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Home My WebLink About11-07-121505610105 REV-1500°`t°~"'~" ~ oFFtcIAL USE ONLY PA Department of Revenue P~Y~ County Code Year Fie Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX ~8D6ot Hanisbum. QA i732fi-o6Oi RESIDENT DECEDENT ,~iJ ~~ ~~ 3 ENTER DECEDENT INFORMATNNI BELOW Social Severity Number Date of Death MMODYYYY Date of Binh MMDDYYYY aoc~ a~ ss~i ~ r~ aaa osa3 rga? Decedem's Last Name SuRuc Decedent's First Nerne MI C~i Iber~ L ~el~H -+~ (HApplicsbM) EMar Surviving Spouse's Infomratbn Bebw Spouse's Last Name Sufix Spouse's Fst Narm: MI Spouse's Socal Searity Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRMITE OYALS BELOW Ui~ 1. Original Realm O 2. Supplemental Realm O 3. Remainder Renarr (Date of Death Priorb 12-13-32) O 4. Limited Estate O 4a. Future Intermit Compranise (date of O b. Federal Estate Tax Retum Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ ~B. Total Number of Sale Deposit Bmces (Atferdr Copy of WBI) (Attach Copy of Tmst.) O 9. Liligafion Proceeds Received O 10. Spousal PoveAy Cre&1(Date of DeaDr O 11. EleGiat b Tax order Sec. 9173(A) Between 72-37-91 and i-1-95) (Atlarh Schedule O) CORRESPOIWBTT- 7H18 SE INIST BE COMPLETED. ALL CORRESPONDENCE AND CONFOENiIAL TAX NfORYA7WN SHOULD tN: DIRECTED IYY. Na~jme DaylBme Telephone Number f~u~ ~uYki etu 1 Lz~ i! ~ ~ SE-¢ ~ 87 '-~; -r, -Y ::. I First Line of Address Lug-`: r- - = '7 ~ i s fJ r. ~~, ... ~„- ~ .r - - Second Line of Address - ~ ~ -` i ~~ r~ r. ~ O D N City or Post Office State ZIP Code DATE FlL.ED Pp w~~uLL«~u ~ ~os~"" „~ ComspondsnYs s-mail adr~ress: i 5 - CA Under penaaies of PerW7• I drat I have examined this realm, ndudmg arying sdxttlules and sbdemeras, and b the best d my krbwledga and naNeL a M Wa, mnect and mmpbfe. of paperer ether dren dre pasanel repeaentadve is nosed m as intorrrraean ar which paperer has arty iarowlaaga. SIGN/~SIlRE OF PFRS~F~ES SIBLE FOR FLUNG RETURN DATE '7 O~ i ~ Qr Wleelnawtesb4~~ P~ r )o~-S~ SIGNATURE OF PREF'ARER O R THAN REPRESENTATIVE DATE AOORESS PLEASE US# ORIGINAL FORK ONLY Side 1 150561D105 ]b50561D105 J 1505610205 REV-1500 EX (FI) ~7 /~ L C>ecedent's Social SecGUricty~~ Number Oecedwrt's Name: lr ~ G-~ ~(V1 111 - V 1 I b ~-1~'I '~• ~ (a .; (o S O b 1 RECAwnILwrloN 1. Real Estate (Schedule A) ............................................. 1. -~-- 2. SMdcs and Bonds (Schedule B) _ ..................................... 2. -'~ 3. Closely Held Coryoration, Partnership or Sde-Proprietorship (Schedule C) ..... 3. '~ 4. Mortgages and Notes~,ReceivaWe (Schedule D) ........................... 4. -^ 5. Cash, Bank Deposits ynd Miscellaneous Personal Properly (Schedule E)....... 5. ~ S~.Z . 3 6. Jointly Owned Properly (Schedule F) O Separate Billing Requested ....... 6. "-- 7. Inter-Vrvos Transfers ~ Miscellaneous Nan-Probate Pmperly ,I~ (Schedule G) O Separate Billktg Requested........ 7. S`s ~ (• ~ B. total Gross Assets (~aal ones 1 tnrougn 7) ............................. a- $ "j (0 3 3 ~ t• ~ 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. !~ 8"G aZ , (pQ 10. Debts of Decedent, Mortgage LiabAities and Liens (Schedule I) ............... 10. -^' 11. Total Deductions (iotal Lines 9 and 10) ................................. tt. !O$~~ - 72. Net 1/elw of Estate (~ine 8 minus Line 11) .............................. 72. ~(o~j 9 I . G~ 13. Charitable and GovertVmental Bequests/Sec 9113 Trusts Tor which an election to tax has hot been made (Schedule J) ........................ 13. --'-" 14. Nat Valw Subject toTax (Line 72 minus line t3) ........................ 