HomeMy WebLinkAbout11-16-07
REV-1500 EX + (11-0O)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
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FILE NUMBER
21 -0 7 0 8 8 9
""COuNTYCOOE -YEAR- - - Nii'MBER- -
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
HORICK
DATE OF DEATH (MM-DO- Year)
PHYLLIS W.
DATE OF BIRTH (MM-DO-Year)
1 79- 2 0 - 7 1 9 3
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
09/15/2007 03/26/1925
(IF APPUCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
001. Original Return
D 4. Limited Estate
[X] 6. Decedent Died Testate (Allach copy of WIll)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12.12-82)
D 7. Decedent Maintained a Living Trust (Allach copy of Trust)
D 10. Spousal Poverty Credit (date of death between 12-31.91 and 1-1-95)
D 3. Remainder Return (dateoldeathpriortD 12.1~82)
D 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under See. 9113(A) (Allach Sch 0)
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NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
, 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
OFfOliIAL USE ONLY
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66,457.18
(8)
524,079.15
29,289.60
1 ,000.87
(11)
(12)
(13)
30,290.47
493.788.68
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
493,788.68
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15. Amount of Line 14 taxable at the spousal tax
rate. or transfers under See. 9116 (a}(1.2)
0.00 X _ (15)
493.788.68 X .045 (16)
0.00 X .12 (17)
0.00 X .15 (18)
(19)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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Decedent's Com lete Address:
STREET ADDRESS 170 PARK STREET
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CITY BENDERSVILLE
STATE
PA
ZIP
17306
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
22,220.49
1.111 .02
Total Credits (A + 8 + C)
(2)
1,111.02
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty (0 + E) (3)
4. If Line 2 is greater than Line 1 + Une 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Une 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58)
Make Check Pa able 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; ........................................................................... 0 l&]
b. retain the right to designate who shall use the properly transferred or its income; ........................................ 0 l&]
c. retain a reversionary interest; or ...................................................................................................... 0 l&]
d. receive the promise for life of either payments, benefits or care? .......................................................:..... 0 l&]
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration?............................................................................................... 0 l&]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 00
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 00
0.00
0.00
21,109.47
21,109.47
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS 1914 DOUG
CARLISLE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE IJ
/b.~
PA
ADDRESS
60 WEST POMFRET ST
CARLISLE
PA 17013
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 retum are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The ~ 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 i~posed 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. ~9116(1.2) [72 P.S. ~9116(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. ~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.
REV-1503 EX + (6-98)
.
SCHEDULE B
STOCKS & BONDS
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HORICK
PHYLLIS
W.
FILE NUMBER
21 07
0889
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
DESCRIPTION
VANGUARD BALANCED INDEX FUND INVESTOR SHARES
FUND & ACCOUNT - 0002-09885472317
2,338.217 SHARES
VANGUARD WELLINGTON FUND INVESTOR SHARES
FUND & ACCOUNT - 0021-09885472317
1,796.393 SHARES
VANGUARD PRIME MONEY MARKET FUND
FUND & ACCOUNT - 0030-09885472317
96,401.420 SHARSE
VANGUARD - CONTINENTAL BK SALT LAKE CITY UTAH CTF
CASH
VALUE AT DATE
OF DEATH
51,814.89
61,472.57
96,401 .42
49,679.50
VANGUARD - LEHMAN BROS FSB WILMINGTON DEL CTF DEP
CASH
49,833.00
VANGUARD - LEHMAN BROS BK FSB WILMINGTON DEL CTF
CASH
49,528.00
500 SHARES - KNOUSE FOODS PREFERRED STOCK CERTIFICATE NO. 17477
50,000.00
KNOUSE FOODS REVOLVING FUND CERTIFICATE NO. 68364
800.95
KNOUSE FOODS REVOLVING FUND CERTIFICATE NO. 68464
141.35
KNOUSE FOODS REVOLVING FUND CERTIFICATE NO. 66865
493.21
KNOUSE FOODS REVOLVING FUND CERTIFICATE NO. 66965
87.04
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
410,251.93
REV-1508 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
HORICK
FILE NUMBER
PHYLLIS W 21 07
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
0889
ITEM
NUMBER
1.
DESCRIPTION
ADAMS COUNTY NATIONAL BANK - ESTEEM CHECKING ACCOUNT #605174
VALUE AT DATE
OF DEATH
47,370.04
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
47370.04
REV-1510 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
HORICK
PHYLLIS
w.
FILE NUMBER
21 07
0889
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INClUoe THE NAME Of THE TRANSFEREE. THEIR RElATIONSHIP TO OECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER ATTACH A COPY Of THE oeED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPlICABLE) VALUE
1. THRIVENT FINANCIAL FOR LUTHERANS 33,002.81 100. 33,002.81
CONTRACT #50016891 A
2. THRIVENT FINANCIAL FOR LUTHERANS 19,696.91 100. 19,696.91
CONTRACT #50019050
3. THRIVENT FINANCIAL FOR LUTHERANS 13,757.46 100. 13,757.46
CONTRACT #50022891
TOTAL (Also enter on line 7 Recapitulation) $ 66457.18
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HORICK PHYLLIS
W.
FILE NUMBER
21 07
0889
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
2.
FUNERAL EXPENSES:
DUGAN FUNERAL HOME
BETHLEHEM LUTHERAN CHURCH - PATH FINDER CLASS - FUNERAL LUNCHEON
9,770.00
300.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Numbe~s)IEIN Number of Personal Representative(s)
StreelAddress
City Stale . Zip
Yea~s) Commission Paid:
2. Attomey Fees IRWIN & McKNIGHT 18,150.00
3. Family Exemption: (If decedents address is not the same as claimants. attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees REGISTER OF WILLS 444.00
5. Accountants Fees
6. Tax Retum Prepare~s Fees PATRICIA A. ROSENDALE, CPA 350.00
7. REGISTER OF WILLS - FILING FEE 30.00
8. CUMBERLAND LAW JOURNAL - ESTATE NOTICE 75.00
9. THE SENTINEL - ESTATE NOTICE 166.60
10. REGISTER OF WILLS - SHORT CERTIFICATE 4.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
29289.60
REV-1512 EX + (6-98)
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SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HORICK
PHYLLIS
W.
