HomeMy WebLinkAbout03-0059 PETITION FOR PROBATE and GRANT OF LETTERS
Estateof John I. Kauffman.-'~r. '"~:~by~. ~ No.
also known as John I. Kauffman To: '
Register of Wills for the
, Deceased County of Cumberland in the
SocialSecurityNo. 047-07-3321 Cornmonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut ri~( named
in the last will of the above decedent, dated Mav 13. 199~
and codicil(s) dated
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decedent was domiciled at death in Cumberland County, Pennsylvania, with
hi~ last family or principal residence at 801 N. Hanover Street. Carlisle. PA 1701;~
(list street, number and municipality)
Decedent, then ~8 years of age, died 12/28/2002 , ,
at Church of God Home. Carlisle. Cumberland Countv
Except as follows, decedent did not marry, was not divorced and did not have a child bom or adopted
after execution of the will offered for probate; was not the victim of a killing and was never ajudicated
incompetent:
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ 11.000.00
(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:
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters testamentary
thereon. (testamentary; adminis'--wation C.t.~L; administration d.b.n.c.t.~,)
~;C~ d ~_~,/ 3925 Mountain View Road
~ ~ Mechanicsburq PA 17050
:g yUdith E. Zarker ~ -
OATH OF pERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~
COUNTY OF Gumbedand; SS
The petitioner(s) above-named swear(s) or afl.mn(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 andrg'uly administer,the estate according to law.
Sworn to or affmned and subscribed . Uvq.( ~ ~-~ ~;~d/~
be/f~e me thisc~/.o~'t , day of [ ~ ~'
Estate of John I. Kauffman, Sr. , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW ~JJ~/, o ~' ~)o.9_~. a2~(3,~ , in consideration of the petition on
the reverse side h~ereof, satisfactory proofha~ing been presented before me,
IT IS DECREED that the instrument(s) dated 5/13/1995
described therein be admitted to probate and filed of record as the last will of John I. Kauffman. Sr.. ago
John I. Kauffr00n ;
and Letters Testamenta~
are hereby granted to
Judith E. Zarker
l~gist~r of~Will~s ~.~/~ ~/6~~
FEES Marielle F. Hazen
Probate, Letters, Etc ......... $ ~, ~ 68003
Shrfrt Certificates (o ) ...... $ ATTORNEY (Sup, Ct. I.D. No.)
Renunciation ............ $ 2000 Linglestown Road, Ste 303
/c~ $ ,,~v.oo Harrisburq PA 17110
ADDRESS
~-~.~ TOTAL $ _~o O0
FiledL,,f~e~.~< ~.~.?....~o...o~. 717 540-4332
PHONE
I, JOHN L KAUFFMAN, of East Pennsboro Township, Cumberland County,
Pennsylvania, declare this instrument to be my last will and testament, hereby expressly revoking
all wills and codicils heretofore made by me.
1. I direct my executrix to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my executrix to sell any realty owned by me at my death, and
not specifically devised herein, at either public or private sale, and to give good and sufficient
deeds therefor, in fee simple, as I could do if living.
3. I devise and bequeath all of my estate of every nature and wherever situate to my wife,
Dorothy M. Kauffman, providing she shall survive me by sixty days.
4. Should the gitt in Paragraph No. 3 not take effect, I devise and bequeath all of my
estate of every nature and wherever situate as follows:
(a) 1/3rd to Judith E. Zarker, and if she is not living at the time of my death, to
her children, share and share alike,
(b) 1/3rd to JoAnn E. Myers, and if she is not living at the time of my death, to
her children, share and share alike,
(c) 1/6th to Janet Kauffman, and if she is not living at the time of my death, to
her children, share and share alike, and
(d) 1/6th to Karen L. Kauffman Reeder, and if she is not living at the time of
my death, to her children, share and share alike.
(e) In computing the share of JoAnn E. Myers, she shall be considered to have
already received the sum of $30,000.00 in the form of land and $2,200.00 in the form of
advances, so that these amounts will be added to my residual estate before being divided by thirds
and then the above amount will be deducted from JoAnn's share. Any unpaid loans made by me
to JoAnn's children shall also be treated in the same fashion and deducted from her share.
5. I appoint Dorothy M. Kauffrnan to be the executrix of this my Last Will and
Testament; she is to serve as such without bond. Should she die before my death, renounce or
refuse to serve for any reason, or die leaving any of my estate unadministered, I nominate and
appoint Judith E. Zarker, as substitute executrix, also to serve as such without bond, with the
same powers as are given herein to my executrix. Should she die before my death, renounce or
refuse to serve for any reason, or die leaving any of my estate unadministered, I nominate and
2
appoint JoAnn E. Myers, as substitute executrix, also to serve as such without bond, with the
same powers as are given herein to my executrix.
6. I hereby suggest that my personal represemative retain the services of Irwin, McKnight
& Hughes, as attorneys in the settlement of my estate.
IN WITNESS WItEREOF, I have hereunto set my hand and seal this t3' day of
May, 1996.
