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Home My WebLink About02-21-08 -.J 15056051047 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Last Name Suffix MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW _ 1. Original Return c:::> 2. Supplemental Return c:::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c:::> 4. Limited Estate c:::> 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) c:::> c:::> 6. Decedent Died Testate c:::> (Attach Copy of Will) c:::> 9. Litigation Proceeds Received c:::> 8. Total Number of Safe Deposit Boxes c:::> 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number W ill i a m F. e Stepha e Firm Name (If Applicable) r 7 7 2 4 5 3 4 4 REGISnhU>F WILLS~.~E ONLY 1_- ) ~~~~ First line of address i' : '...;...} '" ... I .._~ 870 E a s y R 0 a d Second line of address City or Post Office State ZIP Code . DATE FILED!"..) Carlisle P A 7 0 5- 9 5 5 5 Correspondent's e-mail address: 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. ,SIGJ'lA~UR~ OF PERSOt'} RESPONS~~LE FOR FILING R'7lURN Q.+.- I a, 4' DATE \0~..::;h ~.t~9(1..., L ~ -i.. __ 2/21/08 ADDRESS I 870 Easy Road, Carlisle, PA 17015-9555 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 --.J _J 15056052048 REV-1500 EX Decedent's Social Security Number Decedent's Name: Jeremy Ross Keifer RECAPITULATION 6 68 3 6 3 8 1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. o 0 2. Stocks and Bonds (Schedule B) . . . 2. o 0 4. Mortgages & Notes Receivable (Schedule D) . . 4. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. 5. Cash. Bank Deposits & Miscellaneous Personal Property (Schedule E) . 5. 6. Jointly Owned Property (Schedule F) c::::> Separate Billing Requested 6. l. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c::::> Separate Billing Requested.. . . 7. a. Total Gross Assets 8. 3. Funeral Expenses & Administrative Costs (Schedule H). 9. 11. Total Deductions (total Lines 9 & 10).. ... . . 11. 1 D Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . 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) . . . . . . . . . . . . . . . . . 12. . . . . . 13. 14. Net Value . . . . . . 14. 6 TAX COMPUTATION - SEE 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.D.4.5. 17 Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . . . 15. 2 . 2 16. . 17. . 18. 19. 2 2 . 2 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT <=> Side 2 L 15056052048 15056052048 --.J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Jeremy Ross Keifer STREET ADDRESS 106 A Street File Number 21-07 -00 526 P.O. Box 205 CITY Plainfield PA ZIP 17081 STATE Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) $ 12.21 TotaICredits(A+B+C) (2) 0.00 3. InterestJPena.lty if applicable D. Interest E. Penalty TotallnterestJPenalty ( 0 + E ) (3) 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 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. S 12.21 A. Enter the interest on the tax due. S 12.21 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: Ves No a. retain the use or income of the property transferred;......................................................................................... 0 IKJ b. retain the right to designate who shall use the property transferred or its income; ......................... 0 lKJ c. retain a reversionary interest; or..................................................................................................................... 0 IKJ d. receive the promise for life of either payments, benefits or care? ......................................................... 0 fKL 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................... .................................................... ... 0 IX] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? '''' 0 IKJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................................ 0 IKJ 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. 99116 (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 zero (0) percent [72 P.S. 9911E; (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 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 zero (0) percent [72 P.S. 99116(a)(1.2)J. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. S9116(1.2) [72 P.S. s9116(a)(1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(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~ 1508 EX. (1~>7) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jeremy Ross Keifer 21-07-00526 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 2. Members 1st Federal 5000 Louise Drive P.O. Ibx 40 M2chanicsburg, PA 17055 Vehicles (Kelley Blue Book): 1990 Jeep Cherokee Limited Sport Utility 4D Credit Union (account #148333) Jun 24 checking account ending balance Jun 24 -- savings account ending balance $ 2 6 5 . ,0 3 5,783.96 Trade-in value: $ 650.00 1985 BMW 3 Series 325 Sedan 2D Trade-in value for 1988: $ 450.00 1988 Nissan Pickup E Short Bed Trade-in value: $ 285.00 3. Internal Revenue Service 2007 Income Tax Return Refund $ 901.00 TOTAL (Also enter on line 5, Recapitulation) $ 8,334. 99 (If more space is needed, insert additional sheets of the same size) Send Inquires to: 5000 Louise Drive PO Box 40 Mechanlcsburg, PA 17055 www.members1s1.org Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 ex!. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 MEMBERS 1st FEDERAL CREDIT UNION JEREMY R KEIFER C/O WILLIAM & STEPHANIE KEIFER, EXECUTOR 870 EASY KEIFER CARLISLE PA 17013 Statement of Accounts May 25, 2007 thru Jun 24, 2007 Account Number: Account Balances at a Checking: Savings: Certificates: Loans: Money Management: 148333 Glance: 265.03 5,783.96 0.00 0.00 0.00 Page: 1 of 2 Are you looking for a way to invest your hard earned money? Consider a certificate from Members 1st. Ask an associate about our monthly specials or visit www.members1st.org for more information. CHECKING ACCOUNTS 11 - CHECKING Date . May 25 May 25 May 29 May 31 May 31 Jun 24 Transaction Description Balance Forward Withdrawal Debit Card OS/24178501983997 B & C SOUTHSIDE TAVERN MOUNT Check 000232 Tracer 0529020483 Deposit Swipe 5 Rebate Withdrawal Monthly ATM Fee Ending Balance CHECK SUMMARY Check # OCl0232 Amount 60.90 Date May 29 Date SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Transaction Description May 25 Balance Forward May 30 Deposit by Check May 31 Deposit Dividend 1.000% Annual Percentage Yield Earned 1.010% from 05/01/2007 through 05/31/2007 Jun 08 Deposit by Check Jun 24 Ending Balance Additions Subtractions 23. 75- 0.50 60 . 90- 1.00- Balance 350 . 18 326 . 43 265.53 266.03 265 . 03 ~ . Q65. 03-~; -------..- Balance 5,131.60 5,359. 60 5,363. 67 YTD SUMMARIES 5.783. 96 ~ C5,783.96~ TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 11 CHECKING 18.28 0.00 Check # Amount Additions Subtractions 228.00 - r(~ (~c..rL 4.07 420.29 - \"''1 Gha K - - - Continued on following page - -- ~l~t !:W~~!l~.!: Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.members1st.org Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 ex!. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 May 25, 2007 thru Jun 24, 2007 Account Number: 148333 Page: 2 of 2 Total Year To Date Dividends Paid NOTE: Total includes closed shares Total Year To Date Interest Paid NOTE: Total includes closed loans 18.28 20.04 Add Your Photo For Security Your personal safety and financial security are top rriorities at Members 1st. As a result of increased scams and fraudulent activity tllroughou the entire country, we are strongly encouraging members to have their photos added to their account records. When visiting our branch offices, you may be asked by one of our Associates to allow us to take your photo. This member identification program will assist in our fraud deterrence initiatives and will take our identity theft prevention program to the next level. We are experiencing an increasina number of attempted fraudulent activities and as a result, we need to be able to verify your identity immediately upon retrieving your account information. In addition to having your photo in our files, you may be required to show additional forms of identification based on the type of transaction you are seeking. This is for your protection and security and we appreciate your ongoing cooperation and understanding. Kelley Blue Book - Trade-In Pricing Report - Jeep, Cherokee 2/15/0810:12 AM tI~~~ .. Send to Printer advertisement Jee~ [~~~~~ $~~...:...._;~; ~tAt.f!R ~ "\"")ni4-ONi~CASHQ~SftfCTM()OU.S~ ~ 4'::! L~:~"~': ------ PP'5ItiENTSOAVf'iENl l!Il1M$2,29IWlA'I'__' I)U eIlM"::; CMtR".n:u~;R4 1990 Jeep Cherokee limited Sport Utility 40 advertisement Close Window ../ Fair $650 BLUE BOOK' TRADE.IN VALUE Condition Value Excellent $1,375 Good $1,100 (Selected) Search Local Listings: View Jeep Cherokee Search all Ciassifieds in 17013 Average Consumer Rating (173 Reviews) Read Reviews uuu'l1'l 4.4 out of 5 Review This Vehicle Vehicle lHighlights Mileage: Engine: Transmission: Drivetrain: 170,000 6-Cyl. 4,0 Liter Automatic 4WD Selected Equipment Standard Air Conditioning Power Steering Power Windows Power Door Locks Tilt Wheei Cruise Control AM/FM Stereo Cassette Leather Dual Power Seats Roof Rack Alloy Wheels Blue Book Trade-In Value Trade-in Value is what consumers can expect to receive from a dealer for a trade-in vehicle assuming an accurate appraisal of condition. This value will likely be less than the Private Party Value because the reselling dealer incurs the cost of safety inspections, reconditioning and other costs of doing business, Vehicle Condition Ratings Excl~lIent CX)U(7Cl $1,375 .. Looks new, is in excellent mechanical condition and needs no reconditioning, .. Never had any paint or body work and is free of rust. .. Clean title history