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HomeMy WebLinkAbout07-09-09 (3)J REV-1500 1505607120 EX (OS-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.2aoso~ 21 0 9 0 0 3 5 9 Harrisburg, PA 17128-OS01 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 211226690 04142009 04211930 Decedent's Last Name Suffix Decedent's First Name MI DODGE HELEN M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required (date of death after 12-12-82) ^ g Decedent Died Testate ^ ~ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) --- ^ 9. litigation Proceeds Received ^ 1 D. 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 GALEN R WALTZ 7172459688 Firm Name (If Applicable) TURO LAW OFFICES First line of address 28 SOUTH PITT STREET Second line of address City or Post Office CARLISLE State ZIP Code PA 17013 REGISTER OF WILLS USE ONLY ~ ~ .> -, ~. i ;' c__ -; --l , ~~-~ r__ , i ~ -' I_-r.1 I pA'~f )~ED ~ I ~, -, r _~ r_.._ .-.a.. ... ,..i ., . , .-'...7 ~i .. ' .~ ~. Correspondent'se-mail address: gWaltz@turOlaW.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 tr correct and complete. Decl ration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN T RE OF PER~`'N PONSI OR FI NG RETURN DATE /~/~'GU~a' /~ ~ ~ /r .(~ , David E. Dodge (n /,~ ~/~i ADDRESS /J ~ / 1080 Starlight Terrace Way/ Mesquite, Nv 89034-1023 SIGNAj OF PREPARER O -ER~ PRESEN TIVE DATE ~ Galen R Waltz ~ ~~~ ~~0 y A ESS 28 South Pitt Street, Carlisle, PA 17013 Side 1 1505607120 1505607120 ~~. 1505607220 REV-1500 EX Decedent's Social Security Number Decedents Name: DODGE , HELEN M. 2112 2 6 6 9 0 RECAPITULATION 1. Real Estate (Schedule A) ....................................................... .............................. 1. 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. 5~ Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. .. 5. 6 7 , 1 5 1 2 4 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............ . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ............ . 7. 8. Total Gross Assets (total Lines 1-7) .................................................................. ..... 8. 6 7, 1 5 1. 2 4 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ..................................... .... 9. 2 0, 3 1 1 5 7 10. Debts of Decedent, Mortgage Liabilities, ~ Liens (Schedule I) ............................ .... 10. 11. Total Deductions (total Lines 9& 10) ................................................................ ......11. 2 0, 3 1 1 5 7 12. Net Value of Estate (Line 8 minus Line 11) ........................................................ .....12. 4 6 , 8 3 9 6 7 13. Charitable and Governmental Bequests/Sec 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. 4 6 , 8 3 9 . 6 7 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 .00 15. 16. Amount of Line 14 taxable at lineal rate X .045 4 6, 8 3 9. 6 7 1s. 2, 10 7 7 9 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due ............................................................................................................. ......1 s. 2 , 10 7 . 7 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505607220 1505607220 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 - 09 - 00359 DECEDENT'S NAME Dodge, Helen M. STREET ADDRESS Claremont Nursing and Rehab Center CITY STATE ZIP Carlisle Pa Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2,107.79 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 105.39 Total Credits (A + B + C) (2) 1 05.39 3. Interest/Penalty if applicable p. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2 002.40 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 2 0 ~ 2.4 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................. I x b. retain the right to designate who shall use the property transferred or its income :....................................! I x c. retain a reversionary interest; or..... - ...................................................................................................1.. I x '. d. receive the promise for life of either payments, benefits or care? ........................................................._... '~ x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .....................................................................................................................~ I x 3. Did decedent own an "in trust for' or a able u on death bank account or securit at his or her death?......... P Y P Y x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ~ ~ I~ x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETU' For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF Dodge, Helen M. 21 - 09 - 00359 Include the proceeds of litigation and the date the proceeds were received by the estate. Atl property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 PSECU Account No. 0211-22-6690 5.07 Share Account 1 Credit Union Place, Harrisburg, Pa. 17110-2990 2 PSECU Account No.. 0211-22-6690 8,223.58 Checking 1 Credit Union Place, Harrisburg, Pa. 17110-2990 3 PSECU Account No. 0211-22-6690 45,587.68 Money Market 1 Credit Union Place,Harrisburg, Pa. 17110-2990 4 PEBTF Health Insurance Refund Check 1,107.34 150 S. 43rd St. Harisburg, Pa. 17111-5700 5 Burial Reserve: Account No. 105-113-5-60 7,530.46 First National Bank of Liverpool 104 N. Front Street Liverpool, Pa. 17045 6 Claremont Refund 4,697.11 Claremont Nursing and Rehab Center 1000 Claremont Road Carlisle, Pa. 17013 TOTAL (Also enter on Line 5, Recapitulation) 67,151.24 SCFEDULE H FUNERAL DIES ~ COMMONWEALTH OF PENNSYLVANIA T INHERITANCE TAX RETURN A~N~~A,1 ~!