HomeMy WebLinkAbout08-29-07
~
15056051047
REV-1500 EX (06-05)
PA Department of Revenue '*
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(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
~
2. Supplemental Return
~
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
c::;)
~
c::) 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 Da ime Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
4. Limited Estate
~
~
-'....,,--)
CJ) /',
~~~5 ~~
'""0
-."
.~
:..0
0---1
)>
. (
<::)
-..J
correspondent.se-mailaddress:iAJQ...bee.bs25~@COMCAst.h.et
Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSO R PONSIBLE FOR FI URN '
~
ADDRESS J, 5 tj E 'Ed
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
--.J
--.J
15056052048
REV-1500 EX
Decedent's Name:
DDR.oTl-l'f f;:... t:.Be,/""1 rv&
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) <::::) Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) <::::) 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
TAX COMPUTATION - SEE
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
16. Amount of Line 14 ~xable
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
()
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ................ 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056052048
r
~
Decedent's Social Security Number
, ); e ~ fa' .3 U, J 7. 2... U
.'d ...... ...... ./. ,..... . .... ..1.
15.
16.
17.
18.
c:>
15056052048
--.J
REV-,1500 EX ~age 3
/"'l
File Number LOD 7 -- 0 ooy 3
Decedent's Complete Address:
DECEDENT'S NAME D
o'f<.DjH\I r::.- lSe.E.L1NG-
>--~~~___~~~_~~.~~ _~.~~_~__~L_______
STREET ADDRESS
701 HALDEMAtV BOULE:VA(t.1)
I-----~-~--~~~~---~-~-~~-~--_._--~-~~----- _~~________~.._
CITY
---jSTATE--,o ;-
ZIP } 7 () 7 0
NeW
C fA 'fVI etJ2.LA,J D
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
12) 201.18
Total Credits ( A + B + C ) (2)
3. InterestlPenalty jf applicable
D. Interest
E. Penalty
------ TotallnterestlPenalty ( 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)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(5A)
(5B)
J 7.)2 g 1- I B
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
I Z) If I" I L
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did de~ent 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 ~
c. retain a reversionary interest; or..........................................:~.:............................................................................ 0 ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 gJ
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 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ I8l 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)]. '.
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 PS. ~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 PS. ~9116(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 deced~nt's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
RE.V-1502 EX+ (6-98)
..
.. COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
1) D€.6\H '1 E: ~ f::.~c l-l N G-
Ail real property owned solely or as a 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.
FILE NUMBER "
,).007- 0 () 0 Lf J
ITEM
NUMBER
1.
DESCRIPTION
Slf'Uj./.,E. rAW\I\.~ DWOLUNG- ~oCAn;() AI 7t> 1
HII,-Or;;~ArJ BOl.lL{:'VA~b tlt.1II C/).rr..a.f5(LLANl>
J ~ )
PA, J707lJ I JH~ {<.tSrDtNUfS a'F rNE. DGc..E..t>~".rr
VALUE AT DATE
OF DEATH
~. IS OJ bW. DO
(If more space is needed, insert additional sheets of the same size)
TOTAL (Also enter on line 1, Recapitulation) $ /5' t) 000 ~
I
.
REV-150B EX > (1-97) _~
,.~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
DO{LoTHj S.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
Sf;6 LHJ G-
FILE NUMBER? '(3
-< 007 DOo'"
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
'2..,
DESCRIPTION
/'11 f 5 c.. . f6t. 50 N AL, f f..oP6.~fLt - HoLt(.,!JltiUJ CA>tV Th:NT> 0 f
70 Cf H,lJt....P~N BLVD. I (2."-5lt.>6N(.6 of l)f~D6NI
ft1 fT ~lt- ~ C~~k.& W1T# JA.I~ST
~ '301 L.( O~y,
VALUE AT DATE
OF DEATH
Z2. 05 . ()O
J
I~ 75~. fo 7
3.
e.~e-a~\CAlb of nt:iP~S)T @ W\ q T Bt.\N~
W- oJID1>3'/JJ31,54Sbl
10)571.107
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
$ Z7..fiIe; .3,-/
J
REV-1510 EX. (1-97)
'*
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
D(){Ll>TH~ G.B~LtfJG-
FILE NUMBER
;2,a>7000Y3
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.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE}
NUMBER
1. V A~CnA.A.P-t> GRPlA..f' D/tLEC..T6D B6N'€rlGl,:I P-'1
70, Sl~.o7
S6~\'T1 p.~~Nr $F CJ22 iOh 2.0 \ UJ.to S
""(U\IJS"~n n ~ 34
A. &~ i? cS, 73, ~1&# 5 ~ '2-31 ~7g,S"
IS. R,.\vJ.JALO J\. E;~u I-JCr 23 2, 7J . 2.1 33 Z~ 271. 2-
J
c.. l..A,^~ .J. e:~lJf.J& lj ,'-73.2.1 ?3 2127;. (.
J
... V A (If (;'''JU~.o ~'AP C>~1U(,:n:.t> f:>et.Jr=f\C.tA R. 'I
~. 'Ii >16.2.1
S~R.t"1 A(..C()""tJT -# q 2..2t>? 1507 WA.S 1
TR.AtJSfl7~~ 1'b'.
A DORtf:tJ c. f:.tJ.'1 Ill; i.J gz . 71 ]~ 14 4"'" 7
) l>t..
2>, ft\v-HAiUl A. $tS\..\tI>(?- '4Jo5(,~1t] 37 Jt.f, IJ5b. 7
C. /""f\v.M :So -t:6 t;u N& /L{l ~ /'" 7 r; 77 It ~S6, 75
TOTAL (Also enter on line 7, Recapitulation) $ JiJJ/2.i.Z.g
. .
J
7
7
s
(If more space IS needed, Insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
, .
ESTATE OF
ITEM
NUMBER
A.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
UOP-.-oIR'1 t... l;&~LltJ6-
Debts of decedent must be reported on Schedule I.
FILE NUMBER
~oo'7 ODD 43
1.
DESCRIPTION
FUNERAL EXPENSES: \
PA~~~1:.. F\.tNt:1tAL t-Io~ ~ ~~"\Olool SfR)\'-e.S
'-1/ fo'l.'I3
AMOUNT
l..
~&C.€Pi,O~
553.81
3. fv1e-MO ltl AL
3 IS. 2..2.
1.
B. ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal RepresentatiVe(sL~OUbtJ 8..~\~~ €f,~ ~. G~cc..u.tR..t'X.
Social Security Number(s)/EIN Number of Personal Representative
Street Address 2,S ~ fj,Q~ /..oAD
City ,lIlE:.('''H~N\c.s8\'\({'& State fA Zip 17oSS'
Year(s) Commission Paid: a.. 007
~oSo.o'J
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
4.
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
5. Accountant's Fees
Probate Fees
z ~ 8..1X)
7.
6. Tax Return Preparer's Fees
B,
rba.:'(N~ AlA.C.-1'IO,J66R..s-SALt Of"- ~AL f Pt;1t~C>Ntl.l_ PRofE:.J!..'~
EXpu-iSt:s fo((. 1VI,A1NTltINJtJ6r f<.tAL ffY"~ ,tT 7()~ J.lA~r-J
&t.A.lt91A~1 N6~ CI1.~I..LA~O,PA )707() UNr/L ~L~~' SGifl.$WNr
IJ 7l-J I, ~()
)
~t.f3S. JJ
TOTAL (Also enter on line 9, Recapitulation) $ z.~ 5Sf..J8
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
J)ofU>;Hy t;, E6eLJNG-
FILE NUMBER
20b 7 000'-13
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. '-Jts. S~ ~- fV\. S.. : 'TAA~5rl>R.ltr1l4lV ~
~ r;~o...AJ"" .' · J- t~~g;r~~ ~ ~l..i 's-PJfi:..1T ~f\~\..)
LAIV,e,611'Y\~~~$-60 &'1 Mf!;f)IC~L. INSlA-(<'AN~fE j7)
Sbt OL.-' ~).jDQ) CAR:!L )
2~ PA t>CPAR.TM~ 0;:' P.E~NlAf: FoR. 'loDb
STA1"f jAJCI>M/1!;. "f,A'K
J()fo~67
8, ' 1:>3
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
/ 9 ~ .20
REV-1513 EX+ (9-00)
..' .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
]) 0 r<.. () TH '1
S. c..f3€LING-
FILE NUMBER
;;'06i-060Y3
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. DoRaN E. Ef3ij
25'1 EWe ;eoAJ> fr/eGHANtCUJv.eG PIJ )7655'
RELATIONSHIP TO DECEDENT
Do Not ListTrustee(s)
AMOUNT OR SHARE
OF ESTATE
DA IJ.G I+- Tt(L
~
~. R.lCi-\'A~ A. 6€>EL/#J(;- (' ~
5"rJ LllTLE f2-UIJ ~OAO CAf)tf HIlA-. fA 176 1\ uo~
3- jl4A~ teE. u 11) Gr. Ji
6tfl fI~/YIM6~ AveNue Ll:.lYJb~/IJf: PA Iftl'l3 Gr<.~ $otJ
lj. E~Ic. c.J!:,E;,UIJ G- GRJJt'o.rt SON
SS BeAbLEY Vil.fl..T INf)/A,rJA. fA /57o{ h
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
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)
./
1Ect6t 31il1 ctun Qrt6tcttlttUt
OF
DOROTHY E. EBELING
I, DOROTHY E. EBELING, of New Cumberland, Cumberland County, Pennsylvania, do
ake, publish and declare this to be my Last Will and Testament, hereby revoking and making
oid any and all former Wills made by me.
ARTICLE I
I direct that all my legal debts and funeral expenses including my gravemarker and all
xpenses of my last illness that my Executrix is obligated to pay, shall be paid from my residuary
state as soon as practicable after my decease as a part of the expense of the administration of
y estate.
ARTICLE II
I direct my Executrix to pay all inheritance, transfer, estate and similar taxes (including
nterest and penalties) assessed or payable by reason of my death on any property or interest in
roperty which is included in my estate for the purpose of computing taxes. My Executrix shall
ot require any beneficiary to reimburse my estate for taxes paid on property passing under the
erms of this Will or otherwise.
ARTICLE III
I bequeath my automobile, household and personal effects and other tangible property of
like nature (not including cash and securities) together with any existing insurance thereon, to
y children, RICHARD A. EBELING, DOREEN E. EBY and EDWARD A. EBELING, to be divided
etween them by my Executrix in as nearly equal shares as practical.
