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Home My WebLink About07-03-13 � 1505610143 REV-1300 EX`°Z-,,, `�' OFFICIAL USE ONLY PA Department of Revenue pennsylvania co�my coaa vear File NumEer Bureau of Individual Taxes �•^*��*^�•�E PO BOX.280601 INHERITANCE TAX RETURN pl 12 1156 Herrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 10 09 2012 08 09 1921 Decedent's Last Name Suffix DecedenYs First Name MI ZOOK BETTY M (If Applicable)Enter Survlving Spouse's Informatfon Below Spouse's Last Name Suffx Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Retum � 2. Supplamenql Return � 3. Remaintler Retum(Date of Death Pnorto 12-13-82) � 4. Limitetl EsWte � 42. Fulure Intarect Compromiae � 5. Federal Estate Tax Return Required �date of deeth atler 12-12-82) g Decatlant Dietl Teatete � peu t Main1 neO a LivinB T�+et � 8. TOttl NumbB�Of Sa/e De Slt BOXES � (Attech Copy W Wilp ❑ (Atl��LOpy o(4ruat) � C 9. Litiga�ion PrOCeeds Recelvetl � 10.��Pgv��raedat{Oe�s�f Oaeth � ��,EleCtion�01�(undef Sec.9113(A) (Attach Schedule O) CORRESPONDENT•THIS SECTION MUST BE COMPLETED.A�L CORRESPONDENCE AND CONiIDENTIAL TA%INFORMATION SMOULD BE DIRECTED TO: Name Daytime Telephone Number EDMUND G MYERS (717) 761 4540 RA ISTER OP V�IItiS USE�JJLY C `-^' � m Firat Line of Address W � � � n _ a 301 MARKET STREET r'� _ � ' '' "' r _ � Second Line of Address n � � CJ �; c3 PO BOX 10 9 c� � �` ° ° r� �, -c -n -�� City or Post Office State ZIP Code � C �TE{�ED-�- �� LEMOYNE PA 17043 ro -a+ ~ = � n cn U' � w correapondenes e-maii addross: egm�jdsw.com Untler penaltiea of perjury,I declere that I have examined Mis reNm,including accompanyinp pchedules antl atatements,and to the beat of my knowledge and belief, it ia true,correct entl complete.Declarotion of preparer oMer than the peBOnal represenW6ve ia based on all information ot which preparer hes any knowledge. SIGNFTURE PERSON RESPONSIBL OR FILING ftET N DATE ��?,A� � �j a4J� Norman F Zook `�I I I � ADDRE55 733 West Locust Street- Unit 201. Mechanicsbura, PA 17055 SIGNATU OF PREPARER OT R THAN REPRESENTATIVE DATE , �,u,� Edmund G. Myers � I � LI � AD�RE$$ 1 301 MARKET STREET, Lemoyne, PA Side 1 L 1505610143 1505610143 J �� J 1505610243 REV-1500 EX DecedenCs Social Security Number Decetlent'eNeme: ZOOIC, Betty Mae RECAPITULATION 1. Real Estate(SChedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietarship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property(Schedule E)............... 5. 37 , 672 . 07 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Trensfers&Miscellaneous�oq Probate Property (Schedule G) U Separate Billing Requested............ 7. 232 , 5 0 B . 62 8. ToWI Gross Assets(total Lines 1 through 7)........................................................ 8. 2 7 0 � 1 B 0 . 69 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 13�481 . 04 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 12 �340 . 68 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 2$ , 821 . 72 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 244 � 35 B . 97 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an eledion to tax has not been made(Schedule J)............................................... 13. ta. Net Value Sub)ectto 7ax(Line�2 minus Line�3)............................................... 7a. 244 � 358 . 97 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Lina 14 taxable at the spousal tax rate,or transfers under Sec.91 i6 (a)(1.2)X.00 15. � . 0� i6. Amount of Line 14 taxable 244� 358 . 97 �s. 10 � 996. 15 at lineal rate X .045 17. Amount of Line 14 taxable at sibling rete X .12 0 . 00 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 0 . 00 18. 0 . 00 19. TAX DUE................................................................................................................ 19. ZO � 996. 