HomeMy WebLinkAbout08-02-13 (2) � zsos61o1os
"' REV-I500�'���"'""�+
OFFtLYAt USE ONLY
PA Department oFAevenue ��� �nry Cade Year File Num6er
Bureau of Indn�dual Taxes �NHERITANCE TAX RETURN
PO BOX ZSO6o1
HarASbum,PA i7�28•o6oi RESIDENT DECEDENT Z I �Z Q�O
E!l7ER DE�F�ENT 1HFOATdAT}OT!8E1_OW
Sociai Securlty Number Date of Death MMODYVYY Date of Birth MM�OYYYY
OS114/2012 01/31/1923
Decedent's lest Name S�z DecedenCs First Name MI
Lefevre He1en t '
(If Applicable)Enter Surviving Spouse's Information Below
Spouses Last Name Suffix Spouses Firsl Name MI
Snouse's Soclel Securlry Number
THIS RETURN MUST 8E FILED IN �UPLICATE WITH THE
REGISTER OF WILLS
Flll IN APPROPRIATE OVALS BELOW
�� i.Odgtnal ReWm � 2 Supyfeml+tel f3nlum �� 3.KsmAindar RaWm(Date ut Qeath
PQor Fu 12-1382)
�� 4.Llmited Estate ��,'� 4a.Future Interest Canpromfse(date oi i=� 5. Federal Estare Tax Retum Requlred
dcath afler 12-12-82)
�C� 6.Decedent Died Testate ,_, 7.Decedent Maln�alned a lJNng 7ruet _ 8. Total Number ol Sate Deposit Bwces
�nceaa�copy�r wg,y� (Attade Copp d 7�.)
�� 9.litigatinn Proceeds Received �.'^� 90.Spousal Poverry Cwedit jDate nf Death ��'� 17.Eledlon to 7ax under Sec 9]]3(A)
ae:,�r� az-aaa�a�+da-aes3 inttaor+sa,edweo)
CORRESPONDENT- THIB&ECTION MU&T BE COMPLETED.ALL CORRESPONDENCE AND CONFIUENTIAL TA%INfORMATION SHOUL�BE DIRECiED T0:
Name Daytime Telephone Nui�dier � rn
TimoihyJ. Lefevre 7f7-663-Sfi29 �:� rn �
-n o 0
�� .
.{ISTER�OF WILYS USEONLY�
�A � r. �,7 rii
i— _. rn r�� � �'
Firt Line af Pddresa � C/� 'p O n
- � � }� �I
i2'L S. SCY2AiFt $i � C� � .-3 _' e)
Second uneotAddress V }i �v r rn
r
2rcd Fbor --� '� c,� cn o
s.- co
Cky ot Post ORice State ZiP Code DATE FILED
Lemoyne PA 17043
CortespondeM�s e�mau adaress:lefevre.tJ@gmail.com
tlnderpmalties ot pajury�t aecte�e ttret t tmae czamined uds retum.InCUINn9 eo�my9m�stl�e0utes end uatemants e�d ro ehe best of my knowteage mw bd�ee.
It k W e,conect eM comdeSe.Dad o rer aNer Men tho percanal repfesenie[Ne Is 6esed an all in(ormetlon of whlch praperer has eny knovAedge.
SIGNATURE OF P S RESP FOR FILING RENRN DATE
� ay i3
ADD
/Bd� S, �e..nr s�_ a4� f�� ��a'i.�e' �A �7�Y3
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRE9S
PLEASE USE ORIOINAL FORM ONLY
Side 1
� 150561�1�5 1505610105 J
�
� 1505610205
��
REV-1500 EX(FIj
Oecedent's Social Security Number
o���..�,;.;�ae: �a.e��.Lafsvre
RECAPITULATION
1. Real Esiate(Schedule A). .. ............................... ........... 1. -�j .-,
.. 5:;,:...'�e a„d Bcr�a(�:.FedWs�i . .................... .... ...... ...... �..
