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HomeMy WebLinkAbout11-04-11..J 1505610140 REV-1500 EX ~~,_,~, PA Department of Revenue Bureau of Individual Taxes OFFICIAL USE ONLY Po BOX 280601 INHERITANCE TAX RETURN County Code Year File Number Harrisbur , PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 0 6 9 3 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 6 4 3 0 2 0 7 3 0 6 0 5 2 0 1 1 0 6 1 4 1 9 3 8 Decedent's Last Name Suffix Decedent's First Name B E L F O N T I MI J O H N R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name B E L F O N T I MI K A R E N Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BEL REGISTER OF WILLS OW 0 1. Original Return ^ 2. Supplemental Return ^ 4. Limited Estate ^ 3. Remainder Return (date of death i ^ ^X 6 D 4a. Future Interest Compromise (date of death after 12-12-82) Pr or to 12-13-82) ^ 5. Federal Estate Tax Return Required . ecedent Died Testate ^ (Attach Copy of Will) 7. Decedent Maintained a Living Trust 9. Litigation Proceeds Received ~ (Attach Copy of Trust) 10 S _ 8. Total Number of Safe Deposit Boxes . pousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 11. Election to tax under Sec. 9113(A) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL T Name t AX NF ORMATION SHOULD BE DIRECTED T0: D A R Y L J G E Daytime Telephone Number R B E R E S Q 7 1 7 8 3 8 5 4 1 1 r~ , REGISTER OF x SSE ONLX ~~ First line of address ~ ~~-~ '~- ~-1 •• "" c ~-~ r ~ y G E R B E R & A S S O C I A T E S ~ t l -,. ? ~ ? - - - ... ' Second line of address : •-J r--~. " ~ % ~`_: _., 4 6 E M A I N S T 1 ! ~ ~ ` w - ~` -~ City or Post Office . ~ ~~ ~"~ r . , .i P A L M Y State ZIP Code r DATE FILED ~ ~ ~i1 R A P A 1 7 0 7 8 Correspondent's a-mail address: DGERBER anGERBERLAWOFFICE COM Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowled it is true, correct and complete. Declaration of preparer other than the personal representative i e SIGNA d b TURE E SON R PONS FOR FILING R s ased on all in RN g an belief, formation of which preparer has any knowledge. ~' ADDRE DATE ~ J R. BELFONTI, JR, 6 E OF P SHEILD ST HARRISBURG ~ REPA OTH THA P ESEN TIVE P A 1710 9 ADDRESS DATE S -~ ~'2 DARYL J• G BER, ESQ, 46 E MAIN ST PALMYRA - PLEASE USE ORIGINAL FORM ONLY PA 17078 1505610140 Side 1 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: JOHN R• B E L F O N T I 1 6 4 3 0 2 0 7 3 RECAPITULATION 1. Real Estate (Schedule A) ................... . . . . ............ 1. 2. Stocks and Bonds (Schedule B) ...................................... • 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages and Notes Receivable (Schedule D) ...................... • .... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 7 9 6 7 2 • 6. 7 1 6. Jointly Owned Property (Schedule 7. Inter-Vivos Transfers & Miscellaneous NaP ©bate Pr PIIertY Requested ....... 6. 1 4 8 7 6 0 • 3 8 (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 through 7) .............. • -~~~-~~~~~..- 8. 9 4 5 4 8 7. 0 9 9. Funeral Expenses and Administrative Costs (Schedule H) .... . ~~---~~~--~~~ 9. 2 5 3 3 3. 4 4 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. ip. 11. Total Deductions (total Lines 9 and 10) ............................... 11. 2 5 3 3 3 12 . Net Value of Estate (Line 8 minus Line 11) ... .4 4 13. ..... , Charitable and Governmental Bequests/Sec 9113 Trusts for which 12 9 2 0 1 5 3 • 6 5 an election to tax has not been made (Schedule J) .............. ..... 13. .. . 14. Net Value Subject to Tax (Line 12 minus Line 13) • .............. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE R ..... ...14. 9 2 0 1 5 3. 6 5 15. ATES Amount of Line 14 taxable at the spousal tax rate or , transfers under Sec. 9116 16. (a)(1.2) x.o _ 3 9 9 9 7 3 3 Amount of Line 14 taxable 8 15. 