HomeMy WebLinkAbout07-30-09 (3)COMMONWEALTH OF PENNSYLVANIA
REV-1162 EX111-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 01 1554
SEMICK PATRICIA
505 ELLEN ROAD
CAMP HILL, PA 1701 1
fold
ESTATE INFORMATION: ssN: iso-is-3747
FILE NUMBER: 2109-0707
DECEDENT NAME: WISDA ELEANOR B
DATE OF PAYMENT: 07/31 /2009
POSTMARK DATE: 07/29/2009
couNTY: CUMBERLAND
DATE OF DEATH: 01 /08/2009
REMARKS:
CHECK# 412
SEAL
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
09133141 ~ 5271.74
TOTAL AMOUNT PAID:
INITIALS: JN
RECEIVED BY:
REGISTER OF WILLS
5271.74
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
PENNSYLVANIA INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 C~ ~~~~ ~
PO BOX 280681 - '-
HARRISBURG PA vlz8-0601 -~. ~.' ~ - TAXPAYER RESPONSE ACN 09133141
REV-1543 E%APP (OB3Y8?.~ - ..., _ .. 1„ ~ DATE 06-08-2009
20"~ ~~~" `~u ;~" ~~
~ ~ TYPE OF ACCOUNT
EST. OF ELEANOR B WISDA ~ SAVINGS
SSN 190-18-3747 ® CHECKING
~-~;~ ~•
__ :~ ,i
DATE OF
DEATH o1-O8-2009
~ TRUST
CPt ~ ~~)i ~`j~ COUNTY CUMBERLAND ~ CERTIF.
I
CU ~ _„ , ~~~ , r, REMIT PAYMENT AND FORMS T0:
PATRICIA SEMICK REGISTER OF WILLS
505 ELLEN ROAD CUMBERLAND CO COURT HOUSE
CAMP HILL PA 17011 CARLISLE, PA 17013
WACHOVIA BK NA provided the Department with the information below, which has been used in calculating the
potential tax due. Records indicate that at the death of the above-named decedent, you were a ioint owner/beneficiary of this account.
If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form
and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of
Pennsylvania. Please cell (717) 787-8327 with gaeetions.
COMPLETE PART 1 BELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 1010084283395 Date 02-05-2004
To ensure proper credit to the account, two
Established copies of this notice must accompany
Account Balance $ 44,992.22 payment to the Register of Wills. Make check
payable to "Register of Wills, Agent".
Percent Taxable X 16.667
Amount Subject to Tax $ 7,498.85 NOTE: If tax payments are made within three
months of the decedent's date of death,
Tax Rate X ~ 1[j deduct a 5 percent discount on the tax due.
Potential Tax Due $ 1, 124.83 Any Inheritance Tax due will become delinquent
nine months after the date of death.
PART TAXPAYER RESPONSE
1
FAILURE TO RESPDND WILL RESULT IN AN OFFICIAL TAX A55E55MENT
A. ^ The above information and tax due is correct.
Remit payment to the Register of Wills with two copies of this notice to obtain
CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of
0 N E Wills and an official assessment will be issued by the PA Department of Revenue.
B L 0 C K ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
0 N L Y to be filed by the estate representative.
C• ~e above informs ion is incorrect and/or debts and deductions were paid.
Complete PART 2~ and/or PART 3LJ below.
PART If indicating a different t rate le se s mite
relationship to decedent: ~,~ u ~ ~ ~~ /F'
TAX RETURN - COMPUTATION OF TAX ON JOINT/TRU T ACCOUNTS
LINE 1. Date Established 1 ij " ~ [)
2. Account Balance 2 $` a,
3. Percent Taxable 3 X
4. Amount Subject to Tax 4 $ ~
5. Debts and Deductions 5 -
6. Amount Taxable 6
7. Tax Rate 7- X , /~ (f ~ '
8. Tax Due a ~ ~ ~7l ''I
PAD
1
2
3
4
5
6
7
8
OFFICIAL USE ONLY ~ AAF
PA DEPARTMENT OF REVENUE
- - ~ yr iax VOmpULaLlOn) $
Under penalties of perjury, I declare that the facts I have reported above are true, correct and _/
com o tC~ of mY owledge and belief. ,~
HOME ( )
'' WORK ( )
~~ TAXPAYER SIGNATURE
TELEPHONE NUMBER DATE
IAIFORMATION NOTICE
PART DEBTS AND DEDUCTIONS CLAIMED
DATE PAID PAYEE DESCRiPTrnN ....,,,.,r .,. _..
