Loading...
HomeMy WebLinkAbout09-22-0915056051058 REV-1500 EXcos-o5) PA Department of Revenue Bureau of Individual taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisbrxg, PA 17126.0601 RESIDENT DECEDENT OFFICIAL USE ONLY Couniy Code Year Fla Number ~1 0~ ~~~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 208-22-2239 07/11 /2008 11 /23/1924 Decedent's Last Name Suffix Decedent's First Name MI Littleton Kathryn A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL 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 Irrterest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) • 6. Decedent Died Testate 7. Decedent Mairrtained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of III) (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 - THI8 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Christine A. Littleton (949) 874-0145 c ~ ~' Finn Name ff livable r_•-a (REGISTER OF WAfil] 5~SE ONLY ~ !'`"i ~;') . _Z n ~ ~ ~ - _,. _.. ~ _~.r s_ `~ *] ~ 1 ~ ' First line of address ' fV .c=C;:~. ~ - i - 1295 Cerritos Drive \ ~ C1~~ _J ~ " ~ Second line of address ~ - - ~ , _. ~ City or Post Office Spate ZIP Code DATE FILED ~' ' j Laguna Beach CA 92651 Correspondent's e-mail address: Under permlfies of perjury, I dedare that 1 have examined tlNs return, inducting accompanying sdredules and statements, and to the treat of my knowledge and belief, it is true, correct nd complete, Declaration of preparer other than the personal represerNative is based on all information of whir3r preparer has any knowledge. SIGNAT ~ NSIBLE FOR FILING RETURN DATE - 09/01!09 ADD -- ~ _ _ _ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS ---- _""- --- PLEASE U8E ORIGINAL FORM ONLY Side 1 15056051058 15056051058 US. FI RST C'_.i~S t ~.:s sirs c~~ s { Us 7u~-C.ASs ~ ~~ ~~ i. is ~f ~ a 1~ / ~ r i a j ~ U A f~RST~LLg55 USa U C~ASS° ~ X iS ~.:4 ti c _ - T !' ~~ - - _ ~ ~ , ~ ~ _ ~ = - v - r ~ ;~. (~~ ~ +' ~: } ;~a ~~. ,, ~~a ~~ ; ~ .~~ c:~ r~Cy'~ C.I 43~ C~ J 'i S3 ~~~ ~ ,~ 4r ~~ ~ '~ ii •. rp 4. ~`^.~ ~- ~^a~ .1 "~.. 1~ ~,::., :~ ~ ~'., C . ~. _ . ,~ ~ ~ ~ y ~ ~ .~ ~. ~.~. ., r~ J `~.. ,; ... ~:.:~,....~ ,e..~ R ~i1t ~h n . ~~~ :.... - J 15056052059 REV-1500 EX Decedent's Social Security Number Kathryn A Littleton ' 208-22-2239 Decedent s Nema: RECAPITULATION 1. Real estate (Schedule A) ................................. . . . . ........ 1. 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages 8~ Notes Receivable (Schedule D) ............................. 4. 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 23,329.89 6. Jointly Owned Property (Schedule F) Separate BNling Requested ....... 6. 5,426.29 7. Inter-Vrvos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ 7. 0.00 8. Total Gross Assets (total Lines 1-7) .................................... 8. 28,756.18 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 7,892.00 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 1,469.05 11. Total Deductions (total Lines 9 & 10) ................................... 11. 9,359.91 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 19,394.03 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Sd~edule J) ........................ 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 19,394.03 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of tine 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) X .0_ 0.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate x .0 45 19,394.03 16. 862.73 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17 0.00 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18 0.00 19. TAX DUE ......................................................... 19. 