HomeMy WebLinkAbout05-26-15 (2) f +
pennsylvania
1505618627 3M464710.000
OEPARWENT OF REVENUE EX(03-14)JP)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
BOX 280601
Ha INHERITANCE TAX RETURN I T
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
09192014 07081933
Decedent's Last Name Suffix Decedent's First Name MI
MOATS SONIA R
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
X❑ 1. Original Return 2. Supplemental Return F-13. Remainder Return(date of death
F-1prior to 12-13-82)
4. Agriculture Exemption(date of 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
❑ 7. Decedent Died Testate F-1 8. Decedent Maintained a Living Trust _ 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
71 10. Litigation Proceeds Received ❑ 11. Non-Probate Transferee Return F 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
13. Business Assets F-1 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
CRAIG A . HATCH , ESQ • 717-731-9600
First Line of Address
2109 MARKET STREET
Second Line of Address
City or Post Office State ZIP Code
PA 17011
CAMP HILL
tet .
Correspondent's email address: C - H A T C H a H H G L L P - C 0 M ' ;'t ',• — �'
REGISTER OF WILLS_ISE ONLY
REGISTER OF WILLS USE ONLY r D
DATE FILED MMDDYYYY - "A (da
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
11111111111111111111 IN IN
1505618627 1505618627
1505618635
REV-1500 EX(TP)
Decedent's Social Security Number
Decedent's Name:M0ATS SONIA R
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. $0 . 00
2. Stocks and Bonds(Schedule B) , , , , , , , , , , , , , , , , , , , , , , , , , 2, $0 • 00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(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. $0 . 00
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested. . . . . 6. $0 • 00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested. . . . . 7. $5 4 , 516 • ?8
8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , 8, $54 -,516 • 78
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9, $765 • 00
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1), , , , , , , , , , 10. $0 • 00
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. $765 • 0 0
12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , 12. $53 i751 • 78
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which
an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , 13. $0 • 00
14. Net Value Subject to Tax(Line 12 minus Line 13), , , , , , , , , , , , , , , , 14, $531751 • 78
TAX CALCULATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers urlGier Sec.9116
(a)(1.2)X.01_ $0 . 00 15. $0 . 00
16. Amount of Line 1Wable
at lineal rate X.044- $531751 . 78 16. $21418 . 83
17. Amount of Line 14 taxable
at sibling rate X.12 $0 . 00 17. $0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 $0 . 00 18. $0 . 00
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. $2-1418 - 83
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT El
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 person responsible for filling the return is based on all information of which preparer has
any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ATE
CURTIS W • MOATS10S (�t 5
ADDRESS
1112 WHITE DAWN LANE MECHANICSBURG, PA 17055
SIGNATURE OF PREPARER OTHER THAN PERSON RESPOjJSIBL G THE RETURN DATE//
CRAIG A • HATCH, ESQ • / cS�`�5116_
ADDRESS
2109 MARKET STREET CAMP HILL, PA 17011
1plippi 1pill Side 2
1505618635
3M464810.000
REV-1500 EX(TP) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
MOATS SO IA R
STREET ADDRESS
4831 E . TRINDLE ED . -, APT . 32
CUMBERLAND
CITY STATE ZIP
CAMP HILL PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) $2-il-118 - 83
2. Credits/Payments
A. Prior Payments $0 . 00
B.Discount $0 . 00
(See instructions.) Total Credits(A+6) (2) $0 . 00
3. Interest
(3) $0 - H
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) $0 . 00
5. If Line I + Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) $2 14 18 - 8 3
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . El [Y]
b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . . . . . 1-1 F_X�
c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . .
. . . . El N
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E]
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? . . . . . El NX
4. Did decedent own an individual retirement account,annuity,or other non-probate property,which
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1A W-1 I ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS 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 172 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
172 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 step-parent of the child is 0 percent[72 P.SJ§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 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 defined,
under Section 9102, as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
3M4671 4.000
REV-1510 EX+(08-09) SCHEDULE G
pennsylvania
DEPARTMENT OF REVENUE INITER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Sonia R. Moats
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.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OFTHE TRANSFEREE,THEIR RELATIONSHIP TODECEDENTAND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH ACOPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE VALUE
1. Thrivent Financial
Annuity No. B469790
Owner/Annuitant: Sonia
R. Moats $54,516.78 100.0000 $0.00 $54,516.78
Beneficiary: the
surviving spouse,
William C. Moats is
named as primary
beneficiary. By
Disclaimer dated March
23, 2015, William C.
Moats disclaimed his
interest in the annuity;
therefore, the balance
will pay to the
contingent beneficiary,
the decedent's son,
Curtis W. Moats.
