HomeMy WebLinkAbout04-14-08
REV-1500 EX + (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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SCHOCK
DATE OF DEATH (MM-DD-Year)
EVA
G.
DATE OF BIRTH (MM-DD-Year)
01/09/2008 12/08/1913
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[X] 1. Original Return
o 4. Limited Estate
[X] 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
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 oITrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1.95)
OFFICIAL USE ONLY
FILE NUMBER
2 1 -0 8 0 1 2 7
COuNTYCciiiE --VEAR- - - NuMBER- -
SOCIAL SECURITY NUMBER
1 64- 3 4 - 3 5 7 7
THIS RETURN MUST BE FilED IN DUPUCA TE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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:;tHISSEC110N MUST BE COMPLETED. AllCORRESPONDENCSANDCONFIDENTlALTAXtNFOR MATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
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)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subjectto Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
0.00 X _ (15)
309,431.99 X .045 (16)
0.00 X .12 (17)
51 ,572.00 X .15 (18)
(19)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> >. BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
419,523.62:
OFFICIAWUSE ONLY
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38,073.04
5,591.45
(11)
(12)
(13)
(14)
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456,240.47
43,664.49
412,575.98
51 ,572.00
361 ,003.98
0.00
13,924.44
0,00
7,735.80
21 ,660.24
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Dece ent's omplete ddress:
STREET ADDRESS
633 HOll Y HEIGHTS
CITY r STATE I ZIP
MECHANICSBURG PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
21,660.24
1.083.01
3. I nterestfPenalty if applicable
D. Interest
E. Penalty
Total Credits (A + B + C)
(2)
1,083.01
TotallnterestfPenalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check AGENT
0.00
0.00
20,577.23
20,577.23
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 0
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 0
c. retain a reversionary interest; or ...................................................................................................... 0 0
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?............................................................................................... 0 0
3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 0 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 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.
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. il is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FRill R URN DATE
(\
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ADDRESS
PA
ADDRESS
PA 17013
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 3%
[72 P.S. 99116 (a) (1.1) (ill,
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 0% [72 P.S. 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 dal,!ls 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 tlf the child is 0% [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 4.5%, 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 12% [72 P.S. 99116(a){1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX + (6-98)
'*
SCHEDULE B
STOCKS & BONDS
COMMQNWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHOCK
FILE NUMBER
21 08
0127
EVA
G.
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.
13.
14.
15.
16.
DESCRIPTION
ANCHOR FINANCIAL GROUP - ACCOUNT #08Z036777
AMERICAN FUNDS GR FND OF AMER F - GFAFX
199.69 X $32.65 = $6,519.75
ANCHOR FINANCIAL GROUP - ACCOUNT #08Z036777
DODGE & COX STOCK FUND - DODGX
47.40 X $133.43 = $6,324.45
ANCHOR FINANCIAL GROUP - ACCOUNT #08Z036777
MANAGERS FREMONT BOND FUND - MBDFX
637.53 X $10.72 = $6,834.34
ANCHOR FINANCIAL GROUP - ACCOUNT #08Z036777
REALTY INCOME CORP COM - 0
200 X $22.71 - $4,542.00
ANCHOR FINANCIAL GROUP- ACCOUNT #08Z036777
REALTY INCOME CORP MTH INCM SR NT - OUI
200 X $25.35 = $5,070.00
ANCHOR FINANCIAL GROUP - ACCOUNT #08Z036777
ROYCE LOW-PRICED STOCK FUND - SRVC CL - RYLPX
291.94 X $14.05 - $4,101.69
ANCHOR FINANCIAL GROUP - ACCOUNT #00052327310
JOHN HANCOCK FREEDOM PORTFOLIO
62.34 X $18.60 = $1,159.54
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
HERSHA HOSPITALITY TR
VALUE AT DATE
OF DEATH
6,519.75
6,324.45
6,834.34
4,542.00
5,070.00
4,101.69
1,159.54
57,138.75
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
BLACKROCK ENHANCED DIV ACHV TR
1,275.09
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
EATON VANCE TXMGD GL BUYWR OPP
19,350.84
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
FHLMC REMIC SERIES 2643
1,832.21
JANNETY MONTGOMERY SCOTT - ACCOUNT #7381-4775
FHLMC REMIC SERIES 2614
10,286.13
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
FHLMC REMIC SERIES 2627
3,669.45
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
BA MTG SECS INC 2003-5
10,059.64
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
GNMA REMIC TRUST 2004-16
3,936.46
JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775
FHLMC REMIC SERIES 2802
3,892.81
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
419 523.62
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Page 1
21 08 0127
File Number
SCHOCK
Decedent's Name
EVA
G.
Schedule B - Stocks & Bonds
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
17. JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775 1,005.03
FHLMC REMIC SERIES 2824
18. JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775 2,847.83
FHLMC REMIC SERIES 2844
19. JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775 19,769.23
FORD MTR CO CAP TR \I
20. JANNEY MONTGOMERY SCOTT - ACCOUNT #7381-4775 249,908.38
BLACKROCK INSD MUN INCOME TR
SUBTOTAL SCHEDULE B 273,530.47
GRAND TOTAL SCHEDULE B $ 419,523.62
REV-1508 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
SCHOCK
FILE NUMBER
EVA G. 21 08
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.
0127
ITEM
NUMBER
1.
2.
DESCRIPTION
ANCHOR FINANCIAL GROUP - ACCOUNT #08Z036777
BROKERAGE MONEY MARKET
1,925.47 X $1.00 = $1,925.47
PNC BANK - CHECKING ACCOUNT #5070098886
VALUE AT DATE
OF DEATH
1,925.47
3,915.37
3.
PERSONAL PROPERTY - APPRAISAL ATTACHED
1,676.00
4.
JANNEY MONTGOMERY - CASH ACCOUNT
1,200.01
5.
MESSIAH VILLAGE - GUARANTEED REFUND (COTTAGE)
28,000.00
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
36 716.85
REV-1511 EX + (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
SCHOCK
ITEM
NUMBER
A.
1.
2.
3.
4.
5.
6.
7.
8.
B.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
FILE NUMBER
EVA
G.
0127
21
08
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
S. GERALD WEAVER FUNERAL HOME
REV. MARLIN RESSLER
REV KEN ENGLE
REV ELDON BYER
RON SIDER
HALDY KEENER MEMORIALS - INSCRIPTION
CROWN EXCAVATING
WEST SHORE BIC CHURCH
911.48
75.00
75.00
75.00
75.00
125.00
225.00
100.00
16,700.00
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 247 ACORN ROAD
City MILLERTOWN
State P A
Zip 17062
Year(s) Commission Paid:
Attomey Fees IRWIN & McKNIGHT
17,450.00
Family Exemption: (If decedent's address is not the same as c1aimanfs, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
Probate Fees REGISTER OF WILLS
448.00
Accountanfs Fees
Tax Retum Preparer's Fees PATRICIA A. ROSENDALE, CPA
450.00
REGISTER OF WILLS - FILING FEE
CUMBERLAND LAW JOURNAL - ESTATE NOTICE
THE SENTINEL - ESTATE NOTICE
ROY GOTTSHALL - APPRAISAL ON REAL ESTATE
JOE McBETH - REIMBURSEMENT -Tfu\lfJ 1~"Vr.(~' fx \\;).)\~ (~liC"]' \J'I~
ROSCO SCHOCK - REIMBURSEMENT
JULIA FElTNER - REIMBURSEMENT
ALBERT F. SCHOCK, JR. - REIMBURSEMENT
H&R BLOCK - TAX PREPARATION
30.00
75.00
158.62
60.00
669.36
27.03
138.55
45.00
160.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
38 073.04
REV-1512 EX + (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHOCK
FILE NUMBER
21 08
EVA
G.
Include unreimbursed medical expenses.
0127
ITEM
NUMBER DESCRIPTION
1. MESSIAH VILLAGE - NURSING
2. PP&L - ELECTRIC
3. MCI - TELEPHONE
4. SPIRIT PHYSICIAN SERVICES - MEDICAL
5. ASSOCIATED CARDIOLOGISTS - MEDICAL
6. QUANTUM IMAGING - MEDICAL
VALUE AT DATE
OF DEATH
1.527.29
434.21
108.95
811.00
1,025.00
1,685.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
5 591.45
.",."" ex "*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
,...""'..,.....,......
NUMBER
1.
SCHEDULE J
BENEFICIARIES
FVA
r,.
FILE NUMBER
?1 OR
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
0127
AMOUNT OR SHARE
OF ESTATE
25% REMAINDER
25% REMAINDER
25% REMAINDER
51,572.00
12.5%
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
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a)(1.2)]
1.
EV AL YN S. LONG
10 LENOX AVENUE
WHEELING, WV 26003
JULlANNA G. HENRY
247 ACORN ROAD
MILLERTOWN, PA 17062
ALBERT F. SCHOCK, JR.
6328 WAYNE HIGHWAY
WAYNESBORO, PA 17268-9622
R. MARIE McBETH
PO BOX 135921
CLERMONT, FL 34713
Lineal
2.
Lineal
3.
Lineal
4.
Collateral
1.
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
CENTRAL CONFERENCE OF THE BRETHREN IN CHRIST CHURCH
C/O JULlANNA HENRY, 247 ACORN ROAD
MILLERSTOWN, PA 17062
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
(If more space is needed, insert additional sheets of the same size)
51,572.00
$
51 572.00
LAST ~VILL AND TESTAMENT
I, EVA G. SCHOCK, of Upper Allen Township, Cumberland County, Pennsylvania,
realizing the uncertainty of this life, but with confidence in God and trust in His Son, my Lord
and Savior, Jesus Christ, who died for my sins upon the cross and rose again to redeem me and
give me eternal life, do hereby make, publish and declare this instrument to be my Last Will and
Testament, hereby expressly revoking all prior Wills and Codicils made by me.
I. I direct my Executrix to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my Executrix to sell any realty owned by me at my death,
and not specifically devised herein, at either public or private sale, and to give good and
sufficient deeds therefor, in fee simple, as I could do if living.
3. I direct that all estate and inheritance taxes that may be assessed in consequence of my
death shall be paid out of the principal of my general estate to the same effect as if said taxes
were expenses of administration, and all property includable in my taxable estate, whether or not
. .
passing under this Will, shall be free an,d c.lear thereof.
4. I intena to keep wi~h this' my Will a separate memorandum concerning disposition of
certain items'oftangible personal property. I bequeath the items on said list to the persons
designated.
5. Any money owed to me by any of my children, according to a list kept with my Will,
shall be deducted from that child's share and be divided equally between my three (3) children,
share and share alike.
6. All the rest, residue and remainder of my estate of whatever nature and wherever
situate, I devise and bequeath as follows:
a. Twenty-Five Percent (25%) unto my daughter, EV AL YN S. LONG, /
or her issue, per stirpes;
b. Twenty-Five Percent (25%) unto my daughter, JULIANNA G. .
HENRY, or her issue, per stirpes;
c. Twenty-Five Percent (25%) unto my son, ALBERT F. SCHOCK, JR.,/
or his issue, per stirpes;
d. Twelve and One-Half Percent (12 1/2%) unto my foster daughter,
MARIE McBETH, or her issue, per stirpes; and
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e. Twelve and One-Half Percent (12 1/2%) unto the fiw (5) churches
in the CENTRAL CONFERENCE OF THE BRETHREN IN CHRIST
CHURCH in Kentucky in memory of Albert and Marie Engle. My Executrix
shall determine what amounts shall be distributed to each church in her
absolute discretion.
7. I nominate and appoint JULIANNA G. HENRY to be the Executrix of this my Last
')
Will and Testament; she is to serve as such without bond. Should she die before my death,
renounce or refuse to serve for any reason, or die leaving any of my estate unadministered, I
nominate and appoint EV AL YN S. LONG and ALBERT F. SCHOCK, JR. as substitute
Executors, also to serve as such without bond, with the same powers as are given herein to my
Executrix.
6. I hereby suggest that my personal representative retain the servIces of Irwin &
McKnight as attorneys in the settlement of my estate.
IN WITNESS \VHEREOF, I have hereunto set my hand and seal this
~~
~, 2005.
D-~
c: day of
L/{<H /~C2(MJ" (SEAL)
EVA 'G. SCHOCK
Signed, sealed, published and declared by EVA G. SCHOCK, the above-named
Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request, in
her presence and in the presence of each other have subscribed our names as witnesses hereto.
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ACKNOWLEDGMENT A~^lDAFFIDAVIT
WE, EVA G. SCHOCK, MARTHA L. NOEL and SHARON L. SCHWALM, the
Testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and
executed the instrument as her Last Will and Testament, that she had signed willingly, that she
executed it as her free and voluntary act for the purpose herein expressed, and that each of the
witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to
the best of their knowledge the Testatrix was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.
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EVA G.SCHOtK '
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~ MARTHA L. OEL
l,,(':(/') /. :' { .,."( .'~'1Z /-'/." I,f:.t<.;.....-
SHARON L. SCHWALM
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by EVA G. SCHOCK, the Testatrix
herein, and subscribed and sworn to before me. by MARTHA L. NOEL and SHARON L.
SCHWALM, witnesses, this ,e: day of fJiu.ity, 2005.
/'//ll,ui "-3 . d11~
t7ry Public
A
415 Fallm\lield Rei
STE 300
Camp Hill, PA 17011-4906
1857 William Penn Way
STE 202
Lancaster, PA 17601..6741
717-975-0509
800-377-3097
717-975-0587 Fax
February 12, 2008
www.anch\)rfinancialgr\)lIp.com
anc hon (/ a nc hort] nancia I gWlI p. com
Irwin & McKnight
Roger B. Irwin
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, P A 17013-3222
RECEIVED
fFEB 1 3 2008
RE: Estate of Eva G. Schock
Dear Mr. Irwin:
IRWIN & McKNIGHT
LAW OFFiCES
This letter is in response to your request for information on the above named deceased.
Mrs. Schock did have an account with Anchor Financial Group. The following is a list of
answers pertaining to your questions:
1. The registered owner of the account was Eva G. Schock. It was an individual
account.
2. The account was established on 07/12/2002.
3. There was never a change of ownership on this account.
4. No accounts have been closed.
5. This account is a brokerage account and will remain invested until instructions
have been received from the Estate. This account may need to be reregistered as
an Estate account. The account value will fluctuate with the market on a daily
basis.
6. The attached Holdings by Investor lists the balance as of the date of death.
Please feel free to contact Nelson or me with any further questions. Thank you.
Best Regards,
~"'\ .
( L-t_v,,-,,-/'~C:.
Denise K. Wurster
Director of Client Relations
Ene: Holdings by Investor
Solid Advice from Trusted Advisors
Securities and Advisory Services offered through Multi-Financial Securities Corporation. Member: FINRA*SIPC
Anchor Financial Group is not affiliated with Multi-Financial Securities Corporation
Ho.ldings by Ir .\lr
Eva G Sr;hock
633 Ho,;y Heights
Mechanicsburg, PA 17055
L. Nelson Wingert & Michael Howard
Anchor Financial Group
415 Fallowtield Rd.
Suite 300
Camp Hill, PA 17011
717-975-0509
Combined Account Portfolio
Date: 01/09/2008
Created: 02/07/2008
Eva G Schock
Acct Name: EVA G SCHOCK 633 HOLLY HEIGHTS MECHANICSBURG PA 17055-6178
Acct No:08Z036777
~K~al11e
AMERICAN FUNDS GR FND OF
AMER F
BROKERAGE MONEY MARKET
Ticker Asset Type
GFAFX EQUITY
CASH OR
EQUIVALENTS
DODGE & COX STOCK FUND
DODGX EQUITY
MANAGERS FREMONT BOND FUND MBDFX FIXED INCOME
REALTY INCOME CORP COM 0 EQUITY
REALTY INCOME CORP MTH INCM OUI EQUITY
SRNT
ROYCE LOW-PRICED STOCK FUND RYLPX EQUITY
- SRVC CL
Mgt. Name
AMERICAN
FUNDS
BROKERAGE
MONEY
MARKET
DODGE & COX
FUNDS
MANAGERS
SURPAS
ROYCE FUNDS,
THE
Quantity
199.69
1,925.4 7
47.40
637.53
200.00
200.00
291.94
Account Total:
Acct Type: Individual
Prlce($) Value($)
32.65 6,519.75
1.00 1,925.47
133.43 6,324.45
10.72 6,834.34
22.71 4,542.00
25.35 5,070.00
14.05 4,101.69
$35,317.70
Acct Name:JOHN HANCOCK FREEDOM 529 EVA G SCHOCK FBO SEAN ALBERT SCHOCK 633 HOLLY HTS
MECHANICSBURG PA 17055-6178
Acct No:00052327310
~~t"e):
"w~>"
PORTFOLIO 2017-2020C2
Ticker
Asset Type
BLEND
Mgt. ""srne
JOHN
HANCOCK
FREEDOM 529
Acct Type: Spac - Imf Group Single Pymt
Quantity Prlce($)
62.34 18.60
Account Total:
Investor Total:
1,159.54
$1,159.54
$36,477.24
Incomplete if presented without accompanying disclosure page
Page 1 of 2
Estate Valuation
Date of Death: 01/09/2008
Valuation Date: 01/09/2008
Processing Date: 02/25/2008
Estate of: Eva Goodin Schock
Account: 7381-4775
Report Type: Date of Death
Number of Securities: 14
File ID: Eva Goodin Schock DOD 010908
Shares Security Mean &/or Div & Int Security
or Par Description High/Ask Low/Bid Adj'ments Accruals Value
1 ) 6750 HERSHA HOSPITALITY TR (427825104 ; HT)
SH BEN INT A
American Stock Exchange
01/09/2008 8.65000 8.28000 H/L
8.465000 57,138.75
0.18 E 01/02 R 01/05 P 01/16/08 1,215.00
2)
114
BLACKROCK ENHANCED DIV
COM
New York Stock Exchange
01/09/2008 11.29000
ACHV TR (09251A104; BDJ)
11.08000 H/L
11.185000
1,275.09
3)
1128 EATON VANCE TXMGD GL BUYWR OPP (27829C105; ETW)
COM
New York Stock Exchange
01/09/2008 17.35000 16.96000 H/L
17.155000
19,350.84
4 )
15000 FHLMC REMIC SERIES 2643 (31393WKN8)
Financial Times Interactive Data
Mat: 02/15/2032 5.000% Fact: 0.12473592
01/09/2008 97.92461 Mkt
97.924610
1,832.21
CMO Accrual
2.08
5)
43000 FHLMC REMIC SERIES 2614 (31393QNB4)
Financial Times Interactive Data
Mat: 05/15/2033 5.500% Fact: 0.24573488
01/09/2008 97.34574 Mkt
97.345740
10,286.13
CMO Accrual
12.91
Page 1
This report was produced with EstateVal, a product of Estate Valuations &
Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for
accuracy or completeness of the information provided, the Date of Death and the
specific securities, which are valued. While we deem this information to be
reliable, we do not warranty or guarantee its accuracy. This service is not
intended to constitute legal or tax advice. You should consult with your tax
professional and attorney to discuss estate settlement and any legal matters.
Date of Death: 01/09/2008
Valuation Date: 01/09/2008
Processing Date: 02/25/2008
Estate of: Eva Goodin Schock
Account: 7381-4775
Report Type: Date of Death
Number of Securities: 14
File ID: Eva Goodin Schock DOD 010908
Shares
or Par
Security
Description High/Ask Low/Bid
Mean &/or Div & Int Security
Adj'ments Accruals Value
6)
4000 FHLMC REMIC SERIES 2627 (31393V3L3)
Financial Times Interactive Data
Mat: 06/15/2033 5.000% Fact: 1
01/09/2008 91.73619 Mkt
91.736190
3,669.45
CMO Accrual
4.44
7 )
12000
SA MTG SECS INC
Financial Times
Mat: 07/25/2033
01/09/2008
2003-5 (05948XLW9)
Interactive Data
5.750% Fact: 0.8940643
93.76319 Mkt
93.763190
10,059.64
CMO Accrual
13.71
8 )
4000 GNMA REMIC TRUST 2004-16 (38374FHHO)
Financial Times Interactive Data
Mat: 02/20/2034 5.500% Fact: 1
01/09/2008 98.41140 Mkt
98.411400
3,936.46
CMO Accrual
4.89
9 )
10000 FHLMC REMIC SERIES 2802 (31394YLZ5)
Financial Times Interactive Data
Mat: 05/15/2034 5.250% Fact: 0.4033806
01/09/2008 96.50454 Mkt
96.504540
3,892.81
CMO Accrual
4.71
10)
5000 FHLMC REMIC SERIES 2824 (31395AY58)
Financial Times Interactive Data
Mat: 07/15/2034 5.500% Fact: 0.2065065
01/09/2008 97.33616 Mkt
97.336160
1,005.03
CMO Accrual
1. 26
Page 2
This report was produced with EstateVal, a product of Estate Valuations &
Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for
accuracy or completeness of the information provided, the Date of Death and the
specific securities, which are valued. While we deem this information to be
reliable, we do not warranty or guarantee its accuracy. This service is not
intended to constitute legal or tax advice. You should consult with your tax
professional and attorney to discuss estate settlement and any legal matters.
Date of Death: 01/09/2008
Valuation Date: 01/09/2008
Processing Date: 02/25/2008
Estate of: Eva Goodin Schock
Account: 7381-4775
Report Type: Date of Death
Number of Securities: 14
File 10: Eva Goodin Schock 000 010908
Shares
or Par
Security
Description High/Ask Low/Bid
Mean &/or Div & Int Security
Adj'ments Accruals Value
11)
3000 FHLMC REMIC SERIES 2844 (31395EV20)
Financial Times Interactive Data
Mat: 08/15/2034 5.500% Fact: 1
01/09/2008 94.92781 Mkt
94.927810
2,847.83
CMO Accrual
3.67
12)
631 FORD MTR CO CAP TR II (345395206)
PFD TR CV6.5%
New York Stock Exchange
01/09/2008 31.66000 31.00000 H/L
31.330000
0.8125 E 12/27 R 12/31 P 01/15/08
19,769.23
512.69
13)
16710.635 BLACKROCK INSD MUN INCOME TR (092479104; BYM)
COM
New York Stock Exchange
01/09/2008 15.01000 14.90010 H/L
14.955050
249,908.38
14)
1200.01 Cash (CASH)
1,200.01
Accrual
1.13
Total Value:
Total Accrual:
Total: $387,948.35
$386,171. 86
$1,776.49
Page 3
This report was produced with EstateVal, a product of Estate Valuations &
Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for
accuracy or completeness of the information provided, the Date of Death and the
specific securities, which are valued. While we deem this information to be
reliable, we do not warranty or guarantee its accuracy. This service is not
intended to constitute legal or tax advice. You should consult with your tax
professional and attorney to discuss estate settlement and any legal matters.
Mar.21. 2008 4:36PM
PNC BANK 412-705-2747
No. 1363. P. 1
Q PNCBAN<
March 21,2008
Irwin &, McKnight
West Pomfret Professional Bldg
60 West Pomftet Street
Carlisle, PA 17013-3222
RE: Estate of Eva G Schock
SSN: 164-34-3577
DOD: 01/09/2008
Dear Mr Irwin:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Checking Account
Account #5070098886
Established 05/03/1988
EVA G SCHOCK
DOD balance: $3,915.37 + 0.00 accrued interest (non interest bearing)
Please note that this office only provides date of death balances for deposit accounts
(lRAs, CDs, Checking and Savings accounts). We do not process any financial
transactions or provide statements. If you need assistance with any of these items,
please call1-888-PNC-BANK (1-888-762-2265) or stop by your local me Bank branch
office.
~SDu:ere~, A ____r
m Garzo~
1-8 0-762-1775
Firstside Center
SOO First Ave. 4lb Floor
Pittsburgh PA 15219
Member FDIC
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Apr 04 08
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Messiah
Village
717 795 5566
p.2
~~~~jah
Cont;'lIIing Care Reti;"emmt Services - Founded 1896
March 24, 2008
Julianna Henry
247 Acorn Rd.
MilIerstown, P A 17062
Dear Ms. Henry:
I am writing to you concerning the refund due for the cottage occupied by Eva Schock at 633
Holly Heights, Messiah Village.
The acquisition fee paid for the unit in April 1985 was $56,000.00. The agreement was
terminated March 11, 2008. Fifty percent of the acquisition fee was amortized over 108 months
leaving a refund in the amount of $28,000.00 (see enclosed amortization schedule).
The payment of the refund will take place in six months or after the unit is acquired by another
resident, whichever comes first.
If you have any questions regarding the refund, please call me at (717) 591-7204.
Sincerely, ,
rn It.ilJJJ. rruj0cll {hewn
Michele Maglich Brown,
Director of Financial Operations
Enel.
! 00 M r. Allen Drive. Mechanicsburg, PA 17055-6100
(i 17) 697-4666 . Fax (717) 790-8200 . ww\v.messianvillage.org
r ~ L _ __ _. _ _ T. r
ResIdence :
Woodbury, PeDDSylvama
S. Gerald Weaver Funeral Home
Woodbury, PeDI18ylVBDia. 16695
Sheldon H. Weaver, Supervisor
Telephone:
Loysburg, (81") 766-263'i
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will
explain in writing below. ,:
If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming
you did not approve if you. selected arrangements such as a direct cremation or immediate burial. If we charged for embalmi~g, "fe will explain why below.
For the Service of I,;VI\ G. SCHOCK DateofDWu'09/0d
Charge to:
E;,;Tl\Ir;:
Name
Address
City
Other clothing
State
A. CHARGE FOR SERVICES SELECTED:
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff . . .. S ~
Embalming. . . . .. . . . . . . . . .. .. . . .. s-1.1.L
Other preparation of body
Dressing & Cosmetology 155
Sanitary Care C\ Cj
SUB-TOTAL OF 'PRoiESSIONAi: SERVI~~.... Al $~
2. FACILITIES AND SERVICES
Use of facilities and services for
viewing (VisitationlWake)......... $~
Use of our fucilities or 42
church service ceremony. . . . . . .. .-L
Use of facilities and services for
Memorial Service ............... .-
Use of equipment and services
for graveside service............. .-
Other use of facilities
.-
.-
.-
Cremation urn . . . . . .
(Description)
r
.-
.-
.- ~l~:d.,,(;
TOTAL MERCHANDISE SELECTED. . . . . . . . . . . . . . . . . . B '_' .
C. SPECIAL CHARGES:
Forwarding of remains to
OTHER
.-
~
(Funeral Home)
Receiving of remains from
.-
................................-
SUB-TOTAL OF FACIUTIESIEQUlPMENT........... A2'
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home.
Local. . . . . . . . . . . . . . . . . . . . . . . . . .. ..-ill-
Hearse (Casket Coach)
Local. . . . . . . . . . . . . . . . . . . . . . . . . .. $~
Limousine
Local. . . . . . . . . . . . . . . . . . . . . . . . . .. .~
Family car (
Local. . . . . . . . . . . . . . . ... . . . . . . ... ._
Flower car or floral disposition
Local........................... $~
1)0.,
f
;
(Funeral Home)
Immediate Burial. . . . . . . . . . . . . . . .. ._
Direct Cremation. . . . . . . . . . . . . . . . . ._
.-
SUB.TOTAL OF SPECIAL CHARGES................ C'_
, D. CASH ADVANCED
Opening Grave .................. ._
Cemetery Equipment. . . . . . . . . . . . .. ._
Lot and Deed. . . . . . . . . . . . . . . . . . . . ._
Newspaper Notices-Local . . . . . . . .. ._
Newspaper Notlces-Out.of.town. . . . . .-'..L1...,,-.Y ("
Telephone & Telegrams........... ._
Airfare. . . . .. . . . . . . . . . . . . . . . . . .. ._
ClergylMass Offering. . . . . . . . . . . . . . ._
Pallbearers. . . . . . . . . . . . . . . . . . . . .. ._
I \ Certified Copi~s of the Death
~', ,.l :4/' iV )( IS
71 Certificate .. L .. .. . ~ .. .. \, .. .. .. . ~
t ' Police Escort. . . . . . . . . . . . . . . . . . . . s_
Flowers ............. . . . . . . . . . . . S
Vault Service Charge. . . . . . . . . . . . ... I !>O
\...1 ^ .c.j~" - ~C'~
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.
.
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Econo Lodge (SC148)
1145 Sniders Hwy.
Walterboro, SC 29488
(843) 538-3830
gm.SC 148@choicehotels.com
Econo
Lodge
~
BY CHOICE HOTELS
MCBETH, JOSEPH
PO BOX 871
CHAMBERSBURG, PA 17201
Post Date
Description
2/24/08
Visa Payment
Account: 113143441
Date: 2/25/08
Room: 117 Rack
Arrival Date: 2/24108
Departure Date: 2/25/08
Frequent Traveler 10:
You were checked out by:
You were checked in by:
Total Balance Due: 0.00
Amount
(41.06)
2/24/08
2/24/08
2/24/08
2/24/08
Room Charge
State Tax
City / County Tax
Sales / Mise tax
XXXXXXXXXXXX7371
#117 MCBETH, JOSEPH
STATE TAX
CITY/COUNTY TAX
SALES/MISC TAX
36.99
1.11
0.74
2.22
Room Charge
State Tax
City / County Tax
Sales / Mise tax
Visa Payment
Rack is eligible for partner rewards. If this rate is changed, you may no
longer be entitled to partner rewards.
.,..,.,;t_......,ii><:..,
BUDGET INN-GOLDROCK
7531 NC Hwy 48.1-95 Exit 145 . Battleboro. NC 27809
Telephone: 252-977-3505 . Fax: 252-977-7705
NAME .5 0 _ S t P /-! tu. 11,-'7 c 1-:; L:: j /I
STREET l? C. . I 3(~ X '>?' '7 J
CITYC II /? >; f, I: J'."; ;:>(./)' b-- STATE p,ll.
I
DRIVERS LICENSE NO. / t :<: '/ '/ ().5 2.
CAR TAG NO.
ZIP /72'0 I
,
iC'j 11
STATEr if
NO. IN PARTY :2-
~i"
NOllCE TO GUESTS-ThIs property is a privately owned and management reserves ~t to
refuse serviCe to anyone. and win not be responslble fer accidents or injury to guests or losS
of money. jewelry. or voluables of ooy kind.
Date 0;; / /7 6 >'Ie Room J ;;{;:;) Total S
OMC )J1isa AEX TOx (if any) S
ODD Cash T otel Amount paid
S
$
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Check out at 11:00 a.JI1., ,
Payment In full at Registr}.tlnn.
Signature ~ ~.,.."'~ -:J
,.. ,i t
i.
36.99
1.11
0.74
2.22
(41.06)
Balance Due:
0.00
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THE VALID AND COLLECTIBLE L1ABIUTY INSURANCE AND PE SONAL INJURY
X.OENT -.SCRATCH PROTECTION INSURANCE OF ANY AUTHORIZED-RENTAl; OR LEASING DRIVER PAID BY
F OUT E 1/8 1/4 3/8 1/2 518 314 7/8 F IS PRIMARY FOR THE LIMITS OF LIABILITY AND PERSONAL INJURY PROTECTION
~ COVERAGE REQUIRED BY FLORIDA STATUTE SECTION 324.021(7) AND FLORIDA RECEIPT OF .
L IN E 1/8 114 3/8 1/2 5/8 314 7/8 F STATUTE SECTION 627.736. CASH REFUND,
OWNER IS AN AFFILIATE OF ENTERPRISE RENT.A-CAR COMPANY, WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS, @ ENTERPRISE LEASING COMPANY OF ORLANDO, 21
.terprisel
CUSTOMER COPY
,
lWNER OF VEHICLE:
BRANCH ADDRESS:
MilE-
AGE
----------PHON-e---ex;::-----
REFERENCE NUMBER:
o
ADDITIONAL AUTHORIZED DRIVER(S) . EXCEPT AS REQUIRED BY LAW, NONE PERMITTEQ WITHOUT OWNER'S WRITTEN
APPROVAL. . . 1:. ' . ...,
I RE T OWNER'S PERMISSION TO ALLOW
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OUT E 1/8 1/4 3/8 112 518 3/4 7/8 F
C;aso%;ne
IN E liB 114 318 1/2 5/8 3/4 718 F
OPERATION IN ANY OTHER STATE OR COUNTRY WILL AFFECT YOUR LIABILITY AND RIGHTS UNDER THIS AGREEMENT.
RENTER DECLINES OPTIONAL DAMAGE RENTER ACCEPTS OPTIONAL DAMAGE /
WAIVER (OW) AND ASSUMES DAMAGE WAIVER (DW) AT FEE SHOWN IN COLUMN ~: X )
RESPONSIBILITY. SEE PAGE 2, PARAGRAPH 6. TO RIGHT. SEE OPTIONAL PRODUCTS .";;-/' /1,11\.
NOTICE TO LEFT AND PAGE 3, .):: \ / r' ,-.
PARAGRAPH 16. OW IS NOT INSURANCr \,./.f-!:,:: > "./.,
COLOR
OPTIONAL PRODUCTS NOTICE:
WE OFFER FOR AN ADDITIONAL
CHARGE THE FOllOWING OPTIONAL
PRODUCTS: DAMAGE WAIVER;
PERSONAL ACCIDENT INSURANCE;
AND SUPPLEMENTAL LIABILITY
PROTECTION. BEFORE DECIDING
WHETHER TO PURCHASE ANY OF
THESE PRODUCTS, YOU MAY
WISH TO DETERMINE WHETHER
YOUR PERSONAL INSURANCE OR
CREDIT CARD PROVIDES YOU
COVERAGE DURING THE RENTAL
PERIOD. THE PURCHASE OF ANY
OF THESE PRODUCTS IS NOT
REQUIRED IOJiENT VFHIClE
/ ". .~~,
BE!iIEB: X
RENTER DECUNES OPl1ONAL PERSONAL
ACCIDENT INSURANCI!'<!,A1) 11 ,1/'
! U,l- Vr I
~ . -~
RENTER ACCEPTS OPTIONAL PER. ..
=~~g~~~~~~U~~~~(PAl) />. ~;X '\
RIGHT. SEE OPTIONAL PRODUC~S.. ....... ..... /..1
NOTICE TO LEFT ANO PAGE 3, p. '. -6
GRAPH 18. ; " . ..' ,;.,. /..
-"-
RENTER ACCEPTS OPTIONAL SUPPLE.
MENTAL LIABILITY PROTECTION (SLP) AT
FEE SHOWN IN COLUMN TO RIGHT SEE
OPTIONAL PRODUCTS NOTICE TO LEFT
AND PAGE 3, PARAGRAPH 17.
.
.
,
REF' CEMENT VEHICLE
MODEL
ECAR#
MilE-
AGE
IN
OUT
ADDITIONAL INFORMATION
DRIVEN
CONDITION AND FUEl X
LEVa- AGREED TO RENTER
o
'SC REC IS THE FLORIDA STATE RENTAL CAR SURCHARGE AND THE
WASTE TIRE AND BATTERY RECOVERY SEE PAGE 2, PARAGRAPH 3.C.B.
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TOTAL CHARGES
DEPOSITS
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17<-(,3~
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REFUNDS
AMOUNT DUE ~
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CLOSED BY
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IHess #760
mtanta. VA
# 0000000
02/24/08
01:43PM
09603B
Hess 38257
1878 Lincoln Hwy
Chambersburg,PA17281
--------------------
t #
****7371
e 11/09
2/23/88 7:18 PM
Term: JD42251478881
Appr: 858548
Seqtt: 888781
PUMPtt 12 CREDIT.I
Unl Regula@ $3.899/G
VOLUME 5.16 GAL
I Ions
. 131
P r ice
$3.039
D
Amount
$27.75
GAS TOTAL $16.88
Visa
XXXXXXXXXXXX7371
82/23/2888 19:17:85
Ie
$27.75
Nice Day!
ink & Drive
I agree to pay the
above Total Amount
according to Card
Issuer Agreement.
THANK YOU FOR
SHOPPING AT HESS
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OWNER-6F VEHICLE: \ '~Ja' . :"
BRANCH ADDRj:;SS: .
START CHARGES IF DIFFERENT
ORIGINAL VEHICLE
,Gqt.PR
.UCE.N,gNO.
" MOOEL
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MILE.
AGE
DRIVEN
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5/8 314 71B F
()IIt,ffiOfFERS,FOR
AOOmCWIL CHARGE, N3 OPTIONAL S: llM'AGE WIWER
(OW); PERSONAl ACCIDENT INSUR#JCE (PAl); AND SUPPlEMENTAL
LLABILI1l' PROTECTION ISlP). THESE ARE DESCRIlED IN DETAIL
ELSEWHERE IN THIS AGREEMENT. THESE ARE OI'TIOOAL PROOUClS
ICH !lAY DUPlK:ATE COVERAGE I ALREADY HAVE THROUGH MY
OWN INSURANCE POLCIES OR MY CREDIT CARD. I AM NOT REQUIRED
TO PURCHASE THESE PROOUCTS IN ORDER TO RENT A Y&lIClE FROM
OWNER
BEFORE DECIDING WHETHER TO PURCHASE
THESE OPTIONAL PRODUCTS I MAY WISH TO EXAMINE MY
INSURANCE POLICIES OR CREDIT CARD AGREEMENT, OR I MAY
WISH TO CALL MY INSURANCE AGENT OR CREDIT CARD COMPANY.
TO DETERMINE WHETHER THEY PROVIDE COVERAGE FOR
DAMAGE TO A RENTAL VEHICLE OR FOR LOSS OR INJURY CAUSED
OR SUFFERED BY ME.
PENNSYLVANIA LAW REQUIRES OWNER TO
BEAR CERTAIN MINIMUM FINANCIAL RESPONSIBilITY FOR ITS
VEHiCLES. OWNER IS SELF.INSURED FOR THIS RESPONSIBILITY.
WHICH DOES NOT CONSTITUTE LIABILITY INSURANCE FOR ME
THE RENTER, OR FOR ANY PASSENGER.
IF I ELECT TO PURCHASE ANY OPTIONAL
INSURANCE PRODUCT OR OW, I MAY ELECT TO CANCEL MY
PURCHASE AT ANY TIME DURING THE RENTAL BY BRINGING THE
CAR AND MY COPY OF THE CONTRACT TO ANY ENTERPRISE RENT.
.CAR BRANCH DURING BUSINESS HOURS AND AGREEING IN
ITING TO MODIFY THE CONTRACT I WILL NOT BE CHARGED
FOR THE CANCELLED ~ECTIONS BEYOND THE DAY OF
CANCElLATION. 1': /" :
RENTER: ~' r
REP MENT VEHICLE
LiCENSE NO.
MODEL
ECAR#
MILE.
AGE
IN
OUT
DRIVEN
CONDITION AND FUEL X
lEVEL AGREED TO
RENTER
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F OUT
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L IN
E 11B 114 31B 172' ~'B 3/4 7/B F
INVOICE
ATTN:
PHONE
EXT.
REFERENCE NUMBER:
~~~~~~~~~~~~~~IZED DRIVER(S) . EXCEPI.1}~ RE?Y\F,l}~~Y ';^W:N2j'lE p~Y~ 'f\TfiOUT OWNERS
I REQUeST OWNER>S PERMISSION TO AllOW
. , . . ~l~""~f~~ .
I -. __~ J I ~ _ t :..~"_'". . .J.J,_ . .&"., ,'" ...JJ._-. .
-~ .~.r':-" .~.::A.-;r -~.r;:-~'~:::~:r .~./~-.. _".~::A.-:; -:.~~-....-:
WHO IS UNDER MY CONTROL AND DIRECTION TO DRIVE VEHICLE FOR ME AND ON MY BEHALF. I AM RESPONSIBLE FOR THEIR
C~~SO~~~~I~t~Y ARE DRIXLNT~t~Str?~~~~~~:~E J~~~ ~~DL~~~LW~I~~g 2~~~ ~~~~~LT~~:~~~~~~~~REEMENT)
1>'1. n
OPERATION IN ANY OTHER STATE OR COUNTRY WILL AFFECT MY LIABILITY AND RIGHTS UNDER THIS AGREEMENT.
RENTER DECLINES OPTIONAL DAMAGE RENTER ACCEPTS 0fJ110NAL DAMAGE WAIVER (DW) AT FEE SHOWN
WAIVER (DW) AND ASSUMES DAMAGE IN COLUMN TO RIGHl\ SEE OPTIONAL PRODUCTS NOTICE TO LEFT
RESPONSIBILITY. SEE PAGE 2. PARAGRAPH 6. AND PAGE 3, PARAGRAPH 16. OAMAGE WAIVER IS NOT INSURANCE.
&ill:EB; X
#/
DATE
EMPL.
#
~PAID BY
~~"~~~
J 1 (_:l~ i .. :,)(t .=..': "_ ,f .,;_:l =. '~ !--:.'::'
, : T.:..;..t; ~ H
INSURED I CLAIMANT
ADDITIONAL I'IFORMATION
/
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I ~j.
LOSS DATE
THEFT
ACCIDENT
REPAIR SHOP
~
LOCAL ADDRESS
LOCAL PHONE
PAGE 1 "
579PASPR
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TOTAL CHARGES '
\ '.. .9\
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DEPOSITS
REFUNDS
j
AMOUNT DUE "Ill
REJECTION OF UNINSURED MOTORIST PROTECTION: I AM REJECTING
UNINSURED MOTORIST COVERAGE UNDER THIS RENTAL OR LEASE AGREEMENT AND
ANY POLICY OF INSURANCE OR SELF.INSURANCE ISSUED UNDER THIS AGREEMENT, CLOSED BY
FOR MYSELF AND ALL OTHER PASSENGERS OF THIS VEHICLE. UNINSURED
COVERAGE PROTECTS ME AND OTHER PASSENGERS IN THIS VEHICLE E.OfHQSSES PAID BY I CA~H'
AND DAMAGES SUFFERED IF INJURY IS CAUSED BY THE NEGLlGENCtOF A...DR. IVE.R. RECEIPT OF 'r DATE 'AMOUNT fEGEI
WHO DOES NOT HAVE ANY INSURANCE TO PAY FOR LOSSES AND ~AMAGE-S. ~ >! p.tlHREFUNDI ' I "-.!
@ ENTERPRIS! N'T-A-CAR COM~ANY OF PITTSB
,
..
E l/B 1/4 31B 1/2 5/B 3/4 7/B F
OWNER is AN AFFILIATE OF ENTERPRISE RENT-A-CAR COMPANY, WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS.
w
(
REJECTION OF UNINSURED MOTORIST PROTECTION: I AM REJECTING
UNINSURED MOTORIST COVERAGE UNDER THIS RENTAL OR LEASE AGREEMENT AND
ANY POLICY OF INSURANCE OR SELF-INSURANCE ISSUED UNDER THIS AGREEMENT, CLOSED BY
X_DENT __SCRATCH Q.MlSSlNG FOR MYSELF AND ALL OTHER PASSENGERS OF THIS VEHICLE. UNINSURED
E 1/8 1/4 3/8 1/2 5/8 3/4 7/8 F COVERAGE PROTECTS ME AND OTHER PASSENGERS IN THIS VEHICLE FOR LOSSES PAID BY
AND DAMAGES SUFFERED IF INJURY IS CAUSED BY THE NEGLIGENCE OF A DRIVER I RECEIPT OF.. I.. DATE I AM...O. UNTl. R R-EEi\JIi7EtJ../ .
IN I'. 1/8 1/4 3/8 1/2 5/8 3/4 7/8 F WHO DOES NOT HAVE ANY INSURANCE TO PAY FOR LOSSES AND DAMAGES. ,. ~CASHREFUN~ L_L ~
liNER IS AN AFFiliATE OF ENTERPRISE RENT.A.CAR COMPANY, WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS. @ ENTERPRl E REN -A-CAR COMPANY OF PITTSBURGH, .
~terprisel
INVUICE
OWNER OF VEHICLE:
BRANCH ADDRESS:
i- ,
; i-:
~. -?;"iL
SOURCE #
1.0. #
START CHARGES IF DIFFERENT
ORiGINAL VEHICLE
CqLOR
LICENSE. NO.
/.AQDEL
MILE.
AGE
ATTN:
PHONE
EXT.
DRIVEN
REFERENCE NUMBER
ADDITIONAL AUTHORIZED DRlVER(S) . EXCEPT AS REQU1RE.U BY LAW. NON.E PERMj,UliD l(II\.THOUT OWNER'S
WRITIENAPPROVAL. ;...:_ ,,;;;'''..;'..' " ,. ,- f'll,.t.'L I 'i
I REQUEST OWNER'S PERMISSION TO ALLOW
iJ
X,. DENT o..t.ttSSI~ /,-
F OUT 1/8 J!4 3/8 ..1/2 5/al
~ /_:~ ~":1 ';) 0.;, :'~ n f.~ rJ
L IN I'. 1/4 3/8 1/2 5/8
OPTIONAL PRODUCTS NOTICE:
IN AOOrTIONAl CHARGE, /IS OPTIOOi'I. PROOUCT5: WPMR
M; PERSCtIAl ACCIOENT INSUR.AK:E (PAli 00 SUPPtEMENTM.
~1AB1L11Y PROTECTION (SlP). THESE ARE tJESCRIBED IN DETAIL
:LSE'v'lHERE IN THIS AGREEMENT. THESE ARE 0PTKlNAL PRODUCTS
M1K:H MAY DUPLICATE CO'iERAGE I ALREADY fV\VE THROUGH MY
~ INSURANCE PCLK:IES OR MY CREDIT CARll lAM NeT REQUIRED
ro PURCHASE THESE PRODUCTS IN ORDER TO RENT A VEHIClE FROM
~ER
BEFORE DECIDING WHETHER TO PURCHASE
rHESE OPTIONAL PRillluCTS I MAY WISH TO EXAMINE MY
NSURANCE POliCIES OR CREOIT CARD AGREEMENT. OR I MAY
~ISH TO CALL MY INSURANCE AGENT OR CREDIT CARD COMPANY.
'0 DETERMINE WHETHER THEY PROVIDE COVERAGE FOR
JAMAGE TO A RENTAL VEHICLE OR FOR LOSS OR INJURY CAUSED
lR SUFFERED BY ME
PENNSYLVANIA LAW REQUIRES OWNER TO
IEAR CERTAIN MINIMUM FINANCIAL RESPONSIBILITY FOR ITS
'EHlCLES. OWNER IS SELF.INSURED FOR THIS RESPONSIBILITY,
VHICH ODES NOT CONSTITUTE LIABILITY INSURANCE FOR ME
HE RENTER. OR FOR ANY PASSENGER
IF I ELECT TO PURCHASE ANY OPTIONAL
~SURANCE PRODUCT OR OW, I MAY ELECT. TO CANCEL MY
'URCHASE AT ANY TIME DURING THE RENTAL BY BRINGING THE
:ARANO MY COPY OF THE CONTRACT TO ANY ENTERPRISE RENT.
,.CAR BRANCH DURING BUSINESS HOURS AND AGREEING IN
/RITING TO MODIFY THE CONTRACT. I WILL NOT BE CHARGED
..OR THE CANCELLE. U.~CTIONS BEYOND THE DAY OF
ANCELLATION /':: \
RENTER: I /
,. r::~'jL
OPERATION IN ANY OTHER STATE OR COUNTRY WILL AFFECT MY LIABIlITY AND RIGHTS UNOER THIS AGREEMENT.
RENTER DECLINES OPTIONAL DAMAGE RENTER ACCEPTS OPTIONAL DAMAGE WAIVER (OW) AT FEE SHOWN
WAIVER (OW) AND ASSUMES DAMAGE IN COLUMN TO RIGHT SEE OPTIONAL PRODUCTS NOTICE TO LEFT
RESPONSIBILITY. SEE PAGE 2, PARAGRAPH 6 AND PAGE 3. PARAGRAPH 16. DAMAGE WAIVER IS NOT INSURANCE.
~x
~-
, )
!ID::!liB;. . r"'..0
RENTER DECLINES OPTIONAL PERSONAL
ACCIDENT INSURANCE (PAl). SEE PAGE 2.
PARAGRAPH 9.
~x
.;. ~ l ...... ~ ;'~
o 0
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COLOR
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LOSS DATE
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LEVEL AGREED TO RENTER
THEFT ~_ ACCIDENT
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PAGE 1 0
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REFUNDS
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.-------'
IF PAYING BY CREDIT CARD, PLEASE FILL OUT BELOW
CHECK CARD USING FOR PAYMENT
;'~\
rMuterCardl 0 I WA" 10
~ MASTERCARD VISA
CARD NUMBER AMOUNT
SIGNATURE EXP, DATE
QUANTUM IMAGING & THERAPEUTIC ASSOCIATES
PO BOX 1805
INDIANAPOLIS, IN 46206-1805
FORWARDING SERVICE REQUESTED
STATEMENT DATE
PAY THIS AMOUNT ACCT. #
03-02-08
1685.00 242888-QQITA
I I SHOW AMOUNT $
PAID HERE
I RESPONSIBLE PARTY
EVA G SCHOCK
INVOICE: 777740
ADDRESSEE:
,T,rif3..-.m:r~'1:l"W..l:~II::a(.;:
no.. _ _ _ __ ___
EVA G SCHOCK
247 ACORN RD
MILLERSTOWN, PA 17062-8827
11111111111111111111111111111111111'111111111111111111111111.1
QUANTUM IMAGING & THERAPEUTIC ASSOCIATES
PO BOX 1805
INDIANAPOLIS, IN 46206-1805
111111.111,111.11111111111111111,11.1111111.111111111.111.11,1
D 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 PAYMEN I
INSURANCE' ,
, COMPANY r"
.' ,YOU
OWE
CHARG
1-06-08 70450-26 CT HEAD/BRAIN W/O DYE HOLY SPI AOVANTRA 198.00 198.(
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM RICA (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 905 80)
12-29-07 73060-26 X-RAY EXAM OF HUMERUS HOLY SPI ADVANTRA 35.00 35.(
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 890 43)
12-29-07 71020-26 CHEST X-RAY HOLY SPI ADVANTRA 45.00 45.C
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 890 46)
12-29-07 72050-26 X-RAY EXAM OF NECK SPI HOLY SPI ADVANTRA 63.00 63.C
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 890 56)
12-29-07 73510-26 X-RAY EXAM OF HIP HOLY SPI ADVANTRA 43.00 43.(
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 890 57)
12-29-07 73030-26 5 X-RAY EXAM OF SHOULDER HOLY SPI ADVANTRA 36.00 36.(
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 890 58)
12-29-07 72170-26 5 X-RAY EXAM OF PELVIS HOLY SPI ADVANTRA 34.00 34.(
02/06/08 FILED P IMARY TD ADVANTRA/ EALTH AM (AD 02)
02/11/08 GUARANT R RESPON IBILITY D TE (Char 892 15 )
10-03-07 71275-26 9 8 CT ANGIOGRAPHY, CHEST HOLY SPI ADVANTRA 380.00 380.(
02/06/08 FILED P IMARY TO ADVANTRA/ EALTH AM (AD 02)
02/18/08 GUARANT R RESPON IBILITY D TE (Char 695 07)
10-03-07 71010-26 9 8 CHEST X-RAY HOLY SPI ADVANTRA 36.00 36.(
TOTALS:
'SlA TEMENi'OA TE
0.00 o.oof 0.00 I
':'PAYTH1SAMOUNT
1685.(
03-02-2008 EVA G SCHOCK 242888-QQITA
"". pAY.el'i'S~EcBveoARERnUSSTA1aImDA1Ewal'APPEAR ON:voUaHmUAlE.uT. PAYr.ENTDUE,~POHRECElPT. THAHK'l'OU:. "
DAYS 0 - 30 31 - 60 61 - 90 91 - 120 Over 120
ACCOUNT AGING 870.00 0.0 0.00 0.00 0.0
INVOICE #:
777740
1685.00
MAKE CHECK PAYABLE TO:
QUANTUM IMAGING & THERAPEUTIC ASSOCI
FOR BILLING QUESTIONS CALL 1-866-822-8415
-
IF PAYING BY VISA OR MASTERCARD, FILL OUT BELOW
OVISA ~ o MASTERCARD.
CARD NUMBER AMOUNT
SIGNATURE EXP. DATE
ASSOCIATED CARDIOLOGISTS
856 CENTURY DRIVE
MECHANICSBURG, PA 17055
For Billing Questions Call: (717) 591-7122
For Toll Free Call: 1-800-845-1742
Patient Name: EVA SCHOCK
STATEMENT DATE PAY THIS AMOUNT ACCOUNT N
02/20/2008 $ 1025.00 248565
CHARGES MiD CREDITS MADE MTEf< '3TMEMEN'c I SHOW AMOUN~ $
DArE WILL APPEAR ON NEXT STAfEMENT PAID HERE
o.
ADDRESSEE:
- MAKE CHECKS PAYABLE I REMITTO:-
0122-427
EVA SCHOCK
247 ACORN RD
MILLERS TOWN PA 17062-8827
111.11111111111111.1111.1111.11111111111111.1111.1111111111111
ASSOCIATED CARDIOLOGISTS
856 CENTURY DRIVE
MECHANICSBURG, PA 17055
o Please check box if above address is incorrect or insurance
information has changed. and indicate changers) on reverse side.
Dill
12/30/07
12/31/07
01/01/08
01/02/08
01/03/08
01/04/08
01/05/08
01/06/08
01/07/08
01/08/08
Insurance Balance
Patient Balance
Procedure
Code
99255
99232
99232
99232
99232
99232
99233
99232
99232
99232
STATEMENT
PLEASE DETACH AND RETURN TOP PORTION WITH
YOUR PAYMENT IN ENCLOSED ENVELOPE
Diagnosis Charge Credit Balance
427.31 370.00 188.78 181.22
427.31 125.00 61.94 63.06
427.31 125.00 .00 125.00
427.31 125.00 .00 125.00
427.31 125.00 .00 125.00
427.31 125.00 .00 125.00
427.31 150.00 .00 150.00
427.31 125.00 .00 125.00
427.31 125.00 .00 125.00
427.31 125.00 .00 125.00
Description
HOSP CONSHIGH COMP11 0
SUBSHOSPMOD COMPLEX25
SUBSHOSPMOD COMPLEX25
SUBSHOSPMOD COMPLEX25
SUBSHOSPMOD COMPLEX25
SUBSHOSPMOD COMPLEX25
SUBSHOSPHIGH COMP35
SUBSHOSPMOD COMPLEX25
SUBSHOSPMOD COMPLEX25
SUBSHOSPMOD COMPLEX25
t~_~. .....~F
SERVICE F.OR THESE ClAIMS.. plEASE CALL dUR
OFFtCETO"VERft)(eeRtNSURANee,tNFORMAl'ION,
OR TO MAKE PAYMENT ARRANGEMENTS,
Total Currenl 31-60 Days 61-90 Days 91-120 Days Over 120 Days
Amount Due:
$1025.00
$1025.00
ASSOCIATED CARDIOLOGISTS
856 CENTURY DRIVE
MECHANICSBURG, PA 17055
$ .00
$ .00
$ .00
$ .00
Account Balance $ 1269.28
L. ~ Althouse, M.D., FACC (1941.1998)
00nlIId C. Durbeck, M.D., FAce
Jelfrer S. Fugate, D.O., FACC
Stuart B. Pink, M.D., FACC, FSCAI
KenIMllh J. May, Jr, M.D., FAce
Robert A. Skotnlckl, D.O., FAce
David L. Scher, M.D., FACF, FACC
Joy C. L. Cotton, M.D., FACC
Ira Sackman, M.D., FACC
Robert D. Aronofl', M.D., FACC
David C. Man, M.D., FAce
Edward C. Brannan, D.O., FACC
All billing questions can be made between
the hours of 8:30 PM and 4:00 PM.
Andreas U. Wali. M.D., FACC
Michael D. Bosak. M.D., FACC
Lenke Erki, M.D.
Rajeeh M. Dave, M.D.
Sang Kim. M.D.
For Billing Questions Call: (717) 591-7122
For Toll Free Call: 1-800-845-1742
Patient Name: EVA SCHOCK
STATEMENT
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
I11111I1 ~lllllllllllllllllti 1111111111111111111111111111
n1..,., _ .04"'7
'-
SPIRIT PHYSICIAN SERVICES
205 GRANDVIEW AVE STE 210
CAMP HILL PA 17011
STATEMENT OF PHYSICIAN SERVICES
~
EVA SCHOCK
633 HOllY HEIGKTS
MECHANICSBURG PA 17055-6178
1 of ~
STATEMENT
DATE: 03/15/08
LAST STATEMENT
DATE: 02109/08
ACCOUNT #
-$- IF ANY QUESTIONS, PLEASE CONTACT: SPIRIT PHYSICIAN SERVICES
DATE .. PROCEDURE . DIAG. .. 'QTY. DESCRIPTION..'
. ..... . . .' COD~, CODE .... '. ..
>>> PATIENT: EYASCtUK 1467299
!If 12130107 99223
!If 02/14/08
!If 12131107 99232
!If 01101108 99232
!If 02/14/08
!If 01102/08 99232
!If 02/14/08
!If 01103108 99232
!If 02/14/08
!If 01104/08 99232
!If 02/14/08
!If 01105108 99232
!If 02/14/08
!If 01106108 99232
!If 02/14/08
!If 01107/08 99232
!If 02/14/08
!If 01108108 99233
!If 02/14/08
427.31
427.31
427.31
427.31
427.31
427.31
427.31
427.31
427.31
427.31
1467299
717-972-4490 FED TAX 10 # 25176697
INS CHARGE . PAYMENT I GUARANTO
AD.lUSTMENT BALANCE
PERFORHED BY: BHAYIt<<.LtIAR MESHAPARA MD HD
PLACE OF SYC: 21
PERFORHED AT: tIS
INITIAL IIJSP CARE LEYEL I 198.00
INS NOT IN EFFECT - NIE 0.00 198.00
PERFORHED BY: CHRIS KAHLENBORN HD MD
PERFORHED AT: tIS
SlBSEQUENT imP, LEVEL II A02 73.00
PERFORMED BY: AII/TI DESAI MD
PERFORMED AT: tIS
SlBSEQUENT ImP, LEYEL II 73.0D
INS NOT IN EFFECT - NIE 0.00 73.00
PERFORMED AT: tIS
SlBSEQUENT imP, LEYEL II 73.00
INS NOT IN EFFECT - NIE 0.00 73.00
PERFORttED AT: tIS
SlBSEQUENT imP, LEVEL II 73.00
INS NOT IN EFFECT - NIE 0.00 73.00
PERFORHED AT: tIS
SlBSEQUENT imP, LEVEL II 73.00
INS NOT IN EFFECT - NIE 0.00 73.00
PERFORMED AT: tIS
SlBSEQUENT IIJSP, LEYEL II 73.00
INS NOT IN EFFECT - NIE 0.00 73.00
PERFORMED AT: tIS
SlBSEQUENT imP, LEVEL II 73.00
INS NOT IN EFFECT - NIE 0.00 73 . 00
PERFORHED AT: tIS
SlBSEQUENT imP, LEYEL II 73.00
INS NOT IN EFFECT - NIE 0.00 73.00
PERFORMED AT: tIS
SlBSEQUENT imP, LEYEL II 102.00
INS NOT IN EFFECT - NIE 0.00 102.00
BALKE: EYA SCtUK $811.00
!If INDICATES HEN FINKIAL ACTIVITY SINCE LAST BILL.
NIE - COVERAGE NOT IN EFFECT AT TIME OF SERVICE
PATIENT BALANCE StDN ~ THIS STATEMENT IS DUE FRDI1 YClJ. PLEASE
REMIT FULL AIO.WT PlDlPTL Y . PAYMENT IS DUE U~ RECEIPT DF THIS
STATEMENT.
~HESE SERVICES MERE PADVIDED BY SPIRIT PHYSICIAN ....
....sERVICES AND ARE SEPARATE FRIll >>rf ImPITAL FEES ....
....PLEASE CALL 717-972-4490 NITH >>rf QUESTIONS ....
~ERNINS THESE CHARGES. ....
_ o CHECK BOX AND ENTER ANY ADDRESS OR ;NSURANCE CORFlE:c::_T~()NS ON BACK -
STATEMENT OF PHYSICIAN SERVICES
PAGE
SPIRIT PHYSICIAN SERVICES
205 GRANDVIEW AVE STE 210
CAMP HILL PA 17011
EVA SCHOCK
633 HOLLY HEIGHTS
MECHANICSBURG PA 17055-6178
2 of ~
ACCOUNT # 1467299
-tit- IF ANY QUESTIONS, PLEASE CONTACT: SPIRIT PHYSICIAN SERVICES 717-972-4490
DATE.' P~~RE g:~.. ... QTY. .. DESCRIPTION ...
STATEMENT
DATE: 03/15/08
LAST STATEMENT
DATE: 02109/08
FED TAX ID # 251766971
INS . . H . .. PAYMENTI GUARANTO-
C ARGE.. ADJUSTMENT BALANCE.
---------------______-'-IA.e.Q1l.r.~!tr.=_!!_'..~~~~.J2~L4.'ftAIJ!tMry.!!!Lq.QrI_QM...e.Q!tnQtLQE~r~L~M..ENT..:f!!..r.Ii!.OUIt.e.4.YMENL___________________________
STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMEN.
SI2 03/15/08 $ 811.00 $ 811.00
SPIRIT PHYSICIAN SERVICES
205 GRANDVIEW AVE (HP)
STE 210
CAMP HILL PA 17011
1'1111111111111111111...11'111111111111111111111111111111..1.1
Maff SPIRIT PHYSICIAN SERVICES
T~ 205 GRANDVIEW AVE STE 210
CAMP HILL PA 17011
00001996 02
EVA SCHOCK
633 HOLLY HEIGHTS
MECHANICSBURG PA 17055-6178
_M/C
_VISA
I 1IT:.QJI.CHmK::.E;
1467299
OFFICE USE ONLY
CHECK ONE
FOR CREDIT CARD PAYMENT, PLEASE ALL IN INFORMATION BElDW
EXP DATE
$ 811.00
He: 1250
CARDHOLDER NAME (PRINT)
...Yi
SPIRIT PHYSICIAN SERVICES
CREDIT CARD SIGNATURE
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTION!) ON BACK