14, tE ~ ^~ q ~ . 0 (~ TAX CALCULATION - S INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxpMe at the spousal fax rate„ or transfers under Sec. 9h 16 (a)(12) X .0_ 16. AnauM of Line 14 taxable at lineal rate X .0 ~$ 17. Amount of Line 14 taxable at sibling rate X .t2 18. Amoum of line 14 fax$Me at cdlateral rate X .15 ,I 15. 'fV~CI~-O~ 16. 17. 18. 19. TAX DUE ......................................................... 19. 20. FlLL IN THE OVAL IF'YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT a~ bS . brJ a 165-• (00 O Side 2 L 150561d2U5 1.505610205 J REV-1500 EX (Fl) Page 3 Decedent's Complete Address: Flk Number DECEDENTS NAME L~~U~cvt ~. Gr]bu'~ STRI>=raDORFSS ? Odic pL~' cm iWl ~a VL t cg Vjts r srA1E /~~ nP / 7d SS Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CrerkLslPaymerds A. Prior Paymerds B. Discount 3. Interest 4. p Line 2 is greater than Line 1 + Lira 3, enter the difference. This is the OVERPAYMENT. Fft in oval an Pape 2, Line 20 to Aagrrest a refund. 5. H Line 1 + Lme 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) a lbS. leo Total Credits (A * 6') (2) O . b O (3) (4) (5) albS•6~ Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did derxident mak@ a harrsfer and: Yes No a. retain the use dr income of the propeny transfwred ................................................................................... ....... ^ [~]' b. retain dre right b designate who shah use the properly transferred or its insane ...................................... ...... ^ [~ c. retain a reversi¢rrary interest ........................................................................................................................ ...... ^ d. receive the prc(nise far life of eidrer paymerds, benefits w cere? ................................................................ ...... ^ 2. ff death occurred Dec.12, 1982, did derxMent Transfer property within are year of death without receiving apequate censiderafiorr? ........................................................................................................ ...... ^ 3. lad decedent own pn 5n tnrst for" w payableupoo-death bards acmunt w secedty al his a her death? ........ ...... ^ []~ 4, lad decedent own an individual refirarierrt aocowrt, annuity w oHrer non{xaba~ property, which cadarrs a benefialary designation? .................................................................................................. ................ ...... ~ ^ IF THE ANSWER TO ANY OF THE IABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FlLE IT AS PART OF THE RETURN Fw dates of death an w after Juty 1, 1994, and before Jan. 1, 1995, the Tax rate imposed an the rret value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (aj (1.1) (i)]. Fw dates of d~th err w after Jan. 1, 1995, the tax rate imposed on the net v~ue of transfers to w for the use of the surviving spouse is 0 percent (/2 P.S. §9116 (a) (1.1) (ii)]. The stalrrtrb does not exerr~t a transfer to a surviving spouse from tax, aril the staWlay raquremerds for discbsure of assets and fiNng a tax rehm are still applicable evgn if the surviving spouse is the only benefitaary. Fw dates of deatlr On or after Juty 1, 2b00: • The tax rate inyrosed an the net vtrlue of transfers from a deceased child 21 years of age a younger at death to w fw the use of a naWral ~rerd, an adoptive parent w a stepparerd of {he child is 0 perrxnt [72 P.S. §9116(a)(1.2)]. • The tax ra0e imposed an the net v~ue of trarrsfers to a fa the use of Nre deoedenTs lire berrefiaaries is 4.5 prxoent, except as rated in (72 P.S. §9116(a)[1)]. • The