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HomeMy WebLinkAbout04-23-09Pennsylvania REV-1500 EX Tax Return for ELAINE E WALL It~lel•J H&R BLOCK PREMIUM 4811 JONESTOWN RD, SUITE 125 HARRISBURG, PA 17109 717-657-0316 15056041114 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 //,, c Harrisburg PA 17128-0601 RESIDENT DECEDENT . ~ C~d~ a d 7~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 210-26-6225 09022006 05071924 Decedent's Last Name Suffix Decedent's First Name MI WALL ELAINE g (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return 4. Limited Estate ® 6. Decedent Died Testate (Attach Copy of Will) 0 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Q 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) Q 7. Decedent Maintained a Living Trust (Attach Copy of Trust) Q 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) Q 3. Remainder Return (date of death prior to 12-13-82) 0 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 0 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number WENDY C RUMBLE 717-732-275 Firm Name (If Applicable) First line of address 124 WOODS DRIVE LOT 12 Second line of address City or Post Office State ZIP Code MECHANICSBURG PA 17050 n.a REGISTER_ ~ ~LLS USE)~LY ~ 35. - _~ ~ ~ `.t~4_~ ~ to =' ~ r:~ W __a ~ - SATE FILED Correspondent's a-mail address: 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 SIGNATI~RE OF PERSON RESPON LE FOR FILI RETU DATE ADDRES~~~ ~ ~~LLC~Lc:~J/!~i`/L~~ (,~^-`~ ~ G~ ~ /G~~~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE PLEASE USE ORIGINAL FOR ONLY Side 1 1505641114 15056041114 J 15056042115 REV-1500 EX Decedent's Social Security Number Decedent's Name: ELAINE E WALL 210 - 2 6- 6 2 2 5 RECAPITULATION 1. Real estate (Schedule A) ........................................... 1. 6 0 0 0 . 0 0 2. Stocks and Bonds (Schedule B) ...................................... 2. NONE 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. NONE 4. Mortgages & Notes Receivable (Schedule D) ............................ 4. NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... . 5. 14 8 6 . 0 0 6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... . 6. NONE 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) OSeparate Billing Requested ....... . 7 NONE 8. Total Gross Assets (total Lines 1-7) ................................. . 8. 7 4 8 6 . 0 0 9. Funeral Expenses & Administrative Costs (Schedule H) ................... 9. 8 O 5 4 . 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. . 10. 2 4 5 2 . O 0 11. Total Deductions (total Lines 9 & 10) ................................ . 11. 1 O 5 0 6 . 0 O 12. Net Value of Estate (Line 8 minus Line 11) ............................ . 12. - 3 O2 0 . O O 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... ig. 0 . 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... 14. - 3 O 2 O . 0 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 .0 O 1 5. O. O O 16. Amount of Line 14 taxable at lineal rate X .0 4 5 0. 0 0 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate X • 12 17. O . 0 0 18. Amount of Line 14 taxable at collateral rate X , 15 18. 0 . 0 0 19. TAX DUE ...................................................... .19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAY MENT ~ Side 2 15056042115 151J56~42115 217 REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER ELAINE E WALL 21-06-0876 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. (If more space is needed, insert additional sheets of the same size) 217 REV-1508 EX+(6-98) SCHEDULE E p COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ELAINE E WALL 21-06-0876 Include the proceeds of litigation and the date the proceeds were received by the estate. 11t more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ELAINE E WALL 21-06-0876 Debts of decedent must be reported on Schedule I. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT A. FUNERAL EXPENSES: 1. MYERS FUNERAL HOME ,INC. B. 1 2. Attorney Fees State Zip 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant WENDY C RUMBLE Street Address 124 WOODS DRIVE, LOT 12 City MECHANCISBURG State PA zip 17050 Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. MINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: NT $4,429.00 3,500 125 TOTAL (Also enter on line 9 Recapitulation) ~ $ 8 054 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) SCHEDULEI COMMONWEALTH OF PENNSYLVANIA I DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ~ ESTATE OF FILE NUMBER ELAINE E WALL 21-06-0876 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (It more space is needed, insert additional sheets of the same size) 2n REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA I BENEFICIARIES INHERITANCE TAX RETURN ESTATE OF ELAINE E WALL FILE NUMBER ~1_nF_nn~a RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] WENDY RUMBLE DAUGHTER 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed, insert additional sheets of the same size) Estate of ELAINE E WALL 21-06-0876 Schedule A v1EW MT. PARK 124 WOODS DRIVE MECHANICSBURG, PA 17050 717.602$374 September 26, 2006 Dear Wendy, The partnership has met and discussed the issue of buying your mother's home. In view of the fact that her home is 34 years old, a 1972 mobile home, we cannot offer you the $12,000 that you desire. We are willing to offer yourSOOtf~~^ We realize this is much less than you had expected, but because it needs repairs and updates the buying price of $12,000 is more than we want to put in it. We forsee you also having difficulty selling it to someone else, also, at that price. If you are willing to accept our offer, please call 502-8374 and we will make fiirther arrangements with you. ~, manager ~ - . r O „=aa o ~ 0 o ~ 0 c 4 v d b Q ~~ 1 N e+f Q ~ a z I-j¢a ~O~ V. ¢1 ~mj O ~ ~\ `v o ~ _04 T a ~~ J ;, Q J O O l .. ~ :. O ~ V O C.. O ~ ° z n . o ,~ a ~ ca '~ ~ J m c o U ~ a ~ v ~ g i ~ ~ ;~ ~-.o CERTIFICATE OF TITLE TO A MOTOR VEHICLE OR TRATLFR923 - issued in accordance with Section 1105 of the Vehicle Code, Title 75, Pennsylvania Consolidated Statutes ACCOUNT CONTROL NUMBER 800 -- 8©1275218933-62 PAUL M WALL SR fi ELA IPIE CEDE LEGEND E WALL A=ANTIQUE VEHICLE R D 5 C=CLASSIC VEHICLE WOODS C1R E =ELECTRIC VEHICLE ,,, F=OUT OF STATE VEHICLE MEt.H#NI CSBURG PA 17055 P=FORMERLY A POLICE VEHICLE ~_/~ ,~,. ~~~~ - - :;~R ,RECONSTRUCTED VEHICLE ! T 1"' T~t,t ~^ y' ~ ••-,T~ OVERSIZE-TIRES V"AL'"A`I... WI [L~ 3~~~1RL P/ ~~ ~t FORMERLYATAX7~,~~ _ _. ~. ~ ... .- ~ x llT Hi M a j . ~ ~- ~_ _ _S ~ ~ "~, w ' V HIC ~'~~DENT(FIG%1T.1/ ..NUMDER- % r~"~ '.fir NEHICE~ EIQh1T I Mme( aRp53 ~Q~.iB. WEIGHT ~ AXLES L.F'~~1Y«~~ ~/ ~ ~. I` ~ X~'~a ~f r -. _ .~ ~ . ,^ ICI .~ "'t `w ~" ' ` ~~~ ~& ~ ~ I O~TE CF .15551E .~-~L'~TE_-~HL(~.._LLl '~ ~ ~~ f "^t SE~i .~P' ODOMETER1TIiCUS'A7-PURCH_ .. ~_ a ~- =, i ~ .._ .,~ ,sue i ,,~~! Themotor~en~ ~' ~rrrc.~l~ru~scnbedhe'ti~t~u~~ub~etl~~ ~gll"~fai~t$hei~s - ~ ~~~~~~ - ~, ._.. _ FIRST LI>;iti ,_ ~;~ f ~~!~~b~- ~~C~"~~~L'~~5~1~ ,~g`+~~~~~^°~ FAVOR OF:- _ ~ _ --~ ~ `~~TI~~;~~i~~~~ ~r"~~~ DAUPH~Ii~i .DEPOSIT ~RNK ~ ~RItST. ~0 -_~.` !~"`P' `~^,°` ierr rio ~a ".ffi r - CARLISLE'; Pi4 3~7f2~c3 ~ -,. - - -" " - "O i- 7FT RFRR GENT TiVF SECOND LIEN FAVOR OF: LIEN RELEASED LIEN NOLDER BY 1w o. *..,,~ AUTHORIZED REPRESENTATIVE ~~ ~ Icertifythatreasonabledi[igencehasbeenusedinexaminingthestatementspresentedintheapplicationforCer- tificate of Title to the uehicle described hereon, and that the proof of ownership of said vehicle presented with 3' said application warrants the issuance of this certificate naming the applicant as lawf ul owner of said vehicle. Wherefore,Icertifythatasofthedateinscribedhereon,theoffi- ,w'~ cia[recordsofthePennsylvaniaDepanmentofTransportacion "~" °` reflect that said applicant is the lawful oumer of said vehicle. ,, ,;.~ ~ ~~ ~A. ASSIGNMENT OF CERTIFICATE OF TITLE _ I/WE warrant this Certificate of Title and certify that, except as l1) this vehicle is'AEbject?o no encumbrances listed in Section C , and (2) there are no unsatisfed judgments or outer legal claims . , against me/us which arose from a motor vehicle a::ciilent. Ir Null uS °M I I 1 M 1 l~ j l c,~- c:y =- /a I Pf ~ r Dv0. ! I ~ I x 51 NATURE Oc OIVNEP OP Au THOR12ED P RSO ~~ ,w .E. X•S~GNATUHE OF CU OWNERO NTED rvPxE Of fIPM DO NOT SIGN UNE t PURCHASER'S NAME ANU AOORESl AMeAR TO TNF RIGNT PIeeO ANO ORN TO BEFOR! Mt THIS ~1 SUeSC t . tf rr~,.