The URL can be used to link to this page

Home My WebLink About02-0753 c. REV-1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 /7- &3 -& DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FIL~BE\ ,5 HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 02- COUNTY CODE YEAR NUMBER SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Une 14 taxable at the spousal lax rate. or transfers under Sec. 9116(a)(1.2) 5,161.64 x.D 00 (15) 16. AmounlofLine14taxableatlinealrale 0.00 x.D 0.045 (16) 17. Amount of Line 14 taxable at sibling rate 0.00 x.12 (17) lB. Amount of Line 14 taxable at collateral rate 0.00 x.15 (18) 19. Tax Due (19) 20. D I~KHl!~Eijji@ij~~ml!l(lA!l~NQ!)f~QYl!l!llih'.~rl .i~'iir!li$$J!!\~t$i9I$W~mQI)i!l!rn~lMilltii!~ll_!l$Wll!!l. DECE- DENT CHECK APPRO- PRIATE BLOCKS COR- RE- SPON DENT RECA- PITULA- TION TAX COMPU- TATION o PA 15001 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER payes Michael 180-22-2481 DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD.YEAR) THIS RETURN MUST BE FILED IN DUPLICATE 02/24/2001 c:> 'if-I - ~ WITH THE REGISTER OFWILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Shirley G. payes ~ 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach copy of Will) 9. Litigation Proceeds Received ~ 2. Supplemental Retum 4a. Future Inlerest Compromise (date of dea1h atter 12-12-82) 7. Decedent Maintained a Living Trust AttaCh a copy of Trust) 1 O. ~poosaJ Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return D (date of death prior to 12-13-82) D 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes D 11. Election 10 tax under Sec. 9113(A) (Attach Sch 0) tH!$~1!lQ!ii~iil!l<<PM!lij!l'tiW;i!t'i:!Qi!Iij.!!~_lIi.ijl_im;W**I\'I!!Ql!l.i\tlQj!ijjj!lQ!I@!l!j~Il!l.iWfilii NAME COMPLETE MAILING ADDRESS Mark E. Halbruner, Esquire 1013 Mumma Road, Suite 100 FIRM NAME (If Applicable) Lemoyne, PA 17043 Gates, Halbruner & Hatch, P.C. TELEPHONE NUMBER 717-731-9600 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested OFFICIAL USE ONLY (1) (2) (3) (4) 0.00 0.'00 0.00 0.00 (5) 5,935.64 (6) 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) (7) 0.00 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Oecedent. Mortgage Liabilities. & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (8) 774.00 0.00 (11) (12) (13) 5,935.64 774.00 5,161.64 0.00 (14) 5,161.64 0.00 0.00 0.00 0.00 0.00 JUL. '~) 2'DlJ2 NTF 29755 Copyright 2000 GreatlandfNelco LP - Forms Software Only PA REV-1500 EX (6-00) Page 2 Decedent's Comnlete Address: STREET ADDRESS 35 Kensington Drive Cumberland CITY r STATE I ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 0.00 0.00 0.00 Total Credits (A + B + C) 3. InteresVPenalty if applicable D. Interest E. Penalty 0.00 0.00 TotallnleresVPenalty (D + E) 4. If Une 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund 5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. Make Check Payable 10: REGISTER OF WILLS...A.GEN.T... :-"':"-";--";"""'-';';""';"-:":'::":'::":':::':'::'::,:::::::::::,::::::::::,::::::::::::::::::::::::::::::::}::::::::::::::::::::::::::::::::::::::::::}}::::::t:::::::::::::=:=:::=:::::::::::::::=:: :::::=:::::::=::t?:::=::t::::tt:::::;::::::;:::::::;.;.;...;.;........ . .......... ....-......... .............w__... (1) 0.00 (2) 0.00 (3) 0.00 (4) 0.00 (5) 0.00 (SA) 0.00 (58) 0.00 .................pLEASEANsWER THE FoCCoWiNG OUES'fIONS BYPLAC fNGAN..;;X;;..iN..THE.APPROPRIATE.BLOCKS.. Yes No ~ I 8 ~ 1. Did decedent make a transfer and: 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 either payments, benefits or care? .............................. 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Did decedent own an "in trust forM 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 SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perlury, 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 01 preparer other than the personal representative is based on information of which re arer has an knowled e. SIG AT OF PERSON RESPO SI R FILING RETURN DATE ;:);9 . 170~/ SI ADDRESS 10('-:> II",,.,, "'" a. Ai!.. ,\~.h. /(")0 r ~aY~R PA-- 1/01-(---...., :-;.,.:.;.:.:.;.,-,.:.:.:.:.:.:.,.