HomeMy WebLinkAbout05-04-07 (2)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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DECEDENrs NAME (LAST, FIRST, AND MIDDLE INITIAL)
Kahler, Florence A
FILE NUMBER
21 06
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00701
NUMBER
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
133-38-1464
THIS RETURN MUST BE FilED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
3. Remainder Return (date of death prior to 12-13-82)
6, Decedent Died Testate (Attach copy
of Will)
9, Litigation Proceeds Received
4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10, Spousal Poverty Credit (date of death between
o 5, Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113{A) (Attach Sch 0)
2100 Longs Gap Road
Carlisle, PA 17013
(1 ) None
(2) 50,54
(3) None
(4) None
(5) 13,566.76
(G) None
(7) 5,458.36
(9) 15,388.50
(10) 4,908.04
Cj\il.,Y
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08/03/2006
02/23/1944
, I
(8)- ':-')19,075.6'6
C.'
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
1, Original Return
4. Limited Estate
2. Supplemental Return
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
AME
rh !z Stephen L. Bloom
~ ~ IRM NAME (If applicable)
8 ~ Stephen L. Bloom, Esquire
ElEPHONE NUMBER
717/249-7717
1, Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4, Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
G, Jointly Owned Property (Schedule F)
o Separate Billing Requested
7, Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate,
or transfers under Sec. 911G(a)(1.2)
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1G.Amount of Line 14 taxable at lineal rate
17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
x .00
x .045
x .12
x .15
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT,
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
1400 Bent Creek Blvd
CITY
I STATE PA
I ZIP 17050
--
Mechanicsburg
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(3)
(4)
0.00
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(5A)
(5B)
0.00
0.00
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:
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 atter 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 No
~ I
D ~
~ D
D ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN.
Under penalties of peljury, 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
preparer other than the personal representative is based on all information of which preparer has any knowledge. .... _
SIGNATURE OF PERSON RE PONSIBLE FOR FILING RETURN ADDRESS DATE -
Steven S. Kahler \ / i . 213 Country Ridge Road
~ Red Lion, PA 17356 ~ /'$ JOt__
SIGNATURE OF PERSO ADDRESS DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Stephen L. Bloom
ADDRESS
DATE
2100 Longs Gap Road
Carlisle, PA 17013
~J$/Ol
For dates of death on or atter July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or atter 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 (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 filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or atter July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S, 99116
1.2) [72 P.S. 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) (1.3)]. 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.
*'
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Kahler, Florence A
] FILE NUMBER ---
121 - 06 - 00701
~----~--_..._-
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1
DESCRIPTION
--------,-----------
UNIT VALUE i VALUE AT DATE OF
I DEATH
--,-----------
50.54
Fidelity Investments - 401 (k) Account #40038328
i
TOTAL (Also enter on line 2, Recapitulation)
50.54
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I I FILE NUMBER
21 - 06 - 00701
I
-~'_..~-----_._----._---
ESTATE OF Kahler, Florence A
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
DESCRIPTION
VALUE AT DATE OF
DEATH
6,052.20
Orrstown Bank - Certificate of Deposit #4000010841
2
PNC Bank - Checking Account #50-0482-3031
352.56
3
PNC Bank - Savings Account #50-0482-2469
162.00
4
2002 Saturn Automobile - 34,000+ miles (VIN #1G8ZK52782Z233805)
7,000.00
f--~. .---..---..-_....
TOTAL (Also enter on Line 5, Recapitulation) 13,566.76
.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
1
[ " FILE NUMBER
Kahler, Florence A 21 _ 06 _ 00701
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
! 1---,-----------
I ! %~ I I
DATE OF DEATH I DECD'S ,EXCLUSION TAXABLE VALUE
VALUE OF ASSET , INTEREST I (IF APPLlC~_______
5,458.36 I 5,458.36
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DESCRIPTION OF PROPERTY
Include the name of the transferee, their relationship to decedent
and the date of transfer. Attach a copy of the deed for real estate.
ESTATE OF
ITEM
NUMBER
Community Banks - Certificate of Deposit #385089100
(Totten Trust ITF Steven A. Kahler)
TOTAL (Also enter on line 7, Recapitulation)
I
I
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I
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i 5,458.36
.
SCI-EDUL.E H
fUNERAL.. EXPENSES &
ADlVlNIS1RA11VE COSlS
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES:
A. 1 Myers Funeral Home, Inc., Mechanicsburg, PA
FILE NUMBER
i 21 - 06 - 00701
ESTATE OF Kahler, Florence A
DESCRIPTION
AMOUNT
8,952.00
2
John J. Kaczor Funeral Home, Inc., Hamburg, NY
4,765.00
3
SS Peter & Paul Cemetery, Hamburg, NY
550.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City
State
Zip
2.
Year(s) Commission paid
Attorney's Fees Stephen L. Bloom, Attorney and Counsellor at Law
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
1,000.00
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Cumberland County Register of Wills
99.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1
PennDOT - Application for Duplicate Certificate of Title
22.50
TOTAL (Also enter on line 9, Recapitulation)
---------------------
15,388.50
*'
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Kahler, Florence A
FILE NUMBER
21 - 06 - 00701
Include unreimbursed medical expenses.
ITEM DESCRIPTION
NUMBER AMOUNT
1 GMAC Automobile Loan 2,532.87
2 Capital One - Mastercard #5291-4917-3321-5782 217.96
3 National Water & Power - Account #740906783-001 34.93
4 PPL - Account #49899-88010 35.08
5 Verizon - Account #717-697 -3062-625-09Y 50.68
6 Kohl's - Account #038-5242-326 21.18
7 Silver Spring Ambulance & Rescue Association 480.00
8 West Shore EMS - BLS 98.64
9 Cumberland-Goodwill Fire Rescue 1,436.70
--~.-._-..-
TOTAL (Also enter on Line 10, Recapitulation) 4,908.04
ft~(tl~(il)f
Catholic Diocese of Harrisburg
401 (k) RetirernE!Iit:".Saving~:Plan
Retirement Savings Statement
October 1, 2006 - December 31, 2006
flORENCE KAHLER
1400 BENT CREEK BLVD
APT 127
MECHANICSBURG, PA 17050
ENV#40038328
40 57506 T
~ For online access, log on at:
http://www.fidelity.com/atwork
For information, call: (800) 343-0860
Your Account Sumrnary
Your Asset Allocation
Beginning Balance
Change in Account Value
Ending Balance
Additional Information
. Dividends Be Interest
$48.34
2.20
$50.54
$1.80
. Stocks 50%
. Bonds 40%
o Short-Term 10%
Your Personal Rate of Return
This Period 4.6%
Yeano Date 7.1%
Your Personal Rate of Return is calculated with a lime-weighted
fonnula, widely used by financial analysts to calculate investment
earnings. It renects the results of your investment selections as
well as any activity in the plan account(s) shown. There are other
Personal Rate of Return fonnulas used that may yield different
results. Remember that past perfonnance is no guarantee of future
results.
Your investments are currently allocated among the displayed
asset classes. Percentages and totals may not be exact due to
rounding.
The Additional Fund Information section lists the allocation of
your blended funds.
-
Account Value
This section displays the value of your account for the period, in both shares and dollars.
Inyestment
Shares on
O}j/.10/2006
Shares on Price on Price on
12/3//2006 09/30/2006 <12/31/2006
Market Value
all 09/30/2006
Market Value I.
on.12/31/2006
::.'-:':.:';::::-i::;i::'i:i:~:;:+::t....
"'~ndjdi~nv~~1ffl~ffl~.~.Ff..!;i!~!;.i.['~f;.'ji'iji:f::;'i!Hiijijiiijiiijf:jtif:iWf.!i!ii!ni'fi!tif!jij.n'!j:iii.i!.iiiWiiiiiiiH;i!,.ji;iii;J;i;mmt!iNmW:!Jj'!imm~ftfirjfim!!ltiimM_la4'ii:;mfmiiiHMmmt..:;i!M;~'ff.i
Fid Freedom 2010 3.334 3.457 $14.50 $14.62 48.34 50.54
Remember that a dividend payment to fund shareholders reduces the share price of the fund, so a decrease in the share price for the statement
period does not necessarily reflect lower fund performance.
* Some of your investments are claSsified as a Blended Investment. Blended Investments may include a mixture of stocks, bonds, and/or short tenn
assets. Please refer to the "Additional Investmentlnfonnalion" section to detennine the allocation of your blended Investments' underlying assets.
The asset breakdown of your portfolio is reflected in the pie chart in the "Asset Allocation" section.
Please read this statement carefully. Any error must be reported to Fidelity Investments within 90 days.
38328 40038328 0001 20070109 403B
Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277-0090
Page 1 of 7
August17,2006
TO: law Offices of
Stephen L. Bloom
2100 longs Gap RD
Carlisle, PA 17013
FROM: Todd L. Miller
Cust. Service Specialist
P.O. BOX 250
SHIPPENSBURG PA 17257-0250
RE: ESTATE OF: Florence A. Kahler
DATE OF DEATH: August 3,2006
IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD, ON THE ABOVE DATE, THE
FOllOWING ACCOUNTS WITH ORRSTOWN BANK:
CERTIFICATES OF DEPOSIT
ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPAL & ACCRUED INTEREST
4000010841 Florence Ann Kahler 06/02/06 $6,051.37 $0.83
0PNCBANK
April 24, 2007
Dear Stephen L Bloom,
You requested the following information regarding accounts held at PNC bank by
Florence A. Kahler.
An individual checking account opened on 917/04 has a current balance of 352.56
An individual savings account opened on 5/6/05 has a current balance of 162.00
She held no additional accounts at our bank.
If you need any more information you may contact me directly at 717-691-4000.
T1nk you,
\~./~.
J lyn B~ess
Branch Manager
Member of The PNC Financial Services Group
6560 Carlisle Pike Mechanicsburg Pennsylvania 17050
Communit~Banks
Account Number 385089100
Account Type Time Deposit
Date Opened 01/29/04
Principal Balance $5,455.05 $
Accrued Interest at Date of Death $3.31 $
Balance at Date of Death $5,458.36 $
Maturity Date 01/29/09
Account Ownership Totten Trust
Names of Joint Owners, if any
Date Joint
Ownership/Beneficiary was
Established 01/29/04
Interest Rate 3.6900% %
Additional Information ITF Steven A. Kahler
Decedent's Name Florence A. Kahler
Social Security Number 133-38-1464
Date of Death August 3, 2006
i:;~",,,,\~~~,- i' \1'\ "'~
Authorized Signature '
L(l4(~1
Date
P.O. Box 350 . Millersburg, PA 17061 . Phone 1-866-255-2580
Fm/r Ge"~rl/tiOIJ.,
~RS
~9"nb'ra-! ~mtJ, ~1C.
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Chargos art only for Ihose items Ihar you- s<lecled or Ihal are required. If we are required by law or by a cemelery or crematory to use any il~ms, we will
explain in writing below.
If you selecled a (unerallhat may require embalming, such as a (uneral wllh viewing, you mal' have 10 pay (or embalming. You' do not have to pay (or embalming
you did nOl approve I( you selected arrangemenls such as a direcl cremalion or immediate burial. I( we charged (or embalming, we will explain why below.
For the Service of 1::'/.>/ 1'.) c.li ,k. ',h / i;( (l. Date of Death ? - ,j -OlP
Charge to: .::5rI".J..... :;;, /2....I,lt,'. /_f;;, Cc;....I,.l tt,lr p/. [\ed t..;J.- {./'1"
Name Address City State
A. CHARGE FOR SERVICES SELECTED:
I. PROFESSIONAL SERVICES
Services of Funeral DireclOr/Slaff .
Embalming
Olher preparllion o( body
.:1.:.. f
s ..:L.L
. 2'7 f
SUB. TOTAL OF PROFESSIONAL SERVICES.
2. FACILITIES AND SERVICES
lIse of facililies and services for
viewing (Visilalion/Wake).
lIse of facililies and services
for funeral crrrmon)'
list" of f2cililies :tnd services for
~'Iemorial Service
Use o( equipmeOl and services
for gr3veside sf'n'ice .
Olher use of (acililies
AIILS..S'
1-
1-
1-
:~''',-. ""
I
SUB. TOTAL OF FACILITIES/EQUIPMENT.
3 AUTOMOTIVE EQUIPMENT
Vehicle 10 transfer remains 10 Funeral Ho":!c:;.
local. I.f,.,(
Hearse (Casket Coach)
Local.
limousine
Local.
Family car
Local.
Flower car or noral disposilion
Local
lead car/clergy car
local
Car for pallhe"ers
Local
Out of fown tr3nspowuion
.
I
.-
1-
SUB.TOTAL OF AUTOMOTIVE EQUIPMENT.
TOTAL OF PROFESSIONAL SERVICES,
FACILITIES AND Au;rOMOTlVE
EQUIPMENT
..A11_
s_
A31_
A 12..5Jf~
B. CHARGE FOR MERCHANDISE SEI.ECTED: f _ .' .. v
Caskel .. .. . . .. . . . . . . .. .. . . . . 1.!~..1)'
(Descriplion) IZ l'V (I f... { ..
C.>/- I.h'; I (~:;IJ
Other Receplacle .
(De~CripliOn) ...5~L)P'~'~,:
, /";" ~ .\:;.:. I f'-p.....,.
Olller burial container . . . . "i1.Jr..P )'(
(Descriplion) i).I.:>.... .~.; . ",II,)
.),,,., it.:., r-'
s~c,':1(')
Acknowledgemenl cards
RegiS!er book(s) . .
Mrmory fulders
Pra)'er c~rds . . . . '''; .
Temporary gral'r marker..
Burial clOlhing .
.. ,'.!._. ,. f
. . . . . . . . . . . :~i:~J
I
'-
'-
BOYD L. MYERS, JR., S"pervisor
37 E. MAIN STREET
MECHANICSBURG, PA 17055
(717) 766-3421
Other c10lhing
I-
I-
1-
Cremalion urn .
(Descriplion)
OTHER
I-
,_
1-
B 17;,0'-6/
TOTAL MERCHANDISE SELECTED.
C. SPECIAL CHARGES:
Forwarding o( remains to - f
/(q(.l.O/' f.-f
(Funeral Howe)
Receiving of remains from
I "Z /'is;:' 0
1-
(Funeral Home)
Immedialr Burial. 1_
DirecI Cremarion. 1_
SUB,TOTAL OF SPECIAL CHARGES . 1_..... C . 2-1 J.f.c.
D. CASH ADVANCED -ot.CO <'> '" ....
Opening Grave .. I~. ....
Cemrlery Equipment. .<:.{ (.: . I ~ '....
Lut and Dord. . 1- IV i
I):: .'., t....
Newspaper NOlices-Ldcal I~ liP"''' _ V
Nrwspaper Notices-Oul.o(.town. . . . 1_
Tekphone & Telegrams 1_
Airfare I
Clergy/Mass Offering....... .....:... 160 <!? ~~
Pallboar<rs. .. '_
Cwified Copl.. of Ihe Dealh .... :,
Cellificarr :ll. r.. .l.., ... 1..:1.!...:.....
Police EsCOII I
Flowers . I Ii} <' ~ '" ~
Vault Ser~!cr Charge. " I
A/f're'N. I ?.z.S~;
(..,.~" '/"'\ E"f"" 1-1 OC;' ~
, . ,
I?; ci C -i. .~/' P (-I I /7, .,-).. ~' ~
c' {.l.:....~ t; ) S
1-
o r!!JI!!15~
'''!7'?f
3 ,,7,7
...>
SUB.TOTAL OF ADVANCES.
We charge you for our servicrs in oblaining:
(speclfv cash adl'allees Ihal are marked,"p)
NON.rr'
SUMMARY OF CHARGES
A. Professional Services. Facilities and
Equipme'nl, and AUlomolivr
Equipment .
B. Merchandise.
C. Special Charges .
D. Cash Advances.
TOrAL OF ALL SECTioNS.
PAID AT TIME OF OR PRIOR TO
ARRANGEMENTS.
BALANCE DUE.
.......29"-;'.
s ~ (._?t.f~..{"'
. 12i5...;;J" , ...' .~( '{I -7
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REASON FOR EMBALMING
'<,
If any law, .temelery. or cremalory requireme IS have r<quired Ihe purchase
of a~l .of thr Irrms lislod abuv.. the I~w or requirement is .:.xplained below.
(.. c ,"J-I ~ 17':0"'"[ /Z.t"$"'! I.. "t..t T., t" c., ~-<tI,..., 1:/:;......;' 1/:.. (
1-- 0... ,.) r.fi-.l'. , .
I agree Ihall h3l'e examined Ihe ilems o( goods and services selected atove and found Ihrm to be correcl and according 10 the arrangements I have rcquesled. I acknowledge
receipl o( a COP)' of this Stalement of Funeral Goods and Srrvim Selected. I represe!,lthat I have sufficient funds available (or paymrnt o( the cash prier (or the goods
and s",'im selwrd. I also agre~ 10 make paymenl o( I :1";, fJi.. :1 wilhin'''l (;I da)'S. I agree to be ~)intly and severally liable with anvone els< 1fh1l '
signs below. A late charge or 2.0 ''", per mOnlh amounting 10 ..? 'Y're) per year will be applied 10 Ihe unpaid balance bqinning ';1 i da!"".'.""
from the dale of Ihis agreemenl. I will also pay to Ihe Funeral Dirwor all reasonabk com p.id hy the Fun<ral Dirrclnr 10 collecl amounls I owe under Ihis 'agreemenr.
Those COstS may in 'Iude allorneys' (ees, court costS and Olher costs. Any addilional services or merp,rndilr'yrdered or requested a(ler the dalr o( this agrttmenl will
be considmd par _ Ih!~a e mem and the COSI Ihereof will be reOwed on Ihr final bill ~l:Iremrnl. , .'~.. . '
(Sui) \, ,-,," , I .,.f /5-- ''i-Olf'
. (Purchaser) " ...../ ./ JEhle) .
(Seal) (Purchaser) // ,::;...., .t,"'" .?Zr(!:!~~~';':;:;::~=-:>
WHTTE - funeral Di(lot YELLOW - CU,'IIlfTM!!~."." -.....--
1
3450 South Park Avenue
Blastfell. NY 14219
7161824-6377
5453 Southwestern ~lvd.
Hamburg. NY 14075
7161646-5555/
FUNERAL HOME 'HC. I
Number I
..~~' I~/r;((;
;:'lMofo.c.~} !tJl t,n (c 7[-r~>ilTZ;;C-1
Oat.arDeen,Auf, -i ({.~, PlKeo'O..th I-Ln,)' ,I ~/{, ..t t'.\
, I I
ITEMIZATION OF FUNERAL SERVICES AND MERCHkNDISE
SELECTED
I
The followinl are the charaes for the services. merchandise, and Iive~ you have
selected. You will not be chllraed for any item you do not choose unless it is neces-
sary because of other selections you have made. Any such charles lrelexpllined
below.
. I
I. FUNERAL HOME CHARGES i'
(Indicate NI A for items of service Ind/or merchandise that are not I" .)
A. Alternative Services i
I, Direct Cremation. . . . $ 1-:)(. '1
2. Direct Burial $ ).1 1'7
B. Transfer of remains to the ~neral eSlablishmelll including I /
personnel. equipment and vehicle. . S ##,7
I '
$}'~
C. Preparation of Remains
I. Embal"linl (includinl use of preparation room).
If you select a funeral for which this firm requires
embalmin, such as I funeral with viewinl. you may
have to pay for embalminl. You do noc have to pay for
embalming you do not approve if you select arrange-
menU such u direct cremation or direct burial. If we
charge for e:mbalmina. we will explain why below.
2. Other Preparation (including use of preparation room
but ncludin, embalming)
a. Topical Disinfection.
b. Custodial Care
c. Dressinl/Caske1ing
d. CosmetolOlY .
e. Restoration
f. Other (specify)
D, Arranpmems
Basic arran,emenlS: includinl funeral director, Olhc:r slaff.
equipmc.. and facilities to respond to initial request for
service. the arranacment conference, securina of neces.
sary IIlIIhorization and coordi..tion of service plans with
panics involved in the fi..1 dispolition of the deceased.
E. Supervision (funeral director and stam
I. Su"crvision for visitation
2. Supervision for funeral service
3. Other supervision (specify)
I
I
!
I
$. )/;;
$ ~l. J~~J
$ ;1 (,7
S~W1
II ,
S /'/l/
I
S,~,/;J
i
$J.,l'l
. I I I
~ :~'~.."'<
$; '(, .
$ I '.J.,)
I/I'{
F. Use of.. r.ciliIiea
I. Use of Ihe fIciIiIia' for visiwion.
2. U. of facilities for funeral service. .. .. . . . . . ..
3. 0dIer use of facilities (lpCCify)
G. Uvery
I. 10 Hancor.................
b. AIIcmalive vehicle . . . . . . . . . . . .
(Specify type:
2. Flower vehicle.. "
3. Umousine(l).....
(Specify number: @ S llimousine)
4. Passenger car(s) (Lead car/Clergy Car) ...................
(Specify number: 0 $ /clr)
H.Merchandix
I. Casker or alternative container
a. Supplier
b. Model name or number
c. Material: Species of wood
or kind of metal weight or gaugc_
or alternative container (describe)
d. Inlerior
2. Outer IlIlerment Receptacle: ,
( . .... I <
a. Supplier h" I I-u,n:' i (>..
, I. ,
c. Materia
b. Model name or number
J
I. Additional Services and Merchandise Selccted (Describe
and show price)
I. Memorial Cards.
2. Acknowledgcment Cards
3. CUkCI Plate.
4. Crucifix/Cross
5. Hairdressing
6. Flowers
7. Clothing or Burial Garments. '
8. Relisler Book.
9. Death Notices.
I r'
IOJ1V,j.r..>f.Il"/lc, yU-'t-I.I:",'{'
II.
12.
1. Limited Services
I. Forwardinl rcmains to
2. Rcceivina remains from
TOTAL OF FUNERAL HOME CHARGES
S ~45}1::':':~~'." ~.
s Jr"'~l"'"
s ...!: 1// J.. .
I'
$ .()i.::~'.:.. . ~.
$ Jll)...
,
,
S J I:'" i
..11.1......
S .)./.."1.'.1.. . . .
$N.~~L..
/
S ..ll)
,.I: .1...
$/ j{ {
j
S ' /PI
lur'",
$ Ii.lt'l .
S /''';),:1
$Mh'}
1 .
S }l1;:1
:~~i .
$ JIlll
s/~.. '-
$ /l;~- -.
s.
$
S FltZ
71.1"
$.. 1{J.~.
"(c -, . I'.
S '_. if.,.-
II. CASH ADVANCES
These are estimated charges for items to be paid to others. We
will chuJe you no more for these items than is actually paid
the third putia. (Describe and show estimated charges.)
I. Cemetery or Crematory .
2. Clergy Honoraria.. .
3. DeJth CertiflQte Transcripts
'.'..
-). .. "j .-
$...-' (,. .
/ . - ,
$;(..--
s .fJijJ
$ HI/I
:~~
$ .1:.,%.
$IL'fJ..
S ,tJ!/I
"
4. Livery........
S. Pallbearers .
6. Public Transponation.
7. Gratuities. ...
8. Bridge cl ROId Tolls
9. Telephone &. Telegraph Charge:s
. I. 'I ("
IO,~;'. kfl/tJ(" (:ret l\
(..'/ . /-:.t'I'~ 'I
~.J._,i. l.
~ ..:S
II.
12.
s
s
L 7')/.
$ Jr"' U.
ESTIMATED lUTAL OF CASH ADVANCES
III. SUMMARY OF CHARGES
I. Funeral Home Charges
2. Cash Advances.
TOTAL FUNERAL CHARGES
$ :'?5 7r:
~. .
s 13;';.'0.
s'l;x (It;. ~~
IV. EXPLANATION OF CHARGES
Explain charges for embalming and for any items that are not required by law but
may be necessary because of cemetery requirements, crematory requirements or
othe selections made.
i J '/ r .
(di.11 J' : (t. r J ;/ trt",;. .1"
, I
Combined charge for facilities and staff for visitation is S
,-
,1~"'_.O.
Com. ~...~.c1!l1I'ge for. fa. .. ti~ and staff for funeral servilirr ::; '.~
,... ,~,- .
. ./' I _. ..... . :l 8; :')
Si~e.~reof lcen . FunWDircctor ' Date
"..r- --__. L/ I
. ,JIU1 K'j I) ... tnt'/f"
Printed or Typed N'ame of Funeral Director
ACKNOWLEDGEMENT OF RECEIPT
I '"'1":"::-.... _... 0' "~nl ~~i~... =rehaod7..cltCd.
V ~ \"'J'\ ;) " ,. ~.,
I~ignalure Dale:
PUBLIC NOTICE
The New York SlJIte Depanment of Health is responsiblc for licensing and regulat-
ing New York State funeral directing under the Public Heahh Law.
You may c:ontac:t the Depanment at:
Bureau of Funeral Directin,
New York State Depanment of Heahh
Coming Tower, Empire State Plaza
Albany. New York 12237
EXCLUSION OF WARRANTY. The only warranties. express or implied.
grallled in connection w.ith the goods sold with this funeral service are the
express written ..arranties. if any. extended by the manuflldUrers thereof.
No other warranties and no "'lrTllntles or merchlntlbiHty or fttnas ror a
,.rtieullr ,....... are utended by the funeral director.
."'.
I
t~
"
t l
"
. es the above funeral esIabIishment or its
o not 10 embIlm the ret'lllins of
Initii and stale your relation to deceased
o
Othe:; AUlhorization by
"Ch. ges Ire only for lhose items that are used. Ir we are required by law 10
use a items. we will expltin the reasons in writ.ns below:'
t.
!
I.? I
ITOTA f1JNERAL CHARGES..
I
I .
i { I (...., ,/ '.- I~,
,.. ! Date .. I.,.. ......./........................ 20J.....;'.\-<.....
: The oregoing statement has been read by (to) runndl hereby acknowledge
I receipt of a copy of same and aleee to pay the ;I6bve funenJ account and for
i such addilional ~eyices and material~ IS ue ordered by.
i me. on or before ..Ji:/..;,r......... 20a\ In the event that this account is not
i paid in accordance with lhe terms of this a.eeemenr. the u~rsig~ here~y
I agre:e~ II pay any and all COSIS and allurney s fee5 lIIcurred In connection with
1 the col ection of this account.
! Prior I the discussion of these funeral arrangelTlt:nts, I was presented with a
! copy 0 ihis funeral firm's "General Price List" fer which I hereby acknowl.
I edge r e:ipl. and have had an opponunity to review lhe fi 's Casket Price List
I and ter Inlerment Receptacle Price List.
ITER : This account~"ts dUJ: ~ - I . ICbill
I remai 5 unpaid beyond r ,/jt;/t.- {: a la e (.harge of ." per month
(annul rateK..,,) may be added to lhe unpaid ponlon o( the balance due.
~. Th~ liability hereby assumed is in addilion to the liability'imposed by law
upon I e e:state and others. and shall not conMitute .. release thereof,
t
Signa! re~R ItA~.'
Rel21\ n 10 Deceased _'5 c: /..../ . ". '"
,
i Signat re
s i 'r: '1 (,. I :,:.
Relati n 10 Deceased .
,,;.-~-)./ /
By.::+ ;;/'/-.-l.~;".
---. -.. ./.1 ;
.. ...j /?/?;~~,,_r;;P/-/T/ ( Ie.
"'t" S_ rI lie.- F_.. Diooc:,or
A D) IONS OR ALTERATIONS OF SERVICES AND
MER; HANDISE SELECTED. The followinl citanps rep-
resent terns of service and/or merchandise ordered or altered
subse: uent 10 the ori.inal funeralaareement.
