HomeMy WebLinkAbout08-27-08R~-,.ooEx.t.~o, ~ REV-1500 ~:F~t ~~:a=,~;_
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COMMONWEALTH OF PENNSYLVANIA INHERI 1!'1~VG IF1/~ ftG 1 ~RIY
DEPARTMENT OF REVENUE FILE NUMBER ~ a
p~~~
DEPT. 280801 K
~RGJIDGI~ 1 DCV GDGIY 1 J
21 O8 `
HARRISBURG, PA 17128-0801 _ _ COUNTY CODE YEAR _ IJUMBER
-~
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
~ SOCIAL SECURITY NUMBER
KAPP, Eugene C 160-16-5844
c __ _
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
W 03/21/2008 05/24/1916 REGISTER OF WALLS
~
o __ _ ____
--
- --- -- - -
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL) ~ ~ _
-- --
----------
--
~ SOCIAL SECURITY NUMBER
Kapp, Selma E
w ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82)
a w
w 4. Limited Estate 4a. Future Interest Compromise date of death after
(
~ ^ ^ 12 12
2
^ 5. Federal Estate Tax Return Required
a U
~ a m a
)
® 6. Decedent Died Testate (Attach copy ^ 7. Decedent Maintained a Living Trust (Attach 0 e. Total Number of Safe Deposit Boxes
4 of Will) copy of Trust)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death between - --
[] 11. Election to tax under Sec. 9113(A) (Attach Sch o)
' _ 1231-91 and 1-1-95)
,THIS SECTION MUST BE COAAPLETED. ALL CORRESPONDENCE AND CONF4DENTIAt, TAX INFORMATION SHOULD BE DIRECTED TO:
JJAME COMPLETE MAILING ADDRESS
Edmund G Myers
rc p IRM NAME (If applicable)
a Johnson, Duffle, Stewart & Weidner i P.O. Box 109
lI
{{{
----
Lemoyne
PA 17043-0109
,
TELEPHONE NUMBER
. 7171761-4540
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O
g
a
U
W
rc
-- ---
1. Real Estate (Schedule A) ----
(1) ---------
Non e
2. Stocks and Bonds (Schedule B) (2} N 0 n e
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 'N O n e
4. Mortgages & Notes Receivable (Schedule D) (a) Non e
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) None
(Schedule E} - __ __
6. Jointly Owned Property (Schedule F) (6) 40
392.93
^ Separate Billing Requested ,
-------
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
S h d l G (7) Non e
( c e u e or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
-~;; I r- ce~:.;~
c~ :=
~- J r:
~,'
-;, ~
~:_
L--}
- , .
c. ~
; ~-1 ~~
t J ---{
= ..
c,~l
($> 40,392.93
515.00
26.38
(11) 541.38
12. Net Value of Estate (Line 8 minus Line 11) (12) 39, 851.55
i 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 39, 851.55
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, 1 9, 925.78 x .00 (15) 0
00
or transfers under Sec. 9116(a)(1.2) ------------ -__ .
_-__ -___-__-_
i=
16.Amount of Line 14 taxable at lineal rate 1 9, 925.77 x .045
(16)
896.66
~ 17.Amount of Line 14 taxable at sibling rate x
12 (17)
0 .
------- - -------
~ 18. Amount of Line 14 taxable at collateral rate x .15
-------_- - -- (18)
19. Tax Due (19) 896.66
20. ^ . ..
~ - . - _. - -- ----
» BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH «
Copyri ght 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
Decede'nt's Complete Address:
STREET ADDRESS
824 Lisburn Road, Apt. 421
CITY Camp Hill i STATE PA j ZIP 17011
I
I ax r'ayments and credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
D. Interest
E. Penalty
(1}
Total Credits (A + B + C) (2)
0.00
Total Interest/Penalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q)
Check box on Page 1 Line 20 to request arefund ---
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 896.66
A. Enter the interest on the tax due. (5A) _ _ _____
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 896.66
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; or ...............................................................................................................
d. receive the promise for life of either payments, benefits or care? .............................................................