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.,.:-:.:.:.:.:.:.;.:.:./.;.:.:.:.,.:.:.:.,.:.:....... o PA15002 NTF 29756 Copyright 2000 Greatlano'lNelco lP . Forms Software Only o ~ REV-1508 EX + (1-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Michael payes Include proceeds of litigation & date proceeds were received by the estate. FI LE NUMBER DESCRIPTION All prop. jointly-owned with right of survivorship must be disclosed on 5th. F. VALUE AT DATE OF DEATH ITEM NO. 11. prudential Annuity No. 99721936 Owner: Michael payes Beneficiary: Estate 5,935.64 TOTAL (Also enter on line 5, Recapitulation) S (If more space is needed, insert additional sheets of the same size) 9 PA15OB1 NTF 10875 Copyright 1999 GreatlandINelco lP - Forms Software Only 5,935.64 REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Michael payes SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FI LE NUMBER Debts of decedent must be reported on Schedule I. ITEM NO. DESCRIPTION A. FUNERAL EXPENSES: 1. AMOUNT B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN No. of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. 3. Attorney Fees 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 750.00 4. Probate Fees 24.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 9 PA15111 NTF 10878 Copyright 1999 Greatland/Nelco LP - Forms Software Only TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 774.00 REV-1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER Michael payes No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 1. Shirley G. payes 35 Kensington Drive Camp Hill, PA 17011 RELATIONSHIP TO DECEDENT AMOUNT OR Do Not List Trustee(s) SHARE OF ESTATE Surviving Spouse 5,161.64 ENTER DOLLAR AMTS. FOR DISTRIBS. SHOWN ABOVE ON LINES 15 THROUGH 17 AS APPROPRIATE ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRiBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 9 PA1S131 NTF 10B80 (If more space is needed, insert additional sheets of the same size) Copyright 1999 GreatlandlNelco lP - Forms Software Only Hl05,905 REV,I09100l This is [0 certify that this is a true COPy of the record which is on file in the Pennsylvania Division of Vital Records in accordan..:~ ":i,h Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. C\~s~-' -~...- /~ Robert S. <ZimInerman, Jr., MPH Secretary of Health No. ~)/~ Charles Hardester State Registrar 1418977 1.":) ~J g 2001 ..J1.1 ~ _ Date Hl05.1'l.3R....<IIT ~ r:,~ COMMONWEALTH OF PENNSYUfANlA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH YI'EIP_T . !fII_AH!MT ~.. NAMEOl"OEClDl!NT(F...._l.. I. Michael payes /lGlE(lMI--' IJNllElIlIYVIII - - UNDl!1II10011l1' -1-- Lma1e -~- ~~- . 180 _ 22 - 2481 DReOl'~;_O"'-_ ,reb. 24,2001 ~""- _",,_Cra.owYl I'l.M:I'OFOE.alfO"C""""____...__ - __0 ~O ::"0 75 ..-... COUN1'YOl"OEIlI"H Cumberl8lld Triadelphia,WV .. F.-aLfTYHAME....._____, Lc>;er Allen 1lIICI000lIl/SlIOl!SSIlNOUSTIlY ,. M_~ - -- -.S1lG\II._ --- -.. -- 411-''''5.. ied Ik.Q.....__.. Lower .............. tI____ Klinge - ,~ .,.0::....-==.. ~.,----~ I Anna Vukovich ..............____ ~...._C'*I 35 Kensington Dr. Hill PA 17011 .....u ~._"'c-..~ .~.....ZiltCo* ._- ~ i "---_....0 .... M~ "pst Harrisburg Crematory _AND.-oDlIIl!!SSOf'fAClUTY zzi ......- Harrisburg, PA 8 Market Plaza Way ...- OAJ1iF'flONOUNCEDDEAD~o...~ 9: 15 N. Februa 24. 2001 n.","" ~-_''''-'''___'''_.Da'''___'''''''''-'_''__."",-,,__.__ 1..1II...._____. Y1NCASl!lIIEFMlII!DlOM!OCAI.IVlAMMMXlAONUl'I _iQ- .0 L'f...N"....... out:lOlOI'...s"'CClNSfoutNl;;f;OI'): ,- '-- :--- !1.t4 "0 _.. O"...-_-......_.tIuI _-....~_...iI_l DUEIO(OII...s...C(lNSEClU(NCECif'l: . . . .. .... . . .c u ... >: DUEIO(OII...s...CONSlOUENCECif'l: ~OIf-DUI'H - -- A. o o ..."'~ ...- ...."'..... 1NJUlIIY1II~ DUCN8l!HCM'IOI.IlJRYOCCUlIIlIII!D. ... D....~ - 0 ....;t.. ~ ... ... c:on_o-__ 'CBl'rIl"flNQ~Il'It..--"""""_~______--.l__--"'_m ......_.....,~.--_.....UUM(sI__.._............................... -- o o o "'-""CE0If-.......w...._.-._-,..-. N. --- - _ 0....0 - 1.:',1,2..1(' I o ~.._- ~ I ~ I . . 'J c INCINGNtDcun...-..a...n.cw.~....;.'---:______._",_ 1O..__...,--...,.~_...._._._,....__._'*-"l~____ ............... '''CMCAL~1Ul ~-=-..:::.~.~.......IipI-........,...-....__..l..._._._~.__..__~I_ ~". ; .......................................... ........ .................. ...... ..... ........ M~' PA 17033 u. LAST WILL AND TESTAMENT OF MICHAEL PAVES LAST WILL AND TESTAMENT OF MICHAEL PAYES I, MICHAEL PAYES, of Camp Hill, County of Cumberland, and Commonwealth of Pennsylvania, being of sound mind, memory, and understanding, do make, publish, and declare this to be my Last Will and Testament, hereby revoking any and all wills and codicils by me at any time heretofore made. ITEM I. I give, devise, and bequeath to my wife, Shirley G. payes, all my estate, real, personal, and mixed. ITEM II. In the event that my said wife should predecease me, or in the event that she should die simultaneously with me, or in the event of her death within a period of thirty (30) days after my death, the said devise and bequest of my estate to my said wife shall lapse, and in such event I give, devise, and bequeath all my estate, real, personal, and mixed to my daughter, S~lly Jo Payes Ohrum and my son, Philip M. payes, in equal shares. ITEM III. I authorize my personal representative, hereinafter named, to deliver to any beneficiary hereunder property in kind at the election of said beneficiary at such valuation as may be determined for the purpose of determining my taxable estate. ITEM IV. I hereby nominate, constitute, and appoint my wife, Shirley G. Payes, as Executrix of this, my Last Will and Testament. In the event my said wife fails to survive me or is otherwise unwilling or unable to serve as my Executrix, I then appoint my aforementioned daughter and son as Co-Executrix and Co-Executor. IN WITNESS WHEREOF, I have hereunto set my hand and seal this /:) day of Cr~-I' , 1981. Signed, sealed, published, and declared by the above named MICHAEL PAYES as and for his Last Will and Testament in the presence of us, who at his request and in his presence, and in the presence of each other have hereunto subscribed our names as witnesses thereto. W I! f~ residing at ~ 11. 1f"J)..f\ 3" b .;d t-, r fc, 1 ' ,A U '--fi' , ) [[lCLK- C T residing at 1.30D YJ(a CL-I.-L "lei (I 1k;jVJldL , PeL . - 2 - COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN ) ) SS ) I, MICHAEL PAYES, testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by MICHAEL PAYES, the testator, this 'day of C',l(<~ , 1981. ~ ;::~ NOTARY PUBL'IC My Commission Expires: .' ,,~'.'J ,.....,,(. 01 pennsylvania . Illy Commission Expires Nov. 2, 198.L. CO~MONWEALTH OF PENNSYLVANIA ) ) SS COUNTY OF DA!lPH'N ~ ) We, ~-j C ~and JZLtLili E. RJ~/~ the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw testator sign and execute the instrument as his Last Will that he signed willingly and that we executed it as our free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testator have signed the will as witnesses; and that to the best of our knowledge, the testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by D(LfJ r: E~ and 9~ f ~~) ,witnesses, this /.5- T^-- day of ()C~ , , 1981. (Qwifesst: p ~ Z. \..jJ . . :; ufLt/rt~~ 'V:-~-jJ 4rmAt; P~ My Commission Expires: .. ........, 'u..u(; ot rennsyNania Illy commi..lon Wires Nov. 2, 198.L PRUDENTIAL ANNUITY IRS FORM 712 Fam 712 (Rev. May20oo) Oepartment:dtheTreuury l"terrl.,R:......u.~ce Decedent Insured (To be filed by the executor with Form 701, United State Estate (and Generation..skipping Transfer) Tax Relurn, or Form 701-NA. United States Eatale and Generftion-Ski in Transfer TI)( Return Estme of nonresident not III citizen offheUnited Slates. 1 Decedent's 'first name and midde initia 2 Qecedenrs last name 3 Decedent's social security numbEr" (if 4 Date of death MICHAEL PAYES knOlln 180-22-2481 02l241ll1 5 Name and adct'ess d inSJrance company The Prudentiallnsur..ce an of America, 711 BrOlld stree 6 T e of oIie ANNUITY 8 Owner'sname.lfdecedenlisnotowner, allecl1 copy 01 application. Prudential 5/29/02 2:11 PAGE 2/2 RightFAX Life Insurance Statement 9 Date issued 7 7 PoIi num 99721936 10 ASBignor's name. Attach copy of assiWlment. 05104190 12 Value of the policy at the 13 Amount of premium (see instructions) time of assignment 14 Name of beneficiaries ESTATE 15 Face amount of policy ............................................... 16 IndelTlnity benefits. . . . . .' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Addtional insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Pnndpal 01 any indebled1esslo Iheeompany thai Is declJ~ble In determining net proceeds . . . . . . . . . . . . . 20 Inlereslonlndebled1ess(8ne19)ec<ruedlodaleoldeelh.............................. 21 Amount of accumulated dividends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Amount of posl..f11ortern dividends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Amount of returned premium ............................................ 24 Amount of proceeds if payable in one sum .~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as Dfdate of death (ifnot payabtein one sum) . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Policy provisions canC8'ning deferred payments or Installments. Note: If ether than lump-sum settlement is authorized fer a BJrviving &POOH. attach a copy of the inSJrance policy. 27 Amou nt of inslallm ents 28 Dite ofblrth, sex, and name at any person the dJration otwhose lite may measure the number otpayments. Dite of birth: Sex: Name: 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits 30 Basis (matality table and rate of interest) used by inSJrer in valuing installment benefits a..e No. 1545- 0022 11 Dale assigned 15 $ 16 S 17 S 18 S 19 S 20 S 21 S 22 S 23 S 24 S 25 S 5,935.64 31 W...elh...eany~ansl...soflhepolieywilhinlhelhreey....pnorlothedealhoflhedecedenr?............ 0 Yes 0 No 32 Date of assi!7'menl (y transfer. 33 WaslheinSUredlheannuilantabeneflcia-yofanyannullycontractlssuedbylheeompany?.............. 0 Yes 0 No 34 Did the decedent have any incidents of ownership on anypalicies on hiS/her life, but nd owned by himhler at the date of death? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D Yes D No 35 Nnes of companies with which decedent caTjed other poides and amount of such policies if this information is disdosed by your records. J..- TIll. SOCfetary Date 01 Certtnatlan Theunoersigned ofticer d the abov~amed In&.lr&"lce company (a appropriate Fed..aJ &gena, a rellrem8l1 sySl!m oIIlciBl) hereb,/ anIl1es Ihalthls "1Il!menl sets forlh Irue IWld COITecI information. Signature 05129102 s.....~ * ZFam 712 Rev S.2000_PRU.doI Fam 712 (Rev. 5-2000) AUG-20-2002 09 12 GATES~HALBRNR~HATCH 717 731 9627 P. 82 PA OEPART1ABiITOF REVSNIJ~ ' cv T~ ~A° ~•'"•"'°' ESTATE tNt=~RMATION SHEET ~ ;;71 ~ ~ a ~ ~,~3 DECEDENT tNFORMAT1pN: Enter data ae it will appear on all documents submitted to the dspardnent. lama ((-ast) (Ftrs~q tM+ddle) Payrs YlGhtiN lsaedent's 8ocisl 3oa,rity Number Dane of Oaglt Date of BirtA 18Q ZZ Z~1 Febrtl~My ~, Z007 February, iS~ TYPE FILING: Enter cluck (r) maNric to ~dkxte the nature of the return to be tiled with the depertmeAt. ~ ~Prwbate i~ehim ^Joktt Ae~a orr~- Dr~ate Tax only ~Lietgaelat purpa~ (Na other aseata) Enter checlt (r) mrk ~ Indlmte the nature of the proaeadin~ at the Register of WiNs ~ LETTERS GRANTED. per, (poach atlditio~ $ If explanation b nee~tleary.) "~ []Te~otamerrtary DAeminion ~Na Letters Dover ( Explain) ATTORNEY/COpp~~~~PONDENT Inter all data conaeming the attorney ar other individual to receive all iNFORMATION: tax IMarmatlon and correspondence. Nome (Leah (First) (Middle) Supreme Court I.D. ~ - Helpnlller~ Mark E 86737 Stroet Addreaa Gaps„ Halbrunsr ~, NaEdt. P.C.,1813 Munan~l RO~dr Sulbs 10Q Cdy State Zip Code Telephone Number Lerrs<cyrte, PA iTA4S Ti7-7S7~600 PERSONAL REPRESENTATIVE Enter all data cortceming the personal represrettadve(s) of the estate INFORMA'1"14N: ~ by ~ Re9ister pf Wills ExecutorlAdminitrtrator ' Nenle (Lest) (First) (Middle) Social Security Number P+yes, Shhiey G. Street addnoas 35 I(erstsbtpton Drills (may State Zip Cods Telephone Number ~p Hnl, PA 17Qit T'l7 nr-o6~s Co.Exsoutor/Adminfs#rator . Nye ~,~) ~;~) (Middle) Social Secunly Number ~roel Address - ~y State ` ..- Tip Code telephone Number Ce.EYa~uter/~ldminist~ter ~~ (~) (Fri (Middle) Social Y Number Serest Address (~ State Z,p Code Tebphane Number r-epeted ey pee Hark E Flabruner tins A 49, ZOOZ TOTAL P.02 ~~- ~°3 v'1 COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0681 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX ~FP coi-oz~ DATE 09-30-2002 ESTATE OF PAYES MICHAEL DATE OF DEATH 02-24-2001 FILE NUMBER 21 02-0753 COUNTY CUMBERLAND MARK E HALBRUNER ESQ ACN 101 GATES ETAL Amount Remitted 1013 MUMMA RD STE 100 LEMOYNE PA 17043 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ---------------------------- - RETAIN LOWER PORTION FOR YOUR RECORDS -~ ---- -- - - REV-1547 EX AFP (01-02) - - -- ------------------------------------------------------------------------ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF PAYES MICHAEL FILE N0. 21 02-0753 ACN 101 DATE 09-30-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED [ ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds iSchedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) t3l .