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Home My WebLink About05-26-06 REV-1500 Ex (D~-o5> PADeparlrnent of Revenue f3lxeau of Individual Taxes PosoxzeDSO1 rlarisburg,PA1712fl-0801 15056041169 OFFlCUIL USE ONLY County Code Year Fik Number INHERITANCE TAX RETURN RESIDENT DECEDENT (Q~ Os IO.~.~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 171-16-4757 090920 05 09201917 Decedent's Last Name Suffoc Decedent's First Name MI HOLLASH ALBERT J (If Applkaibk) ErMsr SurvWing Spouse's IMonnaUon Below Spouse's Last Name Suffix Spouse's First Name MI N/A N/A Spouse's Social Security Number THIS ~~ MUST BE FILED IN DUPLICATE YYITH THE N /A REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Ratum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death prior to 12-13-82) 4. Limikd Estate ~ da. Future Interest Compromise (date of ® 5. Federal Estate Tax Retum Required death alter 12-12-62) ® 8. Decedent Died Testate ~ 7. Decedent Malntalned a Living Trust 0 B. Total Number of Safe Deposit Boxes (Attach Copy of wrlq (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. O) CORRESPONDENT - THIS SEC110N fdllST BE CDAIPIET®. ALL COR~SPOIIDENCE MID CDIFIDF1111AL TAX MFORMATiON SHOULD ff dRECTED TD: Name Daytime Telephone Number JO ANNE GORDON 717-728-3441 Frrm Name (IfApphcable) First line of address 3619 GOLFVIEW DRIVE Second line of address Cily or Poat Office MECHANICSBURG Correspondent's o-mail address: JOANNE 9 8 7 @ COMCAST .NET REGISTER OF IMLLS USE ONLY N n Q e ~ rn --_, ; zs+ ~ :: ;-n rv r -i i ~'~ Q~ - -. ,-~ DAB ~rL.ED ~ -- State ZIP Code PA 17050 - _~ tV ,:? Under penalties of perjury, I declare Mat I have axaminetl this rotum, inGutling acoomparrying schedules and statements, and to the best of it is true, eorrecK and otxnpkte. Declaration of preparer other than Me personal re mY knawktlge and belief, presentative K based on all information of which preparer has any knowledge, SIGNATp(tE~S~ RE NSIBL FO~LIN(i RETU~ ~~ ~ ~ ~ ~, ~ /^ DATE 3619 GOLFVIEW DRIVE; MECHANICSBURG, PA 17 415 FALLOWFIELD ROAD; CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15D56041169 15056041.169 J REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWN~d pROP~RTY ESTATE OF FlLE NUMBER. ALBERT J. HOLLASH 2005-01024 H an asset was made joiTrt within ane year ofthe decedent's date of death, k must be reporbd on Schedule G SURVIVING JOINTTENANT(S)NRME ADDRESS RElATIONSHIPTO DECEDENT A JO ANNE GORDON B. ELEANOR BURD C. 3619 GOLFVIEW DRIVE DAUGHTER MECHANICSBURG, PA 17050 6035 BLUE MOUNTAIN TRAIL GRANDDAUGHTER ENOLA, PA 17025 JOINTLY-OYYNED PROPERTY: ffEM NUMBER LETTER F'0(i JOIM TENANT DATE MADE JOIM DESCPoPTION OF PROPERTY INCLUDE NAME OF FeiAHCIAL BiSTTTUnON ATO BNaCACCOUNT NIAABER OR SIMILAR IDENfIFYaMa NUMBERATTACH DEED FOR JdHTLY+fLD REAL ESTATE. GATE OF DEATH VALUE OF ASSET %aF DECD'S INTEREST DATE aF DEATH VALUE OF DECEDENT'S INTEREST ~. A 2000 CITIZENS BANK CD; A/C 6244374350 103545.30 50 51772.65 2 A 2000 F&M TRUST CD; A/C 020-2982063 114751.61 50 57375.81 3 A 2000 F&M TRUST CD; A/C 020-2978652 112244.20 50 56122.10 4 A 1999 PNC BANK CHECKING ACCOUNT 5002088504 67.54- 50 33.77 5 A 2000 PNC BANK MONEY MARKET A/C 5002088491 1862.02 50 931.01 6 A 2000 PNC BANK CD'S; A/C 31500267733 73878.56 50 36939.28 7 A 2000 SOVEREIGN BANK CD; A/C 2895341937 119905.85 50 59952.93 8 B 2000 CITIZENS BANK CD; A/C 6244374342 103545.30 50 51772.65 9 B 2000 F&M TRUST CD; A/C 020-2978653 121570.91 50 60785.46 10 B 2000 SOVEREIGN BANK CD; A/C 289526859.3 119641.35 50 .59820.68 11 B '86 '89 '96 US GOVERNMENT SERIES HH BONDS 54000 50 27000.0-0 0.00 0.00 .0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00. 0.00 0.00 0.00 0.00 .0.00 0.00 0.00 0.00 TOTAL {Also enter on line 6, Recapitulatbn) I S 4 62 , 5 0 6. 3 4 (H mon: space is needed, insert addi8onal sheets of the same size) REV-1510 EX+ (g.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCWEC~I~LE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY ESTATE OF FlLE NUMBER ALBERT J. HOLLASH 2005-01024 This schedule must be completed end filed N the answer io any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCUJDE7lENRhffOFTNE7RANSFEREE,TriEIRREU710NSFi1PTODECEDENfAND 1HEOA1EOFrnrv~srER.nnncHncoProFn€oEEOFORREUESraTe. DATEOFDEATH VALUEOFASSET %OFDECD'S INTEREST EXCLUSION pvnPPUr.~I.Et TAXABLE VALUE t. HARTFORD ANNUITY; CONTRACT 710024036 311910.99 100 3 1,910.99 2 PROTECTIVE ANNUITY; POLICY #VA3507766 221835.35 100 2 1,835.35 3 PRINCIPAL FINANCIAL ANNUITY; A/C 009189290 2795.84 100 2,795.84 4 ALBERT HOLLASH TRUST; A/C 6FX-122098 109478.94 100 1 9,478.94 5 1/16/05 GIFT TO THOMAS BURD 8000.00 100 8,000.00 6 1/16/05 GIFT TO JEFFREY GORDON 8000.00 100 8,000.00 7 1/16/05 GIFT TO JO ANNE GORDON 8000.00 100. 8.,000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 .0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00. 0.00 .0.00 .0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on line 7, Recapitulation) I i 6 7 0 , 0 21.12 (If more space is needed, insert addi4onal sheets of the. same. size) REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCH~~ULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FlLE NUMBER ALBERT J. HOLLASH 2005-01024 Debts of decedent must bs roporbd on SeMdule L ITEM NUMBER DESCRIPTION AMOUNT A 1 B. 1. 2. 3. 4. 5. B. 7. FUNDERALEXPENSES: NEILL FUNERAL HOME ADMINISTRATIVE COSTS: Personal Representative's Commissbns Name of Personal Representative(s) JO ANNE GORDON Social Securiy Number(s)/EIN Number of Personal Representative(s) 16 0 - 3 9 - 0 8 5 9 StreetAddress 3619 GOLFVIEW DRIVE City MECHANICSBURG State PA ZIP 17050 Year(s) Commission Paid: 2 0 0 5, 2 0 0 6 Agomey Fees Fatuity Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant StrsetAddress City State ZIP Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Retum Preparer's Fees 143 95000 74 5, 000 TOTAL (Also enter on Gne 9, Recapitulation) S 10 5 , 217 (It morn space is needed, insert additional sheets of the same sae) REV 1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDWLEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8r LIENS ESTATE OF FILE NUMBER ALBERT J. HOLLASH 2005-01024 Repot debt irn:urted by the daeederd prior to death which rernairted unpaid ae ofthe date of death, hwluding unreimbursed medical exQenses. (I(more space is needed, insert additional sheets of the same sae) REV-1513 EX+ (9-00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIAIVES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF AT,RF.RT .T_ HnT,T~ASH FILE NUN6ER 