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Home My WebLink About09-26-07 (2) -I 15056041125 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes ' INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 17128-Q601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 7 File Number 012 9 Date of Birth 262903421 1229200 6 072 5 1 9 4 8 KEPHART DONNA MI J Decedent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix K E P H ART S R F RED MI A Spouse's First Name Spouse's Social Security Number 19132 9 9 3 2 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW [&I 1, Original Return o 4. Limited Estate [&I o o 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach Copy of Trust) o 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT. THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number o o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes R . MAR K THO MAS , ESQUIRE 7177962100 Firm Name (If Applicable) ~..) Second line of address --t I: 1 0 1 SOU T H MARKET STREET REGISTER OF WILLS use ONLY '-;: (:J --J ~:--: C0 ~--I !-:-.j -0 ,,) G~'l First line of address _)i City or Post Office State ZIP Code --1 ,~~ bATE FILED N MECHANICSBURG P A 17055 Fort M ers FL 33912 PRESENTATIVE ADDRESS 101 South Market Street Mechanicsburg PLEASE USE ORIGINAL FORM ONLY PA 17055 Side 1 L 15056041125 15056041125 -I -.J 15056042126 REV-1500 EX Decedent's Social Security Number Decedent's Name: DONNA J. KEPHART RECAPITULATION 262903421 2. Stocks and Bonds (Schedule B) .................................. 2. 380000.00 7913 7.5 5 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 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. 4 1 4 2 9 . 5 4 ...... . 6. Jointly Owned Property (Schedule F) D Separate Billing Requested . . . . . . . 6. 4 1 1 6 O. 2 4 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) D Separate Billing Requested . . . . . . . 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 5 4 1 7 2 7 . 3 3 7 6 8 2 1 . 5 1 4 0 8. 9 8 7 7 2 3 O. 4 9 4 6 4 4 9 6. 8 4 9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . 14. 4 6 4 4 9 6. 8 4 TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.O _ 4 5 0 5 o . 2 4 15. O. 0 0 16. Amount of Line 14 taxable 9 at lineal rate X .O~ 3 9 4 4 6 . 6 0 16. 1 7 9 7 5 . 1 0 17. Amount of Line 14 taxable 2 0 0 0 o . 0 0 at sibling rate X .12 17. 2 4 0 O. 0 0 18. Amount of Line 14 taxable o . 0 0 at collateral rate X .15 18. O. 0 0 19. Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 2 0 3 7 5 . 1 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT D Side 2 L 15056042126 15056042126 -.J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 07 0129 DECEDENT'S NAME DONNAJ.KEPHART STREET ADDRESS 108 Junioer Drive CITY \ STATE I ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 20,375.10 16,000.00 800.00 Total Credits (A + B + C) (2) 16,800.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( 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) 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 3,575.10 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) A. Enter the interest on the tax due. 3,575.10 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 00 b. retain the right to designate who shall use the property transferred or its income; ............................... 0 00 c. retain a reversionary interest; or ................................................................................................ 0 00 d. receive the promise for life of either payments, benefits or care? ....................................................... 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ..................... ...... ...... .......................... ............................ 0 00 3. Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? ......... 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 0 00 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. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~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 decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER DONNA J. KEPHART 21 07 0129 All 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 properly 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 aroaertv which is iointlv-owned with riaht of survivorshia must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 185.000.00 08 Juniper Drive. Mechanicsburg. PA 17055 This property is a3 bedroom house set on .33 acres. It is also located in a flood zone. It has been isted for sale for several months. but only recently was an offer of $195.000.00 made. However, when he potential buyer realized that the purchase of flood insurance was required, the offer was withdrawn. t is believed that this property will not sell for more than $185.000.00.) 2. Band 2C West Springville Road, Boiling Springs. PA Duplex sold for $195,000.00. A copy of the settlement sheet is attached which reflects the closing costs o the estate which are itemized hereinafter.) 195.000.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 380 000.00 REV-1503 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF DONNA J. KEPHART FILE NUMBER 21 07 0129 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 79,137.55 =dward Jones 01 Progress Parkway lIIaryland Heights, MO 53043-3042 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 79 137.55 REV-1508 EX + (6-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DONNA J. KEPHART SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 07 0129 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. DESCRIPTION VALUE AT DATE OF DEATH 10,000.00 Personal jewelry Sovereign Bank, Account No. 1681716054 98 East Simpson Street Mechanicsburg, PA 17055 :)overeign Bank, Account No. 1684006131 798 East Simpson Street lt1echanicsburg, PA 17055 Sovereign Bank, Account No. 1684010067 98 East Simpson Street lt1echanicsburg, PA 17055 Citizens Bank West Main Street lt1echanicsburg, PA 17055 ~ersonal Property 15,684.49 860.12 120.02 7,354.14 3,115.00 995 Cadillac DeVille Sedan 40 (Given to surviving spouse) 3,390.00 Cemetery plots at Rolling Green Cemetery (Given to surviving spouse) 500.00 Reimbursement of 2007 property tax (Boiling Springs, PA, property) 220.21 ~eimbursement of 2006-2007 school tax (Boiling Springs, PA, property) 57.90 Cash 49.72 inal pension payment from NEBF 77.94 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 41 429.54 REV-1509 EX + (6-98) '* SCH"EDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DONNA J. KEPHART FILE NUMBER 21 07 0129 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS ~ELA TIONSHIP TO DECEDENT A. Fred Kephart 08 Juniper Drive Mechanicsburg, PA 17055 ~pouse B C JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY '10 OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. 'I. fl/31/07 :sovereign Bank, Checking Account No. 1681720396 35,420.47 50. 17,710.24 2. n.. 2/20/01 4 North 19th Street 46,900.00 50. 23,450.00 ;arrisburg, PA TOTAL (Also enter on line 6, Recapitulation) $ 41 160.24 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 07 0129 DONNA J. KEPHART ITEM NUMBER A. 1. 2. 3. 4. B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT FUNERAL EXPENSES: Funeral - Neil Funeral Home, Inc. Funeral dinner Rolling Green Cemetery - internment of remains Rolling Green Cemetery - memorial marker 7,115.21 184.63 1,175.00 1,626.00 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Kimberly A. Caudill Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 15451 Sweetwater Court 18,000.00 City Fort Myers Year(s) Commission Paid: 2007 State FL Zip 33912 Attorney Fees R. Mark Thomas, Esquire Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant 17,000.00 Street Address City Relationship of Claimant to Decedent State Zip Probate Fees 495.00 Accountanfs Fees Tax Return Prepare(s Fees Doug Mangle 175.00 Publication - Cumberland County Law Journal Publication - The Patriot News Appraisal of Personal Property - Chuck Bricker Auctioneer Appraisal of Jewelry - Jamie D. Davis of Joseph James Jewelers Repairs to automobile Reimburse Executrix travel expenses - February 2007 Wire fees from Edward Jones U-Haul - transport household furnishings from estate Reimburse Executrix travel expenses - August 2007 Fulton Bank - estate checking account fee UPS - ship financial records to Florida Staples - purchase office supplies, boxes, etc. 75.00 141.18 100.00 42.40 30.20 860.46 11.00 1,008.68 956.06 26.60 36.48 16.96 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 76 821.51 Continuation of REV-1500 Inheritance Tax Return Resident Decedent DONNAJ.KEPHART Decedent's Name 21 07 0129 File Number Page 1 Schedule H - Funeral Expenses & Administrative Costs - 87. ITEM NUMBER AMOUNT 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. DESCRIPTION UPS - overnight delivery of death certificate from Kentucky to Pennsylvania Reimburse Executrix and sister for travel expenses - June 2007 Federal Express - overnight return to Executrix for signature and return to attorney's office Hazard insurance - 2B and 2C