ARTICLE IV
I give, devise and bequeath all the rest, residue and remainder of my estate of every
nature and wherever situate to my three children, RICHARD A. EBELING, DOREEN E. EBY and
EDWARD A. EBELING, in equal shares. Should any such child predecease me, then his or her
share shall pass per stirpes to any issue of that child in equal shares. If my predeceased child
has no living issue, the portion of my estate otherwise reserved for that child shall be divided
equally among my surviving children.
ARTICLE V
I nominate and appoint my daughter, DOREEN E. EBY, Executrix of this my Last Will and
Testament, and require that said Executrix serve without bond.
IN WITNESS WHEREOF, I hereunto set my hand and seal this ~ \ ~ay of ~
1997.
'\ ~\ ,\)~Q.~'~'\\ ~. E:'oQ. \, ~'\ (SEAL)
Dorothy E. Ebeling .
Signed, sealed, published and declared by the above-named Testatrix as and for her Last
Will and Testament in the presence of us, who, at her request, in her presence and in the
presence of each other have hereunto subscribed our names as witnesses.
,~ , U~~ ':, ~ ~ . iJ ~ \. ~ t. Q..
,,:>\ f'f'\'~'~~'\~ "~~'\'\
-/
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
:ss:
COUNTY OF CUMBERLAND
I, DOROTHY E. EBELING, Testatrix, whose name is signed to the foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I signed and executed
the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as
my free and voluntary act for the purposes therein expressed.
,~\ ~Q!::::\"",~"\ ~. e:b~ \~ .J~
DorothyE. Ebeling .
Sworn or affirmed to and acknowledged before me, by Dorothy E. Ebeling, the Testatrix,
this '3:.'\~ay of ~ ,1997.
,:>, '\:), ~ ~ ,.) Q.. 1- ~ 1>..1 ~ ~
Notary Public
. -
.
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
:ss:
COUNTY OF CUMBERLAND
We, ~\.:.... ~ \N .~~ and ~~t~ '\~~thewitnesses
whose names are signed to the foregoing instrument, being duly qualified according to law, do
depose and say that we were present and saw the Testatrix sign and execute the foregoing
instrument as her Last Will and Testament; that she signed willingly and that she executed it as
her free and voluntary act for the purposes therein expressed; that each of us in the hearing and
sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the
Testatrix was at that time at least 18 years of age, of sound mind and under no constraint or
undue influence.
,.", ~~~~5:l ~ ..\:\.~
'~1~'~ ~
Sworn to or affirmad to and subscribed to before me by ~.~ ~. ~ ' ""
'~~ ~' witnesses, this ~ '\~day of ~ ' 19 .
and
'\ "';> \
D;~NrJQ. ~~ N"~
Notary Public J
:65528
.
.
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
Register for the Probate of Wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 12th day of January, Two Thousand and Seven
Lett'ers TESTAMENTARY
in common form were granted by the Register of
said County, on the
, la te of NEW CUMBERLAND BOROUGH
estate of DOROTHY E EBELING
(First, Middle, Last)
(First, Middle, Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 12th day of January
Two Thousand and Seven.
File No. 2007-00043
PA File No. 21- 07- 0043
Date of Death 1/09/2007
S. S. # 186-34-1724
~~~~
~~M-
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
FORTNA
AUCTIONEERS
.
fII' .o~~iATlilN .~ ~C::He:DL1L~ A
26 E. Main Street, Annville, PA 17003
Harrisburg: (717) 236.7888 Annville: (717) 867-4451
AGREEMENT OF SALE
THIS AGREEMENT made this _19_ day of _May_, _2007_ between
(hereinafter referred to as "SeOer(s)") and _~een Eby. ExecJ1ix for Dorothy Ebeling
(hereinafter referred to as "Buyer(s)"). V It tY r Mr{ I" . ~ r c:..-"I ."'VI .vi
WITNESSETH, that Seller(s) agree(s) to sell and Buyel(s) aQree(s) to buy Seller(s) the premises sihsated at 709 Haldeman Blvd. New Cumberland, PA 17070
upon the following mutual teons, covenants, and conditions:
1. The purchase price for said propeZ shaH be the sum ot/5l?" ~oO ($ /.5 0' <?}~OLLARS, payable from Buyer(s) to Seller(s) as follows:
(a) The sum of . / _ .. L?OC (s/~ &'00 ) DOLLARS upon the execution of this agreement which said sum shall be retained in escrow by FORTNA
AUCTIONEERS until settlement
(b) The balallal of the purchase price, to wit /3.5; LPO () ($/~ of /10 ~ I DOLLARS. payable by cash or certified check at the time of setttement.
2. SetUement shall be held within 45 days from the date hereof in the offICe of the Recorder of Deeds of A,d .#JJ/ r, _ County, or at such other plaoo as the parties mutually agree upon.
,
3. Tille to the aforesaid property shall be conveyed by General warranty deed and Seller(s) hereby agree(s) that a title shall be good and marlretable and such as is insurable at standard rates
by a title insuranoo company licensed to do business in Pennsylvania. Title to said property shall be free and clear of all liens and encumbrances, but subject to currenlly exisq restrictions,
reservations, conditions, easements. covenants, zoning, regulations, ordinances, statues. and regulations now or hereafter promugate<l by any constituted public authority.
4. In all instances, time shall be of the essenoo of this agreement unless extended by mutual consent of the parties in writing.
5. Real Estate taxes. utililles. fuel oil in the tank, and other such charges shaH be apportioned between the parties, prorata. as of the date of settlement All realty tJansfer taxes imposed by any
govemmental body shall be paid buy the Buyer(s).
6. AU plumbing, heating. and lighting fixtures. and systems appurlenant thereto. and forming a part thereof. as well as all ranges and other pennanent fIXtures, together with screens, shades,
Venetian blinds, and awnings, if any. together with such other peISOI18I property specifically, listed herein. and all trees. shrubbery. and plants now in or on the pIllIllises helein intended to be
conveyed unless specifically excepted in this agreement are included in this sale and purchase price and shall become the property of Buyer(s) at the time of seItIement without further
documentation. All personal property is being sold in its "as is" condition. The following items are specifically induded in the sale:
7. Possessions shall remain with the Seller(s) until the time of settlement at which time possession shall be given to BuyeI(s). and. if the premises are tenanted, than to be subject to said
tenancy.
8. The deed shall be prepared. acknowledged. and recorded at the expense of the Buyer(s). All title searches, title insurance. and usual conveyancing expenses shall be paid by the Buyer(s) and.
if a survey should be required, the cost thereof shall be paid by the Buyer(s).
9. THERE IS NO CURRENTLY EXISTING COMMUNITY SEWAGE SYSTEM AVAILABLE, Section 7 of the Pennsylvania Sewage Facililies Aa provides that no person shall install, construcl,
request bid proposals for construction, alter, or occupy any building or structure for which and individual sewage system is to be installed without first obtaining a panni!. Buyer should contact the
local agency with admilistering the act before signilg this conlract to detennine the procedure and requirements for obtakling a pemIit for an individual sewage system.
10. If there are any GROWING CROPS on said premised. they are not included in this sale and the owner, his agent or nominee shall be permitted to retum at harvest time to harvest said crops.
11. Any loss of damage to the property caused by fire. casualty. or loss commonly covered by the extended coverage endorsements or reputable inslll'aOO:l companies, between the date of this
agreement and the dale of settlement shall not in any way. void or impair any of the conditions or obligations hereof. SeOer(s) shall maintain existing fire and extended coverage of homeowner's
type insuranoo policies. if any, until the time of final settlement Buyel(s) lsIare hereby notified that it is hislherltheir responsibility to insure hislherftheir interest in the said premises at hislherltheir
own cost and expense. Seller(s) shall maintain the property and any personal property specifically scheduled herein in its present condition, normal wear alld !ear accepted.
12. In the event Seller(s) lsIare unable to give and marketable title or such as will be insured by a title Insurance company licensed to do business in Pennsylvania at standard rates. as set forth
above. Buyer(s) shaD have the option of taking such title as SelIer(s) can provide. in which case the purchase price shall be reduced by the amount which is necessary to eliminate defects in title.
or, of declaring the agreement nuR and void, in which case Buyer(s) shall be repaid all monies paid on account of the purchase price, and in such event. there shall be no further Iiabitity or
obligation by either of the parties hereunder and this agreement shaD become null and void.
13. Should the Buyer(s) violate or faU to fulfill and perform any of the terms or conditions of this agreement. than, Buyer(s) shall be deemed to be in defauU under the terms of this agreement and
aU sums paid by the Buyel(s) 011 account of the purchase price shall be retained by the SeHer{s) either on account of the purchase price. or as liquidated damages for such breach, as the Seller(s)
may elect, and in the latter event the Seller(s) shall be released from all liability or obligation and this agreement shag become null and void.
14. SeUel(s) hereby warrant(s) that helshelthey have received no notioo of violation of any zoning ordinanoo or other govemmentallaw or regulation with respect to the aforesaid premises and the
property is being used in a manner which does not violate the current zoning law.
15. Assessments for improvements commenced prior to the date of this agreement shall be paid by Seller(s) or allowance shaH be made for such payment by Seller(s) at the time of setUement
Assessments for improvements commenood after the date of this agreement shall be the responsibility of Buyer(s).
16. Property is being sold "as-is' without any representation or warranties of any kind. Any radon. water, septic. lead paint hazardous substallal. insect infestation, building, structural. eIec1rical,
plumbing, heating, or any inspections of any type required by Buyel(s) or Buyer(s) financial inslltutlon will not void or impair the agreement This agreement is not contingent on any of the
aforementioned items and the results will not void or impair this agreement
17. It is understood and agreed that FORTNA AUCTIONEERS is acting as agent only and shall in no case whatsoever be held liable by either party for the performanoo of any term or covenant of
this agreement of for damages for nonperformance thereof.
18. Buyer(s) acknowtedge(s) that helshellhey haslhave inspected the premises prior to the time of auction and before signing the agreement and enters this agreement to purchase as a result of
said inspection and not as a result of any advertisement of announcement or representation made by the Seller(s) and/or FORTNA AUCTIONEERS.
19. This agreement may not be assigned by Buyer(s) without the prior written consent of SeOer(s).
20. This agreement contains the whole agreement betweEln Seller(s) and Buyer(s). and.there are not other tenns, obligations, covenants. representations, statements, or conditions, oral or
otheIWise. of any kind whatsoever.
21. This agreement shall be construed in aa::ordanoo with the laws of the Commonwealth of Pennsylvania; no modification of this agreement shall be valid unless the same is in writing and signed
by both parties hereto. No waiver of any of the provisions of this agreement shall be valid unless in writing and signed by the party against whom it is sought to be enforced. If there are any growing
crops on said premises, they are not included in this sale and the Seller(s). hislherltheir agent or nominee shaH be permitted to retum at harvest time 10 harvest said crops.
