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03-16-10 (2)
J 15056051058 a REV-1500 ~ cam) ,,. ~ o~LY ~ ~ of Raverwe CourMy Cade Year Fb Nunber Bureau of Individual Taxes INHERITANCE TAX RETURN /I _ q '/~' ~ O 0 ~ !! __ p~ Hartisaxg, PA 17128-0801 RE SIDENT DECEDENT ( l~ D ENTER DECEDENT INFORMATION BELOW Sodal Security Number Date of Death Date of Birth 184-26-7329 07/12/2009 07/10/1935 Decedent's Last Name _ _ _ Suffix Decedent's First Name MI Dively Mrs Patricia M (If Applk~ble) Enbar SurvivMy Spouse's IniorrrreUon Bslow Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soaal Security Number THIS RETURN MUST BE FILED IN DUPLICATE YYIl'H THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~7 1. Original Realm O 2. Suppleman181 Return O 3. Remainder Return (date d death prior to 12-13-82) O 4. Limited Estate O 4a. FuWre Interest Compromise (dated O 5. Federal Estate Tax Rehm Requked death alter 12-12-82) O 8. Decedent Died Testate O 7. Decedent Maintained a living Trust __ U __ 8. Total Number d Safe Deposit Boxes (Attach Copy d wi8) (Attach Copy d Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty CredN (date d death O 1 t . Election to tax under Sea 9113(A) between 12-31-91 end 1-1.95) (Attaati- Sch. O) CORRESPONDENT - TiNB SECTIDN MUST BE t~IPLET~. ALL ©ORRE3PONDEpCE MID t~NNFlDENTIAL TAX NFOlalA710M BNOIILD 8E DNlEC'T~ T0: Name Daytime Telephone Number r.,~ ca r ; Susan Rowell, Extra o 717) 921-294Q~ T~ =t ~ _ ~ ~ ~~ > > Flrrn Name (H Applicable) REGISTER O (~ E ON~ ~. ~ ~ ~', A ." • First line d address ~• rr ~ r ` , r=j C~ ~ y. r=; 1109 Red Hill Rd -~ `:3 `', _ ' --, . Second line daddress - ~ a c,~ ~ a ~, Ctly or Post CMFCe State ZIP Code DATE FILED Dauphin PA 17018 Correspondents e~rnan address: msrowellmgti~comcast.net under panaltles of per)ixy, I declare tlmt I Nave examined 1Na return. IndudMy accornpanylrp adredulss and statements, and to the bast d my ~~ and belief, i< b tn,a, c«rea and oomplaa. Dsdaratlon d preps-x other then the personal represxrfatlve Is Neaaa on au Inramistlon of vrhich preperer has arty larowledge. SIGNATURE OF iERSON RESPONSiBt~ FOR ~ ILING RETURN DATE J1/CLL. 03/12/10 1109 Red Hill Road Dauphin PA 17018 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEAS! USE OIRIOINAL fFORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Securky Number l~denrs Nar~,e: Patricia M Dively 184-26-7329 __________._,___ .______~_-.__ RECAPITUU-noN _____~v_ ______~___------.__~.w___...._______________.- 1. Real estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 9,946.82 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 0.00 5. Cash, Bank Deposits 8~ Miscellaneous Personal Properly (Schedule E) ........ 5. 3,088.00 6. Jantly Owned Property (Schedule F) C~ Separate Billing Requested ....... 6. 0.00 7. Inter-V'rvos Transfers & Miscellaneous Non-Probate Property (Schedule G) c~ Separate Billing Requested........ 7. 0.00 8. Total (cross Assets (total Lines 1-7) .................................... 8. 13,034.82 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 6,190.20 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 3,487.79 11. Total Dsductlons (total Lines 9 i£ 10) ................................... 11. 9,677.99 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 3,356.83 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Nst Value Subjaet to Tax (Line 12 minus Line 13) ........................ 14. 3,356.83 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~ ~ ~~~ ~~~ _ ~~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 6 201.41 16, 201.41 _. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 201.41 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~y 15056052059 Side 2 15056052059 RE~1500 EX Page 3 FIN Nurmber Decedent's Complete Address: DECED S NAME DECEDENTS SOCIAL SECURITY NUMBER Patriaa M Dively 184-26-7329 STREET ADDRESS 1109 Red Hill Rd ctrY Dauphin srATE PA ZIP 17018 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 201.41 2. CreditslPayme-rts A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + g + C) (2) 0.00 3. Interest/Penaky ff applicable D. Interest E. Penalty Total lnterestlPenalty (D + E) (3) 4. H Line 2 is greater than Line 1 + Line 3, enter the ditlererloe. This is the OVERPAYMENT. FNI bl oval on Pape 2, Line 20 to request a refund. (4) 5. ff Line 1 + Line 3 is greater than Line 2, errter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the ~ of Line 5 + 5A. TMs is the BALANCE DUE. (5B) 201.41 Make Check Payable fo: REGISTER OF WILLS, AGENT i _ 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 designaUe who shall t~ the propeAy trensferred or its income :............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise far life of either payments, benefits or care? ...................................................................... ^ 2. ff death ocaxted after Decar~er 12,1982, did decedent transfer property witl~ one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an 'in bust 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-priobate property which contains a benefiaary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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 [12 P.S. §9116 (a) (1.1) (ii)J. 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 evenrf the surviving spouse is the only benefiaary. For dates of death on or after Juty 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) pertent (72 P.S. §9116(aK1.2)]. 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. TDC+DEPARTMENT OF THE TREASURY INTERNAL REVENCIE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 07-24-2009 Employer Identification Number: 27-6144797 Form: SS-4 PATRICIA M DIVELY ESTATE SUSAN D ROWELL EX 1109 RED HILL RD DAUPHIN, PA 17018 Number of this notice: CP 575 B For assistance you may call us at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN~EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN). We assigned you EIN 27-6144797. This EIN will identify your estate or trust. If you are not the applicant, please contact the individual who is handling the estate or trust for you. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 1041 11/15/2009 If you have questions about. the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue). Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. To obtain tax forms and publications, including those referenced in this notice, visit our Web site at www.irs.gov. If you do not have access to the Internet, call 1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office. REV-1502 EX+ (11-08) Pennsylvania ~7 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Patiiaa M Dively 27-6144797 All real property owned solely or as a tenant in common must be reported at fair market value. fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Indude a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 • iWA TOTAL (Also enter on Line 1, Recapitulation.) I # 0.00 If more space is needed, insert addftional sheets of the same size. REW1503 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEp~ILE B STOCKS & BONDS ESTATE OF FILE NUMBER Patricia M Dively 27-6144797 AN woosKr Idntl~r-owiNd with r1oFM of wrvhrarshiP must bs disda~d on 8dNduk F. (h more space is rbeded, insert add'~ional streets of uie same sae) Beneficiary Information We have the following beneficiaries on record for the deceased's accounts. Account Number: 00704808243 7 001 Designation: Not applicable for this ownership type. Account Number: 00012314159 0 021 Designation: <Not applicable for this product.> Account Number: 00019918119 9 021 Designation: PRIMARY BENEFICIARY LIVING, LAWFUL CHILDREN IN EQUAL SHARES 100.00% `~ „-~~" _,~,eripr~se nM[;RIPRISE 7-Ri1STCOMPANY IonM1;Rt1'R[SI's FINANCIAL, CP.NTER MtNNI?APOLIS. 1viN i~~17d-9900 I'ATRK'ifa 't4 Dt~'I:LY I'nTRICIt~ ~i l~i~'I~I:Y" IRA r3<„~ ~ '~~ego„• AMERIPRISE TRUST COMPANY Trustee's or Issuer's Federal IdeatiticatMn Nnmber: 51-G041053 Phone No: (800) 862-7919 Acconat Naa~ber :0001 9918119 021 • Partklpant's Social SecarNy Number: 184-2G-7329 Statement I)>te: 01/24/09 .~»>otnf ~~ ~~~~. ~~/ IRn contributions (other than amounts in $0.00 lxi~es 2-4 and 8-10) _ Rollo~•er contributions 50.00 3 Roth II2A conversion amount 0:0O -l Recharacterued contributions $0.00 2008 Form 5498 Fair market value of account $9,946.82 C. Life insurance cost included in box I Copy B: For Partlclpset 7 Plan Type IRA This infrtrmation is being fitmished !n the lnlemal Revenue Senicc. 8 SEP contributirnls $0.00 9 SIMPLE contributions 50.00 10 Roth IRA contributions $0.00 11 If checked. required minimum distribution for (X) 2(>n9 + This is the account number of one of your investment accounts within your plan. This is the account number thM ~~ ill he rel+orted to the Internal Revenue Service frn this p{an. .-. -~ --.-- I~~IIII~I~INII^II 'rise r++-~ Amerip financial AMERIPRISE TRUST COMPANY 10 AMERIPRISE FINANCIAL CENTER MINNEAPOLIS, MN 55474-9900 PATRICIA M DNELY PATRICIA M DNELY IRA 16 S ENOLA DR ENOLA, PA 17025-2722 AMERIPRISE TRUST COMPANY Traatee'a or Isstter'a Federal Ideotiflca/bn Nntaber:51-6041053 Phone Ne: (800) 862-7919 Account Nntnbor :0001 9918119 021• Partkipant'a Secbl 3ecnrtty Nan~ber: 184-26-7329 State®eat Date: 01/25/10 ~~m1~~~tt1~~f'161i F - m ~ 4 _ Boz # Category Amount 1 IRA contributions (other than amounts in S0.00 boxes 2-4, 8-10, 13a, 14a, and i5a) 2 Rollover contributions 50.00 3 Roth IRA conversion amount 50.00 4 Recharacterized contributions S0.00 2009 Forts 5498 5 Fair market value of account S0.00 Copy B: For Partic~ant 6 Life insurance cost included in box 1 This information is being furnished to the 7 Plan Type IRA 8 SEP contributions S0.00 9 SIMPLE contributions S0.00 10 Roth IRA contributions 50.00 11 If checked, required minimum distribution for ( ) 2010 12a RMD date 12b RMD amount 13a Postponed contribution 13b Year 13c Code 14a _ __ . Repayments _ .__ _.. 14b Code 15a Other contributions 15b Code • This is the account ntrmbea of one of your imesrment accounts within your plan. This is the account numbs the will be reported to the Internal Revenue Service for this plan. Internal Revenue Service. ~o w 0 a IM 7SM3-3 ia61926 ltltDFi AL24R 1 ~ ~i ~O __ „ ~ o~ 00 a-I ~' e 0 ~ ~ N ~ C M C $ ~ ~ ~ o'~ ~1 C J ~ O N ~ _ Q ~ r-1 ~ Z Q a U Q a Yvwa W m N ~ ~, ~ U O ,~ a~~ ~ °'v W O Qava .ir C v eR ~ o 0 ~+ 0 •-7 ~ ~ ~ .O1c, ~ $ g g c ~ ~' W CC < ~ ~ w ~ ~C !A (gyp N ~ M Q,Qj a C ~ pp cp C0pp 0p a b ti ~ 5 p t0 ~p ~Q'~-+ ~ N t~ ~ ~ N o t p ~6 ~ d! ~ •-i O 00 Cf 11') OQ O ~ , tR ~ N N ~ ~ ~ ~ O V M ',+~~ j Q m H m ~ C 8 O N ~ ~ C W ~ r+ ~ ~ C ~ O V , Q O C ~ 0 pO 8 ~m ~ N ~ ~ D y C ~~ M U ~ ~ €> ~ ~ a ~ ~ ~3 'T V C N H ~ Q ;w~ O ~ o - cv moo. ~ O ~c~ C ~ ~ ~, ~ c ~ ~ ~ ~ ~ ~ ~ J j ~ ~ a. ~a. Ln O W O ~ ~ ~v a aim .' ~,d°o ' ~a~a N ,,ao ~ .a j Q~?5 V~ ~~5~ c o~ ~ m ~ a ~ ap ` 4~Q ~ J J J J U~U~ ~ ~ ~ ~v'' d ~ . = ,~ o ~ N ~~~ ~; ~~ W 7 ~ ~ ~ ~ - L ~ ~ ~ Q'co x ~ U ° ~~ ° HN V c 0 1) O O °~ W ~ p p Z O S N ~ ~ ~ ac w C ~ $w.Z ~~ ~o ~~ ~ '~ Q 4 a~Nr~~ Z a ~~ ~~ ~ N ~ M_ N 4 ~ o ~~1<~„ .