`_f1CTC RESIDENT DECEDENT vw ~ v ESTATE OF Dodge, Helen M. Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION NUMBER FUNERAL EXPENSES: A. 1 ~ George P.Garman Funeral Home Inc. 606 North Front Street B. 1 2. 3. a 5. 6. 7. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions FILE NUMBER 21 - 09 - 00359 AMOUNT 7,737.32 Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid Attorney's Fees Turo Law Office, 28 S. Pitt St., Carlisle, Pa. 17013 2,950.00 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees Register of Wills -short certificates, probate Register of Wills -Inventory and inheritance tax Register of Wills -Additional Probate Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs Cumberland Law Journal -Estate Notice 32 S. Bedford St., Carlisle, Pa. 17013 132.00 30.00 45.00 75.00 TOTAL (Also enter on line 9, Recapitulation) 20,311.57 COM ESTATE OF 2 3 4 5 6 7 8 9 10 11 12 13 14 ScFted~ie H Funeral F~er~ses ~ ~AONWEALTH OF PENNSYLVANIA w~N ^~ ~~ ~ INHERITANCE TAX RETURN /'Y, ^1 pYC~YVG \+1J0~ RESIDENT DECEDENT Dodge, Helen M. The Sentinel -Estate Notice PO Box 130, Carlisle, Pa. 17013 Claremont Nursing Home Carlisle, Pa. Special Event Emergency Medical Services Pharmerica Walmart -Thank You cards Postage Executor travels to Harrisburg (gasoline) Exhibit A Executor lodging in fulfillment of duties Exhibit B Executor travel costs return to Nevada (gasoline and turnpike) Exhibit C Executor lodging costs return to Nevada Exhibit D Pastor of 29th St Methodist Church - (funeral service) Brachendorf Memorial (stone engraving) 2131 Herr St., Hbg., Pa. Executor travel while at Harrisburg (Register of Wills, Attorney, other fiduciary responsibilities related to banking and arrangements) FILE NUMBER 21 - 09 - 00359 208.78 7,650.00 122.53 122.72 37.12 35.56 55.33 372.37 168.29 256.75 100.00 195.00 17.80 Page 2 of Schedule H REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dodge, Helen M. NUMBER I. 1 SCHEDULE J BENEFICIARIES NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS[include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] David E. Dodge 1080 Starlight Terrace Way Mesquite, Nevada 89034-1023 RELATIONSHIP TO DECEDENT Do Not List Trusteels) Son FILE NUMBER 21 - 09 - 00359 SHARE OF ESTATE I AMOUNT OF ESTATE (Words) ($$$) The entire estate Enter dollar amounts for distributions shown above on lines 15 through 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 SH 0.00 /74~~i /~~~Cf ~ ~~ ~`~ a/ _ ~€i,~lkii° ~.~t~ ~: i)~l~:cm~ ail Gd~a~1[R~1'2Cd ~~~ ;I~jjr; it : !:~ ' ~, J II~Jflll@ ~ (1E3~~~~Q a>;rK= i ~ ;~ .k D~Ye (3~l~~,~4~~ ~,tt~~ ~ ~~1.~". ~ dime ©~t-19F~~1 __- Attt~t ~ ffi~i~57 -: ~ ~ ~x~rs~, ..s,~.;,.._ [~I~G Acct p xsxrK~~~~+~x~b722' -_ ;,~; r,.t:a.r ~1.~~a t1FAk3it~ UAO~E t°€.ra aka-«~l Rum{ ~~1Lai~~ Prlc~ z~iE't~d.d•~ ~~, ~r, ~i1 7.SA~ ~'1.~145~ UNE g'~ $iS.AA li~~+k 'r~~, f~<. ~t _~.~_ ~Frank~ Fn~~ ~~~~pistiy~ Havp R Nice payi EXHIBIT _ / , ! / rr 9 ~~~ ~ ~ - '; ~~~ f ~~.~ ryry ( {' (f Y I ~~~ ~ ~ ~~~ ~~~~ ~rFEF°k'~L ~tl14j241~9 x:17 ~l1# _~__ ~h~~~~~x #:3~7 21~i1 SttU~iit~at~ [',at°lttt ti~~, :;Lf Laa~~~•i~i~€~, ~ui~ f~aT~ ` rr~~~~,r ~<<..~J {~~~j $.~~ t~~17ti Fum{x h!n » 1 i Ui~l~~adt~~d C~° ~1.97~/~, _. 1~2 ~'~'it '~1t ~~:.~3b~ ~JoL~3~t~_ ~ ~.~i~i '6~i 1~":r~ ~`rl ~ ~ ~~h ~~ Tate. ~~Li.~t1 ~:.ka~~~}~,-~~}~}{~~~1'i~;~ F`r~~~.~h gaud Fait ,'l:~i ~~ ~ ~~~JTt~~ E:,~~': ,~~~~~~~~ ti~5C01~~1' ~`' i,~~ I.Gt~@~ t}~!~ :i~X;f~A;ti~t;ti~X4=+722 ~iif}; ~~~~~~~.''Gf~:r ~ lt3:I15/2~~~ (~#S~:'1~.~~ (~ gg ~~.t~~(~ ,~ ~3'~r ~~~,~1.{ ~t12i1Fc5 f[if ~L1tii' ~r~~~~; ~~~p~.f~~f:iCtti ~i~~~~~~al~ ~~r~~;~ .:~r~~ -=tt ftt~*: 9~. ~:~ ESE `~trl'~~q ~ O~~ v~ ~ t~ /~~~a~s~u2~r COMFORT INN -CAMBRIDGE (OH2O4) ~ 2327 SOUTHGATE PARKWAY ` CAMBRIDGE, OH 43725 USA B. = X O ~= E M O T E L S Phone: (740) 435-3200 Fax: (740) 435-3200 gm.oh204@choicehotels.com DODGE, DAVID 1080 STARLIGHT TERRACE WAY MESQUITE, NV 89034 US pasus1987@yahoo.com Post pate Description 04/14/09 PET CHARGE 04/14/09 ROOM CHARGE 04/14/09 CITY/COUNTY TAX 04/14/09 SALESlMISC TAX 04/15/09 DISCOVER Account: OH2O4 - 258879 Date: 04/15/09 Page: 1 of 1 Room: 124 Arrival Date: 04/14/09 20:04 Departure Date: 04/15/09 09:15 Frequent Traveler ID: You were checked out by: MWW You were checked in by: DH Comment PET CHARGE #124 DODGE, DAVID CITY/COUNTY TAX SALES/MISC TAX DISCOVER Acct: `*"*""""4722 Amount 10.00 85.49 5.13 5.98 -106.60 Balance Due: 0.00 If payment by credit card, I agree to pay the above total charge amount according to the card issuer agreement. x COMFORT INN -CAMBRIDGE (OH2O4) Room: 124 Approval Number: 014593 2327 SOUTHGATE PARKWAY Arrival Date: 04/14/09 Card Type: DS CAMBRIDGE, OH 43725 USA Departure Date: 04/15/09 Date: 4/15/2009 Account: OH2O4 - 258879 Card Number: """"""`4722 B Y = „ O I C E MOTELS Phone: (740) 435-3200 Frequent Traveler ID: Total: 106.60 Fax: (740) 435-3200 gm.oh204@choicehotels.com If payment by credit card, I agree to pay the above total charge amount according to DAVID DODGE the card issuer agreement. 1080 STARLIGHT TERRACE WAY MESQUITE, NV 89034 US pasus1987@yahoo.com x Thank you for your business! Book your next rese EXHIBIT r the best Internet rates guaranteed. ~- 04/20/09 7:54 AM L ~ ~ ~ N ~ ~ ~ / /l~/~~/,5,6 Ga9,~' NiteVision 2009 :~ ~~i~~~~ - ~ i 9~~ ~ LA QUINTA INN HARRISBURG AIRPORT HERSHEY T ~ T -T~ 990 EISENHOWER BOULEVARD L A Q, U 1 1 r 1 A HARRISBURG, PA 17111 INNS a SUITES 7179398000 DODGE, DAVID Folio#: 103247698 1080 Starlight Terrace Way Room: 325 Mesquite, NV 89034 Arrival: 04/16/09 Company: L Departure: 04/20/09 Returns Club No Voucher/Ship/PO: Trans # Date Description Charges Payments Balance 199674 4/16/2009 Rm: 325 AARP -AARP RATE $62.10 $0.00 $62.10 199675 4/16/2009 TAX -OCCUPANCY -CITY $3.11 $0.00 $65.21 199676 4/16/2009 TAX -OCCUPANCY -STATE $3.73 $0.00 $68.94 199946 4/17/2009 Rm: 325 AARP -AARP RATE $62.10 $0.00 $131.04 199947 4/17/2009 TAX -OCCUPANCY -CITY $3.11 $0.00 $134.15 199948 4/17/2009 T'AX -OCCUPANCY -STATE $3.73 $0.00 $137.88 200190 4/18/2009 Rm: 325 HARP -AARP RATE $62.10 $0.00 $199.98 200191 4/18/2009 TAX -OCCUPANCY -CITY $3.11 $0.00 $203.09 200192 4/18/2009 TAX -OCCUPANCY -STATE $3.73 $0.00 $206.82 200369 4/19/2009 Rm: 325 AARP -AARP RATE $53.10 $0.00 $259.92 200370 4/19/2009 TAX -OCCUPANCY -CITY $2.66 $0.00 $262.58 200371 4/19/2009 "I'AX -OCCUPANCY -STATE $3.19 $0.00 $265.77 200385 4/20/2009 CC PMT -DISCOVER $0.00 $265.77 $0.00 Balance: $0.00 Method of Pay: Credit Card: DIS -XXXX XXXX XXXX 4722 Signature THANK YOU WE APPRECIATE YOUR BUSINESS ~~~ ~~ ~H_ 1~_ rya: ~~~~.~~ ~ ~Q (~~ __ '~~~u~~`~ 1_.t7_ 2~e~ ~~3~ Via; ~N ~~~ "~ 3~2.~~ ~`lti:~~~r~r n!i`~ WEATxi~~: :-86~~~t6-~~~7 JST~~!ER ,~~:5?~hCt ~ENt~~: 1-~C~D-333-3~~4 ~. ~aT~~N~I~(c. ~;~t SPTEDWflY, 8A~€3815 ___ Ictc~ i~ rra~F~ct ~ ~i ~s G~~TGt3 IN 4Ei2+41~--'173 [~~° 1 i € _~w~ ~ 1 ^-~ lt~~ ~as~ (~~.' lip P~k~~ ~~~ e~ -__--- - __ ~Y~ade~l, Self ~~acve f7at~ {~~. ,~t~t tiCz~~ o~.f~8P5 ~ ~i.999l~~1. T~in~ : '11.=~~;-~~ z~ i$ ~TgTkL, '~G~@.~t~ Tran~t I~k~~ ~ : ~ 15[y ITAL ~x~ , t~8 f~r~~~3uc~,~ ~~t~.t`~[`I ~f; i.l5ti[.,~A saau~r ~~mpw : I ~}t}{M?4XXXXX}i4 ? 22 iRM : ' ~a l l U~rs .~ . fir',' 15886~~1~i~81 A~~ux-k 1 ~ . ~C 'l'tft# ;, ~~AS~~ Ta#a i ~ ~~ . ~C~ iQ~i : 1Y88928+~"l '_ ~ ~____._r__,_____.___. irdh~Id~ayr agrees to :,s, _ ..__ .-- ~~5+ ~t- :K~suEer total t}:~~~~,=~{~9 1~ :~?~}c~ ih~~~es peyr the ~~~~ ~C31_ 3~ ~~k~52 agr~reme~ ~ be~wee-~ _ _ . m _~. _..___ ~ _ sars~t~oid+ar ~ 'lf~snk Yc~~ i~wlW . S~E~1~WA~'~~« QOM ~~S~UM~R ~~I~VICE -----------------_., 1-$88-fi+4~-19~i6 it'1--~'RX ? 38A-?~" E~'T EXHIBIT G ,~ ~ ~ ~ 9 :. 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T+.' d ~3u+ ~~: ~l~ ~ ~ -v ~ :.~s Q ~ ~sth ~ ss'11~~t1 y _ ~ ~ ~ ..> ~ Ct o t? t+~r ~ ~- ~ ~4 e + ~ ~ _ ~a .a, ar ~ ~ . , n e VV rr~~ // ~{~rt ~.~7~ ~#~lh h~f~4 1~ ~' . . . lS7 `C (C~71t W Q C? to tp }'iE~i ~~ilJ ~ii~ra ~'I ti.t~ -- r ~~{~~ C~ ~.JtY) ~~ ~:1t:.4 _ ~"r«:tt:f P~~g~l 1~1~f~1~ $1.