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HomeMy WebLinkAbout03-20-0915056051058 REV-1500 EX (06-05) PA Depadment d Revenue BureaudlndividualTazes oFFICwL USE ONLY ~~~ Veer Fie Number INHERITANCE TAX RETURN Po Box 280601 Hamffiurg, PA 17128-0801 RESIDENT DECEDENT 21 08 00868 ENTER DECEDENT NFORMATN)N BELOW Social Security Number Date of Death Date d Bhm 08/18/2008 11/18/1914 Decedent's Last Name Suffix Decedent's First Name MI Woods Myrtle I (If Applic~le) Enter Survhing Spouaek Infotmatlon Below Spouse's Last Name Sulflx Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FlLED IN DUPLICATE WITH THE REGISTER OF WILLS FlLL IN APPROPRIATE OVALS BELOW • 1. OdDlnal Retum 2. Supplemerxal Retum 3. Remainder Retum (date d death prbr re 12-1382) 4. Limped Estate 4a. Fubxe Intereal Comprdnise (dared 5. Federal Estate Tax Retum Requked deem after 12-12-82) • 6. Decedent Died Testate T. DeceOerrt IvlairdaYretl a LNYg Tnut S. Total Number d Safe Deposft Boxes (Attach Copy d Y1711) (Attbirh CapY d Trest) 9. Litlgatlon Proceeds RaceNed t0. Spousal Povedy CredB (date d deem 11. Elerxbn ro tart under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL IbRRESPONDENCE AND CONFIDENTIAL TAl(INFORMIITION MOULD BE DIRECTED TO: Name Daytime Telephone Number John Kopala (602) 992-8651 Firm Name (If Applicable) rte, REGISTER OF LLS USE ONL> ' F Q ti J aQ c5 . First line daddress riSr"~ ~ -. 2645 E Sierra St r?~ ~.• f ~a - -.. a = . . ~ v~„ o Second line of address (;~,- - 0 n ,_] Gity or Post Qifice State ZIP Code oA~PIeED N iV Phoenix AZ 85028-1828 W comespoMenrs e-mail address: Jkopala~gmail.com Under penaeies d perjury I dedera that I have axernnad mis realm, indWinp acownpanying schedules aM statements, aM m 8re best d my krgwledga and belid, H is true, mrrerd and complete. Dederalion d pmperer ether than fhe parser-I repreaenfa8ve is based on all intonnatlon d which preparer hae anY krgaAetlOe. StGNANR IBLEG RETURN DATE ~ 03/18/09 ADDRESS 2645 E. terra St., Phoenix, AZ 85028-1828 SIGNATURE OF 1'REPARER OTHER THAN REPRESENTATIVE SS PLEASE US® OR101NAL PONS OMLY Side 1 t_ 15056051058 15056051058 „r~ J 15056052059 REV-1500 EX Decedent's Social Secudty Number Decedents Nama: MyAle 1 Woods RECAPRULATION 1. Reel estate (Schedule A) ........................................... .. 1. 2. Stocks antl Bonds (Schedule B) ......... ............ .. ..... ... .. .. .. .. 2. 3. Closely Held Corporation, Partnership or Sole-Propdetorship (Schedule C) ... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 175,326.81 6. Jointly Owned Property (Schedule F) Separate Billing Requested ..... .. 6. 7. Inter-Viws Transfers 8 MLcwllaneous Non-Probate Property (Schedule G) Separate Billing Requested...... .. 7. 8. Total Gross Asset (total Lines 1-7) .................................. .. 8. 175,326.81 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 549.70 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............. .. 10. 6,929.03 11. Total Daductlons (total Lines 9 & 10) ................................. . . 11. 7,476.73 12. Net Value of Eafale (Line 8 minus Line 11) ............................ .. 12. 13. Charitable and GovemmeMaf Bequesta/Sec 9113 Trusts for which an election to tez has no[ been made (Schedule J) ...................... .. 13. 14. Nat Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 167,848.08 TAX COMPUTATION ~ SEE INSTRUCTIONS FOR APPLICABLE RATES t5. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X.045 167,848.08 tg, 7,553.16 17. Amount of Line 14 taxable at sibling rate X .12 17. t8. Amount of Lina 14 Faxable at collateral rate X .15 18. 19. TAX DUE ....................................................... .. 19. 7.553.16 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 I._ 15056052059 REV-1500 EX Pega 3 Decedent's Complete Address: Flle NumWr DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Myrtle I Woods 177-10.2468 STREETAWRESS 100 Messiah Circle, #428 CfTY Mechanicsburg STATE DP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. GreditsJPaymerrLs A. Spousal Poverty Credit B. Prior Payments C. Discount InterasUPenalty if applicable D. Interest E. Penalty (t) 7,553.16 Total Credits (A+ 8 + C) (2) Total InteresUPenalry (D + E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 2a 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. 0.00 (3) (4) 0.00 (5) 7, 553.16 (5A) 0.00 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (56) Make Check Payable to: REGISTER OF WIU.S, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property trensferred or its income :...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred a11er December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration7 ........................................................................................................ ...... ^ 3. Did decedent own an "in Wsl for" or payable upon death bank acmuM m sewrily at his or her death? ........ ...... ^ 4. Did decedent own an Individual ReBremenl Account, annuity, or other non~probale property which contains a beneficiary designation? .................................................................................................................. ...... ^ 7,553.16 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 w 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, dre tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [/2 P.S. §9116 (a) (1.1) (ii}]. The statute does not exemot a transfer to a surviving spouse ftom tax, and the statutory requirements for disdosure of assets and filing a tax return are stiN applicable even if the surviving spouse is Me only beneficiary. For dates of death on or after Juty 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-0ce 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)j. The tax rata imposed on the net value of transfers to or for the use of the decedent's Areal benefidaries is Tour and one•haff (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 [/2 P.S. §9116(a)(1.3)j. 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-1908 EX+ (&98) COMMONVVFALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Myrtle I. Woods 2008-00868 (If more space is needed, irrsert add'Rionai sheets of the same s¢e) REV-1511 EX+(12-99) SCNEPULE N COMMONWEALTH OF PENNSYLVANIA FUN'E'RAL EXPENSES & INHERITANCE TA%RETURN A~Mtl\~SfRA~CO~S RESIDENT DECEDENT ESTATE OF FILE NUMBER Myrtle I. Woods 2008-00868 Debts of decedent must be reported on SeMduk L A. I FUNERAL EXPENSES: t' Lewistown Monument Co., Headstone Engraving B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Securely Number(suEIN Number of Personal Representative(s) Street Address City .State Veer(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, atmch explanation) Claimant StreetAtld25s CflY Stale Relationship of Claimant m Decedent 4, Probate Fees 5. AcccuMant's Fees 6. Tax Return Preparer's Fees 7. Published Legal Notices Zlp Zip TOTAL (Also enter on line 9, Recapitulation) I $ more space is needed, insen additional sheets of the same size) 125.00 298.00 126.70 549.70 REV-1512 EX+ (12-OS) pennsytvania SCHEDULE I DErnnrneNT or nEVEUUE DEBTS OF DECEDENT, wNEwTnNCE TA% REruxrv MORTGAGE LIABILITIES A LIENS RESIDENT DECEDENT ESTATE OF Myrtle I. Woods 2008-00868 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. RFVd 513 EX+ ~ 11-081 ~i Pennsylvania SCHEDULE J DEPARTMENT °F REVENUE INHERITANCE TA% RENRN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Myrtle I. Woods ~nna_nnnan RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTONS [include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] 1. Susan E. Kopala, 2645 E. Siena St., Phoenix, AZ, 85028-1828 Daughter 50% 2. Marsh J. Woods, 1808 Old Meadow Rd., X18, McLean, VA 22102-1830 Daughter 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1588 COVER SHEET, A S APPROPRIATE, 11 NON-TAXABLE DISTRIBUFIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 Of REV-1500 COVER SHEET. ; 1r more space Is neeced, Insert apoltiDDal sheets of the same site. ~1VI&T B~.~k :ACCOUNT. NO ,. ACCOUNT TYPE 487554 M8T CLASSIC CHECKING N/INTEREST MYRTLE I WOODS MARSHA J WOODS 2Q45 EAST SIERRA ST PHOENIX AZ 85026 INTEREST EARNED FOR STATEMENT PERIOD INTEREST PAID YEAR TO DATE 2.19 00 0 04350M NM I17 12840 0.39 AC Cf111NT SIIMMARV ,STATEMENT PERIOD PAGE' AUG.09-SEP.09,2008 1 OF 2 TRINDLE ROAD OFFICE '-.:.BEGIMNING: BALANCE DE OSITS $ ::.OTHER ADDITIONS CHECKS PAID I : OTHER :SUBTRACTIONS : :CURRENT .:INTEREST PD PENDING .BALANCE NO. AMOUNT NO. AMOUNT N0. AMOUNT 13,395.75 1 10,000.00 2 8,735.00 2 6,143.23 0.40 8,517.92 A CC(]L1NT AC.TTVTTV : OST NG 'DATE '. :TRANSACTION DESCRIPTION :DEPOSP' , IN:ERE$T '8'-0THER 'ADOTIONS -.1CMECKS $, :.OTHER -'SUBTRACTIONS DAIIY- BALANCE 08-09-OB BEGINNING BALANCE 513,395.75 08-12-08 MESSIAH HOME STATEMENTS 6,119.72 7,276.03 08-18-08 NEB XFER FROM SAV 15004218987913 10,000.00 17,276.03 08-19-08 HECK NUMBER 4123 8,635.00 8,641.03 08-25-08 CHECK NUMBER 0055 00.00 8,541.03 08-26-08 VERIZON Pey.wntONE 23.51 8,517.52 09-04-OB INTEREST PAYMENT 0.40 8,517.92 ENDING BALANCE 58,517.92 CHECKS PAID SUMMARY 55 08-25-08 100.00 4123* 08-19-08 8,635.00 ANNUAL PERCENTAGE YIELD EARNED = 0.04 GOOD NENS! EFFECTIVE SEPTEMBER 12, 2008, IF YOU DEPOSIT CHECKS NITH ROUTING NUMBERS STARTING NITH 0110, 0111, 0112, 0113, 0114, 0115, 0116, 0117, 0118, 0119, 0211, 2110, 2111, 2112, 2113, 2114, 2115, 2116, 2117, 2118, 2119 OR 2211, FUNDS FROM THOSE DEPOSITS MILL 8E AVAILABLE FOR NITHDRAMAL SOONER. FUNDS FROM THESE CHECKS MILL NOM BE AVAILABLE ON THE SECOND BUSINESS DAY AFTER THE OAY OF YOUR DEPOSIT. LOOeA (6I0~ ) (,m~t'tsaru~ ACCOUNT PAGE 000000000487554 2 OF 2 MAME eio...__ Io~ot F~/~ - ' `` ~7~ ~ ~ pr~a~ 1 azoo o ~:a o ~s~: Doss Check 1155 Psid :08/25/2008 100. 00 Check k55 Paid :08/25/2008 loD.oo - .+~~. o NVgTLE ~. waoos n~_"_ 4123 k,.., ~. ~~ • aansH.a ~. woods e 3 noes o-uA~s roAO ~p~/~ ~, r+ECw+nesa~n~, vn ++oesxss n..e~(~p~_~~~ D$~ I `,~ '~/ Q res9~ : bnb=6+ ~~9i ~7~ lea. :(S2i70c t4l f~it8 ' ~`o:ora~n J/ldf~~-~~/9~arwei~ 1506J.S ~~~ ,^,1? ~y..`~ m ~:o~ao~4B7 4e'4~2~ ~. ; Check pa123 Paid :08/19/2008 6635. OO Check tla123 paid :08)19/2008 6635. OD r~~~l~i&TB~r~.