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03-08-13 (2)
f 1 i 1505610105 �•1 REV-1500-(02-11)tFI, OFFICIAL USE ONLY PA Department of Revenue pennsytvarde MO,�INH�w. County Code Year File Number Bureau of Individual Taxes ERITANCE TAX RETURN ot A a7 zooPO H RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1211812012 03/0811925 Decedent's Last Name Suffix Decedent's First Name MI Klein Philomena T (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 T=ILED IN DUPEICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW tip 1.Original Return O 2.Supplemental Return O 3. Remainder Realm(Date of Death Prior to 12-13.82) O 4,Limited Estate t=) 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 8.Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Michael Klein (717)439-2 w C5 rn �. REO �`ta.us us LY M x c� First Line of Address A. : b 336 West Meadow Drive o ac 0 o Second Line of Address CI). C :-3 Co f- rn City or Post Office State ZIP Code DATE FILED f"^ G Mechanicsburg PA 17055 Correspondents e-mail address: Mir Under penalties of perjury,I declare that I have examined this return,including accompanying sbtloulos and statements,and to the best of my knowledge and belief, 9 is true,arced and complete.Declaration of preperer other than the personal representative is on all ktdormi tion of which pnMxm has any knowledge. GNATU OF CIBLE FOR FILING RETURN DATE ESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE r DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 t 1505610205 REV-1500 EX(Fl) 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. 800.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 75,280.87 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule c) o Separate Billing Requested.,...... 7. 3,616.77 8. Total Gross Assets(total Lines 1 through 7)............................. 8. 79,697.64 9. Funeral Expenses and Administrative Costs(Schedule H). .......... 9. 18,767.67 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). ..... 10. 2,733.29 11. Total Deductions(total Lines 9 and 10) ........................ 21,300.96 12, Net Value of Estate(Line 8 minus Line 11).............................. 12. 58,1 96.68 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(Lire 12 minus Line 13) ........................ 14. 68,196.68 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_ 15. 16. Amount of Line 14 taxable at lineal rate X.0 48 30,938.68 16. 1,392.24 17. Amount of Line 14 taxable at sibling rate X.12 27,258.00 17. 3,270.96 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE........................ .......................... 19. 4,663.20 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1 500 EX(FI) Pap 3 File Nu~ Decedent's Complete Address: DECEDENTS NOE Philomena Klein ST EETADDRESS 336 West Meadow Drive Mechanicsburg STATE PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 4,663.20 2. Credits/Payments A.Prior Payments a.Discount 245.42 3. Interest Total Credits(A+B) (2) 245.42 4. If Line 2 is greater than Line I+Line 3,enter the difference. This is the OVERPAYMENT. (3) 0.00 Fill In oval on Pop Z Line 20 to request a refund. (4) 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This Is the TAX DUE. (5) 4,417.78 Make check payable to: REGISTER OF WILLS,AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN")r IN THE APPROPRIATE BLOCKS 1. Did decadent make a transfer and: Yes No a. retain the use or income of the properly transfarred......—................. .......... E) 0 b. retain the right to designate who shall use the property transferred or its income............................................ C-1 ■ c. retain a reversionary interest......................................................--................................ ............................ d. receive the promise for I*of either payments,benefits or care? ...............—............ ............... 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?........................................................ ............................................... 3. Did decadent own an'm trust W or payable-upon4eath bank account or security at W or her death?........ ❑ ■ 4. Did decadent own an individual retirement account annuity or other non-probate property,which contains a beneficiary designatlon? ..........--.................................................................. ....................... ■ ❑ 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 not value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(11)(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 sur4MM 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(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 C72 P.S.§9116(a)(1.3)1 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-i5o8 EX+(ii-io) pennsylvania � SCHEDULE E u it �/� DEPARTMENT OF REVENUE CASH, DEPOSITS S&MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointly owned with right of survivorship must be disclose!on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH tAI�Aia.t►J�4 �pp1!�£,L q�t�saJ' oG��tP�Ttt AT4SAT1v/4'j:MVAh '0 ,566 V t LLPV-) 36 Q t SCHEDULE F COMMONwEWHOFPENIMLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN i RESIDENT DE I .STATE OF FILE NUMBER Ph>•Lnnt.�.tlra K•Lcz.► � Ilan asset was made joint within one year of the decedents date of death,it must be reported on Schedule G. SURVIVING JOINT TENANTIS)NAME ADDRESS RELATIONSHIP TO DECEDENT �.J� wNtu�l-t� SfW+arJ ?SO So'Alr\c-sNt-o- 51��,T S Isif,p- �� tCt. Sid[1io 14S52Sd 3. ?Aiv0.i L.t- KLQ— tv Pf,i L kA,NP, S 1��.5 l t3o�c 9ti1 So►J )�re32- c. 330 tx?,s i MLc.Ir+�ctJit.S1eJIL�, Pry �'�05� sad . JOINTLY-OWNED PROPERTY: LETTER DATE DEXIMIONOFPROMW %OF DATE OF DEATH REm FORJOW MADE I namaof finantial ins6lu6onand to*8=001nwrWorwaft ftp(MwnlbecAttach DATEOFOEATH OEM VAUIEOF UMBER TENANT JOINT deed for jo*pI ldd rad estda. VALUE OF ASSET INTEREST DECEDENTS KTEREST 1. A. 3^71- 15 0.114 Pe-A,IS op L#-aoA u�in, rth�t>uv5tagN{� 1$541 6tb eha.0 st 1.�. cat--60-02-40 0 t Af-K5atosr_ 'Its KIL-4k"D' N. 13JLL-1 j CAur+ A .. C a-17 {� ( - -- -— �-IT-D 4Pcnllt {�c.GL�OIJ�, �uShoR't�r�� ��(i Ib,GL7 C. ��r�3 o U � q Ik.4 CIT1Z.f.NS �Na'fl'�'l�£IRIJ 5'jac•ll. Cru�'F', I°&`�- 30 Oda �o1Z 5op i�>J w I TA% Pfd lmA.r- ter n C i i"12 b+J S 6�C I�L�A� �Ta c, Gs PL'r L 1-10r 3cP�a3 �o�a >a �� 1-2.o-0c) $ I; J 14%;A(soN� Cr11z�r�5 tJoA.�H�W.� sTtc.tZ Cf. 3a Hu I ;t1 da /-/7-61 GrTt-2,smS )Morro%1gJJ Slack Wor iJ 1_a4.y !�r-3u,t 47 1-�O c t"rt J�bl�"1 1JA J s-rr"K <,Q'i -7. J TOTAL(Also enter on line 6,Recapitulation) �3),, /Q, (if more space is needed,insert additional sheets of the same size) CoO�.rt2� = SCHEDULE F ` COMMNINEALTHOFPENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN i�S�ENT DECEDENT STATE OF FILE NUMBER STATE Kl4j�410 If an asset was made joint WNW one year of the decedents"of death,it must be reported on Scheduk G. SURVIVING JOINT TENANT(S)NAIAE ADDRESS RELATIONSIOPTO DECEDENT A. 8. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FORXMT MADE Aftach DATEOFOEATH OEM VALUEOF %WER TENANT JDe1T deed for iaitlg7l-om rad a6w VALUE OF ASSET WTMST DECEDENTS KIEREST tz cam. T Timis i +tlQttl �CSQ�� l� s .l--' G-nt' 1 . ps ` r-�rJ- $ SL4 N�,ate 4o:64 i_fib-a5 !� �-� T�>J ,tic, P �Cso^)) ! " s��l� �T. T`+�, wr'�'in �tr'C�1zI2 �tSZ:nn.�satil� ��+•� �b�J 9 .0 b TOTAL(Also erAer on One 6,Recapihulabon) $ i r 75 (If more space is needed,insert additionid sheets of the same size) mvasm Go 0-97) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RE NT ESTATE OF FILE NUMBER If an asset was made joint within one year of the decedents date of death,d must be reported on Schedule G. SURVMNG JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT A. B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OFPROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Nwludenweof bang imlidon and be*amuntown6erorsuftkknffnp ranter.Aftwh DATEOFDEATH DECO'S VALUE OF IUMBER TENANT JOINT dead tor)a*j4i dmgede& VALUE OF ASSET INTEREST DECEDENT5NTEREST ID-6� NVF 19A-MK MT 1'45-) l A ,,, d sill to -b-�vDor j r/ / /,�ds.6b SAG., $�da•8d WT�n �Pc1�IZK �'Lei�(5ah�� 5. Y tT kyx-0,1tA s�au$� ,Spa 6� sd�'�}►,��13� JorrvrL-j h ld wIihSoilPk-tiV� TOTAL(Also enter on line 6,Recapitulation) $ 5 a- (if more space is needed,insert addiflonal sheets of the same size) ) , 54 o *T-/6 6 sip , within instrument,and acknowledged that I he exeMea are same Tor tine PUIrpvses UWT n contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. �-� Title of Officer. do hereby certify that_the precise residence and complete post office address of the within named grantee is 19 Attorney for zo °aw H A P4 z Pq ti U W COMMONWEALTH OF PENNSYLVANIA, County of RECORDED on this day of A. D. 19 4_`�, in the Recorder's 08cee of said County,in Deed Book Vol. Page Given under my hand and the seal o f the Said office,the date above written. Recorder. I MADE THE twenty-first day of March in the year of our Lord one thousand nine hundred seventy-five BETWEEN JOSEPH BIANCHI, widower, of Mildred, Cherry Township, Sullivan County, Pennsylvania, Grantor , and NICHOLAS B. BIANCHI and PHILOMENA KLEIN, of Mildred, Sullivan County, Pennsylvania, and JEANNETTE MARIE SIMON, of Versailles, Ohio, as joint tenants with right of survivorship, and not as tenants in common, Grantee s WITNESSETH, that in ooneideratson of ONE ($1.00)--------—--------- ----------- - ------------------------------Dollars, in hand pajd, the receipt whereof is hereby acknowledged, the said grantor d e-s hereby grant and oonvey to the said grantee s, ALL those two certain lots, pieces, and parcels of land situate in the Village of Mildred, Cherry Township, Sullivan County, Pennsylvania, bounded and described as follows: LOT 1. BEGINNING at the corner of Pennsylvania Avenue and Monument Alley; thence along said Pennsylvania Avenue Eastwardly one hundred (100) feet, more or less, to Lot No. 19, land of James Connors; thence along said land Southwardly one hundred twenty-five (125) feet to Pauline Alley; thence along said alley Westwardly one hundred (100) feet, more or less, to Monument Alley; thence along said Alley one hundred twenty-five (125) feet Northwesterly to Pennsylvania Avenue, the place of beginning. BEING Lots Nos. 11, 13, 15 and 17. BEING the same premises conveyed to Joseph Bianchi and Josephine Bianchi, his wife, by John S. Diltz and Blanche Diltz, his wife, by deed dated October 10, 1935 and recorded in Sullivan County Deed Book 51 at page 738. LOT 2. BEGINNING at a point on Jackson Street, in said Village of Mildred, formerly Sullivan City, and extending along said Street in a westerly course fifty (50) feet to a corner; thence in a northerly course one hundred twenty-five (125) feet to a corner; thence in an easterly course fifty (50) feet to a corner; thence in a southerly course one hundred twenty-five (125) feet to the place of beginning. The same being designated in a plot of said lots Nos. 12 and 14. Together with all improvements thereon. BEING the same premises conveyed to Joseph.Bianchi and Josephine Bianchi, his wife, by John S. Diltz and Blanche Diltz, his wife, by deed dated October 28, 1935, and recorded in Sullivan County Deed Book 51 at page 747. The said Josephine Bianchi departed this life in March, 1973 and title to the said premises became vested in Joseph Bianchi in fee simple- i I WITNESS WHEREOF, said grantor AG s hereunto set his hand and seat the day and year drat above written. bz tip ftmews of --------_____---______----- I do hereby certify that the precise and complete post office address of the with grantee is c/o Nicholas B. Bianchi, Mildred, Pennsylvania. March 21, 1975 Attorney for grantees State of Pennsylvania County of Sullivan as. On this, the twenty-first �l of March , 1975 , before me, the undersigned officer, personally appeared Joseph Bianchi known to me (Or satisfactarity proven) to be the person whose none is subscribed to the within instreament,and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and ofieW seal , : i RECORDED y—/--- Er1fiuYDaL "se1 : d �3 os�ot°''�,5''"` y:"_,v►--gin------�-�' �c = APR l 15x5 c0 RECORDER - _ eflitiM1 a moaMUIH Y.sKwGmV% mm .Min= 0 w�l4tR1'rMAtOOI ��♦BlA XfYw fEfiv. NkMYbM1YM Ir•...n... AIAhA AfIYYW ,+. �{P IAirA4 1Y'.IIMMM 1wAM+{I�A .� fMfww'fY� 1f.wllww�l a JXeuAwflwerlNYS/.gfw. Irww •r.arww�._._ :1 fw. ww.dwww4..+Yttwkw. G Atwy ID},fwAw.w� o fti...w.awta+t C vww■wh 3 I�Aewl4w«N "1 M D H kaeawf f.MM rfey f`rwXe*w�wfeferw Yrl.. aw.Y7f�MAOMMwMXIM Xm••x• —M"k" MPYXrYUtMn++!Mw•nw Ws}e�wwfalMw•«lfwww«eEawf7fwm a.q •� MM�e tom• wMwywwwywwayw�YwfselMw.Wwf#Yf1Ytw MXtMwtwT`�Ar♦ .w.if M.fwwYrM«.YwewKR«I«w1}.+�w fMIwIMf!/�I�MIYIMw�1Mw}e*YW�.�M S�!�f4Mr�/wYfw.YwYrYM..11 erww1fe11f AwMM }wYYIMYIw.XA1w.tlYwQw.wYr,Rw1lXwMwWAUf�AM rY..Ywb.gtY�+YYY«OYYI9MY flMyfA../w �w.prw...w.wr.lwwwwYw.,• WYt/Yf1P! �_ ww'��1wM�F Y11i�w.M.f rMwMlfYrMi MYMXWIw.wpF�r.w yw'arp.�w+r—wW.ffYwle lfwi/wwM XMyf Y. N Nf�. �ry+.wrlbwfMwp.1X[!Y.w f+a1M.Y+Af lwfwwlwMA#wAFSM'IMM�IIMMfM �AIw1Yw�w MYrM MYIMfwhYM`r !i�rXT+MnM hrw.Y t Tfl tr� ID Twr11w1«wwrwY wwawMipt OAl/�+ !�Y� ,.,...,r .war. m rt.ww+_�ao.•AYA11�1+ to JUA3& eo-w Mtlle� a�,et4i w T ACCOUkf 3!144 :., ACCt1UNT TYPE STATEMENT PERIOD PAGE � 15325855 MST SELECT WITH INTEREST DEC.15-JAN.14,2fl13 j 2 pF 2 00 0 06111H NH 117 000002842 FlDS164lG7010114l3Ol 01 000000 2842 PHILOMENA T KLEIN PATRICK J KLEIN 336 W MEADOW DR MECHANICSBURG PA 17055 INTEREST EARNED FOR STATEMENT PERK 0.27 HARRISBURG MAIN INTEREST PAID YEAR TO DATE 0.27 ACCOUNT SUMMARY ago RR NT E I NO 3NTERES7 GALA NO. AMOUNT NO. AMOUNT N0. I AMOUNT 83,S22.63 1 2 1 3p256.97 1 31 "'V522.63 1 2 1 88.30 fl.27 470.94 ACCOUNT ACTIVITY N - E Y .. -1':RAG•f ONS ,�.: BALANCE::: : T 12-IS-1 BEGINNIXC BALANCE 083,522.63 12-20-12 DEPOSIT 2,500.00 s 12-20x12 CHECK NUMBER 3362 284.D9 85,736.54 12-21-12 AMERICAN GENERAL G5 RPISEFT 756.97 S 12-21-12 CHECK NUMBER 3363 5,415.07 81,082.44 n 12-24-12 AMERICAN GENERAL RECLAIM 758.97 80,323.47 `0 12-27-12 CHECK NUMBER 0055 79,823.47 500.00 01-09-13 LIBERTY MUTUAL PAYMENT 29.33 470.67 j ' 01-14-13 INTEREST PAYMENT 0.27 470.94 ENDING BALANCE -_ 5470.94 :'aat?a. t�x 55 12-27-12 79,823.47 3362* 12-20-12 264.49 3363 12-21-12 5,415.07 ANNUAL PERCENTAGE YIELD EARNED = 0.00 7 MIT BANG MACES PAYING BILLS EASIER THAN EVER. MST WEB AND MOBILE BILL PAY WILL HELP YOU AVOID LATE FEES,, SAVE ON POSTAGE, AND HAVE PEACE OF MIND KNOWING YOUR BILLS ARE PAID ON TIME. OUR BILL PAY SERVICE IS FAST, EASY AND CONVENIENT TO USE AT NOME OR ON-THE-00. LEARN MORE AT MTB.COM BILLPAY. MEMBER FDIC. tooms(6+12) C -r I-2-t t,�)s CZNC Historical Prices Citizens&Northern Corp Stock-Yahoo! Finance Page 1 of 1 New User?Register Sign In Help Get new Yahml Mail apps Mail My Y! Yahoo! Search g yYeb CHOME INVESTING NEWS PERSONAL FINANCE MY PORTFOLIOS EXCLUSNES Got Guobs Finance Search Sun,Dec 30,2012,10:32AM EST-US Markets are closed Dow }1.21%Nasdaq 40.86% TRADE;" 200 s7 FREE NDAY - p...tt....s IMIC Citheem&Northam Cory.(CZNC)-NasdagDM Add to Portfolio Like 0 18.64 10.13(0.69%) Deb 28,4:ODPM EST i Mier Hours:18.84 0.00(0.00%)Dec 28,4:37PM EST Historical Prices Go Historical Pans for. GO Set Dab Range 'a Daft Slay Oeb: Doe �.. 15 2012 Eg.Jan 1,2010 ,-,may FREE Phone, End Oats:IDec 2012 - -'M°mnry UNLIMITED Talk, Dividends Only py Text,and Web First I Previous I Next I Last $30;Month Prices Date Open High Low Close Volume Adj CloW Dec 24,2012 19.01 19.06 18.75 18.75 3,100 18.75 Dec 21,2012 19.40 19.40 18.80 18.94 82,100 18.94 Dec 20,2012 18.43 19.58 18.31 19.49 24,300 19.49 Dec 19,2012 18.30 18.50 18.10 18.47 11,200 18.47 Doc 16,2012 16.06 18.38 17.90 18.33 33,500 18.33 Dec 17,2012 18.03 18.21 17.82 18.07 20,900 18.07 Dec 14,2012 17.80 18.11 17-80 17.89 26,300 17.89 Close pave ellusPed for divitlends S M Wis. First I Previous I Next I Last Download to Spreadsheet p Currency in LISD rn. I ''�� assurance wireless icC4L copyright 1 2012 Y.1--Inc AN r lfhls reserved.Pmacy Policy-About Our Ads-Teens of Service-copydghVIP Potcy-Send Feedback-Yahoo!-ABC News Network Quotes are real-time tar NASDAQ.NYSE.and NYSE MKT.See also delay times for other exchanges.All information provided"as is"fail informational purposes only,not intended for trading purposes or advice.Neither Yahoo nor any of independent providers is liable for any informational errs,incompleteness,or delays.or for any actions taken in reliance on information Contained herein By accessing the Yahool site,you agree not to redistribute the information found therein.Re mime continuous streaming quotes are available through our premium service.You may turn streaming quotes on or off Fundamental company data provided by Capital IQ,Historical Than data and daily updates provided by Commodity Systems,Inc.(CSI).International historical chart data.daily updates fund summary fund performance,dividend data and Morningstar Index data provided by Morningstar,Inc. 1 http://finance.yahoo.com/q/hp?s=CZNC&a=11&b=15&c=2012&d=11&e=25& 2012&... 12/30/2012 CERTIFICATE NO. CERTIFICATE OF COMMON STOCK V SHARES 30000 CITIZENS & NORTHERN CORPORATION **120** DATE ORGANIZED UNDER THE LAWS OF THE COMMONWEALTH OF PENN V A 1/29/98 CUSIP 172922106' This is to certify that the holder named below is the registered owner of the number of shares specified above of Common Capital Stock of(]tnsrts elk Northern Corporation,wltb a par value of SI.O hare.transferable only on the boob of the Corporation by the holder hereof in person or by duly authasiad attorney,upon the surrender of this Citizens N properly endorsed. In witness whereof.the Corporation has caused this certificate to be signed by its duly authorial of£wers and w be c®led with the seal of this Corporation. F Philomina T Klein & MirUg-,p � � Vi Ata.�}I 5338 Patrick Joseph Klein Jt Tens WROS 1 f PRESIAENT r 9 CORPORATE SECRETARY �S s \ ii aRTiFICATENO. CERT/F/CATE OF COMMON STOCK SHARES 56783 CITIZENS & NORTHERN CORPORATION Y DATE ORGANIZED UNDER THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA 1./20/00 CUSIP 172922106 This is to certify that the holder named below is the rq esed owner of the number of shares specified above of Common Capital Stock of Citveas&Northern Corporation,with a per value of SI.00 are,tramferable only on the hawks of tke Corpmatiouu by the holder hereof in person,or by duly autborittd attorney,upon the aurrrndc of this cartiftcate properly endorsed. in witrtem whereof,the Cotpceatioa has onmd this artificue m be signed by its duly authorized officers and to be sealed with the seal of this Corporation. FPHILONINA T KLEIN & 5388 PATICK JOSEPH KLEIN JT TENS WROS BOX 22 (,!`ri ,•:.ter.�,,'...f4.:•r.--; "ILDRED PA 18632 F PRESIDENT CORPORATE SECRETARY CERTIFICATE NO. CERTIFICATE OF COMMON STOCK SHARES 39449 CITIZENS & NORTHERN CORPORATION DATE ORGANIZED UNDER THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA 1 /19/01 CUSIP 172922106 This is to certify that the holder named below is the registered owner of the number of shares specified above of Common Capital Stock of Citizens&Northern Corporation,with a par value of$1.01 hare,transferable only on the books of the Corporation by the holder hereof in person,or by duly authorized attorney,upon the surrender of this certificate properly endorsed. In witness wbereof,the Corporation has caused this certificate m be signed by its duly authorized officers and to be sealed with the seal of this Corporation. PHILOMINA T KLEIN & 5388 r PATICK JOSEPH KLEIN JT TENS WROS 41 BOX 82 � �` .r•--°.r' y PRESIDENT` MILDRED PA 186322 g y n !CORP0VJkt5 SECRETARY' CERTIRCATENO. CERTIFICATE OF COMMON STOCK SHARES 34347 CITIZENS & NORTHERN CORPORATION DATE ORGANIZED UNDER THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA 1/20/99 CUSIP 172922106 This is to eertiry that the holder named below is the registered owner of the number of shares specified above of Common here,tramftrabk only on the books of the Corporation by the holder hereof in or d authorized alt Capital Stock of his certificate ic Northern Corporation,with a par value of$I.IX In witness whereof,the Corporation has camed this certificate to be i' ornery,upon the the seal o t this artifatioe properly endorsed. sipted by its duly authorised offcets and to be aeakd with the seat of this Corporation. , r PHILOMINA T KLEIN & 5388 PATICK JOSEPH KLEIN JT TENS WROS BOX 22 PRESIDENT LILDRED PA 18632 J CORPORATE SECRE RY i • tsr i ,r• t y ��. ,1614$--7 �i. 9'A o3© ,r ,?i�.� fit .�• i�; ":-'�-,'.�: z 4 • w w ON / Y ■ - O � • Y 122,�7 Y_ . 0.... •, zam lr �Al PIP// / Aoi',,�//ice: d A o / � / f z .:Q o :;� / z m ° * rub °d p C y N O 00 yy % w y ' 1 � f z %� // � ,puungp rtl CL JF 'yppi ° // o 9 y $ z °ate �s` fl'1 it "' 9 •�J�s 3 n i/% / r $ :A i i ir (N 9 MEN n a � / > /M ID CL EMS, 20 jj / m2 S �. . //� /// AD / '/ % ' N ni CL FWOSW@�UK ru 3WUVNDS U3aHOFWAf .. Ir u�ua�m�r fu'wnrrwl �Q °.% E ' A 7 / 0 ^ C— /f ` C X �. O C — w - '" C`\�C O FU c ~ 2 /# © j Z z * a v /. m p r11 °`� c G s N '� �, Z 0 0 1"1'1 i n o 24 � 77C1z 02 m CA Ln 1 F N z iG`i m` ;z c t' ' m +,+ a m C to 0 cn 1TIZ g` t0 s $5 z r : c m 1°19 tr o "'•.,� N011W� ��• ^ f y ` 3 1 T ® rfJl" �ON 3 �Q m En co +^ieSG{y' F 20 s m_ cr m m a o a' fL CD A8 a, IN30tl tl3dSNYtl1 (A'N'NtlOA N13N) � _ . M- IN jz; OR cr w � 6 - /e ° oo- L 0 off_ j/ // ! n °n ¢ o -� � K / '% jai '/ z "♦ k' ai r / / y > kz * 0 1 47= m 6- nz m a o W �, / 1+, o v,02 m DO CL �. rU C3 rn UJ TL M 8a _ % ` 2c Xkn �:;./Pry., All ii %/�%/,%% j z m CD m CD ..: i Y�of ru uvutsm3u am ;An ANMN U3d6NVtll WN)MM MM) �, r' p w y er � X � r�r✓ .fie'' j///��. ¢tip w " 1� P � 1 s I VIII 1 1 �, 111111 1 � • ti IIIIIIII jjjyyy ■ I N " r t F 24 ,p a Z may. O ✓ s ' O /ice to k m A p W O ru s S✓ . C7 4t + �' �� '— to o c T - ii C5 o c W o `9�s lu a \� p N 3A1 O CD r ca m r„ CD .p K S T I _< m_ m _ 9 y tr Ll 0 1'17 L 0 f CD �j�+�ICC-J,�. .• '::� � � a y0y 0 m f 2 r y < _ Z N T Z mm 50 8 om o ru ru o S cr .: Ate t d 6 . z4 6 -760 gd M&T Bank Corporation-Historical Stock Price Page 1 of 1 i M&T Bank Historical Stock Price Week of December 17,2012 Date Open High Low Close Volume Dec 17, 2012 98.22 100.15 97.81 99.89 1,367,215 Dec 18, 2012 100.03 101.23 99.57 101.23 11882,364 06y C Dec 19, 2012 100.81 101.63 100.35 100.62 695,587 r' Dec 20, 2012 100.62 101.42 100.47 101.13 654,113 Dec 21, 2012 99.96 100.58 99.47 99.86 1,693,568 December • ;18 2012 • Lookup Year End Stock Prices tco 90 $87.05 581.57 80 576.34 70 $66.89 60-w $57.41 d (L 50 Y O « 40 ' N 30 20 10 0 2007 2008 2009 2010 2011 Year The historical stock information provided is for informational purposes only,and is not intended for trading purposes.The historical stock information is provided by Mergent,a third party service,and M&T Bank Corporation does not maintain or provide information directly to this service.Prices display split-adjusted cost basis per share on that date. 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DESCRIPTION OF PROPERTY DATE OF DEATH 96 OF DECD'S EXCLUSION TAXABLE ITEM INCLUDE THE NINE of THE TRWSre�,THEIR REIAnoxs»To DECEDENT AND NUMBER TIE DATE OFTR�ER,ATTAaA0W(OF THE o®FOR RF�uESM VALUE OF ASSET INTEREST (IFRFFUCaeu: VALUE I. w�s�r�.,RN Sdtr1-I,,�,Q� L,F"- ANNv��y 3414.77 /66 W 0 6615, !0 -!