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Home My WebLink About07-30-07 (2) --I 15[]5b[]51[]47 REV-1500 EX (()6.{)5) PA Department of Revenue *' Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 1712~1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY Comly Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT ob 01 06/ d. ( Date of Birth I ~ 1: 3 "t / <g 9 ~- I / 0 15 J. t:? 010 Ob 06/9'11 Decedent's Rrst Name Kf t -r I-J A Decedent's Last Name Suffix GA 4GL Et: (If Applicable) Enter Surviving Spouse's Infonnation Below Spouse's Last Name Suffix Spouse's Rrst Name Spouse's Social Security Number THIS RETURN MUST BE RLED IN DUPUCATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW _ 1. Original Return C) 2. Supplemental Retum C) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required C) 4a. Future Interest Compromise (date of death after 12-12-82) C) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) C) 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 BI: COMPLETED. ALL CORRESPONDENCE AND CONFlDENJIAl TAX INFORIIATlON SHOULD BE DIRECTED TO: Name Daytime Telephone Number C) 4. limited Estate C) C) 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes C) MAR-V Al l1eCLfLL-.AN 570 037 3Ia,/ o R I REGISTER OF Wli.C;B>USE ONL,....-J '"11 L "0 C :T(j I '"r- ....cT] W :=(-J 0 Firm Name (If Applicable) First line of address " ::r: J Jo q N E \IV '8 f R 1-1 IV Second line of address J./wy City or Post Office f;\ I OD L FB L( RG, State ZIP Code '; DATE:Ffl..ED o PA I 7 7>'I~ Correspondent's e-mail address: ,11 c.. C. ~ I V I Cj 1 3 tV ve i ; Zor~ , fl (.;, +- ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L --.J 15[]5b[]51[]47 15[]5b[]51[]47 MI MI . ~ .-J 15056052048 REV-1500 EX Decedenfs Name: Decedent's Social Security Number I 1) g- 3 g I ~ 9~ RECAPITULAllON 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) c:::> Separate BiDing 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 Govemmental Bequests/See 9113 Trusts for which 6 % an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . p. . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .. . . . . . . . . . . . . . . . . . . . . . . 14. q 0000. 1/3117. I C; / :261. I 3 / 636 5.). ~ (;f! /. !) .:2: 5 <g'. <[.. :2.'/ g'. t 35 %. 5/3075: 307B'-.S: Lf CJ ;).. ~9 o. . . . TAX COMPUTATION - SEE INSTRUCllONS 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 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 15. . 16. .3 ~ g 3 b~. 15)9:2.~. 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 39 'fo4. ;i3 0 zg-. 10 2 4'12... 15056052048 . . c:::> -.J REV-1500 EX Page 3 Decedent's Complete Address: ~~1LA~d~~~LEc]L n}>LN,3 6_'__5___ _n_n_____n__ File Number CITY -J-I. / I / STATEp A . ZIP I 70/1-;;2 762., Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) (0 ..~ I ~ 9 2.... n-r~IQ~Q-Q_n_ 3, as_2_nn_ _ Total Credits ( A + B + C ) (2) ~I . {)S~ I 3. InterestlPenalty if applicable D. Interest E. Penalty TotallnterestJPenalty ( D + E ) 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Une 20 to request a refund. B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (58) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. / I ~S9 , I A. Enter the interest on the tax due. / ~ q~~ 9 . 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 ~ ~: :::~ :::~~:st7:..~.~.~.I~.~~~.~~~.:.~~:.~~..t.~~.~.~~~~~~.~.~.~:.:.;.:::::::::::::::::::::::::::::::::::::::::::: B ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 IZJ 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" Of' payable upon death bank account or security at his or her death? .............. 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other ~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. 99116 (a) (1.1) (i)]. 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. 99116 (a) (1.1) (ii)]. The staMe 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. 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 four and one-halt (4.5) percent, 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 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. ---ri>. l I ~:_"t_ ...-} ( i'";- I -or' ." , " / t'")" Keith Gaugler Estate Computation of % of Estate Applicable to each Type of Beneficiary and Descendant % of Net %of Value Net Value Subject of Estate to Tax $513.075.00 $482.290 Charitable Distributions Botschaft's Lutheran Church Cemetery Fund 3.00% 0 Botschaft's Lutheran Church Building Fund 2.00% 0 Botschaft's Lutheran Church General Fund 1.00% 0 6.00% 0.00% Lineal Descendants Lois Hartman, sister 21.33% 22.6950% Mary McClellan, sister 21.33% 22.6950% Gail Koveleskie, sister 21.33% 22.6950% 64.00% 68.0851% Collateral Descendants Edgar B. Hartmam, III 3.00% 3.1915% Richard McClellan 3.00% 3.1915% David McClellan 3.00% 3.1915% Candice Koveleskie 3.00% 3.1915% Kimberly Lehman 3.00% 3.1915% Kimberly Lehman, in Trust for Victor B. Lehman 3.00% 3.1915% Carol Hartman 3.00% 3.1915% Carol Hartman, in Trust for Nikki Hartman 3.00% 3.1915% Justin Hartman 3.00% 3..1915% Tom Koveleskie 3.00% 3.1915% 30.00% 31.9149% Total 100.0000% 100.0000% 100.0000% 100.0000% Keith Gaugler Estate Inheritance Tax Computation Net Value Subject to Tax Applicable Amount Subject Percentage to Tax Tax B!!! ill Lineal Descendants Collateral Descendants Totals $482,290.00 $482,290.00 68.0851% 31.9149% 100.0000% $328,367.64 $153,922.36 $482,290.00 0.12 0.15 $39,404.12 $23,088.35 $62,492.47 REV-1502 EX+ (6-9. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER ;; 'y' h . a.. (A /.e r 2oo(p - 0 { Oral P A ;;;.. { -06-10(:;,1 All real property owned solely or IS I tenant in co.mOll be reported at fU martet value. Fair marlret value is defined as \he price at which property would be exchanged between a wiling buyer and a ~ seier. neilher being compeIed to buy or sell. both having reasonable knowledge of the relevant facts. Real property which Is jointly_ed with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION ~ ..e.,S 0'(\0--\ 1Z -e ~,. de nC e ~. p.e ( -jo 1',,: ( P to p-e (-I '(\ o...--t ~I N,33rJSf C ' ,I, I 'II n 11 /7 () ( (-.J. 70"1- a... <<") p 1-11 / r rr VAlUE AT DATE OF DEATH q 0 I 0 DO TOTAL (Also enter on line 1. Recapitulation) $ (If more space is needed. insert additional sheets of the same size) eel \ '" 1. C-cc REV-1503 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ;l(;O r, -(;>, /, I with right of survivorship must be disclosed on Schedule F. (,.e r--. FILE NUMBER 'PA ;;1 , -()~ - c>(ol ITEM NUMBER 1. DESCRIPTION A Yf1-R--r/Ctt~") ~.Ia yt('ed Fu nd AC(-f.# 3fol9'30iftf VALUE AT DATE OF DEATH eb/12 !^ ~ Y~n4u.~.,--J 6,IV'Mft. .:II qq0 gg"O;);,l/'5 I () 7, ;/;('1 TOTAL (Also enter on line 2, RecapituIatioo) $ / I (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER p~\ .:2 t . "" -/0(,1 ESTATE OF K r / tll A. ~Jl fA ~ I- E P -" MOC, "Ol()(' ( Indude the proceeds of 1iligali0ll and the date the proceeds were received by the estate. AU property joilltly-owned with right of survivorship must be dlsdosed on Schedule F. ITEM NUMBER J, ~. 3, 'I. s-: ~. 1. i, ct, \ 6, I I J). DESCRIPTION ful.f.-o-.."> Nctl-"~,.,~J ~,-, Ie. CAt ( ''''',If.J/I S'$tJS.6;;i,C;3 r y'\ -I eq 1" '!1f ~ hI::.. CAe tlu'/71V~ v I y,,,/s.:li ~ 10 Il-f ~,q So ve rei ".., ,.