22. This agreement shall be binding on the parties hereto, their executors. administratols, successors, and assigns.
22. A _% L- percent) buyers premium will be paid by the buyer at the time of settlement If the buyer is unable to make settlement due to fault of his own, the _% buyers premium is still
due to Fortna Auctioneers.
parties hereto, intending to be legally bound, have hereunto set their hands and seals the day and year first above written.
(SEAL)
u.s. Savings Bond Redemption Receipt
DOC\Amf:N\A\U>N:
~C~\)\l\!: &
ESTATE OF DOROTHY E EBELING
254 EWE ROAD
MECHANICSBURG, PA 17055-
186-34-1724
Redemption Date:
02/21/2007
Transaction Number:
6113051015
Serial Number
Series Denom
Issue
Date
Issue Price
Interest Earned
Redem ption
Value
60002194563 EE $10,000.00 09/ 1992 $5,000.00 $6,004.00 $11,004.00
Total Total Total
Price Interest Value
Total number of bonds redeemed: 1 $5.000.00 $6,004.00 $11,004.00
Highland Park Office
344 South 10th Street
Lemoyne, PA 17043
(717) 737-3322
..
FORTNA
AUCTIONEERS
26 E. Main St. . Annville, Pennsylvania 17003
SETTLEMENT
Personal Property
Seller: Mrs Doreen Eby, Executrix
254 Ewe Road
Mechanicsburg, P A 17055
DactAr'i\ f;.N TA\1 f)t-J t
&N-E:1)\Alf C J:'bl""~ I
)
Y AllJ.~ , ~R.sONAL ft<J,MY
2205.00
Ref: Personal Property located at 709 Haldeman Blvd., New Cumberland, P A
Personal Property
Cost:
10% Commission
Auction set up fee
220.50
500.00
(717) 236-7888
(Harrisburg)
<f'.
.
Michael Fortna, CAI
www.fortnaauctioneers.com
FAX: (717) 867-5265
720.50 ~
1484.50 l
DOG~'M~rATlotJ ~
8c.~tt>~ H-
ADM\ N \~T'?,4h)~ LbSTS'
(717) 867-4451
(Annville)
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
BIDDER #
1 MASON JARS, TOOLS
2 TOOLS
3 NUTS, BOLTS
4 HAMMERS
5 STATIONARY, MONEY BAGS
6 FLASH LIGHT, CLOTHES PINS
7 CHAINS
8 TUPPERWARE, MILK JUGS, POT
9 YARD TOOLS
10 CANE, UMBRELLA
11 BOOKS
12 GARDEN TOOLS
13 WRENCHES
14 DRY GOODS
15 KNIVES
16 OLD STAPLER, PENCIL SHARPENER
17 ADVERTISING BOX, METER STICKS
18 TEA POT, MIXING BOWLS
19 BOX OF GLASSES
20 DRY GOODS
21 TRAY OF GLASSES, FRAMES
22 CUPS AND SAUCERS
23 TOASTER OVEN, GLASSES
24 CLEANING SUPPLIES
25 MEAT CUTTER, CDS
26 PAIR OF LAMPS
27 TRAY OF GLASSES
28 WALL SHELF, SERVING TRAY
29 BOWL, DISHWARE
30 TWO BOXES OF GLASSWARE
31 MISC. TRAY OF FIGURINES
32 LINENS, CLOTHING, BEADS, BOARD
33 SHOT GLASSES
34 GLASSES
35 TRAYS OF GLASSWARE, MUGS
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QTY
UNIT
PRICE
1
1
1
1
1
1
3.00
2.00
4.00
2.00
2.00
1. 00
3.00
1. 00
5.00
4.00
1. 00
3.00
3.00
3.00
5.00
3.00
2.00
1. 00
1. 00
5.00
1. 00
3.00
2.00
1. 00
3.00
1. 00
1. 00
1. 00
1. 00
1.00
7.00
3.00
1. 00
1. 00
2.00
1
1
1
1
1
1
1
1
1
1
CON TIN U E D
TOTAL
PRICE
3.00 10%
2.00 10%
4.00 10%
2.00 10%
2.00 10%
1. 00 10%
3.00 10%
1. 00 10%
5.00 10%
4.00 10%
1. 00 10%
3.00 10%
3.00 10%
3.00 10%
5.00 10%
3.00 10%
2.00 10%
1. 00 10%
1. 00 10%
5.00 10%
1. 00 10%
3.00 10%
2.00 10%
1. 00 10%
3.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
7.00 10%
3.00 10%
1. 00 10%
1. 00 10%
2.00 10%
Oe.t+6t)lA ltb f
.ITEM ~ 1
PAGE 1
AUCTION NUMBER 070519
COMMISSION
AMOUNT
.30
.20
.40
.20
.20
.10
.30
.10
.50
.40
.10
.30
.30
.30
.50
.30
.20
.10
.10
.50
.10
.30
.20
.10
.30
.10
.10
.10
.10
.10
.70
.30
.10
.10
.20
SELLER'S
NET AMOUNT
2.70
1. 80
3.60
1.80
1. 80
.90
2.70
.90
4.50
3.60
.90
2.70
2.70
2.70
4.50
2.70
1. 80
.90
.90
4.50
.90
2.70
1. 80
.90
2.70
.90
.90
.90
.90
.90
6.30
2.70
.90
.90
1. 80
RESERVE
AMOUNT
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
849
849
835
835
849
849
835
853
849
846
849
835
849
842
843
849
846
849
847
850
849
839
842
849
845
845
838
840
849
838
849
849
849
838
849
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
ITM
NO.
36 LAWN EDGING, SPRINKLER
37 SPRINKLING CAN
38 REYNOLDS WRAP, SERAN WRAP
39 PAIR OF LAMPS
40 BAR B Q SET
41 CASETERS, STAPLER, EXT. CORDS
42 OLD MAPS, PENCILS, TABLETS
43 POT
44 FRYING PANS, CAKE TINS
45 WORLD WAR TWO BOOKS
46 RADIO W/ CD PLAYER
47 POT
MORE RECORDS
48 GARDEN BOOKS
49 LIFE BOOKS
50 KITCHEN WARE, SPOONS
51 ALBUMS
52 1962 NIGHT BEFORE XMAS BOOK
53 MEAT GRINDER
54 RECORDS
55 ALBUMS
56 ALBUMS
57 ALBUMS
58 ALBUMS
59 KITCHEN WARE
60 ALBUMS
61 PAIR OF LAMPS
62 GLASS WARE
63 HERSHEY COOK BOOK, KITCHEN
UTENSILS
64 KITCHEN UTENSILS, STEAK KNIVES
65 FLOWERS, POTTERY, COOK BOOKS
66 SKILLET
67 SHOVEL, PICK
68 COOKIE JAR, GLASSES
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
1
1
1
1
1
1
1
1
1
1
1
1
5.00
9.00
2.00
3.00
3.00
1. 00
2.00
1.00
1. 00
1. 00
3.00
2.00
1
1
1
1
1
1
1
1
1. 00
2.00
2.00
1. 00
2.00
1. 00
1. 00
1. 00
1. 00
1. 00
1. 00
1. 00
1.00
3.00
1. 00
4.00
1
1
1
1
1
1
1
1
1
1
1
1
1. 00
3.00
1. 00
6.00
2.00
CON TIN U E D
TOTAL
PRICE
5.00 10%
9.00 10%
2.00 10%
3.00 10%
3.00 10%
1. 00 10%
2.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
3.00 10%
2.00 10%
1. 00 10%
2.00 10%
2.00 10%
1. 00 10%
2.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
3.00 10%
1. 00 10%
4.00 10%
1. 00 10%
3.00 10%
1. 00 10%
6.00 10%
2.00 10%
PAGE 2
AUCTION NUMBER 070519
COMMISSION
AMOUNT
SELLER'S RESERVE
NET AMOUNT AMOUNT BIDDER #
.50
.90
.20
.30
.30
.10
.20
.10
.10
.10
.30
.20
4.50
8.10
1. 80
2.70
2.70
.90
1. 80
.90
.90
.90
2.70
1.80
.10
.20
.20
.10
.20
.10
.10
.10
.10
.10
.10
.10
.10
.30
.10
.40
.90
1. 80
1. 80
.90
1. 80
.90
.90
.90
.90
.90
.90
.90
.90
2.70
.90
3.60
.10
.30
.10
.60
.20
.90
2.70
.90
5.40
1. 80
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
849
846
842
835
849
835
847
838
842
843
849
842
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
838
839
835
846
850
835
864
846
846
846
846
835
846
840
838
847
.00
.00
.00
.00
.00
835
846
840
853
849
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
TOTAL
PRICE
AUCTION NUMBER 070519
PAGE 3
COMMISSION
AMOUNT
SELLER'S
NET AMOUNT
RESERVE
AMOUNT
-----------------------------------------------------------------------------------------------------------------------------------