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this fora with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) t5) 5,9 35.64 tax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. Total Assets (g) 5,935.64 APPROVED DEDUCTIONS AND EXEMPTIONS: 774 .00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule Il (10) .00 11. Total Deductions (11) 774. DD 12. Net Value of Tax Return (12) 5, 161 .64 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 5,161 .64 NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 5,161 .64 X 00 _ . 00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) .00 X 045 . .00 17. Amount of Line 14 at Sibling rate (17) • 00 X 12 - . 00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 1 5 - .00 19. Principal Tax Due (1g)= .0 0 Tev reenTTC. DATE ~ NUMBER ~ INTEREST/PEN PAID (-) I AMOUNT PAID TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ^ IF PAID AFTER DATE INDICATED, SEE REVERSE [ IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT`' (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) RESERVATION: Estates of decedents dying on ar before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxe: at the lawful Class B (collateral) rate on any such future interest. PURPOSE OF NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S. Section 9140). PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side. --Make check or money ardor payable ta: REGISTER OF HILLS, AGENT REFUNO (CR): A refund of a tax credit, which was not requested on the Tax Return, nay be requested by completing an ^Applicatian for Refund of Pennsylvania Inheritance and Estate Tax^ (REV-1313). Applications are available at the Office of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour answering service far forms ordering: 1-800-362-2050; services for taxpayers with special hearing and / or speaking needs: 1-800-447-3020 (TT only). OBJECTIONS: Any party in interest mat satisfied with the appraisement, allowance, ar disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Natica by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CORRECTIONS: Factual errors discovered an this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 2806D1, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet ^Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 hear interest at the rate of six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are: Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor 1982 20% .000548 1992 9% .000247 1983 16% .000438 1993-1994 7% .DD0192 1984 11% .000301 1995-1998 9% .000247 1985 13% .000356 1999 7% .000192 1986 10% .000274 2000 8% .000219 1987 9% .000247 2D01 9% .000247 1988-1991 11% .D00301 2D02 6% .000164 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. LAW OFFICES OF LOWELL R. GATES Also Admitted to Massachusetts Bar MARK E. HALBRUNER Also Admitted to New Jersey Bar CRAIG A. HATCH CORY J. SNOOK ALBERT N.PETERLIN Also Admitted to Maryland Bar STACEY L. NACE ParalegaUOf(ice Manager TRACT L SEPKOVIC Paralegal Cumberland County Courthouse Office of the Register of Wills One Courthouse Square Carlisle, PA 17013 RE: Estate of Michael Payes Dear Sir or Madam: August 15, 2002 BRANCH OFFICE: 3 WEST MONUMENT SQUARE, SUITE 304 LEWISTOWN, PA 17044 (717) 248-6909 WEB SITE: www. GatesLawFirm.com CORRESPONDENCE ADDRESS: Lemoyne Office Enclosed for filing are a Petition for Settlement of Small Estate and PA Inheritance Tax Return (in duplicate). A check in the amount of $24.00 is enclosed as the filing fees. Please certify one (I) copy of the Order to the Petition and return it along with the additional time- stamped copy of the Petition and PA Inheritance Tax Return to our office in the enclosed envelope. Please contact our office if you have any questions or need any additional information. Sincerely, GATES, HALBRUNER &. HATCH, P.C. 1013 MUMMA ROAD • SUITE 100 • LEMOYNE, PENNSYLVANIA 17043 (717) 731-9600 • FAX: (717) 73i-9627 Traci L. Sepkovic Paralegal Enclosures cc: Shirley Payes n AUG ~02 IN RE: ESTATE OF : IN THE COURT OF COMMON PLEAS MICHAEL J. PAYES, :CUMBERLAND COUNTY, PENNSYLVANIA Deceased. :ORPHANS' COURT DIVISION NO.2~.