HomeMy WebLinkAbout01-1121
PETITION FOR PROBATE and GRANT OF LETTERS
IJ)t:siJ8
Estate of E.J.s/.E L sr""'rrfA No. ~/-O '-I \ ~ \
alsoknownas EL,(,Ii:' E. :S"T(,\'~t:~~. To:
Register of Wills for the
, Deceased. County of C,ih'" tiE IU-~ /II f) in the
Social Security No. ~ O-?- .- t' ~ -. '77/'8 Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut.R/,J( named
in the last will of the above decedent, dated AP/f /~ d2..:r ,19~
and codicil(s) dated
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in ~/\1t3..c~.lA A-' D County, Pennsylvania, with
her" last family or principal residence ~A'Ir? "'..EN/II (!'.ENT.FR) GA';:N I?IO/s; VIJ.J...l1eJ
Jj/" /JiG ~ ,cA'/NG Iicl10 '"FWVI,l.J..E,P,if /?,;1.. "/
, , . _4 A -0P
(list street, number and muncipality) h.E 57 rk If//t/..> 100" ('.1 I
o cendent, then <6/ years of age, died ,
at /1:.' A'.. T#' eFNr.E1? G;..;'k,E/V RIJ)G.€ Vi "/ /tI ~ WV/~..E I~.H'I
xcept 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:
Decendent at death owned property with estimated values 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: AloN.c
$4~
$
$
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters' .~. . ....' .
theron.
i 1J)~ CCXJ-o-€ 6+()~f-J ~cluJ
1l-;;;- ~~.~;f'~,.(.ST".Jr;c..G'I1'. RENIlif,f
~1r I: .s1l//,~.,FNS8Q~c;. !foAl)
-g.g SHI"P-ENSBiJ/Ki;~,if 1?;1~-7
ro '';:
3~
"''-
:; 0
'"
c
OJ)
Ci'i
OATH OF PERSONAL REPRESENTATIVE
COMMONWEAL TH OF PENNSYLVANIA I ss
COUNTY OF eLJ/'1I5"E/f'dJ.-/1/VO j
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 represen-
tative(s) of the above decedent petitioner(s) will wel~ and tr~l~ administer the~s~ate ,according to law':)
Sworn to or affirmed and subscribed j1/c,iM/ (~lrlc;:::::/!2V ~ /~,l~
before me this 4 t h day of /~.
Decembe $9 200 1 ~
- l::
~
Mary C ~
/ 7-,;(~ ~L/
No. 21-2001-1121
Estate of
ELSIE STOUFFER, a/k/a/
ELSIE E. STOUFFER
DECREE OF PROBATE AND GRANT OF LETTERS
, Deceased
AND NOW Decemb~~lO!=!1 _~_._~001. in c,;r:~iueraliun ,
the reverse side hereof, satisfactory proof having been presented before me,
_' April 25th, 1996
IT IS DECREED that the mstrument(s) dated
described therein be admitted to probate and filed of record as the last will of
,:,.~. Elsie Stouffer, a/k/a Elsie E. Stouffer
and Letters Testamentary
are hereby granted to Mary Carol Stouffer Bender
"\1:
Q, '., ". Mt<iL~ifIj
Register of Wills Mary C. Lewis
FEES
Probate, Letters, Etc. ......... S 25.00
Short Certificates(l) . . . . . . . . .. S 3.00
Renunciation ................ S
( S 9 . 00
x-Pages 3)
JCP TOTAL _ $ 5.00
Filed ~c;~E?~. .1.Q1;:l:1! ~9.Q+. . .~ . ~7...qQ . . .
ATTORNEY (Sup. Ct. LD. :-10,)
ADDRESS
PHONE
00
,.. ~'-
:::: ~.
~ ."
0- "
C':
d
---
t::l
C"'J
1
~
;g
-->
MAILED LETTERS AND ORDER TO EXECUTRIX
j:;.
\.0
21-2001-1121
N "':t:
';'t 0..:
.....
E:
o:;:r
I
c.,.;) ~~
..1."0'" CJ ro
,"11
.,' .0
....!'.i ",::a;:;:
I:J.; - .... J::
a: 0 ..I :::
. """'" .-I
OU
\ ... , .
\ .
LAST WILL
21-2001-1121
I, ELSIE E. STOUFFER, of Star Route #2, Shippensburg, Hopewell Township,
Cumberland County, Pennsylvania, declare this to be my LAST WILL. I hereby revoke
all prior Wills made by me.
