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J 1505611185
REV-1500 EX(02-it)(FI)
aFFICIAL U3E ONI.Y
PA DepeRment d Revenue County Code Year File Number
Bureau dindividualTaxes INHERITANCE TAX RETURN 27, ],� 0501
PO BOX 280601
Harrlsburg,PA 17128-0801 RESIdENT DECEDENT
ENTER DECEDENT INF�RMATION BELOW
Social Securiry Number Date of Death MMDDm�Y Date of Birth MMDDYYYY
04062D13 02251945
DecedenYs Last Name Suffix DecedenYs First Name M�
MESSNER RUTH A
fif Applicable) Enter Surviving Spouse's Information Below
Spouse's last Name Su�x Spouse's First Name ��
Spouse's Social Security Number THIS RETURN MUST BE FILED IN OUPLICATE WITH THE
- - REGISTER OF WI�LS
FIIL IN APPROPRIATE BqXES BELOW
� 1. Original Return � 2, Supplementai Return � 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 aiter 12-12-82)
� 6. Decedent Dled Testate ❑ 7. Decedent Maintained a Living Trust 0 8. Totai Number of 5afe Deposit Boxes
(Attach Copy of Will) (Attach Copy of TrustJ
❑ 9. Litigation Proc�ds Recefved ❑ 1�•Spousal Poverty Cred�t(Date of Death ❑ 11. Eleciion to Tax under Sec.9113{A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTlAL TAX INFOR1NA710N SHOULD BE DIRECTED TO:
Name Daytime Telephone Number #•.,+
�
CRAIG A • HATCH, ESQ • 717-731°�960� � � �
. REGIST�O�1'ILIS US lY � q
r� � � � f!'� 4
r; � r- w `�
r- � �, �"�f �
First Llne of Address Q ��'`^ �
._ U� :, > �
2],�9 MARKET STR�ET � o � � -� �
Second Line of Address ca C `� n
_ � N t"- �
'� --a r'"" p
City or Post O�ce State ZIP Code
DATE FILED � � -�
CAMP HILL PA 17D11
CorraspondenYa e-mall address: C•H A T C H o�H H G L L P•C 0 M
Under penalHes of pery'ury,I declero thet I have examined thia rotum,inGudinp accompanying schedules and sketements,and to the best of my knowledge and belief,
it IS true,eorrett and complste.Oeclaretion of preperer other than the peraonal roprosentative is based on ail intormation of which preparer has any knowledpe.
SIGNATURE OF PERSON RESPONSIBLE FOR FIUNG RETURN ,� '' DATE f
KRISTA A• MESSNER, EX• "��)�� „ 1C-�-�{�X �I�'�I �`I"
ADDRESS
1473 TIMBER CHASE DRIVE MECH ICS G, PA 17�50
SIGNATURE OF PREPARER OTHER THAht REPRESENTATNE DATE
CRAIG A • HATCH, ESQ• �� �aC� r��C�
ADDRESS
2109 MARKET STREET � AMP HILL� PA 1,701],
PLEASE USE RIGINAL FORM ONLY
Side 1
� 15056]�1185 OM48473.000 7�5056117,85 � �
� 1505611285
REV-1500 EX(FI)
DecedenYs Social Security Number
178-36-1189
oecedentsName MESSNER RUTH A
RECAPITULATION
1. Real Estate(Schedule A) . . • • • • • • • • • • • • • • • • • • • • • • • • � ' 1• $� •��
2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . . p. $� •�0
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , , 3, $0 • ��
4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , 4. $0 •�0
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , , , 5. $5,8 51 • 9 4
6. Jointly Owned Property(Schedule F) � Separate Billing Requested , , , , g, $� •��
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested . . . . 7. $� • 0�
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . g, $5,8 51 • 9 4
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . g. $1�2 2 4 • 7 2
10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) , , , , , , , , , �p, $� •��
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. $1�2 2 4 •7 2
12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , 12. $4,6 2 7 • 2 2
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13. $� • 0 0
14. Net Value Subject to Tax(Line 12 minus line 13) , , , , , , , . . . 14. $4,6 2 7 • 2 2
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers un�ier Sec.9116
(a)(1.2)X.OU $� •�� 15. $O •��
16. Amount of Line 1 4�xable
at�inea�ratex.o- $4,627 • 23 �s. $208 •23
17. Amount of Line 14 taxable
at sibling rate X.12 $� •�� 17. $� • ��
18. Amount of Line 14 taxable $0 • 0 0
at collateral rate X.15 $� • �0 18.
