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HomeMy WebLinkAbout06-14-10REV-1500 EX cos-OS) PA Department of Revenue Bureau of Individual Taxes PO 80X 280601 Hanisburg, PA 17128-0601 15056051058 INHERITANCE TAX RETURN RESIDENT DECEDENT BELOW Social Security Number Date of Death __ - - r- _ ~._.~ ~ 200-34-1501 ~ i 01/09/2009 ~_ _ ..__ - _m~ Decedent's Last Name Suffix ~ _. Jones E _~ ~ ....__ ~_ _ ._W_ _ ____ _ _ ____._ _ ~__..; ~~ ~__ (It Applicable) Enter Survhing Spouse's Irtt'ortnatlon Below Isom Spouse s Last Name Suffix Spouse's First Name Mj [ __ _ __ _.. _. ~.______ ... __ Spouse's Sodal Security Number '~~~ ~"~~ ~""""~"~`' THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~_________~. __. ~3 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Olp 1. Original Retum p 2. Supplemental Retum t 3. Remainder Retum (date of death prior to 12-13.82) p 4. Limited Estate p 4a. Future Interest Compromise (date of C~ 5. Federal Estate Tax Retum Required death after 12-12.82) t~ 5. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust _____.. 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) t 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and i-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION 8HOULD BE DIRECTED T0: Name Daytime Telephone Number _....._. Nathan C. Wolf Finn Name (If Applicable) Wolf & Wolf First line of address 10 West High Street Second line of address City or Post Office State ~ ; Carlisle ! [ PA _ _; t Correspondent's e-mail address: Under penaltlea Of perjury, I deGare that I have examined this return, Including accompenying schedules and statements, and to the It fa true, correct end complete. Declaredor~parer othor than the personal representative Is based on all information of whkh SIGNATURE OF my knowledge and belief, ~r has any knowledge. ADDRESS ~~~ 10 West Hi a Isle, PA 17013-2922 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 OFFICULL USE ONLY County Code Year File Number 21 i 09 10378 Date of Birth ~____ ._ , 08/29/1945 Decedent's First Name ~ MI - -- I Juddh ~A (717) . ~ ~ •+-~ _ ~ ~ 7C "C' r: ~ ~~ i V 3p i 17 `: .C- A fv ``'~ ~ _.___ "~ DATE FILED . ZIP Code ................ 17013-2922 J REV-1500 EX Decedent's Name: Judith A Jones Decedent's Social Security Number 200-34-1501 RECAPITULATION ~_~__._~_..M,_ _......_~__ _~~~~......_..~ 1. Real estate (Schedule A) ............................................. 1. 100,000.00 i 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporstion, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 1 4. Mortgages 8 Notes Receivable (Schedule D) ............................. 4. ; 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 4,747.86 6. Jointly Owned Property (Schedule F) C,~ Separate Billing Requested ....... 6. 1,233.04 i 7. Inter-Vvos Transfers $ Miscellaneous Non-Probate Property (Schedule G) C'.~ Separate Billing Requested........ 7. 14,896.83 8. Total Gross Assets (total Lines 1-7) .................................... 8. 