Loading...
HomeMy WebLinkAbout08-20-08,COMMONWEi{LTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, Pa 171za-gaol * REY-1543 EX AFP (09-DO) INFORMATION NOTICE AND TAX P AY E R R E S P O N S E * REVISED NOTICE * * * FILE ACN DATE p p N0. 21 ~~) b~' 08132829 08-12-2008 TYPE OF ACCOUNT EST. OF CARMELA L NAPOLI ~ SAVINGS S.S. N0. ~ CHECKING DATE OF DEATH o6-20-2008 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMEN T AND FORMS T0: THERESA NAPOLI REGISTER OF WI LLS 1316 WELL DR CUMBERLAND CO COURT HOUSE CAMP HILL PA 17011-1233 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a ioint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. puestions may be answered by calling (717) 787-8327. CGMPLETE PART 1 BELOW * * ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0 1 95163317-050 Date 10-14-1999 To insure vroper credit to your account, two Established (2) copies of this notice must accompany your 23, 007.75 payment to the Register of Wills. Make check Account Balance payable to: "Register of Wills, Agent". Percent Taxable X 50.000 11 , 503.88 NOTE:: If tax payments are made within three Amount Subject to Tax (3) months of the decedent's date of death, Tax Rate X 12 you may deduct a 5i discount of the tax due. Any inheritance tax due will become delinquent Potential Tax Due 1,380.47 nine (9) months after the date of death. PART TAXPAYER RESPONSE 1 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~ :::::::::::::::::::::::::,.,.,.:.,.,.:.:.,.,.,.,.:.,.,.:.,.,.:....................................................................................................................... . :~~~R:;'f~l€ ~~~~. #?':~IMD;;~1 ~:L~::sR:E~.~! E.fi.:IN:~:~:;AN.... #~ F.F..I~ I~kE....... :.. ,; :: ~. ~: ~:~:: > :. ~:: :::::;: ."CAS:: ~~i:~ S.E~~N.EH.T......BA~:ED....:QN _: fiH:I:S :::::::.. .. . . ..._.. ..............................................:.........................................:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.::::::::::::::::::::::-,:::::::::::::::.:........................................................................:.................................... N d.TI.C E ... A. ~ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of C 0 N E ~ Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid wii:h the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the decedent's representative. C. ~ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. If ou indicate a d' €:~;:~;:~;:~;:::::::~::ss:sus:s ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,::;- :::::;: ~:::.....:::::::::~:::::::::: PART y afferent tax rate, please state your ... .::::::. ~ :.::: . ~ ::::::::::::::,•: : _~::: i~€€~ ~ ~':''siiiiEsiEi':iE ~ ~'s':siiiii~~si": ' `:`iiiiil~i~L~ : ,:~:.:;~::::,~:::`::~::::~ ., , .::~: r e l a t i o n s h i p t o d e c e d e n t: ::::::::.:.:.:.:.:.:.:.:.:.:................................... .:.....::::::::::::: ~:; ~ ,~r.:::::;:s:::l•~I: ~i::: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 11,503.88 5 _ 734.03 6 10,769.85 7 x .12 B 1,292.38 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID 6/27 08 krei D Services 478.00 Pinnac e Hea P ysician Services ~ •JL L, nt lt]\.11 L' L ) r,- w.. amine ~ ur i ax ~omputaia on) S Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C 71 7 ) 763- 9590 -~~' ~ ' ~ ,~~ ~ ~ ~~<< y(' t..C.~tY " WORK C ) ~ ~ g u S TAXPAYER SIGNATURE TELEPHONE NUMBER DATE GENERAL INFORMATION FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. Inheritance tax becomes delinquent nine months after the decedent's date of death. A joint account is taxable even though the decedent's name was added as a matter of convenience. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. Accounts established jointly between husband and wife more than one year prior to death are not taxable. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "T ax paver Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 260601, Harrisburg, PA 17128-0601 in the envelope provided. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one C1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (~~) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. Enter the total balance of the account including interest accrued to the date of death. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7% (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50% (TAXABLE FOR EACH SURVIVOR) The amount subject to tax (line 4) is determined by multiplying the account balance Cline 2) by the percent taxable (line 3). Enter the total of the debts and deductions listed in Part 3. The amount taxable (line 6) is determined by subtracting the debts and deductions Cline 5) from the amount subject to tax (line 4). Enter the appropriate tax rate (line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%* 12% 15% ^The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0%. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x I1". Proof of payment may be requested by the PA Department of Revenue. DEe rs' . v ~ v D, ~D [ x ~ ~o ~ n a' / a ri v T~ DATEPALD PAYEE L~ESSCX~77011V 3/26/08 EASTPE/I~V 11AIf~SEIPVKf.Y' S/S/O18 EASTPE/I~N AMBUCA/IKFSERV1CfS' 6/14/08 EASTPE/V/V AMB[I[AIIK.ESERVICES ,~• ~. i .r~.~ 46.00 40.50 40.50 TOTALS 734.03 Account #: PHE 910075428 Please Pay: $478.00 05/28/08 KRIEG DO CC E/M CRITICALLY ILL/INJ MEDICARE PAYMENT DENIED/REDUCED PER COB PLEASE CONTACT OUR OFFICE TO UPDATE Payment Due: 07/O6/of 478.00 475:00 .00 ~~ ~ ~ IMPORTANT NOTICE '~*~~ Account mss- ~~~ PAYMENT IN FULL IS REQUIRED. IF YOU ARE UNABLE TO Balance: Amount Due PAY IN FULL, PLEASE CONTACT US IMMEDIATELY TO MAKE FORMAL PAYMENT ARRANGEMENTS. $478.00 $478.00 Patient Name: CARMELA NAPOLI Physician Services Provided By: .