2005-01024 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAMEANDADDRESSOFPERSON(S)RECEMNGPROPERTY Do Not ListTnastee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[includeoutrigMapousaldistributions,andtranstersunder Sec.9116(a)(1.2)j 1 JO ANNE GORDON DAUGHTER 469,492.68 3619 GOLFVIEW DRIVE MECHANICSBURG, PA 17050 2 ELEANOR BURD GRANDDAUGHTER 519,289.78 6035 BLUE MOUNTAIN TRAIL ENOLA, PA 17025 3 RANDY F. HOLLASH NEPHEW 12,500 819 OVERHILL DRIVE BRANDON, FL 33511 4 WILLIAM HOLLASH, JR. NEPHEW 12,500 9603 STARLITE DRIVE RIVERVIEW, FL 33569 5 BRAD WEYANDT NEPHEW 625 7 WHITTIER FRIENDSWOOD, TX 77546 6 JAMES WEYANDT NEPHEW 625 5921 BACK BAY AUSTIN, TX 78739 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWNABOVE ON LINES 15 THROUGH 1 B,AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 0. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR NMICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLEANDGOVERNMENTALDISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET = 0 . 0 0 (K more space Is needed, inseA additional sheets of the same aae) REV-1513 EX+ (g_00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE) BENEFICIARIES ESTATE OF FlLE NUMBER ALBERT S_ HOLLASH CMS-M fled RELATIONSHIPTODECEDENT AMOUNTORSHARE NUMBER NAMEANDADDRESSOFPERSON(S)RECEMNGPROPERTY Do NotLiatT t OF ESTATE 1 TAXABLE DISTRIBUTIONS[mdudeoubightspousaldislributions,andtransfersunder Sec.9116(a)(1.2)] 7 THOMAS WEYANDT NEPHEW. 625 P.O. BOX 140 GLEN ROSE, TX 76043 8 DAVID WEYANDT NEPHEW 625 3912 BUENA VISTA CIRCLE GRANBURY, TX 76049 ENTER DOLLARAMOUNT5 FOR DISTRIBUTIONS SHOWNABOVE ON LINES 15 THROUGH 1 8,AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICHAN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLEANDGOVERNMENTALDISTPoBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ; (n more space IS neeaea, insert atldi80nal sheets of the same size). +~r~t dill ~ttD ~e.~t~meitt OF ALBERT HOLLASH I, ALBERT HOLLASH, of Hillsborough County, Florida, being of sound and disposing mind and memory, do hereby make, declare and publish this, my Last Will and Testament, and do hereby revoke all former Wills and Codicils made by me. ARTICLE OI~iE All tangible personal property owned by me at the time of my death I devise to my wife, MARY JANE HOLLASH. If my wife fails to survive me, I devise all of my tangible personal property to my then living daughter, JO ANNE HOLLASH. In the event my daughter fails to survive me I devise my tangible personal property to the then living descendants of my deceased daughter, per stirpes. ARTICLE TWO ,!_ Under the prow sions of that certain trust dated NO()Q~11~ ~ , 19 ~ , and created by my wife, MARY JANE HOLLASH, I have been given a power of appointment to be exercised by this will over certain property governed by that trust. I hereby elect not to exercise that power of appointment. ARTICLE THREE All the rest, residue and remainder of my estate, including insurance policies payable to my estate and any property over which I have a power of appointment, I devise to the trustee then serving t~~}der the ins rument of trust heretofore executed by me on the ~'1'~ 3ay of ~ e(' , 193 and entitled ALBERT HO:,LASH REVOCABLE TRUST to be added to the property then held in trust by it and