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HomeMy WebLinkAbout06-05-07 REV-l500 EX + (6.00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128.0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT t- Z W C W o w c w .... ll&:SIIl c.> a: ~ wa.u .00 c.> fal a. cc DECEDENfS NAME (LAST. FIRST. AND MIDDLE INITIAL) BASSETT DATE OF DEATH (MM-DD-Year) KENNETH C. DATE OF BIRTH (MM-OQ.Year) OFFICIAL USE ONLY FILE NUMBER 21 -0 7 0 3 6 2 COuNi'YCOOE --VEAA- - - NUMaER- - SOCIAL SECURITY NUMBER o 7 4 - 1 4 - 8 783 THIS RETURN MUST BE FILED IN DUPUCATEWITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Retum (date 01 death prior 10 12.13.82) o 5. Federal Estate Tax Retum Required _ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Altach Sctl 0) i!ttHtS"SEC'I'JQH.US1'(sl'CQ*'t!'r'efi~'..f.''CORRESPQNPENeE!ARQfCQNftO!mt.TM.("'_l1OttSMQut;Di8E'DlRiCitiQ!:T~'i;)!ii1)b;ii NAME COMPLETE MAILING ADDRESS ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET FIRM NAME (If Applicable) IRWIN & McKNIGHT TELEPHONE NUMBER 717 249-2353 CARLISLE PA 17013 z o ~ ..J ;:) t- o: c:( o w a: z o ~ t- ;:) a. :i o o >< c:( t- (1) (2) '. (3) ( . (4) (5) 5,391.12 (6) (7) 03/12/2007 02/23/1914 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) [R] 1. Original Return o 4. Limited Estate [&] 6. Deoedent Died Testate (AllachcopyofWil) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale of death after 12.12-82) o 7. Decedent Maintained a Living Trust (AIlachcopyotTrusl) o 10. Spousal Poverty Credit (date of death between 12-31.91 and 1.1.95) .... z ~ z o a. III w a: a: o u 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointiy 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) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 0.00 X _ (15) 271,221.84 X .045 (16) 0.00 X .12 (17) 0.00 X .15 (18) (19) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable al sibling rate 18. Amounlof Line 14 taxable at collateral rate 19. Tax Due 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ,i. ;. e, FlS8 S!AN~AECffSe . :MAilH/iC':i( i ;v,',. \." " ". '.,' .' ;,;.<-t::;JW;~y1:j'f/;t#i0(Nt1; OFFICIAL USE ONLY (- I , ,~ '-- , ~ ,," (..11 (8) 279,540.37 5,973.92 2,344.61 (11) (12) (13) 8,318.53 271,221.84 (14) 271 ,221.84 'UO!ldOPB JO poolq Jiq JalllallM 'Iuapeoap alllllllM UOWWO:l U! lUaJBd auo ISBallB SBlI OllM IBnp!^!pu! U1'1 S1'1 'GO~6 UO!I:las Japun 'paU!lap S! BU!lq!s V '[(E' ~)('ll)9~~6~ 'S'd GLl "IoU S! sOu!lq!S S.IUepooap a4110 asn a41 JOI JO 01 SJalSUBJHO anl'll^ lau a41 uo pasodw! alBJ XllI a41 . '[(~)('ll)9~ ~6~ 'S'd GLl (G'~)9~ ~6~ 'S'd GL U! palOU SB Ideoxa '%9', S! s9!J'llP!lauaq reau!I s,luepa:>ep a4110 asn a41 JOI JO 01 SJalSUBJIIO anll:M leu a41 uo pasodw! alBJ X'lll a4.1. '[(G' ~)(B)9 ~ ~6~ 'S'd GLl %0 S! 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JO :ISaJaIU! .\JBUO!$la^aJ B U!BlaJ ':l 00 0 ........................................ ~awo:lu! Sl! JO paJJalSUBJI ,{jJadoJd a41 asn IIB4s 04M alBUB!sap 01146!J a41 U!BlaJ 'q 00 0 ........................................................................... :paJJaISUBJI,{jJadoJd alii 10 awo:lu! JO asn a41 U!BlaJ 'B ON sa A :PUB JalsuaJI e alfBW Iuapa:lep PIa . ~ S>I:>OlS 3lYI~dO~ddY 3Hl NI "X" NY ~NIOY1d AS SNOIlS3nO ~NIM0110:J 3Hl ~3MSN\f 3SV31d lN3!)lf 'S111M :/0 1:J31S/93H :OJ 8/qe;{ed >/aal./O a>/ew (8S) '300 30NV1VB a41 S! S!41 'Vg + 9 aUlllo IBlol a41 Jalu3 '8 (V5) 'anp X'lll a41 uo ISaJalU! a41 Jalu3 'V (g) '300 xn a41 S! S!1I1 'a:luaJa!JlP alii JalUa 'G aun UB41 JalB9JB S! f: aun + ~ aun II 'g (,) pun,aJ e JsanbaJ OJ O~ aun L aBed uo xoq 1I:Nt40 'lN3WA VdH3^O a41 Sl S!1I1 'a:luaJamp alii JalUa '8 aun + ~ aun UB41 JalBaJ6 S! G aunll " (8) (3 + a) .