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12-06-12 (3)
J 1505610143 REV-1500 ~'°'-'°''` PA Department of Revenue Pennsylvania Bureau of Individual Taxes aE~^a*-a*~r aE..a~E Po Box.zaosot INHERITANCE TAX Harrisburg, PA 17128-0601 RESIDENT DECE ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Decedent's Last Name Suffix KINTZER (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW OFFICIAL USE ONLY County Code Vear File Number 121 12 0710 Date of Birth 07 18 1923 Decedent's First Name NATALIE Spouse's First Name MI M MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ~X I 1. Original Return !_ i 2. Supplemental Return 4. Limited Estate r ' qa, Future Interest compromise -- --- (tlate or death arter l2-12-92) J g Decetlent Died Testate (Attach Copy of N911) 1 ~ ~ Decetlept Maintdl'nod a Living Tmst (Attach Co of trust py ) i_-.~ 9. Litigation Proceeds Received U t°~ b~'iweenipi 3i ~~entlit lda[°esgf death 3. Remainder Return (date of death ' prior to 12-13-82) - ~ 5. Federal Estate Tax Return Required - e. Total Number of Safe Deposit Boxes J 11. Election to tax under Sec. 9113(A) (Attach Sch. O) vVnrrGSPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL Tp Name Day LEONARD TINTNER ESQUIRE 71 First line of address 315 NORTH FRONT STREET Second line of address City or Post Office State HARRISBURG PA Correspondent's a-mail address: Itlntner@btpal: Under penalties of perjury, I declare that I have examined this return, it is true, correct and complete. DeUaration of preparer other than the L 1505610143 ZIP Code 17101 XINFORMATION ~ULD BEf~tECTED 70 tip TelephoneNifmbeW t*1 '~~6 9~7 ~ o m=~ c~ ~a .~$Tt J't~ WI~¢ US~'TO~Y ~ 2 ~ b C7 ~ C7 ~`? '~i 'rl ~ '" C ~ C~ _1 rl ~ _ :n ; . ~ ~ C.) fJ7 `~ .---- ~ DATE FILED schedules and statements, and to the best of my is basetl on all information of which preparer has 1505610143 belief, J 315 North Front Street, Harrisburg PA 17101 Side 1 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF Kintzer, Natalie Mae FILE NUMBER 21-12-0710 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer~jas any knowledge. Signature #2 Name Addressl Addressl City, State, Zip 1 Date ~~' z y- / Z 1505610243 REV-1500 EX Decedent's Social Security Number °e~aa^~'~"ame Kintzer, Natalie Mae _- _ - - 213 20 1103 RECAPITULATION - -- _ --- _- _-- _ --- 1. Real Estate(ScheduleA) ....................................................................................... 1. 44,725.00 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 76, 254.23 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ........................................................ q. 5~ Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) _, Separate Billing Requested............ 6. 2 6 , $ 91.10 7. Inter-Vivos Transfers 8 Miscellaneous l~Jnq-Probate Property (Schedule G) I Separate Billing Requested............ 7. 130 , $ 05.9$ 8. Total Gross Assets (total Lines 1-7) ..................................................................... - _ - - 8. 278 , 67 6.31 ___ 9. Funeral Expenses 8 Administrative Costs (Schedule H) ....................................... 9. 16 , 008.10 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............................. 10. 1 , 645.66 11. Total Deductions (total Lines 9 8 10) ................................................................... 11. 17 , 653.76 12. Net Value of Estate (Line 8 minus Line 11) ................................. ......................... 12. 2 61 , Q22 . 55 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. 2 61 , 022.55 TAX COMPUTATION -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 .00 15. 0.00 16. Amount of Line 14 taxable at linealrateX .045 261,022.55 16. 11,746.01 17. Amount of Line 14 taxable at sibling rate X .12 Q. Q Q 17. Q, Q Q 18. Amount of Line 14 taxable at collateral rate X .15 Q. Q Q 18. Q, Q Q 19. Tax Due .................................................................................................................. 19. 11,746.01 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-12-0710 DECEDENT'S NAME Kintzer, Natalie Mae _-_ -- - _ _ _ STREET ADDRESS - 4100 Seneca Avenue __ __ CITY __ _.. - _ - - - _. Camp Hill _ ___. _ ___ _ - _T..- STATE ZIP _- - - _- PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 11,746.01 2. Credits/Payments -- _ - - - A. Prior Payments B. Discount 0.00 Total Credits (A + B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box 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. (5) 11,746.01 Make PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :...................................._......................................._ L ] I x b. retain the right to designate who shall use the property transferred or its income :................................_ '_ ~. x~ c. retain a reversionary interest; or ............................. I ~ -_ ................................................... u l YJ d. receive the promise for life of either payments, benefits or care? ............. - _ ~_ J ............................................... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................................... I_~ x 3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death?....._ L._ ~ i x] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ~ x~ ~~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling 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-1802 E%x(11.08) COMMONWEALTH OF pENN6YLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kintzer Natalie Mae 21 72 0710 All real properly owned solely or as a tenant In common must be reported at fair market value. Fair market value is tlehnetl ae the price at which property woultl be exchangetl between a willing buyer end a willing seller, neither being compelletl to buy or sell, bath having reasonable knowledge of the relevant fatls. Real property which Is jointly-owned with right of survlvorehlp must be tllaclosed on schedule F. Attach a copy of the aadlament sheaf If the property has been sold Inclutle a copy of the deatl ahowing decedent's interest if owned as tenant in common. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Real Estate -One-third (1/3) interest in real estate known as and numbered 4100 Seneca 44,725.00 Avenue, Camp Hill, Lower Allen Township, PA -See Deed dated March 4, 2009, and recorded in the Office of the Recorder of Deeds in Cumberland County in Deed Book 2009063090 - Assessed valuation - $134,300 SCHEDULE A REAL ESTATE TOTAL (Also enter on Line 1, Recapitulation) I 44 725 00 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08) Rev-1507 E%+ (6-eel SCHEDULE B STOCKS & BONDS COMMONVrEpLTH OF PENNSYLVANIA INHERITANCE TA%RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kintzer, Natalie Mae 21-12-0710 All propertyJointlyrownetl with right of survivorship must betlisclosetl on 6chatlule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 2,562.894 shares of 2,562.894 shs. ALLIANCEBERNSTEIN 10 75 MUNI INC II PA A -Fund/Account Number - 67/4765863244 . 27,551.11 2 29 shares of MetLife Trust - 29 units 32 05 . 929.45 3 277.758 shares of PPL - 277.758 shs. common stock 28 26 . 7,849.44 4 Non-Qualified Annuity - 2,401.379 units EO/Intermediate 14 10 Gov. Bond . 33,859.43 5 U.S. Savings Bonds 6,064.80 TOTAL (Also enter on Line 2, Recapitulation) 76,254.23 tll n,D,e space Is neeoeD, aD0lnonal pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form Pq-1500 Schedule B (Rev. 6-98) Rev-1509 EXi (6-98) COMMON WEALTH OF PENNSYLVANIA INHERITANCE TAX RETDRN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Kintzer Natalie Mae 21 12 0710 It an avast was made Joint within one yearof the decedent's date of death, It must be reported on schetlule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Becky J. Frank 5 Dishley Drive Daughter Mechanicsburg, PA 17055 8. Sherry L. Deane 1 Sussex Circle Daughter Camp Hill, PA 17011 C. 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 ASSE % OF DECD'S INTEREST DATE OF DEATH DECEDENTUS NTEREST 1 A B 06/12/2002 Members 1st Federal Credit Union -Savings 5 00 33 330°/ Account No. 219125-00 . . a 1.67 2 A B 06/12/2002 Members 1st Federal Credit Union - 10,977.39 33.330°/a 3 658 76 Investment Savings Account No. 276267-05 . . 3 A B 06/11/2002 Members 1st Federal Credit Union - 6,403.53 33.330°/a 2 134 30 Certificate of Deposit No. 219125-40 , . 4 A B 06/11/2002 Members 1st Federal Credit Union - 3,520.52 33.330% 1 173 39 Certificate of Deposit No. 219125-41 , . 5 A B 06/11/2002 Members 1st Federal Credit Union - 3,520.52 33.330% 1 173 39 Certificate of Deposit No. 219125-42 , . 6 A B 12/30/2002 Members 1st Federal Credit Union - 1,839.76 33.330% 613 19 Certificate of Deposit No. 219125-46 . 7 A B 01/30/2004 Members 1st Federal Credit Union - 13,051.93 33.330°/a 4 350 21 Certificate of Deposit No. 219125-07 , . 8 A B 03/29/2004 Susquehanna Valley Federal Credit Union - 13,744.55 33.330% 4.581.06 Savings Account Total of Continuation Schedule ee attached page TOTAL (Also enter on Line 6, Recapitulation) I 26,891.10 (IF more space is needed, additional pages o(the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) Rev-1508 E%i (B-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIpENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY LE NUMBER 21-12-0710 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. JOINTLY OWNED PROPERTY ITEM NUMBER LETTER FOR JOIN TENANT DATE T MADE JOINT INCLUDE NAME ODES NR APTNON OTIONANOD BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 9 A B 03/29/2004 Susquehanna Valley Federal Credit Union - 27 618 15 33 330% Checking Account , . . 9,205.13 TOTAL (Also enter on Line 6, Recapitulation) I 26,891.10 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) Rev-1518 EX+(6~88) SCHEDULE G INTER-VIVOS TRANSFERS & DDMMDNwEALTH qF PENNaVLVANA MISC. NON-PROBATE PROPERTY INHERITANCE Tq%RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kintzer, Natalie Mae 21-12-0710 This schetlule must be c°mpletetl and fil°tl 8 the answer t° any Of questions 1 through 4 on [he reverse sitle o/the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE NAME OF TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TNANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %oF DecD~s INTEREST I EXCLUSION (F APPLICABLE ) TAXABLE VALUE 1 Alllianz -IRA - to daughers -Sherry Deane and Becky 30 347 74 100 000% Frank , . . 30,347.74 2 MONY Life Insurance Company of America -Annuity 58,875.43 100.000°/a 58 875 43 Contract 2VA0057466 - to daughters -Sherry Deane , . and Becky Frank 3 MONY Life Insurance Company of America -Annuity 37,918.49 100.000% 37 918 49 Contract B6007-51-93 - to daughters -Sherry Deane , . and Becky Frank 4 Susquehanna Valley Federal Credit Union -IRA - to 3,664.32 100.000% 3 664 32 daughters -Sherry Deane and Becky Frank , . TOTAL (Also enter on Line 7, Recapitulation) 130,805.98 (If more space is needed, additional pages or the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EXi (10-0B) COMINVvEA1.7HD pDENG RNANIA SCHEDULE H FUNERAL EXPENSES & -DMINISTRATIVE COST' ESTATE OF FILE NUMBER Kintrer, Natalie Mae 21-12-0710 Debts of decedent must be reported on Schedule I. ITEM N DESCRIPTION AMOUNT A. I FUNERAL C.[YtN~tS: See continuation schedule(s) attached I 2,491.42 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) _Becky J. Frank and Sherry L. Deane Street Address 1SnSSeX CIfCIe City Camp Hill state PA Zio 17011 Year(sl Commission paid Waived 2. Attorney's Fees B/)$Well, Tintner 8 PICCOIa 12,750.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees Cumberland County Register of Wilis 366.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 400.1 S See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 16,008.10 Copyright (c) 2009 form software only The Lackner Group Inc , . Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Kintzer, Natalie Mae 21-12-0710 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Auer Cremation Services of PA -funeral 1,841.42 2 Rev. Duncan Johnston -memorial service -honorarium 100.00 3 The Columbarium for Mount Calvary Episcopal Church -interred fee 550.00 H-A 2,491.42 Other Administrativ roster 4 Boswell, Tintner & Piccola -disbursements (copies, postage, etc.) 57.50 5 Cumberland Law Journal -legal advertising 75.00 5 Journal Publications -legal advertising 239.00 7 Susquehanna Valley Federal Credit Union -checkbook fee 18 68 H-B7 400.18 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-051I E%~ (1b08) COMMONVr£gLTH OF PENNSYLVANIA INHERITANCE Tq%RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8t LIENS ESTATE OF FILE NUMBER Kintzer, Natalie Mae 21-12-0710 Report dabta incurtatl by the tlacetlent prior to tleath that remained unpaid atihe tlate of death, including unreimbureetl metlical expenaea. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Comcast -final service bill 33.46 2 Lower Allen Township -real estate school tax 1,145.77 3 Lower Allen Township -sewer 103.55 4 PA American Water -final service bill 41.65 5 PPL -electric service 135.65 6 UGI -gas service 126.93 7 Verizon -final service bill 58.65 TOTAL (Also enter on Line 10, Recapitulation) I 1 645 66 (If more space is neetletl, adtlitional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule 1 (Rev. 12-08) REV~1517 E%.111-08) t.,~s SCHEDULE J COMMpNy~y~7~4TCH ppq%pEN~~YLVANIA INHE SID'~`tJIEDiECED N RN RRE BENEFICIARIES ESTATE OF Kintrer, Natalie Mae FILE NUMBER 21-12-0710 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal (Words) ($$$) distributions, and transfers under Sec. 9116 a 1.2 1 Sherry L. Deane 1 Sussex Circle Daughter 50% of residuary Camp Hill, PA 17011 estate 2 Becky J. Frank 5 Dishley Drive Daughter 50% of residuary Mechanicsburg, PA 17055 estate Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 Total 0 cover sheet as a ro riate. II NON-TAXABLE DISTRIBUTIONS: . A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTA L OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Forrn PA-1500 Schedule J (Rev. 11-08) 23137 91 SaVEREKiN SAVI GS BOND REDEMPTION Sovereign I ~ - SEP 1 ~~ EST REPORTING FORM Sequence # 00035-0914-114517 Date 09/14/2012 Redeemed Branch# 35 Processed Jodi Hammaker _ b --- - Teller #- 003 J TRANSACTION DISBURSEMENT i TYPE(S) ^ Cash ©Check ^ Sovereign Acct Credited Account#: NUMBER OF #9 TOTAL REDEEMED ~ - -~- _ -- BONDS $6,064.80 Ensure that the following information applies to the NAME on BOND/BOND OWNER. TOTAL 1099 INTEREST TO BE REPORTED IS $4,014.80 -- SOCIAL SECURITY NUMBER OR EIN 187.5_2-1671 _ --- _ NAME on BOND/BOND OWNER - -- ---- ___ Beck Frank_ DATE OF BIRTH __ 05/26/1958 _ _ STREET ADDRESS of NAME ON BOND/BOND OWNER 5 Dishley Dr clrY, sTATE a zIP coDE -Mechanicsburg, PA 17055 -__. -.__- __ COUNTRY OF CITIZENSHIP _--- __ United States - CUSTOMER TYPE F - - _._ CUSTOMER NUMBER 1849850 - Complete the information below about the person cashing the bond(s) ONLY if NOT the NAME on BOND/BOND OWNER named above. NAME OF PERSON CASHING BOND(S) -- RELATIONSHIP TO NAME on BOND/BOND ^ ParenUGuardian ^ Trustee OWNER: ^ Conservator ^ Executor/Administrator Certifications Instructions: You must cross out item 2 below if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. I certify under penalties of perjury, that (1) that the number shown above is my Taxpayer Identification Number and is my correct TIN; (2) I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. person (including U.S. resident alien). Signature Legal Representative Title (if any) Date Important! By signing above, you certify that either 1) Your TIN is being used to report the interest earned on the savings bond(s) OR 2) You are authorized to sign on behalf of the registered holderlilN reporter whose TIN is being used to report the interest earned on the savin s bond s i.e., ou are the arenU uardian, trustee, executor/administrator, or conservator . Refer below for additional Federal Reserve Rank r<dem do p n resource Information. i Via telephone: 7-800-245-2804 ~ Via the Internet: http:/lwww.savingsbonds.got BRANCH USE ONLY Provide copy to customer. Retain copy in branch files. Forward on final in Savin s Bond Redem tion Forms s ecial use envelo a the same rocessin da . 1099 PROCESSING TEAM USE ONLY UTJ SBR007 REPORT DATE PZ 250 REPORT DATE Effective 09/14/2012 Revised 02/10/2012 VERIFY THE AUTHENTICITY OF THIS MULTI TONE SECURITY DOCUMENT CHECK BACKGROUND AREA CHANGES COLOR GRADUALLY FROM TOP TO BOTTOM. 2e ..EST„ ~ Am :21~°. Sovere~gn'Bank;~va - ~ ~ 91 ~ ~5 ° PART OF~THE SAN, TAN.D~ER GROUP ~~'~"" ~"~ ~""" O2i i`iG1E~i.j ~y~a1~~.,"~~ ~"~ ~f~if?rn rl: ~ ~ o~/ia/zpF4 B i,r~~rlc i'I; Uu;35" Void Ifi Amount fiver $=r~w~x**x~xr; r,>~,.,i.89 e PAY TO THE .ORDER OF E~i ~rYE, of Na tulle K,1 ri t.Zer ..Drawer SDVereign8ank, N.A ... ' 3 L~ h 'w~ DRAWEE: SOVEREIGN BANK, N.A. ISSUED BY: SOVEREIGN BANK, N.A. A•P ' AUTHORIZED SIGhYATURE " II'2091i651r' r:231372691x: i200i2455311' " ~ T T 1 P/ease Tear Along The Per/orarion Above To Detach Check T T 1 Sovereign Ba11k,1 WA, DETACH AND RETAIN FOR YOUR RECORDS PART OF THE SANTANDER GROUP f~ieHlo: 2p911<.ti p9 J 14 /2p7.?_ ~M;r.:~;r a::Kx:x:~x:c , pad . SC', Account Holder: Becky ~ro Prank Account Number: 1 Branch Nurnberc Op35 OD1001 MA Rev. 12/11 'a ..- ~. , ~,~ NATlWE M KINTZER T00 SHERRY _ Investor ID 8063 6729 3407 AOCOUm Market Value Stock Price as of Total Market 1011 tNvldend Summary f1 09 2011 Yalue ~ 050 Recortl Date Total Trust Dividend per Currerrt $464 73 Interests Trust Irderest Distribution The a~gregete amount paid to ell n/os/2on 1a.sgoo $0.74 $10.73 Trust Benellciarles in this distributi on is $158 212 338 53 Payable Date Tax WRhheld Net Disbibtrtion Prior Year Distribution 12/14/2011 $0.00 $10.73 $10.73 For account inquiries, you may visit www.bnymellon.com/shareowner/equitYaccess, or call 1-800-649-3593. When contacting us please have your Investor ID available, located in the upper right hand corner of this document. •a•ar.elln~~~•a~a~ 7nrt BaMligary htrarrrteaon You may ptachps or Ball shares of MetLile, Inc. common stock through the Ma1LIfe Policyholder Trust (the •Trust~, hee of any commissions or other ksss, under the MetLife Purchase ono Sale Program, as amended. A copy of the brochure Describing the program is available on the Imernet a< www.madife.cpn by selecting Investor Relations antl Men the above. You arse plx~ini~ to lbansfer yourbTrstlllntereatauonly ring the Ckcumehnces deecribeD in the Drochure. You may also inslrlrct that all Ibut not bss than alq of your shares of MetLife, Inc. common stock held by the True) be wieldrawn hom the Trust. IMormatldn regarding your wdfldrawal rights may be buntl in the Purchase and Sale Brochure or by Calling the number listed above. An annual ahareholders~ meeting to elect memDere of the Board of Oiremars of Metlife. Inc. arW for the hansat:tlon of other business is expected to be field on April 24, 2012. The deadline for submitting ~larelAtolder Proposals for colMidaration of this meeting b November Za, coPY of MetLife. Inc.'s annual report and proxy statement will be available hee of charge on or before March 31, 2012, aldng wkh other MetLBe, Inc. erld Trust filings under federal aecur4lea Wvrs, li) on the Internet al www.metlife.com by aelecung About MetLife, Corporate Governance, under Related Links, (ii) by wrRing to MetliM, Inc., c/o BNY Mellon shareowner Services, PO Box 358447, PiOSburgh, PA 15252-6447 Or (iii) by calving the number listed above. These and other SEC filings Dy MetLife and the Trtan are also available on the Internet m www.aec.gov. Please Note: Important 2011 Tax Information FORM 1099-DIV.-- ------------------ ---__-__ _ MettJfe DIVIDENDS/DISTRIBUTIONS U.S. TAX INFORMATION FOR 2011 OMB NO. 1545-0110 COPY 8 FOR RECIPIENT RECIPIENT'S TOTAL ORDINARY 1I-ID-EN-T~IFI-CA-TION NUMBER OMDENDS QUALIFlED DMDENDS 1 )0()00(1103 xla. xte a 1F~61AL 114COk1E TAX WITFM1aD $10.73 $10.73 110.00 DAKOm ueu~ ^` rvoyrln~,,rt 11V1Y NUMEIER BNY MELLON SHAREOWNER SERVI CES AS CUSTODIAN OF THE METLIFE POLJCYHOLDER TRUST 515189@7 SECURITY DESCRIPTION TO WHOM PAID TRUST INTERESTS NATAUE M KINTZER TOD SHERRY KINTZER DEANE SUBJECT TO STA TOD REPORTED BY RULES 4100 SENECA AVE THE BANK OF NEW YORK MELLON CAMP HILL PA 17011.8748 480 WASHINGTON BOULEVARD IMPORTANT 2011 TAX INFORMATttnw ,~,., ...~----_._- JERSEY CITY, NJ 07310 le Is Important tax information and is being furnished to the Internal Revenue Service. you ere regWred to file a return, a negligence penalty or other santtion may be posed on you it this income Ia taxable and [he IRS determines that it has not been caned. x to -Shows total ordinary divitlentls that are taxable. Include this amount on line 9a of Form 30 or 1040A. Also, report it on Schetlule B (Form 1040 or Form t040A), if required. The punt shown may be divitlentls a corporation paid tlireclly (o you as a participant (or beneti- ry of eparticipant) in an employee stock ownership plan (ESOP). Report i1 as a divitlentl on r Form 1040/1040A, but treat it as a plan distribution, not as investment income, for any er purpose. Box 4 -Shows backup withholtling. A payer must backup withhold on certain payments if you did not give your taxpayer identification number to the payer. See Form W-9, Request for Tax- payer Itlentiticaticn Number antl Cenitication, (or information on backup withholtling. Indude this amount on your income tax return as tax withheld. Nominaes. If this fern inclutles amounts belonging to another person, you are consideretl a nominee recipient. You must file Form 1099-DIV with the IRS for each of the ether owners 1o show their share pf the income, antl you must furnish a Form 1099-DIV fo each. A husband or wife is not requiretl to file a nominee return to show amounts owned by the other. See the 20t t General Instructions for Certain Information Returns. a 1b ~ Shows the portion cf the amount in box 1a, that may be eligible for the 15% or zero iitel gains rates. Sea the Fortn 1040/1040A instructions (or how to tletermine this amount. can the eligible amount on tine 9b, Form 1040 or 1040A. NATALIE M KINTZER TOD BECKY Axrwm Market Value Stock Price as of 11 0.9 2011 Total Market Value $32.050 $464.73 The aggregffie amourn paitl to all Trust Beneficlarles in this distribution is $158,212,338.53. Investor ID 8083 6728 8743 2017 DlvlderW Summary Record Dffie Total Trust Dividend per Currern Interests Trust Interest Distribution 11/09/2071 14.5000 $0.74 $10.73 Payable Date Tax WRhheld Net Distribution Prior Year Distribution 12/14/2071 $0.00 $10.73 $10.73 Vou may purchase or ssN shares of MffiLde. Inc. common stock through the MetDfe PdiCyhokler Trust (the 'Trust'), bee d any commissions a other fees. uMer file MetLile Purchase and Sale Program, as amended. A copy d Me brochure deacriDing the program re available on the irrternet al www.rnebife.eom by selecting Investor Relations era then the Slpretgldsr Services Irdormalion page, or by calling the number listed above. You are permitted to transfer your Trust Imerests only in the ckcumsMnces deacribsd in the brochure. Vou may also instruct that all (but not less than all) d your shares of MetLae, Inc. common stock held by Ule Trust be wiMdrawn hom the Trust. Irdormatipn regarding your withdrawal righq may De found in the Purchase ant Sale Brochure or by calling the number listed above. An annual sharehoklera' meeting to elect members of the Board of birettas of MetLife. Inc. and for the paneactipn of other Dusinssa is expected to be heW on April 24, 2012. TM deadkrte for submitting sharahoWar proposals far conaideralion at thh meeting is November 29, 2011. A copy M MBtLife, Int.'s annual report and Proxy statement will be availapb hoe of charge on or before March 31, 2012. abng with other MetLife. Inc. and Trust filings udder federal securihss laws, (i) on the Internet at www.meaife.com by selecting About MetLife, Corporate Governance, urger Related Links, (ii) by writing to MetLile, Inc., c% BNY Melkm shareowner Services. PO Bat 358447, PRtsburgh, PA 75252.0947 a (iii) by calling the number listed above, These and oMer SEC filings Dy MetL'rfe and the Trust are also available on the Imernet at www.sec.gov. Please Note: Important 2011 Tax Information MetLlte FORM 1099-DIV. U.S. TAX INFORMATION FOR 2011 OMB NO.1545-0110 DIVIDENDS/DISTRIBUTIONS COPY 8 FOR REGPIENT REGPIENT'S TOTAL ORDINARY IDENTIFlCATION NUMBER DMDENDS QUALJFlED DMDENDS F~IPIf.•p1AE TAX YVITFIF18p ~~ x to ~X lb $10.73 $10.73 _ BNY MELLON SHAREOWNER SERVICES AS CUSTODIAN OF THE METUFE POLICYHOLDER TRUST . ___._.._~..... .,,.-„rv,. n~mocn 51518987 SECURITY DESCRIPTION TO WHOM PAID TRUST INTERESTS NATAUE M KINTZER TOD BECKY KINTZER FRANK SUBJECT TO STA TOD REPORTED BY RULES THE BANK OF NEW YORK 4100 SENECA AVE MELIAN CAMP HILL PA 17017$749 4B0 WASHINGTON BOULEVARD IMPAtiTABIT 9If1 ~ rev wrtnra....~..... _ JERSEY CITY, NJ 07310 'his Is Important tax Information end is being furnishetl to the Internal Revenue Service. ' you are requlretl to file a return, a negligence penalty or other sencticn may be npoaed on you if this Income le taxable and [he IRS determines [ha[ it has not been sported. bx to -Shows total ordinary tlividentls that are taxable. Include this amount online 9a of Form 040 or IO40A. Also, report it an Schedule B (Form f 040 or Form 1I)40A), If requiretl. The mount shown may be tlivitlentls a corporation paid tlirectly ro you as a participant (or benefi- lary of a participant) in an employee stock ownership plan (ESOPs. Report it as a tlivitlentl on our Form 1040/1040A, but treat it as a plan distributioq not as investment income, for any Iher purpose. eoz 4 -Shows backup withholtling. A payer must backup withhold on certain payments if you did not give your taxpayer identification number to the payer. Sae Form W-9, Request for Tax payer Identification Number and CertiPrcalion, for information on backup withholding. Inclutle this amount on your income tax return as tax wifhheltl. Nominees. If this farm includes amounts belonging to another parson, you are consitleretl a nominee recipient Vou must file Fonn 1099-DIY with the IRS for oath of the other owners to show their share of the income, and you must furnish a Form 1099-0IV to each A husband or wife Is not required to file a nominee return to show amounts owned by the other. Bee the 201 1 General Instructions for Certain Information Returns. ox f b -Shows the portion of the amount in box 1a, that may be eligible for the 15 % or zero apilal gains Tales. See the Form f040/1040A Instructions for how m determine this amount. leport the eligible amount onlirre 9b, Form 1040 or 1040A. For account inquiries, you may visit www.bnymellon.com/shareowner/equityaccess, or call 1-80049-3593. When contacting us please have your Investor ID available, located in the wooer riahf hann r•nrnne ,.r .r.:., .,._..___. Metlife® Natalie M. Kintzer Tod Sherry Kintzer Deane Subject To Sta Tod Rules 4100 Seneca Ave. Camp Hill. PA 1701 I The following shares have been recorded on the records of the Company in book-entry form. Beneficiary of: Metlife Policyholder Trust Issue: Trusl Interests Interests: LdS0p0 Registration: Natalie M. Kinzer Tod Sherry CUSIP Number: Transaction Date: Transaction Advice Number: 000119002 Inrestor lD: 8063 6729 3x07 'I'ranster Agent: Mcllou luceslvr Ser,~ices Transfer Transaction Advice Please be sure the correct address appears in the window of the envelope if you are sub- mitting aPurchase or Sale Instruction. The attached instruction card identifies the correct address for each type of transaction. 59156RI0 OS/13/200g This Transaction Advice is your rerord of the indicated Trust interests being credited to an account en the books of the referenced transfer agent. The Transaction Advice should be kept with your important documents as a record of your ownership of these securities. These Trust interests are transferable only as permitted under the Metlife Policyholder Trust. PLEASE READ THE IMPORTANT INFORMATION ON THE BACK OF THIS FORM AND IN THE PURCHASE AND SALE BROCHURE IacR (REV 13031 Use ONLY if a transaction is requested. Unless you wish to initiate a transaction, no action is required. C OS l4 OGOOI I4 PURCHASE INSTRUCTION Change of address: (See reverse side to SELL) 8063 6729 3407 Natalie M. Kintzer Tod Sherry S>i natUr@' ! f add ~~ he chano m Mellon Investor Services Make check, in U.S. dollars, payable to: PO BOX 382200 Metlife Purchase Program Pittsburgh PA 15250-8200 111r1111J11rIJr11L11111LrIrrllrlllr1r1111JLr11111r111111 104 Please be sure this address appears in the envelope window for PURCHASES ONLYI 0000101 102 806367293407 Amount Enclosed Minimum investment $250.00 (except as described in the purchase and sale brochure) Please sce the enclosed Brochure for imporumt information ou your right to ~~~thdraw from the Trust. Metlife® Natalie M_ Kintzer Tod Becky Kintzer Fra3il; Subject "I-o Sta Tod Rules 4100 Seneca Ave. Camp Hill, PA 170 ( I The following shares have been recorded on the records of the Company in book-entry form. Beneficiary of: Metlife Policyhotder Trust Issue: Trust Interests Interests: l:y,~000 Registration: Natalie Nt I{Illt/_l'r Tod Bcck~ CUSIP Number: Transaction Da[c: Transaction Advice Number. 0001 19UUi 3 Investor ID: 8063 6728 8743 'll'ausfcr Agent: btcllou L1~cslor 5crcices Transfer Transaction Advice Please be sure the correct address appears in the window of the envelope if you are sub- mitting aPurchase or Sale Instruction. The attached instruction card identifies the correct address for each type of transaction. 5915GR10 0~/13/20U4 This Transaction Advice is your record of the inrlicafad Trust interests being credited to an account on the books of the referencsd transfer agent. The Transaction Advice should be kept with your important documents as a record of your ownership of these securities. These Trust interests are transferable only as permitted under the Metlife Policyholder Trust. PLEASE READ THE IMPORTANT INFORMATION ON THE BACK OF THIS FORM AND IN THE PURCHASE AND SALE BROCHURE IBCR (REV 72031 Use ONLY if a transaction is requested. Unless you wish to initiate a transaction, no action is required. C t1j 14 00001 12 PURCHASE INSTRUCTION Change of address: (See reverse side to SELL) 8063 6728 8743 Natalie M. Kintzer Tod Becky Mellon Investor Services PO Box 382200 Pittsburgh PA 15250-8200 $IOnafLf2' f f add e n ' ha edl Make check, In U.S. dollars, payable to: MetLlfe Purchase Program Ifiillilrlirilrlrlilfllri~lirlfi~lrlllirill~iilli~illiiiliirll 04 Please he sure this address appears In the envelope window for PURCHASES ONLY! 017170101 102 806367288743 Amount Enclosed Minimum investment $250.00 (except as described in the purchase and sale brochure) Ylease see the enclosed Brochure for important inLOnnatiou on your right to withdraw from the Trust. ~~~~_ An qxq Financial Company SUMMARY OF BENEFIT Annuitant: Natalie Kintzer Contract: 2VA0057466 June 20, 2012 Date of Death: Date of Calculation: Contract Date: Investment in Contract: Withdrawals Made: Death Claim Payable: Your Share of Death Claim Payable: MONY Life Insurance Company of America PO Box 4720 Syracuse, NY 13221 www.AXAonline.com 800-659-1058 May 15, 2012 May 15, 2012 March 1, 2002 $45, 000.00 $0.00 $ 58, 875.43 $29,437.71 Plus Interest at rate of: Total Death Claim Payable to you: Less Tax Withholding: Net Death Claim Payable to you: Beneficiary: Sherry Deane and Becky Frank, Daughters equally $0.00 $29,437.71 $693.77 $28,743.94 Insurance and annuity products are issued by MONY Life Insurance Company (MONY) in New York, and by MONY Life Insurance Company of America (MLOA) outside of New York. Distributed by AXA Advisors, LLC. MONY, MLOA and AXA Advisors are subsidiaries of AXA Financial, Inc., 1290 Avenue of the Americas, New York, NY 10104, (212) 314-4600. GE-36779 (10/06) ~~~~_ __ An AXq Financial Company SUMMARY OF BENEFIT Annuitant: Natalie Kintzer Contract: 86007 51-93 July 10, 2012 Date of Death: Date of Calculation: Contract Date: Investment in Contract: Withdrawals Made: MONY Life Insurance Company of America PO Box 4720 Syracuse, NY 13221 www.AXAonti ne. com 800-659-1058 May 15, 2012 May 15, 2012 April 3, 1995 $18,100.00 $0.00 Death Claim Payable: Your Share of Death Claim Payable: Plus Interest at rate of 2.75%: Total Death Claim Payable to you: Less Tax Withholding: Net Death Claim Payable to you: Beneficiary: Children equally $37,918.49 $18, 959.25 $79.99 $19,039.24 $906.50 $18,132.74 Insurance and annuity products are issued by MONY Life Insurance Company (MONY) in New York, and by MONY Life Insurance Company of America (MLOA) outside of New York. Distributed by AXA Advisors, LLC. MONY, MLOA and AXA Advisors are subsidiaries of AXA Financial, Inc., 1290 Avenue of the Americas, New York, NY 10104, (212) 314-4600. GE-36779 (f0/06J ~!!-lL. An AXA Financial Company I,,,III,,,III„~„, I I,,,II, II.,I,,,I,I„II,I„II,,,Ii,,,,l„II Mrs Natalie M Kintzer 4100 Seneca Ave Camp Hill PA 17011 Non-Qualified flexible Payment Variable Annuity Report Date: June 19, 2012 Annuitant: Natalie M Kintzer Contract: 2VA0057466 Issue Date: March 01, 2002 Summary status as of Prior Report Date: March 01, 2012 MONY Life of America P.O. Box 4830 Syracuse NY 13221 financial Professional: Harold Hoch 40 Monument Road, 4th Floor Bala Cynwyd, PA 19004 (610)660-4000 Account EQ/Intermediate Gov Bond Unit Value Units Held 100000 - Value Held 14 EQ/Money Market . 2,401.3779 $33,859.43 10.464900 GIA 1 Year Period $0.00 Total $24.685.32 $58,544.75 Summary status as of Current Report Date: May 15, 2012 Account ED/I/Intermediate Gov Bond Unit Value Units Held 14.163800 Value Held EQ/Money Market 10.436000 $0.00 GIA 1 Year Period $0.00 Total $0.00 $0.00 Current Payment Allocation Account EED/Intermediate Gov Bond Allocation GIA 1 Year Period 50% Total 50% 100% ssoot (s/zoom Cat. #134229 (9/04) 2VA0057466 Natalie M Rintzer Summary of Values As of March 01, 2012 As of May 15, 2012 Fund Value: (The Sum of the Amounts Under the Contract Held in Each $58,544.75 $0.00 Subaccount, the Guaranteed Interest Account, and the Loan Account (if Applicable). Total Payments Received During puarter: $0.00 $0.00 Interest Earned on the General Account , Guaranteed Interest Account, Loan Account $208.54 , if any: Total Partial Surrenders During Quarter: $0.00 $0.00 Contract Fee Charged: $0.00 $0.00 Total Investment Gain or Loss: $18 01 $0.00 Surrender Value: (Fund Value Minus Any Surrender Charge, and Minus Any $58,547.08 Outstanding Debt.) The following amounts are not calculated within the values. Free Partial Surrender Amount: For Non qualified Contracts - An amount up to 10 percent of the fund Value of the Subaccount(s) and the Guaranteed Interest Account (not the Loan Account) at the beginning of the Contract Year, that may be surrendered without imposition of a Surrender Charge. For purposes of the Free Partial Surrender Amount only, Non-qualified Contracts include Contracts issued for IRAs and SEP-IRAs. For Qualified Contracts - An amount up to the greater of $10,000 (but not more than the Fund Value of the Subaccount(s) and the Guaranteed Interest Account) or 10 percent of the Fund Value of the Subaccount(s) and the Guaranteed Interest Account at the beginning of the Contract Year, that may be surrendered without imposition of a Surrender Charge. Fund Value for this purpose means only the fund Value of the Subaccounts and the Guaranteed Interest Account (not the Loan Account). For purposes of the Free Partial Surrender Amount only, pualified Contracts exclude Contracts issued for IRAs and SEP-IRAs. ~ ~ ~~ L~ ~ti ~r~~ - ------ --- ~-~-- t-_ Provide Information about Yourself as Beneticiarv This entire sectionLffiust be cotholeted 1 am claiming as: fan individual ^ on behalf of a Minor ^ on behalf of an Estate ^ on behalf bf a Corporation ^ a "trustee, Name of Ttvst -_ -----_._---- Date of llvst _. _._ ^ Other Entity ~~~~~~yy~~~ Are you the spouse of tree Deceased'? ^ Yes f~No If no, yow~ relationship to the Deceased? ~iETt~T .~~ If you are submitting a claim as the SPOUSE of the Deceased, then you represent to the Company that (i) you were lawfully married to the Deceased at his/her death; and (ii) no divorce or annulment had been granted or issued to dissolvd your marriage; and (iii) no marital agreement (i.e., prenuptial, postnuptial separation, property settlement or marital property agreegienq precludes, prohibits or impairs your right to make this claim. lfyou are submitting this claim as a FORMER SPOUSE otthe Deieased then you represent to the Company that the terms of your divorce decree, decree of annulment or property settlement agreement du not disyuality you as a beneficiary and you have no reason to believe that you are otherwise disqualified. ~-^ ', Are you the sole beneficiary? ^ Yes [~,No, percentage of the benefit you are claiming .~._.-°Xo ^ don't know Are you a U.S. Person'? Q~Ycs ^NO (If no, call I-800-659-f058 for further instructions). if the primary beneficiary is deceased include his or her: - - Name Dat@ of Death YourYour Na (first, middle initial, last) (Print Corporation, Tmst or Estate Name, if applic~blc) / .~ --- Street Address (if mailin address is a PO Box also supply a street address). ~' FPH1an'in sAI~(f PR /'J/17~' City, State, p %~G'~~It9 1 ~°~--J'~-110!71 '- - r - - - - - D to Birth Social Security Number Federal Taxpayer I!deniification Number Daytime Telephone Number Evening Telephone Number E-mail y4ddress Federal and Mate Taa Withholdine For Annuity Claims Only Complete this election of Federal Inwme Withholding (F[T) below only if you are a beneficiary ofan annuity contract receiving proceeds in a Lump Sum Check or MONY Access Account (see page 3). '.. - ---- . ^ I elect NOT to have Federal (and state, if applicable) Inwme Taxes withheld on the taxable portion~of my benefits. I ~l elect to withhold Federal (and state, if applicable) Income Taxes from the taxable amount of my benefits. Unless you elect otherwise, the Company will withhold Federal, and in certain cases, State Inwme.~'Tax from the taxable portion. The taxable portion is subject to Federal withholding at l0"/o unless elected otherwise. Withhold ^ 10"/0 ^ °/a Caution: There are penalties for not paying enough tax dwing the year, either through withholding or estimated tax payments. For more information please see Publication 505, Tax Withholding and Estimated Tax, available at www.irs.¢oW. E 14703 DBREQTS Page ~ of 5 j~J Lump Sum Check ~ IRONY Access Atxouat' - Z'he MONYAccess Account is not available if the pr :payable to the benejrciary are less tlliiert StB,~D, the benejrcteery does not have a i'~e , or ~e benefrciary is one of the following: minor, corporation, partnership, tax-exempt e ~ ~ , estate, trust with more than two trustees, represented under a power of attorney, or resides outside of t~te U.S This account is a draft account that wtxks in certain respects like an interest bearing checking accotl~tt. The Company w~i sdt:t~e' interest rah ` ly, based upon ots~igcretion and a review or€curzatflmarket interest ratLS. We reserve the rigl{~ t{e~;t~ttge this procedure. '~'he interest rate wt; ~' "vvlll tio~lbe less than f1.25%. Interest earned may be taata€61e. ~Ve recommend you consult a tax advisor, an ' " t advisor, or any other financial advisor regarding your payout options and any potential tax liability. Intierest is earned from the date the account is established until the account is closed, compounded daily andc¢edited at the end of tht ia~t ai which time aistatement will be mailed. This statement will show w' gals, interest credited and 9~e applicable rate; an8atty other financial activity. The account which is ts4~t~lid in your naarte allows you to write an unlimited number of drafts (minimum $250 each draft) on your balance with no draft-cleazing charges or you may write one draft to withdraw the entire amount including interest in your account at any time. Money in the MONY Access Account is part of each Company's eneral account and fully backed by each Company but not guaranteed by the Federal Deposit Insurance Corporation or any other government or federal agency. Funds held by insurance companies are guaranteed by tote respective state guaranty association. For further information, contact the National Organization of Life and Health Insurance Guaranty Associations at www.nolh a.com. [f the balance in your account goes below $1,000, the account will be terminated and a draft for the balance will be sent to you at the address we hav$ on our record. A fee of $25.00 will apply for returned drafts, stop payments and wire transfers. Express bnail fees of $15.00 to $22.00 also apply. Deposits to this account can not be accepted. The obligation of thle insurer is satisfied when the total policy or contract proceeds are deposited into the MONY Access Accounnt. For current MONY Access Account rate information or to obtain answers fo questions you may have about the MONY Access Account, you may call or write to the following: MONY c/o The Northern Trust Com}~any, P. O. Box 92987, Chicago, IL 60675-2987, Toil-Free Telephone (866) 494-4265. Kentucky residents - FOR FURTHER INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF 1INSi~RANCE. West Virginia residents -you may refer to www.wvlifeea ore. If your account has had no customer initiated activity for a Reri~l of ome y~arQr.mo '~.v., r.t~r_arrnunt.cautrl be _ . _ _ __ considered abandoned under the unclaimed property laws of your state of residence. S ch laws require us to report unclaimed property after a certain period of inactivity and then to fain the funds over to the state. ^ Settlement Option -Pay any part or all of the proceeds into an option with any balance being ~eid under the other payment option chosen above. if choosing a Settlement Option, please choose one of the three options below. ^ Interest Option -This is an interest-bearing contract. There are no penalties or charges for~withdrawals. ^ Installment Option -Pays your proceeds plus interest in annual or more frequent installments for a period you selector in an amount you select. ^ Life Income Option -Pays you a guaranteed income for life. Additional descriptions of these options and eligibility requirements are provided with our election fo To obtain election forms c more information about your payment options other than a lump sum, including our current rates of int s vt and estimates of income you can receive, call 1-800-326-6744. ' If you are the beaa9clary of s MONX Llfe Insurance Company pocky/contract thon you ntalaed asset accoaat is known as the MONYAcceea Aecouat. Oa We other hand, [f you are the ben~dary of • ~ ONY Llte Insunace Company of Amerka pocky/covtract then your retained asset aceottnt i, known as the OA Access Account. E 14703 DBREQTS Pa e 3 g f ~ 1 request delivery by mail to me. ^ I request and authorize delivery by an AXA Equitable Financial Professional. Na4nC of Financial ._ Please Print than X tl~e aPProptiate S :curity 1Vutuber o wyer Identificatia penalties of perji ithholding either Y inteteat or Diva taco. Toe ' loos required to (or other duly authorized signature end title) d weming for (New Yolk St iel Security Ni ify that the inf [ have not bee batkap Print Name of Pe arty Sieaiag Dal State Fraud Warnings: ~ ~ 4U 7 " S /`93 Policy/Contract Number. il.l/q B©S T ~~ New York Fraud Warning: "Any person who knowingly and with intent to defraud any insurance company or othjer 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, comirtits a fraudulent insurance act, which is a crime and shay also be subject to a civil penalty not to exe~ed five thousand dollars and the stated value of the claim for each such violation." ~"5~"Al3'E ~S~L' ~`~ AND SIGN ONIi'Yf `I have read and urid~rstood thr'~Iew York State Fraud Warning. -8encfciary's Signature-- _ __. - __ __ Date.. - __ I ... - Alaska, Arkansas, Lottisktaty I-4arY~ad, Rhode Any person who knowin 1 sd+ Teaas, West ~rgida: g Ypt~esentsa false or fraudulent ehtim forpaymentofa loss or betjefit or knowingly presents false information in an application for insurance is guilty of a crime and may tte subject to fines and confinement in prison. Arizona and California: For yow protection, Arizona or California law requires the following statement to appjyar on this form. Any person who knowingly presents a false or fraudulent claim for payment ofa loss is subject to criminal and civil penalties, which may include confinement in state prison. Cobrado: It is unlawful to knowingly provide false, inwmpleto, or misleading foots or informatiotp to an iastugrtce company for the purpose of defrauding or attempting to defraud the company. Penalgies may include imprisonment, fines, denial of insurance and civil damages. Any inswance company or agent of an instuance company who knowingly provides false, incomplete, or misleading facts or E14703 DBREQTS Page 4 of 5 MONY Life Insurance Company & MONY Life Insurance Company of America P.O. Box 4830 Syracuse, New York 13221 (315) 477-3000 Sherry Deane 05/25/2012 1 Sussex Circle Camp Hill PA 17011 Re: Annuitant - Robert L I{intzer Contract # - 400600751930 2VA0057466 Deaz Mrs. Deane On behalf of MONY, an AXA Financial Company, please accept our heartfelt condolences upon the death of your mother. We know this is a difficult time, and we aze here to help you throughout the claim process. The beneficiazy(ies) is 86007-51-93 -Children Equally 2VA0057466 -Sherry Deane and Becky Frank, Daughters equally _._ - _. The approximate amount payable is B6007-51-93 - $37,918.49, of whic~l9,'D88.49~taxable, and 2VA0057466 - $58,875.43 of which $3,875.43 is taxable. The options avaiIalsle are listed below. The beneficiazy(ies) may want to consult with a tax advisor to determine which option is best for them: 1. Electing an Installment or Life Option can spread the taxable amount out. To obtain election forms or for more information about these payment options, please call toll free at 1-800-326-6744. Please note: If a Settlement Option is elected, it must be elected within 30 days of the date we received due proof of death (the Death Certificate). 2. Immediate Payment Option: • Proceeds are immediately made available by means of an interest-bearing checking account. • Proceeds are paid in the form of a Lump Sum check. 1 of 2 M A7tAFaiarKtal Comply ~ti t>t`.of MONY Lii~ ' ' "ou omidtlterices for youEi QVl~Dn.4 ID comDletina t2 A Message to eiv Beneficiaries ~; (MONY)and: - Life[t~surance y diet thisis a di for you and y df._ /(fNLO,Ks ,accept ~ gave ° fE9.l1eQ18t Or Cell t yonr (1XA Finan ~ c 6f~~. ~ , ~ ~ .-c n UTCeCenTd' ~eC r`~ TY 4irx xii 4 µ x J. y C '.~ , ~ k F Y 3 "' l 5,34 / ~.a = ~ ~ 4 Q [ ~ } M o~ mot{ C~,'- ~ ~ ~ G Y ". ~~ of this form are Tha`~'orm ~s s '~ y "`f i w ~k ~` f" `assurances made 6 Company to the - ° 'ate ~ 91~ i` + ~ . i( Yi'~ Where to Mail this For® Re¢uler Mail MONY i [;~pras Mail MONY ~ Mail Drop 34-31 Mail Drop 3431 PO Box 4830 100 Madison ~St Syracuse, NY 13221 Syracuse, NY 13202 Or you msy fax these doweeab to MONY Claims at866-505-0286. Be sure to include the following items with this foimr - A certified death certificam. ' -Any other form(s) that we have requested. ~tJA °~s ?. ;' . _ bas X43 ~ : ~ :, !~ ~ A ~ ~°~:. ~ ; F~~ ~7' .~_ :. ~-c 8'x-3 Deoemed s Nsme (lust, last) 4i°'~: (Pleas list all ttamss by whis>.Aeeeasedmay have bmo-~m~ant)._ --- ~~ -' Dace of B' _ ___. -l S l7- ~CoKF_ ~ ,Pb ~~,( x-13 - ?~ - i (0 3 Date of Death Cause of Death Place ofDeath ~ Social Security Number X100 S~AJ ~C~ f4~F_ I Street Address .[_~ ~ A M ~ I f•L~ ~ t~- j 7 ~ ~ ~ City, State Z i .. _.°~: E14703 DBREQ'F~` : AAge ~ of 5 ~: ~'' An A%,4 Financial Company June 19, 2012 Becky Frank 5 Dishlcy Dr Mechanicsburg PA 17055 Contract - 2VA0057466 Annuitant --Natalie Kintzer MONY Life Insurance Company of America P.O. Box 4720 Syracuse, New York 13221 (315)477-3000 Please accept our deepest condolences for your loss. While nothing can compensate for losing a loved one, we hope our payment will provide some immediate assistance during a difficult time. At your request, your check has been mailed to your Financial Professional, Harold L Hoch, for personal delivery to you. He/She should be contacting you immediately to arrange a delivery date. For over 150 years, MONY, an AXA Financial company has proudly served the needs of our clients and their beneficiaries. As providers of competitive financial products, our reputation for professionalism and integrity is unchallenged. It has been a pleasure to serve you in this time of need and we welcome any opportunity to serve you now or in the future. Please let us know if we can be of any further help Lenora Pepe Claims Manager 1-800-659-1058 CC: Financial Professional 35424 (9/2004) Cat. #134228 (9/04) A O O O O ~ O ~ OwO 4J ~ ~ ~ cn , ~ O O O m a ^p N o N 0 N 0 ~ p o N O N N N N N N A ~ j O ~ (n ~ D A ~ n _+ ti O ~ O O A C>~ n <_ ~ d N l y l O 3 n _ti ~ ~ a ~ n= m m ° ~ d N G N O N N O .r'.. co w w° a G ~ a w ti~ T `_^n O O ~ I.r O y 3 m m a ~ W W O n O1 N Cn N _ N O N 3 N O O v (D W W a ~ a W~ (U n ~.~ ~ O p GJ L7 L'1 - b y n n ,C no ~ ~ ~ v ~ Q+ ~ 3 v d d ~ ~ v ~ a T v m m m y y ~ ~ °o o ~ ~^ o o' o . . 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' N C 'v ~ y Pi N ¢ O O ~ ~ m N . -~ . C ~ N U ~ ti ' u S S $y OJ ep O C = 'G m p C_ m y -O ti Q ~ a 3 3 ~_ o ~ ~' n To on ~a ~ ".~ ~ ~ ~ o ... a ^: o ~ o. m ~ ~ ~ N o m ~' °~ ` ° c~Q o ~ °' d e '~ N ~ N ~ - ~ O ~ cD O ~ ~-. a S° . .. d E R ~ O ~ p n O O_ ' `C W C `~ _ O_ O K 00 p O y ~ O '~C O N 0 C G N O ` N ~ d N ~ C .1-. ~ O m i ~ S ~ ~ v ;; to sv O `G ~ O_ ~ Oo N a W W ~ ~ ~ m ° e ~ _~ oa to ocn t»t» oO t»N °-' oao~ n `O ~ r. y m o~ O~ ow oO oaf C`~ ~. -.3 ~ ON 00 OW C A N ~.~ ~ _ ~ R O v S ~ 1e O ~ y ~ ~ N _ e d _ ~ _ . -w ~..~ ~ C ~ O ~ l O d ~ m O O `~-' ti N N = ID O OO Oo 00 app IC ~I ~ A N a a = ~h >•e~ ~ W _ V < W T O) a TOz W p C OI O OOC 00 ~ 0 ~ m 00 i 00 00 6 y O ~ ~ i p O_' O N i N ~~ ~ ~ ~ O O ,O ry L' ~ O O ~ +'O ~tn {p n O O_ N H p ZN a ~ .O.w ~ ~ l O N ~ S~ co W ~ N ~ y Vti ~ O ~ U <Dy ~ O [ O ~ < o m ~ v o _ d o ~ ~'~ o G n 0 a m w 3 O C O_ N MetLife° Natalie M. Kintzer Tod Becky Kintzer Frattl. Subject To Sta Tod Rules 4100 Seneca Ave. Camp Hill, PA 17011 The following shares have been recorded on the records of the Company in book-entry form. Beneticiary of: Mellife Policyholder Trust Issue: Trust Lnerests Interests: ]3.5000 Registration: Natalie M. Kintzer Tod Becky CUS1P Number: Transaction Date: Transaction Advice Number: 0001190053 Investor ID: R063 6728 8743 Transfer Agenl: Mellon Investor Services Transfer Transaction Advice Please be sure the correct address appears in the window of the envelope if you are sub- mitting aPurchase or Sale Instruction. The attached instruction card identifies the correct address for each type of transaction. svts6RUl OS/13/20Ud This Transaction Advice is your record of the indicated Trust interests being credited to an account on the books of the referenced transfer agent. The Transactlon Advlce should be kept with your important documents as a record of your ownership of these securities. These Trust interests are transferable only as permitted under the MetLife Policyholder Trust. PLEASE READ THE IMPORTANT INFORMATION ON THE BACK OF THIS FORM AND IN THE PURCHASE AND SALE BROCHURE IBCR TREY 11.0]) C 0514 00001 L2 Use ONLY if a transaction is requested. Unless you wish to initiate a transaction, no action is required. PURCHASE INSTRUCTION Change of address: (See reverse side to SELL) 8063 6728 8743 Natalie M. Kintzer Tod Becky Mellon Investor Services PO Box 382200 Pittsburgh PA 15250-8200 Make check, in U.S. dollars, payable to: MetLife Purchase Program I~~~II~I~I~r~Irlrlrlrll~r~lr~l~~~lrlll~r~ll~r~llr~~ll~rrl~r~ll 04 Please be sure this address appears in the envelope window for PURCHASES ONLY! 0000101 102 806367288743 Amount Enclosed Mlmmum investment $250.00 (except as described in the purchase and sale brochure) Ylwse see the enclosed Brochure for important intonnation on yow~ right to withdraw Crom the Trust. MetLife° Natalic M. Kintzer Tod Sherry Kintzer Deane Subject To Sta Tod Rules 4100 Seneca Avc. Camp HiIL PA 1701 t Transfer Transaction Advice Please be sure the correct address appears in the window of the envelope if you are sub- mitting aPurchase or Sale Instruction. The attached instruction card identifies the correct address for each type of transaction. The following shares have been recorded on the records of the Company in book-entry form. Beneficiary of: Mcllife Policyholder Trust CUSIP Number: >')ISCRIU Issue: Trusllnterests Interests: 145000 Registration: Natalie M. Kintzer Tod Sherry Transaction Date: US/13/2004 Transaction Advice Number: 0001 190052 Investor ID: 80(3 6729 3407 Transfer Agent: Mellon Inveslor Se~~ices This Transaction Advice is your rerord of the indicated Trust interests being credited to an account en the books of the referenced transfer agent. The Transaction Advice should be kept with your important documents as a record of your ownership of these securities. These Trust interests are transferable only as permitted under the MetLife Policyholder Trust. PLEASE READ THE IMPORTANT INFORMATION ON THE BACK OF THIS FORM AND IN THE PURCHASE AND SALE BROCHURE IBCR (REV 12-02) c us to 0000 t I a Use ONLY if a transaction is requested. Unless you wish to initiate a transaction, no action is required. PURCHASE INSTRUCTION Change of address: (See reverse side to SELL) 8063 6729 3407 Natalic M. Kintzer Tod Sherry Mellon Investor Services PO Box 382200 Pittsburgh PA 15250-8200 Sicnature rr aare ben ~,~„e~ Make check, in U.S. tlollars, payable to: MetLife Purchase Program Im111111m111i111111n11n1u11rlllrnlln111nr11u11m11 04 Please be sure this address appears in the envelope window for PURCHASES ONLY! 000101 102 806367293407 1 Amount Enclosed Minimum investment $250.00 (except as described in the purchase and sale brochure) Plwu; see the enclosed Brochure for important iutonnation on your right to withdraw irom the Trusl.