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Home My WebLink About04-01-09 '' (2008-00969) J 15056041125 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PoBOxz8osol INHERITANCE TAX RETURN 2 1 0 8 0 9 6 9 Hamsburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 0 8 0 2 2 0 0 8 0 2 0 9 1 9 4 2 Decedent's Last Name Suffix Decedent's First Name MI K l o u s e r M a r l i n H (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI K l o u s e r P a t s y L Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ^X 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) OX 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 H a r r y J B r o w n E s q u i r e 5 7 0 2 2 ~6 9 3~ ~o -~,-~ i~.~ Firm Name (If Applicable) - - -- ----- - ~ REGIST WILLS U~ONLY~, j `_3 P f e i f f e r B r o w n D i N i c o l a ~ ~ ~'= ~~= ~~~ i ~;; First line of address ~',~? C~ 1 8 0 0 W e s t E n d A v e n u e ~~~ _ ~ ~_; Second line of address ~~ C.3 ~--~ jj ~, ~ ~" City or Post Office cr~ro ~i~ r„,~e DATE FILED P o t t s v i l l e P A 1 7 9 0 1 Correspondent's a-mail address:pbdg@bUl-dell-Of-pPOOf.COm 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 and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT~RE OF PERSON RESP9rJSIBLE FOR FILING RETURN DATE ADDRESS V` 12 Reservoir d He ins PA 17938 SIGNAJ~R PREPARE OT HAN REPRESENTATIVE DATE / A ~t~-~~.v~ ~_ 7 i na 1800 West Avenue Pottsville PLEASE USE ORIGINAL FORM ONLY PA 17901 Side 1 15056041125 15056041125 J ~ 3 ~ 15056042126 REV-1500 EX RECAPITULATION 1 2 7 6 0 0 3. 0 0 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 8 0 3 1 3 0 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... ... 5. , 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6. • 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested .... ... 7. 8. Total Gross Assets (total Lines 1-7) ...................... ... 8. 2 9 4 0 3 4, 3 0 9. Funeral Expenses & Administrative Costs (Schedule H) .... ... 9. 1 5 2 3 2 0 1 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........ ... 10. 2 4 5 8 3 , 3 9 11. Total Deductions (total Lines 9 & 10) ........................ ... 11. 3 9 8 1 5 , 4 0 12. Net Value of Estate (Line 8 minus Line 11) ...................... ... 12. 2 5 4 2 1 8 , 9 0 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ............... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .............. ... 14. 2 5 4 2 1 8 • 9 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x.o _ 2 5 4 2 1 8 9 0 15. 0, 0 0 16. Amount of Line 14 taxable at lineal rate X .0 _ 0, 0 0 16 0, 0 0 17. Amount of Line 14 taxable 0 0 0 0 0 0 at sibling rate X .12 , 17. , 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18 O, 0 0 0 0 0 19. Tax Due ......... ........................... .. ..... ..19. , 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042126 15056042126 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 08 0969 DECEDENT'S NAME Marlin H. Klouser STREET ADDRESS 125 State Road CITY Mechanicsburg STATE PA ZIP 17055 Tax Payments and Credits: ~ Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InteresUPenally if applicable D. Interest E. Penalty Total InteresUPenalty (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 t + 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 + 5A. This is the BALANCE DUE. 0.00 (3) 0.00 (4) 0.00 0.00 (5) (5A) (5B) Make Check Payable fo: 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 : ................................................................ ...... ^ ^Q b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^ ^X c. retain a reversionary interest; or .......................................................................................... ...... ^ 0 d. receive the promise for life of either payments, benefits or care? ................................................. ...... ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................. ...... ^ 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ... ...... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................................ ...... ^ 0 0.00 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 childtwenty-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-1502 EX + (6-98) i ~ SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Marlin H. Klouser 21 08 0969 All real property owned solety or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real roe which is 'ointl -owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ALL THAT CERTAIN tract or parcel of land situate in the Township of Silver Spring, 276,003.00 County of Cumberland and Commonwealth of Pennsylvania, more accurately described in a certain Deed dated December 3, 2007, and recorded in the Office of the Recorder of Deeds in and for Cumberland County, at Instrument Number 200745053. Cumberland County Tax Parcel # 38-08-0567-021 B Assessed Value $219,050.00 x Common Level Ratio 1.26 = $276,003.00 Fair Market Value TOTAL (Also enter on line 1, Recapitulation) ~ $ 276,003.00 (If more space is needed, insert additional sheets of the same size) D E E D ~~~~3 ~- THIS INDENTURE, made this day of ~~~1-'u->e,1-- , in the year Two Thousand Seven (2007), BETWEEN MARLIN H. KLOUSER of 125 State Road, Mechanicsburg, Pennsylvania 17050; and PATSY LEE KLOUSER, of 115 South 4~' Street, Tower City, Pennsylvania 17980, hereinafter called the GRANTORS, -AND- MARLIN H. KLOUSER, of 125 State Road, .Mechanicsburg, Pennsylvania 17050, hereinafter called the GRANTEE; WITNESSETH that in..consideration of tie sum of ONE ($1.00) DOLLAR, in hand paid, the receipt whereof is~ hereby acknowledged, the Grantors do 1~ereby grant and convey unto the Grantee, his heirs and assigns, ALL THAT CERTAIN tract or parcel of land situate in the Township of Silver Spring, County of'Cumberland and Commonwealth of Pennsylvania, more particularly bounded and described as follows, TO WIT: BEGINNING at a point on the Western dedicated right-of--way line of State Road, S.R. 2012 (30' from centerline) at the dividing line between at the dividing line between Lots 3-A and 3-B as shown on the hereinafter mentioned plan of Lots; thence along the Western dedicated right-of--way line of State Road, S.R. 2012 South fifteen degrees, twenty-one minutes, fifty-two seconds Easf (S. 1 S° 21' S2" E.)'a distance of two hundred sixty-one and seventy-five hundredth ~~et.(2C 1:75') to a point; thence continuing along the same by a curve, curving to the left having a radius of two thousand three hundred sixty-nine and thirty hundredth feet (R=2,369.30') and arc length of two hundred thirty-three and sixty-two hundredth feet (AL=233.62') and chord bearing of South sixteen degrees, fifty-nine minutes, fifty-four seconds East (S. 16° 59' S4" E.) and chord distance of two hundred thirty-three and fifty-three hundredth feet (233.53') to a point; thence along the Northern line of lands now or late of Konhaus Farms Inc. South sixty-seven degrees, fifty minutes, zero seconds West (S. 67° 50' 00" W.) a distance of five hundred sixty- one and fifty-two hundredth feet (561.52') to a point at the dividing line between Lots 3-A and 3-B; thence along the dividing line between Lot 3-A and 3-B North five degrees, fifty-four minutes, zero seconds East (N. OS° 54' 00" E.) a distance of five hundred seventy-five and forty- six hundredth feet (575.46') to a point; thence continuing along the same North seventy degrees, twenty-three minutes, eighteen seconds East (N. 70° 23' 18" E.) a distance of three hundred forty-three and fifteen hundredth feet (343.15') to a point on the Western dedicated right-of--way line of State Road, S.R. 2012, being the PLACE OF BEGINNING. CONTAINING 226,059.72 square feet or 5.190 acres. BEING Lot No. 3-A as shown on a Find Subdivision Plan of 125 State. Road. Said plan being recorded in the Office of the Recorder of Deeds in and for the County of Cumberland, in Plan Book 94, Page 79. Project Drawing No. 206052 prepared by Hoover Engineering Services, Inc. CUMBERLAND COUNTY TAX PARCEL # 38-08-0567-021B TAX EXEMPT -TRANSFER BETWEEN HUSBAND AND WIFE BEING THE SAME PREMISES -which Marlin H. Klouser and Patsy Lee Klouser, his wife, by Deed dated August 18, 1987, and recorded in the Office of the Recorder of Deeds in and for Cumberland County in Deed Book W32, at Page 595, granted and conveyed unto Marlin H. Klouser and Patsy Lee Klouser, his wife, Grantors herein. TOGETHER with all and singular the buildings and improvements, ways, streets, alleys, passages, waters, water-courses, rights, liberties, privileges, hereditaments and appurtenances, whatsoever unto the hereby granted premises belonging, or in any wise appertaining, and the reversions , and rern~inders, rents, issues .and profits thereof; and all the