Include unreimbursed medical expenses.
FILE NUMBER
21 07
0889
ITEM
NUMBER DESCRIPTION
1. CUMBERLAND-GOODWILL FIRE RESCUE - AMBULANCE
VALUE AT DATE
OF DEATH
160.37
2. WEST SHORE EMS - AMBULANCE
169.33
3. WEST SHORE EMS-BLS - AMBULANCE
110.37
4. CONTINUING CARE RX - MEDICAL
164.02
5. AARP MEDICARERX PLAN - MEDICAL
396.78
TOTAL (AJso enteron line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1 000.87
REV-"" "'. '.
"
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
. PHYLLIS W. 21 07 nRRQ
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 pnclude outright s~usal distJibu1ions, and transfers under
Sec. 9116 (a) (1. )]
1. JEFFREY C. HORICK Lineal
1914 DOUGLAS DRIVE 1/5TH REMAINDER
CARLISLE PA 17013
2. JENNIFER H. BUCHER Lineal
1544 MUMMASBURN ROAD 1/5TH REMAINDER
GETTYSBURG, PA 17325
3. MARJORIE H. BOTCHIE Lineal
524 LAVINA DRIVE 1/5TH REMAINDER
MECHANICSBURG, PA 17055
4. BRIAN L. HORICK Lineal
10105 GLADSTONE STREET 1/5TH REMAINDER
SILVER SPRING, MD 20902
5. JILL H. LANZA Lineal
448 DARTHA DRIVE 1/5TH REMAINDER
DALLASTOWN, PA 17313
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 II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500COVERSHEET $
(If more space is needed, insert additional sheets of the same size)
LAST WILL A~VD TES~~~ENT OF P~YLLIS W. HORICR
I, PHYLLIS W. HORICK, of 170 Park Street,
Bendersville, Adams County, Pennsylvania, do make and
publish this my Last Will, hereby revoking and making void
all former Wills heretofore made by me.
FIRST:
I direct that my Executor or Successor
Executrix hereinafter named payout of my general estate,
collectible debts, funeral expenses, expenses of
as soon as possible after my death, all my just and legally
administration of my estate, and all estate, inheritance
and like taxes becoming due with respect to any and all
property required to be included in my gross estate for tax
purposes, regardless of whether such property passes by the
terms of the Will; and the transfer of all such property
shall be free and clear of such taxes.
SECOND:
I give, devise, and bequeath all of the
rest, residue and remainder of my estate, wheresoever
situated, in equal shares unto my children, Jeffrey C.
Horick, Jennifer H. Bucher, Marjorie H. Botchie, Brian L.
Horick and Jill H. Lanza, or their issue per stirpes.
Provided, however, that if any share would otherwise vest in
CA.WBEU. &: WHITE. P.c.
A TIORNEYS AT LAW
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R'l'TYSM.'1IQ.l'IHHn'LvANA Inu
or be distributable to issue per stirpes of a deceased
child, and if such issue are under TwentY-Five (25) years of
(7.7IJU-I2.,1
age at the time of distribution or vesting, then in lieu of
Page 1 of Will dated ~.2~_ 0 '/ ~af;:JI~
the actual vesting of the share or distribution outrighc to
said grandchild, I direct that the share of said grandchild
be held IN TRUST, with Adams County National Bank,
Gettysburg, Pennsylvania, who is to hold, administer, invest
and reinvest the funds for the following uses and purposes:
A. I direct the Trustee to create separate
shares (per stirpes) for each grandchild who would
inherit pursuant to the terms of this Will and I direct
that the per stirpes shares be administered as follows:
1. The share to be apportioned to each of
my grandchildren who shall be under Twenty-Five
(25) years of age shall be held In Trust for the
benefit of such grandchild, and all or any part
of the net income derived from the Trust for
such grandchild and all or any part of the
principal of the Trust shall be paid to or
applied for the benefit of such grandchild in
such a manner, in such intervals and in such
amounts as the Trustee, in its uncontrolled
discretion, shall deem needful or desirable for
the grandchild's welfare, maintenance, support
and education, and for medical, surgical,
hospital, or other institutional care of such
grandchild. The Trustee, if it so desires, is
specifically authorized to accumulate income
until the beneficiary of each respective Trust,
if more than one, attains age Twenty-One (21).
Page
2. When each grandchild attains Twenty-One
(21) years of age, the Trustee is directed to
distribute One-half (1/2) of the principal of
said Trust to said grandchild free and clear of
the Trust. When such grandchild attains
Twenty-Five (25) years of age, the Trustee is
directed to distribute the remaining One-half
(1/2) of the principal to said grandchild free
and clear of the Trust. After the grandchild
attains age Twenty-One (21), the net income
earned by the Trust shall be paid to the
grandchild in a manner convenient to all parties
2 of Will dated/-~(,,-Pi fJ~tt/. ~
CAMPBELL a: WHITE, P.C.
ATTORNEYS AT LAW
IlJ 8M.1'IMDUsna:r
OETI"YSaM.~VAHIA 1732'
(71'7) n.tt7I
of interest, but at least annually.
3. If any grandchild whose share is held In
Trust dies before attaining age Twenty-Five (25),
then the entire remaining principal and any
accumulated or undistributed income of his or her
share shall thereupon vest in and be delivered
and conveyed to such grandchild's brothers and
sisters, provided, however, that said shares
would be held In Trust if the brothers and
sisters were under Twenty-Five (25) or
distributed outright if over Twenty-Five (25),
for the uses and purposes hereinbefore outlined.
If a grandchild whose share is held In Trust dies
prior to age Twenty-Five (25) leaving no brothers
and sisters surviving, then his or her share
shall be distributed to my other children or
their issue per stirpes.
4. If, after a grandchild attains
Twenty-One (21) years of age, his or her Trust
should at any time have a principal amount of
less than Ten Thousand Dollars ($10,000.00), the
Trustee is authorized to distribute said amount
to the grandchild free and clear of the Trust.
