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Home My WebLink About02-08-06 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 006310 ALBRIGHT JOHN R 26 GREYSTONE RD CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER ____un fold ---------- -------- 101 I $2,426.42 ESTATE INFORMATION: SSN: 207-14-0014 I FILE NUMBER: 2106-0129 I DECEDENT NAME: ALBRIGHT CHARLES R I DATE OF PAYMENT: 02/08/2006 I POSTMARK DATE: 02/08/2006 I COUNTY: CUMBERLAND I DATE OF DEATH: OS/20/2005 I I TOTAL AMOUNT PAID: $2,426.42 REMARKS: J R ALBRIGHT CHECK# 2663 INITIALS: VZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1500 EX (6-001 REV-1500 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FilE NUMBER DEPT. 280601 ;)...\ o to fl () 1~9_ HARRISBURG, PA 17128-0601 RESIDENT DECEDENT - COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- AL~fhG~T C\-\A{1.LES '2eil - 14- - eo \4- z w DATE OF DEATH (MM-DD-Y AR) DATE OF BIRTH (MM-DD-YEAR) C THIS RETURN MUST BE FILED IN DUPLICATE WITH THE W 05"-20 - 2..ooS 0\- 03 - ,<1'2.lL, REGISTER OF WILLS U W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C w ~. Original Return o 2. Supplemental Return o 3. Remainder Return (date of deafh prior 1012-13-82) f- :.::~en o 4. Limited Estate o 4a. Future Interest Compromise (dale of death after 12-12-82) o 5. Federal Estate Tax Return Required u":':: wa.u J:OO o 6. Decedent Died Testate (Attach copy of Will) o 7. Decedent Maintained a Living Trust (Atlach copy of Trusl) 8. Total Number of Safe Deposit Boxes u".... a.DJ a. o 9. litigation Proceeds Received o 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95) o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) <I: f- THiSSECj'IONMUS't'$SCQMPLEte.l)..Al.LCQ~Re.SP()N:OENCE..ANP.tt)f("1)l!f4'1'1~I!i~__i"~1rtOl'l$.' z w NAME J COMPLETE MAILING ADDRESS 0 (:, \-'\ ,...) 'K. ~L&a.l6~T z jC\-\-~ ~_ A US '?\ cs\-\- T 0 a. FIRM NAME (If Applicable) en G ct.€.. '(S"1'" c r-.J E'K1> . w ON E. 2.io " " TELEPHONE NUMBER C ~a..L15 LE.. '?A ILO\5 ..2~CS- 0 u \1- 'Z.43 -2-; II , 1. Real Estate (Schedule A) (1) t..JOr..)E. 2. Stocks and Bonds (Schedule B) (2) ~DNE:. C') ~.~. ", 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) f-..lO~ e:. 4. Mortgages & Notes Receivable (Schedule D) (4) N Ol.J E. .....-...... I 5. Cash. Bank Deposits & Miscellaneous Personal Property (5) \. '2.00 ,00 Co (Schedule E) , Z -Tj 0 ~ 2 , 1'2..", z.-z.. --~ .~ 6. Jointly Owned Property (Schedule F) (6) !;i o Separate Billing Requested , ( ,.) .. ...J (7) It (P3~. 54 . - ::) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property !::: (Schedule G or L) I D.. 8. Total Gross Assets (total Lines 1-7) (8) ~1.f} qv3..'1~ ~ u 9. Funeral Expenses & Administrative Costs (Schedule H) (9) '1 109 4 . L.{ 0 w 0:: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11 '3y~).qC; f Z.\ ,04'3-3<1 11. Total Deductions (total Lines 9 & 10) (11) . 12. Net Value of Estate (Line 8 minus Line 11) (12) &::;3 <12.0- 37 I 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) ~ONE. made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 5"3 . q 20. '31 . ( SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 15. Amount of Line 14 taxable at the spousal tax 0 rate, or transfers under Sec. 9116 (a)(1.2) ~ c,~E: x .0_ (15) ~O~~ !ci: 16. Amount of Line 14 taxable at lineal rate 53/1.:20, ~ -1 x .0 .YS (16) 2 . 