HomeMy WebLinkAbout02-12-15 � 150561�105
REV-1500`°`°"' "" �
Pa peoartmentofRevenue Pannrybania oFFic�a�use ox�r
Bweau oflndlvidualTaxes ������ Counry Cotle Year Fle Number
PO e0x z8o6o� � INHERITANCE TAX RETURN �y}�� I,
Harrisburg,an i��ze-o5oi RESIDENT DECEDENT 'ZI �� {Jn � �JV�
ENTER OECE�ENT INFORMATION BELOW
Sooial Securiry Numbcr Deta ol DeePi M1Iu00vnv pate of Birib NNooW�v
OS/14/2014 07/OS/1924
Ducotlonfs Last Name Suffx oecedenl's Frst Name MI
Kauffman James E
Qf Appllcable)Enter Surviving Spouse's Information Below
Spousa s Las1 Name SW(x Spouses Fi��Naine MI
Spouse's Social Securily Number
THIS RETURN MUST BE FILEO IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original ReWm O 2.Supplemen�al ReWm O 3 Remainder ReNm(�a[e o�Dea�h
Pnor�a 121J-02J
o a.��meea esie�e o aa.F�wre iniaren compmm�se�aa�a oi o s. Feoe�ai eswoe rax aew�aea��i�eo
tleatM1 aXe�1&4-82)
O 8 DeceOen�Diatl Tes�ate O 1 Deceden�Main�ained a Lrving Trasl 8. To�al Number oi Safe�eposit Boxes
(niiacncopyorwup �niracncouya�rms�.)
O 1 LiLyn�ion Proweas Receiretl O 10. Syousal Povetly Cretli�(Da�e of Dealn O 1l. Eleo�lon�o Tax untlerSea 9113(H)
eetwae��1&9151 an01-1-95) (Al�ac�SCM1e4ule O)
COFRESVONDENT- iH15 SEQION MUSi BE LOMVLETEP.ALL C0R0.RPON�ENCE ANo W NFI�ENTIAL iA%MFORMAiION SHOULU BE DIPECiED TO'.
Name Daylime Telephone Number �
Peter J_ Russo (717) 591-17� -^ � �'�
o -n c�
� o
aEcisrEa or w(eEs use ory�p =�
�� �
� �
FrstLineolAdtlress � N �-�
5006 E Trindle Roatl � � -n �'
. . _3 �' -�.i
Semnd Llne otAddress '�
�v rn
Suite203 � _ �`� T>
C�ity or Posi ORice State ZIP Code onle raeo y �
Mechanicsburg PA 1�050
GorresponaenPs e-mail atltlress:pfusso@pjflaw.COm
Onoer pe�elues ol pe�ury.I tlecere�nal i�ave exammeo Inis eeWm.IncluQmg acrompanving scnetlules antl s19�emen6,antl lo Ine besl o�my knmrleage and�elref
en0 mmp�¢le.Declerelion ol pmpere�ot�e��nen��e parsonal�epre5en2Lve is�asetl on a .n�o�ma4pn u�wmtli prepaer'ius aM knowio�gv.
SIG� T�E O PERSON R PONS BLE FON FlLING RETURN pAiE
Aoa�Ess
� l� LICs I � S
2�z .0 e ti( - , ��. )1s6�,¢ � J7o � � 2�46�i.s—
SIGNATO�EO REP EkOi HHNHEPNE5ENIqINE OATE
AD�ftESS
PLEASE USE ORIGINAL FORM ONLT
Side 1
L 150561�105 1505610105 J
I /
J15056102�5
REV-0500 EX(F1)
Dece4enCs SoualSacurity Number
oe�eae��:mame�. James E. Kauffman
RECAPITULATION
1 RealLstatelScM1eauleA) . . . . . .. . _. . . .. . .. . . .. . . . . . .. . . _. . _.. t. 40,000.00
2 Stocks antl BonJs'(SGietluln B) . .. . .... . . .. . .. . ... . . .. . ... . .. . . .. . 2.
3. Closely Held Corpora�ian. Patlnarship or SoI�P�oprietoahlp(SCM1edule Gl . . . . 3-
4. Mortqages antl No�es Receivable(Schetlule 0). . . .. .. . ... . .. .. . . .. . ... . 4.
s. casn,eenk oepos-its ena Mlswilaneous Personai ProueM Ischeaub E).__. . . 5- 230,602.66
6. Joinlly OwneO Vroperly(Sclietlule F) O Sapereta 91111ng Nequested ._. . ._. 6.
]. Inteo-Vrvos Transfers 8 Miscellaneous Non-Pmba�e Propehy
(Schedule G) O Separate Bliling Raquestetl_ .. . . .. Z
8. To[al Gross Asse[s(to�al Lines 1 �M1mugh��. . . . . .. . .. . .. . .. . .. . . .. . . .. B. 270,602.66
4 Funeral Expenses antl Atlministra�ive Cos(s(ScM1eJule H�. . ... .. . .. . .... .. . . 9. 17,261.09
ip. �abts of�acetlent,Mortgage Liabili�ies and Liens(SCM1etlule I). . . .. . ... .. . . . 10. 74$_15
�1. Total Oetluctians po�al Lines 9 antl 10�. . . . . . .. . . . .. . .. . . . .. . . .. . .. . . n. 18,004.24
12. Net Value of Estate(Line e minus Line 111 . . . . . . . . . . .. . . . . . . . . . i2. 252,598.42
�3. CM1an�ableantlGovemmentalBequeslsl5ec9113Tms�s�orwM1icM1
an eleclion lo lax�as not�een matle(Scl�etlule J) . . . . . . . . .. . . . 13
14. Ne[Value 3ubjec[m Tae(Line�2 minos L�ne t3) . _. . .. . .. _. . .. . .. . . _�6_ 252,598.42
TA%CALLULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15 Amoun�o!Lina 14��xbla
Bl IM1B BpOU88I ld%(B�B,O!
Iransfers under Sec.9ti 6
(e)(L2)X 0_ 15.
i6. Amount of Line 14laxablc
a�nneairate x o45 252,598.42 �s. 11,366.93
t]. nmoum of Line ta taxabie
atsi�linqrate X.12 t].
18 Amounl ol I Ine 14�exablo
a�calle�e�alrate X.15 �5.
t9. TAX DUE . ... . . ... . . . ... . .. ... ... . .. . .. . ... ... t9. 77.366.93
20. FlLL IN THE OVAL IF YOU ARE REQUESTING A REFUN�OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205 J
RhV-0SOUGX(ql Gage3 FleNumbe�
Decedent's Complete Address:
ceceoemrsrvnme
James E Kauffman
�raEErnooaEss
4837 E. Trintlle Road
Cliv -. � SrqiE ziv
Mechanicsburg �"� PA 17050
Tax Payments and Credits:
1. Tex�ue�Page 2,Llne 19� �1) 11.366-93
2 Cretl��slPayments
A.PnorPaymenls .
