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11-09-12
1505610105 REV-1500 Ex ~oz-~ ~, ~F~, OFFICIAL USE ONLY PA Department of Revenue enns lvania P Y Year File Number ~En~RTMENTpi4EV[NpE County Code Bureau of Individual Taxes PO Box 28o6oi . INHERITANCE TAX RETURN / f7 ~ ~ Harpsburg, PA 1y128-o601 ~ ~- RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 206-28-4451 02/10/2012 12/08/1917 Decedent's Last Name Suffix Decedent's First Name MI Scott John W (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI n/a Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) m 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Thomas W. Scott (717) 232-1$51 T_ -~-, _ __ __ City or Post Office State ZIP Code Dauphin, Pa 17018 `,-; --.~ _e_~ ,, ~,_ .~ ,`=rt -.~ Correspondent's a-mail address: tSCOtt killiangephart.com Under penalties of perjury, I declare th I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. De ation of preparer other than the p rs nal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RE SI~iLE FOR FIL TURN DATE ~ 11 /09/2012 ADDRESS 1701 Sunrise Dr., Dauphin, PA 17018 _ _ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 1505610105 Side 1 1505610105 1~1~ 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: 206-28-4451 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 179,700.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 1,705.00 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. 3,413.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 25,326.44 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 187 234 90 (Schedule G) O Separate Billing Requested........ 7. . , 8. Total Gross Assets (total Lines 1 through 7} ............................. 8. 444,332.34 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 63,777.33 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. .... .................. .................. __ 11. Total Deductions (total Lines 9 and 10) ................................. 11. 63,777.33 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 380,555.01 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. 380,555.01 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! 15. . , 16. Amount of Line 14 taxable ,. at lineal rate X .0_ 380,555.01 16, , , 17,124.98 17. Amount of Line 14 taxable at sibling rate X .12 17. .. ,. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 17,124.98 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 150561,0205 150561,0205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME John W. Scott STREET ADDRESS 5213 Terrace Road CITY Mechanicsburg STATE Pa ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) (3) (4) (5) 17,124.98 17,124.98 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Ditl 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 ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 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 tT 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)J. 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)J. • 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(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-1502 EX+ (ii-08) ~ pennsylvania SCHEDULE A ' DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER John W. Scott 21 12-0222 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 iointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (8-iz) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ~ FILE NUMBER John W. Scott 21 12-0222 All property jointly owned with right of survivorship must be disclosed on Schedule F, If more space is needed, insert additional sheets of the same size REV-i5o8 EX+ (o8-i2) i Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ' ESTATE OF: John W. Scott FILE NUMBER: 21 12-0222 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, Household of used furniture, clothing, tools, etc. 500.00 2. 1985 Volkswagon, not running 500.00 3. Penn Treaty Insurance premium refund 1,389.00 4. Final pension check from State Employees Retirement System 672.00 5. Cash on hand at time of death 252.00 6. 1998 Chrysler Concorde, not running 100.00 TOTAL (Also enter on Line 5, Recapitulation) $ I 3,413.00 If more space is needed, use additional sheets of paper of the same size. .._ ~ tnt (OS-1D~ ~~ Pennsylvania DEPARTMENT OF REVENUE ' INHERITANCE TAX RETURN RESIDENT DECEDENT SCFI~lE ~ JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: John W. Scott 21 12-0222 If an asset became jointly owned within one year o. the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANTS} NAME(S) ADDRESS RELAT?ONSNIP TO DECEDENT A. David M. Scott 5221 Terrace Road, Mechanicsburg, Pa. 1?050 son ~5. r ~. JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY 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 % OF DECEDENTS INTEREST -- DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 01!15!95 M&T Bank, Acct. No. 76364208 13,435.35 50 6,717.18 2. A. 12/22106 M&T Bank, Acct. No.15004215020617 9,640.43 50 4,820.22 3. A 06125108 M&T Bank, Acct, No. 31003918 9,775.6 50 4,887.83 4. i A 03131105 M&T Bank, Acct. No. 31003913394191 ~ 17,802.41 ~ 50 8,901.21 - _ ~ TOTAL (Also enter on Line 6, Recapitulation) I $ 25,326.44 If more space is needed, use ,additional sheets of paper of the same size. ~~~tc ~• REV-1510 EX+ (09-C9) ~ pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER John W. Scott 21 12-0222 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 INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. Columbian Financial Flexible Premium Annuity, Contract No. N001299; David 41,937.90 100 41,937.90 M. Scott,son, beneficiary 2 Columbian Financial IRA Account, Contract No. G002623; David M. 5,957.51 100 5,957.51 Scott,son, beneficiary 3 The Hartford, Annuity Acct. # 711449300; David M. Scott,son, beneficiary 82,695.99 100 82,695.99 4 Jackson National Life Optimax 1 Annuity; Contract # 1002447513; James, 41,390.28 100 41,390.28 Thomas and David (sons) equal 113 beneficiaries 5 Jackson National Life Optimax 4 Annuity; IRA Policy # 0059383230; Thomas 10,437.52 100 10,437.52 (son) beneficiary 6 Ohio National Financial Services; Annuity, Policy # S1238420; James (son) 49,947.43 100 49,947.43 beneficiary 7 M&T Bank IRA Account # 35004201770177; James (son) beneficiary 60.46 100 60.46 8 Wells Fargo Bank, NA, IRA Account # 257410050230602 1,760.81 100 1,760.81 TOTAL (Also enter on Line 7, Recapitulation) $ 234,187.90 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 John W. Scott 21 12-0222 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Malpezzi Funeral Home 13,174.60 2 Mechanicsburg Cemetary Association -grave opening and marker 1,065.00 3 St. Pauls United Church of Christ -funeral luncheon expenses 424.05 a Flowers 150.00 5 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 0.00 Name(s) of Personal Representative(s) Thomas W. SCOtt street Address 1701 Sunrise Drive city Dauphin State pa zIP 17018 Year(s) Commission Paid: no commissions charged or paid 0.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant N/A Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: Bank charges to date Leffler Energy -fuel oil Hampden Township Sewer and Trash to date Michael Langden, tax collector, real estate taxes - 2012 Verizon -final phone bill Subtotal form page 2 697.52 i 2,000.00 ' 1,000.00 135.00 544.12 517.49 1,883.15 149.09 42,037.31 TOTAL (Also enter on Line 9, Recapitulation) $ 63,777.33 ZIP If more space is needed, use additional sheets of paper of the same size. SCHEDULE H -EXPENSES AND ADMINISTRATIVE COSTS Page 2 13 MSA Group -fire insurance for 5213 Terrace Rd 544.12 14 Pa. American Water Co. - to date 141.48 15 F.M. Berkheimer -Air conditioner service 293.60 16 PPL Electric to date 258.11 16 Reserve for expenses related to sale of real estate 15,400.00 17 Reserve for expenses to maintain real estate until sale 15,400.00 18 Reserve for contingencies 10,000.00 ~ Subtotal ~ 42,037.31 ~ LAST WILL AND TESTAMENT OF OHN Vv . SCOTT I~ John ti^1. Scott, declare that this is my last will and testament. I hereby revoke all prior wills I may have made. 1, I bequeath all of my property to my wife, Dorothy I. Scott, if she survives me by sixty days. 2. If my wife does not survive me by sixty days I direct my executor to divide my tangible personal property among my children, James, Thomas and David, in aS nearly equal shares as practical, giving due regard for their personal preferences where possible. If there is a dispute among my children over any particular item, I direct them to work it out. If they can't work it out, then they shall draw straws and the short straw gets it. 3. If my wife does not survive me by sixty days I give devise and bequeath the rest residue and remainder of my estate, real, personal and mixed, of whatsoever kind and nature as follows: ~~~~=~' _,,- ~, _~ (A) I bequeath one fourth of the residue of my estate to my son, James W. Scott, if he is alive at the time of my death. If he does not survive me, I bequeath his share of my estate to his children, per stirpes. (B) I bequeath one fourth of the residue of my estate to my son, Thomas W. Scott, if he is alive at the time of my death. If he does not survive me, I bequeath his share of my estate to his children, per stirpes. (C) I bequeath one fourth of the residue of my estate to my son, David M. Scott, if he is alive at the time of my death. If he does not survive me, I bequeath his share of my estate to his children, per stirpes. (D) I bequeath one fourth of the residue of my estate to my grandchildren who are alive or in being at the time of my death, in equal shares, per capita. 5. If any of my grandchildren are. under the age of twenty-one at the time of my death, I name the parents of that grandchild as the trustees of the bequest made to that grandchild and empower the trustees to hold and invest the fund thus created as they deem prudent and to spend principle and income from the fund as necessary to provide for the health, . ~'f `~~ ,~ ~~-'~ maintenance and education of each grandchild. The residue of each grandchild's share shall be paid to the grandchild at age twenty-one. 4. I appoint my son, Thomas W. Scott as the Executor of my estate, and empower him to serve without bond or other security. If Tom is not able or available to serve as my executor, I appoint my sons James [nT. Scott and David M. Scott as co-executors of my estate. 5. I direct my executor to pay all debts, claims and taxes frcm the residue of my estate. IN WITNESS WHEREOF I have hereunto set my hand and seal this 12th day of July, 1990. ;~~ ;,~ ;; ~ . 1 f --~=~-~ 1~ ~ ~ ~` ~ LS ~/ L John ~1. Scott Testator V+?itnessed by: /, ~. 1~ ; , ~,, ~.; ~, ~,- 6'H i f--~LG ~ V. CSILL ~F: zsyou .Michael Langan, TreasurerlTaX Collector Hours: See Reverse MUNICIPAL CODE: Hampden Twp. BILL NO: 8960 '30 S. Sporting Hill Road Phone:717-737-4822 PROPERTY: 5213 TERRACE ROAD BILL DATE: 7/1/2011 .1eChanlCSbUrg, PA 17050 MAP CODE: 10-18-1319-201 SCOTT, JOHN W & DOROTHY NOTICE OF PROPERTY TAX RELIEF Your enclosed tax bill includes a tax reduction for your homestead and/or farmstead property. As an eligible homestead and/or farmstead property owner, you have received tax relief through a homestead and/or farmstead exclusion which has been provided under the Pennsylvania Taxpayer Relief Act, a law passed by the Pennsylvania General Assembly designed to reduce your property taxes. ~~~:, THIS TAX IS DUE AND PAYABLE. YOU ARE HEREBYoRQtI~E TO MAKE PAYMENT THEREOF SCOTT, JOHN W & DOROTHY ~ `~'~ 5213 TERRACE ROAD u~~ ~~ MECHANICSBURG, PA 17050 , ,' aeC. .. C, ;. ASSESSMENT ~ -• $54,800 $124,900 ~ $179,700 HOMESTEAD EXCLUSION $6,942 FARMSTEAD EXCLUSION $0 R!E TAX RATE 8.570 8.570 FULL SCHOOL R/E TAX $469.64 $1,070.39 $1,540.03 LESS HOMESTEAD CREDIT -$59.49 LESS FARMSTEAD CREDIT TAX AMOUNT DUE ~ • •• $1,450.93 $0.00 ~~~ $1,480.54 $1,628.5 If Paid On or Before 8/31/11 10/31/11 12/15/11 NO CHECKS ACCEPTED AFTER DECEMBER 15 .~ ~y, GO s ~ • ~'"'. r ~. F a , ~ ~ ' ~omputershare ~:~ ~ ~ ~~ ,1 J t~ + FsJ '~,,,,.~+il ~.~_~. *'******'*'AUTO'*5-DIGIT 17050 JOHN W SCOTT 5213 TERRACE RD MECHANICSBURG PA 17050-6813 281,7D3 S000001014/P000000000 I~~~III~~~lll~~~~l~l~ll~~~~ll~~l~~l~~~~ll~~ll~~~~ll~~ll~~l~l~l Computershare Trust Company, N.A. P0. Box 43038 Providence Rhode Island 02940-3038 1-800-586-1305 Hearing-impaired 1-800-619-2837 www.computershare.com/investor Account Number 00002426234 I ND Re~~~~~e~- Rer~c~ ~~ lei ~~~ Co~ers~~~~~ As of the close of the market on May 27, 2011, you owned 27 shares} of Prudential Financial, Inc. Common Stock valued at $1,705.59. This letter is being sent as a reminder of the terms of the Sales Facility ,_~,.r,.,~ h„ (~~rs„r„ i+~rc+~nrn ®r~ ~rlonfi~l'S Transfer Agent. your shares. or hearing-impaired, call 1-800-619-2837). utershare.com/investaor. ~ r glow or submitting a signed letter of instruction. ~-~ dour sales transaction is completed and the actual ~ ~ ~° ~-- of the sale. ~ ill be mailed to you within two weeks ransaction fee and an 8¢ fee for each share sold. t any policy or contract you own with Prudential. _ , a .e _ ~ -- F , ~~~~, . .__~. ~ _ LL . _ _ "~' r prudential ~iriar$~i~6, Is.~c. Snares. This ro ram is voluntary. Should you decide to sell all of your shares, sign in the p g es below and return in the envelope provided. Additional information is listed box( ) on the back of this form and in the Sales Facility Term Sheet provided. A1% peC'SOnS l%SteC~ 1'I?USt Sl~'17 eXOCtl)/ aS Oamed abOV2 Please sign inside box e ... ~ ~ o _. ~ ~ Please s?gn inside box _ _,~. .. S _ acv a. - ~.