HomeMy WebLinkAbout05-07-08
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15056051058
REV-1500 EX (06-05)
PA Department of Revenue '*'
Bureau of Individual Taxes . liol
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
~( Of
O~33
Date of Birth
196-14-0376
02/07/2008
05/03/1920
Decedent's Last Name
Suffix
Decedent's First Name
ESHLEMAN
BERNICE
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WillS
FILL IN APPROPRIATE OVALS BELOW
. 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
4. Limited Estate
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
8. Total Number of Safe Deposit Boxes
. 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JOYCE E. STUCKEY
(717) 432-2915
Firm Name (If Applicable)
REGISTER OF WILLS USE ONLY
First line of address
152 ROBSON ROAD
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Second line of address
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City or Post Office
State
ZIP Code
DILLSBURG
PA
17019
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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge IrBbelief,
'l.is- correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
U,RE ~ER I FOR FIL:: RE;.1/c5h g '___ _J.~_5~_
A~ES -
/152 ROBSON ROAD DILLSBURG, PA 17019 & .16 COLLEGE HILL RD ENOLA, PA 17025
--~._.._---,- .--
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Correspondent's e-mail address:
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
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15056051058
Side 1
15056051058
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15056052059
REV-1500 EX
Decedent's Name:
BERNICE
L ESHLEMAN
RECAPITULATION
1. Real estate (Schedule A).
2. Stocks and Bonds (Schedule B) . . . . . . . . . . .
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) Separate Billing Requested . 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested. 7.
8. Total Gross Anets (total Lines 1-7). . . .
9. Funeral Expenses & Administrative Costs (Schedule H).
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) .... . . . .... . .
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J)
. . . . . 12.
........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
althe spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
16. Amount of Line 14 taxable
at lineal rate X.O ~ 3,283.15
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15 2,188.76
15.
16.
17.
18.
19. TAX DUE. . . . . .
. . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
~ I<..h: 2
196-14-0376
Decedent's Social Security Number
1.
2.
5.
8.
9.
15056052059
6,579.93
6,579.93
956.50
151.52
1,108.02
5,471.91
5,471.91
147.74
328.31
476.05
-1
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENTS NAME
BERNICE L ESHLEMAN
STREET ADDRESS
940 WALNUT BOTTOM ROAD
File Number
DECEDENTS SOCIAL SECURITY NUMBER
196-14-0376
MANOR CARE
CITY
CARLISLE
I STATE
PA
I ZIP
17015
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
476.05
23.80
Total Credits (A + 8 + C ) (2)
23.80
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
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.
(5)
(5A)
(58)
452.25
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
452.25
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 [i]
b. retain the right to designate who shall use the property transferred or its income; .......................................... 0 [i]
c. retain a reversionary interest; or........................................................................................................................ 0 Ii]
d. receive the promise for life of either payments, benefits or care? .................................................................... 0 Ii]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................. 0 [i]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?............. 0 [i]
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 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. 99116 (a) (1.1) (H)]. 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 nalural 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 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-1508 EX+ (6-98)
'*
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISe.
PERSONAL PROPERTY
ESTATE OF
BERNICE L. ESHLEMAN
FILE NUMBER
Include the proceeds of litigation and the dale the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1 PNC BANK 403 N Baltimore Street DiIIsburg, PA 17019 Checking Account # 5140018774
D
6,579.93
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
6,579.93
REV-1511 EX+ (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
BERNICE L. ESHLEMAN
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
JOHN C SULLIVAN FUNERAL HOME -51 N ENOLA DR.ENOLA, PA 17025 (Gown)
GINGRICH HUMMELSTOWN, PA 17036 (Headstone)
105.00
125.00
2.
B. ADMINISTRATIVE COSTS:
1.
Personal Representative's Commissions
Name of Personal Representative(s) JOYCE E. STUCKEY
Social Security Number(s)/EIN Number of Personal Representative(s) 168-26-4535
Street Address 152 ROBSON RD
330.00
City DILLS BURG
State PA Zip 17019
Year(s) Commission Paid: 2008
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City Stale Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. COURT FEES
US POST OFFICE
CARLISLE COURT HOUSE FEES
DILLSBURG BANNER - ADVERTISING
REGISTER OF WILLS - FILING FEE
100.00
15.00
11.20
82.30
73.00
15.00
TOTAL (Also enter on line 9, Recapitulation) $
(II more space is needed, insert additional sheets of the same size)
856.50
REV-1511 EX+ (12-99) I':
W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
BERNICE L. ESHLEMAN
FILE NUMBER
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1.
Personal Representative's Commissions
Name of Personal Representative(s) IRENE SWARTZ
Social Security Number(s)IEIN Number of Personal Representative(s) 191-42-8188
Street Address 16 COLLEGE HILL ROAD
1 00.00
City ENOLA
State PA
Zip 17025
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's. attach explanation)
Claimant
Street Address
City
Slate
Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the sarne size)
100.00
REV.1512 EX- (12-03)
'*
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
BERNICE L. ESHLEMAN
FILE NUMBER
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
HEARTLAND PHARMACY OF PA LLC - 7010 Snowdrift Road Allentown, PA 18106
105.00
2.
MCHS CARLlSE - 940 Walnut bottom Road Carlisle, PA 17015
46.52
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
151.52
REV.1S13 EX. (9.00) t.
~~
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BERNICE L. ESHLEMAN
NUMBER
I
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
Bart William Stuckey 106 Center Street Apt 4 Enola, PA 17025
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Grandson
Grandson
Niece
Daughter in law
FILE NUMBER
AMOUNT OR SHARE
OF ESTATE
30%
30%
20%
20%
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
2.
Bret Edward Stuckey 304 Rosedale Aveune Highspire, PA 17034
3.
Irene Swartz 16 College Hill Road Enola, PA 17025
4.
Joyce E. Stuckey 152 Robson Rd Dillsburg, PA 17019
B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets or the same size)
Last Wi[[ and rrestament
Of
BERNIECE L. ESHLEMAN
I, BERNIECE L. ESHLEMAN, of the Borough or West Fairview, County~f
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Cumberland and Commonwealth of Pennsylvania, being of sound mind, memory and
understanding, do hereby publish and declare this to be my Last Will and Testament hereby
revoking and declaring null and void any and all Wills and Codil:ils heretofore written by me.
ITEM I. I direct that all my just debts and funeral c:xpenses be paid as soon after my
demise as may be convenient to the proper administration of m)' estate.
ITEM II. I order and direct my hereinafter named Exel:utor/Executrix to conwrt my
entire estate into cash at either public or private sale, whenever in his/her discretion it may be
most expedient for the proper administration of my estate. In the event of such conversation,
I authorize my said Executor/Exel:utrix to execute a good and sufticient Warranty Deed to the
purchaser of any real estate of which I may die seized, in the same manner and capacity as
I could if living.
ITEM III. I direct that all inheritance and estate taxes be paid on the proceeds of the
above conversion and on all the rest residw.: and remainder of my estate from the residue of my
estate prior to further distribution.
ITEM IV. I then give, devise and bequeath allth<.: r<.:st, r<.:sidu<.: and remainder of my
estate including the proceeds of the above mentioned l:ollv<.:rsion in the following manner:
a) 30% to my grandson, Bart William Stuckey, per stirpes.
b) 30% lO my grandson, Sret Edward Stuckey, per stirpes.
c) 20% to my niece, Irene Swartz. per stirpes.
d) 20% to my daughter-in-law, JOYl:e E. SllIl:key.
However, if she ;;hould pred:.:cease r.i-:: ! the:1 ,.!ir:.:e~ tbt !l;:r sl1a!".: shall be givc.:n to Sret Edward
Stuckey.
ITEM V. I nominate, constitutc and appllinlmy daughkr-in-Ia\\', Joyce F. Stucke)', and
my niece, Irene Swartz to serve joinlly as Exccutrixes or this my Last Will and Testamenl,
Should either be unable or unwilling to serve, I then nominate, cllJ1stilute and appoint the other to
serve individually as Executrix. I direct that my Executor/Lxecutrix shall not be required to post
bond other than her personal assurance for her duties as Executor/Executrix.
IN WITNESS WHEREOF, I, BERNIECE L. ESHLEMAN, have hcreunto subscribed
~ , !
my hand to this my Last Will and Testament, Ihis ,/',; J"day of ,/ / /~/-,-" ,200 I.
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Bernicee L. Eshlc~nan
SIGNED, PUBLISHED AND DECLARED by the;: above-named UERNIECE L. ESHLEMAN,
a::' ..nJ for her Last \Vill a:1d ':(:t:t~m'.:r:t in I!l-: l'!":':':nc~ or >IS, whu ;It hcr n.:qLlcst and in her
presence and in the presence;: of each uthcr, h;lve signcd our namcs ;IS attesting witnesscs hen.:lO.
.)tacu;}., fiu}J
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residing at ,1/ .!ld& hilti' J. Q1', (~{Llde j) /10/3
residing at ~/(~/d~i)I:.j1 J) I~'~ I {Jhi,<j< /4 /7,.)3
Page: 1 Document Name: untitled
STMT CO
ACTION
PROD CODE DDA
STFD
40 OP
PAGE 1
ACCOUNT
1 THF TRANSACTION STATEMENT FORMAT 08/03/03
MS 50852 ACTION COMPLETE
SEARCH FROM THRU
5140018774 SHORT NAME ESHLEMAN BERNICE
11.12.01
ACTN POST EFFECTIVE CHECK NUMBER TRAN AMOUNT D/C BALANCE
TRACE ID DESCRIPTION
* 12/12 0659 62.40 D 6,679.03
085422912 XMKT CHECK 659 REFERENCE NO. 085422912 XMKT
* 12/26 0660 50.00 D 6,629.03
085416681 XMKT CHECK 660 REFERENCE NO. 085416681 XMKT
* 01/02 62.40 C 6,691.43
00020073653045047 196140376 PENSION-CKUNITE HERE RETIR
* 01/08 0662 50.00 D 6,641.43
085405397 XMKT CHECK 662 REFERENCE NO. 085405397 XMKT
* 01/08 .90 C 6, 642 .33 V '-I,.!..
I-GEN108010800004233 INTEREST PAYMENT -+ . -----
* 01/08 15.00 D 6,627.33'
I-GENI08010800004234 CALCULATED SERVICE CHARGE TYPE JD
* 01/08 15.00 C 6,642.33,___
I-GENI08010800004235 SERVICE CHARGE WAIVE TO RELATIONSHIP PRICING
* 01/11 0663 62.40 D 6,579.93 -"r~
086716285 XMKT CHECK 663 REFERENCE NO. 086716285 XMKT, -~ I, '-- ,
PF: 4-TOP 5-BOTTOM 6-INQ 7-SB 8-SF 9-ASUM 10-TRIG ll-CUTO 12-XTFD -STSM
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Date: 3/3/2008 Time: 11:11:56 AM
iI/I\""M::J GafilSlc
~~O Wi1lnut ~8n8m R038
Carlisle, PA 17015
(717) 249-0085
Patient: Esnleman, Bernice (27017)
Localioll:
Statement Date: 3/1/2008
Date
Description
Units Unit Amount
Amount
BALANCE FORWARD
2/4/2008 Payment
2/1/2008 Private Portion Feb 1-292008
2/1/2008 Private Portion Feb 1-62008
$957.52
($911.00)
($960.14)
$960.14
BALANCE DUE
$46.52
In order to prevent collection letters we would greatly appreciate your payment be made by the 12th of the month.
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Heartland -;-
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---. .-------_.--------- - -----,
PHARMACY OF PENNSYLVANIA, LLC
7010 SNOWDRIFT RD
ALLENTOWN, PA 18106
800.270-6351 EXT 6050
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CH[Ct\ CAt II) I J',ING FOR PA~MfNT
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FACILITY: 53720 CARLISLE
PA Y PLAN:
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33978 I ".".,1,'," _______ _~_~_:~_-]~iC c0IJT fXP-,:t=-~_
STATEMENT D~TE[ PAY THIS AMOUNT CUSTOMER 10
MAIL
2/29/2008 $268.28 22619
--.-- -
SHOW AMOUNT $
PAG!:. NO 1 of 1 PAID HERE
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RETURN SERVICE REQUESTED
0101
U~.:'iJU~'
BERNICE ESHLEMAN
C/O JOYCE STUCKEY
152 ROSSEN RD
DILLSBURG, PA 17019
1.1..1.111111111111111111111111111111111111111111111111111111I
HEARTLAND PHARMACY OF PENNSYLVANIA
PO BOX 72413
CLEVELAND, OH 44192-0002
r
O Please check box if above address is incorrect
or insurance information has changed, and
indicate change(s) on reverse side.
33978'T681 85 1 VE000067
~
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PA1MEr-.T
33&78 MAIL 'T6818S1VE000067
I l1li11111 III UIIiIIIIl I l1li11 UillIiIi I iIJi
ESHLEMAN, BERNICE
22619
CARliSLE
~
CUSTOUEA 10
FACILITY
. PRIMARY PHYSICIAN NAME ' .
.
. .
.
DATE
DR GUISTWITE, DARRYL, MD
RX NO. DESCRIPTION
Medicare D Plan: PAClF~CARE SEC HOR/PRES. SOL.
2129/2008
161227
1(0 '
6
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NDC NO. QUANTITY AMOUNT CODE TYP
MCR
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MESSAGES
Finance charges are calculated @ monthly periodic rate 011.5% (or a minimum
or $1.00 per month) ror a Iotal annual rate or 18%. The charges listed
on this invoice do not reflect any balance billed 10 your insurance.
I' .
: .
. .
. .
. . .
265.43
J-
0.00
J-
0.00
1-
0.00 I..
2.85
I..
0.00 1:_..____ o.~~_
268.28
I
-,.----...------- -1
DAYS OUTSTANDING
1 . 30
3 ~8:0 -- -:~o ~~f 1 :~3::{~5~:~ +
DUE DATE:
3130/2008
AGED BALANCE
AMOUNT DUE:
$268.28
2.85
7010 SNOWDRIFT RD
ALLENTOWN. PA 18106
AMOUNT ENCLOSED:
800-270-6351 EXT 6050