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C.J. LUCAS FUNERAL HOME, INC.
FAMILY AFFILIATED SINCE 1891
Over 100 years of Continuous Service
MAIN OFFICE
27 North Vine Street
Mt. Carmel, PA 17851
Telephone: 570-339-4110
Fax: 570-339-1890
Supervisor, C.J. Lucas, IV
BRANCH OFFICE
1053 Chestnut Street
Kulpmont, PA 17834
Telephone: 570-373-3202
Supervisor: C.J. Lucas
February 5, 2009
Patricia Semick
505 Ellen Road
Camp Hill, PA 17011
Deaz Ms. Semick:
Please find cash charges due for the burial of the late Eleanor B. Wilda which were not included or were not
covered by her pre-arrangement:
Pre-arranged price Current price Balance
• Grave Opening & Closing $ 750.00 $ 900.00 $150.00
• News-Item Obit & Notice $ 28.00 $ 115.00 $ 87.00
• Death certificates $ 12.00 $ 36.00 $ 24.00
• Flowers $ 212.00 $ 254.40 $ 42.40
• Harrisburg Patriot $ .00 $ 288.37 $288.37
• Butler Eagle $ .00 $ 123.00 $123
00
• Hired Pallbeazers $ .00 $ 180.00 .
$180
00
• Pallbeazers Caz $ .00 $ 200.00 .
$200
00
• Mileage $ 140.00 $ 230.00 .
$ 90
00
• 2 Additional Death Certificates $ .00 $ 12.00 .
$ 12
00
• Tent Service $ 175.00 $ 120.00 .
- 55.00
Total Amount Due $1141.77
Upon your review of the above information if you have any questions, please feel free to contact my office.
Sincerely,
c
C.J. Lucas, IV, Supervisor
C.J. Lucas Funeral Home, Inc.
P~~~
a laala q C.2*~
ll~~
`7R~-~
WEST SHORE EMS -BLS
205 GRANDVIEW AVE =
SUITE 211 :
CAMP HILL, PA 17011 ~~
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
EMERGENCY MEDICAL SERVICES
PATIENT NAME: ELEANOR WISDA.
INSURANCE: MEDICARE B 190183747A
STATE FARM HEALTH IN; H37290953838
184053W
ELEANOR WISDA
2100 BENT CREEK BLVD
MECHANICSBURG, PA 17050
PATIENT NUMBER
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
REASON(S)
FOR
TRANSPORT
INVOICE
49873
184053W
01 /03/2009
02:50 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
ACUTE REHAB HOSPITAL
ROUTINE TRANSPORT
WCS
NONE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Wheelchair One Way -Member A0130 1.0 46.52 46.52
Transport Van Mileage A0999 5.0 3.74 18.70
Total Charges 65.22
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
~~ /
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All Saints Cemetery
Diocese of Harrisburg
172 All Saints Road
Elysburg, PA 17824-9736
Phone: 570-672-2872
January 22, 2009
Patricia Semick
505 Ellen Rd.
Camp Hill, F'A 17011
Dear Patricia:
Please sign the enclosed contract ~~2160 for refinishing your
parent's bronze memorial and re-install on a new granite base and
return the white and yellow pages, along u+~ith your check of $725.
made out to and sent to All Saints Cemetery; the pink page is for
your records.
You will be notified upon re-installion of your parent's
refinished bronze memorial on a granite base for Memorial Day,
if not sooner. A polaroid photo will also be mailed to you.
Thank you for giving us the opportunity to be service to you
and if eve can be of any assistance in the future, please don't
hesitate to contact us.
Sincerely,
~9 .
Michael S. Rugalla, Jr.
Manager
Enclosures
Office of Catholic Cemeteries
Diocese of Harrisburg
PO Box 3651
Harrisburg, Pennsylvania 17105
Phone (717) 657-4804
k,
NAME ~. ~ ~ ~ ~i ~i~c -~--u- v+.!~ ~ r~
SALES CONTRACT
DATE I'~~~. °-~~ ~ ~ ~r C1Q
N t..
CEMETERY ~ ~ i ._..r'~ ~ r?~S CEMETERY#
A/N~_P/N A/R
PHONE (tf ~~~) ~-. f-_ ~~.~-`~~:
ADDRESS _`:~,.,; ` ~ ~:.
I ~~~.n1 ~.~
~
t l l ~` ~. s~
'' ~~ ' -~' ~" ~ ~~~~ C~.-~
CITY ~~~~~-~~,~~: i ~~ r~
STATE~ZIP CODE >+ ~i i' ~
s "
Interment Space
' ..
.... ~ $ ..
1. Price ............... $ ' ' '` r
1:-~.: ,
Bronze Memorials....... ~
$
2. Down Payment......... r -,s r
~,-...~
Size t
Granite F undat'on.. ! ... C~
$ ; `z~~
3. Un aid Balance(1-2) .....
~
~~ ~:~ ~~.,
Burial Vaults........... Q $ 4. Finance Char e........ .
Crypt Spaces .......... C~ $ 5. Deferred Payment (3+4) . .
Niche Spaces .......... Q $ 6. Total Price (1+4) ....... .
~( Other~.~~ of ~ ~~ ~}~i.~ ZSZ, $ r{' r+ 7. Approx. Monthly Payment
Section '~~ Lot~QGrave(s) 8. Number of Payments ... .
Building Side Crypt or Niche 9. First Monthly Payment Due
Selection must be made within 30 days or cemetery will make choice. 10. Annual Percentage Rate
-~ The payment is due on the date stated above and the remainin payments on the same day of each succeeding month.
Buyer m y prepay in adv~.nce the full amount due without pena ty and will be entitled to a proportionate refund of the
unearned finance charge.
Upon default in the payment of any installment due hereunder for a period in excess of one hundred twenty (120) days,
Seller may, at its option, void this agreement and retain all payments made by Buyer as liquidated damages.
Buyer hereby acknowledges receipt of an exact executed copy of this agreement at the time of execution hereof.
Before any burial is permitted in this lot, or any memorial placed on this lot, the price of the grave and memorial must be
paid in full.
The Purchaser(s) agree(s) to abide by all rules and regulations of the cemetery now in force as well as any rules and
regulations which may hereafter be adopted. Said rules and regulations may be seen upon request at the Seller's office.
' Upon fulfillment of the conditions of this agreement and receipt of all the above described payments, Seller agrees and
binds itself to convey to the Buyer, by its cemetery easement, for interment purposes only, the above mentioned number of
sites.
YOU, THE PURCHASER, MAY CANCEL THIS TRANSACTION BY WRITTEN NOTICE AT ANY TIME PRIOR TO MIDNIGHT
OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
~, i ~ ~ ~.
(Authorized Representafiv'le) ` (Purchaser's Signature)
NOTICE: See other side for additional information. (Co-purchaser's Signature)
.~
,,
• •-
_ _ ~.
Postage $ ~ ~ ~"• ~r= t,i:%''
Certified Fee 'f h~ _ ',~=,
~' l U~.fi-
Return Receipt Fee po
(Endorsement Required) 2~ ~'_~':%%
t
Restricted Delivery Fee ~ i `
(EndorsementRequired) ~di,i;;; ~. <"
Total Postage & Fees $~j ~ _
orPOi3oxNo. ~p r'ij~ s( --------°-°---
City, Slate, ZlP+4 ~---L ------ ~7--~~0
~{ ~C /~~ i9 ~o~
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L
DIVINE REDEEMER CHURCH
MOUNT CARMEL, PA.
gratefully acknowledges a gift from ~l
r /
IN MEMORY~F
~~ ~/~
CAMP HILL POST OFFICE
CAMP HILL, Pennsylvania
170113717
4134870011 -0097
01/16/2009 f800>275-8777 09:00:19 AM
Sales Receipt
Product Sale Unit Final
Description Oty Price Price
PHILADELPHIA PA 19101 $0.42
Zone-2 First-Class
Letter
0.60 oz.
Return Rcpt (Green Card) $2.20
Certified $2.70
Label #: 70051820000712647910
Issue PVI: -$5 32
$8.40 2 $8.40 $16.80
Forever
Stamp PSA
Dbl-Sd Bklt
Total:
$22.12
Paid by:
Cash $30.OC
Change Due: -$7.8>r
~ Order stamps at USPS.com/shop or call
1-800-Stamp24. Go to USPS.com/clicknship
to print shipping labels with postage.
For other information call i-800-ASK-LISPS.
Bill#: 1000303375843
Clerk: 08
All sales final on stamps and postage
Refunds for guaranteed services only
Thank you for your business
xxx~rrczx*~***x~x*>rxx*xrc>r****xaxrc*~~~~~~~~
rcrcxxxxxxzx**>tc~xrcxrczx~czrr~r*~~zaxrcrcxxx:r*x~c*
HELP US SERVE YOU BETTER
Go to: http://gx.gallup.com/pos
, TELL US ABOUT YOUR RECENT
POSTAL EXPERIENCE
YOUR OPINION COUNTS
*;rxx~*xx~xx**~txzrrxlcx~r~c~cxxxx*~txx~rxx~rx~r~t~rz
Customer Copy
C. 219 NORTH BALTIMORE
** THIS AMO[7NT PAST DUE **
,Y SPRINGS, PA 17065
__ .., .,
TOTAL TAX
Previous Balance Charges this month Finance Charge TOTAL CHARGES f roeai Payment a creaks ~ AMOUNT DUE
56.86 + .00 + 1.00 57.86 .00 - 57.86
FOR ALL'PHARMAGY RELATED INQUIRES PLEASE CALLAfert Pharmacy Services, Inc at 1-800-266-9954 ~
Statement Terminology on reverse
ALE1~T
PHARMACY SERVICES INC.
219 North Baltimore Ave
Mt Holly Springs, PA 17065
800-266-9954 (717)486-8606
A FINANCE CHARGE OF 1.50 $ PER MONTH
(AN ANNUAL PERCENTAGE RATE OF 18.0) OR A
MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED
ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE
STATEMENT OF ACCOUNT -
IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR
PRESCRIPTIONS BE SURE TO'SIIPPLY US WITH A COPY.
Date 01/20/2009 `- ----- -
~ FMT"DUE. .02 15 09 WISDA, ELEANOR WISDE
I BRIDGES AT BENT CREEK GRP-58
4(4~ 2100 BENT CREEK BLVD PAGE 1
1, MECHANICSBURG PA 17050 Amount Paid
_ PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
'* ACTIVITY FOR, WISDA, ELEANOR -WISDE - -58
12/10/08
7439215
28
ISOSORBIDE MN'30
O1 ,
8.00
.00
8OOc
12/10/08 7439217 56 PQTASSIUM CL SO M 01 8.0-0 .00- 8.000
12/10/:08 :.7439218 28 ASPIRIN 81MG CHEW O1 * 2.93 .00 2.93
12/10/08 7448951 I4 F'[TROSEMIDE 20MG O1 4.79 .00 4.79c
12/10/08 7439585 28 METOPROLOL 25 MG O1 5.80 .00 -5
80c
12/10/08 7439587 28 DILTIAZEM CD 120M O1 B.DO .00 .
8:'OOc
12/10/08 7439588 28 NE%IUM 4O MG O1 15.00 00 15r00c
12/31/08 ..7468858 6 FIIROSEMIDE 20MG O1
I 4.34 .00 4.340
01/08/09
Payment-Thank Yau.'
II
52.52-
.00 .
52:52-
a.
` ,x
.. }
y ':>,
~~_ 2.93 1
LEGEND NON-LEGEND
FOR MONTH FOR MONTH
Previous Balance ` Charge: lids month Flnsnce Charge TOTAL CHARGES ' Tit ~^r~nt a c,wt~,
52.52 + 56.86 + .00 109.38 52.52
FE3R ALL PHARMACY RELATED ItVQUIRES PLEASE CALL Alert Pharmacy Services, fnc at 1-800-266-5954
_ Statement Termindogy ort reverse
.00
AMOUNT DUE
56.86
PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C. STATEMENT
. ~~ , -----•-- ^- ~- --~ ..,... , -- J - , ., .... . _ 4950 Wilson Lane
~ , u jai wesiei ouwevaru 4o r u ~onaonaerry noaa Micnaei r. ~upinaCCi, M.U. Mechanicsburg, PA 17055
P
O
Box 2028 Bl
Bld
it
S
106 Wi
li STATEMENT DATE PAGE
.
.
oom
g.
u
e
l
am A. Rolle, Jr., M.D. (717) 691-4847
Mechanicsburg, PA 17055 Harrisburg, PA 17109
(717) 691-3755 (717) 561-4242 www.prismdrs.com Christopher Royer, PsyD IZI,?, I>Z+,S / 09 ~ 1
Lisa A. Eaton, PsyD
Billing Dept: (717) 691-4879 Tax I.D. #25-1651500 Please retain this portion of statement for your records. ACCOUNT
NUMBER k^I1F~^y t}
TRANSACTION DATE INV. N0. POS. PATIENT DR. PROCEDURE DESCRIPTION OF SERVICES DIAGNOSIS AMOUNT
>='REVIOUS PALAPlCE 67. ~~1
k~llktt3Ik'~`~ AC ELEIai~l tr1F J`3c::,1 FIU Hf~ISF' VISIT, LEVEL 1 781c: 14~i`.>?i4~
~1I~~'~I~~9 ELEI~IV Mf~' 1k'I F='AYt4ErJT-riEDTCARE E9•c_7•
1~1/E9/~c'~`~ ELEAIV MF 4k"~ MEDICARh DISALLOW 65.41-
k'IcIk16I~`a ELEAlV MF 6 1~'AY-ThlSUR 7• ~;~•
k'I 1 i 4~14I0`a AC El_EAN t*1F 9'a~:c ~~ T r•.l I T I AL HUSF' VISIT, LE V.~ 781; 25E. >Z~~
41ik~7Ik~9 AC ELEAN- h1F 99.='32 FIU HI~SF' VISTT, LEVEL E 781 12c_.k7k7
~~=il~'IS/~'~ ELEAtJ t~IF 14~ F'AYMEN-I--•MEDICAP,E 165. ~~,•
~L i ~T'~I k~9 ELEAr! Mh 4~1 t~IED I CARE DISALLOW 167. k~15•
4?I'c: i 17IV79 ELEAtJ ~ MF 6 F'AY- I tdSUR 41..?'3-
l~
T F Yt_~U H
RETWEEtJ VE
: 3k~ h!Y
AM taUEST I
RlVD 4 : i`l~+,
IZI ~ PLEASE t_•A
h1. L 631-37x5 ~ `~
~
I
FRIEh-lDL`r REMI t`!D R! YOU A C:OUM1lT TS ~' ST Dl1E. F'LEA',~+E REMIT ~
BALAtlCE. THA N. OU. .
67 • ?,1 4A000UNT
AGE .TOTAL
AMOUNT ~ 67. 3
CURRENT
OVER 30 DAYS
OVER 60 DAYS
OVER 90 DAYS
OVER 120 DAYS
ANALYSIS ,
DUE.
PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C.
~~s ~ ancactar Rn, io„~.,~ ,,ain ~ ,,..,,,,..a,..... o..,.a ,.:_~__, r , .._._ ..... 4950 Wilson Lane STATEMENT
.. _ ~..___.... _,,,,,,,,,,,,, ~,,,,,, ",,,,,,,,,,,~„y „tea„ m,cnnCr r. ~up,naccr, m.u. Mechanicsburg, PA 17055
P.O. Box 2028 Bloom Bldg. Suite 106 William A
Rolle
Jr
M
D STATEMENT DATE PAGE
.
