HomeMy WebLinkAbout01-07-14 REV-1500 EX(02-11) v
1505610143
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County cone Year File Number
Bureau of Individual Taxes °^*"tee*°l atheeee
PO 80X.280601 INHERITANCE TAX RETURN 21 12 0710
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
05 15 2012 07 18 1923
Decedent's Last Name Suffix Decedent's First Name MI
KINTZER NATALIE M
(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 LX] 2. Supplemental Return 3, Remainder Return(Date of Death
Prior to 12-13-82)
4. Limited Estate ¢a.Furure interest Compromise 5. Federal Estate Tax Return Required
(dale of death after 12-12-82)
f—I 6 Decadent Died restate I— 7. Deced p
ent Maintained a Living Trust S. Total Number of Safe Deposit Boxes
LJ (Attach Copy of Will) I_I (Atlac Copy of Trust)
9. Litigation Proceeds fteceivetl 10.Spousal Pavers Credit{Date of Death 11,Election to tax under Sec.9113(A)
u ne•,vv 12-31-1 and -1-%) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
LEONARD TINTNER ESQUIRE 710 236 9377 :to co -- mm
RP,IQ_10ctOF vY3KLS tjj�E ONLY
r... _rl v
First Line of Address ] N CY '
315 NORTH FRONT STREET n --1 -
C-3 0 :r
Second Line of Address O = CJ r7l ,
I r"
City Post Office r DAT4.EiLED -n
�' State ZIP Cade -
HARRISBURG PA 17101
Correspondent's e-mail address: Itintner@btpalaw.com
Under penalties of perjury,I declare that 1 have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
Becky J. Frank
ADDRESS
5 Dish rive M-echaniclsburcl, PA 17055-5867
SiGNA Uft PREPARE T HAN REPRES_ENiATIVE DATE
Leonard Tintner, Esquire - a0
ADDR
315 North Front Street, Harrisburg, PA 17101
Side 1
L 1505610143 1505610143
, r
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF
FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
Under penalties of perjury,t declare that I have examined this return,including accompanying schedules and statements,and to the best of
my knowledge and belief,it is true,correct and complete. Declaration of preparer other than the personal representative is based on all
information of which preparer has any knowledge.
Signature#2
Nance _ Sherry L.Deane
Addressl 1 Sussex Circle
Address2
City,State,Zip camp Hill,PA 17011
Date t 2 3G� 2Cl3
J 1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name, Kintzer, Natalie Mae
RECAPITULATION
L Real Estate(Schedule A)...................................... ................................................ 1. 44 , 725 . 00
2. Stocks and Bonds(Schedule 6)..................................... ...................... .............. 2. 42 , 394 . 80
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D).................___..........._._................ 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)........-..... 5.
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 26, 8 91 . 10
7. Inter-Vivos Transfers&Miscellaneous Probate Property
on-
(Schedule G) Separate Billing Requested............ 7. 130 , 805 . 98
8. Total Gross Assets(total Lines 1 through 7).........___... ................. ......... ......... 8, 244 , 816 . 88
9, Funeral Expenses and Administrative Costs(Schedule H)................... ___. __ 9. 16 , 008 . 10
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 1 , 645 . 66
11. Total Deductions(total Lines 9 and 10)................................................................ 11 17 , 653 . 76
12. Net Value of Estate(Line 8 minus Line 11)...._.........__ - 12. 227 , 163 . 12
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. 227 , 163 12
TAX COMPUTATION-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 .00 15. 0 . 00
16. Amount X
ra 0taxable
227 163 . 12 16. 10 222 . 34
at lineal rate e X .045 , ,
17. Amount of Line 14 taxable
at sibling rate 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. 10 , 222 . 34
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
KEV'1s00EX Page 3 File Number 21'1Z'0T10
Decedent's Complete Address:
-EECEDENTS NAME
Kintzer, Natalie Mae
STREETADDRESS
4100-Seneca Avenue
CITY Camp Hill ---PTA-E PA Zip 17011
Tax Payments and Credits:
1 Tax Due(Page z,Line 19) (1) 10�22.34
ZCromt$pmymrnts
A. Prior Payments 11,746.01
S. Discount
Total Credits(\ +8) (2) 11,746�01
o. Interest (3}
4. If Line 2 is greater than Line 1 +Line 3,enter the difference, This is the OVERPAYMENT. (*) 1,523.67
Check box nn Page 2,Line 2o*`request arefund
5� |,Line 1 +Line 3 is greater than Line 2.enter the difference. This is the TAX DUE. (5)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN ^'}('' |NTHE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; .......................................... .. — ...... --- ......