\JleUad/ls9J9lUI lelo1 €L'v6S' ~ ~ 00'0 00'0 .\Jleuad '3 IsaJalUI 'a a)QB:l!)dd'll J! ,\IIBuad/lSaJaIUI '8 9G'0~9 (l) (:) + 8 + V) SI!paJ:) (1'1101 SG'0~9 lUnOOS!a ':) sluaw,\ed JO!Jd '8 l!paJ:) ,(jJa^Od resnods 'V sluaw,\edfSl!paJ:) 'Z (6~ aun ~ aBBd) ana XBl '~ :s~!peJO pUB SlueW,(Bd XBJ. 96'17OG'G ~ (~) CLOH I V'd I 31SIlClV:::> dlZ 31V15 A110 A V M ::n:JOaS~NOl L SS31:100V 133l:1lS :sseJ eeKrwo s ue e~e PPV ~I o .\ P o REV-1508 EX + (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BASSETT FILE NUMBER KENNETH C. 21 07 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0362 ITEM NUMBER 1. DESCRIPTION FIRST FEDERAL OF BUCKS COUNTY ACCOUNT #317027679 VALUE AT DATE OF DEATH 5,391.12 TOTAL (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5.391 .12 REV-1509 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTL V-OWNED PROPERTY ESTATE OF BASSETT KENNETH C. FILE NUMBER 21 07 0362 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. BARBARA ANN BASSETT 155 PARKWAY DRIVE CARLISLE, PA 17013 DAUGHTER B c JOINTL y-oWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY 0/0 OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER, ATTACH DEED FOR JOINTL Y.HELD REAL ESTATE, VALUE OF ASSET INTEREST DECEDENrSINTEREST 1, A, 6/2006 PENNSYLVANIA STATE BANK 151,861.14 100. 151,861.14 #9150008017 MMG $154,861.14 DATE OF DEATH VAL LESS $3,000 YEARL Y (CALENDAR) DEDUCTION 2. A 6/2006 PENNSYLVANIA STATE BANK 4,384.09 100. 4,384.09 #9150008020 BONUS 50 3. A. 07/2006 AMERICAN HOME BANK 5,163.08 100. 5,163.08 CERTIFICATE OF DEPOSIT #290003177 4. A. 10/2006 AMERICAN HOME BANK 10,213.93 100. 10,213.93 CERTIFICATE OF DEPOSIT #290003412 5. A. 11/2006 AMERICAN HOME BANK 23,838.11 100. 23,838.11 CERTIFICATE OF DEPOSIT #290003522 6. A. 12/2006 AMERICAN HOME BANK 12,389.06 100. 12,389.06 CERTIFICATE OF DEPOSIT #290003566 7. A. 12/2006 AMERICAN HOME BANK 10,497.46 100. 10,497.46 CERTIFICATE OF DEPOSIT #290003567 8. A. 01/2007 AMERICAN HOME BANK - CERTIFICATE OF DEPOSIT 19,186.58 100. 19,186.58 #290003721 - $22,186.58 DATE OF DEATH VALUE LESS $3,000 YEARL Y (CALENDAR) DEDUCTION 9. A. 01/2007 AMERICAN HOME BANK 26,552.46 100. 26,552.46 CERTIFICATE OF DEPOSIT #290003722 10. A. 01/2007 AMERICAN HOME BANK 10,063.34 100. 10,063.34 CERTIFICATE OF DEPOSIT #290003742 TOTAL (Also enter on line 6, Recapitulation) $ 274.149.25 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BASSETT KENNETH SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS C. Debts of decedent must be reported on Schedule I. FILE NUMBER 21 07 0362 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hoffman-Roth Funeral Home 1,641.80 2. Thank You Memorium for Minister 150.00 3. Sally Beaver - Panist 50.00 4. Thank You Cards 10.58 5. Family Breakfast 31.92 6. Flowers for Memorial 68.90 7. Stamps 7.80 8. Pictures/Picture Mats 8.62 9. Reception Supplies 8.08 10. Reception 5.67 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attomey Fees IRWIN & McKNIGHT 3,250.00 3. Famity Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees REGISTER OF WILLS 79.00 5. Accountanfs Fees 6. Tax Return Prepare(s Fees PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER OF WILLS - FILING FEE 30.00 8. CUMBERLAND LAW JOURNAL - ESTATE NOTICE 75.00 9. THE SENTINEL - ESTATE NOTICE 144.29 10. NOTARY FEES 10.00 11. REGISTER OF WILLS - SHORT CERTIFICATE 4.00 TOTAL (Also enter on line 9, Recapitulation) $ 5.973.92 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (6-98) *' SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BASSETT KENNETH C. Include unreimbursed