,
.,
.
. (717) 691-4847
Mechanicsburg, PA 17055 Harrisburg, PA 17109
(717) 691-3755 (717) 561-4242 Www.prismdrs.com Christopher Royer, PsyD ~`=/~~'/~~ 211
Lisa A. Eaton, PsyD
Billing Dept: (717) 691-4879 Tax I.D. ~f25-1651500 ACCOUNT
Please retain this portion of statement for your records. NUMBER k143234
TRANSACTION DATE INV. N0. POS. PATIENT DR. PROCEDURE DESCRIPTION OFSERVICES' DIAGNOSIS AMOUNT
1-'REViC7US PALANCE 88.81
0i/05/09 AC ELE:AN MF 99231 F/U HC1SF' VISIT, LEVEL i 781E 102.00
01/05/09 AC ELE:AP! MF 99231 F/U HOS1=' VISIT, LEVEL 1 7812 lk7c. k'~0
01/15/09
' ELE:RN MF 40 MEDICRRE DISALLOW 130,8`
k
+ 1 % 15/ 09 ELE:AN MF 821 AF~~~L I ED TO DEDUCT I RLE 73, i g
Oi/:6/09 ELE:AN MF -4 F'ER STATE FARM THEY UON' T
@1126/219 ELE:AN MF -4 I:OVER MEDICARE DEDUCTIBLE
01/25/09 ELEAN MF -4 THIS YOUR BALANCE
01 /29/09 ELE:AP1 MF 10 PAYMENT-MEDICARE ; g, 27
01/29/09 ELEAN MF 40 MEDICARE: DISRLLOW 65.41
IF Yt7U H VE NY QUESTI NS, PLEASE CA L 591-3755
BETWEEN :321 AM RND 4: 0 M.
57...:,1
~ACCOUftT TOTAL 57. ,,:,1
CURRENT AGE AMOl1NT
OVER 30 DAYS OVER 80 DAYS OVER 80 DAYS . OVER 120 DAYS ANALYSIS DUE
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
ACCOUNT NO. _)
143234
ELEAPIOR B 4! I SDA
2102E BENT CREEK
MECHANICSBURt3, F'A 1 7052+
02/03/09
~~
S 57. 31
PLEASE MAKE YOUR CHECK
PAYABLE TO PRISM.
LOCAL HOUSEHOLD
'~,~ RENTAL AGREEMENT
,. .
~~,~~ HORNUNG'S RENTAL CENTER (4517-41) Agreement 18937476
www.pensketruckleasing.cam 6048 CARLISLE PIKE Check-out 01/23/09 09:04 AM
MECHANICSBURG, PA 17050 USA due-In 01/24/09 09:04 AM
Voice (717) 761-8273 Fax (717) 796-2260
24 Hr Emer enc Service. 800 526-0798
~ •- •
Bill To C LEONARD SEMICK
505 ELLEN RD
Day (717) 737-9556 ' CAMP HILL, PA 17011 USA
Unit Rented with Damage NO
•-
Name
LEONARD SEMICK
- NO HAZARDOUS MATERIAL BEING TRANSPORTED
~• • s s
Description Quant Unit of meas Rate Subtotal
6010 -12FT SAG LIGHT HICUBE Fuel Out FULL
Unit#9903856 Plate # 1074848 St IN Exp 12/31/09 Owner 0723-10
b1ax. Payload 5,5441bs. Height 9 ft. 6 in.