B.Diswunl
- � TatalCretltls�A+O) Q)
3 Imeres.
(3)
1. Il Lme 2 is grea�er Nan Line�+Line 3,en�er�he tlif(erence. This is�he OVERPqYMENT.
Fill in oval on Page l,Line io ta request a refund (4)
5. I(Lne 1-Lme 3 a grealer Ihan Line 2,en'er�he DiHerence.iTis is Ne TAX OUE. (6) 11,386.93
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Dld tlecedent meke a t2nsler entl'. Ves No
a. reteinNeusearincomeo(Ihepmpetlylranslerteo......... ......._ ......_ ...._.. ❑ �
b. relaln�he righl�o tlesignete who shall use�he pmpeny Iranslertea on�s Income._........._........_.............._ ❑ �
c. re�ain a reversionary in�eres; ......... ...._.. ......... ......... ........ ❑ �
tl. receive Ne pmmse(or b(e ol ei�her paYmen�s,benelils or cere� ......... ......... ........ ❑ �
2 II dea�h occurred a(�er Dec.12. 1982,d�,tl decetlemlrangler property within one yearol dealh
withoutrecervicgatlequalewnsideration'+ .___ ......... ......... ........ ❑ �
3. Diadocotlen:ownan"in:msttor"or0ayable-upon-tleethbankawountarsecuriryathlsorherdeath'+. ._...... ❑ �
A. DItl deceden;own an mOiNtlud re�iremenl acwunt annui�y oro�he�norvproba�e O�ope�y.which
con�ainsabene�aarytleegnauo�7 ........ . ._..._ ..__.. —.... .. � ❑
IF THE ANSWER TO ANY OF THE ABOVE QIlE5TI0NS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For tlales of dea�h on orafler Julv 1, 7995,antl before Jan.1, 1995.�he�ax rale Imposea on Ihe ne�value of�ansfers to orfor�he use ot�he surviving spouse
�s 3 Pe�em�z P.s.gsi�s lal li.���'���.
Por da�es of death on or afler Jan. 7, 7995, the tax ra�e imposed on the net value ot �ransiers �o or(or Ihe use oi Ihe surviving spouse is 0 pemen�
[72 P.S§9116(a)(1.1)(li�].The s�aWte does no�exemp�a Iransfer�o a survi�ng spa�se fmm�ax,and the s1a�Wory requiremenls(or disdosure of assets and
filing a�ax raWrn are s�ill eppli;able even.�Ihe surviving spouse is Ihe only beneficiary
For tlates o(aeath on ar afler July 1,2�00:
. Toe tax rate Imposed on ihe net value of iransfers from a deceased child 21 years ol age or younger at tleath to or for ihe use of a naWral parent an
adoplrve parent or a s�epparent of Ihe child is 0 percent[72 PS.§9116(a)�1 2)�.
. ThetexraleimposedonihanetvaWeofiransfareloorPortheuseoilhatlecedenfslinealbenefcianesis4.5pemen�,exceplesnotedin�72P,5.§9116(a)(1��.
. The tax rate imposed on Ihe nel value of transfers ta or(or the use of the decedenl's siblings is 12 percent�72 PS. §9116(a��1.3)�.A sibling�,s de(ined.
under Section 9702,as an lntlividual who has at least one parent in common wi�h�he deceden�,whether by blood or adop�ion.
REV�lS@ E%:(t2�127
`'i�Jpennsylvania SCHEDULE A
... oecnmmervrornevervu[ REAL ESTATE
INNE0.pANCE TN 0.Eip0.N
0.ESIOEM OECEOfNT
ESTATE OF: FIIE NUMBER:
James E. Kauftman 21-14-0503
pll real property owned solaly or ee e tenent in comman murt Ee rcporte0 a[hlr market value.Fair market value is deMed as the pnce at which pmperty
woulE be exchangetl between a willing buyer antl a willing seller,nelther being mmpelleE to buy or sell,both having reasonable knowle0ge of the relevant faRs.
Rwl property that is 7aintly-ownW wlth riqht of survlvor6hip must be discloseE on ScheEule F.
Attach a coDY of Ne settlement shee[If the p�operty has been zold.
REM IntluEe a[opY of th¢EeeE showing decedenPs interes[if ownetl as tenan[in mmmon, �A�UE AT DATE
NOMBE0. OF DEATH
oesca�Pnoe
1� Raw Land on Werirville Road 40,000.00
TOTAL(Also enter on Line 1, RecapiNlation.J ; 40,000.00
It more space is neeGeG,use adEitional sheets of paper o![he same size.
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Page 1 of I
. Full Repart
Mas[e�
DisUict 21 Owner Name KAUFFMAN,JPMES E 8 BAROARA L
ParcellD 210403]1030 MallAtltl� 10]HOLLOWLANE
ProperryNtltlr WERTNILLERD MailAtltl2 DILLSBURGPAI]019
ClrySta[eZip PA SUEtlIvlslon
Owner�isplay JAMESE&BARBARALKAIIFFMAN HouseNumber
Las[Sale Dafe Year Bullt
Last Sale Price
Property antl Owner Informa[ion
Platlmage ProperryType RORESIDENTIAL-OUT-BWLOINGSON
CareotName LantlUseCOEe 109AUXILIARVIMPROVEMENTS
SCM1ooI�ishict 4 Lantl Descrip�lon LAND APPROX i ACRE
NelgborM1ootl 210� LotContloUnitlO
CensusTract 118.01 La11Wtle -]].016458
CensusBlkGrp 0 LonglWde <0281921
Assessment Values
LantlVdlue $39,500.00 BUIItl�ngVelu¢ $500.00
TotalValue $C000000 CleanAntlGreen
� Transfer�Saie�History
Builtling Characteristics
YearBvilt OeetletlAcres 1
EH Year Built StoAea
Llving Area SF 0 Owelling Type
LivingAreaFactor 0 Sewe�Type UNKNOVJN
LivingAreaTotal 0 ftoadType pIRTIGRV
LImltingFactors WaterSource NONE
file:///C:/Users/W indows/AppData/[,ocal/Microsofr/VJindows/Temporary°/a20Intemet%20F... 9/5/2014
aeuasoa ex+toa�iz7
�pennsylvania SClIEDULE E
�17 oeanArner+.orr+Evcxuc CASH� BANK DEPOSITS & MISC.
�r+xex�rar�cE*n.xE.uxn pERSONAL PROPERTY
aesmexroeceoervr
ESTATE OF: FILE NUMBER:
James E. KauRman 21-14-0503
IntluCe[he pmceeds of litigation anA Me Oate Me proceetls were receivetl by[he estate,
All propeety laintly owned with right of survivorship must be disclosed on Schedule F,
REM VAW E AT DATE
NUMBER DESCRIPTION OFDEATH
�, MembersislFCU-AccINo.2037-00 32.77
p, MemberslstFCU-AcdNo.2037-11 22,655.89
3, Trailer 500.00
q JohnDeereTractor 1,200.00
g Shed Contents 200.00
g Clothes 50.00
7 Metro 8ank-AcctNo.7760489306 196,973.68
g. MeUoBank-AcciNo.7760490273 1,346J3
g GunCollection(12total) 7,155.00
�p, PNCBank 488.59
TOTAL(AISo enter on Line 5, RetaOiNlation) S 230,602.66
If more s0ace is needed,use atlditional shee[s o(paper of the same size.
St
� 1�1�
MEMBERSI"
�oew�.caeorr v.ton
REGULAR SAVINGS ACCOUNT:
Account NumbedSuffix 2037-00
Date Account Established 0 V26/1973
Principal Balance at Date of Death $32.77
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $3277
Name of Joint Owner None
CHECKING ACCOUNT:
Account NumbedSuffix 2037-11
Date Accounl Established 01/17/1995
Principal Balance at Date of Death $22,655.49
Accrued Interest to Date of Death $0.40
Total Principal and Accrued Interest $22,655.89
Name of Joint Owner None
MEMBERS 1s'FEDERAL CREDIT UNION
�,/_id/�L � I�'!'Cml_ �.�n�
Leigh-Anne Stallings
Lending Insurance Support Supervisor
July 15, 2014
Esfate oi: James E. Kauffman
Date of Death: OS/14/2014
Social Security Number: 159-24-9526
5000 Louise Drive • HO. Box 40 • Mechanicsburg,Pen�sylvarila 17055 • (800) 283-2328 • www.memberslst.o[g
� KERRY'S
LAWN AND GARDEN EQUIPMENT CENTER
5220 E. TRINDLE RD.
MECHANICSBURG PA. 17050
717 697•3366
NAME: BARBARA MUFtRAY
ADDRESS: P.O. BOX 554 DILLSBURG PA.
PHONE NO.
DATE: SEPT.26 2014
PRICE WILL BE HONORE� UNTIL: WHILE IN STOCK SUBJECT TO CHANGE
MODEL DESCRIPTION Q7Y. LIST TOTAL PRICE �
Ia155 john deere Ia155 2010 modei year 1 $ 600.00
appox. Value $ 800.00
5x8 treller 2009 9 $ 400.00
appox. value
TOTAL PRICE:
LESS TRADE• IN:
SUB TOTAL; �
WHILE SUPPLY LAST T�: —
TOTAL: $ _
SALESMAN: JIM
08/21/2014 10:19 717-920-4666 DEPOSIT SERVICES PAGE 02/B3
METRO
BA N K 3801 Pazton Sireet 888.937.00D4
Harrisburg, Pq 17111 mymetrobank,com
8l21/14
Ashley ft. Malcom
Law Offices of Pete�J. Russo P.C.
5006 East Tnndle Road, Ste 203 �
Mechaniesburg, PA 17050
RE: Estate of: James E. Kauffman
Tax Identifcation Number: 159-24952fi
Date of Death: May 14, 2014
To Whom It May Concern:
This IeNet is in reterence to decedent acoount infortnation you requested for ihe
intlividual listed above.
We are able to provide the following:
AccountType� SV
Account Number. 7760489306
� Date Opened: 11/12/2012
Date BEcame Guardian: 01I24/2014
Date Closed: 07/08I2014
Primary Owner: James E. Kauffman
Guardian: Ba�bara L. Murray
Accrued Interest: ""$ 26.36
Date of Death Balance: $198,973.68
Account Type:SV
Account Number. 7760490273
fJate Opened: 12/09l2012
Date Became Guardian: 01/2412014
Date Clased: O6l03/2014
Primary Owner. James E. Kauffman
Guardian: Barbara L. Murray
Accrued InteresC"$0.10
Date o(Death Balance: $1,346.73
BB/21/2014 10:19 717-928-4666 DEPOSIT SERVICES PAGE 03/B3
i
METRO
BA N K 380� Paxton Stree[ 888.937.0004
Hardsburg, PA17777 mymetrobank.com
"Please note: The accrued interest will not be paid if the account Is elosetl prior to the
date the interest Is schetluled to post.
Please(eel free to wntact us at 1-B88-93�-0004 if we may be of further assistance.
Sincerely,
� JenniferJacobs
Research AssociatelDeposit Servites
Metro Bank
Entlosure
Estate Inventory/Appraisal
Prepared by
G. Creig Caba
Historian,Auc[ioneer,Appraiser,Antiquarian
2520 Lambs Gap Raad, Enola, PA. 17025
Phone 717-732-3204
Estate Appraisal for the late
Mr.lames Kauffman,
Who passed on May 14,2014.
Prepared forthe Estate at request of Mrs. 8arbara Murray
107 Hollow Lane
Dillsburg, PA 17019
Phone 717-514-7785
These guns were thoroughly and carefully examined with Mr. Murray present at his home in
Dilisburg. All items were in exceptionally good but used condition, having been the property of Mr.
Kauffman, known for his shooting and hunting interests. All weapons are of 20`"Century vintage and of
"modem"type. The price reflects a medium of retail and wholesale priws reflective of Central
Pennsylvania,ihus constituting a 'fair market price' as prescribed.
1. Thompson Center Arms,caL 50,k48511—description:a half stock engraved
flintlock with brass mounting of butt plate, ramrod holders,trigger guard, and
patch box. The octagonal barrel is heavily rifled. Modern vintage rather than
antique. (Rangeof$700to1000. Average=$850.00)
2. M-1 Carbine with custom scope, 61ued finish to metal and a handsome
refinisbed stock.Altered to single action for hunting purposes. A customized
smpe has been mounted on the top of the frame. Range$700 to 1000= $850
3. Winchester 12 Gauge Model 50. This Winchester has 2'/.inch�hamber and
checkering on the fore-stock and stock. A muzzle adaptor for flash suppressing
purposes was custom fitted.Some minor wear from usage appears on the rear
ofthestock. $650.00
4. Winchester'Nation-wide Turkey Federation "shot-gun of 12 gauge, Model
1300 with 2'/<and 3 inch pump action with camo grained stock and matching
shoulder strap. $400.00
5. Browning Arms semi-automatic shotgun, 20 gauge for 2'/.inch shells. It has a
lightwalnutstockwithincisedcheckeringonthewristandforearm. Believed
made in Belgium. $400.00
6. Winchester DO single bolt action with smpe rifle has a dark walnut stock with
fine checkering. It is of the 1940's era. Old, buf sturdy, leather military style
strap with some leather custom decoration, 5350.00
7. Winchester Model 88 lever action rifle with scope. It has a plastic butt plate,
fine smck with cross-hatching and oak leaf carved decoretions and attractive
leather shoulder sling. No.243. $350.00
S. "TIKKA" Remington—Model—G6515portwithover/underfeaturecapaciry-12
gauge and 22 caliber mmplete with scope, ornate checkered wrist and forearm
incised carving,and a fine leather sling. It operated as a single shot, users
choice. Rare&customized for owner. Range ot$1200 to 1800=$1500.00
9. "Beofors Steel -COLT-PTFA Hartford Cal. 222 Rifle with swpe and single bolt
action, No.56697. The stock is light weight and the wrist and fore-srock has
decorative incised checkering. A f ne leather shoulder strap is marked"Ruger'.
$500.00
10. Pistol/Handgun—Smith &Wesson (S&W) cal. 357 Magnum#581 with 4 inch
barrel,walnu[checkered grips and leather holster. Serial no,AAE6267. $600.
. 11. Pistol-Smith and Wesson (5&W)357 Magnum with 6 inch barrel,walnut
checkeredgrips, Modell9-3. Serialnumher2K42060. $70D.00
12. Original cased or boxed Model 7, Revolver,22 caliber short with drop-out
rylinder. Excellent original gun bluing surface. Imperial Met. Protector,
Kingston, NCmarkedandserialnumber39470. $450.00
I certify this inventory and appraisal and the values to the best of my ability and knowledge reFlec[
fundamental fair market estimated value. The Commonwealth of Pennsylvania, Department of State,
Bureau of Professional and Occupational Affairs in Harrisburg, Pa issued the Auctioneer/Appraiser
License active since Nov. 14, 1994. No. AU003324L with ezpiration date of 2/28/2015.
Thank you for the opportunity io assis[.
� ������
G.Craig Caba
Sept. 15, 2014
Copy of Will, dated 2/9/93 Noted:
Colin Murray was to receive: Colt 222 Caliber Bolt Ac[ion, Model 30S Cal. Winches[er, Model 50 12
Gauge Shoigun,Tikka 12 Gauge Arm-sport Model 4651,and Model 1300 12 Gauge Turkey Gun.
See Mrs. Murray for the signed document.
Oct. 9. 2014 3: OiPl1 PNC Bank No. 46�6 P. 1
� � I.,V�
October 9,2014
Peter S Russo
Law OFI"ices of Peter 7 xusso
5006 E Trindle Rd STE 203
Mechanicsburg,PA 17050
RE: 7ames B TCauffrnan
SSN: 759-24-9526
DOD: OS-14-2014
Deaz Mr. Russo:
� In iesponse to your request for Date of Death(DOD)balances for ihe customer noted above, our
records show the following:
Checking Account �
Account# 5115132882 Established: 11-04-2013
7AMES KAUFFMAN
BARBATtA T,MURRA'Y GDN'UCO
DOD balance: $488.59 +0.00 accrued interest
Interest paid OI.Ol-2014 tluu OS-14-2014$0.37 YTD
Please note thai this office provides date of death balances for deposit accounts(Ili,4s,CDs,Chec}5ng and
Savings). We do not process any financial transactioas or provide statements. Lf you need assistance wiih
zny of these items,please cell 1-888-PNC-BANK(1-888-762-2265)or stop by your bcal PNC Bank 6rmch
aftice.
Sincerely,
Natioual Financial Services Center
PIVC Bank,N.A.
Member FDIC
� This message is rntendedjor the ure of the individual or endty to which it is addressed and may
conarin inforrnation that is prrvileged, confidential and exempi from disclosure under applicable Imv.
If the reader of fhis message is not the rntended recipient or ihe employee or ogenr responsible for
delivering this message ro the intended recipienf,you qre hereby notified thar�vry dissemination,
distribudon or copying of this communications is strictly prohibited ifyou have received this
couamunicatton in error,please nohfy me immediately by reply or by telephone at 800-762-1775 and
immediniely destroy rhis fased documenY.
Page ] of2
0.[vdSID f%f(08�09)
,�i pennsylvania SCHEDULE G
Ti7 oevanrmervrornevervue INTER-VIVOS TRANSFERS AND
�NxEa�*Ar�ce*n�aE*uzN MISC. NON-PROBATE PROPERTY
xes�oeur oECEOErvr
ESTATE OF FILE NUMBER
James E. Kauffman 21-14-0503
Thls schedule murt be com0letetl and filed I(the answerto any of questions 1 through 4 on page Uree ol Ne REW600 is yes.
�ESCRIPTION OF GROPERTV
REM ixaweme�orwemu�sre�ee,mnaxannoxsmvmrccamruuo DATEOF�EATH %OFpECDS E%CLUSION TA%ABLE
NIIMBER TMEocrtmrewsrw. +*rna�cawcrTMEonoravFas+h. VAWEOFASSET INTEREST iruw<sa.E�� Vf'.UE
�. Metlife Group Life Insurance Claim No.2014 O6 01026 6,250.00 100 0.00
TOTRL(Also en[er on Line 7, RecaOitulation) S 0.00
1!more space is neeaeQ use atltlitional shee[s of paper of the same size.
�
FSGLi MetLife
OFFICE OF FEDERAI EMPLOYEES' GROUP LIFE INSURANCE
PO BOX 6080
SCRANTON.PA 18505-6080
September 25, 2014
Ms. Barbare L Murray
107 Hollow Lane
Dillsburg, PA 17019
Mr. Richard A. Smith
7417 Morningside Drive .
Silver Spring, MD 20904
Re: Insured—James E. Kauffman
Claim Number—2014 O6 01026
Amount of Insurance - $6,250
Dear Ms. Murray:
This lelter is regarding the Federel Employees' Group Life Insurance (FEGLI) benefits of James
E. Kauffman.
We want you to know that we are sorry for your loss and will do everything we can to help you.
The Metropolitan Life Insurence Company (MetLife) pays claims for the FEGLI Program
through its administretive office, the Oftice of Federel Employees' Group Life Insurence
(OFEGl1J. OFEGLI must pay the life insurance benefits to the beneficiary according to Federal
law, as described in the enclosed Order of Payment documenl.
7he terms, conditions and administration of the FEGLI Program is governed by federal s[atutes
and regulations contained in the Federal Employees' Group Life insurance Act (°FEGLIA" or the
"FEGLI statute"), 5 U.S.C. §§8701 -8716 and the federal regulations at 5 C.F.R. Part 870.
Payment ot proceeds under the FEGLI Policy shall be made in accortlance with FEGLI's order
of precedence 5 U.S.C. § 8705(a).
The Policy specifically slates in 5 U.S.C. Statute 8705, that the FEGLI benefits are payable first
to the designated beneficiary named by the employee in a signed and witnessed wriling,
received before dealh in the employing office, or if retired, in OPM.
Our office received a Designation of Beneficiary form from ihe Office of Personnel Management
dated March 20, 2004. A copy of this designation is enclosed for your review. It is unclear how
James E. Kauffman intendetl the FEGLI benefits to be distributed. Since this tlesignation is
ambiguous on tha distribution of the FEGLI 6enefits, we are unable to determine howthe
benefits should be paid.
Re: Insured—James E. Kauffman
Please review lhe enclosed copy of ihe designation ot 6eneticiary Form and inform this office in
a notarized statement as to your understanding of how the benefits should be distributed.
Our oKce will accommodate any agreement raached between the designated parties. If an
agreement cannot be reached, the distribution of the FEGLI benefts maybe determined by a
judicial resolution. Please respond within 30 days from the date of this letter.
For more iMormation on FEGLI policies, please visit the Office of Personnel Management's
website at: �mv✓.00m.aov/insure/life.
Please enclose the requested information in the envelope provided. If you have any questions,
you can call me at 315-792-6671, or you may call our toll-Tree number 1-8D0-633-4542.
Sincer
�
Adam Bice
Case Management Specialist
Enclosure
REV-15ll f%+(OB-13)
�pennsylvania SCHEDULE H
� .. oErnnlnervrornevcnue FUNERAL EXPENSES AND
�xxeannxcera�eae�uan ADMINISTRATIVE COSTS
aesmexroeceoexr
ESTATE OF FILE NUMBER
James E. Kauffman 21-14-0503
Decedent's debts must be reported on Srhedule I.
ITEM
NUMBE0. DESCRIGTION AMOUNT
A. FUNERALEXPEN4ER .
� �IGiant-Wncheon � � � � � � -� �� � �
41Z53
2 Aidare-Deltatir ��. . . . . . . . .. . . . .... . . .. ' ..�....1,317.00
.,.. .__ .. . . .
3 HollingerFuneralHome&Creamalory� � � � 11,768.80
j �-- _. . ._. . - :..-.. . , -. ... r , ._ ^:�._ . .
. ._. ..,__ . , . , .
_ . �_-:_ _ . . . ....
, : ..... .. .. _ .
.. __ _.___. . .____ .____ : �`
. .. _ ._.. .�.-:: _.._ ___._ .. . . .. .
i `_.___ _._. _.__. ... .___'___. _..___. . _. . __ ;�. . ...
B. ADMINISTRATIVE COSTS:
1. PersonalRepresenW[IveCommisslons: �� � ���� ��� �
F
Name(s)o!versonai Representntive(s) " � '" � � � �- �
StreM AGGress
Ciry SWte ZIP
Vear(s)Commission PaiE:
�. Attorney kes. �3,000.00
3. Famlly Exemption: QF EeceEenPs aGAress ls not Ne same as tlalmanPs,attach explana[ion.) i „_.: _ . ..
Claiman[
Street AdEress
CiN SWte 21P
Relationshlp of Clalmant to Oeadent
4. Probate Fees: '.. .. .... �. . . ,.75776
5. Accountant Fees', y � �
fi. Tax Retum PreDarer Fees:
' . . . .. . . . . . .. ... . . . . .
.___ . ..._ ____ ' . ...._ __. _ _. : �. .... .. .: .... . .
I_ ,_._-- ___-_. _ __.__ .._. . . . .... . .
� i ..._. .._ _. _ ,
, _. . :�- ,,. .. ....
L. '__...__._ .____.__. ... ._... . ._. ..____ .__ . __.. __. �. s.
... � _—_ __ _. . _ . _. . ._. . ... , .,.
�-. _�___ __. . .._ ( , .. ..,... .. . .. .
._ _, __"'"_ _:-_ .. ... _ . _ .... _
. . .__ . , t ... . , .. ... : .
._. .__.. . _._ _ _ . . ._ . . _ .... _. .. . _ . .... . .. _ . �;.. . ... . .
. ... _ _._.. ___ —._ . . .. . . .. .. . _ . _ ._ ...
�I . �. .... .
TOTAL(Also en[er on Line 9, Recapitulation) S�� � 17,261.09
If more space is neeGeG,use additional sheets of paper oF[he ume size,
in
q��� . . � � . .
HolIinger Funeral Home &Crematory, Inc.
Edc L. Hollinger,Supernlsor '
August 21,2014 . � �
earbara Murray � . � � � . .
107 Hollow Lane Road . � � - � . � . .. �
Dillsburg, PA 17019 � � . � � �: .
The Funeral5ervice forlames Kauffman: � � � �
We sincerely appreciate the mnfidence you have placed in us and will continue to assist you in every
way we can. Please feel free to contac[us if you have any questions in regard to this sta[ement.
THE FOLLOW ING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACIIITIES,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THATYOU SELECTED WHEN�MAKING THE FUNERALARRANGEMENTS.
Professional5ervice � � � � � .
TraditionalPackage �� . � . � . . . $5150.00 �.
. Merchandise .
Casket—FlatTopCherry . 4275.00
VaWt—Sentinel � 6iftEricandAnnan
MemorialPackage—DeerScene � �
Register Book, Memorial Folders, � �
Acknowledgement Cards,Bookmarks N/C
ATTHETIMEFUNERALARRANGEMENTSWEREMADE,WEADVANCEDCERTAINPAYMENTSTOOTHERS .
