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HomeMy WebLinkAbout12-10-09J REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 15056051058 INHERITANCE TAX RETURN RESIDENT DECEnFNT Date of Birth 02/10/1914 Decedent's First Name MI Rubye .... ........ ; M ter Appllcable) Enter Surviving Spouse's Information Below Spouse's Last Name _. Spouse's Social Security Number OFFICIAL USE ONLY County Code Year File Number 21 08 Suffix Souse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE .... .. ... REGISTER OF WILLS FILL IN APPROPRIATE 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 ....w._....~. 8. 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 CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name °-- - - aYtime Telephone Number Nathan C. Wolf, Esquire . ~ ..... Firm Name (If Applicable) Wolf & Wolf First line of address (717) 241-4436 r.~ QPJ WILLS .`~~ C~ -!~^~~. ~~ ....~ C_~ `v`r .. _~ -I C"7~ c~ .;_ .~" i'=r` °:~ C~ ~ yY :w.. ~ ~? ~~ ~~ ~:.~ :;:a .ar .. ~i - """.i .~ c,~ . ATE FILED ZIP Code L_..__~.w~_.~.__~_~~.~_.._.___w~_~...~,.._. °,17013-2922 .~ Correspondent's a-mail address: nathancwolf@embargmail.com 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 e. Declaration of prepare r than the --.__~ ~~'~ personal representative is based on all information of which preparer has any knowledge SIGN~f~E~~RSON RESPONS~~ ~ SING RETURN ADDRESS 1485 Crystal Lake Circle, Condo #7, Green Bay, WI 54311 SIGNATURE PA R THAN REPRESENTATIVE ADDRESS 10 We ig tre ,Carlisle, Pennsylvania 17013 PLEASE USE ORIGINAL FORM ONLY 1 505605 1 058 Side 1 L 15056051058 REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT rAT~~/~ w SCHEDULE H FUNERAL EXPENSES & ADMINISTRATNE COSTS w ~h~ ~ yr Rubye Minerva Bloser ITEM NUMBER A. FUNERAL. EXPENSES: 1' Ewing Brothers Funeral Home Debts of decedent must be reported on Schedule I. DESCRIPTION FILE NUMBER 21-08-0805 AMOUNT Q AI"1\IILIIQT['f eTn it ~~.v~.. ... ... ,.... .,. 2. Attorney Fees 1, 000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 88.00 5. Accountant's Fees 6. Tax Return Preparer's Fees ~• 'The Sentinel- Legal Advertising 166.60 8. Cumberland Law Journal- Legal Advertising .: 75.00 s.` !Buddy Hartman -Executor -Reimbursement for travel expenses for funeral and estate administration - 800.00 10 Hilton's Lock Service -locks changed for decedent's home to protect personal property 139.53 11 Reserve for outstanding expenses _ 200.00 TOTAL (Also enter on line 9, Recapitulation) $ 3, 510.33 (If more space is needed, insert additional sheets of the same size) J 15056052059 REV 1500 EX Decedent's Name: RUbye M Bloser RECAPITULATION Decedent's 1. Real estate (Schedule A). ....... 1 ....~_ ... ...... _ ......._ 0 00 2. Stocks and Bonds (Schedule B) ........ 2 .•, . ,.•~n . „' .,,.x•,14 80 ............................... 5,0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~.,•~...cx_a~x•_~a .._...w. ,: ~.... 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. • 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 3,130.68 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property .°•.~.~':.~`.T~.~°~.,~.~ w~:~-~ .:,.~<°~>-~..•~-~::Y>.w ,.,~>~~~s~...n:.k>m_.~..~»..„ (Schedule G) Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 3,510.33 .,..M... 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ................ 10. - 17,953.09 11. Total Deductions (total Lines 9 8 10) ................................... 11. ~•~,*~^•~`••~a~~aR~M us~~•,Rw^yc~`~••Un,~21,463.42 .... ~~.., .. aw.:.~ ,~M..~ 12. Net Value of Estate (Line 8 minus Line 11) ..... .... . . . . . ......... 12 , "~~~ -13,31794; 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which '~ °._..° ~°„°°- -~°• - • ~~ ~~ -• ..... .. ...•.._.• .w..... an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value SubJect to Tax (Line 12 minus Line 13) ........................ 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 18. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0.00 15056052059 Side 2 L 15056052059 REV 1500 EX Page 3 Decedent's Complete Address: 21 v 08 ~ 0805 Rubye M BIOSer DECEDENTS SOCIAL SECURITY NUMBER STREET ADDRESS 205-09-9905 553 North Bedford Street cITY Carlisle Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty STATE PA (1) Total Credits (A + B + C) (2) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.tal Interest/Penalty (D + E ) Fill in oval on Page 2, Line 20 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. (3) (4) (5) (5A) (5B) ZIP 17013 0.00 0.00 0.00 0.00 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 "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? ........................................................................................................................ ^ 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 or 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)j. 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 exem~ 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)j. 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)j. Asibling isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV 1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT t,lAlt VF Rubye Minerva Bloser e~~ nrnna.i.i i..i..~l.. ~....