HomeMy WebLinkAbout04-27-12 (3)15W5610140
REV-1500 ~` (°'-'°'
PA Department of Revenue OFFICUIL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 260601 INHERITANCE TAX RETURN 2 1 1 1 0 8 8 8
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Decedent's Last Name Suffix Decedent's First Name MI
B L O S S E R J E A N E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
^X 1. Original Return
4. Limited Estate
® 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 0
(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)
S. Federal Estate Tax Return Required
6. 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 T0:
Name Daytime Telephone Number
I V O V O T T 0 I I I 7 1 7 2,^y 3 3 `~ 4 1
First line of address
M A R T S O N L A W
Second line of address
1 D E H I G H S T
City or Posl Office
O F F I C E S
State ZIP Code
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N
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C A R L I S L E P A 1 7 1 3
correspondent's e-mail address: I O T T O a M A R T S O N L A W- C O M
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, antl to the best of my knowletlge and belle(,
it is true, correct and complete. DeUaraaon of preparer other than the personal representative is based an all information of which preparer has any knowletlge.
150561U140
Side 1
150561140
J
r/~tJ
10 E HIGH STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
1505610240
REV-1500 EX Decedent's Social Security Number
Decedents Name: JEAN E• B L O S S E R
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1 ~ ~ • ~ ~
2. Stocks and Bonds (Schedule B) ...................................... 2. 5 3 3 2 . 6 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .................... .... .. 4.
1 6 5 ~ D . $ 6
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E). .... .. 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . .... .. 6. 0 • ~ ~
7. Inter-Vivos Transfers & Miscellaneous Ny~Probate Property
(Schedule G) u Separate Billing Requested . .... .. 7. 3 5 ~ 7 ~, 3 6
8. Total Gross Assets (total Lines 1 through 7) ..................... .... .. 8. 5 6 9 0 3 5 2
9. Funeral Expenses and Administrative Costs (Schedule H) ............ .... .. 9. 5 9 2 0 . 2 9
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... .... .. 10. 9 2 4 6 . 7 5
11. Total Deductions (total Lines 9 and 10) ......................... .... .. 11. 1 5 1 6 7 . 0 4
12. Net Value of Estate (Line 8 minus Line 11) ...................... .... .. 12. 4 1 7 3 6 . 4 8
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................ .... .. 13. ~ . ~ ~
14. Net Value Subject to Tax (Line 12 minus Line 13) ................ .... .. 14. 4 1 7 3 6 . 4 8
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)X~0 _ Q ~ O 15. 0. 0 ~
16. Amount of Line i4 taxable
at lineal rate x .045 4 1 7 3 6. 4 8 1 s. 1 8 7 8. 1 4
17. Amount of Line 14 taxable
at sibling rate X .12 D D D 17. 0. ~ ~
18. Amount of Line 14 taxable
at collateral rate X .15 ~ ~ 0 18. 0• ~ 0
19. TAX DUE ...................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1 8 7 8. 1 4
Side 2
1505610240 1505610240
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 it osas
DECEDENT'S NAME
Jean E. Blosser
STREET ADDRESS
442 Walnut Street
CITY
Cazlisle STATE
PA ZIP
17013
Tax Payments and Credits:
t. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
Total Credits (A +B) (2)
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
(1) 1,878.14
0.00
5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,878.14
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 trans(erred : ................................................................ ...... ^
b. retain the right to designate who shall use the property transferred or its income; .............. ...... ^
c. retain a reversionary interest; or .......................................................................................... ...... ^
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 receiving adequate consideration? ................................................................................. ...... ^
3. Did decedent own an "in trust for" orpayable-upon-death bank account or secudty 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? ............................................................................................ ...... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
1~!~tf!?~lt~i!!!! ,I'l1+tl""`~'lip!i~;"<<II~II'i"I''IIIVIP~'llt'f,I,IIIII~idlpGp{UH,plifp"I'Prllllll!II'Inl'~Irl,~'fl!;i]1'I~IGI~I~~~[I~IIIIiuillMiiiliillllh9d!i1fl011UIIpi;lllllllllflUiill!(IBIIIIIrOfllii!If~I~I11iiN~11~IN1~11!{I~INI~fN ~
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 beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JEAN E. BLOSSER 21 11 0888
All property ]ointty•ovmed whh dght of sunrNorehlp must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 91 shazes, Prudential Financial Services CUSIP 744320102 5,332.60
See attached
TOTAL (Also enter on line 2,
(If more space is needed, inseA additional sheets of the same size)
REV-1508 EX + (6-9e)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
Include the pproceeds of litigatbn and the date the proceeds wen: received by the estate.