BIDDER #
69 MAGAZINES
70 BOOKS
71 BOTTLE CAN OPENER, VASE, WATCH
72 ELVIS BOOKS, CAR MAG.
73 POT HOLDERS, WASH CLOTHS
74 COOK BOOKS
75 RAKES
76 SCISSORS
77 CLEANING SUPPLIES, MOPS
78 PICK
79 SHOVELS, BROOMS
80 CANDLES
81 PLANET JR. EDGER
82 SALT PEPPER SHAKERS, VASES
83 SLEDGE HAMMER
84 LIBRARY OF HEALTH BOOK
85 SET OF DISHES, DRAPES
86 DISHES
87 COOK BOOKS
88 SERVING TRAY
89 BIRD BATH
90 COKE BOTTLE
91 GLOVES, BASKETS
92 NESTING BOWLS
93 GLASSWARE
94 NUTS AND BOLTS
95 LAMPS
96 MEASURING CUPS
97 BEDSPREAD
98 PAINTINGS
99 CLEANING SUPPLIES AND TAPE
100 MCCOY
101 COFFEE CUPS
102 TRAY LOT
103 BLACK DOG
1
1
1
1
1
2.00
1.00
2.00
1. 00
4.00
2.00
3.00
1. 00
1. 00
5.00
1. 00
1. 00
10.00
10.00
3.00
1. 00
1. 00
5.00
4.00
1. 00
10.00
2.00
1. 00
3.00
2.00
1. 00
1. 00
1. 00
5.00
17 .00
1. 00
30.00
5.00
1. 00
5.00
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CON TIN U E D
2.00 10%
1. 00 10%
2.00 10%
1. 00 10%
4.00 10%
2.00 10%
3.00 10%
1. 00 10%
1. 00 10%
5.00 10%
1. 00 10%
1. 00 10%
10.00 10%
10.00 10%
3.00 10%
1. 00 10%
1. 00 10%
5.00 10%
4.00 10%
1. 00 10%
10.00 10%
2.00 10%
1. 00 10%
3.00 10%
2.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
5.00 10%
17.00 10%
1. 00 10%
30.00 10%
5.00 10%
1.00 10%
5.00 10%
.20
.10
.20
.10
.40
.20
.30
.10
.10
.50
.10
.10
1.00
1. 00
.30
.10
.10
.50
.40
.10
1. 00
.20
.10
.30
.20
.10
.10
.10
.50
1. 70
.10
3.00
.50
.10
.50
1.80
.90
1. 80
.90
3.60
1. 80
2.70
.90
.90
4.50
.90
.90
9.00
9.00
2.70
.90
.90
4.50
3.60
.90
9.00
1. 80
.90
2.70
1. 80
.90
.90
.90
4.50
15.30
.90
27.00
4.50
.90
4.50
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
849
835
851
851
866
838
859
861
842
835
849
840
839
846
859
867
849
850
853
834
861
838
849
853
842
846
871
842
860
847
849
846
861
835
863
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
06/18/07
CONSIGNOR NUMBER
NAME
5
- - CONSIGNOR STATEMENT - -
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
>
104 FLAG AND CARDS
105 GAME,SPRINKLER
106 TABLETS
107 TINS, SEWING MATERIALS
108 SUITCASES
109 LAMP
110 WIGS
111 DISC CHANGER
112 MICROWAVE
113 BOOKS
114 SUITCASE
115 OLD TINS
116 ADVERTISING TINS
117 TOBACCO TINS
118 PILLOW
119 XMAS TREE LIGHT
120 DRY GOODS
121 BED SHEETS
122 LINENS
123 SCARFS
124 PEPSI CRATE
125 COKE CRATE
126 ADV. FANS AND DOG
127 OIL AND SEALER
128 LIGHT BULBS
129 DEHUMIDIFIER
130 OLD CALENDARS
131 TUPPERWARE
132 RUG AND BEDDING
133 TABLE TOP SHUFFLE BOARD
134 COOKBOOKS
13 5 COOKBOOKS
13 6 COOKBOOKS
13 7 COOKBOOKS
13 8 COOKBOOKS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QTY
UNIT
PRICE
1. 00
5.00
1. 00
10.00
2.00
30.00
1. 00
2.00
12.00
1. 00
1. 00
1. 00
2.00
1. 00
2.00
1. 00
1. 00
1. 00
3.00
1. 00
3.00
5.00
4.00
1. 00
3.00
1. 00
7.00
3.00
12.00
1. 00
1. 00
1.00
1.00
1. 00
1. 00
CON TIN U E D
TOTAL
PRICE
1. 00 10%
5.00 10%
1.00 10%
10.00 10%
2.00 10%
30.00 10%
1. 00 10%
2.00 10%
12.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
2.00 10%
1. 00 10%
2.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
3.00 10%
1. 00 10%
3.00 10%
5.00 10%
4.00 10%
1. 00 10%
3.00 10%
1. 00 10%
7.00 10%
3.00 10%
12.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
1. 00 10%
PAGE 4
AUCTION NUMBER 070519
COMMISSION
AMOUNT
SELLER'S RESERVE
NET AMOUNT AMOUNT BIDDER #
.10
.50
.10
1. 00
.20
3.00
.10
.20
1.20
.10
.10
.10
.20
.10
.20
.10
.10
.10
.30
.10
.30
.50
.40
.10
.30
.10
.70
.30
1.20
.10
.10
.10
.10
.10
.10
.90
4.50
.90
9.00
1.80
27.00
.90
1. 80
10.80
.90
.90
.90
1. 80
.90
1. 80
.90
.90
.90
2.70
.90
2.70
4.50
3.60
.90
2.70
.90
6.30
2.70
10.80
.90
.90
.90
.90
.90
.90
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
842
855
835
846
863
863
849
851
871
845
839
846
845
840
840
850
842
842
861
840
845
839
846
836
875
867
849
846
839
873
840
840
840
840
840
.
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
BIDDER #
13 9 CIVIL BOOKS
140 LINCOLN BOOKS
141 BOOKS
142 BABY DOLL
143 STUFFED ANIMALS AND BRUSHES
144 HAMPER
145 SKEE BALL
146 OLD PIN BALL GAME
147 JARS AND CARD SHUFFLER
148 BON TON CHIP TIN
149 CHECKERBOARD
150 GAMES AND PERFUMES
151 ADV. BOOKLETS AND MISC.
152 MIRRORS
153 JUICE GLASSES
154 TIE PRESS
155 GLASS BOWLS
156 LIQUOR CLOCK
157 OLD HEATER
158 SERVING TRAYS
159 JEWELERY
160 JEWELERY BOXES
161 '45 RECORDS
162 TOYS AND MISC.
163 JEWELERY
164 FIGURINE
165 OLD BUTTONS AND DICE
166 RECORDS
167 INDY 500 CANISTER
168 BASEBALL CANISTER
169 PLATES AND BASKET AND CANISTER
170 MT. RUSHMORE CANISTER
171 RECORDS
172 FLORIDA CANISTERS AND GERMANY
CANISTER
..
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QTY
UNIT
PRICE
1.00
3.00
1. 00
1. 00
2.00
1. 00
25.00
12.00
1. 00
1.00
3.00
1. 00
3.00
3.00
4.00
1. 00
7.00
1. 00
3.00
1.00
2.00
1. 00
7.00
1. 00
3.00
12.00
3.00
4.00
3.00
10.00
3.00
1. 00
1. 00
2.00
CON TIN U E D
TOTAL
PRICE
1. 00 10%
3.00 10%
1. 00 10%
1. 00 10%
2.00 10%
1. 00 10%
25.00 10%
12.00 10%
1. 00 10%
1. 00 10%
3.00 10%
1. 00 10%
3.00 10%
3.00 10%
4.00 10%
1. 00 10%
7.00 10%
1. 00 10\
3.00 10%
1. 00 10%
2.00 10%
1. 00 10\
7.00 10%
1. 00 10%
3.00 10%
12.00 10\
3.00 10%
4.00 10%
3.00 10\
10.00 10\
3.00 10\
1. 00 10\
1. 00 10\
2.00 10%
PAGE 5
AUCTION NUMBER 070519
COMMISSION
AMOUNT
.10
.30
.10
.10
.20
.10
2.50
1.20
.10
.10
.30
.10
.30
.30
.40
.10
.70
.10
.30
.10
.20
.10
.70
.10
.30
1.20
.30
.40
.30
1. 00
.30
.10
.10
.20
SELLER'S
NET AMOUNT
.90
2.70
.90
.90
1. 80
.90
22.50
10.80
.90
.90
2.70
.90
2.70
2.70
3.60
.90
6.30
.90
2.70
.90
1. 80
.90
6.30
.90
2.70
10.80
2.70
3.60
2.70
9.00
2.70
.90
.90
1. 80
RESERVE
AMOUNT
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
849
868
867
866
865
879
849
842
838
845
850
871
849
850
840
839
874
849
849
834
833
874
850
849
874
868
846
849
873
846
850
867
864
834
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
TOTAL
PRICE
PAGE 6
AUCTION NUMBER 070519
COMMISSION
AMOUNT
SELLER'S
NET AMOUNT
RESERVE
AMOUNT
-----------------------------------------------------------------------------------------------------------------------------------