- r5et t\ Ie. C he clc f 'g, .... itS7/11:;). tI'"2- Sov e((' iq n 1:P" Ie.. Cc d, 1 i('(( 1/ D~fdSj +- /J<L wrnob; Ie. - /C(C(r the vrole-fC~va.j/e r- ea S h 0 '(\ ha V\d P.i2 r SO),'la ( 7" -If d'S; p-uyc h~ $-k J. +r(n"">~ c s-ltIt...f<:.. '5 e c 0 f4a. (h {(( ,,5/)('~-f' VAlUE AT DATE OF DEATH ,07 1;1/3'1'1 ) s ~ I, /;0 .3 , a 00 ~1 :;~ I D lA-c.e -h-.~ {tC{ (5 / Y')'(' 11 erne:.,. DD:-e '" f w".,' (' ~, ,b (.., e C", pet n'~ <+9 P L . .( YO}'", \ , I lS 1.( (<A I' (0 ..... ..' l'";lF ,1 (J OLI{ .~ (( 'n I ~SC,( Ie.? f S.('C (.,I. i",'.f c" 1\. r VC<e -\ (o'n 1 1 (2.s ;;; ,;;. 00 ;;; e:' ~ ~/t.o J ,$1 q, S- TOTAL (Also enter on 6ne 5, Recapitulation) $ / q ( ,?- 0 f- (If more space is needed, insert adciliOllal 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 ~~l// A ~~ l~ 11' ./-l . I G A u b\ L.t K.... ;)<>(J (" . o/~ I PA:;" fo.t}' tDtP/ This schedule must be completed and filed if the ~ to any of questions 1 lhrough 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INClWE THE NAME OF THE TRANSFEREE. 1IER _TO DECEDENT AN) DATE OF DEATH 'Yo OF DECO'S EXClUSION TAXABLE NUMBER THE DATE OF TRANSFER. AlTACI\" COPY OF lIE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (F APPlICAIllE} VALUE 1. .TNt; re'r 'f: I~.k<v'.l (Cl.{ 11 ~ ~. .' t (.) Acc-( fl. Co 3'6/ :2 3 -(:,4 13/,630 ! 600lt 13/," L 0 is If a"d. ",0 >, I Si~.f.R( (-1,') . J't ("\ " .:;leJo "7d I ) !V\ctf1 M d-/~ (r;:~IS:to~)?3 {, ct I , I\~v-R It 5 k ,. e /51 ':./~' (( j~) :1(.( ti \ ;,)tY "1 TOTAL (Also enter on line 7 Recapitulation) $ I :3 ( I (P 3c> ., 30 (If more space IS needed. msert addiIionaI sheets of the same SIZe) REV-1511 EX+ (10-06>W COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESDENT DECEDENT SCHEDULE H RJNERAl. EXPENSES & ADMINISlRATIVE COSTS ESTATE OF 1/ / FILE NUMBER IU- /TI/ 1/. &4 u (~if K :;JOb (, , () I Of, I Debts of dec:edenI must be reported on ScheeIuIe 1 ITEM NUMBER A, PA ;11 -tj', - /o(pl DESCRIPT10N AMOUNT 1. FUNERAL EXPENSES: C;eC)--rqt 6ar rf)~/1 r (1/)( {4.! J:"C-{ nerd ( f)' )ee::t. r /(16)11 (,.<. rr' en + ,,::l II" j k. r) I -<:. ;).{O / I '1-1 ,I B. ADMINISTRATIVE COSTS: 1 . PeISOIl8l Represenlative's Commissions Name of PeIsonal Representalve(s) Street Address City Year(s) ComnissIon Paid: State _Zip 2. .:260 AIIomey Fees 3. Family Exemption: (If decedenfs adchss is not the same as dainIInl's, atIach explanation) Claimant Street Address City State _Zip Relationship of Oairnanl to Decedent 4. 3'fL/ Probate Fees 5. Actounlanl's Fees 6. Tax Return Preparer's Fees 6 {JH' ( Ac/n'); ;!;~;.';' r~ J,c.,< f X P ~.. . I} 5L ,~. .i f I f' ')1' .. .f ~ I if 7. (~ 5.150 Lj0g-- d5S- ~. TOTAL (Also enter on line 9, Recapitulation) $ 5.) D g- (If more space is needed, insert additional sheets of the same size) REV-l512 EX+ (12-00) . COMMONWEAI..TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIlENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABIlIJIES, & UENS ESTATEOF Kr 1711 A. 6,11U. 61L E e~!\t) f,-OI()(P I fA A~~U~;:"O" I Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including urnlmbursed medical expenses. VAlUE AT DATE OF DEATll ~ ,/S'// /p,071 to/to ITEM NUMBER 1. DESCRIPTION X\[i c! i (a I Ex fJ.(: n se $ :T ('\ C (; t)\ fa y C:.;J C-t) 51 .f!1 )(-, : ;).( a i n i nr pr opr ~j (j ~ .*?Ct:, ( f.5 fCt."f '/~( 'I ( S /D ~. 3, if TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) Z ;J.7g- REV-1513 EX+ (9-00) .- COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF // / r,eli-A A ~ (;:/t? u ~/{J r , NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY TAXABLE DISTRIBUTIONS rmclude llIIlr9rt spousal dislriJulions. and transfets under Sec. 9116 (a) (12)] RLE NUMBER NUMBER I ,;).(X.)(p . 01 oCr; I fJ A .;J I ~ 0' .. I 0 ~ I RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not list Trustee(s) OF ESTATE ENTER DOlLAR AMOUNTS FOR DISTRIBUTIONS SHOWN N30VE ON LINES 15 THROUGH 18. AS APPROPRIATE, ON REV-1500 COVER SHEET n NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHIai AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABlE AND GOVERNMENTAl DISTRIBUTIONS ~I schall ~ Lu'fh~ Yl2 n Ce 41.e.,t.e?/ r tr(.l1 cI .3 % B6'I5C/~ ffI5Lu.{A..(va ;"' ~"ill/n1 Ft-1. nrl ,;)% &-1 ~/-,qr{IS Lu..fh.f ya...1-t C;;~n.f' till / r f.,.{"'c/ 1% "'5 'I /)/! 111'c{ c.(' 'Rei rnl ;J 1ft:? 54 J'"/ /Jl, //.$" ~/J / 7'15 3. ;,.: 71..') I I ~ 1393 /0 I .;;J. 47 / 51 I .3 / 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) $30,7ZS- (\ ~ ~\ ~\ ~\ J \ \. \k. \ A \ .. " f. ~ r~:' '.;.. \ .~ , ,,"O"""''''''''"'';;-~'''''''"'W''".'''''_'^'~'' " ....- "'~""'{.-.'..,.-."."..- '" r~t'l1)~- '.. 4QlJ...~'i; LAST WILL AND TESTAMENT OF KEITH A. GAUGLER I, Keith A. Gaugler, of 31 North 33rd Street, Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. ITEM I. I direct that all my debts and funeral expe.nsea{ including my cemetery lot and grave marker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my death as part of the expense of the administration of my estate. ITEM II. I make the following specific devises and bequeaths: my 1999 Chevrolet Cavalier to Charles A. Christine, Jr. ITEM III. I devise and bequeath all of the rest, residue and remainder of my estate of every nature and wherever situate as follows: 1. 2. to Edgar B. Hartman, III - 3% of my net estate; to Botschafts Lutheran Church - 3% of my net estate for their Cemetery Fund; to Botschafts Lutheran Church - 2% of my net estate for their Building Fund; to Botschafts Lutheran Church - 1% o,~my nee~estate .. -"' ~_ _:._J for their General Fund; :~ to Richard McClellan - 3% of my net esta:te; ~~ (--'n to David McClellan - 3% of my net estat'e:: to Candice Koveleskie - 3% of my netes,i~~te1:"': to Kimberly Lehman - 3% of my net es~~ie; 3. 4. 5. 6. 7. 8. C:) 1'0 II , I <"'!~"""""-~""'N_'~"',""'""~"",,,,,,,,,,,,,,,V.""'"''....'....N."".,'~'""'''~8..'!,,:;~l'',~""<!li lfJ:l1.~~Jl.1lll {U "j"'l~ l' -- UL' I i~~i*".x ! I Lehman, I - 3% of .:. l.-'~:~ = II I' to Kimberly Lehman, in Trust for Victor B. until he attains eighteen (18) years of age my net estate; 10. to Carol Hartman - 3% of my net estate; 11. to Carol Hartman, in Trust for Nikki Hartman, until she attains eighteen (18) years of age - 3% of my net 9. estate; 12. to Justin Hartman - 3% of my net estate; 13. to Tom Koveleskie - 3% of my net estate; among Mary McClellan, Lois Hartman" Koveleskie and their issue per stirpes. 14. the remaini::g 65% of ::-.y ::e': es':a':e is :ii-.-ided ITEM IV. I direct that any and all Inheritance, Estate and ransfer taxes imposed upon my estate passing under my Will or ,therwise, shall be paid out of the principal of my residual estate. ITEM V. I appoint my sisters, Mary McClellan, Lois Hartman, nd Gail Koveleskie, Co-Executrixes of this my Last Will and estament. I relieve my Co-Executrixes from the necessity of posting !ecurity in connection with their duties as such in any jurisdiction n which they may be called upon to act. ill IN WITNESS WHEREOF, I have hereunto set my hand to this my Last and Testament, which consists of ~pages, to each of which f., '+"L-.. day of ~ e have affixed my signature this housand and six (2006). two ?/ ~.~~ Keith A. Gaugler .~ u .s c.\\ A r+ STANDARD AGREEMENT FOR THE SALE OF REAL ESTATE This form recommended and approved for, but not restricted to use by, the members of the Pennsylvania Association of REALTORS~ (PAR). A1S-R SELLER'S BUSINESS RELATIONSHIP WITH PA LICENSED BROKER PHONE FAX BROKER (Company) ADDRESS LICENSEE(S) BROKER IS THE AGENT FOR SELLER. Broker is NOT the Agent for SeDer and is alan: Designated Agent? 0 Yes 0 No OR (if checked below): o AGENT FOR BUYER o TRANSACTION LICENSEE BUYER'S BUSINESS RELATIONSHIP WITH PA LICENSED BROKER PHONE FAX BROKER (Company) ADDRESS LICENSEE(S) BROKER IS THE AGENT FOR BUYER. Broker is NOT the Agent for Buyer and is alan: Designated Agent? 0 Yes 0 No OR (if checked below): o AGENT FOR SELLER 0 SUBAGENT FOR SELLER 0 TRANSACTION LICENSEE When the same Broker is Agent for SeDer and Agent for Buyer, Broker is a Dual Agent. AD of Broker's licensees are also Dual Agents UNLESS there are separate Desiguated Agents for Buyer and SeDer. If the same Licensee is designated for Seller and Buyer, the Licensee is a Dual Agent. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 36 39 40 41 1. m;bis ~greement, dated ~-iJ fl f.1 . SELLER(S): J<.E.f::tk GAU3\1 P."r , is between , caUed "Seller," and BUYER(S): (} 1"1 R.O I 'j A J A (~J., A r.J (' ;;:;- , caUed "Buyer." 2. PROPERTY (9-05) SeDer hereby agrees to seD and convey to Buyer, who hereby agrees to purchase: ALL THAT CERTAIN lot or piece of ~und with buildings and improvements thereon erected, if any, known as: 3 I f\t(\..-:~ 33 /!.d sf-~,iI . _ in the eAll-lf> J./: J/ 130 r'~ 'l;i ~_ of County of c.. U M h f', 'r I ~ Ai A in the Commonwealth 0 ennsylvania. Identification (e.g., Tax ID #; Parcel #; Lot, Block; Deed Book, Page, Recording Date): 3. TERMS (9-05) (A) Purc~ase Price d/ ttfJ JJ - '- . U.S. DoUars, ,0 CjOb~O (B) (C) (D) (E) (G) Payment of transfer taxes will be divided equally between Buyer and Seller unless otherwise stated here: (H) At time of settlement, the following will be adjusted pro-rata on a daily basis between Buyer and Seller, reimbursing where applicable: cur- rent taxes (see Information Regarding Real Estate Taxes); rents; interest on mortgage assumptions; condominium fees and homeowner asso- ciation fees; water and/or sewer fees, together with any other lienable municipal service. All charges will be pro-rated for the period(s) cov- ered. Seller will pay up to and including the date of settlement and Buyer will pay for all days following settlement, unless otherwise stat- ed here: Buyer II.litials: ..;rcL Seller IDitials: ~a.cJ. AlS-R Page 1 oft 0 Revised 9/05 COPYRIGHT PENNSYLVANIA ASSOCIATION OF REALTO~ 2005 9/05 ra ~nIa AMocIation of 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 26 29 30 31 32 33 34 35 36 37 38 39 40 41 " s C-~, A A. Settlement Statement U.S. Department of Housing and Urban Development * 1r OMB No. 2502-0265 (page I) B. Type of Loan I. 0 FHA 2. D FmHA 3. D Conv. Vnins. 6. File Number 4. 0 VA 5. 0 Conv. Ins. 17. Loan Number 8. Mortgage Insurance Case Number C. Note: Tbis form Is rurnlshed 10 p"" you . 5lalem..1 of actullCtllcloo.alCOSb. Amouau paid 10 .ad by tbe _......18&..10..., ...0..... It.... 8Ilrked "(P.o...)" were p.1d .ulsld. lb. do5ia:; ...,. we _.. lurona.lIe.... pu........ ..d ...., _ Ia_ed Ia tbe lotaIs. IE. Name, Address, and Taxpayer identification # of Seller Mary McClellan, Executrix Estate of Keith Gaugler 1209 New Berlin Highway Middleburg, P A 17842 F. Name and Address of Lender D. Name and Address of Borrower Carolyn A. Chance 1173 Wicklow Court Hummelstown, PA 17036 G. Property Location H. Settlement Agent Name, Address and Taxpayer Identification Number Debra K. Wallet, Esq. 24 North 32nd Street Camp Hill, P A 17011 Place of Settlement t Seniement Dlm: 24 N. 32nd St., Camp Hill, PA UI0l2007 K. Summary of Seller's Transaction 400. Gross Amount Due To Seller 31 North 33rd Street Camp Hill, PA 17011 J. Summary of Borrower's Transactions 100. Gross Amount Due From Borrower 101. Contract sales price 102. Personal Property 103. Settl~ent charges to b~rrower (line 1400) 104. 105. ~---,- ____ Adjustments for items paid by seller in advance 106. City/town taxes to 107. County taxes to 108. Assessments to 109. SchoolTax 01/10/07to 06/30/07 110. Garbage Fee III. 112. 90,000.00 i 1,478.50 i I I 750.58 401. Contract sales price 402. Personal Property 403. 404. 405. Adjustments for items paid by seller in advance 406. City/town taxes to 407. County taxes to 408. Assessments to 409. School Tax 01/10/07 to 06/30/07 410. Garbage Fee 411. 412. 90,OOO.()( ----~ I I ~-~ I 750.58 120. Gross Amount Due From Borrower 92,229.08 420. Gross Amount Due To Seller 90,750.58 # .' 200. Amounts Paid By Or in Behalf Of Borrower 20I. Deposits or earnest money , 501. Excess deposit (see instructions) i 202. Principal amount of new loan(s) 502. Settlement charges to seller (line 1400) 995.00 ..- 203. Existing loan(s) taken subject to ---------,------------ 503. EXisting 10an(s) taken subject to ._------ 204. 504. Payoff of first mortgage loan 205. 505. Payoff of second mortgage loan -"_.~~- 206. 506. I 207. 507. ~- 208. 508. -- m__'__.___ 209. 509. ----_._~-- Adjustments for items unpaid by seller Adjustments for items unpaid by seller ----.-- 210. City/town taxes to 510. City/town taxes to I 21I. County taxes 01/01/07 to 01/10107 I 13.17 51 I. County taxes 01/01/07 to 01/10/07 I 13.17 .--- 212. Assessments to 512. Assessments to =t= 213. School Tax to 513. School Tax to 214. 514. 215. 515. 216. 516. I I ... -- 217. 517. =L---- 218. 518. 219. 519. I I 220. Total Paid BylFor Borrower I 13.17 520. Total Reduction Amount Due Seller 1,008.17 300. Cash At Settlement FromITo Borrower 600. Cash At Settlement TolFrom Seller 301. Gross Amount due from borrower (line 120) 92,229.08 60 I. Gross Amount due to seller (line 420) I 90,750.58 302. Less amounts paid by/for borrower (line 220) ( 13.17 602. Less reductions in amt. due seller (line 520) ---t< 1,008.17 [K] From o To Borrower [K] To o From Seller , 303. Cash $ 92,215.91 QB. Cash I $ 89,742.41 ! I i :;uo; lUOUmO'dS'm Amount Due 11) 1Seller- ~~. J- .. w.... I have carefully reviewed the HUD-I Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my accoun.t b. y me in this nsaction. I certify that I IJfve ~ved a completed copy of pages I and 2 of this HUD- I Settlement Statement _ .. \ ,/!{t . ~. ./ ' t1vC7-u;c) Borrower Carolyn McC ellan, Executrix Seller Seller-'s Taxpayer- Identification Number- Solicitation and Certification You are ~uin:d by I_to Jl!'Ovide the Settlement A&c!It named above with your com:ct ~ ldcntificalion number, If ~ do not Jl!OVlde the Settlement A&c!It With your correct _ identificalion number. you I!"'Y be subject tq civil or cril"inal penalties ill1JlOSC!l. by ,law, Ynd<r J!Cl'8ltiei of pctjuay. I certifY that the numbir shown on this statement IS my correct IIXpayer tdciinficallon nun1ber, Borrower SETTLEMENT AGENT CERTIFICATION The HUD-I Settlement Statement which I have ~ is a ttuc and ....... account of this transaction. I have caused the funds to be disbursed in a<:cordance WIth this _oment. Settlement Agent Date WARNING: 11 is a crime to knowinidy make fill.. _IS to the United SbII9 on this or ..y ocher similm' ti:Jnn Penalties upon conviction can inchuIe a fine and imprisonmcnL For dclails see: Tnle 18 U.s. COde section 1001 and Section 1010, Seller's Signature Date RESPA, HB 4305.~ HUD - I 3/91 . Sc. \ B r &- S '\. c\ \ D c... 'i\ Q ,>'<.. l\ .. ,r",. l...l '\.~-) ~G- 1/10/07 Mary A. McClellan, Executrix for the Estate of Keith A. Gaugler 1209 New Berlin Highway Middleburg, P A 17842 RE: Date of Death Values for Estate of Keith A. Gaugler (D.O.D. 11/8/06) (" Security Value as of 11/8/06 .< ! ING Annuity - Contract C038123 GG $131,630.07 1- :r..R~ ING Annuity - Contract COI0878GG " $109,119.09 ~ American Balanced Fund (BALBX) $6,486.96 l ....Reserve Fund Money Market Acet $0.61 TOTAL: $247,236.73 ,;:l., The information contained in this document is from sources we believe to be reliable, but we cannot guarantee its accuracy or completeness. The prices listed here are averaged over the course of the trading date of the death of the account owner. The information in this document does not constitute tax or legal advice, which FBW and its investment executives do not offer. Please consult with your tax advisor or lawyer before using this data for any tax or estate settlement purposes. FERRIS, BAKER WATTS Incorporated / . ING.IIJ CLAIMANT STATEMENT o ING USA Annuity and Life Insurance Company,~) f'L o ING Life Insurance and Annuity Company M Q.. ~ \ \":j -=t \"\ IT P.O. Box 9271 ~ Des Moines, IA 50306-9271 ~ 1-800-366-0066 Please indicate plan type: ~. Qualified 0 Non-Qualified If this is an election of Spousal Continuation, please complete sections 1,2,7,10 If this is an election for Life Expectancy Deferral. complete sections 1,3,7,8,9,10 If this is an election of Lump Sum Payment, please complete sections 1.4,8,9,10,11 If this is an election for a 5 Year Deferral, please complete sections 1,5,7,9,10 If this is an election to Annuitize the Contract, please complete sections 1,6,8,9,10 CONTRACT/OWNER INFORMATION (This section must be completed for all transactions) C 01 0 %7~ frb- Deceased's Name k('e /1 fI A . /1 ! CJ g I C) h Beneficiary ~ A R Y A 1'/\ c.L t. c I- LA. rJ Beneficiary's SSN ,q ~ ".. 3 Z, ~. 5'.5 :2.. ~ (':) :L fdL 7 (4 g Nw.)]Jer: (Ih City (YJ; clel (-e b 1& r J-- Contract # G,AU6II-I3IC- Date of Death Deceased SSN 1~8 - 3g - 1~9g-' Beneficiary's Date of Birth Beneficiary Address 1;)0 q Relationship to Deceased S I 5 'T ~ ~ Beneficiary Phone c-~ 7 t) - 83 7 - .3 I 0 I 1-/ w 'I State PIl Zip J 7 g-tt2-. INSTRUCTIONS 129842 0613012006 · Provide a certified copy of the Death Certificate (which must indicate the cause of death) and if death occurred outside of the United States, a Consular's Report of the Death of an American Citizen. · Please complete one Claimant Statement for each beneficiary. · If a Trust is the benefidary, please submit the entire Trust agreement. · When a policy is payable to the estate or executors or administrators of the annuitant, the statement must be made by the executor or administrator and a certified copy of their appointment must be furnished. · When the policy is payable to a minor, the statement must be made by the guardian of the minor's property and a certified copy of their appointment must be furnished. . Some benefit options may require multiple signatures. Make sure when completing this form that the beneficiary has signed in all requested places. · If an alternate mailing address is desired, please complete section 8 in full. If this section is not complete, checks will be mailed to the address entered in section 1. For non-spousal beneficiaries, during the period between the date of claim and this election, the account value will be allocated into an interest bearing account with ING. Page 1 of 4: Incomplete without all pages S c\\c (~-.\ ~ ..... '-.) THEVanguardJROUR _-? KEITH A GAUGLER 31 N 33RD ST CAMP HILL PA 17011-2702 Trade date Transaction Beginning balance 10!31---'ooOJnelf1vkten:cr----- - 11/10 Checkwriting 1001 , Income dividends $ 4,687.51 VANGUARD GNMA FUND ADMIRAL SHARES · Do not alter or photocopy this Invest-By-Mal slip. · Visit www.vanguard.com or call to change your address. Llsteachcheck $ D,DDD,DDD.DD separately. $ D,DDD,DDD.DD $ D,DDD,DDD.DD $0,000,000.00 Totalamount $ D,DDD,DDD.DD 053b1 091:fb8802215 307 20 November 10, 2006 Page 1 of 1 Vanguard GNMAFund Admiral Shares I\:) (03 8 800-345-1344 (800) 662-6273 Fund number: Account number: - Flagship Service J LIDDELL 5352 F/S - T ele- Account 536 9968802215 ACCOUNT VALUE On 11/10/2006 $ 107,228.77 DoBar amot.I1t Share price Shares transacted Total shares owned 10,844.895 4/.408 - 10,892.353 -410.557 10,481.796 $ 484.55 -4,200.00 $ 10.21 10.23 FUND/ACCOUNT NO. 0536/09968802215 KEllH A GAUGLER Make checks payable to: The Venguerd Group - 0538 VANGUARD FLAGSHIP SERVICE PO BOX 13750 PHILADELPHIA PA 19101-9897 I.. .111.1.....1111. ... ..111.1..1..1.1.1..1. ..1.1.1.1 019396040 013161 2 1 - 1 2396 DLY Q1 2 p<i 1..URmIWIUH..uu.mnU.U.IUffinmu,m, 1057 0425 12896 Y r-s-~~ ------~~-----I-----Fw;~Bank STATEMENT OF ACCOUNTS 5505-62603 STATEMENT PERIOD FROM THROUGH 10-10-06 11-06-06 0 PAGE 1 OF 1 LISTENING. ......-.' x 1'1.111...111'111"11".11"1.11,"111.....1.1..11....11.1.111 KEITH A GAUGLER 31 N 33RD ST CAMP HILL PA 17011-2702 FULTON - CLASSIG-- CHECKING PREVIOUS DEPOSITS/ STATEMENT BALANCE CREDITS 981. 06 CHECKS/ o DEBITS .00 o ENCLOSURES o ACCOUNT: 5505-6260G SERVICE ENDING 4 FEES BALANCE 274.29 .00 706.77 INTEREST PAID THIS YEAR ACCOUNT/INTEREST INFORMATION 2.14 DATE ACTIVITY DESCRIPTION REFERENCE 10-10 BEGINNING BALANCE 10-17 PAWC PAYMENT 061016 00077900000 -- 0637754 10-20 VERIZON PAYMENTREC 00077900000 URRING 7177613839324 11-01 COMCAST CENTRAL 00077900000 CENTRAL PA 110106 18577401 11-02 PP ELEC BILL 00077900000 4345317379WS 11-06 ENDING BALANCE DEPOSITS/ CHECKS/ CREDITS DEBITS BALANCE 981. 06 943.09 903.42 37.97 39.67 47.85 148.80 855.57 706.77 706.77.;/,,( SERVICE FEE BALANCE INFORMATION FROM 10-10-06 THROUGH 11-06-06 AVERAGE LEDGER BALANCE 890.26 AVERAGE COLLECTED BALANCE MINIMUM LEDGER BALANCE 706.77 MINIMUM COLLECTED BALANCE 890.26 706. 77 "EFFECTIVE NOVEMBER 2, 200~i WE WILL BE INCREASING THE DAILY VISA DEBIT CARD PURCnaSE LIMIT TO $2 000 OR T~ AVAILABLE BALANCE IN YOUR ACCOUNT, WHICHEVER IS LESS. ,---. DIRECT FULTON BANK DIRECT BANKING CENTER TlITnnTlHlt'!::: Tn. pn 'Rmr l\nla. Member FD.I.C. s c, \\ c d. L.{ I e..- - ')~;. "..-., .~~ ~l;;;r /)i0(fJ((; ,- F: --- d-' 11 ~ r- CD co . i' ~ ~ u CJ) ~ E9 ::r:: CJ) <( u I- 1*' . I: Uii : ~ t"a ~m :: ~ Illii~ ; g 0 im~ . e... f;!~ ~ I~id <~~;ili ~~~l!l9 :~;"'''-'"':;';'''''''''''''''''''''''''~''-:Im''''~ ~ (8 I ~". i cD L ~ ~ ~ -- ::e ~ ........ ~ ~ ~ ti -3* ~ So... <U - ICI"o ::$ ~ <.!:) ...;e:;. -I-" -.... o(IJI ~ -.- o o(IJI ........ "-ot> ....... tA l..LJ ~ ~ ~ ~ "* -r.:::a ..- c:: ~<C ~ ~ ....~ ~ --....... -- ....... tC""'-I 0 ;ClI ....... ~ ..ac: oM- oc::J'o "* -.-. -3HE-LLJ ~ . :::=-. ....... o(IJI -= ...... :z: -0 oQ.I L. ""1CI c:: ~ :x: 01' o(IJI L. ...;e:;. J-- -r.:::a c:: n:li u\ ::$ o ...;e:;. I-- (U II;: 9 :::=-. ..,i-J' -= o(J.t :::F I-- ~ u\ ....... c:: o(I.lI oC....:lr ...- CD '!.: [\- c:c C'- c:c - rl'l - rl'l o .. - ~ .J [lo- U t:C C C ~ -r.:::a ~ ~ c.~ J-- -g "J!'l : i ~ ::$ .r ~ ~~; ~ I ~~o ~~..:_..u - _._~~::~3:~~~~~~~~~_~~~'i-W:~~'~ ,...- ) ~) c:..\t co ....-\ C F~ 3 Or1, , Sovereign Bank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Keith A. Gaugler 188-38-1898 November 8, 2006 Account #: 2335360554 Type: In the name of: Keith A Gau er ITF Elsie Date of Death Balance: Int.(YTD) from 1/1/2006 to Accrued interest to date of death: $72.21 Other Info: Accounf closed on 01109/07 for $62,215.97. ----. \. CD) _ ",.;,;:;- , Open date: 5/31/2002 : $2,386.84 /'" ~ Account #: 0571112412 Type: ( Checking) In th~=:'~~~Ugler ~.~ Int.(YTD) from . 11112006 to '11. Accrued interest to date of death: $0.00 Other Info: Account closed on 01102107 for $5.07. Open date: 9/411996 : $0.07 7 Blue ~oo~\~ tPri~ate~a~:riCi~ Report - Che~le~. Cavalier p"'~~ ,'; j~-"""..' ;"'~'"'l .... ....."'" ,',"~.},:..'",.,f KeUev Blue Book THE TRl.STEr) RESOURCE, kbb.~"m http://www.kbb.comlKBBlUsedCars/PricingReport.aspx?trid=3&Ve... .......""1...... Flu> ..----- advertisement Quick Dealer Price Quote Search Used Car Ustings Lis ~~ H()ITlE1 > USE!d~T!i > S..E1d~!) > l:hE!Y~"E!! > 9!valier > !~~ > ~~~1!4D > Equipment Her Sedan 4 Trade- In Value Private Partv Value Suggested Retail Value Photo Gallery Review Specifications Compare Vehicles Shopping Tools Free CARFAX Record Check Auto Loan from 6.65% APR Compare Insurance Rates Payment Calculator Extended Warranty Quote Print For Sale Sign r; J' ~. lSL: :.M: on Blue Book Classifieds.... Chevrolet Cavalier 30 Miles or less ZIP Code 17842 To View Ads, Click ;;.:_l YC:_.I.~ j S:U ,>. on Blue Book Cla.sifieds.... Reach millions of shoppers on kbb.com, Cars. com, and other popular sites. of4 HUt gOOK JRI'/,~.l t p,~,y Y Vj,JJl: '"', ~~r ...-....... ...................... ...._..,...~...:_-,...,......~........".....:..... '.......... . ...... '. - .... " .. __XH" :-,"V~ . ..... .."..l"."'"'''''''' More Photos Vehicle Highlights Mileage: 80,000 Engine: 4-Cyl. 2.2 Uter Transmission: Automatic Drivetrain: FWD Condition Value Excellent .$3#'~O ....' ....::,..,.. ( i~,~~~j Good Fair $2,525 Search Local Listings Sell Your Sedan Prir Estimated Pay $59 lmo 0 6.95% Get a Pre-Owned L 6.65% APR Your Credit Score 1 Get a Free Insuran ad C- \'1\. E 17 o.;h4 r 'Prrs6h:i? l'fropn+/f ITEMS PURCHASED FROM KEITH'S ESTATE MARY Sewing Machine $ 25 Vase 10 Chair 9 Quilt 25 Clock 12 81 LOIS Chest 25 Rocking Chair 25 Bank 10 Figurine 10 Box .2 75 GAIL Horse Statue 10 Coffee Grinder 48 Drindle 17 75 <-7~f(( ( ~2 ( HOSPICE OF CENTRAL PENNSYLVANIA P.O. BOX 266 ENOLA. PA 17025 S c..'v\ E- >? PENNSYLVANIA STATE BANK 60-2441313 DATE 34584 AMOUNT Nov 15, 2006 $ ***$2,200.00 AAY ~wo Thousand Two Hundred and 00/100 Dollars TO THE" ORDER OF: Keith A. Gaugler c/o Mary McClellan 1209 New Berlin Highway Middleburg, PA 17842 9:~-u.II: ~ '~I-':~l":'" \:~/:;i':l)l~E --- i'",? 11.0:\....58....11. I:O:\~:\O~........?I: ~q5 OOO~ bill "'",. / ,- rJ' LA. /." ",. 1 :ii '/ "--'" - '?PL Electric Utilities Corp. Date 03119/2007 Vendor Code 0000257562 Check No. 0010880960 Allentown PA 18101 Print No. 58294000076 Total $..........189.38 Invoice Dat(!__~_______..__ Invoice Reference Message Code Net Amount 03/1212007 434531737900 189.38 Customer Refund Service Address: 31 N 33RD ST CAMP HILL. PA 17011 '-_.-~ Message Code Key ~~ \ ) '- NA . THIS IS WATERMARKED PAPER - DO NOT ACCEPT WITHOUT NOTING WATERMARK - HOLD TO LIGHT TO VERIFY WATERMARK PPL Electric Utilities Corp. Two North Ninth Street Allentown PA 18101 . . . .. \..~_.I * "V..-<f~# ,. ppll=: ......, .... No. 0010880960 62-4 311 Void after 180 days Date 03/1912007 $*-***-189.38 --One Hundred Eighty-Nine and 38/100'US Dollars-- OAYTOTHE ~DER OF: '--" KEITH A GAUGLER 31 N 33RD ST CAMP HILL PA 17011 Mellon Bank NA. /~~;;~ / ----- /' , , ""~).:. l'.f cf u.,t..<... E~ iL l COMCAST CABLE COMMUNICATIONS 040CBDT-00000369165I 4008 N. DUPONT HIGHWAY ATTN: SUPPORT SERVICES NEW CASTLE, DE 19720 @omcast. ~ 05131 KEITH GAUGLER 31 33RD ST N CAMP HILL, PA 17011-2702 '1111"1111"111111"1111111'111111"'11111111111'1111"1'1'1' Dear Keith Gaugler, '-" Check Date: 02/03/2007 Check Number: 158223986 -- ~ - . = E . iiE5iii - !II iil - - Ii E . - Ii == - The attached check represents a subscriber refund for account number 09547-185774 in the amount of $12.38. If you have any questions or concerns regarding the refund check you can write us at the address above or call Comcast's toll free customer service number at 1-888-COMCAST. DETACH AND RETAIN THIS STATEMENT THE ATTACHED CHECK IS IN PAYMENT OF ITEMS DESCRIBED ABOVE IF NOT CORRECT, PLEASE NOTIFY us PROMPn Y. NO RECEIPT DESIRED. --------,-------- ---~--~._^ ,.----- r --..-- ---._"-~*~""~~-~".~'--"''''''''''~~_._'' ~ .::~;;~{~~J~r;~_;~,~~-;;;;;i~;J-;J~~i""~~Ji~illi~~;F~~;h;;iim-[~~:;~,~!-~Tl. -- ~. OMCAST FINANCIAL AGENCY CORPORATION COM CAST CABLE COMMUNICATIONS GROUP COMPANY 158223986 23-97 1020 02103/2007 w EXACTLY: TWELVE DOLLARS AND 38 CENTS I $ ********12.38 ) THE ORDER OF: KEITH GAUGLER ~RIBER ACCOUNT NUMBER: 09547-185774 "-..... .I ~4, >1 Al'THORIZED SIGNA Tl'RE JetI by Illteuraled P3\-rnem: SV51ems IlK.. Englewood. Colorado \-1org.nn C~$e Bank.- N.A.. D-m\'er. Colorado ""': '. ". c ~ -liAmmoN BF'ADDJlIlONALSEClm!iJ:X ~'t J.NJ)1 ~l . N EV, 5e J < i" , ' ~ . e '~\ \ ~..- y-- .....--- GAUGLER KEITH A C/O MARY MCCLELLAN MIDDLEBURG PA JO AGENT NUMBER: 0005564 ISSUE DATE: 01/24/2007 17842 PLEASE FOLD AT PERFORATION BEFORE SEPARATING CHECK MCO 05; MOD 00 ~ # . GAUGLER KEITH A C/O MARY MCCLELLAN MIDDLEBURG PA 17842 . AGENT NUMBER: 0005564 ISSUE DATE: 01/24/2007 MCO 05; MOD 00 PLEASE FOLD AT PERFORATION BEFORE SEPARATING CHECK 1:I=-;r'III::ll']..:n:t"I'IIIIJ~I:u..:r''''-':'.II'].'J:I:''.:J..n~~~e):I'lIJ~I'I"~.'I'J:I.'=-:l'I~::lI:_!.'I'lI'.:l'UU'Ie'I:lo1:l:.'UI'.'~1l'm'J.I~I=-:l:m"ln( PJW to THSORllER OF DONEGAL INSURANCE COMPANIES FOR RETURNED PREMIUM liP 5036556 INSURED: " GAUGLER KEITH A r;;-A.UGLER KEITH A C/O'MA.Rv MCCLELLAN MIDDLEBURG .' PA MEllON BANK PITTSBURGH, PA ~ 433 ISSUED BY: DONEGAL MUTUAL INS. CO. DATE: JANUARY 24, 2007 CHECK NO. 2627902 . L 17842 PAVI$******1<**211.00<1 CHECK IS VOID OVER $5,OOO.OOWf'THOUT1'WO SIGiIIATURES VOID IF NOT PRESENTEDWlTHIN 6 MONTHS FROM ISSUE.DATE , .. - ... .. THE fACE O~ HIS q~!J EN1I1A~ ~ CqLOR!:.D BAC~~ 01.1 DO, I;lIJi!.i A , A \lOID BAN\ljOGRA H ANQ Ie QUNE BINiflNG .. . . . FOR PAE KEITH A PAVTO THJ;OROER OF 1 784;~ II- 2 I; 2 I; I, 58".' 1:10 l., :I 3110 I. 1;10 ~I: rvE .L:N 'IM,I' ~]!L). PlnSFlIFI3H, i',\ 43< lSSUE) f,": DONE':;Al. MlT'UAL INS. CO, DATE: ~Jl,NUAR If 1.5, 2007 CiECK NO. 2626J.58 PAY [;:*1.*;r'~~~~~~ .::Hl:C< IS VOID OVI5R $5,OOIl.OO WITHOUT TWO SIGNAtuRES VOID IF NOT PRESENTED WITHIN 6 MOr~THS FROM Issue DATE 10 LI,I'II] 'i'1:1 ~1I1 . . GAUGLER KEITH A C/O MARY MCCLELLAN EXEC 1209 NEW BERLIN HIGHWAY MIDDLEBURG PA 17842 AGENT NUMBER: 0005562 ISSUE DATE: 01/15/2007 MCO 05; 01 CAe!:: enl n AT r:'lIr'Cr.n~^nA . MOD = 09 . .".\ C--\ ,,";~Y;'~J;~ fl~' ~~'.' ,i - . ~f \i!Z~~':;;;~"~~ 11120521:.111 8 / 1 r 'ps([rrnSllIIJ 1tfi7t P 062, 769 , 731 . .... ~~ Check No. ~ 11 08 06 81 PHILADELPHIA, PA 2052 25371674 28045300 S1 B 1...11I11.1111'"111111I11"1.11'1111I11'111.11111'11I11.1.1.1 KEITH A GAUGLER 74 31 N 33RD ST CAMP HILL PA 17011.2702 2052 25371674 P SOC SEC FOR OCT $***1519*00 11IO......__ VOID AFTER ONE YEAR .: 0 0 0 0 0 0 5 ~ B.: 2 5 ~ 'i' ~ I:. 'i' ... q III 0 B ~ ~ 0 I:. '('.'nf(ril.~lrmmtm1~~~1 P 106,741,660 b' \ "~~I\, "i ~~~~/ 05 04, 07 66 AUSTIN, TEXAS ~ -' 2308 06338539 20092800 130 OGAUG Pay to 111111111111111111111111.11.1'11111.1..1.11111111111.1..1.1..1 the order of KEITH A GAUGLER 1209 NEW BERLIN HWY MIDDLEBURG PA 17842-9380 ;;!; M M = III ~ j [) 8 C; III "'-......J c' . e Check No. B:Yo':':' . .. I 2308 06338539 PHILA TAX REFUND 12/05 39 $******5*12 ............-u0Rl:lR VOID AFTER ONE YEAR -:0000(]0518-: 0 b ~ ~8 5 ~ q q,,1 01.050 '1 E- '-;;l /. .' '"f ""'.1 " . ., 'i I )<;;...,c.r, L-v.'{ ., .' ",. ~ "~. ( ,f Privacy Office One CVS Drive Woonsocket, RI 02895 1371785 MARY MCCLELLAN 1209 NEW BERLIN HWY MIDDLEBURG PA 17842 1...111...11. .1. .1..1..1.11.1....11.1..1.11...11...1.1..1.1..1 DOOOOS U1 . tl0 PRIVATE" CONFlDE."lTIAL INTENDED FOR ADDRESSEE ONLY February 7, 2007 Enclosed is your Patient Prescription Record, as recently requested from CVS/pharmacy. To cover the expense of processing these records, please remit a payment of $6.00 to: CVS/pharmacy, Privacy Office, One CVS Drive, Woonsocket, RI 02895. The Federal Tax ID number is 05-03-40626. If you have questions regarding this report you may contact the Privacy Office at 1-800-287-2414 or e-mail usatPrivacyOffice@cvs.com. Thank you, CVS/pharmacy Privacy Office CVS phannacy A,,~'../(/",<-,t{ . ( Privacy OffICe One CVS Drive Woonsocket, RI 02895 1371785 MARY MCCLELLAN 1209 NEW BERliN HWY MIDDlEBURG PA 17842 \ (p( 01 ~l ll~ ,# I" ~ l/ Private and Confidential Intended for Addressee Only 0210212007 Enclosed is your Patient Prescription Record, as recently requested from CVS/pharmacy. To cover the expense of processing these records, please remit a payment of $6.00 to CVSlpharmacy, One CVS Drive, Woonsocket, RI 02895, Attn: Privacy Office. The Federal Tax 10 number is 05-03-40626. If you have questions regarding this report you may contact the Privacy OffICe at 1-800-287-2414 or e-mail usatPrivacyOffice@c.com. Thank you, CVS/pharmacy Privacy Office ~ .J..:~)~., .'((,(PL j " VNA of Central PA, Inc. 3315 Derry Street Harrisburg, PA 17111 (717) 233-1035 .f:./ / INVOICE 12/1/2006 MCCL001 1 /Afn'ouiit1ditHF/'C' "I' 'I Customer 10: Payment Terms: MCCL001 MARY MCCLELLAND 1209 NEW BERLIN HIGHWAY MIDDLEBURG PA 17842 The VNA accepts Mastercard & Visa for your payment! Credit Card # Expiration Date (mmddyyyy) Name Address --- - _.M. -C1ty-State-Lip- Signature 3-digit card verification* *Found on back of card within signature block ^Please return top portion with your payment^ ITTI 12/1/2006 12/1/2006 SLS SLS $174,59 $255.17 NOTE: IYd I v , t ~ l. Codes: SLS SCH DR Invoice Scheduled Payments Debit Memos \/MA nf ('on+r~1 PA In,.. Hospice Pharmacia for Oct 06 Hospice Pharmacia for Nov 06 $174.59 $80.58 PER DIEM CHARGES FOR HOSPICE PATIENT - KEITH GAUGLER. !/~;/{) 7 1tJ(?J $255.17 FIN = Finance Charges SVC = Service I Repairs WRN = Warranties CR RTN PMT Credit Memos Returns Payments ":l":l1" nor.." ~+..oo+ ....~rri~hll..n PA 17111 1717\ ?":l":l_1n":l" ':::::.. 1_ J, .. ..-/ ' .:;:"'" rE1TH A GAUGLER = 31 N33RDST CAMP Hill, PA 17011-2702 -r- ..,., .CASH CONVENIENCE CHECK 1081 Oiiiiiiiiiiiii - Oiiiiiiiiiiiii ;;;;;0;;::= - , - , -..... ~ - PAY TO THE ORDER OF" ...% VlZ 0\% 0% ..... I .....z "'Z ....z 0% O. NZ ....< NZ ...z O. 0< 0< ...< z $1 55-7267/212 I DOLLARS Oiiiiiiiiiiiii Oiiiiiiiiiiiii - Oiiiiiiiiiiiii !!!!!!!!!!!!!!! ---.-- ....- This document contains protecllon aqalnst alterations; absence of a watermark wllllncllcate . COPY. AT&T Unlvltrsal Card Cltlbank FS8 111 Sylvan Ave EnIJlewood Cliffs, NJ 01632-1514 0330149~038090809030 MEMO 1:0 ~ . ~ 'i' ~b 'i' .1: qo 38oQ08oQo 3011- .08 . AT&T Universal Platinu~~ard Chorter Member ':)l ~ ~~ ~ ~\t KEITH A GAUGLER Account 5396 5501 9328 5330 Calling Card + PIN October 12 - November 10, 2006 Quick Reference Minimum Payment Due........................................... $10.00 Due Dat8"........................................... November 30, 2006 .Payment must be _elwd by 5:00 pm local time on the payment due dllle. Credit Line ..... .... .... ......... .... ........... ........... ............. B'SOO .00 Available Credit.................................................... ,311.00 Cash Advance Limit............................................. .500.00 Available Cash Advance Limit............................. 6;500.00 Account Summary PreviOUll Balance Payments ~d Adjustments ~~~W~~- o - Servl~ New Balance 90S 93 -fgl~~ $188.74 Note: Detailed activity starts on page 3. Pu:~~~~~i:...w.e ,. t..... ""'11" ....... 11ft. ~ A"nIaT Universal Card Page 1 of 4 How To Reach Us Visit: www.universalcard.com Customer Service: 1-800-423-4343 or write Cardmember Services; PO Box 44167 Jacksonville, FL 3223 -4167 Because of the careful way you manage your account the minimum payment due on this statement has been reduced to $10.00. If you prefer to pay your regular minimum amount due, it is $20.00. Please remember finance charges will accrue as usual. Thank you. .cASH~EN.YQU_KEEllJT- !t'g .."..ier-than- ever to get cash, up to your available Cash Advance Umit. Tear off the attached check, deposit it into your bank account, or use it like any personal check. Convenience checks access the cash advance portion of your credit line. Refer to your Card Agreement for specific finance charges. MANAGE YOUR ACCOUNT ONLINE-FREE, EASY & SECUREl View your statement, recent purchases, and balance; pay your bill and sign-up for customized email alerts about your account. Do all this and morel Register at universalcard.com Use your Cltl card to receive $10 off your first 20 lb. gift box of AI's Family Farms Florida Citrusl Navels, grapefruits or mixed. Reg: $34.95, intro price $24.95 plus s&h. To order: 1-866-743-6277, Dept. 07)(, or www.enjoycitrus.com r.'........-L...&.__ !I'(' '. ~ ..,d,1 ~// f' ij;~.%-'(( /.ltl / ./ " . .. VNA OF CENTRAL PENNSYLVANIA 3315 DERRY STREET HARRISBURG, PA 17111 Phone: 717-233-1035 Fax: 717-233-2759 Invoice Date: 11/30/2006 Invoice No: 2711711302006 Tax 10: 231352571 Insurance No. 27117H Patient 10. 27117H Send remittances to the address shown above: MARY MCCLELLAN 1209 NEW BERLIN HIGHWAY MIDDLEBURG, PA 17842 Services For: GAUGLER, KEITH 31 N. 33RD ST. CAMP HILL PA 17011 INVOICE .......... _.__,___. ............'..............__. _' ...._.".,.._.. .. .,' ..... __. _.........,.'_,............,............v.......'....... --," ..'c",.,',. ," 'INVOiCe -F()R'iHOME:-HEAtTri~ER\ffCest1/o11200$.TI-lRoUGH-.1113012006 Si;RY'CJ: .. '. .... . SKILLED NURSING SKILLED NURSING TOTAL ~l RATE 120.00 120.00 UNITS $ AMOUNT 1.0 120.00 1.0 120.00 TI.ME .IN-QUT . 10:00A-11:25A 12:30P - 01 :40P 240.00 ..... ........\.. ..~. ~....l b1 \l ... TOTAL AMOUNT DUE $ PJ:RSON RMULHOLLANO J NEFF 240.00 . -' /{ -Cl J ,.'-.f '1'" .fl ( INVOICE I , HOSPICE OF THE VNA 3315 DERRY STREET HARRISBURG, PA 17011 (717) 233-1035 Invoice No: Invoice Date: 00001771 10/31/2006 Payor: Client: 27117 Gaugler, Keith 31 N..33rd S1. Gaugler, Keith 31 N. 33rd St. CarnpHiII, PA 17011 CampHiII. PA 17011 Quantity Service Service Date Price Total Charge 1.000 Skilled Nursing 10/19/2006 120.00 $120.00 1.000 Pastoral Services 10/23/2006 120.00 120.00 1.000 Medical Social Worker 10/23/2006 110.00 110.00 1.000 Skilled Nursing 10/26/2006 120.00 120.00 Invoice Total 470.00 ~~ ~\ \~~ , [, ,( .,,- '" J--. /4c-f'r "t;,c,.cA.:.., -- it ( BILL TO: MARY McCLELLAN 31 N. 33RD S~REET CAMP HILL, PA 17011 CENTRAL MEDICAL EQUIPMENT CO. 35 SARHELM ROAD HARRISBURG, P A 17112 (717) 657-2100 717-657-2176 FAX TOLL FREE: 1-800-845-4204 www.centralmedicalpa.com .. .... DELIVERED TO: KEITH A GAUGLER 1701 LINGLESTOWN ROAD HARRISBURG, PA 17110 .. ***********0979 FEDERAL TAX #: AMOUNT ENCLOSED $ Pt.fASE DETACH NlD IlEIUIlN MS I'OllIlON WItH VOUR _IfJANCIlO INSURE PllOPIR CRBllJ A:S:&:TIi A-GAtiGLEA EACH 02 CONCENTRATOR 01.F256245 . $1.85.00 EACH $185.00 185.00 (eY /\0 \V'v ~ Pt.fASE _1Hf IOIlOM I'OllIlON Of THIS IlLL FOR INSUlIANCI AHOIOA TAX PIIIIPOSB. I (pO J/Z) ~ T = TAXABLE C = COPAY D = DEDUCTIBLE TERMS: DUE UPON RECEIPT THANK YOU VNAH CENTRAL MEDICAL EQUIPMENT CO. . 35 SARHELM ROAD, HARRISBURG, PA 17112 (717\ h<;7-11 00 717_h<;7_'17h FAX TOJ.J.FRFF,I_ROO_R4"_4?04 , c .l~{/.~lj....1 _"z-J / BILL TO: MARY McCLELLAN 31 N. 33RD STREET CAMP HILL, PA 17011 CENTRAL MEDICAL EQUIPMENT CO. 35 SARHELM ROAD HARRISBURG, PA 17112 (717) 657-2100 717-657-2176 FAX TOLL FREE: 1-800-845-4204 www.centralmedicalpa.com ............. 0 .. . .. DEliVERED TO: KEITH A GAUGLER 1701 LINGLBSTOWN ROAD HARRISBURG, PA 17110 ~ FBDBRAL TAX t: AMOUNT ENCLOSED $ PlEASE DETACH N/I) IIl1\IIlN 1HIS POI!IION WI1H YOUR REMnTANCE to INSURE PROI'Bl CREDIT AE!Tii A GAuGLER 11/02/2006 BED ELBC EACH ALTERNATING PRES PUMP WITH PAD 0945-17056203 ental. $40.00 EACH 1 EACH BED FULL BLBCTRIC RAILS/MATTRESS INCLUDED 0570-IVC03L868421 ental . $120.00 EACH $40.00 ORt 00152961 40.00 $120.00 120.00 u\f . I ~ \1 ~\ 160.00 PUASE mAIM 1HI! IOl1OM POIlIION OF 1HIS IlU FOR INSllIIANCI AND/OR TAX PIJlll'O\'5ES. T = TAXABLE C = COPAY D .. DEDUCTIBLE TERMS: DUE UPON RECEIPT THANK YOU VNAH CENTRAL MEDICAL EQUIPMENT CO.' 35 SARHELM ROAD, HARRISBURG, PA 17112 '..,1"'1\ 1"..1:,.'1 "1nn ""1.-' ~c., ')1.,1'.. I7AV Ten I J;"DJ;"J;". 11lOO~1l"<::~""OA "'~ '---' -.,... ,......, vI, /<~f <~ - J!. .,( (_ ~?Y 2- MMY~~~ IIifIt 121 .:u":...~= ..,. 'C;?~~/~ 7 :::..::IR.s-,..;,jED~"I\Tt~ iliWu",,", ,S /9Sr.tfd ~f~~~;(.Tri~:t!"l,~:: .s~ ...:Pb",~~"h~ ~.~w ';:llUU3&l?': OOO~03BB5~ O.?z~~A5qOO" 121 04/12/07 1.959.00 ~~~ 9' 122 . ::....~? -,,~ ,-,~ :::.':: It AQll" ~ ' S !Jt3~.g Ji.u<.JI~~,,",,-4~-/.f.~. /j "c.' . .$~ -ftUii:Z~-. . <t:~~ w I:03~3~3&l?l: OOO~038B~l~)0'3?OO" 122 04/12/07 3.437.00 Swin~ord -National Bank \ Member ED.I.C. .......,;""......f............. ,................ .' ,1' ~l Z- Swin~ord -National Bank - 1WrY~~~ ltjJI1 116 I_JC:"lII''''''''~, _ ~~- f~ -~""~1'~7 ::.::;:< 1';;. i).p/: t: -ik aft/(.. , S.;l 7. nJ ~ -kl:.-<2../~ - _,un 81 '",.... ~ .~~ ' .Jdf~-NIU4; ~<f.J,lr~. ':ouu.. 21': 800~0.88S" 'ol(, "'000000/100'" 116 03/23/07 27.00 KEITH A. GAUGuJI ESTATE lIMY A.1Ic:CUUAN,. EXB:UtRIX r-.ICW ...... ..... --..- .IS 1:1.. n 117 03/09/07 1:2":00..-----... IWIY~~~ 9' 118 ~~= _n~,,4~.f..h7 ==:-~~d~~~~~~:~~~~ I SElflJ,c-c) .-.k<.e.<<. ~,{. a.-/ ~d-_,... fil :,.. ~ .4"~ ..~.5~ 'mv."qd.)J;'fC<<ittd-. ':0 u. H. n.: ooo~o .88 S" 0 1I-l1 ( -I,IOOO~oo'" .=.1 \ ) 118 03/14/07 300.00 ~~~~ -;PI 120 ......,..... ttW'f. .... ~M ,,. _'17}lee/.-0~ 1 ::.::;:,PA. ~;t'1'4-~ . ;,~ s.;y,..s..-D "/1....... ~uL-~1f -.:1.......a...r)l\j,..u.. 81 =- ~ . _n. . 7rJ:v-1lCl >>It ~__ . ':OHHU/1': 000~D"8BS" lX'J/D{~EIodol>>l,soo... \ \ \ \ \", 120 03/12/07 375.00 ../ ~ --~..----' -. --.---..-.-.---" .~ Member FD.I.C. ... ", ~ 'l (l-7/r3 -~-;;;7i7-- -------------- Fulton Bank 1057 0425 12839 Y LISTENING. STATEMENT OF ACCOUNTS 5505-62603 X STATEMENT PERIOD FROM THROUGH 11-07-06 12-06-06 0 PAGE 1 OF 1 --./ 1...111...111.1111.11...11..1.11...111.....1.11111111111.1.1.1 KEITH A GAUGLER 31 N 33RD ST CAMP HILL PA 17011-2702 o ENCLOSURES 6-d 0/ ,~'/?lu~ll)~. 71.: d:;.. (f... f. (& /~ o ( ~ ~ /1 /(.,t:.>')J/~d ') o FULTON-GL-ASSIC CHBeK-fNS-- PREVIOUS DEPOSITS/ STATEMENT BALANCE CREDITS 706.77 ACCOUNT: 55e5-62697-- CHECKS/ o DEBITS 4 .00 266.86 SERVICE FEES .00 ENDING BALANCE 439.91 INTEREST PAID THIS YEAR ACCOUNT/INTEREST INFORMATION 2.14 ~-~" DEPOSITS/ DATE ACTIVITY DESCRIPTION REFERENCE CREVITS 11-07 BEGINNING BALANCE 11-14 PAWC PAYMENT 061113 00077900000 0637754 11-20 VERIZON PAYMENTREC 00077900000 URRING 7177613839324 12-01 COMCAST CENTRAL 00077900000 CENTRAL PA 120106 18577401 12-01 PP ELEC BILL 00077900000 I 4345317379WS 112-06 ENDING BALANCE I' SERVICE FEE BALANCE INFORMATION FROM 11-07-06 THROUGH 12-06-06 AVERAGE LEDGER BALANCE 621.34 AVERAGE COLLECTED BALANCE MINIMUM LEDGER BALANCE 439.91 MINIMUM COLLECTED BALANCE BALANCE 706.77 675.55 636.36 -'" 439.91 439.91 621. 34 439.91 ALL OF US AT FULTON BANK WISH YOU A VERY HAPPY HOLIDAY SEASON AND PROSPEROUS NEW YEAR. WE APPRECIATE YOUR BANKING RELATIONSHIP! - DIRECT INQUIRIES TO: FULTON BANK DIRECT BANKING CENTER PO BOX 504 "TC'IA,.."" nT:ll'ITr."n"""T'Tnn nA 1""~""n___"~n'. Member F.D.I.C. f11Ht"\nh~n"" ('f'\m /' .7' 1057 0425 39772 Y Fulton Bank ...~. .... LISTENING. STATEMENT OF ACCOUNTS 5505-62603 X STATEMENT PERIOD FROM THROUGH 12-07-06 1-07-07 0 PAGE 1 OF 1 1.11111...111......11.1111..1.1111.111...111.1..11111111.1.1.I KEITH A GAUGLER 31 N 33RD ST CAMP HILL PA 17011-2702 FULTON_ CLAS_SH;;_CHECIUij.G . _ _. PREVIOUS DEPOSITS/ CHECKS/ STATEMENT BALANCE CREDITS 2 DEBITS 439.91 1,000.37 o ENCLOSURES o ACCOUNT: 5505-62603... SERVICE 5 FEES 306.40 .00 ENDING BALANCE 1,133.88 INTEREST PAID THIS YEAR ACCOUNT/INTEREST INFORMATION .37 .......... DATE ACTIVITY DESCRIPTION REFERENCE 12-07 BEGINNING BALANCE 12-13 PAWC PAYMENT 061212 00077900000 0637754 12-20 DEPOSIT 03253407760 12-20 VERIZON PAYMENTREC 00077900000 URRING 7177613839324 01-02 COMCAST CENTRAL 00077900000 CENTRAL PA 010107 18577401 01-02 PP ELEC BILL 00077900000 4345317379WS 01-05 PENN WASTE DEBITS 00077900000 18576 01-05 INTEREST CREDIT 01-07 ENDING BALANCE DEPOSITS/ CHECKS/ CRE~ITS DEBITS BALANCE 439.91 414.68 / 25.23,\ 1,000.00 It !\ 39.99 I 47 . 85 \ \ 148. 72 ) \ 44.61// 1,374.69 1,178.12 .37 '-.-^ 1,133.88 1,133.88 *** ANNUAL PERCENTAGE YIELD EARNED DISCLOSURE FROM 12-07-06 THROUGH 1-07-07 *** ANNUAL PERCENTAGE YIELD EARNED .45% . AVERAGE DAILY COLLECTED BALANCE 948.38 INTEREST EARNED .37 SERVICE FEE BALANCE INFORMATION FROM 12-07-06 THROUGH 1-07-07 VERAGE LEDGER BALANCE 948.38 AVERAGE COLLECTED BALANCE INlMUM LEDGER BALANCE 414.68 MINIMUM COLLECTED BALANCE 948.38 414.68 EVERYONE NEEDS EXTRA CASH SOMETIME. FOR BIHS HOME IMPROVEMENTS..._A NEW CAR OR THAT VACATION YOU vt BEEN PROMISING YOuxSELF. WE HAVE LOANS FOR ALL YOUR NEEDS. CALL US AT 1-800-FULTON 4 APPLY ONLINE AT FULTONBANK.COM OR VISIT ANY OF OUR OFFICES! P. S. DON I T FORGET TO FUND YOUR lRAt TOO. EVERY DOLLAR HELPS TOWARD MAKING YOUR RETIREMEN YEARS BETTER! DIRECT INQUIRIES TO: FULTON BANK DIRECT BANKING CENTER PO BOX 504 ~A~T D~~D~~Tmr- DA '7~~n_n~n~ Member F.D.I.e. .~ I' l'" <' ':,cl( , ,. , """ -,. " . 1057 0425 12902 Y ... ~~ Fulton Bank LISTENING. STATEMENT OF AccotmTs 5505-62603 X STATEMENT PERIOD FROM THROUGH 1-08-07 2-06-07 0 PAGE 1 OF 1 1...111...111",,"1111I11..1.11".111.....1.1..11....11.1.1.1 KEITH A GAUGLER 31 N 33RD ST CAMP HILL PA 17011-2702 o ENCLOSURES o FULTON-CLA~SIC CHECKING PREVIOUS DEPOSITS/ STATEMENT BALANCE CREDITS 1,133.88 CHECKS/ 1 DEBITS .50 - -ACCOUNT:- 55-05-62603 SERVICE FEES .00 ENDING BALANCE 1,091. 75 2 42.63 INTEREST PAID THIS YEAR ACCOUNT/INTEREST INFORMATION .87 DATE ACTIVITY DESCRIPTION REFERENCE 01-08 BEGINNING BALANCE 01-12 PAWC PAYMENT 070111 00077900000 ~. 0637754 02-02 PAWC PAYMENT 070201 00077900000 0637754 02-06 INTEREST CREDIT 02-06 ENDING BALANCE DEPOSITS/ CHECKS/ CREDITS DEBITS BALANCE 1,133.88 1,109.26 1,091 . 