120,877.73 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 25,507.58 '': 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. 192,217.86 ' 11. Total Deductions (total Lines 9 8 10) ................................... 11. 217,725.44 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. -96,847.71 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. 0.00 ': 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 45 16. 17. Amount of Line 14 taxable """""""""" at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate X .15 1g, 19. TAX DUE ......................................................... 19.E 0.00 c _ ............._______._.___..._.~ _ ._ -, 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 C~ 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Num r 21 09 0378 ~~ DECEDENT'S NAME DECEDENTS SOCIAL SECURITY NUMBER Judith A Jones 200-34-1501 STREET ADDRESS 1004 S. Hanover Street CITY STATE 21P Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FIII In oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................. ........ ^ b. retain the right to designate who shall use the property transferred w 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 12,19132, 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 acceunt 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? ................................................................................................................. ....... © ^ 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 p2 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 disdosure 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-1502 EX+ (11-08) ~pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT __-- - - ESTATE OF FILE NUMBER Judith A. Jones 2109-0378 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 fads. Real property that is jointly-owned with right of aurvivorehip must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant In common. VALUE AT DATE NUMBER OF DEATH DESCR[P'TION -.,_.., m ..~- .._.e „....~. ~ ............. .,~~..~ ..._ ...... ...... .~W,..~.,e,am , m . ., ,air ~Mrr „ ,...a.-a niaa ~r~ sra *~ 1' ;Residence at 1004 Holly Pike, Carlisle, PA 17013 100,000 00 (Value per agreement ofsale -attached) TOTAL (Also enter on Line 1, Recapitulation.) 100,000.00 If more space is needed, insert additional sheets of the same size. REV-1508 EX+ (8-98) SCI~IEDULE E COMMONWEALTH OF PENNSYLVANIA VMS~"'i BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT E8TATE OF FILE NUMBER Judith A. Jones 2109-0378 InGude the proceeds of litigation and the dale the proceeds wero received by the estate. All properly jdMly-owned with right of survivorship moat be disclosed on Schedule F. NUMBER _-__ ..1 VALUE AT DATE 136.30 75.59 933.94 ~~ i~i4 1.66 l~~l~ ~:x,~il 1,284.12 a F.p i3 m.. i 2,116.25 i.3,~ kip ~,. ~~.~~, 200.00 •••• , _..... fib. iY ' Yvtiiia 4 p ' ltMP~'. v ~wr~.