$'m TOTAL(Also enter on line 7,Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. k-i -OuT hT sJz-�A-i y� " 3b iIc-- -7 '7 WESTERN-SOUTHERN LIFE ASSURANCE COMPANY ® CINCINNATI OHIO STATEMENT OF DEATH CLAIM SETTLEMENT INFORCE DEPT 1-17-2013 MAIL TO 980 5144 KLEIN PHILOMENA T PAYEE W0020570615 CHECK NOC 01193371 HAS BEEN ISSUED FOR $3,616.77 THE CLAIM ON THE ANNUITY LISTED ABOVE HAS BEEN APPROVED AND A CHECK FOR YOUR SETTLEMENT AMOUNT IS ATTACHED BELOW. WESTERN-SOUTHERN LIFE WILL � NOTIFY THE IRS THAT THE TAXABLE AMOUNT OF THIS PAYMENT IS $8.01 FOR THE 2013 TAX YEAR. IF YOU HAVE ANY QUESTIONS, CALL A WESTERN-SOUTHERN LIFE REPRESENTATIVE AT (800) 926-1702. t_ AMOUNT OF CONTRACT $3,608.76 TOTAL PAYABLE THIS CONTRACT $3,608.76 INTEREST $8.01 AMOUNT OF THIS CHECK $3,616.77 Detach the check below. •,Cn.ame• as WESTffiM-Sodium V LIFE ASSES OMPA'NY PNCeank,NA rcro %N441: CONTRACT ID DIST 1-17-2013 0C 01193371 W0020570615 980 EXACTLY ******3,616* DOLLARS AND 77 CENTS Amunt of Check PAY TO MICHAEL KLE8+1 THE 336 WET MEADOW DRIVE OROHR MECHAROM URG PA 17065 OF 090 L 1933 7 1110 1:04 L 2038951: 4 2606 19684u' Western-Southern Life Assurance Company Agrees to provide the benefits and rights set out on this and the pages that follow which are a part of the Contract. They are provided as consideration for the application and premium for the Contract. The Contract, the attached application, and any amendments, riders or endorsements make up the entire Contract. The Contract does not take effect until the Contract Date and until we have received the premium. TEN DAY FREE LOOK. Please examine the Contract. If you are not satisfied, you may cancel the Contract by returning it to us at our Annuity Operations Service Center or delivering it to our agent within 20 days after you receive it. When the Contract is returned to us, the Contract will be considered void from the beginning.We will refund the premium paid. P' President and Secretary Chief Executive officer This Annuity Contract is a legal contract between the Contract Owner and the Company. READ YOUR CONTRACT CAREFULLY Issued by a Stock Company Home Office: 400 Broadway, Cincinnati, Ohio 45202 SINGLE PRI MIIIM DEFERRED ANNUITY Income Payable at Income Date Death Benefit Prior to Income Date Non-Participating 9901-5555 wSA PA �� ,v,ititnii uererrerl Annuity Application and Specifications Westem-Southem Life Assurance Company 430. Box 2916, Cincinnati, Ohio 45201 Contract Number: W 2 O ANNUITY DOLLARS Lp/� With Premium Paid $ I c%r 1 7�. Initial Interest Rate: % y�p.Up Percentage: 0.15% With Application Minimum Guaranteed Rate:3% Has there been,or wdl there be,a lapse,stxrerxW,,loan,or dher C#wW of a4silrig tine insurance or v _ annuities as a result of,or in antidpaton ot,fins app�ion?°No 0 Yes Of yes,use a standard applicant) C Date: IRA PLANS ONLY: . lrxxxtte Data: This is a°Traditional IRA °SEP•IRA °SIMPLE IRA °Roth IRA contribution* This is a0 Traditional IRA or°SEP4RA rollover from a: °Traditional IRA DSEP4RA 0403(b)TSA ❑Pension Plan MorxMy Inoorrte at j *Contract Year for contribution: Year S Yew $ Maturity Factor OWNER 01ndMduat Worporation rylimet Name - First Mld last Birth [� _ Ferrnle Date: t7 V Address - Street OORR T.I.N. CI V6 ,3: AL A;_ smote l� �l�' to Ann � r JOINT OWNER j: Name - First Middle Last [pride Birth OF a Date: Address - Street Sockd Serxaily # or VA.. City State ZIP Rafatlorwhlp to ANNUMANT Complete If d oera nt frets Owner Name - First Middle fast ❑ BrrBt oil Address - Street �_ Social Security # -AI City !'�( L x State ZrpA 'r} CONTINGENT ANNU T G7" Name - First Middle last ❑Male Bum OFemale I Date: Address - Street Social Seedily # city State zip trtdlotde additional Bo 'll"11 ln+Special RwnwkL Namel>11c l�r t1 R BIft t ) ° Name (To owns Birth Date, ) °Primary °C�ontirgeM (To owned a d - _ Name Relstionstdp BM Date: (to owner) (a W-40 - - °Prinary °CorttirigeM SPECIAL REMARKS SIGNATLIRES The statements and answers in the application are true and complete to the best of my(our)knowledge and belief. Under penalty of pefjury,l(we)certify that the social security number(s)listed above is correct.The internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. lix�!OLWW(8 gnature mq*W O*for tax pbns.) sbr,ed A� � smote °�f� -- To the best of your knowledge, wil annully applied for replace any insurance or arnxdty? 13 Ye,.N No Agent's Amt III, X C 14469-IC W s Fix 11 Whke COW ( ) - YOm and Pads Copies to Anent - M ^ A. DO-i i-STEP-rf-PA-990 i WESTERN-SOUTHERN LIFE ASSURANCE COMPANY ENDORSEMENT FOR INDIVIDUAL RETIREMENT ANNUITY The terms of this endorsement apply and replace contrary contract terms only if the Application indicates the contract is an Individual Retirement Annuity ("IRA") under Internal Revenue Code ("Code") Section 408(b). In the event of any conflict between this contract and any Code sections applicable to this annuity, the Code will govern. To qualify under the Code, your contract must meet the following requirements: 1. You may not change ownership of this contract at any time. 2. Your entire interest in the contract is nonforfeitable. It is established for the exclusive benefit of you or your beneficiaries. 3. Your contract is not transferable and may not be used as security for a loan. 4. You must be the Annuitant and no joint owner or contingent owner is permitted. 5. All distributions made under the contract shall be in accordance with the requirements of Code Section 401(a)(9), including the incidental death benefit requirements of Code Section 401(a)(9)(G), and the regulations thereunder, including the minimum distribution incidental benefit requirement of Section 1.401(a)(9)-2 of the Proposed Income Tax Regulations. You must begin taking distributions no later than April I following the calendar year in which you attain age 7M ("required beginning date") over (a) your life or the lives of you and a beneficiary designated by you ("your designated beneficiary") or (b) a period certain not extending beyond your life expectancy, or the joint and last survivor expectancy of you and your designated beneficiary. You must receive additional minimum distributions by December 31 for each year after the calendar year you attain age 70Vz Payments must be made in periodic payments at intervals of no longer than one year. In addition, payments must be either nonincreasing or they may increase only as provided in Q&A F-3 of Section 1.401(a)(9)-1 of the Proposed Income Tax Regulations. In addition to meeting the distribution requirements referenced above, payments under a partial withdrawal option or an annuity option must also comply with the minimum distribution incidental benefit (MDIB) requirements applicable to IRAs. The amount to be distributed each year beginning with the first calendar year for which distributions are required and then for each succeeding calendar year shall not be less than the quotient obtained by dividing the owner's benefit by the lesser of (1) the applicable life expectancy, or (2) if your spouse is not the designated beneficiary, the applicable divisor determined from the table set forth in Q&A-4 of Section 1.401(a)(9)-2 of the Proposed Income Tax Regulations. Distributions after your death shall be calculated using the applicable life expectancy as the relevant divisor without regard to Section 1.401(a)(9)-2 of the Proposed Income Tax Regulations. This MDIB rule may increase the amount of your payments. If you are required to take a distribution at year end because payments made to you during the calendar year are insufficient to meet MDIB requirements for this contract, we will waive any surrender charge that might otherwise be applicable. You may satisfy the minimum distribution requirements applicable to two or more IRAs by receiving a distribution from one IRA equal to the amounts required to satisfy the minimum distribution requirement for all your IRAs, as described in more detail in IRS Notice 88-38, 1988 I-C.B. 524. Life expectancy is computed by use of the expected return multiples in Tables V and VI of Section 1.72-9 of the Income Tax Regulations. Unless otherwise elected by you by the time distributions are required to begin, life expectancy shall be recalculated annually. Such election shall be irrevocable and shall apply to all subsequent years. The life expectancy of a non-spouse beneficiary may not be recalculated. Instead, life expectancy will be calculated using the attained age of such beneficiary during the calendar year in which you attain age 70V2 and payments for subsequent years shall be calculated on such life expectancy reduced by one for each calendar year which has elapsed since the calendar year life expectancy was first calculated. 9801-5606 WSA END 1 6. In the event of your death, your entire interest in this contract must be distributed in conformity with the regulations described below. The contract's provisions relating to the death of the Annuitant/Owner are changed to the extent necessary to conform with those regulations. a. If you die after distribution of your interest has commenced, the remaining portion of such interest must be distributed at least as rapidly as under the method of distribution being used prior to your death. b. If you die before distribution of your interest commences, your entire interest must be distributed by December 31 of the calendar year containing the fifth anniversary of your death, unless an election is made to receive distribution in accordance with (1) or (2) below. (1) Your entire interest may be distributed over the life or over a period certain not greater than the life expectancy of the designated beneficiary commencing on or before December 31 of the calendar year immediately following the calendar year of your death. A designated beneficiary may elect at any time to receive greater payments, or (2) If your designated beneficiary is your surviving spouse, your spouse may elect to receive equal or substantially equal payments over the life or life expectancy of the surviving spouse commencing at any date prior to the later of (i) December 31 of the calendar year immediately following the calendar year of your death, or (ii) December 31 of the calendar year in which you would have attained age 70V2. This election must be made no later than the earlier of December 31 of the calendar year containing the fifth anniversary of your death or the date distributions are required to begin pursuant to the preceding sentence. The surviving spouse may accelerate these payments at any time, i.e., increase the frequency or amount of such payments, or (3) If your designated beneficiary is your surviving spouse, your spouse may treat the annuity as his or her own individual retirement arrangement. This election will be deemed to have been made if your surviving spouse makes a regular IRA contribution to the contract, makes a rollover to or from such contract, or fails to elect any of the above provisions. Life expectancy is computed by use of the expected return multiples and Tables V and VI of Section 1.72-9 of the income tax regulations. For purposes of distributions beginning after your death unless otherwise elected by your surviving spouse by the time distributions are required to begin, life expectancy shall be.recalculated annually. Such election shall be irrevocable by the surviving spouse and shall apply to all subsequent years. In the case of any other beneficiary, life expectancy shall be calculated using the attained age of such beneficiary during the calendar year in which distributions are required to begin pursuant to this section, and payments for any subsequent calendar year shall be calculated based on such life expectancy reduced by one for each calendar year which has elapsed since the calendar year life expectancy was first calculated. Distributions under paragraph 6 are considered to have begun if distributions are made on account of your attaining your required beginning date or, if prior to the required beginning date, distributions irrevocably commence over a period permitted and in an annuity form acceptable under Section 1.401(a)(9) of the Regulations. 