~-*- .. Sales Facilit Term Sheet included in this mailing. I (we) agree to the y IIIIUII~~III~IIINllllllll~llllllllllll~lllllllll'~,If!Illlh (mrri/dd/YYYY) ;a fi i 4 4.4,x: 00002426234 I N D JOHN W SCOTT 00002426234 SUCF PRU 1 160$7_PRU_PRODUCT_ I _DOM ESTI C_4/2R 17(13/23 ] 703/i 12 ' .~11~~ ~ ~ ~~~ ~J 1_~ PENN TREATY. June 21, 2012 ESTATE OF JOHN W SCOTT C/O THE LAW FIRM OF KILLIAN & GEPHART, LLP ATTN: THOMAS W SCOTT, EXOR PO BOX 886 HARRISBURG PA 17108-0886 tel 800.362.0700 www.penntreaty.com RE: P263331 Dear THOMAS W SCOTT: Please accept our condolences on the death of JOHN W SCOTT. Enclosed please find our check(s) in the amount of $1,389.41 for the unearned premium on the above-referenced policy. If you have any questions, please contact Policyholder Services at 1-800-362-0700, ext. 3190. Sincerely, ~ t " ~ ~.~ Connie L Reigel, Senior Analyst Premium and Commission Services Enclosure Penn Treaty Network America Insurance Company (In Rehabilitation) (Penn Treaty Network America Life Insurance Company in California) American Network Insurance Company (In Rehabilitation) 3440 Lehigh Street :: Allentown, PA 18103 pH PENNSYLVANIA INHERITANCE .TAX '~ INFORMATION NOTICE FILE N0. 21 12-0222 BUREAU OF INDIVIDUAL TAXES Po eox 280601 pennS~.~~;[alc~_; ; -;r_~,~-:-- ~. AND ACN 12129208 HARRISBURG PA 17128-0601 DEPARTMENT Q7=~i~vEr~~E!- 'tJ~ ~~XPAYER RESPONSE ~,C, ,~.~ DATE 05-02-2012 REY-1543 EX{A~P `CP'5 -;11)` ~~,;~ ~. ~ ~ TYPE OF ACCOUNT ``'' ~ ~ r.~ + ~. f F , ~ ~; 4~ ~ EST. OF JOHN W SCOTT ^ SSN 206-28-4451 X^ CHECKING "~~~ ,- DATE OF DEATH 02 -10 - 2012 ^ TRUST ~~ r, ~ ~-. COUNTY CUMBERLAND ~ CERTIF. ~~~~~~i~~ ~~(1~~ REMIT PAYMENT AND FORMS To: ~.~~~~~ sir I ;;i±'',~I) (;1 DAVID M SCOTT ~FA' REGISTER OF WILLS 5221 TERRACE RD 1 COURTHOUSE SQUARE MECHANICSBURG PA 17050-6813 CARLISLE PA 17013 M & T BAN K provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above named decedent, you were a joint owner/beneficiary of this account. If you are the spouse Of the deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. Please call 717-787-8327 with questions. CQh~PLETE FART 1 BELOW * SEE REi''Et~SE SIDE F(3R F iLiNv AND- PAYMENT Ii;.^sTRUCTIONS Account No. 76364208 Date 08-28-1964 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 13,434.35 payable to "Resister of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 6,717.18 months of the decedent's date of death, Tax Rate ~( . 045 deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due ~` 302.27 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT. IN AN (IFFICTAL.TAX ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or return this notice to the Register of Wills and O N E an official assessment will be issued by the PA Department of Revenue. BLOC K B. The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return O N L Y filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART 2^ and/or PART ~ below. PART If indicating a different tax rate, please state lAF' relationship to decedent: TAX RETURN - CALCULATION DF TAX DN JOINT/TRUST ACCDI LINE 1. Date Established 1 2. Account Balance 2 X - '~y ~ p a 3. Percent Taxable 3 ~~ l.C=-G, ~- 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PART DEBTS AND DEDUCTIO a DATE PAID PAYEE DESCF D Under penalties of perjury, I declare that the facts I reported above arer~'t7rue, correct and com~le~te to the best,/ of my knowledge~.an belief . HOME C ~ t ( ) ~~ 7 ~~j~ ~~ TA~P~YER SIGNATUR TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation] S BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 a ~..... ~~'. penns~~~~p~~ DEPARTME R REv~ ~;- s . _ ~.., REV-1543 EX i7tf~~(D5~.~11) PENNSYLVANIA INHERITANCE TAX. INFORMATION NOTICE FILE N0. 21 12-0222 AND ACN 12129209 -'-~I.~~ ~~XPAYER RESPONSE ~ '~..`~ ! ~'~~ DATE 05-02-2012 r Cl~ER~ ~~ QRF~~1,/~N'~ CO~JR~ DAVID M SCOTT Cl~~°~~~~; '~`~~~~ ~'~ ~ ' PA 5221 TERRACE RD MECHANICSBURG PA 17050-6813 EST. OF JOHN W SCOTT SSN 206-28-4451 DATE OF DEATH 02-10-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M 8~ T BAN K provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you are the Spouse Of the deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the de artment of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe ~he information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15004215020617 Date 12-22-2006 Established Account Balance $ 9 ~ 640.43 Percent Taxable X 50.000 Amount Subject to Tax $ 4 ~ 820.22 Tax Rate X . 045 Potential Tax Due $ 216.91 To ensure proper credit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check payable to "Register of Wills, Agent". NOTE: If tax payments are made within three months of the decedent's date of death, deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent nine months after the date of death. PART TAXPAYER RESPONSE 0 ` ? E SSMENT AN OFFICIAL TAX.'ASS FAILURE TO `:RESPOND WILL RESULT IN A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or return this notice to the Register of Wills and C H E C K an official assessment will be issued by the PA Department of Revenue. ONE BLOC K B. The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ~ The above information is incorrect and/or debts and d Complete PART 2~ and/or PART 3~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNT LINE 1. Date Established 1 ~ ~ ~~ ~ $ 2. Account Balance 2 ~ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 ~ 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 $ PART DEBTS AND DEDUCTIONS DATE PAID PAYEE DESCRIPI Under pen lt~es~f perjury, I declare that the fact I reported above are true cor ect"a~nd"~ l complete o he est of,.r kno a and eli f . --- HOME C~~~ ~ G r~ ~''-~ 1 C WORK C ~ _ AXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) $ PENNSYLVANIA INHERITANCE TAX ' INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE NO. 21 12-0222 Po sox 2ao6o1 pennsyli'a ' '' _'~ , ~ !!}~~^ ~- AND ACN 12129210 HARRISBURG PA 17128-0601 DEPARTMENT OFREtItE1~UE~. r'' ;17~ PAYER RESPONSE „ _ .,.;~ DATE 05-02-2012 REV-1543 EX AFP (05'-I7~ ~ '°~ t - -- TYPE OF ACCOUNT e.,; ~ , -~ t, r, "~'`~ ~~-~~ -' r fit'' ".~' "~~ EST. OF JOHN W SCOTT ^ SAVINGS S$rj 206-28-4451 ^ CHECKING ~~_~~{~ ~~ DATE OF DEATH 02-10-2012 ^ TRUST GRF'i ~~~~~u ~;~~fi,~,! COUNTY CUMBERLAND ~ CERTIF. ~r, r;± ~.~l~l>`tL'7C~~~ ~~~~) r~i nA REMIT PAYMENT AND FORMS T0: DAVID M SCOTT REGISTER OF WILLS 5221 TERRACE RD 1 COURTHOUSE SQUARE MECHANICSBURG PA 17050-6813 CARLISLE PA 17013 M 8~ T BAN K provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above named decedent, you were a joint owner/beneficiary of this account. If you are the spouse of the deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe the information Is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW.....