to be held and administered in accordance with the terms of the trust as stated in said instrument of trust as from time to time hereafter amended. If for any reason the said trust shall not be in existence at the time of my death, or if for any reason a court of compe- tent jurisdiction shall declare this testamentary transfer to the trustee of said trust to be invalid, then I declare that said residue shall be held, managed, invested and reinvested in exactly the manner described in said instrument of trust for the period beginning with the date of my death, giving effect to all the then existing amendments of said trust if it shall be legal to do so, by the same trustee therein named and defined which trustee is to serve hereunder without the necessity of complying with the provisions of any law or statute requiring the furnish- ing of bond or registration or qualification by my said trustee with any court. I hereby incorporate into this will by this reference the provisions of ALBERT HOLLASH REVOCABLE TRUST referred to above. ARTICLE FOIIR I appoint my wife, MARY JANE HOLLASH, as my personal repre- sentative to administer my estate under this Will. In the event that my wife is unable or unwilling to serve or to continue to serve, I appoint my daughter, JO ANNE HOLLASH, to be my alternate personal representative to administer my estate under this Will. I direct that neither personal representative shall be required to furnish bond. ARTICLE FIVE In addition to all common law and statutory authority, my personal representative at any time serving hereunder shall have the power to lease, sell, mortgage, transfer and convey in any manner and on any terms as my personal representative may deem advisable any and all property, real or personal, belonging to my estate without the necessity of obtaining leave of any Court; and no purchaser shall be held liable to see to the application of any purchase money. ARTICLE SIX If any devisee under this Will shall die within thirty (30) days after my death, any devise given to or for the benefit of such devisee shall be divested and my Will shall be applied and interpreted as if such devisee had predeceased me. IN WITNESS ~EREOF, I, ALBERT HOLLASH, hereunto set my hand and seal this ~ day of 1+(0001I~~]CY A. D. , 1992 . x-1-~' '~'G' /7 y-L't'c~dxr ALBERT HOLLASH Signed, sealed, published and declared by the said ALBERT HOLLASH, as his Last Will and Testament in the presence of us, who at his request and in his presence and in the presence of each other, have hereunto su scribed our names as attesting witnesses this ~ day of UPa-~bC ~ , A. D. , 1992 . ..~J , Florida City Ti4l~1~~ , Florida City 2 STATE OF FLORIDA COUNTY OF HILLSBOROUGH We, ALBERT HOLLASH and the above named witnesses, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned officer that the testator in the presence of the witnesses, signed the instrument as his last will and that he signed voluntarily and that each of the witnesses in the presence of the testator at his request and in the presence of each other signed the will as witnesses and to the best of the knowledge of each witness, the testator was at that time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. a /~~~ ALBERT HOLLASH Subscribed