~:`"' To Pay Your Bill Oniine Billing Inquiries: PINNACLE HEALTH EMERG Please Visit: PO BOX 8500-55168 440-717-5555 or 800-579-7777 PHILADELPHIA PA 1 91 78-51 68 w.,~~ www.shclbillpay.com/PHE E-MAIL: questions@shcservice.cc MON. - FRI. 8:OOam to 6:OOpm E; 3888 ~" ,~ 4> CARMELA NAPOLi 1316 WELL DR CAMP HILL PA 17011-1233 STATEMENT DATE: 05~20~0$ LAST STATEMENT ~ of ~ PII~JNACLEHEALTH AccouNT # 501823 DATE: - ~~` IF ANY QUESTIONS, PLEASE coNTACT: PHMS AT 717-231-8960 OR 1-800-565.6229 \ FED TAX ID # 25170905 PROCEDURE C-IAG DATE. QTY DESCRIPTION PAYMENT! iNS CHARGE GUARANTO CODE CODE ADJUSTMENT BALANCE »> PATIENT: CARMELA NAPOLI 20401b307 IP D425D8 043008 5720401b307 04/25/oe Ta PERFORMED BY: ENDOCRINOLOGIST * 04/28/08 99253 250.02 INITIAL INPT CONSULT LVL3 135.00 * D5/20/08 MEDICARE PAYMENT 84,69- * D5/20/D8 MEDICARE ADJUSTMENT 29.14- ~ 05/20/08 MEDICARE TRANSFER 21.17 * 04124/08 94232 250.02 SUBSEQUENT HOSP CARE LVL2 7b.00 ~__~.-~~'~ * 05/20108 MEDICARE RAYMENT 49.46- * 05/2D/OB MEDICARE ADJUSTMENT _. 14.18- __---~~~. * 05/20/08 MEDICARE TRANSFER ` ~ ~~ ~ \ , 12.3b ~ INDICATES NEW FINANCIAL ACTIVITY SINGE LAST BILL. OTHER CHARGES BILLED TO INSURANCE 48D.D0 FULL PAYMENT ON YOUR ACCOI~IT BALANCE IS DUE. IF THIS BILL ODES NOT REFLECT THE CORRECT INSURANCE INFORMATION, PLEASE CONTACT DUR OFFICE. THANK YOU FOR USING PINNACLE HEALTH MEDICAL SERVICES. OUR OFFICE HDQRS ARE 8:30AM TD 4:DOPM, MONDAY, WEDNESDAY, FRIDAY AND 8:30AM TO b:ODPM TUESDAY AND THURSDAY THIS BILL REFLECTS CHARGES FOR PHYSICIAN SERVICES PROVIDED BY PINNACLE HEALTH MEDICAL SERVICES. PLEASE NOTE, ANY LAB DR DIAG~DSTIC SERVICE WILL BE BILLED SEPARATELY THROUGH PINNACLE HEALTN HOSPITALS OR AN INDEPENDENT LAB. PAGE APOLI 2 u 1316 WELL DR CAMP HILL PA 77011-1233 STATEMENT ' DATE: 05/20/08 LAST STATEMENT 1~Il~Nr~CLEF~EALTH AccouNT # 501823 DATE: IF ANX QUESTIONS, PLEASE coNTACT: pHM3 AT 717-231-8960 OR 1-800-56x6229 FED TAX ID # 25170905 PR(3CEDURE DIAG QTY DESCRiPT1ON DATE CODE CODE INS 'CHARGE- PAYMENTf GUARAN A[)JUSrt'MENT _ BALAN 3Be~ GUARANTOR RESPONSIBILITY ~ ~ 33.53 ~~ ~ tG ~ ~~5~6 ~/ Pb ~,(f~`l off' ~~.an~or~ur- of ~a..s nFrfCH l.YO N~TVRN 4tirT~M ~=^ria~-v~~....--0axa:~aawu~e~w.2tC_Y.I,}4~4.P-AYJIE..N.T_~._.-___:_ _. - East Pennsboro Ambulance Service, Inc. Post Off ce Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Tax Number 23-2464545 Invoice DATE INVOICE # 2!7/2008 08-239 BILL TO PATIENT NAME: Carmella Napoli Napoli,Carmella ADDRESS: 1316 Well Dr. 1316 Well Dr. Camp Hill, PA 1701 1 ADDRESS: Camp Hill, PA 17011 PICK UP: Holy Spirit Hospital TAKEN TO: Manor Care West DESCRIPTION: Wheelchair TRIP NUMBER 08-14372 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 2/6/2008 Van Rate 1 Way (Non-Member) 4~:A '~~- ~~ Vt~C~ ~S~ ~~ f'' ~p ~ ~, For your convenience, we now accept Mastercard, Visa and Discover. Card Type: Name on card: Credit Card Number Eapiration:_ _1 _ Amount to be charged: $ I agree to pay We above total amount according to card issuer agreement. TOTAL DUE Comments: Paymeat due upon receipt. Medicare and most insurances do not cover this service. Unpaid accounts Y will be sent to a collection agency aRer 90 days. East Pennsboro Ambulance Service, Inc. Post Offrce Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Tax Number 23-2464545 BILL TO Napoli,Carmella 1316 Well Dr. Camp Hill, PA 170] 1 I TRIP NUMBER I Invoice DATE INVOICE # 2/25/2008 08-376 PATIENT NAME: Carmella Napoli ADDRESS: 1316 Well Dr. ADDRESS: Camp Hill, PA 170] 1 PICK UP: Manor Care West TAKEN TO: 2250 Millennium DESCRIPTION: Wheelchair 08-14415 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 2!22!2008 Wheelchair Transport -Round Trip 55.00 55.00 t 1 ~~ ~. ~y ~ l f `J~ ~T '\`{j V ~~ ~, ~~, ~ .~~- ,~, ~ For your convenience, we now accept Mastercard, Visa and Discover. Card Type: Name on card: Credit Card Number Eapiration:_ / _ Amount to be charged: $ I agree to pay the above total amount according to card issuer agreement. TOTAL DUE Signature: Comments: Payment due upon receipt. Medicare and most insurances do not cover this service. Unpaid accounts will be sent to a collection agency after 90 days. $ 5 5 , 0~ East Penasboro Ambulance Service, Inc. Post Office Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Tax Number 23-2464545 BILL TO Napoli,Carmella 1316 Well Dr. Camp Hill, PA 17011 PATIENT NAME: ADDRESS: ADDRESS: PICK UP: TAKEN TO: DESCRIPTION: Invoice DATE INVOICE # 31]4/2008 08-530 Carmella Napoli ]316 We11 Dr. Camp Hill, PA 17011 Harrisburg Hospital Health South Rehab Wheelchair TRIP NUMBER 08-14767 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 3/13/2008 Van Rate 1 Way (Non-Member) 46.00 46.00 ~ '~ ~~~ ~ ~~ (P .,(~ .d `rl For your convenience, we now accept Mastercard, Visa and Discover. Card Type: Name on card: Credit Card Number ---- ---- ---- ------ Eapirstion:_ / _ Amount to be charged: $ I agree to pay the above total amount according to card issuer agreement. TOTAL DUE Signature• Comments: Payment due upon receipt. Medicare and most insurances do not cover this service. Unpaid accounts will be sent to a collection agency after 90 days. $46.00 East Pennsboro Ambulance Service, Inc. Post Office Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Tax Number 23-2464545 BILL TO Napoli,Carmella 1316 Well Dr. Camp Hill, PA 17011 I TRIP NUMBER I 08-15304 Invoice DATE INVOICE # 5/1/2008 08-951 PATIENT NAME: Carmella Napoli ADDRESS: 1316 Well Dr. ADDRESS: Camp Hill, PA 17011 PICK UP: Harrisburg Hospital TAKEN TO: Osteopathic Hospital DESCRIPTION: Whee]chair DATE OF SERV... I DESCRIPTION I UNIT I RATE ~ AMOUNT 14/30/2008 Van Rate-1 Way Member Discount 40.50 40.50 V `'~5 a. ~i~i~ ~~~ ~~~ For your convenience, we now accept Mastercard, Visa and Discover- Card Type: Name on card: Credit Card Number ---- ---- ---- ---- Eapiration:_ / _ Amount to be charged: $ I agree to pay the above total amount according to card issuer agreement. TOTAL DUE Signature: Comments: Payment due upon receipt. Medicare and most insurances do not cover this service. Unpaid accounts will be sent to a collection agency after 90 days. $L~Q, SQ East Pennsboro Ambulance Service, Inc. Post Office Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Taz Number 23-2464545 BILL TO Napoli,Catmella 1316 Well Dr. Camp Hill, PA 17011 PATIENT NAME: ADDRESS: ADDRESS: PICK UP: TAKEN TO: DESCRIPTION: Invoice DATE INVOICE # 6/12/2008 08-1302 Carmella Napoli 1316 Well Ih. Camp Hill, PA ]70] 1 Hamsburg Hospital Health South Ltach Wheelchair TRIP NUMBER 08-15749 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 6/1 ]/2008 Van Rate-1 Way Member Discount 40.50 40.50 C:= ~t~.:~~ ~ ~ f~ ~' t ~~;~~/~3 ~~© For your convenience, we now accept Mastercard, Visa and Discover. Card Type: Name on card: Credit Card Number Eapiration:_ ! _ Amount to be charged: $ I agree to pay the above total amount according to card issuer agreement. Signature• Comments: Payment due upon receipt. Medicare and most insurances do not cover this service. Unpaid accounts will be sent to a collection agency after 90 days. TOTAL DUE $40.50 COMM,:NWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INFORMA AND NOTICE FILE N0. 21.~~`.~ TAXPAYER RESPONSE ACN 08132828 * * REVISED NOTICE * * * DATE 08-12-2008 REV-1543 EX AiP f99-00) THERESA NAPOLI 1316 WELL DR CAMP HILL PA 17011-1233 __ _. TYPE OF ACCOUNT EST. OF CARMELA L NAPOLI ^ saVINGs $.S. N0. 204-01-6307 ^ CHECKING DATE OF DEATH 06-20-2008 ^ rRUSr COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 P SECU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Funeral Services 11 342.07 Cat o is Cemeter Grave 0 enin g Service nonation 2 19 08 Hol S irit P Ser Ph sician Services IUTAL ctnier on L1ne 5 of Tax Computation) $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and co/mpl-ete to the best of my knowledge and belief. HOME C 71 7 ) 763-9590 TAXPAYER SIGNATURE TELEPHONE NUMBER DATE GENERAL INFORMATION I. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. b. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLDCK A - If the informatioh and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part I of the "Taxpayer Response" section. Sign on. copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions helow. Sign two copies and submit them with your check for the amount-of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in joint names within one C1) year of death are taxable fu11Y as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (*~) appears before your first name in the address portion of this notice, the S3,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 1DD = PERCENT TAXABLE JDINT OWNERS SURVIVING JDINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7% (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): I DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ ,50 X 100 = 50% (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). 7. Enter the appropriate tax rate (line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%~ 12% 15% *The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0%. The lineal class of heirs includes grandparents. Parents, children, and lineal descendents. "Children" includes natural children whether or not they have beenadopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may 6e requested by the PA Department of Revenue. ,~, ~~ ~~ a ~ A Family Tradition Of Caring® PARTHEMORE Funeral Home & Cremation Services, Inc. Miss Theresa L. Napoli 1316 Well Drive Camp Hill, PA 17011 1303 Bridge Street P.O. Box 431 New Cumberland, PA 17070 (717)774-7721 (Fax)774-5546 www.parthemore.com Gilbert W. Parthemore, Founder Gilbert J. Parthemore, Supervisor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC Professional Memberships: NFDA•PFDA DCFDA•CCFDA m~„eno.d o.,+,. N+n~ GC~~~ ULE The Rule You Know; The People Yocr Trust _~~HI /-\ ~~ - - ~ ~ i For the service of Carmela L. Napoli 7!9/2008 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, faci]ities, automotive equipment and merchandise that you selected when making the funeral arrangements. Terms Due Date Account # Net 30 8!8!2008 2008063.0 Description Amount SERVICES & MERCHANDISE Memorialization Funeral Service Grouping 5,910.00 18 Gauge Steel Pieta Casket 2,795.00. 12 Gauge Galvanized Steel Vault 1,690.00 Total Services and Merchandise 10,395.00 CASH ADVANCE ITEMS ~ Death Notice, Harrisburg Patriot 188,27 7 Certified Copies of Death Certificate 42.00 ~ Clergy Honorarium 200.00 Organist Honorarium 125.00 Soloist Honorarium 75.00 Altar Servers 20.00 Flowers, Casket Spray 296.80 Total Cash Advances 947.07 l ~~ t I ~ : i`~ ; ~~ ~~~ Thwrk yon. hl~asc c.4 ~1 ~~ Total $11,342.07, W~ rYta~~ be a ScrVICC PaymentsJCredits $o.oo . Balance Due ~-~ - - -• r v/uuw $11,342.07 Office of Catholic Cemeteries 1Diocese of Harrisburg PO Box 3651 Harrisburg, Pennsylvania 17'105 Phone (717) 657-4804 Invoice No. I-2-1384 ~n-vo~cE - customer Name THERESA NAPOLI Address 1316 WELL DR _ _. City CAMP HILL State PA ZIP 17011 Phone __ _____ Date 6/28/2008_ Order No. I-2-1384 Rep Gate of Heaven _ Terms 90 DAYS --Date ~- - ~_ - --p Description - - - ___- __ _ T L_ - ---- ; -\ 06!23/08 ,Interment for Carmela L. Na oli ~ $850 00~ \ 1 ~: I ,~ - ,, .--/ 1 f SubTotal i _____ $850.0 $0.00 TOTAL $850.00 Please return one copy of this invoice along with your payment. !f not paid within 90 days from the date of this invoice, a finance charge of 6% will be added. CHURCH OF THE GOOD SHEPHERD 3435 Trindle Road Camp Hill, PA 17011-4489 (717) 761-1167 Fax: (717) 761-5313 July 31, 2008 The Estate of Carmela Napoli c/o Theresa Napoli, Executrix 1316 Well Drive Camp Hill, PA 17011 Dear Ms. Napoli, This letter is to acknowledge receipt of a check from the Estate of Carmela Napoli in the amount of Three Hundred ($300) Dollars to the Good Shepherd Church Helping Hands far the funeral luncheon for Carmela Napoli, which took place on June 23, 2008. Thank you for the generous donation to Helping Hands. Sincerely yours in Christ, 4 ~~~~ Reverend Paul C. Hel i Pastor kem " ` STATEMENT OF PHYSICIAN SERVICES ~-~. k ~ , SPIRIT PHYSICIAN SERVICES CARMELA NAPOLI _ ~ PAGE ._ 1 of 2 205 GRANC-VIEW AVE STI 210 1316 WELL DRIVE CAMP HILL. PA 17011 CAMP HILL PA 17011-1233 --- STATEMENT DATE: 02~09~08 LAST STATEMENT ACCOUNT # 1525849 DATE: IF ANY QUESTIONS, PLEASE CONTACT: SPIRIT PHY SICI AN SERVICES 71T-972-4490 L ~ FED TAX ID # 2517669T h'ROCEDURE DATE CODE DIAG CODE ..QTY DES. CRIPTION INS `CHARGE PAYMENTI GUARANTnI . - ; ADJUSTMENT BALANCE »> PATIENT: CARMELA NAP'OLI 1525849 PERFORMED BY: VIDA FARHI MD MD PLACE OF SVC: 21 PERFORMED AT: HS ~ 01/24!07 44233 428.4 SUBSEQUENT HDSP, LEVEL II 102.OD 1D2.D0 PERFORMED BY: GOKHAN GORMUS MD MD PERFORMED AT: HS * O1/28/D8 44223 428.4 INITIAL HDSP CARE LEVEL I MID 148.OD PERFORMED BY: VIDA FARHI MD MD PERFORMED AT: HS * D1l30/DS 44233 428.4 SUBSEQUENT HOSP, LEVEL II M10 102.OD PERFORMED AT: HS ~ D2/D1/DB 94233 428.9 SUBSEQUENT HOSP, LEVEL II M10 1D2.OD PERFORMED AT: HS * 02/D2/DS 44233 428.9 SIBSEQUENT HDSP, LEVEL II M10 102.OD PERFORMED AT: HS ~ 02lD3/D8 99232 428.9 SUBSEQUENT HDSP, LEVEL II M10 73.00 PERFORMED AT: HS * DZ/D4/08 44232 428.9 SUBSEQUENT HOSP, LEVEL II M10 73.OD PERFORMED AT: HS * D2/D5/OS 44232 428.9 SUBSEQUENT HOSP, LEVEL II _ ~ "`` MID 73 D0 BALANCE: CARMELA NAPOLI r$102.00 . ~ INDICATES NEN FINANCIAL ACTIVITY SINCE LAST BILL PATIENT BALANCE SHOhN ON THIS STATEMENT IS DUE FROM YOU. PLEASE REMIT FULL AMDI~(f PROMPTLY. PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT. 3eee~THESE SERVICES HERE PROVIDED BY SPIRIT PHYSICIAN 3sese 3eeeESERVICES AID ARE SEPARATE FROM ANY HOSRITAL FEES 3eese ~sesEPLEASE CALL 717-472-4440 NITN ANY QUESTIONS 3eeee 3eeetCONCERNIN6 THESE CHARGES. 3eeeE ~/ ,-- -- ,, ~ ~; ~~ 4 Q\ ,~ ~~ ~~ \~~ ~~ ^CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK ~.. ~3uaeantor`s Name iF ~'tiERE ~FiE A-~tY 9UtfSSPELLII~lGS OR ERR®FiS, ALEASE P6~[h,El' ~t?RRECT!(3P~lS.. Phcn:: # Guarantar's Address i-_----------------_-- , Giiy (State I Zip Code ~~f~Q~Y Patient'sfielationshipto#nsured ~ ? ~~,C4~~~~~ ~Patien~sRelationshipta#n I ^ SELF ^ SPOUSc ~e A~wC ~~rJ~DRAE~ICiE ~y'~~~~1"14ic - ^ SELF ^ SPSSUSE ~ -~L, CHSlD ^ OTHE`ri ---T ~p~+.i ~~j p~.i~+[~/^~'j p/~ ~7Y.~7b/FilPi.5•Ss~ ylEY~r'!lY~.~~ _---`-- C N ~ ~_[] CHILO ^ oTHER_ Phone # #nsurance Company Flame Phone # ompany ame #nsurance -~----- ' --- I i #rsurance Company Address I ~ #' nsirrance Company Address; t------- ------ ~ Policy #io#der's Name --~ , -- Birthda'te I I Pa#icy Ha#der's Name 6irthdate ~ I I ~------ -- -- - --- ------ 3 G # P #i -- t ----- Policy Effective D~ ~ Po#icy & Group # Folic Effective Date y roup n cy i ~ ~ I i _ -------------- I ----- ------ # Ph - ~ I ~ i--- --- ------- - ---- - --- - Empioyse's Name ----- --------------- Phone #: ~r,ptoyee's Name one i ~ ~ z r ~-- ~---- -- --- --- ' ~ - r - --- ---- ---- i Emp#oyer's Address - --- I I Emp#oyer's Address •• STATEMENT OF PHYSICIAN SERVICES .___-- _ 2 of 2 CARMELA NpPOLI SPIRIT PHYSICIAN SERVICES 1316 WELL DRIVE STATEMENT 205 GRANDVIEW AVE STE 270 CAMP HILL PA 17011-1233 DATE: 02(09108 CAMP HILL PA 17011 LAST STATEMENT 1525849 DATE: ACCOUNT # N SERVICES TIT-972-4490 FED TAX ID # 251766971 ~.. ANY QPR~~R~ ~~~NTACT: SPIRIT PHYSICIA ION 1~ CHARGE ADJUSTMENT BALANCE Q'IY DESCRIPT PAYMENT! Gi7ARANTOR IF DATE: .CODE Ci~DE ~,~~ l ~i~ i`' ~ ~I W ' (vl L7 ¢ Y / ~ Q ~- ~ N F- b ^ ~ OOJ-. •z ~l ~'M ¢2n^OJ~•o mad -C~2 ~'To • E ~ ~ Q Q V M O n w" ~ I.f7 f" W O ~ -N _u ~ O N ~ !-~ o Q. v r C 1.~ <_~; _~ ~~ ~~ r ~~~~ ~- ...~~~ ~~..~~ ~.~- ~~ ~~...--- r ..r .s ~ ~~ Q"' O r~ O 0 0 0 0 a O O O N ~~~ L_ ,~~ ~~ i w~ l_ - L, _ . LJ ~_ - CJ ~_ '1 0 ~~ ~` ,~ V ~,s ~•• W l.r~ ~ 6~1 ~~ 'd ~~' ~~`~'~ R ~~ wi v ~ ~~ .. ~~ Li~C