TOTAL(Also enter on line 7,Recapitulation)$ $54,516.78
If more space is needed,use additional sheets of paper of the same size.
9W46AF 2.000
REV-1511 EX'(0&13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Sonia R. Moats
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
None
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees: $750.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
1 Register of Wills
filing fees $15.00
TOTAL(Also enter on Line 9,Recapitulation) $ $765.00
3w46Ac 2.000 If more space is needed, use additional sheets of paper of the same size.
I I i
REV-1.513 EX+(01-10) SCHEDULE J
pennsylvania
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Sonia R. Moats
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec. 9116(a)(1.2).]
1. Curtis W. Moats
1112 White Dawn Lane
Mechanicsburg, PA 17055
A11 of Residue: $53,751.78 Son $53,751.78
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. $ $0.00
9W46Ai 2.000 If more space is needed, use additional sheets of paper of the same size.
DEATH CERTIFICATE
H105.805 REV(9/111
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 11,rya 11 --yam This is to certify that the information here given
STH OF p
Ey' _ correctly copied from an original Certificate of Dea
duly filed with me as Local Registrar. The origin
o Z certificate will be forwarded to the State Vit
v n Records Office for permanent filing.
P 20734174 kl, A�=
1 �Y
Certification Number Local R istrar Date Issued
./Print In COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
HeInk, CERTIFICATE OF DEATH State File Number:
1.Decedent's legal Name IFirsl.Mlddk,Last,SuKa) 2.S<v 3.Social Security Number a.Data of Death I""Day/Yf)Ispell Mo)
Se R2�M.e)e /7700{s F ys9 yL 99.�s is /
St.Age-last Birthday(Ys) Sb.Under l Year 15c.Under l Da 6.Dale of Birth(m./Day/Yearl(Spell Month) 7a.Birthplace(Cryand State ,Foreign Country)
Months Days Hours Mhutes T p S
2a J Ul O )9.33 7b.Birthplac¢(Cpunryl
Ba.Residence(State or Foreign Country) BE.Residence(Street and Number-In ud���,Ietademllvad
d Decedent Live in a T.,Zlp7
P& �/&3/ E"4 -i- r d I1 In !Intwo.
Be.Residence .- I ')av pr. 3a
.ter an Be.Residence(2Ip CMeI decedent lived within limits of city/bor..
9.Evi�aP[[In US Armed Forces] 10.Marital Status at lime al Death .,Mari ❑Widowed 11.Surviving Spouse's NZ,11 1fe,r,name prior to Rrst maMage)
B'Yes 0 No 0 Unknown 0 Divorced 0 Never Married O Unknown S
�2-nFatharri
aes Name(Fl,H,Middle,Last,S,ffia( 13.Moher',Name Prior to First Mage(First,Middl,Last)
//1 M 0,5, )�A /
Irl'.Informant's Na ]Ab.flel•tionship to Decedent Iac_Inlormant's Mailing Address lStreet and Number,C[y,$tale.2lp Code) /7USS-
C
G __ __ _______ 15x.PI-ace-o Dea t C!H 1 e ___ r 4
Q Il Deathylcc-- ina Hosp- ♦�Inyat�ent Hr Oeath Occurred Somewhere Other Than a Nofpltal: Hpspla fatlllty T]Oecedent's Hame
c �•� rgencyflooMOutpat- 0C.,don ANival ONunmi,Home/LonB'Term Care Facility ❑Other(Spedfvl
15b.Facility Name llFnot lnstitu[lon,g!ve street end number) IISc.Otygr Town,State,and 21 Code 15d.County off Oeeth
cr
m16x.Met Mo10 position 0 Bur al PTremation 161I.Da[e f-posluan ]6c.Place of Dlspositlon(Name of cemetery,crematory,or other place)
0 Removal from State 0 Donadgn
o 0therl5p¢Ify) 9 as ac/y ,n / Q
2 f6tl.Location of Dlspositlon(City or Town,Slate,and 2b) l IGuner 15erylce ......
or Pe inCs ge gllnterment 176.Lkense Number
E 17c.Name nd Complete Addre4 of Funeral Facility O L
/7 S
m S• 3'7 _f /Y7GeQc 'c9
m 1 g ecedent',(ducatlon-G ck the bqx that best describes the 19.Decedent of Hi panic Origin Check the 20.Decedent's Race-heck ONE OR MORE races to Ndi .what
r highest degree or Mel O nluc II cempkted at the timeof death. boa that best describes.tether the decedent the��d...dent considered himself or herself to be.
