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HomeMy WebLinkAbout03-06-13 (2)J 150561D143 REV-1500 Ex(°2_"' PA Department of Revenue OFFICIAL USE ONLY Pennsylvania County Code Year File Number Bureau of Individual Taxes DENIRTNENTOF NEYENUE PO 60X.280601 INHERITANCE TAX RETURN 21 12 07 61 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 06 24 2012 05 16 1927 Decedent's Last Name Suffix Decedent's First Name MI KENNEDY DOROTHY M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW 1. Original Return ^ 2. Supplemental Return ^ 3, Remainder Return (Date of Death Prior to 12-13-82) ^ 4. Limited Estate ^ qa, Future Interest Comppromise 5. Federal Estate Tax Return R ulred (date of death after 12-12-82) ^ ~i g Decedent Died Testate (Attach Copy of Will) ^ ~ Decedent Maintained a Living Trust 1 (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ 10• b6tvieenl2 31 ~1 a dit~Da95~ f Death ^ 11.Election to tax under Sec. 9113(A) (Attach Schedule O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numbed WM D SCHRACK III ESQ 717 43~' 9733 ~ ~ ~ .. -~, _ First Line of Address State PA ZIP C d REGISTEFtOF~1~'II~}5 US&UNLY, •,:~ r ~"" ~ --~ _ rn " ~ ;XT CTj r,1 . _ r,~ I, ~w ~ y ^ Art c.. ~ ~.._, . - m.~ , t _ . i .. t..., r.._ DATE FILED 124 W HARRISBURG STREET Second Line of Address City or Post Office DILLSBURG oe 170191268 Correspondent's a-mail address: SChraCklaW@COn1C1St.net Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ...__ 2525 Bretz Drive Enola PA 17025 SIGNATURE9F'fsR ,F@.Bi+f~R THAN REPRESENTATIVE Harrold A. Bretz ~ ~~~' ~~-~ Wm. D. Schrack Esq. 124 W. Harrisburg Street, Dillsburg, PA 17019-1268 Side 1 1505610143 1505610143 J REV-1500 EX oecaaent•s Name Kennedy, Dorothy M. Decedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ...................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages 8~ Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 274 , 7 $3 , 61 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous Ikon; Probate Property (Schedule G) Se r t Billi R u pa a e ng equested............ 7. 8. Total Gross Assets (total Lines 1 through 7) ........................................................ g, 2'7tj ~ '783 , 61 9. Funeral Expenses and Administrative Costs (Schedule H) .................................... 9. 37 , 398.66 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............................ 10. 2 , 354 , 42 11. Total Deductions (total Lines 9 and 10) ................................................................ 11 3 9 , 7 53.0 8 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 235 , 030.53 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 23 , 503.05 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14. 211. , 52 7 . 4 8 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 15. Q , 00 16. Amount of Line 14 taxable at lineal rate X .045 0. 0 0 16. 0, 0 0 17. Amount of Line 14 taxable at sibling rate X .12 105 , 7 63.74 17. 12 , 691.65 18. Amount of Line 14 taxable at collateral rate X.15 105, 763.74 18. 15, 864.56 19. TAX DUE ................................................................................................................ 19. 28,556.21 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 1505610243 Side 2 1505610243 1505610243 J Rev-1508 EX+I~~_~0) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA% RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Kennedy, Dorothy M. 21-12-0761 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntlyownodwlth the right of survlvonhlp must be dtaclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Cash on hand (face value) 14.50 2 Belco Community Credit Union -Savings Account #000001130050001 4,942.67 3 Apartment furnishings (see attached exhibit) 2,514.00 4 Messiah Lifeways (refund of amortized acquisition fee) 29,625.00 5 Belco Community Credit Union -IRA Account #0000011300-S0100 5,959.33 6 CUNA Brokerage Account Statement 6CQ-493585 109,944.38 7 CUNA Mutual Group Policy Number 000048008425 72,258.26 8 Lincoln Benefit Life Original SureHorizon Fixed Annuity #LBF1172635 (New SureHorizon 49,525.47 Annuity #AC1122102A) TOTAL (Also enter on Line 5, Recapitulation) I 