* SE"~`~~V'ERSE SIDt FOR FILIP+G ANi3 PAYMENT INSTRUCTIONS - Account No. 31003918742163 Date 06-25-2008 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 9 , 775.65 payable to "Register of Wills, Agent". Percent Taxable X 50.0 0 0 NOTE: If tax payments are made within three Amount Subject to TaX $ 4 ~ 887.83 months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due $ 219 • 95 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ^ The above information is incorrect and/or debts and deductions were paid. Complete PART 2^ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUh LINE 1. Date Established 1 2. Account Balance 2 3. P e r c e n t T a x a b l e 3 X_ _ _.___,~__~_. ____-_,_.__„~ 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ ._. 7. Tax Rate 7 X 8. Tax Due 8 $ PART DEBTS AND DEDUCTION: L" J DATE PAID PAYEE DESCRI F' Under pen es of perjury, I declare that the facts I reported above are true, correct;, d complete p ~he best of my no led and belie HOME C ~ ) - ~~ ~~ WORK C ) ~~~ /d :~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL (Enter on Line 5 of iax l,ompuLatluni Y BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 ~,, PENNSYLVANIA INHERITANCE ~\ syLv~ni NT OF~R 1lENl~ ' EX AFP ~~1~ L, ~_. r~ x f'r;s~ i f i 1 .~ ~~ f ~, C- ER~< G~= DAVID M SCOTT 5221 TERRACE RD MECHANICSBURG PA 17050-6813 TAX FILE NO. 21 12-0222 ACN 12129211 DATE 05-02-2012 EST. OF JOHN W SCOTT SSN 206-28-4451 DATE OF DEATH 02-10-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. M & T BAN K provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you are the 5poU5 a of the deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe the information ~s incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 31003913394191 Date 03-31-2005 To ensure proper credit to the account, two Established copies of this notice must accompany pavme.nt to the Register of wills. Make check Account Balance $ 17 ~ 802.41 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 8 ~ 901.21 months of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discount on the tax due. Anv inheritance tax due will become delinquent Potential Tax Due $ 400.55 nine months after the date of death. PART - TAXPAYER RESPONSE FAILURE TO :RESPOND WILL RESULT: IN AN OFFICIAL TAX 'ASSESSMENT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or return this notice to the Register of wills and 0 N E an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return 0 N L Y filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state ~F, relationship to decedent: TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOU LINE 1. Date Established 1 2. Account Balance 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ ,~~.,,.,-~'~ 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PART DEBTS AND DEDUCTIOf 0 DATE PAID PAYEE DESCR ~ Under penalt'es of per~ury, I declar complete to h~best o~ my know~,ledge, TAXPAYER S~'GNATURE _..___. penn DEPARTME REV-1543 INFORMATION NOTICE ~', . ~-;., :_.- _ AND >~'~ ,'r~ ~ !._;--~-li~i4AYER RESPONSE ~` ~' "~i ._. ~~ . ~ i hat facts orted above are true, correct and ~-~ lief . HOME C ~l7 } ~~„3~' ~ ~.J%' WORK t } TELEPHONE NUMBER DATE l--'`~ TOTAL CEnter on Line 5 of Tax Computation) ~ i Ii~ ~ ~'~ - ° - COLOMBIAN FINANCIAL GROUP March 6, 2012 Tom W Scott Killian & Gephart PO Box 886 " Harrisburg PA 17108 RE: John W. Scott, Deceased Policy `Number N001299 & G002623 s ~ l ~'~ ~ ~~ ~ ~~ ~~~N (.__ ~ r ~~~~ Dear Mr. Scott, We are sorry to hear of your loss and wish to extend our deepest sympathies. In order to consider aclaim-for benefits, Columbian Mutual Life Insurance Company requires the following items: • Beneficiary Statement (enclosed) -This form must be completed by the designated beneficiary(ies), David 1l~. Scott. Federal regulations require that a valid social security or taxpayer identification number be furnished to us for each individual. • Certified Death Certificate -The certificate will be printed on special paper or have a raised seal. A copy of this original document is not acceptable. • Entire Policy Contract - If you are unable to locate the policy, please notify us in writing. A statement on the bottom of the claim form will suffice. Upon receipt oft e requirements, the claim process will begin. If you have any questions, please call me toll free at 1-8 -347-0960, extension 7539. n i cerely, r ~ ~ ,~ r 4 ~'jC~, " - Heather Pagcaliwagan Life Claims Specialist cc: ,file - COLOMBIAN MUTUAL LIFE INSURANCE COMPANY • HOME OFFICE: BINGHAMTON, NY COLOMBIAN LIFE INSURANCE COMPANY • HOME OFFICE: CHICAGO, IL -ADMINISTRATIVE SERVICE OFFICE: 5788 WIDEWATERS PARKWAY • PO BOX 1056 • SYRACUSE, NY 13.201-1056 (800) 347-0960 • (315) 471-5656 • (315) 475-6612 FAX • www.FTLife.com COLOMBIAN FINANCIAL GROUP March 26, 2012 David M Scott 5221 Terrace Road Mechanicsburg PA 17050 Re: John W. Scott, deceased Claim: 43774 Policy: N001299 .- Dear Mr. Scott: ,/~ /\ / ! /`) ~ ~ ,/ ~~ 1 L~~ ~p1 ~~ G ~~ ~. ~~ Listed below is an outline of the settlement proceeds. Your check as listed in "Amount Paid to Beneficiary" is enclosed. Benefit Summary Natural Death $41,781.96 Accidental Death Paid-Up Additions Dividends & Interest Accumulations Interest on Benefits Payment ~ $155.94 Premium Refund Total Benefit before deductions $41,93.7.90 Less: Unpaid Premium Unpaid Policy Loan Total Payment $41,937.90 Amount Paid to Beneficiary $41,937.90 Thank you for your cooperation in assisting us to fulfill the terms of this policy. If you have any questions or concerns, feel free to contact me at 1-800-347-0960 ext.7539. _ Sincerely, i J~ls .J,. A :. t f'' - ~. Heather Pagcaliwagan Life Clai;ns Specialist ~~: COLOMBIAN MUTUAL LIFE INSURANCE COMPANY • HOME COLOMBIAN LIFE INSURANCE COMPANY • HOME ADMINISTRATIVE SERVICE OFFICE: 507 PLUM STREET • PO BO} (800) 347-0960 • (315) 471-5656 • (315) 475-6612 FA: ~~ ~~ ~ e ,,..~~~_ ~1 _-" COLOMBIAN FINANCIAL GROUP =_ =-_ Columbian Mutual Life Insurance Company -=_ Columbian Life Insurance Company c = Administrative Services Office: Syracuse, NY s~ POLICY NUMBER: N001299 DEPT/DESK: 17HAP NO. 0200453196 DATE: 03/27!2012 AMOUNT: $~~~~~~41,937.90 C~~~ t ~~ COLUIVII3IA.N FINANCIAL CIZ®-UP Columbian Mutual Life Insurance Company Columbian Life Insurance Company Administrative Services Office: Syracuse, NY NO. 020Q453196 DATE: 03/27/2012 POLICY NUMBER: N001299 DEPT/DESK: 17HAP AMOUNT: $~~~~~~41,937.90 C- - _° ~®LU~~IA~ ~~A~CgA~., ~~®U~ HSBC o Columbian Mutual Life Insurance Company ~ One HSBC Center 50-682 Columbian Life Insurance Company Buffalo, NY 14203 213 .= Administrative Services Office_ Syracuse, NY Check.. No. Gheck Date. ~~ 0200453]96 03/27/2012 POLICY NUMBER: N00~299 DEPT/DESK: 17HAP ~ ` ' CHECK AMOUNT '~ t $~~~~~~41,937.90 ~~ PAY Forty One Thousand Nine Hundred Thirty Seven Dollars and Ninety Cents VOID iF NOT CPSi±ED VfiTHlN TO David M. Scott THE 5221 Terrace Rd ORDER Mechanicsburg PA 17050-6813 OF S1X UONTHS OF ISSUE DATE -- ./ BY ~ AUTtiORnFn SIGNATURE BY SECOND SIGNATURE REQUIRED FOR AMOUNTS OVER ST5,000 ~~'0 200 4 5 3 L 9 6~1° e:0 2 ~ 30 68 2 2e: ? 9 ?0 ~ 9 2 ?~~~' COLOMBIAN FINANCIAL GROUP March 23, 2012 David M Scott 5221 Terrace Road Mechanicsburg PA 17050 Re: ,101111 W. Scott, deceased Claim: 43775 Policy: G002623 __------ Dear Mr. Scott: D . ~~ z. ~~ ~, -'~ ,~~~ ~ ~~~ S ~.~ Listed below is an outline of the settlement proceeds.. Your check as listed in "Amount Paid to Beneficiary" is enclosed. Benefit Summary Natural Death $5,935.84 Accidental Death Paid-Up Additions Dividends & Interest Accumulations Interest on Benefits Payment $21.67 Premium Refund Total Benefit before deductions $5,957.51 Less: Unpaid Premium Unpaid Policy Loan Total Payment $5,957.51 Amount Paid to Beneficiary $5,957.51 Thank you for your cooperation in assisting us to fulfill the terms of this policy. If you have any questions or concerns, feel free to contact me at 1-800-347-0960 ext.7539. - Sincerely, ~< s _ r ~ ~;~' s; J ( 'i'e > J } .. %_ ~.. .. i . i i~ ':.; ~ Heather Pagcaliwagan Life Claims Specialist cc: `~ ~~~.~. `~ COLOMBIAN MUTUAL LIFE INSURANCE COMPANY • HOP COLOMBIAN LIFE INSURANCE COMPANY • HOME A©MINISTRATIVE SERVICE OFFICE: 507 PLUM STREET • PO BC (800) 347-0960 • (315) 471-5656 • (315) 475-6612 F = ~ ~ COLUIYIBIAN FINANCIAL GROUP ~• Columbian Mutual Life Insurance Company ,_ _= Columbian Life Insurance Company = Administrative Services Office: Syracuse, NY POLICY NUMBER: G002623 DEPT/DESK: 17HAP NO. 0200452Ja8 DATE: 03/24/2012 AMOUNT: $~~~~~~~5,957.51 ~- Z ~,- COLOMBIAN FINANCIAL GROUP ~sBc = Columbian Mutual Life Insurance Company one Hsac center 5ass2 -_ -_ Columbian Life Insurance Company Buffalo, NY 14203 213 =~ Administrative Services Office: Syracuse, NY ,Check No. Check- Date': POLICY NUMBER: G002623 ,~~ 0200452968 03/24/2012 DEPT/DESK: 17HAP 4 j (~ CHECK AMOUNT' ~~ l $~~~~~~~5,957.51 ~J J PAY Five Thousand Nine Hundred Fifty Seven Dollars and Fifty One Cents TO David M. Scott THE 5221 Terrace Rd ORDER Mechanicsburg PA 17050-6813 OF VOID IF NOT CASHED WITHIN SIX MONTHS OF ISSUE DATE BY AUTHORIZED SIGNATURE BY ' SECOND SIGNATURE REQUIRED FOR AMOUNTS OVER 55,000 II°0 2004 5 296811° ~:0 2 ~ 3068 2 2~: ?9 70 L9 2 7811° TF~II~ ,,: IiAE~Y~t31R© #BWNGSGR #VI9ESSYJCFARRO# MB 02 007366 12622 H 38 A iii,,,I~~~~~,ll~iii~lli,.i~i„lip,iliiiiiil~ill~~ii~iin~~l~i~l~i JOHN W SCOTT 5213 TERRACE ROAD MECHANICSBURG PA 17050-6813 CONTRACT NUMBER 711449300 PURCHASE BATE August 27, 2003 CONTRACT TYPE Non-Qualified ~V1(N ER John W SCOtt ANNUITANT Joh11 ~ SCOtt ~NE D'iREC~C~R~ VARIABLE ANNUITY QUARTERLY STATEMENT ®CTOBER 1, 2011 -DECEMBER 31, 2011 SUMMARY QUARTER 10/1 /11 -12/31 I11 YEAR-TO-DATE 1 /1 /11 -12/31 /11 SINCE PURCHASE 8/27!03 -12/31/11 Beginning Value 82,079.06 80,283.70 Premium Payment 0.00 0.00 66,200.77 Total Surrenders ~` 0.00 0.00 -30.00 Annuity Performance 606.93 2,402.29 16,515.22 Ending Value $82,685.99 $82,685.99 $82,685.99 * Total Surrenders include Contingent Deferred Sales Charges and Annual Maintenance Fees, if applicable. YOUR ANNUITY AT A GLANCE S% Min 1~ ~ FOR ASSISTANCE, CONTACT: Your Investment Professional Kimberly J Heavner M & T Sec Inc 100 S Spring Garden St Carlisle PA 17013 As of August 13, .2011, please send mail to The Hartford, Global Annuities by overnight delivery to 745 West New Circle Road; Building 200, 1st Floor; Lexington, KY 40511; and by standard mail to P.O. Box 14293, Lexington, KY 40512-4293. r.° .~f } ~ ~', ~ ~ 1 i ... ~ ~'~ . ~ ~,' !. N Things to Know, for Annuity Contract Number 711449300 March 23, 2012 Contract Owner: Decedent: Recipient of Proceeds: Contract Type: Plan Type: John W Scott John W Scott David M Scott Variable Product Non-Qualified ~;; THE HARTFORD Please note, the information provided is for the above contract and the specifics outlined here may not apply to other contracts owned by the decedent. Submission of Benefit Option Election Instructions On Non-qualified contracts -instructions must be received in good order within 60 days of receipt of due proof of death in order to avoid a possible taxable event. *** CALCULATION OF DEATH BENEFIT*** For Variable Contracts: The guaranteed death benefit will be calculated for all individual annuity contracts associated with the decedent upon receipt of due proof of death. The calculated benefit amount, if any, will be invested into the investment option(s) in accordance with the last investment instructions received. This will result in the guaranteed death benefit invested in the same manner as a subsequent premium payment. During the time period between our receipt of due proof of death and receipt of complete, in good order, benefit option election instructions, the entire calculated benefit amount will be subject to market fluctuations. Due proof of death has not yet been received. Due proof is a certified (raised seal) death certificate (long form) or any other proof of death acceptable to Hartford Life. For Fixed Contracts: The death benefit will be determined when the due proof of death and the benefit option election are received in good order. The Hartford strongly recommends that you consult with your tax advisor for any questions pertaining to distributions of benefit proceeds from an annuity contract. Please keep this information for your records ~~~~ SM ~.- ~ NATIONAL LIFE INSF.IRANCE COMPANY Claims Administration Proceeds Payable to: Thomas Scott Policy Number: 005933230 Claim Number: 201203070000130 Policy Information: Policy Benefit: $10,437.52 Loan Payoff: $0.00 Premium Due: $0.00 Beneficiary Information: Benefit Paid: $10,437.52 Interest Paid: $0.00 Misc Interest Paid: $0.00 Premium Refund: $0.00 Foreign Withholding: $0.00 Federal Withholding: $0.00 State Withholding: $0.00 Distribution Amount: X10,437.52 Policy Number: 1002447513 Claim Number: 201203070000130 Policy Information: Policy Benefit: $13,796.76 Loan Payoff: $0.00 Premium Due: $0.00 Beneficiary Information: Benefit Paid: $13,796.76 Interest Paid: $0.00 Misc Interest Paid: $0.00 Premium Refund: $0.00 Foreign Withholding: $0.00 Federal Withholding: $0.0Q State Withholding: $0.00 Distribution Amount: $13,796.76 ~~ ~ ~~~_ ~ ~~ ~ - l~ ~.