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HomeMy WebLinkAbout08-05-09 r o ! 15056117121 _. REV-1500 EX (O6-OS) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po eox zaosof 2 1 0 8 0 5 9 4 Hartisbum PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0 2 4 6 7 3 3 0 0 4 1 7 2 0 0 8 0 6 1 4 1 9 5 9 Decedent's Last Name Suffix Decedent's First Name MI R U S S E L L D A V I D W (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI R U S S E L L V I C T O R I A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE 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 (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust B. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT • THIS SECTION MUST BE COMPLETED-ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number R I C H A R D P M I S L I T S K Y 7 1 7 2 4 1 3 6 3 C7 e ~, Firm Name (If Applicable) '.; ocr_~~! a wu i c ues nw Y_=, First line of address '~- Z 7i ~, jt ~_,'' • ~' 1 W E S T H I G H S T S T E 2 0 8 ~~~~~ -fl ~' Sewnd line of address r'' ~ ~ ~ w P O B O X 1 2 9 0 v w ` ''. ', City or Post Office State 21P Code DATE FfLEDw C A R L I S L E P A 1 7 0 1 3 correspondents a-mail address: rpmlawl(cilembargmail.com Under penalties of perjury, I declare that I gave examined this tetum, including anmmpanying schedules and statements, and to the best of my knowledge and belief, ft is We, correct and complete. Dedaretion of preparer other than the personal representative is based on all information of which preparer has any knowledge. ~IG TU OF E ONSIBLE FOR FIALIN RETURN ~ _ / ~ DAT(~ e l n O Y r~ CJ ADOR SS v /7cZi I SIGNATU F P EPARE OT T REPRE RES `O. (t ~ ~ ~ u ~~^ ~~~~ ~O[Ar/1 PL SE USE'ORIGINAOLVF RM ONLY r W ~ ~-911 Sf Side 1 1505607121 1505607121 J i J 1505607221 REV-1500 EX Decedent's Social Security Number Decedent's Name: DAVID W• RUSSELL 2 ~ 2 4 6 7 3 3 0 RECAPITULATION 1. Real estate (Schedule A) ...................................... 1 . . d. ~ ~ 2. Stocks and Bonds (Schedule B 2. ~ • ~ ~ 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. ~ ~ • ~ ~ 4. Mortgages 8 Notes Receivable (Schedule D) ..................... ... 4. ~ . 0 0 ~ ' ~ ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... ... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6. • 7. inter-Vivos Transfers 8 Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested .... ... 7. 6. Total Gross Assets (total Lines 1-7) ........................ ... 8. ~ • ~ ~ 9. Funeral Expenses 8 Administrative Costs (Schedule H) ............. ... 9. 2 ~ 6 2 . 5 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ......... ... 10. 1 2 4 8 . 9 6 11. Total Deductions (total Lines 9 8 10) ........................ ... 11. 3 3 1 1. 5 2 12. Net Value of Estate (Line 6 minus Line 11) ...................... ... 12. - 3 3 1 1 . 5 2 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. - 3 3 1 1. $ 2 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 100 15. ~ . ~ ~ 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 16. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due ................................................ 19. ~ . ~ ~ 20. FILL IN THE OVAL IF YOU ARE REpUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505607221 1505607221 REV-1500 EX Page 3 De~eden#'s Complete Address: File Number z1 oa oss4 DECEDENT'S NAME DAVID W. RUSSELL STREET ADDRESS 644 WEST LOUTHER ST CITY CARLISLE STATE ZIP PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. CreditslPaymenis A. Spousal Poverty Credit 8. Prior Payments C. Discount TotalCredits(A+g+C) (2) 0.00 3. Interesi/Penalty if applicable D. Interest E. Penalty Total InieresUPenalty (D+E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 +5A. This is the !3ALANCE DUE. (5B) 0.00 Make Check Payab-e 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 : ................................................................ ...... ^ b. retain the right to designate who shall use the property transferred or its income; ..................... ...... ^ c. retain a reversionary interest; or .......................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................. ...... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................. ...... ^ 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ... ...... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a benefciary designalion? ............................................................................................ ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1,1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent (72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twentyvne years of age or younger at death to or for the use of a natural parent, an adopfive parent, or a stepparent of the child is zero (O) 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) [/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) percent ]72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (8-98) ' SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN DAVID W. RUSSELL 21 08 0594 All real properly owned solety or as a tenant in common must be reported at fair marketvalue. Fair market value is dehned as me 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 relevantfacls. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NOT APPLICABLE -All real property owned jointly with spouse, Vikki Russell. See 0.00 attached Deed for marital home. No other property owned by either decedent or spouse. (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-98) ' SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT DAVID W. RUSSELL 21 08 0594 AtI property jointyovmed vrilh right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH APPLICABLE - no stocks or bonds owned TOTAL (Also enter on line 2, Recapitulation) ~ E 0.00 (If more space is needed, insert additional sheeb of the same size) REV-1504 EX + (5-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scHSUU~e c CLOSELY•HELD CORPORATION, PARTNERSHIP OR SOLE•PROPRIETORSHIP DAVID W. RUSSELL 21 08 0594 Schedule C-1 or C-2 (incNding all supporting iniortnation) must be attached for each closelyheld corporation/partnership interest of the decedent, other than a sole-proprietorship. See insWctions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NOT APPLICABLE - No business entity owned in whole or part 0.00 (If more space is needed, insert additional sheets of Ne same size) REV-1505 EX + (5-9e) e ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE C-1 CLOSELY-HELD CORPORATE ESTATE OF FILE NUMBER DAVID W. RUSSELL 21 08 0594 1. Name of Corporation NOT APPLICABLE State of Incorporation Address City _ 2. Federal Employer l.D. Number 3. Type of Business 4. State Zip Code Product/Service Total Number of Shareholders Business Reporting Year STOCK TYPE Yo9n 1Fotfn TOTA! NUIyBER OF ' SHARES Ot1TSTAND4IG' PAR VALUE NUMBER OF SNARES OWNED BY THE DECEDENT VALUE OF THE DECEDENTS STOCK Common Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ....................................... ^ Yes ^ No If yes, Position Annual Salary $ 71me Devoted io Business 6. Was the Corporation indebted to the decedent? ....................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ 8. Owner of the policy Did the decedent sell or transfer stock in this company within one year prior to death or within two years If the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares - Transferee or Purchaser Consideration $ Attach a separate sheet for additional transfers and/or sales 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ............ ^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ................................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ....................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ...................... ^ Yes ^ No If yes, report the necessary information on a separate sheet, including aSchedule C-1 or G2 for each interest. Date THE FOLLOWING INFORMATION MUST BE SU8N11TTED WITH'HIS SCHEDULE B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market values. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. Listthose declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. Date of Incorporation (If more space is needed, insed addNonal sheets of the same size) REV-1506 EX + (9-00) ' SCHEDULE C-2 COMMONWEALTH OP PENNSYLVANIA PARTNERSHIP IN RESIDENTED ~ DENTRN INFORMATION REPORT ESTATE OF FILE NUMBER DAVID W. RUSSELL 21 OS 0594 1. Name of Partnership NOT APPLICABLE Date Business Commenced Address Business Reporting Year City State Zip Cade 2. Federal Employer I. D, Number 3. Type of Business ProducUService 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................ ^ Ves ^ No 1f yes, provide amount of Indebtedness $ 8. Was there life insurance payahle to the partnership upon the death of the decedent? ........ ^ Yes If yes, Cash Surcender Value $ Nel proceeds payable $ _ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years it the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferced/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a wdtten partnership agreement in effect at the time of the decedent's death?.... .... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ............................... ... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? .............. ... ^ Yes ^ No If yes, provide a breakdown of distdbutions received by the estate, including dates and amounts received. 13. Was thedecedent related to any of the partners? ............................. ... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? ................. ^ Yes ^ NO If yes, report the necessary information on a separate sheet, including aSchedule C-1 or C-2 for each interest. • • •~ • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. 8. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. ^ No REV-1507 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE DAVID W. RUSSELL 21 p8 0594 All property jointty-owned with the rt®ht of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH NOT APPLICABLE I 0.00 TOTAL (Also enter on line (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (8-98) ~ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE YAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY DAVID W. RUSSELL 21 08 0594 Include the proceeds of litigation and the date the proceeds were received by Ne estate. All propaM iointlyovmed whh right of survNorshiD must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH NOT APPLICABLE -ALL PROPERTY OWNED WAS MARITAL PROPERTY. The couple had two bank accounts. Both were joint accounts. See attached account numbers with Orrstown Bank. The Couple had approximately $300 in cash on hand. Entire amount was actually cash put aside and property of surviving spouse. pecedent's only personal property was his clothing which had no value and was given to the Salvation Army. TOTAL (Also enter on line 5, Recapitulation) ~ S (If mare space is needed, Insert additlonal sheets of the same size) REV-1508 EX « (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE F JOINTLY•OWNED PROPERTY DAVID W. RUSSELL 21 08 0594 d an asset was madejoint within one year ofthe decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS 70 DECEDENT A. B C JOINTLYAWNED PROPERTY: APPLICABLE -Please see Schedule "A" Spouse ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANGAL WSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FORJOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST OATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I E (If more space is needed, insert additional sheets of the same size) REV-1510 EX+(8-9a) COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY DAVID W. RUSSELL 21 08 0594 