and will pass a smog and safety inspection, .. Engine compartment is clean, with no fluid leaks and is free of any wear or visible defects, http://www.kbb.com/KBB 1 UsedCars 1 PricingRe port .as px?Y earld = 1990& Ve h." rue%7 c4 3 483 2%7 ctrue%7 c4 3 4886%7 ctrue&Cond ition = Fai r&Printa ble =true Page 1 of 2 Kelley Blue Book - Trade-In Pricing Report - Jeep, Cherokee 2/15/0810:12 AM . Complete and verifiable service records. Less than 5% of ail used vehicles fail into this category. Good u(1OO $1,100 . Free of any major defects. . Clean title history, the paints, body, and interior have only minor (if any) biemishes, and there are no major mechanical problems. . Little or no rust on this vehicle. . Tires match and have substantial tread wear ieft. . A "good" vehicle wiil need some reconditioning to be sold at retail. Most consumer owned vehicles fail into this category. ../ Fair (Selected) ODD $650 . Some mechanical or cosmetic defects and needs servicing but is stiil in reasonable running condition. . Clean title history, the paint, body and/or interior need work performed by a professional. . Tires may need to be replaced. . There may be some repairable rust damage. Poor (~j N/A . Severe mechanical and/or cosmetic defects and is in poor running condition. . May have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. . Branded title (salvage, flood, etc.) or unsubstantiated mileage. Keiley Blue Book does not attempt to report a value on a "poor" vehicie because the value of these vehicles varies greatly. A vehicle in poor condition may require an independent appraisal to determine Its value. * Pennsylvania 2/15/2008 Kelley Blue Book - ;rrade-In ~ricing Report - BMW, 3 Series 2/15/08 10:07 AM -~~~ A Send to Printer advertisement ,~' ..., ..J( ~, ,-.. '/\ I Nfl " ; r ; 1988 BMW 3 Series 325 Sedan 20 \(\'lS? BLUE BOOKc~ TRADE-IN VALUE Good $800 Close Window Condition Value Excellent $1,025 ./ Fair $450 (Selected) Search Local Listings: (~) View BMW 3 Series o Search all C1assifieds in 17013 Average Consumer Rating (49 Reviews) Read Reviews t'rt'rt'rt'riJ 4.8 out of 5 Review This Vehicle Vehicle Highlights Mileage: Engine: Transmission: Drivetrain: 169,000 6-CyL 2,7 Liter 5 Speed Manual RWD Selected Equipment Standard Air Conditioning Power Steering Power Windows Power Door Locks Cruise Control AM/FM Stereo ABS (4-Wheel) leather Sun Roof Alloy Wheels Blue Book Trade-In Value Trade-In Value is what consumers can expect to receive from a dealer for a trade-in vehicle assuming an accurate appraisal of condition, This value will likely be less than the Private Party Value because the reselling dealer incurs the cost of safety inspections, reconditioning and other costs of doing business, Vehicle Condition Ratings Excellent r~7r~'[,;r_j[j $1,025 . Looks new, Is in excellent mechanical condition and needs no reconditioning, . Never had any paint or body work and is free of rust . Clean title history and will pass a smog and safety Inspection, . Engine compartment is clean, with no fluid leaks and is free of any wear or visible defects. http://www.kbb.com/KBB / UsedCars / PricingRe port .aspx?Y earld = 1988&Ve... 7 c 170 13%7 c 100%7 c 1 0%7 c48662 3%7 cfalse&Cond ition =Fair&Printable=true Page 1 of 2 Kelley Blue Book - Trade-In Pricing Report - BMW, 3 Series 2/15/0810:07 AM . Complete and verifiable service records. Less than 5% of all used vehicles fall into this category. Good O~O $800 . Free of any major defects. . Clean title history, the paints, body, and interior have only minor (if any) blemishes, and there are no major mechanical problems. . Little or no rust on this vehicle. . Tires match and have substantial tread wear left. . A "good" vehicle will need some reconditioning to be sold at retail. Most consumer owned vehicles fall into this category. ../ Fair (Selected) Ot'10 $450 . Some mechanical or cosmetic defects and needs servicing but Is still in reasonable running condition. . Clean title history, the paint, body and/or interior need work performed by a professional. . Tires may need to be replaced. . There may be some repairable rust damage. Poor NjA . Severe mechanical and/or cosmetic defects and is in poor running condition. . May have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. . Branded title (salvage, flood, etc.) or unsubstantiated mileage. Kelley Blue Book does not attempt to report a value on a "poor" vehicle because the value of these vehicles varies greatly. A vehicle in poor condition may require an independent appraisal to determine Its value. ~.'If; t~_t * Pennsylvania 2/15/2008 http://www.kbb.com/KBB/ UsedCars/PricingReport.aspx?Yearld = 1988&Ve... 7c 170 13%7c 100%7c 10%7c48662 3%7cfalse&Condition =Fair&Printable=true Page 2 of 2 ,~ ~ K:lley Blue Book - Trade-In ~ricing Report - Nissan, Pickup -~~~ advertisement [cJA[~IFjA;r1! !