Z. --. e
3. Closely Held Coryoration,Partnership or Sole-Propnetorship(Schedule C) . .. .. 3. ^ � -
4. Mortgages and Notes Receivable(Schedule D)........................... 4. - � ^
5. Cash,Bank Deposits and Miscellaneous Personal Properry(Schedule E)....... 5. , �. '18'��?�7
6. Jointly Owned Property(Schedule F) �O Separate Billing Requested .. . _.. 6. � B �
7. Inter-YVOS Transfers ffi Misceflsneous Non-Probate Praperty -- - - ��� �� - - - - - �
(SchedWe G) ,G: Separate 8elti��Reqete ted....... . 7. --. � - ...
8. FtetalC+rots,Rceeis{&i;aLar,esl3tt'<a;t�F.7}......................... .... 3. ' •�.r. 7d[ti�?i7
°. Funeral Expenses and Adm:nistretive Costs(Schedule H).... ............ ... 9. ��'a' t�/6
Si3. tJebts ot Deceden[,Mortgage Liabi�iEies an6 L'rsns{SChedute i).... .. ......... SG. �3 g'a.q l
. . .. _. ... . _ . ..
11. ToWI Oeductians(totai lines 9 and 10)............ ............ . .. .. ... . 11. ?�'�s '�!� ,
12- Net Value of Estate(Line 8 minus Line t'i)..... ............. ............ 12. ++ p ---.
i3. CbariCabteaad6�mntartiat8e�itesfisTSec89t3Trttsistorw4s,cts ... .. . . .. �- - '� ��� -�---. . .. .
an e�ection to tax has not been made jSchedule Jl .. .. ..... .... .... ....... 13.
14. Idet Value Su6ject to Tax(Line'12 minus Line 13) ................ .... ... . '14. � ^ U ^
TIlX CRF.CFJlATlQN-SEE Ni3TRUGZtON3 FOR RPPLFCA6tE RRTES
Y5. Rmount af C'rne t4 tazabCe
at 1he spa.�ss=!ax;aS?,.�!
transfers under Sec.9116 " � � � � �
�a)l12)X.0_ 'IS_
16. Amount of line 14 taYable � �- - � - � � � � � - �
at lineat rate. X A_ 46.
.. . . .__ . . . .. .. .. __ -..�
17. Amount of Line 14 taxable - � --
at si6ling rate X.12 �7.
18. Amount ot Line 14 taxable � � � - � - � � � � � � � � --� � """�"" " -
at collateral rate X.15 �g, '
'19. TAX DUE .. .. ......... .. . . ......... ... . . .......... ..... .... .. . .. .. 19. � p ,�-� .
20. FILL IN THE OVAL IF YOU ARE REpUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 15056I,02Q5 7,5056LQ2Q5 �
REV•1500 EX(Ft) Pege 3 File Number
@eceden4`s �ampietel�ddress:
0.f.67EA7'S AF1,IE
N ECEN � . �.E7`E�2 E
S7f2EETA�DRESS
Ym S�H_�7?e��/11�oRI�L _ .�rf
1 a o0 (,�� Sa�Tr �
cm
STATE 2Ip
c.�s�CC �i}- t70/3
Tax Pa;�mer�is and Gredits:
1. Tax Oue(Page 2,Line 19) (�) ^ � �,
2. CreditslPaymertts
A F�Paymenta ,3.Z 7, (8�
B.Discount
3. Interest To�al CrediLs(A+B) (2) ,3j�17,�P'
{3)
4. 1!L1,-a 2 ts�a;t;t G'�;r,L;na t e L'ms 3,sn,at tha d;�t;rarus. P,;is!s�a CVERFA;^!.:^,.
Fill in oval on Page 2,Llne 20 to request a refund. (4) _�017. 1�
5. If Line 1 +�ne 3 is greater lhan Line 2,enter the diBerena.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 vansfer and: Yes No
fi. l2i611�l2 iiio ui StCASvi Gi ui2'yi6('i����-.�;e�..__... ...._..�....____.._ o e
b. retain Iha right to desiqnate who shall use the proroperty transferred or Its income ............................................ ❑ �
c. retain a reversionary interest.............................................................................................................................. ❑ �
d. receive Ihe promise far li(e of either payments,6enefits or care?...................................................................... ❑ �
2. If dealh ocatned after Oec.12,49&2,did decedeni 6anster y.operly xdlh'trt one year d death
wtlhout�eceiNng adequale consideretion?.............................................................................................................. LI �
3. TId deceEenl oxm an'in wst Fa`or paya�te-upon-deafi bank acoount w secudty athis wher Aea'6i7.............. [3 �
4. Did decedent ovm an fndividua�retirement account,annuiry or other nornprobale property,which
contalns a benefidary deslgnation? ........................................................................................................................ ❑ �
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 dales of dea�h on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on Ihe net value of Vansfers to or for the use of the surviving spouse
is s p�cmt(7z P.s.ystts(a)(tt){J).
for dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the �se of ihe surviving spo�se is 0 percent
[72 P.S.§9116(a)(1.1)(i)J.The statute does not exempt a transfer to a surviving spouse ftom tax,and fhe statutory requirements for disclosure ot assets and
filing a tax 2tum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July t,2000:
. The 4ax rate imposed cxi the nei vawe a i�ansiers from a deceased dNld 24 years ai age or yaunger at dea{n io a fw ihe�ese uf a naiwai puerA,an
adoptive parent or a stepparent of the child is 0 percent j72 P.S.§9116ja)j1.2)].
• The tax rate imposed an the net value ot Vans(ers to or for the use of the decedeni's lineal benefidaries is 4.5 percent,except as noted in�72 P.S.§9116(a)(1)].
• The tax rete imposed on the net value of transfers to or for the use of the decedenl's slbiings is 12 percent[72 P.S.§9116(a)(1.3)).A sibling is defined,
c�13es Sec+ian 9ia2,as an inGiv�duat wha hra at Iess:a1a pa;en.in cumman vr'��ffie dG�derw wlau�r hy td:,�d a�adopGan.
REV-1512 EX+(12-12)
�['i�pennsylvania s�w����-� f
'��' DEPARTMEMOFREVENUE DEBTS OF DECEDENT,
INNERITANCETA%REIUqN MORTGAGE LIABILITIES & LIENS
RESIDEM DECEDEM
ESTATE OF FSLE RuKBER
Helen L. Lefevre
Report debts incurced by the decedent pdor to death ffiat remalned unpaid at the date of death,induding unreim6ursed mediwl e�cpenses.
REM VALUE AT DATE
NUMBER DESCRIFf10N
OF OEATH
1' Sarah A.Todd Memorial Home 3015.22
2. West Shore EMS(Pro-Rated) ZgZ 3�
3. PA Department of Public Welfare(Estate Recovery Program) 2986.38
TOTAL(Also enter on Line 10, Recapitulation) � 6382.91
If more space is needed,Insert additional sheeu of ihe same size.
, . REV-1511 EX+(30-09) � . .
. ��pennsylvania SCFiE�ULE ii � . . � .
OEPAPTNENT OFNEVENUE FUNERAL EXPENSES AND
INMERITANCETA%REll1RN ADMINISTRATIVE COSTS ' � � �
' - RESIDEM OECEDENT � -
ES7AiE QF � . FILE KU�iBER
� J
Helen L. Lefevre � . '
, � DecedenPs deMs must be reported an Schedule I. - ,
ITEM
. �NUMBER DESCR]PTION
AMOUNT
A• FUNERAL EXPENSES:
1' Ewings Funeral Home Balance �'� T � �°'"4"""°""""""
, :� 154.69
' � z Eby Grenite Works-Footstone T—_.�—��'�� ���� �� � ~" f"� "�""""`p,00
f'l ,f _ " �.c:.-� -s4._:_^.{..� . - �--.•. a,�a� ._-�.:s.._._--:..�-..._ .�.. =�-x-z. Rw.y..+......�.+.�r...
(-"'1� 1� �..:-=.-��c�-,��`�t--�m�__^__�,�.sr.== "
, �--- ' . . '=¢—. ' ` �'1'r �'--- , .
i � �^ r — e r— _.sz� - �` �
.._ .� ` � T j.-�-=-�,_-.-. _ �:� _�.y--,.._ _ � _� �_.:�.. '<,�...-....�.....�..�... -
��
�--, w--�-.�,�._.._�.:�--x��� - --
• � - � .I. , . .. . _ • � . � _ � T. . . � . _ �� .
e. ADMINISTRATIVE CO5T5: .
� ' �
1. Personal Reoresentative Commisslons: . - � ' . -- . 39"� '
Name(s)of Personal Represeniative(s) Timothy J. Lefevre' � - � •
street address 122 S Seventh St, 2nd Floor � ' ' �
�;ty Lemoyne � � � state PA Z�P 17043 '
• Year(s)Commission Paid: 2013 • � `
• , ""`."".�"'R
' Z• Attnmey Fees: .. ' ' , 0.00
_ . . ' �_.___ �+� 0.0
3. Family Ezemption: (If decedent's address is not the same as daimant's,attach ezplanation.) �� �
r ` �
, Gaimant - � - � • • , �
�
• Street Address • i � '
Ciry State ZIP ' . y
� � Relationship of tlaimant to Decedent ' • .
. . . '+..wr°....�„'1
9, Y Prchz[e Fees: - � �, 1'16.50
..�..
� 5. AccountantFees. • . ' � ���� ' -
- - � ' , • �+.+.,..a..�,.,.r..�
6� Tax Retum Areparer fees: � a . �
' • a 0.00 .
7.� r,-.�''-�.�.�..__��...�.�...�.�,.,�.�.��,..— -T._��-----�--.�', ':.rs.++.+..�...r.....I
� l �% l _ ,� '_ .�_ — _ -L _� •
�� � �-.—r-.r—_..3_....�.�..'. t� . ... � ��� �
� _ �- _-;-- r�:_._..�._.--=_._-�_ --�- . _._...:.��.;
�_� �_ ��:.�._:_.: � �� � ..�.,.�_.�....��
r_'�l {-' ' ' �-+�..�. . _++f..'.4.`r `�.�...�.�....---i-` .--��.-. .r.�-.�y
t..� L�____ � - =.._� • � _���;_ � ." ��
� � ��--�_�_.�-.,` �...r_,_,,....--.r ;,...�"`—_:_.. ..-_,,_ .,.,,. ,,,,..,.�,,,q,,,,+.� .
�- - — -- ��.... .» _..�.... _._._ _. _�_._._ _. , � �...��
� �. ..f -
TOTAL(Also enter on Line 9, Recapitulation) � � 1521.46
- ---�
� if more space Is needed,use addittonal sheetr of paper oi[he same size. � � _
. . . .
HEV-i5o8 EX+(o&u)
,�i pennsylvania S¢i�iEDfi�rE E
+�� DECARTMENTOFqEVENUE CASH, BANK DEPOSITS & MISC.
INMHIRAN�TA7(RETURN pERSONAL PROPERTY
RESIOENf OECFOEM
€SiATE 6Ft FII.E RUtdBER:
Helen L Lefevre
indude the proceeds of litigation and the date the proceeds were received by the estate,
All Aroperty jolntly owned with ripbt ot survivorship must be dlsdased on Schedule F.
�M VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
1• Members tst Federal Credit Union Savings Account 5183.20
2. Members 1st Federal Credit Union Checking Account 26zZ ��
TOTAL(Atso enter on Line 5,Recapitulation) $ 7b�Ds,3�
if more space Is needed,use additlonal sheets of paper of the same size.
Aeeoucjt Statement Fage ] of t
�
MEMBERS 1St
•FEDBRAL CREDTT'UWION
Account Statement
HELEN L LEFEVRE For Account: 0000102389
122 S 7TH ST FL 2
!k CARF OF TIMOTHY LEFEYRP
LEMOYNE,PA 17043
Reporting Period: 5/OiR012 to 5/31/2012
0000 REGULAR SAVINGS
Post Date 7ransaction Descriptlon Amount Plew Belance
5/01/12 Deposit:AXA EQUITABLE $239.46 $5,371.46
TYPE:AC1698PY011D:9135570651
CO:�:XA€�UlTAELE
5/01H2 Withdrawal Trensfer.To Share 0017 $239.4E $5,132.00
5/01/12 Deposit:AETNA INC $380.69 $5,512.69
TYPE:BENFT PYMT ID:9949371001
G9;AETNA INC
5/01/12 Withdrawal Transfer.To Share 0011 $380.69- $5,132.00
5l03/12 Deposit:XXSOC SEC $1,137.00 $6,269.00
ID:3031036030 CO:XXSOC SEC
5l03/12 Withdrawal Transfer.To Share 0011 $ 1,137.00- $5,132.00
5/23/12 Deposit Check $51.20 $5,183.20
Check Received 51.20
0011 CHECKING
Post Date Transaction DescrloUon
Amount New Baiance
5/Oi/12 Deposit Transfer.From Sha�e 0000 S 239.46 $1,734.11
51Q1/12 Dep�sit Transfar.Frnm Share 40L� �390.BA $2:114,80
5lOt/12 WitAdrewal:CAPITALBLUECROSS $228.09- $1,886.71
TYPE: INS. PREM ID: 1230455154
CO:CAPITALBLUECROSS
5/03N2 DepositTransfer:Fram ShSre 0000 $ 1,137.00 $3,023.71
5/09/12 Draft:001161 $20.85- $3,002.88
5/25/12 Withdrawal:AETNA INC $380.69- $2,622.17
x �j?(�� Dated 0 5/3 1 2 01 2
Matt Faust MSR I
file://C:\ProgramDataUack Henry and Associates\Episys For Windows\HTML\HTMLVie... 5/31/2012
.
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�� pennsylvania
DE7ARTMENT OF 7UBL7C WELfAFE
]an�ary 7, 2013
TIMOTHY ] LEFEVRE
122 S SEVENTH STREET
2Ni3 ftOOft
LEMOYNE PA 17043
Re: Helen Lefevre
Cf5 #: 410549795
Incident Date: OS/14/2012
Dear Mr. Lefevre:
This letter in in response to you le[ter GateG December �, 2012 and [he verfflcatlon
you have provided regarding the above referenced estate. Based on the information you
have provided the amount due the Department up to the value of the estate is $2,986.38, a
breakdown of thfs informat(on is listed below:
,
Gross Assets:
Bank Account Members lst Savings $5,183.20 `
Bank Account Members lst Checking $2,622.17
$7,8G5.37
�
Expenses: ,
Register of Wi�ts $ 101.50
Register of Wflls $ 15.00
IVursing Home $3,015.22
Funeral $ 154.69
Stone $ 860.00
Executar Commissinn $ 39D.27 ��
Am6ulance Biil (pro-reted) $ 282.31 �
$4,818.99
Please submit payment fn the amount of$2,986.38 payable to The Departme�t of
Pubiic Welfare to my attentlon at the address below. ff you fiave any questions or if there
are any changes in circumstance that couid effect this agreement please contact me.
Sincerely,
`"�1R- `ll���-Ql�
Tina M. Wise
Bureau of Vrog2m integrlry � Dlvlsion of Thlyd Garty lJablfity� Recovery Section
PO Box 8486 I Harrisbutg,PennsyWania 17105•6486
_
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX�11-961
�EPARTMENT OFREVENUE
eUREAU OF INDIVIDUAL TAXES
�EPT.280601
HARRISBURG,PA 1J128-0601 �
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 016204
LEFEVRE TIMOTHY J
122 S SEVENTH ST
2ND FLOOR
LEMOYNE, PA 17043
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
_'__"_ �oia
'_'__'_'_ _"_'__
101 � $327.18
ESTATE INFORMATION: ssrv: I
FILE NUMBER: 2112-0608 I
oECEDErvT NArvtE: LEFEVRE HELEN L �
DATEOFPAYMENT: 07/02/2012 I
POSTMARK DATE: 07/02/2012 I
couNTY: CUMBERLAND �
DATE OF DEATH: 05/14/2012 I
�
TOTAL AMOUNT PAID: 5327.18
REMARKS:
INITIALS: CJ
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
,�� pennsylvania
DEPARTMENT OF PUBIIC WELFA0.E
February 21, 2013
TIMOTHY J LEFEVRE
122 S SEVENTH STREET
2ND FLOOR
LEMOYNE PA 17043
Re: Helen Lefevre
CIS #: 410549795
SSN: ###-##-
Date of Death: OS/14/2012
Dear Mr. Lefevre:
This is to acknowledge receipt of payment in the amount of $2.986.38 regarding the
above-referenced estate. This reflects payment up to the value of the estate. If any
additional funds become available, please contact me.
Your cooperation in resolving this matter is appreciated.
Sincerely,
�"/aR- `�L��-A.Q
Tina M. Wise
TPL Program Investigator
717-214-1204
%17-7%2-OJ53 rHX
. : • � . �., . .. . . . .��. .., . . .
Bureau of Program In[egrity � Division of Third Party Liablliry I Recovery Se[[ion
PO Box 8486 � Harrisburq, Pennsylvania 17105-8466
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�al� (� ___.. . ' - ---- - - _ _ . _
Eby (�ranite Works
_ F. O. Bo� 1 S7, 1�ewVillE, Ftz. 17241-QI o°' set
Phone: (71�) 776-SII8
..�.,�.
Name 7m LF<-t vr1 E Date � _ � - iz.
� Address/��t S 7r`�I f.'�t�O fir� ,. , �iv Zip 1 �d`� 3
� Phone � �. � �9. s� Z 4 Corner Post,O
� Monument Flower Vases�] `
��
� Slant
Sase j � > �� F Kind of Granite �.s�a.tt.
Bevel Cemetery �-tSN��t.ti10
�; --`r� Grass A,4arker /•✓o .nio� o•s� ,.,i �,p. _ _ N�me �n back FQ���ATiOA�
�` Design ,����,.� , n�fn �4.�C Yes No WARRANTY
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. �,r�.,.�...�(,.,J4��-.�...................... take full responsibility for the accUracy 8& �
�oi the.Abovg.sp�rSgs and dates.
� ❑ Check How to Letter etter this wa - opposke
: - .
. Unit Price $ O. °� Flower Vase $ Corner Post $ Misc. $
� — $ Total $ �''Sd• °� Deposit $ N_3n.� Balance $ �!30 • a°
� i agree thet sflid memorial,with tflle thereto and dght ot possesslon thereof,shall remain your personal property unUl I have paid for it in
full.tn defeult of any paymeM hereunder, I license you to repossess and remove the said memorial,withoW guilt or trespass or other wrang,
j }and autborize and empower you,in my name and on my behaB,to apply to the manegement of said cemetery or other prem(ses tor e pertnfl
, for tts removal and to take any atAer ateps you may deem necessary or expedient and fuAher agree to save you harmless from any entry,
f repossession and rertwval;you may retain said mertrorial or dispose of it at your own discretion withoui 6eing answerable to me for it or any
proceeds ifiereirom.