862.73 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: Flk Number DECEDENTS NAME DECEDENTS SOCIAL SECURRY NUMBER Kathryn A Littleton 208-22-2239 _ _ _ _ STREETADDRESS Church of God Home 801 N. Hanover Street -- CITY STATE ---- ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenaltyrfappBcable D. Interest E. Penalty (3) (4) (5) (5A) (5B) (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYINENT. FII in oval on Page 2, Line ZO to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT 862.73 0.00 0.00 0.00 862.73 21.57 884.30 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: y~ ~ 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 rcwersionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. H death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an 'in trust for" or payable upon death bank account or security at his or her death? .............. ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................... ......................................... © ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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 exemot a transfer tp 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 benefaary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to ~ for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) peroerrt [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is four and onefiaff (4.5) percent, except as noted in 72 P.S. §9116(1.2) p2 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedents 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-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEpt~LE E CASH, BANK DEPOSRS, 8 MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Kathryn A. Littleton Include the proceeds of itiga6on and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship moat De discbsed on Schedule F. (n more space ~ needed, insert additional sheets of the same size) 0 c _- _ m _ T Z "-" O { 0 c C ~ Z - < O n m z 0 -~ , o _ ~ m ~ ~ 1 m z O n m a o c z -i D O C Z -{ D O v n 0 c z D x _ m z z n __ m n s_ ~ O :' c z --i m n C C1 O 0 v 0 m z n N N W Cll N CHECK NO t 0001923789 Mp CONSECO SENIOR HEALTH _ 580827-1 _ 05 -4_TC INSURANCE COMPANY 11825 N. PENNSYLVANIA ST, CARMEL, IN 46032 THE BANK OF NEN YORK MELLON PHILADELPHIA, PA 62-4 311 -~•000 L9 23?89i~' ~:D3 L L00047~: 2~~~969 889ii' CHECK NUMBER: 0001923789 CHECK DATE: 09/19/08 ATL /BCPPA/BPH / POLICY-CERT. N0. PATIENT NAME PAT.NO. PYMT N0. DATE PAID 444219 LITTLETON KATHRYN 580827-1 09/19/08 3ti~ti7,140.00 THE FOLLOWING SERVICES WERE CONSIDERED FOR PAY MENT: AMOUNT PAYMENT AMOUNT MEDICARE BASED ON SERVI CES BY DATES OF SERVICE BILLED APPROVED THIS AMT. CHURCH OF GOD HOME 4-1 TO 30-2008 24568.77 CHURCH OF GOD HOME 5-1 TO 31-2008 9105.26 CHURCH OF GOD HOME 6-1 TO 30-2008 8649.05 CHURCH OF GOD HOME 7-1 TO 31-2008 8890.64 LONG TERM CARE R SKILLED NURSING HOME 2100.00 SKILLED NURSING HOME 2170.00 SKILLED NURSING HOME 2100.00 SKILLED NURSING HOME 770.00 T O T A L 7140.00 TOTAL POLICY BENEFITS 7140.00 CHECK TO YOU 7140.00 ~-~ T~~ /`~ I ; j P.O. Box 67013 (717) 234-8484 (Harrisburg) ~~~ ~ ~~ ~ j Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide) KATHRYN A LITTLETON USE YOUR VISA® CAPITOL CARD® OR YOUR PSECU CHECK CARD AND YOU COULD NIN A GPS! FOR DETAILS, VISIT PSECU.COM/SNEEPSTAKES OR CALL US. JONT WMWER PAGE 2 ___ 0208XXXXXX 107/31/08 I 0701 ID 04 MONEYHANDLER BEGINNING 0731 ENDING BALANCE DIVIDEND YTD: YEAR TO DATE ....... 