4- Zv _ &..; 2- ~ , ::) ~()~E.. to C f...) ~ D.. 17. Amount of Line 14 taxable at sibling rate x .12 (17) ::2: 0 18. Amount of Line 14 taxable at collateral rate ~Ot~E, x .15 (18) No~k- U >< 19. Tax Due (19) 2 .'1'z..~ ~'+ z ~ , 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: STREET ADDRESS 'Z.1P G R t'lS-1"'OtJ E KeA\) CITY I STATE vA I ZIP CACZ,l...\ $""U~.. 17DI3 -'2-(.,,0) Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2./'; l{g~4L 2. Credits/Payments A. Spousal Poverty Credit ~~E B. Prior Payments N)O ...::.e. C. Discount ~ 0 t-,) €:... Total Credits (A + B + C ) (2) rvOc-..)E.. 3. InteresUPenalty if applicable D. Interest NOI~E.. E. Penalty ~OIV'i:. Total Interest/Penalty ( D + E ) (3) ,vcr...)€-. 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 (4) ~Or0 E 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2 .4'2(..,~42. / A. Enter the interest on the tax due. (5A) ~O (\..) E.. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 2 _ Y-'2...lo.~2. . Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... D [91 b. retain the right to designate who shall use the property transferred or its income; ............................................ D g c. retain a reversionary interest; or.......................................................................................................................... D ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... D l0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D [g 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D [g' 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................,....................................... QI 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 perjury, t declare that I have examined this return, including accompanying schedules and statements. and to the best of my knowledge and belief, it is true. correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. LE FOR FILING RETURN DATE ADDRES . 'Z.Cu Ge~"'5"10~€.. ~oAS> CAa..UsLE, ?A (10 '3- 2~or- 2o,"l-(, . SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 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. S9116 (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. S9116 (a) (1.1) (ii)l. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 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. s9116(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.S. S9116(1.2) [72 P.S. s9116(a)(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. s9116(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 COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER C~A~LE.S 'K. AL8R\C::>\-\T 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. It1Cf4 Q..'"'I"3\<<' -rOWI' ~CcUtt\t-~ (V\,"'; -Vo.." - POOr- Col'\~t\-,c f\. SOb .00 20_ Me..c"-'o."" ,c.S -reo \ 5 300.00 ~o~ 'BcA, - \ ~ ( - I q,o 's VV\ode\ :;loo,..oo 3. 4, A tv\e.., QX-'\ L~'O''''\ 'b(',V"ICL,.\-CO>, -\0 E s..~k 2.00..00 TOTAL (Also enter on line 5, Recapitulation) $ , 'Z.O~~~O I (If more space is needed, insert additional sheets of the same size) ~_~'l'~ . SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER C"'w-\es ~.. A\bri ~~ If an asset was made joint within one ar of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ...\O~o""\ 'K r ~\b-\cf\ Z (p G~S\c,<\e.. ~oo.J Ca..\.S\~ ?A f701'3 5o~ , 8, C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for jointiy-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1- A. 21q~ m-+"\ ~~ Acd-..u. \SDD'i'2..D<DO \~\ ~~ 5\ I '34(,p, ~(p 50 'Z5,L. "13-43 L, A. 2{Qz.. (Y'\......., ~'1~ Acc-\- it 10 '3'\ C><.P ~ <.J 3ec _'-l~o. 41 50 11,2\0.2.\ ( 3- A, 2i9l (Y'\ - {" 3Cl."\ 'l. C'D ~ '31C:>O '3 ~ I t.fSCJcr86, 7.,D I DOO. 00 S-o t 0(000.00 If. ~. I~J ()() c.o"",,,~(""c<, ~Q;1t. 11cd-ti; u\ ~ 1{P .., '8. t Y. ILD, 4S" \5" So ')5/2.'+ 3. 5X TOTAL (Also enter on line 6. Recapitulation) $ (p Z, 17.1. z. 2.. (If more space is needed, insert additional sheets of the same size) ACCOUNT NO. ~CtOUNT'.TVPE ST~TE"ENTPERIOD P~GE ::J.SO 04206016188 "&T PERSONAL SAVINGS APR.29-JUL.28,2005 1 OF 1 00 o 06128H NH 017 --- 15705 --- CHARLES R ALBRIGHT -- ---- OR JOHN R ALBRIGHT 26 GREVSTONE RD MR 2 CARLISLE PA 17013-2605 Nl'EREST PAID YEAR TO DATE 61.18 CARLISLE WEST : . BEGINNING DEPOSITS'& ENDING &ALANtE OTHER ADDITIONS ItALAMeE NO. AHOUNT 51,346.86 0 18.64 0.00 ACCOUNT ACTIVITY ~STING DEPOSITS, INTEREST W/DRAWALS&OTHER D~ILY DArE <. TRANSACTION DESCRIPTION & OTHER ADDITIONS SUBTRACTIONS BALANCE . . . 61--29-05 BEGINNING BALANCE $51,346.86 0&-27-05 INTEREST PAY"ENT 10.20 51,357.06 0&-21-05 INTEREST PAYHENT 8.44 0&-21-05 CLOSEOUT 51,365.50 0.00 ENDING BALANCE $0.00 ANNUAL PERCENTAGE YIELD EARNED = 0.25 % EFFECTIVE SEPTEHBER 15, 2005, A $12 FEE WIll BE ASSESSED FOR EACH INCOHING WIRE TRANSFER TO YOUR SAVINGS ACCOUNT. ALSO, EFFECTIVE IHHEDIATElY, THE FOLLOWING CLARIfYING STATEHENT IS ADDED TO THE END OF THE '.FOREIGN TRANSACTIONS" SECTION OF THE ELECTRONIC BANKING CARD AND TELEPHONE TRANSACTION DISCLOSURE AND AGREE"ENT: "ALSO, THERE HAY BE SPECIAL CURRENCY EXCHANGE CHARGES, WHICH YOU AGREE TO PAY. WE HAVE NO CONTROL OVER THE EXCHANGE RATE OR THE DATE OR PLACE OF EXCHANGE OR THE A"OUNT OF ANY SPECIAL CURRENCY EXCHANGE CHARGES." IF YOU HAVE ANY QUESTIONS, PLEASE CALL THE "&T TELEPHONE BANKING CENTER AT 1-800-724-2440. k..OOBA 10390669 RELATIONSHIP CHECKING WITH INTEREST HAY.21-JUN.21,2005 1 OF 1 00 o 06128H NH 017 - 17136 -- CHARLES R ALBRIGHT - OR JOHN R ALBRIGHT - 26 GREYSTONE RD MR 2 CARLISLE PA 17013-2605 INTEREST PAID YEAR TO DATE 17.77 CARLISLE WEST ACCOUNT SUMMARY BEGINNING DEPOSITS. : OTHER .... CURRENT ENDING BALANCE . . OtHER ADDITIONS ..:: ..' tHEtKSPAID StJ&fRACTIONS INtERESTPD BALAHtE NO. I AHOUNT NO. I AHOUNT NO. I AHOUNT 36,420.41 11 51,365.50 51 1,648.19 1 I 61.80 3.24 86,079.16 ACCOUNT ACTIVITY POSTING DEPOSITS, INTEREST CHECkS' I OTHER DAILY DATE TRANSACT!ONDESCRIPtION . & OTHER ADDITIONS StJ&tRACTIONS BALANCE 05-21-05 BEGINNING BALANCE $36,420.41 05-24-05 VETS INSURANCE PREAUTHDEB 61.80 36,358.61 05-26-05 CHECK NUHBER 4529 1,045.00 35,313.61 06-06-05 CHECK NUHBER 4521 49.72 06-06-05 CHECK NUHBER 4522 47.82 35,216.07 06-13-05 CHECK NUHBER 4519 25.00 35,191.07 06-17-05 CHECK NUHBER 4523 480.65 34,710.42 06-21-05 DEPOSIT 51,365.50 06-21-05 INTEREST PAYHENT 3.24 86,079.16 ENDING BALANCE $86,079.16 I CHECKS'PAID.SUHHARY I 4519 06-13-05 25.00 4520 05-26-05 1,045.00 4521 06-06-05 49.72 4522 06-06-05 47.82 4523 06-17-05 480.65 ANNUAL PERCENTAGE YIELD EARNED = 0.10 % , STATE"'ENTPERIOD PAGE . 