o. retain the right tv designate who shall use the property transferred m its iocumn:— ................-- ......
c. retain*reversionary interest;or —...... --------- ------- ......---... ......—........--- ...... LJ bd
a. receive the promise for life of either payments,benefits or care? ................—..... .... .......................... [l [J
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................----......... ............. .......... ......... .............. ..... — ...... '' [l []
3� Did decedent own wo'in trust fo, 'npuxaWnu*ood*avhu*nxacn/uotors*cxmxut his v/her death?....— | l E]
4. Did decedent own an individual retirement account, annuity,or other non-probate property which
contains a beneficiary designation?.............. .................. ......— .......... ...... ......... .........................
—~~— [J Fl
IF THE ANSWERTO ANY OF THE ABOVE QUESTIONSIS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
For dates m death vnvr after July 1, 1oy4 and before Jan. 1, `o9s,the tax rate imposed oo the net value v/transfers tvor for the use o/the surviving
spouse isu percent[7up.S.§9116(a)(11)<1)].
For dates or death oov/after January 1,1Vos,the tax rate imposed on the net Value of transfers to or for the use of the surviving spouse is 0 percent
[ruP,V.§9 116(a)(1,1)(u)), 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 io the only beneficiary.
For dates o/death vno/after July ,,z0oo:
~ nhe tax rate imposed oo the net value of transfers from a deceased child 21 years of age m younger m death wm for the use of a natural parent,an
adoptive parent, v,a stepparent o the child is0 percent[r1P,S. §9116(a)(1.2)l
. The tax rate imposed on m*mgva|uedtransfersmo,hxneomofmedeceuon&|oeal*eoefidammb^.spexent,except as noted m
yoP.S.§9116(*)(I)]-
° Thc tax rate imposed on the net value n,transfers mor for the use v/the decedent's siblings is12 percent 172 P.S.09ns(4n.3D. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent,whether uy blood oradoption,
Rev-1502 EX-401-10)
SCHEDULE A
pennsylvania REAL ESTATE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
All real property owned solely or as a tenant in common must bereported at fair market value.Fair market value is defined as the price at wich p
exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the rehlevant pro(aerty would be
.is
Real property that is jointly-owned with right of survivorship must be disclosed on schedule F.
Attach a copy of the settlement sheet if the property has been sold
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Real Estate-One-third (1/3) interest in real estate known as and numbered 4100 Seneca 44,725.00
Avenue,Camp Hill, Lower Allen Township, PA-See Deed dated March 4, 2009, and recorded
in the Office of the Recorder of Deeds in Cumberland County in Deed Book 2009063090 -
Assessed valuation -$134,300
TOTAL(Also enter on Line 1, Recapitulation) 44,725.00
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule A(Rev.01-10)
Rev-1503'EX*(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OFPENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kintrer, Natalie Mae 21-12-0710
All Property jointly owned with right of survivorship must bedisclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 2,562.894 shares of 2,562.894 shs.ALLIANCEBERNSTEIN 10.75 27,551.11
MUNI INC II PA A-Fund/Account Number-67/4765863244
2 29 shares of MetLife Trust-29 units 32.05 929.45
3 277.758 shares of PPL-277.758 shs. common stock 28.26 7,849.44
4 U.S. Savings Bonds 6,064.80
TOTAL(Also enter on Line 2, Recapitulation) 42,394.80
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.6-98)
Rev-1505 EX.(01.10)
pennsylvania SCHEDULE F
DEPARTMENT OFREVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kintner, Natalie Mae 21-12-0710
If an asset was mad.knot within one yearof the decedent's dale of death,it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Becky J. Frank 5 Dishley Drive Daughter
Mechanicsburg, PA 17055
B. Sherry L. Deane 1 Sussex Circle Daughter
Camp Hill, PA 17011
C.
JOINTLY OWNED PROPERTY:
LETTER BATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE NUMBER OR SIMILAR IDEN 1FYNG NUMBER ATTACH DEED FOR DATEOF DEATH DECD'S DECEDENT SINTEREST
NUMBER TENANT JOINT VALUE OF ASSE INTEREST
J6INTLY-HELD REAL ESTATE.
