HomeMy WebLinkAbout04-0092 PETITION FOR PROBATE and GRANT OF LETTERS
Estate ofANNABELLE SWEGER, No. ~ ~ - ~'[ - qB
also known as To: Register of Wills for the
Deceased. County of Cumberland in the
Social Security No. 196-14-0495 Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner is 18 years of age or older and is the Executrix named in the Last Will and
Testament of the above Decedent, dated May 22, 2002, and codicil(s) dated [none]. : ·
Decedent was domiciled at death in Cumberland County, Pennsylvania, with h~:r last family or
principal residence at 442 Walnut Bottom Road, Carlisle Borough, Pennsylvania. , ~
Decedent, then 92 years of age, died Janaury 14, 2004, at Thornwald Home, 442 Walnut
Bottom Road, Carlisle Borough, Cumberland County, Pennsylvania.
Except as follows, Decedent did not marry, was not divorced and did not have'a child born or
adopted after execution of the Will offered for probate; was not the victim of a killing and was never
adjudicated incompetent: [none]
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ 65,000.00
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows: None
WHEREFORE, Petitioner respectfully requests the probate of the Last~/,Will and Testament
presented herewith and the grant of letters testamentary thereon./~ ~/g6oa . ~)//'~ ~/r)~//~,__~ ....
Doris'D~ihl
931 North College Street
Carlisle, PA 17013
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
The Petitioner above-named swears or affirms that the statements in the foregoing Petition are
true and correct to the best of the knowledge and belief of Petitioner and that as Personal Representative
of the above Decedent, Petitioner will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed
before me this 30th day of Doris Delhi
January, 2004.
~C~..~ ~ Register
Estate of ANNABELLE SWEGER, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW, ~~ .~ ,~,C) , 2004, in consideration of the Petition on the
reverse side hereof, sat ctory proof having been presented before me,
IT IS DECREED that the instrument dated May 22, 2002, and described therein be admitted to probate
and filed of record as the Last Will of Annabelle Sweger and Letters Testamentary are hereby granted to
Doris Delhi.
Will Book #
Page Registerer ~3~ills
FEES Stephen L. Bloom, Esquire
Probate, Letters, Etc. $ !t,~ .(Dc% Sup. Ct. I.D. No. 49811
Short Certificates $ l,,. ~)c~ 2100 Longs Gap Road
~ ~c~ $ q.c~o Carlisle, PA 17013
~_)~o $ t O. c~,~ (717) 249-7717
TOTAL $
Filed [ - 2,C~ -~.~o ht
C \\Office - Estate Administration\8659 2pet. l.doc
I0S.80~, REV 9/86
This is to certiB/that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WAFINING: It is illegal to duplicate this copy by photostat or photograph.
ocal Registrar
P 9 9 9 0 4 5 3 JAN 1 5 200
No. ~ Date
H105.143 Rev. 2/87
COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH * VITAL RECORDS
CERTIFICATE OF DEATH
SEX OClAL SECURFP¢ NU~BE'~'~ DATE OF DEATH
.~K INK 1. ,~[~be ,]...~e St;~e(~er "]'2 ~ ~ -' - '-r (Month. Day. Year)
I ..... I 'Jays I Hours I Minutes I (Mo.th, Day, Year) I ~{~;'~oreietn"'~ua~t°~,* ~rH h n . - in in ~sidel *
DECEDENT'S USUAL OCCUPATtON 10 '~'1 'te
~ ' '~ ~ .... ~ ~ ~..~ o~ Carlisle
,,. Allen William Albright
~ ~Morriso~
~4E~ '-r ~lege St., Carlisl
CAUSE (DtM~e or injur~
reMM~lng on deel~i ) I.~T d
/COMPLETION OF CAUSE I Natura~ ~ fha:mm D v ¥ ) .
.~ OF DEATH? /Ac~:Jent [._] Homicide
Yel. [] No ~JJ Yes [] NO [] J Suicide [] Pending Investigation
Co~ld not be d .... inecl []~ M. Ye, [] No []
~y one)
LAST WILL AND TESTAMENT
I, ANNABELLE SWEGER, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking any and all former Wills or Codicils by me
made.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and all
inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any
property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representative shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
I direct that my Executor shall sell all of my property, both real and personal, and, after the
payment of all the expenses of my estate, shall distribute the residue in the following manner:
(A) The sum of Two Thousand Dollars ($2,000.00) shall be set aside and held in trust
by my personal representative or her successor(s) for the purpose of purchasing,
in such quantity and for such prices as shall be determined in the sole discretion
of such personal representative or successor(s), floral arrangements for periodic
placement (at least two times per year) on the graves of myself and my late
husband;
(B) I give, devise and bequeath the sum of One Thousand Dollars ($1,000.00) unto
MIDWAY PENTECOSTAL CHURCH of 31 Heisers Lane, Carlisle,
Pennsylvania, for its general uses and purposes; and
P agel of 4 Pages ~~,
A.S.
(C) I give, devise and bequeath all the rest, residue and remainder of my estate, in
equal shares, unto the following of my nieces and nephews: DORIS DEIHL,
DENNIS FETTER, JOYCE FETTER, KENNETH FETTER and MARSHALL
FETTER, absolutely.
3.
I nominate, constitute and appoint my said niece, DORIS DEIHL, as Executrix of my estate.
In the event she shall be unable or unwilling to serve in such capacity, then I appoint my said niece,
JOYCE FETTER, and my said nephew, KENNETH FETTER, or the survivor of them, as Co-
Executors of my estate.
4.
I direct that my personal representative shall not be required to file a bond to secure the
faithful performance of his or her duties in any jurisdiction.
5.
I authorize and empower my personal representative, in his or her sole and absolute
discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any
real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of
or grant options in regard to any or all property of any kind forming a part of my estate for such
terms and such prices as he or she may deem advisable; to borrow money for any purposes connected
with the protection and preservation of my estate; to mortgage or pledge any real or personal property
forming a part of my estate or to join in or secure the partition of same; to compromise any claims or
demands of my estate against others or of others against my estate; to make distribution in kind and
to cause any share to be composed of cash, property or undivided fractional shares in property
different in kind from any other share; to employ agents, attorneys and proxies and to delegate to
them such power as my personal representative considers desirable and to pay reasonable
compensation for such services as may be rendered by such agents, attorneys and proxies; and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my personal representative shall have the power to conduct an inventory of any
safe deposit box necessary to the administration of my estate.
Page 2 of 4 Pages A~' S,
A.S.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 22nd day of May, 2002.
EAL)
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and
for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testatrix and of each other.
Page 3 of 4 Pages
COMMONWEALTH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERLAND )
I, ANNABELLE SWEGER, Testatrix, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and
voluntary act for the purposes therein expressed.
Sworn or affirmed to and acknowledged before me by ANNABELLE SWEGER, the
Testatrix, this 22"d day of May, 2002.
Notary Public -
Notarial Seal
Marika T. Chronister, Notary Public
COMMONWEALTH OF PENNSYLVANIA ) N°rthMiddletonTwp.,CumberlandCounly
My Commission Expires Mar. 14, 2005
'SS.
COUNTY OF CUMBERLAND )
We,-4"7a'~' ~/ ~/_0~o/.)../ and
the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw ANNABELLE SWEGER, the
Testatrix, sign and execute the instrument as her Last Will; that the Testatrix signed willingly and
that the Testatrix executed it as her free and voluntary act for the purposes therein expressed; that
each of us, in the hearing and sight of the Testatrix, signed the Will as witnesses; and that to the best
of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
Address .~/00 /_o,-,OlX ~la ~:, ,~d
Adtlr~ess
Sworn or affirmed to and subscribed before me this 22"a day of May, 2002.
Notary Public
Notarial Seal
Marika T. Chronister, Notary Public
C :\S LB\Estate Pianning\8659.1 will. l.doc North MiddletonTwp., Cumberland County
My Commission Expires Mar. 14, 2005
Page 4 of 4 Pages Member, Pen~aAssodationofNolafles
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: ANNABELLE SWEGER
Date of Death: January 14, 2004
File No. 2004-00092; PA File No. 21-04-0092
To the Register:
I certify that Notice of Beneficial Interest required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above estate on March 4, 2004:
Name Address
Midway Pentecostal Church 31 Heisers Lane, Carlisle, PA 17013
Doris Delhi 931 North College Street, Carlisle, PA 17013
Dennis Fetter 100 Regency Woods South, Carlisle, PA 17013
Joyce Fetter 413 Reno Avenue, New Cumberland, PA 17070
Kenneth Fetter 1808 Sterretts Gap Avenue, Carlisle, PA 17013
Marshall Fetter 505 Rock Run Road, Newville, PA 17241
N6~ice, has n~v ~'
been ~ven to all persons entitled thereto under Rule 5.6(a) except: N/A
D~::!Marcl~% 2004 ~:
':~, ~-: ,~i~ ~"~
c,~r:' .v ~:'~' :.~:: ~ Stephen L. Bloom, Esquire
2100 Longs Gap Road
Carlisle, PA 17013
(717) 249-7717
Capacity: Counsel for Personal Representative
C:\Office Documents\Office - Estate Administration\10402.2cert.not.doc
OOMMO"WE~-~OF,EN.SYLV,~.A INHERITANCE TAX RETURN iFILENUMBER
DEPARTMENT OF REVENUE
DEPT 2SOSO, RESIDENT DECEDENT i 21 04 00092
HARRISBURG, PA 17128-0601 COUNTY CODE
.... ~E-~. D E ~M~T~ ~ I R S Ti ~A N D ........... I YEAR NUMBER
MI-~)DLI:: INl'i:i~.~) ............. SOCIAL SECURITY NUMBER
J Sweger, Annabelle 196-14-0495
I-
~ ]~ATE 0~' ~EATH (MM-~D--Y~AR~ ]-'~)~,, TE OF-E~i~TH (IViM:E)D-Y-E~i ....... ~, THIS RETURN , US'I" .E FIEED IN DUPliCATE WITH THE
i 01/14/2004 ! 05/23/191 l REGISTER OF WILLS
~ J(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) SOCIAL
SECURITY
NUMBER
/
[~ 1. O~i~al~ [] 2. Supplemental Return [] 3. Remainder Retum (date of death prior to12-13-82)
~ ~ ~ [] 4. Limited Estate [] 4a. Future interest Compromise (date of death after
ma. o 12-12-82) [] 5. Federal Estate Tax Return Required
~ ~m o, [] 6. Decedent Died Testate (Attach copy [] 7. Decedent Maintained a Living Trust (Attach 0 8. Total Number of Safe Deposit Boxes
. of Will) copy of Trust)
~ [] 9. Litigation Proceeds Received [] 10. Spousal Poverty Credit (date of death between [] 11.Election to tax under Sec. 9113(A)(AttachSchO)
12.31-91 and 1-1-95)
~IAME COMPLETE MAILING ADDRESS
~ ~ Stephen L. Bloom
~ ~ :IRM N-,~.ME (if applicable)
2100 Longs Gap Road
~o ~ ........... Stephen L. Bloom, Esquire ........ i Carlisle, PA 17013
tELEPHONE NUMBER
? ] ?/249-?? ] ?
1. Real Estate (Schedule A) (1) None "-~'~ /'' ~..,s,~ o'-~ ~
2. Stocks and Bonds(Schedule B) (2) N o~]-~
3. Closely Held Corporation, Padnership or Sole-Proprietorship (3) N
4. Mortgages & Notes Receivable (Schedule D) (4) No~t~"':
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 65,929.3:5
(Schedule E)
6. Jointly Owned Property (Schedule F) (6) None !
z
_o [] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) None --~
(Schedule G or L)
E. 8. Total Gross Assets (total Lines 1-7) ' (~'.~ ' 65,929.35
" 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 14,4 1 5.22
10. Debts of Decedent, Modgage Liabilities, & Liens (Schedule I) (10) 3,596.00
11. Total Deductions (total Lines 9 & 10) (11) 18,0 ] 1.22
12. Net Value of Estate (Line 8 minus Line 11) (12) 47,918.13
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) 1,000.00
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 46,918.13
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
o_ 16.Amount of Line 14 taxable at lineal rate x .045 (16)
~ 17.Amount of Line 14 taxable at sibling rate (17)
· x .12
~ 18. Amount of Line 14 taxable at collateral rate 46,918.13 x .15 (18) 7,037.72
19. Tax Due (19) 7,037.72
20. []
: ~> BE SURE TO ANSER ALL QUESTIONS ON REVERSE sIDE AND RECHECK MATH<< ----
Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
442 Walnut Bottom Road
[C~ Carlisle ?STA'TE~
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1) 7,037.72
2. Credits/Payments
A. Spousal Poverly Credit
B. Prior Payments
C. Discount 351.89
Total Credits (A + B + C) (2) 35 1.89
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 1 Line 20 to request a refund
5. If Line l + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 6,685.83
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 6,685.83
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; .................................................................................. [] []
b. retain the right to designate who shall use the property transferred or its income; ....................................
c. retain a reversionary interest; or ..................................................................................................................
d. rece ve the promise for fe of ether payments, benefts or care? ..............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate cons derat on? ....................................................................................................................... [] []
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? ...................................................................................................................... [] []
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 knowle-dge and-~elief, it is irue, corr;~:i~nd corselette. De;i~ration of
preparer other than the personal representative is based on all information of which preparer has any knowledge.
StGNAT. URE ,OF PE.RSON RESPONSiBLy FOR FILING RETURN ADDRESS DATE
1)o;~?~, ~ 931 North Colle[e Street
Carlisle, PA 170'13
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
SIGNATURE OF PREPARER OTHER THAN~EPRESENTATIVE ADDRESS ............ D~¥~ ....
Stephen L./~I~J ~ 2100 Lones Gat~ Road
....~~ ~ Carlisle, Fa 17013 q.-.Q-O(../
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. §9116 (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 0%
[72 P.S. §9116 (a) (1.1) (ii)]. lhe statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. §9116 (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. §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 12% [72 P.S. §9116 (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.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
ooMMoNw~. OF.EN.S~LVAN,A PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Sweger, Annabelle J FILE NUMBER
21 - 04 - 00092
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE OF
DEATH
1 Citizens Bank Checking Account #6100732002 --~ 651~22.96
2 The Sentinel, Refund for Newspaper Subscription 6.39
TOTAL (Also enter on Line 5, Recapitulation) 65,929.$5
,~ SCHEDULE H
FUNERAL EXPENSES &
COMMONWEALTH OF PENNSYLVANfA
,..~R,T~oE T*X.~.. ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF
Sweger, Annabelle FILE NUMBER
21 - 04 ~ 00092
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
I Ewing Brothers Funeral Home 8,375.70
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions 3,296.47
Doris Deihl
S) / EIN Number of Personal Representative(s):
Street Address North College Street
City Carlisle State PA Zip 17013
Year(s) Commission paid 2004
2. Attorney's Fees Stephen L. Bloom, Attorney and Counsellor at Law 2,381.62
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ~ Zip
Relationship of Claimant to Decedent
4. Probate Fees Cumberland County - Register of Wills 140.00
5. Accountant's Fees
6. Tax Return Preparer's Fees Francis A. Marchal, PC, CPA 50.00
7. Other Administrative Costs
I Additional Death Certificates 8.00
2 The Sentinel - Publication of Legal Notices 88.43
Total of Continuation Schedule(s) 75.00
TOTAL (Also enter on line 9, Recapitulation) 14~4]$.22
~ SchedubH
COMMONWEALTH OF PENNSYLVANIA ~ Expenses ~
INHERITANCE TAX RETURN
ESTATE OF
Sweger, Annabelle FILE NUMBER
21 - 04 - 00092
3 The Cumberland Law Journal - Publication of Legal Notices 75.00
Page 2 of Schedule H
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE ,
co~.oNw~. OF"EN"S~.V~",A LIABILITI ES. & LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT I
ESTATE OF Sweger, Annabelle .................
I 21 - 04 ~ 00092
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Carlisle Pathology Assoc. ' ...... 29.~35
2 Lancaster HMA Physician 44.04
3 Mobilex USA 37.94
4 Blue Mountain Anesthesia Assoc. 23.37
5 Carlisle Digestive Disease Associates, Ltd. 93,43
6 Bronstein Jeffries, PA 31.82
7 Moffitt Heart and Vascular Group 80.60
8 West Shore ALS 68.95
9 Yellow Breeches Family Practice 71.68
10 United Church of Christ Homes, Thomwald Home 2,918.73
11 Sprint 2.67
12 West Shore EMS 68.95
13 Central Penn Medical Group Emergency 28.40
14 Nurse Anesthetists of Carlisle Regional Medical Center 37.37
15 PharMerica 58.70
TOTAL (Also enter on Line 10, Recapitulation) 3,596.00
REV-1513 EX+ (9-00) ~
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Swcger, Annabelle FILE NUMBER
21 - 04 - 00092
I RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY ~ DECEDENT
~ Do Nat List'[rustee(~) OF ESTATE
L TAXABLE DISTRIBUTIONS (include outright spousal distributions)
I Doris Deihl Niece $2,000.00 plus 20% of
931 North College Street residuary
Carlisle, PA 17013
2 Dennis Fetter Nephew 20% of residuary
100 Regency Woods South
Carlisle, PA 17013
3 Joyce Fetter Niece 20% of residuary
413 Reno Avenue
New Cumberland, PA 17070
4 Kenneth Fetter Nephew 20% of residuary
1808 Sterretts Gap Avenue
Carlisle, PA 17013
See Continuation Schedule(s) attached
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 Midway Pentecostal Church 1,000.00
31 Heisers Lane, Carlisle, PA 17013
TOTAL OF PART Il - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 1,000.00
SCHEDULE J
COMMONWE^LTN OE PENNSVLV^N,^ BENEFICIARIES continued
INHERITANCE TAX RETURN !
RESIDENT DECEDENT
ESTATE OF
Sweger, Annabelle I FILE NUMBER
I 21 - 04 - 00092
RELATIONSHIP TO
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT AMOUNT OR SHARE
DO Not List Trustee(s) OF ESTATE
[include outright spousal distributions, and transfers under
I. tAXABLE DISTRIBUTIONS Sec. 9116(a)(1.2)]
5 Marshall Fetter Nephew 20% of residuary
505 Rock Run Road
Newville, PA 17241
Page 2 of Schedule J
LAST WILL AND TESTAMENT
I, ANNABELLE SWEGER, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking any and all former Wills or Codicils by me
made.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and all
inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any
property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representative shall have no duty or obligation to
obtain reimbursement tbr any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
1 direct that my Executor shall sell all of my property, both real and personal, and, after the
payment of all the expenses of my estate, shall distribute the residue in the following manner:
(A) The sum of Two Thousand Dollars ($2,000.00) shall be set aside and held in trust
by my personal representative or her successor(s) for the purpose of purchasing,
in such quantity and for such prices as shall be determined in the sole discretion
of such personal representative or successor(s), floral arrangements for periodic
placement (at least two times per year) on the graves of myself and my late
husband;
(B) I give, devise and bequeath the sum of One Thousand Dollars ($1,000.00) unto
MIDWAY PENTECOSTAL CHURCII of 31 Heisers Lane, Carlisle,
Pennsylvania, fbr its general uses and purposes; and
Page l of 4 Pages .~, ~
(C) I give, devise and bequeath all the rest, residue and remainder of my estate, in
equal shares, unto the following of my nieces and nephews: DORIS DEIHL,
DENNIS FETTER, JOYCE FETTER, KENNETH FETTER and MARSHALL
FETTER, absolutely.
