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HomeMy WebLinkAbout12-10-09 (3)1505607121 REV-1500 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 Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 9 0 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 8 0 0 9 4 2 1 4 0 9 1 1 2 0 0 9 0 6 3 0 1 9 1 5 Decedent's Last Name Suffix Decedent's First Name MI F U L T O N M A R Y F (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 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 0 1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Retum (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ prior to 12-13-82) 5. Federal Estate Tax Retum Required © 6. Decedent Died Testate (Attach Copy of Will) ~ death after 12-12-82) 7. Decedent Maintained a Living Trust Att h C 8. Total Number of Safe Deposit Boxes 9 Liti ation Pro d R i d ( ac opy of Trust) . g cee s ece ve ~ 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 R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3 Firm Name (If Applicable) 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 REGISTER OF WILLS U~ONLY 'r.='w` ~ v.^". .~........ ..~ -. ~ d T ~.a ' ~~ f ' ~ cf~ ~ c0 ~ :- 4._~ ~ -~ .. _.. `~ t ~ t ~ ZIP Code L 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 knowledge. ~i~rvA i urct ~r NtRSON RESPONSIBLE FOR F~~~"/ RN DATE ADDRESS /G y ~ 911 W SOU~TgH STREET CARLISLE PA ],7013 SIGNATURE OF P~R;~~~Af~R OTHERN REP SENTATIVE DA~T~E ADDRESS r ~ ~,L-L~ ~~ 60 WEST POMFRE STREET L 1505607121 PLEASE USE ORIGINAL FORM ONLY Side 1 RLISLE t'~-" ' PA 17013 1505607121 J r '[22L.095054 'C22L095U54 Z aP!S 1N3WAb~d213A0 Nb~ ~O aNf1~321 d JNIlS3f1D3213a~d f1OJl ~I ~VAO 3H1 NI '1~1~ 'OZ 66 ................................................ ana xel•66 h 6 ''C 0 2 2 h 6' '[ 0 2 2 8 6 g ~' X a}e~ lea}epoo }e 6 2 9 h E Z algexe} {, ~ aul~ ~o }unowb •g ~ 0 0' 0 L 6 Z 6' X a}e~ 6ullgls }e 0 0' 0 algexe} ~, ~ aul~ ~o }unowy •~ ~ 0 0' 0 g 6 . 0• X a}e~ leaull }e 0 0 0 algexe; b 6 aul-l }o }unowy •g ~ 0 0' 0 'S ~ 0 0. 0 0' x (z' 6)(e) g ~ 66 •oag ~apun s~a~sue~} ~o 'a}ea xe} lesnods ay} }e algexe; ~,~ aul-i ~o }unowy 'g6 S311~2! 3~9V~IlddV 210 SNOI1~fRI1SN133S - NOI1V1(1dW0~ X~dl .~~ .................. 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(~-6 saul-l le}o}) s;assd sso~O le}ul '8 •~ • • • • • • • pa}sanba~ 6u!II!8 a}e~edaS n (O alnpayoS) 2 6 ' S E Z 6 ~ snoaue aosl spa sues song as}ul 'L I(}iadad a}egad- N II W '8 } 1 n- •g • • • • • • ~ pa}sanba~ 6ulll!8 a}e~edag ~ (~ alnpayoS) ~adad paunnp ~l}ulo~ •g 2 E ' 0 Q 6 h .5 ~ • • • • ~ • (3 alnpayoS) ~adad leuos~ad snoauellaoslW'8 s}lsodaa ~lue8 'yse~ .5 .~ ........................ (a alnpayoS) algenlaoaa sa}oN'8 sa6e6}~oW .b '£ ' ' ' ' ' (O alnpayoS) dlys~o}al~dad-agog ~o dlys~au}~ed `uol}e~od~o0 plaH ~(lasol0 'E ,Z .................................. (8 alnpayoS) spuo8 pue s~loo}S 'Z 6 ........................................ (d alnpayoS) a}e}sa lead • 6 NOllf/lfllldH~321 N ~ .L 1 f l~ ~~ Jl ~ d W :auaeN s,luapa~ad h 'C 2 h 6 0 0~ 'C aagwnN it}unoaS leloog s,}uapaoaa X3 005 6-n32i '[22L09505'C ^ REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0901 DECEDENT'S NAME MARY F. FULTON STREET ADDRESS 770 S. HANOVER STREET CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: 1 • Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 55.10 3. Interest/Penalty if applicable D. Interest E. Penalty (1) 1,101.94 Total Credits (A + B + C) (2) 55.10 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 +5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 0.00 (5) 1,046.84 (5A) (56) 1,046.84 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? ....................................................................................... ^ Q 3. Did decedent own an "intrust 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? .................................................................................................. 