HomeMy WebLinkAbout05-27-08 (2)15056051058
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue Counh~ Code Year File Numlter
Bureau oflndividualTaxes INHERITANCE TAX RETURN
PO BOX 280601
Harrisburg, PA 17128-0601 _ RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
03!02/2008 01 /19/1917
Decedent's Last Name Suffix Decedent's First Name Wit
Lore Mary E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return
THIS RETURN MUST BE FILED IN DUP4,ICATE WITH THE
REGISTER OF WALLS
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required
death after 12-12-82)
• 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFiDENT1Al TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Patricia Schaal
Firm Name (If Applicable)
First line of address
11 Hellam Drive
Second line of address
City or Post Office
Mechanicsburg
Correspondent's a-mail address:
REGISTER OF WILLS USE ONLY
r~.~
r"") ,,
c r--
~,a
~ ._t
`~
1
-,.1 _ i
7 _,, _- ~
State ZIP Code _uaTE FILED -<
--
PA 17055 :
r,, ~ - -
-, ,
c~
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 t ,correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SI ATU ~ P~F~rR-SON RESPONSIBLE FOR ILING jtETURN DATE .~ p
11 Heflam Drive Mechancisburg PA 17055
SIG~tATURE OF PRE.pARER OTHER THAN REP ESENTATIVE DATE
~ l~l ~~ n ~ ; L Y~t CZ~,;G'/'~r r,L~ ~- ~l?7 ~ tY , _ ~_ P~ `~~,~ f ,l ~- C`~C? ~
ADDRESS Q
282 Lowther Street Ste 201 Lemoyne PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058 15056051058
REV-1500 EX
15056052059
Decedent's Name: Mary E Lore
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) ........ 5.
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 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 6 minus Line 11) .............................. 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ........................ 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 15.
16. Amount of Line 14 taxable
at lineal rate X .0 45 161,778.33 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 ~a
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059 Side 2
Decedent's Social Security Number
176,437.32
176,437.32
14,378.68
280.31
14,658.99
161, 778.33
161,778.33
7,280.02
7,280.02
15056052059
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER
Mary E Lore 142-09-5308
_
STREET ADDRESS
11 Hellam Drive
CITY
Mechanicsburg STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 364.00
3. InterestlPenalty if applicable
D. Interest
E. Penalty
(1)
Total Credits (A + B + C) (2)
Total InterestlPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Flll in oval on Page 2, Line 20 to request a refund. (q)
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. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable fo: REGISTER OF WILLS, AGENT
7,280.02
364.00
0.00
6,916.02
6,916.02
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN TFIE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
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 receiving adequate consideration? ............................................................................................................. ^
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...............................................................................
......................................... ^ ^x
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. §9116 (a) (1.1) (i)J.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a Vansfer 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 a,t death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)). Asibling is defused, 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.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary Elizabeth Lore
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 PNC Bank -Interest Checking Acct #50-7003-2326 6,040.02
2 PNC Bank -Performance Money Market Acct #50-3001-0261 33,329.19
3 PNC Bank -Certificate of Deposit Acct #31200264391 5,042.79
4 PNC Bank - Certificate of Deposit Acct #21001010801 5,030.65
5 PNC Bank - Certificate of Deposit Acct #21001028744 15,020.39
6 PNC Bank - Certificate of Deposit Acct #21001028810 10,038.25
7 Sovereign Bank -Certificate of Deposit Acct #1685164368 5,018.15
8 Sovereign Bank -Certificate of Deposit Acct #1685373118 10,040.30
9 Sovereign Bank -Certificate of Deposit Acct #1685378273 5,005.24
10 Sovereign Bank -Certificate of Deposit Acct #1685379479 10,041.61
11 Sovereign Bank -Certificate of Deposit Acct #1685391300 5, 018.58
12 Sovereign Bank -Savings Acct # 1684000134 65,532.15
13 Jewelry -Ladies 14K White Gold Diamond Engagement Ring -Value per Appraisal 340.00
14 Jewelry -Ladies 14K White Gold Diamond Ring -Value per Appraisal 640.00
15 Jewelry -Ladies Strand of Cultured Pearls -Value per Appraisal 90.00
16 Jewelry -Ladies Platinum Diamond Ring -Value per Appraisal 210.00
TOTAL (Also enter on line 5, Recapitulation) S I 176,437.32
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12.99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary Elizabeth Lore
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~' Malpezzi Funeral Home-8 Market Plaza Mechanicsburg PA 17055 -Funeral Services 9,256.52
2 Fisher Monuments-Bridgeton New Jersey-Marker Engraving 265.00
s Giant,Mechanicsburg Beverage and Wine & Spirits Store-Luncheon 100.04
B. ADMINISTRATIVE COSTS:
1. Personal Representatve's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City .State Zip
Year(s) Commission Paid:
2. Attorney Fees 120.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 3, 500.00
Claimant Patricia Schaal
street address 11 Hellam Drive
city Mechanicsburg State PA Zip 17055
Relationship of Claimant to Decedent Daughter
4. Probate Fees 325.00
5. Accountant's Fees 400.00
6. Tax Retum Preparer's Fees 70.00
7. Cumberland Law Journal-Legal Advertisement 75.00
8 The Sentinel-Legal Advertisement 118.72
e Joseph James Jewelers-301 Main Street Mechanicsburg PA 17055-Jewelry Appraisal 148.40
TOTAL (Also enter on line 9, Recapitulation) $ 14,378.68
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Mary Elizabeth Lore
Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbursed medical expenses.
(It more space is needed, insert additional sheets of the same size)
REV•1513 EX+ (g-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Mary Elizabeth Lore
RELATIONSHIP TCl DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1 TAXABLE DISTRIBUTIONS [inGude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)J
~ Barbara Cullen Daughter 50%
890 S Manor Drive
Dunedin FL 34698
Z Patricia Schaal Daughter 50%
11 Hellam Drive
Mechanicsburg PA 17055
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
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 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)
LAST WILL AND TESTAMENT
OF
MARY ELIZABETH LORE
I, MARY ELIZABETH LORE, now domiciled in Cumberlland County, Pennsylvania,
declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may
have previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate
shall be paid by my Executor from the principal of my residuary estate as soon as practicable
after my death.
Artic a II
All inheritance, estate, and succession taxes (including interest and penalties thereon, but
not including any generation skipping tax) payable by reason of m}~ death shall be paid out of
and be charged generally against the principal of my residuary estate without reimbursement
from any person. This provision is not a waiver of any right which. my Executor has to claim
reimbursement for any such taxes which become payable as the result of any property over
which I have the power of appointment.
Article III
I give, devise and bequeath. my tangible personal property in accordance with any
memorandum I have handwritten or signed, located with my will or with my valuable papers and
found within 30 days of the probate of my will. Gifts may only be to persons who survive me or
to organizations which exist at my death, and if there is a conflict, the memorandum having t,~e
latest date shall govern. To the extent no such memorandum is found, or all of my tangible
personal property is not disposed of pursuant thereto, my tangible personal property shall be
added to my residuary estate and pass under Article IV hereof.
Article IV
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath 1N EQUAL SHARES to my children, PATRICIA. L.
SCHAAL, of Cumberland County, Pennsylvania, per stirpes and BARBARA CULLEN, of
Dunedin, Florida, per stirpes. If a beneficiary fails to survive me by thirty (30} days, but leaves
descendants who survive me by thirty (30) days, those descendants shall receive, per stirpes, the
share the beneficiary would have received had he or she survived me by thirty (30} days. The
share of any deceased child who does not have living issue shall be divided and distributed to my
remaining child, per stirpes.
Article V
I nominate, constitute and appoint my children, PATRICIA L. SCIiAAL and
BARBARA CULLEN, as Co-Executors of my Last Will and Testament. I direct that my Co-
Executors be permitted to serve without bond. In addition to those pourers granted by law, I grant
them power to distribute in cash or in kind, in like or in unlike shares, and to file any qualified
disclaimer I could have filed if living. My Co-Executors shall receive reasonable compensation
for services rendered to my estate.
Article VI
In addition to the powers conferred by law, I authorize my Co-Executors, in her absolute
discretion:
(a) to retain in the form received and to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein,
2
(b) to manage real estate,
(c) to invest and reinvest in all forms of property withaut being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownerslup of investments,
(e) to compromise claims without court approval andl without consent of any
beneficiary,
(fj to file any federal income tax return for any year for which I have not filed such
return prior to my death,
(g) to make distributions in cash or in kind, or in both, and to determine the value of
any such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by
my Co-Executors; and to pay from my estate reasonable compensation for all their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have
an interest in at time of my death, and
(j} to receive reasonable compensation in accordance with their standard schedule of
fees in effect while their services are performed.
1N WITNESS WHEREOF, I,`MARY ELIZABETH LORE, thereby set my hand to this
my Last Will and Testament, on gl ~~ , 2007, at Harrisburg, Pennsylvania.
E ZAEET ORE
In our presence, the above-named MARY ELIZAB H LORE signed this and declared
this to be her Last Will and Testament and now at her request, in her presence, and in the
presence of each other, we sign as witnesses.
Name Address
+.~, 2000 Ling~estown Rd.. Suite 202, Harrisburgs PA 17110
- 2000 Ling_lestown Rd.. Suite 20~i Harrisburg. PA 17110
3
I, MARY ELIZABETH LORE, Testatrix, who signed the foregoing instrument, having
been duly qualified according to law, acknowledge that I signed and executed this instrument as
my Will, and that I signed it willingly as my free and voluntary act for the purposes therein
expressed.
Sworn to or affirmed and
Acknowledged before me by
MAR .ELIZABETH LORE, the Testatrix
on v , 2007.
o Public
Y ~LIZA H LORE
raaLr~ oF~r
sMeri~ ei H~axea, N~ota_sy ~u~blincty
1\4y cocnmision 1 ' D1~~plhin ~3, ?Alo
We, the undersigned witnesses who signed the foregoing inst~°wnent, being duly qualified
according to law, depose and say that we were present and saw the: Testatrix sign and execute
this instrument as her Will; that she signed and executed it willingly ors her free and voluntary act
for the purposes therein expressed; that each of us in her sight and hearing signed the Will as
witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or
more of age, of sound mind, and under no constraint or undue influence.
Sworn to or affirmed and
Subscribed to before me
by(~rnne ~ G~oxL~idwsQ
and irYIA~RC,~ S. !Y)1 G1.E ~.
witnesses, on t / av , 2007.
No Pub i
'T OF
Muioik p ~ ~~al
8wgt r'ubiio
~' ~~lul~ sxvln~tient, lr~.'`~~
Witness
fitness
4
Total Banking Statement
PNC Batik
i~PNCBANK
Primary account number. 50-7003-2326
Page 1 of 2
For the period OZ/Z7lZ008 to 031Z6JZ008 Number of enciosures: 0
M E LORE DECD~~` ~F'or 241tour banking, and transaction or
I`1 ~ HELLAM DR interest rate Information, sign on to
'j! F'NC Hank Online banking at pnc.com.
MECHANICSBURO PA 17055-6130
~
~ , r ~ F'orcustomerservicecall t-888-PNC-BANK
~
~" ~„~:; between the hours of 6 AM and Midnight ET.
"
;~
~ ` ~.`
' ~' ~ -^" .~ F'ara servicio en espaffol,1-866-HOLA-PNC
~
X
~, ~ ~ ~
y; ',~ ~ Moving? Piease contact us at 1-888-PNC-BANK
® Write to: Customer Service
PO box 609
Pittsburgh PA .15230-9738
Visit lls At pnc.com
® TDDtermtnal:1-800-531-1648
, For hearing Impahed clknts only
Relationship Overview
Bank Deposit Aoaounts
Description Account Number Deposit t3alance
htiterest Checking 5x'1003-232s ,~
Performance Moncy Market 50.8001-0261 ,00
Totai Depoai6s .UO
Interest Cheoking Aaoount Summary M E Lor® Dead
Acxount number. 50-7003-2328
Balanoe Summary Please see the Aaiviry Detail section for
Beginnlny Deposits and Chocks and other Endlny additional information.
balance other additions deductions batance
5,202.02 838.00 6,040.02 .00
Average monthly Charyss
balance and tees
1,813.45 .00
Intersat Stlnnmary
Annual Percentage Number of days Average collected Intarost Pald
Yield Earned (APYE) In Intarost period balance for APYE this period
As of 03!26, a total of $1.38 in interest was
;paid this year.
0.00% 7 x,441.44 .00
Activity Dstaii
Deposits and Other Additions 'There was t Deposit or ocher Addition
date Amount Description totaling $838.00.
98/OS 858.00 Direct lleposlt - Soc Sec
US Treasury SOS XXXXX4840D
Other Deduotions 't'here were 2 Other Deductions totaling
Hta Amount Description $6,040.OZ.
)9105 .00 Outstanding Item Cloae
)3/05 6,040.02 Debit Memo Reference No 025521922
Total Banking Statement
~•. a.• a•~ oya»soos eo o~zazoos
For 24hour information, sign on to PNC Bank Ontlne Banking M E LORE DECO
on pnc.oom. Primary account number. 50-7003-2326
Account numfxm bo.700:t-Y37t6 -continued Papa Y of 2
Daily Balance Dati91i1
Date Balance Dats 8alanee Data Balance
U2j 27 5,'.tU2A2 U3/U3 ti,t3•iU.U2 U3/U5 .W
Do you receive a Social Security or SSl check by mail? lloro arc tltst~e good reasons to switch to dimet deposit. It's Sal'cc - mailed clacks ca
be lost or stolett; Casicr - your fitttds are deposited to your PNC Dank account electronically; and best of all it's Convenient -your money is
availaWc without making a trip to the bank. Frrtroliutg is easy. Stop in at any PNC Bank bmnch or call us at 1-888-7G2.2265 Gant•12 tnidnil
Account number. 50.3001-0281
6alatnce stuntmary
Beginning Deposits and Checks and otMr Endlnq
balance other additions deductions Wlance
99,x'30,143 .00 38,S2~J.lrJ .UO
Average monthly Charges
Wlancs and tees
8,Ut14.4t7 .UU
late~est 8umanary
Annual Percentage Number of days Awrags collsctsd Intsnst Paid
Yield Earned iAPYE3 Itl Intsnst period Wlancs for APYE this period
Please see the Activity Oetail section foe I
additional information.
As of 08/26, a total of ~4iM.f+O in interest
was paid this year.
O.OOX 7 3g,924~.10 .UO
AotiWty Detail
Othetr Deductions ~ There were 2 Other Deduction: totaling
Data Amount Deseription t$S$.9Z9.419.
U3/U5 ,W Chttatamdimg itetu Glasc
Ug/U5 93,92ft.18 Drbit Ateuw Rrfrrence No 02b521g21
Daily Balance Deta~
Date Balance Dats Balance
02/2'7 99,9::41.10 U;i/U5 ,OU
Total Banking Statement
so. tan. por~od ovzsizoos eo otizsizoos
For 24-hour information, sign an to PNC Sank Online Banking M E LORE
~--' on pnc.com. Pt unary account number. 50-7003-2328
Arcuunt numbers 51h71111:i-2;t'tfi . continued Px-ge 2 of 4
Activity Detail _
Deposits and Other Additions There were 2 Oeposils and Otiter Additions
Date Amount Description totaling $838.65.
l1'_!pi s;:i$.01) 1)Irccl 1Jcpusil • S~x• Scr
US'1'rc asnr•t• :;U;t XXt;XX'1>;•h)11
1)':,",2G .liCi lntcrest l'a}'n)rnt
Checks aad Subatituto Chocks
Check Date Reference
number Amount paid number
32.'': ti(1{Lt)t) O3J It) nr112l++kt7»
Online and Electronic banking Deductions
Data Amount Dascripllon
u3:'t)7 :)~-.1`_> pitcrt Pa~•mrnt • I)irrrt Pav
l.ifi`linr Spxtcnt~ ltr•i4);tl IU
There is 1 check listed totaling X600.00.
There was 1 Online or Electronic Banking
Deduction totaling:SS.1Z.
Daily Balance Detail
Date Balance Date Balance Date Balance
1)i: `~<,) *i,lx)`_.•141 U'_>JU7 ri,)301.:)7 1)'2J'lti 5;_n'„O`er
Premium Plan M Elizabeth tore
Performanoe Money Market Account Summary
Account number: 50-3001.02G1
Balance Summary
Beginning Deposits and Checks And other
balance other additions deductions
Average monthly
balance
Ending
balance
3:),:~31~. I ~)
Charges
and lees
Please see the Activity Detail section for
additional information.
Interest Sutftt)ttsary As of 02126, a total of ~1~44.90 in interest
was paid this year.
Annual Percentage Number of days Average collected Interest Paid
Yield Earned {APYE) in interest period balance for APYE this period
3.:i7Y. ~!) 3:t;>ti51.3$ lil ~l'1
Aotivity Detail
Deposits and Other Additions _
Titers was t Deposit or Otl)er Addition
Date Amount Description totaling t~131.94.
O'~ "~li lil ~)•1 lntcrrst Pa~'nu'ut
Daily Balance Detail
Date Balance Daie Balance
(I L/'~:) 3:i;ai7.~.'i O'.'.;'?(i 33,3'~~).1<)
Certificates of Deposit
M Elizabeth Lore
Inwstmanl Description
number
:tI'axP~ti9:t~)1 a ~(outh(s) l:ixrrt K:rtc~
'_llx)lult)~u)l t; ~trmlh(s) Pixc<I Ratc
'_RUUIu`>:179.1 13 ~t<rnUt(s) Fixr~l Rate
Certificates of Deposit continued on next Daae
Maturity data Interest Original or Cwr~s
rate renewal value wM
a:t/ultzuas '~:;-t ;,, 5,093.70
s !c,u77w
uli,'13r~uua •~.~ii7 ~, ~-,txx).tx) 5o~~ ~c.tr~7.~
Oa.: 17/`d(x)$ ;)•1l rr, 1!-,I)(x).QO/5~20.3~ I!i,tllt).:
05/20/08 T[JE 15:03 FAX 717 T66 0190 Schaal _ 1001
Total Banking Statement ~PNCBANK
For tbo porlod 07/ZS/Z00$ to O?JZ8/Z00$
For 2d-hour lntormation, sign on to PNC Bank Oniine Banking M E LORE
on pnc.com. PHmary account number: 50-7003-2326
Account numbest 50-3001-0261- cotrtiuued Patae 3 of 4
Corlffioatas of Dapoait -continued
M Elizabeth Lore
InvealmeM Description Maturity date lntensst OrlOinal or turraM
numpsr rate renewal value ~ value
21001028810 12 Month(s) Fixed Rate 10/i4/2008 2.80 96 10,000.00 -oU~a.!~~ 10,082.13
Total ourro~rt value 35,14'7.58
FDMA95~R•t006
DATE RECEIVED FROM AMOUNT >• TOTAL
o c'!1 ~ ~ p~Or - ,
O ~ ~
V (J IJ
~
L
/ t
~
TOTAL RECEIPTS
~,., coAit saw. sovereign Banl~
Chxking (Savings l Loans
1.877SOV.BANK I sovereignbankwm CUSTOMER RECEIjIPT
r t
Data 03/05/08 12:22 TellEr 004 "i0
WitY~drawal Sea: 060
~y l ~ g~~~! ~~„~ AEI: #~tlx~~~0134 0168
~Cr_~ Transaction Rnount: ~b5.~32.15~~
Friar Day Closing DaI: X65.532.15
Current Aalance: ~O.OU
A'+~ailahle P~siance: X0.00
eaooos wo7 ~,
~, co~.~iu«it sang. Sovereign Banl~
Checking ~ Savings l Loans
1.87750V.BANK { soverelgnbankcom CUSTOMER RECEIPT
TD Wth Datt~ 03!05/08 12:28 Tlr 004 TO
AN ib8537827'b Sea 0085 0168
Ant $5.002.02
~- ` '~~
~; bd ~ .
aaoooa~~ _~.. __ ~
~,', convenient saw. Sovereign Banl~
Checking ~ sav{ngs l Loam:
1.877SOV.BANK I sovereignbanktom CUSTOMER RECEIPT
TD Wth DatE 03/05/08 12:25 T1r 004 TU
Aid ib8537947y SEq 0083 01x8
Ant ~10,OOb.13
eaaooasro7 _. 1' (~ U'-~-` ~ ~O ~ Meneu ~
Easy, con.~nient Ban>ang sovereign Banl~
Checking I savinYs !loans
1.877SOV.BANK I sovsrelgnbank.com CUSTOMER RECEIPT
1l1 Wth~ Datf: 03/0:,/08 12:2~i i'lr 004 'I'G
AN 188~3731rii3 5rU OUtI/ 6168
Any. il(1,005.43
._.~--~-
J~~b`~D~ 3U ~
~., convenient Banking. ~~overeign Banl~
Checking I Savings I Wans
1.877.SOV.BANK (sovereignbankcom CUSTOMER RECEIPT
TL Wth [gate 03/05/08 12:31 Tlr 004 TU
AN 16851b43b8 Se~J 0089 0168
Ant $5002.68
anooossro~ ~~ 5~ , g, , .~ ~
Easy, Convenient Banking. sovereign Banl~
Chocking I Savings I loans
1.877SOV.BANK I sovereignbank.wm CUSTOMER RECEIPT
TD Wth Date 03/05/08 12:32 T1r U04 TQ
AN 1b8539130G Seq 0091 0168
Ant 35,002.75
h'
~~ i g. 58
a stir
004071 * 004071 001 004071
M ELIZABETH LORE
11 HELLAM DR
MECHANICSBURG PA 17055-6130
,_:z
f
,.
R
+ ~ r....
lw~-V
..fit
"~.4
INTEREST CHECK 0009531296
SAVINtiS/CERTIFICATES CHECK DATE 02/29!2008
NUMBER AMOUNT AMOUNT AMOUNT
1685164368 15.476 15.471
1685373118 34.376 34.371 ~
1685378273 3.226 3,221 /
1685379479 35.486 35.481 ~
1685391300 15.836 15.831 '
LEGEND
P -PRINCIPAL PAYMENT G -GROSS INTEREST PAYMENT
1 • INTEREST PAYMENT W -FEDERAL TAX W TTHHELD
~$OVP,PCI~II Bahl{
Memo:
03/05/2008
Account Holder_
Account Number:
branch Number: 0168
TOTAL CHECK
DETACH AND REfA1N FOR YOUR RECORDS
0006549
f
r
i ~" ~.. '•
tao
~,~ ;, ;.
i~-d~le.~- ~ ~c~,-~c e S
oDtomMAww ~a
~~~
I EV1/E~ERS
TO WHOM IT MAY CONCERN:
Thie is to wrtilY thu we aro engaged in the jowo{ry bWInD53, DppfDID10Q diDI110IId3. wBICheS. lt'1A'tary 9tld prECi000 atonal of all dDacriptiona, 'We Ibrewith co~tify that wa haw this day eu+fully
...mines u,. rottowma turec anA eescrl0 artlcHa, the pcopeny of
NAME: Mr, Chuck Schaa!
ADDRESS: 1 I Helam Drive
Mechanicsburg, PA 17055
W a estimate the value u lined for insuranx or other Durpoxs at the currant retail vaiuo, excluding Federal and other taxes. In making thin A.ppniaal we DO NOT agree to purchase or replacc
The following items were evaluated for estate purposes:
~,ESCRIPTION
Lady's l4K white gold diamond engagement ring. The round old European cut
diamond measures approximately 4.8mm x 3.Omm deep. This diamond weighs approximately .49ct. The clarity is
SI1. The color is G. The table is approximately 53%. The depth is approximately b2.5%. This is framed with
flower and scroll filigree. The shank measures lOmm tapering to 1.2mm. The shank and the crown area show
excessive wear. This is constructed from a three piece die struck assembly.
Value: 5340.00
c~---- Apri18, 2008
TAMES . DAVIS P.G.
The foregoing Appraisal is made with the understanding that the Appraise aawmoa no liabil'uy with respect to any anion thu may be taken on the basis of this Appraisal.
301 East Main Street • Mechanicsburg, PA 17055 • (717;1 795-9224
~%~~.~a<~aG
~~h~~
~OSEPIi DAMES ~EWEI.ERS
TO WHOM IT MAY CONCERN:
Thi^ is a oenily thu we an engaged in the jewelry business, appralanY diamonds, watches, jewelry and precious u011la Of all descriptiona We hmewith certify that wa haw this d.y aenfully
examined tM lbilowing Ilued and daacrlDed aniclea, the propany aC
NAME: Mr, Chuck Schaal
ADDRESS: I 1 Helam Drive
Mechanicsburg, PA 17055
We estimue the value ss listed for Instuance or other purposes at the current mail value, excluding Federal and other taxes. In maltlllg this A.ooraisd we DO NOT aloes to DLL[Clt8f6 Or reolax
The following items were evaluated for estate purposes:
DESCRIPTION
Lady's 14K white gold diamond ring. Each of the five round central diamonds
measures approximately 2.Smm - 4.lmm in diameter. These are framed with eighteen, 1.3mm -1.Smm single cut
diamonds, 23 = .78ctw. The clarity is VS. The color is G-H. Each crown is 14K white gold with four prongs. The
shank measures 9.3mm tapering to 1.7mm. This is constructed from amulti-piece calst assembly.
Value: 5640.00
~-----
JA s D. DAMS P.G.
April 8, 2008
The foregoing Appraisal is made with the utldastudiag that the Appraiser aswmes ao liability with respect to any action thu may be taheo on the basis of this Appraisal.
301 East Main Street • Mechanicsburg, PA 1755 • (717j 795-9224
~~~~
JOSEPIi DAMES JEWELERS
TO WHOM IT MAY CONCERN:
This is to certify thu we us engaged in tha jewelry business, sppnising diamonds, watches, jewelry and praciow cones ofall descriptions. 'iVe herewith certify that we have this day carefblly
examined the following listod and described articles, the property of:
NAME: Mr. Chuck Schaal
ADDRESS: 11 Helam Drive
Mechanicsburg, PA 17055
We estimate the value as listed for inwrance or other purpous at the current ratan value, excluding Federal and other taxes. In making this Appraisal we DO NOT agrae to ptuclYSe or replace
The following items were evaluated for estate purposes:
DESCRIPTION
Lady's strand of cultured pearls. Each of the eighty-nine cultured pearls measures
approximately 3mm -7mm in diameter. The color is a creamy white with good lustE;r. The clasp is 14K white gold
with one 1.Smm single cut diamond.
Value: $90.00
Apri18.2008
JAM . DAVIS P.G.
The foregoing Appraisal is made with the undarAanding that the Appraiser aswmes no Lability whh respect [o any salon [hat may be taken on the basis of this Appraiul.
301 East Main Street • Mechanicsburg, PA 17055 • (717) 795-9224
~~~~~
JOSEPIi JAMES ~EWE~ERS
TO W HOM IT MAY CONCERN:
This is to txxtity that we aro engaged in the jeweky business, appraising diartands, wuchea, jewelry and precious uona of all descriptions. Wa huewlth rceattity that we lava this day ruefully
examined tM folbwina listed end described ertioles, the property ot`.
NAME: Mr. Chuck Schaal
ADDRESS: 11 Helam Drive
Mechanicsburg, PA 17055
We euitnue the value as listed for insurance or ahu purpows at the currem retail vdue, excluding Federal and txhu taxes. In malcinu this P.poraisal we DO NOT aurae to purchase or replace
The following items were evaluated for estate purposes:
DESCRIPTION
Lady's platinum diamond ring. The old European cut diamond measures
approximately 4.62mm - 4.72mm in diameter x 2.7mm deep. This diamond weighs approximately .42ct. The
clarity is VS-. The color is H. This is framed with ten, 1'.Smm - 1.7mm single cut diamonds, approximately .16ctw.
This is designed and manufactured by Kasper & Esh. This is constructed from a three piece die struck assembly.
The central diamonds has several chips on the girdle. The shank and prongs display excessive wear.
Value: $210.00
Apri18, 2008
JAMES . DAVIS P.G.
The foregoing Appnisal is made with the underuandiag the the Appraise ass;.ua rip liability with respect to any cation tlut may be tskon on the basis of this Appraisal.
301 East Main Street • Mechanicsburg, PA 17055 • (717i 795-9224
WEST SHORE EMS -BLS
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: MARY LORE PATIENT NUMBER:
CALL NUMBER:
INSURANCE: MEDICARE B 153014840D DATE OF CALL:
CAPITAL BLUE CROSS YWM80031672600 TIME OF CALL:
CALLER:
171453W FROM:
TO:
MARY LORE
11 HELLAM DR REASON(S)
IYIECHANICSBURG, PA 17055 FOR
TRANSPORT
INVOICE
~_
~~
°~il'.R(~I?N['1' :~11'1)ICAI 51=..R\'li'Pti
5962~i WCS
1714;i3W NONE
02/2812008
02:45 PM
HOLY' SPIRIT HOSPITAL
HOLY' SPIRIT HOSPITAL
WEST" SHORE HEALTH AND REHAB ,. ~
Syncope n ~`~.• ~ ~ ~ ,,
~ ~.
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher One Way Transport A0999 1.0 91.49 91.49
Transport Van Mileage A0999 1.0 3.40 3.40
Oxygen Administration A0422 1.0 58.96 58.96
Total Charges 153.85
DESCRIPTION OF,PAYMENT
RECEIPT ..
PAYMENT;'PATE
AMOUNT,
Total Credits 0.00
PLEASE PAY 7HIS AMOUNT -INVOICE DUE UPON RECEIPT ~-~-
RETURNED CHECK FEE - $31.00 $153.85
2 I`L
~~
/.
J
~`
--
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT Due 153.85
PATIENT NAME: LORE, MARY CALL NUMBER 171453W AMOUNT S
PATIENT NUMBER: 59625 BILLING DATE: 03/06/2008
ENCLOSED
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL ---- -
ASSISTANCE. y~y~ VISA
ANA _ _.---_.__ _.
MASTER CARD
ACCEPTED
WEST SHORE EMS -BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
STATEMENT OF PHYSICIAN SERVICES
' PIRIT PHYSICIAN SERVICES MARY LORE 1 ~ 2
15 GRANDVIEW AVE STE 210 11 HELLAM OR
AMP HILL PA 17011 MECHANICSBURG PA 17055.6130 sTATEMEKr
DATE: 04!12/08
LAST STATEMENT
ACCOUNT # 1465384 DJ-rE:
IF ES AC
F ~ •f~1 ~J r SERVICES 717-97244,90 FED TAX ID #251766971
f ,.
~ _ r°
s,
~~
,~«a; ~ '1
•» PATIENT: MARY LORE 1465384
PERFORMED BY: 60KHAN MD M®
PLACE DF SVC: 21
PERFORIED AT: HS
02/23/08 94223 441.21 OQTIAL HOSP CARE LEVEL I
03/17/08 !CARE ERA PMtT
03/17/08 MCARE ERA CONTR/ADJ
04/07/08 BLUE CROSS PAYMENT
PERFORMED AT: HS
02!24/08 99232 491.21 SUBSEQUENT HOSP, LEVEL II
03/17/08 MCARE ERA PMtI'
03/17/08 !CARE ERA CONTR/ADJ
04/07/08 BLUE CROSS PAYMENT
PERFORMED AT: HS
02/25/08 94232 491.21 SUBSEQUENT MDSPs LEVEL II
03/17/08 !CARE ERA PMT
03/17!08 !CARE ERA CdVfR/ADJ
04t/07/08 BLtR: CROSS PAYMENT
PERFORMED BY: TAPASDIP GAJJAR MD MD
PERFORMED AT: NS
02/26/08 99232 491.21 SUBSBQUENi' HOSP, LEVEL II
03/17/08 MCARE ERA PMi
03/!7/08 MCARE ERA CONTR/ADJ
04x/07!08 BLUE CROSS PAYMENT
PERFORMED AT: MB
02/27/08 44232 441.21 SUBSEQUENT HDSP, LEVEL II
03!17/08 MCARE ERA PMf
03/17/08 MCARE ERA CONTR/AQJ
04x!07/08 BLUE CROSS PAYMENT
PERFORMED AT: HS
02/28/08 44238 491.21 NOSPITAL DLSCHAA6'E c30 MI
03/17/08 MCARE ERA PMT
03/17/OB MCARE ERA COFITR/ADJ
04/O7/OB BLUE CROSS PAYMENT
DADICATES NEM F~IAMMCIAL ACTIVITY SIMCE LAST BILL.
1 -APPLIED TD YOUR DEDUCTIBLE
PATIENT BALANCE SJIDMN ON THIS STATEMENT IS OUE FROM YdM. PLEASE
REMIT FULL AMEABIT PRONE+'TL.Y. PAYMENT IS DUE UPON RECEIPT OF TNLS
STATEMENT.
aaeeEl'IESE SERVICES MERE PROVIDED BY SPIRIT PHYSICIAN :eaeE
aeee:gERVICES AND ARE SEPARATE FROM ANY HOSPITAL FEES ~eeeE
~eeetPLEASE CALL 717-972-4490 MR1'H ANY QUESTIONS aeaeE
~eee:138CERNING TNESE CHARGES. jeeeE
33.26-
24.97-
8.31-(' 126.46
4x4.46-
11.18- ~ ~~~
12.36- .00
44.46-
11.18-
12.36- 0.00
44.46-
11.18-
12.36- 0.00
49.4b-
11.18-
12.36-
0.00
50.34-
37.D7-
12.59-
198.OD
- DED
73.00
73.00
73.00
73.00
100.00
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK