HomeMy WebLinkAbout04-0387PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
also known as .~',~V'~ To:
Social Security
Register of Wills for the
County of (.L~,-c,~x~-~c~,,,i
Commonwealth of Pennsylvania
in the
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in 0,-dj fig ~ ~tC. d/~t ~t/f) Coun. ty, Pennsylvania, w~t]~
h 1 5' last family or principal residence at
(list street, number and municipality)
Decer~d~nt, then ,~ '~ /~ ,~
at /4/0/7 ~%/~/~-/7~ yea[s of age, died ~/Z_~ do
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not dOmiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
Petitioner after a proper search ha
the following spouse (if any) and heirs:
/~/////.~ Name
ascertained that decedent left no will and was survived by
Relatio~hip Residence ~
THEREFORE, petitioner(s)
appropriate form to the undersigned.
respectfully request(s)the grant of letters ~j.~idminis~l'ation i:~:'~.'e
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~
COUNTY OF ~~~ ss
The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
Sworn to or affirmedc~and subscribed
bef0~e me ,this_ ~ ~ ~_ day of
Estate of-~-~v ,~x<_ ~ ~¼e_\\ , Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW (~._ ~ ~..~l.. ,~0'~ ~9 , in consideration of the petition on
the reverse side hereo~f, satisfactory progf hayir~g, been p~g. sented before me,
IT IS DECREED that
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate of '~Y~"~
FEES
Letters of Administration ..... $
Short Certificates( ) .......... $
Renunciation ................ $
TOTAL
Filed ..~.. :~,~,.':. ~.~.C~.. A.D.
Register of Wi~s~ C'(~ -~~__t~
ATTORNEy (Sup. Ct. I.D. No.)
ADDRESS
PHONE
his. is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
I0!376-',
No.
Local Registrar
APR 0 8 2004
H105 143 Rev 2/87
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
NAME OF DECEDENT (First, Middle, Last)
,. Patrick B. Schell
AGE (Last B~thday)
67
COUNTY OF DEATH
,b. Cumberland
OECEOENT'S USUAL OCCUPATION KIND OF BUSINESS I iNDUSTRY ~VAS DECEDENT EVER N DECED~NT'S E~UCATION ~ MAR TAt STATUS - Married, ~ SURVIVING SPOUSE
.; ....................... . m ~,,~ ~m ~ "'.~ m c.~,. I oi~(~.~) ' I '
,,. tanager ,b. Velocity Expres~, ~ I' 7 '*'~) I ~ .... "~ 1,4 Married I I~lvita Grezor
213 North 36th Street [~%c~ ..... '"-~ ~., ~c.~.,.~,,,,.~, Hempen
Camm Hill Pa 17011
16 ~ O ~r rode)17b C P 17d
' I ' ~ ' ~ witch ~1 limits of
FATHER'S NAME (First, Middle La~
18. [~//~
(Type/Print)
20,. Alvita Sche].l
CERTIFICATE OF DEATH
STATE FILENUMBER ~ J
I SEX SOCIAL SECURITY NUMBER ' DATF~OP D6~TH (Moab, Day. Year
12 Male 13 171 - 28" - 14~
~TE OF BIRTH I BIRTHP~CE (Ci~ and IP~CE OF DEATH IC~ onl ....... inst~ti
(Mon~. Day. Ye~) / Sta~ or F~m~ C~) HO~T~: OIHE~:
~arch 12~3~7.~p Hill ~"~ ~'~
CI~. BORO. T~ OF ~TH [ FAClLI~ ~ME (lf ~O~ ~8til~, ~ve 8Eeet a~ num~) ~WA~ ~CEDENT OF HISPANIC ORIGIN? IRACE - Amed~n I~ian, ~ack, ~ite, eb
.,l~*~"' P~",~. ~c. J ,o. ~ite
MOTHER'S NAME.(First, .Mi(~le, Maiden Surname)
~,. Catherine Cameron
~NFOR~MA~N~T'S MAILING.ADD_RE_SS IStreet, City,Town, State, Zip Code)
12~. z~.3 North 3bth Street Camp Hill~ Pa 1701
[ P~iCnEefOFFi DIaceSPOSmON-Name o~ Cemetery Crematory ILOCAT ON-C4tyFl'own, Stale, Zip Code
12..
Rolling Green Cemetery 121d' Camp Hill, Pa
city/bo~O
DATE OF DISPOSITION
[k~atio~l ~] Burial D~emoval from Sl~e ~ (~ ...... Ye~)
I,,~prii 12,2004
O~ (S~) ~ .
Cl1654-L ,2~Myers-Ha~er Funeral Homelnc~ ,
LICENSE N~BER I~TE SIGNED
~Ys~useiS ~t~ ~.~l~e at ~ of ~a~ to (Sig~l~ ~ TEle) ~(M~lh, Day, Ye~)
2~b. ~ 2~c.
DATE PRON~NCEO O~O (Month, Day, Year) WAS CASE REFERRED TO A MEDICAL E~MINER/COR~ER?
IMMEDIATE ~USE (Fin~ ' ', ~set and dealh
~use. En~ UNDERLYING
reciting ~ ~a~ ) ~ST d "
WASpERFORMED?AN ~UTOPSY AVAI~BLE~RE AUTOPSYPRioRFINDINGSTo ~ MANNER OF ~ATH__ I~ (M~m,DATE ~,lNJURYyear TIME OF INJURY INJURY AT ~RK9. ~ DESCR BE ~W INJURY OCCURRED
-- I -- I ~1 ~~ON (SI~. Oty~n, Stete)
(11~ 27) Type ~ Pdnt
~la.
,,. N/,<*,' I ... FILED (M*,h, Day, Year)
MBNA America
P,O, Box 'tSZ37
Wilmington, DE
877-767-9383
19850-5137
REGISTER OF WILLS
CUMBERLAND COUNTY COURTHOUSE
1 COURTHOUSE SQUARE, #102
CARLISLE, PA 17013
05/24/04
'04 i-ifff 2~}
Re: In the Estate of
PATRICK B SCHELL
Probate Case No.
Social Security No:
Last known residence:
Our Client:
Account Number:
Amount of Debt:
21-04-387
171281432
213 N 36TH ST CAMP HILL, PA 17011
MBNA AMERICA
5490999017340919
$ 21955.13
Dear Sir or Madam
Enclosed please find a Creditor's claim to be filed in the record with the above-referenced Estate.
Please remm a file stamped copy of the claim in the enclosed self-addressed, stamped envelope. Thank you for
your assistance. If you have any questions or if this is a duplicate claim, please call our finn toll free at
1-877-767-9383.
Cordially,
MBNA America
Enclosures
A check for $5.00 for the filing fee.
cc: Attomey for Estate
Personal Representative
This letter is an attempt to collect a debt and any information obtained will be used for that purpose. This letter
is from a debt collector.
4479 5/19/2004 1126936
COMMONWEALTH OF PENNSYLVANIA
In Re: The Estate of:
COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY
ORPHANS' COURT DIVISION
NO TICE OF CLAIM
Cour~ File No: 21-04-387
PATRICK B SCHERI.
Deceased ~! ~.
TO: THE CLERK OF THE ORPHANS' COURT DIVISION:
Notice of claim by creditor, Pursuant to Section 3532(b)(2) of the Probate,
Estates, and Fiduciaries Code, 20 PA.C.S.A. §3532(b)(2).
MBNA AMERICA
1)
2)
Claimant's name:
Claimant's address:
3)
P.O. BOX 15137
WILMINGTON, DE 19850--5137
877-767-9383
Creditor listed below is the owner and holder of a claim in the amount of
$. 21955.13
4)
5)
The facts upon which this claim is based:
This claim is based on an account for credit evidenced by the attached
Affidavit of Account Stated.
Decedent's address: 213 N 36TH ST CAMP HILL, PA 17011
6) Date of Death' 04/06/04
7) That the claim arose prior to the death of the decedent on or about
8) That the claim is secured by.
On behalf of the claimant, ! do solemnly declare and affirm under the penalties of
perjury that they !nformation and representations made herein are true and correct
to the best of my knowledge, information and belief.
Dated:
~/ Lucille Roberts/dessica Lerbs~orized Representji~ive For MBNA America
Written notice of claim was given to Personal R~l~resentative'' an/~/or-- his/her counsel
as stated below:
ALVITA G SCHELL
Name
213 N 36TH ST
Address
CAMP HILL, PA 17011
City/Stat. eJ~ip .
Date notic~ ma~led
IN RE ESTATE OF:PATRICK B SCHELL
AFFIDAVIT OF ACCOUNT
The undersigned, being first duly sworn depose~.and states the follows:
Your Affiant is authorized by the Claimant as its Authorized Representative-
In-Fact to make this Affidavit.
Your Affiant has reviewed the account records of the Claimant with respect
to the decedent. Your Affiant is familiar with these records and accounts and
reviews them as a regular part of his/her duties.
o
The Decedent purchased merchandise in the amount of $ 21955.13
evidenced by account number 5490999017340919
The unpaid balance does not include any post-death late payment charges,
accrued interest, collection costs or attorney's fees.
Further your affiant sayeth not
MBNA America.
On, its Authorize)l/Represe~ntatives:
Lucille Roberts
Jessica Lerbs
MBNA America
P. O. Box 15137
Wilmington, DE 19850-5137
Subscribed and sworn before me
This 2¢ day of c~
,2004.
Cumberland County - Register Of wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 08/02/2004
SCHELL ALVITA G
213 N 36TH ST
CAMP HILL, PA 17011
RE: Estate of SCHELL PATRICK B
File Number: 2004-00387
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of Wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 08/01/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
GLENDA FARNER STRASBAUGH
Clerk of the Orphans' Court
CLAIM FORM
ORPHANS'
COURT OF
COURT DIVISION OF
COMMON PLEAS OF
COUNTY
PATRICK B. SCHELL
CUMBERLAND
NO. 21-04-387
ESTATE OF
Notice of claim by
in the amount of S 512.54
KOHL'S DEPT. STORE
filed pursuant to section 3384, Probate, Estates and
Fiduciaries Code LawB ot 1972, Act No. 104 effective July 1, 1972 as amended.
in the amount of S
KOHL'S DEPT. STORE
(Claimant and Address)
512.54
Data
Ci441 LBJ;{EEWAY
Lock Box ;'u
Dallas, TX 75243
19
TO TH~ CLERK OF THE ORP~S' COURT DIVISION:
Enter the claim of
against the above entitled Estate. The decsdent
who resided at
213 N. 36TH ST., CAMP HILL PA
(Address)
17011
4/6/04
died on
(Date)
ALVITA G. SCHELL
Written notice of said claim was given to
t
(Personal Representacive or Counsel)
at 213 N. 36TH ST., CAMP HILL PA 17011
(Address)
The basis of aforesaid claim is as follows:
on
(Date)
(Itemize fully to enable personal f~pre8entative
to make proper investigation).
";"
Acct. #0332188606
I
-..,..1
-~"'
'.'
C!
ClaLmant's Counsel
(Name)
" ~-,
/ eme)
441 ' FREEWAY
Lock ,; 30
[)a1lauira~) I :>,4;j
(Address)
J
PROBATE COURT
cumberland County, State of Pennsylvania
Patrick B. Schell, Deceased
Case #2l-04-387
Proof of Mailinq
I mailed the creditors claim to the fiduciary (and attorney, if applicable) as
follows:
I deposited a copy/copies of the t.:laim irlith tile Unit.ed States Postal Service in
a sealed envelope with the postage fully pre-paid. I used first-class mail. I
am employed in the county where the mailing occurred. The envelope(s) was/were
addressed and mailed as follows:
Ms. Alvita Schell
213 N. 36th St.
Camp Hill, PA l70ll
Date of Mailing:
~/
County of Mailing:
Dallas, Texas
I declare
of perjury that the foregoing is true and correct.
Date: .1
for
Kohl's Department Store
P.O. Box 741026
Dallas, TX 75374
.
Pry Bal:
pur/Adv:
Returns:
Fee/Int:
Cr/Dr
Pymnts :
CIs Bal:
SC8820/1 10/29/2004 KOHL'S ACCOUNT STATUS DISPLAY 10/29/2004 08:02 ID: KDD2
Acct, : 0332188606 52 Cycle: 90 Bi: 10/03/2004 Due: 10/28/2004 MVC: N VIP: N
St~ 90 601 CBS - DECEASED Op: 12/04/2001 Closed: 09/03/2004 Ins: N
Namel: PATRICK B SCHELL Home: 717 731 - 6155 W Pull:
Name2: Bus1: AScr:
Addr 213 N 36TH ST Srce: I 00000001 Emp: NScr:
R N cis : 39 10/28/2004 EMS Rstr:
CAMP HILL PA 170112606 AdChg: 01/03/2002 :
Instr: PRMENT dad 4-6-04
Pymnt H: 5432NMNMN-------F------- Dun H: 543210101000000000000000
Last Stmnt Curr Stmnt Auths Last Reage:
483.63 512.54 Av1 Credit:
Disputes
Last pymnt:
Cr Lmt E
Limit Ext :
MVC Pur
537.54 Issued Cards
384
766
5
06/04
12/01
05/04
-37.54
28.91
25.00
38.00 04/13/2004
500 10% 08/03/2004
512.54
537.54
Cnt Sts Issue date
Glenda Farner Strasbaugh
Register of Wills
and
Clerk of Orphans' Court
Marjorie A. Wevodau
First Deputy
Kirk S. Sohonage, Esq
Solicitor
Register of Wills and Clerk of the Orphans' Court
County of Cumberland
One Courthouse Square
Carlisle, PA 17013
(717) 240-6345
FAX (717)240-7797
INVOICE
Bill To:
InvoiceNo:
Invoice Date:
Estate of:
Estate No:
275
3/29/2005
PA1RICK B Sa-IELL
21-2004-0387
Alvita G. Schell
60 Rosemary Court
vz
Manchester, P A 17345
Qty
1
Fee Description
Additional Probate
Fee Total
32.00 $32.00
Total:
$32.00
(becks should be made payable to the Register of Wills. Terms: Net 30.
Please return one copy of this invoice with your payment. Thank you.
Glenda Farner Strasbaugh
Register of Wills
and
Clerk of Orphans' Court
Ma~orie A. Wevodau
First Deputy
Kirk S. Sohonage. Esq
Solicitor
Register of Wills and Clerk of the Orphans' Court
County of Cumberland
One Courthouse Square
Carlisle, PA 17013
(717) 240-6345
FAX (717)240-7797
INVOICE
Bill To:
Alvita G. Schell
60 Rosemary Court
InvoiceNo:
Invoice Date:
Estate of:
Estate No:
275
3/29/2005
PATRICK. B SGffiLL
21-2004-0387
"
Manchester, P A 17345
Qty
1
Fee Description
Additional Probate
Fee Total
32.00 $32.00
Total:
$32.00
'Pd
J
Lj-111
ql-f
Olecks should be made payable to the Register of Wills. Tenns: Net 30.
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 1712~1
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I-
Z
W
Q
W
(J
W
Q
FILE NUMBER
fli-i2!1
COUNTY CODE YEA.R
03B'2_
NUMBER
SOCIAL SECURITY NUMBER
1"1 - 2.5 -
THIS RETURN MUST BE FltEO IN otlPlICA TE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
;2bl -:; 303
~ 1. Original Return
o 4. Umned Estate
o 6. Decedent Died Testate (_copy ofWilO
o 9. Utigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale of death after 12-12.jl2)
o 7. Decedent Maintained a Uving Trust <AlIachcopyolTIUSl)
o 10. Spousal Poverty Credit (dale of dealh between 12-31-91 and H-95)
o 3. Remainder Return (dale of deafh prior to 12-13-82)
o 5. Federal Estate Tax Return Required
8. T olal Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (AllachSch0)
-':0;-;:"",::'.>,,,,
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Une 13)
'0
z
o
5
;::)
l-
ii:
<(
(.)
w
a::
1. Rea! Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation. Partnership or Sole-Pmprielorsljp
4. Mortgages & Notes Receivable (Schedule D)
5. Cash. Bank Deposns & MisceUaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Bilfing Requested
7. Inter-VIVOS Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (lotal Unes 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent. Mortgage Uabilitles. & Liens (Schedule I)
11. Tolal Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(1)
(2)
(3)
(4)
(5)
COMPLETE MAlUNG ADDRESS
00 R.CSf_VV\aR~
M ~ t'lc-hz:-s~",
j~~2
NDN IE
Nt)N~
.5 ~/S":93
"
/ 9{::>. ~OO. 00
/
NONe:;
~~
CDvr-T
(JA. 1,34..s--
(6)
(7)
{9)
(10)
(8)
/ffl%;;:tgf
(11)
(12)
/ 5 3 3 IS:-- 93
I
(13)
/q~ ,;ziP /. 0:2-
5joS<J:9/
fi/aA/c
50509
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES
15. Amount of Line 14 taxable at the spousal tax # 5" C) .,c- t" L rJ
rate, or transfers under Sec. 9116 (a)(1.2) ._____.._______._____.:::!_7~_.____j..L_.___ x .0 ~..- (15)
z
o
~
~
;::)
0..
:E
o
(J
><
i!
16. Amount of Line 14 taxable at 6neal rate
17. Amount of line 14 taxable at sibfing rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
~o-
x .0_ (16)
0-
. x .12
CJ-
'-0-
x .15
(17)
(18)
(19)
--0-
20.0
c:;.::~~:, ,K~.0.:r,y-""K.,,}':~:'?'Sf.(
""',~"-"
:J'U.
. ".l<'",,~?,
_,,-_<~_~__:E~?
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
'~::,"~!i:',~
. :..~S!..f;~~~-fff5<:~::?~ -;~h:/,
dt,":i{C:i";"\--:
Decedent's Complete Address:
STREET ADDRESS ;;J. t ~ I\J . Z> '=> ~
-~~---------_._----_._-
CITY
L-1.-
c.~
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
ZIP I,e \
-'0_
--~---
C.7
()
3. InteresUPenalty if applicable
D. Interest
E. Penally
Total Credits ( A + B + C ) (2)
-0.-
(3) -0-
(4) --0-
(5) -0 -
(SA) .-0-
(5B) - 0-
()
---~--~-_.~---~~ ._.._.._---_._------~-
d
TotallnteresUPenally ( D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
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
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........ ..................... ..................... ..................... .................... ..................... ........ 0
No
~
~
~
~
J8l
rEJ
l&I
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, ij is true, correct
and complete.
Declaration of preparer other than the personal representative is based on all infonnation of which preparer has any knowledge.
~~NA:1Z~... _~SB~:d;:J,;?,7Vn___.___________ ._____._._. ____ '-.r ----C--- ~.~~ ~s=-i~?"r
AOORESS ?, :e 9;; !// / - I') /75</'S /' ~ / _
SIGNATUREOF-P~PARER OTH~-;;:R~;:~.E (p.Zc..--7.--:L/ / ~~/~cL-~--J/l____ i~{- S-L~~'=?":"__
ADDRESS
For dates of death on or after July 1, 1994 and before January " 1995, the tax rate imposed on the net value oftransfers to or for the use ofthe surviving spouse is 3%
[72 P.S. 99116 (a) (1.1) (i)l,
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (i1)].
The statute does not exemDt 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 ch~d 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 ch~d is 0% [72 P.S. 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(l)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (6'00*
COMMONWEALTH OF PENNSYLVANIA
INHERfTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
.5 C \-\f-LL \ p~\ c.\<.. b. ~ \ 0 '-+ C>-~ 8,
All real property owned solely or as a tenant in common must be reported at fair market value. Fair marilet 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.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
5rCl"n:+.s Gt AP Hun" NGt Cf\'NI P
-:to% o{~s'J I 000.
L'bE:\\", "I f\t~L)
VALUE AT DATE
OF DEATH
" \ L.\oQ>
TOTAL (Also enter on line 1, Recapitulation) $
(If more space IS needed, Insert additional sheets of the same Size)
//t./tJp
DAVID A. WION
FRANCIS A. ZULLI
JEAN D. SEIBERT
LAW OFFICES
~gdli~~
109 LOCUST STREET
P.O. BOX 1121
HARRISBURG, PENNSYLVANIA 17108-1121
(717) 236-9301
(717) 232-1488
FAX (717) 236-6100
Email: wzs@mindspring.com
VICTOR A. BIHL
OF COUNSEL
113 EAST MAIN STREET
HUMMELSTOWN, PA 17036
(717) 566-2501
January 19, 2005
Carole S. Seneca
205 Paxtang Avenue
Harrisburg, PA 17111
Donna S. Justus-Meisel
1750 Towpath Road
Dauphin, P A 17018
Paul R. Dillman
3520 September Drive, Apt. #3
Camp Hill, PA 17011
Frank Greenawalt
5044 Erb Bridge Road
Mechanicsburg, P A 17050
Alvita Shell
213 North 36th Street
Camp Hill, PA 17011
Re: Sterrets Gap Hunting Camp - 1099 Form
Dear Carole, Donna, Alvita, Paul and Frank:
As you will no doubt recall from my letter to all of you of June 17, 2004, concerning
the settlement of the hunting camp, I had indicated, in relation to the income taxes resulting
from this sale, as follows:
"The original Deed of December 19, 1967 into Frank Greenawalt, Paul Dillman and
Albert J, Seneca, In Trust For Sterrets Gap Hunting Camp listed a consideration or payment
price of $600.00. This price would establish the capital gains "basis" for IRS purposes;
since there were no other improvements made to the property this would remain the basis
today. Since the property was sold for $57,000.00, the amount of capital gains would be
$56,400.00. Each of you would then have to consider $11,280.00 (except for Donna whose
capital gains would be $5,640.00 and Carole whose capital gain is governed by estate law),
as the amount of capital gains which would have to be considered in relation to your own
income tax return for the year 2004. This information ought to be supplied to whatever
individual or firm you utilize for your personal income taxes."
The law firm which handled the settlement for the purchaser, Doug Kuhn, i.e., the
law firm of Kathy Morrow (Attorney Charles F. Chenot, III) will be actually providing the
1099's to you based on the information I have provided to him. The 1099's for Alvita,
Paul and Frank will be in the amount of$11,400.00, the 1099 to Donna will be $5,700.00
and the 1099 to the estate of Donald A. Seneca will be $17,100.00. While those are the
amounts provided on the 1099' s, when you or whatever individual or firm you use for your
personal income taxes prepares your income tax, Alvita, Paul and Frank will put in the
"basis" the amount of$120.00; Donna will utilize the amount of $60.00 and Carole's
separate basis will be governed by the income tax relating to fiduciaries and estates, which I
will be handling.
Since I am supplying the information to Attorney Chenot's office this week I suspect
that you will be receiving your 1099's within the next few weeks.
If you have any questions do not hesitate to contact me.
V\ eryj truly yours,
t'~)
David A. Wion
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j SCHEDULE E j
I CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
j1lJHERITANCE TAX RETURN
RESiDENT DECEDE\~T
ESTATE OF
S~-H ELL. P~\R.'C'f(..b.
l loclude 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.
FILE NUMBER
~i OL-\ 0"3:>57
ITEM
NUMBER
:,2.
'Sc~ \J I nc, 6 Acc:::t~
(!..LOTH/N~ v.sJloZ5
50 - 0 ).--0 S- OC)-/ \
fJf\J c.:.. I6Ar0K
P i'-l c &.a.. ~ K
DESCRIPTION
CHELKIt0~ A-cct-d: 5 \-- '1 c38- ~-3 tog
~3
~:r)
L/ 6, V1J 6:) liE: ('h01 ~ 5~uc:/"~{).s-
s
HA/J LJ r- /Jc'pu'c:e 7Z' cJ LS
~ :J7~ qg.
TOTAL (Also enter on line 5, Recapitulation) $ 1'/5"5 i~ 93
(If more space is needed, insert additional sheets of the same size)
Total Banking Statement
PN C Bank
For the period 02120/2004 to 03/23/2004
E
F
H
PATRICK B SCHELL
ALVITA G SCHELL
213 N 36TH ST
CAMP HILL PA 17011-2606
Primary account number: 51-4038-3368
Page 1 of3
Number of enclosures: 11
Q For 24-hour banking, customer service and
interest rate information, sign-on to
'It Account Link ill bV Web on pncbank.com
or call1-888-PNC-BANK
Moving? Please contact us at 1-888-PNC-BANK
~ Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Q Visit us at pncbank.com
III TDD terminal: 1-800-531-1648
For hearing impaired client$ only
Relationship Overview
Bank Deposit Accounts
Description
Interest Checking
Savings
Total Deposits
Account Number
51-4038-3368
50-0205-0071
Deposit Balance
815.91
.02
815.9:l
Premium Plan
Interest Checking Account Summary
Account number: 51-4038-3368 Account Link@ number: 0171281432
Patrick B Schell
Alvita G Schell
Balance Summary
Please see the Activity Detail section for
additional information.
Beginning
balance
1,131.82
Deposits and
other additions
2,522.42
Checks and other
deductions
2,838.33
Average monthly
balance
442,86
Endi ng
balance
315.91
Charges
and fees
,00
Transaction Summary
Checks paidl
withdrawals
Check Card pas
signed lransactlons
Check Card/Bankcard
POS PIN transactions
11
o
Total ATlv\
transactions
PNC Bank
ATM transactions
Other Bank
ATM transactions
1
2
o
Activity Detail
Deposits and Othel' Additions
Date Amount Description
Dit'ect Deposit - Pension
Lasalle Bank N.A 171281432
Dit-ect Deposit - Soc Sec
US Tl"easury 303 261383038A
Deposit Reference Ko. 027825961
Funds Transfer From Acet 5002050071
Direct Deposit - Soe See
US Treasury 303 171281432A
Deposit Reference Ko. 024390348
03/01 168.39
03/03 67:'>.00
03/08 358.00
03/16 156.83
03/17 864.00
03/22 300.00
There were 6 Deposits and Other Additions
totaling $2,522.42.
Total Banking Statement
Q For 24-hour customer service information, sign-on to Account Link @
by Web on pncbank.com or call1-68B-PNC-BANK
Account number: 51.4038-3368 - continued
For the period 02120/2004 to 03/23/2004
PATRICK B SCHELL
Primary account number: 51-4038-3368
Page 2 of 3
Checks
Check
number
313
314
315
316
317
318
Amount
16981
7928
40.00
11200
39.08
26.41
Dale
paid
02/26
02/24
02/24
02/23
02/24
02/23
Reference
number
Check
number
025399896
026648161
026756675
E')94')B735
029080630
024778815
319
320
321
322
323
Date Reference
Amount paid numO'af
18289 02/23 028472977
13.85 02/24 028562834
34.90 03/04 0282850 18
442.04 03/11 026806893
400.00 03/16 026251634
* Gap in check sequence
There were 11 checks listed totaling
$1.540.26.
There was 1 Banking Machine Withdrawal
totaling $20.00.
Banking/Check Card Withdrawals and Purchases
Date Amount Description
02/23 27.58 POS Purchase Giant Food Sto Canlp Hill PA
03/01 20.00 ATM Withdrawal 4242 Carli;;le Pike Camp Hill PA
03/04 47.30 POS Purchase Giant Food Sto Camp Hill PA
There were 2 Check Card/Bank card PIN POS
purchases totaling $74.8B.
There were 5 Online or Electronic Banking
Deductions totaling $240.04.
Online and Electronic Banking Deductions
DatE! Amount Descrlpllon
03,/02 14.05 Direct Payment - 7-6452 Hap Ins 800-47
03,/03 99.00 Di.'ect Payment - Ins. Prem
Ad&D800-252-2148643945107
24.60 Direct Payment - Ins Prem AAA. Life 3970914901
83.67 Dil'ect Payment - Insurance
03/16
03/ 19
03/19
AARP Life Ins. .'\0895127
18.72 Direct Payment - Insurance
AARP Life Ins A0895128
Date
03/03
Amount
Description
There was 1 Other Deduction totaling
$963.15.
Other Deductions
963.15 Loan Payment 00000 4001008109332448
Daily Balance Detail
Date Balance Date Balance Date Balance Date Balance
02/20 1,131.82 03/01 589.51 03/08 464.11 03/19 515.91
02/23 782.94 03/02 575.46 03/11 22.07 03/22 815.91
02/24 610.73 03/03 188.31 03/16 245.70 -
02/26 440.92 03/04 106.11 03/ 17 618.30
Premium Plan
Savings Account Summary
Account number: 50-0205-0071 Account Link ill number: 0171281432
Patrick B Schell
Alvita G Schell
Please see the Activity Detail section for
additional information.
Balance Summary
8egl nning
balance
156.83
Deposits and
other additions
.02
Checks a nd other
deductions
156.83
Ending
balance
.02
Average monthly
balance
Charges
a nd fees
118.81
.00
Annual Percentage
Yield Earned (APYE)
Number of days
In interest penod
Average collected
balance for APYE
Interest Earned
this period
As of 03123, a total of $.09 in interest was
eamed this year.
Interest Summary
0.19%
33
118.81
.02
Total Banking Statement
Q For 24-hour customer service information, sign-on to Account link @
by Web on pncbank,com or call1-688-PNC.BANK
Account number: 50.0205-0071. continued
For the period 02120/2004 to 03/23/2004
PATRICK B SCHELL
Primary account number: 51-4038-3368
Page 3 of3
Activity Detail
Deposits and Other Additions
Date Amount Description
03/23 _02 Interest Payment
There was 1 Deposit or Other Addition
totaling $.02.
Date
03/16
Amount Description
156.83 Funds Transfer To Acct 5140383368
There was 1 Other Deduction totaling
$156.83,
Other Deductions
Daily Balance Detail
DatE!
02/20
Balance
156.83
Date
03/16
Balance
.00
Dale
03/23
Balance
.02
~~~cZI!i7dif
ESI+tft: C~'f)ic.- ~6t~'177t>
---
SUBJECT
FOLD HERE
DATE ~ _ i7- 0,/ I
/- Uj(; l1:f<'if ''&~FY'fl:~~.,,''L-
.3 rnll4. ~aFR-~
,1 \~~;~, l'ld:fL-s
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71 $ZS. 00 /!J7'14L
~~~~?'?;';;i' ;~'i;
IOO~ ~
FORM 61203 RAPIDFORMS. INC.. BELLMAWR. NJ 06031
--,: ,.st'W It -7'
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,
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/uft11 la" {~y,;:.;;
'4Oa State Roan. GOODS
Duncannon. PA )"020
Phonl!7X "?,S~~~" , ; "'~, "'J';~
""',., t.., ~ -,
Fa)' d;', 32:.';:
'l9i1t H"'-/.'( s-~;.~'
r:ntlu ~1"JnO'.> Dan.................._ ..._ __
1'.- ~-
REV'1509 EX+ (6-98)
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
5c H t:. LL) PAT R l C 1<. b ' :2 l 0 If O?J 8 7
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
ADDRESS
RELATIONSHIP TO DECEDENT
A. 5c \-'\ ELL J A LV IrA 6
d-\'~ tJ. =2>lo-1-h .:st-
L(-1-YY1 P tt I L1-, PR-. 170 \ 1
10 \ FE..
B.
C.
JOINTLY.OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF ANANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTL Y.HELD REAL ESTATE VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. J';I/.I2uf.J], ~\~ I\J.. :? Co +~ ~+- /.'3t/oor,) IrJO / :XI OtTO
CAMP H\LL\ PA~ 'i 0 II f I
PAl L/?:>AN 1< AC.A:.:fJi /f'~o/ 008/" 9 33:z.Lf. ~
.., A, Jllly1tff1 ,Cliff (i;Y-l..D ~r'j)Jt~ VAN t.~ 0/(10 Itl(.~) ~l/ 00
-,
TOTAL (Also enter on line 6, Recapitulation) $ /36, tlOC)
.. ,
(If more space IS needed, Insert addl\lonaJ sheets of the same size)
",~~'.y
Il;i~h"
~~,'i~~
COf\l~}ON\<'iiEAtTH OF P[\l:\JSYLVAN\A
INHERIT/I,M~E TAX RETURN
ESTATE OFS"'o. _" J
<.- If ~LL~ .
I
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ffl/IE'/CK. 6
Debts of decedent must be reported on Schedule 1.
FILE NUMBER
~j
O~-I
ITEM
0387
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES:
1. /'rv..' lz- 55-; c.r/!i-P S'e:, VI L J!~ 3 77:;-' c.' (l
Ca 6KE'f I G"?KdV::-'-//?1€ tC. . .. // 50 . '-'t')
/f..' ~ ...J.~ ~-L. A...I",;h-, -{, . CiE~) h ~b,h hi /. '-"<'.f);'E.5, 401, UCJ
.- ,
Ft.-,..,......,.. f'.~::'5
~J,.n bt /VW~/r:6~. .easi j,1uh.-.'8v .<./.:----( if?; 07/. () l.1
C":'"P"J '17:<. I t.-t c:;c 4- / I
.:L; f~f"'''?f ~,,;j-I;zr,: $-' 7t.J r ,I,{.i
B ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative{s)
Social Sewrily Number(s)IEIN Number 01 Personal Representative(s)
Street Address
City State ~Zip
Year(s) Commission Paid:
2 Attorney Fees
3. Family Exemption: (If decedent"s address is not the same as claimant"s, attach explanation)
Claimant
Street Address
Cify 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 Ime 9, Recapitulation) $ It) 51.) 7
(It more space IS needed, Insert additional sheets 01 the same size)
ROLLING GREEN CEMETERY
1811 CARLISlE 1tO. . CAMP HIll.. PA 17011 . (717) 761...405..5
N~ 005105
CEMETERY INTERMENT RIGHTS, MERCHANDISE AND SERVICES PURCHASEISECURITY AGREEMENT
THIS AGREEMENT PROVIDES FOR ENDOWMENT CARE
RETAIL INSTA. LLMENT CONTRACT Ii \ _ i l ~.. \;.
~ - --1l1l..!l~
This Agreement is made thiS~::,\ J (. dayof lip "I / . 20~, by and between the undersigned "Seller"
and ---1lJ '" I hl_ 9( :S( Ag{ ( ._ heremafier called the "Purchaser"
Address -------.11'.~~c() LJ 154 Lit tv' [0- !Yl.(CJ-lAIJiI:p,u~ fJfI-----.l70Y,)
ResidenceTelephoneNo.c_s:'-.l 7:3) - Io/~ cl'layTelephoneNo.L-) s.." ----z;p--
WITNESSETH THA T: The Seller agrees to sell and Purchaser agrees to buy the following described Interment Rights, Merchandise and Services.
o Developed 0 Predeveioped 0 Lot 0 Lawn Crypt 0 Mausoleum 0 Ni<;j1e . [J Q!her_
Description of Intenllent Rights: '- r L.j I L/ Ii {(f ~
No. !NTE~\1ENT RIGHTS, MERCHANDISE AND SERVICES
Intennent Rights (inc. $ ECF) $ Less:
Memorializ3tion - Type ~~NCc:
Size1</. )<./'1 Jl"ignW~'~I')(e?;I.
Memorial Base - Type C-1.P-{f-tJ{ 7 ~
Si,e~ X I'f; Color ::5""(~
Memorial Installation/Inspection Fce ..
Memorial ~aintenance
Casket - Description
Maleria]:WoodlMetal~ Gauge~
Outer Burial Container - Typ0'fif. ('vi'\. (I rl fL
Interment and Recording Fee..
~:~:SSi~~1-=; CL:'"/~~~;d'S'''
Away From Home Protection'''' Plan (see below)..
Sales Tax
(a) Total Cash Price ([neluding Sales Tax)
LJ copy
lie. # oq
Down Payment Cash ... ................../.......
cd-3 7/ fJ\j)
c )
($1/37/ejl::, )
-'::J -
/?/59 (j()
.3 8\l ,\);j
':)"'-' .\l'O
Credit For
(b) Total Down Payment..
(e) Unpaid Balance of Cash Price (Amount Financed)...
(d) Service Charge (Firumce Charge)
(e) Time Balance (Total of Payments)
(f) Time Sale Price..
$'l:),'/I \~
7'h .~'"
'ii"/'Il.I:.J\.\
4".~
~--
Remarks
I.
The Away From Home Protection Plan being purchased hereunder is a product provided by a third party, not by the cemetery identified in this Agreement. The third party
provider is nOI owned by or affiliated with the cemetery, and the cemetery is not responsible forthe perfonnanceofthe services associated with theAwtry From Home Protection
Plan. The Purchaser will be required to enter into a separate contract with the third party provider pertaining toAway From Home Protection Plan. That plan has been referenced
in this Agreement and included in the purchase price above solely for the convenience of the Purchaser in making payments.
ITEMIZATION OF AMOUNT FINANCED of $
Amount paid to others on your behalf: $
(we may be retaining a portion of this amount).
.$
to public officials, $'
shall be credited to your account with Seller.
to Assist America Prearrangement Services, Inc.
ANNUAL FINANCE Amount Financed Total of Payments Total Sale Price
PERCENTAGE CHARGE The amount of credit The amount you will have The total cost of your Jilif-
RATE The dollar amount the provided to you or paid after you have made aU chase on credit, inclu ing
The cost of vour credit credit will cost you. on your behalf. payments as scheduled. your down payment of
as a yearly rate. $ - (b)
- " (d) $ - (e) $ - (e)$ -- (a+d) $
"
Your payment schedule will be:
Number of Payments 1 Amount of Payments When Payments Are Due
I) Beginnin.g
One IS
Prepayment: If you payoff early, you will be entitled to a rebate of all or part of the Finance Charge.
Security: You an~ giving a security interest in the goods and property being purchased.
Late Charges: Ifful1 payment is not made within 15 days after it is due, you will be charged $5.00 or 5% of such payment, whichever is less.
Other Provisions: See this Agreement for any additional information about nonpayment, default, any required repayment in full (exclusive ofuneamed finance
charges) before the scheduled date, and prepayment rebates and penalties.
If accepted by Seller, the partles hereto agree to the followmg terms and condItIOns:
I. Agreement to Pay. Having first been quoted both a Total Cash Price and a Total Sale Price for the items described above, and for value received, the
undersigned Purchaser, jointly and severally, if more than one, promises to pay to the order of Seller, at its address shown below, the amount identified above
as the Total of Payments in accordance with the payment schedule dates set out above.
2. Title. Seller will retain title to said Interment Rights and Merchandise until the Total Sale Price has been paid by Purchaser to Seller.
3. Cemetery Rules and Regulations. Purchaser agrees that all rights conveyed under this Agreement are subject to. and Purchaser agrees to at all times
comply with, the present (and as may be hereafter adopted, amended or altered) Rules, Regulations and Bylaws of Seller, which are available for examination
in Seller's office.
4. Prepayment. Upon prepayment in full, whether voluntarily or upon acceleration by reason of Purchaser's default and payment in full or judgment being
entered against Purchaser for the unpaid balance, Purchaser shall receive a rebate of any unearned Finance Charge computed in accordance with the" Actuarial
Method" If the Total Sale Price is paid within 12 months of the date of this Agreement, or on or before its maturity if it matures in less than 12
months, Purchaser will be entitled to a full rebate of aD): Finance Charge.
5. Interment and Recording Fee. Unless otherwise specifically provided herein, a charge for opening and closing the interment space and applicable
cemete!)' document recording (herein referred to as "Interment and Recording Fee"), is not included in the Total Cash Price set forth herein, and there will
be an added charge for this service at the time ofnee~. lfth~ Interment and Recording Fee is purchased hereunder, the price set forth herein r~f1ccts normal
work hour rates. There will be an additional charge If the mterment service is provided on a weekend, holiday, or after normal work hours.
6. Issuance of Certificate ofInterment Rights. Upon payment of the Total Sale Price by the Purchaser, the Seller agrees to convey the above-described
Interment Rights by issuance of a Certificate of Interment Rights to the person(s) designated below:
NAME
ADDRESS
CITY
NAME
ADDRESS
CITY
NEXT OF KIJ\
Cily,St"t~.Zip
Phone
Notice to the Buyer - (1) Do not sign this Agreement before you read it or if it contains any blank spaces. (2) You are entitled to a
completely filled-in copy of this Agreement. (3) Under the law, you have the right to pay off in advance the full amount due and under
certain conditions to obtain a partial refund of the Sen:ice Charge.
NOTICE: BY SIGNING THIS AGREEMENT, PURCHASER IS AGREEING THAT ANY CLAIM PURCHASER MAY HAVE AGAINST
THE SELLER SHALL BE RESOLVED BY ARBITRATION AND PURCHASER IS GIVING UP BISfHER RIGHT TO A COURT OR JURY
TRIAL AS WELL AS HlSIIIER RIGHT OF APPEAL.
Buyer hereby acknowledges that this Agreement was completed as to all essential provisions before it was signed by Buyer and a copy
thereof was delivered to Buyer at the time this Agreement was signed.
Time tJ; 3(::, 0 AM fi4\P~source F5 Seller (Creditor):
Signed this ~ I day of , ii, lolli. SCI
The Internal Revenue Service does not quire your consent to any provision
of this document ot~th~anthe certifica~ns re ired to avoid backup withhol 'ng. J '\
Purchmr " ce.u...;z:::. /J .~ .$ /\)Nq
*S.S,l'.'. }L / '-- ~ 'if' 30 ;J-,J(" dt~;al:n ~Female Accepted
Co-Purchaser Counsel
Lla{~ olll..1b
*l'nder penalties of perjury, the Purchaser represents and warrants that the Social Security number shown on is Agreement is h or her correct identification number
and that he or she is not suhject 10 federal backup withholding or any order from the Internal Revenue Scniee that would require special reporling to the IRS b~' Seller.
If This Sale Was Solicited And Your Agreement To Purchase Was Made At A Place Other Than The Seller's Place of Business: YOL, THE BUYERl
MA Y CANCEL TIllS TR~"iSACTION AT AliY TIME PRIOR TO MlD~JGHT OF THE THIRD BUSINESS DA Y AFTER THE DA TE OF TIllS
TRANSACTION. SEE THE A IT ACHED NOTICE OF CAli CELLA TION FORM FOR A:'i EXPLANATION OF THIS RIGHT.
NOlICE: SEE OTHER SlOE FOR ADDITIONAL TERMS THAT ARE PART OF THIS AGREEMENT,
MYERS-HARNER FUNERAL HOME, INC.
1903 MARKET STREET
PO. BOX 291
CAMP HILL. PENNSYLVANIA 17011
ROBERT H. HARNER
SUPERVISOR
LOCALLY OWNED AND
OPERATED
TELEPHONE
717.737,9961
April 26, 2004
Mrs. Alvita G. Schell
213 North 36th Street
Camp Hill PA 17011
Services for Patrick B. Schell
April 12, 2004
Charges for Services Selected
Professional Services
Use of Facilities
Automotive Equipment
$ 3,775.00
$ 3,775.00
Charges for Merchandise Selected
Casket
Graveliner
$
550.00
600.00
$ 1,150.00
Cash Advanced
Newspaper Notice/Local
Clergy
Certified Copies
Flowers
$
85.00
100.00
30.00
186.00
Total due within thirty days, please:
$ 401.00
$ 5,326.00
ROLLING GREEN CEMETERY
1111 CAI1ISU! Ill. · CAMP "IU. PA 17011 . (7In761-4055
THIS AGREEMENT PROVIDES FOR ENDOWMENT CARE
CEMETERY I:'>ITER\lE:'>IT RIGHTS, :\tERCHANDISE AND SERVICES PURCHASEISEClJRlTY AGREEMENT
NTC
.J. .
802705
624 No.
\ CLDY :1;
Date: ~/ ~/ 0 'i
The undersi.gned. referred to as "Purchaser", hereby agrees to purchase the Interment Rights, :i\1erchandise and Services described
herein, subject to acceptance and approval of the above named cemetery, hereinafter referred to as "Seller".
A J vJA C; 5,-:-he--/f
;v. '3(,' D 5-.t-.
PURCHASER
TELEPHOl"E: 717- 73/- <;; I ;is
//J 170i /
ADDRESS
,;2. I '5
C-o?- VY. P' ;-h / )
/'
Zip
Stllfe
Cit)
StrC:et
:'<ameofDeceased Fe", 1-;.--,' c k
Description of Interme~t Rights: ; )
Issue Certificate of Interment Rights to:
,;J. :;;c~A e. ) /
4-/ !.fA
I
Address
----
Stre-et
City
Zip
Stille
~
INTERMENT RIGHTS, MERCHANDISE AND SERVICES
Interment Rights (including Endowment Care ofS
Interment Fees. .
Memorialization - Type
).. .
$
'670.00
Size
'Iemorial Base - Type
Size
Memorial Endowment Care of .
l\Jemorial InstallationJInspectinn Fee..
Outer Burial Container ~ 'Iaterial
Model
Cremation Charge.. .
Urn - Type
Flower Vase - Type
Nameplate ..
Lettering ...
Other
Other
Sales Tax. .
Design_..
Color
Supplier
Size
570,00
TOTAL CASH PRICE..
LESS:
<;/70,00
,f?5"
?7t?,OO>
...e-
DO\'fD Payment Cash ....
Other Credit.
Total Down Payment .'
UNPAIDBALAACE OF CASH PRICE .'
$
S<
$
REMARKS:
To
~!
he.
,Y~e/
TERMS - CASH SALE
The Total Cash Price is due and payable as of the date of this Agreement. A delinquency charge of percent will be
assessed monthly on any balance not paid within 30 days ofthc date of this Agreement. Ifless than full payment is received, Seller
shall deduct the accrued delinquency charge from the amount received, and credit the remainder of the payment received to the
Unpaid Balance.
SECURITY INTEREST: Seller (or its assigns) will have a security interest in the Interment Rights and Merchandise being
purchased as described above. Seller will retain title to said Interment Rights and Merchandise until the Total Cash Price,
together with any delinquency charges thercon have been paid by Purchaser to Seller.
Purchaser agrees that all rights conveyed under this Agreement are subject to, and Purchaser agrees to at all times comply with,
the present (and as may be hereafter adopted amended or altered) Rulcs, Regulations and Bylaws of Seller, which are availahle
for examination in Seller's office.
NOTICE: BY SIGNING THIS AGREEME:'IT, PURCHASER IS AGREEING THAT ANY CLAiM PURCHASER MAY Hi\. VE
AGAINST TIIE SELLER SHALL BE RESOLVED BY ARBITRATION AND PURCHASER IS GIVING UP HISIHER RIGHT TO A
COURT OR JURY TRIAL AS WELL AS HISIHER RIGHT OF APPEAL.
Signed this ?p day of /~'Y' I
Purchaser j (t~ .2J, >><t.d!---
Purchaser :;:;;c. 5ec.#;;2~ /? '3 /3.0 .5)
, 2 fJ .i1!:t-
IVi'Fe-
Relationship
Counselor:
Rei;ltloDship
elfz:::--
!\OTtU:: SEE OTHER slIn: FOR AlJDITlONAI. TERMS A'i\} eO'iDITIO!\S willen ARE PART OF THIS AGRFE'lE'iT
i'OR\1
I\F\
~: 211(i~ ~CI
U'
\'.:\11 i f: __ Cr;\'IFT?~Y UW', 'ITLL()\\ .l.,PPkO\'ED Ci_sn)\lER COpy I'I:\K CLST()~lI-R CCWl
LJ COpy
REV-1512 EX+ \12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF 'I' _ r, FILE NUMBER
.:sC.H I:=.. L L I r-'(:} ~ I c..l-<... [3. <~ \ '-0 t.{ - 038 -r
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
VALUE AT DATE
OF DEATH
ITEM
NUMBER
I(,~
I I.
f~ (C_T'lL q C\ (j 0 \ '1 :~+oc; let i7 d. I J q 5(:) DC
I~ (ct ,t;b I O()(>o I c\ I (.e '+c:l,3cZv 'J?l ri~1 433. (JC)
A (<:+ --ti: 400 I eCI is I () <1 :3d2L, tfS 1/ q c1 {:; cf~~ .i)O
~ /
//~:,~, (") c.~ ; /..f-'t :> 91
~.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DESCRIPTION
(" H f\ ':J t: ~ {~'Il. 0 .."\.u c.-- 1.Z~l\ N \~ I'\c. c+ ..:t:t-S i -, q '-IS~:2 S ::3 (J
.J.,
D I 5i C' ,) t ~ c ,0. {.~, D
,1,,~-t .d:. CcCl I , oo~'-H:;o~cl
,-I ....:d..:2 .-. .Z' . '0 ~- , .c:-
." c (,,\ ._/ -:) \.:) 8 <.oc\ ~,,~ 2-
7/
I. Sc{-q. 60
I
3.
,
I~D H LS c: I~ 1<20
*
l!>
t.o \ Ci 0 Gel
J
Y02.o(.)
Y.
f\~V\ C:J2( c A
1 (/:{) . 00
/ ~. (r b
- c'
521 6'. If)
;'7Lj 9~~
905 ;20
f\;l 01~(~
5,
t""j 'f..T k\ .~\ 1\ K
( \J t\ N.)
G.
()fJL '-'hANk-
7
Il/i-Jrrol/!4t.- ;Qcc.J!/o.j - V.J:n "jar
("1
-1.
/1 J /" / /' j' ./ , / 1 .f::tL /' - c-:-i-....]
j, C-(flS/7(") fer! 71ft.. 109/..( <.. L '>/.s,,} /'2/..-;.,v75 !-fl!.. /t.lt/ :J::.Jv-
. IV
j,,,,,<.Jhr/- r/. clc;.,I:.; Ii!!), Na;/ffi :J-}I-J7+Ug-I.., ~
/ 1t) fir' illlfcr. ,--I- ,,,:.- d; $(--, t.) ;t-: p'. {? K!.c'r Aar J Z Z. 71!:. 9Y
lizi {y .f;; r/-IIIo5;~~'. ,hJ? Jit (-1:/.1- Z Z (1 57,5:3 ~ ;{/
7',
TOTAL (Also enter on line 10. Recapitulation) $ /:3 7 ~9t/: t) 2-
(If more space IS needed. Insert addlbonal sheets of the same size)
PERSONAL CREDIT REPORT
SCHELL, PATRICK B
213 N 36TH STREET
CAMP HILL, PA 17011
SSN#: 171-28-1432
Reference #:
Password:
UEDPL-430053 ]
waApK6y6Y2
lU. mt.... 41~. Report from these
Credit Bureaus
Trans Union,
Equifax and
Experian
> - Derogatory' Ti~ades- - -- - -. . , -. : ~ _-.--.-:
Creditor Name
Historical Status
Past Due
Account Number
60
90 Last Past
FST USA BK B 11/01 05/94
546664030090 11/99
Late Dates: 60 SLOW-312000 30 SLOW-212000
CREDIT CARD, CANCELED BY CREDIT GRANTOR
12897
13500
o
REV
CURR 23 1 1 0
INDIV TRANS UNION-l
o
03/00
FIRST USA 11/01 05/94 13500 0 CURR
546664030090 06/00 REV INDIV
Late Dates: 60 SLOW-3/2000 30 SLOW-212000
PAID ACCOUNT 1 ZERO BALANCE, ACCOUNT CLOSED BY CREDIT GRANTOR
26 1 1 0
EQUIFAX-l
03/00
FIRST USA BANK N A
5466640300901070
Late Dates: 60 SLOW-312000 30 SLOW-212000
CREDIT LINE CLOSED-GRANTOR REQUESTED-REPORTED BY SUBSCRIBER, PAID ACCOUNT/ZERO
BALANCE, CURRENT ACCOUNTIW AS DELINQUENT 60 DAYS PAST DUE DATE, CREDIT CARD, TERMS
REV
11/01
05/94
CURR
13500
REV
INDIV
25 1 1 0
EXPERlAN-1
03/00
MBNA AMERICA BANK NA 10/99 04/97 0 CURR 31 2 0 0
042011323256 03/99 500 REV NOT-ASSOC EXPERIAN-l 02/99
Late Dates: 30 SLOW-211999 30 SLOW-I0/1998
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, CLOSED ACCOUNT,
CURRENT ACCOUNTIW AS 30 DAYS PAST DUE DATE TWO TIMES, CREDIT CARD, TERMS REV
Trades
Creditor Name T enns Current Status Historical Status Past Due
Times Past Due
Account Number eel. Type ECOA # Mo 30 60 90 Last Past
BANK AMERICA 08/99 06/94 75000 CURR 25 0 0 0 0
6020030543177 07/99 MTG JOINT TRANS UNlON-l
Loan Term: 360M
CONVENTIONAL RE MORTGAGE
BANKAMERIC 09/99 06/94 75000
6020030543177 08/99
FANNIE MAE ACCOUNT, PAID ACCOUNT 1 ZERO BALANCE
o
INST
CURR 40 0 0 0
JOINT EQUTFAX-l
UEDPL-4300531
Page 1 of 13
Trades (continued)
Creditor Name
Current Status
Account Number
ECOA # Mo 30 60 90 Last Past
Historical Status
Times Past Due
Past Due
BANK OF AMERICA MORTGA 09/99 06/94
6020030543177
75000
INST
CURR 31 0 0 0
JOINT EXPERIAN-l
Loan Term: 360M
AMOUNT IS ORIGINAL LOAN AMOUNT, PAID ACCOUNT/ZERO BALANCE, THIS IS AN ACCOUNT IN GOOD
STANDING, CONVENTIONAL REAL ESTATE LOAN, INCLUDING PURCHASE MONEY FIRST
BK1 DENAR 05/96 09/92 0 CURR 44 0 0 0
5348189996093259 10/92 REV JOINT EXPERIAN-1
INACTIVE ACCOUNT, TillS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
CBUSASEARS 03/04 01/95 126 0 CURR 24 0 0 0 0
512107188489 08/98 4400 REV INDIV TRANS UNION-1
CREDIT CARD
CBUSASEARS 03/04 01/95 0 CURR 78 0 0 0
512107188489 03/04 4400 REV INDIV EQUIFAX-I
CREDIT CARD
CBUSASEARS 03/04 01/95 0 CURR 85 0 0 0
5121071884896675 08/98 4400 REV INDIV EXPERIAN-l
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
CHASE 04/96 08/85 0 CURR 99 0 0 0
5465988610 2100 REV INDIV EXPERIAN-l
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, CLOSED ACCOUNT, THIS IS AN
ACCOUNT IN GOOD STANDING, CREDIT CARD, TEIUv1S REV
CHASE NA
,.\,5179452530
Loan Term: MIN
CREDIT CARD
03/04 09/02
1549
3200
1549 30 CURR 12 0 0 0
REV AUTHSPOUSE TRANS UNlON-1
o
CHASE NA
5179452530
CREDIT CARD
03/04
03/04
09/02
3200
1549 30 CURR 11
REV AUTHSPOUSE
o 0 0
EQUIFAX-l
CHASE 03/04 09/02 1549 30 CURR 12 0 0 0
5179452530 3200 REV AUTHSPOUSE EXPERIAN-l
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
CITI 06/02 12/87 0 CURR 48 0 0 0 0
412800230068 03/02 6700 REV INDIV TRANS UNION-!
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
CITI 06/02 12/87 0 CURR 99 0 0 0
412800230068 03/02 6700 REV INDlV EQUIFAX-I
ACCOUNT CLOSED BY CONSUMER
UEDPL-4300531
Page 2 of 13
Trades (continued)
Creditor Name Past Due
Account Number 60 90 Last Past
cm 06/00 03/98 0 CURR 27 0 0 0 0
412800392198 5000 REV AUTHSPOUSE TRANS UNlON-1
CREDIT CARD
cm 06/00 03/98 0 CURR 27 0 0 0
412800392198 03/98 5000 REV AUTHSPOUSE EQUIFAX-l
cm 06/00 03/98 0 CURR 28 0 0 0
412800392198 REV AUTHSPOUSE EXPERIAN-l
INACTIVE ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
cm 02/02 07/89 0 CURR 48 0 0 0 0
542418039428 12/01 3500 REV INDIV TRANS UNION-l
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
cm 02102 07/89 0 CURR 99 0 0 0
542418039428 07/01 3500 REV INOIV EQUIFAX-l
ACCOUNT CLOSED BY CONSUMER
cm 03/02 07/89 0 CURR 99 0 0 0
542418039428 12/01 0 REV INDIV EXPERIAN-l
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, CLOSED ACCOUNT, THIS IS AN
ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
cm Il10 1 03/98
542418053835 5000
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
CITI IlIO 1 03/98
542418053835 09/01
ACCOUNT CLOSED BY CONSUMER
o CURR 07 0 0 0
REV AUTHSPOUSE TRANS UNION-I
o
5000
o CURR 07 0 0 0
REV AUTHSPOUSE EQUIFAX-I
cm 12101 03/98 0 CURR 09 0 0 0
542418053835 0 REV AUTHSPOUSE EXPERIAN-l
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, CLOSED ACCOUNT, THIS IS AN
ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
CITl-TEXACO 05/03 03/97 0 0 CURR 48 0 0 0 0
1181 ]6 05/98 1600 REV JOINT TRANS UNION-l
CREDIT CARD, CLOSED
TXACO/CITl 05/03 03/97 1600 0 CURR 19 0 0 0
II 8 1168582 05/98 REV JOINT EQUIFAX-l
PAlD ACCOUNT / ZERO BALANCE, CREDIT CARD
TXACO/CITI 05/03 03/97 CURR 20 0 0 0
1181168582 1600 REV JOINT EXPERIAN-l
PAlO ACCOUNTIZERO BALANCE, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
UEDPL-4300531
Page 3 of 13
Trades (continued)
Creditor Name
Past Due
60 90 Last Past
Account Number
.~IilIIW~ FIN
601 100246029
Loan Term: MlN
CREDIT CARD
03/04 09/00
02/04
...,:' 6190 246 CURR 48 0 0 0
6000 REV AUTHSPOUSE TRANS UNION-I
o
DISCOVR CD
601100246029
CREDIT CARD
03/04
03/04
09/00
6190
6190 246
REV
CURR 42 0 0 0
AUTHSPOUSE EQUIFAX-I
DISCOVER FINANCIAL SVC 03/04 09/00 6 I 90 6190 246 CURR 43 0 0 0
601100246029 02/04 REV AUTHSPOUSE EXPERIAN-I
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
r \ St?tb~nDlSa~;\I,ER.FIN 07/01 10/91 0
..J 601100272852 10/98 7400
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
o
REV
CURR 18 0 0 0
JOINT TRANS UNION-I
o
DISCOVR CD 07/01 10/91 0 CURR
601100272852 05/01 REV JOINT
ACCOUNT CLOSED AT CONSUMERS REQUEST, PAID ACCOUNT / ZERO BALANCE
99 0 0 0
EQUIFAX-I
DISCOVER FINANCIAL SVC 05/01 10/91 CURR 24 0 0 0
601100272852 7400 REV JOINT EXPERIAN-I
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, PAID ACCOUNT/ZERO
BALANCE, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
DISCOVER FIN 04/04 07/00 2204 0 CURR 45 0 0 0 0
601130023015 07/02 4900 REV AUTHSPOUSE TRANS UNION-I
CREDIT CARD
DISCOVR CD 04/04 07/00 2204 0 CURR 45 0 0 0
601130023015 04/04 REV AUTHSPOUSE EQUIFAX-I
CREDIT CARD
DISCOVER FINANCIAL SVC 04/04 07/00 0 CURR 44 0 0 0
601130023015 07/02 4900 REV AUTHSPOUSE EXPERIAN-I
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
DISCOVER FIN 11/95 04/92 80
601130066850 08/94 7500
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
o UNRATED 0 0 0
REV JOINT TRANS UNION-I
o
DISCOVR CD 11/95 04/92 7500 0
601130066850 08/94 REV
PAID ACCOUNT / ZERO BALANCE, ACCOUNT CLOSED BY CONSUMER
CURR 42 0 0 0
JOINT EQUIFAX-I
DISCOVER FINANCIAL SVC 08/94 04/92 CURR 29 0 0 0
601130066850 7500 REV JOINT EXPERIAN-I
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, PAID ACCOUNT/ZERO
BALANCE, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
UEDPL-4300531
Page 4 of 13
Trades (continued)
Creditor Name Current Status Historical Status Past Due
Times Past Due
Account Number ECOA #Mo Last Past
30 60 90
FRD MOTOR CR 03/96 05/93 9567 0 CURR 0 0 0 0
JJA2755BX3 04/94 INST JOINT TRANS UNION-I
Loan Term: 48M
AUTOMOBILE
FMCC 02/96 05/93 9567 0 CURR 33 0 0 0
JJA2755BX3 02/96 INST JOINT EQUIF AX-I
PAID ACCOUNT / ZERO BALANCE
FORD CRED 12/95 05/93 9567 CURR 32 0 0 0
JJA2755BX3 INST JOINT EXPERlAN-l
Loan Term: 48M
AMOUNT IS ORIGINAL LOAN AMOUNT, PAID ACCOUNTIZERO BALANCE, THIS IS AN ACCOUNT IN GOOD
STANDING, AUTO LOAN
FST USA BK B 12/99 02/98 9000 0 CURR 23 0 0 0 0
479133800205 9000 REV AUTHSPOUSE TRANS UNION-I
CREDIT CARD
FUSA NA 12/99 02/98 0 CURR 22 0 0 0
479133800205 05/99 9000 REV AUTHSPOUSE EQUIFAX-l
CREDIT CARD
FIRST USA BANK N A 04/00 02/98 9000 CURR 12 0 0 0
479133800205 REV AUTHSPOUSE EXPERIAN-l
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, PAID ACCOUNT/ZERO
BALANCE, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
FUSABK NA 03/04 01/00 0
424631127403 4500
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
o
REV
CURR 38 0 0 0
INDlV TRANS UNION-l
o
FUSABANKNA 03/04 01/00 4500 0 CURR
424631127403 03/02 REV INDlV
ACCOUNT CLOSED AT CONSUMERS REQUEST, PAID ACCOUNT / ZERO BALANCE
50 0 0 0
EQUIFAX-I
BANK ONE 03/04 01/00 4500 CURR 50 0 0 0
4246311274035051 REV INDlV EXPERIAN-l
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, CLOSED ACCOUNT, THIS IS AN
ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
GECAF/MBGA
44808222929
07/98 04/98
06/98
880
7500
o
REV
CURR 04 0 0 0
INDlV TRANS UNION-l
o
GECAF/GECC
CG6H4480-8222929
07/98 04/98
06/98
880
o
REV
CURR 03 0 0 0
INDIV EQUIFAX-l
GECAF/MCCBG 07/98 04/98 0 CURR 05 0 0 0
CG6H4480822 06/98 7500 REV INDIV EXPERIAN-I
INACTIVE ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, REVOLVING CHARGE ACCOUNT
UEDPL-4300531 Page 5 of 13
Account Number DLA ECOA
HDMBGNCDTCR 04/97 04/97 0 0 UNRATED 0 0 0 0
79510025830 5000 REV JOINT TRANS UNION-I
HOMED/MBGA 04/97 04/97 0 UNRATED 0 0 0
CG327951-0025830 04/97 REV JOINT EQUIFAX-l
HHLD BANK 05/96 03/87 0 CURR 99 0 0 0
3148352 REV INDlV EXPERIAN-l
INACTIVE ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
HHLD BANK 03/00 03/87 0 0 CURR 27 0 0 0 0
848752 4000 REV INDIV TRANS UNION-I
LINE OF CREDIT, ACCOUNT CLOSED BY CONSUMER
HHLD BANK 03/00 03/87 4000 0 CURR 99 0 0 0
03848752 11/97 REV INDlV EQUIFAX-I
PAID ACCOUNT / ZERO BALANCE, LINE OF CREDIT
HHLD BANK 01198 03/87 CURR 99 0 0 0
848752 REV INDlV EXPERIAN-l
PAID ACCOUNT/ZERO BALANCE, THIS IS AN ACCOUNT IN GOOD STANDING, CHECK CREDIT OR LINE OF
CREDIT
JUNIPER BANK
5140210002
CREDIT CARD, CLOSED
03/04 12/01
o
5000
o CURR 26 0 0 0
REV AUTHSPOUSE TRANS UNION-I
o
JUNIPER BK 03/04 12/01 5000
514021000276 02/04
PAID ACCOUNT / ZERO BALANCE, CLOSED ACCOUNT
o CURR 25 0 0 0
REV AUTHSPOUSE EQUIFAX-l
JUNIPER BANK 03/04 12/01 CURR 27 0 0 0
5140210002 5000 REV AUTHSPOUSE EXPERIAN-l
CREDIT LINE CLOSED-GRANTOR REQUESTED-REPORTED BY SUBSCRIBER, PAID ACCOUNT/ZERO BALANCE,
THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
KOHLS DEP ST
33218860652
Loan Term: MIN
CREDIT CARD
03/04
02/04
12/01
408
1200
398 19
REV
CURR
INDIV
36 0 0 0
TRANS UNION-l
o
K.OHLS
33218860652
CREDIT CARD
04/04 12/01
04/04
1200
402 20
REV
CURR 27 0 0 0
INDlV EQUIFAX-l
KOHLS 04/04 12/01 402 20 CURR 28 0 0 0
033218860652 02/04 1200 REV INDIV EXPERIAN-l
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
UEDPl-4300531
Page 6 of 13
Trades (continued)
Creditor Name
Date Date High
Re crted Opened Credit
Account Number
DLA
Credn
Limit
M W ARDIMBGA
14114970816
03/95 07/91
o
1700
o UNRATED 0 0 0
REV lNDlV TRANS UNION-\
o
MONTIWARD 03195 07/91
CP8P1411-4970816
PAID ACCOUNT 1 ZERO BALANCE
o UNRATED 41 0 0 0
REV INDlV EQUlFAX-l
MW ARDIMBGA 04/96 07/91 0 CURR 59 0 0 0
CP8PI411497 REV INDlV EXPERIAN-I
INACTrvE ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING. REVOL VING CHARGE ACCOUNT
MBGNHECHING 05/96 05/96 0 0 UNRATED 0 0 0 0
50392776907 2000 REV JOINT TRANS UNION-l
HECHI/MBGA 05196 05/96 0 UNRATED 0 0 0
CG4D5039-2776907 05/96 REV JOINT EQUIFAX-l
MBGNJC PENNEY 04/96 12/9\ 76 0 CURR 53 0 0 0
767378771 01193 REV COMAKER EXPERlAN-l
INACTIVE ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, REVOLVING CHARGE ACCOUNT
MBNAAMERICA 03/04 08/96 21956 21956 413 CURR 48 0 0 0 0
999017340919 03/04 2\000 REV !NDIY TRANS UNION-I
Loan Tenn: MIN
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
MBNAAMER 03/04 08/96 21956 413 CURR 64 0 0 0
999017340919 03/04 20700 REV INDIV EQUIFAX-l
CREDIT CARD
MBNA AMERICA BANK NA 03/04 08196 2\956 21956 413 CURR 92 0 0 0
999017340919 03/04 REV INDIV EXPERIAN-I
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
MBNA AMERICA 05103 12/97 719
294027059890 04/03 18700
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
o CURR 47 0 0 0
REV AUTHSPOUSE TRANS UNION-l
o
MBNA AMER
294027059890
CREDIT CARD
05/03 12197
04/03
18700
o CURR 65 0 0 0
REV AUTHSPOllSE EQUIFAX-I
MBNA AMERICA BANK NA 04/04 12197 0 CURR 77 0 0 0
294027059890 04/03 18700 REV AUTHSPOUSE EXPERlAN-l
OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
REV
CURR
INDIV
16 0 0 0 0
TRANS UNION-I
MBNA AMERICA 02/03 11/01 0
297967796504 6000
CREDIT CARD, ACCOUNT CLOSED BY CONSUMER
UEDPL-4300531
o
Page 7 of 13
Trades (continued)
Creditor Name
Account Number
MBNA AMER 02/03 11101 6000
297967796504 11101
ACCOUNT CLOSED BY CONSUMER, CREDIT CARD
CURR 15 0 0 0
INDIV EQUlFAX-l
o
REV
MBNAAMERICA BANK NA 02/03 11101 0 CURR 15 0 0 0
297967796504 6000 REV INDlV EXPERIAN-J
CREDIT LINE CLOSED-CONSUMER REQUESTED-REPORTED BY SUBSCRIBER, CLOSED ACCOUNT, THIS IS AN
ACCOUNT IN GOOD STANDING, CREDIT CARD, TERMS REV
03/04
03/04
07/99
23360
6433 433
INST
CURR
48 0 0 0
TRANS UNION-l
~ MfBANKES
10000191640130001
,td k\ ( Loan Term: 12M
AUTOMOBILE
M&TlL
r 10000191640130001
\ AUTO
\ . M&TBANK
~ 10000191640130001
Loan Term: 12M
AMOUNT IS ORIGINAL LOAN AMOUNT, OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, AUTO
LOAN .
INOlV
03/04
03/04
07/99
23360
6433 433
INST
56000
EQUIFAX-I
CURR
1N00V
02/04
01/04
07/99
23360
7170 433
INST
CURR
57 0 0 0
EXPERIAN- J
INOlV
OCWEN FSB 05/03 08/99 95000 0 CURR 42 0 0 0
35052745 06/02 MTG JOINT TRANS UNION-I
Loan Term: 360M pJ-J .~ \~.t-
REAL ESTATE, CLOSED
OCWEN FED 06/02 08/99 95000 0 CURR 31 0 0 0
35052745 05/02 INST JOINT EQUIFAX-I
REAL ESTATE MORTGAGE
OCWEN FEDERAL BANKlQC 06/02 08/99 95000 CURR 18 0 0 0
. 35052745 INST JOINT EXPERIAN-I
\ I Loan Term: 30M
\I AMOUNT IS ORIGINAL LOAN AMOUNT, PAID ACCOUNTIZERO BALANCE, THIS IS AN ACCOUNT IN GOOD
STANDING. REAL ESTATE SPECIFIC TYPE UNKNOWN
~
\ ilY
'\ V.;'if
\:~
PNC BANK,.
4001008109332448
Loan Term: 180M
HOME IMPROVEMENT
03/04
03/04
06/02
bC
107305 -- 99.686
) ,
963
INST
CURR 22 0 0 0
PARllC1PAT TRANS UNION-I
PNC BANK
400J 0081 09332448
HOME IMPROVEMENT LOAN
02104
02104
06/02
107000 loqooO 963
INST
CURR 20 0 0 0
COIvIAKER EQUIFAX-I
UEDPl-4300531
Page 8 of 13
o
I
O'fJ 1'"
l'A}w11 V~ I
rrrlP ( .
~ ' f!{~/(
o
~/ )p./
VjiU
r
,
f}f
o
~
~
Trades (continued)
Creditor Name
Historical Status
Times Past Due
Current Status
ECOA # M 30 60 90 Last Past
Account Number
PNCBANK 03/04 06/02 107305 99686 963 CURR 22 0 0 0
,I0---/' 4001008109332448 03/04 INST COMAKER EXPERIAN-l
0t.. /r ,.///'""" Loan Term: 180M
~ AMOUNT IS ORIGINAL LOAN AMOUNT, OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING, HOME
. IlI1PROVEMENT LOAN
~~.=.:..::-:-~
II
;(
PNC BANK 06/95 12/92
~o.QQQlLOQ~2Q.Ql8.~~ 06195
REAL_E~TATE.M~~~fGAGE~
PNC BANK 06/95 12/92
40000000420018558 06/95
(~PAID ACCO~1 ZE~O BAL~:;
PNCBANK 07/95 12/92 24697 0
40000000420018558 INST
Loan Term: 120M ,/ ------- _
AMOUNT IS ORIGINAL LOAN AMOUNT, PAID ACCOUNT/ZERO BALANC/VTHIS IS AN ACCOUNT IN GOOD
STANDING, REAL ESTATE MORTGAG~~d(LATERAL. USUALLY A SECOND
MORGAGE
24697
o
CURR
o 0 0
TRANS UNlON-1
MTG
MAKER
24697
o
CURR
30 0 0 0
EQUIFAX-I
INST
MAKER
./l
/
CURR
32 0 0 0
EXPERIAN-l
MAKER
PNC BANK
40000008006552713
/---~ Term: 60M
CAUTOM~L~ CLOSED
07/99 08/96
07/99
17200
o
CURR 24 0 0 0
INDlV TRANS UNlON- I
INST
PNC BANK 07/99 08/96
AQQO{)OQ8-.O!!..~552-'ZJ.L____ 06129
',--- PAID ~UNT I ZERO BALANCE, AUTo--;,
PNCBANK 07/99 08/96 17200 CURR 35 0 0 0
40000008006552713 INST INDlV EXPERlAN-l
~erm: 60M -~'-----..._--.-.._- .....-----,
( AMOUNT IS ORIGINAL LOAN AMOUNT, PAID ACCOUNT/ZERO BALANCE/THIS IS AN ACCOUNT IN GOOD
---2!'ANDING, AUTO L()_~--- --' --"
--- -. -
17200
o
CURR
35 0 0 0
EQUlFAX-J
INST
INDIV
PNC MORTGAGE 02/96 06/94 75000 0 CURR 0 0 0 0
1550090305389 01196 MTG JOINT TRANS UNION-I
Loan Term: 360M
CONVENTrONAL RE MORTGAGE, TRANSFERRED TO ANOTHER LENDER
WAMUTUHM 02196 06/94 75000 0 CURR 09 0 0 0
1550090305389 01/96 INST JOINT EQUIFAX-l
TRA VLRS ACPT 08/95 04/95 9298 0 CURR 0 0 0 0
20591 INST lNDlV TRANS UNION- I
UNSECURE~
UEDPL-4300531
Page 9 of 13
Past Due
, /;tL./
't'r~~
OC)
.:.
)
rei
L)
_ i ~
f1'"
Trades (continued)
UGI CORP
217561380024
UTILITY COMPANY
01/04 06/94
12/03
40
Historical Status Past Due
Times Past Due
30 60 90 Last Past
0 CURR 11 0 0 0 0
OPEN INDIV TRANS UNlON- 1
0 CURR 10 0 0 0
OPEN INOlV EQUIFAX-l
Creditor Nwne
Account Number
UGI CORP
2 I 7561380024
UTILITY
01/04 06/94
12/03
40
UGI UTILITIES INC
217561380024
Loan Term: 1M
AMOUNT IS ORIGINAL LOAN AMOUNT, OPEN ACCOUNT, THIS IS AN ACCOUNT IN GOOD STANDING,
UNKNOWN - CREDIT EXTENSION, REVIEW, OR COLLECTION
03/04
02/04
06/94
40
30
CURR
INST
INOlV
13 0 0 0
EXPERIAN-I
WELLS FARGO 10/98 05/94 13500 0 CURR 15 0 0 0 0
541037873666 09/98 13500 REV INOlV TRANS UNlON-1
CREDIT CARD, TRANSFERRED TO ANOTHER LENDER ~ ~L
WFB CD SVC 10/98 05/94 13500 0 CURR 52 0 0 0
541037873666 09/98 REV INOlV EQUIFAX-l
ACCOUNT TRANSFERRED OR SOLD, CREDIT CARD ~-.....-c-9-~_
Account Number
Client
Credit Limit
ECOA
~)
!
,I
NATL RECOVER 01103 12/02 160
36293128 VASCULAR ASSOCIATES
DATE OF LAST ACTIVITY WITH ORIGINAL CREDITOR: 12/0112002
PLACED FOR COLLECTION
160
o
COLL ACCT
lNDlV TRANS UNION-l
~
i
n i NATIONAL RECOVERY AGEN 01103 12/02 160 160 I CHG OFF 160
,'( \ 36293128 VASCULAR ASSOCIATES INDlV EXPERIAN-l
rf 1)'0- ' AMOUNT IS ORIGINAL LOAN AMOUNT, ACCOUNT SERIOUSLY PAST DUE DATE/ACCOUNT ASSIGNED TO
(l./"'"' ~ ATTORNEY, COLLECTION AGENCY, OR CREDIT GRANTOR'S INTERNAL COLLECTION DEPARTMENT,
---- ,COLLECTION DEPARTMENT/AGENCY/ATTORNEY
'-
NATIONAL RECOVERY 01103 12/02 160
36293128 VASCULAR ASSOCI
DATE OF LAST ACTIVITY WITH ORIGINAL CREDITOR: 06/01/2002
UNPAID
160
INDIV
CHG OFF
EQUIFAX-l
160
Public Record Information
No Public Records exist on this report.
Inquiries
PNC BANK
5/28/2002
TRANS UNION-I
UEDPL-4300531
Page 10 of 13
Pennsylvania Gastroenterology Consultants
899 Poplar Church Road
Camp Hill, PA 17011
(717)763-0430 Fax (717)763-9854
July 29, 2004
PatrickB Schell
213 N 36th Street
Camp Hill, PA 17011
Re: Account: 100552 Patrick B Schell
Dear Schell:
Re: Overdue balance of$18.96
We have exhausted all efforts in trying to contact you. Since we have not had any explanation for your non-
payment, we have no alternative but to prepare your account for further collection activity, small claims
court, and possible TRW reporting.
So that this matter can be resolved, make payment immediately. If you would like to pay your account by
credit card, complete the section below and return this letter to us.
Thank you for your prompt attention to this matter.
Sincerely,
VIVIAN SLAGLE
Collections Department
Re: Account: 100552 Patrick B Schell
_ I will contact my insurance company immediately to [md out why the claim hasn't been paid and then
call your office.
Your records must be wrong. I paid $
on this date
with check #
_ Your records are correct, my check is enclosed.
PLEASE CHARGE MY CREDIT CARD
Visa
Mastercard
AMOUNT AUTHORIZED
Account #
Expiration Date
Signature
l..._....__A......_...~..__'IIII._.._a___.._
TIMOTHY A. CLARK, MD LLC
5 WILLOW MILL PARK RD #1
MECHANICSBURG, PA 17050
Page No.: 1
Tax I.D. 562382216
Tel: 888/624-3704
Patient: SCHELL,PA TRICK
STA1'EIIIENT DATE MY1lIIS AMOUNT ACCOUNT NO.
07/12/04 $ 218.90 21474878 - 1
!
'SHOW AMOUNT $
PAID HERE
SCHELL, PATRICK
213 N 36TH ST
CAMP HILL,PA 17011
TIMOTHY A. CLARK, MD LLC
5 WILLOW MILL PARK RD #1
MECHANICSBURG, PA 17050
o Please check box if above adoress is incorrect Dr insurance .
information has chall!llld. and InolCale changl:(s) on r&ver5e Sloe.
Place Codes: IH:;:;ln Patient OH:;:;Out Patient
STATEMENT
PLEASE DETACH AND RETURN TOP PORTION WITH
YOUR PAYMENT IN ENCLOSED ENVELOPE
ER:;:;Emergency Room
Date ICD9 CD PL* Description Amount Balance
Balance forward 0.00
04/05/04 518.81 IH 99291 CRITICAL CARE, (74 400.00 119.68
04/21/04 MED MEDICARE PAYMENT -78.71
04/21/04 MCDD MEDICARE DEDUCT NOT 100.00
04/21/04 MCDS MEDICARE DISALLOWANC -201. 61
04/05/04 -
04/05/04 518.81 IH 99292 CRITICAL CARE, ADD 400.00 39.69
04/21/04 MED MEDICARE PAYMENT -158.77
04/21/04 MCDS MEDICARE DISALLOWANC -201. 54
04/06/04 518.81 IH 99291 CRITICAL CARE, (74 400.00 39.68
04/22/04 MED MEDICARE PAYMENT -158.71
04/22/04 MCDS MEDICARE DISALLOWANC -201.61
04/06/04 518.81 IH 99292 CRITICAL CARE, ADD 200.00 19.85
04/22/04 MED MEDICARE PAYMENT -79.38
04/22/04 MCDS MEDICARE DISALLOWANC -100.77
-~_. --.- - - .-_. .-...- -
Current Amount Past Due Amount I Please Pay This Amount: I $ 218.90
$ 0.00 $ 218.90 TIMOTHY A. CLARK MD LLC
YOUR ACCOUNT IS SERIOUSLY DELINQUENT! ANY FURTHER
DELAY IN PAYMENT MAY CAUSE YOUR ACCOUNT TO BE
REFERRED FOR COLLECTION.
5 WILLOW MILL PARK RD #1
MECHANICSBURG. PA 17050
Tax I.D. 562382216
Tel: 888/624-3704
Patient: SCHELL,PATRICK
~T4TI=MFNT
r
MOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT STREET
WORMLEYSBURG, PA 17043
174.96*
Address Service Requested
MC VISA Disc
Cardlf-=-- -=- _ _ Exp _/_
Signature
*******AUTO**3-DIGIT 170
20108
PATRICK B SCHELL
213 N 36TH STREET
CAMP HILL PA 17011-2606
1'11111'1111I'111111111I11111.1.1111111111111111.1111111111.11
20 56
MOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT STREET
WORMLEYSBURG, PA 17043
_4&~I~~~~
Date Pat# Prv# i Ms t Service Oescri tion C t Ox Char e
'--M-ESSAG-ES-EXPLAINE-D--.~-<BELOW---------------.-'-<----------.. ---------
Payment Adjust
.~
~
*** Your Account Balance is Overdue! Please make Payment Immediate1v!!! ***
*****************************************************~***************~*************
Insurance Charges pending to Prv: 145.00 145.00
04/05/04 1 13 CATHERIZATION RIGHT & LEF 93526 427.41 800.00
04/23/04 Accept Assign Adj. -467.99
04/23/04 Medicare Payment 265.61 66.40*
04/05/04 1 13 INTRA-AORTIC BALLOON PUMP 33967 427.41 500.00
04/23/04 Accept Assign Adj. -372.54
04/23/04 Medicare Payment 101.97 25.49*
04/05/04 1 13 CARDIOPULMONARY RESUSCITA 92950 427.41 360.00
04/23/04 Accept Assign Adj. -177.12
04/23/04 Medicare Payment 146.30 36.58*
04/05/04 1 13 Insert Heart E1ectrode/Pa 33210 427.41 350.00
04/23/04 Accept Assign Adj. -263.61
04/23/04 Medicare Payment 69.11 17.28*
04/05/04 1 13 IMAGING SUPERVISION PUL/C 93556 427.41 90.00
04/23/04 Accept Assign Adj. -46.38
04/23/04 Medicare Payment 34.90 8.72*
04/05/04 1 13 INJECT FOR CORONARY ANGlO 93545 427.41 90.00
04/23/04 Accept Assign Adj. -69.22
04/23/04 Medicare Payment 16.62 4.16*
04/05/04 1 13 X-RAY & PACEMAKER INSERTI 71090 427.41 60.00
04/23/04 Accept Assign Adj. -31.96
04/23/04 Medicare Payment 22.43 5.61*
04/06/04 1 78 HOSPITAL SUBSEQUENT CARE 99232 414.01 80.00
05/12/04 Accept Assign Adj. -26.41
05/12/04 Medicare Payment 42.87 10.72*
00/00/00
0.00
DATE lAST PAlO
AMOUNT
MAKE
CHECK
PAYABLE TO:
MOFFITT HEART & VASCULAR GROUP
1000 NORTH FRONT STREET
WORMLEYSBURG, PA 17043
PAT# I-PATRICK B SCHELL
PRvlf 13-BACHINSKY. WILLIAM, MD
PRvlf 78-WALSH, TIMOTHY, MD
Ph: (717)-731-8315
Acct//: 122995
Date: 07/09/04
Page 1 of 1
~HOLY
SJ:~I
The Spirit of Caring
Holy Spirit Hospital
503 N 21ST STREET
CAMP Hill PA 17011
#
717-763-2141
..d.................................................. .................... ,.......
.....................-.-......-........................ ....... .... ..........
..... ............................................. ...........................
~Qn~~~,r-+W~J($J<;~:.
$~ry~r,.~:i:J~:t~{:<::#~tMiM<
)$~J:6a4eJ:6~~.....:>..<.ijAi9~?(JA.......
L~#$~$~$+m~r'ip#*~t/g~1~'r(Jit>
AC~()lIl1tN0i2Z9.S7534.<}..""........ .
"or Account Information, Please Call 717-763-2141
Statement of Account
07/22/04
04/28104
04/30/04
05/17/04
Q5/F 19_4__
05/17/04
OS/21/04
OS/21/04
Description
PREVIOUS BALANCE
MED CIA HOSP-IP M90 MEDICARE lIP
OTHER PATIENT NON CO M90 MEDICARE lIP
MEDI PYMT-HOSP IP M90 MEDICARE lIP
MEDICIA HOSP-IP M90 MEDICARE lIP
. MED c/At:ioSfi--n.-- M9uMEiJICARE-TlP-
MEDI PART B PYMT-IP M90 MEDICARE lIP
MEDI PART B C/A-IP M90 MEDICARE lIP
Amount
Transaction Date
26,156.12
7,665.71-
9.60-
17,633.87-
7,292.65-
7,665.71
116.81-
197.99-
Estimated Insurance Due:
.00
Total Patient Credits:
Account Balance:
905.20
M90 MEDICARE liP .00
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
__ _ _________ ______ _ __ __________ ___ _ ____ __ _______ ____.+_ __~ _,__.______ _e~~_a:oE!_d_~~a~.~. ~~~ !~!.U.r~ _~i!ry_ y~~~ p~y'!'~~!.________ ._________._ _._ _ ______________________________
_____________
For Hospital Use Only Acrount Number:
22957534
SCHELL ,PATRICK B
D.D~
D
HOLY SPIRIT HOSPITAL
503 N 21ST STREET
CAMP HILL PA 17011
#
ADDRESS SERVICE REQUESTED
ADM DT: 040504
DSH DT: 040604
S8: 21020
717-731-6135
Patient Name:
Cant Number:
H R: HSG
410.91
Signature:
Make Check Payable To HOLY SPIRIT HOSPITAL
. The CVV2 Number is the last 3 digits on the back of your credit card, by your signature
1...111...111......11...11..1.1.11..1111..11.....11..11...1.11
00007993 1 AT 0.292 01
22957534
PATRICK B SCHELL
213 N 36TH ST
CAMP HILL PA 17011-2606
1...111...111......11...11..1.1..1.111....1..111.....11.1.1..1
HOLY SPIRIT HOSPITAL
503 N 21ST STREET
CAMP HILL, PA 17011
rJ _._ _ _ _ _11-_ _.. "II-t_ II- ___ :c . _____ _ .......____ __ r___._____ ~_III____..:__ '-__ _'-____.... __.... _____..1 ....._ _..._____ __ Il&.._ ....__... _, _..:_ ____....._....._Il
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 3/06/2006
SCHELL ALVITA G
213 N 36TH ST
CAMP HILL, PA 17011
RE: Estate of SCHELL PATRICK B
File Number: 2004-00387
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
4/06/2006
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
Gl~r~~
Clerk of the Orphans' Court
cc: File
Counsel
~r
MAY 1 0 2006
~~
.::J
IN RE: ESTATE OF
SCHELL PATRICKB
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2004-00387
NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE
Personal Representative: SCHELL AL VITA G
Counsel for Personal Representative:
Date of Decedent's Death: 4/6/2004
Date of Delinquency Notice:
The undersigned, Glenda Farner-Strasbaugh, Clerk of Orphans' Court, in accordance
with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule
6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12,
Supreme Court Orphans' Court Rules was given on the above date and that the ten (10) day
notice to file the Status Report has expired. Accordingly, in accordance with Rule 6.12 the Court
is hereby notified of such delinquency and the undersigned requests that a Court conduct a
hearing to determine whether sanctions should be imposed upon the delinquent personal
representative or counsel for the delinquent personal representative.
Date:
5/10/2006
~~~
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled Julv 17th. 2006 at 8:45 a.m.
in Courtroom No.3. If the Status Report is filed prior to t
automatically be cancelled.
Edgar B. Bayley, J.
\
l"'-
<0
CJ
...LI
U.S. Postal ServiceTM
CERTIFIED MAlbM RECEIPT
~~~~~~~~~~~~~~~~
Lf1
.-=l
...LI
.:r
ru
CJ Certified Fee
CJ
CJ Return Receipt Fee
(Endorsement Required)
CJ Restricted Delivery Fee
~ (Endorse. ment Required) I.
.-=l Total Postage & Fees ~
&. /:z
JLe ~~~~
Here
I '-111t:ulLtG
5-/S-{)~
Postage $
Lf1
~ ! ~~~:.~~..(U./!!:k~~m.L!..m.JJe.&:tL--m'-ll
~;:~:::~:~4'" .m.__ - ..m __.n.... _ ....--......---.-. n...m...._.__.. - -...-- .
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
Name of Decedent: FA WICK j) 5c-hf: //
Date of Death: Jj -f:, .- ZOO if
Estate No.: .::J.t;tJ f -- 00387
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes ~ No 0
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes 0 No ~
b. The separate Orphans' Court No. (if any) for the personal representative's
account is: :;200 L/ - Ot) .38 7
c. Did the personal representative state an account informally to the parties in
interest? Yes 0 No ~ .
c. Copies of receipts, releases, joinders and approval of formal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be
attached to this report.
S/;9/C6
, ,
(?iC/~~ ~.~-k/~
Signature
Date:
-- --- -------- ,
-~-...
/ - ~
-410':6 Gr. ScI7€./!
Name
[ptJ {1sc/V/71:h (;burl
Address '/?1AIVL/I~' :.E2/ P~l /73,/s
7/7-~6-677LJ
Telephone No.
"- '...,
Capacity: B Personal Representative
o Counsel for personal representative
/~
/ ~I
(^~ )
In Re: Estate of
SCHELL PATRICKB
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 2004-00387
NOTICE OF FAILURE TO FILE STATUS REPORT
Personal Representative: SCHELL AL VIT A G
Counsel for Personal Representative:
Date of Decedent's Death: 4/6/2004
The Orphans' Court record indicates that neither the above named personal representative
nor the above named counsel for the personal representative have filed with the Register of Wills
or Clerk of the Orphans' Court his, her or its Status Report required by Rule 6.12, Supreme
Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12, Supreme Court
Orphans' Court Rules, is hereby given by that the you have ten (10) day to file the Status Report.
If the required 6.12 form is not filed in accordance with Rule 6.12 the Court will be notified of
such delinquency and the undersigned will requests that a Court conduct a hearing to determine
whether sanctions should be imposed upon the delinquent personal representative or counsel for
the delinquent personal representative.
Date:
~~~
4/2512006
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
SENDER: COMPLETE THIS SECTION
. Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
. Print your name and address on the reverse
so that we can return the card to you.
. Attach this card to the back of the mail piece,
or on the front if space permits.
1. Article Addressed to:
a/1/ I t a, (j. 5th e if
., f .f h S'J--
eX / 3 Ai 3ft} I.
Camp HI/I) f4.
17()11
2. Article Number
(Transfer from service label)
PS Form 3811, February 2004
COMPLETE THIS SECTION ON DELIVERY
3. Servjs:e Type
!D'tertified Mail 0 Express Mail
o Registered 0 Return Receipt for Merchandise
o Insured Mail 0 C.O.D.
4. Restricted Delivery? (Extra Fee) 0 Yes
7005 1820 0002 4615 6087
Domestic Return Receipt
102595-02-M-1540
UNITED STATES POSTAL SERVICE
First-Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
· Sender: Please print your name, address, and ZIP+4 in this box ·
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:._~ Glenda Farner Strasbaugh
c.' Register of Wills and Clerk of Orphans' Court
',,'. County of Cumberlalld
One Courthouse Square
Carlisle, P A 17013
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