HomeMy WebLinkAbout02-25-08
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15056041147
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
OFFICIAL USE ONLY
~
~
County Code Year
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT 2 1 0 6
0919
Date of Birth
164 80 1745
09 26 2006
10 11 1945
Decedent's Last Name
Suffix
Decedent's First Name
MI
DERVISEVIC
SAHA
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
[!] 1. Original Return D 2. Supplemental Return D 3. Remainder Return (date of death
prior to 12-13-82)
D 4. Limited Estate D 4a. Future Interest Compromise D 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
D 6. Decedent Died Testate D 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
D 9. Litigation Proceeds Received D 10 Spousal Poverty Credit (date of death D 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..,
( 7 1 7) '2?9 3 1 4 QP
o 'co
--u. I'-'f
REGISTER O~ W1fLS USE::ONL Y
NINA
G.
MILOVANOVICH
ESQ
Firm Name (If Applicable)
. I
')
First line of address
I [-1 r"".)
UI
..~. .~
129 E. ORANGE ST., 2ND FL
C"J
.)
., I
Second line of address
- 1
fo.)
"'
i--:-:J
City or Post Office
State
DATE FILED
LANCASTER
PA
ZIP Code
17602
Correspondent's e-mail address:ninamilovanovich@verizon.net
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG TURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
Sejfudin Dervisevic
!2 -/~-D~
Nina G Milovanovich
PA 17602
L
Side 1
15056041147
15056041147
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--.J
15056042148
REV-1500 EX
Decedent's Name: Saha Oervisevic
Decedent's Social Security Number
164 80 1745
RECAPITULATION
1. Real Estate (Schedule A).......................................................................................... 1.
2. Stocks and Bonds (Schedule B)............................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D).......................................................... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E)................
6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) 0 Separate Billing Requested............. 7.
8. Total Gross Assets (total Lines 1-7)....................................................................... 8.
9. Funeral Expenses & Administrative Costs (Schedule H)......................................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)................................ 10.
11. Total Deductions (total Lines 9 & 10)...................................................................... 11.
12. Net Value of Estate (Line 8 minus Line 11 )............................................................. 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J)................................................. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13)................................................. 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, of
transfers under Sec. 9116
(a)(1.2)X~
16. Amount of Line 14 taxable
at lineal rate X .045
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
o . 00
15.
10,212.61
16.
o . 00
17.
0.00
18.
19. Tax Due..................................................................................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
L
Side 2
15056042148
5.
69,981.73
69,981.73
17,440.78
42,328.34
59,769.12
10,212.61
10,212.61
o . 00
459.57
o . 0 0
o . 0 0
459.57
D
15056042148
--.J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-06-0919
DECEDENT'S NAME
Saha Dervisevic
STREET ADDRESS
530 Second Street
CITY I STATE IZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
459.57
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2)
0.00
Total Interest/Penalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5) 459.57
(5A)
(5B) 459.57
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes
D
D
D
D
D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... D [!J
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;..................................................................................
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest; or..................................................................................................................
d. receive the promise for life of either payments, benefits or care?..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receivi ng adequate consideration?................................................................................................................ ......
No
[!J
[!J
[!J
[!J
[!J
[!J
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. !l9116 (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. !l9116 (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. !l9116 (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. !l9116 1.2) [72 P.S. !l9116 (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. !l9116 (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-1508 EX+ (6-98)
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dervisevic, Saha
FILE NUMBER
21-06-0919
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property ]ointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Dervisevic V. Schriml No. 07-7450 - Cumberland County Court of Common Pleas 62.500.00
Wrongful Death/Survival Action (See Exhibits "A" and "B")
2 Money Market Account #8728-18 - Cornerstone Federal Credit Union, P.O.Box 1181, 5.145.07
5 East Gate Street, Carlisle, PA 17013
(See Exhibit "C")
3 Savings Account #8728-01 - Cornerstone Federal Credit Union, P.O. Box 1181,5 2.336.66
East Gate Drive, Carlisle, PA 17013
(See Exhibit "C")
TOTAL (Also enter on Line 5, Recapitulation)
69.981.73
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
REV.1151 EX+ (12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dervisevic, Saha
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-06-0919
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
See continuation schedule(s) attached
7,320.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State Zip
2.
Attorney's Fees
Nina G. Milovanovich Esq
6,508.78
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Seifudin Dervisevic
Street Address 524 Third Street
City Carlisle State PA Zip 17013
Relationship of Claimant to Decedent Son
3,500.00
4.
Probate Fees
112.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL (Also enter on line 9, Recapitulation)
17,440.78
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (6-98)
*'
SCHEDULE H-A
FUNERAL EXPENSES
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Oervisevic, Saha
FILE NUMBER
21-06-0919
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Coble-Reber Funeral Home, Ltd., 208 North Union Street, Middletown, PA 17057-
Funeral Goods and Services - (See Exhibit "0")
3,075.00
2
Funeral Meal
600.00
3
James R. Gringrich Memorials - Grave Marker - 5243 Simpson Ferry Road,
Mechanics, PA 17055 (See Exhibit "E")
3,645.00
Subtotal
7,320.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-A (Rev. 6-98)
Rev-1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Dervisevic, Saha
FILE NUMBER
21-06-0919
Include unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Broome Volunteer Emerg. Squad, P.O. Box 126 WVS, Binghamton, NY 13905 645.00
2 Cardiology Associates, P.C., 30 Harrison St., Suite 250, Johnson City, NY 13790 122.92
3 Court of Common Pleas, Cumberland County, PA - Filing Fee - Petition to settle 19.62
Wrongful Death and Survival Claims
4 Milovanovich & Espinosa, LLC, 20.833.33
5 New York State Pollice, Div.HQ.lCentral Records, Building 22, 1220 Washington, NY 2.25
12226-2252 - Police Accident Report
6 Park Avenue Assoc. in Radiology, 32 36 Harrison Street, Johnson City, NY 13790 913.00
7 Richard C. Low, Esquire, 234 North Duke Street, P.O. Box 1533, Lancaster, PA 118.87
17608-1533 - Arbitrtation Fee (Re apportionemnt of insurance proceeds among
several competing claims)
8 United Health Services Hospitals, P.O. Box 5214, Binghamton, NY 13902 - Medical 37.11
Records
9 United Health Services Hospitals/Wilson Memorial Regional Medical Center, P.O. 18.575.90
Box 5214, Binghamton, NY 13902 - Hospital Services
10 United Medical Associates, 346 Grand Avenue, Johnson City, NY 13790 - 1.060.34
Physicians Services
TOTAL (Also enter on Line 10, Recapitulation)
42,328.34
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV-1513 EX+ (9.00)
SCHEDULE ..
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Dervisevic, Saha
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
FILE NUMBER
21-06-0919
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
I.
1
Lutvija Dervisevic
135 C. Street
Carlisle, PA 17013
Daughter
1/3 of
Residuary
Estate
2
Lutvo Dervisevic
524 3rd Street
Carlisle, PA 17013
Son
1/3 of
Residuary
Estate
3
Sejfudin Dervisevic
524 3rd Street
Carlisle, PA 17013
Son
1/3 of
Residuary
Estate
Total
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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)
/"
.. .
. ,
.-
SEJFUDIN DERVISEVIC, as
Administrator of the Estate of
SABA DERVISEVIC
530 2.d Street
Carlisle, PA 17013
Plaintiff
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYL VANIA
: CIVIL ACTION - LAW
v.
.
.
: NO. ~- Ci\lil1erf'f\
David A. Schriml
2713 Owego Road
Vestal, NY 13850
Defendant
ORDER
AND NOW, on this .3~ day of ..):1.", ~ ' 2014 upon consideration
of the foregoing Petition to Approve Settlement of Wrong Death and Survival Actions, it is
hereby ORDERED that the Petition be, and the same is, GRANTED. The settlement of lite
above-captioned matter in lite amount of two hundred fifty thousand ($250,000.00) dollars is
hereby APPROVED. It is further ORDERED and DECREED that the counsel for the Petitioner
is to distribute the settlement proceeds as follows:
1. Attorneys fees and costs:
a. To: Milovanovich & Espinosa, LLC,
(attorneys fees - personal injury action)
$ 83,333.33
b. To: Milovanovich & Espinosa, LLC,
(attorneys fees - estate administration)
$ 6,508.78
c. To: Milovanovich & Espinosa, LLC
(reimbursement of costs)
1,134.55
2.
Inheritance taxes on survival action proceeds:
a. To: Pennsylvania Department of Revenue
(to be escrowed pending preparation of inheritance tax return)
$(2,812.50)
3. Wrongful death and survival action proceeds ($156,210.84) to be distributed to:
a. Lutvo Dervisevic
$52,070.28
EXHIBIT
I If
. ..
- I
..
b. To: Sejfuclin Dervisevic
$52,070.28
$52,070.28
c. To: Lutvija Cehajic
TOTAL:
$
BY THE COURT:
/1/ v'1,~~ MI'
DISTRIBUTION LIST:
Nina Milovanovich, Esquire, (Milovanovich & Espinosa, LLC, 129 E. Orange Street, Suite 2,
Lancaster, P A, 17602)
Mary Altman (Encompass Ins. Co., 333 Glen Street, P.O. Box 5000, Glen Falls, NY 12801)
Lisa Staff (Allstate Ins. Co., P.O. Box 1064, Buffalo, NY 14240)
2
, .' -, .."
~.. r ~..,~ ....! ~.
wo ADDRESS www.state.Da.us
IluIlfAU OF INIllVlOUAL TAXES
INHERITANCE TAX DMslON
Po Box 280601
HAItRIs8URG. PI. 17121-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REvENUE
December 4, 2007
Nina Milovanovich, Esq.
Milovanovich & Espinosa, LLC
129 E. Orange St., Ste. 2
Lancaster, PA 17602
Re: Estate of-Saha Dervisevic
File Number. 2106-0919
Court Number. CCP Cumberland Co. No.
Dear Ms. Milovanovich:
The Department of Revenue has received the Petition for Approval of Settlement Claim to
be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action.
It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the
proceeds paid to settle the actions.
Pursuant to the Petition, the 60-year-old-decedent died as a result of a motor vehide
accident. Decedent is survived by her adult children.
Please be advised that, based upon these facts and for inheritance tax purposes only, this
Department has no objection to the proposed allocation of the net proceeds of 75% to the wrongful
death action and 25% to the survival action. Please be aware that the payment of Inheritance Tax
is not an allowable deduction for inheritance tax purposes, therefore we would agree to the
breakdown of the net aJlocation for this action, $119,267.51 to the wrongful death claim and
$39,755.84 to the survival daim. Proceeds of a survival action are an asset included in the
decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa. C.S.A.
S8302; 72 P.S. ~~9106, 9107. Costs and fees must be deducted in the same percentages as the
proceeds are allocated. In re Estate of Merrvman, 669 A.2d 1059 CPa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this
matter. As the Department has no objections to the Petition, an attorney from the Department of
Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has
any questions or requires anything additional from this Bureau. Finally, the approval of this
allocation is limited to this estate and does not reflect the position that the Department may take in
any other proposed distribution of proceeds of a wrongful death/survival action.
iince ely, '.
.10\<'(' {I ' ,.+ r. J/
-~-^' '" LCl:.A...-
oily A. M~lintock .; .
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes
PHONE: 717.787.1794 . FAX:
EXHIBIT
j /!;
. ntoc@state.Da.us
r:
CORNERSTONE
Federal Credit Union
P.O. Box 118/, 5 East Gate Drive, Carlisle, PA 17013
Telephone (717) 249-1661 FAX (717) 249-8208
www.comerstonefcu.coop
Member founded - Service based
November 13,2006
Milivanovich & Espinosa, LLC
129 East Orange Street, Suite 2
Lancaster, P A 17602
RE: ESTATE OF SAHA DERVISEVIC
To Whom It May Concern:
At the time of her death, Saha Dervisevic had a savings and money market account owned
jointly with Seifudin Dervisevic. Listed below is the information requested per your letter dated
October 23, 2006:
# 1. Account # 8728-01 savings and account # 8728-18 money market account.
#2. The saving was opened November 16,2001 and the money market account was opened
July 6,2005.
#3. There was no principal amount - Saha did not have a loan.
#4 Accrued interest for each of the above referenced accounts:
8728-01 - $10.01
8728-18 - $104.72
#5. The name on each account is Saha Dervisevic with Seifudin Dervisevic as joint owner.
#6. Account # 8728-01 became a joint account on November 20, 2003 and the money market
was joint at the time it was opened.
#7. There is no life insurance.
#8. Account balances at time of death
8728-01 - $2,336.66
8728-18 - $5,145.07
Saha did not have a certificate of deposit, loans, credit cards or safe deposit box with
CornerStone Federal Credit Union. If you require any additional information, please do not
hesitate to contact me at 717-249-1661 ext 240.
Sincerely,
~41t/;)>If;bJ
Donna J. MIckey - rJ
Financial Services Administrato j
EXHIBIT
/C-
MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED To $100,000 By THE NATIONAL CREDIT UNION ADMINISTRATION
COBLE-REBER
FUNERAL HOME, LTD.
208 NORTH UNION STREET MIDDLETOWN, PA 17057
Brendan J. McGlone, Supervisor (717) 944-7413
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
FIle " 41111
IV 1I1.....HlI.
Cad<etICoaIoiur.
l..r......aU.. o. Doc......
Nuao: Saba Dcrvisevic
D... orllcalb: $cplanbcrZ6,2GOll
SIt... AddIaI: $JG W SIteot
Cily: Carlisle
Slllr.~ Zip: 1701J
11lia A..-.em r....iIIIcd ill OIICIIJltiUlCC willa Soai.. 13.Z0A o(lIlc Rul..
IIld Re...loIioru alllla PcMyJnAia Slota Board .r,..,on! OUcclotl.
CIlatcca.... only ror m.. ilIllU 1bal )'Cll1Clec1ed Of IIIat .... "qWr.d.
Jt w. .... ......ind 'y law or 'r a ccmatal)' or erematory 10 UM uy ilems
_ will..pIaiA........... ia wriliac below.
I PROFESSIONAL SERVICES
Dalia s.m- alFuaaal D_ aad StaIr........................._...
5poQal Servicea .tFuaenl D_ aad StaIl'(Specify)
ElIIboImiaC
It you seloolcd a fuDaol .........y require -"Imin&. lUdl u a IIularal
willi vlewla&. you may bYe 10 poy ror 1llIbaImia,. You 40 oat ......
pay (or .1IIIlaIminJ )'OIl di4 DOlIIf'PI"YC i( you selcclocJ arraaC-
lUdl u a direCl enmatioa.r immediata .....L I( we cJwCed (ot
Olllllolmiq. we wig ..plaia ....y 1IeIow.
Odlcr l'RpaIalioD .r duo JIody
O....lasfCaakcIiD&" c..-lGIY............................._......
IhinllaaiDr--..................._.........._...................................
Saniluy Can. (TopicoI Dilia/'IIlion)....._...................._......
Other (speCiry)
SUBTOTAL: PrDr_.al s.m..
St4$.oo
11 onlER STAPF AND llELATED 'ACIUTIIS
Use .r PaciliU... $laIT, .... Equipmenl (00:
V'u1lalloft (vicwiq)......._..........._................._._.._......
F....nl.._.._.._............................._......................_..
Fiul Collllllillal (Ora_ide or .....)......_._.._................
M-w Scrvlce......._.__........._..............._.._..........
S"lIcrinc.r Jtaaaw....._...._._........_.._......_._.._......
Otber (SpooiCy)
SUBTOTAL. 01'" S..Il..... Rda.... ,..WUII
III 11tANSPORTAnON
TrlAlr... or.....una... (uncnI..........._......_..............._...
u.. .r:
Cub! CoadI (HatIe)....................-.._......_.....................
FlIOily l.iaIotuI8oIScv (7) '-c...................-............
Family VohiclcIFour (4)P_...................._............._...
PntI...ioMK:l~lilily TtallIpDIWion..............
0..... (Spedfy) Milcap
SUBTOTAl.: T..........'...
SUBTOTAL nJNE1lAL CHAJlGES (llIuu III)
$l10.oo
S110.oo
S3$O.oo
mo.oo
SI,715.oo
OmOHAL PACKAGED SUVlCES (lr.. .plio.... pacuc. llt'lioo is
Idoclad, ealeprico J . III an 00' appI~..)