estate, right, title, interest, property, claim and demand whatsoever of the said Grantors, as well at law as in equity, of, in and to the same. TO HAVE AND TO HOLD the said lot or piece of ground above described, with the messuage or tenement thereon erected, hereditaments and premises hereby granted, or mentioned and intended so to be, with the appurtenances, unto the said Grantee, to and for the only proper use and behoof of the said Grantee, his heirs and assigns forever. r AND the said Grantors, for themselves, their heirs, executors and administrators, do hereby covenant, promise and agree, to and with the said Grantee, his heirs and assigns, by these presents, that they, the said Grantors and their heirs, all and singular the hereditaments and premises hereby granted or mentioned and intended so to be, with the appurtenances, unto the said Grantee, his heirs and assigns, against them, the said Grantors and their heirs, and against all and every person or persons whomsoever lawfully claiming or who shall hereafter claim the same to any part thereof, by, from or under it, them or any of them, shall and will WARRANT and forever DEFEND. ~ WITNESS WIIERE~F, the Grantors have hereunto set their hands and seals the day and year first above written. SEALED and DELIVERED in the presence of: ~L~ ~. (SEAL) MARLIN H. KLOUSER (SEAL) PATSY L OUSER STATE OF PENNSYLVANIA SS COUNTY OF ~ H V Y L ~~ LPL . On this, the 3~~ day of ~e2rrL~y~ , 2007, before me the undersigned officer, personally appeared MARLIN H. KI.OUSER, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within Deed and acknowledged that he executed the same for the purposes VV)rIEREOF, I hereunto set m} hand and official seal.. (SEAL) tary Public My Commission Expires: STATE OF PENNSYLVANIA COUNTY OF SCN U `l L K~ ~. t-- s :SS CO MONV~ ,AL"fH~ PENNS`n-VAN(A Notarial Seal Heather L. Bixler> Notary Public ill Haven Boro, Schuylkill County Schuylk' tres July t2, 2008 Nly Commissio,~,J:xp On this, the ~~o day of ~eP.t'~'tb..2.~ , 2007, before me the undersigned officer, personally appeared PATSY LEE KLOUSER, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within Deed and acknowledged that she executed the same for the purposes therein contained. ~REOF, I hereunto set my hand and official seal. (SEAL) Notary Public My Commission Expires: is CQMMONVI' :ACTH OP PENNSYLVANIA Notarial Seal 1-leather L. Bixler, Notary Public Schuylkill Haven Boro, Schuylkill County My Commission Expires July 12, 2008 115 South 4`~ Street Tower City, PA 17980 ROBERT P. ZIEGLER RECORDER OF DEEDS CUMBERLAND COUNTY 1 COURTHOUSE SQUARE CARLISLE, PA 17013 717-240-6370 Instrument Number - 200745053 Recorded On 12/4/2007 At 10:45:33 AM * Instrument Type -DEED Invoice Number -10025 User ID - AF * Grantor - KLOUSER, MARLIN H * Grantee - KLOUSER, MARLIN H * Customer - PFEIFFER BROWN ET AL * FEES STATE WRIT TAX $0.50 STATE JCS/ACCESS TO $10.00 JUSTICE RECORDING FEES - $11.50 RECORDER OF DEEDS AFFORDABLE HOUSING $11.50 COUNTY ARCHIVES FEE $2.00 ROD ARCHIVES FEE $3.00 TOTAL PAID $38.50 * Total Pages - 5 Certification Page DO NOT DETACH This page is now part of this legal document. I Certify this to be recorded in Cumberland County PA cf cuye~ . ~~ ~~-~~° RECORDER O ciao * -Information denoted by an asterisk may change during the verification process and may not be reflected on this page. III IIIIYInIYll~llfllm REV-1508 EX + (6-98) ' SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Marlin H. Klouser 21 08 0969 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Members 1st Federal Credit Union 49.01 Account No. 263602-00 Date of Death Balance 2. Members 1st Federal Credit Union 17,895.29 Account No. 263602-11 Date of Death Balance 3. Erie Insurance Exchange 87.00 Policy # Q07 1206389 H Refund of Unused Premium TOTAL (Also enter on line 5, Recapitulation) I $ 18 031 (If more space is needed, insert additional sheets of the same size) MEMBERS 1St FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix 263602-00 Date Account Established 04/22/2005 Principal Balance at Date of Death $49.01 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest $49.01 Name of Joint Owner None CHECKING ACCOUNT: Account Number/Suffix 263602-11 Date Account Established 04!22/2005 Principal Balance at Date of Death $17,895.17 Accrued Interest to Date of Death $.12 Total Principal and Accrued Interest $17,895.29 Name of Joint Owner None LOAN ACCOUNTS: Account Number/Suffix Date Loan Established Principal Balance at Date of Death Loan Type Interest Rate Collateral Held as Security Name of Co-Borrower 263602-01 12/31 /2007 $24,583.39 Home Equity/Contractual Pledge of Shares 6.99% 125 State Road Mechanicsburg, PA 17050 None *Loan does not have credit life coverage. E BERS 1sT DE L CR D NION ~~ ~ ~~~ Danielle A. Kline Insurance Services Specialist October 17, 2008 Estate of: MARLIN KLOUSER Date of Death: August 2, 2008 Social Security Number: 202-32-4114 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 www.memberslst.org Erie Insurance ~\ Exchange Member Erie Insurance Group 100 Erie Ins. PI. Erie, PA 16530 ERIE INSURANCE EXCHANGE P.O. BOX 1699 ERIE, PA 16530 CANCELLATION NOTICE NAMED INSURED COPY MAIL DATE 01/05/09 CANCELLATION EFFECTIVE BAL: $87.00 CR POLICY NUMBER QO7 1206389 H 01/02/09 12.01 AM POLICY EFFECTIVE DATE 07/12/08 PIONEER FAMILY AUTO POLICY STANDARD TIME NAMED INSURED ESTATE OF MARLIN H RLOUSER 125 SLATE RD AA7646 MECHANICSBURG PA 17055 WE ARE NOTIFYING YOU THAT THE ABOVE POLICY IS CANCELLED AS OF THE CANCELLATION EFFECTIVE HOUR AND DATE SHOWN ABOVE. IF WE HAVE BEEN ASKED TO PROTECT OTHER INTERESTS, WE ARE REQUIRED TO ADVISE THEM OF THIS CANCELLATION. THE REASON FOR THIS ACTION REQUEST OF NAMED INSURED - SOLD PREVIOUS BALANCE UNUSED PREMIUM PRESENT BALANCE 00090 FETR AA7646 FETROW INS ASSOC LLC $.00 $87.00 CR $87.00 CR REFUND CHECK ENCLOSED 932EXC 6/00 REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Marlin H. Klouser 21 08 0969 Debts of decedent must be reported on Schedule t. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Malpezzi Funeral Home -funeral expenses 2,097.00 B 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)IEIN Number of Personal Representatives; Street Address City State Zip Year(s) Commission Paid: 2, Attorney Fees Pfeiffer, Brown, DiNicola & Frantz 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Relationship of Claimant to Decedent 4. ~ Probate Fees Register of Wills of Cumberland County 5 I Accountants Fees 6. I Tax Return Preparers Fees 8, 821.03 430.00 7. Capital One Credit Card (Account No. 5291-4925-5802-3525) 539.74 8. Schuylkill Otolaryngology Assoc. (Account No. 38710) 30.00 9. Jackson Siegelbaum Gastroenter (Account No. 29160) 70.00 10. West Shore Endoscopy Center (Account No. 29160) 250.00 11. Olivetti Chiropractic Chiropractic Office (Chart Number KLOMA000) 30.00 12. Sadler Health Center Corp. 63.00 13. Holy Spirit Hospital (Account No. 30755870) 1,500.00 14. Darren Barbacci DPM (Account No. KLOMA000) 30.00 15. West Shore Surgery Center (Account No. 47641-1&2) 500.00 16. Hartzell Eye M.D.s (Account No. CA40172) 100.00 17. Verizon -Final Telephone Bills 71.01 18. Comcast -Final Cable Television Bills 191.05 TOTAL (Also enter on line 9, Recapitulation) $ 15.232.01 Zip (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent Marlin H. Klouser 21 08 0969 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses 8~ Administrative Costs - 67. ITEM NUMBER DESCRIPTION _ AMOUNT 19. I PPL Electric Utilities -Final Electric Bills 20. Travelers -Homeowners Insurance Premium (Account No. 035214716) 92.18 417.00 SUBTOTAL SCHEDULE H~67 I 509.18 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are otily for those items that you selected or that are required. If we aze required bylaw or by a cemetery or txematory to ttse atry items, we will explain the reason in writing below If you selected a funeral that may requke embalmitg, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalm- ing you did not approve ff you selected atxangements such as direct cremation or immediate burial. If we charged for embalming, we ~ explain why below Foc the Service of ~ ° I ' > >a !G l e - o r Date of Death +' 4+_ i~ ~~` ^•~ Chuge to: I ' .1 ~ f /f(o~,~ -r S ! llk~r+A ~'"~ s'rr t- ~{rc„«---` Ai5l~ jb'/ l z.t,.,~.t! ~~ ~ ' ~'~'1. ame Address Ctty State ,.s'" A. CHARGE FOR SERVICES SELECTED: t. PROFESSIONAL SERVICES Services of Funeral DtrectodStaff .... f t•~' t Embalming ...................... i Other preparation of body ............................... f SUB-TOTAL OF PROFESSIONAL SERVICES......... Alf ~^ct• 2. FACILITIES AND SERVICES Use of facilities and services for viewing (VisitatioNWake)......... i Use of facilities and services for funeral ceremony ............ i Use of facilities and services for Memorial Service ............... f Use of equipment and services for graveside service ............. f Other use of facilities ............................... f i~ct SUB-TOTAL OF FACILITIESBQUIPMENT ........... A2 f 'n<t. 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home. Local ........................ ... f ~...t. Hearse (Casket Coach) Local ........................ ... i Limousine Local ........................ ... f Family cu Local ........................ ... i Flower cu or floral disposition Local ........................ ... f Lead cu/clergy cu Local ........................ ... f Cu for pallbearers Local ........................ ... f Out of town transportation ...... ... f ~i n An,\ t., Cro •~ u.rV f .rte t f Other clothing Cremation urn (Description) _ OTHER _ f f f TOTAL MERCHANDISE SELECTED .................. B f ` c C. SPECIAL CHARGES: Forwarding of remains to f (Funeral Home) Receiving of remains from Home) Immediate Burial ................. f Direct Cremation ................. f l~'~ f SUB-TOTAL OF SPECIAL CHARGES . ........ . D. CASH ADVANCED Opening Grave ................. . f Cemetery Equipment ............. . f Lot and Deed ................... . f Newspaper Notices-Local ........ . f ttx~ Newspaper Notices-Out-of-town ... . f ! [~ Telephone & Telegrams .......... . f Airfare ........................ . f Clergy/Mass Offering ............. . i PaBbeuers ..................... . f Certified Co ies of the Death ~ rr.Eg2'!+t.~sa,(o.Uq... Certificate . f ~~ Police Escort ................... . f Flowers ....................... . f Vault Service Charge ............. . f f f t f f s SUB-TOTAL OF ADVANCES ....................... D f SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 i -~<-!, We chuge you for our services in obtaining: TOTAL OF PROFESSIONAL SERVICES, (specify crib aduarues that are marked-up) FACILITIES AND AUTOMOTIVE EQUIPMENT ................................... A f tti. B. CHARGE FOR MERCHANDISE SELECTED: Casket .......................... i_ (Description) Other Receptacle ................. t (Description) Outer burial container ............. i (Description) Acknowledgementcazds ..... ...... f Register book(s) ............. ..... i Memory folders ............. ..... f Prayer cods ................ ..... i Temporary grave muker ...... ..... i Burial clothing .............. ..... f SUMMARY OF CHARGES A. Professional Services, Facilities and Equipment, and Automotive Equipment ...................... f i...l B. Merchandise ..................... f - a C . Special Charges .................. f ~~ D. Cash Advances ................... f~G,. TOTAL OF ALL SECTIONS ........ ............. ... f ~ b i ~7 PAID AT TIME OP OR PRIOR TO ARRANGEMENTS ................ ............. ... f Y" "" BALANCE DUE .................. ............. ... i GbY 7 REASON FOR EMBALMING If any law, cemetery, or crematory requirements have required the purchase of any of the items listed above the law or requirement is explained below. I agree that I have examined the items of goods and services sekcted above and found them to be correct and according to [he arnngemrnts I have requested. l acknowledge receipt of a copy of this Sntement of Funeral Goods and Service Selected. I represent that 1 have sufficient funds available for paymrnt of the cash price for the goods and services selected. I also agree to lnake payment off 7n / .~ within ~~° days. I agree to be jointly and severally liable with an ot~e else who signs below. A late chuge of 1 / per month amounting to per year will be applied to the unpaid balance beginning ~~ ~ u days from the date of this agreement. I will also pay to the Funeral Dvector all reasonable costs paid by the Funeral Director to Collett amounts I owe under this agreement. Those costs may include attorneys' fees, court costs and other rnsts. Any additional services or merchmdise ordered or requested after the date of this agreemrnt will be conside/red part of this agreement and the cost thereof wiB be reflected on the fmal bill or stuement. %;f (Sean Af , ~/~ ~ r.i .~.c~ . C C~k' (Purchaser) ,'/'~~ . (I1;te (Seal) l ./sue-~~-_:-- .~~~_ (Purchaser) ~~(/ .(eensed FunerA Director) ©Pennsylvania Funeral Direttors AuociaNOn WHITE Funml Director YELLOW Funeral Dlrttlor PINK Cusromer form - 600 Revised 4/94 f f .................. f ...... C f j 7~ What,you're saving for ... it's just a click away. R Get there faster with one of the best savings Annual Percentage Yields (APYs) among the top national banks. Go to www.capitalonedired.com Please use Offer Code DG3RPNDDF ~ ~~ Capital Ones R Online Savings Account 3.50% APY* on balances of $10,000 or more MEMBER FDIC ~p~I CapIW One Bank (IJSAi, N.A. Direct Banking C.a{Tltal One, N.A. www.capitalone.com what's !n your walTelT flNANCE Prwiow Balsna Paynwtts i4 CPadks Traraacf(orts New Balarrce M1Nmtun Payment Dw Dsts 3543.57 - 50.00 + 50.00 + $0.00 = $543.57 $0.00 Oct. 06, 2008 Aug. 10, 2008 -Sep. 10, 2008 Page 1 of 1 '~'' YastwCard PWlnum AecasR ts2o1~ Your Account Intormatlon TOTAL CREDIT LINE 55,000.00 TOTAL AVAILABLE CREDIT 54,156.3 CREDIT LINE FOR CASH 52,500.00 AVAILABLE CREDIT FOR CASH 52,500.00 RrASa ar a IrASr na waorrR Pa9rment:. Crodits ~ Adiustlnents Are you irderatedn reprlarldrg your arrant martpepe9 Capitd One cm help. lNe offer great nabs, ra hidden bar. end you vrip receive the one-anaa alknlion of the same personal ben oorlsrdtent fiom cap to close. Visit www.capiWalaflrnlabena.t>orrlTor mare nformefion. Flnance Charges (Please see reverse for important information) Bderlce rate Periodic Carrespondirg FlNANCE applied b nab APR CHARGE Purdrosas 50.00 0.02p6Y. 8.90% 50.00 Cash 50.00 0.02436% 8.9091 50.00 ANNUILL P6tCENTAIiE RATE applied srb parlod: 0.00% At Your Servka - C,o b b nrr0e yar exoua, afYt 1dOD96ti-T070bnporteMtarabYncrdrctpeekbQelanr RslrOarn ® Pay 0r1NrN atratprf~ippp,~or mapyav payleenl b: ~ &iac (USA). NA • P.O. Bon 70pp/ • purbee. NC A SendfagWrlasb. . C+pw On• P.O. Bae 30285 • Sel Late (Yy, LR 8t13001D5 IIiW a gYaaeOe abOrk a C1W~e OR y011r tfala~arKT Please refer b the Big RiDhb Summary an tl1e bads of your sbbment ar visit PLEASE RETURN PORTION BELOW URTN PAYMENT OR LOG ON TO W W W.CAPRALONE.COM TO MAKE YOUR PAYMENT ONLINE. Qt1e" I whops b,ow walletT' 0 5291492558023525 10 0543570288000000009 Account Number. 5291-4925-5802-3525 Please Print address or phone number duuges bebw using blue or black ink. ,tddrc.~ New Balance Minimum Payment Due Date 5543.57 $0.00 Oct. 06, 2008 PLEASE PAY AT IfAST TNIS AMOUNT Amount Enclosed Capital One Bank (USA). N•A• P•0• Box 70884 Charlotte. NC 28272-Oaa4 I1111111111.11'Ilhl'111111111111111111111111'11'1'1111 1'1111'11 Abme Prwwe AAtrwtr Prrune f-nrwyaaHnxt Q 116TOe502 AT OA71 "AUTO 7a2091017ae1 1Z Ol•PeT339 1/90255002(5540551511 MAIL ID NUMBER M~"c~ MARLIN N KLOUSER 51 N CRESCENT ST APART 304 TRERONT, PA 1T~a1-1534 "I'111I'111'I'11I I11'II"11111..Ilrlllrll rlllllllllllllll"1'11' Pleax write your account number on your payment made psyable to Capital One Bank (USA), NA and mail with this coupon in the enclosed envelope. ~~ MARt VI'1tl:R, YATACLt IU:~~ SCH4JYLKILL OTOLARYNGOLOGY ASSOC. 26 SOUTH CENTRE STREET POTTSVILLE, PA 17901-3001 16466-XP69 ADDRESS SERVICE REQUESTED STATEMENT DATE PAY THIS AMOUNT ACCT.# oioi LAST PMT: 08/25/08 $30.00 38710 AMOUNT: 0.00 PAGE: 1 of 1 SHOW AMOUNT rl Please check box if address is incorrect or insurance PAID HERE LJ information has changed, and indicate changelsl on reverse side. i~~~ ~rn~~~rrr~~~rrn~r~r~~nnr~~uri~~r~i~r~ui~n~i~r~r~rr~rr~~ MARLIN H KLOUSER 125 STATE ROAD MECHANICSBURG, PA 17050-3157 ~nr~~~nr~~r~rr~~riun~~ir~~r~~nr~~niur~~n~r~i~~n~~ru~ SCHUYLKILL OTOLARYNGOLOGY ASSOC. 26 SOUTH CENTRE STREET POTTSVILLE, PA 17901-3001 16466-XP69`TG60V937T000692 STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Ins. Date Billed Code Descri tion Dia Char a Ins. Pmt Pat. Pmt. Ad~ust. Amount Ins 11/05/07 11/12/07 99243 Consult, Office Interm 381.4 180.00 72.31 77.69 30.00 *** PAYMENT MUST BS MADE TO AVOID COLLECT ION ACTION *** - _: * - Current _._ . __ . 0.00 0.00 0.00 0.00 30.00 30.00 0.00 $30.00 Message FREE .PARKING at One Norwegian Plaza and Mahantongo Parking Garage.. Please call the office for more details. Make Checks Payable To: SCHUYLKILL OTOLARYNGOLOGY ASSOC. 26 SOUTH CENTRE STREET ,'POTTSVILLE, PA 17901-3001 16466-XP69'TG60V937T000692 Account Number :...38710: Statement Date 08/25/08 Billing Questions (570) 622-5751 29160 JACKSON SIEGELBAUM GASTROENTER 4z3 N 2~ST ST STE 100 CAMP HILL PA 17011 STATEMENT 8113 5372A 3A19 Please Include Securit Code From Back Of Card MASTERCARD ~ CHECK CARD USING FOR PAYMENT VISA VISA DISCOVER AMERICAN EXPRESS ~~ ®^ ^ CARD NUMBER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT REMIT TO: JACKSON SIEGELBAUM GASTROENTER >01914 3913520 001 092096 423 N 21ST ST STE 100 MARLIN H KLOUSER •: CAMP HILL PA 17011 125 STATE RD MECHANICSBURG PA 17050-3157 PLEASE: RETURN THIS PORTION WITH PAYMENT Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT (717) 761-0930 07/18/08 29160 01 CONTINUED PAID HERE CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT MICHEL DO/HIEB MD 110807 OFFICE/OUTPATIENT VISIT, EST, EXTENDED 95.0.0 DX: 009..1 COLITIS, ENTERITIS, AND G r 110807 ADDITIONAL DIAGNOSIS DX: 414.9 CAD 110807" ADDITIONAL DIAGNOSIS DX: 530.81 ESOPHAGEAL REFLUX 110807 ADDITIONAL DIAGNOSIS DX: 455 HEMORRHOIDS 110907 IINISON ADVANTAGE MC # 213219 Filed 0.00 110807 CASH PAYMENT, THANK YOU -15.00 121007 W/O UNISON ADVANTA c# 21321:91 -19.34 121007. Co-ins 30.00 011808 PMT UNISON ADVANTAGE MC c# 2132191 -45.66 021908 Claim Released AARP HEALTH c# 2132192 -0.00 ****** Visit Totals 95.00. 0.00 -8'0.00 15.0 MICHEL DO/'ROLLING3-MAZZA 011408 OFFICE/OUTPATIENT VISIT, E3T, EXTENDED 95.00 DX: 009.1, COLITIS, ENTERITIS, AND.G 011408 ADDITIONAL: DIAGNOSIS DX: 783.21 L035 OF WEIf3HT 011408 UNISON ADVANTAGE MC # 226590 Filed 0.00 011408 CASH PAYMENT, THANK YOU -15.00. 021208 PMT UNISON ADVANTAGE MC C# 2265901 -41.88 021208 W/O UNISON ADVANTA c# 2265901 -18.12 Statement PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: Date: 07/18/08 29160 CONTINUED SEND INQUIRIES /PAYMENTS TO: JACKSON SIEGELBAUM GASTROENTER (717) 761-0930 :423 N 21ST ST STE 100 CAMP HILL PA 17011 01914 39135201H15741 005741 00001/00003 NOTF• Charms and navmanic nnT annaarinn nn this aTatomont will annoar nn Wort mnnth'c ctatomonr 920RfiS110 29160 JACKSON SIEGELBAUM GASTROENTER 42,3 N 2~ST ST STE 100 CAMP HILL PA 17011 MARLIN H KLOUSER STATEMENT 8113 537ZA 8A19 Please Include Securit Code From Back Of Card ^ MASTERCARD CHECK CARD US/NO FOR PAYMENT ^ ®^ Y/SA VISA DISCOVER ^ AMERICAN EXPRESS CARD NUMBER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT REMIT TO: JACKSON SIEGELBAUM GASTROENTER 423 N 21ST ST STE 100 i ~ CAMP HILL PA 17011 PLEASE: RETURN THIS PORTION WITH PAYMENT Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT (717) 761-0930 07/18/08 29160 02 CONTINUED PAID HERE CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT 021208`' Co-ins` 35.00 021908 Claim Released AARP HEALTH c# 22fi5902 0.00 *****• Visit Totals: 95.00 0.00 -75.00 20.01 MICHEL DO/HIEB MD 031708` OFFICE/OUTPATIENT VISIT, EST, INTERMEDIA 70.00 DXs 00:9.1 COLITIS, ENTERITIS, AND G 03170.8 ADDITIONAL DIAGNOSIS DXs 414.9 CAD 031706 ADDITIONAL DIAGNOSIS DXs 530.81 ESOPHAGEAL REFLUX 0317 OS ADDITIONAL DIAGNOSIS DXs 455.0 INTERNAL HEMORRHOIDS WITH 031808 UNISON ADVANTAGE MC # 244792 =Filed 0.00 040308` 60 DAY STATEMENT 041508 PMT UNISON ADVANTAGE MC c# 2447921 -15.45 041508 W/O UNISON ADVANTA c# 2447921 -1:9.55 041508' . Co-ins 35.00 050708:- Claim Released AAAP HEALTH c# 2447922 0.00 ****** Visit Tatals: 70.00 0.00 -35.00 35.0 05070.6: 90 DAY STATEMENT 060908 PRE COLLECTION LETTER SENT $35.00 MICHEL `DO/HIEB MD 061708 -OFFICE/OUTPATIENT VISIT, EST, EXTENDED 110.00 DXs 009.1 COLITIS, ENTERITIS, AND G (Statement PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: Date: 07/18/08 29160 CONTINUED SEND INQUIRIES! PAYMENTS TO: JACKSON SIEGELBAUM GA3TROENTER (717) 761-0930 423 N 21ST ST STE 100 CAMP HILL PA 17011 D1914 3913520005742'.00574200002/00003 NOTE Charms and navments nM annearinn nn this stafamant will annaar nn naxt month's statement- 92096S11( o m ~ Z A Z ~ D a C N o ~N~ w PI ~ 'w roZ'W { S 5C O m ~ r 1-+ zZi w rye -~i g ~WQ Q ~ ~ ~' '~ oH~ F~ C1 o~ H O x H _ ~ N a- N 1 0 ~o w 0 'm 0 d 3 0 m N n ra '.b `A z H 0 0 w 0 1 m ~ o o d o rqC ~o w m 0 1 0 K m v to 0 v o G o K o GO 0 r m 0 m O G f+ C A ~~+ C 3 O C o ~ c rt H x to b N ~ r x,' a C ~t' O ~ N O l0 N GI 'o'o O -.~ S D V O O c Z O ~ O O * O O * O O O O J J 1 * 01 O1 1 eF 01 01 O- 01 1~ ~ ~ ~ ~ » F+ r t+ ~ 01 O 1 aF O V 1 • O v J J 0 0 ~ o o * o 0 0 0 OD OD L aF O, GD 1. * CD 9D O. O '. ro m ~ C d 70 ~ 1 t; d i d b d~ ~ H O x O H H 1 n ^J v L t lJl A+. R H r~ o-e z ~z r z o+H U,H ~•H r 1 w~ 1 ~oulo~o. ~ ~ ~: 1 ~ H ~ _ Q 1 ~ t71 ~ O r ~O ~ ~ ~ 1 '~7 1 '~7 , , H H M O$ 1 y h7 C+! 1 y o z ~ ~ ~ m ~ ~ ~ ~ ~ z 1 orz 1 odc~Hranc~ rH t~o~z t~H zzz~z [sf X11 y 1 O H ~ 1 ~1 O O M W ~ ~ ~ ~ f A C .' «~ ',S1 G O G O 1 ~ ° n [~ 1 nxwxw w a 7 0 Sx ~ ' ~ 1 ~ r i/, ~ ~ ~ W w 1 $ I ~ ~ ~ I 01 H 1 tJf L~ C ~ ~ H o I H I ~ Cw Q~a. ~ w 1 1+ O 1 W w H 1 1 x O fT fT 'y / H N o I W 1 W r w 'r H H ~ or 1 or 1 I : I 1 1 I , 1 :~., 1 1 i 1 1 t F+ N I A ip 1 O 1 0 o I o r o a o l 1, 1 1 1 1 ~ ~ 1 1 F+ r r- Ip' O O i t 0 0 0 0 1 a o r o 0 1 1 1 1 1 1 1 O I O 1_ O 1 0 _ O..: O 1 1 1 i 1 1 1 1 O O 1 1 1 O A 1 _O n 013070 29160 i+~'1''g.~ Pf' Ci~NItrR 423 N 21ST ST SZE .]Lt2 QINPfIttL PA 1'7n11 JY 1}'f .S 0013070 OOtll/000] 00000 3Z332ti07 MARLIN H KLOUSER 125 STATE RD MECHANICSBURG, PA! 17050-3157 111111111l1111f111l1111/1111''1111111111111111!111111111111111 REMIT TO: Please include Seturl Code From Back Of Card ®DSTERCARO CNECK CARD USMVG fOR PAYINEM Y/SA VISA ®O COYER ~ AIAERICAfJEXPRESS CARD CrtNJ18ER EXP. DATE CARDHOLDER NAME 6ECURITY CODE HIGNATURE AMOUNT WEST SHORE ENDOSCOPY CENTER 423 N 21ST ST STE 102 CAMPHILL, PA 17011-2((207 '111'If11/~I'111111 ~'/11"1f'f'1/'!'~'1 //111111111'1111"'1111 PLEASE RETURN THIS PORTION WITH PAYMENT Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT (717) 975-2430 12/11/07 29160 01 250.00 PAID HERE ------------------------------------------------------------------------------------------------------------------------ CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT `MICAEL/MICHEL 081307= CPT: 45380 FACILITY FEE: COLONOSCOPY, M KLOUSER 1200.00 DX: 564.5 081307.-CPT: ADX ADDITIONAL DIAGNOSIS DX: 569.3 081507. UNISON ADVANTAiGE'MC ~ 61537 Filed' 0.00 ~09240~i PMT UNISON ADVANTAGE MC c~ 615371 -183.16 092409 W/O UNISON ADVANTA c~ 6153'1 -766.84 092407 Co-ins 250.00 ***+~** Visit Totals: 1200.00 `0.00 -950.00 250.0 110607 60 DAY STATEt4HNT 120507 90 DAY STATEI4ENT ,y ,,; IF YOU HAVE ANY QUESTYONS, I CAN BE EMAILED AT BILLING@GICARE.COM - 12/11/07 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 29160 CURRENT 30-60 DAYS 60-90 DAYS >'90 DAYS TOTAL ?IN5 PE2~ING 250.00 250.00 0.00 SEND M-CtIJIR1ES ! ~AVM~µ7S TO: WEST '~HOI~ ENDQSCOPY CENTER (717) 975-2430 ~t23 N- 2157 ST 5TE 102 CAMPHILL PA .17011 STATEMENT 8113b 85372li liPE12 t3Nt3 O01 8284 R 250 ---.~ .........,..,o.,t m ~ ~ t6 a m O L O O Z ~ ~ ~ V Y w ~a ti G 0 C N m O w N R ~ N m H ~ ~ ~ ~ O 0 m ti > a , ~ R ~ a a •c ~ u, o O ~ ~ V L ~' ~ O ~ ~ w H U ti ~ m m U ~ t Y ~ CO !_ U N ti ~ 0 O ~ ~ m v ~ o O ti v :. v Q ~ a O •c ~ v~ ~ ~ _ V ~ ~ N O ~ . . c ~ U v •c m ~ ~ c~ ~ Cfl ~_ V ~ ti 0 ~ ~ O ~ v 0 ti Q a N Q. ~ ~ ~ 7 y ~ N U Y ~ •c c Cn L 'C U N O ~ ~ ~ O O C • O ~ M O O ~ ~ ~ O rn c a> ti ti E i1i U N ~ ' C :6 O Q f6 m rq ~ N ` T O p N m ~ y '~ ;c ~ a o ~' C7 0 0 N _~ O ~ O N O r C 0 ~ ~ E Y ~' ca d a~ +• ~ y E J Z o ~ c? co ~ L 0 U E Q ~ Z' N •p ~ N a •` a y o ~ o ~ o ~ ~ U a~ N ~ ~, o Y ~ ~ ~ U O f9 O ~ O g o d N C N O ~ y h ~ :r ~ ~ N a U ~ o ~~~ `~ ~-- ~1 C -~ ''~ 11/20/07 HIEB OFC/OUTPT E&M ESTAB 96.00 -60.Ii6 -20.34 15.00 MOD-HI 25 MZN 5/13/OS 0 HIEB OFC/OUTPT E&M ESTAB 96.00 -60.:34 -20.06 15.00 ~ MOD-HI 25 MIN 05/21/08 GRIMSTE UA DIP STIK/TABLT;WO 10.00 0.00 0.00 10.00 MICRO NON-AUTO 05/21/08 GRIMSTE COLLECTION VENOUS BLD 8.00 0.00 0.00 8.00 VENIPUNCTURE 06/05/08 HIEB OFC/OUTPT E&M ESTAB 96.00 -71.:30 -9.70 15.00 MOD-HI 25 MIN ***"Y" IN INS COLUMN = INSURANCE FILED,"*" AFTER BALANCE = PENDING INSURANCE*** SADLER HEALTH CENTER CORP PROVIDER/ SADLER HEALTH CENTER CORP ~ ~'O s~ GNU (717)218-6670- PRACTICE NAME ~ iNQUIHfES.'..;ALL - T - --- - - -- --- -- - _ ._. . AN ASTERISK APPEARS ON ACCOUNT 8213 KLOUSER NA DATE OF LAST 07 22 0$ INSURANCE O. ~ ~ r'Al ;~AENT 10 04 08 ' / / PENDING / / CHARGES FILED FOR INSURANCE NUMBER _ I PAYMENT ~ DUE DATE 09/04/08 0.00 0.00 0.00_--- ~ - 48.00 _- 15.00 - t 63 00 ~ Over 30 Days Over 60 Days Over 90 Days Over 120 Days ~ ~,~rr~ THisAV~ouNr >TATEMENT DATEI CURRENT _ _ ` ~ TRANSACTIONS AFTER THE CLOSING DATE WILL APPEAR ON YOUR NEXT STATEMENT I~IBIN~I~IIIAp~IV~~n~1~I~q~II~VagIIq~I~IIU~~II _, _ Hol S irit Hos ital CJLY y p p 503N 21ST STREET - -- --- -- - --- --= - -- -- O S P I T A L CAMP HILL PA 17011 ....::'~-~.~-.~:::::::::::::::::: :.::::::::::::::::::::::.~::::.;-: The Spirit of C rt B ~==;~3e'x3~e>~3~i~~#:=-'-.=>=z:_>:~===~>:>:Q~:~~.~ ..........:...:... 800-997--8573 == = - = --- ----- -- -=--- - -- -----=---------=---=---=--- For Account Information, Please Ca11800~997-SS73 ....`-'.;--"""',---`."-.