2. If death occurred after December 12, 1982, did decedent 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
contains a beneficiary designation? ...................................................................................................................~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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
preparer other than the personal representative is based on all information of which preparer has any knowledge. __ __
SIGNATURE OF PERS{dN RESPONSIBLE FOR FILING RETURN ADDRESS 824 LISbUrn ROa(~ DA"rE
Se{ma E. ICapp,> (/// Apartment 421
l J_/ ~ _ Camp Hill, P_A__17011 _ ~ ~~ Q,f~
SIGNATURE OF P RES ONSIBLE FOR FILING RETUR ~ ADDRESS DAl"E
~ _ _ ______ _ _ _ pia /~
SIGNATURE OF PREPARER 0 ER THAN REPRESENTATIVE ADDRESS DAi"E
Edmund G Myers
P.O. Box 109
Lemoyne, PA 17043-0109
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemo~ 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 0% [72 P.S. §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%, except as noted in 72 P.S. §9116
1.2) [72 P.S. §9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116 (a) (1.3}]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
896.66
SC
HEDULE F
COMMONWEALTH OF PENNSYLVANIA i
INHERITANCE TAX RETURN i JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT-- _~__-
ESTATE OF ~ FILE NUMBER
KAPP, Eugene C 21 - 08 -
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
Selma E. Kapp 824 Lisburn Road, Apt. 421 Wife
A
Camp Hill, PA 17011
Eugene Edward Kapp 561 Dogwood Drive Son
B Mechanicsburg, PA 17055
JOINTLY OWNED PROPERTY:
TEM
NUMBER - --
LETTER DATE
FOR JOINT MADE
T
t~F~SCRIPT.IO~V C~F PRO~'ERTY % OF
Include name o Inanclal Ins Itu Ion an bank account number DATE OF DEATH I
or similar identi in number. Attach deed for 'ointl -held real VALUE OF ASSET DECD'S I
~ 9 t Y _____
DATE OF DEATH
VALUE OF
'
TENANT JOINT
estate. INTERESTI
+ DECEDENT
S INTEREST
1 A&B 111/10/2005 Wachovia Bank Savings Account
I 553.66
33.33% 184.53
2 ~ A&B 05/02/2001 Wachovia Bank Checking Account 8,258.23 33.33% 2,752.47
3 A&B
i 11/01/2005 i
Fidelity Investments
112,379.02 33.33%I
37,455.93
Date of Death Valuation is Attached to this
Return ~
~ ~------ ~- - --~~ --- -L.- - ------ --
TOTAL (Also enter on line 6, Recapitulation) j 40,392.93
SCHEDIRE H
i FZ,11~1_ D~EJVSES &
COMMONWEALTH OF PENNSYWANIA i ~~
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF KAPP, Eugene C
Debts of decedent must be reported on Schedule I.
-T - --. - -
I I tM
NUMBER+FUNERAL EXPENSES: DESCRIPTION
A.
B.
1
,DMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EiN Number of Personal Representative(s):
FILE NUMBER
I 21 - 08 -
AMOUNT
-- -
Street Address
City State Zip
Year(s) Commission paid
2. I Attorney's Fees Johnson Duffle Stewart & Weidner
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Chimonh
Street Address
City State Zip ~~
I Relationship of Claimant to Decedent
4, f Probate Fees ~
i
5.
6
7
1
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Cumberland County Register of Wills Office
Filing Fees for Inheritance Tax Return
TOTAL (Also enter on line 9, Recapitulation)
500.00
15.00
515.00
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES
INHERITANCE TfJ( RETURN , LI j
RESIDENT DECEDENT
ESTATE OF KAPP, Eugene C
FILE NUMBER
21 -08-
Include unreimbursed medical expenses.
ITEM
NUMBER
Wachovia Bank Visa Account
DESCRIPTION AMOUNT
26.38
TOTAL (Also enter on Line 10, Recapitulation) ~ 26.38
ESTATE OF EUGENE C. KAPP
SCHEDULE OF EXHIBITS
EXHIBITA Copy of the Last Will and Testament of Eugene C. Kapp signed
and dated November 2, 1998. This Will was not probated. No
probate assets
EXHIBIT B Copy of Death Certificate
EXHIBIT C Wachovia Bank Date of Death Letter on Accounts
EXHIBIT D Fidelity Investments Date of Death Valuation of Account
342497
EXHIBIT
A
099999-000051 10.27.98JHAJJPAR/116305.1
~rtt~t Atli ttn~ ~~e~~crnent
(~f
I, EUGENE C. KA.PP, of Lemoyne, Cumberland County, Pennsylvania, declare
this to be my Last Will and revoke any Will previously made by me.
