapitulation) (If more space is needed, additional pages of the same size) Form PA-1500 Schedule A (Rev. 11-08) Copyright (c) 2009 form software only The Lackner Group, Inc. Rev-1503 EX+ (5-88) cone+wNwennt•TI'+oF ~NSnvnNln IN RESRITIS DE~N'T DECEDENTRN ESTATE OF ~~~cc~CK_ SCHEDULE B STOCKS & BONDS FILE NUMBER 21-11-0530 A .ownedwith right of survivorship must bedlsclosed on Schedule F. All property jointly ITEM CUSIP DESCRIPTION NUMBER NUMBER ~ AlliancelBernstein - AllianceBernstein Intermediate Bond Fund A Account No. 38943 "~- VALUE AT DATE UNIT VALUE OF DEATH 727.38 I 727.38 TOTAL (Also enter on Line 2, Recapitulation) (If more space is needed, additional pages of the same size) Form PA-1500 Schedule B (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. Rev-1508 E7(+ (&98) COMMONNIEALTI'I OF PENNSYLVANIA IN RER ID ~ DECEDEM7RN EST----- SCHEDULE E CASH, BANK DEPP SOIPE ~ ISC. PERSONAL FILE NUMBER 21-11-0530 Include the proceeds of ik~9~1On and the date the proceeds were receNed by the estate. pll property lointlyownedwith the right of survivorship must be disclosedon schedule F. VALUE AT DATE OF DEATH ITEM DESCRIPTION 60.94 NUMBER being held through the Commonwealth 1 Pennsylvania Employees Benefit Trust Fund -Money of PA Unclaimed Property 5.053.20 2 PNC Priority Checking Account No. 5140042694 14,903.53 3 Sovereign Bank Certificate of Deposit Account No. 1055315574 500.00 Personal Property value and Appraised by Chuck Bricker 4 282.00 5 Erie Insurance -Refund on Account I I 20,799.67 TOTAL (Also enter on Line 5, Recapitulation) (If more space is needed, additional pages of the same size) Foml PA-1500 Schedule E (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. Rev1509 EX~ (6.98) COMMONWEALTH OF pENNSYWANIA INHERITANCE TA% RETURN RE$IDENI UC~G,~.-..~ ESTATE OF -.~~c~~ SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER 21-11-05~'0 Been assett was made joint within one year of the decedenps date of death, it must L» reported on schedule G. _ ADDRESS RELATIONSHIP TO DECEDENT SURVIVING JOINT TENANT(S) NAME A. John W Messick B. C. 17 Hunter Lane Camp Hill, PA 17011 Son % OF DATE OF DEATH JOINTLY OWNED PROPERTY: vALUE of DESCRIPTION OF PROPERTY DATE OF DEATH DE~,D'S DECEDENT'S INTEREST LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT ALUE OF ASSE INTEREST ITEM FOR JOIN MADE NUMBER OR SIMI 0 NTLY-HELD REAL ESTATETrACH DEED FOR 11,340.80 NUMBER TENANT JOINT 22,881.60 50.000% 1 A 1210511985 Metro Bank Checking Account No. 512009291 4730.88 9,461.75 50.000% 2 A 08/2011996 Metro Bank Savings Account No. 410157809 TOTAL (Also enter on Line 6, Recapitulation (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. 16,071.68 Form PA-1500 Schedule F (Rev. 6-98) Rev-1510 F,(+ (8-98) ' OF PENNSYLVANIA SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY cW~ INHERRANOE TAX RETURN I nc,.'.nFCEDENT cal ~ w ~MFtFR ... -~ -- ns.a.. ~.....--- - 21-11-0530 ESTATE OF A MESSICK, Be uestions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. This schedule must be completed end filed 'rf the answer to any of q 96 OF DECD'S EXCLUSION TAXABLE DESCRIPTION OF PROPERTY DATE OF DEATH INTEREST (IF APPLICABLE) VALUE ITEM INCLUDE NAME OF TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND 22,9$7.1$ NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE 22 9137 113 ~ Allstate Annuity -Beneficiaries: John Messick, Son and Sue Quarterson, Daughter I 22,987.18 TOTAL (Also enter on Line 7, Recapitulation) (If more space is needed, additional pages of the same size) Form PA-1500 Schedule G (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. REV-1151 EX+ (10-0B) COMI~~~p~ I~NANIA SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF uccc~C ITEM NUM~E A. A Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: See continuation schedule(s) attached AMOUNT 936.00 g, ADMINISTRATIVE COSTS: 1, Personal Representative's Commissions Name of Personal Representative(s) Street Address Zio State City Yearlsl Commission paid 