7. If your contract is a single premium annuity only an initial payment, and any subsequent allowable payments as permitted under your contract, of up to $2,000 or a rollover contribution as permitted by Code Sections 402(c), 403(a)(4), 403(b)(8) or 408(d)(3) will be accepted to pay the premium or purchase payment for your annuity. If your contract is a flexible premium or purchase payment annuity, then except in the case of a rollover contribution (as permitted by Code Sections 402(c), 403(a)(4), 403(b)(8) or 408(d)(3)), no premiums or purchase payments will be accepted unless they are in cash and the total contributions under Sections 219(b) and 408(0) shall not exceed $2,000 for any taxable year. The $2,000 annual contribution limit does not apply to the following: (1) funds you receive as a result of the payment to you from a qualified pension or profit sharing plan (corporate or Keogh) which has terminated, excluding any funds you receive that represent a return of your contributions to the plan; 9801-5606 WSA END 2 Surrender The Surrender Value is the Contract Value less any applicable surrender charge. When you send us a written request for surrender of the full Contract Value, along with the Contract, the Company will pay you the Surrender Value, In the event that the full Contract Value is surrendered, the Company guarantees that the applicable surrender charge will be applied only to the extent that allows a 100% return of the premium paid, less partial withdrawals. Free Withdrawal Amount If you have not elected to take systematic withdrawals of interest, you may withdraw each Contract Year, without a surrender charge, 10% of the Contract Value as of the date of withdrawal, less any amounts withdrawn without surrender charge during the same Contract, Year. This 10% free withdrawal privilege is non-cumulative and available each Contract Year. Systematic Withdrawal Plan You may elect to take systematic withdrawals on a monthly, quarterly, semi-annual, or annual basis in amounts not less than $100 ($50 if withdrawals are made through electronic funds transfer). Your election must be in writing on a form provided by the Company. Provided that you have made no partial withdrawals during the Contract Year, no surrender charge will apply if you elect to take systematic withdrawals of, interest only or if you elect to systematically withdraw up to 10% of the Contract Value. Otherwise, a surrender charge may apply in accordance with the Surrender Charge provision. You may discontinue systematic withdrawals at any time by notifying the Company in writing. The Company reserves the right to discontinue offering systematic withdrawals upon 30 days' written notice to you; however, any such discontinuation would not affect a systematic withdrawal plan already commenced. The Company also reserves the right to assess a processing fee for this plan. Surrender Charge If part or all of the Contract Value is withdrawn or surrendered or if annuity payments begin within ten years of the Contract Date, a surrender charge will be deducted except as described below. The surrender charge is 6% of the Contract Value for every Contract Year during the Initial Guarantee Period. During the Second Guarantee Period, the surrender charge is 5% in the first year, 4% in the second year, 3% in the third year, 2% in the fourth year and 1% in the fifth year. There is no surrender charge after the tenth Contract Year. The surrender charge will be waived if at least 2 years after the Contract Date, payments begin under one of the plans allowed under Income Payment Options. Such a plan must have payments which will be made for at least 5 years. Any withdrawal from a plan within 10 years of the Contract Date will be subject to a surrender charge; see Lump Sum Removal of Value Applied Under a Payment Option (Commutation). The surrender charge will be equal to the surrender charge that would have applied had the plan not been in effect. Guaranteed Minimum Values The Table of Guaranteed Minimum Values on page 3 shows Surrender Values and Contract Values on selected Contract Anniversaries. If you make no partial surrenders, Surrender Values will not be less than the values shown in the Table. We have filed a detailed statement of the method we use to determine values with the state where the policy was delivered. Any paid-up annuity, cash surrender or death benefits that may be available under the Contract are not less than the minimum benefits required by any statute of the state in which the Contract is delivered. 9941.5585 WSA PA 6 • • • Death Provisions Death of Owner If the Owner of a Contract dies before the Income Date, the death benefit will be paid upon receipt of due proof of death and instructions regarding payment. The death benefit is equal to the Contract Value as of the date of death. If there are joint Owners, the term Owner means the first joint Owner to die. If the Owner is a trust and a beneficial owner of the trust has been designated, the beneficial owner will be treated as the Owner of the Contract solely for the purpose of determining how the death benefit provisions of the Contract apply. If no beneficial owner has been designated, the Annuitant will be treated as the Owner for the purpose of the death benefit provisions. The death benefit will be paid to the joint Owner, if any, otherwise to the Beneficiary; see Priority of Beneficiaries provision. If there is no Beneficiary, the death benefit will be paid to the Owner's estate. Any death benefit will be paid either in one sum or under one of the Income Payment Options of this Contract. Payments must be completed by December 31st of the fifth calendar year immediately following the year of the Owner's death, except that, if the Beneficiary is a natural person and so elects, the payments may be made 1) over the life of the Beneficiary; or 2) according to a fixed schedule which does not extend beyond the life expectancy of the Beneficiary; provided that payments begin within one year from the date of the Owner's death. If the Beneficiary is the legal spouse of the deceased Owner, the Beneficiary may elect to succeed to such rights in this Contract as the Owner held upon his or her death. If the Beneficiary succeeds to these rights, the death benefit will not be paid upon the death of the Owner, and the Contract will remain in force and the Beneficiary will be the Owner. If an Owner dies on or after the Income Date, any payments that remain to be made must be made at least as rapidly as under the Income Payment Option in effect on the date of the Owner's death. Death of Annuitant If the Annuitant dies prior to the Income Date, and a Contingent Annuitant has been named, the Contingent Annuitant becomes the Annuitant (unless the Annuitant is deemed to be the Owner as provided above, in which case the death benefit becomes payable). If there is no Contingent Annuitant when the Annuitant dies prior to the Income Date, the Owner will become the Annuitant. The Owner may designate a new Annuitant within 60 days of the death of the Annuitant. If there is no Contingent Annuitant when the Annuitant dies prior to the Income Date and the Annuitant is deemed to be the Owner as provided above, the Beneficiary will be paid the death benefit then due. The Beneficiary will be as provided in the Beneficiary designation then in effect. If no Beneficiary designation is in effect, or if there is no designated Beneficiary living, the Owner will be the Beneficiary. Priority of Beneficiaries You may designate the Beneficiaries as primary or contingent to indicate the order in which they will receive any death benefit payable. If you name two or more Beneficiaries of the same class, they will share equally unless you state how they are to share. If you identify a Beneficiary as a relative, we will interpret that to mean a relative of the Owner unless you state that the relationship is to another person. If there are joint Owners, any death benefit will be paid to the surviving joint Owner. Otherwise, any death benefit will be paid to the primary Beneficiaries who are living when payment is due. If there are no living primary Beneficiaries, payment will be made to the contingent Beneficiaries who are living when payment is due. If all Beneficiaries have predeceased the Owner, the death benefit will be paid to the Owner's estate. 9o1-5585 WSA PA 7 -n Any beneficiary who dies within 10 days after the Owner's death will not be entitled to any benefits payable on such a death unless that beneficiary is living when we receive due proof of the Owner's death. •++ Income Provisions Income Date On the Income Date, we will start annuity payments under an Income Payment Option or we will pay the Surrender Value in a single sum. The Income Date is the Contract Anniversary on or following the Annuitant's 80th birthday or the 10th Contract Anniversary, if later, unless otherwise indicated on page 3. The Income Date can be changed by sending a written request to us. The new date will go into effect when we receive the request. Your written request must be received by us at least 31 days prior to the existing Income Date. The Income Date may not be later than the Annuitant's 85th birthday. Annuity payments will be paid to the Owner unless you designate another payee. You may change the payee at any time by written notice to us. Such notice must be received at our Home Office at least 31 days prior to a payment due date for the change to be effective on such date. An executor, administrator, trustee, corporation, partnership or association other than the Owner may not be a payee without our approval. A payee designation is automatically revoked by the death of the designated payee. If there are remaining guaranteed payments to be made when the Annuitant dies, they will be paid to the Annuitant's estate if the Annuitant is the Owner. If the Annuitant is not the Owner, they will be paid to the Owner. Form of Payment The minimum Surrender Value that may be applied under an Income Payment Option is $1,000. The amount of income shall be determined by applying the Surrender Value as of the Income Date to that Income Payment Option. If prior to the Income Date no Income Payment Option has been chosen, the Owner will be deemed to have chosen Option 2 - Payments for Life, with monthly payments for 10 years, continuing thereafter during the life of: 1. the Annuitant; or 2, if the Annuitant is no longer living on the Income Date, the contingent Annuitant, if a valid contingent Annuitant has been named; or 3. if neither the Annuitant nor a valid contingent Annuitant is living on the Income Date, the Owner. Choice of Option Choice of an option may be made by the Owner by written notice to us on or prior to the Income Date while the Annuitant is living. See Income Payment Options on page 9. Equivalent payments for monthly, quarterly, semi-annual or annual intervals may be chosen. The options are described in terms of monthly payments. We will quote the amount of the other payments upon request. We may issue a document stating the terms of the option. Lump Sum Removal of Value Applied under a Payment Option (Commutation) The Owner, or the Beneficiary if the Owner is no longer living, may take lump sum payments from the remaining proceeds placed under Income Payment Options 1 or 3, though no more than four transactions may be made during any calendar year. The commuted value shall be based on the interest rate used to determine the amount or number of payments. No lump sum removal of value may be made under Options 2, 4 or 5. 9"1-558s wsA PA it - • Additional Interest We guarantee interest under all Income Payment Options at a minimum effective annual interest rate of 3% a year. We may increase the interest rate above the minimum on these options. Payments under these options will be based on the interest rate in effect on the due date of the first payment. General Payment Option Terms If the Surrender Value to be placed under an Income Payment Option is less than $1,000, we will pay that amount in one sum. If any payments would be less than $50, we will change the frequency to provide payments of at least $50. If the Surrender Value is assigned on the Income Date, we will pay the assignee's share in one sum and place only the balance under the option. After the Income Date neither the payments nor the remaining value may be assigned or encumbered. The schedule of payments under any operational Income Payment Option may not be extended upon the death of the Owner. ••• Income Payment Options In lieu of a lump sum settlement, all or part of the Surrender Value may be applied under an Income Payment Option. When value is applied under an Income Payment Option, all other rights and benefits under this Contract shall cease. In addition to the following options, other payment options may be available. Option 1 - Payments for a fixed FIXED PERIOD MINIMUM INCOME TABLE* Period Monthly Payments for each$1,000 applied Equal monthly payments shall be made for a Number Monthly Number Monthly Number Monthly stated number of years, which you select from the of Install- of Install- of Install- Fixed Period Table. The monthly payment will not Years ments Years ments Years ments be less than those shown in the table. 1 $84.47 11 $8.86 21 $5.32 2 42.86 12 8.24 22 5.15 3 28.99 13 7.71 23 4.99 4 22.06 14 7.26 24 4.84 6 17.91 16 6.87 25 4.71 6 15.14 16 6.53 26 4.59 7 13.16 17 6.23 27 4.47 8 11.68 18 5.96 28 4.37 9 10.53 19 5.73 29 4.27 10 9.61 20 5.51 30 4.18 *Values are based on compound interest at 3%a year. Option 2 - Payments for Life - Guaranteed Period Equal monthly payments shall be made for any guaranteed period chosen and thereafter during the life of the Annuitant. The amount of each monthly payment depends on the Annuitant's age and sex on the date of first payment and on any guaranteed period chosen. We may require proof to our satisfaction of such age. We may require like proof that such person is alive on the date any payment is due. The guaranteed period may be 10 or 20 years. • 9901-5585 WSA PA 9 OPTIONS 2 AND 4 ONE LIFE MINIMUM INCOME TABLE* Monthly Payments for each$1,000 applied Aga of Lit* Lite Lift Age of Life Life L a Payee No Year* 10 Years 20 Years Pay** No Years 10 Years 20 Years Last Certain Certain Cartel" Last Certain Certain Certain Birth- Birth- day Mal* Female Mai* Female l* •*male day Male Female Maio Female Maio Fame 16 and under $2.82 $2.76 $2.81 $2.76 81 $2.75 50 $3.91 $3.66 $3.88 $3.64 $3.80 3.60 i6 2.83 2.77 2.83 2.77 2.76 61 3.98 3.71 3.94 3.70 3.85 3.65 17 2.84 2.78 2.84 2.78 83 2.78 52 4.05 3.77 4.01 3.75 3.91 3.70 i8 2.86 2.79 2.85 2.79 85 2.79 63 4.12 3.83 4.08 3.82 3.96 315 19 2.87 2.80 2.87 2.80 2.86 2.80 64 420 3.90 4.16 3.88 4.02 3.81 20 2.89 2.82 2.88 2.81 2.88 2.81 55 4.28 3.97 4.23 3.95 4.09 3.87 21 2.90 2.83 2.90 2.83 2.89 2.82 56 4.37 4.04 4.32 4,02 4.15 3.93 22 2.92 2.84 2.91 2.84 2.91 2.84 67 4.47 412 4.41 4.09 421 3.99 23 2.93 2.86 2.93 2.86 2.93 2.85 68 4.57 4.21 4.50 4.17 428 4.06 24 2.95 2.87 2.95 2.87 2.94 2.87 69 4.67 4.30 4.60 4.25 4.35 4.12 26 2.97 2.89 2.97 2.89 2.96 2.88 60 4.79 4.39 4.70 4.34 4.42 4.19 26 2.99 2.90 2.99 2.90 2.98 2.90 61 4.91 4.49 4.81 4.44 4.49 426 27 3.01 2.92 301 2.92 3.00 2.92 62 5.04 4.60 4.92 4.54 4.56 4.33 28 3.03 2.94 3.03 2.94 3.02 2.93 63 5.18 4.71 5.04 4.64 4.63 4.41 29 3.05 2.96 3.05 2.96 104 2.95 64 6.33 4.84 6.17 4.75 4.70 4.49 30 3.08 298 3.07 2.97 3.07 2.97 66 5.49 4.97 5.30 4.87 4.76 4.56 31 3.10 3.00 3.10 3.00 3.09 2.99 66 5.66 5.11 6.44 5.00 4.83 4.64 32 3.13 3.02 3.12 3.02 3.11 3.01 67 5.85 5.26 5.59 5.13 4.90 4.72 33 3.15 3.04 3.15 3.04 3.14 3.03 68 6.04 5.43 6.74 5.27 4.96 4.79 34 3.18 3.06 3.18 3.06 3.17 3.06 69 6.25 5.60 5.89 5.42 5.03 4.87 35 321 3.09 3.21 3.09 3.20 3.08 70 6.48 5.80 6.06 5.58 5.08 4.94 36 3.25 3.12 3.24 3.11 3.22 3.10 71 6.71 6.00 6.22 5.75 5.14 5.01 37 328 3.14 3.27 3.14 3.26 3.13 72 6.97 6.23 6.39 5.92 6.19 5.08 38 3.32 3.17 3.31 3.17 3.29 3.16 73 7,24 6.47 6.57 6.10 6.24 5.14 39 3.35 3.20 3.35 3.20 3.32 3.19 74 7.53 6.73 6.75 6.29 5.28 520 40 3.39 3.23 3.38 3.23 3.36 3.22 75 7.84 7.02 6.93 6.49 5.32 5.25 41 3.43 3.27 3.42 326 3.39 3.25 76 8.18 7.33 7.12 6.69 5.35 5.29 42 3.48 130 3.47 3.30 3.43 3.28 77 8.53 7.66 7.30 6.90 5.38 5.34 43 3.52 3.34 3.51 3.33 3.47 3.31 78 8.92 8.02 7.48 7.11 5.41 6.37 44 3.57 3.38 3.56 3.37 3.51 3.35 79 9.33 8.42 7.67 7.32 5.43 5.40 45 3.62 3.42 3.60 3.41 3.56 3.39 80 9.77 8.85 7.85 7.53 5.45 5.43 46 3.67 3.46 3.65 3.45 3.60 3.43 81 10.24 9.31 8.02 7.73 5.47 5.45 47 3.73 3.51 3.71 3.60 3.65 3.47 82 10.75 9.82 8.19 7.93 5.48 5.47 48 3.78 3.56 3.76 3.54 3.70 3.51 83 11.29 10.37 8.35 8.13 5.49 5.48 49 184 3.60 3.82 3.69 3.75 3.66 84 11.87 10.96 8.50 8.31 5.50 5.49 86 and 12,49 11.61 8.64 8.48 5.50 5.50 QYer *Values are based on the "Annuity 2000 Table,"with Projection Scale G, adjusted for age last birthday, with interest at an effective annual rate of 3910. Option 3 - Payments of a Fixed Amount Equal monthly payments of a fixed amount shall be made until the value applied under this option, with interest credited on the unused balance, is exhausted. The amount chosen must be at least $5 per month for each $1,400 of proceeds placed under this option. The last payment will be for the balance only. Payments may not be for more than 30 years. Option 4 - Life Annuity - No Guaranteed Period Equal monthly payments will be made during the life of the Annuitant. The amount of each monthly payment depends on the Annuitant's sex and age on the date of first payment. We may require proof to our satisfaction of such age and we may require proof that such person is alive on the date any payment is due. There is no guaranteed period. This means that when the Annuitant dies no further payments will be made, even if only one payment has been made. 9901-5585 WSA PA 10 ♦ Option 5 - Joint and Survivor Equal monthly payments shall be made during the lifetimes of two designated persons. Upon the death of either, pa;ments will continue to the survivor or may be reduced to a preselected percentage (75%, 66 2/3%, or 50%) of the original payment. Payments will cease upon the death of the survivor. The amount of each monthly payment depends on the ages and sexes of both persons on the date of first payment, and the preselected percentage for continuing payments. The payments for each $1,000 applied will not be less than those in the Joint and Survivor Table. Values not illustrated in the Table are available upon request. We may require proof to our satisfaction of their ages. We may require like proof that any designated person is alive on the date any payment based upon the life of such person is due. JOINT AND SURVIVOR MINIMUM INCOME TABLE* Sample Monthly Payments for each$1,000 applied Male Female Joint & Joint & Joint & Joint & Age Age 100% 75% 662/3% 50% Survivor Survivor Survivor Survivor 60 60 $3.93 $4.23 $4.34 $4.58 60 65 4.14 4.48 4.61 4.88 60 70 4.34 4.75 4.90 5.24 65 60 4.07 4.44 4.58 4.88 65 65 4.36 4.75 4.90 5.22 65 70 4.66 5.10 5.27 5.64 70 60 4.18 4.65 4.83 5.23 70 65 4.56 5.03 5.22 5.62 70 70 4.97 5.48 5.68 6.12 *Values are based on the "Annuity 2000 Table,"with Projection Scale G, adjusted for age last birthday, with interest at an effective annual rate of 3%. ••• General Provisions Annual Report On each Contract Anniversary, we will provide a report which will be mailed to the Owner. It will show the Contract Value, surrender value, premium payments, annual interest rate(s) applied to each premium payment, interest credited, withdrawals made and any applicable charges. Statements In Application All statements made in the application are considered to be representations and not warranties. No statement will be used in defense of a claim unless it is in the application. Modification Of Contract Any change in the Contract or waiver of its provisions must be in writing and signed by our Chairman, President or Secretary. No other person can change or waive any of its provisions. Incontestability The Contract will be incontestable after it has been in force during the Owner's lifetime for two years from the Contract Date. ♦ 0"IA595 WSA PA 11 Incorrect Age Or Sex If the age or sex of the Annuitant has been misstated, we will adjust all benefits to those that the premium (s) for the Contract would have purchased for the correct age and sex. Any overpayments we make will be charged with compound interest against subsequent payments. Any amounts we owe as a result of underpayments will be paid with compound interest upon receipt of notice of the underpayment. The rate will be the rate we, use to determine the number or amount of the payments or 6%, whichever is Iess. Place Of Payment We will make all payments due under the Contract at our Home Office. Submission Of Contract We may ask you to relinquish the Contract or send it to us for endorsement before we make any payment. Failure to have you relinquish the Contract or to note payment on it does not indicate that we have not made payment. Creditors' Claims All payments under the Contract will be exempt from the claims of creditors and legal process to the extent permitted by law. No payment will be transferred, assigned or withdrawn before it becomes payable unless we agree. Proof Of Facts We may ask any person claiming the right to payments for proof satisfactory to us of such person's right to payment. Any payment we make relying on that proof discharges us from any obligation to make that payment to another person. We will require proof of date of birth of the person(s) on whose life (or lives) payments are based. Non-Participating This Contract does not participate in surplus earnings of the Company. 9o1-5595 WSA PA 12 REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND RESIDENT DE EDENTTURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: qey- - -- ";aJS4� 1.7 �7 p4-V(5 t N y ,{—aQ ,v �,v.�,r`ta,1t 3►S 1. 4� B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Years)Commission Paid: 2. Attorney Fees: 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address city State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5• Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) s If more space is needed,use additional sheets of paper of the same size. P.DEAN HOMER FUNERAL HOME 206 Water Street PO BOX 1 Dushore,PA 18614 Tel 570 928-8163 Fax 570 928-8116 December 18,2012 Funeral Expenses of Mrs.Philomena T. Klein Professional Services,Use of Facilities&Equipment 4,245.00 Casket-Stainless Steel 4,740.00 Concrete reinforced stainless steel lined vault 2.785.00 Total Funeral Home Charees 11.770.00 Cash Advances: Opening&Closing Grave 500.00 Jackhammer at Grave 100.00 10 Transcripts&Burial Permit 60.00 Mass at St.Francis 150.00 Daily Review 70.00 Cemetery Fee 100.00 Flowers 996.40 Patriot News 415.77 Singer&Organist 125.00 St.Francis Hall 50.00 Hairdresser 50.00 The Sullivan Review 143.50 Saturday Vault Charge 50.00 Total Cash Advances 2,810.67 Other Charges Lettering of Tombstone 165.00 Transportation from Mechanicsburg Milage 285.60 Driver 145.00 Total Other Charees 595.60 Total 15,176.27 WYALUSING I CYM af ANNEX �.r CAT=G Philomena Klein Funeral Luncheon Saturday,December 22nd Noon Start Mildred(Community Hall across from St.Francis Church) 120 ppl. Contact:Ashley Klein(570)220-6070 Menu Salad Lasagna Chicken Mozzarella Meatballs Garlic Bread Green Beans Cake w/Icing Iced Tea/Lemonade/Coffee Additional Supplies Chafers/Fuel Real Dishes/Silverware/Etc. Serving Utensils Banquet Table Linens$7 ea. Price $22 22/Person=$26402 6%Sales Tax=$158.9 25%Gratuity=$660.92 19 Banquet Table Linens @$7.-M ea._$131M Grand Total $3591. 54 Main SL P.O.Box 730•Wyalusing,PA 18853•Phone:570.746.1204•Fax:570.746.1247 REV-1512 EX+(12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES &LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 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. M Li ��V�Y} S ��- �tss)A UtLL At:� �d 737J. g-9 TOTAL(Also enter on Line 10,Recapitulation) $ 'a �AS.a If more space is needed,insert additional sheets of the same size. (2) funds you receive as a lump sum distribution from a qualified corporate or Keogh plan, excluding any funds you receive that represent a return of your contributions to the plan. A lump sum distribution is a distribution that occurs on account of your attainment of age 5ft your separation from service (if you are a common law employee), your becoming disabled (if you are self-employed) or your death; (3) funds (other than the plan termination and lump sum distributions described above) that qualify as eligible rollover distributions under Section 402(c); (4) funds you receive from another individual retirement annuity or account, however, rollover contributions from one individual retirement annuity or account to another may occur only once per year; (5) funds you receive from a Savings Incentive Match Plan for Employees (SIMPLE) that are permitted as a rollover under Section 408(d)(3)(G). Funds you receive in one of the ways described above must be applied toward your contract within 60 days of the date they are received by you, unless you elected to make a direct rollover of such funds before distribution. For direct rollovers, a reasonable period of time is allowed. 8. If your contract permits a refund of premium or purchase payment (other than excess contributions), any refund of premium or purchase payments will be applied before December 31 of the calendar year following the year of the premium or purchase payment refund toward the payment of future premium or purchase payments or the purchase of additional benefits. If your premium or purchase payments are being made pursuant to a program of automatic withdrawals, and your contract is terminated due to an interruption in premium or purchase payments, you will have the following reinstatement rights. Your contract may be reinstated at any time prior to maturity upon payment of a premium or purchase payment to the Company in the monthly amount of$50. However, if no premium or purchase payments have been received for two full consecutive contract years and your annuity benefit at maturity would be less than $20 per month, the Company may terminate your contract without any right of reinstatement by paying you the Surrender Value computed as provided in your contract. P Y nd Secretary Chlef Executive Officer 9801-5606 WSA END 3 �►+• Definitions "The Company", "we", "our" and "us", is Western-Southern Life Assurance Company. "Annuitant" is the person designated by the Owner to be the measuring life in determining the amount of each payment and the period of time payments will be paid under one of the Income Payment Options; see Annuitant provision on page 4. "Beneficiary" is the person designated by the Owner to receive the death benefit if the Owner dies prior to the Income Date; see Beneficiary provision on page 5. "Contingent Annuitant" is the person designated by the Owner to become the Annuitant if the Annuitant dies before the Income Date; see Annuitant provision on page 4. "Contract Year" is a year starting with the Contract Date indicated on page 3 or with a Contract Anniversary. A "Contract Anniversary" is the same day and month as the Contract Date in each subsequent year. "Income Date" is the date annuity payments begin. This date may be any Contract Anniversary on or before the Annuitant's 85th birthday. The Income Date can be changed by written notice to us. "Initial Guarantee Period" is the 5 year period beginning with the Contract Date. "Second Guarantee Period" is the 5 year period beginning with the fifth Contract Anniversary. "Owner" is the person, persons or entity having all rights under the Contract unless otherwise provided. If there are joint Owners they own the Contract equally with a right of survivorship. "Qualified Contracts" are Contracts purchased in connection with a plan that qualifies under Sections 401, 403(b), 408 or 457 of the Internal Revenue Code. "You" and "your" refer to the Owner or Owners if there are joint Owners; see Owner provision on page 4. •+• Owner, Annuitant, Beneficiary Owner You are the Owner of the Contract. You are also the Annuitant unless you name another person as Annuitant as shown in the Contract Specifications on page 3. You also have all other rights under the Contract unless provided otherwise. The Contract may be owned by two persons as joint Owners. In this case, both joint Owners must consent to any withdrawals, surrenders or changes to the Contract or beneficiary. Transfer of Ownership During the Annuitant's lifetime you may transfer the ownership of the Contract (unless it is a Qualified Contract) by written notice satisfactory to us. The transfer will not take effect until our records show that we have received the notice. Such change in ownership may be subject to state and federal income and/or gift taxes. We are not responsible for the tax consequences resulting from a transfer of ownership. A muitant The Annuitant is the person designated by the Owner to be the measuring life in determining the amount of each payment and the period of time payments will be paid under one of the Income Payment Options. You may also name a Contingent Annuitant. This person will become the Annuitant upon the Annuitant's death, but only if the Annuitant dies before the Income Date. You may change the Annuitant or Contingent Annuitant after the Contract begins but before the Income Date by written notice to us, and you may name a new Annuitant if the Annuitant dies before the Income Date and there is no Contingent Annuitant; see the Death of Annuitant provision on page 7. 9s01-558s wsA PA 4 Beneficiary The Beneficiary is the person you name to receive the death benefit if an Owner dies prior to the Income Date and there is no surviving joint Owner. You may change the Beneficiary at any time by written notice satisfactory to us. The change will take effect on the date the notice is signed. A change will not apply to any payment we make or any other action we take before the notice is received and recorded by us at our Home Office. ••• Accumulation Provisions Contract Value The Contract Value is the premium paid, plus interest credited monthly, less partial withdrawals and any charges applicable to those partial withdrawals. Interest Credited Interest will be credited at the initial interest rate shown on page 3 for the first year of the Initial Guarantee Period. The Company guarantees that the interest rate for each succeeding year of the Initial Guarantee Period will increase by the Step-up Percentage. The Step-up Percentage is shown on page 3. At the end of the Initial Guarantee Period, the Company will declare a new interest rate for the first year of the Second Guarantee Period. The Company guarantees that the interest rate for each succeeding year of the Second Guarantee Period will increase by the Step-up Percentage. On each Contract Anniversary beginning with the tenth Contract Anniversary, the Company will declare a new interest rate which will be guaranteed for that Contract Year. The effective annual interest rate will never be less than 3%. We will mail you a notice prior to the end of the Initial Guarantee Period stating the interest rate declared for the first year of the Second Guarantee Period. The notice will be sent to your address on our records. During the 60 day period after the Initial Guarantee Period expires, you may withdraw all or a portion of the Contract Value without surrender charge, subject to the restrictions set forth in the Partial Withdrawals provision. We will pay interest on any such withdrawal from the end of the Initial Guarantee Period to the date of the withdrawal at the interest rate set forth in our notice. Provided you do not withdraw all of the Contract Value during this 60 day period, the Contract will continue and the surrender charges will apply as set forth in the Surrender Charge provision. ••• Surrender and Withdrawal Provisions General Surrender Provisions The Owner may withdraw part or surrender all of the Contract Value at any time this Contract is in force and prior to the Income Date, subject to the conditions set forth below. The withdrawal or surrender will be effective on the date we receive your request at our Annuity Operations Service Center. The Company is not responsible for the tax consequences of any withdrawals or surrender. The Company further reserves the right to delay withdrawal of Contract Value for up to six months in those states where applicable law requires the Company to reserve such right. Partial Withdrawals You may request in writing to withdraw part of the Contract Value in amounts not less than $250. Your request must be received before the Income Date. The Contract Value may not be reduced to below $2,500 by a partial withdrawal. If you request a partial withdrawal which would reduce the Contract Value to below $2,500, the Company will notify you that you may either: (1) surrender the Contract in its entirety; or (2) withdraw a lesser amount such that the remaining Contract Value is at least $2,500. If we do not receive further instructions from you within 7 days, we will terminate the Contract and pay the total Surrender Value to you in a lump sum. The amount withdrawn from the Contract Value will include any applicable surrender charge. 9901-SSSS WSA PA 5 Surrender The Surrender Value is the Contract Value less any applicable surrender charge. When you send us a written request for surrender of the full Contract Value, along with the Contract, the Company will pay you the Surrender Value. In the event that the full Contract Value is surrendered, the Company guarantees that the applicable surrender charge will be applied only to the extent that allows a 100% return of the premium paid, less partial withdrawals. Free Withdrawal Amount If you have not elected to take systematic withdrawals of interest, you may withdraw each Contract Year, without a surrender charge, 10% of the Contract Value as of the date of withdrawal, less any amounts withdrawn without surrender charge during the same Contract. Year. This 10% free withdrawal privilege is non-cumulative and available each Contract Year. Systematic Withdrawal Plan You may elect to take systematic withdrawals on a monthly, quarterly, semi-annual, or annual basis in amounts not less than $100 ($50 if withdrawals are made through electronic funds transfer). Your election must be in writing on a form provided by the Company. Provided that you have made no partial withdrawals during the Contract Year, no surrender charge will apply if you elect to take systematic withdrawals of interest only or if you elect to systematically withdraw up to 10% of the Contract Value. Otherwise, a surrender charge may apply in accordance with the Surrender Charge provision. You may discontinue systematic withdrawals at any time by notifying the Company in writing. The Company reserves the right to discontinue offering systematic withdrawals upon 30 days' written notice to you; however, any such discontinuation would not affect a systematic withdrawal plan already commenced. The Company also reserves the right to assess a processing fee for this plan. Surrender Charge If part or all of the Contract Value is withdrawn or surrendered or if annuity payments begin within ten years of the Contract Date, a surrender charge will be deducted except as described below. The surrender charge is 6% of the Contract Value for every Contract Year during the Initial Guarantee Period. During the Second Guarantee Period, the surrender charge is 5% in the first year, 4% in the second year, 3% in the third year, 2% in the fourth year and 1% in the fifth year. There is no surrender charge after the tenth Contract Year. The surrender charge will be waived if at least 2 years after the Contract Date, payments begin under one of the plans allowed under Income Payment Options. Such a plan must have payments which will be made for at least 5 years. Any withdrawal from a plan within 10 years of the Contract Date will be subject to a surrender charge; see Lump Sum Removal of Value Applied Under a Payment Option (Commutation). The surrender charge will be equal to the surrender charge that would have applied had the plan not been in effect. Guaranteed Minimum Values The Table of Guaranteed Minimum Values on page 3 shows Surrender Values and Contract Values on selected Contract Anniversaries. If you make no partial surrenders, Surrender Values will not be less than the values shown in the Table. We have filed a detailed statement of the method we use to determine values with the state where the policy was delivered. Any paid-up annuity, cash surrender or death benefits that may be available under the Contract are not less than the minimum benefits required by any statute of the state in which the Contract is delivered. i 9901-5586 WSA PA 6 ♦ • • Death Provisions Death of Owner If the Owner of a Contract dies before the Income Date, the death benefit will be paid upon receipt of due proof of death and instructions regarding payment. The death benefit is equal to the Contract Value as of the date of death. If there are joint Owners, the term Owner means the first joint Owner to die. If the Owner is a trust and a beneficial owner of the trust has been designated, the beneficial owner will be treated as the Owner of the Contract solely for the purpose of determining how the death benefit provisions of the Contract apply. If no beneficial owner has been designated, the Annuitant will be treated as the Owner for the purpose of the death benefit provisions. The death benefit will be paid to the joint Owner, if any, otherwise to the Beneficiary; see Priority of Beneficiaries provision. If there is no Beneficiary, the death benefit will be paid to the Owner's estate. Any death benefit will be paid either in one sum or under one of the Income Payment Options of this Contract. Payments must be completed by December 31st of the fifth calendar year immediately following the year of the Owner's death, except that, if the Beneficiary is a natural person and so elects, the payments may be made 1) over the life of the Beneficiary; or 2) according to a fixed schedule which does not extend beyond the life expectancy of the Beneficiary; provided that payments begin within one year from the date of the Owner's death. If the Beneficiary is the legal spouse of the deceased Owner, the Beneficiary may elect to succeed to such rights in this Contract as the Owner held upon his or her death. If the Beneficiary succeeds to these rights, the death benefit will not be paid upon the death of the Owner, and the Contract will remain in force and the Beneficiary will be the Owner. If an Owner dies on or after the Income Date, any payments that remain to be made must be made at least as rapidly as under the Income Payment Option in effect on the date of the Owner's death. Death of Annuitant If the Annuitant dies prior to the Income Date, and a Contingent Annuitant has been named, the Contingent Annuitant becomes the Annuitant (unless the Annuitant is deemed to be the Owner as provided above, in which case the death benefit becomes payable). If there is no Contingent Annuitant when the Annuitant dies prior to the Income Date, the Owner will become the Annuitant. The Owner may designate a new Annuitant within 60 days of the death of the Annuitant. If there is no Contingent Annuitant when the Annuitant dies prior to the Income Date and the Annuitant is deemed to be the Owner as provided above, the Beneficiary will be paid the death benefit then due. The Beneficiary will be as provided in the Beneficiary designation then in effect. If no Beneficiary designation is in effect, or if there is no designated Beneficiary living, the Owner will be the Beneficiary. Priority of Beneficiaries You may designate the Beneficiaries as primary or contingent to indicate the order in which they will receive any death benefit payable. If you name two or more Beneficiaries of the same class, they will share equally unless you state how they are to share. If you identify a Beneficiary as a relative, we will interpret that to mean a relative of the Owner unless you state that the relationship is to another person. If there are joint Owners, any death benefit will be paid to the surviving joint Owner. Otherwise, any death benefit will be paid to the primary Beneficiaries who are living when payment is due. If there are no living primary Beneficiaries, payment will be made to the contingent Beneficiaries who are living when payment is due. If all Beneficiaries have predeceased the Owner, the death benefit will be paid to the Owner's estate. ♦ "01-55as WSA PA 7 FAnly beneficiary who dies within 10 days after the Owner's death will not be entitled to any benefits able on such a death unless that beneficiary is living when we receive due proof of the Owner's th. +++ Income Provisions Income Date On the Income Date, we will start annuity payments under an Income Payment Option or we will pay the Surrender Value in a single sum. The Income Date is the Contract Anniversary on or following the Annuitant's 80th birthday or the 10th Contract Anniversary, if later, unless otherwise indicated on page 3. The Income Date can be changed by sending a written request to us. The new date wilt go into effect when we receive the request. Your written request must be received by us at least 31 days prior to the existing Income Date. The Income Date may not be later than the Annuitant's 85th birthday. Annuity payments will be paid to the Owner unless you designate another payee. You may change the payee at any time by written notice to us. Such notice must be received at our Home Office at least 31 days prior to a payment due date for the change to be effective on such date. An executor, administrator, trustee, corporation, partnership or association other than the Owner may not be a payee without our approval, A payee designation is automatically revoked by the death of the designated payee. If there are remaining guaranteed payments to be made when the Annuitant dies, they will be paid to the Annuitant's estate if the Annuitant is the Owner. If the Annuitant is not the Owner, they will be paid to the Owner. I Form of Payment The minimum Surrender Value that may be applied under an Income Payment Option is $1,000. The amount of income shall be determined by applying the Surrender Value as of the Income Date to that Income Payment Option. If prior to the Income Date no Income Payment Option has been chosen, the Owner will be deemed to have chosen Option 2 - Payments for Life, with monthly payments for 10 years, continuing thereafter during the life of: 1. the Annuitant; or 2. if the Annuitant is no longer living on the Income Date, the contingent Annuitant, if a valid contingent Annuitant has been named; or 3. if neither the Annuitant nor a valid contingent Annuitant is living on the Income Date, the Owner. Choice of option Choice of an option may be made by the Owner by written notice to us on or prior to the Income Date while the Annuitant is living, See Income Payment Options on page 9. Equivalent payments for monthly, quarterly, semi-annual or annual intervals may be chosen. The options are described in terms of monthly payments. We will quote the amount of the other payments upon request. I We may issue a document stating the terms of the option. Lump Sum Removal of Value Applied under a Payment Option .� (Commutation) The Owner, or the Beneficiary if the Owner is no longer living, may take lump sum payments from the remaining proceeds placed under Income Payment Options 1 or 3, though no more than four transactions may be made during any calendar year. The commuted value shall be based on the interest rate used to determine the amount or number of payments. No lump sum removal of value may be made under Options 2, 4 or 5. 9981-5585 WSA PA R • Additional Interest We guarantee interest under all Income Payment Options at a minimum effective annual interest rate of 3% a year. We may increase the interest rate above the minimum on these options. Payments under these options will be based on the interest rate in effect on the due date of the first payment. General Payment Option Terms If the Surrender Value to be placed under an Income Payment Option is less than $1,000, we will pay that amount in one sum. If any payments would be less than $50, we will change the frequency to provide payments of at least $50. If the Surrender Value is assigned on the Income Date, we will pay the assignee's share in one sum and place only the balance under the option. After the Income Date neither the payments nor the remaining value may be assigned or encumbered. The schedule of payments under any operational Income Payment Option may not be extended upon the death of the Owner. ••• Income Payment Options In lieu of a lump sum settlement, all or part of the Surrender Value may be applied under an Income Payment Option. When value is applied under an Income Payment Option, all other rights and benefits under this Contract shall cease. In addition to the following options, other payment options may be available. Option 1 - Payments for a Fixed FIXED PERIOD MINIMUM INCOME TABLE" Period Monthly Payments for each $1,000 applied Equal monthly payments shall be made for a Number Monthly Number Monthly Number Monthly stated number of years, which you select from the of Install- of Install- of Install- Fixed Period Table. The monthly payment will not Years manta Years manta Years mente be less than those shown in the table. 1 $84.47 11 $8.86 21 $5.32 2 42.86 12 8.24 22 5.15 3 28.99 13 7.71 23 4.99 4 22.06 14 7.26 24 4.84 5 17.91 15 6.87 25 4.71 6 15.14 16 6.53 26 4.59 7 13.16 17 6.23 27 4.47 8 11.68 18 5.96 28 4.37 9 10.53 19 5.73 29 4.27 10 9.61 20 5.51 30 4.18 *Values are based on compound interest at 3% a year. Option 2 - Payments for Life - Guaranteed Period Equal monthly payments shall be made for any guaranteed period chosen and thereafter during the life of the Annuitant. The amount of each monthly payment depends on the Annuitant's age and sex on the date of first payment and on any guaranteed period chosen. We may require proof to our satisfaction of such age. We may require like proof that such person is alive on the date any payment is due. The guaranteed period may be 10 or 20 years. ♦ 9901-5585 WSA PA 9 OPTIONS 2 AND 4 • ONE LIFE MINIMUM INCOME TABLE* Monthly Payments for each$7,000 applied Aga of Life Life Life Age of Life Life Life Payee No Years 10 Years 20 Years Pays* No Years 10 Years 20 Yaara Last Certain Certain Certain Last Certain Certain Certain Birth- Birth- day Male Female Male Female Male vemala day Male Pamela Mate Female Male emu 16 and under $2.82 $2.76 $2.81 $2.76 $2.81 $2.76 60 $3.91 $3.66 $3.88 $3.64 $3.80 $3.60 16 2.83 2.77 2.83 2.77 2.82 2.76 51 3.98 3.71 3.94 3.70 3.85 3.65 17 2.84 2.78 2.84 218 2.83 2.78 62 4.05 3.77 4.01 3.76 3.91 3.70 i8 2.86 2.79 2.85 2.79 2.86 2.79 53 4.12 3.83 4.08 3.82 3.96 316 19 2.87 2.80 2.87 2.80 216 2.80 64 4.20 3.90 4.16 3.88 4.02 3.81 20 2.89 2.82 2.88 2.81 2.88 2.81 66 4.28 3.97 4.23 3.95 4.09 3.87 21 2.90 2.83 2.90 2.83 2.89 2.82 So 4.37 4.04 412 4.02 4.15 3.93 22 2.92 2.84 2.91 2.84 2.91 2.84 57 4.47 4.12 4.41 4.09 4.21 3.99 23 2.93 2.86 2.93 2.86 2.93 2.86 58 4.57 4.21 4.50 4.17 428 4.05 24 2.95 2.87 2.95 2.87 2.94 2.87 59 4.67 420 4.60 4.25 4.35 4.12 25 2.97 2.89 2.97 2.89 2.96 2.88 60 4.79 4.39 410 4.34 4.42 4.19 26 2.99 2.90 2.99 2.90 2.98 2.90 61 4.91 4.49 4.81 4.44 4.49 426 27 3.01 2.92 3.01 2.92 3.00 2.92 62 5.04 4.60 4.92 4.64 4.56 4.33 28 3.03 2.94 3.03 2.94 3.02 2.93 63 5.18 4.71 5.04 4.64 4.63 4.41 29 3.05 2.96 105 2.96 3.04 2.95 $4 5.33 4.84 5.17 415 4.70 4.49 30 3.08 2.98 3.07 2.97 3.07 2.97 65 5.49 4.97 5.30 4.87 416 4.56 31 3.10 3.00 3.10 3.00 3.09 2.99 66 5.66 5.11 5.44 6.00 4.83 4.64 32 3.13 3.02 3.12 102 3.11 3.01 67 5.85 5.26 5.59 6.13 4.90 4.72 33 3.15 3.04 3.15 3.04 3.14 3.03 68 6.04 5.43 6.74 527 4.96 4.79 34 3.18 3.06 3.18 3.06 3.17 3.06 69 6.25 5.60 5.89 6.42 5.03 4.87 35 3.21 3.09 321 3.09 3.20 3.08 70 6.48 5.80 6.06 5.58 5.08 4.94 36 3.25 3.12 3.24 3.11 3.22 3.10 71 6.71 6.00 6.22 6.75 5.14 5.01 37 3.28 3.14 3.27 3.14 3.26 3.13 72 6.97 623 6.39 5.92 5.19 6.08 38 3.32 3.17 3.31 3.17 3.29 3.16 73 7.24 6.47 6.67 6.10 624 5.14 39 3.35 320 3.35 3.20 3.32 3.19 74 7.53 6.73 6.75 6.29 5.28 520 40 3.39 3.23 3.38 3.23 3.36 3.22 76 7.84 7.02 6.93 6.49 5.32 526 41 143 3.27 3.42 3.26 3.39 325 75 8.18 7.33 7.12 6.69 5.35 5.29 42 3.48 3.30 3.47 3.30 3.43 3.28 77 8.53 7.66 7.30 6.90 5.38 5.34 43 3.52 3.34 3.51 3.33 3.47 3.31 78 8.92 8.02 7.48 7.11 5.41 5.37 44 3-57 3.38 3.56 3.37 3.51 3.35 79 9.33 8.42 7.67 7.32 5.43 5.40 45 3.62 3.42 3.60 3.41 3.56 3.39 80 9.77 8.85 7.85 7.53 5.45 5.43 46 3.67 3.46 3.65 3.45 3.60 3.43 81 10.24 9.31 8.02 7.73 5.47 5.45 47 3.73 3.51 3.71 3.50 3.65 3.47 82 1076 9.82 8.19 7.93 5.48 5.47 48 3.78 3.55 3.76 3.54 310 3.61 83 11.29 10.37 8.35 8.13 5.49 5.48 49 3.84 3.60 3.82 3.59 3.76 3.56 84 11.87 10.96 8.50 8.31 5.50 5.49 86 and 12.49 11.61 8.64 8.48 5.50 5.60 over *Values are based on the "Annuity 2000 Table,"with Projection Scale G, adjusted for age last birthday, with interest at an effective annual rate of 3%. Orion 3 - Payments of a Fixed Amount Equal monthly payments of a fixed amount shall be made until the value applied under this option, with interest credited on the unused balance, is exhausted. The amount chosen must be at least $5 per month for each $1,000 of proceeds placed under this option. The last payment will be for the balance only. Payments may not be for more than 30 years. Option 4 - Life Annuity - No Guaranteed Period Equal monthly payments will be made during the life of the Annuitant. The amount of each monthly payment depends on the Annuitant's sex and age an the date of first payment. We may require proof to our satisfaction of such age and we may require proof that such person is alive on the date any payment is due. There is no guaranteed period. This means that when the Annuitant dies no further payments will be made, even if only one payment has been made. 9901-5585 WSA PA 10 Option 5 - Joint and Survivor Equal monthly payments shall be made during the lifetimes of two designated persons. Upon the death of either, payments will continue to the survivor or may be reduced to a preselected percentage (75%, 66 2/3%, or 50%n) of the original payment. Payments will cease upon the death of the survivor. The amount of each monthly payment depends on the ages and sexes of both persons on the date of first payment, and the preselected percentage for continuing payments. The payments for each $1,000 applied will not be less than those in the Joint and Survivor Table. Values not illustrated in the Table are available upon request. We may require proof to our satisfaction of their ages. We may require like proof that any designated person is alive on the date any payment based upon the life of such person is due. JOINT AND SURVIVOR MINIMUM INCOME TABLE* Sample Monthly Payments for each$1,000 applied Male Female Joint & Joint & Joint & Joint& Age Age 100% 75% 662/3% 50% Survivor Survivor Survivor Survivor 60 60 $3.93 $4.23 $4.34 $4.58 60 65 4.14 4.48 4.61 4.88 60 70 4.34 4.75 4.90 5.24 65 60 4.07 4.44 4.58 4.88 65 65 4.36 4.75 4.90 5.22 65 70 4.66 5.10 5.27 5.64 70 60 4.18 4.65 4.83 5.23 70 65 4.56 5.03 5.22 5.62 70 70 4.97 5.48 5.68 6.12 *Values are based on the "Annuity 2000 Table,"with Projection Scale G, adjusted for age last birthday, with interest at an effective annual rate of 317c. ♦ ' '�' General Provisions Annual Report On each Contract Anniversary, we will provide a report which will be mailed to the Owner. It will show the Contract Value, surrender value, premium payments, annual interest rate(s) applied to each premium payment, interest credited, withdrawals made and any applicable charges. Statements In Application All statements made in the application are considered to be representations and not warranties. No statement will be used in defense of a claim unless it is in the application. Modification Of Contract Any change in the Contract or waiver of its provisions must be in writing and signed by our Chairman, President or Secretary. No other person can change or waive any of its provisions. Incontestability The Contract will be incontestable after it has been in force during the Owner's lifetime for two years from the Contract Date. "OlA585 WSA PA 11 Incorrect Age Or Sex If the age or sex of the Annuitant has been misstated, we will adjust all benefits to those that the premium (s) for the Contract would have purchased for the correct age and sex. Any overpayments we make will be charged with compound interest against subsequent payments. Any amounts we owe as a result of underpayments will be paid with compound interest upon receipt of notice of the underpayment. The rate will be the rate we use to determine the number or amount of the payments or 6%, whichever is less. Place Of Payment We will make all payments due under the Contract at our Home Office. Submission Of Contract We may ask you to relinquish the Contract or send it to us for endorsement before we make any payment. Failure to have you relinquish the Contract or to note payment on it does not indicate that we have not made payment. Creclitors' Claims All payments under the Contract will be exempt from the claims of creditors and legal process to the extent permitted by law. No payment will be transferred, assigned or withdrawn before it becomes payable unless we agree. Proof Of Facts We may ask any person claiming the right to payments for proof satisfactory to us of such person's right to payment. Any payment we make relying on that proof discharges us from any obligation to make that payment to another person. We will require proof of date of birth of the person(s) on whose life (or lives) payments are based. Non-Participating This Contract does not participate in surplus earnings of the Company. 9901-SSSS WSA PA 12 REV-1511 EX+(10-09) pennsytvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: EXPENSE H°.1'&^ r F;w 0. l 1.7 tLN Rt U N B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Years)Commission Paid: 2. Attorney Fees: 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. P.DEAN HOMER FUNERAL HOME 206 Water Street PO Box I Dushore,PA 18614 Tel 570 928-8163 Fax 570 928-8116 December 18,2012 Funeral Expenses of Mrs.Philomena T. Klein Professional Services,Use of Facilities&Equipment 4,245.00 Casket-Stainless Steel 4,740.00 Concrete reinforced stainless steel lined vault 2.785.00 Total Funeral Home Charges 11.770.00 Cash Advances: Opening&Closing Grave 500.00 Jackhammer at Grave 100.00 10 Transcripts&Burial Permit 60.00 Mass at St.Francis 150.00 Daily Review 70.00 Cemetery Fee 100.00 Flowers 996.40 Patriot News 415.77 Singer&Organist 125.00 St.Francis Hall 50.00 Hairdresser 50.00 The Sullivan Review 143.50 Saturday Vault Charge 50.00 Total Cash Advances 2.810.67 Other Charges Lettering of Tombstone 165.00 Transportation from Mechanicsburt Milage 285.60 Driver 145.00 Total Other Charges 595.60 Total 15,176.27 WYIALUSING HC YM al ANNEX CAnMG Philomena Klein Funeral Luncheon Saturday,December 22nd Noon Start Mildred(Community Hall across from St.Francis Church) 120 ppl. Contact:Ashley Klein(570)220-6070 Menu Salad Lasagna Chicken Mozzarella Meatballs Garlic Bread Green Beans Cake w/Icing Iced Tea/Lemonade/Coffee Additional Supplies Chafers/Fuel Real Dishes/Silverware/Etc. Serving Utensils Banquet Table Linens$7 ea. Price $22 22/Person=$2640-0 6%Sales Tax=$158.°4 25%Gratuity=$660.0 19 Banquet Table Linens @$7.9 ea.=$133.0 Grand Total=$3591.0 54 Main SL P.O.Box 730•Wyalusing,PA 18853•Phone:570.745.1204•Fax:570.746.1247 REV-1512 EX+(12-08) iftpennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medial expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&ssi-►Y\ L; � c►,►lk 3 k7- Mtss)x�L, U1LL�� , x,733• 9 ��' TOTAL(Also enter on Line 10, Recapitulation) $ If more space is needed,insert additional sheets of the same size. Vol MESSIAH .,� E,�.a �r � �__ - - _ �_._ Form PB-01 AN Lifewa at MESSIAH VILLAGE YS 100 MT.ALLEN DRIVE,MECHANICSBURG,PA 17055 RESIDENT# UNIT STMT. DATE 10513 022 W 12/3112012 RESIDENT(S) MICHAEL KLEIN Mrs.PHILOMENA T.KLEIN 336 WEST MEADOW DRIVE MECHANICSBURG,PA 17055 TOTAL AMOUNT DUE [-$2,733.29 DATE DUE 01/3112013 DATE DESCRIPTION RATE DaW CHARGES CREDITS BALANCE Balance Forward 5,415.07 12/20/2012 PAYMENT RECEIVED-THANK YOUM 5,415.07 0.00 ***Nursing Care *** 12/01/2012 MEAL CREDIT -12.0016.00 192.00 -192.00 *** Enhanced Living*** 12/01/2012 PATRIOT NEWS-WEEKDAY 12/01-12/16 9.42 1.00 9.42 -182.58 12/01/2012 SUNDAY NEWS 12/01-12/16 3.87 1.00 3.87 -178.71 12/16/2012 ELHS-JUNIATA SINGLE 12/01-12/16 182.00 16.00 2,912.00 2,733.29 RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 10513 2,733.29 0.00 0.00 0.00 0.00 $2,733.29 RESIDENT NAME Mrs.PHILOMENA T. KLEIN ForM P"i WA Please make check payable to Messiah Lifeways at Messiah Village. A 1%finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! H you have any questions or concerns about your bill,please address them directly to Fiscal Services at 790-8220. Thank You! REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. �aP,rt►��.-1�'� SrMd►") - 3o Sov}in C�►�z s�s � �c��, ash,o� �;4,4,T� v�lLSf�f Lt_t5 � dt�►d �53$d S*Rs SoIJ did � b� i '�ass,(L►��1� ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.,CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. 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.