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Home My WebLink About05-24-07 --4 ....J 15056051058 REV.1500 EX (06-05) PA 0epaftmenI of Reveooe . Bureau of Individual Taxes PO BOX 280601 Hanistug, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY Cotmty Code Year 21 06 File Number 00783 Date of Birth 183-12-3890 08/27/2006 11/18/1914 Decedenfs last Name Suffix Decedenfs First Name MI Hornberger (If Applicable) Enter Surviving Spouse's Infonnatlon Below Spouse's last Name Suffix Emma c Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW .- 1. Original Return 2. Supplemental Retum 3. Remainder Return (date of death prior to 12-13-a2) 5. Federal Estate Tax Return Required 4. limited Estate 48. 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 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. AU CORRESPONDENCE AND CONFlDENT1AL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ... 6. Decedent Died Testate (Attach Copy of Will) 9. Utigation Proceeds Received o 8. Total Number of Safe Deposit Boxes Ronald P. Sieg,Executor Firm Name (If Applicable) (717) 564-180~_) REGISTER OF:W~ USE ON~ .._..,~. First line of address 1'_' ...... 3647 Derry Street Second line of address co City or Post Office Harrisburg State ZIP Code 17111 DATE FILED C.T; PA Correspondent's e-mail address:rpsieg1@comcast.net Under penalties of petjury, I declare that I have examined this recum, 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' K ~'1?FClRf!j'EnJRN "^ DATE <3-Y 1...00, ADDRESS 6 tll I ~ \1 II~ I SIGNATURE OF PREPARER OTHER THAN DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY L 15056051058 Side 1 15056051058 --.J Vi( .-J 15056052059 REV-1500 EX Decedenfs Name: RECAPITULATION Emma C Hornberger 1. Real estate (Schedule A). .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or SoIe-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly OWned Property (Schedule F) Separate Billing Requested.. . . . .. 6. 7. Inter-VIVOS Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate BiDing Requested.. . . . . .. 7. 6. Total Gross Assets (total Unes 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Unes 9 & 10). . . . . . . . . . . .. . . . . . . . .. . . . . . .. . . . . .. 11. 12. Net Value of Estate (Une 6 minus Une 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Une 12 minus Line 13) ..... . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTAnON - SEE INSTRUcnONS FOR APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under See. 9116 (a)(1.2)X .0_ 16. Amount of Une 14 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 302,166.90 15. 16. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESnNG A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 183-12-3890 Decedenfs Social Security Number 15056052059 308,756.12 308,756.12 5,563.02 1,026.20 6,589.22 302,166.90 302,166.90 45,325.04 45,325.04 . -.J REV-1500 EX Page 3 Decedent's Complete. Address: 21 File N.-nber 06 00783 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Emma C Hornberger 183-12-3890 STREET ADDRESS Manor Care Health Services Room 321 1700 Market Street CITY I STATE I ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. CreditslPayments A. Spousal poverty Credit B. Prior Paymen1s C. Disoount (1) 45,325.04 43,165.00 2,266.25 Total Credits ( A + B + C ) (2) 45,431.25 3. InterestlPenalty if applicable D. Interest E.PenaJty TotallnterestJPenalty ( 0 + E ) (3) 4. If Une 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FiU in oval on Page 2, Une 20 to request a refund. (4) 106.21 B. Enter the total of Una 5 + SA. This is the BALANCE DUE. (5) (SA) (58) 5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... 0 [iJ b. retain the right to designate who shaH use the property transferred or its income; ............................................ 0 [iJ c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i} 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........ ............. ............................... ................... ............ ...................... ..... 0 [iJ 3. Did decedent own an -in trust for" or payable upon death bank account or security at his or her death? .............. 0 [iJ 4. Did decedent own an Individual Retirement Accoun~ annuity, or other non..probate property which contains a beneficiary designation? .................. ............ .............. .............. ......... ............................................... ...... 0 ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE. IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. S9116 (a) (1.1) 0)). For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)l. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stiD applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. S9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)).Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. . REV-l!oa EX> (6-98) .. COMMONV\lEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Emma C. Hornberger FILE NUMBER 2106 00783 Include the proceeds of ltigation and the date the proceeds were received by the estate. AI property jolntty.owned with right of survivorship must be dlscloled on Schedule F. ITEM NUMBER DESCRIPTION Checking account at Members 1 st FCU, Aa:ount 201043-11 2 Savings account at Members 1st FCU, Account 201043-00 3 Invesbnent Savings account at Members 1st FCU, Account 201043-05 4 CD at Members 1st FCU,Account 201043-41 5 CD at Members 1st FCU, Aa:ount 201043-50 6 CD at Members 1st FCU, Account 201043-51 7 CD at Members 1st FCU, Account 201043-.52 VALUE AT DATE OF DEATH 7,653.33 27.28 8 Cash on hand 58,570.23 67,139.74 38,224.55 97,759.93 39,046.06 0.00 9 Refund from nursing care facility for days paid for in advance but not needed 10 Federal tax refund on individual account 305.00 30.00 11 All banking was \Wh Members 1st Federal Credit Union, 5000 Louise Drive, Mechanicsburg, PA 17055 12 Please note that the first 3 accounts listed had the executor as joint O\M1er as the executor formerly had Power of Attorney and handled banking matters. Executor has renounced all rights to these jointly held accounts. TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 308,756.12 . REV-151t EX+ (1.2-99)* .COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Emma C. Hornberger FILE NUMBER 210600783 Debts of decedent must be reported on Schedule L ITEM NUMBER A. AMOUNT B. 1. DESCRIPTION 1. FUNERAL EXPENSES: Cremation and burial arrangements- Michael Shcblis Funeral Home, Marysville, PA Headstone- Frank Snyder and Son, Duncannon, PA 1,436.00 2,088.00 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Ronald P. Sieg Social Security Number(s)/EIN Number of Personal Representative(s) 208-38-6052 Street Address 3647 Derry Street City Harrisburg State PA Zip 17111 Year(s) Commission Paid: 2006 500.00 2. Attorney Fees 470.00 3. Family Exemption: (If decedenfs address is noIlhe same as clainanfs. attach explanation) Claimant Street Address 0.00 City State . Zip Relationship of Claimant to Decedent 4. Probate Fees 414.00 5. Accountant's Fees 0.00 6. Tax Retum Preparer's Fees 200.00 7. Cumberland Law Journal- Legal Advertisement The Pabiot News- Legal Advertisement Out of Pocket expenses of Executor as of 5/23/07 for administrative related activities. Re-paid on 5/23 75.00 181.59 198.43 5,563.02 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1512a+ (12-03) *' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABIUTlES, & UENS ~ COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ALE NUMBER Emma C. Hornberger 210600783 Report debts Incumd by the decedent prior to death which remained unpaid as of the date of death. Including urnlmbursed medlc:aI'xpenHS. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NeighborCare Pharmacy Services- Prescriptions not covered by insurance 341.01 2 Dr. Rosboschil- podiatrist 37.64 3 Philhaven Hospital- Expenses not covered by insurance 67.55 4 Manor Care of Camp Hill- co-pays for past medical services 520.00 5 PA Dept of Revenue for individual tax return 60.00 TOTAL (Also enter on line 10, Recapitulation) S (If more space is needed, insert additional sheets of the same size) 1,026.20 ~-154'J EX+ (9-00) *' SCHEDULE J BENEFICIARIES . .. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE Of Emma C, Hornberger FILE NUMBER 2106 00783 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERlY Do Not lilt Trustee(I) OF ESTATE I TAXABLE DISTRIBUTIONS ~ncIude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Harry H. Sieg, Jr. 30 North 15th Street Camp Hill, PA 17011 Nephew one third 2 Donald C. Sieg 34 Junction Road, Dillsburg, PA 17019 Nephew one third 3 Ronald P. Sieg 3647 Derry Street, Harrisburg, PA 17111 Nephew one third ENTER DOLlAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET n NON-TAXABLE DISTRIBUTIONS: A. SPOUSAl DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAl DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed. insert additional sheets of the same size) . . C0r)10NWEALTH OF PENNSYLVANIA DEP:~MEN~ OF REVENUE BUREA~ OF INDIVIDUAL TAXES D~PT. 280601 HARRISBURG. PA 11128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SIEG RONALD P 3647 DERRY ST HARRISBURG, PA 17111 -------- fold ESTATE INFORMATION: SSN: 183-12-3890 FILE NUMBER: 2106-0783 DECEDENT NAME: HORNBERGER EMMA C DA TE OF PAYMENT: 11/21/2006 POSTMARK DATE: 11/21/2006 COUNTY: CUMBERLAND DATE OF DEATH: 08/27/2006 NO. CD 007461 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $43,165.