0 • 0 0 at lineal rate X .045 5 2 0 1 8 0. 2 7 17. Amount of Line 14 taxable 16 2 3 4 0 8. 1 1 at sibling rate X .12 0 0 0 18. Amount of Line 14 taxable 1 ~. 0 . 0 0 at collateral rate X .15 0 0 0 18 o. 0 0 19. TAX DUE ....... . ... ..................................... .... .. 1s. 2 3 4 0 8. 1 1 20. FILL IN THE OVAL IF YOU ARE REpUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 1505610240 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 0693 JOHN R. BELFONTI STREET ADDRESS CLAREMONT NURSING HOME 1000 CLAREMONT ROAD clrY CARLISLE Tax Payments and Credits: STATE PA ZIP 17013 ~ ~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. Total Credits (A + B ) (1) 23 408.11 (2) 0.00 (3) (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 23 408.11 Make check payable to: REGISTER OF WILLS, AGENT ~. ~,. , , ., PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred; Yes No .................................... X b. retain the right to designate who shall use the property transferred or its income; ^ c. retain a reversions interest; or """"""'~•••••••••••••~~~~ ^ 0 ry ................................................................................................ ^ X 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 "intrust for" or payable-upon-death bank account or securit at his or her death . X 4. Did decedent own an individual retirement account, annuity or other non-probate property, which ' •. •.. •... ^ ^ contains a beneficiary designation? .................................................................................................. ^ X IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FI ^ `~''~'{~~ ~ ''~''~ °'< ` -` ~ , , LE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the ' ~ " 3 percent [72 P.S. §9116 (a) (1.1) (i)]. use of the surviving spouse is For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [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 21 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 percent [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 percent, 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 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+(6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF JOHN R. BELFONTI Include the All property ITEM NUMBER of litigation and the date the proceeds were received by the estate. I 'ned with right of survivorship must be disclosed on Schedule F. DESCRIPTION 1 ~ PSECU SAVINGS 2• PSECU MONEY HANDLER 3• PSECU MONEY MARKET 4• PSECU CD 5• ALLSTATE CONTRACT NO. 430077 DATE OF DEATH VALUE 6• STATE EMPLOYEES' RETIREMENT SYSTE M CK NO 85 64599813 7• M&T BANK CHECKING ACCOUNT 9836186826 8• M&T BANK SAVINGS ACCOUNT 15004205355371 9• M&T BANK IRA 35004110093925 10. M&T BANK CD 31003917683110 11 • PIONEER VISION ANNUITY CONTRACT NO. VN00408499 12. SOVEREIGN CD ACCNT NO. 2335128068 13. PSECU IRA TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) FILE NUN SCNED ULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY VALUE AT DATE OF DEATH 250.91 1.12 7,144.01 31,880.21 117,345.68 305.33 142,023.87 57,028.09 179, 381.67 52,161.04 89,862.61 48,490.97 70,851.20 ESTATE OF• SCHEDULE F JOINTLY-OWNED PROPERTY JOHN R. BELFONTI FILE NUMBER: 21 11 0693 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. KAREN BELFONTI 617 HILLTOP DRIVE NEW CUMBERLAND, PA 17109-4736 WIFE t3. c JOINTLY-0WNED PROPERTY: TER DATE ITEM FOR JOINT MADE NUMBER TENANT JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JO DATE OF DEATH DEC DATE OF DEATH 1~ A. 12/03 INTLY-HELD REAL ESTATE. M&T BANK VALUE OFASSET EDENPS INTEREST DECEDENPSINTEREST CHECKING ACCOUNT 75,815.59 50. 