HomeMy WebLinkAbout01-29-09 (2)1505607121
REV-1500 EX (Oli-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PoBOx2sosol INHERITANCE TAX RETURN 2 1 0 8 0 1 2 5 4
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 6 4 0 7 7 3 7 8 1 2 0 6 2 0 0 8 0 8 0 4 1 9 1 5
Decedent's Last Name Suffix Decedent's First Name MI
P A U L M A R Y A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
MI
0 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 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 TO:
Name Daytime Telephone Number
R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3
Firm Name (If Applicable)
I R W I N &
First line of address
6 0 W E S T
Second line of address
City or Post Office
C A R L I S L E
Correspondent's a-mail address:
REGIST~2 OF WILLS l.[~~ ONLY ? !_
~ ~ ~-~ . ,a
l ,
~' c ~ ~._ j
_r ~
~ ~:
-p,/tfi~ FILED
W
State ZIP Code
P A 1 7 0 1 3
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct d complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAT OF PERSON R R FILING RETURN DATE ~y
t,_ ..-r -
00 WEST ELM STREET PALMYRA PA 170
SIGNATURE~FpR~PARER OTHER THAN~~P~ R~ ESENTATIVE DATE j 5
r /~z~ ?~ . C- ~~t.~( ~
60 WEST P~IMFf~ET
M c K N I G H T
P O M F R E T S T R E E T
EET
1505607121
PA 17013
PLEASE USE ORIGINAL FORM ONLY
CARLISLE
Side 1
1505607121
J
~~
°~~- ,
'~1„-~~
J
1505607221
REV-1500 EX Decedent's Social Security Number
1 6 4 0 7 7 3 7 8
Decedent's Name: MARY A• P A U L
RECAPITULATION
1.
~
1. Real estate (Schedule A) ••••••••••••••••••"""""""~~~~~~~
2. Stocks and Bonds (Schedule B) •••••••••••••••••""""""'~~~ 2.
~
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3.
4. Mortgages & Notes Receivable (Schedule D) • • • • • ~ • • • • • • • ' ~ ' ' ' ~ ' ' ' ' 4.
'
1 7 8 2 1 5 . 8 5
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ... • ~ • 5.
•
7 6
1 7 1 3
Jointly Owned Property (Schedule F) ^ Separate Billing Requested .....
6 .. 6• ,
1
.
7. Inter-Vivos Transfers & Miscellaneous Ngn-PrSo ParaterBileng Requested .....
u .. 7•
(Schedule G) 1 8 9 9 2 9. 6 1
.........................
8. Total Gross Assets (total Lines 1-7) .. 8.
1 0 8 7 6, 5 7
..........
9. Funeral Expenses & Administrative Costs (Schedule H) • • • • .. 9.
9 . $ Q
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . •
10.
3 7
0 8 8 6
11. Total Deductions (total Lines 9 & 10) ~ • ~ ~ ' ~ ~ ' ~ ~ ' ~ " ' ~ ' ~ ~ ~ ~ 11. .
1
2 4
0 4 3
12. ,
1 7 9
......................
Net Value of Estate (Line 8 minus Line 11)
12
...
.
Charitable and Governmental Bequests/Sec 9113 Trusts for which
13 13.
.
an election to tax has not been made (Schedule J) ], 7 9 0 4 3 . 2 4
...............
14. Net Value Subject to Tax (Line 12 minus Line 13)
...14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 Q ~ Q Q
15. 0 , 0 0
(a)(1.2) X •0
8 0 5 6. 9 5
16. Amount of Line 14 taxable 1 7 9 0 4 3 2 4 16.
at lineal rate X .045 0 Q 0
17. Amount of Line 14 taxable Q 0 0 17.
at sibling rate X .12 0 ~ 0 0
18. Amount of Line 14 taxable Q 0 0 1 g.
at collateral rate X .15
8 0 5 6. 9 5
19.
19. Tax Due ................................................
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505607221
1505607221
J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 08 01254
DECEDENT'S NAME
MARY A. PAUL __
STREET ADDRESS
4905 EAST TRINDLE ROAD
CITY
MECHANICSBURG STATE
PA ZIP
17050
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 8,056.95
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 402.85
Total Credits (A + B + C) (2) 402.85
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
(3) 0.00
(4) 0.00
(5) 7,654.10
(5A)
B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 7,654.10
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ................................................................. ..... ^
^ ^X
X
b. retain the right to designate who shall use the property transferred or its income; .......................... .....
^
^X
c. retain a reversionary interest; or ........................................................................................... .....
^ ^X
d. receive the promise for life of either payments, benefits or care? .................................................. .....
If death occurred after December 12, 1982, did decedent transfer property within one year of death
2
.
without receiving adequate consideration? .................................................................................
?
"
" ...... ^
^ 0
^X
...
or payable upon death bank account or security at his or her death
in trust for
3. Did decedent own an ......
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ............................................................................................ ...... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MARY A. PAUL 21 08 01254
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1, SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #0575138623 10,253.50
2.. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1685212431 10,349.11
3. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1685212563 10,355.46
4. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1685212571 12,419.82
5. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1685212639 13,353.79
6. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1685212704 10,262.17
7. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1685212787 5,158.47
8. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #2335544561 100,148.26
9. COUNTRY MEADOWS - ON ACCOUNT 5,915.27
TOTAL (Also enter on line 5, Recapitulation) I $ 178,215.
(If more space is needed, insert additional sheets of the same size)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
REV-1509 EX + (g-g8)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MARY A. PAUL _ _ 21 08 01254
SCHEDULE F
JOINTLY-OWNED PROPERTY
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
700 WEST ELM STREET
PALMYRA PA 17078
RELATIONSHIP TO DECEDENT
ADDRESS
SURVIVING JOINT TENANT(S) NAME
A. LOWELL PAUL
C
JOINTLY•OWNED PROPERTY:
SON
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. CITIZENS BANK -ACCOUNT #6100706400 23,427.52 50. 11,713.76
TOTAL (Also enter on line 6, Recapitulation) I $ 11,713.76
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
MARY A. PAUL 21 08 01254
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AM(~I INT
A. FUNERAL EXPENSES:
~, FUNERAL LUNCHEON
B.
2.
3.
4.
5.
6.
7.
8.
9.
10
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
SVeet Address
City State _
Year(s) Commission Paid:
Attorney Fees IRWIN & McKNIGHT
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State
Relationship of Claimant to Decedent
Probate Fees REGISTER OF WILLS
Accountant's Fees
Tax Return Preparers Fees PATRICIA A. ROSENDALE, CPA
REGISTER OF WILLS -FILING FEE
CUMBERLAND LAW JOURNAL -ESTATE NOTICE
THE SENTINEL -ESTATE NOTICE
REGISTER OF WILLS -SHORT CERTIFICATE
Zip
298.00
350.00
30.00
75.00
158.62
4.00
TOTAL (Also enter on line 9, Recapitulation) ~ $ 10.876.57
Zip
9,800.00
160.95
(If more space is needed insert additional sheets of the same size)
REV-1512 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
MARY A. PAUL 21 08 01254
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
VERIZON -TELEPHONE
9.80
TOTAL (Also enter on line 10, Recapitulation) I $ 9.80
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (g-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
MARY A. PAUL 21 08 01254
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. LOWELL M. PAUL Lineal 89,521.62
700 WEST ELM STREET 1/2 REMAINDER
PALMYRA, PA 17078
2. ZONA M. FISHER Lineal 89,521.62
20 SPEND A BUCK DRIVE 1/2 REMAINDER
DILLSBURG, PA 17019
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
~~x~~ t~ ~x~~ ~.~~#~x~t.e~
I, MARY A. PAUL, of the Borough of Mechanicsburg, Cumberland
County, Pennsylvania, declare this instrument to be my Last Will
and Testament, hereby expressly revoking all Wills and Codicils
heretofore made by me.
1. I direct my executor to pay all of my debts, funeral and
administrative expenses as soon as may be done conveniently after
my decease.
2. I authorize and empower my executor to sell any realty
owned by me at my death, at either public or private sale, and to
give good and sufficient deeds therefor, in fee simple, as I could
do if living.
3. I devise and bequeath all of my estate of every nature and
wherever situate to my husband, Avon C."Paul; providing he shall
survive me by sixty days.
4. Should the gift in Paragraph No. 3 not take effect, I devise
and bequeath all of my estate of every nature and wherever situate
to my two children, share and sYlare alike, the child or children of
any deceased child taking the share their parent would Yiave taken if
living.
5. I nominate and appoint Avon C. Paul, to be the executor of
this my Last Will and Testament; he is to serve as such without
bond. Should he die before my death, renounce or refuse to serve
for any reason, or die. leaving any of my estate unadministered, I
nominate and appoint Lowell M. Paul, as substitute executor, also to
serve as such without bond, witri the same powers as are given herein
to my executor.
6. I hereby suggest that my personal representative retain
the services of Irwin, Irwin & Irwin as attorneys in the settlement
of my estate.
IN WITNESS T~v'HEREOF, I have hereunto set my hand and seal this
~~' day of April, 1977.
(SEAL)
M Y PAUL
Signed, sealed, published and declared by Mary A. Paul, 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 present
of each other have subscribed our names as witnesses hereto.
ACKNOWLEDGEMENT AND AFFIDAVIT
We, MARY A. PAUL ~ BETZI A. MORRISON
and J. MARIE JONES the testatrix and the witnesses,
respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned
authority that the testatrix signed and executed the instrument
as her Last Will and that she had signed willingly, and that she
executed it as
expressed, and
hearing of the
to the best of
eighteen years
her free and voluntary act for
that each of the witnesses, in
testat rix~ signed the Will as
their knowledge the testatrix
of age or older, of sound mind
the purposes therein
the presence and
a witness and that
aas at that time
and under no
constraint or undue influence.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
MAR A. PAUL
BETZI A. MORRISON
. MARIE JONE
SS.
Subscribed, sworn to and acknowledged before me by
MARY A. PAUL , the testatrix , and subscribed
and sworn to before me by BETZI A. MORRISON
and
J. MARIE JONES witnesses, this ~y~ day of
April 1977 .
~: .. _.. r ,. ...
~~ Citizens Bank
January 15, 2009
IRWIN & MCKNIGHT
WEST POMFRET PROFESSIONAL BLDH
60 WEST POMFRET STREET
CARLISLE PA 17013
Estate of MARY A PAUL
Date of Death: Dec 06, 2008
SSN: 164-07-7378
Dear Sir/Madam:
525 William Penn Place
Suite 153-2618
Pittsburgh, PA 15219
~,~~ ~,~
~,?~v~ ~;
r.~~ ,,. ~ ,r,~-,.
. ~:;
In accordance with your request, the attached information sheet has been provided in the above decedent's
name as of his/her date of death.
For IL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please
call 1-888-999-6884
Sincerely,
Robert Roos
Operations Services
~~~ ~~~ ,
Account Number 6100706400
Account Title MARY PAUL OR LOWELL PAUL
Date O ened 6/6/1966
Account T e Checking
Princi al Balance as of DOD $23427.52
Interest from Last Posting to DOD $ .00
Account Balance as of DOD $23427
52
YTD Interest to DOD .
$25.56
~ Sovereign Bank
MA 1 MB3 02-10
Court Ordered Processing/Decedent
P.O. Box 841005 !,~ g
Boston, MA 02284 }±~f ,~ psi
January 2, 2009
Roger B. Irwin
Irwin & McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
RE: Estate of Mary A. Paul
Date of Death: 12/06/08
SS# 164-07-7378
Dear Mr. Irwin:
~.,/Vfii,~ itllrnlt~(,,y
Jtlh" ~f~;('~'
Per your request, enclosed please find account information as of the date of death for the
above-named decedent. For your information, accrued interest in not included in the date
of death balance.
Please feel free to contact me if I can be of any further assistance.
Ver ruly yours,
l ~ ~~- ,~
Nicole Job
COP Specialist III
Decedent Department
(617) 533-1364
Sovereign Bank
ESTATE OF Mary A. Paul
SOCIAL SECURITY #: 164-07-7378
DATE OF DEATH: December 6, 2008
Account #: 0575138623 Type: _ CD
In the name of: Mary A Paul
Date of Death Balance:
Int.(YTD) from 1 /1 /2008 to _
Accrued interest to date of death:
Other Info: Account closed on 12/30/08.
Account #: 1685212431 Type:
In the name of: Mary A Paul
Date of Death Balance:
Int.(YTD) from 1/1/2008 to _
Accrued interest to date of death:
Other Info: Account closed on 12/30/08.
Account #: 1685212563 Type:
In the name of: Mary A Paul
Date of Death Balance:
Int.(YTD) from 1 /1 /2008 to _
Accrued interest to date of death:
Other Info: Account closed on 12/30/08.
Account #: 1685212571 Type:
In the name of: Mary A Paul
Date of Death Balance:
Int.(YTD) from 1 / 1 /2008 to _
Accrued interest to date of death:
Other Info: Account closed on 12/30/08.
Account #: 1685212639 Type:
In the name of: Mary A Paul
Date of Death Balance:
Int.(YTD) from 1/1/2008 to _
Accrued interest to date of death:
Other Info: Account closed on 12/30/08.
Open date: 3/ 17/ 1993
$10,000.00
11 /30/2008
$5.59
CD
$10,000.00
11/30/2008
$8.33
CD
$10,000.00
11 /30/2008
$7.12
CD
$12,000.00
11 /30/2008
$10.07
CD
$13,000.00
11 /3 0/2008
$11.85
$253.50
Open date: 6/12/1997
$349. I I
Open date: 1 / 19/ 1993
$355.46
Open date: 2/2/1993
. $419.82
Open date: 11/2/1993
$353.79
Page 1 of 2
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
December 6, 2008
Account #: 1685212704 Type: CD Open date: 4/18/1994
In the name of: Mary A Paul
Date of Death Balance: $10,000.00
Int.(YTD) from 1/1/2008 to 11/30/2008 $262.17
Accrued interest to date of death: $6.26
Other Info: Account closed on 12/30/08.
Account#: 1685212787
In the name of: Mary A Paul
Mary A. Paul
164-07-7378
Type: _ CD Onen dates ~/~ nii qQ~
Date of Death Balance: $5,000.00
Int.(YTD) from 1/1/2008 to 11/30/2008 $158.47
Accrued interest to date of death: $3.78
Other Info: Account closed on 12/30/08.
Account #: 2335544561'
Type:
In the name of: Mary A Paul
Date of Death Balance:
Int.(YTD) from 1 / 1 /2008 to _
Accrued interest to date of death:
Other Info: Account closed on 12/30/08.
CD
$100,148.26
11 /30/2008
$91.35
Open date: 11 / 17/2008
$148.26
Page 2 of 2
Country Meadows West Shore 3
4905 East Trindle Road
Mechanicsburg, PA 17050
Telephone: (717) 761-8880
Resident Statement
Date: 01/01/2009
Estate of Mary Paul
°s Roger B Irwin o Irwing & McK
60 West Pomfret Street
Carlisle, PA 17013-3222
DATE BALANCE FORWARD
12/01/2008
12/01/2008
12/01/2008
12/0.1/2008
01/02/2009
12/31/2008
Room, Board and Services
Room, Board and Services
Room, Board and Services
Room, Board and Services
Meal Credit Bldg.3
CURRENT MONTH CHARGES
Interest on Prepay
Re: Mary Paul
Account#: 76663
Balance Due: -5,915.27
Amount Enclosed
65.06
260.25
122.99
(1,979.00)
(5.00)
(4,363.13)
CREDIT BALANCE - DO NOT PAY
(1,535.70)
(16.44)
(5, 915.27)
nterest Earned Year-to-Date: 16.44
Thank you for choosing Country Meadows of West Shore 3!
Please include the top portion of this bill with
your payment by the
Meadows Associates.
Fpr pharmacy questions please contact "Alert" direct at 1-800-266-9954
Resident Name: Mary Paul
.Account#: 76663
Statement Date: 01/01/2009