HomeMy WebLinkAbout09-22-14 (2) � 1505610105
REV-15 00�X`°��",`F°:�
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of Individual Taxes ",�"" County Code Year File Number
Po aox zso6oi INHERITANCE TAX RETURN J �/
Harrisburg PA 1'7i28-o601 RESIDENT DECEDENT �� `� ��/
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
03/15/2014 07/28/1930
DecedenYs Last Name Suffix Decedent's First Name MI
Kuntz Richard L
(If Applicabie)Enter Surviving Spouse's information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Socia�Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WtLLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return O 2. Supplemental Return p 3. Remainder Return(Date of Death
Prior to 12-13-82)
p 4. Limited Estate O 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required
death after 12-12-82)
C� 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust __ 8. Total Number of Safe Deposit Boxes
(Aftach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10. Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Robert R. Black, Esq. (717) 243-3727c o
� � � rn
REGISTER OIF�DlILt�$USE ON�j m �
"Z1 G`� �
� �' 6"'� --� r.') �7
_ �a 1`-
rv _6 �
First Line ofAddress A_� rr; � ., ,.��
_ � `:� z.�
36 South Hanover Street
� ;: c���
,-1 _+„+
Second Line of Address - � -�7
� - .=t.i � V �"�
_i _ ,,; �
City or Post Office
State ZIP Code b�4TE FILED � � �
'�"1
Carlisle PA 17013
CorrespondenYs e-maii address: RBIaCk blaCklaw.COmCastbiz.COm
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 representaiive is based on all information of which preparer has any knowledge.
SIGNA 0 PERSO RE ? NSIBLE FOR�jII,ING RET DAT
IL � I
ADDRES
187 r t oa rdn rs, 17324
SI T P E R E E ESE IVE � �/
A RES
3 South Hanover Street, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 150561�105 1505610105 �
�
� 1505610205
REV-1500 EX(FI) DecedenYs Social Security Number
DecedenYs Name: KUf1tZ, Richard L
RECAPITULATION
1. Real Estate(Schedule A). . . .. . . . . .. . . . . . . .. . ..... . . .. . .. .. .. . .. . . . . . . 1.
0.00
2. Stocksand Bonds(Schedule B) . . . . . . . .. .. . . . . . . .. . . . . . . . .. . . . . . . . . . .
2 104,771.51
3. Closely Held Corporation,Partnership or Sole-Proprielorship(Schedule C) . . . 3.
0.00
4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . .
4 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . . . 5.
59,397.40
6. Jointly Owned Property(Schedule F) O Separate Billing Requested . . . . . 6.
0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property gg,519.55
(Schedule G) O Separate Billing Requested.. . . . . . . 7.
8. Total Gross Assets(total�ines 1 through 7). . . . . . . . . . . .. . . .
8 263,688.46
9. Funeral Expenses and Administrative Costs(Schedule H). . .. . .
. 9 9,289.53
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I).. . . . . . . . .. . .. . 10.
234.48
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . ... . . . . . . . . . .. . . .. . .
�� 9,524.01
12. Net Value of Estate(Line 8 minus Line 11) . . . . .
t 2. 254,164.45
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 0.00
an election to tax has not been made(Schedule J) . . . . . .. . . . . .. . . . . . .
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . .. . . . .
i a 254,164.45
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxabie
at the spousal tax rate,or
transfers under Sec.9116 �5 0.00
(a)(1.2)X.0_
16. Amount of Line 14 taxable 11,437.40 i6 11,437.40
at lineal rate X.0 45
17. Amount of Line 14 taxable �� 0.00
at sibling rate X.12
18. Amount of Line 14 taxable �a
at collateral rate X.15
19. TAX OUE . .. .. . .. . . . . . . . . . . . . .. . .. .. . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . 19.
11,437.40
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT a
Side 2
� 15�56102D5 15�5610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Richard Leroy Kuntz
STREETADDRESS
Church of God Home -
__ _ _
801 North Hanover Street
STATE Z�P
CiTV pq 17013
Carlisle
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 11,437.40
Z. Credits/Payments
A.Prior Payments 8,500.00
B.Discount 447.36 8,947.36
Total Credits(A+B j (2)
3. Interest �3� 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. i4) 0.00
Fill in oval on Page 2,Line 20 to request a refund.
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. l5)_________
2,490.04
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.......................................................................................... � �
b. retain the right to designate who shall use the property transferred or its income ............................................ � :
c. retain a reversionary interest .....................................................................................................................
d. receive the promise for life of either payments,benefts or care?...................................................................... � �
2. if death occurred after Dec. 12,1982,ditl decetlent transfer property within one year of death
without receiving adequate consideration?............................................................................................................. ❑ �
3. Did decedent own an'in trust for°or payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individual retirement account,annuity or other non-probate property,which O
coniains a beneficiary designation? ....................................................................................................................... �
IF THE ANSWER TO ANY OF THE ABOVE QUESTION5 IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
(72 P.S.§9116(a)(1.1)(ii)].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 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the chiltl is 0 percent[72 P.S.§9116(a)(12)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[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 percent(72 P.S.§9116(a)(1.3)).A sibling is definetl,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV•i5o3 EX+(8-iz)
r pennsylvania SCHEDUI.E B
DEPARTMENTOFREVENUE STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
Kuntz, Richard Leroy 21-14-0298
Ail property jointly owned with right of survivorship must be disclosed on Schedule F.
VALUE AT DATE
ITEM DESCRIPTION OF DEATH
NUMBER
1' Note:Ruth Ann Kuntz pre-deceased her husband,Richard leroy Kuntz,on 0212812012
see attached death certificate
� 6 shares of LST @$11.15 66.90
2 23 shares of AT&T Inc.@$34.46 �92•5$
3 82 shares of Energy Transfer Partner LP @$56.58 4,639.56
4 82 shares of SunCoke Energy,Inc.@$20.30 1,664.60
5 Hartford Mutual Funds Inc-Inflation Plus Fund Class C(HIPCX)3,035.661 @$10.54 31,995.86
g Hartford Mutual Funds Inc-Floating Rate Fund Class C(HFLCX)3,854.493 @$8.99 34,651.89
� PIMCO Funtl PAC INVS MGMT SER Short Term Funtl Class C(PFTCX)3,133.616 @$9.88 30,960.12
��
TOTAL(Also enter on �ine 2, Recapitulation) $ 104,771.51
If more space is needed, insert additional sheets of the same size
REV-15o8 EX+(o8-1z)
r pennsylvania SCNEDULE E
DEPARTMENTUFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RES[DENT DECEDENT
ESTATE OF: FILE NUMBER:
Kuntz, Richard Leroy 21-14-0298
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disciosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OFDEATH
1. Wells Fargo Bank-Savings Account XXXXXX5490. See attached report 40,146.12
principal$40,144.50+interest$6.48+interest accrued$1.76
2. Wells Fargo Bank-Savings Account XXXXXX186 100.21
principal$100.21 +interest$.02
3. Welis Fargo Bank-Checking Account XXXXXX8517 100.02
principal$110.01 +interest$.01
4. Wells Fargo Bank-Checking Account XXXXXX3383 13,080.23
principal$13,080.23
***see attached printout***
5, Thrivent Financial-partial payment for Refuntl-Long Term Care Contract No.00578681 1,674.00
g. Proceeds-Prudential Ins.Co. Policy#1405152 as the beneficiary was deceased and proceeds were 2,013.68
to the Estate
7. Highmark Blue Shield-Refund of unused premium 118.09
g, Church of Gotl Home,Inc.-partial refund of residence fee 2,165.05
TOTAL(Also enter on Line 5, Recapitulation) $ 59,397.40
If more space is needed, use additional sheets of paper of the same size.