AUT ORIZATION INITIAL
CJ
CJ
.s
..$ .
djustments to Funeral Charaes
s
s
..v:);': Ie
.L
- $ /t:.,::.,';~-
1[-7' ,/ -~
,S' fn_..
~ement /or Burial
55 Peter & Paul Cemetery
66 East Main Street · Hamburg, New York 14075
Phone: (716) 649 - 2765 Fax: (716) 649 - 5218
This agreement made this
16th
day of AUGUST, 2006 with STEVEN
(month) (year)
RD., RED LION, PA. 17354
FIFTY
KAHLER, 213 COUNTRY RIDGE
FIVE HUNDRED
in consideration of the payment of
easement and license use of Graves: Sec. G
dollars ($ 550. 00 ) hereby grants
I lot #29 Igrave # ONE GRAVE
,Line
as designated on the map of SS. Peter & Paul Cemetery, for human burial purposes only. This
use is subject to the laws of the State of New York, the Codes of the Roman Catholic Church
and the Diocese of Buffalo, and the Rules and Regulations of SS. Peter and Paul Cemetery. The
graves/lots designated by this Certificate are for interment of the owner and members of the
owner's family and shall not be assigned or transferred except by special permission of the Pastor
or Administrator of 5S. Peter and Paul Parish, Hamburg.
Witness our hand and seal this 16th day AUGUST
(month)
2006
(year)
CERTIFICA TE Number:
ILl 3d-
55. Peter & Paul Cemetery
by f: cl-. ... c..r... C:- \>0. .. IQ=-v~ L
<\
STEPHEN L. BLOOM
AT T () R N ,.: Y .\ N D C () U N S ELL () RAT L.\ \XI
.\ I' R 0 F E S S I (1 N ,\ LeO RI'O RAT ION
2100 LON(;S C;.\I' RO.\I)
CARLISLE, 1'1.:N N SYI. V:\ N L\ 17013
TELEI'HONr-: 717-249-7717
I,' A C S I M II. E 71 7 - 249 - 7"757
\~.\~.\~.. PRACTIC:\I.U1L'NSEL.COM
SBI.OO~I@PRACTIC,\I.U 1l.'JSr-:I..(:! )~I
Invoice submitted to:
Kahler, Florence A Estate
c/o 213 Country Ridge Drive
Red Lion PA 17356
Steven S. Kahler, Administrator
May 03, 2007
In Reference To: Estate Administration
Invoice #1860
Professional Services
Preliminary Preparations for Probate; Administrative and estate matters; Telephone conferences; Preparation of
Petition for Grant of Letters of Administration, Oath of Personal Representative, Decree of Probate, Estate
Information Document; Appearance at Register of Wills for presentation of same, conference with client and
review of Letters of Administration
Administrative and estate accounting matters; Correspondence with Orrstown Bank and Department of Public
Welfare; Required Notice of Beneficial Interest in Estate and Certification of Notice Under Rule 5.6(A);
Appearance at Register of Wills for Filing of same
Administrative and estate accounting matters; Preparation and filing of Inheritance Tax Return, Schedules and
Exhibits; Inventory; Correspondence; Final Matters of Administration
For professional services rendered
Amount
$1,000.00
($1,000.00)
($1,000.00)
8/23/2006 Payment - thank you
Total payments and adjustments
Balance due
$0.00
PAYABLE UPON RECEIPT - THANK YOU
PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17G13
Receipt Date:
Receipt Time:
Receipt No. :
8/07/2006
11:17:10
1045292
KAHLER FLORENCE A
Estate File No. :
Paid By Remarks:
2006-00701
STEVEN S KAHLER
AJW
------------------------ Receipt Distribution ------------------------
Fee/Tax Description PaYment Amount Payee Name
PET LTRS ADM OTHER
SHORT CERTIFICATE
JCP FEE
AUTOMATION FEE
Check# 1297
Total Received.........
60.00
24.00
10.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
CUMBERLAND COUNTY GENERAL FUN
$99.00
$99.00
08/24/2006 15:34 FAX
IaJ 002/004
MV-38 0 (09-02)
APPLICATION
FOR DUPLICATE
CERTIFICATE
OF TITLE BY OWNER
.. For oepanment use OnlY ..
Department of Transponadon
Bu~uofMomrveh~
Harrisburg. PA 17104-2518
See Instructions on Reverse
F~E: $22.50
I VEHICLE INFORMATION
TklI NlIl1w Iw.;G'~~K~2~~33805
Olorwr 111_ (8XIKlJy as "-n QI1IlrigI~ Udal
Florence Kahler
CHECK BLOCK IF ADDRESS [J SlrI81Ad1n88
IS TO B~ CHANGED 1400 Bent Creek Blvd Apt 127
NOTE: Complete only if different from addrel!lS cay SllIlII Zipl;edl!l
listed on original title. Mechanicsburg PA 17050
IRI ~-SON FOR DUPLICATE TITLE
APPROPRIA"tl: BLOCK .. D Lostl Dsto/en D [)efwc:ed (Defaced title must D Never (Provide your correct
MUST BE CHECKED Destroyed be attached) Received admw. ab0Y9)
IVEHICLE OWNER'S NOTARIZATION
. ~BSCRlBED AND IMQRN I/WI! state that lfwe IIave te4l<l llnCl slllned lhl$ allllHcallon Oftet its compIelion, and Uw. neor r;r
aliii'm \I'lat ll\e $1lIilementt """de l\erein - lI'Ue lll'ld eetI'eet, and lnlt om:r ~ IIIIIdIll! l;IOl gr
BEFORE ME: MO. DAY YEAR pursuant \0 this lllPpliCll1iotl i$ sllllject \0 Itle pen"'" tit 11 Pt'I C.S. Setllllln 4903(.)(2) (reIaling
.. to raJ!le swea~"g). wl'l1Ch shllll include punishment llf 8 lIlle llllt ~Ing '5,000, or III . leml tit
SI()NATIJRE OF PERSON AOMINI61ERING OATH iII'IptlSOnment of not more than two yea". Of IlOln.
S Sign...." al Ownar Dr ~ PDlSDl1
E DO NOT NOTARIZE UNLESS S91aluro or ~r or 11119 or Aulhorizod SIgnor
SIGNED BY APPUCANT IN
A PRESENCE OF NOTARY Tel8p1lone I\kmIloo'
L (v.ft orly b9 lIMCIlr I/1n 1$ . ( )
"",,,10m with YO'" 8tl\lIicali8n)
NOTE: COMPLETE THE INFORMATION LISTED BELOW ONLY IF A LIEN WAS RECORDED
AGAINST THE VEHICLE AND THE LIEN HAS BEEN SATISFIED AND THE TITLE IS NOT
ATTACHED.