tax rate pnposed on the net value of transfers to w for the use of the d~edenYs siblings is 12 percent [/2 P.S. §9118(a)(1.3)]. A siMirg is defined, under Ser~ion 9102, as an intfividu~l who has al least erne parerd in common with the decedent, whether by blood or adopfion. REV-i5oa EX+(uao) Pennsylvania SCNEpYLE E ~l DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INMERIfANCE TAX RENRN PERSONAL PROPERTY RESnJENi DEQ-0ENT ESTATE OF: FILE NUMBER: Ev ~~ rt 6 t l tx-rt Include the proceeds of litigation and the date the proceeds were received by the estate. All pMparty jointly owned with rlpM of wrvivonthip must be dhxlosed on Schedule F. AT DATE /. yLltw~Jet'S f s? ~ederc~~ CVe~.zf uNrcvt ~ Sc.t~iKgS(cLu~,~ SGCL Lc•alie_ l0Y ~o ('aoKCfo (.Uee,Lcc,wiecbt„v~ l~1 y7~sS- a$~/d•3~ ?. I IlAlsc- Gio~-t~I,.~cl 3. ( ~ewel~ rGO.o~ }oo•ot~ TOTAL (Also enter on Une 5, Recapitulation) ; I ~ S y,Z ~.Z If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (OB-09) ~ ~~~ pennsylvarda SCHEDULE G DEPARTMEM OF REVENUE INTER-VIVOS TRANSFERS AND INHE0.RANCE TAX RENRN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER G ~(GI ti h~ G I 1 {7~-Y't This uhedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ISM NUMBER DESCRIPTION OF PROPERTY INDWDE THE NM1 OF ME TRANSFEREE, iRaA REIATIDNSMIPtt1 DE~DEM FND iRE DnIE CS nTrAa ACwr oPnE Dan roa RFAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST IXCLUSION IE nwuuNE TAXABLE VALUE 1. `.i~,,,~(~ Pr@(AA~EUVU ~rkwA.2d.ic~4e. A-nPtLiL4~ e1 ~~.,.~{ op~to~n C-e~c A/ YRV1tAW]'Ee Kt L~e1 l.~V1 Ei .ll9eX~ p.~-we~nE,wn,~- 2.a~1a.. ~~.rlueau:~.-z, s4~(.a ~c~02i. pai E~ ~ t ~ a s--~- ~~,pt~~ C,t~c tb . c wE.u4~.E~.t ) ~7. =L-rra~Loc9.lo~G ~vu-s{ ~ au~~ln.~~•~,an Pr~ ~38s~.~`t -p,00 TOTAL (Also enter on Line 7, Recapitulation) ; air IF more space is needed, use additional sheets of paper of the same size.. REV-1511 EX+ (10-IMj Pennsylvania !i~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMEER ESTATE OF Decedent's debts must be reported on Schedule I. NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSE5: 1. (~(~{lAetAtQ..~ ~c,,~NO.uca( ~~ ~(a..~Lk } ck, c ~3yS.o0 , .. o Serutct, Tve~Ksp~l-ham ~ ~dl u:..te. 3~EG•oo ' c-l~tt , f-tc~A~rs , (?eF+~ta..k• 6 laloa. e l2¢SF1c.~AJ y-~ Hrol rt lAA4a.Aa , (k. r~C ~~ M~~ r a k s. uo E„,v,s,r4l 'Z+-~rTak M.A.+~S any • ? g, ADMINISTRATIVE QOSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Atldrpss City Sta[e_ZIF' Year(s) Connmission Paid: 2. Attorney Fees: 3. Family Exemption) (If decedent's address is not the same as claimant's, attach explanation.) Claimant cr.aer ennieec City State _ ZIP Relationship of Claimant to Decedent - 4. ~ Probate Fees. 5. I Accountant Fees: 6. ~ Tax Return Preparer Fees: 7, TOTAL (Also enter on Line 9, Recapitulation) I; /0 Fj/{,~ , !PO If more space Is needed, use additional sheets of paper of the same size. REV-1513 EX+ (01~~10) Pennsylvania DEP~gTMENT OF REVENUE INHERITANCE TAJ( RETURN RESIDENT DECEDENT SCHEDULE 7 BENEFICIARIES ~v~L,/n 1'ul G,Ibct~-f FILE NUMBER: NUMBER NAME AND ADDRESS OF PERSON(S) RECENING PROPERTY RELATIONSHIP lb DECEDENT Do Not Lict Tructae(c) AMOUFIT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIO S [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. 12u~-L~ ~'u~rlcic~.L:; ~Z pcu~,lti~e.v^ too qo "1 ~v i s rJ r 1'uex.l.~c.v>.LCS~JL+r~ , ply IlOS~ ENTER DOLLAR AMOUN S FOR DISTRIBUT10N5 SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIB TIONS A. SPOUSAL DISTRIB ONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GpVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART D -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 C'.OVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size:. REV396 FX (03-09) ESTATE INFORMATION SHEET Pennsylvania 3460009101 FOR REGISTER'S OFFICE USE ONLY County Code Year File Number DECEDENT INFORMATION: ErMer dat as it will appear an all document submiMed to the Deeartrrrent. Decedent's So6a1 Seanty Number Date of Death Date of Birth ao(o abs88t' y-/~- 3o~d, ~~ a3-l9,a7 Last Name Suffix First Name MI G i l t ~r+ ~ v e,~ y vl w1 TYPE FILING: Fdl in oval to irelirate the rmOrre of the return to be filed with the department. O Probate Realm Cp tint Assets Only ONon-probate AssNS Only O Litlga[ion Purposes (rto other assets) LETTERS GRANTED: Fxl in oval to iMiot she nature of the proreedingc rt the rtegiater of wxe tllxce. ( additional sheet if explanation is necessary.) O Testamentary Cp Administration O No Letters O Other (Please Explain.) ATTORNEY/CORRES DENT INFORMATION: Errtd all in(orrrration for the attoreey or individual t reoeitre tax information and correspondence. Las[ Name Suffix First Name MI Supreme Court I.D. # Telephone Number ~ Altamey/ GxresporMent's e-mail address: First Line of Address Second Line of Address City or Post Offirn State ZIP Code PERSONAL REPRESE ATIVE INFORMATION: Errt~ ax irdorrrration for tlra persona[ r~reaerrttlva(s) of the seta[ arMrorired by tiro ttegrcer a Yvxm. Executor/Administrator Sodal Searity Number Telephone Number r4~~[~re~*t8' ~r~ S~a4~17 Last Name I Suffix First Name MI 1u rki e.u: ~ ~zt ~a~ 6 First line of Address '~ Q,~ i 5 ~ r OFFICIAL USE ONLY Semnd line of Address i TRANSACRON COUNT City or Post Office State ZIP Code nd,ec,(~t.n.tcshu r~ PA l ~oS~ canplet ymtval setts infr~rrrration yrrestions and indite[ additional personal reprmerrttives an revmse aide, PLEASE USE ORIGINAL FORM ONLY Side 1 L 3460009101 346000910b J EMP~F3'EES trns coin cMtriTJera 916 Sherwood Drive Lake Bluff, IL 60044-2285 May 22, 2012 Ruth Jurciewicz 7 Ovis Dr Mechanicsburg PJA 17055 Re: Policy NoG - L112581 Deceased ~~, - Evelyn M Gilbert Deaz Ruth Jurciet{vicz, We aze in receipt I f the proof of loss documents submitted on the above referenced policy. It is noted that the sett}~ement option elected is the Commuted Value lump sum payment. Accordingly, we ~e enclosing our check for the amount of $54,091.28. This check represents settlement in full or any and all company liability for the claim incurred on or about April 17, 2012. ', We extend our si ~cere sympathy to you for your recent loss. Should you have any questions regarding this ma er, please call us Monday through Thursday 8 a.m. to 4:30 p.m. or before I p.m. on Friday' [Central Time]. Sincerely, EMPLOYEES LIE CO PANY (MUTUTAL) ~G.,V~-. Danielle Ruiz Claim Admin. As~t. 916 SHERWOOD DRhVE • LAKE BLUFF. ILLINOIS 60044-2285 • (847) 295-6000 • (800) 962-8610 • FAX (847) 295-I 145 EMP EES LIFE COM (MUTUAL) 916 Sherwood Drive', Lake Bluff, Illinois 61044-2285 847-295fi000 800-321-ELCO This contract provides a fixed period annuity benefit. The contract's Effective Date and Annuity Date are shown on page 2. Annuity pa ents will be made to the Owner, or as otherwise directed by the Owner, beginning on the Annuity Date. The P ent Amount will be paid on the Annuity Date and on the same day of the months following the Annuity Date, as etertnined by the Payment Frequency. The Benefit Period is measured from the Annuity Date. The last payme twill be the payment which completes the Benefit Period. Neither the Effective Date nor the Annuity Date may be hanged. In the event of Your death, on or after the Effective