HomeMy WebLinkAbout11-30-12 (2)1505610140
-' REV-1500 ~` (°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po Box 28oso1 INHERITANCE TAX RETURN 2 1 1 2 0 8 6 6
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW
1 7 9 1 0 3 9 3 1 0 7 1 7 2 0 1 2 0 2 2 5 1 9 1 9
Decedent's Last Name
Z U L L I N G E R
Suffix Decedent's First Name
E D I T H
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's Social Security Number
FILL INAPPROPRIATE OVALS BELOW
0 1. Original Return
4. Limited Estate
Q 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
Spouse's First Name
MI
C
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Trust)
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 S~I OULD BE DIRECTED T0:
Name DaytZye Telephone~lmb~ ~
JOEL R. ZULLI NGER 7~~ 2F~4~~29
W ~ 4:, -
_ _ c_[n~
c~R OF WILLS H9E LY ~,
"r- Gt S'~"t fT1
D ~ ~ ~ ~ ~
First line of address ~ ~ ~ ~ ~
o ~ ~ =n -n -n
1 4 NORTH MAI N STREET j'"°~"~' ~ ~""`'~
c ~- n
Second line of address ~ -t ~ ~
DATE FILED
City or Post Office State ZIP Code - - - - --J
C H A M B E R S B U R G P A 1 7 2 0 1
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the Lest of my knowledge and belief,
it is [rue, correct and wmplete. 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 RF~URN ~ ~ ` DATA ~
ADDRESS
2649 ROXBURY ROAD
SIGM71'TURE OF PAEPARER.drH
MAIN SyREET, SUITEJL00 CHAMBE
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610140
BURG PA 1
D T
SBURG PA 1
1505610140
1
'_w. ,1
.!
J 1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: EDITH C. ZULLINGER 1 7 9 1 0 3 9 3 1
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1.
2. Stocks and Bonds (Schedule B) ...................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .......... . ............... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ....... 7.
8. Total Gross Assets (total Lines 1 through 7) ........................... 8.
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10.
11. Total Deductions (total Lines 9 and 10) ............................... 11.
12.
13.
14. Net Value of Estate (Line 8 minus Line 11) .....................
Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...............
Net Value Subject to Tax (Line 12 minus Line 13) ............... .....
.....
..... .. 12.
.. 13.
.. 14.
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 1 3 3 2 1 3. 8 2 1s.
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 , Q 0 18.
19. TAX DUE ...................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
5 6 2 6 2, 1 1
8 6 0 6 6, 5 2
1 4 2 3 2 8, 6 3
6 4 1 0. 0 0
2 7 0 4. 8 1
9 1 1 4. 8 1
1 3 3 2 1 3. 8 2
1 3 3 2 1 3. 8 2
0. 0 0
5 9 9 4, 6 2
0. 0 0
0. 0 0
5 9 9 4. 6 2
Side 2
1505610240 1505610240
REV-1500 EX Page 3
File Number
ueceaent's complete Aaaress:
DECEDENTS NAME
EDITH_C. ZULLINGER _ _ _
- - -
S7REETADDRESS
129 Walnut. Bottom Road_ _ __
CITY
GI IG VVVV
STATE ZIP
PA 17257
Tax Payments and Credits:
t• Tax Due (Page 2, Line 19)
2. CrediislPayments
A. Prior Payments 5,557.50
B. Discount 292.50
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.
(1) 5,994.62
Total Credits (A + B) (2) 5, 850.00
(3)
(4) 0.00
(5) 144.62
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ...................................................................... ^ ^X
b. retain the right to designate who shall use the property transferred or its income : ............................... ^
c, retain a reversionary interest; or ................................................................................................ ^
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 "intrust for" or payable-upontieath bank acx;ount or security at his or her death? ......... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? .................................................................................................. ~ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE 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 p2 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 decedents 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-1508 EX+ (11-10)
Pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
CASH, BANK DEPOSITS, 8 MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
EDITH C. ZULLINGER 21 12 0866
Include the proceeds of litigation and the date the proceeds were received by the estate.