37,907.80 10653708 2• A• 02/96 M&T BANK SAVINGS ACCOUNT 221,705.16 50. 110,852.58 15004208655801 TOTAL (Also enter on Line 6, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. 148 760.38 REV-1509 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~ ~.+i c yr JOHN R. B SCWEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: 1. FILE NUMBER 21 11 OR! AMOUNT B. ADMINISTRATIVE COSTS: 1 • Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: I 2. Attorney Fees: DARYLJ. GERBER, ESQUIRE 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 23, 637.17 Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS PROBATE FEE 373.50 5. Accountant Fees: 6• I Tax Retum Preparer Fees: ~• P.A. COUP (LUNCHEON) CK 1016 8• REGISTER OF WILLS ADDITIONAL COST OF LETTERS 1,057.77 9• REGISTER OF WILLS PAIT FILING FEE 250.00 15.00 It more space is needed, use additional sheets of paper of the same size. TOTAL (Also enter on Line 9, Recapitulation) I $ REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~a~nlG Vr: JOHN R. E NUMBER I. 1. 2. SCHEDULE) BENEFICIARIES NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] KAREN BELFONTI 617 HILLTOP DRIVE NEW CUMBERLAND, PA 17070-1721 JOHN R. BELFONTI, JR 516 SHEILD STREET HARRISBURG, PA 17109-4736 FILE NUMBER: 21 11 069; RELATIONSHIP TO DECEDENT Do Not List Trustce(s) Spousal Lineal AMOUNT OR SHARE OF ESTATE 100.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET If more space is needed, use additional sheets of paper of the same size. ~~t ~It11 ttn~ (7P~tttmEnY I, JOHN R. BELFONTI of the Borough of New Cumberland, County of Cumberland and Commonwealth of Pennsylvania, being of sound and disposing mind, do hereby make this to be my Last Will and Testament, hereby revoking all Wills or Codicils by me at any time heretofore made. ARTICLE I I order and direct the payment of all my just debts and funeral expenses as soon as may be convenient after my decease. ARTICLE II I hereby make the following specific bequest: My M&T Bank account titled KAREN BELFONTI as Custodian for John R. Belfonti to KAREN BELFONTI. ARTICLE III I give, devise and bequeath all the rest, residue and remainder of my estate, after the r payment of debts and expenses provided for in Article I above, whether real; personaa~or mixed,- - and wheresoever situate, which includes but is not limited to all financial accounts, except those that I have jointly with Kazen Belfonti, which include but are not limited to, an Annuity, Deferred Compensation Plan, Retirement Account, Savings Account, and Checking Account, and Checking Account, to my son, JOHN R. BELFONTI, JR, or unto his issue, per stirpes. In the event that he has predeceased me leaving issue, that child's share shall be received by his { issue, in equal shares, but in the event that he leaves no issue, that shaze shall be received b the Y surviving residuary beneficiaries of this, my Last Will and Testament. ARTICLE IV In the event my beloved son predeceases me, or in the event that hr and I die in a common disaster, then I give, devise and bequeath all the rest, residue and remainder of my estate unto my KAREN BELFONTI as Alternate Beneficiary of this, my Last Wi11 and Testament. In the event that my has predeceased me then I give, devise and bequeath all the rest residue and remainder of my estate unto my brother PAUL R. BELFONTI. ARTICLE V I direct that my Executor shall not be required to enter security in any jurisdiction in which he may act. ARTICLE VI I nominate, constitute and appoint my son JOHN R BELP'ONTI, JR to be Executor of this, my Last Will and Testament. In the event that he is unable or unwilling to serve in that capacity, then I nominate, constitute and appoint KAREN BELFONTI as Alternate Executrix of this, my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ ~~ (~ ~ ~ _.