0.00 0.00 0202 400 065 2 51 2006392 REV-1509 EX+ (8-98) SCNEp1~LE F COMMONWEALTH OF PENNSYLVANIA ~p~~y-01NNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NU~ER Kathryn A. Littleton Han asset was made joint within one year of The decedents date of death, it must tae roported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• Christine A. Littleton 1295 Cerritos Drive, Laguna Beach, CA 92651 Daughter B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCULL HVSTTTirTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER ATTACN DEED FOR JOINTLY~iELD REAL ESTATE DATE OF DEATH VALUE OF ASSET x OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST t. A. 02N)6l98 Cvrstown Bank, 22 S. Hanover St, Carlisle, PA 17013, #108002054 10 852 57 50 5 426 29 , . , . TOTAL (Also enter on line 6, Recapitulation) ~ = 5,426.29 (M more space is needed, Insert additional sheets of the same size) ORRSTOWNBANK A Tradition of Excellence ORRS P.O. Box 250 o Shippensburg, PA 17257 Date 8/08/08 Primary Account Enc:Losures (n~~~~n~~~~uu~~~~n~~u~u~i~~~~~~n~~~~n~i~u~~~un~~~~ 001406 0.6804 AV 0.324 TR00005 Kathryn A Littleton Christine Anne Littleton 801 N Hanover St Front Carlisle PA 17013-4509 v° 0 0 rn 0 0 0 0 0 .-~ 0 0 0 o~ o~ N O O Ln O ~ ~~ N .--~ ~ o ~~ o .-+ Building? Buying? Remodeling? We can help! 1.888.ORRSTOWN - orrstown.com Account Title C H E C K I N G A C C O U N T S Kathryn A Littleton Christine Anne Littleton ~ti+ Iatereat P~eaktuy- - __ Account Number ~ 108002054 Previous Balance 10,855.02 Deposits/Credits .00 3 Checks/Debits 7,886.44 Service Fee .00 Interest Paid .67 Current Balance 2,969.25 Overdraft item fees this statement period Overdraft item fees year to date Return item fees this statement period Return item fees year to date' Deposits and Additions Date Description 8/10 Interest Deposit Check S-afeKeepiizg _._ _-- _ _ Statement Dates 7/11/08 thru Days In The Statement Period Average Ledger Average Collected Interest Earned Annual Percentage Yield Earned 2008 Interest Paid Amount .67 Page 1 108002054 8/10/08 31 4,629.47 4,629.47 .67 0.17% 19.39 .00 .00 .00 .00 - CHECK SII1rIlrlARY - Date Check No Amount Date Check No 7/11 1085 138.47 7/22 1088 7/17 1087* 6,747.97 * Denotes missing check numbers Amount 1,000.00 REV-1510 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEp1~LE 6 INTER-VNOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY ESTATE OF ~ / FILE NUMBER This schedule must be completed and fled ff the answer to any of questions t through 4 on the reverse side of the REV-1500 COVER SHEET a yes. ITEM NUMBE DESCRIPTION OF PROPERTY INCLUDE THE NAME of THE . THER REUtaNSH~P ro oECEOENTAND THE DATE aF TRANSFER ATTACH A COPY of THE oE® FOR REAL ESTATE DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION APPLICABLE) TAXABLE VALUE 1. 2,000.00 0 0.00 Carol Hoover, daughter, life insurance policy (exempt) 2. Carol Hoover, daughter, life insurance policy (exempt) 1,400.00 0 0.00 TOTAL (Also enter on line 7 Recapitulation) ; I 0.00 (If nave space is needed, insert additional sheets of the same size) .. ~.. .. . ,, _ POLIC`YOWNER SERVICE REQUEST .. .American General Companies Subsidiaries of American General Corporation American General Center • Nashville, Tennessee 37250-0001 Co. Code ~ _ Co 70 ^ American General Life.and-Actrident Insurance Company 19 b2 0 -.American General Life Insurance Company of Delaware 25 56 ^ American General Life Insurance Company.of Oklahoma 48 . -Code . ^ Equitable Life Insurance Company :: `: _ ^ -Gulf Life Insurance Company` isife and Castialty Insurance Company of'C.enne~see POLICY NUMBER , INSURER'S NAME - STAB C DISTRICT NUMBER ~- _ AGENCY NU BE PAID.TO DATE .7 .. _ , ~_ _ As Owner of the above policy, I hereby request: _ - B. A CHANGE OF BENEFICIARY TO: Name (Please Print) Age Relationship to Insured - Address - ~;; c E F~iST~ (~NI Rvv a 4{..~ /L. 3 5 ~ A kG 1-~ i`E R. 3 5 ~Y .