REl'-].57.0 EX+ (08-04j
� pennsylvania SCHEDULE G
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCETAXRETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kuntz, Richard Leroy 21-14-0298
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY
(NQUDE THE NAME OF THE TRANSFEREE,THEIR REL1TIIXvSHIF TO DECEDENT AND DATE OF DEATH %OF DECD�S EXCLUSION TAXABLE
NUMBER THE DATE OF TR4NSFEA. ATfACH A CUPY OF ThE DEED FOF REAL ESTATE. VALUE OF ASSET INTEREST (IF APPI.fCABLE VALUE
1. Thrivent Financial Contract No.C2787567.Life contract with fixed payout 4,435.26 100 0.00 4,435.26
see attached letter
2 Thrivent Financial Contract No. LC3345631. IRA variable annuity contract 2,463.66 100 0.00 2,463.66
see attachetl letter
3 Thrivent Financial Contract No.T0003252. Installment agreement 44,464.64 100 0.00 44,464.64
see attached letter
4 EquiTrust Life Insurance Co Annuity Policy#EQ001082386F 31,587.83 100 0.00 31,587.83
see attached letter
5 New York Life Annuity Policy AN735304. see attached letter 16,568.15 100 0.00 16,568.t5
TOTAL(Also enter on Line 7, Recapitulation) $ 99,519.54
If more space is needed, use additional sheets of paper of the same size,
REV-7.511 EX+ (QA-13;
r pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kuntz, Richard Leroy 21-14-0298
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1' Mt.Holly Church of God-used of facilities 500.00
e, ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
0.00
Name(s)of Personal Representative(s) NOn2
__.._.... _---__ ___._._. __.._.. ____._.... ._ _.__..._._..._-
Street Address ____
City------ -- - State _......_- ZIP -- _-_�
Year(s)Commission Paid: __
7,000.00
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 0.00
Claimant None
_ ......... __ _ __.._ _._ _. .___
Street Address
City State___ZIP. __
Relationship of Claimant to Decedent_________ ________ _
4. Probate Fees: _ adVatlCed 638.42
5. Accountant Fees; 100.00
6. Tax Return Preparer Fees: 1 00.00
�• New York Life&Annuity Ins.Corp-return of annuity payment 529.11
s. Deluxe Check Printers-estate checks 22.00
s. Reserve for closing expenses 500.00
TOTAL (Also enter on Line 9, Recapitulation) $ 9,289•53
If more space is needed, use additional sheets of paper of the same size.
REV-151"L EX+(12-121
� pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kuntz Richard Leroy _ 21-14-0298
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medica�expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
i• Alert Pharmacy Services-invoice 51.48
2. Darryl Guistwite,DO 15.69
3. Darryl Guistwite,DO 131.31
4. Misc. 36.00
TOTAL(Also enter on Line 10, Recapitulation) $ 234.48
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
, � pennsylvania SCHEDULE J
���� DEPARTMENT OF REVENUE BENEFICIARIES
INHERRANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Kuntz, Richard Leroy 21-14-0298
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.9116(a)(1.2).]
1. Richard Larry Kuntz Son 100%
187 Frost Road,Gardners,PA 17324
SSN 208-38-5382
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size,
. i ;
i
I
LAST WILL AND TESTAMENT
OF
RICHARD LEROY KUNTZ i
I
I
i
I, RICHARD LEROY KUiV'fZ, of R. D. L, Gardners, pennsylvania, �
declare this to be my Last Will and revoke any Will pre.�iously made by me. I
ITEM I: I direct that all just debts and funeral expenses including my Ii
grave marker shall be paid :rom the assets of my estate as soon as practicablQ
after my decease. I
I
ITEM II: I devise and bequeath the residue of my estate, of e�ery i
nature and wherever situate, to my wife, Ruth Ann Kuntz, providing she shall
survive me by sixty (60) days.
ITEM IfI: Should my wife, Ruth Ann Kuntz, predecease me or die on I
or before the sixtieth day following my death, I devise and bequeath the residu�
of my estate, of every nature and wherever situate, to my son, Richard
Larry Kuntz, or his issue, per stirpes, i
I
[TEM IV: I direct that all taxes that may be assessed in consequence i
of my death, of whatever nature and by whate��er jurisdiction imposed, shall
be paid from my residuary estate as a part of �he expense of the administra-
tion of my estate.
ITEM V: I appoint Bendersville National $ank guardian of any propertiv
I' which passes to a minor and with respect to which I am authorized to appoint al
guardian and have not otherwise sPecifically done so. Said guardian shall i
Ihave the power to use principal as ,�ell as income from rime to !ime for the �
minor's education, support and welfare ;.ithout re�ard ro his or her parent's
Iability to pro•��ide for such education, support and welfare, or to make payment'
for these purposes without further responsibility to the minor or to the minor'
parent, or to any person taking care of the minor.
