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Home My WebLink About11-20-09 J 1505607121 REV-150 0 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601 Harrisbum, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 4 6 9 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 5 9 2 4 9 5 7 5 0 4 2 4 2 0 0 9 0~ 2 ~, 1 9 d~ 03 ~ Z~ ~ ~q, 30 Decedent's Last Name Suffix Decedent's First Name MI G O O D H A R T L E E E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW Q 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ prior to 12-13-82) 5. Federal Estate Tax Return Required ^ 6. Decedent Died Testate (Attach Copy of Will) ^ death after 12-12-82) 7. Decedent Maintained a Living Trust A ~ 8. Total Number of Safe Deposit Boxes ^ 9. Litigation Proceeds Received ^ ( ttach Copy of Trust) 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 CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number S T E P H E N L- B L O O M 7 1 7 2 4 9 2 3 5 3 Firm Name (If Applicable) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS I R W I N & M c K N I G H T P C. First line of address 6 0 W E S T P O M F R E T S T R E E T Second line of address City or Post Office C A R L I S L E State P A ZIP Code REGISTiE61 OF WILLS U NLY 'Tx-y ~. . .~ rn ~ .. , ~_ ~~~".~ C,_._ f __,~ ~..~.._ . ~ f _'~ r - ~wr ATE FILED `-," ~' 1 ? 0 1 3 Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledoe. ai rv urct ur rt -UN FiESPON I E FOR FILING RETURN DATE A R SS ,. 10 5 LONGS GAP R CARLISLE PA 17013 I ATURE O AR R OTHE AN REPRESENTATIVE ~~A~o -~-./`7 WEST POMFRET CARLISL PLEASE USE ORIGINAL FORM ONLY PA 17013 Side 1 1505607121 1505607121 Tax Payments and Credits: ~ • Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments _ 5, 500.00 C. Discount 289 47 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) 5, 789.47 (1) 16, 354.98 Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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) 10.565.51 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 10,565.51 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ 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 beneficiary designation? .................................................................................................. 0 ^ 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 exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. 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-1500 EX Page 3 File Number Decedent's Complete Address: 21 09 0469 REV-152 EX + (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER LEE E. GOODHART 21 09 0469 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the 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 relevant facts. Real roe which is 'oin -owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1. 115 WEST SOUTH STREET, CARLISLE, PENNSYLVANIA 55,000.00 APPRAISAL ATTACHED TOTAL (Also enter on line 1, Recapitulation) ~ $ 55,000 00 (If more space is needed, insert additional sheets of the same size) F2EV-150,3 EX + (6-98) ' SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER LEE E. GOODHART 21 09 0469 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE 1. SERIES EE SAVINGS BONDS -INVENTORY ATTACHED OF DEATH BENEFICIARY: LOUISE MARCENE GOODHART, DECEASED -ESTATE 3,717.60 TOTAL (Also enter on line 2, Recapitulation) ~ $ 3,717 60 (If more space is needed, insert additional sheets of the same size) REV-158 EX + (6-98) ' SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN R SIDE T DECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER LEE E. GOODHART 21 09 0469 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1999 FORD RANGER 2,900.00 2. IM&T BANK -CHECKING ACCOUNT #537136 I 10,322.56 3. IM&T BANK -SAVINGS ACCOUNT #21000000988185 I 68,957.88 TOTAL (Also enter on line 5, Recapitulation) I $ 82,180 44 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER LEE E. GOODHART 21 09 0469 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. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST pFAPPLICABLE) VALUE 1. SERIES E. AND EE SAVINGS BONDS 236,240.46 100. 236,240.46 INVENTORY ATTACHED BENEFICIARY -LORI MILLER TOTAL (Also enter on line 7 Recapitulation) ~ $ 236,2 (If more space is needed, insert additional sheets of the same size) REV-151 ~ EX + (10-06) • SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & IN RE8 DAENT DECEDENTRN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER LEE E. GOODHART 21 09 0469 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B• ADMINISTRATIVE COSTS: 1 • Personal Representative's Commissions Name of Personal Representative (s) Street Address City State _ Zip Year(s) Commission Paid: 2• Attorney Fees IRWIN & McKNIGHT, P.C. 8,000.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State _ Zip Relationship of Claimant to Decedent 4• Probate Fees REGISTER OF WILLS 283.00 5 Accountants Fees 6. Tax Return Preparer's Fees PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER OF WILLS -FILING FEE 8. STEVEN W. BARRETT -APPRAISAL ON REAL ESTATE 30.00 9. IRWIN (HAL) LAW OFFICE -CONSULTATION RE ESTATE 325.00 10. THE SENTINEL -ESTATE NOTICE 423.00 11. CUMBERLAND LAW JOURNAL 198.16 12. CLOSING COSTS FROM SALE OF REAL ESTATE 75.00 13. NOTARY 1,928.07 20.00 TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 11,632.23 REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT IN R SIDENT DECEDENTRN , MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER LEE E. GOODHART 21 09 0469 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VAO DEADHTE 1. PEERLESS INSURANCE -HOMEOWNERS INSURANCE 410.00 2. CUMBERLAND-GOODWILL -AMBULANCE 434.50 3. KINETIC IMAGING -MEDICAL 55.17 4. SARAH A. TODD MEMORIAL HOME -NURSING 667.50 5. UGI -UTILITY 34.19 6. BOROUGH OF CARLISLE - WATER/SEWER 132.87 7. CARLISLE HMA PHYSICIAN MANAGEMENT -MEDICAL 86 98 8. CRNA -CARLISLE -MEDICAL 57.75 9. PP&L -ELECTRIC 24.67 10. ALLAN J. MIRA, M.D. -MEDICAL 158.73 TOTAL (Also enter on line 10, Recapitulation) I $ 2,062 (If more space is needed, insert additional sheets of the same size) REV-1513~EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF LEE E. GOODHART SCHEDULE J BENEFICIARIES NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. LORI J. MILLER 1035 LONGS GAP ROAD ARLISLE PA 17013 FILE NUMBER 21 09 046! RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Lineal AMOUNT OR SHARE OF ESTATE 363, 443.91 REMAINDER I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) HUD SETTLEMENT STATEMENT 'This form is furnished to give you a statement of actual settlement costs..Amounts paid to and by the ;settlement agent are shown. Items marked (POC) were paid outside closing and are not included in the totals. (NAME & ADDRESS OF BORROWER: Robert L. Foltr, Jr. 11900 Douglas Drive ;Carlisle, PA 17013 _ __ (NAME 8 ADDRESS OF LENDER:^ PROPERTY LOCATION: 115 West South Street Third Ward !Carlisle, PA 17013 (SUMMARY OF BUYER'S TRANSACTION: ~ 100 GROSS AMOUNT DUE FROM BUYER: 1101 Contract sales price ~ 102 Personal property j 103 Settlement charges to buyer (from line 1400) i 104 ~ 105 ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 106 County/local taxes 17-Nov-2009 to 31-Dec-2009 107 School taxes ~ 17-Nov-2009 to 30-Jun-2010 :108 Assessments j 109 '110 ;120 GROSS AMOUNT FROM BUYER ' (AMOUNTS PAID BY OR FOR BUYER: !407 Assessments 501.74 ;408 1409 '420 GROSS AMOUNT DUE SELLER 500 REDUCTIONS IN AMOUNT DUE 6,495.25 501 Payoff of first mortgage !502 Payoff of second mortgage i1v~ ueposit or earnest money ! 1,000.00 ;503 Settlement charges to !202 Principal amount of loans seller (from line 1400) 1 928 07 ' 1203 Existing loans assumed ;504 Existing loans assumed . !204 505 !205 _ ___ __ ~ X506 ___ __ CREDITS TO BUYER FOR _ __ __ _ CREDITS TO BUYER FOR ~- IITEMS UNPAID BY SELLER__________ ITEMS UNPAID BY SELLER: _ _ 206 County/local taxes ____ ____ __ _ _ __ ~ J507 County/local taxes -- ~ 1-Jan-2009 to 17-Nov-2009 0.00 ;1-Jan-2009 to 17-Nov-2009 ~ 0 00 1207 School taxes j508 School taxes . 1-Jul-2009 to 17-Nov-2009 1208 Assessments 0.00 ~ 1-Jul-2009 to 17-Nov-2009 509 A 0.00 ;209 ssessments ;510 ' '210 1220 TOTAL AMOUNTS PAID X511 .,520 TOTAL REDUCTIONS ___BY OR FOR BUYER ; 1 000.00 , IN AMOUNT DUE SELLER ' ______ _ X300 CASH REQUIRED FROM OR PAYABLE _ __ , ___ _ ________ X -~ 1,928.07 ---- 600 CASH TO SELLER TO BUYER AT SETTLEMENT: FROM SETTLEMENT: ___ __ __ ___ __ _ - i ross amount due from buyer ~ _ _ _ _ ______ - - - -- - 601 Gross amount due seller ~ ~--- -------------- (from line 120) 302 Less amounts paid by or for buyer 56,495.25 (from line 420) 602 Less total reductions in amount 55,546.75 (from line 220) _ X303 CASH FROM TO BUYER 1,000.00 ~ due seller (from line 520) 1 928 07 ( ) : 55,495.25 i603 CASH TO ~FROM) SELLER 53 618 _ _____ _ _ _ __ _ _ ___ , .68 TAX PRO-RATION 17-Nov-2009 2009 COUNTY/LOCAL TAXES 2009-10 SCHOOL TAXES BILL DUE: BILL DUE: BILL PAID: 373.35 BILL PAID: 813.93 45.01 DUE SELLER 501.74 DUE SELLER _ 0.00_DUE BUYER ____ _ ___ 0.00 DUE BUYER _ 'SUMMARY OF SELLER'S TRANSACTION: 1400 GROSS AMOUNT DUE TO SELLER: 55,000.001401 Contract sales price ; 55,000.00 1402 Personal property ~ 0.00 !403 948.501404 i 'ADJUSTMENTS FOR ITEMS PAID i jBY SELLER IN ADVANCE: 'NAME & ADDRESS OF SELLER: . ;Estate of Lee E. Goodhart LOAN TYPE: TITLE INS. N0 Page 1 SETTLEMENT AGENT: SSETTLEMENT DATE: WAYNE F. SHADE, ESQUIRE ~ 17-Nov-2009 53 WEST POMFRET STREET CARLISLE, PENNSYLVANIA 17013 1405 County/local taxes _ ! 17-Nov-2009 to 31-Dec-2009 406 School taxes 45.01 17-Nov-2009 to 30-Jun-2010 SELLER: 45.01 501.74 75 Z O (D m ~_ G7 O O ~. S r ~D lD ~' co O d v O .c~'D N o- N (~ (D O -~. . • 3 • *wD v ~ ~ O > ~ a o, n °~ N vi m' ~~'~'3 ~ wwD n~.~,~ ~ ~ ~ v a~o~ ~ rnm~ ~y~~C' a co~~~ m n.o.~~ a-. _.m ~ -*~~~tn OO~"~ 2~ m ~ _ ~ -~ . Q. o~~m~ ~ c `~ ~' ~ ~ O • ~ -'~aX y ~~ ~~~ ~~, aZo fD• > >' o ~ ~ a~ a ~ 3 0. ~ v ~.,~ ~ m cn c~ Q ~• m ?~~'~~- O~OOtQ d X ,O~.O ~D 'O ,~ ~ O 0=ti~~0 ~ C ~ .-r ~ O ~ ~ _ .~n,~ . _ ~o~zo c~~~-~ can O `~ ~ D. O' 3~C O ~. ~ ~: d (D j (D ~ ?0p0 O~O~ ~~a,~ ~ d d1 ,0... a ~ cn a' ~ _ ~ CD l~D j ~ ~ N y O C a~ a a b ~ ~. .