medical expenses. FILE NUMBER 21 07 0362 ITEM NUMBER DESCRIPTION 1. CIT/BANK - CREDIT CARD VALUE AT DATE OF DEATH 275.60 2. PA DEPARTMENT OF REVENUE - 2006 INCOME TAXES 224.00 3. UROLOGY OF CENTRAL PENNSYLVANIA - MEDICAL 10.00 4. AT&T MASTERCARD - CREDIT CARD 461.61 5. HOLY SPIRIT HOSPITAL - MEDICAL 1,042.00 6. WEST SHORE EMS - AMBULANCE 110.23 7. CARLISLE REGIONAL MEDICAL CENTER - MEDICAL 66.66 8. CONTINUING CARE RX - MEDICAL 154.51 TOTAL (Also enter on line 10, Recapitulation) $ (It more space is needed, insert additional sheets 01 the same size) 2.344.61 A"."'~ "'. ".. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER - ..-. ..--. r. ?1 n7 n~~? RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S} RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include OutriSht spousal distributions, and transfers under Sec. 9116 (a (1.2)] 1. BARBARA ANN BASSETT Lineal 155 PARKWAY DRIVE 1/2 REMAINDER CARLISLE, PA 17013 2. CHARLES KENNETH BASSETT Lineal 820 PHEASANT DRIVE, NORTH 1/2 REMAINDER CARLISLE, PA 17013 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 TAXIS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - 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) ~ .... ::tl i ~ 0 · ~ trl 5 tz:j ~ ::tl ~ ~ I , t'4 i. . 1Easlll1ill aub Qrtst~ttUnt OF KENNETH C. BASSETT I, KENNETH C. BASSETT, 71 Cobalt Ridge Drive, East, Levittown, Pennsylvania, being of sound and disposing mind declare this to be my Last Will and Testament hereby revoking all former Wills and Codicils at any time heretofore made by me. FIRST: I direct payment of all my just debts and funeral expenses as soon as convenient after my death. SECOND: All the rest, residue and remainder of my estate, real, personal and mixed, wheresoever situate, including that over which I have the power of appointment, or other disposition, I give, devise and bequeath to my wife, JOHANNA OSL BASSETTi provided, however, in the event she predeceases me or dies within thirty (30) days of my death, I give, devise and bequeath said residue to my children BARBARA ANN STILSON, 1280 Wandering Way, Harrisburg, Pennsylvania and CHARLES KENNETH BASSETT, 820 Pheasant Drive, Carlisle, Pennsylvania, in equal shares, per stirpes. TH I RD : In the event any beneficiary is under legal incapacity to receive their share at the time of distribution thereof, his or her share shall be held in trust by my Trustees hereinafter named to retain said share, invest, convert and reinvest the same without being restricted to what are known as legal invest- ments under the laws of the Commonwealth of Pennsylvania or any other jurisdiction then in effect, and to pay the net income therefrom annually or more frequently to or for the account of said beneficiary. Trustee at any time or times shall have the right to use all or any part of the principal from which any beneficiary is ~~ receiving income in the event of illness or emergency of any kind f ..,.. t': ~ .'- ~ , ~-~ :c -J 0 fIl f'" b~tI:l ~ g trj . !;;~ ~ 3 ~ o ~ x ~ t"'4 "l 'l . c tI:l ~ :Il - <; ~~..,.. ';"4 tI: ~ ~ .. ~ prices and upon such terms as he deems best without liability upon the purchaser to see to the application of the purchase price and free from any trust hereunder. FIFTH: In connection with the administration of my estate, I direct that any estate, inheritance, legacy, transfer, succession or similar duty or tax which shall become payable in respect to any property or interest, passing under this my Last Will and Testament, shall be paid out of the principal of my residuary estate as if it were a debt of my estate. SIXTH: I nominate, constitute and