274,783.61 (If more space is needed, additional pages of the same size) Copyright {c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 11-10) REV-1151 EX+ (10-09) SCHEDULE H COMINwEf,ANCEO~AXRETURNANIA FUNERAL EXPENSES AND SIDE DE EDEN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Kenned , Doroth M. 21-12-0761 Decedent's debts must be reported on Schedule I. ITEM N DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Malpezzi Funeral Home 13,247.22 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Harrold A. Bretz Street Address 2525 Bretz Drive City Enola State PA ZiD 17025 Year(s) Commission Paid 2013 2. Attorney's Fees Wm. D. Schrack III Esq. 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State ZiD Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 11,190.00 11,500.00 365.50 1,095.94 TOTAL (Also enter on line 9, Recapitulation) I 37,398.66 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Kennedy, Dorothy M. 21-12-0761 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex enses 1 Malpezzi Funeral Home 13,247.22 H-A 13,247.22 2 Personal Representative Commissions Harrold Bretz 11,190.00 H-B 1 11,190.00 3 Attorney Fees Wm. D. Schrack III, Esquire 11,500.00 H-62 11,500.00 Probate Fees 4 Register of Wills 365.50 H-B4 365.50 Other Administrative Costs 5 Cumberland Law Journal -estate advertisement 75.00 6 Messiah Lifeways emergency call -last illness 61.86 7 Miscellaneous expenses during administration (postage, faxes, copies, etc.) 30.00 8 PPBL -electric service while cleaning out apartment 30.39 Copyright {c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Kennedy, Dorothy M. 21-12-0761 ITEM NUMBER DESCRIPTION AMOUNT 9 Register of Wills and Clerk of Orphans' Court -additional Short Certificate 20.00 10 Reserve for future administrative expenses 750.00 11 The Patriot News Company -estate advertisement 127.38 12 Verizon -phone while cleaning out residence 1.31 H-B7 1,095.94 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX*(12-OB) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kenned , Doroth M. 21-12-0761 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimburead medical sxpenaea. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Belco Community Credit Union -VISA Credit Card Account #0000011300-L0014 191.70 2 Messiah Lifeways Residential Living -debt of decedent 1,121.00 3 Messiah Lifeways Residential Living -debt of decedent 610.90 4 Messiah Lifeways Residential Living -debt of decedent 400.00 5 PP&L (electric bill) -debt of decedent 5.20 6 Verizon (phone bill) -debt of decedent 25.62 TOTAL (Also enter on Line 10, Recapitulation) I 2,354.42 (If more space is needed, additional pages of the same size) Copyright (c) 2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+ (01.10) SCHEDULE J COMIN~JESIDAENTEDECEDENTR~VANIA BENEFICIARIES ESTATE OF FILE NUMBER nennea , ~vrotn m. ~ 21-12-0 761 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$) I • TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 .See attached schedule Total Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 150 0 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 Messiah Village Endowment Fund 23,503.05 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 23,503 05 Copynght (c) 2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 01-10) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Dorothy M. Kennedy 06/24/2012 204-22-2560 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) .~ narroia A. tsretz Friend 17% of residuary estate 2525 Bretz Drive Enola, PA 17025 2 David G. Stover Brother 15% of residuary estate 19 Stony Run Village Denver, PA 17517 3 Joshua K. Stover Nephew 14% of residuary estate 5054 Hill Road Mohnton, PA 19540-9118 4 Kerry G. Stover Brother 15% of residuary estate 252A S. Sterley Street Reading, PA 19607 5 Martha C. Worthington Sister 15% of residuary estate 2490 Trentwood Blvd. Orlando, FL 32812 6 Michele U. Yost Niece 14% of residuary estate 1880 Long Level Road Wrightsville, PA 17368 1 Bill\CLIENTSIKENNEDY, DorothylWill 82004 ~rxs# i.C.C ttxr.~ (`~est~tmext# OF DOROTHY M. KENNEDY BE I'I' REMEMBERED, that I, DOROTHY M. KENNEDY, an unremarried widow, of 752 Oak Oval, Mechanicsburg, Cumberland County, Pennsylvania 17055-8408, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that my hereinafter named Executor pay all my just debts, my funeral expenses, and the expenses of the administration of my estate. With this direction, I authorize and empower my Executor to expend for my funeral expenses and interment such amounts as may be considered necessary and proper, without regard to any limit that may be prescribed by a court of law. i _. ~, ITEM 2: I direct my Executor to pay all inheritance, estate, succession, and legacy taxes '' ;~~. of whatsoever nature and kind, to which my estate, or the transfer of any property passing hereunder ~ ~.y or otherwise passing by reason of my demise, may be subject, and to charge such taxes against my t~J residuary estate. It is my intention that none of the aforesaid taxes, either federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 3: I give and bequeath all of my tangible personal property to my very good friend, HARROLD A. BRETZ, to be disposed of in accordance with our understanding. ITEM 4: All the rest, residue, and remainder of my estate, of whatsoever nature and wheresoever situate, whether it be real, personal, or mixed, including property over which I have a power of appointment, I direct my Executor distribute in the following shares: A. To MARTHA C. WORTHINGTON, Fifteen Per Cent (15%); B. To DAVID G. STOVER, Fifteen Per Cent (1 S%); C. To KERRY G. STOVER, Fifteen Per Cent (15%); D. To MICHELE U. YOST, Fourteen Per Cent (14%; E. To JOSHUA K. STOVER, Fourteen Per Cent (14%); F. To HARROLD A. BRETZ, Seventeen Per Cent (17%); and G. To MESSIAH VILLAGE ENDOWMENT FUND, Ten Per Cent (10%). ITEM 5: In the event that Kerry G. Stover should predecease me, I direct that his share be distributed to his son, JOSHUA K. STOVER. ~. ~_ ~a ITEM 6: In the event that any of the other named beneficiaries should predecease me, I direct that his or her share lapse, and be added proportionately to the shares of distribution to the ~~,-- rr surviving beneficiaries. ~ J ITEM 7: I nominate, constitute, and appoint my friend, I3ARROLD A. BRETZ, as Executor of this my Last Will and Testament. Page •2- ITEM 8: I direct that my hereinbefore named Executor shall not be required to give bond for the faithful performance of duties in this or any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this _-7`_- day of 2004. rf ~ C~• ~ ~ DOROT M. KE NEDY The preceding instrument, consisting of this and two (2) other typewritten pages, was on the day and date thereof signed, sealed, published, and declared by the Testatrix herein named, 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 subscribed our names as witnesses hereto. OF ~~;t ~,c11.,~ ~ OF Page -3- COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF YORK , /~ ,~/ We, OROTHY M. NNEDY, ~~~~~ ~ pY, and ~ L ,the Testatrix and the witnesses, respectively, whose na es are sig 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 Testament, and that she 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 the time eighteen (18) years of age or older, of sound mind, and under no constraint or undue influence. SWORN TO AND SUBSCRIBED BEFORE 1VIE THIS Z/yl~, DAY OF , 2004. NOtAfj$~ $~ ~ •lenet S. Gae, N p~~ ~~g eoro Y~ County ~y Comrnla~ E,~,4~ oct 25, 2006 J REV-485 EX (05-04) 48500041046 SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEA8E USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Number 204-22-2560 06/24/2012 21 12 0761 Decedent's Last Name Suffix First Name MI Kennedy 'Dorothy M ©ADDRESS OF DECEDENT STREET: 752 Oak Oval CITY: Mechanicsbur STATE: PA ZIP CODE: 17055 NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME' Wm. D. Schrack III, Esguire____ -- -- STREET ADDRESS: 124 W. Harrisbur Street --- -- CITY: Dillsb STATE: ZIP CODE: ur • NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT OF PERSON(S) PRESENT AT THE BOX OPENING PA 17019 a. NAME: Harrold A Bretz RELATIONSHIP: . ___ Executor STREETADDRESS: 2525 Bretz Drive _ __ _ --- - CITY: ___ _ STATE: ZIP CODE: --- - ----- -- - - ------------ - NAME b __ Enola - -- --- PA 17032 . : ~ UJM ~ SfCfL~PA~ ~"~ RELATIONSHIP: _ ._ . _- A770R~u~ STREET ADDrR~,EtSS: I ~y ~ 1~14RKtS8U~f'( (1'T ITY: - - ST TE: - ZIP CODE: _ c. N E: ~A7?l y - MOD~t'E - - L T1ON HIP: ~~G ~9NK ~ ------------ ST EETAD RESS: ~3 K OVAL _ -- ITY: FcNavtrsa~eG _ __ ST T Q~ __ ZIPC DE: ~ " t7 5,5 NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: PNC Bank, NA. _ EETADDRESS: 939 Oak Oval - ---- CITY: STATE: ZIP CODE: Mechanicsbur PA 17055 NAME OF PERyS-~ON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY DATE OF CONTRACT TOR NT BOX ' NUMBER OF 80 1 TITLE UNDER WHIC BOX IS REQUESTED 7 a° ° ~ ! ~ Doroth M. Kenned NAME AND ADDRE S OF PERSON(S) HAVING ACCESS TO 80X a. NAME: Dorothy M_ Kennel STREET ADDRESS: 75_2_0_ ak_ _O_va_ I _ CITY STATE: ZIP CODE: Mechanicsburg PA 17055 NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY b. NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: WAS A WILL IN THE BOX? ^ YES NO If yes, a. Date of will: b. Name and address of personal representative, If named in the will -- NAME: -- - STREET ADDRESS: c. Name and address of attorney, if any NAME: --- -- ---------------------- STREETADDRESS: 48500041046 CITY: --- STATE: ZIP CODE: CITY: STATE: ZIP CODE: 48500041046 REV-485 EX SAFE DEPOSIT BOX INVENTORY Page__~Df Z i~lternl InTl~uc+ ~rw ~ I~VV 1 IVIYa7 (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, Warne of bank and branch, and balance. (8) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION -- ~ _- -------- _ Ash -- - i4. so (ro~w~6F~ - - _ _ -- I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND C MPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNATURE SIGNATURE ff~~IN (~. Pt J /~A Qn 1~~0~,"/ ~ y ~Q PRINT NAME AND CHECK APPROPRI TE BOX BELOW: PRINT TITLE - 17~~F~~ IT' ~E TZ _, _-_.-_ DATE C,H~E,/C/K APPROPRIATE BOX: - '--~~- l'oUuS&~ rf9l~ ~~~~ g~'~I4 O~~ (JrJ Executor( ~ Administralor(trix) L ^ Eslate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/:" x 11"sheet(s) if necessary or use duplicates of this page of form. The Department is authorized bylaw, 42 U.S.C. §405 (c)(2)(C)(i), to require disGosure of Sodal Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the inftxmadon in exchange of tax information agreements with Federal and local taxing authorities. The slate law omhihita x,o r~mm„~,.,o~ut,~~ ..e...,.....,.~ ~.._ ~:__~__:__ _ __~ . .... . . . _.-_...---...._ ~_.°°...••^ ~~•^~~ ~,~~~~~~~~y ~~~~~~~~~~ea~ ma euormanon except rorottiaal purposes. ~ 7/24/12 Law Office of Wm. D. Schrack III 124 W Harrisburg St Dillsburg, PA 17019-1268 Dear Attorney Schrack, Below is the information requested regarding the accounts held by Dorothy M. Kennedy at Belco Community Credit Union. A. Savings Account B. Acct # 0000011300-S0001 C. 6/24/12 Balance: $4,942.67 D. No joint owner A. Traditional IRA B. Acct # 0000011300-S0100 C. 6/24/12 Balance: $5,959.33 D. N/A A. Visa Credit Card B. Acct # 0000011300-L0014 C. 6/24/12 Balance: $191.70 D. No joint owner 0 If you require any other information please contact us at 717-232-3526. Thank you, Sarah Davis Assistant Branch Manager Camp Hill Branch 1 LIST OF CONTENTS 7S2 OAK OVAL MESSIAH VILLAGE MECHANICSBURG PA 17055 Living Room: Value Two swivel rockers (@ $19S each) $ 390.00 One love seat 100.00 26" Samsung TV 125.00 Miscellaneous lamps 150.00 Porch awning 250.00 Kitchen: Kitchen table and chairs Coffee maker 75.00 20.00 Den: Swivel chair/rocker Small desk and swivel chair 100.00 1 S" TV 75.00 Lamp 50.00 Cedar chest 79.00 1 S 0.00 Bed Room: King size bed Night stands 400.00 Bureau 250.00 300.00 TOTAL CONTENT VALUE 2 514.00 . ~ .luly 26, 2012 I-Iarold Bretz 252 ~ I3retr Dr. Lnola, PA 17025 Dear Mr. Bretz: I alll WI'ltlllj to you concerning the refund due for the apartment occupied by Dorothy Kennedy at 752 Oak Oval, Messiah Village. The acquisition fee paid for the unit in Apri12003 was $118,500.00. The agreement was terminated .iuly 18, 2012. Seventy-five percent of the acquisition fee was amortized over 100 months leaving a refiuld in the amount of $29,625.00 (see enclosed amortization schedule). The payment of the refund will take place in six months or after the unit is acquired by another resident, whichever comes first. If you have any questions regarding the refund, please call me at (717) 591-7204. Sincerely, Michele Maglich Brown- Director ofFinancial Operations Fncl. -.