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HomeMy WebLinkAbout01-23-13 (2)J 1505610143 REV-1500 Exi°'-'°' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes °EP"'TMENiOFREVENOE Po Box.zaosot INHERITANCE TAX RETURN 21 ~ ~ I ~~ Harrisburg, PA 17128-0501 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 168 36 6416 08 14 2012 12 30 1907 Decedent's Last Name Suffix Decedent's First Name MI KIEFFER MARY D (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ ^ Supplemental Return 3. Remainder Return (date of death 2 1. Original Return . prior to 12-13-82) 4. Limited Estate ~ qa, Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death after 12-12-82) s Decedent Died Testate f Will ~ ~- AelacheCopy Hof rrust)a Living Trust ~ 8. Total Number of Safe Deposit Boxes ) (Attach Copy o 9. Litigation Proceeds Received ~ 10. Spousal Povert Creditl(date of death t t,Election to tax under Sec. 9113(A) between 72-31 ~Jt and -t-95) ~ (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD 8E DIRECTED TO: Name Daytime Telephone Number JAMES D BOGAR (717) 737 8761 First line of address ONE WEST MAIN STREET Second line of address City or Post Office SHIREMANSTOWN State ZIP Code PA 17011 RESTER OF WI~CS USE ONLY CI7 ~"7 ~_ r~) <~a rrt _ _ _ . ~~ ..~~:. lJ .~ ... ,. , '. ..~' .. ,, DATE ffLED .~.V ...; '.; ~ .) ~~ -~q Correspondent's a-mail address: jbogar@bOgarlaw.COm Under penalties of perjury, I declare that.l have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Beth Snoke ~ ~ ~5 ADDRESS Flamin THAN ICS James D. Bogor DATE One West Main Street, Shiremanstown, PA 17011 Side 1 1505610143 1505610143 1505610243 REV-1500 EX Decedent's Social Security Number oecetlern•s Name. Kleff@~~ Mary D. 168 36 6416 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 8 Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 654.50 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 53 , 557 .24 7. Inter-Vivos Transfers & Miscellaneous i on; Probate Property u Separate Billing Requested............ 7. 077.80 31 (Schedule G) , g. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 85 , 289.54 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 15 , 983.2 4 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 1$ , 983 .24 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 69 , 306.30 13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14. 6 9 , 3 0 6. 3 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 0 , 0 0 (a)(1.2) X .00 16. Amount of Line 14 taxable 6 9 , 3 0 6. 3 0 16. 3 ,118.7 8 at lineal rate X .045 17. Amount of Line 14 taxable 0 . 0 0 17. 0 • 0 0 at sibling rate X .12 18. Amount of Line 14 taxable 0 . 0 0 18. 0 . 0 0 at collateral rate X .15 19 3 , 118. '~ 8 19. Tax Due ................................................................................................................. . . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 DECEDENT'S NAME Kieffer, Mary D. STREET ADDRESS 100 Mt. Allen Drive CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 3,118.78 2. Credits/Payments A. Prior Payments 2,947.84 B. Discount 155.15 Total Credits (A + B) (2) 3,102.99 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 15.79 Make Check Payable, to REGISTER OF WILLS, AGENT , , ,. ~~ , .,,, ~~, ~: r ,..;. 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 :............................................................................... ^ ^x b. retain the right to designate who shall use the property transferred or its income :..........................__.... ^ c. retain a reversionary interest; or ............................................................................................................... 