HomeMy WebLinkAbout07-09-07
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15056051047
REV-1500 EX (06-05)
PA Department of Revenue . County Code
Bureau of Individual Taxes INHERITANCE TAX RETU RN -
PO BOX 280601 cJ (
._._.__.______.__ Harr~~urg, PA 17128-0601 _ __~ESIDEN!-~~-~ENT---..-.-..---.-
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
Year
File Number
olJ;
[; If!!
Date of Birth
I '7 ;l. 3 ~ 0 4 I q oq \ I ';1. 0 C (p
oq -;>.;t l~ 3 Co(
Decedent's Last Name
Suffix
Decedent's First Name
MI
\-\A,- '"2. A R D
S '-t \R:. LL~
Ii
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
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
..,.~~"-;
, ".~,...,j
4. Limited Estate
c=)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
<::::)
2. Supplemental Return
<::::)
::::)
c:J 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 C) 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, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
f'-""""~
'.",",~....'
5 USA.v
Firm Name (If Applicable)
L~ A
0' H fa. RA
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First line of address
City or Post Office
ZIP Code
-0
~
Second line of address
State
W
N
'.' ,. I,
~E.w\JtLL~
PA
1:t'-\\
Correspondent's e-mail address:
.u;;d-;;;'p~~altie;;'fP';;rjury, I declare that I have examined this return, including accompanying schedules and statements, and i~th;;'b~~i-~f';:;;y kn~;;'ledge and' belief,
i:.i~~?~"~~~.::.~~_:?mplete. Declaration of preparer other than the personal representativ:~~~~sed on all info~r1:'a:~_~!_which p'epa'?' has any knowledge.
~~G_E::~:=.(-:)O~\r :::~ RETURN _______ ____.'__"__ ..
ADDRESS '. \ \, ~ ffi .
_..._~~8..L:__1~~~ . ~:.~~;_eV\11..a~J
SIGNAfGRE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
. '"1=.CJ:o ..7
DATE
ADDRESS
=..........--.""..,..,,,.......,......,"'""',--',,.,"""- <^---'.'~
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
---l
.-J
15056052048
REV-1500 EX
Decedent's Name:
RECAPITULATION
1. Real estate (Schedule A). ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-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) c:> Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c:> Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
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)................................... 11.
12. Net Value of Estate (Line 8 minus Line 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 (Line 12 minus Line 13) .. . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
15.
.
16. Amount of Line 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
16.
17.
.
18.
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056052048
Decedent's Social Security Number
o . 00
0.00
0.00
0.00
q t -:)..?. . 'l
O. 00
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IO)..S~. q']
'10\ J... 00
"i 0(.:> L . q 0
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6. 00
15056052048
--.J
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
~3ti I(CL~~ ~.. I\RLfN~_ l-ll\L..-Z~\fC-(J
STREET ADDRESS , .
_____________21i-L2---.J\I\ CD\') L ~. _ Q~------------------------------------
File Number
CITY
P/~ .
I STATE
?A.
I ZIP
1124 I
-..-.--
It ~,-
~ u.)J t L-L~ ,
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
O. (')0
Total Credits ( A + B + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5B)
0, (3<\
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 ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 l)g
c. retain a reversionary interest; or.......................................................................................................................... 0 S.
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ISk
4. Did decedent own an Individual Retirement Account, 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. ~9116 (a) (1.1) (i)l.
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)]. 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 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 decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. 99116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [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.
REV-1502 EX+ (6-9B*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
c A ~. L- ~_
All real property owned solely or as tenant In common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which Is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
"l"\one.
_0-
TOTAL (Also enter on line 1, Recapitulation) $
- 0---
(If more space is needed, insert additional sheets of the same size)
REV-1503 EX+ (6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
ESTATE OF
('
:,..)
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
'1) () '^ -e....
_ 0--
TOTAL (Also enter on line 2. Recapitulation) $
() -
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX+ (6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
FILE NUMBER
ESTATE OF
{--
/
Schedule C-1 or C-2 (including all s porting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER
NUMBER
1.
DESCRIPTION
Y\ CJV\ -e..