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. $2 0 8 • 2 3
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
$I(�2 2
� 1505611285 1505611285 �
OM4648 3.000
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 13 0501
DECEDENTS NAME
MESSNER RUTH A
STREET ADDRESS
UM R AN
c�T, STATE ziP
MECHANICSBURG PA 17050—
Tax Payments and Credits:
1. Tax Due(Page 2,�ine�9) (�) $2 0 8 • 2 3
2. Credits/Payments
A.Prior Payments $0 • 0 0
B. Discount $� •��
Total Credits(A+B) (2) $� •��
3. Interest
�s� $1•78
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in box on Page 2,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) $210 • O L
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � �
d. receive the promise for life 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 decedent own an"in trust for"or payable-upon-death 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 SCNEDULE 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.g9116(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)(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 decedenYs 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 decedenYs 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.
OM4671 2.000
REV-1508 EX+(0&12)
pennsylvania SCHEDULE E
DEPPRTMENTOF REVENUE CASH, BANK DEPOSITS 8�MISC.
RESIDENTDEC ENTTURN pERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Ruth A. Messner 21 13 0501
Include the proceeds of litigation and the date the proceeds were received by the estate.
All ro ert 'ointl owned with ri ht of survivorshi must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Transamerica Life Insurance Co.
Life Insurance Policy No. : 05612649
Policy Owner: Ruth A. Messner
Insured: Krista A. Messner $3,591.62
2 Transamerica Life Insurance Co.
Life Insurance Policy No. : 06378984
Policy Owner: Ruth A. Messner
Insured: Krista A. Messner $1,981.57
3 National Benefit Life Insurance Company
Policy No. 02948448865
Policy Owner: Ruth A. Messner
Insured: Kurt M. Messner $2�8•�5
TOTAL(Also enter on line 5,Recapitulation) S $5,851.94
2wasAD 2.00o If more space is needed,use add'Rional sheets of paper of the same size.
REV-1511 EX+(�pqg) SCHEDULE H
pennsylvania
DEPPRTMENTOF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ruth A. Messner 21 13 0501
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
� None
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
�i�y State ZIP
Year(s)Commission Paid:
2. Attorney Fees: $1,000.00
3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach e�lanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: $138.50
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
1 Transamerica Life Insurance Co.
insurance premium owed $76.70
2 US Postal Service
postage $9•52
TOTAI.(Also enter on Line 9,Recapitulation) $ $1 224.72
swasn�2.00o If more space is needed,use additional sheets of paper of the same size.
REV-1513EX+(01-10) SCHEDULE J
pennsylvania
DEPARTMENTOF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDEM
ESTATE OF: FILE NUMBER:
Ruth A. Messner 21 13 0501
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER �E AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS(InGude outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
�, Krista A. Messner
1473 Timber Chase Drive
Mechanicsburg, PA 17050
One-Third of Residue:
$1,542.41 Daughter $1,542.41
2 Kathleen E. Kane
5302 Pineview Drive
Center Valley, PA 18034
One-Third of Residue:
$1,542.41 Daughter $1,542.41
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 151}iROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
�� NON-TAXABLE DISTRIBUTIONS
A.SPOUSAL DISTRIBU'fIONS UNDER SECl10N 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. S $0.00
swasni z.000 If more space is needed,use additional sheets of paper of the same size.