~~ n~ t S O I 0 1' O F Off' ~ E n A SIG 5 L MD GPAUTV , .. LDDNT M1' 1r5al,ewp~g 19 B. REA M~ pgE a~ t~ 23 2~~8 Register nn~~A~ v$1. f show the t~, I/WE wa , I r Ica e o It a an certify that, except as listed in Section C, I7) this vehicle is wbjeet tb no encumbrances or other legal claims, and 12) there are no unsatisfied judgments against me/us which arose from a motor vehicle accident. a •No^•' sp suT• X SIGNATURE OF OWNED OR AUTHORIZED PERSOH X SIGNATURE OF COJWNER OR PRINTED NAME CF FIRM W NOT SIGN UNLE68 PURCHASER] NAM! AND AOORFf3 APPEAR TO TH/ RIGHT SUaSDRIBED ANp SWORN TD BEFORE ME THIS .S E A L DAY OF We, I, certify to [he hest of ouri my knowledge Nat the odometer reading If and reflects the actual mileage df thevehicle deicnhed N.I~ain or (check if applica6lel. ^ 1. The amount of mileage rtatad is in eztxn of 99,999 miles, Dr , ^ 2. The odometer reading is net [he actual mileage. AN INACCURATE STATEMENT MAV MAKE YOU LIABLE FOR DAMAGE TO YOUR TRANSFEREE PU RSUANT TO §4091A1 OF THE MOTOR VEHICLE INFO RMATION AND COST SAVINGS ACT Of 1912. WE, I, TRANSFER OWNERSHIP OF THIS VEHICLE T0: NA OF PURCHASERISI ITYP Ofl PRINT( t ~~ u) ©>>5 ~K- AO RESS POST OFFICE STATE ZIP CODE We, I, certily tD the oast of Durlmy knowledge that the odometer reading Is and reflects the actual mileage of the uehida described herein or (check if appllcahlel. ^ 1. The amount of mileage rtatad is in ezcess of 99,999 miles, ar ^ 2. The odometer reading is net the actual mileage. AN INACCURATE STATEMENT MAY MAKE YOU LIABLE FGR DAMAGE TO YOUR TRANSFEREE PU RSUANT TO 5409(AI OF THE MOTOfl VEHICLE INFORMATION ANO COST SAVINGS ALT OF 1972. WE, I, TRANSFEfl OWNERSHIP OF THIS VEHICLE TD: 19 I NAME OF PURCHASERISI (TYPE OR PRINT( 5'iGNAtUPE OF PE RSpN 40MIrvIaTERING OPTH MUrv101PA~Iir COUNTv MY COMMISSION ExPIRES 19 ADDRESS POST OFFICE STATE ZIP CODE C. APPLICATION FOR CERTIFICATE OF TITLE BY PURCHASER-TITLE FEE $5.00 (Plus $5.00 Encumbrance Fee If Applicable) The undersigned hereby me/~25 application for Certificate of Title and/or registration to the Registered Pannrylvania vehicle dealers must vehicle described within t Certificate of TitWjsubiect t he encumbrances and other legal show their dealer identification number hare: claims set fonh~thafive asst 1 ps~(eessign ' _~i", ENCUM9RANCE: YES NO AMOUNTS ~` IGNAr F ' O~ ~ IZEO SON ' ~t X 1. ~SIGNATURf OF ~.aWNER ORP TED NAME O4 FIRM TELEPHONE NO. '' 1 1 Area Code Phone No. (~_~1 SUBSCRIBED SWORN TO eEFORfi MS TNiS yy~~ E yy~~~y y~tH~~ .~ ~ ;J A i,Eil~~i11S i ,~ s+i~.' ". t_S.s,ao . L 1 DPHDIPALITV (y~a`i6. DNTT NlexPl~ tt~ii~C is v. ~'~!t'~+I+kct t.r n a Aaa. ~.fil'TJf'1S^4t`JC ~~wiEL~S ;,,ec. _ F, O N ~ E ?LATE x •O TRANSFER Of REGISTPATION PLATE NUMBER EBLUMa PPxEf HOEDEa Aoonfss PefT OFiILE STATE IIr LDBE ~ 2ND ENCUM9RANCE: ^YES~NO AMOUNTS Excuxte.Excf NoseEe c a ASDPESf POn UFFICE StATE 21P CODE ~ DUPLICATE REGISTRATION CARD IAaeroPRM tea at trop rwlln.d Inr ucn avpecate rzewn.dl 'NOTE: Owner's registration card far plate being transferred mutt be attached here. If card Is not attached, an additional tae of 53.00 is required. INSURANCE 'C SUBSTITUTION ANO TRANSFER OF REGISTRATION PLATE NUMBEfl REISSUE REASON O LOST ^ STOLEN O DEFACED POLICY NO.. CODE s VERIFICATION OF RELATIONSHIP 1N CONNECTION WITH TRANSFER OF PLATE. Plate may be transferred between spouses or between parentlsl (including step. parentis) or parentlsl-in-lawl and their childlrenl lincluding step•childlren) or childlran)-in-lawl or to or from a vehicle leased by an individual under Section 73141A) of the Vehicle Cade. X SIGNATURE OF TRANSFEROR X SIGNATURE OF TPArv:FE REF REGISTRATION PLATE NUMO RELATIONSHIP: FROM TO CUN!P7E rv!~M9fP { pf Llf)~~f;,.,V~ Estate of ELAINE E WALL 21-06-0876 Schedule E rM xs~a urM ~~ ~~, ` ~ ;' I ~ c, ~ ~ I-: ~~ ~ ~ ~~° ~..~ ~ b I J \~ ~ ~ ~` ~~ ~ ~ ~ ~~ ~ ,~ O j I-~ ~ ~ i `~J - Z~I~ HZIM HS~IJ KIM ~5 r~ ~~ 4~ O Q. H b S \~ 'J ~`~ ~ ~~ m ~' \ ~~ ~ ,~ ~~ ~1 ~ - .i ~~ ,__~ `~ .~ C _ .y $SHHnSH SSS - Z~~ HZIM HS~J HIM u°i aLi ai Q U O~G ~' •- C N m N Q C ~ T~ O t~0 a~.1 OD f~ +~ ~ L ~ O ~ >+ ~--- H U ai ~ ~ rv o °o ~ N ~ ~ ~ ~ C ~ '~ O CO Q~ ~~ ~ O 7. CD '~Q ~ O H5HSnHH H5S - Z~Y~ HZIM HSKJ HIM SSH; O ,°c~ ~°n 0 0 ~ rn ~ ~~ 0 N ~ ~ C ~ O Q~ ~ m N O ~ Q7 O 0.1 O O ti ~ ~ im m ~ ~ ~ V - Y ti ^ o ' ' . 