ASANACCOMMODATION. THEFOLLOWINGISANACCOUNTINGFORTHOSECHARGES. � �
Cash Advances � . �
Grave Opening � 900.00
Cemetery Equipment 375.00
CertifiedCopiesofDeathCertificate.(10@ $6) . � 60.00
Clergy . � 125.00
Flowers- Family Spray 212.00
NewspaperNotices—Sentinel 313.94 �
Patrio[ 357.86
Total Charges Paid in Full
� SOI NORTH BALTIMORE A4ENIlE • MOl1NT HOLLY SDRINGS. PENNSYLtlANlA I 1065 • (v19) 406-343s • FAX(]v) qeb-3215
www.hollinger(uneraihome.com
- . _ , m ,... ,
Posted Activity
Since Last Stetement •
. _ . ... __._ . . .... . .. .. .. ..__ . . . ._ .__ . . . . . ._ . . �
Trans Date Post�ate Type OescrioNon Amount
.."""__'"_"'__"_'_"""'__"""""""'__""""_"""""_"'___'__"'___""""""""""""__"_"_'_"
[j O6/042014 O6/092074 Sale SOUI}iHILL�FSIGNS §9.95
[� O6/02/2074 O6l022014 Sale SOUIHHILLDESIGNS $9.95
I� OS/1D2074 05/182014 Sale GWPR6310 $47Z53
❑ O5/16/2014 05/162014 Sale SOURiH0.L0ESIGNS $2.99
� OS/14/2414 OS/152014 Sale �ELTAAIR�060767839541 $25.00
� OSH4/2014 OS/t5/20t4 Sale OELTAAIR0062182835430 $633.50
n 05/74/2014 05/762014 Sale OWIKH2STFAKEANOLUeE $43A2
� 05A4/2014 OS/152014 Sale �ELTAAIR00621B2B35431 $633.50
� 05/14/2014 OS/15/2014 Sale �TAAIR0060767839540 $25.00
�] 05l12/2014 05/132014 Sale GRC'MFBEAUlY2of3 ' $39.95
❑ O5l09/2014 OSA22014 Sale SOIfiHHILL�ESICaNS $236.57
❑ 05/09/2014 OS/11/2014 Sale BOSCOVSI2 $185.82
�� OS/07/2014 05/07/2074 Payment PayrtenlThankYou-Web -$100.00
[� OS/07/2a14 OS/082o14 Sale H07lMRESAL6 FlNAL $450.00
�] OS/OS/2014 OS/07/2014 Sale SOIfIHHILLDESIGNS $238.39
�� 3�f.S3 �"�'u-�
in Ws./roards.chaze.cm✓NAccamVACANryai728]615
ii�.a�az�aioi� � -
w,w�r_ —Registero£Wills �d — '
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CUMBERLAND LAW JOLRNAL
32 SOUTH BEDFORD STREET
CARUSLE, PA lyoi3
Telc (TJ)�493�fi6 Fa:(]Il)R693663
September 5, 2014
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: Peter J. Russo, Esquire
RE: James E. Kauffman Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
August 22, August 29 and September 5, 2014
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Paymentreceived $ 0 .00
Total Amount Due $ 75.00
Payment received by
111C SCIII��•CI P�ER J.RUSSO,ESQUIRE AD NUMBER PAGE NO.
ww..��m
6e,li�k.�om SOO6EASTTRINDLEROAD q33295 tofl
SUITE203 — —�- ------_.___.
�� MECHANICSBURG,PA 17050-0327 ___ BILL DATE SA�ESPERSON
ozuvE s�mxvmuc rz.e.raam 777-591-0755 08/29/74 woltc
START DA7E STOP DATE
—_'—___. —'__ _._.
08/75lib OB/29/74 �
�N��� PD D SCRI T N CU55 LINES
433295 EXECUTOR'S NOTICE LETTERS OF ADMIN 10 PUBLIC NOTICES 46 • 2 cols
Publication Insertions Rate NetAmount GrossAmount
3THESEMINEL-LEGAL 3 LGL 5244.26
TOTAL AD CNqRGE $z44 Z6
3PROOFOFPUBLICATION 01PRF $�.00
3 MOBILE SITE MOB2 §3.00
PurchaseOrder Est.J.Kauffman PAY THIS AMOUNT $25426 $305.11'
'AFTER 09/23/id
Lee Enterprises no Ionger accapts cretlit card paymenls sent via e-mail. ------
Emails containing credi�card numbers will be blocked. Please use�he coupon
below to sentl credit card payment to our lockbox. THE SENTINEL
You may aiso send the coupon to a secure fax at 319-291-4074.
c/o LEE NEWSPAPERS
Thank you for advehising with The Sentinell Oeadline for PO BOX 540
in-column leqal atls is 4:00 p.m. two 6usiness days prior to W�17ERL00 IA 50704-0540
date of Insertion. For questions,call(717)24�-7130.
rrnu.��mspomo�vdmyou.paymem Legal
THESENTINEL ❑ ��k# ___.__ _ �Credi�Card qdNumbe� iI <33295
c/o LEE NEWSPAPERS ❑ � ❑ ws.� Q � ❑ � gillin9 D_te_I— 08@9/14
PO BOX 540 (" �' �
WATERLOO IA 50704-0540 �a I—�l��('T� I I I I � �� qmaun[Due $ 254.26
Fap.Oale:l I ' �� " ���
Rmount'��I
rvemamaecicare __ ____ pnclosed--� $
�P�ewre '___"' �..�a�-
_ __.__"__—__..____
�e�emau�cn«�spa�,dem: �THESENTINEL
w` °°0191 THESENTINEL
� PETEft J.RU550.ESQUIRE 4o LEE NEWSPAPERS
5006 EAST TRINDLE ROAD PO BOX 742548
SUITE203 CINCINNATIOH 452742508
MECHANICSBURG, PA 17050A327 ���n������u�i��������u�������l��u�����v�u����������n,��
21540200�000�433295000��000000��003051100000254269
REVA533 EX+(Qdl)
�pennsylvania SCHEDULE I
oevurtnexravaevervue DEBTS OF DECEDENT�
�xrerucwaTu�ruax MORTGAGE LIABILITIES & LIENS
�smerrt o[�oexr
ESTRTE OF FILE NUMBER
James E. Kauffman 21-14-0503
Report debb IncurreE by the EeceEent prlor to EeaM Nat remaineE unpal0 etlha Oata af tlaeth,Includinp unrelmbur9eE madlul aapen�as.
REM VALUE AT DATE
NUMBER �ESCRIPTION OF�EATH
1. .Dr.JeHreyMarks . .. . . . . . . . . . . 51.87
, 2 CouniryMeadowsatHome � �� V�� �� 776.00
, 3.�, GoldenLrving _. . .. .. _. . . . . .._ . ._. .. . _ _ .. . . � :< . . 6179
. ..,_ :: _, . .. . _ ........ .
. .. _ . � . . . ,. x:.�.._ ,_ ^. . ...
:� 4. 'Diamond Pharmacy I, � ,� 93.49
' _. -::.. _. ..,._..: _._.-.: ... �.c;�. .
r .--'
�. S I Ven Steck '�. �� 160.00
. � _.. _. . ..,.. . .. .
'�. � e CraigCaba-GunAppraisal �� � � �� 200.00.
� —.:— : �.-, :_:- _.,.: .:':'. ' . ... .
� _ : - 1
. .-..- ._ . _... . . . . . . _. . . . ......_ .
� �i �,.�.v ��: ' .
'� _._. ... _. _ .___. ....__. ,. �,.., .
. �-. . .-. ... _. ..... _ . ._.
. .,W.�.. �..
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, ,_�, .. . __ .. _. .. . . . . ... . ... . , ��...: _ ._ .
, -.. . . . .. . . . ... . .. .. . ._.. i:�.. � '.L., .0 ,.
� . __ :_-. .__. ... . ... . . . . .. r.�. . .. ._� . .
i 1
. .__ __. .. _ .. .. ._ . _. � r...:.. . . .. .. . .
. ._ .. _:. _:: ,_ . ._ ., ,.._. , .:
¢.
L ___ _. __ _—. 1 4.,e.. » .. .. ..
. "__: .-:.. .._ .__ __.. .. ...._.. _..___ _. .. ..... .
� �
.... . _ : . � � . . . . . . .... w.....
i , . . . . ... .
7w..
E
_ .. __.. _... '� .�... . ..,..
-_-._. :.:�,- . . �-. _ .:.._ _::�_ . ._ . . �.....,.. . ._ _:._ .
i: y
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. ._. ._,: __... ... . . .. ... .. . _ .. k, ._ . .. . .
e
_._. . _. __... .. . . .. _._ �t -..... . :._. . ..
:. _._. _ ___ .:_� ..._ t.,`_.. . ._'.. .:
.. .___- .:._.. ___ . .
.. _. ._.. .... . ..! �.._.. . ._ .. . ._
, ::., . . : :-- . .. . .. . _ _ . .. . . �-.i.'. ':�Jr�
� ____ ___..___. _. _. _____. ___._. . �..:..�
. ..__ -__ . .. .___ . . ... . �,... ...� . .
, r—__ _'____.. _:. , ..._. . ..._. .. _-._ ..,. .._... .
i t
� . �,�, �..,. .. �
TOTAL(Also enter on Llne 10,Recapi[ulation) S�^ � � �43.15 ��.
If more space is needed,insert additional sheets o(the same size.
�. ---
Phona: 717-697-7602 �)MASTERCARD�� �� - OVISA -�-
—_�—'— _ .__
� �rtl Number CVG �Amount
James E Kauffman
_- —__'.- _�_
4833 E, Trindle Road � Signawre Exp Date "�l
Mechanicsburg, PA 17050 � i
... - _- _—_. _ —_ .. ..- - '_—__' _ _. __—_' _'—__. .
. ____ " - _.._
.. . - — _' — " n.::aemm�w�a+� a a.nn>.rm�m . . . .
Charges and Related Paymenis for James E Kauffman . � �
ServiceDale Provider Description DataPostetl Charges C�edits Remaining
1/9l2014 JSweeley 11]21DebtldemenlolToenails(640) $65.00
ProviderAtljus�men[ ��pp�yp�q $21 ��
PA MEDICARE Check 1/22/2074 50.00
Allowetl:$4329 �etluc�ible:84329
APWU Check 1/30/2014 $0.00
PatienlResponsible 1/30/2014 ga8P9
10/31/2013 JSweeley iV2lDebtldemeNOfToenails(6-00) $65.00
PmdtlerAtljuslmen� 11/18I2013 gyy_gp
PAMEDICARECheck it/1B/2013 $33b2
Allowed:$42,89 Co-Iwurance:$B.SB
APWllCheck 1/30/2014 50.00
Palien[Respansible 1/30/2014 $8.58
TolalCharges: E1]0.00
Total Credlis: 5�g.»
Balance Due: $5'1.87
0-29$a�ys�Oua � 30-59 Days Due � 60-89 Oays Due gpa pays Due�
so.ao so.o0 . -.
ss�.e�
- - -� --� — --- -----. _ __.—__ --.
_— —
This is your las[statement. This account will be�Wmed over b.collec�ions�i(no paymenfis made wilhin 10�days: �
Should your account tall more than 90 days past due, il will be turned over to a collec�ion agency and accrue additional
collection fees.
Dr. Jeffrey A. Marks, DPM Page 1 James E Kauffman (Acct: 423780660461
i;
�I
, . . . . _ . . . .. L
Country Meadows At Home STATEMENT � � �`9t n�ewous �
PO Box 3060 o me.
Hershay, PA 17033 4�,
Phone:(888)7542220 Pe.:o�a1Ca.�5m�tces I
Fax:(7'A)520-4760 .
www.countrymeadowsathome.com oate: os/zOnoia �'�'�
Clienl Name:Kauffman,James ��1�
Aocoun�#: 030]2 I'li
JamesKauftman P ge# � �'
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05/O6/2014 Balance(orwartl
OS/18/2014 INV#243t7. 1]6.00 176 0a
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1-300AY5 31-60DAY5 6b90DAY5 OVER90DAYS
CURRENT PAST�UE PAST�VE PASTDUE PqST�UE AMOUNTDOE
1]6.00 0.00 0.00 0.00 0.00 $i"/6.00 f.
Terms: Due Nhihin 14 Days Of Recelpt You may pay by VISA, Mastercard, American Express or Discover On Line at �
https'//counlrv d b II qtl c t or by phone[oll free 1-855-532-7103 = ':�
PLEASE DETACH AND HETl1flN B0170M SiUB WIiH YOUP PAYMENT
MAKE CXECKS PAYAHLE TO: 4^.
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A� 't45u7 Stalemenipate: AcwunlNumber' �j:.
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PO Bo%3060 �
Hershey, PA 77033 $��6�0a t;��.
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PO Box 3060
Hershey, PA'17�33 ome, I�
Phone:(888)754222� P¢..o�dCa.�S�.ma. (i
Fau:Q'I�)520-0�6D
www.countrymeatlowsathome.com oate: os/2o/zoia i'.I
_ Clienl Name:KaoHman,James �i
Account#: 03W 2 I%
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JameaKeuffman Pa0 # 1 ��
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OSA B/2014 INV il24317. 176.00 1]6.00 I„I
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CUftftENT PAST�UE PqST�VE PASTDUE PASTDUE AMOUNTDUE
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176.00 0.00 0.00 0.00 0.00 $1'l6.00 - �'
Terms' Due Wthin 74 Days Of Recelpt You may pay by VISA, Mastercard, American Express or Discover On Line at -
httos�//count vmead b'll' qtl 1 or by phone toll free 1-855-532-7103 „
pLFASE DETACH AND FETl1flN BOTfOM SiUB WITH VOIIA PAYMFNi
MHKE CHECKS PAYqeLE T4 �
A� "F:E71A $IatemenlDele: AccountNumber: r;_
�0711P. 05/20Y2014 030]2 '-.
� � Country Meadows At Home �u��o�e: A,,,o,,,,�E„aosea: cr,tik rv�m�,: ;�e-
PO Box 3060
Hershey, PA 17033 $1]s.oa -
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AMEHIGAN VUSIAL WUHKt NONE
CAILNUMBEP: '15'314�3�W DATEOFCALL: 44l3012014
- FROM: HOLYSPIRITHOSPITAL
TO: GOLDENLIVING
ACCOUNT SUMMARY
JAMES KAUFFMAN
Wo BARBARAMURRAY TOTALCHAflGES: fi���9
107 HOLLOW IANE PAYMENTS/ADJUSTMENTS: 0.00
DILLSBURG� PA1]019 PLEASEPAYTHISAMOl1NT: s���9
_ DETACHALONG PEflFORATIONAND RETUflN STUB WITN PAYMENT _
� OESCRIPTIONOFCHARGE Ul1ANTITY UNITPRICE AMOONT
WheelchairOneWayTranspoM1 A0130 1.0 59.45 59.45
TranspoR Van Mileage 50209 0.5 4.fi8 2.34
Total Charges 6179
DESCRIPTION OF PAVMENi FECEIPT PAVMENT OATE AMOUNT
Total Credits 0.00
PI_EASE PAY 7HIS AMOUNT-INVOICE DUE UPON RECEIP7 --� $6179
RETURNEO CHECK FEE-$37.00
PATIENTNAME: KAUFFMAN,JAMESE CALLNIIMBER: Z�J3'I4737W AMOUNTPAI�:
05/23/2D14
1MPORTANT MESSAGES: This ServiCe IS no[COVefetl by youf 7nsufance. Please remit
payment to our office.
WEST SHORE EMS- BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708
Stalemenf Oate: o5/13/14
. KAUFFMAN,JAMES Balance0ue: $93.49
GO BARBHRA MURRAV
107 HOLLOW LAND Amount Enclosed:
OILLSBURG, PA 17019
" � _
All accamts with outnanding balances will be
assesseE al ihe rale o11.5%per monN(18%annual).
Sta[ement�ate: 05/13/14 Dlamond Phartnacy
645 Kolter Ddve
CustomerNumber. q7g�5 Intliana,PA 15701
Facilityl�: CMW54 (B00)882-633]phone
CustomerGroup: p752 (72h)349-t111to11-free
Balance Fonvard
54Bf B6
Payments
Check�ate I CheckNumber Amount
OiN>/14 I 900006 (5Y�686)
OSN1Hd 90000] (5135]2)
New Activity �
Date Wc No Orug Name qty Price Ins.Pay Amt Pat Pay fvnl
Invai[e-IN00094519
KAIIFFMAN,JAl.ff
09/0</1q SCC216 R%-LISINOPRIL TAB20MG 03 $E2] $000 mpay $A2J
09I04/14 509220 PX-NmOXI/KQAVTABB]5MG B SfiOI E000 mpay E80]
Od/Od/t4 SOOII3 . R%-NoroLOGINJ100/ML 10 E113.t2 $109B0 mpay 543.P9
MI04/19 599424 RX-MONOJECTSAFEINS9]ML39G1 ' � 100 � SE055 530.41 ,copay 510.14
J:iGdif4 SJ62@ GTC-r1LCOHGIPREPPAOS 2C0 E?85 bJ..L acd5
OIHO/14 54]909 H%-MIRTP2APINETABISMG 15 5]J 50.00 mpay �, $3<6�
OE/tV14 548620 OTC-OERMACERINCREAM 1�6 St6 50.00 ��. Y160
W/1BIW 5190i1 OTC-PROSHIELO GREPWS t2o ye.6 EooO 50.6>
04121/iC 5q6202 OTC-ALCOHOLPREPPAOS 100 E20 $OA� �. II89
04121/iC 506363 RX-MONOJECTSRFEIN512ML39G1 ' 10� fE05 53041 copay I $10.14
IN00049519BTMals =--__ I _-- _______
TotalLeqentl-INOOdb5198 S0fi8.02 519U.66 59]d6
TotaIOTC-INOOD195198 St6d� SO.UO f�6.13
TONI-INOO4G45190 5384.1 5190.66 . f9].49
StetemenlTotals . . . . ��'�
To: Barbmurtay�mmcast.net
Subject: Bill for your father
Hello Barb,
Abby asked that I send you a bill for the care I helped with your dad.
Monday 5/12 lhr @ &16/hr
Tuesday 5/13 6hrs @$16/hr
Wednesday 5/14 3hrs @&16/hr
Total:$160
I was glad to be able m help yourfamily
ThankYou
len Steck
Sentfrom myiPhone
l
REV.1513 E%4(01-10)
� pennsyLvania SCHEDULE J
oEo<a.M...oFa�,�E
�x„E,,,,�,�E,,,aE,,,a„ BENEFICSARIES
0.ESIDEM DECEOFM
ESTATE OF: FILE NUMBER:
Estate of James E. KauHman 21-14-0503
REIAIIONSHIP TO DECE�EM AMOUNT OR SHARE
NIIMBER NAME AND A�00.ESS OF PERSON(S)RECEIVMG PROPERTV Po Not Lla[Truftee(s) OF ESTATE
1 TA%ABLE DISTRIBUTIONS[[ndutle ouMght spousal tllstdbutions and trans�ers unEer
Sec 9116(a)(1.2),]
�� RichardA.Smilh Son 20%
2. Carol Yost Daughter 20%
3. Paul Smith Son 20%
4. CindyLaskowsky Daughter 20%
5. BarbareMurtay Daughter 20%
ENTER�OLUR AMOUNTS GOR DISTRIBUrI0N5 SHOWN A60VE ON LLNES IS THROU6H IB OF REV-1500 COVER SHEET,AS AGPROPRIATE.
I� NON-TA%ABLE DISiRIBlITI0N5
A. SPOUSAL pISiRIBUT10N5 UNDER SECTION 9113 FOR WHICH AN ELECpON i0 TA%IS NOTTAKEN:
1.
B. CHARITA9lE AND GOVERNMENTAL�ISTRIBUTIONS:
1.
TOTAL OF PART ll-ENiER TOTAL NON-TA%ABIE DISTRIBUTIONS ON LINE 13 OF REVd500 COVER SHEEL S
If more space is neeGeE,use adtlitional sheMs of Daper of the same si:e.
��
LAW OFFICES OF
PETER J.RUSSOr.c.
Pe�er 1.Rossq Esquire ATTORN EYS AT IAW Ashley R.Malcolm,Pa�alegal
Kathlern Mis�urak-Gingrich.Esquire^ Uerck M.Slmuphaucc Paralegal
Lin�sny Cingrich Maclay,Esquim•• Laorie L. Wa�son,Pn�alegal
Jrnmfu Spews B�enlze,Esquire Melissa M.NehafTey,Pn�alegal
Uavld C. Dagle, Csqoire 'I'ara E. Bullen,Lcgel Seeretary
l'homb D.Gould,Csq�irc
••edmin.a��rn&w
Mondav. Februarv 09. 2015
Register of Wills
Cumberland County
1 Courthouse Square
Cadisle, PA 17013
RE: Estate of James E. Kauffman, Deceased
Uear Sir or Madam:
Enclosed please find the original and one (2) eopies of the Revenue 1500 and check no.
]7-15905 in Ihe amount of$l 1,648.18 i�regards to the above mentio�ed estate. Kindly file the
original and forward the time stamped copies in the envelope provided.
Should you have any questions please feel free to contact our office. Thank you for your
assistance in this matter.
�ry truly yours, L� '/
Ashley R. � •olm, Paralegal
Enclosure
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