HomeMy WebLinkAbout07-17-15 (2) J 1505614134
E.,�,,,,F„
REV-1500 °`F"'"`°sE°"`"
BureauollntllvitlualTaxes CeunryCctle Vear FileNumber
Po Box zeo60i INHERITANCE TAX RETURN � 1 1 4 1 0 5 1
HarrisEurg an m2a-o601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
SocialSecurityNumbe� 03t¢otOeath MMD�VTYT DateofBiflh MMD�YYYV
1 0 1 8 2 0 1 4 0 1 1 9 1 9 2 4
�ecetlenPs Last Name Suffx �ecetlenfs Firsl Name MI
J 0 N E S C A R 0 L Y N G
(If ApplicaEle)Enter Surviving SOouse's Information Below
Spouse's Last Name Suffx Spouse's Firsl Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
O 1.Original Relurn � 2. Supplemental ReWm � 3. Remainder Re[um(date ot tlea�h
Prior la 12-13-ffi)
� 4.AgriculWre Exemp�ion � 5. FUNre Interesl Compromise(date of � 6.Fetleral Estate Tax fteNm Required
(aaleoldealhonorafter]�L2012) deathafter12-02A2)
Q ]. �ecedent Died Tes[ate ❑ 8. Deceden[Maintalned a Living Tmst � 9. Total Number o/Safe�eposit Boxes
(Atlechcopyolwll.) (AnachwpYo��Nst)
� 10. Li[iga[ion Pmceetls Received � 11. Non-Probate Trensieree ReWm � 12. DeferraVElec[ian o(Spousal Tmsls
(ScM1edule F and G Asse�s only)
❑ 13. Business Assels ❑ 14. Spouse Is Sole Beneficiary
(No tmst involvetl)
CORRESPONOENi�THIS SECTION MUST BE LOMPLETE�.ALL CORRESPONOENCE AND CONFlOENTIAL TAX INFORMAiION SNOOLO BE DIRELTEO T0:
Name �ay[ime Telephone Number
D A V Z D H S T 0 N E , E S Q U I R E 7 1 7 7 7 4 7 4 3 5
First Line of Atltlress
4 1 4 B R I D G E S T R E E T
Second Line of Atltlress
City or Post OHlce 5[ate ZIP Cotle
N E W C U M B E R L A N D P A 1 7 0 7 0
Correspo�de�t'se-mai�address: DSTONEaSTONELAW•NET
__ .. —
.`� �
nEci�r�FwiusbSEor+� � �
REGISTEROFWILLSUSEONLV m � r � �
DATE FlLED MMO�YYYY � � n r ''� � ��
-1 �- N '� `� '.
�._. � � _ r-. �I fil .
'�� O
� J
r n i T�
DATEFILE 3 '
O STFMP n
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PLEASE USE ORIGINAL FORM ONLV
Side 1
I IIII'I IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII
L 1505614134 1505614134 J ��
J 1505614234
aev-isoo ex�Fp
oeceaenCs Somalsecwiq Numpe�
oe��e��>Hame CpROLYN G . JONES
RECAPITULATION
i aeai es�are�srneowe nl . . . . . . . . . . . . . . . . . . . . . . i. 1 2 5 0 0 � . 0 0
2. 5mcks ana Bonds;SCM1eaule B) . . . . . . . . . . . . . . . . . .. . . . .. . 2. 4 9 6 6 , 8 �
3. Closely Heltl Corporatioq Partnership or Sole-Propne�orship(Sc�e�ule G� . . . 3 •
4. Morigages and Nores ReceivaCle�Schedule D) . . . . . . . . . . . . . . . . . . . . a .
5. casn,eank oepwits ana Miscenaneous Personai Pwpeny�Scneauie E�. . . . . . 5. 4 1 7 8 2 . 3 G
6. Jointiy Owrietl Pmperty(SCM1etlule F) ❑ Sepere[e Billmg Requestetl . . 6 3 � 9 5 , � �
]. IrteaViwsTransfersBMiscellaneousN ProOateProperty
(Scnetlwe G) � Separa�e Bll�ing Requestetl . . . . z 5 7 6 3 9 , � 5
s. Totai cross assets riotal Lines t �nmugn�) . g. 2 3 2 4 8 3 , 3 �
9. Ponerai Expenses artl Aaminist atrve Costs�Schedule M� . . . . . . . . . . . . . . . . 9 4 6 8 0 4 . 4 7
10. �ebls o(Decedent.Morcgage Lieb'lities.enG Liens(SCM1etlule p . . . . . i p. 8 1 L 3 . $ 3
>>. lotai oeaocuons��o�ai rnes e aoa m;i . . . . . . . _ _ . . . . . . . . . n 5 4 9 1 8 . 0 0
1z. �let vame of estate(�ine 9 minus�ine i t) . . . . . . . . . . . . . . . . . . . . . . . �2 1 7 7 5 6 5 . 3 0
13 CM1a�i[able entl Governmenlel Bequesis/Sec 8113 Tmsis br wM1lch
an eleclion to lax has not been matle�Sc�etlule J) . . . . . . . . . �3 ,
ia. Net vaiue subject m rax(�me�z minvs�ine �a� . ia. 1 7 7 5 6 5 . 3 0
TqX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 16�axable
attM1e spousaltax ra�a. or
transters under Sec. 9nfi
�a��, z,xo _ o , o o ,s o . o 0
16. Amount o�Line 14 tasable
ar n�eai�aee x .oas 1 7 7 5 6 5 . 3 0 �.6 7 9 9 0 . 4 4
1]. AmounlofLinei4taxable
at smmq ra�e x ia 0 . � 0 n 0 . p p
�e n���o�m ot one ta ta.aoie
a�coiia�e�aiare x �s a . 0 0 �a 0 . 0 0
i9. rnxoue . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . i9. 7 9 9 0 . 4 4
20 FILL IN THE OVAL IF VOU ARE REWESTING R REFUNO OF AN OVERPAYMENT �
Unae�penalnes ol ce0ury I Oetlare I neva arsminea nis relum.Inelutling eaompanyinq scM1eaules and statemenls a�d lo ine Oesl ol my Snowletlge ano oelie'
I�Isleue.conutanOmmple�e peciareporo�pre0e�¢roNerNan�hepersonresWnsblelortlingl�e�eWnisba5e4onalimbrmalionolwM1¢�oreparertaz
any knowletlge
SIGNATURE OF PERSON FESPONSIB�' OR FlLING TJRN pq1F
W IZ GGti �
AD�RE55
18 FARMINGTON NEW PROVIDENCE PA 17560
SIGNATORE OF PftEPHR pT ER MFN P 5 R pON51BLE FOR FILING THE RETpRN pqTE
� �. )�
PD�FE55 � �
414 BRIDGE STREET NEW CUMBERLdND PA 17�70
IIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Side 2
L 1505614234 15�5614234 J
REV4500E% (Fl� Page3 FileNumber
DecedenYs Complete Address. 21 14 1051
oECEOENrsNaUE
CAROLYN G ._ JONES
sTREErnooaEss �
_. _ . . ___. ___ ...— _ . _.—__..