1 A B 06/12/2002 Members 1st Federal Credit Union -Savings 5.00 33.330% 1.67
Account No.219125-00
2 A B 0611212002 Members 1st Federal Credit Union- 10,977.39 33.330% 3,658.76
Investment Savings Account No.276267-05
3 A B 06/1112002 Members 1st Federal Credit Union- 6,403.53 33.330% 2.134.30
Certificate of Deposit No. 219125-40
4 A B 0611112002 Members 1st Federal Credit Union- 3,520.52 33.330% 1.173.39
Certificate of Deposit No.219125-41
5 A B 06/11/2002 Members 1st Federal Credit Union- 3,520.52 33.330% 1.173.39
Certificate of Deposit No. 219125-42
6 A B 1213012002 Members 1st Federal Credit Union- 4,839.76 33.330% 613.19
Certificate of Deposit No.219125-46
7 A B 01/30/2004 Members 1st Federal Credit Union- 13,051.93 33.330% 4,350.21
Certificate of Deposit No.219125-47
8 A B 03/29/2004 Susquehanna Valley Federal Credit Union - 13,744,55 33.330% 4,581.06
Savings Account
Total of Continuation Schedule ee attached page
TOTAL(Also enter on Line 6,Recapitulation) 26,891.10
(if more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10)
Rev-1509-E%;(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT continued
ESTATE OF FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
JOINTLY OWNED PROPERTY
177 INCLUDE NAME OFF FINANRAL INON OFON AND ANK ACCOUNT %OF DATE OF DEATH
NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR DATE OF DEATH DECD'$ VALUE OF
VALUE OF ASSE DECEDENT'S INTEREST
JOINTLY-HELD REAL ESTATE. INTEREST 04 Susquehanna Valley Federal Credit Union - 27,618.15 33.330% 9,205.13
Checking Account
TOTAL(Also enter on Line 6, Recapitulation) 26,891.10
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10)
R.,1 61 Cr EX*(08-09)
SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
This schedule must be completed and filed if the answer to any of Questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH of Decor EXCLUSION TAXABLE
NUMBER THE DA E OF TRANSFER.TRANSFEREE.THEIR A COPY OF HHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Alllianz-IRA -to daughters -Sherry Deane and Becky 30,347.74 100.000% 30,347.74
Frank
2 MONY Life Insurance Company of America -Annuity 58.875.43 100.000% 58,875.43
Contract 2VA0057466 -to daughters -Sherry Deane
and Becky Frank
3 MONY Life Insurance Company of America -Annuity 37,918.49 100.000% 37.916.49
Contract B6007-51-93 -to daughters -Sherry Deane
and Becky Frank
4 Susquehanna Valley Federal Credit Union-IRA-to 3,664.32 100.000% 3,664.32
daughters-Sherry Deane and Becky Frank
TOTAL(Also enter on Line 7, Recapitulation) 130,805.98
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX;-(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE T TURN
ADMINISTRATIVE COSTS
RESIDENT DENTDECEDENT
ESTATE OF FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 2,491.42
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Becky J. Frank and Sherry L. Deane
Street Address 1 Sussex Circle
City Camp Hill State PA Zio 17011
Year(s) Commission Paid Waived
2, Attornev's Fees Boswell, Tintner& Piccola 12,750.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zio
Relationship of Claimant to Decedent
4. Probate Fees Cumberland County Register of Wills 366.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 400.18
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 16,008.10
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Exoenses
1 Auer Cremation Services of PA-funeral 1.841.42
2 Rev. Duncan Johnston-memorial service-honorarium 100.00
3 The Columbarium for Mount Calvary Episcopal Church -interred fee 550.00
H-A 2,491.42
Other Administrative Costs
4 Boswell, Tintner& Piccola-disbursements(copies, postage,etc.) 67.50
5 Cumberland Law Journal -legal advertising 75.00
6 Journal Publications-legal advertising - 239.00
7 Susquehanna Valley Federal Credit Union -checkbook fee 18.68
H-B7 400.18
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
•Aav isi2 Ex.(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
Report debts incurred bythe decedent prior to death that remained unpaid atthe date of death,including unreimbu mod medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Comcast-final service bill 33.46
2 Lower Allen Township -real estate school tax 1,145.77
3 Lower Allen Township-sewer 103.55
4 PA American Water-final service bill 41.65
5 PPL -electric service 135.65
6 UGI -gas service 126.93
7 Verizon -final service bill 58.65
TOTAL(Also enter on Line 10, Recapitulation) 1,645.66
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 9X�(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kintzer, Natalie Mae 21-12-0710
NUMBER NAME AND ADDRESS OF DECEDENT RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(S)RECEIVING PROPERTY (Words) ($$$)
Do Not List Tru rec s
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec. 9116(a)(1.2
1 Sherry L. Deane Daughter 50% of residuary
1 Sussex Circle estate
Camp Hill, PA 17011
2 Becky J. Frank Daughter 50% of residuary
5 Dishley Drive estate
Mechanicsburg, PA 17055
Total
Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 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 software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev. 01-10)
MONY Life Insurance Company of America
PO Box 4720
%L1 Syracuse, NY 13221
An AXA Financial Company www.AXAonfine.com
800-659-1058
SUMMARY OF BENEFIT
Annuitant: Natalie Kintzer
Contract: 2VA0057466
June 20, 2012
Date of Death: May 15, 2012
Date of Calculation: May 15, 2012,
Contract Date: March 1, 2002
Investment in Contract: $45,000.00
Withdrawals Made: $0.00 /
Death Claim Payable: $58,875.43 "
Your Share of Death Claim Payable: $29,437.71
Plus Interest at rate of: $0.00
Total Death Claim Payable to you: $29,437.71
Less Tax Withholding: $693.77
Net Death Claim Payable to you: $28,743.94
Beneficiary:
Sherry Deane and Becky Frank, Daughters equally
Insurance and annuity products are issued by MONY Life Insurance Company (MONY) in New York, and by
MONY Life Insurance Company of America (MLOA) outside of New York. Distributed by AXA Advisors,
LLC. MONY, MLOA and AXA Advisors are subsidiaries of AXA Financial, Inc., 1290 Avenue of the
Americas, New York, NY 10104, (212)314-4600.