~a~.,~/'J"-~,~_~ ~,z.-' ~-'-,,,~'-.- (SEAL)
JOHN I. KAUI~I~4AN
Signed, sealed, published and declared by JOltN L KAUFFMAN, the testator above
named, as and for his last will and testament, in the presence of us, who at his request, in his
presence and in the presence of each other have subscribed our names as witnesses hereto.
A CKNO WLEDGMENT AND AFFIDAVIT
WE, JOHN I. KAUFFMAN, BETZI A. MORRISON and CHERYL L. CLELAND,
the testator and witnesses respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do 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 purpose herein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the Will as a witness and that to the best of their
knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under
no constraint or undue influence.
omuso
C~I~ERYL L. CLELAND
COMMONWEALTH OF PENNSYLVANIA :
: SS:
COUNTY OF CUMBERLAND :
Subscribed, sworn to and acknowledged before me by JOHN I. KAUFFMAN, the
testator herein, and subscribed and sworn to before me by BETZI A. MORRISON and
CHERYL L. CLELAND, witnesses, this f~' day of May, 1996.
In the Orphan's Court Division of the
Court of Common Pleas of Cumberland County
COMMONWEALTH OF PENNSYLVANIA
In Re: Estate of John I. )
Kauffman, Sr., deceased. ) Case No. 21-03-0059
)
FIRST AND FINAL ACCOUNT
STATEMENT OF PROPOSED DISTRIBUTION
OF JUDITH E. ZARKER~ EXECUTRIX
DATE OF DEATH: December 28, 2002
LETTERS GRANTED: January 21, 2003
DATES OF ADVERTISEMENT: March 21, 2004, March 28, 2004 & April 4, 2004
March 20, 2004, March 27, 2004 & April 3, 2004
ACCOUNT PERIOD: January 21, 2004 to June 30, 2004
Purpose of the Account: Judith E. Zarker offers this accounting as one of the four (4)
beneficiaries will not sign a Family Settlement Agreement or Receipt and Release so that
the Estate can be closed out.
The Account also indicates the proposed distribution of the Estate.
It is important that the Account be carefully examined. Reqt~s~ for~dditi~o~o
information, questions or objections can be discussed with: ~ ~. ~
2000 Linglesto~ Rd., Suite 303
H~sb~g, PA 17110
(717) 540-4332
SUMMARY OF ACCOUNT
Current Fiduciary Acquisition
Page Value Value
Proposed Distribution to Beneficiaries $0.00
Principal:
Receipts $13,486.85 $13,486.85
Net Gain on Sales or Other Disposition
Less Disbursements
Debts of Decedent $5,317.34
Funeral Expenses $7,036.00
Administrative Expenses $376.69
Federal & State Taxes $3,131.34
Fees & Commissions $2,545.00 $18,406.37
Balance before Distributions
Distributions to Beneficiaries -$4,919.52
$0.00
Income:
Receipts
Less Distributions
Balance before Distributions
Distributions to Beneficiaries
Income Balance on Hand
Combined Balance on Hand -$4,919.52
RECEIPTS OF PRINCIPAL
Current Fiduciary Acquisition
Cash: Page Value Value
PNC Burial Reserve CD $11,546.25
Church of God Nursing Home Refund $253.22
Railroad Retirement Benefit $1,084.70
Church of God Nursing Home Refund $480.34
Blue Shield Premium Refund $122.34 $13,486.85
Tangible Personal Property: NONE
Stocks: NONE
Realty: NONE
Total Receipts of Principal $'13,486.85
DISBURSEMENTS OF PRINCIPAL
Debts of Decedent:
Church of God Nursing Home $4,636.24
Brocke Pharmacy $476.93
Brocke Pharmacy $204.17 $5,317.34
Funeral Expenses:
Sullivan Funeral Home $6,741.00
Grave Marker $95.00
Enola Chumh - Funeral Reception $200.00 $7,036.00
Administrative Expenses:
Register of Wills, Probate Fees $81.00
Register of Wills, Inh. Tax Return Filing Fee $15.00
Cumberland Law Journal- Legal Publication $75.00
Patriot News - Legal Publication $205.69 $376.69
Federal & State Taxes:
PA Inheritance Tax $3,131.34 $3,131.34
Fees & Commissions:
Marielle F. Hazen, Legal Fees $45.00
Marielle F. Hazen, Legal Fees $2,500.00 $2,545.00 $18,406.37
DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES
NONE
PRINCIPAL BALANCE ON HAND
NONE
INFORMATION SCHEDULES - PRINCIPAL
NONE
RECEIPTS OF INCOME
Dividends: NONE
interest: NONE
DISBURSEMENTS OF INCOME
NONE
DISTRIBUTIONS OF INCOME TO BENEFICIARIES
NONE
PROPOSED DISTRIBUTIONS TO BENEFICIARIES
Judith E. Zarker, 3925 Mountain View Road $0.00
Mechanicsburg, PA 17050
JoAnn E. Myers, 44 Cook Road $0.00
Duncannon, PA 17020
Janet Lesher, 130 Imperial Court $0.00
Carlisle, PA 17013
Karen Kauffman-Reeder, 130 Imperial Court $0.00
Carlisle, PA 17013
Note: Excess expenses and debts paid by Judith E. Zarker from non-probate assets
Judith E. Zarker, Executrix of the Estate of John I. Kauffman, Sr., deceased,
hereby declare under oath that they have fully and faithfully discharged the duties of their
office; that the foregoing First and Final Account and Statement of Proposed Distribution
is tree and correct and fully discloses all significant transactions occurring during the
accounting period; that all known claims against the Estate have been paid in full; that to
her knowledge there are no claims now outstanding against the Estate; and that all taxes
presently due from the Estate have been paid.