appoint my children, BARBARA and CHARLES as Co-Trustees hereunder. LASTLY: I nominate, constitute and appoint my wife, JOHANNA OSL BASSETT as Executrix hereunder. In the event she pre- deceases me or dies, renounces, resigns or for any other reason fails to act, I nominate, constitute and appoint my son, CHARLES, in her stead. In the event he should predecease me, die, renounce, resign or for any other reason fails to act, I nominate, constitute and appoint my daughter BARBARA to act in his stead. I direct that no Executor shall be required to enter security in any jurisdiction in which he or she may be required to act. this IN WITNESS WHEREOF, I have hereunto set my hand and seal /...5"d day of C~ 1985. -/~qtA't~d ~,4'<"l~4.I'<f ~~neth C. Bassett (SEAL) SIGNED, SEALED, PUBLISHED AND DECLARED by KENNETH C. BASSETT as and for his Last Will and Testament in the presence of us, who at his request and in his presence and in the presence of each 1] FIRST FEDERAL ot BUCKS COUNTY 118 Mill Street. Bristol, PA 19007-0032 215-788-3344. Fax 215-788-5144 www.firstfedbucks.com April 11, 2007 ~~~aw~~ ,-.. . H 1 -:- _ Irwin & McKnight Law Offices 60 West Pomfret Street Carlisle, PA 17013-3222 IRWIN & McKNIGHT RE: Estate of Kenneth C. Bassett, Deceased Date of Death: March 12, 2007 SS# 074-14-8783 Dear Mr. Roger B. Irwin, This letter is being sent in response to your correspondence dated, April 11, 2007, regarding the above-mentioned decedent. The following information is pertinent to the Estate: ACCOUNT ACCOUNT DATE OF INTEREST DATE OF DEATH OWNERSHIP NUMBER ORIGIN RATE BALANCE Kenneth Bassett 317027679 10/17/03 3.59% $5,391.12 Kenneth Bassett 307002578 9/13/94 CLOSED 11/17/06 $0 Johanna Os1 Bassett Kenneth Bassett 307023130 8/21/01 CLOSED 10/24/06 $0 Kenneth Bassett Johanna Osl Bassett 325000539 4/11/90 CLOSED 10/12/06 $0 Kenneth Bassett Johanna Osl Bassett 337001733 12/07/87 CLOSED 6/8/06 $0 Kenneth Bassett Johanna Osl Bassett 355000791 3/29/93 CLOSED 12/7/06 $0 I will retain the Authorized letter and Death Certificate on file at the Bristol Office. If I may be any further assistance, please feel free to contact me at 215-788-3344, Ext144. Crystal M. Flack Assistant Manager Bristol Office FDIC insured Right Choice. Right Service. Right Here. @ ........- LENDER Pennsylvania State Bank April 6, 2007 Irwin & McKnight 60 West Pomfret Street Carlisle Pa 17013 RE: Kenneth C. Bassett Date of Death: March 12,2007 SS# 074-14-8783 Dear Sir: The following information was requested: Opend 5/3/06 in Kenneth C. Bassett; became joint ownership on 6/28/06. Between Kenneth C. Bassett or Barbara Ann Bassett #9150008017 MMG #9150008020 Bonus 50 Balance as of 6/28/06 $14,725.84 $1.831.95 Balance as of Date of Death 3/12/07 #9150008017 MMG #9150008020 Bonus 50 $157,861.14 $4,384.09 interest just posted 3/12/07 both No accounts closed. Interest for 2007 until DOD #9150008017 MMG $1,670.56 #9150008020 Bonus 50 $57.30 Thank you, and if you have any other questions please contact me. Very truly yours, (1J&-f.~ Annetti J. Tingle 717-243-3189 1 North Hanover Street Carlisle, PA 17013 717.243.3189 fax 717.243.9649 pastatebank.com ~ ~~~~~~ We help build your future. SM ~\t~~UW!~ - ..' .., ,. .~' ; .,h{ ~...:L .... .,.-.,'...... ~ .