- Jackson National Life Insurance Company {,,,,~z 1 Corporate Way, Lansing, MI 48951 ~' , 800/644-4565 Flexible Premium or Single Prernium ®eferred Fixed Annuity Application USE DARK INK ONLY (print or type) Name (first, middle initial, last) Owner Jackson )!rational Life Insurance Company® Home Office: Lansing, Michigan www.jnl.com SSN ^ TIN (include dashes) Address (number and street) City, State, ZIP ForJointUwners, statements/correspon- v '~ i Date of Birth (mm/dd/yyyy) Age Gender U.S. Citizen? ~ dente wilt be mailed ~"~ ~ M ^ F Yes ^ N o C the address listed t ~ o in thissection only. E-Mail Address Phone No. (include area code) Name (first, middle initial, last) ^SSN ^ TIN (include dashes) Joint Owner Address (number and street) City, State, ZIP Proceeds will be distributed on death offirstowner. Spousal Date of Birth (mm/dd/yyyy) Age Gender ~ U.S. Citizen. ^Yes ^ NO JointOwnerhas ^ M ^ F i i nue on to cont opt the controctin force. E-Mail Address Relationship to Owner Phone No. (include area code) Name (first, middle initial, last) SSN (include dashes) Annuitant Date of Birth (mm dd/yyyy) Age Gender U.S. Citizen? If other than Owner ^M ^F ^Yes ^No Phone No. (include area code) Relationship to Owner Name (first, middle initial, last) SSN (include dashes) . JointAnnuitant Date of Birth (mm/dd/yyyy} Age Gender ~ U.S. Citizen? ^N ^Y ^M ^F o es If other than Joint Owner Relationship to Owner Phone No. (include area code) Beneficiary(ies) CAP Name (first, middle initial, last) ^SSN ^ TIN (include dashes) Relationship to Owner Percentage (%) t I 1 % ®C O Must to Foradditiona! ~ J benefiriaries, please ~P include on separate page. Must be signed ^ ~ Q and dated by the Owner(s). C3~P P-primary C-contingent ^ ~ ~Q ((~(jh ((~ _ _ _ , ~ Nonqualified ^ Pension/Profit Sharing ^ HR-10 u 4u~(n~ ~~H Plan Type ^ IRA-Individual* ^ IRA-Custodial* ^ IRA-Roth* ^ IRA-SEP * Contribution year and amount: Year amount $ Transfer p~IRC 1035 Exchange ^Nan-Direct Rollover ^ Direct I Information Will this annuity replace any existing life insurance or annuity? R L nt Form (where required -, r Replacement Nave you completed a State ep aceme ;t , Company Name: ,~'~C~1(1 ~4L~n L?L~ ~' ~ j" ;~;~,~' 1~~ Annuity Product Product Name: i'~~Y ~-- Mustcheckonebox. ~'--Year Interest Rate Guarantee Premium with Application $ Subject to certain limitations and restrictions, higher credited intE Initial Premium meets of a certain amount. Please ask your Financial Representat Make check payable to: Jackson National Life Insurance Cor ARIZONA RESIDENTS, PLEASE NOTE: RIGHT TO ExAMINE. On ~rrritten r~ within a reasonable time, reasonable factual information regarding t reason, the contract Owner is not satisfied, the Contract may be returnE YOU WERE AGE 65 OR -OLDER ON THE DATE THE APPLICATION WAS SIGI '.~ delivery and the Company will refund the premium paid to the Compam .~- _ X0928F ~{ `_ u v~iiC~ r, iy if er ~5 Subsequent Premium Minimum Premium ^ PAC Monthly Quarterly FlexibfeF-em;u,7; Orly $1,000 or $80 per ^ L1St Blll i~iont hly Quarterly Semiannually, Annually (Notavailabfe in CT or OR) month for PAC/List Bill ^ Yes N o EarningsMax° Election o this benefit will result in credited interest rate(s) of .20% less than the annual credited interest rate(s) that would apply to the Accumulated Value if the Earnings Protection Benefit had not been elected. Ask .,ni~r Ginanrial RanYPCPntatl\/P i'r-r mnrP (iPtaliS_ Antidpated If none is selected, the Company will default to the Latest Income uate as shown in the cenLrd~~ ~~ ~u~~~ ud~c Incorrre Date as required by the qualified plan or law. Indicate date: (mm/dd/yyyy) Indicate the name of the person(s) the Company is authorized to release information to. Authorized Name (first, middle initial, last) Caller Name (first, middle initial, Last) SSN (include dashes) I Date of Birth (mm/dd/yyyy) ISSN (include dashes) Date of Birth (mm/dd/yyyy) Statements/ If you have provided us a valid a-mail address, Jackson National Life® will, if possible, forward statements/corre- Correspondence spondence electronically unless you elect direct mail as your preferred method of contact. If you prefer to receive statements/correspondence via direct mail, please initial. Owner Joint Owner 1. I (We) hereby represent to the best of my (our) knowledge that each of the statements and answers contained above are full, complete and true. 2. The Social Security or taxpayer identification number shown above is certified to be correct. 3. The contract I (we) have applied for is suitable for my (our) insurance investment objective, financial situation-and needs. 4. I (We) understand that the amount payable on surrender may be adjusted up or down by the application of an excess interest rate adjustment (market value adjustment} factor (in states where applicable) or withdrawal charges. No excess interest adjustment f market value adjustment) will be applied to death benefit proceeds. Signed at (city and state) .~,~ ' ~ s P her . ~ Joint Owner Signatures ~t , Annuita (ifotherthanOwner) ~ JointAnnuitant Date (m ~~~ Date (mfi/ d/~fyyy 4'Z 'Z `ZcJ ~ 7 Date (mm/dd/yyyy) I certify that: I have fully explained the Contract to the client, including contract restrictions and charges; I believe Producer Report this transaction is suitable given the client's financial situation and needs; I have complied with requirements for disclosures and/or replacements as necessary; and to the best of my knowledge and belief the applicant's statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate. (If a replacement, please provide a replacement form or other special forms where required by state law.) Financial Representative's Full Name (please print) Fina es~ttta~iG-' re Date (m /dd/ ) 1~l ~-t-yam--i Agency Name / ~ P one N . (include area cod No. ~ nclud rrea code) JNL®Financial Rep No. License I No. - FL Only mil ~°T S~ ~u st~/~-~.. S (~ ~Z:~s ~a . E-Mail Address ~ Special Remarks: ARKANSAS, COLORADO, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, OKLAHOMA, PENNSYLVANIA, AND TENNESSEE RESIDENTS, PLEASE NOTE: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In COLORADO, any insurance company, or agent of an insurance company, who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding, or attempting to defraud, the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. files a statement of claim or FLORIDA RESIDENTS: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, an application containing any false, incomplete or misleading information, is guilty of a felony ofthe third degree. NEW JERSEY RESIDENTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Mauro AQCareSS anu t,,cnna~.~ unv~.~ic+...+.. If purchased through anon-bank Broker/Dealer, or a Deal I Institution Direct Producer, send to: JNL° Service Center Regular Mail Overnight Mail P.O. Box 30421 1 Corporate Way Lansing, M) 48909-7921 Lansing, MI 48951 For questions or assistance, please call: 800/644-4565 (8:00 a.m. to 8:00 p.m. ET). t t s @'nli com Fax• 517/706-5519 if purchased through a Bank or F~nanaa send to: JNL/IMG Service Center Requiar Maii Overnight 1\/iai) P.O. Box 30386 1 Corporate Way Lansing, MI 48909-7886 Lansing, MI 48951 For questions or assistance, please call: 8000777-7779 (8:00 a.m. to 8:00 p.m. ET}. E-Mail: contactus @ jnli.com Fax: 517/706-5534 E-Mail. con ac u ~ ~,~•t Not FDIC/NCUA insured Not BanWCU guaranteed May lose value Not a deposit Not insured by any federal agency X0928F 06/05 X0928F O O ~ /"\ O / T O\ O ~=O N 0 ~ ~ IOo ~ ~ a• z c z o CL Q ~ ~ .