2. pttornev's Fees JOHNSON DUFFIE g Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address Zip State City Relationship of Claimant to Decedent 7,800.00 3,500.00 623.00 q, Probate Fees 5, Accountant's Fees g, Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 13,942.60 Copyright (c) 2009 form software only The Lackner Group, Inc. FILE NUMBER 21-11-053 Form PA-1500 Schedule H (Rev. 10-06) 150.00 933.60 SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued FILE NUMBER ESTATE OF 21-11-0530 MESSICK, Be A AMOUNT ITEM DESCRIPTION NUMBER ~....er~i pxuenses 936.00 1 Myers Harner Funeral Home H-A 936.00 an~r odmini¢•rative Costs 73.50 2 Administrative Expenses for the Estate of Hugh Messick -Being administered for Assets passing to the Estate 100.00 3 Chuck Bricker, Certified Appraiser 30.00 4 Cumberland County Register of Wills Office -Filing Fees 15.00 5 East Pennsboro Twp. Police Department -Cost for obtaining police report 300.00 g Reserves: Miscellaneous Administrative Expenses 2p,00 7 Sovereign Bank -Fees for Date of Death Valuation Letter 75.00 g The Cumberland Law Journal -Notice of Estate Administration 169.00 g The Patriot News Co. 151.10 10 The Patriot News -Notice of Estate Administration H-B7 933.60 Form PA-1500 Schedule H (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. Rev-1512 F~(+(12-08) CDMM~ENYdEAI CE TAX RETURNANIA RESIDENT DECEDENT ESTATE OF . A SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-11-0530 .....__ bts incurred by the decadent prior to death that remained unpaid at the date of death, Including unreimbursad medical expenses• d VALUE AT DATE e Repoli OF DEATH ITEM DESCRIPTION 1.73 NUMBER 1 Chase Card Services 193.86 Ciccarelli -Final medical payment Clem A 2 . 125,59 3 Comcast 67.50 4 Comcast 130.30 5 Comcast 202.43 g Crossings 506.71 7 Debbie Lupol, Treasurer 1,544.99 g Debbie Lupol, Treasurer 241.50 g East Pennsboro Twp. 335.00 10 Erie Insurance Group 97.00 11 Howard Roy Cohen MD 10.00 12 Howard Roy Cohen MD 117.98 13 PPL Utilities 166.48 14 PPL Utilities 130.00 15 PPL Utilities 70.55 16 Treasury Division 101.40 17 UGI See attached page Total of Continuation Schedule 5,844.27 TOTAL (Also enter on Line 10, Recapitulation) (If more space is needed, additional pages of the same size) Form PA-1500 Schedule I (Rev. 12-08) Copyright (c) 2009 form software only The Lackner Group, Inc. Rev-1572 E7C+ (6-961 COMMOPNyEpL7H OF PENN3YWANIA IN RERIT~~pECEDEVT~ ESTATE OF __~~~„~~ ~ A ITEM NUMBER 18 UGI 19 UGI 20 UGI Y9 Verizon 22 Verizon 2g Verizon 24 West Shore EMSIALS SCHEDULE ~ DEBTS OF DECEDENT, MORTGAGE LIABnuIedES~ & LIENS contl FILE NUMBER 21-11-0530 DESCRIPTION VALUE AT DATE OF DEATH 128.00 115.43 232.28 212.56 117.34 70.15 925.49 I 5,844.27 TOTAL (Also enter on Line 10, Recapitulation) Form PA-1500 Schedule I (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. REw•1513ex+(11-0e1 SCHEDULE J qN~q BENEFICIARIES COMI~~ i~l~~"~"`~D~~ i ESTATE OF MESSICK, Be A NAME AND ADDRESS OF NUMBER PERSON(Sl RECEIVING PROPERTY TpJ(ABLE DISTRIBUTIONS di st buti nsn9and transfers I. under Sec. 9116 a 1.2 1 John W Messick 17 Hunter Lane Camp Hill, PA 17011 2 Sue A Quarterson 333 Andersontown Road Mechanicsburg, PA 17055 FILE NUMBER 21-11-0530 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) Son 1112 of Residue Daughter 11J2 of Residue I ~ Total I nter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover shs NOT TAKEN E NON-TAXABLE DISTRIBUTIONS: III A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO T B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1500 cuwtR ~~~" Form PA-1500 Schedule J (Rev. 11-08) TOTAL OF r'AK ~ ~~ - "' ' -' ' - Inc. Copyright (c) 2009 form software only The Lackner Group, ESTATE OF BETTYA. MESSICK SCHEDULE OF EXHIBITS EXHIBIT A Copy of Extension Approval from PA Department of Revenue assessed value of property located at EXHIBIT B Copy of Cumberland County 17 Hunter Lane, Camp Hill, PA EXHIBIT C Alliance/Bernstien statement of value for Hugh Messick account which passes to Estate due to his passing. EXHIBIT D PNC Bank Date of Death Letter EXHIBIT E Sovereign Bank Date of Death Letter EXHIBIT F Metro Bank Date of Death Letter Allstate Date of Death Letter showing value of Annuity payable to EXHIBIT G Beneficiaries at Time of Death 466298 Page 1 of 1 E X GRANTED TEMPLATE Dana L. W1e8eman ,~.