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 "in trust for" or payable upon death bank account or security 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? .................................................................................................................. ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. k ,.. ,. 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 t0 or for the use Of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 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 fo 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. §9716 (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)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+(6-98) SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE iAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER _ _ Kieffer, Mar~r D. 21 _ _ Include the proceeds of litigation and the date the proceetls were received by the estate. All property Jointlyowned with the right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-7508 EX+ )6-98) :` SCI~IEDULE F GOMMONwEALTHOFRENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kieffer, Mary D. 21 Iran asset was made joint within one year of the deextlent's data of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Mary Beth Snoke B. Diane K. Aiken C. 115 Flamingo Drive Daughter Mechanicsburg, PA 17055 106 Winwood Drive Daughter Moon Township, PA 15108 JOINTLY OWNED PROPERTY: ITEM NUMBER FOR JOINT TENANT MADE JOINT DESCRIPTION OF PROPERTY INUMBDR ORR SEMILARNDENTIFYWG INUM ERAATTACH DEED OR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH DECEDENT'S INTEREST 1 A 06/06/1966 Citizen's Bank -Checking Account No. 5.432.88 50.000°/a 2,716.44 6100681882. Principal balance at date of death $5,432.83; accrued interest $0.05. 2 A 06/11/2010 Citizen's Bank -Checking Account No. 6,288.68 50.000% 3,144.34 6230557316. Principal balance at date of death $6,288.56; accrued interest $0.12. 3 A 1 0108/1 9 96 Federated Fund for US Govt Secs A - Accoun 26,967.02 50.000% 13,483.51 No. 2506741. Date of death balance $26,967.02. 4 A 07/18/2001 Morgan Stanley Smith Barney -Account No. 68,425.90 50.000% 34,212.95 410-016456-003. Date of death balance $68,425.90. TOTAL (Also enter on Line 6, Recapitulation) I 53,557.24 (If more space is neetled, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule F (Rev. 6-98) %. October 26, 2012 James D Bogar Attorney At Law One West Main Street Shiremanstown PA 17011 Estate of Mary D Kieffer Date of Death: Aug 14, 2012 SSN: 168-36-6416 Dear Sir/Nladam: One Citizens Drive ROP112 Riverside, RI 02915 In accordance with your request, the attached information sheets have been provided in the above decedent's name as of his/her date of death. For Installment Loans or Line of Credit accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 877-579-2667 option 2. Sincerely, ~ d Kristen B. Correia Decedent Account Processing REF#:567162 ~~~r~. Account Number 6100681882 Account Title Mary DKieffer/Mary E Snoke Date Opened 6/6/1966 Account T e Checking Principal Balance as of DOD $5432.83 Interest from Last Posting to DOD $ .05 Account Balance as of DOD $5432.88 YTD Interest to DOD $2.26 __ _ _ _ FUSGX Historical Prices ~ FEDERATED FD FOR US GOVERNMENT Stock -Yahoo! ... Page 1 of I r t. .. _ r. .. ,gip, ~.. 6': A..' '. K} f3VrY(n.14J~~ _. ~ ,.. ... Search Weh h6Mf°_ ~ IW E:EI%Nd ~ r~Ic'v'~S PER53hAL fiNANCE FaY PCR GL10E ~ E s 15,4`ES i r .. e Get Quotes Finance Search ~" ' " ` ' ' ~ C;r ~ nl " ~~ ~~ ~` ~'~ ` `''" Dow 10.25 % Nasdaq 18.84° Amcritrade FUND FICKS~ _,. , .,,a ., Frdefity!. , n in r°'rrxcr. s ,.. cc Federated Fund for US Govt Secs A (FUSGX) 7.85 x0.01(0.13%) oets Add to Portfolio Historical Prices Set Date Range p Daily Start Date: Aug ~ 14 2012. Eg.Jan1,2010 ;. Weekly End Date: Aug ~ 14 2012 .. Monthly Dividends Only Get Prices. Prices Date Open Aug 14, 2012 7.83 High Low Close 7.83 7.83 7.83 ' Close price adjustetl for tlividends and splits. ''~' Download to Spreadsheet Currency in USD. -- GetHistorical Prices for: '~~ GO li First ~ Previous ~ fJext ~ Last __ Volume Adj Close' 0 7.81 Frs[ ~ Precious ~ Next ~ Lasi ti4E 1itII1Eq L ''GIVE. AF)VOCATE.'