HomeMy WebLinkAbout02-0213PETITION FOR PROBATE and GRANT OF LETTERS
also known as' ...... / ' To:
Deceased.
Social Security No.
The petition of the undersigned respectfully represents that:
YouI pethioncr(s), x~ho is/are 18 years of age or older an the execm
in the last will of the abov~decedent, dated
and codicil(s) dated
Register of cWfj~Lg[R.~J[ND
County of
Commonwealth of Pennsylvania
in the
0" P'~ named
,19__
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in L~r~/.,to _,~,,~//~a,, ,4/ . County, Pennsylvania, with
h I(..~ last family or principal res. idsnce, at - "~,,~6
,¢,,x a2 ,., /Ag
(list street, number and muncipality)
Decendent., then ~;;r ./~;v _ year~., of age, died
, 19_ =__~,
7-~ o ~-~, ,,,~
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
~/~ a6, oo
WHEREFORE, petitioner(s) respectfully
presented herewith and the grant of letters.
request(s) the probate of the last will and codicil(s)
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
theron.
~ ~ ....... /. ......
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTIt O~ PENNSYLVANIA ~ ~s
COUNTY OF CUMBERLAND
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed
before me this ._ 27'ch day of
k FEBRUAR~ ,2~2 19 J'
Iq-qB-II--
No.
Estate Of EPURATM A KAUFF~AN , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
FEBRUARY 27, 2002
AND NOW
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated DECEMBER 8, ] 980
described therein be admitted to probate and filed of record as the last will of EPHRAIM A
19 , in consideration of the petition on
'I'ESTAMEN'I'AMX
~d Letters
~eherebygrantedto JAMES E KAUFFMAN AND ROY E KAUFFMAN
KAUFFMAN
FEES
Probate, Letters, Etc .......... $ 25.00
9.00
Short Certificates( ) ..........
x~~t~RMnx..e.x..t.r..a..p.a.g.e.s$ 3.00
TOTAL ~ $. 39.00
Filed FEBRUARY 27, 2002
will pick up on same day
MARY C/~EWI~ster of will~
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
03-3 ~0.
REGIS,~ER OF WILLS OF~'% COUNTY
or SWSCRm . W, ss
(each) a.subscribing witness to the will presente~erewith, (each) being dulyhitualified according to
law, dep~ and ~y(~ that ' ~- X present and saw
e testate, ~ the same and that ~. signed as a ~ess at the
request of testat - ~ presence and (in the presence O~ch other) (in the presenCe of the
other subscribing witness(es)~
Sworn to or affirmed and subscribe~fore ~
me this _ da~ (Name;~
Register ~ ' (NamO~
(Address) ~
REGISTER OF WILLS OF CUMBERLAND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
21-02-213
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
"-~-t.x !~.~ familiar with the signature of ~.~.~ ~r~ ~ Kg u 4; f ~1 r~
testator- of (cme of tho .......... ~,,~,,o~a,; ..... -~, ...,,,.~,.o: ......... ,,~, the will presented herewith and
· E"o k~,,,,., k..,
to the best
believe~kthe signature on the will is in the handwriting of
knowledge and belief.
Sworn to or affirmed and subscribed before
me this 27th day of~ 7
.~/~Idress)
(Namer[/
(Address)
105.805 REV 9/86
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be. forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
P 8168719
No.
Local Registrar
FEB 1 5 2002
Date
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
man ,~a~¢ ,.195 --07 --7929
99 i ] 1/22/1905 ,,~,~ ~o,,,m~ ~o,,U
Id CarZ~te Thornwa~d Hom~ ,~
.~.t,c~) 7 ~'~ ,,. widowed
442 Watnut Bottom Rd. ~ ,,,.0~.~
Cartlste PA 17013
_O. 2117/2002
6burg, PA 17019
Mountain, PA
21-02-213
LAST. WILL AND TESTAMENT
OF
EPHRAIM A. KAUFFMAN
I, EPHRAIM A. KAUFFMAN, of 320 Hogestown Road, Mechanicsburg,
Silver Spring Township, Cumberland County, Pennsylvania, being of sound
and disposing mind, memory, and understanding, do hereby make, publish
and declare this my Last Will and Testament, hereby expressly revoking
all other writings in nature testamentary by me at any time heretofore
made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I hereby give, bequeath and devise all the rest and
residue of my estate and property, real, personal and mixed, of what-
soever nature and wheresoever situated, of which I may die seized or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absolutely and in fee simple
to my wife, Ida E. Kauffman, provided she survives me for 30 days.
THIRD: In the event that my wife is not living 30 days after my
death, then I give, bequeath and devise all my property to the Dauphin
Deposit Bank and Trust Company, through its Carlisle, Pennsylvania branch,
IN TRUST NEVERTHELESS, for the following uses and purposes:
All monies in said Trust Fund shall be placed in
interest bearing accounts or Certificates of
Deposit, and the interest therefrom shall be paid
by my Trustees for the support and education of my
granddaughter, Jodi Bea Kline, in the sole dis-
cretion of my Trustees until the said Jodi Bea
Kline reaches the age of 21 years on May 16, 1989.
On May 16, 1989 or at the death of Jodi Bea Kline,
EPH~IM A. KAUFFMAN
PAGE ONE OF TWO
(SEAL)
whichever first occurs, my Trustee shall
terminate this Trust, and distribute the
assets among my sons, Daniel W. Kauffman,
Roy E. Kauffman and James E. Kauffman, and
my granddaughter, Jodi Bea Kline, each to
share equally. In the event any of the above
named sons, or my granddaughter shall die
prior to the above dates for distribution,
I direct that the share of said deceased son
or granddaughter shall go to those sons or
granddaughter who are surviving at the date
for distribution.
FOURTH: I hereby appoint my sons, Roy E. Kauffman and James E.
Kauffman, as Trustees of the above Trust, and in the event they are
either unable or unwilling to serve, I then appoint Dauphin Deposit
Bank and Trust Company of Carlisle, Pennsylvania, as my Trustee.
FIFTH: I hereby appoint my wife, Ida E. Kauffman, as Executrix of
this, my Last Will and Testament, but in the event that the is unable
or unwilling to serve, I then appoint my sons, Roy E. Kauffman and James
E. Kauffman, as Executors of this, my Last Will and Testament, and I
direct that they shall not be required to give bond or other security in
any jurisdiction wherein proceedings may be held in connection with my
estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 8th
day of December, 1980.
W I TN~S:
EAL)
EPH.~AIM A. KAUFFMAN
PAGE TWO OF TWO
CERTIFICATION UNDER NOTICE UNDER RULE 5.6 (a)
Name of the Decedent: Ephraim A. Kauffman
Date of Death: February 14, 2002
Will No. 00213 of 2002
Admin. No. 2002-00213
To the Register:
I certify that notice of a beneficial interest
required by Rule 5.6(a) of the Orphan's Court Rules was
mailed to the following beneficiaries of the above-
captioned estate on March 21, 2002.
Name Address
James E. Kauffman
736 W. Siddonsburg Road
Dillsburg, PA 17019
Roy E. Kauffman
7556 Wertzville Road
Carlisle, PA 17013
Daniel W. Kauffman
Jodi Allan A/K/A
Jodi Bea Kline A/K/A
Jodi Bea Kauffman
Morningside Apartments #141
Paduka, KY 42003
814 Doubling Gap Road
Carlisle, PA 17013
Notice has now been given to all persons entitled thereto
under Rule 5.6(a) except
Date: May 10, 2002
Name: Kathleen K. Shaulis, Esq.
Address: 44 South Hanover Street
Carlisle, PA 17013
Telephone: (717) 243-6655
Capacity Personal Representative
X Counsel to Personal
Representatives
NOTICE OF BENEFICIAL INTEREST IN ESTATE
BEFORE ~ REGISTER OF WILLS, COUNTY OF CUMBERLAND
In re Estate of Ephraim A. Kauffman deceased
No. 2002-00213
TO: James E. Kauffman
736 W. Siddonsburg Road
Dil lsburg, PA 17019
Please take notice of the death of decedent and grant of letters to the personal representative
named below. You may have a beneficial interest in the estate as follows:
You are ~aamed as one of the beneficiaries under Mr. Kauffman's Last Will and Testament.
Name of the Decedent: Ephraim A. Kauffinan
Last Known Address: Thomwald Home
442 Walnut Bottom Road, Carlisle, PA 17013
Date of Death: February 14, 2002
Place of Death: Thomwald Home
County of Grant of Original Letters: Cumberland
Decedent dies X testate intestate
A copy of the will __ is _X is not attached.
Name(s), address(es) and telephone number(s) of all personal representatives appointed
Name Address Telephone
James E. Kauffman
Roy E. Kauffman
736 Siddonsburg Road
Dillsburg~ PA 17019
7556 Werlzville Road
(717) 432-5791
(717) 249-7568
Carlisle, PA 17013
Name(s), address(es) and telephone number(s) of all counsel
Name Address
Telephone
Kathleen K.
44 South Hanover Street
Shaulis, Esq.
Carlisle, PA 17013
(717)243-6655
Date:
Additional information may be obtained fi.om the undersigned.
Name: Kathleeh IC Shaulis, Esq.
Address: 44 South Hanover Street
Carlisle, PA 17013
Telephone: (717) 243-6655
Capacity:__
X
Personal Representative
Counsel for Personal
Representatives
NOTICE OF BENEHCIAL INTEREST IN ESTATE
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND
In re Estate of Ephraim A. Kauffman deceased
No. 2002-00213
TO: Roy E. Kauffman
7556 Wertzville Road
Carlisle, PA 17013
Please take notice of the death of decedent and grant of letters to the personal representative
named below. You may have a beneficial interest in the estate as follows:
You are named as one of the beneficiaries under Mr. Kauffinan's Last Will and Testament.
Name of the Decedent: Ephraim A. Kauffman
Last Known Address: Thomwald Home
442 Walnut Bottom Road, Carlisle, PA 17013
Date of Death: February 14, 2002
Place of Death: Thomwald Home
County of Grant of Original Letters: Cumberland
Decedent dies X testate intestate
A copy of the will __ is X__ is not attached.