Estate of: Ruth A. Messner 21 13 0501
Schedule J Part 1 (Page 2)
Item
No. Description Relation Amount
3 Kurt M. Messner
254 Plymouth Road
Wilmington, DE 19803
One-Third of Residue:
$1,542.41 Son $1,542.41
DEATH CERTIFICATE
LAST WILL AND TESTAMENT
*_ s�
LAST WII,L AND TESTAMENT
OF
RUTH A. MESSNER
I, Ruth A. Messner, having my legal residence at 491 Woodcrest Drive, Mechanicsburg,
Cumberland County, Commonwealth of Pennsylvania, hereby declare this to be my Last Will and
Testament, revoking all other Wills and Codicils heretofore made by me.
ITEM ONE: I direct that the expenses of my last illness and funeral be paid from my
estate as soon as practicable after my death.
ITEM TWO: I devise and bequeath a11 of the remainder of my estate and property,
of whatsoever nature and wheresoever situate, to my husband, Edwaxd M. Messner, if he survives
me ninety (90) calendar days after my death. I intentionally make no devise to my children should
my husband survive my death by ninety(90) calendar days for the reason I am confident that he will
provide adequately for any children now living or hereafter born to us or adopted by us.
ITEM THREE: If my husband, Edward M. Messner, does not survive ninety(90)
calendar days after my death, I devise and bequeath all of the remainder of my estate and property,
of whatsoever nature and wheresoever situate, to my issue, per stirpes, who so survive.
ITEM FOUR: Should all of the above persons predecease me, or fail to survive my
death by ninety(90)calendar days, then all of the remainder of my estate and property, of whatsoever
nature and wheresoever situate, I devise and bequeath to the Green Ridge School Library.
ITEM FIVE: All estate, inheritance, succession and other death taxes, imposed or
payable by reason of my death, and interest and penalties thereon, with respect to all property
comprising my gross estate for death tax purposes, whether or not such property passes under this
Will, shall be paid out of the principal of my general estate, as if such taxes were administration
expenses, without apportionment or right of reimbursement. I authorize my legal representatives to
pay all such taxes at such time or times as may be deemed advisable.
ITEM SIX: I appoint my husband, Edward M. Messner,Executor of this Will and
direct that he be permitted to serve without bond and without any intervention of any court except
as required by law. I authorize my Executor to sell, encumber, mortgage, invest, distribute in kind,
or retain any items of personal property of my estate in such manner as he sha11 deem proper, limited
only by his own discretion. If for any reason my Executor appointed under this Will should fail to
serve in that capacity, I appoint my children, Krista A. Messner, Kathleen E. Kane and
Kurt M. Messner, my Co-Executors, with the same powers and privileges set forth above.
IN WITNESS WHEREOF, I have at Hershey, Pennsylvania, this %�/�``' day of
J �c( , 2003, set my hand and seal to this,my Last Will and Testament consisting of four
(4) pages, including the acknowledgment.
� `"}'� (SEAL)
Rut A. Messner
SIGNED, sealed, published and declared by Ruth A. Messner, 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.
. ��-- � � � Residence � �1'�
� �
i�`� �; s�,��%uiL�y-� Residence �'�t,��t��+���, ��
2
ACKNOWLEDGMENT
We Ruth A. Messner �?S and ' ` � �`�J•!����` the
, ,
__,�� i�--� , �`N� ,
Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix
signed and executed the instrument as her Last Will and that she had signed willingly (or willingly
directed another to sign for her), and that she executed it as her free and voluntary act for the
purposes therein expressed, and that each of the witnesses, in the presence and hearing of the
Testatrix, signed the Will as witnesses and that to the best of their knowledge the Testatrix was at
that time eighteen years of age or older, of sound mind and under no constraint or undue influence.
l �. �� ,/'. .�1�
Ru . Messner
�
��`.;
�y1�-- � , `
WIT SS
,;
�- -�''�..�'`i�c����--
,,.
WI�� SS
Subscribed, sworn to and acknowledged before me by Ruth A. Messner, the Testatrix, and
subscribed and sworn to before me by J0� � y�s� and �.�;t�ti� �. �����'1���/
,
witnesses, this � day of aJ �� 2003.
NOTARY LIC
Notarial seal
Robyn L. Br�ce, Notarp P�blic
JurvLG�3�isk.'.'l.'cvtessner Ruth Will'73-03 �m' �P•+ Dauphin Counry
My Commission Expires June 12, 2006
3
PA REV-1500
SCHEDULE E
CASH, BANK DEPOSITS &
MISCELLANEOUS PERSONAL
PROPERTY
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Pa e 2
Form 712 Rev.4-2006
Living insured
(flle with Form 709,United Siaies Gifi(end Generetfon-Skipping Transfera Tax Reium.May aiso be filed wifh Form 706,Unlied Sfates Estate(and
pnr�deM not aic�IUzen o�the)United States,where deCedeM ar�ned inseuranoe onaife of another.-Skipping Transter)Tax Rett�m,Eslate of
SECTION A—General information
36 First name and middle initial of donor(or decedent) 37 Last name
38 Sociaf seeurity number
39 Date of c�ift for which valuation data submitted ...............................
.................................................. ►
40 Date of decedent's death for which valuation data submitted......•••..••...•.••,.••.
................................... ►
SECTION B—Policy Iniormation
42 Sex 43 Date of birth
41 Name of insured Female 2/211f 976
Krisia A Messner
44 Name aixl address of insurance company
Transamerica Life Insurance Company 4333 Edgewood Rd NE,Gedar Rapids fA 52499
46 Policy number 47 Face amount 48 lssue date
45 Type of policy $1 p,pp0.00 5/27/1976
Traditional 05612649
50 F'requency of payment
49 Gross premium Annuai
$0.00 52 Date assigned
51 Assignes's name
53 If irrevocable designation of beneficiary made,name of beneiiciary 54 Sex 55 Dkpe�oNi birth, 5& Date designated
57 If other than simple designation,quote in fuU.Attach additional sheets if necessary.
68 If policy is not paid up: i
a Interpolated terminal reserve on date of death,assic�nment,or irrevocable �Sa $3 59�,62 : '
designation of beneficiar ' """"' ' ` �'
y ...... .................. .
...............
.....
; ,;
b Add proportion of gross premium paid beyond date of death,assignment,or g$b �
irreuocable designation of beneficiary •..••.•_..•••.•..� ••�• ••� � �••� � �Sc '
c Add adjustment on account of dividends to cred�t of poticy ''� - �` �`
dTotal.Add lines 58a,b,and c............................................ ......................................................................... 88d $3,591.62
e Outstanding indebtedness against policy........•....•.•.,....••...•. �• •• •��
................................................... 58e
.. g8f $3>59162
E Net total value of the poVicy(for gift or estate tax purposes).Subtract line 58e irom line 58d.............. ..... .
99 If policy is eiiher paid up or a single premium: , :': ,;
59a Total cost, on date of death, assignment, or in•evocable designation of ; ,
beneficiary, of a single-premium policy on life of insured at attained ac�e, for ; ; ;
original face amount plus any additional paid-up insurance (additional face g9a
amount$_) �
(If a sing�e-premium policy for the total face amount would no1 ha•ae been ' , ;.
issued on the life of the insured as of the date speciiied,nevertheless,assume , , ;,i
that such a policy could then have been purchased by the insured and state
the cost tliereof,usinc�for such purpose the same formufa and basis employed,
on the date specrfied,by the company in calculating sinc�le premiums.) i ; ;;,
P Y ................................................
39b ,:. ,, ,
b Adjustment on accounl of dividends to credit of olic 59C
c Totai.Add lii�es 59a and 59b................................................................................
.......................................
