HomeMy WebLinkAbout05-20-13 1505610105
REV-1500 EX(oz-v)(H)
OFFICIAL USE ONLY
Department of Revenue Pennsylvania
Bureau County Code Year File Number
Bureau Individual.Taxes INHERITANCE TAX RETURN
PO BOX 280601 (----------
__-a
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
02/16/2012 ( 106/20/1923
Decedents Last Name Suffix Decedents First Name MI
_ ,......_�� _...—.___. __,...__..._..__._ .__.___.._�..—...,,..,
Kauffman Gerald D
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
:
- --- --------
Spouse's Social Security Number
-- ---"------ - -i THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
m 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82) ,
COD 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Nathan C Wolf Esquire (717)241-4436
_.- _ _ ------ _-_.._ _--------------_ _.__ ------------
REGI,%3ER OF WILLS xrx ONLY,
C M
First Line of Address
-_......_..._.._
Wolf&Wolf y r- ry n 1
__.._,..._...__.
---------------- _ r- -. m
_-___ v o c
Second Line of Address _ vi ,
10 West High Street
C
- �
City or Post Office State ZIP Code CD 'DATE FILED-
Carlisle I PA j :17013 c o Cf> °
-----------—------_— —i _ _ ?s_ ry _rI
Correspondent's e-mail address: nathancwolf @embargmail.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG RE OF PERS SP IB FOR FILING RETURN DATE
24 Jac is
ADDRESS
364 Beverly Road, Camp Hill, PA 17011
SIGNATURE ER OTHER THAN REPRESENTATIVE ATE
ADDRESS
10 W Street, Carlisle, PA 17013-2922
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
1505610205
REV-1500 EX(FI)
RECAPITULATION
(.______....._._._._______ ___..__......I
1. Real Estate(Schedule A). . . .. . .. ..... .. . . . . .. ...... . . .... . . . ..... . .. . 1. j
2. Stocks and Bonds(Schedule B) .... . . . .... .... .. . . . ..... . .. .... .. . .... 2. 8,616.39
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .. . . 3 ; �II3�" ----__
4. Mortgages and Notes Receivable(Schedule D). . .... ... . .. .. . .. ..... . . . . . 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). ...... 5. 141,776.20
6. Jointly Owned Property(Schedule F) O Separate Billing Requested . .. . .. . 6. 131.66
,._�. .._....._...,._�.„_._....._,. i
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested... . . . .. 7. i 37,536.97 I
8. Total Gross Assets(total Lines 1 through 7)... .. . . . ....... . ..... . . . ..... 8. 188,061.22 1
9. Funeral Expenses and Administrative Costs(Schedule H)... . . . .... . . . 9. 20,075.24
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)...... .... .. . . . 10. 539.86
11. Total Deductions(total Lines 9 and 10). .. . . . .. ...... .. . . . .. ... ...... .. . 11. 20,615.10
12. Net Value of Estate(Line 8 minus Line 11) .... .. . .. . . ... . .. . ..... . . ... .. 12. _ 167,446.12
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to lax has not been made(Schedule J) ... . ... ..... 11 I
14. Net Value Subject to Tax(Line 12 minus Line 13) .. . . . .. . .. .. . . ... . . . . . . 14. 167,446.12
TAX CALCULATION•SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 ........... ..__.. ............ ..... i ...... __.. ...__.. .........._
(a)(1.2)X.0. _. 15.
16. Amount of Line 14 taxable
at lineal rate X.0 45 167,446.12 16.I 7,535.08
17. Amount of Line 14 taxable
at sibling rate X.12 17.
.......�..._.,..s____.."... ..._.....�.
18. Amount of Line 14 taxable
at collateral rate X.15 1 g,
19. TAX DUE ... . ...... .. . .... .. . . . . ...... .. .. 19 7,535.08.1
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C@D
Side 2
L 1505610205 1505610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Gerald D. Kauffman
STREETADDRESS
364 Beverly Road
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 7,535.08
2. Credits/Payments
A.Prior Payments 8,000.00
B.Discount 376.75_
3. Interest Total Credits(A+B) (2) 8,376.75
4. If line 2 is greater than Line i +Line 3,enter the difference. This is the OVERPAYMENT. (3)
Fill in oval on Page 2,Line 20 to request a refund. (4) 841.67
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
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: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑ E
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ 0
c. retain a reversionary interest.............................................................................................................................. ❑ E
d, receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ 0
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 0
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.
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 use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1) (i)].
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(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-n503 EX+(8-v.) .
10 pennsylvania
SCHEDULE B
DEVARTMEMOFpEVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Gerald D. Kauffman 21-12-0244
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION - OF DEATH
1' Prudential Financial Inc(102 Shares @$60.92/Share)
6,213.84
2 Banco Santander(95 Shares @25.29/Share) 2,402.55
TOTAL(Also enter on Line 2, Recapitulation) $ �LL8,616.39 ,
If more space is needed,insert additional sheets of the same size
REV-isoe EX+(o&u) ,
[ J pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Gerald D. Kauffman 21-12-0244
Include the proceeds of litigation and the date the proceeds were received by the estate. -
AII property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM I I VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. MA T Bank Account No 2675020875 — ——— - 6,010.86
2 Wells Fargo Checking Account Ending in 1001 2,897.77
3 Wells Fargo Savings Account Ending in 9163 32,960.14
4 Wells Fargo CD Certificate Account Ending in 5128 41,018.58
5 Wells Fargo CD Certificate Account Ending in 5134 30,763.93
i
i
6 Wells Fargo CD Certificate Account Ending in 5135 17,852.53
7 2011 IRS Income tax refund 587.00
8 Refund from Presbyterian Homes 6,716.18
9 Refund from Presbyterian Homes 2,427.18
10 Refund from Penn State Hershey Med 13.35
11 Refund from Stonebridge Life 4.78
12 Miscellaneous Personal Property 500.00
13 2012 IRS Income tax refund 23.90
I
- i
TOTAL(Also enter on Line 5, Recapitulation) $ 141,776.20
If more space is needed,use additional sheets of paper of the same size.
