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s
1505610140
REV-1500 EX I°'-'°'
OFFICWL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes INHERITANCE TAX RETURN County Cade Year File Number
Po Box 2eosol 2 1 1 1 0 5 9 0
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 1 1 6 6 8 8 0 0 4 2 9 2 0 1 1 0 8 1 5 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name MI
M I T T E N M I R I A M G
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL INAPPROPRIATE OVALS BELOW
0 1. Original Return
4. Limited Estate
QX 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
S U S A N J H A R T M A N 7 1? 2 4 9 7 7 8 0
REGISTER OF WILLS USE ONLY
First line of address
1 I R V I N E
Second line of address
State ZIP Code
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correspondent's e-mail address: s u s a n h a r t In a n 51 p a• n e t -~ -'~'
Under penalties of perjury, I declare that I have examined this return, including aocomparrying schedules and statements, and b the beat of k
it is true. correct and comple6e. Dedaratlon ~ preparer other than the personal mY 9e and belief,
repreaentaffve is based on aU information of which preparer has any knovdedge.
City or Post Office
SIGNA~l1RE OF PERSON RESPONSIBLE FOR FILING RETURN
~. ~ .. _ . ~ DATEi
225 E• ORANGE ST• SHIPPENSBURG PA 17257
SIGNAT~ OF PREPARER OTHE~IAN REPRESENTATNE ~ pq~
PLEASE USE ORIGINAL FORM ONLY
R 0 W
Side 1
L 1505610140 1505610140 J
REV-1500 EX Page 3
Decedent's Complete Address:
Flle Number
21 11 0590
DECEDENTS NAME
MIRIAM G• MITTEN
STREET ADDRESS
15 W• MAIN ST•
CITY
WALNUT BOTTOM STATE
PA ZIP
17266
Tax Payments and Credits:
~ ~ Tax Due (Page 2, Une 19)
2. CredilslPayments
A. Prior Payments 9 , 0 0 0.0 0
B. Discount 4 7 3.6 7
3. Interest
4. If Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
(1)
9,844.13
Total Credits (A + g) (2) 9 , 4 7 3.6 7
(3)
(4)
0.00
5. If Line 1 +Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) 3 7 0 • 4 6
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; ............................... ^ X^
c. retain a reversionary interest; or ................................................................................................ ^
d. receive the promise for I'rfe of either payments, benefits or care? ....................................................... ^ ^X
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ ^X
3. Did decedent own an 'in trust for" or payable-upon~eath 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? .................................................................................................. 0 ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after 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 benefiaary.
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 benefiaaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) (72 P.S. §9116(a){1)J.
• 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, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedents Name: M I R I A M G• MITTEN 2 0 1 1 6 6 8 8 0
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. 3 3 9 5 0. 0 0
2. Stocks and Bonds (Schedule B) .................................... .. 2. ~ u ~ ° ~ • ~ ~
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. 4 3 8 5. 7 3
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. D • D 0
7. Inter-Vivos Transfers & Miscellaneous N Probate Property
(Schedule G) ~] Separate Billing Requested ..... .. 7. 1 4 6 2 1 5. 3 3
8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 2 3 5 5 1 4 • 0 1
9. Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9• 1 6 4 0 2. 2 8
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... .. 10. 3 5 3. 2 7
11. Total Deductions (total Lines 9 and 10) ............................. .. 11. 1 6 7 5 5. 5 5
12. Net Value of Estate (Line 8 minus Line 11) .......................... .. 12. 2 1 8 7 5 8 . 4 6
13. Charitable and Governmental BequestslSec 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. 2 1 8 7 5 8. 4 6
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
16. Amount of Line 14 taxable
at lineal rate x .045 2 1 8 7 5 8. 4 6 1s. 9 8 4 4. 1 3
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0. 0 0 18. 0. 0 0
19. TAX DUE ...................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610240
9 8 4 4. 1 3
^X
1505610240 J
REV-1502 EX+ (01-10)
Pennsylvania ~ SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MIRIAM G• MITTEN 21 11 0590
All real property owned solely or as a tenant in common must be reported st fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller; r>etther being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly~ovrned wMh right of survivorship must be discka'sed on Schaduk F.