- Ordare sub�ect to cancellation.Attcon[ractscontingent upon stdkes,eccidents,and other causes beyond our control.
! Iunderstandthat30daysafterplacementoithememorialaFINANCECHARGEwillbeenleredontheblllingdate.Itiscomputedbyaperiodic
rate oi i l�z%per monih which is an annual percentage rate af 18 qo applied to the previous balance betore deducting credita,peyments or edding
purchases appearing on this statement.To avoid FINANCE CHARCaE pay ihe'New balance'betore the btlling date neM month.
• _ �enflce�.,:bs.wi� 1 CT:G::iif.diif;-it�:FEi f:fdF::.:�ii 8iiit:t.:1'.qiiFG GRC t?[3AR�t?T
❑ .�
ESTATE OF HELEN L. LEFEVRE
104 •�
TIMOTHY J.LEFEVRE,EXECUTOR �����13
�n s s�NrH sr.zNO�.
IEMOVNE,PA 17043 `
'/G -{ ~��DATF
�' 0 ER OF� EB y G��'►���E �ORX I OC
I $ y3o.
���-.��?�.� o.�� ~O�nt�'—�� notuas 8 e�::�
�SCI`�'
NARRISBURG.M 111t62BA
f0R i �
�: 23i38 � i �6�: 0458453560+�' L04
�' �
" Ewing Brotfiers Funeral Yiome, Inc.
�� 630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
May 21, 2012
Timothy J. Lefevre
122 S. 7th St,2nd Floor •
Lemoyne, FA 170�13 ,
The Funeral Service for Helen L. Lefevre
We sincerely appreciate tfie confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if�vu have any questions in regard to this statement. �
THF,FOLLONING 1S A,�`1'fE1SIZED STATEM6NT OF THE SERVICES,FACIUTIES,AUTOMOTIVE EQUIPMEM, �
� AND MERCNANDlSE THAT YOU S£LECTED 1VHEN�4AKIi�1G l'HE PUNERAL ARRANGEMENTS.
� 1. PROFESSlO\ALBER�'ICES- �
� Basic Sen•ices of Funeral DircctorlStaff , , , , , , , , , , , , , , , , , 51200.00
j Bathing&Emhalmin8 . . . . . . . . . . . . . . . . . . . . . . 5895.00
Drcs3ing Casketing Cosmorology etc, , , , , , , , , , , , , , , , , , 5295.00 ,
� .. GACILlTIESJSERV3CESlSTAFFlGQUIFA9ENT
� Basic Use of Faciliry. . . . . . . . . . . . . . . . . . . . . . . 5200.00
Document Prep/Pcrmanent Recording, , , , , , , , , , , , , , , , , , 5325.00
� FacilityUsagc for VicwinpJVisitalion, , , , , , , , , , , , , , , , , , $375.00 .
� Staff Umgc for V iewinpJV isi�ation, . , , , , , , , , , , � 3375.00 �
r . . . . . . .
' S[affforGraveside/Intertnent $I25.00
�` 3. AUTOP10TiVE EQUIPb7ENT i
Vehick to transCer remains to Funernl Home, , , , , , , , , , , , , , , , $295.00
� Hearst(Cacl-et Coach) , , , , , , $295.00 �
. . . . . . . . . . . . . . . �
' SHftNi.eSNdtrBY� . . . . . . . . . . . . . . . . . . . . . . E733.00 '
i
U�iliryCar . . . . . . . . . . . . . . . . . . . . . . . . . . $135.00 �
FU\ERAL HOD1E SERVICE CHARGES . . . . . . . . . . . . $4650.00
i
SELECTED D7ERCHAIVDISE: �
20G Sparlan Cmai Gask.Caskct . . . . . . . . . . . . . . . . . . . $i 350.00 j
$1695.00 �
American Chicf OBC, �
� . . . . . . . . . . . . . . . . . . . .
Acknowledgcmcntcards, , , , , , , , , , , , , , , , $10.00 �
RegisterBOOk(s) . . . . . . . . . . . . . . . . . . . . . . . . $40.00 .
� Mcmorial folders, _ . . _ _ _ _ _ _ , , E85.00
- THE COST OF OUR SERVICES,EQUIPMEN`i',AND MERCHXNDISE '
THAT)'OU HAVE SE4£CTED , , , , , , , , , , , , _ , 57830.00 �
Cash Advnnces �
: OpeningGre�•c. . . . . . . . . . . . . . . . . . . . . . . . . 51595.00 �
' SentinelObituaryNoPhoto, , , , , , , , , , , , , , , , , , , , , S168Z6 �
Patriot Obituary No Phoro . . . . . . . . . . . . . . . . . . . . . 5293.82
Cenifled Copies of Dcath Certificate , , , , , , , , , , , , , , , , , , $30.00
Clargy Honorarium . . . . . . . . . . . . . . . . . . . . . . . 5125.00 �
� Flcwcrs. . . . . . . . . . . . . . . . . . . . . . . . . . . e!5'�.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES . . . . . . . . 52371.08
Total
Total Cost . . . . . . . . . . . . . . . . . . . . . . . . . . 510201.08
QVe�PIP� �
� - . _ - - #
, SUB-TOTAL SI020I.08 'f _
i MITTAL PAYMENT/DISCOUNT/CREDITS 9998.98 " {'T�Y��+O�,��
� TOTALAMOUNTDUL S . 0
� �c unpaid balance over 30 days is subjectcd to a I.SO%service cherge per momh-I8.0000%per annum.
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REY•1313EX(1-101 APPLICATION FOR
ji, pennsylvania � CRuEuFUND OF w I O�cial Use Only
� b'YVRf1TMEN7 Oi REVENtiE �.EL�l�SYLV����{ �
�������=,��s INHERITANCE/ESTATE �
PO BOX 280601 TAX
HARRISBURG,PA 17128-06�1 5ee Instructions on Re'verse
TO: PA Department of Revenue
Bureav of Individvei Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
Fa4bl: Q�cEat ReRrererctaLive Deceden! Irifcrrrcat.ict�
Name Timothy J lefevre Name of Decedent Helen L Lefevre
Rddress »�Seve.n�S! �� �u�. 2i �2-osoa
2ndFloot Date oP Death osnanoi2
Lemyone,PA 17043 _ SOCIdI SCCUfI� NUfT1b21' �
Phone Number ����9�29
E-m8il Addl'e55 �etevre.y�gmail.com
The undersigned requests a refund in the amount of $ 3 r�7, 18� for the above-referenced
�fQ�e��nrs Qcrare.
REfUND REQUESTED ON:
� Origina!or SupplPmental ❑IoinY/7rust ti4seYs �Remainde,r ReYum �FsYate Tax
Probate Return �
EXPIANATION OF OVERPAYMENT
1 was informed by the Register ofi Wills that 1 was required to pay the inheritenceTax.What tfiey did not
tell me was that the Inheritence Tax is paid on the amount of the Estate after expenses. I spoke to Tina
Wise attt�e Oepartrnent of Publlc Welfare,Division of Third Party Liabi{ty,and asked why tfie Inheritance Tax
was not fisted as an expense.She told me that since ti�ere are no proceeds in the estate after expenses,
9nciuding t'he recovery amount,t sfioufd request a refund of tfie532i•ISffiatwas paid on 7J21�fli2.
I have enclosed a copy of the letter from Department of Public Welfare, Division of Third Party Liabfity
that shows the expenses,a copy oP the Tnhericance artd EstateTax recetpt artd the AssessmeM. vlease
ietme know ifthere ss anoiher any other dsscume tatscxs ss�fcsttrtatson r2gusted.
!
� � te
Pfease af(ow six to eight weeks for the processing of your refund request. •