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HomeMy WebLinkAbout10-17-0815056051058 REV-15 0 0 EX (06-05) OFFICU\L USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN ~ I O ~ ~,1 Harrisburg, PA 17128-0601 RESIDENT DECEDENT LJ I ~ Q ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 188-12-1035 02/01 /2008 01 /26/1924 Decedent's Last Name Suffix Decedent's First Name MI Stoppe Avalon W (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW • 1. Original Return c;;,„~ 2. Supplemental Retum ':r 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate t 4a. Future Interest Compromise (date of ;.~'„" 5. Federal Estate Tax Retum Required death aker 12-12-82) • 6. Decedent Died Testate '"~ 7. Decedent Maintained a Living Trust 2 .. 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received t`-:':~a 10. Spousal Poverty Credit (date of death ?~:~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name _ Daytime Telephone Number Jocelyn P. Stoppe (717) 761-3433 Firm Name (If Applicable) __ . ~~7 __ OF 1 VREGISTER ~ ~~ rU USE ONLY . wE 1 ~ •• CJ First line of address _ _ _ ~~ n " (j p 501 Rupley Road __ -_ . r_ -! , 17 J , _ . 1 , , ~ Second line of address ~ --~ ,: , - -fix. !. City or Post Office _ State ZIP Code _ DATE~ILED ~'~ [,.) Camp Hilt Pa ,;17011-1841 ~' ' Correspondent's e-mail address: jStoppe@VeriZOn.net Under penalties of perjury, I deGare that I have examined this return, inGuding axompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Dedaretion of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU E OF PERSON RESPO ISLE FOR FILING RETURN DATE ADDRESS mac'` D ©~ (~! ~~~ 501 Rupley Road, Camp Hill, PA. 17011-1841 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ttss PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 -T - i `~ _ i_ ~ =-. ~'b ~~~ O ` `- `~ ~~=___) v~ i ~ ~~ O O ~ v O \^J `^V] V J 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: Avalon W Stoppe ......~.__ ~..r.~..~ . 188-12-1035 .a.. ..... _ _ ~.__.._........_,._...._.,...._.._r..,....__~ RECAPITULATION '.~`"'."~"......_"..,.`w' "".°",""~.~""°'"".~'~'"'" 1. Real estate (Schedule A) ........................................... .. 1. i 148,420.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 5,762.70 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. '; 4. Mortgages 8 Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ...... .. 5. ', 310,216.62 6. Jointly Owned Property (Schedule F) t Separate Billing Requested .... , .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ` (Schedule G) Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. ', 464,399.32 9. Funeral Expenses 8 Administrative Costs (Schedule H) ................... .. 9. ' 24,955.03 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) .............. .. 10. 5,290.30 11. Total Deductions (total Lines 9 & 10) ................................. .. 1L ' 30,245.33 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 434,153.99 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) ...................... :...~....~~..e~.~ ., ...e._..~.._.__.....~._~..._ . .. 14. 434,153.99 ....~~A~m..... TAX COMPUTATION _ SEE INSTRUCTIONS FOR APPLICABLE RATES _ _ _ _...~. m_m_ _~,~~.- ~n~...........w.. 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 j 434,153.99 16. ', 19,536.93 ,. 17. Amount of Line 14 taxable at sibling rate X .12 ' 17. 18. Amount of Line 14 taxable __ at collateral rate X .15 1 g, 19. TAX DUE ........................................................ . 19. ' 19,536.93 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~ ,3. 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number _~.~.,.,..~, me.., d,~,. DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Avalon W Stoppe 188-12-1035 STREET ADDRESS 416 Deerfield Road CITY STATE zip Camp Hill Pa 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) (1) 19,536.93 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 oval on Page 2, Line 20 to request a refund. (q) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT o.oo 0.00 0.00 19,536.93 0.00 19,536.93 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :................................................................................... ....... ^ b. retain the right to designate who shall use the property transferred or its income :..................................... ....... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ ^x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)J. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a 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 benefiaaries 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, whether by blood or adoption. REV-1502 FJC+ (B-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Avalon Ward Stoppe 2008-00160 All real property owned 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 exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. RBI property which Is Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCflIPTION OF DEATH ~• 416 Deerfield Road, Camp Hill, Pennsylvania 17011 148,420.00 Parcel # 13-24-0809-040 Lot- 37 LOT DIMENSIONS APPROX. 11T X 121' Lot size 12,632 sq. ft. .290 acres Deed # 0020M00742 Residential Building - Split level Brick and Aluminum House TOTAL (Also enter on line 1, Recapitulation) $' 148,420.00 (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Avalon Ward Stoppe 2008-00160 All property Jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH t. Stock: MetLife, Inc. 3,338.27 Shares- 54.0000 Price per share- $61.81 2. Series E Bond Denomination $50.00 259.78 3. Series E Bond Denomination $25.00 185.97 4. Series E Bond Denomination $25.00 125.88 5. Series E Bond Denomination $25.00 126.19 6. Series E Bond Denomination $25.00 128.05 7. Series EE Bond Denomination $50.00 59.56 8 Series EE Bond Denomination $50.00 39.00 9. Series HH Bond Denomination $1000.00 1,000.00 10. Series HH Bond Denomination $500.00 500.00 TOTAL (Also enter on line 2, Recapitulation) ;; 5,762.70 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ea iwl t ur FILE NUMBER Avalon Ward Stoppe 2008-00160 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Integrity Bank- Savings Account #401003650 16,679.44 2. M&T Bank- Checking Account #2679020640 5,553.28 3. M&T Bank- Checking Account #2100000119892 11,492.12 4. M&T Bank- Savings Account #82232105 6,648.87 5. Citizens Bank- Checking Account #610061889 387.63 6. Citizens Bank- 7-8 mo. CD #6241046174 17,501.35 7. Citizens Bank- CD interest #6241045399 0.68 8. Citizens Bank-13 mo. CD #6140851084 50,179.88 9. Citizens Bank-12-14 mo. CD #6146919276 40,189.06 10. PNC Bank- Money Market Account #5130159696 20,349.93 11. PNC Bank- Checking Afxount #5140235592 2,435.44 12. Ambassador Advisors/Charles Schwab- frozen- not opened 137,000.00 13. Furniture, household & personal items from Country Meadows Retirement Community 1,400.00 14. Lady's 14 kt. yellow gold diamond ring, 0.18 ct. 337.00 (perfection grade 6, color grade 5, set in illusion head, poor proportions) 15. Silver Coins- condition circulated/wom 61.94 16. 1996 Chrysler Concord Automobile 0.00 (not driven or started for many years in need of major repairs to get inspection, signed over to a stranger) see Affidavit of Gift TOTAL (Also enter on line 5, Recapitulation) S 310,216.62 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Avalon Ward Stoppe 2008-00160 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: ~' Parthemore Funeral Home and Cremation Services, Inc. Traditional Funeral Service, casket, concrete vault, death notice, 13 certified copies of death certificates, hairdresser, tent + cemetery equipment, clergy honorarium, alter servers and grave opening. 2. Dioceses of Harrisburg, Office of Catholic Cemeteries Interment Space -Section 2 Lot 116 Grave 1 Bronze Memorial Marker w/name and date($1450.00) Granite Foundation($300.00) 3. Royer's Flowers -Casket spray B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)lEIN Number of Personal Representative(s) _ Street Address City .State Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is no! the same as Gaimant's, attach explanation) Claimant Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) ~ $ 9,267.07 750.00 1,750.00 106.00 12,500.00 581.96 24,955.03 (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 LIABILJTIES, & IJENS ESTATE OF FILE NUMBER Avalon Ward Stoppe 2008-00160 Report debts Incurred by the decedent prior to death which remained unoald as of the date of death- includlne uent~n6~v..a .~,sa~,.,r .........e to more space ass neeaea, insert a(lanlonal sheets of the same size) REV-1513 EX+ (9.00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Avalon Ward Stoppe 2008-00160 NUMBER NAME AND ADDRESS OF PERSONS RECENING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE () Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)j ~ • Jocelyn Patricia Stoppe daughter 60% 501 Rupley Road, Camp Hill, Pennsylvania 17011 2• Brian Mark Stopper son 40% 2425 Davis Mill Road, Goochland, Virginia 23063 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I S (If more space is needed, insert additional sheets of the same size) KEGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 2008- 00160 PA No . 21- OS- 0160 Estate Of : A VAL ON WARD STOPPE (First, Middle, Last) Late Of : LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY Deceased Soci a1 Securi ty No : 188-12-1035 WHEREAS, on the ISth day of February 2008 an instrument dated September 16th 2006 was admitted to probate as the last will of AVALON WARD STOPPE (hurt, Middle, Lastl late of LOWER ALLEN TOWNSHIP, CUMBERLAND County, who died on the 1st day of February 2008 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: JOCEL YN PATRICIA STOPPE who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. 1Iv TESTIMOivY WrIEREOF, I have hereunto set mfr h ar_d and affixed the seal of my office on the 75th day of February 2008. a ,~ J Register of Wi Is Il/, Y~/ ~~/~lA ~1. Deputy **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) LAST WILL AND TESTAMENT I, Avalon W. Stoppe, now residing in the County of Cumberland, Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and form my Last Will and Testament, hereby revoking all Wills-rand Codicils heretofore at any time made by me. ,:; --, ~.._; FIRST: I hereby name, nominate, constitute and appoint my daughter, Jocelyn Stoppe, Executrix of my Estate, to serve without bond in any jurisdiction in which she may act. If Jocelyn Stoppe is unwilling or unable to serve as Executrix of my Estate, I hereby name, nominate, constitute and appoint my son, Brian Stoppee as Executor of my Estate, to serve without bond in any jurisdiction in which he may act. SECOND: I direct the payment of all my just debts and funeral expenses as soon as practicable after my decease. THIRD: I specifically give, devise, and bequeath certain specific items or classes of items as follows: To my daughter, Jocelyn Stoppe, I give, devise, and bequeath all of my porcelain and china collectibles and my diamond engagement ring; To my son, Brian Stoppee, I give, devise, and bequeath all of my antique clocks and all crystal stem- and barware. 1 FOURTH: All of the rest, residue and remainder of my estate and effects, whatsoever and wheresoever, whether real, personal or mixed, to which I may be entitled or over which I may have power of disposition at my decease, I give, devise and bequeath unto my children, Jocelyn Stoppe and Brian Stoppee, to be divided as follows: To my daughter, Jocelyn Stoppe, in recognition and compensation of the many services she rendered me in my times of need, SIXTY (60%) PERCENT of my net Estate after the payment of all debts, taxes, expenses, and any cost or fee related to the settlement of my worldly affairs and my Estate; To my son, Brian Stoppee, FORTY (40%) PERCENT of my net Estate after the payment of all debts, taxes, expenses, and any cost or fee related to the settlement of my worldly affairs and my Estate. FIFTH: My Executrix or Executor named herein may sell any and all real estate and other property of which I am possessed or to which I may be entitled at my decease, or to which my Estate may be entitled after zny dc;cease, at either private or public sale and at such prices and in such amounts as in her or his discretion may. deem fit. SIXTH: I direct that all estate, inheritance and other taxes in the nature thereof, together with any interest or penalties thereon becoming payable because of my death, with respect to the property constituting my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid from the residue of my estate; and no legatee or devisee or any person having a beneficial interest in any such property, whether under this Will or any Codicil thereto or 2 otherwise, shall at any time be required to refund any part of such taxes. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament, this r day of }r_r?~~ ~ ,~~.~ r~?~:. , 2006. R ~.~...-.t~.~' lc....-`' ~~. `.,,~, (SEAL) '~ AVALON W. STOPPE This instrument consisting of THREE typewritten pages, was on the date hereof, signed, sealed, published and declared by AVALON W. STOPPE, the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other, all being present at the same time, have hereunto subscribed our names as witnesses. WITNESS: r? R ~ .~ ADDRESS: ~ 7i'S'C7 ~f, ~~~ ,, ~ ~ ~~~ (lil p~~~Y ~ ~ i l~ ~ ~,, `~ 7 ~ ~ c~ COMMONWEALTH OF PENNSYLVANIA Notarial Seal Donna E. Grimwood, Notary Public Lower Allen Twp., Ctmberiand County My Commission Expires June 19, 2010 Member, Pennsylvania Association of Notaries 3 ~ .... , .~ v1~~.~. '~--~' COMMONWEALTH OF PENNSYLVANIA COUNTY OF CiJMBERLAND I, AVALON W. STOPPE, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament, that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. Sworn or affirmed to and acknowledged before me, by Testatrix, AVALON W. STOPPE, this ~~"' day of '_ 20 AVALON W. STOPPE ` r ~,~f Notary Public My Commission Expires: WE, _,.._;`~'~%,1~{=- .~.. oa ~ and ~,~ : ~t%1 l~a~1~-Nt ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix, AVALON W. STOPPE, sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix, AVALON W. STOPPE, was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ..~ Sworn or affirmed to and subscribed before me, by,..~ ~~~~~ ~ I ~ ~~ ~ ~ ~~. and --;~~~_~~T!_; ~`~'~~/'~~= ~/°' ,witnesses, this / ~~ day of-' :~~ (-i s ~ l~f` f-- , 2006 ;~ - ~ //, ~~ ~< U ~` ~~ Notary Public My Commission Expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal - - Donna E. G-irrnvood, Notary Public TAXING AUTHORITY: WEST SHORE SCHOOL DISTRICT fAX YEAR: 2008-09 REAL ESTATE TAX NOTICE LOWER ALLEN TOWNSHIP SAYABLE BONNIE K. MILLER, TIC (717) 975-7575 PROPERTY ID f0: 2233 GETTYSBURG ROAD 13240809040 CAMP HILL, PA 17011 TAX SCHOOL • • • ~' RATE 10.5 NOR 8 E BATE ATE ON OR BEFORE FACE DATE AFTER PENALTY DATE REBATE 1,447.11 By 09!01/2008 1,447.11 FACE 1,476.64 BY 11/01/2008 1,476.64 PENALTY 1,624.30 AFTERII/O1/2008 1,624.30 ASSESSED VALUE 148,420 HOMESTEAD EXCLUSION 7,788 FARMSTEAD EXCLUSION 0 NET ASSESSMENT 140,632 TO: STOPPE, HARRY 8 AVALON W 501 RUPLEY ROAD CAMP HILL PA 17011 WEST SHORE SCHOOL DISTRICT PAID TO: REAL ESTATE TAX NOTICE BONNIE K. MILLER, T/C (717) 975-7575 2233 GETTYSBURG ROAD CAMP HILL, PA 17011 LOCATION OF TAXED PROPERTY PROPERTY ID d1R IIFFRFIFI n onwn SCHOOL TAXES PAID AT v ASSESSED VALUE ^ ^ ^ 148,420 10.5 REBATE FACE PENALTY HOMESTEAD EXCLUSION 7,788 BY 09/01/200 1,447.11 REBATE FARMSTEAD EXCLUSION BY 11101!200 1 476 64 0 AFTER 11/01/200 , . 