HomeMy WebLinkAbout12-05-12 (4) 1505610140
REV-1500 EX (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601
RESIDENT DECEDENT 2 1 1 2 0 8 0 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYY
1 5 9 1 8 1 3 0 7 0 6 3 0 2 0 1 2 1 1 3 0 1 9 1 5
Decedent's Last Name Suffix Decedent's Firs t Name MI
B A L T O S S E R W I N I F R E D B
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
OX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Ted>rphone Numb~~'
A D A M P B R I T C H E R 7 1 ~~ 6 7~ ]r,~3~'9
First line of address
2 2 0 M A R K E T
Second line of address
City or Post Office
N E W P O R T
Correspondent's a-mail address:
S T R E E T
State
P A
ZIP Code
~~ ~_
REd3T ILL U E ONLY~^
r....
~~ -. ~ ca
~
~ ~" ~
_ ~ -r~ -..~, .I
~..
',~
"~
DATE FILED
1 7 0 7 4
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 has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
,,.~
ADDRESS
1 AM NE MECHANICSBURG PA 17050
S PRE RER OTHER THAN REPRESENTATIVE D TE
L
ADDR
220 MARKET STREET NEWPORT PA 17074
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
1505610240
REV-1500 EX Decedent's Social Sec urity Num ber
Decedent's Name: WINIFRED B• BALTOSSER 1 5 9 1 8 1 3 0 7
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. •
2. Stocks and Bonds (Schedule B) ...................................... 2. 1 9 6 5 3 9. 5 0
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. 1 ~ 4 3 5 . 5 2
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. •
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
~
3 2
9
5
1
5
0
2
(Schedule G)
Separate Billing Requested ....... 7. .
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 5 4 3 4 9 0 . 0 4
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 2 2 4 9 4 . 6 8
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 5 ? ~ 8 • 7 7
11. Total Deductions (total Lines 9 and 10) ............................... 11. 2 8 2 7 3 . 4 5
12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 5 1 5 2 1 6 . 5 9
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 Tau (Line 12 minus Line 13) ...................... 14. 5 1 5 2 1 6 . 5 9
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 5 1 5 2 1 6. 5 9 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18.
19. TAX DUE .................. .......................... ... ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
0. 0 0
2 3 1 8 4. 7 5
0. 0 0
0. 0 0
2 3 1 8 4. 7 5
Side 2
1505610240 15056],0240 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 12 0801
DECEDENT'S NAME
WINIFRED B. BALTOSSER
STREET ADDRESS
337 MESSIAH CIRCLE
CITY
MECHANICSBURG STATE
PA ZIP
17055
Tax Payments and Credits:
~ • Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments 22,000.00
B. Discount 1,157.86
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) 23,157.86
(1) 23,184.75
(3)
(5)
(4)
0.00
Make check payable to: REGISTER OF WILLS, AGENT
26.89
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 : ................................................................. ..... ^
b. retain the right to designate who shall use the property transferred or its income; .......................... ..... ^
c. retain a reversionary interest; or ........................................................................................... ..... ^ 0
d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................................................................. ..... ^
3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .... ..... ^ Q
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ............................................................................................. ..... ^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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WINIFRED B. BALTOSSER 21 12 0801
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Edward Jones Investment Account #270-09525 with date of death value of 196,539.50. 196,539.50
See attached documentation from Edward Jones dated August 29, 2012.
TOTAL (Also enter on line 2, Recapitulation) ~ ~ 196,539.50
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX+ (11-10)
Pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT
PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
WINIFRED B. BALTOSSER 21 12 0801
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. Checking Account #5140343614 with date of death value of 2044.57 plus .02 accrued 2,044.59
interest. See attached letter from PNC Bank dated July 31, 2012.
2. Savings Account#5000839175 with date of death value of 3789.33 plus .04 accrued 3,789.37
interest. See attached letter from PNC Bank dated July 31, 2012.
3. Refund from Verizon 22.33
4. July benefit payment from SERS 712.43
5. Prepaid Burial Account through Bank of Landisburg with date of death value of 10,616.80
10616.80
6. Miscellaneous personal property 250.00
TOTAL (Also enter on Line 5, Recapitulation) I ~ 17,435.52
If more space is needed, insert additional sheets of paper of the same size
REV-1510 EX+ (08-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
WINIFRED B. BALTOSSER 21 12 080.1 ___ __ __ __
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. Lincoln National Life Insurance Annuity Account #95-9718943 329,515.02 100.00 329,515.02
with date of death value of 329515.02. See attached
documentation from Lincoln Financial Group dated 6/29/12.
TOTAL (Also enter on Line 7, Recapitulation) ~ ~ 329, 515.02
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
WINIFRED B. BALTOSSER 21 12 0801
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Nickel Funeral Home 9,132.78
B.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State ZIP
2, Attorney Fees: Allen E. Hench Law Office P.C
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
4.
5.
6.
7.
8.
9.
10.
11.