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)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 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)J. (4) 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 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-a 508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESIIDENT DE EDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER MARY F. FULTON 21 09 0901 Include the proceeds of litigation and the date the proceeds were nceived 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. CASH ON HAND 45.00 2. ~PNC BANK -CHECKING ACCOUNT #5140184342 ~ 4,935.32 TOTAL (Also enter on line 5, Recapitulation) I $ 4,980.32 (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 MARY F. FULTON 21 09 0901 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. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER ATTACHACOPrOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IFAPPLICaeLE) TAXABLE VALUE 1. ALLSTATE LIFE INSURANCE COMPANY 9,735.91 100. 9,735.91 ANNUITY -CONTRACT NO: GA0682727 BENEFICIARY: HAROLD CLIPPINGER TOTAL (Also enter on line 7 Recapitulation) I $ 9,735.91 (If more space is needed, insert additional sheets of the same size) REV-1311 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY F. FULTON 21 09 0901 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. EWING BROTHERS FUNERAL HOME 419.16 B. 1. 2. 3. 4. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Year(s) Commission Paid: Attorney Fees IRWIN & McKNIGHT, P.C. Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees REGISTER OF WILLS 5 Accountants Fees 6. Tax Return Preparer's Fees PATRICIA A. ROSENDALE, CPA 7. REGISTER OF WILLS -FILING FEE SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Zip Zip 750.00 69.00 350.00 30.00 TOTAL (Also enter on line 9, Recapitulation) I $ 1,618.16 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER MARY F. FULTON 21 09 0901 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. (SPECIAL EVENT EMERGENCY MEDICAL SERVICES -AMBULANCE I 45.12 2. MILLENNIUM PHARMACY SYSTEMS, INC. -MEDICAL 151.67 3. CHAPEL POINTE -NURSING 5,554.99 TOTAL (Also enter on line 10, Recapitulation) I $ 5,751.78 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00) _ ~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY F. FULTON 21 09 0901 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. JAMES R. FULTON Collateral 7,346.29 911 W. SOUTH STREET 1/2 REMAINDER CARLISLE PA 17013 2. ELIZABETH M. CUTTER Collateral 209 N. SECOND STREET BOX 425 1/2 REMAINDER NEW FREEDOM PA 17349 3. HAROLD CLIPPINGER Collateral 209 HILL STREET ALLSTATE ANNUITY MT. HOLLY SPRINGS PA 17065 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. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF MARY FRANCES FULTON I, Mary Frances Fulton, of Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and codicils heretofore made by me. FIRST I direct the payment of my debts and the expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. SECOND I give, devise and bequeath my entire estate of whatever nature or wherever situate to my beloved husband, John Edward Fulton, if he shall survive me by thirty (30) days. THIRD In the event I am not so survived by my said husband, John Edward Fulton, I give, devise and bequeath the remainder of my estate of whatever nature or wherever situate to my niece, Elizabeth M. Lutter of New Freedom, Pennsylvania, and my nephew, James R. Fulton of Carlisle, Pennsylvania, per stirpes. I wish that James keep the dry sink as a part of his share of my estate. ~~r~ u ~ ~usl~ ~ ~s~ri ~.