____~---~--__~___ a. ov From: Heimbach, Amber [aheimbach@p 9 Sent: Thursday, October 27, 2011 1:23 PM To: Dana L. Wieseman Subject: Extension Letter Attachments: image001.jpg a~~~!~~~r=r~-r ol" a~v~u~ The following message is being sent from an unmonitored account. Please do not reply Re: Estate of Betty A Messick File Number 2111-0530 Dear Sir or Madam: letter of October 12, 2011 concerning the inheritance tax return due In This is In response to your the above referenced estate. t ou will be unable to file a tax return in the near future, the estate reco riod of six (6) months so that the Since it is apparent tha y will be p until April 27, 2012. At the end of that p be dl d at laced in an informal hold status for an additiona pe for our file. The return may department wtl ou (contact us to p ovnde anvupdated status would ask tha y any time during the informal hold period. for failure to make a timely enalty revert interest from accruing on any tax remaining unpaid after the Kindly note that this acts notlP avoid the imposition of a p return. However, It doe delinquent date. ration and if I may be of any further assistance please feel free to contac Thank you for your coops my office. Sincerely, Laurel Fulmer Supervisor Inheritance Tax Division Ifulmer@state oa.us mail. This mailbox is not monitored and you will not receive a response. For assistance, visit us on the web at Please do not reply to this a contain confidential and/or privileged ,Hww.revenue.state.pa.us or call us at 717-787-8327 arson or entity to whom it is addressed and may the intended rec`pie St is prohibited. If you receive this message in error, please sen a rep The information transmittedo~at on other t am by p material. Any use of this in e-mail to the sender and delete the material from any and all comp 10/28/2011 Page 1 of 1 TaxDB Result Details e109-19-1590-118. in the 2010 Tax Assessment Database Detailed Results for Paxc_„~~___~...-.~__.. 09-19-1590-118. _ ._ ....._ ................... .............. 17 .23 1 x:: 4/27/2011 htt ://taxdb.ccpa.net/details.asp?id=09-19-1590-118.&dbselect=l p ' 's I AflianceBernstein ~~~ ` 7g6fp3SaA~ritarral ]gJg2T@fi~3 „ j~~~Ll'.ANC~E~ERNS'TEZN ~n~estrnents AT 02 O~gii~ 113116OB3'8'i'~;'`3~Gi I ,1 1..1. i ,I,II,I,.111, L - II III I I I III I II II II I ~gg Page 1 of 5 i HUfHW taESSICK - 17 HUNTER LANE CAPAP HILL PA 17011-2403 q,;,;ount X18 7.011 tMarrh 31.2011 i Jrnuory ; Dg.+ulaoeu ~~ I~ r~DRD STE 95 H- ~ LLC Dranah No.: HD 20 EF>FOM Advicor No. ND25 LEpg0yNEPA 17043-1157 Afitiror Name: ~ pA gt~11STED in a few easy steps by charming paper ~ ga~a@dato your dalivQry Presence trees alliaaeabe~tamcoa•19 g Same a Tree Go P ~!~ fag is to your aeeeaat at vouuw• ~wg natarial da6very its goon. Or caD as at 1.BDO221.!•i872. apneas on ffie e•Deaaa NAV FundlA~eot Nnaaber Eoad Name ;COUnt Begaaiag Psrtfolia Balaoce 104 Immary AWANCEBERNSTEIN INTERMEDIATEBQMD A Eadiag Portfolio Balance Irnings O:aadName Immary pWAPICEBERNSTEIN INTERMEDIATE BOND A Total Eacaiags ~upNg~~g15T8N IN'fERAlED1ATE BO{~D A utual Fund ~Np1A000UNT NUMBER 104138943 ;tlVlty Confirm Trade... ...-..... - ~ Data Date Traaaeetioa 01.20 01-20 Income Div Cash 02.18 02-18 Income Div Cash 03-18 03-18 Income Div Cash 03-31 03-31 Your Paymeat OG ~ °~ Divid~rdsCASH CASH loterestl Tax Exeo~t D'~aideais Dinideads 55.99 50.00 $6.99 #0.00 Fnnd Symbol: ABOUX Shares 67.598 510.170 Dagar Amoaat of Traasaeti®a 51.47 52.47 52.05 50.00 Sbert Yae~ Laag•Tera~ Cap Gain Cap Gain 50.00 $O.DO oo.oo so.9o Value 1727.38 $727.30 ~= 4727.38 Your Ta Date .. 55.99 = 56.99 Share shares Ibis . Total Shares Prioo Traea 000 0 67.538 50.00 . 