__ ~_ day of `1 U ~. ~iV~ Q P' , A.D. 2003. (SEAL) John R. Belfonti SIGNED, SEALED, PUBLISHED and DECLARED by John R. Belfonti the above named Testator, as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence and in the presence of each other, all being present at the same time, have subscribed our names as witnesses. Address: Palm a PA Address: Palm a PA PSEC~k August 17, 2011 Gerber & Associates Law Offices 46 East Main Street Palmyra, PA 17078 Attn: Daryl J. Gerber el-y Re: John R. Belfonti, Deceased. Account # 0164302073 Dear Mr. Gerber: The account was opened on 4/21/1998. The Share accounts were held solely by John R. Belfonti. The following are the Date of Death Balances for Mr. Belfonti's account with PSEC U. Account Date of Death Balances Interest -June l-5 Savings (S1) $ 250.90 Money Handler (S4) $ 1 12 $ O.Oi Money Market (S7) $ 7,143.57 $ 0.00 Certifcate (S53) $ 31,871.57 $ 0.44 $ 8.64 Funds were released to the Estate and the account is closed. If you have any questions, please contact me at (717) 234-8484 or toll-free at (800) 237- 7328, then press 6, extension 3120. Si erely, ~, ,,. . ~-(.,~. Rox~Myers Service Advisor PSECU .. . P.O. Box 67013, HarrisburgnpA 17106-7013 E'7p7.234.8 84tl~800.237.7328 • » THIS CREDIT UNION IS FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY LENDER. I Y ~~ Allstate..: You're in goad hands. July 1, 2011 Irma Shuey Gerber and Associates 46 East Main Street PALMYRA, PA 17078 Re: John R. Belfonti Sr. Contract No: 430077 Dear Ms. Shuey: We received a request to complete IRS Form 712 for the above referenced 712 is to provide an estate or donor with the value of a life insurance contrac date (usually the owner's date of death or date of transfer of the contract , contract. The purpose of Form t or its proceeds as of a certain Because this contract is an annuity, it is not reportable on IRS Fo ) following information for estate purposes: rm 712. I can, however, provide the Date of Death: Annuity Value as of Date of Death: June 5, 2011 Cost Basis: $ 117,345.68" Named Beneficiary: $ 20,000.00 `The actual amount paid ma John R. Belfonti, Jr Charges. Y differ due to Market Value Adjustments and/or any applicable Surrender If you have any questions, please contact me at 1-877-4gg~18 Ext. 24597. Sincerely, Jennifer Evans Sr. Claim Examiner Allstate Life Insurance Company P.O. Box 94212, palatine, IL 60094-42A2 nphonel 877-499-6418 Fax 866-63 - 5 4523 ~QT ' a 7 r ~ ''',,, :::~~~~~~i :.r a '~ ' `` a s aa + :; ~ _~ i '~ ~ ti ~Q~Q~O ~ •• :~~ - ' ~ (L S> ,~ 0 Q M } .. Q ~ r ~~ O ~~ ~ W ~ _ ~ m~ Q a °~ ~ ~ z ~ -r '~' ` ~o °i~ ~ ~ Q o i wwv ~ W mmZ J ~ • - o W zC9 =O~~ ~v ~' ~V~a ~} A ~~(~~I~N~fl~tf~~u~i~~ur~~~,~ -- * O 2 ~ _ ~ 0 ...0 ...O..O ~.3u,l~o n5e~3n~3 II I*1` ~~~ W O I '_ U' `<- N ~ N ~ ~ ~ ~ 00 ~ (.~. C~ t 'udiNn U M = Z a h W N ~ O. LL W N ~~ co Z w cp ~, ,- W n r y~~r 0 QN ~ W T- W .c~~a ~,- oc~ 3 W = ~ c W ~ m E~=~ ci g o Q zz W W Q F N ~~ ;. ~.: ~,;'~ ~~ mot.. ~ nz~rsa~,k 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Gerber and Associates ,. 46 East Main Street Palmyra, PA 17078 ~ ~- f'~ ~ ~-`~ Phone 888-502-4349 Fax (302) 934-2955 July 6, 2011 Re: Estate of John R Belfonti Social Secl~rity• 164 30-2073 Date of Death: June S 2011, . ,. r ~} ,1 ;:~ fr ~ '-.~ Dear Sir or Madam: ~ ~`~ ~ , ~~.~ ~ ~ " ,. Per your inquiry on June 29, 2011, please be advised that at the time of death 2t ' ~s, "" '' deposit with this bank the following: ~ ~~~ named decedent had old' ~ ~~ ~ .~ '~ i~' ~ ~ (~ ~~1 r , i 1 • Type ofAccount H ~. ~ ~~ ,~t` Checking Account ' Account Number 10653708 Ownership (Names o, fl John R Be~nti ~ ~ , , . , .