~ ACCOUNT N0. ACCOUNT TYPE 15004218987913 _ M8T (-MONEY MARKET 00 0 01262M NN 017 MYRTLE I WOODS 2645 EAST SIERRA ST PHOENIX A2 85028 INTEREST EARNEG FOR STATEMENT PERI00 340.21 INTEREST PAID YEAR 70 DATI: 3,681.66 99306 A CCf111NT CIIMMARY STATEMENT PERIOD PAGE JUL.31-AUG. 29,2008 I 1 OF 1 CENTRAL PA SERVICE CENTER `...BEGINNING. BALANCE'' D POSITS 8 OTHER ADDITIONS NIYNDRAMALS-B.OTHER -. SUBTRACTIONS {URRENT INTEREST PAID I ENDING <- 'BALANCE ~ ~ N0. ~ AMOUNT ~ NOS AMOUNT T I 186,223.05 I 01 0.00 3 186,563.27 340.22 ~ n nn ACC.OLINT ACTTVTTY STING DATE - : TRANSACTION DESCRIPTION DEPOSITSi;INTERESY- 8'OYHER ABOITIONS .N/pRANALS.. BOTHER 'SUBTRACTIONS DAILY BALANCE 07-31-08 BEGINNING BALANCE 5186,223.05 09-04-08 NEB %FER TO CHK 00000000487554 10,000.00 176,223.05 08-18-08 NEB %FER TO CNK 00000000487554 10,D00.00 166,223.05 08-22-08 INTEREST PAYMENT 340.22 08-22-08 CLOSEOUT 166,563.27 0.00 ENDING BALANCE 50.00 ANNUAL PERCENTAGE YIELD EARNED = 3.25 LOOBA (6/0]) Lewistown Monument Company 730 Valley Street Lewistown, PA 17044 BILL TO John Kopala 2645 East Sierta St. Pheonix, AZ 85028 -_J DESCRIPTION 5 Digit Death Date ---- 2008 FOR MYRTLE WOODS IN MT ROCK CEMETERY, LEWISTOWN, PA Invoice DATE_ INVOICE # 9/18/2008 _ ~ SS/142 .- l __ _ _~ -. - -J -- -~-- P.O. NO. TERMS I PROJECT _ i NET IS DAYS --_-.--L--r---- - L_-_ _. RATE AMOUNT --- L-. - - _ i __- - -- ~ 125.00 125.00 I COMPLETED ON INVOICE DATE ..- -- __-_.. -. -- _. ._ ~`Tota1 - ---..- -$125.00 it I QUANTITY ~ RETAIN THIS PORTION FOR YOUR RECORDS THE SENTINEL - LEGAL JOHN KOPALA P.O. BOX 130, CARLISLE, PA 17013 AD NUMBER CLASS SALESPERSON BILLING DATE LINES 355764 10 PUBLIC NOTICES wolfs 09/19/08 30 * 2 AD DESCRIPTION START DATE STOP DATE EXECUTOR'S NOTICE LETTERS TESTAM 09/05/08 09/19/08 PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 119.70 TOTAL AD CHARGE 119.70 3 PROOF OF PUBLICATION O1PRF 7.00 PREVIOUSLY PAID -126.70 Est.MyrtleWOOds PAY THIS AMOUNT .oo MESSAGE: Thank you for advertising with The Sentinel. oo* Deadlines for in-column legal advertisements: Monday is Friday at 11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon; Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday is Thursday at 12 Noon. If you have any questions regarding your Legal bill please call Tammy Shoemaker 717-240-7176 Fax your legals to 717-243-3754 attention Tammy Shoemaker You can also EMAIL your legal to Classified ads: classified@cumberlink.com Please send a cover letter including your name and address as an attachment DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT THE SENTINEL -LEGAL Est . M rtlewoods P_O_ BOX 930_ CARLISLE. PA 97093 ~' AD NUMBER CLASSO START DATE STOP DATE 355764 PUBLIC NOTICES 09/05/08 09/19/08 AD DESCRIPTION BILLING DATE TELEPHONE NUMBER EXECUTOR'S NOTICE LETTERS TESTAM 09/19/08 602-992-8651 JOHN KOPALA 2645 E. SIERRA ST. PHOENIX, AZ 55028-1828 II~~I~~I~I~II~~~~~I~II~~1,1~~111~~1~~~1~1~11~~1 GROSS AMOUNT OF Q~ DUE AFTER 10/19/08 TOTAL AMOUNT DUE . ~ D ENTER AMOUNT ENCLO SED 20200000003557640000000000000000000000000000008 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Erica Peterson, Classified Mana¢er, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13w,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): Seytember 5,12,19, 2008 COPY OF NOTICE OF PUBLICATION a,; x cvounty.asr,`nayr~at~rail§Eeas 'Oe4nt~~'~s~'z6tf8j° Affiant further deposes that he/she is not nave bean ~rnitea~tb tn~ apdarsi nee interested in the subject matter of the "An pSi'song'kYUWmg~hamkelVes tq b~In~aa(s~a~said. aforesaid notice or advertisement, and that Estate uSm"a56~k~peymerJt irhmedir;ta7y andttti$sr#^- ' hewing olair9s wil~,presenttnem rar~aanrem~ero: all allegations in the foregoing statement s , ti •- ~JOnnwl~op~da, Exepuidr as to time, place and character of 38b6`fftts651erra street waoerior, nae6nza-raze publication are true. 6g4•gg2-8851 //~/ J, ',{('/~ (/v 1 Sworn to and subscribed before me this ~~ ~l. t~p~,o~ainr~ie~l. a,9a&. ems. ~. ~aiiruo.. Notar Public My commission expires: NOTARULL SEAT. BONIiA A CANUP Notary Public CART IStE BOROUGH, CUMBERL4ND COUNN MY Commission Expires Jun 8.2009 J ~Oa'~ ^700210057 PA-40 'ttn Social Security Number (shown first) 177-10-2468 N~,,18ta, p 12. PA Tax Liability. Multiply Line 11 by 3.07 percent (0.0307) ...................... 12. 113,00 13. Total PA Tax Withheld. See the instmctions . .................................. 13. 14. Credit from your 2006 PA Income Tax return . .................. .............. 14. 15. 2007 Estimated Installment Payments . ...................................... 15. 16.2007 Extension Payment .................... ..... .............. ..... ...... 16. 17. Nonresident Tax Withheld from your PA Schedule(s) NRK-1. (Nonresitlents only) .... 17. 18. Total Estimated Payments and Credits. Add Lines 14, 15, 16, antl 17 ............. 18. Tax Forgiveness Credit, submit PA Schedule SP Dependents, Pad B, Line 2, 19a. Filing Status: Unmarried or Married • Deceased 19b. pp Schedule SP........... . Separeted 20. Total Eligibility Income from Part C, Line 11, PA Sdhedule SP, . 21. lax Forgiveness Credit fmm Part D, Line 16, PA Schedule SP . ................. 21. 22. Resident Cretlit. Submit your PA Schedule(s) G-R with your PA Schedule(s) G-S, G-L, and/or RK-1 .................................... 22. 23. Total Other Credits. Submit your PA Schedule OC ............................ 23. 24. TOTAL PAYMENTS and CREDRS. Add Lines 13, 18, 21, 22. and 23 . ............. 24. 25. TAX DUE. If Line 12 is more than Line 24, enter the difference here ................ 25. 26. Penalties and Interest. Sea the instructions for additional information. Fill in oval if including Form REV-1630. .... 26. 113.08 •. - 127. TOTAL PAYMENT. Add Lines 25 and 26 . .................................... 27. ~ ~ S.O8 I 28. OVERPAYMENT If Line 24 is more than the total of Line 12 and Line 26, enter the difference here ............................ .. ..... .. ... ......... ..... .... 28. The total of Lines 29 through 35 must equal Line 28. 29. Refund - Amount of Line 28 you want as a check mailed to you......... REFUND 29. 30. Credit -Amount of Line 28 you want as a credit to your 2008 estimated account. .... 30 3L Amount of Line 28 you want to donate to the Wild Resource Conservation Fund... . 31, 32. Amount of Line 28 you want to donate to the MIIKary Family Relief Assistance Program . ..................... .... ...................... . 32. '. 33. Amount of Line 28 you want to tlonate to [he Governor Robert P. Casey Memorial Organ and Tissue Donadon Awareness Trust Fund . ........................ . 33. 34. Amount of Line 28 you want to tlonate to the Juvenile (Type 1) Diabetes Cure Research Fund .. _ ......................... ......... ....... ....... ... . 34. 35. Amount of Line 28 you want to donate to the Breast and Cervical Cancer Research Fund ............................... .. ....... .......... .... ... . 35. siuXPi oaElsl. uMer pareHles m penury, I lwel aedem }hat I Iwe) have axeminnC this return, InduGmg all accompanying achadu ba antl atammente, ene to the bent M my rwrvign rvre pme PreperoYn aSN wPTIN f o~~~ y C KGG CJTO/~ 12/16/08 379-42-0075 John Kopala ~o ~-992-8'6 sr PLEASE DO NOT CALL ABOUT YOUR REFUND UNTIL EIGNT WEEKS AFTER YOU FILE. Side 2 L 0700210057 070021057 ,~Or38 Q7QO11QO59 PA-40 9~A'~ (os-o7y (R) Pennsylvania Income Tax Retum PA Department of Revenue, Hanisbuig, PA 17129 oFFICtAL use oNLY PLEASE PRINT IN BLACK INK. ENTER ONE LETTER OR NUMBER IN EACH BOX. FI LL IN OVALS COMPLETELY. Your Social Security Number Spouse's Social Securty Number (if filing jointly) Extenabn. See the instructions. 177-10-2468 Nnentlad Return. See the instmd'nns. Realtleney Status. Fill in only one oval. Last Name Suffix ~ R Pennsylvania Resitlent W ds N Nonresident oo . P Part-Year Resident from Your First Name MI , -/tom to _ _ !2007 MVA LRSEAa M rtle i Filirg Status Fill in only One oval. y nsefal~remm a Single {Spouse's Flrs! Name MI adarassto incWae c?i, muavy em J Marred, Filin Jeintl g y zF Coca in local M Married, Filing Separately faimets. F Final Return, Indicate reason: I Spouse's Last Name -Only if d"rfferent from Last Name above Suffix ~ D Deceased. Dale of death 8~~8 /2007 First Line of Address Menlificatlon Label Change. p 428 100 Messiah Circle Fill in this avai if the label is not , wmpletely mrrect. Disprd the ircarred Second Line of Address label. Fill in lMS oval it you did not file a 2006 PA tax realm. City or Post Office State ZIP Code Farmers. Fill in this oval if atleasi iwo-thiNS of your gross inmme is Mechanicsburg PA 17055 trom tarmirg. DaySme Telephone Number School Code Name of school district where you lived on 12/31/2007:2~65~ (602) 992-8651 Your occupation Spouse's occupation Homemaker 1a. Gross Compensation. Do not include exempt income, such as combat zone pay and qualifying re5rement benefits. See the Instructions . ............................. ta. 1b. Unreimbursed Employee Business Expenses . ...................... ........... 1b. 1c. Net Compensation. Subtract Line tb from Line 1a .. . ............................ 1c. 2. Interest Income. Complete PA Schedule A if required . .......................... 2. 3,683.45 3. Dividend and Capital Gains Distributions Income. Complete PA Schedule B if required... 3. 4. Net Income or Loss from the Operation of a Business, Profession, or Farm.... 4. 5. Net Gain or Loss from the Sale, Exchange, or Disposition of Property. ....... 5. 6. Net Income or Loss frem Rents, Royalties, Patents, or Copyrights. .......... 8. 7. Estate or Trust Income. Complete and submit PA Schedule J . .................... 7. 8. Gambling and Lottery Winnings. Complete and submd PA Schedule T ............. 8. 9. Total PA Taxable Income. Add only the positive income amounts from Lines 1c, 2, 3, 9 683 45 3 4, 5, 6, 7, and 8. DO NOT ADD any losses reported on Lines 4, 5, or 6 .............. . , . 10. Other Deductions. Enter [he appropriate code for the type of tleduction. Sea the instructions for additional information . ........................ 10. 11. Adjusted PA Taxable Income. Subtract Line 10 from Line 9 ...................... 11. 3,683.45 Side 1 FC OFFICWL USE ONLY FC O7OO11QO59 m ® m 0700110059 J SCHEDULES AEr6 Schedule A-Itemized Deductions °Ma "°. ,545-°°" (Form loco) ra~rjj O O (Schedule B is on back) [S Department of trre Treasury imerrei aevenue serv;ce (99) - Attach to Form 1040. - See hrotructions for Schedules AB.B (Porto 1040). Attachment Sequence No. D7 Name(s) shown on Farm 1040 Yaur soelal s¢curlry number Medical Caution. Do not include expenses reimbursed or paid by others and 1 Medical and dental expenses (see page A-1). 1 Dental 2 Enter amount from Form 1040, line 38 2 6tpenseS 3 Multiply line 2 by 7.5% (.075) 3 4 Subtract line 3 from line 1. If line 3 is more than line 1 enter -0-. 4 Taxes You 5 State and local (check ony one box): Paid a Q Income taxes or 5 , (See b ^ General sales taxes page A-2.) 6 Real estate taxes (see page A-5) . 6 7 Personal property taxes . 7 8 Other taxes, List type and amount -..- ._.-. 8 9 Add lines S through 8 . . . . . . . . . . . . . . . . . . . . 