All properly jolnty owned with right of survNorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Checking Accouint #97590126, M8~T Bank 459.06
2. Checking Account #98171828, M&T Bank 51,696.55
3. Elmcroft, refund of nursing care services 2,072.00
4. Magnolias of Chambersburg, refund of nursing care services 2,016.30
5. Highmark, refund 18.20
TOTAL (Also enter on Line 5, Recapitulation) I S
If more space is needed, insert additional sheets of paper of the same size
REV-1510 EX+ (DB-09)
Pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
EDITH C. ZULLINGER 21 12 0866
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, THEIRRELATIDNSHIPTODECEDENfAND
THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
°k OFDECD'S
INTEREST
EXCLUSION
(IFAPPLICABLD
TAXABLE
VALUE
1. Contract #XP221529, Western National, jointly owned by
decedent and her son, Paul E. Zullinger, as shown by copy
of contract attached; value on date of death $172,133.04, as
shown on date of death valuation letter from Western .172,133.04 50.00 86,066.52
National; beneficiary of decedent's interest in contract is her
son, Paul E. Zullinger
TOTAL (Also enter on Line 7, Reca'itulation) $ 86,066.52
If more space is needed, usa 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
EDITH C. ZULLINGER 21 12 0866
Decedents debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. Attorney Fees: Joel R. Zullinger 6,000.00
3, Famiy Exemption: (If decedents address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: JCS fee - 23.50; automation 5.00; short certificates 12.00; will 15.00; 205.50
letters 90.00; additional probate fee 45.00; filing return 15.00
5 Aooountant Fees:
6. Tax Return Preparer Fees:
7. Cumberland Law Journal, advertise letters 75.00
8. News-Chronicle, advertise letters 129.50
9.
TOTAL (Also enter on Line 9, Recapitulation) I E 6,410.00
li more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12.08)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
wHERIrnNCErnxREruRN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
EDITH C. ZULLINGER 21 12 0866
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. Shippensburg Area EMS, ambulance transport 500.00
2. Borough of Chambersburg, ambulance transport 375.00
3. Care First Pharmacy, prescriptions 127.63
4. Fayetteville Volunteer Fire Company, ambulance transport 99.00
5. Summit Physician Services, medical services 36.10
6. Chambersburg Hospital, medical services 195.00
7. WSEMS-Chambersburg ALS, ambulance transport 1,005.74
8. Chambersburg Imaging, medical services 194.00
9. Spartan Pharmacy, prescriptions
55.82
10. WSEMS-Chambersburg ALS, ambulance transport 116.52
TOTAL (Also enter on Line 10, Recapitulation) I $ 2 704 81
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:
EDITH C. ZULLINGER ~~ ~~ ns;aa
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 [Indude auto' htspousal distributions and transfers under
Sec. 91 f6 (a) (1.2).]
1. Pauline L. Snake, 300 West Main Streeet, Walnut Bottom, Lineal
PA 17257 1/4 of residue
2. Paul E. Zullinger, 2649 Roxbury Road, Shippensburg, PA Lineal
17257 1/4 of residue
3. Janet I. Jones, 336 Horst Avenue, Chambersburg, PA 17201 Lineal
1/4 of residue
4. Patricia Lautsbaugh, survivor of Norma Jean Ross Lineal
1811 Wood Duck Drive, Chambersburg, PA 17201 1/20 of residue
5. Bonnie Davis, survivor of Norma Jean Ross Lineal
128 Park Avenue, Chambersburg, PA 17201 1/20 of residue
6. David Ross, survivor of Norma Jean Ross Lineal
59 Monarch Drive, Carlisle, PA 17013 1/20 of residue
7. Steven Ross, survivor of Norma Jean Ross Lineal
467 Heintrelman Avenue, Chambersburg, PA 17201 1/20 of residue
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 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 15 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. S
IT more space Is neetletl, use atltlltional sheets oT paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
EDITH C. ZULLINGER
Decedent's Name
Page 1
21 12 0866
File Number
Schedule J -Beneficiaries -1
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee s) AMOUNT OR SHARE
OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outrights usal distributions and transfers under
~
Sec. 9116 (a
1.2).]