°.. Karen B Be~nti ~ ,, `'' Opentng Date ~ r far, ~ ~'~ OS/19N5 ~' ~ ~ ~„es ~ ~~~~4 r ., a., r -.- Balance on Date of Death ~j ~ ~ '' ,~}~ ` , ix ~ , ` $7,~ 815.52 - _ ..._ „ :, ~,tia,! x t .: ~ , r ~ ~'! Accrued Interest , • i $ .07 ~ ~ ~ M~1, ,y ; Total -------------------------------------------------- --- $75,815.59 - `Y 2• Type ofAccount Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 9836186826 John R Be~nti (Principal) Karen B Belfonti (Rep Payee) 12/153 $142,022:96 $ .91 ------------------------------------ - -- ~~ 3. ~'Pe ofAccount .. .: Savings Account -- ,., ........ _..,. Account Number 15004205355371. ~ - - ' Ownership (Names o, fl -_ John R Belfonti (Principal) 0 Karen B Belfonti (Rep Payee) Opening Date 12/15/03 Balance on Date of Death $57,024.34 Accrued Interest $ 3.75 y ,: ,. .Total. .---- $57028.09-------------------- - 4• Type ofAccount Savings Account AccduntNumber 1 ~i ~ ,. ~ IS0042086S580X ~. Ownership (Na»:es oft John R Be fond Karen B Belfonti John R Be fnnti Jr (POA) _ Openiit8 Date . . Q2/l2/96 Balannce on Date of Depth $221, 702.43 Accrued Interest $ 2.73 Total ------------------------------------------ $221,705.16 ------------ 5 Tyke o fA~~ i a, ,, , . Irulivrdual.RetirQmentAccount - Acccs~ntlftum$,~r' ' ~ ~,;. 350!0411 Op93925 r (,~ . C .'Ownership (,Names o~ John R Bg fond 1 John R Be fnnti Jr (Beneficiary) Opening Date X,4%02/06 , - Balance on Date'of Death 4. ~ . I . $1 X79,222.0 2 ~~ Accrued Interest $ 159.65 Total -- $179,381.67 - 6• Type ofAccount Certificate of Deposit Account Number 31003917683110 Ownership (Names o, fl John R Be fnnti (Principal) ~ 1 Karen B Belfonti (Rep Payee) Opening Date 12!27/07 Balance on Date of Death $52,13804 Accrued Iruerest $ 23 DD Total ~- ------._._._.-----------------._.----------------- $52,161.04 ------ i I_ .. or eny additional information on the above -- accounts, including ownership and an please ~ the IFighland Park Office at #717-?3'7.3322. Y changes, closures and/or reimbur sement of funds, We were unable to 1 ovate any safe deposit box f or the above-mentioned decedent. This letter does not include an y accounts in which the deceased may have been listed Representative Payee or Trust as Power f A , ee under a Written Agreement o ttorn eY, Custodian of Uniform Transfers, Sincerely, ,, s ~, ; ~: ~ Tammy S e ~. ~.. C ~' .yam 4 y' i ~ ~ ~ ~ ~ ~ p ncer Adjustment Servi ~ h r s~ ~ 5 - ~ d4 '' Su ~' s.~; ~~ '. ~ ~~ ces ,,,,, - d ° ' ~! Y a if ' 4 ~ ~ ~ tiY~~ Y : ~. ' ~ ~ ~ 'o ; i r ~r'~ : =~.r. ~&~ t~e ~ ~ ~ - T~ ,'~a. ' ,, ~. ~,,fi> ,ys1 ~r ;~ ~~ i . a , ~~ .. .. - .. ~ .~ 5b ~}~ (iC r~ r y a 1' Y ~~ b 1 ~ ~ . 7 I ~ SS 'p ~t ~' ~ ' '"~'Cri .t.., 1 ,_ 4iy:, '~"' ~: 1~.; ~: ~~i': A;~ ):.:. i P'I011iEER ~ISIQN`" ~P.D. Box 768bb0 ~ ~ I Y A R! A d! 6 A N N U f T Y. Topeka, KS 8667b$650 August 15, 2011 GERBER & ASSOCIATES ATTN DARYL J GERBER 46 EAST MAIN STREET PALMYRA PA 17078 Re: Contract Number: VN00408499 Deceased's Name: John Belfonti "~"-- - -~~- Type of Annuity: Pioneer Vision II Annuity; Non-Qualified Dear Mr Gerber: '~ We have been notified of the death of John Belfonti. Please accept our condolences the family, and extend them to Our records indicate the beneficiary designation for the above referenced annuit is The Belfonti. in order to ro Y Estate of John with the death claim we re wire a certified on final death certificate for Mr. Belfonti which indicates cause and manner of death and a Claimant's Statemen b the Executo s or Administrator(s) ~f thw ~.