Street Address
City State
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
Estate Notice and Proof of Publication in Cumberland Law Journal
Estate Notice and Proof of Publication in The Sentinel
Filing Fee for Inheritance Tax Return
Filing Fee for Family Settlement Agreement
Miscellaneous and final probate
ZIP
12,000.00
520.50
75.00
221.40
25.00
20.00
500.00
TOTAL (Also enter on Line 9, Recapitulation) I a 22,494.68
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, ~ LIENS
ESTATE OF FILE NUMBER
WINIFRED B. BALTOSSER 21 12 0801
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Repayment of July benefit payment from SERS 712.43
2. Messiah Lifeways 4108.34 + 154.00 4,262.34
3. Capital Area Health Associates 100.00
4. Alert Pharmacy 176.51
5. Verizon 22.33 +5.16 27.49
6. Miscellaneous 500.00
TOTAL (Also enter on Line 10, Recapitulation) I ~ 5,778.77
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
Pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:
FILE NUMBER:
WINIFRE D B. BALTOSSER 21 12 0801
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).J
1. Donald S. Baltosser Lineal
1 Amity Lane 50% Residuary
Mechanicsburg, PA 17050
2. Joann H. Black Lineal
2800 NW 47th Terrace, Apt. 210 50% Residuary
Lauderdale Lakes, FL 33313
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
a~
~~.
;~~
,~y
,~
ALLEN E. HENCH
ATTORNEY AT LAW
220 MARKET ST.
NEWPORT, PA 17074
TEL: (717) 567-3139
FAX: (717) 567-3130
I, WINIFRED B. BALTOSSER, with an address of 337 Messiah Circle,
Mechanicsburg, PA 17055, being of sound mind, memory and understanding, do hereby
make, publish and declare this to be my Last Will and Testament, hereby revoking any
and all Wills by me heretofore made.
FIRST: I direct payment of the expenses of my last illness, funeral and burial
costs from my residuary Estate, as an expense of my Estate, as soon after my death as
conveniently maybe done. I note that Ihave apre-paid burial fund. and account
established for expenses covered thereby. All Federal, State and other death taxes
payable b?cails~ of r~~y death; with ~-esnec.t to the property forming my gross r/state for tax
purposes, whether or not passing under this Will, including any interest or penalty
imposed in connection with such tax, shall be considered a part of the administration of
my Estate and shall be paid from my residuary Estate without apportionment or right to
reimbursement.
SECOND: All the rest, residue and remainder of my estate, whether real,
personal or mixed, of which I shall die seized and possessed, and to which I may be
entitled at the time of my decease, and wheresoever the same maybe situate, including
my American Legacy investment account, or its successor, as well as all furniture,
household goods, and personal effects, I give, devise, and bequeath to my children,
DONALD S. BALTOSSER and JOANN H. BLACK, in equal shares.
In the event either fails to survive me, I direct that the share of the
deceased child, be given to his or her child (or children in equal shares).
. ~ .THIRD:.. In.addition.to alllpovvers._granted by law, I give. my Executors,. ,
hereunder, .the following powers, which maybe exercised without leave of court: ~ to
retain and io invest in all forms ofreal and personal property; to compromise claims anti
tv abdflClGi1 a.riy prv~i> y 'vViliC h l~ it iitti~ or ri~i 'v`al'u' c, if CiEviii~:~ a~,~,r~.,~iiiut~ tCv i~3y
Executors; to sell at public or private sale, to exchange, or to lease for any period of time,
any real or personal property, or interest therein, and to give option for sales or leases,
and to give a good deed of conveyance or bill of sale for the transfer thereof; to allocate
any property received or charge incurred to principal or income or partly to each, without
being obliged to apply the usual rules of Trust accounting; to distribute in cash or in kind
(according to the fair market value prevailing at the time of distribution) or partly in each.
The Executors shall also have the power to disclaim, in whole, or part, any and all
interests in property owned by me at the time of my death including those passing to me
by will, intestacy, contract, joint ownership, operation of law or otherwise.
FOURTH: I nominate, constitute and appoint my children, DONALD S.
BALTOSSER and JOANN iI. BLACK, as Co-Executors of this my Last Will and
Testament and my Estate. In the event either is unable or unwilling to serve, I direct that
the Other serve solely as Executor(tnx}. I fort her direct that r~~y Executors(tr~x} engage
the services of the Allen E. Hench Law Office to assist in the administration of this Estate
and as the legal counsel of my Estate and the Executors.
FIFTH: I direct that no Executor(trix) acting under this Will created thereby
shall be required to enter bond for the faithful performance of duties, in any jurisdiction.
IN WITNESS WHEREOF, I, the said WINNIFRED B. BALTOS~ER, have
hereunto set my hand and seal, to this my Last Will and Testament, this ~ day of
November, 2005.