~2.., TOTAL (Also enter on line 5, Recapitulation) i ~ 4, 747.86 ~~ (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (OS-10) pennsylvania ~i1 DEPARTMENT OF REVENUE INHER[rANCE TAK RETURN RESIDENT DECEDENT SCMEpULE F 70INTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: JudRh A. Jones 2109-0378 If an Betel became Jointly owned within one year of the dacedent'a data of death, It moat be reported on Schedule 0. SURVMNG]OINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TD DECEDENT A• Lynn Jones ~~ ~~~~~~~~ ~~~ 306 N. Old atone House Road ~~~~~ ~~~~~~~~ ~ ~~ ~ ~ ~ ~~~ Daughter-in-Law Carlisle, PA 17015 i JOINTLY OWNED PROPERTY: LETTER DATE DFSCRIPI]ON OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FlNANCIAL [NSTTTUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE Of DEATH DECEDENTS VALUE OF NUMBER TENANT JO[I!T IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DEC®ENT5INTEREST t. A. ~06111/OU Members 1st Joint Checkup Acct No 19802511 ~ '- 328 75 50~ i ~ 164.38 2. E A. w... i 08111/00 ~ _ ~ m. _ ._ ~Memt>ars 1st Regular Savings Aat No 196025-00 ,~.~ ~ 26 46 _ ~ 50~ ~as~~~~a~~.~ = 13 2 ~ . • ,. ,~ ~ " » I %N~' '~S.'tY.1~684968S~ed4Y1" ~ . kA&Yrc 2F&Y'J' 3. ~ ~ C. ... 02116N1 ~ . Members 1st Regular Sarongs Acct No. 202066-00 a 5 66 50 I. 2.83 e k ~ . _ ~ ._ _ ~ Rva~,m~.m~,. ~ .a~~. ,~ n~ ... ~ ., ._~ _ .. ~~. __ ~ 4 ' ) B. ~ 11110193 ' Members 1st Regular Savings Account 130540-00 ~ x~ 2,048 51 " ~ 50€ ~ ~ 1 023 26 r[ i i • •• ~ ~ ~Ift^ k5 b ~" .~ .,.., ,_ . ~~ 1M t Yt ll 9 ~6{ ~8y d vY 4L N ASRN ~I ~I ( ' . r ~ 5 ' ~ B. 11/10193 Memberts 1st Investment Saw s Account 130540-05 ~ 58 68 50 29.34 , a a~ ~ ~ E , ,~ ,_ ,~~ j 1 QE Et ' t . ..., ...u.. i +ryNIpBd9YA ~` ¢ ~ i d d S . ~ LL J WYll9 ld' 35 9ry ~~N 94 x... 14 A!e 1 j ~ ~ i a 1 e - " " ~ 7~ . _. f .. _ ., _, _, ~__ .. :*i N k d8&d& dlu4 s~ S~AY383b PN rnFdNA$(¢ C[( f : 3 ~}x~ .tl aPA A i +. x a a - . ~3'Sa~ e^e $9~aRi~.i3T 3 ' ~ ( ( ~-~ ,..,. ,. C rnw_.. € .,r.,. ,. __ y :1 ~ _, . ....:_ ..,..r_...: ".,:, . :~ _ ., .~... ~ ~ .a. _ ~ ... ^° ~ ~.~ mraa r.,w«..,-.«waww~wnyx #~wz,,~wcavaP s ~~ .., ,: _ E ~ ,,~n~.. -~tt~~r +, r ruwt wFrs.~:a~n~m - _~ . . ~ S~ ` ~m E r z Sr;~, ~~ E ~ ram r -. ~ ", { M~ GVwPd d9A~kfitledMr o 4kN3P'M~ K ~. ~-. .-. ...- ., .... .... ..,, C d Xr9vis °AAYS%6%Y:LP w S ~ ~ ~.3~(~ NdIYtL6 4N12 i MSkH1dIG •~ •• p '~ -'.' i XG,%L^ Sa#YN RY&'B EG~ ~ b . ~ aa aj~~*Nmi PI] 61(rOs HR p e~ ~ i ~ j I 5 .„........ ,., L , .. YF = ` YS +~RFdPd~ _~F-`.ter ry I 1 ~a'. ~S x ^dN4Y~6RLe.C .. r. - e L .. ) ... .. .. ... .......~--. . ern . v v n m. 0.°A ~ Z r +R ~g Sa~,.~ a '~ ~ "iS s . . f ... . . . e ee .. e gym. ypyq .. J/.i ~n ~i ~ f oy ~ vim" ~'sJSJVW ~j fa jj ~' ... _~_ ., ... tVet Oa ~0.rc'ttD 81 x((i /~ ~~~ 7a ' .. .... 3MU YfA M1XM1rF.s.e . ~. :. sikd~7{.,y i JF . w .. ., u.rt. _ .... ~: .i... .......~ .e. :`.' ~ ~~ " . nY 3 IA ~ A a .: .~ ". t 19 1 Ale ( . A ~ . .. . . e V vA1 x .c x 6GY6fy ~A, '" t :. "w,+! . PLeE9C&5„14~°6.uY_ ': r ' r ~. .. ( i.... . ....... ...... ...... .. r oa. ._..n ..x .. ..... a„ `4 ~5. .@ i ~+.U/nr N L........ ..».. 9 ~, SL 1 Y. ... . `~'iAi}bVX8S9 ~, ~~~ , ~s. ,;, TOTAL (Also enter on Line 6, Recapitulation) # ~ 3 04 ~`~, ~~. »~~.