VALUE AT DATE
OF DEATH
_ O~
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
'_ 0--
REV-1507 EX+ (6-98) .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
- 0.-
Y) (SY"I-iL
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
.- Cf- --
REV-15GB EX+ (6-9B)
SCHEDULE E
CASH, BANK DEPOSITS, & MISe.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
, c..,
Includ 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.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
I
1'i 58
Srn"4 R.J. / ~v \, to <.
Pc-
gI22.1\
I.
M+I'
P->0Jv..k.
A(!.er ::t+ 10'-(40<0 q 5
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
q\~I.J,'1
REV-1509 EX+ (6-98)
SCHEDULE F
JOINTlY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
If an asset was made joint w hln 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.
no"" -e.....
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %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 JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A
Y"") Cl"V\.-e..
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX+ (6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
FILE NUMBER
gw i rLL t;, \..{ A . WA ?.Z llR.D
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER
1.
DESCRIPTION OF PROPERTY
INCLUOE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE
DATE OF DEATH % OF DECO'S EXCLUSION
VALUE OF ASSET INTEREST (IF APPLICABLE)
TAXABLE
VALUE
-":'')f) Le,.. ()"iArf'..<.\
... .... ''0. n .- ()1\"'tJc:w~
~KfI,':\~() ~. Ci'\ ewe_o;".) - SC,;J
'i~.-..
i t.~Cl- \ r SU M~.\ l.i G: !. ~ ~ (' r'll.... c' \.,... r.'\r '\ h I
. "'-IV 1::: ";, Il)c \,\./l ~I IV
~ i~ s 1'Gt,\-,......... - '. i . .0.4 il . _
.. .......VV'-'VlU:' ~k: \i\J\a:,s
&lue~te MQ(e G.q;'-l:\ AnJ.Q.f S~d'"
1~J.") , , .,'
c. ..'"> (,.\J. tJT t\^i"CfL:1S elllP -AX.- S)-
~ l \J \ h. t...~.t"l l? J f\j C:..
I , 3) .""
"'31:7t
~
,1E.2'J ...~~22.
TOTAL (Also enter on line 7 Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
\l 3:J..7(
REV-1511 EX+ (10-06)*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FILE NUMBER
(\ \ LL~'
-J \'"' I ~ c:.,-/
A.
N A 22-j\-.[2' 'J
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: r- v.t\'\Jl.;Lc....L ~~ 3 (i:)Cj 5 . 00
1.
C' 'G'l.O. {'(l
to ",q Ic::..o2-t
C.Lv~'i- '1S o ()
\ t(.\.J.,..lC\....UL.~l~..Q ~- Js. eo
D<? (\~ ~\t-. 4~ 00
~. CW-i5;~~.~- i 25. CC
~~ ~ C{C~()~ i ( 50 0
rLu,-w-eJ~ ...2..'5 (J
B. ADMINISTRATIVE COSTS: 1
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State _Zip :l'"', ..:.. .') e..
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State _Zip
Relationship of Claimant to Decedent
4. Probate Fees !.;q .00
5. Accountant's Fees
6. Tax Return Preparer's Fees SS.oo
7.
TOTAL (Also enter on line 9, Recapitulation) $ i701 J. .GO
Debts of decedent must be reported on Schedule L
c
o
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX. (12-03) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF (' FILE NUMBER
":':;>\., II'CLE.l--( A 1,\ 1\ Z:Z.il {(>D
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
i\CCT fF ~o 9 s c..t ~ cl q -,
C.i~.e-DIT ft~,sr l\J,Xn.. A~.s-0
Ke-vOLVUNC (\+t-C i\Ccr- ~\'~s.'1t.1f..JB Q.wv\PU'f~ f}Vt'O
-0 J<: 17:> /,<:::ud..\" Qr or
PC C:::.c~' ~h ~Ol
C lQ~ \...(~ (Jk.I c
/ "-i~I2SI.~Cll
~ ((.33
v~ ·
i1CCT tt 5~r,,, ~c 01 Os- (",4 ; \..:)S
..-,
C. ,"1 , C G R-P" ~lCc D rt S,,~L So Ace""
f) Cj 6C N \.U a I "': 'n-.