-~:;<::;::-~---=::.n-,=,.;--.::_-: ;.:_~;::~:;:;;;;;:-.;;.::: ~~ Stat~rit o ~CGl.tJ~lt ~~~J,~'d~ Transaction Date Description Amour PREVIOUS BALANCE 7,279.00 11/19/07 OTH COMM C/A MH IP 5,779.00- Estimated Insurance Due: .00 Total Patiert Credits: Account Balance: 1,500.00 Z94 MH IP COMM 1N .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. ______ Plo~ao d~ch and n•turn rrkh your ~jrmunt HOLY SPIRIT HOSPITAL 503 N 21ST STREET CAMP HQ,L FA 17011 ADM DT: 092807 DS H DT: 100807 SB: 21045 717-697-3817 KLOUSER MARLIN N ~ 3 /p ^ ^ ® ^ l_ ADDRESS SERVICE REQUESTED ^ char~igaffd. P~leasemaice°r inaranc~ ~iMorinatlon 00005039 0l ool 30755870 MARLIN H KLOUSER 125 STATE RD MECHANICSBUR6 PA 17050-3157 HR: HSG 296.90 lulake Check Payable To HOLY SPIRIT HOSPITAL • The Ct~V2 Number is the last 3 dlRits an the halt of your aedtt n,d, by your dputore Itt~llltl~~~t~llit~l~ttl.Ital.1...Illt~l~t~ll~it~l~t~ll.~l..ll HOLY SPIRIT HOSPITAL P.O. BOX 822183 PHILADELPHIA,PA 19182-2183 0000307558700000000001500000100?35000000011302 I1BCS,i 118 LUKENS DRIVE NEW CASTLE, DE 19720 ,H< Temp-Returnl~Seruvice Requested v® IIIIII~INII~INII~IIIN ~I~II '~~:~~ ~~~~~~:r~~~ AUG 16 2008 Date of Service: 09/28/07 Original Creditor: HOLY SPIRIT HOSPITAL Patient Name: Marlin h Klouser .. .. _.. Patient Responsibility: ~~~@~~s ~~a3s~ MARLIN H KLOUSER 125 STATE RD MECHANICSBURG, PA 17050-3157 M V1 4 V'1 N Account Number: 30755870 Dear Marlin H Klouser: Your account has been assigned to us for collection. In order to avoid further collection activity, please send payment in full or contact our office at: 1-800-323-1023. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume the debt is valid. If you note' this office in writing within 30 daps from receiving this notice, this office will: obtain verification of the debt or obtain a copy o~ a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice, this office will provide you with the name and address of the onginal creditor, if different from the current creditor. This communication is from a debt collector. Sincerely, Collection Division 1-800-323-1023 Hours: Monday-Thursday 8:OOam-9:OOpm, Friday B:OOam-S:OOpm EST. Payments received will be applied to the oldest account. To have your payment applied to a specific account, please call the toll free number listed above. Hospital Billing & Collection Service, Ltd. is a debt collector that is attempting to collect a debt and any information obtained will be used for that purpose. ` _ _ ` If Payment Has Already Been Made Please Disregard This Letter _ eD-0~~~,~~~ PLEASE RETURN THIS PORTION WITH YOUR PAYMENT Re: HOLY SPIRIT HOSPITAL Patient Name: Marlin h Klouser Account Number: 30755870 ......................... Patient Responsibility: ~~'Q~~' 05301 51 OOOOOOOOOD000000000 005925626 3 00150000 2 N Payment Amount $ 0 a N A HBCS BOX 510232 PHILADELPHIA PA 19175-D232 (IIII V III IIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIII nnnn N NI ''IIII 1 of 1 I'I' Imu N~~~ 'I 'I I ~'~II~ III III'I11(~ I~tll ~II) IIII uuI tl,Il 11111 IIII I~' Darren Barbacci DPM ' 996 E ORANGE STREET LANCASTER, PA 17602 (717)393-4503 MARLIN H. KLOUSER 125 STSTE ROAD MECHANICSBURG, PA 17050 Statement Date 07/23/2008 Chart Number Page KLOMA000 1 Make Checks Payable To~ Darren Barbacci DPM 996 E ORANGE STREET LANCASTER, PA 17602 (717)393503 Date of Last Payment: 4/8/2008 Amount: -37.84 Previous Balance: 0.00 Patient: MARLIN H. KLOUSER Chart Number. KLOMA000 Case: 12/7/07 'Paid. by Paid By Dates Procedure Charge Primary. Guarantor Ad}ustments Remainder 2/07/07 99202 75.00 -28.85 -16.15 30.0( FrIVA~ ~vo TICS If we do not Bear from you within 10 days, this account will be turned over to our collection agency. I Amount Due ..30.00 iNEST SHORE SURGERY CENTER 2015 TECHNOLOGY PARKWAY MECHANICSBURG, PA 17050 7177912500 Statement Date: 07/23/08 Account # 47641 - ~ d' aZ Date of Service: 01 /17/08 Thank you for choosing our facility. Please call our Billing Office, 800-827-3458 Ext 223, with any regarding this statement. MARLIN KLOUSER 125 STATE ROAD, MECHANICSBURG, PA 17050 Please contact this office within 5 days to stop your account from being turned over to collections. Account Activity: Date: ~ Description: 01/07/08 COMMERCIAL BILLING % % BILLING EIW ME 0 4 08 /O DICAR 03/14/08 MEDICARE PAYMENT 03/25/08 MEDICARE W/O 03/25/08 MEDICARE PAYMENT Transaction: 2522.25 2522.25 -1583.10 -689.15 -1572.95 -699.30 BALANCE DUE: $ 500.00 PLEASE DETACH AND RETURN THE BOTTOM PORTION WITH YOUR REI Patient: KLOUSER, MARLIN Amount Due:$ 500.00 Account # : 47641 Amount Paid: Credit Card Payment:(circle one) Visa Mastercard card Number: I I I I~ I I I I I I I Expiration Date: / / Signature: X ~, IIolBOll II,~11111111111111 I III HARRISBURG. PA 17106-701 RETURN SERVICE REQUESTED ~~ Q by! 18lus y~ ~J` v\~ ~ ~~ RT3326/028 201 47869361 NATIONAL RECOVERY AGENCY A PROFESSIONAL .OLLECTION A ENCY (717) ~-IO-i(0~ (80t1) ;60-~ ~ 19 IN RE: H.aRTZELI. EI"E KIDS TOT.~L..1RiOti1~;T DL1E: $100.00 ~CCT~: C.-14(1172 D.~1TE ClF SERVICE: ]0 22'07 0002517!0011 ~u~~~~n~~~~~n~u~un~~n~~~~~~~n~~~~~n ~~n~~~~~un~~~~ Marlin H Klouser 51 N Crescent St Apt 30 ~i~i,j~r1~,PA,~981-15;8 ~ d~`~(j ~ " ~p ~~. ~~ , Dear Marlin H Klouser, . ~d_ SEND TO: NATIONAL RECOVERY AGENCY PO BOX ti7015 HARRISBURG. PA 17106-7015 u~~~~u~~ui~~~~nn~~n~n~~~~nun~~i~i~n~~~ Your account has been forwarded to this office for collections. The balance shown. above includes interest of $.Oll along with collection charges of $.00. This is a formal demand upon you for payment of this debt. Tliis is an important matter, which needs to be resolved, and requires your attention. By resolving this matter, you ~~°ill make continued collection efforts unnecessary. These efforts may include calls, letters and/or reporting to the credit bureaus. Our demand for payment does not affect your right to dispute this debt. Unless you notify this office within 30 days after receiving this notice that you dispute the validitt• of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice, this office will: obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice, this office 1vi11 provide you lvith the name and address of the original creditor, if different from the current creditor. * Below is a listing of all accounts included in the total amount due listed above: HARTZELL El"E MDS CA40172 10'22/07 $100.00 Unless you dispute this debt, your payment should be made directly to this office for prompt credit to your account. A tweni<•-dollar service charge will be added to all checks returned to us by your bank. Should you desire areceipt, aself-addressed. stamped envelope is required. For payment options please see reverse side of this notice or visit our secure Website at ww•c~~.nationalrecovery.com. The purpose of this conununication is to collect a debt and any information obtained will be used for that purpose. Sincerely, NATIONAL RECOVERY AGENCY This communication is from a debt collector. ***Please contact your account representative NRA HOUSE MEDICAL at extension 67-18 regarding this account. NRA/ALS-28 NRA ID #: RT3326 Calls to or from National Recovery AgencS° may be monitored or recorded for qualit<~ assurance. PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION V~ ~ ' MARLIN KLOUSER Account Summary Previous Charges $ 28.17 No Payment Received .00 Past Due Charges (please pay now) $ 28.17 New Charges Verizon (page 3) - $ 6.40 Total New Charges Due - $ 6.40 Total Due Please pay upon receipt Billing Date: 09/16/08 Page 1 of 6 Telephone Number : 717 697-38'17 Account Number: 717 697-3817 451 96Y Moving? Moving? 1-866-VZ-MOVES One call gets you up & running! Count on the Verizon network to make of least one parf of your move easier. Across the street or across the nation all you need is one cal! to Verizon to set up yourlnternet, phone & digital TV in your new home in no time. Service availability varies. $ 21.77 T r~ Verizon Foundation - FINAL BILL - This Final Bill may have already been referred to an outside collection agency. Pay your bill online at verizon.com/payfinalbill Questions about your bill? Call 1 800 688-2880 See page 2 for all other Verizon contact information. Change of billing address? Go to verizon.com/billingaddress or see page 2. Visit Thinkfinity.org for thousands of FREE educational resources for teachers, students, parents and the after-school community. ~ Detach & return payment slip with your check, payable to Verizon. Representative before the payment due date. The number to call is included in the How to Reach Us section on page 2. You may write to us at P.O. Box 9000, Annapolis, MD 21401-9000. Residence Customers: You can obtain a rate schedule, an explanation of how to verify the accuracy of your bill and an explanation of various charges, if necessary, by calling your Service Representative or writing to the above address. You can also find rate and service information in the Customer Guide pages located in the front of your telephone directory. Antenna on Your N? You Need to Read Below With the digital television (DN) transition, the United States is moving from analog to digital service for full power over-the-air N broadcasts. After February 17, 2009, analog-only Ns will require a converter box to receive full-power over-the-air N broadcasts with an antenna. Ns connected to FiOS N will not be affected by the broadcast DN transition. Analog-only Ns should also continue to work as before to receive low power, Class A 33 P136 7176973817 03 PA212'HBRDAi 00005577 370000032167 ~i .~ MARLIN KLOUSER Account Summary Previous Charges $ 21.07 No Payment Received .00 Past Due Charges (please pay now) $ 21.07 New Charges Verizon (page 3) $ 7.10 Total New Charges Due Sep 15 $ 7.10 Total Due $ 28,17 Questions about your bill? Call 1800 688-2880 See page 2 for all other Verizon contact information. Change of billing address? Go to verizon.com/billingaddress or see page 2. Billing Date: 08/19/08 F'age 1 of 6 Telephone Number : 71 7 697-381 7 Account Number: 717 697-3817 451 96Y Moving? Moving? 1-866-VZ-MOVES One cal! gets you up & running. Count on the Verizon network to make at leasf one part of your move easier. Across the streef or across fhe nation all you need is one call to Verizon to set up your Internet, phone & digital TV in your new home in no time. Service availability varies. ____________ ~ Detach & return payment slip with your check, payable to Verizon. ~' Account: 717 697-3817 451 96Y pppg6 07R 70000309077 V@f'lZQ~1 New Charges Due: Sep 15, 2008 ~ii6v73ai7 zo~osos2e Total Due: $ 28.17 08190.8 Yesi /want fo be a Liferacy Champion. Sign me up fora $1 monthly donation Amount Paid to Verizon Reads. 00046907 O1 AV 0.324 ECP23411 0160 MARLIN KLOUSER 125 STATE RD MCHNCSBRG PA 17050-3157 n~~(~u~~~~nn~~~~~~nn~~~un~~~~~~~~n~(n~~~~~~~n~n $ ^oo^ Verizon PO BOX 28000 LEHIGH VALLEY PA 18002-8000 ~m~~~u~~~~u~~~nn~~~~~u~i~~m~~n~~~nnn~~~ 10971706973817451402802135000006000000210710000002817500000 it Billing Date: 07/19/08 Page '1 of 6 ` Telephone Number : 71 7 697-361 7 ~n Account Number: 717 697-381 i' 451 96Y MARLIN KLOUSER Account Summary Moving? Moving? 1-866-VZ-MOVES Previous Charges $ 28.18 One calf gets you up & running. Payment Received Jul 10. Thank You. - 28.18 Count on the Verizon network to make Balartce $ .00 at least one part of your move easier. Across the street or across the nation all you need is one calf to Verizon to New Charges set up your Jnfernet, phone & digital Verizon (page 3) $ 21.07 TV in your new home in no time. Total New Charges Due Aug 14 $ 21.07 Service availability varies. Total Due $ 21.07 ~~ Verizon Foundation Visit Thinkfinity.org for thousands of FREE educational resources for teachers, students, parents and the after-school community. Questions about your bill? Call 1800 888-2880 See page 2 for all other Verizon contact information. Change of billing address? Go to verizon.com/billingaddress or see page 2. ~ Detach & return payment slip with your check, payable to Verizon. ------------------------------------------------------------------------------------------------------ i ~" Account: 717 697-3817 451 96Y z10•HBRDAI 00048348 tT000029658s 33-PA P136 V~IYL,,Ol1 New Charges Due: Aug 14, 2008 7176973617 zoosos26 Total Due: $ 21.07 0 719 0 8 ^ Yes! 1 want to be a Literacy Champion. Sign me up fora $1 monthly donation Amount Paid to Verizon Reads. 00048348 O1 AV 0.324 ECP20411 0227 MARLIN KLOUSER 125 STATE RD MCHNCSBRG PA 17050-3157 m~~~m~~~nn~~~~~~nm~~m~~~~~~~~~m~u~~~~~i~n~u $ ^Q^^ Verizon PO BOX 28000 LEHIGH VALLEY PA 18002-8000 ~m~~~n~~~~m~~uui~~~~n~~~~m~~u~~~nun~~~ 10971706973817451402802189000006000000000000000002107100000 Comcast® Vls/t us on the web 8t www.comcaslcom ACCOUNT DATE TOTAL NUMBER DUE AMOUNT DUE 09547204447-01-9 PAST DUE $105.78 How to reach us: 4830 Carlisle Pike, Suite D-14 Mechanicsburg, Pa t 7055 (717)540-8900 Telephone Customer Service 24 hours a day, seven days a week MARLIN KLOUSER ~ How to reach us... For service at: 125 STATE RD MECHANICSBURG PA 17050-3157 News from Comcast Our office has not received payment for your previous balance as of this billing. If payment has been made, thank you. If you have not made payment, you must remit immediately in order to avoid late charges. If you would like an updated account balance, please call the Customer Service Phone number in the upper right corner of your bill. Hearing /Speech Impaired Call 711 Looking for a new career? Comcast is currently hiring Direct Sales Representatives in York, Harrisburg and State College. Join our team in selling our innovative products and services! Apply online at www.comcast.com. Casamayor and Marquez will meet in the ring on Mexican Independence Day weekend, treating boxing fans to an all out battle! See it Sat., September 13th at 9pm, LIVE on Pay-Per-View. COMCAST CABLE Comcast® LEBANON PA 87046-8317 RETURN SERVICE REQUESTED #BWNMZNH #PIEDGBPDDDGPA6# AV 01 025116 77671 B 65 A*•5DGT ~n~~~~ni~~~nn~i~i~~nm~~nn~~i~i~i~n~~n~i~~~~~n~n~~ MARLIN KLOUSER 125 STATE RD MECHANICSBURG PA 17050-3157 Summary of Charges statement Prepared oar2vos Billed from 09!04/08 to 10/03!08 Previous Balance 52.89 Comcast Cable Television 50.25 Taxes, Surcharges & Fees 2.64 Total Due $105.78 ono [~ ^ / Indicates the Comcast services you subscribe to Detail of Charges on back Please detach and enclose this coupon with your payment. Do not send cash. Make checks payable to: COMCAST GABLE Date Due Total Amourtt Due AMOUNT ENCLOSED PAST DUE $105.78 $ 030-08-08-A-C Axount Number 09547 204447-01-9 ~ui~~~i~un~~~~~~u~u~ni~~~~~ui~~nu~~n~~nn~~n~~i~~~ COMCAST CABLE P 0 BOX 3006 SOUTHEASTERN PA 19398-3006 ~~~~t~n~~~~~~n~i~~~~~~~i~~~~~~~~~n~~~~~~~u~~fui~~~~i~~~n~~~~~~~~~~ 09547 204447 01 9 5 010578 1111111 II 1 IIIII 11111 II I 1111111 111111 II 111111 N ~~ O O` Z E N O ~ ~,~~ am ~ D~~ ~ m ~~.~o~ ~ mom' n m ~33~m ~, Zm~ Z O ~ ,~ ~-a ~ 0 3 ~~om ~ y m 3~°7^~ ~ ~~ c = s m m~ g.~ 9 ~ m 3 y to m pp O A ~ C 3 om3::.~ ~ n ~o ~ ~ C ~ N ~ y .~.r fj O- 3 Sy -_+. O O tp `2' ~ O ~ ~ ~ m ~.o~.~o ~ 3~ o~_amw m A D m CT p m `G O O ~ ~- ~_ 7 C N ~ to ~ A .C V 7 O~ t~0 C a O >Z Q m m N y ym y-`~ N aoO ~. ~~ me ..o ~ ~ g s z ~_ A '~ m v °_ b m m J X O ~ C O GO y ~ _ ~ ~ m mm fp .. In p~ .. ~ ~ C~~ ~ ~m~~ma C -1 ~ ~ w Q = sv m Ao ~ ~ N <D m ? !n m W ani ~' G ~~pp y~ s ~ m 1 ID C O= m n M ~ S Tl fA- `D N O 7C C ~ N O~ m~ ~ m~ ' gy m Y c D N O '~ m ~+ CD z r v C '~ -1 a ~ ~ m G _~ ~~ _ A v ~~ m o ~ 3~ ~ ~ ~~ ^. ° m ~siV ~' ~ m °~ ~ ~. m a ~a ~ m ~ ~ ~ ~' a ~ ~ _ ~ m m ~ N O) O o^ i~~ 1 >S W V ~ V ~ ~ yy G'! 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Please contact us Aug 22 at 1-800-34 -5775 {1-800-DIAL-PPL) or write to: Customer Service 827 Hausman Rd. Allentown, PA 18104-9392 www.pplelectric.com ~ 1 1 ~'~0~•~.'%~ Page 1 •' •..' ~_ _ _ :. ~ ..cam: Blx:4s~iamc ''fir .'~.;' ., TM 47440-77007 Summary Page Balance as of Aug 1, 2008 $0.00 Chaz es: Tota~PL ELECTRIC UTILITIES Charges $29.93 Total Charges $29.93 Account Balance $29.93 G' o ?'lr1 '~'~''~~ ~vn' n'' d Electric Use This graph shows your electric use over the last 13 months. Types of Meter Resdiugs: Actual - Estimated Customer 0 36 30 24 18 l2 6 0 KWH -Average Per Day Meter Reading Information Meter #79012391 Aug 1 Actual 34365 Jul 2 Actual 34161 30 Da s KWH Billed 204 Average -Aug 2007 2008 Temperature 75F 76F KWH Per Day 24 7 Yearly Uae: Total Average Use Monthly Sep 2006 -Aug 2007 8138 678 Sep 2007 -Aug 2008 5314 443 ASONDJFMAMJJA 2007 Months 2008 Other important information on back ~ - Return this part to address below with a check payable to PPL Electric Utilities Corporation ;~t4ta 11~. ~u~ I~Ir : = .:.: ],a~ Ps. f B' R ...._J'a: r Thr~ tt~.... ~: 47440-77007 Aug 22, 2008 $29.93 Armunt Enclosed AV 01 016289 235886 83 A"5DGT ^ ~ ~, a o o. a o HAROLD KLO[JSER 125 STATE RD MECHAMCSBURG PA 17050.3157 PPL ELECTRIC UTILITIES 2 NORTH 9TH STREET RPC-GENNI ALLENTOWNPA L8101-1175 ~nl~~~nl~~~nu~i~l~~nnl~~un~~~~~~l~nl~n~l~l~l~n~u~~ 1 2400000299340000029931 474407700? PPL Electric Utilities Electric Service Fot: PATSY KLOU5ER 125 STATE RD MECHANIC5BURG PA 17050 Questions about this bill? Please contact us by Oct 23 at 1-500-342-5775 (1-800-DIAL-PPL) or write to: ~~ Customer Service 827 Hausman Rd. Allentown, PA 18104-9392 www.ppleleciric_com .~ ~~~ ;~; ~'~;.~'•:.%,.- Page 1 :--' p p .. _ _ yapt B11t igECO~tnt ~friit;tc .::; ., n 47440 77016 a~t~ o.~waa .. Summary Page Electric Use This part of yow bill helps you understand yow electnc use. Types of Meter Readings: Actual - Estimated Customer 0 12 10 8 6 4 2 0 KWH -Average Per Day Meter Reading Information Meter #79012391 Oct 2 Actual 34798 Sep 3 Actual 34563 29 Davs KWH Billed 235 The graph shows the average number of KWH you used each day. You used 235 KWH to 29 days, or an average of 8 KWH a ~Y- The average dailyy temperature for your area last month was 67F. O 2007 Months 2008 Other important information on back ~ ~xq ~'tdroy~H ~y~prw'dH <~a'oc~,a~~ .~- • O .~ p~ ~ ~. ~~ .,bppi~ ~oq fir,.. 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Members 1st Federal Credit Union 24,583.39 Loan No. 263602-01 Date of Death Balance TOTAL (Also enter on line 10, Recapitulation) I $ 24,583.39 (If more space is needed, insert additional sheets of the same size) r s ~1$t 5000 Louise Orive, P.O. Box 40 Mechanicsburg, PA 17055 MEMHER51• BORnOwER'S NAME ANDA MARLIN H KLOUSER FlxeD ANNUAL PERCENTAGE FINANCE CHARGE: Amount Financed: The amount of Total of Payments: The amount RATE; The cost of your credit as a The dollar amount the credit wNl credlt provided to you or on your you will have paid aRer you have yeady rate. • cost you. ,behalf. made all payments as scheduled. •• 6.99 °~^ • $ 21,492.12 • $ 25,000.00 • $ 46,492.12 a VaHabb Rau: N yow ban has a vMaDM nts as Indicated above aN Annual Perwntaga Rala may Ylereasa aunnq iM ronn d MSS Iransadlon M the (Index) rhanpes. The pedN union wM add • margin d b the Manx vslua. TM rate wNl rhenge monthly an Vls flM dry d Ula manM. Tha rota wNl ewer W hlghar man iM maxMUmrote aNOwea by law, and N wal nwar M Mu awl . My Interest tale kwreases wlll nwtt N more paymenu d me same amount. For Example, d your ban was fp 55,000 at 15% /p 4a rr1or11M and me MnuY Peruaags Rate npeassd by 2% alter one year, Nro term d yaw loan woub inrroase by two months •PrNemd Rab: N tltadwd, ale lolbwinq appUez to your ban: © Adomalk P m malid deduction Imm s nt Db i d oMN ents ttxo h an aul ow CneekU lSwin bd R U 8 M d b k y ay e coun e your requ re m y paym ug o ro g a : eoause you w agree ma Acoaatl, yow ANNUAL PERCENTAGE RATE has been dlwountW Dy .20X. TM ANNUAL PERCENTAGE RATE tliubsed abwa kl the ANNUAL PERCENTAGE RATE box is Iha Aulematk Payment Disaolnbd Role. Thfa rats wftl klcraaw by .ZO% N you eeaw tlfa aulomMk gylwm artangamanl p faN to maintain suaieieM Mds it your account ro rover IM aubmatia payrtrada. b such a pea, Ma affect d the krrrna wiU a b exurld aw farm d your ban. For example, r yaw Aubmalk Payment Oiscorxxed Rafe is 10% an • 55.000.00 ban far e0 ntoMM and you ease tlw aubmalk paym.d arrangamanl, your nla wi increase b 10.20%. rowNbq b 1 addwonal payment. VaAabb Rao Prelemd Loam. a ywr ban Is • variable me ban and you qualNy tar a pnfarred Ma, your prNertad diswunl k taken al Me dme you lake out your ban. This ~~ vNll men vary xtoroirg W ohongas b Me bdex (as dsdosed above). Far exempts, if a variabN rota bocce initial ANNUAL A dE ~ P/T ERCE GE BATE K 12% ma tkns You ales tM ban, your InNial prMarted ANNUAL PERCENTAGE RATE wiU be NIA%. Your bilal pnfertad ANNUAL PERCENTAGE RATE wiN man vary apardbp to the kldex, as dladoaatl in IM Variabb Rate' provision above. flaw RaM Pnferred Loans. II yow Iron is a fixed tale loan and you quaJay Ip ^ pMartad rata, your ANNUAL PERCENTAGE RATE will Da me palarred ANNUAL PERCENTAGE RATE dfadostl above Ip as Iona as prNertea status mruba In Mect. Number of Payments Amount of Paymens Payment Frequency Whan Paymenb An Due Property Insuranes: You may Obtaln property ya,,, ~ insurance fran anyone you want that is acceptable to 239 5193.72 Mordhly - Beginning 01nr~008 Paymaru the asdlt union. II yyou get the nsurance hom the uedit union o wiU SdwAAe wi a: 1 f 193.04 Final Due - On 1225/2027 y pay u S N/A Satudry: CoNatarol aeawirg oMar bans with ms crcdt union al. goods p prdpmry qMr rvlll NIIO aewre Mia ban. You are givirp • feCanly Inllroat In ~ being purdla«d. and: X (D«tribe): yow ahans andlar depose in me ueaN unbn , Ufa Charge: tt a paymaa is Mle by 70 days p rope you wUl RagW nd Deposit Balance: TM AnnuN Percantapa Rata does FII ~ F«a: INrg Insurance: W awYed a we he d 5% d yow aUledule0 payment. S WA not take ino accala your raquir tlapostt balanaa. a arty. $ s d Y~marl~«6na i PN . yw na oaP • ~ r / yOYf dale orb Paplmanrrahags rW parWMS. a nanDaYnas. .any raW~ wPayman n IICIa1rL/AIIVIe Vf AMOUNT FINANCED $ 25,000.00 Amount Pant to others on your behalf (Describe) S To S To AMOUNT GIVEN TO YOU DIRECTLY S 25.000.00 = o i To S To S To S To f To S To AMOUNT PAID ON YOUR ACCOUNT $ S To S To S To S To S To S To S To S To PREPAID FINANCE CHARGE $ O.op f To f o.oo To F«z S To Awe Sakrbrla S To Acted SoY1ow MAKE MODEL YEAR I.D. NUMBER TYPE VALUE OTHER (DBtcrfbe): 125 STATE ROAD MECHANICSBURG PA 17050 and/or Deposits of I f ~ ~ f rou agree Mn IM tarns and eormittons yr ma dudowro statement and the loan and aeauroy agreamems heated on page z d Mia dowmaM aMN spy loylis ben. II them isnldre Man orr brxrdwar, we ayaa 111N as ale aonditlans of Me loan and seaurUy agroemeaa goverrlnq this ban MaU apply b bah lolnty and severalty. You acknowledge mat ou Mw received • spy d Me ban and aacudly agreemema antl discbawe statarnant. Co-e'pnar; H yw arc signing a oo- ' net, Ma you aeknovvledga receipt d me naW b eo-atpner on papa 2. X R % SIGNA E (/ DATE ^ CO•MAKER ^ 'OTHER OWNER /OY ^ "CO-SIGNER DATE i ) ~( (sEAL) ^ O•MAKER ~ ^ 'OTHER OWNER ^ ••CO•SIGNER GATE ^ CO•MAKER ^'OTHER OWNER ^ ''COSIGNER DATE (~) X (SEAL) ^ CO•MAItER ^'OTHER OWNER ^••Cf}SIGNER GATE ^ CO-MAKER ^'OTHER OWNER^ "CO-SIGNER DATE X (SEAL) X (SEAL) roTUSa awrla:Aay s...,wr rr.r+r•rorwwrlwr aw «. r.w.r r w.en w r.v..e v..v.a.vv.arwr.y. sr...lrr a,.r.vr..,.+.v.rv. w.rr..,r.,.r.asr.v u a..r.wi.nl,a awraaywMNwvr eastrwr.Vl+4rdi.tlwaariM AP+~A••GOabNEa:YYa arW4en swix ww. srrws Yrrrnrib rwtr+rarrarati r.r eaeMU au awrrrr,d. ant Iraaa,atr w.,q .w a .w,. r «, s. w. n. a~Mr waiti raaav M tarA Iw aralw w.waa.,vit. d an1tM0 M ~+/- NOTICE TO CO-SIGNER You are being asked to uazaMee this debt Think carefully bebre you do. If the bortovrer doesn't pay the debt, you wll have ta. Be wrc you ran afford to pay if you have to, ant that you want to accept this responsibility. ao~u rm~y fwve to pay up to the lull amount of the debt ii the borrower does rot pay. You may also have to pay late fees or cogedion wsis, which in«oase this Tile creditor can co18« Ihis debt froum~yhou without fxst trying torgcolte« 6om the borrower. Tha credltor an use the same colleUion methods against ou Mat record. This 1~mce s ndbhoe W Ua« Ihal ma es you~IlaDle fof the debt apes, etc. If Iflls debt Is ever in default, that (aU may Demme a part ofyotx cyredit Pape 1 of 2 ~ r ~ MEMBBRS 1st l~l~ MEhiBFSS t" BORRONER8 W WE AND ADDfiESS 5000 LoWSe Drive, P.O. Box 40 MARLIN H IO.I'wSER Methardcsburg, PA 17055 ~ 95 RTATC anon FIXED I I VARIMLE ANNUAL PERCENTAGE FINANCE'CHARGE: Arnautt Fiwltred: The amount of Total tN Paymems: The amount RATE; The cost of your credit as a The dour amount the IXedlt will tsedd Provided b You or on your you W91 have paid after you have yeady rote. ' cost you, beha9. mach all payments as scheduled. 6.98 ~ S 21,446.70 S 25,000.00 S 48,446.70 Varisbb Rob: ft yow lore has a wdaMe Ms ea indkaled above Me Annwl Pareentape Rab may increase dudnp the brm of Mis transaction i the (index) danpes. The aedit union veil add a margin of b the index value. The me wiM change momlYY on the erst day of the month. The Tab wA never De higher hen Me maximum rate elbwetl by 4w, and M Wi nevp bs less Fan Arly irxuYea rsk kraeaxa wW rcaue in ngre peyment7 of the same amount, Fa Example. K your ben vras for 55.000 et 15% for 4a monMa and the Amrri Perrantape Rats Increased by 2% ant one yesr, the lerrrr of your loan would Inaeaae by tro monMa •PnhrrW Rob: N rlterYed, Me tdlowinp applies to yow ban: ^X Aubmatk Pryment Dlacounted Rob: Becews you haw aprced b make your raQUired monlMy payments Ihrouph an aWanatlc deduction Inm your Clbtlring15evirrpa Ar~a a ANNUA P a . yow L ERCENTAGE RATE has Been 6soounled bbyy 20%. The ANNUP.L PERCENTAGE RATE ~adoaed above in Fe ANNUAL PERCENTAGE RgTE oox is ~AWOmaaC~waylirerR Discantstl Rob. TNs rats wit kwsaas by 20% i you uaae Me aWwnalio payrtrrlt margwrNrd ar Yi b maintain aulerient fundc in ywr a¢aal b payrtbnb. b sudr ^ case, Ma seed of Ma kRrsaae wiN be b mdend Me term al yow loan. for axampls, if gar Aubmakc Payment Discounted Rate a 10% an • 15,000.00 ban for a9 nronNS end you was Me sulometk payment amanpemera, yow rate wi krdease to f 0.20%, rcwlf{np in 7 addilbnal payment VarlebN RAM Pnbmd loans I(your ban is • wdabk me loan arW you ruagry br • prefrrcd rats, yow pMamstl dkcowa is taken al the lima you take out your ban. 7nia ketlal pn4nad ANNUAL PERCENTAGE RATE wlN Men wry aceatllrq ro stooges in tM Index (u dlscbsetl allow) Fore^srn k i a wri d m B t i iti l ANNUAL . p , a e e er a n a PERCENTAGE RATE is 12% al Ms ems you bka Ms ban, yea inital prMSn~O ANNUAL PERCtMAGE RATE wet M WA%. Yow NiWI prNarted /W NUAL PERCENTAGE RATE vA Man wry aeeonerq b tIN Index. as dstloaed b Mr'Jriabls Rats" provlaion above. Fisw Rar Pnbrntl Loam If yow ban b a dxad raN loan and you plNily br a prrarraa rata, your ANNUAL PERCENTAGE RATE wail ue the prcfrred ANNUAL PERCEMAGE RATE d0obsad above for as as pnNasd stabs nmaku b onto. Number of PaymaMS Amount of Paymenb Payment Frepuenry Yvlten Psymanb An Duo Property IlasuruYCe: YOU may Obtain properly Year IrleUrinOe ffOnl anyme y0U Want that K alxeplabk to r 239 1193.64 Monthly - Be9infifg OV25/2006 Pa ~ ~credit«nkW II yo~yet the dnuranre hom the a dr a web. 1 5190.64 Final Due - On /2/25!2027 f NIA volt Secudry: Coealral securing other loans with the aadit union IM goods a Drapery Obrr v ll also sears Mif loan. You arc pivilp a seardy interest k ^ being purchaaad. ^ ywr ahras rdlr depose b Ms asst urim and: x (~~~): , UM Charge: Il a payment is lab by 10 days ar max you veil Rsauind OslYeslt Balancr. The AnnuN Psrowdape Rale does Fllinp Feea: Non-FMnp bsunnu: be chrped a Mb fee of S%ol your scheduled payment. rwl lake irao awtxu yow repWr a d depwi balarru, R arty. S WA f WA -e'lrlearn eMSY.PM .Yoe eel wbpaye ae n~ y tl1e aNMubd doh sect papeprntarlanOs eneymWr a ronpe rryn apryrrrMn AMOUNT FINANCED ; AMOUNT GIVEN TO YOU DIRECTLY j 25,000.00 AMOUNT PAID ON YOUR ACCWNTS PREPAID FINANCE CHARGE S 0.00 Amount Paid b omens on yow behalf (Descrbe) To f To To S To 7o S To To f To To S To To S To To S To To S TO To S To To ftl.ta To Fns To ass Beware S To Aare saWwr MAKE MODEL YEAR I.D. NUMBF1t OTHER (Describe): 725 STATE ROAD MECHANICSBURG PA 17050 TYPE VALUE You Pledge Shares ~ AM WNT ACCOUNT NUMBER /1MOl1NT ACCOUNT NUMBER andlw Deposits of f S You spree Mat Me Yemn and corldilbns b Ma dbdoaurc stremau end Me Wn ant sauvny agreements locatetl on gape 2 of this doamaM aMN appy b elislort R ttrere is mae Man ono boriorwr, we eprce Mat ap 1M urr6tlons of ens ben rrd seoudhr apreemsnb powmkq INS ben ahM apply b bdh Jointly rtd wwrally. You atlr a IMt reaNt4 • wpy of the ban ant ssadry aprsrnenla arM dlacbswe statement Co-slpner. If you sn alpninp q cos r. you adnowl rlovYlstlp you hew rsMalned m papa 2. krrs adpe rocelq of Me ndiu b ruralpnsr BORROWER'S SIGNATURE DATE CO-MAKER ^ •pTHER OWNER ^ '`COSIGNER DATE X (SEAL) X (SEAL) ^ CO•MAKER ^ 'OTHER OWNER ^ ''COSIGNER DATE ^ CO•MAKER ^ 'OTHER OWNER ^ ''COSIGNER iSFAL) DATE ~( X (SEPL) Q CO-MAKER ^ `OTHER OWNER ^ '•C0.SIGN6t DATE ^ C0.MAKER ~ `OTHER OWNER J] '•CO-SIGNER GATE ~( (SEAL) X (SEAL) 'OMea awes: Mr P.~N~e r.w.r.M Ye.r pr ev. r.rwr, s rr.en r rMNw.aralM e.aY.r.r.hK Ys..lMane rarw. sows aaa ewaraw. Y r«aeaarr rw ra.r re.nrr.rae ur eararnlen ar eerrlr hr,sr n ere.nw.ur eyrr.s hr ar.sa Ilp,ww.L "CPreIER user arrK rM sewwrr,.w NNIwwNYY awrrrs Na. ar e~erw Nw M N ew,. eve M w Yrn iM a...wr dw. r „eio r.w, n.> Ne.aM NwMw a.~rYie M r.. NOTICE TO CO-SIGNER You are being asked b guarantee this debt Think carefuly before you do. If the borrower dcesnY pay me debt, you will have lo. Be sure you can aliord to pay y you have b, and That you want b accept mis responslbiity You may have b pay up b the fuA amount Of the debt If the borrOUrer does not pay, Vou may also have b pay late fees Or collection Costs, which increase this wYIOWa. yo ap ~^ be~usbedr a~q~ms O~ie b~pnpwersuUr as suing you ~ga mishinp~~ ~es~ e~If~TEebt is~eve~ tleii>W1, the! tad mayeb~ewme a part of yowtaeWdibat record. Tltis rrolia is not Me txxtbact that makes you Ilable fOr tl+e debt NOV 1 8 Z~ Pape 1 Of 2 REV-1513 EX + (9-00) r •• SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE Marlin H. Klouser ~ I vo vyoy RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustees) OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Patsy Lee Klouser Spousal 254,218.90 12 Reservoir Road Hegins, PA 17938 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 TAX IS 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) ! •~ n LAST WILL AIdD TESTAMEPiT OF MARLIN HAROLD KLOUSER I, MARLIN HAROLD KLOIJSER, of the Township of Silver Spring, County of Cumberland, and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all former Wills by me at any time heretofore made. 1. I direct the payment of all my :just debts and funeral expenses as soon as conveniently may be after my decease. 2. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequeath to my wife, Patsy Lee Klouser, to her own use and benefit absolutely. 3. In the event, however, that my said wife should predecease me, or should die at about the same time as I die, such as in a disaster common to both of us, I give, devise and bequeath my said Estate in equal shares unto my natural children, Kimberly Ann Klouser and Rajuan Lee Klouser and my step-daughter, Stacy Lynn Wolfgang. 4. Should my step-daughter, Stacy Lynn Wolfgang, be under age eighteen t18) at the time of my deat~hereby appoint my wife's brother, Jack Carl, of Williamstown, Pennsylvania, uardian of har est~~ ~ntiOsu`c~ ~ime ac%~J~ (/'eac~ th~ge of eig, e / ~ ~~ I nominate, constitute and appoint my wife, Patsy Lea Klouser, to be the Executrix of this, my Last Will and Testament. If she should predecease me, or for any other reason be unable to act, or to continue to act as such Executrix, appoint The First -1- s ~,~ • Bank and Trust Company of Mechanicsburg, Pennsylvania, to be the i~Executor in her place and stead I further direct that neither ~ of-them shall be required to file bond or other security in the Office of the Register of Wills for th ~ rpose of administrating =~, y Estate. ~ ~. ~~~~ r_ _(6,~ I authorize and empower my personal representative, in her sole and absolute discretion, to purchase or otherwise acquire and retain any investments of which I die seized, or any real or personal property of any nature; to sell, lease, pledge, ~~ mortgage, transfer, exchange, dispose of, or grant. options in \\~' regard to any or all property of any kind forming a part of my Xv Estate for such terms and such prices as she may deem advisable; to borrow money for any purposes connected with the protection ~` t and preservation of my Estate; to mortgage or pledge any real or personal property forming a part of my Estate, or to join in or secure the partition of same; to compromise any claims or demands of my Estate against others or of others against my Estate; to make distribution in kind and to cause any share to be composed . of cash, property in undivided fractional shares in property different in kind from any other share; and to execute and deliver such instruments as may be necessary to carry out any of these powers. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~'~ day of ~~o~,,,,~ A.D. 1987. ~~3~!~~'"~ ~ ~~'~.~' (SEAL ) Signed, sealed, published and declared by the above-named MARLIPI HAROLD RLOUSER, as and for his Last Will and Testament, in the presence of us, who at his request and in his presence, and in the presence of each other, have hereunto subscribed our names as witnesses. e -2- COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SS. I, MARLIN HAROLD KLOUSER, Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein expressed. Jln~1~•L Sworn or affirmed to and acknowledcted before Testator this ~~~-~ day of ~.I_, -~ me by the above , A.D. 1987. -LC~~G-' Notary Public Notne~r ru3! is n ['A Cu"(:.7al,c~;120 L~iYr p;,xhFnicsbur;~ x Tres lane ~y Gomrission c. p COMMONWEALTH OF PENNSYLVANIA: SS. COUNTY OF CUMBERLAND We, Charles E, Shields and Elizabeth A. Curll the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw MARLIN HAROLD KLOUSER, Testator, sign and execute the instrument as his Last Will; that MARLIN HAROLD KLOUSER executed it as his free and voluntary act for the purposes therein expressed; that each of tis, in the hearing and sight of MARLIN HAROLD KLOUSER, Testator, signed the Will as witnesses; and that to the best of our knowledge, the Testator was at that time eighteen (18? or more years of age, of sound mind and under no constraint or undue influence. ~~.a ~ ~®p Sworn or affirmed to and subscribed before me this 1~T~ij day of ~~~~ A.D. 1987. Notary Public Mech2nicsbur;, FA Cu:~:;~r;aaC "AaniY ply Gommissi:rt Erpires J:~r,e 2U, '.323 1 4 w O rn .- W O O I C ~ O O V/ Im ~''~~W W M I F OQ'O ~a~aV ~a [~ ~ N ~ ~ t ~~ ~ ~ o ~ LL n r ` a~-~ ~~ 6 N ~S~trNn o o ~ ~~!p~~c~E'~ N N V i Cam; s r .~. '"~ U ! t.l_! ~ .. ~ JrJ ~ Q L'~ ::~ ~~_ ~. ~ G ~ ~ : -`_~ ~_. ~ ~~ N ~ E- a t ro ~ c ~ :~ Q ~ ~ ~ n a~ ~ a ~ _' ~ ° = ' 0 ~- ~.~ J ' Q U ti i.. - ~ ~ ~ 4-~ o t ~~~ _ ~, ~ c_t O ..~ :~ J C r~ 1, CJ.. ~ Z J J rl C." I`~ j ~ ~ 5 •ri ~ U ~ ~ O UI O ' `~ <r = ~ - ~+ o w -- x - ~ o .b .~.. ~ r = ~ ~_~ ~., v ~'"~ QJ r-~ 7 rl ,~ ~ ~ O to W ~ ~ t`~ ~~ •~ .n ~ ~ ~ a