❑8th gratle or less is Spanish/Hispanit/Lats.Check the"No' 0whlle ❑Korean
0 No tliploma,9th,12th grade boa decedent!,not SPanlsNHispank/l•tlno. ❑Black or Afrit-American 0 Vietnamese
(Ja Highs 101 graduate 11 GED completed No,not SpanishMhPanWLatlno 0 American Indian or Alaska Native ❑Other Aslan
0 Some college credit,but no degree 0 Yes.Mexican,Meak':n American,Chlcano ❑Asian Indian ❑Native Hawallan
O Associate degree(e.g.AA,ASI O Yes,Puerto Rican 0China,, ❑Guamanian or Chamorro
0 Bachelors degree(..,.BA,AB,BS) 0 Yes.Cuban 0 Flllpina 0 Samoan
0 Masters degree(e.g.MA,MS,MEng,MEd,MSW,MBA) 0 Yes,other SFHmbh/Hi.jemc/Lttlno O lapanese 0 Other Pacific Islander
0 Doctorate(e.g,PhD,EdD)gr Professional degree (Specify) 0 Other(5pedfy)
e..VD,
D DDS,
DS DVM LLB 1D
21.Dece�dent's Single Race Self-Dest ruitkn-Check ONLY ONE m indlole what the decedent conddereof himself or herself to be. 22x.Decedent's Usual Occupation-Indicate type of work
1[X 'a ❑lapanese O Samp•n dm d.Hngmostolwprkingllfe.DONOTUSERETIRED.
0 Black or Afdcan American 01-- 0Other Pacirith oder
O American Indian or Alaska Native ❑Vietnamese ODon't K-ftt Sure Gler FGG
0 All-,tn flan 0 Other Aslan 0 Refused 221.KIM al Business/Industry
0 Chinese 0 N.11N,Hawallan ❑One((5peclty;
0 Filipino 0 Guamanian or Chamorro Gr •� �rY•�e
REM313a.23d MUSTBECOMPLETED 23a.Date Pro unced Dnead(Mo/Dayn'r) 231,.lgnature of Person Pronouncing Death Only when applicable) 23c.11-1Number
BY PERSON WHO PRONOUNCES OR a�'Q�. L,._ I-1 �plu is
CERTIFIES DEATH ss"^'ccCE + K,� �S DI43:18'
23d.Date Signed(Mo/Oay/Yrl 2•.Time of Death
5 _TCMHr.- Iq JU1y 5:5� pr+l 25.Was Medical Exam1ner.1 Corona,Centacl.d2 Id Yet 0 No
CAUSE OF DEATH i APProxlm It,
26.Partl.Enterthechalnolevents-diseases,Injuries,or complications-that direcity-ted the death.DONOT¢merterminaleventssuchascardiacarrest, I Interval:
respiratory arrest,or ventricular Hbrillatien without showln8 the etblogy.OONOTABBREVIATE.Enter Pnl,.ne cause on•fine.Add additional lines it necessary. I Onset to Death
IMMEDIATECAUSE ------------> •. CArJIU ✓1F'MOyfdlf Arre.tji- 1011
IFlnal disease or condition Ou to(mF ac-sequence of)',
resulting in death) I
b PCCut's MyD(:Ar(II •11 ,,rarr.ii A-
SequemL,ty lbt condition,, Due to lar11 acon,e
q-ce Pfl:
If any,leading to the cause /'
Ilstedcnlinea.En-the C(2rUnary ArFa('VV D,5ease_
UNDERLYING CAUSE d Duero(or as a consequence of):
(tlisease 11Injury that
initiated the events resulting d.
In death)LAST. Due to Ion as a consequence of):
s 26.Part 11.Enter other II¢nlRcanl rontlltlons contrlbutine to tlealh but not resulting in the underlying cause Ivan in Part 1. 27.Waf an autopsy pe f.,medi
i TC D a102id H l ;Flexr a ❑Yes tB'No
4 Y(� yp�1P Nyprr lLN ion Dai t. ;rn LTD "TlR 28.Wereautopsylindingsavallabk
to Complete the cause of death?
