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Home My WebLink About08-14-091 C 1505607120 J ~ REY« ~JDO ~ (DADS) OFFICIAL USE ONLY PA D rtm t of R ve epa en e nue courxy code v«r h Bureau of IndNidual Taxes NWlbx INHERITANCE TAX RETURN Po eox.zao6ot 2 1 0 9 0 Henisburg, PA 17128-0601 RESIDENT DECEDENT 9 3 ENTER DECEDENT INFORMATION BELOW Socal Sacurtly Number Date of Death Date of Birth 181 16 7732 O1 08 2009 07 22 1922 Decedent's Lest Name Suffix Decedent's First Name MI SEXAUER DOLORES C (H Applicable) Enter Surviving Spouse's Informagon Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH T REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW X^ 7. Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (data of M prior M 12-13-92) ~ 5. Federal Fatale Tax Relum 4. Limimtl EataM ~ 4a. ~~ l ~ ~°~2~ equired 1 a '~ 9. D°c°o"u Died TaaWe ~ 7. w~ cC Mee o LAma Tavel O 9. Total Number of Safe (AWril Copy d VA9 °W 9oxea 9. Utlgetlon Proceetls Received ~ 70. belxa~ m 1zd7Ai e a {.rya tleeur ~ 17. Electlon to tax under Sec. d l3(A) (A9ach Sd7. O) CORRESPONDENT • THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION atiOULDi E DIRECTED TO: Name Daytime Telephone Numbe DALE P. FRAYER ESQ. (412) 571 6 06 Finn Name (H Applicable) REGISTER WILLS US FRAYER LAW OFFICES NLY ~n - ~~ ,; ~ First line of address ~ ~r ~ i 2 5 0 MT . LEBANON BOULEVARD ~^ n~ r Second line of address 0 n ~ ~~ ' ;-~ - ~i SUITE 207 ~~ _ ~ '„ LED Cay or Post 0lflee State 21P Code ~ ~ -'~T . PITTSBURGH PA 15234 Corroapondent'ssanalladdrass: dfrayer~frayerlaw.com een e eE B ~ ~ w d~p a ff ~ e i on~ ~ ~ s~ n r rt eB M ~ ~ a tlu w d ~ ~ e ~ a a a e , al re I a o a ll I^ fo n of hl re r na s teDea. pr r Man the r pla tatl v o n re a a nd I ~l n d n ev m . SI E OF PERSON 81B FOR FILING R RN DATE Leslie A Rasimas 'j, A ESS 1974 Deer Run DNve, Hummehetown, PA 17036 SIO TORE OF PREPARER OTHER THAN REPRESENTATIVE DATE l P F E D a . rayer e sq. IZ AD S 250 Mt. Lebanon Boulevard, Pittsburgh, PA 15234 Side 1 1505607120 1505607120 I' .-~~~ ~$ ~ 0.~0 qg -~,~~o~ ~e a.5 15D56D7220 REV-1500 F~( Decedent's Social Securi Number oeoa~e~. N.n»: Dolores C Sexauer 1 8 1 1 6 7 7 2 RECAPITULATION -- -_- ~_~~~_~- -'- 1. Real Estate (Schedule A) ....................................................................................... ... 1. I~ 2. Stocks and Bonds (Schedule B) ............................................................................ ... 2. ~I 3. Closety Held Coryoretion, Partnership or Sole-Proprietorship (Schedule C)....... ... 3. 4. Mortgages & Notes Receivable (Schedule D) ....................................................... ... 4. 1 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. .. 5. 2 2 9 1 9 1 1 9 8. JoirrBy Owned Properly (Schedule ~ ^ Separate Bluing Requested ........... .. 6. 3 4 , 4 3 . 2 7 7. Inter-Vwas 7rensfera & MMcellsneous Non-Probate Property (Schedub G) ~ Separate Billing Requested ........... .. 7, 8. Total Gross Aasab (total Lines 1-7) ..................................................................... .. e. 2 6 3, 6 9. 4 1 9. Funeral Expenses 8 Adminiatretive Costs (Schedule H) ....................................... .. 9. 3 3 3 0 5 8 10. Dabta of Decedent, Mortgage Liabilities, & Liens (Schedule p ............................. ... 10. 9 . 2 7 4 9 11. Total Deductions (total Lines 9& 10) ................................................................... ... q 1. 3 7 5 8 0 2 12. Net Valw of Estate (Line 8 minus Line 11) .......................................................... ... 12. 2 2 6 , 0 6 . 3 9 13. Chadtable and Governmental BequeatslSec 9113 Treats for whicFr an eledbn to tax has not been made (Schedule J) ............................................... .. 13. 14. Net Valw Subject to Tax (Line 12 minus Line 13) ............................................... .. 14. 2 2 6 0 6 3 9 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9118 (axt.z) x .00 0 . 0 0 15. 16. Amount o/Line 14 taxable 18 at lineal rate x .045 2 2 6, 0 4 6. 3 9 . 