ITEM VI: I appoint my wife, Ruth Ann Kuntz, as primary E:cecutrix, �
and my son, Richard La.rry Kuntz, as Alternate Executor,of this my Last Will.';
ITEM VIi: I direct that my personal representative or guardian sha11 '
not be required to give bond for faithfui periormance of their duties in any
jurisdiction.
�� I
IN WITNE5S WHEREOF, I have hereunto set my hand this 2=Z ��
day of �J�i�G , 1973. i
._,
� i
� v � � i
/ I %. "!,.a �_j.� ,.r: ;�.. v ,.�I.�y,:{;~` (SEAL) I
Richard LeroyYKuntz . �
i
The Preceding instrument, consisting of this one typewritten page,
identified by the signature of thc Testator, was on the day and date thercof i
signed, published and declared by Richard Leroy Kuntz, the Testator herein
LAW OFTIC[5 i
LANDIS,MeINTOSH named, as and for his Last Will, in the presence of us, who, at his request,
&BLACK in his presence and in the presence of each other, have subscribed our names �
.At1lI5LE.PENN�YI.VANIA
as witnesses Eiereto.
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Type/P�Int In COMMONWEAITH OF PENNSVLVANIA•DEPAHTMENT OF HEALTH•VITAL RECORDS
°e"'�'"`"` CERTIFICATE OF DEATH
Black Ink Stste Flle N�mber:
1.DOCedent's Legal Namc(FirSt.Mlddie,Lasf,SuHlz) 2.Sex 3.Social S�c�rify Number 4.Datn o/DlaCh(MO/pay/Yr)(Spell Mo)
Rutl'i Ann Kuntz Femal 207-26-207'1 February zg 2p� 2
Sa.Age-Last Blrthday(Yrz) Sb.Under 1 Yeer Sc.Vnder 1 Da 6.Oate of Blrth(MO/Oay/Year)(Spell Month) 7a.Birthplace(City and State or Foroign Country)
8O Monihs Oays Hou�s Mlnutes ardne S
October '1 7 , '1 9 3 1 7b.Birthplace�ce��cY> um er an oun
8a.Rezitlence(Sta[e or Foreign Coun[ry) Bb.Residence�SSree[and Number-Include Apt No.) Bc.Old Oecedent L�ve in a Townshlp7 y
� PA 80'i N. Hanover St_ �es,de<eae.,.��„ea�� North Middleton Two. c,,,p.
Sd.Resitlence(COUnCy)
� Cumberl and CO. ge.Residcnce(Zip Code) ONO,decedent livetl wl[hin limits of <Ity/bo�o.
� 9.Ever in US med Forcas] 10.Merltal 5[a�us at Time of Oeath Married 0 Widnwed 11.Surviving Spouse's Name(If wife,glve n me p�ior to first merrlage�
pves �NO Ou„k„own O owa.ced p�e�e�nna�.�ed Ou.,k.,ow RiCkiard L_ KuntZa
12.FathQr's Name(F��st,Middle,Last,SuHlx) 13.Mother's Name Prlor to Firs<Marrlage(FIrSt,Mlddle,Last�
ClifPord Beam
14a.Informant's Name 14b.Relationship to Deceden[ 14c.InTOrmant's MaiI1nQ Adtlresz(Street and Number,City.State,Zip Cotle)
� Ric2'iard L. Kuntz 01 N . Hanovar St . , .Carlisle PA 170'13
........ ..........................e. �ce o eac e� o�
......................... ............................ ..... .... 1 o�e
..... ........... .....c.................................Y..................................... ....................................
�rred Somewhere Ocher T�aA a Hos Ifal: tv, """"""""""�""'""""'
s 1/D¢aCh Occurred In a Hospital: Inpatlent :l/Death Oc p ��HOSpice Facllity u��Decetlent's Home
� �EmergCrlcy Room/OU[patlan[ Q Dead on A��IVaI Nurzing Home/LOng-Term Care Facllity Other(Specify)
15b.Facility Name(If not Institutlon,glve s[reeT and number', •i5c.City or Town.Stat¢,and 21p Code 15tl.Councy ot DeaCh
= Church o£ God Home Carlisle, PA 'I7013 u
m16a.Metliod of Disposltlo� 0 Burial Crematlon 36b.Oate of Dispositlon 16c.Place o/�ISpositlon(Name of c�mttery,c�ematory,o other plac<)
� oaa,,,o�ei��o.,,sr.�e poa.,a<�a„ 03/02/20'12 Hollinger Funeral Home r� Cremator
ocn�.(sa����v> y
� 16d.Lo<atlon of Dlsposition(CICy or Town,Staie,and 21p) l�a.Signat�re ( n r I Scrvice LJtepspe P InLharge of Interment llb.�icense Number
� Mt. Holly Springs , PA 17065 ��, ��ij'�j'1.<LnJ������ FD"1 38812
� 1�c.NameantlCOmpleteAddressolFVneralFa�mcY Hollinger Funeral Home & Cremator
y, =nc .
