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Home My WebLink About12-14-07 (2) .-J 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 Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Souse's Last Name Suffix 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 Cl C) 4a. Future Interest Compromise (date of death after 12-12-82) Cl 7. Decedent Maintained a Living Trust (Attach Copy of Trust) Cl 10. Spousal Poverty Credit (date of death Cl 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 time Telephone Number Cl 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required C) 2. Supplemental Return C) Cl 4. Limited Estate o 8. Total Number of Safe Deposit Boxes - 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received " ') )'r1 beame.rcs@~itt.l1et Correspondent's e-mail address: DATE /2-.~ ~7- PI'! /1 DSO .. Side 1 L 15056051047 15056051047 .-J --.J 15056052048 REV-1500 EX Decedent's Name: !If) 11M3, /;Z1JI15f N; RECAPITULATION 11. Real estate (Schedule A). ............................................ 1. ~~. 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. l5. Jointly Owned Property (Schedule F) c:::> Separate Billing Requested . . . . . .. 6. il. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::> Separate Billing Requested.. . . . . .. 7. a. Total Gross Assets (total Lines 1~7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10)................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .O~ . 0 0 16. Amount of Line 14 taxable at lineal rate X.o!::iS 'J if 7' 7 . ~ 0 17. Amount of Line 14 taxable at sibling rate X .12 . 0 0 18. Amount of Line 14 taxable at collateral rate X .15 . 0 () 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ................ 19. :W. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 Decedent's Social Security Number . 7 I b 0 9 S. t 8 (r; . /) 0 It) B' 2..,/S. t'~i, /~ {)5'1.6f I :3 9S. 'f .3 13 'flf7.31.. qtf 7(, 7.80 .()O q if 7(, 7.?'tJ 15. .bD 16. If ~~'1.S~ 17. .00 18. t{ ~ b ".5'~ c:::> 15056052048 --.J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME File Number ~/- 01- () '2 3~ Ell1/ER Ai; /I:IJ,fAl5 STREET ADDRESS eHlIlI.el/ Of= GdJ /JItf~SIA'(; H~IJIE ---------'-"------.'.-...- - -_._...,~--_...- ----_.._-_.--..~.__..-_.._-~-----_.. -------_.._..__.~._- CITY K()! 1f/l#~r6( s-r: _.,.________..._.___..____ ____.._____...._.___~__. .._______U"_.___' ____.___..__.~. ___ __ _nu._......___ CIf~L/S L i: STATE ,PI//- ZIP /70/.3 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) ~ ~ J,tf. sS: o ,." "'3" ,- 3 j.-7~- _._,--~--- _.._.~~.__._-- ____. .J..!L '-....1-f"__._ Total Credits ( A + 8 + C ) (2) ~ , 3, f2S.0-0 3. interest/Penalty if applicable D. Interest E. Penalty () . ---. ----Z;--.. 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) 0 (4) 0 (5) " .If 39. 55 (5A) :<, DO (58) ~ "'II. s-S Total Interest/Penalty ( D + E ) 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. 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. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; .......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. g] D 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? ........................................................................................................................ 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 PS. 99116 (a) (1.1) (0], 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 PS. 99116 (a) (1.1) (Ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. 99116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 PS. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-\S08EX' (1-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF ,4 f) /1-/11 S, ~L/J/a AI ,;z./- () 7- ~3~ 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. ~. J. DESCRIPTION (Jilt! 13/fIlR" lV.d. ~~IIIf7S: .4. (!'IU~kI'i l-uI: AlP. 6'~" 00; '3~ 8 ~. :Lt.1-. /l-ecr. f;" eI.~. rI, ,,~ /f. e. SMl1Jtf~ ~ AI",. 503 011 S8 J 3 ]). :r J1 f: II-eer. 1$ d. tJ. eI. PH e. (see ('}fh~'rtl Yfl!tlli hi"., /etkr a.tta.c.he.d herefoJ. Iq1~ C~t.Y'rpltf Aslro /JJ/I1/Ytut WN /GN~mlsz~NSI4~S~9 r.l9l~ tb,y/JI7/~AI J/A-t.I{G" 11 ~7~. d~ 11lElI1I1. ;t6lVJf~ 517m. r='/2Oh/ LA-wl!E7fI(!If" C!HGJrA&JLeT (f) 'I df;t:J. 79 . ~ /Ve r J/,4tJ/E:: ~ h? 2/ (SG'€ SuPI'~Rr//lIG Z>oCU/J1I3/VTA-77tJH ATTheHE/J) 11/1.'11/1-(. /UFlJ11~l(~SE Me",,,, RJL ()Yk"/fPAYMI:J.JT 10 (J. Jll( It (1.11 of GtJf) fI bAt IF 1. {,Ollil!l> H6A-L7JI el-It.E.I ~EIIJ{I9I{~SEAfENT R:>/l tJr~- {J,f-YIHEN7 17&' /)15 t?F ~tJ(.splVl/i.-ry (Sli"E' /1t~/zE1) L./!:,. T If rrA(U(tD) VALUE AT DATE OF DEATH fI' ~/:! 7R, ~S" {).RS' " ~ 31 oao. ()tJ ~ ;{os.1D1 % If69. 2/ F 7~ fIf. 91 ~ 33t'.Sl/ ';/:1., b{) ~ I. " 5, ~, ;(ErttA//)" oj"a,'lAymIFNt "F ~N/J.I2/J1ACEUIIcA-L /.!JI(,~J Co N"n tV U I AI G- (!