BIDDER #
173 LEBANON CANISTER
174 PAUL BUNYON
175 MISC.
176 WALL HANGER AND CHILDRENS BOOK
177 PATRIOTS OF THE AM.REVOLUTION
CONTAINER
178 CANDY DISHES
179 WHISKEY CANISTER AND BOOKS
180 CANISTERS AND CAT STATUE
181 PITCHER
182 CAT HEAD AND GLASSES
183 DEPRESSION GLASS
184 GLASS VASE
185 GLASSWARE AND PHONE
186 GLASSWARE
187 OLD MAGAZINES
188 MISC. GLASSWARE AND BOOK
189 CARNIVAL GLASS
190 BANK ORNAMENT
191 CANDLE STICK HOLDERS
192 BOBBLE HEAD
193 FAN AND PHONE
194 WAGNER PAN
195 GLASSWARE
196 DISHWARE
197 GLASSWARE
198 JEWELERY AND DRY GOODS
199 TRAY LOT
200 LICENSE PLATES
201 DOILIES
202 TRAY LOT
203 GLASSWARE AND COAL SHOVEL
204 OLD PUZZLE AND SILVER
205 BABY SHOES
206 OLD WHIP AND HORESHOE
1
1
1
1
1
3.00
7.00
3.00
1. 00
12.00
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1. 00
7.00
1.00
10.00
4.00
7.00
4.00
15.00
3.00
1.00
1. 00
15.00
12.00
3.00
2.00
12.00
1. 00
3.00
20.00
45.00
7.00
1. 00
4.00
15.00
1. 00
1. 00
2.00
1. 00
1. 00
1
1
1
1
1
1
1
1
1
1
CON TIN U E D
3.00 10%
7.00 10%
3.00 10%
1. 00 10%
12.00 10%
1. 00 10%
7.00 10%
1. 00 10%
10.00 10%
4.00 10%
7.00 10%
4.00 10%
15.00 10%
3.00 10%
1. 00 10%
1. 00 10%
15.00 10%
12.00 10%
3.00 10%
2.00 10%
12.00 10%
1. 00 10%
3.00 10%
20.00 10%
45.00 10%
7.00 10%
1. 00 10%
4.00 10%
15.00 10%
1. 00 10%
1.00 10%
2.00 10%
1. 00 10%
1. 00 10%
.30
.70
.30
.10
1.20
.10
.70
.10
1. 00
.40
.70
.40
1. 50
.30
.10
.10
1.50
1.20
.30
.20
1.20
.10
.30
2.00
4.50
.70
.10
.40
1. 50
.10
.10
.20
.10
.10
2.70
6.30
2.70
.90
10.80
.90
6.30
.90
9.00
3.60
6.30
3.60
13.50
2.70
.90
.90
13.50
10.80
2.70
1.80
10.80
.90
2.70
18.00
40.50
6.30
.90
3.60
13 .50
.90
.90
1. 80
.90
.90
.00
.00
.00
.00
.00
850
850
849
849
834
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
838
850
863
850
850
838
874
849
871
849
835
847
835
874
846
840
839
874
860
846
874
849
834
860
860
835
833
840
865
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
BIDDER #
207 MISC. LOT
208 JAR
209 BLANKET
210 DRY GOODS
211 TABLE CLOTH
212 WALL HANGINGS
213 DESK LAMP, PHONE
214 SHOE HORNS, BOTTLE OPENER
215 DIVIDER DISH
216 HAMMOCK
217 WALL HANGINGS
218 TV STAND
219 HOT PADS
COOKIE JAR
220 COLBALT BLUE JAR
COSTUME JEWLERY
221 SILVERWARE
222 JARS (GIBSON)
223 GLASSWARE
224 WALL HANGINGS
225 WINDOW FAN
226 STRAUS BURG RAILROAD CARDS
POST CARDS
227 LAMP AND SHADES
228 LAMPS, STEP STOOL
229 LANCASTER, SHAMOKIN POST CARDS
230 ANTIQUE BOOKS, DRY GOODS
231 STERLING SILVER CANDLE HOLDERS
232 EARLY POST CARDS
233 TABLE SETTINGS
234 EARLY POSTCARDS
235 CREAMER DISHES
236 WASTE BASKETS
237 EARLY POSTCARDS
238 VACCUM CLEANER
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
1
1
1
1
1
1
1
1
1
1
1
1
1
12.00
1. 00
6.00
4.00
2.00
6.00
2.00
12.00
3.00
1. 00
5.00
1. 00
45.00
1
4.00
1
1
1
1
1
1
20.00
30.00
1. 00
1. 00
6.00
4.00
1
1
1
1
1
1
1
1
1
1
1
1. 00
1. 00
5.00
1. 00
10.00
7.00
4.00
4.00
3.00
1. 00
3.00
1. 00
CON TIN U E D
TOTAL
PRICE
12.00 10\
1. 00 10\
6.00 10\
4.00 10\
2.00 10\
6.00 10\
2.00 10\
12.00 10\
3.00 10\
1. 00 10\
5.00 10\
1. 00 10\
45.00 10\
4.00 10\
20.00 10\
30.00 10\
1. 00 10\
1. 00 10\
6.00 10\
4.00 10\
1. 00 10\
1. 00 10\
5.00 10\
1. 00 10\
10.00 10\
7.00 10\
4.00 10\
4.00 10\
3.00 10\
1. 00 10\
3.00 10\
1. 00 10\
PAGE 7
AUCTION NUMBER 070519
COMMISSION
AMOUNT
1. 20
.10
.60
.40
.20
.60
.20
1. 20
.30
.10
.50
.10
4.50
2.00
3.00
.10
.10
.60
.40
.10
.10
.50
.10
1. 00
.70
.40
.40
.30
.10
.30
.10
SELLER'S
NET AMOUNT
10.80
.90
5.40
3.60
1. 80
5.40
1. 80
10.80
2.70
.90
4.50
.90
40.50
.40
3.60
18.00
27.00
.90
.90
5.40
3.60
.90
.90
4.50
.90
9.00
6.30
3.60
3.60
2.70
.90
2.70
.90
RESERVE
AMOUNT
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
849
835
874
874
850
845
840
846
850
873
845
835
850
.00
840
.00
.00
.00
.00
.00
.00
834
846
849
835
869
849
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
863
835
852
840
834
849
840
835
834
847
835
875
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
239 EARLY POSTCARDS
240 CHAIR
241 EARLY POSTCARDS
242 GLASSWARE
243 MAGAZINE RACK, VACCUM
244 DIRT DEVIL
245 LAMPS AND STANDS
246 CRUTCHES AND FAN
247 CALENDAR
248 SMOKING STAND
249 STAND
250 MARBLES
251 TRAY LOT
252 KIDS TOYS
253 ARMY ITEMS
254 JAR OF BUTTONS
255 MICKEY MOUSE
256 VACUUMS
257 POP PISTOL
258 CHILDRENS HANDKERCHIEFS
259 CALENDAR
260 XMAS ITEMS
261 OLD REPORT CARDS AND GLOVES
262 BOOKS AND BAT
263 SILVER COIN
264 SILVER COINS
265 AUNT JEMIMA DISPENSER
266 FUNNEL
267 OLD DRINKING CUP AND PINS
268 SALT AND PEPPER SHAKERS AND OL
D BOTTLES
269 ASHTRAYS AND CIG MAKER
270 CHILDRENS NAPKINS AND LITTLE
CHALKBOARD AND PADDLE
271 FIGURINES
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMP~
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
1
1
1
1
1
4.00
4.00
1. 00
1. 00
4.00
2.00
2.00
8.00
2.00
2.00
1. 00
22.00
1. 00
1. 00
10.00
2.00
5.00
1. 00
12.00
5.00
4.00
1. 00
1. 00
1. 00
10.00
5.00
12.00
1. 00
1. 00
15.00
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3.00
3.00
1
10.00
CON TIN U E D
TOTAL
PRICE
4.00 10%
4.00 10%
1. 00 10%
1. 00 10%
4.00 10%
2.00 10%
2.00 10%
8.00 10%
2.00 10%
2.00 10%
1. 00 10%
22.00 10%
1. 00 10%
1. 00 10%
10.00 10%
2.00 10%
5.00 10%
1. 00 10%
12.00 10%
5.00 10%
4.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
10.00 10%
5.00 10%
12.00 10%
1. 00 10%
1. 00 10%
15.00 10%
3.00 10%
3.00 10%
10.00 10%
AUCTION NUMBER 070519
PAGE 8
COMMISSION
AMOUNT
SELLER'S RESERVE
NET AMOUNT AMOUNT BIDDER #
.40
.40
.10
.10
.40
.20
.20
.80
.20
.20
.10
2.20
.10
.10
1. 00
.20
.50
.10
1.20
.50
.40
.10
.10
.10
1. 00
.50
1.20
.10
.10
1. 50
.30
.30
1. 00
3.60
3.60
.90
.90
3.60
1. 80
1. 80
7.20
1. 80
1. 80
.90
19.80
.90
.90
9.00
1. 80
4.50
.90
10.80
4.50
3.60
.90
.90
.90
9.00
4.50
10.80
.90
.90
13 .50
2.70
2.70
9.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
849
842
835
838
875
859
846
861
849
842
846
849
834
849
850
835
849
883
849
839
849
846
839
835
834
834
846
835
849
846
.00
.00
865
849
.00
849
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
--.--- ITEM DESCRIPTION ------- NO.
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
. - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
TOTAL
PRICE
AUCTION NUMBER 070519
PAGE 9
COMMISSION
AMOUNT
SELLER'S RESERVE
NET AMOUNT AMOUNT BIDDER #
-----------------------------------------------------------------------------------------------------------------------------------
272 2 CANDY DISHES
273 PICK UP STICKS
274 OLD BOOKS
275 JACKS
276 OLD BOOKS
277 TOYS, ETC.
278 POCKET KNIVES AND STAMP BOOKS
279 DICE AND BABY BOOKS WITH SPOON
280 BARBIE PARTS
281 TRAY LOT
282 48 STAR FLAG WITH STAMPS
283 FLAGS AND POTATO BAG
284 SOAPS
285 BRACELET
286 TRAY LOT
287 SILVER DOLLAR
288 EARLY DOLLAR
289 1896 DOLLAR BILL
290 1925 DOLLAR BILL
291 1925 DOLLAR BILL
292 1921 DOLLAR BILL
293 1925 DOLLAR BILL
294 1925 DOLLAR BILL
295 1922 DOLLAR BILL
296 1925 DOLLAR BILL
297 1890 DOLLAR BILL
298 1886 DOLLAR BILL
299 1924 DOLLAR BILL
300 1889 DOLLAR BILL
301 1890 DOLLAR BILL
302 1924 DOLLAR BILL
303 1922 DOLLAR BILL
304 1971 DOLLAR BILL
305 1936-7 BUFFALO NICKELS
306 1945-6 AND 1967 PENNIES
1
1
1
1
1
1
1. 00
1. 00
5.00
3.00
1. 00
1. 00
1. 00
3.00
5.00
5.00
12.00
1. 00
5.00
1. 00
6.00
60.00
15.00
15.00
10.00
10.00
9.00
10.00
11. 00
10.00
12.00
14.00
12.00
12.00
14.00
14.00
11.00
11.00
1. 00
2.00
5.00
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CON TIN U E D
1. 00 10%
1. 00 10%
5.00 10%
3.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
3.00 10%
5.00 10%
5.00 10%
12.00 10%
1. 00 10%
5.00 10%
1. 00 10%
6.00 10%
60.00 10%
15.00 10%
15.00 10%
10.00 10%
10.00 10%
9.00 10%
10.00 10%
11.00 10%
10.00 10%
12.00 10%
14.00 10%
12.00 10%
12.00 10%
14.00 10%
14 . 00 10%
11. 00 10%
11.00 10%
1. 00 10%
2.00 10%
5.00 10%
.10
.10
.50
.30
.10
.10
.10
.30
.50
.50
1.20
.10
.50
.10
.60
6.00
1. 50
1. 50
1. 00
1. 00
.90
1.00
1.10
1. 00
1. 20
1.40
1.20
1.20
1.40
1.40
1.10
1.10
.10
.20
.50
.90
.90
4.50
2.70
.90
.90
.90
2.70
4.50
4.50
10.80
.90
4.50
.90
5.40
54.00
13 .50
13 .50
9.00
9.00
8.10
9.00
9.90
9.00
10.80
12.60
10.80
10.80
12.60
12.60
9.90
9.90
.90
1. 80
4.50
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
834
839
835
850
849
849
849
842
846
849
852
849
849
840
849
852
834
834
834
858
834
858
834
858
852
834
858
834
858
852
834
834
865
863
873
06/18/07
CONSIGNOR NUMBER
NAME
5
DOREEN EBY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
-----------------------------------------------------------------------------------------------------------------------------------
>
307 BAG OF DIMES
308 HALF DOLLARS
309 BAG OF NICKELS FROM 1940'S
310 BAG OF QUARTERS
311 BAG OF HALF DOLLARS
312 HALF DOLLARS (6)
313 BAG OF DIMES
314 HALF DOLLARS FROM 1940'S
315 COLUMBIAN HALF DOLLAR 1893
316 DISH WITH COINS AND FRAME
317 JIM BEAM DECANTER
318 LIGHT
319 ENTERTAINMENT CENTER
320 RADIO AND SPEAKERS
321 TREADMILL
322 SINGLE BEDS BOKSHLEF
323 WASHER / DRYER
325 KITCHEN CABINET
326 MAPLE BED BOX SP/MATTRESS
327 BOOK SHELVES
328 RECORD SHELF
329 ROUND TABLE
330 CHEST OF DRAWERS
331 CHEST OF DRAWERS
332 FOAM
333 WALKERS
334 PAIR TABLES
335 TV W/REMOTE
336 NO SALE PILE
337 POTS
338 PILE CHAIRS
339 LAWN CHAIR
340 CHAIR
341 HUTCH
342 SEWING MACHINE
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
- - CONSIGNOR STATEMENT - -
QTY
UNIT
PRICE
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
145.00
14.00
7.00
155.00
50.00
25.00
25.00
27.00
25.00
1. 00
1. 00
1. 00
25.00
7.00
60.00
5.00
5.00
3.00
5.00
10.00
7.00
3.00
30.00
22.00
1. 00
1. 00
2.00
1. 00
1. 00
5.00
1. 00
1. 00
1. 00
10.00
1. 00
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CON TIN U E D
TOTAL
PRICE
145.00 10%
14.00 10%
7.00 10%
155.00 10%
50.00 10%
25.00 10%
25.00 10%
27.00 10%
25.00 10%
1. 00 10%
1.00 10%
1. 00 10%
25.00 10%
7.00 10%
60.00 10%
5.00 10%
5.00 10%
3.00 10%
5.00 10%
30.00 10%
7.00 10%
3.00 10%
30.00 10%
22.00 10%
1. 00 10%
1. 00 10%
2.00 10%
1. 00 10%
1. 00 10%
5.00 10%
1. 00 10%
1. 00 10%
1. 00 10%
10.00 10%
1. 00 10%
COMMISSION
AMOUNT
PAGE 10
AUCTION NUMBER
070519
SELLER'S RESERVE
NET AMOUNT AMOUNT BIDDER #
14.50
1.40
.70
15.50
5.00
2.50
2.50
2.70
2.50
.10
.10
.10
2.50
.70
6.00
.50
.50
.30
.50
3.00
.70
.30
3.00
2.20
.10
.10
.20
.10
.10
.50
.10
.10
.10
1.00
.10
130.50
12.60
6.30
139.50
45.00
22.50
22.50
24.30
22.50
.90
.90
.90
22.50
6.30
54.00
4.50
4.50
2.70
4.50
27.00
6.30
2.70
27.00
19.80
.90
.90
1. 80
.90
.90
4.50
.90
.90
.90
9.00
.90
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
852
834
834
852
834
852
852
834
834
840
865
849
851
851
871
881
833
846
881
846
839
881
846
864
856
881
881
838
838
855
842
842
842
883
883
FORTNA AUCTIONEERS
PREMIER REAL ESTATE AUCTION COMPANY
ANNVILLE, PA
717 867 4451
06/18/07
- - CONSIGNOR STATEMENT - -
PAGE 11
CONSIGNOR NUMBER
NAME
5
AUCTION NUMBER
070519
DOREEN EEY
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
(717) 737-3603
PROD
CODE
ITM
NO.