B. The Trustee shall have the following powers
in addition to any other powers that might be vested in
them by law or by other provisions of this Trust.
1. The power to retain any or all of the
assets of this Trust, real or personal, including
stock, without regard to any principal of
diversification of risk.
2. The power to invest in all forms of
property, including stock, common trust funds and
mortgage investment funds, without restrictions
to investments authorized for Pennsylvania
fiduciaries, as the Trustee deems proper, without
regard to any principal of diversification of
risk.
(lInJ~JI
3. The power to sell at public or private
sale, to exchange, or lease for any period of
time, any real or personal property, and to give
options for sales, exchanges or leases, for such
Page 3 of Will dated 1'-24>-"" -/J~')t/. N~
CAMPBElL &: WHITE, P.C.
AlTORNEYS AT LAW
112I1AL:nwo..:.nan
(;ETTYJIl,'IUJ.P'EMCYLYNlIA Inzs
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prices and upon such terms or conditions as the
Trustee deems proper.
4. To allocate receipts and expenses to
principal or income or partly to each as the
Trustee, from time to time, thinks proper.
5. To compromise any claim or controversy.
6. To distribute in cash or in kind or
partly in cash and partly in kind.
7. To hold property in the name of the
Trustee without designation of any fiduciary
capacity or in the name of a nominee or
unregistered.
8. Be entitled to compensation in
accordance with its schedule of fees in effect at
the time services are performed.
THIRD:
I nominate, constitute, and appoint my son,
Jeffrey C. Horick, as Executor of this my Last Will and
Testament, provided that he survives me and qualifies as
Executor within Sixty (60) days after my death. I
expressly direct that he not be required to post bond for
the faithful performance of his duties in this or in any
other jurisdiction.
FOURTH:
In the event that my son, Jeffrey C. Horick,
does not survive me, or in the event that he fails to
qualify as Executor within Sixty (60) days after my death,
I nominate, constitute, and appoint my daughter, Jennifer
H. Bucher, as Successor Executrix of this my Last Will and
CAMPBELL" WHl"l'E. P.C.
A lTORNEYS AT lAW
111IALTDlCUI'IUEI'
oarn__......,....,ANIA ,"U
Testament. I expressly direct that she not be required to
(717)""-'111
post bond for the faithful performance of her duties in
Page 4 of Will dated 'i>-:J.'--t?t' ~~rJ#'.. -;J/~
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this or in any other ju~isdiction.
FIFTH:
I confer upon my Executor or Successor
Executrix full power and authority to sell, transfer and
convey any property, real or personal, which I may own at
the time of my death, at public or private sale and at such
time and place and upon such terms and conditions as my
Executor or Successor Executrix may determine. I further
direct that my personal representatives designated shall
have the power to make distributions in cash or in kind, or
partly in cash and partly in kind, and in such manner as
the personal representative may determine, and at the
valuations fixed by said ,personal representative.
IN WITNESS WHEREOF, I, Phyllis W. Horick, the
Testatrix, have to this my Last Will and Testament set my
~~V$+
2~~
, day of
, Two
hand and seal this
Thousand Four (2004).
~~'ff!?I~
'Phyl . s W. orick
CAMPBElL &: WHITE. P.C.
AITORNEYS AT LAW
1 n IlALn.... nIUI'
aEI'TY-..o.PDltfnLvAMA I7JU
Signed, sealed published and
declared by the Testatrix, Phyllis W.
Horick, as and for her Last Will and
Testament in the presence of us, who, at
her request, in her presence and in the
presence of each other, have hereunto
SUb~~S Witnesses.
'7~.;;(. jj{))j(1-b
(711)])"'211
Page 5 of Will dated
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COMMONWEALT~ OF P&~5YLV~~IA
55
COUNTY OF AD~.M5
ft.Te, Phyllis W.
/~/~
Horick,
~~ ~~,~
and
the Testatrix and Witnesses
respectively, whose names are signed to the attached or
foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testatrix
signed and executed the instrument as her Last Will and she
had signed willingly, and that she executed it as her free
and voluntary act for the purposes therein expressed, and
that each of the Witnesses, in the presence and hearing of
the Testatrix signed the Will as Witnesses and that to the
best of their knowledge the Testatrix was at that time
Eighteen (18) years of age or older, of sound mind and under
no constraint or undue influence.
~ ~ W~(SEPL)
Phyl s W. Hori'ck
Subscribed, sworn to and
acknowledged before me by
Phyllis W. Horick, Testatrix,
and subscribe~~nd sworn to
befO~y -f~~~~
and ~,
Witnesses this ~~~ day of
~ ,2004.
( SEAL)
R!!-t c;MI
CAMPBBU. 01: WHITE. P.C.
ATI'ORNEYS AT LAW
111.......-rnEET
~.......,..VAMA Inu
My commission expires:
COMMONWEALT OF PENNSYLVANIA
Notarial Seal
Mary Ellen Hall, Notary Public
Gettysburg Bora, Adams County
My Commission Expires June 29, 2007
Member PeJ'n!;\Jfv",,,i:> Association of Notaries
(711) JM.ft1l
Page 6 of Will dated 1- :z(,~(W fJ~ 1d ;y~
:\.:(.<02-...)
& Vanguard"
October 24,2007
p.o. Box 2600
Valley Forge, PA 19482-2600
www.vanguard.com
JEFFREY C HORICK
1914 DOUGLAS DR
CARLISLE PA 17013-1019
RE: Account Valuation
Dear Mr. Horick:
We received a request from your attorney, Irwin & McKnight, to supply them with a
Vanguard Brokerage Services@ (VBS@) account valuation for Phyllis W. Horick.
In order for us to provide account specific information to any third party, we need a
signed authorization from the executors of the estate, and their signatures must be
accompanied by a medallion signature guarantee. Please note, the authorization must
be signed in the presence of an authorized officer of a bank, brokerage firm, trust
company, or other financial institution that participates in the Medallion signature
guarantee program. Note: A notary public cannot provide a signature guarantee.
We have enclosed an account value report as of the date of death September 15, 2007.
Please feel free to forward this information to your attorney.
If you have any questions, please call VBS@ Client Services at 1-800-992-8327. One of
our associates will be pleased to assist you.
Sincerely,
VBS Client Services@
ARC/KAK
Enclosure(s): Account Valuation Report
10234474
. Vanguard"
Page > 1 of 1
Phyllis W. Horick
1914 Douglas Dr
Carlisle. PA 17013-1019
Client Services: 800-662-2739
Total report value: $209,889.75
^_..._,_,_."'____'.~,",,_^~~_.___,~__,___~_.'._,,,_._~____^V_~".__._.,,_,~__,."_.~,_,.^"~.~.~..__.~.,__._,~"'~~___~^"
(Total report value includes any accrued dividends.)
sn t include accrued
.. As of the prior business date, 09/14/2P07. since the report date is a nonbusiness day.
1721925325 10/23/2007 13:02:34
Vanguard Brokerage Services@
A Division of Vanguard Marketing Corporation
Phyllis W. Horick
Individual Account
1914 Douglas Dr
Carlisle PA 17013-1019
VBS Account AL V785385
Below is your date of death account valuation for the above referenced account
.Please nole that the value of your Vanguarde mutual fund accounts will be provided separately
Holdings Summary
Stocks Total
FundAccess Total
Bonds Total
Total Account Value:
Values on: 9/15/2007
$0.00
$0.00
Holdings
Stocks
Symbol
Quantity Price per Share
No stock held in the account.
Current Value
Total stocks
$0.00
FundAccess
Symbol
Quantity Price per Share Current Value
No FundAcceSS@ securities held in the account.
Total FundAccess
$0.00
Fixed Income Cusip Quantity Price per Share Current Value Accrued Interest
Continental Bk Salt Lake City 211163CG3 50000 $99.36 $49,679.50
UT 5.15%
Lehman Bras Wilm NC 5.15% 52521 EKC3 50000 $99.67 $49,833.00
Lehman Bros Wilm NC 5.15% 52521 EKF6 50000 $99.06 $49,528.00
Disclosure:
The fair market value of the individual equity securities is calculated using the average between the highest and lowest quoted price of the securities on the valuation date. If the valuation
date falls on a weekend or holiday, a weighted average of the highest and lowest prices on the nearest business days before and after the valuation date is used. Mutual Fund Securities
are valued uSing the doSing price of the funds on the valuation date. If the valuation date falls on a weekend a weighted average of the dosing prices on the nearest business days
before and after the valuation date is used. Fixed Income Security (Bonds) valuations vary by type. Please consult the VBSe Bond Desk for specific inquiries.
Page 1 of 1
\ KNOUSE
FOODS
Knouse Foods Cooperative, Inc.
800 Peach Glen - Idaville Road
Peach Glen, Pennsylvania 17375-0001
Tel: (717) 6n-8181
Fax: (717) Sn-7069
Web Site: www.knouse.com
October 5, 2007
Roger B. Irwin, Esquire
Irwin & McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
~~Iu'r~
OCT 1 0 2007
Re: Phyllis W. Rorick
K.F.#32060; S.S. # 179-20-7193
Your letter dated September 26, 2007
IRWIN & McKNIGHT
Dear Mr. Irwin:
Please be advised that on September 15,2007 the following Knouse Foods@ stock and revolving
fund certificates were held by Phyllis W. Rorick:
Face Value
Preferred Stock Certificate No. 17477 (500 shares) $ 50.000.00
Revolving Fund Certificate No. 68364
Revolving Fund Certificate No. 68464
Revolving Fund Certificate No. 66865
Revolving Fund Certificate No. 66965
$ 800.95
141.35
493.21
87.04
$ 1.522.55
There were no dividends or interest owing on September 15, 2007, the date of Mrs. Rorick's
death.
Please feel free to contact us if you have any questions.
Very truly yours,
KNOUSE FOODS COOPERATIVE, INe.
'l7kLo9'~~
Mary J. Myers
Assistant Secretary
...
~
ADAMS
COUNlY
NATIONAL BAt'\fK
l~~~~'
IIl'WlN & McKNIOHl
October 5,2007
LAW OFFICES OF IRWIN & MCKNIGHT
AITN: ROGER B IRWIN
60 W POMFRET ST
CARLISLE P A 17013
Re: Estate of PHYLLIS W HORICK
Dear Mr. Irwin:
The following information is being provided as per your request:
Acct. Type Account No. Account Accrued Ownership Date
Principal on Interest to Opened
D.O.D. D.O.D.
Esteem 605174 $47,161.52 $2.83 Individual 4/1/87
Checking
Account
Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5122.
Sincerely,
~
. Barbara J Warn
Adams County tional Bank
Deposit Services Representative II
7vt.A-.
PO Box 3129, GETTYSBURG, PA 17325 I PHONE 717.334.3161 I TOll FREE 888.334.2262 I www.acnb.com
~ \f Thrivent Financial for Lutherans"
Michael P. Smith, M.B.A., FIC
Financial Consultant
Regiona I Management Associate
michael. p.smith@thrivent.com
Million Dol/ar Round Table
Member - NAFIC
101 S. US Highway 15, Suite B
Dillsburg, PA 17019
Office: 717-502-11 00
Toll-free: 877-674-" 00
Fax: 717-502-1119
October 5,2007
Irwin & McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
\JP'Ylt8
OCT 1 1 2007
Dear Karen:
lRWIN& McKNIGHT
Please find the documents you requested for the Estate of Phyllis Horick. Feel free to
contact the office with any questions. Let me know if you need me to speak directly
with any of the beneficiaries.
Thank you,
A{~az
Michael P. Smith, MBA, FIC
Financial Consultant
South Mountain Group
MPS: rm
Enclosure (7): Death Claim Kit
Main Offices: Appleton, Wisconsin, and Minneapolis, Mlnnesata . www.thrivent.cam
Registered representative for securities offered through Thrivent Investment Management Inc., 625 Fourth Ave. 5., Minneapolis, MN 55415-1665, 800-847-4836,
a wholly owned subsidiary of Thrivent Financial for Lutherans. Member NASD. Member SIPC.