GE-36779(10/06)
An AxA Financial Company MONY Life of America
P.O. Box 4830
Syracuse NY 13221
I.,�III�l�lll�����lll���ll�ll,lll��l�l��llllllll���lllllll��ll
Financial Professional:
Mrs Natalie M Kintzer Harold Hoch
4100 Seneca Ave 40 Monument Road,4th Floor
Camp Hill PA 17011 Bala Cynwyd, PA 19004
(610)660-4000
Non-Qualified
Flexible Payment Variable Annuity
Report Date:June 19,2012
Annuitant: Natalie M Kintzer
Contract: 2VA0057466
Issue Date: March 01,2002
Summary status as of Prior Report Date: March 01, 2012
Account Unit Value Units Held Value Held
EQ/Intermediate Gov Bond 14.100000 2,401.3779 $33,859.43—
EQ/Money Market 10.464900 $0.00
GIA 1 Year Period $24,685.32
Total $58,544.75 "
Summary status as of Current Report Date: May 15, 2012
Account Unit Value Units Held Value Held
EQ/Intermediate Gov Bond 14.163800 $0.00
EQ/Money Market 10.436000 $0.00
G 1 1 Year Period $0.00
Total $0.00
Current Payment Allocation
Account Allocation
EO/Intermediate Gov Bond 50%
GIA 1 Year Period 50%
Total 100%
96001 (9/2004) Cat.#134229(9/04)
N f�fP ,
2VA0057466
Natalie M Kintzer
Summary of Values As of March 01,2012 As of May 15,2012
Fund Value: (The Sum of the Amounts $58,544.75 $0.00
Under the Contract Held in Each
Subaccount,the Guaranteed Interest
Account,and the Loan Account(if
Applicable).
Total Payments Received During Quarter: $0.00 $0.00
Interest Earned on the General Account, $208.54
Guaranteed Interest Account,Loan Account,
H any:
Total Partial Surrenders During Quarter. $0.00 $0.00
Contract Fee Charged: $0.00 $0.00
Total Investment Gain or Loss: $18.01 $0.00
Surrender Value:(Fund Value Minus Any $58,547.08
Surrender Charge,and Minus Any
Outstanding Debt.)
The following amounts are not calculated within the values.Free Partial Surrender Amount:
For Non-qualified Contracts-An amount up to 10 percent of the Fund Value of the Subaccount(s)and the Guaranteed Interest Account(not the Loan
Account)at the beginning of the Contract Year,that may be surrendered without imposition of a Surrender Charge.For purposes of the Free Partial
Surrender Amount only,Non-Oualified Contracts include Contracts issued for IRAs and SEP-IRAs.
For Qualified Contracts-An amount up to the greater of$10,000(but not more than the Fund Value of the Subaccount(s)and the Guaranteed Interest
Account)or 10 percent of the Fund Value of the Subaccount(s)and the Guaranteed Interest Account at the beginning of the Contract Year,that may be
surrendered without imposition of a Surrender Charge.Fund Value for this purpose means only the Fund Value of the Subaccounts and the Guaranteed
Interest Account(not the Loan Account).For purposes of the Free Partial Surrender Amount only,Qualified Contracts exclude Contracts issued for IRAs
and SEP-IRAs.