47 KENSINGTON DRIVE
_. .. .____ __ .. __
CITV STATE ZIP
CAMP HILL PA 17011—
Tax Payments and Credits:
�� 1ax0ue(Page2,une19) �i) 7,990 • 44
2. Credi�s�Paymems
A.PriorPaymems 7,200 • 00
e.Discowt 378�• 95
(See'mswctionsJ � �� TotalCredi�s(n.B) (2) 7 ,578 � 95
3. In�eresl
(3) o .00
4. I(Line 21s grea�er�han Gne 1 �Cine 3,enter�he dlfference.lMs is the OVERPAYMENT.
Fill in aval on Page 7,Line]O to request a refund (4) � • ��
6. It Cine 1 t�'ne 31s greatenhan Line 2,enterlhe dlfference.This la ihe TA%DUE. (5) 411 • 4 9
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. �id�ecedenf make a�ransfer and'. �es No
a. re�ainiheuseorincomeat�hepropetly�ransferred ...... ........_ .... ..... ❑ ❑X
b. retain the ngi��o daslgnate wha shall use�he D�oper�y Iranslerred an�s Income __ ._. ❑ ❑X
c. retainareve'sionar mleresl . ...... .___. .... _... ._. ❑ ❑X
d. recelvelheFmmiseforliteofeilherpaymenis benefltsorcare� .__ ...._ .._. ❑ ❑K
2 I`.dealh ocarre�atter Dea 12, 1982,did decetlenl irans(er pmpetly wAhm one year o(death
withoulreceivin3adequa�econsideration7 .._.._._ ._.._. ...._....._ .._. ❑ ❑X
3. �Iddecetlenlavnan'In�mslfor'orpayablaupon-0eathbankaccountorseariryalhisorhertleath� ..... ❑ ❑X
4. Did decetlen�ovm an intlivldual retiremenl account,annuity or other non�mbale pmpetly,which
camainsabeneficiarydesigna�ion?......... ....__. .......... ..._.._._ ._._... 7�❑ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,VOU MUST COMPLETE SCHEDULE G AN�FILE IT AS PART OF THE RETURN.
For tlates of dea[h on oratteNuty 1, 1994,antl before Jan_1, 7995,the tax ate lmposed on ihe net value of transfers to or tor the use of�he survlving spouse
Is a percent pz Ps.gs�is(a)(� 1�(q�,
For dates of dealh on or after Jan. 1,1995,Ihe�ax ra�e Imposed on the net value of Vansfers to or for Ihe use of Ihe surviving spouse Is 0 percent
(72 P.S.§9116(a)(1.1)(II)�. The s�aWte tloes nol exempta iranster ro a survrving spouse from t�,antl the statutory requirements tor aisclosure of assels and
fling a tax return are slill applicable even if ihe surviving spouse is Ihe only beneficiary.
For da�es of dea�h on or after Juty 7, 2000�.
• The tax ra�e Imposed on�he net value of Iransfers 6om a deceased chlld 21 years of aga or younger at death to or for Iha use of a naWral parent,an
adoptive parent or a steo-parenl of the chlld Is 0 perceN[/2 P.S.§9116(a)(L2)].
• The tax rat Imposed on ihe ne�velue of hansfers�o or for the use o�Ihe tlecedenYs lineal beneliclanes ls 4.5 pement,except as notetl 'm [72 P.S.§9116(a)(1J�.
• The lax ra�e imposed on ihe net value of transfers Po or for�he use of Ihe decedenfs siblings is 12 percent�72 P.S.§9116(a)(1.3)J.A si6ling is defined,
under Section 9102 as an individual who has at least one parenl in common wilh�he tlecedent,whether 6y blood or adoption.
reev-isoz ex«�iz.�z7
pennsylvania SCHEDULE A
oeanaimervroFHeveuue
imNeair,�Nce r,ix aEruaN
REAL ESTATE
aEsio_NreEceuervi
ESTATE OF: FILE NUMBER:
CAROLYN G � JONES 21 14 1051
All real property ovmed solely or as a tenant in common musl be reported at fair marketvalue.Fair marke�value is definetl as ihe price a�which Orope�y
wauld be ezchangetl between a willing buyerand a wllling seller,neitherbeing compelled Io buy orsell,bo�h having reasonable knmvledge ol�he relevan�fac�s.
Real pmperty Ihal is joinlly-owned vnth right oi survivorship musl be disclosed on Schedule F.
Avach a copy of�he se�tlement shee�if the Droper�y has been soltl.
ITEM InsludeacopyotthedeetlshowingdecedenCsln�eres�l(ownedastenant'mwmmon. VAIUEA?OATE
NUMBER OFDEATH
oEscaiaTioN
� Property located at 47 Kensington Drive , Camp Hill , 125,000 • 0�
Cumberland County, PA sold to Fady Mansour and
Basma S � Mekhaiel , husband and wife , on January 16 ,
2015
TOTAL(Also enteron Llne 1,Recapilulafion) E 12 5��0 0 • �0
If more space is needed,use a0ditianal sheets ol paper of�he same size.
FEV-�503 EX�(&l2)
pennsylvania SCHEDULE B
oEruerm�ur oF aevenu�
�Nn �rAN�Er,�REr�RN STOCKS & BONDS
a_sioEvr�ECEOENr
ESTATE OF FILE NUMBER
CAROLYN G - JONES 21 14 1051
All property IoinHy owned wi[h righ[o(survivorohip mus[be tllsclosed on Schetlule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF�EATH
i 575 shares JP Morgan—Banco Santander stock a 98 . 638 4,966 • 85
each
TOTAL(AlsoenteronLine2,Recapi�ula�ion� $ y .966 • 85
I/more space is neetled,insert additional sheets o(the same size
aev-isoe ex.�o��z7
pennsylvania SCHEDULE E
oevAa�mevra�eevemue CASH, BANK DEPOSITS & MISC.
INHENrtqNCEiA%RETURN
a�se�NrcECE.Ervr PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
GAROLYN G � JONES 21 14 1051
Include the proceetls of litiga�ion antl�he date Ihe proceeds were rewive0 Oy tM1e estate.
All property jointty ownetl with right o(survivorship must be tlisclosed on Schetlule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
i. M&T Bank-Cert of Deposit �31��3913820609 10,056 . 48
Princ $10 ,056 - 48, Int 5 • 83
2 M8T Bank-Cert of Deposit �31003913820609 - Accr Int 0 . 83
3 M8T Bank-Checking Acct �90�14358 14 ,151 � 4�
Princ �14 ,151� 40 , Int $ • 01 William W • Jones died
Decem6er 11, 1998
4 f1&T Bank-Checking Acct �90014358 - Accrued Int 0 • 01
5 Miscellaneous personal property from home 1,000 . 00
6 Reliance Standard-Annuity Policy #AXMG0007B5 13,570 � 35
benef is estate
7 Santander-Money Market Acct u0571139248 2,602 � 45
Princ 52 ,602 • 45, Int 5 � 09
8 Santander-Money Market Acct #0571139248 - Accr Int 0 � 09
9 State Employees Retirement System-refund received 400 � 69
TOTAL(Also en�er on Line 5,RecapiWla�nn) 5 y 7,,782 • 30
If more space is neetled. use addltional sheets o!paper of��e same size.
Rev-isae ex.@�-�o)
pennsylvania SCHEDULE F
o�anArmeNro�ae�--��oe �OINTLY-OWNEDPROPERTY
INHERITANGEiA%PHL91V
�sioervr oeceoenr
ESTATE OF: FILE NUMBER:
CAROLYN G • JONES B1 14 1051
If an asset was made jointly ovmed within one year of the decedenPs dale ot dealh,it musl be reported on Schedule G.
SORVNING JOINT TENANT�9 NAME(5) AO�ftE55 FEIATIONSHIP TO DECEDENT
n. BARRY W JONES 18 FARMINGTON WAY Son
NEW PROVIDENCE , PA 17560—
s.
c.