8. John Ross, survivor of Norma Jean Ross Lineal
10097 McCreary Road, Shippensburg, PA 17257 1/20 of residue
Z~I? AUG -9 a~ is o3
v1.~_.'
LAST WILL AND TESTAMENT QRp~tS vl~~rtr
CUMBEf~LA1Vp CO.
I, Edith C. Zullinger, of Southampton Township, ' ~ranklin
County, Pennsylvania, being of sound and disposing mind, memory
and understanding, do hereby. declare this. to be my Will, hereby
revoking any and all former Wills and Codicils. thereto by me
heretofore made.
FIRST: I direct. that all my dust debts and funeral expenses,
including all expenses. of my last illness, shall be paid from my
estate as soon as practicable after my decease, as a part of the
expense of the administration of my estate.
SECOND: I give, devise and bequeath the residue of my estate
of every nature and wherever situate to my children, namely,,
Pauline L. Snoke, Norma Jean Ross, Janet I. Jones, and Paul E.
E] Zullinger, in equal shares, provided. that. the share of any child
who predeceases me or dies on or before the. thirtieth (30th) day
following my death, shall be distributed to his or her issue, per
stirpes, living on the thirty-first .(31st) day following my death
and in default of any such living issue, his. or her share shall be
distributed to my other. children named in this paragraph SECOND.
THIRD: Any fiduciary under. this Will shall have the following
powers in addition to those. vested in them by law and by other
provisions of my Will applicable to all property, whether principal
or income, including property held for minors, exercisable without
Court approval, and effective. until actual distribution of all
property:
Page. One of a Four Page Will
A. To retain any and all of the assets. of my estate,
~~
~~
~~}
4
`,.~
real or personal, without regard. to any principle- of diversifica-
tion of risk.
B. To invest in .all forms of .property, including stack,
common. trust funds and mortgage investment-funds without restric-
tion to investments authorized for Pennsylvania fiduciaries, as
they deem proper, without regard. to any principle. of diversifica-
tion of risk.
C. To sell at public. or private sale, to exchange or to
lease, for any period. of time, any real. or personal property, and
to give options for sales,. exchanges or leases, for such prices and
upon such terms. or conditions as they deem proper.
D. To allocate receipts and expenses to principal or
income or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly each.
G. To hold property in their names without designation
of any fiduciary .capacity or in the name of a nominee or
unregistered.
FOURTH: I direct. that all taxes. that may be assessed in
consequence of my .death, of whatever nature and by whatever
.jurisdiction imposed, shall be paid from my residuary. estate as a
part of the expense af. the administration of my estate.
FIFTH: I appoint my daughter, Pauline L. Snoke and my son,
Paul E. Zullinger, Co-Executors_ of this, my Wi11.
Page. Two of a Four Page Will
SIXTH: No bond shall be required. of any fiduciary hereunder
in any jurisdiction.
IN WITNESS WIiEREOF, I have hereunto s.et my hand and seal- to
this, my Last Will and Testament,. consisting. of four typewritten
pages, the first two of which bear my signature in the margin for
the purpose of identification, this ~ ~~ day of ~G ~a~~
1985.
s
~. f=. ~'~ ~ (SEAL)
Signed, sealed, published and declared by the above named
Testatrix, Edith C. Zullinger, as and for her Last Will and
Testament in our presence, who in her presence, at her request and
in the presence of each other have hereunto set our hands as
G~~ d r~~« ~c°~.p ~~~'~ 1~c4
Address
Page- Three. of a Four Page Will
attesting witnesses.
