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HomeMy WebLinkAbout10-09-12• 1505610140 ~ REV-1500 EX (°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year FileNum~be'r~{ PO BOX 280601 ~a ~.~..J" 1 Harrisburg, PA 17128-0601 RESIDENT DECEDENT o~2 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 3 0 7 2 0 1 2 1 0 0 1 1 9 3 1 Decedent's Last Name Suffix Decedent's First Name MI H I L L B E R N I C 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 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 0 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ prior to 12-13-82) 5. Federal Estate Tax Return Required OX 6. Decedent Died Testate ~ death after 12-12-82) 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (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 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number S T E V E N W F A H N E S T O C K C P A 7 1 7 7 3 7 5 4 6 6 hp First line of address 1 5 1 3 C E D A R Second line of address Ciry or Post Office C A M P H I L L Correspondent's 9-mail address: C L I F F D R State P A REGISTER OR~LLS USE ON~1~ `~ r~.:r '~ ~ _ ~ ?' { i t G' ;:; ~ ~ .:1 ~( ~ w DATl~ILED W ZIP Code L 1 7 0 1 1 C~J T ~ ``"y4. f?"t ~~ J (..~ C "` '~L-7l T t.Y/ ' r ,-, f-n r '~ ~- ~~° ~~ Q -rt unaer penalties of perjury. I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, r ct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI TU F PERSON RFCPON IB E R (LING R ~A~~~~~ 212 GRINDING WHEEL MILL CREEK DOVER DE 19904 SIGN OF PRE ~ OTHER THAN REPRESENTATIVE DATE X513 C'~DAR CLIFF DRIVE CAMP HILL PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J 1505610240 REV-1500 EX Decedent's Social Security Number decedent's -vame: B E R N I C E HILL RECAPITULATION 1. Real Estate (Schedule A) .......................................... . 1. 1 4 5 0 0 0. 0 0 2. Stocks and Bonds (Schedule B) ..................................... . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... . 4. 5. Cash, Bank De osits and Miscellaneous Personal Pro e P p rtY (Schedule E)...... . 5. 2 1 6 9 4 . 8 7 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ...... . 6. 2 5 5 0 . 8 7 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ...... . 7. 2 4 5 8 2 0. 7 4 8. Total Gross Assets (total Lines 1 through 7) .......................... . 8. 4 1 5 0 6 6 . 4 8 9. Funeral Expenses and Administrative Costs (Schedule H) ................. . 9. 2 5 5 3 7 . 1 7 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ . 10. 11. Total Deductions (total Lines 9 and 10) .............................. . 11. 2 5 5 3 7 . 1 7 12. Net Value of Estate (Line 8 minus Line 11) ........................... . 12. 3 8 9 5 2 9 . 3 1 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. 3 8 9 5 2 9 . 3 1 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.o _ 0 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 3 8 9 5 2 9. 3 1 1 s. 1 7 5 2 8. 8 2 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. 1 7 5 2 8• 8 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 00 DECEDENT'S NAME BERNICE HILL STREET ADDRESS 407 KENT DRIVE CITY MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: ~ • Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. Total Credits (A + B) (2) (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 17,528.82 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 : ...................................................................... ^ X^ b, retain the right to designate who shall use the property transferred or its income; ............................... ^ ^X c. retain a reversionary interest; or ................................................................................................ ^ X^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ......... ^ Q 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 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. (1) 17, 528.82 0.00 (3) REV-1502 EX+(01-10) . Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: BERNICE HILL 0 0 All real property owned solely or as a tenant in common must be reported at 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, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointlyowned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 407 KENT DRIVE MECHANICSBURG PA 145,000.00 PROPERTY WAS SOLD 6/22/2012 SEE ATTACHED HUD-1 TOTAL (Also enter on Line 1, Recapitulation.) I $ 145 000 00 If more space is needed, use additional sheets of paper of the same size. REV-1508 EXt (11-10) . pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: BERNICE HILL 0 0 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MEMBERS 1ST SAVINGS ACCOUNT NUMBER 37395-00 55.71 SEE ATTACHED REPORT 2. MEMBERS 1ST CHECKING ACCOUNT NUMBER 37395-11 12,320.15 SEE ATTACHED REPORT 3. PERSONAL PROPERTY 1,000.00 4. 2004 HONDA CIVIC 8,000.00 GIFTED WITHIN ONE YEAR OF DATE OF DEATH 5. REFUND OF TAXES/UTILITIES ON SALE OF HOUSE 319.01 TOTAL (Also enter on Line 5, Recapitulation), $ 21 694 87 If mere space Is needed, insert additional sheets of paper of the same size REV-1509 EX+ (01-10) . Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: BERNICE HILL 0 0 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. RICHARD HILL 427 MANOR VIEW DRIVE SON MILLERSVILLE PA 17551 13. C JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTI' INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °k OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTERESI 1. A. 02/2011 MEMBERS 1ST CD ACCOUNT NUMBER 37395-60 5,101.73 50. 2,550.87 ACCOUNT ESTABLISHED 9/13/11, ROLLED FROM A PREVIOUS JOINT ACCOUNT ESTABLISHED 2/11/11 TOTAL ;Also enter on Line 6, Recapitulation) I $ 2 550 87 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (OS-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER BERNICE HILL 0 0 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDETHENAMEOFTHETRANSFEREE,THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IFAPPLICABLE) TAXABLE VALUE 1. MEMBERS 1ST CD ACCOUNT NUMBER 37395-61 25,390.24 100.00 25,390.24 SEE ATTACHED REPORT 2. MEMBERS 1ST CD ACCOUNT NUMBER 37395-62 25,138.76 100.00 25,138.76 SEE ATTACHED REPORT 3. MEMBERS 1ST CD ACCOUNT NUMBER 37395-63 35,819.17 100.00 35,819.17 SEE ATTACHED REPORT 4. MEMBERS 1ST CD ACCOUNT NUMBER 37395-64 28,644.33 100.00 28,644.33 SEE ATTACHED REPORT 5. PRUDENTIAL ANNUITY CONTRACT NUMBER E0689565 62,490.47 100.00 62,490.47 SEE ATTACHED INFORMATION 6. NORTH AMERICAN LIFE INSURANCE 43,287.16 100.00 43,287.16 POLICY NUMBER 8000179055 SEE ATTACHED REPORT 7. GREAT AMERICAN FINANCIAL RESOURCES 25,050.61 100.00 25,050.61 POLICY NUMBER 1192016296 SEE ATTACHED REPORT TOTAL (Also enter on Line 7 Recapitulation) ~ $ 245 820 74 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 BERNICE HILL 0 0 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION nnnni iniT A. FUNERAL EXPENSES: 1. TORBERT FUNERAL CHAPELS B. 2. 3. 4 5. 6. 7. 8. 9. 10, 11. 12. 13. 14. 15. 16. 17. 18. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees: Family Exemption: (If decedents address is not the same as claimant's, attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: STEVEN W FAHNESTOCK, CPA Tax Return Preparer Fees: STEVEN W FAHNESTOCK, CPA ESTIMATE FOR 2012 FORM 1040 ANDREWS & PATEL -MEDICAL HOME INSTEAD SENIOR CARE SPECIAL EVENT EMERGENCY MEDICAL SERVICES, INC SUPERIOR PLUS ENERGY SERVICES-MARCH SUPERIOR PLUS ENERGY SERVICES-APRIL SUPERIOR PLUS ENERGY SERVICES-MAY PPL-MARCH PPL-APRIL PPL-MAY PPL-JUNE UNITED WATER-MARCH UNITED WATER-APRIL 1, 650.00 200.00 140.00 50.75 1, 395.15 238.00 238.00 238.00 42.12 21.55 23.40 65.75 28.73 11.00 1,400.00 ZIP ZIP TOTAL (Also enter on Line 9, Recapitulation) $ 25 537 17 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (D1-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: BERNICE HILL n n 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 outrightspousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. CLAIRE ELLEN HILL Lineal 127,581.98 35 MOUNTAINSIDE TERRACE CLIFTON NJ 07013 2. RICHARD HILL Lineal 134,365.35 427 MANOR VIEW DR MILLERSVILLE PA 17551 3. CHARLES HILL Lineal 127,581.98 212 GRINDING WHEEL DR DOVER DE 19904 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 1 S OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ ~~ nwro sNa~e a neeoea, use aaDiuonai snee> Dr paper or the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent BERNICE HILL Decedent's Name Page 1 File Number Schedule H -Funeral Expenses ~ Administrative Costs - 67. ITEM NUMBER DESCRIPTION AMOUNT 19. UNITED WATER-MAY 11.08 20. UNITED WATER-JUNE 11.09 21. UPPER ALLEN TWP SEWER 112.00 22. VERIZON 53.21 23. STEVEN W FAHNESTOCK, CPA 2011 FORM 1040 ~ 190.00 24. ENTERPRISE -EXECUTOR TRAVEL EXPENSES 214.19 25. DEBBUS ZERBE, TAX COLLECTOR -REAL ESTATE TAXES 519.17 26. GLENN MAY -HOUSE MAINTENANCE 572.40 27. RITTERS TRUE VALUE -HOUSE MAINTENANCE 90.09 28. ZIMMERMAN PLUMBING AND HEATING 345.00 29. REAL ESTATE SETTLEMENT COSTS AND SELLER COSTS PAID 17,676.49 SUBTOTAL SCHEDULE H•B7 ~ 19,794.72 LAST WILL A~TI~ T]ESTAI~I[]EI®TT ®~ ~]EIZI~TIC]E I-IILL I, BERNICE HILL, having my legal residence at 407 Kent Drive, Mechanicsburg, Cumberland County, Pennsylvania, 17055, do hereby declare this to be my Last Will and Testament, revoking all other Wills and Codicils heretofore made by me. I declare that I have the following children born to me, Charles T. Hill, Richard M. Hill, and Claire E. Hill, and that all references to my children are to them. ITEM ONE: I direct that all my valid debts and the ex~enses~of my last illness and funeral be paid from my estate as soon as practicable after my death. ITEM TWO: I give and bequeath all of my tangible personal property to my residuary heirs under Item Four, below as follows: A. All items of tangible personal property shall be inventoried and valued at a fair market value. B. I may leave a Memorandum listing some of the items of my tangible personal property which I wish certain persons to have and request that my wishes as set forth in the memorandum be observed by my Personal Representative. Any items of tangible personal property not so designated shall be divided and distributed among my residuary heirs as follows: 1. Each of my heirs may select one item, in rotation, in order determined by lot, until such time at which the items chosen by each heir reach such heir's proportionate share of the total value of my estate, or until such time as each heir wishes to make no further selections. 