0 Yes „ff No
d 29.If Female: 3D.Did Tobacco Use Corldbule I.Death? 31.Manner of Death
E X Not pregnant withln as,year 0 Yet 0 Probably •,(+J Natural 0 Homidtle
0 Pregnantattimeoldeath so No 0 Unknown
Not pre rant,bu[ a nanf wihin A2 da ❑Accident 0 Pentling lnws[Igatlon
Is 8 prg ,s.Ide.. [I Suicide O Could not be determined
0 Nol pregnant,but pregnant 43'tla"to l Year before death 32.Date of lnjurl'(Mo/Day/Yt)(Spell Month)
0 Unknown 11 pregnant within the past year 33.Time of Injury
34,Place of Injury(e.g•home,construction site;farm,school) 35.i.anon of Injury(Street and Number,City,County,State,21p Code)
36.Injury at Work 37.If Transp,n tion Injury•Specify: 38.Cescnbe How Injury Occurred:
0 Yes 0 Driver/Operator 0 Pedestrian
0 No 0 Passenger 0 Other(Specify)
39x,Certifier-Physlcian,certified nurse practitioner,medical.xaminer/coroner(Check only•�,a):
OCertlMng only-To the best of my knowledge,death occurretl due to the ca C'ac)and mann •ted.
,p•Pronouncing d Certifying-7,the best ofmy knowledge,death occurred at the time,d andpl......dduetothecause(a)and mannerttated.
0 MedkAI Examiner/Coroner-/O'n t,,h�e/b . LmHion and/or lnvestlgatbn,In myo,di death occurred at the time,date,and Platt,and due to the causes)and manner stated.
Signature of certifier: yLEI.& nHe of a.nm.r: - L: 'K01 Ucense Number. V,01a13+-18'
39b.Name,Address and rip Code of PenanCampletlnB Cause of Death(ken,26) 39I Date Sl,ned(Mo/Day/Y,)
52a �n Mod1 p,p. So3 rt,.dl y Sr Cat ri fl P4l�oll s tYkrbr� (H hof H
aD.ReBiftrars Dlstric[Number dl.Regbtrar's 5lgna[ure pp 12.Registrar 111,Date(Mo/Day/Yr)
9 %
43.Amendments
PA REV-1500
SCHEDULE G
INTER-VIVOS TRANSFERS and
MISCELLANEOUS NON-PROBATE
PROPERTY
'�"'Jrhrivent Financia!
for Lutherans®
Death Claim Service Kit
Deceased: Sonia R Moats Date of Death: 09/19/2014
1112 White Dawn Ln Date Prepared: 09/24/2014
Mechanicsburg PA 17055-5328 Claim Number: 541044
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 speclal instructions or messages related to this claim,
Contract Issue Date Issue State Product Type
B4609790 08/27/2007 PA Fixed Annuity
Additional Information:
1. A beneficiary, currently not a Thrivent member,who is interested in becoming a member and is
eligible for membership, can apply for membership by completing the membership application(form
15659). Or, if no product is purchased at the time of claim, the beneficiary can apply for membership
through the associate membership offer and for the first year the$19.95 fee is waived. For an
associate membership, complete either the application available in the Associate Membership
brochure (form 33119)or the Membership Application(form 15659)available in CAP. On the
application include the letters DC at the top of the page to Indicate death claim and we will waive the
fee for the first year. For information about Thrivent's membership rules or the associate
membership program refer to FieldNet or call (800)847-4836, ext 86034.
2. Caller: FR of Record (or OP Jerry Weaver) How notified: Family Member-Curtis Moats- (717) 691-
3162 - 1112 White Dawn Ln Mechanicsburg, PA 17055-5328 -son Funeral Home Info: Myers-
Buhrig Funeral Home- Mechanicsburg, PA
Expectations for Claim Service:
Within 10 days of receipt, 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 personally know 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 and accurate
ALL INFORMATION ON THIS PAGE IS FOR INTERNAL USE ONLY, Page 1 OI 6 Deceased's Customer ID: 500711334
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 assisting a beneficiary and s/he wants to call us, please tell them to call 1-800-847-4836. If
you are a thrivent financial 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:
JAMIE C FRENCH
214 SENATE AVE STE 100
CAMP HILL PA 17011-2336
Contact: 717-525-9535
ALL INFORMATION ON THIS PAGE IS FOR INTERNAL USE ONLY. Page 2 of 6 Deceased's Customer ID: 500711334
VThrivent Financial
for Lutherans®
Death Benefit Information Fixed Annuity Contract: B4609790
Deceased: Sonia R Moats Date of Death: 09/19/2014
Date Prepared:09/24/2014
Claim Number: 541044
Death Benefit
Cost Basis $ 0.00
Taxable Gain $ 54,516.78
Enhanced Benefit $ 0.00
Total Death Benefit $ 54,516.78
Beneficiary Designation
Base Coverage:
PROCEEDS WILL BE PAID TO WILLIAM C MOATS, 716 LISBURN RD, CAMP HILL, PA, 17011-7424,
SPOUSE, IF SURVIVING; OTHERWISE TO CURTIS W MOATS, 1112 WHITEDAWN RD.,
MECHANICSBURG, PA, 17055, CHILD, IF SURVIVING; OTHERWISE TO THE ESTATE OF THE
OWNER.