•s t cam leted the Administrator of Mr. Belfonti's Estate. As a non spousal beneficiaceipt of the Short Certificate naming ry, your interest as a death beneficiary must generally start to be distributed by December 3161 of the calendar ear folio in which death occurred. Y wmg the year- In addition, below is the additionally requested information. Issue Date: May 13, 1008 Owner Name: John R. Belfonti Contract Number: VN00408499 Name of Beneficiaries: Estate of John Belfonti Account.. Value as of June 5, 201 is $89,562.61 Death Benefit as of June 5, 2011: $157,460.79 If you have any' questions, please contact an Account Service Representative at 800-6 - 7:30 am and 5:00 pm Central Time. 88 9915 between Sincerely, Service: Operations Commonwealth Annuity Enclosure clc P.O. Box 758550, Topeka, KS 66675-8550, 800-688-9915, www.pioneerfunds.com ~~ ±• ~ 3• 24 i 1 4: 32AM No, 8427 P, 3 ~' EsT~,~l~ o>~ sac>rAx, sECU~rT~ DATE Op' DEATH: Sovereign ,$a,n~ rohn It. Belfonti 164-30-2073 mine 5, 2011 Account #: 2335128068 rn the name of John RBelfonti -Type. CD {Karen ,B Belfonti - ppA~ Open date: 1/18_ /_ Zppp, Date of Death Bal$pGe; ~nt'~TD~ from 1/1/2011 $47,8$7.25 Accrued interest to date of death; to 65/2011 $603.72 $787.64 other Info: Page 7 of i ual27l2011 15 ; 13 Commonwea I th Packaging {FAX}7176575755 P , 007!001 PSEf~Yk ~O8lP R H~t,gONTI JA S26 J38I1lLb gT ~R~tS80Ra, PA x7109 September 20, ZOl l - -- - _ Ra _ ]OI3N R BELFONTI IRA JOHN R BELFpNTI JR; BENLF'ICIARy - - --- ~-- ~ .-..... _ . _ .._ DEAR MR BELFONTI 3R; The Law dtYlce of Gerber & Aeaociates has requested a dew of death b Belfonti as of the date of his death, June S, 2011. Wo are forty ~~ for the IRA of Iohn R You ere the beneficiary of this IRA, not the Estate, You may then fo ~ ~onnetion directly to Yon ainco attorney, rward this information to your H~-LANCE AS OF 6/S/20I 1 $70,851.20 We may be reached Monday throw Friday, 8 a,m, to S m, or 800.237.7328 nationwide. At the menu p' ~~ by calling 717.234,8484 in FIarrisburg prompt, enter 6, then extension 3570, 3incer ~ ~ r_,,. Member Se 'ce ~ -~-Cr IRA/Certificate Dep ent ~ i~ ~~ Pennsylvania State Employees ~redlt 11n1on P.O. Box 67013, Harrisburg, pq 17106-7013 • 717.234. THIS CREDIT UNION IS FEDERALLY INSURED 6Y THE NATIONAL CREDIT UNIO~ IN STR T ON 3x8 • ~~ psecu.com QUA[ OPPORTUNITY LENDER. RECEIPT_FOR_PAYMENT GLENDA FARMER STRASBAUGH OneCourthousenSyuareeglster Of Wills Receipt Date: 6 20 2011 Carlisle, PA 1713 Receipt Time: 09:33:07 Receipt No.: 1065996 BELFONTI JOHN R Estate File No.: 2011-00693 Paid By Remarks: w~RBER & ASSOCIATES ___ --------- -- Receipt Distribution Fee Tax Description pa yment Amount _____ _ ------ -- PETITION LTRS TEST Payee Name WILL SHORT CERTIFICATE JCS 310.00 15.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL FUN FEE AUTOMATION FEE 20.00 23.50 CUMBERLAND COUNTY BUREAU OF GENERAL GENERAL FUN FUN Check# 7681 5.00 ---------------- R CUMBERLAND ECEIPTS COUNTY & CNTR GENERAL M.D FUN Total Received. 373.50 ..... .. • 373.50 ~'T- l P.A. Coup 708 Pleasant View Road Lewisberry, PA 17339 Phone: 938-2959 Fax; 938-9876 Name: Kamen Belfonti Address: 617 Hilltop Drive New' Cumberland, PA 1'TO'TO Fridley June 10, 2011 z~~? 7 r~^ r ~~~ 2. ~ETTT,FMFNT TA TFMFIVm ESTATE NAME: JOHN R. BELFONTI CUMBERLAND RECEIPTS Description EXPENDITURES Amount P Description $39,339.98 Funeral Home A mount $ 305.33 Register of Wills (Probate Fee) Gerber & Associates (Executor's Fee) $373.SQ Gerber & Associates (Attorney Fees) $ 23,637 17 Postage 10/11/2011 . $7 ~ Additional Cost of Letters $ 2 AIT Filing Fee $ 50.00 15 00 PAIT Taxes Due . $ 23,408 11 Reimbursement to Karen (Luncheon) $ . 1,057.77 Sovereign Bank $ 20.00 TOTAL $ 39,645.31 Receipts $ 39,645.31 UNp~D; Expenditures $ 48,769.19 ACCOUNT BALANCE $ (9,123.88) P TOTAL $ 48,769.19