ker, F,j~ecutrix
Sworn to and subscri~t be)~ore me
this /(9 day of x,,J~xfldt~ ,2004.
(ar~- Pu'~li~ '*
Notarial Seal I
M~ielle F. Hazen, No~. Public
City of Harrisburg, Dauphin Courtly
My Commission Expires Sept. 23, 21~06
JOBl~ I. Ii~
LAW OFFICES
IRWIN, MCKNIGHT & HUGHES
WEST POMFRET PROFESSIONAL BUILDING
60 WeST POMFRET STREET
CARLISLE, PENNSYLVANIA 17013-3222
( 717 ) 249-2353
Register of Wills, Cumberland County, Pennsylvania
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: John I. Kauffman, ~;r.
Date of Death: 12/28/2002
Will No. 2003-00059 Admin. No. 21-03-0059
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphan's Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on 3~6~2003 -
Name Address
JoAnn E. Myers
44 Cook Road Duncannon . PA 17020
Janet Lesher
130 Imoerial C~)urt Carlisle pA 17013
Karen L. Kauffman Reeder
130 ImDerialCourt Cadisle PA 17013
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except:
Date: 3/5/2003
Signature Madelle F. Hazen
Name: Law Office of Mariell~ F. H~i~zen
Address: 2000 Linalestown R<;)ad, Suite 303
Harrisburg PA 1711Q
Telephone(717) 540- 4332
Capacity: Personal Representative
X Counsel for Personal
Representative
Marielle F. Hazen
Attorney at Law
2000 Linglestown Road (717) 540-4332 Certified Elder Law Attorney by the
Suite 303 (717) 540-4313 F^X National Elder Law Foundation
Harrisburg, PA 17110
HazenElderLaw~paonline.com Licensed in Pennsylvania and Texas
February 11, 2003
Register of Wills Office
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
Re: Estate of John I. Kauffman, Sr.
File No. 21-03-0059
To Whom It May Concern:
Enclosed for filing please find the original and two copies of the inheritance tax
remm and the original and one copy of the estate inventory for the above referenced
estate. Also enclosed is a check made payable to the Register of Wills in the amount of
$15.00 for the filing fee for the inheritance tax return and a check made payable to the
Register of Wills, Agent, in the amount of $3,131.34 representing the tax due for this
estate.
Please return date stamped copies of the inheritance tax remm and the inventory
to me in the enclosed envelope.
Thank you for your time and assistance.
Sincerely,
Marielle F. Hazen
Enclosures
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
Estate of Kauffman, Sr.., John I. No. 21 03 0059
also known as Date of Death 12/28/2002
, Deceased Social Security No. 047073321
Judith E. Zarker
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no
real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. INVe
verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities.
Personal Representative:
Name of
Attorney: Hazen, Marielle F. Judith E. Zarker
I.D. No.:
Address: 2000 Lin.qlestown Road, Suite 303 Dated March 25, 2003
Harrisburg PA 17110
Telephone: 717/540-4332
Description Value
Burial Reserve Account- PNC Bank Certificate of Deposit 11,546.25
Refund from nursing home, Church of God Home 253.22
Railroad Retirement Benefit 1,084.70
Refund from nursing home, Church of God Home 480.34
Blue Shield refund of premium 122.34
Total
(Attach Additional Sheets if necessary) 13,486.85
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative,
include the value of each item, but such figures should not be extended into the total of the Inventory.