31003914599807 REGULAR TIHE DEPOSIT JAN.01-JUN.30,2005 1 OF 1 00 o 06128H NH 017 -- 58474 -- CHARLES R ALBRIGHT - OR JOHN R ALBRIGHT 26 GREYSTONE RD CARLISLE PA 17013-2605 HA TURITY DATE 10-17-05 CURRENT INTEREST RATE 1. 980% INTEREST PAID YEAR TO DATE 153.67 CARLISLE WEST ACCOUNT ACTIVITY POSTING DEPOSnS,IHTEREST DAILY DATE & OTHER ADDITIONS BALANCE 01-01-05 BEGINNING BALANCE $20,000.00 01-14-05 INTEREST PAYHENT 18.52 01-14-05 INTEREST PAID BY CHECK (DEBIT) 18.52 20,000.00 02-17-05 INTEREST PAYHENT 18.52 02-17-05 INTEREST PAID BY CHECK (DEBIT) 18.52 20,000.00 03-17-05 INTEREST PAYHENT 16.73 03-17-05 INTEREST PAID BY CHECK (DEBIT) 16.73 03-17-05 -RENEWED AT 1.98%, HATURES ON 10/17/05 20,000.00 20,000.00 04-15-05 INTEREST PAYHENT 33.66 04-15-05 INTEREST PAID BY CHECK (DEBIT) 33.66 20,000.00 05-17-05 INTEREST PAYHENT 32.58 05-17-05 INTEREST PAID BY CHECK (DEBIT) 32.58 20,000.00 06-17-05 INTEREST PAYHENT 33.66 06-17-05 INTEREST PAID BY CHECK (DEBIT) 33.66 20,000.00 ENDING BALANCE lrui1:l:.af11n~\ Commerce Commerce Bank/Harrisburg N.A. .Bank 100 Senate Avenue Camp Hill. PA 17011 888-937-0004 STATEMENT DATE --- --- CHARLES R ALBRIGHT 06/30/05 JOHN R ALBRIGHT --- 26 GREYSTONE ROAD CARLISLE PA 17013 0616167814 ACCOUNT NO. CYCLE-055 *** SAVINGS *** STATEMENT SAVINGS BEGINNING RATE o . 25000 I ACCOUNT NUMBER 0616167814 PP~'nous STATEME1~ BALANCE AS OF 03/31/05 .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. .. .. 14,947.28 PLUS 7 DEPOSITS AND OTHER CREDITS .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 2,238.68 LESS 2 WITHDRAWALS AND OTHER DEBITS .. .. .. .. .. .. .. .. .. .... .. "" .... 17,176.82 LESS CYCLE SERVICE CHARGE .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .... .. .. .. 2.00 CURRENT STATEMENT BALANCE AS OF 06/30/05 .. .. .. .. .. .. .. .." .... .." .. .. .. .. .. .. .. .. .. .. .. .. 7.14 NUMBER OF DAYS IN THIS STATEMENT PERIOD 91 ---------------------------------------.-------------------------------------------- *** SAVINGS ACCOUNT TRANSACTIONS *** DATE DESCRIPTION DEBITS CREDITS 04/06 DEPOSIT 513.29 04/18 DEPOSIT 513.29 05/11 DEPOSIT 513.29 05/31 DEPOSIT 480.65 06/01 SAFE DEPOSIT BOX PAYMENT 25.00 TO BRANCH 0001 BOX 000322 06/03 DEPOSIT 200.00 06/22 FORCE PAY DEBIT 17 , 151. 82 06/23 PMT ON OD ACCT 9.02 06/30 INTEREST PAYMENT 9.14 06/30 CYCLE SERVICE CHARGE 2.00 ----------------------------------------------------------------------------------- *** BALANCE BY DATE *** 03/31 14,947.28 04/06 15,460.57 04/18 15,973.86 05/11 16,487.15 05/31 16,967.80 06/01 16,942.80 06/03 17,142.80 06/22 9.02- 06/23 .00 06/30 7.14 PAYER FEDERAL 10 NUMBER 23-2324730 INTEREST PAID YEAR TO DATE 18.35 - ---------------------------------------------------- \L:./4el~ 15 *** INTEREST EARNED THIS STATEMENT PERIOD *** DAYS IN PERIOD ...... .. .. .. .. .. . .. .. .. . . .. .. . . . . .. .. . . . 91 INTEREST EARNED .... . . .. . .. . . . . . .. .. . .. .... .. . . .. .. 9.14 ANNUAL PERCENTAGE YIELD EARNED (APY) . . . . 0.25% ---------------------------------------------------- NnTF- ~t:J: DJ:VS::DCC C:lnc c:nD ,...nnnTA.~ nllp.,,-.. ._._u ",,,...,,m '* SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA MISC. NON-PROBATE PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Char\eS ~, A \b...tt This schedule must be completed and filed jf the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME Of THE TRANSfEREE, THEIR RElATIONSHIP TO DECEDENT AND THE DATE Of TRANSfER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REIII. ESTATE. VALUE OF ASSET INTEREST 'IF APPLIC!\BLE \ NUMBER 1. \=> r-u..Ob'\\-1tt \ A",i'\v.-;-\, ' Co,,,'ha.c.+ it Et:lO~q gLl L, l\/lD3t..:>.54 (00 ""'ONe.. - 5'l 1\ lo"3Lc.. ~^.A~c'W-'i ...10\..."\ 'X. A\\:)C",O""-\ ,SoN ( c.S' J'3I/z.ocs I '2. "\ I A ~ c..a..E. F' 'Ke-\-,,- e~tI\ \- 9/2.f'l'S '0'" ~,..t'~c\a'I..Jo\""1 ~" A\brtr' ' Sb~ i ~r~"Jo ~ 2.~ ( (P, () \ O. I <J jOt> (00 -0- o ~ jel j ZDc,S TOTAL (Also enter on line 7, Recapitulation) $ \ \,<tJ3lo.54 (If more space is needed, insert additional sheets of the same size) ':0069846 cc Prudential ~ Financial Discovery Preferred Annuity Prudential Annuity Service Center Annuity Transaction Comumation Page 1 of 1 P.O. Box 7960 May 31,2005 Philadelphia, PA 19176 >01572 3068827 001 092001 Investment Professional: CHARLES R. ALBRIGHT SCOTT A. MOYER 26 GREYSTONE ROAD PRUDENTIAL - PIF CARLISLE, PA 17013 150 CORPORATE CENTER DRIVE SUITE 105 CAMP HILL, PA 17011-1759 Annuity #: E0069846 Owner Name: CHARLES R. ALBRIGHT ~ Type: Non Qualified Annuitant: CHARLES R ALBRIGHT .. . _..- - For 24-hour access to your ~ - portfolio performance, investment options, current account values and other information: - == Sign on to our interactive Web site www.prudential.com ~ Or call our Automated Voice Response System at 1-888-778-2888. - For other inquiries on your Annuity Contract, contact your Investment 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. I Total Investment Value $0.00 I Investment Transaction Activity Transaction Investments * of Units! Unit Price! Val.ue! Date Interim Value MVA Account Value 05/31/2005 Transaction Type: Death Benefit Surrender The following amounts were withheld for taxes and/or deducted for applicable surrender charges from the total amount shown below: Federal Tax: $0.00 State Tax: $0.00 Surrender Charge: $0.00 Pre TEFRA Cost Basis: $0.00 Post TEFRA Cost Basis: $10,000.00 Prudential Conservative Balanced (7,424.62153) 1.56729 ($11,636.54) Transaction Total: ($11,636.54) 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 was processed. Important Messages Information regarding agent's compensation (remuneration) is available upon written request. 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 is issued by Pruco Life Insurance Company, and offered through Prudential Investment Management Services LLC, a registered broJ{er/dealer. Pruco Securities LLC is the selling broker/dealer and acted as agent in the transaction(s) listed above. All are Prudential Financial Companies. Pruco Life Insurance Company is solely responsible for its financial condition and contractual obligations. Agent 10#895602 Office #W SH - Teachers Insurance and Annuity Association l: College Retirement Equities Fund CREF 730 Third Avenue New York, NY 10017-3206 212 490-9000 Survivor Benefit Payment for: JOHN R. ALBRIGHT Full Benefit to Survivor With 20-Year Guaranteed Period Decedent Name: CHARLES R ALBRIGHT For TIAA Contract 1046905-3 - Annuity Starting Date: 06/01/05 Payment Date: 06/28/05 = - - TIAA Payment Interest Deductions Net - Contract Payment - - $555.65 - 06/01/05 ID46905-3 $1.44 $33.47 $523.62 -=-- thru Tradit iona 1 252.56 Contractual 33_47(F) = 06/01/05 Standard 303.09 Dividend - G,.and Tota 1 $555.65 $1 .44 $33.47 $523.62 - - - - - - - TIAA-CREF reports all taxable payments to the government for the year in which they are made. If you have any questions. please call our Telephone Counseling Center toll free at 1 800 842-2776. F = Federal Tax Withheld Please Keep This Statement for Your Records I Payment Amount $523.62 J REV-1511 EX+ (12-99) , '* SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Cha.r\t$ ~, A\'bC-\cSh\ Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. I.0qi\""...,S\~r- ~~~a.."1- D~.-\;'''''O Gf'A.U~ \)01..\5,00 2. \-\(JX).,...C.~ - <<O-\\, ~uAUQ..' ~ a.I -tro...d \ -ho'~ \ F.....".,~(C..\ S'e.{'v,c:-c ~c~~ 3,(,,'1"-00 '0) Ca- s~.\- .... \JQ.u.\\:: 3,440. bO c..- ") ~~-r c.c.\e.co'l, ~\~ f & ") '3 i.Jq. LfO J) \/A. Cv...--'-::,<."\o.."'\~ Cb\.4..'\..~ c.\w~>r ( lOO.-60) B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s} -6- Social Security Number(s}/EIN Number of Personal Representative(s} Street Address City State _Zip Year(s} Commission Paid: 2. Attorney Fees - 6- 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant .JOhr'\ ~. A\6('\~\- j I 2-00.00 Street Address L.'" ~r~<;\-of'\R. ed. City ca.~\ .$ \<t.- State ? A Zip 11013 Relationship of Claimant to Decedent ~l':>'t'\ 4. Probate Fees - 0- 5. Accountant's Fees iD.OO 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ <1, (PQ4.'fO (If more space is needed, insert additional sheets of the same size) ~c'''m.'''o '* SCHEDULE I l- COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~DS'eS ~, A-\ brOW Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1. 'Ke~("" e-\ VA :I:n~~c..e...Qs.1~.J ",0\- ea.('Y\,ea ?'~~ -\-0 ~ (P \. gO '\>lU \oe..~ 2- Co~."l\A'f\ 0 ('cre.. Kx orut<; ~IC\ cc\)e!'ed 6r \n~tC.nc.<... ZS-4~S""(P 3.- 1=>r~s~c..<"<4n ~~~c.. - J..JLr.<~s;~ ~~ '6.\\$ 10, 5(:H~Z( '4. A \\ s\-cJ-e.~~u..~.,ce. - \Jel-t(c..\~_ T~s.~...C<:. Qa.~d> ~\.-<-~'tO 3Qt.37 Sre S'e..\ \ \,)~~"c\<- 5. S'e"-h",,,€.\ ~<2.~6" ~ue.r+-,~e,,",,--e.j ..Qc- '-.)~..c. 4- ~4-/~'i Ec-S+ U.M. c~~ ~~.(' hc-...:::c:.<s Co v'\o1_ ~ -i"V\e.J- :;l ~.Oo &. TOTAL (Also enter on line 10, Recapitulation) $ ,\ / 3i.ff6 . '19 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) *' SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~o.\'e S '\<. A \ be \'ik\-d- \J RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not list Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 91~ (1.2)] 1. ~c>\,'-' <<. ~\\oqo r 2(0 6c-e'fs\oV\.e ~, <=3c.~ l CO 70 ~\.~\.{. rvA \L()\3~"'t(.,.oS- I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size)