ITEM I: DEBTS.
I direct that all my debts and funeral expenses, including my gravemarker and all
expenses of my last illness, that my estate is obligated to pay shall be paid from my
residuary estate as a part of the expense of the administration of my estate.
ITEM II: TANGIBLE PERSONAL PROPERTY.
I give my automobiles, personal effects, my household goods and other tangible
personal property of like nature (not including cash or securities), together with existing
insurance thereon to my wife, SELMA E. KAPP.
While this bequest is absolute, it is my wish that any memorandum I may leave
addressed to my personal representative indicating my desire with respect to the disposal of
my tangible personal property shall be regarded.
ITEM III: REST, RESIDUE AND REMAINDER IF MY WIFE
SURVIVES:
I give, devise and bequeath all the rest, residue and remainder of my estate to my
wife, SELMA E. KAPP, provided she survives me by thirty (30) days.
ITEM IV. REST, RESIDUE AND REMAINDER IF WIFE FAILS TO
SURVIVE.
If my wife, SELMA E. KAPP, is not living on the thirty-first (31St) day following
my death, I give, devise and bequeath all the rest, residue and remainder of my estate to my
then-living issue, per stirpes:
ITEM V. PAYMENT OF TAXES:
Federal, state and other taxes payable because of my death, with respect to property
forming my gross estate for tax purposes, whether or not passing under this Will, including
any interest or penalty imposed in connection with such tax, shall be considered a part of the
expense of the administration of my estate and shall be paid from that part of my residuary
estate passing pursuant to I i ENi III or I V hereof without apportionment or right of
reimbursement. All such taxes on present or future interest shall be paid at such time or
times that my personal representative may think proper, regardless of whether such taxes are
then due.
2
ITEM VI. MISCELLANEOUS:
Distributions for Minors. Where under the provisions of this Will the Personal
Representative is authorized to distribute or expend the income or principal of any fund. to,
or for the benefit of, a person who is a minor, the Personal Representative may distribute
such income or principal directly to such minor, to the person having custody of him or her,
to the guardian of his or her estate, to the guardian of his or her person or to a custodian for
such minor under any applicable Uniform Gifts (or Transfers) to Minors Act, whether
previously appointed or appointed by the Personal Representative for the purpose of
receiving such distribution, all without liability on the part of the Personal Representative to
see to the application thereof and without required bond or surety.
ITEM VII: POWERS OF PERSONAL REPRESENTATIVE.
7.1 Administrative Powers of Personal Re~.resentative. In the administration
and management of my estate, my Personal Representative shall have and may exercise
(subject to any other provision of this Will limiting or qualifying in any way any power,
authority or discretion of my Personal Representative) full power, authority and discretion
without the necessity of obtaining the order of any court to do all acts, to execute,
acknowledge grid deliver all writings and to exercise for the benefit of all persons v~ho may
be or become beneficiaries under the provisions of this Will any and all powers, authorities
and discretions given to or vested my Personal Representative by the provisions of this Will
or by law. By way of illustration but not limitation, my Personal Representative shall havE:
and may exercise the following powers:
1. To retain property in the form and character in which the same shall be
received;
3
2. To sell, convey, mortgage, lease for any term whatever, transfer, exchange
and dispose of, either publicly or privately, the whole or any part of the estate;
3. To grant options for such period as my Personal Representative shall
deem advisable for the sale, conveyance, lease, transfer, exchange or other
disposition of the whole or any part of the estate and to exercise any option at any
time held as part of the estate;
4. To invest and reinvest the whole or any part of the estate in any kind of
property, real, personal or mixed, or undivided or part interests therein, including
stocks, bonds, notes, securities, minerals and other natural resources, limited
partnerships, common trust funds, interest bearing accounts and other property of
whatsoever character, located in the United States or abroad, all statutory and other
limitations as to the investment of funds, now or hereafter enacted or in force, being
hereby waived and without obligation to diversify the same and without liability for
any decline in the value thereof;
5. To compromise and settle claims;
h. To car ;~ a*:y prop erly in -the -ramp of a nominee., including a clearing
corporation or depository or in book entry form or unregistered or in such other form
as will pass by delivery;
7. To vote shares of stock, in person or by proxy, in favor of or against