West Springville Road, Boiling Springs, PA Repairs - 2B and 2C West Springville Road, Boiling Springs, PA Water and sewer bill - 2B and 2C West Springville Road, Boiling Springs, PA Final water and sewer bill- 2B and 2C West Springville Road, Boiling Springs, PA Storm damaged tree removal - 2B and 2C West Springville Road, Boiling Springs, PA Realtor commission on sale of 2B and 2C West Springville Road, Boiling Springs, PA Realtor transaction fee on sale of 2B and 2C West Springville Road, Boiling Springs, PA Transfer tax on sale of 2B and 2C West Springville Road, Boiling Springs, PA Wiring fees on sale of 2B and 2C West Springville Road, Boiling Springs, PA Tax certification on sale of 2B and 2C West Springville Road, Boiling Springs, PA 2007 real property taxes for Boiling Springs property (reimbursement of $220.21 listed on Sch. E) Hazard insurance - 108 Juniper Drive, Mechanicsburg, PA 2007 real property taxes - 108 Juniper Drive, Mechanicsburg, PA 2007 school taxes - 108 Juniper Drive, Mechanicsburg, PA PPL Electric - 108 Juniper Drive, Mechanicsburg, PA United Water - 108 Juniper Drive, Mechanicsburg, PA York Waste Disposal- 108 Juniper Drive, Mechanicsburg, PA Interior and exterior cleaning - 108 Juniper Drive, Mechanicsburg, PA Secco Home Services (air conditioner breakdown and damages to property) - Juniper Drive property Zimmerman Plumbing, Heating and Air Conditioning - 108 Juniper Drive, Mechanicsburg, PA Puroclean of Susquehanna Valley - 108 Juniper Drive, Mechanicsburg, PA Michael Vandrew - routine property maintenance on Juniper Drive property 13.58 1,529.42 80.00 445.00 364.41 168.72 198.00 350.00 11,700.00 165.00 1,950.00 31.00 5.00 412.18 743.00 539.68 1,920.57 262.44 137.66 43.50 970.00 69.95 1,576.00 3,275.54 795.00 SUBTOTAL SCHEDULE H.B7 27,745.65 REV-1512 EX + (12-03) '* SCHEDULE' DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 21 07 0129 DONNA J. KEPHART Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. 2. 3. 4. 5. DESCRIPTION VALUE AT DATE OF DEATH Bon Ton Retail Services p. O. Box 17264 Baltimore, MD 21297-1264 Boscovs p. O. Box 17642 Baltimore, MD 21297-1642 CPenney ;). O. Box 960001 )rlando, FL 32896-0001 :sears Credit Cards ;). O. Box 183081 ~olumbus, OH 43218-3081 Bellefonte Emergency Medical, Account No. BEH-000012729 ;). O. Box 5148 /\'shland, KY 41105-0989 148.64 131.92 38.03 58.33 32.06 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 408.98 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Bobbie L. Schwinabart Sibling 20,000.00 (specific bequest) 2. Brenda S. Stinson Lineal 20,000.00 (specific bequest) 3. Kimberly A. Caudill Lineal 0.50 (of residuary) 4. Dana M. Gilsdorf Lineal 0.25 (of residuary in trust) 5. Brandon M. Gilsdorf Lineal 0.25 (of residuary in trust) 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 n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ ''''.'''''''.''* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DONNA J KEPHART SCHEDULE J BENEFICIARIES FILE NUMBER 21 07 0129 (If more space is needed, insert additional sheets of the same size) ;A \' D~ O\dti LAST WILL AND TEST AMENT BE IT REMEMBERED THAT I, DONNA J. HOOVER KEPHART, a resident of 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 any and all Wills and Codicils previously made by me. I declare that I am married to FRED A. KEPHART, SR. Reference is hereby made to the Prenuptial Agreement dated April 26, 1999. I also declare that I have two daughters, ROBYN LEA SMITH and KIMBERLY ANN CAUDILL. Reference is made to my daughter ROBYN LEA SMITH to show that it is my intent to leave her out of this Will. II I direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable atter my decease. III I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. ~.~ '~ -" I ,-.1_' c.) c-,~-~ . '.: 1_0 '-ITI , I hereby make the following specific bequests: '--, \.!:) ,'., ~ ,:' -;~, To my sister, BOBBIE L. SCHWINABART, I give the sum of lxV6rtty t!~usand t)""'-.i '2 IV C) c. , ~-J , .,) C":] t"~_~1 --J A. -~.- : ($20,000.00) dollars; and ..r:- en B. To my step-daughter, BRENDA S. STINSON, I give the sum of twenty thousand ($20,000.00) dollars. Should BOBBIE L. SCHWINABART or BRENDA S. STINSON pj'edecease or fail to survive me by thirty (30) days then their share shall lapse and be added to my residuary ,estate. V I hereby direct my Executor to divide the remainder of my estate into two (2) equal shares to be distributed as follows: A. One (1) share to my daughter, KIMBERLY A. CAUDILL, per stirpes; and -.' . , .' j . " B. One (l) share to be divided equally between my grandchildren, DANA M. GILSDORF and BRANDON M. GILSDORF, pursuant to the terms of the hereinafter included Trust. VI TRUST If I have any grandchildren who inherit property under the tenns of this Will who are under the age of twenty-tlu-ee (23) years, I appoint my son-in-law, GLENN CAUDILL as Trustee of the property that I have given to my grandchildren. A. The assets that are transferred to the Trust shall be divided into shares commensurate with the size of the estate to which each grandchild is entitled until such grandchild attains the age of twenty-three (23) years. B. The Trust estate shall be administered until each grandchild reaches the age of twenty- tlu-ee (23) years. Until that time, the Trustee shall apply all net income and principal of the Trust estate as follows: I) So long as my grandchild is under the age ,of twenty-three (23) years of age, the net income of the Trust shall be paid to, or applied for the benefit of my grandchild at such times and in such amounts as the Trustee shall in his discretion deem necessary for his support, welfare, maintenance and education. Education shall be defined broadly to include not only that available in college, but also trade school and other similar training. In the event that the income shall be insufficient to provide my child with adequate maintenance, support, welfare or education, the Trustee may invade the principal of this Trust for this purpose. 2) The Trustee in exercising his discretionary authority with respect to the payment of income or principal of the Trust Estate to my beneficiary, shall take into consideration any income or other resources available to my child from sources outside of this Trust that may be known to the Trustee. The determination of the Trustee with respect to the necessity of making payments out of income or principal to my beneficiary shall be conclusive onal! persons howsoever interested in the Trust. 3) The Trustee shall accull1ulate and add to principal any net income of the Trust not paid out in accordance with the discretion hereinabove confeITed on the Trustee. 4) In the event my grandchild predeceases me or dies prior to the termination of this Trust, the interest of my grandchild in the Trust shall cease, except that, if he is survived by any children, then the TlUstee shall pay net income of the Trust to or apply the same for the benefits of such children of my deceased grandchild, in such amount or amounts as the Trustee in his sole discretion may determine for support, welfare and maintenance. 2 tt.- , . , '. C. When my grandchild reaches the age of twenty-three (23) years, a calculation of the property remaining in the Trust shall be made and the total thereof shall be distributed to him or her. D. My grandchild, as beneficiary of this Trust, shall not have any right to alienate, encumber, or hypothecate his interest in the principal or income of the Trust in any manner, nor shall any interest be subject to claims of his creditors or liable to attachment, execution or other process oflaw. E. In order to carry out the purposes of this Trust established by this Will, the Trustee, in addition to all other powers granted by this Will, or by law, shall have the following powers over the Trust estate, subject to any limitation specified elsewhere in this Will: 1) To retain any property received by the Trust estate for as long as the Trustee considers it advisable. 2) To spend funds for the maintenance and repaIr of real property. 3) To sell at public or private sale, exchange or lease for a period of time, any real or personal property and give options for sale of the lease. 4) To execute and deliver any deeds, lease,s, assigrunents or other instruments as may be necessary to carry out the provisions of this Trust. 5) To borrow money and to mortgage or pledge any real or personal property. 6) The Trustee shall maintain accurate records and accounts and shall render statements to my beneficiary hereunder showing receipts and disbursements of principal and income no less frequently than mIDually. The Trustee shall serve without bond and shall receive fair and reasonable compensation for administration ofthis Trust, not to exceed five (5%) percent of annual income. 7) To distribute property in kind. 8) To do all other acts that are in his judgment necessary or. desirable for the proper management, investment and distribution of the Trust estate. VII I nominate, constitute and appoint my husband, FRED A. KEPHART, SR. and my daughter, KIMBERLY A. CAUDILL as Co-Executors of this LAST WILL, to serve without bond. If either is unable to serve in this capacity, then the other may act alone, to serve without bond. 3 l"- " IN WITNESS WHEREOF, I, , DONNA 1. HOOVER KEPHART, have set my hand to this LAST WILL this /3'1; day of JV\4Ie ,2003. . A7::-J~-~d DONNA 1. H . VER KEPHART Signed, sealed, published and declared by the above-named DONNA J. HOOVER KEPHART, as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses, ~~ '" 1. t1/$flli 4 (I.' . '. ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND I, DONNA J. HOOVER KEPHART, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualitied according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it as my free and voluntary act for the purposes therein expressed. b~IA~~~ SWOIll or affirmed to and acknowledged before me by DONNA J. HOOVER KEPHART, Testatrix, thisAJ daYt9~ ,2003. . . t. . (: ,,1., ~:r' f) L) ~,j ~ ~ ( .' 3" ; I' .' AF'FlDA VIT ------NotarlaI8eal Anne Carmody, Notary Public Mechanlcsburg Bora, cEum~:~~~r~u~ My Commission ExpIres xp r .. COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND We,12.fJ\O-\\L~~~ and jQ\i\..~LOr\ek:*- , the witnesses whose names are signed to the attached or foregoing instrument being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her LAST WILL; that DONNA 1. HOOVER KEPHART 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 ~s witnesses; and that to the best of our knowledge; the Testatrix was at the time 18 years of age or more, of sound mind and under no constraint or undue influence. ~L _fit /ilJJft6 . SWOIll or affirmed to an~k110wledged before me this /J day of y ~ ,2003. \,' , . I ., , (I U&)udt (~,~,. /.r r ( .... ': ' ft: .. ,;, .\.1),/ \" . "i. r-1:' .,1 .'.' " "'.;~J',..I"'I.'I~~" 5 Notarial Seal Anne Carmody, Notary Public Mechanlcsburg Bora. Cumberland County My Commission Expires Expires Mar. 11. 2006 $209,900 Welcome To 108 .Juniper Dr. Mechanicsburg Upper Allen TWP 14BR BRICK HOME IN MECH SD! Well maintained 4BR brick home wi 1 full & 2 half baths boasts C/^ HW floors, F~l;- ---1 1 rm wi FP, 2 car garage, deck, laundry rm, formal DR. eat in kitchen & lots of storage. ! !Directions: Frm Mech: North on 114 (Market St), Right on Juniper, home on Left j I. --------- ... ----------------------------------------.--.----------nh______________ ------------------ -- __I fSCh DistMechanicsburg .. ,terwarran~: 140. ,.!BRMS: 4 '~BTH full: 2 half: 0 1 I_~~'e: ~raditi_~______________.__J ~__ ITotSqFt 1791 i'LBox: _I IS-"!bdi~_i!5i~[l~_____________h_____h__ 'l~_smt: full, wa~k:-out JGar: 2 Car JPoss: settlement i l~onin9: resi~![l~~ __ h____n__________Jl~i!1~__~, conv. ___________JAcres: 0.33 'II [Heat: b~seboard _e~~~c _ ... lCoo.:C/A ..lTaxes: _ _ _lyre.t +/-: 1968 I !Firep.ace: 1, family room I'L Room .1 Dimension. 'I Level!.,.1 iConstruction:. - /1- II iFoundation: I!EntIYL-_ -L. ___I !~:rc: 11~:i:~ ~= .r ... +-> ..'111 iWater I Sewer: public - public I.. ---;- --- ~!-I.. iExterior Features: ~itchen _ L .1 1 I, !Appliances: IjBreakfast Rm :1 ..iL. ii I . .1--.- ~--- - -II ;lnte~lor Features: IStudy J Den ! iI 11 : Equipment: ,L__ .- L-,! iLot Size: .33 acres !Family Room~L_ ,I LL II I Parking: 2 car garage IMaster Bd"" 'IL 2 II i Remarks: Well maintained 4BR brick home w/1 full & 2 half baths II Bedroom 2 !I !L- 211 Iboasts CIA, HW floors, Family rm wI FP, 2 car garage, deck, laundry i. _I- . . '--p- _ --1.1 Irm, formal DR, eat in kitchen & lots of storage. L~~~~m_j_n. _ -----JL? _ ____II II I' iBedroom 4 'I 2 i' J~~~ n:~=L=--=--=-11 I I - I i Beth Williamson CSP Office Phone: (717) 697-4673 Home Phone: 717-571-1796 E-Mail: beth.williamson@jgr.com 1II1&! HUD - I UNIFORM SETTLEMENT STATEMENT OMB Approval No. 2502-0265 A. U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT SETTLEMENT STATEMENT B. TYPE OF LOAN 6. File Number: 7. Loan Number: I. FHA 2. FmHA 66002077 2007-11 1760726837 3. X Conv. Unins. 4. VA 5. Conv. Ins. 8. Mortgage Insurance Case Number C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(p.o.c.)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. NOTE: TIN = Taxpayer's Identification Number D. NAME AND ADDRESS OF BORROWER: E. NAME, ADDRESS AND TIN OF SELLER: F. NAME AND ADDRESS OF LENDER: Ronald A Turo/Andrew J Turo Fred A. Kephart, Sr. , Exec. JP Morgan Chase Bank, N.A. Claire T. Turo Kimberly Ann Caudill, Exec. 900 Stewart Avenue 28 South Pitt Street 108 Juniper Drive ~^lholesale , 4th Floor Carlisle, PA 17013 Mechanicsburg, PA 17055 Garden City, NY 11530 G. PROPERTY LOCATION: H. SETTLEMENT AGENT NAME, ADDRESS AND TIN 2B & 2C West Springville Rd TURO LAW OFFICES 25-1616709 Boiling Springs, PA 17007 28 South Pitt Street" Carlisle, PA 17013 PLACE OF SETTLEMENT I. SETTLEMENT DATE 40-28-2100-081A 28 South Pitt Street 06/19/2007 Carlisle, PA 17013 J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 10 I. Contract sales price 195,000.00 40 I. Contract sales price 195,000.00 102. Personal property 402. Personal property 103. Settlement charges to borrower (Line 1400) 10,380.44 403. 104. 404. 105. 405. Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance 106. City/town taxes 406. City/town taxes 107. County taxes 0 6 / 1 9 / 2 007 -12 / 31 /2 0 0 7 220.21 407. County taxes 06/19/2007 -12 /31/2007 220.21 108. Assessments 408. Assessments 109. 409. 110. School Tax 06/19/07-06/30/07 57.90 410. School Tax 06/19/07-06/30/07 57.90 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 205,658.55 420. GROSS AMOUNT DUE TO SELLER 195,278.11 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 20 I. Deposit or earnest money 5,000.00 50 I. Excess deposit 202. Principal amount of new loan(s) 156,000.00 502. Settlement charges to seller (Line 1400) 14,019.72 203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to 204. 504. Payoff of first mortgage loan 205. 505. Payoff of second mortgage loan 206. Prorated June Rents 459.96 506. Prorated June Rents 459.96 207. 507. 208. 508. 209. 509. Adjustments for items unpaid by seller Adjustments for items unpaid by seller 210. City/town taxes 510. City/town taxes 211. County taxes 511. County taxes 212. Assessments 512. Assessments 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. . 220. TOTAL PAID BY/FOR BORROWER 161,459.96 520. TOTAL REDUCTION AMOUNT DUE SELLER 14,479.68 300. CASH AT SETTLEMENT FROMITO BORROWER 600. CASH AT SETTLEMENT FROMITO SELLER 30 I. Gross amount due from borrower (Line 120) 205,658.55 601. Gross amount due to seller (Line 420) 195,278.11 302. Less amount paid by/for borrower (Line 220) 161,459.96 602. Less reduction in amount due seller (Line 520) 14,479.68 303. CASH FROM BORROWER 44,198.59 603. CASH TO SELLER 180,798.43 SELLER'S STATEMENT The information contained in Blocks E, G, H, and I and on line 401 (or, if line 401 is asterisked, line 403 and 404) is important tax information and is being furnished to the Internal Revenue Service (see Seller Certification). If you are required to file a return, a negligence penalty or other sanction will be imposed on you if this item is required to be reported and the IRS determines that it has not been reported. You are required to provide the Settlement Agent with your correct taxpayer identification number. If you do not provide the Settlement Agent with your correct taxpayer identification number, you may be subject to civil or criminal penalties imposed by law. Under penalties of ""j''Y, l_lYili'''h'~' t, ,-""",," m;;;;," ld,"<if~rio~ ~ /J',;f2 Fred A. Kephart, Sr., Exec. (Seller's Signature) Kimberly Ann Caudill, Exec. (. iO EASY SOFT, Inc. 2001 Previous editions are obsolete Page I form HUD-I (3/86) ref Handbook 4305.2 L. SETTLEMENT CHARGES 700. TOTAL SALES/BROKER's COMMISSION based on price $ 195, 000 . 00 @ 6. 000 % Division of Commission (line 700) as follows: 70\.$5,875.00 to ERA-NRT, Inc. 702.$5,825.00 to Kimberly Realty 703. Commission paid at Settlement 704. Transaction Fee to ERA NRT, Inc. 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 80\. Loan Origination Fee 1. 549% $ Community Mortgage 802. Loan Discount 0.951% $ JPMorgan Chase Bank 803. Appraisal Fee to Diversified Appraisal $500.00 POC 804. Credit report to Equi fax 805. Lender's Inspection Fee 806. Tax Related Service Fee to 1st American Tax Service W~Underwriting Fee to JPMorgan Chase Bank, NA 808. Flood Determination & Certification to 1st American Flood Svc. 809. Processing Fee to Community Mortgage 810. 81\. 812. 813. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 90\.lnterest from 06/19/2007-06/30/2007 @ $25.110 oer day 902. Mortgage Insurance Premium for 903. Hazard insurance Premium for 1 year (s) to Alan Hostetler Ins $ 685 POC 904. 905. 1000. RESERVES DEPOSITED WITH LENDER 100\. Hazard insurance 8 month(s) @ $57.09 per month 1002. Mortgage insurance 1003. City Property Taxes 5 month(s) @ $5.23 per month 1004. County Property Taxes 5 month(s) @ $29.24 per month 1005. Annual assessments IOO~School Taxes 13 month(s) @ $145.55 per month 1007. 1008. Aggregate Accounting Adjustment 1100. TITLE CHARGES 110 I. Settlement or closing fee to 1102. Abstract or title search to Cumber land- Perry Abstract 1103. Title Examination to 1104. Title insurance binder to 1105. Document preparation to 1106. Notary fees to 1107. Attorney's fees to (iilcludes line numbers: 1108.TitlelnsurancetoTuro Law Off, Agt for Conestoga Title Ins. (includes line numbers: 1101 - 1110 1109. Lender's coverage $ 156000. 00 1110. Owner's coverage $ 195000.00 Ill\. Lender's Endorsements 100, 300, 8.1 1112. Closing Protection Letter to Conestoga Title Insurance Co. 1113. Wire Fees to Conestoga Title Insurance Co. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recording fees: Deed $ 43.50 Mortgage $ 1202. City/cnty tax/stamps: Deed $ 1,950.00 Mortgage $ 1203. State tax/stamps: Deed $ 1, 950 . 00 Mortgage $ 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 130 I. Survey to 1302. Pest inspection to 1303. Final Water/Sewer to South Middleton Twp. Mun. Authority 1304. Tax Cert. Fee to Judy Campbell, TC - Reimb. Beth Williamson 1305. Wire Transfer Fee to Sovereign Bank r 1~6. I 1400. TOTAL SETTLEMENT CHARGES (enter on lines 103, Section J and 502, Section K) I ::RJ, 380. 44 14, 019. 72 CERTIFICATION: I have carefully ;r~~ the HUD-I Settlement Statement and to the best of my 'to...t:tJ~~lb;~:e and accurate statement of all receipts and d;'b"~~" j J;,~~.~,,,u'/Mrt;ry 1b,1I =,;,,, '1!iJfJtf /1,;" Il/ih Seller'- '-'./J \ Fr"'~ All. Kephart BorrowtV' RoKald A Turo/Anrl; ew J Turo 77"'\ "/7/::'-\ //;'1 ., PAID FROM BORROWER'S FUNDS AT SETTLEMENT PAID FROM SELLER'S FUNDS AT SETTLEMENT 11,700.00 165.00 2,416.44 1,483.56 50.00 21.72 84.00 475.00 14.00 295.00 301.32 685.00 456.72 26.15 146.20 1,892.15 -537.57 POC 275.75 150.00 35.00 44.00 21.00 72.50 Release $ 116.00 1,950.00 1,950.00 168.72 5.00 10.00 ~7~ Seller imberly Ann Caudill Borrower Claire T. 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'-c, 5 0<: e~ ln3 ~(\) ..-a p. %1:) ~ ';;;; f. g ~ (') % '0 ~ ~ ~ -b (\) ~ tI) -. o , ~ .c !- ~. ~ ~ o i' U) i ~ i ij; $. -0 ~ ~ ,:,% Donna J. Kephart's Estate Jewelry (appraisal by Jamie D. Davis/Joseph James Jewelers, Mechanicsburg, PA.) Appraised Value (Specified) 1 3/4 Carat diamond ring yellow gold (free style) 1 3/4 Carat total weight wedding ring & band Sapphire & diamond ring Diamond Heart Necklace Diamond Cross (Non-Specified) Solid gold nugget pendant 1/4 diamond pendant w/ enhancer 1/2 carat total weight diamond studs 3 carat diamond tennis bracelet 4 carat diamond tennis bracelet Opal and diamond pendant 2 Pair diamond hoop earrings Diamond earrings w/ scallop around diamonds Diamond in Eastern star ring Assorted gold bracelets & chains Solid gold herringbone thick chain Nana's 1 carat diamond ring set Yellow gold Diamond heart pendant Kim $2,000 Fred fred purcahsed originally Maggie 100 Dana 150 Bobbie 100 100 200 fred purchased originally 100 900 500 175 100 150 200 100 1,675 30 . (Other Specified) Dad's Tools Brandon 50 Christmas Bears Brandon 25 Some Christmas Ornaments Brandon 20 Eagle Gold Coins (5) 3,125 Kim Cole Dana Brandon Fred Royal Daulton China Kim 200 $10,000 r' ., APPRAISAL kt PII, tT J () ;)/ TUN/PEP-- D i<-\ M (;C)(/~,9 P/1 I Date 'J- -/2-V7 ITEM VALUE o "' tv ISo Co u,l1J ~ 0,60 :liJ, () i..' 'io. ()O Sf! ,- o.e/) :l..Do, 00 () () 'l'h;:" .sET ;.,u, 6 i) .J.4 0 D 3D, ~IJ tJ Kelley Blue Book - Private Party Value Pricing Report - Ca~illac, D~ Ville Page lof2 -.. ...... ..........IeIeJ. ......... > ,.... . lHElallSTEDlESOURCE ...... .~ SEND TO PRINTER advertisement 1995 Cadillac DeVille Sedan 40 BLUE BOOK" PRIVATE PARTY VALUE - advertisement - Fair $2,895 Excellent Value $3,810 Condition '" Good $3,390 (Selected) Vehicle Details Mileage: 120,000 Engine: VB 4.9 Liter Transmission: Automatic Drivetrain: FWD Selected Vechile Standard Air Conditioning Power Steering Power Windows Power Door Locks Tilt Wheel Cruise Control AM/FM Stereo Cassette Duai Front Air Bags ABS (4-Wheel) Dual Power Seats Alloy Wheels Blue Book Private Party Value Private Party Value is what a buyer can expect to pay when buying a used car from a private party. The Private Party Value assumes the vehicle is sold "As Is" and carries no warranty (other than the continuing factory warranty). The final sale price may vary depending on the vehicle's actual condition and local market conditions. This value may also be used to derive Fair Market Value for insurance and vehicle donation purposes. Vehicle Condition Ratings Excellent ,~~ $3,810 "Excellent" condition means that the vehicle looks new, is in excellent mechanical condition and needs no reconditioning. This vehicle has never had any paint or body work and is free of rust. The vehicle has a clean title history and will pass a smog and safety inspection. The engine compartment is clean, with no fiuid leaks and is free of any wear or visible defects. The vehicle also has complete and verifiable service records. Less than 5% of all http://www.kbb.comlKBB/UsedCars/Print/PricingReport.aspx?QuizConditions=&ManufaCt... 2/9/2007 PARCEL #()9...{)3I-026 SI-li.:CIAL W AIUlANTY DE"~D ')o~ 6\ I TillS INDENTURE, MADE THE'" day of lA,""'"....... our Lord Two Thousand One (200 I) in the year of BETWEEN SARAH L. BYRD, single person, party of the first part, GRANTOR, . ...... ...... "'" ~ .;g~ sa ,,:.:<::; c:':l I , f"T' --:-1:,:; n :l~~j ....., ~ c:) ~;; :=J f,n 0 < r. ~;,~:: ~ ,.-.. -... 0 <Jl AND FRED A. KEPHART, Sa. and DONNA II. KEPHART, husband and wife, parties of the second part, GRANTEES, WITNESSETH That the said party of the first part, for and in consideration of the sum of TWENTY TJlOVSAND AND 1'40/100 (SZO,OOO.OO) DOLLARS, lawful money of the United States of America, .well and truly paid by the said parties of the second part to the said party of the first part, at and before the sealing and delivery of these presents, the receipt whereof is hereby acknowledged, has granted, bU8amed, sold, aliened, enfeoffed, reJeased, conveyed and c:onfumed and by these presents does grant, bargain, sell, alien, enfeoff. release. convey, and confirm WIto the said parties of the second part, their heirs and assigns "i"i'':!'''lr.~r: :;~::f'}'~, SEE EXHIBIT. A. An ACHED HERETO TOGETlIER with all and singular, the tenements, hereditaments and appurtenances to the same belonging or in anywise appertaining, and the reversion and reversions, remainder and remainders, rents, issues, and profits thereof; AND ALSO all the estate, right, title, inten:st, propeny, claim and demand whatsoever, both in law and equity, of die said party of the first part, of, in, to or out ofthe said premises, and every part and parceJ thereof. BK 4 2 2 3 PG 28 I \ 1: ~ " : ,~ '.. ..-;. .., ," ~1i ,':.-0' :..;t .?:' ,. f 1 i I f. I ! . i I ( I I I I I i i . , . , I I I I \ :'...f. ..:.~..... "of. . ~': ~.. . j: (' ~ . f l' i~' I TO HAVE AND TO HOLD the said premises, with all and singular the appurtenances, unto the said Grantees. parties ofthe second part, their heirs and assigns forever. AND TIlE SAID Grantor, her heirs, executors and administrators, does by these presents, covenant, grant and agree to and with the said parties of the second pan, their heirs and assigns, that the Grantor her executors and administrators shall and will warrant and forever defend the hereinabove described premises with the hereditaments and premises hereinabove described and granted or mentioned and intended so to be, with appurtenances, unto the said parties ofthe second part. their heirs and assigns, against the said party of tbe first pan and her heirs and against all and every other person and persons whomsoever, lawfully claiming or who shall hereafter claim the same or any part thereof, shall and will, by these presents, SPECIALLY WARRANT AND DEFEND. IN WITNESS WHEREOF, the said party of the first pan has hereunto set her hand and seal the day and year first above wrinen. SIGNED, SEALED AND DELIVERED IN THE PRESENCE OF W~~ s:4t J: I2td) COMMONW()1" OF PENNSYLVANIA ) '~ )S5. COUNTY OF ( r1 ) On this, the 2/J!:::-Jay of ~ ,200 I, before me, the undersigned officer, personally appeared SARAH L. BYRD, single person, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purpose therein contained. IN Wl11'IESS WHEREOP, 1.......0.. my bond.... ~ ,~" nlf'~''''-t' Notary*-- . .., 'I:~'.;. ":::~;f'i~:::;-\ '1 ,I ., Co. \".\\~t\..t."'. .., ~ i ~ou'''I'' .,....,...1 nlvJP., l;UrHr..&::OaIl\~ 14 ":-r:.h," .,: . :.~.:II ;.:;,.i,,,. t,::...lJl':::; .JUlIO) I ,.~, . , . .' .1.:.I;;....~!7.",:: -:.~:"....)_.;.~it~;>\ii:."".1 8K ~ 223 PI; 2 B Z CEILTIFICATE OF RESIDENCE I hereby certifY that the Precise Residence of the Grantees, in the within Deed, is: 35 N'. ~ lSt-. . +0Jvu4JLU\1)' At 1"1l.QL A..._(.r~. COMMONWEALTH OF PENNSYLVANIA) . )ss: COUNTY OF DAUPHIN ) RECORDED In the Office for the Recording of Deeds, Mortgages, etc., in and for the County of Dauphin in Record Book . Page WITNESS MY HAND AND SEAL OF OFFICE. this Domini 2001. RK ~ 2 2 3 PI; 2 8 3 :YM IV2II2IOI 15 . Anno QIIIJ IQI 13.51 1.5& 13." 1.1IO . lIII!lElIII I lJ IIBISIJIIDS I 19 lfTBl[ 11IIIS I ~ E1lfl,. PI DIY 111IIO m : ClJIIIfllllIIf USIlIIII .. 1111115111 arr ~ . . sam. nsr _. t.F . 42Y.lI \ I; r- '1': " ',' " , :~.' ,,~~ .~ ,''''' . .~ -. :~:i~' 't '.~. I 1 ). . t i , I I f , i I t- III 111I 1 . \ ! I j " ~ I i .1 . : -'-',' ..-:;:.... ',. }:.. \'" . .{': ." .', ,,:', '. . , i . I I . ",. ...., ',' 1 EXHIBIT 'A' ALL TIIAT CERTAIN lot or parcel ofland, situate in the Ninth Ward of the City of Harrisburg, Dauphin County, Pennsylvania., bounded and described in accordance with a survey and plan thereof made by Ernest 1. Walker, Professional Engineer, dated April 17, 1972, as follows: BEGINNING at a point on the west side of North Nineteenth Street, said point being IS feet South of me southwest corner of North Nineteenth and Helen Streets; thence along the west side of North Nineteenth Street South 20 degrees 30 minutes East 17.5 feetto a comer of premises known as No. 28 North Nineteenth Street; thence along said premises South 69 degrees 30 minutes West 81.5 feet to a point on the east side of a four feet wide alley; thence along tbe same North 20 degrees 30 minutes West 17.5 feet to a comer of premises known as No. 36 North Nineteenth Street; thence along said premises and passing through the center of a partition wall North 69 degrees 30 minutes East 81.5 feet to tbe point and place of BEGINNING. BEING the same premises which Sarah L. Byrd, Trustee for Carolyn Posey, n/kJa Carolyn McNeil and Twione Posey, a/k/a Torounie Posey, n/kIa Torounie Stackfield and Carolyn Posey, nIkIa Carolyn McNeil, individually; and Twione Posey, alkJa Torounie Posey, n/kJa Torounie Stackfield, individually, by Deed dated September 7, 2000 and recorded September 12,2000 in the Office of the Recorder of Deeds in and for Dauphin County, Pennsylvania., in Record Book 3764, Page 174, granted and conveyed unto Sarah L. Byrd, single person, the Grantor herein. UNDER AND SUBJECT, nevertheless, to easements, restrictions, reservations, conditions and rights of way of record or visible upon inspection of premises. BK 4 22.3 Pf, 2 8 ~ 03/13/2007 11:28 2394329238 CAUDILL NEILL Funeral Home Inc. Mr. Fred Kephart 108 Juniper Drive Mechanicsburg, PA 17055 Services For: Donna J. Kephart Services of Funeral Director and Staff. . . . . . . . . . . . . . . . .. $ Dressing Casketing and Cosmetology _ . . . _ . _ . . . . . . . . : . . Visitation .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funeral Service ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . Transfer of Remains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hearse/Coach and Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . Kinkade 'Sunrise Cross' - Box set . . . . . . . . . . . . . . . . . . . . . Flowers .., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crematory Service Fee ... . . . . . . . . . . . . . . . . . . . . . . . . . . Delta Airlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patriot News Obituary ..... . . . . . 4'J~ ,:JdO' . . . . . . keto ~ 'r;j-V- . . 5~F 8~.5 D MOU~TAIN OAK . . - . . .~lUX. ~. r.~. . . .. . . Carmen Funeral Home - Kentucky . . . . . . . . . . . . . . . . . . . . Total Funeral Charges Adjustments (Payments) Balance Due on Account (Due date: 01/04/2007) 1'\ l~ bO\ l' J. . \:}" ~ ?-\\\\O 34{)1 M..rket Street Camp Hill, PA. 17011-4428 tel 717 737-67Zo fllJ<. 717 737-1859 Rebecca J. Donahue, Supervisor 3501PImY StT~l:t Harrisburg, PA-17111-1817 ~el 717 50+Z6J3 fall: 717 561-9918 Stephen J. W1lsbach, Supervisor $ $ $ PAGE 04 January 6, 2007n.-~.... Ret No.: 1003464/ CO? 003 750.00 205.00 315.00 515.00 415.00 315.00 170.00 212.00 265.00 425.38 187.83 1,395.00 1 ,~45.0q.. $7,115.21 0.00 $7,115.21 MeMber of ALDERWOOOS GROUP ~ i" ~'1'~.I!.t$X t':' t'I.ll~ lOlLING GREEN.~llft 11U c:..-" · CItM.... M 'Nn · ~. -. ~ 'q d "' ~ CEMETERY.IN'fERMENT RIGHTS, MERCHANDISE, AND,S THIS AGREEMENT PROVIDES FOR PERP The undei-signed, reftJTed to as 'Purcbaser', hereby agrees toparchase the. Interment Rights, Men:haudise the above IUlIDl!d cemetery, hereafter referred to as 'Seller'. Purchaser: Last Name: tl ~.J...I",,- J I. 1\ I \ I j I I I I I I I I I First: Te1ephone~~_\ ?:i~ ~ SSN: lJ. ~ ,..-.~ -, ........ L.. ~ DOB: Address: t'E t\ 5/\ I b.b k let\- Ud....rr I (1"\1 I I I I I City: Co-Purchaser: Last Name: I I I I I I Telephone: L-J_- SSN: __ Address: I I I I I I I I I I I I I I 1 I I I I I I I I I I Deceased: Last Name: 1r-\ 0 ([) 1.1\ ~ "l r 'Kt p \-.1=- If -\. DOB: '1 I~~ DOD: I~ I~ ~ Description ofJntermeut Rights to be used: - ~ 3 '15 - \ Issue Certificate of Interment Rights to: I I I First I r I .,. I r Email: ""<.:at~::~.'., I I I I 1--1 City:11I111111I111 I I 1 FIrSt: ~ln Jr..1~ I I Burial Date: 4? I-..::LJ tl? DaB: State: I I I Zip: -,"';'" I I I I I Veteran: 0 . '$"!-ti:J" MiddJe: , I I I ~Rights: Address: City: State: Zip: J INTERMENT . Interment Rights (Includes PerpetwdlEndowment Care of $ . Interlnent and Recording ,Fees . Outer Burial Containerf'\2. S Supplier I.)" \ \1....,..... .do ModeIJDesign (. (: l.....:....... ~~ ~ {-.-... MateriaUColor (~ r-" '.Cj -\ '7 . . Outer Burial Contmner Inst8llation MEMORIALIZATION . Memorial Supplier Type/Color Design/Size . Memorial Base Supplier Type/Color Design/Size . Memorial PerpetnallEndowment Care . Memorial InstaUation Fee . Memorial Inspection Fee . Nameplate/Scroll . Lettering . Flower Vase Supplier Type/Color Design/Size . Vase Base $ ) MERCHANDISE & SERVICES . Urn Supplier Type/Color Design/Size . AdminJProcessing Fee . Other ,,'" l'1S DC; 3'-iS. cc .6'\5 ,ti.J /cPff) ,. . .3-5 . to Other ~ -' . Other . Other . Other . Other : TOTALS, ALLOWANCES & TAXES . , . Interment Rights.......................................~..:._.:~._..::..._~ ( Reason ~ ~- _. ) . MerchaBdiselService..........................................__ Reason Apply to . Mercbandise/Senice ........................................................ ( Reason ) -~~~r}fi !~ - J .......,' -;...;.; Apply to SubTutaI \ ~~ S.ot=:,,:: -' -' Total Taxable . Sales Tax (if applicable) ................................................... TOTAL CASH PRICE $ \ \'1S. 00 .'. SOO' Less: DownPayment{'~-il {{)(G( ~'ll'l. Other ( ~ \'lS .00 -l;+- Total DOWIl Payment Unpaid Balance of Total Ca.sb Prit%> $ \.0.1- 0\ SizelMaterial Notes&PaymentTerms(whereapplicable):~...:. L", .\ 0 \',.. \ TERMS The Total Cash Price is due and payable as of the date of this Agreement. A delinquency charge of -=- percent will be assessed monthly on any balance not paid within 30 days of the date of this Agreement.. If less than full payment is received, Seller shall deduct the accrued delinquency charge from the amount received and credit the remaiDderoftheplly1J1ellt'~~.. .. . ...,.,..,.,.. ".....'i, .,. i':,".-.,..""v"-....."'...t""~___~,.....,..,""',,..,...JI',.... . ..... . Security IDteRst: Seller (or its assigns) will have a security interest in the Interment Rights and Merchandise being purcbasedas described abOve. Seller will retain title to .-1 ~ddn -.:& n~~ foIl~ ~ ~~~i ~ _......~ a:r 1 a......~ ~~ - t) ('1>. ~ .... -.:& Jd n:& ~-0 ~ ~ :l~ S' ~;t~; .,.. a!. a'1 ;~ 1 ~?'" 3 ~~~~ ~ ~~J1 ~. ~ ~('I>~* Ul l"d=-(t tla Ul ~tt' ~~ -~ ~~~ it ?;i ~!n '*.~ ;. o ~ .....:l.~ --0 ~ ~ "'" Q. aQ.e ~ i ;- ...... ~ ~ =- to a ~ "l::t " ~ ~ ~ d~~~ i to o ~ ~ .....:a ;& , ~~~~ - ~,...,...~ 'S ~ , ~ \It; \It/; . f"'~"'~ =- 'CS i a O'~~ ~ ~ .;e-1-1 ..... I ~ n ;: .... ~ ~ ~ .:z. '? '? '? ... ~ .., ~ ~ ~ ~ ~ f ~ ~ - ~ =' - 'CS t: a ~ Ci ~ a "'" ~ - ".. ~ ~ tI1 """ ~ 0 t . 9 e;'ri ;& e. Ia (fJ =- Q ;:t .... ;" ~ "" to ~ ~ ~ -. .... Q.o a- i:t. ~ !.. fI.1f1.1 & ~ , ~ ~ ~ ~ , =- Q.o ~ ~ (t " ~ =- , ~ ~ e "l::t ~ ~ ~ e< ... ~ ~ >CJ ('I> .. -. e. ?;i ~ ~ S' Q.o ;& ~ ~ ,...... (') d ..... "'l ~,...~ ~ i l ~ s- o (.J\ . s 1 - tIl "'" .e , :r .... "..tIlCf ~ ~ C). ~""('I> ~ 0 i " ... ~ rJ) "'" "3 de; ~ ~a l- S" ;; ~ ('I> "" a cJQ fI.1~n ('It - "". ..., t;' ...~ ~ ~ ;: l (\ ~~Q. :r .. ~ftl~ f1 ~""1p;.- ~ " ...en ~~ ... ~ ~ I :& - a 'i: .:r RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Receipt Date: Receipt Time: Receipt No. : 2/09/2007 09:42:34 1047283 KEPHART DONNA JEAN Estate File No. : Paid By Remarks: 2007-00129 R MARK THOMAS ATTORNEY AT LAW AJW ------------------------ Receipt Distribution -----------------------_ Fee/Tax Description PaYment Amount Eayee Name PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 1246 Total Received......... 260.00 15.00 40.00 10.00 5.00 ---------------- $330.00 $330.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN STATEMENT C'lt{.,.~# B&lc~~RA-vClj(Jj{)c~/~ q2:J ~x.+co P-,.d, ;VI f:CJ(,4/IJ I. S,SB~i/ 1.9.. ..e.~ ... 1'"2 (l,Se T 0 1"'/11 f?-./<. m (j /1-1.5" ..1 Try, 5, M K T; ST, !vI Eell R..0 I P/~, ) 7 0.':;];'- . 7-/2..-07 ^ Oi> Terms~ -- TOPS 3409.0 LITHO IN U. S. A. JOSE"" Jjl.MES JEWElERS lOl E. MAi"STREEI' MEChANicsbullG, PA l10iS · 111.1".9224 RECE\PT _1-08941 __"I.." 2J8l2OOT 5:%1 PII JOII8Ph ....- ......... (T17)~ you...... T 1 f bY ..... 0IIlriS (11) sold To: to01-01357 Kim caudill 15451 s~court Fort Myers, fL 33912 USA Consult c:-uIt: ~ Fee ~- ,.oJlll for estate SUIJb*I- $40.00 penn8Ylvan'- saleS Tax-. $2.40 . Total.- $42..40 . Charged to ..-card #1400-. $42.40 .,......._... _"~__~~"'" '.'w~" -~--, ---------,------...-. ---~-_. SALES DRAFT ~ IftfS ~ 311. E. Ml" S1 ~tsIII' fI\ 11155 __ 233565 =::Uft\ r'tC~. _ llM'S~ m trA1bZ111 _ICE 42,811 tit . _ tlJ)t ..8488 ~~ =- ~ .42.48 \-- 1Gt t\lfI~ tllP'I~ :...:.~;..A. EXPENSE STATEMENT for: Kimberly Caudill 2/15/2007 1/28/2007 US Air - Flight to Pa. (Robyn's ticket) 280.09 2/13/2007 Cell phone overage while in PA. 67.64 TOTAL: $347.73 EXPENSE STATEMENT for: Glenn Caudill 2120/2007 12/30/2006 Valvoline - Oil change for cadillac 30.2 1/3/2007 Giant - Food for funeral wake 74.71 1/4/2007 Giant - Food for funeral wake 109.92 1/6/2007 UPS - Ship financial records to FI. 36.48 1/17/2007 Staples - File storage box for records 16.96 1/28/2007 US Air - Flight to Pa. 279.6 1/31/2007 UPS - Send death cert. to PA. $13.58 2/8/2007 Appraisal of jewelry 42.4 2/13/2007 Meals and gas during February visit (see receipts) 233.13 TOTAL: $836.98 *T 0 be reimursed to Glenn Caudill for credit card expenses (see attached back up) EXPENSE STATEMENT for: Kimberly Caudill 6/26/2007 6/5/2007 McDonalds - lunch $ 18.40 6/4/2007 Peppermill restaurant - lunch 31.72 6/212007 Palm city market - lunch 12.71 6/3/2007 Cracker Barel - breakfast 30.36 6/212007 Sheetz - lunch 8.60 6/7/2007 Outback - dinner 70.77 6/6/2007 Isaac's - lunch 60.34 6/5/2007 Hillside cafe - dinner 105.04 6/7/2007 Red Robin - lunch 46.09 6/8/2007 Fazoli's -lunch 28.01 6/5/2007 Giant - grocery 3.40 6/212007 USAirways - plane ticket 378.10 TOTAL: $793.54 EXPENSE STATEMENT for: Robyn Smith 6/19/2007 6/1/2007 Kangaroo - gas $ 45.00 6/212007 Exxon - gas 50.50 6/3/2007 Sheetz - gas 54.25 6/4/2007 Holiday Inn - lodging 98.02 617/2007 Turnpike toll fees -: 7.75 - 6/7/2007 Sheetz - gas 10.06 6fl /2007 Sheetz - gas for rental truck 75.00 6fl /2007 Turnpike toll fees 5.50 6/7/2007 To Go Mart - gas 35.00 6/7/2007 ToGo Mart - gas for rental truck 50.00 6/7/2007 Sheetz - Gas for rental truck 65.28 6/8/2007 Speedway - gas for rental truck 50.00 6/8/2007 Speedway - gas 20.57 6/8/2007 Loves - gas 45.04 6/8/2007 Shell - gas for rental truck 75.00 6/8/2007 Arby's - meal 15.83 6/9/2007 Fuel 33.08 TOTAL: $735.88 EXPENSE STATEMENT for: Kimberly Caudill 8/18/2007 7/16/2007 Secco Home Services - Inpection of a/c problem $ 69.95 8/5/2007 US Air - Flight to Pa. 655.90 8/5/2007 Quiznos - food 9.50 8/5/2007 Budget Rental - car rental 172.50 8/6/2007 Cracker Barrel - food 9.83 8/6/2007 Giant - food, house supplies 31.04 817/2007 UPS - Shipping of estate items 12.88 8/8/2007 US Air 50.00 8/8/2007 Sheetz - gas, coffee 14.41 TOTAL: $1,026.01 DEPOSITS RECORD OF CHECKS DRAWN II AMOUNT OF CHECKS NO. 101 g /)~ DATE b/7/07 BALANCE FORWARD PAY TO . J v . I, ov9' 6f DATE ~ 1 3bO 0 . 11;5 NO. 10;,'), . CJ70 00 TOTAL DEPOSITS LESS CHECKS PRAWN , . c'I1~'\<- BALANCE FORWARD TO'1'AI.. CHECJ(S DRAWN X~(FIlONT) ~J/14/~~~1 0~:~~ 2394329238 83/07/2~87 16:a4 7177615818 CAUDILL CHRITIAN 8A'<ER PAGE 03 PAGE 01/05 CHRISTIAN..BAKER COMPANY ~surance ~..... 1711) 781...q12 ,. m71181-&41O 1iQG'T9A'ICI! BOX 1. CNItP HlJ... PENN$\'\.VANIA 'l1IlO1-41!ilJ March 7, 2007 Kimberly CaudiJl 16451 Sweetwater Court Fori Myera. FJ.. 33912 Re: Owelling Fire Polley PoIJcy 1P. 00S69953S3 Dear Kim: I have ~nQIo$ed the App&ation far your new Dwelling Fire Policy for ttae prcperiy located at: 28 & 2C W. Sorinovme DriVe, Boiling SJ)rings, PA 17007. PIQS8e elgn Md date thf:. .c;;hed Application Where indicated (Page 4) anet fax back to our ofPIce. Return the oriQinal signed Application to oW' agency with. cheok for $445.00 payable to ~remost Insur.ance. These signed forms MUST BE RETURNED WfTHIN 1& DAYS to ensure continuous cwerage. We.will forward tM Application and payment to the Company. You should rece.ve your pcliey within 10 to 14 busine81 days. Thank you fer allowing Christian-Baker Company an opportunity to serve you. [;lleae. Mp in mind that our agency handl.. a full line of Propertyl ClI8Uatty, life and heaith Insurance for. bottI individuals and businesses. PI_ElM call if you have any questions or if we can te of ft.n'tI"tir service. :n ~ -~ ~~ _........,..--~~_.....-._-_.._._..._~<#.. ~ _____.~_-_..._.__~----~~....-..-... 'M",lII".. ,- ......... A Member of tbe IDSUr.llUCe AJ1Jance of Central PemmylVDDia 03/14/2007 09:50 2394329238 MAR-14.2007 07l33A FROM: CAUDILL TO: 12394329238 BRAD FARNER 304A HILLCREST DRIVE NEW CUMBERLAND, PA 17070 OFFICE: 938-2028 FAX: 938-2028 lllKIM I FIXED THE LEAK AND THE DAMAGED KITCHEN CEILlNG FOR YOU AT UNIT %C WEST SPRINGVILLE RD. THE Plf'E! INTBAT UNIT ARE GETI1NG OLD AND WEAK. I WOULD FIX ONE JOINT AND THE NEXT ONE WOULD LEAK. I ENDED UP REPLAClNG THEPlPE FROM THE SHlIT OFF VALVE TO THE TUB OUTLET. I ALSO PUT A NEW SHOWER BEAD ON. THE OLD ONE WOULD NOT STAY UP IN PLACE. IN THE KITCHEN I CUT OUT THE DAMAGED DRYWALL AND REPLACED AND FINISHED THE PATCH. MATElUALS FOR nUMBING AND DRYWALL $94.41 LABOR TO REPAIR LEAKS AND DRYWALL , 1I0URS @ $38.00 PER HOUR $276.00 TOTAL DUE $364.41 .PLEASE MAKE THE CHECK PAYABLE TO: BR.AJ}P'ARNER AND MAlL IT TO THE ADDRESS ABOVE. KIM JF 11IERE IS ANYI'BlNG ELSE THAT YOU NEED DONE AT THE UNIT PLEASE GIVE ME A CALL rAM A GENERAL CO:N1'BACTORAND CAN BANDLE ANYTHING THAT YOU MIGHT NEED DONE TO SELL THE PROPERTY. I WILL CHECK BACK WITH RENE IN A COUPLE OFDA YS TO MAKE SURE THERE ARE NO MORE PROBLEMS WITH TBlt TUB. THANK YOU PI1GE 02 P.i 86/15/2887 14:25 717-697-8822 JACK . GAUGHEN I'il REALTOR E R~ I pages including the cover sheet To: ICim I'~ , Office: Fax; . RE: .:2.~ q t.f .3;l q p.. 3. g- ~. This FAX consists of ~ JAa< GAlJ&EN foEQi PAGE 81 Beth WIIIiamso. ABR, CSP Jack GaupeD Realtor ERA 101 Old SclloolJlolIIe Laue Meeh~rr.PAl7055 0fIIce - (717) 697-4673 BXT. 148 CeII- (717) 571-1796 EMaiI- beth. williamson@jgr.COllI Date: ~ J IS 101 Phone: f . . f- ~"~~'~';'~"'~";:"~-:',~:;:,~.~:''':'~'':''<:'''-''~ :.:.:.~..:....:..::. ~..:...::.:.~/t~':.;A::;..~ "".': ", ....~. '~J.'......:., ~.......~...... ~ .......... .......~- ~ . --.. -~..."" -"-:..:fIo~ .......~-----..:..d'lf.L-,.-"'''''m . z'" ....,.z.. "'f'r, '07'" ..... .:...........N.'""";..~....... '. ""tt, =.:~~~~.~:~~;;::~~J: - uJ" ~.~~~... U?~~ JJJ =. ~..~E . I. , . .. . . .. ,f _, f DOLlAAS Black" s Tree ServiC'~ TraT~ ! JJd2r.is CJaanup .=."::. . -== Daft: a: a.-4drltu 25 P8DI\Y r.-e f71'11 .1-01. EDola. PA 1702S Cell U1'n 460-3654 Tht: iD;lbrmaUon CODf1rirted in ttJjj :tiIcsmnle C(m1mlmication is ~ and iDtm2dec;1 cmly forfhe lJSf:oft1u:penoa to wbomit is addroPcd. Ifthc reader of1his co..'m.\I.;cation is not.the ~eclrceipicat. tt. employee Ol' agcut ~.le for i1a delivery to the iJatom&d ~. you are ~ 1.lOtified 1bat tbr: reproduction, distributiml or dilcJo~ of ~ part oftbis '" n ;~u: ~~~ the iDtmdeci ICCipieDr. is $tric;tly prohibm:d. Jf)'OU have ~ this '--~r.tWml in em'It, ~ \ 0 OV lIIdopoIIdeody ()wDocIODd o,.-byNlrr - ~~, l.\ \ \) " \o~ C ~\ 1<;0 ; 03/19/2007 11:42 2394329238 CAUDILL PAGE 02 03/14/2007 09:50 r:J~{ a~ ..::.t:ll:l( U:; lob 2394329238 (1 f fbl::itllU CAUDILL ORITIAN fW\ER DWElUNG FIRE APPLICATION ~ 31220 jOI;MC't ~ID SII8aQlIe ""!lIlIonI <<...... If... "'.l'NJ ",.. .... noiJn ......-,1~d' .,-.. ._<<1 4. PAGE 04 PAGE 82/ ~ M\'S~~..l't M/D2/'21107 _.-uI8T'r" 467~7lS!oI- t~ ~ -~li3t~tt..~~ ,::~~.;::=~\]~;; . .. ~1i:t*,'tl'~~lF.~'~~~'::7'.; ""_~__'~____:_'_~'''_'_'___''''__''____'''''''_'''''_' . ~~"!'"J'.. .;1.&M<; ......~' ...... ..." . ....{ f . . .~........~:.......;;...,.."". .. :..... ", .... --~~tl.~___.__.... ~lr.1....J~_...._"-_....,,... ._W_~_"i.,,~;~___._. ~ An).) ~_Uz._._f.fl...____..___~.~_ ~:~ I IUMtOJR , -.$ '73 g .. 00 - ~T... .,------_...,_..."..........._~.._-,_.., ."'. ....- c:o.oP . =-fl;ifLJw.f44-f:"7-''''-'- '_"~''''_..,_~. _M......_."_. l-~~ II'IIp 1 aU = " I JIPItA,..UATE I .ACOIU) CORf'QRAT1OM 1ll11~ r'~~ CAUDILL 11 ~ 42 2394329239 ?-/19/2007 MAKE CHECKS PAYABLE TO: Marlin A Yohn Sr., Treasurer 6 Hickory Lane Mechanicsburg, PA 17055 RETURN SERVICE REQUESTED MECHANICSBURG SCHOOL DISTRICT 2007,U8 REAL ESTATE TAX NOTICE BLL DATE: aTJ01tr11 BLL NO.: 2482 TAXES PAYABLE TO: MIIrtIn A. YoIIn Sr., T~ TAXPAYER'S COPY · KEEP THIS PORTION fOR YOUR RECORDS MUNICIPAL CODE: 42 PROPERTY: 0108 JUNIPER ORNE MAP CODE: 42-25-G030-1048 TAX IIILLS: 13.28 ASSESSED VALUE: 144840 CHECK. AMOUNT $ 2"- DISCOUNT FACE PENALTY 10 08I31J07 QQlO1J07 10 1lY31J07 11J01J07 TO 12131107 $1,882.17 $1,920.58 $2,112.64 FIRST PAYIIENT SECOND PAYMENT FINAL PAYMENT $640.19 $640.19 $640.19 . ...... On or....... . PIlId On or ....... If ...... On cw IIefonI 8I31J07 9iSDJ07 1ll/31J07 THIS TAX IS DUE AND PAYABlE, YOU ARE HEREBY REQUESTED TO MAKE PAYMENTTHEREOF. CASH 11588 - 6449 FULL PAYf'.lENT \ 9;)<6 l~\~~\O1 \{1. ~~qo.\q 81 \~D1 DONNA HOOVER ESTATE ~01~1SWEEnNATERCOURT FORT MYERS FL 33912 OR :S-', '::-~.- Pi f\~' NO DISCOUNT SEE REVERSE SIDE FOR TAX tJOTICE IlJSToUCTICtJS .....................-.......................................................-...---.....-..-..............--.-........-.--...---..-...-..-.:....-.....-.-....--.-.--..-.--...-.-..-.--...-....----........--.-.-..........-..-................... MAKE CHECKS PAYABLE TO: Marlin A. Yohn Sr., Treasurer 6 Hickory Lane Mechanicsburg, PA 17055 RETURN SERVICE REQUESTED MECHANICSBURG SCHOOL DISTRICT 2007 J08 REAL ESTATE TAX NOTICE RETURN THIS PORTION WITH PAYMENT FOR FINAL INSTALLMENT PROPERTY LOCATION 0108 JUNIPER DRIVE LOT 138 BLK J PB 19 PG 25 Residential Building BILL I: 2492 Please indicate: o FINAL INSTALLMENT 0 FINAL INSTALLMENT WITH PENALTY CASH CHECK # MAIL 10: FINAL INS fALLL.Etn Marlin A. Yohn Sr., Treasurer 6 Hickory Lane Mechanicsburg, PA 17055 111.11111111111111.1111,1,1 If I'IIId On or ....... 10/31/07 HOOVER, RICHARD E & DONNA J 108 JUNIPER DRIVE MECHANICS BURG , PA 17055 o V\ N E R AMOUNT $ NO DISCOUNT $640.19 $704.21 If I'IIId AftIr 10/31/07 ................__.....................n....._...................................................._........_._..........................................-.........-..............-........................-.-...-....................-............................_...._........_........_......._................................ MAKE CHECKS PAYABLE TO: Marlin A. Yohn Sr., Treasurer 6 Hickory Lane Mechanicsburg, PA 17055 RETURN SERVICE REQUESTED MECHANICSBURG SCHOOL DISTRICT 2007/08 REAl ESTATE TAX NOTICE RETURN THIS PORTION WITH PAYMENT FOR SECOND INSTALLMENT PROPERTY LOCATION 0108 JUNIPER DRIVE LOT 138 BLK J PB 19 PG 25 Residential Building BILL #: 2492 Please indicate: o 2ND INSTALLMENT :J 2ND INSTALLMENTWITH PENALTY CASH CHECK # MAIL 10: Marlin A Yohn Sr., Treasurer 6 Hickory Lane Mechanicsburg, PA 17055 111111111111111111.1111.1. I SEcm.O ItJST."kU.1Ern It I'IIId On or ....... 9/30/07 c '^ _ N E R HOOVER, RICHARD E & DONNA J 108 JUNIPER DRIVE MECHANICsBURG, PA 17055 AIIQUNT $ NO DISCOUNT $640.19 If PIIId AIIiIr 10/31/07 $704.21 8Ef22/2887 18:38 717-761-8824 2ND F1.1IR MAIL R(Dt PAGE 82 t. "\ Michael Vanclrew 560 Lisbum Rd. Wellsville, PA 17365 Phone 717-432-7456 INVOICE INVOICE #183 DATE: 6/21/07 TO: Kim Caudill 15451 Sweet Water Port Ft. Myers, FL 33912 FOR: 108 Juniper Dr. MechaniCStIurg, PA 17055 DEst.ur..LON HOURS RAn AMOUNT Clean up of rendom Items. $60.00 Genel'lll straightening up of III the rooms. TOTAL $60.00 Thank you for your tnasine88! rJ.'of lD}'O 8 q10.0 ~IIJrD1 <;( d- ,11, -:t:f )83. \ 0 , Y~1g, \g\ Make all checks payable to Michael Vandrew 66122/2687 18:38 717-761-6824 2ND ~ MAIL Ra:M PAGE 81 Michael Vandrew 560 Lisbum Rd. Wellsville, PA 17365 Phone 717-432-7451 INVOICE INVOlC! '182 DATE: 6/21107 '10: Kim Caudill 15451 Sweet Water Port Ft. Myers, FL 33912 FOR: 108 Juniper Dr. Med'1anfaIDUrg. PA 17055 D&!ICR1PTIOR HOUU RATE AMOUNf MowIng a Tnmmlng $40.00 TOTAL ~.oo Make all checks payable to Michael vandrew Thank you for your bulli...... 06/18/2007 14:23 717-761-8824 2ND FL.l:ffi MAIL ROlJwt PAGE 82 Michael Vandrew S&O Usburn Rd. We.laville, PA 17365 phon. 117-432-7456 INVOICE INVOICE #119 DA1!:6/18J07 TO: Klmberiy CaudID 15451 Sweet Wate' Port Ft. Myers, FL 33912 FOil: 108 Juniper Or. Mecharticsburg. PA 17055 DESaUPIlON HOURS RATE AMOUNT Trimming of all bushes and the 0Jf!ing dawn d me tNelbush on the east $125.00 side d home. Rem<wal of aD debris. Edging, weeding and spreading tanbark. $S2S.oD Removal of flf'eWClO(1 and skid. Removal of bride edging. Grass seed the $50.00 bare areas. TOTAl. $700.00 Make all checks payable to Michael Vandrew Thank you fOr your bu.lnlPSl ....Lt-tC..L-OO""q :lNIJ ~Ll..l..t( MAlL fodUi1 PAGE 81' Michael Vandrew 5&0 Usbum Rd. Wellsville, PA 17365 Phone 717-432-7456 INVOICE INVOICE #178 OATI!:6118/07 TO: IOmberlY Caudill 15451 SWeet Water Port Ft. Myers, R.. 33912 FORI 108 JLJI'IiPI!!I' Or. Mec:hBnIl::sl:u, PA 17055 MSCRIPT10N flOURS RATE AMOUNT Mow and Trim on 6/11/07 $40.00 TOTAl. $40.00 Make all checks payable to Michael Valldrew Thank you for your business! . 06l21/2007 12:17 717-761-0924 2ND F'LClCR MAIL RfDiI PAGE 81 ,. . Michael Vandrew 560 Llsbum Rd. Wellsvllle, PA 17365 Phone 711....32.7456 INVOICE INVOICE #181 DAT;, 'I:J.1j01 TO: KIm Caudlll 15451 Sweet Water Port Ft. Myers, R. 33912 I"UK: 108 JunII*' Dr. Mechank::sburg, PA 17055 DESCIUPTION HOURS UTI! AMOUKf Cleaning home 1791SQft. $130.00 Vacuum, Mop, Bathrooms cIeoned, and dusmd. Rernr:Md window tint and glue residue In bedroom TOTAL $130.00 Make all checks payable to Michael Vanclrew Thank you for your bU8inM8J , AUG-30-2007 01:59 PM ZIMMERMAR PLMING & HEATG 717 697 6746 P.03/04 Zimmerman Plumbing. Hedng. Ine. 110 E. AlIBn 9lnIIt Meehanialbulg. PA 17055 ImJltmart Number 167M Im...a~..nt Dille 713J1(f1 Page: 1 Voice: (717) l597ft3528 Fax: (717) 8&7-6748 enl To: Km Cald11 108 JunipIr DrWe Mech8l'iclburg, PA 170&6 InaII n_ ~ thin ~n and chin iii.. tooutaide ~8: HEr 15llAYS"'-"""" ... 11m! ii1anINy I Nice ~ (1ft PeR ANNUM) wi be added tu all CIU1t1 30 days.-1 due. NO PAR~L PAYME~ ~NU:88 PRe-Nl~NGEO 1.000.00 1.000.00 1,000.00 . AUG-30-2007 01:59 PM ZIMMERMAN PLMING & HEATG 717 697 6746 P.02/04 Zimmerman Plumbing & MutIng, Inc. 110 E. Alln snet MedlanicIblIg. PA 1709 l.-tmInt NIInbIr 1031 ,....,..,.nt 0&t8 818/07 p.ge: 1 VCliCa; (71 n 697-3828 Fax: (717)681-814 811 To: Kin CaudI 108 J~ DrIve MechanlaJbUIg. PA 17081J ~ua NET ll1llo\'t8.... _ "'112'J6""""" j Mce chII'ga (1ft PER ANNUM) wi _ ... to 11II .. 30 d.,. _ duo. PNmAL PAVUENTS UN..ESS PRE-ARRANGED SUI::ItotII SaIee Tax TGbIIlrwokll Amount paymlntlCMdI 575.00 Purodean.ofSusquehanna Valley 220 Fox Jrive McchenicshuT[! P A J 7050-2515 71 i -920-9611 Ollicc 717-920-9612 FAX 1-800-324-2S.~7 Summary for Water Damage Line Item Total T~)hl1 i\Jjll:>1mco1:s !()f Bu:<c :)~ice (harg..:s Subta'a! Cic::aning Tol.D..l T a~ ;{f 6JJOO"/o S GNu.d Total 2007 -06-24- 1914 2,288. 95 -~\O~q ll- '1.0\ 01 ~\,I p.6 1,952.47 336AlC 2,288.95 137.34 2,426.29 n_____ __ - -- -- -. --.. 06/24/2007 Pa~~: 5 p.5 Pnrodea.n of Susquehanna Valley 220 Fox Drive Mechanicsburg PA 17050-25 J j 717-920-9611 Office 717-92D-9612 FAX 1-800-324-2887 Summary for Water Damage Line Item TolDl Totul M.iUS~lts lor Bu.'C ~e('\.ic~ Cbarg~ 669.60 131.5li Suhtotol C1~..llling Total Ta... ;Q~ 6.00G% X 80 1.1 ~ 80LlS 4Kvj Grand Total 849.25 -.-.---- ----..- --- 2007-07 -19-0838 07il912007 Puge: 5 BON+rON t:;ustomer Service (Servicio al Cliente): 1-800-942-0739 Payment Address: Retail Services, PO Box 17264, Balimore MD 21297-1264 Mail Billing Inquiries to: Retail Services, PO Box 15521, Wilmington DE 19850-5521 Days in Billing Cycle: 30 possibilities be~ with kids ED:I oursl HoIday-mollf plush stacIdngs to hang by the chimney willi care. Choose from snowman (shown). penguin. tree and Santa designs to liven up your space. $10 each. All proceeds benefit local Boys & Girls Clubs and Boys & Girls Clubs of America to support youth education. Available while supplies last. BON+rON ACCOUNT NUMBER 2116-041 ()..()()72-4915 Statement Date: 12/17/2006 Account Summary Account Number 2116-0410-0072-4915 PAYMENT DUE DATE 01/0912007 TOTAL MINIMUM PAYMENT DUE $34.00 NEW BALANCE $148.64 PAST DUE AMOUNT $0.00 AVAILABLE CREDIT $1,351.36 PIeaee see reverse for. important.disclosurea, .including grac:e.period information. Transactions TransactiOn.Date.Transaction Detail Promo..Type/CreditPlan Amount 11/t8l2006 Previous Balance ......n... ....... ................ ........ ........ .............. ............ ..... $166.30 12/17/2006 Current Cycle Finance Charges ........... ............. .......... ..... ....................... $3.34 121t0/2006 . Late Charge Assessment.................................................................... $29.00 12117/2006 Payment Received . - Thank\Yau ............... .......................... .... .... ... ........ -$50.00 121t7/2006 New Balance....................... .............. .... .......... ........ .................. .... ... ..~ $148.64 Promotion Type! Promotion Credit . Purchase Expiration Plan Date Date Regular Purchase N1A N1A 000CJa.0l Regular Purchase. N1A N1A 00007~ Average Previous Daily Balance Balance $166.30 $166.26 O,06698'l'0 24.45% 24.45% $3.34 $0.00 $0.00 0;06698o/c 24.450/0 $0.00 Minimum Payment Due' N1A $119.64 $5.00 - - - N1A $29.00 $29.00 - - - - - - - - - - - - - Pagelof2 16 Please return coupon below with your payment. 12170026679 NEW BALANCE PAYMENT DUE DATE $148.64 01/09/2007 CUstomer Service (Servlcio al Cllente): 1-800-942-0739 RECOMMENDED MAIL DATE TOTAL MINIMUM PAYMENT DUE 12/29/2006 $34.00 AC 01 000777 599648 11 A**C001 DONNA HOOVER-KEPHART 108 JUNIPER DR MECHANICSBURG PA 17055-4717 00211 AMOUNT ENCLOSED $ Please complete using black or blue ink only. Make checks payable to Retail Services. Include your account number on your check or money ord&r. 111.111...111'11.1.1..1.1..1..11...111.111...111...1..1..1.1.1 RETAIL SERVICES PO BOX 17264 BALTIMORE MD 21297-1264 1111.111.11111.11.1111...1...11111.1.1111.1..1.1111.1..1.11111 00014864000034000002116041000724915002117 '- ~~ fj) ,ewa,ded See the final page of your statement for important messages, offers, and a summary of your rewards account activity! '\lm"''''''"_' .\;):\f,~~';i~7J%' ~*ki,'\'!};~~ ~ ~UNT NUMBER 1..()038..1478 Account Summary Account Numbel: 1-0038-1478 PAYMENT DUE DATE 01/1912007 Customer Service (Servicio al Cliente): 1-800-755-7872 Payment Address: Boscovs, PO Box 17642, Baltimore MD 21297-1642 Mail8illing Inquiries to: Retail Services, PO Box 15521, Wilmington DE 19850-5521 Days in Billing Cycle: 30 Statement Date: 12/27/2006 TOTAL MINIMUM PAYMENT DUE $17.00 NEW BALANCE $131.92 PAST DUE AMOUNT $0.00 AVAILABLE CREDIT $2,468.08 Pktaee see reverse for important c:hcIosu.... including grace period information. AT 01 043301 703448245 A**3DGT DONNA HOOVER-KEPHART 108 JUNIPER DR MECHANICSBURG PA 17055-4717 TI ansactlons TransactionDate Transaction Detail Promo. Type/Credit Plan Amount 11/28/2006 Previous Balance ................ .... ...... ....... ................ ........... ............,..........$47.93 12/19/2006 Purchase. Camp Hill PA .................... Waived Finance Charge ....... $40.32 Womens Budget 12/19/2006 Purchase. Camp Hill PA .................... Waived Finance Charge ....... $47.67 Storage/Organiz.Tv.ltems Billed. Finance Charges.. ........................................................................ $1.00 Late Charge Assessment .... .......... ........ .......... ............ ....... ............. .... $15.00 Payment Received - Thank You ........................................................... -$20.00 New Balance..... ............................ ....... ................................... ............ $131.92 12/27/2006 12/20/2006 12/24/2006 12/27/2006 Promotion ExpiratIon Alert! Promotional Deferred Payoff Amount RNANCE CHARGES Promotion Type $87.99 $0.00 Waived Finance Charge 30713-2 Promotion Expiration Date 01/31/2007 ;;; - - Rnance charges will begin to accrue and minimum payments will be due if the Promotional Payoff Amount(s) is not received by each Promotion' Expiration Date. = - - - - - An bonus this hofiday season, Boscov's has extended the tenns forHoliday Money! You have an extra month to enjoy this ~ promotion, with no finance charges and no payrnentson approved Holiday Money purchases until February 2007! ;;; Page 1013 = - - - - 12270034314 6 Please retum coupon below with your payment. NEW BALANCE PAYMENT DUE DATE $131.92 01/19/2007 CUstomer Service (Servlclo al Cllente): 1-800-755-7872 RECOMMENDED MAIL DATE TOTAL MINIMUM PAYMENT DUE 01/10/2007 $17.00 00300 AMOUNT ENCLOSED $ Please complete using black or blue ink only. Make checks payable to Retail Services. Include your account number on your check or money order. 111.111...111'11.1.1..1.1..1..11...111.111...111'111..1..1.1.1 BOSCOVS PO BOX 17642 BALTIMORE MD 21297-1642 1111.111.11111.11.1111...111.11.11...1..1111.1.1..1111.111'111 00013192000017000000000000100381478003006 IVIIIIIIIIUIII r.JlllaUL UUI:I .jlIO.UU Previous Balance $88.03 ~ayment Due Date 01131/07 it'sall inside: - . (-) Payments & Credits $50.00 Credit Limit $400.00 (+) Charges $0.00 Available Credit $360.00 Billing Date 01/01/07 (+) FINANCE CHARGES (NET) $1.15 Days in Billing Period 31 New Balance $39.18 jcp.com ... co I I lioIN lioI ~ III 0- co '" - '.' PAG~ 01()~01ForllCcou~tinf.~rrn~~11 ?/l1l:1:.~~2~8()() v.vritll:ep:E!())(981131 ELPASO, TX!999~ Online: jepsnney.com TRANSAC'ilONSUMMARY} .<:":>:::)): ... .:::... ...... ~ - f"" Balance Type Tran Date Reference Number Item Description Ch"'lles Payments & Credits 12-18 P911900PH016B045V PAYMENT-THANK YOU 50.00 iiii !!!!! - BALANCE TYPE COMPUTED ON PERIODIC RATE(S)% CORRESPONDING ANNUAL AVERAGE DAILY BALANCE PERCENTAGE RATE(S)% -- !!!! REGULAR E 64.50 .05754 daily 21.00 .... Your Balance Computation Method is indicated above. See reverse side for an explanation. = ANNUAL PERCENTAGE RATE FOR THIS BILLING PERIOD 21.000 % TOTAL PERIODIC FINANCE CHARGE 1.15 THE JEWELRY STORE AT JCPENNEY OFFERS A QUALITY SELECTION OF FINE JEWELRY TO SA TlSFY YOUR GIFT GIVING NEEDS. YOU WILL FIND QUALITY, CONVENIENCE, SERVICE AND VALUE. THE STORE IS STAFFED BY PROFESSION ALL Y TRAINED SPECIALISTS AND OFFERS A FULL ARRAY OF SERVICES. FROM WATCH BATTERY REPLACEMENT, REPAIR AND EXTENDED CARE PLANS TO KEEP YOUR JEWELRY LIKE NEW. MONITOR YOUR ACCOUNT 24n. ENROLL IN FREE ESERVICING AT JCP.COM AND TAKE ADVANTAGE OF THE EASY WAY TO: VIEW RECENT TRANSACTIONS, CHECK YOUR BALANCE, UPDA TE PERSONAL INFORMATION AND MUCH MORE. Please note your mailed payment must be received by 5PM or your in-store payment must be received during store hours on the due date. Your payment may be converted into an electronic debit. See reverae for details. ~ REQUEST A FREE HOME VALUES CATALOG THAT FITS THE WAY YOU LIVE. ~RE VALUE THAN YOU CAN BARGAIN FOR! ( ) (3552) CHECK BOX, LOGON OR CALL TOLL FREE 1-800-222-6161 ASK FOR TA003-5527A PlEASE DETACH AND RETURN THIS STUB WITH YOUR PA YMENT JCPENNEY ACCOUNT NUMBER: 080-743-654-81 PAYMENT SHOULD REACH US BY : 01-31-07 :::::::::rO'fAL::;:; :::::::::M1M1MUII':::: : ::BALANcE: PAYMENr" :::::::::..' ::: .-..........--.-... . 39 1 8 1 5 00 Remit to GEMB D CHECK HERE IF ADDREss/PHONE NUMBER HAS CHANGED. SEE REVERSE SIDE. ., ALL IN TOTAL BELOW.., $DDDDD DD . DONNA J HOOVER-KEPHART 108 JUNIPER DR MECHANICSBURG PA 17055-4717 147951 P.O. BOX 960001 ORLANDO, FL 32896-0001 1..11...1.11111.1.111.11..11'1111'1111""1111...111 1'1111111.111....1.1..1.1..1..11...1...11111.111...1..1..1.1.1 0147951 352 0807436548 20 00015000003918 5433 0001 T9D 7 1 070101 Page 1 Of 1 002 9119 0800 "147 147951 1 --- - - - - - - - - - - - - - - - - == - - - - - - - --- ~ - = - - == ! I Vour AccountSumma~" Billing:Cycl& Closing;Dat& ...... Amount Over Credit Lina.; .... Amount PastDu& Total Minimum Due' Previous Balance- Payments Bl. Credits Purchases & Debits: Other Charges" Total RNANCE CHARGES: Account Balance 1211910&. . .... $O.oe " , $0;00 . $0:00 .$1'06.27 $50.00 . $0.00: $0.00. $2.06 . $5&.33 ':-,,', - ,;~\" " "':/H Your Credit Summary Total Credit Una Total Credit Available. $5,600.00 $5,541.0.0 Activity Sal& Date Post Date Deecription Amount 12/17106 12/17/06 PAYMENT -THANK YOU - 50.00 Rates "Rate Varies Average Corresponding Periodic Rate Daily ANNUAL D=Day Balance Balance PERCENTAGE RATE M=Month $58.33 $102.12 25.40%* .0696%(0)* $0.00 $0.00 25.40%* .0696%(0)* $0.00 Periodic FINANCE CHARGE SEARS REGULAR EXTERNAL REGULAR CASH ACCESS REGULAR Days in Billing Period: 29 $2.06 $0.00 $0.00 26.40%* .0724%(0)* $0.00 Effective ANNUAL PERCENTAGE RATE: 25.40% Minimum FINANCE CHARGE: $0.00 Cardmember News Fast Online Card Payments with Click-to-Pay. Pay your Sears card bill online anytime, day or night. Sign-on to searscard.com and choose the Make A Payment menu to enroll today. Sears Premier Card<8l Account Number: 5049 9480 5442 2953 1111111111111111111111111111111111111111 Account Balance Payment Due Date Amount Enclosed Total Minimum Due ( ($ J J( J ( $0.00 J $58.33 01/16/07 I Signature AccountCare Optional Enrollment: Yes! By signing, I want to enroll ~n the optional AccountCare plan and help protect my account. I received the enclosed Program Summary. Bill the fee to my account. 0088864 06353 1 TRS006 FXG 001 7 N 13 1ZB 1...111...111....1.1..1.1..1..11...1...111...111...1..1..1.1.1 DONNA J KEPHART 108 JUNIPER DR MECHANICSBURG PA 17055-4717 1.1..1..11...1.1...111..1...11.11...1..1"11111..1"1.11,..111 Make check payable to SEARS CREDIT CARDS PO BOX 183081 COLUMBUS, OH 43218-3081 Please make address changes on reverse side. 206 5049948054422953 0005833 0000000 0005000 1311 BELLEFONTE EMERGENCY MEDICAL PO BOX 5148 ASHLAND, KY 41105-0989 -- IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW CHECK CARD USING FOR PAYMENT ~~ '( ~ I MIA" I~ _oto.canl 0 . 'X' . MASTERCARD CARD NUMBER AMOUNT SIGNA IDRE EXP. DAlE STATEMENT DATE PAY THIS AMOUNT ACCT. # I 02/15/07 $32.06 BEH 000012729 I~HOW AMOUNT $ PAID HERE RETURN SERVICE REQUESTED Tax Id.: 204473863 Phone Number: 888-516-2303 ADDRESSEE: MAKE CHECKS PAYABLE TO: DONNA KEPHART 15451 SWEETWATER CT FORT MYERS, FL 33912-2353 1..11'1111.1.1111'111..11 1..111,111,11.111.111.1.11,1.111.1111 BELLEFONTE EMERGENCY MEDICAL PO BOX 5148 ASHLAND, KY 41105-0989 1.1111...11'1.111111'11.1..1.1'1..11.11.11'111.1..11..1.1111.1 :J Please check box if above address is incorrect or insurance Information has changed, and indicate change(s) on reverse side. STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT 12/28/06 01/19/07 01/19/07 01/19/07 1 DONNA 23 99285 940 840 DOS: 12/28/06 processed Total for Claim: Seen by: RAY, DANI EL M D. Services rendered at: OUR E & M LEVEL V BLUE SHIELD PAYMENT BLUE SHIELD DISALLOW by BLUE SHI ELD OF KENTUCKY 434. 00 128.24- 273.70- 32. 06 LADY OF BELLEFONTE HOSP YOUR INSURANCE HAS PAID THEIR PORTION OF THE ABOVE SERVICES. YOUR RESPONSIBILITY. THE BALANCE DUE IS 1 RAY, DANIEL M D. 2 3 4 PRIMARY INSUR: SECONDARY INSUR: LOCATION OF SVC: REFERRING PHYS: BLUE SHIELD OF KENTU OUR LADY OF BELLEFONTE * NOT ON FILE * BELLEFONTE EMERGENCY MEDICAL PO BOX 5148 ASHLAND, KY 41105-0989 Phone Number: 888-516-2303 Q