We, Edith C. Zullinger, ~caoQ ~`-(~ on~ and
7 (~' -~-
~~:a;s, ~ -~~L~,.r-°~~-r. the Testatrix and the witnesses,
respectively, whose names are signed to the attached. or foregoing
instrument, being first duly sworn, do hereby declare to the under-
signed authority that the. Testatrix signed and executed the instru-
ment as her Last Will and that she had signed willingly (or will-
ingly directed another to sign for her), and that she executed it
as her free and voluntary act for the purposes. therein expressed,
and. that each of the witnesses, in the presence and hearing of the
Testatrix signed the Will as witnesses and to the best of their
knowledge, the Testatrix was at that time eighteen (18) years of
age or older, of sound mind and under no constraint or undue
influence.
Testatrz
~= ~ , .
Witness
Subscribed, sworn to and acknowledged
before me by Edith C. Zullinger, the
Testatrix, and subscribed and sworn to
before me b y ~-~ y Q. ~ `'(~-.~0 0~.p ~e,~~
and ,~,~nxu ~~ ~p, ~a~uY-; ~, e
witnesses, thi` :~g~ ' ay of .,~,`,
1985.
`~-ccs~ .i ~ SU • 011 a ~, ~ r~ . .
_ : ,. NOTARY PUBLIC
~ ~amrnlsslan exFcires May 25, 14&9
~harnbsnbur~r, Franklin Go., i'A
Page Four of a-.Four Page Will
10-05-`12 15:37 FROM-M&T BANK
~1~~
499 Mitchell Road, Mllsborq DE 19966 AAjusnn~nc se[vicc,
Law Offices Of .
Ztillinger-Davis
20 East Burd Street
P.O. Boa 40
Shippensburg, PA X7257
fie: Estate of Edith C. Zullinser
Social Security; 179-10-3931
Date of Death: Juty l 7 2012
Phone 888-~02~3a9
F a+c (302) 934 2955
October 5, 201?
Dear Sir or Madam:
ker your itaquiry o>a August 8, 2012, please be advised that at the time of death, the above-named decedent had
on deposit with this battlc the following
1. Type oJAcco:mt ~~,~~~
AccountNtanber 97590126
Owrr~ship (Names o,~ Fdith C. Zulling~
Paul E Zulli-tger(PO~
Janetl Jone(POA)
Paulbml. Srmke(PO.~
Opening Date OI/28/I980
Balance on Awe ofpeath S4S9.06
Accruedlnterest g ,00
Testa! - -----------------------------------
$459-60
? TjPe oJAccowrt Checlangilcaotatt
Accorort Number 98171828
Ownership (Names o,~ Edith C ZuUittger
Paula Zullir{get(PO.!y
Janet 1. Jone(POAJ
Pauline L. Snoke(PO~
OpenirgAate 05/30/97
Balance on Aare of1)eaiJi $5],696.54
Accruedlraerest S .OJ
3029342955 T-248 P0001/0002 F-626
Total 851,696 55
WESTERN ~ NATIONAL
Life Insurance C o m p a n y
P0. Bcx 877
Amarillo, Tetras 79105-OR71
1A00424A9J0
October 17, 2012
JOELLULLINGER
14 N MAIN ST STE 200
CHAMBERSBURG PA 17201
Re: Deceased: Edith Zullinger
Contract #: XP221529
Dear Mr. Zullinger:
Thank you for your recent inquiry regarding the referenced annuity contract(s). It is our pleasure
to be of service to you.
The value of the contract as of July 17,.2012 was $172,133.04.
We hope this information is helpful; however, should you have additional questions or require
further assistance, please feel free to contact our Client Care Center at 1-800-424-4990.
Sincerely,
Maty n is er~;t~P'~~~ ~
Claims Department
AEG Annuity
INSIJRANCF. COMPANY
AIG Annuity Insurance Cnmpany
A Stock Company
205 East I Olh Avenue
Amarillo, Texas 79101-3546
Telephone: 80Q424.4990
AIG Bonus Annuity Flex 7
Owner Acknowledgment
Policy Number: X~'Z.~ ~~2~
This is a sununary of the provisions of your annuity, but it is not a part of your contract. Your annuity policy contains complete details.