~5 t.E ~} R $13E~' t~~Z+~.E. ' c~t~ fT~ N ~ ~ ~ 1 11~ ~ a A/ . `~'-~ (ifs t-t ~~ t`Cs /L ~ p s- S ~T C.RN ~ ~ 2 . _ 1_05 ~.n1G~L~.S ~A ~ao3S ..i. A designation of a change of first or primary beneficiary: swill revoke- all preyiousiy ~amed';:beneflclanes of every class, ar~d a designation of a~ change of second or contingent beneficiary witirevoke_all previously named benefiolanes of that-class.. ~ , A change of benefiaary requested hereinshall not be effective unless recordecfby the.Company T_lg effective Mate pf'a'recorded . .- _ _ change'shall be the date this request is signed; if signed during the IIfetirne of the insured, vVtiether ornotthe (nsured~is livlrg when the change is recorded: A change of beneficiary is subject to any payment rriade of other action #aken tiy~he Company before, the _ . .. ., _ :: .. change is reco>:ded. Afterrec~rding,~a copy of this form will be.returned tq~be attached to the policy: '`~~ ~ x~ r ACKNOWLEDGEMENT OF THIS CHANGE IS NOT AN ADMISSION -THAT THE POLICY !S IN BENEFIT NOR -THAT THE PERSON"SIGNING THE CHANGE REQUEST IS THE OWNER. A RECORDED CHANGE, NOT SIGNED BY THE OWNER, MAY NOT CONSTITUTE A VALID CHANGE 01= BENEFICIARY. C. ~ CORRECTION OF NANtE -Choose prte: tN©ICATE REASON FQR CHANGE: 1 _ _ ,. .. Of ^ Insuredy, ^ Owner By ^ Marriage ^ ~ Beneficiary ^ Payor - ~' : ^ Court Decree (No. ) ^, ~ Applicant - ~- - -: -. -,~ _ _ - :-: ; _ .r;.~ :,-._ .__ ; ~ - , . ^ Correction :. ~ _ _ _ ~ _ To: ~ _. - -- -- . _ 1 ;..: t~~~ ,,,.y t I hereby request that any provision in the above numbered policy requiring the endorsement of a change of beneficiary to be waived with the express u~derstandir~g that such waiver, if granted, will relate only to this request for change of beneficiary. I warrant that the above numbered policy is,not in the possession of another person and that no other person has any present claim against it. I agree that upon receipt of an acknowledged copy of this form, I shad attach it to my policy. InsuJed/Owner Address: ~~ ~~, ~ ~~l n ~(~,~ ~i li~~PT (05 11 ~ G~L(,~ L L ~~ 1 '7U) 3 Signed at ~ ~ - •r^'" _ th' ~ d. ~ f . -~- ' ~~ / J ~'s'~`1 ! ~ ~ e ~:: ~•f - ,_ , is ..L (~ :: ay.o / ~ y~ ~ :.~~ ~ , 19. ~t al tns1=ed a fs Signature, rf dttier than Insured ~ witness to ~gr,anre - - ° . - -,..r- -,_ - 1:...~._x :.v1_ ,;. r: `: >~ignee~gnawre;it.anr .. _ ACKN01~lU`C~DGMENT AND WAIVER _ - , Recei t of the above re nest is acknowted ed. An p q g y policy provisi ns requiring d"orsemenfot a change of beneficiary on the policy are waived with respect to this change of beneficiary on Recording ~ r i 218189 1 . POLICYOWNER SERVICE REQUEST Am_ erican :General- Companies Subsiddaries of American General Corporation American General Center • Nashville, Tennessee 37250-0001 Co. Code --. _ ~ Co Code.. , 10 ~ .American General Life and Accident-lnsurari~x~ ~pany a9 ^ :F~quitab(g Irfe ~risurance Company 52 ^ American General Lffe Insurance Company of Delaware '~`2~5 ~t_~Gulf Leif-~Ins~irance~Company - - 56 ^ American General Life Insurance Company of~Oklahoma '48 C~ Life and"Casualtylnsurance Company of Tennessee POLICY NUMBEF~- COMPANY. PI§U D'S NAht J _ A' STATE CODE ~ pISTR~CT NUMBER t i~ ~ t ,. AGENCY ` i `' _ ~. PAID T~ f3l~TE~,~~. s As Owner of the above policy, I hereby restuest: `~ 6 1 ~~~r • '°`"~ - •- ,-'} ~_ ± ~ ~ ° A CHANGE`OF BENEFICIARY TO: B ~~ -'` "' "- , -- ~ . ~ F. "' a - ~ . _~Name (Please Prir><~ -- -- `: _:. , Age Relationship to Insured° Address .°. cHAr~E~~={Piimary-'"`i~ERetAa~rtr. - :.. - ~- - ., - > . - - _ - C'' ~` o ~~a a~ 2 ~5 u~K ~xh. ~. 3S'S. - LE t~E' ~'v~t ~". - aj.~ - 6~ .