. ', VOLUNTEER. LIVE UNITED„ Visit tivellnitetl.Org to learn how 3,444.0630 Shares X 7.83 Value Per Share 26,967.0132 Date of Death Value ~ t r i~~cfl ~' CA..e,e3 arc reabtirne is N.+3 aA i. N'-oL. ann NYSE th' S°6 or ~ u~~ l ~ncs ~ ~t .. ..~oha ue.. A ~ .. ~ .. ~.-.~Ev _ f,r inf;, .,r., ;,u r. ~. -- ~ ~ '~o'. ..c 1, ., admq >u „ <amco. N_Itn_ ~r^a r~cr. n,t.,~c .,.. i, o . ~~J~.,. i., -. ble for an, 'clan. _~ . ,gin , Imo. ~ -c-. ur uc pc o ro+ v i .., c-,_ iak< rmor ce n ,coon e_^cained ~ o aif3a ...e r,r5~... ... ^,IL'r .~' Ycc-av'frta ~ ~.v.~.R ~,,.e,_, .~ih~e~,~ pile S ~, ~Utt .. ,,.,.~_ ti .i ~ i~iar, ,., Chu .,n R- _ nn .,....L 3ui u, 5_ ,.nir ..r ~r uf( w -._ o~ 1 ,. ~. ...., r ,n,.e ~ „., .,,_...,.~i, ,... .. a^, a.~u d•, t ^~:.v-.. ~i c~...~u>.. .. .. ;rs.i, i, ..~. .~. _. .i_,c'i_e ri _. .. ... i~ u , i r -. . ~ i , _.~~ i ~ _ 1m ,t. I ~, > oa cicE h, h1~ r ~ -.r. lac. http: //finance. yahoo. com/q/hp? s=FUSGX& a=07 &b=14&c=2012&d=07&e=14&2012&... 10/8/2012 ~~~~~~~~~ PO Box 8600 ~n:1 ra ~ r~~a~.r ~ ~_~ ~~k+.i~ ~r+~. <v Boston MA Q2266-3600 d ur s~aceEsoa~. age ~ ~ ts° " ~,~~a iTunes AT 02 029609 98278H101 D"3DGT MARY ~ KIEFFER MARY E SNOKE JT TEN 222 MESSIAH CIR RM 406 MECHANICSBURG PA 17055-8619 I~IIr41111~11~lllll~~lllllllln~ll~~ll~~lllrllllll~lllrllml Quarterly Statement For the period ending June 30, 2012 Page 1 of 6 RET 279497 J 0 To assist in managing the process by which the funds' Board considers the funds' advisory fees, the funds" Senior Officer prepares an analysis. This analysis is summarized in the °Evaluation and Approval of Advisory CorftracY for each fund that is available at Federatedlnvestors.com. Portfo io Overview TOTAL MARKET VALUE as of 06/30/2012 $26,898.13" Questions about your statement? Review"How to Read Your Investor News Statement" on Federatedlnvestors.coMCustomerService Diversification--a sensible long-term investmefrt strategy! No single market sector performs well year-in and year-out. A diversified portfolio of stocks, bonds, and cash may reduce risk and offer potential rewards. Federated offers an extensive selection of funds to suityour investment needs. New addition to the family? Give the perfect gift! Establish a Coverdell Education Savings Account. It is never too early to start saving far a college education. Important note: Please carefully review your statement and promptly report any discrepancies in writing, within 30 days. This statement is not for tax purposes, but it should be retained for your permanent records. O Don't Become a 'Lost Shareholder' Most states require Federated to turn over assets of 'lost shareholders' after a certain period of time. Be sure to notify us of changes to your address and email. Account Information Fund number 309 _-_ Account number 2506741 ("'~ For account questions, balances, yields, etc. ® call 1-800-245-4770. For automated phone access call anytime t-800-245-2999. Access to fund information is available at Federatedlnvestors.com. Federated Securities Carp., Distributor Federated is a registered mark of Federated Investors, Inc. 2008 ©Federatedlnvestors,lnc. 029609 1 /3 P e a~ Portfolio erformance 1.48k 0.66 Federated PD Box 8600 ® Boston MA 02266-8600 r.ne'I +ks I" 9 cr19e~NV Ana ~p F'carYc;ast~ c~~ Fa,eebool< €?a'e'xv4'te~ am iTunes (luarterly Statement Forthe period ending June 30, 2012 Page 2 of 6 Portfolio Summary (Please note that percentages are rounded.) Ending Percent Inveshnerrtcategory Fund marketvalua ofcurrerR Fnnd name number D6130/AI72 assets Government Federated Fund U.S. Gov Securities A 309 526,898.13 100.00% Income SummarylYear-to-date) -;t0 This section summarizes the ending marketvalue and percentage of current assets by investment type. Portfolios with multiple accounts in the same fund display combined totals. Fund name Taxable Tax-exempt Short-term Long-term Fnndnumber Accourrtnumber dividends dividends gaiaa gains Total Federated Fund U.S. Gov Securities A 309 2506741 $431.55 $0.00 $0.00 $D.00 $431.55 Account Detail Visit Federatetllnvestors comfor fund performance and currentyields. _ Any Cost Basis detail provided is for informational purposes only. Your cost basis tax information for year-end reporting will be provided on your year-end tax forms. Information may be obtained about the Securities Investor Protection Corporation (SIPCI, including the SIPC brochure, by contacting them at 202-371-8300 or visiting their web site at www.sipc.org. ~odur•otnd Fund I I S Gnv Seruritit?c A MARY D KIEFFER Fund number 309 Account number 2506741 MARYESNOKEJTTEN NASDAItsymbol FUSGX AecomRopened 10/08/1986 Dividends Cash Capital gains Cash CoctBasis Election Method Average Cost Transaction detail Con6nn Trade date date Transaction dascriplion Dollar amount Share price Shares this transactloa Total shares owned Previous balarice as of 04/01/2012 $26,932.57 $7.82 3,444.0630 05/01 04/30 Income Div 0.0224 Cash $77.15 $0.00 0.0000 3,444.0630 06/01 05/31 Income Diu 0.0204 Cash $70.26 $0.00 0.0000 3,444.0630 07102 06/29 Income Div 0.02 Cash $68.88 $0.00 0.0000 3,444.0630 Chan a in investment value -~4•'~ Ending balance as of 06/30/2012 526,898.13 $7.81 3,444.D630 450'? Vorth Prom Scari Suite 201 Harrisburg, PA I?110 rc 71? 255 6(i66 tax 71? 255 6651 Lull fi-ce 800 6?6 06?3 MorganStanley SmithBarney October 11, 2012 James ll. 13ogar Attorney At Law One West Main Street Shiremanstown, PA 17011 RF,: F,sta±e of Mary D. Kieffer Date of Death: August 14, 2012 SSN: 168-36-6416 Dear Atty. Bogar: Please be advised that Mary D. Kieffer held one brokerage account with Morgan Stanley (acct #410-016456-003) at the time of her death. The account was ajointly-owned brokerage account titled Mary Kieffer & Mary E. Snoke J"f TEN (joint tenants with rights of survivorship) with no change in ownership or registration within the past year. The account was opened on July 18, 2001. The following information represents the date of death values for all securities held in acct #410-016456 on her date of death (August 14, 2012): Share Security Name/ Symbol No. of Shares price Total Value on 08/IA/12 INVBSCO VK EQUITY AND INCOME CLASS C (ACF,RX) 7,705.619 shs $8.88 $68,425.90 Please feel free to contact our office at ?? 7-255-6690 with any questions. Sincez~ly, , ,.~ - ~~~ G Emily L. Biden Reg'd Client Service Associate The Bcshore/Owen/'T'homas Group Investments and services offered through Morgan Stanley Smith Barney LLC, and accounu carried by Morgan Stanley & Co. Incorporated; members SIPC. Marian Stanley Smld~ Name}' 1 JL. Member SIPC Rev-1510 EX+ (6-98) SCHEDULE G INTER-VIVOS TRANSFERS 8r, MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kieffer. Marv D. _ 21 This schedule must be completetl and filetl if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THELDATE OF TRANSFERSATTACiiTA CIOPYEOF TIHE DEED FOOR REAL ESTATDE. DATE OF DEATH VALUE OF ASSET ~ OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Symetra -Annuity No. AN0880571. Date of death 13,276.95 13,276.95 value $13,276.95. The Decedent's two (2) daughters are the payable on death beneficiaries of this account. 2 Western National Life Insurance Company -Annuity 17,800.85 17,800.85 No. BA033373. Date of death balance $17,800.85. The Decendent's two (2) daughters are the payable on death beneficiaries of this account. TOTAL (Also enter on Line 7, Recapitulation) ~ 31,077.80 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Forrn PA-1500 Schedule G (Rev. 6-98) SYMETRA ft El IRe MCNT 9ENEFITS LIFE December 20, 2012 James D. Bogar Attorney at Law One West Main Street Shiremanstown PA 17011 Symetra Life Insurance Compony Retirement Division 777 108th Avenue NE, Suite 1'Z00 Bellevue, WA 98004-51 35 Mailing Address: PO Box 305156 Nashville, TN 37230-5156 Phonel-800-796-3872 TTY/TDD 1-800-833-6388 www.symetra.com RE: Symetra Life Insurance Company Annuity AN0880571 for Mary D. Kieffer Dear Mr. Bogar: Per your request, the date of death value on the above mentioned annuity is as follows: Date of Death Value 08/14/2012 $13,276.95 Cost Basis $ 4,900.00 Owner: Mary D. Kieffer Original Policy Date: December 18, 1991 We appreciate the opportunity to serve our customers. Our service center is located in Bellevue, Washington. If you have any questions or would like help finding an agent or advisor in your area, please contact us at 1-800-SYMETRA or 1-800-796-3872. Select option 2 for Retirement Services, followed by option 3 for the Individual Retirement Plans unit. To reach me directly, please press 9 followed by my extension 65712. Our customer service representatives are available from 6:00 a.m. to 4:30 p.m. Pacific Time, Monday through Friday. Sincerely, ~C~ li~`L~rj",~~n~ Jul Manning Claims Examiner Retirement Services Symetra Life Insurance Company WESTERN ~ NATIONAL Life I n s u r a n c e C o m p a n y P.o soXs~i Amarillo,'CX 79105-0871 1.800-424-4990 December 19, 2012 JAMES D BOGAR ONE WEST MAIN ST SHIREMANSTOWN PA 17011 Re: Contract #: BA033373 Deceased: Mary Kieffer Dear Mr Bogar: Thank you for your recent inquiry regarding the referenced annuity contract. It is our pleasure to be of service to you. The value of the contract as of 08/14/2012 was $17,800.85. Should you have any questions or require further assistance, please contact our Client Care Center at 800-424-4990. Sincerely, ~ ~~~ Brandon Pollreisz Annuity Claims Dept. REV-1151 EX+(10-06) E y COMMNH RITANCE TAX RETURN ANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER Kieffer, Mary D. 21 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N M R A. FUNERAL EXPENSES: See continuation schedule(s) attached B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) 9,867.05 Street Address City State Zip Year(sl Commission paid 2. Attorney's Fees Bogar & Hipp Law Offices 3,150.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 2,966.19 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 15,983.24 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Kieffer, Mary D. 21 ITEM NUMBER DESCRIPTION AMOUNT 1 Funeral ExRenses Garden Bouquet -flowers for memorial service 97.52 2 Johnson Memorial -fee to engrave memorial 130.00 3 Malpezzi Funeral Home -funeral bill 9,049.37 4 Marilyn Ebersole -organist for memorial service 75.00 5 Messiah Village -funeral luncheon 515.16 H-A 9,867.05 6 Other Administrative Costs Alert Pharmacy 39.07 7 Alert Pharmacy 89.34 8 Messiah Community Support Services -health care 537.78 9 Messiah Lifeways -room fee 2,300.00 H-B7 2,966.19 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) REV-1513 EX+i11-08) ~~~ ~~ pp SCHEDULE J COMMNHERITANCET~ RETURN ANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Kieffer, Ma D. 27 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions, and transfers under Sec. 9116(alf 1.211 Diane K. Aiken Daughter One-half of rest, 106 Winwood Drive residue and Moon Township, PA 15108 remainder Mary Beth Snoke Daughter One-half of rest, 115 Flamingo Drive residue and Mechanicsburg, PA 17055 remainder Total Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet, as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET[ Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) LAS'P WILL AND TESTAMENT OF MARY D. KIEFFER I, Mary D. Kieffer, of 305 North 31st Street, Harrisburg, Dauphin County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils made by me at any prior tiine. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. If the assets not specifically devised or bequeathed are not adequate for the payment of all such taxes, then the recipients of the property specifically devised and bequeathed shall each pay a pro rata portion of any such taxes based upon the valuation of the property received by each such recipient as finally determined for Federal Estate Tax purposes, or if no such determination is made, then for applicable State Inheritance Tax purposes. ITEM II: I hereby give, devise and bequeath all of my estate, whether real, personal or mixed, of whatsoever nature or kind and wherever located, in equal shares, to my two daughters, Mary E. Snoke and Diane K. Aiken. If either of my daughters fail to survive me, her share shall go to her sur<!ivinrt issue, per stirpes, and if she leaves no issue, then her share shall go to my other surviving daughter. PAGE 1 OF 2 PAGES ITEM III: Any person who shall have died at the same time as Testatrix or in a common disaster with her, or under such circumstances that it is difficult or impossible to deter- mine who died first, or who shall have died less than thirty (30) days after the death of Testatrix, shall be deemed to have pre- deceased her. ITEM IV: I hereby nominate, constitute and appoint my daughter, Mary E. Snoke, to be Executrix of this my Last Will and Testament. In the event of her death, disqualification, resigna- tion or refusal to act, I nominate, constitute and appoint my daughter, Diane K. Aiken, to be my Executrix. ITEM V: I hereby direct that my personal representative shall not be required to give bond for the faithful performance of her duties in this or in any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament, consisting of this and the preceding page this ~~, day of l~"~~~.-~ ~_~" 1984. ;'jJ ti t~ `'" ,d r%"1~ ~ (~c.:~'~ ( SEAL) Mar's D. Kieffer We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence and in the presence of each other, have hereunto set our hands and PAGE 2 OF 2 PAGES seals the day and year above written, and we certify that at the time of the execution thereof, the said Testatrix was of sound and disposing mind and memory. - `1 G ~~~. -~- ~,~,-~f ~`, /"`~.~i-=--`, (SEAL Residin at ~. {} v- 7_~ ~. ,~ - ~ ; ) g ~ ~~ ~ ~ c- ~ l ~ i c 2r' ~~ ~_ r i !~ ~ ~ -ai,~., ~--r~~-~-~_. (SEAL) Residing at - _r-~, i< (SEAL) Residing at ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN I, Mary D. Kieffer, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by Mary D. Kieffer, the Testatrix, this 1%~ day of,-,,_ *„_, i 1984. ' Notary Public ' PHiliiC,A Vl FEI; FER, 1'vo+.;:?7 P::.,: i,: ( SEAL ~ Har(Sb'~rg, L'o;p hin Cu., Fe. My Curnmissioa Expires June c5, tDZ.~ AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUP~IIN f ~ ~. 4y and the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Wil] as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by .. -. ( , ~; ~ _ ~~ 1, ,) ~ and Witness this r_l day of ~+-~.-s -- - 1 1984. '~ C°', - ,; Witness Witness ;9itn~ys i' - ~ ~ 1` ~~ ; _~ 1. Notary Public j (SEAL) Loy Commission Expires: PAT21C!.4 4 !'LFlEp. ?1ct,:ry public Narn~6urg. Da;; p;~in Co., P~, ~7 Comrnis;iun Expires June 29, 1395