ADDITIONAL BENEFICIARY INFORMATION FOUND
Updated/additional Information for beneficiary WILLIAM C MOATS -Customer ID 500711059 -
PRIMARY
Date of Birth- 10-20-1931
Address(es)
1112 White Dawn Ln, Mechanicsburg, PA 17055
Telephone Number(s)
Residential - (717)737-5963
Updated/additional Information for beneficiary CURTIS W MOATS -FIRST CONTINGENT
Date of Birth -04-02-1961
Address(es)
1112 WHITEDAWN RD., MECHANICSBURG, PA 17055
ALL INFORMATION ON THIS PAGE IS FOR INTERNAL USE ONLY. Page 3 of 6 Deceased's Customer ID: 500711334
Beneficiary Designation
Special Messages
1. The spouse is the beneficiary and can choose to continue this contract with the Annuitant
Exchange/Spousal Beneficiary Option (SBO), If this Is a qualified annuity, SBO is elected and the
deceased did not have RMD satisfied,then the RMD is required to be satisfied before the SBO is
processed. Please mark the RMD on the Beneficiary Statement form 28E. If the contract is a
variable annuity,a new Telephone Transaction Authorization(form 15771)is needed, if desired and
the Transfer of Ownership form (26872) should also be completed. If the contract has an Indexed
account,the interest earned since the last index crediting date,if any, is reflected in the death
benefit value, If the SBO is elected, this interest will not be credited until the next index crediting
date for this contract.
2. 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 Notification
for Federal and State Income Tax Withholding section on the Claimant s Statement. If NO
withholding is desired, the first box in the Withholding section should be checked. If the beneficiary
DOES want withholding,the appropriate section should be completed.
3. To assist the beneficiary In selecting a distribution method, you should refer to the Annuity Spouse
First Generation Beneficiary Option Guide(Roth IRA). This guide can be printed from FieldNet,
Products& Marketing, Know Your Product,Annuities, Claims,Annuity Beneficiary Option
Guides/Death Tax Charts..
ALL INFORMATION ON THIS PAGE IS FOR INTERNAL USE ONLY, Page 4 of 6 Deceased's Customer ID: 500711334
Thrivent Financial
for Lutherans®
September 24, 2014
Estate of Sonia R Moats
1112 White Dawn Ln
Mechanicsburg PA 17055-5328
Subject : Estate of Sonia R Moats ROTH IRA Contract 84609790
To Whom It May Concern:
Thrivent Financial for Lutherans is required by the Internal Revenue(IRS)to report the contract value as
of the date of death to the estate of Sonia R Moats. The IRS form 5498 will be sent to the above
address in January of next year. Form 5498 will report the fair market value of the ROTH IRA plan to
Sonia R Moats's estate.
This letter should be retained for income tax purposes when filing the decedent's income tax return.
Date of Death: 09/19/2014
Contract Value as of Date of Death: $54,516.78
If you have any questions regarding the above information, please contact your Financial Associate,
JAMIE C FRENCH, whose telephone number is 717-525-9535. You are also welcome to call Thrivent
Financial for Lutherans at 800-847-4836.
Sincerely,
Death Claims
Death Claims&Services
Product Services Department, FSO
Cc : JAMIE C FRENCH 0165 43402 00
Sonia R Moats , deceased, Contract#64609790, CIF#500711334
Deceased's Customer ID: 500711334
VThrivent Financial
.for Lutherans®
Forms and Other Requirements Needed to Pay Death Claim
Deceased: Sonia R Moats Date of Death: 09/19/2014
Date Prepared: 09/24/2014
Claim Number: 541044
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 Forms:
1. Clalmanfs Statement(Form 28E).One per beneficiary.
2. For claims$25,000 to$250,000,fax the front and back of the certified death certificate to 800-225-
2264 or e-mail a scan to Death Claim DeathClm. For claims under$25,000, a copy of a death
certificate for the insured is required. For claims that exceed$250,000 an original certified death
certificate is needed. The original needs to be mailed. It cannot be faxed.
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.
7. If Annuitant Exchange/Spousal Beneficiary Option is elected, complete the Beneficiary Designation
section on the Claimant's Statement(Form 28e).
8. The Substitute W-4P section on the Claimant's Statement(Form 28E) must be completed.
ALL INFORMATION ON THIS PAGE IS FOR INTERNAL USE ONLY. Page 6 of 6 Deceased's Customer ID: 500711334
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