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK#107 SEAL INITIALS: JA RECEIVED BY: T AXPA YER $43,165.00 GLENDA FARNER STRASBAUGH REGISTER OF WILLS CERTIFICATES OF DEPOSIT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner 201043-51 04/01/2006*** $97,463.49 $296.44 $97,759.93 None 201043 -52 07/2112006**** $38,901.13 $144.93 $39,046.06 None *Established by transfer of funds from 201043-05 **Established by transfer of funds from certificate 201043-44. originally established 1/19/01 ***Established by transfer of funds from certificate 20104347, originally established 04/01/03 -Established by transfer of funds from certificate 20104349, originally established 07/21/06 Estate of: EMMA HORNBERGER Date of Death: August 27,2006 Social Security Number: 183-12-3890 ;Q;ERS 1ST FEDERAL CREDIT UNION . ~ ;f /t1z:0 D iseA. Wolfe Insurance Services Su rvisor November 27, 2006 tv MEMBERS 1st FEDERAL CREDIT UNION CORRECTION REGULAR SAVINGS ACCOUNT: AccountNumb~/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Int~est to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner Date Joint Ownership Established INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner Date Joint Ownership Established CERTIFICATES OF DEPOSIT: Account NumberlSuffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner 201043-00 01/1212001 $27.28 $.00 $27.28 Ronald Sieg 01/1212001 201043-11 01/1212001 $7.652.34 $.99 $7.653.33 Ronald Sieg 01/1212001 201043-05 01/19/2001 $58.453.70 $116.53 $58.570.23 Ronald Sieg 01/19/2001 201043-41 01/1312005* $66.927.11 $212.63 $67.139.74 None 201043 -50 07/19/2005** $38.117.84 $106.71 $38.224.55 None ./ Michael J. Shalonis Funeral Home 206 Maple Avenue Marysville, Pennsylvania 17053 Fax (717)-957-2077 Michael J. Shalonis, Owner Phone (717) 957-3451 We Care About Service To You ~~9~ (/V\ 9J,,'~b Monday, September 11,2006 Mr. Ronald P. Sieg 3647 Derry Street Harrisburg, P A 17111 Dear Mr ..Sie.g,- . Thank you for selecting our funeral home to provide services for your family during your time of bereavement. I hope that you found our services, so far, to be of the highest standards that we always try to achieve. The following is a summary of the service charges as previously explained and provided in written fonn on the services for: E~C.HORNBERGER TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT Memorial Folders 30 $ included Temporary Grave Marker $ included Cremation Urn White Marble Urn $ included SPECIAL SERVICES Direct cremation $ 1225.00 TOTAL SPECIAL CHARGES $1,225.00 CASH ADVANCES Cemetery Charges $ 250.00 Certified Copies of Death Certificate 6 $ 36 Flowers $ included Cumberland Co. Cremation Pennit $ 25.00 TOTAL FUNERAL CONTRACT LESS: Credits granted Discount allowed $311.00 $1,536.00 $100.00 $100.00 BALANCE DUE $1,436.00 ~____}!~ are an)'~uesti~~ or ~!lceE'!_~tn~n \IO~s~~red'J)I~ call me. o _,_ _ ~,_ _. ~_~. .'_ ~._____., _~_"'_ Sincerely, ~ Michael J. Shalonis Owner Michael J. Shalonis Funeral Home 206 Maple Avenue Marysville, Pennsylvania 17053 Fax (717)-957-2077 Michael J. Shalonis, Owner Phone (717) 957-3451 We Care About Service To You Tuesday, September 12, 2006 Mr. Ronald P. Sieg 364 7 Derry Street Harrisburg, PA 17111 Dear Mr. Sieg, Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form and herein indicated as PAID-IN-FULL. Emma C. Homberaer SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED LESS: Credits granted LESS: TmalPa~enffi CURRENT BALANCE $1,536.00 100.00 1,436.00 $0.00 Credits Granted: $100.00 Discount allowed If there are any questions or concerns that remain unanswered, please call me. Sincerely, /JiJ.-.v Michael J. Shalonis Owner 'i";':TT;~' ... .-"----------..,..", .....-.-.. ............... .:.~~~I . 11 P^ 11821H5H , 717-834-9289 (ji.'Panlt Snyds'P & Son 4X/ N. High Street Duncannon, Pa.17020 I Date.. ...~ 5;...L... 1. 6.... ..~o.Q.' ..... This .Agreement, between FRANK SNYDER it SON, the SRi ~ Rl\ and u ~o~u. S~ ~:.S.. u..... u u --......-:0 Address .. .3.6_~.l. _.. Il.ex J"..1-. .st -...... .I:l.o..~~_'s.b).l~.. -. Pa...... --'-'.\\ \.. -- -, the BUIKIi. , . FRANK SNYDER &: SO~ agrees to fomish and erect, on foundation provided by -........... . . . . .. .. . "\VITNESSETH. . . ." The enera1 in "" ~Q.~"'. h~:t... .~.l".cUI.4...... - ~y. S a.". . .. . . . .. _ - - ... . . . . .. . . - .. .." ...... - ... .. - .. .. .. - .. - -,. .. . ... dimensions and inscriptiDn being; GRANITE BRONZE ... MARBLE /-Ie l' t\ b~ ~se f" f" MfV\.~ L~~ rQI'C e C'~""hQ,",~ l-- ~ ~ e~~ ~Ov <<8 1(,,'1 Aprt"\ \S- 'f I. A""5 1..7 J..O(J' 0 cT. J,Cl J..f)(, I The material and craftsmsrmohip to be of Dnest quality. Completion within ...'-... _ _ . .. .. . weeks. subject to strikes and contingencies beyond our control This order is not subject to cancellation. And in consideration of the faithful performance of the foregoing, .""........... _ _ .. .... . .. . .. . . . . ~.._" _. . _ _ " _.. ".", agrees to pa)r to the order of FRAI'\T]{ Sl\tyDER &: SON" the smn of $.. ~J' 0.. 