~-. -- CHANGE SECOND {Cargingenq BENEFlCUWY TO: - _ ~ ~y~~- ~r .: '~ ~t i~2 (S r l - rJ ' / 4 ~l~ ~ ~ ER t 1 o s S S -z{~nl . D ~ ~b5 ~ ~ ~ E ~ ""s ~1~. `~ a X35 A designation of a change of first or primary beneficiary will revoke all prevloiisly named benl3ficlaries of every class, and a designation of a change of second or contingent beneficiary will revoke all previ~Sly named beneficiaries of that class. A change of beneficiary requested herein shall not be effective unless ~reco`rded by the Company :.The effectlye`date of a recorded change shall be the date this request is signed,.if signed during the lifetime of the Insured, whether or nofthe Insured is living when the change is recorded: A change, of beneficiary is subject to,any .payment- made or other action. taken by the Company before the change is recorded. After recording, a `copy of this fon~n will be retum~ to be attached to the policy. ACKNOWLEDGEMENT OF THIS CHANGE IS NOT AN ADMISSION THAT THE POLICY IS 1N BENEFIT NOR THAT THE PERSON SIGNING THE CHANGE REQUEST IS THE OWNER. A RECORDED CHANGE, NOT SIGNED BY THE OWNER, MAY .- NOT CONSTITUTE A VALID CHANGE OF BENEFlCIARY. C. CORRECTION OF NAME Of '~ ^ Insured ^ Owner By ^ Mamage ^ Beneficiary ^ Payor CI Court Decree (No. ) ^ Applicant ^ Correction I hereby request that any provision in the above numbered policy requiring the endorsement of a change of beneficiary to be waived with the express understanding that such waiver, if granted, will relate only to this request for change of beneficiary. 1 warrant that the above numbered policy is not in the possession of another person and that no other person has any present claim against it. I agree that upon receipt of an acknowledged copy of this form, I shall attach it to my policy. of nib , 19 ~1 ~Q i`/%, d r r., - _ _ n ~ ~~ ~~ ~ ~r~,+' OC1er Required Signature. - ACKNOWLEDGMENT AND WAIVER - _ - Receipt of the above request is acknowleged. Any policy provisions r ' ' g - ent of change of beneficiary on the policy-are.waived with respect to this change of beneficiary only. _ - e Recording - _ G16TCE01 R1001001UD1011Z001'TCE• ALEXANDER SPRINGS EMER PHYS PO,BOX 37720 PHILADELPHIA, PA 19101-7720 n~~~~m~~~uun~~u~~un~~r~~~~~~~n~~~u~~~n~i~n~~~u 031212-0000094034766-04 #BWNJFDB #OOOOOOOOC LL41744# KATHRYN A LITTLETON 801 N HANOVER ST CARLISLE PA 17013-1599 Account Detail STATEMENT OF ACCOUNT (2) Statement Date: August 31, 2008 ACCOUNT NUMBER: CLL94034766 Patient Name: KATHRYN A LITTLETON Tax ID #: 26-2419497 Account Balance: $461.94 Amount Pending Insurance: $0.00 Amount Due From Patient (Current): $0.00 Amount Due From Patient (Past Due): $461.94 Pay This Amount: 5461.94 YOUR ACCOUNT IS NOW SERIOUSLY PAST DUE, AND A DELINQUENCY REVIEW IS BEING CONDUCTED. Please refer to coupon below for payment instructions. ii Date # Description Charge Paid By First Ins. Paid By Other Ins. Paid By Patient Amount Ad~usted Due From Insurance PATIENT BALANCE 06/02/08 1 99284 EMERGENCY EVAL 8 MGMT $589.00 (LVL 4) DX:780 97 DR. GUARRACINO/CARLISLE REGIONAL M DICAL CE R 07/22/08 INSURANCE PAYMENT 5-107.06 $481.94 TOTALS: $SSS.oo s-1o7.os so.ao so.oo so.oo so.oo $asl.sa Important Messages: This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Carlisle Regional Medical Center. The fees for this private physician are billed separately from any hospital charges or other professional fees for which you may also be responsible. Therefore, should ycu receive a bill from the hospital or other physicians for charges in connectbn with this visd, it will not include the items listed on this statement. "Payment Plans" Accepted Questions about this statement? / Llame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM. Your automated system access code is 947-94034766, or you can send email to billing_questionst~emcare.com. Please detach and return bottom portion with your remittance. KATHRYN A LITTLETON 801 N HANOVER ST CARLISLE PA 1 701 3-1 599 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE. Make Check/Money Order payable to: ~n~~~~~~unr~~~~uun~~~u~~~n~~n~t~~~uni~~~~ ALEXANDER SPRINGS EMER PHYS PO BOX 37720 PHILADELPHIA, PA 19101-7720 The insurance information in our file appears below. Please make any corrections and/or additions on the reverse side of this form and return R to us. Thank you. AVF65 ADVANTRA FREEDOM 80169187601 7602300510 25152 ATTN: GROUP HEALTH CLAIMS LONDON KY 4 0742 ^ If your address has changed, check this box and complete the reverse side of this form ATEMENT OF ACC Statement Date: August 31, 2008 ACCOUNT NUMBER:CLL94034766 Patient Name: KATHRYN A LITTLETON Payment Due By: PAST DUE Amount Due: 5461.94 Amount Enclosed: ,, ~~ 0312120000094034766000461940000000D00003 CQiti4TIhdUTC+iG GARS RX 28 5 SECOND ST hdEWPORT PA f 7474 ~~ S T A T E h1 E N T~# Statement Date: 14/31!48 Page: 1 A c c o u n t ## : 144442497 F~ATHRYN LITTLETOPd HQ'OVER, CAROL 3594 GLEN ABBEY DRTVE CHAh1BERSBURG, PA 17241 Date Description City Amount Previous Balance 868. b4 Ending balance - Pay this amount ---------_ 868.64 Past Due Past Due Past Due Current 31-b4 days 61-94 days 94+ days . 40 . 44 . 40 8b8. b4 ANT GtUEST T OCJS C ALL i 844 b 7 5 6279 X 1425 Please c~~t Here and remit this portion wit h payment Remit to: COhJTI!~!UIt~1G CARE RX 5775 ALLENTOWN BLVD SUITE 141 HARK ISBLIRO, PA i7i i2 blame: I~.ATHRYN LITTLETON H~?OVER, CAROL 3594 GLEN ABBEY DRIVE CHAC~iBERSBURG, PA 17241 Statement date: 10/31!48 Account #: 100042447 COG Ending balance: 868.64 ~`~ ~~ Amount enclosed: ~ ~v 0 REV-1513 EX+ (11-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TA% RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF ,~~ // /~ FILE NUMBER d n r i l ft ~l n~ !~_ ~ 1 T T l l---r-m r/ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. David Hoover, 3594 Glen Abbey Dr., Chambersburg, PA 17201 grandson 1 /7 2 Brinna Hoover, 3594 Glen Abbey Dr. Charnbersburg, PA 17201 granddaughter 1 R 3 Ben Hoover, 3594 Glen Abbey Dr., Chambersburg, PA 17201 grandson 1/7 4 Lydia Hoover, 3594 Glen Abbey Dr., Chambersburg, PA 17201 granddaughter 1R 5 Tyler Littleton, 773 Pine Hill Rd., Duncannon, PA 17020 grandson 1 /7 6 Drew Littleton, 773 Pine Hill Road, Durx~nnon, PA 17020 grandson 1 /7 7 Martin Littleton, 773 Pine Hill Road, Duncannon, PA 17020 grandson 1 /7 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABIf DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBlJ1TONS ON LINE 13 OF REV-1500 COVER SHEET. $ ~ It more space is needed, insert additional sheets of the same size. Law Offices of Derek J. Cordier, Esquire 319 South Tront Street Harrisburg, PA 17104-1621 Pl~oue: (717) 919-4002 Email: derek<<Uderel:jcordier.corn September 21, 2009 Office of the Cumberland County Register of Wills One Courthouse Square Carlisle, PA 17013-3387 RE: Estate No. 2008-0925 Dear Register of Wills: F~Lx: (717) 213-4984 n q ~© o r_ ~ ~ ,, z ~ ~- ~'' ,~ - c~ m ~~ ~ ~ ~~ =I'1 N r ~_3 ~~ ~ f. .~- Kindly file the enclosed Inheritance Tax Return and Inventory for the above mentioned Estate. Enclosed, are the original and two copies of the Return and an original and one copy of the Inventory. Please return the filed copies of the Notice to this office in the enclosed self addressed stamped envelope. Thank you for your attention to this matter. If you need anything further please contact me at the above address or telephone number. Respec~trl-ly yours, ~ ~ -+,;' ;, J,~ .. r ~ ;. Derek J. Cordier, squire