~ I-lT April 5,2007 Irwin & McKnight Law Offices 60 West Pomfret Street Carlisle, Pennsylvania 17013-3222 RE: Estate of Kenneth C. Bassett Dear Mr. Irwin, I have listed the open certificates of deposit held by American Home Bank For Mr. Bassett. In addition to these, there was a six month CD dated July 12,2006 that matured in January 2007. The original CD was for $50,000 and the proceeds were split into two CDS 290003721 and 0290002722 that included the interest. That CD was also titled Kenneth C. Bassett or BarbaraAnn Bassett. CD Number Date opened Title Principal Interest accrued to March 12, 2007 290003177 28-Jul-06 Kenneth C Bassett or $5,000 $163.08 Barbara Ann Bassett 290003412 13-0ct-06 Kenneth C Bassett or 10.000 $213.93 Barbara Ann Bassett 290003522 24-Nov-06 Kenneth C Bassett or 23838.11 $369.53 Barbara Ann Bassett 290003566 12-Dec-06 Kenneth C Bassett or $12,231.24 $157.82 Barbara Ann Bassett 290003567 12-Dec-06 Kenneth C Bassett or 10,363.73 $133.73 Barbara Ann Bassett 290003721 18-Jan-07 Kenneth C Bassett or 25,000 $186.58 Barbara Ann Bassett 290003722 18-Jan-07 Kenneth C Bassett or 26,355.77 $196.69 Barbara Ann Bassett 290003742 26-Jan-07 Kenneth C Bassett or 10,000 $63.34 Barbara Ann Bassett total 122788.85 $1,484.70 Principal and Interest total 124273.55 417 Village Drive / Carlisle, PA 17013-6929 . Phone 717/218-6635 · www.bankahb.com Page 2 s, <;.~ > j, ," ~v~ . ._-......... ..-- - -~........ ....... .. Pr8Yious points balance Points earned on purchases Total points expired this period New Ictal points balance 70 points Ic expire on statement date in May 2007 1,432 4,292 75 5,649 back of your card or log on to www.chase.comlcredltcards TRANSACTIONS Trans Date Reference Number Merchant Name or T ransaclion Description Amount Credit Debit ::~~~~~~;= -X~~-=-~_~~~~~ifS~~PA.. ~.. ~~'( 04102 24226387093360584927094. SUPEf!<;I;~E~ CARLISLE PA ~l.l'~AoC.' 8.os. 04102 24445007093784743827086 .~~GS R.~E~~ER.ED 0151 CAMP'~. ~n.;L~~ 04103 24401407093001354764290 SPS 4134870013 CARLISLE ~~.. -.6_ 7.80' 04103 244450070947858740107~VS PHARMACY #1646 003 CARLISLE PA' 4.74 04104 2438n57095Q.04037~7~~ICHAELS ~TORE "167.19 CAR!-ISLE PA._ .. 3.88- 04105 24388947096038301110564~D.GEORG. ES' FLO,^-,J;RS CARLISLE PA . ~1J~'("h .90' 04I0824029467099980001292195~IDDLESEXDINERCARLlSLEPA ~I d:.. 31.92. 04I1124.755427101731013272869...DIAKONLUTHERANSO.-CIA.!-MI717-7950300~.~~~. _.- W 't~. 2,444~. 04I12241640nl02091007149343 vTARGET. 00020990 CARLISLE PA ~~. ~ 5.29- 04113 2401..33971 0401 01T1412754 \.o6TARRKING SCHOOL. FOR THE BERKELEY cA- (.1< - . Wl-e.Y)f&l'l:1L.Ir 150.()O. -9~ .'O-I9-f'.e.<< FINANCE CHARGES Calegory Purchases Cash advances Dally Periodic Rate Corresp. 31 days in cycle APR .02737% 9.99"/C> V .06436% 23.49% Average Daily Balance Finance Charge Due To Periodic Rate $0.00 $0.00 Transaction Accumulated Fee Fin Charge $0.00 $0.00 $0.00 $0.00 FINANCE CHARGES so. 00 so.OO SO.oo so.oo so.OO Total finance charges Effective Annuaf P...cen~e Rate (APR): 0.00% Please see Information About Your Account section for balance computation method, grace period, and other important information. The Corresponding APR is the rate of interest you pay when you carry a balance on any transaction category. The Effective APR represents your total finance charges - including transaction fees such as cash advance and balance transfer fees - expressed as a percentage. X 0000001 FIS33335 D 9 000 N Z 18 07/04/18 Page 1 011 05686 MA MA 13717 1081000009046137170 ~ J 6'515-73 * 5-67 + 27-96 .,. 33-53 * *** THE GROSS-ERY *** 308 Chery] Avenue Mechanicsburg PA 17055 (717 )918-0138 04/02/07 14:50 OPER 75 59999 Valued Gross-ery Customer 867707 MARCAL NAPKIN DINNER BELLA 2 @ 1.70 3.40 850105 DART TMBLR PlSTC TRANSlUCNT 1 @ 1.89 1.B9 822401 DART CUP 10KY10 FOAM 10 Z 3 @ .75 2.25 Merchandise Total $7.54 Tax $.45 ' '~~ .'7' I~" t? 7 ~ Invoice Total $7.99 AMOUNT TENDERED $7.99 . Check $7.99 Cash ~, . t:. .':) 1 1::... ,.., J ~ ......._ .... ""....