17. Amount of Line 14 taxable at sibling rate x .12 0 0 0 17. 18. Amount of line 14 taxable at collaterel rata X .15 0 0 0 18. 19. Tax Due ................................................. ................................................................... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 15D5607220 1505607220 0.00 10,1 2.09 0.00 0.00 10,172.09 J REV-1500 EX Page 3 Docedent's Complete Address: Flle Number 21-09-0093 DECEDENTS NAME Dolores C Sexauer 5TREETADDRESS Thornwald Home 442 Walnut Bottom Road 1 CITY STATE ZIP Carlisle PA 17 13 Tax Payments and Credks: 1. Tex Due (Page 1 Line 19) (1) 10,172.08 2. CreditalPayments A. Spousal Poverty Credit B. Prior Payments 8,000.00 C. Discount 421.05 Tmalcredas(A +B+c) (2) 8,421.05 3. InterestlPenahy H applicable p, Interest E. Penalty Total InterosNPenatty (D + E) (3) 4. M Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Cheek box On Page 2 Line 20 to request a refund 5. N L'me 1 +Lina 3 is greater than LYne 2, enter the difference. Thin is the TAX DUE. (5) 1, 751.04 q, Enter the interest on the tax due. (5A) B. Enter the total of Lina 5 + 5A. This is the BALANCE DUE. (56) , 7 51.04 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE 1. Did decedent make a transfer and: Yes No a. retain the use or income of the Property transtertad :.................................................................................. x b. retain the right to designate who shall use the property trensferted or its income :.................................... x c. retain a reversionary interest; or .................................................................................................................. x d. roceive the promise for life of either payments, benefits or care7 .............................................................. x 2. If death occurrod after December 12, 1982, did decedent transfer property within one year of death without receiving adequate wnsWeretion? ....................................................................................................................... ^ 0 3. DM decedent own an "In trust for or payable upon death bank account or security at hie or her death?......... ^ ~ ^x 4. Did decedent own an Individual Reflrement Arxount, annuity, or other non-probate propeAy which IF THE ANSVYER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF,1~ RETURN. For dates of deaM on or after Juy 1, 1994 and before January 1, 1995, the tax rate imposed on Ma net wrlue of transfers to or ror the of the survving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or attar January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of lha aurvivin9 apou is zero (D) percent 172 P.S. §9118 (a) (1.1) (I<)]. The statute dose not exempt a transfer to a surviving spouse from tax, end the statutory raquiro ants for disdosure of assets and filing a tax rotum ere still applicable even H the surviving spouse is the ony beneficiary. For dates of death on or after July 1, 2000: Tha tax rate imposed on the net value of transfers from a deceased child twentyone years of age or younger at death to or for the use of. natural parent, an adoptlve parent, or a stepparent of the child is zero (0) percent (72 P.S. §9116 (a) (1.2)j. The tax rent imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-haH (4.5) percen except as noted in 72 P.S. §9116 1.2) [/2 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) paroant [72 P.S. §9116 (a) (1. )]. A sibling is defined antler Sedion 9102, as an individual who has at least one parent in common with the decedent, whether by blood or ad'. ption. RN•160a FX~ 14W1 SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ccaeorkxFJ~~nI of FFRRanvuw yakaarsRCEr~xpansw REaGENTfIECEOIXI ESTATE OF FILE NUMBER Sexauer, Dolores C 21-09-0093 inaud. m. pmcaew or apapn.ntl ab asro th. pxaetl. wwa racaatl W 1M atlau. M propMly)elMlyowlwtl wa11IM tlW M aurhvonMp mun M tlbNWM on seMtlub F. ~ ITEM V LUE AT DATE NUMBER DESCRIPTION OF DEATH 1 CRizens Bank -Checking Account # 622350-727-9 5,002.88 2 Citizens Bank -Money Market # 620833-875-1 20,031.63 3 Ckizens Bank - 6 Month CD # 6255206379 178,359.91 4 Citizens Bank -Savings Account # 6255208395 0.01 5 National City Bank -Checking Account #4438485 27,746.61 TOTAL (Also enter on Line 5, RecapRulatlon) 29,141.14 - _- - _ (If more space is needed, addltltxlal pages of the same size) Copyright (c) 2002 form software ony The Lackner Group, Inc. Form PA-1500 Sehedu E(Rev. 6-98) Rw-1608 EX~ IB-86) SCHEDULE F . JOINTLY-OWNED PROPERTY aLTM~,~ h~,,,,,,, NHERRNlCE TAZRETIpN RE910ENi oECEOFxr ESTATE OF ILE NUMBER Sexauer, Dolores C 21-09-0083 a 6n 886°f xw 1116a pIM wlMln °M yur W eu tNC°GIII'6 UM a NNh, tt mu6r W 16pelrae on KOMW° O. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP O DECEDENT A. Lealle A Rasimas 1974 Deers Run Road Daughter Hummelstown, PA 17038 B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE of DFaTH ITEM FOR JOINT MADE RIGLUOE NAME OF FINANCIAL INSTm1nON AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF NUMBER ~~~ JOINT NUMBER OR 81MIlAR IDENTIFYING NUMBER. ATTACH DEED FOR ALUE OF ASS INTEREy~r DENT'S INTEREBT JOINRY-HELD REAL ESTATE. 1 A 4/27/2001 National City Bank -Savings Account # 68.948.54 50.000°k 34,473.27 9048269587 TOTAL (Also enter on Line 6, Recapitulation) 34A73.27 (p more apace le nee0ed, aEtlBionai papas a the same size) Copyright (c) 2002 form software only The Ladcnar Group, Inc. Form PA-1500 Schedu F (Rev. 6.98) aEV-»s~ Ex. tu-s>h COMMONWFaLTN OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8r ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Sexauer, Dolores C 21-09-0093 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION NUMBER AM UNT A. FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal RapreseMathre's Commissions Lestfe A Rasimas Social Securly Number(s) / EIN Number of Pereonal Rs street Address 1974 Deer Run Drive city Hummelstown state Year(s) Commission paid zIp 17036 2, Attorneys Fees Frayer Law Offices S, Femiy Exemption: (If decedent's address is not the same as Galmant's, attach explanation) Claimant Street Address Ciy State Zip _ Reletlenship of Claimant to Decedent 4. I Probate Fees 7,886.18 11,500.00 13,500.00 150.00 5. Accountant's Fees 6. Tax Ratum Preparers Fees 7. ether Administrative Costs 294.40 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) ,13,330.58 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-0500 Schedule ~.. (Rav. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Sexauer, Dolores C 21-09-0093 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Applebee's Restaurant -Funeral Luncheon 2 Bagnato Funeral Home, Inc. -Funeral Services Other Administrathre Costs 3 Cumberland law Journal -Advertise Estate 4 The Sentinel -Advertise Estate 119.18 7,767.00 H-A Subtotal ~ 7,886.18 75.00 219.40 H•B7 Subtotal U 284,40 Copyright (e) 2002 form aoflware only The Lackner Group, Inc. Fonn PA-0li00 Schedule ~ (Rev. E98) Rer-168 EX+(&N) SCHEDULE DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS corw+om-hKTH or rErwnnwww eAFRRMIUE TNt RETURN REEIOEMOECEOENT ESTATE OF FILE NUMBER Sexauer, Dolores C 21-09-0093 Induoe umNmbureaa medeel exgnaee. ITEM V LUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Carlhtle Regional Medical Center - Co-payment for Medical Service 50.00 2 Cumberland-Goodwill Flre and Rescue -Ambulance Service 83.50 3 Cumberland-Goodwill Flre and Rescue - Co-Payment for Emergency Medical 50.00 Services 4 Millennium Pharmacy Systems East -Past Due Prescrption Biil; December 2008 1,354.93 5 Millennium Pharmacy Systems East -Past Due Prescription BIII; January 2009 369.75 B Unked Church of Christ Homes -Final Rent Payment 2,142.86 T West Shore EMS - CaHfale -Ambulance Service to Hospital 137.00 8 West Shore EMS -Carlisle - Co-Payment for Emergency Medical Services 50.00 TOTAL (Also enter on Line 10, Recapitulation) 4,237.44 (K more apace la nestled, etldldonal popes of tha Same slu) Copyright (e) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedu~. I (Rev. 6-98) REY-161] IX~ fe-08\ r SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESN~EN(DECEDENT ESTATE OF FILE NUMBER Sexauer, Dolores C 21-08-0093 NUM BER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUN OF ESTATE PERSON(S) RECEIVING PROPERTY ooNaLwr (Vyo~a) S55) I TAXABLE DISTRIBUTIONS [include outfight usal dbtnbutbna and~nafers under Sec. $118(a)(1.2)] i 1 Christine E Adamson Granddaughter Twenty Percent 45,208.28 4 Larchmont COutt of Residue Hockessin, DE 19707 (2110) as per Will 2 Amy Lynn Bellini Granddaughter Twenty Percent ,209.28 181 Margaretta Street of Residue i Carnegie, PA 15106 (2H0) as per WIII 3 Leslie A Rasimas Daughter Sixty Percent q 5,627.83 1974 Deers Run Road of Residue Hummelstown, PA 17036 (8110) as per Will Total 2 8,046.38 Enter dollar amouMa for distributions shown above on lines 5 throw h 18, as a ropn ate, on Rev 1500 cove r 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 OFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.90 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7508 Sehedul~ J (Rev. 8-98) LAST WII,L AND TESTAMENT OF I DOLORES C. SEXAUER I, DOLORES C. SEXAUER, of Allegheny County, Pennsylvania, being of soY~tnd mind and memory, do make, publish and declare this my Last Will and Testament, hereby resoking all prior Wills and Codicils heretofore made by me. FTRST: I authorize that the legally enforceable expenses of my last illness and my funeral and burial expenses be paid out of my Estate as soon as may be convenient after my death. SECOND: Except as I may have provided in a Letter of Instructions signed' by me and found with this my Will or other valuable papers, I give so much of my tangible property, together with any insurance thereon, to LESLIE A. I3ENK, CHRISTIl~iE E. ADAMSON and AMY L. BELLINI as they may agree upon and select in writing. As ~o any items not distributed by said Letter or not so selected or agreed upon, I authorize my Executor to sell the same and add the proceeds to the residue of my Estate. All costs of insuring, packing, and storing my tangible personal property before its distribution and th6'A cost of delivering each item to the residence of the beneficiary of that item shall be treated ~ an administrative expense in my Estate. THIRD: I give, devise and bequeath all the rest, residue and rema~nder of my Estate as follows: HENK, if she survives me; A. Sixty (60%) percent thereof shall be distributed to A. B Twenty (20°fi) percent thereof shall be distributed BELLINI, if she survives me; C. Twenty (20%) percent thereof shall be distributed to AMY L. E. ADAMSON, if she survives; and D. In the event any of the above-named individuals fail to survive me, their share shall be distributed to their issue, per stirpes, and in default of issue then liking, shall be added pro rata to the other share or shares herein created. FOURTH: In addition to the powers conferred on her by law, my Execut~~c or her substitute shall have the following powers, to be exercised in her absolute capacity to which such powers may be applicable, including without limitation, the power to retain for distn3ution in kind, without duty of diversification, all property me at my death, or to sell all or any part of such property, upon such terms as my deem advisable; to hold any proceeds and other cash uninvested or to invest in all property; to exercise all rights of security holders; to compromise any claim or without court approval; to borrow money from any source; to delegate discretionary to make distributions in cash or in kind at current values, in undivided interests or shares. FIFTH: All estate, inheritance, and succession taxes, including in the ionaty ied by ~ shall ms of rversy ~; and ~ rata and - 2 - penalties, payable with respect to all property included in my gross taxable Estate xcept any property over which I have a taxable power of appointment, shall be paid from the incipal of my residuary Estate, at such times and in such manner as my Executor shall deem dvisable, without apportionment or right of