25 1,091.75 1,091.75 .50 *** ANNUAL PERCENTAGE YIELD EARNED DISCLOSURE FROM 1-08-07 THROUGH 2-06-07 *** ANNUAL PERCENTAGE YIELD EARNED .55% AVERAGE DAILY COLLECTED BALANCE 1,109.54 INTEREST EARNED .50 SERVICE FEE BALANCE INFORMATION FROM 1-08-07 THROUGH 2-06-07 AVERAGE LEDGER BALANCE 1,109.54 AVERAGE COLLECTED BALANCE MINIMUM LEDGER BALANCE 1,091.25 MINIMUM COLLECTED BALANCE 1,109.54 1,091.25 ARE YOU PREPARED FOR THE FUTURE? EVEN IF THE ANSWER IS NO", FULTON BANK CAN HELP. WE HAVE GREAT RATES ON IRA CDS AN!) IRA MONEY MARKET ACCOUNTS. REMEMBER, MONEY SAVED TODAY IS ONE LESS THING TO THINK ABOUT TOMORROW. DIRECT INQUIRIES TO: FULTON BANK DIRECT BANKING CENTER PO BOX 504 ---- ---______ _a ..____ Member F.D.I.C. .,:', '(AJ ~ "1-- , , x> :L ':? J /:'j P.~j y PRO~'~P7!._V C~r::>l~jFd.[:F;~ !<T": I 'fj. { /) '():1,.-:':, I ~ ;';:.,= ''J1.,,, I d' [Ii r ~Th :/.,',;::>, C::.A~~:L:_i~:A';.I.~' \,'+~--.i'?O'! ~ ~ JtL/o'l!~ . C:!h:('! 1-,.; ('!:C.i , UNPA!D r:~[,(d.. i::~:.~"f ':i~,;':iE '::";~";~~::;~)~~;~~::>:T~:EL!NQUENT COl.LECTiON t,FTER _____''__ i'((iYE:i:,: t'rePE:r::;!..i:J) I ". .j /;: --./<....~./ . It~t' 1 </' If ,:\\..".:: fJ!-..j {)F:~ ;";,, ,n:;,~ :.::~ ;; j''j:Ji.; THL.!!::'::::; ,...,.... -. ~_. : ,J .~.:'(liy~ ,';" .1:~; - '1.'; j 1..) /-L' l1J ;::~ J:) l",f F:~ ':::, Ll{>j'f ':? (.:) l"~ i': _., ()~:~r:',;~:: ~,:;(:1T ,::.: ," ':Ot.. o ~J :1.::::/,:;:1 :(::l::;::UI':.:(, ... ,--'" , <' ~ ~ 1--:7Ji~-1 ~ IVC~7'-<--, "- -e.. (._"t-?~\.(:_'\ L'(~'-.' k ~ (tbe patriot -NtlUS Now you know Order Confirmation frrtl.t'r:;~ MCCLELLAN 1209 New Berlin Highway Orderer Account Number Ad Order Number 0001618742 132851 Sales Reo. kkline Payer Account Number Order Taker kkline 132851 Order Source Phone Soecial PricinQ None PO Number omer ~CLELLAN . \ 61 J d~ ~ 9c Middleburg PA 17842 USA Ordered By Customer Fax Customer EMail Customer Phone 717-948-5434 Mary Payer Phone 717-948-5434 Tear Sheets o Proofs o Affidavits 1 Blind Box Promo Tyoe Invoice Text - Materials Total Ad Cost $170.22 Payment Amount $0.00 Payment Method Amount Due $170.22 Ad Number Ad Tyoe 0001618742-0' Legal Liners Ad Size : 1.0X 12 Li Color <NONE> Production Method Production Notes Ad Booker Product Information Classification # Inserts Run Dates PNCO: :Full Run 806-Estate Notices 3 12/19/2006, 12/26/2006, 1/2/2007 Run Schedule Invoice Text ~ !:::"'IERS TESTAMENTARY Estate of Keith A. Gaugler, late of Camp Hi "-- .IJ,._.~ ~ ..... ..",,_~,,~~J.l ,-- . . -::_~rr ~ '- - L THE PATRIOT NEWS THE Sr:\'DAY PATRIOT NEWS Proof of Publication Cnder _-\ct ~o. 587, Approved May 16,1929 Commonwealth of Pennsylvania, County of Dauphin} ss Joseph A. Dennison, being duly sworn according to law, deposes and says: i'hat he is the Assistant Controller of The Patriot News Co" a corporation organized and existing under the la ws of '.; Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Streec, i :he City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot- News mi" The Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market --streec, i: 1 the City; County and State aforesaid; that The Patriot~News and The SundayllafiloT-News were estab iish,' J March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since 'hat the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sunday/ Metro editions which appeared in the 19th and 26th day(s) of December 2006 and the 2 nd day(s) of January 2007. That neither he nor said Company is interested in the subject matter of said printed ]~utice or advertising, and that all of the allegations of this statement as to the time, place and character of publicatH'1l 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 ".\c Volume 14, Page 317. - PUBLICATION COpy Estat Notke~ LETTERS l'ESTAMENTARY Estate of Kelthl.. Gaugler, late of Camp Hili, CumberlClllcl Coullty, PA, de _ ceased. Letters Tl!stamentary on the above estate have been granted 10 the underslOned. All persons Indebted 10 the estate are recwest€,c11o make payment, and those havIng claIms 10 present them without delav to: Mary A. MCClellan 1209 New lIerlln HWY Mlddlebul'll, PA 17842 MARY A. MCCLELLAN 1209 NEW BERLIN HIGHWAY MIDDLEBURG, P A. 17842 ...... I I J/ ct/? ~ t J ......C Ilc;{1'( ~ 'j~ " , \ ([be patriot-News Now you know Order Confirmation Payer Payer Account Number 133084 Ad Order Number 0001620484 Sales Rep. kkline Order Taker kkline Order Source Phone Special PricinQ None PO Number Gaugler Estate Ordered By Mary Customer Fax C'l.stomer MCCLELLAN Orderer Account Number 133084 MCCLELLAN 1209 New Berlin Highway Middleburg PA 17842 USA \ t~ \\ \\ \ Customer EMail Customer Phone 717-657-4157 Payer Phone 717-657-4157 Tear Sheets o Proofs o Affidavits 1 Blind Box Promo Type ice Text '-' Materials Total Ad Cost $170.22 Payment Amount $0.00 Payment Method Amount Due $170.22 Ad Number Ad Type 0001620484-0' Legal Liners Ad Size :1.0X12Li Color <NONE> Production Method Production Notes Ad Booker Product Infonnation Classification # Inserts Run Dates PNCO: :Full Run 806-Estate Notices 3 12/23/2006, 12/30/2006, 1/6/2007 Schedule Invoice Text i::1::rTERS TESTAMENTARY Estate of Keith A. Gaugler, late of Camp Hi A ,n,,..,,,,.....,. n."A.A'1^"" 1 '-~'\C,~~:lil'Y~0!.liJl~ '---" '~- "~ _ _".._ !r'~ 1-- --c. THE PATRIOT ~EWS THE SUNDAY PATRIOT NEWS Proof of Publicatio. Und~r Act No. ::~- .\pproved \tay Uk. l'ii':; Commonwealth ofPenr.s:.!-.ania, County of~, "" Joseph A. Dennison, being ddy sworn .::~.::ording to law, deposes and 9)s- That he is the Assistant Contrc lIer of The Patriot News Co., a corporatk)fl ~~ ;md existing under the laws of the Commonwealth of Pennsyhania, with its principal office and place of~ .;J,! 5::: to 818 Market Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and~ of The Patriot- News and The Sunday Patriot-News newspapers of general circulation, printed and pub~ J;:t 5::: to 818 Market Street, in the City, County and Sta~ aforesaid; that The Patriot-News andIhe S1IDdayPa~Se......s were established March 4th. 1854. and September 18th, 1949. respectively, and all have been published ever smce: That the primed noti~e or puti~arion 'shi~h is se~urely ana.:hed hereto is exactl:. as ponied and published in their regular daily and or Sunday \1erro editions whi.::h appe.1red in the 23rd and 38tII da}"'5(s) of December 2006 and the 6th day(s) of January 2007. That neither he nor s.ald Company is interested m the subject matter of said printed notice or advertising, and that all of the allegations of thi" st.1!ement as to the ill"De'. place and character of publication are true; and That he has personal knowledge of the facts aforesaid and is duly :::.mhonzed and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant 10 J. resolunon unanimously passed and adopted severally by the stockholders and board of directors of the said C omp.u1Y and subsequently duly ~ recorded in the office for the Recording of Deeds in and for said County of Dauphin in \hscellaneous Book "M", Volume 14, Page 317. PUBLICATION COPY s;~;;;~';;;'~'~w~~~&~;~:'" I Notarial Seal . I i Terry L. Russell, Notary Public ! I City Of Harrisburg. Dauphin County ; i JlIly Comm ission. ExpiresJU!1e 6,2010 ' ) 1;i;""'~~ ~~'~~'" N,~ri" NOT. Y PUBLIC L&TTERSTESTAMENTARY Estate OfKIJtIl A. GclUtIltr, late Of Camp HilI- Cumberland County, PA. de - ceased. Letters Testamentary on the above estate have been granted to the undersigned. All persons Indebted to the estate are teCluested to make PClvment, and those havIng claIms to present them wltlv>ut delav to: Mciry A. McClellan 1209 New BerlIn HwY. Mlddleburv, PA 17842 MARY A. MCCLELLAN 1209 NEW BERLIN HWY. MIDDLEBURG. PA. 17842 ~r