I ~., ,5r.
l~ AI L / eo\:) E i C
I<A N~;-l-~ C tl'V) I I\\.O bL' 1'5.3
3"l51.5'1
TOTAL (Also enter on line 10, Recapitulation) $ L.t 0 (, 2... 4 ()
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX' (9-00)
ESTATE OF
NUMBER
I
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
s~ I fCLtC~
A l---1-A~z-A'? D
RELATIONSHIP TO DECEDENT
Do Not list Trustee(s)
"'>"f ,r ~':C.. r-,.
'...J.. v\t.:..h I '-~'-
--S,t-.J
FILE NUMBER
AMOUNT OR SHARE
OF ESTATE
- I"
'?C .~
't....
'? 0 j L
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON.TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
,,-
...::':J~l ~ i'\ tV
L OJ
eO. ' H j\. Rr'\
Q ~ C ~-l i\ iZI"')
:5.
(:';,\ k":u.::.o 0 I~
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)
rlIM&rBank
10440895
CLASSIC CHECKING
00 0 06128M NM 017
18532
SHIRLEY HAZZARD
586 MIDDLE RD
NEWVILLE PA 17241-8633
. Bl;:GINNI}jG>
. "BALANCE" .'.
8,660.17
'"DE P"O'S!''l'''S'&' ......
.. . . - -, ..-_....
..:..@~tlt::1ili6l4.:r6~~H
NO. AMOUNT
2 1,431.54
AUG.29-SEP.28,2006
1 OF 2
CARLISLE WEST
SUMMARY
..............'O'rHER........ " ....
<>%,Bt'iAcT:thJM
NO. AMOUNT
13 1,679.65
..:"c~~t><. . .~IN(>.. ..', ..
'iN<rER.ESTPO:. .B:li:tAN'CE:.... .'.
0.00
8,262.11
<PJ~)s.~@G< ..
:':':OATE'"
.."...................--......--.......... .,,, .....-.
..........--....---......---...--................".....
."..................-....-.--...-.-,.......--..'.......,....'....,.
..........--..........-...--....-.- .......... ..
. ':TlOOiISACTifutnESCR1PTioN>:
ACCOUNT ACTIVITY
. . ..
08-29-06 BEGINNING BALANCE
08-29-06 CHECK NUMBER 1611
08-31-06 DEPOSIT
08-31-06 CHECK NUMBER 1614
09-01-06 BANK OF NEW YORK PENS PMTS
09-01-06 WAL-MART 7 ECA PURCHASE 1615 CARL PA
09-05-06 ATM CASH WITHDRAWAL ON 09/02
ADAMS 37 CARLISLE ROAD NEWVILLE PA
09-05-06 EFT SERVICE CHARGE
09-05-06 ATM CASH WITHDRAWAL ON 09/02
ADAMS 37 CARLISLE ROAD NEWVILLE PA
09-05-06 EFT SERVICE CHARGE
09-05-06 BENEFITS PACKAGE SEP DUES
09-06-06 CHECK NUMBER 1618
09-07-06 AMERICAN PROGRES PAYMENT
09-07-06 CHECK NUMBER 1617
09-08-06 M&T ATM CASH WITHDRAWAL ON 09/07
STONEHEDGE,960 WALNUT BOTTOM RD,CARLISLE,PA
09-11-06 866-290-0505 INS PYMT
09-13-06 M&T ATM CASH WITHDRAWAL ON 09/12
STONEHEDGE,960 WALNUT BOTTOM RD,CARLISLE,PA
09-13-06 M&T ATM CASH WITHDRAWAL ON 09/12
BOILING SPRIN, 1 FORGE RD,BOILING SPRINGS,PA
09-28-06 M&T ATM CASH WITHDRAWAL ON 09/27
WALNUT BOTTOM SHIPPENSBURG PA US
09-28-06 M&T ATM CASH WITHDRAWAL ON 09/27
WALNUT BOTTOM SHIPPENSBURG PA US
ENDING BALANCE
DEW;j~I'I'~i1:NT~~Est.
'&...611IE:~.,.ADi:lf'l't6Ns:
"OiECjcS::.&:::OTHER
stm'l'AAC'l'IONS<
.. ,'d ::..
5.00
$8,660.17
8,655.17
1,000.00
36.30
9,618.87
431.54
26.75
301.50
10,023.66
1. 75
201.50
1. 75
2.00
65.50
128.00
43.15
140.00
9,515.16
9,449.66
9,278.51
16.40
200.00
9, 13? :.5.l .
(:::.......9,.122.11.
)
160.00
8,762.11
300.00
200.00
8,262.11
$8,262.11
Register Of Wills
Cumberland Cnty. Crthous
#1 Courthouse SQuare
Carlisle, PA 17013
IN RE: ESTATE OF
Shirley A. Hazzard
586 Middle Rd.
Newville, PA 17241-8633
File Number:
Division:
DECEASED DATE: 09/11/06
STATEMENT OF CLAIM
The undersigned hereby presents for filing against the above estate
this statement of claim and alleges:
1. The basis of the claim is goods and services provided
Shirley A. Hazzard and charged on account number #609545097.
2. The name and address of the claimant is:
3.
Credit First National Association
Revolving Charge Account for Firestone Complete Auto Care Customers
BK13/Credit Operations
PO Box 818011
Cleveland, Ohio 44181-8011
", . "'.",
T:Weina9m.ount of the claim is(~~~~.~YWhiCh amount is now due and
The claim is not contingent.
The claim is not secured.
A statement of the account is attached.
4.
5.
6.
Under penalti~5 of pe~jurv, I ~~~l~~~ that T h~vp. r~?d ~h.~ t-0re~ci~g
and the facts alleged are true, to the best of my knowledge and belief.
Executed this 12th day of October, 2006.
CREDIT FIRST NATIONAL ASSOCIATION
REVOLVING CHARGE ACCOUNT FOR FIRESTONE COMPLETE AUTO CARE CUSTOMERS
BY:
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PROOF OF SERVICE OF CLAIM
I served upon THE EST ATE of SHIRLEY A. HAZZARD
Name
fiduciary, a copy of this claim on NOVEMBER 6, 2006 by REGULAR MAIL! FAX
Date
State manner and address of service
SUSAN L. O'HARA, RP
586 Middle Road
Newville PA 17241
I declare that this proof of service has been examined by me and that its contents are true
to the best of my information, knowledge, and belief.
f{JM.R ,,~ ~%~
Date ' Signature
ACCEPTANCE OF SERVICE
Service of the attached claim is accepted.
Date
Signature
STATE OF
PENNSYLVANIA
FILE NO:
STATEMENT AND PROOF
OF CLAIM 21 06 844
PROBATE COURT
CUMBERLAND
COUNTY
Estate of SHIRLEY A. HAZZARD
I, Howard A. Enders, Esq. on behalf ofCITICORP CREDIT SERVICES, INe. located at
7930 NW 110TH STREET, MAIL CODE 10, KANSAS CITY, MO 64153 submit the
following claim against the estate for the sum set forth.
DECSRIPTION VALUE
CITICORP CREDIT SERVICES ACCT# 5491130010564755
CLIENT ACCOUNT:
AMOUNT CURRENTLY DUE: $ 3,451.57
PCA ACCOUNT:
There is now due on the claim, above all legal set-offs, the sum of : $ 3,451.57
o Notice to interested persons: This is a claim by a personal representative. This claim
will be allowed unless notice of an objection by an interested person is delivered or
mailed to the personal representative not later than
I declare that this claim has been examined by me and that its contents are true to the best
7J;;;J;JITI/;J:;/ief
Authorized signature
Howard A. Enders, Esq., General Counsel
Name (type or print)
The Creditor's Rights & Bankruptcy Group
A Division of Phillips & Cohen Associates, Ltd.
258 Chapman Road Suite 205
Address
Newark DE, 19702
City, State, Zip
302-355-3500
Telephone
To whom it may concern,
Due to the voluminous nature of the documentation supporting this claim,
the following account summary is provided:
sUMMARY OF ACCOUNT
1. ACCOUNT NUMBER: 5491130010564755
2. NAME IN WHICH CARD ISSUED: HAZZARD, SHIRLEY A
3. PRIMARY CARD HOLDER(S): Shi~ley A Hazzard
4. OPEN DATE:
5. CREDIT LIMIT: $
6. FINAL BALANCE: $3451.57
7. PRIMARY USE OF CARD: Purchases