~ .~~ i ~" 1 ~ ~ ,p ~ ? ~ W N -~ OZ d f~ O V1 --~ rn rn m m o m m m m ~ N N ~ ~ ~ U1 o° C17 o° O OO O °o O 3 o v ~ 3 w W y ~ D O ~ O O d O O N _ (O O ~"~ ~I rn ~1 C m C v m m ~ O ~ ~ O N ~ ~ ~ ~ y ~ ~ ~ ~ O H CO CO CO CO r* G CO (O CO CO O ~p N ~ -~ N NN U1 CJ1 oo O O UI O o O C~J1 O o O = n ~ ~, ~ ~ ~ ~ ~ ~ ~ 0 W W rno~ ~I V ~ _ ~ co co O~ w co N w co I c~ to ~ c O O O V O O OO ~ IV ~ N < ~ ~ w W CO (O t O C O ~D O O O O ~ _~ ~ ~ ~ ~ ~ A ~ 00 0 0 '"" ~ o o o ~ ~ 0 O U 7 Cn U1 Cn '~ ~ ~ 0 o ~ a ~ o °' '"h Z O N ~ 0 00 ~ 0 0 0 0 ~1 O y NN N N ~ ~ ~ ~ ~ O ~ ~ ~ ~I C O ~ rn ~O ~ ~ ~ ~ O „ o ~ ~ ~ v ~ N N N N _ ~ ~ _ 0 ~ N N N N ~ ~ _ N -' -' N O ~ O d9 C ~ O O ~ ~ ~ ~ ~ 0 * * * * O 0 O ~ ~ ~ 1999 Ford Ranger -Private Party Pricing Keport - Utticial Kelley 131ue t3ook bite rage i or ~ I~~ley~ Blue Ba~~ok THE TRUSTED RESOURCE • I~L.md advertisement _.Tr ~- ;` :, .~,,+ a~ r '~'` icle Highlights ileage: 9,967 ~gine: V6 3.OL Flex Fuel •ansmission: Automatic rivetrain: 2WD Condition Excellent Good Value $3,525 $3,250 ~ Fair $2,900 (S~lected) (Selected Equipment Standard (,Power Steering AM/FM Stereo Dual Front Air Bags (Optional (Air Conditioning Cruise Control Tilt Wheel Pickup Shell/Cap Blue Book Private Party Value Private Party Value is what a buyer can expect to pay when buying a used car from a private party. The Private Party Value assumes the vehicle is sold "As Is" and carries no warranty (other than the continuing factory warranty). The final sale price may vary depending on the vehicle's actual condition and local market conditions. This value may also be used to derive Fair Market Value for insurance and vehicle donation purposes. Vehicle Condition Ratings Excellent ~~~~~ $3,525 • Looks new, is in excellent mechanical condition and needs no reconditioning. • Never had any paint or body work and is free of rust. • Clean title history and will pass a smog and safety inspection. • Engine compartment is clean, with no fluid leaks and is free of any wear or visible defects. • Complete and verifiable service records. Less than S% of all used vehicles fall into this category. Good Send to Printer Close Window http://www.kbb.com/KBB/UsedCars/PricingReport.aspx?Yearld=1999&Mileage=9967&... 5/21 /2009 iyyy rota Kanger gong Bed SLUE ~UOI~~~ PRIMATE PARTY VALUE advertisement 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888)502-4349 Fax (302)934-2955 May 27, 2009 Law Offices Irwin & McNight, P.C. 60 West Pomfret Street Carlisle, Pennsylvania 17013-3222 Re: Estate of Lee E. Goodhart Social Security: 159-24-9575 Date of Death: April 25, 2009 Dear Sir or Madam: Per your inquiry dated May 21, 2009, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: ] . Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total 2. Type ofAccount Account Number Ownership (Names o,~ Opening Date Balance on Date of Death Accrued Interest Total Checking Account 537136 Lee Edward Gooa~liart* 9/1/76 Closed 5/26/09 $10,322.56 $ 0.00 -- ----------------------------- - $10,322.56 Savings Account/ Passbook 21000000986185 Lee Edward Goodhart* 8/1/76 Closed 5/26/09 $ 68,955.33 $ 2.55 $ 68,957.88---~--~----_-~~--~ Please be advised, there was no safe deposit box found for the above decedent. * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact our High Street Carlisle Office # 717-240-4536. 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PHILA, PA 19176-0910 • • (800) 367 0512 Federal Tax ID. 23-2298422 PATIENT NAME: LEE GOODHART INSURANCE: FEP - PA BLUE SHIELD 801397445 MEDICARE B 159249575TH CG0901317 LEE GOODHART 1035 LONGS GAP RD CARLISLE, PA 17013-8671 PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: REASON(S) FOR TRANSPORT ~e V ~®~~ 8994 CG0901317 03/20/2009 NMI 11 CARLISLE REGIONAL MEDICAL CTR SARA A TODD MEMORIAL HOME HIP INJURY DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT BLS NON EMERGENCY A0428 MILEAGE CHARGE A0425 1.0 3.0 400.00 11.50 400.00 34.50 I DESCRIPTION OF PAYMENT I RECEIPT ~ PAYMENT DATE ~ AMOUNT PLEASE PA~f T HIS AIVI®UNT ~- ~~~~ ~~ t0 ~ ~ i ~ y 197 $434.50 PREMIUM NOTICE Ohio ACCOUNT NUMBER: HP7M521351 Casualty- Mcmbec of tJbe~ty Mun~al croup Agent: TELE ONE (717)-249-2812 Account of: J DNEY FICKEL INS AGENCY IN LEE EDWARD GOODHART P BOX #1 115. WEST SOUTH STREET CARLISLE PA 17013 0001 CARLISLE PA 17013 Notice issued to: LEE EDWARD GOODHART 115 WEST SOUTH STREET CARLISLE PA 17013 Insurer: PEERLESS INSURANCE COMPANY 6281 TRI-RIDGE BLVD LOVELAND OH 45140 SEE REVERSE SIDE FOR INFORMATION ON: FUTURE PAYMENT SCHEDULE, SERVICE FEES, 24HOUR STATUS HOTLINE, ADDRESS CHANGE REQUESTS AND-OTHER IMPORTANT NOTICES. Co: 10 Loan Number: Agent: 3202486 Payment Plan: MONTHLY Invoice Date:05/07/2009 Policy Number Trans. Date HP7 M521351 0323/2009 Description of Transactions EFF 06/032009 TOTAL POLICY PREMIUM SERVICE CHARGE Charges/ Policy Minimum Credits Balance Due 410.00 410.00 61.50 5.00 5.00 Payment Due Date: 06/03/2009 Account Balance: $ 410 . o o Minimum Amount Due: $ 6 6 . s o Policy Type: HOMEOWNER Future Payment Schedule: Please See Reverse M o - o Q a e~ o o ~ r- M --.---. Enroll today at-- -~---- ---.:-- ...:.~ .._.._ _~--1. v~rww.oh iocasualty-i ns.com/bi I I i ng N To enroll, please have available your account number(s), zip code of your billing address and ~ ~ current email address to receive your enrollment confirmation. _Simply follow the ~ a ~ on=screen instructions to enroll and create a list of your accounts. ~ _ _. i _ c ... ..,;_ . . o It's secure, fast and easy! M ~ O O ~: Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Statement Date: 06/10/2009 Lori Jeanne Miller 1035 Longs Gap Road Carlisle, PA 17013 Due Date: 06/25/2009 Re: Lee E Goodhart Account Nr: 102060 ------------------------------ Date Description Days Rate Charges Payments Balance Quant BALANCE FORWARD 31.50 31.50 05/28/09 PAYMENT ~~ 31.50 .00 04/30/0.9 COINSURANCE BILLED. 133.50 667.50 667.50 NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on your statement. Include the ACCT# from the statement on the MEMO LINE of your check. Payments after 06/08/09 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25$ LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** Irwin Law ~ ice 64 South Pitt Street Carlisle, PA 17013-3220 Invoice submitted to: Lori J. Miller 1035 Long's Gap Road Carlisle PA 17013 May 19, 2009 Invoice #12042 Professional Services Hrs/Rate Amount 5/7/2009 Conf to open estate file 1.00 235.00 235.00/hr 5/8/2009 Draft petition for letters, estate information sheet notice of estate , administration, and certificate of notice 0.60 141.00 235.00/hr 5/11/2009 Phone calls a appointment dates and sale of truck 0.20 47.00 235.00/hr For professional services rendered 1.80 $423.00 Balance due $423.00