REV-i5og EX+(oT-lo)
Qpennsylvania SCHEDULE F
DEPARTMENT OF REVENUE
RJTrU JOINTLY-OWNED PROPERTY
INHERRANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Gerald D. Kauffman 21-12-0244
If an asset became 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 L. Sykes 364 Beverly Road Daughter
Camp Hill,PA 17011 -
B.
C.
JOINTLY OWNED PROPERTY: -
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
REM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT HUNT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. II VALUE OF ASSET INTEREST !`! DECEDENT'S INTEREST
07101108 j Wells Fargo Savings Account 263.31 50 131.66 77,,•
❑ I 1 (Date made joint is approximate-but known to be greater than one year I lrlL - i
❑ ii❑JJ ��J before death) f -
❑ ❑° ° ' ❑
❑ ❑ ❑ e € ❑ ❑°
� o� �❑ ❑ .
� ❑
❑ ❑
❑❑ .. � � ❑
TOTAL(Also enter on Une 6, Recapitulation) $ • 131.66 I
1
If more space is needed,use additional sheets of paper Of the same size.
REV4510 EX+(08.09)
U pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND + '
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Gerald D. Kauffman 21-12-0244
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 Is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECDS EXCLUSION TAXABLE
iNQTH E THE NAME of THE,A ATTACH AE,THEIRVTHE DES)FOR TO A ESTATE.AND
NUMBER THE DATE OF iNANSFER.ATTADIACWT of THE DFED FOa REAL ESTATE. VALUE OF ASSET INTEREST OF AEFU VALUE
I. Wells Fargo IRA Certificate of Deposit Account Ending in 6723 2,596,12 100 2,598.42
2 Wells Fargo IRA Certificate of Deposit Account Ending in 3500 i 1,503.20 100 1,50120
Wells Faro IRA Certificate of Deposit Account Endin in 6871
3 9 � g 8,285.37 100 8,285.37
4 Prudential Securities(See attached breakdown of holdings as of date of death 2515218 100 25,152.28
1
f
Each of the above accounts were IRAs and were distributed after death in 1l3
shares to decedent's surviving children listed on the schedule J
F7
i
-
TOTAL(Also enter on Line 7,Recapitulation) $ �( 37,536.97 ,
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Gerald D. Kauffman 21-12-0244
Decedent's debts must be reported on Schedule I.
REM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES ..... .yF,..
1' _...IHoffman Roth Funeral Home 1,573.64
I „
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 7,500.00
Name(s)of Personal Representative(s) Karen L. Sykes '
Street Address 364 Beverly Road
City Camp Hill State PA zip 17011
Year(s)Commission Paid: 2013
2. Attorney Fees:
9,250.00
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
'iCSfiny,gpyp„"
4. Probate Fees: 183.50
5. Accountant Fees: 300.0on,
6. Tax Return Preparer Fees: a
4
7 Cumberland Law Journal Legal Advertising 75.00 :1
a The Sentinel Legal Advertising I 168.30
. . ._.....,_,..._.______r.
�s Sovereign Bank-Estate Checks j g,gp
7 o Register of Wills Inheritance tax return N 15.00
1 !Reserve for outstanding expenses 1,000.00
TOTAL (Also enter on Line 9, Recapitulation) $ 20,075.24
If more space Is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-08)
-Y-AX- pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Gerald D. Kauffman . 21-12-0244
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unrelmbursed medical expenses.
REM VALUE AT DATE
NUMBER DESCRIPTION - OF DEATH
1 iMillenium Pharmacy 209.55
2 Darryl Guistwite,DO 240.79
3 Minnesota Life 89.52
I _
TOTAL(Also enter on Line 10, Recapitulation 539.86
If more space is needed,Insert additional sheets of the same size.
REV-1513 EX+(01-10) '
IDEPARTMENT OF REVENUE
ji Jpennsylvania SCHEDULE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Gerald D. Kauffman 21-12-0244
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) - OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
Y Y P ��
(—(1. Karen L.S kes 364 Beveri Road,Cam Hill,PA 17011 Daughter 33%
L 12 Frederic Kauffman,358 Strathmore Drive, Bryn Mawr,PA 19010 Son ` �r 337
DKristen A.Hall,823 Spruce Street,Roaring Spring,PA 16673 Daughter 1 33%
D _ �JJJJI
D I I A
D I� - F �......,..__
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:
D
Dra,or.�rnrw,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
D 1 .
D I
D I L
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. -
M1
LAST WILL AND TESTAMENT OF
GERALD D. KAUFFMAN
I, Gerald D. Kauffman, of the Borough of Carlisle,
Cumberland County, Pennsylvania, declare this to be my last Will
and Testament and revoke all Wills and Codicils previously made
by me.
ITEM I: I direct that my just debts, funeral expenses, and
the expenses of the administration of my estate, including. any
state, federal or other death taxes payable because of my death,
shall be paid from my residuary estate as soon as practicable
after my decease, as a part of the expense of the administration
of my estate.
ITEM II: I devise and bequeath all of my estate of every
nature and wherever situate unto my wife, Eleanor L. Kauffman,
provided she shall survive me by thirty (30) days.
ITEM III: Should my said wife, Eleanor L. Kauffman,
predecease me or die on or before the thirtieth day following my
death, I bequeath all of my jewelry and other personal effects,
household furniture and furnishings and other tangible property
of like nature (not including automobiles, cash or securities) in
equal shares unto my children (I have three children: Karen
Louise (Kauffman) Sykes, Frederic Hershey Kauffman and Kristen
_ ,_._ _
,.
s
. : ,.
. �. ,
Anne (Kauffman) Hall) who shall be living on the thirty-first day
following my death, to be divided among them as they shall agree.
ITEM IV: Should my said wife, Eleanor L. Kauffman,
predecease me or die on or before the thirtieth day following my
death, I devise and bequeath the rest, residue and remainder of
my estate of every nature and in equal shares unto my three
children, Karen Louise (Kauffman) Sykes, Frederic Hershey
Kauffman and Kristen Anne (Kauffman) Hall, provided, however,
that the share of any of my said children who predeceases me or
dies on or before the thirtieth day following my death shall be
distributed to his or her issue, per stirpes, living on the
thirty-first day following my death, and in default of such then
living issue, such share be added to the shares for my other then
living children and the issue, per stirpes, of my then deceased
children.
ITEM V: I appoint Farmers Trust Company, of Carlisle,
Pennsylvania, guardian of any property which passes, either under
this Will or otherwise, to a minor and with respect to which I am
authorized to appoint a guardian who have not otherwise
specifically done so. Provided that this appointment of a
guardian shall not supersede the right of any fiduciary in its
discretion to distribute a share where possible to the minor or
to another for the minor's benefit. Such guardian shall have the
power to use principal, as well as income, from time to time for
the minor's support, medical and health care, and education or to
make payment for these purposes, without further responsibility,
to the minor or to any person taking care of the minor.
ITEM VI: I appoint my wife, Eleanor L. Kauffman, Executrix
of this my last Will and Testament. Should my said wife fail to
qualify or cease to act as Executrix, I appoint my three
children, Karen K. Sykes, Frederic H. Kauffman and Kristen K.
Hall, Executors of this my last Will and Testament.
ITEM VI: I direct that my personal representative, as well
as their successors, shall not be required to give bond for the
faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal,
. l' e
this �day of August, 1995.
yo
Gerald D. Kauf an
The preceding instrument, consisting of this and two (2)
other typewritten pages, each identified by the signature of the
Testator, was on the date thereof, signed, published and declared
by Gerald D. Kauffman, the Testator therein named, as and for his
last Will, 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.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Gerald D. Kauffman, Dale F. Shughart, Jr. and Mary M.
Price, the Testator and the 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 purposes therein expressed, and that each
of the witnesses, in the presence and hearing of the Testator,
signed the Will as witness and that to the best of his/her
knowledge the Testator was at that time eighteen years of age or
older, of sound mind and under no nstraint or undue influence.
Testator
40'0
'Wi tin e)s
F✓uZe,
Witness
Subscribed, sworn to and acknowledged before me by
Gerald D. Kauffman, the Testator, and subscribed and sworn to
before me by Dale F. Shughart, Jr. , and Mary M. Price, witnesses,
this o2 V day of August, 1995.
Notary blic
NOTARIAL SEAL
BONNIE L. COYLE. NOTARY CUR.IC
MGIY COAIAII SIOON Y E xSPPIRRIEN
X?IRES OCTOuER R1L7. .
RFr'FjVFP FEB 191013
fomputershare
Computershare Investor Services
250 Royall Street
Canton Massachusetts 02021
www.computershare.com
NATHAN C WOLF
WOLF&WOLF
10 WEST HIGH STREET
CARLISLE PA 17013
February 13, 2013
Company: PRUDENTIAL FINANCIAL INC
Registration: GERALD KAUFFMAN
Holder Account Number: C0001973703
Document I.D.: 13044WF00912882
Our Reference: PRU/0002807848/15/
Dear Sir/Madam:
Thank you for contacting Computershare, Prudential's transfer agent. We appreciate the opportunity to be
of service to you.
Below is the account balance information you requested as of February 16 2012 for the above account.
Shares Held by Agent: 102
Shares Held in Certificate Form by Holder: 0
Total Shares: 102
Closing Price Per Share: $60.92
On February 13, 2013, all shares were transferred from account number C0001973703 in accordance with
your request. An account statement containing the information for the new account is being mailed directly
to the transferee.
Should you have other account related questions, please call us at 1-800-305-9404 between the hours of
8:30 AM and 6:00 PM Eastern US time, Monday through Friday. Please note that any available
representative can assist you. A telecommunications device for the hearing impaired(TTY/TDD)is also
available at 1-800-619-2837.
Sincerely,
04 , 5944-Ij
Service Representative
Enclosure: None
3
��
Banco Santander, S.A.
American Depositary Receipts 4o Santander
Account Information Dividend Summary Current YTD Totals
Account Number 7000427780 Gross Dividend $27.44 $42.27
Record Date 04112112 Gross Dividend Paid in Cash $27.44 $42.27
Payable Dale 05/09/12 Gross Dividend Reinvested $0.00 $0.00
Rate Per Share $0.2888800 Fed.Tax Withheld $0.00 $0.00
Record Date Shares 95.000 NRA Tax Withheld $0.00 $0.00
Foreign Tax Withheld $5.76 $8.87
ADR Fee $0.24 $0.48
Other Fee $0.00 $0.00
Depositary Service Charge $0.00 $0.00
Foreign Commission $0.00 $0.00
Net Dividend $21.44 $32.92
The attached check represents the cash proceeds due to you as a result of your Banco Santander scrip dividend election.
Retain for Tax Purposes
View your stock account online at: www.adr.com/shareholder /b�
Some features available online are:
• View your account balance and dividend information
• Change your address
• Enroll in the Global Invest Direct Program
• Sign up or change your bank account information for direct deposit of dividends
How to sign-up to use this site:
You may activate your account for online access at www.adr.com/shareholder. Under"I am a Current Shareholder," select the Sign Up
Now link, and enter the following:
1 Authentication ID* 2 Account Number: 7000427780
3 Select the Authenticate button 4 Follow the prompts to create your sign on information
` If you do not have your Authentication ID, you may select the"I do not have my Authentication ID" box. Your Authentication ID will be
mailed to your address on record.
You will need your Username, Password, and the answer to the Security Question each time you sign onto your account in the future.
Questions?Please call 888-810-7456 or 651-453-2128
5479 I I III III II III1IIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIII II IN Z13091C0415479�1�1�YjY�Y�y
i
Santander Holdings USA Depositary Shares Repstg 1/1000 CUMUI (NYSE:SOV-C) + []
24.73 t +0.01 +0.04%D
MORE ON SOV-C SANTANDER HOLDINGS USA DEPOSITARY SHARES REPSTG 111000 CUMUL
SUMMARY
Quote DATE HIGH LOW OPEN CLOSE VOLUME
Options 5/14/2012 24.72 247 247 2432 700
Historical Prices 5/7/2012 25 24.75 25 24.75 6,200
CHARTS 4/3012012 25.01 24.81 25 25 7,300
Inlereewe Chart 4127/2012 0.456 Ex-dividend
NEWS 4/23/2012 25.35 24.95 25.3 25 6.500
Headlines 4/16/2012 25.3 2498 25 253 2,800
KeyDevelopments --_....______..___._._.....__..____.__.___ ........,._.-_.._...._-.._.__._...._._...._.
4/9/2012 25.25 24.9 25.06 24.9 3,900
FUNDAMENTALS 4/2/2012 - 25.29 2506 214 2508 1,600
FinancialHighlights -_._.._.._.. .__ .____.. .___..._._..._..._..._..__._..____.....__._.__-__.._....__-._...
3/2612012 25.35 25.25 25.25 25.3 2,400
Profile .......-_..__...____.....------._._.
Key Ratios 3/19/2012 25.27 25.06 25.27 25.11 2,800
10-Year Summary 3/12/2012 26.2 25.07 26.2 25.35 5,700
Earnings 3/5/2012 25.4 25 25.09 25.25 4,200
SEC Filings 2/27/2012 25.91 25.23 25.91 25.25 4,000
RATINGS/ANALYSIS 2/20/2012 25.85 25.37 255 2572 24,900
StockScouter Report 2/13/2012 25.65 25.16 25.39 25.29 38.400
Analyst Ratings 2/6/2012 25.69 25.1 25.43 25.18 5,700
INSIDERACTION 1/30/2012 0.456 Ex-dividend
Insider Trades _._. . _..._ ........ ....-. ........... ..... _._
113012012 25.7 25.02 25.53 25.39 1,500
Ownership ...... ..... __. .....-..
1/23/2012 25.7 25 25.52 25.39 7,600
FINANCIALS .... _ ... . _..... -. ........ .........
1/16/2012 25.2 2495 252 25.1 4,200
Income Statement _.. _. .. _.. _... ....... .... _..
Balance Sheet 1/9/2012 24.82 24.8 24.81 24.8 800
Cash Flow 1/2/2012 25.35 24.5 25 24.79 1,300
12/26/2011 25 24.21 24.52 25 10,000
12/19/2011 25.5 24.04 24.04 25 8,600
12/12/2011 25.6 24.05 24.05 24.51 3,300
12/512011 25.45 23.84 25.45 24.05 2,800
11/28/2011 25.35 24.74 24.75 24.85 2,800
11/21/2011 24.75 24.42 24.42 24.47 4,000
............ .......... .. .. _.... ........... ............
11/14/2011 25.15 24.53 25.06 25.13 10,400
11/7/2011 25.5 24.84 25.16 25 3,600
10/31/2011 25.49 24.43 24.99 25.19 13,000
10/28/2011 0.456 Ex-dividend
10/2412011 25 23.98 23.98 24.5 780,500
10/17/2011 24.5 22.34 22.34 23.41 11,900
10110/2011 22.5 21.29 22.15 22.05 17,000
10/3/2011 23.01 18.24 22.85 21.75 25,000
9/2612011 24A 22.8 24A 22.81 15,600 h _
9/19/2011 24 4 23 45 24 4 24 1 11 700 _.
9/12/2011 24 5 23 98 24 45 24 25 4 700 C
. _ _ 96- �1
915/2011 24.52 24.3 24.3 24.52 700
8/29/2011 25.19 24.29 25.19 24.59 1,600
8/22/2011 24.99 24.41 24.8 24.85 14,100 .
8/8/2011 25.3 23.88 24.53 25.3 8,800
8/1/2011 25.03 24.85 25.02 24.85 15,000
DATE HIGH LOW OPEN CLOSE VOLUME
7/28/2011 0.456 Ex-dividend
7/25/2011 25.63 25.01 25.42 25.05 7,400
7/18/2011 25.48 25.02 25.46 25.35 5,100
7/11/2011 25.5 25.34 25.37 25.37 1,500
7/4/2011 25.44 25.25 25.3 25.44 1,600
6/27/2011 25.39 25.23 25.26 25.3 6,600
6/20/2011 25.4 25.16 25.16 25.4 900
6/13/2011 25.64 25.03 25.53 25.15 5,300
6/612011 25.7 25.37 2569 2545 1,700
513012011 25.29 25.17 25.17 25.29 500
5/23/2011 2515 25.08 2515 2519 4,500
5/16/2011 25.25 25.01 25.01 25.05 6,000 -
DATA PROVIDERS
Copyright D 2012 Microsoft.All rights reserved.
Quotes are real-time for NASDAQ,NYSE and AMEX.See delay times for other exchanges.
Fundamental company data and historical chart data provided by Thomson Reuters(click for restrictions).Real-time
quotes provided by BATS Exchange.Real-time index quotes and delayed quotes supplied by Interactive Data Real-
Time Services.Fund summary,fund performance and dividend data provided by Morningstar Inc.Analyst
recommendations data provided by Zacks Investment Research.StockScouter data provided by Verus Analvtics.IPO
data provided by Hoover's Inc.Index membership data provided by SIX Telekurs. _
Japanese stock price data provided by Nomura Research Institute Ltd.;quotes delayed 20 minutes.Canadian fund
data provided by CANNER Financial Exchanges Ltd.
Financial data in US dollars I Page generated 294 PM ET .
�' � � 1VI&TBanlc
ACCOUNT NO:; - :� ACCOUNT TYPE_ -:_ STATEMENT PERIQD " PAGE,'
2675020875 CLASSIC CHECKING JAN.04-FEB.03,2012 1 OF 2
00 0 04319H MM I17
9566
_ GERALD D KAUFFMAN
ELEANOR L KAUFFMAN
364 BEVERLY RD
CAMPHILL PA 17011
INTEREST EARNED FOR STATEMENT PERIOD 0.00 HIGH STREET-CARLISLE
ACCOUNT SUMMARY .
BEGINNING!::: ...::'i-i DEPOSITS .8 : .- r :i'. :I::i :ii i i... - i_i:OT HER'-: ;;i:. . - - !i':CURRENT'.': :i:' J TENDING -.
:.."BALANCE::::'. .:'iiiOTHER4DDITIONS- : ii :itHECKS PAID -:: :i' . : :ii'iSUBTRAtTIbNS": . - ;:INTEREST'PD' ii: :BALANCE --::i'.
N0. AMOUNT NO. AMOUNT N0. AMOUNT
8,745.88 5 4,602.68 1 11 71337.70 1 0 1 0.00 0.00 6,010.86
ACCOUNT ACTIVITY
DE`. POSITS INTEREST: :::CHECKS::Si?OTHER
DAILY:POSTING..
64TE &-0THER ADDITIONS` :SUBTRACTIONS
BALANCE'" . ::
01-04-12 BEGINNING BALANCE - 08,745.88
01-20-12 CHECK NUMBER 7901 7,337.70 1,408.18
01-31-12 PNC BANK ACH CREDIT 508.45 1,916.63
02-01-12 UMC BENEFIT BRD PENSION 2,403.55
02-01-12 MINNESOTA LIFE ANNUITY 89.52
02-01-12 UMC BENEFIT BAD PENSION 46.16 4,455.86
02-03-12 US TREASURY 303 XXSOC SEC 1,555.00 61010.86
ENDING BALANCE 06,010.86
;CHECKS PAIDSUMMARV "-
7901 01-20-12 7,337.70
DID YOU KNOW THAT YOU CAN SAVE TIME BY USING MST NEB OR MOBILE BILL PAY?
IMAGINE ELIMINATING THE STRESS OF HAVING TO WRITE A CHECK, OR WAITING IN LINE TO
BUY STAMPS. WITH MST WEB AND MOBILE BILL PAY, YOU CAN SKIP THE HASSLE AND MAKE
PAYMENTS QUICKLY AND EASILY. LEARN MORE AT MTB.COM/BILLPAY. MEMBER FDIC.
by:'-
• A 6I0�
t l i I
u C n a M
.N. N
G O
O W
G P
� N u n OD CI
M OR d M C
O O O M MN N
n d,a
o a
y I U u O O O O m P
U V O S O O O O iq M N
i�'O I fn N N N N h V) 43 to
us
u
i x u i
C
N 1� 0 N
•dV P P P T N N P n M
.S O 00 N h N O O rz
I V v N M N N 06 V M
1
1
fY2 f'Fj
c c c
> > >
LJ o 0
Yri Q i Q
v v v
w N m u v ca ca .y
[n O N U�Y d v d 'O •O 9
O o O
� � � " 3 � I v � d• v
o 0 0 0 0
o > o
n ''O O v 0 0 O O O O y O y O y
U Q rno a ti m vi rpi a —Wo a° Mo a°
.-r
cC '
c
y A n n A m n m m m
W r. a � .0 � e� o `� o � o o > > ❑ o
p C ti E n n Y N x y
® b D y G N
U 7 z 7 'd C v O •O C 'O 'O b b C V C 'o C
U P y
0 U �
$tOnebridge Life. Ins6tyOrice Company fy +�'' y? w< `yr •jc��+� :' 1PNOrpSn tn,ta`Benk• N.A.
't 2700
'.• y. r•- 'r W;Pl.a�n?o�{r +
Pk
Wy,
P1ano, �Texas 750757 `r
5.t0K,9.3r
T 6 ,,.;%i C' °
t 3 May O 1 i2012
Zy ,'r.r +
,
Pay FOUR AND 78/100 --- =------ -- --------- ---- -- -- --- s ' ------Ir
fir <�
NOT VALID-AFTER SI%MONTHS
i •` • -� ' b ?� F
t s ' . �a �I1�IJllpl �ll�iJ�I�IIn��nllllly�llh�Il�lll�l;fr��ll��'I'I' »� i.1 a p
To the order of GERALD D. KAUFFMAN' 4u
•:�, X364 BEVERLY RD eta+ . rh $4.78
:iCAMP HILL P.A 17011 '{ T .- sm�e' Life ' R
L Yr• . I .. 12�. t to br dBr o,G4mPNy ,!F, y�It,
f ,. ^�5 ar 4 d' A � , �xl +•r + �: '4,r �.�,' -:,,t, 'i+ 1� ra'F i ~.L.`
4. .a,9y`�` -•�,�'+xr ..
Authorized Countersianature Required if $50,000 Or Over
GERALD D. KAUFFMAN �,,, w„r REFUND 4-,
-,82AH1433320 45/01/12d *A0193664 t!CD;PF EIJb��' BY 7' "�.`. i •ern
t . w - y •y',,}�s Z ` i` (a :k --.� '1�AUknorSZa Signature .,tr, ';.' j t
11. 70 70 3 6 38 2 411' 1:0213093791: 60L-6..15751911' �y
THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER •e}Q-0 `.fj':Y
PRESBYTERIANMOMES• ;; Bad%ofAmerica No. 573179
ONE TRINITY DRIVE-ESUITE201 3 R
DILLSBURG PA 17019,
60.208 i k
-� ``,_',. , ' "'+« .-. '+ • . r R - 312
_ •r �,•, n.-- I !,A*• .,'DATE u. Z17S._CHECKAO. .It " ,'.rAMOUNT F
0 5/04/2012 + .573179 .$2,427..1.8,-,
PAY Two Thousand Four HUn'dred Twenty;Seven:Dollars and 181166 Cents. "t i t ,• '' T !; B
TO THE ESTATE OF GERALD�KAUFFMAN
ORDER C/O KAREN SY,1<ES
364 OF F * a
BEVERLY ROAD
CAMP HILL PA 97011 '
THE BACK OF THIS DOCUMENT CONTAINS AN ARTIFICIAL WATERMARK—HOLD AT AN ANGLE TO VIEW
11.057317911• 1:0 3 1 20 20841:00383051548711•
_ q•L`UYtT•7_F9:ItI�1��'i.3i:IF3 •l r _ :u a:. • •_ .• • • • r l • • l u •••• l
Payable Date 0194099
5/9/12 g,o
I
Payable at:
Wells Fargo Bank,NA.
Twenty One& 44/100 U.S. Dollars AMOUNT OF CHECK
PAY TO THE ORDER OF ***$21.44***
GERALD D KAUFFMAN 8 Vold after 180 days
ELEANOR L KAUFFMAN JT TEN
364 BEVERLY RD
CAMP HILL PA 17011-2838
I BOB,
Authorized signature 5479
CUSIPNUMBER:05mH10p,_Slgnature May Be CgflAUtfN GerwrBted 0,94090 J
11'019409911• 1:0910000191: 683500154311•
IPEIVIVST>+T }HLRSH Y } .3
�",' ` .' S7 �,�PNC;Bank'N A iOT 1 y' 160 162
..t.� �A� T .Y
'�..JEANNET3E-;PA
�����iCent� ��� .,� i � �M�yAatell�/�lr Check No�A�'�I11�'.sr�Arhoffrfrl(1���Il�l
-.'0 Bo 357MC A430 .!R \ `i-iii»»»»»»
W°°ersifeVP�A' 17D3310857.� , @A? /�' 005/
»22/112p834592 �y�,,,�Rw ;.. h,$1335
■THIRTEEN DOLLARS A7VDT IRTI,-F7,V'BfQE�im ! { K im►�"
�PAV ERALD D"uk' MA'Ni �"•`• ip �'� yl
O Tt�E GREEN RIDFiE vI�
?0BIG5PWNl3ROADf A� r MM
ORDER OF
I1EWfI :E, rPA 17241 V !; �
u9008 34 59 2110 1:04 3 30 16 2 71: 100899 7 36411•
�* DEPOSITTICKET II------��
CASH
v , LYJJ ► .
�e ESTATE OF GERALD D KAUFFMAN 02/12 y��o 72fi9�?313
'P KAREN L SYKES, EXE f�V ► ' t� yt
B GO 10 W HIGH ST.
CARLISLE,PA 17013 ►`P
'3€ DATE aI�1Z— oin�LRFf oE:
E°rte gg DEPOSITS MAY T BE AVAILABLE FOR IMMEDIATE WITHDRAWAL
YS SUB TOTAL
=51g SION MERE GOP CASH RECE OPF REWIRED)A
°tT .
LESS CASH
• �
RECEIVED
►,
v Sovaelgn Bank,NA
PART OF THE SANTA DER GROUP
*1: 561755 2051: 1 7 2 180913 130
L �
PRUDENTIAL Apr 18 2012 11 : 56 P. 01
The Prudarntial 7nourance c6tipany of
Pmdeni ial Prue*S a
Prue* ecurRlas,LLC
ComwND i rQmoe centar
PO B9x 70196
Phlladebhls,PA 10178
(800)235.7639
April 12, 2012
Robert P,Xockin
The Prudential Insurance Company of America
150 Corporate Ccjoter Drive, Stite 105
Camp]dill,PA 17011-1759
Re: Account X—I=-9776
GERALD D.KAL1FFIvIAN IRA DEC'D
Dear Financial Professional:
Per your request,we are confirming the balance on the above-referenced Pmco Securities Account. Our
records indicate that as of February 16,2012,the value of this account was:
ant ores ce Value
BURIdX 231.307 $3100 87,401.82
MMIJFX 354.646 $17.55 $6,227.55
QVG1X 261.911 $14.80 $3,876.28
PFGA,X 456,499 $11.24 $5,131.05
FOGAX 174,451 $14.42 $2,515,58
Total Portfolio Value $25,152,29.
If you have any questions or need additional information,please contact the COMMAND Service Center at
(900)235-7637. Customer Service Representatives are available to assist you between 830 a.m. and 7:00.
p.m.ET,Monday',through Friday.
Sincerely,
ar I
Re stored Principal
Frio Command Operations
Pruoo Securities,LLC
Rogletered Principal of Pruco Seeurfaaa.LLC(Pruco).
Semmes products and services are offend through Pnroo.The Prudential Insurance Company of America,Newark,NJ and Prueo
am Prudential Financial companies.1-800.201-6600
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date : 2/23/2012
Cumberland County - Register Of Wills Receipt Time : 15 : 02 : 57
One Courthouse Square Receipt No . : 1068881
Carlisle, PA 17613
KAUFFMAN GERALD D
Estate File No. : 2012-00244
Paid By Remarks : WOLF & WOLF
CJ
------ ----- ----- -------- Receipt Distribution -- ------ -------- --------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 90 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 40 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 10 . 00 CUMBERLAND COUNTY GENERAL FUN
----------
Check# 3437 $183 . 50
Total Received. . . . . . . . . $183 . 50
r
219 North Hanover Street
Carlisle,Pennsylvania 17013
717.243.4511
toll free .451.451 1
fax x 1.866.451.4511
717 717.243.3723
w .hoffmanroth.com
FUNERAL HOME & CREMATORY, INC. Info @hoffmonroth.com
April 3, 2012
Karen L. Sykes
364 Beverly Road
Camp Hill, PA 17011
Statement of Funeral Expenses for: Rev. Dr. Gerald D. Kauffman
Date of Death: February 16, 2012 Account Id: 16474-043
PACKAGE:
Package to set individual costs of funeral expenses
CCC $ 1,995.00
Sub Total: $ 1,995.00
FACILITIES AND PROFESSIONAL SERVICES:
Other Services $ 260.00
Equipment and Staff for Memorial Service $ 320.00
Equipment and Staff for Graveside Service $ 190.00
Sheltering of Remains $ 250.00
Sub Total: $ 1,020.00
MERCHANDISE:
Casket:Whitmire II $ 2,545.00
Register Book $ 20.00
Memorial Folders $ 25.00
Acknowledgement Cards $ 25.00
Sub Total: $ 2,615.00
AUTOMOTIVE EQUIPMENT:
Hearse $ 400.00
Sub Total: $ 400.00
OPTIONAL SERVICES:
Transfer of Remains $ 320.00
Sub Total: $ 320.00
TOTAL FUNERAL HOME CHARGES: $ 6,350.00
CASH ADVANCES:
12 Certified Death Certificates at$ 6.00 each $ 72.00
Newspaper Notice-Sentinel $ 263.76
Newspaper Notice- Patriot $ 447.62
Clergy 4 @100 Ea $ 400.00
Newspaper Notice-York $ 386.00
Child Care $ 100.00
Organist $ 100.00
Sub Total: $ 1,769.38
Total Funeral Expense: $ 8,119.38
Total Payments Made: $ 6,545.74
Payments Made:
Unity Financial Life Check 3622 Mar 8, 2012 6,545.74
SERVING OUR COMMUNITY SINCE 1907
WILLIAM E. HOFFMAN, PRESIDENT CHRISTOPHER H.HOFFMAN, OWNER ROBERT A. FILBURN III, SUPERVISOR
219 North Hanover Street
Carlisle.Pennsylvania 17013
717.243.4511
toll free 1.866.451.4511
r fax 717.243.3723
v✓w v.hoffmanroth.com
FUNERAL HOME & CREMATORY, INC. info @hoffmonroth.com
Balance: $ 1.573.64
-------------------------------------------------------------------------------------
Please return this portion with your Remittance.
$ Amount Enclosed
"'°
ffm an E$TA7-EOF '°°$W pGSERALD
EXE D KAUFFM AN C HT' 02j
i-
1
Oro 17073 - �-7269/2313
I • f TT'' a� 3p3% 201.,.
I8 �
sovereign
PART NA
OP THE SAWANDER GROUP. '
6 =�
� 1Gy ` o
�f3
2gg1��
37238098 3R•03p3 �"
SERVING OUR COMMUNITY SINCE 1907
PRESIDENT WILLIAM E. HOFFMAN, .PHER H.HOFFMAN, OWNER ROB •'
The Sentinel WOLF&WOLF ATTORNEYS AD NUMBER PAGE NO.
www.cumberlink.com 10 WEST HIGH STREET 408100 1 Oft
CARLISLE,PA 17013 BILL DATE SALESPERSON
C+�yVIG� 717-241.4436
04110/12 wolfc
an:e;e :dwvnae',etrecs �t.c000nr
START DATE STOP DATE
03/27112 04/10/12
AD NUMBER AD DESCRIPTION CLASS LINES
408160 EXECUTOR'S NOTICE LETTERS TESTAMEN 10 PUBLIC NOTICES 30 ` 2 cols
Publication Insertions Rate Net Amount Gross Amount
3 THE SENTINEL-LEGAL 3 LGL $159.30
TOTAL AD CHARGE $159.30
3 PROOF OF PUBLICATION 01 PRF $7.00
3 MOBILE SITE MOB2 $2.00
Purchase Order Est. G.Kauffman PAY THIS AMOUNT $168.30 $201.96*
*AFTER 05/05/12
ESTATE OF GERALD D KAUFFMANk'02112 6g-7269/2313 301
KAREN L SYKES, EXE THE SENTINEL
C/o w HIGH sr. [/ c/o LEE NEWSPAPERS
CARLISLE,PA 17013 PO BOX 540
WATERLOO IA 50704-0540
3oo der o
Invoice
SOYePeignBmk,N.A. Ad Number 408100
PART OF THE SAWANDER GROUP mil^ Billing Date 04110112
/dam ��d 0 �/ - Amount Due $ 168.30
±1: 23137269 &I: 172 &8098 & 311.030 & rc p`un43
Signature
Please make checks payable to: THE SENTINEL
t 000262 THE SENTINEL
WOLF&WOLF ATTORNEYS c/o LEE NEWSPAPERS
10 WEST HIGH STREET PO BOX 742548
CARLISLE,PA 17013 CINCINNATI OH 45274.2548
11111 1,1,11111111,,,1 L,1,1 111111111 1„111111111111„11111111
21540200000004081000000000000000002019600000168308
D ti
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tale: (717)249-3166 Fax:(717)249-2663
April 20, 2012
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Nathan C. Wolf, Esquire.
RE: Gerald D. Kauffman Estate
ESTATE OF GERALD D KAUFFMAN- dv 2 so-�zss/xsla 302
KAREN L SYKES, EXE
C/O 10 W HIGH ST.
CARLISLE;PA 17013 - y f,, poi .-gal advertising
�j, _aw, Journal.
o�del o{ ��N?!6'a�ol wY,¢L�ei� O�v.✓Qb � � �S.dV
7 —1 m
Soverelo Bank,Nn.
PART OF THE SANTANDER GROUP
+1: 2 3 13 7 269 0: 17 2 18098 1300 30 2 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0 .00
Total Amount Due $ 75.00
Payment received by
Brenneman &Associates, PC
236 South Hanover Street, Suite ioi
Carlisle, Pennsylvania 17013
717-245-2726
March 27, 2012
CONFIDENTIAL
GERALD D KAUFFMAN
364 BEVERLY ROAD
CAMP HILL,PA 17011
For professional services rendered in connection with the preparation of your 2011 individual tax
return:
Form 1040(Individual Income Tax Return)....................................................$ 70.00
Schedule A(Itemized Deductions).................................................................. 65.00
Schedule B (Interest and Dividend Income).................................................... 50.00
Form 1116 (Foreign Tax Credit)..................................................................... 45.00
Form 8853 (Medical Savings Account)........................................................... 50.00
Social Security Worksheets............................................................................. 40.00
Tax Refund Worksheet ................................................................................... No Charge
IRA Distribution Report ................................................................................. 50.00
Pension/Annuity Report .................................................................................. 15.00
2 Yr Comparison Report ................................................................................. No Charge
PA Form PA-40(Income Tax Return)............................................................. 60.00
Mailing............................................................................................................. 10.00
Preparation fee 455.00
Discount -155.00
Amount due $ 300.00
r
[4-t: 2 F GERALD D KAUFFMAN"ovtz
E0-,269/23 a 3 0 5
SYKES,EXE
4 GH ST. •a3^>
PA 17013 :< -
I overeign Bankx&
RT OF THE SANTANDER GROUP
37269L�: i7211309a13100305
Millennium Pharmacy Systems ��
100 E Kensinger Or Millennium
Bldg 120 Suite 500 A-V Pharmacy Systems Inc.
Cranberry Twp, PA 16066
1-866 - 466 - 7779 Opt. 4
INVOICE DATE: KAUFFMAN, GERALD
June 15, 2012 SYKES, KAREN Account Number
364 BEVERLY ROAD GRVN1495
Balance Due: $209.55 CAMP HILL, PA 17011
Pharmacy Location:
MECH 3
Please Detach here and Return Top Portion with Payment
Re: KAUFFMAN, GERALD Invoice Date: 6115/2012
Facility: Green Ridge Village NC - PHI Balance Due: $209.55
Account#: GRVN1495 Last Payment: $138.29
Pharmacy Loc: MECH Last Payment Date: 2/15/2012
ACCOUNT PAST DUE
Dear Millennium Valued Customer,
Our records indicate there is still an outstanding balance on the account over 90 days past due. To
date we have not received this payment.
Please remit payment today to keep your account in good standing. We also accept Visa and
MasterCard. Please make checks payable to Millennium Pharmacy Systems.
Tic and ask to
If you feel ESTATE OF GERALD D KAUFFMAN ozi12 160-7269/2313,
speak with a KAREN L-SYKE% EXE 307
C/O 10 W HIGH ST. �,
CARLISLE,PA 17013
e i �
Sincerely,
Collections ii SovereignBank,N.A,
Millennium 1 PART OF THE SANTANDER GROUP
Tel: (724)' —_ kcT GkVN 1*
Fax: (866)' : 2 3 13 7 26 9 111: 17 2 180 98 1 3ku•
0307
DARRYL GUISTWITE,DO (717)609-2639
56 ASHTON STREET
CARLISLE,PA 17015-6914
Account Number Billing Date Page Office Use Only
Gerald D.Kauffman 1285 07/05/12 1 MED
C 0 Karen Sykes
364 Beverly Road
CAMP HILL,PA 17011
Service Date CPT4 Description Prov. Units Mesg Charge Ins.Paid Adjustment Patient Paid Balance Due
01/06/12 99309 Nursing Home Est.Patient Level 3 DG 1 105.00 77.85
Patient:Kauffman,Gerald D- 1285
Servicing Provider:Darryl K Guistwite DO
02/02/2012 Medicare 5.72 20.59
Applied towards deductible
02/14/2012 Medicare 0.00 0.84
02/29/2012 Capital Blue Cross 0.00
Applied towards deductible
01/09/12 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 12.72
Patient:Kauffman,Gerald D- 1285
Servicing Provider:Darryl K Guistwite DO
02/02/2012 Medicare 50.86 15.78
02/14/2012 Medicare 0.00 0.64
02/29/2012 Capital Blue Cross 0.00
Applied towards deductible
01/16/12 99309 Nursing Home Est.Patient Level 3 DG 1 105.00 16.71
Patient:Kauffman,Gerald D- 1285
Servicing Provider: Darryl K Guistwite DO
02/13/2012 Medicare 66.86 20.59
02/14/2012 Medicare 0.00 0.84
,,Emnohm 9 nt„P nn
01/23/12 99308 E$TpT( OF!GERALD D KAOFFMA�I & 2 X60 Tamlzals- 308
KAREN L.SYKES, EXE 12.72
C/010 WHIGH ST.
CARC18 E,,PA 17013 „-x, k •' t'`: '" -
Comments: a 3{dat o{ 1 1 $
Sovereign Bank,NA.
PART OF THE SAWANDER GROUP
A�•�, i�S � do E�
+i:
23 137 269 i�: 17 2 18'0 98 131110 308 57
Minnesota Life Insurance Company
A Securian Company ,
400 Robert Street North
St.Paul,MN 55101-2098
www.minnesotalif..com
651.665.3500
May 31, 2012
MINNEWTALIFE
KAREN SYKES
364 BEVERLY RD
CAMP HILL PA 17011
RE: Gerald Kauffman
Contract No: 19999
Dear Ms. Sykes:
Thank You for the recent reimbursement of$89.52 for a payment made after death for April 2012, but
after viewing her file some more we realized that two payments were made to her after death for
March 1, 2012 and April 1,2012.
I do apologize for the inconvenience,but in order to close out the file we will need one more payment
of$89.52 for the payment made for March 1,2012.
If you have any questions,please feel free to contact me at 1-800-272-4772 or 651-665-3530.
Sincerely,
Mayla Vang Vwpq`/
Settlement Contract Division
Encls.
ESTATE OF GERALD D KAUFFMAN o2/12 M-7M/2313-
KAREN L SYKES, EXE - - AL 309
C/O 70 W HIGH ST.
CARLISLE,PA 17013 //II nzA-1-1
I� 1 ��
nom` n
80vere19n Bmk,NA.
PART OF THE SANTANDER GROUP
a �2r. 9 )? 2+�: 23 1379 ii: 180981311.0309
46e4C- R— PWw