Name(s), address(es) and telephone number(s) of all personal representatives appointed
Name Address Telephone
James E. Kauffman
736 Siddonsburg Road
Dillsburg, PA 17019
Roy E. Kauffman
7556 Wertzville Road
(717) 432-5791
(717)249-7568
Carlisle, PA 17013
Name(s), address(es) and telephone number(s) of all counsel
Name .Address
Kathleen K.
44 South Hanover SWeet
Shaulis, Esq.
Carlisle, PA 17013
(717)243-6655
Date:
Additional information may be obtained from the undersig0, ed.
Name: Kathle~n K. Shaulis, Esq.
Address: 44 South Hanover Slree~
Carlisle, PA 17013
Telephone: (717) 243-6655
Capacity: __
X
Personal Representative
Counsel for Personal
Representatives
NOTICE OF BENEFICIAL INTEREST IN ESTATE
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND
In re Estate of Ephraim A. KatflYman deceased
No. 2002-00213
TO:
Daniel W. Kauffman
Momingside Apartment # 141
1700 Elmsdale Road
Paduka, KY 42003
Please take notice of the death of decedent and grant of letters to the personal representative
named below. You may have a beneficial interest in the estate as follows:
You are named as one of the beneficiaries under Mr. Kauffman's Last Will and Testament
Name of the Decedent: Ephraim A. Kauffman
Last Known Address: Thornwald Hume
442 Walnut Bottom Road, Carlisle, PA 17013
Date of Death: February 14, 2002
Place of Death: Thomwald Hume
County of Grant of Original Letters: Cumberland
Decedent dies X testate __ intestate
A copy of the will X is __ is not attached.
Name(s), address(es) and telephone number(s) of all personal representatives appointed
Name
James E. Kauffman
Roy E. Kauffinan
Address
Telephone
736 Siddonsburg Road
Dillsburg, PA 17019
(717) 432-5791
7556 Wertzville Road
Carlisle, PA 17013
(717) 249-7568
Name(s), address(es) and telephone number(s) of all counsel
Name Address
Kathleen lC
44 South Hanover Street
(717) 243-6655
Shaulis, Esq.
Carlisle, PA 17013
Date:
Additional information may be obtained from the undersigned.
~-/O--O? Signature: ~~~'~f~~-~
Name: Kathleda lC Shaulis, Esq.
Address: 44 South Hanover Street
Carlisle, PA 17013
Telephone: {717) 243-6655
Capacity: __
X
Personal Representative
Counsel for Personal
Representatives
LAST. WI.LL.AND TESTAMENT
OF
EPHRA. IM A.'.KAUFFMAN
I, EPHRAIM A. KAUFFMAN, of 320 Hogestown Road, Mechanicsburg,
Silver Spring Township, Cumberland County, Pennsylvania, being of sound
and disposing mind, memory, and understanding, do hereby make, publish
and declare this my Last Will and Testament, hereby expressly revoking
all other writings in nature testamentary by me at any time heretofore
made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I hereby give, bequeath and devise all the rest and
residue of my estate and property, real, personal and mixed, of what-
soever nature and wheresoever situated, of which I may die seized or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absqlutely and in fee simple
to my wife, Ida E. Kauffman, provided she survives me for 30 days'
THIRD: In the event that my wife is not living 30 days after my
death, then I give, bequeath and devise all my property to the Dauphin
Deposit Bank and Trust Company, through its.Carlisle, Pennsylvania branch,
IN TRUST NEVERTHELESS, for the following uses and purposes:
All monies in said Trust Fund shall be placed in
interest bearing accounts or Certificates of
Deposit, and the interest therefrom shall be paid
by my Trustees for the support and education of my
granddaughter, Jodi Bea Kline, in the sole dis-
cretion of my Trustees until the said Jodi Bea
Kline reaches the age of 21 years on May 16, 1989.
On May 16, 1989 or at the death of Jodi Bea Kline,
PAGE ONE ~F TWO
(SEAL)
~hichever first occurs, my Trustee shall
terminate this Trust, ~and distribute the
assets among my sons, Daniel W. KaUffman,
Roy E. Kauffman and James E. Kauffmlan, and
~y granddaughter, Jodi Bea Kline, .each to
share equally. In the event any of the above
~aamed sons, or my granddaughter shall die
?rior to the above dates for distribution,
~ direct that the share of said deceased son
.~r granddaughter shall go to those sons or
~randdaughter who are surviving at the date
for distribution.
FOURTH: I hereby appoint my sons, Roy E. Kauffman and James E.
Kauffman, ~as ?r above Trust, and in the event they are
either unable or
Bank and Trust Company of Carlisle, Pennsylvania, as my Trustee.
FIFTH: i~ hereby appoint my wife, Ida E. Kauffman, as Executrix of
this, my Last Will and Testament, .but in the event that the is unable
or unwilling to serve, I then appoint my sons, Roy E. Kauffman and James
E. Kauffman, as Executors of this, my Last Will and Testament, .and I
direct that t?~ey shall not be required to give'bond or other security in
any jurisdict~on wherein proceedings may be held in connection with my
estate.
IN WITNE£~S WHEREOF, I have hereunto set my hand and seal this 8th
day of Decemb~.~, 1980.
WIT,S:
/~ ~ . f~ ....... (SEAL)
PAGE TWO OF TWO
NOTICE OF BENEFICIAL INTEREST IN ESTATE
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND
In re Estate of Ephraim A. Kauffman deceased
No. 2002-00213
TO: Jodi Allan A/K/A Jodi Bea Kline A/K/A Jodi Bea Kauffman
814 Doubling Gap Road
Newville, PA 17241
Please take notice of the death of decedent and grant of letters to the personal representative
named below. You may have a beneficial interest in the estate as follows:
You are named as one of the beneficiaries unde~ Mr. Kauffman's Last Will and Testament.
Name of the Decedent: Ephraim A. Kauffinan
Last Known Address: Thornwald Home
442 Walnut Bottom Road, Carlisle, PA 17013
Date of Death: February 14, 2002
Place of Death: Thomwald Home
County of Grant of Original Letters: Cumberland
Decedent dies X testate intestate
A copy of the will X__ is __ is not attached.
Name(s), address(es) and telephone number(s) of all personal representatives appointed
Name Address Telephone
James E. Kauffman
Roy E. Kauffman
736 Siddonsburg Road
Dillsburg, PA 17019
7556 Wertzville Road
(717)432-5791
(717)249-7568
Carlisle, PA 17013
Name(s), address(es) and telephone number(s) of all counsel
Name Address Telephone
Kathleen K. 44 South Hanover Street (717) 243-6655
Shaulis, Esq.
Carlisle, PA 17013
Date:
Additional information may be obtained from the undersigned. ~.,
__5"-- / t~ - ~2.-- Signamr~
Name: Kalhlcen ~ Shaulis, Esq.
Address: 44 South Hanover Street
Carlisle, PA 17013
Telephone: (717) 243-6655
Capacity:
X
Personal Representative
Counsel for Personal
Representatives
LAS~ WI.LL.AND
OF
EPHRAIM A...KAUFF.MAN
I, EPHRAIM A. KAUFFMAN, of 320 Hogestown Road, Mechanicsburg,
Silver Spring Township, Cumberland County, Pennsylvania, being of sound
and disposing mind, memory, and understanding, do hereby make, publish
and declare this my Last Will and Testament, hereby expressly revoking
all other writings in nature testamentary by me at any time heretofore
made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I hereby give, bequeath and devise all the rest and
residue of my estate and property, real, personal and mixed, of what-
soever nature and wheresoever situated, of which I may die seized or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absqlutely and in fee simple
to my wife, Ida E. Kauffman, provided she survives me for 30 days'
THIRD: In the event that my wife is not living 30 days after my
death, then I give, bequeath and devise all my property to the Dauphin
Deposit Bank and Trust Company, through its Carlisle, Pennsylvania branch,
IN TRUST NEVERTHELESS, for the following uses and purposes:
All monies in said Trust Fund shall be placed in
interest bearing accounts or Certificates of
Deposit, and the interest therefrom shall be paid
by my Trustees for the support and education of my
granddaughter, Jodi Bea Kline, in the sole dis-
cretion of my Trustees until the said Jodi Bea
Kline reaches the age of 21 years on May 16, 1989.
On May 16, 1989 or at the death of Jodi Bea Kline,
EPH~IM A. KAUFFMAN
PAGE ONE OF TWO
(SEAL)
whichever first occurs, my Trustee shall
terminate this Trust, and distribute the
assets .among my sons, Daniel W. Kauffman,
Roy E. Kauffman and James E. Kauffman, and
my granddaughter, Jodi Bea Kline, each to
share equally. In the event any of the above
named sons, or my granddaughter shall die
prior to the above dates for distribution,
I direct that the share of said deceased son
or granddaughter shall go to.those sons or
sranddaughter who are surviving at the date
for distribution.
FOURTH: I hereby appoint my sons, Roy E. Kauffman and James E.
Kauffman, as above Trust, and in the event they are
either unable or ~i~i~i
Bank and Trust Company of Carlisle,.Pennsylvania, as my Trustee.
FIFTH: ~ hereby appoint my wife, Ida E. Kauffman, as Executrix of
this, my Last Will and Testament, .but in the event that the is unable
or unwilling to serve, I then appoint my sons, Roy E. Kauffman and James
E. Kauffman, ~s Executors of this, my Last Will and Testament, .and I
direct that riley shall not be required to give bond or other security in
any jurisdiction wherein proceedings may be held in connection with my
estate.
IN WITNE'.i~S WHEREOF, I have hereunto set my hand and seal this 8th
day of Decemb~r, 1980.