9 Interest 10 Home mortgage interest antl points reported to you on Form 1098 10 You Paid 11 Home mortgage Interest not reported to you on Form 1098 8 paid (gee to the person from whom you bough the home, see page A-6 page A-5.) and show that person's name, identifying no., and address - Note. .. ..__ _ . .. 11~'; -... .- . _ Personal 12 points not reported to you on Form 1098. See page A-6 interest is for special rules 12 . not deductible. 13 Qualified mortgage insurance premiums (see page A-6) 13 14 Investment interest. Attach Forth 4952 if required. (See page A-6.) 14 15 Add lines 10 through 14 15 Gift3 to 16 Gifts by cash or check. If you made any gift of $250 or Charity more see page A-7 i6 , If you made a 17 ether than by cash or check. If any gift of $25D or more, g"rft and got a see page A-8. You must attach Form 8283 if over $500 17 benefk for it, 1g Carryover from prior year 18 see page A-7. 1 19 Add lines 16 throw h 18. 9 Casualty and Theft L63se$ 20 Casualty or theft loss(es). Attach Form 4684. (See page A-8.) 2p JOh Expenses 21 Unreimbursed employee expanses-job travel, union dues job and Certain education,etc. Attach Form 2106 or 2106-EZif required. (See page '' . _ .. __ __ ___ ___ __ Miscellaneous A-9.) --._ 21 __- .- .- -_ ___ ___ DedUCtiOnS 22 lax preparation fees . ~ (Sae 23 Other expenses-investment, safe deposit box, etc. List type and page A-9.) amount-.-__ 24 Add lines 21 through 23 ~ 25 Enter amount from Form 1040, line 38 ~ 26 Multiply line 25 by 2% (.02) 26 27 Subtract line 26 from line 24. If line 26 is more than line 24 , ent er -0- 27 Other 28 Other-from list on page A-t0. List type and amount - _ _ __ _ ~~~ Miscellaneous Deductions 2lf Total 29 Is Forth 1040, line 38, over $159,950 (over $79,975 if marded filing separately)? Itemized ^ No. Your tladuction is not limited. Add the amounts in the far right column for l Deductions lines 4 through 28. Also, enter this amount on Form 1040, line 40. } - 29 ^ Yes. Your deduction may be limited. See page A-1 D for the amount to enter. J 30 If you elect to itemize deductions even though they are less than your standard deduction, check here - ^ For Paperwork Reduction Act Notice, see Form 1040 instructions. Cat. No. t 733oX Schedule A (Form 1040) 2008 Schatlulas A88 (Porto 1040) 2008 OMB No. 1545-0074 Page 'ta Name(s) shown on Form 1040. Do not errter name antl social security number if shown on other side. Your social security number Nlywie r w....aa me~e~eedt 177 10 ! 2468 Schedule B-Interest and Ordinary Dividends s~~e~ a°Nn. os 1 List name of payer. If any interest is from aseller-financed mortgage and the Amount Pali 1 buyer used the property as a personal residence, see page B-1 and list this Interest interest ftrst. Also, show that buyer's social security number antl address - M8T Bank 3683 45 (See Page B-1 -..-___...------'---..__.--_.__.--_----'_..-_..____--.--_ .............. and the -__.-____-..__.._.._...__--_-____-_-_._._._.... _.________.____.._..__. instructions for Form 1040, Tine Ba.) ...._-..._.._.._-.__..-.._-.._._..__....-._ .............._-.----_...-...--..-__ _--__-________-._________-__-_____-_-__-__.-__-__--____--__.__-- 1 Note, if you received a Form 1099-IN7. Form .__.._..__-_____ .................._-__-.~__..__.--__..__...__~_..-___.__--__ 7099-0ID, or _-.___.________.______________.__--_-.._.._____-___.._____.-___.._ _ substitute statement from ~.-----.____.__-....__-_._...-_.-___ .................. _..____.__...-_. a brokerage firm, ---_._.-.__-._.._.__._.-__..._.._ .................... __--..__-_.__.-__.._ list the firm's -...._---.-_.__......._-____.__..-_.-._.--.-..-__.--_....._.-_-.-.__. _.-.. name as the payer and enter -.._._.__....__._.-_.....-._._.-.--__.__.___.-_ ............... ...._.__... the total interest -_.._.__--._._-.._.._-.....-_--..___-_ .... ........._.-_--_.--__-_-__.... shown on that 2 Add the amounts on line 1 2 3683 45 form. 3 Excludable interest on series EE and ! U.S. savings bonds issued after 1989. Attach Form 8815 3 4 Subtract line 3 from line 2. Enter the result here and on Form 1040, Ilne 8a - 4 3683 45 Note. If line 4 is over $1,500, ou must com late Part III. Amount Part 11 5 List name of payer - ----------.---_--------------------,-----------. Ordinary - - - - -- - -- - -- - - Dividends - -- -- - - - - - - -- -- - (SeePageB-t -----~_____--__-__-__.._..__-.____-__.__-__--_____. ___-.__.__-__. __.. and the --~_-___..__..._..__-_..._...._-....--_-..--..____--____..--.-_..-....._.. instructions for Form 1040, _..__-_--..._..__._--__.-._.__.._--_-.__._.... _..____--. _..-_..-_..-___ line 9a.) -----------__.-...-....._.-__-.-...-._._... _._.._-.... _.._.__--___._. _.-.. Note. If you ------------------------~--------------~-~------'-----~-----~-------------~----- 5 received a Form 1099-DIV or .__-____-__..___._.__-___-__-.__.__-__-..__... _.__.--__.._-__.-.__.-._.. substitute statement from a brokerage firm, .__..__.-_-__.-_._-__..______._____-._-._-___.-_____-.__-.__. _.-.___ list the firm's .._-__.__-_____-__..__.-._.__-__..__.__-__________._____.-.____ name as the payer and enter the ordinary ..-..--_.---_._-.____-.,_--..--.-_--__.__.._-__.-___.__..__..___-.._ divitlends shown .-_....._.-._.___.___..._-__.--_.__. __...____..___.___..._-_______ on that form. 6 Add the amounts on fine 5. Enter the total here and on Form 1040, line 9a . - 6 Note. If line 6 is over $1,500, ou must complete Part III. You must Complete this part if you (a) had over $1,500 of taxable interest or odinary dividends; or (b) had Yes No Part III a foreign account; or {c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust. Foreign 7a At any time during 2008, did you have an interest in or a signature or other authority over a financial ~iCCOUr1tS account in a foreign country, such as a bank account, securities accoum, or otherfinancial account? and Trusts See page B-2 for exceptions and filing requirements for Form TD F 9D-22.1. `~ b If "Yes," enter the name of the foreign country - .............._-.____. _..-_-.._--._---._.--. (See g During 2008, did you receive a distribution from, or were you the grantor of, or transferor fo, a page B-2.) forei n tmst? If "Yes," ou ma have to file Fortn 3520. See pa a B-2 / For Paperwork RedueOon Act Notice, see Form 1090 instructions. Schedule B (Porto 1040) 2008 Fonn 1040 (2008) Page 2 TaX 38 Amount from line 37 {adjusted gross income} ~ 15947 45 and 39a Check (®You were barn before January 2, 1944, ^ Blind. ~ Total boxes 1 Credits if: Sl ^ Spouse was born before January 2, 1944, ^ Blind. checketl - 39a b If your spouse aemaes on a separate return or you were a tlualstatus alien, see psge 34 and check here - 39b Standard c Check if standard deduction includes real estate taxes or disaster loss (see page 34) - 39c Deduction 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) , 0 800 0 for- 41 Subtract line 40 from line 38 41 9147 45 • People who checked any i boz on line 39 39b 4p If line 38 is over $119,975, or you provided housing to a Midwestern displaced individual, see Page 36. Otherwise, multiply $3,500 by the total number of exemptions claimed on line 6tl 42 3500 00 , or a, 39c or who 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41 enter -0- 43 5647 45 can he claimed as a , 44 Tax (see page 36). Check if any tax is from: a ^ Forrn(s) 8814 h ^ Form 4972 ~ S63 00 dependent, 45 Alternative minimum tax (sea page 39). Attach Fonn 6251. ~` see page 34. • All thers ~ Add lines 44 and 45 . - 46 563 00 o : Single or 47 Foreign taz credit. Attach Form 1116 if required 47 Married fiing qg Credd for child and dependent care expenses. Attach Form 2441 ~ separately, $5,450 49 Credit for the elderly or the disabled. Attach Schedule R . ~ Married filing 50 Education credits. Attach Form 8863. ~ jointly or 51 Retirement savings contributions credit. Attach Form 8880 51 Oualrfying widow(er) 52 Child tax credit (see page 42). Attach Form 8901 if required . 52 , $10,900 53 Credits from Form: a ^ 8396 b ^ 8839 c ^ 5695 ~ Head of 54 lAtler credits from Form: a ^ 3800 b ^ 8801 c ^ ~ household, 000 $8 ~ pdd lines 47 throw h 54. These are our total cretlits 9 Y 55 . 56 Subtract line 55 from line 46. It line 55 is more than line 46, enter -0- . - 58 563 00 ~ Self-employment tax. Attach Schedule SE ~ Other ~ Unreported social security and Medicare tax from Form: a ^ 4737 6 ^ 8919 ~ Taxes 59 Additional tax on IR4s, other qual'rfied retirement plans, etc. Attach Form 5329 'rf required . `~ 80 Additional taxes: a ^ AEIC payments b ^ Household employment taxes. Attach Schedule H ~ 61 Add lines 56 through fi0. This is your total tax - 61 563 00 ments ~ Federal income tax withheld from Forms W-2 and 1099 , Pa ~ y _ 63 2008 estimated tax payments and amount applied from 2007 return ~ L If you have a 64a Earned Income credit (EIC) 13r1a qualifying child, attach Schedule EIC. b Nontaxable combat pay election 64b BS Excess social security and tier 1 RRTA tax withheld (see Page 61) 85 66 Additional child tax credit. Attach Form 8812 ~ 87 Amount paid with request for extension to file (sse page 61) 87 88 Credits from Form: a ^ 2439 b ^ 4136 c ^ 8801 tl ^ 8885 ~ 69 First-time homebuyer credit. Aiach Form 5405. ~ 70 Recovery rebate credit (see worksheet on pages 62 and 63) . 70 71 Atltl tines 62 through 70. These are your total payments - 71 Refund 72 If line 77 is more than line 67, subtract line 61 from line 71. This is the amount you overpaid 7R Direct deposit? 73a Amount of line 72 you want refunded to you. tt Form 8888 is attached, check here - ^ 73a See page 63 - b Routing number - c Type: ^ Checking ^ SaNngs and fill in 736, 73c, and 73d, - d Account number or Ferm 8888. 74 Amount of line 72 ou wants lied to our2009 estimated tax - 74 Amount 75 Amount you owe, Subtract line 71 from line 61. For details on how to pay, see page 65 - 75 563 00 Y 78 Estimated tax penalty (see page 65) 78 Third Party Do you want to allow another person to discuss this return with the IRS (see page 66)? © Yes. Complete the following. ^ No Designee Designee= Phone ` Personal idemification _ I~A~ Ir,~tinl., , Cl\~f , rr1V1 CCCA _.. 1 Sign UMer pereltias of perjury, I declare that I have examined this return ant accompanying schedules and statemems, alyd to the best of my knowledge and belief, they era true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knawletlge. Here y r si lure Date Vour occupation Daytime phone number Joint return? ' See Page 15. I Z//'~io rf G~l/t~Fl~ f6 Dpi `nl a -8-c5"/ Keep a copy ousels signatur . If a joint return, both must sign. ate Y~ Spouse's occupation for your records. Paid Preparers Date signature Preparer's Firm's name (or USeOnly voNrsifaek-emoieved),/ ® PmWMrx9~IVW1r Check if Preparer's SSN or PTIN c ) Form ~ U4U (2008) r J /~ ~. ~ + 040 Department of the Treasury-Intornal Favenua Service 11©0 /~ a t U.S. Individual Income Tax Return /~/ Vx (99) IR6 uss Ony-0o not write a staple in this space. For the year Jan. 1-Dec. 31, 2C08, or other [ax year begiming Jan 1 .2008, ending AU J 18 • 2d OMB No. 1545-0074 Label Vour first name and initial last name ; Vow social security number (~ t Myrtle 1. Woods (DECEASED, Au ust 18, 2008) j 177 i 10 ; 2468 instructions A On page 14.) a If a joint return, spouse's first name antl initial Last name Spouse's social security number E Use the IRS ~ 7abe1. N Home address {number antl street). IF you have a P.O. box. see page 14. Apt. no. you must Bnter Otherwise, E 100 Messiah Circle 428 1', • your SSN(s) above.. please print a or fype. E City, town or post office, state, antl ZIP code. If you have a foreign address, see page 14. Checking a bOX belOW will nOt Pt'esideMial Mechanicsbur , PA 17055 change your tax or refund. Election Campaign ~ Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see page 14) - ^ You ^ Spouse 1 ~ Single 4 ^ Head of househdd (with qualifying person). (See page 15.) If Fifing Status p ^ Married filing jointly (even if only one had income) the qualifying person is a child but not your dependent, enter Check only 3 ^ Married filing separately. Enter spouse's SSN above this child's name here. - one box. and full name here. - 5 ^ QuaNtymg widow(er) wdh dependent child (see page 16~ Ba Exemptions b c If more than four dependents, see page 17. Yourself. If someone can claim you as a dependent, do not check box 6a . . Spouse .i. Dependents: (1) First name Last name Q) Dependent's sacral security number (a) Dependent's relationship to eu (Q if qusliTyirg child for child tae credit see a e V poxes cneoxee t an Ba antl 66 No. of dlildren on Bc who: • lived witlr you _ • did tpt IWe with you due to dNace or aepareeon flee Page 18) Dependems on Bc rrot entered abov®^ Atltl numhere onn Attach Form(s) W-2 7 Wages salaries tips etc r , . , , Income 8a Taxable interest. Attach Schedule B it required Se 3683 45 Attach Form(s) b Tax-exempt interest. Do not include on line 8a ~ W-2 here. Also 9a Ordinary dividends. Attach Schedule Brf required 9a attach Forms b Oualttied dividends (see page 21) ~ W-2G antl or offsets of state and local income taxes (see page 22) 10 Taxable refunds credRS if 10 . , , 1098-R tax was wfthheld. 11 Alimony received 11 Attach Schedule C or C-EZ 72 Business income or (loss) 72 . tt not required check here - ^ ain or (loss) Attach Schedule D if required 13 Ca ital 13 . , g . p It you did not 14 Other gains or (losses) Attach Form 4797 14 . get a W-2, 158 IRA distributions 158 . b Taxable amount (see page 23) 156 see page 2l. 188 Pensions and annuities tBa 12264 00 b Taxable amount (see page 24) 16b t2264 00 etc. Attach Schedule E partnerships S corporations trusts but do 17 Rental real estate royalties EnGose 17 , , , , , , not attach, any 18 Farm income or (loss) Attach Schedule F 18 . payment. Also, t9 Unempbyment compensation 19 please use - 208 Social security dene8ts ~ 20a 25151 40 h Taxable amount (see page 2fi) Form 1040-V 20b 0 00 . List type and amount (see page 28) 21 Other income 21 . 22 Arlo ihw amounts in ihw far right cOlumnforlines 7throueh 2l. This is vourtotal income - 22 15947 45 23 Educator expenses (see page 28) ~ AdJUSt@d 24 Certain business expenses ct reservists, performing artists, and Gros$ lee-basis government offcials Attach form 2106 or 2106-F1 ~ . Income 25 Health savings account deduction Attach Form 8889 25 . . Attach Form 3903 26 Moving expenses ~ . 27 One-half of self-employment tax Attach Schedule SE 27 . . and qualified plans SIMPLE 28 Self-employed SEP ~ , . , 29 Sett-employed health insurance deduction (see page 29) ~ 30 Penalty on early withdrawal of savings ~ 318 Alimony paid b Recipient's SSN - 31a 32 IRA deduction (see page 30) ~ 33 Studem loan interest deduction (see page 33) ~ . 34 Tuition and fees deduction. Attach Forn 8917 ~ . 35 Comestie production activities deduction. Attach Forn 8903 ~` 38 Add lines 23 through 318 and 32 through 35 ~ 37 Subtract line 36 horn line 22. This is your adjusted gross in come - 37 15947 45 For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 88. Cat No. 113208 Form 1040 (2008} /~. /~~ JOHN KOPALA Account Summary ~~ Previous Charges No Payment Received 00 Balance $ .00 New Charges Verizon Long Distance(page 3) -$ 4.20 Total New Charges Due - $ 4.20 Refund cheek to follow $ 4.20 Total Due $ .00 - FINAL BILL - Pay your bill online at verizon.com/payflnalbill Billing Date: 09/11/08 Page 1 of ~~ Telephone Number : 717 691-6381 Account Number: 717 691-6381 743 42Y Moving? Mov7ng? 1-866-VZ-MOVES One call gets you up & running! Count on the Verizon network to make at least one paM of your move easier. Across the street or across the nation all you need is one call fo Verizon to set up yourlnternet, phone & digital TV in your new home in no time. Service availability varies. ~~ Verfzon Foundalfon Visit Thinkfinity.org for thousands of FREE educational resources for teachers, students, parents antl the after-school community. 1/@I'/~Oifl JOHN KOPALA Billing Date: 08/i0/08 Page i of 6 Telephone Number : 717 691-6381 Account Number: 717 691-6381 743 42Y Account Summary Previous Charges $ 23.50 Payment Received Jul 23. Thank You. _ - 23.50 Balance $ .00 New Charges Verizon (page 3) $ 15.63 Venzon Long Distance (page 3) 7.88 Total New Charges Due Sep 04 _ _ $ 28.51 Total Due $ 23.51 ^-^' JOHN KOPALA Account Summary Moving? Moving? 1.866-VZ-MOVES One call gets you up & running! Count on the Verizon network to make at least one part OI your move easier Across the street or across the nation all you need is one call to Verizon to set up your Internet, phone & digita! TV in your new home in no time. Service availabilty varies. Billing Date: 09/02/08 Page 1 of 4 Telephone Number : 717 691-8381 Account Number: 717 691-6381 743 42Y Moving? Previous Charges $ 23.51 Payment Received Aug 22. Thank You. - 23.51 Balance $ .00 New Charges Verizon (page 3) - $ 10.47 Total New Charsies Due - $ 10.47 Refund check to Total Due - FINAL BILL - Thank you for letting us serve you. Pay your bill online at verizon.com/payfnalbill Moving? 1-866-VZ-MOVES One call gets you up & running! Count on the Verizon network fo make of /east one part of your move easier. Across the street or across the nation a!! you need rs one call to Verizon to set up your Internet, phone & digital TV in your new home in no time Service availability varies. _ $ 10_47 $ .00 ' I"~ Verizon Foundation Visit Thinkfinity. org for thousands of FREE educational resources for teachers, students, parents and the aRer-school community * ACTIVITY FOP. WIOODS, MYRTLE 08/15/08 7410064 14 ACETAMINOPHEN 500 08/15/08 7410067 4 PANTOPRAZOLE 40MG '0$/15/08 7410071 4 VITAMIN H-6 100 M 08/15/08 7410077 7 DOCUSATE SODIUM 1 O$/15/OS 74].0184 4 FERROUS SULFATE 3 OB/1S/OS 7410079 3 LEVOTHYROXINE 75 08/20/08 7410061 1 LISINOPRIL 5 MG 09/0$/08 1 Pymt- - 00032943 -LVOODMI - -120707 Ol • 2.79 .00 2.79 O1 3.42 .00 3.42c. O1 * 1.59 .00 1.59 ~ O1 * 2.69 .00 2.69 I O1 * 2.63 .00 2.63 O1 .56 .00 .56c O1 .37 .00 ,37c 74.92- 74,92-' - - _ _ __ _. I .00~ 4.35 - -9.70 I LEGEND NON-LEGEND rora~_rax ~ FOR MONTH FOR MONTH] AMOUNT DUE _ ___ Charges thin month Finance Char a TOTAL CMAR6ES meat Paymone s cream 74.92 + 14.05 + .00 88.97 74.92 - 14.05 FOR ALL PHARMACY RELATED WQUIRES PLEASE CALL AIert Pharmacy Services, Inc at 1-800-266-9954 Statement TertninolotlY on reveree y* ACTIVITX FOR WOODS, MYRTLE -WOODMl - -120707 07:/24f0:8 _7410064 86 ACETAMINOPHEN 500 O1 * 3,75 .00 3.75 ~'~ 07/24/08- 7410067 21 PANTOPRAZOLE 40MG O1 16.46 .00 16.46c ', 07/24/08 7410070 11 POTASSIUMCL TOME- O1 .97 .00 .97ci .07/24/08 .7410071 1 VITAMIN B-6 100 M 01 * 1.59 .00 1,59 07/24/08 7410076 33 CARVEDILOL 3.125 O1 7.13 .00 7, 13c 07/24/08 7410077 43 DOCUSATE SODIUM 1 O1 * 3.18 ,00 3.18 ' 08/O1/O6 7410083 1 FUROSEMIDE 40MG 01 .36 ,00 ,36c 08/07/08. 't406009. 11 OMEPRAZOLE 20MG O1 18.27- ,00 18,27- 0&/10/08 7410.079 12 LEVOTHYROXINE 75 O1 1.20 .00 L 20c 08/11/08 1 Pymt- - 00032223 ~ 107.89- 107,89- 08/12/08 7414062 5 ALLEVYN ADHESIVE O1 * 29.60 .00 i 29.60 08./12/08 7410081 12 LISINOPRIL-b MG O1 .59 .00 ,59c 08/.14/08 7417297 28.35 HYDROCORTISONE 1~ 01 * -4.71 ,00 4.71 ~~ 08/18/08. -7418500 5 ALLEVYN THIN 4X4 01 * 20.35 .00 20.75 08./28/08 7418628 28.35 PETRQLATUM WHZTE - 'O1 * 2.63 .00 2.67 i Q8/20[08 7418500 5 ALLEVxlN THIN .4X4. Ol.. * 18.04- .00 18,04- '. M ~-' g f~ ja 7' Sig ~ ~~~ ~~ I - _. - - $ . 4~ - -- 444444 .2~ ' . O O - - - - - II- LEGEND, NON-LEGEND Torah Taxj s reuious Balaece chaises thin month Frranee CNarge TO AL Ci~tA GE so~+~ r"~+tO ~.w~~ AMOUNT DUE 126.16 + 92.96 + .00 _ 219.12 144.20 74.92 FOR ALL PNARMACYRELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 S~atemeril Terminology on reveres essiah v~ ~~A~~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 i °im PB U1 OUESTIONS? CALL: 717 697-4666 RESIDENT # UNiT STMT. DATE 120707 026 D 08/31/2008 RESIDENT S SUSAN KOPALA Mrs. MYRTLE WOODS 2645 E. SIERRA ST. PHOENIX, AZ 85028 .TOTAL AMOUNT DUE $6,155.14 DATE DUE 09/30/2008 DATE DESCRIPTION RATE ~f~t4 CHARGES CREDITS BALANCE Balance Forward 6,119.72 08/12/08 PAYMENT RECEIVED -THANK YOU!!! 6,119.72 0.00 08/31/08 PAYMENT RECEIVED -THANK YOUrrr 320.00 -320.00 GUEST RM 876 - 8/13-8/14/08 *** Assisted Living *** 08!13/08 SRC - JUNIATA 08/01-08/13 116.28 13.00 1,511.64 1,191.64 *** Nursing Care *"* 08/14/08 GUEST ROOM -APARTMENT 40.00 8.00 320.00 1,511.64 GUEST ROOM 8/13-8/20/08/ 08/17/08 RM! BRD -NURSING -SEMI-PVT 272.00 17.00 4,624.00 6,13_5.64 08/01-08/17 08/18/08 PREVAIL PROTECTIVE UNDERWEAR L30 15.00 19.50 6,155.14 RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 720 TOTAL AMOUNT DUE 120707 6,155.14 0.00 0.00 0.00 0.00 $6,155.14 RESIDENT NAME Mrs. MYRTLE WOODS F°,m P6-0, A ] % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! R,A` } m,~p0... 4 ur mF s `~~+ -, .-~ ~~ '' m ~. ~~ r~ ~,~ ~u >T~,_,_, M - M M `!; C O = ~ ~ ~ ~" 3 ~,~ ~ ~ ¢ o~ o a ~ ~ ~ . .~ ~ ~ o _' ~ o U ~ = aU -~ U ~p ' "E ~ ~~ I l I S . ~ ~~ ~ ~i, II~ l~ I '! I t p ~ ~ I ,~ g I, F~ „ i g f~ ll .I $ 4 i ' ~ ~ ~ ~ ` i l l I " ~ t ~ h ~~ ~ `, 1 i ~.~ ~ II I ~~~ 1 ~ l1 ~ `rr I. a ~E i~ l M d~ Ck ~ I~ ~ ~ ~~ ~ ~~ ~ ~ ~ ~ ~ C A ~ ~~~ ~ a ~ ~ ~~ ~~ ~ ~ ~ ~~ ~~ ~ ~I ~ ~~ ~~ ~ k ~ ~ 1 ~~ ~ 4 ~ ~ ~ ~ ~ '~f ~ ~ I l ll~ ~f l l ~ ~~ 1 6 N ~ G~ ~~ I ~ ~ ~°~ li ~ ~ I l I i i ! ~ o, ' ` 6 ~i l l~ Y ~ 1/'~ °O I ~ ~ X ' p ) { ~ ~S i l l I I ~ l~ I ~ ~ ~ ~ ~ ~ M s ~ $ t 2 l ~ 4 ` j ~~„ ~ i I ~~ i f i ~ ~ ~l' ¢ ¢ 2 ~~ ~ ~~ o , ,~ Itw~ q ; I l i i l ~ ii ~„ ~ v ~l . ~ ~ v'i N ~ 1. ,~ a II l lol ~ l ~ l ~ r ~ l ~ ~ l l ~lel ~.: