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Home My WebLink About09-15-05 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT AMMERMAN KAREN J B 408 BURGNERS ROAD- CARLISLE, PA 17013 __n___~ 10"1 ESTATE INFORMATION: SSN: 188-12-3339 FilE NUMBER: 2105-0607 DECEDENT NAME: BOWERS ZELLA K DATE OF PAYMENT: 09/15/2005 POSTMARK DATE: 09/15/2005 COUNTY: CUMBERLAND DATE OF DEATH: 06/23/2005 NO. CD 005796 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $7,992.11 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: K AMMERMAN CHECK# 106 SEAL INITIALS: VZ RECEIVED BY: REGISTER OF WILLS $7,992.11 GLENDA FARNER STRASBAUGH REGISTER OF WILLS Register of Wills of Cumberland County, Pennsylvania INVENTORY , Deceased No. 21 - 05 - 00607 Date of Death 6/23/2005 Social Security No. 188-12-3339 Estate of Bowers, Zelia K. also known as Karen J.B. Ammerman The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. l!We verify that the statements made in this Inventory are true and correct. l!We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Personal Representative Attorney: Dale F Shughart, Jr. Esquire Signature: I.D. No.: 19373 Signature: /ZJ3- 0 ,..) -C) , ,-..) r" -:c::;) ~'l r"j'} ~'::! ~ "J:) :~n '.> (-:;, "TJ '") I:'::r, '~:J " .~") : -" ." ","'5 _ ill ')0 --I, Karen J.B. Ammerman ",--" Signature: U'I Address: 35 E. High Street, Suite 203 Address: 408 Burgners Road Carlisle, P A 17013 -C] Carlisle, PA 17013 Telephone: 717/241-4311 Telephone: 717-249-6762 Dated: 9 f '1/ 0 ~ N CD Personal ProDertv Furniture and furnishings 300.00 M & T Bank checking account #404365 Principal $3,841.20 Accrued interest -0- 3,841.20 M & T Bank, Certificate of Deposit #031003910534196 Principal $13,966.91 Accrued interest $ t 26.06 14,092.97 Hoffman-Roth, refund of overpayment 37.09 Penn Treaty, nursing care insurance 1,500.00 Penn Treaty, refund of premium 721.03 Chapel Pointe, refund 699.30 Sprint, refund 1.27 (Attach additional sheets ~ necessary) Total Personal Property and Real Estate $21,192,86 AE\I.ISODEX.($.(l(I\ '. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT Of REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 05 COUNTY CODE YEAR SOCiAl SECURITY NUMBER 00607 NUMBER ~ z w o w o w o DECEDENrs NAME (LAST, FIRST, AND MIDDLE INITIAL) Bowers, Zelia K. DATE Of DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-[)[)"YEAR) 06/23/2005 1111411920 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST AND MIDDLE INITIAL) ()F-Fi(;IAL li;~r: l:~.H." 188-12-3339 THIS RETURN MUST BE FILED IN DUPUCATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER ~ 1.0riginalRetum 0 2. SupplementalRetum 03. Remalnder Retum (date 01 death priOr 10 12-13-82) w ::.:: ~ ~ 0 4. Limited Estate 0 4a. Fulure Inlerest Compromise (dale 01 death aller 0 5. Federal Estate Tax Return Required u g: u 12-12-82) ~ ~ 9 181 6. Decedent Died Testate (Anach copy 0 7. Decedent Maintained a living Trust(Allach 0 8. Total Number of Safe Deposit Boxes u ~ CD of Will) copy 01 Trust) <0( 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (dale oldealh between 0 II.Section to tax under Sec. 9113(A)(Atlach Sch 0) \~'~'~'~~:f~~,Wi.B~~~@$~i!'~~Wj.\w{l,;\~ NAME ; COMPLETE MAILING ADDRESS , ~ Dale F Shughart, Jr. Esquire ffi~ ~ ~ FIRM NAME (If applicable) 00 0.. TELEPHONE NUMBER 717/241-4311 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) z o F S ~ ~ ~ < u w ~ 3. Closely Held Corporation. Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Join~y Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) 11. Total Deductions (total lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 35 E. High Street, Suite 203 Carlisle, P A 17013 (1) None Cl ('") -.'-' (2) None 1--':; (3) None (4) None (5) 21,192.86 (6) None (7) 185,368.94 (8) (9) 19,306.53 (10) 305.36 ....., OFF1(;IAf}{_~E ONI]_-, I.'~g ") ['~;~ ,ir'n '.' C:J -, ~.:..") ~ ---r 1 _ -rl ...") 110 :J -:-, c..-' N c:> 206,561.80 (11) 19,611.89 186,949,91 (12) 13, Charitable and Governmental Bequests/Sec 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) (13) (14) 186,949,91 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES IS. Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) z 186,949.91 .045 (16) 0 16. Amount of Line 14 taxable at lineal rate x F < ~ ~ .. 17. Amount of Line 14 taxable at sibling rate x .12 (17) '" 0 0 x 18. Amount of Line 14 taxable at collateral rate < x .15 (18) ~ 19. Tax Due (19) 8,412.75 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 8,412.75 20. 0 >> BEslJRE TP:AI1i~Ell AU:;dUE~Q,.:lDl!I'l~SlQl;AiID ~CIiECKMAm..<. .'-'-. _'~._.._~-'..ci."_'....~.-",-,,-,.".,,-,,"..,..-,.c--,,~,",,,,=," ...... .."........ ........~~~.. ........ . .......,'.., ............ '=,",-,,-;.,,",;"""":';;';"~~~~....'~..._ Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS Chapel Pointe at Carlisle 770 South Hanover Street CITY STATE PA ZIP 17013 Carlisle Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 7,992.11 420.64 Total Credits (A + 8 + C) 3. lnteresVPenalty if applicable D. Interest E. Penalty TotallnteresVPenalty (0 + E) 4. If Line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 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. (1) 8,412.75 (2) 8,412.75 (3) (4) (5) (5A) (58) 0.00 0.00 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT _UiIl2HHJJJJJJJJiiil4i1i1ljjjjUC_iliflii'__ ~~~~4'kmfWfID2~. ~ _~=~~ 1I ._""" - PLEASE ANSWER THE FOllOWING QUESll0NS BY PLACING AN "X"'N THE APPROPRIATE BLOCKS 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 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?.... ................ ........................... .................... ......................................... IlliUJl '~ i D ~ D ~ ~ D 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 pe~ury. I declare that I have examined this retum, including accompanying schedules and statements. and to the best of my knowledge and beliel, it is ti'\.Je, correct and complete. Declaration of preparer other than the personal representatIVe IS based on all information of which preparar has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN ADDRESS Karen J. . Ammerman Sl A OF PE~~IBLE FOR FILING RETURN 408 Burgners Road Carlisle,PA 17013 ADDRESS ADDRESS 35 E. High Street, Suite 203 Carlisle, PA 17013 SIGNATURE OF PREPARER OTHER TH D;:) ~J'~ESqUi' 7/;Y}U~ DATE DATE 9 /rz IlJ~r For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1 .1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot 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 twenty-one 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% [72 P.S. ~9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P .8. ~9116 1.2) [72 P.S.~9116 (a) (1)1. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [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. *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY C~MOOWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT -- - ___________n_ ESTATE OF Bowers, Zelia K. FILE NUMBER 21 - 05 - 00607 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshIp must be disclosed on schedule F. ITEM NUMBER I Furniture and furnishings DESCRIPTION VALUE AT DATE OF DEATH 300.00 2 M & T Bank checking account #404365 Principal $3,841.20 Accrued interest -0- 3,841.20 3 M & T Bank, Certificate of Deposit #031003910534196 Principal $13,966.91 Accrued interest $ 126.06 14,092.97 4 Hoffinan-Roili,refundofove~a~em 37.09 5 Penn Treaty, nursing care insurance 1,500.00 6 Penn Treaty, refund of premium 721.03 7 Chapel Pointe, refund 699.30 8 Sprint, refund 1.27 TOTAL (Also enter on Line 5, Recapitulation) 21,192.86 '* SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Bowers, Zelia K. FILE NUMBER 21 - 05 - 00607 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF Include the name ollhe transferee, their relationship to decedenl and the date ollransler. DECD'S EXCLUSION TAXABLE VALUE NUMBER Attach a copy of the deed tor real aslale. VALUE OF ASSET (IF APPLICABLE) INTEREST Great American Loyal Integrity Vision 10 Annuity 90,000.00 100% 0.00 90,000.00 Contract #45005418; transferred on death; Beneficiaries: Gary L. Bowers, son; Karen 1.B. Anunerrnan, daughter; Mary Ann Traina, daughter. 2 Great American Loyal Integrity Vision 10 Annuity 10,000.00 100% 0.00 10,000.00 Contract #45005539; transferred on death; beneficiaries: Gary L. Bowers, son; Karen 1.B. Anunerrnan, daughter; Mary Ann Traina, daughter. 3 Western-Southern Life Annuity Contract #0020570166 18,596.68 100% 0.00 18,596.68 transferred on death; beneficiaries: Gary L. Bowers, son, Karen 1.B. Anunerrnan, daughter; Mary Ann Traina, daughter. 4 Prudential Financial Discovery Select Annuity Contract 66,772.26 100% 0.00 66,772.26 #E02l750 121750 I, transferred on death, beneficiaries: Gary L. Bowers, son; Karen 1.B. Anunerrnan, daughter; Mary Ann Traina, daughter. TOTAL (Also enter on line 7, Recapituiation) 185,368.94 ESTATE OF . COMMONWEALTH OF PENNSYLVANIA INl-IERlTANCETAX RETURN RESIDENT DECEDENT Bowers, Zelia K. SCtEDUL.E H FUERAI... EXPENSES & ADNWSTRAllVECOSI:S FILE NUMBER 21 - 05 - 00607 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. B. FUNERAL EXPENSES: Hoffman-Roth Funeral Home, funeral 2 First Church of the Brethern, family meal DESCRIPTION AMOUNT ADMINISTRATIVE COSTS: Personal Representative's Commissions Karen J.B. Ammerman Social Security Number(s) I EIN Number of Personal Representative(s): 206-36-2453 1. 2. Street Address Carlisle 408 Burgners Road State PA City Year(s) Commission paid 2005 Zip 17013 Dale F. Shughart, Jr., Esquire (estimated) Attorney's Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address 4. City State Zip Relationship of Claimant to Decedent Probate Fees Paid (55) (probate 20) owe 40 5. Accountant's Fees 6. 7. I 2 Tax Return Preparer's Fees (Estimated) Other Administrative Costs Register of Wills, Short Certificates Cumberland Law Journal, advertise Letters Total of Continuation Schedule(s) TOTAL (Also enter on line 9, Recapitulation) 8,503.09 75.00 2,900.00 5,800.00 95.00 500.00 8.00 75.00 1,350.44 19,306.53 ESTATE OF 3 4 5 6 7 '* COMMONWEALTli OF PENNSYLVANIA INHERITANce TAX RETURN RESIDENT DECEDENT Bowers, ZelIa K. The Sentinel. advertise Letters Penn Treaty, return over payment Postmaster, certified mail Sc:hedUe H Fu1emI Expe. s: s & Am. "".1Ie CosIs COI1inJed Register of Wills, filing inheritance tax return and inventory Reserve for Account FILE NUMBER 21 - 05 - 00607 Page 2 of Schedule H 650.00 164.44 6.00 30.00 500.00 '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEAl. TH Of PENNSYlVANIA INHERIT MIce TAX AElURN AE$IDENTOECEOENT ESTATE OF Bowers, Zella K. Include unrelmbursed medical expenses. ITEM NUMBER I 2 3 DESCRIPTION Checks written before death, clearing after death: #3052 First Church of the Brethem $100 Alert Pharmacy Services, prescriptions (49.40 + 119.73) Sprint, phone FILE NUMBER 21 - 05 - 00607 TOTAL (Also enter on Line 10, Recapitulation) AMOUNT 100.00 169.13 36.23 305.36 REV-1513 EX+ (9-00) '. SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Bowers, ZelIa K. FILE NUMBER 21 - 05 - 00607 NUMBER RELATIONSHIP TO DECEDENT Do Not Ust Trustee(s) NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) Gary L. Bowers 623 Upper Grassy Hill Road Woodbury, CT 06798 Son 2 Karen J.B. Anunennan 408 Burgners Road Carlisle, PA 17013 Daughter 3 Mary Ann Traina 33 Quarry Street Newton Falls, OH 44444 Daughter 4 Tara Alexis Bowers 40 Millbrook-Stillwater Road Hardwick, NJ 07825 Granddaughter See Continuation Schedule(s) attached Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet AMOUNT OR SHARE OF ESTATE 25% 25% 25% 3.125% II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Bowers, ZelIa K. NUMBER SCHEDULE J BENEFICIARIES continued I. NAME AND ADDRESS OF PERSONIS) RECEIVING PROPERTY 5 (include outright spousal distributions, and transfers under Sec. 9116(8)(1.2)) TAXABLE DISTRIBUTIONS Justin A very Bowers 5 East Main Street Flemington, NJ 08822 6 Jennifer Lynn Lopiano 206 Ponderasa Road Carlisle, PA 17103 7 Vincent Salvatore Lopiano 2201 East Dauphin Street Philadelphia, PA 19125 8 Amanda Sue Fair 51 Hillside Drive Carlisle, P A 17013 9 Shannon Michelle Stull 312 9th Street New Cumberland, P A 17070 10 Derek Michael Stull 208 Bane Street Newton Falls, OR 44444 II Elizabeth KathrynTraina 33 Quarry Street Newton Falls, OR 44444 FILE NUMBER 21 - 05 - 00607 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do. ~ list Trustee(s) OF ESTATE Grandson Granddaughter Grandson Granddaughter Granddaughter Grandson Granddaughter 3.125% 3.125% 3.125% 3.125% 3.125% 3.125% 3.125% Page 2 of Schedule J m1 M&TBank 499 Mitchell Road, MiIlsOOIO, DE 19966 Mail Code DE-MB-12 Phone (888) 5024349 Fax (302) 934-2955 July 18, 2005 Dale F. Shughart, Jr. Attorney At Law 35 East High Street - Suite 203 Carlisle, Pennsylvania 17013 Re: Estate of: Zella K Bowers Social Security: 188-12-3339 Date of Death: June 23. 2005 Dear Sir or Madam: Per your inquiry dated July 12,2005, please be advised 1hat at 1he time of deaJh, the above-named decedent had on deposit with this bank the following: I. Type of Account Checking Account Account Number 404365 Ownership (Names of) Kenneth E Bowers, Zelia K Bowers . AmandaSFair, POA Opening Date 09/01/67 Balance on Date of Death $3,841.20 Total $ 0.00 --S3:84Tiif-........... Accrued Interest 2. Type of Account Certificate of Deposit Account Number 031003910534196 Ownership (Names qf) Ze//aKBowers · Opening Date Il/08I99 C/osed07/Il/05 Total $13,966.91 $ 126.06 .Sl'4:o'9'Xi7-......--.-.---....--m--.---.-m-...---.-.-.m Ba/ance on Date of Death Accrued Interest Please be advised, there was no safe deposit box found for 1he above decedent . For further account information, regarding ownership, closures and/or reimbursement offunds, etc., please caD the High Street Carlisle Office # 717- 240-4536. Sincerely, ~~ Nancy Clagett Records Management ---- z Life & Annuity Group ? GREA~RICAN. P.O. Box 5420 Cincinnati, Ohio 45201-5420 www.gafri.com FINANCIAL RESOURCES Shipping Address: 525 Vine Street. 7th Floor Cincinnati, Ohio 45202 August 4, 2005 KAREN J. AMMERMAN 408 BURGNERS ROAD CARLISLE, PA 17013 RE: Great American Life Policy Number: Deceased: Beneficiary: 45005418 Zelia K. Bowers Karen J. Ammerman Dear Ms. Ammerman: This is in response to the lump sum election of your portion of the death benefit proceeds. Enclosed is our Check #00 II 0003084 in the amount of $30,099.77, representing the death benefit payment. The Total Death Benefit as of today is $90,000.00. As a beneficiary, you are entitled to 33% of this benefit. As per policy provisions and/or your instructions, we have made the following additions/deductions: Totai Death Benefit Your Portion of the Death Benefit 3% interest from 6/23/05 to 8/3/05 Federal Income Taxes State Income Taxes TOTAL AMOUNT PAYABLE $90,000.00 $30,000.00 $99.77 .00 .00 $30,099.77 The accumulated interest ($99.77) payable to you is taxable and reportable to the IRS under Federal Tax Number 206-36-2453. If you have any questions, do not hesitate to contact our office at (800) 854-3649. ~SinCereIY'a jl / ..li0i( .-uA-1..),VA.-t/>tfI i anAnn Buring {/ { ,~.CI,;= ,",m;~' Claims, Ext. 12230 Great American Life Ins. Co. cc: FFO 140064/1'1'0009999 FOR OFFICE USE ONLY APPROVAL ----r!!!!J.--- DATE MAILED i~.UE \! /i /[1[)~ Our subsidiaries include: Great American Ufe Insurance Company" Annuity Investors Life Insurance Companye Loyal American Ufe Insurance Cornpany'M United Teacher Associates Insurance Company Great American Ufe Assurance Companye of Puerto Rico ---- z Life & Annuity Group ? GREA14MERICAN. P.O. Box 5420 Cincinnati, Ohio 45201-5420 www.gafri.com FINANCIAL RESOURCES Shipping Address: 525 Vine Street, 7th Floor Cincinnati, Ohio 45202 August 4, 2005 KAREN J AMMERMAN 408 BURGNERS RD CARLISLE, PAl 7013 RE: Great American Life Policy Number: Deceased: Beneficiary: 45005539 Zelia K. Bowers Karen 1. Ammerman Dear Ms. Ammerman: This is in response to the lump sum election of your portion of the death benefit proceeds. Enclosed is our Check #00110003085 in the amount of $3,344.42, representing the death benefit payment. The Total Death Benefit as of today is $10,{l{){}.00. As a beneficiary, you are entitled to 33% of this benefit. As per policy provisions and/or your instructions, we have made the following additions/deductions: Total Death Benefit Your Portion of the Death Benefit 3% interest from 6/23105 to 8/3/05 Federal Income Taxes State Income Taxes TOTAL AMOUNT PAYABLE $10,000,00 $3,333.33 $11.09 .00 .00 $3,344.42 The accumulated interest ($11.09) payable to you is taxable and reportable to the IRS under Federal Tax Number 206-36-2453. If you have any questions, do not hesitate to contact our office at (800) 854-3649. i'iJJ.erCiY, " /J ;j : .' W4~i&<(Jj,UA.-L''f4 J nAnn Buring U ssoc. Claims Examiner Claims, Ext. 12230 Great American Life Ins. Co. FOR OFFICE USE ONLY APPROVAL r:;::,. (~~._ ~llf'i'" (d' DA TE MAILED ~~~~ if ce: FF0140064/FF0009999 OUf subsidiaries include: Great American Life Insurance Company'" Annuity Investors Life Insurance Company<!l Loyal American life Insurance Company'" United Teacher Associates Insurance Company Grear American Life Assurance Compant' of Puerto Rico ::::it:.I-' l:Il dl:!.1~'::) 11:..:.CC t-K. W':l Lll-t:.-HNNUIIY Ut-':::. ::>1.,) b.:=.'::;. 1('::1':;1 IU '=Jl-(j-(.:=.'414I::;:1dl t-'.1C1~/t1.= ~'". ".-," . ."- ". ,.- . -" __ .. ,;~':"-"::':-:' -:" _~' _:, " ;>i_-:::,;_':' ',_ . . . , . Member W.~l!'m& Southern Rnanc,iill G~9l1pe . Annuily Opel'llliol!s Grou~;.rI;'O Bo)c 2918. (;in~nlll!ti;,Otiio. 45201-2918 Phone (800), 926-1702 ~ Fax (513) 62~1799 ** TOTAL PAGE.02 ** SEP 02 '05 12:55 FR PRUDE/HIl'lL INS CO 7177638974 TO 2414021 P.02/03 Prudential ~ Financial l::00::11;;,l)1 FC E-AC Pruden~} AMUity Service Center P.O..Box 7960 Philadelphia. PA 19176 Discovery Select Annuity Annuity Transaction Confirmation August 11, 2005 Page 1 of 2 >00439 3093427 001 092001 ZELLA K. BOWERS 770 S HANOVER ST #M230 CARLISLE, PA 17013-4105 Inv8stm~nt Professional: SCOTT A. MOYER PRUDENTIAL - PIF 150 CORPORATE CENTER DRIVE SUITE 105 CAMP HILL. PA 17011-1759 Annuity #: E0217501 Type: Non Qualified Owner Name: Zelia K. Bowers Annuitant Zelia K. Bowers For :24-l:Iour access to your . portfolio Pertonnance. investment options, current account value>; and other information: Sign on to our interactive Web site www.orudentiaI.C,om Or call OUr Automated V~ice Response System at 1-888-778-2888. For other inquiries on your Annuity Contract, contact your InvestmEmt Professional at (717) 975-8150. We recommend that you review this statement promptly, If yOU believe this statement does not properly reflect the transactions. features or allocations you have selected, contact the Annuity Service Center Immediately. Total Investment Value $0.00 Investment Trans.action Activity Transaction Dale Investments # of Unitsl "Interim Value Unit Pricel "MVA Valuel "Account Value 08/11/2005 Transaction Type; Death Senefit Surrender 'The followi.-.g amounts wen;: withheld for taxes and/or deducted for applicable surrender Charges from the total amount shown below: Federal Tax; $0.00 Pre TEFRA Cost Basis: $0.00 State Tax; $0.00 Surrender Charge: $0.00 Post TEFRA Cost Basis: $56,202.85 1 Year Fixed 07/20/2006 3.000% Prudential Diversified Bond Prudential Value Fund Prudential Jennison Franklin Small-Mid Cap Growth Securities Davis Value Fund Transaction Total: (35.307.39) (4,175.15292) (1,308.78914) (3.797.15094) (1,570.03703) (11.461.6310a) so. 00 U,83Z3 2.40631 1.860Z8 1.55736 1.06409 ($35,307.39) ($6,610.23) ($3,149.35) ($7.063.76) ($2.445.11 ) ($12.196.42) ($66,772.26) Transactions in your variable annuity contract are priced at the end of the business day (generally 4 p.m. Eastern time) on the day the transaction ...vas processed. Important Messages Information regarding agent's compensation (remuneration) is available upon written reQuest. Agel'lt ID#;:895602 Oft'~e IJW SI-I .SEP 02 '05 12:55 FR PRUDENTIAL INS CO 7177638974 TO 2414021 Discovery Select Annuity Annuity Transaction Confirmation August 11, 2005 P.03/03 ....v.......". 'C E-AC Page 2 012 For ease of reference, we use a single set of defined terms in this statement. In certain cases, your contract may use a different name for a contract feature than what is used in this statement. Annuity 1.'$ issued by Pruco Life Inwrance CQmpEmy, and cffarod tf\fQugh Pruoen'Us\ lffi'e~Wnent Management Services LLC, a registered brokGrfde:aler. Pruco Securi11es LLC is the $ellinQ broker/dealerand acted 8S89ent in the transactlon{s) liste(j above. All are Prudential Financ1~' companies. PnlCO Life Ins\Jrance Comp&ny is safety responsitlletOr its financial condition Bnd contractual Obligations. ** TOTAL PAGE.03 **