-02-~5~ ORDE AND NOW, this / day of , 2002, upon consideration of the foregoing Petition and pursuant to 20 Pa.C.S. §3 02, it is hereby ordered that the proceeds from Prudential Annuity Contract Number 99721936 shall be distributed to Shirley G. Payes, surviving spouse of the above-named decedent. Shirley G. Payes shall have the authority to execute and endorse any documents required to accomplish said distribution. This decree of distribution shall constitute sufficient authority to all transfer agents, registrars and others dealing with the property of the estate to recognize the person named herein as entitled to receive such property without administration, and it shall in all respects have the same effect as a decree of distribution after an accounting by a personal representative. BY THE COURT, J. IN RE: ESTATE OF IN THE COURT OF COMMON PLEAS MICHAEL J. PAVES, :CUMBERLAND COUNTY, PENNSYLVANIA Deceased. :ORPHANS' COURT DIVISION PETITION FOR SETTLEMENT OF SMALL ESTATE- TO THE HONORABLE, THE JUDGES OF SAID COURT: The Petition of the undersigned respectfully represents: 1. The name, address and relationship of your Petitioner to the above-named decedent are: Name: Shirley G. Payes Address: 35 Kensington Drive, Camp Hill, Cumberland County, PA 17011 Relationship: Spouse 2. The decedent died on February 24, 2001, a resident of 35 Kensington Drive, Camp Hill, Cumberland County, Pennsylvania 17011. 3. The decedent died testate, leaving a Will, a copy of which is hereto attached, in which the personal representative named therein is the Petitioner, Shirley G. Payes. 4. The names, relationships and interests of all parties beneficially interested in the estate are as follows: Name Relationship Interest Sui Juris Shirley G. Payes Spouse 100 percent Tres 5. As decedent's spouse, Petitioner is entitled to the family exemption of $3,500.00 pursuant to 20 Pa.C.S. §3121. 6. Decedent's estate consists solely of Prudential Annuity Contract Number 99721936 which has a date of death value of $5,935.64, per attached IRS Form 712. 7. There were no expenses associated with Decedent's funeral and burial. 8. Petitioner is not aware of any other claims against Decedent's estate. 9. Petitioner will simultaneously file the Pennsylvania Inheritance Tax Return with the Cumberland County Register of Wills Office with the filing of this Petition. 10. There are no parties other than Petitioner who are beneficially interested in Decedent's estate. WHEREFORE, Petitioner respectfully prays that the Court enter an order, pursuant to 20 Pa.C.S. §3102, directing that the proceeds from Prudential Annuity Contract Number 99721936 be distributed to her. Respectfully submitted, GATES, HALBRL]NER & HATCH, P.C. Date: ~~ ~ ~ ~ Z , 2002 By: I G C, ~,t. Mark E. Halbruner, Esquire PA LD. #66737 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 (717) 731-9600 (Attorneys for Petitioner) VERIFICATION This~~"day of ~ ~ , 2002, the undersigned hereby verifies, subject to the penalties of 18 Pa.C.S. §4904 (relating to unsworn falsification to authorities), that the facts set forth in the foregoing petition which are within her knowledge are true, and as to the facts based on information received, after diligent inquiry, she believes them to be true. 1,~~ -~' Shirley G. P es, Petitioner Date: ~ ~~" ~~ ~`~ KtV.(09/00) This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance with Act 66, P.L. 304; approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. ~s . - ,~. Robert S. erman, Jr., MPH Secretary of Health 1418977 No. AGE ILal B~Mpayt UNDER1rEM UNDERIDAY OATEOF BIRTH BIRTNPIACE IC<r arN PRACE OF DEAiNIG~a<A der ma-u<nmucedn d, dlNr apal MorMa Days NorAa , MraAaa ~Md,m. Day,'berl AaN d Fdegn CodNYI ,pSpUy OTHER: 7 5 rn. :. < 2 / 2 8 / 2 5 Triadelphia, WV py µ ++ ^ ERpu1pMNN ^ DDA ^ ,~ ^ R.admp.CS aRo•<NI ^ COUNTYOF DERN CITr, BORO.iW POF OEATN FACNTY NAMERnd am~AAdr, Q,a ebeelaM raniOen NRS DECEDENT OF MSRWK: giK.INT RACE-Amanun MpiaR BMCt Wldla a,C Cumberland Lower Allen 35 Kensington Dr "°~ y"^"""''°'°"'°°'"• . . I~ ~ M B4 EI. . M..dn. ruwN aleln,.K. f wh ite 10. DECEDENT'9 USUAL OCCUPRKM (Give Anpd adM dprN pur rnpal +q KMD OF BUSMESSIINDUSTRY ra,B DECEDENT EVERW U.S. ARMEDfORCE87 DECEDENT'S EDUGEgN aW . MARTBILSUTUS•MrriW Haw MartM4 W,daaad, SURVIVNq Spq/$E IM nla. gaamiipan ramp d w.: eem .uYinO raNed.) . 1aRet. Claims P'lanager ,,,Insurance ./q M~ No ^ „- ENm „ anlary/Sw.dpary R+r Coaap 4 N+dB.I Dlw<a41SP«h) ,ytarried ~hirley G. Klinge ~ DECEDEM'3 MAEMD AODIIESF (Stra0. Gy/fdw~. Slsla. ZV C<tlel DECEDENT'S "`~"" FA p r~,..,., v< C~.