WIl~TIFRE B. BALT SSER
ALLEN E. HENCH
ATTORNEY AT LAW
220 MARKET ST.
NEWPORT, PA 17074
TEL: (717) 567-3139
FAX: (717) 567-3130
The writing contained in this and the preceding sheet was signed and sealed by the above-named
WINIFRED B. BALTOSSER, and by her published and declared as and for her Last Will and Testament,
in the presence of us, wlo have hereunto subscribed our names as witnesses at her request, in her presence.
word:common:wills:Battosser, Winifred.will
%~aa~o-, //f i 7~ ~y
13 0 Edward Jrnes B~1
6'~ F bor
St Lour, M 0 6 3 04 3
314-F 15 2000
www edwa~~ne~.c~m
August 29, 2012
FACSIMILE (717) 567-3130
ALLEN E. HENCH LAW OFFICE, P.C. (717) 567-3139
Adam P. Britcher
220 Market Street
Newport, PA 17074
RE: RECEIPT OF AUTHORIZATION
Dear Adam P. Britcher:
EdwardJones
This letter will acknowledge receipt of the above referenced Authorization pertaining to:
Estate of Winifred B. Baltosser
Case No: N/A
Enclosed please find the following:
1. Estate Valuation Report & Account Documents
2. Affidavit of Records
We trust that presentation of the requested materials will be sufficient.
If you have any questions, please direct your written correspondence to the Subpoena Team
via facsimile at (314) 515-6101 or via US Mail to the above address. If you need immediate
assistance, please contact me direct at (3 i 4) 5 i 5-b224.
Thank yo
A3~thony Whitehead
Subpoena Specialist
Enclosures
C ~
~ ~
~ ~
C
. C
oQ ~ v ~
~~
~ ~,
~ ~
~
~`
~~
~_
O Cn
y i--t
N ~
~
~
••
D
a. ~
~
c~
~-,
~ ~
d ,°
~
(n
~_-~
~
o
y
v
I
• •
-~
o
f'~
~"r
~ _
O
~
o~
m
~ m
n
~,
~
~' ~
~.
~,
~
~,
N
o ~
Z
-n V
o a
~. -v
D ~ ~
~ a ~ ~' m
N O
o~ y
d ~;
~
o ~
~ o
~ ~
~
.-~- W
D
~, ~
d O
~ ~
(D „H," ~
~ r
O
O ~
~ (~D
O "D
°'
v ~
m
N ~
~ `~
(D N
C')
~_ ~
C'1 Q
N. C1 T
N
C ~
v ~
~ ~
~ O
~ .a
O
G
Q
GD
d
X
O
GD
Vq
v
d
d
G
[~~
(D
3
~ ~
~
a
z
n
m
z ~
N
m ~ o
~
~
N
O `
Z O C
~, ~.
m
N ~
'i ~
~
3
~
z
to o
8ooz aav v-vz9e-ado
n ~ n a a
o~n orrt
Q. n ~ w N r n C N
r.. r v ...i v v ~ a
•
~ M
~ fi O'' f.,. O
o m a ~ ~ v
t-n n ro rs w m
•• a
~ ~ K N r
va c
t ~ ~ Y a
c n
c t
S~ ca w r N
c
a Y• o 0 o rn m ••
,.q rt to o 0 0
N o 0 o a~
(A C (D
rt a '~ H
~ O O v '~1 ('~
~ rn H Y• O H
~ O O v ~] t")
a
H Y• H H
~ O O v ~J ~
~
Y• '~
~ v !1] Oo Ol 01
N• r O
rt
\ \ v ~ C
ct rn
\ \ v ~ H
ct rn H
\ \ v ~ ~ n
(2 (!1 rD N
to Q \\\
N W W
o C rt •• O N•• a O N•• a H O N•• a i-t x f2 C JO O
'~ art N t0 J H N lfl ',~ (i] N lG ',~ ~. rs hi \ \ \
to ct
W ~ o \\Nn ;v
NN
~
'• o \\on 7d
' o \\on Z
=i a.-.
r
•
oa to
\ !-
F
~
oo\a RS
\ N~30~F
•O
oo\ar r
\ NNE] W t
oo\aE r ~
r
~ 000
b '-3 fA r rrrrH O ~
rrOr ~ E--1---Nr (!~ W NNN
rfll ~ NNE v W NNW CT1 NN(n -C x O
a ct+ rt N N t~• N N Y• d N N F•6•
Uf O O O~'~J O O~ O O O~
(D b a r O (D H I--` O (D F~ O (D
N tJ1 U! ~ N J Ul N J Ul
n Y• f' ~ ~
o n m rt '~ H rt ',~ H ('~ rt ~ H ('~
~Y•a. o a~n o a~ o ~
O
`~ ~ ~
a ~q b' o m
~ o m t~ o m bd
~
A
r cn
c ~ rw ~ ow ~ ~ oa n
''G L3] W r (•~ W Oo (~ H W J (1 O
~~ a
t o \rt
• o \rt r
• o \rt 9d
d
p, c
~
~'
u a \
N r Y
~ ~', \
N o Y
W C \
N ~ o
•
cn C Z
~
a n o \ (D bd o ~
\ fD o \ (D O
ft U1 Q• N N 'jr' r N F-+ N H
A. N ov N ovtn N ov tsi
Hc, wa.-. wa wa to
C.1 `.~' O (.Ti cr N ~1 cr .-. N ft
o n e a N a r a
~ fD 01 N Cl J C1 O
(D U! dP W W al
N Oo r O N ~
~
am° ~ °~ i
~
v ~ x
~ zz
C (A C
v N bd W
ama ro -- cn ~
cr r a -- \
Y• Fs C W ~
a tD
r
~ C c ~
Y• w r
cn m o
m ~ ~
a
~
m o
•t
-gy
n r r~ r r ~
tD C ~~o ~o~ oo \
n Y• c.r~ to ~ a~ o o bd
a o ~ Y.