15 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Side 2 L 1505610243 1505610243 � REV-1500 EX Page 3 File Number 21-'12-1'156 DecedenYs Complete Address: DECEDENT'S NAME Zook, Beriy Mae STREETADDRESS Messiah Village 100 Mt.Allsn Drive CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) 70,996.15 2. Credits/Payments A. Prior Paymants 9,000.00 B. Discount 473.68 Total Credits(A +B) (2) 9,473.66 3. Interest (3) q. If Line 2 is greater than Line 7 +Line 3,enter the difference. This is the OVERPAYMENT. (q) Check box on Pape 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) ��522.47 Make Check Pa able to: REGISTER OF WILLS AGENT. PLEASE ANSWER THE FOLLOWING �UESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of tha property transferred:............................................................................... ❑ b. retain the right to designale who shall usa tha property transferred or its income:.................................. ❑ � c. retain a reversionary interest:or............................................................................................................... � � d. receive the promise for life of either payments,benefits or wre?............................................................ x 2. If death occurred after Dec. 12, 1982, did decedent trensfer property within one year of death without receiving adequate consideration7.................................................................................................................... ❑ ❑X 3. Did decedent own an"in trust fo�' or payabla upon dealh bank account or security at his or her death?....... ❑ ❑x 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneflciary designation7.................................................................................................................. ❑X ❑ IF THE ANSWER TO ANY OF THE ABOVE�UESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 7, 1994 and before Jan. 1, 1995,the tax rete imposed on the net value of transfers to or for the use of the surviving spouse is 3 parcent(72 P.S.§9176(a)(1.1)(i)]. For dates of death on or after January 1,1995,the tax rete imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. 7he statute does not exempt a trensfar to a surviving spouse from tax,and tha 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 atter July 1,2000: • The tax rate imposed an 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 parant,an adoptive parent,or a stepparent of the ehild 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 lhe decedent's 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 trensfars to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(e)(1.3)]. A sibling is defined under Section 9102,as an individual who has et least one parent in common with the decedent,whether by blood or adoption. Rw-1608 EX+(71-70) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, 8� MISC. DEPARTMENT OF REVENUE INHERITANCETAXRETUftN PERSONAL PROPERTY RESIDENT�ECEDENT ESTATE OF FILE NUMBER Zook, Betty Mae 21-12-1756 All propsrty'jalntlyo�wn tllwllh�lhs rlpht Wsunlvon�i�p mu t ba tll�seloseOtl an sch�etlula F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Highmark•Reimbursement 151.55 2 Members First Checking Account No.440967-11 749.28 3 Members First Investment Savings Account No.440861•05 31,146.70 4 Members First Regular Savings Account No.440961-00 4,725.14 5 Personal property-Inventoried and appreised by C.G. Buser 1,500.00 TOTAL(Also enter on Line 5, Recapitulation) 37,672.07 (II more apace is needed,adtlitional pages of Me sama size) Copyright(c)2010 fo�m software only The Lackner Group, Inc. Fortn PA-1500 Schedule E(Rev. 11-10) __. . _._... . . Xev-1670 E%+�0E-08) SCHEDULE G pennsylvania lNTER-VIVOS TRANSFERS AND DEPARTMENT OF REVENUE INMERITANCETA%RETURN MISC. NON-PROBATE PROPERTY RESI�ENT DECEDENT ESTATE OF FILE NUMBER Zook, Betty Mae 21-12-1156 T�ie echetivle muet be wmpletetl antl 91etl H t�e enswer 10 eny ot queatione t t�rouph 4 on pape Mree W the REV-1500 ia yee. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TR�ANSFERSATTACHTA COPVEOF TIHE DEED F�OREREAL ESTATE. VALUE OF ASSET INTEREST (�F APPLICABLE) VALUE 1 AIIsWte Annuity Controct No. GA79265348- 232,506.62 232,508.82 Beneficiary: Norman F.Zook,Son Value of Annuity as of Date of Death TOTAL(Also enter on Line 7, Recapitulation) 232,508.62 (It more apace is neetled,atltlitional pages o1 the same size) Copyright(c)2009 form soilware only The Lackner Group, Inc. Form PA-7500 Schedule G(Rev.08-08) REV-08N E%��10-09) pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND RESIDENTDEC ENTTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Zook, Betty Mae 27-12-1156 DecedenYs debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuatfon schedule(s)attached 9,252.73 B. ADMINISTRATIVE COSTS: 1. Peraonal Representative's Commissions Name of Personal Representative(s) Street Address City State _ Zio Year(s)Commission Paid p, AttorneYs Fees JOHNSON DUFFIE 3,250.00 3, Family Examption: (If decedenYs address is not the same as claimant's,attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 4. Probate Fees 153.50 5. AccountanPs Fees 6. Tax Return Preparer's Fees 717.00 7. Other Administrative Costs 707.81 See continuation schedule(s)attached TOTAL(Also enter on Iine 9, Recapltulatfon) 13,487.04 Copyright(c)2009 form software only The Lackner Group,Inc. Fortn PA-7500 Schedule H(Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Zook, Betty Mae 21-12-1156 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 7 Malpeui Funeral Home-Funeral Services 9,252.73 H-A 9,252.73 Other Adminlstrative Costs 2 Alert Pharmacy-Prescriptions Invoice 106.74 3 Alert Pharmacy-Preacriptions•Final invoice 88.63 4 C.G. Buser-Breakdown of Jewelry items 106.00 5 Cumberland County Registerof Wills O�ce-Filing Fees for Inheritance Tax Return and 30.00 Inventory 6 Reserves: Miscellaneous Costs and Expenses 150.00 7 The Cumberland Law Journal-Notice of Estate Administratfon 75.00 8 The Patriot News Co. -Notice of Estate Administration 141.24 H-67 707.61 Copyright(c)2002 form soilware only The Lacknar Group,Inc. Form PA-1600 Schedule H(Rev.6-98) Rev-7612 EX��12-08) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 2ook, Betty Mae 27-12-1156 Repon tleEb Incumtl by Ihe tlwMSnt prlor to MHh t�at nm�IneE unpelE�t tha data oT C�ap�,lnclutlinp unrolmburwd mWle�l e:penw. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Messiah Village-Final Invoice for Nursing Home Care 72,340.68 TOTAL(Also enter on Line 70, Recapitulation) 72,340.68 (If more space Is neetled,atlditional peges of the seme size) Copyright(c)2008 form soilware only The Lackner Group,Inc. Fortn PA-7500 Schedule I(Rev. 12-08) REV-7577 EX+�O7�10) pennaylvania SCHEDULE J OEPARTMENTOFREVENUE INMERITANCE TA%RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Zook, Be Mae 21-12-1156 RELATIONSHIP TO NAME AND ADDRESS OF SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (yyords) ($$$) I TAXABLE DISTRIBUT�ONS [include outright spousel distributions,end trensfers under Sec.9116 a 12 7 Larry E Patrick Son 20% of Residue 150 Kennedy Lane Dauphin, PA 17018 2 Norman Zook Son Personal 133 West Locust Street Property; 80%of Apt. 207 Residue Mechanicsburg, PA 17055 Total Enter dollar amounts fot distributiona shown above on lines 15 throu h 78 on Rev 7500 cover sheet as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form soflware only The Laekner Group, Inc. Form PA-1500 Schedule J(Rev. 01-10) ESTATE OF BETTYMAE ZOOK a./ka BETTYM. ZOOK SCHEDULE OFEXHIBITS EXHIBITA Last Will and Testament .for Betry M. Zook signed and dated October 27, 2005. EXIYIBIT B Copy of Receipt of Pre-Payment of Inheritance Taxes on December 19, 2012 EXHIBIT C Date of Death Letter from Members First Federal Credit Union for Decedent's Savings, Checking and Investment Accounts EXHIBIT D Allstate Annuity Account. Value of Annuity on Date of Death 566817 i �.a�t �irY a�nD� �e�t�mcent OF BETTY M. ZOOK I, BETTY M. ZOOK, of Silver Spring Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoldng and making void any and all Wills or Codicils at any time heretofore made by me. AR'1TCLE I DEBTS I direct the payment of all my legal debts and the expenses of my last illness and funeral from my Estate as soon after my death as conveniently may be done. ARTICLE II TANGIBLE PERSONAL PROPERTY I give and bequeath my motor vehicles(s),household and personal effects and other tangible personalty of like nahue (not including cash or securities), together with any existing insurance thereon, unto my son NORMAN F. ZOOK, provided he survives me by thirty(30) days. In the event that my son, NORMAN F. ZOOK, is not living on the thirty-first (31st) day following my death, I direct that such tangible personalty and insurance thereon shall be distributed as part of my residuary estate. � � h J F�a �/ � ARTICLEIII REST,RESIDUE AND REMAINDER I give, devise and bequeath all the rest, residue, and remainder of my Estate, of whatsoever nature and wheresoever situate, as follows: A. 80%thereof unto my son,NORMAN F. ZOOK. If my son, NORMAN F. ZOOK, is not living on the thirty-first (31st) day following my death, I give and bequeath his shaze to his wife, DOROTHY E. ZOOK, and if his wife, DOROTHY E. ZOOK, is not living on the thirty-first (31st) day following my death, I give and bequeath the shaze of my son, NORMAN F. ZOOK,to lus son, ZACHARY T.ZOOK B. 20% thereof unto my son, LARRY E. PATRICK If my son, LARRY E. PATRICK, is not living on the thirty-first (31st) day following my death, I give and bequeath his shaze to his wife, DORIS J. PATRICK, and if his wife, DORIS J. PATRICK, is not living on the thirty-first (31st) day following my death, I give and bequeath the shaze of my son, LARRY E. PATRICK, in equal shazes, to his cluldren, ROBERT PATRICK, JAY PATRICK, RAY PATRICK, and PATRICIA MTI'CHELL. AATICLE IV EXCLUSION I have made no provision in this my last will and testament for my son, Thomas A. Patrick, as I do not intend for him to receive any shaze of my estate. 2 ARTICLE V UNIFORM TRANSFERS TO MINORS In the event any beneficiary of my Will has not reached the age of twenty-five (25) yeazs at die time for distriburion of his or her share, dis4ibution of said shaze may be made in the discrerion of my Personal Representative after considering the age and needs of the beneficiary, either directly to the beneficiary or to a Custodian for such beneficiary until age twenty-five (25) under the Pennsylvania Uniform Transfers to Muiors Act, 20 Pa. C.S.A § 5301 et seq., or the applicable Uniform Gifts to Minors Act or Uniform Transfers to Minors Act in the state of residence of such beneficiary as the case may be. My Personal Representative may designate as such Custodian any insritution or person, including my Personal Representative, qualified to act as a Custodian for such beneficiary under such Act in effect at the time such distribution is made. A receipt for any payment or distribution so made shall be a full dischazge therefor to my Personal Representative, who shall not be responsible to see to, or be liable for,the application of such proceeds thereafter. ARTICLE V TAXES I direct that all taxes that may be assessed in consequence of my death, of whatever nature or by whatever jurisdiction imposed, shall be paid out of my residuary estate as a part of the expense of the administration of my estate. ARTICLE VI PERSONAL REPRESEPiTATIVE I name, constitute and appoint my son, NORMAN F. ZOOK, Executor of this my Last Will and Testament. Should my son, NORMAN F. ZOOK, fail to qualify or cease to so act, I name, constitute and appoint my son, LARRY E. PATRICK, alternate Executor to complete the 3 _ __ _ _ administration of my estate. I direct that no fiduciary appointed herein shall be required to post bond for the faithful administration required in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this,my Last Will and Testament,this d 7TXday of ��r 2 q E�p 2005. YJ � � � (SEAL) BETTY M. OOK Signed, sealed, published and declazed by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us,who at her request, in her presence and in the presence of each other,have hereunto subscribed our names as witnesses. � ,C15 s�l��/� ,^� AFFIDAVIT AND ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVAIVIA . : SS COUNTY OF CUMBERLAND . We, BETTY M. ZOOK, and (,V,,Ii� �J/tpdP/' , and r ' the e�d the witnesses, respectively, whose 7 � names aze signed to the attached or foregoing instrument,being fust duly swom, do hereby declaze to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly and that she executed it as her free and voluntary act for the purposes therein e�cpressed, and that each of the witnesses, in the presence and hearing of the 4 Testatrix, signed the Will as witness and that to the best of lus lmowledge the Testatrix was at that time eighteen yeazs of age or older,of sound mind and under no constraint or undue influence. �� BETTY M OOK �G�..��1%ll��O1^'�- Witnes itne ��. � Subscribed, swom to and aclmowledged before me by BETTY M. ZOOK, Testatrix, and subscribed and sworn to before me by ��' and i � �witnesses,this day of �,� , ,2005. COMMONWEALTH OF PENNSriVANIA __ I NOTARIAL SEAL Notary b1iC I CARLEEN S. JENSEN, Notary Public f Lemoyne Boro.,Cumbedand County ( My Commission Expires Dec.17,2007 2G1771 5 COMMONWEALTN OF PENNSVLVANIA REV-7162 EX�i 1-96� DEPAPTMENT OFREVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 1]128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 016951 ZOOK NORMAN F 133 WEST LOCUST STREET UNIT 201 MECHANCISBURG, PA 17055 ACN ASSESSMENT AMOUNT CONTROL NUMBER ------ �o�d ---------- -------- 101 � 59,000.00 ESTATE INFORMATION: SSN: I FILE NUMBER: 2112-1156 � DECEDENT NAME: ZOOK BETTY MAE I DATEOFPAYMENT: 12/20/2012 I POSTMARK DATE: 1 2/19/2012 I COUNrY: CUMBERLAND � DATE OF DEATH: 10/09/2012 I � TOTAL AMOUNT PAID: 59,000.00 REMARKS: RECEIPT TO ATTY CHECK# 094 INITIALS: HMW SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER . � � F�bibi� a �— � a � St � MEMBERS 1°� P�HRALCRBDIT UMON REGULAR SAVINGS ACCOUNT: Account NumbedSuffix 440961A0 Date Account Established 11/23/2011 Principal Balance at Date of Death $4,124.91 Accrued Interest to Date of Death $0.23 Total Principal and Accrued Interest $4,125.14 Name of Joint Owner None CHECKING ACCOUNT: Account NumbeNSu�x 440961-11 Date Account Established 11/23/2011 Principal Balance at Date ot Death $749.19 Accrued Interest to Date of Death $0.09 Total Principal and Accrued Interest $749.28 Name of Joint Owner None INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix 440961-05 Date Account Established 11/23/2011 Principal Balance at Date of Death $31,143.38 Accrued Interest to Date of Death $2.72 Total Principal and Accrued Interest $31,146.10 Name of Joint Owner None MEMBERS 15T FEDERAL CREDIT UNION `J.�.O�-s�../[' / Tessa L Klugh Lending Insurance Support Specialist November 30, 2012 Estate of: BETTY M ZOOK Date of Death: 70/08/2012 Social Security Number: 177-16-0790 RECEIVED . � � a � a 5000 Louise Drive • P.O. Box 40 • Mechanicsbuxg,Pennsylvania 17055 • (800) 283-2328 • www.membesslst.oxg � Allstate� You're in good hands. December 5, 2012 Norman F. Zook 133 W. Locust St. Unit 201 Mechanicsburg, PA 17055 Re: Betty M. Zook Contract No: GA19265348 Dear Mr. Zook: We received a request to compiete IRS Form 712 for the above referenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contrect or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the contract). Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the following information for estate purposes: Date of Death: October 9,2012 Annuity Value as of Date of Death: 232 5 * Cncf Rasis: 02,876.1 Named 8eneficiary: orman . ook *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-641 S Ext. 23329. Sincerely, Leah Shoman Senior Claim Examiner s AIIsEete Life Insurance Company W � Life and Annuity Cla(ma � P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635 " �