< a<.e Lsower Allen .w .l D 35 Kensington Dr. ~E~ . .. N . n_ ip ,,,,.., ea< d.W Camp Hill, PA 17011 . "' " ; ,„ ,.. ,m Cumberlan „ „ ,, ,Ip, „aa,,,a",~, d »4^ aaiylw.nrTm<.a d, ,,~,8 f'°"E'~li"c"'~idFla" '°°~ej ok i h , - MOT/IERS NALE,F.a Miae.. MPtlen sdnrrN, s ov c ,.. ,.. Anna Vukovich '~~~ir~ey ar(~P•..T~IC r/a MfoPWwr3 MAE,ND ADDRES315.... cR./fpw+.m».LpcoeN ,B4 l"~' ,,, 35 Kensington Dr.Camp Hill, PA 17011 ~S 1Y' S NIOS.tU Rev. vB7 COMMONWEALTH OP PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH rPEmMNT IN SLUE FAF NUMBER °_RMANENT Nn,1E ~ DECEDENT IFaa. MgAa. Leal SE% SOCIAL SECURITY NUMBER DATE OF DERN IMCn1i, Oaa'mArT ,LACK MK ,. Michael Payes ,male , 180 - 22 - 2483 .1•eb. 24 2001 o w Iy~.cd cNmrbrl ® R.mo.r spar SNIa ^ ^ Mdan, Dw ,e.r~ deb. 26,2001 an.ro.r.da<I.r olydarn. i ^~ Z___'- L C ~~1~ Charles Hardester State Registrar Date PA Way ' ~ 17e~~ n Mama li-211m~1uu~MMOy TIME OF DENN DATE PRONOUNCED DEADIMaI~, D.y Marl fAS GASE REFERRED IO MEDICAL E]UMINERIf.ORONERI pwapr,MbpnaaancM pYl11. ~~ ~^ • :.. 9:15 M. ]3. Februar 24, 2001 „- n. PART I: Edw BN pia<ays,'vMaia.dmmplicatdNVMicftr'ausW lM CaaIN. DO mladwlM nNM dCyirq. suM as nrOix ar Negrabry arryL SM[ta MNla<da. ~Apprp..YnMa PART E: p/yr aigJipra<ddadataorerLaigbMMN pul LN waY orN <wfa MeaUf N. I . r'•'m•'a'•'E~tlNUMaM+9uusa VNann RVTF 1. MMEOUITE GUSE IFnr dwlanppaaN auawad mn.or. ,.,rw., w+x--• a. l.• `~ Nq ~~ O ~MPc I ~ Zy No DuE ro IDR As A cONSE WENCE oFl: SapYMiBaayfYfar,ppv,a D. darry,WbgbmMWN WE roIOR A$ACONSEOUENCE OF): aea. ENw UMDE/1LrMD 1 GUSE R7.aaaa<r <aAy e. ; ri tialep awe DVE ro TOR AS A CONSEQUENCE DF}. reaullrq a, oeaaN IAST I a • WASAN AUTOPSY WERE AUTOPSY FNDM0.4 MANNER OF DEATH DATE OF MAIRY PERFOR-ED9 A<11LABlE PRK7R ro TIME OFINA/RY NUIMVR WL1ip(7 DESCRIBE NOW B<RIRY OCCUPIED. IMdNr.OW. MaR ~ETTd1 OFCAUSE OF NMwN ~ N<micipa ^ Ka ^ No ^ Attipara ^ Pw~q MaMrgtbn ^ r~1~-~~A,I y~ Ma ^ Np raa ^ No pLT Sukipa ^ CoW nd Ea palarminap ^ ~' M. ]0/. PIACE OP MLIU1ir.AllNrM - Mn aoeM N<tdY olfita locArE%~IAea eMlT , l 3l I , . ! 4ui6q. at. ISpaUM ]M. ]W N. ],N- . . . . •I . wu a ]p, CERTIFIER IChct myorW •CEATIFYIND PNrsICUNIPnrso.a wuy..yca.rs<aa<w+~.~I.er~m~u,..on.7cNnna, ddwrupaean aro cd~wNr.e ne.r z]I SIGNRURE TITLE Of CERTIFER TerNS.wamr.rN..NeEa~a.aao«w..asua,<m.exaN•I.nam.rw.na,wp ..................................................... ~ ],a UM/~ 'MgIK7tMt/W AND CERTIFYMG PHr51ClAMIFTYacMnlwarddwwc<q aaaln wNCeNynq gcaKSdpNlnl ' •p tlN EaalM myYmrYpe.,pa<Nra«arr<p aTyy lhN.yl<. and place. andpwblM<auaalal.^p mamNru aNla4 ......................... ,,,(((yyy 1[1 LICE// NUMBER. GATE SIGNEDIMmn. Dar. Map - y ~ ~/_ O ]ta. ~ - 3T4 L r0 ' /7S• ,per 11SQ({W11Q Ef $~ Inem Y7l TyPriM~W. 1. L1r S8~tOPRE@L L'nll13Rn MD MEDICAL E%AM/NERMORQNER on ll,a TNah MaawnMp~hand/wNwlallgalion, in my opinion. pealN OC<u..ed a11TN 1irna,dal<.aM plxa, and dud to,na uuaaOand Nnn .a t , d _~ • ilton S. Hershey Medical Center a w < a . -.-...- :.. ~----~-~--~---.-~~~...~ .............'.-"-"---'.-'--"'-'- ],.. , ~ n.. 00 Universit Drive Hershe PA 17033 REGIST K:NATURE ACID -- ~ ~~ I ~ DATEFKEDIMdan. Day rbarl C:. ]]. ---- -- ].. K ~~th 2 ~d0 LAST WILL AND TESTAMENT OF MICHAEL PAVES LAST WILL AND TESTAMENT OF MICHAEL PAYES I, MICHAEL PAYES, of Camp Hi11, County of Cumberland, and Commonwealth of Pennsylvania, being of sound mind, memory, and understanding, do make, publish, and declare this to be my Last Will and Testament, hereby revoking any and all wills and codicils by me at any time heretofore made. ITEM I. I give, devise, and bequeath to my wife, Shirley G. Payes, all my estate, real, personal, and mixed. ITEM II. In the event that my said wife should predecease me, or in the event that she should die simultaneously with me, or in the event of her death within a period of thirty (30) days after my death, the said devise and bequest of my estate to my said wife shall lapse, and in such event I give, devise, and bequeath all my estate, real, personal, and mixed to my daughter, Sa11y Jo Payes Ohrum and my son, Pizilip hI. Payes, in equal shares. ITEM III. I authorize my personal representative, hereinafter named, to deliver to any beneficiary hereunder property in kind at the election of said beneficiary at such valuation as may be determined for the purpose of determining my taxable estate. ITEM IV. I hereby nominate, constitute, and appoint my wife, Shirley G. Payes, as Executrix of this, my Last Wi11 and Testament. In the event my said wife fails to survive me or is otherwise unwilling or unable to serve as my Executrix, I then appoint my aforementioned daughter and son as Co-Executrix and Co-Executor. IN WITNESS WHER~EOF,~ I/ have hereunto set my hand and seal this / ~ day of 1981. 