HomeMy WebLinkAbout01-0082
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF PENNSYlVANIA
OEPARTMENT OF REVENUE
OEPT.280601
HARRISBURG, PA 17128-0001
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Klingensmith,RaffaelaR.
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
01/03/200 I
07/23/1922
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDL.E INITIAL.)
2. Supplemental Return
1. Original Retum
w
~~V,I 0 4. Limited Estate 0
,,~~
w~" 0 0
::t:~g 6. Decedent Died Testate (Attach copy
"~m of Will)
~
., 0 9. Litigation Proceeds Received 0
QfnCli\L USE ONLY
I
FIL.E NUMBER
21 2001
COUNTY CODE YEAR
SOCIAL. SECURITY NUMBER
00082
NUMBER
196-16-5355
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
3, Remainder Return {date of death prior to 12-13-82}
4a, Future Interest Compromise (date of death
after 12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10. Spousal Poverty Credit (date of death between
12-31.91 and 1-1-95
'iAL~R ~~~liIbEI~ Il C
o 5. Federal Estate Tax Retum Required
8. Total Number of Safe Deposit Boxes
o 11.Election to tax under Sec. 9113{A) (Attach Sch O)
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~~
",0
OZ
"Ii'
THill ll~TIOllIMUllT,,!;iE C~
AME
Samuel VV.~ilkes
IRM NAME (If applicable)
JACOBSEN & ~ILKES
'0 BliIl' RE
EL.EPHONE NUMBER
717/249-6427
1. Real Estate (Schedule A)
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3
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it
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~
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
52 East High Street
Carlisle, PA 17013
(1)
(2)
(3)
(4)
(5)
(6)
(7)
OFFICI/IL lJSE ONLY
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
-0-
-0-
-0-
-0-
29,474.54
5,412.17
-0-
(8)
34,886.71
(9)
(10)
10,166.79
1,305.41
(11)
11,472.20
(12)
23,414.51
(13)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not
been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
23,414.51
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
Z 23,414.51 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
"
;!
~ (17)
~ 17.Amount of Line 14 taxable at sibling rate x .12
~
0
"
~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
1,053.65
1,053.65
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
1029 Northfie1d Drive
CITY
Carlisle
[STATE PA
[ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
1,053.65
Total Credits (A + 8 + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
(3) 0.00
(4)
(5) 1,053.65
(SA)
(58) 1,053.65
TotallnleresVPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
8. Enter the lolal of Line 5 + SA. This is Ihe BALANCE DUE.
Make Check Payable 10: REGISTER OF WILLS, AGENT
Wmlmmlmlmmllllm~IlIII..mmll.llmmlllllUmllllllllmllllll.lIII_nmml.im1.III1I1I_1_lIIIml.IIIIIIIIIII..m.IIIIIIIIII.llillllllmmllli
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE 8LOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................. ~ I
~: ~:::~ ~h~e~~~:i~~~~s:~~:r:s;~~.~~~~I..~~~.~~~ .:.~~:.~~.~~~~~~~~~~~. ~~.~~.i.~.~~~~:~ .':~ ::::~~:~ ~:~ ~:~ :::~: ~:: ::: .':.
d. receive the promise for life of either payments, benefits or care?.........................................................
2. If death occurred after December 12,1982, did decedent transfer property within one year of death without
receiving adequate consideration?... ............. ... .......... ...... ... ... ... ..' ... ......... ... ..' ........... ... ...... ............ 0
o
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3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.....
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?......... ......... .......... ............. .......... '" ........................... ... ........... ................
181
181
181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury. I declare tM11 have examined this relum, includinfj accompanying schedules and slalements, and 10 Ihe besl of my knowledge and belief, il is true. correct
and complete.
Declaration of pre parer other thar.lhe peffiOl\al representative IS based on al\ IfIforma\ion of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
. ~1
LE FOR FILING RETURN
625 Adams Road
Carlisle, P A 1701
7-/~-';OOI
ADDRESS
DATE
ADDRESS
DATE
52 East High Street
Carlisle, PA 17013
1..\
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
172 P .S. ~9116 (a) (1.1) (ii)l. The statute does not exemot 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 twenty-one 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% [72 P.S. 99116 (a) (1.2)].
The tax rate imposed on the net va.lue of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116
1.2) [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% [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.