-.J ...eaL ___~. _~ .. _ FILE NUMBER 21-08-0805 ~-~ • • •-• - -r-~~ •~ • •~~~`~, ~~ ww ~ auunwi ~di ~Iiee[S Oi [f[6 SB~Ie SIZ@) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCNEDIJLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Rubye Minerva Bloser FILE NUMBER 21-08-0805 Include the proceeds of litigation and the date the proceeds were received by the estate. All proDertV lointlv.ewnad uii+h ~„ti* ..f Q...,,:..,._.~:_ _.._. ~ _ „_ _ . .-- --~--- -r--., .........,....., ,,,~~~~ a~~~~~~~~a~ ~nee~s or me same size) REV-1511 EX+ (12-99) SCI~IED~ILE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT !-AT~~~ w w~r~ic yr FILE NUMBER Rubye Minerva Bloser 21-08-0805 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES; AMOUNT 1' . .Ewing Brothers Funeral Home 1,041.20 B. ADMINISTRATIVE COSTS: _ ... 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City _ - State Zip . Year(s) Commission Paid: 2. Attorney Fees 1,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant _ Street Address City _ State ; Zip Relationship of Claimant to Decedent 4. Probate Fees 88.00 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. The Sentinel- Legal Advertising 166.60 13. Cumberland Law Journal- Legal Advertisin g 75.00 s. Buddy Hartman -Executor -Reimbursement for travel expenses for funeral and estate admini t ti s ra on 800.00 10 Hilton's Lock Service -locks changed for decedent's home to protect personal property 139.53 TOTAL (Also enter on line 9, Recapitulation) $ 3,310.33 (If more space is needed, insert additional sheets of the same size) REV-1~~7 ex+ (12-os7 ~ pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER Rubye Minerva Bloser 21 08 0805 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses ITEM . NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. 'Medical Expense Lien per Dept of Public Welfare (Priority) 16,673.40 2 UGI Gas Service - account no 215773809503 . 2$7.39 3' PP&L Electric Service -account no. 78930-75009 86.17 4 Embarq telephone - 717-249-5361 31.77 5 'Lorraine Clepper (Final week of in home care) 50.00 6 Janet Hartman (Final week of in home care) 126.00 7 SmartMed (Prescription filled prior to death) 6.25 8 Giant Food Stores (check written prior to death) 203.50 9 ' Comcast Cable (check written prior to death) 114.54 ~ o ..Embarq telephone - 717-249-5361 (automated payment scheduled prior to death) 25.46 1 ~ Yellow Breeches Family Practice (check written prior to death) 100.66 12 , Borough of Carlisle (check written prior to death ) 141.95 13 'Gilbert's Pest Service (service contracted prior to death) 106.00 TOTAL (Also enter on Line 10, Recapitulation) ~ 17,953.09 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ {11-US} ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ] BENEFICIARIES tSTATEt Rubye ~ NUMBER I 1. II 1. 100% Div i trc uuu.AK AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN If more space is needed, insert additional sheets of the same size. FILE NUMBER 21-08-0805 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) nF ESTATE LAST WILL AND TESTAMENT OF RUBYE M. BLOSER I, RUBYE M. BLOSER, widow, of 553 North Bedford Street, Carlisle Borough, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understandin g~ do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. 1 I order and direct my personal representative hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my personal representative need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. If I do not own a burial plot or a grave marker at the time of my death, I authorize my personal representative, in his, her or its sole discretion, to purchase a burial plot and to erect a suitable grave marker at my grave, and to expend sums from my estate for this purpose. 2 I give, devise and bequeath the rest, residue and remainder of my estate, together with all insurance proceeds thereon of whatever nature and wheresoever situate to my son, DONALD C. KARTMAN, of 533 North Bedford Street, Carlisle, Cumberland County, Pennsylvania, providing le shall survive me by sixty (60) days. Page 1 of 7 LAST WILL AND TESTAMENT OF RUBYE M. BLOSER 3 Should my son, DONALD C. HARTMAN, predecease me or die on or before the sixtieth (60th) day following my death, then I give, devise and bequeath the rest, residue and remainder of my estate in equal shares to my grandson, BUDDY LEE HARTMAN, JR., of 1829 Ridgeview Drive, Carlisle, Cumberland County, Pennsylvania, and my granddaughter, VICHI LEE HARTMAN, of 34 Bellaire Avenue, Carlisle, Cumberland County, Pennsylvania ,providing they survive me by sixty (60) days per stirpes. It is further my desire that my personal representative, after consultation with any heir or heirs of mine who survive me, and in his, her or its own discretion, choose such articles from my tangible personal property (exclusive of cash, stock certificates, bonds, and all other tangible evidences of intangible personal property) as he, she or it believes will be useful to such heir or heirs or desirable for him or her or them to have, either from a sentimental point of view or otherwise, and to deliver such articles to sLich heir or heirs or anion g such heirs in equal or unequal shares as determined by the further exercise of his, her or its discretion, provided no other heir objects to the distribution. All tangible personal property not so distributed is to be sold, either publicly or privately, by my personal representative, adding the proceeds of such sale or sales to my residuary estate and to be disposed of in equal shares among m Y surviving heirs after payment of my estate debts, taking into account the tangible personal property otherwise provided to them. 4 I grant my personal representative the following powers in addition to and not in limitation ~f such powers as my personal representative shall hold by law: (a) To retain all property received including the stock of any corporate fiduciary acting hereunder, provided such property remains productive. Page 2 of 7 LAST WILL AND TESTAMENT OF RUBYE M. BLOSER (b) To join in any corporation, partnership, recapitalization, merger, reorganization o~ voting mist plan; to delegate authority with respect thereto; to deposit investment under agreements and pay assessments; and generally to exercise all rights of investors, including but not limited to, the voting of shares. (c) To manage, operate, repair, improve, mortgage or lease on any terms any real estate held or owned by my estate. (d) To operate any business that I may own at my death. (e) To invest any fiends of my estate in any stocks, bonds, notes or other securities or property, real or personal, without regard to the principle of diversification or any other statute or general rule of law in his, her or its absolute discretion, it being my intention to give mypersonal representative the broadest investmentpowers possible, providing such investments do not unnecessarilyprevent the prompt settlement ofmy estate. (fl To sell or otherwise dispose of any property, real or personal, tangible or intangible, at any time forming a part of my estate in any manner and on such terms and conditions as my personal representative shall see fit in his, her, or its absolute discretion. (g) To borrow money for the payment of taxes or for any other proper purposes in the administration ofmy estate, and to mortgage or pledge estate assets as security. (h) To compromise claims without court approval including, but not limited to, any controversies with the United States of America or the Commonwealth of Pennsylvania concerning estate and inheritance taxes on any interests that may pass under this my Last Will and Testament. (i) To distribute in cash or in kind upon any division or distribution ofmy estate. Page 3 of 7 LAST WILL AND TESTAMENT OF RUBYE M. BLOSER (j) To undertake any and all acts deemed necessary and proper by my persona. representative for the proper, advantageous ~ and prompt management of the settlement of my estate. (k) In general, to exercise all powers in the management of my estate, which any individual could exercise in the management of similar property owned in his own right, upon such terms and conditions as to hiln, her or it may seem best and to execute and deliver all instruments and to do all acts which he, she or it deems necessary or proper to carry out the purposes of this, my Last Will and Testament. 5 No interest of any beneficiary of lny estate, either in income or in principal, shall be subject to anticipation or pledge, assignment, sale or transfer in any manner, nor shall any beneficiary have the power in any manner to charge or encumber his interest either in income or principal, nor shall the interest of any beneficiary be liable or subject in any manner while in the possession of my personal representative for the liability of such beneficiary. 6 I nominate, constitute and appoint my grandson, BUDDY LEE HARTMAN, JR., as Executor of this my Last Will and Testament. In the event my grandson, BUDDY LEE HARTMAN, JR., is deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint my granddaughter, VICKI LEE HARTMAN, as personal representative of this my Last Will and Testament. I direct that my personal representative shall not be required to give or post bond for the faithful performance of his, her or is duties in this or any other jurisdiction. Page 4 of 7 LAST WILL AND TESTAMENT OF RUBYE M. BLOSER 7 I hereby declare it to be my express desire that my personal representative employ Michael J. Hanft, Esquire, of the law firm of Hanft & Knight, P.C., of Cumberland County, Pennsylvania, for legal advice and assistance regarding this my Last Will and Testament, they having considerable knowledge of my affairs, views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. Any mention of Michael J. Hanft, Esquire and Hanft & Knight, P.C. in this my Last Will and Testament, is my free and voluntary act and through no influence by any person. IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament this ~~day of ~-~ i n, 2003. ~ wiTrrESS: Rubye M. Bloser Page 5 of 7 LAST WILL AND TESTAMENT OF RUBYE M. BLOSER ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. I, Rubye M. Bloser, the Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. Rubye .Bloser Sworn or affirmed and acknowledged before me byRubye M. Bloser, the Testatrix, this ~~ day of /~~1~, 2003. - _._._ R1ot~rial Seal Dolly til, a-iousel, iUolary Public South tvlitidleton Two., Cumberland Courtly Niy Corrtrrtis.~irsr ;"w;r:;r~ eft. 24, 2006 ,v..i~,-.,rti~~ ~i1t;c;r~yf'I%api~")r! f~~1K7tc~riF~s Page 6 of 7 LAST WILL AND TESTAMENT OF RUBYE M. BLOSER AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. WE, ,~~ r ~~~ is C,~~,~~r and _ z~ t~ ~~ . ;~~°t ~ ~ ~' °~,._. the witnesses whose names are attached to the foregoing document, being duly qualified according to law, do depose and say that we were present and saw Rubye M. Bloser sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Last Will and Testament as witnesses and that to the best of our knowledge the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. r, ~''? / ~..