RW-4
REV-1500
PENNSYLVANIA_
INHERITANCE TAX RETURN F,LE.U..ER
RESIDENT DECEDENT -
DE~N~S ~ME (~ST, FIRST, AND MILLE INITI~) S~I~ SECURI~ NUMBER
Kauffman, Sr., John I. 0 4 7- 0 7- 3 3 2 1
DATE OF D~TH (M~D~Y~) ~DATE OF BIRTH (M~D~Y~) ~ ~ MU~ ~ FILED ~ ~TE ~H THE
~ REGISTER OF WILLS
12/28/2002 04/13/1914
(IF APPLI~) SU~ING SPOUSE'S ~ME (~ST, FIRST, AND MIDDLE INITIAL) S~IAL SECU~ NUMBER
~_"' [~] 1. Odginal Return O 2. Supplemental Retum E] 3. Remainder Retem (da~ofdea~ p~. 12-1~2)
O~''' O 4. Limited Estate E] 4a. FutumlnterastCompmmise(dae~'deaha~-12-12-82) O 5. Fedeml Estate Tax Retum Required
,,,0~o
~m'~'°c"1 ~ 6. DeosdentDiedTastate(A~achcopyofWi,) O 7. DecedentMaintainedaLivingTrost(A~chcopyofTn~st) __ 8. Total Number of Safe Deposit Boxes
< O 9. LitigatJon Proceeds Received O 10. SpousalPovertyCredit(da~o~dea~be~.~e. 12-31-91andl-l-95) O 11. Election to tax under Sec. 9113(A)(AeachScho)
~ THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
z NAME COMPLETE MAILING ADDRESS
,-,
z H~.en, Marielle F. 2000 Linglestown Road, Suite 303
a. FIRM NAME (IfApplicatde)
"' Law Office of Marielle F. Hazen
O TELEPHONE NUMBER
717/540-4332 Harrisburg PA 17110
1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY
2. Stocks and Bonds (Schedule B) (2) '
3. Closely Held Coq~omtion, Parlnemhip or Sole-Pmprietomhip (3)
4. Morlgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Pemonal Property (5) 13,486.85 '.
(Schedule E)
Z
O 6. Joirdly Owned Property (Schedule F) (6) 9,903.82
I.- r-~ Separate Billing Requested
::::) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 64,800.00
~-- (Schedule G or L)
,q: 8. Total Gross Assets (total Lines 1-7) (8) 88,190.67
LU 9. Funeral Expanses & Administrative Costs (Schedule H) (9) 9~625.55
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 5,317.34
11. Total Deductions (total Lines 9 & 10) (11) 14,942.89
12. Net Value of Estate (Line 8 minus Line 11) (12) 73,247.78
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) 73,247.78
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
~_ rate, orb'ansfers underSec. 9116 (a)(12) X ~ (15)
~ 16. Amount of Line14 taxable at lineal rate 73,247.78 X .045 (16) 3,296.15
O~ 17. Amount of Line 14 taxable at sibling rate X .12
(1
7)
>~ 18. Amount of Line 14 taxable at collateral rate X .15 (18)
19. Tax Due (19) 3,296.15
20. E~] ...... ' ....:[iii;,~-- * I I a ~- I ,~ I · · ,~ · ~ ' ·, ' a
' Decedent's Complete Address:
$~ ~bl= I ADDRESS
Church of God Home,
801 N. Hanover Street
Cl'~'
Carlisle J STATE PA I z~P 17013
Tax Payments and Credits:
1. Tax Due (Page l I_ine19) (1) 3,296.15
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments 3,131.34
C. Discount 164.{H
Total Credits (A + B + C) (2) 3,296.15
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3)
4. If Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a ~Hund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE, (5B) 0.00
Make Check Payable to: R£GISTER 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 h s or her death? ............. [] []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate pmporty which
contains a beneficiary des gnafion?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
[~a~.~nal~f%of __p~'j~ u~ ! _d~ .,~am~that, have. examine~l. ~Js .re .l~m, i .ncludi~g..accon~panyi. ng.s.c.hedules ~ statements and to the best of my knowledge and b~ ef, it is flue, correct and complete. parer omer man me persona represen~ve ,s oasea on all irltormattofl o1' wnicn preparer nas any knowledge.
SIGNATUP. E"O.F PERSON RESPONSIBLE.FOR FILING RETURN DATE
~Judith Zarker ~
"3925 Mountain View Road, Mechanicsburg PA 17050
SIGNATURE OF PREPAI:~I;,[ O~T-~AN REPRESENTATIVE DATE
ADDI~ES~S --~ri[~l'~'e F. Hazen
2000 Lin,qlestown Road, Suite 303, Harrisbur,q, PA 17110
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 Januanj 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 benefidary.
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 benefidades is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imoosed on lhe net value of transfers to or for the use of the decedent's siblinas is 12% 172 P.S. 69116~aIH.3}l. A siblina is defined, under Section 9102. as an
I~'V-t508 EX + (1-87)
~ SCHEDULE E
COMMO.W~LT.~O~ PE..SYLV^.,^ CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kauffman. Sr.. dqhn I, ;~1 09 qO~9
Include l~e proceeds of litJgaUon and ~he date ~e proceeds were received by I~e estate. All properly jointfy-ovmed with the right of sun~ivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Burial Reserve Account- PNC Bank Certificate of Deposit 11,546.25
2 Refund from nursing home, Church of God Home 253.22
3 Railroad Retirement Benefit 1,084.70
4 Refund from nursing home, Church of God Home 480.34
5 Blue Shield refund of premium 122.34
TOTAL (Also enter on line 5, Recapitulation) $ 13,486.85
REV-15~} EX + (1-97}
/'g'"J SCHEDULE F
COMMO.WEALTH OF ..SYLV^.,A JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kauffman. Sr,, John I, 21 03 0059
If an asset was made joint within one year of the decedent's date of dealh, it must be repo:ted on Schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Judith Zarker 3925 Mountain View Road daughter
Mechanicsburg, PA 17050
C
JOINTLY-OWNED PROPERTY:
L~- ~ ! bh~ DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH
ITEM FOR JOINT MADE I.clude name o~ financial institution and bank account number o~ similar identifying number. Atlach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTERE8
1. A. 07/99 PNC Checking Account #5000930438 19,807.63 50. 9,903.8;
TOTAL (Also enter on line 6, Recapitulation) $
9.903.82
REV-1510 EX + (1-97)
SCHEDULE G
INTER-VIVOS TRANSFERS &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEOENT
ESTATE OF FILE NUMBER
Kauffman. Sr., John I. ;21 03 00~9
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is, ,es.
