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Home My WebLink About12-09-11FIORE ~ BARB ER, LL.C ATTORNEYS AT LAW AMAN M. BARBER, III abarber@Rorebarber.com 425 MAIN STREET, SUITE 200 HARLEYSVILLE, PA 19438 CHRISTOPHER P. FIORE 215-256-Q20g chore@fiorebarber.com FAX 215-256-9205 www Rorebarber.com December 6, 2011 Register of Will Cumberland County Court House 1 Courthouse S uare Carlisle, PA 17013 Re: Estate of William gaks No 21-11-0418 a, deceased Dear Sir or Mad~jm: Enclosed lease find an original and two co ies of Tax Return. Also~enclosed p the Penn please find a check m the amount of $15y00 foathe i:fling fee. Please pro ide me with atime-stamped co of self-addressed, st~rnped enve pY the Return and lope provided. a receipt in the Thank you.l AMB, I I I/sld Enclosures cc: Jaclyn S. Bakst (w/o encl) Ill ~ ;,«~> j ~~ ~ ' g ~- C7 2s: ; c ~ :":? h `,~-, ~ -.. ~7~ `TT =~~ --r- b --1 ~ V .:~ ~Ti ~~ c../a~ G'~ 1505610105 R; V~ i 5 ~ 0 IX (oz-u) (FI) PA D' Bure PO B partment of Revenue u of Individua(Taxes X z8o6o pennsy(vania °`°""'"`"'°'"ESE"°F OFFICIAL USE ONLY Harri NTER DECEDENT IN i bur , Pq i 128-D6o>. FORMATION BE INHERITANCE TAX RETURN County Code Year RESIDENT DECEDENT File Number a l Soaal Securi ty Numbe LOW r 1 l ~ y ~ c/ o Date of Death MMDDYYYY 171-38-3796 - Date of Birth MMDDYYYY Decedent's Last Name ~ 03/07/2011 08/24/1953 BakSa I Suffix Decedent's First Name __ ' Jr. William MI Su' ivmg Spouse's Information Below (SPoPSe''saLatst N G ame Suffix Spouse's First Name ty' Spouse's Social Securi Number MI F THIS RETURN MUST BE FILED IN DUPLICATE WITH T ILL IN APpROPR1ATE C'VALS BELOW HE REGISTER OF WILLS QD 1. Original Return O 2. Supplemental Return O 4. Limited Estate O O 3. Remainder Return (Date of Death 4a. Future Interest Com Prior to 12-13-82) ro i O 6. Decedent Died Testate p m se (date of death after 12-12-g2) O ;i. Federal Estate Tax Ret (Attach Copy of Will) O O 9. Litigation Proceedsl Received urn Required 7. Decedent Maintained a Living Trust (Attach Copy of Trust.) 8• Total Number of S , O afe Deposit Boxes 10. Spousal Pove th B f De CORRESPONDENT - NIS SEC Name a etween 12-3 91 and jD1_95~ O 11. Election to Tax under Sec. 9113(A) ON MUST BE COMPLETED. ALL CORRESPOND (Attach Schedule O) Arran . Barber III ENCE AND CONFIDENTIAL TAX INF ORMATION SHOULD BE D IRECTED T0 , E, , ~qU : Daytime Telephone Number (215;) 256-020 First Line of A ~ _. _ -~~ REGISTER OI'F~p~ US ~ '~ ddress 425 Main St ~ Second Line of Address :Suite 200 ~' City or Post Office :Harleysville Correspondent's a-mail addr Under-pena~s of perjury, I deGare t it is true, correct and complete. Derl State PA _ -_. -r~~~+wudlDer.COffI I have examined this return, including a~ ion of preparer other than the personal 3LE FOR FILING RETURN ~ ._ 978 Katie ~ , oyersford, P tIGNATU OF R OT 194 ESENTATIVE DD SS i 12`~~n St. Suite 200 Harleysville, PA 18438 L 1505610105 Side 1 E ONLY ,- -.~ :': ~ .. - _ ~ a r--. ~~ .._ ~ir f._ ZIP Code DATE FILED t. ^ O ' ~~ _~t :19438 _ schedules and statements, and to the best of my knowledge and belief, 3 is based on all information of which preparer has any knowledge. ~L. 15D5610105 C~ Decedent's Nam RECAPITULATION 1 • Real E to 1505610205 500 EX (FI) Decedent's Social Security Number 171-38-3796 s to (Sdi hedule A)..... . 