JOINTLY�OWNE�PROPERTY:
�errea enrE oescaiPr'�cNOFPaCaearv °noF o,�reo�oa'n
REM FORJOINT MF�E W0.0DENFMEOFFlNANCIALINSiITUTIONAV�BANNACC00MNOMBEROR51MilAR �AItO'.DEOiH DECEOENi'S VAWEOF
NUMBER TENANi JOIM DENiIFY�NGNUMBEN. A'iACHOEEDPoRJ01NiLY�HEL�RFALESiAtE VnWE0FA55Ei IMERESi OECEOENPSIMERE_i
i a o3iz�iaaSantander—Cert af Deposit 6 ,189 • 99 50 • 3,095� 00
u0575546387 joint w/Barry W .
Jones dtd 3-27-11 Princ 56,189 � 95,
Int 5 • 04 = 56,1B9 � 99 divided by 2 0 . 00
iOTAL(Also enter on Llne 6,Recapilulation) 5 3�0 9 5 • 0 0
II more space is neede0,use atltli[ional sheek ot Daper of the same sire.
REV-05ID EX�(08�09)
pennsylvania SCHEDULE G
o�PnRrMeH.or�ie�eHue INTER-VIVOSTRANSFERSAND
wnEair�NCEr;.xR_r�aN MISC. NON•PROBATEPROPERTY
aEsmera oeceoervr
ESTATE OF FILE NUMBER
CAROLYN G � JONES 21 14 1051
TM1Is scM1eaWe must be complale�ana fletl ii the erewer to any ol quastions 11M1mugM1 4 on page:hree o�Ihe REV-15001s yes.
DESCRIPTION OF PROPERTV
ITEM wcwoe*rvervnMeorrHeranmsv=_aee,rneaae.nnorvswa*o�ecm=mzvo DATEOFDEATH 960F�ECD'S ERCLUSION TA%ABL
NUMBER *rveo,rt=oFrau�sFea.nnnwncoavo�rrveoeeora+zeuesrRre VALUEOFASSET IMEREST - VAWE
t EquiTrust Life Insurance Co—Annuity 36,136 � 02 100 • 00 36,136 • 02
Contract �EQ0�01116326F with Barry
W • Jones as benef
2 Great American Insurance Group- 21,503 • 13 100 • 00 21,5�3 • 13
Annuity Palicy �06312863 w/Audrey
Belsak and Barry Jones as benef
TOTAL (Alsoen�eronLlne7,RecaplWla�lonJ 8 57,639 � 15
If more space ts needed,use epeltlonel sheals ol paper of Ne same size.
qev.isi i �.�a�i s7
pennsylvania SCHEDULE H
o�anarw�nrorawervoe FUNERALEXPENSESAND
va�airnNCEr,�xaEnaN ADMINISTRATIVECOSTS
r<sioEvr oeceoervr
ESTATE OF FILE NUMBER
CAROLYN G • JONES 21 14 1051
Decedenfs Eebts must be repotletl on Schetlule I.
ITEM
NUMBER CESCRIPTION AMOUNT
A. Fl1NERALE%PENSES'.
i. Barry Jones-Reim6 for funeral luncheon 380 • 25
2 • Myers-Harner Funeral Home-funeral expenses 4 ,583 • 00
B. FDMINISTRATNECOSTS.
1. PersonalRep:esen�ativeCommissions:
Namels�otPersonalRepreseniz�ive�s� BdPPy JOfIES 8�587 � ��
SVeetAaaress 18 Fdl^fA111qtOn Wdy
CpyNew Providence s�a�ePA Zi? 17560
Yeaqs)Commission aaitl�. 2 015/2 016
Z, nnomeyFees: David H Stone, Esquire 11,624 . �0
g, FamilyExemptiortJ�dece�anCsaaaressisno�NesameasdaimanYS,atlechexplenetionJ
Claiman�
SVee�Atltlress
City Slate ZIP
Relatlonshlp oi Qelmentlo Deceden�
a. a�ooareFees: See �3 below
5 A¢ountanlFees'.
6. TaxReWmPreoarerFees:
z PA American Water-servi�es at property 1& � �S
2 Barry Jones-Reimb for real estate taxes at prop 482 � 16
3 Barry Jones-Reimb for probate costs 350 . 50
4 Barry Jones-Reimh for filing ITR and Inventory 30 • DO
5 Barry Jones-Reimb for hardware and misc for prop 134 . 82
6 William Stauffer-lawn mowing etc for Oct-Nov 130 � 00
7 Maintenance Unlimited-work done at property 259 � 50
8 Home Patamount Pest Control-services at property 24 . 27
9 G David Boyer-plumhing services at property 425 � 00
10 Home Paramount Pest Control-service at praperty 24 � 27
11 Barry Jones-Reim6 for Maintenance Unlimited exp 4 ,550 • 50
12 Barry Jones-Reimb for RG Prop Mgmt serv at prop 2,soo . 00
TOTAL(NsoenteronLine9,RecapiWla�ion) S y6.804 • 47
If more epece Is neeaeq use atldltlonal sheets of papar ol IM1a sama sire.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
CAROLVN G. JONES 21 14 1051
Decetlenfs Name Page 1 File Number
Schedule H -Funerel Ezpenses &Administrative Costs -B7.
ITEM
NUMBER �ESCRIPTION AMOUNT
13 UGI-services at property 90 � 00
14 PPL Electrirservices at property 42 � 63
15 11GI-services at property 90 � �0
16 Cum6erland Law Journal-adv grant of letters 75 � ��
17 The Sentinel-advertising grant of letters 19� � 54
18 Settlement costs (512,751 . 49) less reim6 (5765 � 41 ) 11,986 � 08
19 Stone LaFaver B Shekletski-Reimb for bank bal fee ao . 00
20 Stone LaFaver B Shekletski-Reimb for mailings 6 . 90
21 Reserve for closing expenses 20� � 00
SUBTOTAL SCHEDULE H�B7 12 ,7�1 � 15
REV.�aizE%+(�aiz7
pennsylvania SCHEDULE I
oePaannrHro�ae��eNue DEBTSOFDECEDENT�
�N�ea�.ANCF r,,x�Er.�eN MORTGAGE LIABILITIES& LIENS
a�siowr oeceoEur
ESTATE OF FILE NUM6ER
CAROLYN G • JONES 21 14 1051
Report de6ts inwrred by�he decedenl prior to death that remained unpaitl at the date of dealh,including unreimbursed medical expenses.
ITEM VAWE AT DATE
NUMBER DESCRIPTION OF DEATH
i Minnich ' s Pharmacy—debt of decedent 6 � 21
2 Wellspan Physician Billing—debt of decedent 10 � 00
3 Yark Regional Emergency Med Serv—debt of dec 768 • 40
4 York Regional Emergency Med Serv—debt of dec 73 � 49
5 Wellspan Physician Billing—debt of decedent 10 � 00
6 Wellspan Physician Billing—debt of decedent 27 • 24
7 Barry Jones—Reimb for living exp for June at The 2 ,948 • 19
Haven at Springwood
8 Barry Jones-Reimb far living exp for July at The 4 ,27� � 00
Haven at Springwood
TOTAL(Also enter on Line 10,RecapiWlalion) S 8 ,113 � 53
If more space Is needed, insert atlditional sheets ot I�e same slze.