6! &>~ _. -CI as follows: _"" ~ _ _ _ .. .. .. _ _ _ .. .. .. .. .. .. _ .. _ . . . . - - . . . .. - - . .. .. .. - - - - .. - .. .. - .. .. - .. .. .. - - - .. .. .. .. - . ... Deposit Received: $... ./:)- Q .o.G! ... C-' .c, .. .. .. .. _ . ... No verbal agreements:o not inclnded in this con~ shall be binding upon the SRT.1 .Rll -The-..su.perlntendent or se.non ' of the cemetery, where said mouc.u.uem; ~50J~ or maiker may be located, is herebY ~ aud instructed to permit said seller" agents:o employees, or assigns,. to enter and n:move the same at any time after default by the buyer in paying the above stated sum, or 3llY installation thereof. FRAJ.'\"1C SNYDER & SON ............... -. ---.. _.. -.. - -............ - (Buyer} .:::! ~../.._ o-,..L, It .lJ .... (Seller) Future lettering is not included. ~T.,-r Dc~b\-€. sl,',riT IEt~Se I~'(,\ ~\c..c~ 3 '-0 )t i - 0 j. I..t, /3 - 'Yo i... 'I ,.. 0- 6 FDir,V'd(4..+" c.~ II J." '>, /6 i, S_.Q V' ~ '\ C:; -i D V Q... I) 0 fJcP. fJC : Frank Snyder 10 SaInt .JoIms DI'. I>imcaJmaa. P^ 17020-9569 P JG-g ~ ltJs i 0 1 ~s { () b c~ lO \ (Y\~ 10 110 It> 6 INVOICE I DATE I 9/30/2006 Diane G. Radcliff, Esquire 3448 Trindle Road Camp Hill, PA 17011 I TO: Ronald Seig Estate of Emma Hornberger 3647 Derry Street Harrisburg, PA 17111 AMOUNT DUE $150.00 ~-,_..__.._,..,.- ,--.-~'~-- .,--.... ,,_.'---'-~-- DATE DESCRIPTION HOURS AMOUNT BALANCE 08/31/2006 Balance forward 0.00 09/0112006 9.1.06 client consult 0.75 150.00 150.00 --- . ....-. -- CURRENT 1-30 DAYS PAST 31-60 DAYS PAST 61-90 DAYS PAST OVER 90 DAYS AMOUNT DUE DUE DUE DUE PAST DUE 150.00 0.00 0.00 0.00 0.00 $150.00 TERMS: NET 30 DAYS: 1.5% PER MONTH SERVICE CHARGE ON UNPAID BALANCE AFTER 30 DA YS. (18% APR). VISA AND MASTERCARD ARE ACCEPTED. -P~ l(y,l~} c~ l \ L INVOICE I DATE I 12/J/2006 Diane G. Radcliff: Esquire 3448 Trindle Road Camp Hill, PA 17011 I TO: Ronald Seig Estate of Emma Hornberger 3647 Deny Street Harrisburg, PA 17111 I I AMOUNT DUE $320.00 DATE DESCRIPTION HOURS AMOUNT BALANCE 10/31/2006 Balance forward 0.00 1112012006 11.20.06 client consult 1 200.00 200.00 11/29/2006 11.29.06 prepare Receipt and Release (3) 0.4 80.00 280.00 11/2912006 11.29.06 Jetter to client 0.2 40.00 320.00 .- . ---- -- -- --, ....- CURRENT 1-30 DAYS PAST 31-60 DAYS PAST 61-90 DAYS PAST OVER 90 DAYS AMOUNT DUE DUE DUE DUE PAST DUE 0.00 320.00 0.00 0.00 0.00 $320.00 TERMS: NET 30 DAYS: 1.5% PER MONTH SERVICE CHARGE ON UNPAID BALANCE AFTER 30 DAYS. (18% APR). VISA AND MASTERCARD ARE ACCEPTED. RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Receipt Date: Receipt Time: Receipt No.: C9{OS~20~ 5: 8:4 1045584 HORNBERGER EMMA C Estate File No. : Paid By Remarks: 2006-00783 RONALD P SIEG JA ------------------------ Receipt Distribution ------------------------ - -- Fee/Tax De-sc:ript-ibh- - -------paymen1.--mffounc - ----payee--wame-- -------.,- ----- PETITION LTRS TEST 360.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D Cash ------~i1..06~ Total Received......... ~i~ ~ ~ ~ p-o.-..& ~ ~ I~ ~ (j'V\ Il \''1(Ob Diane G. Radcliff, Esquire 3448 Trindle Road Camp Hill, P A 17011 INVOICE I DATE I 4/1/2007 I TO: Ronald Sieg Estate of Emma Hornberger 3647 Derry Street Harrisburg, P A 17111 AMOUNT DUE $200.00 DATE DESCRIPTION HOURS AMOUNT BALANCE 02/28/2007 Balance forward 0.00 03/27/2007 3.27.07 prepare Fiduciary Tax Returns (Pa and I 200.00 200.00 Federal) C f- )2P l( Is -/0/ -- -- --- -- -- -- - - I--- CURRENT 1-30 DAYS PAST 31-60 DAYS PAST 61-90 DAYS PAST OVER 90 DAYS AMOUNT DUE DUE DUE DUE PAST DUE 0.00 200.00 0.00 0.00 0.00 $200.00 TERMS: NET 30 DAYS: 1.5% PER MONTH SERVICE CHARGE ON UNPAID BALANCE AFTER 30 DAYS. (18% APR). VISA AND MASTERCARD ARE ACCEPTED. ./ PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA 55. COUNTY OF CUMBERLAND Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, aJegal periodical-published in-the.Borough ofCarlisleinthe County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, V1Z: September 22 & 29, and October 6, 2006 Affiant further deposes that he is authorized to verify this Statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. o AND SUBSCRIBED before me this day of October. 2006 Honabelger. Emma C., dee.d. Late of Camp Hill. Executor: Ronald P. Sieg. 3647 Derry Street. Harrisburg, PA 1711l. Attorney: None. L~L.'~N .'" ...""..,..."~.,,,.,.,,.,.,,,,.~...... " --,....'..,,"'..) ht(.J.,~Ar~~/\L. .'3Ei~.L ~; LOr; F. SrNDEfi, Notary P!..lhHc C~,. h.+'~ 80w: Cumbet;t,nd County / THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin} ss Joseph A. Dennison, being duly sworn according to law, deposes and says: lbat he is the Assistant Controller of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg, County of Dauphin, State ofPennsy1vania, owner and publisher of The Patriot- News and The Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market Street, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were es~~!i~he~March 4~ 185~,_ and~S_~~lia~ 1-2.49. respectiy~lYJUd..AlLhaY-e-heeJLcontinuously published eVeL_~ since; lbat the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sundayl Metro editions which appeared in the 29th day(s) of September and the 6th and 13th day(s) of October 2006. That neither he nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book uM", Volume 14, Page 317. PUBLICATION COPY :~d~ s,,;.;~.