Mileage Out 40273 20 MILE 0.59 11.80
Days Used 1 1 DAY 19.95 19.95
AAA Discount 10.0 % DISC -3.18
LIMITED DAMAGE WANER / LDW Household) *DECLINED*
SUPPLEMENTAL LIABILITY *DECLINED*
PERSONAL ACCIDENT INSURANCE *DECLINED*
CARGOINSURANCE *DECLINED*
environmental fee 1.0 DY 1.50 1.50
Customers who return Vehicles with less fuel than when rented will be charged $5.00/gallon to refuel the Vehicle, plus an additional $15 Refueling
'
Service Charge
rf a Vehide is returned to a Penske location that does not have fuel on site.X
Initials
^
-
Type Tran Date Details Amoun#
VI AUTH 01!23/09 Card# 6785 Appr 015296 on 01/23/09 for x34.47 '-0.00
• • ~ ~
HORNUNG'S RENTAL CENTER (45171) Created by J.RIVERA ITEMS 30.OT
6048 CARLISLE PIKE Completed by J.RIVERA PA $2/DAY RENTAL TAX 2.00
MECHANICSBURG, PA 17050 USA Entered at 4517-41 PA 2% HH RENTAL TAX 0.60
Voice (717) 761-8273 Fax (717) 796-2260 Status OPEN PA 6°!o SALES TAX 1:80
By signing below, Customer agrees that he/she received, read, understands and agrees with all ESTIMATED TOTAL 34.47
terms, conditions and obligations shown on the rental folder and appropriate User's Guide. Penske
makes no warranties, express, implied or statutory, including but not limited to, the implied war-
ranties of merchantability and fitness for a particular purpose.ln addition, if Customer is entering into
this Agreement in FL, HI, MI or MN, Cus omer ackn ledges t elshe has read, understands and
agrees with the terms of the sta 's re red Ian ag a et ort in Paragraph A Sections 1 - 4 of
the rental folder. Minimum dri a s 18 ye s of .
Customer agrees that truck i cie dditionai s e rged if truck i of returned clean. 587829
Customer's Signature 1/1
ru ~ m ;tia
~~~
~~
Hess 38285
4175 Market St.
Camp Hi11, PA 17H11
1123/89 12:58 PM
Term: JD42251544881
Appr: 855738
Seq#: 856216
PUMP# 18 CREDIT/
Unl RegulaL~ #.1.799/G
VOLUME 3.34 GAL
GAS TOTAL $b.88
Visa
>CXXXXXKS{XXXX7538
81/23/2889 12:57:22
I agree to pay ttie
above Total Amount
according to Card
Issuer Agreement.
THANK YOU FQR
SHOPPING AT HESS
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ALERT PHARMACY SERV.INC. A FINANCE CHARGE OF 1.50 ~ PER MONTH
219 NORTH BALTIMORE AVE. (AN ANNUAL PERCENTAGE RATE OF 18.0$) OR A
MT.HOLLY S PRINGS,PA 17065 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED
ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE
PHONE: 800-266-9954
IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR
PRESCRIPTIONS BE SURE TO SUPPLY US WITH A COPY.
12/20/2008
PMT DUE..Ol/15/09 WISDA, ELEANOR WISDE
BRIDGES AT BENT CREEK GRP-58
2100 BENT CREEK BLVD PAGE 1
MECHANICSBURG PA 17050
ALERT PHARMACY SERV.INC. 219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA 17065
** ACTIVITY FOR WISDA, ELEANOR
11/I2/08 7439215 28 ISOSORBIDE MN 30 O1
11/12/08 7439218 28 ASPIRIN S1MG CHEW Ol
11/12/08 7439585 28 METOPROLOL 25 MG O1
11/12/08 7439588 28 NEXIUM 40 MG O1
11/18/08 7439587 28 DILTIAZEM CD 120M O1
11/19/08 7439217 56 POTASSIUM CL 10 M O1
11/19/08 7448951 14 FUROSEMIDE 20MG O1
12/04/08 Payment-Thank You
59.07 52.52
.00
-WISDE - -58
8.00 .00
2.93 .00
5.80 .00
15.00 _00
8.00 .00
8.00 .00
4.79 .00
59.07- .00
.00
49.59 2.93
LEGEND NON-LEGEND
FOR MONTH FOR MONTH
111.59 59.07
8.OOc
2.93
5.80c
15.OOc
8.OOc
8.OOc
4.79c
59.07-
52.52
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