PAGE TWO OF TWO
'~ RE¥-1500 EX
~ COMMONWEALTH Of
~ PENNSYLVANIA
'~ .md~2~~:~ DEPARTMENT OF REVENUE
~'~-~-,[~,~t1~ ~ DEPT. 280601
"~ff~,~ HARRISBURG, PA 17128-0601
.~oo
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENT'S NA~E,J,LAST, FIRST, AND MIDDLE INITIAL)
DATE OF D~TH (MM-DB-YEAR) BATE OF BIRTH (MM-DB-YEAR)
02-1 - o1- -
use ONlY
IqO
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
- 07
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
[]1. Original Return
[~4. Limited Estate
[~6. Decedent Died Testate (Attach copy.of Will)
~]9. Litigation Proceeds Received
[~2. Supplemental Return
[~] 4a. Future Interest Compromise (date of death after 12-12-82)
E~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)
] 3. Remainder Return (date of death prior to 12-13-82)
[--"] 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
E~11. Election to tax under Sec. 9113(A) (Attach Sch O)
FIRM NAME (If Applicable)
TELEPHONE NJJMBER
COMPLETE MAILING ADDRESS
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
--]Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines I-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)
12. Net Value of Estate (Line 8 minus Line 11)
13.
· 804, z. s-o
OFFICIAL USE ONLY
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)
(13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15)
16. Amount of Line 14 taxable at lineal rate x .0 __ (16)
17. Amount of Line 14 taxable at sibling rate x .12 (17)
18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
20. []
~o
Decedent's Complete Address:
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Interest/Penalty if applicable
D. Interest
E. Penalty
STAT~O/~._
(1)
Total Credits ( A + B + C ) (2)
Total Interest/Penalty ( D + E ) (3)
If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page I Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
A. Enter the interest on the tax due.
(5A)
BLOCKS
No
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE
1. Did decedent make a transfer and: Yes
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 of )reparer other than the personal representative is based on all information of which preparer has any knowledge.
/7o1
DATE
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 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 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.
~v.,=~..~,~ ~ SCHEDULE E
' cOM~O.W~LT. OF,E..SYLV~.N~^ CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
FILE NUMBER
Include ~e ~s of I~gafion and ~e da~ ~e p~s were ~iv~ by ~e ~a~. All pm~ ~i~m~ ~ ~e ~ght of suwbomhi~ ) mu~ ~ d~los~ on ~h~ule F.
ITEM
NUMBER
DESCRIPTION
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
VALUE AT DATE
OF DEATH
allfirst
E A KAUFFMAN
C/O J KAUFFMAN
736 W. SIDDONSBURG RD
DILLSBURG PA 17019-9340
I,,,111,,,111,,,,,,111,1,,I.1,,,,11,,I,,111,,,,,11,, I1,,I,,,11
Page 1 of 6
Relationship With Interest
March 15, 2002 thru April 11, 2002
E A Kauthaan Acct No
00502-6624-'~
Customer Service
1-800-533.4630
Activity Summary
Number of images enclosed
Annual percentage yield earned 0.2S~
Avg. daily ledger balance SI,q79.29
Avg. daily collected balance Sl,q78.78
Interest earned this statement .28
Interest paid this statement · 28
Interest paid this year SI..
Days covered by this statement 28
Deposits and additions
Date Description
Balance on 03/14
Deposits and additions
Checks
Sl,617.18
lq.q9
-255.52
Balance on 04/11
Sl,376.1S '~
Amount
O3/27 DEPOSIT
04/11 INTEREST PAID
slq.21
.28
Checks
* Denotes missing sequence number
NumOer Date Amount
Slq. H9
240 03/27 S255.52
S25S. 52
End of Day Ledger Balance
Account balances are updated in the section below on days when transactions posted
to this account.
Date Balance Date Balance Date Balance
03114 SI,617.18 03~27 SI,375.87 04111 SI,376
000169
0007-98317476965 050
E.A. KAUFFMAN ~.~
~ s:~. - ,~..~T.4~ 871 '1 '1 0
~ 442 WALNUT' 8QTTOM'~OAD ....
~ CARUSI~E. PA- 17013 .... ;'.~'.,",.. ...... ~41
¢"~. · '" · .;* , :;. , .:- - ":.~,..'.':-~:..;: * · ' -: ....4 · - · *
-., .... , ..... _ ....... ~., ,~~
,'.~~ouph~n' DePos~,:a~n~; ~' -''~~~ ~
-
FORETHOUGHT CENTER, BATESVILLE, INDIANA 47006
Proposed, ur 47 6770
i~s '1 S~ S~urity Number
Ftrst N~ / Mi~e Intnal / ~st N~e
.... -' .... ~un~ ~umoer
~ ". ' '" . Heal~ Qu~tions (Op~onai). Multi-Pay Plans ONLY.
~ " ' : · ~BE CO~LETED ONLY BY ~ PROPOSED
~ "..~D; 'Pl~e ~wer e~h queS~0n m ~e ~st of
..1). ~ you ~nflY ~mM'm a hospi~ hospice, n~g home
(~clu~g cm~ c~) or o~er such faerie; or. wi~ ~e p~t
~ ~ ~elvo mon~; ~ve you ~n mid by a m~ practitioner ~at you
shoed ~ co~ but ~ve chosen not to follow ~ ~s~ction?
...... ~ Yes ~ No
~e ~k ~yable ~ Fom~ou~t L~e ~ Comfy. ~V~ you '~lvoa ~uvo ~a~ent ~m a m~c~ practitioner for
· Aum~c ~mt Au~ - A~h c~ple~ ~o~ fo~ ff~ ~y of ~e following:
QYes QNo
' BI~ Disorder "C~o~ D~o~r ~ver Disorder
B~ Di~r He~ Disor~r L~g Disorder
~ ~e ~wer to ~ h~ ques~o~ is "no," a ce~ca~ which
p~vi~s ~ core.ge w~ ~ ~u~. ffei~er.~swer is "yes," or if
8~!~ ~ P~~ to ~ p~d to ~ Benefi~
wmcn ~s me es~te ot~e ~ed. ff~o~er Beneficia~ is des~ ~°~' a c~ca~ wi~ ~ ~ ~fi~ d~g ~e f~t one
provide ~e ~o~a~on ~low. ~s desi~on is' subj~t m ~y ur two.yea~ ~n~g on age ~d pl~) wffi~ ~su~.
~s~ent or o~er ~tions ~ived ~m ~e Ce~hol~r ·
. ~s ~ent. Fo~, ~y m~c~ p~oner or f~, or o~er
~ , , ~on is au~o~ to'give Fox.ought Life ~ or ~o~ation
F m m~m. ~la~.to.~e H~ Question. ~ au~omfion is
"eff~five for a ~ of ~o yem ~d s~ mon~.
~ve info--on ~ ~ ~d comp~ to ~e best of my ~ow~dge ~ be~'Any pe~on w~ ~ow~gly ~ w~ ~ ~ defra~
I any insurance company or o~,r person ~s ~ ap~n for i~c, or ~~ o
~fo~onorconce~ orthe u · ' ~ c~ con~
P ~e.~ been nsued wh~ ~ Insured n~v!ng; · . ~ ~ been
giggle of Pro~sed l~ed $ig~e ~ ~ ~ ot~r t~ l~ed)
~~/~ r ........ ~ ~' mo ~o~on w~ provmm ~cuy Dy ~e ~o~sed ~. Yes ~o
i~.J I~,i: r
THOUGH'
~.,.~ _ _.~.~ent~d~oz~ssion~e~zces..$ ........ ~.--'s-.. ~:None '
.....~ Y~ ~c1, ch' -.-:,' ':'- .'' ....
.-.. You ........ &[P~' ~-~ ....... ' ~:~ ~> ':d~'~w,~'~c,aii~-.' .... ;' .' .....
~ ~or.~ & Color,',,.
, : ....... ". ..... . .. ,;',,,i., :"..,.' . -.'
. Faelem6~-Sem~,,~ ..... "- :'% :~,;i ',a~' ;,?,~,-.:~-.~; · , ..~B~~~N~ ', · [ ~. ~ t~...L,.. ]
.... , ......... . ........ . . dN~ ........ .
........ ~,.'-~"r" ....... 'U'',':~ ~ , ' -..a.,; ..... ' " -. ;.'. " . '' ' · '
' '~"~ se 't t~' ';ti: ..... :' ~ F, '. r.:' .~ ";c~ . :' ~ ..... " . , ' *~"~" ' ~!~ '~;'~.~al~'~,..4.~;I,'-:~'4ga~sC~)
'-: .-.;;,~l}{~tt~.~j~]:F6~-:],.:~ .?..itilt ,,.~.:;'~ ,',.'"' · '.;,...~. ~. i..'~ ',. '. , -... . '. '.,. 1.~..'.. ""F
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.... .. . ....... . ..... - / · ~ .~ ,-. ?...; ...? :.. ..._ . ~..~
C~ges a o!Y f6r ~se itd~ ai vOff sele~;~};ii~ ~;~.?~i: 4~;'-: .' ~,:'}: ~-?a;~'f; ~':' 1;~ ~,,,"-a~', 'Ir; .... ,~,", ' ':: ~ "':"" "''
- - ....... ,;_ - - ~ .... ~'~' a~m~t.~~'~ ~16~'f'". ' "" ....
I
~ ,a~...~-a__~'~'~ -., . ~ . . . . ~., l J~O~ Itt -,, ~h,~,'~ ~;~ ~{t$~,l~ri~O~.~n
.~ . .' .." ' .. .rr ~v~ ' '-.'" '" " .'.~'- --' '1~ ~ t,:" J
. obi~ofi~~ .... '~. · , '., -."L? "''/ ' .~'": :':C'~ ~,;.;". -" '.'...:.' ." - .' C :'.7. '7"~':~. I
· .7.' . ........ ~;~-. '.7':~'~,;,;~?,-:~ ;:.:. ~%~.~ ,;. ?. ~' ~.'"' -"-.-.-" ~.~v~.~~.~s;.. -.:.~ ..... .. ,.:~,.:.~::.~. ;'~.~'.., :: '.. '. '1
- . W ..... ' ' · ' . - ~ -' - .... , ~ t~.~ t ~..,, '4.~,~ ~ '..,, · -. · ·
-:.:....:. = ,, .~, .. . . ~ : ~ .'.'-P~'~.',~...~r,,~,.-~-,.~.~'i ,, , { .~ ,...,-. :.... .