/H2,E I<,x TOTAL (Also enter on line 5, Recapitulation) $ 10 & I 2. J S. J'l (If more space is needed, insert additional sheets of the same size) MRP-28-2007 15:44 F'IJC BRIll ,.. 41 ~I 7~1:=: 34S.;::: F'.Ol/l]l ~PNCBAl\K March 28, 2007 Charles E. Shields, II1 Attorney at Law 6 Clouser Road Mechanicsburg, PA 17055 RE: Estate of Elmer N. Adams, deceased SSN: 716-09-5886 DaD: 3/1/2007 Dear Mr, Shields: 111 respons' to your request for Date of Death balances for the customer noted above, our records show the follOWing: Checking Account Account #5070076388 EstablIshed 08/27/1986 ELMER N .W.A.MS DOD balance: $6,278.35 + $.85 accrued interest Savings Account Account #5030115813 Estabbshed 07/23/1991 ELMER N ADAMS DOD balance: $93,000.00 + $205.61 accrued interest I was unable to loeate a Safe Deposit Box for the decedent. Please note that this office only provides date of death balances for deposit accounts (TRAs, CDs, Checking and Savings accounts). We do not process any financial transactions or provide statements. If you need assistance wlth any of these items, please call1-888-PNC.BANK (1-888-762-2265) or stop by your local PNC Bank branch office Sincerely, &/Jj~)1Y1& ~. Rae.helle Wells 1-800-762.] 775 Pi.PFSC,04-F .soo first Ave. Pittsburgh P A J 5219 Member FDIC If a co-purchaser other than your spouse is listed and you want the title to be listed as "Joint Tenanls With Right of SurvIvorship" (On death of one owner, title goes to surviving owner.) CHECK HERE D. Otherwise, the IllIe will be Issued as "Tenants m Common" (On death of one owner, mterest 01 deceased owner goes to his/her heirs or estate). 1ST LIENHOLDER ... IF NO LIEN. CHECK : 1ST LIEN DATE. COM NV\![ALTH OF :"ENNSYi.,,\lP:,NIA IUO:l::!";; i, :---::~;:"7\-L-'''--._'-_.; . hi ' ,.~ ','1"\... ,,~, I ! Mary Ann C, Garbarino, i'<k:t:1ry PUD!ic i Silve,! Spring. Twp.. ClJmheriMld., C~unl~' ! '. My "ommlSSlon ExpIres Dec. 1.:;, L008J STREET CITY STATE Fli~Ar..JCli'l,L INSTITUTION i-lUMBER ... IF NO LIE",. CHECK - ~ 2ND L1Ehl DATE -.J N CD en CO OJ 2nD LlElJHOlDER ------- STREET ZIP -- ZIP CITY STATE -~~~ _:I.lj~.l=-_~I:l'J;"'''~':+..---i''' USED CARS .'1 Horrtt= > UsedCars > ~~JJIMjnivim > c:nevro.l~t :;. Ast(o ;> t~9_2 > Mtnjv.~n > Equipment Print This Page advertlSeH'lent Quick Dealer Price Quote Search Used Car Listings List Your Car for Sale COMPARE NEW CARS "~l'll~ftJ_ REVIEWS & RATINGS FINANCING & INSURANCE 1992 Chevrolet Astra Minivan Trade-In Value Private Party Value Suggested Retail Value Photo Gallery Blue Book Review Specifications Compare Vehicles ~. Shopping Tools Free CARFAX Record Check Auto Loan from 6.09% APR Compare Insurance Rates Payment Calculator SElL YOUR USED CAR on Blue Book Classifiedsn< Reach millions of shoppers on kbb.com. Cars.com, and other popular sites. Find out more, Click BUY A lJSED CAR on Blue Book Classifieds'M Chevrolet Astra 30 Miles or less ZIP Code 17055 To View Ads, Click FIND THE RIGHT CAR <:ompare Used vs. New Under $5.000 Both New and Used Van/Mmivan To View List, Click View Another Vehicle Select Year.. BLUE BOOK' TRADE-IN VALUE More Photos advertisernent NEXT STEPS: Get Pricing on New Vehicles Sell Your Van/Minivan Vehicle Highlights Mileage: 87,000 Engine: V6 4.3 Liter Transmission: Automatic Drivetrain: RWD Selected Equipment Change Equipment Standard 5 Passenger Air Conditioning Power Steering AM/FM Stereo ASS (4-Wheel) Blue Book Trade-In Value Trade-in Value is what consumers can expect to receive from a dealer for a trade-in vehicle assuming an accurate appraisal of condition. This value will likely be less than the Private Party Value because the reselling dealer incurs the cost of safety inspections, reconditioning and other costs of doing business. Vehicle Condition Ratings Check Vehicle Title History Carl Crone Collision Center Manager L... .~." awrence CHEVROLET Lawrencechevy.com 6445 CARLISLE PIKE MECHANICSBURG, PA 17050 717-766-0284 800-427-4505 FAX 717-918-2999 ccrone@lawrencechevrolet.com http://www.kbb.comIKBB/UsedCars/PricingReportaspx?V ehiCle1Q=MYlSXJ'IIClSYMVA.HV... _if f /J /111 J I Great People. Great Service. Great Deals. Kelley Hiue Hook - Trade-in pncmg Keport - Chevrolet, Astro page 1. ot 4 Excellent '"'-......'lI\\~'_,.."'"."'. !....."WW"--'......f $1,125 Or Search by Category Or Change ZIP Code "Excellent" condition means that the vehicle looks new, is in excellent mechanical condition and needs no reconditioning, This vehicle ~)as never had any paint or body work and is free of rust. The vehicle Ilas a clean title history and will pass a smog and safety inspection. The engme compartment is clean, with no fluid leaks and is free of any wear or visibie defects. The vehicle also has complete and verifiable service records. Less than 5% of all used vehicles fall Into thiS category. Good -.....