HomeMy WebLinkAbout94-00146
Estate ofi,REDITH HURLEY SHOWVAKER
also known as FREDITH E. SINGER
PETITION FOR PROBATE and GRANT OF LETTERS
21-94 ltJl.
No.
To:
Register of Wills for the
Deceased. County of CilllBERLAND in the
Social Security No. 208-42-3301 Commonwealth of Pennsylyania
The petition of the undersigned respectfully represents that:
..
Your petitioner(s), who is/are IS years of age or older an the execut ORS
in the last will of the above decedent, dated APRIL 24
and codicil(s) dated AUGUST 2. 1993
named
, 19..2!L-
(Slate relevant circumstances, e.g. renunciation, death or executor, etc.)
Decedem was domiciled at death in CUMBERLAND
h ER last famil)' or principal residence at R. D. 112, Box 94B.
Pennsylvania 17241, Upper Mifflin Township
(list street, number, Twp. or Boro.)
County, Pennsylvania, with
Newville.
Decedent. then 76 )'ears of age, died DECEMBER 4 ,19 93
at Carlisle Hospital. Carlisle. PA 17013
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 propeny with estimated yalues as follows:
(If domiciled in Pa.) All personal propeny S 95,400.00
(If not domiciled in Pa.) Personal property in Pennsylyania S
(If not domiciled in Pa.) Personal property in County S
Value of real estate in Pennsylyania S 88.500.00
situated as follows: Real Estate. R. D. 112, Box 94B, Newville, Pennsylvania
Upper Mifflin Township
WHEREFORE, petitioner(s) respect full)' request(s) the probate of the last will and codicil(s)
presented herewith and the srant of leners TESTAMENTARY
(testamentar)'; administration c.I.a.; administr:uion d.b.n.c.t.a.)
theron. .
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;.= NEWVILLE. PA 17241
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NEWVILLE. PA 1/241
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA } ss
COUNTY OF CUMBERLAND
The petitioner(s) above-named swear(s) or aflinn(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.
tatiYe(S) of the above decedent petilloncr(s) will well.l!nd truly administer the estate according to law.
I) f - 1 .
Sworn to or affirmed and subscribed { '~<-A/l.{ V ....::.~r ~l(."L-_ !!>
before me this 02 dgt Of:.1 PE~KL v" liA~ lJ\K ~ ~.
ibru,,~ 19_, t.<.~.~i\ <,,"5:1"')t: {/~ ..
'1. )'1" 0 t'. ';/~., '<0 'i JAMES R'. SHOWVAKER ~
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LAST WILL AND TESTAMENT
OF
FREDITH HURLEY SHOWVAKER
I, Fredith Hurley Showvaker of 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 revoking all other wills
and codicils heretofore made by me.
FIRST
I direct the payment of my debts and the expenses of my
last illness and funeral from my estate as soon after my death as
conveniently may be done, If there be no cemetery lot available
for my interment, owned by me at the time of my death, I
authorize my personal representative to purchase such cemetery
lot with a contract for perpetual care, using therefor funds from
my estate, in such amount as he shall consider necessary and
desirabler and I authorize my personal representative to cause
title to or ownership of such lot so purchased to be vested in
such person as my personal representative shall designate.
Further in this connection, I authorize my personal
representative to expend funds from my estate, in such amount as
my personal representative shall consider necessary and desirable
for the purchase, erection and inscription of a suitable marker
for my grave,
SECOND
I give, devise and bequeath all of my estate of
whatever nature or wherever situate, together with all insurance
polices thereon, unto my issue, per stirpes,
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Signed, sealed, published and declared by the above named
testatrix Fredith Hurley Showvaker, as and for her Last will and
Testament, 'in the presence of us, who, at her request, in her
sight and presence, and in the sight and presence of each other,
have hereunto subscribed our names as witnesses.
ADDRESS St" lJ-"VlfS II Cw,/,..f,. I"vI (7 ~ I)
ADDRESS 75'00 ,;4/c-d,__m~.A /!(.{N .Lc-tsO
6h)xj ';0,4 /7OJS7
1'/. /ftJ'-/'l
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
,
REV.I.5OO EX +"17,.QAI
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o 2. Supplemental Return
o 40. Future Int.rtll Compromise
(lor do'.. 01 dea,h af'er 12.12.821
1XJ b. Deeedent Died Testare 0 7. Decedent Maintained a Living Trull
(Allach copy of Will) (Allach copy 01 T rUlll
'AIJ;(CORRISl'ONDINCI.AND..CONFIDfNT,AL.TAX INFORMATION. SHOULD. BE:DIRECTED:TOi"i,,'0..jj'ii"i.lf'~Jil.,
AM COMPLETE MAiliNG ADDRESS
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COMMONWEAI.TH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISaUAG. PA 17128.0601
DfCEOEN 'S NAME (lAST, fiRST, AND MIDDlE INITIAL)
Sin er Fredith H. s.
SOCIAL SECURITY NUMBER DATE Of PlATH
c...
FOR OATIS OF DEATH A"ER 12131/91 CHICK HIRE
IF A SPOUSAL
POVIRTY CRIDIT IS CLAIMED 0
Fill NUMBIR 2191- _ Of .{'0
COUNTY CODE
DECEDENT'S COMPLETE ADDRESS
YEAR
NUMBER
208-42-3301
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bllE~
=09
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119 1. Original Return
RD 2 Box 94 B
Newville, PA 17241
Coo", Cumberland
AMOUNT RECEIVED (SEE INSTRUCTIONSl
o 3. Remainder Relurn
(lor dot.. 01 deoth prior to 12.13.821
o 5. F,deral Estale Tax Return Required
_8. Total Number of Safe Deposit 80xes
.'~li~4'/i.'1i3~: .
36 S, Pitt St<,.
Carlisle, 'Ac~701
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TElEP140NE NVMlfR
243-6090
91.000.00 IT .
(11 r. I '-
( 2) nnn~ ~'J . ~
( 31 NONE: N
.' Ul
NONE r, ....-
( 4) _...e.
100.324,59 o. :J:o
(51 " ,)
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(61 JfONE ~~ -
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(7) NONE
(9) 8.956,01
(101 3.627.27
(a I
191.324.59
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1. R.al Eliot. (Schedule A)
2. Stacks ond Band. (Sch.dule B)
3. Clollly Held Stock/Partnership Inleresl (Schedule C)
4. Mortgages and Notes Receiyable (Schedule 01
S. Cash, Bank Deposits & Miscellaneous Personal Property
(Sch.dul. EI
6. Jointly Owned Prop.rty (Schedule F)
7. Tron.f... (Schedul. G) (Schedule l)
8. Total Gron Auets (totallinos 1.7)
9. Funeral Expenses, Administrative Costs, Miscellaneous
Expenses (Schedule HI
10. Deb,s, Mortgage liabilities, liens (Schedule II
11. Total Oeductions (Iotollines 9 & 10)
12. Net Value of estale (line 8 minus Line 11)
13. Charitabl. and Goyernmental Bequests (Schedul. Jl
14. Net Valu. Subj.ct to Tax (line 12 minus Line 131
15. Spousol Tranders (for dates of death aher 6.30.94)
set Instructions for Af,plicobl. Percentage on Rey.ne
Side. (lndude values rom Schedul. K or Schedule M.)