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY ixcwoc nee xune or ms rwwaf>:xee. rxaw xeunoxaxivro oacen[xraxo TMEO"TE OFTPPNaFExnrrncxncoworrxa oeeo voaaea asrnre. DATE OF DEATH VALUE OF ASSET °h OF DECD'S INTEREST EXCLUSION pa nppucgalE) TAXABLE VALUE 1. NOT APPLICABLE TOTAL (Also enter on line 7 Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(10-OB) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER DAVID W. RUSSELL 21 08 0594 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. See attached bill for funeral and cremation 1,237.56 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: p, AttomeyFees RICHARD P. MISLITSKY, ESQUIRE 750.00 9, Family Ezemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent d. Probate Fees LETTERS OF ADMINISTRATION, SHORT CERTIFICATE, JCP FEE, 75.00 AUTOMATION FEE TO REGISTER OF WILLS 6 AarountanYS Fees 6. Tax Retum PrepareYS Fees 7 TOTAL (Also enter on line 9, Recapitulation) ~ $ (It more space is needed, REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8r LIENS ESTATE OF ~ FILE NUMBER DAVID W. RUSSELL 21 D8 0594 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimburoed medical expenses. ITEM I I VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. IOne bill has recently surtaced. Attached is the claim filed by Hershey Medical Center. There are other significant medical expenses outstanding as of the date of death. The amount cannot be specifically determined at this time, but can, if necessary. TOTAL (Also enter on line 10, Recapitulation) I S mot space is needed, insert additional sheefs of the same size) 1,248.96 1 REV-1513 EX+(9-00) ' SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER DAVID W RUSSELL 21 08 0594 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 out~Msp~ usal distributions, and transfers under 1. Sec. 9116 a 1.2 ] All property in the Estate was marital property. There are no beneficiaries to put on notice. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET E (If more space is needed, insert additional sheets of the same size) REV-1514 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN ESTATE OF FILE NUMBER DAVID W. RUSSELL 21 08 0594 This schedule is to be used for all single life, joint or successive life estate and term certain calwlations. For dates of death prior to 5-1 -89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors ran be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S)DFLffETENANT(S) DATE OFB6TTlF 'NEARESTA(3EAT DATE QF DEATH TERM OP YEARS LSE ESTATE 1$ PAYABLE .. NOT APPLICABLE ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years 1 Value of fund from which life estate is payable ......................................... $ 2. Actuarial factor per appropriate table .. . . . . . . . . . . . ... . . ............................. . Interest table rate - ^3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ...................................... $ ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years ^ Life or ^Term of Years 1. Value of fund from which annuity is payable .......................................... $ 2. Check appropriate block below and enter corresponding (number) , , ,, , ,,,, , , , , , , , , , , , , , , , , , , Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (z) ^ Annually (1) ^ other ( ) 3. Amount of payout per period ......................................................$ 4, Aggregate annual payment, Line 2 multiplied by Line 3 . ................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor(see instructions),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 7. Value of annuity- If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ...........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 . . . .............................................. $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resuNing INe or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (It more space b needed, insert additional sheets of the same size) REV-1644 EX r (3O4) INHERITANCE TAX SCHEDULE L COM ANw O TA REMAINDER PREPAYMENT H RI NCETAxRETURN N RESIDENT DECEDENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 21 08 0594 I. ESTATE OF RUSSELL DAVID W. (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on NOT APPLICABLE (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets. Complete Schedule L-1 1. Real Estate .............................. $ 2. Stocks and Bonds ......................... $ 3. Closely Held Stock/Partnership ............... $ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................ $ 6. Total from Schedule L-1 ....................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities .......................... $ 2. Unpaid Bequests .......................... $ 3. Value of Unincludable Assets ................ $ 4. Total from Schedule L-2 ....................................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) ................................. $ F. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . G. Taxable Remainder value (Line E x Line F) ........................................ $ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed ........................................................... $ D. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . E. Taxable value of corpus consumed (Line C x Line D) ................................ $ (A1so enter on Line 7, Recapitulation) REV-1645 EX+(3-84) INHERITANCE TAX SCHEDULE L-1 COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- 2~ ~8 ~59~ FILE NUMBER I. Estate of RUSSELL DAVIp W. (Last Name) (First Name) (Middle Initial) II. Item No. Descri Lion Value A. Real EsiaTe (please describe) NOT APPLICABLE Total value of real estate $ include on Section II, Line C-1 on Schedule L B. Stocks and Bonds (please list) Total value of stocks and bonds $ include on Section II, Line C-2 on Schedule L C. Closely Held Stock/Partnership (attach Schedule C-7 and/or C-2) (please list) Total value of Closely HeldlParTnership $ include on Section II, line C-3 on Schedule L D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ include on Section II, Line C-4 on Schedule L E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ include on Section II Line C-5 on Schedule L III. TOTAL Also enter on Section II, Line C-6 on Schedule L $ (If more space is needed, attach additional 8'/s x 7 7 sheets.) REV-1b46E%+p-H4) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA IN IT NCE T X RETURN REMAINDER PREPAYMENT ELECTION Z1 08 0594 HER A A RESIDENT DECEDENT -CREDITS- FILE NUMBER I. Estate of RUSSELL DAVID W. (Last Nome( (First Namel (Middle Initial) II. Item No. Descri Lion Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) NOT APPLICABLE Total unpaid liabilities $ include on Section II, Line D-1 on Schedule L B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) Total unpaid bequests $ include on SeNion II, Line D-2 on Schedule L C. Value of assets reported on Schedule L-1 (other Thon unpaid bequests listed under "B"above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets $ include on Section 11, Line D3 on Schedule L III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ (If more space is needed, attach additional 8Yz x 11 sheets.) REV-1647 EX+(9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE FILE This Schedule is appropriate only for estates of decedents dying after December 12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other L Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF 81RTH AGE TO NEAREST BIRTHDAY ~ NOT APPLICABLE 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercisetl or intends to exercise a right of withdrawal wltnln 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest .............. $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ...... $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0°h ................ $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5°!0 ...................... $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12°k) (also include as part of total shown on Line 17 of Cover Sheet) ...... $ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ...... $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) $ ^ (It more space is neeae< same REV-+eaeEx(1t-ea)p> SCHEDULE N • SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION (AVAILABLE FOR DATES OF DEATH 01101/92 to 12/31194) ESTATE OF FILE NUMBER ~......,., .,,,,...~„ ~~ na nFOe must be completed and filed credit box on the cover sheet. 1. Taxable Assets total from line 8 (cover sheet) ...................................................................................... 2. Insurance Proceeds on Life of Decedent .............................................................................................. 3. Retirement Benefits ................................................................................................................................ 4. Joint Assets with Spouse ...................................................................................................................... 5. PA Lottery Winnings .............................._...................................._............._.........................._............. 6a. Other Nontaxable Assets. List (Attach schedule if necessary) .. 6. SUBTOTAL (Lines 6a, b, c, d) ............. 7. Total Gfoss Assets (Add lines 1 thru 6) 8. Total Actual Liabilities ............................................................................................................................ 9. Net Value of Estate (Subtract line 8 from line 7) _ ..................................................................._............ /r lion s is orearer than S20pdoe -STOP. The estate is not ellbible to claim the credR. If not, continue Po Part11. Income: a. Spouse ............................. b. Decedent ......................... c. Joint ................................. d. Tax Exempt Income ......... e. Other Income not listed above ..................... 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1f) + (2fl * (3~ 1. U.UU 2. 3. 4. 5. (>3) 4b. Average Joint Exemption Income ............................................................................................................... I/line 4!b) is oreater then 540,000 -STOP. The estate is not eligible to calm the credit. if noL continue to Part m. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less 2. Mutiply by credit Percentage (see instructions) .................................................................................... 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet .............................................................. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ........................................................................................................................ 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet .......... REV-1649 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) FILE NUMBER DAVID W. RUSSELL 21 08 0594 Do not complete this schedule unless the estate is making the election to tax assets under Sedfon 9113{A) of the Inheritance & Estate Tax Act If the election applies to more than one trust or similar arrangement, a separate form must be f led for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, elc.l. If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferors personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such tmst or sim- ilarproperty treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar artangement. Part A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's survivin souse under a Section 9113 A trust or similar arran ement. Description NOT APPLICABLE Value Part A Total $ Part B: Enter the descri tion and value of all interests included in Part A for which the Section 91 13 A election to tax is bein made. Description Value Part B Total (If more space is needed, insert additional sheets of the same size) ,~~n ~ 7 ~~UZ PARCEL N0. L"5-~~C'-_ 11`l~-.~i_;~3 ~~ ©~~'~,.~"` T~iLS DEAD MADE THE l! ~ day of ~1~-0 ~j.~.~ in the year of our Lord two thousand _ and five (2005). `' ~ `' __, - -- s a f:? ir. BETWEEN TIMOTHY M. FRONTZ and ELIZABETH J. FRONTZ, husband-and wife, of Cumberland County, Pennsylvania, Grantors herein, :J f•,~ IV :. ~a ~- N "~ m D crt .i ~~ x~ c, =, DAVID W. RUSSELL add VICTORIA L. RUSSELL, of Cumberland County, Pennsylvania, Grantees herein. WITNESSETH, that in consideration of ONE HUNDRED FORTY-FIVE THOUSAND AND XX/100 ($145,000.00) Dollars, in hand paid, the receipt whereof is hereby acknowledged, the said grantors do hereby grant and convey to the said grantees, their heirs and assigns as tenants by the entireties. ALL that certain lot of ground situate in the Fourth Ward of the Borough of Carlisle, County of Cumberland, and State of Pennsylvania, bounded and described as follows: BEGINNING at a point on the Southern side of West Louther Street, which point is a comer of lot of ground now or formerly of Walter S. Rasp and Viola S. Rasp, husband and wife; thence Southwardly along the land now or formerly of Walter S. Rasp and Viola S. Rasp, husband and wife, a distance of one hundred twenty (120') feet to a point in the Northern side of an alley; thence Westwardly along the Northern side of said alley, a distance of sixty (60') feet to a point in line of Iand now or formerly of Lewis N. Kimmel and wife; thence North along other lands now or formerly of Kimmel one hundred twenty (120') feet to a point in the southern side of said West Louther Street; thence Eetwardly along the Southern side of West Louther Street a distance of sixty (60') feet to a point, the place of BEGINNING. BEING the Eastern thirty (30') feet at Lot No. 49 and all of Lot No. 50 and the Western five (5') feet of Lot No. 51 of the Plan of Lots of John Lindner, which Plan is recorded in Plan Book 2, Page 45, in the Office of the Recorder of Deeds in and for Cumberland County. BEING the same premises that Timothy M. Frantz and Elizabeth J. Lacontora, now by reason of marriage, Elizabeth J. Frontz, husband and wife, by their deed dated the 23rd day of January, 2003, and recorded in the Office of the Recorder of Deeds in and for aooi< 2~g PacF~g~ Cumberland County, Pennsylvania, in Deed Book 255, Page 2604, granted and conveyed unto TIMOTHY M. FRONTZ and ELIZABETH J. FRONTZ, GRANTORS herein. And the said grantors hereby covenant and agree that they will warrant specially the property hereby conveyed. IN WITNESS WHEREOF, said grantors have hereunto set their hand and seat the day and year first above written. Signed Sealed and Delivered he Presence of ~_/ ~_ Commonwealth of Pennsylvania SS. County of Cumberland .n ~ " "~=~- (SEAL) TIMO M. FRONTZ. (SEAL) ELTLA ~THJ. ONTZ On this, the '~~- day of ~~~,~ , 2005, before me, the undersigned officer, personally appeared Timothy M. Frontz and Elizabeth J. Frontz, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and o,~icial seal. ~~ - , NO ARIAL SEAL NOB BOSHORN, NOTARY PUBLIC CARLISLE BORO. CUMBERLAND COUNiY AIYCOMMI IONE%PIRESAPRILII 20 7 I do hereby centj~ that the precise residence and complete post o,~ce address of the within named grantees is (G~~ `~ IrUi ~5t Lv u:fl~ter -- SCrr. eta L'CZ.r~ 1 tst e P/i 17 o t =:. n Attorney for C~Tar~Eees COOK `,~r7~. k'AGk'~,g~~ ~f Gx' ~ ~y y~i-4 u~ a ',•~ ~ Y T~ r~~+'t Pfd T 1. C~ f~" I' 4:? GJ :.J ~'~ :S" F' ~ :~cCt t1] G~r1p~ uYf--~~' ,.'A'+ ti~ i .'.J~3 -Y i'f1 •M lYl Y+'1 Gq f5 yz+ Sv -. r'°, .... '~Sy tM .q9. M. {'wJ h-r •.O .Y.. .1:. ..•.:1 ~..] .Yt. zS: C> CC! f.,cl ~J ."~ •. C!Y ti..r: +", t.,. s :YJ ....+ ?J '! +~t Y ^4 F xC a~ t~ 3 1 Y ~1 e~1 Y f~ li'i P.l ~. iM: 4~+ r_•• '" r.: S eJ Y}. ~ti ty.., hJ C7Y f,.ry s;LL h.l f~ I;'J 6_ rTl ~ ^. L,~ ": ~ ~ Y": ti SLO rtY n:+ •t n r+ ',-i -c .: Y% ~~.~ +.1J1 4`1 Hi Cy~Y]S' ~L 4Y1 eco~ ~~1 PAC~i84~ ~ Iaavia! w. Ruse!! 861 ~ 14v31sArn~c~nsyLvnnia Avenue PH. 717-249-0291 Q0.1503/313 Car[rak, PA D013 .DATE PAY TOTHE -ORDER OF DOLLARS ~ ~ 4 UNN37OWN BANK FOR M D~03i3L5036~: 106 00239~n' 08$L ~~ 313 fsav~k~s acc©u~r) NAME M , ~; AVER MEMORIAL HOME ~vn CREMATION SERVICES, INC. ~~ ~~ 4100 Jonestown Road • Harrisburg, PA 17109 • 1-800-720-8221 • Fax 717-541-9943 • Shawn E. Carper, Supervisor 280426 DA-5 Apr 18, 2008 Mrs. Vtkki L. Russell 644 West Lowther Street Carlisle, PA 17013 David W. Russell - Deceased SPECIAL CHARGES X Direct Cremation $1,395.00 Forwarding Remains Receiving Remains Immediate Burial Nationwide Guarantee Program X Worldwide Travel Protection $395.00 TOTAL SPECTRE CHARGES $1,790.00 PROFESSIONAL SERVICES Services of Funeral Director & Staff Embalming Other Preparation of the Body Facilities & Staff for Viewing ($200/hour) Facilities & Staff for Funeral Service E'acilities & Staff for Memorial Service Staff & Equipment for Viewing ($200/hour) ArrangeJDeliver Remains To A National Cemeter Staff & Equipment for Memorial Service Private Family Viewing/Witnessing Cremation Witnessing the Cremation X Packaging And Forwarding Cremated Remains $55.00 Personal Delivery of Cremated Remains Scattering of Cremated Remains Medical Documents/Courier Fee TOTAL PROFESSIONAL SERVICES $55.00 AUTOMO'IVE EQUIPMENT Removal Vehicle Casket Coach flower Car Lead Car/Clergy Car Service Vehicle Family Car TOTAL AUTOMOTIVE EQUIPMEN'1" $0.td0 MERCHANDISE X Register Book $45.00 6e Tax 52.70 $47.70 Memorial Cards Thank You Cards Remembrance Package Casket X Cardboard Container Cremation Container Urn liurlai Vault Veterans Flag Case Grave/Memorial Marker TOTAL M1•;RCHANUlSE CASH ADVANCED ITEMS Grave Opening Cemetery Equipment Vault Service Charge Newspapers X Carlisle Newspaper S159.86 Clergy Church/Organist/Soloist Flowers Crematory Charge X County Coroner Cremation Approval Fee $25.00 X 20 Certified Copies of Death Certificate $120.00 TOTAL CASH ADVANCED ITEMS SUMMARY OF CHARGES Special Charges Professional Services Automotive Equipment Merchandise Cash Advanced Items SUB TOTAL CRED I'P S TOTAL AMOUNT PAID Apr 18, 2008 BALANCE DUE $1,790.00 $55.00 $0.00 $47.70 5304.86 $2,197.55 -$960.00 $1,237.56 -$1,237.56 $0.00 $47.70 $304.86 THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES Commonwealth of Pennsylvania County of Cumberland STATE OF PENNSYLVANIA Estate of: Estate of David W. Russell Case# 21-08-0594 In the Cumberland County Probate Court 1 Courthouse Square ls` floor Cazlisle, PA 17013-3387 STATEMENT OF CLAIM 1. Milton S. Hershey Medical CenterlBureau of Account Management hereby presents for filing against the above estate this statement of claim in the amount of $1248.96 2. The basis for the claim is Milton S. Hershey Medical Center Account # 9652344 for the various dates of services within. 3. The tax identification number of the claimant is 251857035 4. The name and address of the claimant is Milton S. Hershey Medical CenterBureau of Account Management 3607 Rosemont Avenue Suite 502 Camp Hill, PA 17001. 5. This claim is not contingent. 6. This claim is not secured. I under penalties of perjury, I declare that I have read the foregoing, and the facts alleged aze true, to the best of my lmowledge and belief. . State of Pennsylvania, County of Cumberland IN WITNESS WHEREOF. I have set my hand and notarial seal this ~ ~ day of ~~t t1Ylf1.~ , 20 ~~1 / ~~!(~~~ Notary Pu lic My Commission Expires: Heather M. Thom, Lower PJlen 7wp., Cui Executed this _~day of ~~ i rn 0 . , 20~q OF PHYSICIAN SERVICES PENNSTATE DAVID W RUSSELL 844 W LOUTER 37 The Milton S. Hershey Medical Center CARLISLE PA 1703-2214 The College of Medicine ACCOUNT # 1593797 '' IF ANY QUESTIONS, F~LEASECONTACT: MSHMC PATIENT FINANCIAL SERVICES l~ ~ PR~+w,,y~{.31ZE', V~ t^~~lA.!.~~i` +~~:;v V~~ ,/{., r '.Fw~ 4 y rii ° '~"'~'~F sJ .a~.s ~'~~i:~`~,~,m~^i`~'~~~~I r`~ `~*+ t .~l' ~1 rM[~ i Se~1 p ~ * ~ ry ; ~ ~ ~i/G Y~MG ~. ~~ R ~" d !: 772 ~ ~ Y $ d14~fF~IRM +W ~ 116 ~"t'~Y pu~tS' ' unY44~A~+pJ~ 05/14IOT! N ~ . ~, BIIE~ SHIELD PAYI4MV D7/22/06 BLUE SHIELD PAYMENT' 04/17/06 90445 584.4 PERIf P1r0 M SING PNY EVAL 240.00 05/14/OB BLUE SHIELD PAYMEM7t 07!22/08 BLUE SIIELD PAYMf3lT PERFOWED BY: DEBORAH L NDLBRETiE MD ELECTR~IIYSIDIOGY 04/17/08 43010 427.89 EC6 ELECTROCARD INTERP 75.OD D5/28/DB BLUE SHIELD PAYlENI?fL STATEMENT DATE: 05/29/09 LAST STATEMENT DATE: 12/24!08 8 DT 8 0.00 505.00 D.OD 0.00 240.00 12.18- IF YOU NAVE AW4 QUESTSONS ABOUT T1E AltllliT YOUR DEURAIICE CDMPIWY PAIDt CONTACT THEM DIRECTLY. FOR A1N OVER HXESFIDL4 REGARDDHG YOUR BALANCE, PLEASE CgATACT DUR OFFICE. IF PAYMENF NAS BEEN MADE TNANC YOU AND DISREGARD TITS BILL. SENT TO KJF1 BBIW COLLEGTD]lS/P 0 BDlI 8875/CMP TILL PA 170D1 TRAM( YOU FOR USING MSIMC PNYSICIAN4 6RalP FDR YdHR PHYSICIAN SERYLCES. IF YOU HAVE AN'f QUESTION4 REGARDING TITS BILL, PLEASE CONTACT US AT 717-531-5069 al 8D0-254-2614 BEIIEEN B:OOIW AND 5:31PM MDHDAY TTRIOJ6N IEdIE~AY OR BETIIET?H B:OOAN A!A 4:30PM TNAASDAY AND FRIDAY. BALANCE SUMMARY RESPtMISIBLE PARTY POLICY i TOT'AL BSO BLUE CUSS DIJr DF ST ATXAN0715473aE0D3325300 4 ]50.OD t6eL HRlARAMaI RESP014S1BILITY 0 1248.% __ _,__ lNPORTANT: PLEASE OETACN AND RETORN BOTTOM PORT/0 OF STATEIfFENLWITN YOI/$ PAYA(~j~(T STATEMENT GATE` ODARANT00. RESPONSI6ILFTY: MINIMUM PAYMENT. ga, 05/29/09 S 1248.96 ; 1?A8.96 MSHFAC PHYSICIANS GROUP BIWNG SERVICES HERSHEXI/~P4A 17033-0654 OOOD1593797 UP DOOOD00000124Hl96052909 '111~'l'l'\!l'f'i~74N h11\l'~ll {tllOtl~1 t'~11H"tl'~1IO~11 AraL~ NSHMC PHYSICIANS GROUP DAVID W RUSSELL ra 644 W LOUTER ST PO BOX 643313 CARLISLE PA 17013-2214 PITTSBURGH PA 15264-3313 OFflCE OBE ONLY CNBKONE WR CREDIT GRD PAYMENT, PLEASEFlLLIN IMWRMIITN)N EElD7 -~~=~- ' I I I I I I( I I I I I I I' 159879 M/C CARD NUMBER EXP DATE -~~I~ ! ~www we ^DISC CARDHOLDER NAME (PRINT) HC: FBBO TYP: DMND CREDIT CARD SIGNATURE ~ CHECK tiOX AND ENTER ANY ADDRESS OR INSURANCE C MSHMC PHIBICIANS GROUP ON BACK STATEMENT OF PHYSICIAN SERVICES PENNSI`AT~ DAVID W RUSSELL 644 W LOOTER ST ®The Milttm S. Hershey Medical Cenoer CARLISLE PA 17013.2214 STATEMENT The College of Methane DATE: 05/29!09 LAST STATEMENT ACCOUNT # 1563797 uATe: 12/24/08 '~'__IF ANY RUESTIONS, :4EASE coNTACT: MSHMC PATIENT' FINANCIAL SERVICES FED TAX ID # 2 T or 8 RcRF0yFE0 8Y: ROBERT L VEI87ER MD DIV OF PUURNTARY MEDICINE OrF/16/08 99233.6L: 518.81 DAILY HOSPITAL CARE 254.00 05/14/08 BLUE SHIELD PAYMENIII 100.00- 05/14/08 B SHIELD CONfRACi11AL ADJN 154.D0- O.DD PERF016ED BY: DEBWlAN L NDLBRETTE MD ELECTAOPIN'SIOLDGY 04/16/08 43010 794.31 EC6 ELECTROCARD DTTERP 75.00 05/ffi/08 BLUE SHIELD PAYFEMt: 12.1b- 05/28/OB B SHIELD CONTRACTUAL AD.If 62.82- 0.00 PERFORMED BY: EpVARD 6 LIS2KA MD IMAb'IT16 D4/17/OB 9330826 424.0 2D/M-FODE ECHDy LIMIT 196.00 D4/30/OB BLUE SHQELD PAYMENi1e 24.62- D4/30/OB B SHIELD CONTRACTUAL ADJN 166.38- 0.00 D4/17/06 9332526 424.0 DOPPLER COLOR FL VEL MAP 235.D0 D4/30/08 Bilk SHIELD PAYlENT~ 4.17- 04/30/08 B SHIELD CDNTRACTUAL ADJ:1 230.83- O.DO PERFd6ED BY: CTkISTOPIER Jd6NiDES MD VASCULAR,SUR6ERY DM1/17/06 9397526 79D.4 pIPLE% SCMI VAY- CQPLETE 2%.00 04/3D/OB Bllk SHIELD PAYMENIV 91.00- 04/30/08 B SHIELD CONTRACTUAL ADJsF 205.x- D.00 PERFORIED 8Y: RICKIESVAR NAHRAJ MD DIV OF DIAO RADIOLA6Y 04/17/08 7400D26 V56.62 ABOOTI@1 SINGLE YIBI 64.OD 04/30/08 BLUE SHIELD PAYMENTS 14.00- 04/30/08 B SHIELD CONTRACNAL ADJ>E 5D.00- 0.00 PERFO6ED BY: BRENT J NA61kR MD DIV OF DIA6 RADIOlD6Y D4N17/08 71D1D26.54 511.9 CHEST 1 VIEM 04,00 D!i/30/06 Bilk SHQELD PAYMENIII 0.00 08/13/06 BIIUE SHIELD PAYMENtX l2.DD- 06/13/OB B SHIELD CONTRACTUAL AD.R[ 52.OD- 0.00 PERFORMED BY: JOIN F lC6URRAd MD DIY OF DIA6 RADIOLOGY 04/17/08 7101026.54 511.9 CHEST 1 VIEN 04,00 04/3WD6 BLUE SHIELD PAYHEM* 12,00_ 04/30/08 B SHIELD CQJTRACTUAL ADJlE 52.00- 0.00 04/17/06 71D1026 511.9 CHEST 1 VIE11 yl,Dp 04/30/06 BLUE SHIELD PAYHEM1t 12.00- 04/30/08 B SHIELD CONTRACNAL ADJ>E 52.DD- D.OD PERTOIBED BY: ROBERT L VENDER MD DIV OF PULFQIARY MEDICT?E D4/17/06 99233.60 518.81 DAILY HOSPITAL CARE 254,OD 05/14/06 BLUE SIQELD PAYIH@TT~1 100,00_ 05/14/06 B SHIELD CONTRACTUAL ADJ1: 154,p0_ D.00 PERFTXBED BY: RONALD P MILLER MD D]YISIdT DF NEWRIDLDGY 04/17/06 99255.?5 584.4 ]1JITIAL 1yFT COFISULTATIOYI 506.E ^ CHECK. BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK SERVICES PENNS~`AT~ DAVID W RUSSELL The Million S. Hershey Medical Center CpRLISE PAR 177013-2274 The Colle;g:; of Medicine ACCOUNT # 7593787 STATEMENT HATE: 05/29/09 LAST STATEMENT DATE: 12/24/08 6 of 8 ICE3 ~F ANY puFSrloxs auILSE aoxrACT MSHMC PATIENT FINANCIAL 3ERV #251857.1 F E D TAX ID ._ ` ~h~£1 /~1l ~ ~ ~~ y ,. ~e~ v y~ } ~~ {~~ 6 ~ ~ 10. ~I~y~p~~~ J f~~^~ ~y~~Y~~~'~YW^{ ...~ W~~ I `~' ~ ~ ~ @ I } ~ YY ..F~~y~y~ ~'1 ~ , " ~ ,~a . 6 AHN i K- bU ~,'A ~~d1; a~'~. .P di frt ~~~~laN dtrl r R ~" ~ 110 ., NLt A ~ , !. . . + n _ PERFORMED BY. RICICHESVAR MAHRAJ MD DIV DF A6 IRADIDL06Y D4/14/06 71D1026.59 511.9 CHEST 1 VIEM 64.D0 0+x/30/06 BLUE SHIELD PAYlETII~ 9.90- D4/30/DB B SHIELD CONTRACNAL AD.Rt 52.00- 04/30/08 BALANCE TRASEiFERN 2.10 D4/14/06 7101DZ6 511.9 CHEST 1 VIEN 64. D0 pry/3D/D8 BIDE SHIELD PAYNENtst 12.00- 04/30/OB B SHIELD CONTRACTUAL ADS 52.00- D.00 04/14!06 7101D26.54 511.9 CHEST 1 VIEN ~•~ 04/ip,/D6 BIlA< SHIELD PAYMENTIt 12.00- 04/30/08 B SHIELD CONTRACTUAL ADS 52.00- O.Op PERF~IBED BY: ROBERT L VENDER MD DIV OF PULMONARY MEDICINE 04/14/08 94233.60 518.81 DAILY HOSPITAL CARE ~•~ 05/14/06 BLUE SHIELD PAYlENtlt 100.00- 05/14/08 B SHIELD CONTRACNAL AD.AF ]54.00- D.00 PERFORMED BY: RICITHESVAR NAHRAJ MD DIV OF DIA6 RADIOlA6Y D4/75/OB 7101026 511.4 CIEST 1 ViEN ~•~ 04!30/08 BLUE SNIELO PAYMENtxl 1Z.00- 04/30/08 B SHIELD WiT'RACTUAL AO.lE 52.00- D.~ PERFORRcD BY: Ep1ARD 6 LLR2ICA MD DIA6III6 D4/15/08 9332DZ6 424.D OOPPLERS COMP 330.00 D4/30/D8 BLUE SHIELD PAYMFNT+t 16.95- 04/;0/08 B SHIELD CONTRACTUAL AD.Rt 308.81- 04/30/08 BALANCE TRMA3FER~ 4•Z4 04/15/06 933D726 424.0 2D/N-FADE ECMOS CQMP 492.00 04/30/08 BLUE SHIELD PAYMENItt 40.47- 04/30/08 B SHIELD COHTRACTIIAI AD.Re 44D.79- 04/30/08 BALANCE TRANSFERIS ~.~ 04/15/08 9332526 424.0 DOPPLER COLOR FL VEL NAP 235.00 04/30/08 BLUE SHIELD PAYMQIf~ 3.34- 04/30/08 B SHIELD CdITRACTIIAL AD.bF 230.83- D4/30/08 BALANCE TRANSFERS[ 0.83 PERFO@IED BY: ROBERT L VENDER MD DIV OF PULMONARY NEDIC]IE 04/15/08 99233.66 518.81 DAILY IDSPITpL CARE ~•~ 05/14/06 BLUE SHIELD PAYMETIT~ 1~•~- ~/14I06 B SHIELD CONTRACTUAL AD.Ar 154.00- O.OD PERFOAIRED BY: DAVID N VAN HOpC MD OIV OF DIA6 RADIOL06Y D4/16/08 7101D26 511.9 CHEST 1 VIEM 64.00 D4/30/08 BLUE SHIELD PAYMENAt 12.D0- 04/30/OB B SHIELD CONTAfA:TUAL ADJit 52.x- O.DO !T-(CHECK BORLAND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK __ STATEMENT OF PHYSICIAN SERVICES PENI~SYAT~ BD4Aa~w ~tRrr~RE $sT ® The Milton S. Hershep Medical Center CARLISLE PA 17013.2214 The CDlleg~e of Methane ACCOUNT # 1383797 STATEMENT DATE: D5129/D9 U13T STATEMENT DATE: 12/24/08 5 of 8 IF ANY QUESTIONS PLEASE CONTACT MSHAAC PATIENT FINANCIAL SERVICES V' ~~3` wy,~ I'~,"'.^, ~ a ,....~ r.~,;y ,r'~,+~ 'r ~~d o4 ~'~, ~ i~tl~yy~y e ~ 4~7~~', '7" ~"~'~ ~, ~ ~a dia.~~y~'?f~l~ f~r,~,~ i ~} ~~js, ~ }G { ~ ~ ~. 3 ~ ' i~ ~ 't ~ °~gm n~ft. ~~,, u+'6i~r~~{c~'h '#Oex..~ .. °$d?~~~ ~+~ aY k~fli ~ ~ , ~i ` hv~ 04/30/08 . , . . ~ n BLUE SIRE~ID PAYMENf1t py/~/OB 8 SHIELD CO)IfRALNAL AD.~ D4/3D/OB BALANCE TRANSFERN 04r/1L08 7416026 959.12 C T ABDD}EN ENHANCED 447.00 04/30/06 BLUE SHIELD PAYMENI~ 04/30/06 B SHIELD CODRRACTUAL AOJII 04/30!08 BALANCE TRANSFERII D4/11/06 7219326 959.8 CT PELVIS ENHJWCED 406.00 D4/30/08 BLUE SHIELD PAYIENfII 04/30/08 B SHIELD CONTRACNAL ADJtI 04/30/08 BALANCE TRANSFERII PERFORMED BY: NASSAN N HAL MD DIY DF DIA9 RADIDW6Y 04/11/08 7103526 424.0 CHEST SPECIAL VIENS 64.OD D4/30/08 BIDE SHIELD PAYMENIlI D4/30/OB B SHIELD CDiRRACNAL AWN PERFOIBRED BY: SHDAIB ALAN ID) DIV DF PULMONARY MEDICINE 04/11/06 99233.60 518.81 DAILY HOSPITAL CARE 254.00 05/14/06 BLUE SHIELD PAYMEtrt4l 05/14/08 B SHIELD CDN111ACTUAL ADJN PERFORlED BY: SUSAIN E SCHETTER DD DIV OF DIA9 RADIDLD61f D4/19108 71D1926 424.D CHEST 1 ViEN 64.W D4/30/06 BLUE SHIELD PAYIENIII D4/3D/DB B SHIELD CONIRACIUAL AWIt PERFO@ED BY: JAVIER E BANCIL4 MD ELECTROPIIYSIOL061f 04/12/D6 99233 424.0 IgsP VISIT FXIEN !x 254.D0 05/07/08 BLUE SHIELD PAYIEMII 05/07/08 B SHIELD Cg1fRAC1UAl ADJII PERFOIBED BY: REBECCA BASCdI MD DIV DF PUUp1ARY MEDICINE D4/12/p6 99233.60 518.81 DAILY HOSPITAL CARE 254.00 0.r/14/08 BLUE SHIELD PAYMEMI41 05/14/08 B SHIELD CDMRACNAL ADJ>! PERFORFED BY: JANET A MEURE MD DIY Of DIA6 RADIOtA6Y D4/13/08 7101026 786.00 CHEST 1 VIEM 64.00 04/30/06 BLUE SHIELD PAYIEMtI 04/3D/08 B SHIELD CON-'RACTUAL A0.6t D4/30fOd BALANCE TRANSFERII PERFORMED BY: REBECCA BASCdI MD DIV OF PULMONARY MEOICIIIE 04/13/08 49233.60 536.81 DAILY IdSPITAL CARE 254.DD 05/14/08 BLUE SHIELD PAYMENII: 06114!06 B SHIELD CgRRACitlAL ADJN FED TAX ID # 2 357.00- 15.40 61.60- 370. ~- 15.40 61.60- 329.D0- 15.40 21.00- 43.D0- D.00 100.D0- 154.00- 0.00 12.00- 52.OD- 0.00 100.00- 154x.00- O.OD 1~.00- 154.OD- O,DD 4.60- 52.00- 2.40 lOD.~- 154.D0- D.OD CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK STATEMENT OF PHYSICIAN PENNS~AT~ DAVID W RUSSELL 644 W LOOTER ST The MiBon S. Hershey Medical Center CARLISLE PA 17013.2214 The College of Medicine ACCOUNT # 1593797 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC D4/23/OB B SIQELD CWTRACIUAL AD.AF 83.78- D4/23/OB B SHIELD CONTRACTUAL ADJ* 571.44- 04/23/08 BALANCE TRMLSFER>E 16.76 D~/10/06 7582526.59 V07.8 VEND6RM1 IVC SUP i INfERP 403.00 04/Y3/O6 BLUE SHIELD PAYN9JT* 82.40- 04/23/08 B SHIELD CONTRACTUAL ADJ>E 3pp,00_ 04/23/08 BALANCE TRANSFER+~ Y0.60 PERFORNED BY: RIpC1ESVAR NANW MD DIV DF DIA6 RADIOL06Y 04/10/08 7101026 518.0 CIEST 1 VIEN yF,p0 D4/23/O6 BLUE SID:ELD PAYlfM~ 9.60- 04/23/OB 6 SID:ELD CORRAC7UAL AD.kF 52.00- 04/23/08 BALANCE TRAN3FER>E Y,40 PERFDRNED 6Y: FRANC C LYNCH MD DiTERVBlTID11AL 04/10/08 75940Y6.6C V07.8 PERC PLCM7T/IYC TILT INTE 195.00 04/23/08 BLUE SHQELD PAYN9dAE 36.D0- D4/23106 B SHIELD CONTRACTUAL ADJN 150,00_ 04/23/08 BALANCE TRMISFER>E 9.00 PERFORlED BY: JAVIER E BANCNS !D ELECTIIDPIIYSIOL06Y 04/10/06 99233.60 424.0 N13P VISIT EXT@1 CC 254.D0 05/07/06 BLUE SHIELD PAYMENTS[ lOD.00- 05/D7/OB B SHIELD CpDRACNAL ADJx ]54.00- D.00 PERFdBED BY: SHDAIB ALAN !® DIV OF PUlNx1ARY MEDICINE 04/10/06 99233.60 518.81 DAILY NISPITAL CARE r2„:4,p0 05/14/06 BLUE SHIELD PAYMFMSE 100,0D_ 05/14/06 B SHIELD CONTRACTUAL AD.kE 1SF.00- O.OD PERTIMIlED BY: JOIN F M~URRIN N1 DIV DF DIA6 RADTDL06Y 04/1L08 7101026.59 511.9 CMEST 1 ViEN 64,00 04/30/06 BLUE SHIELD PAYMENTSt 9,60_ D4/30/OB B SHQELD CONTRACTUAL AD.RF 52.OD- 04/30/06 BALNICE TRANSFEITi~ Y.40 PERFORTED BY: KEVDi P N~IANARA MD DIV DF DIA6 RADIOL06Y D4/11106 7212526 959.8 Cf CERVD:AL SPIHE UNT581AN 406.OD 04/30!06 BLUE SHIELD PAYMEMSf 53.60- 04/30/06 B SHIELD CONTRACNAL AD,M 339.00- D4/3D/ob BuANCE TRANSFER* 13.40 D4t/1L06 7045026 954.D1 CT HEAD UNENIANCED 298,00 D4/30/O6 BLUE SHIELD PAYMENTSE 46.60- D4l30/OB B SHIELD CONTRACTUAL ADJ>E 23T.00- 04/30f06 BALANCE TRANSFER>E 12.20 PERFORlED BY: BRENT J NA61~R !D DIV OF DIA6 RADIOL06Y 04l1L08 7126026 959.19 CT TIORAX WCDNTRART ENT 434,E ^ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK OF PIiYSICIA-n PENNSIATE. DAVID W RUSSELL The Milton S. Hershey Medical Cencer CA4FwLISE PA 7TT0'13-2214 The Cone€:e of Medicine ACCOUNT # 1583787 '~" IF ANY QUESTIONS, P:FASE CONTACT: AASHMC PATIENT FINANCIAL SERVICES STATEMENT DATE: 05/29109 LAST STATEMENT DATE: ~'ff'~JOB 3 of s 04/23/08 BALANCE TRANSFERiE PERRRBAcD BY: SHDAIB ALAM MD DIV OF PLAJOIARY MEDICINE 04/08/08 99233.60 518.81 DAILY ROSPITAL CARE 254.00 05/14lDB BLUE SHIELD PAYMENT* 100.~- 05/14/OB B SHIELD CONTRACTUAL AO.AE 154.00- PERFORMED BY: DEBORAH L IOLBREI'TE MD ELECT110PFNSIDL06Y 04/O8/D8 43010 V81.2 EC6 ELECTA'OCARD LiIERP BSO 75.D0 05/21/08 BLUE SID:ELD PAYMENTN 0.00 PERFORMED BY: STEVE N ETTIN6ER MD LITTEERYEt1TI011AL D4/09/08 9355626.60 424.0 IN('ERP - AI~IO 521.D0 04/23/08 BLUE SID:ELO PAYMENI* 44.8D- D4/23/OB B SIIELD CONTRACTUAL ADJie 465.OD- D4/23/08 BALANCE TAANSFERB D4/09/OB 9361026.6E 424.0 LEFT HRi- PEAL 1288.OD 04/23/08 BLUE SHIELD PAYIB3~R8 40D.00- 94/83/08 B SHIELD COIiIRACTiJAL ADJN 788.00- 04/23/08 BALANCE TRANSFERN 04/09/08 43645.60 424.0 AN6I0 -CORONARY 887.00 04/23/08 BLUE SHIELD PAYMENTN 45.43- D4/23/OB B SHIELD CAITRACNAI ADJN 830.21- 04/23/06 BALANCE TRANSFER9E PERFORMED BY: LOUIS S IH>aRHER MD DIV OF DIA6 RADIOL06Y 04/09/08 71D1026 518.84 CHEST 1 VIEM 64.00 04/23/08 BLUE SHIELD PAYIIFNNT9E 9.60- 04/23/08 B SHQELD CONTRACTUAL AD.R[ 52.00- 04/23/08 BALANCE TRMISFERlE PERFORMED BY: JAYIER E BAIHCiLS MD ELFJ:TROPINSIDL06Y D4/09/06 99253 424.D DJITIAL >7~ CONSULTATION 288.00 Q5/07/OB BLUE SHIELD PAYMENTS 120.OD- 05/07/OB B SHIELD CONTRACTUAL ADJN 168.00- PERFORMED BY: SIOAIB ALAN MD DIY OF PULlgiARY IOiDICITE D4/09/O6 99233 518.81 DAILY HOSPITAL CARE 254.OD 06/14!08 BLUE SHIELD PAYMf]HT4i 100.OD- 05/14/08 B SHIELD CONTRACTUAL ADJN 154.00- PERFORMED BY: FRANK C LYNCH MD >TITERVENTIONAL D4/10/06 37620.60 V07.8 REV MAJOR VEIN LAVAL FILT 3275.OD 04/23/06 BLUE SHIELD PAYMENT4E 604.68- 04/23l08 B SHIELD CONTRACTUAL ADJ>F 2459.]5- 04l23/Ob BALANCE TRANSFER 2.40 D.00 O.DO 11.20 lOD.OD 11.36 2.40 0.00 O.OD 151.17 04/10/08 36010.51 V07.8 INTR OATH SUP/INF VENACAY 739.8 ^CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BJ1CK PENI~TS'~ATE DAVID W RUSSELL ® The Milton S. Hershey Medical Center CARWLISLE PAR 170'13-2214 The College, of Medicine ACCOUNT # 7593797 IF ANY QUESTN)NS, PLIFASE CONTACT: »> PATIENT: 9652344 PERFDIBED BY: BAENf J MA6f8;R MD DIV OF DIA6 RADIOL06Y PLACE OF SVO: INPATIEM' 04/03!08 71D1D2b 48b CREST 1 YIEN 64.00 04/16/08 BLUE SRQELD PAYIEN11t 04/16/08 B SHIELD COMRACiUAL ADJff 04/16/08 BALANCE TRAISFER:f 04/04/08 T1D1026 48b CREST 1 YiBI 64.00 04/16/D9 BLUE SHQELD PAYIENI'A D4116/08 B SHIELD CDNIRACNAL AOJN Di/16/08 BALANCE TRAtiSFElbf 04/D4N09 7126026 415.19 CT T1DRA% NICONIRA.4T EIN 43+1.00 D4/23/09 BLUE SHRELD PAYIEIIt1f 04/Z3/09 B SHQELD 00NIRMCfUAt ADJa OB/1~/09 B/S rA14EBACK 08/13/08 BLUE SiRELD PAYIEIRR D4yD4lO9 7101D26.76 48b CHEST 1 VIEN 64.OD 04/23/08 BUE SRIELD PAYMEIR~ 08/13/06 BLUE SI¢ELD PAYIEI'Rtf 08/13/09 8 SHIELD CONI'RACTIIAL ADJ:f PERFDRIED BY: INERT L VENDER IID DIY DF PULMQIARY IEDICIIE 04;/04/09 99223.90 518.81 1MTIAL HOSPITAL CARE 479.00 05/14/08 BLUE SRIELD PAYIENftf 05/14/09 B SRIELD I~III'RACTUAL ADJ>E PERFDIBED BY: 9ERALD V NACCARELLI M1 EI.ECTROP4NSI0L09Y 04/DA/O9 93010 V81.2 EC6 ELECTROCARD IMERP BSO 75.00 05/2L08 BLUE SHQELD PAYHENIte PERFDRlED BY: CLAIMYIA J KASALES iD DIV DF DIA6 RADIOLOb'Y 04/05/08 71D1026 511.9 CREST 1 VIEN 64.00 D4/23/09 BLUE SHIELD PAYIEN11f D4/23/09 B SIQELD CONIRAOiUAL ADJN 04/23/D6 BALANCE TRML4FERN PERFOAIED BY: KEVIN 6LEESON !Dl DIV OF PULIdJARY lEDICIIE 04/05/09 99291.60 518.81 CRITICAL CARE FIRST NR 571.00 05/14/09 BLUE SHIELD PAYIENTif 05/14/09 B SIIiELD ODNTRAOTUAL AD.Re 19;RPoRIED BY: CLAUDIA J KASALES HD DIY OF DIAB RADIDL09Y D4/06/09 7101026 786.00 CHEST 1 VIEN 64.00 D4/23/O6 BLUE SHIELD PAYMENI~ 04/23/D9 8 SRIELD CQi1RAC1UAl ADJN 04/23/08 BALANCE TRAIASFEIBf ^ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON STATEMENT DATE: 05!29!09 LAST STATEMENT narE: 72!24/08 ~ of 8 9.bD- 52.00- 2.40 4.60- 52.D0- 2.40 61.60- 357.OD- 61.60 61.60- 15.40 O.DO 12.00- 52.OD- D.00 195.00- 284.00- 0.00 0.00 0.00 9.60- 52.00- 2.40 233.75- 337.25- 0.00 9.60- 52.00- 2.40