~ ikl ~~ ~ CC7iT1~ t ~3 Qu i kT r- i p it;~~~ ~~~~f ter .'~k.`~At~~~91~1t 3~J .._~_ Qu i kT r ip ~O(~02~3 ~~~~ ~~.~ 5144 ~ : M~~4~ ~~~~~s ~ Tulsa,G-~ ~~18~~22-2862 //~}~~ i~ ff)~~ pp-{-{~~ff~~ ~~~61.~6+.{~ 'J~~~~~V I I~~ c j~^}[fir *f~ 7 ~4~iJ6.47 T~'V~4 </~ ~y 4a~ V~1~T ~kV ~Vl~ cr~a~: u~~E~~Ea auitcTRP #~~~~~ Pump: ~ 2815 H , _Kansa;~ ~xpre Spr i n~f i e l d, Ma G~1 tins; x.557 ~PJ: 1.7+3}G~1 I n u~ €r a~ o ~e ~# ~fi @ 8 f3l~ ~ f~ ~u~-X6.31: $10,14 'Da~,~e OA',~~1,/99 ~i~~ 81 E ~~6~'h~ lax: $.f~11 Atxth # 821.23@ x~txxMxxxxxx~ta~~~_ Payment M~th~.ds Fumy Gallons Pritse 89 5.498 #l.'8i9 $10'.Da 0is~over' S3~E Pr o ' d~o t u n ~n a t ~~}}ryry ~~~~~~*~~$*~`t7L.L ii ~pp ~~ y nn~ ~yy l ~ pj~ ~yy 5117 ~E I'fV~~ ~ip r'f7V Auth ~a~e: 42137$ ~`ota l Sa l ~ *.8.88 Thartlc Yo~x far. ShoPPin9 QuikTrip± Please Come Bank ~t~itd"~U'Cf: ~{~~. ~"~gt11CEt~ AS~a i n! ! e] U P ~ `7 C 2i "~: ~ 4~e ,Thank `{cau ~~ ~ ~ ~ ~3 UA 9 SHALL t! F'CIWER AGT~V~LY' CL4=AM~= A5 YUU URIL- SN~t..L 1247~i N HWY 14 SANi? I A PARK NM ~z~# ~~8~"~?888818 84J23/89 i8 ; ~3 : 43~ E?©DiG~/pAt1 i t} U I SCQI~~k~ AGGT`# >CXSt}{ }C~XX }q}{}{}S q 72 ftCPT# '9-2948 INt!# 1554872 AtlTli# 43434123344 PtttdP# 7 F'Lll5 4i . 9?BG SELF PRI~EfGal ~2. 149 ~"tfi_L TOTAL ~~~.438 '~4)TAL X15, 841 ; v ~4~w~~ ~ s ~ Mt~sr r~uvaN~~Q FtlEL E1lER _~_ _ ~ ~ ~ ~~ ~9 r~~r+tss ruK c:tiuusin~ WD~AY;S FA(}p '>~Oitf~ C I Ft~L.E It ~?~i8 ~: , ANC33t i1t_V TEV ~{ ItyGh1AN, AZ v STfY ~ifd21.314+~ T~rrn ~~#,~~~/~~ 1.3 : 5th : ~ 1 8R8~3B886~?72Y9~ --__-f~p~rrr e~~~~i4~ - E/~ i SCQtJ~F? PUMP# 82 GEtEb~~'/SHI.F x~x~cx>c~x~rx~c~c~F'C~2 El?+~L~-REG C~ ~~.1~#~lG Iirtt~aic:e~ 4~42CrF36? VaLUh~E 6. ~?8 GAL Au£t-w#t ~1~24b4~ _ Pump~F " ....;GAS TOTAL X15. ~8 7. ~G~F `G 1~ ~ 2.859, TUTAt_ X15 . 8B `Ta Ga 1 ~ .~ ~ , 88 Oiscouer Gard Nc~r« t S ~ ?t?CXXXXX?C3{XXX4'~ 22 ~ e X I ~~ ~ a lb opt t: - S E~IA 1~' S h U P i> ~'1!) 84/24/2819 18:38:29 ~atper- ence , ti#~- l~~t~~h~ ant,o Sc~z~vey . Gh+~ux°~rn . c~u~ I asY`ee to PaY the abc~ue T~stal An~oec~~ accarrfing to Card TNAH~4 YCltl Issuer Agx`eer~tec~st. PL,~F-S~ G1~1+'~E t~1#A IN THANK YAt! FUR YOUR BUSYNESS I~Ia~~RIK li~4z __ 1~~ H. 5ar7dt~iT1 Bla~f. ier•m: 342 apps: fl25970 Rtl~t#~~ Et2 GREtTII"!~t~I~F tiNt~aii~b 8th $`1.Z49IC Ugf.Ul~~ b.578 Gi~i. GAS.T(?Ta!_ $14_7'4 TQTRL $14_.79 iliscouer- KXXXAx}~X1h}~Xti722 ~~/2~l2~i[1~1 1it:1S?:~C1 I agree to Pa,~ the ab,~ra+e Total ae~~un~ a~~ordng tv Card Issuer Ac~reetaetrL _ Ctr~~k Yout• Club Card Or fit: 1--~bd~h!(I~EEiItC 04/21 /09 7:53 AM /~~ rpC' / ~G~ Ck ~a /" ' /P S~ Gt / G (" ~ v v LA QUINTA INN INDIA/NAPOLIS AIRPORT LYNHURST J~{~`~ 5316 W. SOUTHERN AVE LAC~U I N TA INDIANAPOLIS, IN 46241 INNS s SUITES 317-247-4281 DODGE, DAVID 1080 Starlight Terrace Way Mesquite, NV 89034 NiteVision 2009 Folio#: 053450081 Room: 114 Arrival: 04/20/09 Company: HARP Departure: 04/21/09 Returns Club No Voucher/Ship/PO: Trans # Date Description Charges Payments Balance 222666 4/20/2009 Rm: 114 HARP - AARP RATE $62.10 $0.00 $62.10 222667 4/20/2009 TAX -OCCUPANCY -CITY $3.73 $0.00 $65.83 222668 4/20/2009 TAX -OCCUPANCY -COUNTY $1.87 $0.00 $67.70 222669 4/20/2009 TAX -OCCUPANCY -STATE $4.35 $0.00 $72.05 222894 4/21/2009 CC PMT -DISCOVER $0.00 $72.05 $0.00 Balance: $0.00 Method of Pay: Credit Card: DIS -XXXX XXXX XXXX 4722 Signature: THANK YOU WE APPRECIATE YOUR BUSINESS EXHIBIT 04/22/09 1:53 AM LaQU I N TA INNS a SUITES DODGE, DAVID 1080 Starlight Terrace Way Mesquite, NV 89034 i1 /~ NiteVision 2009 Folio#: 059535999 Room: 124 Arrival: 04/21/09 Company: HARP Departure: 04%22/09 Returns Club No Voucher/Ship/PO: Trans # Date Description Charges Payments Balance 169034 4/21/2009 MISC-NONTAX -Post card $0.15 $0.00 $0.15 169035 4/21/2009 CASH $0.00 $0.15 $0.00 169084 4/21/2009 Rm: 124 AARP - AARP RATE $49.50 $0.00 $49.50 169085 4/21/2009 TAX -OCCUPANCY -CITY $2.48 $0.00 $51.98 169086 4/21/2009 TAX -OCCUPANCY -STATE $4.22 $0.00 $56.20 169241 4/22/2009 CC PMT -DISCOVER $0.00 $56.20 $0.00 Balance: $0.00 Method of Pay: Credit Card: DIS -XXXX XXXX XXXX 4722 Signature: ~/~~ d ~ LA QUINTA INN LSA SOUTH 12525E 52ND ST. SOUTH TULSA, OK 74146 918-254-1626 THANK YOU WE APPRECIATE YOUR BUSINESS 04/24/09 4:10 AM ~~I cLy'C. / '~~C ~ ~~ `~`/~5~ ~~ ~~ y~ ~ NiteVision 2009 ~~~~ a ~ ~ ~ ~~ ~9 - LA QUINTA INN ALBUQUERQUE AIRPORT r'~%r' ~` 2116 YALE BLVD SE LAQU I N TA ALBUQUERQUE, NM 87106 INNS & SUITES 505-243-5500 DODGE, DAVID Folio#: 081652340 1080 Starlight Terrace Way Room: 104 Mes uite NV 89034 Arrival: 04/22/09 9 Departure: 04/24/09 Company: AARP Returns Club No Voucher/Ship/PO: es Char Payments Balance Trans # Date Description g 193854 4/22/2009 Rm: 104 AARP -AARP RATE $89.10 $0.00 $89.10 193855 4/22/2009 TAX -OCCUPANCY -CITY $5.35 $0.00 $94.45 193856 4/22/2009 TAX -OCCUPANCY -STATE $6.02 $0.00 $100.47 194186 4/23/2009 Rm: 104 AARP -AARP RATE $138.60 $0.00 $239.07 194187 4/23/2009 TAX -OCCUPANCY -CITY $8.32 $0.00 $247.39 194188 4/23/2009 TAX -OCCUPANCY -STATE $9.36 $0.00 $256.75 Balance: $256.75 Method of Pay: Credit Card: DIS - XXXX XXXX XXXX 4722 Signature: THANK YOU WE APPRECIATE YOUR BUSINESS ~~ ' ,~~ ~~ G? ~~~~~.~~~~~ TO Su~~~ _ ~u~+acO BI~i EISEHN04?~R H~iRR~St#Ultti, PA #7't## I~LR#: Fi342~237124g1 .._~_ Q#11+1104 #9:23:24 Pu~p~: !Self product : Regul~t• F'ur 68~.1t3p~ 5.50! Fuel Sale $ #7.8It Total. Sale $ #7.80 X~X'XXX~tX}~r1X4722' DIS Trans# '1,9302 pPpraual0 019~14Q 5tf91b~-sS85c3 THANK YOU FOR YOUR BUSIN~~S EXHIBIT J