3.
I nominate~ constitute and appoint my said niece, DORIS DEIHL, as Executrix of my estate.
In the event she shall be unable or unwilling to serve in such capacity, then I appoint my said niece,
JOYCE FETTER, and my said nephew, KENNETH FETTER, or the survivor of them, as Co-
Executors of my estate.
4.
I direct that my personal representative shall not be required to file a bond to secure the
faithful performance of his or her duties in any jurisdiction.
5.
I authorize and empower my personal representative, in his or her sole and absolute
discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any
real or personal property of any nature; to sell, lease, pledge, mortgage, transfer~ exchange, dispose of
or grant options in regard to any or all property of any kind forming a part of my estate fbr such
terms and such prices as he or she may deem advisable; to borrow money for any purposes connected
with the protection and preservation of my estate; to mortgage or pledge any real or personal property
forming a part of my estate or to join in or secure the partition of same; to compromise any claims or
demands of my estate against others or of others against my estate; to make distribution in kind and
to cause any share to be composed of cash, property or undivided fractional shares in property
different in kind t'¥om any other share: to employ agents, attorneys and proxies and to delegate to
them such power as my personal representative considers desirable and to pay reasonable
compensation for such services as may be rendered by such agents, attorneys and proxies: and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my personal representative shall have the power to conduct an inventory of any
safe deposit box necessary to the administration of my estate.
Page 2 of 4 Pages ~,Sm
A.S.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 22nd day of May, 2002.
EAL)
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and
for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testatrix and of each other.
Page 3 of 4 Pages
COMMONWEAl. TH OF PENNSYLVANIA )
: SS.
COUNTY OF CUMBERI,AND )
I, ANNABELLE SWEGER, Testatrix, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and
voluntary act tbr the purposes therein expressed.
Annabelle Sweg~r
Sworn or affirmed to and acknowledged before me by ANNABELLE SWEGER, the
Testatrix, this 22"~t day of May, 2002.
Notary Public -
Notarial Seal
, -, Marika T. Chronister, Notary Public
COMMONWEAL I H OF PENNSYLVANIA ) N°nh~ldd~etonTwp.,Curnber~andCounW
· My Commission Expires Mar. 14. 2005
'SS.
-CO U N-TY.'O F C [ J M B E R L A N D ) Member, Pennsylvania Associatm of No~anes-
the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw ANNABELLE SWEGER, the
Testatrix, sign and execute the instrument as her Last Will; that the Testatrix signed willingly and
that the Testatrix executed it as her free and voluntary act for the purposes therein expressed; that
each of us, in the hearing and sight of the Testatrix, signed the Will as witnesses: and that to the best
of our knowledge the Testatrix was at that time 18 or more years of age, ofsound mind and under no
constraint or undue influence.
Sworn or affirmed to and subscribed before me this 22"d day of May, 2002.
Notary Public
Notarial Seal
':\Sl.lP, l".sta:.'P~,mni~:~\S659. Iwill. Idoc Marika T. Chronlster, Notary Public
- North MiddletonTwp.. Cumberland Counly
My Commission Expires Mar. 14, 2005
Page 4 of 4 Pages I~tgml~r. P~o~/N~nia/k~ooiatiooof~::~
TO THE ~*~*******THE ESTATE OF. ANNABELL
ORDER OF
~ ~ Drawer: Cidzens Ba~ of Pe~sylv~ia
TO / /
~ ~sued By Integrated Payment Systems ~nc., Englewoad, Colorado ~ / ~HO~SIGNATU~
J~.Uank One NA Denve~ Colorado / ~ ' ·
,' 225 ~27,' ~: ~O 2OOO~?~:
· 60-~50343
313
COIN
CHECKS
CHECKS ANO OTHER ITE~,IS ARE RECEIVED FOR DEPOSIT SUBJECT TO THE PROVISION O~ THE UNIFOR~ COMMERCIAL CODE OR ANY APPLICABLE COLLECTION AGBEE~aENT,
Note: Citizens Bank of Pennsylvania has not timely responded to the formal
request of the Estate for a statement of date of death account balance, however
the Executrix believes and avers that the balance reflected on the above Official
Check accurately and substantially reflects the date of death balance in the
aforesaid account, which amount was deposited into the Estate Checking
Account at Orrstown Bank as also noted above.
REMOVE DOCUMENT ALONG THIS PERFORATION
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
January 21, 2004
Doris Deihl
931 N. College Street
Carlisle, PA 17013
The Funeral Service for Annabelle Sweger
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, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff ................... $3460.00
FUNERAL HOME SERVICE CHARGES ............ $3460.00
SELECTED MERCHANDISE:
18G Steel LordsPrayer PrayingHands .................. $2750.00
American Chief Vault $1325.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED ............... $7535.00 ~
Cash Advances
Opening Grave. $945.00
Clergy/Mass Offering. ...................... $70.00
Certified Copies of the Death Certificate $10.00
Flowers ........................... $127.20
Stone Cutting (Ordered 1/21/04) ........ ........... $100.00
Burial Dress & Underclothing .................... $125.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES ........ $1377.20
Total
Total Cost $8912.20
SUB-TOTAL $8912.20
INITIAL PAYMENT / DISCOUNT / CREDITS 8375.70 -'-
TOTAL AMOUNT DUE
The unpaid balance over 45 days is subjected to a 1.00 % service charge per month. 12.0000 % per annum ~ I~'~Z,~O~,/L} ~_ ~'~
Member of National Funeral Directors Association
STEPHEN L. BLOOM
,\'I"I'()I~,N I';Y .\NI) (]()I'NSI,~I,I,()R .\T l,.\\\
www PRACII('AI.('IIIJNSI.iI. COM
2 100 l,t)Nt;S (; \1' lit)II) 'l'l.'f.l.l'[tt)~. 71 '7-249-77 I '"
(~.\RI.151.{,.. ])IiNNSYI.\',\NI.\ 17013 J"x( SIMII. I.. 717 249 Vw57
SIII.()()M({{eI'RA~51'IC XI.I t)t:NSI,;l. Ct)M '['t~l I [:RI I. 8w7- 5,18 9602
Invoice submitted to:
Sweger, Annabelle Estate
cio 931 North College Street
Carlisle, PA 17013
Doris R. Delhi, Executrix
April 02, 2004
In Reference To: Estate Administration
Invoice #1392
Professional Services
Hrs/Rate Amount
1/14/2004 Preliminary administrative and estate accounting matters 0.33 61.67
18500/hr
1/29/2004 Preparations for Probate; Draft and finalize Petition for Grant of Letters 1.25 231.35
Testamentary, Exhibits and Proposed Decree re same; Prepare 185.00/hr
required Estate Information Document
1/30/2004 Appearance at Register of Wills Office to present Petition for Grant of 1.43 263.88
Letters; Conference with Executrix; Draft memorandum to file; Prepare 185.00/hr
and file IRS Form SS-4 (Application for Employer Identification
Number); Correspondence with Executrix
3~4~2004 Review correspondence; Preparation of required Notices of Beneficial 1.80 333.72
Interest in Estate, related correspondence and Certification of Notice re 18500/hr
same; Appearance at Register of Wills to file Certification of Notice;
Preparation of Legal Notices for publication and correspondence with
Cumberland Law Journal and newspaper re same
3~9~2004 Administrative and estate accounting matters; Correspondence with 0.70 128.88
Department of Public Welfare, Estate Recovery Section; 185.00/hr
Correspondence with Citizens Bank re official date of death account
valuation documentation
3/24/2004 Review correspondence from Department of Public Welfare Estate 0.08 15.42
Recovery Program 185.00/hr
I:)RA(;TI(~AL(~()UNSI:,I, '~' (~HRISTiAN PI'~RSI'I.,C'I"IVt.~
Sweger, Annabelle Estate Page 2
Hrs/Rate Amount
3/30/2004 Administrative and estate accounting matters; Review Proof of 2.28 421.70
Publication of Legal Notice from the Cumberland Law Journal; 185.00/hr
Preliminary preparation of Pennsylvania Inheritance Tax Return and
Schedules; Telephone conferences with Executrix
3/31/2004 Finalize Pennsylvania Inheritance Tax Return, Schedules and Exhibits; 1.00 185.00
Review status of administration and remaining requirements 185.00/hr
4/2/2004 Conference with Executrix for review and execution of Inheritance Tax 4.00 740.00
Return and Inventory; Appearance at Register of Wills for filing of 185.00/hr
same; Reserve for final matters of administration (including review of
correspondence from Register of Wills and Department of Revenue re
status of Inheritance Tax Return and correspondence with Executrix re
same; Preparation of Release, Receipt and Refunding Agreement for
execution by beneficiaries; Correspondence re same; Preparation of
Status Report of Administration and appearance at Register of Wills for
filing of same; Miscellaneous matters)
For professional services rendered 12.87 $2,381.62
Additional Charges:
1/30/2004 Probate Fee - Register of Wills of Cumberland County 140.00
3/4/2004 Publishing Fee - Legal Notice - The Cumberland Law Journal 75.00
3/29/2004 Publishing Fee - Legal Notice - The Sentinel 88.43
Total costs $303.43
Total amount of this bill $2,685.05
Balance due $2,685.05
PAYABLE UPON RECEIPT - THANK YOU
PRAC'I~I(::\I. (~()UNSI.:I. · CIIRISTiAN Pt':RSPF:C'I"I\,'[,:
RECEIPT FOR PAYMENT
Cumberland_County - Register Of Wills Receipt Date 1/30/2004
Hanover and Hiqh Street Receipt Time 08:15:37
Carlisle, PA ~7013 Receipt No. 1035424
SWEGER ANNABELE
File Number 2004-00092
Remarks STEPHEN BLOOM, ESQ.
JA
........................ Distribution Of Receipt ........................
Transaction Description Payment Amount Payee Name
PETITION FOR PROBA 115.00 CUMBERLAND COUNTY GENERAL FUN
EXTRA PAGES 9.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 6.00 CUMBERLAND COUNTY GENERAL FUN
JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D
Check# 003222 ~140.00
Total Received ......... 140 00
FRANCIS A. MARCHAL, PC
CERTIFIED PUBLIC ACCOUNTANT
49 WEST ORANGE STREET
SHIPPENSBURG, PA 17257
TELEPHONE: (717) 532-8927
Leon & Doris Deihl
931 North College Street
Carlisle, PA 17013
February 6, 2004
For the preparation of individual income taxes for 2003 - 4t t ! ~.2~
federal, state and local $ 265.00 ~--/
~~ documents [-~ Prepare federal return Annabelle Swenger 2003 and review
TOTAL DUE AND PAYABLE $ 315,00
l(l:: lAIN I HI5 FURl IUN PUl( YUUl(
i REMITTANCE ADDRESS I BILL ~0
~ SENTINEL - LEGALI STEPHEN L BLOOM, ATTORNEY
P.O. BOX 130, CARLISLE, PA 17013
AD NUMBER J CLASS ' " SALESPERSOI~ BILLING DATE LINES
260599I 10 PUBLIC NOTICES c30 03/24/04 24
AD DESCRIPTION START DATE STOP DATE
NOTICE LETTERS TESTAMENTARY ON THE 03/09/04 03/23/04
PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 82.08
TOTAL AD CHARGE 82 . 08
3 PROOF OF PUBLICATION 01PRF 6.35
DAYS RUN
PURC.ASEORDER PAY THIS AMouNT 88 43 106 12'
est. annabelle swegr ' '
* AFTER 04/23/04
MESSAGE:
Thank you for advertising with The Sentinel.
Deadlines for in-column legal advertisements: Monday is Friday at
11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon;
Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday
is Thursday at 12 Noon.
If you have any questions regarding your Legal bill please call
Tammy Shoemaker 243-2611, ext 203.
Fax your legals to 243-3754, attention Tammy Shoemaker
You can also EMAIL your legal to Classified ads: ads@cumberlink.com.
Please send a cover letter including your name and address as an attachment
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
March 26, 2004
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by the Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Stephen L. Bloom, ESQUIRE
RE:
Annabelle Sweger, ESTATE
Legal advertisements must be received by Friday Noon. All legal advertising must be
paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
MARCH 12, 19, 26, 2004
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment Received $ 75.00
Total Amount Due $ 0.00
Payment received _ MARCH 10, 2004
by Becky H. Morgenthal/Executive Director
CARLISLE PATHOLOGY ASSOC. PATIENT: ANNABELLE D. SWEGER
P.O. BOX 188 LOCATION: CARLISLE HOSP.
LANDISVlLLE PA 17538 STATUS: M1 IP
0051 DUN
TEMP.RETURN SERVICE REQUESTED
BILLING INQUIRIES: MONDAY THRU FRIDAY I STATEMENT DATE I PAY THIS AMOUNT I ACCT. #
8:00 AM TO 4:00 PM
TOLL FREE PHONE: 1-888-223-5649 01/21/2004 $29.35 IA126.0059550_01
SHOW AMOUNT
II,lh,,lll,,lll,,llllh,hlhlll,h,,llllhhlhh,,llh,lll,llhlhhl PAGE #1 OF 1 ~. PAID HERE $ C~ 4. 3,..~
ANNABELLE D. SWEGER CARLISLE PATHOLOGY ASSOC.
442 WALNUT BOTTOM Rd P.O. BOX 188
CARLISLE PA 17013-3742 LANDISVILLE PA 17538
I,,,111,,,111,,,,,,11,,11,,,11,1,,,I,1,,I,,I,1,1,,I,,I,1,11,,I PRO242T 410TOiJZZAO04VPS. 001876
Please check box if above address is incorrect or insurance information has changed, and PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
indicate change{s) on reverse side.
IMPORTANT
Medicare has finalized this claim for payment. If you have secondary
insurance, please complete the reverse side of this form and return.
Otherwise, please remit your prompt payment.
PRIMARY INSURANCE
MEDICARE PENNSYLVANIA PHONE: 800-633-4227
PO BOX 890418 CAMP HILL PA 17089
POL: 203101840D PLAN: GRP:
SECONDARY INSURANCE
PRIVATE PAY PHONE:
POL: PLAN: GRP:
DATE CODE DESCRIPTION -- CHARGES ~ BALANCE
THIS IS A ~ILL FOR ?ROFESSIONAL LAB SERVICES, SUPERVIS~.D BY A BOAR~ CERTIFIED
PATHOLOGI: . THESE SERVICES WERE REQUESTED BY YOUR ATTENDING PHYSiCIAN,
**** IF YOU b~VE ALREADY MADE PAYMENT PLEASE DISREGARD THIS NOTICE.
11-22-03 88305 LEVEL IV- SURG PATHOLOGY 150.00 150.00
GROSS AND MICROSCOPIC
EXAM
11-22-03 88305 LEVEL IV - SURG PATHOLOGY 150.00 300.00
GROSS AND MICROSCOPIC
EXAM
11-22-03 88305 LEVEL IV - SURG PATHOLOGY 150.00 450.00
GROSS AND MICROSCOPIC
EXAM
11-22-03 88312 SPECIAL STAINS; INTERP 65.00 515.00
12-16-03 PAYMEN'. PMT-MEDICARE 117.48 397 . 52
12-16-03 ADJUST CONT LOSS-MEDICARE 368.17 29.35
BILLING INQUIRIES: MONDAY THRU FRIDAY ~S
8:00 AM TO 4:00 PM GO ~'"~"~'~T'PL~ .
TOLL FREE PHONE: 1-888-223-5649 I ........ Go ~ AMOUNT $29.35"
MAKE CHECK PAYABLE ILANDISVILLE PA 17538 J ANNABELLE D SWEGER
AND MAIL TO: CARLISLE PATHOLOGY ASSOC.
IRS#: 25-1645787 ~, ~ ACCT NO: A12~§gSf.0-01
BILLING PROCEDURE
Payment../s. .r?quested at. the?. rne this bill Is received. In the case of health care insurance, this office will bill your insurance as a courtes . The patient or guarantor is ultimately
responsll~e ;or paymem on me account. In communicating with this office regarding your account, please use the account number foun~n the top rfclht so,don of this staternent.
Claim number 11-03337-370-810
Laneasler Hma Physician, Po Box 619,
East Petersburg, PA 17520-0000
Dr. Fronko, Gerald M.D.
11/19/03 I Emergency dept visit (99285)
)
number 12-03349-200-930
Lancaster Hma Physician, Po Box 619,
East Petersburg, PA 17520-0000
Mose, ~indee CNA
11/22/03 4 Anesth, upper gi visualize (00740-QX) $7t~ .86 $78.19 $62.55
PAGE: 1 842
obilex-,
The Highlands 02 / 02 / 04
920 Ridgebrook Road "'
Sparks, Maryland 21152 NURSING HOME:
FORWARDING SERVICE REQUESTED DATES OF SERVICE: 09/23/03 11/17/03
************************************
629 1 MB 0.309 ~ Mobilex USA
ANNABELLE SWEGER ~
° P.O. Box 17452
DORIS DIEHL o
931 N COLLEGE ST ~ Baltimore, MD21297-1452
CARLISLE PA 17013-1307
I,,,111,,,111,,,,,,11,,11,,,,11,,11,11,,,I,,,I,,11,,,,11,,11,1
Please detach here, and enclose this porlion with your prompt payment. Thank you!
These charges are billed directly to the patient because a copay, deductible is due onr your claim.was denied by your
insurance company. It is the patient's responsibility to provide current, insurance information (see reverse side).
llnm nmlmm lm
09/23/03 71020 CHEST AP/LATER.AL VIEWS 67.0£
09/23/03 ALLOWANCE WRITE DOWN' 40.54
12/09/03 CA_RE PENN PAYMENT 26.18-
12/09/03 ALLOWANCE WRITE DOWN 6.26 6.54
09/23/03 Q0092 SET UP FEE X RAY 23.0
09/23/03 ALLOWANCE WRITE DOWN 9.63.
12/09/03 CARE PENN PAYMENT 8.98-
12/09/03 ALLOWANCE WRITE DOWN 2.15. 2.2,
09/23/03 R0070 TRANSPORT X RAY 1 PT SEEN 175.0(
09/23/03 ALLOWANCE WRITE DOWN 60.28
12/09/03 CARE PENN PAYMENT 116.66
12/09/03 ALLOWANCE WRITE DOWN 31.10 29.i6
DATT~..19"P RI~..qDC)~.qTRTT,TT¥:
(Ju.,~.RENT 30- 29- 29- OVER 120 BALANCE DUE
37.94 .00 .00 .00 .00 37.94
CALL BETWEEN THE HOURS OF 9:00 A.M. AND 6:00 P.M. EST
TELEPHONE 1-800-786-8015
)3
STATEMENT
BLUE MOUN"r^ZN ANEETHESTA ASS0C .HEN CALLTNG THE OFFTCE DTAL E×T 1~3 O,,' LSq
P O BOX 249
GREENCASTLE PA ~7225
SHOW AMOUNT - - ti
PAID HERE $ C~ 2, /'
(BOO .27-5 . Ol/ 9/o Ol
OFFICE PHONE NUMBER CLOSING DATE YOUR ACCOUNT NUMBER PAGE NO. NEW BALANCE
BLUE MOUNTA!N ANESTHESIA ASSOC
ANNABELLE D SWEGER ~ P O BOX 249
442 WALNUT BOTTOM RD m GREENCASTLE PA 17225
CARLISLE PA 17013
I,,,llh,,llh,,,,,Ih,ll,,,ll,h,,l,l,,I,,I,hl,,l,,l,hlh,I I,,,lll,,,I,,I,h,l'hhl,ll,,,,,h l,h,ll,l,,,h,lhl,,,h h
NOTE: Charges and payments not appearing on this
statement will appear on next month's statement. RETURN THIS PORTION WITH PAYIV,
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEME~rT
112205 KAPOOR SERVZCES RENDERED ANNABELLE ,&17,SO
112605 BZLLED:HGS ADN/NISTRATORS
120205 ALSTER SERVZCES RENDERED ANNABELLE 923.00
120905 B/LLED:HGS ADfl/N/STRATORS
121905 HED/CARE PAYHENT ~2,55-
· 121905 NED/CARE ADJUSTHENT $39.~1-
121905 CO-/NSUR $15.&~ 0.00
125005 HED/CARE PAYNENT 93.50-
12~005 NED/CARE ADJUSTHENT 806,1~-
125005 CO-/NSUR $25.57 0,00
01070q PATZENT PAYNENT
010704 CHECK# 06~1 0.00
/HPORTANT: PAYHENT DUE /N FULL UPON RECE/PT OF STATEHENT.
/F YOUR /NSURANCE CARR/ER NAS NOT HADE A PAYHENT PLEASE
CONTACT THEH /HHED/ATELY. /F YOU HAVE ANY QUEST/ONS PLEASE
CALLOUR OFF/CE. THANK YOU,
STATEMENT
CLOSING DATE: 01/19/0~ PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 9~83
BALANCE PAYMENTS NEW BALANCE OVER BALANCE OVER BALANCE OVER BALANCE OVER NEW BA~NCE
FORWARD & CREDITS CHARGES ~ DAYS 60 DAYS ~ DAYS 1~ DAYS ' PAY THIS AMOUNT
0.00 1517.15- 1~0.~0 0.00 0.00 0.00 0.00 25.37'
SENDINQUIRIES TO:
(800)827-5458
BLUE HOUNTA/N ANESTflES/A ASSOC
P 0 BOX
GREENCASTLE PA 17225
CARLISLE DIGESTIVE DISEASE n~
ASSOCIATES, LTD.
241 Alexander Spring Road., .. __Patient State
Carlisle,
PA'17013'
Wednes~ay,~ Va nuarY 28/ 20~4
717-245-2228 ~ · ...... ~-. ¥'-
,payment Type: . , :-, ,5 ~, ..~,; .~
E]Visa [] ~:Mastercard
Annabelle D Sweger ACCount#
442 Walnut Bottom Rd
Carlisle, PA 17013 Expiration;Date __/__/
Signature
Date / /
Reflects transactions posted through 112812004 for 23624
Annabelle D Sweger(24346)~Robert B Levy DO/037576 ,5,1
Location: Carlisle Regional Medical Center
11/20/2003 Consu It-I nitial/Detailed
12/22/2003 Medicare Adjustment from Medicare ~,~ ] 0'~ $175.00 1.00 $175.00 $0.00
12/22/2003 Payment from Medicare ($74.16)' $0.00
12/22/2003 Transfer from Insurance oq "/~ -0 ~ ($82.30) $0.00
($18.54) $18.54
Coinsurance
$o.oo $18.s4
Annabelle D Sweger(24346yrheodore Berk MD/037866
Location: Carlisle Regional Medical Center
11/24/2003 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00
01/o2/2004 Medicare Adjustment from Medicare 1052130 ($58.29) $0.00
01/02/2004 Payment from Medicare 1052130 ($25.37) $0.00
0 i/0£/2004 Transfer from Insurance 1052130 ($6.34) $6.34
Coinsurance
$0.00 $6.34
Annabelle D Sweger(24346)/Amit Sadana MD/038521
Location: CaHIsle Regional Medical Center
11;2:', 2003 Egd-W/Biopsy(s) $645.00 1.00 $645.00 $0.00
~ 1/2:;,'2003 Colo-W/Biopsy(S) $844.00 1.00 $844.00 $0.00
0~/; ;'~004 Medicare Adjustment from Medicare 1052548 ($1,177.92) $0.00
0 ~ / 12:2004 Payment from Medicare 1052548 ($248.87) $0.00
01/12/2004 Transfer from Insurance 1052548 ($62.21) $62.21
Coinsurance
$0,00 $62,21
Annabelle D Sweger(24346)/Amit Sadana MD/038522
Location: Carlisle Regional Medical Center
~ ~/:~:~/?_003 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00
oI/: 2 2004 Medicare Adjustment from Medicare 1052468 ($58.29) $0.00
o~/~ 2~2004 Payment from Medicare' 1052468 ($25.37) $0.00
01,'~: 2004 Transfer from Insurance 1052468 ..($6.34) $6.34
Coinsurance " .. : '
· ' ~:' ' "'~ ':$0,00 $6.34
$0.00 $74.89 $0.00 $0.00
Carlisle Digestive Disease Associates * 241 Alexander Spring Road * Carlisle, PA 1 7013 * (71 7) 245-2228
Make Cheeks Payable To: Ghe~k ~ard Using For Payment
~ Vi~a ~ Ma~ter ~ard
Bronstein Jeffries, PA Card Number Amount
4830 Londonder~ Road Signature Exp. Date
Harrisburg, PA 17109
Acc°unt ~ Statement Date ~ DueDate I To~lDue
25313 Feb 3, 2004 Feb 17, 2004 31.82
Amount Enclosed $ ~/~ ~
I.,llh,,h,,lllh,d,l.,,,hll
Bronstein Jeffries, PA
h,,llh,,llh,,,,,ll,,Ihh,l,I 4830 Londonderry Road
Annabelle D. Sweger Harrisburg, PA 17109
442 Walnut Bottom Road
Carlisle, PA 17013
[] Please check box and indicate any change in address on reverse side.
Detach at perforation and return above portion with payment.
~ Service Provider J Des r'" J ' ' Payments/ ]
c Ipuon Charges Adjustments
Patient Account: 25313 - Annabelle D. Sweeer Previous Balance:
~"~~.- ~ o~c, 4 ,85.oo o.oo
01/21/2004 [ JPAY: Medicare HGSA I
.............. I lAD.I: Medicare Ad'u -127.26
,,.,~. ~.- ..... *.~ ~~.~ · ~J stment
' ~ ;~': '~ ,' :,~' ',7..,;. ~ ,~r ~ ~,~
now Your
responsibility
Statement DateI 1-30Days I 31-60Days 61-90Days_~ 91-120Days 121-150Days OverlSODays~
7,7oT o.oo I o.oo o.ooo.oo
~ronstein .leffries, PA · 4830 Londonderry Road. Harrisburg, PA 17109. (717) 657-2599
kccount Number: 25313 1.13.1.0 BEAZ20040203-00000602_00000752 Page 1 of 1
MOFFITT HEART & VASCUL~LR GROUP
1000 NORTH FRONT STREET
WORMLEYSBURG, PA 17043
80.60*
· Address Service Requested
ANNABELLE D SWEGER 100 79
41 OTTO AVENUE
CARLISLE PA 17013-3129 ~?i~ MOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT STREET
1/21/03 1 10 HOSPITAL CONSULT INITIAL 99254'~427.3t¥ 225;00
2/24/_03
12/24/03
Medi care Payment
Accept Assign Adj 106.68
-91-. 65 26.67*
11/21/_O3 1 10 ECHOCARDIOGRAPHY COMPLETE 93307 427.31: 115.00
12/24/03 Medicare Payment
12/24/03 Accept Assign'Adj. 37.30: i
· -68.37 9.33* '
11/21/03 1 10 DOPPLER COLOR FLOW VELOCI 93325 427.31 65.00
12/24/_03 Medicare Payment
12/24/03 Accept Assign Adj. 3.09
-61.14 0.77*
[1/21/.03 1 10 DOPPLER ECHO READING INTE 93320 427.31 50.00
[2/24/03 Medicare Payment
[2/24/03 Accept Assign .Adj. 15.39-
[ 1/.22/03~to- -30.76 , 3.85*
[1/.2~03 1 8 HOSPITAL SUBSEQUENT CARE 99231 427.31 100.00
L2/2~/_03. Medi care PaB~nent
[2/24/03' Accept' Assign Adj. "' 50.74
"-36.58" 12.68'
.1/25/03-to-
.1/26~03 1 18 ~HOSPITAL SUBSEQUENT CARE 99232"427.'3'i.~:''~ 160.00:, '
· 2/24~O3 Medi care ,Payment "~" 83.:84~'
2/24/03 Accept Assign ~d~. ~ ~',',':'? :~ :.
· 1/28Z03 1 18 ;HOSPITAL SUBSEQUENT.,CARE
2/_24~03,: Med¼'care .Pa.~n~'. · 50.00:,
2/24i/03,. Accept Assi~;n/Ad3. 25.37'
,~ '~-18~'29,'~ 6 34*'
80.60 O. O0 O. O0 O. O0 O, O0
.::,~. ':' ~ · .... :.. 80.60*
1-ANNABELLE D SWEGER' pRvt/ 8.PANLUSH. DAVID, MD Acct,/: :92552.'
PR~$/,iO'LINE, DENNIS E, ~ Date:' 12/30/03
PRV# 18-MYERS, LOUIE, DO Page 1 of 1
Claim number 11-03342-669-100 pt( ~ -)' 7 0 ~(
West Shore Als, Suite 2 ! I,
205 Grandview Avenue, Camp Hill, PA 17011-1708 ~ ~ ~ '~ °9`
11/19/03 I ALSl-emergency (A0427-NH) $812.17 $323.87 $259.10 $6q .77 a
11/19/03 I Ground mileage (A0425-NH) 8. lq t4.71 3.77 0 .gq a
1 ! / 19/03 I Ambulance 02 life sustaining qB. 50 16.20 12 96 .
(A0422-NH) · 3 2q a
Claim Total $868.81 $3qq. 78 $275.83 $68.95
YELLOW BREECHES FAMILY PRACTICE
1358 LUTZTOWN ROAD · BOLLING SPRINGS, PA 17007
Phone: (717) 258-3274 · West Shore: (717) 697-0001
[] Donald J. Kovacs, M.D. [] Bradford J. Wood, M.D. Tax ID # 23-2221983
M.D. 019737-E · B.S. No. K0060936 M.D. 024822-E · B.S. No. W0141016
Group B.S. No. YE 153146 Tax ID No. 23-2221983 Account;No. ~ Amount Due
Date Amount Enclosed
Pin r~ ,a~.e 1 ].~.: ..:~,~ ~ ;:'~- '~"'~ ' '~'"' '
Tl"~o¥'n~a~d :,,.1o~-:
,'.:/'-"-" [.~.=: ~] Lt !: .... ,, t ......... ~ ......... Make checks payable to:
? ~ ~ -~.~ ~ YELLOW BREECHES FAMILY PRACTICE
C ~.~ r' I i s 1 e, .,. , ~.~. I
Pay~ent by C:edit
Please remove and return this portion with your pa'
YELLOW BREECHES FAMILY PRACTICE
1358 Lutztown Road
Boiling Springs, PA 17007
Tax ID #23-2Z21983
PLEASE RETAIN THIS PORTION OF 5~. ,~
STATEMENT FOR YOUR RECORDS
, .
Account Analysis Total Current 31~60 61-90 91-120 ' 120+ PATIENT
Insurance Balance k'~. I~:~ 1,.~. "~'"~ ~. ,'~,
..... ~' ~-'~ ~. ~'~ '~ I ~
~ ~' L,~, BA~NCE
Patient Balance ~. ". 86 ' ~cl.,.~. 8~ ~[~ k~ ~" ~ ~,, ~ L~. ~ AMOUNT DUE
59.86
YELLOW BREECHES FAMILY PRACTICE
1358 LUTZTOWN ROAD · BOLLING SPRINGS, PA 17007
Phone: (717) 258-3274 · West Shore: (717) 697-0001
[] Donald J. Kovacs, M.D. [] Bradford J. Wood, M.D. Tax ID # 23-2221983
M.D. 019737-E · B.S. No. K0060936 M.D. 024822-E · B.S. No. W0141016
Group B.S. No. YE 153146 Tax ID No. 23-2221983 ~ A~Cc'ount,No. Amount Due
Date Amount Enclosed
~ i'~ ..... ~ .....
', .-:~ ~ ',-'.~,
,, ,, _ ,~ ~ ,,.~ ~:.,,.~ ~ ~: ~ ~}'~ ,'~<:~
, ........ · ...... Make checks payable to:
~ ,~. ~ ~ ~ ~ ~ ?~C~ ' ~'~' ~ YELLOW BREECHES FAMILY PRACTICE
t,..' i ':-~ ,~-, i','; C
Please remove and return this portion with your payme~ ,' ~ ;'"' ~J ....
.... ~k F, nnabellc-~ ~"~311 ',Ih I ............... ~E'-' '~ '~-'
,'~.:~mi~k.~ E ;..;;"i'td ~ ~ '.,,
,.- r t ~ =~ ~ ~ i 1 ~, . ...... i '~ .... f o c:. ~ ~ e c; z~ L~:'7, ~.~ ',.
,
YELLOW BREECHE~ FAMILY PRAOTICE
1358 Lutztown Road
Boiling Springs, PA 17007
Tax IO ~23-2221983
PLEASE R~AIN THIS PORTION OF ~
STATEME~ FOR YOUR RECORDS "
Account Analysis Total Cu~er,{ ~ 31-~ 61-90 91-120 120+
Insurance Balance ~" ~"~ '~" ~ ~. ~ ~. C~ ~. '~ TM ~. ,.~
~,~, PATIENT
Patient Balance i . ~ '"' i :[ m .z, ~ v:. ,~
; .~ .... ~]. ~ '~ ~. ,~ ~, BALANCE
~=..~.,,,,.a:R.,,,1~ 37. ~[~: AMOUNT DUE
Statement
United Church of Christ Homes
Thornwald Home
442 Walnut Bottom Road
Carlisle, PA 17013
Statement Date: 02/01/2004
Doris Deihl
931 N. College St.
Carlisle, PA 17013 Due Date: 02/25/2004
Re: Annabelle Sweger
Account Nr: 758
Date Description Days Rate Charges Payments Balance
Quant
BALANCE FORWARD 1,401.73 1,401.73
BALANCE FORWARD
02/12/04 PAYMENT 440.00 1,841.73
02/12/04 PAYMENT ~ ~$~¢~ ~-105.00 1,946.73
~-315 oo 2,261.73
02/12/04 PAYMENT ~?¢L ~n~f¢~q ~7 00 2,918.73
TRIANGLE TR3IVELING STORE WILL BE HERE 2/25/04
41st Annual Corporate Meeting of UCC Homes will be held Sunday 2/22/04
at The Lebanon Home at 3:00 p.m.
May 1, 2004 Helping Hands Dinner & Auction at Colonial Country Club
Please return this portion with payment.
_-~Sprint Customer service ,nternet address Cus, omer number
® 1-800-829-8009 sprint.corn~local 717-249-2518-045
Date due: February 9, 2004
Total amount due: $2,67
S2.69 if received after February 12.
Amount enclosed: l (~/~, ~71
Write your 13-digit customer number on check.
Make checks payable to:
m--. + 000320
Sprint
ANNABELLE SWEGER PO Box 740463
DORIS DEIHL Cincinnati OH 4§274-0463
931 N COLLEGE ST
CARLISLE PA 17013 1,1,,I,1,1,,,I,I1,,,I,1,,111,,,,I,,I,I1,,,,11,,I,1,1
12 71724925180451 00000000000267 000002671 0407407
DO NOT DETACH THIS VOUCHER
O ~ ,,,~ ',=,)-0 V* No .... O~
DATE ¢;~--I- O~ 313
~ PAY ~
OF THE ~ST*T[ OF ORDER OF ~ _ ~ :
WEST SHORE EI~.4S _ CARLISLE
IN VOICE
PATIENT NAME: A~'~',JA~LLE S":,"',-~,~ ~: PATIENT NUMBER:
CALL NUMBER:
........
INSURANCE: k.-~EDhZ.A~:E B 2~3 ~ ~-; 84~ DATE OF CALL:
TIME OF CALL:
CALLER:
0~03~0~ FROM: T'H
TO: C:J)'.RL_iSLE ~GhDFJAL ~v~ED~C.AL C:T~:
ANNABELLE SWEGER
4~2 WALNUT BOTTOM RD REASON(S)
CA RLtSLE, PA !70i3 FOR
TRANSPORT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
...................... 0 '?:?,7.5:,
-i -, *4-r-r '"i i ....
'-'-: ~ '~- ':'- A'3._:g~ '! .0 '"':':: .... .:5':z
........... " ' ..... ! .'? 4.75
,. r--~.-..?.~,~ ~-. .., .'
EiK,':; Ew- .......... L '_'::-'. '~.O.:-:gf .i 0
,.;m~;,~.4,',~ .q2, .~ ~n,-~--C --
'- ..... '* ................. A F, 394 !.~5 3.'_:;
O~' SiTE /..~53.~4 1!, -4
ALS ~',.'hLEA. G?. .A0425 ; ..3 E..'!4 ~: .,~
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
: ~ -~d,.=: ~ .'~.~--~!g!W."~e?..~,~u~rr~r:.~ '! ?'~: i/'7.'-j0_:
.,'viedic:?-e F'~ B P-='y'¢r~nr .i 0~>' 207 -' >-":,; ,'.-,hr .- -
¢..,' ~.~:: d
PLEASE PAY THIS AMOUNT ~ '
, . r :
DE
ANNABELLE D
=
' Visa
~,¢ledicare has paid their portion of your ambulance bi!!. The
b-~!~nce is the Co-P~y or Deduc~_ib!e th.~t is your AND
~sponsibitity. MASTER CARD
ACCEPTED
Central Penn Medical Group Emergency
P. O. Box 468 East Petersburg, PA 17520-0468
Phone 866-247-3141 Fax 1-405-607-1326 28.40 c/'O
TAX ID# 23-3013255 '
patientinquiry~mjca.net ~,~',;, ,;~,~
visit us online at www.mjca.net ~ 9267994 ~ 01/1§/04
~~ SWEGER, ANNABELLE D
o SWEGER, ANNABELLE D
~} FRONKO M.D., GERALD
I,,,111,,,111,,,,,,11,,11,,,11,1,,,I,1,,I,,I,1,1,,I,,I,1,11,,I % ......
~ ," CARLISLE REGIONAL MEDICA
SWEGER, ANNABELLE D oooo~ ~"~ ~CARLISLE. PA
442 Walnut Bottom Rd .............................. , ........
Carlisle, PA 17013-3742 [] 1/l.,~,4' []
....................................... ~E~E ~^c. ~ ~,u~ ms ~o~rtoN wxm ~--~c~
11/19/03 1105 FRONKO EMERGENCY DEPT VISIT 391.00 28.40
12/22/03 1105 FRONKO PENNSYLVANIA MEDICARE -113.62
12/22/03 1105 FRONKO INSURANCE WRITE-OFF -248.98
WE HAVE FILED MEDICARE AND ACCEPT ASSIGNMENT. ANy
PORTION ABOVE THE MEDICARE ALLOWABLE IS WRITTEN OFF.
ANY BALANCE REMAINING IS A REFLECTION OF YOUR 20%
CO-PAY OR DEDUCTIBLE PORTION OWED TO THE PROVIDER.
PLEASE REMIT BALANCE TO THE ADDRESS INDICATED ON THIS
STATEMENT. THANK YOU FOR YOUR COOPERATION.
Referred by FRONKO M.D., GEP~ALD
DO NOT DETACH THIS VOUCHER
Please Remit Payment to:
poC~T~LBox 468PE~ MEDIC~ GRO~ EMERGENCY "~ .... 1-86~-247-3 141 (toll ~ee)
~AST P~SRSBURO, PA ~7S20-046S patientinqui~m}ca.net. T~ YOU.
FOR YOUR CONFENIENCE, YOU ~Y PAY ONLINE ~T www. mjca. net
MEDICAL DATA SYSTEM, INC. Cha~ Number[]Sweger Patient
767 JACKSON ST 0000014773 Annabelle D
BILOXI, MS 39530 '
-Note: All payments md charges posted after ~e [ Amount Paid
above closing date will appe~ on ~e $
ne~ statement, c~ ~ 7 3
Make Check or Money Order
Payable To:
Annabelle Sweger
442 Walnut Bottom Rd Nurse Anesthetists Of Carlisle Reg Med
Carlisle, PA 17013-3742 P O Box 468
E Petersburg, PA 17520
Pl~e de~h and retujn_the top portion of Mis statement with your payment in the encl~ed envelope. ~min
Da~s
From To Code Description Q~ Amount
Patient : Sweger, Annabelle D
Account : 0000010470
Diagnosis: 5789 42731 4280
11/22/03 11/22/03 Previous Balance $15.64
Account Balance $15.64
Patient : Sweger, Annabelle D
Account : 0000010546
Diagnosis: 56989 2859 4280 42731
12/02/03 12/02/03 CHG 00840 -Anesth, Surgery Of Abdomen 1 $987.34
12/16/03 Medicare Filed...
2/10/04 PMT Medicare Payment $86.91-
2/10/04 ADJ Medicare Write-Off $878.70-
Account Balance $21.73
P~t Du~ Curren~ ~ Balance Due
Over 90 Days Over 60 Days Over 30 Days 0 - 30 Days
Federal Tax ID: 23-3013255
~ Please Make ChecksPayableToProvider
MEDICAL767 JACKsoNDATA sTSYSTEM' INC. I Cha~ Number 0000014772 II I Sweger AnnabellePatient D Il
BILOXI, MS 39530 '
ReturnServiceRequested I2/03/2004Cl°singDat¢ IIPreviousBalance$0.00 Il $15.64BalanceDu~
Note: ~1 payments md charges posted after ~e Amount Paid
above closing date will appe~ on the
ne~ statement. $ ] ~', [O ~
Make Cheek or Money Order
Payable To:
Annabelle Sweger
442 Walnut Bottom Rd Nurse Anesthetists Of Carlisle Reg Med
Carlisle, PA 17013-3742 P O Box 468
E Petersburg, PA 17520
Please detach and retur the top portion of this statement with your payment in the enclosed envelope. Retain the bottom portion for your records.
-- Dat~
Code Description Amount
From To
Patient : Sweger, Annabelle D
Account : 0000010470
Diagnosis: 5789 42731 4280
11/22/03 11/22/03 CHG 00740 -Anesth, Upper Gastro Endoscopic $744.86
1/19/04 Medicare Filed...
1/29/04 PMT Medicare Payment $62.55-
1/29/04 ADJ Medicare Write-Off $666.67-
Account Balance $15.64
to7
Past Due I CurrentI I BalanceDue
$0.001 $0.01 $0.00 $15.64 $15.64
Over 90 Days I Over 60 Days Over 30 Days I 0 - 30 Days
t Please Make Checks Payable To Provider
PHARMERICA
PHARMERICA
491-A BLUE EAGLE AVE ~F PAYING BY MASTERCARD, D~SCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW.
HARRISBURG, PA 17112 C~ECK CARD USING FOR PAYMENT
-- 31111-U817
~ CARD NUMBER AMOUNT
I RETURN SERVICE REQUESTED
~ SIGNATURE EXP. DATE
/ICUSTOMER NAMB: ANNABELLE SWBGER DUE DATE PAY THIS AMOUNT ACCT. #
m ~--I Please check box if address is incorrect or insurance 03/01/04 $58 . 70 5702 - 01 - 15696
~ U information has changed, and indicate change(s) on reverse side.
---- ANNABELLE SWEGER PHARMERICA
__ C\O DORIS DEIHL P.O. BOX 6413
-- 931 NORTH COLLEGE STREET CAROL STREAM, IL 60197-6413
~ CARLISLE, PA 17013-1307
5702010105060906000058708
31111 -U817 ' 15POWA39HOO6623
OJSTOm R: SW O R F^CrUTy: PHARMERICA
DATE: 01/31/04 ACCOUNT: 5702-01-15696 491-A BLUE EAGLE AVE ~11'~
HARRISBURG, PA 17112
PAGE: I of 1
PRIMARY PAYOR: INSURANCE POLICY#: 196140495
EFFECTIVE DATES: 01/08/04~01/14/04
PREVIOUS PAY1VIENTS
BALANCE: RECEIVED: CREDITS: NEW
CHARGES: $58.70 BALANCE
DUE: $58.70
I
DATE
I RX NUMBER DESCRIPTION QTY BI~LED DUE FROM INSURANCE CHARGES/
AMT INSURANCE ADJUST CREDITS
Balance Forward:
01/13/04 841852.02 CALMOSEPTINE OINTMENT 113.000 5.00 5.00
01/13/04 854046.00 NEUTROGENA ORIGINAL FORM 1.000 2.20 2.20
01/13/04 854047.00 ALOE VESTA 2-N-1 OINTMENT 226.000 10.95 10.95
01/13/04 854049.00 ,*'LEX SKIN PROTECTAR~T 49.8I 60.000 4.55 4.-55
COPAY OR DEDUCTIBLE PER ~MEMBER'S INSURANCE
01/09/04 852319.00 PROCTOSOL_HC 2.5% CREAM 28.350 30-20! 19.22 4.98 6.00
01/10/04 ' 832298.04 COUMADIN 2MG TABLET 24.000 30.00 11.25 9 75 . 9.00
01/12/04 847189.01 HYDROCODONE/APAP 5/500 TA 30.000, 30.00 1.46 22.54 6.00
01/12/04 853611.00 NEXIUM 40MG CAPSULE I 23.000 117.20 88.11 20.09 9.00
01/12/04 853758.00 MORPHINE SULF 20MG/ML SOL 30.000 30.00 14.76 9 24 6 00
Amount Due: J ...... t 58.70
lNG QUESTIONS: MEDICATION QUESTIONS:
08:30 AM - 05:00 PM 09:00 AM - 04:00 PM PAYMENT ADDRESS:
P.O. BOX 6413
PHONE: 800-352-9161 PHONE: 717-651-9996 CAROL STREAM, IL 60197-6413
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
Estate of Sweger, Annabelle
also known a~- .................... No. 21 - 04 . 00092 .
Date of Death 1/14/2004
_ , Deceased Social Security No. 196-14-0495
Doris De/hl
The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory
include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania
of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the
Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that
which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true
and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904
relating to unswom falsification to authorities.
Personal Representative
Attorney: Stephen L. Bloom
....... - - Signature: ~~ ~
I.D. No.: 49811 Doris Delhi .
Signature:
Signature:
Address: 2100 Longs Gap Road .... ' ...............
Carlisle, PA 17013 Address: 931 North College Street
Carlisle, PA 17013
Telephone: 717/249-7717
.................... Telephone: 717-258-5421
Citizens Bank Checking Account #6100732002
65,922.96
The Sentinel, Refund for Newspaper Subscription
6.39
Total Personal Property -- $65,929.3~-
(Attach additional sheets if necessary)
(~OMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DE~'~RTMENT QF REVENUE
BUREAU OF INDIVIDUAL TAXES
DE T. 28O601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
, OFFICIAL RECEIPT
NO. CD 003758
BLOOM STEPHEN L
2100 LONGS GAP ROAD
CARLISLE, PA 17013
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
........ fold ..........
101 $6,685.83
· ESTATE INFORMATION: SSN: 196-14-0495
FILE NUMBER: 2104-0092
-DECEDENT NAME: SWEGER ANNABELE
DATE OF PAYMENT: 04/02/2004
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 01/14/2004
'ii" TOTAL AMOUNT PAID: $6,685.83
REMARKS:
!~:. CHECK# 118
...... INITIALS. JA
.... SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
CONHONWEALTH OF PENNSYLVANIA
BUREAU OF INDIVIDUAL TAXES DEPARTHENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601 NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX ~EV-Z;4; EX AFP c0z-0s~
~ DATE Oq- 12-2004
?~?i ESTATE OF LUTZ HELEN C
DATE OF DEATH 01-15-2005
FILE NUNBER 21 05-0092
'0~ APR 15 ~ CUHBERLAND
HURREL R WALTERS III ESQ ACN 101
54 E HAIN ST
HECHANICS~URG PA 17055 t~;~ Amoun~ RemA~ed
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
RE~ISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS
REV-15~7 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT~ ALLOMANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSE$SHENT OF TAX
ESTATE OF LUTZ HELEN CFZLE NO. ~1 0~-0092 ACN 101 DATE 04-12-2004
TAX REI~JRN WAS: (X) ACCEPTED AS FILED ( ) CHAN~ED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN ~ASED ON: ORIGINAL RETURN
1. Real Es~a~e (Schedule A] (1) O0 NOTE: To Ansure proper
2. S~ocks and Bonds (Schedule B) (2) O0 crodA~ ~o your account,
$. Closely Held $~ock/Per~nershlp In~eres~ (Schedule C) ($) O0 submi~ ~hm upper por*lon
~. Mortgages/No,es ReceAvable (Schidul. D) (~) O0 of ~hAs form ~A~h your
$. Cesh/Benk DeposA~s/H1sc. Personal Proper~y (Schedule E) ($) O0 ~ex payment.
6. Jotn*ly O~ned Proper*y (Schedule F) (6) 5 ~ 709.67
7. Transfers (Schedule G) (7) 102;000.00
8. To*el Asse~s (8) 107,709.67
APPROVED DEDUCT/ONS AND EXEHPTZONS: 9,255.00
9. Funeral Expenses/Adm. Cos~s/Hisc. Expenses (Schedule H) (9)
10. Deb~s/Horigage Lia~ilities/Lians (Schedule Z) (10) 29 ;78~.60
11. To*el Deductions (11]
12. Ne~ Value of Tax Re~urn (12) 68,671.07
15. CherA*eble/Govern.an~al Bequests; Non-elected 9115 Trusts (Schedule J) (15) .00
lq. Ne~ Value of Es*a~e Subjec~ ~o Tax (1~) 68,671.07
NOTE: Z~ an assessment ~as issued previously, lines 1~, 15 and/or 16, 17, 18 and 19 ~11
reflect flgures that include the total o~ ALL returns assesse~ to date.
ASSESSHENT OF TAX:
15. Amoun~ of LAne 1~ a~ Spouse1 re~e (15) .00 X O0 = .00
16. A~oun* of LAne 1~ ~exeble e~ Lineal/Class A re*e (16). 68,671.07 X 045 = $,090.20
17. Amoun~ of LAne lfi a* SAbling re~e (17) .00 X 12 = .00
18. Amoun~ of L/nm 1~ ~axable a~ Collateral/Class B ra~e (18). .00 X 15 = .00
19. PrincApal Tax Due (19)= ~,090.ZO
tAX CREDITS:
PAYH[NT R~CEZPT D/SCOUNT (+)
AHOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
02-25-2004 CD005598 .00 $,090.20
BALANCE OF UNPAID INTEREST/PENALTY AS OF OZ-Z6-ZO04 TOTAL TAX CREDZT $,090.20
· ALANCE OF TAX DUEI .00
I
INTEREST AND PEN. 5Z.48
TOTAL DUE 5Z. 48
~ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE TS LESS THAN $1, NO PAYHENT IS REQUIRED.
FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.*)
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
@UREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 003821
WALTERS, MURREL R. III
54 EAST MAIN STREET
MECHANICSBURG, PA 17055
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
........ fold ..........
101 $52.48
ESTATE INFORMATION: SSN: 170-05-6870
FILE NUMBER: 21 03-0092
DECEDENT NAME: LUTZ HELEN C
DATE OF PAYMENT: 04/15/2004
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 01/1 3/2003
TOTAL AMOUNT PAID' $52.48
REMARKS:
" CHECK# 10563
INITIALS: JA
?' ~' SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
...... REGISTER OF WILLS
REGISTER OF WILLS
COMMONgEALTH OF PENNSYLVANZA ~
BUREAU OF ZNDZVZDUAL TAXES DEPARTMENT OF REVENUE
ZNHERZTANCE TAX DIVISION
DEPT. 180601
HARRZSBURG, PA 17128-0601 NOTZCE OF ZNHERZTANCE TAX
APPRAZSEMENT, ALLO#ANCE OR DZSALLO#ANCE
OF DEDUCTZONS AND ASSESSMENT OF TAX tEV-I;47£XAFPCOl-OS)
DATE 05-2q-200q
:: ESTATE OF S~EGER ANNABELLE
DATE OF DEATH 01-1q-200q
FZLE NUHBER 21 0~-0092
STEPHEN L BLOOM ESQ '04 I"iA¥ 24 ;~ :(}4 COUNTY CUHBERLAND
ACN 101
2100 LONGS GAP RD Aeoun~ Remi~ed
CARLISLE PA 1~$
HAKE CHECK PAYABLE AND RENZT PAYMENT TO:
REGISTER OF NILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THZS LZNE ~ RETAZN LO#ER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTZCE OF ZNHERZTANCE TAX APPRAZSEHENT, ALLOgANCE OR DZSALLOgANCE OF DEDUCTZONS AND ASSESSMENT OF TAX
ESTATE OF SgEGER ANNABELLE FZLE NO. 21 0~-0092 ACN 101 DATE 05-2~-200~
TAX RETURN NAS: (X) ACCEPTED AS F/LED ( ) CHANGED
RESERVATZON CONCERNZNG FUTURE ZNTEREST - SEE REVERSE
APPRAZSED VALUE OF RETURN BASED ON: ORZGINAL RETURN
1. Real Es~a~e (Schedule A) (1) .00 NOTE: To insure proper
2. S~ocks and Bonds (Schedule B) (2) .00 credi~ ~o your account,
$. Closely Held S~ock/Par~nership Zn~eres~ (Schedule C) ($) .00 submi~ ~he upper portion
~. Mortgages/No,es Receivable (Schedule D) (~) .00 of ~his form wi~h your
5. Cash/Bank Deposits/Misc. Personal Proper~y (Schedule E) ($) 65~919.$5 ~ax payment.
6. Jointly Owned Proper~y (Schedule F) (6) .00
7. Transfers (Schedule ;) (7) .00
8. To,aX Asse~s (8) 65,929.$5
APPROVED DEDUCTXONS AND EXEHPTXONS: 1~,~15.22
9. Funeral Expenses/AdH. Cos~s/Hisc. Expenses (Schedule H) (9)
10. Debis/Morigege Liabilities/Liens (Schedule 1) (10) 3,596.00
11. Total Deductions (11) ]8.~11.~
12. Ne~ Value of Tax Re~urn (12) ~7,918.15
15. Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15) 1,000.00
lq. Ne~ Value of Es~a~e Sub~ec~ ~o Tax (lq) q6,918.15
NOTE: Z~ an assessment was issued previously, lines la, 15 and/or 16, 17, 18 and 19 ~ill
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line lq at Spousal ra~e (15). . O0 X O0 = . O0
16. Amount of Line lq ~axable a~ Lineal/Class A ra~e (16) . O0 X Oq5 = . O0
17. Aeoun{ of Line lq a~ Sibling ra~e (17). . O0 X 12 = . O0
18. Aeoun~ of Line lq ~axable a~ Collateral/Class B ra~e (18). q6,918.15 X 15 = 7,057.72
19. Principal Tax Due (19)= 7,057.72
TAX CREDZTS:
PAYMENT RECEXrl DZSCOUNT (+)
AMOUNT PA[D
BATE NUMBER ZNTEREST/PEN PA~D (-)
Oq-OZ-ZOOq CD005758 $51.89 6,685.85
TOTAL TAX CREBZT I 7,037.71
BALANCE OF TAX DUEl .00
ZNTEREST AND PEN. . O0
TOTAL DUE . O0
ZF PAID AFTER DATE INDTCATED, SEE REVERSE ( ZF TOTAL DUE TS LESS THAN $1, NO PAYMENT TS RE;)UZRED.
FOR CALCULATTON OF ADDZTZONAL ZNTEREST. ZF TOTAL DUE TS REFLECTED AS A "CREDZT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE STDE OF TMZS FORM FOR ZNSTRUCTZONS.)
RESERVATION: Estates of decedents dying on or before December 12, 19DZ -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Common#ealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such futura interest.
PURPOSE OF
NOTICE: To fulfill the requirements of Section Zl~O of the Inheritance and Estate Tax Act, Act Z5 of 2000. (7Z P.S.
Section 91riO).
PAYNENT: Detach the top portion of this Notice and submit with your payment to the Register of Rills printed on the reverse side.
--Hake check or money order payable to: REGZSTER OF #ZEES, AGENT
REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1515). Applications ara available at the Office
of the Register of Hills, any of the 15 Revenue District Offices, or by calling the special Z~-hour
answering service for forms ordering: 1-800-561-2050; services for taxpayers with special hearing and / or
speaking needs: 1-B00-~47-$020 (TT only).
OBJECTIONS: Any party in interest not satisfied aith the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 1B0601, Harrisburg, PA 17118-0601
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
DISCOUNT: If any tax due is paid within three (3) calendar months after the decadent's death, a five percent (5Z) discount of
the tax paid is allowed.
PENALTY: The 1SI tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one il) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rata of
six (6Z) percent per annum calculated at a daily rate of .O0016q. All taxes which became delinquent on and after
January l, lPDZ will bear interest at a rate which will vary from calendar year to calendar year with that rata
announced by the PA Department of Revenue. The applicable interest rates for 1981 through 2004 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
~ 20Z .OOOSq8 lgDD-19gl IIZ .O00~Ol ~ 9Z .0002~7
1985 16Z .000458 1992 9Z .000247 2002 62 .000164
1984 X1Z .000301 1993-199~ 7Z .O00XPZ 2003 SZ .000157
1985 ISZ .000556 1995-1998 91 .0002~7 200~ 41 .000110
1986 lOX .O00Z7q 1999 72 .000192
1987 IOZ .00027~ ZOO0 7Z .000192
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent mill reflect an interest calculation to fifteen (15) days
beyond the date cf the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
REGISTER OF WILLS OF CUMBERLAND COUNTY
STATUS REPORT UNDER RULE 6.12
(For Resident Decedents Dying After July 1, 1992)
Name of Decedent: ANNABELLE SWEGER
Date of Death: January 14, 2004 ~::':: ? ~ ~"~ ,::~c~
File No.: 2004-00092; PA File No. 21-04-0092 . "~
Social Security No.: 196-14-0495 :~
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the followi~ with resl~6'ct to
completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal representative reasonably believes that the
administration will be complete: N/A.
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No X
b. The separate Orphans' Court No. (if any) for the personal
representative's account is: N/A.
c. Did the personal representative state an account informally to the parties in interest?
Yes X No
d. Copies of receipts, releases, joinders and approvals offormal or informal accounts
may be filed with the Clerk of the Orphans' Court and may be attached to this report.
Date: September 17, 2004 Signature: ~
Name:
-- Stephen L. Bloom, Esquir~
Address: 2100 Longs Gap Road
Carlisle, PA 17013
(717) 249-7717
Counsel for Personal Representative
C:\Office Documents\Office - Estate Administration\8659.2statrpt. 1 .doc