~""...,... .:.:....JWWL.._ $955 "Good" condition means that the vehicle is free of any major defects. This vehlcie has a clean title 11lstory, the paint, body and intenor have only minor (if any) blemishes, and there are no major mechanical problems. There should be little or no rust on this vehicle. The tires match and have substantial tread wear left. A "good" vehicle will need some reconditioning to be sold at retail. Most consumer owned vehicles fall into this category. Fair ~nn $670 "Fair" condition means that the vehicle has some mechanical or cosmetic defects and needs servicing but is still in reasonable running condition. This vehicle has a clean title history, the paint, body and/or interior need work performed by a professional. The tires may need to be repiaced. There may be some repairable rust damage. Poor ..., N/A "Poor" condition means that the vehicle has severe mechanical and/or cosmetic defects and IS in poor running condition. The vehicle may have problems that cannot be readily fixed such as a damaged frame or a rusted.through body. A vehicle with a branded title (salvage, flood, etc.) or unsubstantiated mileage is considered "poor." A vehicle in poor condition may require an independent appraisal to determine its value. Kelley Blue Book does not attempt to report a value on a "poor" vehicle because the value of cars in this category varies greatiy. * Pennsylvania 3/12/2007 Accurate Condition Appraisal Change Condition Accurately appraising the condition of a vehicle is an important aspect in determining its Blue Book value. Taking our 16 question condition quiz will ensure you know the correct condition rating. NEXT STEPS: Get Pricing on New Vehicles Sell Your Van/Minivan @2007 Kelley Blue Book Co., Inc. All rights reserved. Jan-Apr 2007 Edition. The specific infonnation required to determine the value for this particular vehicle was supplied by the person generating this report. Vehicle valuations are opinions and may vary from vehicle to vehicle. Actual valuations will vary based upon market conditions, spec;{ications, vehicle condition or other particular circumstances pertinent to this particular vehicle or the transaction or the parties to the transaction. This report is intended for the individual use of the person generating this report only and shall not be sold or transmitted to another party. Kelley Blue Book assumes no responsibility for errors or omissions. (v.07D33) Aroul CL'1r'~c>r:: F.AO Contact U,,;; Slt~ HaD l'1ec\\c Center AclVE!tisino Bu\' thp Buol Privacy Policy CoPyri9ht & Trademarks httn" / /UTUTUT Ichh {'{un fT(RR IT T<,,,,r1r,,,..<,ID":~:_~D ~---'- ____In T .1.. 1 T' Kelley Blue Book - Private.Party pncmg Report - Chevrolet, Astro _:[.]I'''=-_(1I;&~l.''~1:~___( USED CARS) _HQm,e > UseJ:tCars > \1'Q.JJIMjnlvan > <:tl~VrP1gt > Astra ::> 199,~ > Mlnj~(Qn > Equipment _~~~~BOa: Page 1 01 4 advertisement Quick Dealer Price Quote Search Used Car Listings List Your Car for Sale FINANCING & INSURANCE ~~l.l'J[t4__ COMPARE NEW CARS REVIEWS & RATINGS Print This Page 1992 Chevrolet Astra Minivan Trade-In Value Private Party Value Suggested Retail Value Photo Gallery Blue Book Review Specifications Compare Vehicles I~' Shopping Tools Free CARFAX Record Check Auto Loan from 6.65% APR Compare Insurance Rates Payment Calculator Extended Warranty Quote Print For Sale Sign BU)' A USED CAR on Blue Book Classifieds'M Chevrolet Astro 30 Miles or less ZIP Code 17055 To View Ads, Click SElL YOUR USED CAR on Blue Book Classifieds'M Reach millions of shoppers on kbb.com, Cars. com, and other popular sites. Find out more, Click FIND THE RIGHT CAR Compare Used vs. New Under $5,000 Both New and Used Van/Minivan To View List, Click View Another Vehicle BLUE BOOK" PRIVATE PARTY VALUE < HH--- -." "~ - ~-~- ~ @; . More Photos --.-- advertisement "__'n NEXT STEPS: Search Local Listings Sell Your Van/Minivan Vehicle Highlights Mileage: 87,000 Engine: V6 4.3 Liter Transmission: Automatic Drivetrain: RWD Selected Equipment Standard Change Equipment 5 Passenger Air Conditioning Power Steering AM/FM Stereo ABS (4-Wheel) 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). 1he 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. Check Vehicle Title History htt-n-/lnrn,rn:T 1.,.:J.......... ro_-..-.. /VDD IT T............11'1....._... m-= ~~~ _T\ --- Kelley Hiue Hook - Pnvate J:'arty pncmg Keport - Chevrolet, Astro Select Year... Or Search by Category Or Change ZIP Code Vehicle Condition Ratings Excellent .,-"''''''....~--.'''... ....i'..jLJ';.....Jw $1,630 "Excellent" condition means tllat 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 rLlst. The vehicle has a clean title history and will pass a smog and safety inspection. The engllle compartment is clean, with no fluid leaks and is free of any wear or visible defects. The vehicle also has complete and verifiable service records. Less than 5% of all used vehicles fall into this category. Good r*'~""-*."li<: ,-lLo.i~w $1,365 "Good" condition means tllat the vehicle is free of any major defects. This vehicle has a clean title history, the paint, body and interior Ilave only minor (if any) blemishes, and there are no major mechanical problems. There should be little or no rLlst on this vehicle. The tires match and I,ave substantial tread wear left. A "good" vehicle will need some reconditioning to be said at retail. Most consumer owned vehicles fall into this category. Fair O::')W $1,020 "Fair" condition means that the vehicle has some mechanical or cosmetic defects and needs servicing but is still in reasonable running condition. This vehicle has a clean title history, the paint, body and/or interior need work performed by a professional. The tires may need to be replaced. There may be some repairable rust damage. Poor .. L.i N/A "Poor" condition means that the vehicle has severe mectlanical and/or cosmetic defects and is in poor running condition. The vehicle may have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. A vehicle with a branded title (salvage, flood, etc.) or unsubstantiated mileage is considered "poor." A vehicle in poor condition may require an independent appraisal to determine its value. Kelley Blue Book does not attempt to report a value on a "poor" vehicle because the ,alue of cars in this category varies greatly. , Pennsylvania 3/12/2007 Accurate Condition Appraisal Change Condition Accurately appraising the condition of a vehicle is an important aspect in determining its Blue Book vaiue. Taking our 16 question condition quiz will ensure you know the correct condition rating. NEXT STEPS: Search Local Listings Sell Your Van/Minivan @ 2007 Kelley Blue Book Co., Inc. All rights reserved. lan-Apr 2007 Edition. The specifiC information required to determine the value for this particular vehicle was supplied by the person generating this report. Vehicle valuations are opinions and may vary from vehicle to vehicle. Actual valuations will vary based upon market conditions, specifications, vehicle condition or other particular circumstances pertinent to this parlicuJar vehicle or the transaction or the parties to the transaction. This report is intended for the individual use of the person generating this report only and shall not be sold or transmitted to another party. Kelley Blue Book assumes no responsibility for errors or omissions. (v.07D33) j\bout Us '<......--,~..........~"'---"---"---"""""""--~~~_.--........ CcHeE'r~;, FAO t',. Cnntclct U;, ~;it~ Har' l>1erlizl C>::,ntel AcJveltlsill(' Buv thE- BODI httn.//,.TUTUT1rhhf''''mfT(nnITT~oAr.,..",ID'':~;~~D~_~-+-~__.''''T_t...:-'_T-'_"iC. " ~T~'" "~._~ t'age L. or 4 03/12/2007 at 02:55 PM 48410 Job Number: LAWRENCE CHEVROLET Federal ID #:232147212 We'll Be There! 6445 Carlisle Pike P.O. Box 510 Mechanicsburg, PA 17050 (717)766-0284x3345 Fax: (717)918-2999 PRELIMINARY ESTIMATE Written By: CARL CRONE #131104 Adjuster: Insured: Owner: Address: RON ADAMS RON ADAMS 8 E WILLOW TER MECHANICSBURG, PA 17050 (717}697-4503 Claim # Policy # Deductible: Date of Loss: Type of Loss: Point of Impact: Car: Inspect Location: Ins\.?-rance Company: Days to Repair 1992 CHEV MI0 4X2 ASTRa CL 6-4.3L-FI 2D VIN: IGNDM15Z4NB142549 Lic: Intermittent Wipers Tinted Glass Dual Mirrors Fog Lamps Power Steering Power Brakes Anti-Lock Brakes (4) Hiback Bucket Automatic Transmission Overdrive VAN Int: Prod Date: Seats Odometer: Body Side Moldings Clear Coat Paint AM Radio 7 Passenger Option Rally Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT BUMPER 2* Rpr Bumper painted w/o license 1.0 0.0 plate mount w/o strip 3 GRILLE 4** Repl A/M Lower panel 1 46.00 1.5 0.0 5 FRONT LAMPS 6 Repl LT Bezel w/standard grille 1 25.82 0.3 ------------------------------------------------------------------------------- Subtotals ==> 71.82 2.8 0.0 03/12/2007 at 02:55 PM Job Number: 48410 PRELIMINARY ESTIMATE 1992 CHEV MI0 4X2 ASTRO CL 6-4.3L-FI 20 VAN Int: Parts Body Labor 2.8 hrs @ $ 42.00/hr ---------------------------------------------------- SUBTOTAL Sales Tax 71.82 117.60 $ 189.42 $ 189.42 @ 6.0000% 11.37 GRAND TOTAL ADJUSTMENTS: Deductible CUSTOMER PAY INSURANCE PAY WE AT LAWRENCE CHEVROLET GUARANTEE ALL COLLISION AND PAINT REPAIR WORK PERFORMED TO ITS CERTIFICATION STANDARDS FOR AS LONG AS YOU OWN YOUR VEHICLE.ALL PARTS WILL FOLLOW THE MANUFACTURE WARRENTYS. $ 200.79 0.00 $ 0.00 $ 200.79 03/12/2007 at 02:55 PM Job Number: 48410 PRELIMINARY ESTIMATE 1992 CHEV MI0 4X2 ASTRO CL 6-4.3L-FI 20 VAN Int: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEN YEARS AND PAYMENT OF A FINE OF UP TO $15,000. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:D=DISCONTINUED PART A=APPROXIMATE PRICE B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ #=MANUAL LINE ENTRY *=OTHER [IE. . MOTORS DATABASE INFORMATION WAS CHANGED]. **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE NAC;S=NATIONAL AUTO GLASS SPECIFICATIONS. MQVP=MANUFACTURER'S QUALITY AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM. THE ATTACHED ESTIMATE REPRESENTS AN APPRAISAL OF THE COST OF REPAIR FOR THE VISIBLE DAMAGE TO THE VEHICLE NOTED AT THE TIME OF INSPECTION NECESSARY TO RETURN THE VEHICLE TO ITS PREDAMAGED CONDITION. COSTS ABOVE THE APPRAISED AMOUNT MAY BE THE RESPONSIBILITY OF THE VEHICLE OWNER. THERE IS NO REQUIREMENT THAT THE VEHICLE OWNER USE ANY SPECIFIED REPAIR SHOP. INFORMATION REGARDING REPAIR FACILITIES WHICH WILL BE ABLE TO REPAIR THE VEHICLE FOR THE APPRAISED AMOUNT IS AVAILABLE FROM THE INSURANCE COMPANY. IF USED PARTS ARE SPECIFIED, THEY ARE REQUIRED TO BE OF LIKE KIND AND QUALITY TO THOSE BEING REPLACED. INCIDENTAL CHARGES SUCH AS TOWING, PROTECTIVE CARE, CUSTODY, STORAGE, DEPRECIATION, BATTERY AND TIRE REPLACEMENT ARE NOTED WHEN APPLICABLE. AFTERMARKET CRASH PART - A NONORIGINAL EQUIPMENT MANUFACTURER (NON-OEM) REPLACEMENT PART, EITHER NEW OR USED, FOR ANY OF THE NONMECHANICAL PARTS THAT GENERALLY CONSTITUTE THE EXTERIOR OF THE MOTOR VEHICLE, INCLUDING INNER AND OUTER PANELS. THIS APPRAISAL WILL INDICATE IF AFTERMARKET CRASH PARTS ARE SPECIFIED. IF THE USE OF SUCH PARTS VOIDS THE WARRANTY ON THE PART BEING REPLACED OR ON ANY OTHER PART, THE AFTER MARKET CRASH PART WILL BE WARRANTED BY THE M,ANUFACTURER OR INSURANCE COMPANY EQUAL TO OR BETTER THAN THE REMAINDER OF THE EXISTING WARRANTY. 03/12/2007 at 02:55 PM Job Number: 48410 PRELIMINARY ESTIMATE 1992 CHEV MI0 4X2 ASTRO CL 6-4.3L-FI 20 VAN Int: Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DRIGG85 Database Date 02/2007, CCC Data Date 02/2007, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have corne from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. A 03/12/2007 at 02:55 PM Job Number: 48410 PRELIMINARY ESTIMATE 1992 CHEV MIa 4X2 ASTRO CL 6-4.3L-FI 2D VAN Int: ALTERNATE PARTS SUPPLIERS 4 AIM Lower panel Part No. 1075 221 Price $46.00 Action Crash-BodyMaster 1005 SHERMAN AVE. PENNSAUKEN, NJ 08110 (800)223-0171 (856)661-0282 c; ! I I. ! 1 I I :? : t I T€/YJ$ tJr /It,es p#'/1t.7Y G-7Ja t?~/!/d?&X /JECGPt9fT ~ (!.1I11/,e -a:.LJ Ae C!ttAl6f! /.s-; all w/Zl>r w.lfTd# ". S. 00 , 3.! C.U)(!/( ~ ~. 00 ~-:22,~P I ti/JE~IflJE'NT L/tpvlt);ifr@ h'~ P~t')III~-ry ~~c €N~eE /A//P #QA'S"/N~ .-?t.l.4-'E. /IE /Y~ ~ ~ . ~# #//If. REV-1510 EX + (1-97) SCHEDULE G - INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER "ZI -~ 7- z32.. It-OA-m 5" tf211f€7C #, 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 lHE NAME Of lHE lRANSFEREE.1HEIR RELATIONSHIP TO DECEDENT AND THE DATE Of TRANSfER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE ATTACH A COPY OfTHE DEED FOR REAl ESTATE_ ~UM8ER VALUE OF ASSET INTEREST (If APPLICABLE) 1. 1'''0 ChtJIrDltf CQAlCl..I i er - (,OJ 000 Mil~ " kt-Ily 'Blue. 'Boo~ Value - '73S"IDO ~ lo~Z 7 3S'. Of) 3, ~JtJZJ -0-- G;.f.f dutil'r! /,leh;,,~ frlJ"" deeedt!At ~ I" 's SfJ11, /l.,ma/II E. "f.K~A1S pll{! IUIJ11,el' (fpp, Pf)) ~,/lln Ii ,f,n .It:! e. 't po, ()() /a>~ II 2. -0 - ,l-dtJIIJS "-- .6t, .3. hlUlaJ-uI ~pp,pp) "'liar.! Ii 1Ya-.It&y P.kI~ ~/p&J,~o /ooj1 5. ()()O -0- Pill " A'AHfhju Jf)(),O{)) p!ll,..1 ~ lJM'lQl~. 'I, ulJt. huntl~ ~ t)t:J..~P /bt'h, ~ .3 ()M' DtI -0- "/ /k!ltH15/ SPA. TOTAL (Also enter on line 7, Recapitulation) $-0- (If more space is needed. insert additional sheets of the S;Jme sm~) REV-1511 EX+ (12-99) . ~;.,~ .......... -%\-~ SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF A.l)/fIJ1~ EZmd /l/ FILE NUMBER ;)./- 0 7-Z-32 ITEM NUMBER A Debts of decedent must be reported on Schedule L DESCRIPTION 1. FUNERAL EXPENSES: fYIvCJ2.S ;:'Lll/lt~ HOmE of IHet!NI1-AlICSL5<<JeG, jJA t=/()wer StJ~ay FUlle;'tl! ~t/ t.ad;~.s Aet~,'/,'a/'! / Isf eJt<<~h pf c;e,r/ ~,. ,c;UK/'IJ/ /Jt~/,~' :/. 3. I{, t B. ADMINISTRATIVE COSTS: 2. Personal Representative's Commissions Name of Personal Representative(s) RofJlrLI> E. A-tJIfM$ Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 8 J?~ ll...t/)pJ r.G72JlAeG City /J1E(!JI/fAl/eSl5ttJe.G State .t!tt- Zip /1oSV Year(s) Commission Paid: Attorney Fees (!.H II-IUcS E. Sf{ I G" ? f).5' 7lI 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 4. 5 6. 7. 8, 1. IP, II. Claimant NOAlG ELIG/elE' Street Address City State _ Zip Relationship of Claimant to Decedent Probate Fees M-td ori(fil1a! i.ss ue l>T short cerfiklOfes Accountant's Fees L Tax Return Preparer's Fees 1 J MJ ~ r 8t<./I-{!.j(6/ u.. f.I f It 15Lf)~K. of IUGC.HAIJ lCSS uJ(!.f;- fi(l,/;'iJ /11"1, PAL/I, tiz . ~sh''''') c.e.rt; f,' c..Cl.re.s Q,clcl'.'kot\CL! shorr 4..dd;h4Jtal j.l1'Y) 6ak fee. F /// "I Fee- -a R&J/siv cf t(l'///.5 11-/1 JI e I' f;,f,o/ /#/ e U H1 oer/anq Law ,ftu rna/ /f4j/!rl;~/;rf i" e 4/'"//s/e S~h'nt:./ AMOUNT ~ ::;../9, SO 1'- 3t>. DD .; / bc:J, DO ~/4'O.e"? ~ S; 3~8. 100 f S; 3.:<? bo NONE t 1.25. cO "! 3SfJ, 1)0 ~ ~O. DO '/ ::'-. () 0 fI 7 s-. 00 , /07, 91 TOTAL (Also enter on line 9, Recapitulation) $ I a.1 () S- i e' 9' (If more space is needed, insert additional sheets of the same size) StJ./J;;1). H, ~d. _____n ____ _E~ZLPE_kO ,+lJ?~___BA1~,e~________ __ ______ ...._ .:If .~{-:_~Z-1- 3~ . ..._________. ____L2->. __~1:!.!'.__e.Iw:,e..-ii _____7A-)GS/apjj~.I}L_LJ1._~I1LJed1~_IL_ltI'_tb_ uC!!_'!{____.____._. ..---.-------.---.- ..._______._....._______ k~q,.INlit: _f1/!!f-__~._~iP()ut. /#t/_ ~ 1!1u!:!!/__~__(~e~_~.~}-.---~.~~-- _______________ I~_ .J,( 4t'6.~1L8L_.I!(!ilZ t_____.___.._ ________._.________________. _n_ _n____ .__. ___ ._ ~~~~~_I!!~n - __________._1..'1-. ___~!'!1.I?<<lStll1lJJt__4:___~dts._E;__:!l!!!:{~ ~_!r -.;;~d?_7'--. . _.____.__._____. , ? -------------------..-Jl!-~)--~~.( -~t/!il----.---------.-.-.----.--- --- u. _._____.u__m___ ~2. ?~m___ I __,._~__.._____.____ ______._._.__..___..___ ...._.______.__~____~_..__~__~___~_ ..__,._.____.__..____~____.___~______.______._.._~,.____",___,_,"" . ___________~_._._.__ __n _______._______._.____~_"_..___~_.....__..'____ ~___....____~_.__..__..._.___________________~___._.____~_._.._______...__ ___~_~.__._.__________.______.~.__~.____..~______.__._.._.m___._ __.___. _ ..._____ __ ~__<____~_~_____~._._ .._______ ____._._.___.____.._.~.~_.____________.____.~_________'^___.__._~_~____ _._..____________~~_._.__._.__.___.._..___~_r______ _ . __ _____.___________....___~_.. _ _~_._.___._ ___ .-.. ___~____________._._____.__ __________..._____...______..__._~___..~_.~._________..~__._.____.__._______...___.________"'..._.__ ._______".____.___.,,~_u____".__.._.____ .______.__ _._-----_._------_._----_.~---------~-_. ---------_._--_._.._---------_._._--_._._------~._----_..--_.._._----_.._~--.._-.----~---_.~._----- ---------~-------_..._----- ---- --.--- .._--_..~---~------_.._._.- _._---~---.~._-_..._-------_.-~._------------~-----~----~~,-_._~._------_.._~--_._------~------~..--._-- -..-- ---.--.----.'.-,,-- . ,.--..-- ..-.----- .~_._._--~_.--.-".^----~--_._~-_._--~~_._.._"_._------~--~---..-.---... ..^. _._---~_._._---_._-.--<-_._---~--~-_._---_.- -- ._---.._--_.~----._-- _..~--~-------._._--------~~- -.---.--.-.'--- -------- ----._..__.._---_...-~----.---------- -----~~..-.._.._~-------_._-"'._.._._~--------~~---------._-..-..~_..._--------~--_.--._" .~.--..- ~-_.__._-_..--.- .._-.._".----_.__._._~._.-.-._-.._--~._.-..-- .-_~"_..__..---_.._-,--- _.."._-_....__...------_._"._-----~._------~--_._--_._-_. -...-,.-.---.------ '-'" -- ---_.--_._....._-~--_._.._..-.._- ._n_~.________ .__.~_._ --.....-_...-. ---,.----.-.~--.~---.-------.~---~--.-"--....-. ---....~.....--..-..-..---.-_.~-~-...---...----- --.-------~~-~-.--.-......---..--- ..---.---~...- __'__'__~____ ..__ _~ .__.._.____._.~__~_ _______________... .___.____.__.~~___________________~___.^"__.______._._.____.~~____" " __n_.___.__._.._.....____...__..__... - --- __ .... --~--_..__._-~--- --"--------- --------..-.. -- ------------~-------_.._._---.--_._---'- -~_._--_..._------~--- _'___' _ ."_.___.______ ..____ ._. _~,,-___.~_.________~~___ ___...._.___..~... .___~__n_'.~___~____w._~_____________n._".._ _____~.-~___.___"_'_..m______ . ____ -----,,-.-..-....~,_____.____..____._____........_._..___..___--.-.---- TaxSlayer.com SFiIe .Stepe: rage 1 01 1 ,At<d/i.ul1J -,-I;t y<" Need help? Type your question here... Submit Your Return Submit Your Return to TaxSlayer.com TaxSlayer.com Survey Where did you hear about TaxSlayer.com ? (Please Select One) Previous Year customer Email IRS website (irs.gov) A friend referred me State website -- specify: Please select- Other (please specify) Search engine -. specify: - Please Select - Military (please specify) Please review all information before submitting your return(s). Fee Summary : Tax Return Fee: $9.95 (Already Paid) You will not be charged this fee again. Federal Return Summary : Return Type: Balance Due: Balance Due - Electronic Funds Withdrawal $73 $73 Payment Amount Payment Date Signature Option Taxpayer PIN State(s) Summary : 4/11/2007 Self-Select PIN Program 32918 State Amount Electronic Type Balance Due. Mail Payment Pennsylvania Amount Due. $44 If you are ready to transmit the following return(s) to TaxSlayer.com , simply click on the 'Submit My Return' button below. To Submit your return to TaxSlayer.com , click this button: SubmitMy'Return To Exit without sending your return, click this button: (717) 766-3421 Myers Funeral Home, Inc. Boyd L. Myers Jr., Supervisor 37 East Main Street Mechanicsburg, Pennsylvania 17055 Fax (717) 