INV
------ ITEM DESCRIPTION ------- NO.
QTY
UNIT
PRICE
TOTAL
PRICE
COMMISSION
AMOUNT
SELLER'S
NET AMOUNT
RESERVE
AMOUNT
BIDDER #
-----------------------------------------------------------------------------------------------------------------------------------
343 TV AND STAND 1 12.00 12.00 10% 1.20 10.80 .00 869
344 LOVE SEAT 1 5.00 5.00 10% .50 . 4.50 .00 881
345 END TABLE 1 3.00 3.00 10% .30 2.70 .00 838
346 SEWING MACHINE 1 10.00 10.00 10% 1. 00 9.00 .00 834
347 END TABLE 1 1. 00 1. 00 10% .10 .90 .00 881
348 HUMIDIFIER 1 5.00 5.00 10% .50 4.50 .00 861
349 SEWING CHAIR 1 1. 00 1. 00 10% .10 .90 .00 838
350 TABLE AND CHAIRS 1 1. 00 1. 00 10% .10 .90 .00 881
351 CHAIR 1 3.00 3.00 10% .30 2.70 .00 861
352 DESK 1 1. 00 1. 00 10% .10 .90 .00 883
353 TABLE 1 12.00 12.00 10% 1.20 10.80 .00 839
TOTAL GROSS SALE AMOUNT
ACTUAL SALES TOTAL
LESS COMMISSION
AUCTION SET UP FEE
2,205.00
2,205.00
220.50
500.00
COMPLETED
YES
NO
TOTAL NET PROCEEDS
TOTAL ITEMS: 352
TOTAL DUE TO SELLER
1,484.50
1,484.50
NOTE
THANKS FOR CONSIGNING WITH US.
BIDDER OF THIS ITEM IS ON ACCOUNT.
~. ,
F:! M8a'Bank
00 0 06113M NM 017
78642
s c.~~O ~\..e=s
-
J.'~M 1:j. ~
E::
DOROTHY E EBELING
C/O DOREEN ELAINE EBY
254 EWE RD
MECHANICSBURG PA 17055
I
.-............................,.........-..., .............-..."..................,.
:':SEtSCTEt>':ACCOtrN1\:StJMMAltt:
........'-... "......".
. . . . . . . - - . . . , , , . . . . . . . . , . .
....,...-...."'.--......
............",............
... .............-..
...... .....-.-.
.........,
............."..
;:;:;:;:;:;:;:;:;:::;:::;:;:;:;::<
...............
............. .
...............
ACCOUNT ACCOUNT INTEREST EARNED MATURITY ENDING
TYPE NUMBER YEAR-TO-DATE DATE BALANCE
M&T SELECT WITH INTEREST 000000030140641 1. 05 2,759.67
REGULAR TIME DEPOSIT 031003913154561 12.48 07-13-07 0.00*
TOTAL DEPOSITS 2,759.67
* INTEREST EARNED IS INCLUDED IN YOUR TIME DEPOSIT ENDING BALANCE
ONLY IF IT HAS BEEN PAID TO YOUR ACCOUNT.
I:mi~m <.1 DOROTHY E EBELING
M&T SELECT WITH INTEREST
ACCOUNT NO.
30140641
HIGHLAND PARK
'..'...:.:.:...."..:,B..,...,E.'B~:~. }'c..NG...E..:,'..,...':::' ..::...... '..,.':':.WPOSI'I'S&:::'.:":.:>
........~ ,'.:'..',:,',' :"'::::mHER:::AriniTioNS:::':':
NO. AMOUNT
13,089.42 3 2,122.15
;:....::!:;~~....:::~~'N:l3::::::':::
'.::.::::iNTEREST':pb :: .. "BALANCE:::':
1. 05
2,759.67
::~~RW@4.~~~
:.....<.:. ,.. ':DJitt.y..::,..:
.............-.......-...
':::::::BAilii.NCE'::::"
12-15-06 BEGINNING BALANCE
12-20-06 CAPITALBLUECROSS INS. PREM
12-20-06 VERIZON PaymentREC
12-26-06 PP ELEC BILL
12-27-06 PAWC PAYMENT
01-02-07 DEPOSIT
01-02-07 COMCAST CENTRAL CENTRAL PA
01-03-07 US TREASURY 303 SOC SEC
01-09-07 VAIN TREAS 220 FEDVAINSUR
01-09-07 CHECK NUMBER 3851
01-11-07 UGI UTILITIES UGI BILL
$13,089.42
115.60
20.44
46.00
17.43
12,953.38
12,907.38
12,889.95
1,100.00
47.68
13,942.27
14,862.27
920.00
102.15
84.80
121. 00
14,879.62
14,758.62
r
'"
. .
'. . 1-
> /-/dZ-O _
'., ';, P,:P~J~ITS MAY NOT BE AVAILABLE FOR IMMED ATE~/TI1VfAff1Y
' ::: . ? .. eti...
" _.
~,.,
9f~o l(;;t"
I. fliYi;:;::. ;(')~r'lif:-"i:':
{!tifI fUR JOfAL l-
e;: tESS CASIl ..
RECEIVED
$
ot..cJ S 1.:", ~ 7
w" "
;~ ftlM&r Bank
~ ~ ~ ~nT""'ThIIlCompsny
~
1:0 ~ I. ~O 2 ~ 5 51:
~8 ~ 2 I. 2 ~OOO"- E,
(
\
NAME ~tX(')~!" .e: ,ii?{E7..//V~
X JtJ) /-</ ~h '1/ ~ II_
DATE /-/;1-07
;::':':00:'" r1qCJf i.J-n5&-~_ ~ ,,)
~ ~U/~%"IV.(/1~ r- ~ -:'/00 om,,",
JJ.I M&rBank ~QfY)t" tJOlf"__ li'U/dE"'fli '
~ l::aJ_'M'___..._ 0
Memo~~.A ~ ~"9c1: aflrCr U:OO?'7S,fsL/h V~'Jf- z;;
':02 WOcibl,",: U
ScijC(M.Lb t..) X ~~ L-
t 1</61>0.0. + Z,7S'f. b 7 ,~ Illf,7S'f.t;
)
I', ,~'$I
$ ~-</ t' t8.~:
11
NO. _.
1(1,4
;'20
..
6C.1J."DI;'-LI>' E, ~-g-'- CB<<:r. "j;' U6PDS IT
oJ,
..~~
~ ~-1IZ~:)
DP.T~
Original - Processing Work
Copy 1 - Central Balancing
Copy 2 - BranchlDept.
8
~I!I:!NIi!J.IIIAlg~. . c OMER SIGNATUR~~ _
"'-NO, POSimofosrcm, JUUANDATE [3'1'111
~ ~ l~[II~] I I
AMOUNT
CMJ
.: 550 21., ~ SOD.:
-1
fl!1M&rBank
DOROTHY E EBELING
0c.Ut>DVv\..r6 €) In::~ ~.3
ACTIVITY
P~~9S.;t:~S.~OO~~~l!>t ...........w...........I..........DlU\...:...;".. :..".",....J1N<.;.;.".L. &..."........;e;a. .S.........E<.......R..............
.si...o.THEi:l:','AriliiTiONS' .,.,"'''' """,,","'..J;v."t
01-12-07 PAYOFF ACCOUNT - WITHOUT PENALTY
ENDING BALANCE
** END OF STATEMENT **
10,579.67
0.00
$0.00
. .
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
-""DEPARTMENT 280601
HARRISBURG. PA 17128-0601
D6(l,\MtJff/(flbV'.
~~ '^t.~ G-
Telephone
February 13, 2007
717-787-6201
jwatts@state.pa.us
DOREEN E EBY
254 EWE ROAD
MECHANICSBURG PA 17055
Re: Estate of Dorothy E Ebeling
----FOe filumbe,2fOr-0043-
Social Security 186-34-1724
Dear Ms Eby:
The Department issues this waiver for the following security held in beneficiary format by
the decedent. The security will be subject to Pennsylvania inheritance tax. The Department will
not issue an information notice to the transferee. of the potential Pennsylvania inheritance tax
due for this asset as the estate representative has informed the Department that the asset{s)
will be reported on the REV-1500 filed by the estate representative. A copy of this waiver is
to be used by you to notify the transfer agent that the reporting requirements of Section
6411 of the Probate Estates and Fiduciaries Code (TItle 20, Chapter 64, Pennsylvania
Consolidated Statutes). have been satisfied.
Name of Company: VANGUARD GROUP
Type of Account: D Capitol Stock
o Registered Bond
o A Security Asset
181 A Security Account
10 Number: 922906201 & 922031307
Acg)Uflt Balal]~: _ _ _ _ $70,S25_..07 __ & ~2-L596.21
Sincerely,
~ lJoiJL
Tax Examiner II
Inheritance Tax Division
r
SC~O~\) (,
..
Vanguard Directed Beneficiary Plan Application
..ttt
CffiSPi
-
Complete this foon to establish, change, or delete beneficiaries on your individual or joint Vanguaf'dGD accounts, including
Vanguard Brokerage Servicese accounts, ooder the Vanguard Directed Beneficiary Plan (the Plan).
- Please print in capital letters, preferably in black ink.
- Be sure to read pages 6 through 10 of the Vanguard Directed Beneficiary Plan brochure. All registered owners of the Plan Accounts must
sign in SecliOR 4.
- Only individual accounts and accounts held as joint tenants with right of survivorship are eligible for coverage under the Plan. IRAs and
other retirement accounts, community property accounts, and joint accounts held as tenants in common cannot be covered under the Plan.
- For new accounts, you must also complete an Account Registration Form.
- The registration (the name, address, and Social Security number) for all accounts listed in S.oIioo 2 must be identical. Complete
a separate Vanguard Directed Beneficiary Plan Application for accounts that are registered differently.
If you need assistance or other Vanguard forms, call us toll.free at 1-1QJ.662.Z739. Most foons are available on our website at www.vanguanLcom/
?serviceforms. Return this completed fonn and any other required documents in the enclosed postage-paid envelope, or mail to: The VengUllfd
Group. P.O. Box 1110. Valley Forge, PA 19482.1110.
I( Shareholder Information (If this application is accompanied by an Acrount Registration Form, skip to Sllt:ti0ll3.)
(Check one.) vi New request Change in information Delete plan (Complete SectiollS 1. 2, and 4 only,
}JeW
City
c. v. fl1861( L.A tJ D
PA
S1ate
J 7 0
Zip
DIO- !S.
o 7.... 0 2. -/ L
D.o.]),
oJ - ()Cf- 07
(
16" 3c.j 172-,,/
Social Security Number
Dot2..o-rl.l'l c;. -IS.:B€L-) NG-
NIIIII8 of Account Owner /first, middle initial. last)
70 q HA l-Ot.MAN
Street Address or Box Number
60 u LE-V AQ...D
~{e~Z! '-I b > t) 7 2.iwJ,z-,Zs! l./ ':3 () 7
NellIe of Joint Account Owner (ff tIRJ/icable; first. middI8 initial. last)
II Plan Account Infonnation (List the identically registered existing accoonts to be covered under the Plan.)
Flmd Number Fuad NellIe Account NIIIIIber
o 0 3 0 PI2.\ (\'\'f;. M{)wl;!.f Jl11t(e.fl.lT riJND 88 0
00.3 ~ GI>JW\A F~~D Be ~
OB 7 7 b 3 ()
"8 7 7 G 3 0
Vanguard Brokerage Services Acc:oImI NunIbefs (if applicable)
V
V
lAx .JJ)
J Bb :?t..{ I 72 i
.J
L
-
.
~ FOBP-page 2 of 3 --,
I[ Plan Beneficiary Designation (Your beneficiaries will share equally in your accounts covered under the plan unless you specify
different perr:entages below.) If you need more space, list the additional information on a separate sheet and attach it to this form. If percentages
are not indicated. the assets will be divided equally among the beneficiaries.
A. Primary Beneficiaries. If a primary beneficiary dies before you or the last surviving joint owner. his or her share of the accounts covered
under the Plan will be divided proportionately among the surviving primary benefICiaries. General instructions, such as U All my children,"
"Per stirpes." or "lineal descendants," are not acceptable. Any changes will replace all previous designations.
\)oYLE::E:N e~ E6 '1
Name of 1IIlIividu81 (fiJst. middle initial.lBs1). 1hIIt. Cllldy, or CorporetiOII
3 Li %
Percentage
AHocated*
./ 03 2..2. 195(,
Spouse Other Birth Date (if applicable; TTIM1h. day. year)
R.\C.~ A f..P J:.... t~l.-l~G-
Name 0' ladlvldual (first. middle initial. lest), T....... CIIarlly, or Corpol'lltiOR
Relationship
~ '3 %
Percentage
AHocated*
/ j 0 "2..7 i ~ Lj.3
Spouse Other Birth Date lif BfJP/icable; month. day. yesrJ
LA /.I R. f?:r: EB>ELI N &
N8IIIe of 11divi....' (first middle initial. last! TruIt. Qarity, or CorpoI'lltioD
Relationship
Relationship
V I G, 2..9 I Cf .? I{
Spouse Other Birlh Date (if swlicab/e; month. day. year)
:3 3%
Percentage
AUocated*
TOTAl. 1 0 0 %
*Minimum of 10% per beneficiary. Total must equal 100%.
B. Contingent Beneficiaries. Vanguard will transfer ownership of accounts covered under the Plan to your contingent beneficiaries only if there
are no SUlViving primary beneficiaries at the time of your death (or when the last surviving joint owner has died).
N..... 0' individual (first. middle initial. last), Trust, Charity, or Corpol'lltion
%
Peicen1age
AHocated*
Relationship
Spouse Other Birth Date (ff applicable; month. day. '/88fi
... of 1ftd1vl_1 (first, middle initial. last), 1hIIt. Charity, 01 Corpol'lltion
%
Patcentage
A11cxated*
Relationship
Spouse Other Bir1h Date (ff appIicsbIe; month. day. year)
.... of 11IlI1viIIaa1 (first, middle initisl. 1astJ. hit. Charity, or CorpondIon
%
Pen:entage
AIlocated*
Relationship
Spouse Other Bir1h Date (rf appIicsb/e; month. d8y. year)
TOTAL 100%
L *Minimum of 10% per beneficiary. Total must equaI100%~
-
.
~
r:- FDBP-page 3 of 3 -,
I[ Shareholder Signatures-YOU MUST SIGN BELOW (All owners must sign exactly as their Vanguard accounts
are registered)
The undersigned Plan Account owners hereby acknowledge having received and reed the Vanguard Directed Beneficiary Plan Agreement and
agree to all terms and conditions set forth therein as supplemented by this application. The undersigned further understand and agree that
any se/Vice options previously established for Plan Accounts will remain the same until otherwise changed by the undersigned.
])OR-oTHV ~. t;gfSL-1lJb-
Name of Aa:ount Owner {Ptesse (Xint)
~;JJmV( -~ G ~rf
Signature of Account Owner
10 0\ 'l.ob~
Date (month. day. year)
Name of Joint AccoIIlt Owner (if _able) (PIeBs8 pri1t.)
~
Signature of Joint Account Owner
Date (month. day. year)
VarvJard Brokerage SeMcas is a liYision of Vanguard Marlcetilw.l Corporatioo.
L
..J
-
.
DOCUMENTATION FOR SCHEDULE H
A. Funeral Expenses: Items 1.,2. and 3. total $5,033.46, which is well within customary and
reasonable limits for such expenses. The documentation checklist on page 22 of Form Rev-1500
indicates that further documentation is not required.
B. Administrative Costs:
Personal Representative's Commissions: The total gross asset value ofthis estate, indicated
on line 8. of the Form Rev-1500 Recapitulation, supported by appropriate schedules and
documentation thereof, is $301,669.62. After review of various publications and guidance, it
was determined that a 3% commission was a reasonable fee. $301,669.62 times .03 equals
$9050.09. As Executrix ofthis estate, I have been able to save considerable expense by
completing the tasks necessary to settle the estate and distribute its funds to the beneficiaries
without the aid of lawyers, accountants and tax preparers. Many hours of research, information
gathering and preparation of forms were necessary to offset the cost of professional fees. I
incurred personal expenses such as telephone and postage charges, computer and printer/copier
costs, vehicle mileage, tolls and parking fees. I spent numerous hours in meetings and on
phone calls with the funeral director, auctioneers and realtors, bankers, utility companies, taxing
entities, the purchaser of my mother's real estate and his attorney, and others. I oversaw the
donation or disposal of a large volume of personal property that could not be sold at auction,
including household hazardous waste. I also oversaw the maintenance of the real estate until
closing and settlement. Compared to the fees charged by professionals, such as $250.00 per
hour for an attorney, or 4% and 10% commissions, plus costs, for the auctioneer, the 3%
Personal Representative's Commission is a reasonable amount.
Probate Fee: Receipt from the Register of Wills is attached for fees totaling $298.00.
Fortna Auctioneers-Sale of real and personal property: The attached contract excerpt
indicates a 10% commission for sale of personal property, and 4% for sale of the real estate,
plus expenses. Other attachments document advertising cost of $4,257.00 and $1,484.50 for
sale of personal property. The commission for sale of real estate was $6,000.00 (sale price of
$150,000.00 times .04, as noted on documentation for Schedule A).
Expenses for maintaining real property until sale & settlement: Cost of utilities from date
of death 01-09-07 until property was $1119.20, and a real estate tax bill for $586.31 was also
paid during this time period.. The remainder, $729.82 ofthe $2,435.33 total, paid for sewer and
trash bills, grass cutting and other property maintenance.
OCfJ-fSDUL5 HJ .11i~ ~. '-I.
RECEIPT FOR PAYMENT
===================
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17cr13
Receipt Date:
Receipt Time:
Receipt No.:
1/12/2007
to:13:02
1046945
EBELING DOROTHY E
Estate File No. :
Paid By Remarks:
2007-00043
EBY DOREEN E
AJW
------------------------
Receipt Distribution ------------------------
Payment Amount Payee Name
260 . 00 CUMBERLAND COUNTY GENERAL FUN
15 .00 CUMBERLAND COUNTY GENERAL FUN
8 . 00 CUMBERLAND COUNTY GENERAL FUN
10.00 BUREAU OF RECEIPTS & CNTR M.D
5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
$298.00
$298.00
Fee/Tax Description
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
JCP FEE
AUTOMATION FEE
Check# 6039
Total Received.........
FORTNA
AUCTIONEERS
26 E. Main St. . Annville, Pennsylvania 17003
6~~DLA.LtS J+
116 Iv\, e. 7.
Mr. & Mrs. John Eby
254 Ewe Road
Mechanicsburg, P A 17055
Ref: List of items sold and advertising costs for estate
located at 709 Haldeman Blvd., New Cumberland, P A.
June 18, 2007
Dear Mr. and Mrs. Eby,
Please find attached the information you requested. Including your consignor statement.
This includes the list of personal property items sold at the auction along with their costs.
Also, here is the total for advertising that you requested. Please keep in mind this cost
includes advertising for both the real estate and personal property.
The advertising and marketing program costs include not only the charges assessed by
publications used, but also our professional marketing expertise and time expended for
the same;
Advertising design
Delivery of ad copy, VIA mail, fax, email and/or hand delivery to publication
Proofreading ad copy from publications prior to actual printing
Phone calls necessary with approvals, and/or corrections to ad copy
Mailing preparation (Labels and assemblage of mailing materials)
Telemarketing and set up for auction
- . Travel time for any of the above mentioned tasks
Erection and removal of signs
(717) 236-7888
(Harrisburg)
Michael Fortna, CAI
www.fortnaauctioneers.com
FAX: (717) 867-5265
(717) 867-4451
(Annville)
.
FORTNA
AUCTIONEERS
26 E. Main St. . Annville, Pennsylvania 17003
Publication:
The Guide
Column Size:
2x4
2x5
2x4
2x5
# oflnserts:
2
2
2
2
4
Run Dates:
4/23, 4/30
5/7,5/14
4/23,4/30
5/7,5/14
4/22,4/29,
5/6, 5/13
Paxton Herald
Patriot News
(in-column Sunday)
Total:
$4257.00
Please contact our office if you have any further questions.
Thank you,
~~~
Michael R. Fortna, CAI, President
(717) 236-7888
(Harrisburg)
Michael Fortna, CAI
www.fortnaauctioneers.com
FAX: (717) 867-5265
(717) 867-4451
(Annville)
FORTNA
AUCTIONEERS
26 E. Main St. . Annville, Pennsylvania 17003
SETTLEMENT
Personal Property
Seller: Mrs Doreen Eby, Executrix
254 Ewe Road
Mechanicsburg, PA 17055
Dac l^.lV\ ~N TA\l t> t-J ~
&J-E:{)\Alf: f3. J"T~m~)
)
VAllJ.~ J fE:.RsoNAL 'fRbMY
Ref: Personal Property located at 709 Haldeman Blvd., New Cumberland, P A
Personal Property
2205.00
Cost:
10% Commission
Auction set up fee
220.50
500.00
720.50 ~
1484.50l
D OC.:v.."'" &oJ fA TL b tJ '
8CH-tt>~ H-) ~7
~. ADM\'" \S'TI?A~)\I't: LbSTS'
7. Fott..TNI4 Au.c..""t\bl\> E~5j
SAL6 aF-~L ~
.
(717) 236-7888
(Harrisburg)
Michael Fortna, CA'
www.fortnaauctioneers.com
FAX: (717) 867-5265
(717) 867-4451
(Ann vii/e)
JC iV-GDu u;; H-
:tr6M B. 7.
J
FORTNA
AUCTIONEERS
26 E. Main St. . Annville, Pennsylvania 17003
AUCTION PROPOSAL FOR
Mrs. Doreen Eby,Executrix
254 Ewe Road
Mechanicsburg, P A 17055
****************
IN REFERENCE TO:
Both real estate and personal property for the
Estate of the late Mrs. Dorothy Ebling, located at
709 Haldeman Road, New Cumberland, P A
(717) 236-7888
(Harrisburg)
Michael Fortna, CA'
www.fortnaauctioneers.com
FAX: (717) 867-5265
(717) 867-4451
(Annville)
.
*FOUR*
FINANCIAL
Fortna Auctioneers will be authorized to charge a (10%) ten commission on all
personal property and a (4%) four percent commission on the real estate sold, to be
paid by the buyer at time of settlement.
Fortna Auctioneers will be responsible to set up the sale so the auction can proceed in
a time efficient manor and generate the most possible dollars for the estate. Fortna
Auctioneers will provide staffing for the set up approximately one week prior to the
auction. The cost to the seller/estate will be approximately $500.
Fortna Auctioneers will provide all of the necessary personal on the day of the
auction at no additional cost to the seller/estate.
All advertising costs will be paid by the seller/estate and can be deducted at the
settlement of the personal property.
Fortna Auctioneers recommends a Job Johnny be placed on site prior to the day of the
auction for the convenience to the potential buyers, the cost therein to be paid by the
seller/estate.
,
.
*SIX*
EXECUTION OF THE AUCTION PROPOSAL
Fortna Auctioneers has all the resources at hand to begin work on this proposal
immediately upon your authorization.
This proposal agreed to and accepted this ~ 7 day of ~ 200Gr
[)~~.
fuoreen Eby Executrix
Estate of Mrs. Dorothy Ebling
~) ~<<-.
~///~ -'-
rMiCh~~~
Fortna Auctioneers
~f)\fNTATI iJ rJ
~Clt6DIAL6 :r
II>
.
WSEMS - Chambersburg ALS/BLS
205 GRANOVlEW AVE
SUITE 211
CAMP Hill, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
+.)
WE:ST SHORl
PATIENT NAME: DOROTHY EBELING
INSURANCE: MEDICARE B
CAPITAL BLUE CROSS
CAPITAL BLUE CROSS
149893W
186341724A
aBS 186341724
YWM8003072220
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
22032 GWCS
149893W NONE
12/21/2006
02:21 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
SEIDlE EXTENDED CARE
DOROTHY ESEUNG
709 HALDEMAN BLVD
NEW CUMBERLAND, PA 17070
REASON(S)
FOR
TRANSPORT
ACCIDENTAL FAll
INVQIC~
__u____.~.____ -.--..- -- ,- -
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher One Way Transport A0999 1.0 87.13 87.13
Transport Van Mileage A0999 6.0 3.24 19.44
Total - 106.57
DESCRIPTION OF PAYMENT
RECEIPT
PAYMENT DATE
AMOUNT
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT .......
RETURNED CHECK FEE - $32.00
$106.57
PATIENT NAME: EBELING. DOROTHY E
PATIENT NUMBER: 22032
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
106.57
CALL NUMBER
BILLING DATE:
149893W
01/05/2007 .
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
ASSISTANCE.
=/~l ~:: \.1
MASTER CARD
~ ~
.
..J
0600210025
D dCun,(;:.,J} Ai) b,...J
SC~[)U~ I.
PA.40 2006
.
Social Securily Number shown fIrsl
I B I:., J Y ).'1 ...?:i.. ~,!~~.).bp~'i ~-GlS~lNV
12. PA Tax Liability. Multiply Une 11 by 3.07 percent (0.0307). . . . ., .. ... .. .. . . ., . . .
18. Total Estimated Payments and Credits. Add Lines 14, 15, 16, and 17. . . . . . . . . . . . .
. To Fo..glV8ne;;cnKii..Uain1It-PA'ich;i.-sp-'-~~"w,"- .
198. Filing Status: 4B w:::.= or . C) MarrIed
20. Total ElIglbl11ty Income tom PartC, Une 11. PASchldule SP. .
c=) Deceased
12. 2-2.1{-O 7
13. o.
14. 0-
15. O.
16. 0_
17. 0_
18. Q-
Dependents, Part 8, Line 2,
19b. PA Schedule SP. . . . . . . . . . . .
13. Total PA Tax Withheld. See the Instrucllons. ..................................
14. Credit from your 2005 PA Income Tax relUm. .................................
15. 2006 Estlmaled Installmenl Payments. ......................................
16. 2006 Extansion Paymenl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17. Nonresidenl Tax Wllhheld from your PA Schlldule(a) NRK.1. (Nonresidents only) ....
721&-55
21. Tax Forgiveness Credit from Part D. Une 16, PA Schedule SP. ................. 21.
134-':\4.
22. Resldenl Credit Submit your PA Seh.".{a) GoB, GoL, and/or RK.1. ............ 22.
23. Total Olher Credits. Submil your PA Schedule OC. . . . . . . . . . . . . . . . . . . . . . . . . . .. 23.
0-
0_
25. TAX DUE. If Une 12 18 more than Une 24, enter the difference h8l'8. . . . . . . . . . . . . . ., 25.
26. Penalties and Interesl See the il'l8trud1ons.
If altaching fonn REV-1630, fill in lhls oval .......................... 26.
27. TOTAL PAYMENT. Add lines 25 and 26. .................................... 27.
28. OVERPAYMENT. Line 24 is more than the lotal of Line 12 and Une 26. enler the
difference here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 28.
The totel of Un.. 29 through 35 must equal Une 28.
29. Refund - Amounl of Line 28 you wanlas a check mailed lo you.. . . . . . . . REFUND 29.
3Y.Y If
81- b 3,
24. TOTAL PAYMENTS and CREDITS. Add lines 13, 18, 21, 22, and 23. ............. 24.
o.
8~.f:,3
.
-
30. Credit - Amount of Une 28 you want as a credil to your 2007 estimated account .... 30.
.
31. Amount of line 28 you wanl to donate lo the WIld Resource Conservation Fund. . .. 31.
32. Amount of line 28 you want to donata to the MUItary F.m11y Relief
Assistance Prognam. ................................................ 32.
33. Amounl of line 28 you wanl to donate to the Governor Robert P. Casey Memorl.1
Organ and TI..ue Donation Awarene.. Trust Fund. ......................... 33.
34. Amount of Une 28 you wanl to donate to the Juvenile (Type 1) Diabetes Cure
R....rch Fund ........................................................ 34.
35. Amount of Une 28 you wanllo donate lo the Breast and Cervical Cancer
Reaearch Fund. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 35.
.
-
.
-
.
'SIGNATUReisi~Ui1*r-p;;iliWg;..ij;Y.-,iWiI) dHiin_,...fhm ........iiiiiSnitUm;.~. .il.~:;pj,i~ng tiCt1i.dU....Iiftd~..~ IiIdeDiiWtiMt Of Iii,
(our) belief, .,., -1rlIe, CltIYKt, IIIId GOIlIp".
.. ... .. ....~t.p~\{~)2::..l~.i.~-~I.:-Yt~f\A;<L::r:J ;
1>f,6 )~iUfI!?,,1) 'O"-~~!fc;-l~1i;g+i ... + I Y - 0] ) t '1 'f ~ 1..7 'i~
i~,~:~rJJ1-::,Za--I((5.
81de2
L
0600210025
0600210025
...J