DESCRIPTION OF PROPERTY % OF
ITEM rNCLUDETHE NAMEOFTHE TRANSFEREE. THEIRRELATIONSHIPTO DECEBENTANOTHE BATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
NUMBER AT]'ACH A COPY OF THE DEED FOR RE~L ESTATE. VALUE OF ASSET INTEREST [IF APFtJCABLE)
1. Cash transferred to daughter, Judith Zarker, February 2002 67,800.00 100. 3,000.00 64,800.0£
TOTAL (Also enter on line 7. Recaoitulation~ $ =.~ onn ,-,,',
REV-1511EX ~(1-97)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kauffman. Sr., ,19hrl I, ~1 0:~ OO~;9 ,
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Sullivan Funeral Home 6,741.00
2 Funeral Lunch Paid to Enola Church of God 200.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Pemonal Representative (s)
Social Security Number(s) / EIN Number of Personal Representative{s)
Slmet Address
City Slate Zip
Year(s) Commission Paid:
2. Attorney Fees Law Office of Marielle F. Hazen 2,500.00
3. Family ExemplJon: (If decedent's address is not the same as claimant's, attach explanalion)
Claimant
Street Address
Ck'y State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 81.00
5. Accountant's Fees
6. Tax Return Preparers Fees
7. Cumberland Law Journal 103.55
TOTAL (Also enter on line 9, Recapitulation) $ 9,625.55
REV-1512 EX~+ (1~)7)
~ SCHEDULE I
~Mo.w~LT, OFPE..SY,V^.~ DEBTS OF DECEDENT,
INHERITANCE TAX RETURN
REs~D£~rD£CE~.T MORTGAGE LIABILITIES~ & LIENS
ESTATE OF FILE NUMBER
Kauffman. Sr.. John I. 21 03
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1. Church of God Home 4,636.24
2 Pharmacy Bill, Brocke Pharmacy 476.93
3 Pharmacy Bill, Brocke Pharmacy 204.17
TOTAL (Also enter on line 10, Recapitulation) $ 5,317.3~.
(If more space is needed, insert additional sheets of the same size)
REV-1513~EX + (9-n~ I
SCHEDULE J
COM~NWEALTH OF PENNSYLVANIA I BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kauffma~. Sr.. J~hn I, Z1 , 03 0059
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Oo Not List Trustee(s) OF ESTATE
]. TAXABLE DISTRIBUTIONS [indude outright spousal disffibufions, and transfers under
Sec. 9116 (a)(1.2)]
1. Judith Zarker daughter 1/3rd residue
3925 Mountain View Road
Mechanicsburg, PA 17050
2 Karen L. Kauffman Reeder granddaughter 1/6th residue
130 Imperial Court
Carlisle, PA 17013
3 JoAnn E. Myers daughter 1/3rd residue offset by
44 Cook Road amounts previously gifted
Duncannon, PA 17020
4 Janet Lesher daughter 1/6th residue
130 Impedal Court
Carlisle, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, 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
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
flf mnm ~nnc~ i~ n~c~cl~c~ in~,~rf ndclifinnnl ~h~t~ nf th~ nnm~ ~i7pl
CONNONNEALTH OF PENNSYLVANIA ~
DEPARTMENT OF REVENUE ZNFORMATZON NOTZCE FILE NO. Z1 05-0059
BUREAU OF TNDZVTDUAL TAXES AND
DEPT. zso601 ACN 05106Z50
HARRISBURG, PA 17XZ8-0601 TAXPAYER RESPONSE
DATE 05-0q-2005
RE¥-1;~$ EX AFP
TYPE OF ACCOUNT
EST. OF JOHN J KAUFFMAN [] SAVTNGS
S.S. NO. 0q7-07-$$21 [] CHECKTN;
DATE OF DEATH 12-28-2002 [] TRUST
COUNTY CUMBER LAND [] CERTTF.
REMTT PAYMENT AND FORMS TO:
JUDITH E ZARKER '~ REGISTER OF HILLS
$925 MOUNTAIN VIER RD CUMBERLAND CO COURT HOUSE
MECHANTCSBURG PA 17050 CARLISLE, PA 17015
PNC BANK has provided the Department with the information listed beloN mhich has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you mere a ~oint omner/beneficiary of
this account, zf you feel this information is incorrect, please obtain mrittan correction from the financial institution, attach a copy
io this form and return it to the above ad.~ress. Th'Cs account is tawoble in =ccordance with the Tnhsritanoo Tax La~s of ~ha Commonwealth
of Pennsylvania. Ouestions may be answered by calling (717) 787-85Z7.