~~ FOURTH I direct that no trustee, personal representative, guardian or other fiduciary named, nominated, or appointed by this my Last Will and Testament shall be required to post any bond or give any security of any type for any purpose whatsoever, any law or rule of the court of the Commonwealth of Pennsylvania or any other jurisdiction to the contrary notwithstanding. FIFTH My personal representative shall have the following powers in addition to those vested in them by law and by other provisions of this will, applicable to all property, real, personal or mixed and wheresoever situate, including property held for minors, whether principal or income, exercisable without court approval, and effective, with respect to each item of said property until actual distribution thereof. A) To retain, as investments of my estate or trust, any or all assets of my estate, real, personal, or mixed, without regard to any principal of diversification, and to purchase and acquire real or personal property and to hold any or all of such real and personal property retained or acquired without making the same productive of income. B) To permit my heirs, or any of them, to occupy any real estate retained or acquired upon such terms and conditions as my trustee shall deem proper. C) To pay all taxes, charges and expenses of maintenance, upkeep, improvements, development, protection, preservation and investment of any retained or acquired real or personal property, such payments to be made from either principal or income as my trustee shall determine. D) To retain or invest any and all funds, whether principal or income, in any real or personal property without restriction to legal investments; to purchase investments at premiums; to exercise all rights of a security holder or share holder in any corporation; and to lease, mortgage, pledge, give options upon or sell at public or private sale and without approval of any court, any real or personal property, or portion or portions thereof, irrespective of the manner or the means by which the same was acquired by my said trustee. E) To make payment or distribution herein provided for in cash, kind or partly in cash and partly in kind, at valuations fixed by my trustee at the time of distribution. SIXTH Any and all payment or payments of any sum or sums, whether in cash or in kind and whether for principal or income, payable to an heir, shall be made upon the sole receipt of the respective individual to whom the payment is made, and free from anticipation, alienation, assignment, attachment, and pledge, and free from control by the creditors of any such beneficiary. All shares of principal and income herein given shall be free from anticipation, assignment, pledge, or obligations of any beneficiary and shall not be subject to any execution or attachment. SEVENTH I appoint my husband, John Edward Fulton, Executor of this my Last Will and Testament. Should my said Executor fail to survive me or for any reason fail to qualify as Executor, then I appoint my niece and nephew, Elizabeth and James, as Co- Executors of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of four (4) typewritten pages, the first four (3) of which bear my signature in the margin for the purpose of identification, this 19th day of November, 2001. (Seal) ry Frances Fulton Signed, sealed, published and declared by the above named testatrix, Mary Frances Fulton, as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as witnesses. ~C~ f ADDRESS ~ '~ ~- Oa.k.~~? ~ ~. ~ Ca~•~~s~,2 Q {~ ~ ^?0 ~ 3 ADDRESS~"I ~ U.Uk.. ~~~~~ I70~3 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND : We, Mary Frances Fulton, a~ ~D.~~ and S~.y the testatrix 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 testatrix signed and executed the instrument of her Last Will and Testament, and that she signed willingly and that she executed as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as witnesses, and that to the best of their knowledge, the testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this 19th day of November, 2001. ~L x seal Ar>~ela F Ur~er, Notary publics Ml+ iss~iEm~ ~umberlat~d County p res Oct. 7, 2004 Member, Pennsylvania Association of Notaries ~'. Allstate Life Iusuruice Compalry P.O. Rox 94212 Palatine, IL GUU94-4212 Tclcrhonc: (877) 499-641 A Facsimile: (8GG) G35-4x23 October 27, 209 Roger B. Irwui Law Offices of Irwin & McKnight, P.C. West Pomfret professional Building GO V~'est Pomfret Street Carlisle, YA 17013 Owner/llruiuitant: Mary F. Fulton Contract No: GA0682727, issued March 22, 211011 Dear Mr. Irwin: vIA 1~ACSIMIL~ We received a request from PNC Insurance Services, Inc. to provide a response to your letter dated October 16.2009. 'There have not been any ownership changes or any accounts closed within one year prior to MarS~ N. Fulton's death. As of August 22, 2006, this contract matwed and has been is its payout phase. At this time, actuarial tables have been used to determine the payment amounts which factor in the interest. Since this contact is an annuity contract, it is not reportable on I1~S Norm 71'1. i can. however, provide the following information for estate purposes: Date of Death: September 11, 2009 Annuity Yalue as of llate of lleath: $9,735.91 *1'his value is an illustration for estate pwrposes only. It does not represent a cash value or a lump sum withdrawal offer. If you have any questions, please contact me at 1-877-49~-6418 Ext. 48371. Sincerely, Robin J. Gay Claim Representative you're in good ha~~is~. . UC 1. L 1. LUUy I ; ~yrlvl IYV, I VU'T ~ L rlu~ DHlun ~+IL-IU7-Ll~+l ~~ i.EADMI6TNEWAY October 27, 2009 Irwin & McKnight PC Roger B Irwin Esq V~ Pomfret Professional Bldg 60 W Pomfret St Cazlisle, PA 17013• RE: Name: Mary F Fulton S3N: 1 SO-09-4214 DOD: 09-11-2009 Dear Mr. h'vvin: In response to your request fvr Date of Death (DOD) balances for the customer noted above, our records show the following: ~ . Checking Account ,A,ccotuat # 5140184342 Established: 04-01-1963 MARY F FULTON DOD balance: 54,935.18 + 0.14 accrued interest Interest paid 01-01-2009 thru 09-1 I-2009 $3.29 YTD . Please note that this office provides date of death balances for deposit accounts (IItAs, CDs, Checking and Savings). Rye do not process ~ financial transactions •or provide statement'. If you need assistalsce with any of these items, please cal! 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bank, N.A. ~ . Member FDIC r ~ _r~ September 24, 200 Elizabeth M. Lutter 209 N. Second St. New Freedom, PA 17349 Ewing Brothers Funeral Home, Inc. 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 The Funeral Service for Mary F. Fulton Mti 1 a • . `~~,E ~~ .: .. ~.. 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 STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WIN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff , $4895.00 FUNERAL HOME SERVICE CHARGES $4895.00 SELECTED MERCHANDISE: Pieta 18G Casket Gasketed Brushed $2460.00 Regular Concrete OBC $1195.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $8550.00 Cash Advances Opening Grave. . Certified Copies of the Death Certificate , , Flowers . Church Related Honorariums , The Sentinel Obit , , The York Newspaper, , Hairdresser, , St. Patrick Honorarium , TOTAL CASH ADVANCES AND SPECIAL CHARGES . Total Total Cost , , SUB-TOTAL INITIAL PAYMENT /DISCOUNT /CREDITS TOTAL AMOUNT DUE The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum. $650.00 $36.00 $132.50 $340.00 $129.78 $176.65 $40.00 $60.00 $1564.93 $10114.93 $10114.93 9572.38 = !'d ~1e ,'~ a`s~ ~ 'r o ~ ~9.JN per( o~ DoT /~ L uA~•9,•~T ~~ r/~~ ~ P,,,T,,,,e ~. o ~~ ~,~.y emu- e. /~ 'ar ,S'l , 7 ~- ~ r,~ e ~-` ~~ ~ ~p ~. % ~; ~ H ice' ~ rs? y~ ~- .~ ~~. e A/ Form PB-01 c~l~~ r~a~~~ cA~c~ 71 249-1363 _ :RE~.10~I~1'1" ~......: IJN:IT. :. 'STMT.::I~ATE 13279 H-04-A 12/01/2009 .._ ~_ I ~~.; NT(S) Mrs. Mary F. Fulton Roger Irwin 60 W. Pomfret St. Carlisle, PA 17013 DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE Mrs. Mary F. Fulton :. T~TA~. ~~(~'UNfi C?UE $5 554.99 ~ATf ;DUE U on Recei t ------------------------------------------------------------~-------------------------_FlMQIlIYIhi~M~TTED_ _ .,...... :.,_. ._. n.Y. ...n. d.i a:.....,<..!_ ,,,! ,.e!vn ..7.» . •::_.,.....,_ ~, .,,. .,. s. , ....n ~,V ....ti•r,'.ge.'! +L !s .. ./.".in. .... .SF .7 .. , r. ., -::n: .e: a-•n :r ...... ,.... ,..4:#.`~ ... .~ . ... ,,..... _. .,, .,..., , .1. P ....... ..... . . r _!,:. ._:. T,. -, ,~ .7.. r •r ...n.~;~~• -2;rt ti' ~ ~,:,•,..::,.. ..:::.~! ,: a r Y~` •~ Z7r ,..:..... ~.,:.~...~'71t~a:.~',r~_ ., <,.:~.'.`~€.~....h~ ~,, y ~. ..<,~,. 'x .:•7•:!' = ,-"~ . «... ..f ! . fi F:a•:. ~ •.; :., ^•C ..: ::. .. :. .:.r...c... •J~ • : t' . ?S:rM,.,.a..~_ ...-o.,.,s:r,,, .I r.. t.. r:~y t.~i_.r,ir M 7... - {. t ~ ~' isr, of ~:.. _ iU...:.X..: ~..:,.y..~:... ....ur t ..... ~ .. ..~.. :: ~u ~ J .:,' _ ~ ..jk ~. ., f IF L. ~~".3 .. :i':i'r:::}~•~ 1 '~'7. ~ y:E" 7 ... r._ ::: ,f .:::.. ... ... .:. ..C ..~, ... •L I. r tom. '_ .._sw.i:c...l.. .r.1...FF fU._,.C. L. F.Al..KS_.4.N .~.~5~_.. ...~'J.t~. ~].~.. L. ....t~.. ;...4 .Sl._.fAI, :. ..U ._,...~1. .~Yr. ... .-S•t~'F.... :, ,..._:::'::.~•.._..r. -il~. ~. . '. FT...rn.~ ~~ ~1'^a..t ...:. -- ..:L :-/~~~ :Balance, For!ward~ ` - ~ 'S;55~99. RESIDENT # 13279 CURRENT 0:0'0 OVER 30 OOD OVER 60 1,646.73 OVER 90 3,908.26' .OVER 120 0.00 TOTAL AMOUNT.~DUE $5.;554:99 ,: ••- • • a e otnte . at Carlrsle 770 S. HANOVER STREET, CARLISLE, PA 17013 RESIDENT NAME Mrs. Mary F.Fulton CHAPEL` PUINTE SAT CARLISLE; :770 S. HANOVER STREET, CARLISLE, PA 17013 ~FomrP&01.. • e ol~te . at Carlasle 770 S. HANOVER STREET, CARLISLE, PA 17013 Mrs. Mary F. Fulton Harold Clippinger 209 Hill St. Mt. Holly Springs, PA 17065 DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE Form PB-01 QUESTIONS? CALL: (717) 249-1363 R'ESID'ENT # UNIT: STMT. DATE 13279 H-04-A 10/01/2009 RESIDENT S Mrs. Mary F. Fulton TOTAL AMOUNT DUE $5,554.99 DATE: DUE Upon Receipt \ \ \A I I \ IT !1 P~ \ DATE ... _ .. _ .. __ _ n DESCRIPTION ; __~_ ._ _._ .Days/ CHARGES: Units .I.IV _ _. _. CREDITS VIA. •VI.11I IVV _ BALANCE . .. . . . Balance Foz-v~vard . .. .. ...... 4,534.50 09/09/2009 Payment -Thank You!! ~' ~` ~ 626.24 3,908.26 09/10/2009 Room and-Board Private C 09/04-09/10 ~ 7 1645.00 5 553.26 09718/2009 Miscellaneous `'`'~°~° 1 -" 1.73 5,554.99 Postage RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 13279 1.,646.73 3,908.26 0.00 0.00 0.00 $5,554.99 RESIDENT NAME Mrs. Mary F. Fulton Form PB-0, CHAPEL POINTE AT CARLISLE, 770 S. HANOVER STREET, CARLISLE, PA 17013 TN ~~ ~,~c 3~ ~c~' 30,rru ~ ~~~