reimbursemem. SIXTH: I do hereby make, constitute and appoint LESLIE A. HENK be the Executrix of this my Last Will and Testament. In the event that LESLIE A. HENK does not survive me or is at any time unwilling or unable to serve for any reason, I nominate appoint E. ADAMSON as successor Executrix in her stead. Ia the event both LESLIE A. HENK and CHRISTINE E. ADAM5ON aze both at any time unwilling or unable to serve for any reason, I appoint AMY LYNN BELL]TiI as substitute Executrix in both of their SEVENTIi: No fiduciary appointed herein shall be required to post bond ~ other security in any jurisdiction in which he of she may serve. IN GVffNFSS WHEREOF, I, DOLORES C. SEXAUER, the said Testatrix, have' et my hand and seal, to this my Last Will and Testament contained herein, this I-r~ y of j~ ,2002. DOLORES C. SEXAUER SIGNID, SEALED, PUBLISHED and DECLARED by the above-named DOLORES C. SEXAUER, in the presence of us, who at her request, in her presence and in - 3 - presence of each other have hereunto subscribed our names as witnesses in attestationthereof. ~~~ naA wf~'i1ESs ice, d ~, NESS 21 - 9 - ..~. ~m i ~r avenue -~"~- BUREAU OF INDIVIDUAL TAXES DEPT. 280801 HARRISBURG. PA 1 ] 128-0801 PENNSYLVANIA RECEIVEp FROM: INHERITANCE AND ESTA OFFICIAL RECEIP' RASIMAS LESLIE A 1974 DEERS RUN ROAD HUMMELSTOWN, PA 17036 ------ ESTATE INFORMATION: SSN: 181-is-7732 FILE NUMBER: 2109-0093 DECEDENT NAME: SEXAUER DOLORES C DATE OF PAYMENT: 03/27/2009 POSTMARK DATE: 03/25/2009 couNTY: CUMBERLAND DATE OF DEATH: 01 /08/2009 REMARKS: RECEIPT TO ATTY SEAL CHECK#1010 TOTAL AMOUNT I INITIALS: WZ RECEIVED BY: TAXPAYER TE TAX NO. CD 0 ACN ASSESSMENT AMO CONTROL NUMBER 1049 NT 101 ~ S8,00 .00 'AID: 58,000: GLENDA EARNER STRASBAU 0 H REGISTER OF WILLS i /" <~ ~~~ - N J ~ x C~~71 ~ m O J y W m S n i m Dp m 'n' , 00 „n vm . ~z .. ;°! ~v r o o m ao n °om m~ e m ~, z ~~ ~ 7 m ANN RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 SEXAUER DOLORES C Estate File No.: 2009-00093 Paid By Remarks: ADZE P FRAYER Receipt Date: Receipt Time: Receipt No.: ------------------------ Receipt Distribution ----- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30.00 CUMBERLAND COUNTY GE1 WILL 15.00 CUMBERLAND COUNTY GE] SHORT CERTIFICATE 40.00 CUMBERLAND COUNTY GE2 JCP FEE 10.00 BUREAU OF RECEIPTS & AUTOMATION FEE 5.00 CUMBERLAND COUNTY GE2 --- Check# 9289 ------------- $100.00 Total Received......... $100.00 1/29/2009 13:25:51 1055541 Fi N FUN M.D FUN ......~.~,w ~ ctc yr 'COURT, DAUPHIN RECEIPT Cuatomsr. Last Change: DOLORES C. SEXAUER Fee Detail NO FEE $0.00 OATH FEE $20.00 TOTAL CHARGES $20.00 PAYMENTS CHECK 9288 $20.00 TOTAL PAYMENTS $20.00 AMOUNT DUE $20.00 PAYMENT ON INVOICE ($20,00) BALANCE DUE $0.00 PA By: GJC (v) research and communicate with Knights Life Insurance Co pany re Policy 110272; and (w) any and all other services required for the administration of the Estate; as well as matters related to settlement of Dolores exauer Estate. 2.) The Estate shall pay all costs and expenses in connection with thislmatter such as, but not limited to, court costs, advertising costs, investigative a enses, photocopying, long distance telephone charges, and extraordinary postage. omey may require the Estate to advance these costs. This fee excludes any Ikigation in ..Estate not currently anticipated in any manner. 3.) The legal fees for the administration of the Estate of Doores uer, Deceased shall be a flat fee totaling $13,500.Ob and shall be based on the anticipated Attorney's hourly time for lega~'servlces necessary for the settlement of the to at Attorney's hourly rate of $275.00 per hour. Attomey estimates that this Estate will uire between 45 and 50 hours of the Attorney's professional time. 4.) The legal fees shall be paid in three installments as follows: (A) $6,500.00 of the fee shall be due upon completion of the process; (B) $3,500.00 of the fee shall be due June 8, 2009; .and (C) Remaining $3,500.00 shall be due October 8, 2009 5.) .The Executrix shall have the right to terminate