000 0 61.538 50.00 . 000 0 67.538 50.00 . 0 000 67.538 510.71 . ~ ~ 6 049066/ No. 9019 P. 1/1 Jun. 30. 2011 8:40AM PNC BANK 412-705-2741 ~T1iEWAY June 30, 2011 Dana L ~Vieseman wart & Johnson Duffs ydeidner P.C. 301 M~ket St p O Box 109 Lemoyne, PA ]7043-0109 gE; Betty A Messick SSN:185-26-0724 DOD: 07-]8-2070 JUN 3 p ~p11 Dear Sir/Mad~n: re nest for Date of Death (DOD) balances for the customer noted above, our In response to your 9 . records show the following. Checking Account Established: 07-01-1973 Account # 5140042694 BE.~ ~, MESSICK DOD balance: $ 5,053.12 + 0.08 accrued interest Merest paid O1-O1-2010 thru 07-18-2010 $ 0.75 YTD ces for deposit accounts (IRAs, CDs, Checking and rovides date of death balan rovirle statements. If you need assistance with Please motew d~not pr~oaess any financial transactions or p ow local PNC Bank branch Savings)' lease ~ 1-888-pNC-BANK 11-888-762-2265) or stop by y any of these items, p office. sincerely, National Financi~~Services Center' PNC Bank, N.A. Member FDIC to which it is addressed and cab a law. This message is intended for the use of the individual or entity om disclosure under app ' contain information that is privileged, nt~r~d ~ pen om ~ employee or agent responsible for ed that arty dissemination, If the reader of this message is not the ~ yja,,e received this this message to the intended recipient, you are hereby nohfi delivering ohibited If Y distribution or copying of this communications is strictly pr tele hone at 500-762-1775 and communication in error, ,please notZfy me immediately by reply or by P immediately destroy this faxed document. Page 1 of 1 Sovereign Bank Be A. Messick ESTATE OF 185-06-0724 SOCIAL SECURITY #: July 18, 2010 DATE OF DEATH: CD Open date: 12/31/2001 1055315574 Type: Account #: In the name of: Betty A. Messick $14,903.53 Date of Death Balance: 6/30/2010 $299'21 from 1/1/2010 to Int.(YTD) $31.76 Accrued interest to date of death: Otherlnfo: Page 1 of 1 METRO BANK June 15, 2011 a88.g37.oo04 3801 Paxton Street mymetrobank.com Harrisburg, PA 17111 Johnson, Dana Wieseman Weidner PC Attention D 301 Market St PO Box 109 Lemoyne, Pa 17043 RE: Estate of: Betty A Messick Tax Identification Nu gb2010 5-269-0724 Date of Death: July To Whom It May Concern: ou requested for the individual listed This letter is in reference tvide the following nt information y above. We are able to pro Account Type: Savings Account Number: 4us 2,80996 Date Opened: Aug Primary Owner: Betty A Messick Secondary Owner: John W Messick Date of Death Balance: $9461.75 Account Type: Checking Account Number: 512009291 1985 Date Opened: Decem A Messick Primary Owner: Betty Secondary Owner: John W Messick Date of Death Balance: $22,681.60 be of further assistance. Please feel free to contact me at (717) 412-6126 if I may Sincerely, amela Lighty SavingslClF Associate Metro Bank Allstate D You're in good hands. June 29, 2011 Dana L. W ieseman 301 Market Street p, O. Box 109 Lemoyne, PA 17043-0109 Betty A Messick Re: Gp,207387 Contract No: Dear Ms. W ieseman: ur ose of Form e lete IRS Form 712 for the above referenced contract. The p st to comp life insurance contract or its proceeds as of a certain W e received a requ 712 is to provide an estate or donor with the value o a rovide the usually the owner's date of death or date of transfer of the contract). 712 I can, however, p date it is not reportable on IRS Form Because this contract is an an uu oses: following information for estate p rP July 18, 2010 Date of Death: $ 22,897.18 Annuity Value as of Date of Death: $ 0,00 Cost Basis: John W .Messick and Named Beneficiary: Sue Ann Quarters°n iffer due to Market Value Adjustments and/or any applicable Surrender *The actual amount paid may d Charges. If you have any questions, please contact me at 1-877-499-6418. Sincerely, Patricia Biggs Sr. Claim Examiner dg Allstate Life Insurance Company L'rfe and Annuity Claims Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523 P.O.