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HomeMy WebLinkAbout10-15-13 (2) 1505610140 REV-1500 EX (0140) PA Department of Revenue OFFICIAL.USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 3 0 6 4 0 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYWY Date of Birth MMDDYYYY 0 4 2 4 2 0 1 3 0 4 1 8 1 9 2 6 Decedent's Last Name Suffix Decedent's First Name MI S H U G H A R T Id R 0 8 E R 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 FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW © 1,Original Return 2.Supplemental Return ❑ 3.Remainder Return(date of death prior to 12-13-82) 4.Limited Estate 4a.Future interest Compromise(date of n 5.Federal Estate Tax Return Required death after 12.12.82) ® 6.Decedent Died Testate [] 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) n 9. Litigation Proceeds Received E] 10.Spousal Poverty Credit(date of death n 11.Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch,O) r" CORRESPONDENT-THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX IMF,._ RON SHOOLD BE DIREFED TO: Name Daytime_i`etep�i one Number 77r cy M A R C U S A M c K N I G H T I I I 7 1 �7 : r-A ct-� 2 r3 :5 3 REG1S'17ER-OF MlII- SE ONLY> ;.r • , �7 cs c7 First line of address �'� _J I R W I N & M c K N I G H T P C - ;« `rI -t r- 0 0 Second line of address 6 0 W E S T P 0 M F R E T S T R E E T City or Post Office State ZIP Code DATE FILED C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the beet of my knowledge and belief, it is true,conect and complete.Declaration of preparer other than the personal representative Is based on all Information of which prepwer has any knowledge. SIG TORE O ER$O,Ip RESP NSt9 E FOR FILING RETURN �p D/TE ADDRESS cGVfLUrt �T� � _ 106 SYCAM E DR MT. HOLLY SPRINGS PA 17065 SIG PREP RER OTH HAN REPRESENTATIVE E� ADD SS 6 WEST POMFRET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: W . ROBERT SHUGHART 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. 1 5 1 8 6 , 5 0 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 4 2 6 2 7 , 7 7 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 4 6 6 6 9 , 7 8 (Schedule G) ❑ Separate Billing Requested . . . . . . . 7. 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . I . . . . . . . . . . . . . . . . . . . 8. 1 0 4 4 8 4 , 0 5 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 1 5 6 8 7 . 7 3 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) . . . . . . . . . . . . . 10. 2 0 • 0 0 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 1 5 7 0 7 . 7 3 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 8 8 7 7 6 . 3 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .. . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) .. . . . . . . . . . . . . . . . . . . . . 14. 8 8 7 7 6 . 3 2 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 _ 4 3 8 . 1 9 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X.045 8 8 3 3 8 . 1 3 16. 3 9 7 S . 2 2 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE 3 9 7 5 . 2 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 L 1505610240 1505610240 REV-15M Ex Page 3 Fire Number Decedent's Complete Address: 21 13 0640 DECEDENT`S NAME W. ROBERT SHLIGHART STREETADDRESS 106 SYCAMORE DRIVE CRY STATE LP MT. HOLLY SPRINGS I PA 17065 Tax Payments and Credits: I. Tax Due(Page 2,Une 19) (1) 3,975.22 2, Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Une 2 is greater than Line 1 +Une 3,enter the difference.This is the OVERPAYMENT. Fill In oval on Page 2,Une 20 to request a refund. (4) 0.00 5, If Une 1+Une 3 is greater than Une 2,enter the difference.This is the TAX DUE. (5) 3,975.22 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred: ...................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income; ............................... ❑ c. retain a reversionary interest;or ................................................................................................ ❑ d, receive the promise for life of ether payments,benefits or cam? ....................................................... ❑ 2. if death occurred after December 112,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 3. Did decedent own an'in trust for'or payable-uponMeath bank account or security at his or her death? ......... ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ® ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(1)]. For dates of death on or after Jan.1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent ]72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is 4.5 percent,except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent[72 P.S.§9116(8)(1.3)].A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1508 EX-(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. (RESIDENT DECEDENT U� PERSONAL PROPERTY ESTATE OF: FILE NUMBER: W. ROBERT SHUGHART 21 13 0640 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T BANK-CHECKING ACCOUNT#9861590413 2,950.96 2. MEMBERS 1ST FEDERAL CREDIT UNION 12,235.54 SAVINGS ACCOUNT#140318-00 TOTAL(Also enter on Line 5,Recapitulation) $ 15 186.50 If more space is needed,use additional sheets of paper of the same size. REV-15%EXr(01-ta) pennsylvania SCHEDULE iF OEPARTMENTOF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN - RESIDENT DECEDENT ESTATE OF: FILE NUMBER W. ROBERT SHUGHART 21 13 0640 If an asset was made Jointly owned within one year of the decedents date of death,it must be reported on Schedule G. SURWNG JOINT TENANT(S)NAME(S)- ADDRESS RELATIONSHIP TO DECEDENT A.WAYNE ROBERT SHUGHART 44 SCHOOL HOUSE ROAD SON GARDNERS, PA 17324 8. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FORJOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEEDFORJOINTLY-HELAREAL ESTATE, VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 02/1995 OPPENHEIMER 83,336.70 50. 41,668.35 ACCOUNT#A25-0015227-B84 2. A. M&T BANK-CHECKING ACCOUNT#507916 1,918.83 50. 959.42 TOTAL(Also enter on Line 6,Recapitulation) E 42 627.77 If more space is needed,use additronal streets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER W. ROBERT SHUGHART 21 13 0640 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDETHE NAME OF THE TRANSFEREE,THEIR RELARONSHIPTO DECEDENTAND DATE OF DEATH % DECUS EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH ACO"OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST nrrraOCnat1 VALUE 1. TRANSAMERICA LIFE INSURANCE COMPANY 23,001.10 100.00 23,001.10 ANNUITY#02CBT115440 BENEFICIARY: W. ROBERT SHUGHART 2. METLIFE-ANNUITY#9200748080 16,897.43100.00 16,897.43 BENEFICIARY: W. ROBERT SHUGHART 3. METLIFE -ANNUITY#9200762974 6,771.25 100.00 6,771.25 BENEFICIARY: W. ROBERT SHUGHART 0.00 TOTAL (Also enter on Line 7,Recapitulation) 46 669.78 If more space is needed,use additional sheets of paper of the same size. REV-1511 EXF(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER W. ROBERT SHUGHART 21 13 0640 Decedertrs debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOLLINGER FUNERAL HOME 11,254.69 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representalive(s) Sheet Address City State ZIP Years)Commission Paid: 2, AttomeyFees: IRWIN &MCKNIGHT, P.C. 3,500.00 3. Family Exemption:(If decedents address is not the same as claimaets,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: REGISTER OF WILLS 153.50 6 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 500.00 INCOME TAX AND FINAL FIDUCIARY TAX RETURN 7. THE SENTINEL-ESTATE NOTICE 189.54 8. CUMBERLAND LAW JOURNAL-ESTATE NOTICE 75.00 9. NOTARY FEES 15.00 TOTAL(Also enter on Une 9,Recapitulation) 5 15 687.73 If more space is needed,use additional sheets of paper of the same size. REV-1512 EXi(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER W. ROBERT SHUGHART 21 13 0640 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. CAPITAL TAX COLLECTION BUREAU -TAXES 20.00 TOTAL(Also enter on Line 10,Recapitulation) $ 20.00 If more space is needed,insert additional sheets of the same size. REV4513 EX.(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERTTANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: W. ROBERT SHUGHART 21 13 0640 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pndude ouM�hts usat dRNbutions and transfers under Sec.91 f6(a(111).1 1. IVA S. SHUGHART Spousal 106 SYCAMORE DRIVE REMAINDER MT. HOLLY SPRINGS, PA 17065 2. WAYNE ROBERT SHUGHART, II Lineal 44 SCHOOL HOUSE ROAD ANNUITIES & GARDNERS, PA 17324 OPPENHEIMER ACCT ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. Il. 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 11-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. L ® h I,W. ROBERT SHUGHART,of Mount Holly Springs Borough,Cumberland County,Pennsylvania, declare this to be my Last Will and revoke all prior wills and codicils. FIRST -- FAMILY A. I declare that I am married to Iva S. Shughart and that all references in this Will to "my wife"are references to her. B. I have one adult son, W. Robert Shughart, II, from a prior marriage. All references in this Will to"my son"are references only to him. C. I have no other natural children,living or deceased; and I make no provision for unadopted stepchildren. SECOND -- EXECUTOR A. I appoint my wife, Iva S. Shughart,executrix of this my last Will. Should my wife fail to qualify or cease to act as executrix, I appoint my son, W. Robert Shughart, II, executor of this my last Will. B. I direct that my executrix or executor shall not be required to give bond for the faithful performance of her or his duties in any jurisdiction. THIRD -- TAXES All federal, state and other death taxes payable because of my death,with respect to the property forming my gross estate for tax purposes,whether or not passing under this will, including any interest or penalty imposed in connection with such tax, shall be considered a part of the expense of the administration of my estate and shall be paid out of the principal of my estate without apportionment or right of reimbursement FOURTH -- DISPOSITION OF PROPERTY A. I devise and bequeath all of my estate of every nature and wherever situate to my wife, Iva S. Shughart,providing she shall survive me be thirty days. B. Should my wife, Iva S. Shughart,predecease me or die on or before the thirtieth day following my death, I devise and bequeath all of my estate of every nature and wherever situate to my son, W. Robert Shughart, II. &,r,I IN WITNESS WHEREOF, I have hereunto set my hand this jZ day of Ibhtreli;` 2013. , (SEAL) W.R BERT SHUGHART The preceding instrument,consisting of this and one other typewritten page identified by the signature of the testator, W. ROBERT SHUGHART,was on the day and date thereof signed,published and declared by W. ROBERT SHUGHART,the testator therein named, as and for his last will,in the presence of us,who, at his request, in his presence, and in the sence of each other have subscribed our names as witnesses hereto. © M&TBank 499 Mitchell Road,Millsboro,DE 19966 Adjustment Services Phone 888-502-4349 F nx (302)934-2955 June 13,2013 Law Offices Irwin & McKnight,P.C. West Pomfret Professional Building RECEIVED 60 West Pomfret Street Carlisle,PA 17013-3222 JUN 1,7 2013 INN&N1cXNIGHf iAW OFFICES Re: Estate of W.Robert Shughart Social Security: 162-22-0344 Date of Death:April 24,2013 Dear Sir or Madam: Per your inquiry on June 6,2013,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type ofAccount Checking Account Account Number 9861590413 Ownership(Names ofi W.Robert Shughart Opening Date 03/29/2013 Balance on Date ofDeath $2,950.95 Accrued Interest $ .01 Total $2,950.96 2. Type ofAccount Checking Account Account Number 1161881 Ownership(Names )9 W Robert Shughart Opening Date 02IM993 Balance on Date ofDeath $0.00 Accruedlnterest $ .00 Total 3. Type ofAccount Checking Account AccomaNumber 607916 Ownership(Names qn W.Robert Shughart Iva s.Shughart Opening Date 0912611983 Balance on Date ofDeath $1,918.82 Accruedlnterest $ .01 Total $1,918.83 For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds, please cell the MountHOBy Springs at 717486-9838. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the decessed may have been listed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Valarie Mercer Adjustment Services St MEMBERS V FEMALCAMN RECEIVED JUN 11 2013 IRWIN&McKNIGHT REGULAR SAVINGS ACCOUNT: LAW OFFICES Account Number/Suffix 140318-00 Date Account Established 05118/1994 Principal Balance at Date of Death $12,234.40 Accrued Interest to Date of Death $1.14 Total Principal and Accrued Interest $12,235.54 Name of Joint Owner None MEMBERS 1sT FEDERAL CREDIT UNION Tessa L Klugh Lending Insurance Support Specialist May 6, 2013 Estate of: W ROBERT SHUGHART Date of Death: 04124/2013 Social Security Number: 162-22-0344 5000 Louise Drive • P.O.Box 40 Mechanicsburg,Pennsylvania 17055 (800) 283-2328 wwwmemberslstorg PPENHEIME Oppenheimer ma Road� 1015 Mumma Road Wormleysburg,PA 17043 Phone 717-763-8200 Fax 717-763-1765 Tog Free 800-722-2294 Transacis Business an all Principal Exchanges i July 9,2013 ���� JUL 10 2013 Marcus A. McKnight, III IRWIN E McKNIGHT Irwin&McKnight, P.C. I_AW1 OFFICES 60 West Pomfret Street Carlisle, PA 17013 RE: Acct#A25-0015227-1384 W. Robert Shughart(dec'd)& W. Robert Shughart, II A Wros Dear Marcus: Per your request dated June 6, 2013 regarding the above-referenced account,please find the following information below: 1. Title of Account: W. Robert Shughart&W.Robert Shughart, II Jt Wros 2. Date Account Opened: February 2, 1995 3. N/A 4. N/A 5. Amount of accrued interest:N/A 6. Date of Death Total Value: $83,336.70 Should you require any further information,please do not hesitate to call. Thank you. Sincerely, This report Is?m .Ilu-tra?i ouronses only it is not and should not be consirue0 as a su[ rur,-ite;e tot 4cur Uppenhelmer&Co.Inc.account - statement or Form 1054 ann memo not be relied upon for tax reporting Patrick K.Neal purposes. Market prcvs mfiemed are as o? y 7cL. t 3 and are from sources helleven to he reliable but are not warranted by us as Financial Advisor to accuracy or completeness nor do they represent guaranteed markets for the securities. This Information is subject to change. Commissions, sales charges or deferred charges might apply if the account were to he immediately liquidated Oppepneimer g Co. Inc., nor any of its PKN/hk employees or affiliates does not otter legal or tax advice. Admi i 4333Edgcwood Rind NE ® LIFE INSURANCE COMPANX Cedar Rapids,1A 524" www.transamcricaannnitics.rnm RECEIVED May 2, 2013 IJUL 2 SBWIN&IVICKNIGN7 W ROBERT SHUGHART II LAW OFFICES C/O M & T SECURITIES INC ATTN: KIMBERLY J HEAVNER 100 S SPRING GARDEN ST CARLISLE PA 17013 RE:., Aanuitg•Number(s) 02CBT115440 - Dear Claimant: We have received notification of the death of W Robert Shughart. We extend our sincere condolences to you for your loss. The information in this letter is being provided to assist you in submitting death claim paperwork. Our records reflect the following information regarding this annuity: Annuitant: W Robert Shughart Owner: W Robert Shughart Claimant: W Robert Shughart II 100% Annuity value: $23, 001. 10 as of 04-24-2013 Annuity type: Qualified Tax Information This letter includes general tax information that should not be relied upon for personal tax planning. Transamerica Life Insurance Company does not give legal, tax, or accounting advice. You may want to consult -your attorney;--tax- advisor, or accountant- with ' questions regarding the direct tax consequences when selecting an option. General Information The financial professional of record will remain on this annuity unless we are notified of a change in writing. Please be advised automatic operations such as Systematic Payouts and Automatic Payments have been stopped. an AEGON company • eftel Page 1 of 1 Acknowledgement Mefer MotLife Investors USA Insurance Company W28107 MU USA Bullet SPOA(Non MVJ, P.O.Box 295 Overnight Address Des Moines,IA 50306-0295 4700 Westown Parkway Suite 200 9200748080 Non-Qualified 1(600)255-9445 West Des Moines,IA 602662266 2a www.rrteUlfeinvestors.com W ROBERT SHUGHART 002:01SO 15 W ROBERT SHUGHART W ROBERT SHUGHART 106 SYCAMORE DRIVE MT HOLLY SPRINGS, PA 17065-1819 Patrick Neal Transaction Description Beneficiary Designation: Primary Beneficiary. IN ROBERT SHUGHART 11 Relationship: son Percent., 100 Messages: The requested change has been made and our records now reflect the above information,Please review this acknowledgement carefully and nol of any errors. This acknowledgement should be kept with your contract records. Page t of 1 Me t L If�® Important - Renewal Notice MetLife Investors USA Insurance Company 06/26106 MLI USA Bullet SPDA(Non MVA) P.O.Box 10366 Overnight Address iiConlracfiNumber'= �� s'"`' �_ A�cao_$ni� ;ype_ Des Moines,IA 50306-0366 4700 Westown Parkway,Suite 200 1(600)255-9448 West Des Moines,IA 50266-2266 9200762974 Non-Qualified f"�":a`Er + •�Owriei s .5',b , � - ,... www.metlifeinvestors.com � > >^+ ( )r 8 W ROBERT SHUGHART :J ^' ' o- W ROBERT SHUGHART W ROBERT SHUGHART 106 SYCAMORE AVENUEPA�gent Name a Agent Phones $ MOUNT HOLLY SPRINGS, PA 17065-1819 Patrick Neal Accumulation Period i Your contract will automatically renew into a 3 year period on 07/10/2012. 'Your new renewal rate will be set on 07/10/2012,and will end on 07/10/2015.This information will be sent to you on your renewal confirmation. Your Accumulati Period will automatically renew unless you notify us within 30 days of the renewal date. If you choose to surrender your contract withdrawal charges and MVA (Market Value Adjustment)are waived if your request is received within 30 days from 07/10/2012. 'If available. If your automatic renewal period exceeds the contract maturity date,then your contract will be renewed into the longest guarantee period that will not exceed the contract maturity date. _ .- wCurrent:Co'htract Ra e:'" r f`, r X07/10/12ate Current A 3 Year 3.00%Period 3.00% C n ifiContraet Value ° $6,543.75 g 0 � a Notice: Withdrawal Charge schedule and Market Value Adjustment will apply to the period for which your contract may be renewed. No withdrawal charges or Market Value Adjustments will apply if your request to surrender the contract is received within 30 days following 07/10/2012, the contract renewal date.. 407463--Q021P-001-0098 1e1 bomb �/ se sa m Hollinger Funeral Home& Crematory, Inc. Eric L.Hollinger.Supervisor April 24,2013 Iva Shughart 106 Sycamore Dr. Mt. Holly Springs, PA 17065 The Funeral Service for W. Robert Shughart: We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES,AUTOMOTIVE EQUIPMENT,AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. Professional service Traditional Services $ 5150.00 Merchandise Jewel Mint 18 ga Batesville 2495.00 12 Ga Clark Vault 1325.00 Memorial Package—Register Book, Memorial Folders, Acknowledgement Cards, Bookmarks 175.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. Cash Advance Certified Copies of Death Certificate (15@$6) 90.00 Flowers 238.50 Sentinel Newspaper 196.30 Minister 125.00 Grave opening 700.00 Cemetery Equipment 375.00 Patriot Newspaper 209.89 Engraving Stone 175.00 • BALANCE $ 11,254.69 Payment by Iva 2000.00 4/25/2013 BALANCE 9,254.69 501 NORTH BALTIMORE AVENUE • MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065 (717) 486-3433 • FAX(717) 486-3415 www.hollingerfuneralhome.com Q ro �k" �Sf CD d O CCDi O P #. � G ww� a : Cho o G ro CD 0 x H°a � xO m p G Cd y w 0 y<y o O S+' crFOy o. m CD 5 o G yc Ux y p' Q C) O o a � CO H O o �,. w to 0 21 rn 0 �scri Cf. O •f Q (D �` v FN, 0 O A � O � u 4tjy� O C w P. CD C p -h Co 0 0 CD CD k: O' iOC '0 G O N o CD O CD C �. M 41 ON 5' o O �t"_ CO, C O cl 0.004 O n tj Y'yM",I O O � O pO � O O, bawl C3 O o tz O G p a O O CO " " �� C O w C7. O C Oq ,COO CD p •. a � fi. nl yy pW� b u� •.-fixR 0 o CD 0 CD O N p hn; rn -s c 0 Co rn •o O' CD 0 .sail N `G .-] (D y N i ru 51