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HomeMy WebLinkAbout10-28-08' ~ 15056041169 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO Box 280601 INHERITANCE TAX RETURN ~ 3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~" ~ (1 ~ 1 (~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 202-36-6561 07282008 0116194; Decedent's Last Name SOUTNER Suffix Decedent's First Name THOMAS (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First (Jame Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE BOXES BELOW MI R MI ® 1 Original Return ~ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after l2-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~_ 8. Total Number of Safe Deposit Boxes (Attach Copy of Willj (Attach Copy of Trust) 9 Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~I 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1.1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number FRA NK H KELLY 717.774.753,6., Firm Name (If Applicable) KELLY F=:NANICAL SERVICES INC First line of address 400 BRIDGE STREET, SUITE #4 Second line of address City or Post Office State ZIP Code NEW CUMBERLAND PA 17070 correspondent's a-mail address: FRANKKELLY@KELLYTAX . COM Under penalties of perjury, 1 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 complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN TU E.OF PERS N RES O SIBLE~FOR FILING RETURN DATE 1912 CARLISLE ROAD CAMP HILL PA 17011 SIC~DFAfitiRE'Off, PREPAR ER THAN REPRESENTATIVE UA 4~ BRIDGE STREET, SUITE #4, NEW CUMBERLAND, PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 15056041169 15056041169 J nb REV-1500 EX Decedent's Name THOMAS R SOUTNER Decedent's Social Security Number 202-36-6561 RECAPITULATION 1. Real estate (Schedule A) ..................... ..................... 1. 2. Stocks and Bonds (Schedule B) .................. ..................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1 - 7) ................................... S. 9, 603.00 51,638.00 61,241.00 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............... 10. 11. Total Deductions (total Lines 9 8 10) .................................. 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 14,770.00 9, 455.00 24,225.00 37,016.00 37,016.00 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 15. 16. Amount of Line 14 taxable at lineal rate x .0 1g, 17. Amount of Line 14 taxable at sibling rate x .12 17, 18. Amount of Line 14 taxable 3 7 016 at collateral rate x .15 r ig, 19. TAX DUE ...................................................... .. 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056042160 5, 552.40 5, 552.40 Side 2 15056042160 15056042160 REV-1500 EX Page 3 Decedent's Complete Address: File Number 2 0 0 8. 0 0 9 3 8 DECEDENT'S NAME Thomas R. Soutner STREETADDRESS 1912 Carlisle Road CITY STATE Camp Hill PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 2 7 7 Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 5.275.40 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 ............................................. ........... ^ x^ d. receive the promise for life of either payments, benefits or care? .................... ........... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ..... [] ;~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .......................................................... ~] ^ 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(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve ;12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, ~vhether by blood or adoption. 5.552.40 277.00 0.00 5,275.40 REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R. ~~outner 2008.00938 All real property awned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchange between a willing buyer and a willing seller, neither being compelled to buy or sell, both having re asonable knowledge of the relevant facts. Real property which isjointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VAIUEATDATE NUMBER DESCRIPTION _ OF DEATH ~ None TOTAL (Also enter on line 1, Recapitulation) ~ ; (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS 8 BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R. Soutner 2008.00938 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Soutner SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP FILE NUMBER 2008.00938 Schedule C 1 or C-2 (including all supporting information) must be attached for each closely-held corporafionlpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sale-proprietorships. ITEM VALUEAT DATE NUMBER DESCRIPTION OF DEATH _ ~. None TOTAL (Also enter on lines 3, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1505 EXf (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. ~~outner 1 Name of Corporation C1 o n e Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Business Reporting Year 5. Was the decedent employed by the Corporation? ....................................... Yes ~No ff yes, Position _ Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ......................................... Yes ~No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............ Yes []No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer any stock in this company within one year prior to death or within tuvo years if the date of death was prior to 12-31-82? Yes ~No If yes, [Transfer Sale Number of Shares ` Transferee or Purchaser Consideration $ Attach a separate sheet for additional transfers and/or sales. Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? .......[]Yes ~No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ...................................................... Yes ~No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ...................... :]Yes ~No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? .................... I~Yes ~No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • ~ ~' • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market valuels. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. Date of Incorporation State Zip Code Total Plumber of Shareholders Prod uct/Service SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT FILE NUMBER 2008.00938 State of Incorporation G. Any other information relating to the valuation of the decedent's stock. (If more space Is needed, Insert additional sheets of the same size) Provide all rights and restrictions pertaining to each class of stock. REV-1506 EX~ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Soutner SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT FILE NUMBER 2008.00938 1. Name of Partnership None Address City 2. Federal Employer I.D. Number Date Eusiness Commenced Business Reporting Year State _ Zip Code 3. Type of Business ProducUService 4. Decedent was a ~ General ~ Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. • • ~ • • ~ B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ......................................... ~ Yes ~ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ............ Yes ~No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? Yes ~No If yes, Transfer Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers andlor sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ......... ~~ Yes ~ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? .......................................... [Yes ~ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ........... .. []Yes ~No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? ........................................ []Yes ~ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. .. []Yes ~No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Soutner SCHEDULE D MORTGAGES ~ NOTES RECEIVABLE FILE NUMBER 2008.00938 All property jointly-owned with right of survivorship must be disclosed on :ichedule F. (If more space is needed, insert additional sheets of the same size) i v rA~ (r+iso enrer on une w, rcecapliwanon) ~ REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, a MASC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R. Soutner 2008.00938 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on !ichedule F. (Ii more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Soutner FILE NUMBER 2008.00938 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G SURVIVING JOINT TENANT(S) NAME I ADDRESS I RELATIONSHIPTO DECEDENT A. None B. C. JOINTLY-OWNED PROPERTY: 'TEM NUMBER LETTER FQR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S WTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. i SCHEDULE F JOINTLY-OWNED PROPERTY TOTAL (Also enter on lines 6, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Soutner SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY FILE NUMBER 2008.00938 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side ni the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIPTO OECEDENTAND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OFAS.iET % OF DECD'S INTEREST EXCLUSION pF APPLICABLE) TAXABLE VALUE 1. TSP - Federal Employees Retirement 51,6:!8 100 51 ,638.00 TOTAL (Also enter on line 7, Recapitulation) 5 51, 6 3 8 . 0 0 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCHEDULE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R. Soutner 2008.00938 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ 1225Musselman Funeral Home Inc Lemoyne PA 2. Rolling Green Cemetary - Internment Rights 3. Rolling Green Cemetary - Lot and Marker Feed B. 1 2. 3. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address Ciry Year(s) Commission Paid: State ZIP Attorney Fees Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address Ciry State Relationship of Claimant to Decedent 4. 5. 6. ~. 8. Probate Fees Accountant's Fees Tax Return Preparer's Fees Death Notice Advertising Wake Cost ZIP 5,102 1, 495 3, 830 1, 750 300 1, 225 570 323 175 TOTAL (Also enter on line fl, Recapitulation) 5 14 , 7 7 0 . 0 0 (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 ESTATE OF Thomas R. Soutner SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS FILE NUMBER 2008.00938 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t Capital One Credit - 0405721436344068 1,529 2. Members 1st Credit Union - 134459 - Auto Loan 7,308 3. Praxair Helath Care 23 4. Camp Hill Emergency Physicians HYP32640385 31 5. Camp Hill Emergency Physicians HYP32595241 18 6. Holy Spirit Hospital - 32640385 112 7. h4offitt Heart & Vascular Group - 38849 291 8. Internist of Central PA - 25805 25 9. Holy Spirit Hospital - 32560484 101 10. Cardiovasular Surgical Group - 12566-1-1 12 11. Snoke Family Practice - soutth-001 5 TOTAL (Also enter on line 10, Recapitulation) 1 S 9, 4 5 5. 0 0 Of more space is needed, insert additional sheets oithe same size) REV-1513 EX+ (9-00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Thomas R. Soutner 2008.00938 RELATIONSHIP TO DECEOEN7 AMOUNT OR SHARE NUMBER NAMEANDADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) ~ OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)J Susan G. Pearlman 1912 Carlisle Road Camp HIll PA 17011 Friend ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPF;IATE, ON REV-1500 COVER SHEET 11 NON-TAXABLE DISTRIBUTIONS. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICHAN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS Entire TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I E (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Soutner SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Boz 4 on REV-1500 Cover Sheet) FfLE NUMBER 2008.00`38 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for date's of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other • • ~~ ~ • ~~ ~ ~ None ^ Life or ^ Term of Yeats ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable .............................................. $ 2. Actuarial factor per appropriate table ...................... .............................. . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ........................................... $ ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................ . ................... $ 2. Check appropriate block below and enter corresponding (number) ............................. . Frequency of payout - ^Weekly (52} ^Bi-weekly (26) ^Monthly (12) ^Quarterly (4) ^Semi-annually (2) ^Annually (1) ^Other( ) 3. Amount of payout per period ............................................................ $ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ...................................... . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 i/2% ^6% ^ 10% ^Variable Rate 6. Adjustment Factor (see instructions) ................................................ . 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ............................. $ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................... $ NOTE: The values of the funds which create the above future interests must be reported as part of the Estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on tines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same sae) REV-1644 EX* (3-04) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULEL REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 2 0 0 8. 0 0 9 3 8 1. ESTATE OF SOUTNER `CHOMAS R (Last Name) (First Name) (Middle ~nitiaq , This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. 11. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on None (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate .............................. $ 2. Stocks and Bonds ........................ $ 3. Closely He-d Stock/Partnership .............. $ 4. Mortgages and Notes ...................... $ 5. Cash/Misc. Persona! Property ............... $ 6. Total from Schedule L-1 .................................................... $ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ......................... $ 2. Unpaid Bequests ......................... $ 3. Value of Unincludable Assets ................ $ 4. Total from Schedule L-2 .................................................... $ E. Total Value of trust assets (Line C-6 minus Line D-4) ............................... $ F. Remainder factor (see Table I or Table It in Instruction Booklet) ....................... . G. Taxable Remainder value (Line E x Line F) ...................................... $ (Also enter on Line 7, Recapitulation) Ill. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B, Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpusc or annuity is payable consumed C. Corpus consumed ................................................. ........ $ D. Remainder factor (see Table I or Table II in Instruction Booklet) .............. ........ . E. Taxable value of corpus consumed (Line C x Line D) ..................... ........ $ (Also enter on line 7, Recapitulation) REV-7647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev-1500 Cover Sheet) FILE NUMBER _ _ _ Thomas R. Soutner 2008.00938 This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other i. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. None 2. 3. 4. 5. 1. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. [] Unlimited right of withdrawal ^ Limited right of withdrawal 111. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future interest ...................................................... $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) .. $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% .................. $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One [] 6%, ^ 4.5% ........................ $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) .. $ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) .. $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal line 1) .................. $ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99)(1) SCHEDULE N SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01192 7012131194) INHERITANCE TAX DIVISION ESTATE OF FILE NUMBER Thomas R. Soutner 2008.00938 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. • • ~ 1. Taxable Assets total from line 8 (cover sheet) ............................................... 1. NonF' 2. Insurance Proceeds on Life of Decedent ................................................... 2. 3. Retirement Benefits ...... ............................................................ 3. 4. Joint Assets with Spouse .. 4. .................................................. 5. PA Lottery Winnings ................................................................... 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary) ... 6a. 6b. 6c. 6d. 6. SUBTOTAL (Lines 6a. b, c, d) ................. ...................................... .... 6. 0 . 0 0 7. Total Gross Assets (Add lines 1 thru 6) .......... ...................................... .... 7. 0 . 0 0 8. Total Actual Liabilities ........................ ..................................... .... 8. 9. Net Value of Estate (Subtract line 8 from line 7) ... ...................................... .... 9. It line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. if not, continue to Part lt. 0 . 0 • ~ ~ - • • • Inc ome: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse ........ ... 1 a. 2a. 3a. b. Decedent .......... 1 b. 2b. 3b. c. Joint .............. 1c. 2c. 3c. d. Tax Exempt Income .. 1d. 2d. 3d. e. Other Income not listed above ........ ie. 2e. 3e. f. Total ....... .... 1f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1f) + (2f) + (3f) (=3) 4b. Average Joint Exemption Income ................ ...................................... ..... If line 4(bJ is greater than $40, 000 -STOP. The estate is not eligible to claim the credit. If not, contirnre to Part Ill. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less 2. Multiply by credit percentage (see instructions) ............................. ............... . 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet .................................. . 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ................................................................ 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet....... . REV-1649 EX+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Thomas R. Souther SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUM9ER 2008.00938 Do not complete this schedule unless the estate is making the election to tax assets under Section 91t3t.A) of the Inheritance 8 Estate Tax Act. If the election applies to mare than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the N O n e Trust (marital, residual A, B, By-pass, Unified Credit, etc.). Ii a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. H less than the entire value of the trust or similar property is included as a taxatrle transfer on Schedule 0, the persona! representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator o1 this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0 The denominator is equal to the total value of the trust or similar arrangement. Part A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedents surviving spouse Part 8 Total' $ more space is needed, insert additional sheets of the same size) Fart f3: Enter the description and value of all interests included in Patt A for which the Section 9113(A) elt:tction to tax is being made. description ', Value I,~• „I Illy rcurrxl vluth n inn illy In ,i:l~ I'_'nn~~l~ Intl ill'.i`nrn :il ~~ It.ll ~r„nls in I~~Irni.ul~c ICI. I. tr' ~rluly~ Ih_u II,I. iv , nun :. '~f) {, 11'(111 r~r'tl ~~\ I~I~ { ~i 11~1.1~ ~,-•CIlli~l\'_ ~li'1 ~~ "1 I'In i I'.I . ' ' ~ II ~I ~r I f1(t. WARNING: It is illegal to duplicate this copy by photostat or photograph. ,~~~,~'iH ~F Pf vyf ~ ~ ,;~ ~ = ~ ~ G' ~! r a . " ~ S +~ . O~~q r 9 ; !' ~~.~`Z% ~ yjENT i1~..rr~` x.11. - ', x. ': Ink ', I'r(a;li ~~'I.if~' ..~ j`fl~lF -~-(.WV Y.tIL~ ,,,,,5,,: 4, ; :. ,,~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT Of HEALTH • VITAL RECORDS 069672 ;`:,;_",~'•„r' CERTIFICATE OF DEATH 'I>' ^ ,Nk (See instructions and examples on reverse) s-ATE PILE mufAREH 0 N r 0 s „..r_.-le~.d 1,.I -ame +~. ~dnl Sex 7local Securlry Number 4Date of Dsatn~Lknln. aay. yaarl -- 20 -36 -6561 Ju1.28,2008 S aqe 4 as R~nnuavl '. it„µr '~ rru v, pr • ny 6ale :A .l~rm ~r.lomn. v.~.r. fian ~ P.:^np:rce iGry and +ale a ty¢gn ccunlryl 3a dace of Cealn rCheck nnry one) ,:, ~ ,., ,w,•ws Hosptal odi«: • 61 ~ ~ , Jan.16,1947 Harrisbur~,PA ^ Inpatwnt ~R i Outpstlem ^ DOA ^ Nursing Home ^ Residence ^Olher ~ Slkcity. '. wr r, ,r OFeln 5C & "'" cola. 'wp :r Deann Ad =+auiv Nam¢ III ml Sldulaln ;ve street and ^Ixlderl 9 'Nos Dececenl of Mispanc Orxpnx No ^ yes 10. Race: Amercan inolan BIacA.'Whne. ek. - Ilf yes. spenry Cuban, isw^e5 Cumberland East Pennsboro Holy Spirit Hospital MexroanPuenoRican.ek.l white - Ent s ~suai DcwpslMxl Kpd ' u N 'ne wit sl "~ nvikin0 ht¢ ro 'll dlale rptir?d 12 .NaS Ca>cedent e'rer in I'w 13 Docecents Educalrm'Soecity ~~ry'vgnosl yade [OmGelfd) 14 MEnlal SlaluS: Manned. Never Marnad, 15. Bullring Spouse llf wle, give maden name) lddewed DNOrfCd ISoesrly) U ~~ :MUx , . c-ss v-nusiry .LS a med Forces) ':meotary ~ Sv.adary i0.13i Coeege II-a or S,f , t of ZQ-eS ^"° 12 never married 16. Dxeueni s MaiMg Address Sneer. c:N '.cwn .tale.: ~o eAei Decedents Dh Decedem +iludl Pesderrce .'a Nate Pennsylvania L;ve in a I,~ ~ Yea. Decedem ~~¢a n T, o v e r a t la n Fwp 1 9 1 2 Carlisle R d . Township? '.7d. ^ No. Deccdem Lived wtlm - C 3 m H i 11 , P A 17 011 16 r""ry (' n m h P r l a n d aceaar Limda m OIry l3ao IB nro~ s Name IF~.rst, mdde last aunixl 15. MoOer's Name IFrsl. mitlde.'raden surname) John A. Souther Irene Adams 'ce ,n'o•mants `kme ,Trot : Pnnu `OO. Inkrrtant s MaiMng Address (Street cIry I town. state. zp code) Susan Pearlman 1912 Carlisle Rd.,Cama Hi11,PA 17011 21a !demod a Di¢pp<ilan "; emaldn Li Donaldn 216. Date of DI¢Irosltion p"Awen, Day, yeaq 21c Place M Dtslwsro« )Name d csrrxlery, cremalay o' olAer pWcel 21 d Localdn ICay; town, stale, nD code) • ^ s~~ ^ Removal Iron Sale ' waa crematgn «D«ration aumonaed ^ A u 4 2 0 0 8 ~ • x Evans Crematory Leo 1 a , P A 17 4 0 "y; ^ . gp~yy~ ;try Medical Euminer I Coroner? Yes twe of Finer .. ce Licensee Icr F~ersm arng as such 2?b L6ensE Numoer FD-013163-L ^?: !4arrx=. ono 4daess of Facets Musselman FHSICS,Inc.,324 Hummel Ave.,Lemoyn~,2'~17043 e Items 23at ~unly when ceniryxrg 23a. 'o'ne test of my knowledge, deam ouuned al Ine'~ime..ule a'q Gace s!ado. i5xyutae ono unel 23b. Licenss Number 23c. Dale Slgled !MOnpl, day, year) prryeKlarl 5'ql avalladle at hlfk d dedih IO cemty -cruse of dean. kerns 2n ~'6 nIm x _cmpiered by p¢rsat ~4 ".me ,I Death - 25. Cale w,rouncEd Dead!Mmlh, day, year) 26 Was Case Referred to Medical Examiner Coroner kr a Reason Other than Cremation a Donatdn? ~ Mn oronar,xs seam. C A r ~ 5 /* M. II ~( ~ ~ I ~ U ~ ~ ~ g ^ Yea ~No CAUSE OF DEATH (See instructions and eaa pks) , Approumale mtenal: Pan II'. Eller Diner sdndroam candlkns cdntrbuone td death :B Did'obaan Use ContMUte!o Dean? Item 2' Pan I: Emer me coon of evems - a seases.'~njunes, a compicatkns -Ina) directly caused Inc Beam. DO NOT Enter lertmnal events such as cardac arrest, 1 Oraet ro Deadr but nd residing in!he urdedyng cause given n PaA I. Yes ^ Prohady -esprahaY,rrest, a rerencu'ar'ibNlaWn wnMla stgwrry the Wrobgy Ust mly ore cause m each Yoe. ~ ^ No ^ Unkrrown IMMEDIATE CAUSE iFwl asease a ~^ r V comllnn ~swking n ~eaN) ~ a. C/9'2 ~~ Q ~ /7 J6Q ~S t ~ •V+ - . ~~ ~~~ ~/•Cf 29~ II F ~1 ~ um Mn sl ex. a ^ ! /a"/ y ` ]ue ro'. a ronseouetke dl: /' p~~! , , ~/ SeouentWty hsl conoitiaw. A any, y_ ~()~ ~ ti ~')/Z 7 rL~ ~~ J e-~/O ~ i A` ~!/~/Q e r w Y p 9 D I] Pregnant al time d deaM •eadq o the cause kstetl mane a. / r r USE Due Ic for s a cars uence o0: ~ G C ^ Na OregnaM, bJl «eg!um wdhn 42 OayS A Enkr the UNDERLYRI " ~ idlsease nr ~neuy lhal nitut¢d ew _ ~~~-~A~~`'~ ~yv1 Ar(j~~~~(Il~ i/GL~~, ~ L of katA / .- evena'esultnc'~n dead) LAST. f.~. r t ' ^ Not Dregnant. MA prelyun143 days l0 1 year J . Due IG a as a consequence O a hEfae death :I. r ^ Unknown d pregnant wkhn me past yex Xd 'Nos ar: 4se0sY 306. Were Aalopsy Findngs 3t "Ramer >i DeaN 32a. Date ol'inlury IMmth. day, ysarl 32b. Descnbe How Inryry Occuned 32c. Place of Injury Home, Farm, greet Factay, ' 'a"coned? A.a1ub'e Pay '.o CemPlehm Ot iause ^t CeaN? p~ uN¢Ntal ^ Hon`Kde '„ yfice Euidrg, e+c. iSpecih) ^ Acnderrl ^ ?endag Irneslx{alim 32tl. Time d Injury 32e. Inury at Wakn 321. tl Transponation'~.ryury ;SpecAy) 32g. Localan dl Injury iStreet crry 11own, slate) ^ vP$ I~NO ^ yes ~ ~ x:de ^ Could Na De Determined ^ : ^ Dmerl Operata ^ Passenger ^PEdesman ^ Yes ^ No u M odrer ~ spe<M: 33a ~eddier Icneck all' one) 330. Sgnawe M T of Cerdker • Cenltying Physician (Phvsxran cevtymg cause of seam wren another physidan has prorwurced dean and rAmpiel¢d hem ?31 _ , To the nest of my Nnowkdge, deaM «earnd tlue to the causefs) and manner as shted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ LJ Pronomcug and certiryt~ ny~src~ occurted ~ the opine datenand alxe, aMnidue m the caua s amend mannn u smed_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ',~ To d1e Dell d m know P ~ I '~ lac se Number /~ 77~~ 33d ]ate Signed IMonth,]ar, year) /~/1~ /~~~ ..