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Home My WebLink About01-29-10 (4) 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes Coun Code Year File Number INHERITANCE TAX RETURN ry Po sox 2sosol Harrisburg, PA 17128-0601 21 09 0430 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 207-07-7858 04/30/2009 07/16/1918 Decedent's Last Name Suffix Decedent's First Name MI Ensminger IV John T (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Ensminger Hilda M Spouse's Social Security Number __ 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 _ 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 Daytime Telephone Number Elizabeth A. Ensminger (412) 243-1428 Firm Name (If Applicable) _ REGISTERWILLS USE Ootdr l It Q ° First line of address , . ~, _,. ~ :T ~ ~-~ ~ ~ ~ ~ ~ ~ -_f.. ~ -.~,. ,., r - 108 Blackhawk Street , - _ ~ r-n n~ ; Second line of address . , -v .r~.l r =' r_, z .-:.-~ ~ :: ~; _. ~ ~J .. , i .. ' ) ~ M s ~ ~-~,~w _' f.~~ City or Post Office - .. }} ra.r t...,.1. State ZIP Code D~T - ILED .. ~_. _.._. ~~ _ . - ; Pittsburgh _ PA 15218 c~ Correspondent's a-mail address: bensminger@verizon.net 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 belie ue, correct and complete. Declaration of preparer other than the personal representative is base, on a~formation of which preparer has any knowledge. SIG1 NATUR~ ~N SPONSIBLE FORS G RET//.1 t/ ~ D ~//t'~G~~~/ i~l. ~~~`~G6~~ DATE/Z~ ~D~~ 108 Blackhawk St, Pittsbl(ug~l', PA 15218 3557 Elmerton Ave, Harrisburg, PA 17109 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: ~Ohn T Ensminger ' 207-07-7858 RECAPITULATION 1. Real estate (Schedule A) . ............................................ 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 752,707.74 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 178,785.00 6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... _ __ 8. 931,492.74 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 5,400.99 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. 389.90 11. Total Deductions (total Lines 9 & 10) ................................... 11. 5,790.89 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 925,710.85 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 925,710.85 ~.. .M..~,.... , ......_ .., .. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ..... ... ....... .. ..r._..., ,.....r~_....... ...,. .._~.~...w, 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 2,510.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 923,200.85 ' 16, 41,544.04 17. Amount of Line 14 taxable at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate X .15 1 g, 19. TAX DUE ......................................................... 19.' 41,544.04 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0430 DECEDENT'S NAME DECEDENTS SOCIAL SECURITY NUMBER John T Ensminger 207-07-7858 STREET ADDRESS 824 Lisburn Road Apt. 308 CITY --_- - -- - - - STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 41,544.04 2. CreditslPayments A. Spousal Poverty Credit _ _ ___ ____ ___ ___ B. Prior Payments 37,000.00 _ _ ---- C. Discount - _ _ _ ___ 1,947.31 Total Credits A + B + C ( ) 2 O 38, 947.31 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2,596.73 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 2,596.73 Make Check Payable fo: 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 :.......................................................................................... ^ Q 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? .............. ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^ ^x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 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-1503 EX+ (6-98) Y COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER John T. Ensminger IV 21-09-0430 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) s COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER John T. Ensminger IV 21-09-0430 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. (If more space is needed, insert additional sheets of the same size) REV-1737-6 EX + (6-08) REVERSE ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS Use Schedule H ONLY for proportionate method of tax computation. ESTATE OF FILE NUMBER John T. Ensminger IV 21-09-0430 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~~ Auer Cremation Services -cremation, urn, obituary, death certificates 2,395.97 2. Pastor, memorial service 100.00 3. Catering, memorial service 480.18 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commission(s) Name(s) of Personal Representative(s) __ ---_ _ _ __ (Submit requested information for additional personal representative's on additional sheets) Social Security Number(s) or EIN Number(s) of Personal Representative(s) Street Address(es) City(ies) State(s) ZIP(s) Year(s) Commission Paid 2• Attorney Fees 3• Probate Fees 715.00 4• Accountant's Fees 5• Tax Return Preparer's Fees 6• Miscellaneous Expenses Reimbursement for opening estate account 500.00 Advertising of estate 220.06 Broker's commission and fees 989.78 TOTAL (Also enter on Line 9, Recapitulation.) I $ 5,400.99 (If more space is needed, use additional sheets of paper of the same size) REV-1737-7 EX + (6-OS) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT Use Schedule I, Part 2, ONLY for i proportionate method of tax computation. MORT6A6E LIABILITIES, & LIENS ESTATE OF FILE NUMBER John T. Ensminger IV 21-09-0430 Part 1 must include mortgage liabilities, liens and taxes against the Pennsylvania realty that were due and owed as of the date of decedent's death. Complete Part 2 ONLY when the proportionate method of tax computation is elected. •S ~ • ITEM NUMBER DESCRIPTION AMOUNT 1. TOTAL PART 1 $ 0.01 ITEM NUMBER DESCRIPTION AMOUNT ~ ~ Bank of America credit card 331.90 2. East Pennsboro Ambulance Service 46.00 3. Healthsouth Rehab Hospital (television charges) 12.00 TOTAL PART Z $ 389.90 TOTAL (Also enter on Line 10, Recapitulation.) $ 389.90 fir more space is neeaea, use aaaitional sheets of paper of the same size) REV 1737-7 EX + (6-08) REVERSE ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCNEDVLE J BENEFICIARIES ESTATE OF FILE NUMBER John T. Ensminger IV 21-09-0430 When flat rate method is elected, list the beneficiaries of the Pennsylvania property. When proportionate method is elected, .list all beneficiaries. ITEM NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. 2116 (a)(1.2)] 1. Martha Jane Diehm, 9912 E. Boulder Dr, Mesa, AZ Daughter 184,640.17 2~ John S. Ensminger, 415 Bernheisel Bridge Rd, Carlisle, PA Son 184,640.17 3. Robert A. Ensminger, 3557 Etmerton Ave, Harrisburg, PA Son 184,640.17 4. Elizabeth A. Ensminger, 108 Blackhawk St, Pittsburgh, PA Daughter 184,640.17 5. Diane L. Ensminger, 411 Michael Drive, Murphy, TX Daughter 184,640.17 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON REV-1737 COVER SHEET OR THE PROPORTIONATE METHOD WORKSHEET ON THE REVERSE SIDE OF REV-1737 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE - 1. Hilda M. Ensminger, 9912 E. Boulder Dr, Mesa, AZ 2,510.