2.rc" \ _ MICHAEL PAVES Signed, sealed, published, and declared by the above named MICHAEL PAVES as presence of us, who at presence of each other witnesses thereto. and for his Last Will and Testament in the his request and in his presence, and in the have hereunto subscribed our names as r ~, ` 3 residing at ~~ ~ '~(. ~ ~~ ~_ . residing at 1.3GG ~~~~ ~-d.-~.4~-. ~~G~ cz lC ~t~.~,~C~. _ Z _ COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS I, MICHAEL PAYES, testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by MICHAEL PAYES , the testator, this ~ day of l', ~~ -(~.c.~ 1981. NOTARY PUBL C My Commission Expires- ,. ,,,~ .;,~~ ut rennsylvania tpy Commission Expires Nov. 2, 198.1, COr1MONWEALTH OF PENNSYLVANIA ) SS COUNTY OF DAUPHIN ) ~~ and ~IL1L~-i~~ ~. ~)'~Iy We , ~---- ~ ~ _ , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw testator sign and execute the instrument as his Last Will that he signed willingly and that we executed it as our free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testator have signed the will as witnesses; and that to the best of our knowledge, the testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by ~~.~,(' ~ ~~„ and ~ ~ witnesses , this ~- day o f ~,^(~..~ , 19 81, (- Witness Witness ~_ ~ NOTARY P TC My Commission Expires: „ ,.,, , ~.,~~c or rennsylvania My Commission Expires tVou. 2, 198.L„ PRUDENTIAL ANNUITY IRS FORM 712 Prudential 5/29/02 2:11 PAGE 2/2 RightFA}( Form 7~2 I . (Rev. rv1ap2000) Life Insurance Statement OhlE3 No.15A5-0022 Department d the Trea~ry Internal Reveiue Service Decedent-Insured (To be filed by the executor with Form 706, United State Estate (and Generation-Skipping Transfer} Tax Return, or Form 706-NA, United States Estate and GenerationSki in Transfer Tax Return, Estate of nonresident not a citizen of the United States. 1 Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number (if 4 Date of death MICHAEL PAYES kntxvn 180-22-2481 02124101 5 Name and address of insurance company The Prudential insurance Co an of America, 751 Broad Street, Newark, New Jerse 07102-3 7 6 Type of policy ANNUITY 7 Policy num r 9972193fi 8 Owner's name. If decedent is not owner, 9 Date issued 10 Assignor's name. Attach copy of 11 Date assigned attach copy of application. assignment. 05/04/90 12 Value of the policy at the 13 Amount of premium (see instructions} 14 Name of beneficaries time of assignment ESTATE 15 Face amount of policy .. .... .... ............ ....... ........ .. ...... .. 15 S 16 Indemnity benefits ... .. ......... ..... .. ..... ....... .... ........... 16 S 17 Additicnal insurance • • . • . • . • . • . 17 S 18 Other benefits .. • . • . 18 S 19 Prindpal of any indebtedness to the company that is deductible in determining net proceeds • • • • • 19 S 20 Interest on indebtedness (line 19} accrued to date of death 20 S 21 Amount of accumulated dividends 21 S 22 Amount of post-mortem dividends • 22 S 23 Amount of returned premium 23 S 24 Amount of proceeds if payable in one sum 24 S 25 Value of proceeds as of date of death (if not payable in one sum) 26 Policy provisions concerning deferred payments or installments. Note: If Oher than lump-sum settlement is authorized for a surviving spouse, attach a copy of the insurance policy. 25 S 27 Amountotinstallments 27 S 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. Date of birth: Sex: Name: 29 Amount applied by the insurance company as a single premium representing the purchase of 29 $ installment benefits 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits 31 Were there any transfers of the policy within the three years prior to the death of the decedent? ^ Yes ^ No 32 Date of assignment or transfer. 33 Wasthe insured the annuitant or beneficiary of any annuity contract issued by the company? • ^ Yes ^ No 34 Did the decedent have any incidents of aern ership on any policies on his/her life, but not owned by him/her at the date of death? ............................... ^ Yes ^ No 35 Names of companies with which decedent carried other polices and amount of such policies if this information is disdosed by your records, The undersigned ofLcer d the above~amed insurance company (or appropriate Federal agency or retirement system oRicial) hereby certif es that this stdement sets forth true ~d correct information. Signature ~ ^ ~ Title Secretary Date or Certification 05/29/02 ~. ~Sr~'~ ZForm 712 Rev 52000_PRU.dot Farm 712 (Rev. 52000)