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{
~ .'~ - ~ · ' ............ ' ' ' ..... .-~,~t~ I'¢~ '
.-.. -... · ..... .. . '17
': ~ '~!' ' '
,: :'~ .,(.. ~ ., , . · :' . ..,--.'. .:..'.--. .: .-'. /.?.'"' .~., ...~.~:~.~. /.,.~ '.".<.-:"......" ..., ,.: :....',.... ~..
l~~7~ ' -' '- . · · v ' . ..' · ". - ' '~..,.. ," :'.'~'.,.':':~, -'
~7 - -- '., ." ' - ' ' · ' "-
~--* ' - ~ .... ~ r~ - rmK.~o~- F~y .. ' 1193 '
may ~ chosen. .~,,,, -~ -~ ~,.~iml-,~ -~i-m~z~{ - - ......... '
p~ch~ed-to fund Non-Oua~tcca c~n ~ov~,~ ...... co ~_~ .....
............... : ......... ~-.-~z~ . '~: ~' . . · .. ·
~..a~l ~cc for dca~ ~om ~y cause, ~_$~~ ............ m ~-me effective at ~c end of ~c lm~
:~ ... isNOT~u~; Nej~eryoun~y . .' 'm___L ......... ;~m~bt~a~teevo~s~ivo~mustpay-~e.
However, ~*e pre.urns p~O ~e ~ess *~ .~,u2,.
erg ce ~tw~ ~e at-ne~ re~i pn ~ _ '~, ' ·. · · , ~ ,.
__Freedo~of Ooice Guar~ee: . - -~.~ .... h, ;-,,,~-c~d~ u0t gsMct ~y d~t m pm~ ~er~
Designating ~c Funer~ F~ to r~e~v~ ~e pr~
. ' ~c adv~m
' Mn ~e Fo~m uKpt ~e,~ruup
, . Y P g ~-, .; ' - ~-Con~erpn~pnor . g ..........
; ~ ~nreseu~Ve of ~e F~e~ F~ ~d ~ agent of
......... 'i!,'i{i'} i;,',l,-~ig'..'~ {ii!tCi'il :_
1001-05
.. 2 WHITE COPIES. - Company .... . y~J.LOW COPY_- FllaeraLFkm~.
.... :.'., .:: ,:.~-i. ', ' .
llg3
....
· Chan§~:.6f P~I[~
IMPORTANT~ Bo~:Sections O(:form:'must b~. C?m~(e~e~:~: '/:,~:-.:: '...'.::~.,:~::: :::' :...:.:: :?:..~.~ 5~
Na~e of Insured ' ' " ·Number bf Policy/Ce~ificatWAnnUi~
I hereby irrevocably assign ownership of the Forethought Life insurance policy/certificate or annuity to the Funeral
munemam~y transzer ownership o! me policy/certifiCaT~/iinnuifF.,t6 rrb~ Fo3~-~li3ii~gh'~ 'Tr~ o/~ .....
my behalf. .,...,,.:: ~,.
By assigning ownership of the policy/certificate/annuity to the Funeral Firm, it is understood:
i. This is permanent and irrevocable, and except as stated below, I renOunce my power to control the policy/
certificate/annuity,;, and . .. " ' '
2: Ownership of tile l~]i~'9'/ce'rtifica'fb/annuity Will SubseCluenfly be transferred by the'Funeral Firm to The ::
Forethought Trust which shall assure payment to the Funeral Firm,. or;anY:sUbSequently de'signa~l:fune~
· I w~.mv,e allin_ghts,.unde.r.~e policy/cenificate/ang, m..ty, t0 surrender,it' for'.ca~h-':~d"[O .'ob~ :a. l°~,.'ag~ti~!~.
4. [ understand that it is my persOnal ObligatiOn to pay all premiums due .on the:poiicy/certificatedan~ui~y
identified above; that I retain the...right to change the designated funeral fa; :and that I retain the right to
change the named beneficiary./ '.,
On behalf of the Funeral inn, I accePt the above assignment, and hereby transfer ownership of the policy/certificate/
annuity to The Forethought Trust. I understand that any,right to receive payment of the proceeds is contingent upon
delivery of funeral Services and merchandise. .' ·
· ::":'Name'ofyurf~[al~irm,:.(~leas~:Pfint;Name)::'"'::.":i,:: :.:.!i :-' :.d'7.::: !," :: ~!( :?!i"::i: !i:.,,:':'i ii:~ ':;:~::i.: J :~:~ i':ii;~i~ .' :~.~i(i "':'
:' , : 'T .---_7~: "~ :' ': .... ' -:' · :.;:: :...:: ." ::""":':. '/2' ' 1 (.~". ::"::ii:"-;:ii:-?!.:.-'<:'.":.
S'gnature of Authorized Repr'esen~/e " '" · ':'- : ': ": :' :"": Date · ::: .
" ' , x&_":'i," ,:.. ' ........ :",: ..... .'' .'- : -
2401-03
Wl-u'll~ - Company Copy Y~.T .T OW - Funeral Finn Copy PINK - Family c~PY 0 19~6 F°mthought
· 0696
...... ' ..... :,~,..- ......... : '...L :'.~. ........
Gibson-HolIin er Funeral Home, Inc.
Eric L. Hollinger. Supervisor
August 4, 1998
James E. Kauffman
736 W. $iddonsburg Road
Dillsburg, PA 17019
RE: Revised Statement of Funeral Goods
Dear Mr. Kauffman,
Enclosed is a copy of the updated Statement of Funeral Goods and
Services for the prearrangements of your Father.
Please make the check payable to Forethought and return the check
to me in the self-addressed envelope which I have enclosed for you.
Should you have any further questions, please feel free to contact
me at 486-3433.
Sincerely,
Eric L. HolIinger, S~pervisor
Gibson-Holtinger Funeral Home, Inc.
ELH/ ddm
qo ~ Nr"~I~TH BALTIMOt~E AVENUE o MOUNT HOLLY SPl~IN(3S. PENNSYLVANIA 17065 o (717) 486-34325 ,. PAX (7 ! ?) 486-3~ 15
· ,.,,,-,=u~,-numnger Funeral Home, Inc.
· Eric L. Hollinger, Supervisor
501 N. Baltimore Ave.
~ Mt. Holly Sprgs, PA 17065
(717)486-3433 ·
we ~v~l explain ~e reasons in writine b~]ow ~ or mat are required. It- we are u'
l.f. ou selected a fimeral that .. . . req ired by law or by a cern or a crc ·
d,~not approve ifw,, seS~.~-a~Y -r~q.~u-u?embalmm~, such as a funeral with view; .......... etery mntory to use nny stems,
........ ~u~angemcnts sucn as a direct crc .,,, ~,, ;~,..~.~..u_u._m~a_y_ .na. ve..to pay [or embalming. You do no ave to ·
mati ...... ...~u~m~ ounm. 1! we char ed . t h. pa~/t'or cmbalmm ou
For the Service of: _.Ephraim Adam Kauffman g 1for embalm,nE, we will explmn why below g y
Charge to: James Edward Kauffman Date of Death
'--~ 736 W. Siddonsburg Road Dillsbu.~~ PA
A. CHARGE FOR SERVICES SELECTED:
1. PROFESSIONAL SERVICES
Services of Funeral Dlre~torlStaff.
Embalming , . .....
Other prep.;;tion' ii/,;,d;, ...............
Other Clothinq
-- $
Cremation Um ................. $
(Description) CremntL~n Um
2. FACILITIES AND SERVICES
Use of facilities and services for
Viewing (Visitation/VVake) ................ ~
Use of facilities and services for
Funeral Ceremony
Use of facilities and' ~e;r~ic~'s' f'o~' ........... $~'
Memorial Service
Use of equipment ~d'~iC~ f~' ........ $~'
Graveside Service ..................... ~.
Other use of facilit es
SUB-TOTAL OF PROFESSIONAL SERVICES ...... · · · · A1 $
Incl.
$
TOTAL MERCHANDISE SELECTED ....
C. SPECIAL CHARGES
Fon~arding of remains to
--
(Funera! Home) -
Receiving of remains from
Immediate Burial ................... $
Direct Cremation ..................
3350.00
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral
Local ...............................
Hearse (Casket Coach) S-
Local .............................
Limousine
Local .......
Family Car .......................
Local .............................. $
F ower car or floral disposition
Local ................... . $
Lead car/Clergy ............ --
Local ........
Car for pallbear;r~ .....................
Local ................................ $
Out of town transportation ................
UB-TOTAL OF FACILITIES/EQUIPMENT ............ A2 $
SUB-TOTAL OF SPECIAL CHARGES C $ 0.00
D. CASH ADVANCED: ..........
Opening Grave .................... $ 250.00
Cemetery Equipment ............... $ 75.0~
Lot and Deed ...................... [
Newspaper Notices - Local ........... $_
Newspaper Notices - Out-of-town $
Telephone & Telegrams ............. $. _
Airfare ...................... ~"
Clergy/Mass Offedng. ' ' '$ 75 00
Police Escort ..................... i~'
Flowers .......................
Vault Serv ce ~harge .............. '$~ 127.20
Oroanlst $
$
$ -
EV-1511 EX+ (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
'~/-02.- 07-(3,
Debts of decedent must be reported on Schedule ].
ITEM
NUMBER DESCRIPTION AMOUNT
A.
1.
q
5.
6.
7.
FUNERAL EXPENSES:
ADMINISTRATIVE COSTS:
Personal Representative's Commissions 'T,,.
Name of Personal Representative(s) ~ f'3',J ~ ¢~O~
'
Social Secufi~ Number(s)/EIN Number of Personal Representative(s)
Street Address 7~ ~.
City D ) ~1 ~ ~~ State
Year(s) Commission Paid:
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
RECEIPT FOR PAYMENT
Cumberland County - Reqister Of Wills
Hanover and High Street
Carlisle, PA I7013
Receipt Date
Receipt Time
Receipt No.
2/27/2002
10:46:42
1028477
KAUFFMAN EPHRAIN A
File Number
Remarks
2002-00213
JAMES E KAUFFMAN
JA
Transaction Description
PETITION FOR PROBA
JCP FEE
SHORT CERTIFICATE
EXTRA PAGES
Cash
Total Received .........
Distribution Of Receipt
Payment Amount Payee Name
25.00 CUMBERLAND COUNTY GENERAL FUN
5.00 BUREAU OF RECEIPTS & CNTR M.D
6.00 CUMBERLAND COUNTY GENERAL FUN
3.00 CUMBERLAND COUNTY GENERAL FUN
9.00
9 00
~ARRISE',URG~ ~'A !71£0
'.~EA ~H CASi~
t:A.S -~l ~. ] ..w4.,4
E[.MI]-FANCEADDRESS BILL TO
SENTINEL - LEGAL LAW OFFICES SHAULIS, KATHLEEN
P.O. BOX 130, CARLISLE, PA 17013
AD NUMBER J CLASS SALESPERSON BILLING DATE LINES
222899I 10 PUBLIC NOTICES c32 05/29/02 27
AD DESCRIPTION START DATE STOP DATE
EXECUTORS' NOTICE LETTERS TESTAMENT 05/10/02 05/24/02
PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 87.48
TOTAL AD CHARGE 87.48
3 2002 PROOF OF PUBLICATION 01PRF 6.35
DAYS RUN
"URC,ASE ORDE. PAY THIS' AMOUNT 93.83 112.60*
Ephriam Kauf fman
AFTER O6/28/02
MESSAGE:
Thank you for advertising with The Sentinel.
Deadlines for in-column legal advertisements: Monday is Friday at
11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon;
Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday
is Thursday at 12 Noon.
If you have any questions regarding your Legal bill please call
Lori Saylor 243-2611 ext. 201
Fax your legals to 243-3754, attention Lori Saylor
You can also EMAIL your legal to Classified ads: ads@cumberlink.com.
Please send a cover letter including your name and address as an attachment
DETACH AND-RETURN' THiS-PORTION WiTH YOUR PAYMENT -
THE SENTINEL - LEGAL Ephriam Kauffman
P.O. BOX 130, CARLISLE PA 17013
AD NUMBER C~SS0 START DATE STOP DATE
222899 PUBLIC NOTICES 05/10/02 05/24/02
AD DES~IPTION BILLING DATE TELE~ONE NUMAR
EXECUTORS' NOTICE LETTERS TESTAMENT 05/29/02 717-243-6655
LAW OFFICES SHAULIS, KATHLEEN K.
44 SOUTH HANOVER STREET
CARLISLE, PA 17'013
GROSS AMOUNT OF
112.60
DUE AFTER 06/28/0;
TOTAL AMOUNT DUE
93.83
ENTER AMOUNT ENCLOSED
CUMBERLAND LAW JOURNAL
2 LIBERTY AVENUE
CARLISLE, PA 17013
MAY 31,2002
Cumberland Law Joumal is published every Friday by the Cumband County Bar
Association and is designated by the Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Kathleen K. Shaulis, ESQUIRE
Ephraim A. Kauffman, ESTATE
Legal advertisements must be received by Friday Noon. All legal advertising must be
paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
MAY 17, 24, 31, 2002
Advertising Cost
Proof of Publication
Second Proof Request
Payment received
Total Amount Due
Payment received MAY 13, 2002
by Becky_ H. Mor~enthal/Executive Director
$ 75.00
$ 0.00
$ 0.00
$ 75.00
$ 0.00
THE LAW OFFICES OF
KATHLEEN K. SHAUUS, ESQ.
44 SOUTH HANOVER STREET
CARLISLE, PA 17013
PHONE: (717) 243-6655 FAX: (717) 243-6618
EMAIL: JRS037CARLISLE~)SPRINTMAILCOM
James E. Kauffman and
736 W. Siddonsburg Road
Dillsburg, PA 17019
Re: Estate of Ephraim A. Kauffinan
No. #1098-2002
Roy E. Kauffman
7556 Wertzville Road
Carlisle, PA 17013
Account to Date
1/30/2002 Reimbursement for
Sentinel Advertising
(See Attached)
2/13/2002 Reimbursemem for
CC Law Journal
(See Attached)
6/26/2002 Preparation of Notices to
Beneficiaries and Inheritance Tax
Return
6/26/2002 Reimbursement for Filing Fee
Inheritance Tax Return
Hrs/Rate
N/A
N/A
N/A
N/A
Amount
93.83
75.00
150.00
10.00
Total 6/26/2002
Paid 6/26/2002 Estate Check No. 242
328.83
(328.83)
Balance due 6/26/2002 $(0.00)
· REV-1512 EX * (1-97) ~
COMMONWEALTH OF PENNSYLVANIA
)NHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
IVIORTGAGE LIABILITIES, & LIENS
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1.
AMOUNT
'-FAo
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
MR JAMES E KAUFFMAN
736 W SIDDONSBURG RD
DILLSBURG PA 17019
COMMONVVEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
May 09, 2002
J
Re: EPHRAIN ~AUFFMAI~
CIS #: 550146646
SSN: 195-07-7929
Date of Death: 02/14/2002
Dear Mr. Kauffman:
Please be advised that the Department of Public Welfare is attempting to
recover the monetary value of any and all eligible assets in the subject
estate. Although the amount in the estate may be considerably less than that
which is owed to the Department, our claim is against the estate, no one
else. Your responsibilities, as the primary next of
kin/administrator/executor, is to advise the Department of any assets in the
estate and to insure that the remaining money, after all funeral and
administrative costs are deducted, is sent to the Department.
The Department of Public Welfare maintains a claim in the amount of
$96,246.17 against the above-mentioned estate. This claim is for restitution
of medical assistance granted on behalf of the decedent for which the Probate
Estate is now responsible to reimburse the Department according to Act 49, 62
P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June
30, 1995. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely $26,212.40, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $70,033.77, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise when payment may be
expected. If the estate accounting is complete, please provide a copy. If
the estate contains real estate, please provide copies of the deed, the
latest tax assessment and a current appraisal, if available.
Enclosure
Sincerely,
Susan E. Naylor
TPL Program Investigator
717-772-6265
717-772-6553 FAX
COMNIONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNFr
PO BOX 8486
HARRISBURG PA 17105-8486
May 9, 2002
STATEMENT OF CLAIM SUMMARY
Estate of KAUFFMAN, EPHRAIN I
550146646
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 22,087.78 66,685.94 87,773.72
DRUG 4,124.62 4,347.83 8,472..46
~.,~,~l 26,212.40 70,033.77 68,246.17
May 9, 2002
STATEMENT OF CLAIM
~!! KAUFFMAN, EPHRAIN
I
PHARMERICA INC #22000 I
111 RUTHAR DRIVE I
NEWARK DE 19711 I
I
01/10/01 - 0t/10/0t 02/05/01 101070194701 000000000000 66.86 60.63
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
01110101 - 01110/01 02/05/01 101070204101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.90
01/10101 - 01110/01 02/05/01 101070471201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 156.05 134.68
01/10101 - 01110/01 02/05/01 101070392201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 87.90 75.90
01/10101 - 01110101 02/05/01 101070194801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 92.80 83.92
01111101 - 01111101 02/05/01 101170670901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 16.85 8.77
01129101 - 01129101 02/26/01 102971300301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 62.45 56.60
01130101 - 01130101 02/25/01 103072765301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 42.30 38.46
DEPAR~E~ OF PUBLIC WELFARE
May 9, 2002
STA~MENT OF C~IM
~..,~:~.~,.~.~1 ~UFFMAN, EPH~IN
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
02/07101 - 02/07101 03/05/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
103870119601 000000005000 4.90 4.90
PRESCPRESCRIPTION DRUGS
02/07101 - 02/07101 03/05/01 103870079201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000500000 92.80 24.46
02/07101 - 02/07101 03/05/01 103870364201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000050000 155.05 139.90
02/07101 - 02/07101 03/05/01 103870394701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000005000 87.90 79.50
02/07101 - 02/07101 03/05/01 103870170201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 68.85 62.33
02/22/01 - 02/22/01 03/19101 105373531401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 79.95 75.91
02/28/01 - 02/25/01 03/25/01 105972141301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 197.50 187.29
02/28/01 . 02/28/01 03/26/01 105970407801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 59.55 56.60
May 9, 2002
STATEMENT OF CLAIM
· i!i i E;~ KAUFFMAN, EPHRAIN 550 146 646
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
03/03/01 - 03/03/01 03/26/01 106270915501 000000000000 40.40 38.46
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
03/07101 - 03/07101 04/02/01 106672553201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.75 79.50
03/07101 - 03/07101 04/02/01 106670203401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 88.40 24.46
03/07101 - 03/07101 04/02/01 106672553301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.50 139.90
03/07101 - 03/07101 04/02/01 106670232801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.90
03/07101 - 03/07101 04/02/01 106670184001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 65.60 62.33
03126/01 - 03/26/01 04/23/01 108572064501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 197.50 187.29
04/02/01 - 04/02/01 04/30101 109272643001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000005000000 59.55 55.60
May 9, 2002
STATEMENT OF CLAIM
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
04/04/01 - 04/04/01 04/30/01 109470211701 000000000000 88.40 24.46
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
04/04/01 - 04/04/01 04/30/01 109470232801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.90
04/04/01 - 04/04/01 04/30/01 109470224201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.50 139.90
04/04/01 - 04/04/01 04/30/01 109470191801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 65.50 62.33
04/04/01 - 04/04/01 04/30/01 109470313101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
005000000000 83.75 79.50
04/12/01 - 04/12/01 05/07101 110273377101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000005000000 79.95 75.91
04/30/01 - 04/30/01 05/28/01 112071318401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 40.40 38.46
05/01101 - 05/01101 05/28/01 112172145901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000500 59.55 56.60
May 9, 2002
STATEMENT OF CLAIM
KAUFFMAN, EPHRAIN
550 146 646
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
05/02/01 - 05/02/01 05/25/01 112270344701 000000000000 88.40 24.46
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
05/02/01 - 05/02/01 05/25/01 112270372401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.90
05/02/01 - 05/02/01 05/28/01 112270334401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 66.60 62.33
05/02/01 o 05/02/01 05/28/01 112270449501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.75 79.50
05/02/01 - 05/02/01 05/25/01 112270520701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.50 139.90
05/02/01 - 05/02/01 05/25/01 112272270401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 197.50 187.29
05/14/01 - 05/14/01 05/11/01 113472628301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
05/16101 - 05/16/01 05/11101 113672961901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 9.65 7.18
000000000000 40.40 38.46
May 9, 2002
STATEMENT OF CLAIM
KAUFFMAN, EPHRAIN
550 146 646
PHARMERICA INC #22000 I
111 RUTHAR DRIVE I
NEWARK DE 19711 I
06/21101 - 05/21/01 06/15/01 114172648101 000000050000 30.35 28,92
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
05/23/01 - 05/23/01 06/15/01 114373367001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 44.45 42.28
05/29101 - 05/25/01 06/25/01 114975520301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 69.55 56.60
05/29101 - 05/29101 06/25/01 114973192601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000500 197. 50 187.29
05/35/01 - 05/30/01 06/25/01 t15070293601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000050000 83.75 79.50
05/30101 - 05/30101 06/26/01 115070234301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.90
05/30101 - 05/30101 06/25/01 115070192601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000500000000 88.40 24.46
05/30101 . 05/30101 06/25/01 115070215001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000500000000 65.60 62.33
May 9, 2002
STATEMENT OF CLAIM
KAUFFMAN, EPHRAIN
550 146 646
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
05/30101 - 05/30101 06/25/01 115070312801 000000000000 147.50 139.90
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
06/27/01 - 06/27101 07123/01 117870430701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.75 79.50
06/27/01 - 06/27101 07/23/01 117870411801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.80 139.90
06/27/01 - 06/27101 07123/01 117870352401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 88.40 24.46
06/27101 - 06/27101 07123/01 117870333001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 65.60 62.33