~.~.#~~~;:~.~;;;,;:~~~.;.:~.."'" COMMONWEAlTH OF PENNSYLVANIA NoIariaI Seal Teny L RusseU. tiotarY Public City Of Harrisburg. . CoIp)' . . June~2910 . f Nota.:._~e~ /. ~~~4~ PUBLIC ;iwl'l=-'T.-'''~~JftCI C, H....... ..r .:;, . ./~tarY have been grant- ~'tqfheundetSlOMd Executor of fl1e 85- tate of Emma C. Homberver, late of ~ H.m,Cumberland County, Penn- $Y)ycJn~~.~I..' an AUGUSt 71, 2lI06. ~UPerloltl tiMnv'clalm's CIOCIlnst fl1e es- tate are, requeshtd to make suc:hc;lalm$ lbOwn bJthe: Executor. All PltI"SOI'lS In- -fed to tile. ~t are l'eClUesfed to m.c:tkePGYmel1tWlthout delay to the Ex- eeytorR'dJk11d P. SJeg, 3647 Derry Str'eet, H~rl'lsbtJnI, Po 17111. ESTATE OF EMMA HORNBERGER C/O RON SIEG 3647 DERRY STREET HARRISBURG, P A. 17111 Expenses of the Executor through 5/23/07 These notes list the out-of-pocket expenses of the Executor through 5/23/07. Executor was re-imbursed for these expenses on 5123/07 via check 122 from the estate account. Expenses total $198.43. In addition to these expenses, Executor was paid 8 fee of $500.00 (check 106 on 11/14/06) as compensation for the time spent in settling estate matters in 2006. This was shown on federal, state and local tax returns for 2006. Executor will not be paid any additional compensation for any time in 2007. However, Executor will be re-imbursed for any further out-of-pocket expenses. I In addition, Executor was re-imbursed via check 105 on 11/14/06 for the $414.00 of probate costs which were paid out-of pocket. I I Mileage is at 44.5 cents per mile- IRS rate. My Mileage Date stamps Mileage Expense OtherExp For 8/28/06 22.00 9.79 Meeting with Mike Shalonis, Funeral Director, and side trip to cemetary, both in Marysville, to make burial arrangements. 8/28/06 22.00 9.79 Meeting at cemetary with Mr. Dawn to verify locaton of burial plot and burial plans. 9/1/06 45.00 20.03 Trips to Emma's lawyer, Diane Radcliff, in Camp Hill, then Members 1st in Camp Hill, then the courthouse in Carlisle. 9/5/06 44.00 19.58 To courthouse in Carlisle for short certificates, letters testamentary. Fee at courthouse was $414.00 which I paid in cash. I was reimbursed via. check 105 on 11/14 so this expense is not in the total below. 9/6/06 12.00 5.34 To AAA on Progress Ave to get renunciations notarized then to Members 1 st on Union Deposit Rd to set up new bank account for the estate I 9/8/06 40.00 17.8 Meeting with Frank Snyder in Duncannon to order headstone. I 9/11/06 1.17 Mailed bill payment to Manor Care Phannacy Services. Mailed short certificate, death certificate, and letter to HR dept of UGI to stop health coverage, etc. Mailed final payment to Mike Shalonis for headstone. I I I 9/12/06 1.56 Mailed notices of administration to Donnie, Hafner, Louella, and a certification of this to the courthouse. I I I 9/12/06 5.00 2.23 18.02 Trip to post office for stamps, then to Giant for supplies !(envelopes and folders). Receipts attached for $7.80 and 10.22 for total of $18.02. 10/24/06 9.00 4 To Members 1 st on Derry St to deposit check and cash to Emma's account. 10/27/06 0.39 Mailed some fonns to Dept of Revenue. 11/8/06 9.00 4 To Members 1st on Deny St to get copy of a missing monthly statement. 11/8106 0.39 Mailed bill paYment to NeighborCare Pharmacy. 11/20/06 16.00 7.12 Meeting with attorney in Camp Hill. I 11/21/06 44.00 19.58 Trip to courthouse to pay estimated estate tax. 11/30/06 0.39 Mailed bill payment to Dr. Rosboschil. 12/1/06 16.00 7.12 To Camp Hill for meeting with lawyer. 1/4/07 0.78 Mailed bill paYments to two locations. 1/10/07 0.39 Mailed one bill payment. 3/15/07 9.00 4 To Members 1st on Derry 51 for corrected 1099 R's. 3/21/07 16.00 7.12 To attorney Radcliffs office in Camp Hill to deliver 1099Rs. 3/27/07 16.00 7.12 To attorney Radcliff's office to pick up estate tax returns. 4/14/07 12.00 5.34 1.8 Trip to Mernbe~s 1st then Derry St post office to mail tax returns. Receipt for postage for tax returns is attached. 5/16/07 9.00 4 To Members 1st to deposit tax refund. 5/23/07 44.00 19.58 To courthouse in Carlisle to file estate return. Subtotals 5.07 390.00 173.54 19.82 Postage 5.07 Mileage 173.54 Other 19.82 Total 198.43 This was repaid to executor on 5/23107 by check 122. ~ .~ G 00 Quality.Selection. Savings. Ewry Day. ~~. ..........e-....,... Visit us on the Internet www.GiaritFoodStores.com Visit us on the Internet www.GiantFoodStore8.co~ My goal is to ensure your satisfaction every time you shop with us. If there is anything more I can do to improve your experience please call or write. Regan Fisher, Store Manager Gi ant Food Store #304 4211 Union Deposit Road Harrisburg, PA 17111 Store Telephone: (717) 920-0437 Pharmacy Telephone: (717) 920-1323 09/12/06 1:03PM My 90a1 i8 to ensure your satisfaction every tiRe YOU shop with us. If there is anything _ore 1 can do to iRProve your experience please call or write. Regan Fisher, store Menager Glent Food store 1304 ~211 Unton Deposit Road Harrisbur9, PA 11111 (111) 920-0431 (111) 920-1323 Store Telephone: PharRaCy Telephone: 09/12/061:06PM 48001553607 2.45 T 7.19 T QO.