The AIG Bonus Annuity Flex 7 is a flexible premium deferred annuity which offers a premium guarantee backed by AIG Annuity
Insurance Company ("Company"). The premium guarantee provides that your value at cancellation will be equal to or greater than your
premiums paid, less any previous withdrawals of interest or premium payments.
ANNU 1"LIES: are not a deposit; are not FDIC/NCUA/NCUSTF-insured; are not insured by any federal govenunent agency; are not guaranteed
by the bank/credit union; and may lose value.
The expense charges may be higher and/or the interest credits may be lower for a contract with a bonus than the charges or credits for a
contract without a bonus. The amount of the bonus may be more than offset by the charges and/or reduced interest associated with the
bonus.
EFFECTIVE ANNUAL INTEREST RATE: The present effective annual interest rate on the initial premium is '~ a ~ °/n and is
guaranteed to be in effect for one year from the Policy Date. To achieve this rate, the initial premium must be left on deposit for a full year
without any withdrawals. This rate includes a ~% enhancement to the current credited interest rate and is payable for the first
twelve (12) months only. Additional premiums will be credited with the then current interest rate. interest is credited and compounded daily
to achieve the annual rate.
MINIMUM GUARANTE ED RATE: (Select the cw•rent guaranteed minimum interest rate, which is predetermined by the Company.)
The effective annual interest rate for each premium ill be declared from tune to time by the Company's Board of Directors and is guaranteed to
always be at least a 1.5% ^ 2.0% ~% ^ % (Other). This guaranteed minimum interest rate will remain in
effect for the life of your policy and is not subject to change.
WITHDRAWAL PRIVILEGES: You may withdraw the accumulated interest earnings free of any early withdrawal charge at any time
atter thirty days from the Policy Date. F,ach premium is subject to an early withdrawal charge for aseven-year period. The oldest premiums
are considered withdrawn first for purposes of determining withdrawal charges.
Withdrawal Charge Schedule
Years from Payment 1 2 3 4 5 6 7 8
Charge 9°/n 8% 7% 6% 5% 4% 2% 0%
(% of Premium Withdrawn)
EX'T'ENDED CARE RIDER (Not available in all states):
Early withdrawal charges may be waived in the event an Owner receives qualifying extended care. I/We understand that:
• Extended care must begin at least one year after the Policy Datc;
• Fxxtended care must be provided by a qualified institution for at least ninety consecutive days; and
• Coverage terminates on the earliest of the date on which any Owner turns age 86, the date income payments begin, or the date on
which the amenity policy terminates.
FEDERAL TAX PENALTY: Withdrawals prior to age 59% are generally subject to a 10% federal income tax penalty.
The undersigned owner(s) acklrowledges that he/she has read and underst~a,~ the above items, has received a copy ofthis acknowledgment
and certifies that be/she has paid au initial premium of $ ~ ~ agto purchase an AIG Bonus Annuity Flex 7 from AIG Amiuity
insurance Comp n_y,,,a. statement~o'f`your account will bnne provtded at least once)),,~~e^^a~~ch policy year.
Signed this ~_ _ day of ~~p 1 ~/~~ ~.te-- «iL.J~
+~J h'l ~ ~~ C . Z~ f.1.~ I.t~~(L T A-c.(.C '~ ~ Zl„ I..LLi n~ G4,rZ
GE "S NAME (Please Pri OWNER'S NAME (Please Print) JOINT OWNER'S NAME, IF ANY (Please Print)
T'S SIGNATURE OWNEK'S S1G ATURE lO1~T OW~R'S S-IG~ATURE, IF AN
AIGA 316-BAF7 (FVCU) (3-04) White-Owner Yellow-AIGAIC Pink-Agency G°Id-Agent (All7-9R, /il 17-03, A347-97, R370-02,8374-02, R373-03)