HomeMy WebLinkAbout01-21-14 J 1505610140
r•� REV-X1500 EX (02-11)(FI)
RE V-1500 l�J\eV OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 3 0 5 5 1
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
0 4 2 2 2 0 1 3 0 9 0 9 1 9 2 5
Decedent's Last Name Suffix Decedent's First Name MI
N A G Y W I L L I A M A
(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 E] 3.Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required
death after 12.12-82)
❑X 6. Decedent Died Testate 7.Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
F1 9.Litigation Proceeds Received 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 Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
H U B E R T X G I L R 0 Y 7 1 7 2 4 3 3 3 4 1
R�OR OF An ISE�7�-cl
First Line of Address M S {^j Z it1 S
czar- ry -4v
1 0 E A S T H I G H S T R E E T n CO CO � a
Second Line of Address o _D C) C5 `
C7 i T7
o a D °n
City or Post Offce State ZIP Code DATE i4CED fl, rs7
C A R L I S L E P A 1 7 0 1 3 Cn co C)
ca 'n
r
Correspondent's e-mail address: HGILROYPMARTSONLAW.COM
Under penalties of perjury,I 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.
SIG TUREE,OFF PERSON/f,JSP,.OpNSIBLE FOR FILING RETURN
/ vl
ADDg§S
10-a, SCHOOLFilELD ROAD CARLISLE PA 1701
S N T E(VREP ER O ER THAN REPRESENTATIVE 7E
ADDRESS I 1 IF
10 EAST HIGH REET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 � �
J 1505610240
REV-1500 EX(FI)
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . 0 0
2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 4 2 8 1 , 2 0
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, 4 1 4 7 0 , 5 8
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 0 , 0 0
7. Inter-Vivos Transfers&Miscellaneous N -Probate Property
(Schedule G) t Separate Billing Requested . . . . . . . 7. 2 1 4 9 0 8 , 3 2
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 2 6 0 6 6 0 , 1 0
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 1 1 4 6 0 . 1 5
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 8 8 4 5 . 9 8
it. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 0 3 0 6 . 1 3
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . .. . . . . . . . . . . . . . 12. 2 4 0 3 5 3 . 9 7
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. 2 4 0 3 5 3 . 9 7
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec.9116
(a)(1.2)X.0 _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate x.045 2 4 0 3 5 3 . 9 7 16, 1 0 8 1 5 . 9 3
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 1 0 8 1 5 . 9 3
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240 1505610240 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 13 0551
DECEDENT'S NAME
WILLIAM A.NAGY
STREET ADDRESS
2 STRAWBERRY DRIVE
CITY STATE ZIP
CARLISLE PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 10,815.93
2. Credits/Payments
A.Prior Payments 15,000.00
B.Discount 789.47
3. Interest Total Credits(A+B) (2) 15,789.47
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. (3)
Fill in oval on Page 2,Line 20 to request a refund. (4) 4,973.54
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
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 properly transferred ...................................................................... ❑ ❑
b. retain the right to designate who shall use the property transferred or its income ............................... ❑ ❑X
c. retain a reversionary interest ..................................................................................................... ❑ ❑X
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ Q
2. If death occurred after December 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ 0
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ Q
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑X ❑
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)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(it)].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 172 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)I.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].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-1502 EX+(12-12)
p6nnsylvania SCHEDULE A
DEPARTMENT OF REVENUE
REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
WILLIAM A.NAGY 21 13 0551
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which properly
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
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.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
I. Real Estate located at 22 Strawberry Dr., So. Middleton Twp, Cumberland Co.,PA, 0.00
known as Tax Parcel No.40-23-0600-012,being described in Deed dated 9/29/06 and recorded in
Cumberland Co.,PA Deed 13k 246,Page 4965 and being conveyed to William A.Nagy,Decedent
herein.
SUSPEND ASSET
TOTAL(Also enter on Line 1,Recapitulation.) $ 0.00
If mare space is needed,use additional sheets of paper of the same size.
REV-1503 EX+(8-12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE -
INHERITANCETAXRETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WILLIAM A.NAGY 21 13 0551
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 77 shares,Prudential Financial, Inc. CUSIP 744320102 4,281.20
See attached
TOTAL(Also enter on Line 2,Recapitulation) $ 4,281.20
If more space is needed, insert additional sheets of the same size
REV-1508 EX-(e8-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITACE TAX RESIDENN ECED NT�RN PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
WILLIAM A.NAGY 21 13 0551
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. PNC Bank checking 64-0847-3917 25,021.68
(25,021.54+.14 interest)
See attached
2. Personal property and house hold goods 10,000.00
3. Stifel,payment received by not deposited prior to date of death 91.87
4. Highmark,refund 308.37
5. Sarah Todd Home,refund 5,948.66
6. VA,death benfit I WOO
TOTAL(Also enter on Line 5,Recapitulation) $ 41 470.58
If more space is needed,use additional sheets 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
WILLIAM A.NAGY 21 13 0551
This schedule must be completed and fled if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPRUI VALUE
1. ING Annuity 00O3 5278-0614:Beneficiaries:Elizabeth M Nagy 164,327.15 100.00 164,327.15
33.3%,daughter;Jennifer A.O'Brien, 33.3%,daughter;Amy K.
Nagy Powless,33.3%, daughter. See attached
2. John Hancock Annuity 2414337: Beneficiaries:Elizabeth M.Nagy 50,581.17 100.00 50,581.17
33.3%, daughter; Jennifer A. O'Brien,33.3%, daughter;Amy K.
Nagy Powless,33.3%,daughter. See attached
TOTAL (Also enter on Line 7,Recapitulation) $ 214 908.32
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WILLIAM A.NAGY 21 13 0551
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home and Crematory,Carlisle,PA 17013 3,784.34
2. Reimbursement for travel expense for family from IL to plan and attend funeral 1,315.60
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Years)Commission Paid:
z, Attorney Fees: Martson Law Offices(estimated) 5,700.00
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: Cumberland County Register of Wills 358.50
6 Accountant Fees:
6. Tax Return Preparer Fees:
7. Cumberland County Register of Wills,filing fee,Inherimace Tax Return 15.00
8. The Sentinel,advertising Letters Testamentary 210.16
9. Cumberland Law Journal 75.00
10. EVP stock valuation report 1.55
TOTAL(Also enter on Line 9,Recapitulation) $ 11 460.15
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WILLIAM A.NAGY 21 13 0551
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. Outstanding check on date of death,PNC checking 8,790.00
2. Millennium Pharmacy, account payable 55.98
TOTAL(Also enter on Line 10,Recapitulation) $ 8,845.98
If more space is needed, insert additional sheets of the same size.
REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
WILLIAM A.NAGY 21 13 0551
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 outri hl spousal distributions and transfers under
Sec.9116(a)(1.2).]
1. Amy K Nagy Powless Lineal 80,117.99
109 Schoolfield Drive 1/3 Sch G,Lines 1&2+
Carlisle,PA 17013 1/3 estate residue
2. Elizabeth M.Nagy Lineal 80,117.99
129 Gale Avenue 1/3 Sch G, Lines 1&2+
River Forest,IL 60305 1/3 estate residue
3. Jennifer A. O'Brien Lineal 80,117.99
220 N.Oak Park Avenue,3V 1/3 Sch G,Lines 1&2+
Oak Park,IL 60302 1/3 estate residue
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.
0 0
LAST WILL AND TESTAMENT
I, WILLIAM A NAGY, of Titusville, Crawford County, Pennsylvania do make this my Will, hereby
revoking any and all Wills at any time heretofore made by me.
FIRST: I direct that the expenses of my last illness and funeral be paid out of my estate as soon as may
be convenient after my death.
SECOND: I give all my tangible personal property to my spouse, Janet K. Nagy, if my spouse
survives me. If she does not survive me,except as I may have provided in a memorandum which may
be attached to my Will, I give my tangible personal property to my daughters who survive me as they
may each select.
TH RD: If my spouse survives me, I give all the residue of my estate to be held in trust with my
daughter, Amy K. Nagy Powless, acting as Trustee. The Trustee shall distribute the income from
the trust to or for the benefit of my spouse. If the income is insufficient to provide for the health,
welfare and comfortable support of my spouse, the Trustee shall have the discretion to use principal
for said purposes. Upon the death of my spouse or upon my death if my spouse does not survive me,
the residue of my estate or the trust as the case may be shall be distributed in equal shares to my
daughters who survive me, Amy K. Nagy Powless, Jennifer O'Brien and Elizabeth M. Nagy. The
share of any daughter not then living shall be distributed to her issue per stirpes or if she has no issue,
said share shall be distributed to my other daughters in equal shares. Provided, however, the share
any grandchild may receive under this article who has not yet attained the age of thirty(30)years shall
be held as follows:
(i)Until my said grandchld's thirtieth{30th}birthday, the Trustee may pay to said grandchild
or to the person having custody of him or her,without liability on the part of the Trustee to see to the
application thereof, or may expend directly such sums from Income or principal as she deems
advisable for his or her health, welfare, comfortable support and education, in view of other income
of which she has knowledge and shall add any excess Income to principal and invest it as such.
(u)Upon said grandchild's thirtieth (30'h) birthday, the trust shall terminate and the principal
shall be transferred and delivered to him or her free of trusf. In the event of his or her prior death, the
principal, including any accrued or undistributed Income, shall be transferred to said grandchild's
surviving children equally, or, if he or she has none, to the then living issue per stirpes of his or her
parent who was my child, the share of any other grandchild under such age to be added to his or her
separate trust hereunder.
(B) The interest of any beneficiary hereunder, in Income or principal, shall not be subject to
I assignment,alienation,pledge, attachment or claims of creditors until after payment has actually been
made by the Trustees as hereinbefore provided.
FOURTH: The Trustee and Executrix shall have the following powers, in addition to and not in
limitation of those granted by law; to accept assets in kind in distribution from my estate;to collect
proceeds of insurance on my life; to retain assets in kind, to sell the same and to invest and reinvest
the proceeds without being restricted to investments which are fisted as legal for trust funds;to pledge,
exchange or mortgage real or personal property and to lease the same for terms exceeding five (5)
years;to give options for sales, leases, and exchanges;to borrow money, to compromise claims;to
make division or distribution hereunder either in cash or in kind; and to allot different kinds of or
interests in property to different shares.
FIFTH: I appoint my spouse, Janet K. Nagy, Executrix of this my Will. If my spouse is unable or
unwilling to serve as Executor, I appoint my daughter, Amy K. Nagy Powless, Executrix. If she is
unable or unwilling to serve as Executrix, I appoint my daughter,Jennifer O'Brien, Executrix. If she
is unable or unwilling to serve as Executrix, I appoint my daughter, Elizabeth M. Nagy, Executrix.
No bond shall be required of my Executrix in this or any other jurisdiction.
SIXTH: I direct that all estate inheritance,and other taxes whatsoever, whether or not the property
upon which such tax is levied passes as part of my estate,be paid from the principal of my residuary
estate.
I
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
We, William A. Nagy, �LG P.�I j� u; rlp and .1..1 c
�^��tFr,n the
Testator and the witnesses, respec vely, wh se names are signed to the foregoing Will, being first
duly swom according to law, do depose and say that the Testator signed and executed the foregoing
instrument as his Will and that he signed willingly, that he executed it as his free and voluntary act
for the purposes therein expressed, that each of the witnesses, in the presence and hearing of the
Testator, signed the Will as witnesses and that to the best of the knowledge of each of them the
Testator was at that time eighteen years of age or older, of sound mind and under no constraint or
undue influence.
Testator
CiAQ ,Alh C1
Wr ess
Wit#ess
Subscribed, sworn to and acknowledged before me by William A. Nagy, the Testator, and
subscribed and sworn to before me by IMP I. fflPP j F and
ju witnesses, this 3N day of EffiEMB R 1999.
Lwt-- S• Fiwc� P� r2
Notary Public
. .... _ WTAAIAI SEAL
DARLA L FRALICIL,NwY Waac
flMae am,CMW%r/coNw,►A
AV"W""bob"A";7000
Estate Valuation
Date of Death: 04/22/2013 Estate of: William A. Nagy Estate
Valuation Date: 04/22/2013 Account: 13682.1
Processing Date: 07/10/2013 Report Type: Date of Death
Number of Securities: 1
File ID: 13682.1.nagy
Shares Security Mean and/or Div and Int Security
or Par Description High/Ask Low/Bid Adjustments Accruals Value
1) 77 PRUDENTIAL FINL INC (744320102; PRU)
COM
New York Stock Exchange
04/22/2013 56.17000 55.03000 H/L
55.600000 4,281.20
Total Value: $4,281.20
Total Accrual: $0.00
Total: $4,281.20
Page 1
This report was produced with EstateVal, a product of Estate Valuations 6 Pricing Systems, Inc. If you have questions,
please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.3.1)
G, PNC
June 14, 2013
Amy Powess
109 Schoolfield Dr
Carlisle PA 17013-4429
RE: William A Nagy
SSN: 124-22-7952
DOD: 04/22/2013
Dear Sir/Madam:
In response to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
Checking Account
Account# 6408473917 Established: 02/24/1984
WILLIAM A NAGY
DOD balance: $25,021.54 + 0.14 accrued interest
Please note that this office provides date of death balances for deposit accounts(IRAs, CDs, Checking and
Savings). We do not process any financial transactions or provide statements. If you need assistance with
any of these items, please call 1-888-PNC-BANK(1-888-762-2265)or stop by your local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank, N.A.
Member FDIC
This message is intended for the use of the individual or entity to which it is addressed and may
contain information that is privileged, confidential and exemptfrom disclosure under applicable
law. If the reader of this message is not the intended recipient or the employee or agent
responsible for delivering this message to the intended recipient,you are hereby notified that any
dissemination, distribution or copying of this communications is strictly prohibited. If you have
received this communication in error,please notify me immediately by reply or by telephone at
800 762-1775 and immediately destroy this faxed document.
Page 1 of 1
William Nagy Annuities
ING Annuity] Death Benefit Cost Basis Taxable Portion
$164,327.15 } $33,784.98
$164,327.15 $33,784.98 $130,542.17
John Hancock Annuity J Death Benefit Cos Basis Taxable Portion
$50,581.171 $49,530.87
$50,581.17 $49,530.87 $1,050.30
i
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