Attach a copy of the settlement sheet if the property has teen sold.
ITEM Include a copy of the deed showing decedent's interest'rf owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1• 15 W• MAIN ST•, WALNUT BOTTOM, PA 33,950.00
ASSESSMENT: X135,800.00
1/4 INTEREST [RESIDED IN 1/4 APARTMENTS IN BLDG ]
[SEE ATTACHMENT]
TOTAL (Also enter on Line 1, Recapitulation.) I i 3 3, 9 5 0
fl more space is needed, use additional sheets of paper of the same size.
REV-1503 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERRANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS 8~ BONDS
--
ESTATE OF FILE NUMBER
MIRIAM G• MITTEN 21 11 0590
AN property joiMlyowned with riyM ofsurvivorship must be dbcbsed on Schedub f.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~. MTB MONEY MARKET CLASS 2 50,962.95 X $1.00 50,962.95
[SEE ATTACHMENT]
TOTAL (Also enter on line 2, Recapitulation) ~ i 5 0, 9 6 2. 9 5
(H more space is needed, insert additional sheets of the same size)
REV-1508 EX + (8-98)
SCHEID~ILE E
Cot~toN4VEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, 81 MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MIRIAM G• MITTEN 21 11 0590
Include the proceeds of Ntigadon and ti-e date the proceeds wane received by the estate.
All property bintlyowned with night of sunMorship must be discbsed on Schsdub f.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~. ERIE INSURANCE GROUP REFUND 15.00
2• M&T BANK CHECKING ACCT• # 97406201 2,274.12
[SEE DOD LETTER ATTACHED]
3• M&T BANK SAVINGS ACCT• # 21000001219212 1,496.61
[SEE DOD LETTER ATTACHED]
4• PERSONAL PROPERTY 600.00
TOTAL (Also enter on line 5, Recapitulation) ~ ; 4 , 3 8 5 • ? 3
(If more space is needed, insert additional streets of the same size)
REV-1510 EX+ (08-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEI~WT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF
FILE NUMBER
MIRIAM G• MITTEN 21 11 0590
This schedule must be completed and ftledrf the answer fo any of questions 1 throtgh 4 on page three of the REV-1500 a yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
~~ THE HAME ~ T-+E . THE ~ TD ~ Art
THE DATE OF TRANSFErt. ATTACH A COPY OF THE DEED FOR REAL E5rATE
DATE OF DEATH
VALUE OF ASSET
96 OF DECD'S
INTEREST
EXCLUSION
~ APPLICABLE)
TAXABLE
VALUE
~. WESTERN NATIONAL LIFE INSURANCE CO• 37,642.78 100.00 37,642.78
ROBERT A• MITTEN; SON; 06/03/2011
[SEE ATTACHMENT]
2• EQUITRUST ANNUITY CONTRACT 108,572.55 100.00 08,572.55
EQ0001073971F
ROBERT A• MITTEN; SON
TOTAL (Also enter on Line 7 Recapitulation) I s 14 6 , 215 3 3
If more space is needed, use additanal sheets of paper of the same size.
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
MIRIAM G• MITTEN 21 11 0590
DecedsM's debts mutt be reportx+d on Schtduk 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~, FOGELSANGER-BRICKER FUNERAL HOME 9,859.78
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2, AttomeyFees: DUNCAN & HARTMAN, PC 6,OD0.00
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address '
City State ZIP
Relationship of Claimant to Decedent
4. probate Fees: REGISTER OF WILLS 315.50
5. I Accountant Fees
6. Tax Retum Preparer Fees:
7. REGISTER OF WILLS - SHORT CERTIFICATES 12.00
8• REGISTER OF WILLS - FILING FEE 15.00
9• HELD IN RESERVE 200.00
TOTAL (Also enter on Line 9, Recapitulation) I i 16 , 4 0 2 • 2 8
If more space is deeded, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8 LIENS
ESTATE OF FILE NUMBER
MIRIAM G• MITTEN 21 11 0590
Report debts incurred by the decedent prbr to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. WEST SHORE EMS 275.63
2• DELUXE CHECK FEE 1?-64
3• M&T BANK CHECKING .ACCT. ~ 9847581643 60.00
[SEE DOD LETTER ATTACHED]
TOTAL (Also enter on Line 10, Recapitulation) I S 3 5 3 •
If more space is needed, insert additional sheets of the same size.
REV-1513 EXr(01-10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE
FILE NUMBER:
MIRIAM G• MITTEN Cy yy u.~~u
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS Pn ~outrigs ~e)spa~jdistribudons and transfers under
9911~~
1. ROBERT A • MITTEN Lineal
225 E• ORANGE ST• 10D%
SHIPPENSBURG, PA 17257
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS;
1.
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
SCHEDULE J
BENEFICIARIES
If more space is needed, use additional sheets of paper of the same size.
~7 .~~:
LAST WILL
8c
TESTAMENT OF
IvIIItIAM G. MITTEN, of South Newton Township, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make,
publish and declare this as and for my Last Will and Testament, hereby revoking any and all
other wills and codicils heretofore made by me.
FIRST. I direct that all my just debts and funeral expenses be paid from my estate as
soon after my death as practically and conveniently may be done.
SECOND. I direct that my remains be irnerred within my family's burial plot in accord
with my expressed wishes.
THIRD. I authorize my personal representative to expend funds from my estate, in such
amounts as my personal representative shall consider necessary and desirable for the purchase,
erection and inscription of a suitable marker for my gave.
FOURTH. I give, devise and bequeath any and all tangible personal property owned by
me at the time of my death unto my husband, PAUL R. MITTEN, provided he survives me by
thirty (30) days. In the event he fails to survive me by thirty (30) days, I give, devise and
bequeath all said tangible personal property unto my son, Robert A. Mitten.
FIFTH. I give, devise and bequeath any and all real estate owned by me at the time of
my death, unto my husband, PAUL R. MITTEN, provided he survives me by thirty days. In
the event he fails to survive me by thirty (30) days, I give, devise and bequeath all said real
estate urno my son, Robert A. Mitten.
SIXTH. I give, devise and bequeath all the rest, residue and remainder of my estate
unto my husband, PAUL R MITTEN, provided he survives me by thirty (30) days. In the
event he fails to survive me by thirty (30) days, I give, devise and bequeath all the rest, residue
and remainder of my estate unto my son, Robert A. Mitten.
SEVENTH. I direct that any and all Inheritance, Estate and Transfer taxes imposed
upon my estate passing under my will or otherwise, shall be paid out of the principal of my
residuary estate.
EIGHTH. I hereby nominate, constitute and appoint my husband, PAUL R. MITTEN
as Executor of this my Last Wiq and Testament. In the event of renunciation, death,
resignation or inability to act for any reason whatsoever of Paul R. Mitten, I nominate,
constitute and appoint my son, Robert A. Mitten, as Executor of this my Last Will and
Testament. I hereby relieve my Executor from the necessity of posting security in connection
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
. SS.
I, Miriam G. Mitten, Testatrix whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed
and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as
my free and voluntary act for the purposes therein expressed.
Sworn or affirmed to and
acknowledged before me, ~b~~
Miriam G. Nf~tten this ~i'ay
of Max, 2001. ~
!'
,~ ~~" ~_
No Public - ~~~
COMMONWEALTH OF PENNSYL MANIA
COUNTY OF CUMBERLAND
G. MITTEN
NOTARIAL SEAL
Cynthia L Darr, Notary Public
South Middleton Twp., County of Cumberland
My Commission Expires Aug. t a, 2004
SS.
We,~ctm _ ~~GLZ~h?p~and ~`''~~~~ ~ ~ ~-~1-t--r~~'~ the witnesses
whose names are si ed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw Miriam G.1Vrtten sign and
execute the instrument as her Last Will; that she signed willingly and that she executed as her
free and voluntary act for the purposes therein expressed; that each of us in the hearing and
sight of the Testatrix signed the will as witnesses; and that to the best of our knowledge, the
Testatrix was at that time eighteen (18) or more years of age, of sound mind and under no
constraint or undue influence.
Sworn or affirmed to and
s scribed bef a rye by
1~C1"~'~~'.t~~l~ t'~~` K l i~t`C witnesses,
this~?)day of May, 2001.
r~ ~ ~ ~ ~_.
=i ~.. ~ ~
Not Public
NOTARIAL SEAL
Cynthia L Darr, Notary Public
South Middleton Twp., County of Cumberland
My Commission Expiroq µup, t a, 2004
TaxDB Result Details
Page 1 of 1
Detailed Results for Parcel 41-31-2230-024. in the 2010 Tax Assessment Database
DistrictNo 41
Parcel 1 D 41-3 I -2230-024.
MapSuffix
HouseNo I S
Direction W
Street MAIN STREET
Ownerl MITTEN, ROBERT A
C/O
PropType RA
PropDesc
LivArea 3188
Cu rLa nd V sl 24900
CurlmpVal 110900
CurTotVal 135800
CurPreNal
Acreage .47
CIGrnStat
TaxEx 1
SaleAmt 1
SaleMo 03
SaleDa 27
SaleCe 20
SaleYr 07
DeedBkPage 00279-01478
YearBlt 1925
HF File Date 02/05/2009
HF Approval_Status D
http://taxdb.ccpa.net/details.asp?id=41-31-2230-024.&dbselect= l 5/25/2011
~ M&T Investment Group
285 Delaware Avenue, Suite 2000, Buffalo, NY 14202-1885
M&T Securities, Inc.
July 5, 2011
Miriam Mitten
AZC037944
Date of Death: 04/29/2011
Description of Security Quantity in
Shares Price per share on
04/29/2011
MTB MONEY MARKET CLASS A2 50,962.95 $1.00
We have received the information presented above from sources, which we believe to be
accurate. However, we do not guarantee their accuracy. The stock price per share on
valuation date is the closing price on that date. The mutual fund price per share is the
low/nav price on that date. Previous business day price is used if DOD falls on a weekend
or holiday.
Please contact Client Solutions with any further questions, or if we may be of further
assistance to you at 1-800-724-7788, Option #1. Thank you.
Sincerely.
Investment and Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured ey Any Federal Government Agenq
• Have NO Bank Guarantee • May Go Down In Value
MBT Investment Group'" is a service mark of M3T Bank Corporation and consists of M6T Securities, Inc., the investment-related areas of M6T Bank and
the investment advisory firm MTB Irnestment Advisors, tnc.
Brokerage services and insurance products are offered by M8T Securities, Inc. (member FINRA/SIPC), not by M$T Bank.
M8T 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.
Brokerage Operations Specialist
M&T Securities, Inc.
WESTERN J NATIONAL
life Insurance C o m p a n y
PO. Box 871
Amarillo, Texas 79105-0871
1.800.424 4990
June 3, 2011
Ms. Susan J. Hartman, Esq.
One Irvine Row
Carlisle, PA 17013
Re: Western National Life Insurance Company
Miriam G. Mitten, Deceased
Contract/Policy #AN201995
Deaz Ms. Hartman:
The Internal Revenue Service requires reporting of all death benefits for federal estate tax purposes. Form
712 is prepared for regular life insurance contracts only. Since this contract was an annuity, the Form 712 is
not applicable.
Listed below is the death benefit information for the above-referenced annuity contact.
Type of Annuity Contract:
Date of Issue:
Contract Owner's Name:
Original Investment:
Cost Basis
Cash Value as of Date of Death on 04/29/2011:
Total Payment for Death Benefit on 06/03/2011:
Proceeds made payable to:
Non-Qualified Tax Deferred Annuity
10/19/2011
Miriam G. Mitten
$25,952.33
$25,952.33
$37,642.78 (interest $11,690.45)
$37,767.16 (goss) (interest $11,814.83)
Robert A. Mitten
If you have any questions or require further assistance, please contact our Customer Care Representatives,
available Monday through Friday, 8:00 AM to 6:00 PM Central Time, at (800) 424-4990. We appreciate this
opportunity to serve you.
Sincerely,
~rna~,.
Diana Martin
Annuity Claims Team Member
Q m~z~~
499 Michell Road, Millsboro, DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302) 934-2955
June 6, 2011
Duncan and Hartman PC
One Irvine Row
Carlisle, PA 17013
Re: Estate of Miriam G Mitten
Social Security: 201-16-6880
Date of Death: Apri129, 2011
Dear Sir or Mariam:
Per your inquiry on May 25, 2011, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1. Type of Account
Account Number
Ownership (Names o, fl
Opening Date
Balatce on Date of Death
Accrued Interest
Total
Checking Account
9847581643
Miriam G Minen
10/19ro7
$ .00
--------------------------------------------------
2. Type of Account
Account Number
Ownership (Names o~
Opening Date
Balance on Date of Death
Accrued Iruerest
Total
Checking Account
97406201
Miriam G Mitten
Paul R Minen
Robert A Minen (POA)
01/18ro8
$2,274.10
$ .02
--- -- - --
$2,274.12
3. Type of Account
Account Number
Ownership (Names o~
Opening Daate
Balance on Date of Death
Accrued /merest
Total
Savings Account
21000001219212
Miriam G Mitten
Pau1R Miaen
Robert A Mitten (POA)
1 /~t72~9
$1,494.56
$ .OS
$1,494.61
For any additiooai iatormatlon on the above aarounta, lududing ownaahip and any change, dawres and/or rehabnrsemmt of fonds,
please call the Walnut Bottom OQiae at #'717-532-2414.
We wen mnbk to locate any sate deposit bo: for the above-mentioned decedent.
'Ibis klter dots not hxilutk any aooounts io whkh the daxaxd may have ban Ifshd as Pourer d Attorney, a[ Ih~arm Tramlas,
Rive P'aya; or'Ilwtee under a Wrtlta~ Ag.eanaN
Sincerely,
Tammy Spencer
Adjustment Services
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EquiTrust Life Insurance Company®
West Des Moines, Iowa
Executive Office
5400 University Avenue
West Des Moines, Iowa 50266-5997
1-866-598-3692
III E ulTrust
Financial Services
In this Certificate, "you" or "your" will
refer to the Owner and "we", "our', or
"us" will refer to EquTrust Life
Insurance Company®, a stock
company.
We will pay the Proceeds of this Certificate according to the terms of the Certificate. The Proceeds will
provide a monthly income, or other settlement, in accordance with the Payment Plan selected. The terms
of this Certificate are contained on this and following pages.
READ YOUR CERTIFICATE CAREFULLY. This is a legal Contract between you, the Owner, and us, the
Insurer.
RIGHT TO EXAMINE AND RETURN THIS CERTIFICATE
Right to cancel. H you are not satisfied, you may cancel your Certificate by returning lit within 20
days after the date you receive it. Mail or deliver tt to us at the address shown above or to your
agent. (If you return the Certificate by mail, it will be deemed returned when postmarked, properly
addressed, and postage prepaid.) This Certificate will then be void from its start. Any premium
paid will be refunded.
The Certificate may be terminated by either the Contractholder or us with respect to new applicants, but
Certificates issued under the Contract will continue in effect until al- obligations to Certificate Owners have
been fulfilled.
This Certificate is signed by us as of its Certificate Date.
~~A~
President
~ ~~
Secretary
GROUP SINGLE PREMIUM FIXED AND EQUITY INDEX DEFERRED ANNUITY CERTIFICATE
Annuity benefit payable at Income Date.
Death benefit payable in event of the Certificate Owner's death prior to Income Date.
CASH SURRENDER VALUES MAY INCREASE OR DECREASE BASED ON THE EQUITY INDEX
AND MARKET VALUE ADJUSTMENT FEATURES OF THIS CERTIFICATE. THE INITIAL INTEREST
RATES FOR THE FIXED RATE ACCOUNT ARE FOR ONE YEAR ONLY. WHILE CERTIFICATE
VALUES MAY BE AFFECTED BY AN EXTERNAL INDEX, THE CERTIFICATE DOES NOT DIRECTLY
PARTICIPATE IN ANY STOCK, BOND OR EQUITY INVESTMENTS.
NONPARTICIPATING
ET-MPP-2000C(01-07)
i ~
CERTIFICATE DATA PAGE
ANNURANT MIRIAM G MITTEN
ANNURANTS SEX Female
AGE 81
OWNER : MIRIAM G MITTEN
CERTIFICATE NUMBER: EQ0001073971 F
CERTIFICATE DATE: 10-01-2007
INCOME DATE: 10-01-2031
PREMIUM PAID AS OF CERTIFICATE DATE: $110,879.45
MINIMUM GUARANTEED CERTIFICATE RATE: 3.00°x6
PAYMENT PLAN MINIMUM INTEREST RATE: 1.5°x6
PAYMENT PLAN MORTALITY TABLE: Annuity 2000 Mortality Table
MVA DURATION 14 Years
PREMIUM BONUS PERCENTAGE: 10.00%
PREMIUM BONUS AMOUNT FOR PREMIUM: $11,087.95
Specific Premium Allocations are detailed on the following pages.
The Surrender Charge is a percentage of the Accumulation Value surrendered or withdrawn and is measured from the
beginning of each Certificate Year. The percentage is shown below:
Certficate Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 and
Later
Percentage 20 20 19 19 18 17 16 14 12 10 8 6 4 2 0
ET-MPP-2000C(01-07) 3
. DATA PAGE (cont)
1-YEAR INTEREST ACCOUNT
Minimum Guaranteed Interest Rate: 2.00%
ALLOCATION OF INITIAL PREMIUM
premium Allocation (°h) Premium Allocation (S)
100.00% $121,967.40
Premium Allocation ($) shown includes Premium Bonus allocated to this Account.
Initial Interest Rate
3.45%
The Initial Interest Rate shown above is guaranteed for one Certificate Year on all Premiums and any Premium Bonus
allocated to the 1-Year Interest Account.
Any reference to the Fixed Rate Account shall be replaced with the 1-Year Interest Account.
TRANSFERS
You may transfer amounts to this Account on each Certificate Anniversary by sending a written request, on a form
acceptable to us, to our Executive Office.
Transfers out of this Account into an Interest Account and/or Index Account are allowed on each Account
Accumulation Date. The Account Accumulation Date is every Certificate Anniversary after the Premium or Transfer
Amount is received into this Account. '
A transfer will be effective on the Account Accumulation Date next following receipt of the request. All requests are
subject to the following:
a. Your written request for transfer is received at least five business days prior to the next Account Accumulation
Date;
b. the amount transferred is not less than $2,000; and
c. any remaining Account Accumulation Value after a transfer is not less than $2,000.
ET-MPP-2000C(01-07) 4 1-Year Interest
^ CORRECTED {N checked)
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