rt p (p wo Ito 0o p.
ft J J N F' iA W
1--~ (D J A (J1 Oo ~ F-~
i J N O CT1 W Cl N
Goc'1'H o
0 00 otn
ISO
~ "
~ ~ ~~
!1
f 7. 7c
~ n cr cr rt rt cr bd
~
~ ~m
i
nro r,
cn n O to ~ o u. a
~ C ri Cn ~ o G ~
~ rs rt ~,
cn a N ~ o rt a
(] $ N N W ~ O
~ ~C a w -~ J (D t:Z
N
y
a O O N ft O
C p n o o to m fi C~
• n
C a
m
o
oC i
c c
r
~~r n zro m
m
' a ~~
°
~
m t
-~Q. n
~
A.
W N ~ ~
..
N N rn H r
s H
O~ N tJ1 lD J I--~ ~ H
~
~
t
'r W O
f
!
• UI H• O !-~ W O r M (D (~ x
~Il `J O l0 W ~ fD •• O H
am na
~
~ rtrl
c
d
HfA rn ••cct••v
~' N
O
a r r r lD n N
•
N W
~ 'p' Oo U7
O (D c,f. O W M O C
~ a N ~ o w ~ a
o
o0
a
O u
i v
~' r w w w a, ~o • • c~ co to
pu ~ to a to vi
C ~ ~ W o N~
N
~
~
D a
( t
n
t
n
rt
a
cr
m
C
a
r
a
rt
w
0
~d d roCd
n ~ • n a a
C N v rn cn ~ a N
v v v
n a to ct o
ct N• o cn rn ~• ~+-
m ~ a •
o ~ d
~
rn rs ro n ~ m
•• a m d a
tr! K to d a ct
N H ~ ~- to act ~'
cr ~' o cr o c•r m ..
a N• o 0 o m ••
,s~ ct u, 0 0 0
G cu o 0 0
m n o 0 0
f!1 C(D H OOd~]ro H OOd~1G1 H OOd~47 dU2 Oodl01
~•t a 'zf O J a~ H w 7d ~ v a~ H F•~• ti] O J rn H F•+• CrJ (D (D \ \ \
W N O ct \\ d~ C. ct \\ d~ c'r \\ d O N n N W W
O d ~"'1 •• O N •• a d •• O N •• a C7 •• O N •• a (7 n C ~l O O
".3 p1 ft N lC J L=J N lG ~
~ N lC J hi f'S \ \ \
(A fr O \\ O n 'Yi O \\ O n O \\ O n F'• N• N N N
F'•$ w NNW'r+•~3 cs NNgW•H ~. NNF-~F~•H ~ f•r 000
O a \ oo\a H \ oo\a H \ oo\a H c~r~C ~~~
p
N
~ ~~ ~~ ~~ • NNN
l
1
--~U (l~ NNN (J~ NNO CJ~ NN(I1 0
N 'Lf \ \H \ \H \ \H ~
a a+rs N NF'•~ N NWH N NF•i•H
f!! O O O~ H O O~ '~ O O~ 'lam
(D ro p. H-- o cD Z N o (D ~3 ~-•~ o (D H
~"'! C N J fA t-~ N ~1 Uf Ci
] N ~P Ul Cr1
~d
~
~N•p. o a~z o ago o ~o
cr ~ ct ct (~ ct ct H ct ct H
a w tr' o •• m o •• ca t~ o •• m t~
n ~C G1 rS H G1 rt cn C1 rs to
crtn \ oa z \ oa \ oa
~C t~7 w w n H w oo fi ~. w ~ n -.
t~ rn p. o \ fi t~ o \ cr w o \ c•r w
~
a N Cf1 C N cn C, lfl N cn Q lD
~
a n o \(D O o \(D rn o \m rn
F•s Ul (1. F•~ N H F•-' N 01 F-` N
Cl
a N ~ N H N '
N
HC~ Wa Na N
3
O n N J WW
~
g a J a o~ a
i~
Ul OO w N rn
C I...d O
amd cn ~ ~ ~c
~ a t~ ~•
a v x
a m ro
n a ~ ~
o m a m ~
~ C rr x'
N• H• N
v~ a o
m ~ ~
~acn r
•
n
rn rr rN r ~
m C o0 00 0~ \
n F,• 00 00 0~ bd
a o n ~•
ct p tD o 0 0 0 0 0o p.
~t N O l~ ~U F-` ~]
1-+ (D N O t--' W J N
I '.3' W O (.T1 ~] ~ (J1
o~ct'y o0 otn o0
o ~
•
~ ~\ ~~ ~~
~K d
,
a ~
N
j
(
j~ r r R
.
o ~ ~
~ G n o G
v F! c-r to
qo u, ~ o, ~c ~ \
~ o o
~
~ o , r
u
s t~
• A. N
h ~
N• n n 7d a
~ ~ zo m
~va a
~ a ~
~
fD fD F
-'~• c
'r M
to
~
O O C Ol Oo (J1 O ~
~ ~ ~
~
v N N• C1 N ~O F-~ F"h ID f1 'Yi
to J 00 ~ fD
• •
~
Ctn ~
~ ~
H(D do
~
~
HM I-'n C f't
d
M
~ O
p
1 ~ F•' ~ (D h'S NW
NW
~C ct o ls~ to N• J ct O J
cr oN•hho
~ C o o ~ k I tD I H
(!1
~ I--' ,p W N lC
N to f/1
a • cn a cn cn
,p 00 ,p N f-' f'r N Cr1
N a 01 ~ oo to N ;3' to qd
LJ
a
m
a
N
C
a
ct
~•
0
•
O N rt
n C
Q. n ~ o ~c o t
D
C F•, v v v v ~ a
n a to cr O
ct F+• I O (/~ W N• M
m ~a ~•~
o c~
~' ~ a m W
a
~ w N v
°° K to a
N
~
in H N ~ N c
r
c-r ~ ~ rr (p ..
a w w cn f-- o m
,.q ct to N O ~C. O
C (D W C1 l0 O
U! CN O'~'(/~ n ~ 0,.'~f7 W ~1 O~(7
~ H OOd~]~
J
• dV]
m m 0~a101
\\\
ctaro
N• N o a,~ ~c
\ rt ~ ~
~ a,G r
\ c•r o ~
o a,~ r
\ ~* a
rr o,Hr
\ \ ty ~ n to n N w w
O C !•s NC bCI H p. NC .b ¢. NC b ~d •• ON•• a H f1 C JOO
~a~t ~at~l
' H
b Ica
~
~
b Boa
~ H N~c ~~ nn
W H• \\\
N N N
(~ ft
F+• ~ \ F-
z
N ~ CZ \ !-
N 1
d ,
c1 \ 1--
N ~ O
01 \ \ O n
N N W W z ro rr O O O
O a o~9H n o-~7 n o~ \ oo\a fi~ ~~~
''~ ".1 N I--` C 27r Za'' f'S t-~ C F•t I--' C O F••~ F•~ t-` N C F+• N N N
N~! NJ H O G NC ~ C NC ;~ I--~ NNO H O
N ro Q. ~
y a ¢. a
~' Q. H \ \ H H
•r ~
~ ~?+O tv Y ~ x O o~
m ro R. a a ..
~
N
° ~
~' ~' ~
~~•~ o ~ z
~ N
Q '~ 7d '~ ~ `~ o o ~ ~ con
•
. o o w o ~ ~ N
w w ts' t
c ~ t
c c
t o H
a o
fi
~ ¢. ~ ~ ~ w ~ n ~
r•C
S•C ~ ~•C .•. \ o N• co
a~°ra z ~ z z ° o ~mN
s
Q• ~ N ~
H ~-1 d .D d
v d ~ W a
~
o ~ o o ~ am
`~ a
o n ~ ~ ~ ~ c
,
~ (~ ..~ O ~ ... O dl O
~ ~ ~. ~. v
~'
ro v ~ ~ ~
Coo
a X X W
G t
il C
\
m y
o m a
~ C fi 7s'
N• N• w
cn m o
m ~ ~
~
• ~ m ~
~--- ~---
W
ct
~
~ o ~ o o
~ ~''
t
c o
o
~tD o 0 0 of
I~ o 0 0 ~n o
Qo ct y o o O O o
oOMF'•
~ fS N
, ~
N
j
p~ r R
.
~
,p. C Ft O N O C ~
J f'S Cr N
cn a ~ J ~ cn rt a
0 o w N p
~~ N o .
qd m o 0 0 ~ ~ \
0 o an
° o t ~
N• Q. w
~ n° w
N•nc
i ~
n~ ro m
~ z
roa
vrfi NA ~
o
~
o . c
t r
t,
t•R.
wc ~ m N ..
O~ F-+ N O ~ n H
N t't N O
•
• M N
y ~ ~ lG W O H
N
am ~
cna~
~ •
H m N n •• C~ •• L7
M (D
a
N
tD Fi
N ~7d
N F'•
t•r O F+• Fh 0
~
C ~ w ~ o a
o O
p
, ~ ~ o
o i d
~• N W Cl F•~ N tp • • N tp t!~
cn a cn ~
C '
(
p a1 (T~ O N V7 U7 N "r.f
(l1 y0
ct
a
fi
m
a
N
G
a
rt
w
0
''d v
t•s ~•
°n. ~
r+ E'•d
~ a
,* ~.
o m
ron
vii H
ct ~
a r•
'~m~'
m n
fiaro
~•I~o
O G ~"S
~ ~ `~
~• ~
o a
N ~ ~
m 'if
a ~+ n
~ o
m ro Q.
i-s C
~ N• n
~ ~• a
fi ~
a w rs•
~ ~~
~ ~
`* a
n ~ a
a
H C.~
C.~ J O
o n ~
G m
m cn
N
ro t7
C a•~ o
a m v
~ y C
a m a
cr N
~• t•s G
o m a
p C ct
w N•
cn m o
m ~ ~
a cn
W I--~ m
~ ~C
n N•
a o ~
cr ~ m
~r
N (D
I O
0o ct H
00 ~'
o~ ro N•
I O m
~n
~ ~
~a m
I n 'zf
cn n o
~ C ~•S
~ rt tt
cn a
~ ~
~~ a
7d N
m a
C ~ (~
a/•aa
~ ~
~• ~ ~
~ 'v a
~' m m
w cr p.
o~ N
~, N.
N G
. ~
H Ul
~'' a
o ~
G a
~~
a~
m a
ro
a
m
y roCv
o n a a
a o m
n
n a
I-~ ct -- m a
a v, cr o
~N o ~ u, N•ro
~ •
ynC a ~v
~
°
~ a W
~ N m va
~ ~'
Nam ~ a ~~
.. .. .. ct (p ..
0o m ..
~ ~ . .
~ a,
O° n °
G m~ ~~~
v
,
x z
~ n ~ ct H to n N w w
Ol I.3 N G W C'h (~ G ~1 0 0
~Z~ •
sv ~ ~ -ro
~ o00
i-~ O ~J H d f~'•C I--` I--~ 1--~
y
G • N N N
N ~
N'
.3' ~
a y ~
o t~
H, .-.
a od
o u, v
rn
w ~ d
0 0
` ~
ro a
~
~c tr
-~ -,
cn o0
o d o
01 '~ to
b F-'
N ~ O
l0 ~.
N b
~ w x
N N•
~ ~
'
r
E
\
w d
b
• F.,-
~ a
0
0
O
ct
~~
~. m
N u• a
W G ~
N
~ cr a
~ ~ ~
o m Q..
o ~~
o ct o
o to n l~
v
n a
r 7~
~
n zro m
cc v, m • -
w a, rt NO~c~iH
~ w From ~ z
F-+ W m • • O H
(/~ C ~
~'
a na~~
°
r
u i
o
~ N (~ •• G ct •• d
N
m
lG m r•i N W
N
•
rn w N• ~ ct o ~
ct o F+• ro o
~ 0
W W OUl 07
0
~ ~ ~•• m you,
. cn a cn v~
Ct1 CD N F-+ C'r N Cr1
O ~ V1 N ~' tJ1 '~S'1
L=J
a
r•r
m
C
a
G
a
rr
~•
0
~~ ~~ ~~
.~tl~ V ~? ~. ~'~'' '~
.~,~ ~ .:~
~a..Cir~9'i .~~ ~'aT'1~L'~.1~I'; ~S~
~~3~i ~'~r~,i'1~:~~ ~I
.4~;: ~~-~'i~t.r~?~"c~ $ L~~~~tc,{~~ =mar
1 J ` L /
~", ~~.;;
~~1 ""c'S~.)ti?I1S~: r"~ :4'i)1T I'~~lli''~t `is)~ ?~~..1;? !'1~ ~+'~~h 4.~.~Q_~~_i ~~~~.~~iT~S::'."_~ ~:t~?a .~'3C° 4i~_~~~~?Il~~I' I~C:~~:r~~. ~.~'r~ 1~~, 'U-J..
r~c~urt~s ~.'s.~~t.3~'~' ~.~~: fo' lnaE-~i~.~.
~~~~~~~~ :~.~~~~~~a~~
~~~~~uT~t ~ ~ _~4~3~~~~ ~-~
.~~~L3 ~~rxi~nr.~: ~; ~,C~=~r°1.:~7 ~t ~~ f:~~: ~~:cz~~.~t3 ur~~.r~~t
~.:i~..C?"~~~ t~~x6~ t71.!{77 ~.~~{~.~~ ..~7i't:~ ~)t~ ~E:),~~tl~~? ~ ().~~<1 `~i1_%
~~"~T~~S r~l.Ci:~~~3Yt
~a~.~t~~.~~1~€ ~x ~Ol'~l~F~~~1iY,
~~~I..~:~~~.: 0 i'•x U~'~ ~$
t_~~;~b~Ys~Z~c~_ )~-'1 l;'1~~ ~'
Ma::~t' tjtT_C T1;~lt ~2~1'i C)l~lt::[; ~.~I'~~~"x~ ~ t~~~~~ ±?~ {~~i~1:~1 h%i1~sTt;:t':i I~yI t£~j>~:?-~i~.:X{r~.~: 1111?., 1.;:.~ 5. : ~.~i. l.~s.~~.c,.tl-t~, ~.,~?'i
~~~r~~Y~s~:;. ~~~~ r~~i ~~t pz~~~:~~~~ ~~~€~~ ~.r~i~~~;~.~ !~'~i~~~~:~~Ai-~r~ ~~;:~ ~5r~?°~~[~tE' ~C~.LE'.~k~~'BAC4. Is• ~~~3ti s~~~~~ xxa~~;~si~t4~i~c.~ u.~i.t~~
efIib' l`1a r~l:;;ir l.al'.'~.S, ~J~i;:3..7C l.~i~: 1 -SJCill'~~''v1_-~r~'~~..' 1-b~~~- ~tl'~ ~:~..'~;~) i ~„)~- `~~'..~~F ~ti y+J'i1t1T ~";'t3! ~`_~~_ L~i~Tt~s ~?I•iuT!L:F~1
~. ~ i
.~r~~l1~+'i" !'~~~~.~
~ ~ ~ ~~~~
d
J - i ~~~ ~ ~• ~ ESTABLISHED 1903
P.O. BOX 119 LA.N~ ;-~!~~E3U'>.. ~ ' r~ ~ ~~~;~
Ban k records indicate the following account
balances on 6/30/ 12 for
Baltosser, Winifred B
337 Messiah Circle
Mechanicsburg PA 17055
Balance
Acct Sole Jt Acct Account Prior to Interest Accrued
O ened Ownership With Number Type Interest Bearing Interest
08/30/99 Irrevocable Burial Fund with 700008580 CD 10,509.66 Yes 107.14
Nickel Funera Home
BY
l_ANC)! Si3l~!<~~ - 71! -189-, ~21?~
SS # 159®18-1307
-,r~~~~ - ,r: .
,~,v - ~'t_ _ ..
'f
Fri ~~.I~',i ..'~r,..~',;'
';i-i:i.~1/' f11~IC f1n I C ~O~ 0!'11
m~~1~~.n ~~ ac
~ ~
Financial Graup~
The Lincoln Nation~-t Lila Insurance Company AnnU.xty' Quat'tCrly Statement
Fo gox23g4t 2nd Quarter 2Q12
Fort Wayne, IN46801-2.348 •
:-'-'ii:: ?:_:-:i :-:: :::: -: :.._ .~ .... . ..: ...: .: ':.::::v:: i:.; :....:.~ -.z-:,:•. ;.... ..,.~ .. ......... .. .. ..... -.~: n:••: •: .ter:::::_: ::.v.~ •:.: ~ ~. .•. 7 ~ ':~::: • :~•"•.::'
:.:• :.....:.................:..........:.:.:..::.:........:::::::•:.•:::•:.:~?r. .. ~ ~5fc •~~i'i . ~ ~ ~':;>'.~.=;--;:>:x.:.,... Y'~[~nll~ .C'r1a~~~»lYft~!3.,3Q'R.....
Gontrxct: Ow~aer. WINII~RED M BALTC)SSER S7iareludder`s Adelg: 95-97 L8943 Representati~vc: TH4_ntIAS D KTMMETT
Annuitant: WIlVIFRI~ M BALTOSSER Plan Type: Non-Quzlilxed Brokurl~caler: EDWARD D JC3NFS & CO
Contraci ~11`ecti~t°c+ Date: .i.l'16!2001 I)"you have any questions rogarding this stxtemc:nt,
please call Lincoln Finina`ial Group xt 8d0~-443-8137
tn• Yri sit our websito at rxnvav.Ameri.canLegacy.com.
~: ~~ ::
Vxlne 313(111.2 ~14t Aclisity Gain / Lf-ss Value G1z4/12
5342,755.18 _ (S?,SOO.dO) ($5,740_l.G) $328,51.5.02
...........
.: "r~.:
..ciistt
~:B~n~iit
~Z~b Lii~r
A living benefit feat<tiie bas not been elestad For your a;ontmct, xlthaugh some products al.o not allotiv these features. Flea. contaict your R~prescntiative vrith
any questions.
•~' ~rl3ie~.
~~s~t~
1r
A.S of 6129/12, the loath benefit for the owner wi-s the greater of $13G,2Gti37 oz the account value. The actual benefit amount m~~.y be ttiore or lass depending
on tha date of death, market fluctuations, premium payments and. partial rx*it6.drt~svals. For detailed infnrmnticm rogarcling your death benefit, ploase refzr to
yfNirconiract or ptti~spectus_
Tuatl Name Asset Class* Percentage Aronunt VAlnc
~ Asset Ailoc Asset Allocation 79_S °r° $2G3,011,48
:~ Ciov't/AAA Sec Bond. 20~ % $6fr,503.54
• Fercentagac less than 1°fa ratty not be represented an the pie chart. ]h:o to rounding, tha percentaga:s shown ttiay not be ualiu-1 t~o .I.UU~Iw
• *A.sse~t Class is detennincd b"S' Lincoln National Life Insurance Wmpany <xotl is nit considered. investment xcivice.
..,...•.
.•,,4 ,rte' .
.. .. .... ..... .... .. .. .. ........ .... ~ ' ~ t7'Nw.YF..
...... ................................,.,..... ......................... . Yn~l~' ~. ~A7712~h1~%.
1~1~11~Y~~~vd ~vr1.9priifiTwGLiri•
C'urxeat Quarter '~1'a:ar tm Datt: 1 Year
(:1.70 %j b.31 "/0 3.53 "/°
:i Year S Year 10 '~'esar
$?(y 4/a 0.74 % 721
• Your Perfvrniance Suraitiary is the personal rate of r~ura that represents the indivydual pt-tformance o'Fthe investment(sj you have selecfod. for yaur
pa>rtfolio. The calculation includes activity in your account (such as Wntrt`buiions, exchanges among investment optians, etc.) using daily share price in effact
when the activity occurred. I3ecausc3 tha timing of your investments and withdrawals will vary, your persanal investment results will ganarally not be the samo
as the investment relums quoted for the individual funds yfxt ha1~e chosen. Foe'Farmance data represents past perfarraance. Fast perForniance does not
guarantee :future results.
• perFormanca figures clay not •reflect sales chi oes.
Ili ncoln Financial Crroup is the marketing Warne for Lincoln National Corporation and its uFfilixtes.
8 2012 The Lincoln Natianal Life Insurance Cfympxny.
4S-471894 WINfFRED M BAL' TOSSER
dd0000() Q01U,T 3G188I KIMMETT, THC)MA~S D 7702 330
aooa2a ana
Continued on back
Ytiit~.if~tcetstianr ~~i-~)il!~t~~~a~t1a~
Gross Conttibatipns Net Ct~ntriLations Withdrawals GautnlLoss
X219,366 ~7 ~. X211,805.50 ~83,1U0.0U $2U0,809.52
* Gross contributions isthe amount sent to Lincoln; net contributions is the gross contrih~utians less the sales charge.
+ Cxain/I.oss :nay t~:znclerstated. if you.* contact ±s su~jeet. to adrrrini~satitTe fa,s.
_ := ~:<:~'~ lid>~o[uii ~ ' :.
na '.
'. ~~ ~:Viituc .a
As of 3/30112 11s of 6129!12
. ~ Number Ni~mbcr
Ftmd Name i3nit Vaine o£ilnits Vainc Net: Activity GabslLass Unit Valn~ of l'~lllt<S VaIxL'
Asset A11oc 1.76676fi 15G,03i.~.7U+~9 5275,6[15.65 {$5,585.74) (~G,688.43) 1.724168 172,543.9c~74 ~263,41I.48
Gor'4JAAA Sec; 1..817583 36,9UU.3939 .~(i7,069.53 (51.,514?6 j $94f1?7 1.K4354.5 36,073.7295 $66,5U3.54
~::;'
'r ~!
.a.
~`•~'~.
it
Date Actixlty rand Name A~niinnt IInit Valne Ntcmber. E-.t [Jnits
4~Si l2 Airtomxti.c vvithdrdwal ($2,5(l4.()U )
Asset; Allot {$2,008.05 j
1..755664 ~
(:1.,143.7579 )
Gov't~A1~A Sic {5491.95) 1.81.8846 (270.4737
5/4112 Ai~tomati.c zvithdntwal. {52,:~U4.00 )
Asset Allvc ($2,000.59)
1.736898
(1,151.81.7#1 }
Cav'tIAAA Sec ($449.•4:[) 1.8335()8 (272.3795 )
6/5i 12 Automatic witlticlrawal {$2,540•(){3 )
Asset Allot 01,977.1.())
1.6473c}5
{1,204.1372 j
t;ivv'i:~AAA Sec: 0522.9()) 1..842422 1283.8112 )
`~'.
:i~ ~'u>lur~A.
~Il
~o
As of G/29112, your contrnct instructions show [,.hat additional conti~iLmtion9 will he allocated acc:orciing to these perccmtages:
110% Asset Allot: 20°io Gov'tI11AA Sea
i,'~ ~N ~
iiid:~s~trir''ir~ .
It
inf. f~tion~`a
4
+Acc~'ss to your contract information is available online. Register at wwr~~ Ameri.car-Legacy.com today. 'T'his document and many others can be react online
by signing up f-or eDelivery. I•Ielp make a positive enviraninent:at impact by signing rtp today.
•This confirmation is prepared by The Linu~ln National Life Insurance Company or one of its Lifo Insurance cr~mpany afIitial:es pursuant to its agreement with
the principal unclen~Yitar of the insurance srcw•ities ticsctil~ct herein, for the l~na~t oFthe selling broker stealer,
+Notify Linraln promptly ifinformat"son contained in. this document is not accurate. please Feel free tore-confrrn any oral communication in writing to further
;protect your rigb.>~s.
+lnterast ratzs and crediting methodology t~cili be prnvid~sci to you ~spon request and free of charge.
+For your upclatecl accouat values and fund peiFor~nance infosrnatitm, go to wc~'vc.Amaiycant.~eg~~.cy.ccmi.
Lincoln Financial Groug is Lhv marketing Warne fcyr Lincoln National Corgoratioa and. its af~ili:rtes.
~ 2032 The Lincoln National Life Tnsur<~snco Company.
9'5-971894.3 V4'TNIFRF~ M IiAJ~TDSSER
0000040 QO:lU3T 3fi1881 ICIMItRETT, TZiC}NL4S D 7702 330