SATISFACTION 0
im70~
F"_a1IM1iIJliol\ NLlmblt
I !tate Ill~ I l\:lVe re3d and siglled lIlis lllppllCaticMl alll!r Its completion. and I ~ or ;d!inn th
\hill! stRlmenls made henlin iII'II! lnIe ;and ~ i1m:1lhilt i111J slilblmcnt made on gr pursu
la Ihia IIppliClltion illlubject to the penllli.. of 19 PA C.S. Seation -4103(8)(2) (IWlnng Ia fal..
&W9B~nD). which shllll include punlahlllllnt of B line not UC8tIding 15.000. Dr to B lIIIm
mpn&OIlment of nollllOl1llhBn two~. or both.
_p/Klnlo Nunb9r
gco ~'d.'d..
Cte.\~st
THIS APPLICATION MAY BE PHOTOCOPIED
It ALS
MERRY L NIiWCOMER
NOTAFlY pUBUC . OReGON
COMMISSION NO. 3749111
MY COMMISSION EXPIRES NOV. 20. 2007
$A... I.A"t 1< .HA$A .1 -10. CUA
U~IU~14UUf ~U.UU
-, A~ ,"'it"--~f"".c C ":~
..L....,..a.U~...Jl..VU...J
Cfl ~Ee-e- "fh\C"
.I...'\..IIV................,-' .1.1 "-"
PAGE 01101
STEVE KABLER
lfi92S-A'l~ koad
P.O. Box 310
M PFu.~;ZIHl
(410) 319-6800
~1: ~QJm
May 1, 2007
;:c r....
~;;,:.
Stmphen L. Bloom
2100 Longs Gap Road
Carlisle, Pennsylvania 17013
VIA FAX 1-1J.7-249-"~7
RE: Ploren.ce A. Kahler deceased - GMAC auto loan
payoff amount (OMAC acc.ount# 0209(0590814)
Stephen.:
Please be advised that the above loan was paid in full by final.payment of
$2,532.87 on. 8117/2006.
Please contact me if further details are 'Nquired.
~'r~
TEVE KAHLER
Burgess InsuraDu Agency
(410) 329-6800
N~Mrttnl Fhj~C........,
)tiMID""'" MftIItIllI1lt1Jtrrm<< ~.1
1'I11f1D1lllllftl'rrlpmy.t ~ CO..,..,.,
~';-.: ;,.-;;; ~;..;;.-.... s~;~ ...,,; ; w.. i-i-;:-1rw.....o:-'.
~;.,.; _.....".._;::..~, ir....":'J
..~~ nl' Q<+
~iliivnn.
~~'"; .~~A~ ~~.~; ~~T
\S~~
'" ._.--...........--.~:i '-..' ......~;;;;...
-_._~~.__._._- _.,-
.,=;::l.:: c;;;-: "'-'.. _.'
M <IV 1 .,M?
rWi~A~~~;
213 CountJy:RiQe Dr
h _ ..i .. ~__ S J. 1 ""!:I ~
~ .IA........., A I"'- .., .6""'"
/Vr.OOlA No::
Ve1dc1e-
VIN:
~W5i4
N02 StrmI2
108ZKSz112Z233105
Dar.PJoreoce A Kai:der.
llurvc cnc1ased. a mstozy of your paymc:ms OIl the ~ tef<<~ accowd. as
_ ~~~. Tf1hC1.e are my c!i*-&..pIIflCies OJ' if you baYe my tbdher questions,
plcue do not hesi~ to call the toO free number listed above.
1'hBak~you fOr ~iqg with GMAC.
Sitlcerely,
/~~~
Account ~t1ist
~
-
,....<<vY... ....
..........' ~.....! -.vv \
........,.....'JwJ.:...;-,..'""'tj.~
n;.nl/2n07 14:08 P41
....
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'=
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i
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...at..............'"
"""....................H" IN'" III
.
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'"
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~
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0 f-<
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0 2
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"
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0. ~
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5
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~,
;-- =~ :~g~~~~~it~~~&:~2
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fiI <:I 5a
b: . l'O
r-q
!~ ~~ ~'g
r.o.e.r: ..~
!:l-;:;;....
~~~ Ii ..~ . "''''11I'''"0........--....... ~
~ 8 =a :~~~~:~~~~~~~~~
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cc .O............CJoou~"....~..:..G
01.Jr:',:t~:r:;
J.l't::l
r~ u..:.itl~
1iI00C/004
~ CapllalUne-
~~ c{~=~
~ Account Summary
; Previous Bala~
~ Payments, Credits and AdjJstmew
II T ransactiollS
~ Fimnce Charges
$145.23
$.00
$71.39
$1.34
..
:; New Balance
; Minimum Amount Due
: Pa}1IIent Due Date
r;J
"'
$217.96
$20.00
September 15, 2006
$10,000
$9,782.04
$2,000
$2,000.00
:: Total Credit Line
:: Total Available Credit
Credit Line for Cash
; Available Credit for Cash
a
a
~ At your semce
: To call Cwlom". Rdation, or to aport. lort or stolen ani:
1-800-955-7070
For /iu online a<<oant ,mi", and ,peri" cwtom<:r offtn, log on to:
MoW-capioo6lf.;i:6m'
Smd paJ'mmlt to:
Attn: Remittance Proca,ing
Capital On. Bank
P.O. Box 790216
St. Loui" MO 63179~216
Smd inquiri.. to:
Capital On.
P.O. Box 30195
SLC, UT 8-4130~2S5
Important Account Information
Take control and start paying your bill online for free.
Eliminate the hassle of writing checks, finding stamps, and
sealing envelopes. Em=}thing you need to access, review, and
paY}'01D' bill is available online. Our website offers }'OU a
con~nient, simple, and seClD'e way to manage }'OlD' account.
V JSit www.capitalone.com and register }'OlD' account to start
simplifyillt }'OlD' life today!
0-
m
(l)
o
'"
<0
PLATINUM MASTERCARD ACCOUNT
5291-4917-3321-5782
}UL 16 - AUG 15, 2006
Page 1 ofl
Payments, Credits and AdjIstments
Your scheduled payment hllS not been re~. Please remit the amount due appearing on this st2tl:ment. If
}'Ou have already made }'OlD' payment, please accept our thanks.
T I3.l1!Illctions
1
2
24 JUL TLr--ROYERSlSTEPHENSNS LEBANON PA
15 AUG PAST DUE FEE
$42.39
29.00
Your account is one payment behind. Remember that making)'QIII" minimum payments by the due dlte, keeps
}'OIII" accOIlnt in good sta..Iing. When you miss a payment, late ~ start adding up. And nobody WIInt! that.
So make SlJre you send in the minimum amount due on your lll:atement to keep your account in good standing
and to keep from paying extras fees.
As of08l15/06, your current No Hassle Miles balance is 2,644
miles. Please note that rewards information reported here may not reflect all
purchases on this statement or recent redemptions. Simply go online to
www.capitalone.comlmilesrewards when}'Ou are ready to redeem.
YOII were assessed a past due fee of $29.00 on 08115/2006 because}'OlJr minimum payment was not
. received.by the due date of 08115/2006. To avoid this fee in the. futUre, we recommend thatymt. .
allow at least 7 business days for your payment to reach Capital One.
t\,Q ~~ \-1)')~ /
~(~~~\P V
F'Ul3J1ce Charges
PlellJe Jee reverse siJe fOr ;mportard ;njmtrlZi;on
P::ic Cor.njpR6ml ~8E
.0143lM 8.~ SI.34
.0143"" 8.9'* S.OO
PURCHASF.'l
CASH
Bit/."it Nt<
Illflicl frJ
$177.29
S.OO
ANNUAL PERCENTAGE RATE applied this period
8.90%
T PLEASE RE11JRN PORTION BELOW WfIH PAYMENT T
CapitalOne-
0000000 0 5291491733215782 15 0217960015990020005
~*'
PI'M( prirrtfltllilmllllJrtss.",M"..--il c&m"s Sthm flSm.,ShH ",.SlIlCi. m!
New Balance
Minimum AmOllnt Due
Payment Due Date
S.m.
Apt'
Total enclosed $
Account Nnmber:
September 15. 2006 City Sb.. ZIP
I Horn. Phon. .AIt.m... Pho..
5291-4917-3321-5782 .
Rmail Add..n
..,
Capital One Bank
P.O. Box 790216 1.111111111.1.1.111111
St. Louis, MO 63179-0216
1.11....11....111...11.1..11"'1.1.11..11.11.....11.11111111.1
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190228128759851631 MAIL 10 NUMBER
FLORENCE A KAHLER
1400 BENT CREEK BLVD
APT 127
MECHANICSBURG PA 17050
111111111111111111.1.1111.111.11
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Please write YJllr DCCOUrd numbn on JDU1' c~d or 7WJrlLY ordLr 11U1Ik payahle to Capital Orre .BarrA. and ma;1 ;n t~ enclosed tl'lWlope.
(6491-740906783-001 )
CUSTOMER ACCOUNT 740906783-001
cUSTOMER NAME FLORENCE KAHLER
SERVIC~ ADORE:SS 1400 BENT CREEK BLVD APT 127
BILLING PERIOD 07/01/2006-07/30/2006 I DAYS BILLED 130
" NW&P
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NA:1'IONAL WATBll. POWER
National Water and Power
PO BOX 790275
St. Louis, MO 63179-0275
SERVICE TYPE -DESCRIPTION AMOUNT
Submetered Water Service 115 units @ 0.057300 per unit , $6.59
Service Fee $3.00
Meter Fee db $0.25
Sewer Base Fee 10,7 $26.00
-fhs-n
q. ~
Rw8n9. 07/0112006 07/3012006 ~
Hol/Cold 5533 5648 115 115 x 10 GAL units
PREVIOUS BALANCE
PAYMENTS
CREDITS
CURRENT CHARGES
LATE FEES
DUE DATE
.09
45.00
.00
35.84
0.00
09/07/2006
Resident account and payment information available at:
www.nwpco.com
To ensure prompt and accurate processing, plesse write your
account number on your check or money order.
SEE REVERSE FOR CERTAIN DISCLOSURE AND CUSTOMER SERVICE
CONTACT INFORMATION
PLEASE NOTE _ Your payment by check may clear the bank electronically. This electronic payment occurs each time we
receive a check from you. If you have any questions about this process please call us at 800-845-6767.
......--........................................................................................................................................................................................................................................................................................................
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PPL Electric
Utilities
Electric
Service
For:
FLORENCE KAHLER
1400 BENT CREEK BLVD
MECHANICSBURG PA 17050
Questions about
this bill? Please
contact us by S~ 7
at 1-800-342-5775
(l-800-DIAL-PPL)
or write to:
Customer Service
827 Hausman Rd.
Allentown, P A
18104-9392
www.pplelectric.com
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Page 1
49899-88010
$ 0.00
$ 26.63
$ 26.63
Accouut Balance
$ 26.63
J- 11Y
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9 ( ~ (\~
This graph shows
your electric use
over the last 13
months.
Types of
Meter Readings:
Actual
Estimated
-
~
~
D
Electric
Use
Customer
Summary Page
Balance as of Allg 11, 2006
CharRes: "
TotafPPL ELECTRIC UTILITIES Charges
Total Charges
KWH - Average Per Day Meter Reading Information
36
30 14890
14699
24 ----m
Average - Allg 2005 2006
18 Tem~erature 79F 78F
KW Per Day 15 7
12
Yearly Use: Total A\'era~e
6 Use Mont" V
Sep 2004 - Aug 2005 7268 60(;
0 Sep 2005 - Aug 2006 7319 610
A SON D J F MAM J J A
2005 Months 2006
Other important information on back ...
~
PPL Electric
Utilities
Electric
Service
For:
FLORENCE KAHLER
1400 BENT CREEK BL VO
MECHANICSBURG PA 17050
Final Bill
QnesHons about
this bill? Please
contact us by S€lQ 22
at 1-800-342-5775
(1-800-DIAL-PPL)
or write to:
Customer Service
827 Hausman Rd.
Allentown, P A
18104-9392
www.pplelectric.com
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Page 1
49899-88010
Summary Page
Balance as or Sep 1,2006
Char~s:
TotafPPL ELECTRIC UTILITIE-S Charges
Total Charges
$ 26.63
$ 8.45
$ 35.08
Electric
Use
This graph shows
your electJic use
over the last 13
months.
:Types of
Meter Readings:
Actual _
Estimated ~
Customer D
36
KWH - Average Per Day
Meter Reading Information
30
e er
Aug 31
Aug 17
14 Da s
14938
14890
~
2006
76F
3
Actual
Actual
KWH BlIled
24
18
12
Average - Aug
T emIJerature
KWH Per Day
Yearly Use:
2005
74F
13
Total Average
Use Monthly
7496 625
6944 579
6
Sep 2004 - Aug 2005
Sep 2005 - Aug 2006
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Other important information on back ..
tor vom COll\'elllence. vou can llOW Dav vow' bill usinQ vom. Visa:
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SONDJ FMAMJ JAS
2005 Months 2006
..::....... ---~------=-=--:-'--'-----------'-- ------------
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veriZ9D
We never stop working for you.
FLORENCE KAHLER
Account Summary
Previous Charges
Payment Received Aug 03. Thank You.
Balance Forward
$ 78.77
- 79.00
-$ .23
NeW Charges
Verizon(page 3)
Total New Charges Due Sep 14
Total Due: (Past Due + New)
$ 50.91
$ 50.91
$ 50.68
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S;-, ..en)
l{~(lf
Questions about your bill? Call 1 800 660-2215
See page 2 for all other Verizon contact information.
Change of billing address?
Go to verizon.com/billingaddress or see page 2.
Billing Date: 08/19/06 Page 1 of 6
Telephone Number: 717 697-3062
Account Number: 717697-3062625 09Y
1m.. r... Fo< A e,..r Pric.
The Verizon Freedom Essentials
plan is everything you need at a
price you want. You get unlimited
calling anYWQere in the U.S. for only
$39.95 a month, plus taxes and fees.
You'll also get Home Voice Mail,
Caller ID and Call Waiting included.
Call 1_888-362-6280 for details.
rn
Tired Of Writing
Checks Each Month?
Now there's an easier way to pay
your bill - with Direct Debit. Just
fill out the form on the back of this
bill and send it in. And each month
the amount of your bill will be
automatically debited from your
checking account. Talk about easy!
~*
Who Says You Can't
Take It With You?
Just because you're moving doesn't
mean you have to leave your phone and
Internet service behind. Just contact
us and we'll make reconnecting at your
new place easier than ever.
Visit verizon.comleasymoving or
call your local business office.
~ Detach & return payment slip with your check, payable to Verizon
----77~~=~=~==~7~~7~~~~-------------------------------_______________________~7~~---------------------
Total
Verizon local toll charges **
MONTHLY SERVICE - NON-BASIC (Aug 19 to Sep 18)
Description Qty Unit Rate
14 lnside Wire Maintenance residential 1 3.95
Total
NON-BASIC SERVICE TAXES AND SURCHARGES
15 State tax at 6.00%
Total
Verizon non-basic charges **
S 2.20
$ 38.70
3.95
$ 3.95
.24
$ .24
S 4./9
33 P136 7176973062 040913 05 PA211.HBRDA1
00004529 2TOoo0025183
Page 1 of 1
Account 038-5242-326 as 0' Aug 17, 200~
Your Payment Is Due on Sep 17, 2006
.
PROGRAM TO DATE
Previous Balance
Total Chgrges
Total Payments
Total Credits
Finance Charge
$
0.00
21.18
0.00
0.00
0.00
+
+
Your Kohrs Charge purchases are $21.18.
$600 In Kohl's Charge purchases from Feb. 2006-Jan. 2007
qualifies you for Exclusive MVC Privileges through
Feb. 2008.
New Balance
To Avoid Finance
Charge Pay
s
21.18
21.18
Minimum Due
s
10.00
Transaction Summary of Account 038-5242-326 .1QtgJ.
JUL 18 Purchase at the Mechanlcaburg Store ...................................................................................... $21.18
(2) Bed Pillows .............................19.98 (1) TOl<..............................................1.20
Notice: See reverse side for important information.
(U): Quantity greater than 99
DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT.
7/22/06 Basic Life Support Emergency A0429 1
7722i06-M1i~~9~-------- u_ _____u_ -----A0425 -- 12
Total
390.00
-7.50
390.00
90.00-
480.00
0.00
0.00
'"
0.-4j,,'1 ()1J t L-1 fD
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Silver Spring Ambulance & Rescue Assodation, 877 214-6018
KAHLER, FLORENCE A. 06-40740
PAY THIS AMOUNT 1111.
$480.00
111111111111111111111111
AMBULANCE BilLING OFFICE: PO. BOX 726, NEW CUMBERLAND, PA 17070-0726
.---'
WEST SHORE EMS - BLS
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
INSURANCE: HIGH MARK
ZAH1105951350Q.1
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER: ....
FROM:
TO:
41844 IBAL
145201W NONE
07/26/2006
03:10 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
MANORCARE HEALTH SVCS - CARLI:
PATIENT NAME: FLORENCE KAHLER
145201W
FLORENCE KAHLER
213 COUNTRY RIDGE DR
RED LION, PA 17356-8866
REASON(S)
FOR
TRANSPORT
BACK PAIN
INVOICE
A0999
A0999
QUANTITY
1.0
21.0
U~ITP~iCE
98.64
3.24
AMOUNT
DESCRIPTION OF CHARGE
STRETCHER One Way Transport
Transport Van Mileage
98.64
68.04
0Y'I.J "1
QN"''-\, ~ \t"lt- ,
'1 S-.Ie} r 60 "3
'1111/01, '\
Total Charges 166.68
.' DESCRIP110NOF pAYMENT . RECeiPT ...... pAyMENT DATE AMOUNT 11
. " ,_... . ' ." , '';,','; ".+" ".:'...' ,-I,,'
111
HIGHMARK PAYMENT - HIGHMARK - BOX 890 15490831 09/07/2006 68.04
Total Credits 68.04
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~ $98.647
RETURNED CHECK FEE - $31.00
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Cumberland-Goodwill Fire Rescu
GENERAL RECEIPTS
PO BOX 12910
PHILADELPHIA, PA 19101
Phone #: (800) 367-0512 Federal Tax 10: 23-2298422
r~\T'ENT NAME:
FLORENCE KAHLER
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALt..:
TIME OF CALl.:
CAlLER:
FF10M:
TO:
7285
CG0602767
07/26/2006
'NSURANCE:
HIGHMARK
ZAH110595135001
NMI
12
CG0602767
Police/Fire/911
MANOR CARE HEAL TH SVCS - CARLI:
HOLY SPIRIT HOSPITAL
FLORENCE KAHLER
213 COUNTRY RIDGE DR
RED LION, PA 17356.8866
REASON!S)
FOR
TAA"'S~"mr
ARM PAIN
INVOICE
. -'--~--'''''''---'_._'--'--_....._----_.,,-,..,-,.-
-------.---- ------..-...-..--- 'T"
QUANTITY UNIT Pn/CE :
--.._~---------- ._--._._-"-_......_..__._~...-..,..~.-_..
1.0 350.00 I
22.0 7.00
PF.SCRIPTION OF CIfMlr:;~
r-SLS EMERGENCY BASE RATE
, MILEAGE CHARGE
I
I
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I
I
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I
L
A0429
A0425
,i'. ~,~f d
350.00
154.00
V) ( ~{(}0
E"1U"09
Total Charges
504.00 /
-
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE
Total C
PLEASE PAY THIS AMOUNT___
'-----
-------------_.~---
AMOUNT
redlts 0.00
$504.00
/
Cumberland-Goodwill Fire Rescu
GENERAL RECEIPTS
PO BOX 12910
PHILADELPHIA, PA 19101
Phone #: (800) 367-0512 Federal Tax 10: 23-2298422
PATIENT NAME:
FLORENCE KAHLER
INSURANCE:
HIGHMARK
ZAH110595135001
PATIENT NUMBEfl:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FnOM:
TO:
7285
CG0602848
08/02/2006
NMI
11
CG0602848
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
MANORCARE HEALTH SVCS - CARLI:
FLORENCE KAHLER
213 COUNTRY RIDGE DR
RED LION, PA 17356-8866
nEASOI\I(SI
FOFl
fR/\NSPORr
FRACTURED ARM - CLOSED
INVOICE
r----~~~TIO'" OF-;H~~~~E---'----I-~~~N;;;~-'-'-' ---- 1.INIl~~R~;~'-- '-.---" .__.....--.i~~~;~~.!NT
'--- .-.---..-- -----------.. -.--.-.-....---.---.--....
AlS NON-EMERGENCY
OXYGEN
MilEAGE CHARGE
A0426
A0422
A0425
1..0
1.0
20.0
742.70
50.00
7.00
742.70
50.00
140.00
1 () { <r1fJ ~
; U? IOo~
Total Charges
932.70 V
--- ---
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
...-
Total Credits 0.00
PLEASE PAY THIS AMOUNT -..- $932.70
--..------