COMPLETE PART ! BELON x # # SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5000950q$8 Data 02-26-1999 To insure proper credit to your account, too
Established (23 copies of this notice must accompany your
payment to the Register of Rills. Make check
Account Balance 19,807.65 payable to: "Register of Nills, Agent".
Percent Taxable X 50.0 0 0
NOTE: Zf tax payments ara made within three
Amount Sub:fact to Tax 9,905.82 (3) months of the dacadent's date of death,
Tax Rate X · 0~5 you may deduct a 5g discount of the tax due.
Any inheritance tax due mill become delinquent
Potent/aX Tax Due qq5.67 nine (9) months after the date of death.
PART TAXPAYER RESPONSE
A. ~'~ The above information and tax due is correct.
1. You may choose to remit payment to the Register of Nills with tmo copies of this notice to obtain
CHECK · discount or avoid interest, or you may check box "A" and return this notice to the Register of
~ ONE ~ ~ Hills and an official assessment will be issued by the PA Department of Rmv.num.
BLOCK a. The above asset has been or will be reported and tax paid with the Pennsylvania Tnharitance Tax return
ONLY v~to be filed by the decedent's representative.
C. [] The above information is incorrect and/or debts and deductions ware paid by you.
You must complete PART [] and/or PART [] balom.
~. Aocount Balance ~, i !!!{{ !!!!!!!!!!!!!!i!!!!!!!i!i!i!i!i!!!i!i!!!!
$, Percent Taxable $ ~ i i
q, Amount Sub~ect to Tax q, .. . ..................................
.......... ::::::::::::::::::::::::::::::::::::::::::::
PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on Line .~ of Tax Computation) $
Under penalties of perjury, I declare that the facts ! have reported above are true, correct and
complete to the best of my knowledge end belief. HOME ( )
NORK ( )
TAXPAYER SIGNATURE TELEPHONE NUMBER DATE
~ENERAL ~NFORHAT~ON
1. FAILURE TO RESPOND NZLL RESULT ZN AN OFFZC/AL TAX ASSESSMENT with applicable interest based on information
submitted by the financial institution.
Z. Inheritance tax becomes delinquent nine months after the dacedent's date of death.
5. A joint account is taxable even though the dacedant's name ams added as a matter of convenience.
q. Accounts (including those held between husband and wife) ehich the decedent put in joint names eithin one year prior to
death are fully taxable as transfers.
5. Accounts established jointly between husband and wife more than one year prior to death are not taxable.
6. Accounts held by a decedent "in trust for" another or others are taxable
REPORT(NO iNSTRUCTIONS - PART ! - TAXPAYER RESPONSE
l. BLOCK A - If the information and computation in the notice ara correct and deductions are not being claimed, place an
in block "A" of Part L of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount
tax to the Register of Mills of the county indicated. The PA Department of Revenue wi(1 issue an official assessment
(Form REV-15q8 EX) upon receipt of the return from the Register of Hills.
Z. BLOCK B - If the asset specified on this notice has been or wiLL be reported and tax paid with the Pennsylvania Inheritance
Tax Return filed by the decedant's representative, place an "X" in block "B" of Part L of the "Taxpayer Response" section. Sign one
copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Bapt Z&060I, Harrisburg, PA 17[ZB-060[ in the
envelope provided.
5. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block 'C" and comp[ate Parts Z and
according to the instructions below. Sign two copies end submit them with your check for the amount of tax payable to the Registar
of Hills of the county indicated. The PA Department of Revenue wi(1 issue an official assessment (Fora REV-ISle EX) upon receipt
of the return from the Register of Wills,
TAX RETURN - PART Z - TAX COMPUTATION
LINE
L. Enter the date the account originally was established or titled in the manner existing at date of death.
NOTE: For a decedent dying after 12/[2/81: Accounts which the decedent put in joint names aJthin one (I) year of death are
taxable fully as transfers. Howaverj there is an exclusion not to exceed $3,000 par transferee regardless of the value of
the account or the number of accounts held.
If a double asterisk (ax) appears before your first name in the address portion of this notice, the $3,000 exclusion
already hms been deducted from the account balance as reported by the financial institution.
Z. Enter the tote! balance of the account including interest accrued to the date of death.
5. The percent of the account that is taxable for each survivor is determined as follows:
A. The percent taxable for joint assets established more than one year prior to the decedant's death:
i DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE
JOINT OWNERS SURVIVING JOINT OWNERS
Example: A joint asset registered in the name of the decedent and two other persons.