795-7291 A standard of exceIIence in Centm1 Pennsy1vania~ince 1910 Tuesday, May 1,2007 Mr. Ronald E. Adams 8 East Willow Terrace Mechanicsburg, PA 17050 i'i" Dear Mr. Adams, Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form on the services for: Elmer N. Adams SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED LESS: Credits granted LESS: Total Payments PLUS: Items ordered later CURRENT BALANCE Credits Granted: $1,695.00 Package Price Discount $10,325.00 1,695.00 8,630.00 219.50 $219.50 PLUS: Items ordered later Additional day Patriot 150.00 Additional Certs 69.50 Interest at the rate of 1.5 % per month ( 18 % per a~num) will be added to balance after 30 days. If there are any questions or concerns that remain unanswered, please call me. Sincerely, ~/#r--/ pol )!~ /07 ~. I OC) Y REV-1512 EX+ (12-03) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT EST A TE OF A-.D Am 5, I:L /J( a AI. FILE NUMBER .2/- 07- 23;l. Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. If. s. C. 7. J. 3. DESCRIPTION a.s. T/lGA-5/(~Y- 'pB(SP/Y.I!-t. /A(!f;/JfE r~E~ - ~~ fl,4-. LJEPr; t:F t<EVENtte - ,.tJF;qSo/llA{.. /1VC!PdlE ~E$ -S"Zl/?'E YP/J/f?. //LAA! (~ blfuG h.#A;) atJllrllllllNG eA-~E I<x - (JI<.ESf!.AlfJTfP/(/.f VALUE AT DATE OF DEATH ... 7~ ,t)tJ ~LJ J.I. /)0 ;- S- '1. DO , ;J, S~. "i' ~ I 3 t?J' 0.:2. ~ / J. /1 ~ ~ 'I 3. h2 , /7 .:z. ()tJ ~ S"- tiP !Sz, , I!U7 ~ tSl>,,&9P (!/-IURCH DF Got> HDm~ 8'. {NESr SJ.{OIeI: .emS CoNT IN tl.IN (;. C/HU: R.x - fJne:SdJlIP 1i/)N~ UAJI Tt:j) HEtJ.L7J.{ CIfJ-~E (/NP() Alp~: .Z'Te-blS '" 7" f ;9-~ CHEtU::S tcJA!.JrrGN J3E"FOIeG 7).~.j)_ /tUNIC}{ CL.~E1) D€CE'tlE"l\I7S A-c!LT. H-F72f:7L a-b. P.) CJ. f~1Jr TIE ;(e(JcJ/E/(IES, /A'e.. f,r G~ C!I1P/1/1i.. &ft.I1.. PIA- C UUJ 5lilltlCE51' ,Al,A-. fi,f {!/h(/} SdlYICES" A/A /~, 1/. TOTAL (Also enter on line 10, Recapitulalion) $ 1/ 395'". fJ (If more space is needed, Insert additional sheets of the same size) YOUIX..PLAN From Medea -"7 P: I '0' 0 c '-1 ("Z-) () '1 ~:.-,'---:-~....... 11 c:J1 ) MONTHLY PREMIUM INVOICE Member ID Number: 378016282925 Member Name: ADAMS ELMER Member Address: 502 W ELMWOOD AVE MECHANICSBURG, PA 17055 Coverage Period: 03/01/2007 To 03/31/2007 Balcmce Forward Adjustments Current Medicare Part D Premium Totol Medicare Part D Premium Due Group Number: 3734 Total Amount Due By: 03/13/2007 $31.00 0.00 59.00 $90.00 Please see the reverse side of this invoice for payment instructions. ..-:..... ~1edicare "R Pl'esel'il'lioll Drllg Covel'ag; X Invoice Number: 25539012 Invoice Date: CONTINUING CARE RX #001 28 S 2ND ST /PO BOX 355 NEWPORT PA 17074 * * S TAT E MEN T * * Statement Date: 4/11/07 Page: 1 If you have any questions regarding your bill please call (717) 567-2147 or (800) 675-2279. Thank you!! Date 3/01/07 2/10/07 2/10/07 2/10/07 2/10/07 2/10/07 2/10/07 2/12/07 2/20/07 2/20/07 2/21/07 Account #: 100030353 COG ELMER ADAMS RON ADAMS 8 EAST WILLOW TERRACE DR MECHANICSBURG, PA 17050 Description Previous Balance DOC#99102046 PAYMENT - THANK YOU RF 4054584 ALLOPURINOL 100MG TAB RF 4054585 FERROUS sulf 325MG/5GR TA RF 4054586 METOPROLOL 50MG TAB RF 4054587 COZAAR 50MG TAB RF 4129627 SIMVASTATIN 20MG TAB RX# 4337262 FUROSEMIDE 40MG TAB RX# 4361149 CIPROFLOXACIN 500MG TAB RX# 4382988 SERTRALINE 25MG TAB RX# 4386376 SERTRALINE 25MG TAB RX# 4384869 ARGINAID(RESOURCE)ORANGE ** continued on next page ** Qty 30 30 60 30 30 30 7 20 1 1 Amount 293.62 293.62- 5.00 1. 95 5.00 56.83 5.00 5.00 5.00 52.82 6.44 89.66 COPAY COPAY CO PAY COPAY COPAY COPAY CONTINUING CARE RX #001 28 S 2ND ST /PO BOX 355 NEWPORT PA 17074 Statement date: 4/11/07 Name: ELMER ADAMS RON ADAMS 8 EAST WILLOW TERRACE DR MECHANICSBURG, PA 17050 Account #: 100030353 COG CONTINUING CARE RX #001 28 S 2ND ST /PO BOX 355 NEWPORT PA 17074 * * S TAT E MEN T * * Statement Date: 4/11/07 Page: 2 Account #: 100030353 COG ELMER ADAMS RON ADAMS 8 EAST WILLOW TERRACE DR MECHANICSBURG, PA 17050 If you have any questions regarding your bill please call (717) 567-2147 or (800) 675-2279. Thank you!! Date Description Qty Amount --------- -------------------------------------------- ---------- 1/10/07 RX# 4281021 ALLOPURINOL 100MG TAB 1 3.32 COPAY 2/26/07 RX# 4396946 MORPHINE SULF 20MG/ML SOL 1 5.00 COPAY 1/10/07 RX# 4281040 FUROSEMIDE 40MG TAB 1 3.31 COPAY 1/10/07 RX# 4281042 METOPROLOL 50MG TAB 2 3.35 COPAY 1/10/07 RX# 4281049 SERTRALINE 100MG TAB 1 5.00 COPAY 1/::-(003 Lf / I 'z.-( c) "7 Ending balance - Pay this amount ---------> 252.68 Past Due Past Due Past Due Current 31-60 days 61-90 days 90+ days ----------- ----------- -.---------- ----------- 252.68 .00 .00 .00 1 i ; PAST DUE I 0 0 \ -'{Y \ \ 0"1 (\",v I G I - '1../" g'(7'6 i) I I I STATEMENT DATE PREVIOUS BALANCE I CURRENT CHARGES PAYMENTS ADJUSTMENTS I CURRENT ACCl BALANCE ADVANCE CHARGES i 5/31/2007 I 138.02 [ .00 .00 .00 i 138.02 .00 THE CHURCH OF GOD HOME, INC. I PLEASE PAY >1 $ 138.02 i THIS AMOUNT I TO REORDER CONTACT CONSOLIDATED GRAPHIC COMMUNICATIONS. KEVIN MANN' (570) 366-8866 . REV-1513 EX+ (9-00* SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /J-/J/f/J1~ /;ZIIIE7e AI. FILE NUMBER 2/-07-232 RELATIONSHIP TO DECEDENT NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not ListTrustee(s) I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 1. J2.oIJ /H.J) P. Ad) /fmS .50N 8" F""'r Wllt_l)t() ~f!E IJ1E(!,'/{/ffslIMS""G/ #/'1- /1-050 :? #/l-tf/ey A. tPKLEY J)Atl6Nr~ /7 B ,L)//JIEJ{)f)oi) jJUfeE 7EkAlEFC!k, AIr () 7~b" .3. J) A-J/I jJ /3_ .4lJ/f/J1~ 3 (!..HtflP/E e 7:- Ve:s-rIN" r=t. 325'1/ Solll AMOUNT OR SHARE OF ESTATE Y3 Y3 Y3 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 ll- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (11 more space is needed, insert additional sheets 01 the same size) CODICIL I, ELMERN. ADAMS, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this a Codicil to my Last Will and Testament dated September 11,1974. 1. I hereby revoke the appointment of my daughter, NANCY ANN OXLEY, as contingent Executrix of my Last Will and Testament, in the event that my wife, KATHERINE M. ADAMS, should predecease me, or should she be unable to serve as Executrix of mv Estate for anv reason. and I do herebv nominate. constitute eI .,/" eI .; and appoint my SOil, RONALD E. ADAIVlS, Executor of my Last Will and " Testament, in the event that my wife, KATHERINE M. ADAMS, should predecease me, or should she be unable or unwilling to serve as Executrix of my Last Will and Testament for any reason, and in all events, I direct that my said personal representatives be excused from posting bond or other security for the faithful performance of their duties in any jurisdiction. - 1 - _ ~ _~"""_T~'" _~~.._ ___""-_~_____ ~___ 1= 2. I hereby ratify and confirm my Last Will and Testament dated September 11, 1974, in all other respects and to all intents and purposes not inconsistent herewith. IN WITNESS WHEREOF, I have hereunto set my hand and seal this .:t.o day of April, A. D. 2000. ~. k d'/} U-1 ~ Elmer N. Adams Signed, sealed, published and declared by the above-named, ELMER N. ADAMS, as and for a Codicil to his Last Will and Testament, in the presence of us, who, at his request and in his presence, and in the presence of each othet, have hereunto subscribed our names as witnesses. - 2 - LAsrr \\fILL AND TEST AMEN'r OF' ELMER N. ADAMS I, ELMER N. ADAMS, of the Borough of Mechanicsburg, County " 1 of' Cumberland and State of Pennsylvania, being of sound and disposing '~ mind, memory and understanding, do make, publish and declare this my Last Will and Testament. '1 ,1 1. j ~~1 I direct the payment of all my just debts and funeral expenses "., , , :1 J j 1 d " :i I :'j J \;1 i ij 1 .l as soon after my decease as the same can be conveniently done. 2. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed, whatsoever and wheresoever the same may be situate, to my wife, Katherine M. Adams, her heirs and assigns, absolutely and unconditionally. \ 3. In the event that my wife, Katherine M. Adams, should predecease me, or should she die at about the same time as I do, such as in an ace i dent COlmnon to both of us, then in such event, I gi ve and bequeath my entire estate, of whatsoever ne,tnre and wheresoever situate, to my three children, to wit, Nancy Ann OXley, David B. Adams and Ronald E. Adams, share and share alike. Should my wife predecease me or should she die at about the same time as I do, such as in a common disaster, then in such event, for the purpose of facilitating the settlement and distribution of my estate, I authorize and empoVler' my Executrix, hereinafter named, to sell any and all real estate which T may Ov-In at the time of my decease, at either public or private sale or sales. LASTLY, I nomi.nate, constitute and appoint my wife, Katherine H. Adams, Executrix of this my Last Will and Testament, and in the event that my said wife should predecease me, or should she be unable or unwilling to serve in such capacity for any reason, then in such event, I nominate, constitute and appoint my daughter, Nancy Ann Oxley, Executrix of this my Last Will and Testament, in her place and stead. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day of September, A. D., 1974. ~/} ).1/ /~I. ;)'4 tJ / ~/c. J{ '(~//:::>;!<:V[~ . 0t.;'ui'-;J~ .~( SF Elmer N. Adams Si.gned, sealed, published and declared by the above named, Elmer N. Adams, as and for his Last Will and Testament, in the presence of us, who have subscribed our names hereto as witnesses, at the request of said testator, in his presence and in the presenqe of each other. to E~/;(e' .{ ,t J/ ;&~{~. (12.. t/ /) t [ /J [/ ff,[I-.' -?7 e It ~~'vvJ