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Boyd L. Myers Jr., Supervisor 37 East Main Street Mechanicsburg, Pennsylvania 17055 (717) 766-3421 A standard of excellence in Central Pennsylvania since 1910 Monday, October 2, 2006 Ms. Wendy C. Rumbel 124 Woods Drive Lot #12 Mechanicsburg, Pa. 17050 Fax (717) 795-7291 Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form on the services for: Elaine E. Wall SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED $8,616.80 LESS: Credits granted 1,695.00 LESS: Total Payments 2,492.89 CURRENT BALANCE $4,428.91 Credits Granted: $1,695.0 Package Price Discount Interest at the rate of 1.5 % per month (18 % per annum) will be added to balance after 30 days. If there are any questions or concerns that remain unanswered, please call me. Sincerely, /., ~ ~-~ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 WALL ELAINE E Estate File No.: 2006-00876 Paid By Remarks: WENDY C RUMBEL WZ ------------------------ Receipt Distribution * DUPLICATE Receipt Date: 10/04/2006 Receipt Time: 08:16:27 Receipt No.: 1045885 Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 60.00 CUMBERLAND COUNTY GENERAL FU WILL SHORT CERTIFICATE 15.00 12.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FU FU JCP FEE AUTOMATION FEE --- 10.00 5.00 ---- BUREAU OF CUMBERLAND RECEIPTS COUNTY & CNTR GENERAL M. FU Cash --------- $102.00 Total Received......... $102.00 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 WALL ELAINE E Estate File No.: 2006-00876 Paid By Remarks: JA Receipt Distribution Receipt Date: 10/12/2006 Receipt Time: 10:15:00 Receipt No.: 1045968 Fee/Tax Description Payment Amount Payee Name PHOTOCOPIES .50 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash $.50 Total Received......... .50 No. ~3~42a~ ~~ A. - PA TITLE NUMBER (AS SHOWN ON ATTACHED TITLE) MAKE OF VEHICLE MODEL YEAR PURCHASE c ~ ~, ~ -s ,y . , ~ r ~ ~ / G ` r` "'' '~ l i t'i r s Yi r ~ i . ` ~ > = PRICE (See note on reverse) ^ v i , ' ' _ ~ ~- ^ VEHICLE IDENTIFCATION NUMBER CONDITION r LESS ~ a . 1 i~ =R I?= ~~' /r~'% r~~ ^ GOOD Ll FAIR ^ POOR TRADE-IN ^ ^ B LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE INITIAL . TAXABLE J '' ~ AMOUNT w CO-SELLER 9. Sales Tax Due x 6%( 06) or See rate on reverse). W C. LAST NAME (OR. FULL BUSINESS NAME) FIRST NAME MIDDLE INmAL DATE ACOUIRED/ ~ ' to Exemption i _? , PURCHASED ( o d odee ~C ~ ) t u °.." . t r ... ~ a Fes,..- ;- `~ ~'' ~ r from t nu mh e to 23 0r 0} f w ~ ~ CO-PURCHASER - - 16 First Assgnment - ~, t6 Secorxf Assignnrent ~ ,..~ c.- _ L ~ STREET COUNTY CODE f i . - ~ 1 / ~ 2. Title Fee - ~a ^ ^ CITY STATE ZIP CODE REFER TO COUNTY CODES LISTING ON REVERSE SIDE 3. Uen Fee OF PINK COPY ^ ^ D. LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE INITIAL DATE ACQUIRED/ PURCHASED 4. Registration or Processing Fee ^ ^ = CO-PURCHASER Fee Exertg7t Number W as assx,}ned by the W ~ 2 w Bureau ~ N STREET COUNTY CODE 5. Duplicate Reg. a a ~ Fee = a No. of Cards ^ ^ ~ 2 CITY STATE ZIP CODE REFER TO COUNTY CODES LISTING ON REVERSE SIDE 6. Transfer Fee OF PINK COPY ^ ^ E. MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER 7. Increase Fee W JW ^ ^ °a MODEL YEAR BODY TYPE (CP, TK, ETC.) CONDITION > ~ ^ ^ 8. Replacement F GOOD FAIR ^ POOR ee ^ ^ F. ORIGINAL PLATE / Check One ^ TRANSFER OF PREVIOUSLY ISSUED PLATE TOTAL PAID 9. ; i. . ~ /, ~ ~ .~Q' ;~ ^ PLATE TO BE ISSUED BY ^ TRANSFER & RENEWAL OF PLATE (Add 1 thru 8) Y ^; BUREAU (PROOF OF IN ^ - SURANCE ST ^ TRANSFER & REPLACEMENT OF PLATE Send ~ MU BE AT- TACHED.) ^ TRANSFER OF PLATE & REPLACEMENT OF STICKER t t.GRAND TOTAL Check in (Add 9 8 10) This Amount y ^ EXCHANGE PLATE TO BE ^ ISSUED BY BUREAU PLATE NO. REASON FOR REPLACEMENT ^LOST ~ DEFACED ~ STOLEN o Z ^ TEMPORARY PLATE EXPIRES NEVER RECEIVED (LOST IN Mau a p ISSUED BY FULL AGENT Month Year NOTE: If "NEVER RECEIVED" block is checked a licant must com lete Form MV-44. F g TRANSFERRED FROM TITLE NO. VIN vw a ¢ TEMP. PLATE NO SIGNATURE OF PERSON FROM SIGN HERE WHOM PLATE IS BEING TRANS- RELATIONSHIP TO APPLICANT . FERRED (IF OTHER THAN APPLICANT) VEHICLE PURCHASED GVWR WEIGHT INFO UNLADEN WEIGHT REQ. REG. GROSS WT REQ. REG. GROSS COMB. . IF APPLICABLE INCLUDING LOAD WT. (IF APPLICABLE) INSURANCE COMPANY NAME POLICY NO. (OR POLICY EFFECTIVE POLICY EXPIRATION ATTACH BINDER) DATE DATE ISSUING I CEFITIFY THAT ON MONTH DAY YEAR ISSUING AGENT (PRINT NAME) - AGENT NO. AGENT I HAVE CHECKED TO DETERMINE THAT THE VEHICLE IS INSURED AND INFOR- ISSUED TEMPORARY REGISTRATION TO THE ABOVE APPLICANT IN , ISSUING AGENT SIGNATURE TELEPHONE NO. NATION COMPLIANCE WITH ALL APPLICABLE PROVISIONS OF THE VEHICLE CODE AND DEPARTMENT REGULATIONS. ( ) G. I/WE CERTIFY THAT I/WE HAVE EXAMINED AND SIGNED THIS FORM AFTER ITS COMPLETION AND THAT THE INFORMATION GIVEN IS TRUE AND CORRECT IF AN EXEMPTION . IS CLAIMED, THE PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIS EXEMPTION. I/WE