2. Any items not selected shall be sold and the net proceeds added to the residue of my estate. 3. To the extent my heirs are unable to agree, the. decision as to what may constitute "one item" for purposes of this selection shall be made by my Personal Representative(s). 4. Any disputes concerning this method of allocation shall be resolved by my Personal Representative(s) in my Personal Representative's sole discretion. 5. To the extent my Personal Representative is unable to resolve a dispute among two or more of my heirs concerning the in-kind distribution of any of my personal property, I direct my Personal Representative to sell the disputed property and the net proceeds there from shall be added to the residue of my estate. ITEM THREE: I give and devise any interest I may own in any real property together with the insurance thereon to my residuary heirs under Item Four. My Personal Representative may either distribute any real property at its then fair market value to one or more of my residuary heirs under and in accordance with Item Four below, or may sell any such real property and the net proceeds there from shall be added to the residue of my estate. ITLM FOUR: I give, bequeath and devise the entire residue of m~ estate, of whatever nature and wherever situate, to my children, CHARLES T. HILL, RICHARD M. HILL, and CLAIRE E. HILL, in shares that take into consideration the beneficiary designations on my non-probate assets in order to ensure that my children inherit equally from me, per stirpes. In determining the value of a beneficiary's share of my residuary estate, I direct that the value of my residuary estate be augmented by the value of any personal and real property distributed in-kind under Items Two and Three, above. ITEM FIVE: Should any beneficiary of mine be under the age of twenty-five (25) years, my Personal Representative shall hold such beneficiary's share of my estate, as Trustee, IN TRUST and shall invest, reinvest and distribute the principal and net income of such beneficiary's share as follows: A. Until such beneficiary attains the age of twenty-five (25) years, my Trustee, in my Trustee's sole but reasonable discretion, may pay or apply the income and any or all of the principal of such beneficiary's share for the health, maintenance, support and education of such beneficiary considering all other sources of income available to such beneficiary and known to my Trustee. Upon such beneficiary attaining the age of twenty-five (25) years, my Trustee shall distribute the balance of the principal and accumulated income, if any, of each such beneficiary's share to such beneficiary. B. Should the principal of the Trust Estate, in the sole opinion of my Trustee, be or become too small to warrant placing or continuing of such fund in trust or should its administration be or become impractical for any other reason, my Trustee, in the exercise of their sole discretion, may pay such share absolutely to the person maintaining such beneficiary or may place such shares in the beneficiary's name in aninterest-bearing deposit in any bank, bank and trust company or national banking association of his choosing, payable to the beneficiary at majority, or if said beneficiary has reached his or her majority, then to him or her directly. C. All shares of principal and income hereby given shall be free from anticipation, assignment, pledge or obligation of my beneficiary(s), and shall not be subject to any execution or attach- ment. ITEM SIX: I appoint, my son, CHARLES T. HILL, Personal Representative of this my Will. In the event my son is unable or unwilling to act or continue to act as my Personal Representative, I appoint my son, RICHARD M. HILL, Personal Representative of this my will. I give to my said Personal Representative(s) the same powers as are hereinafter given to my Trustee. Such powers shall be in addition to those conferred by law. ITEM SEVEN: I appoint my duly appointed Personal Representative as Trustee of any Trusts} created pursuant to Item Five, above. ITEM EIGHT: No bond shall be required of any fiduciary hereunder in any jurisdiction. No fiduciary hereunder shall have any liability for any mistake or error of judgment made in good faith. ITEM NINE: I authorize my Personal Representative(s) and Trustee(s) to exercise the following powers in addition to those given bylaw, to be exercised in their soli discretion: A. To retain any or all of the assets of my estate, without regard to any principle of diversification, risk or productivity; B. To invest u~ all forms of property without restriction to investments authorized for any type of fiduciary ; D. To loan money to or buy property from my estate; E. To bon ow money from any person, including any Executor or Trustee, and to mortgage or pledge any real or personal property; F. To sell at public or private sale, to exchange or to lease for any period of time, any real or personal property, and to give options for sales, exchanges or leases, all for such prices and upon such terms and conditions as they deem proper; G. To allocate receipts and expenses to principal or income or partly to each as they deem proper; H. To repair, alter or improve any real or personal property; I. To distribute in cash or in kind or partly in each at valuations fixed by them; J. To keep reasonable amounts of cash in a bank uninvested if deemed advisable for the protection of the principal; K. To subscribe for or to exercise options for stocks, bonds or other investments; to join in any plan of lease, mortgage, merger, consolidation, reorganization, foreclosure or voting trust and to deposit securities thereunder, and to generally exercise all the rights of security holders or employees of any corporation; L. To register securities in the name of a nominee or in such manner that title shall pass by delivery; M. To add to the principal of any trust created by this instrument any real or personal property received from any person by Deed, Will or in any other manner; N. To exercise all power, authority and discretion given by this instrument after the termination of any trust created herein until the same is fully distributed; O. To use their sole discretion in deciding whether stock dividends on stock they hold in trust should be apportioned to principal or income, except stock dividends of regulated investment companies which shall be added to principal; P. To commingle the assets of any trust estate created by this Will in any one or more common funds for greater convenience and flexibility; Q. To employ agents, accountants, engineers and such other persons, professional or otherwise, as may be necessary for the proper administration of this estate or trust and to pay their compensation from such funds; and R. To disclaim all or any interest in a property passing to me or my estate. ITEM TEN: I realize that Personal Representatives are given discretion by law to make various elections which affect the income and estate taxes payable by estates and beneficiaries, as well as the relative shares of beneficiaries, such as taking administration expenses as deductions for either estate or income tax purposes, selecting options for the payment of employee death benefits, electing to take a qualified terminable interest as part of the marital deduction, selecting alternate valuation dates, postponing the payment of taxes, filing joint income tax or gift tax returns and redeeming corporate stock. The decisions made by my fiduciaries in any of these matters shall be binding upon, and not subject to question by, any affected persons. I rely upon my fiduciaries to take into consideration the total income and estate taxes payable by reason of their decisions including those payable by my survivors, and they are authorized in their discretion, but not required, to make adjustments between income and principal as a result thereof ITEM ELEVEN: I direct that all estate, inheritance and other taxes in the nature thereof, together with any interest and penalties thereon, becoming payable because of my death with respect to the property constituting my gross estate for death tax purposes, whether or not such property passes under this my Last Will and Testament, shall be paid from the principal of my residuary estate, and no person receiving or having a beneficial interest in any such property, whether under this my Last Will and Testament or otherwise, shall at any time be required to contribute to or refund any part thereof; PROVIDED, however, that this direction shall not apply to the taxes on any property included in my estate solely because of a power of appointment thereover which I possess but have not exercised or on any qualified terminable interest or to any generation- skipping transfer taxes. ITEM TWELVE: No gift or beneficial interest shall be subject to anticipation, assignment, pledge, obligation, or alienation of my beneficiary(s), whether voluntary or involuntary, and the income and principal thereof shall not be s2abject to any execution or attachment. ITEM THIRTEEN: If any beneficiary, person or entity in any manner, directly or indirectly, contests or attacks this Will or any of its provisions, or objects to the accounts or actions of my fiduciaries, without probable cause, such beneficiary, person or entity shall pay all costs, including but not limited to attorneys' fees, arising in connection with such contest, attack or objection incurred by my estate, such trust or such fiduciary personally. In the event that such beneficiary, person or entity does not prevail in such action, any share or interest in my estate or such trust which would otherwise pass to such beneficiary, person, entity or remainderman under this Wil] shall be revoked and the property consisting of such share shall be disposed of in the manner provided herein as if that contesting person or entity had predeceased me without surviving issue. ITEM FOURTEEN: Should any of the provisions of my Will be for any reason declared invalid, such invalidity shall not affect any of the other provisions of this Will and all invalid provisions shall be wholly disregarded in interpreting this Will. This Will shall be construed, regulated and governed by and in accordance with the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, I have at Mechanicsburg, Pennsylvania, on February 15, 2012, set my hand and seal to this my Last Will and Testament consisting of four (4) pages plus any witness, acknowledgement, affidavit and certification pages. u~ ~,~~ (SEAL) BERNICE HILL SIGNED, SEALED, PUBLISHED AND DECLARED BY BERNICE HILL, the above named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. G~ Witness: ~ Witness' Address: ~ << - G Ad ~' ~ ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS: I, BERNICE HILL, the 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, and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. BERNICE HILL Sworn to or affumed and acknowledged before me, by BERNICE HILL, the T tatrix on Febn~ary 15, 2012. ~,~ A Attorney AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . SS: I, -.l~rss~ ~~ lf~6G~'~ , a witness whose name is signed to the attached or foregoing instrument, being duly sworn and qualified according to law, do depose and say that I was present and saw the Testatrix sign and execute the instrument as her Last Will; that she had signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix, signed the Will as Witness; anti that to the best of my knowledge the Testatrix was at that time eighteen (l 8) years of age or older, of sound mind and under no constraints or undue influence. v e~ ~ Sworn to or affirmeu and acknowledged before „~e, by ~ ~ s4~~~p(-~' , a Witness on February 15, 2012. _. ~., N ~c or PA Attorney AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . SS: I, David D. Nesbit, a witness whose name is signed to the attached or foregoing instrument, being duly sworn and qualified according to law, do depose and say that I was present and saw the Testatrix sign and execute the instrument as her Last Will; that she had signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix, signed the Will as Witness; and that to the best of my knowledge the Testatrix was at that time eighteen (18} years of age or older, of sound mind and under no constraints or undue influence. -.~ ~~ . Witness Sworn to or affirmed and acknowledged before me, by David D. Nesbit, a Witness on February 15, 2012. Notary Public NOTA AL CERTIFICATION MARCIA M NESBIT Notary Public UPPER ALLEN TVIIP., CUMBERLAND COUNTY COMMONWEALTH OF PENNSYLVANIA My Commisslon Expires ,Jun 4, 2014 . SS: COUNTY OF CUMBERLAND On February 15, 2012, before me, the undersigned officer, personally appeared David D. Nesbit, Esquire (Pennsylvania Supreme Court ID No. 77411), known to me or satisfactorily proven to be a member of the bar of the highest court of Pennsylvania and certified that he was personally present when the foregoing acknowledgement and affidavit(s) were signed by the Testatrix and witnesses. IN WITNESS WHEREOF, I hereunto set me hand and official seal. Notary Public NOTARIAL SEAL MARCIA M NESBIT Notary Public UPPER ALLEN T~NP., CUMBERLAND COUNTY My Commisslon Expires Jun 4, 2014 This informal letter of instruction to my family and Personal Representative serves to convey my personal wishes concerning distribution of selected personal effects. In any situation where the provisions of this letter may be deemed to be inconsistent with or contrary to the terms of my Will, or other formal Estate Planning Documents, it is my desire and intent that the provisions of my Will and other formal Estate Planning instruments shall govern and be controlling since I do not intend that this letter shall serve in any respect as a Will nor shall the terms of this letter override the provisions of a Will or a Trust executed by me whether it was signed prior or subsequent to the date of this letter. Distribution of Personal Property Descriution of Property Beneficiary 1. 1. 2. 2. 3. 3. 4. 5. 4. 5. 6. 6. 7. 7. 8. 8. 9. 9. 10. 11. 10. 11. 12. 12. 1 Description of Property 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Beneficiary Other Directions To My Family: z ~~~tiM6Nr~h ~` w K ~ R OMB Approval No. 2502.0265 ~ QZ A. Settlement Statement (HUD-1) ~ ` 9~H oeJE~~ B. Type of Loan 6 Fl 1. ©FHA 2. Q RHS 3. ^Conv, Unins. . e Number: 201200073 7. Loan Number. 8. Mor~age Insurance Case Number; 4. D VA 5. [~ Conv. Ins. 970075278 446-1265700-703 C. Note: 71tis form is furnished fo give you a statemenf of actual sea8ement costs. Amounts paid to and by the settlement agent are shown. Items marked "(p.o.c.)"were paid outside the closing; the are h h D. Name and Address of Borrower: y s own ere for informational p ur poses and are not Included in fhe totals. Christopher D. McCoy and E. Name and Address of Seller: F. Name and Address of Lender. Bethanne R. McCoy, husband and wife Estate of Bernice Hill Fairway Independent Mortgage 407 Kent Drive Go Charles Hill ~ 4720 Carlisle Pike, Suite 300 Mechanicsburg, PA 17055 212 Grinding Wheel Drive Mechanicsburg, PA 17050 Dover, pE 19904 G. Property Location: H 407 Kent Drive . Settlement Agent; 20-2039731 Capital Area Abstractors, LLP I• Settlement Date: Mechanicsburg, PA 17055 .500 North Progress Avenue Cumberland County, Pennsylvania Harrisburg, PA 17109 Ph. (717)920-9179 June 22, 2012 Place of Settlement: 500 North Progress Avenue J. transaction 1 to 110. - ~•o~ ~rva. sewer ~narges 06!23/12 to 07/01/12 410 9.8F 111. . 112. 411. 412. 120 . Gross Amount Due from Borrower 154,289.36 420. Gross Amount Due to Seiler 200. Amounts paid or in Behalf of Borrower 201. De osit or earnest move 500. Reductions in Amount Due Seller: 145,319.01 202. Prins al amount of new loan{s 1,000.00 501. Excess de it see instructions 203. Existin loans taken sub'ect to 142,373.00 502. Settlement char es to Seller Line 1400 12 676 49 204. 503. Exislin loans taken sub'ect to . . 205. 504. Payoff First Mortgage 206. 505. Pa Second a e 207. 506. 208. Seiler Pd Borrower Costs 507. De osit disb. as roceeds 209. Setter Escrow Credit 4,286.15 508. Seiler Pd Borrower Costs 4 286 15 4d'ustments for items un id b Selier 713.85 509. Seller Escrow Credit ' , . 713 85 ?10. Ci !town Taxes to Ad ustments for items un id b Seller . ?11. Coun Taxes 510. Ci Mown Taxes to ?12. School ;~ 511. Coun Taxes r~ 216. aia 217. 516. 218, 517. Escrow for Inh Taxes due to Ca Itai Area Abstracto 9 787 50 219. 518. , . 519. 220. Total Paid b /for Borrower 300. Cash at Settlement fromlto Bo 148,373.00 520. Total Reduction Amount Due Seller rrower 301. Gross amount due from Borrower ine 120 600. Cash at settlemerrt to/from Seller 27,463.99 302. Less amount paid by/for Borrower Ane 220) 154,289.36 { 148 373 00 601. Gross amount due to Selier li a 420 602 145 319 01 303. Cash ~ From ~ To Borrower , . 5 9 , Less reductions due Seller (line 520) , . { 27,463.99 , 16.36 603. Cash ~ To ~ From Seller 117,855.02 The undersigned hereby acknowledge receipt of a completed copy of this statement & any attachments ref fr t ~ ~ , e o herein L. Settlement Charges 700. Totai Real Estate Broker Fees $ 8 700 00 , . DiVlsion of commfssion (line 700) es fa1lows: Paid ~~^ Wald From 701. 4 545.00 to ERA NRT LLC ep"tea senors 702. $ 4350.00 to Exit Real Ca ltal Area Funds at Funds al ~ 703. Gommission aid at settlement setuement Settlement 7~• 8 895.0( 705. Compliance Fee to Exit Realty Capital Area 800. Items Payable in Connection with Loan 154.00 801. Our on ination cha e $ 961.00 from GFE #1 802. Your credit or charge {points) for the spedfic interest rate chosen $ 803. Your adjusted origination char es (from GFE #2) 804. sisal fee to FLS from GFE #A 961.00 805. Credit Re rt to Kroll Factual Data from GFE #3 $475.00 POC B 806. Tax service to from GFE #3 25.00 '' 807. lood cert~gtion to FLS (from GF #3) 808. (from GFE #3) 9.75 809: (from GFE #3) 810 (from GFE #3) 811 (from G E #3) 900. Items Re aired b Lender to Be Paid in Advance (from GFE #3) 901. Daily interest charges from 06/22/12 to 07/01/12 9 $14.627400/day (from GFE #10) 902. Mo a e insurance remium for months to De t. of HUD ' from GFE #3 131.65 903. omeowner s rnsurance for ears to Advances lnsurence Solut(ons from G E #11) $460 00 POG B 2448 69 , 904. 905. . (from GFE #11 {from GFE #11) 1000. Reserves Deposited with Lender 1001. Initial deposit for your escrow account omeowne s rnsurance mon s per mon (from GFE #9) - 1,906.14 1003. o a e insurance months $ 144.54 er month ` ~ ' 1004. Property taxes ~ s ~~' Assessments months ~ $ per month $ Coun Taxes months $ er month 1005. 1006. County Taxes 5.000 months @ $ .43.26 per month $ $ 216.30 1007. School Taxes 13.000 months ~ $ 140.35 per month $ 1,824.55 1009. Aggregate Adjustment $ '~~~ '=''"4si ;<y ! 1100. Tine Charges $ -249.70 ,: -I( :;I- ~ ~, t! :: r ,..it u-r,~ ~' ~ . '..'; ..,.. 1101. Title services and lender's title insurance {from GFE #4) 11.02. Settlement or closin fee to Ca ital Area Abstractors, LLP ' $ 1'627'12 1103. Owner s title insurance to First American Title Insurance Company - ~ ~~~ `~` 135.00 ~ `, , 1104. lender's title insurance to First American Title Insurance C from GFE #5 1 0.00 om an p 1105. Lender's title oli limit $ 142 373.00 ~ 1,332,12 1108. Owner's title li limit $ 145 000.00 1107. enYs ortion of the total tltle insurance remium to Ca ital Area Abstractors, LLP $ 1 14 0.80 1108. Underwriter's orlon of the tote[ fide insurance premium to FrstAmerican Tite Insurance Com an $ 1109. p 201.32 , . . . ...............: ............... ..::..... 1110. 1 1. 1112. 1113. 1200. Government Recording and Transfer Charges 1201. Govemment recordin char es to Recorder's Office from GFE #7 1202. Deed $ 65.00 Mortgage $ 74.00 Releases $ Other $ 139.00 1?.03. Transfer taxes to Recorder's Office (from GFE #8) 1204. CitylCoun tax/stamps $ 1,450.00 $ 1,450.00 1205. State tax/slam s $ 1,450.00 g 1206. ~ - ' 1,450.00 1207. 1300. Additional Settlement Charges 1301. Re aired services that u can sho for 1302. from GFE #6 1303. 1304. 1305. See addiYl disb. exhibit to 1400. Total Settlement Cha (enter on fines t03, Section J anq 502, Section K) 112.00 2,196.49 ~ /~ ay stgning page 1 of this seatemant, the signatories adatowledge reeeipt ofa Competed copy of papa 2 & 3 or Nis three pope a~tart(enl .// /ice " 8 970.35 12 676.49 tr ~ /d -~."r----- .. y f~^ Capi Area Abstractors, LLP, Settlement Agent Certified to be a true copy. '-` St MEMBERS 1St FEDERAL CREDTT UNION SAVINGS ACCOUNT: Account Number/Suffix 37395-00 Date Account Established 04!12/1984 Principal Balance at Date of Death $55.71 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest $55.71 Name of Joint Owner None CHECKING ACCOUNT: Account Number/Suffix 37395-11 Date Account Established 06/02/1984 Principal Balance at Date of Death $12,319.96 Accrued Interest to Date of Death $.19 Total Principal and Accrued Interest $12,320.15 Name of Joint Owner None CERTIFICATES OF DEPOSIT: Account Number/Suffix 37395-60 Date Account Established 09/13!2011 Principal Balance at Date of Death $5,100.69 Accrued Interest to Date of Death $1.04 Total Principal and Accrued Interest $5,101.73 Name of Joint Owner Richard Hill Date Joint Ownership Established 09/13/2011 *Rollover from certificate 37395-40, originally established 02/11!2011. CERTIFICATES OF DEPOSIT: Account Number/Suffix 37395-61 37395-52 Date Account Established 09l19/2011* 09/26/2011** Principal Balance at Date of Death $25,385.07 $25,133.64 Accrued Interest to Date of Death $5.17 $5.12 Total Principal and Accrued Interest $25,390.24 $25,138.76 Name of Beneficiary Charles Hill & Clair Hill Charles Hill 8 Clair Hill *Rollover from certificate 37395-52, originally established 02/16/2011. **Rollover from certificate 3739 5-58, originally established 10125/2010. CERTIFICATES OF DEPOSIT: Account Number/Suffix 37395-63 37395-54 Date Account Established 11/14/2011* 11/28/2011** Principal Balance at Date of Death $35,813.28 $28,639.62 Accrued Interest to Date of Death $5.89 $4.71 Total Principal and Accrued Interest $35,819.17 $28,644.33 Name of Beneficiary Richard Hill Charles Hill & Clair Hill *Rollover from certificate 37395-53, originally established 04/13/2011. **Rollover from certificate 37395-59, originally established 04/23/2011. 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org VISA ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Name of Joint Cardholder LOAN ACCOUNT: Account Number/Suffix Date Account Established Loan Type Principal Balance at Date of Death Interest Rate Name of Co-Maker 4672090000121905 11!15/1993 $.00 None 37395-01 07/21/1988 Personal Service Loan/Contractual Pledge of Shares $.00 11.00% None EM ERS 1sT rFE,D, RAL CR IT U ~l~/~-~ Danielle A. Kline Lending Insurance Support Specialist July 5, 2012 Estate of: BERNICE HILL Date of Death: 03!07/2012 Social Security Number: 204-24-8569 The Powsr of Vehicle lrformation NADAg~ides.cotn 2004 Honda Civic Coupe 2D DX Value NADAguides.com Price Report Rough Trade-In Base Price $3,475 Mileage: 70,000 miles $900 Options: TOTAL. PRICE ~~'r ~ ~ RJ Specs & Performance Engine Specifications Type: Gas I4 Size: 1.7L/102 Horsepower: 115 @ 6100 RPM Torque: 110 @ 4500 RPM MPG (Miles Per Gallon) EPA Fuel Economy Est -City (MPG): 32 EPA Fuel Economy Est -Hwy (MPG): 38 Fuel Tank Capacity, Approx (gal): 13.2 Drive Train Drive Train: Front Wheel Drive Transmission: 5 speed Manual Weight Information Base Curb Weight (Ibs): 2456 Interior Specifications Passenger Capacity: 5 Front Head Room (in): 39.0 Front Leg Room (in): 42.5 Front Shoulder Room (in): 52.8 Front Hip Room (in): 50.2 Second Head Room (in): 35.4 Second Leg Room (in): 32.8 Second Shoulder Room (in): 52.6 Second Hip Room (in): 46.7 Exterior Specifications Turning Diameter -Curb to Curb (ft): 34.1 Turning Diameter -Wall to Wall (ft): -TBD - Wheelbase (in): 103.1 Length, Overall (in): 175.4 Width, Max w/o mirrors (in): 66.7 Height, Overall (in): 55.1 Track Width, Front (in): 57.8 Track Width, Rear (in): 57.8 Min Ground Clearance (in): -TBD - Wheels Front Wheel Material: Steel Rear Wheel Material: Steel ® Close Window 8/10/2012 Average Clean Clean Trade-In Trade-In Retail $4,325 $5,000 $7,100 $900 $900 $900 vww.nadaguides.com/Cars/2004/Honda/Civic-4-Cyl/Coupe-2D-DX-Value/Specs/Print 1/2 I'rud~n i . „~ t al Annuities Services Advanced Series LifeVest II P.O. Box 13467 Annuity Transaction Confirmation Philadelphia, PA 19176 March 30, 2012 >07346 8214950 1701 092001 BERNICE HILL 407 KENT DRIVE MECHANICSBURG, PA 17055 E0689565 cc Page 1 of 3 Financial Professional: DANIEL J. FULLER H. BECK INC 5249 SIMPSON FERRY ROAD MECHANICSBURG, PA 17050 Contract Number: E0689565 Type: Non Qualified Contract Issue Date: 04/07/2008 Owner Name(s): BERNICE HILL Annuity Date: 10/01/2026 Annuitant: BERNICE HILL ~~ P1_ease refer to the "Contact Information" section of this confirmation statement, if you need any additicnai information on your contract. ~v ~® Please review your statement and contact us within 30 days if you find any information you believe to be inaccurate. Total Investment Value $0.00 Investment Transaction Activity Transaction Investments # of Units/ Unit Price/ Value/ Date Unad,~usted MVA Account Vrxlue Account Value 03/30/2012 Transaction Type: Death Benefit The following amounts were withheld for taxes and/or deducted for applicable surrender charges from the total amount shown below: Federal Tax: $0.00 State Tax: $0.00 Surrender Charge: $0.00 Pre TEFRA Cost Basis: $0.00 Post TEFRA Cost Basis: $19,872.55 AS7' Money Market (2,073.76674) 10.04450 ($20,829.95) Transaction Total: ($20,829.95) 03/30/2012 Transaction Type: Death Benefit The following amounts were withheld for taxes and/or deducted for applicable surrender charges from the total amount shown below: Federal Tax: $0.00 Pre TEFRA Cost Basis: $0.00 A5T Money Market Transact;an Tote2: State Tax: $O.GO Surrender Charge: $C.00 Post T;/FRA Cost Basis: $19,873.14 (2,073.8284Ei) 10.04450 ($20,830.57) ($20,830.57) Agenl IUpB7F;517 Office NZAAXO 07346 821496n m 4RQ9 n97n9q nnnn~ ~nnnn~ E0689506 CC Advanced Series LifeVest II Annuity Transaction Confirmation March 30, 2012 Page 2 of 3 Investment Transaction Activity. [continued].,.,...,;: Tiransactioin Irivestxnents # of Units/ Unit Price/ Value/ Date Unadjusted MVA Account Value Account Value 03/30/2012 Transaction Type: Death Benefit The followi~7g amounts were withheld for taxes and/or deducted for applicable surrender charges from the total amount shown below: Federal Tax: ($95.74) State Tax: $0.00 Surrender Charge: $0.00 Pre TEFRA Cost Basis: $0.00 Post TEFRA Cost Basis: $19,872.54 AST Money Market (2,073.76674) 10.04450 ($20,829.95) Trsnsacticn Total: ($20,829.351 03/30/2012 Transaction Type: Death Transfer Tl~e following amounts were withheld for taxes and/or deducted for applicable surrender charges from the total amount shown below: Federal Tax: $0.00 State Tax: $0.00 Surrender Charge: $0.00 Pre TEFRA Cost Basis: $0.00 Post TEFRA Cost Basis: $59,618.23 AST CLS Moderate Asset Allocation (5,188.24658) 9.94425 ($51,593.22) AST Investment Grade Bond (759.12886) l 4.35494 ($10,897.25) AST Money Market 6,221,36194 10.04450 $62,490.47 Transaction Total: $0.00 Transactions in your variable annuity contract are priced at the end of the business day (generally 4 p.m. Eastern time) on the day the transaction was processed. Contact Information Annuities Services Hours: Monday-Thursday 8 AM to 7 PM ET Friday 8 AM to 6 PM ET Phone Number: Fax Number: (888) 778-2888 (800) 207-7806 Website: www.prudentialannuities.com Standard Address: Annuities Services, P.O. Box 7960, Philadelphia, PA 19176 Overnight Address: Annuities Services, 2101 Welsh Road, Dresher, PA 19025 Thanis you for chocsing FruCential Annuities for y:;ar financial needs. Explanation of Your Benefits North American Company Prepared By: Cheri Bauer For Life and Health Insurance Tuesday, April 10, 2012 Mailed to: Charles Hil] 212 Grindingwheel Dr Dover DE 19904 Claim Number: 2144541 Policy: 8000179055 Date Paid: 4/11/2012 Insured: Bernice Hill Total Settlement: $43,287.16 annuity Amount $43,173.32 Claim Interest 2.75°ro $113.84 Annuity Service Center * P.O.Box 79905* Deg Moines, IA 50325-0905 Phone:877-880-6367* Fax 877-586-0249 GREAT µ AMERICAN. FINANCIAL RESOURCES March I5, 2012 CHARLES T H]LL 212 GRINDING WHEEL RD DOVER DE 19904 Company Name: Great American Life Ins. Co. Policy Number: 1 1920 ] 6296 Deceased: Bernice Hill Dear Mr. Hill: Please allow us to express our sincere sympathy in this time of sorrow. Our records indicate the beneficiaries of the above annuity contract are Charles, Richard and Claire Hill.. This contract is anon-qualified annuity. The total death benefit as of March 7, 2012 was $25,050.6 ] ,representing the Armuity Value. The non-taxable portion of the death benefit distribution is $25,000.00. In order to make a claim and distribution election, please complete a Claimant Statement & Election Request Fo»n (K26550] 1NW) electing ONE of the options below: • LUMP SUM SETTLEMENT: Please complete the informational section at the top of Page ]and also all applicable sections under Election B (page 2). • ANNUITIZATION: Please complete the informational section at the top of Page 1 and also all applicable sections under Election C (pages 3 & 4). Please note that payments cannot exceed your life expectancy and must start prior to 12/31 of the year following the date of death. Also, please be aware that a state premium tax may be withheld from the death benefit prior to the calculation. In addition to the completed Claimant Statement & Election Request Form, we will also require the following: • Original Certified Death Certificate that reflects the cause and manner of death. If Claire Hill has had a name change due to marriage, we will also require a copy of her marriage certificate. If you have any questions about this claim or completing the form, please contact me at 1-800-854-3649, extension 11962. Sincerely, `` / P Travis Bowling Life & Annuity Claims Department Great American Financial Resources cc: SP6215529 / SP6219697 Enclosures: Claimant's Statement & Election Request Fori7~ (K2655011NW) (31 Fraud Warninbs Interest Notice P.O. Box 5420, Cincinnati OH 45201-5420, 1-800-854-3649 (i. ~f 6) W o ~ I ¢ N O~, F- W cn or-• ~- ['`v 00 •r~ •z .o a_~-.¢cnvo 1 ,co ¢zcnoo (l ~Vo cn~~~ F-¢ T~To • ~ U ~ U7 O ~~~ ~~ ~~~ M ~~~ o n ~~ m ro ,~ ~ D ti N ~ a o ~ o N N O w ~ r ~ti 2Q ~ e