06/27101 - 06/27101 07123/01 117870323401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.90
07101101 - 07101101 07123/01 118271014001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07102/01 - 07102/01 07/30101 118372283401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 59.55 56,60
000000000000 207.00 187.29
May 9, 2002
STATEMENT OF CLAIM
~ KAUFFMAN, EPHRAIN
ID,cicerOni 550 146 646
%~::'~'~
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
07111101 - 07111101 08/06/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
1t9272765801 000000000000 4t.20 39.23
PRESCPRESCRIPTION DRUGS
07119101 - 07119101 08/13/01 120071797101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 52.15 49.58
07125/01 - 07125/01 06/20101 t20670161601
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 65.60 62.33
07125/01 - 07125/01 05/20/01 120670151501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.80
07125/01 - 07125/01 08/20101 120670161301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 88.40 24.46
07125/01 - 07125/01 05/26/01 120670468101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.75 75.50
07125/01 - 07125/01 06/20101 120670355701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.50 139.90
07130101 - 07130101 05/27101 121170109101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 59.55 56.60
May g, 2002
STATEMENT OF CLAIM
I i~:~;~:¥'1 550 146 646
PHARMERICA INC #22000
1 tl RUTHAR DRIVE
NEWARK DE 19711
08/01~1 - 08/01~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
08/27/01 121372150101 000000000000 207.00 196.28
PRESC PRESCRIPTION DRUGS
08/01101 - 08/01101 08/27101 121372117001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 41.85 39.85
08/22/01 - 08/22/01 08/1~01 123470161201
DIAGNOSIS1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS2:
PROCEDURE:
000000000000 88.40 24.46
08/22/01 - 08/22/01 08/17101 123470158401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.50 139.90
08/22/01 o 08/22/01 08/17101 123470132201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.80
08/22/01 - 08/22/01 09117101 123470046001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 65.60 62.33
08122/01 - 08/22/01 09117101 123470167901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.76 79.50
08/29101 - 08/29101 08/24/01 124172105301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 50.55 56.60
May 9, 2002
STATEMENT OF CLAIM
i~ KAUFFMAN, EPHRAIN
lID ;~1 SS0 146 646
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
08/29/01 - 08129101 09/24/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
124172636001 000000000000 207.00 196.28
PRESCPRESCRIPTION DRUGS
09105/01 - 09105/01 10101/01 124872415401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 52.15 49.58
09112/01 - 09112/01 10/08/01 125572359301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 76.40 71.60
00/14/01 - 09/14/01 10/05/01 125770026101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 43.35 39.85
00/19/01 - 09/10/01 10/15/01 126270095901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 66.60 62.33
00/10/01 - 091t9101 10/15/01 126270076001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 4.90 4.80
00/19101 - 00/19/01 10/15/01 126270142201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 88.40 24.46
00/19101 - 09119101 10/15/01 126270623201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.75 79.50
'::i DEPARTME~ OFPUB~iC WELFARE :'i :
May 9, 2002
STATEMENT OF CLAIM
KAUFFMAN, EPHRAIN
SSO 146 646
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
09/19101 . 09119/01 10/15/01 126270562701 500000000000 t47.50 139.90
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
00/25/01 - 05/26/01 10122/01 126971248101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000500000000 207.00 196.28
09127101 - 09127101 10/22/01 127070480501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE .'
505000000000 59.55 50.60
10117101 - 10117101 11112/01 129070206801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 147.50 139.90
10117101 - 10117101 11112/01 129070161201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 66.60 62.33
10117/01 . 10/17101 11112/01 129070141801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000005000 4.90 4.80
10/17101 - 10/17101 11112/01 129070096101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
005000000000 88.48 24.48
10/17/01 - 10117101 11112/01 129070321401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000500000000 83.75 79.50
:DEPA ~E~QE PUBEICWELFARE
May 9, 2002
STATEMENT OF CLAIM
550 146 ~6
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
10/27101 - 10127101 1111910t
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
130070019401 000000000000 89.55 56.60
PRESC PRESCRIPTION DRUGS
10/30/01 - 10/30/01 11126/01 130373210301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 207.00 196.28
11114/01 - 111t4/01 12/10/01 131870165301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 96.65 24.46
11114/01 - 11114/01 12/10/01 131870294601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 160.95 139.90
1t114/01 - 11114/01 12/10101 131870223901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.75 79.50
11114/01 - 11114/01 12/10/01 131870214901
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 68.05 62.33
11114/01 - 11114/01 12/10/01 131870204901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 6.28 4.99
11127101 - 11127101 12/24/01 133170669001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 59.55 56.60
May 9, 2002
STATEMENT OF CLAIM
':D~'~: ~ $50 146 646
PHARMERICA INC #22000
111 RUTHAR DRIVE
NE~NARK DE 19711
11/29/01 - 11/29/01 12/24/01 133373788601 000000000000 207.00 196.28
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
t2/12/01 - 12/12/01 01107102 134670362401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 83.76 79.50
12/12/01 - 12/12/01 01107102 134670266301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 160.95 139.90
12/12/01 - 12/12/01 01107102 134670067401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 68.05 64.66
12/12/01 - 12/12/01 01/07102 134670067601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 96.66 24.46
12/12/01 - 12/12/01 01107102 134670027001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 5.25 4.99
12/20/01 12/20101 01114/02 135471362601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 228.35 196.28
12/24/01 - 12/24/01 01121102 135873282401
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 65.40 56.60
May 9, 2002
STATEMENT OF CLAIM
:~!/ KAUFFMAN, EPHRAIN
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
,,, ........., ~ . ,,, , ~'~' ~.~ ,~r~,, ,:~'~1: , '~ ~'i~~ ~, ,,
01/09102 - 01109102 02/04/02 200970098801 000000000000 5.20 4.99
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
01109102 - 01109/02 02/04/02 200970086201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 74.80 64.66
01109/02 . 01109102 02/04/02 200970108701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 106.40 24.46
01109102 - 01109102 02/04/02 200970315701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 92.10 79.50
01109102 - 01109/02 02/04/02 200970122301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 177.45 152.65
01123/02 - 01123/02 02/18/02 202371574301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 228.35 196.28
01124/02 - 01124/02 02/18/02 202470501301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 68.40 56.60
02/06/02 - 02/06/02 03/04/02 203770326701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 92.10 79.50
May 9, 2002
STATEMENT OF CLAIM
~%~' I
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEINARK DE 19711
02/06/02 - 02/06/02
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
03/04/02 203770208901 000000000000 177.45 162.66
PRESC PRESCRIPTION DRUGS
02/06/02 - 02/06/02 03/04/02 203770106901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 106.40 24.45
02/06/02 - 02/06/02 03/04/02 203770098101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8,20 4.99
02/06/02 - 02/06/02 03/04/02 203770087801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 74.80 64.66
PHARMERICA INC #22000
19 1718840
10,081.80 I
8,472.46
May 9, 2002
STATEMENT OF CLAIM
KAUFFMAN, EPHRAIN
550 146 646
THORHWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
10123/99 - 10131199 01124/00 001888610401 000000000000 1,000.17 1,000.17
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11101199 - 11/30/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01124/00 001888611001 000000500000 2,735.25 2,736.25
12/01/99 - 12/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
02/07100 003188405201 000000000000 2,846.38 2,846.38
01101100 - 01/31/90
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
00/29100 014388479001 005387781901 2,890.26 2,890.26
02/01100 - 02/29/90
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
05/29100 014388479101 007690210501 2,664.04 2,664.04
0~01~0 - 0~31/90
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
05/29100 014388479201 010888950201 2,890.26 2,890.26
04/01100 - 04/30/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
05/22/00 013698109501 500000000050 2,953.90 2,953.90
05/01~0 - 05/31~0
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
05/19100 016488420101 500000000000 3,064.79 3,054.79
I
May 9, 2002
STATEMENT OF CLAIM
INAMEi?I KAUFFMAN, EPHRAIN
IID~I 560 146 646
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
06/01100 - 06130/00 07117/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
07/01100 - 07131100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
0~01~0 - 0~31~0
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
08/14/00 022186938901 000000000000
09101100 - 09~30~00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
09118/00
1~01~0 - 10131~0
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
10123/00
11101100 - 11130100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11120100
1~01~0 - 1~31~0
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
12/18/00
01~1~1 - 01~1~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
3,378.58 3,378.58
025588565601 000000000000 3,305.58 3,305.56
029391687001 000000000000 3,179.10 3,179.10
032198631001 000000000000 3,213.82 3,213.82
034996868501 000000000000 3,090.30 3,090.30
01122/01 101688305101 000000000000
11119101
3,213.82 3,213.82
131856006561 104494839301 3,191.25 3,191.25
May 9, 2002
STATEMENT OF CLAIM
550 146 646
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
02/01/01 - 02/28/01 11119/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
0~01~1 - 0~31~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11119101
04/01101 - 04/30101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11119/01
05/01~1 - 05/31~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11105/01
05/01~1 - 0~3~01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11/05/01
07101101 - 07131101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11105/01
05/01101 - 05/31~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11105/01
09101101 - 09130101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10122/01
131856006601 108385753701 2,820.69 2,820.69
131856006701 111086199501 3,191.25 3,191.25
131856006801 113186218801 3,112.13 3,112.13
130693756701 11 6490959801 3,335.13 3, 335.13
t 30693756801 119486855101 3,112.13 3,112.13
130693756901 122687049701 3,490.71 3,490.71
130693757001 126885060201 3,490.71 3,490.71
128895221501 000000000680 3,357.53 3,357.53
May 9, 2002
STATEMENT OF CLAIM
KAUFFMAN, EPHRAIN
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
, , I I : : ~ ~i ~,~ ~ ~/~ ~ ~,~:~,~?~,~ /.~~
10/01/01 - 10/31/01 11/26/01 132380667201 000000000000 3,490.71 3,490.71
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11101101 - 11/36/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
12/17/01 134797642101 000000000000 3,357.53 3,357.53
12/01~1 - 12/31~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
01114/02 201196647801 000000000000 3,472.42 3,472.42
01101102 - 01/31102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
02/18/02 204685982301 000000000000 3,731.32 3,731.32
02/01102 - 02/13/02
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
03/18/02 207188351201 000000000000 1,187.56 1,187.56
allfirst
Acc! No 005026624;
Chec): #240 Paid :03/27/2002 255.52
0OO169
0007-98317476968 001
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE
OF
NUMBER
1.
SCHEDULE J
BENEFICIARIES
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outdght spousal distributions)
FILE NUMBER
zl-- oz.--- o
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
AMOUNT OR SHARE
OF ESTATE
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II . ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
estate of KAUFFMAN EPHRAIM A
( L~'£', ~'i 1/~'1', MIL313~ ,~)
in said county, deceased, to
KAUFFMAN ROY E
(]-un~'l', ~'l~'l',
SHORT CERTIFICATE
MARY C. LEWIS
Register for the Probate of Wills and Granting
Letters of Administration &c. in and for said
County of CUMBERLAND do hereby certify that on
the 27th day of February A.D.,
Two Thousand and Two,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
, late of CARLISLE BOROUGH
KAUFFMAN JAMES E
and
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of said office at CARLISLE, PENNSYLVANIA, this 27th day of February
A.D., Two Thousand and Two.
File No.
PA File No.
Date of Death
s.s. #
2002-00213
21-02-0213
2/14/2002
195-07-7929
Register
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
his is to certi~ that the infbrmation here given is correcdy copied l~¥om an original certificate of death-duly filed with me as
Local Registrar. The original certificate will bo ~brwarded to the State Vital Records Office for permanent fiiing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, 82.00
P 8168722
No.
~"~ Local Registrar
'
~'..~,,g.%.%.%._~/, .~/
~.?/~."--~5,~;/ FEB 1 5 2002
Date
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF OEATH
I/2~/1905
Tho~rm,~Zd Home
2/17/2002
Ceme:t.g,tV
uAdou~d
tg, PA 17019
' LAST WI.LLAND TESTAMENT
OF
EPHRAIM ~.~.KAUFFMAN
I, EPHRAIM A. KAUFFMAN, of 320 Hogestown Road, Mechanicsburg,
Silver Spring Township, Cumberland County, Pennsylvania, being of sound
and disposing mind, memory, and understanding, do hereby make, publish
and declare this my Last Will and Testament, hereby expressly revoking
all other writings in nature testamentary by me at any time heretofore
made.
FIRST: I direct that all my debts and funeral expenses be paid
as soon after my decease as may be practicable.
SECOND: I hereby give, bequeath and devise all the rest and
residue of my estate and property, real, personal and mixed, of what-
soever nature and wheresoever situated, of which I may die seized or
possessed or to which I may be entitled or of which I may have the
right to dispose at the time of my death, absqlutely and in fee simple
to my wife, Ida E. Kauffman, provided she survives me for 30 days.
THIRD: In the event that my wife is not living 30 days after my
death, then I give, bequeath and devise all my property to the Dauphin
Deposit Bank and Trust Company, through its.Carlisle, Pennsylvania branch,
IN TRUST NEVERTHELESS, for the following uses and purposes:
All monies in said Trust Fund shall be placed in
interest bearing accounts o~ Certificates of
Deposit, and the interest therefrom shall be paid
by my Trustees for the support and education of my
granddaughter, Jodi Bea Kline, in the sole dis-
cretion of my Trustees until the said Jodi Bea
Kline reaches the age of 21 years on May 16, 1989.
On May 16, 1989 or at the death of Jodi Bea Kline,
ONE
(SEAL)
whichever first occurs, my Trustee shall
terminate 'this Trust, and distribute the
assets among my sons, Daniel'W- Kauffman,
Roy E. Kauffman and james E. Kauffman, and
randdaughter, Jodi Bea Kline, each to
my g -"~-- I- the event any of the above
share equa~- - ~ .... ~=,~eer shall die
named sonS, or my gr~~--
prior to the above dates for distribution,
I direct that the share of said deceased son
or granddaughter shall go to.those sons or
granddaughter who are surviving at the date
for distribution-
FOURTH: I hereby appoint my sons, Roy E. Kauffman and James E.
Kauffman, as Trustees of the above Trust,.and in the event they are
either unable or unwilling to serve., I then appoint Dauphin Deposit
Bank and Trust Company of Carlisle~ Pennsylvania, as my Trustee.
FIFTH: I hereby appoint my wife, Ida E. Kauffman, as Executrix of
this, my Last Will and Testament, .but in the event that the is unable
or unwilling to serve, I then appoint my sons, Roy E. Kauffman and James
E. Kauffman, as Executors of this, my Last Will and Testament, .and I
direct that they shall not be required t° giveb°nd or other security in
any jurisdiction wherein proceedings may be held in connection with my
estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 8th
day of December, 1980.
WITNESS: ·
PAGE TWO OF TWO
STATUS REPORT UNDER RULE 6.12
Name of the Decedent: Ephraim A. Kauffman P. Hershey
Date of Death: February 14, 2002
Will No. 213 of 2002 Admin. No.:
00213 of 2002
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to
completion of the administration of the above-captioned
estate:
State whether the administration of the estate is
complete: Yes X No
If the answer is No, state when the personal
representative reasonably believes that the
administration will be complete:
Date:
If the answer to No. 1 is Yes, state the
following:
a. Did the personal representative file a final
account with the court? Yes No ~
b. The separate Orphans' Court No. (if any) for
the personal representative's account is :
c. Did the personal representative state an
account informally to the parties in
interest? Yes X No.
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may
be filed with the Clerk of the Orphans' Court
and may be attached to his report.
Kathleen K. Shaulis
44 South Hanover Street
Carlisle, PA 17013
(717) 243-6655
Capacity:
X
Personal Representative
Counsel for Personal
Representative
BUREAU OF XNDIVTDUAL TAXES
XMHERXT&NC[ TAX DIVISION
DEPT. 2.80&0X
HARRISBURG; PA XTXZS-0&01
COHNOH#EALTN OF PENHSYLVANZA
DEPARTNENT OF REVENUE
NOTXCE OF XNHERXTANCE TAX
APPRA'rSEHENT, ALLOHANCE OR DXSALLO#ANCE
OF DEDUCTZQN$ /d~ ASSESSHEHT OF TAX
REV-]~47 EX AFP (IX-~)
KATHLEEN K SHAULZS ESQ
HANOVER ST
CARLXSLE PA 17013
DATE 08-12-2002
ESTATE OF KAUFFHAN
DATE OF DEATH 02-14-2002
FZLE NUHBER 21 02-0213
COUNTY CUNBERLAND
ACN 101
I Amount R~mlttmd
EPHRAZN A
"1
HAKE CHECK PAYABLE AND RENZT PAYHENT TO:
REGXSTER OF gZLLS
CUNBERLAND CO COURT HOUSE
CARLZSLE, PA 17015
CUT ALONG THZS LZNE ~. RETAZN LONER POR.T.Z.O..N, .F.O..R__Y.O.U_.R._R._E.C_O_R.9..S... ,_.-~..
ESTATE OF KAUFFNAN EPHRAZN A FZLE NO. 21 02-0215 ACN 101 DATE 08-12-2002
TAX RETURN gAS: ( X ) ACCEPTED AS FZLED ( ) CHANGED
RESERVAT/ON CONCERNZNG FUTURE ZNY~REST - SEE REVERSE
APPRAXSED VALUE OF RETURN BASED ON: ORTGXHAL RETURN
1. RmmX Estmte (SchecJule A) (1)
2. Stocks and Bonds (Schm:luXm B) (2)
3. CloseXy HeXd Stock/Pmrtnershtp Xnterest (Sc:heclule C) (3)
q. Hortgmges/Notes Receivable (Schedule D)
5. Cash/Bank I)eposits/Hisc. Personml Property (Schedule E) ($)
6. Jointly Ovmed Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Tote1 Assets
APPROVED DEDUCTZONS AND EXEHPTZONS:
9. Funersl Expmns~s/Adm. Costs/Hlsc. Exp~nsss (Schmduls H) (9)
10. Dmb~s/Hortgmgm Limbili~les/Limns (Schedule Z) (10)
11. Total Deductions
8a062.50
.00
.00 HOTE: To insure proper
· O0 crmdA4: to your account
.00 submit ths upper porti,
· O0 of thAs form with your
(8) 8,062.50
6,954.05
96.501.69
95,39.~..22~-
.00
ASSESSNENT OF TAX:
15. Amount of LAne 1~ st Spousal re~s
16. Amount of Line 1¢ tmxmbXs mt LAneal/Clmss A rats
17. Amoun~ of Line 1~ st Sibling rm'l:m
18. Amount of Lies
19. Principsl Tax Due
rAX CREDZTS
PAYflENT K~CP. IPT
DATE NU~ER /NTEREST/PE#
ZF PAXD AFTER DATE ZNDXCATED~ SEE REVERSE
(z$) .00 x O0 = .00
(16) .00 x 045= .00
(17) .00 x 1Z = .00
(18) .00 x 15 = .00
(19)= .00
AHOUNT PAXD
13. ChmrttmbXs/Governmmntml Bequests; Non-mXsctmd 9113 Trusts (SchmduXs J) (13)
lq. Net Vmlum of Eststs Sub,mot to Trax (1~) 95,393.22-
re~lec~ figures iha~ incluae the gaal o~ AL[ re~urn$ assesseu ~u ua .
TOTAL TAX CREDXT [ .00
EALANCE OF TAX DUEl .00
XNTEREST AND PEN. ] .00
TOTAL DUE I .00
[ XF TOTAL DUE XS LESS THAN $1, NO PAYHENT X$ RE(IUXRED.
.00
THE LAW OFFICES OF
KA'I"HLEE:N K. SHAULI$, [SQ.
44 SOUTH HANOVE:R STREET
CARUSLE, PA 170 ! 3
FAX (71'7) 243.,6618
PHONE, (717) 2~..~S
EMAIL: jRS037CARLl~l..E.@SPRINTMAIL-COM
July 5, 2002
Susan E. Naylor, TPL Program Investigator
Pennsylvania Department of Public Welfare
Bureau of Financial Operations
Estate Recovery Program
P. O. Box 8486
Harrisburg, PA 17105-8486
Re:
Ephraim A. Kauffman
CIS #: 550146646
SSN: 195-07-7929
Dear Ms. Naylor:
Enclosed as promised is a copy of the Inheritance Tax Return that was filed in the
above-referenced case. As you can see, the decedent had no real estate or worth of any
kind. The Executors decided to forego any commissions to which they would be entitled
and to pay what remains in the bank account to the Commonwealth on its c~irns.
Enclosed please find cashier's check #2232191160 in the amount of $1939.41~
This represents the remaining balance in the decedent's bank account after the few
remaining bills were paid. The difference between the amount in the account shown on
the inheritance tax return as the date of death balance and the amount of the check is that
the decedent had a small life insurance policy, the proceeds of which the executors
deposited into the bank account, interest and a ~ amount of miscellaneous income
that was collected by them during their administration of the estate.
Finally, enclosed you will find a copy of the Final Account that the Executors are
providing to the other beneficiaries of the estate. If you have any questions, please
Sincerely,
Enclosures
cc: James E. Kauffman, Executor
Roy E. Kauffman, Executor
Daniel W. Kauffman, Beneficiary
Jodi Allan, Beneficiary
FIRST AND FINAL ACCOUNTING
James E. Kauffman and Roy E. Kauffman
Executors for
Estate of Ephraim E. Kauffman
Date of Death:
Date of Executors' Appointment
First Complete Advertisement of
Grant of Letters
February 14, 2002
February 27, 2002
May 10, 2002
Purpose of Account: James E. Kauffman and Roy E. Kauffman,
Executors, offer this account to acquaint interested
parties with the transactions that have occurred during
their administration of the estate.
ASSETS
Allfirst Bank checking No. 00502-6624-ll
Forethought- prepaid funeral expenses
$2568.76
6580.20
TOTAL ASSETS
9148.96
DISBURSEMENTS
Funeral expenses (prepaid)
Executor's Fee
Attorney's Fees
150.00
Probate Fees Petition, Short cert.
Legal Advertising
Inheritance Tax Filing Fee
Parking
Division of Vital Statistics
Thornwald Nursing Home
Pa. Conun. Of PA, DPW2
6580.20
0.00
39.00
168.83
10.00
3.00
3.00
255.52
1939.41
TOTAL DISBURSEMENTS
NET ASSETS
EXPECTED DISTRIBUTION
EXPECTED DISTRIBUTION PER BENEFICIARY
9148.96
0.00
0.00
1 Includes date of death balance of $1482.30, insurance proceeds of
$979.00 and $107.46 in miscellaneous income and interest.
2 The Commonwealth of Pennsylvania Department of Public Welfare filed a
Class 3 claim against the estate for medical expenses for the last six
months of Ephraim's life in the amount of $26,212.40 and a Class 6
claim for all other expenses paid by the Commonwealth in the amount of
$70,033.77. The Commonwealth's total claim against the estate was
$96,246.17.
May 9, 2002
STATEMENT OF CLAIM SUMMARY
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
22,Q87.78
4,124.62
.00
.00
87,773.72
8,472.45
98,24~17
OF ZNDTVZDUAL TAXES
BUREAU
INHERITANCE TAX DZVTSZON
DEPT. 280601
HARRTSBURG, PA 17128-D601
COHHONWEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAZSEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
KATHLEEN K SHAULIS ESQ
qq S HANOVER ST
CARLISLE
PA 17.015
DATE 08-12-2002
ESTATE OF KAUFFHAN
DATE OF DEATH 02-1q-2002
FILE NUHBER 21 02-0213
COUNTY CUHBERLAND
ACN 101
I Amount RemLtted
EPHRAIN
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-0:~) NOTTCE OF TNHERTTANCE TAX APPRATSEHENT, ALLOWANCE OR D~SALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF KAUFFHAN EPHRAIN AFTLE NO. 21 02-0213 ACN 101 DATE 08-12-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATTON CONCERNTNG FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Reel Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
q. Nortgages/Notes Receivable (Schedule D) (q)
$. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTIONS AND EXEHPTZONS:
9. Funeral Expsnses/Adm. Costs/Hisc. Expanses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule Z) (10)
11. Total Deductions
12. Nat Value of Tax Return
8;062.50
.00
.00 NOTE: To insure proper
.00 cred/t to your account,
.00 subnit the upper portlon
.00 of this form with your
tax payment.
.00
6,95q.03
96~501.69
(11)
(12)
13.
lq.
NOTE:
(S) 8,062.50
1~3.~55.72
95,393.22-
Charitable/governmental Bequests; Non-elected 911:3 Trusts (Schedule J) (13)
Nat Value of Estate Subject to Tax (lq)
:]:f an assessaent was issued prev$ously, lSnes 14, 15 and/or 16, 17,
reflect fSgures that Snclude the total of ALL returns assessed to date.
.00
95,393.22-
ASSESSHENT OF TAX:
15. Aeount of Line 1~ et Spouse1 rata
16. Amount of Line lq taxable et Lineal~Class A rats
17. Amount of Line lq at Sibling rets
18. Amount of Line lq taxable at Collateral/Class B rata
19. Principal Tax Due
TAX CREDITS:
PAYMENT RECE/PT
DATE NUMBER
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
18 and 19 ~ill
0I$COUNT (+)
INTEREST/PEN PAID (-)
(1~) .00 x O0 = .00
(16), .00 x Oq5= .00
(17) . O0 x 12 = . O0
(18) .00 x 15 = .00
(19)= . O0
ANOUNT PAID
TOTAL TAX CREDTT I .00
BALANCE OF TAX DUEI .00
INTEREST AND PEN. .00
TOTAL DUE . O0
( IF TOTAL DUE TS LESS THAN $1, NO PAYNENT TS RE(~UIRED.
TF TOTAL DUE TS REFLECTED AS A 'CREDIT' (CR)~ YOU NAY BE DUE
A REFUND. SEE REVERSE S/DE OF THTS FORN FOR TNSTRUCTTONS.)
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR)
OBJECTIONS:
ADNIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December ZZ, 198Z -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of tho decedent after the expiration of any estate for
life or for years, the Commonaaalth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section Z140 of the Inheritance and Estate Tax Act, Act ~ of 2000. (72 P.S.
Section 9140).
Detach the top portion of this Notice and submit with Your payment to the Register of Hills printed on the reverse side.
--Hake check or money order payable to: REGISTER OF NILES, AGENT
: A refund of a tax credit, ahich ems not requested on the Tax Return, amy ba requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISiS). Applications ara available at the Dffice
of the Register of #ills, any of the Z$ Revenue District Offices, or by calling the special Z4-hour
anseering service for fores ordering: 1-800-36Z-20S0; services for taxpayers aith special hearing and / or
speaking needs: 1-800-447-SOZ0 (TT only).
Any party in interest not satisfied aith the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice oust object aithin sixty (60) days of receipt of
this Notice by:
--arittan protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-lOZI, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in eriting to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z80601, Harrisburg, PA 171Z8-0601
Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
If any tax due is paid eithin three (3) calendar months after the decedant's death, a five percent (SI) discount of
the tax paid is allowed.
The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation
penalty is appealable in tho same manner and in the tho same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (6Z) percent par annum calculated at a daily rate of .000164. All taxes ahich bacaaa delinquent on and after
January 1, 1982 mill bear interest at · rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through 2002 are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
1982 ZOZ .000548 1992 9Z .000247
1983 162 .000458 1995-1994 7Z .OOOlgZ
1984 llZ .000301 1995-1998 92 .000247
1985 131 .000356 1999 72 .000192
1986 lOZ .000274 ZOO0 82 .O00Zl9
1987 92 .000247 2001 92 .000247
1988-1991 Ill .000301 2001 62 .000164
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (15) days
beyond the date of tho assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.