. . . . ................................................ 69d
d Outstanding indebtedness against policy....••. ••• �• • • �• � � •� � � "
• 59e
e Net total value of policy(for gift or estate tax purposes}.Subtract line 59d from iiie c...............................
The undersigned officer of the above-named insurance company (or appropriate federal agency or
retirement system official) hereby certifies that this statement sets forth true and correct information.
���.�� �.��.�.�--�-�
Signature ► Title► Vice President Date of Certification
►i/13/2014 Form ��z(Rev. 4-2006)
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CRASRFAX01 1/13/2014 5 : 10:06 PM PAGE 3/005 Central Standard �me
Form 712 Rev.42006 Pa i
Living Insured
(Fie u�iM form 709,UniEad States Oft(and Generation-Skipping Transfer)Tax Return.May also be filed wilh Fam 706,United Sfates Esfate(and
peneretion-Slupping Tr�sfer}Tax Retum,or Form 706-NA,United 9fates Estate(and Generation-Sldpping Trensferj Tax Retum,Estate ol
nanresideM not a citizen of the United Sfates,whaa decedent owned insurance on ife d another.)
SECTION A—General InformaEion
36 First name and middle infial of donor(or decedent) 37 Last name 38 Social security number
39 Date o(gift for which valuation data submitted .................................................................................. ►
40 Date oS decedenYs death for which valuation data submitted............................................................. ►
SECTION B—Policy InFortnation
4f Name of insured � 42 Sex 43 Date of birth
Ku�t M Messner Male 1/26/1980
44 Name and address of insurance company
Transamerics Life Insurance Company 4333 Edgewood Rd NE,Cedar Ra 7a e a oun99 48 Issue date
45 Type aF po�icy 46 Policy number
Traditional 06738984 $10,000.00 8/20/1980
49 Gross premium 50 Frequency of payment
$76.70 Annual
52 Date assigned
51 Assignee's name
53 tf irrevxable designation of beneficiary made,name of beneficiary 54 Sex 55 DaQt'e��eirth, 56 Date designated
57 If other than simple designation,quote in full.Attach additional sheets iF necessary.
5g If policy is not paid up:
a Interpolated terminal reserve on date of death,assignment,or irrevocable 58a �1,923.15
designation oF beneficiary... .. ....... .. ... .... . . .. .. ... ` =
h Add proportion of gross premium paid beyond date of death,assignment,or 58 42 �
irrevocable designation of beneficiary............. . . ...................... ................. S8b $ • ;_
...
c Add adjustrnerrt on accouM of dividends to credit of policy 58c �- -
d Total.Add lines SSa,b,and c................_........ ........................_....__-........._............. S8d' $1,981.57
..............................
e Qutstanding indebtedness a ainst 1ic .. .... .. .. . .. . 58e
9 Pa Y.......................................................
t fYet total value of the poficy(for gi(t or estate tax purposes}.Subtract line 58e from line 58d...................... 58t $��gg�,57
59 If policy is either paid up or a single premium:
59a Total cost, on date of death, assignment, or irrevocable designation of __ �
beneficiary, of a single-premium policy on life of insured at attained age, for "- `
wiginal face amount plus any additional paid-up insurance (additional face 59a - - -- -- - --
amount 5_) '
(If a single-premium policy for the total face amount would not have been b. _
issued on the Ifie of the insured as of the date specified,neverlheless,assume :
that such a policy could then have been purchased by the insured and state -
the cost thereof,using for such purpose the same formula and basis employed,
on the date spe�ed,by the company in calculating single premiums.) 59b ' - - - - --
b Adjustment on account of dividends to credit of olic -`-"''""`''"'"°°""''`�� ��
p Y ................................................
c Total.Add lines 59a and 59b........................ ...............................,............................................... 39c
..............
d Outstanding indehbedness a ainst lic _---....-_---.---..._--_---------- +�9d
9 pa Y - - - -- -----
� - 59e
e Net totai value of policy(for gift or estate hax purposes).Subtract line 59d from fine __......................
The undersigned officer of the above-named insurance company (or appropriate federal agency or
retirement system official)hereby certifies that this statement sets forth true and correct informatian.
�---� ����.
Signature ► Titfe► v�oe President Date of Certification
►1/13I2014
Farm 7iz(Rev. 4-2006)
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(;tSAStSt'AXUl 1/l;i/"LU14 5 : lU. Ut� Yf7 NAIi� 4/UU� L6ritY'al �tanaar o i ime
,.I�R�NSAMERIGA Tru�sunerica Life Insurance Company
4333 Edgcwood Rauid NE
CcdarKapids,FA 52499
L1FE INSURAIICE COMPANY
January 13, 2014
Kurt M Messner
254 Plymouth Rd
Wilmington, DE 19803-3117
Policy Number: 06378984
Insured(s): Kurt M Messner
Dear Policy Owner:
Enclosed is the requested Form 712. Please note that Line 58(a) in Part II of Form 712 refers to the
interpolated terminal reserve (ITR) in reaching the net total value of the policy in Line 58(�. ITR is generally
considered to be the amount that is required to be held in reserves to cover the future liabilities af each policy.
Currently, we believe there is no general agreement as to whether a (ife insurance policy has an ITR.
However, we have included an ITR value in the form which best reflects our analysis of an ITR for such a
policy.
The IRS issued guidance on the valuation of Irfe insurance policies in Rev. Proc. 2005-25, issued on April 8,
2005. Under this guidanoe, the fair market value of a (ife contract generally is the greater of the Inferpofated
Terminal Reserve ("ITR") or a formula amount involving Premiums that have been paid plus policy Eamings,
minus Reasonable Charges ("PERC"). Please note that the PERC amount is not curren�y catled for on iRS
Form 712. Rev. Proc. 2005-25 came out after the creation of Form 712, and the form has not been updated to
include PERC.
We understand that the fair market value of a life insurance policy for federal tax purposes is a
question of tax law for the individual taxpayer. Transamerica cannot provide legal or tax advice and
cannot determine the vafue of this poiicy for federal income tax purposes fior you.You must seek out
and rely on the advice of your own qualified tax and legal advtsors.
To assist you in determining the fair market value of the policy,we are providing you certain informa6on:
•The policy's reserve value as of the beginning and end of the policy year_
Policy's Reserve Value $1,899_33 as of August 20,2013
Policy's Reserve Value $1,999.27 as of August 20,2014
We appreciate your business and this opportunity to be of service to you. If you have any questions or need
additiona!assistance,please contact the Customer Service Qepartment at 1-800-852�678.
Thank you for choosing Transamerica!
Customer Service Department
Fax1-866-622-5051
tii.customerser�ice@transamerica.com
cc: Zimmerman,William 994420
. . ,
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CRASRFAX01 1/13/2014 5; 10 :06 PM PAGE 5/005 Central Standard Time
Enclosure(s): IRS Form 712-Life Insurance Siatemerrt
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or trr�va�ab�ds�sg���et;on+st ben�tjciary . . , , . . . ,
c Add�d�uscmant on ac�ounr of�iv���n�1s co crgdit a�poticy . . . �-.�.w- -.�-�
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f S�gt N��1 Valum oi th�pc�licy(1nr c�N�or Qstate tax p�.�rposes)-�uti2ra�Mn�5B�frar:�Itn�SBsJ , .