Article I I give my grandson, KEVIN S.BENDER, the sum ofTEN-THOUSAND
DOLLARS if he survives me. If KEVIN S. BENDER does not so survive me, no
property shall pass under this article.
Article II
I give all of my property that is not effectively disposed of under the
foregoing provisions of this will, including all property over which I hold a power of
appointment, to my daughter, MARY CAROL STOUFFER BENDER, if she survives
me. If my daughter does not so survive me, I give my residuary estate to my descendants
per stirpes.
Article III
I appoint my daughter, MARY CAROL STOUFFER BENDER, as
executrix of this will. If MARY CAROL STOUFFER BENDER does not survive me or
otherwise fails or ceases to act as executrix, I appoint my son-in-law, HAROLD A.
BENDER, to serve as executor in her place. I authorize my executrix to employ, at the
expense of my estate, such attorneys, custodians, accountants, investment advisors, or
,~ l I .
other professionals as my executrix believes are in the best interest of my estate. In
addition, I authorize my executrix to serve without bond and to administer and to settle
my estate independently, without the participation or supervision of any court, to the
maximum extent permitted by the applicable law. If an ancillary administration of my
estate is required in other jurisdictions, I authorize my executrix to serve in such
jurisdictions or to designate an executor to serve in each ancillary jurisdiction.
I direct that my executrix shall not be required to give bond for the faithful performance
of their duties in any jurisdiction.
Article IV
(1) I direct my executrix to pay all expenses of administration and all
inheritance, estate, succession, and similar taxes "[death taxes]" imposed
upon my estate by reason of my death, from the assets of my residuary
estate, whether or not the expenses of administration of death taxes are
attributable to property passing under this will.
(2) I authorize my executrix to exercise all elections available under
Federal and State law with respect to:
(a) the date or manner of valuation of assets,
(b) the deductibility of items for State or Federal income or death
tax purposes.
(c) the marital deduction,
1-
(d) other matters of Federal or State tax law, in accordance with
what my executrix believes to be in the best interests of my estate.
I relieve my executrix of any duty to make adjustments to the
shares or interests of persons who may be adversely affected by
such elections and from any liability for making such elections.
Article V For purposes of this will, a beneficiary is deemed to survive me only if the
beneficiary is living on the 60th day following my death
In witness whereof I have signed this will on
~i?.5> 19~
( ) / . (
'E-Qft--<-^- .) '<:-'l(/f->tr
Elsie E. Stouffer
Signed, sealed, published and declared
by ELSIE E. STOUFFER, The Testator,
as and for her LAST WILL, in the
presence of us who have at her request
signed our names as witnesses hereto in
the presence of the said Testator and of
each other.
. .
COMMONWEALTH OF PENNSYL VANIA )
) ss.
COUNTY OF CUMBERLAND )
On this, the J 5 f'1-, day of 11f1~" / , 1996, before me, a Notary
Public, the undersigned officer, personally appeared Elsie E. Stouffer, known to me ( or
satisfactorily proven) to be the person whose name is subscribed to the within instrument and
acknowledged that he executed the same for the purpose therein contained, as and for his Last
Will and Testament.
IN WITNESS WHEREOF, I hereunto set my hand and Notarial seal.
@(p/
-...---.........---.., ._.- --_..~.
i
Notanaj Seal I
Robert J. Kreidler. Notary Public
Susquehanna Twp" Dauphin C8unty~ I
My Commission Expires Aug. 24, 199~
Member, Pennsylvania I~ssociation of Notaries
COMMONWEALTH OF PENNSYL VANIA
)
) ss.
)
COUNTY OF CUMBERLAND
.
On this, the J r-#. day of 11(741/ , 1996, before me, a Notary
Public, the undersigned officer, personally appeared T: / / 1?1. {1/" Ie.- and
Sh.~/,'( C"I'U. r; f,J/ , known to me ( or satisfactorily proven) to be the persons whose name is
subscribed to the within instrument as witnesses and acknowledged that they executed the same
as witnesses in the presence of said Testator and in the presence of each other, at his request.
IN WITNESS WHEREOF, I hereunto
and and Notarial seal.
U
Notal'ial Seal
Robert J. Kreidler, Notary Public
Susquehanna Twp., Dauphin C8unty
My Commission Expires Aug. 24, 1998
Member. Pennsylvania i\ssociatio,l of Notaries
'0
,J":
,., ..
(;: "',
'!,.,,~
C:,l C,:',;
~Q.l
a:Cl:
!:"-J
::::!"