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SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DEceOENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21 - 2001 - 00082
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the
price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having
reasonable knowiedge of the relevant facts. Real property which is jointly-owned witn right of survivorship must De disclosed on
schedule F.
ITEM
NUMBER
1 None
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on Line 1, Recapitulation)
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SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21 - 2001 - 00082
All property jointlyoo()wned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE
NUMBER OF DEATH
1 None
TOTAL (Also enter on line 2, Recapitulation)
.
SCHEDULE C
CLOSELY.HELD CORPORATION,
PARTNERSHIP or
SOLE.PROPRIETORSHIP
COMMONWEALtH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21-2001-00082
Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the
decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM
NUMBER
1 None
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on Line 3, Recapitulation)
.
SCHEDULE D
MORTGAGES & NOTES RECEIVABLE
COMMONWEALTH OF Pf:NNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21-2001-00082
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1 None
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on Line 4, Recapitulation)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DeCEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21 - 2001 - 00082
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorshIp must be disclosed on schedule F.
ITEM
NUMBER
I Personal property
DESCRIPTION
VALUE AT DATE
OF DEATH
1,401.00
2
M&T Checking Account and M&T Money Market
24,732.22
3
Cash
46.00
4
Proceeds from the Estate of Leo E. Valasek
2,500.00
5
Refund from Sprint
73.80
6
Refund from Comcast Cable
13.92
7
Refund of security deposit
650.00
8
Refund from Lititz Mutual Insurance
54.00
9
Refund from Publishers Clearing House
3.60
TOTAL (Also enter on Line 5, Recapitulation)
29,474.54
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SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21 - 2001 - 00082
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
A David Klingensmith
ADDRESS
RELATIONSHIP TO DECEDENT
625 Adams Road
Carlisle, PA 17013
Son
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LETTER DATE Include name of financial institution and bank account number DATE OF DEATH
ITEM FOR JOINT MADE DECO'S VALUE OF
NUMBER TENANT JOINT or similar identifying number. Attach deed for jointly-held real VALUE OF ASSET INTEREST DECEDENT'S INTEREST
estate.
1 07/13/1999 Armstrong Assoeitaes FederalCredit Union Account 10,824.33 50% 5,412.17
TOTAL (Also enter on line 6, Recapitulation) 5,412.17
'W
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Klingensmith,RaffaelaR.
FILE NUMBER
21 - 2001 - 00082
ESTATE OF
This schedule must be completed and filed if the answer to any of Duestions 1 throu h 4 on paQe 2 is ves.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF
NUMBER Include the name of the transferee, their relationship 10 decedent and the date of transfer. \/ALUE OF ASSET DECD'S EXCLUSION TAXABLE VALUE
Attach a copy of the deed for real estate. INTEREST (IF APPLICABLE)
1 None
TOTAL (Also enter on line 7, Recapitulation)
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SCHEDULEH
RJNERAL EXPENSES &
ADMNISTRA11VECOSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21-2001-00082
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
1 Ewing Brothers and Mantini Funeral Homes 8,076.60
2
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Nurnber(s) I EIN Number of Personal Representative(s):
Street Address
City State - Zip
Year(s) Commission paid
2. Attorney's Fees JACOBSEN & MILKES -- Samuel W. Milkes 1,744.33
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 95.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
I Rowes Auction Service 75.00
2 Publication Notice to the Cumberland Law Joumal 75.00
3 Publication Notice to the Patriot News 100.86
TOTAL (Also enter on line 9, Recapitulation) 10,166.79
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21 - 2001 - 00082
Include unreimbursed medical expenses.
ITEM DESCRIPTION
NUMBER
I Borough of Carlisle
2 Blair
3 Sprint
4 PP&L
5 Comeast Cable
6 Karen Coon
7 Larry Wa!ker
8 PP&L
9 Carlisle Hospital
10 Darlene Moyer Tax Collector
II Davidson Memorials
AMOUNT
53.91
44.80
61.84
119.37
33.91
650.00
20.00
221.68
35.00
9.90
55.00
TOTAL (Also enter on Line 10, Recapitulation)
1,305.41
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Klingensmith,RaffaelaR.
I FILE NUMBER
21 - 2001 - 00082
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
RELATIONSHIP TO
DECEDENT
n.
AMOUNT OR SHARE
OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
I David A. Klingensmith 625 Adams Road,
Carlisle, PA 17013
Son
One fifth of remainder
2 Richard Klingensmith 514 Grahams Woods Son One fifth ofremainder
Road, Carlisle, PA 17013
3 Janice Kellar 436 Donnell Road, Daughter One fifth of remainder
Lower Burrell, P A 15068
4 Beverly Shaffer 1337 4th Avenue, Ford Daughter One fifth of remainder
City, PA 16226
5 Linda Rodina 4420 Manor Hall Daughter One fifth of remainder
Lane, FaITfax, VA 22030
Enter dollar amounts for distributions shown above on lines 15 through 17, as appropriate, on Rev 1500 cover she t
II. NON-TAXABLE DISTRIBUTiONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX is NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHE T
PETITION FOR PROBATE and GRANT OF LETTERS OF TESTAMENTARY
Estate of: ~affaela B l{bngepsmitb
Also known as
,Deceased.
No. 21-01-82
To:
Register of Wills for the
County of Cllroberland in
the Commonwealth of Social
Pennsylvania
Social Security No. ] 96-16-5355
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older and the executor David A
Kljng~nsmith named in the Last will of the above decedent, dated A11g11st 27, 199.9... and
codicil(s) dated
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decedent was domiciled at death in Cllmberland County, Pennsylvania, with his last
family or principal residence at 1029 Northfield DrilT~, North Middleton Township]
Carlis1p, PennsyllTallia 17013
(list street, number and municipality)
Decedent, then -18-years of age, died JanlH~ry 3] 2001 at Harrisbnrg Hospjtal]
Harrjsb1lrg] Da11P l1in COlluty] P A
Except as follows, decedent did not marry, was not divorced and did not have a child
born or adopted after execution of the will offered for probate; was not the victim of a killing
and was never adjudicated incompetent:
Decedent at death owned property with estimated value as follows:
(If domiciled in Pa.)
All personal property
$
(If not domiciled in Pa.)
Personal property in Pennsylvania $
(If not domiciled in Pa.)
Personal property in County
$
Value of real estate in Pennsylvania
$
Situated as follows: Estate opened for
/6' -.cQCJ8-//
21-01-82
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and
codicil(s) presented herewith and the grant of letters
testamentary theron.
Name
Relationship
Address
David A Klingensmith Son
j)a4!l~
k~~
625 Adams Road, Carlisle, PA 17013
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
ss
COUNTY OF CTTMR~RT.A NO
The petitioner(s) above named swear(s) or affirm(s) that the statements in the
foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s)
and that as personal representative(s) of the above decedent petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
Before me this ~hday of January, 2001
I
~?2'd/ cf,5jic / // <1" (J//~() C · A..:t"" ~<.L;i'
R glstet . j
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Name
)~~/~
Address
Name
Address
No. 21-01-82
Estate of R~fff'(\l~ R Klingensmith , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW JANUARY 18 , 2001, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated Allg11~t 27} ] 999
Described therein be admitted to probate and filed of record as the last will of
Raffaela R Klingensmith
and Letters TESTAMENTARY
are hereby granted to David. KliJ1gensmjtb
,~~,:~~[y~,/~ /2~ j'~/<ao/
FEES
Probate, Letters, Etc. . . . . . .
Short Certificates ( ). . . . . . .
Renunciation. . . . . . . . . . . . .
x-pages
JCP
$
$
$
$ 15.00
5.00
TOTAL $ 95 00
Filed.. .JANUARY.18,. .2001................
60.00
15.00
SaID11el W Milkes} Esq
ATTORNEY (Sup. Ct. LD. No.) 30130
J ACORSEN & MIIJKRS
52 Rast Higb Street
Car]l~le} PA 17013
(717) 249-6427
Phone and Address
c2~- az&~~/
Tl~' ;-0 certlly t;lat tile information here given is correctly copied from an original certificate of death duly filed with me as
Lo:.;d R\.:'gistrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph,
Fee for this certificate, $2.00
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P 6947723
No.
21-01-82
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. 1-1001 1'iJ;,r.
~~~. ~bJ.-~~~~
Local Registrar
JAN 1 0 2001
Date
Hl0S.1 ~ AItY 2/87
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
STATE FILE NUM8ER
SOCIAL SECURITY NUMBER
3. 196 16
liNT
ENT
NI(
NAME OF DECEDENT (f"sl. Mddl..l.uo,
1. Raffaela
s~emale
2.
R.
Klingensmith
78
'Irs.
PUoCE Of' DEATH ICl'eCk OI'Iy I)('e -- '" .O$IIUC1000S on omer -.
HOSPllAL:
InpelienC ~ E~ti.nl G
7. ...
FACILITY NAME (II nol .ns/'MlOI>. g..e!lteet ano numoer,
Harrisburg Hospital
Did
dK4IdenI
_ina
lDWntftjp? 17d.~ ~~=0I
MOTHER'S NAME iF.II. ModOle, MalOen Su<namel.. .
tt. Mary. .1Jen ZJ.
INFORMANT'S MA'LlNG ADORESS (SIr.... Cil'tfbwn, Slate. Z'o Cade)
2Gb.625 Adams Road, Carlisle, PA 17013
P\.ACE Of' OlSPOSfTlON. tq.... 01 c-,ry, C,_ory LOCATION. CityITown. 51.", XII) CoOe
orOtllel'Ptac. Ce:nete Armstrong County,
Marys Catholic Church 2'''. Manor .
NAME ANpAOORESl,.Of FACl4TY 63 Sou anover
~wJ.ng bro~nersICarlJ.sle
LICENSE NUMBER
AGE (Lasl 9t1l11<lay)
uNOER 1 YEAFl
MQI1ttIa Days
UHOER 1 DAY
HourI Mlnut..
S.
COUNTY OF OEJlI'H
~~'....
Dauphin
Harrisburg
Ie.
KINO Of' BUSINESS/INDUSTRY
DECEDENT'S USUAL OCCUMION
1~.-II~Iif~=':::~:'f
. 11.. Homemaker "11.
OEa:OENT'S MAILING AOOAESS (SI,.... ClIylbown,~. 1'0 CoOe\
1029 Northfield Drive
Carlisle,Pennsylvania170
,..
FATHER'S NAME (Firsl. MiOdl.. Ljb s e ph
II.
INFORMAHT'SNAME(Typel1jlvid A.
2011.
METHOO OF OISPOSI~
D 8uNI Cr_iort 0 R-.rllomSta,.O
00rwIi0rl 0tIlel' \
. 21..
SIGNATURE OF
Own Home
DECEDENT'S
ACTUAL
~IOENCE
( In$IIVCllOnll
Olher SIOeI
Cumberland
t 711. eo..
Giardino
Klingensmith
,
dOl
~~~i~
I :.
d.
WERE AUTOPSY FINDINGS
"""l.A8LE PFllOFllO
COMPLETION OF CAUSE
Of' DeATH?
J1$1
f)Up~
MANNER Of DEATH
DATE OF INJURY
(Monlh. Day. -.-ar)
MAAITAL STATUS. ....rriecl
Ne_ Manie<l. W_.
O!"P'Cfd (Spec"",
WJ.QOW
SURVIVING SPOUSE
1ft ""'e. 9"" matderl """'el
14.
17C.o ..... decedent.....,...
~.
Carlisle
Cil'y/bot'o
PA
2311. 23c.
WAS CASE REFERRED TO hlEOlCAL EXAMINERlCORONER?
~aD
No~
21.
I ApptOximat.
: inl""" bar<<een
I onMI and Ileattl
I
l
PARTJI:
OIhe. signillcant condIliona QOnlrilluIing to Ilealh. bul
not resullinQ in lI\e uncIafIying _ 0;- in ~ I.
TIME OF INJURY
INJURY AT WORK? DESCRIBe HOW INJURY OCCURFlED.
Accident
P.nding I_;gatlon
o
o
o PLACE Of INJURY. AI home. 'a.m~;..t. laclOfy, ottlc.
buildlng, Me. \Spec:dV\
3l1a.
~
o
o
tqtural
Homieide
Y.. 0
NoD
Suic:ida
Could not ~ det.rm.ned
29.
:na.. 28b.
~II'1ER 100eek oniy one\
'C8JTIFYINO PHYSICIAN (PtI~_ ef!lll/ylnq caoM oJ deal" ""'en af'\Olher gl\ySlC.... has pronounc.ed deall> ana compte/eO Rem 231
To"" MaC ot "'Y know~, deal" oeeumtd _10"" eauH(aland ma"...... a,ated. . . . . , , . , . . . . . . . . . , . . , . . . . , . . . . . . . . . . . . . , . . . . . . . . . . . .
'PAONOUNCING AND CERTIFYING PHYSIet"" (PhyKoan lXllh ;lIOOOUOC"'O Ilea'" and ce.-IIIV"'9'o C8Ute Of deall>\
To.... ~ ot my k/\Owtadg.... deatlt oc:curred at"" time, d.'.. and place. and due to ,he cavH(a) and manner.. .'.'ed.. . . . . . . . . . , , , . . . , . . . , . . , .
'MEDICAL EXAMINER/CORONER
On the b..i. of ...",;".tlon and/or Investigation, In my opinion, de.lh occurred allhe ttm., det.. e"d place, and due to Ihe cause(a) .nd
",.nn.r .. stated.. , . . . . , . , . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . , . . . . . , , . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . .
31a.
REGISTRAR'S SIGNATURE AND
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SIGN~URE
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I)A1J II> CAt ~ C-
U.
DATE FILEO (Month. Day.
34.
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CERTIFICATION OF NOTICE UNDER RULE 5.6(3)
Name of Decedent: Raffaela R. Klingensmith
Date of Death: 01 /03/2001
Will No. 2001-00082
Admin. No. 21- 01- 0082
To the Register:
I certify that notice of (beneficial interest) estate adnJinistration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on May 11, 2001 :
Name
Address
David A. KLinggnsmith
Richard Klingensmith
Janice Kellar
625 Adams RORd, CArliRlp, PA ]7013
514 Grahms Woods Road, Carlisle, FA 17013
436 Donnell Road, Lower Burrell, FA 15068
Bev'erly Shaffer
1337 4th Avenue, Forg~ City, FA lfi??6
Linda Rodina
4420 Manor Hall Lane, Fairfax. VA 22030
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
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S i gnatllre
Date:
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Name Samue 1 W Milke E
. . -. s, , sq.
Address 52 Eas t High Street
Carlis1e,PA 17013
Telephone (
(717) 249-6427
Capacity: _ Personal Representative
~Collnsel for personal representative
..
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STATUS REPORT UNDER RULE 6.12
Will No.
?,,~O~\~'- q- ~\~\\:fC\~
Admin. NO.~\~6:l
Name of Decedent:
Date of Death:
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes)( No
f """
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attac t the re~o
Da te: \ \7-\9~
'gnature
~t"lc- \ ~ , \-\\\~,~
Name (Please type or print)
~j, C~\Je ~\\ \:)r:,CD~l~('ffi
Addres s ' I
<Ai) ~-4 q ~ ~t-b
Tel. No.
Capacity: Personal Representative
~counsel for personal
representative
(MAH:rmf/AM3)
.
Cumberland County - Register Of wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 12/06/2002
DAVID KLINGENSMITH
625 ADAMS ROAD
CARLISLE, PA 17013
RE: Estate of KLINGENSMITH RAFFAELA R
File Number: 2001-00082
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 1/03/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
MARY C. LEWIS
REGISTER OF WILLS
cc:
/File
Counsel
Judge
Name of Decedent:
STATUS REPORT UNDER RULE 6.12 eL/'
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~
Date of Death: ) - 0:) '0 ,
Will No.: ~\- ~
Admin. No.:
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the
following with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes~ No 0
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal ~esentative file a final account with the Court?
Yes _ No ~
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the persona1~esentative state an account informally to the parties
in interest? Y es ~ No 0 -
c. Copies of receipts, releases, joinders and approval of fonnal or
informal accounts may be filed with the Clerk of the. Orphans' Court
Date: 1/d0'-{ and may be attached to this ~ep~~::::/
SIgnature
~~~~\ M~~,~
Name
\" CQ. ~ ~\\ \)~ Ct~~t ~~
Address . \'/C:)\ )
1\/ -;Z~~-% "f-l .
Telephone No.
Capacity: 0 Personal Representative
R Counsel for personal representative
\, /~-c:2c~ - / /
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG1 PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
SAMUEL W MILKES
JACOBSEN & MILKES
52 E HIGH ST
CARLISLE PA 17013:
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
AC-N
08-27-2001
KLINGENSMITH
01-03-2001
21 01-0082
CUMBERLAND
101
*
REY-1S47 EX AFP el2-00)
RAFFAELA
R
Allount Relli tted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=is4-j-ix--AFP-(,i"2-:olir-Ncffici:--OF-YNHEifiTANCE-'~fAi-jrpPRAisEitENT-'--Ai:.i-owANcE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KLINGENSMITH RAFFAELA R FILE NO. 21 01-0082 ACN 101 DATE 08-27-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
NOTE: If an assessment was issued previously, lines 14, 1S and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
IS. Allount of Line 14 at Spousal rate (IS)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00 = .00
23,414.51 X 045 = 1,053.65
.00 X 12 = .00
.00 X 15 = .00
(19)= 1,053.65
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(S)
(6)
(7)
.00
.00
.00
.00
29,474.54
5,412.17
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
10,166.79
1,305.41
(11)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this forll with your
tax paYllent.
34,886.71
11.472 20
23,414.51
.00
23,414.51
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-13-2001 CDOOO050 .00 1,053.65
TOTAL TAX CREDIT 1,053.65
BALANCE OF TAX DUE .00
INTEREST AND PEN~ .00
TOTAL DUE .00
~ IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
MILKES SAMUEL W ESQ
52 EAST HIGH ST
CARLISLE, PA 17013
u______ fold
ESTATE INFORMATION: SSN: 196-16-5355
FILE NUMBER: 21-2001- 0082
DECEDENT NAME: KLINGENSMITH RAFFAELA R
DATE OF PAYMENT: 07/13/2001
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 01/03/2001
NO. CD 000050
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $1 ,053.65
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$1 ,053.65
REMARKS: SAM MILKES, ESQ.
CHECK# 1173
SEAL
INITIALS: AC
RECEIVED BY:
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
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LAW OFFICES OF
JACOBSEN & MILKES
52 EAST HIGH STREET
CARLISLE, PA 17013-3085
(717) 249-6427
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Ifutzt ~iIl mro m
21-01-82
of
RAFFAELA R. KLINGENSMITH
I, RAFFAELA R. KLINGENSMITH, of North Middletown Township,
Cumberland County, Pennsylvania, being of sound mind and memory, and not
acting under duress or undue influence of any person or persons whatever, do
make, publish and declare this to be my Last Will and Testament hereby
revoking all prior wills and codicils heretofore made by me.
FIRST
I direct that my funeral be conducted in accordance with the wishes I
have made known to my Executors, hereinafter named.
SECOND
I direct the payment of my debts and funeral expenses from my estate as
soon after my death as conveniently may be done. I direct that my Executors
shall pay all inheritance, estate, succession and legacy taxes to which my
estate or the transfer of any property hereunder may be subject, and to charge
such taxes as part of the expenses of administration, payable out of my estate.
1
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LAW OFFICES OF
JACOBSEN & MILKES
52 EAST HIGH STREET
CARLISLE, PA 17013-3085
(717) 249-6427
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THIRD
I give, devise and bequeath the entire rest, residue and remainder of my
estate, whether real, personal or otherwise, and wherever situated, which I
may own or be entitled to at the time of my death, or in which I may have any
interest whatsoever, vested or unvested, matured or not matured, including
any property over which I may have a power of appointment, I give, devise and
bequeath to my issue living on the Thirty-first (31st) day following my death,
per stirpes.
In the event that any beneficiary is under the age of Twenty-one
(21), I nominate and appoint LINDA RODINA to receive that portion of the
distribution, as Trustee, and to hold that distribution in trust. The income
and/or principal of said trust may be accumulated or expended for the
maintenance, education, and support of such beneficiary as my Trustee in
his/her sole discretion may determine; and my Trustee may, at his/her
discretion apply the same directly without the intervention of a Guardian or
pay the same to any person having the care or control of said beneficiary or
with whom the beneficiary resides, without duty on the part of the Trustee to
supervise or inquire into the application of the funds by any person to whom
any payment is so made. The balance of such income and/or principal shall be
paid to such beneficiary upon reaching the age of Twenty-one (21) years or to
such beneficiary's estate in the event of death prior thereto. Upon such
distribution, the trust shall terminate.
2
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LAW OFFICES OF
JACOBSEN & MILKES
52 EAST HIGH STREET
CARLISLE, PA 17013-3085
(717) 249-6427
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FOURTH
I hereby nominate, constitute and appoint DAVID KLINGENSMITH
as Executor of this my Last Will and Testament to serve without bond or
security of any type for any purpose whatsoever, and I hereby authorize,
empower and direct he/she to sell and convey, by good and sufficient deed, in
fee simple estate, any and all of my real estate, at public or private sale, for
such price or prices, upon such terms and conditions, as in their judgment is
best for my estate, and to that end to sign, seal, execute, acknowledge and
deliver all deeds or other instruments necessary therefore, as effectively as I
could do if I were personally present.
My Executor shall have all of' the power and authority granted a
personal representative under presently existing Pennsylvania statutes, and
such additional powers and authorities as may be granted under Pennsylvania
statutes existing at the time of my death. I authorize my Executor to pay such
debts, funeral or cremation expenses, administration expenses, and taxes that
may be chargeable against my estate from my estate prior to any distribution.
In addition, my Executor is authorized to make any election permitted
by any tax law and no adjustment of any kind shall be made between or among
beneficiaries because of the exercise of any of the powers granted herein.
I direct that my estate be settled without the intervention of any court,
except to the extent required by law; and that my Executor shall settle my
estate in such manner as shall seem best and most convenient to them, and I
empower him/her to mortgage, lease, sell, exchange and convey the real and
personal property of my estate, without an order of court for that purpose, and
without notice, approval or confirmation, and in all other respects to
3
LAW OFFICES OF
JACOBSEN & MILKES
52 EAST HIGH STREET
CARLISLE. PA 17013-3085
(717) 249-6427
II
administer and settle my estate without the intervention of any court.
My Executor shall be entitled to take reasonable and just compensation
for his/her time and expense incurred in the execution of my Will.
FIFTH
In the event that DAVID KLINGENSMITH is unable or unwilling to
serve as Executor, then I nominate and appoint RICHARD
KLINGENSMITH, Executor of my estate, and to serve without bond, and
grant to him/her all the powers and authority that I have herein granted to my
first named Executor. .
SIXTH
If a court of competent jurisdiction rules invalid or unenforceable any of
the provisions in this Will, each such provision shall be disregarded, but the
remainder of this instrument shall be given full force and effect. All questions
pertaining to the interpretation, construction and administration of this
instrument shall be determined in accordance with the laws of the
Commonwealth of Pennsylvania.
IN WITNESS WHEREOF, I have hereunto set my hand and Seal to
this, my Last Will and Testament, consisting of ~ typewritten pages, the
first :j of which bear my signature in the margin for the purpose of
identification, this d1~\ day of
rl u ~,!,f;\*: 1999.
;(Q~~~/? ~ .
RAFFAELA R. KLINGENSMITH
4
LAW OFFICES OF
JACOBSEN & MILKES
52 EAST HIGH STREET
CARLISLE, PA 17013-3085
(717) 249-6427
II
SIGNED, SEALED, PUBLISHED AND DECLARED by the above
named Testator, as and for her Will, in the presence of us, who, at her request,
in her presence, and in the presence of each other, have hereunto subscribed
our names as witnesses in attestation thereof.
WI~S:~
-~ . residing at
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residing at
I, RAFFAELA R. KLINGENSMITH , having been duly qualified
according to law, acknowledge that I signed the foregoing instrument as my
Will, and that I signed it as my free and voluntary act for the purposes therein
expressed.
;{?~ /!. /{~~
RAFF AELA R. KLiNG NSMITH
5
LAW OFFICES OF
JACOBSEN & MILKES
52 EAST HIGH STREET
CARLISLE, PA 17013-3085
(717) 249-6427
II
We, having been duly qualified according to law, depose and say that we
were present and saw RAFFAELA R. KLINGENSMITH sign the foregoing
instrument as her will; that she signed it as her free and voluntary act for the
purposes therein expressed; that each of us in his sight and hearing and at her
request signed the Will as witnesses; and that to the best of our knowledge she
was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
~~.~ 7
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Witness C
Subscribed, sworn to or affirmed,
and acknowledged before me by the
above named Testator and by the
witnesses w ase n euppear
'te on . 61/, 1999.
J
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NOTARIAL SEAL
ANGELA S, GARLAND, NOTARY PUBLIC
I CARUSLE BORO, CUMBERLAND co., PA
~<A1 MY COMMISSIPN EXPIRES JULY 23, 2003
6