~ ~ ~ ~ ~ .~~..~w •ry ~I 0 ti a REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEp1~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Patricia M Dively 27-6144797 Ir-dude the proceeds of litigation and the date the proceeds were received by fhe estate. Ap propsAy Jointly~ownsd with right of survivorship must bs dbebssd on 8chsduis F. (If more space is needed, insert additional sheets of the same size) Free checking Account Statement For th• psrbd 08/10/Z009 to 07/Of1/2009 For 24-hour information, sign on to PNC Bank Online Banking PATRICIA M DIVELY on pnc.com. ~ Primary account number: 51-4016-1829 Page 2 of 5 ere Its to your account, or re use to accept a or part o t e eposlt. a w>< not a Ia a to you or any sue a ays or refusals. We will have no obligation to provide you with notice of any nonpayment, dishonor or protest regarding any items credited to or charged against your account. Free Checking Account Summary Patricia M Dively Account number. 51-4016-1829 Overdraft Protection Provided By: Contact PNC to establish Ovordrak Prot~otlon Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance 3,231.92 3,115.05 2,813.12 3,533.86 Average monthly Charges balance and tees 3,888.66 2.00 Transaction Summary Checks paid/ Check Card POS Check Card/Bankcard withdrawals signed transactions POS PIN transactions 1 ~i 0 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 0 0 Please see the Activity Detail section for additional information. Activity Detail Deposits and Other Addiltions There were 4 Deposits and Other Additions Data Amount Deacriptlon / totaling $3,115.Oa. Ofi/10 1,079.60 Direct Deposit -Soc Sect U5'Treasu,y 303 tiCXXY~7329A 07/01 837.72 Direct Deposit -Pension Retirement 07/07 l 18.13 Deposit Reference No 522488056 07/08 1,079.60 Direct Deposit -Soc Sec US Treasury 303 Y~~YX7329A Chsclcs and Substitute Checks Check Date Reference Check number Amount paid / number number / 9240 31.01 Ofi,/ 16 J/ o~i337ossg 9270 '~( 0254 * ri0.00 0(i/ 16 ~ UA5991992 9271 920,7 * 300.00 OG/17 - o+1~7U55ss 9272 9258 31.43 O( i/ 16 ~ or~ss7oss / 9273 18.35 9261 * (><,/`~~~ ' os~,3s2~R2J _ _------.__ - __~_,`!t74- ---- . _ 92~id ~ -- 48.00 -- -- 0(i/ Lfi~ - 022551047 9275 9265 2 ~.1 Oti/19 ~ osssls~+2) 9277 * T 9266 31.34 O6/ 19 083645ora " Gap in check sequence -- "T" Teller Cashed Check On~ae and Electronic Banking Deductions Date Amount Description Ofi/1G 4.43 Direct Payment -Loan Pmt Baltimcn•c Lifc A 0502582 ~ Ofi/ 17 25.1 R ~ ," Payment,E-Check Payment Tmobile 9260 06/19 30.00 TwhAutoTransferTo 5130214632 voj' I ~ ~O.OJ r..1 n.~.ul,T. Ql.a.a.h Ul.~a 1. r) u.i r3.. ~. o PwT.nc.,t okG7 06/26 100.00 Payment,E-Check C:hegkpaymt .•// Retail Sc,vices2 9259 06/26 32.83 Paymcnt,E-check Ghcclypay,nt Retail Sctvices2 9268 ~ Date Reference Amount 0 paid number 97.5 Ofi/30 tu33-tr357z 40.00 07/07 urk.s~;7~~t 640.ou J o7/07 n~;,~;2,os 25.0() 07,07 fu3i;It;2o~Ni _ f~ti.ri0 f17i07 ~ r~~~~~;~;o 60.(N) O7/O9 OR312~i29o 2a).oo 07/08 522~.a~+u•5 There were 15 checks listed totaling s2,204A0. There were 11 Online or Electronic Banking Deductions totaling $800.72. Online and Electronic Banking Deductions continued on next page Free Checking Account Statement For tha palrffod 06/10/2008 to 07/08/2008 For 24-hour information, sign on to PNC Bank Online Banking PATRICIA M DIVELY on pnc.com. Primary account number: 51-4016-1829 Page 4 of 5 Check Images PATMCN M. DlrElr 9240 Is s EAOU os APr 7s1 FN711J~ PA IaOPy ~• {~ O flNara~ arae.~i ~64fZ0~ 1 $ .3(~(e Q PNCBANK NA r°i3t3(3()ti i ' i:ii'.C3~i.+ln-1043(1 'fr i 1 OY i S%'i tV.l 1:031312738/: Si4Di6i829F' 9240 ,e0000~003104e' 9240 $51.04 Ilfi/16/2009 MTIgCM Ile. DIVELY 92b7 w s FNau oA APr ml f1glA, ti no10 a"ufwaa __.~L 8 - r -rte r,. ro J» e "!h.7E'tr..t .~l._t RJOG_4J t}~ D/oa~-I~--_'-~- D..11.iw 8 :ri ~_ ~ PNCBANK r:.:ur.»n 1,e rwd rA ~ Ivr ~'.'~ --~ 1:03 i3 i 2?981: 511,0 1618291/ 9257 9257 $300.011 OG/17/2009 PATRICIA M. DIVELY 9281 IEOOIOW ~AiA 17Nmel~ ~1 n um~ ~PNCBIINK arY ANA 001 for-_.--..__ --"-~-'~ -- ---- L~:.. _~~ 1:0313127981: 511,016i829r 9261 r'OOOOOOi895,'' 9201 518.35 OG/25/2009 PAtA1C1A M. DIVELY 928$ w s eNO1~ oa API 7s1 eNOEA, Pn 11rs - L ~.Z B 9 _ wNa7 Par n dw 7sdol/itM ~-' Cr"'~~~~ DoMw a ~.T:. ~ PNCBANK C~O»i MA M ti MI' ~ • ~1_._~.._ 1:031312?361: SieaOi6i829r 9265 9265 52.24 06/19/2009 PATIncu LI. DwELr 9270 M E EM7U 00 AR 701 E Fuel4 PA 17021 / ~ Ia ~}^ U y BnIVINra -~-F--~ r„r.ra. ~{~1~rc%rzt ~/aJlc?_S _I $ 9~~~ O.J....1__._- aP ~PNCB~SNK ~~~ l'gwlfA nw ~1,~ /,A, 1:031312?361: 5 140 16 16 2 91• 9270 ,x'0000009950,+ 9270 597.50 06/30/Y0119 PATRIpA M. gr[lY 9254 N 8 FlIO11 011 API 701 E71011~ PA 1>•0! ~~ ~~ r 11I3'71a O IY T>~!£~t~~L~ /E~y .__ o'dle~ d~?-~Z[ I $ ~j' -D a e/ e Q ~C F~'_L~-._~Io c_, -~-.-s_~ odlw. Q ~:: Q PNCBANK MA M r A /IOA F>.~..rf?aJ bE'4F'u6A71 a1aLS- ~y~i ~t ~ ~/1~~ ~ ~ Y1 fvts+1_F1.L pLki+.l.xyT_ ~ / 1:031912?381; Si1.D161829E• 925ti 9454 550.110 Ofi/ l 0/21NNJ -ATMtu M. otvELr 9256 N ~ ENOIA 011 API 701 i11D1.4 M IamE •ralVall Py m d.r L20c,L.~ large. •1 ~~P •_ 1 $ ~~ yes G13 ~ 17dla s 8 . _ ~ PNCBANK n ... ~~NA ^'~ oc313oo 1 s :i~~3 i ~l z t c.3.