~./ 1. 1.00 1.12 1.06 1.00 1.12 1.06 1.08 1.06 .50 .00 THANK YOU TP FLGHT ENVELO STPLS FILE lOPK T AX PAID nuTOTAL CASH CASH CASH CASH CASH CASH CASH CASH CASH CASH CHANGE TOTAL NUMBER OF ITEMS SOLD: 2 9/12/06 1:06 PM 0304 81 0099 872263 NP 1.80 N .00 C 1,8r It.V .20 POSTAGE STAMPS TAX PAID ....TOTAL CASH CHANGE TOTAL NUMBER OF ITEMS SOLD = 0 9/12/06 1 :07 PH 0304 83 0083 812263 *****~******************************** Stop by the Custo~er Service Desk to sign UP for your own BONUSCARO. **********1*************************** I'~ glad yOU shopped here todaH. Your Cashier -- EASV-SCAN QUALITY. SELECTION. OPEN 2~ HOURS SA\llt.1t.:~ I:"C:DY~ . a=tlI:DV ft6y.._. ... ~~ 6'8";"SS' o 0 " --i 11 ::J: 11 ::I: " " C" ~ ::T at I>> 0 H o _. ::I> H o -. ::I> H .... - ::I: CD, ~:::: , ClO 0... I>>CD- ..... (I) ,~ (J) .'A) CD - , f-I CDO ....... :0> 'Ooe ::J ::T 0.. ~ (J) U> (J) ~ (I) COU)A) U) 01.. r ~~ .... (I) - "'. 0.,0, co C 0......... i 0"''''' c: or+> ....... -1 -fo- r+- I CD tT CD I U) I U) CD I C -0 ....... C :T::J U) fI} '<: oo~ oom OOI'T1 -0 ..... ~ ::JfI) ............ CD,..,....... 0 eo V N- " N-C " !"C;~ ~ 8 --i 0.. Qt AO "CDI~ t: <: -I>> <: at:o <: :x: :T fI) - 0 CD H t/)t;} .... cot;} H CD :x: 0 ...... ;)> Qt CD g - ::ro "0 (I) eo CD .. CD H ::J :0 0 ::J -fo CD ::J -~(t) " " > :0 "'0 0 .....-0 .co. ::I> ;)> H .,.... .... ~~. 01 " .co. U)U) '<: - U> ..... ...... ...... ;)> - ...... a:r ::a: (") o co ::J ..... iiI::J ...... ...... ~~......ii~ c: eel>> Ol Qt ~ c;) C ...... ...... ....... 00 (/) 01- 0') ..... o U) ~ ~ U> QI o ClO...., Q ;)> r+ -foJ W " 00 U> tv OU)- -...........- :0 0 01>>0 U> 01>>r+U) UI ..-+ DI II) ~o..... > :3 .:J:::J ::JtTO- UI '<-G ................" CD r+ CD 0 ID U1 0 (.0) CD m -; '<:ID(/) o -co :0 100U1::J:O 01Dr+ m U) 003 G ~l~i~ (") c: 0.. I>> - "....... "CO 0 I a -~ U)fI) ~.~.~ ......0 '<: (") "0 CD "0 ::T ......0 -:J: '< tT(I)U) .....-+00 o .-+ 'U W < CI I ::TO"O CD .-+ U1 QI U)<OJ 00 a ~. --::J 0"0 ....... 0 ::JOe... 0001 0 OJ Q)Q) I U)- A (/)u)"O >,..-0 (/) 0 ~QtOQJ ;1 ~ 0(1) CD "'- " II II A ::J'-+ ICD::J- I II II II " ." -QI C. U) .. etll et etll et etll ~ ., _. 0 ,<co 00 ::T Otv 011 0 011 0 011 0 --::J 00 . (I) " II II " (,)G1 U) U alO (.)11 Go) (.)11 Co) 0')11 en (1;'- " WO U>" ..0 ..011 CD t.) 11 t.) :x II II II / .J ~~ ~ N. hborCare'" . eIQ ~ '3419 CON~rl'lfil.Services . YORK, PA 17403 NCPDP#: 3972634- E: 888-565-6708 HOURS: M-F 8:30 AM - 5:00 PM . . 08/26/06 R6141724 CHARGE 00182044810 OTC 08/26/06 R6141725 CHARGE oo78150n01 OTe 08/26/06 R6141726 CHARGE 00904546080 OTe 08/26/06 R6141727 CHARGE 00182014110 OTC BILL FOR SERVICES PAGE: 3 of 3 CUSTOMER NAME BILLING DATE ACCOUNT NO. EMMA HORNBERGER 08/31/06 19-1947 FACILITY PRIMARY PHYSICIAN MCHS CAMP HILL #19 BINDER, ERIC ',' . ASPIRIN EC (SUB:ECOTRIN) ** 325MG TABLET (RP:ECOTRIN) DAYS SUPPLY: 30 LORATADINE ** 10HG TABLET (RP:CLARITIN) DAYS SUPPLY: 30 OYST-CAL-D**(OYSTER SHELL CALCIUM W/VIT.D) 500MG/200IU TABLET (RP:OS-CAL 500+0) DAYS SUPPLY: 30 ACETAMINOPHEN ** (GENEBS) 325MG TABLET (RP: TYLENOL ****) DAYS SUPPLY: 30 BINDER 30 BINDER 30 34.69 BINDER 60 5.29 BINDER 180 6.41 Our re it tane change is ref an on- ine eh addres~ to th b (k. Oa.B r:\~1I']I~~1~~1'.q :l-\'~I',I~"." RETUR~ _'Ulll'J."i.",I~n,,"".;mr:.u[......;r:'~ne}__"I:l'I'.tiI:r:'l:[e}:t...... 0.00 [-178.541 0.00-1- 328.46 J 0.00 $328.46 0.00 DAYS OUTSTANDING AGED BALANCE I................. STATEMENT OF PHARMACY CHARGES ~ NeigtlborCareTM t: Pharma~ Services . 3419 CONCORD RD. YORK, PA 17403 NCPDP#: 3972634 IF PAYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW. CHECK CARD USING FOR PAYMENT !: I 0 . 0 ._.....:m.__.... 0 ""'~ERj()'\N 0 . ~J, . .... MASTERCARD DISCOVER U,A VISA S<?!1ESS AMERICAN EXPRESS CARD NUMBER AMOUNT II D Please check box if below address is incorrect or insurance information has changed. and indicate change(s) on reverse side. ACCOUNT NO. 19-1947 . . SIGNATURE AMOUNT DUE . . " I CARDHOLDER NAME TEMP-RETURN SERVICE REQUESTED PHONE: 888-565-6708 HOURS: M-F 8:30 AM - 5:00 PM 09120/06 3071J-1VYOVRKK1000703 See Last Page PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT MAKE CHECKS PAYABLE TO: 652546A 11111111111111111111111111111111111111111111111111111111111111 NEIGHBORCARE PHARMACY SERVICES INC BOX 8900 ' . PHILADB.PHIA, PA 19175-0001 0303 ADDRESSEE: 11111111111111111111111111111111111111111111111111111111111111 EMMA HORNBERGER C/O RONALD SIEG 3647 DERRY STREET HARRISBURG, PA 17111-1920 ~ NeighborCareTM ~ PharI!1Q..l;Y Services . 3419 CONCORU KD. YORK, PA 17403 NCPDP#: 3972634 HONE: 888-565-6708 HOURS: M-F 8:30 AM - 5:00 PM BILL FOR SERVICES PAGE: 1 of 1 CUSTOMER NAME BILLING DATE ACCOUNT NO. EMMA HORNBERGER 10131/06 19-1947 FACILITY PRIMARY PHYSICIAN MCHS CAMP HILL #19 BINDER, ERIC DATE I RX # I TRANS I NDC I CAT I DESCRIPTION I PHYSICIAN I QTY. I $ AMOUNT 08/15/06 R6159245 CHARGE 59011010025 RX Medicare D Plan: Aetna Medicare OXYCONTIN (OXYCODONE) 10HG TABLET SA DAYS SUPPLY: 1 BINDER 2 12.55 ~J G~ \; ~ It/'(Ob 1, 2 . S; S THANK OU FOR ALLOWI G NEIGHBOR E PROVIDE YOUR PHARMACY NEEDS. HE TOTAL UE IS YOUR BE PAID BY ERSO AL CHECK, MONEY ORDER, VISA, MAS ERCARD, Iseo ER, HE FAVOR 0 A PR MPT PAYMENT IS APPRECIATED. Our r change an on- addres has chang d. If you include the tear-off stub wi the stub d no addi tional action on your part i ce and/or 0 st is returned wi th your payment, reflected on th stub below. Thank you. [""........""'......"'1' 0.00 I RETURNS 'l~l..l-'"'lIt'1l~~II'"~.illlr..'l[ltaItTr..1i~~_ll:t'I'..It:r..,:{ct~.... 0.00 I O.OOJ 0.00 L 12.55 I TAX 0.00 I ,elt.'I.IIIJ 0.00 $12.55 DAYS OUTSTANDING AGED BALANCE ,................. STATEMENT Tll.fll'HONC (7 I 7 I 657-338D EDWARD A. RDSBDSCH'L. O. P. M. 1M5 SIR THOMAS COURT. SUITE I HARRI.URD. PAt '71 D9 c ~ 108 \ \ \ )c \ 06 11/26/06 Ronald Sieg 3647 Derry Street Harrisburg, PA 17111 roll PROF_'ONAL SEIN'CU. f 0 0 t s e r v ice 0 7 /1 0 / 0 6 for Emma Hornberger Our office insurance. is $37.64. payment. doesn't participate with Aetna Amount owed to our office Thank you for your prompt I-;~ ~:L2 ~ ~ ~~ .. ilhlJv'tii Pn.wdIIg,,~"'''''' tEo ..0 ~o Account: Hornberger, Emma C. (213577) Program: Consult-Older Adult Admit Date: 0310712006 DisdIarge Date: CKdll Statement Date: Due Date: February 7, 2007 February 22, 2007 Please Pay This Amount: Amount Enclosed: S so.. Ezp Date: Sipdure: 2415-145 PraleS N ut.t: DPlease check this box if your address or insurance has chanaed and then cornolete the form on the back of this RIa RONALD SIEG, EXECUTOR 3647 DERRY STREET HARRISBURG, P A 17111 Payment Arrangement Exists? No :~ : ~ ~ ie, ::~ :_:::r~..:~:~~2;::~ :::~; <~ : ~ ~I :- ! ':~:-.:~>~J::[~1~~~~t~~~ ----------------------------------------- - - - - - - - - - - ~ iieb;ch U;'; ;;d- Ret;.; y;; Portio. wi.. Voar Pay..... Botte. Portiea is for Voar Records.> ~_ ...j.w~ .iiiis p;,y,.1II"'" "*'. SIIJIPIU4/n .;M___ ~ . (lfytJIIlII'r ~f...JIlpIe IICCOIUfIS wilt ". ~,.........,.".....) Summary Statement of Services (Detail OD Revene Side) ACCOUDt: Hornberger, Emma C. (213577) ~ Due Date: Program: Consult-Older Adult Statement Date: Admit Date: 03/0712006 Previous Statement BalaDce: Discharge Date: Payments Received SiDce Last Statement: Total New Charges: Amount You Now Owe: February 22, 20071 February 7, 2007 $67.55 $67.55 SO.OO SO.OO The account balance for the services received is now due. All insurance activity, if any, has been processed and the remaining balance is due ftom you. If your balance is zero, please retain detail for your records. Services provided in the new calendar year may be subject to additional patient liability over and above the usual co-payment and co-insurance amount. Co-payments, co-insurance, deductibles and non-covered services will be your responsibility according to your health insurance coverage Please contact your insurance carrier with questions regarding deductible and co-insurance amount (5). Please remit the balance in full within fifteen (IS) days using the enclosed reply envelope. Our office accepts checks ~-aAd.credit-eards..-lf.yoo..are-unable to pay your balance.in-fUILor.needas5istancein understandiOg.yow:statement please contact our office at (717) 270-2413 or toll free at 1-800-932..0359, ext 2413 Monday - Friday 8:30AM - 4:00PM. Someone will be glad to assist you. Thank you for choosing Philhaven for your healthcare services. 0-59 .... ~.l..rl... ... . . ~~ PO Box 550 MtGretna, PA 17064; Phone (800) 932"()359 En 2413 or (717) 270-2413 .ZITitlVen Billing Office Hours: 8:30am - 4:00pm Monday through Friday ~...~-~ HCR-ManorCare ,'\ L ~. . , ..I 1. ! .I j'/j rq n : .; () ~-.:: i"~ C'; LJ :'.~, ;..< : -< '{ ,- i 1'1,:- :._} r-... j) f:'f :q:;' i i I,,,. t,l, :'1'1 ;... I ~'i J Fl ,I .. i'i L ,L ), _~ ~.~~;J'~~~~~_~.;::-~~~~ill~~'~_~~-~~.-=.~..~_-_~-~ _"'"- _'.T.~' __'-,~ ~ i'~; /.',! {\ )....J C~ /\ CJ .,',1 ,'! .'< ~ d~ 10 ~ \\l{ 2,~ G 1 } i\1 ,j f-'Iease k\?Wtll ! filS I"uruun With 'o'our f"clymene .-~-' _~-~ ~l";;_~~_~_.:.~_~_~ ~~w-!-_0-.J-~: ~!-.~ _.~. '__i<~!,"'~~~ i,~~-,~---1...1:: .:;- :) i/i ~.) " \:-::1 i,.) PAST DUE ,,^, ~_~~ [I t'.jT DL."::: ;,1 ;< .1 i.'! I (."j 1,,J ;,,'1 :.:.., ~', 1:':< >:' (j .j 0600212146 L PA-40 - 2006 Social Security NlMT1ber 183123890 Name(s) ElRma C Hornberger 12 PA Tax Uability. llultiply Une 11 by 3.07 percent (0.0307). 12 240 13 Total PA Tax Withheld. See the instructions. 13 0 14 Credit from your 2005 PA Income Tax return. 