...-
,~:
~
I
c..J
<::J
.-1
,)
p
~i "g
Go
EJ:::--7~~~-"~ c.
\. ~ L J /', ') Q () J ..:; ""uf-/f)J
M<l'r\~) bJecBY~x)~' L-, ""
-L , l'Ylo-c,\ ~c'l\ ~~OL'~" Bencicr J ~~ i'. GL\.,},
'Pe.x-yY'\\S~\<J I, 'tc Ch~~-<s\ WI 1-\ -te("'s, +0 C~(Q.vLJ~
pc:-t.-lt'<OtJ to rt~ '~ -e-~+:~ Q~ E\~;~.
St-(~u~r Q..k.q. 2'ls"e- ~. S-!ou.sre-ro
'frl~ ~ S~F] ~~
/;). - j (J- 0/
..
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: ~ l.s\ e. 5-\0 ~\\e..r
a.~. E\~,~ ~. S-\-t,L(\t~,
Date of Death: Nlu~" 14) :t. 0 0 ,
Will No. ~ C' () J -0 Ita I
Admin. No.
P J\ No. ~ I - 0 1- I\";;t, \
To the Register:
I certify that notice of (beneficial interest) estate administration 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 V'YlQ\d~ lo J ~oo"Z-
Name
Address
J< e..Uly.. S .~€.;..,,~~~
/...':1 ~ 0Vffe..n s\'\S..rr1 Roo.-J) ~\lpf>eYl~\::' U.(~ q A
J 1 ~ 31
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: fV\CL<:U, ) '-4 ~OO~
11tr~- ~ ~~~ ~
Signature
Name f"\o. C--Lll ~c\ S \-0 1.L~("~€.A,ld~<-
)
Address lL\s ~C:;~(~~~IY\~\:;>CL'Q ~u,--J(
)
~ens~LU~\ Pi\ ~1~~-7
Telephone (711) Lf ~ J - SLi In ,s-
Capacity: VPersonal Representative
_Counsel for personal representative
REV-1,,;JEX 16 ',01
I-
Z
W
C
W
U
W
C
W
I-
::.::~(I)
,,0::':
W""
:rOO
,,0:-'
..m
..
..
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
DATE OF DEATH (MM-DD-YEAR)
II -L/-~OOj
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DATE OF BIRTH (MM-DD-YEAR)
7 -:,,3) - J9d 0
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
0' 1, Original Return
o 4. Limited Estate
o 6, Decedent Died Testate (Attach copy 01 Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date 01 death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy 01 Trust)
o 10, Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95)
or:FW!l\.L USE
J ~l.l
J_"],
FILE NUMBER
aL-QL
COUNTY CODE YEAR
LLd.L_
NUMBER
SOCIAL SECURITY NUMBER
;:I.o'f - 03 - 77/?
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date 01 death prior 10 12.13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (AftachSch0)
I-
Z
W
o
z
o
..
U)
W
0:
0:
o
"
z
o
<
...J
::::l
!:::
Q.
<(
U
W
a::
TELEPHONE NUMBER
) - 4;),3-$";
1. Real Estate (Schedule A)
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)
COMPLETE MAILING ADDRESS
/"I~ ~f'e.nS;b,^) ~Q~
en~'o\-L fA-- p;;{5:"'7-?6::J..7
(1) h(}n~
(2) no (\~
(3) \"It) f\ e..
(4) h()(\e.
(5) ;< ~) 020. q~
(6) no"e.
(7) no,,€..
(B)
(9) ~, J70, 0-0
,
(10) -14. Ji'X<-l, '1~
/
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (ScheduleJ)
z
o
!.i
I-'
::::l
Q.
:i
o
u
X
~
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15 Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
19. Tax Due
200
,,0_ (15)
1~.(fFFICIAL USE ONLY ----,
I
i
;;71, OYO, 99
.
(11)
(12)
(13)
If I . OS 4) . 'Z9
- I::J.., 773-glJ
(14)
0,
ere
,-
',';:l]~;~i
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS S\..k:.
CITY
STATE P A
Tax Payments and Credi
1. Tax Due (Page 1 Line 19)
2, Credits/Payments
A, Spousal Poverty Credit
B. Prior Payments
C, Discount
(1)
1~4.s7-d'(P::>,
c> . GO
Total Credits (A + B + C) (2)
3, InteresVPenalty if applicable
D, Interest
E_ Penalty
TotallnteresVPenally ( 0 + E ) (3) ~
4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 2010 request a refund (4)
5_
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
~,
c-D
A. Enter the interest on the tax due.
(5)
(5A)
-
0,
~
(5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
.!ll\LlInl\llH\llll_Vl~r 1'II11_I.mUliilJII... r - m lIlUJUlllllll1r~" JUIllI II I 1111 ~lIllm.., ]lJ1~
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
..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,
B, Enter the total of Line 5 + 5A. This is the BALANCE DUE,
1. Did decedent make a transfer and:
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? ............. .
2, If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................
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? . .
Yes
........0
..0
..0
.....0
.....0
o
No
~
~
~
18
181
g
Under penalties of perjury, I declare that I have examined this return. including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete.
Declaration of pre parer other than the personal representative is based on all infonnation of which preparer has any knowledge
SIGNATURE OF PERSON DATE
ADDRESS
DATE
__JUILIlII;~'-l~'I!E'" .lIlIJLlill._.;,_ U~I~...]i~UL.iITh.!lI[1 JlI ElIllIIIIII\IM!.lIil1ll1R
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 PS 99116 (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% [72 P,S, 99116 (al (1,1) (illl,
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 rale Imposed on the net value of transfers to or for the use of Ihe decedent's lineal beneficiaries is 4,5%, except as noted in 72 P.5. 99116(1.2) [72 P,S, 99116(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, 99116(a)(1.3I1, 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.
""""'".,".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
E h.fe.. E. SbQW
FILE NUMBER
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
1.
~.
Q.k~
~-p<u'J
VALUE AT DATE
OF DEATH
DESCRIPTION
00.-~~6~ - ~\-'~ ~k..
~~) ()!(), 9.1.
rJ.
CU\AM1~
IoJ ()()O.OQ
TOTAl(Alsoenteronline5,Recapilulation) $ ;::>, 8, 0 Po. ~
(If more space is needed, insert additional sheets of the same size)
c~
ORRS~rOWN BANK
() [< I~ S T () \V N. I' E N N S Y L V i\ N I j\ ] 7 :2 I I
ELSIE E STOUFFER
j-lARRH L ~'fO{1F-f!ER-
145 SHIPPENSBURG RD
SHIPPENSBURG PA 17257-8627
Date 11/23/01
PRIMARY ACCOUNT
TAX ID
ENCLOSURES
Page 1
103697532
204-03-7718
~~~
C H E C KIN G A C C 0 U N T S
THINKING ABOUT SOME HOME IMPROVEMENTS? RATES ARE FALLING!
NOW IS THE TIME TO GET A HOME EQUITY LOAN FROM ORRSTOWN BANK
CALL 1-888-0RRSTOWN FOR DETAILS.
CARRIAGE CLUB OPPORTUNITY
ACCOUNT NUMBER
PREVIOUS BALANCE
3 DEPOSITS/CREDITS
CHECKS/DEBITS
SERVICE FEE
INTEREST PAID
CURRENT BALANCE
103697532
20,287.85
1,783.92
.00
.00
9.22
22,080.99
CHECK SAFEKEEPING
Statement Dates 10/26/01 thru 11/25/01
DAYS IN THE STATEMENT PERIOD 31
AVERAGE LEDGER 21,712.23
AVERAGE COLLECTED 21,712.23
Interest Earned 9.22
Annual Percentage Yield Earned 0.50%
2001 Interest Paid 97.23
ACTIVITY IN DATE ORDER
DATE DESCRIPTION , TRACE NO AMOUNT BALANCE
10/31 ANNUITANT PA TREASURY DEPT 391202183 518.92 20,806.77
PPD
11/01 CIVIL SERV US 'T'REASURY 312 070200951 304.00 21,110.77
PPD
11/02 SOC SEC US TREASURY 303 437495450 961. 00 22,071.77
PPD
11/25 Interest Deposit 9.22 22,080.99
REV-1511 EX+ (12-99)
-!j~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
E).sl-=-
E. .s~U.f\<e..--
FILE NUMBER
ITEM
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES:
1.