I. D.... CRmoliool..........._.............__................................_
Z. IIIlOIIadialo 1IuriaI_......._.._.._............_..........._..
J.OIller:
SUBTOTAl.: 0pc/0I... P-cd Some..
$0.00
lEASON FOR EMI1ALMJNG:
( ) Filiiii)' audloriaa4 C ) Odlc"
PI" I at 2
EXHIBIT
I 4)
Vault:
Ea&lc. CoIlCllla I1ox, c-... Bwi.1 Vaul1
rn,.oo
Ura:
MeIlIorial Oroup-.............................._....................._............_......
Rqiallt BDDk............._......._.........................................._..._.......
Acbow............ Cardt........_......_.................._..._..._..._..
Memorial FoIdenIPrayer COrda......._............._....._..........._..........
CDlhiac_..._._........................................._........_...................
~ 1_ .rMotcbadisc.... SotYice
I. FIowcn
2.
3.
SUBTOTAL: 1110............ Olller Servlc..
$1'0.00 TOTAL FUNERAL CHARGES (llbru IV)
snuo
$1,<<0.00
S9S.00
V CASH DJ$8URSDlENT
Caa-,..-....-.......-...........-....................................................
Caaulory...........__................................._......................_......
CJoray IlIIdIar CIn&reIa............_......._........._..__................._..
OrclllilllSoloilllScaloa................_............._............._.............._.
PJatIllio.... P..lbearen................_......................._................._
Catifi. Copia otDcadl Cellifi_" PIIlIliI F..........._...........
IIcwo,.,., Noticca (Eltimala)
I.
Z.
J.
GnluitiCI........_.............._....................................................._..._
0Ih0t (Specify)
0IIler (Specify)
I. Commercial TraupcIIlIIliDII_..__..............._..._..............
Z. o..t.rTown Puocnl Oil'lClor..........._._..............._........
J. T....
4.
$.
-mu:m
UJS.oo
SUBTOTAL: Co.. D...u..........
TOTAL BSnllIA TE (I- V 4 ,......... 5.lYlc.)
563'.00
13,07$.00
SO.OO
IF ANY LAW. -.".r on......" ""lU- .....le'lUirocJ...
,........ a/'...,.r... itenu 1i.1Od ...... ........ Of "'lw....m' i.
dacri.... ........
( ) CrcIIIaIory......... ......i...1O IIlftOIIIIII ... ......i...
(X) Your........" lCCIWra 14 _ burial ....1Iincr.
( ) Odlor:
. DaY. pn:,... UI8 UJ9". tlI~\CUlClU CN TIIIICRI uoou aog .xl"'KCI
Selcctod:
Bmadaa J. "'cOlon. (PA)
II.... a/' Pncliu_... u.- ,
PO Ol4714L
~I......... as t.....u_
I...........avcd.copy .rIllaS_a" alFuaenl Ooocb aad
Servlca Sclllloll:
"lpaIUI'C 01 r_ IDUlllllVUllpmcIIU
UIII
Cue Wortu
IW"""""'''' UOCC""
rI. Salljt Silic: 5010 Leak.. St. Birob Bid..
SUCCI AddIaI
MooIwoicsloq PA 170U
.....,.
(717)4]9-1010
PIloae NIIIIlbcr
~uw
'"
IXlLANAnON O' PAYMENT ARRANGEMENTS
"II On"IIIIr"""""",, at.... COBLE.REBEIl FUNERA1. HOME, LTD.
.... ..Illy 10 loll. fWI rllllily IIIIII)' _y ..... you wiN. W. .....1hiI opporhoni\)' 10 IhaIIk YOlO ror" lII&Il ud
COIlf...... ..... you ...... p...... ill III.
11lc", on two IYJICI or elpcllSCl iDcumd in _iaA wiIb . IiulaaL
,.""'.... cosll c1i.bunomcaIs. ThOll.......... paid lei dWd panics""" u.... cemclay. clcrI)',lIcwspope1S.
TheIe III lioIcd ill Seclioo V orduo Swaaau or FlIIlOlal Ooodlllld $e",;... $eleclcd.
COBLE.REBEIl fUNEML 1l0ME. LTD. will rOlWllllIbo
po)'lllelll or cub cIis~.. tolllird partics Oil )IOIII'......r.1 00 o4cIiti-' _10 you. Howcvct, you mllJl
mob,.)'IlleIlI orlhcH.... c1i.lIuncmaIIts.lly.... or cbcdt llIIIy, prior 10.... CuaenI NMcc. Tbcsc cbuJa IRl NOT
OUARAHTEED,IIIlIIRl1lbjec\ 10 price chaIlces ..... IIIIY occur bctw_ date ofthi. Fu...... PwdlaM Ac-cm IIId tile
date or 1CIYicc. A Minell 111_ or octuaI....... will... ptoridcd ror such iIau Won lII.li..1 biU is pnICIIICd.
Second, III OUt pmrcssiollll clI&raa flit .... teMccs pctfonacd Of aoocb providelllly ....
I. ... elron to lIIIke IhiIlp u _ u po..ible rot YOU. .e o/fer the rollowin, opliolll ror.... ...ymena or
- pAlr.........1 wren-
.\. P.~ lly cull, eIlack. Visa.. MutaCard bel...... 01\.... oIay or.... r-I
suriee.
B. P.~ I/uoup the ...1.......... or"""'-c policy(icI) lhot .... lllaood SIOAdinI.
1.1IIe....... Ibat .... (a.,. _ orilla iluunIIu po\iey(ia).........."'IU'I
1M _I CuIIcnI cbataa. IMlIIllIICC ID1III lie paid 111I0Il" opIiaA" or D.
C. P.ymCIII ill Cull tIuou,b . prc-occd CuaenI trusI Aaod dablilhccl willi _ rw.-l
home. III lito .....ollhot 1M _ Ie ....IIUII fiIluI..... DOl .........._1
.....1tII.........II1. boI_... lie poid 1IIrou" opliou A. B.. D.
D, Crwcli1Ibwlcilll'.oiIablelllrou" .Famil)' Asli_.
No - .bicIo poymcal optioa you .dOCl, you III rapolllillle ror.... paymco1 orllle NoonI..peIlICS. It you
UIlidpalallw die rUllola tor lito CuIIcnI will be rcoiv04 rrom the......... _, you on ""1......10 pay ror Ill.
ruoenl aad .....leOkr~ from....CItate. IrYOll "'pcct Ilw.... oIhcr laIIlily III........ will_In'buto 10 .......)'IlIC'l1
or....luutaI "'_, you ore requiRd 10 poy tor.... r_lllId.... oollec\ r..... the..... family mom"",,.
11lc 'uoc",l Purcbuc ApccIIlOlll1Ct rOM below will'" si......lly '- (1) tamily _bon (th. "PuocAucr',.)
BolIl tamily _bon wiU..... ... rctpOIUiIllc rot.......... __ orllto ftulltll obUptioII incum:d
ill _iaA willi dlo III......
FUNERAL PURCHASE AGREEMENT
Pure....n .....10 purchase fiolD COBLE-REIlEll FUNERAL HOME, LTD.
("FUMnI Home"), whlcIl......1O provide ...... .... ...... II\d ..... ... Coni> on 111.511_ or
.1IIlCDI Oooola ODd Scnica SolecIcd ror 5011a DcrviICYic ,
Dcccuod, ill w _ or $J,ll7S.OO (.... .Pwdoaocr Price"), .hidl inc.... ..... dillluncJD..... or UJS.OO
Tloe ......... Price IholI be paid oallle oIay ar 1Ito..me.. I...... cwollllat .... Purchuc Price
is..... poid OIl .... day ot.... !uIIcroI....,icc. i_ .heIl...... OIl W......ld ...,....
ar dlc nlC or US% per mOlllll (IS% pet 1lIlIUIlI).
The -..." oclcAowIedp ODd .....lly ,ipia,lhiI F...",I Purchuc ...........~ the '-rei HOlIlll has ...
....ed ill ri.... III m. . claim"",1l 1Il.._ orthe ~ rl1llll.... ....................
Tbc ........... ..... ..... ill dlc __ lIlat ... F--' H...... i. ...uiRd 10 ....i1111\ artorI\Iy 10 coI~ ....
PuIdwo Price. or..y part thoreo(, .... Purca.....1holl lie rwopouilll.1O pay oIl_1lIc atlOrlleyl' tea,
ioclu4i1l1-" COI". iIIcuncd .y F....nl Ho_ 10 collcc. .... Purchuc Price.
The fUDe",1 Homa i. DOl W I\IIlIUrlClum or ony ,_ bcira,pwdwcd"""""". Accordi.sIy,.... F_ Home
diIcJ..... oil Wotnl\lia, &a_' or implied. or ..............iIiIy or 6_ tor a particular JI'IIIlOIC.
Bodo Purehaacn ...... to ... joiAlIy aad ......01 liebl. tor \he PO_I or,... Pwaue Pri..,.
Tbia FlIIlOlal Purchuc A........... COI\tai.u .... ..lire .......... ..._ .... Purdla.... ...d .... FIIIlCDI H......
aad COI\IOIbc naodiflell or -..dId uccpI ill . wriu.. a..u-.t .......lly ...... portia.
Thi. funeral Purchuc AarcancrM ......... billdill, upoll..... ran7"-. ...i&l\l aad paso.... rcptaoallli....
W. ..... reed aad .-ived . copy or......._ otFuoenI Oooda and Seovi.... w...... read aad ~ved . copy
or the 1!aplll\a1iAn or Pa)'I\ICIII AJrua- IlId........._ po,.- oplion " . We..... ICed IlId ceccived
· eopy of......_ or.... f-.l ......... ,,__ aad _10.... ....... ucIC01ldilio...
TOTAl FUNEML OiAROes 0 ...... IV)..._.............._........_.
Less Pre.p.ilI ..............._.............._.._._............._.............
Las OilCOUoII.............._.._...._._........_._...._..._.._...
BALANCE............._............._...................................................
PIu CallI 01........--....._..._........_......._...._...._.......
Less Dcpo'iL_..........._...._..._..........._......._.....................
ESTlMATE OF BAlANCE DUE.._...._..................._...............
p. Z of Z
12.410.00
soon
So.oO
12,410.00
WS.oo
1),07S.oo
SO.OO
COaLE-REllER FUNERAL "GMt:, LTD.
8y:
Pure.......
PNY bl_ c.......
000.00.000o
2G'J8-!) l..2: l~;'
>;
71:' 233S~3B
9'9W!Jl!JSaJ!.
--- - -- - ---- - -- -- -- -- - -..- -- -- - - - - - - - - --
........ 9..
5-; (:1
.'l.dc1,..,~:
C'<rl.!<
5243 Simpeon FenyRoed. Mwh~, PA 170SS. (717J 76E.5622
).1 'i - j- ~ 7 p I. -:- "1 / - ~ 'I
Dale:.
IJ e/, ytJ e v', C
~ . /) I."
..; ~ } ,.. ~.t,u.:..~
PIOj)o)sal submi!ted 10;
._"?~~Sl. _.__
D f!r'" i.S..~y",-'C .
PtoOtle;
)Cf!.fi
Name (Jf memorial:
,4
1 701 J
.lall.A Ci"; /
~~eruoria: C\ll15ultant
Name 0)( cemetery:'
CO"'"^!
..,.........9...~..f..................~._...~............**..
....................t........~........M....................~.
We heret.y submit ~-pecilica!inn~ (.:>r:
_ 3 l't. &(';1f
_-.!'!l ( 't\J!.l...:t{ I J 0 ~ J
fl~.~.LL~_~. __-'14.1
l(1 c.' \.L I'l j ___.., fill ~ r >. J~.
/1'l ~ n..- /,'If I
(} ra. ". 'I: of'
n .., f _... ,'ro~ I~ c/-e
('('* hl
. . I n C I..... J~
C 'wI ~ I'~
.................*...........................................
.................................4...........................
T1w above memoti8l is of the fine.: \liorkll'.anship. The ~OSI iU:lIIi~s m.:murilll. ll!tterinB and cem'l!~ tbll:Jlktion.
Fu:we Ictter.r1i is cllln..
3 r:.. (j r' ""~
"'" .",,,f .. (.J " ...,~" "", .." ",,,.
AUlilorizec signalure: Il!z:...:!__). __. . ___
ClISlomer signliture; _.~.~ /'] ~
/ .
~
tiJ
EXHIBIT
j E
F Iii