L DIVIDED BY 5 (JOINT OWNERS) DIVIDED BY Z (SURVIVORS) = .L67 X ZOO = [6.71 (TAXABLE FOR EACH SURVIVOR)
B. The percent taxable for assets created within cna year of the dacedant's death or accounts owned by the decedent but held
in trust for another individual(s) (trust beneficiaries):
1 DIVIDED BY TOTAL NUNBER OF SURVIVING JOINT X [00 PERCENT TAXABLE
OWNERS OR TRUST BENEFICIARIES
ExampLe: Joint account rag[stared in the name of the decedent and two other persons and established within one year of death by
the decedent.
I DIVIDED BY Z (SURVIVORS) = .50 X 100 = SOZ (TAXABLE FOR EACH SURVIVOR)
~. The amount subject to tax (line ~) is determined by multiplying the account balance (line Z) by the percent taxable (line
5. Enter the total of the debts and deductions listed in Part 3.
6. The amount taxable (line 6) is determined by subtracting the debts and deductions (1ina 5) from the amount subject to tax (line ~).
7. Enter the appropriate tax rate (line 7) as determined below.
Da~e of Death Spouse Lineal Sibling Collateral
07/01/9q ~o 12/$1/9~ SZ 6X 15X 15Z
01/01/95 ~o 06/30/00 OX 61 15X
07/01/00 ~o presen~ 0Z q.5Z~ 12X
wThe tax rate imposed on the nat value of transfers from a deceased -~='~ twenty-cna years .z age or younger at
death to or for the use of a natural parent, an adoptive parent, or a stapparent of the child is OZ.
The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "'Children" includes natural children
whether or not they have been adopted by others, adopted chiIdren and step children. "Lineal descendents" includes all children of the
natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants
and step-descendants. "SibLings" ara defined as individuals who have at least one parent in common with the decedent, whether by blood
or adoption. The "Collateral" class of heirs includes a11 other beneficiaries.
CLAIMED DEDUCTIONS - PART $ - DEBTS AND DEDUCTIONS CLAIMED
Allowable debts and deductions ara determined as follows:
A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient
to pay the deductible items.
B. You actually paid the debts after death of the decedent and can furnish proof of payment.
C. Debts being claimed must be itemized fully [n Part 5. If additional space is needed, use plain paper 8 1/Z" x 11". Proof of
payment may bm requested by the PA Department of Revenue.
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
/~>-/,//~_~L~' CONNON.EALTH OF PENNSYLVANIA
BUREAU OF INDIVIDUAL TAXES DEPARTHENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. ID060!
HARRISBURG, PA Z7]ZD-060! NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLONANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX REV-ZS~?EXAFP(OZ-OS~
DATE 05-05-2005
ESTATE OF KAUFFMAN JOHN
DATE OF DEATH 1Z-Z8-2002
FILE NUHBER 21 03-0059
COUNTY CUMBERLAND
MARIELLE F HAZEN ACN 101
M F HAZEN LAW OFFICE I Amount Remitted
ZOO0 L[NGLESTNN RD 30
I
HBG PA 17110
MAKE CHECK PAYABLE AND RENZT PAYHENT TO:
REGISTER OF HILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LO#ER PORTION FOR YOUR RECORDS
REV-15q7 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR
DZSALLO#ANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF KAUFFMAN JOHN ! FILE NO. 21 03-0059 ACN 101 DATE 05-05-2003
TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) {1) .00 NOTE: To insure proper
2 Stocks and Bonds (Schedule B) (2) .00 credit to your account,
$ Closely Held Stock/Partnership Interest (Schedule C) ($) .00 submit the upper portion
q Mortgages/Notes Receivable (Schedule D) (q) .00 of this fore with your
$ Cash/Bank Oeposits/Hisc. Personal Property (Schedule E) (5) 13;186.85 tax payment.
6 Jointly Owned Property (Schedule F) (6) 9;903.82
7 Transfers (Schedule G) (7) 6~;800.00
8 Tote1 Assets (8) 88,190.67
APPROVED DEDUCTIONS AND EXENPTIONS: 9,625.55
9. Funeral Expenses/Ada. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule Z) (10)
11. Total Deductions (11) 1~.q~.89
12. Net Value of Tax Return (12) 73,Zt7.78
13. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (13) .00
lq. Net Value of Estate Sub~ect to Tax (1~) 73,Z~7.78
NOTE: l~ an assessment ~as issued previously, lines lq, 15 and/or 16, 17, 18 and 19 ~ill
reflect figures that include the total of ALL returns assessed to date.
ASSESSHENT OF TAX:
15. Amount of Line 1~ at Spousal rate (15) .00 X O0 = .00
16. Amount of Line 1~ taxable at Lineal/Class A rate (16) 73,Zfi7.78 x OR5 = 3,296.15
17. Amount of Line lq at Sibling rate (17) .00 X 12 = .00
18. Amount of Line lq taxable et Collateral/Class B rate (18) .00 X 15 = .00
19. Principal Tax Due (19)= 3,296.15
TAX CREDITS:
PAYMENT RECEZPT DZSCOUNT
AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
05-25-2005 CD002350 161.81
TOTAL TAX CREDIT 3,296.15
BALANCE OF TAX DUEI .00
INTEREST AND PEN. .00
TOTAL DUE . O0
IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT TS REgUIRED.