~ r s ~r:, tv,.r ~ r ":.;~o F Fer ( //~. y ~. ppp ~. / y ~ • iAJLL rf • •• J / / / ~~_r 1:031312?381: Si40t6 1A291` 9258 r'00000091e.9/' 9258 $31.43 Ofi/16/2009 rAn1IUA 1e. OwELr 9264 11 S E,g1A 011 APr 701 [NOU1, 141 /1017 ~ / -NA'7~ 1v___.~, adw dZrnvagwStc~~.~F 11_(3~G.rl I $ ~f~ °~ r ~ PNCBANK lC1Y' y; 'A ON FM-~-1`s ------ ~c~.~.1_7_~~P~~qq 1:03L3i27381: 514D16L829r 9264 IOODOOOi800.+ 9264 548.011 Ofi/1G/2009 PATRICIA M. OIrELY 9288 11 s ENau sA 71nr ]01 ~. odrr wi __~...~~ ~ 8 4~--uaw. (i ~7. . Q PNC1 K ~MNA 001 ~'~ 1:031312?381: 511,0161829r 9266 9266 534.34 06/19/211119 PAm1aA M. oR1iLr 9271 le 6 ENaA OR AR i1, 61014 PA 1100. ~ls~b /~ 1F„Anl, 1'•F lx,k _--Y_i'_^a._/ V~._L'/CT_AL~~~-. _ _. I $ yD ~M Order ry_ DeM1.. c ~._ QIf'BANK~ ~~_.----- .. fr.WlA b.A 1;0913127381: 5140163 291• 92?i 9271 $40.011 07/07/200!1 Check Images continued on next page Free Checking Account Statement For 24-hour information, sign on to PNC Bank Online Banking on pnc.com. Account nuntbcr: 51-4016-1829 - continttcd O.^liue: and llescstronlc QanKing Dequcslona - COr)tll7uet7 Date Ofi !29 Amount ti0 48 Description P E Ch k ` " , . aymcnt, ec - State Farm Ro 27 9 ~GJ 07/03 30.(x) '1'tvhAutu'1'ransCer'1•o 5130214632 07/03 4.00 llirect Payment - XXXXtl'23l 1 Prinrily fiO Pitt 095749(1 07/07 2t'r0.95 Direct Payment -Ins Prem 9 (htited:\merican ~XX~~\14.41 070 / 07/08 30.76 Payment,E-Check Checkpayntt AtRT Consumer 9262 ~/ ~PNCBANK For the period 00/1 O/ZO08 to 07/09/2008 PATRICIA M DIVELY Primary account number: 51-4016.1829 Page 3 of 5 Othor Deductions Date Amount Description 07/09 2.00 Ghcck Images In Statement Fee There was t Other Deduction totaling $2.00. a~ y Balance"ate ~aiC- Date Balance Oti/ 10 4,311.6`? Date (xi X25 Balance 3,708.•42 Date 0'7/01 Balance Date Balance 4,255.33 07/09 3 533 85 OGjl6 4,1.1G.G2 cx;/`~G 3,Ci75.59 07/03 , . 4 `~~1.33 OG/17 3,821.~1~1 OG/~~9 3,615.11 07/0'7 , 2,717.01 OCi/19 3,7`~1i.77 Ofi/30 3,417.61 07/08 3,5Jfi.85 Tra~•eling Oniside the I-ni1cK1 Stairs? Stop by your local PN(' branch to order fi-reign currency before you go. - Convenience -carry currnncy with you for immediate expenses st(ch as taxi flares, lips and meals. - Avoid delays and save time when you travel. - Haring local currency for your destination will give you added peace of mind. - Competitive rntcs and no trnnsaction fees. - When you rehtrn with excess currency, PNC can buy it Uack for U. S. dollars. Visit. any PNC' branch for more information. FORM953R-1005 REV-1511 EX+ (10-09) Pennsylvania ail DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS -__ _ - ESTATE OF FILE NUMBER Patricia M Dively 27-6144797 Decedent's debts must be reported on Schedule I. ITEM A. FUNERAL EXPENSES: I' SuAivan Funer~ Home -Burial Servio~ Bolting Green Cementary -Grave OpertirxilPbt Marker Stephenson's Flowers -Flowers for Church, Funeral home and Cemetery Brewhouse -Funeral Reception Church Doanation B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Susan D Rowell Street Address 1109 Red Hill Rd city Dauphin state PA ZIP 17018 Year(s) Commission Paid: 2. Attorney Fees: 3. Family Exemption: (If decedent`s address is not the same as claimant's, attach explanation.) gaimant Street Address qty State Relationship of gaimant to Decedent __ a. 5. 6. ~. Probate Fees: Accountant fees: Tax Return Preparer Fees: ZIP TOTAL (Also enter on Line 9, Recapitulation) I ~ 4,555.00 255.00 194.50 658.70 125.00 0.00 106.00 200.00 100.00 6,194.20 If more space is needed, use additional sheets of paper of the same size. RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 DIVELY PATRICIA M Estate File No.: 2009-00683 Paid By Remarks: SUSAN ROWELL WZ ------------------- Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 4565 Total Received......... Receipt Date: 7/23/2009 Receipt Time: 13:00:02 Receipt No.: 1057605 Receipt Distribution ------ ------- ------- ---- Payment Amount Payee Name 60.00 CUMBERLAND COUNTY GENERAL FUN 15.00 CUMBERLAND COUNTY GENERAL FUN 16.00 CUMBERLAND COUNTY GENERAL FUN 10.00 BUREAU OF RECEIPTS & CNTR M.D 5.00 CUMBERLAND COUNTY GENERAL FUN ---------------- $106.00 $106.00 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED DECEASED :...,.;. ,ic,_ ~ ,',,9,,t,~ *'-' _ t1 DATE OF DEATH PLACE OF DEATH ~' -`'~ ft`.,~'-''s .~".e { ~"` DATE OF STATEMENT i a. ,l ;t Charges are only for those items that you selected or that are required. !f we are ~~quired by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. !f you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pa y for embalming you did not approve if you ~\ elected arrangements such as a direct cremators or Immediate l ~/ ~- pal. If we charged for embalming, we wlll explain why below. V f ~ " ,`'CASH ADVANCES .w ~~.RM. ®..._~._..._.._...._~_.~~._s..._~,._...~_~ " ' (/{'. ~~ ' Certifj~d Copies of Death Certificate ,' = _ ' ~ $ - each $ ~~ .'~'Ii% V~ F '~ A. CHARGE FOR SERVICES SELECTED 1. Professional Services: Basic Services of Funeral Director & Staff .. '` r ~~ .r 4}'I ,~'; > = ~~ Embalming ........................... "r Other preparation of body ................. . 2. Facilities, Equipment & Staff: Use of Facilfties & Staff for Vfievwng /Visitation .. . Use of Facilities & Staff for Funeral Ceremony .. . Use of Facilities & Staff for Memorial Service... . Use of Equipment & Staff for Graveside Service ... Use of Equipment & Staff for Church Service.... ~1 tYs~ "t9 3. Transportation: _ , Transfer of Remains to Funeral Home ........ ~ 1 ~+ . V ' ^%'y l Hearse ................................ ~ ~_, Limousine ............................ Sedan ... ....................... Service /Utility Vehicle ................... . ~ .~ ,~ ' C i t~ 4. Other Services /Facilities /Equipment: TOTAL OF SERVICES SELECTED ......................$ _~ ~'~~t•' B. CHARGE FOR MERCHANDISE SELECTED ~ ~. ~ Casket (or other receptacle)............ ` 77 ; ' .M;}W Name/No. j` ".~1 -' _ -! Material u Color Outer Burial Container .................................. . .' " r. ~' _ ~ ~„ .. Name/No. Material _ tir AcknowledgementCards ................................ .... - Register Book ............................. ~....;..)<-S ,.. .... ar "~ `'~{'1 Memory Folders /Prayer Cards ............................ .... Clothing ................. ......................... .... _ ! ,. .~ {' Musician f ^-T~ ii Paid Newspaper Notice ' ~!% Cemetery ` Other . ,t?~ ~ 1 ; ~`' _ ~_~ TOTAL CASH ADVANCES $ i=' J -~ We charge you for our services in obtaining: (specify cash advance items). SUMMARY ~~~~ ,:•~f Total Funeral Home Charges ................. $ i' u y •' Local Sales Tax (if applicable) ................ $ State Sales Tax (if applicable) ................. $ Total Cash Advances ....................... $ ~ ,' , , t;0. GRANDTOTAL $T`; '" , `11 Less Credits and Payments Total Credits ........................$ BALANCE DUE -~ $ ~ Billing To DISCLOSURES Reason for embalming N any law, cemetery or crematory requirements have required the purchase of any items listed, the law or requirement is explained below. ACKNOWLEDGEMENT AND AGREEMENT I hereby acknowledge that I have the legal right to arrange the final services for the deceased, and I authorize this funeral establishment to perform services, furnish goods, and incur outside charges specified on this Statement. I acknowledge that I have received the General Price List and the Casket Price List and the Outer Burial Container Price List. Terms of Payment: . (Q~ \ ~j ('~ N to 1 1 I I O lf! O t!l lf) O 1 U7N1171~NO 1 lI) O O ll7 pp pp Nlf7 tf]1'~1J~O O Q ~ N0O7 M Qh l W mn W 1 i I M07M.---lA t17 I .--. O t0 f~ I.f)Q'1~.- N ~ M O I ' E O ~ 1 Q ' 1 v i O N ; M j W I I I I 1 I ~ 1 I I // ^~ ~y I M Lf~ i I /~ V E ~ I I j I - ~ I 1- 1 I W a^ ~ I i (p O I I ~/ ~ I I ~ {~. ,N ~ m ~ I 1 C/7 I 1 11TT 0 y I .-• ! i i U Y ~ ~ ~yy J tE0 J 91 ?. ~ Q i ~ i ~ M Y = (n 3 m Q to ~ -+- O~ 1 0 l O 3 m C.,.) ~ f 7 I O m a V ~ ~ }C ~ ~ I ~ UF~-p1T ~~~~~~ mW~~~ ~ ~ ~ m m faA m Y C~' ~ N ~~ m C9 fn to Y I Yn ~ ~ OFV12'UU~d O O O NCO COUCD 1 1..11 Z G L (7'I I S OM'7 O I ~- L MO I C.: .-:~-~ M.- NN.-N Q' I ~ 1 ( Previous Month's Balance 08/05 1997008 Symp -peaceful mem ur 08/05 1997008 Symp -Discount 08105 1997008 Symp -miscellaneous - 08/17 0208047 -Payment-thank you ~a : ~~~ $19.07 $86.31 $-11.70 $36.99 $-19.02 ~~ ~ Gib ~ 9a~~v Please use the RETURN ENVELOPE provided for your convenience Your easy order a«amt number is: -008047 uue upon receipt billing Outstanding Balance Date Cu.rcnr 30 Days (A Oars ~J DaSs & Geer 08/15/09 $111.60 $0.05 $0.00 $0.00 $111.65 Balances unpaid by the JQh o(nur month wiB b- wbjecr ~u a re•bi1W~g charge of l 114% (Aanud B,a I S%) nr a Minimum rebiliing charge is $2.99 RE1F1737-7 EX + (6-0B) ~ pennsylvania DEPARTMENT OF REVENUE INHERirANCE TAX RETURN NONRESIDENTDECEDENi scNEOULE ~ pEBTS OF pECEplNT, Use Schedule I, Part 2, ONLY for MORTQrAiE LIAdILIT1ES~ ~ LIENS Proportionate method of tax computation. ESTATE OF FILE NUMBER Patricia M Dively 27-6144797 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 proportionab method of tax computatlon ie elected. ,• ITEM NUMBER DESCRIPTION AMOUNT ~ • N!A TOTAL IM~1f w ,. S o.ol ITEM NUMBER DESCRIPTION AMOUNT t • Belco Credit Union 1,825.07 2. South Central EMS & EP Ambulance Transport 157.50 3. United American Health Insurance Supplemental Insurance Payment 260.95 4. Andrews 8 Patel Oncologist & Central PA Oncology 368.92 5. Pinacle Health Hospice 300.00 6. Heritage Medical & Quest Diagnostics 154.48 7. Stephensons Flowers 287.25 8. Comcast, Verizon, QTL 133.62 TOTAL M!T 2 s 3,487.79 TOTAL (Also enter on Line 10, Recapitulation.) ; 3,487.79 (If more space is needed, use additional sheets of paper of the same size) Free Checking Account Statement 1~ Pr~3.A,NK For 24-hour information, sign on to PNC Bank Online Banking FOB ~~° p°~iOa a~/~aZ008 to 08/11/009 on pnc.com. EST OF PATRItiIA hlt DIVELY DECD Primary account number: 51-4016-1829 Page 3 of 3 Check Images Pwra~cu r~. n~rELr 9276 ~s s v/ou ort ssr x ~ n i a,. ~ v,• a..n. 7'Tl'l al v4J i ', Q4'4G.1 g ~ ~ ~w.a..a ---- ---- __ -_I $ ~ _..__.... d_O~ lp,ylf ~ 3S •f!-C41YY,XA OO Y YA ~:03i3i2738~: 5i4016iA29•' 9176 .~`000OOC]30j5. :•uv Aau.3b 117'1(1;'1009 ^,~.. ~. a..E~. szao --.~auawa_nnr an ~____---__.. __._.-----.,.__.-_. sr~aw r~ nms 7 / ~ o / n 9 - - eHin~n~• --~ . .- _ _ _ Iq r_,wa,. F~ lr~ 4.JS.d-_.__ _._.__ a QPNCBANK ~~ NA. ___ _ _ C09i31273A•: Si~016-A29s• 92A0 _ - 9YSO $1,198.5'7 07/13/loop PATRKIA N. pVELr 8279 ~9 ~~ poi N[:4 RidFhil/~d. --- ~ ~ - 1, -~ ~... Yw.•.F• ~ PNCBANK --- _ ~` rr ~u.a,ww or ~:03i9i2738~: SLti016i824s' 9279 ~~•~ az.za o7jl4j$tln9 ~_ Itm ni.~ ~J, ~ ~d.