Attorney's services pon written notification to that effect. Attomey shall have the right to terminate his se' ' upon written notification to that effect in the event Executrix either fail to cooperat with the Attomey in any reasonable request, to timely pay the monthly statements in f II as submitted, or if the Attomey determines in his reasonable discretion that to continua egal services would be unethical or impractical li.) Upon receipt of an executed Legal Representation and Fee Agree nt, Attomey shall devote his full professional effort to this matter and shall make every ffort to expedite the administration of the Estate promptly and efficiently according to. the highest legal and ethical standards. Date: A. Rasimas, Date: deb 24~ 2~9 -z- PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tames IQeinklaus, Advertising Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Cazlisle, County and State aforesaid, was established December 13,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): Febru 2ary 0.2009 COPY OF NOTICE OF PUBLICATION , Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or adverliseatent, and that all allegations in the foregoing statement as to time.,ela¢e and character of Notary Public My rnmmission expires: CpMMON`iJi.4+_rN Of PENNSYLVANIA NUl'ARIA1. SEAL puoua BAMBI ANN HECKENDORN, NotlrY ty Camp Htt Boro., Cum ~edand C ~ 2010 My Commisslun Exprce ~` PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the Corn State aforesaid, being duly sworn, according to law, deposes and says that the Gtilmberlal Journal, a legal periodical published in the Borough of Carlisle in the County and State a was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of aIl legal notices, and has, since January 2, 1952, been rei issued wceldy in the said County, and that the printed notice or publication attached here exactly the same as was printed in the regular editions and issues of the said Cumberland Journal on the following dates, viz: February 20. February 27 and March 6. 2009 Affiant further deposes that he is authorized to verify this statement by the Law Journal, a legal periodical of general circulation, and that he is not interested in the matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Coyne, eaanar, Doloxs, decd. Late aS Cae3tale. Executrix: Leslie A. Rasimas, 1974 Deere Run Road, Hummela- towa, PA 17036. Attorney: Dale P. FTeyer, Esquire, 2s0 Mt. Lebanon Hlvd., Este. 207, Pittsburg, PA 15234. SWORIF(TO AND SUBSCRIBED before me tl 6 day of March. 2009 C~ Notary I~OLgR1AL SEAL DEBORAH A COLUNS Notary Public CARLISLE BORO, CUMBERLAND C My Commlaslon Exp4ea Apr 2B, 'and Law is DOLORES C. SEXAUER ~ 4 7 4 9 1974 DEER RUN DR. 117Ml5 NUMMELSTOWN, PA 17038 p DA7HT~ _ ~..+/./.77..... //ma~yy;; PAORUWl OF .. ~l~S..Yl ~ w..e - - - ~86~c°d,~~ ~°- _.-:b630O0L22~: 66ig48,5a' 4769 ~' flOO~~OO~' ,,•* ~, '~ . -__" ~, I 8ppiebee's APPLEBEE'S NEIGHBORHO~ GRILL & BAR 6570 Route BO Robinson,PA (412)-494-9331 USER: STEPHANIE G VISA GATE: Oi-13-09 TINE: 12:18 CTRL: 1! CARD M~BER: *#**#*****7058 EXP DATE: #/** APPROVAL CODE: 185848 AMOUNT: •103.6 GRATUITY: 15.5 ADTL TIP: TOTAL : ~ ~~ __v._____. r____ __ ~_. ~___. ... accordance with agreeaeht ®overning use of such card. ** GUEST COPY ** 1 ww run~uin unu , •+.+ 1 COORS LT PINT 3.25 1 ULTIMATE TRIO 10.99 1 W1FF 1.49 Check TOTAL: 98.87 TAx: 8.77 Total Due: 103.64 VISA 103.64 BALANCE: 0.00 CHANGE DUE: 0,00 Duplicate it 3 Carside To Go !!! You call it in, We bring it out! 11ae6ela Pa lsaao INVOICE 12/31/2008 Account Number: DELORIS SEXAUER do LESLIE RASIMAS ~~~ 1974 DEER RUN DR PVT HUMMELSTOWN PA, 17036 _~ _ _ _ _ _ _ _ _ ^ Please Detach Here antl Retum Top Portion VYith Your Payment Invoice Date:12/91n008, Accff:TWNC1320, SEXAUER DELORIS, ThomwalA NC, P, Michael Daniels 19J31n006 6535542 124.00 Ssnns S 07N Teebt 8.830 MG oolez-1118.10 1zr~lnooe 6699955 6z.oo A.pBinandrmlelszsMc 00182-04N-0t 12/31n008 4029606 93.00 Alpamhm Orel Tadst 0.25 MG 00781-1081.05 12/31n008 6509557 31.00 MarelOWrrb HG 01st G~paWe sa MG cocas-oelz-o1 12/312006 6699979 31.00 WeOaldone Tede10.5m0 soe6e.osel3o 12/31n006 4039313 3.00 LofaSeDam INeraOn Saiuoon 2 MGlML 1001&0102.01 12f31n008 4039312 12.00 I.olaxeOYm O+W TBMM 0.6 MG OO8a1-0240-05 ~~ ~ /~~r~~ L''~/~/y~ !