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
RESERVATION: Estates of decedents dying on or before December 1Z, 19aZ -- if any futura interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of tho decedent after tho expiration of any estate for
life or for years, the Comeoneaalth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the 1aclu1 Class B (collateral) rate on any such future interest.
PURPOSE OF
NOTICE: To ~ulfi11 the requirements of Section ZlqO of the Inheritance and Estate Tax Act, Act Z3 of ZOO0. (TI P.S.
Section 91qO).
PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side.
--Make check or money order payable to: REGISTER OF MILLS, AMEN?
REFUND (CR): A refund of a tax credit, ~hich ams not requested on the Tax Return, may ba requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office
of the Register of Mills, any of the 23 Revenue District Offices, or by calling the special Iq-hour
anseering service far forms ordering: 1-800-36Z-Z050; services far taxpayers eith special hearing and / or
speaking needs: 1-800-~q7-30ZO (TT only).
OBJECTIONS: Any party in interest not satisfied aith the appraisement, alloeanca, or disalloaance of deductions, or assessment
of tax (including discount or interest) as sheen on this Notice oust object ~ith]n sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 171Ia-lOll, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS: Factual errors disceverad on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Reviea Unit, Dept. Z80601, Harrisburg, PA 171Z8-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-1SOl) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three [3) calendar months after the decedent's death, a five percent (SI) discount of
the tax paid is allo~ad.
PENALTY: Tho 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 end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same tiaa period as you mould appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: Interest is charged beginning aith 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 I, 1982 bear interest at the rate of
six (6Z) percent per annum calculated et a daily rate of .O0016q. All taxes ~hich became delinquent on and after
January 1, 1982 mill bear interest at a rate ahich will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 19aZ through ZOO3 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
19BI ZOZ .0005q8 1987 9Z .000247 1999 7Z .00019Z
1983 16Z .000q38 1988-1991 llZ .000301 2000 BZ .000219
198q IIZ .000301 199Z 9Z .000Z47 2001 9Z .0002~7
1985 13Z .000356 1993-199~ 7Z .O00Igz 200Z 6Z .O0016q
--Interest is calculated as follows:
IH?ERES? = BAL&HCE OF TAX UNPAID X MUMBER OF D&¥S DELZNQUEN? X DAILY ZM?ERES? FAC?OR
--Any Notice issued after the tax becomes delinquent ~ill reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation data sheen on the
Notice, additional interest must be calculated.
STATUS REPORT uNDER RULE 6.12
N~mc of Decedent: ~ -
Date of Death: _
Admin. No.:
'P~su~t to Rule 6.12 of~e Supreme Co~ O~h~' Cou~ Rules, I repo~
follow~g wi~ respect to completion of ~e ad~s~ation of the above-captioned estate:
1. State whe~er adm~s~ation of~e estge is complete:
Yes
2. ~ ~ ~w~r is No, stat~ when ~ p~on~ r~r~s~nta~w r~onably b~H~v~s
3. ~ ~ ~n~r to No. 1 is Y~s, stat~ ~ foHo~g:
a. Did ~ p~mon~ r~z~s~ta~v~ ~ a ~1 acoo~t ~ ~ Co~?
b. ~ s~p~t~ 0~' Co~ No. (if ~y) for ~ p~mo~l r~r~s~nta~v~'s
~. Did ~ p~rson~ r~r~s~mfiv~ s~t~ ~ aooo~t ~o~lly to ~ p~s
~o~ ~oo~ m~y b~ fil~d ~ ~ Cl~rk of ~. ~h~' Co~
~d may b~
~ ' ~elephone No.
Capacity: ~ p ersonM Representative
~ Co.scl for personal representative
or-r
STATUS REPORT UNDER RULE 6.12
Name of Decedent- JOHN I. KAUFFMAN
Date of Death- 12/28/2002
Will No. Admin. No. 21-03-0059
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-
1. State whether administration of the estate is complete-
Yes X No ~
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete ·
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court ? Yes X 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 this report.
S'~gnat'ur~'- ~ V ' "~ v
Marielle F. Hazen
Name (Please type or print )
2000 Linglestown Road, Suite 303
Harrisburq PA 17110
Address
-:;r (717) 540-4332
'7': .... '~' ' :: Tel No
' Capacity- ~ Personal Representative
I
~ :: X Counsel for personal
c~ .: representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 002350
HAZEN MARIELLE F ESQUIRE
845 SIR THOMAS COURT
HARRISBURG, PA 17109
........ fold
ESTATE INFORMATION:' SSN: 047-07-3321
FILE NUMBER: 2103-0059
DECEDENT NAME: KAUFFMAN JOHN I
DATE OF PAYMENT: 03/27/2003
POSTMARK DATE: 03/25/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 12/28/2002
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $3,131.34
TOTAL AMOUNT PAID:
$3,131.34
REMARKS' MARIELLE F HAZEN ESQUIRE
SEAL
CHECK#4
INITIALS: AC
RECEIVED BY'
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS