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HomeMy WebLinkAbout10-09-08 (2) 15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue Count Code Year Bureau of Individual Taxes ~ ~. y Dept. 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT o~ ~ d (~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 0?3©~ooS I_~_t r f~~ e Decedent's Last Name Suffix Decedent's First Name ~-~.Z~LE~ ~E~~~~TN (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name File Number © 8". ~~~ O ©O MI MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) Spouse's Social Security Number CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Firm Name (If Applicable) First line of address ~3 ~ MSO~:~-~ ~o ,~ D Second line of address City or Post Office State ZIP Code Correspondent's a-mail address: r'~~/n /e J] /J (~~~/$ `lQ~r C/~~'1 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and col e. DeclarationRf prepareryther than the personal representative is based on all information of which preparer has any knowledge SIGNATURE RESP9t>t$I R G FTYt~ N . / ! r,~T~ ADDRESS~~~ ~~U w(;~ a~/f~C:l i ~~~/ /C/~~/'/ / VC~~/!`~i l ~/ ~(/ ~(©~~ SIGNATURE OF PREPARER OT ER THAN RE RESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 15056041046 Side 1 15056041046 REV-1500 EX v RECAPITULATION -- _ 1. Real estate (Schedule A) . ............................................ 1"-__~ • 2. Stocks and Bonds (Schedule B) 2~J ~- 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • ------- ---- 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. • -- _. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. l~ p • 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. "^~' ~ l f7' 6 ~ o • °~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property __._ (Schedule G) l~ Separate Billing Requested........ 7. ~j - / Q' • 8. Total Gross Assets (total Lines 1-7) .................................... 8. --~~ ~ l ( Q ~ y 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9""'-"-f-- V u • i 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. `~- ~ ~ ~ Q • J 11. Total Deductions (total Lines 9 & 10) ................................... 11. '°-"~`-- ' f ~ ~ ~ ~~ ... .. .. 12 ~ ~ s'~~ c.j I 12. Net Value of Estate (Line 8 minus Line 11) ~~~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which _._-...,, an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ""-'r~~ / (~ ~ ~ ~ ~ ~ 1 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ ~ . __-------- (a)(1.2) X .0 • 15. 16. Amount of Line 14~b1e ~~ r / ~ J ~ Ci ~ ~ t 16 `~-~-~ ~ - ~ ~ ~ • 1 P at lineal rate X .0 1 0 . 17. Amount of Line 14 taxable - - - at sibling rate X .12 • 17 ` • 18. Amount of Line 14 taxable at collateral rate X .15 ' 18. • '~ ~ ~ s 19. ................. TAX DUE ................................. ....19. 15056042047 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~. 15056042047 Side 2 O 15056042047 J REV-1500 EX Page 3 File Number Decedent's Complete Address: ~ -; ~ a - -' 4 0 DECEDENT'S NAME f ~en~~ ~.~i L. P~`n ~~ ~ STREET ADDRESS / n, / , p`~~ ,i/ - rte` - CITY /~V,~J/ ^ ~ ^ I t ~/; STATE //~///~~ ZIP '/~/ /A/ C/ / I ~C ~~1//C/ ~t:'L/C/ Y G/( ~l ~r l / /l ~J Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Pa ments - _ ~ _ C. Discount ~ `n 01 K e ~s'aG •7 3. Interest/Penalty if applicable D. Interest " _ - © "~ E. Penalty _ _ ....__-___~_. _i v _._ Total Credits (A + B + C) (2) ~~~i~ Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) ._._ (4) ~ /~ (5) '1~ 46 D, ~ ~ (5A) ~ /'_ (5B) ~ ~ C ~. ~p~> Make Check Payable fo: 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 revf;rsionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurrE~d after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Ditl 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. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a 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 zero (0) percent [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 four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(x)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(x)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1509IX . {1A7) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ~/L ~~ /P ~ ,~ Q D Q(O RESIDENT DECEDENT ~~''TT t 0 ~ V ESTATE tDF t / FILE NUMBER ~enr7e~~ ~.. p.n len cd60$- eo~jo ff an asset was made joint within one year of the decedent's date of death, ~ nu~st be reported on Schedule G. SURVNING JOIM- TENAM-(S) NAME ADDRESS RELATIONSHIP TO DECEDE A. ,~~ 41~rna /off L ~ /~e;,l le rt B. C. s~ only c~;1~ ~xeca~{aro~ E~~rll JOINTLY-0WNED PROPERTY: •LETTER DATE DES(xtIPTION OF PROPERTY % OF DATE OF DEAL ITEM FOR JOINT MADE Indude name of financial instihlfion and bank accamt number or skrilar idenfiTying number. Attach DATE OF DEATH DECDS VALUE OF NUMBER TENANT JOINT deed for Jointly-Feld real esta6e. VALUE OF ASSET INTEREST DECEDENT'S INTE 1. A. ~'eb:ll`~2 /~e{~ri/J L nch L`~?A ~ g~'S'~ ~~~~~ ,~~~,d a~~~ - $~- 6va~~ ~63~ ~d ~_ ~`~ s D~ 131 6o4.~f~ a• ~, ~d,l`~~ ~c~e~ ~~/ 7a ~'es`~iK~t~s' ®rr`f~~P >~'cc~sS ~ jc~j of j9, D/ S'D~ 3~~~a~,s"j t~~ca~~ aaR-~?ooa9o 3, ~- ~6~i9~, Nl~`r~ B~nli ~lass;c s ~ ~Ky' ~ ~6~88~s'~ S'0`~ ~ r3,y~fa.?Y ~ ccG~47f 664 6 TOTAL (AID enter on lute 6. Recapitulation) I S !If mnro cn~ro is nm.lori inCGA 9Itltltl(1r1A1 Cltcwfc Af HIA CAmP. SI7P.) ~0 3 s' ~(~ a~w~y 6~ir~, Yfi~1~3r'Pi~, G~i'~ ~~.~ ?D REV-1511 EX+ (10-06) SCNEDt~LE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TA><: RETURN ADMINISTRATIVE COSTS ~A ~-'e RESIDENT DECEDENT / J r,< ~ Q'~®f~Y~ ESTATE OF ~ P` ~ e~ FILE NUMBER V ~l ~~~~n~~ ~ ~00~'~ 008~1~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ro e s's~ rn a SC'~'~'~C~S ~ s ~ . ~~n~~ ~~ C ~ "PS ~~t~wersl ~~~y^ ' l~f~'l~/'c'I'r~/n~ ~5"D,~D y ~ ~y ~~, P ~ ~~ (~~'1~~r` ~ CZ- ~~' S ~~~+° lit ~~ r~C ~'~ZY'/ c ~r /~~urs~?~~~er ~~r` ~a a ~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) _ ~~~/(~ L~ ~~ /j /E/1 __ Street,4ddress L _1~G'c~ __ City _ Ya?" /( d y e~ State ~ Zip ~ ?~_ ~!/ Year(s) Commission Paid: LLl~ff'f 2~ Attorney Fees (J '"' 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant /~T Street Address _. City _ State Zip Relationship of Claimant to Decedent __ 4. Probate Fees ~~~D~ l:~d 5. Accountant's l=ees -" (~ "- 6. Tax Return Preparer's Fees ~. I~ds~~~ ~~~ ~~P~`sn P ~~~~ Ps ~ ?~ /~ TOTAL (Also enter on line 9, Recapitulation) $ ~j S~ /. 36 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ~~ ~C`~F~ ESTATE OF ~ ~~ P -~f ~( J~' ~~ F(R /P~ l FILE NUMBER o~ G'~-~Og70 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. ~' S~S rya ~ e` ~ ~~e ~l~Gi l`s~`.( y' /'It~art e ~/l~W~~S « ` ~ r ~~~~`~~~~ ~ s r~e ~~l ~o~s ~Od ~~ ~~~ -a9 y y n l ~~ ~ ~~r/~ J~1?~r-r~~c ~ SPr'V~G~s~ .~nG. ~ , r ~ ;~ ~' u~~Glh? ~~c~`~K ~'" /~(~I'e~~l~~(~'c ~Sscr~r~/eS ~ Y ~? ~, ~~d~ l So.S' ~n off, t'n a~~~ s/ ~~ ~~~06~ ~a ~%~ ~W lt(e c~%cL~ ~,r~p~ se ~ l4 ~~ ~' X~a s TOTAL (Also enter on line 10, Recapitulation) $ ~ b o S (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) ~, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ~~ ~`~P ~ 02 ~ 48 D~/~ ESTATE OF // ( FILE NUMBER ~e ~1 n ~~ ~. ~ ~ff°~ n ~ n a a0S"- 80 6 /7 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ,/ Oha ~~ L ~ N~~~n ~~'K ,Son t Qn ~YC~,` ~~ ~3 S" ~~ ~a ~ol ~j~ecu ~Grd~vvr`~ ~r~ ld Ian" ( d 2rt~ ~ ~rsertzlll~; reS~,f~ ~~ l~r'S~~ ,~ ~er n ~P~ l~a ~ ~/~~l° ~l PPh°~~ ~/~~e 1 / ' ' ~~e ~' ~~ ~ of Q ~o ~ ` a IP~ ~ d ~ ~ ~, / ~ /~~~ ~ 9~ / ~3 ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II 1. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ ~-- Q (If more space is needed, insert additional sheets of the same size) after paying all expenses incident t0 the management of the Tr»st, t0 apply s•~~r: part, of the net incca~e and. principal as may he necessary, in tY:e sole discretion of my said Trustee, for the s?ipport, welfare and education including eduGati~n at an insi:a.tution of higher leasrir~? of said: ~~°_._ ^.--:..~ _~e __ac~~s . e 3^e of to?only-one (?11 ~ou'!d _ ~ ~:~ : -_=- .:._~ .:.~_~.:_~ ~_-~;= _ =_- _ ~.- -._._ (21~ , the Z~ust sh?1.1 4~:~..~-.~ .s ._... s~.:~~e ~~:. , ~°^~ ~' distr~}auted ~ her heirs: 5. PERSONAL REPR~EL~ATIVB. I r.~:.i^=ate, constitute _w: a^_~i""~t my wife, M.nRION E. HEItQLEN, EXeCUtrix of this my Will. Ip case og ~_."_~y i_n said office„ I noarinate, constitute and a~,rppi nt T'•'•Y son, RON.AI~D Tu. ~'~"'"'';.~., Executor in her stead. In case of furthpx vacancy in said office, I n~-~~.tA, constitute ?nd appoint my daughter-iri lawn MARY V. HE?I~:N, Executrix in ~~s stead. I direct that rx~ fiduciary ~.:nder this Will shall re required to gi-e bond in any jurisd:'Lction in which she or he :ray act, conditioned upon the fai th_~u]. perform- ance of the duties of said office. 6 . FT...DIx.,'7.ARY' S PUWF.E2S . I direct .hat my personal rea~resertativc and Tn.Stee herein appointed, in addition to and ~t in limitation of a_ny authority given to the same by ? aw; sha11 rave the follot:*in~* powers: (a) For the payment of debts or for arty purpose of admi_nistrat..ion or McCORMICK, REEDER, NICHOLS, SARNO, BANL 8 KNECHT ATTORNEYS AT LAW WILLIAMSPORT, PA. distri}?uti-on; to se11, mortgage, Lease, alter, ir.~rove, partitio:~, ar.~1 eXch?nge all or any of my prnperty, real or perso?~al; at any time during th? administra- tion o:E my estate, and at the tp~mination thereof for purposes of distribution, selli._ng at public or private sale without an order of rourt for such prices and r upon. such t..nn~ as too cash and credit as said Fid~~ci~y ;~~-~ ~~_ _ ~__ __ grar_t at~d convey good and suffic? ent title c:ithout lial~i lit jr --- ==_ - - _ _ _ = _ purchasers to see to the appli catio_T of t..e _ _-_-_ _ == =`=~-_ --~ =- __ _ _-.. __ . _- any statute, rttl.e or case ~ c ~...^ _ - _ ='_ - _ - _ ~ _ _ - _ _ _ _='..~ _ . ,.. _,_ inve.Ct~n~..s maw.. ~.. _ _ _ _ yam, v r. . any statute; xu? e c. ;.Q=,e.~ .; w _ w wr- _ _ _ _ _ -- _ _ _ Gcl Tb retain ~= in ;-es~,-~ of t.e .~., .~. ~e ~ -- = - - - - - - ir_ mutual, inveS~nt trusts c~e~n trust -- .funds, ar?d ot~er _-- • ,.;. ~.~ _- - . _ _ _=~- _ bring cor_fined to what axe knaum as "legal ir~aestments" and to s-~_ ~: ~ 1,.-^--__== the s~~, e.tll~eer ~„ perm or h'Y attorney, without liability on try part of L'~ purchasexs +,.o see to .the appl.i~,.~; on of the purc_~ase or consideration moneys, 7 . COrfi~uCrTON. The headings at the ~1i ~i ngG of the paragraph in tha.C Will are fc~r reference p»,rposes only and shall be disregarded in tt~P cor-stx'uction of this instrtment ~,le„s the context clearly ; n~; ~ othera•~~e. I,~ WZTt~ S W_~OF; Z have hereunto set *^~_ ?~.~-~d e~ sew, ~- ~ - . -,:-~, .. ~~~ of ;-,, ~` 1985. i j " `Kenno ~ . L•. H,_in' en~ -. I AAcCORMICK, REEDER, NICHOLS, SARNO, BAHL & KNECHT ATTORNEYS AT LAW WILLIAMSPORT, PA. - 3 - Gigned, se'led, published ar_d dAclarec~ by the abo~Te-rte Testator as snd for his Last Will and Testsmert in our presence, who, at his request a*:d in hic presence ?nd in the presence of each other; have here~uito subscribed o?~s names as witr_esses: ,,. .~ ~: ~cCORMICK, REEDER, NICNOLS, SARNO, BAHL E KNECHT ATTORNEYS AT LAW VlLL1AMSPORT, PA. ~~-c~.-~ L. th Testator e _ _~. .. _ ~:esses j respectively, whose names are siyrsed to tY:e attached or fore~_. ••~ :?,~._.rllt*'ent, being fixst duly sworn, cb rereby declare to the undersigned a~=~_r.ty trot the Testator signed and executed the instrt3r-ent as his Last Wil3. z-~: ~ :sf.,an>ent and that he had signed willingly and that he executed it as his f-~ and volunta~~ act for the purposes therein expressed, and that each of the ~r'~^wsses, in the presence and hearing of the TP.,.statAr, signed the Will as witness and that to the best of his kna~~ledge the Testator was at that time eighteP~a years of age or older, of sound mind anr~ under no constraint or u.*~ue influence. ~> ,' ''f Kenrls~ L. Heerlen ~ / ~~-~ ,ti `~-~~'-`- t~,~.--..: ~ r ~~ ~ _ S~?bs~ibed, sworn to and ar.Jcnaaledged before m? by R~L" t~I`:i I,. I'~^:~:, ~ ~ > t r !; ~ the Testa~..or, and subscr' and sworn to before ::te b~l ~,%`,~j~,,;, -/r , ~ L~-'~, r _ , and ~tL S`ZZ-; ~n v~!~Yj'14.~t,:' ?:_~^=~_S . ___ r ~~*~-' K -_ _ r ,.. ,+Nr , "~..+~ C ~' McCORMICK, REEDER, NICHOLS, SARNO, BAHL & KNECHT ATTORNEYS AT LAW WILLIAMSPORT, PA. - 5 - M&T Bank ACCOUNT N0. ACCOUNT TYPE 664565 CLASSIC CHECKING 00 0 04524M NM I17 5238 KENNETH L HEINLEN RONALD L HEINLEN 635 MIDWAY RD YORK HAVEN PA 17370-9020 nrrnuuT cnuuwov STATEMENT PERIOD PAGE JUL.04-AUG.05,2008 1 OF 2 NEMBERRY BEGINNING DEPOSITS 8 --- ----- ------ OTHER. CURRENT- ENDING BALANCE bTHER ADDITIONS CHECKS-PAID SUBTRACTIONS INTEREST PO BALANCE NO. AMOUNT NO. AMOUNT N0. AMOUNT 34,788.30 3 1,549.67 4 7,894.17 2 325.86 0.00 28,117.94 ACCOUNT ACTIVITY POSTING DATE DEPOSITSINTEREST ....CHECKS & OTHER DAILY TRANSACTION DESCRIPTION & OTHER ADDITIONS SUBTRACTIONS BALANCE 07-04-08 BEGINNING BALANCE 534,788.30 07-07-OS BL CROSS NEPA PAYMENT 162.93 34,625.37 07-14-08 METIIfE INVESTOR ANN.PYMT. 29 31 07-21-08 DEPOSIT . 34,654.68 107.06 34,761.74 07-23-OS CHECK NUMBER 1477 07-25-08 CHECK NUMBER 1476 /~ < < /~ ~ ~ ~ ~ 79.93 7,736.25 34,681.81 56 07-29-08 y UB L°T CHECK NUMBER 1478 " `G ~~ ~ . OS-O1-0 08-01-08 US TREASURY 303 SOC SEC hcj(Pt~ ~ ~C~~ CH f~ ! 1,413.30 59.99 26,885.57 OS-05-08 ~ ~ ECK NUMBER 1479 BL CROSS NENA PAYMENT 18.00 2g,2gp,87 162.93 28,117.94 ENDING BALANCE 528,117.94 CHECKS-PAID SUMMARY 1476 07-25-OS 7,736.25 1477 07-23-08 79.93 1478 07-29-08 59.99 1479 08-01-08 18.00 ~ i i ~~~ r ~ ~ ~~~ LL O O ~~ C i O n d O O ~ ~ ~ N F- N ~ ~ I~ C T ~ ~ O 7 ~ r/1 Q U ~ O N . EQ ~~ ~ ' >, C cU cn > _ ~ _ Ora` N C1 - h. 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N ~m ~ 3 ~ ~ ~ ~ a' a ~ N f!i o `- Q01 m `~ ~ a- a ~ e ~ o C ii I ~. w'. w . ~~ w w cn cn w n n o c o . . ~ ~ . . . `~c H G fD W O D T 0 1 4i m m W m m 0 v N O ~ w ~ ~ ~ °~ cwi~ ~ ~ ~ ~ O m < ~ D m z.~~°= 3 D ~ = r O ~ v Z m 3 w r z A O Z m O ~ `z 3 a ~ z o ° A n O C 7 '+ Z c fD N t~fi ~ mD~ 0°1 ~ ~3 D ~ Z T i~D { rF ~~ gmc)o ~' x' W ~ ~ ~ ~~ 0 O A S -I n n N o v o a 0 3 D ~ < w p N ~ F, o 1 G = v o ~ i~ ~ N 1 ~ fll 7 A (D O O m _~ ~ r r c 0 N ~ O ~ N ~ `N m ~~ N N ~ ~ ~ N ~ ~ r ~ ~ ~ Larry H. Sanders Licensed Suipervisor Mr. Ronald L. Heinlen 63S Midway Road York Haven., PA 17370 >>rr~ 1 anberg ~iortuarp ~Lta. 821 Diamond Street Williamsport, PA 17701 (570) 322-3466 Re: Services for Kenneth L. Heinlen Date of Death: Wednesday, July 30, 2008 Professional Services Traditional Funeral Service Package "A" Total Professional Services Merchandise Yorkb~wne Ashland -Solid Ash Hardwood Casket Lycoming Burial Air-Seal Concrete Vault Total Merc6aadise Cash Advances Cemetery Charges Flowers Clerg;/ Honorarium Death Certificate Copies-Ten Date on Grave Marker-Gibbons Newspaper Obituary Total Cash Advances Nancy A. Sanders Invoice Date: Friday, August 15, 2008 Account No: 200811 S Funeral Date: Monday, August 04, 2008 Total of All Selections Invoice Total Payments Received to Date Total Amount Doe 3,090.00 3,090.00 3,150.00 975.00 4,125.00 700.00 243.80 200.00 60.00 80.00 176.40 1,460.20 8,675.20 8,675.20 125.00 8,550.20 l~j~ ~ ~-~~'~'g----- ~~5~t f ~f~~~ tvl f`T~ r. t ~ _ ,. .~~ ` _ Form PB-C lessi21h v~ ~_~A~~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 RONALD L. HEINLEN 635 MIDWAY ROAD YORK HAVEN, PA 17370 QUESTIONS? CALL: 717 697-4666 RESIDENT # UNIT STMT. DATE 90518 262 D 07/31/2008 RESIDENT S Mr. KENNETH L. HEINLEN TOTAL AMOUNT DUE $4,479.58 DATE DUE 08/31/2008 DATE DESCRIPTION _ RATE Una CHARGES CREDITS BALANCE 07/29/08 07/29/08 07/30/08 AIR MATTRESS 07/01-07/29 PREVAIL BRIEF REGULAR OXYGEN 4.00 1.30 17.50 29.00 38.00 1.00 116.00 179.40 17.50 4,282.6 4,462.0 4,479.5 P~~ . ~~` ~,~ ~o ~ a-'~g ~ ~~~~ ~~~ ~ `~C ~ V 1 z-~ / a q I ` g '~`` ~ ~~ -~ ~ f~~ 3 D - ~~ ~ ~~a ~g 5', 4 d C I a'/ ~~ ' ~$ ~, t RESIDENT # 90518 CUI~RENT 4,479.58 OVER 30 0.00 OVER 60 0.00 OVER 90 0.00 OVER 120 0.00 TOTAL AMOUNT DUI $4,479.5 RESIDENT NAME Mr. KENNETH L. HEINLEN F«mP8-0 N/A A 1% finance charge may t-e assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! a 0 00 ~ N ~ o ,c .~ °c ~ •- m p ~'3 •- v m 0 0 ooocooooo00000000 0 00 ~ J ~ vJJ~7~1~1~1JJJJ~1J~1vJ~l ~~~~~~~~~~ J ~.1~1 ~ m N ~~~~~~~ N N N N N N N N N N ~+~+~+~-+i-+i-+O ~ ~~ N N N D ~ ~D ~O 00 J O~ fJ1 is W N ~-+ O ~G 00 J C~ (J1 i~ ~-+ ~O ~O A - 1 ° 0 00000000000000000 0 0o m z o0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 ~ O° ~o ~000000000000000~ ''ti 'b `b ~~~~~~~~~~~~~~~o~r~r~~ ~ ~C ~..~ ~ -C ~C ~C ~C -C -C -C ~C -C FC -C -C -C -C -C y ~- ,.~ ~ ,,~ -C ~C ?:, c~o ~~c~c~~c~c~c~c~~c~~~~~~~z ~ n~~ ~ C r~~ ~r~r~r~r~r~~r~r~r~r~~r~r~r~r~o~ +. ~ r~~ L N ~ _ Z~ Z Z Z~ Z Z Z Z Z~ Z Z Z ~ m ~' ~ ~~"~~yy ~ z ,q ~ ~~~~~ ~ z ~~ zn~~n ''" ~ ~~~~~ tz m ~ ~ ~ CoCC ~ ~ ~ ~ p ' ° d dd .~-~ ~ ~ ~ ° ~-3 ~] ~3 ~ O Z ~ Y ~~ y ~ ~ ~~ O 00 o ~ ~ ~ ~ •_ •- •_ m 0 in o i~ in ih i~ i~ i~ in in i~ i~ i,n in i~ in i~ ~ m p o 000000000000000000 m 0 O C O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ~ o O O O O O O O O O O O O O O O O O O A = J D h ~ ~ o ~-+ r+ ~+ ~+ i-+ ~+ --~ ~+ r ~.+ ~+ --~ ~+ ~ ~ O p J N J J J J J J J J J J J J J J J •ia m m ui c i~ i~ ih c!i i,n i~ i~ in t1i in i~ i1~ i~ i~ in c~ ~ ~ O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 N O N ~-+ ~1 m ~w v _ -i O O O~ ~ ~ O N D O V i r D m 0 W ~ ~ ~ A ~~~ ~ ~ ~~ ~~ ~~ ~ ~ ~~~ AWWWWWWWWWWWWWWWW ~ ~ W ~+ J Z -1 ~ 2 D C Fr O~ ~+ W W W fW ji A A ii .P i~ C/~ f!1 VI (11 tI1 f!1 AWUO~COONW(J1J~OON.PC~~I~C Q~ W O (JI ~.1 W Z m ~ O~ ~ON0~1 W NOJU1NOJt11NOJtI1 O 00 C~ n m Q~ ~OOtNGOWOOWO0WO0tNCOWOOWCOW C COO N RI 00 OONNNNNNNNNNNNNNNN O 00 f!1 ** ACTIVITY FOR HEINLEN, KENNETH L -HEINKE - -090518 06/20/08 7375600 27 ARICEPT lOMG O1 36.00 .00 36.OC 06/20/08 7375606 54 METOPROLOL XL 25M 01 5.00 .00 S.OC ,06/20/08 7375608 27 ASPIRIN 81 MG CHE O1 * 2.90 .00 2.9C !06/20/08 7375609 27 THERA TABLET O1 * 3.10 .00 3.1C X06/20/08 7375610 27 CITALOPRAM 20MG O1 5.00 .00 S.OC 06/20/08 7388514 27 LEVOTHYROXINE 25 O1 5.00 .00 S.OC .07/01/08 7400871 20 AMOX/CLAN 500-125 O1 5.00 .00 5.OC ;07/01/08 7400872 26 FLORASTOR 250 MG Ol * 21.41 .00 21.41 07/07/08 7403322 1 FLUCONAZOLE 150 M O1 3.90 .00 3.9C 07/14/08 7406025 120 PROSHIELD PLIIS SK O1 * 11.33 .00 11.33 07/14/08 7406023 1 FLUCONAZOLE 150 M O1 3.90 .00 3.9C 07/14/08 7406133 9 METRONIDAZOLE 500 O1 4.65 .00 4.6~ ,07/14/08 7406135 12 FLORASTOR 250 MG Ol * 11.28 .00 11.2E '07/17/08 7406133 1 METRONIDAZOLE 500 O1 3.41 .00 3.41 107/17/08 7406135 2 FLORASTOR 250 MG O1 * 4.05 .00 4.0~ j07/22/08 Payment-Thank You 79.93- .00 79.93 ;07/23/08 7409452 15 NYSTOP 100,000 UN O1 5.00 .00 S.OC 07/23/08 8081692 113 CALMOSEPTINE DINT O1 7.13 .00 7.13 07/29/08 4095742 30 LORAZEPAM 0.5 MG 01 10.62 .00 10.6 ',07/29/08 2031736 30 MORPHINE SULF 20M Ol 5.00 .00 S.OC 108/04/08 7390821 1 CYANOCOBALAMIN 10 O1 3.44- .00 3.49 ~ v ~? ,~~ !