2. Stocks and Bon ....... s Schedule B 1 • ( ) ............. 0.00 3. Closely Held Co ' ' ' ' ' 2• poration, Partnership or Sole-Proprietorshi P (Schedule C) 0.00 4• Mortgages and .. , . 3 otes Receivable (Schedule D) • . 0.00 5. Cash Bank D ...... 4. ................... , e po 6 sits and Miscellaneous Personal Pro ert P y (Schedule E) 0.00 . Jointly Owned P nter-Vivos Transf .. . ' ' ' ' S• Perty (Schedule F) (~ Separate Billing Requested rs & Miscella 8,287 71 (Schedule G ) ... • neous Non-Probate Property • ~ ' 6' 8. Total Gross Ass C~ Separate Billi n Re g nested........ 7• 0.00 e s (total Lines 1 through 7) • 1,840.00 9. Funeral Expenses ............... 8. nd Administrative Costs (Schedule H) 10,127.71 ~ 10. Debts of Decedent ( . . ................. s. Mort , gage Liabilities and Liens (Schedule I) 13,865.68 11. Total Deductions ({ .... • ~ ~ ~ ' • • • • 10. otal Lines 9 and 10) , • • • • . 5,344.28 12. Net Value of Estate 13. Charitable and Go .... •~~~~~•••~"""••• 11. (Line 8 minus Line 11) 19,209.28 ' v an election to tax ha • • • ~ • 12. rnmental Bequests/Sec 9113 Trusts for which not been made (Schedule J) . , , .. 0.00 14. Net ValueSub'ectt 1 T ••~~'''''''••••13.i Tax (Line 12 minus Line 13) 0.00 AX CALCULATION - SE 15• Amount of Line 14 t ....... 14.: INSTRUCTIONS FOR APPLICABLE • ... • • . , • able RATES 0.00 at the spousal tax rat transfers under S ec. (a)(1.2) X .0_ ~ 116 I 16. Amount of Line 14 tax~ ble 1 at lineal rate X .0 45 5. 17• Amount of Line 14 taxa at sibling rate X II 1 ble 0.00 16. . 2 18. Amount of Line 14 taxa ~le 0.00 at collateral rate X , 15, _ 17. 19. TAX DUE I 18. ..... .... ..................... 19. 20. FILL IN THE OVAL IF ARE REQUESTING A REFUND OF qN OVERPAYMENT 0.00 O L 150561020 Side 2 150561D205 REV-1500 EX (FI) page 3 Decedent's Com William G Baksa Jr STREETADDRESS 1102 Yverdon Dr Apartment A-8 cir~ Camp Hitt Address: File Number Tax Payments and Credits: 1 • 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 OVERPAYM Fill in oval on Page 2, Line 20~to request a refund. ENT. 5• If Line 1 + Line 3 is greater than (Line 2, enter the difference. This is the TAX pUE. PLEASE ANSWER 1 • Did decedent mai a. retain the use b. retain the right c. retain a reversi d. receive the pros 2. If death occurred a without receiving a~ 3• Did decedent own 4• Did decedent own contains a benefl~ia IF THE ANSWER TO ANY 0 PA I ZIP -~~- 17111 (1) 0.00 Total Credits (A + g) (2) (3) (4) (5) ', Make check payable to: REGISTER OF WILLS, qG ENT. E FOLLOWING QUESTIONS BY PLACING AN "X" IN THE App a transfer and: ROPRIATE BLOCKS income of the property transferred ,,,,. designate who shall use the roe ~•~"""""""°°•••••• Yes No P P rty transferred or its income ........ ~•••~~~~• nary interest .... .................................... se for life of either payments, benefits or care? . IrDec.12,1982,diddecedenttransferprope •.••'•.•.~..~••~••~~~•~~•~~~~~••~~"""""'~~•~••••• ^ rty within one """""""~ quate consideration? ............................................................year of death............................. ^ "in trust for" orpayable-upon-death bank account or security at his or her death?.......,. individual retirement account, annuity or other non-probate roe ^ designation? ...,.,,•, ""' ................................ P P rtx which 0.00 0.00 0.00 F THE At3pVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G For dates of death on or after July 1, 199, and before Jan. 1, 1995, the tax AND FILE IT AS PART OF THE RETURN. is 3 percent [72 P.S. §g116 a rate imposed on the net value of transfers to or f or the use of the surviving spouse For dates of death on or after Jan. 1, 995, the tax rate imposed on the net valu [72 P.S. §9116 (a) (1.1) (ii)]. The statute d es not exempt a transfer to a survivin sou e of transfers to or for the use of the surviving spouse is 0 filing a tax return are still applicable even the surviving spouse is the only beneficia 9 P se from tax, and the statutory requirements for disclosure of assets and For dates of death on or after July 1, 2000• • The tax rate imposed on the net valu of transfers from a deceas ry adoptive parent or a stepparent of the hild is 0 percent [72 pS ed child 21 years of age or younger at death to or for the u se of a natural parent, an • The tax rate imposed on the net value of transfers to or for the use of the d(e )cedent's lineal • The tax rate imposed on the net value f transfers to or for the use of the decedent's ' under Section 9102, as an individual who has at least one parent in comm beneficiaries is 4.5 percent, except as noted in [72 P,S. §9116(a)(1)]. on with the decedent) whether by bloodd os~adoptlo~a)(1.3 . )] A sibling is defined, I REV-lso8 p~+ X11-io) pennsylv~n~a SCNED~ILE E DEPARTMENT OF REI~ENUE ^ ~+L~ INHERTfANCE TAx REtURN CASH/ BANK DEPOSITS $~ RESIDENT DECEDENT PERSONAL PROPERTY ISC, ESTATE OF: William G Baksa, Jr. FILE NUMBER: Include the proceeds of litigation and the date the All grope 21-11-0418 ITEM rty jointly owned with right of survivorsh~eeds were received b NUMBER P must be disclosed on Schedule F, 1. Metro Bank- C ecking Account 538263526 DESCataTIDN VALUE AT DATE ---'---- OF DEAT~_ 2. KNBT - Checking Account 5500338456 91.41 3. LCL Management -Security Deposit Refund 1,170.25 4. Comcast Refun~ 200.00 5. Erie Insurance F~efunds 56.42 6. YRC -Final Wages 237.00 7. IRS 2010 Refimr~ more space is needed, use additonal sheets of paper~of the 5, Recapitulation) $ 8,287.71 e same size. REV-1510 EX+ (08-09) ;~Y~ ` pennsy~lvania SCHEDULE G DEPgRTMENTO REVENUE INTER-VIVO$ T INHERITANCE T RETURN RANSFERS AND RESIDENT DECE ENT MISC. NON-PROggTE PROPERTY ESTATE OF William G Baksa, Jr. ', FILE NUMBER 21-11-0418 This sche ule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is es. ITEM ' DESCRIPTION OF PROPERTY y (UMBER INCLUD THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT qND THE DATE OF TRANSFER g7TACH A COPY OF THE DEED FOR REAL ESTATE. 1 • VALUE OF ASSET INTEREST Central Pennsylva is Teamsters Pension Fund -Lump Sum Death Benefit• DATE OF DEATH 9'o OF DECD~S EXCLUSION TAXABLE transfered to Jacly S Baksa, Daughter approx 9/15/11 'F APPUCae~E vA~uE 1,840.00 100 2 Central Pennsylva is Teamsters Pension Fund -Retirement Income Plan 1,840.00 1987; transfered to Jaclyn S Baksa, Daughter approx 8/15/11 Decedent not 59 1/ years old as of date of death 300,629.19 100 300,629.19 0.00 TOTAL (Also enter on Line 7, Recapitulation) $ 1 84 If more space is needed, use additional shee 0.00 ' is of paper of the same s¢e. I REV-1511. EX+ (10-09) ~~~ pennsy~(vania DEPARTMENT OF REVENUE INHERITANCE TAx RETURN _ RESIDENT DECE ENT ESTATE OF William G Baksa, Jr ---- ITEM N_ UMBER A• FUNERAL EXP I NSES: 1. Long Funer I Home SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER Decedent's debts must be reported on Schedule I. 21-11-0418 B• ADMINISTRATIVI COSTS; I• Personal Representative Commissions: Name(s) ~f Personal Representative(s) Street Ad~ress ___ City '' ----.__ Year(s) CoMmission Paid: State ZIP ------ ----- 2. Attorney Fees: ', 3• Family Exemption (If decedent's address is not the same as claimant's, attach ex lanati Claimant P on•) Street Addr~'ss ~_ City -~---_ Relationship ~f Claimant to Decedent State ZIP ---- 4• Probate Fees: ---- 5. Accountant fees: 6. Tax Return Preparer~ees: ~• Cumberland Law Jolurnal B• The Sentinal s• Cumberland Coun ty ~ 1500 filing fee If more space is needed, use additional shOTAoL Pape of the samei s ze./ ReCdpituldtion) $ 11,490.40 2,000.00 74.50 75.00 210.78 15.00 13, g I REV-1512 EX+ (12_pg~ ~ ~ Pennsylvania SCHEDULE I DEPARTM ENT OP REVENUE INHEruTANCE TAX RETURN DEBTS OF DECEDENT R , ESIDENT DECE ENT MORTGAGE LIABILITIES ESTATE QF & LIENS William G. Baksa, Jr Report debts incurre by the decedent prior t FILE NUMBER ITEM NUMBER o death that rema(ned unpaid at the date of death i , ncludin 21-11-041 g I ~ DESCRIPTION g unreimbursed medical expenses. PFL VALUE AT DATE ' 2. West Shore Ta~ C Bureuau 2010 OF DEATH local income tax 95.53 3. Alma Berresfor~ -Tax Collector 245.99 4. KNBT Bank Ch~ rge 9.80 5• US National Bar k Assoc (KNTB Credit Card) 3.00 ~ 4, 989.96 If more space is needed, insert addT on I sheetsnof the same 10, Recapitulation) ~ 5,344,28 size. I REV-1513 EX+ (01-10) pennsy~lvania SC DEPggTMENT OIF gEVENUE HEDUI.E ~ INHERITANCE T4~( RETURN BENEFICIARIES RESIDENT DECE ENT ESTATE OF: wlliam G Baksa, Jr. FILE NUMBER: NUMBER NAM AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I RELATIONSHIP TO DECEDENT 21-11-p418 TAXABLE DISTRI UTIONS [Include outright spousal distributions and transfers under Do Not List Trustee(s) AMOUNT OR SHARE Sec. 9116 (a) (1.2).] OF ESTATE 1 • Jaolyn S Baks~, 978 Katie Cir, Royersford, PA 19468 ~!, Daughter I, 100% ENTER DOLLAR AMOUNII S FOR DISTRIBUTIONS SHOWN AB I NON-TAXABLE DISTRIB TIONS II OVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. A• SPOUSAL DISTRIBU IONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: L I ill B• CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. i EN TOTAL OF PART II - ER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 1 If more space is needed, use additional sheets of paper of theEsame Oze.OVER SHEET. $ ~I REV-1500 EX (FI) Page 3 Decedent's Complete Address: DECEDENTS NAME File Number William G Baksa Jr STREETADDRESS 1102 Yverdon Dr --- _ Apartment A-g clTV -- Camp Hilt Tax Payments and ~ PA ziP redits: 17111 1 • Tax Due (Page 2, Line 19) ', 2• Credits/Payments A. Prior Payments (1) 13,155.61 B. Discoun# 3• Interest Total Credits (A + B) (2) 4• If Line 2 is greafgr than Line 1 Line 3, enter the difference. This is the OVERPAYMENT. 0.00 Fill in oval on Page 2, Line 20~to request a refund. (3) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the T (4) AX DUE. (5) 13,155.61 ', Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACIN 1. Did decedent ma e a transfer and: G AN "X" IN THE APPROPRIATE BLOCKS a. retain the use or income of the ro ert transferred ............... Yes b. retain the righ to desi Hate who shall use the roe No g ........................................................................... ^ c. retain a revers ovary interest ....... P P rty transferred or its income .... d. receive the pr mise for life of either payments, benefits or care? .............. 2. If death occurred fter Dec. 12, 1982, did decedent transfer roe ^ ^ without receiving a equate consideration? ......... P P rty within one year of death 3. Did decedent own n "in trust for" orpayable-upon-death bank account or security at his or her de ~ 4. Did decedent own n individual retirement account, annuity or other non-probate ro erty ^ contains a benefici afh ............... ~ ^ ry designation? ...,,, _.. P P ,which ........ ..................................................................... .... IF THE ANSWER TO ANY OF THE AIBOVE QUESTIONS IS YES, YOU MUST COM ^ ~ For dates of death on or after July 1, 194, and before Jan. 1,1995 the PETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. is 3 percent [72 P.S. §9116 (a) (1.1) (I)]. tax rate imposed on the net value of transfers to or for the use For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of of the surviving spouse [72 P.S. §9116 (a) (1.1) (ii)]. The statute oes not exempt a transfer to a surviving spouse fro filing a tax return are still applicable even if the surviving spouse is the only beneficia transfers to or for the use of the surviving spouse is 0 percent m tax, and the statutory requirements for disclosure of assets and For dates of death on or after July 1, 200: ry • The tax rate imposed on the net valu of transfers from a deceased child 21 years of a e 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 o transfers to or for the use of the dece g or younger at death to or for the use of a natural parent, an • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblin dent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. under Section 9102, as an individual w o has at least one parent in common with the decedent gs Is 12 percent [72 P,S. §9116(a)(1.3)]. Asibling is defined, whether by blood or adoption. IMIEiRO BANK September 26, 12011 Fiore & Barber, LC 425 Main St Ste 200 Harleysville, Pq 9438 3801 Paxton Street Harrisburg, Pq 17111 888.937.i~004 mymetrobank.com RE: Estate of: illiam G Baksa, Jr Tax Identific tion Number: 171-38-3791 Date of Dea h: March 7, 2011 To Whom It May Concern: This letter is in refe ence to decedent above. We are able~to provide the f account information ollowing: You requested for the individual listed Account Type; Chec ing Account Number: 53 Date O 263526 pened: Febru ry 12, 2009 Date Closed: April 01 2011 Primary p+Nner: William G Baksa Jr Date of Death Balanc $91.41 Please feel free to con~act me at (717) 412_61 Sincerely, ', 26 if I may be of further assistance. Pamela Lighty Savings/CIF Associate '' Metro Bank ~NR ~„,~,,,„~i , ~V T w~nnlv.knbt. ~ ' bm1 Pone fiink com o , B6UIKIN611NSURgNCEIINYESTMENTSIrRUSi 1'800.996.2062 o Member FDIC ~0. Box 547 Bbyertown, PA 19512 YCNBT Te~P-Return Service Requested YOUR FINANCIgL PROFILE =-- STATEMENT DATE 03/11/11 ~~ PAGE 1 I~~~IIL,~III~~~~~~II~~~II~~~ILrI~I~I~~IJJJ~I~~I~LJI~„I 5500338456 ~_ 002917 0.6370 MB 0 CS ~ ' 0.382 TR00015 WILL Ap02 A 8 ~BN DR ', CAMP HILL Pq 17011-1245 CHE~KING ------------------------------------- WILLIAM G BAKSA~ ------------------- KNBT FREE 50+ CHKG BALANCE LAST STA~'EMENT ACCOUNT NUMBER 550033-845-6 DEPOSES/CREDIT'S I $ 1, 344.65 CHECKS/DEBITS + 3,186.15 DATE OF LAST STATEMENT - ____ 2,584.8$ 02/11/11 BALANCE THIS STgThEMENT $ 1,$45.91 __ ' : TOTAL FOR TOTAL TOTAL OVERDRq-+-------------THIS_PERIOD-----_----------- ___ _ F~{ FEES ~R-TO-DATE ; --TOTAL RETURNED ~-~-F- -------------~~__-- .00 , o ------------ EES .00 ------------- ~, ----------- --- .00 ~ ------_----CHECKS P ID THIS PERIOD *----------''--- ------- o -------~-------------- (--~ENOTES Gqp IN N--------------------------- NUMBER -- -----____-- UMBER SEQUENCE) ---------- '°' ~UNT DATE ---------- - - M 8?0 NUMBER AMOUNT --------- --------- - 2j0.00 02/15 I DATE ---------- - 875° NUMBER AMOUNT '" 151.04 02/25 DATE °. 876 151.85 02/25 o -------- TOTAL NUMBER OF CHECKS -~---- -- 3 $322.89 ~ ___-- TRANSACTI N D ------------------------- ~, ---------- ETAIL ------- o ~ ------!-------------- ------------ _ o N DATE DESCRIPT10~ ----------------------------------------- --------------- Y o 02/11 BEGINNING WITHDRAWgLS DEPOSITS ---------------- 02/14 WTHDRL DDA 9910 02 13A~CE BALANCE 02 15 1023 STATE STREET LEMO 15:01 300.00 02/17 A -- RC INC. ~E PA 1,344.65 02/17 20.00 1,044.65 WTHDRL DDq 5114 02/161R DEP 02/22 1200 ~~ ST LEMOyNE PA17~09 141.00 915.63 1,024.65 WTHDRL DDq 535 02 19 1'9`10.28 02/23 gC00 MARKET ST L / 15:09 141.00 1,799.28 CARDMEMg R EMOYNE PA SERV -ELECT PYM7' 700.00 1,658.2$ 958.28 4irisim W Nati~~ T aWl Pgin 88nN UANKINCIINSURgNCEIINVESiAfENTSITRUSi P0. Box 547 8oyertown, PA 19512 YOUR FINANCIAL PROFILE 0 ... rn N O O M O ,-, 0 0 0 0 ti rn N O O N O O F- m Z Y WILLIAM GBAKSq www.knbt.com 1.800.996.2062 Member FDIC STATEMENT DATE 03/11/11 PAGE 2 5500338456 0 CS --IRAN ACTION DETAIL ----------------------------- ---- DATE -------- --------------- ----------- DESCR~IPTION ------------------- 02/24 AC-YR WITHDRAWALS D ------ IN 02/24 WT}tDR 1200 DDA 6756 02 232R DEP / EPOSITS BALANCE % RICE7- ST L 16:57 EMOYNE PA 141.00 689.22 1,647 50 02 25 CHECK 02/28 R # 876 151.04 . 1,506.50 1200 03/02 AC-AES DDA 7886 02/27 15:11 OAN q~MOYNE PA 151.85 ~-21.00 1,355.46 1 203 61 CHECK# 03/03 AC-YRC 0878 INC 440.00 , . 1,082.61 03/03 AC-ERI 0 q E A# . INSURANCE-125~p38677 0877 780 6 642.61 3/04 03/04 0 pRL F U A RE DDgS7302 0 132.00 . 4 1,423.25 1,291.25 0 03/10 AC-YRC I 7 3/03 N31 RKET ST LEMOYNE pq NC 141.00 20.00 1 311 25 03/11 CHECK I 03,/11 FOREIGN . GE FEE -DIR DEP qTM CHAR 780 66 , . 1,170.25 03,/11 ENDINGA GES TATEMENT BALANC 2.00 3.00 . 1,950.91 1948.91 E 1,945.91 ___--------FOR-YOU~'I-INFORMgTION-- 1,945.91 --------- H~ME EQUITY RAT ------------ ------------- ES ARE STILL HOW YOUR HOUSE CAN LOW. WORK R ~D ASK US - ----------- EQUAL HOUSING FO YOU. OpppR-NNITY. ~Eintral Pe _ • nnsylvania Teamsters JOSEPH J. SAMOLEINICZ, Administrator ., ~nn„_ Board ofT:vstees: WII.ISAI~[ M. SHAPPELL, Chairman and Trustee TOM J. VlENTTiRq, Secretary end Trustee KEVIN M. CICAK, Tmstee T'OMM FORREST, Tnistee J. CxgIST'OPHBR IvIICHAEL,',Tzvstes KEITH L. ]NOEL, Tmstee xowAxD w xrzavn~, KHNNETFIA. ROSS, Tivstee DANIEL, ~{'. SCxMmT, Trustee KEITH A 1~OUST, Trustee April 14, 2011 Ms. Jaclyn Bakst 978 Katie Circle Royersford, PA '19468 Re: William G. ~aksa Jr., Deceased S SN XXX-~X-3 796 Dear Ms. Baksa: Pension Fund MARTIN L. CULLEN, AssistantAdministrator 1055 Spring S1r,eet, yVy pA 19610 M~SAd~ess: P.O. Box 15223 Reading PA 19612-5223 ~'•~tralPATe~msters.com TOLL FREE IN PA:~1-H~343--0136 TOLL FREE IN USA:1-800-331-0420 FAX: 610-320-9239 We wish to acknowledge receipt of the death certificate for your father, William member. G. Baksa Jr., our The Trustees and 1Vlembers of the Staff of the Central Pennsylvania Teamsters wish to express out- deepest sympathy in your loss. pension Fund all .Please be advised jthat you are entitled to receive a lum sum $1,840.00, which represents the 12 years of Pension Fundprri death benefit in the amount of the Defined Benefit Plan. You may choose to receive the death benefitBanlcsa accrued under payment, (2) rollover to an Inherited IRA, or (3) combination of a lum a (1) lump sum rollover to an Inht~rited IRA. Under the Federal Income Tax Law, the Fu um payment and withhold and pay td the IRS twenty percent (20%) of the amo nd is required to unless you completie and return the enclosed Defined Benefit tPlanhIRS Code death benefit, Election Form requesting no Federal Income Tax withholdin . Section 402(f) completed Election (Form (page DB21A) indicatin g Once the Fund receives a process your benefitjcheck, g Yom' distribution preference, the Fund will Also, be advised ',that you are entitled to receive a lum the Retirement Income Plan 1987. P sum check representing March 31, 2011, was'',$300,629.19. This amoun bdoes notanclude net aI onthly valuation date, valuation date. Und 'r Feder 1 Income Tax law, the Fund is required~o w`t~oosses after the last IRS twenty percent ( 0%) o the amount of the lump sum distribution, unless o and pay to the y u complete and return the enclosed etirem nt Income Plan 1987 IRS Code Section 402( Electio requesting no Federa I Incom Tax withholding or a different form of payment) Once th Form e Fund ~~ 31n ~ wo re;ceives a co pleted Election Form (Page RIP21A) indicating your distribution preference t Fund will pro~ess your check with the ne he xt monthly distribution. We trust this information is satisfactory; however, if you should have an ue ' regard, please eel free to contact the Pension Fund office. Y q shops in this Very truly yours, CENTRAL PE SYLVANIA TEAMSTERS ENSIGN FUND `~1~ ~ I!,, ~-~ Michelle L. Ho ck Pension Benefit Manager MLH/jag Enclosure CENTRAL PENNSYLVANIA.TEAIVISTERS PENSION FUND RETIItEMENT INCOME PLAN 1987 IRS CODE SECTION 402(f) ELECTION FORM (NON-SPOUSE BENEFICIARY} Name of Decease SS # of Deceased A. Beneficiary L ~,:~ Name: ^ Date of • ss#: Participant: William G. Baksa Jr. 171-38-3796 _.. _ _,,, I _ _ ._ ~~ ~1R~ a~~`~~~-35C~z~ B. Please choose ~ne (1) of the following options: ~ 1. I elect receive my distribution in cash, I understand that my payments will be sub' 20% m~ndatory Federal income Ject to a tax withholding. 2. I elect t have the Fund directly rollover my distribution t be iden fled explicitly as an IRA with respect to a decedent 'The namese aeCe~ and the ben ciary must be included in its title. For example, Mary Smith as beneficiary of John Jones, d ceased.} ~ 3. I elect t receive $ of my distribution and have the Fund directly rollover the re ' ' amount of my distribution to an Inherited IRA. explicitl as an IRA with respect to a decedent. The names of the~decedentand thefied benefici must be included in its title. For example, Mary Smith as beneficiary of John Tones, d ceased} __. _ NOTE: a amount you rollover to the Inherited IRA must be at least $500. And, the " _., amount yp~u receive will be sub'ect o J to a 20 /o mandatory Federal income tax withholding. I understand that: ~ I can request a ' ect rollover of my distribution o-~X if my distribution is greater than $200. ~ I must attach a ' ect rollover acceptance form identifying the 1RA as an Inherited IRA. ~. ~ ~ . . eficiary Signs e ate revised 11/2010 ' Page R.Il' 21A CENTRAL PENNSYLVANIA TEAMSTERS PENSION FUND DEFINED BENEI~T PLAN IRS CODE SECTION 442(fj ELECTION FORM (NON-SPOUSE BENEFICIARY) Name ofDecea~ed Participant: William G. Baksa Jr. SS # ofDeceas~d participant. 171-3g-3796 A. Beneficiary Informai;~n _ _ ~ Name: ~A t^ L.y N ~ `~ n ~S ~ Date of B firth: °I ~ (p ~ ~ ~ a Ss#: D (o- .,~' SOCK B. Please choos~ one (1) of the followin o g phons: 0~ 1 • I elect ~ o receive m a ~0% ~n Y distribution in cash. I understand that m andatory Federal income tax withholding. Y payments will be subject to 2. I elect ~o have the Fund directly rollover my distribution to an Inherited IRA. must b identified explicitl as an (The IRA deCed t and the Y IRA with respect to a decedent. The names of the benefic~ benefici ary must be included in its title. For example, Mary Smith as ary of John Jones, deceased,) 0 ~• I elect t receive $ ~_ of mY distribution and have the Fun re ' g amount of my distribution to an d directly rollover the explicitl as an IRA with respect to a decediennhten~e names of th de m~ be identified benefici must be included in its title. For exam le M edent and the Jones, d ceased) P ~ ary Smith as beneficiary of John __ _ NOTE' ~ e amount you rollover to the amount y'ou receive will be Inhented IRA, must be at least 5 _ subject to a 20% mandatory Federal. income tax0~ And, the I understand that: ! 'Withholding. • I can request a ' ect rollover ofmy distribution only. if my distribution is • I must attach a d' ect rollover acre Lance form idea ' greater than $200. P ~3'ing the 1RA as an Inherited IRA. I have received and r lad the attached S ecial p Tax Notlce Regarding Plan Payments. 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