\PThrivent financial
for Lutherans™
Death Claim Service Kit
Deceased: Phyllis W Horick
1914 Douglas Dr
Carlisle PA 17013-1019
Date of Death: 09/15/2007
Date Prepared: 10/03/2007
Claim Number: 393981
This death claim service kit will provide you with the details and requirements needed to enable this
claim to be reviewed. Included with the kit is:
· Claim quotes for amounts on all inforce life, annuity or settlement agreement contracts.
· A list of forms that are required for this claim review.
· Any special instructions or messages related to this claim.
Contract Issue Date Product Type
S0016891A --...--------- Settlement Option
S0019050 --------- Settlement Option
S0022891 ------------ Settlement Option
Additional information:
1. All beneficiaries in receipt of a Death Claim are now eligible for membership with Thrivent Financial
for up to one year after receipt of the proceeds. After that, if they are not otherwise eligible, they
would not be eligible for membership. If no product is purchased at the time the claim is submitted,
beneficiaries are still eligible to apply for membership through the family associate membership
offer, and for the first year the $10 fee is waived. You may either complete the application available
in the Experience the Membership Difference Brochure (20760), or 15659 available on CAP. On
the application please include the letters DC at the top of page 1 to indicate the death claim and we
will waive the fee. For information about the family associate membership call (800) 847-4836, ext.
85909.
2. OP Rachel Miraglia called in death.
3. MASC B2011340: Guaranteed payment period expired, no death benefit payable.
4. FOR OFFICE USE ONLY: Core
5. EXPECTATIONS FOR CLAIM SERVICE:
Within 10 days of receipt of this claim kit, please contact the beneficiary to provide a claim form and
explain payment options. This is to comply with the National Association of Insurance
Commissioners (NAIC) Model Unfair Claim Settlement Practices. The claim decision can be made
at a later date.
If you do not have information to locate the beneficiary, contact the funeral home, family members,
individuals who may know the person, or the church to try to locate the beneficiary. We do not
expect you to go beyond these contacts. If you need assistance, the Death Claims Staff is here to
help you.
Please communicate with us so our records are current. We need to keep our file records current
Page 1 of6
Deceased's Customer 10: 507358528
and accurate to meet state claim practice requirements.
At FieldNet, enter Death Claim without the quotes in the Search for helpful information to assist you
in serving our members and beneficiaries with a life insurance or annuity claim.
If you are a beneficiary or an attorney assisting the beneficiary and you have questions, please call
1-800-847-4836. If you are a Thriventfinancial associate and you have questions, please call 1-888-
422-5737 or send an e-mail to the subject mailbox 'Death Claims'.
The financial associate who will be helping with this claim is:
MICHAEL P SMITH
STEB
101 S US HIGHWAY 15
DILLSBURG PA 17019-1554
Contact: 717-502-1100
Page 2 of6
Deceased's Customer 10: 507358528
\PThrivent Financial
for Lutherans™
Death Benefit Information
Mpls Settlement Option Contract: S0016891A
Deceased: Phyllis W Horick
Date of Death: 09/15/2007
Date Prepared: 10/03/2007
Claim Number: 393981
Death Benefit
Cost Basis
Taxable Gain
$
$
17,638.72
15,364.09
Total Death Benefit
$
33,002.81
Beneficiary Designation
Base Coverage:
Primary: Jeffrey C Horick, Jennifer H Bucher, Brian L Horick, Ma~orie H Botchie, Jill H Lanza, Child(ren)
Special Messages
1. IMPORTANT TAX REQUIREMENTS: Each beneficiary will be subject to federal income tax
withholding for their share of the taxable gain. Each beneficiary needs to complete the substitute
W-4P section on the Claimant's Statement. If NO withholding is desired, the first section in the
substitute W-4P should be checked. If the beneficiary DOES want withholding, the appropriate
section should be completed.
2. Beneficiary payment options for MASC contracts are 1.) Cash and be taxed immediately on the
entire gain portion of death proceeds; 2.) Continue payments for the remainder of the contract's
guaranteed payment period; or 3.) Apply the commuted death benefit amount to a new settlement
option that cannot exceed the remaining guaranteed period set up under the original MASC
contract.
If option 2 (continue payments) is chosen for a MASC contract, and the MASC contract is a life
income agreement, the cost basis will be distributed first and gain distributed last. Tax gain is
reported to the IRS in the year of distribution. Cost basis first-tax - gain last is sometimes referred to
as cost basis recovery or death pay continuation. If the MASC contract is a fixed period installment
agreement the payments will be made on a pro-rated basis.
Page 3 of 6
Deceased's Customer 10: 507358528
\1J Thriven! Financial
for Lutherans™
Death Benefit Information
Mpls Settlement Option Contract: 50019050
Deceased: Phyllis W Horick
Date of Death: 09/15/2007
Date Prepared: 10/03/2007
Claim Number: 393981
Death Benefit
Cost Basis
Taxable Gain
$
$
14,433.56
5,263.35
Total Death Benefit
$
19,696.91
Beneficiary Designation
Base Coverage:
Primary: Jeffrey C Horick, Jennifer H Bucher, Brian L Horick, Marjorie H Botchie, Jill H Lanza, Child(ren)
Special Messages
1. IMPORTANT TAX REQUIREMENTS: Each beneficiary will be subject to federal income tax
withholding for their share of the taxable gain. Each beneficiary needs to complete the substitute
W-4P section on the Claimant's Statement. If NO withholding is desired, the first section in the
substitute W-4P should be checked. If the beneficiary DOES want withholding, the appropriate
section should be completed.
2. Beneficiary payment options for MASC contracts are 1.) Cash and be taxed immediately on the
entire gain portion of death proceeds; 2.) Continue payments for the remainder of the contract's
guaranteed payment period; or 3.) Apply the commuted death benefit amount to a new settlement
option that cannot exceed the remaining guaranteed period set up under the original MASC
contract.