~ YO~rN~xtUsed Car V",,'.. ....TOR' R,"""" .\ iI~~:;;/1 ;:':;":: I'} rl,B!~ to Be True=- ~ <,,;"'1#' Lrt,/}: \~*'%2~ . 1988 Nissan Pickup E Short Bed BLUE BOOKb TRADE-IN VALUE Condition Value Excellent $600 Good $495 ../ Fair $285 (Selected) Search Local Listings: View Nissan Pickup Search all Classifieds in t 7013 Average Consumer Rating (79 Reviews) Read Reviews 'tn;.':ruui 4.5 out of 5 Review This Vehicle Vehicle Highlights Mileage: Engine: Transmission: Drivetrain: 220,000 4-Cyl. 2.4 Liter 5 Speed Manual 2WD Selected Equipment Standard Optional Power Steeri ng Sliding Rear Window Bed Liner Blue Book Trade-In Value Trade-in Value is what consumers can expect to receive from a dealer for a trade- in vehicle assuming an accurate appraisal of condition. This value will likely be less than the Private Party Value because the reselling dealer incurs the cost of safety inspections, reconditioning and other costs of doing business. Vehicle Condition Ratings Excellent [,}("X".."10(7 . Looks new, is in excellent mechanical condition and needs no reconditioning. . Never had any paint or body work and is free of rust. . Clean title history and will pass a smog and safety inspection. . Engine compartment is clean, with no fluid leaks and is free of any wear or visible defects. . Complete and verifiable service records. $600 2/15/089:56 AM .... Send to Printer Find Out Now! Enter a VIN to get started: IEnter a vtN Q":Ul'iillil" advertIsement Close Window http://www.kbb.com/KBB/ UsedCars/ PricingReport.aspx?Yearld = 1988&Veh.. .ue%7c517 5 52%7ctrue%7c517 5 52%7cfalse&Condition=Fair&Printable=true Page 1 of 2 . t' .", K~iley Blue Book - Trade-In P,ricing Report - Nissan, Pickup 2/15/089:56 AM Less than 5% of all used vehicles fall into this category. Good Ctr.1l".'fr.l $495 . Free of any major defects. . Clean titie history, the paints, body, and interior have only minor (if any) blemishes, and there are no major mechanical problems. . Little or no rust on this vehicie. . Tires match and have substantiai tread wear left. . A "good" vehicle will need some reconditioning to be sold at retail. Most consumer owned vehicles fall into this category. ./ Fair (Selected) Ot'lfJ $285 . Some mechanical or cosmetic defects and needs servicing but is still in reasonable running condition. . Clean title history, the paint, body and/or interior need work performed by a professional. . Tires may need to be replaced. . There may be some repairabie rust damage. Poor o NjA . Severe mechanical and/or cosmetic defects and is in poor running condition. . May have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. . Branded title (salvage, flood, etc.) or unsubstantiated mileage. Kelley Blue Book does not attempt to report a value on a "poor" vehicle because the value of these vehicles varies greatly. A vehicle in poor condition may require an independent appraisal to determine its vaiue. * Pennsylvania 2/15/2008 http://www.kbb.com/KBB/ UsedCarsl PricingReport.aspx?Yearld= 1988&Veh.. .ue%7c5 175 52%7ctrue%7c5175 52%7cfalse&Condition=Fair&Printable=true Page 2 of 2 .. " Form 1040EZ label L (See page S.) A B Use the IRS E label. L Otherwise, H please print E or type. R E Presidential Election ~ Campaign (page 9) 1 Income Attach Form(s) W-2 2 here. Enclose, but 3 do not attach, any payment. 4 5 Payments and tax Refund Have it directly deposited! See page 15 and fill in 11b, 11c, and 11 d or Form 8888. Amount you owe Third party designee Sign here Joint return? See page 6. Keep a copy for your records. Paid preparer's use only " Department of the Treasury-Internal Revenue Service Income Tax Return for Single and Joint Fliers With No De endents (L) 2007 OMB No. 1545-0074 I Your social security number Ila I : Lt 11' :3V'Sa>' Spouse's social security number .... You must enter .. your SSN(s) above. Checking a box below will not change your tax or refund. .~ o You o Spouse l \ (Q c\ ')... 2 5' 3 I'S'DI 4 1~?5~ Your first name and initial je..c~ R. Last name K t;-I c=.t-L If a joint return, spouse' fir name and initjal Last name Home address (number and street). If you have a P.O. box, see page 9. Apt. no. ~t. IP code. If you have a foreign address, see page 9. ~L\<;' -RA- \I D I -:{" Check here if you, or your spouse if a joint return, want $3 to go to this fund. Wages, salaries, and tips. This should be shown in box I of your Form(s) W-2. Attach your Fornl(s) W-2. Taxable interest. If the total is over $1,500, you cannot use Form 1040EZ. Unemployment compensation and Alaska Permanent Fund dividends (see page 10). Add lines 1, 2, and 3. This is your adjusted gross income. If someone can claim you (or your spouse if a joint return) as a dependent, check the applicable box(es) below and enter the amount from the worksheet on back. o You 0 Spouse If no one can claim you (or your spouse if a joint return), enter $8,750 if single; $17,500 if married filing jointly. See back for explanation. 6 Subtract line 5 from line 4. If line 5 is larger than line 4, enter -0-. 111is is your taxable income. ~ 7 Federal income tax withheld from box 2 of your Form(s) W-2. 8a Earned income credit (EIC). 5 ~/~ 6 7 8a 4'5"02- , S- b Nontaxable combat pay election. 8b 1- 9 9 \ 7:> )L ~ 10 Tax. Use the amount on line 6 above to find your tax in the tax table on pages 18-26 of the booklet. Then, enter the tax from the table on this line. 11a If line 9 is larger than line 10, subtract line 10 from line 9. This is your refund. If Foml 8888 is attached, check here ~ 0 l ~lJ ~ c Type: 0 Checking 0 Savings L.l.L 10 '1S: lla '10 ~ b Routing number ~ d Account number 12 If line 10 is larger than line 9, subtract line 9 from line 10. This is the amount you owe. For details on how to pay, see page 16. ~ 12 Do you want to allow another person to discuss this return with the IRS (see page 16)? 0 Yes. Complete the following. D No Phone Preparer"s .. signature r Firm's name (or ~ yours if self-employed), address, and ZIP code Date ) Form 1040EZ (2007) For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 32. Cat. No. 12617R STATEMENT FOR RECIPIENTS OF PA UNEMPLOYMENT COMPENSATION PAYMENTS UC-1099G ,., -'. Payer: This form shows the total unemployment compensation paid to you by the Department of Labor & Industry in the tax year indicated, and the amount of Federal income tax withheld (if you requested tax withholding). This is important tax information and is being furnished to the Internal Revenue Service (IRS). If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. For income tax purposes, unemployment compensation benefits are reported in the calendar year in which they are paid, regardless of when the claim for benefits was filed. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF UC BENEFITS & ALLOWANCES HARRISBURG, PA 17121-0001 (717) 783-3140 OMB NO. 1545-0120 FEDERAL 10 NO. 23-6003107 SOCIAL SECURITY NO_ TAX YEAR THIS IS NOT A BILL - DO NOT DESTROY - KEEP WITH YOUR TAX RECORDS Dear Recipient: YOU MAY BE ELIGIBLE FOR THE EARNED INCOME CREDIT, which is a Federal benefit for both married and single parents who worked either full or part time during all of or part of the year and earned less than the Federal qualifying amount. If you are eligible, you will either owe less taxes or qualify for a larger tax refund. To file for the Earned Income Credit, fill out and attach "Schedule EIC" to your Federal income tax return. For more information, call the IRS toll free at 1-800-829-1040 or visit www.irs.gov. NOTE: If you were overpaid benefits, and repaid the amount, it is still included in the "TOTAL PAYMENT. n If the repayment was made in the same year as the overpayment, make the necessary adjustment and notation on your Tax Form 1040 or 1040A. Your cancelled check or copy of money order may be used as your proof for adjustments claimed. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity EmployerlProgram TOTAL PAYMENT TAX WITHHELD 161-68-3638 1,507.00 160.00 2007 RECIPIENT'S name, address, zip code JEREMY R KEIFER PO BOX 205 PLAINFIELD PA 17081 UC-1099G REV 1 -08 (f) " " ~ If q; ~ : co .c x 0 c5 5 0 r-- '"' 0 3' " c "' 0- S 0 3' <1l E x lXl Ul J, x q; cO 1'1 x ~ ~ CIl '" '" 1'1 <1l '" 2 '" ---'0 '" " z '" - " 3' a. .~c:: r<'! E z ~ '"' o <1l W <1l 0 -Co xr<'! u "0 <) E ~ 5 z iP: 2'" W <1l S '" c . ~O: (f) " c ::a "6 (l] ~ ~ <1l :::< <) "'C 0 ~ "'..0 c " " " " U5~ Ci -- i:jr- '" " " -0 " " > 0 0 0 0 <) ar- 0 " -0 U U U u ~.3 0 u- (f) :::< <( '" .0 " ." e- N '" '" en ~ ~ N ~ _0 ~ N - <J Qi ci. "' vi E g- O 0- ~ 0 "' " q .. <) " 0> C 0 "' vi rn Q; '" '" Q ~ ;: c g x -s: .c "' '" 0 ",1'1 0 C " Ci 0> '" "' N ;: " >- ~ i;€l ,"0 '" a. " $ E N 0 ;:0 R .. ~ 0 0 J!! 0 0- ii. ;: I <1l " . CIl " 0 0 ... 1'1 <) ~ "N ~N W W ... W I W <ii ... (/) .~ N E ~ i'lo- " -0 "' " 0 8 I- 0 ~ <) CT 0 ",0; 0- W OlD iJ.- :a\oO ==~ <. <) .Q c e-.:: .3 ... ~ W'" tL 0 ;; <n<- :::<... tL ~;;; ~ N ;:;: z ~ M on N "" ~ '" ;: " en C ~ -0 CIlo C!J- -0 UJ .c ~~m c en c u..1- ~ 6 '" <>- co: '" -L.l.l .0 .. E - '0 I: Z vi "" :) ui ~~ :! ~ " ~ :; 0 '" CIlI- lXl Ul 0 0 c Iii ~ i!' zz CIl W I- -I 0 Jf! LLa; c -0 ~~ U i; CO:CIl W Qi 9 u >< " - -0 - 0 '" ala: alcro Q; '" c !w f- '" 20 Z >- u.. "' W W "'r<'! "'", :)u < ci ::11:< z g- "' W '"' Cii (I)~ 0 ." al>< ci '"' '" -..0 E... E ..... ::c E W :;( W 0 C 0- Ul .Q. 0 " ol'll ~ro;"' ~:g 0 u ~ '" ffi8 '"' (;; Ci '" ...- " 1-1- '" ~~ UJ ~ c -I E Ci '" ~ vi N .. c <) u -~~ QN ::II: "' ........ ~ ~ " C -iii $ 01 1-1 ,,:::J "' -w c ~~ " -~ c W <1l e:- (I) € E '" ... 3: ale:( WI W <1l "' E ~ %~ '"' ~ '"' " 0 '" w ;: ... a: 0 0 c :; .~ N >-w Ci Ci 0; W '?- _"ro i ~ u a. 10 Qi c.c E E 0 E 0 W Iii 1" < ~.3 OW w W LL U W (f) 0 a: :c E Ou.. '" .0 " .., (I) .... ;! ~ f- ~ on'" 0 LL ~ " E ~ .9 u ~ ~ g> iii .0 c o E (; ~ "' .EO >- .. REV-1511 EX+ (12-99) . . " , ~.L . .~ , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Jeremy Ross Keifer 21-07-00526 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Hoffman-Roth Funeral Home Timothy Funk -- minister for memorial service Romaine Mellott -- organist at memorial service Gingrich Memorials -- memorial stone Guy A. Eckert -- digging, forming, and placing foundation at Waggoner's United Methodist Church cemetery $2,707.79 $ 50.00 $ 50.00 $3,750.00 $1,228.69 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2. Attorney Fees 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 $61.00 + $15.00 -- Register of Wills $ 76.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 8. Transfer of Title for 1990 Jeep 2007 Commonwealth of PA, Department of Revenue Tax Due $ $ 60.25 1. 00 TOTAL (Also enter on line g, Recapitulation) $ 7, 923 . 73 (If more space is needed, insert additional sheets of the same size) ORIGINAL 2861 ACCT. NO, FE 0 '.Il1W'J.' .~~ '"" . 'L_ }J'p~-t4L<?' 7 ~~... ~ .~"war?j[; ~ j . / % . -rzC~~ <<2..' 9-,"~~JJ ~~" "'-zk'_ ~ ~ k<" Funer?~::~;es l /'1 o./t~ 1<tJ,5:S: ,"-rt -" p.c:FiECK # --I-,y0 ( Name of Deceased o CREDIT CARD ~-(O/(otib Funeral Home & Crematory. Inc. ~ o OTHER ....... .- C7 YJakl _.:2 - c>' J -- J. f?l3y' LAST BALANCE $~ 70771 D INTEREST D LATE PAYMENT CHARGE SUB TOTAL CREDITS LESS PAYMENT ().., 707v 7 ? NEW BALANCE $ __() 11880 f-eb . ' lU,UtJ U"t:ltJp l:jIn~rICn MemorIals '/l'/-'/f.:iti-tJUU'/ p. 1 . 5243 Simpson Ferry Road, Mechanicsburg, PA 17050 (717) 766-5622 · Fax (717) 766-8007 · www,gingrichmemorials,com RECEIPT Date: ~ It ~ ~ O~ Received From.: \2;, ~l t S-\ ~~kQ.~\{' Ke:f~, Amount: $ 51! SO. ~ ( ~.,;,d, wi ~ (.\.~<.~S: "(z410. ~l, (;00 , \./ \<acc- \ Cash J<..... Check # \ q 0 L\ Visa . ~11~(o~ ~2)(Su.) / Me Account Name Je'n.\ft\'1 \2. Ke.~ te:r Acct. # ~ - ~ ~ q s R Balance Rem.aining: $ -e- Notes: __ Tcto1 ~s\ TJf: M~\"M)V'\~: <f 3t1S'o 'Pit l1) (tJ 'F U L L . Gingrich Memorials Representative: ~th\ C~~ " .. ORDER FORM 5243 Simpson Ferry Road, Mechanicsburg, PA 17050 (717) 766-5622 · Fax (717) 766-8007 www.gingrichmemorials.com SOLD TO: j, ...., ". . i I, '\; L ,~ ')-.~/ i''''''''i f"'); ,'~ jJ.. \,/\ { " n'll \:\, \ . K .{ '( \ \ ': ~" (~'" :"-' (~\f t l '''' I v f', i' \" tj l-j "\ I C' 1 I C'l ., Phone (H) J. i..\::\ '\ I"'" ,.".\ \.",i "~) c,{ ~'1 (W) I I \ Foundation By 0,\ '((CI'~ 'I h i o Carved Lettered o Drawing Required o Drafter o Sandblast By Manufacturer Date of Order !!-l4-l1 N 2 d" t1 t"\l'''' ~::Jl . O. -I~~~ ,.;;.,,~')b Supplier Ack. # Date Rec'd Found. Ordered ,\:,''ii"r, 'j j Position Verified 'r, .' i . d iV'1 ., \ ;!)\\ (, ( Cemetery Location Center Over \y\ J ").\\ '. ., ., c.... J !I l rH' \ I .,(,~ Lot # Ie \ ""." '. :; Pf'\ n., !. I"~ 1 ' x Graves ,.,1.. ;", ' , ~t t I{ V\ 11 1\" I i,;:'\ eJ. \ 1\:) " (,") 1'" ,. i ! " j , '. \ I{ \ " -.-\ - ..-,' \ \.., t. ,', \" ,.... , ~ " J \- ~ ...."".. ,~ :\.1 t 1 ...1 \......' ~., 1~ /~.~ ..-......-'.- ~--... <._.~.~,...,..-".,_._----~---~ ; . 1 I ! \1, /.,1 ,..--.-.---) , I \ i \ If -....--- \ \ 11 \ \ I \ , j \ ~ ''''''-~_..___L~'''_____.__.------ I Approx. Date of Completion r- \< E \ FEe. :', '\ I--{ f~, f) r' , \,,~ f..... ~ ,.." , ..." i L'l 'C.' "'--/ L ,~,l \"'l 1,,: r ~ Spelling and dates have been approved. ~ /, II , ' 1'" i \. "i l'" , Lettering f..~ '-"""-'-'"'-"-~-""'----'-~--"~'-'''''''''__ ...... l '. J D, Vase / '\ (- )(! (J r Agreement: A 50% deposit is required to commencement of work. 'J ~, ,'\ ~ i \ ~""\ \" Agree to pay stated balance upon erection regardless of labor troubles or shipments or any other good reasons. This order or contact cannot be cancelled by customer unless agreed by both parties. The article herein mentioned shall remain the property of James R. Gingrich Memorials until paid in full and they reserve the right to remove the same is not paid as stated. 1-1 I agree to carefully proofread all names and dates for accuracy and accept full responsibility for any errors or omissions. THERE WILL BE AN ADDITIONAL CHARGE FOR ANY LETTERING ADDED TO THIS MEMORIAL AFTER ERECTED ON THE CEMETERY. Price Foundation .lLtr.h ; "!i > c \., ;"nJI;:\' '. :\, f\_ .\:... I further agree to pay the balance stated for the work performed under this contract within thirty (30) days of receipt of the final invoice and further agree that interest shall accrue at the rate of one and one-half percent (1%%) per month on the unpaid balance owed to James R. Gingrich Memorials not paid within thirty (30) days of the invoice date. In addition thereto, I agree if it becomes necessary for James R. Gingrich to institute legal proceeding to collect any funds due from me for my account being past due thirty (30) days, to pay all court costs and attorneys fees incurred by James R. Gingrich Memorials to collect the same. TOTAL DEPOSIT Type of Memorial \. A 0 $ i ~ \'" '\ Material "\ A 1\ i". r /' \ '-, fl. \ !.L \ \ Sized." () X ~ X ~ Finish (.l c,. '-, ,C\\c\\i<,\ It I/~,;\ t,l,'.,.' ., 1\', \ . ~.' ) SizeJ,,(OX ;-0 X D.?: Finish h',-\, \"'(): ~r 0(')/. \f'\,,$(il)\ . 1/ '. r}) 11 " \ MISC. -'r". 1\\ \', K f.- \.' E k 7'\ \\ \':1;,,< C 'F Design, .L/ ~:(,h;nj~" On s.+.o.nIL_ (-kl3~.) , I 1 ~ +. I n'r t". ." I.. t ..~ '\)() t~<t '),:::\ V.;", f\V\\ ~Y\ti\$II\'-, ay'Vlli\-j()t\t\ \, \"v $11\ ',,/ ii....j\'V. " Loca~ion (~j ~; t th C"..,. n" \ \ .(Cv'~, S'{ /t'~\ ,v'. ,.t11\ '~it I''''~l' I '. C f. II .ot ""1;,, f,')'" l_-.t\ " : l,'....)i.(:., L, I \'" 1 l\ \ ( " \ \' 0 Corner Posts .M"'~--"""', Dealer , ~, "'1..' .. i \~. ;", WHITE-Office YELLOW-Production ck ~. i);; ~ I Balance Due Upon Completion Customer b", \1\(..,-"., "u~,~,I, "7' . -I ", r '- $ l ttSQ , $ $ $ -, $-\1(" $ I C . I (-.' 3. 00. OQ $ -'-~ J5' O. !I (I further agree that the above names, spelling, and dates are correct) PINK-Customer GOLDENROD-Branch Guy A Eckert 475 Sample Bridge Road Enola, PA 17025-1025 Invoice iDATEi- INVOICE #! L~~/200CI~_~~9~79 ....~~ BILL-TO ~______=---=~ ----=--=--=--J [YlR1- (hfZ5 wdl,~ KEff'erz I '810 ~1Is Y v<c> I C/!(2J.-{ 'OlE p/f- {'10/5 ---____________,---.-J QUANTITY I . PO NO. . ...j- .. T1'RMS =+ --:-PROJEC"=-l Due on receipt ! I . ---~ESC~IPTIO~------L-- T----~ATE _1._ --- AMO~NT -~ -- --- ---------------------------- ----i -------"---- 1 Dig and form and place foundation at Wagners Cemetery 1,228.69 ! 1,228.69 4.5 yards of concrete !' 6.00% 0.00 ~r/-)~ ~ Return one copy with payment thank you ------ -.-------- -------- -------- -----------.---------------_____________n__ i Total -- ----------------~------------ -------- $1,228.69 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of wills One Courthouse Square Carlisle, PA 17013 KEIFER JEREMY ROSS Estate File No. : Paid By Remarks: 2007-00526 STEPHANIE KEIFER JA Receipt Date: Receipt Time: Receipt No. : 5/31/2007 11:17:39 1048638 ________________________ Receipt Distribution ------------------------ Fee/Tax Description PETITION LTRS ADM AUTOMATION FEE SHORT CERTIFICATE JCP FEE Check# 1845 Total Received......... Payment Amount 30.00 5.00 16.00 10.00 ---------------- $61.00 $61.00 Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D Messenger Service Receipt SOLLENBERGERS MESSENGER SERV 29 WESTMINSTER DRIVE CARLISLE, PA 17013 717-249-8149 For: WILLIAM KEIFER 870 EASY RD CARLISLE, PA 17013 717-249-9529 Invoice #: 21277 Date: 07/25/07 Time: 09:40 AM Clerks Initials: DMC File Name: CARL07 42426964005 Title # or Date of Birth: VIN or Driver's Number Tag Number or Eye Color -Year-Make or Soc. Sec.# Transaction Odometer Comments: MAIL EYT6616 ...i ~"-f Transfer Deal o This item will be Mailed to you. WARNING: Bureau regulation require that any item left in our office for 60 days be returned to the Bureau of Motor Vehicles as unclaimed. I/We swear that I/we have applied for the above item ( s) . Sworn & subscribed to before me on 07/25/07. Notary Seal State Fees Ti tle Fee............. Encumbrance Fee....... Tag Transfer. . . . . . . . . . Registration. . . . . . . . . . Dup. Fee.............. Increase Fee.......... Replacement Fee....... Tax-On $0.00.... Total State Fee....... Check #. . . . . . . . . . . . . . . 22.50 0.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 28.50 Service Fees Messenger Fee. . . .. .... Temp Tag Fee... ....... Notary Fee............ Copy/Fax Fee. . . . . ..... Document Fee.......... Check or M.O. Fee..... MAIL TITLE & REG Total Service Fee..... Service Fee Check #... 0.00 0.00 5.00 0.00 25.00 1. 25 0.50 0.00 31.75 Cash Grand Total........... Total Due............. Amount Paid........... Paid in Full 60.25 60.25 60.25 No Refunds on Service or Notary fees. We are not responsible for work the State fails to process. Include this voucher with your payment. If your name is not correct, see the ahove instructions. Please do not use this voucher to make estimated payments. ~: Please write the last four digits of your SSN, "2007 PA-V", and daytime telephone number on your check or money order. ':2007 PA-V PA PAYMENT VOUCHER Commonwealth of PA Department of Revenue PA-V (09-07) Enter your Social Security Number and amount of your payment. 070914 Your Social Security Number /(P/D ;y- 3~3~ ~: Spouse's Social Security Number KEIFER JEREMY R PO BOX 205 PLAINFIELD, PA 17081-0205 OJ .... '" ::t: ..c '"' " - '" o Enter Whole Dollars. Do Not Use Cents. $ /. tJO Make check or money order payable to the PA Dept. of Revenue DO NOT WRITE IN THIS SPACE L 30018129637498500025200712310000000000000006 ~ . REV-1512 EX+ (12-03) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jeremy Ross Keifer FILE NUMBER 21-07-00526 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION DCM Services, LLC -- a debt collector representing Sprint together with Nextel VALUE AT DATE OF DEATH $ 140.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) $ 140.00 , . . OCM SERVICES, LLC 4150 OLSON MEMORIAL HIGHWAY, SUITE 200 MINNEAPOLIS, MINNESOTA 55422-4811 TELEPHONE 763-852-8620 FAX 877-326-8784 TOLL-FREE 877-210-9144 Hours (CST): 7:00 am - 9:00 pm M - TH 7:00 am - 5:00 pm F 8:00 am - 12:00 pm S Account No ***** 1289 July 24, 2007 UnDald Balance $186.66 Reference No 3950121 Dear Sir or Madam: Our company represents Sprint together with Nextel. We have learned that JEREMY KEIFER, who was a valued customer, has passed away. Please accept condolences from our client and our company. As indicated above, there is an unpaid balance on this account. Please accept this letter as a Notice of Claim on behalf of our client. This letter is sent to you solely in your capacity as personal representative of the Estate of JEREMY KEIFER. Please call our office toll free at 1-877-210-9144 to discuss resolution of this matter and payment on this account. If you are not the personal representative, please contact us with the name and address of the personal representative or attorney who is handling the estate. Cordially, DCM Services. LLC *IMPORT ANT NOTICE* Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will obtain verification of the debt or a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice this office will provide you with the name and address of the original creditor, if different from the current creditor. This company is a debt collector. We are attempting to collect a debt and any information obtained will be used for that purpose. Calls may be monitored or recorded for quality assurance purposes. NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION -Side 1 of 2- IONBALOO IINTL 700 I 1~~I~~II~~III~~lm~I~1111 OCM Services, LLC 4150 Olson Memorial Highway, Suite 200 Minneapolis, MN 55422-4811 ADDRESS SERVICE REQUESTED Reference #: 3950121 ...... ~~~ . ~~ Balance: $186.66 5""";:' J,\c<>"..r-L 0+ -BL-jb.bb bj'T\4.""'(l~ '-tlo./t;b r~....\tA GV\ 'oil>" CI'l) ~ ~ ^ J: ~ \"-\0,00 a,> -k\\<,"S io ~e"" (~/~\lo1) July 24, 2007 111111111111 11111 1111111111 IIUIIIIII 1111111111 11111 11111 I 1111 Iglllllllll 11111 Ilgl II 111111 11111 11111111 OCM Services, LLC 4150 Olson Memorial Highway Suite 200 Minneapolis MN 55422-4811 1,1,1"1,1"1,,1,,1.1,,1,1.11111,,111,,11,.,11,1,1.11,,,,,11,1 0503880 0020709 3950121-7001 1",111",11111.1.,1""1111,",.1,11111.,1,1.11.,,,1,1,,"11I The Estate of JEREMY KEIFER JEREMY KEIFER PO Box 205 Plainfield PAl 7081-0205 We are required under State Law to notify consumers of the following rights. This list does not include a complete list of rights consumers have under State and Federal Laws. *ADDITIONAL INFORMATION* FOR CALIFORNIA RESIDENTS The state Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Practices Act require that, except under unusual circumstances, collectors may not contact you before 8am or after 9pm. They may not harass you by using threats of violence or arrest or by using obscene language. Collectors may not use false or misleading statements or call you at work if they know or have reason to know that you may not receive personal calls at work. For the most part, collectors may not tell another person, other than your attorney or your spouse, about your debt. Collectors may contact another person to confirm your location or enforce judgement. For more information about debt collection activities, you may contact the Federal Trade Commission at 1-877-FTC-HELP or www.ftc.gov. FOR COLORADO RESIDENTS FOR INFORMATION ABOUT THE COLORADO FAIR DEBT COLLECTION PRACTICES ACT, SEE WWW.AGO.STATE.CO.US/CADC/CADCMAIN.CFM. FOR MASSACHUSETTS RESIDENTS YOU Hf'.VE THE RIGHI TO MAKE A WRITTEN OR ORAL REQUEST THAT TELEPHONE CALLS REGARDING YOUR DEBT NOT BE MADE TO YOU AT YOUR PLACE OF EMPLOYMENT. ANY SUCH ORAL REQUEST WILL BE VALID FOR ONLY TEN DAYS UNLESS YOU PROVIDE WRITTEN CONFIRMATION OF THE REQUEST POSTMARKED AND DELIVERED WITHIN SEVEN DAYS OF SUCH REQUEST. YOU MAY TERMINATE THIS REQUEST BY WRITING TO THE DEBT COLLECTOR. FOR MINNESOTA RESIDENTS This collection agency is licensed by the Minnesota Department of Commerce. FOR NEW YORK CITY RESIDENTS New York City Department of Consumer Affairs License # 1239504. FOR NORTH CAROLINA RESIDENTS North Carolina Department of Insurance Permit # 4440. FOR TENNESSEE RESIDENTS This Collection Agency is licensed by the Collection Service Board of the Department of Commerce & Insurance. REV-1513 EX+ (9-00) ., . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Jeremy Ross Keifer 21-07-00526 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] William F. Keifer, Jr. Stephanie I. Keifer 870 Easy Road Carlisle, PA 17015-9555 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE NUMBER I father mother > 100% 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-1500 COVER SHEET $ 0 . 00 (If more space is needed, insert additional sheets of the same size)