1,624.30 FACE PENALTY NET ASSESSMENT 140,632 ~~GJ 1 Jf1VRG JVflUVL UIJ I KII. I STOPPE, HARRY & AVALON W 501 RUPLEY ROAD CAMP HILL PA 17011 BILL DATE-07/01/2008 BILL # 015868 ~OR: 416 DEERFIELD ROAD ALLENDALE REBATE - o9JO1/2o09 FACE - t1lo112ooe TAX YEAR: 2008-D9 TILL DATE - 0 7/0 112 0 0 8 BILL # 015868 IELINOUENT BILLS ARE TURNED OVER TO TAX CLAIM ON 12!31!2008 TAXPAYER'S COPY TAX COLLECTOR'S COPY = TAXES ARE IN ESCROW, FORWARD TO MORTGAGE CO. lVneLE Control No: 013 TAXPAYER COPY 8111 NO: ro: BO Assessed - 003590 L 2008 S1~ellleflli Of R~~ a 5041 NNIE K. MILLER, TREASURER 1993 HUMMEL AVEN values COUNT and Improvement Mineral 42 te Taxd BIII Date: 3/01/2008 UE CAMP HILL PA 17011 59 Y OF Rate 0 CUMBERLAND~PENNgy~y ~ 0 Total 148 , - 38 s COUNTY R/E .00228500 •00228500 DlsCpyM 420 Face sc: ASSESS.NO -130 MAP NO: 13-24-0 ~QIUE~ Y~fENT 4 Rates CoUNTr LIB 68.55 -0001800p 270 59 .00018000 2 ~ 332.36 339.14 10 ~ 37 16 DEERFIELD R ,ICp AC T0IMNSFIIP O 5.40 F LOWER ALL 21.32 2 } 3.05 10 RES .290 DEED 0020M 00742 ALLENDALE Rates MUNIC' R/E EN .oolooooo .00100000 26.19 26.72 ~ 29.39 LOT-37 J U N~ 0 2008 Rates 30.00 118.42 2~ Residential Building RESIDENTIAL FIRE SRVS .00050000 • 00050000 145.45 148.42 10 ~ 163.26 d~NNlr ~. DEL! ~~, Treas. DEBTSSVC •00050000 .00050000 72.73 74 21 10 $ Lowo~ A4ien Township 15.00 x9.21 2 ~ 81.63 x STOPPE, HARRY & AVALON W ER 501 RUPLEY ROAD / ~ TAX AMOUNT DUE -- 72.73 74 • zl to ~ 81.63 CAMP HILL PA 17017 ~ ~ ~ U > ~49- ~y,70 r~ ~ =E MON, TUES & THURS 9-4 OR BY APPT as. BONNEE MILDER®LOWERLALLEN.PA.US PHONE (717) 975-7575 EXT 1707 If Paid Oa or 1lftar If Paid Oa or ealora 3 O1 200 5 O1 08 7 O1 2008 IF NOT PAID BY 01 4/30/2008 6 30/2008 CLAW BUREAU FORTHIS BILL WILL BE RETURNED TO TAX YOUR PROPERTY. CTION AND RLINO OF A LIEN ApA~gT "SEE REVERSE SIDE OF BIV„ FOR A BREAImOyyN OF YOUR COUNTY TAX pOLLA~ ,~ Retum Bill with Payment. For a Receipt ,Enclose Self Addressed Stamped Envelope. Please ote: Your Sale Proceeds Check is Attached BROKER'S Name, Address, ZIP Code Federal Identification Number and Telephone Number: Mellon Investor Services Washington Blvd. ey City, NJ 07310 22-3367522 Telephone: 1-800-649-3593 TO WHOM PAID JOCELYN PATRICIA STOPPE EX UW AVALON WARD STOPPE 501 RUPLEY ROAD CAMP HILL PA 17011-1841 OMB NO. 1545-0715 ZOOH Proceeds From Broker and Barter Exchange Transaction Form 1099-8 s Instructions for Recipient Substitute COPY B FOR RECIPIENT ,Brokers and barter exchanges must report proceeds from transactions to "'IMPORTANT TAX INFORMATION*•• ' You and to the Internal Revenue Service. This form is used to report This is important tax information and is being these proceeds. ' i furnished to the Internal Revenue Service. If _ - -- - - - ~~ to Date of Sale -- - -- ---- -__ _- ---_-- i you are required to file a return, a negligence penalty or other sanction may be im osed _ 16. CUSIP Number ~ - 05/13!2008 i 59156R10 p on ~, you if this income is taxable and the IRS determines that it has not been reported ------ -- ____ i 2 Stocks, Bonds, etc '~ 4. FEDERAL INCOME TAX WITHHELD 3 . $ ,338.27 $0.00 REPORTED Q/ Gross Proceeds ~~, TO IRS ~ Gross Proceeds less commisson and options premiums i 7 Descnption -- ... _. ___.. - _. _- - .---- METLIFE, INC. -- - _- _ __ , Investor lD "__--- -------------- Reapient s Idenfificahon Number on File 125110722433 188121035 Box 1a. -Shows the trade date of the transaction For aggregate reporting, no entry well Box 4. -Shows backup withholding. Generally, a payer must backup withhold at be present. Box 1 b. -For broker transactions, may show the CUSIP (Committee on Uniform Security a 28°/ rate if you did not furnish Po~r taxpayer identification number to the payer. See Form W-9, Request for Tax a er Identification Number and Certification, for Identification Procedures) number of the item reported. information on backup withholding. Include this amount on your income tax Box 2. -Shows the proceeds from transactions involving stocks, bonds, other debt return as tax withheld. obligations, commodities, or forward contracts. Losses on forward contracts are shown Box 7. - Shows a brief description of the item or service for which the proceeds or in parentheses. This box does not include proceeds from regulated futures contracts. bartering income is being reported. For regulated futures contracts and forward Report this amount on Schedule D (Form 1040), Capital Gains and Losses. contracts, "RFC" or other appropriate description may be shown. For inquiries about your account, contact BNY Mellon Shareowner Services, MetLife's Transfer Agent: Telephone: 1-800-649-3593 E-Mail: metlife@bnymellon.com U.S. Mail: Internet: www.bnymellon.com/shareowner/isd MetLife c/o BNY Mellon Shareowner Services PO Box 358447 Pittsburgh, PA 15252-8447 'OUR ACCOUNT HAS BEEN CLOSED. THE ATTACHED CHECK REPRESENTS THE FULL VALUE OF YOUR ACCOUNT. ______________________________ "IMPORTANT TAX RETURN DOCUMENT ATTACHED ^ ---------- RETAIN FOR YOUR RECORDS ~'I~hISAC~'I©N DETAIL >: - SHAREHOLDER OF METLIFE, INC. TRANSACTION DATE DESCRIPTION CUSIP INVESTOR ID 05/13/2008 SHARES SOLD 001 928 59156R10 ACCOUNT KEY CHECK NUMBER 125110722433 STOPPE---AVA3WOF00 CHECK DATE CHECK AMOUNT OPENING TRUST INTEREST BALANCE 558746 05/16/2008 $3,338.27 SHARES SOLD PRICE PER SHARE ($) 54.0000 54.0000 GROSS PROCEEDS. TAX WITHHELD NET PROCEEDS 61.8198000 $3,338.27 $0.00 CLOSING TRUST INTEREST BALANCE $3,338.27 00.0000 - ---------------------------------------------------------PLEASE DETACH BELOW ------------------- -------------------------------------------------------- _.._ .- ------------- CHECK NUMBER: 558746 MetLife 35070100002350000469 The MetLife Policyholder Trust ("Trust") BNY Mellon Shareowner Services Transfer Transaction Advice P.O. Box 35842D Pittsburgh, PA 15252-8420 Account Registration: F~Lr-.TAIN THtS Dc~cuMl_rrJT ~ad~ ~°c~u~ RECC-~~Ds 0000235 02 MB 0.494 **AUTO T3 0 3557 17011-184101 COl E1MA1 - z3 _ Date: 05/13/2008 I...III~~~lll~~~~~~ll~~~ll~„III~~I~~I~~I~~~IIII~~~~~~II~I~I,I JOCELYN PATRICIA STOPPE EX UW AVALON WARD STOPPE 501 RUPLEY ROAD CAMP HILL PA 17011 For information concerning this statement, please call BNY Mellon Shareowner Services, MetLife, Int.'s Transfer Agent, toll free at 1-80Q-649-3593 Trust Interests (Shares) 54.0000 CUSIP Number 59156R10 Transaction Date 05/09/2008 Transaction Advice Number 0002105418 InvestorlD 1251 1072 2433 This Transaction Advice is your record of the indicated Trust Interests being credited to an account on the books of the referenced transfer agent. The Transaction Advice should be kept with your important documents as a record of your ownership of these securities. These Trust Interests are transferable only as permitted under The MetLife Policyholder Trust. Please read the important information on the back of this form and in the Purchase and Sale Brochure. If you wish to request a purchase or sale transaction, detach coupon at the perforation and complete the applicable side of the form. PLEASE BE SURE THIS ADDRESS APPEARS IN THE ENVELOPE WINDOW FOR PURCHASES ONLY Purchase Instructions 1251 1072 2433 (See reverse side to SELL) Change ofAddress: JOCELYN PATRICIA STOPPE EX UW BNY Mellon Shareowner Services P.O. Box 382200 Pittsburgh, PA 15250-8200 lu~llrl~ln~l~l~l~l~ll~nl~~ln~l~lll~~~llu~ll~ulln~l~ull Siunature (if address is being changed) Make check in U.S. dollars; payable to: MetLife Purchase Program Amount Enclosed ~~ Minimum investment $250 (except as described in the Purchase and Sale Brochure) 0000],01 102 125110722433 9 :~~. S:av~~n,gs :Bond Redemption ;R:ecei;p~t ~. JOCELYN P STOPPE 188-12-1035 "N..'1 RUPLEY ROAD ~~AMP HILL PA 17011- Serial Number Series Denom Issue Date Issue Price Redemption Date: 04/24/2008 Transaction Number: 6113115239 Interest Earned Redemption Value 1031427162 E $50.00 05 / 1973 $37.50 $222.28 $259.78 2111231958 E $25.00 06 / 1965 $18.75 $167.22 $185.97 2615039781 E $25.00 01 / 1972 $18.75 $107.13 $125.88 5002932034 E $25.00 04 / 1972 $18.75 $107.44 $126.19 5018877026 E $25.00 08 / 1972. $18.75 $109.30 $128.05 50484169259 EE $50.00 11 / 1991 $25.00 $34.56 $59.56 80558860175 EE $50.00 OS / 1997 $25.00 $14.00 $39.00 Total Price Total Interest Total Value Total number of bonds redeemed: 7 $162::50 $761..93 , $924.43 Highland Park Office 344 South 10th Street Lemoyne, PA 17043 (717) 737-3322 ~~ SERIES RH u N~- itlu~(~:~~ 'I~~i$~('~~7 ~~~~ 1l~~lf'1W~~~Sj ~(f1;1~11~~f;Idl~j~jt~,\,lf ,~.~ 1)IViL; ~(GIs!(e)~~.tiS~Y~ilr)~1~1c)dL1::\d;:;~i. ,.~.a„~... _. 191-14-8592 T- HARRY STOPPE 416 DEERFIELD ROAD CAMP HILL, PA 17011 OR AVALON W STOPPE DEFERREDINTE:REST $ _ _ L..,...v.,,A. ;.....,..., 00405099195050 L 5 `~'' 6000 ? 15 2 9 9 4~~' ~l~~;r~~ ~~~a~~t~~~r~~~~~~r;~~~~~~4n~~~~w~~~rr, :a~~l~~dv; »sit!~~u=~ii;u3~i~~oxc~~;;~:.,~a::~;. 191-14-8592 %:~ HARRY STOPPE 416 DEERFIELD ROAD CAMP HILL, PA 17011 OR AVALON W STOPPE DEFERRED INTEREST $ ~_ .,....,..,A. ,:.u..,,. 00405099.195050 ~ 1, ~ ~' 6000 50 2 ~ 580~~' ~,.,~,.Y...,~.,~.,..~,y.M,.y, .: ,:...: ,. ...~ ..~,, „.....:...,.. ,. INIEHES'I (:EASES "[C~ YEARS FROM ISSUC DATk OF 06 1999 07152994 M~15299'+HH IN 1'ER E51' CEASES 20 YEARS FROM ISSUE DATE OF 06 1999 05021560 D5021580HH SERIES HH For use only: Customer No. ' PD F 5396E OMB No. 1535-0128 r Department of the Treasury Direct Deposit Sign-Up Form Bureau of the Public Debt lRwviswd Aunuct 90n41 Check one: Interest payments ©Redemption payment Check this box if the addressi~umished below should not be used fo update HH/H accounts. Please Print: Name (or names, if joint account) ~~ T/~~~ ~ ~ I/~~d/(/ /~ , S'T ~0/0,~'. Address _e~~/ JP,U'rU~,~/ r Telephone No. (Home) - (Work) Social Security No. ®-~-® OR Employer Identification No. ~- .Enter the following information OR attach a voided check: De ositor's Account No. Type of Account d a ~ ~ ~ Checking Savings Bank Routing No. ~~ - ~__~,{~ y(,~ ~ -,© Phone No. Financial Institution Name T" ~~~ ~~~~~ - ~~~ ~ ~ * If you want payments deposited at a credit union, DO NOT ATTACH A VOIDED CHECK. Ask the credit union to tell you the correct routin number to use on this form. For a joint account, only the person whose taxpayer identification number is shown should sign the form. Under penalty of perjury, I certify that: 1.The taxpayer identification number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS} that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) I have been notified by the Intemal Revenue Service that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). (Instructions -You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failecl to report all interest and dividends on your tax return.) (signature) (ate) urauuc.a.an~a. Complete and sign this form to request the direct deposit of Series HH/H bond interest payments or a savings bond redemption payment. Unless otherwise notified, the address and direct deposit information furnished will be updated on all HH/H accounts under the taxpayer identification number provided. WHERE TO SEND -Unless otherwise instructed, send the completed and signed form and, if applicable, the properly signed and certified bond(s), as well as any other appropriate forms and evidence, to one of the Treasury Retail Securities Sites shown below: Treasury Retail Securities Site Treasury Retail Securities Site PO Box 299 PO Box 214 Pittsburgh, PA 15230-0299 Minneapolis, MN 55480-0214 1-800.245-2804 1-800-553-2663 NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS We're asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which authorizes the Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain forms when we report taxable income to IRS. It's voluntary that you provide the requested information, but without it, we may nol be able to process your transaction requests. Information concerning your securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the tollowirrg routine uses of this infonnaiion may include disclosure to the following persons or entities: agents and contractors who help us manage the public debt; oihen> entitled to the securities or payment; agencies (including disclosure through approved computer matches) delennining eligibilfty for benefits, finding persons we'vo lost contact with, or helping us collect debts; agencies for investigations or prosecutions; courts, counsel, and others for Illigation and other proceedings; a Congressional office asking on your behalf; and as otherwise authorized by law. We estimate it will take you about 10 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg. WV 26106-1328. DO NOT SEcND completed form to the above address; send to the correct address shown In the instructions. Thursday, February 21, 2008 Page 1 of 1 Integrity Bank Avalon Ward Stoppi , Poa Jocelyn P Stoppe Account Number 401003650 242312 Trindle Rd. PRIVILEGED SAVINGS Mechanisburg, PA 17050 Transactions For Current Statement Period Previous Statement Balance as of Monday, December 31, 2007 0 Deposits and other Credits. 2 Withdrawals and other Debits. Service Charges. Current Statement Balance as of Thursday, February 21, 2008 Number of Days in this Period: Beginning Interest Rate Interest Paid Year To Date $16,647.25 +$0.00 -$10.00 -$0.00 $16,637.25 52 1.240°~ $0.00 Date Description Debit Credit Balance 12/31/2007 BEGINNING BALANCE 01/17/2008 DEBIT'MEMO - ~,~~ r r ~,/~ a, ~ ~`~ ~ IIS $5~ hle ~ $16,647.25 1 2 01/30/2008 RATE CHANGE TO 1.24000 . c o~ $ 6,642. 5 02!13/2008 DEBIT MEMO - ~-~,~ ,,, mat ~ _ krmv+ C 'Wl¢ ~,c~ow5 ~$5 00 $16 637 25 ~r ~3 ~ CA `I oy 1. 12/31/2007: $16,647.25 2. 01/17/2008: $16,642:25 3. 01/30/2008:. $1`6,642.25 4. 02/13/2008: $16,637.25 NO"I'ICE TO CUSTOMER .AS A CONDI7TON TU THIS WSTI'fUT'ION'S ISSUANCE OF THIS CHECK, 1'URCHASEIt AGREES TO PROVIDE AN INUEMNITI" HONU PIZlOIt TO THG REFUND OR KEPLACEMEN'I OF T'Hl5 CHECK IN TEIE EVENT IT 1S LOST', MISI'LACEU OR STOLEN. CASHIER'S CHECK 31283 DATE ~r . X60-1878/0313 . _, .t ... ... r'AY ;. r - TO THE ... -. - ORDER OF , ,:.,; EMPLOYEE NUMBER ORIGINATING ~ DEBIT: WIP COST CENTER AUTHORIZATION SUB PRODUCT AC OUS~T # ~ ,/ /ni ~~I~la~l~l /ni'Su1~91 I I I YY} I } ~n`~ ~ GF-269 (5/981 DATE ~~ Original -Processing Work ( - Copy 1 -Central Balancing Copy 2 -Branch/Dept. CUSTOMER SIGNATU E G/L PO ING COST CTR. JULIAN DATE COOSTICENITER SEQ. NO. 0 8/~~. 2 1 9 0 7 8 7 ® ~/ ~r-I ~S t C. ~in,QCIL~ ~,Ut AMOUNT J ~g I ~: 5 50 2••' 1500: I ORIGINATING COST CENTER EM~ PLOY~NUM~ DEBIT: WIP J / ~ AUTHORIZATION original -Processing Work }~ .:opy 1 -Central Balancing r`~ Copy 2 - Branch/Dept. .r/ - ~-~ ~ ~ ~/ 3Q,3O~ Q G/L NO. ~ (,`t ! J 2 1 9 ~~~ tZ'~~ac ~n.Q ~~ ~~r~.c~'t n.~ ~ f i ,~-~-r e ~'~ I ~: 5 5 10 .•I • 2 i 500. I ORIGINATING EMPLOYEE NUMBER pEBIT WIp COST / ~ / CENTER r AUTHORIZATION SUB PRODUCT A OU # Original -Processing Work Copy 1 -Central Balancing Copy 2 - Branch/Dept. ~- r~~/~D O N GF- 915/89, DATE ~ ~ G/L ~~ ,2 1 9 POSTING COST CTR. 0 7 JULIAN DATE ORIGINATING COST CENTER SEQ NO. 8 7 O ~ / / ~ I y I~ I j~d SGv ; nc~ S 'JOo~ - - ~: 5 50 2••I 1 500: GF-76915/96) AMOUNT 02. _ _ __ - -- ------ ---1 AMOUNT I m ' E ~ ~. C ~~ ~ °'w ~ n ° ~ ~ ~ ~ u ~ a _ a .-~ ~ ~ ~ ~ ~ y ~r G Y o V V Q1 N d t f6 ~ V V L ~ ~ ~- n c~- N`~ ac ~ ,.. ~ , ~ ~ r~a ~ ~ ~ ~U ~ n -~ -~I - 1 -i~I~- C i I _'~ aI y _ _ __ ~ ~~ U A ~ ~ u + i i ~ c ra n v N o ~, ~ = c ~ U H ~ C N o v c s v J o ~ o c ¢ ~ L E E ~ ~ 3 a '~ N V C ~ y6 O IIC z , a a ~ ~., i~ SO/L 100ZZ ~1_~ i-. ~ , 1 v `~ J o E ~ ~ Z `~. ~ y a C /~ ~ ~ a 0 G v ~ IY_ .~. d G ~ a U L ~ Q Q L ~ a ~ V U c°~ Z F ~ ~ i~ W fH `~ '~ '! ~ ~ , ~' m ~ ~-~ ~ ~, o ~ ~ ~ ~~~ ~' ~~ H -U i ~~ ~', I I ", ~ ~--~ ~ ~ ~ ~ ,~ a u +'~ i i i c ca m v N o y, ~ ~ c V u ~ c N o v c r ~ ., Y ~ 0 ~ L '+'~ ? c E ~ z o V E v i m 3 a R o 711 z a a ~ ~ ~ SO/l LOOZZ r ~ „o F ~~_ ,. ~`.' n-_ ~" J ~~ c V ~~ to ~ /too? /Cf ~ .Bank/Branch_ ~`~'~~ /;~~~~ an count has been charged to your account. Please adjust your records. Name ---'%~ ~C t'~ ~ ~~ -y~ Amount Debited $ ~ ~ ~ ~ ~ For: ~~ 1~ ~ ~~ r~l~/'~ ~~i Debit ACCt. G / ~~ ~ ~~ ~ ~~ Pr By /` Appr ( 1 ` {{-+~ /1 L~~ Cu Omer signs re requi ed when u tourer requests account be closed r: 5 9 9 0 ~~i 1 10 5 r: l - ~-~ ~ C\'. p <,~:~ ,E. ~~ ~ ~l.© . ', u ~v~ :_. o_~-h ~ti~ rE Sfi a~ Citizens Bank SAVINGS DISBURSEMENT ~J Net Amount to Customer Accruedlnterest +~ ,T l C~,~ Penalty Amount - =~ 1--L~ 1_- ~ c Federal Withholding _ -~ ~~-- 0 N State Withholding _ I _ ~ ~ " --~--~1-_ ~_-_~ Gross Amount ~~I;~~I~ '~i~~~~I ~~ Citizens Bank SAVINGS DISBURSEMENT ~ ~~'~1~~' ~ ~ Net Amount to Customer = I~- C?~ Account Number Accrued Interest r ~~Sty~~ I + ~ ~ _~~ ~ ism-1_S.L_J Date Penalty Amount _ ! ~ IRA Code ~~ i_ I i _ i Federal Withholding Check,~_ ~_ .~ ~ - Cash > o° -l a N State Wlthholding _ ~ j ~ _T _ Shaded oreos to be completed by Bank. ..._ _1_ Gross Amount ~_~_ ~ ~ stonier Signatur ~j~j~ i i , . ~, ,: - ~,. OFFICIAL CIiECK ~~ ~~ ,I ,.r,T . , , t ;, ;w~,< <,. _.6~ .; ~ 2323_97 - ~-_.. . .... __ i ~..; - ~~ Citizens Bank ,020 612332218 9 fi February 22 2008 . ,.. .... .... .. u::.., ,,. : PAY :~u~:::rur: ,,: ,... ,,.... D0~ (_ ~ .,..i, ...... I~....~I ~...~~i ,,,, .,e::........n ~(::~~ :,.. .p... I~ ~I _ipc qtr: h TYJ `I'HF apr„ il:::::.~c:::...u::.. riii:IL ...II::~. rF J! C:::::I...q:::: rr• , ::::. I / ,....,. Ir::~u rti, r....G....N... ~I::::::U tt....u 9~raU .,r ..... ollut-;r of ~ ,..,r, °b:::.,1:::::a~~(....ulf:::arrl:~::,, :rug: .`' r~ MEMO: Drawer: Citizens Rant. of Pennsylvania ~ ~,~~~;,';?, (' i/. KiaA ~1 Issued by atte~i ated Payment `y -tern ~ Ir c _. Crglr.•woor,l. GolCxado __ ~ / ~~/~ ~~~ _~ ~ [' 1_..~ JPMorgan Chase Ranh. N.A., Denver, (.oloradu T"' -~ ~., l~K .FD SIC NAl URF tt' 2 2 5 1 2 7tt' is LO 20009 79~: 68006 1 2 3 3 2 2 L88tt' .~ ~1 ~~/ ~1 ~1'\ 60-1271/31) PNC Bank, National Association Cashier's Check No. 01073861 Date February 22, 2008 0 0 Pay to the ot-der of THE ESTATE OF AVALON WARD STOPPE ~ 20,349.93 ~ Twenty Thousand Three Hundred Forty-nine Dollars And Ninety-three Cents PNC Bank, National Association 5130159696 Remitter Si iature tt'0 ~0 7 38 6 Ltt' ~:0 3 1 3 1 2 7 38~: 5000 L00 6 4 5tt' Remure~ (~ -~° CBAI~K iation (>U-I?73/313 I'NC Bank, National Assoc No p1073841 Cashier's Check Date February 22, 2008 !, 0 o $ 2,435.44 ', o Pay to ti,e Order of THE ESTATE OF AVALON WARD STOPPE o Two Thousand Four Hundred Thirt -five Dollars And Fort -four Cents PNC Ban ;'National association ' w ,~ ~ ~ i ~ ~ ' ~i/t~ ~ tc/ r I L ~ Siarature '~ 5 1 40235 592 _ ..._.._.-_ ----- - ---- . --- Remitter .-._.._... .......__ I --__ .._---..__.._....-'--_-_._-------------~--'---..__.__._ _-- ...r.,n~1AL111' ~:03L3L2738~: 5000L0064511' EFORM 100472-0900 - P`~iCBAI~K Your account was DEBITED for the following reason: ^ Check # posted on encoding error _ posted to incorrect account ® CIOSed aCCOUnt 5130159696 ^ Branch adjustment (branch name) ^ Service charge error ^ Other. tuber I I F 5130159696 ~ ~ 040 p'THE ESTATE OF AVALON WARD STOP E 501 RUPLEY RD B CAMP HILL, PA 17011-1841 I T AMOUNT $ 120, 349.93 PNC Bank„National Association FOR BANK USE ONLY Branch #/Dept. # 0000114 Prepared By (PRINT Name) LINDA SCHERM By Date 02/22/2008 omer' s Adv~lce of Charge Cashier's Check ~NBAN~ PNC Bank, National Association NO. 01073861 Date February 22, 2008 $ 20,349.93 Pay to the Order of THE ESTATE OF AVALON WARD STOPPE LL Twent Thousand Three Hundred Fort -nine Dollars And Ninet -three Cents W Non-Negotiable Customer Copy 5130159696 Remitter EFORM100472-0900 ~'NCBAIV~ Your account was DEBITED for the following reason: ^ Check # posted on encoding error _ posted to incorrect account ® Closed account514o235592 ^ Branch adjustment (branch name) ^ Service charge error ^ Other: p'THE ESTATE OF AVALON WARD STOP E 501 RUPLEY RD B CAMP HILL, PA 17011-1841 I T ~CBAIV< PNC Bank, National Association Cashier's Check NO. 01073841 o Date February 22, 2008 0 Pay to the order of THE ESTATE OF AVALON WARD STOPPE $ 2,435.44 ° Two Thousand Four Hundred Thirty-five Dollars And Forty-four Cents w Non-Negotiable Customer Copy 5140235592 Remitter Customer's Advice of Charge ,.~ t .~ March 13, 2008 Jocelyn Stoppe 501 Rupley Road Camp Hill, PA 17011 Dear Jocelyn; Because of an error on your mother's social security number, the Charles Schwab Institutional account your mother was beginning to open has been "frozen." Included with this letter are the W-9, needed to correct your mother's social security number so Schwab can "un-freeze" your mother's account and the Affidavit of Domicile which is needed in order to do the actual transfer of the money from the Schwab account into an estate account at any financial institution. We will also need the original or a certified copy of the Letters Testamentary (Short Certificate) that Adrian Young advised you to obtain. The third item enclosed is a letter of instructions to tell Schwab to close the account and send you a check for the balance made out to "Estate of Avalon Stoppe." The Schwab representative I spoke with said that the check would be processed within 24 hours of receiving all the requirement. Please sign, date, and return the forms and the letter of instructions, and send us as well the Short Certificate, in the postage-paid envelope I have included. Thank you for your help. Best Regards, `~ i~~ Ted Demck gb Encl.: W-9, Affidavit of Domicile, Letter of Instructions (~ e,fN.~n En ~relo~o~ AMBASSADOR ADVISORS, LLC IS A FOR-PROFIT SUBSIDIARY OF LANCASTER BIBLE COLLEGE AMBASSADOR ADVISORS, LLC IS A REGISTERED INVESTMENT ADVISOR Aeria® G.m 3oeWy Rpi.hs.d J~w~Me~ J• 1~G~ZS aewelers iNC. 2129 MARKET STREET BOX 481 CAMP HILL, PA. 1701 1 TELEPHONE 737-8024 Property of Mrs . Harrv Stoape Address 416 Deerfield Road Camo Hill Penna 17011 Date_ Feb. 18,1981 DESCRIPTION OF ARTICLE Lady's 14 kt. white gold diamond ring, the diamond approx. 0.30 ct., perfection grade 7, color grade 2, set in four prongs. Lady's 14 kt, yellow gold diamond ring, the diamond approx. 0.18 ct., perfection grade 6, color grade 5, set in illusion head, poor proportions. Received the first mentioned white gold diamond ring from Avalon Stoppe from the .1/state of Kathryn A. Ward. 4l~''"~"'' Due to the fluctuation in the prices of metals and gem stones, the above figures represent our best estimate of current values. Jewelry Appraisal ESTIMATED REPLACEMENT COST 715.00 337.00 These estimated replacement costs are based only on estimates of the quality of the stones (unless specifically stated that the stones were removed and graded). We assume no liability with f,~~ respect to a~ action that may be taken on the bas of the apprailsal i //i' ,' ~ •%' / DEPARTMENT OF TRANSPORTATION % "-`~ ~ _i CERTIFICATE OF TITLE FOR A VEHICLE ~`~\ .a 2 t 680 -s`~;, 962180072004041-001 ~~- °=- 2C3HD56F7TH?62537 I 96 CHRYSLER 149957,387401 ST VEHICLE IDENTIFICATION NUMBER YEAH MAKE i]F VEHICLE TITLE NUA1GcR =_'`- SDN D 8/22/96 OGDD27 D BODV 7'!PE I OUP I SEAT GAF' I I'RIIIR TITLE STALE I ODOA1 PHOCD DATE ODOM MILES I ODOM STATUS rT'' 8/?2/96 I 8/2?/96 I rr„~ ' DATE PA TN LED DATE OF ISSUE uNL ADErJ WEIGHT GvwH ,,., ~ .,.,....... O T~ V (V /~ Tom/ V REGISTERED OW NE RIS HARRY E AVALON W STOPPE 416 DEERFIELD RO CAMP HILL PA 17011 FIRST LIEN FAVOR OF SECCNU uEN FAVOP OF ODOMEIEH STATUS U ACTUAL MILEAGE I MILEAGE CXCE ~Oti THE ME(.riANl(;AL LIMITS NOT THE ACTVAL MIL`_Ali[ ~ NDr iHF Af'.TUAL MILEAGE-LI U:JMEIFR iAMVf RIr:G V(RIFIFp -I rY,E MPT FROM ODOMETER DISr:LOSl1RF TITLE. BRANDS A gfJT10i1F VEH'.i~,LE CLASSIC: VEHICLE F OI1T Or ~OIIN rRY C: ORIGINAL. L'! MF GG FOR M)N-U.S. DISTRIBU TIUr.' H AGRICULTURA'. VEHICLE L LOGGING VEHICLE FORMERLY A POLICE 'fE HICL~ R RECONSTHUCrED S7NEE'ROD T RE COVE RED THEFT VEHICLE VEHICLE C(JNTAINS RE'SSUED VIN W -FLOOD 'IEHICih % FORMERLV P TAxI If ~ Se'_ond IlenholtlP.r Ls IlSletl. upon sah5laction ul the tlBt lien. the first penholder muss lorward INS Tllle to the Bureau of Moor Vehicles wdh the FIRST LEN RELEASED ' :1PProPnale corm and fee. DATE BY SECOND LIEN RELEASED AUTHORIZED REPRESEN iATIVE DATE MAILING ADDRESS 9Y 3 7 0 ~ ~ AUTHORIZED REPRESENTAT;VE HARRY t: AVALON N STOPPE 416 DEERFIELD RD CAMP HILL PA 17011 I certify as N the date of issue. truF official records of the Pennzvlvnma Oeuartmenl of TranSportatlpn reflect that the perSOnts l or company named herein is the lawh II owner of the Said vehicle. SRAD~rY L MALLORY SecrclArY Or Transporla lion SUBSCRIBED AND SWORN ~.i ~ when applynxJ for Mlle with ~ co-owner other than your SPOUSe. check one of TO BEFORE ME ~ j~ J , ~ ~ Ihesa Mocks II no block Is cnecked, Inie well be Issueo as T>nanis m Common-' NIO OnV ) YEAR A ~ JOlnl Tenants with Rlyhl of Survlvorshio Ion Je~llh of one owrk'. tine goes .. ~. r to the s v ry owwr B^ Ten.lnlsL n Common Ir n nealh nl n :nlerrsl I n 15en n r' I ~ Jl Y.. ~ • c)pVS 'O I Jr her he rS ]r es'alei ~~ ~wnrr ...: wnel ..: ~.' ;~J ' " A1E I! V ~ IISTENINES .qHl.,~ f~ _ r~ ~ -~ " LIEN IF NO LIEN r ~ (COMMONW~'ALTH OF PENNSYLVANIA '' ~RS uENHOLDER cHECn B(~x ` J Notarial Seal NAME w Jennifer A Shuey, Notary Public cn Lower Allen Twp., Cumberland County STREET My Commission E~ires June 20, 2011 c'T'' _ Member, Pennsylvania Association of Notaries sTArE zIP ~~ LIEN IF NO LIEN The ~,InUerSl9ned het etrl mTJkps aPPllenlion IOr Cerl:liCaie nt TIII~ In m~. v-•hl•.; Ir (:eSV ib+i: DATE CHECK BOX j_ anove slDlecl le Ine encumhr.Jnces alxl other IeJal 'Ja'ms Set lorlh hrly SECOND LIENHrJLGER NAME , X ~Ji'IIATIIHE OF nPPl.l(nNr n+A InI!`PILCf) JtirlFR (ITr iTATF f-"AI Rf .: AVM A TI IF FnIT (CL 1 L4 ~I- ~' - ' ' • L • ' .Mr.:,•' n .r :.I ~. .. • .,r,.r I,.:~,.., . r .il....y i.Al qp,. ~I X01-00) of Transportation AFFIDAVIT OF GIFT rulotor Vehicles r"ront Street ourg, PA 17104-2516 ~STRUCTIONS: This form must be completed by all transferees and transferors and attached to Form MV-1 or MV-4ST for any transfer for which a gift exemption (Exemption 13) for purposes of Pennsylvania Sales and Use Tax is claimed. NOTE: This exemption may be used for vehicles currently titled in Pennsylvania and for vehicles given as a "Gift" that are transferred on an out-of-state title. The donor of a vehicle purchased out-of-state that is to be given as a "Gift", must provide proof that sales tax was paid in a reciprocal state, i.e., bill of sale, in order to use this exemption. If no proof of sales tax being paid is available, or the sales tax was paid in anon-reciprocal state, sales tax must be paid on the current fair market value of the vehicle. Title Number: ~ `7Clrj) ~~ ~~ y ~~ S ~ Make of Vehicle: ~ ~ J ~'~ Transferor No. 1: ~i ;~(_~ ~ ~% ~ ~Y'/, - ~ k~~ (= p se prrn l Transferor No.2: ~ L~~ ~''~ ~ ~ ~ j~~~' - ~ x /`'~ , I-I p {;}t,,~ ~ R J~,l(~;/J ~1 . 5 tt pP r _ (please pant) DP c mac:-~~-c:k VIN Number: olL.J I-1 J ) ~ t" 7 j f~{ ~~ ~~`~ 7 Model: (,i ('~' ~~ Year: -~~~'! V/ Transferee No. 1: ~ (~~ /; /~~) ~ ~r}'lCC pease pnn Transferee No. 2: (please pnnfJ Is the transferee related to the transferor? Yes ^ No '~ Identify all the parties and relationship (for example: father/son; mother/daughter, uncle/nephew; friend/friend): WARNING: FALSIFICATION OF THIS AFFIDAVIT COULD RESULT IN CRIMINAL PROSECUTION AND THE REVOCATION OF YOUR DRIVING PRIVILEGES FOR A PERIOD OF ONE YEAR The undersigned transferor(s) hereby declare(s) under penalty of perjury that Ilwe have received nothing of value, either directly or indirectly, from the transferee(s) or any other individual or entity in consideration of the transfer of the above-described vehicle, including but not limited to money, property, services or the forgiveness or waiver of any debt, obligation or encumbrance and that all information provided herein is true and correct to the best of my/our information and belief. Transferor No. 1: `~!~-t~_~~ ~ ~.~ „ ~ ~- x c l -T 3 ~/ ? C~ C~ c~ Lip t,. I ~, 2c,o,~ ~-a 'transferor rgnature (or Authon~ed~erson for Corporatron) Onver's Lrcense Numbe Date Address: ,_. Transferor No. 2: Address: `J L ~1. ~~~;' ~~!' The undersigned transferee(s) hereby declare(s) under penalty of perjury that I/we have given nothing of value, either directly or indirectly, to the transferor(s) or any other individual or entity in consideration for the transfer of the above-described vehicle, including but not limited to money, property, service or the forgiveness or waiver of any debt, obligation or encumbrance and that all information provided herein is true and correct to the best of my/our information and belief. Transferee No. 1: ~ ~S~ ~ 7rartsreree argnature (or AUthonzed Person /or Corporation) Address: ~ f `- L ~~ ~ i' i F ~/ r y F'` ~~ /1/'~ i/ Transferee No. 2: Address 17~ 7 3 9 L od A P r. 11, Zcx_~, Orrver's Lrcense Number Date P~ l lei I ~.t q' ,~ 1 G' ~d Dnver's Lrcense Number ~~ o~/, i ~~ Date ' ~`~'~ (or Aulhonz ed Person Ion l u t./' -~ avers rcense um er THIS FORM MAY BE PHOTOCOPIED TYPE OR PRINT) Certificate of Title must be submitted within 20 days, unless the purchaser is a registered dealer holding the vehicle for resale. VVHI"SIVIIVU - TO COMPLETE OR PROVIDING A FALSE STATEMENT MAY RESULT IN FINES AND OR IMPRIISONMENRANSFER OF OWNERSHIP. FAILURE REylsleBd tlealers muss complete loans MV27A Or MV2T8 LAST FIRST ASSIGNMENT OF TITLE- 9 ilxwirad Dy law a pumha9ar 19 NOT H Tegulerad dealar M I Section D on the Iron) Of Ihls loan mus be completed p H i I y /We certll 1o the best OI m / k l d u f C HASER OR FULL ~~ 'W ,~A ( N y BUSII E y y Our now e r a that the odometer readrn / JE55 NAME /Y E C / r~ ~ Lam, l f ~I ,) A•a TENTHS _! ~ , 1 ~? X / I CO-Pl1RCHA5ER ----~._~_ ~ - SSSaaa f Si. miles and r«Ilects the actual m~leaya of the vehlcte unless one of the lollOwuSg Uoxes Is checked STREET Rellects Inr amount of mdeaye Is NOT hTe actual mdea e ^ y n ex Less OI Its rnechanlcal limits ^ WARNING Otlplneler Uiscrepuncy CITV G I' r ~ ~ L ^ ' ~ I /We lurthw certlly that the vahicle Is IreH ul any encumbrance antl that nwnarshlp Is hereb i W C ~ A1 K~ ~ ~ ~ ~r ~ ~ r~ I y ran9lelred l0 the pelSOnlsl Or the dealer IlsteU STATE Tt(.. ZIP , ~~ ~i ~~ PURCHASE PRICE OR DRJ SUBSCRIBED AND SWORN _ TO BEFORE ME. J f ) ~~ ~ ~ ~ ~ -- ~` L/~lr ~ ~ ~~/~~?/,r~ / -{MO DA' EAR /~ ~ LF{fR,AERSIGNAIURE 4 I15 ~ (;O F ':U~PUHLHA9LH SIGNATURE r NIA ~ ' ' T ' N PURCHASER AND OR i ty ~j(' 1 L MO~v~YEA t CO-PURCHASER IAUST ~y A' G , ( ~ ~ ~ OM HANDPRINT NAME MERE L/ V J ! A~. •Nc»ac~l lei - -- `. ~ Q 5 Jec u ~ Y 7 ~e~~liid~C.o ~ X. ___... ti4iAAT J ti ~~E A ~/ ~ T, ,y~ .+~ iation of Notaries til(:NAI IIHE OF CO-SELLER Memt~er, Pennsylvania Assoc SELLER AND1oR CO-SELLER MUST ~~,, HANDPRINT NAME HERE ~ ~ ~~' N 7 B. ~ ~ ~ ~ ~ ~ IrWe certlly, to the Desl of my/our knowledge Thal the odometer reading .s LAST FIRST M I iE\NT/Hti l /\ f . . mi --- t -_- es antl re lects the actual mdeaye of the vehlcte. Unle95 ODe Of Ih2 IOIIOWmg boxes Is Checked VURCHASER OR FULL BUSINESS NAME ^ Rallacls the amount of mileage ^ Is NOT the actual mdeaga in excess OI Its Inecnanlcal Ilmlls WARNING Odomet r d C0.PURCHASER e rscreplncy 1/We further certlly that the vehlcte 5 free of any encumOralSCe antl that ownership is hereby transferred t0 the personlsi or the dealer hsled ,-,TREC7 ADDRE 55 CITY SUBSCRIBED AND SWORN TO BEFORE ME . MO DAY VEAP srnrE zIP PugcHASE PRICE OR DIN SIGNATURE OF PERSON AUMINISIENING OATH PUFCHASER SIGNATURE 1-~ I ~ ,.. .,. - 1 - - - ..., / ~,W ;;, .,Vt ,. ~ t;O.PURCHASEI SIGNATURE J T PAR RASE AND, R Q ?~{ ~ - y C -PURCHASER MUST W _ - - " - a HAN PHIN7 NAM H R . ..+ . 51T~;' Yt .. l ..:.. .r.~ .... t .. : t ` i ~~ ' ~ r - ^' i ' ^~ -~ ~ ~-~ `- SIGNATURE OF SELLER SELLER MUST HANDPRINT NAME HERE ' ~ ~ ~ • ~ • I/We certdy, to the best of myrour knowledge Thal the odometer reading Is LAST FIRST TE NT HS M.I. \ / /\ l --- r ___ mi es and reflects the actual mdeaye of tha vehiOle. UDIe95 One Of ine 101105ving DDxa$ i5 Checked. PURC HASEP OR FULL BUSINESS NAME ^ Rellects the amount of mileage Is NOT IIY actual mdeaye In exCe55 of ITS TechanlCal Ilmlls ^ WARNING OttomPter dlscre ln CO-PURCHASER p; cy I/ We lurther certlly that the venlcle Is free Of nny encumbrance and Thal ownership Is hereby STP~ET ADDRESS transferred Io the personlsi or the dealer Ilsled CITV SUBSCRIBED AND SWORN TO BEFORE ME MO OAY YEAR STATE ZIP PVRCHASE PRICE OR PIN SIGNATURE OF PERSON AOIAINISTERING OAfI-I PURI;HPSER ~IGNAf URE 1 ^- {„ ~ • ... ,. - - _ (;O-PURCHASER SIC NATUFE J Q ~` ,,, `~j r- - ~( PU HASER AN R CO-PURCHASER MUST w -- ' - - •' HAN PgINT NAME H RE r '- '1 ~ `-' ~ M` >_)ti: -+-~ "" SIGNATURE OF SELLER SELLER MUST HANDPRINT NAME HERE ~ ~ ~ ~ 1 • I/We certify. to the Uesl OI my/ovr knowledge Thal the Odometer reatliny is LAST FIRST TE\NT/HS /\ tu l d M.I. l - f --- es an rPllecls Ine actual mileage of the vehlcte URI2S5 OTIC 01 the IOIIOwlrly dOxeS is CheCkad PURCHASER OR FULL BUSINESS tJAME ^ Rellects the amount of mdeaye ^ Is NOT tfre actual mdeaye n excess DI Its mechanical limd5 WARNING Odometer discre an CO-PURCHASER p cy I/We further certify Thal the vehicle Is Tree of any encumdranc~ and Thal Ownersnru Is hereby STREET ADDRESS transferred to the personlsi Ur IhP daaler listed. CITV SUBSCRIBED AND SWORN TO BEFORE ME: MO DAY YEAR STATE pp PURCHASE PRICE OR DUI JICNAIURE OF PERSON POrAIN1 ~l ERInI(: (ATH PURCHASER ti1GNA111HE ~~ ~ I ~ ~ ~ - - ~~ CO-PURCHASER SIGNATURE J PURCHASER AND-OR Q - ~ _ CO-PURCHASER MUST ( C L - - HAN PRINT A H P - - ~- ~ SICrIPTUHE ~?F ~ELLEH SE LLEH MiJ ~T HANDPRIAT NA!~1E HERE C, ^ CHECK HERE IF APPLICATION FOR DEALER TITLE AND COMPLETE SECTION D. TITLING FEES ~EV•485 EX + (3.04) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 SAFE DEPOSIT BOX INVENTORY c~~ Please Print or Type MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE FILE NUMBER SOCIAL SECURRY (Required) OR DEATH CERTIFICATE NUMBER )only if SSN is unknown) DECEDENT'S NAME (LAST, FIRST, MIDDLE) f~ ,~ /~ V/~I ~Q~ 1N' , DATE OF DEATH of /-~ ADDRESS OF DECEDENT (STREET) ~~ d (CITY) (STATE) ~~ (ZIP CODE) NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX (NAME) ~~ C:~z~,v ~' ~5fi~pr°~ (STREET NAME) (CITY) (STATE) (ZIP CODE) NAME, ADDRESS AND RELATION IP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. (NAME) c.~~yiV ~ ~s~-©~i~.~ , (RELATIONSHIP d ~4-y ~,~T~,P y~x~ c ~~~x (STREET NAM ~'E" , (CITY) (STATE) ~ (ZIP~CyODE) Ll b. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE) (ZIP CODE) c. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE (ZIP CODE) ' NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) ~~ ~~~ (STREET NAME) ~~ (CITY) (STATE ) ~~~ (ZIP CODE) NA E OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY DATE OF C TRACT T~~NT BOX NUMBE~ OF BOX /E~ - i VDO ~ TITLE UNDER WHICH BOX IS REQUESTED ~ ~~ .'d is ~ o~ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX Q ~ v~P ~ _~~D a. (NAME) ~OV~~4itl ~,r1AR,(l .~'~ b. (NAME) ~c~i~ % '~C9 l' .C ~' Vi1i' ~- S~/~' (STREET ADDRESS) ,p /~ . . t (STREET ADDRESS . (CITY) (STATE) (ZIP CODE) (CITY) 7 /'(~ STATE) (ZIP CODE) i NAME AND TffLE OF EMPLOYEE TAKING THE INVENTORY WAS A WILL IN THE BOXT ^ YES I~ rv0 If yes, a. Date of will: b. Name and address of personal representative, if named in the will (NAME) (STREET NAME) (CITY) (STATE) (ZIP CODE) c. Name and address of attorney, if any (NAME) (STREET NAME) (CITY) (STATE) (ZIP CODE) SAFE DEPOSIT BOX INVENTORY Page~of~_ INSTRUCTIONS The Department is authorized under federal law , 42 U.S.C. § 405(c), to use the decedent's Social Security number in administering this state tax law. The Department uses Social Security numbers to establish a decedent's identity and ensure proper credit for tax payments. (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. ITEM NO. ITEM DESCRIPTION h-~' ~ ,~ - ,~. v~ ~-- I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT AND COMPLETE TO THE BEST OF Y KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNATURE ~ / //C//-- ~ NATU PRIN N E PRINT NA AND CHEC P RIATE BOX BELO PRINT TITLE ~I t // 1 r ~_/~-!/ it A-~~ DATE ~/ /,/~ ///"`}~ /-.h_/_A lV CHECK APPROP IATE BOX: xecutor(lrix) ~ Administrator(irix) ~ Estate Representative ®Joint owner of safe deposit box NOTE: Attach additional 8'!z" x 11" sheet(s) if necessary or use duplicates of this page of form. J 48500041046 REV-485 EX (1-07) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue Social Security or Death Certificate Number Date of Death PLEASE USE ORIGINAL FORM ONLY ~~` ~ Coun Co 1 de Year File Number 1~!. ~i Decedent's Last Name Suffix First Name r ; n MI - ~ ~ ~ t ., ADDRESS DECEDENT STREET: CITY: "11Ln C _ `\ (1 ~ ?STATE: ZIP CODE: NAME AND ADDRE~F PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME: '^ ~U ____ -- --- - STREET ADDRESS: ~ ------- --- __ NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) P ESENT AT THE BOX OPENING a. NA ~ -\ ~ \ ` ELATIONSHIP: -- ~O. ». a~~d.°M~~ - .p STREET ADDRESS: --- - -- _ ~~-~Q- ~S~_~~ \\ CITY: STATE: ZIP CODE: ~~~` ~ -- ~~~~ ~~ RELATIONSHIP:, STREETADDRESS:~ 1.5._. ~ _-_ ~-~__C~ _ _ .------ _ _ _ S ~ \ ; `\ ~ ~ ~ "STATE: - ZIP CODE. c. NAME: -~~-- ' ' ` - `~ ~?~-~- ~-~--- . 1,~~ - - _ _ _ _ ~ RELATIONSHIP: STREET ADDRESS: ---.--- - ---"" -- _----- - --- CITY: STATE: ZIP CODE: .+~.~ r~wrccaa ur rnygNGIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX tS LOCATED NAhRt~ i - - ~.. - - .. .. -. STREET.ADDRESS; -`-- - -- -- -_ -- -- Q _ CI Y~ ` 1. ATE: ZI^P~CODE: ~ `~ NAME F PERSON MAKING LAST ENTRY DATE ND TIME OF LAST ENTRY V ~e ~`~ `O DATE OF CONTRACT TO REN B X • NUMBER OF BOX TITLE l1N R WHICH BOX IS REGISTERED ~~ ~ S~ o NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX ' a. NAME: b. ME: STREET gpD S ~-- ST ~~~ ~~"~ _ _ _ REIE`T-A R SS: CITY: _ _ _- --- - - STATE: ZIP CODE: tIY: I STATE: ZIP CODE: NAM AND TITLE OF EMPLOYE ING E IhIVEN ORY ` \ 1 WAS A WILL IN THE BOX? ^' YES p If yes,: , a: Date of will: b..Name and address of'Personal representatwe, if named in the will - - -" NAME: s - -. _ STREET ADDRESS: c. Name and address of attorney, if any NAME: STREET ADDRESS: CITY: STATE: CITY: --- - ------STATE: ZIP CODE: __ i ZIP CODE: 48500041046 48500041046 J REV-485 EX SAFE DEPOSIT R[~X INVFNTnRV Page of INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fu11y as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION .PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION -- ----- - _ --- - .. __ --- - --~r`- - ~~ _-- - -- _ _ ___ ~~eS-_ ~~~ ------- -- - - _ ___ _ - -- - --- - - __ __ ____ -- ___ ~- -- - .__._ - - - _...._ .._... _ ~...r~!._ Y~ ~ ~--------1~~~...-~~~~.... _._---. ---. _ -.._ -- -~. ~~~ '~`~•~+.c -e. c~1c~ ~. o ~~c~r ~o~.o, a. I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNATURE SIGNATURE -. .-__ - PRINT NAME PRINT NAME AND CHECK APPROPRIATE BOX BELOW PRINT TITLE DATE CHECK APPROPRIATE BOX' Executor(trix) ~ Administrator(trix) Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/z" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by taw, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes. 1Z~ ~ al ~ ~ ~ ~~ v w ~ ~ z / O ~ O ~ U W Z / m ,J ~ ~ O 7 z U F Z_ ~ ~ W ~ ~ ~ oo U ~ ~ ~ W F Z Q m ~ J U O w LL O h 0 Z 0 O m~ 1\A Z V h LL N ' z~ l mZ ~ Z YD OW NN ~ ~ W N y LL 0 W Q O W m 7 Z O 0 m `w a v W U W Q 2 Y 2 Q a O U ~i = o ~ s~~ ~~ ~I Q Z W ~Z O w Z ~ wo~ 1 ~ ~ ~ Q W O~Na JWm~ ¢~ ~ N ~ , ~~ ~{%J ~~ ~ ~/1 I Om ~°'~ 3 y/ .Y ~ za ~ ~ I' ~~ x 0 U o N O _ X W H = / ~ / / /1 I~/ V w G ~ ~i ~ ~~ Y~I ~ I I I REV-485 EX SAFE DEPOSIT BOX INVENTORY Page of INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. {3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (13) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION __ ___ - _ -- _'A11~-b~c __ __ _~~~--- ---- - -- _ _ __ I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: NATURE , c-`~ M`~`~ EC~I~ SIGNAT RE ~- t _ 1 ~~GYL.~ c..1 4.. `~. PRINT N E AND C K APPRO IATE BOX BELOW' _ -` c RINT T LE DATE CHECK APPROPRIATE B X: ~Executor(trix) ~ Administrator(trix) \~ 1r~ ~ Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/z° x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes. C i ,, ~~ ~, A Family Tradition Of Caring~~' PARTHEMORE Funeral H Ms. Jocelyn Stoppe 501 Rupley Road Camp Hill, PA 17011 For the service of Avalon Ward Stoppe 1303 Bridge Street P.O. Box 431 New Cumberland, PA 17070 (717)774-7721 (Fax)774-5546 www.parthemore.com Gilbert W. Parthemore, Founder Gilbert J. Parthemore, Supervisor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC Professional Memberships: NFDA • PFDA DCFDA • CCFDA /numouorw! order Wrhr G ' L~N The Rule You Knoll; The People 3'ozr Ti-ust Cremation Services, Inc. 2/4/2008 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement. of the services, facilities, automotive equipment and merchandise that you selected when making the funeral arrangements. Terms ~ Due Date Account # Net 30 3/5/2008 2008014.0 -- - -_ __ Description Amount SERVICES & MERCHANDISE Traditional Funeral Service Wildflowers Stationery Set 20 Gauge Steel Blue Casket Concrete Vault Total Services and Merchandise CASH ADVANCE ITEMS Death Notice, Harrisburg Patriot 13 Certified Copies of Death Certificates Hairdresser Tent & Cemetery Equipment Clergy Honorarium Altar Servers Grave Opening 5,595.00 135.00 1,395.00 990.00 8,115.00 106.37 78.00 40.00 125.00 l 50.00 15.00 800.00 Total Cash Advances Immediate Pay Discount -Thank you! 1,314.37 -162.30 ~oc~,~n~ ~1ti~~ ~ ~~'c Oll~ ~ ~S ~~ ~~ Q~ ~ ~,~ ~ ~ ~Q ~'o ~a.,1 Q . Q a~ 110 ~ ~~" ~ ~ ~ ~ ~ c -_ "~'~ -- - - -- -- - - __ -_ __ __ `~~ __ ~' ~~ S U Total $9,267.07 Ci.R,c-e,, ~p ~r-Q,~~ _ Payments/Credits $-9,267.07 v`~~~ Balance Due $o.oo -- ___ _- t Office of Catholic Cemeteries Diocese of Harrisburg PO Box 3651 Harrisburg, Pennsylvania 17105 Phone (717) 657-4804 SALES CONTRACT DATE ~~~~ ~~ ~~ CEMETERYC~i~.~r'//c~:i~ CEMETERY# -~ A/N P/N A/R NAME 5/4Cc ~~-.~.-r ti-~~'~~~c+ PHONE ( ) ~~~'` Y.'~~_'J ADDRESS ~'/,~ii.~''~' ~ "' ~C%. ~x CITY !~~~'~'i=~,ii//`~I.r'~ STATE t'~ ZIP CODE .~~©./~ Interment Spaces ....... @ $ Bronze Memorials. ~ S ~ • ~~ $ a7~i~'. ~ Size Granite Foundation...... @ t-~~•~ $~~•pv ~/ 7x~~ Burial Vaults ........... @ $ Crypt Spaces .......... @ $ Niche Spaces .......... @ $ Other ` $~_ Section •~ Lot~Grave(s) jr.~ Building Side Crypt or Niche Selection must be made within 30 days or cemetery will make choice 1. Price ................. $ L.3c•YJG. ~e~ 2. Down Payment......... ~.~mIG. ~% 3. Unpaid Balance(1-2) ..... f..) 4. Finance Charge ........ . 5. Deferred Payment (3+4) . . 6. Total Price (1+4) ........ ~~ A'J 7. Approx. Monthly Payment 8. Number of Payments .... /' ~~ 9. First Monthly Payment Due 10. Annual Percentage Rate The payment is due on the date stated above and the remaining payments on the same day of each succeeding month Buyer may prepay in advance the full amount due without penalty and will be entitled to a proportionate refund of the unearned finance charge. Upon default in the payment of any installment due hereunder for a period in excess of one hundred twenty (120) days, Seller may, at its option, void this agreement and retain all payments made by Buyer as liquidated damages. Buyer hereby acknowledges receipt of an exact executed copy of this agreement at the time of execution hereof. Before any burial is permitted in this lot, or any memorial placed on this lot, the price of the grave and memorial must be paid in full. The Purchaser(s) agree(s) to abide by all rules and regulations of the cemetery now in force as well as any rules and regulations which may hereafter be adopted. Said rules and regulations may be seen upon request at the Seller's office. Upon fulfillment of the conditions of this agreement and receipt of all the above described payments, Seller agrees and binds itself to convey to the Buyer, by its cemetery easement, for interment purposes only, the above mentioned number of sites. YOU, THE PURCHASER, MAY CANCEL THIS TRANSACTION BY WRITTEN NOTICE AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. (Authorize esentative) (P,urchaser's Signature) NOTICE: See other side for additional information. (Co-purchaser's Signature) RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 STOPPE AVALON WARD Estate File No.: 2008-00160 Paid By Remarks: JOCELYN STOPPE CJ ------------------- Fee/Tax Description PETITIOI`~ LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Cash Total Received......... Receipt Date: 2/15/2008 Receipt Time: 08:35:38 Receipt No.: 1051577 Receipt Distribution ----- -------- -------- --- Payment Amount Payee Name 3 i 0. U 0 CU i3ERL~IND COUNTY GENERAL FUN 15.00 CUMBERLAND COUNTY GENERAL FUN 24.00 CUMBERLAND COUNTY GENERAL FUN 10.00 BUREAU OF RECEIPTS & CNTR M.D 5.00 --------- CUMBERLAND COUNTY GENERAL FUN ------- $364.00 $364.00 ._ ~. E RETAIN THIS PORTION FOR YOUR RECORDS THE SENTINEL - LEGAL JOCELYN STOPPE P.O. BOX 130, CARLISLE, PA 17013 AD NUMBER CLASS SALESPERSON BILLING DATE LINES 346092 10 PUBLIC NOTICES wolfs 04/14/08 28 * 2 AD DESCRIPTION START DATE STOP DATE ESTATE NOTICE LETTERS OF TESTAMENT 03/29/08 04/12/08 PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 111.72 TOTAL AD CHARGE 111.72 3 PROOF OF PUBLICATION OlPRF 7.00 PREVIOUSLY PAID -118.72 DAYS RUN PURCHASE ORDER PAY THIS AMOUNT . 0 0 Est.A.w.Stoppe .oo* MESSAGE: ~~k.:~k~. (~~ Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: Monday is Friday at 11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon; Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday is Thursday at 12 Noon. If you have any questions regarding your Legal bill please call Tammy Shoemaker 717-240-7176 Fax your legals to 717-243-3754 attention Tammy Shoemaker You can also EMAIL your legal to Classified ads: classifiedC~cumberlink.com Please send a cover letter including your name and address as an attachment DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT THE SENTINEL -LEGAL Est.A.W.Sto e P n R(3X'13C1 CARI ISI F P4 ~7(1~~ PP AD NUMBER CLASSO START DATE STOP DATE 346092 PUBLIC NOTICES 03/29/08 04/12/08 AD DESCRIPTION BILLING DATE TELEPHONE NUMBER ESTATE NOTICE LETTERS OF TESTAMENT 04/14/08 717-761-3433 JOCELYN STOPPE 501 RUPLEY ROAD CAMP HILL, PA 17011 L~JII~~~III~~~~~~IL~JIIL~~I GROSS AMOUNT OF .00 DUE AFTER 05/14/08 TOTAL AMOUNT DUE .00 ENTER AMOUNT ENCLOSED 20200000003460920000000000000000000000000000006 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tames Kleinklaus, Advertising_Operations Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): March 29, April 5,12, 2008 COPY OF NOTICE OF PUBLICATION Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. Sworn to and subscribed before me this 14th da,.y of April, 2008. Notary Pu c My commission expires: g~//(~tS COMMONWEALTH OF PENNSYLVANIA Notarial Seal Christina L. Wof(e, Notary PubNC Carlisle Boro, Cumberland County My Commission Expires Sept 1,2008 Member. Pennsylvania Association Of Notaries i T~: The Sentinel P.O. Box 130 Carlisle, PA 17013 ESTATE NOTICE Letters of Testamentary on the Estate of Avalon W. Stoppe, late of Camp Hill, Cumberland County, Pennsylvania, deceased, having been granted to the undersigned. All persons knowing themselves to be indepted to said Estate will make payment immediately, and those having claims will present them for settlement to: Jocelyn Stoppe, Executrix 501 Rupley Road Camp Hill, Pa. 17011 Advertising cost: Estate Notice $118.72. These run once a week for 3 consecutive weeks. ~ ~ CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 April 18, 2008 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Jocelyn Stoppe Avalon W. Stoppe Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: Apri14, April 11 and April 18, 2008 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director ~?;~c ~t~.. #~ i nod ~ ~ PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, vlz: Apri14 April 11 and April 18 2008 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Stoppe, Avalon W., decd. Late of Camp Hill. Executrix: Jocelyn Stoppe, Rupley Road, Camp Hill, 17011. Attorney: None. isa arie Coyne, Ed' or SWORN TO AND SUBSCRIBED before me this 18 day of April. 2008 Notary NOTARIAL SEAL DE80RAN A COLLINS 501 Notary Public PA CARLISLE BORO, CUMBERLAND COUNTY My Commission Expires Apr 28, 2010 ~ ~ TO: CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 ESTATE NOTICE Letters of Testamentary on the Estate of Avalon W. Stoppe, late of Camp Hill, Cumberland County, Pennsylvania, deceased, having been granted to the undersigned. All persons knowing themselves to be indepted to said Estate will make payment immediately, and those having claims will present them for settlement to: Jocelyn Stoppe, Executrix 501 Rupley Road Camp Hill, Pa. 17011 Advertising cost is $75.00 payable in advance. Make checks payable to: Cumberland Law Journal WEST SHORE EMS -ALS -I ~ '~ 205 GRANDVIEW AVE SUITE 211 t ~.~- ~- ~ ~' ~ ~ i CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: AVALON STOPPE INSURANCE: MEDICARE B 191148592D CAPITAL BLUE CROSS YWM80034931500 3099628A AVALON STOPPE 4905 E TRINDLE RD APT 28 MECHANICSBURG, PA 17050 PATIENT NUMBER: 69149 CALL NUMBER: 3099628A DATE OF CALL: 02/01/2008 TIME OF CALL: CALLER: ~~ V~VES ORE EMERGENCY" MEDICAL SERVK:ES MDEN C FROM: 4905 E TRINDLE RD APT 28 TO: HOLY SPIRIT HOSPITAL REASON(S) CARDIAC ARREST FOR TRANSPORT INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT PARAMEDIC INTERCEPT A0999 1.0 797.87 797.87 ANGIOCATH (14-24) A0394 1.0 5.78 5.78 ATROPINE 1MG A0394 1.0 5.13 5.13 EKG ELECTRODES (4PK) A0396 1.0 4.94 4.94 END TIDAL C02 DETECTOR ADULT A0422 1.0 18.51 18.51 ENDOTRACH TUBE A0422 1.0 3.30 3.30 ESOPHAGEAL INTUBATION DET BL A0396 1.0 15.51 15.51 ET TUBE HOLDER A0422 1.0 8.25 8.25 PERIPHERAL IV A0394 1.0 36.75 36.75 STYLET A0422 1.0 6.29 6.29 Total Charges 902.33 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~ $902.33 RETURNED CHECK FEE - $31.00 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE 902.33 PATIENT NAME: STOPPE, AVALON W CALL NUMBER 3099628A AMOUNT $ PATIENT NUMBER: 69149 BILLING DATE: 04/03/2008 ENCLOSED This account is now PAST DUE!! Payment must be received WITHIN 10 DAYS. Collection process will begin. ~ VISA ( 5 --`~ - AND MASTER CARD ACCEPTED WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 47011 DATE BALANCE .FORWARD T2/28/2007 01/14/2008 12/31/2007 01/15/2008 01/21/2008 02/01/2008 PAYMENT PAYMENT Wash Set Cond & Deep Condition Wash Set Cond & Deep Condition Pharmacy Charges Room, Board and Services CURRENT MONTH CHARGES CURRENT BALANCE DUE 6,153.94 (3, Q69..41; (3,084.53 24.00 24.00 189.87 2,909.00 Thank you for choosing Country Meadows of West Shore 3! 3,146.8.7 3,146.:7' :,~~~.,ease nc,l:,ude 'ahe trop portion o:f this bila .with :your payment .by -the 1~t=~' using the enc7o.sedenvelope.. Make youu check payabae ao Country • ~Ieadaws Associate -. r. _ _ .. '~-.~'or- ,.pharmacy .questions pl:ease contact '"Alert" -direct at .l-:8:00-.266-9:5:5~~' a ~, ., ° - '~I~sde~a `Na'me: .Avalon _Stoppe Account# : 8D~6~5:5 ' f '~` Statement :Date: '"02/O1/2'Q:08 "~• _...:3 - i ~ r{ 5 i'-..... DATE BALANCE FORWARD 02/29/2008 Meal Credit Bldg.3 CURRENT MONTH CHARGES CURRENT BALANCE DUE (50.00) Thank you for choosing Country Meadows of 'West Shore 3! 809..65 (50.00 759.65 ~~ease inc""lode t;he :toep tport:ion .af 'tYri~s .b.i1`1 with your _paym~i~.-t ~1~y "the ' :1;~~i- u;s~.ng °~t1ze ~en;c.losed 5envel.ape : 'Make ,you check `payable 'tQ Country . ,~. ~adaws: Ass:oci:ates.. ~'or ~~pharmacy ague<~tiQns pl--ease ~contaot"'Al-.ert~":direct ,at .1~-:8'QO-b2:66-_9954 s~dent ,'Name: :`Avalon„ :Stop~pe AGCOU .80:65=5 . Statement I1a e.: :03;/0.1 /.2D:08 .: , . , . - 5 ~ „~