---, _ ,~.-.__ ~ ~ ~____- Sworn or affirmed and subscribed before me by ~G~~~ ~ ~,~.~sv~j' and °~~'`~"n ~- ~t ~1~"'Z_- this ~ day of 2003. f ,~ . .... __ ~ '~~_.._-.~. IVatarial Seal f Dally A,9. Hoi~s~~l, P~otary Public South Midctleton -f~~vp., Cumberiarx! Courrty My COf11!7-iSSirsrt CX€~ire, Sept. 24, 20QCi IV1Pmtter sar.~>>c„~„M.;~ ...=~~~r,~ti0f1 Gf NotalieS \User FolderlFimi Docs\Wills\3347- I rnib.will.wpd Page 7 of 7 N t0 n N O O x i O ~ ~ a v O ~ v e¢~ M ~ ~ +, za ~ y. 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W y ~ y ~ aL~~ ~Z ~ U ~ ,~ U U a Hpr IJ uy ua;o~a Please Note: Your Sale Proceeds check is Attached 4~suuu~4~syts p..s f111A0 IJ/1 .ItIC' MI r• BROKERS Nsme, Address. ~JP Code, 208 Proot:eas From Broker: and barter Exchange Transacdorts Federal ideatrYlcaibn atumbeFand F~~•m +' 0~9~B Instructlorl5 for Reeiplt'ttlt Telephone Number_ ' ~ Brofaers and barter exchsnBes mttet report ptooeeds from transactions to COPY 8 F4R RECIi'EM "" ~ you and to the Internal Revenue Service. This form ~ used to report McNon Mvealor Services IMPORTANT TAX INt=aRMATI4N-'- + these prO0eed5 ' 480 Weshington Blvd. This is important tb0r irltot:rnsRion and is being . Jenssy Ciy, Iti110731D fumist[ed to the Irrtemat Reversue Service, 3t ta, t)ate orS~1e 1D. Ci1SP Number you are required ro flie a nelurn, a rraglipence 12/16J2tXt8 591 S612t 0 22-3367622 - Penalty or otltei sancdan may Me imposed on 'r'~~~g; 1 ~pD.,649,~ you if tAt6 lecom@ Is taxable arai the IRS Z' ~~ ~~~ °~. 4. FEDERAL fNCOhtE TAX WrFHHELD delemtines ihel it has not Dean reported. Slt4-B5 gp~p To wtaoWr PAID I- REPORTED Q Grooa Proeeede f TO IRS Q G/0OS i~n~eaetls tees cammission 9nd ~ optlons prerttiums 7. Oescnption BUDDY L HARTMAN JR METUFE INC 18310 EARRt7WVi4LE OR , . CHANDLER AZ 8524$-1651 I fivesto[ iG Recipierd's Idendticarion rJumber on File 125226329072 208386123 vox ~a. - 5rwws the tuaae Aare at the ttrensactton_ For aggregate reporlmg, rro entry vrrll liox 4• -Shows backup wi~holdirrg. Generagy, a payer must backup withhold al ~ Prese~l- a 26°.6 Tale if ytw did nd tTumish your la~tpayer iderrti6t~litxl trtrmher to the peyar. Box 1 b. - For broNer Irartsactiorrs, easy show the CU51P {Committee on tJnlf4mt Securigr See Form W-9- Request for Taxpayer IdentT~fion Number and Cettificatlan, for IdorttiflcatkHr Prooeduraa) number of the Kam roporrod. Ir>Tcrmatiocr on backup vrilhltolding. Include lhts ameirrrt oa your lnCDrrrQ ttax return as lax wrthhetd. Box 2 -Shama the provsads Irom trarrsactlons in~oivbtg stoalcs, bondsti other debt o611petlona, commodities, ar forarard aor~ecls. Losses on forward contracts are shown 8coc 7. - Shows n brieF deacriptiorr of the item or eervioe for which the proceeds ar In parontlreaes. This boot does net include proceeds kom regulated fuWres contracts. barteflng insane is betrr0 r•epaded, efor re8uleted tnb~u+as contracts and forward Rapat tlrfs anwurat vrt Schedule D (ForRr f0i0?, Cepllai Oalna and Lrosses• caotracts, -RFC or other appropriate dsscripion may be shown. C :~'; yy.. <R:'• i L:i:;r • :-.,Z' :?.::~ :• . }• .•:•S_. Y.•::Y•}}}iv: •:?] ~ 4 :., •- Y..: ~ {, •_ vnv. ..~'wfdi•.• •'}- .} f- :'9'•f ^•5.• ,p ..•.•.`~'.~ x L,a,r ¢6.... h:.~.ir'~ rt~•,:~;;:: .~`:.. ;i'~Y Z..~ :y'} .:j.{{•X :•: i'.+:...{..•{. ;:}~ .T tt;i?ia:G. ?r •+.i ~, Y:•• i; :.{•^' v9'... ,/.r 1:3•:}..: _.. J.5•:•i:. ~... ._A: .:M,~: ::.. \•:.,: •:. .}. ~. ti. •-0~ .~T vn{1~:.~,~ '~ .;:r, : }sr r,~': r: r^~ ar~:" t;±S~,2$ .~> .d3:'; ~c• .xS';;.,..•;t .R-•,~: •,r.••ct- 4.5..:,,..,:.. .:r'•..•.,r..,.. }'%:'.. „f.. .•t,4• .~t'~ZF;.~..a.;a: :'t . ..~~ • f ,•~ .. a~s~..G ` .t r i •~..:: ~~'ir;. ~s?? .:..txa.U.,E•,•..{:..{.. nr•..?S:t'•t,.' 'r~, f ':c~:.. •,'r.>.e;•._..:..a. •'.i~:}.1 .#F,.~- '~h:, .~~,e<2•..t:?~...b -~: v~~~`f~~,''..• 7~..... .3~•.~~:{:~~~,t..:.A~?.~14~c.....r~:..{~~•'..Y.tit~re~~C.~s~~t....a:,..,~C~., xr•'-^~, ••-...~ .......,..... ...... , ,,.+ .t+'...;#' .:c::..•.,.: .:...... '~ .,;.,.^~~'~:•.~~'••,~? ',•a~•.•,:•:.,:~•.•~::#: a:{•}.4:.;•„_.~ For inquiries about your account, contact BNY Mellon Shar+eowner Services, MetLffe's Transfer Agent: Telephone: 1-800-649.3593 U.S. 141a f t: E-Mall: metlifel~bnymetlon.com MetLife ttrtecnet: vwuw bnymellan.cornfshareQwnerlsd do 8NY Mellon Share~owner Services PO Box 358447 Pittsburgh, PA 15252-8447 YOUR bCCOUNT ERAS BEEN CLOSED- THE ATTACHED CHECK REPf2ESENTS THE FULL VALUE OF YOUR ACCOUNT. " IMPORTANT TAX RETURN DOCtlIt9ENT ATTACHED ^ ...------------------------------------------------~:uu~eii-YOUiii~-mss -~.___.__...--------•--------------------.____~._..___. __ . f : } ,••• "~ sf $:;};v :~.~-___ - __?j~yr _ :}}.~i~~•~>,a:. ~::• f •!: L ice' •. i7 ~v' i. ~; iJY,. k' '~fh __=fv{~. _ -__ ,~tt : :.4•^7:7C _ -,} . _ _ rn-::t~~:t;: {- y~y'.yL.i{-{2:i:~'.:j f.'_~A, ~9•..~. ;~i .:5:•'-. ;..{4'•,:; .• .fit . ~fi: r:-•:..-.`: 0,:;:~~ ':,?`. ~: i,7lj (. ,~: ` 9••:r, • t;,•' • h. ,.t~i.w.. ft}._:t•r: :;}...~ .:::}~.,i'~}{ ?ti$::' ~.t•.tff: ~ ~•^['~~'~•: ••J~7• •:~. .~a:}~• .^• SHAREHOtOER OF TRAfVSAC'TION DATE DESCR~TION MErLFE, INC. 12/182008 SHARES SOLD Cl1SrP ~ tNVESTOrt t0 ACCaUI~rr KEY CHECK NUr~l16B2 ` CFIECK GATE CHECFt ArutBUIVT OOt 92b5®1SBR1D 12a22t9~80?2 l)D1.1000 662756 i 12I19fZ008 $7'14.85 GPENNdf3 TRUST MI~RES7 8ALJINCE SHARESSOLD PRICE PER SHARE {Sl GROSS PROCEEDS Za.0000 23.0000 3t.080400D $714.85 TA7r1ARTHFIE~D METPROCEEr]S I CEOSINGTRUSTMiTERESTt3aLANCE iQ•DO 5714.85 00.0000 PLEASE DETACH BELOW CHECK I~It~I1t8_ ER: 66275b s• ~s i ~• • ~ -1T • r ~~ i~etl". "o r . BO-18D • e CHECK DATE GHECK IdlA1lIBER Q33 ~~~~~~~ ~ - 121191'2008' 662756 P.O.80K 490 9~UTH H/ICKENSACK, NJ 07608-20-I D gAYABLE AT THE BAt~IK OF NEVr/ YO~P.K MELLON IW U.S. DOLLARS 1000i42S 01 M9 0.389 " /tUrQ T7 0 8253 85248-78o t 103 C~Ord000rA101 Ilr.l~.f.I~..1.1.I~rll~.I~I~~~Irllrr,I>,f~><~rll.~.llll~~~~~i1~[ PAY TO THE oROEROF:. • BUDDY L HARTMAN JR 103'F0 E AR~RfJWY.ALE DR - CHANDLEfR AZ .85248-7651 11`OD66 2? 5611' 1':Oti 3 30 ~IbO fie: 0 i ~~~[0 ~D 311° AUTHORIZED SIGr~fATJRE Please Note: Your Sale Proceeds Check is Attached BROKER'S Name, Address, ZIP Code, Federal Identification Number and Telephone Number: Mellon Investor Services 480 Washington Blvd. Jersey City, NJ 07310 22-3367522 Telephone: 1-800-649-3593 TO WHOM PAID Zoos Form 1099-B Substitute COPY B FOR RECIPIENT `"IMPORTANT TAX INFORMATION"' This is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. BUDDY LEE HARTMAN JR EX UW RUBYE M BLOSER 10 WEST HIGH ST CARLISLE PA 17013-2922 Box 1a. -Shows the trade date of the transaction. For aggregate reporting, no entry will be present. Box 1 b. -For broker transactions, may show the CUSIP (Committee on Uniform Security Identification Procedures) number of the item reported. Box 2. -Shows the proceeds from transactions involving stocks, bonds, other debt obligations, commodities, or forward contracts. Losses on forward contracts are shown in parentheses. This box does not include proceeds from regulated futures contracts. Report this amount on Schedule D (Form 1040), Capital Gains and Losses. OMB NO. 1545-0715 Proceeds From Broker and Barter Exchange Transactions Instructions for Recipient Brokers and barter exchanges must report proceeds from transactions to you and to the Internal Revenue Service. This form is used to report these proceeds. .~~ 1a. Date of Sale _ _.------------__--- 1b. CUSIP Number ~~ 08/15/2008 59156R 10 ~~ 2. Stocks, Bonds, etc. 4 FEDERAL INCOME TAX WITHHELD $3,603.23 __ $0.00 ,..~ REPORTED © Gross Proceeds ~~ ~~ TO IRS ~ Gross Proceeds less commission and options premiums ~~~~ 7. Description _ -- --------- --- ------ ~~ METLIFE, INC. ~~~ InvestorlD ~~ Recipients Identification Number on File ~~ 806788668090 205099905 -~ ~^~ Box 4. -Shows backup withholding. Generally, a payer must backup withhold at a 28% rate if you did not furnish your taxpayer identification number to the payer. ~~ See Form W-9, Request for Taxpayer Identification Number and Certification, for ~'~! information on backup withholding. Include this amount on your income tax return as tax withheld. ..~~ Box 7. - Shows a brief description of the item or service for which the proceeds or bartering income is being reported. For regulated futures contracts and forward contracts, "RFC" or other appropriate description may be shown. . .. ::: ::: __ <: or inquiries about your account, contact BNY Mellon Shareowner Services, MetLife's Transfer Agent Telephone: 1-800-649-3593 U.S. Mail: E-Mail: metlife@bnymellon.com MetLife Internet: www.bnymellon.com/shareowner/isd c/o BNY Mellon Shareowner Services PO Box 358447 Pittsburgh, PA 15252-8447 YOUR ACCOUNT HAS BEEN CLOSED. THE ATTACHED CHECK REPRESENTS THE FULL VALUE OF YOUR ACCOUNT. " IMPORTANT TAX RETURN DOCUMENT ATTACHED ^ ----------------------------------------------------------- , .:::::::::.:::.:.:..:,,..,, ............... ORDS . ~® N T ""'~°'a"~+ - PLEASE DETACH BELOW - - - - - - ~,.,~ ~t'til':~~~l~lr.t~' +~ z ~'~'~~°~ ~ - - _ _ _ _ CHECK NUMBER: 589296 ~~.s~.ft~~,Y#.~~,~~ ~d~.' ~~,° m w~ T""` V Y~ ~aE:$% gam-- ~-o- ~,"~~°..,~,~,y.-,.. ~ '' - - - - - - - - • ® ~+' ~°~'` r " ". - Gd ! i a3a.5-no-~..~;~~!i~d.i~6~a~ e „~~e.~..~»p...~.~a~~~.s.D:,.l,usi..:~~..~~ ~` ' ~e c~ ~~-,t,. MetL~fe CHECK DATE CHECK NUMBER 60-160 08/20/2008 433 589296 P.O. BOX 4410 SOUTH HACKENSACK, NJ 07606-2010 PAYABLE AT THE BANK OF NEW YORK MELLON IN U.S. DOLLARS 1002767 01 MB 0.369 ''AUTO T9 0 6166 17013-2922 102 DOM00000101 'IIII~~III~~IIIIIIIIIII~IIIIIIfIl~llll'I~tl'IIIII~~I'11111'Ilf PAY TO THE ORDER OF: BUDDY LEE HARTMAN JR EX UW RUBYE M B L O S E R PAY****'~******"***$3,603.23 10 WEST HIGH ST CARLISLE PA 17013-2922 AUTHORIZED SIGNATURE 11'00 58 9 2 9 611' 1:0 ti 3 30 l 60 11: 0 L 1~tr0 ~0 311' MST B ~1iti~~rst~na~ii~ wa~.i ~p~r~ant" Secured Message Reply From: KRISTY LEHMAN-MARTSON <klehman-martson@mtb.com> To: nathancwolf@embargmail.com Date: August 6, 2008 8:40:06 AM EDT Subject: Fwd: Re: prod -Date of Death Request Kristy Lehman-Martson M&TBank Customer Representative II One West High Street Carlisle PA 17013 (717) 240-4581 (717) 240-4518 FAX »> DATE OF DEATH REQUESTS 8/6/2008 8:31 AM »> To: Kristy, 8/6/2008 Please print a copy for your files. Please find below the date of death balance for: Rubye M Bloser, social security # 205-09-9905 1. Account # 528889, Balance $2,197.01 + accrued interest $ 0.00 = $2,197.01 total Records Management /DOD Unit M&T Bank- "Understanding what's important." »> <klehman-martson@mtb.com> 8/1/2008 4:50 PM »> Account Information Date of death: 06/23/2008 Account Number: 528889 Product Type: Deposit Account Additional Information Name Rubye Bloser SSN 205099905 Request Details Deliver to: Requestor Delivery Options: E-mail Delivery Details: ebrnkjl Reply ©M~TB~ank ACCOUNT Np . ACCOUNT 'H'YPE 528889 CLASSIC CHECKING 00 0 04319M NM 017 LESTER V BLOSER RUBYE M BLOSER 553 N BEDFORD ST CARLISLE PA 17013-1914 STATEMENT PER.IOI~ PAGE JUN.24-JUL.23,2008 1 OF 2 HIGH STREET-CARLISLE ACCOUNT SUMMARY DEGINNING ... D~PQSI:TS: & BALANCE . . .;: QT~iER O'£HET2 `AlOT72T20NS CT~EC~tS >BAID . SUBI~RA . CURRE~'~: r ~NpING.:;: NO. AMOUNT N0. AMOUNT N0, . AMO T TNTERE5 2' BI5 BALAN'CE' 2,197.01 1 250.56 12 2,161.99 2 57.23 0 00 . 228.35 . ACCOUNT ACTIVITY , POSTING ' .:DATE ,, ., DEPO~I'T5', INTEREST C~#ECKS~' & 'OTHER.' . TRANSACTION DESCRI.PTiON >OT'HER AODITTONS + DAII;~C . . . S:UB TR ACTI:ONB. B~1IiAN 06-24-08 BEGINNING BALANCE 06-24-08 DEPOSIT $2,197.01 / 250.56 06-24-08 CHECK NUMBER 9808 / 06-24-08 CHECK NUMBER 9805 800.00 06-24-08 CHECK NUMBER 9803 203.50 06-24-08 Embarq BILL PYMT 000000000009804 114.54 ,~~, ~~-;~~ 06-24-08 CHECK NUMBER 9809 25.46 06-25-08 CHECK NUMBER 9799 6.25 1,297.82 06-25-08 CHECK NUMBER 9806 100.66 , 06-26-08 CHECK NUMBER 9813 86.17 1,110.99 ,f 06-26-08 CHECK NUMBER 9800 126.00 '{ ~~'' ~ 06-26-08 CHECK NUMBER 9810 141.95 `- 06-26-08 Embarq BILL PYMT 000000000009807 139.53 ~ 06-27-08 CHECK NUMBER 9811 31.77 671.74 06-27-08 CHECK NUMBER 9812 106.00 '07-03-08 CHECK NUMBER 9814 50.00 515.74 287.39 228.35 ENDING BALANCE - $228.35 CHECKS 'SAID 3Z3MMAR~ 9799 9805* 06-25 06-24 -08 -08 100.66 9800 06-26-08 141.95 9803* 06-24 -08 9809 06-24 -08 203.50 6 25 9806 06-25-08 86.17 9808* 06-24 -08 114.54 800 00 9812 06-27- 08 . 50.00 9810 9813 06-26-08 06-26-08 139.53 9811 06-27- 08 . 106.00 126.00 9814 07-03- 08 287.39 21802 FINAL SETTLEMEN T SELLER =~ NAME ~ ~-~ ~~ ~ . ~ •~ ~ ~, 1 S DATE OF SALE ';~ i t._._ < i `, f; -. ADDRESS - . ; ~ , '~ ,'~_ x ~, , ; ~, _ F ` PHONE r....- ~.-.. ~._. ., . . ... .. _ ,~. _ _.._-;~ -•- ._. ZIP LOCATION OF SALE -_ -='~~~ . ~ ~ ••, ~ ~- AUCTIONEER f~ ~ ,, ~.~.. ~-- ,~,', .~ ,~ ~ a ~; .~-, _, SELLER'S EXPENSES PROFESSIONAL FEES '~ ~ ~ AUCTIONEER CLERK CASHIER •~ $ ~'~`:~" OTHER EXPENSES n ! t ~~ PHONE ~~ -~~ :~~ ~; ~ ~ ~~ ;~, ~ECEIFTS ,.r_...- Tom, ~'C~ ,~"' '~..~,~ ! - h,, C=.N:E-CAS $ OTHER RECEIPTS $ l -3 $ $ $ ~ r . ~ ~~ $ $ $ $ $ $ $ $ TOTAL RECEIPTS $ ~~ b? . ~; ,~° $ LESS TOTAL EXPENSES TOTAL EXPENSES $ ~' 1. ~ NET PROCEEDS PAYABLE TO SELLER $ ~ ~,~,~`~ I (or we), the seller, accept this settlement and acknowledge receipt of the above s ecified from the auction of my goods and property sold on the above date. I accept all responsibility fort Povideds merchantable title to all goods, and property sold, and for delivery of title to the purchaser. p g _ .._ _ <~ ,. - ~ - _ fem. ~ ---. .r' ~`-' ~,i ~~,d • Auctioneer or cashier's Signature ._ ~ ~~~~ .~ ~ M , '~-~....+.~ Date ,~ ~~ '~~'x~~ t ~ _ ~"~` (Seller s Signature) <:,C . ~:_. + (~"; '~:' Date ~` (Seller's Signature) Date Ewing Brothers Funeral Home, Inc. 630 South Hanover Street Carlisle, PA 17013- (717)243 -2421 September 5, 2008 Buddy L. Hartman; Jr. 10310 East Arrowvale Drive Chandler, AZ 85248 The Funeral Service for Rubye M. Bloser We sincerely appreciate the confidence you have placed in us and will continue to assist you in every Way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEM)/NT OF THL- SERVICES, FACILIT[ES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff , _ _ _ $395.00 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home, _ _ $530.00 FUNERAL HOME SERVICE CHARGES S925.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $925.00 Cash Advances Certified Copies of the Death Certificate , _ _ $30.00 2 Days Refrigeration , _ _ $90.00 Sentinel Obituary , $96.20 TOTAL CASH ADVANCES AND SPECIAL CHARGES . 5216.20 Total Total Cost $1141.20 SUB-TOTAL $ l l 4 i .20 INITIAL PAYMENT/DISCOUNT! CREDITS 100.00 TOTAL AMOUNT DUE $1041.20 The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum. r -- r ._ r /A //~~ e / 'O~ /~ j~d EsSLEfrzLiL suay~oug ~utm~ dtro =fro eo so das RETAIN THIS PORTION FOR YOUR RECORDS THE SENTINEL - LEGAL B P.O. BOX 130, CARLISLE, PA 17013 AD NUMBER CLASS 361731 10 PUBLIC NOTICES AD DESCRIPTION EXECUTOR'S NOTICE LETTERS TESTAMEN 3 THE SENTINEL - LEGAL TOTAL AD CHARGE WOLF & WOLF ATTORNEYS kamok01/05/09 12/20/08 'IONS RATE NET AMOUNT 3 LGL 159.60 159.60 3 PROOF OF PUBLICATION DAYS RUN O1PRF ~ 7.00 PURCHASE ORDER PAY THIS AMOUNT 166.60 Rubye Minerva Bloser MESSAGE: Thank you for advertising with The Sentinel. 