____ -~, 9282 ~..s. ~. ^") /f. J w~ ~- N•r ~' .nr ! ~~ ~IM~^MA. MO ~:o313i27394 5140i61829r 2e2 _ ~~~ ~o.ov v//'YY~YW9 With PNC Online Banking, you can view, print and save up to the most recent 90 days of your canceled checks -front and back -FREE of charge. Please contact us for additional options. FORM953R-1005 Free Checking Account Statement For 24-hour information, sign on to PNC Bank Online Banking 1 -4 on pnc.coln. For the period 08/12/Z009 to 09/10/Z009 ESl' OF P/1TRICIA M DIVELY DECD Primary account number. 51-4016-1829 Page 4 of 4 Check Images FATATE OF PATg1CIA M OIVELV 929{ SUSAN O gOWELL EXTFIX C ~ toa nce Nat ao -u~ / 7 / as.nnim tN+ur+ . m+. 04 _ - -r.: s~~a: • S.~lliVa,,. ~nt-valL 1~.+v~.~ ~ $'•4553~'a~~; ~'s ~ _ _ rt v~ l..L~„d-ud:~~~~~4-'`°1.-ate. o ;:~ BANK •:03-3i273AV Si40i61A29/~ 9291 ~~~• 92!11 SA „~i55.fi0 Ots J l !1!2009 EBTAT! OF PATRICM M SNV[lV 9294 BVBAN O RONIELL FXFpX 7t~t am Nll RD m-+mon ownan,vwttau ~°2~L0~{--~ r.,+. a. ~P.~Co o.~.,e - - ---- _ _ _ - -- J $ /0/~ Ufa .tme-~F,ol~,,~_eaMd~IIb..IO ~5~7- _--R..!tnn a :-:~:. QPNCBANK ~i'~aw. N w Mn p ~/~ ro. ~!'r~e.rL_Q4.~~+-.a~ ~4Q-.,r_v /J_ IK..~..+.~_It~. I:[73i3i27381: SL4Ui6iA29M'" 9294 ~Kf~JC• 9294 $ I ,1114.55 t18,~ 18; 21109 ESTATE OF PATRICIA M DIVELY 8Z9G SU9AH O ROWELL EXTRX nm neo rn+ no ~o-ma,w awvt+r,, rw +,a+a _ _ ~ ~~. C~ a -T ;, ~c _f`.-s.~aul..v~~~elcv-c:l.dclla.r,•o!~ ~~a'"'~1hA1~.~ ~( L1°- Q YNC B/\NK ..~., wn, I:0313i2738~:__Si4Ui61829•• 9296 .~pf~l'165r' 929fr ~III.fiS /18,~2fi,'2111W ESTATE OF PATRICIA M OIVELV BUBAN O gOWELL EXTRX 97.A3 nwtn••N, vn tmta rtN a.c tt.~:fv~1:,Nw nq Fw~.k_.___._ ~!-~,...~ /V 1Ys-~-w1-JLQ-r ~:03i312738~: 51~.(]i61829+~• 9293 £,~-'hr'-1~ 9293 1;CiR.4 2 118,'2 ,'211119 ESTATE OF PATRICIA M OIVELV 92sy SUSAN Q gO1MSLL k1RgK pr / ^} tlq llf:D IIKL IID _, U II `'~ w. owuvrart. rw tfNla .., o.a~.a.[.~Uf..St'_ ~ia.~ho'S~'+GS ) $ f~fDr`~/ `y~~ ~7. _]_ M "- ~ /~'-wf- !fie 1. 1040 ~... .. .. +a~a,n 8 PNCBANK. M'I+~NA M ~,_...,. I:03131273AI: 5i40i~iA29 9295 ~~-~~`--'t 9`29ti $9(i.l Y 118; 211;'21111!1 With PNC Online Banking, you can view, print and save up to the most recent 90 days of your canceled checks -front and bark -FREE of charge. Please contact us for additional options. Free Checking Account Statement Forth. pa-rioa ~z~ovzoos to ovosiZO~io For 24-hour information, sign onto PNC Bank Online Banking EST OF PATRIGIA M DIVELY DECD on pnc.com. Primary account number. 51-4016-1829 Page 4 of 4 Check Images EfTATE Of PAT111C1~ M OlraLr 9304 aVBAq A RQYitLL EITNX IaAwwN. M ne°,i As7I o /oq ••.,n~m u d is e~s ~+ rytMw~e Cr~~l.+/-rl..a wit .Q . ~oXCo% ~J $:tJ38.67~m t L ~ ~ ~ ~,i,~ h-+.~.la(•u~ •'..~^^Y /!- •_ WET OL/~4~~mlulr-+~.~'~. ~ ~ ICBANK 1:D3L3127361: SLa0161629r 93D4 ~`i1•,-< i1 8AN ROWELL Im0'pX WaLr 9305 >!~~^~ ~ .3~/---------- oil, ®i'~~.- 1~•~ ~,:.is.k"" "" ,~ _..~. Fex _ w1~~ r 1:031312?361: 5 140 16 18 29r 9305 ,~00ooO1539.~ 9304 $388.b7 12/10/2009 930b $1b.39 12/10/2009 ~UTAN~O~IIOWIUCINXTMR7~LY 9308 IIYi IIeD Ili{. Ilp 11 O/1 n-xNlMf DMN10N, -w IAIi ~_ Ir o `~ P ~#~c s 3cb ^~~ 1:03-3127361: 511.D161B29rn 43QC tUODOOry tU8A11N o p PoNf~EU suxrMiui IvELr. ..9307 110 11f01rLL IIO rFxxxY)N dWA11N,M 17011 I ~ D-1 ~ 111 ',„a.; d .Ste 5/tr'+ o wk_(l ' $ ~~h~ ~C .~Q~~a~ ~` "~ ~...„ a ~~ ~y~.c, -1• Crwh~4B1 nl~,Oq Pp y~~ V11 ":-N1'D 12x3: ':JS'L_fQa 1fS ~iLL97da! :L.(.L~~ ~ . /: 13127361, 51016162 9307 b~Y400D0~+ 9306 $300.00 l2/lt/2009 9807 $400.00 12/28/2009 aarwTa oP PAmlca r ow>1Lr 930a svaAw o rtowaLL axrnz 11M N[D 1101. IM N„yyhlN s~,•.~ S 1 $ ~ ~ lfl~r, -;,~ : ~ skp ti ten ` 1 _.~llo ~t-w ~r.~ ~t~ -~---. ~LC.LU.! J~n[a Ciao"` `rt]~,~...3 _~'~ ~5' QPNCBANK I~~tlJPA~gN`A~ ~~yp~~{~~~~ 1:0 3 x 3 1 2 7 361: 5 140 16 36 29. 9 306 1~f115I413 2tiD.r 9308 $132.40 01;08/2010 fsiAra oP PATRIq~ 0i wratr 8309 aus7-n o aowau axmx 110 1118 1101. MO p,yyy,y,y 17wVMN4MIlili ~ 5 /V x. c">;a a .~.srlrl /left /~ -~.,~1 $ ,3Q(j'j.-1.~ QPNCBANK 1~•~J i~ J wD 13127361: 534015182 1P 9309 9309 $300.00 01/06/2010 With PNC Online Banking, you can view, print and save up to the most recent 90 days of your canceled checks -front and back -FREE of charge. Please contact us for additional options. ANDREWS ~ PATEL ASSOCIATES, P.C. 3912 TRINDLE RD. CAMP HILL, PA 17011 PHONE: (717) 761-8740 06/19/09 PATRICIA M.* DIVELY 16 SOUTH ENOLA DRIVE ~~K.i~m.~^.m~v~aa a APT 301 792 (1) ENOLA PA 17025 _. ~• ~ '' ' PATRICIA M. * DIVELY ( 7~~ . 0) _ 1 _ .~_ 0 3 / 0 3 / d9 IV PUSH NON CHEMQ D~Z~T~# ~ -~ 7 9. O p 03/18/09 Ins Pmt-MEDIC:E ~. , ,~~ ; 20.'4 .$25.17 was° 2~pp~~-~~i=~ to your- deductible 03~18/Q~ Adjus meet 27.91 03/20'/09 Reject-UNITED AMERT~ ;~~~TSURANGE 0.40 05/27:/09 Reb11--UNITED AMI~R~I ~~~TSUR.ANC~ 0...00 TOTAL` 'FAR PATRICT:~1:s M. * DIVELY. ,{~, ': ~1~ ~ , ~~~ ~~ ~y ~- _ _ .~. WE AC+L`~PT VISA AND MASTER CAR1~-~'T GTVE ZT~.. A CALL! TOTAL DUE CURRENT 37 - 60 DAYS 61 - 90 DAYS 91 -120 DAYS OVER 120 DAY; 30.3'5 3 0.3?~ " 0.0~' 0.0 0' ` 0.0 (~ O.O Q, i STATEMENT OF ACCOUNT www belw.org BEL CO COMMUNITY CREDIT UNION ' Because li cs or ~ivihy. 11AA1 OF CE: 448 Eisenhower &vd. Narrls6urg, PA 17111 PATRICIA DIVELY JOINT OtNNERS Pape z ,. ,, XXXX90 0 0801 i 'VISA LOAN BEGINNING BALANCE 0818 PAYMENT VIA OFFICE/MAIL 101 55 0831 NEW BALANCE-PERIODIC RATE.03284996 ( ATE IS ARI BL ) » ANNUAL PERCENTAGE RATE 11.990°6 « ******* CREDIT LINE SUMMARY ******** ** CREDIT LINE 0.00 C EDIT A AILABLE TOTAL DIVIDEND YEAR-TO-DATE for ar sarhgs azcept IRA. reporud m ~Innmal ORewnua ~vlc"a for Ws calel~r 1roar. *INDICATES EFFECTNE DATE 0 . 