~em~ ~ 1 23 a~,~~ . if more space is needed, use additional sheets of paper of the same size REV-i51p EX+ (OB-09) Pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Judith A. Jones 3109-0378 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFERff, THD0. PEUTIgI51aP TO DECED9iT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE Of iTUNSFER. ATTACH A COPY aF THE DEED FO0. REAL ESTATE. VALUE OF ASSET INTEREST pP APPUCA&F) VALUE I• m __ ... _ ~ ~_,.. ......u Members First IRA Account No. 130540-10 Ex-husband David Jones ~~~ ~ __». .~ .~. ~ .__ _ ~. -,~ , 2103 100; 21.03 2 Members First IRA Certificate No. 130540-16, Ex-husband David Jones ! ~ 14,875.80 100 14,875.80 TOTAL (Also enter on Une 7, Recapitulation) ; Ifl 14,896 83 is a~ If mare space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (12-99) SCMEpULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUIYIBER Judith A. Jones 2109-0378 Debts of decedent must be roportsd on Schedule L ITEM DESCRIPTION Name of Personal Representative(s) 2. ~ Attorney Fees 3. I Family Facemption: (If decedent's address is not the same as daimant's, attach explanation) ... __ ~..,.,„ew......._ . ..._ ....... ... ... _.... _ .., Claimant '~ .~ _.._. Street Address City `State. _.. _'. Zip .._. ....,,.. ..~...._ ._......u. _._.__, .,.,..o,o.o..., .. ~ ., ee.~a~q RNationship of Claimant to Decadent 4. I Probate Fees 5. I Aceountent's Fees 6. ~ Tax Return Preparer's Fees TOTAL (Also enter on line 9, Recapitulation) ~ ,31. Su zrz -Y"_YEM1`k?Y'e0..914.ih 1. INX~ ~ .w~ .~ , ~.r,~ „P~~ ,.,~ ~~~ 6,000.00 °:.°~ro~~„~,.~:,,~~~ ~r ~.. .~.~~ .,, x1r~~~W~~~~~.~ ... ~.,. ~~.,..~,~b. ~ ~ ~w9, ~ ~,~ ~ ,~,.~~~ 335.00 roes. .~w,.9 ~„ „ u nw~,w ~..Rl~w. ". 9~ .~ ,w. ,- . , .~w,~ r~l~~ ' R ..x ~ ~ ~~ ~ ~~ ~ _. S ~ ~ ~. ,....~. ~ . ~ ~, ~ ,w~ , 9~1~~ ..y~s~ a 198 16 1. ~ . ~ ~~.~ ~~~ .~~ 75 00 , 19.1 ~ ~ . p.iMAF94H9uY P ~ ~ ~ 8 534.78 ~~. ~.. ~.1 ~ ~ ~~19~~1 9~ ~~~ ~ ~ R~9~~~ ~ 998 00 ' „~,... '" , 9 3~ ~..~ i~ 453.02.E ... ,..1~ ; , , ~ . 25,507.58 (If more space is needed, insert additional sheets of the same size) r, ...., ~ ~.~~11 4.,, ~'!: aev-ISIZ ex+ BIZ-os} LE I SCHEDU pennsytvania DEPARTMENTOF REVENUE /~ DEBTS OF DECEDENTr INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE Of FILE NUMBER Judith A. Jones 2109-0378 Report debts Incurred by the decedent prior to death that romafned unpaid at the date of death, including unrolmbuned medkal expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH I. ,Members First Loan Account No. 210975-01 14,224.39 ....._ .., m^~ _. _., .. s:....,.. ..., .. .. .. _ .. u,._ ..... .~ .. . ............ ... _, _...._ .q 2 ` ~Everhome Mortgage 1409000299119 @' 131,177.00 ti. _-. 3~ _._ .. ._.. .. ~ .._ _~ __ PPL Electric Uhlfies 37201-22013 ~ .~, ~, ~~R,~ , „~,.~~~7s.,, ~ 1346 10 barq Acct. No 717 258-8144-093 ~ . ~ ~ , , 483.57 ~. 5 ~ .:... ~ ~~ ...._ ~ ~ ... .. _~ ...,- u..,_.m.._._. 'Borough of Carlisle wateNsewer 011999-000 r~~.~...~Sa~6 a~~a~,. Pe ~~ y, 62 25 ~: ,~ ~ , r . : : V~H 6B Ea Hd e.. xn ~ A= . _ -. ...