management and shareholder proposals and to join in or dissent from and oppose the
reorganization, recapitalization, consolidation, merger, liquidation, or sale of
corporations or properties;
4
S. To employ accountants, agents, attorneys, brokers, employees, investrnent
counselors and other representatives to perform any act of administration (whether or
not discretionary), to act without independent investigation upon their
recommendations and to determine and pay their compensation and expenses out of
the estate;
9. To distribute, without the necessity of filing a judicial accounting or
obtaining judicial approval, the whole or any part of the estate upon the receipt and
release of the beneficiary entitled to receive such distribution, in which event my
Personal Representative shall be relieved of all further liability with respect to the
properly so distributed with like effect as if such distribution had been made pursuant
to an order of court;
1.0. To borrow money from any person in such amounts and upon such terms
as my Personal Representative shall determine and to pledge all or any part of the
assets of the Trust estate to secure such borrowing;
11. To permit any beneficiary to occupy any real property forming part of
the estate without rent or upon such other terms and conditions as my Personal
Representative shal_1 determine;
12. To make any distribution or division of the estate either in cash or in
kind, or partly in cash and partly in kind and to allot different kinds of, or interests in,
property to different shares, all as my Personal Representative, shall determine to be
equitable to effect such distribution or division.
5
13. To allocate receipts and expenses to principal or income or partly to
each as my Personal Representative from time to time think proper.
7.2 Exercise of Discretionary Powers. Each and every power, authority and
discretion given to or vested in my Personal Representative by the provisions of this Wi11 or
by law, whatever may be the nature or extent thereof, shall be freely exercisable by my
Personal Representative at any time and from time to time in its sole and absolute
discretion, as it alone shall determine. Each exercise thereof shall not be open to question in
any manner whatsoever by and shall be binding upon each person having an interest in the
estate.
7.3 Disclaimer By Personal Representative. I authorize my Personal
Representative to disclaim in whole or in part any property or interest therein passing to :me
or to my estate by reason of a testamentary or inter vivos transfer or an intestate disposition
or by any other means.
7.4 Option with Respect to Expenses. In the event any expense of administration
of my estate shall, at the option of my Personal Representative, be deductible either in
computing any federal income tax payable during the administration of my estate or in
computing the federal estate tax payable with respect to my estate, my Personal
Representative shall exercise such option as my Personal Representative shall deem to be in
the best interests of my estate and the beneficiaries thereof. In the event any such expense is
deducted for federal income tax purposes, my Personal Representative may, but shall not be
required to, transfer from income to principal an amount equal to the additional federal
estate tax which my estate may be required to pay by reason of the failure to claim any such
expense as a deduction for federal estate tax purposes.
6
ITEM VIII: PERSONAL REPRESENTATIVE.
I hereby nominate, constitute and appoint my son, EUGENE E. KAPP, Executor of
this my Last Will and Testament. In the event my son, EUGENE E. KAPP, fails to qualify
or ceases to so act, I name, constitute and appoint my daughter-in-law, KAREN J. KAPP.
Executrix of this my Last Will and Testament
ITEM IX: BOND.
No fiduciary acting hereunder shall be required to post bond or enter security in any
jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand and seal this c~~ day of
~.. , , 1998.
~~ ~~ (SEAL)
EUGE . KAPP
Signed, sealed, published and declared by the above-named Testator, as and for his
Last ~~Vill and Testament, in the presence of us, who, at his request, in his presence and in
the presence of each other have hereunto subscribed our names as witnesses.
7
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
We, EUGENE C. KAPP, "~~~,s..~..~. ~ _ ~~c.~~---•--~,~'1 and
~~-~ ~ , -,~~ ~,, r ,the Testator and the witnesse ,respectively, whose
r_ames are signed to the a hed o~~ foregoing instrument, being first duly sworn, to hereby
declare to the undersigned authority that the Testator signed and executed the instrument as
his Last Will and that he had signed willingly and that he executed it as his free and
voluntary act for the purposes therein expressed, and that each of the witnesses, in the
presence and hearing of the Testator, signed the Will as witness and that to the best of
his/her knowledge the Testator was at that time eighteen years of age or older, of sound
mind and under no constraint or undue influence.