-~ m~ _. -,_. f • ..~ r ~ ~ . _~~. ... E -. ,,; ~- - ,~ ,- 1'.Y.. n. -. q Sr2 I CUNA Brokerage Services, Inc. Member FINRA/SIPC September 19, 2012 Wm D Schrack 111 Attorney At Law 124 West Harrisburg St Dillsburg PA 17019-1268 Re: 6CQ493585 Dorothy M Kennedy Dear Mr. Schrack: The individual account for Dorothy Kennedy, 6CQ493585, was opened on November 6, 2000. Dorothy's account had the following market prices as of the close of business on Friday, June 22, 2012: • $1.66 per share for 71 shares of Alcatel Lucent (ALU) t (7. ~6 • $35.17 per share for 246 shares of AT&T Inc {T) %6S ~• g2 • $38.64 per share for 3 shares of CenturyLink Inc. (CTL) ~ f S• RZ • $30.83 per share for 213 shares of Comcast Corp Class A (CMCSA) (ps6b•~Q • $4.02 per share for 307 shares of Frontier Communications Corp (FTR) 12 ~~. 1~ • $6.37 per share for 19 shares of LSI Corp Com (LSI) 12 I • d 3 • $43.95 per share for 1,282 shares for Verizon Communications Inc (VZ) ~(~ 3~3. QO • $27.675 per share for 26 shares of Vodafone Group PLC (VOD) -~ IQ. 5' • $16.09 per share for 2216.599 shares of Dreyfus GNMA Fund (GPGAX) 3S, b(oS, 0~ • $408.30 in Federated Capital Reserves (FCR -money market) ~ p $, 3~ Pershing LLC carries this account as clearing broker pursuant to a clearing agreement with CUNA Brokerage Services, Inc. Both Pershing LLC and CUNA Brokerage Services, Inc., do not provide tax, investment, or legal advisory services. The market prices have been obtained from various quotation services which we believe to be reliable; however, we cannot guarantee their accuracy. Our customers are encouraged to consult their tax advisors for verification. If you have any questions, please be sure to contact our Customer Service Department at 1-800-369-2862 between the hours of 7:00 a.m. and 7:00 p.m., Central time. Sincerely, LL's ~~J'ti~I~.-- aa•~ Amber Downing •~ ~~a~A Brokerage Processing CUNA Brokerage Services, Inc. Office of Supervisory Jurisdiction 2000 Heritage Way .Waverly, IA 50677-9202 Business: 319.352.4090 Fax: 319.483.2525 Member FINRA/SIPC -- Office Use Oniy: v 1941120625076 S~Z I CUNA MUTUAL GROUP CMFG Life Insurance Company August 22, 2012 Dorothy M Kennedy Estate c/o Wm D Schrack III Law Offices 124 West Harrisburg St Dillsburg PA 17019-1268 Re: Insured Certificate/Policy Claim Dear Mr. Schrack: Dorothy M Kennedy 000048008425 120625076 Thank you for your recent request for information regarding the above-mentioned claim. The value of policy 000048008425 as of June 24, 2012, was $72,258.26. Enclosed is a copy of the settlement letter and Statement of Values sent to Mr. Harrold Bretz and returned to our office undelivered. Our records show that the claim settlement check dated July 20, 2012 has cleared our bank on August 15, 2012. If you have any questions, please contact your representative at the information below or me at 1-800-798-6600, Ext. 4832440. Emmor E. Boslet, CFP Belco Community CU 3500 Trindle Rd Camp Hill, PA 17011 (717) 720-6220 Sincerely, (~/~ Jolene White, FLMI, ACS, ALHC, AAPA Claim Specialist 3JW cc: 08874 Emmor E Boslet, CFP Enclosure 2000 Heritage Way .Waverly, IA 50677-9202 Business: 800.798.6600 VoicelTDD:319.352.4090 Fax: 608.236.8030 Website: eservice.cunamutual.com LINCOLN BENEFIT LIFE A N A L L S T A T E C O M P A N Y August 27, 2012 William Schrack 124 West Harrisburg St. Dillsburg, PA 17019 Re: Dorothy M. Kennedy Contract No: LBF1172635/AC1122102A Dear Mr, Schrack: We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the contract). Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the following information for estate purposes: Date of Death: Annuity Value as of Date of Death: Cost Basis: Named Beneficiary: June 24, 2012 $ 49,525.47" $ 49,501.29 Estate of Dorothy M. Kennedy *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. 24520. Sincerely. /~~v~;~;a ~3~~y Sr. Claim Examiner ~/v / Lincoln Benefit Life Company Life and Annuity Claims P.O. Box 94212, Palatine, IL 60094-4212 Phone 877-499-6418 Fax 866-635-4523