__,. ~ . ... . ...... :....... . - - ~pnz ua„u sawapt..wa...r a~ k.+s..,ui n=.. ~~ y 6' AOL0993201076 a99 ........: ... ......._..., ....,w._., ......_...... ... .... .... _ .. _... ~ ... r„x~,:~~~a~:~e~a,~: ,~ ~ ~,W~ 7 . ~ Cam Hill Eme n Ph iaan HYP33596354 p ~ ~ 22.90 ~~ ~, ... . ...... .. _,. . _., ...... ..... , ... -. . ~.,~ . ~~~,~m~ - _ -.. __ .. 8 Hershey Kidney Speaalists Inc. HKSI 4175 ~ 36.58 _ _ __-_ . =ie .... ~ ~~~ :~:~e~~g~~~~ „~x 9 DirectTV 38244959 198 64 - ~~ m.:. m - ,~ ,, , " ~ . ~" ft ~ IV , .... ..- . , ..,. .- . ...___...... .. ' .s i x~x5p2&5gv84 f 1„~ 10 Landstar Investments II 20LS0129 43,052.58 ~: __ -~ .- ~__-_.. ~ ........ ..... : ~ ~: ~: a:: ~ .,u__..~,: ~,:~~~~~~~ _ .. ._. ...____ - .........~~_.. ___. ~,,,,,~~ e r-ro ,~~,~~~~~~r~ 11 HSBC 5458002211301769 ~ 975 67 w. 12 ,~~r ~. n - ...- Citibank 4621205041460888 j ~,.~~,~~~~,.~ ~ 595.28 . ~:.-... ..- r~ m_: ~ ~ :~: ~ :, ~ . .µ ~ ~~ - ~m~ _ - _ _. ~... - . . ..-. ..... . .._-M_ . ... ... 13 Healthsouth Rehabilitation Hospital 732812 i ~ 11 00 _ W ~ ,.... i _ . ::: ip 2'W+.R`FC$LpN.~G fs.U.b~eR 'k ~ Jl( _ 14 . . _••• •._•~ , • ~ West Shore Pathology ~aax -flk.`EB +YP1E15""8H9dd9e 21 fl 3 vi 7 31 W : < <: . ~~- r - ~ o~ a ~ ~a~~,~~s, . _.~ ~ .- ~~ ~ ~ 6 ~, A,~,~~ ~~ ~ ,. 1 ationwide Policy 5837C 503731 5.60 ...f . D. aP£ Y 3 3wEd~PJv NPr4VJ WrYdie'CA3Rii .. .. .. A,«..,....«o.. a '°`% i>2}rrn.x343 i r,.~f45 r.. _ i 3 ~ x .. ,.~...... -........ .. ....e ............. .. ...~.~..., e -..P ........e..... „ . ..... ..................,..., . ......... ..........~ ~ i ~.rv*z°.+et~'tiLi:~btitl3+29H5~'a291. d9 rII~CA"e `+~ "~ _. ... ........ .. ..... .....,_,, __..._.~ _... races-~~s avawreaiat awi~nivexew^~7*rAgo- '. yk, ,. .... .. ,__.. rvW .,., .::~r .. .,,~~ ._ .,,. :. ,. ~........ ~_. .~ ,_ .. .:. ..._ ~..~.~ ~ Us bid 4M eu~maflrriwiutiw.a u~~ r. ~,._..~a~i ~u~rawhm~r ~ ~ 3 Y. ~ - M ~ ~ ~ ~ ~ ;: r - Y 3 K+ 3'0.Atidfl 4Mlhtl "i'£Y.C(4+'f.""'T ' „ . . . . a . «.~ f~rtni yeas=: ~°'" ~t~na .na er~ip A I e ~ - ._.. • ••••• •,• •. ~. VBpbBNJ i'~Z'ARW$BPsP ~~B.+dWPN%'~VMHBPN.(&tlRft9gvevf' f~.Wdwf#h a6E ~ ~ 3 ti3'i~Sd RLkitik`Jip 'M3Y.J~kWbvd 7 9 i aa S j y dd $ 4 ~9 2 _,,.n '~ ..... ON, P .~..., ........ o~Y.a ........ .~ .~~ ,.,.~ .......... .::. ... llu ......_. .~` _ ., __ r ~ H ~ e 2 5 lifl'B~M~J Y i ~pevn4 o i Ds e v , . , ^atla Y 1~jy '°~~ 91 ¢W 11 i 9 ~ Y le 4 V: dYx'SHH e89. m. . T _ ., n ~ m e e..y,, - ~ it1 P . f ^f^ "F`,~b 1 t.wLYC~ L:M1e'!A', 4Y 3 r ..-- .. ... .., ,. ,,.,,., I yp idiiifniXaei aAY$N:.."!.L44.LCALt4YG&Ap4L'aia~ta5~i. -"" •.•..• ~ ljiWNNI oM' AARtiI( A2..s S4v.4d Odd (~ 33333 ~. ... .:.~ 'PI! 6'icn ,. .r.., .' x'~'' YlMililli rix~n~~ppv„prt{:2@.. ~,:a& a t .... ., ~ _. _ ,._. ... , ..... .. .. ~_ ~ ~~~ _ .w _ .. ..~ -. ~~ _ _- .,..~. , , , .., .~ ._._ ( yy pb it i~ ~ u~ ,~ eszaw ern ~~ ~~ ., ., .. w. ~I4Yb1'IYwed3ea ""~'~.k'-r ._~.«iP',P lqk TOTAL (Also enter on Line 10, Recapitulation) # 192 217.86 if more space is needed, insert additional sheets of the same size. FROM JU11 GJ VJ V. ~ i..N (MON)JUN 28 2008 14:24/ST,14:23/No.8301851132 P 2 FO13lIe RAYAG20t AGREEMENT GF SALE Rev. yos Page 1 d( Forth approved b1' REAtrORSt) Aaeclafion of Yak and Adams Countfee, ino. Ths rua of tMa Poem is rasensd rpr and rnMdsd to mwnbew of tha AIALTORifJ Asaoeptlon of York Md AAMne Catolles, inc. '1 / f~~~k ~~"1'~-~~7"s suesnss(xutrE: y~.:ucr~ 'l~J gR010FR: .- -~ ( ) Trsnxctien licensee Adlrlg ": ( ) suysn A°°"` ()Duel Apap ( ) suba-gant ( 1 DKI4na9ad Agord br gayer w(th &beer a Ouai Apanf of Seger and buyer tar r`^^P r10N 1Mr ~ ~ ,L,~C SALGS ASSOCIATE: ~T~d / ~OLt Iwt,~V Awing as: ( ) Seilels Agent ( - Tgntsdlan Lbensae ( ) Dual AgaM ( ) pwlansead Agart f!or Seller w(dl9rokar sa DuN Agent of Seller and Rryar THiS AGREBdENT k made {Ms 1, pARTtlS: akioswt ~!~e karaikMeralNd 9Nrr, and (raafdlnp >< hlreMatlar ralNd 6afa~ ~,d _ pyre ,2009 2, pNp'gp?Y' $Misr hereby aaraes b sNl and- eonwy b Buyer, who hsroby ageaaa is purdrose ALL THNT CERTApJ end M ~aurtd sntlt tr+proaamerl4 araraan, a arty, known ae ' nni a a..ewrc alt Cam1111a _ Y~ (,ad G4~batlaAA . SIeM_ y~_ . ZID IMnSfinRon: (Taw 10 r; ParaN dl; Deed YesklPapc~ ~ X02 j 3, aONNiG: TIM ZONMG CLASSIFIG4TIOat dthe PrtlPKhr h >~aroieiaatial , . Fsiure d Nis 14otaemelN b oaaala the t:wrbMl olMrNwHar l~M let gases rArora are pro)rerb and cook aeoal tlrrstlf, i< lrbdyh/abla. K earrsd Ady a prMrMdy b psesat airtON isndly daapnae) slal rarrdM NfE Agteemtnl voidsbk al Oe QOdo^ N ItM tauyar, and. t Iraidal. any depNi tendead Oy tIM 6uyM sties bs roturnad M bM euw- asptaul anY re0~ro"M^t ter wart asdan. a, -URCIM>Iti PgICE: The DarrhaN v!lee A f )<QO.D00.00 (Ohs hu ~)tAobaa~ salt aeauMalenlaty7ae otsaalsmcrd. S, paFOtRJt: 9eCVray ter the pwehasa Y b N as foaows: ! a> CMhktreak at danlnp dddt AgraaaMrd. ` b) Casb/rJMd` as °` belbre ~ --~"'-' Z 1.000.00 p lrotHbNNlso~f)!at tw RNr-NglKti t:Ow>itlsOeNCY: Tha sale to eentinpael upn IM tetlowrrg aerartdnp br t'Juyar. r} Tlrs aewaat d t'rral iMa+akq of ti ~- _ . k for a term d ~ teak. TIM 41ia d NMnabra i n~+y_ ^ Flyd ~ Ad}eRaW Cl Ilwlnd wkh an NENwI tale a ,~_ 'li: karrawr. euyst apnea asargtlha inhwe! talc aft myr be oamnitbd by w modpaos IeMKI rtal b akoad a erNltMrlm MtraM rats d n/a aA. b! Tha atato-wrt d taesrd rrMrOagl 9ninarp b1 i 8f!• , Is far a teen a n/s yawn wN(h an iwnse rate d Qua x- gTha BNsr apraw to teat' tieyefs olosMp asaY. PnP~ axvartstro b the nuslnMa antoum d d) 1'ha npaMnum fYtMOb1p pls0artract, arYiMlbn. a leak dMosurp tlss, b 6a Pall by !tlYER ehai nal arced % of loan amaum. e) Urdeaa amsrwes agreed by SOlbr.b~snpNY krTMamt ~ M Wlon Mgt a koMomwR of any nM awtf owned h~ sryar. q salter shag make a aompkNd ayp ktr arW Paaa sspert, m • rasponMbN tsnd'rnp hatbrrllon oeWr babre n/a . Sneuq ill ltuyarhi b mMM such narrrldsted ~bn w1NrM tM aaadpetl IbrrR IntAN svap. Ne Salkr shad halts pN eerlDlr b tlaWer! etkf AgMNnara nutt Dad sold Nrd sled a aeaapt MM fbtleild Nearly dapeap as liquidstad danraess eN NtMlaWaly fealr ardua tlarrttfgn agatnse M aeryay as n aor~fwarenee wph appicalts Itw one regutaaens as roots hear sat fever ik para0raplts t71 and la dares Aoeaamere. 9) AI arras na laths as above stked eanerot t» d„rgea wtutoea Use wMlpn osnaant d atl genial, h) M wrNtars mer~aae wmrrdtmsrds must be prtlvldad b Satter by n(a providM, however, gayala mortgage eammNnad must not M condltbnad upon aerpiastbn of Buyer's amphymant, era8, Ineaerte or oerrrPlottso d reel samte eppraieM. H wdaen oorranikreents ate not received by the shots data, Buyer and Sower agree m esterW the oeemm~twM ems until SsNes latminotaa dvs Agrownem in wripkg; aotl in such event. arty depoell ahal ba retumcd eo Sayer. 7. ADDITIONAL T@1tliS AND CONrINtiBiclES ARE a) tllhwen aa'sWarrra o1 ell paAMs must W obtsirwd oa or uetoro: June 29 2009 - 6) gaabnrent fa W be made on d helots: Sae 7f t) Potaeaslbrr e b ba daiverOd: E-r - «..y~asnt q Paymerk IOF Iranskr tikes wlu N OM+ded e9ualy hateaan sayer and Seller. N A1! Mleorne and eapaneea. IneNahg bw rral purled m rest aststa teas. rend, wabr, sorter sad refuse charges, condo Nos, homeowners' osseelarion teas sad slrtstlr aear°at. Prate er vrMaEe. shall ba gestated to dell a/(aoalameeWposaeseiore) on a teal ysor bash. n Dsnosit to hs Qirs~s_to attotnsv'a osesrow aesuio pt witJffn 3 dsvs of duo tliliawrsoe pos~iod. borpan 4bairs 40l $auW Gcoge Strew. Yok. PA 1710? `~ ~~ '~~C2f , ! 1~n/ c...r. ,.r r...r: allnwr 171'11 a1F , d[M F.r /91'.1 ArA -Han a^- ~~^'1 / ~' , ~- ~L C.~ June 24, 2009 NATHAN C WOLF Esq 10 W HIGH ST CARLISLE PA 17013 Estate of JUDITH A JONES Date of Death: Jan 09, 2009 SSN: 200-34-1501 Dear Sir/Madam: 525 William Penn Place Suite 153-2618 Pittsburgh, PA 15219 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of her date of death. The decedent had 2 active accounts at the time of her death and she had no Safe Deposit Box. For IL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-888-999-6884 Sincerely, Phillip Lynch Operations Services ~~ ~~ L'J Account Number 6219043700 Account Title JUDITH A JONES Date O ened 10/17/2008 Account T e Checkin Princi al Balance as of DOD $136.30 Interest from Last Postin to DOD $ .00 Account Balance as of DOD $136.30 YTD Interest to DOD $ .00 ~~ ~iiz~r~s ~r ~~ Account Number 6254-636612 Account Title JUDITH A JONES Date O ened 10/17/2008 Account T e Savin s Princi al Balance as of DOD $75.52 Interest from Last Postin to DOD $ .04 Account Balance as of DOD $75.56 YTD Interest to DOD $ .00 St ~~ MEMBERS 15` FEDERAL CREDI7 GNIOV REGULAR SAVINGS ACCOUNT: Account Number/Suffix 210975.00 Date Account Established 11/07/2001 Principal Balance at Date of Death ,,[ $933.76 ) Accrued Interest to Date of Death $ 18 Total Principal and Accrued Interest to Date of Death $933.94 Name of Joint Owner None SUPPLEMENTAL SAVINGS ACCOUNT: Account Number/Suffix 210975-01 Data Account Established 1 110 7/2 0 0 1 Principal Balance at Date of Death $1.66 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest to Date of Death $1.66 Name of Joint Owner None CHECKING ACCOUNT: Account Number/Suffix 210975-11 Date Account Established 11/0712001 / f 1 Principal