16. Amount of line 14 taxable at 6% rate
(lndude values from Schedule K or Schedule M.)
17. Amoun' Qf lint 14 taxabl. ot 15% rat.
(Include valu.s from Sch.dul. K or Schedule M.J
18. Principal Pax due (Add tax from Lines 15, 16 and 17.)
19. Cr.dits Spousal Poverty Credit Prior Paymenls
NONE + NONE
(15)
(16) 178,741.31
(171 NONF.
Discounl Interest
+ NONE NONE
(11) 12.583.28
(121 17R,741.31
(13) NONE
(141 178.741.31
X.__II
x ,06 = 10,724.48
x .15 II; NONE
(181 10.724.48
(191 . NONE
(20) -0-
(211 10,724.48
(21AI
(2IB)
20. If Une 19 is gr.ater than line 18, enler the diff.rence on Lin. 20. This I. the OVERPAYMENT.
II D..l'PI!I!II.....,.I~....._....I,II.I_.II......Dlnr.r:n..,.I.I..1...11....1....111:..,
21. If lint 18ls gflG1er than line 19, tnter the diR.re"ce on Line 21. This i, the TAX DUE.
A. Enter the inlerest on th. balonce due on lIn. 2'A.
8. Enter the total of line 21 and 21A on lint 218. This is the BALANCE DUE.
Mak, Check '.v.ble tOI R..lat., of Will., Ag,n'
USUI. TO ANSWa AU QUunONS ON RIVERSE SIDE AND TO IECHlCIC MAn!
Und., penalli.. of P.lrlury, I d.dare fhat t have e.arnined this r.turn, induding accompanying sch.dul.. ond statements, and fo th. best of my knowl.dge and b,U.f,
it iI true (O"let ond compft.,.. I d.da" thot all 1101 ,,{ol, has b..n r.portea at true marte! volue. O.c1oration of preparer olher thon the personcl repr."n'Qti~l.
bONd oft alllnformolion of which pr.paror has ony.nowl.dge.
~GN4,'U.f Of ,u~ <<UPON"ltl}-oa f!Ll""p_.lnuIN ADOJ:U$ DAn-
:-; .,........_t (/ {. tou,'1.. RD 2 Box 111 Newville, PA 17241 1//9/95
tVIE Of '<<f~^Ill:U OtH~.,.~N ,!'I)'Nt rv! ., ADDRf~' DATE
'1",~;(1__r.... /f-1,';C.,( "T/(~'J D 2 Box 211D Newville. PA 17241 1/ij/95
THIS INDENTURE
MADE THE ~ day of July, in the year of our Lord one thousand nine hundred and
ninety.four (1994)
BETWEEN JAMES R. SHOWVAKER and PEARL V. SALINGER, Executors of
the Last Will and Testament of FREDITH E. SINGER, late of Upper Miffiin Township,
Cumberland County. Pennsylvania, hereinafter called party of the first part, and MICHAEL S,
MOOMAW and SHARON A. MOOMAW, bis wire. of Upper Mimin Township, Cumberland
County. Pennsylvania, hereinafter called parties of the second part:
WHEREAS, the said FREDITH E. SINGER, by her Last Will and Testament, duly
. proved and recorded in the Register's Office of Cumberland County, Pennsylvania to File No. 21-
94.146, authorized her executors to sell at either public or private sale and real property owned
by her at her death and nominated James R Showvaker and Pearl V. Salinger as her executors.
who have subsequently been appointed and continued to act as such.
NOW THIS INDENTURE WITNESSETH, that the said party of the first party, by
virtue of the power and authority aforesaid, in said Will contained, and in consideration of the
sum of Ninety.one Thousand and nollOO ($91,000.00) Dollars to then paid by the said parties of
the second part, at and before the ensealing and delivery or these presents, the receipt whereof is
hereby acknowledged, has granted bargained, sold and conveyed and do hereby grant, bargain,
sell and convey to the said parties of the second part, their heirs and assigns, as tenant by the
entireties,
ALL that certain messuage and tract of land situated in Upper Mifflin Township,
Cumberland County. Pennsylvania, bounded and described as follows:
BEGINNING at a nail in the center line of Whiskey Run Road (L.R. 21040) at the
intersection ofJands now or formerly of 10hn D. Salinger and Pearl V. Salinger; thence along said
center line North 48 degrees 30 minutes West 17 feel to a nail; thence continuing along said
center line by a curve to the right with a radius of 391.20 feet and length of 177.52 feet to a nail;
thence along lands now or formerly of Glenn Gayman South 64 degrees 30 seconds West 215.00
feet to an iron pin; thence along the lands now or formerly of Fredith H. Showvaker South 44
degrees 19 minutes East 160.20 feet to an iron pin; thence along land now or formerly of 10hn D.
Salinger and Pearl V. Salinger, North 55 degrees IS minutes 30 seconds West 232.48 feet to a
nail, the place of BEGINNING.
. BEING Lot No. 1 of the subdivision plan of Oscar M. and Fredith H. Showvaker
prepared by Larry V. Neidlinger. P.E., dated December 19, 1977, and to be recorded even date
herewith in the Office of the Recorder ofDeeds of Cumberland County.
BEING the same premises which Oscar M. Showvaker and Fredith H. Showvaker, his
wife, granted and conveyed to Oscar M. Showvaker and Fredith H. Showvaker, his wife, by deed
dated February 6, 1978, and recorded in the Office of the Recorder of Deeds for Cumberland
COUnty in Deed Book "Q", Volume 27, Page 303. The said Oscar M. Showvaker died on
. thereby vesting full title in Fredith H. Showvaker. Fredith H. Showvaker
subsequently intermlllTied with Frank R. Singer who subsequently executed an antenuptial
agreement, a copy of which is anached hereto, wherein Frank R. Singer waived his right to make
any claim whatsoever in the property herein conveyed.
TOGETHER with all and singular the rights, lib~rties, privileges, hereditaments and
appurtenances whatsoever thereunto belonging or in anywise appertaining, and the reversions and
remainders, rents, issues and profits thereof, and all the estate, right, title interest, property, claim
and demand whatsoever of the said Estate of Charlotte L. Walters at and immediately before the
time of her decease, in law or equity or otherwise howsoever, of, in, to or out of the same:
TO HA VE AND TO HOLD the said granted premises to the said John E. Bolen, his heirs
and assigns forever.
And the said party of the first part does covenant, promise, grant and agree, to and with
the said party of the second part, his heirs and assigns, by these presents, that he the said party of
the first part not done, committed or knowingly or willingly suffered to be done, any act, matter,
'Or thing whatsoever, whereby the premises aforesaid, or any part hereof, is, are, shall or may be
charged or incumbered, in title, charge or estate, or otherwise howsoever.
IN WITNESS WHEREOF, the said party of the first part has hereunto set his hand and seal the
day and year above written.
SIGNED, SEALED AND WITNESSED
L" THE PRESENCE OF
ESTATE OF FREDITH H, SINGER
IS/...Jes (SEAL)
JAMES R. SBOWVAKER, Executor
I.JI P t/ .s (SEAL)
PEARL V, SALINGER, Executrix
STATE OF PENNSYLVANIA
:88:
COUNTY OF CUMBERLAND
On this, the _ day of July, 1994, before me, the undersigned officer, personally
appeared JAMES R. SHOWY AKER and PEARL V. SALINGER, Executors of the Estate of
Fredith H. Singer, known to me (or satisfactory proven) to be the persons described in the
foregoing instrument and acknowledged that they executed the same in the capacity therein stated
and for the purposes therein contained.
. IN WITNESS WHEREOF, I hereunto set my hand and official seal.
(SEAL)
STATE OF PENNSYLVANIA :...
COUNTY OF CUMBERLAND
:88:
...... ,........".:.......-,
RECORDED on this day of AD. 19 , in the Recorder's
Office, in Deed Book , Volume ,Page
Given under my hand and the seal of the said office, the date above written.
Recorder
" ..Rf....150~.fh [2.871
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COMMONWEALTH OF PENNSYlVANIA
INHERITANCI TAX RETURN
RUIDINT DICE DENT
SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
Plea.e Print a~.Type
mE NUMBER
2194-0196
ESTATE OF
FREDITH H. S, SINGER
(All property Jolntly.owned with the Right of Survlvonhlp mUlt be di.clol.d on S,hedule F)
ITEM
NUMBER
1
2
3
4
5
6
7
DESCRIPTION
VALUE AT
DATE OF DEATH
CD# 30008497 dated Sept. 20, 1993
CD# 5007270 dated Aug. 14, 1991
CD# 5007919 dated Aug. 19, 1992
CD# 3008555 dated Nov. 6, 1993
CD# 5007412 dated Nov. 4, 1991
CD# 5008049 dated Dee, 1, 1992
Household property and furniture- value based on
pUblie sale price
50,333.90
10,032.39
10,017.06
10,024.93
10,000,OO
5,001. 56
4,914.75
TOTAL (AI.a enter an line 5, Recapitulation S 10.0,324.59
(Atloch additionallY," Ie 11" Ih..11 jf more IPOC' il ne.ded,)
. ~".''';'';.11'''1 *' ~ SCHEDULE I
. COMMONWfAllHO"'NNmYANIA DEBTS OF DECEDENT,
IN~:::~~~~'D~'c",::~'N . MORTGAGE LIABILITIES AND LIENS
ESTATE OF
Plea.. Print or Type
FILE NUMBER
2194-0196
FREDITH H. S. SINGER
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
Internal Revenue Service- 1993 Income Tax
$257.00
$142.00
2. PA Department of Revenue- 1993 Income Tax
3. Patricia A. Rosendale- 1993 Income Tax-
Preparation Fee
4. Patricia A. Rosendale- Fiduciary Income Tax
preparation
$50.00
$85.00
$8.91
$30.00
5. ~nited Telephone- Final Bill
6. Larry Strouse- Transportation to Hospital
7. Pearl V. Salinger- Snow Removal and Clothing
Reimbursement
$65.00
$209.97
$20.00
$200.00
$30.00
8. Kough's Oil Service- Fuel Oil
9. Delanor Kuntz- Snow Removal
10. Steven Barrett- Real Estate Appraisal
ll. Frank Singer- Reimbursement for Electrical Bill
12. Transfer Taxes and other Expenses of Real Estate
Sale
$1,006.84
$65.00
$66.30
S32.80
$194.31
$61.84
$30.84
$75.00
$55.00
$34.19
13. EBY Granite Works- Headstone Engraving
14. Koughs Oil Service- Fuel Oil
15. Adams Electric- Electric Bill
16. Francis E. Oiler- Real Estate Taxes
17. Kaughs Oil Service- Fuel Oil
18. Adams Electric- Electric Bill
19. Newville Lions Club- Building Rental
20. James E. Showvaker- Reimbursement for Water Test
21. Koughs Oil Service- Fuel Oil
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TOTAL lAlla eMler on line 10, Recapitulation)
(II more 'pace is needed, ;"I,rf additional sheets of some 5iz..J
S
NEXT PAGE
.. /!aL .F .GaLu .5 ft? A1".~ /
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V.. ~47 EX AFP (12"94*
. COHHONWEAL TH OF PENNSYLVANIA .
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
. DEPT. 280601
HARRISBURG, PA 17128-0601
J</- J 'l,?.. /'1
NOTICE OF INNERITANCE TAX
APPRAISENENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
ACN 101
DATE 04-03"95
Q"
fl.. .
1/
FILE NO.
12-04-93 COUNTY CUMBERLAND
NOTEI TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBNIT THE UPPER PORTION OF THIS FORN WITH YOUR TAX
PAVNENT TO THE REGISTER OF WILLS. NAKE CHECK PAVABLE TO "REGISTER OF WILLS, AGENT"
REMIT PAYMENT TO:
HAROLD S IRWIN III
36 S PITT ST
CARLISLE PA 17013
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
Allaunt R..itted
CUT ALONG THIS LINE .... RETAIt.! LOWER PORTION FOR YOUR RECORDSlO....
iiE'Y:i547"Eii"AFP"n'2:94"i"iiiificr"oF"i"NHEiiifAiicE-i'Ax"iipiiRAisEifENT~--Arnicl'GAiicE...WR"---:ii~-.""-_..
. DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX i~ P
ESTATE OF SINGER FREDITH E FILE NO, 21 94-0146 ACN. 101 "-, DATE ',04-03-95
35
If an assessment was issued previously, lines 14, 15 and'or 16, 17 and 11 will
reflect figures that include the total of abb returns assessed to dete.
ASSESSMENT OF TAX:
15. Aaount of Line 14 .t Spou..l r.t. 1151
16. Aaount of Line 14 t..obl. .t Lln..l/Cl... A r.tl 1161
17. ~ount of Lln. 14 t..obl. .t Coll.t.r.l/Cll.. S rlt. 1171
II. PrinciPII T.. Due
TAX CREDITS:
PAVNENT
DATE
01-25-95
TAX RETURN WAS I I X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL
1. RI.l Eat.t. ISoh.dul. Al
2. Stockl and BondI (Schedul. 8)
5. Clo..ly Held stock/Partnership Interelt CSchedule C)
4. Hortgag../Not.. Receivable (Schedule D)
S. C..h/Bank Depolitl/"Jlc. Perlonel Prop.rt~ (Schedule E)
6. Jointly Owned Property ISchedule F)
7. Tran.fera ISchedule G)
8. Tot.l A...t.
APPROVED DEDUCTIONS AND EXEMPTIONS:
,9. Funeral Expen.../Aa.. COlts/"ilc. Expen... (Schedule H) (9)
10. D.bta/Nortgegl Llebllltl../Llln. ISohldull II Cia)
11. T~tal Deduction.
12. N.t Value of Tlx Return
IS. Charitable/Goyern.antal Bequ..t. (Schedule J)
14. N.t V.lu. of Eat.tl Subject to T..
NOTE:
RECEIPT
NUIIIER
AA022750
DISCOUNT C_I
INUREST ('1
309.20-
INTEREST IS CHARGED FROM 01-26-95 TO 04-11-95
AT THE RATES APPLICABLE AS OUTLINED ON THE
REVERSE SIDE OF THIS FORM
. IF PAID. AFTER DAYE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
I I CHANGED
111
121
151
(4)
151
(6)
171
"'-'
91.0Jl~00 ;,;;;
"'~.OO ~
.00
.00
100.324.59
.00
.00
CII
I
.....
V) 0
-h
191,324.59
l'.IiA~ 'A
178,741. 31
.00
178,741.31
.00
10,724.48
.00
10,724.48
10,415.21
309.20
5.80
315.00
C IF TOTAL DUE IS LESS TIIAN 11, NO PAI'IlENT IS REWIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICII, vau !lAV IE DIll
a REFUND. SEE IEVEIISE SID! 0' TIIIS 'Ollll 'OR INSflIUCflONS.1
8,956.01
3.627.27
IUI
1121
IUI
1141
.00
178, 741. 31
.00
x,OO.
X .06.
x .15.
llal
_T PAID
10.724. I
TOTAL TAX CRIDIT
BALANCI OF TAX DUI
INTEREST
TOTAL DUI
REY-1547 EX AFP (12094*
COHHONWEAlTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
. BUREAU OF INDIVIDUAL TAXES.
DEPT.. za06Dl
HARRISBURC, Pi 17128-0601
NOTICE OF INHERITANCE TAK
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
DF DEDUCTIONS AND ASSESSMENT OF TAX
ACN 101
DATE 04-03-95
FILE NO,
12-04-93 COUNTY CUMBERLAND
NOTE. TO INSURE PROPER CREDIT TO YOUR ACCOUNT, suaMIT THE UPPER PORTION OF THIS FORM WITH YOUR TAK
PAYHENT TO THE REGISTER OF WILLS. MAKE CHECK PAYABLE TO "REGISTER OF WILLS, AGENT"
REMIT PAYMENT TO:
HAROLD S IRWIN III
36 S PITT ST
CARLISLE PA 17013
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
Anount R'.1 U.d
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
ilEV:iil4TEx-Ar.io"-ii:f:9~-'--rjcjfici:"-oj?-I-rl':1Ei:-i;:AiicE-TAx-:'-r;;~Xi:iciicriT~--Ai.roiiAiicn:i~---------.-_. ----
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SINGER FREDITH E FILE NO, 21 94-0146 ACN 101 DATE 04-03-95
TAK RETURN WAS. I X I ACCEPTED AS FILED
I I CHANGED
RESERVATION CONCERNING FUTURE INTEREST 0 SEE REyERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL
1. Reel Eltete ISch.dule Al III
2. Stock. and aond. ISoh.dul. BI 121
3. Clo.lt, Heldstock/Pertnlrshiplnter..t (Schedule C) 13'
4. Hartgagl,/Not.. Reclivable (Schedule D) (4)
5. Cash/Bank Deposita/Hi.c. Perlonll Property (Schedule E) (5)
6. Jointly Owned Propert, (Schedule f) (6'
7. Tranlfers (Schedule G) (7)
a. Totel A...ta
91. 000.00
.00
.00
.00
100.324.59
.00
.00
lal
191,324.59
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expans../AdM. Costl/Hisc. Expense. (Schedul. H) (,)
10. D.bt./Hortgogo Llabllltle./Llon. (Schedul. II 1101
11. Total Deduction.
12. N.t ValuM of rax Return
11. Ch.ritabl./Covar~.ntal B.qu..t. (Schedul. J)
14. Not V.lu. of E.tet. Subject to Tex
8,956.01
3.627.27
IllI
1121
1151
1141
1,.I\RJ 'A
178,741.31
.00
178,741. 31
NOTE:
I~ an asses.ment was i.sued previously, lines 14, 15 and/or 16, 17 and 18 will
reflect figures that include the total of ~ returns assessed to date,
ASSESSHENTOF TAX:
15. Aeount of Line 14 .t Spou.el r.t.
16. A~t of Line 14 taxabl. at Lin..l/CI... A rat.
17. Aeount of Lln. 14 te.able .t Colleterel/Cl... . r.t.
lB. Prlnclp.l T.. Duo
1151
11"_
1l7l
.00 K .00.
178,741.31 K .06.
.00x.15.
Ill'
.00
10.724.48
.00
10,724.48
TAX CREDITS:
PAYHENT
DATE
01-25-95
RECEIPT
_BER
AA02Z750
DISCOUNT 1-'
INTEREST (-I
309.20-
AHDUNT PAID
10,724.4
INTEREST IS CHARGED FROM 01-26-95 TO 04-11-95
AT THE RATES APPLICABLE AS OUTLINED ON THE
REVERSE SIDE OF THIS FORM
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST
TOTAL DUE
10,415.28
309.20
5.80
315.00
· IF PAID AFTER DATE INDICATED, SEE RfVERSE
FDI CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN n, NO PAYMENT IS REOUI8ED.
IF TOTAL DUf IS REFLECTED AS A "CREDIT" ICII, YOU IlAY IE DUE
A REFUND. SEE RfVEIISESlDE OF THIS FOIIII FOI INSTSUCTlONS.1
I lR-b~q-.z,
LA. REV~1607 EX AFP (12-94* 1'1-196.- 11
, COtItDHW[AL TH OF' PENNSVLVANIA
. .. DEPAllT....T OF REVENUE INHERITANCE TAX
. :'~~UZ~6:~DIVIDUAl TAXES STATEMENT OF ACCOUNT
HARRISIURO, PA '11128-0601
ACN
DATE
101
~i/
05-01-95
ST OF SINGER FREDITH E FILE NO. 21 94-0146
DATE OF DEATH 12-04-93 COUNTY CUMBERLAND
NOTE. TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUSHIT THE UPPER PORTION OF THIS FORN WITH YOUR TAX
PAVNENT TO THE ADDRESS SHOWN. HAXE CHECX PAVABLE AND RENIT PAYNENT TO. 1jr
HAROLD S IRWIN III
36 SPIn ST
CARLISLE PA 17013
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
AMount R..ltt.d
CUT ALONG THIS LINE . RETAIN LOWER PORTION FOR YOUR FILES ~
i({V:i60j-Eif-AFP--nz-:94j------.iiii-iilHERii'iiiic'E--flix-si,'liTEH'E-rif-ilTlic-ciiiitff--iii.--m------------m-
ESTATE OF SINGER FREDITH E FILE NO.21 94-0146 ACN 101
THIS STATENENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NANED
ESTATE. SHOWN BELOW IS A SUHHARV OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAVNENTS,
THE CURRENT BALANCE, AND, IF APPLICAaLE. A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT,. 03-27-95
PRINCIPAL TAX DUE ....._._.._...___
PAYMENTS (TAX CREDITS),
PAYMENT
DATE
01-25-95
04-06-95
RECEIPT
NUMBER
AA022750
AA023013
DISCOUNT (+)
INTEREST (-)
309.20-
5.42-
AMOUNT PAID
10,724.48
315.00
00
em
3;-
Ci
n, .
vI..
):'-'
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST
TOTAL DUE
. IF PAID AFTER TNIS DATE, SEE REVERSE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
t IF TOTAL DUE IS LESS THAN '1,
HO 'AVltENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI,
YOU HAV IE DUE A REFUND. SEE REVERSE SIDE OF TNIS FO~ FOR INSTRUCTIONS. I
DATE 05-01-95
10,724.48
:0
:Om
<D a
,~.-:. p
,..
(J) ~~.
10,724.86
.38CR
.00
.38CR
14-IQ:J. 5'
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
REV.~5OC'tX+ ,'?o94J
~.rtlt.~
~
15
Ii!
III
a
COMMONWE.4lTH OF PENNSVlVANIA
DEPARTMENT Of REVENUE.
DEPT. 280601
Ho\RRISIURG, PA 11128.0601
D~CEDENT'S NAME ILAST, FIRST, AND MIDDLE INlHAlI
Shoemaker, George L.
SOCIAL SfCURITY NUMIER
OATfOt BIRTH
'OR DATES O' DEATH AFTER 12/31/91 CHICK HIRa
" A SPOUSAL
POVIRTY CRIDIT IS CLAIMID 0
fill NUMBIR
21-94-0167
YEAR
COUNTY CODE
DECEDENT'S COMPlETf ADDRUS
NUMBER
106 Locust Street
Shippensburg, PA
Co.., Cumberland
AMOUNT RECEIVED (SEE INSTRUCTIONS)
17257
o 1. Orlglnol Return Q9 2. Supplemental Return
o 4. limited Ellale 0 40. Future Inler.s. Compromise
(for dale. of dea'h ofier 12.12.821
o 6. Decedent DIed Tellole 0 7. Decedent Maintained Q living TrUll
fAllach copy of Willi fAllach copy 0/ Trulll
'AUi.coRRISI1ONDENCI;AND .CONFIDENnAL TAX .INFORMATION.$HOULD II DIRICTID,TOi.b/,;;;';~:'i,I.l;:r,\.. .
COMPLETE MAlliN ADD ES
MARK, WEIGLE AND PERKINS
126 East King ~~et
i m
DAlE Of DEAtH
179-44-8836
Ilf ",mICA'lll SU.VI~INO 5POt.!U'5 NAill IIAn. flftU AND MIDDIl ttmlAII
w
....
.lIl:~UJ
IlllE~
=a9
"'~OI
illS
=a
=z
8~
David C. Schanbacher,
TElEPHONE NUMBER
717 532-7388
Esquire
z
a
S
~
c
...
w
=
z
51
~
.
8
g
o 3. Remainder Return
(for da'e. 01 dealh prior 10 12.13.B21
05. Federal Estate Tax Return Required
_ 8. Talal Number of Safe Depolit 8011.11
.,. :!l{i~_
:ciS'
1'1\'"
en , 0 -~. ....
~.c
". n ,"-. c..
.:.;, ...:..
(] , N .-
0 .." .:::~
0.. .'<,:;h
0 ;:r::o
.; I,. :::<D
" 0) fij
~~ 0
l:O. -
.l>o
( 81 2,608.19
(111
(121
(13)
(141
6,284,03
(3,675.84)
20. If Une1911 greal" Ihon line 18, enler ,he difference on line 20. This is the OVERPAYMENT,
ElD
21. If line 18 is gr.ater than Un. 19, enter the diff.r.ncI on linl 21. This is Ihl TAX DUE.
A. Enter Ihe inl.,"t on thl bolonc. dUI on lint 21A.
8. En'er thl total of lir.. 21 and 2lA onlin. 218. This is th. BALANCE DUE.
Mak. Check P~tol a.gllt., of Will., AIOI'l'
II $UU TO ANIWIR ALL QUISlIONS ON tMlSl $lDl AND TO IIICHIQC MATH
Ul'lder plI'lahies of P.erjury. I dedart that I how. exomin.d this tllUl'n, including accompanying sch.dul.. ond stot.m.nts, and to thlt best of my Icnowledgl a. nd bill",
41 Is true, torrid and compltle. I dldor. thai all tlol ..lot. has bHn r.ponla ot true morbt velu.. Declaration of prepar.r othtr than Ih. personal r.pr."nfolivels
bated On aU infonnaliOft Of w~ich prtportr hosony "nowl.dg..
A If Of HUON 1a[~'I.lUOI:fIIl""G IlffUIlN ADPJ(~$ DAn I J...J7..l/'
n') )'J1'..., Connie M. Manges, 109 W. Orange St., Sh1ppensburg, PA 17257
· 'f H['AllfIOtH[I'MANJtPUUN AbDI(U DAn (;t"'fl-t'
Q)~ C J'.~~ David C. Schanbacher, 126 E. King St" Shippensburg, PA 17257
1. Real ellale (Schedule AI (1)
2. Slack. and Band. (Schedule BI (2 I
3. Closely Held Stock/Partnership Inlerest (Schedule q 131
4. Mortgages and Notes Receivable (Schedule 0) (4 )
5. Cash, Bank Deposits & Miscellaneous Personal Properly (5 ) 2,608.19
(Schedule EI
6. Jainlly Owned Property (Schedule FI (61
7. Trande" (Schedule GIISchedulel) (7) _
B. Total Gran Auels (lotallin.. 1.7)
9. Funtral fx~en$ls, Administrative Cous, Miscellaneous (91 6,284.03
Expenses I chedule H)
10. Debts, Mortgage liabilitilS, Uens (Schedule I) (10)
11. Total Oedudions (lola! lines 9 & 101
12. N.t Value of Eslote (line 8 minus line 11)
13. Charitabl. and Gowernmental Bequests (Schedule J)
14. Nit Value Subj.ct to Tax (Une 12 minvs line 13)
15. Spousal Transfers (for dales of death ok., 6.30.94)
S.. Insfrudions for Afrplicabll Percentage en Reverse (15)
Side. (Include valuII rom Schedul. K or Schedule M.)
16. Amount of line 14 laxobl. at 6% rote 1161
(Includ. wol~.. from Schedull K or Schedule M.I
11. Ameunt of line 14 taxabl. at ! 5% rot. (17)
(Indud. valulS from Schedule K or Sthedule M.J
18. Principal tall, due (Add tax from Un.. 15, 16 and 17.)
19. C"dill Spousal Powerty Credit Prior Payments Discount Int.r"I
+ +
(3,675.84)
x.__
NONE - INSOLVENT
x .06.
x .IS .
(IB)
Clll'ck !,C'rc d you Qle '('qu('~lmg a rcfu"d of YOU1 9Vt"poym!;'"'
119)
(201
(211
(21AI__
(21B)
REV.1511 EJ(~ 11-111
ESTATE OF
ITEM
NUMBER
A.
B.
.4.
C.
1.
2.
3.
4.
5.
6.
7.
8.
9.
~.'Jl:rl\
~:.U'.tNO
COMMONWfALTH OF PENNSYLVANIA
INHUITANCE TAX RETURN
RESIDENT DECEDENT
. SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
George L. Shoemaker
PleaH Print or Tvpe
MBER
21-94-0167
DESCRIPTION
1.
Funeral Expen..s:
Egger Funeral Home
Administrative Costs:
1.
Penonal Representative Commissions
Social Security Number 01 Personal Representative:
Year Commissions paid
2.
Attorney Fees
Mark, Weigle and Perkins
3.
Family Exemption
Claimant Connie M. Manges
Relationship Spouse - Common Law
Add.... 01 Claim"nl at decedent's death
106 Locust Street
Street Add....
shippensburg
State _~ Zip Code
17257
City
Probate Foes Register of Wills, Cumberland County - Lettet's of
Administration and Short Certificates
Miscellaneous Expen....
Cumberland Law Journal - advertising Letters of Administration
News Chronicle - advertising Letters of Administration
Vital Records - death certificates
Franklin County Coroner - report
Register of Wills, Cumberland County - filing Insolvent PA
Inheritance Tax Return
Mark, Weigle and Perkins - reimbursement for posrage, xerox
copies, and long distance telephone calls
Internal Revenue Service - COPy of tax return
Mark, Weigle and Perkins - preparation of 1993 income tax retur s
Internal Revenue Service - 1989 tax )'ear federal income tax due
TOTAL (Also enter on line 9. RlCClpilulalionl
(If more spa.. Is need.d, In..rt addltlOflalshHh of _. .....)
AMOUNT
150.00
182.57
2,000.00
38.00
40,00
65.00
15.00
100.00
10,00
10.00
4,25
50.00
3.619,21
S
6,284.03
. WILLIAM II. MAliK
(1912.1910).
MARK, WEIGLE AND PERKINS
Jt:lllI\' A. Wt:IGI.E
DAVID I'.I'EIIKINS
DAVID c.ScllANDAClIEII
Alloclllle
JOSI:I'lI I'. IIlIANE
AllodMle
Attomeys-at-Law. ~(Q)~. .
126 I:AS'I' KING S'I'IIEE1' . . D
SlIlI'I'EN~.~\'LVANIA 17257.13 0.. . t
TELEI'1I0NE t7l7) 532.7388 011 (717) 776-4295
(lAX (7171 S32.65S2
Dcccmbcr 5. 1996
ConmlOnwcalth of Pcnnsylvania
Departmentof Revcnue
Bureau ofIndividual Taxes
Department 280601
Harrisburg, P A 17128-060 I
Attention: Deborah Washington
Tax Examiner
In Re: Estate of George L. Shoemakel
Dcceascd 10-12-93
File No. 21-94-0167
Dear Ms. Washington:
. Please find encloscd herewith the following four (4) proofs of common-law status before death
. for the estate of Gcorge L. Shoemaker, with respect to the P A Inheritance Tax Return captioncd
above:
I. , Social Security Administration Notice of Decision- Fully Faverablc
2. P A Blue Shicld medical benefit statement indicating "Connie Shoemaker" as the
patient, and George Shoemakcr as the subscriber, filed on behalf of them as
husband and wife
3. 1993 Per Capital Tax Notice from the Chambersburg Area School District
addressed to "CoMic Shoemaker"
4. Wage Attachment for 1992 per capita taxes demandcd of "George Shoemaker
for his wife COlUlie"
Iffurther proof or documcntation is required, please contact this officc at your first opportunity.
v cry truly yours,
MARK, WEIGLE AND PERKINS
David C. Schanbacher
DCS:lk
Enclosures
O:mie M3ne,es
(CI.imlnll
'.: .':"
178-1l8-O156
(SoCI.1 SttVrlly Numbttj
G.t. S'x:Em3ke1' / 17~1Kl836
IWage Earnor) (Loavo blank In Tille XVI Calel or II namll. limo II above)
EXHlDlT NO or
....!!L DESCRIPTION ~
Applicatioo fO!' M:ltOOl"S Insurance Baoof'1ts dated Novarbel' 15, 1993 4
2 Request fo:' Rea:ns1deratioo dated Apl'11 6, 1994 2
3 Reo:nsideratioo J:etenn1natioo Notice dated Aue,ust 18, 1994 7
4 Request fol' !laal'1rl1; dated Septa1be1' 26, 1994 2
5 Farn1ne;3 Recol"d for' COOrge Sl:iaIBkeI' 3
6 Cl?l'tif'1catioo of J:eath fol' George Sxlemlkel' 2
, 7 StatenEnt of J:eath by fUneral D1rllCtol' dated O:tobel' 14, 1993
' -.'
8 Wl'itten StataJaJt fron Cla1m3nt dated O:tobel' 19, 1994 4
9 Wl'ittaJ StataJaJt fron I3l'andi Smlakel'dated O:tobel' 19, 1994 2
10 written StataJaJt fron 8l'1an M:lclrey dated O:tobel' 20, 1994 2
11 written StataJaJt fron Glenna Mlcmel dated O:tobel' 20, 1994 2
12 written StataJaJt fron Kemath L. Mffel', Jl'. dated Novarbel' 4, 1994 4
13 Rep;ll't of O:rltact fron Soc1al.Sea.ll'1ty Off1ce dated Novarbel' 15, 1993 with 12
attachad cXx:1.m;nts ~ issue of paterntty
14 StatenEnt of M:Il'1tal Relatiooship dated Noverber 15, 1993 4
15 StatenEnts Ree;ml1ng M:II'r~ dated lbvetDel' 16, 1993 and Noverber 17, 1993 8
16 M:Ir'l'iage and D1 voroa D::iaJJmts of ela1IlIlnt and Wil!!/1l earner fO!' previoJs 4
lIBI"l'1Jl8es
17 1991 and 1992 Ina:x1E Tax Ratums 5
18 D:x:urdlts Sn/1rl1; Cla1nEnt Relat1oosh1p to ~ fameI' dated 1993 to 1994 17
19 Brief in support of el's. entitl.arent to Ilt)trer's insJrancc under tJ-e
Social Security Act dated JW1e 21, 19% 10
. Form HA.540.UI (6.181
. ~. .
t'"
,
AnACH TO CLAIMS FOLDER COPY OF THE DtclltDn
179-44-8836
Page 2 of 3
You may file your request at any local Social Security office
or a hearing office. You may also mail your request right to
the Appeals Council, Office of Hearings and Appeals, 5107
Leesburg Pike, Falls Church, VA 22041-3255. Please put the
Social Security number shown above on any appeal you file.
Time To File An Appeal
To file an appeal, you must file your request for review within
60 days from the date you get this notice.
The Appeals Council assumes you got the notice 5 days after the
date shown above unless you show you did not get it within the
5-day period. The Council will dismiss a late request unless
you show you had a good reason for not filing it on time.
Time To Submit New Evidence
You should submit any new evidence you wish to the Appeals
Council to consider with your request for review.
How An Appeal Works
Our regulations state the rules the Appeals Council applies to
decide when and how to review a case. These rules appear in
the Code of Federal Regulations, Title 20, Chapter III, Part
,404, Subpart J.
If you file an appeal, the Council will consider all of my
decision, even the parts with which you agree. The Council may
review your case for any reason. It will review your case if
one of the reasons for review listed in our regulations exists.
Section 404.970 of the regulations lists these reasons.
Requesting review places the entire record of your case before
the Council. Review can make any part of my decision more or
less favorable or unfavorable to you.
On review, the Council may itself consider the issues and
decide your case. The Council may also send it back to an
Administrative Law Judge for a new decision.
If No Appeal And No Appeals Council Review
If you do not appeal and the Council does not review my
decision on its own motion, you will not have a right to court
review. My decision will be a final decision that can be
changed only under special rules.
REPRESENTATIVE
CONNIE MANGES
179-44-8836
2
which must be considered. A claimant may qualify on the basis of
a valid ceremonial marriage, a deemed marriage, or a common-law
marriage.
The record establishes that the claimant was born on November 19,
1956 and is 39 years of age. She is not entitled to widow's
benefits because she has not attained age 60. The claimant filed
an application for mother's insurance benefits on November 15,
1993 and is unmarried. She currently has two children of the
deceased in her care and presently residing with her. These
children, Brandi Shoemaker, age 14, and Brandon Shoemaker, age
II, are receiving child's insurance benefits on their father's
account.
The record indicates that the claimant was denied benefits
previously because the claimant and the wage earner's purported
common-law marriage was not considered a valid marriage. Based
upon the testimony of the claimant and a review of the record,
the undersigned Administrative Law Judge finds that the
claimant's marriage to the wage earner was valid.
The Regulations provide that the laws of the State where the wage
earner had a permanent home when he died is examined to determine
the validity of a marriage (20 CFR ~ 404.345). In Pennsylvania,
"lcolhabitation of a man and a woman, both of whom are capable of
contracting marriage, and a reputation as husband and wife in
their community together raise a presumption that the parties
have contracted marriage." In re Estate of Garqes, 474 Pa. 237,
241 (1977). Evidence that two persons agreed to be married and
agreed that they were married has been held sufficient to
establish a common law marriage. Garqes, 474 Pa. at 241-242.
The undersigned notes that the record indicates that when the
wage earner and the claimant began living together in 1980, the
claimant was married to another man, however, the claimant's
divorce became final in 1982 (Exhibit 16). Thereafter, she was
capable of contracting marriage.
At the hearing, the claimant testified that she resided with the
wage earner in Pennsylvania from 1980 until 1993, the year the
wage earner died, and that they considered themselves married
since 1985. She also testified that the wage earner asked her to
RBPRESENTATIVE
CONNIE MANGES
179-44-8836
3
marry him, and that they exchanged "wedding" vows in July of 1990
in a private ceremony in their living room. During the ceremony,
the wage earner gave the claimant a wedding ring which she still
wears. The claimant further testified that the wage earner
introduced her as his wife, and that friends and neighbors
considered the claimant and wage earner as husband and wife. The
claimant's daughter, Brandi Shoemaker, also testified that she
considered her parent's married, and that her teachers and
neighbors referred to her mother as "Mrs. Shoemaker."
The record indicates that a Lincoln Intermediate Unit No. 12
parent permission form, health insurance statements,
Shippensburg Area School District taxpayer records, and Franklin
County/Chambersburg Area School District taxpayer records all
refer to the claimant as "Connie Shoemaker" (Exhibit 18). The
record also contains several statements regarding marriage and
affidavits from relatives and individuals within the community
who affirm that the claimant and the wage earner lived together
for 13 years, referred to each other as husband and wife, and
were'considered to be husband and wife in the community (Exhibits
9-12 and 15) .
In the instant case, there is uncontroverted evidence that the
claimant lived with the wage earner continually from 1980 until
his death in 1993. The claimant and the wage earner introduced
each other as husband and wife and were known by family, friends,
and people in the community as husband and wife. The claimant
considered herself as the wage earner's wife. The wage earner
provided health insurance for the claimant, and official records
referred to the claimant as the wage earner's wife. Finally, in
a private ceremony in 1990, the claimant and the wage earner
exchanged "wedding" vows, and the wage earner placed a wedding
ring on the claimant's finger. The claimant continues to wear
this ring. This evidence is sufficient to raise the presumption
that the claimant and the wage earner entered into a common law
marriage if not in 1985, then certainly in 1990.
There is some evidence in this case which would weigh against the
existence of a common law marriage. The claimant continued to
use her maiden name in some instances, such as on the lease for
the couple's home and on 1991 and 1992 income tax returns
(Exhibits 17 and 18). In Mckenzie v. Harris, 679 F.2d 8, 11 (3rd
REPRESENTATIVE
EXPLANATION OF BLUE SHIELD BENEFITS
PIIIIlI1I'IN.mo;
CONNIE SHOEMAKER
E~pllln'hon Oalll: J ANI 3 , 1 986
IdllntllltalionNu; H 179448836
C'"mN,m'", 85364739750 003
SIH\'iCIII
Pello.rnltdbv.
ROBERT D. RECTOR MD
DATES OF SERVICE
TYPE OF SERVICE
OCT 16,1985 47600
SURGERY
SEE REVERSE SIDE fori ADDITIONAL EXI'LANATlONS
BLUE l[5S lESS If.5UI.l' un
"L~~~l~cr OCOUC1IOL[ C~~~~". E~~H8J~O c::~~~~::cr
I I I,' ".1 :1
I I. ',.1 ,;. I ',II
813D'00 I , , ,
,
,
88000
NO ,
0' I
svcs ~
. "
_[II'
PAYMI:.NT uu;~
COP
fllIOCtOUl1t
AMOUNT
CHAnoeo
,
,
950'00
1
" , , ,
(II.'-' :".'1 'I , , :";" .;, ~ " :'L~ ".,,,oJ I
,
0","'1'10"; .. .;'. , r .. .. , "~'l '.
;"1' I;' I. '!I',' '. " , ., .. , I .'!'I
, .. , , '.
"',(,.11',1' :....:....1 ..;' .j.... ., , . '::,..1
1",~ 'il .1 I ':".: : 'r ".' , , ""I
':'1 . ,': I ,
,
","\'1:'>;
,
,
~. 'I' ,;
I
~ ~ .:
.'
"'/:'.~ : '....
,
~ 88000
PENNSYLVANIA BLUE SHIELD PARTICIPAT-
WILL BE ACCEPTED BY THE DOCTOR
TOTAL AMOUNT PAID TQrllOVIDCn
THESE SERVICES WERE PROVIDED BY A
%HC OnCT~e. THE 'BLUE SHIELD ALLOWANCE'
AS PAYMENT IN FULL FOR COVERED SERVICES.
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$ubICIltM'1'1 Name and "'ClOr....
r GEORGE SHOEMAKER
304 N FAYETTE ST
SHIPPENSBURG PA 17257
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NOTICE AND DEMAND
County of FRanklin
City
Borouah of Guilford
Town.hlp
Township
!Ill.
.
In Tha
OI011U1t01twealt4 of '2n116ul&nnia
JUN 09 1993
hh---------------------------
TO
Robert Martin Farms
-wlil-dy-iic:res--Farm----------------
167 Overcash Road Rt II
------------------------------------
IN IIE'L Y REFER TO ,_
ACCT. NO. 2-17905
17906
_QDE_m_~~f~_~~f9___~~___~1~_O_l_______
I d~mand Ihal YOll deducI rrom the wages (and/or commi~sions).or......Ge.Cl.r.~.e....SI;1Cl(;!.m.<lker:...~...Clg!i\i.!:l.st him
one or YOllr ~mploy~es. the slim of $.qJ,.qO....f~l~r ni; ~~\ftrs w1fc1W~ersonalla.es as listed aboyc and
turn the same ov~r to me within sixly (60) days. This demand is made in accordance with the provisions of the
statutory law set limh helow. and cerlilied by me 10 be true and correcl. Failore to comply will result in the
imposition or the penalt;.:s as Slaled. Make checks payabl~ direct 10 me.
Y.., II) CO. rer,C'Dlt. 1u ell. Plr,C,pll, T.. "n.tt, COlt Tot.1
h.p, ROld hr.C,p!!. Ioro. "r.C.pll. T..
19 92 $ $ $ $ INC . INC .
61 00
Yr(s)
THESE TAXES MUST BE MAOE PAUlLE
ANo.rOlWARoEO TO COLLECTOl WITHIH
SIXTY 160! OUS OF DATE SHOWN AIOVE.
wHEN PlOPER RECEIPTS FOl SAME WILL
BE MAILED TO YOU.
,&~~
REMIT TO:
G. H. HARRIS
DElINQUENT TAX COLLECTOR
P O. Bo. 216
Dallas. Pennsylvania 1 B6 12
ruul III..D TIS
Un' oovnNI~O
ra.1 .lenON.
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Tlw ta. tallfl'tOl' wll dfm.nd, 't'Ct'Ivt' .nd tOlllt1 IIom.lI torVO"llOlU, pol~lflllluhdlvjtoOn.. ItKl(IIlUon., CtImFanlf", Ilrml and Indlvldualt, ,mrOOVlnQ lM'lIoonlo....nlll'l"' c"pu.
poll Of OOupallOO~ II." hllli"llln po",..lon unp.,d commllllUIU Of ulnlng\ b.olCll\llllllllo .n~ IM'~ 01 pl'r\Ol" Owl"ll pn capilli, poll 01 occuplllon I....., 01 ""haM WIll' Olllfl
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Upon 1M ",.."'lIlallon oIll1Ch WlIlI,n noUn .nd d,mllnd, II \h.ll br Ih, dlll~ ol,nl/lllth (OIpo,,,Uon, polttlcallllbdlvlllon. alllXlaHon. (omJlln~, Ill'm (If Indj\liduallo dt!dllCl
hm Ih, wagfl, commluklnl 01 fIllnlnll' olluch Individual ..mployn. I~,," owlnll or Ih.1 ....U within II~t~ d.Y' Ihfrnhn btt(lm' dlH', 01 110m .n\lllnl'.lIl, Cl)mml'lIOnl 01
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th,
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10 wII<<t,d ....d paid OWl 10 IN I.. follrctOl. Upon thao 1,lluI' oj .nYlllCh mtJIDIllloll, polnKallubdMllon, .....lfl"lnn, mmp.ny. Iffm Of Indlvtdu"llo d,dllCllh, .rnounl 01
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pilei 0"", or thll ., wIlhhfold end not plld (lYt'f I"twr ....1'11 I pt'n,111/ oIl,n JI<<'I "n!ulII .dd,d Ih'I"O, tl'! lw IrtOVllt'd b~ In llI1k)n ollllumpld ill. IUK III br IntlKutH
b\I
IN I.. coIIItlOl', eM b~ IhI JIIftJII'Ilulhoi'KII'I of IhI' ".lni d;tlllt1. III drill oll,\o., ,mllunt .., now byla""'ffll~fl"hlt. nUJIllhlt ourh ""noot then 110I II'Vllh, btf>Il_ 0111I1/
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dt\InQIWnl I~ npKI. IX"tupllloll, oc:llp.lInn pt'YllfW", .nd tI"lI'd l!lrolTlf' ""'" o....d by Ihf lIth," 1fIOln, lh, collf'nlllll of Jlf'I np"' end oct'lIl"lItkJII ..... !tom ,....
C.mo__I~h IUI !ilar,..~tlll'lI'Id!l1Jfd h,lt'~h
SINCE YOU. AS THE EMPLOYER, ARE OBLIGATED BY LAW UNDER PENALTY TO EXECUTE
THIS WAGE ATTACHMENT, DO NOT GIVE THIS ATTACHMENT TO YOUR EMPLOYEE.