Date, but prior to completion of the Benefit Period, pa ents will continue to the Beneficiary to complete the Benefit Period. We have issued this c ntract in consideration of Your application, a copy of which is attached to and made a part of this contract, and pa ent of the single premium shown on page 2. Secre President READ Txts CONTRA T CAREFULLY. This contract is a legal contract between its. Owner and Employees Life Company (Mutual). Pease read it cazefully. The above telephone number may be used to request information or for assistance in resole ng any complaint. RIGHT ~ro CANCEL. a Owner may return this contract for cancellation before midniight of the twentieth day from the date of its receipt. This contract may be returned to: Us, at the address shown above; or, Our authorized agent. Return of this contract y mail is effective on being postmarked, properly addressed, vrith prepaid postage. We will return all amounts paid for this contract Cancellation will void this contract as if it had not been issued. :E PREMIUM IMMEDIATE ANNUITY CONTRACT SCHEDULE ON PAGE 2 INCLUDES THE EFFECTIVE DATE, ANNUITY DATE, PAYMENT AMOUNT, PAYMENT FREQUENCY AND BENEFIT PERIIOD. FIXED PERIOD SINGLE LIFE ANNUITY. PARTICIPATING. Form AIFXB-02 DEFINITIONS ANNUITY DATE. The date annuity payments begin. BENEFICIARY. The 1}revocable beneficiary as stated in the application for this convact. EFFECTIVE DATE. The date from which contract months, years and anniversaries are: measured. OWNER. The Annumant named in the Schedule will be the Owner of this contract; except, if the Applicant/Owner signing the applicatiop for this contract is an entity other than a person, such entity will be the Owner. You, YOUR. The Art~tuitant named in the Schedule. WE, US, OUR. Empl~yees Life Company (Mutual). ~ DIVIDENDS Dividends have not b en projected for this contract. Each yeaz, We will determine the share, if any, of Our divisible surplus to credit to th~s contract as a dividend. Any dividend will be applied to increase the Payment Amount in the next following contra t year. GENERAL PROVISIONS ENTIRE CONTRACT~The entire contract between the Owner and Employees Life Company (Mutual) will consist of: this contract, incl ding the attached copy of the application and any Rider, Amendment or Endorsement We included in this con ct. INCONTESTABLE. T rs contract will be incontestable from its Effective Date. We. consider all statements in the application to be repr sensations and not warranties. IRREVOCABLE. This contract is irrevocable. It may not be transferred, assigned, surrendered or commuted during Your lifetime. This c ntract has no cash or loan value. Neither the Annuitant nor the Beneficiary may be changed. PAYMENT. Each Payment Amount will be paid from Our Home Office. C:ovERNINC LAW. his contract is subject to the law of the State in which it was dlelivered. If part of it does not follow such law, it w~ll be treated as if it did. The law will, at all times, govern: Our and the Owner's rights and obligations; and, rhos of all others who may make a claim against this contract. ANNUITANT: OWNF,R: SINGLE PREMIUM: '.. PAYMENT AMOUNT: ~~ PAYMENT FREQUENdY: *s•rw SCHEDULE Evelyn M Gilbert CONTRACT NUMBER: Evelyn M Gilbert $66,$75.00 EFFECTIVE DATE: $6,109.85 ANNUITY DATE: Monthly BENEFIT PERIOD: L112581 02/01/2012 0:3/01/2012 0 Years and 11 Months -2- EMPLOYEES LIFE COMPANY (MUTUAL) RIGHT TO COMMUTE RIDER This Rider is attache to and made a part of Single Premium Immediate Annuity Contract, Fotm AIFXB-02, on its Effective Date. This 'der is subject to the contract terms and provisions that are not in conflict with the terms and provisions in this Rid r. In the event of Your death prior to completion of the Benefit Period, the Beneficiary has the right to receive the discounted value of a remaining payments in one sum. Signed at Our Home ~ffice on the contract Effective Date t/~ ~/ Secretary z~' 9 ~-.~.., President Form R-RC/A[FXB-02! EMiN.OYiEEB LIFE CWINPANY (Mll1'UAL) Annuity Application t-RKE t3LUFF, rt (+0044-2285 s-8QO-32s-ELCO Pt~ase,pri.~ur.da,wi..~ Name: ~alvn M. Gilbert Dare of Blrtht oe/23n 9n se>G F ~~,~~ ~o~ -ac. -seal p~ C ~, ~7 ~ 7 bid. Ur~~~ !Y)P ~.,..,~~<~,r~. Pit t7or~ tl~li~t.~..~~r. ® Proposed Annuttant. O ApplkartN Owner, (must be an entNy other Ihan a person - lrvst, corporation, etc.) Name of Emity: F.E.I.N.IT.I.N.: Relationship to proposed annuitant: Address: __ ® Level Benefd. O Inrereat Plus. O pthw; `MO$ ,:;'~re• ~~ ^ Life Expectancy. Yes. Cd'Plo. tdit~?tt tcA~OYTES LIFE COMPANY (iNfl`t`tJ~i T ~ ) plart9 " MakrChocksPe-ae6N S "f T _-y~ ~ ~ Ga,tinge~d: o. c o~ t• The tmdsrsigned: (1) RE belief, compete and true; UNDERSTAND that: {A) t the date of Its receipt of (a) make w modi-v ranlrar Any person who, with the aPP~atiort w files a claYn c Payment Frequency: mthly ` S_Colo,875 5d 30~ T paY f0 8IIlI-t Ollaavomvr. 6/.n4 any existing -naurence or Caen t roar the information shown in this applicatbn is, to the beat of their krxiwledg AGREE that this applkation shall be the basis for and a part of any contract issued; and (3 contract will be effactlve on the date the Company approves issue of the contract or ' single Premium for the contract; and (B) onry an ottk:er of the Company may, in writing: w (b) waive any of the Company's rights or requbemerds. Fraud Statement to defraud or knowing that he is facilitating a fraud against an insurer, submits an rg a false wdecepttve statement is guitly of insurance fraud, which is a crime. ,20~_ Agent's Statement: Do you may be invohred? Oyes. wkness picensed agent): Form App. AIFx&62 Do you hereby constitute bylaws, as your lawful ark at any meetlng of the poi person or~rev~oke it by give +4narv8r-. f3Yas. O No. APP1fcBnrrthmer by.' ds w reason to believe that replacement of existing life insurance or annuiries Agenq code number: ®'C,G7 ~~ Ed. 69/02 PROXY appoint the proxy committee of Employees Life Company (Mutual), as established in the and proxy and in your name and stead hereby authorize and empower R to cast your vote Idere of the company? This proxy shall contlnue in force except when you are present in r company written notice in accordance with the Employees Life Company (Mutual) bylaws. ~,c.. /l._.I a -ay-ia ~ECEfYED FEB 1 9 TOf7 S~ MEMBERS 1" reo>?>~-L.cnBOrr tnvLON SenA InQukas to: sooo Baal.. Dm. PO gas 10 Maahanlwbwy, PA 17055 ww..m.me«,t.cary Male 9Waah6ord: (9001283-2325 fZ CW: (717) 997-4372 or (909) 293.1372 TDD: (717) 697.5312 or (900) 293.2329 ext. 5312 TaNenneh: (800) 237.7299 18218 1 AV 0.350 18218-18218 I,~~111~~~111~~~~1~1111~1,~~~11~~1~~11~~~1,I~II~„I~~~I~~1~11 EVELYN GILBERT 1 REVOCABLE TRUST C/0 RUTH G JURKI WICZ 7 OVIS DRIVE MECHANICSBURG FIA 17055 Statement of Accounts Apr 25, 2012 thru Jun 24, 2012 Account Number: 446382 Balances at a Glance: Checking : 0.00 Savings: 0.00 Certificates : 0.00 Loans: 0,00 Money Management: 0.00 Swipe 5 YTD Reward: 0.00 Page: 1 of 1 Your aggregate balance as of June 1st is 573,855.18. An aggregate balance of 52,500 and having 3 products wtll place ypu in the Silver MLR level. Go green with eStatementsl See the enclosed insert for more details. SAVINGS 0000-REGULAR Apr 30 Deposit Dividr M7n~lal PBIO9nfsgs Y~aH Ea Jun 01 Deposit Trans Jun 01 Withdrawal RE6UL4R SA "'71ns is OM ••• Posse rel 0.25096 i O.s'S071G hwn 0 4 /0 1/2 11 12 OnwAah 0!/30•/21912 From Share 0005 GS Chaed f slefsrr7enf pieeendi~g hh7miadi7n on Nee p7oduct'•' Oaie lfn~ sl$ta~7aslTt /6r 07x 7apo79i~g pppa~seis ••• 9.81 14.61 73,840.58 73,856.19 73.856.19- 0.00 D005 -MONEY MANAGE ENT ~ T Apr 30 Deposit Divide d Tiered Rate 110.01 73,812.37 Amua/ Pertienbgis Yk4d 0.1(60X hDm 04/2r1/2012,OrOrrou~Ir 04/.x/2011 May 31 DeposK Divid nd Tiered Rate 28:21 73,840.58 A7xasl Peraenferjn Yesfd D.gL50X lawn OSl'Of/2r1f2 Hybuglr rR5/31/ZOI~ Jun 01 WRhd~ewel Tr nsfer Td Share GOOD 73,840.58- 000 Mo/vEr cEMENr cnaeo "'7hi is dhe sfe/snrsnt P~p+~9 i>tlarnasawr an ahis ,wData-r••• ••• PA9sse Cab /ham s1sls~R /or le7z n6yvar~iTg ~p5rposssr ••• YTD SUMMARIE TOTAL DMDENDS PAI~ 0000 REGULAR SAVIN S 45.42 0005 MONEY MANAGE. ENT 98,22 Total Year To Date Dividends Paid. X3.84 NOTE: Totat includes closed shares Certification of Trust Evelyn Gilbert Irrevocable Trust The currendyactinB Tnistee of the Evelyn Gilbert Irrevocable Trust, dated September 8, 20l 1, decl as follows: 1. The Gra}ttor of the trust is Evelyn Gilbert. 2. The is irrevocable and presently exists. 3. The Wily acting Tnrstee of the taut is: R Th G. Jurkiewicz 4. The T tee may conduct business on behalf of the trust without the consent of any other pe nor entity. 5. The taxi entification number of the trust is f-~j -(„ y ~ ~ $~ 6. Assets h Id in the trust may be titled in any manner that identifies the Trustee and the name and date of the trust, for example: Ru G. Jtrrkiewicz, Trustee of the Evelyn Gilbert Irrevocable Tnut dated Se~tember 8, 2011. 7. The trust (holds the following real property: Th~ property located at 1683 Gulley Road, North Huntingdon, Pennsylvania, 1G A7 8. The pow rs of the Trustee include the power to acquire, sell, assign, convey, pledge, a cumber, lease, borrow, manage, and deal with real and personal property interests fall kinds, including accounts at financial institutions. 9. Excerpts m the trust agreement that establish the trust, designate the Trustee, and set forth a powers of the Trustee will be provided upon request. 10. The trust agreement provides that a third party may rely on this Certification of Trust in 1 eu of a copy of the trust agreement. It further exonerates third parties from any iability for acts or omissions in reliance on this Certification of Trust, and for the ap lication that the Trrstee makes of funds or other property delivered to the Tn~stce. The statements I ade above are accurate and the trust has not been revoked or amended in any way th would cause the representations in this Certification of Trust to be incorrect. All f the currently acting Trustees of the trust are identified above and are signatories to s Certification of Trust. Page 1 Dated: September 8, 2011 Stu ~I. ~` Ruth G. Jnrkiewiez, ruatee COMMONWE~ILTH OF PENNSYLVANIA ) ss. COUNTY CU ERLAND ) On this day, S ptember 8, 2011, before me personally appeared Ruth G. Jurkiewicz, personally lcno to me (or proved to me on the basis of satisfactory ewidence) to be the individual wh se name is subscribed to the foregoing Certification of Trost, and aclmowledged at she executed the same as her voluntary act and deed for the purposes therein co Witness my hadd and official seal. (Beall ~I ~~2Gr.LGLCe )21 ~ZG~2~7;~-v~. Notary Public My commission expires: ~e ~/ ,.~ a / ~I ~~ NOTMIK EE#L MNtCIA N MEIitItT li IIPPEA KLEN T~CW1~A1~ l:OUMtY it M!' eaimMpla HyMe.lae 1.2011 II I it I I I i Page 2