~ ~ z~w Z ~ ~ Q ~ Q OQ~ U Q p ~ ~ M O N ~ ~ ---~ 0 0 ~ v ~ ~ c~ N Q~ O O N O ~ ~ N ~ C ~ ~ ~ c'~ C ~ R5 ~ ~ T cfl T ~ ~ Q ~ N G N O O ~ O _ ~ ~j ~ ~ O Y Z M U t -7 V t0 ~ ~ O ti ~ ~ O ti O ti ~ ~ ~' ~ U O O O T T T a ~ ~ O N N T U N~ N G N ~ ~ ~ ~ O r- N ~ T EA ~ ~ ~ G ~ ~ ~ ~ .~ ~ m 0- m ,-, ~ N ~ ~ O U C ~ ~ Q o 5 ~ ~~ ~ - a U y ~ a ~ ~ U ~ «S ~ ~ r,. F+-1 .~ CJ ~ °' z o ~ ~ H ° a ~ U a ~T r CL Q ~ ~ t ~ ~ J Q ~ •- Z O p O aS cn ~ ~ ~ N ~ c Z o Z M Z M O ~ ~ LL. o ~ Q . _ °F~ ~ Q ~ '- O fn M Q ~ ~ w h- ~ ~ ~ o Y rn U o ~ cn ~ ~ ;~ cn ~ ~ OU ~ ~ ~ Q Q i ~ ~ 0 ~~ o 0 O d o N C'~ c~ rn _a, ~ _~ _L,~ ° .~:~ ~ ,~ .o O U N r 0 N N O 0 M L v L ct7 G O .~A ~/ ^~ LL o ~ t- W ~ ~ ~ Q ~ w/' 'v/ ~ ~J T y sp} ~/• '. O O U U z z ~ W LL O W z M ° `~ N ~ ~ °' M U ~ ... o N J ~ ~ Q U Cn .C Z ~ I` ° O z v~ - ~ O ~~ o aNi ~ W r O M Q ~, o o ~, ~. i ,~ ~ ~ ~ ~ U (n to - Z ~ ~ two } N ~ •~ E V Q i.. Q Q N "~ O F-- ~ Z ~ y d~ ~ ~ //~ Z , W C ~ ~ ~ Z W O o O y -' ~ ~ V . W ~, J ~ v E' ~ .C ~ - Q p ca ~, r.. ~ -,~u..<-.~- ro o c ~~O 5 a a U U O ~ a m M r-i i o o a - oa = m __ ~ w~ U ~ - oam V ~ V1 In a V W H -_ 3F-Z ZM2 ON W n in ~ i 0 _~ ^U1 W^^ .i.~ Q a U, N T lT^ W O 0 C\O O O O Cfl O ~ ~ O ~ N O 'V' O ~ O CO T ~ Nl~~ N T T Efl Ef? vJ 5000 ~ i ar L~ RJ ^C W i a o~ O O O O T O ~ri N V O T Efl EA Eli EH EA Efl f-A Q~ .~ ~ ~ i ~ ~ ~T V W ~ ° (~ ~ ~ ~ ~ ~' > ui ~ ( Q U ~~ ~ ~ ~ o ~ ~ ~ w ~ ~~ ~ ~ ~ °' o ~ ~ ~ Z ii CC Q Z U ~~ ~~ VJ .~ ~~'~ 0 ', U inn Q rn o 0 0 o° o 0 ~ O O O O ~ N O O N r-- '~ p O r- r m O i cC V/ v r ~ i i ~ >~ ~, , >~ ~ L 3 s 3 ,~ 3 3 U ~_ ~_ c L T •~ ~+-.+ Q tf? Et? Ef3 EfJ EA EA ffl fA E9 C ~~ L H r O O O O ~ ~ O O ~ o 0 0 0~~ o 0 0 0 .- T ~ ~ C O ~ ~ ~ Q.. N t C ~ ~ U ~ ~ry• /~'~- /"' rf " ~ ~ ~ L ~1~, ~ D ~ S 1 (U / w U .~ a W ~ a~i c C~ W O O O O T 'f• 1 ~ r. .ti Ohio I~Tattona f '' Financial Services Life changes. We'll b e there. o COnCraCC Informar>_on Annuitant: John W Scott Owner: John W Scott Contract No: ~-- (S 1?38420 Policy Issue Date: 0~/?4-X1-998 Contract Type: Non-Qualified Choice Annuity Annual Report for period Ending August 24, 2010 Through August 24, 2011 The Ohio National I~i~e Insurance Company Account Value Date Amount Balance Beginning Balance 08/24/10 $47,444.21 _lncreased Income Total Incurred Interest 08/24/ 10 Thai 08/24/ 11 1,589.38 Ending Balance 08/24/11 $49,033.59 ~cfi~<k-C C~- te ~ Lire changes. `~'e'ii be there. Since 1909 Ohio National has provided quality life, disability income and annuity products to the public. We are committed to building long-term relationships v~'ith our customers to provide them ~~ith solutions as their needs change over time. If you are interested, please contact your agent. For more information about Ohio National Financial Services, please visit our website at www.ohionational.com. Review Carefully. Review your statement ro vet"lf}~ its accuracy. You must report an}'error or inaccuracy ro us ~uichin 3U days. Otherwise, we are not responsible For losses due to the error or inaccuracy. 018384-000001 page 2 of 2 Beneficiary Claim Form ~""""'~ Ohio National Financial Services Any person who is named as an annuity beneficiary must complete this INSTRUCTIONS: form. If an annuity has more than one beneficiary, each beneficiary must complete a separate form. All beneficiaries must submit every requirement requested before death benefit proceeds will be paid to any beneficiary. Please print or type all information. I AM A BENEFICIARY FOR THE FOLLOWING ANNUITY(IES): (If you are the beneficiary for multiple annuities, you may use this form for all of them.) Name of Deceased John W. SCOtt Date of Death February 10, 2~ The Contract Number(s): S 1238420 PERSONAL INFORMATION ABOUT THE DECEASED: Date of Birth 12 / 8 / 1917 At the time of death, the Deceased's address was: Street Address 5213 Terrace Road Cary Mechanicsburg E-mail jwscott43@gmail.com BENEFICIARY INFORMATION Name of Beneficiary James W. SCOtt Name of Trustee or Executor if applicable n/a Street Address of Individual Beneficiary, Trustee or Executor (required) 4 Ea. Mailing Address (if different) Cary Annville Social Security Number of Individual, Trustee or Executor Tax ID Number for Estate or Trust (if applicable) n/a Relationship to Deceased SOn Social Security Number 206 _28 _4451 State Pa ZIP 17050 G~~ Z e- Date of Birth of Individual, Trustee or Executor 02 / 26 ; 1943 If you want your payments sent to a different address from the one given above, you need to attach: • a dated letter of instruction From the Beneficiary, Trustee or Executor • a signature guarantee State Pa ZIP 17013 Daytime Phone Number (717) 867-1983 Form 9104-ON-DOD Rev. 8/09 Page 4 of 8 """"'~~ Ohio National ® F1Ila11Clal SerV1CeS ® One Financial Way Cincinnati, Ohio 45242 f_~ The Ohio National Life Insurance Company P.O. Box 237 L~ Ohio National Life Assurance Corporation Cincinnati, Ohio 45201-0237 USA PATRIOT Act Compliance This form is required to be completed for each Annuitant/Insured; and if different than the Annuitant/Insured.,, for each owner, payor and assignee. This form is also required on all beneficiaries when a claim is filed. Important information about procedures for opening a new account or entering into a contract or policy or making a claim, To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account or applies for a contract or policy: What does this mean for you? When you open an account, apply for a contract or policy or make a claim, we will ask for your name, street address, date of birth and other information that will allow us to identify you. We will also ask for a copy of your driver's license or other identifying documents. L7 Pending-Policy/Contract ~Jl Inforce-Policy/Active Policy/Contract 1. Contract/Policy Number 2. Insured/Annuitant S1238420 John W. Scott 3. Name (Check one) QOwner DAnnuitant/insured 1-1 Joint Owner Q Payor L~7 Assignee `?~ Beneficiary James W. Scott Information in 4-8 is based upon name shown in #3 4. Street Address (Do not use P.O. Box ) 4 East High Street 5. Date of Birth (IvIM DD Y~r`YY) 02 / 26 / 1943 4a. City, State, ZIP Annville, PA 17013 6. Taxpayer Identification Number (SSN or TIN) 7. Document Viewed Document Information 11 State Issued-Driver's License ~ ~ ~ Issuing State/Country PennsylVartla O State-Issued ID Card. Cl Military ID Card ~ ID Number r` Q Passport ~1 US Alien Registration. Card Expiration Date Q Other 8. Entity Verification For a Corporation, Partnership, LLC, Trust, Sole Proprietor, or other entity please indicate and attach a copy o the document reviewed: ~J' Articles of Incorporation Q LLC Operating Agreement [7 Partnership Agreement Q Organizing Documents Q Trust Documents ~~ Other 9. Signature i certify that 1 have reviewed and accurately recorded the documentation provided by the above-named individual. 10. Agent Signature 11. Print Agent Name This information must be recorded for all Owners, Annuitant/Insureds, Joint Owners, Payors, FORM C¢Tj I2FV. g10~ Assignees and Beneficiaries. ~~ ~ - One M & T Piata, Buffalo, New York 14240 Hampden March 2, 2012 -~ - ~~ JJ( n 3652 ,JOHN W SCOTT 5213 TERRACE RD MECHANICSBURG PA 17050-6813 Re: Retirement Account Renewal Confirmation Dear John W Scott, Thank you for renewing your Retirement account with M&T Bank. Please review the following information regarding your account: Account Number: 35004201770177 Current Account Balance: S 60.43 Renewal Date: 02/20/ 12 Maturity Date: 08/20/ 14 Term: 30 Months Interest Rate: 0.150 nnual Percentage Yield: 0.15 Daily Percentage Rate: 0.00041 (NOTE: This letter is issued 10 days after the renewal date. The current account balance reflects any activity during that 10-day period, including any deposits, withdrawals, and interest paid.) On the next maturity date, we'll automatically renew your account for a similar time period, unless you advise us otherwise prior to that date. if you have any questions regarding your account, please call the MST Telephone Banking Center at 716-626-1900 or 1-800-829-1924. Thank you for banking with M&T Bank. Sincerely, M.~ehueQ N . T>eccd yen Michael N. Tradyer CONREN RNRRSi G - ~ ~ z. THE LAW FIRM OF Of Counsel: THOMAS W. SCOTT' y ~T g,~ LL~ JOI-lN D. K(LLIAN ~LLI~l~I ~ ~'L~H~~T TERRENCE J. McGOVVAN MICHAEL J. O'CONNOR ~ 218 PINE S'TREE'T' SMITH B. GEPHART LINDA J. OLSEN P. O. BOX 886 ROBERT J. DANIELS* HARRISBURG, PENNSYLVANIA 17108-0886 * NEW JERSEY BAR TELEPHONE (717) 232-1851 FAX NO. (717) 238-0592 •-- -- www.killiangephai-t.coin tscott~killiangephart.conl June 21, 2012 Wells Fargo P.O. Box 5110 :~~ Sioux Falls, SD 57117-5110 ~~ RE: John W. Scott, dod February 10, 012 Traditional IRA Account No. 25741005023060' Attention IRA Benefit Claims: My father (your account holder) John W. Scott died on February 1 U, w ~ ~. copy of his death certificate is enclosed. At his death he owned the above referenced IRA account No. 25741000230602. I am the Executor of his estate and one of the named death beneficiaries of the account, along with my brothers, James and David. I have enclosed completed, executed and notarized death benef t claim forms for the account and request distribution in accord with the elections attached. Please process these claims and send proceeds checks to each the beneficiaries as appropriate. Since there will be tax consequences on account of these payments to each beneficiary, please provide each beneficiary with an indication of the taxable poz-tion of each payment. If you have questions or require other information to process this request, please contact me. ~.,. .~# 1 ,, ~,, Si e- }t ~`` ~ omas W. Scott Cc: James W. Scott w/o attachments -- David M. Scott w/o attachments WELLS FARGO BANK, N.A. ' 1-800-237-8472 (800-BEST-IRA) P.O. BOX 3908 345 PORTLAND, OR 97208 TAX YEAR 2011 '`~':L ~~ S Date: 04/23/12 E.I.N. 94-1347393 8000106831 THIS TAX RETURN DOCUMENT ISSUED AS A YEAR 2011 STATEMENT FORA 1099-Q, 1099-SA, 5498-SA, FORM 5498 AND/OR FORM 5498-ESA FOR TAX YEAR DCT540HTAA 007901 .~ •: JOHN W SCOTT 3 H 2011 TRADITIONAL IRA 5213 TERRACE RD MECHANICSBURG PA 17050-6813 TAXPAYER ID NUMBER 206-28-4451 2.01.1 -..5498, IRA CONTRIBUTION INFORMATION ACCOUNT NUMBER RETIREMENT 3202 257410050230602 BOX 5 FAIR MARKET VALUE OF ACCOUNT BOX 7 ACCOUNT IS AN IRA Form 1099-Q OMB No. 1545-1760 Payments from Qualified Education Programs (Under Sections 529 and 530) This is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. Form 1099-SA OMB No. 1545-1517 This informs on is being furnished to the Internal Rev nue Service. Form 5498-SA OMB No. 1545-1518 The information next to boxes 1 through 6 is being furnished to the Internal Revenue Service. Form 5498 OMB No. 1545-0747 IRA Contribution Information This information is being furnished to the Internal Revenue Service. Form 5498-ESA OMB No. 1545-1815 Coverdell ESA Contribution Information The information next to boxes 1 and 2 is bein furnished to the Internal Revenue Service. 1,760.81 c c C ~_ Z Z c c a c L c c c c i r c c c c DE FOR INSTRUCTIONS IRA/ESA beneficiary Surviving Child Certification __ Name Customer Number (ECN) JOHN W SCOTT ~ 725105030451456 Account Number(s) ~ 257410050230602 ____ As deter ed under the app 'cables t~ law, I ~~'~--~S ~ " S ~"~"~ a personal representative of _ ~ whose account information is id tified above, ereby certify that the following is a coin lete list of all the survivin children, as defined by the applicable state law, of ~~ ~~ ~~~ ~t p g I certify that the information provided below is true, correct and in accordance with state law. In accordance with the terms and conditions of the Wells Fargo Bank, N.A.IRA/ESA Custodial Agreement, I authorize Wells Fargo Bank, N.A.to acknowledge each of the surviving children named below as the beneficiary/beneficiaries of the IRA/ESA of the owner listed above. In submitting this Surviving Child Certification, I acknowledge that I have sought legal and/or tax advice and that Wells Fargo Bank, N.A. and its respective affiliates and agents are not responsible for legal or tax advice with respect to the IRA/ESA and/or Inherited IRAs and that Wells Fargo Bank, N.A. and its respective affiliates and agents have not reviewed the legal or tax ramifications of the request.) shall indemnify, jointly and severally, and hold harmless Wells Fargo Bank, N.A. and its respective affiliates and agents, from and against any and all liabilities, claims, demands, charges, claims for negligence, mistakes of law or fact, losses or expenses of any kind or nature whatsoever which may be asserted by anyone against Wells Fargo Bank, N.A. and it's respective affiliates or agents, arising out of or in connection with the transfer of the IRA, or payment of the IRA or ESA assets, to the surviving children named below: Name Date of Birth Social Security NJumber ~~ r i Address City r Statpy~ Zlp Code tt a 5t ~ e ~~ ~- . ( ~ I ~ ~~yJ Name ' ` ~ f Date of Bi th ` ~ / ~ ~ ~ ~ I Social Srecurit/y Number ~ `~' '~ - ~ ~ Q ~- ~ ~L~ S ~ ~J ~ ~9' ! 6 Address L-( Cit~'~ Stat Zip Code Name ..... /q' Date of firth ~ ~ ~~ ~ Social S~ffe~`clurity Number `W S \ ~~ Address City Zip Code State Name Date of Birth Social Security Number Address ~ City ~ State Zlp Code ~ ~ Name of Person ~, Representative Signature s nal Representative Date Street Address, City, Sta e and Zip Code of Personal Repr tative - Telephon Num er _ ~ Subscribed and sworn to before me this Day ofi ,Year State Signature of Notary Public I City/County M Commisslon Ex Ires Y p Year CNS1768 (2-10126952) ®2010 Wells Fargo Bank, N.A. All rights reserved. Memher FDIC.