Witness
Sworn to or affirmed to and subscribed to before me by EUGENE C. KAPP,
T estatcr, and ~.,-~..~..._~ ~~ - .-~. and ~~..,~. `rte . -~~.~~^~-,~~_~~
and ,witnesses, this ~~ ~~ ~ ~.klay
of '~'> ~•~`s.:°~-~1,-~_~ , 1998.
~~ ~~ ~.
Notary Public
~y Carr~~?s~oc^ E~PerPs Bec. 21, 23C}1
8
NO~A.~i~L SEF~.L
Di~idf~lE LEN4G, ~fota~y Put~{ic ~
Lemoyne Borough Cumberland Ce. ~
EXHIBIT B
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
ee for this certificate, $6.00
P ~.4124~.62
Certification Number
IEV 11Y[006
'RINT IN
ANENT
:K INK
This is to certify that the information here given i
correctly copied from an original Certificate of Dead
duly filed with me as Local Registrar. The origins
certificate will be forwarded to the State Vita
Records Office for permanent fi]ing.
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE FILE NUMBER
1. Name d Decedent (Fxsl, miMOe, lass, sudix) 2. Sex 3. Social Security Number 4. Date of Death (Mtnih, day, year)
male 160 - 16 -5844 Mar.21,2008
Eu~ana C. Ka
5. Age,tasl Birthday) Udder 1 year Under f day 6. Dale d Birth (Monts, day, year) 7. Birthplace (CAy and stale a lor eign txwmry) Ba. Plxe of Death (Check ody ore) '
~~ p.yr w~.x ~~ ~ i
~ Hospital: Other:
91 Yrs. May 2 4 , 1916 O
i~~ S b
East P ^Inpadenl ~ERlpApatknt ^DOA ^NUrsing Fbnie ^Residence ^Other-SpedN:
Bh. Camry of Death &. GAy, Born, Twp. d D~th Bd. FacaN Name (Ii not initiation, give slrsel end number) 9. Was Decedent of H'ISpsdc Origin? No ^Yes 1D. Race:~American Indian, Bkck, While, alc.
Cumberland
East Pennsboro (u yes, spedN Cuban, (speay,
Holy Spirit Hospital Mezican,PuenoRican,etc.) white
1 t. Oacedenl's llnref tier Khd d woA O or~e moat of ~ Gk. Do nd skle retied 12. Wes Decedent ever in the 13. Decedents Education (Spectly any highest grade compleledJ 14. Marital Sktus: Monied, Never Married, 15. Surviving Sgwse (II wile, give maiden name)
d
dl
Wd
d
Di
S
Kkd of Work Kxrd d Busness f Industry U.B. Armed Forces? Ekmentery / SecorWary (0.12) Coaege ltd or 5+) vome
owe
,
j
pe
y)
u e fed. o t. j~Yea ^N0 10 married alma Lehman
• 16. DecatlenYa MelYmg Atldress (Street dry /town, stele, zip rode) Decedent's ~ ~~nt
Liva in a
Lower A
112 n
1
i
'
8 2 4 Lisburn R d . ,Apt . 4 21 .
Twp.
17c. Yes, DecedaM Uved
er a n
a
n
Aduel ResNerwre 17a. Skte p ? n n ~ ~
T°'"iship4 „ ^ tip Detedenl lived wuNn
Cam H i 11 , P A 17 01 1 nh. CounN C u mb a r l s n d Actual umne d CAy, mr°
I8. Fatlrer's Name fFust m10tlk, lost adlix) 19. Mother's Name (First. midge, maiden surtlerrre)
Harry Kapp Kathr n Mant2ar
20a. Intormad's Name (Type !Piing 20b. Inhxmam's MaiFg Address (Street city (awn, slate, xp code)
E. Edward Kapp 561 Dogwood Dr.,Machanicsbur~,PA17055
21 e. Matlwd d Disposkbn ~ ^ Cremation ^ Donetim 21h. Date d D'sposikon (MmN, day, Year) 21c. Place d Disposkan (Name d cemNery, cremaary w other pace) 21tl. twaaon (City ! Lawn, state, zip mda;
B~ I1rD'/Bl Irpn sate ; w.a crenratan or Daratlon almrodzed Mar . 2 6 , 2 0 0 8 R o 11 i n g Green Cemetery Camp H i 11 , P A 17 01 1
r . may: ;try Metlinl Ezemker / Coroner? ^Yes ^ N°
stare d F Se ~ Ucereee for person sd^9 es such) 22h. license Nlmber 22c. Name erg Address d Fecpiry
FD-013163-L Mussalman FH~rCS 324 Hummel Ave. Lano n> PA1704:3
e kerns 23ac oNy wMn certlN"N 23a To the best d my knvMedge, death acarned at fime, date aM place SlBletl. (SkyaNre arts tltle) 23b. License Number 23c. Dale Signed (Month, daV. year)
physiden a not available al lime d death to
xnAy cause d death.