ACKNOWLEDGE THAT I/WE MAY LOSE MY/OUR OPERATING PRIVILEGE(S) OR VEHICLE REGISTRATION(S) FOR FAILURE TO MAINTAIN FINANCIAL RESPONSIBILITY ON THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. I/WE ACKNOWLEDGE THAT I/WE MAY BE SUBJECT TO A FINE NOT EXCEEDING $5,000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY FALSE STATEMENT THAT I/WE MAKE ON THIS FORM. o Signature of First Purchaser o[ Authorized Signer -~" ~ TELEPHONE NUMBER Signature of Seller F 1ST ,'. '. -, _ f` ~ - ,~ , ~ ( ) ~-: ' ~ ' ~ ASSIGN- SI nature of Co-Purchaser/Title of Authorized Signer ~ ` MENT g .. . :. .. ~ _-C. _ Signature of Co-Seller - W _ O Signature of Second Purchaser or Authorized Signer TELEPHONE NUMBER Sgnature of Seller 2ND ASSIGN- ( ) MENT Signature oP Co-Purchaser/Title of Authorized Signer Signature of Co-Seller H. J = NOTE: If a co-purchaser other than your spouse is listed and you want the title to be listed as "Joint Tenants With ZW< Right of Survivorship" (On death of one owner, title goes to surviving owner.) CHECK HERE ^. Otherwise the title oF¢ , will be issued as "Tenants in Common" (On death of one owner, interest of deceased owner goes to his/her heirs or °a = estate). - NOTE: IF THE VEHICLE IS TO BE USED AS A DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK ^ . IF BLOCK IS CHECKED, COMPLETE AND ATTACH FORM MV-IL. n your re islranon aocuments are not receives wlthm 9 days, please contact PennDOT 3. APPLICANTS COPY/TEMPORARY REGISTRATION {VALID FOR 90 DAYS] MESSENGER NUMBER: Estate of ELAINE E WALL 21-06-0876 Schedule to o00 ~ mm .-i ~ ui ui ~~ W m z ova J J Zao m 5~~ ch l0 \ H N O ~ ~ I ~ N ~ ~f1 ~ C7 \ H PAG oQ ~ WNO\iH 77 iy \ ~ O~ 00 N .-i 'i~ N rl \ \ W I N OD 01 .-i tp cp N A ~~ InN\[~~ rnaD~ 0 Az~u~x w~za ~oW~°w zc°nOw~ ~~UOU ~ ' Z ~~ ~ G Q ~ ~ 3 ~ ~ ~ x a o LL N W 2 W ~ a Q j g .-I x a yr ur v} a v ° 3wo ~ WW a ' H ~ ~7 H Ua ~ o0o U w~ H ° 0 0 o z ZO ~ a I H ~ ~ o H fq .-I .-I n1 n'1 M rl o z7 E ~ ~ M O q N ~ WO OD~$x J Z ~U W OA i ~ ~ r W~ NN~,+ J I ~ 'i rl l ? m N y a r'~i ~ ~AHW _ R~ 5rwnz oFM~Iw~a°~ O ZW ~U ~~ ~Z W ~ w ~o J F- N ~ W I 0 ~ w 0 o~ ~ = W ~ ~ J 0 1 ~ ~~ ~ w ~ r WW ai H (9 t0 i-~ W ~ ~ ri A ~ F- H`.' Q V ~ W 0 J P0rnU a ~ ~ a ~ J O n ~, Y .. 00 ~ N W O U ~ = ~ ~> W Q x N Y } ~ ~ a ~_~ ~ a ~~ ~; 4 ~' ~: i ;~ ° ~ ". 1 e~~=- } ~~~ J H a O ~ ~ ~ N O a ~ r 'i } Q H a as W Q W H J (~ ~ A " W J ~ H ~ m Q a ~ x ~ p ~ ~ U a 3~~ , 0 ~ ~ ~ W In a 1 Ifl W 0 r-I tp O O N ri rl a. W N W ~~ J AQ 2 Ir W Qa= ZDU OWw UZp J W O ~W{R U~~ ~w0 W ~ W ~°w Z¢= 0 Waz ~~a. o~~ ~ Q m >~J OpJ wZ3 W 4. W J W ~ J_ ~ Q Q w~Z W O a o °a Z ~ ~ ~~ We never stop working for you. ELAINE E WALL Account Summary Previous Charges $ 28.91 No Payment Received .00 Past Due Charges (please pay now) $28.91 New Charges Verizon (page 3) - $ 16.08 Total New Charges Due _ 6:98, ~ Total Due: (Past Due + New) $12.83 , Please pay upon receipt Billing Date: 11/13/06 Page 1 of 6 Telephone Number : 717 766-9828 Account Number: 717 766-9828 880 91Y T ~~ Convenience) Access Your Verizon Account Online, Day or Night) Enjoy the benefits of managing your Verizon account onfine. View and pay your bill, order services, request repair, and more. Visit us today at verizon.com/selfservice to register. / - !~ /'-~ (~'~ - FINAL BILL - ~~ ~ ~ °"/ This Final Bill may have already been referred to an outside collection 1~ ~ ~ ~ , agency. 'r ,<<:?( .r ~ ~ ~ r~ /q/ftr - U' Questions about your bill? Call 1800 660-2215 See page 2 for all other Verizon contact information. Change of billing address? Go to verizon.comibillingaddress or see page 2. ~ Detach & return payment slip with your check, payable to Verizon. 0 0 N ~w c lf) ~ CO O O ~ O 0 1~ 00 O_ ~ N r ~ ~ ~ U z Q EA d9 ~ W U ~ ~ ~ W Z a _ ~ M N ~ ~~ ~ O cfl ~ o w a m ~ o ~ ~ o U - a K O~ ~ ~ O J fL Q Q ~ } a 0 W= ti a ~ ~ O ,,, W ~ ~ C ~° ~ O c~ m ~ ~ a cn Z ~ w W O W ~ W 0 O a ~ ~ W Y ~ Q U Z J WW Z ~ o m ~ N ~ Q 7 ~ ~ Q = - ~= \ / W o ~ N ~ ~ Q ~ ,l O ~ U ~ ~ O Z ~ Ur ¢ Z a 3 ~ ~ d ~ ~ Q ~ W o W J >~ a U U~ m to cn Q ~ ~ W w Q ~ ~ d ~ ~ o ~ ~ ~ U d ~ ~ ~ v`r'rn LL ~ m W OQ N ~ co z v c i.' O p o Q f- ~ W L ~ - O O M~ LL `ti W ~ ~~ t U cM M rn rn G N LL d `~ 0 0 0 0 p O O M O ~ a O O O O a N U N N` ~ Ir ~ z a 0 W o ~ o a o 69 z °<° 0 0 U o EA Z o a m a ~ ~ n e u v >_ '- ~ o z <- Q Y L Y 0 Y O W ~ ~ Z W ~ j ~ Q M O m o ap ~4 Page 3 - ' ~'°w Btll A~cl~utiY 1tliunber PPL Electric pp < ~~`` 51860-75002 Utllit~es TM