40 * 2 01/03/09 GROSS AMOUNT 199.92* Deadlines for in-column legal advertisements: Monday is Thursday at 5 p•m; yuesday is Friday at 5 p.m.; Wednesday is Monday at 5 p.m; Thursda is Tuesday at 5 p.m; Friday is Wednesday at 5 p.m ;.Saturday is Wednesday at 12 Noon; Sunday is Wednesday at 5 p.m. If you have any questions regarding your Legal bill please call Classified Manager at 717-240-7176 Fax your legals to 717-243-3754 attention Classified Manager You can also.. EMAIL your legal to Classified ads: classified@cumberlink.com Please send a cover letter including your name and address as an attachment 1~ ~ " V ~ ~~~ ~~f i ~ CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2663 December 12, 2008 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official le al publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Nathan C. Wolf, Esquire Rubye Minerva Bloser Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: November 28, December 5, and December 12, 2008 Payment received by Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 +~ r ~~ `a .r~ 1, , ~ ,; f S ~f a~ 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 August 14, 2008 WOLF & WOLF NATHAN C WOLF ESQUIRE ATTORNEYS AT LAW 10 WEST HIGH STREET CARLISLE PA 17013 Re: RUBYE BLOSER CIS #: 550178223 SSN: 205-09-9905 Date of Death: 6/23/2008 Dear Attorney Wolf: Please be advised that the Department of Public Welfare maintains a claim in the amount of $86,808.40 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $16,673.40, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $70,135.00, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, ~~ ~ Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure x =___ 6AS SERY/CE Billing Summary for Service to: LESTER V BLOSER 553 N BEDFORD ST CARLISLE PA 17013 Past Bill Information -UGI Utility The account balance on your last hill was ................ $ 149.00 Thank you for your payment of ..................................... -149.00 Adjustments ....................................... 287.39 ............................... Your balance as of 06/25/2008 (due now) ............... 138.39 ':::~. 215 773 8095 03 Rate Classification: Residential Heating Billing Period: n 05/22/2008 to 05/22/2008 (0 days) v Questions? Current Bill Information -UGI Utility Call 1-600-276-2722 or write to UGI at See Messages Below PO BOX 13009 UGI Utility charges owed this bill ......... ................................................................... eading, PA 19612-3009 Total Amount Due, Please Pay by Due Date (06/18/20 CPT 215 773 8095 03 1 """"""""""""'°°•°°•° ~287.3F 287.3.E Meter Reading Information 8.3( Meter Number Previous Reading Present Reading CCF Used 7.4~ 1300726 6625 (remote) 8625 6.64 0 5.81 Messages from UGI 4.98 4.15 3.32 2.49 1.66 0.83 0.00 • =Estimated Usage Last This Average Year Year CCF/day 1.14 2.31 Daily temperature 61°F 56°F 0001376 ^Your current price to compare is $ 1.24950 /CCF. ^Your total annual usage is 1,169 CCF. Your average monthly usage is 97 CCF. ^Your annual budget year began with September 2007. To date you have been billed $ 1,688.39 To date you have used $ 1,688.39 'The final reading on the meter equaled the meter reading on your last bill. No final bill will be issued. Balances, if any, are shown on this statement 'Thank you for your business. You have maintained an excellent payment history with UGI. This bill may be used as a credit reference for obtaining future utility service. ^ Help prevent pipeline damage, accidents and service disruptions. Call 811 before you dig. If you pay at a payment agent please take your entire bill. Make check payable to UGI. Keep this part for your records. Important information is on the back of this bill. MJJASONDJFMAM 2007 Months 2008 PPL Electric Utilities Electric Service For: LESTER V BL05ER 553 N BEDFORD ST CARLISLE PA 17013 Questions about this bill? Please contact us by Jul 7 at 1-800-342-5775 (1,800-DIAL-PPL) or write to: Customer Service 1 ~ `, 0 ~ ® ~, P ~ ~ ~~SB ®~ ~®a'~y M y ~gm_ ~~. ~~~_ ~~h~ pp ~ . ~ ~ TM Summary Page Balance as of Jun 16, 2008 Page 1 $0.00 Char es: Tota~PL ELECTRIC UTILITIES Charges $86.17 Total Charges $86.17 ....:. ~; ~~ia~~i~.#,~.~~1t~r. ~# psi: ~,: ~t~f~: _ Account Balance $86.17 .~ 4 tJl _ 1~ 827 Hausman Rd. Allentown, PA 18104-9392 www.pplelectric.com Electric KWH - Avera a g Per Day Meter Reading .Information ITSe 4s Meter #48503089 This graph.shows 40 Jun 16 Actual ~y 15 Actual 33737 { your electric use over the last 13 32 32 Da s KWH Billed 793 months. 24 Average -Jun 2007 2008 Tyy es of Tem erature 70F K P D ~ 67F ~ Meper Readings: 16 er a y 19 25 Actual - Estimated Customer 8 0 Yearly Use: Ju12006 -Jun 2007 Ju12007 -Jun 2008 78930-75009 •. .. :• -. Total Average Use Monthly 6541 545 7268 606 Other important informatioa on back ~ JJA50NDJFMAMJ 2007 Months 2008 EMBARQ ,i~ ~ ~Y ~ ~ t ~ ~, ~ r7 '~ /' 1 ~ ~, ~ _ J Monthly Statement ~~ '~"~ ,,,> ~ June 13, 2008 Page 1 of 4 Account Number 717-249-5361-742 Payment Options & Contact Info Current harges At-~-Glance N Retail Store in Your Area o. CARLISLE EMBARQ Services ~ 346 York Road Total In the Embarq Building ~ Local and Optional Services -Page 3 23.95 Pay Online EMBARQcom/myaccount Pay by Phone 1-877-813-7604 Customer Service 7 -800-829-8009 Repair Service 1-800-788-3600 Internet Address EMBARQ.com/residential Taxes and Surcharges -Page 3 7.82 Total Current Charges s3"#.77 Previous Balance Payments & Adjustments Past Due, Please Pay Now Total Current Charges Total Amount Due 242.09 I -50.92 I 191.17 I 31.77 $222.94 Current Charges Due By: 07/08/08 6 Please Recycle Y9-CF-056253644 1555 Suzy Street Lebanon, PA 17046 RETURN SERVICE REQUESTED ~'~'., g~ r ~~y,~~ ~~ii~~~~~~~~~~~ a ~i~~~~~~~ n ~~~~~~~ n u ~~i~~~~~~~~~ n ~~~~~i~~~ Lester Bloser 553 N. Bedford St. Carlisle, PA 17013-1914 A .REMINDER ABOUT .YOUR SERVICE Dear Lester Bloser, -- - - Comcast~. Date: Account #: Past Due: Total Balance Due: Due Date: June 12, 2008 09547-362811-01 5 $5'1.27 $114.54 June 24, 2008 As of June 12, 2008, our records indicate that your account has a past due balance of $57.27. Your last payment of $114.54 was received on March 21. We