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� 7otei oA�'t, on �lais c�f t��dth, assigrtme�t, n� +�r�vocab� de�ign�4lo� of �
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c�rk�in�rl tac,�6�Y�ount piug�ny acid�tFOn�l pcatrJ-��p tnsurar�ce{adaition�l f�oe �g� 0
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on tt�e date speclfi , thR cvmpan.y;n catculattng s�n�l�}�em�,��l�.) �� { ..�, n ' I
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thg ��;�ards of th�camp�nY, mvst b9 retaine�3 t�s tong�9 4heir cos�tar�ts m�Y
�nr pt�rpqSeS or thls startembrtt, �f��i�x+ihe si�n�luCe become metenaf;n the administrat+¢n s�f�ny Int�rnal
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��perwork Fl�q�t�on Ao@ Na'tice.We esk!'or the �f oU Fta.ve aotllltlent�CbrtceCR►Rg th��CCu�a�y D�
lrtiformatlon on �fa fnrm to carry�ut tha Ic�te�r►at ����� ���irnat�� �r scx�estlons fr�� rrl�king ihEs
F��venue �aw�d#th�l�nit�,Statas. You ar�re�lu�red#o �rm slrnplpr, we wauld be he�pK'Y to t�ear i'ram you.
g(v��7s th�informatlUn_We neecf it ta eneurA th�t you
ar�coma�►ying wEtr� thsaa I�ws ar�d to�now us to fipure S�e the ins4ructions for t�e tax reiur�r�ith whsch tt�is
ar���c�Iiec:#the right ambunt ot t$x. iorrrl 19 fEleti. F,?c� r�t�t send the tax foCrn tG that offfCe.
)nst�e�d, rekurt�ii to the�x�reutAr�a►repr��ntativ�whra
rec}ue�t�d it.
� prsr�w,a.K�ow�
PA REV-1500
SCHEDULE H
FUNERAL EXPENSES and
ADMINISTRATIVE COSTS
RECEIPT FOR PAYMENT * DUPLICATE *
GLENDA FARNER STRASBAUGH Receipt Date : 10/08/2013
Cumberland County - Register Of Wills Receipt Time : 13 :27 : 14
One Courthouse S quare Receipt No. : 1075819
Carlisle, PA 17613
MESSNER RUTH A
Estate File No. : 2013-00501
Paid By Remarks : KRIST A MESSNER
WZ
------------------------
Receipt Distribution ------ ---------------- --
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 30 . 00 CUMBERLAND COUNTY GENERAL FU
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FU
RENUNCIATION 10 . 00 CUMBERLAND COUNTY GENERAL FU
SHORT CERTIFICATE 25 . 00 CUMBERLAND COUNTY GENERAL FU
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FU
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FU
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FU
----------------
Check# 1401 $138 . 50
Total Received. . . . . . . . . $138 . 50
� EOR CH4�!GE OF AD�RLFSS CHF.CK gnX, PR!NT ME1N ADnRESS nN BACK
NAME POLICY NO. CO UE DATE PREMIUM LOAN INT LOAN PAY DIV CR TOTALS
Kurt M Messner 06378984 07 UG 20 2013 76.70 76.70
�
PAYMENT DUE 76.70
TOTAL AMOUNT PAID ��� `d
106007�63789848&&&&&& 08202013 0000000000 OOD0�07670 OODO�OOOOORB
11�6JI���U�����Il�il���lh����l�l�ll���ll���ll��dl����l�ll
RUTH A MESSNER TRANSAMERICA LIFE
1473 TIMBER CHASE DR INSURANCE COMPANY
MECHANICSBURG PA 17050-9145 PO BOX 30266
LOS ANGELES CA 90030-0266
FOREM
� _ •
EST OF EDWARD M MESSNER COMMAND ASSET PROGRAM �VO
• KRISTA A MESSNER EXEC 99-7t6/7023 10007
1473 TIMBER CHASE DRIVE
MECHANICSBURG,PA 17050 ��) ;�
� Date
r , Pay to the 1�l.Ef...��p O-�MQ.'u.�—� �1 h'`Z "�''
t Order of � � �� l C�
�� � °`La� � �, s.��„„
�"' Dollars IJ �;?�����•
,�, ,.•=
• payable throu9h '
WeMS Fargo Bank,N.A.
For �`�-� ! � ` °� � �
�: LO 2307 �64�: 909 2 � 59645��' 0 �60
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��* END OF ATTACHMENTS **