0 0 TOTAL FINANCE CHAR6E YEAR-TO-RATE far ap bans. NOTICE: See rovarse slde for iaportaic Y~formaUon. 1014' 5' 00 00 0.00 143.11 0620265 +ir V r~ ~~ .~ ^ Visit www.my.t-mobile.com to pay your bill online, check your balance & minutes, get product support, and shop for the latest ringtones and wallpapers for your phone! ummary Previous Balance $ Pmt Recd -Thank You $ 25.18 (25.18) Total Past Due $ (Due Immediatety) - Monthly Recurring Chgs $ Other Charges $ Taxes 6 Surcharges $ 19.99 1.21 3.87 Total Current Char s S 25.07 Current Charges Due isy 7/25/09 Grand Tota $ 25_.07 Your Statement Statement For: PATRICIA DIVELY Mobile Number. (717) 608-1799 Account Number: 290660307 Page 1 of 3 AT 02 036549 57307H151 A"3DGT PATRICIA DIVELY 16 S ENOLA DR APT 301 ENOLA PA 17025-2733 ~~~I~~II1~1~~1~~~~~~1~111111111~"~I~I""'~~'~II~II~I~y~~II~~L 128 ~`~ QLT Consumer Lease Services Visit our website at: www.gltcls.com ACCOUNT NUMBER 717-737-6522 CUSTOMER CODE -7600 JUL 16, 2009 PAGE 03 FOR CUSTOMER SERVICE CALL 1-800-555-8111 ~ JUL 16 EQUIPMENT RECOVERY CHARGE FOR PRODUCT(S) NOT RETURNED* ~ TRIMLINE ROTARY TELEPHONE 17.00 ~ TRIMLINE ROTARY TELEPHONE 17.00 TRIMLINE ROTARY TELEPHONE 17.00 *THIS REFUNDABLE CHARGE HAS BEEN ADDED TO YOUR BILL BECAUSE THE PRODUCT(S) REMOVED FROM THIS ACCOUNT HAS NOT YET BEEN RECEIVED. THIS CHARGE WILL BE CREDITED ONCE THE PRODUCT(S) IS RECEIVED. PLEASE ALLOW 2 WEEKS FROM THE o DATE THE PRODUCT(S) IS SENT FOR THE CREDIT TO BE APPLIED. 8 /~ `~"\ ,~ ~ `~ ~~ ~~~; CELT Consumer Lease Services Visit our website at: www.gltcls.com ACCOUNT NUMBER 717-737-6522 CUSTOMER CODE 7600 JUL 16, 2009 PAGE 04 i~ FOR CUSTOMER SERVICE CALL 1-800-555-8111 _~ FEDERAL TAXES .27CR~ STATE AND LOCAL TAXES .54CR~ - ~ TOTAL CURRENT CHARGES 41 25 TOTAL AMOUNT DUE UPON RECEIPT 58.42 *** F I N A L B I L L 0 r comcast® A(xOUNT DATE TOTAL O d NUTABER DUE AMOUNT DUE ® i ~ D Vis/f lIS OR th@ ItYOb 8t 09547409875-02 08/25/09 52.24 / Indicates the Comcast WWW.COl11C93t.C0111 services you subscribe >n __ _ - -- PATRICIA DIVELY I How to reach us... For service at: 16 S ENOLA DR APT 301 ENOLA PA 17025-2733 News from Comcast Hearing /Speech Impaired Call 711 Haw to reach us: 4830 Carlisle Pike, Suite D-14 Mechanicsburg, Pa 17055 (717)540-8900 Telephone Customer Service 24 hours a day, seven days a week Summary of Charges ~ l~eparea o7rlero9 Blued from oaro9ro9 to o9ro8ro9 Previous Balance 2.24 Payments (received by 07/28/09) 2.24 cr Comcast Cable Television 2.00 Taxes, Surcharges & Fees 0.24 Total Due 52.24 Detail of Chargers on back I c~ ~ i~~`y ~.~ ~~ ~'~``~ ~, ;~.~ ' 1 ~~ ~~' ~ ~ ~ ~~ COMCAST CABLE Comcast. 1555 SUZY STREET LEBANON PA 17048-$317 #BWNMZNH ##'I EDGDPI FGFPBI # AV 01 010164 816928 27 A"SDGT 1'1'111'1"IIIIIII'I'II'111'11'111'IIIIIIIII"I11'I111111~~111111 PATRICIA DIVELY 16 S ENOLA DR APT 301 ENOLA PA 17025-2733 Please detach and enclose this coupon with your payment. Do not send cash. Make checks payable tD: COMCAST CABLE Date Dw Teel Amount Dua AMOUNT ENCLOSED 08/25/OS X224 $ 000-08-0~B-C Account Number 09547409676-02-5 I11111'lllliltlll'I"11111'III"'1'1111"1111111111'1111'I'I"II' COMCAST CABLE P 0 BOX 3005 SOUTHEASTERN PA 19398-3005 09547 409676 02 5 6 D00224 CENTRAL PENNSYLVANIA RADIATION ONCOLOGY PO BOX 11268 LANCASTER, PA 17605 1-800-615-8170 I' G ~"/lern ~, ~~4nQ ~ is ~ ~.t~ N.~ ~ Dear Sir/Madam: We are unable to process the check recently received from you for the reason (s) indicated below: DATE: ~ C~ ~ RE: Acct#_ 1o a S(~ i~/75~ Signature Missing Check Not Endorsed Written and Figure Amounts Do Not Agree Check Expired on Not Payable to Paid by You on Unable to Identify the patient; Please send copy of bill. _ B e ue is Less an^%heck. asd by Y ~ the on If you have ar~y questions, please contact our office at the number listed above. Thank you. Sincerely, Billing epresentative for Central PA Radiation Oncology Billing Date: 07/29/09 Page 1 of 6 Telephone Number : 717 737-6522 ' Account Number: 717 737-6:122 001 31 Y MRS P DIVELY Account Summary Previous Charges $ 31.11 No P_ay_ment Received _00 Past Duo Charges (ploas® pay now) $ 31.11 New Charges Verizon(page 3) -$_9.04 Other Providers (page 4) 50.88 Total Naw Charges Duo $ 41.84 Total Due $ 72.95 i--M6-VZ-MOVES Moving? 1-866-VZ-MOVES One call gets you up & runnings Count on the Verizon network to make at least one part of your move easrer. Across the street or across the nation all you need is one call to Verizon to set up your Internet, phone & digit~rl TV in your new home in no time. Service availability varies. ~~ Please pay upon receipt -FINAL BILL - This Final Bill may have already been referred to an outside collection agency. Pay your bill online at verizon.com/paynnalbill CONSUMER ALERT! Check your bill this month for a new service provider. Questions about your bill? Visit verizon.com or call 1-800-VERIZON (1-800-837-4966) Change of biNing address? Go to venzon.com/billingaddress or call us. Get More, Save More. Lei Us Heip. At Verizon. we want fo make sure you're getting the best services of the best value -from phone and Intemet, to TV and money-saving bundles. Call 1-888-652-811 i today, and together we'p evaluate your current services. and find ways to save you even more. ~ ~'~ V ~ ~ 1 ,~~ ~,~~ u (,. ~' i I1 ~ ~,, °t (~ ~ Detach 8 return payment slip with your checl<, payabb~ to Verizon. RE1F7737-7 EX + (~} REVERSE ~ ~~`.