understand that in the rush of our daily lives, we sometimes overlook bills. SUSPENSION OF SFR~C c To avoid suspension of your service, interruption fees and a reconnection fee, we must receive payment of the past. due balance by June 24, 2008. If this payment is not received by June 28, 2008, then your total balance of $114.54 must be paid or your service(s) will be suspended. if your account is suspended, your cable channels and intemet will be blocked. Additionally, if you subscribe to Comcast Digital Voice, you will only be able to place calls to 911. TERMINATION OF S RVICE Your account will be terminated soon after your suspension of service. If we do not receive your payment, you will ibse all television and Comcast High Speed Internet services. If you have Comcast Digital Voice, you will lose all telephone services including 911. If payment is collected at the door at the time of termination, a collection fee will be assessed to your account. If you wish to resume service with us after your account is terminated, you will be required to pay the full amount due and will be subject to all installation charges. You may be assigned a new Digital Voice number. PAYA4ENT INFORMATION If you haven't sent your payment, please do so today. Of course, if payment is on the way, please accept our thanks. For your convenience, you may pay by phone using VISA® and other major credit cards. In addition, we also accept electronic check payments. Please contact us at 1-800.COMCAST to make this payment. Electronic check payments could take up to 3 da s to st t Payment Locations Harrisb ~ 4601 Smith Street Harrisburg, PA 17109 Mon. -Fri. 8:00 a.m. - 7:00 p.m. Saturday 8:30 a.m. - 4:00 p.m. Mechanicsbur 4830 Carlisle Pike Hampton Center Suite D 14 Mechanicsburg, PA 17050 Mon. -Fri. 9:30 a.m. - 5:30 p.m. Hershey Seven Briarcrest Square Hershey, PA 17033 Mon. -Fri. 8:30 a.m. - 5:30 p.m. Saturday 9:30 a.m. - 1:00 p.m. Shippensbul~ 339 Baltimore Road Shippensburg, PA 17257 Mon. -Fri. 8:15 a.m. - 6:00 p.m. Saturday 8:15 a.m. -12:00 p.m. y po o your account and may not keep your services from being suspended or terminated. Please visit www.Comcast.com and enroll in Comcast Pay DirectTM with your checking account, VISA®, or other major credit cards. You can also make a payment by using the detachable stub to mail your payment. Unfortunately, we cannot be responsible for payments mailed but not received by the due date. Payments can also be made at any one of our Comcast Payment Locations listed on the front of this notice. Please be advised that making a payment at a non-Comcast payment center may delay in the receipt of your payment and your services may still be suspended. yy Detach Here and Return With Payment Fer Prmm~t Pmr.Pec;no J.~L ,,r---, I ~, ~ :, ; I'; ~. ~ ~~u ,_~r BOROUGH OF CARLISLE P.O. BOX 340 CARLISLE, PA 17013-0340 BUSINESS HOURS 7:30 A.M. TO 4:30 P.M. (MONDAY -FRIDAY) BUSINESS PHONE: 717-249-4422 VISIT OUR WEBSITE www.carlislepa orq UTILITY BILL THIS BILL BECOMES DELINQUENT 45 DAYS FROM THE BILL DATE. A LATE PENALTY OF 1.5% WILL BE ADDED AFTER 45 DAYS AND ADDITIONAL PENALTIES OF 1% WILL BE ADDED EVERY 30 DAYS THEREAFTER. IF PAYMENT HAS NOT BEEN RECEIVED WITHIN 72 DAYS OF THE BILL DATE, YOUR WATER SERVICE WILL BE DISCONTINUED. LocATION: 553 N BEDFORD ST LESTER V BLOSER 553 N BEDFORD ST \ ~ ~~ CARLISLE, PA 17013-1914 ~ \~ ~1 :CODE FROM Tp EVIQUS READING CURRENT READING USAG£ {CCF) CHARG~~ ~ - /~°," T,h,ATER 3 ~, o/ ''00~ ,~~ ~ ~; 02; 2008 1105 1122A 17 X3.85 /8" SEWER 73.10 QUE DATE DUE IMNIr"DIATEE.1l CURF?EN T Gt~ARE~ES TpTAt DUE 0 7 /2 7 /2 0 0 $ . 0 0 141.95 95 141 SEE REVERSE SIDE FOR ADDITIONAL . PAYMENT INFORMATION • ~ ~ ~. ~, SERNVOICE~P / G~LBERT'S 200 S. Spring Garden Street, Suite C professional Carlisle, PA 17013 .pest control, Inc. ,° .. ',. C" f' r , - Previous Balance y . ~ _ - - - . 3 ° `, .~~~ Charge(s): ~ r. a ~,.: 1. , Tax: ,-~~~. ~ rV:,~ Total Due: r~ -~ Carlisle: (717) 249-6667 Carlisle Fax: (717) 249-8493 Mechanicsburg: (717) 697-8815 GENERAL~pEST CONTROL ,~.!• Ants, Centipedes, Millipedes, Roaches, Spiders SPECIFIC.FEST..COI~i'R0~• '' Fleas, Ticks, Ground Beetles, Stored Product Pests, Bedbugs, Other RODENT CONTROL Mice, Rats 'WEED CONTROL Industrial Bare Ground Weeds ORNAMENTAL TREES. & SHRUBS APPLICATIONS Bagworms, Oak Worms, Woolly Adelgid, Gypsy Moths WOOD DESTROYING INSECTS , _-,_ _,;.;,_ ..___, .~ Subterranean Termites,. Powder Pdst Beetles, Wood Borer, & Carpenter Ants BEE CONTROL Carpenter Bees, Bald Faced Hornets, Yellow Jackets, Wasps FALL INVADERS Boxelder Bugs, Lady. Bugs, Stink Bugs OTHER: `` REFER TO THE LIST OF'MATERIALS USED' FOR THE CONTENTS AND CONCENTRATION OF THE TREATMENT AS INDICATED IN THE'TYPE OF SERVICE' . Advion Gel & Maxforce EZ-Bore Archer IGR Gentrol® IGR Baygon® 2% __ In-Tice G - ,Bedlam Merit 2.5G CB-80 Extra"' Onslaught Contrac® Blox Phantom ...__Contrac Paks Precor IGR Cykick Premise®75 D-Foam Rozol Dormant~0il Sahara® DG Evercide Suspend® SC Talstar® EZ Talstar PL Granular TalstarOne""- _ Tempo® Dust Tempo® SC Ultra Tempo® Ultra WSP Termidor SC Transport V Clear-Out Fogger Wasp-Freeze® ;~ Otfier ' ~ ~s• .` {~ ~ q _._ , ,,, . ~ ~ ~ APPLICATION DATE _ TIME IN ;.1 TIME OUT TECHNICIAN ~ PDA LICENSE # . PAYMENT DUE UPON FtECE/PT OF THOS INVOICE RETAIN PINK COPY FOR YOUR FILES; REMIT YELLOW COPY WITH PAYMENT IN THE ENVELOPE PROVIDED