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II I (Enter total non-taxable distributions on Line 13 of REV-1737 cover sheet) $925,710.85 (If more space is needed, use additional sheets of paper of the same size) ~~~~ ~s ~5~~~~~~ I, John T . Ensminger, of the `Township of Hampden, Co~anty of Cumberland, ar~d Commonwealth of Pennsylvania, hereby declare the following to bz my Last Will and Testament. FIRST: T revoke all previous wills and codicils. SEC431D: i direct that the expenses of my last ilir.ess an^! funeral be paid out of my estate as soon as practicable after my ~~~ death. THIRV: T d.ire~~t that my Executor pay ou.t of my zesidi~a:r_~;~ estate without apport.~.or_ment, all estate, inheritance ar~d li,~~e ~~ taxes in~p~~sed by the governr.-en.t of ~tr~.e United ~'ta*es, or. ar:v '7 state or territory trrereof, .;;r by any foreign go~,~ernrr~ent or political subdivision thereof, ~n r.espect to all property ~.. ~~--~ ~ required to be included in my gross estate for estate, `.~ ~ ~~ inheritance or like tax purpose by any of such governments, whether the property passes under this will or otherwise, T,as_thout. contribution by any recipient of any such .property.. FOURTH: I give all of my personal property, including household furnitsre, furnishings, books, pictures, jewelry, silverware and all other :item: of pe.rsor?al. or household use to my wife, Hilda NI. En.sr^~inuer, if she- shall survi_~;e me for a period cf not less than. thirty (30 j ,days, =i rrt,~l~:e no other provision for .my J wife in this will, having previously made other arrangements for her. FIFTH: In the event that my wife, Hilda M. Ensminger, should predecease me or fail to survive me for a period of thirty (30) days, then I give all the rest, residue and remainder of my estate to my children, Martha Jane Diehm, John S. Ensminger, Robert A. Ensminger, Elizabeth A. Ensminger and Diane L. Ensminger, to be divided equally among them if they shall survive me. If any such child of mine has predeceased me, such child's issue shall take per stirpes the share of my estate to which the ~'~ child so dying would have been entitled, if living, with the ..~ ,~-,~ following exception: should my daughter Martha Jane Diehm fail fi ~;~ to survive me._, her issue shall be deemed to exclude Heather Diehm and Paula Diehm, my express intention being to disinherit said ~-. . grandchildren. ~- ,, '~;:;`,:~v SIXTH: If any income or principal shall be payable to any ~. _ ~' ~pe.rson who shall be a minor or who shall be incapacitated for any reason, my Executor as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support, and education of such person during minority or incapacity, without the appointment of any guardian or committee or any authority of court, and shall be entitled to make direct application hereunder or to make application by payment thereof to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Gifts to Minors Act or the Pennsylvania Uniform 2 Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be paid and distributed to such person upon the termination. of minority or incapacity. SEVENTH: I appoint Robert A. Ensminger and Elizabeth A. ~~1~ti ~' _.. Ensminger as co-Executors of my will. If .either one of them is unable or unwilling to act or continue to serve in that capacity, then I appoint either one of them to serve as sole Executor of this will. My Executor hereunder shall not be required to post bond or to enter security in any jurisdiction. IN WITNESS WHEREOF, I, John T. Ensminger, subscribe my name this day of ~~~"~ 19~. ' ~ ,r THE FOREGOING INSTRUMENT, consisting of this and two (2) other typewritten pages, was signed, published and declared by John T. Ensminger, the Testator, to be his Last Will and Testament,. in our presence and we, at his request, and in his presence, and in the presence of each other, have hereunto subscribed our names as witnesses this _~~- day of ~~ 19 ~~ Name ~ ~, ~G~' *~' Address ®.~ ~f,~.1' 3 Name ~ ~y~,~~ Address ~!Z! DQ.Qs ~~~,~ `~~ ~ Kr~_C_FhX~N 1LS"~u~Ei P~ ! ~5 AFFIDAVIT COMMONWEALTH OF PENNfSYLVANIA ) COUNTY OF ~ ~ ~ ~ -~Y" ` a. ~~~ j s s . We, John T . Ensminger, / ,~ ~~~ the -~ ~ Testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and that he had signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed, and that each ~ of the witnesses, in the presence and hearing of the Testator, signed the will as a witness and that to the best of his or her knowledge the Testator was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ~ /,~ / r ~~ ~ , ,~ r J hn T. Ensminger ,..•\, Subscribed, sworn to and acknowledged before me by John T. Ensminger, the Testator, and subscribed and sworn to before me by witnesses, this 22 day of ~,.,vti , 19 ~~. ,~ Notary Publi HOt~a~ suet Hast=.~o~ T~ ~:,, C:um~~t~ir-~f C.OU~ty ~•~ Ccrr.-~T;G~.,;~~ ,:xplras Fsb. 4.2002 4 Mertoer, P+~-utytvania A;sOC:a'~n of+v~tarie~ Jeffrey L. Hoachlander, AAMS® Financial Advisor 4227 Elmerton Avenue Harrisburg, PA 17109 Bus. 717-541-5474 www.edwardjones.com Edward Jones MAKING SENSE OF INVESTING January 19, 2010 John Ensminger Est. c% Robert Ensminger 3557 Elmerton Ave. Harrisburg, PA 17109-1132 Dear Robert & Betsy: Per your request, I am writing to provide valuation for the following securities belonging to John T Ensminger, now deceased. Qty Description Cusip or Symbol Value per Item Total Value 6,800 Nuveen Municipal NUV $9.17 $62,356.00 Value Fund Stock 1,654 Van Kampen PA VPV $11.11 $18,375.94 Value Muni Income Tr Qty Description Maturity Rate Total Value Accr Int Date (*muni) 85,000 Philadelphia Pennsylvania 06/15/32 5.00% $72.295.90 $1593.75* Airport Muni-Bond 60,000 Bank of America Internote 07/15/27 6.65% $60,000.00 $1163.75 125,000 General Electric Capital 02/15/34 5.75% $125,000.00 $1497.40 Corp Internote 400,000 General Motors Acceptance 06/15/17 6.95% $400,000.00 $10425.00 Corp Smartnote The values listed are as of April 30, 2009, the day that John T Ensminger passed away. The values were obtained from an outside historical pricing service, and while we believe that they are reliable, we do not guarantee their accuracy. Please let us know if you need any other information or assistance. Best regards, Kim Garcia Branch Office Administrator __ Penns fvania State Bank New CDItRA Accounf Checksheet Date & Time Open: .200510:00 Add to Product Plan? NO Account # First Name: JOHN T. NSMINGER TIN1: 207-07-7858 DOB1: 07-16-1918 Second Name: TIN2: DOB2: Third Name: TtN3: D063: Address: 824 LIBSURN ROAD APT. 604 No. Yrs. CAMP HILL PA 17011 Home Phone: 717.763-9779 Employer 1: No.Yrs. Work Phone 1: Em io er 2: No.Yrs. Work Phone 2: Additional Details: Account type: 80-Nlonth Aia Carte Certificate of Deposit - [280] Automatic-Renewable Account #: Interest Distribution: [Tc-001] Interest Added Monthly To Checking Account # 10117018 Opening Amount: X100,000.00 interest Rate: 4.88% Product Pfan Interest Rate: Date of CD: 8/412005 Annual Percentage Yield: 5.00% Product Plan Annual Percentage Yield: Maturi Date: 8/4/2010 IRA Type: Bonus Interest: Renewal?: NO New Account #'?: YES Offtcer Approval: Request for Certification of Taxpayer Identification Number: Under penalties of perjury, 1 certify that: 1. The number shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a} I am exempt from backup withholding, or (b) I have not been noted by the Intemal Revenue Service (IRS) that 1 am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. person (including a U.S. resident alien). Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. The Intemal Revenue Service does not require your consent to any provision of this document other than the cert~cations required to avoid backup withholding. ACKNOWLEDGEMENT: I/VVe authorize the Bank to make whatever credit inquiries it deems necessary in connection with establishing and maintaining accounts and services with the Bank in the course of review for collection or any deficiency which 1/We would create in my/our account(s). I/1Ne authorize and instruct any person or consumer reporting agency to compile and furnish to the Bank any information it may have or obtain in response to such credit inquiries and agree that same shall remain your property whether or not the account(s) are established. All information set forth in this signature card is declared to be a true representation of facts made for the purpose of establishing the account(s) and services requested. The undersigned agrees to the terms stated in the Terms and Conditions on f7eposit Accounts disclosure and acknowledges the following information has been explained to me and a copy given to me for my records; fee schedule, account disclosure statement, W-9 information, signature information for joint accounts (if applicable), telephone transfer information (if applicable). ,, .-.' ., ) f k I /~ f Si ature `e Sggnature Date J; ;` , t Si nature Date Waive Reason: New/Existing? EXISTING 10117018 New/Existing? Pnmary lD Joint ID: Primary 2nd ID Joint 2nd ID: Branch# 001-Camp Hill Officer: CRS Emp #: 21i843 ''yy Public Funds: NO On Line? NO Non Prof? NO Personal? PERSC?NAL N~~t~~1~ PaState304 3.04 Page: 1 Document Name; untitled DDMAIN Time Deposit Display Main 6017 ACCt 1055545394 Alpha key ENSMIJT.02 Product T614 -----------Balances------------ Face amount 75,000.00 Branch Compound value 76,624,26 Officer 00105 Issued 003 Maturity Opened Last int Next int 06/08/09 ACTIV. -----Dates_____________ 11/24/200 11/24/200' 11/24/200; payment 05/31/200' payment 06/30/200' AVAILABLE BAL 76,624.26 Last activity 11/24/200; Initial deposit 75,000.00 Last principal change 00/00/000 Recalc effective date 05/31/200' - - - - -Interest Information- - - - - - Rate (RR ) 4.1600 Accrued int 78.63 Int adjustment 0.00 Account Type Last int paid 270.24 TIME ACCOUNT Total penalty 0.00 _ TDDINT TDDMISC _ TDDHIST _ TDDHISTMONE' COMMAND = _ _ > F2=Retrieve F3=Exit F4=CRFwindow Sov~~~,~ ~uK ~~ ~ 75~~ V~L~~ ~N 6I ~ l.~~S ~C~2~~~ ~n~t' 1n,.~- rotZ ~~~ j~A~vE ~F'3QI2°o~ ~6,Gz`~ 2l 7N.~3 7~e~- 2~~- Z~ ~-- 7~, 295.3"7 F6=Toggle Prepared for. JOHN T ENSMlNGER Account Numbei;• 54~ 83001288 4731 °' b ~ .a.y . i Forlrtformetion on YourAccouni Visit: ~ i Summa of Transactions Billin C l d ; www.bankofamerica.com ll l Prevwus Balance g yc e an Payment Information to i .Ca l-free 1-800-626-2556 Payments and Credits $197.03 $197A3 Days m Billing Cycle Cl i 31 ~ TDD hearing-impaired 1-800-346-3178 ' M ilP Purchases and Adjustments + $331.90 os ng Date 05/26/09 ~ eyrnentsto: I BANK OF AMERICA ~ Periodic Rate Finance Charges + $0.00 Payment Due Date 06/15/09 I P.O. BOX 1509 i Transaction Fee Finance Charges + $0,00 I -Current Payment Due $15 ~ !WILMINGTON, DE 19886-5019 New Balance Total $331 90 Past Due Amount 1 • , + $0.00 Mail Billing Inquiries to: BANK OF AMERICA . Total Mrnrmum Payment Duo ` ~~ g`~ ~ P.O. BOX 15026 'WILMINGTON, DE 19850-5026 y:.., ;. Credits WorldPonts ~w~ May 2009 Statement /~~ Credit Line: ~y9,ppp.pp Cash or Credit Available• Promotional .Offer ID ----- - osting Transaction Reference. Account Date Date Number Number Amour 05/15 5049 1.97:03 - I HAN K YOU Purchases and Adjustments GIANT FOOD #253 NEW CUMBERLANPA GIANT FOOD #253 NEW CUMBERLANPA WEIS MARKETS #133 SHD WILLOW ST PA WEIS MARKETS #133 SHD WILLOW ST PA WETS MARKETS #125 SHD CAMP HILL PA 331 MONTHLY EARNINGS 0 .BONUS POINTS THIS MONTH 5-; 54-6 ...-f~O~I~'1'S -`4G~iT1:.Al~LE - -- .: _ ... ........ .:... . ... . . .. -._ .. ,,:~:° ~~ s 04/27 04/25 4244 4731 90 89 04/28 04/27 4300 4731 . 36 26 04/30 04/28 9986 4731 . 112.48 05/01 04/29 9648 4731 58 00. 05/01,.. 04/29 3496 4731- . 34.27 WORLDPOINTS Promotional Category Transaction T Ypes Daily Periodic Rate B Corres o g P ndin Annual Aercentage Rat APR T Balance Sub/ect to alance Transfers e ype Finance Charge Offer GKKD-XWW2P 0.027123% BT, CB, DB 0.005452% Offer GKKD-XWW2Q 9.90% 1.99% S P ~,~ $0 00 BT, CB, DB 0.002712% Cash Advances 0•~9o P . $0. 00 Purchases 0.068466% 0 027123% 24.99.% S , ~.~ . Mnuai Percentage Rate for this Billin Period 9.90% S $0.00 g : (Includes Periodic Rate Finance Charges and Transaction Fee Finance Charges that results in an the Corresponding APR above ) APR which exceeds See Corresponding . Annual. Percentage APR T Rate Above ype Dennitions: Promotional Transaction Types: BT .Balance Transfer, CB =Check treated as Balance Transfer, DB =Direct De Transfer, APR Type: S= Standard APR (APR nonnalty in effect) posrt treated as Balance P_ Promotional APR P , (A R for limited ti me on eligible transactions) East Pennsboro Ambulance Service, Inc. Post Office Box 47 Enola, PA 17025 (717) 732-5552 FAX (717) 728-9501 Federal Tax Number 23-2464545 BILL TO Ensminger,John 824 Lisburn Road Apt # 308 Camp Hil1,PA 17011 PATIENT NAME ADDRESS: ADDRESS: PICK UP: TAKEN TO: DESCRIPTION: Invoice DATE INVOICE # 4/16/2009 09-772 John Ensminger 824 Lisburn Road Apt # 308 Camp Hi11,PA 17011 Hamsburg Hospital Health South Rehab Wheelchair TRIP NUMBER 09-19022 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 4/15/2009 Van Rate 1 Way (Non-Member) - A0130 46.00 46.00 For your convenience, we now accept Mastercard, Visa and Discover. Card Type: Name on card• Credit Card Number Ezpiration•_ / _ Amount to be charged: $ I agree to pay the above total amount according to card issuer agreement. TOTAL DUE Signature: Comments: Your payment is due upon receipt. Medicare and most insurances do not cover this service. If you need to check with your insurance company, please ask if your plan covers transportation code A0130. ~t~6 ~~ Please Note: Unpaid accounts may be sent to a collection agency after 90 days. • HEAL THSO UTH Rehabilitation Hospital ~f Mechanicsburg 175 Lancaster Blvd. Mechanicsburg, PA 17055 (717) 691-3700 BILLING DATE: April 30, 2009 PATIENT NAME: John T. Ensminger PATIENT NUMBER: 735504 BILL TO: John T. Ensminger 824 Lisburn Road, Apt 3 Camp Hill, PA 17011 DESCRIPTIQN AM~t3~IT TELEVISION: ($1.00 PER DAY) DATE: TV Service from 04/16/2009 - 04/27/2009 $ 12.00 PAST DUE AMOUNT: $ DATE: DATE: $ PREVIOUS PAYMENTS RECEIVED: TOTAL: (PLEASE': PAY THIS A~lf~UNT) ~ ~`~~O (For proper credit, please return the bottom portion with your remittance) PATIENT NAME: John T. Ensminger PATIENT NUMBER: 735504 MAKE CHECK PAYBLE TO: HEALTHSOUTH **VISA/MASTERCARD ACCEPTED RETURN THIS PORTION WITH PAYMENT TO: HEALTHSOUTH Rehabilitation Hospital of Mechanicsburg 175 Lancaster Blvd. Mechanicsburg, PA 17055 (717) 691-3700 COMPLETED BY: vcl, TV BILL