� 18.Dettdent's Educatlon-Check ihe box that best tlezcribes th¢ 19.Decedent o Hlspa C Origin- hec the O.Dece eni's Race-Check ONE ON MORE racez to Indicat<what
�- h�ghast degree ar level o�school completed aT the time of death. box that best describes whether�he deceOen� th deceCen[consitlered himself or hersetf to be.
0 8in gred<or less i Spanish/Nlspanlc/Latino. Check Che"NO" Whlte � Koreen
��H� o diploma,9th-12th grede bo If deceden(i5 not Spanish/Hiapanic/Latlno. �Black or African Ameritan � Vietnameze
lgh schooi graduate or GED completed �NO,not Spanlsh/Hlspanit/Latlno �American Indian o�Alaska Native � Other Aiian
� $Ome collegG credlt,but no degree �Yes,Mexl[an,Mexlcan AmeriCan,Chlcano 0 Aslan Indian Q Native Hawallan
� Assoclate deBr<e(e.g.AA,AS) O�'es.Puerto Rican
Q Bachelor'z deg�ee(e.g.BA,AB,BS) �Yes,C�ban Q Chln¢se � Guamanian or Chamorro
� Master's dGgree(e.g.MA,M5.MEng,MEd,MSW.MBA) Q Ves,o[her Spanish/Hlspanlc/Latino O�a"P'n� O SamOan
� Doctorace(e.g.PhD,EdD)or Pro/esslonal degree � panese � Other Patlfic Islantler
(SpecifyJ_ . __ �Other(Speclty)
@. .MD DDS DVM,LLB 1D '- -
21.Decedent'z Single Ra<e Self-Designatlon-Check ONLV ONE to indi[aee what[he tlecedent consitleretl himself or herzelf to be. 22a.Decedent's Vsual Occupation-IntliCate type of wor4
�Blacke0�Afrlcan American O Koreanfe � Samoan done during most o/wqrkinQ 11/e DO NOT USE RETIREO.
0 0 oone�va��r�i.ia.,ee� Laborer
� Q Am@FlCen InOlan or AlaSka NaHve Q Vletndmese � DOn't Know/NOt S�re
�Aslan Indian �Other Asian � qef�setl 22b.Kind o1 Business/Industry
� pehinese QNativeHawailan pocne��spe��r,.� _ ManuPacturing
4 O Fulpino p�uamaNanorCnamorro
IT8M5 23a-23d MUST BF COMPLETED 23a.D te Pro d Dead(MO Day Yr) 23b.Signature of Perzon Pro o ncing Death(On y when applica le� 23c.License Number
BV PERSON WHO PRONOUNCES OR � � ��^ � � � ����
CERTIFIES DEATN !N � :
23d. �Sjlg (MO/Oa /)y�) 26.Time 1 D ath
C� ` �r 25.Was Medical Examiner or Coroner ContactedT � Vez No
, •CAUSE OF OEATH ApprOximate
26.Part 1. Enter the chaln of events--tliseases,InJurles,or complicatlons--that tlirec[ly causetl[ha tleath. DO NOT entar terminal sventz s�th as c�rdlaC arrest Intarv�l�
rezpiratory arrest,or ventrlcutar fibrillacion wichout showing the etlology. OO NOT ABBREVIATE. Enter only one cause on a Iine. Adtl atltllflonal Iines lf neceszary OnseT to Oeath
IMMEOIATECAUSE •----------___> a. C � �/'L'�+ � L a� �-_A �` � O__ �
(Final dlzease or condltlon Due to(or as a consequence of):` �
resulting in deafh7 '
b. j
Sequent�ally Ilst condi[lona, Due co(or as a<onsequence o�:
Ii any,leading to the cayc• 1
listed on Ilna a. Enter the +
UNDERLYING CAUSE c Due to(or as a consequenCe of):
W (disease orin)urythet �i
� Initlated the events resulting d. 3
� In deach)lAST. D�e io(or as a eonsequence of)�
t
� 26.PaK II. Enter other If ant conditlons but not resulting In the underlying cauze given in Gart I 17,yyas an autopsy peHO etl?
� o va: e No
� 36.Were autopsy 1lndings avallable
4 to romplete the ca of death?
\ _� 29.If Female:
� g 3(1.Dld Tobacco Use ConYribuCe to Death� �ef � Ves � No
S E � Not pregnan[wi[hin past year V95 Probabl 31.M of Dea<h
� O v 1�Natural Q Nomicide
Q Pregnan�at[Ime o/death nto unkn�wn ���
c�' 0 NOt pf2gnant,but pregnent wlthin 42 days of death � � O A�<ident 0 Pending Invlstiga[lon
�- Q Not pregnant,but pregnant 43 days to 1 year before tleath 32.Date o�In'u (MO/Da /Yr 5 � Suicide � Could not be tlet<rmin4d
1 �'V Y )( Pell Mon[M1)
0 Vnknown 1/pregnant witliln Ihe pas[year
33.Tlm¢a(In(�ry
� 34.Place of�nJury(e.g.home;construcSion site;farm;school) 35.Locaibn ot In)��y(Street antl Number,City,State,Zip Cotle)
36.Injury at Work 37.�f Transportation Inj�ry,Spe<I/y: 38.Describe How Infury Occurred:
� Yai Q Orlver/Operator � PedeStrian
Q No �PaSSenge� Q Otl�er(Speci(y)
39a.Ce er(Chetk Only one):
Ortllying physiclan-To fhe best ol my knowledge,tleeth occurred d�e io the<ause(z)and manner staiatl
0 Pronouncing&Certlfying vhysiti -To the bes[of my knowledge,death occurretl a[the Cime,tlate,antl place,and due to the ca�se(5)and manner zta(eG
0 MetliCal Examiner/COroner- the of examination, tl/or Investlgation,In my opinlon,tleath ocCUrretl a(the time,date,anq place,and due to the Cause(s)antl manner Stetetl
si¢.,aoura o��er<�t�.r. -- � n�ie or certmer ucense N�,,,ee,: °'p�O �( S"-`
39b.Na�ALdre�s s�tl Zip C erson Co I�ting Ca�se f Oeat (Item 261 39<.Data Sigr�etl(MO/pay/vr)
� �--� s ts� P ,9 < �� , i �; � Z
� 40.Regiztrar's Dis[rict Number 41.Pegi 's Signature 42.Reglstrar File pafe Mo ay vr
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43.Amendmantf
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Welis�argo Online�
Last Sgn On:March 28,2014
Account Summary
Cash Accounri
_____---._.__._- __ __------_ --- _.._ _ �.__ --- -- - --_ --�_ .__�...
l+.ccount Av;nlahl.Balancr Relate!1 Activrt�e�
PREMIER CH�KINO XXXXXX8517 SC f 100.01
CHECKINO XXXXXXXXX3383 � si$,080.23 Try Mobile Banidng
SAVIN0.S XXXX7(X0186
,k 5100.21 Make tra�sters on the go
SAVINl3S XXXXXXX7(X3490 ;4p,1 qd,6p FrsFtime HomebuyerT Download Guide
Total s(+.qr4y`.g6
Investment Accounts
____ — --- --. __ __ __----_ _._._ _- --_ _._.. _—.. ----
P.ccount Tota�.4cro�n?Value Relaten A tivities �
BROKERAf3E WXXXXS9S8= S.q7,$50.92 Orders•Hddin Stalements•qctiv'
,,ai�<cargo a'..+snrs _.._ Quotes&Resea�ich•Markets �Y•
7ota1 597,360.92
Credk Accounta_____
__ _-- -_._.---._.
____.— __... __—.-
Account _.--_ ___..__--- ------
--_ — ----
Outstanding Bala•i�e Availahle Cretlit Relatea Acve�ities
PIATINUM CARD XXXX-XXXX-XXXX� �pp
55,000.00 ���e Transfer Now
Total 50.�0 :5,000.00
_.._-----------._...---_ -----
. ---- ---------_—
.—____--. __.___.._._
-_—__. —- -- _--------,
:#Dnnotes investment products which are-Not FDIC�nsured-Not g��arantoed by thn Bank-fday Inse value. `�—.�
i_..--'_—..__.-------._.._ '
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._—._.._---------—�---_._..___._..----....—
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�Equal Nousln9 lsnder
O 7895-2014 Wells Farqo.All rights reserved.
https:/lonline.wellsfargo.com/das/cgi-bin/session.cgi?screenid=SIGNON PORTAL PAU... 3/31/2014
� .
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�� �
April28, 2014
Robert Black
Landis bi Black
36 S Hanover St
Carlisle PA 17013
Subject: Estate of Richard Leroy Kuntz
Dear Mr.Black:
This letter is in response to your letter dated April 24, 2014 regarding the Estate of Richard Leroy
Kuntz.
At the time of his death,Mr. Kuntz owned contracts C2787567, LC3345631 and T0003252 with
Thrivent Financial.
Contract C2787567 was a certain &life contract with a fixed payout. The date of death value was
$4,435.26. The entire amount was cost basis. The contract beneficiary was Richard Larry Kuntz.
Contract LC3345631 was an IRA variable annuity contract. The date of death value was $2,463.66.
The enrire amount was taxqble. The contract beneficiary was Richard L. Kuntz�r.
Contract T0003252 was an installment agreement. The date of death value was $44,464.64. The cost
basis was$9,009:92 and the tax gain was $35,454.72. The contract beneficiary was Richard L. Kuntz
�r.
Please let me know if you have any questions or if I may assist you in any way. You may reach me at
800-847-4836 ext. 6Z82407.
Sincerely,
Deb Wenninger, ALHC, ACS
Sr Claims Examiner
Claims Operations
MFSS Service Operations
dkw
Richard L Kuntz,deceased
502221716
. _ �
■III �I-� �u:17 r'ustt
� Life Insurance Cornpany
April 8, 2014
Richard L Kuntz
187 Frost Road
Gardners, PA 17324-8812
RE; Policy Number: EQ0001082386F
Owner: Richard Kuntz, Deceased
Dear Richard Kuntz,
Thank you for your letter dated April 4, 2014, requesting information for the above listed
contract as of March 15, 2014.
The value of the above listed contract as of March 15, 2014, was $31,587.83.
If you have any questions, please call our Customer Service Support line at (866)-598-3692.
Thank you,
�
��
' 4�.,���,c�.
Annette Nelso
Sr Customer Service Representative
Annuity Services
EquiTrust Life Insurance Company•PO Box 14500•Des Moines, lowa 50306-3500•866/598-3692
�. _ , . .,_� �� �.., , � -��--�.�. .N �
� .
;� New York Life Insurance Company
New 1'ork Life Insurance and Annuity Corporation
(A Delaware Corporation)
The Compnny Yorr Keep� NYLIFF,Insurance Company of Arizona
(Not licensed in every state)
P.O.Box 6916
Cleveland,OH 44101
1-800-695-9873
ivri�ir.neivyorklije.com
April 15, 2014 Agent/Representative:
James D. Day LUTCF CHFC CLU
(717)486-8866
ESTATE OF RICHARD L KUNTZ
C/O RICHARD L KUNTZ
187 FROST ROAD
GARDNERS PA 17324
Anriuitant(s): Richard L. Kuntz
Policy(s): �iN 73� 304
Claim #: 399 385
Dear Richard L. Kuntz:
We are pleased to reply to your request for information on the above annuity(s). The following
information should be of assistance to you:
Annuity Policy Number: AN 73S 304
Issue Date of Annuity: July 17, 2001
Value as of Date of Death: $16,568.15
Beneficiary(s): Richard L. Kuntz, son
We hope this information will be helpful to you. If you have any questions, please contact us at the toll-
free number above.
Any one of our representatives will be happy to assist you.
Sincerely,
��C.'��:�!
Tricia A. Manuel
Customer Service Representative
cc: James D. Day LUTCF CHFC CLU V;9