14 0 15 2006 Estimated Installment Payments. 15 1 iH) 16 2006 Extension Payment. 1b D 17 Nonresident Tax Withheld from your PASchedule(s) NRK-1. (Nonresidents only) 17 0 18 Total Estimated Payments and Credits. Add lines 14, 15, 16, and 17. ],tJ 180 Tax Forgiveness Credit. 19a Filing Status: 01 Unmarried or Separated 02 Married 03 Deceased 19a DO 19b Dependents, Part B, Line 2, PA Schedule SP 19b DO 20 Total Eligibility Income from Part C, Line 11, PA Schedule SP. 20 0 21 Tax Forgiveness Credit from Part 0, line 16, PA Schedule SP. 21 0 22 Resident Credit. Submit your PA Sdledule(s) G-SIG-l. and/or RK-l. 22 0 23 Total Other Credits. Submit your PA Schedule oc. 23 D 24 TOTAL PAYIIENTS and CREDITS. Add lines 13 and 18,21,22, and 23. 24 laD 2S TAX DUE. If line 12 is more than line 24, enter the difference here. 25 bO 26 Penalties and Interest. See the instructions. 26 0 If attaching form REV-1630, mark the box. N Z1 TOTAL PAYMENT. Add Lines 25 and 26. 27 60 28 OVERPAYMENT. If line 24 is more than the total of Line 12 and Line 26, enter 2a 0 the difference here. The total of Unes 29 through 35 must equal Une 28. 29 Refund - Amount of Line 28 you want as a check mailed to you. Refund 29 0 30 Credit - Amount of Line 28 you want as a credit to your 2007 estimated accot.I1t. 3D 0 31 Amount of Line 28 you want to donate to the Wild Resource Conservation Fund. 31 0 32 Amount of Une 28 you want to donate to the Military Family Relief Assistance Program. 32 D 33 Amount of line 28 c= to donate to the Governor Robert P. Casey Memorial 33 0 Organ and Tissue . Awareness Trust Fund. 34 Amount of Line 28 you want to donate to the Juvenile (Type 1) Diabetes Cure 34 D Research Fund. 35 Amount of Line 28 you want to donate to the Breast and Cervical Cancer 35 0 Research Fund. Your Signature I Spouse's SignaUe. if filing jointly 10* Firm ElN Preparer's SSNIPTIN Se1f-Prepared I Preparer's Name and Telephone Number I PAlA0412 llf14J06 Page 2 012 L Ob00212146 Db0021214b --.I RENUNCIATION To MEMBERS 1 Sl Federal Credit Union and The Register of Wills of Cumberland County, Pennsylvania Re: The Estate of Emma C Hornberger and Her Account 201043 at MEMBERS 1st Federal Credit Union I, Ronald P. Sieg hereby renounce all my rights and claims on the portion of the accounts that I held jointly with my aunt, Emma Hornberger, at MEMBERS lilt Federal Credit Union, account 201043. My name was on these accounts only because she had granted me Power of Attorney to handle her affairs if and when she became unable to handle matters by herself I understand that I am now legally entitled to the money in the accounts where I am shown as a joint owner. However, it was never her intention that any of the money in this account go to me other than as specifically prescnoed elsewhere in her Last Will and Testament. It is not my desire that I take this money even though I may legally do so. My desire is that this money goes into her Estate account along with all other money that now becomes part of her estate. 4~ day of _~ R~pj' Ronald P. Sieg. ~ ..2006. WITNESS my hand and seal this s~and~itbis JJ~ day of ~ ( ~ ~~/' Notary Public ..2006. \,UMMUNWt.AlTH Of PENNSYLVANIA CAROL l NOTARiAl SEAL susquehai.n~~Y'DNot.!'Y . Public My Commtssio,; ;~.:~ auphln County IooAfIff.S Nov. 9, 2008 RENUNCIATION In Re Estate of Emma C. Hornberger, deceased To the Executor of the Estate of Emma C. Hornberger and the Register of Wills of Cumberland County, Pennsylvania. I, Leah Louella Hummel, hereby renounce and renunciate all my right, title, interest, claims and distributions in and to the Estate of Emma C. Hornberger, including all right, interest, claim and distributions arising out of the said Estate and the Trust created for my benefit in the Last Will and Testament of Emma C. Hornberger dated June 25, 2001. I respectfully ask that the Estate be distributed to the alternate residuary beneficiaries provided for therein. WITNESS my hand and seal thi~ day Of~, 2006. /J ~ ~A"V;(~ ~ Leah LoueUa Hummel Subscribed ancl..~m to b;f~~ ~h~~ day ov~, 2006. ~ '~:"2.::',~~t.~~fEAlTH OF PENNSYLVANIA i r'~OTARIAL SE.AL ~ Sl .'. 111' lFR r!':~+~ry Public ~- :- '!'>;;'\;, CUf!1b~~t;nd County . -.! .L.:mgL~gRt_J~~_. .2C ~/; ~ Distributions of the Estate As of May 23, 2007, which is just before the 9 month deadline to resolve and pay the Inheritance tax, essentially all of the money from the estate has been distributed to the heirs. About $2328.11 remains in the account. This will be distributed in about 3 months after final tax bills, lawyer's fees and all other expenses are paid. The money was distributed through two partial distributions. Distribution 1 Check Ckdate Amt To 109 12/1/06 60,000.00 Donald Sieg 110 12/1/06 60,000.00 Hany Siegl 111 12/1106 60,000.00 Ronald Sieg Distribution 2 115 2/25/07 26,500.00 Hany Sieg 116 2/25/07 26,500.00 Donald Sieg 117 2/25/07 26,500.00 Ronald Sieg