and sworn before me by ALBERT tor, and by t~e above named witnesses who are me, on the r day of /~OU211'1hP.t', 1992. t ub is My Commission My Commission pab\O1\holashwl HOLLASH the testa- personally known to State of Florida Number is: expires: 3 ~~~~a~er~s B~~k~. RE: Albert Hollash DATE OF DEATH 09/09/05 ACCOUNT INFORMATION CHECKING SAFE DEPOSIT SAVINGS X CERTIFICATE OF DEPOSIT SHARES OF STOCK DATE OPENED 08/03/04 DATE CLOSED still open ACCOUNT NUMBER 020-2978652 ACCOUNT BALANCE AT DATE OF DEATH ~ $ 111 845.11 ACCRUED INTEREST S 399.09 TOTAL ACCOUNT BALANCE S 112 244 20 NAME(S) ON ACCOUNT Albert Hollash or Jo Anne Gordon REGISTRATION OF ACCOUNT Join - --------------------------------------------------------------- ACCOUNT INFORMATION CHECKING SAVINGS X CERTIFICATE OF DEPOSIT SAFE DEPOSIT SHARES OF STOCK DATE OPENED 05/20/05 DATE CLOSED still open ACCOUNT NUMBER 020-2982063 ACCOUNT BALANCE AT DATE OF DEATH S 113 559 88 ACCRUED INTEREST S 1 191 73 TOTAL ACCOUNT BALANCE S 114 751 61 NAME(S) ON ACCOUNT Albert Hollash or Jo Anne Gordon REGISTRATION OF ACCOUNT Joint - ~~ V V W Va Z~~ iN/.7 Aii. ~ Wl1Wfi 3619 Golfnew Dr. Moehtnicsbia8. PA 17050 RE: Estate of AA~ect Halte~t (Deoased) SSN: i?1-16h757 DOD: 09-09-2005 Dear Ms. aondon: In response to your request for Date of Death bsiancea for tlfs cuetomc noted abova vor recaeda show the fallowing Certllksta otDepwft Account X31500267733 F_.tihiisi+~i 07-31 2004 ALBBi~tT HOLLAS~i ro.+rn~s aol~iDOx non balanox S73,S37.n + S3eo.s{ axnred interest caeert~ Aeeo.at Aooount ikS002088504 8ebihliahed 08.4-1949 Aj,$gR'j' Rift I.~RR JOANNE OORDON DOD baLmce: (67.39 + S0.1 S aor~+ued i Salop A~o~ Auooont X3002088491 Estaf~iishd 03-20-2000 ALBERT I~pLL~ASH JOANNB GORDON DOD balance: S 1,859.92 t S2. i0 accrued inmereet ( ~ Paee i of 2 11/Or/ZOOa SON 11:04 FAg Sove~reagm Bank ~ 003/003 ESTATE OF Albert 3 Hoilash SOCIAL SECURITY #: 171-16-4757 DATE OF DEATH: September 9, 2005 Account #: 2895268593 Type: CD Open date: 2!3/2000 In the name of: Albert Iiollash or Eleanor S Burl ' Dstc of Death Ba)ance: $119,641.35 Int.(YTD) from 1/1/2005 to 8/31/2005 $3,932.00 Accrued interest to date of death: 5197.85 Other Info: _--_ Account #: 2895341937 Type: CA Opca date: 2/16/2002 In the ~aamc of: Albert Hollash or Jo Gordoa Date of Destb Bshuee: $119.905.85 lnt.(YTD) from Ul/2005 to 8/31/2005 53,756.01 Accrued interest to date of death: $188.83 Other Info: Pspe 1 d 1 ~~~~~er~~ Sank ~. Account Number 6244374342 Account Title ALBFdtT I~OLLASH OR EJ EANOR S SURD Date ned 3/18/2004 Account T Time De 'ts Princi Balance as of DOD $203329.44 Interest from Last Postin to DOD $215.86 Account Balance as of DOD $103545.30 Y'TD Interest to DOD $1812.45 RE: Albert Hollash DATE OF DEATH 09/09/05 ACCOUNT INFORMATION CHECKING SAVINGS X_CERTIFICATE OF DEPOSIT SAFE DEPOSIT SHARES OF STOCK DATE OPENED 08/03/04 DATE CLOSED still open ACCOUNT NU'MBER' 020-2978653 ACCOUNT BALANCE AT DATE OF DEATH S 121,138.66 ACCRUED INTEREST S 432.25 TOTAL ACCOUNT BALANCE S 121,570.91 NAME(S) ON ACCOUNT Albert Hollash or Eleanor S Burd REGISTRATION OF ACCOUNT Joint ACCOUNT INFORMATION CHECKING SAFE DEPOSIT DATE OPEIQED ACCOUNT NUMBER DATE CLOSED ACCOUNT BALANCE AT DATE OF DEATH ACCRUED INTEREST TOTAL ACCOUNT BALANCE SAVINGS -CERTIFICATE OF DEPOSIT SHARES OF STOCK NAMES} ON ACCOUNT REGISTRATION OF ACCOUNT J.IV~ J14. ~14i4.~,!4.~~ ~A -. .. ~ ~~~i sr .«r nw w.YM'~. MT.q.~n rote- .. / • ~ _ _ - ~ al.~' ~~ " ~++ INT[~[~} 4LAi[t 10 YlAR4. ~ '^~ rr' VIID4 J1WE DAT[ OF F` 171-16'-.4757 10:7 ~ ~-198 , is - ~ ..AOI:Tri [ q _y :, SJC :. .. .. r r t ... To ~ _ - -- ~- _ - - T ~ ~ ~ ,~ 5 ~ N R, ~ ~ ~E i AP .~!0 I x ,~ .,`. _ . ~~ , ,~ ,. ___. t_. ._ .... .. _ . :.. .. ~= - - . . OR ELEANOR S BURD 052-~7~51 _ 00614100089191 i 4 `'z 8000 S 2 i 7 L 5 lei' s~~T~~ ~3 fpp,~, ffi --, .D€FI ~ ~ - r.u rn a t.r nw v w`rw urp un w nwt - 171-16-4757 Y - yy ~. _ S ~ :E Tn ` .~ - ~~ A 5 la _ ,, i ~E ~ ;~ ' I ~ _, I v ~~I i x'0'1 ~ ' .. ` '_~ ~,,, F: OR ELEANOR S BURD ~p=_1NT~REST $ Rl.9. ~iF. ~~~£ i74~ .T ..e..y+.W 1I1 .v - -- 00614100089191 L 5 ~ 8000 7 4 3 3 4 7 411' INT[R[fT'C[AR[S YO Y[AR6 IRON ISSY[ DAT[ D/ _ 1 _07 ~ 1989. I ~wn .~ .esr 07433474 M~4334~4HH . .'. INTEREST CEASES 20 YEAR6 FRbN ISSUE DATE OF _U4 __I :. 1998 .. ~ ff'~R. _ ..~ ~ = OR E.LfANOR S BURD 01015579 !E$T S 8-rt 9a~ rb 8 ~~l~Si ~. ~~6.ti Y 1 _ 9 d-..wv.~ALT y I\ eF O +F ~ ~~.~ 1~~~. OOb141OOO89191 x"+ ' i7 1000i0i5S79-~' __ _ ~. _.' 17.1-1b-4;_1 .p~Jr~t11NTER~SF INT[RLiT'L /ROM 11 ~~. NOl1lM 1998___ YC~R 07433.472 M~4334~2HH OR ELEANOR S BURD S R97 _ 26 ~~1~.9-4. ~~ .4.nGrC/Rli'(.w1n+C 00614100089191 i 5 "~ 6000 74 3 34 7 2--' Date: 10/24/05 Contract Number: 01569 ALBERT HOLLASH 3619 GOLF VIEW DR I~CHANIC3BiJRG, PA 17050 ROSLYN S CARTER AG EDWARDS & 50N5 INC Po Boa 25900 BRADENTON, FL 34206 Putnam Insurance Products Services 1.800-521-0538 01860 Monday through Friday 8:30 am to 8:00 pm Easborn time Transaction Detail PAGE 1 of 1 trade Dabs 8ub,Aocount Name Tronsacgon Descriptlon DoNarAmourot Unk Vafus Unks T LO/24/OS GROWTH & INCIi - REINSTA _;` `~ b~~'` $311,911.00 _49.615599 6286.551 AS o~ 10,24,os Value By Sub-Account ~OWTH & INCH 6286.351 ant By Mail Sub,Account ~~ Ma Name Allocation this ttO6TPH & INClt 100.00X Total I 10076 I 100!6 'UTNAMINYBSTIIBNTS 710024036 use Total Contract Value $31.1,910,99 ALBBRT HOLLASH 3619 GOLF VIBW 1lR ICSBDRG, PA 17050 49.615599 $311,910.99 CorNrad Number: 710024036 PW'iChasA MIOW'It; Please make your CFteClcs payabb to: Flarlford Life ^ Invest this payment as shown Urafar 'Present ANocatbn' in the chart to the IsR ^ Inwst only tlds payment as 1 have IrWiptsd in tM dmt to the left Please re6ak~ my `Presarrt Allopition' loons as shown. ^ InveatlMs paymar~t as I haw kidicatkd to the IaR and krvest any futuro payments in aooordanoe with this new allocation. ^ +D Addroa9 Plosck boot, note new address on raNerss, and velum b us in the enclosed envelope, ~IL_., Nstim~nun PROTECTIVE LIFE INSURANCE COMPANY OPTION AGREEMENT The undersigned named annuitant, JoAnne Gordon (herein "Payee") of Policy Number, VA3507766 issued by Protective Life Insurance Company ("Company") hereby elects to receive the cash value (herein "proceeds") in the amount of X221,835.35 from said policy which is payable as follows: Beginning November 24, 2005, in the amount of $1,396.47 per month, less federal withholding (if elected) for a Period Certain 20 years. In the event of death of the Payee before all of the proceeds are paid in full under the option selected above