/v~h C vurl~ ~~/ ~~, ~~ $ 9.92 $ o.oo $ .9z oTc $ 0.69 $ 0.00 $ .69 OTC $ 59.47 $ 0.00 $ .47 RX s a.oo c $ o.oo $ .oo R)C $ 4.00 c $ 0.00 $ ' 00 RX $ 6.84 $ 0.00 E 6 84 RX $ 10.99 $ 0.00 $ 1 '99 RX ~~ ~r ~ ~~~~ $ 0. $ 126., 12N52008 $ 0. $ 0. ..~ -~ nnium Pharmacy Systems East 1500 Industry Road, Suite A Hatfield PA, 19440 wvolce 01/31/2009 Account Number: DELORIS SEXAUER ' Mo LESLIE RASIMAS 1974 DEER RUN DR HUMMELSTOWN PA, 17038 - Please Detach Here and Return Top Portbn VYNh Your Payment --------------------------- - - - - - Inwke Date:01/312008. AcchC:TWNC1320, SEXAUER DELORIS, Thomwald NC, P, M(chesl Danbb olro3rzoo9 zo46o2a 10.00 Mdd~na SuBtla lriao0on Solution 2 MG~14L oo+oe~neza9 01/042009 8931343 2.00 Aoaohan tiecEal SupOaaorv 850 AAO 00713.0186.12 01ro42009 8931347 1.00 r-abeNrarrldn Mapwmtal Oral GwWa 100 MG 00093.2131-0i 01105!2009 6902983 18.00 NTho0aan0oll Manotrvd Macro OrM CaOaule 100 MG 09186-0122.01 01/05/2009 6904791 45.00 Cb~ 60emW Cream 1-0.06 % 61872.4MB-08 01/05/2009 6931352 1.00 AcagrenRxW BOCPWlldy 650 MG 00719-018612 01!0512009 4041696 1.00 Loraaeoem Oral TaDMt 0:5 MO 00591-0240-06 01/052009 2048330 20.00 MaptWrs Su6aEe Iniac6on SdWbn 2 MOAdL 00.108.1782,90 01/062009 4039961 6.00 laraLepern 9riaNOn SdutlOn 2 MCJhLL 10019-0102A1 Dt/06/2009 6908024 2,000.00 C1~ 410averroua 3dutlan 0.9 % D1/062009 6869079 12.00 Aceplwr RedN Sup0oei0orv 850 MO 00719-0'18612 r11.M¢MMO ¢p'ltnl'/ + M e....,x... Cyr..., a........U..... s. ~u1 ~~~~ $ 5.00 e ; 0.00 ~ S S 0.85 S 0.00 S $ 4.80 c $ ' 0.00 S $ 5.0o c $ o.oo $ S 5.00 c $ 0.00 S $ 0.42 S 0.00 S $ 4.58 S 0.00 S $ 5.00 C $ 0.00 S $ 9.66 $ o.oo $ $ 5.00 c S 0.00 $ S 5.07 S 0.00 5 40557 PVT RX oTc RX RX RX OTC RX RX Rx RX OTC ~ ..... a .. n... w ... M n+n C L- o uN~ ~~g~9 ~~~~ PHILA, PA 19176-0910 Phone #: (800) 367-0512 Federal Tax ID: 23-2298422 ?7a:;tC_EV?'rdArY'": DOLORESSEXAUER 'r.;i'['rr:FTra?wita:ctr 12712 tisE,'..?, ;V.'J;~i"s;_t_ CG0900006 irasuFAr~r.F: HIGHMARK -FREEDOM BI FER102909962001 x-"'"~~ ''~ ` "t°~ 01/01/2009 T3pY;E CG €;aL:.: CJFgt i„F.lK: CG090DOOB "~~"`t` THORNWALD HOME `~` CARLfSLE REGIONAL DOLORES SEXAUER 442 WALNUT BOTTOM RD **E~5«}Nis1 Generalized Weakne89 CARLISLE, PA 17013 ~~"` Tdt A ridSF'OPT gg pp « d~E ~~~ IBAL NONE CTR ~ ^ESCRIPTlpN OF CHARGE-~`~_~~- j 'p(IRNTiTY UNIT PRICE AMO' NT _- _ __ BLS EMERGENCY BASE RATE A0429 i 1.0 400 00 J GLOVES A0398 ~ 3.0 . 3.65 400.00 10.95 MILEAGE CHARGE A0425 1 ~ 1.0 11.50 i 11.50 + ~ 1 i i ' f { ~_.._ ,._..m._.~»_.,....-____--.__.__-.....____.~ ._.~_._......-__.~ ,.,._-_._ TotalC 422.45 FJE~GRi~TF^k! l;1F !=A`~ WiEPST j `:i:.ti..'.FiP i ~ FAYR4ENT ~7ATf.-: t kMQC I Medk~re Assignment Adjuslmem ~ 1 02/03/2~~ 80.80 ~ Insurance Payment - HIGHMARK =FREEDOM Bl ( 19201703 ( 02/03/2009 ~ 2g1,&5 i t i _^ 1 t ! ,. _" _... t. _.~..__. _.-... ,_. ._ ..__ ~ .. .,.:._ ~:,....,L,rs94+1M,1.AkARA~L......,... .,+, ai}?I . ~'~ l~ ~( ~ w.._._._._.._ ~..._: ~., __ _. - i. _.~ ~,-, 1'h.415v -!'^C .I/„ r. ~t. .Li .. ^;if;tti ~ .IiaJ .kri9. ~: ARE CJS' rant<xtsaT ra~_=, 50.00 r~r- eNr tvr<.fiaz: SEXAUER, DOLORES C ::r ~ ~ r ~ >~;. CG0900006 ~~lfn~,~t~f<' ^. ~ - +a~.rEe~aTNUMF¢n~ 12712 ~s~sr~r,.~E ~~~ 02/06/2009 ^-t-c, .,_.____ This is the amount duo after your Insurance Carrier's ;~; ~;~~ F, payment. ' ~rs~ ~ _-___~ ncar, I~14A5 [ER ~'AI n4G'CEa i (t Cumberland-Goodwill FireRascus PO BOX 12910 PHiLA, PA 19170-0910 "° ~~°~ 1 WIJ,~QI `lr1L 45 SPAM DAve ~^ MEDICAL CENTER CeAele, Pq 17013 ADDRESS SERVICE REpl1ES7ED M~CHECK • qD U F ~ ~ • uAeTegcAlo ® DISCWEp V5/, lv,Yraaa.'~'. AEEitlCAN EXPIIF88 ~ ICE DD p fa7!~YRlpitilRii~ ur+au Qerc~wr I ~ 9421545 I 02/09/2009 150. 0 MAKE "CNECKS PAYABLE TO: Delores C Ssxausr 442 Walnut Bottom Roed e Carlisle PA 17013 CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD ~u~~~~u~~~~ann~~u~~u~~~~~u~~i~o~u~~~~~n~u~~~~~~u~ CARL03LE PA 17016-3861 ~m~~~u~~~~uou~~~~~~i~~~uu~~ ~u~ ~~~~~w ~~~ uu~~~u~~~ ^ Please check'rf above eEdress le Incorteq entl hWicete cMnye an IBVBIBB BMe. TO INSUgE PRDPER CREDIT DETACH AND RENRN THIS POR'flDr~ IN __ .... _ _.__... _ _._. _ """TTT .~ llfJ! .. _._.-_._ PATRI9RS IIIM t711WRE8 R[•~YED AF7FA TIE 61N1BIBR D11TE tYR.t BE RERF81® OR iNE NEIIf STA79161r. ?heBtROt61t Sf10YYl1;t)t11'hiS StB~Rlt~18,c11~a~i[~ st FOR BBA.ING OUE8710NS, t~~ r tmrtnp~ paytnei# wNl ~.~ ~1 ~ sBO-1 sBo Bills Dan bs pdd onOM et our www.carfiskrmc.com 150.00 E CALL: rreb sib zus csRA 11 CAMP FULL, PA 17017 Phone #: (800) 367.0512 Fetierel Tax ID: 23.2463002 PATIENT NAME: DOLORES SEXAUER PATIENT NUMBER: CALL NUMBER: INSURANCE:. HIGHMARK -FREEDOM BI FER102909962001 DATE OF CALL: MEDICARE B 16'2188629D TIME OF CALL: CALLER: 3118941 FROM: TO: DOLORES SEXAUER 442 WALNUT BOTTOM RD REASON(S) CARLISLE, PA 17013 FOR TRANSPORT INVOICE 78062 IBAL 3118041 NONE 12/27/2008 442 WALNUT BOTTO~RD CARLISLE REGIONAL EC CTR ALTERED MENTAL FEBRILE . DESCRIPTION OF CHARGE - OUANTTM UNR PRICE - AM .UNT BLS EMERGENCY BASE RATE A0429 1.0 785.47 785.47 BLS MILEAGE A0425 1.0 13.08 13.08 Toted 798.55 DESCRIPTION OF PAYMENT. RECEIPT PAYMENT DATE AMO Medicare AaaiBnmeM Ad)uatrnent 02/D3/2008 475.71 Insurance Payment - HIGHMARK -FREEDOM Bl 19225776 p2/032009 272 ~ Tooll.ndlb 7 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~-~ ;~ ~ /~ RETURNED CHE:t~{C FEFd~ 531.90 s _ / /_.I DETACH ALONG PERFORMATION AND RETURN STUB YVTTTi PAYMENT AMOUNT Dl NAME: SEXAUER,DOLORES C - CALL NUMBER 3116941 AMOUNrs NUMBER: 78082 BILLING DATE: 02/05/2009 ENCLOSED Thla hr< the amount due after your Insurance CarHer's VISA payment. AND MASTER CAI ACCEPTED WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE5Z11 CAMP HILL, PA 1 50.00 ~ Cumberland-Goodwill FireRescue - PO BOX 12910 PHILA, PA 19176-0910 Phone #: (800) 367-0512 Federal Tax ID: 23-2298422 PATIENT NAME: DECOKES SEXAUER PAT{EN7 NUMBER: 12686 Wt„ CALL NUMBER: CGT0805803 NONE INSURANCE: DATE OF CALL: 12/27/2008 TIME OF CALL: CALLER: CGT0805803 FROM: CARLISLE REGIONAL EDICAL CTR TO: THORNWALD HOME DECOKES SEXAUER 442 WALNUT BOTTOM RD REASON(sl URINARY RETENTION CARLISLE, PA 17013 FOR TRANSPORT INVOICE DESCRIPTION OF CHAAGE QUANTITY UNIT PRICE A STRETCHER NON MEMBER 1 WAY A0999 MILEAGE A0999 1.0 2.0 50.00 1.75 60.00 . 3.50 ,11y ~~ D ~ ~ (~ ~5J ~ ~; ` Phone #: td00) 367-0512 Federal Tax ID: 23-2463002 V'dEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE#211 CAMP HILL, PA 17011 PATIENT NAME: DOLORES SEXAUER PATIENT NUMBER: CALL NUMBER: INSURANCE: HIGHMARK -FREEDOM BI FER102909982001 DATE OF CALL: , MEDICARE B 162188629D TIME OF CALL: CALLER: FROM: TO: T}IORNWALD 442 WALNUT BOTTOM RD REASON(S) CARLISLE, PA 17013 FOR ' TRANSPORT INVO/CE 78082 ~ 183013W ~ 12/30/2008 ~ '' i('~Q ~ 01:10 PM I ," THORNWALD HOME i i-, ~„ „ ..,, . -_ THORNWALD 1~6ME---- .__ .: `..._ CARLISLE REGIONAL MED CAL CTR OESCAIPnON OE CHARGE OUAN'TKY UNRPRICE AMO Stretcher 2 Way Tx -Member A0999 1.0 137.00 137.00 G~LL~' ' V ~ 6 ~~ ~G ~3~ IS ~ ~ Total Ch 37.0 RECEIPT.PAYMEN AMOUNT ' I i Statement United Church of Christ Homes Thornwald Home 492 Walnut Bottom Road Carlisle, PA 17013 Leslie Rasimas 1974 Deer Run Road Hummelstown, PA 17036 Statement Date: O1/O1 Due Date: 01/25/2009 9 -Re: Dolores C~-SexauEZ-"._ ____. _...,.. _.___ Account Nr: 1055 Date Description Days Rate Charges Payments ~ Bal nce Quant BALANCE FORWARD 7,537.07 7,53'' .07 12/12/06 PAYMENT 7,537.07 .QO 12/31/08 Room 6 Board - Priv 9 241.00 964.00 964 .00 12/31/08 Room a Board - Priv 1 291.00 241.00 1,205 .00 12/31/08 Room ~ Board - Priv 31 241.00 -7,471.00 -6.,266 '.00 12/31/08 Cable Television 1.00 16.50 16.50 -6,249 50 12/31/08 Personal Supplies 1.00 12.34 12.39 -6,237 .16 12/31/08 Medical Supplies 1.00 57.46 57.46 -6,179 70 ' 12/31/08 Room ~ Board - Priv 26 241.00 6,266.00 86 30 12131!08 Incontinence Suppli 1.00 32.56 32.56 118 86 01/31/09 Room ~ Board - Priv 8 253.00 2,029.00 2,142 86 i ~/,~ y~