w r , Electric Total from Last Bill $ 88.25 Service Billing Details For: Amount You Still Owe as of Oct 30, 2006 $ 88.25 ELAINE E WALL 124 WOOD DR, LOT 12 MECHANICSBURG PA 17050 Current Charges Char~es.for -PPL ELECTRIC UTILITIES Residential Rate: RS for Oct 6 -Oct 28 Final Bill Distribution Charge: Customer Charge 146 KWH at 2.19300000¢ per KWH 5.86 3.20 PPL Electric Utilities Customer Service 155 KWH at 1.98400000¢ per KWH PA Tax.Ad~Surcharge at -0.09700000% 3.08 -0.01 827 Hausman Rd. Transmission harge: 6x500000¢ per KWH 301 KWH at 0 1.82 Allentown, PA 18104-9392 . Transition Char e: 36100000¢ per KWH 146 KWH at~ 1 87 1-800 342-5775 (1-800-DIAL-PPL) . 155 KWH at 1.20600000¢ per KWH : www.ppletectric.com Generation Chargge: Capacity and Energy 146 KWH a.t 5.66300000¢ per KWH 8.27 155 KWH at 4.97500000¢ per KWH PA Tax Adj Surcharge at -0.06900000% 7.71 -0.01 Total PPL ELECTRIC UTILITIES Charges $ 33.78 76 $ 115 Budget Plan as of Last Bill . P~ "t"lils Antoiint iSo I~at~r Tli~t~F zti, ~ ~ ~~y~t' 1 Account Balance ~~<;i' ~~_ ,;2k_~-~--:~-1~~~/ ~~,~ ,$ 237.79 _ ~~ y~ ~~ /_~_ \ ~'f!'"`. ' lam'/-- ~~ ~"~~.-^i ~` ~ /~,l `~ ,// ~'rt-. ~~f' General gudget Settlement Summary after 12 months: Information W"e billed you $481.54 Including Phis bill, you used 481.54 We have added $115.76 to this bill to settle your Budget Billing Plan. Generation prices and chargges are set by the electric generation supplier you have chosen. The Pubric Utility Commission re elates distribution prates and services. The Federal Energy Regulatory~ommission regulates transmission prices and services. ~1 additioncaboutt$14e17 of this~b,l lpays the PA GrossoKece pts Taxes. In The Transition Charge includes an Intangible Transition Charge (ITC) and the applicable toss receipts tax which to ether amount to $3.18. The ITC is a per usage c~arge approved by the Pu~ic Utility Commission which PPL Electric Utilities collects as agent for PPL Electric Utilities Transition Bond Company LLC and which that company uses to service debt incurred to recover a. portion.of PPL Electric Utilities' stranded costs. The gross receipts tax, which is collected for the Commonwealth of Pennsylvania, is equal to 5.96% of the ITC. For your convenience ou can now pa. our bill using your Visa Bi1lMatrixdwnili charge your credit and ATM card a s rvice fe0ef or mak g this payment. 03-24-~ 09 13:15 rHUC~- ~ M&T I3anic March 24, 2009 Estate of Elaine E WaII 124 Woods Dr. Mechanicsburg, PA 17050 RE: Account: # 10900119857200001 Case: # 2062175 To Whom It May Concern: t -~ r ~ r~ur~c.I r~~L r-;.,11 At this time, M&T Bank will accept $1,597.48 as payment in full on the above- mentioned account, if received in our office by March 31 S`, 2009. Please remit your payment to your nearest M &T Bank, or express mail it to the address below. M&T Bank Amherst Center 1100 Wehrle Drive Williamsville, NY 14221-7748 Attention: Patrick Mannella Please call (800)-724-2445 x 6502 if you have any questions. Sincerely, ~. /~ /~i Patrick Mannella Lending Services Specialist x ~, ~. ~'11~ ~~ vY1~I'5~11(~1TIg W11~a51I17~70I'hdilY~ Hampden Office If you have any questions, please call our Telephone Banking Center at 1-800-724-2445 Today's Date: Business Date: 03/25/2009 03/25/2009 Time: 11:18 AM Loan Payment - COF ****57200001 $1,597.48 6109 / 04 54 What's So Extraordinary? Visit www.mtb.com/fantasticplastic Certificate Number/Numeeo de certificado: 26043 008004 915590 WIN CASH! Take a short survey and let us know how we're doing. Visit ~etww.mandtbanksurvey.com or call 1-800-670-7494 This invitation expires 7 days from date of receipt. No purchase or transaction re'Iired to enter. j~ANE DIN'~RO EN EFECTIVO! Tome una breve encuesta y dejenos saber como le estamos sirviendo. Vsite www.mandtbanksurvey.com o (lame al 1-80070-7494. Este invitacibn se vence 7 dial despu~s de la fecha mostrada en el recibo. Ninguna compra ni transacci(m es necesar~ pare participar. WEST SHORE EMS -BLS ---- 205 GRANDVIEW AVE SUITE 211 ~°~ ~~~. CAMP HILL, PA 17011 ~~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 `~~ -- +~~~ 49906 TIME PATIENT NAME: ELAINE WALL PATIENT NUMBER: 30625066 TIMP INSURANCE: MEDICARE B 210266225A DEPARTMENT OF PUBLIC 2501439729 3062506B ~~' ~~ ELAINE WALL -~~ 124 WOODS DR LOT 12 ~: ~,i' !v~ MECHANICSBURG, PA 17050 (: ..- CALL NUMBER: 04/14/2006 DATE OF CALL: TIME OF CALL: CALLER: 124 WOODS DR LOT 12 FROM: HARRISBURG HOSPITAL To: ABDOMINAL PAIN REASON(S) DIARRHEA FOR TRANSPORT 1NVOIGE DESCR{PTION OF CHARGE QUANTITY UNIT PRICE AMOUNT BLS EMERGENCY BASE RATE A0429 1.0 429.48 429.48 BLS MILEAGE A0425 11.0 10.78 118.58 Total Charges 548.06 DESCRtPT10N OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Private Payment /Check 7348 09/06/2006 15.00 Private Payment /Check 7334 08/04/2006 10.00 Private Payment /Check 7316 07/06/2006 10.00 Medicare Assignment Adjustment 05/12/2006 194.30 Medicare Part B Payment 107369737 05/12/2006 283.01 Total Credits 512.31 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --->• $35.75 ,, - ..r-~...~..~~ ~.ucnv rcc Q~~ nn _.-- ,r, ~' G l~ r n, , ,~, i ~ ~~,;5 Pinnacle Health Hospitals o x 2353 - - --- --- -- ---- -_ -- -_=_ _- .__--_ - _ ___ - - - _ . - . __-__ -=---- - P. . BO -- - -- - - - HARRISBURG, PA 17105 =-_ =--__ -________ _ ____ _ ___ _ _ _ _ __ _ _____ _ -- _ _-_ :_-_ -- -_==__ =_ _ __--=-__ (717) 230.3717 . -~- ::- --:_-::: .:.: ..::::.....::.._.___:__: __-_- --_.._......_.:-__::_- ~~ Transaction Date Description PREVIOUS BALANC E 09/07/06 1 FERRITIN 82728 D9/07/06 1 LD 83615 09/07/OS 1 RETICULOCYTE CQUNT 85044 09/07/06 1 URIC ACID 84550 09/07/D6 _. _._. .1_ _CQMPREHF@ISIVE METABOLI80Q53__ _ ___.~___.._ 09/07/06 1 HAPTOGLQBIN 83010 09/07/06 1 FOLIC ACID 82746 09/07/06 1 VITAMIN B12 82607 09/07/06 1 YENIPUNCTURE CHARGE 36415 09/07/06 1 VENIPUNCTURE CHARGE 36415 09/07/06 1 CROSSHATCH 86920 09/07/06 1 CROSSHATCH 8692D 09/07/06 1 DIRECT COOMBS - IGG 86880 09/07/06 1 DIRECT CQQMBS - COMPLE86880 09/07/06 1 ANTIBODY SCREEN 86850 D9/07/06 1 ABQ K RH TYPING* 09/07/06 1 ABQ BLQQD TYPING-A 86900 09/07/06 1 RH BLOOD TYPING-B 86901 09/07/06 1 LEUKOCYTE REDUC RBC PRP9016 09/07/06 1 LEUKOCYTE REDUC RBC PRP9016 Estimated Insurance Due: .00 Total Patient Credits: YOUR ACCOUNT IS PAST DUE! PLEASE CALL OR PAY IMMEDIATELY. Account Balance: Amount .oo 112.00 57.00 51.00 47.00 127.00 97.00 117.00 74.00 17.D0 17.00 232.00 232.00 62.00 46.00 62.00 .00 27.00 23.00 605.00 605.00 126.48 CUSTOMER SERVICE HOURS HON-YYED-FRI 7:OOAM TD 4:OOPM TUES-THUR 7:OOAM TO 6:OOPM CALL 717-230-3717 LOCAL OR 1-800-603-60iB4 OUT OF AREA For Account Formation, Please Cali(717} 230-3717 :......:..: ......:...:......:......................--_.:-_---....:-----.------...--- .1~.CCO~t ~ 1153 ~I .StQt~'l~lerit 0f ACCfll[ilt 111Qbf 06 ~' ~- Pinnacle .Health Hospitals P,O, BOX 2353 HARRISBURG, PA 17105 11 Jt~~~ts .Statement of account For Accou~ Information, Please Call (717) 23(1-3717 Transaction Da#e Description 09/07/06 1 INSULIN 70/30 VL 00000 09/07/06 1 LEVOTH 150MCG TB OOOOD 09/07/06 1 WARFAR 5MG TB 00000 09/07/06 1 GABAPENT 300GM CP 00000 09/07/06 - -- - -7:_ "IV-"PUAP~-DAILY"CHGE-~. _UUD"0"D- 09/07/06 1 SETUP IY PUMP 00000 09/07/06 1 IV OR IPID CHECK 00000 09/07/06 I MEDIPRT ACCESSCTIME ~ 09/07/06 1 IV BLOOD SPECIMN FROM 00000 04/07/06 3 IV BLOOD SPECIMN FROM 00000 09/07/06 1 IV BLOOD SPECIMN FROM 00000 04/07/06 1 PORT TERMNAL FLUSH/DI S00000 09/07/06 22 OBSERVATION PER HOUR G0378 09/07/06 1 BLOOD TRANSFUSION 00000 09/08/06 1 PROTHROMBIN TIME 85610 09/08/06 1 CBC AND MANUAL DIFF 09/08/06 1 CBC AND MANUAL DIFF A 85027 09/08/06 1 CBC AND MANUAL DIFF B 85007 09/08/06 1 HAPTOGLOBIN 83010 09!08/06 1 VENIPUNCTURE CHARGE 36415 09/08/06 I VENIPUNCTURE CHARGE 36415 09/08/06 1 VENIPUNCTURE CHARGE 36415 09/08/06 5 HEP FL 1000N VL J1642 09/08/06 1 ALLOPUR 300MG TB 00000 09/08/06 1 INSUL REG VL 00000 09/08/06 1 MOM lOML CUP 00000 09/08/06 1 ZOLPID 5MG TB 00000 09/08/06 1 GABAPENT 300GM CP 00000 10/02/06 PMT MEDI B VERITUS 701 MEDICARE 10/09/06 MEDICARE DISCOUNT 701 MEDICARE 10/09/06 MEDICARE DISCOUNT 701 MEDICARE 10/09/06 MEDICARE DISCOUNT 701 MEDICARE Amount 106.75 3.00 3.00 3.00 28.00 24.00 217.00 44.00 132.00 44.00 48.00 1,100.00 321.00 44.00 .00 59.00 23.00 97.00 17.00 17.00 17.00 35.00 3.00 79.10 3.00 22.40 3.00 627.59- 1,985.25- 848.09- 1,602.84- ~~~~~'~- Pa¢e # 2 w ~v _, ; , U ~ ~ ~+\ _ ° V W J a w w w a g~ T ~. w w Q - ~ ~ ~ g w ~` G ~ ~ O U ~ U U ~ " - 1 - a - ~ \ ~ ~ _ -~ m fn O J J_ H W} LL w _ W - __ J a -- ~~ rte ¢~ a ¢JF'ZpaO ¢ - w "-'a x x ¢ p3~m~ w w .. 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Q1~~ rwvQ j~mg~~ Ya r ^Q ^ ~ C7~ to ~ ~ Q ~ ~ i ~ ~ ,~ j U ^~ a W ~wFm ~-UU N ~ MJ ~ ~>m Q J N~~ W ~ ~ °e lav~w - I I f3 - W a ¢O W ~ [ L J m Z ~ Z^em a ro cnp¢~ O W ~ wu~~~ v ~z ¢c~ jWC? ~C'f Z mc~~Y OOmmLLfUUJ°w~2m~Qaff~m>xmFmo~ ¢ W w ~ _ ~ a d O Y Q m f' F d U d Z 0 3 n W W LL Z J_ I"' Z J H, w a M a 0 y F H ~ ~ t7~~ ~ Q ~ g ~ > = y~ W ~ ~ ~ ~ ~ J / Ozz~ U alQim Q OJ 2 > ~ w WIDLLa O O WW JQ~ W ULLC~ v Om=~wOUOO w X (J ~ X U V ~ ti W U Q Z W ~ ~ ¢ w z ¢ a F¢ gQ ~F ~ ~ W F v i U ^~ ~ ~~~ ~ o ^'~ ~ U W ~ a~ ~_ 3 ` . i - ~ ~i~ b -~~a~~~F 2 , - .r s { .t ~- * '-~ 3 3: _ t ~ ~ ui ~ +~'h f kJ ~ F _ (~i ~i~t~al~~ ~~r° :f ' ~ , _ ~. f ~ ~~ ~ nom-'': r*, , ~~ ~f ' ~ ~ . ~ s S r: ~ ~ d n t` L ~ ~ - I ~ -4Y K- i ' r L`„~ 4 ~ T ~~+~ ~ ~ Ay.~ S Mrt ~,,_, -,_ ~t~ r`` r-,~ ~ ~ u - ~~ Fh. ~-~- ~ ~ . ~-. ~,~,x r.~ - - `,~ _ ~ ~ ~ ` ~~ r,,~.r~, ~;" . . _ `4 ~ ~ -`~. _~ ' '1 `~~ • :~ a'ti -: s ,'_`~x -~ w* 1 F ate. 2 ;'u''i: ::t-,~' t 3' ~.. ~, ~ _ ~._: ~~~ . f t Y }' J!. ?i c ~ ~':} ~~~ ~l' _ ~ '. 1y ~` rid t}~ ~' k, r'~~ 3213H 2iV31 c 0 d U C O ~ e~--1 ~ 0 ~ ~ ~ a--, ~ f6 ~ fa U ~ :~ T O '~ ~~ ~ ~ ~ IQ fp ~ j ~J+ (6 a °' nom... ~ O T +-' ~ ~ "d ~ ~ C ,.y ~ O ~ W ~a ~~ ~_ W -a 3 H ~w = as v w~ U Q Z ~ QZ Z Z ~, a Contract Receipt Page 1 of 1 ROADSIDE ASSISTANCE: CALL 1-800-528-0355 EQ#: - DC 2448Y Contrail: 00288681 Dispatched From: 811055 SAFE-PROTECTION(YES) U-HAUL EQUIPMENT CONTRACT In-Town Rental (OUT) Contract Number: 00288681 Saturday 10/28/06 3:49PM Customer Name: Customer Ph No(s): wendy rumble 717-766-1828 124 woods dr lot 12 mechanicsburg, PA 17050 Rental Out Date/Time: 10/28/2006 3:SOPM U-HAUL MECHANICSBRG 4725 OLD GETTYSBURG (717)763-7677 (811055) MECHANICSBURG PA, 17055 Customer D/L: Customer DOB: 15963826 Marll 1952 PA 0308 Rental Due Date/Time: 10/29/2006 3:SOPM Equipment fMI OUt MI Rate MI SafeMove/SafeTow/CDW Rental Rental Estimated Estimated Actual } 'Charge Rate Charge Tax: ,Charges Charges DC 2448Y 184771.0', $0.79 X ! $39.50: $14.00 $19.95 $19.95 $7.88 ` $73.45 AA83069 AZ ' 50.0 `UTILITY ~Q antity Rented: 1 ~ $7.00 $7.00 $0.421 $7.00 DOLLY Estimated Subtotal: $80.45 ' r ~, '" -7-" . ~ : Estimated Tax: $6.30 a ( ; ( ) ; R Motor Vehicle Tax: $2.00: --~-~-' Estimates Total Charges: X88.75 Rental Deposit Paid: $100.00 Cash Payment: $100.00 Net Paid Today: $100.00 • I confirm that the mark on the picture of a fuel gauge on this contract matches the fuel gauge reading on the truck. I agree to return this truck with this amount of fuel or pay a $30 fueling fee and a minimum of $4 per gallon for fuel used. U-Haul does not reimburse if this truck is returned with more fuel than when it was dispatched. U-Haul pays for oil (save receipts). • U-Haul provides the Customer with minimum limits of protection required by that state or province where arises any claim, suit or cause of action. This provided protection is in excess or secondary to any insurance coverages) of the Customer. Customer assumes Sole Responsibility for any and all liability that exceeds the applicable minimum limits of protection for that state or province. This description of coverage supersedes and renders void any Liability Insurance Coverages) described or implicated in the U-Haul Document Holder. • I understand that this equipment must be retumed to the same U-Haul location where it was rented. I understand that the minimum rental charge for equipment retumed to a different location is twice the amount of the current One Way rate from this U-Haul location to the actual drop-off location. • Failure to return this equipment by the contract due date and time and pay all amounts due (including the cost of damage) can be construed as intent to defraud and is punishable in accordance with state and local laws. • I confirm that the equipment I am renting is clean and I agree to return this equipment clean or pay a cleaning fee. • I understand that the equipment rented is water resistant and not water proof. • I agree to pay all fees incurred in collecting unpaid rental charges and fees. • I acknowledge that I have received the appropriate User Instructions and acknowledge my responsibility to fully read and understand these User Instructions before operating the equipment. • Watch for overhead objects. I understand and agree that a collision with an overhead object is one of several exclusions under the damage waiver portion of SafeMove protection. • I acknowledge that I have received and agree to the terms and conditions of this Rental Contract and the Rental Contract Addendum Scott Greenfield Customer Signature - (wendy rumble) https://uhauldealer.corn/ContractPrinting/ContractPrint. a ter""