All aroaeM binWrowned with rlahl of survhrorshlo must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
M&T Bank checking 614432
See attached
TOTAL (Also enter on line 5,
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX+ (08-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
JEAN E. BLOSSER 21 I 1 0888
This schedule must be completed and fled if the answerto any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THENAME OF THETRANSFEREE, THEIR REIATIDNSHIP TO OECEOENTANO
THE DATE OF TRANSFER. ATfACHACOPV OF THE DEED FOR REAL EBTATE.
DATE OF DEATH
VALUE OF ASSET
'N, OF DECD'S
INTEREST
EXCLUSION
(IFPPPLICPBLE)
TAXABLE
VALUE
1. Equitrust Annuity E00001014216F: Beneficiaries: Bonnie 27,365.92 I D0.00 27,365.92
L. Gutshall, daughter, 1/3; Jeffory B. Blosser, son, 1/3
Therese J. Cucuzella, daughter, 1 /3
2. Fidelity Guazantee Life Annuity L9076221: Beneficiazies: 7,704.44 100.00 7,704.44
Bonnie L. Gutshall, daughter, 1/3: Jeffory B. Blosser, son, 1/3;
Therese J. Cucuzella, duaghter, 1 /3
TOTAL (Also enter on Line 7 Recapitulation) ~ S 35 070 36
If more space is needed, use additional 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
JEAN E. BLOSSER 21 11 0888
Decedent's debts must be reponed on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman Roth Funeral Home & Cremetory, Inc. 3,160.58
2. Funeral Luncheon 231.66
B.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) or Personal Representative(s)
Street Address
City
Year(s) Commissbn Paid:
p. Attorney Fees: MARTSON LAW OFFICES
3, Family Exemption: (Ii decedents address is not the same as claimant's, attach explanation.)
Claimant
SVeet Address
City State _
Relationship of Claimant to Decedent
4. ~ Prebate Fees: Cumberland County Register of Wills
5. I Accountant Fees
6. Tax Return Preparer Fees: Wagners Tax & Accounting Service, Inc.
(Prepazation of 2011 personal income tax returns)
7. Filing Fee, Inheritance Tax Return
8. EVP Stock Valuation
9. Additional probate fee
86.50
95.00
15.00
1.55
30.00
TOTAL (Also enter on Line 9, Recapitulation) I S 5,920.29
State ZIP
ZIP
2,300.00
more space Is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (72-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
JEAN E. BLOSSER 21 11 0888
Report debts intoned by the decedent prior to death that remained unpaid at the date of death, Including unreimbureed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. M&T Bank checking 614432, outstanding checks on date of death 8,764.58
2. ~Thornwald Home, account payable
3. ~Millennnium Pharmacy, account payable
4. ~Philhaven, account payable
336.19
120.98
25.00
TOTAL (Also enter on Line 10, Recapitulation) ;
If more space b needed, insen additional sheets of fhe same size.
REV-1513 EX+(01-10)
pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
TFAN F RT (1CRFR o1 11 nuuu
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 (Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. Bonnie L. Gutshall Lineal 13,356.65
320 Enola Road 1/4 estate residue + 1/3 Sch.
Carlisle, PA 17013 G, Items 1&2
2. Jeffory B. Blosser Lineal 13,356.65
105 Susan Lane 1/4 estate residue + 1/3 Sch
Carlisle, PA 17013 G, Items 1&2
3. Teresa J. Cucuzella Lineal 13,356.65
483 Elwyn Terrace 1/4 estate residue+ 1/3 Sch
Manheim, PA 17545 G, Items 1&2
4. Elizabeth Valle Lineal 333.30
152 Fieldstone Drive 1/20th of estate residue
Carlisle, PA 17015
5. Dana Blosser Lineal 333.30
P.O. Box 48 1/20th of estate residue
New Kingstown, PA 17972
6. Nina Blosser Lineal 333.31
P.O. Box 48 1/20th of estate residue
New Kingstown, PA 17972
7. Sheila Blosser Lineal 333.31
P.O. Box 48 1/20th of estate residue
New Kingstown, PA 17972
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAH;EN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. E 0.00
If more space is needed, use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
JEAN E. BLOSSER
Decedent's Name
Schedule J -Beneficiaries - 1
21 11 0888
File Number
NUMBER
NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not LlstTrustee(s) AMOUNT OR SHARE
OF ESTATE
1 TAXABLE DISTRIBUTIONS llnclude outright spousal distributions and transfers under
Sec. 9116 (a)(i.2).]
8. Heather Thompson Lineal 333.31
117 Cobblestone Way 1/20th of estate residue
Dillsburg, PA 17109
F ~FILES\DATAEILE\WILLS\8]]0. W IL
~... `/ O
I, JEAN E. BLOSSER, of 140 Tower Circle, Cazlisle, Cumberland County, Pennsylvania,
being of sound and disposing mind and memory, do hereby make, publish and declaze this to be my
Last Will and Testament, hereby revoking any and all former Wills or Codicils by me made.
1.
I direct that all my just debts, funeral expenses, testamentary expenses and all inheritance
taxes (whether such taxes may be payable by my estate or by any recipient of any property) shall be
paid from my residuary estate as soon as practicable after my decease and as part of the
administration of my estate. My Executor shall have no duty or obligation. to obtain reimbursement
for any such tax so paid, even though on proceeds of insurance or other property not passing under
this Will.
2.
I give such items of personalty as are itemized in a certain list attached hereto to the persons
named thereon, which list is signed and dated by me at the end thereof.
3.
I give, devise and bequeath all of my estate, both real and personal property, in equal shazes,
unto my children, DONALD L. BLOSSER, JR., BONNIE L. GUTSHALL, JEFFREY B. BLOSSER,
and TERESA J. QUESENBERRY, absolutely.
4.
In the event any of my said children shall predecease or fail to survive me by more than thirty
(30) days, and leave issue surviving, then I direct that his or her shaze shall be held by my Trustee,
in trust, for the following purposes:
a. I direct that my Trustee shall hold, invest and reinvest the same, collect the income
arising therefrom, and after paying all expenses incident to the management of the trust, to use and
apply as much of the income and principal as may be necessary in the sole discretion of my Trustee,
in equal shazes, for the support, well-being and education of the issue of .such deceased child.
b. I direct that each of such beneficiaries shall have the right of withdrawal of his or her
,'l,~ ~' 6
J.E.B.
Page 1 of 4 Pages
equal share of the principal and any accumulated income of said trust as each attains the age of
twenty-one (21) yeazs.
c. In the event any of my said children shall predecease or fail to survive me by thirty
(30) days and shall not be survived by issue, then his or her shaze shall be distributed by my said
Executors equally to my remaining children in accordance with the terms hereof.
d. To the extent that the same is permitted by law, none of the beneficiaries hereunder
shall have any power to dispose of or to chazge by way of anticipation any interest given to such
beneficiary; and all sums payable to such beneficiaries hereunder shall be :&ee and cleaz of the debts,
contracts, alienations and anticipations of the beneficiaries, and all liabilities for levies and
attachments and proceedings of whatsoever kind, at law or in equity.
I nominate, constitute and appoint my children, BONNIE L. GUTSI-TALL and JEFFREY B.
BLOSSER, as Executors of my estate.
6.
I nominate, constitute and appoint my children, BONNIE L. GiJTSHALL, JEFFREY B.
BLOSSER and TERESA J. QUESENBERRY, or the survivor(s) of them, as Trustees under the
terms of this Last Will and Testament.
7.
I direct that neither my Executors nor my Trustee(s) shall be required to file a bond to secure
the faithful performance of their dudes in any jurisdiction.
8.
I authorize and empower my Executors and Trustee, in their sole and absolute discretion, to
purchase or otherwise acquire and retain any investments of which I die seized or any real or
personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or
grant options in regazd to any or all property of any kind forming a part of my estate for such terms
and such prices as they may deem advisable; to borrow money for any purposes connected with the
protection and preservation of my estate; to mortgage or pledge any real or personal property forming
a part of my estate or to join in or secure the partition of same; to compromise any claims or
J.E.B.
Page 2 of 4 Pages
demands of my estate against others or of others against my estate; to make distribution in kind and
to cause any share to be composed of cash, property or undivided ~frac;tional shares in property
different in kind from any other share; to employ agents, attorneys and proxies and to delegate to
them such power as my personal representative and Trustee consider desinible and to pay reasonable
compensation for such services as may be rendered by such agents, attorneys and proxies; and to
execute and deliver such instnunents as may be necessary to carry out any of these powers. In
addition, I direct that my personal representative shall have the power to conduct an inventory of any
safe deposit box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this .moo? ~1Oe"day of
Q-,~y , 1997.
,d-%z~o (SEAL)
Jean E. Blosser
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and
for his Last Will and Testament, in the presence of us, who at his request, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testatrix and of each other.
~~ ,
cx~
Page 3 of 4 Pages
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND
I, Jean E. Blosser, 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.
~an E. Blosser
~ Swom or affirm and acknowledged before me by Jean E. Blosser, the Testatrix, this
a?oZ day of , 1997.
Notary Public
COMMONWEALTH OF PENNSYLVANIA Notarial seal
Corrine L. Myers, Notary Public
S$. Carlisle Boro, Cumberland County
My Commission Expires May 27, 1999
COUNTY OF CUMBERLAND )
We, =.(o ~(. Q "f-7"d ~- crud TIQ-l C.t A~ ~ • I~..>f~~ t-F y~
the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw Jean E. Blosser, the Testatrix, sign
and execute the instrument as his Last Will; that the Testatrix signed willingly and that the Testatrix
executed it as his 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 18 or more yeazs of age, of sound mind and under no constraint or
undue influence.
Address /~
~r/r t
G r
it/
Address /~ ~2p~J// ~7
~iOD ~ ~ t /G /-~ /757
Sworn or affirmed to and subscribed before me this °~a ~ day of n,'t~-Q~ , 1997.
Notary ublic U ~
Notarial Seal
Corrine l.. Myers, Notary Public
Carlisle Boro, Cumberland County
My Commission Expires May 27, 1999
Page 4 of 4 Pages
Estate valuation
Date of Death: 07/31/2011
Valuation Date: 07/31/2011
Processing Date: 04/20/2012
Shares Security High/Ask Low/Bid
or Par Description
1) 91 PRUDENTIAL FINL INC (794320102; PRU)
M
Estate of: Jean E. Blosser
Account: 0770.1
Aepoxt Type: Date of Death
Number of Securities: 1
File ID: 0770.1 .blosser
Mean and/ox Div and Int Security
Adjustments Accruals Value
CO
NYSE 59.57000 57.68000 H/L
07/29/2011 59.62000 57.53000 H/L 58. F00000
00/01/2011
Total Value:
Total Accrual:
Total: $5,332.60
5,332.60
55,332.60
$0.00
Page 1
This report was produced witR EstateVal, a product of Estate Valuations & Pricing Systems, Inc. Tf you have questions,
please coot//act EVP Systems at (0181313-6300. (Bevis loo 6.9.1)
p ~s~
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Phone 588-502-0349
F ax (302) 934-2955
August 30, 201 l
Manson Law Offices
10 East High Street
Carlisle, PA 17013
Re: Estate of Jean E Blosser
Social Security 174-20-0563
Date of Death: July 31.2011
Dear Sir or Madam:
Per your inquiry on August 22, 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 Checking Account
Account Number 614432
Ownership (Names ofl Jean E Blosser
Bonnie L Gutshall (POA)
Opening Date 05/12/82
Balance an Date of Death $16,500.56
Accrued Interest $ •~
Total $16,500.56
For any additlonet information on the above amounts, induding ownership end any changes, dosures and/or reimbursement of tLnds,
please ~ the Efigh sired Carlisle O®ce at #717-7AIW536.
We were unable to locate any safe deposit box for the abovo-mentioned decedent
17ds letter does not indude auy attrounts in which the deteas<d may bate bem listed ee Power of Attorney, Custodian of Uniform Trand'ers,
Represmmdve Payee, or 1lvstee under a written Agreement
Sincerely,
Tammy Spencer
Adjustment Services
April 24.2012
SENIORADVISING SERVICES
LIGHTING THE WAY THROUGH RETIREIwIENT
From: Brian Brassell
To: Vicki Otto
)tE: Jean Bloaser estate
Vicki,
Here are the annuity values and beneficiary information for Jean Blosser's Equitrust Life account
as of her date of death:
Equitrust Life
Account # EQ0001015216F
Value at time of death: $27,365.92
The proceeds are to be distributed equally among the three surviving children as follows:
Bonnie Gutsha]l -
Jeffrey Blosser -
Teresa Quesenbem, -
If you require any additional information, you may reach me at (717) 514.1005.
Sincerely,
Brian Brassell
C-ire c lam- ~C tS ~ ,~y~ ` I
Z'd 9ZZt+-69tilLlL) Ilesse~guela8 ELb60ZL7Z~dH
Frain: Clams OepartmeM iax: (BOD) 771•Na9 To'. 71~a694225~cfax.pon Fax: •7717a694225 Page 6 of 6 3/22l20tt 6:5p
FIDELITY 8 GUARANTY LIFE
Fidelity & INSURANCE COMPANY
Guaranty Lifea"" 77P Resr~rch Drive, t.incoln, NE 6552^
P O Box 82068, Lincoln. NE 6850'.
866-702-2' 94 !Office) 40279-0198 {Fax)
www.fglife.com
Mazch 22, 2012
BRIAN BRASSELL
1814 FOX HAVEN LN
PALIl'ly'R.4 PA 1?078
Poticy: L907G221
Owner: Jean Blosser
Annuitant: Jean Blosser
Deaz Mr. Brassell:
We have been notified of the death of the policy owner. We wish to convey om sincere sympathy to the family
in their [ecent loss.
Our records indicate that rite beneficiary of the policy is Donald L. Blosser Jr, Bonnie L. Gutahali, Jeffrey B.
Blosser and Teresa Queaenbenry. The approximate benefit amount is 57704.44. 'fhe approximate taxable gain
is $7704.44.
.4 beneficiary, who is a natural person (i.e. not a corporation, estate, trust, etc.), may choose only one of the
following settlement options. A beneficiary that is not a natural person (e.g. corporation, trust, estate, etc.) may
only choose option 1 or 3. If you are selecting any of the options 2 - B, please enclose a letter of instruction to
indicate who you would like your beneficiaryfies to be. Please pro~tide their name and relationship to you, and
also sign and date the attachment
1. P,umn Sum Payment -The beneficiary will receive a single lump sum payment of the policy
proceeds.
2. Substitute Owner Election - "•"THIS OPTION IS AVAILABLE TO THE SURVIVING
SPOUSE ONL1'""" -The surviving spouse beneficiazy will become the new o~mer of the
policy. All terms and conditions of the policy remain unchanged, including any remaining
surrender charge period.
3. 5•Year Deferral -The beneficiary may defer settlement of [his claim for a period not to exceed
5 years from the policy owner's death. The beneficiary may withdraw all or part of the proceeds
at any time during the 5-year period. Withdrawals may be subject to surrender charges, if the
policy includes surrender chazges on the death benefit.
4. Stretch Annuity Payout - "'"THIS OPTIO\ IS AVAILABLE TO NON-SPOUSES
ONLY""" -The death benefit is paid out over a period of time based on the Gfc expectancy of
the beneficiary. A Stretch Annuity payout cannot be 1035 exchanged to another insures once
elected.
5. Income for a Fixed Period -This option guarantees to pay the beneficiary regular income over
the period of years chosen by the beneficiary. L`, the beneficiary should pass away before the all
the payments are made, the beneficiary may designate a beneficiary who may receive a lump
sum benefit or elect to continue receiving the income payments for the remainder of the fixed
petiod. Paytnents must be for a minimum period of 5 years and for no more titan 50 years.
Fidelity 8 Guvanty Lae z tM marketing name m Fl6elay i Guarany Lire Irmraanee Comparry and, in Naw York only, Fidakiry & Guaranty Litu Insurance
GDmpany of now York. Only Fidslitya Guaranty LHe lneunneu eompeny al New YOrRe au[harind basil irniuraixa antl arnuiaes in New York.
£'d 9ZZb-694 (L lL) ~ C K-~c`k /~ ~ ~r-e Z Ilesserg taeirg eZ6 60 Z l bZ rdd