REV-151J E%�(01-10)
pennsylvania SCHEDULE J
oEPAA.MF�r oF aevE���:e BENEFICIARIES
irvneairnrvce*ax acruwa
aesmeNroeceneN-
ESTATE OF: FILE NUMBER:
CAROLYN G • JONES 21 14 1051
RELATIONSHIPTO�ECE�ENT AMOUNTORSHAR'c
NUMBER NAMEAN�A��RESSOFPERSON�S�RECEIVINGPROPERTY DaNatListTmstee�s) OFES7ATE
� 1AXA8LEDISTRIBUTIONS ;IrcluOeoWrlqh�spouealtlls�nbutionsan0�ransfersuntler
Sec.8116(a)(1 2).J
i BARRY W JONES Sch E1-2 8 Sch F as per Lineal 95, 358 • 8�
18 FARMINGTON WAY Item Third of will
NEW PROVIDENCE PA 17560— and 1/2 res
2 ALIDREY EMILIE BELSAK 1/2 residue Lineal 82 ,206 . 50
152 FLIRLONG WAY
RED LION PA 17356—
ENTER W LIAR FMOl1NTS FOR DISTRIBUTIONS SHOWN ABOVE ON LWE515 THROl1GH 78 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRI6UT'.ONS.
A.SPOUSAL DISTRIBUTIONS 11N�ER SEC710N 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1
B.CHARITABLE AN�GOYERnMENTAL DISTRIBUTIONS'.
t.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRBUTIONS ON LWE 130F REV-0500 COVER SHEEL S
If more space is needed,use addltional sheets of paper of�he same size.
' V/ c�b�.e Y� /vyY
LAST WILL AND TESTAMENT OF
CAROLYN G.JONES
1,CAROLYN G.JONES,af Lowa Alla�Township,C�nnberland County, Prnnsylvania,being of
soimd mivd memory,and imdastm�d'mg,do hereby make,publish and declffie ihis to be for my Last WiII
and Testamrnt,haeby revoking aIl other wills a cadiciis heretofore made by me.
FIRST:
I haeby direct the paymrnt af myjust debts and ihe expenses of my last ilinesv and funcal be
made&om ihe a.ssets of my esfate as soon afta my deat6 as conveniently may be done. If thae be no
ceme[ery lot aveilable for my intammt and owned by me at the time of my death,[direct tAat my remains
6e intared az the Indientown Gap Military Resevatiw Cme[ery nerzt to the grnve of my husb�d, W illiem
W.Jones.
SECOND:
I haeby givq devise,and bequwth all�gible pcswial property owned by me at Ihe[�e of my
death,togelhc with all ins�aance policies peyable thaeon,equally[o my sw.Barty Willimnlmes and my
dau�tet,Audrey Emilie Belsak.
i7IIRD:
I haeby give,devise and bequmih all the certificates of deposi[owned by me at Ihe lrtne of my
death, wta my aforrnmned san, Barty. In the evmt my son fails to swvive me,seid certificates ofdeposit
shall be considered a pw[ion of Ne n.sL residue end ranamda ofhis estate,and peyable to his heirs.
'
�
i
FOURTH:
I haeby give,devise and bequeath alI the rest,residue and remainda of my estste imro such of my
children pa stiryes es shall sim�ive me by thvty(30)dayy.
FIF17i:
My amounts which are payable to a minar under this will may at the discretion of my Exavtor(a
Executrix)be paid ro the guardian of Ne person or su<h mmar,to the pason witli whom such minu
resides.or dvectly to such minv,or may be applied for the use or beneHt of such minor.
SIX'ffl:
f d'vect that mry m�d eIl inhaitance,evtate arid transfa tarzes imposed upon my estate pessmg w�da my
will a ahawise, shal�be pafd out of the pnncipel of my residuary estete.
SEVEN77{•
In addition ro powm givrn him by Iaw,my Executw(or Executrix)herein shall have ihe following
powers appliceble ta all real and perspia�prpper(y held by him(or her)effxtive without caut ordc end
until acfua�distribution:
(a) To remin m�y Prq�e�ty,real rn peryonal,received by him;
(b) To invest and remves[in all fams of pro�erty, real and personal,wifhout restrictio�tu
inveshnrnts authaized by Iaw for fiduciaries:
(c) Towmpramisecontroversies;
(d) To sell,conveY,exchange.Partition.Bive op[ions upon,or othawise dispose of any
P�oP�S��a pasonal,at any timeheld by him(or ha),at publio or privete sale, for �
2 �
i
cash or aha coosideretion a m Qed'a,and upon such terms and az such prices ss he(or
she)my determme;
(e) To hold investrnmts in ihe name of a nomioee;
(� To determu�q es to all s�uns of mwies or otha things of value received by him(or ha)
whahc and to what extrnt tlie same shall he deemed to be principal v mcomq snd as to
al��arges snd expenses paid by him(on c�r)whetha and ro what nctent the seme shell be
charged agemst principal or income;
(B) To borrow monry fa arry PisPose in wnnac[ion with the administra[ion of my estate.to
execute promissory notes or ofher obligetions for amounts yo borrowed,and ro seaue the
payment of such amoimts by mort�ges or pledges of any property which mey be included
in my eslate;
(h) To rmew w e�ctaid the time for paymrnt af any obligation,sxiaed a wisecured,payable
to a by my estace,for as Iong a period a paiads of timq and on such tams as he or she
may determine,
(i) To holQ manage,and develop any real eslate which may be held by him(on c�)at any
timF to lease my such propaty for such tam v tmns,ar�d upm sudi condirions�d
rrnmis as he or she may deem adviseble, irtespective of whetha the tmn of any such lease
shell exceod the periad pamitted by law or the probeble periad of re[rntion wda the will;
and to meke repavs,replacemrnts and improvemmts,structurel or othenvise,m
connec[ion with e�y yuch property;end
(j) To make any distribution hereimder m cesh,in kind W per[ly in cash and pertty in kind.
EIGHTH:
My and all payment ar paymrnu of any sum ar sians,wheihe in cash or in kmd and whetha for
principal or mcome,payable to Ihe said brneficiaries,or any of[hem,shall be made uqm the soie receipt
3 '
�
�a
�
oft6e respec[ive individuel W whom the paymdrt is made,and Gee Gom anticipetion,alia�ation,
usipsmmt,attechmmt and pledge,and Gce from control by the aeditas ofm�y such beneficiery. Ail
shares of prmcipal arid'mcome haem giva�shall he free Gom mticipetim,avsignma�k P��6�.a
obligations ot m�y bene6ciary,end shall not be su6jea m any executiou of attad�mmt.
NINTH:
!haeby nomina[c,constitute end appom[mY son,Bmry Willi�Ja�es,F�ce�tor of Nis my Las[Will�d
Testamm� In the event of Uie rm�mcietiqy deeth,resignffiion a inabifiry to act far any ree.qpn whefscev¢r
oCmy said son,I haeby naminatq constitute and appamt my daughter,Au�ry Emilie Belsek,Executrix of
il�is,my Last Wil�and TestemmG I hereby relieve my Executor(w Ezecutrix)of the nxasity of posting
securtiy in co�meRim with his(a ha)duties as such in anyjuriydictipp�which he a she mey he wlled
upori ro aa insof�av I am able by law to do so. NOTAqIAL SEAL
MARK A. GRIFFIN, Notary Public
�y Camp Hill Boro,Cumbedantl Counry
� p���,(/�/ �n7 My Commission Expires Dec.22,2003
IN W Il'NESS W tiEREOF,f have hceimm set my hand m�d swI N;s y.dey of mcY , 1999,
��sen�,)
� CAROLYN JONES
Si�ed,sealed,published and dxlared by CAROLYN G.JONES,the Testatriz above n�ed,as m�d for
ha las will end testmnrnt m ihe presence of us who,at ha request,in ha presence and'm tha preu��ce of
each ofha,have hae�mto subscnbed our names aq wip�eyyey hereto.
Address: � Ad�esc:��e!
� ' 771L�Ls' l Q.
� 0¢'Lzol/ C+�Q l�.0 14. t'lai
a
Inst # 2C15�SfiBe - page 1 of 9
CEATIFIEO PROpERTY IDEVTIFICATION MR0QR6
/.�ARL'.IuncS.Ca�O�yn-J1Kcnsine�U�U�iv[ I 13-25-0022-028 - LOWBA ALyyN TP
CCGI9 RE6ISTRY O1/2$/$O15 0Y TB
T+a Perrcl p: 13!¢I1023-02fl
AJJrcea:A]KrneinF������lrire
c:.��n xai,rn nnu
DCF,D
w�i
THIS INDCNTURL made the �b' day of ��0.�n��ar< < aolS �n the yeer 20li,
benveen BA2RY W. IONGS, L-'xccutor of the Lnst Will and �estament of CAROLYN G.
.IONGS, late of Lower Aflen Township, Comity oC Cumberland, and Commomveahh of
Pennsylvania, of Ihe 6rst part, hereinnfter called Ihe Grancor,
-AND -
PADY MANSOUR and BASMA S. N(EKI-IAtHL, husband and wife, of the second part,
hereinaftcr cnlied the Grantees;
WHEREAS, the said CAROLYN G. JOVLS became in her lifetime seised, as of fee, of
and in a certuin tract of la��d, together ��ith the improvemen[s themon erected, situate in the
. County of Cumberland, and Commonwealth of Pcnnsyh�ania, and more parliculady described
hereinaher; and being so thereof seised, died on Ocrober 18, 2014, having first made her Last
Will and Tes[ument in writing dated October 4, 1999, duly pmbared and registcred in the
Offce of die Register o( Wills of Cumberland Cowity on Nnvcmber i, 2014, ��herein and
whercby shc appointed as Executor, the said UARRY W. JONES, to whom Letters
Tes[amenlivy were duly issued by said Rcgister of Wills on November 5, 2014, wherein nnd
whereby said premiscs hereinatter deseribed uere not specifically devised, all as in and by said
Will �nd the recurds of said Register of Nills, recourse thereunto being had, appcars:
NOW THIS INDErTURG WITNESSETH, that the said Granror, 1'or and in
consideracion ot tlte sum of ONE HUNDRED TWENTY-�fVE and
NO/100----------(512�,000 .00)------Dotlms, which hus been paid to thcy 6y the said
Grantees at or beFore the sealing and delivery hereof, receipt whereof is hereb}� acknowledged,
has �ranted, bargaincd, sold, afiened, released end conti�med, and by [hese presents does grant,
bargain, scll, alien, release and contirm unm the said Granlees,
ALL THAT CCRTAIN tr¢et or parecl of land simnte in Lowcr Allen 'I�ownship,
Cmnbcdand County, Penns}'Ivania, morc particularly 6nunded and descfibed as lollows, to wit:
6ECINNINC ¢t u poinl on tlie northerlv line oY Kensington Drive which point is
1700.20 feet west of[he northwesterly corncr of Kensington llrive and Scnrsdple Drivc and a[
dividing line be(ween Lots Nos. ?4 and 25, Block "A" on [he hereinafrer men[ioned plfln oF
lols: THFtiCE nlong the nonhe:ly Ifne of Kcusington Drivc Soutli 55 degrees 20 ntinutes West
75 feet to a point a[ dividine line between Lots Nos. 25 and 26. Block "A" on said Plun:
TI{F.NCF along same Nnnh 34 degrees 40 minutms West IAO feet to a point at sou[herly line ot
New U.S. Rou[c kIS_ �PHENCL a�ong same North 55 degrees 20 ininuCes East 75 feet to a poin[
nt dividing Iine be[ween Lots Nos 20. ond 25, Bbek "A" aforesaicl; 'PHENCE along same
Sowh 34 degrees 40 minutes Fast 140 feet to a point, the placo of BF.G7NNINC.
_l .
msc, q zoismeee - eaq� z oe a
I3EING Lot Nu. 25, Block "A" in Plan of Country and 'Lown Homes, Inc. which plan
was recorded in the Cumbedand County Recorder's Otfce on May 14, 1956 in Plan Book 7,
Page 41 and having thereon erectcd pre;niscs knoe�n as No. 47 Kensing[on Drive.
&XCIiPTING THCRF,FROM, AL[, THAT CERTAIN lot,. parcel or tract of land
loce[ed in Lower Allen Township, Cumbedand Coun[v, Pennsylvanie,recorded in the Otlice of
the Recorder of Deeds in and for Cumbednnd Countp, Pennsylvania in 25Q Page 4264.
BEfNG the samc premises which Country ai�d 7own T-Idmes, Inc., by Deed dated June
3, 19i8, and reeorded June 3; 1958.. in the Ot�ce of the Rc-corder of Deeds oC
County ii� Deed Dook L-I8, Page 437, granted and conveycd unto William W. Joncs and
Carolyn G. Jones. William W. Jo�es dicd on IJecember I1, 1998, thus by operation of law
ves[i»g [itle in Carolyn G. Jones, deceased.
TOG�THER with all and singular Ihe buildings, improvements, ways, stree[s, alleys.
passa�es', waters, watervcourses, rights, liberties, privileges, hereditaments ;md appurtenances
whatsoevcr, thereunto belonging or in any wise appenaining and the reversions and remainders,
rents, issues and profiu thereof, and all the estate, right, title, interest, property, clai�n and
demend whatsoevcr of her, the said CAROLYN G. JONGS, at and immediately 6efore tlte time
of his/her decease, in law, equity, or otherwise howsoever, of, in, [a or aut nf the s[une.
TO HAVC AND TO HOLD the said lot or piece aF ground above described, with the
buildings and improvements thereon erected, hereditamcnts and premises hereby granted or
mentioncd. and intended so l0 6e, with the appurtennnces unto the said Grantees, to and for the
only proper use and behootbf thc said Grantees, forever.
ANll thc snid Granfor, for himself and his respec[ive heirs. executors and
adminishstors, does covenant, promise and leree to and wi[h the said Grantees, [heir heirs and
assigns, that they, the said Grantor, has not heretofore done or commitred eny act, matter or
lhing whatsoever whereby thc premises hereb}' gr�nted, m�any purt thereof, is, are, shall or may
be impeached, charycd, or encumbered in title, chnrge, esteite or otlienvise howsoever.
IN WITNF,SS WHF,RCOF. tha said Crantor hns hercunm set his hand and seal [he day
and year Ilrsl abovc wrilten.
Signed_ Sealed, and Delivered
in the Presence oF
�, .
C � ti (S6Ai.)
Witness` '' ; R, y W ES, Executor of(he Las[ Will
u Icsmm t of CAROLYN Q JONF.S
_, �
InsL X 203501688 - Page 3 0£ 4
COMMONWEALTFIOPPENNSYI.VANIA .
��� SS:
COINTY OF
On this, Ihe ���`` day of ��""'` `/ � , 2015, before me a Notary Public,
tF,e undersigned o�cer, personally appeared BARRY W. JONES, Executor of Ihe Last Wi11
and 'ies[ament of CAROLYN G. 10NES. known ro me or satisfacmcily proven co be[he person
whose name is subscribed to the �vithin instrmnent, and acknowledged that he exeeuted the
same for the purposes therein contained.
1N WITDICSS WHERL'OF, I have hereto set my hand and notarial seal.
�aer.toxwe,ti*x a rrxxmvu,u
NOUNIqL SEA� .
��60N 6 BppNHOIDFR
NOI�ryPuplit = `—' -..
� MnNNEIM Tµq LANCASiEP COI/Niy � '�'��
�+rcomm�:am�e,uin:ra:yzo.zoie -� NotaryPublic
_--�_.....
I her �hy certity that Ihe precise address oF the Grantees is
�f7 �ns�`.��f�n .�r �ci,. � ,�� ��.17.01// ,
i
DA"f8: � 11¢ IS _ �� -
jtyft v � r �
�/
_�_
Inst. y Ip1501688 - Page 4 of 4
�_... _ —.. ..— . _. ,.
TAMMY SHEARER
RECORDER OF DEEDS �
CUMBERLAND COUNTY -�=� T -
1 COURTHOUSE SQUARE � — -
CARLISLE, PA 17013
717-?40-6370 - : '
S �
__-- - -
t�i � : ' '
-y-;..N, . , -
Instrumwl Number 2015016R8
Recorded On 122/2015 At 12:57:22 PVI ^To�al Pages-4
" Instrument Type-DEED
InvoiceNumber- V6399 UserlD -SW
r Grantor-JONES,CAROLYiY G
• Grantee-�74.VSOIJR, F.4D�'
"Customer SIMPLIFILE LC F,-RECORDI�G
"FEES
STATE TRAN3FER TAX $1,250.00 C01'LIF1C3t1011P8gC
STATE WRIT TA7C $0 .50
STATE JCS/ACCESS TO $35.50 DO NOT DETACH
NSTICE
RECORUING FEES — $11.50
E2ECORDER OF DE6DS This page is now part
PARCEL CERTIFICATION $15.00 ofthislegal document.
FEES
AFFORDABLE HOVSINC� $11.50
COVNTY ARCHIVES FEE $2.00
ROD ARCHIVES FEE $3.00
WEST SHORE SCHOOL $625.00
DISTRICT
LOWER ALLEN TOV]NSHIP $625 .00
TOTAL PAI� $2,579.00
I Certify this to be recorded
in Cumberland Count`v.PA
7 1"_'}
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RECOl2DER OF DEIDS
"-In(ormatlon denated by an asterisk may change during
�M1e eerllicatlon process and may not M1e rellened on Ih6 peRe.
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a ��
449 Mimhell Road.MilisMm,DE 19966 Recrnds Managemenl
Phonc 888-50243<9
Fu (307)934-2955
December2.2014
Stone LaFaver& Shekletski
Attorney at Law
414 Bridge Street .
P.O. Boa E
New Cumberland, PA 17070
Re: Estate ofCarolyn G Jones
Social Sewriri� 193-12-5770
Date of Death� Oc[ober 18 2014
Dear Sir or Madam:
Per your inquiry on November 24,2014,please be advjsed that az[he[ime of death,the abov�narned deceden[
had on deposit with this bank the following:
1. 75yeofAccount Check>rgArcormt
.4ccwntNvmber 90014358
(Tvnership Mamec o� Bmay W.Jones/POA)
Cmolyn G.Jortes
Wil(imn W.Jones
OpeningDare 02/28//98/
BalonceonDmeofllealh $ l4.15/.JO
Acnued/nterut $ .01
Totd S N.IS/Al_. . .. . __.. .
2. Type ofAccoun! Cerlific�e ojDeposit
Account,Number 3/0039/3820609
Ownership(Nomer oJJ B�ry W.Jorier/POA)
C�olyrt L'.Jorres
Opening Dme 06/24/1999
Balance on Date ojDeath S 10,056.48 �
Accruedlnteres! 3 .83
Toml 9' l0.057.31 .
Y
j.
I�
For any e00itional infnrmanon oo t�e above ettounb,indvding ownenM1ip and any chengn,alosures enJ/ur reimpunement uf funds
pltax nll�h<M1lmM1vnieabuig�1]I)-69')-ISIS.
We were uneble ro lonte vny sa(e depoeit�ox for tM1e�bave-mrnlionetl Jettdrn�
Thia kller Jon op�iotlu0e ovy utauno in wNch�he dne�etl m�y M1ave btte lithtl u Power M AMnnty,Cuflodhe M Litif TnneRn,
Rep�venNnve PSYee,orTrvske uM�ra W Nthn Apeement
Sincerety,
Valarie Me`cer
Records Management
�
IRELIANCE STANDARD
UFE INSURANCE COMPANY z001MarketS�reet, Suitei500
Philadelphia, PA t9103-7090
♦ MEMlffl OF THF TORIO MIRINE GROVF (B00)351-75001 (267)256-3500
OI/30/2015
ESTATE OF CAROLYN G 70NES
4"7 KENSMGTON DR
CAMP HILL PA 17011
Re: Policy Number: AXMG000725
Decedenbinsured : CAROLYN G JONES
Policyowner : CAROLYN G JONES
The Date of Death value foc the above contract is $13,57035.
If you should have any further questions or require additional assistance,please contact our
Customer Care Center nt 1-800-351-7500.
Sincerely,
Annuity Department
�nF
I
� .,, � -
� :' .
Coutt Order Pmcessmg\Decedenis- MAI-M63-Oi-21 - p.O. Bax A41005 - Bosroq MA 022R4
December 3, 2014
David H. Stone
Stone LaFaver& Shekletski
414 Bndge St
P.O. Box E
New Cumberland, PA 17070
RE: Estate of Carolyn G. Jones
Date of Death: 10/18/2014
Dear David H. Stone:
Per your request, enclosed please find the account information as of the date of death
for the abov�named decedent. For your information, accrued interes[ is not included in
the da[e of death balance.
Please feel free to contact me if I can be of any further assistance.
� Very truly yours,
<�:�v�
Donna Penta
Lead Specialist
617-514-5189
Santander
ESTATE OF:CAROLVN G JONES
SOCIAL SECURIN R: 193-12-8770
DATE OF DEATH: 10/16/2074
Account#:0571139248 Type: MONEY MARKET Open date: 1228/1982
In the name of: CAROLYN G JONES(BARRY W JONES POA)
Oate oftleath balance: $2,602.45
Int�YTD)from:01/01/2014 To: 10/13/2014 g5,p�
Accruetl interest to tlate of tleath:$0.09
Other into:CLOSED 1128/14
Account N:0575546387 Type: RETAIL STATEMENT CD Open date:03/27/2011
In the name of: CAROLYN G JONES or 6ARRY W JONES
Date of deaM balance:$6,189.95
Int.�YTD�hom: 01/01/2014 To:09/30/2014 $OAS
Accrued interest to date of deafh: $0.04
Otharin(o:
Page z/2
Jennifer A. Mearkle
From: JenniferA. Mearkle
Sent: Wednesday, January 28, 2015 3:57 PM
To: David S[one; Tina Burkey
Subject: RE: Jones Estate
I called EquiTrust to follow up on our dod request and[hey said that since the policy was already paid out they cannot
give us dod values in writing. She did tell me verbally that the dod value was$36,136.02.
I don't know what we do since we can't ge[any[hing in wri[ing[o submit with Ihe ITft??
Jennifer A. Mearkle, Parelegal to
STONE LaFAVER & SHEKLETSKI
414 Bridge Street
Post Office Box E
New Cumberland, PA 17070
Phone: 717-774-7435 x103
Fax: 717-774-3869
imearkle(�o.stonelaw.net
The information contained in this e-mail message is intended only for the personal and confidential use of the
recipient(s) named above. This message may be any attorney-client communication and as such is privileged
and confidential. If the reader of this message is not the intended recipient or an agent responsible for
delivering it to the intended recipient, you are hereby notified that you have received this document in erzor and
that any review, dissemination, distribution, or copying of this message is strictly prohibited. If you have
received this communication in error, please notify us immediately by e-mail, and delete the original message
at once. Thank you.
i
.�III EquiTrust,
�,�a��,�„�<,�omo,��
Novamber 24, 2014
Barry W Jones
78 Farmington Way
New Providence PA 17560
Re: Carolyn G Jones Deceased
ContracWumber EQ0001116326F
Dear Barry W Jones:
On behalf of our Company, please accept our sincere sympathy on the recent passing of your loved
one. Please eMend our sympathy to the famity.
We have received notification of death. As a result, we are fumishing you with the requirements for
filing a claim. Please be advised that the submittal of these documents does not confirm the contract
is active, nor does it guarantee a death benefit. Once we receive the required information, we will
research our files and provide you with the status of the contract. If the contrect remains active we
shall continue processing and settle the claim with the option you have chosen.
Please provide the following:
- Annuity Claimant Settlement Statements (enclosed), completed by you as the benefciary
- IRS for W-9 form (enclosed) completed by each beneficiary
- Certified tleath certificate (must have raised seal or colored stamp), If the beneficiary is
deceased a copy o/his/her death certificata is required.
- The original wntract for cancellation. If lost or destroyed, please certify on the claim form.
Please Nota: per the terms of the CertaintySelect contract, if you choose a lump sum settlement
option, you may incur penalties and charges. Please call our office if you have any questions or to
discuss the settlement options availa6le to you.
Please disregard if the information has previously been sent.
If you have any questions, please feel free to call our toll free number 866-598-3692.
Sincerely
c� �
--���,'% �
Troy yh 5
CusfomcF Service Representative
Annuity Services
EquiTrusi Li�e Insurance Comaany•]iCO Westown pkwy Swta 200•PA. Box t4500•Oes Moines, IA 50308-3500
CLAIMANT STATEMENT
�III Eqaili•ust.
we i�aunrc•camoenv
Return campleted form to: Ovemight Mail Address:
EquiTrust Life Insurance Company EquiTrust Life Insurance Company �
PO Box 14500 7100 Westown Pkwy Suite 200
Des Moines IA 50306-3500 West Des Maines, IA 50266-2521
• Pleace print clearly when completing this form
• Complere each section and answer all questions
• Original ink signatures required in Sections 5 and fi
• Each beneficiary must complete a separa[e Claimant Statement
• An IRS Form W-9 must be submitted for each 6eneficiary
• Retum the original contrnct or complete Section 4-Lost Contrnct Statement
• Provide a<ertified copy of the Physician's/Medical ExaminePs Certificate of Death(which must
indicate ihe cause of death)and ifdeath occurred outside ofthe United Slates,a Consular's Report of
ihe Death of an American Citizen.
• Any Assignment on[he contract will need[o be revoked or released prior ta comple[ing this farm.
• If the proceeds are to be paid out in a monthly,quarteriy or semiannual payment mode complete the
attached Automatic Deposit Authoriration Agrcemrnt Note: Annual payments may be made 6y check.
SECTION 1
ContraaNumber(s) EQ0 0011 1 6 32 6F
Uecedent'sFullName Carolyn G. Jones
fullNameofBeneficiary Barry W, Jones
Ta�epayerfDNumbe � �5-40-7379 (Forindividuals,thisisyoursacialsecurirynumbeoForotheremities,
i� is the employer iden[ification number—EIN).
Other names you may have been k�own by
Address 18 FarminqT w �
�ew Providence, PA 17560
Relationship m Decedent son
DateofBirth > > /07/7952 DaytimePhoneNumber �� �'786-4�83
Signature required on Page 3 and 5
EquiTmst Life Insurance Company•PD. Box 74500•Des Moines,IA 50306-3500
Phone 86&598-3692
Paga t of 5—Incompletewilnout all pages
ET-2]00(0249)
Insured: Carolyn G. Jones
Bari ContrecWumber. EQ0001116326F
Beneficiary: Y F7. JoRes
SECTION 2 •Election of Payment Option
Please indicate your choice of payment option by checking one of the Pollowing baxes.
%7 Lump Sum-see next page for Federal Income Tax Withholding Election(if applicable).
Nah: Elec[mnic Funds Transfer(EFT) is not available for Lump Sum payments
❑ Spoueal Continuation-(subject to the distribution requiremenu of the annuiry contract). Spousal
beneficianes o(certain contracts may continue the contrzct in his or her own name as the contract owner.
Note: If you are choosing this option you do not need m retum ihe onginal contract.
❑ Stretch IRA—if electing ro stretch an IRA, Fortn ET-2536,StreMh IRA Disclosure, must also be complered.
Note:Addi[ional forms are required. Pieaze contact our o�ce prior ro submitting the Claimant Statement
for the additional forms.
Pleaee note: Whrn Ihe Shetch IRA Payment Option is elected and finalized, a surtender charge may
apply to any surtender or withdrawal of fiinds in excess of the minimum required dishibution payment.
❑ Payout Option(subject m the provisions of the annuiry contract)
Notr.The minimum payment penod is 5 years.
`lumber of years payout requested
SlatlingMonth_DayofMon[h (I°-28'�) Year
�1ode: o Nonthly oQuarter�y ❑Semi-Annually oAnnual
`Note: I(any mode other ihan Annual ia cho�en, [Ae qutometic Depofit Author'vallon Form ET-
2513 ie required.
❑ Other
SECTION 3—Withholding Sectlon—Thie section must ba completed
The distribution you receive will be subjmt ro Fedenl income Tax withholding unless you elec�mt ro have withholding
apply. W ithhoiding will onty appry m the pottion ofyour distribution[hat is included in your incom<and subject to Fedeal
Income Tar.
You may elect not to have withholding apply to your disinbution. Ifyou do mt complete thia section,Pedenl income
Tax wiil be withheld lrom fhe taaable portian ofyour Abtributian at n Oat 10%nte.
Ifyou clec�nm m have wirhhoiding appty to your distri6ution,or if you do mt have enough Fedenl Income Tax wi�hheld
from your dismbu[ion,you may be responsible for paymenl ofes[imated[az. You may incur prnalties under the estimared
tav rules ifyour wi[hholding and es�imamd taz paymems are not su�ciem.
State Income Tax may.be withheld from your distribution. Certain stares baze your withholding dection on your federal
wirhholding election. Other stams requim that the Company withhold state tares regardlexs ofyour Fedeml election. in the
evrn[yov live in one of those stares,your disttibution will be subjec[[o State Income Tax wilhholding.
Instrucflom: Check the applicable box below if you do not want am Federal Income Taa withheld from Ihe taxable porcion
ofyour disin6ution or ifyou want more than the 10%Federal Income Tac withheld. Even ifyou elect mt ro have Federal
and/or State Income Tax withheld,you are liable for paymen[ofFederal and,if applicable,State Income Tar on th<taxable
pottion ofyour disvibution. You may also b<subject m taz penalties under the estimamd tax payment rules ifyour payments
of estima[ed tax and withholding,if any,are not adequatt.
�91 do not wanf to have FeJerel Income Tax withheid (rom the taxabie portion otmy distribution.
❑ 1 would like the following Federal Income Tas withheld: 5 or%
❑ 1 would like Ihe following State Income Tax withheld: $���/
Equiimst Life Insurance Company•p,0. Box 1450a• Des Moines, IA 5030fi-
Phone 868-598-3692 3500
]00 (�2-tA) Page 2 of 5—In[om0�ate wilhoW all Oages
Insured: Carolyn G. Jones
ConnactNumbec EQ0001116326F
Benefciary: BarrY W• Jones
SECTION 2 -Elactian of Payment Optlon
Please indicah your choice of payment optioo by checking one o(the foliowing boxa.
Y7 Lump Sum-see nezt page for Federal [ncome Tu Withholding Election (if applicable).
Note: Electronic Funds Transfer(EFT) is not availabk for Lump Sum payments
❑ Spousal Continua[ion -(subject to ihe distribution requirements of[he annuity cont2ct). Spousal
beneticianes of certain contracts may continue the contract in his or her own namt as the contract owner.
Note: If you are choosing this option you do not need m return the original contract.
❑ Sfretch IRA—if electing to strecch an IRq, Fortn ET-2536,Strefch IRA Disclosure, must also be completed.
Yote:Additional forms are required. Pleue contact our office prior to submitting the Claimant Statement
for the additional fortns,
Pleaae no[e: When the Siretch IRA payment Option is elected and finalized,a surtendcr charge may
apply to any surtender or withdrewal of fiinds in excess of[he minimum required distributian paymcnt.
❑ Payout Option (subject to the provisions of the annuiry contract)
8ote: The minimum payment period is 5 years.
Vumber of years payout requested
StartingMonth _DayofMonth(I"-28'^) Year
Hode:o .Ylonthly' oQuartcrly oSemi-Annually� oAnnual
"Note: Ifany made other than Annual ie chosen, [he AutomaNc Deposit Author'reaqun Form ET-
:513 ie requimd.
❑ Other
SECTION 3—Withholding Saction—Thia sectlon must 6e completed
The distnbution you rcceive will be subject m Federal Income Taa withholding unless you elect not to have withholding
appty. Withhoiding will only appty m Ihe portion of your disrtibution that is included in your income and subjecl m Fedeml
Income Tax.
You may elect not to have withholding appty m your distribu[ion. If you do mt complete Ihie section,Federel Income
Tax will be withheld lrom fhe taxable ponlon o!your diaM1ibuHon af a Oat 10%nh.
Ifyou elect nm w havt withhaltling apply to your disRibution,or if you do not have enough Federal Income Tax withheid
Rom your disiribution,you may be respansibk far payment of estimated taz. You may incur penalties undet the es�ima[ed
tat rules i(your wi�hholding and estimahd tae payments are not sufficient.
S�are Income Tan may be withheld from your distribution. Cenain states base your withholding election on your federal
wilhholding election. Other stares requirc that the Company wi�hhold state taxes regardless ofyour Pederal dmtion. In Ihe
evrnt you lioe in one of those seares,your disnibution will be subject ro Stam Income Tu withholding.
instructiom: Check the applicable boz below ifyou do not wam any Federal Income Taz withheld from the tasable portion
ofyour distribution or ifyou wam more�han ehe 10%Federal Income Taz withheid. Hven i(vou elect not ro have Federal
anNor Stam Income Tax withheld,you are liable for payment ofFederal and, if applicable,State Income Tze on the taxable
portion o(your disuibution. You may also be subject to[ax penalties under the estimated taz payment rules ifyour paymente
of esumated tac and withholding, if any,are not adequate.
'9 1 do not want m have Federal Income Tax withheld from the taxable portion of my disiribution.
❑ i would Iike the following Federal Income Tax withheld: $_or%_
� I would like the following Stah Income Tax withheld: 5_or%
EqwTrust�ife Insurence Company•pp. Box 14500• �es Moines. IA 5030fi-3500
�pp ��2 ��� Phone e66-598-3692
Page 4 0�5—Incomplele withoul all pages
�Z}
GREAT�EHI(.'AN,
INSUPANCE6fl0UP �
Annuities
January 22,2015
DAVID STONE
STONE, LAFAVER&SHEKLETSKI
414 BRIDGE 5T
PO 80% E
NEW CUMBERLAND PA ll070
Re: Grea[American Life Insurance Company
Policy No: 06312863
Deceased: Carolyn GJones
Dear Mr. Stone:
In response to your letter oflanuary 9, 2015, below is the informa[ion you requested.
Date of Death: 10/18/2014
Acmunt Value: 521,503.13
The daim was settled December 30, 2014.
If you have any questions, please feel free to mn[ac[ us at 1-800-854-3649.
Sincerely,
/�--.�L�..a.4„J
Brian Anderkin, FLMI,ACS,ARA
Claims Supervisor
Life &Annuity Claims Department
Cc. file
6ieatAmencan Finarroial Resou¢es: Adminisbafion lorLile Insuronce and Annuities:
Annuity Inves�ors Life Insurance Company� AmeAcan Re�irement Life Insurance Company
Continental General Insurance Companya Central Reserve tife Insurance Company
GreatAmencanLilelnsuranceCompany° LoyalAmencanLifeln5uranceCompany�
Manhattan National Life Insurance Company Provident Amencan We 8 Heal�h Insurance Company
lJnitea Teacher Associales lnsurance Company
P.O.Box 5420•Cincinnati,OH 45201-5420
�Z�
G�wrAmsx�c.w
INSUflPNCEGROUP
Annuities
December 2,2014
DAVIDSTONE
414 BRIDGF,ST.
NEW CUMBERLAND, PA L7070
Great American Life Insurance Company
Poliry Number 06312863
Deceued: Wrolyn G. Jones
Dear DAVID STONE:
Ow u(fice has rece�Ny been informed ofthe passing of Carotyn G.Jones. Pleaze accept our condolenres.
The beneficiaries of record are Audrey Belsak And Barry Jones.
In order to make a claim and distribution electioq an Original Certified Death Certifica[e(tha[reflects the cause and
manner of death)will be required along w{th a Claimant Statemenl& Election Request Form fiom each beneficiary. Gach
beneCmiary should select ONF of the op�ions below:
. F.lection A—Lmnp Sum:To receive a check issued to each beneticiary;
• Election B—Annui[iiation:"fo receive a periodic stream of payments ofthe death beneFi[proceeds.Please nore
tha[paymenis cannot exceed ywr life expectancy and mus[start prior[0 12/3I of Ihe year following death. Please
refer ro Page 7, Section 2C regarding possible RMD's.
Ifyou have any questions regarding this claim, you may reach me at(800)8543649.
Sinrerelg
���
Martin 1. Gcksrein
Life&Annuity Ciaims Department
ca file/AA420
Ench Claimant Slatement& Flection Request Form(K6042312N W)(2)
Great Amencan Financial Resources: Adminisfrefion(or Lile Insmanca and Annudies:
Annuiiy Inves�ors Life Insurance Companyo Amencan Retiremenl Life Insurance Company
Continental General Insurance Company� Central Reserve Lite Insurance Company
GreatAmencanLifelnsuanceCompany0 LoyalAmencanLi�eln5uranceCampany�
Man�attan National Gfe Insurance Company Providen�Amencan Lite 8 Healih Insurance Company
Uni�etl TeacherAssociales Insurance Company
P.O.Box 5420.Cincinnati,OH 45201�5420 il
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