~/(~ `~~ ~~~ ~~b ~ ~~ I M . o o'! LEGEND NON-LEGEND I TOTAL TAx i FOR MONTH FOR MONTH' _ _ - __ _ -_ g ° - yn,enc s creatls AMOUNT DU Previous Balance Charges this month Finance Char a TOTAL CHARGES Totat Pa 79.93 + 153..68 ~ .00 - 233.61 83.37 - 150.24 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse , ** ACTIVITY FOR HEINLEN, KENNETH L 07/18/08 7375600 11 ARICEPT 10MG ;07/18/08 7375606 13 METOPROLOL XL 25M ',07/18/08 7375608 12 ASPIRIN 81 MG CHE 107/18/08 7375609 12 THERA TABLET 107/18/08 7375610 12 CITALOPRAM 20MG '07/18/08 7388514 12 LEVOTHYROXINE 25 07/18/08 7390821 1 CYANOCOBALAMIN 10 .07/18/08 7406133 21 METRONIDAZOLE 500 ',07/18/08 7406135 17 FLORASTOR 250 MG 07/25/08 7410513 5 METOPROLOL 25 MG 07/28/08 7406139 16 FLORASTOR 250 MG 08/13/08 Payment-Thank You `08/15/08 4095742 30 LORAZEPAM 0.5 MG IMORE AVE. O1 O1 O1 O1 O1 O1 Ol 01 01 O1 O1 O1 -HEINKE 36.00 5.00 2.73 2.82 5.00 5.00 7.99 5.00 14.89 3.54 14.18 150.24- 6.72- LY~~A 1®~ - -090518 .00 36.00 .00 5.00 .00 2.73 .00 2.82 .00 5.00 .00 5.00 .00 7.99 .00 5.00 .00 14.89 .00 3.54 .00 14.18 .00 150.24 .00 6.72 ~~~ ~'~, G~ ~~ :. ____ ~~ ',~~ Sli ~'~ ~~~ 4.62 LEGEND NON-LEGEND': FOR MONTH FOR MONTH -- -- - _=_ Previous Balance Charges this month Finance Charge TOTAL CHARGES Total Payments Credits 150.24 + 102.15 + .00 - 252.39 156.96 FOR ALL PHARMACY RELAY ED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse .00 TOTAL TAX AMOUNT DU - 95.43 DATE OPT-MOD RP SERVICE LOC INSURANCE COMPANY AMOUNT PAID BY INS ADJUST You PAID You OWE CHARG S FOR PATIE ENNETH HEINLEN (294397 OQITA) 4-20-08 73070-26 4 X-RAY EXAM OF ELBOW HARRISBU MEDICARE 31.00 5.64 23.95 05/07/08 FILED P IMARY TO MEDICARE ART B (M 002) 05/29/08 Med 'care Pay ent 5.64 05/29/08 Med 'care Non Allowed 23.95 07/16/08 GUARANT R RESPON IBILITY D TE (Char eID: 107 501) ADOIT ONAL INFORMA I0 CONCERNING YOUR ACCOUN PLEASE CO AC US IF YOU CANNOT PAY T IS BILL. THANK YO . REFERRING F!O IDER 324 IS ERIC KRIEG UPIN: D 7324 REFERRING F!0 IDER 590 IS DOMINIC MIR RCHI - U IN: H2559 i ' ~` C1~ ADDIT ONAL STATEME l ESSAGE For bill ng questions , c 11 toll free 1-866-254- 629. t3 / ~~;'" t/~~ 11 V 1,,• -~~ (f .i~ 0~ 1 %~ ~j Y ~ % ~ . v TOTALS: 41.27 172.41 0.00 1 3TATEMENTDATE RESPONSIBLE PARTY ACCOUNT# PAY THI S AMOUNT 07-16-2008 KENNETH HEINLEN 294397-QQITA 10.32 PAYAEIITSREC04EDAFRBt1NISSTAIO~ENTLIATEWLLAPPEARONYOURNEXTSTF181FMT. PAY1E81TD11E1~ONRC~CEIPL 1NANKYOU. MAKE CHECK PAYABLE TO: DAYS 0 - 30 31 - 60 61 - 90 91 -120 Over 120 ACCOUNT AGING 1.41 O. 0.00 0.00 O. QUANTUM IMAGING & THERAPEUTIC A55 FOR ONLINE ACCESS TO YOUR ACCOUNT VISIT US AT: https:llwww.ezmedinfo.comllgita INVOICE #: 834919 FOR BILLING QUESTIONS CALL 1-866-822-8415. Balance reflects current patient responsibility only and does not include charges pending with your insurance carriE 20 02102 R571-]55 L031704 STOCK •F-AW QUANTUM IMAGING i~ THERAPEUTIC ASSOCIATES PO BOX 1805 INDIANAPOLIS, IN 46206-1805 FORWARDING SERVICE REQUESTED RESPONSIBLE PARTY KENNETH HEINLEN KENNETH HEINLEN 100 MOUNT ALLEN ]JR RM 458. MECHANICSBURG, Pig 17055-6171 IIIIIIIfI~I" IIIIIIII n Illllll~~ n n 'I'1(i~'~~~IIIIII~I~' n (111'1) ~ Please check box if above address is incorrect or insurance information has changed, and indicate change(sj on reverse side. IF PAYING BY CREDIT CARD PLEASE FILL OUT BELOW CHECK CARD USING FOR PAYMENT MasteLrC+r01 ^ ~" ~~ bIASTERCARD VISA GIRD NUMBER AMOUNT 9GNATURE E7fP. DATE STATEMENT DATE PAY THIS AMOUNT ACCT. # 07-16-08 10.32 294397-QQITA SHOW AMOUNT INVOICE: 834919 PAID HERE QUANTUM IMAGING & THERAPEUTIC ASSOCIATES PO BOX 1805 INDIANAPOLIS, IN 46206-1805 (~~~I'~ " I~lll~'I'fl~~ " ~~II~III~~'lI~ a I~III~III~ a III~~IIIII PLEASE DETACH AND-RETURN TOP PORTION WITH YOUR PAYME DATE OPT-MOD RP SERVICE LOC INSUw-NCE COMPANY AMOUNT PAID•BY INS ADJUST You PAID rou OWE CHARG S FOR PATIE ENNETH HEINLEN (294397 QQITA) 4-21-08 73550-26 O X-RAY EXAM OF THIGH HARRISBU EDICARE 35.00 6.53 26.84 1 05/07/08 FILED P IMARY TO EDICARE ART B (M 002) • 05/29/08 Med care Pay ent 6.53 05/29/08 Med care Non Allowed 26.84 07/16/08 GUARANT R RESPON IBILITY D TE (Char eID: 107 478) 4-20-08 72040-26 4 X-RAY EXAM OF NECK SPI HARRISBU EDICARE 45.00 8.02 34.97 2 05/07/08 FILED P IMARY TO EDICARE ART B (M 002) 05/29/08 Med care Pay ent 8.02 05/29/08 Med care Non Allowed 34.97 07/16/08 GUARANT R RESPON IBILITY D TE (Char eID: 107 072) 4-20-08 72170-26 3 4 X-RAY EXAM OF PELVIS HARRISBU MEDICARE 34.00 6.53 25.84 1 05/07/08 FILED P IMARY TO EDICARE ART B (M 002) 05/29/08 Med care Pay ent 6.53 05/29/08 Med 'care Non Allowed 25.84 07/16/08 GUARANT R RESPON IBILITY D TE (Char eID: 107 073) 4-20-08 71010-26 4 CHEST X-RAY HARRISBU EDICARE 36.00 6.83 27.46 1 05/07/08 FILED P IMARY TO EDICARE ART B (M 002) _ 05/29/08 _ _ _Med care Pay_ nt __ ___ 6,83_.___. _ _____, _ _ 05/29/08 Med care Non Allowed 27.46 07/16/08 GUARANT R RESPON IBILITY D TE (Char eID: 107 076) 4-20-08 73510-26 4 X-RAY EXAM OF HIP HARRISBU EDICARE 43.00 7.72 33.35 1 05/07/08 FILED P IMARY TO EDICARE ART B (M 002) 05/29/08 Med care Pay nt 7.72 05/29/08 Med care Non llowed 33.35 07/16/08 GUARANT R RESPON IBILITY D TE.(Char eID: 107 328) TOTALS: 41.27 172.41 0.00 10 STATEMENT DATE RE8PONSIBLE PARTY ACCOUNT # PAY' THIS AMQUNT 07-16-2008 KENNETH HEINLEN 294397-QQITA 10.32 ParuolTS eI~IrEO aFTel Txls sraTEMxr I1aTE wiL APPEAR OM roue xExr sraTaolT. rarla9lr oue UPON R[~EIFf. 11YUIK YDU. DAYS 0 - 30 31 - 60 61 - 90 91 -120 Over 120 MAKE CHECK PAYABLE TO: ACCOUNT AGING 8.91 O. 0.00 0.00 O. QUANTUM IMAGING & THERAPEUTIC ASSO RONALD L HEINLEN l O 7 2 MARY S HEINLEN 635 MIO~WAY RD ,/``~~ J p ~ ~ 8G-5oo!1012 YORK FIAVEN, PA 17370 VG~ d0 ~'~ (,? ©~~ f ~~~~r r f ci~c;,•, ~a~, a ~s er ~ ~ s~,~f 4e~t '7 ~~ ''p Fide/ity ~ ;.~ ~~rvestments ~' ~ ~' ~:L0~~20568L~: L07211'77L0547LL325511' RJFIMI.AND 1993