If option 2 (continue payments) is chosen for a MASC contract, and the MASC contract is a life
income agreement, the cost basis will be distributed first and gain distributed last. Tax gain is
reported to the IRS in the year of distribution. Cost basis first-tax - gain last is sometimes referred to
as cost basis recovery or death pay continuation. If the MASC contract is a fixed period installment
agreement the payments will be made on a pro-rated basis.
Page 4 of 6
Deceased's Customer 10: 507358528
\P Thrivent Financial
for Lutherans™
Death Benefit Information
Mpls Settlement Option Contract: 50022891
Deceased: Phyllis W Horick
Date of Death: 09/15/2007
Date Prepared: 10/03/2007
Claim Number: 393981
Death Benefit
Cost Basis
Taxable Gain
$
$
8,737.00
5,020.46
Total Death Benefit
$
13,757.46
Beneficiary Designation
Base Coverage:
Primary: Jeffrey C Horick, Jennifer H Bucher, Brian L Horick, Ma~orie H Botchie, Jill H Lanza, Child(ren}
Special Messages
1. IMPORTANT TAX REQUIREMENTS: Each beneficiary will be subject to federal income tax
withholding for their share of the taxable gain. Each beneficiary needs to complete the substitute
W-4P section on the Claimant's Statement. If NO withholding is desired, the first section in the
substitute W-4P should be checked. If the beneficiary DOES want withholding, the appropriate
section should be completed.
2. Beneficiary payment options for MASC contracts are 1.} Cash and be taxed immediately on the
entire gain portion of death proceeds; 2.} Continue payments for the remainder of the contract's
guaranteed payment period; or 3.} Apply the commuted death benefit amount to a new settlement
option that cannot exceed the remaining guaranteed period set up under the original MASC
contract.
If option 2 (continue payments) is chosen for a MASC contract, and the MASC contract is a life
income agreement, the cost basis will be distributed first and gain distributed last. Tax gain is
reported to the IRS in the year of distribution. Cost basis first-tax - gain last is sometimes referred to
as cost basis recovery or death pay continuation. If the MASC contract is a fixed period installment
agreement the payments will be made on a pro-rated basis.
Page 5 of6
Deceased's Customer ID: 507358528
\P Thrivent Financial
for Lutherans™
Forms and Other Requirements Needed to Pay Death Claim
Deceased: Phyllis W Horick
Date of Death: 09/15/2007
Date Prepared: 10/03/2007
Claim Number: 393981
The required forms to evaluate this claim are listed below. If a claim investigation is necessary and
payment of the proceeds will be delayed, you will be notified.
To avoid delays, complete the correct form for the correct beneficiary.
Required Fonns:
1. Claimant's Statement(Form 28E). One per beneficiary.
2. Certified death certificate that includes the cause and manner of death for the insured and a death
certificate for any predeceased beneficiary(s).
3. Dated newspaper account (obituary) of the death when possible.
4. If the beneficiary wishes to use the claim proceeds to purchase a Thrivent Financial for Lutherans
product, the appropriate application needs to be completed and submitted.
5. If a Power of Attorney (POA) is signing on behalf of a named beneficiary, please submit a copy of
the POA document.
6. We recommend that you review any contracts the beneficiary may hold to verify their beneficiary
designations are current and valid.
Page 6 of6
Deceased's Customer 10: 507358528
Irhrivent 10
5u,3S?5z..7
\P thrivent financial for LutheransfJ
4321 N. Ballard Road, Appleton, WI 5491 9-0001
800-THRIVENT (800-847-4836) · www.thrivent.com
Instructions: Complete Section A, B, and the Authorization for Information Regarding a Deceased Person if the insured held a
life contract and one of the following conditions apply: (a) the death was the result of injury or trauma; or (b) the death occurred
within two years of any contract change of the death benefit; or (c) the life insurance contract is contestable.
_ If the above conditions do not apply and the insured held a life contract, complete the Claimant's Statement for Life Contracts.
- If no life insurance, complete the Claimant's Statement for Annuity, Settlement AgreemenUMASC.
-If both life and annuity, complete the Claimant's Statements for Life and Annuity.
Deceased's Information Statement
Name of deceased (print title, first, middle, last name and suffix, as applicable)
Ph Ilis W. ~1c.L
Resi ential street address of deceased ity I' "\
L-Qr ,s t..
I q I L/ /JOUj I a S 1r .
Date of birth (mm/dd/yyyy)
3/&) rq'l.CS
Date of reath Place of death
~ 115 2-00"1 Cumbu lal\d Croir/{1
!Sectlofi's:~rdom;lit 3i16wW""fnfo'.......'atf3n(t
"....(>'.,....,......,.,........,...'''...'",'.".,....... ..p, "..... ."..,.,.,."."...."..$l,.,w,;........"rm.........:.,.,.......,,,.:,.,..
List Physician(s) Consulted for Last Illness
IP code
1/01 ~ -lb\C1
Cause of death
fJa fu.r a ( (!a~t.-J
e'clalrifto ~8fficientr;::eva
Y' .,.....,.....:'". ,.,'.y' .'. ...y,. .'.'. .'"
Name, Address and Phone Number
Date deceased first
complained of or gave
indication of last illness
Date deceased first
consulted medical
practitioner for last illness
List Physicians Who AttendedlTreated Deceased and All Hospitals Where Treated During Past Three Years
Name, Address and Phone Number Dates of Visit Disease or Condition Treated
28E R10-06
Authorization for Information Regarding a Deceased Person
(This authorization complies with the HIPAA Privacy Rule)
This authorization applies to Thrivent Financial for Lutherans, Thrivent Life Insurance Company, and Thrivent Insurance
Agency, Inc., their employees, representatives, agents, reinsurers and any other persons performing business, legal, medical
or insurance services for them or on their behalf, hereafter called "You" or "Your."
For the purpose of evaluating and processing my claim for insurance benefits, You may need to obtain, use or disclose
any and all physical and mental health information, including but not limited to services for preventive, diagnostic and
therapeutic care, tests, counseling and medical prescriptions; and non-health infoprnation, includi~g but not limited to
financial, insurance, credit, ojCUpational, avocational and drivi~ history aboutn~llii 0, HD(,(.L
deceased, date of birth 3/ lJ 1'\ 'L l , date of death ~ ':\/2-0<::" .
f ' f I
I authorize any health care professional, medical facility, mental health facility, laboratory, paramedical facility. medical
examiner, pharmacy, medical records service. prescription history clearinghouse, other financial institution, Your affiliate,
health care component of Your company, Department of Motor Vehicles, Social Security Administration, consumer reporting
agency, Medical Information Bureau (MIS), Health Claim Index (HCI), employer, case manager, social worker, financial
advisor, attorney, family member, and acquaintance to provide information about the above-named deceased person,
including the entire medical record, to You.
Information about the health of the deceased person may be released as required or permitted by law. such as to the
Medical Information Bureau (MIB) in an effort to deter fraud, misrepresentation or criminal activity. This health information.
which is used or disclosed pursuant to this authorization, may be subject to redisclosure by the recipient, and may no
longer be protected under federal law. I authorize you to share any information concerning this claim with Your affiliates
for purposes of processing a death claim or changing registration on accounts. I understand this information will not be
disclosed to non-affiliated third parties that are not conducting speCific business activities for or on behalf of You.
This authorization is valid for 24 months following the date of my signature shown below. A copy, image or facsimile of this
authorization is as valid as the original. I have the right to revoke this authorization in writing as outlined in the Privacy of
Information about Your Health notice. I acknowledge that such a revocation is not effective to the extent You have relied on
the use or disclosure of health information or to the extent that You have a legal right to contest the insurance contract or
my claim under the insurance contract.
I understand You may not be able to evaluate and/or process my claim for insurance benefits if I do not agree to the terms
of this authorization. I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my
signature below. I am entitled to receive a copy of this authorization.
Signature of claimant and date signed (mm/dd/yyyy)
Description of claimant's authority to act or
relationship to deceased
Note: This authorization is required when:
1 . A life insurance contract has been in force for two years or less, or;
2. There is an accidental death benefit rider on the contract, or;
3. In any situation involving unusual circumstances of death.
If additional information is needed, Thrivent Financial for Lutherans will obtain it or contact a beneficiary for it. In either case,
it is likely to take additional time before a final claim decision can be made and communicated.
Proceed to Claimant's Statement for Life Contracts.
28E R10-06
\P Thrivent Financial for Lutherans~
4321 N. Ballard Road, Appleton, WI 54919-0001
. 800-THRIVENT (800-847-4836) · www.thrivent.com
hrivent ID
5'0135852-7
Claimant's Statement for Annuity, Settlement AgreementlMASC
$~on 1.f#.....~.[)eceasecl. .lnfonnation...ReqlJireafl)r'A"rilJjtY;$~lerriQIl,Agreer1l~ratlMA$Ci'c;laim~
Name of deceased (print title, first, middle, last name and suffix, as applicable) Oat of birth (mm/dd/yyyy)
h H'd W, tb-it,.L 3 ~ Iq?'5
S~i()n..i2A'AClairri&ll'ltl."f'qi'l'hjtion..4l{eqUireCt.'forAI[C;Jaim~'.i..~<~.p~ratij'forrn.'iilsi.l'le8cIecl. forea~h..ijJ'l1efi~ijrv;.i..i'.'.i
In what capacity are you claiming these proceeds? Relationship to deceased
o Trustee 0 Executor/Administrator of estate 0 Other
o Named beneficiary 0 Legal Guardian for named beneficiary (attach explanation)
Name of claimant (print title, first, middle, last name and suffix, as applicable) Date of birth (mm/dd/yyyy)
City
~$~ioni'3A~::cOl1:f let.e tfd$SQctJoniari'd: $~j~n$ :4AatiC(5A:(Qr;AhriijltY;'Se~lementAgreemenfJMASc'Ctajms:::Ji' ....
Annuity or Settlement Agreement contract number(s)
Residential street address of claimant
tate
IP code
rea code and phone
Note: A Claimant's Distribution Request for each Variable Annuity Contract must be for the total value of that contract
payable to that Claimant.
Annuitant Exchange/Spousal Beneficiary Option is
Available - ONE BOX MUST BE CHECKED for each contract
and the contract number written on the corresponding line:
o Exercise Annuitant Exchange/Spousal Beneficiary
Option for:
Contract number(s) -
Complete Annuitant Exchange/Spousal Beneficiary
Option (form 11997) and Beneficiary Designation
(form 307).
o I choose not to exercise the Annuitant Exchange/
Spousal Beneficiary Option for:
Contract number(s) -
o Spousal Beneficiary Rollover to a New or
Existing - IRA to IRA, TSA to TSA, QRP to QRP.
Complete Transfer/Direct Rollover/Conversion
Request (form 11502).
Contract number-
o Non-spouse IRA to IRA Transfer (or TSA to TSA
Transfer), also referred to as Inherited IRAs. Complete
Transfer/Direct Rollover/Conversion Request (form 11502).
Contract number-
o Apply to Settlement Option. Complete Application
for Settlement Agreement (form 9368) and a form
W4P for the Settlement Option.
o Apply to Thrivent Financial Mutual Fund
o New 0 Existing Mutual Fund
Account number-
28E R10-06
o Apply premium payment to:
o Life 0 Health 0 Annuity
Contract number -
o Apply loan payment to:
Contract number(s) -
o Continue payment on existing Mpls settlement
option. Complete Beneficiary Designation (form 307).
o Other (See Special Instructions on next page.)
o Cash - complete for a total or partial cash disbursement.
o Lump Sum
o Specific Amount - $
Interest will be added to this amount unless
instructed otherwise.
Select one of the following:
o A. Open a Thrivent Financial Bank Benefit Management
Money Market Account (See next page.)
Would you like a form sent to you to designate a
beneficiary for this account? 0 Yes 0 No
o B. Deposit in an existing or other Thrivent Financial
Bank account.
Account number -
o C. Direct deposit into another account
Attach a voided check. Do not submit a deposit slip.
o D. Send the check to financial representative.
DE. Send the check to the beneficiary.
Name of claimant (print title, first, middle, last name and suffix, as applicable)
In compliance with Federal law, you are required to provide your name, residential street address, date of birth, and
identification number (as indicated on page 3 of this claim form) in order to establish an account with Thrivent Financial Bank.
We may require other information that will allow us to identify you.
A Benefit Management Money Market account will be opened for you with the full or partial share of your proceeds provided
that (1) your claim is approved; (2) you do not request an alternate method of payment; (3) applicable state regulations do not
limit the availability of this payment option.
By signing this Claimant's statement and completing section 3 or 4, as applicable, you acknowledge that you are opening
a new account with Thrivent Financial Bank as a single party and that subsequent to your account being opened, along with
your personal checks, you will receive an information kit containing our Privacy Notice, Funds Availability Disclosure,
Electronic Funds Transfer Disclosure, Deposit Account Agreement, Truth-in-Savings Account Disclosure, and Fee Schedule
(Disclosures). In addition, you will have the option to designate a beneficiary for this new account.
You certify that (a) everything stated on this application is true and correct to the best of your knowledge; (b) Thrivent
Financial Bank is authorized to make inquiries from any consumer reporting agency, including a check protection service,
in connection with this account; and (c) you are over the age of majority.
You acknowledge that if this account is approved, the account will be governed by the applicable federal laws and regulations,
and the laws of the State of Wisconsin. You acknowledge that you agree to be bound by the terms of the Deposit Account
Agreement. Rates, as well as the Deposit Account Agreement and Disclosures are available on the bank's website at
www.thriventbank.com or by calling toll-free (866)226-5225. Your account will earn interest from the day the deposit is made
and for as long as account minimums are met.
Your account will be opened when the deposit application has been accepted by the bank. You may then immediately use
all or a portion of these funds by writing checks against your account. All checks and checking services are provided to you
free of charge if account minimums are maintained and transaction limits, outlined in the Truth-in-Savings Disclosure, are not
exceeded.
On the date of death, if the deceased was past the Required Begin Date (RBD), RMD federal tax rules apply when any
monies, including death proceeds, are payable from an IRA, TSA or other pension plan. The RBD is April 1 the year after the
annuitant attained age 701/2.
RMD for the year of death is required to be distributed prior to any tax free movement of funds or prior to December 31 in the
year of death (whichever is the earliest).
Unless the box below is checked, RMD will not be released.
o Distribute my RMD to me before completing my request. Claimant is responsible for complying with RMD requirements.
I acknowledge that if the distribution from the above plan is an eligible rollover distribution and is not a direct rollover to a
qualified retirement plan or IRA, the taxable amount of the distribution will be subject to 20% income tax withholding.
I understand that the 20% income tax withholding will not apply if I roll over the taxable amount of the distribution to a
qualifiedretirement plan or IRA. I also acknowledge that I have received and read the 403(b) and Qualified Plan Distribution
Disclosure form (9972). I acknowledge that I have the right to delay making a decision regarding the distribution from the
above plan for at least 30 days after receiving the 403(b) and Qualified Plan Distribution form and have been given this
opportunity. I hereby elect to waive my right to the 30 day waiting period and request Thrivent Financial to make this
distribution as soon as administratively possible. Due to the tax consequences, I have been advised to seek competent tax
advice pertaining to this distribution.
28E R10-06
Name of claimant (print title, first, middle, last name and suffix, as applicable)
,
"S~ion 5A - Substitute W-4P. Compl$te this section only for claims for death proceedsfrom annuity cOntracts Or
$taftl$ment agreement contracts.
The distribution you are requesting from your contract(s) with Thrivent Financial will be subject to income tax withholding
unless you elect not to have an amount withheld. Withholding is completely voluntary. Withholding generally applies
to the portion of the distribution that is subject to federal income tax. All or part of the distribution may be subject to
federal income tax.
You may elect not to have withholding apply to the distribution by signing and dating the election below. If you do not sign
the election, federal and possibly state income tax will be withheld from the taxable portion of the distribution. If you elect
not to have withholding apply to the distribution, you may be responsible for the payment of estimated taxes. There are
penalties for not paying enough tax during the year, either through withholding or estimated tax payments. You may wish
to check with your tax advisor to determine if withholding is necessary.
If no box is checked, federal (10%) and possibly state income tax will be withheld.
Federal Tax Withholding:
o Do not withhold for federal income tax.
o Withhold federal income tax at a rate of 10%, or as noted % (must be at least 10%).
State Tax Withholding: (Not allowed in AK, FL, HI, NV, NH, SO, TN, TX, WA, and WY.)
North Carolina residents: If you are electing not to have withholding on your distribution, Form NC-4P is required.
o Do not withhold for state income tax.
o Withhold the applicable state income tax rate, or as noted %.
Taxpayer Identification Number Certification
I certify under penalties of perjury that:
1. The Social Security Number or Taxpayer Identification Number provided is correct (or I am waiting for a number to be
issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to
report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding and
3. I am a U.S. person (including U.S. resident alien).
You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
Signature of claimant and capacity (Le. trustee, guardian, etc.) and date signed (mm/dd/yyyy) ocial Security/Tax 10 #
Name of Thrivent Financial representative
MIcl1c.~ { t' Jrnl ft.
FOR YOUR PROTECTION, state laws require the following to appear on this form: Any person who knowingly
and with intent to defraud or deceive any insurance company or person files or facilitates the filing of a
statement of claim containing any materially false information, or conceals information concerning any fact
material to the statement, is guilty of insurance fraud, which may be a felony crime, subject to civil penalties
or criminal prosecution, including fines and/or confinement in prison.
If you have questions regarding the claim form, please contact your Thrivent Financial Representative or call Death Claims
at 1-800-847-4836.
ode number
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Mail completed form to: Thrivent Financial for Lutherans, 4321 N. Ballard Road, Appleton, WI 54919-0001
28E R10-06