• tlems 21 26 rmW tx wmpleted al person 24. Tine of Death ~ 25. Dale Proriazrcetl Dead (Month, day, year) 26. Was Case Relknetl It Medical Examiner /Coroner for a Reason Omer than Cremalan or Donation?
~
y
N
' s4ro proraunces death. M. a O C o
^Yes ~
s
l
CAUSE OF DEA InatrueUons end examples) r Approximate IMenal: Pen II: Enter other glgnif~nl cuMdions contrAulkm a death, ?3. D'M Tobacco Use ConillZple to Deem?
Item 27. Pan 1: Eder Nre g~gjp d evMtta - dsaases, nryries, or conpkations - that direly caused the deeds. DO NOT enter lemliral events such as cardiac attest r l7rxsel b Deem Wt rpt resdlirg m me rmdenying cause given h Pan 4 ^Yes ^ Probably
resprsrory erred, or ventdcWer fibdlle9on wstwd strowkrg the etkAogy. Liss onN are cake on each line. ~ ^ No [] Unxnown
IMMEDIATE CAUSE Fznl Gsease a .}" (~ r~~y r
r:on0ilan rearYSng in ~eNl -~ a, L ~~C ~K p~ 4.1'YX~hY ~Y~ (~1~y. _ _ i
_
29. tl Femak: d
eN
s
^ N
r
Due t° for as a consequence of):
r w
n as
ear
d qe9" ° P Y
^ Pre9nanl al Ikne of death
Se lid WMalpne, g any, b
.
Me a cause Fsied an lire e. r ^ Not gegud, but pra,.ynanl wtlhin 42 days
Einar UNDERLYMG CAUSE Due to (or as a con egrrerrce off: r
of Beam
(decease or inM^Y that kYlkted the ° r
evenm resrrMin9 m death) LAST.
Due a jot as a mnegrrence og: r Nd qe nt bN re(
^ 9na p Yranl 43 days to 1 year
belore tleath
d. r ^ Unknowm it gegnani wAhin dre pall year
3Da. Was en Autopsy 30h. Were Aulapsy Endings 31. Mercer d Death 32a. Date d Injlzy (Monts. day, year) 32b. DesMbe Flow Injury Occurted 32c. Pkce d Injury: Home, Farm, SlreeL Factory,
ORke Building
ea
(SpeayJ
Pedormed? Avaaahle Prior to Campklion
d Cause of Dealh7 ~.NaN21 ^ Hommute ,
.
^ Acdtled ^ Pending avestigation 32d. Tone d Hyrvy 32e. Iryury el WoA? 321. II Trensponalion liryury (Specify/ 32g. Lac an o ' ry (Street, CAy {lawn, slate)
^Yes ~° ^Yes ^ "°
^ Srridde ^ Could Nd be Detemined
^Yes ^ No ^ Driver! Operator ^ Passenger ^Pedesaan
M Otlrar ~ SpeaYy
33e. Cenifrer (tlieA only one)
leled Item 23)
hen andher
sidan has
ronounced deem and corr
h
k
f d
N
iF 33h. Sigreture and TAIe of Certifier "'~It,n,~q ~
J ~ ` • { ~
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~ -)
p
w
P
y
p
q ease o
ae
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• Certlryhg Physktian (Physidan cert
deaM octumed due ro the cause(s) and rrranrrer u slated- _ _ _ _ _ .. _ . _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
To the beet of mY aroMedge , „~,
,~
.