~ L/D ~j • tAediul &aminn I Coroner w / LQC(( G Cn the oasis of examnation and i « inmtigali«, in my opinion. deaU acvrred at the time, date. and place, and due to the causNs) and manner as stated_ ^ ~ ,, a Address of Person C'J~ cruse s JJ7~e~-th ,u 2P ,qe i P,m /v ^CY Ki~ /I ~, /C H i5 aegistrai s Signature a- trKl 4umoEr ~ ~~ / ~ ~~ ~ ~ / I %. Dale F. 'M ,day, leaq .~ ` ~ y///J !, /~{'~y ( //~f~ ~~ ~ ~~~ ~ ~ ~ ~~~~ ~ ~ pn ~ [ ~ / Y L LlJ Jc.` il~ V ~ ~f//~~ V ~;spcankn Pe,mit \d o a a 8 s a -~~ 1~1&1' lianic ACCOUNT N0. ACCOUNT TYPE 61192201 RELATIONSHIP CHECKING STATEMENT PERIOD PAGE JU1.04-AUG.01,2008 1 OF I 00 0 06113M NM 017 THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011-5911 43641 ACCOUNT SUMMARY HIGHLAND PARK BEGINNING BALANCE DEPOSITS 8 OTHER ADDITIONS CHECKS PAID OTHER SUBTRACTIONS CURRENT INTEREST PD ENDING BALANCE NO. AMOUNT N0. AMOUNT NO. AMOUNT 635.45 2 4,718.13 2 292.78 3 350.00 0.00 4,710.80 ACCf111NT Af TTVTTV POSTING DATE TRANSACTION DESCRIPTION DEPOSITS,INTERESt 8 OTHER ADDITIONS CHECKS 8 OTHER !iUBTRACTIONS bAILY BALANCE 07-04-08 BEGINNING BALANCE 5635.45 07-14-08 CAPITAL ONE ARC CNECK PYMT 000000000003146 100.00 07-14-08 M8T ATM CASH NITHDRANAL ON 07/13 50.00 HIGHLAND PARK, LEMOYNE, PA. 485.45 07-21-08 CHECK NUMBER 3147 282.98 202.47 07-22-08 US TREASURY 312 CIVIL SERV 3,552.06 3,754.53 '07-28-08 M8T ATM CASH NITHDRANAL ON 07/26 200.00 NEST SHORE PLAZA, LEMOYNE, PA 07-28-08 CHECK NUMBER 3148 9.80 ~ 3,b~i":'T,~i 08-01-08 US TREASURY 312 CIVIL SERV 1,166.07 4,710.80 ENDING BALANCE 54,710.80 CHECKS PAID SUMMARY 3147 07-ZI-08 282.98 3148 07-28-08 9.80 ~~~ea s:or, St MEMBERS lst 19iDERA1.l:RLDI'1' L'NION DISYOSI"LION ON PROCEEDS SALE NO"LICE OcRrber _' I, 2008 I?S1~A1~1: O!~ 1~lIOMAS R SOUI~Nf:R 191 Z C.IRLISLF IZU CAMP HIE,I_, PA 1701 I-911 fZe: :lccuunt ;! I;-i4~y-01 VEEi1CLE: 3003 E3UICK IZL:GAL LS-V6 VIN ,'t: 3G<~W[3S3K13 (161414 F.S'I~A'fl UF'I'1tOMAS R SOUTNF;IZ, This letter is to notify you of the disposition of the proceeds from the sale of the above referenced repossessed vehicle. Outstanding Loan Balance $ 7,308.38 (+) Interest $ 66.16 (+) Late Fees $ 5.66 (~) Repossession Fees $ 0.00 (-) ,Auction Fee $ 270.00 ( -) Proceeds of Sale $ 6,000.00 (__) Deficiency Balance Due $ 1,650.20 Please call Arfanda Uintlman in the Collections Department of Members 1" Federal Credit L'nion immediately upon receipt of this letter to make the necessary payment arrangements to pay this balance in full. You may call (717) ?9i-6031 or toll free at (800) 383-3328, extension 6031. If satisfactory payment arrangements are not made, Memhers I'' Federal Credit Union could forward this account to our attorney. this could result in legal action and the liquidattion of this loan account. Sincerely, :lrlanda Dintarnan Collateral Liquidation Specialist Copy: file ~1)U(I Luui,r I~ri~r P-O. 13u.v 10 :~dechanicsburg. Prnns}Ivunia 17U» (800):?83-3338 ~~~~tc.mcmhrrslst.urg "i~ .~ ~ f-, l MEMBERS 1St FEf)ERALCF2E1)I'f L'vIUN ~~ s = Send Ingwres lo: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.memberstst.org Main Switchboard: (800) 283-2328 EZ Call: (717) 697 4372 or (800) 283-4372 TDD: i 11 I) 697 5312 or (800) 283-2328 ext. 5312 TeleBranch: (800)237-7288 1478 1 AV ~J.324 u9_`,5-3478 I~~~III~~~III~~~~~~II„~II~I,I~I~I~~~„II~~~II~~~II~~I~I~,IIII THOMAS R SOUTNER 1912 CARLISLE RD r~~ ~`~ Statement of Accounts Mar 25, 2008 thru Jun 24, 2008 Account Number: 134459 Accolunt Balances at a Glance; Checking : 0. Savings : 341. Certificates Loans cr , ~ 5~ Money Management 0 7,787 0 00 37 00 30 00 CAMP HILL PA 17011-5 ~ ~ C' ~,~~ ~, ~~ d L ~. :~ `= ~ , ~ ~ `'~ ~. "~-~' ~ r` r'~ Page : 1 of 2 ,~ \ (~` ~ With zero origination fees, lower ititerest rates and flexible repayment options, it's easy to see why our new sturient loan product is a better gray to pay for college. Visit http:!/members1st.studentchoice.org for more information. ~\ _, SAVINGS ACCOUNTS ~~< <~ 00 -REGULAR SAVINGS Date Transaction Description Additions Subtractions Balance Mar 25 Ba/ance Forward 905.81 Mar 30 Withdrawal Transfer To Loan 01 282.98- 622.83 TRANSACTION DATE - 03/29/2008 Mar 31 Deposit Dividend 1.000% 0.75 623.58 Annua! Percentage Yie/d Earned 1.0 f03S from 03/01/2008 through 03/31/2008 Apr 30 Withdrawal Transfer To Loan 01 282.98- 340.60 TRANSACTION DATE -04/29/2008 Apr 30 Deposit Dividend 1.000% 0.50 341.10 Annual Percentage Yie/d Earned 1.010% from 04/01/2008 through 04/30/2008 May 30 Withdrawal Transfer To Loan 01 282.98- 58.12 TRANSACTION DATE - 05/29/2008 May 31 Deposit Dividend 1.000% 0.27 ~.- 58.39 Annual Percentage +'~e~d Famed 1.02L9~ from D5/01/?008 ~reugh 05/3112008 Jun 18 Deposit by Check 2Et2.98 341.37 Jun 24 Ending Balance 341.37 LOAN ACCOUNTS 01 -INDIRECT USED AUTOS Date Transaction Description Amount InterE;st Fees Principal Balance Mar 25 Ba/ance Forward 8,497.97 Mar 30 Payments Transfer From Share 00 282.98 45. ~4 0.00 237.14- 8,260.83 TRANSACTION DATE - 03/29/2008 Apr 30 Payments Transfer From Share 00 282.98 47.64 0.00 235.34- 8,025.49 TRANSACTION DATE - 04!29!2008 May 30 Payments Transfer From Share 00 282.98 44.?9 0.00 238.19- 7,787.30 TRANSACTION DATE - 05/29/2008 ~ - Jun 24 Ending Balance 7 , 787.,30 Annual Percentage Rate 6.790°10 Daily Rate .018602% ') { - -- Continued on following page - - - '~ tined hn:3inre~ Iq vt Main Switchboard: (800) x8323'18 5000 Louise Drive PO Box 40 EZ Call: (717) 697 4372 or (riU03 7H3 43/2 MechaNcsburg, PA 17055 TDO: (117) 697-5312 or (800) 283 2328 ~rxl 1,;312 NEWNFliS ly• www.memberslst.org TeleBranch: (800) 23/ l28~ ti ~, YTD SUMMARIES Mar 25, 2008 thru Jun 24, 2008 ""'° "'e Account Number: 134459 Page: 2 of 2 TOTAL DIVIDENDS PAID TOTAL LOAN INTEREST PAID 00 REGULAR SAVINGS 3.64 01 INDIRECT USED iaUTOS 240.30 Don't forget about our new Member Loyalty Rewards Program. The more products you have with us, the more benefits you'll receive. Ask an associate for details or visit our website at www.members1 st.org for details. THRIFT SAVINGS PLAN Page I /)r 2 PARTICIPANT STATEMENT For the period: 07!01/'I008 - 09/30!20(18 Nle~.~• revihw this stateuu•n1 fur accuracy, as the information in i1 ls.ontiult>r~-~r{ 1 urrect lnllE•ss yc~u n<,Irfy us. f<~ ~ „rrv•~ t t~rrors ~~rt illis slal~~nl~•nl, flleax~ cunta~ tl>e ItiP at the IhrihLil~~ nunik>E~r I>,~luw. 73~)7t,a i43H71) l)(7 0741)1 t3 '17380500 10/Ot3 0134175 ~NAt!)346 ••AUfU 17 0 51 70 17011-591112P343181N7 (+:r~~~~~u~~~nnr+~~i»~~r~~~~~r~nu~~~~u~~rfu~~n~~~m~~~ l l IE ES l Al E OF TH( )MAS K. sc )t 11NER 1413 CARLItiLE RD CAIv1P I I I I L, PA 1 "01 1- ,91 1 Account Number. 1502 1833 83058 I )ate of Birth: O1 t 1 t,/1 ~>-1? Kt•tirrnlr~nt (:ov~~ra;;t'. I I KS k nglloyrnent Stalus: f )l,cF~ased, dated I)7;2t3/ZOOH Benetiriary L>f~signatiun: Yes, dated OSr' 30~2t)(lh Service Rerluir~•d fnr A2~~stin~: 3 years (r~Jm 02;1')/1~)8~ YOUR QUARTERLY ACCOUNT SUMMARY Besiming Contribution Withdrawals Change in Ending Balance and and Interlard Value from Balance TSP FUNDS (07/01/Oa) Additions Deductions Transfers Previous Quarter (09; 30/06} Individual FurKls G Fund $29,718.35 $0.00 $0.00 $2~1,6Ei1.20 5344.78 $ i1,7Z4.3:3 F fund 11,60554 0.00 1).00 11,829.30 223.85 ').00 C Fund 10,31459 0.00 1).00 'l,8?'~1.81 182.78 x).00 Total $51,h38.48 $0.00 $0.00 g~0.00 885.85 $.i 1,724.33 How your future contributions and loan payments were allocated as of 09130/08: Individua! Fund(s) G Fund 50°% F Fund 25°io C Fund 25°b How your ending balance was distributed as of 09/30iC8 {see pie chart): !>tdividual Funrl(s) G Fund 1OO" S, F Fund n°>> C Fund li"b TSP Web Site: www.tsp.gov THRIFTLINE: 1-TSP-YOU-FRST (1-877-968-3778) Outside the U.S. and Canada, call 404-233-4400 TDD: 1-TSP-THRIFTS (1-877-847-4385) ~ ~ 14 ~ r:;-, xxxx>Ul-e 187987 How your ending balance is distributed among the funds 0 G Fund 1 ~/ ~'~~ ~ ,~- ' ~? V l~ r 1 ~ i~ r ~~ \t `" '. .. r;; - co O O N N C71 M t~ "= - p.~ - , . ~. - s - y~ :. . _ - W Z E-+ O O ~; O F r _~ I ti` ~` __ .} l~ O ~n O Q' ~~ oaoo ooo~n c ~n o u~ ONOCo t0 CO N ~--+ C~ 2 r--~ 3 W > ~, ~+ • C • J J.~ Q} ~ ~'- ~ Q,' .--+ O ff' !0 ~ i--{ fn U1 r0 v ~ Ea rtS ~+ ,.-, n, a U v ,~ U1 O Q1 ro ,-~ ~ z ra v~~ o +~~ (1, rJ ~~ H 5.:. A ;n U W F-~ N .b ~+ C ~' d, L~ rJ1 ~ ra N a m ~: r0 3 .n .-{ E o rs =a 1 ~ U a a~ ~ o~ a ro ro r-+ N ~1l o ~ ~+ O -~ N ,~ W~ t!l N O 0 0 0000 ~ooc r-+ r+~ O u~ N --~ b4 OI RS U .,~ ~ w U -~ •~ ~ .. .~ ~ ~ 'O O Q1 ~ L, ~ a C ~ ,~ .C ~ H 1~ 11 ~ fd 1a L Q1 CJ (U t7i G U_ "~ 'O C in Q ro s~ w - ,~ ~vos~ ~ Q~ ~ Lr c' ~ m .~ o ~ v m w u] •~ •~ 3 ~ C Oa (~ (ll Q -rl -ri `i Z U ~ ~ .~ W y C v .b n~ O U m .-~ N v ~7 A ~ E ~ ~ O U ;-, a• • ~ •+ y 'M --' ~~ ~ ~' . _ .~ ~, a ~~ ~; v ~ _~ ~ u b ~ 1 ~; ~ 3 ~, ~, =~ .A ~ :.. E-~ i m '' '"~ -r ' ; T _ M ~ ~i ~ ~n `~ i s :i i s 0 -~Y ,. .. .Yx. '.,P :L, ,n . iaS ~ ,i7t~5r ;a,:9 C'F,,~1F.TER1' IN'I'E:RMENT RICH I'S, M1IERCHANDiSE ;AND SERVICES PCIRCHASE/SECURITY AGREEMENT THIS :1GREE~tENT PROVIDES FOR ENDOW'M1IENT C:~RE RETAIL INSTALLMF,NTCONTRACT _~_- 1'hr., AErccnunt is made this __ day of , +0 , by and between the undersigned "Seller and hereinafter called the "Purchaser ------ ------ ----------------- \ddn~ss __-._., rea --~ i ~. ___. --_~-_ ip ResldenccTelrphr.neNu.l_-_-~1--______-__----_DayTckphoneNo.( 1 _ W ITN ESSE'TFI THAT: The Seller agrees to sell and Purchaser agrees to buy the fallowing described Interment Rights, Merchandise and Servl ^ Develr,pcd ^ Prcdevcloped ^ Lot ^ Law'n Crypt ^ Mausoleum ^ PJiche ^ Other Uc;cription of hucnnent Rights: --- -----..-_ __ '~~~ ( INTERMENT RIGHTS. MC-RCHANDISE AND SERVICES Intcnnent Ri_hls line. S__________CCFI $__-_ _ \tcnnaializalron • Type -_ tiiu _ Dcsrgn -- -,-- _ Memariul Base -Type - Si~e i'olor _ _-_- -- --- Mcnxnial Installatiott/Inpection Fee _...__ ................_..... _ Memorial.'vlaintenance ..................._._.... _........................ _ C: skct ~ Description _ ytutenal: WoodiMetal Gauge _ ' Outer Burial Container -Type _.-_ _-__ lntemtcntnndRecnrdingFee ..............._............._.....,........ _ Processing Fee ................................................................... Other Away From Home Pmtection'° Plan Isee helmvl ...._,..._.. -- iales 1'ax ............_ .............._ ......._....._............._.....___... - _-T- IaI Total C;ish Price Ilncluding Sales Tasl ....._._ ............. $ Less: Down Paymem C:tsh.........___,... _...._...........__.__. .._...._ IS Credit For ___-_-- (----- Ibl Total Down Payment..._....__..__.__ ...............__....... 1$ _____ RI I tnpnid Balance of Cash Price f Amount Financedl._.. _ _ Idl Service Charge I Finance ('harge) ............................._ Ie1 Ti one Balance i Total of Payments) .................._......... _ (f) Tine Sale Price (Total Sale Pricel ............._............... S Remarks: ~ i tie . nr,n~ entire nonre rrorecnort clan being purchaseU hereunUer is a pntduct provided by a Third party. not by the cemetery identified in this Agreement The Third party i prociderisnotuwnedbynrafTiliatedwiththecemetery.andthecemeteryisnotresponsiblefortheperformanceoftheservicesassociatedwiththe.wnrFromHomrPr,aernrvr Plan. The Purchaser wi I I he required to en(er i ntn a separrte contract with the third party prov ider pertaining to : fica r~ From Home Prnrecrinn Plan. That plan has been ret rrenced in Thu A~recnxmt and included in the purchase price chose solely fur the ronvenicnce of the Purchaser in nta4.ing payments. ITEMIZATION OF AMOUNT FINANCED of S . $ shall be credited to your account with Seller \mount paid to others on your behalf`. $ to public officials, $_ to Assist America Prearrangement Services, Inc 1we may he retaining a portion of this amounU. 1NNUAL FINANCE Amount Financed Total of Payments Total Sale Price PERCENTAGE RATE CHARGE The dollar amount the The :unount of credit provided to you or The amount you will have paid after you have made all The total cult of your ppur- chase on credit includine The cost of your credit credit will cost you. on your behalf. payments as scheduled. , your down payment of as a yearly rate. $ tb) Ynur pa ~ment schedule will he: Number of Payments Amount of Payments \4'hen Payments Are Due $ Beginning i•rcp;tymcnt It you pay ort early. you w!II hr enntlzU to a rebate of all or part of the Finance Charge. ccurity: 1'ou are giving a security interest in the goods and property being purchased. Late l'hargr;: If fill payment is not made within t ~ day's after it is due, you will be charg:d 85.00 or 5"6 of such payment, whichever ii less. Other Provisions: See this Agreement for any additional information about nonpayment, default any required repayment in fall I exclusive of unearned finance charged hefore the scheduled date, and prepayment rebates and penalties. If accepted by Seller. the panics hereto uLrez t.r Ihr t~~lh~u ing rams ;,ml ~onaitions: I .-lgrerment to Pay. Having f test baen quoted bath a T~ nal Ca.h Pr'-:r .uul a T~ ~tal Side Peke ti,r thz i:eurc descrilwd ,hnv+ ,~U r,.., ~l,~a .,-..:., .+ .a_.. - ,, ... ~.. . - ~ r PRENEED COUNSELOR SALIES RECEIPT DATE ~' ~L-D~ RECEIVED FROM )((( `/~ ~/~f~-_l THE AMOUNT O~,,ry~-'s~sS~~ AS: DOWN PAYMENT CASH ~'SOL~RS I S, aim]-! REGULAR PAYMENT~~r~~,~, C CREDtT CARD CHARGE ~~~ ~ ~~ CHECK [] r1 ,.-~ ;'CLiRDTYPE ^ FOR THE PURCHASE OF INTERMENT RIGHTS ANDiOR MERCHANDISE AND RECEIVED BY CEMETERY DATE I Lr l `~ ~ -~" '~~ ~~er; aoo2 ;o~o?I s~z ~, NAMED CEMETERY. .. rc .+c i. r.GK.ittAt~. lit KE..~UL 1 LU tt1 112tsI t~Ft11 l(1N .V\D PURCFfA~ER FS GIy'1v~G UP H15iHER Rl(~FiT -fO A COURT f>R .I l R' TRIAL AS 1b'ELL AS HISiHER RIGHT OF APPE:\L. Buser hereby acknowledges that this Agreement was completed as to all essential provisions before it was signed by Buyer end a cop t r. l'~nnr.tct _ - _.-_._--- __ __. __.- Pile Folder Namc/Numhcr __ _ l'F,~(ETERY INTF,RhIF,NT RIGH'CS, h1ERCF[ANDISF., :IND SERVICES PURCHASE/SECI IRfI'Y AGREEhIF:NI' THIS AGREEMENT PROVIDES FOR PERPF.T'UALlF.NDOWM1IE;N"f (';IRE. 7hr uuderxigned, referred In as 'Purchaser', hereby agrns to purchase the Interment Rights. 1lerchandisr and Services de.cribed hereto, subject In acceptance and appntval u the aM,ve named cemetery. hereafter rcferrcd to as'Seller'. Purchaser. Lau Name: ~ I 1 1 1 1, 1 1 { I I I I I I l i I First: t_..L I l t l I ~~ I I I I I M~Jdie. I I I__ I I_ I hlrphunt: (_) .. StiN: UUH. / J/ r.in.nl. sddrrss~ I I 1 1 1 i l l l l I I I I I' I I I I I I I I City Style- i Lip: I I I I j. I L I_.I 1 1 1 1 1 1 1 _~ ~~4 -._ ______` ___ II Ca-Purchaser: Lau N;nne. ~ I l l l l l l l l l l hliJdle: l l l l l l t"~` ~ 1 1 1 1 1 1 1 l l l i l I I I I _J-1___~ lFlrphune: S.SN: ( ) ~ UUR: / / P.med: _ - - sddre"' I I I I I I I I I I I I I I I I I I I I I I I I I I c'ty. I_ I I I I I I I I I I I I Sia"~ ~I I /ip Urcrased: La,r Name, I I I I' I ~l I I 1 1 1 1 1 1 1 ..,t. ~_i h l l l l l l SOdule I I I I l i Ixl6. / / UOD: / / _ Ronal Date: /_~/ Vcicran i~ Description of Interment Rights to be used: ~ xlemorialization Rights: ~ Is,ut Ca nhcate of Intcnneat Rights ur: __ _„ -___,-__ .\ddress: City: State: lip INTERMENT MERCHANpISE & SF,RVICES • Interment Rights 5 Iles _ ~ _ _~--. -- IIncludes Perpetual/Endowment Care of S '~ ..1~ ! Supplier _ • Interment and Recording Fees _ Type/Color _. • Uuter Rurial Container Design/Site Supplier _ .AdminiProcessingFee ~~__- ,Vndel/Design Other: -',-.~ Vlaltrial/Color Other_ _ -~ • Outer Rurial Container Installation Other _ __-_ --.- \lF:MORIALlZA'CION Other _ ___~~ _ • M1temurial Other _ _- ^.---- tiupplter _. Other__ _ ~ ._.__.~ T}pe/Color ~ TOTALS,: ALLOWANCES & TAXES Dc,iSn/Size Interment Rights .....................__......... _.... _. _. _..... _....., . ( 1 • M1lemorial Base Reason _ tiupplicr M1lerchandise/Service .__._............ _......__. _ ................... I __-^ 1 Tyi,elColor Reason __ Design/Size _ Apply to - • M1femorialPerpetual/EndowmenlCan __ M1ferchandlse/Service.......__...._ ....................._...........__ t _____-_ I • Memorial Installation Fee Reason _ • Memorial Inspection Fee __ 4pply m _ _ • Nameplate/Scroll ._~ _ .- Sub Total '__________ • Lettering Total Taxable • flower Yase Sales Tax tit applicable)....__._..... ..._. ._.._... ... _........... Suppl tar TOTAL CASH PRICE ~ __ T. pe/Color Less: Down Payment ' Dc,ign/Size - Other _._ -_ • Vase Base Total Down Payment 1 - _ __ Sizeibtattrial l'npaid Balance of Total Cash Price 'S _ Votes St Payment Terms Iwhere epplkable): ' - ------ - TERMS The Total Cash Price is due and payable as of the date of this Agreement A delinquency charge of ______ percent will be assessed monthiy on any ba{ance not paid within U) days of the date of this Agreement. If less than full payment is received. Seller shad deduct the accrued delinquency charge from the amount received and credit the remainder of the payment to the Unpaid Balance. Savorily Interest: Seller ptt its ussignsl will have a security interest in the Interment Rights and Merchandise being purchased as described above. Seller will rctaiu urle to said Intermem Rights and Merchandise antic the Total Cush Price. together with any delinquency charges thereon, have been paid by Purchaser to Seller. NOTICE: Ry ,igning this Agreement. Purchaser is agreeing that a ny claim Purchaser may have against the Seller shall be resolveA by arbitral ion and Purchaser i, giving up his/her right to J court ur jury trial as well as his/her right of appea l. tiigned this day of ~ ,'d Purchaser: Relationship: _ Acceptzed by. --_-_-- - _--_-- '- I ~h~Ih ~ i r..~..I ~li~ -Jii~umcni r~~r ia, ui inJ ~ n~I. inc.. C'u-Yurchastr: Counselor Relationship: _ pate: _^/J/ Ir--~ -- S.xt #_ ~ ! ! ~ D:ue -J NOTICE: See Other Side for Additional Terms and Conditions which are Part of 1'fiis Agreement Kelly Financial Services Inc 400 Bridge St. Suite 4 New Cumberland PA 17070 Tel: (717) 774-7536 Fax: (717) 774-4802 October 27, 2008 Estate of Thomas R Souter c/o Susan Pearlman, Administrix 1912 Carlisle Road Camp Hill, PA 17011 For Professional Services Rendered: Preparation of RE1500 - PA Inheritance Tax Return 1,225.00 Preparation of final 2008 Federal, State Tax Ret. 275.00 Preparation of 2008 Form 1041 _ U S Fidicuary Tax 295.00 Total Fee ................................................... $ 1,795.00 Prior Balance ............................................. $ 0.00 Received on Account ................................ $ 0.00 Amount Due .............................................. $ 1,795.00 ~ www.capitalone.com what's in your wallet) FINANCE Previous Balance Payments b Credits CHARGE Transactions New Balancs~ Minimum Payment Due Dats $1,628.54 -~ $100.00 J + ~ $16.86 + $0.00 ~ _ $1 545.40 $32.00! Aug. 26 2008 J , 1 J ` , Jul. 02, 2008 -Aug. 01, 2008 Page 1 of 1 ~-_~ %E/SE R1Y Al LEAST TINS AMOURr Visa Platinum Account Rewards Summan a3os•~2t4-3e34-4oee ~~ °revrous available balance: 8,51 Your Account Information REWARDS Earned ih~s period: (reflects trenaectons posted dunrrg Cris ding cycler) TOTAL CREDIT LINE $8,900.00 ' Available Balance: 8,51 TOTAL AVAILABLE CREDIT $7,354.60 ~ CREDIT LINE FOR CASH $1,295.00 AVAILABLE CREDIT FOR CASH $1.29`'"~ payments. Credfb b AdJustntenb ~- 1 12 JUL PAYMENT $i0p 0( Finance Charges (Please see reverse ror important Information) ai~nce gale ~'enudlc C;.;~:esFwn~mg FINANCE ?ppheo to 'ste APR CHARGE '~,; Pur,;hases S 1 5fi9 05 0 0346696 P 12 6596 S 16 86 ~ ` r~ dash 50100 005408% P t9 74°6 50.00 ANNUAL PERCENTAGE RATE applied this period: 12.6:196 ~ ~~ 1 r\' ~, ~ •~~: Q At Your Service - Go m ,vwrv cacrtabrre com to menage your eccounL ' C ~ .,.~ ~ ` d _` L N Tat t-800-y55-7070 to ~epat a ust or syulan card cx speak to G,stomer ~ /` ~~ ~ ~`..~ j J Y cam, } %aletans `t'J I ~; ~ J . ,, Pay Online et r~nwv caonebrre com or mail your payment to: ~``~ r natal One Sank fUSA 'J A • ? 0 Box 70884 • Charbrte. NC 7 ~ ~' .'32120884 I V C-t~ J~V~ Send Inquiries to: fir' ~ ~ '.;}Ntal i?rre• N 0 Birx 30285 • Set Lake Gty, UT 84130-0285 ~ w? ~ ~c - C.. \ 4~ h yj'./ Manage your Rewards online by visdmg l°•`~ '"~ ~ '1,v Ntl,. W~~IA1'V1Y MT/ITIkifJPWM(IC , <! ~~ ~~- ~r Cal t i3oo-228-30i1t `~ 3 S ~ C `~~\ Have a question about a charge on your state ~~, ~-/~ ~C ?.ease refer to the Billing Righis Summary on the nack~ of you t. Z ~.,y ,r -,ratement or visit ,vww ydQitalone com/ ilsputes 4 -(-_~~ ~ •^''~` Zs`` ~ ' ~.~_ L 1-s `- ~ ~~~~i PLEASE RETURN PORTION BELOW WITH PAYMENT OR lAG ON TO WWW.CAPITALONE.COM'r0 MAKE YOUR PAYMENT ONLINE. 1-/ / 0 4305721436344068 01 1!545400100000032003 ~aP~Ot1e~ I what's m your wallet7• New Balance Minimum Payment Due Date $1,545.40 ; ~ $32.00 Aug. 26, 2008 J ~ 1 PLEASE PAY AT LEAST THIS AMOUNT Amount Enclosed '~ ~ ~ Capital Ono Bank EUSA), N•A• P•0• Box 70864 Charlotte, NC 26272-0864 I'I1Ill"tt'll'1111''IIIIIItIIIII"inlllll'I'll'Irlllllrnilrll Account Number. 4305-72:14-3634-4068 Please print address or phone number changes below using blue or black ink. Aatdirss home Rhone Akemate FYrone E-mai/sardress ;g 1071130 01 AV 0.324 "AUPO T2 0 0801 1'011 1 01-P71220 1Y90215527745!;'72371t MAIL ID NUMBER 4 ~ THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL, PA 17011-5911 'll~rll~l~llll~lllll'IIrIrIllurI1111rIrIr11111~1IllnlrflnL~lx Please write your account number on your payment made payable to Capital One Bank (USA), N.A. and mail with this coupon in the enclosed envelope. St MEMBERS 1St FEDERAL CREDIT ONION NOTICE OF REPOSSESSION September 8.'008 TI IOMr1S R. SOUTHER 1912 CARLISLE RD CAMP HILL, PA 17011-591 1 Re: Accouirt # 134459, Loan ID: O1 This is to notify you that Members 1" Federal Credit Union has repossessed your 2003 BUICK REGAL LS-V6, Title # 621 10638, Vehicle [dentilication Number (VIN) 2G4WB52K131 161414, because of your default on account number 134459-O1 under the security agreement and provisions of the Pennsylvania. Uniform Commercial Code. The subject vehicle is presently stored at Harrisburg Auto Auction, 983 W Trindle F:oad, Mechanicsburg, PA 17055 and may be redeemed by you for the sum of $7,388.82 by 09/22/2008. Payment should be in the form of cash, money order or certified check made payable to Members I'' Federal Credit Union. Any other fees incurred with Harrisburg Auto Auction are also your responsibility. Principal Balance: ~ .. $ 7,308.38 ~ ~ Accrued Interest: $""'~- •~~:~°••°-'--° Late Fees: $ 5.66 Repossession Fees: $ 0.00 "Total To Redeem Vehicle: $ 7,388.82 Unless Members 1'` Federal Credit Union hears from you within I S days of the date of this letter (09/22/2008), the subject vehicle will be sold and personal items disposed of. If the amount received from the sale of the above referenced vehicle is not sufficient to payoff the present loan balance plus interest and fees, you will be liable for the balance owed. You can reach the Collections Department at (800) 283-2328, extension 5188. Sincerely, '~ Lynn Unger Bankruptcy Specialist Certified Mail Receipt #:9171082133393582999231 Copy: file X000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 w~ww.memberslst.org Praxair Healthcare Services PO Box 33842 North Royalton, OH 44133 1-866-738-0388 MONTH >H:ND STATEMENT I~~~III„~III~~~~~~II~~~II~I~I~I~I~~~~~II~~~II~~~II~~I~I~~~III **AUTO**ALL FOR AADC 170 31 - 7483 16 THOMAS R SOUTNER 1912 Carlisle Rd Camp Hill PA 17011-5911 PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT OR INSURANCE INFORMATION HAS CHANGED, AND INDICATE CHANGE(S) ON REVERSE SIDE 7 Patient Name THOMAS R SOUTNER Date of j Invoice Item Service ' Number 7a Patient Name tb Account A Page . THOMAS R SOUTNER 1 of 1 2 Statement Date 3 Due Date 4 Amount Due 5 Amount Enclosed Tuesday, September 30, 2008 10!30/2008 $23.01 6 IF PAYING BY CF2EDIT CARD FILL OUT THE FORM BELOW CARD TYPE V/5A ~ ,.., CVV2 CARD NUMBER AMOUNT SIGNATURE EXP DATE y MAIL PAYIMENT TO PRAXAIR HEALTHCARE SERVICES DEPARTMENT 1107 PO BOX '121107 DALLAS, TX 75312-1107 3G PLEASE DETACH AND REIfURN THE TOP PORTION OF THIS STATEMENT 'K VNTH YOUR PAYMENT. RETP~IN THE BOTTOM PORTION FOR YOUR RECORDS. 8 Statement Date Page _. Tuesday, September 30, 2008 1 of 1 Item Description Customer Balance 07/23/2008 X362018 OXPORTD PORTABLE D SYSTEM W/REGULATOR 3.17 ~ i 07/23/2008 ~, X362018 OXYCONC ~ 02 CONCENTRATOR, RESPIRONICS 19.84 9 Total Amount Due Upon Receipt __ 10 0-30 Days 31-60 Days 61-90 Days 91-120 Days $23.01 $0.00 $0.00 ,$0.00 $23.01 121+ Days $0.00 For Questions About Your Praxair Healthcare Services Statement or Billing, P/e.-~e Call 1-866-738-0388 CAMP HILL EMERGENCY PHYSICIA PO BOX 13693 PHILADELPHIA, PA 1 91 01-3693 0 u ll ll nl'I~nuuIIn IIIlI1I111Iuu1'Iu1llulllu lllur w 0 D82516-DDDD032640385-06 #BWNJFDB #OOOOOOHYP1794589# THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011-5911 Account Detail ~Uate d - Uescuption ~~~~ 0728!08 ~ 1 y19'>0 '5 CARUI! ~PIiLMy~rIARY RCSUSial ArIUN I ~x 427 5 f 7R PAUi hlul. Y t:PlRli Ht ~~SPI I AL. UelU4l08 BLUE 5iIlELD CUN1 RAt,TUAL 4l LUWANCE JBl07'n8 I ~ °V_'~::IcELU P^.`~M~NT ~ 0728IOB 2 ~ 3U00 ENDGTRACHEAL IPI I U6A TIGN DX 427 ~ DR 1'AUIJHGI_Y ~F'IRii HPaPITAL. 05104rU8 I ~ 8L':F ~i IIELD C. ~;NTRAU IUAL ALLO'NANCE 0&OJlOB I RVJE SHIELD PA'f MENT J I Fl I CIVICIV I Vf' H~.I.VVIV r ~ i j Statement Date. September 10 X008 ACCOUNT NUMBER: HYP32640385 f Patient Name: THOMAS R SOUTNER - __ __ _ _ _ Tax ID if ~0-4667340 Account Balance. $31 10 Amount Pending hisurance $0 00 Amount Due From Patient (Current): $31.10 Amount Due From Patient tPast Due): $0.00 Pay Thrs Amount: $31.10 PLEASE REMIT PAYMENT BY "PAYMENT DUE BY" DATE. THANK YOU. Please refer to coupon below for payment instructions. .harge By Paid 8y Pa~d Paid By I l s i5 Jther n5 __- r'ehenL -.. Y~d24 UO i I + i • 7 -,n S 84 00 S 122 4U oun^ r Due Flom ~ f~ATIF Ni ~~,ted ~ Insurance HAI ANC.t s ane iio 5 248 00 s 7 t~ ~1fb0~ I ~ I I ~ ! OTALS: , t ooa UO I ---- - s 27s so r-- sa L1U - - sc oo $ ss~ a~ - ----1 o 0o - - ; sit ro --- -~ important Messages: I his statement is rue the duect treatment and/or supervision of ;:are you recently ~ecerved from an Eneryency Physaan al Holy Spent Hospital the fees fog this pnv ate pl~ysirian era billed separately from any hospital charyes of other prcfessanal fees for wfuch you may also be res{xmsible 1 herefore shoved you receive a Gdl horn the hospital or ~,ther ~~ physiaans for charges in ccxrnection vnri, this v~sd d .till not inUUde the items fisted un this s[atenent "Payment Plans" Accepted Questions about this statement? /Llama de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM. Your automated system access code is 801-32640385, or you can send email to billing_questions@emcare.com. y y Please detach and return bottom portion with your remittance. THOMAS R SOUTNER STATEMENT OF ACCOU ITT 1912 CARLISLE RD Statement Dale. September 10, 2008 CAMP HILL PA 17011-5911 - _ -- ACCOUNT NUMBER HYP32640385 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD ~ patient Name: THOMAS R SOU_TNER __ _ _ r~l_EASE SEE REVERSE SIDE. Payment Due By: 10/01%08 Make ChecklMoney Order payable to: Amount Due: $31.10 Amount Enclosed: ( ~~~ ~ ~~~) ~~ ~~ ~~ ( ~ ~~ ~ ~~ Tfie msuran„e inlonnahun in uw ftle appeals below Please makN any cons.e bons ; ;~ 111 t 11111 111111 11 11 11 1 1111 1 111 endy~r addrtic ns on ttie rav else site of this town anJ rtw r..t W us Thank y~;u d CAMP HILL EP~IERGENCY PHYSICIA PO BOX 13693 PHILADELPHIP,, PA 19101-3693 -EIS PA eels FtUERAL l;t AIMS I ~ r R59 nbei83 104 4771 I ! :~ ~"33 j ^ If your address has changed, check this box and complete the reverse side of this form i i 0825160DDDD3264038500DD3],1DD000DDDODDD07 J ,~ CAMP HILL EMERGENCY PHYSICIA PO BOX 13693 PHILADELPHIA, PA 1 91 01-3693 0 w 0 ~ur~~~nr~~~uuu~~u~~~i~r~r~r~nut~~n~~~nr~~u~i~ur~~~ 082516-0000032595241-06 #BVIMJFDB #OOOOOOHYP1787286# THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011-5911 A__ccoun_t Detail r CJate r p T ilescnption i:harye 07/11108 ~KH04!(l8 nW~e/nA 1 ~ «J~85 EMER~~f=rdl:Y E'JAL .'1 PM.;MT ~ s8~ 00 ,L Vl S) DX J86 lT9 UR UU BIPJMUI 'l SPIR IT Hr,,,pITAL ~ k1LUE SHIELU CUIJIIi At~.(UAL ALLUWANt E HI.IJF ~HrR r1 PA: MEN r ! I A I tMtN I Vf HIa;UUN I (1) Statement Date. September 10, X008 ACCOUNT NUMBER: HYP3259. 5241 _ ~ Patient Name: THOMAS R SOUTNER Tax ID # 20 -1667340 Account Balance. $18 00 Amount Pending Insurance. $0 00 Amount Due Frorn Patient (Current) $18 00 Amount Due From Patient (Past Due) $0 00 Pay This Amount: S18 00 PLEASE REMIT PAYMENT BY "PAYMENT DUE BY" DATE. THANK YOU. Please refer to coupon below for payment instructions. P:~~ri by P~~i t1y"" usr Ins I ~ ~Ihei Ins Y 1h~lK) I I _.__._ __ _-_. TOTALS: ~ ss5ooo ~ ~,ezoo ,000 so 00 ~s r~ooo ~ ,o~ ,euo~ Important Messages; f his statement is foi the dues L ueaunwit arnuor „ipervioicn ~rt tare you recernly recrrved hom an E rneryency Physician at Holy Sr,nnt Hospital The 'aes for this pnv ate phy~rc~an ,.re btlled separately from any I~osprtal ~.haryes or ~,thei pwfessiunai fe.~., h,r whion 7ou may also L,a re spun~rGle i heretur e. should you iecerve a biL horn ttie hosµtal ur other ph ysic~ans fa ~haryes in wnnectron wuh tnis ~ivt .t well nut uu.Wde the items listed on [Yns statement I~ "Payment Plans" Accepted Questions about this statement? / Llame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM. Your automated system access code is 801-32595241, or you can send elmail to billing_questions@emcare.corn. Please detach and return bottom portion with your remittance. THOMAS R SOIJTNER 1912 CARLISLE RD CAMP HILL PA 1 701 1-591 1 YOU MAY PAY THIS BILL WITH 'r OUR CREDIT CARD PLEASE SEE REVERSE 51DE. Make Check/Money Order payable to: irr,nirirr,rrinirrrrr,~irrn,rntririrrr,iirirrrn CAMP HILL EMERGENCY PHYSICIA PO BOX 13693 PHILADELPHIA, PA 19101-3693 I he insw ani.e infonnah~.n vi our hie apr,ears beluw Pl~dse make any ~,ouections and/or aaddions on the ir~erse side of this form and return d to us Chank y~~ ~ I FEP PA f~J S'FEDERAL CLAIMS-~~~~-- ~_~ ~--_I RS92o96Ns 104 b4771 i I ^ If your address has changed, check this box and complete the reverse side of this form 082516000003259524100001800000000000DD06 STATEMENT OF ACCOUPJT Statement Date. September 10, 2008 - - _ -1 ACCOUNT NUMBERHYP32595241 __ Patient Name: THOMAS R SOUTNER _ __ Payment Due By: 10/01108 Amount Due: $18.00 Amount Enclosed: ------ ~~ \ .~~~_.!HoLY ~1.1_~l Ifi~:~PITAL The Sptric o` Cnring holy Spirit Hospital 503 N 21ST STREET CAMP HILL PA 17011 800-997-8573 F'or Acrnunt Information, Please ('.all 8007-8573 -~ SOUTNER ,THOMAS R Service Date: 07!28/08 Service End: Last Statement Date: 08/04/08 Account No: 32640385 Statement of .Account 10/I2/O8 Transaction hate Description PREVIOUS BALANCE 07/28/08 LIDOC 2% lOML AMP 07/28/08 LIDOC 2% lOMI AMP 07/28/08 CANISTER SUCTION 12000C 07/28/08 DISC ELECT AD 4 07/28/08 HI-LO EVAC ENDO TUBE 8.0 07/28/08 HOLDER ENDO TUBE 07/28/08 D FID PAD RADIOTRANSLUCENT ADT 07/28/08 STYLET INT 14FR 07/28/08 IS TNI COLLECTION 07/28/08 IS TNI COLLECTION 07/28/08 IS CHEM 8 COLLECTION 07/28/08 IS CHEM 8 COLLECTION 07/28/08 METABOLIC PANEL,C 07/28/08 METABOLIC PANEL,C 07/28/08 CPK (GREAT. PROS) 07/28/08 CPK (GREAT. PROS) 07/28/08 CKMB 07/28/08 CKMB 07/28/08 CBC,AUTO DIFF 07/28/08 CBC,AUTO DIFF 07/28/08 ABO TYPE Estimated Insurance Due: .00 `Total Patient Credits: 4crnunt Balance: 111.58 Amount .00 35.00 35.00 4.00 5.00 110.00 10.00 93.00 30.00 .00 .00 .00 .00 134.00 -134.00 54.00 -54.00 53.00 -53.D0 99.00 -99.00 32.00 YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. 609 361 .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. 32640385 HOLY SPIRIT HOSPITAL X03 r 21S'T STREF.'1' CAMP HILL. PA 17011 ADDRESS SERVICE REQUESTED Check Dox if your address or insurance information has Changed. lease make changes on back. 00031784 002 0.72 32640385 THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011-5911 ADM DT; 072808 I DSH DT: 'NONE' Paaetit Name: ss: 21020 SOUTNER ,THOMAS R 717-737.9868 ~ L f=ud Number. HR: HSG 427.5 W1ake Cneck Payable To: HOLY SPIRIT HOSPITAL ' The CVV2 Number a the last 3 Ayits nn the hack of your credit ord, by your c~gnature Itt~lll~la~~t~lll~i~l~„i~il HOLY SPIRIT F-iOSPITAL P.O. BOX 822183 PHILADELPHIA,PA 19182-2183 AmnunL 10/27/08 00003264038.50010D000011158D0100735000000011309 ~. ._ _. CHC~LY PIRIT Iltl~l IT:\t. The Spirit af~ CurinR Holy Spirit tfospital 503 N 21ST STREET CAMP HILL PA 17011 800-997-8573 F'or Acrnunt Information, Please Galt 800-997-8573 SOUTNER ,THOl41A3 R Service Date: 07/28/08 Service ERd: Las! Statement Dale: D8/04/08 Account No: 32640385 Statement of 1~ ccount 10/ 12/ 08 Transaction Date t)escription Amount 07/28/08 ABO TYPE -32.00 07/28/08 TYPE/SCREEN .00 07/28/08 TYPE/SCREEN .00 07/28/08 RH(D) 57.00 07/28/08 RH(D) -57.00 07/28/08 AB SCREEN PT 102.00 07/28/08 AB SCREEN PT -102.00 07/28/08 TROPONIN T 77.00 07/28/08 TROPONIN T -77.00 07/28/08 OXYGEN PER HOUR 54.00 07/28/08 CRITICAL CARE 30-74 MIN 1,417.00 07/28/08 NON-EVA EAR/PUL OX FOR 02SATUR 55.00 07/28/08 TRACING ONLYW/0 INTER & REPORT 122.00 07/28/08 CARDIOPULMONARY RESUSCITATION 919.00 07/28/08 EKG 158.00 07/28/08 EKG -158.00 09/10/08 BC PYMT OP B09 361 -1,407.77 09/10/08 BC C/A HOSP OP B09 361 -1,374.65 Page 2 MOFFITT HEART & VASCULAR GROUP 1000 NORTH FRONT STREET WORMLEYSBURG, PA 17043 Address Service Requested 10/03/08 29181 ; j Continued _MC _VIiSA -Disc Security Card~~ __ Code _ Sign Exp `/_ 38849 ESTATE OF THOMAS R SOUTNER 1912 CARLISLE RD ~--- CAMP HILL PA 17011-5911 MOFFITT HEART & VASCULAR GROUP 1000 NORTH ]?RONT STREET WORMLEYSBURG, PA 17043 r *** ANY QUESTIONS REGARDING YOUR BILL PLEASE CALL (717) 731-8315 -~** *** Your Account Balance is Overdue! Please make Pa~ment Immediately!!! *'~* :c~c~csE:'c7t:Y*ic:lriric~r~c*:'c:k:'c:t:tick:'c:Y:Y:'c:'c:Y:Y:t:'c*:t*:c**:'c9r;c:'r*:'c~r:'c:Y~r*~c~c~r:>; ~k~c~c:t~c:'c~c~c~c:t~c:t:'c~c:Y :'c~c*:'c:'c~c:'c:'cic*~c~c:t:Y 02/28/08 1 2 OFFICE VISIT EST LEVEL 4 99214 414.01 120.00 03/12/08 BS FEDERAL Payment 80.00 03/12/08 Accept Assign Adj. -25.00 04/07/08 Check-Personal Payment 15.00 07/15/08 1 16 E CATH LEFT HEART 93510 794.31 600.00 07/30/08 BS FEDERAL Payment 310.66 07/30/08 Accept Assign Adj. -100.00 07/15/08 1 16 L INJECT FOR CORONARY ANGIO 93545 794.31 200.00 07/30/08 BS FEDERAL Payment 51.12 07/30/08 Accept Assign Adj. -143.21 07/15/0$ 1 16 L INJECT FOR-HEART ANGIOGRA 93543 794.31 200.00 07/30/08 BS FEDERAL Payment 21.20 07/30/08 Accept Assign Adj. -23.54 07/30/08 Accept Assign Ad). -152.91 07/15/08 1 16 L INJECT DURING CARDIAC CAT 93540 794.31 200.00 07/30/08 BS FEDERAL Payment 64.58 07/30/08 Accept Assign Adj. -128.25 07/15/08 1 16 L INJECT FOR OPACIFICATION 93539 794.31 200.00 07/30/08 BS FEDERAL Payment 62.66 07/30/08 Accept Assign Adj. -130.38 07/15/08 1 16 L IMAGING SUPERVISION PUL/C 93556 794.31 100.00 07/30/08 BS FEDERAL Payment 50.40 07/30/08 Accept Assign Adj. -44.00 07/15/08 1 16 L IMAGING SUPERVISION VEN/A 93555 794.31 100.00 07/30/08 BS FEDERAL Payment 40.50 DATE LAST "AID ~ MOUNT _ ~ r + ~ • • • ,+ , .. ,., , --r-- 04/07/08; 15.00 ~ '~ '~~ ', '~~ ------__~__- __ -- ~--------1 ----.- - ------------~-- --------__~_ --~ --- ----1-- - -- --- .---- ---_-~ MOFFITT HEART & VASCULAR GROUP i4AKE HecK 1000 NORTH FRONT STREET vavne~e To WORMLEYSBURG, PA 17043 PAT~~ 1-THOMAS R SOUTNER PRV~~ 2-GUTIERREZ, FELIX, MD, FA PRV~~ 13-BACHINSKY, WILLIAM, MD, PRV~~ 16-JONES, STEVEN, MD, FACC PRV~~ 17-RADTKE, NANCY, MD, FACC 0.00 189.34* 5.67* 2.35* 7.17* 6.96* 5.60* Continued Ph:(717)-731-8315 Acct~~: 29181 Date: 10/03/08 Page 1 of 2 MOFFITT HEART & VASCULAR GROUP 1000 NORTH FRONT STREET WORMLEYSBURG, PA 17043 Address Service Requested ESTATE OF THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011 10/03/08 ~ 29181 !` 290.79* _MC V:ISA Disc Card~~ _ _ Sign MOFFITT HEART & VASCULAR GROUP 1000 NORTH 1rRONT STREET WORMLEYSBURG, PA 17043 Security Code _ Exp _/_ x 07/30/08 Accept Assign Adj. -55.00 4. 50* 07/15/08 1 17 E ELECTROCARDIOGRAM COMPLET 93000 411.1 50.00 07/23/08 BS FE DEDUCT Payment 0.00 07/23/08 Accept Assign Add. -25.00 25. 00* 07/16/08 1 13 L HOSPITAL DISCHARGE DAY 99238 786.05 125.00 08/06/08 BS FEDERAL Payment 67.50 08/06/08 Accept Assign Adj. -50.00 7. 50* 07/21/08 1 78 L HOSPITAL INITIAL CARE 3 99223 786.05 230.00 08/06/08 BS FEDERAL Payment 175.50 08/06/08 Accept Assign Adj. -35.00 19. 50* 07/22/08 1 78 L HOSPITAL SUBSEquENT CARE 99232 786.05 80.00 08/06/08 BS FEDERAL Payment 63.00 08/06/08 Accept Assign Adj. -10.00 7. 00''° 07/23/08 1 78 L HOSPITAL DISCHARGE DAY 99239 786.05 140.00 0$/06/08 BS FEDERAL Payment 91.80 08/06/08 Accept Assign Adj. -38.00 10. 20* E-This bill applied against your deductible. You are responsible to pay us. L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. DATE LASTr'AID ~^.10UNT `' • ~~ ~ • : • -:. ~ • ~ • :. . q 04/07/08 15.00 0.00 44.20; 246.591 0.00 0.00 0.00 I -------_ _ _ - ------ _ - i------ -----'- ---------- -- -_~..-- ---- ~ __ ---- r MOFFITT HEART & VASCULAR GROUP '~A"E 1000 NORTH FRONT STREET ,..NECK `nYaEj~E ro WORMLEYSBURG, PA 17043 PAT~~ 1-THOMAS R SOUTNER PRV~~ 78-WALSH, TIMOTHY, MD, FACC 0.00 I 290.79 'J 290. 79* Ph:(717)-731-8315 Acct~~: 29181 Date: 10/03/08 Page 2 of 2 __ INTERNISTS OF CENTRAL PA 108 LOWTHER STREET LEMOYNE, PA 17043 Forwarding Service Requested 10/22/08 57882 ',' 24.60~~ _MC -VISA -Disc Security Card~~ __ Code _ Sign Exp _/` 25805 ESTATE OF THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011-5911 INTERNISTS CIF CENTRAL PA 108 LOWTHER STREET LEMOYNE, PA 17043 F. ., $ , , i ; a ~~''~''° PLEASE PAY UPON RECEIPT, IF BILLING QUESTIONS CALL 774-:(366 AND PICK ''~~`'~ •~ `'ti BILLING ''~~~'~ '`''`'ti Please ' PaY ' -Amount Due Now From Patient- See Red Box Thank ' ' ' ' ' ' ' ' ' ' ' ' ' You ''~~"~ i;icic~c csc;c:csYic :::cs i;s c.tic s:icic:;; c%: cs,scs4:cs rscs cstsFstscs4s cicst~s c;csFsYs cscs~s c: cxs cic:csYsksts ci cs c~::c'c'cs csYsc ;c9c:cic~c ;Y$ic>'; scic:'c ~:c'cs'cs'c4c 07/15/08 1 7 L INPATIENT CONSULT COMPREH 99254 414.00 175.00 08/25/08 BS FEP Payment 155.70 ' 08/25/08 25/08 Accept Assign Ad'. i A -5.00 'ti 08/ Insurance Deb t dj. 3.00 17.30 07/16/08 1 3 L HOSPITAL SUBSEQUENT CARE 99232 414.00 80.00 08/25/08 BS FEP Payment 65.70 08/25/08 Accept Assign Adj. -10.00 08/25/08 • Insurance Debit AdI. 3.00 7.30' L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. ~ '~, ` .Sr nip ~_ 7~;i,rvr _~;~rwL6J..J~~µs • ': • .. +~~~~'~~ i~!~ 00/00/00 _0.00_x__ 0.00 I 24 60 0 00 ~ 0.00 0.00 II 0.00 ,,nF ' INTERNISTS OF CENTRAL PA -`~~K 108 LOWTHER STREET a~~~~ e pro ~ LEMOYNE, PA 17043 PAT~~ 1-THOMAS R SOUTNER PRV~~ 3-TYNDALL, JAMES A., M.D. PRV~~ 7-DEMICHELE, MICHAEL A., M ,~ ' 24.60'` Ph: (717)-774-1366 Acc t~~: 57882 Date: 10/22/08 Page 1 of 1 ~` :©-HOLY SPIRIT I I ~) : • P 17 : \ l . The Spirit u(' Ctinnq ~loly Spirit Hospital 503 N 21ST STREET CAMP HILL PA 17011 800-997-8573 For Acrnunt Information, Please ('all 800-997-857:1 -~" SOUTNER ,THOMAS R Service Date: 0711510$ Service End: 07/16J08 Last Statement Date: 07/21/08 Account No: 325604B4 Statement of .~4 ccount Transaction Date Description PREVIOUS BALANCE 07/25/08 HMRK BS OP PMT 809 361 07/25/08 HMRK BS OP C/A 809 361 07/30/08 BC PYMT IP $09 361 07/30/08 BC C/A HOSP IP $09 361 07/30/08 BC C/A HOSP IP B09 361 Estimated Insurance Due: .00 'Total Patient Credits: 809 361 QO PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. 08/06/08 :mount 9,314,80 -10.97 -20.82 -10,329.00 .00 1,147.20 lccount Balance; 101.21 riease uetacn anq return wltn your payment Fqr Hospital Use Only AD~t DT: o7tsoe Acmunt Number. ! 'i25b0484 32580484 HOLY SPIRIT HOSPITAL DSH OT: 071608 se: 21020 ~SOUTNER ,THOMAS R >03 V 21ST S'i'RNET ('AMP HILL PA 17011 717-~37-sass ~ ~ /~ ADDRESS SERVICE REQUESTED HR: HSG C.aM Number. SisnaturC Check box rf yyour ar~dress or insurance intormanon Make Check Payable to: HOLY SPIRIT HOSPITAL ^ has Ghanged.PleaSe rtlake Changes on back. ' The CVVZ Number is Ne last ]diets nn the hack qt }lour credit nrd, by your vanature 00023082 001 0.53 32560484 THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA i 7011-5911 Itttllltl~tt„Ill,~ltttl~ll HOLY SPIRlT' HOSPITAL P.O. BOX 822183 PHILADELPHIA,PA 19182-2183 08/21/08 IJ~0032560484000000000Z01,2100100735000000011307 • • 1L700-1-1 CARDIOVASCULAR SURGICAL INST. ., 423 NORTH 21ST STREET CAMP HILL PA 17011 ADDRESS SERVICE REQUESTED >~2126 3981584 001 X92096 THOMAS R SOUTNER 1912 CARLISLE RD CAMP HILL PA 17011-5911 12376 5372 WE01 AMOUNT CREDIT CARD PAYME CREDIT CARD Epp. Date' / CARD NUMBER Security Code' CARDHOLDER NAME SIGNATURE !:11 1- CARDIOVASCULAR SURGICAL INST. 423 N 21ST ST ~+~ CAMP HILL PA 17011-2207 . 4 ~ IIIIIIIIIII'IIIIIIII'1r~'III~tI11It IIIIIIIi lll~l'IIIIIIIIIIII' ,. ~ ~SN N:"MCINI (717) 975-0900_09/30/ p ~ ~ ; 08 12566-1 1 ~ O1 12.00 << , ~ ~~I~ ~F ------------ -- --~.~__._ _ - _-- ;~_._ __ ~..L.__~ .- ---------- ~ - 9 __ __ - - -- ---- ~' ~ ~r,r`_; ,t~u~f~ 1in~~l ; (!N !His ~',al ~-".~1t tl f \:-1E NUT ;N~;L_ ;~f'=L1 ~N r~.PIY 'yU~PITAL iSl( ~ _r-i = ?I F.Mt=°~T ~~ ~~ ~ ~ ~s . • 071508 CPTs 99253 INITIAL INPATIENT CONSULT- T SOUTNER HSI 414.01 COPAYMENT DUE 072308 HIGHMARK FILED 080108 BLUE SHIELD PAYMENT 080108 BLUE SHIELD ADJUSTMENT PERSONAL PAYMENTS RECEIVED SINCE LAST STATEMENT:$ WE ACCEPT MOST MAJOR CREDIT CARDS 250.00 0.00 0.00 ~ ~ ~ i t , _. r 09/30/08 ~ rl' ~i;E ~;~~.,~'I ~ __ INS PENDING PATIENT BAL TOTAL BAL CURRENT BAL PAST DUE 12.00 12.00 ia.oo CARDIOVASCULAR SURGICAL INST. (717) 975-0900 423 NORTH 21ST STREET BALANCE SHOWN I3 PATIENT DUE. CAMP HILL PA 17011 IF YOU PROVIDED U9 INSURANCE IRS iks 23-2432943 INFO, IT HA3 BEEN SUBMITTED. PLEASE REMIT PAYMENT PROMPTLY. 12 . -108.00 -130.00 12566-1-1 12_ ' 02126 3981584 002127 002127 00001/00001