F 0 I ~\ 5 ,t/\,-l.,\ iN - ~....J,Le.- f:\.oC...~ \~ Lv\~. S' 73(! 4-0
\
I
N~ ~pe., Ll YY\ . a\U"~ ~~)~j~~ ~(e).~
~J OdcJ. 0"
-
AnMINISTRATIVE COSTS:
Name of Personal Representative(s)
Social Security Number(s}/EIN Number of Personal Representative(s)
Street Address
City __________._________..____ State___Zip
Year(s) Commission Paid:
-
f 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 4~. Oc
-
.. . ",,=
6 Tax Return Preparer's Fees \~ ~R ~OC/\ ) J "3 0C
-
7. ~,\""~ ~eC ~ c) '-<Xq ') ~~
'<'>-<l )0
TOTAL (Also enter on line 9, Recapitulation) $ (, ) 7(). Of.,)
)
Debts of decedent must be reported on Schedule I.
;-0
-
(If more space is needed, insert additional sheets of the same size)
----
RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Receipt Date 12/10/2001
Receipt Time 16:04:09
Receipt No. 1027701
STOUFFER ELSIE
File Number 2001-Ql121
Remarks BENDER CAROL S
SK
------------------------ Distribution Of Receipt ----____________________
Transaction Description Payment Amount Payee Name
PETITION FOR PROBA
SHORT CERTIFICATE
EXTRA PAGES
JCP FEE
25.00
3.00
9.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
Check# 411
Total Received...... ...
$42.00
$42.00
H&R Block
15 RICHi'lALTER STREET
. SHIPPENSBlIRG. PA
Office: 37018 (7]7)532--7744
Profess lona]: #000128 JOliN rl FORBES
Client: HARRY STOlIFFER
rax Preparat icn 118.00
Total 1/8.00
Check #94 Tendered 118.00
Chdnge Due 0.00
Employee No. 000128
rhdnk Yo" far choos i ng H&R B 1 aLiI
for your tax services.
3/20/02 11 :14;30 AM
7090896
-
REV TS12EX+:1.,1j ,~
W"^
~
- ,'"1,' :f~~, -
~~ -~ :J."
COM\i!O~~WEALTH OF PENNSYLVANIA,
INHfil.lTANCE TAX RETURN
RFSIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
F-. '5rOIl ~
FILE NUMBER
ESTATE OF
6J6fe...
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
f'('e$"o,\-\'~"CU\ }tc.WI€S, +h'\.
16 j 5"1o/. '1':>
~,
PI\. ~er\" ",'It- "Re.;'il",''")IA.-e.......
~~
- ra r- s. (tv'l. cJ! W'I ~O>>t.r( t o..x
'-IT ?'8
J.
PA
t, ) ~ ~ q
S~:r<1.-k. ~U\l E',
P{-06~
;{ <./ ~ 7.)-' ~
I
TOTAL (Also enter on line 10, Recapitulation) $ ...34, :? J' 4. 7 c:j
(If more space is needed, insert additional sheets of the same size)
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE PA 17241-9486
(717) 776-8256
!
ACCOUNTS RECEIVABLE STATEMENT
Statement Date: 03/31/2002
.:l;'1f:lllli=--.II["'I'I']..I:.Ito{;.Jl~
'l'resGyterian J{omes, Inc.
Balance Due: 10,561.75
ELSIE STOUFFER
cia CAROL S BENDER
145 SHIPPENSBURG RD.
SHIPPENSBURG PA 17257
Account Number: 60656
Balance Forward: (1,378.80)
;'~:';)L.C:;~~lJJe ,,:>,~~j,(f,m1f~aYroent(9redii:8TJL:"~;:~~-al~flce~C~~~
r.. \~,Date/~,;:,>,<'
03/01/2001 - 03/12/2001
04/01/2001 - 04/13/2001
05/01/2001 - 05/13/2001
06/0112001 - 06/13/2001
07/01/2001 - 07113/2001
08/01/2001 - 08/13/2001
09/0112001 - 09/13/2001
10/01/2001 -10/13/2001
11/01/2001 - 11/03/2001
, iF:, 'K <>:; i:~i,l;;>\' ,f;t:pesc~~ptlon,j"< >,At~:';;
Patient Liability
Patient Liability
Patient Liability
Patient Liability
Patient Liability
Patient Liability
Patient Liability
Patient liability
Patient Liability
1,455.92
1,455.92
1.455.92
1.456.92
1.456.92
1.456.92
1,456.92
1.456,92
288,19
77.12
1,533.04
2,988.96
4,445.88
5,902.80
7,359.72
8,816.64
10,273.56
( /~:.:~:)
TOTAL:
11,940.55
0.00
p~fD
.;;flu S;L..~ r ~ SfUClr
-#- 'is-
'I'-Ij-O.}..
'l/ /() S" .1,j, 7~
-' -
. - It
.
. . .. . .
- ..
.
.'
.
SWAIM HEALTH CENTER: ELSIE STOUFFER 60656
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE PA 17241-9486
(717) 776-8256
ACCOUNTS RECEIVABLE STATEMENT
Statement Date: 04/30/2002
! 1Jres6yterian :Homes, Inc.
a ance ue u on recel t.
Balance Due: 0.00
ELSIE STOUFFER
c/o CAROL S BENDER
145 SHIPPENSBURG RD.
SHIPPENSBURG PA 17257
Account Number: 60656
Balance Forward: 10,561.75
lI!i:ijl'i'illitl!a~"'~~~='~!l!f!~~- -'-~I=--~' _Hl:~I~~_
04/15/2002 - 04/15/2002
04/15/2002 . 04/15/2002
Payment from statement 03/02
Payment from statement 03/02
10.094.87
466.88
466.88
0.00
TOTAL:
0.00
10.561.75
0.00
.
.
.
.. .
SWAIM HEALTH CENTER: ELSIE STOUFFER 60656
-
, -
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX B4e6
HARRISBURG, PA 17105-8486
February 19, 2002
MARY C BENDER
145 SHIPPENSBURG
SHIPPENSBURG PA
RD
17257
Re: ELSIE STOUFFER
CIS #: 770148060
SSN: 204-03-7718
Date of Death: 11/04/2001
Dear Ms. Bender:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $75,420.84 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department1s
itemized statement of claim.
A portion of this medical expense, namely $24,275.16, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $51,145.68, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
:S~l.~
Sharon E. Smith
TPL Program Investigator
717-772-6397
717-772-6553 FAX
Enclosure
,
.
COMMONWEAlTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION. CASUAL TV UNIT
PO BOX 6486
HARRISBURG PA 17105-8466
February 13, 2002
STATEMENT OF CLAIM SUMMARY
NAME
10
Estate of STOUFFER, ELSIE
770 148 060
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 22,186.89 49,559.08 71,745.97
DRUG 2,088.27 1,586.60 3,674.87
REIMBURSEMENT TO DPW 24,275.16 51,145.68 75,420.84
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN. 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
*'
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0432
HARRISBURG, PA 17128-0432
.a~U4tEX'''' U-Ol)
HARRY L STOUFFER
ELSIE E STOUFFER
145 SHIPPENSBURG
SHIPPENSBURG
ASSESSMENT
DATE OF NOTICE:
SOCIAL SEC. NUM:
TAX YEAR:
ASSESSMENT:
NOV 29 2001
203-10-2895
1999
M90317
BALANCE[S) DUE fOR YOUR ACCOUNT AS OF DEC 09 2001
. BALANCE INCLUDES ESTIHATED TAX UNDERPAYHENT PENALTY
OWED PAID BALANCE
L PEN/ADD .00 .00 .00
U/EST PEN 47.77 .00 47.77
LEGAL .00 .00 .00
INTEREST .00 .00 .00
TAX/RFD 1312.00 1312.00 ~
PLUS OTHER TAX YEARIS) LIABILITIES .00
TOTAL DUE NOW 47.77
PLEASE PAY THIS AHOUNT USING THE DETACHABC OW
YOUR 1999 TAX RETURN WAS PROCESSED AS FOLLOWS. SEE CALCULATIONS BELOW.
YOUR FIGURES OUR FIGURES
lA. GROSS COHPENSATION -- .... . ... .. .. .. .. .. . .. .. . .00 .00
.LB. $C:h~UULt ut fXPENSt:::.o........................ .CO .Ou
lC. COHPENSATION................................ .00 .00
2. INTEREST ISCHEDULE A).......... ....... ...... 2,354.00 2,354.00
3. DIVIDENDS ISCHEDULE B)...................... 551.00 551.00
4. NET INCOHE OR LOSS.......................... .00 .00
5. TAXABLE SALE - GAIN OR LOSS... ........ ...... 43,941.00 43,941.00
5A. CAPITAL GAIN EXCLUSION...................... .00 .00
6. RENTS, ROYALTIES, PATENTS, COPYRIGHTS... .... .00 .00
7. ESTATES AND TRUSTS ISCHEDULE J)............. .00 .00
B. GAHBLING AND LOTTERY WINNINGS............... .00 .00
9. GROSS TAXABLE INCOHE [ADO LINES lC,2-5,6-8). 46,846.00 46,846.00
10. CONTRIBUTIONS TO HEDICAL SAVINGS. .... ... .... .00 .00
11. NET PA TAXABLE INCOHEILINE 9 HINUS LINE 10). 46,846.00 46,846.00
13. TAX LIABILITY [HULTIPLY LINE 11 BY .02800).. 1,312.00 1,311.00
14. TAX WITHHELD IFROH W2.S).................... .00 .00
15. CREDIT FROH PREVIOUS TAX YEAR... ............ .00 .00
16&17 ESTIHATEO TAX & EXTENSION PAyMENTS.... ...... .00 .00
18. TAX WITHHELD AS REPORTED ON NRK-l....... .... .00 .00
19. TOTAL CREDITS IAOO LINES 15-18). ....... ..... .00 .00
20B. NUMBER OF DEPENDENTS........................ 0 0
22. TAX FORGIVENESS CREDIT............. .. .. . .. .. .00 .00
23. OUT STATE CREDIT ISCHEOULE GJ............... .00 .00
24-27.CREDITS [LINES 24-27).................. ..... .00 .00
28. TOTAL CREDITS [ADD LINES 14,19,20C-25J..... .00 .00
29. TAX DUE ILINE 13 MINUS 26).. .... ........ .... 1,312.00 1,311.00
30. OVERPAYMENT [LINE 26 MINUS 13).............. .00 .00
31. REFUNDED.................................... .00 .00
32. CREDITED TO NEXT YEARS ESTIMATED TAX..... ... .00 .00
33-37.TOTAl OONATIONS (LINES 33-37)..,......... .00 .00
ROAD
PA
17257
SEE REVERSE SIDE FOR MORE INFORMATION
DETACH AT PERFORATION
'"
.
,
, .
I 'i ';;,~ ,::, "'" \' f Ie ,-, ~'t"~"1 R.o Li...J.
S he Pt~<<n':. \, '-~"'\.J P'1 \ 1), S"7 -
Q", c. ~ I'Y, \, \:: ," ~) .~ \) () I
:? I, ., '7
... l.Y ,,'"
en. D~ pnx\-\Y\.\C{\\ ('\~12\:'J"'nl(,(:_,
'\01.: ft- J,? 01~:3 J."
H OJr,s \,,' 'j' Pi\! -; /J?5 - 0 '-J J ~
Snl:..\c,'.i \-'(\.
7<::-: ,..... ~~ 1...'. {l, (j.., \
\ 'S Q.~i:'<:.k i:i 41':1, -\;.,r <J) 4 'l1J ~o r- -\--\l E:..
\'-)('.",'1"<': l-<>...x bQ.\Q-"'1(..~ c\-- \-to...q-,) L. Sh':'lC~t''':
\'c,- \ 'i <i q .13, Q t h I-.!.(L\'\[' '1 L. cu..,J,
()..('e,. d.~c:..ea...s e.S. .-1.. Gl n, ~-'" ~ \ r
(!Jut:., 6f 1"h'<. \ r a.q:-;<.; r<. ,
ex. '-1"1
-tee k; )
s.s '*:<03 -10- :J.'ZC;S-
I
[kli:: E. St(>\..l~e.r
Qx, Cl u.. <. \r, \b- 0-4'\&
/\
, '
s;. \ "~(-'-,,. <::...1'1'
(1 C(\ \~,[ ~. l~c.nckJ
r PIT
, BUREAU OF INDIVIDUAL TAXES
PERSONAL IHCoHE TAX
REV-364C [3-011
TAXPAYER NAME:
NOTICE DATE,'--
SOCIAL SEC. NUM:
TAX YEAR:
HARRY L STOUFFER
NOV 29 2001
203-10-2895
1999
$
'-I '7.7 '7
PAYHENT AIl0UNT:
CAROL S. BENDER
HAROLD E. BENDER
t 45 SHIPPENSBURG ROAD
SHIPPENS8URG, PA 17257
60-1503/313
103000734
412
. REVENUE".
DATE
I;)., -05>01._
Pi~ "D"'pl--. - \-
1<<;:,-..) <:.-n'-'-,0.
3:l _-----------'--~----
,..: .....
, $ Lf'7, 7J
-.l
f~L "IJ ,s \:.v<..,
~
P~~~~yv~ l7aM~ S. irS?Q'>-~>J ,,,.
1-t.'.('"~ L. - ............. <: L
:1.(;.:; - 10 -.A. 7<;.';)- 1 2
l:n'lLI~5ojbl: 10'1 CeO?3L,II' 01.,.
o.A.-'"'C.\
"---',- -'- ~
_/ - n'OI.LAH!; III
/?-d<.6- Y
'" BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
l: .
MARY CAROL STOUFFER BENDE
145 SHIPPENSBURG RD
SHIPPENSBURG PA 17'257
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
u COUNTY
ACN
09-10-2002
STOUFFER
11-04-2001
21 01-1121
CUMBERLAND
101
'*
REV-1547 EX AFP 101-02)
ElSIE
E
Allount Rellitted
t .. ~
. \
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=i5'4-j-E3f-AFP--foY:02Y-NOYicE-OF-YNHEifiTAifcE-TAX-A-PPRAISE;''-ENT~--Ai:.rowANCE-(fR------------ -----
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF STOUFFER ElSIE E FILE NO. 21 01-1121 ACN 101 DATE 09-10-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
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. Mortgages/Notes Receivable (Schedule D)
5. 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)
(5)
(6)
(7)
.00
.00
.00
.00
28,080.99
.00
.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. Charitab1e/Governllenta1 Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
6,170.00
34.884.79
(11)
(12)
(13)
(14)
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount 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:
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
28,080.99
4] .054 79
12,973.80-
.00
12,973.80-
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
... ..-. l+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
.00 X 00 =
.00 X 045=
.00 X 12 =
.00 X 15 =
(19)=
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
.00
.00
.00
.00
.00
( 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.)
RESERVATION: Estates of decedents dying on or befDre December lZ, 198Z -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life Dr for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMIN-
ISTRATIVE
CORRECTIONS:
DISCDUNT:
PENALTY:
INTEREST:
To fulfill the requirements of Section Z140 of the Inheritance and Estate Tax Act, Act Z3 of ZOOO. (7Z P.S.
Section 9140).
Detach the top pDrtion of this Notice and submit with your payment to the Register of Wills printed on the reverse side.
--Make check Dr money order payable to: REGISTER OF HILLS. AGENT
A refund of a tax credit, which was not requested on the Tax Return, may be requested by cDmpleting an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-13l3). Applications are available at the Office
of the Register Df Wills, any of the Z3 Revenue District Offices, Dr by calling the special Z4-hour
answering service for forms ordering: l-800-36Z-Z050; services for taxpayers with special hearing and I Dr
speaking needs: l-800-447-30Z0 (TT only).
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days Df receipt Df
this Notice by:
--written protest tD the PA Department Df Revenue, BDard of AppealS, Dept. Z8l0Zl, Harrisburg, PA l7lZ8-l0Zl, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors disCDvered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z8060l, Harrisburg, PA l7lZ8-060l
Phone (717) 787-6505. See page 5 of the bODklet "Instructions for Inheritance Tax Return fDr a Resident
Decedent" (REV-150l) for an explanation Df administratively correctable errDrs.
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount Df
the tax paid is allowed.
The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participatiDn
penalty is appealable in the same manner and in the the same time period as you wDuld appeal the tax and interest
that has been assessed as indicated on this nDtice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of
six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOOZ are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
198Z ZO% .000548 199Z 9% .000Z47
1983 16% .000438 1993-1994 n .00019Z
1984 11% .000301 1995-1998 9% .000Z47
1985 13% .000356 1999 n .00019Z
1986 10% .000Z74 ZOOO 8% .000Z19
1987 9% .000Z47 ZOOl 9% .000Z47
1988-1991 11% .000301 ZOOZ 6% .000164
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculatiDn to fifteen (15) days
beyond the date Df the assessment. If payment is made after the interest computatiDn date shown Dn the
Notice, additional interest must be calculated.
~
dK
STATUS REPORT UNDER RULE 6.12
Name of Decedent:~\s\~ t. Stc)l..J..~er
Date of Death: It-Lt-O\
Will No. ~OOl - C)'l~\ Admin. No. PA ;(1-01- lI~l
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 t/ No
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 v/
2. st(k\~ \'So 'I~So\"~Y\{:.
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 attached to this report.
Date: 9 -I~ - 03
~~l~. ~ &Kiw
~ Q.os'-o\ StO\l~e,(" "is ~ \'1("\P<:.
Namel (Please type or print)
Jl..JS' S~\:Y)~6lA-~ ~O~~
~eJffs~y\~\::.~~) PA ) II )'S'?
17/7) 4;), '0- ~ I.o~-
Tel. No.
~personal Representative
Capacity:
(MAH:rmf/AM3)
Counsel for personal
representative