,
.
• Pronoulydng antl xrlifying Physicim (Physidan both promuncirrg death and cerlilying to reuse d gees) _ _ _ _ _ _ _ _ _ _ _ _
To its beet d my knowledge, death occurred at the Nme, tlek, end plate, end due Io the cause(s) and manner as eteled_ _ _ _ _ _ ^
C 33c icerse Number
`'r9 n Y?1~ 1. (-~'? ,~j ,,,,, 1
A \1r J >,} J(
l Lam. 33d. Da ' rnd (Mon
'7 ~~
a . daY, year)
Q
oroner
• MedkM Euminer(
On tie bash d examination and / or irneshgetan, a my oplnan, death oecumed at the tlme, date, and place, end due to the cause(s) end manner as sated. ^ .
~ Name 8rrtl Address of Person Who Lanpkted Cause d Death (Aem 27) Type f Print
35. Registrar's lure and Dkl I>~"~ ff 'y ~ /
~~ ~~ ~ ~ ~ %. Date F' (Mmtlr day, year?
~ ~ ~ ~ ~ Ju\ ` ~v °~ ~ G.~ yr ~.,1 11 , ~~'>
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~~~~
Disposition Pennil Na. ® / ~ /
EXHIBIT C
Tax Transmission 7/11/2008 9:25 Ai+S PAGE 1/002 Fax Server
y~t~y ~$~~ Reference ID: 2500165
~'~- Wac)loviaBankN.A.
Balance Confirmation Services
P O Box 40028
RDanokc, VA 24022-7313
July 11, 2008
JOHNSON DUFFLE STEWART & WEIDNER
ATTN: DANA L WIESEMAN
301 MARKET STREET
P O BOX 109
LEMOYNE, PA 17043-0109
SUBJECT: Verification /Confirmation of Account and Balance Information provided for:
Customer: EUGENE C ICAPP (SSN# XXX-XX 5844)
Date of Death: March 21, 2008
Deposit Account Information
Account Accaml Date ofDeafh Average Date Ma4irity Intursi Accrued YTD Date
Type Number Balance Balanex~ Opened Date Rate Lrtaest IrdesestPaid Closed
HECIa2.'G6413 $8,258.23 S/2t2001 .OS $030 $0.83
EGAL TITLE: EUGENE C KAPP
ELMAE KAPP
,UGENE EDWARD KAPP
AVINGS XKJ4fl4O0IX784b S553.66
~iAL TITLE: EUGENE C 1ZAPP
ELMA E KAPP
UGENE EDWARD ICAPP
LOSING BALANCE: $653.93
11/10!2005 .15 $0.06 $0.12 6/11Y1008
Revolvint= Credit Information
Accowa Asoowrt Data of Death Gaetit Date Data Times Legal Title
Type Number Balance Limit Opened Closed Late
ISA X143 552.75 4!302007 SE.LN.AEKAPP
EUGENE C KAPP
ISA 7i7~:X3OO00OO~t8486
fBNA-Revolving credit aaaorrta are no longer aetviced by Wadwvia Bank Please conlaci MBNA at 800-477-9131.
Other Account Information
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August 26, 2008
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Dear Register:
~_~
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RE: Estate of Eugene C. Kapp - ~ ~ _~ -
Date of Death: March 21, 2008 ~ ~_
Our File No. 4895-2 . -' c:Jt
~~
Enclosed for filing please find the following documents for the above referenced decedent:
1. 2 Original PA Inheritance Tax Returns. There is tax due in the amount of $896.66 on the joint. assets
that the decedent held with his spouse and son . Check No. 2004 is attached to the Return.
2. Two copies of Pages 1 & 2 of the Pa Inheritance tax return, which we ask that you time-stamp and
return to us in the enclosed envelope.
4. Check No. 2005 attached to this correspondence in the amount of $15.00 representing the filing
fee for the Inheritance Tax Return.
Should you have any questions, please do not hesitate to contact our office. Thank you for you
Very truly yours,
S N, F_ FIB, STEWART &WEIDNER
a Wi an
Estate Administration Paralegal
Enc.
cc: Selma E. Kapp
:sa2sss
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