~ Pennsylvania SCNEpYLE J DEPARTMENT OF REVENUE s~N~'j'C,wR,~ INHERITANCE TAX RETURN NONRESIDENT DECEDENT ESTATE OF FILE NUMBER Patricia M Dively 27-6144797 When flat rate method is elected, list the beneficiaries of the Pennsylvania property. When proportionate method is elected, list all beneficares. ITEM NUMBER NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions and transfers under Sac. 2116 (a)(1.2)j 1. Susan Dively Rowell 1109 Red Hill Road Dauphin PA 17018 2. ~ David Dively 55 Edgewood Drive Mechanicsburg PA 17055 3. ~ Kimberiy Dively White Caisson Court Enola PA 17025 4. ~ Lisa Dively Cale 3501 Matter Drive Mechanicsburg PA 17055 5• ~ Ronald Dively PO Box 219 Ocean Vew DE 19970 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE o Not List Tnutsslsl OF ESTATE Daughter Son Daughter Daughter Son II. 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON REV 1737 COVER SHEET OR THE PROPORTIONATE METHOD WORKSHEET ON THE REVERSE SIDE OF REV1737 COVER SPIFFY, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1 B. CHARRABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF M~ II (Enter total non-taxable distributions on Line 13 of REV 1737 cover sheet) ;0.00 (If more space is needed, use additional sheets of paper of the same size) ~~ ~ ~~ W } ~. ~.;~ ~ ~ 0 ~ Z 'a ~~~j ~~E~ v0~0 ~" ~ ~"zA o~ cn ~(>`~O~M O w U¢ W o 0o Ey O U Q' ~ Q~~ N O C~ ~ U ,~'~ O H ~ a~~~'w ~ N W~~~ °a ~ ~~~A ti N ~~~ ~~~ W Q oW. ~ °' ~,, ~, ~ e~ o W a QU QW~~~U a ~ w o Z E-~ a ;~ z a ~ ~ ~ ~ ~~ w w REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF~~tETTERS No . 2009- 00683 PA No . 21- 09- 0683 Estate Of: PATR/ClA MDIVELY (First, Middle, Lastl Late Of : EAST PENNSBORO TOWNSH/P CUMBERLAND COUNTY Deceased Social Security No: 184-26-7329 PIHEREAS, on the 23rd day of July 2009 an instrument dated August 26th 1997 was admitted to probate as the last will of PATR/ClA M D/VEL Y (First, Middle, Lastl late of EAST PENNSBORO TOWNSH/P, CUMBERLAND County, who died on the 12th day of July 2009 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: SUSAN L ROWELL who has duly qualified as EXECUTOR(R/Xl and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 23rd day of July 2009. * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) n o - :~ p . ~ - -~ ~~-- w r ~ ~ ~ ~ ~ r_ ~ T.> r LAST WILL AND TESTAMENT PATRICIA M. DIVELY ;-~,```; ; - '~~. `. _ - . T` ~ _ N ~- - I, PATRICIA M. DIVELY, of Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make and publish this my Last Will and Testament, hereby revoking and making void all former Wi-lls by'me at any time heretofore made. ITEM I. I direct that all my just debts and funeral expenses be fully paid and satisfied as soon as conveniently may be after my decease. ITEM II. I give the following specific gifts to the following grandchildren: (a) I give my gold ruby ring to my granddaughter, Alizabeth Dively. (b) I give my white gold diamond. ring to my grandson, Daniel Joyce. (c) I give my antique rose gold turquoise ring to my granddaughter, Catherine Rowell. (d) I give my gold ruby with diamond ring to my granddaughter, Devon Cale. ITEM III. I give all of the rest, residue ~ and remainder of my estate unto my five (5) children, Susan Rowell, Kimberly Joyce, Lisa Cale, David Dively and Ronald Dively, in equal (shares, share and share alike, or to their living issue per I'stirpes. _ ITEM IV. In addition to the powers conferred by law, I authorize my Executor, in absolute discretion: A. To retain in the form received, and to sell either at public or private sale any real or personal property. B. To manage real estate. C. To invest and reinvest only in forms of property defined as legal investments according to the laws c>f the Commonwealth of Pennsylvania. D. To exercise any optional rights arising from ownership of investments. 2 E. To compromise claims without court approval, and without jthe consent of any beneficiary. ITEM V. It is hereby directed that my Executor, hereinafter named, shall pay all inheritance, state, succession and legacy taxes to which my estate or the transfer of any property hereunder may be subject and to charge such tax as part of the administration, payable out of my residuary estate. ITEM VI. I nominate, constitute and appoint my daughter, Susan Rowell, to be and act as my sole Executrix of this my Last Will and Testament. In the event of renunciation, death, resignation or inability to act for any reason whatsoever of my daughter, Susan Rowell, I nominate, constitute and appoint my son, David Dively, as Executor of this my Last Will and Testament. No personal representative or fiduciary appointed herein shall be required to post bond or give any security. 3 li IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~ ~ day o f ,~'~ ~-,; .- ;~ - j 19 9 7 . i ~t-~'~G~~r~..;' ~~~/~• I .r (SEAL) PATRICIA NI. DIVELY ~ .The preceding instrument, consisting of this, and three other typewritten pages, was on the date thereof signed, published and declared by PATRICIA M. DIVELY, the Testatrix therein named, as and for her Last Will, in the presence of us, who at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto. 1 ~~...-~~_~.! Residing at -~ Charles d. DeHart,1II 3631 North Front Street Harrisburg, Pennsylvania 17110 L ~ y'..:~'}~C=~'~~ Residing at 91354-1 4