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Home My WebLink About05-28-15 (2) � �' pennsylvania 15 0 5 618 4 0 3 OEPARTMEM OF REVENI�EX�0,3-�4� REV-1500 OFFICIAL USE ONLY County Code Year File Number Bureau of Individual Taxes �NHERITANCE TAX RETURN Po eox 2soso� 21 14 116 3 Harrisbur PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MnnDDYYYY Date of Birth MMDDYYYY 11 03 2D14 �5 21 1930 DecedenYs Last Name Suffix DecedenYs First Name MI KEEFAUVER HARRY W (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Su�x Spouse's First Name M� THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Return � 2. Supplemental Return � 3. Remainder Return(date of death prior to 12-13-82) � 4. Agricultural Exemption(date of � 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) � 7. Decedent Died Testate � 8. Decedent Maintained a Living Trust _ � 9. Total Number of Safe Deposit Boxes (Attach copy of will) (Attach copy of trust.) � 10. Litigation Proceeds Received � 11. Non-Probate Transferee Return � 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) � 13. Business Assets � 14. Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT•THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number EDMUND G MYERS (717) 761 4540 First Line of Address 301 MARKET STREET Second Line of Address PO BOX 1D9 City or Post Office State ZIP Code ,_..� LEMOYNE PA 1704� � � � u-� � r-r� G Q �"+� � eqm(cDjdsw com � ^� � '''� �-� CorrespondenYs email address: _,.,--�—� --� m� REGISTER,OF�lf�(IL�S USErQyLY ; ...,: �, Cp _s REGISTER OF WILLS USE ONLY > DATE FILED MMDDYYYY —r} 3 �,,, ._. ':,: �.'3 ►J _ I"'.+l (�.� :.:'� <v� � DATE FILED STAMP� Side 1 � I I�I�I I��I�III)��I'I'III�'IIII II��I I�III�I�II�II'�IIII I��I 1505618403 1505618403 � � � 1505618411 REV-1500 EX DecedenYs Social Security Number DecedenYs Name: Keefauver, Harry W __ RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3. Closely Heid Corporation, Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages and Notes Receivable(Schedule D).................................................... 4. 5. Cash,Bank Deposits and Miscelianeous Personal Property(Schedule E).......... 5. 14 ,2 4 3 • 3 5 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 1 ,4 D 9 • 7 6 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested............ 7. 9 5,7 9 8 - 2 3 8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 111,4 51 • 3 4 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 16,2 4 2 - 8 8 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 8 • 0 0 11. Total Deductions(total Lines 9 and 10)................................................................ ��. 16,2 5 0 • 8 8 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 9 5,2�� • 4 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J)............................................... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 9 5,2 0 0 • 4 6 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.00 15. 0 • ❑� 16. Amount of Line 14 taxable at lineal rate X .045 0 • ❑0 16. 0 • ❑D 17. Amount of Line 14 taxable at sibiing rate X.12 ❑ • 0❑ �7• 0 • ❑0 18. Amount of Line 14 taxable at co��ateral rate X.15 9 5,7 9 8 - 2 3 18. 14,3 6 9 • 7 3 19. TAXDUE................................................................................................................ 19. 14 ,369 - 73 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the person responsible for fiiing the return is based on all information of which preparer has any knowledge. S ATURE OF PER N RE�NSIBLE OR FILING RETURN Romaine M Neidigh DaTE s�-� ,5'-.z t-.ta/,s- DDRESS 112 Wesley Drive, Mechanicsburg, PA 17055 SIGN��EPA�ER�N REPRESENTATIVE Edmund G. Myers DATE �l/ � L.�O - n�� ADDRESS 301 MARKET STREET, Lemoyne, PA _ I �'I'I III�I�I II�'II�III"I'I II��I IIII�II' I'�I II�I II�I Side 2 L1505618411 1505618411 � REV-1500 EX Page 3 File Number 21-14-1163 Decedent's Complete Address: DECEDENT'S NAME Keefauver, Harry W STREETADDRESS 112 Wesley Drive __. CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) 14,369.73 2. Credits/Payments A. Prior Payments 12,500.00 B. Discount 657.89 Total Credits(A +B) (2) 13,157.89 3. Interest �3� 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) �,211.84 Make Check Payable to REGISTER OF WILLS, AGENT _ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred:............................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income:.................................. ❑❑ � c. retain a reversionary interest;or............................................................................................................... d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑X 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without ❑ ❑ receivingadequate consideration?.................................................................................................................. . 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ 0 4. Did decedent own an individual retirement account,annuity,or other non-probate property which containsa beneficiary designation?.................................................................................................................. 0 ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. � �� ,. � � � �:, . : _ . �� _ _.. For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and fiiing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-7508 EX+�08-12) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OFREVENUE p E RS O NAL P RO P E RTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keefauver, Har W 21-14-1163 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 M&T Classic Checking Account No.ending 1927-Date of Death Letter from M&T Bank is 3,547.85 Attached 2 2009 Chevrolet Impala Sedan-30,000 Miles. Valued using Kelly Blue Book. Value is 10,103.00 attached. 3 Men's Ring-Appraised by C.G. Buser 400.00 4 Nationwide Mutual Insurance-Refund of Policy Premium 192.50 TOTAL(Also enter on Line 5, Recapitulation) 14,243.35 (If more space is needed,additional pages of the same size) Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12) Rev-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keefauver, Harry W _ 21-14-1163 If an asset was made joint within one year of the decedenYs date of death,it must be reported on schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT A. Romaine M Neidigh 112 Wesley Drive Friend Mechanicsburg, PA 17055 B. C. JOINTLY OWNED PROPERTY: DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S DECE ENT'S NTEREST NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACH DEED FOR VALUE dF ASSE INTEREST TENANT JOINT JOINTLY-HELD REAL ESTATE. 1 A 02/03/2000 Santander Checking Account No. Ending 2,819.51 50.000% 1,409.76 8733-PA Department of Revenue Notification with Date of Death Value is Attached TOTAL(Also enter on Line 6, Recapitulation) 1,409.76 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10) Rev-1510 EX+(OS-09) SCHEDULE G pennsylvania lNTER-VIVOS TRANSFERS AND DEPARTMENTOFREVENUE MISC. NON-PROBATE PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keefauver, Harry W _ 21-14-1163 This schedule must be completed and f led if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD�s EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.SATfACIiTA CIO Y OF TI�E DEED F�OR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1 Allianz Non-Tax Qualified Annuity Contact No. 53,978.19 53,978.19 70064598 -Beneficiary: Romaine Neidigh 2 Allianz Tax Qualified Annuity Contact No.70321922- 41,820.04 41,820.04 Beneficiary: Romaine Neidigh Allianz Date of Death Letter is Attached TOTAL(Also enter on Line 7, Recapitulation) 95,798.23 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group,Inc. Forrn PA-1500 Schedule G(Rev.08-09) ..��iuir.i.re nar�rr v REV-1511 EX+(OS-13) SC H E D U LE H pennsylvania DEPARTMENT OFREVENUE F U N E RAL EXP E N S ES AN D INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Keefauver, Harry W 21-14-1163 Decedent's debts must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT NUMBER q, FUNERAL EXPENSES: See continuation schedule(s)attached 12,402.00 B, ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s)Commission Paid 2. Attorney's Fees JOHNSON DUFFIE 3,000.00 3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant Street Address City State Zi� Relationshio of Claimant to Decedent 4. Probate Fees 160.50 5. AccountanYs Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 680.38 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 16,242.88 Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13) .�,�, ��„��,.,�s�,�, � SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Keefauver, Harry W 21-14-1163 ITEM DESCRIPTION AMOUNT NUMBER Funeral Expenses 1 Musseiman Funerai Home 7,635.00 2 Woodlawn Memorial Gardens-Headstone Expenses 4,767.00 H-A 12,402.00 Other Administrative Costs 3 AAA Auto-Expenses for transfer of Automobile 44.00 4 C.G. Buser-Appraisal of Men's Ring 50.00 5 Cumberland County Register of Wills -Filing Fee for Petition to Open Probate Record 25.00 6 Reserves:Additional Miscellaneous Estate Expenses 250.00 7 The Cumberland Law Journal-Notice of Estate Administration 75.00 8 The Patriot News Co. -Notice of Estate Administration 236.38 H-67 680.38 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) ��'ll`1I...r-1�-ltl'llll'� e Rev-1512 EX+(12-72) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENTOFREVENUE MORTGAGE LIABILITIES AND LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keefauver, Har W 21-14-1163 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1 Veterans Affairs Payment 8.00 TOTAL(Also enter on Line 10, Recapitulation) 8.00 (if more space is needed,additional pages of the same size) Copyright(c)2012 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-12) REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OFREVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Keefauver, Har W 21-14-1163 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NAME AND ADDRESS OF DECEDENT NUMBER PERSON(Sl RECEIVING PROPERTY Do Not List Trustee s (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal I. distributions,and transfers under Sec.9116 a 1.2 Romaine M Neidigh Friend Entire Estate 112 Wesley Drive Mechanicsburg, PA 17055 Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) ESTATE OF HARRY W. KEEFAUVER A./K/A HARRY W. KEEFAUVER, JR. SCHEDULE OF EXHIBITS EXHIBITA Last Will and Testament of Harry W. Keefauver signed and dated July 28, 2014 EXHIBIT B Cumberland County Register of Wills Receipt of Payment for Inheritance Tax Prepayment of$12,500.00 EXHIBIT C M&T Bank Date of Death Letter fo�° Decedent's Individual Checking Account EXHIBIT D Kelly Blue Book Valuation for Decedent's Automobile EXHIBIT E Santander Checking Account/Jointly owned Account. PA Department of Revenue Assessment showir��> Date of Death Value of Account as Reported by Santander EXHIBIT F Allianz Date of Death Letter for Annuity Cantracts :�o2s4o . . , , Last Will and Testament OF AARRY W.KEEFAWER I, HARRY W. KEEFAUVER, of Lower Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament,hereby revoki.ng and making void any and all Wills or Codicils at any time heretofore made by me. ARTICLE I DEBTS I direct the payment of all my legal debts, and the expenses of my last illness and funeral from my Estate as soon after my death as conveniently may be done. I authorize my Executr�to expend funds from my Estate for the purchase, erection and inspection of a suitable grave marker. All the foregoing shall be considered expenses of the administration of my Estate. ARTICLE II TANGIBLE PERSONAL PROPERTY � I give and nequea"��'rie re��a;n��OI u2y i�G'uSc�;:fiu�ti�i�t�°..��Sv`�ii�� effects a�d ot��er t�T bii5:� personalty of like nature (not including cash or securities), together v��ith any insurance thereon, unto my those of my friend, ROMAINE M. NEIDIGH,provided she survives me. If my friend, ROMAINE M. NEIDIGH, predeceases me, I give and bequeatl� the same unto those of my children,BRUCE A..KEEFAWER, CRAIG KEEFAWER, and CAROL CARBERRY,who survive me,to be divided among them in as nearly equal shares as is practicable. __ _ _ _ . _ � ExHieir A Yw� ` � � ' n • • ARTICLE III REST,RESIDUE AND REMAINDER I give, devise and bequeath all the rest, residue and remainder of iny Estate, of whatsoever � nature and wheresoever situate, unto my friend, ROMAINE M. NEIDIGH. If my firiend, ROMAINE M. NEIDIGH, predeceases me, I give, devise and bequeath the same unto my children, B12�JCE A. �EFAiTV�R, CRAIG ��FAW�R, a�-�d CAROI. CAI2BERRY, in equal shares, provided that should any one of my children predecease me, such child's share sha11 pass to his or her then-living issue,per stirpes. . . ARTICLE VII PERSONAL REPRESENTATIVE ' I name,constitute and appoint my friend,ROMAINE M.NEIDIGH,Executr-i��of this my last Will and Testament. If she fails to qualify or ceases to so act, I name, constitute and appoint my son, BRUCE A. KEEFAUVER, Altemate Executor to complete the adininistration of my Estate. I direct that no fiduciary acting under this, my Will, sha11 be required to post bond for the faithful adininistration of the duties required in any jurisdiction. IN WITNESS WI�REOF, I have hereunto set my hand and seal to this, my Last Will and Testament,this �day of 2014. � � (SEAL) HARRY W. EFAU��ER 2 .��n ii rn r��m � F ' , . e ' ; p . Signed, sealed, published and declared by the above-named HARRY W. KEEFAUVER, as and for his Last Will and Testarnent, in the presence of us, who at his request, in his presence and in the presence of each other,have hereunto subscribed our n�'tnesses. � �� _ _ �,. � - . , AFFIDAVIT AND ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA . : SS COUNTY OF CUMSERLAND . We, HARRY W. KEEFAUVER, � Q/��{. � �-��,,Q.t�' and �; ��/�,! � �,. �yVJ�, , the Testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, beulg first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and that he had signed willingly and that he executed it as his free and voluntary act for the purposes therein. expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and that to the best of his/her knowledge the Testatar was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. � �� , ��vv; �R s� �� ,. - - - � Wi ess 3 .��*•,�iv ir..rn.i.m.rnr�. � �� - > a ` k Subscribed, sworn to and acknowledged before m by IIARRY W. KEE�AWER, Testator, and subscri ed and sworn to before me by �� - ��f� and ��,f� �„ � (�, ,witnesses,this�day o � ,2014. �� Edmund G.Myers Attorney I.D. #20558, Supreme Court of Pennsylvania ACKNOWLEDGMENT BY ATTORNEY COMMONWEALTH OF PENNSYLVAlVIA . . ss: COUNTY OF CUMEERLAND . On this, the � day of Z�9� , EDMUND G. MYERS, Attorney I.D. No. 20558, known to me (o satisfactorily proven) to be a member of the bar of the highest court of Pennsylvania and certified that he was personally present when HARRY W. I�EFAWER, whose name is subscribed to the within instrument executed the same, and that said person acknowledged that he executed the same for the purposes therein conta.ined. IN WITNESS WHEItEOF,I hereunto set my hand and official seal. � ��J�-��-�..�4,1� � (SEAL) Notary Public QNYU�1.7k�„1JF PLN[�.S�f.Y . Notarial Seal :640578 Da[aa L.Wi�semas�,iVotary.Public Le�+ne Borq Cumbe�Ja�d Cuunty My Commission Bcpkes 3an.15,20,�7 • ME7'46ER,DENNSYLYANIA OLIATiON OP Np7�s . � 4 ��nnri irin7�u_ � COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-9F) DEPAFTMENT OF REVENUE " BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 1 7 7 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 020214 NEIDIGH ROMAINE M 112 WESLEY DRIVE MECHANICSBURG, PA 17055 ACN ASSESSMENT AMOUNT CONTROL NUMBER '___'___ fold ___"____ __'_"" 101 � $12,500.00 ESTATE INFORMATION: ssN: 200-22-74�s � F��E NUMeER: 2114-1 163 � �ECE�Ervr NaME: KEEFAUVER HARRY W � DATE OF PAYMENT: 02/04/201 5 I POSTMARK DATE: 02/02/201 5 � COUNTY: CUMBERLAND � DATE OF DEATH: 1 1/03/2014 � � TOTAL AMOUNT PAID: $12,500.00 REMARKS: RECEIPT TO ATTY CHECK# 1584 INITIALS: HMW sEA� - RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF -WILLS - - TAXPAYER ��., ��,.,n�„r � Q M�B� . - 4.99 Mitchell Road,Milisboro,DE 19966 Records Management - Phone 888-502�1349 F ax (302)934-2955 � January 23,2015 Law Offices _ Johnson Duffie 301 Market Street P.O.Bog 109 Lemoyne,PA 17043-0109 � - - Re: Estate of Harry W.Keefauver Social Security:200-22-74�9 � Date of Death:November 03,2014 �- - Dear Sir or Madam: Per your inquity on January 13,2015,please be advised that at the time of death,tlie abov�named decedent had on deposit with this bank the following. 1. Type ofAccount CheckingAccount AccountNumber 90081927 Ownership(Names o,f) Harry W.Keefauver - Romaine V.Neidigh(POA) Opening Date 04/28/1975 Balance on Date ofDeath $ 3,547.85 � Accrued Interest $ ' .00 -------___----__----------------------------- Total $ 3,547.85 --- ExHieir C I 1 .�, �,,��,.�,,,rr� � , �aur Blu� Boak� Val�� _ :: , �� _ , .K `._�=�;.,:.:;:.f.,-� � _ _ ;` �� ' . a�a'a'�"�-'�, w c�-3'.�.'-�A��`- f�• - "_ _` _ �_:"1 i"Ii"ti�E7�: �0 �S^�e�?r �t:�Ct?`�FE . if��F`r.i;;?1• ��l r�il�1 SS�..�i i��:a`T�'€V c.s ;��1�..�. ,� .�t.� au'��. _�z� - �J�� `V��f�� `�?'�:�xr��g�':'E�'�i`��s��?ti�*�a��v-�.�'�'£��'�� iL t��f��+.�?Fi��"��1��esi :«A� i\a.�,��:j �n�t� ��aYa��: :;;.��?��i�is��f��F=.�'��.�atF��,��.�� !^..�� :�s r��CHs�."_Fr(p�e�y��"a:9 F`;�T�F�t'{?��'7uiLi`v te!:�i� �+k„ ii 3 V3 C 7 ' . e�.F V � ��(�� €�r5v�+�i?k�.�'.4:�3��7:�€.�'�G7`�Gry il�E�E.��.�'��"_� ,szt:�cui.€�:�;��.4�"ii�v&'��it`6iC. €'i�s�s:�c i ci �S.iL �c��.`��t3�. EXCE'��tt�C4i'��t[Q!'E i rade-�n i�ange V�r� �e�c�d ��E�� Trade-in Range ..-,��.v�ir.r�n�7rt�n�.. r Gaod Candition Trade-in Range Fair Condition Trade-in Range s��-isa��a�€��r v�r�r�t�r�a�€��2��a�� r�'e�'��e��c�F'c�4��"€��°�`a�5.§'�`€��uS`.$�4�°..��e Q's�sz.�.° �4 CE��32 li30�'ffl,IL Gr' I£��.CGr3 Fast. Easy. �onvenient. Avoid the hassfe Qf �e[I�ng �our-�ar-E Get cash fram dealers in your area. 3Q-day Instant Eas� t ��r��erage fQr a * *�n good condit�on wi#► average miles :�z��a��:�e��y��e��s:�� tn ge�t��a t�u�� KB�.eosn Info unavaitab[e �si�vef��cle is��v�valc�rr�rs��dzf,��v�� ,��d�t a T�-��e-��s�r P�i�a��Pa��afal�6 Exceilent �t�nclition $10,72� Very Good Condition $10,355 Good Cand�t�on $10,103 Fair Condition $9,313 BUREAU OF INDIVIDUAL TAXES Pennsylvania lnheritance Tax �i � pennsylvania PO BOX 280601 } } p � DEPARTMENT OF REVENUE HARRISBURG PA niza-osoi II1�OI•IT�aIIOC� NOIICG ------- REV-1543 EX DocEXEL�oa-�z� And Taxpayer Response FILE NO.2114-1163 ACN 15114848 DATE 03-19-2015 Type of Account Estate of HARRY W KEEFAUVER Savings SSN 200-22-7419 X Checking Date of Death 11-03-2014 Trust R�MAINE NEIDI6H CountyCUMBERLAND Certificate 112 WESLEY DR MECHANICSBURG PA 17055-3541 SANTANDER BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No. 1051078733 Date Established 02-03-2000 REGISTER OF WILLS Account Balance $2,g1 g.51 1 COURTHOUSE S�UARE CARLISLE PA 17013 Percent Taxable X 50 Amount Subject to Tax $1,409.76 Tax Rate X 0.150 NOTE�: If tax payments are made within three months of the Potential Tax Due $211.46 decedenYs date of death, deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any ofher boxes and disregard fhe amount sh�wr abave as Potenral Tax�ue. g �The information is The above information is correct,no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent, child, grandchild,etc.)of the deceased. (Select correct tax rate at ^., � right, and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none)� ��'��' v�'� ��' J " :�- �' �� ,,�`-��`�� $�� _;J,�.r- �, � �Changes or deductions The information above i�'f�correct and/ r debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. i_F.!,� � . . E�Asset will be on The above-identified asset has been or will be reported and tax pai with the PA Inheritance Tax . heritance tax form Return filed by the estate representative_ 1 RE - . Proceed to Step 2 on reve I • ExH►e►r E I t�� f � I Please sign and date the bac Allianz Life Insurance Company �� of North America PO Box 59060 Minneapolis, MN 55459-0060 800.950.1962 � November 19, 2014 ROMAINE NEIDIGH 112 WESLEY DR , MECHANICSBURG PA 17055-3547 Re:Annuity Contract Number(s) 70321922 and 70064�98 Dear Romaine Neidigh: We sent you this letter because you are the named beneficiary of Harry Keefauver. Please accept our sincere sympathy on your loss. Listed below is information needed to file a ciaim for benefits on the fixed annuity contract number(s). PaLrment Options Choose one of the options on the claim form. IMPORTANT NOTICE: In accordance with the lnternal Revenue Code and contract provisions, if annuitization is selected,the first annuity payment must be received within one year from the date of death for non-qualifiied funds and by December 31�following the year of death for qual'rfied funds. After these dates,this option is no longer available. Contract Information Minimum Surrender Annuitization pnnuitization Tax Status Contract Number Value Value Pa out Period 70321922 $41,820.04 5 years �.$22,312.�� Tax-Qualified 70064598 �f�$53,978.19 5 years �'$53,978.19 Non-Tax-Qualified Contract values are atfected by withdrawals,partial surrenders, loans, and market value adjustments;as a result, values quoted in this leiter may increase or decrease and are not guaranteed. Claim Requirements . Copy of the ce.rtified death certificate (onl�C one copy is required for the deceased) • Fixed Annuity Claim_Form Once we receive your claim requirements, allow 15 business days for processing. For more information or assistance: please contact us at 800.950.1962, Monday through Friday, 8 a.m.to 5 p.m. Central time or the agent of record. Thank you, in advance,for your prompt response. We look forward to serving you. Sincerely, Annuity Claims Aliianz Life Insurance Company of North America LCL-1005 EXH/BIT F I I