and upon receipt of due proof of the death of said Payee, the remaining unpaid proceeds shall be continued and paid by the Company pursuant to the option selected above to beneficiary named in the application if living, until said proceeds have been paid in full. While this Option Agreement is in effect, the Payee may change any person or persons to whom the proceeds become payable upon her death, without the consent of said person or persons, by filing at the Home Office of the Company a written request for such change accompanied by this Option ~greement for endorsement. Any such change will relate back to a take effect on the d to the request was signed. The Company will not be liable for any payment we make before such request has been received and acknowledged at our Home Office. Before making any payment under this Option Agreement, we may require proof of the existence and proof of the age of any Payee named to receive the proceeds. No Payee named to receive the proceeds shall have the right to assign, encumber, alienate or commute any of the payments hereunder or to change the option selected above. To the extent permitted by law, no benefits payable under this Option Agreement will be subject to the claims of creditors of any Payee designated to receive such payments. Upon the death of the last'surviving Annuitant the beneficiary may elect to terming#e the contract and received a lump sum death benefit equal to the commuted value of any remaining certain period payments discounted at an annual effective inten3st rate equal the current Treasury Rate +5% on the date a proper request to commute is received at our Home Office. We reserve the right to pay the proceeds in one lump sum, if less than $5,000.00. If monthly payments are less than $100.00, we may make these payments quarterly, semi-annually, or annualy at our option. Pt+o>becti~s Life Insurance Company H165-99 ~ Principal Life Insurance Company Des Moines,lA 50332-0001 RECIPIENT NAME: JO ANNE (CORDON CHECK NUMBERS 05633056 RPS NUMBER:~0859-001 DATE 10-19-05 REFER TO YOUR RPS NUMBER IN ALL CORRESPONDENCE 000135 ff You Have Any Questions Contact: PRINCIPAL FINANCIAL GROUP REPETITIVE PAYMENT SERVICES Jo ANNE GoRDOx P.O.BOH 4926 3619 (~DLFVISW DR GRAND ISLAND, NE 68802-4926 1l~CEANICSBURGr PA 17050-2217 PHONE 1-80Q-247-7011 DES MOINES AREA AND FOREIGN COUNTRIES CALL 1-515-247-782Q Pay To JO ANNE CORDON 3619 GOLFVISW DR lll;7~iANIC3811RG, PA 17050-2217 TiiO THOUSAITD SBVSli HtINDRSD NINSTY-FINS AND 84/100-=--~__~~~ THE NORTFERN TRUST COMP/1NY• CHICAGO, IL 0710 PAYABLE 7FROUGFI NORT1fRN TRUST BANK/DUPAGE, OAK BROOK, IL ~% k 6 i :- ; •' 12PS"°RjftIBEIYe 7ClQt$X0859 )~~/~ 4 ~ >. s 'i. r t v i ~ ~ -Y y' ~ y. ~. • .: A ;70-z1BZ/719x ,,'va { ~ ~ - NO V~1~ID;'AFTEti X180 DAYS ; ;. < .Amount $><++~*+~+~**a2.795.84x• " r. " •irrii~riiiiiiiii ;;~}}}}=::}SSYS •rrrrrrrrrrrur• rrrrr -wr vfrNlrr+•• +rrr rN •rrrNll •++ ~ rrr- •$rrrrr rirrrr •riiii' riiiiiii r rrr - r-rrrrrr By[{Si~fr. {+,rrrrKrr~{r~~r{r{;{i{i( AutAOriz6d Signature(t) _ _ __ __ pM O pV^p~' O 4~9 O ~ ~ b W m 7 W 0 0 tD ql O V N d' M tt ~I ~. 0 t$ a ~, O N ik ~ ~ J ~ LL ~ ILA O F- N f/1 ~ ~ ~ m ~ w a ~ = y o ~ ~ w m ~ m m ,~. ,. > r X 1i ~ tG z 3 f/1 o a ~+ J ~ ~ C ~ ~ ~ m -~ ;~ ~2 a~i v G D