Balance at Date of Death $1,294.12 J Accrued Interest to Date of Death / ` 7 $.00 I ~- /J / Total Principal and Accrued Interest to Date of Death $1,284.12 Name of Joint Owner None LOAN ACCOUNT: Account Number/Suffix 210975-01" Date Account Established 0 111 9/2 00 5 Principal Balance at Date of Death $14,224.39 Interest Rate 6.49% Collateral Held as Security 1004 Holly Pike Carlisle, PA 17013 Contractual Pledge of Shares Name of Co-Maker None *Loan does not have credit life coverage. M BERS 1sT FEDERAL CREDI UNION Danielle A. Kline Insurance Services Specialist May 14, 2009 Estate af: JUDITH A. JONES Date of Death: January 9, 2009 Social Security Number: 200-34-1501 x(1011 Louise ]?rice P.O. ]3os -F(1 Mechanicsburg, Pennsyh~ania 171)55 (8111)) 28.3-2328 www.memberslst.or i' ~..~. ... ... i .:.~i.. /~ J . _ ..~ _. F J. , i t_7 i~ c:. .... ,.. .. ~, ... ,:1 ...... .._... , _. ...'r .: .: (..: ~_ I?.111 :. -._ .. :i. . }. ,.... ':.r~ i,~t i~~Ir_I i.: ,. .. .. .. _. . .r r . w .....,.. 'Ii~:i1, F4 r_Ci 1_I, 'f`lJr~ ~._~,f~:jc ;.., 1.) ~,.=1"1 ti,:i i", .. 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W Fw 0 ~ ~~ O T ~ aQ. O waare •asers W ~~ ~ LOT # CONSIGNMENT CONTRACT AND SETTLEMENT RECEIVED BY: DATE(. ~1'~~( _ _ `` ~ { (/ f CONSIGNOR'S NAME `/ •li~ (~: ~l ~Ct1 ~~ 1~_~,F ~1~; f !.'f r:<~ 1~r -~_.l_,>~ 1 l (~ ~ ~ ~~ ~ I{ ~ ~. I ~ ,r .~ ~ i. 1( ADDRESS~i.~~~~~(~~~~ f ~(.(~l,t~iii~lY'~~~lfib/l"rl l~tli, ~~~(/il~~, /~;~ ~ r ~,. PHONE ~/~~ ~``~~ ` ~~~( ZIP CODE ~ .~~~ ~ ""~ c , ~'i i ~ C I rl ~'I~ I ~ ~ ." I ~ ~~ t ~ ~,~ _ ~ )r I ~ l it ~ ~ ~ Cry ~f ~(~l ~ } ~ ~'','u ~~ } ~ / i .. _ ,. ~ ~ _ i i `. n ~ lc ~ c . r, ~ i ~ ~ ~~ c ~~ .,_ , ~ , t. ~ k~~~ , -- ~ h, .~ %yy ~ %%:I ~~ ~ , _ / ~ { ~ ~ I / t~C l.G) ~ / ~ ~T i.1~_. s~ ~ 7 F , , ,,-_ r 1 % ~ _ ~ f ,_~ rr - ~-• - 4 ~ / ~ ~~•- ,. . %r -, ) r ;~ i -;). i , / . ' 1 J)~ U;.~~"~~'~ t~ ) ~ L t a 14 _ t 1 `_~_. ~ F .. i _ ._ . ,; „ ~ I SHEET # r OF ~ TOTAL SHEETS I (consignor) hereby commission you to sell the items listed above & on the attached sheets to the highest bidder by public auction. I certify that I am the owner of the above listed items and have good title and the right to sell them. 1 certity that the items listed are free from all incumbrances. I agree to accept all responsibility for providing good title end for delivery of title to the purchaser. It is agreetl that the consignee is not responsible for th~(¢s ~qt any item due to fire, [heft, damage, etc. I understand that a =~~ - °~6 commission will be deducted from the gross sales of my tams. "No Bid" items will be disposed of at the discretion of the Aucl eriAuction Hqquse. Payment will be made to the consignor within ____ .days frohfdafe of sale. `~ Consignor Signature 'i~ ~ r. ++ /~ r / ~~._ l ( ,h% 1 f ~ Date ~/ ./ Auctioneer/Auction StafF Signatwe EXPENSES: SETTLEMENT TOTAL CONSIGNOR SALES ~/s::__ % COMMISSION $ _ ~ $. ~- TOTAL EXPENSES $ CHECK NO..JC~I~..~L-NET PAYABLE TO CONSIGNOR J •' LOT # ~ RECEIVED BY: ~ ,'r', DATE';t. CONSIGNOR'S NAME ! "• ` ~ ~ r '- ADDRESS ~ ~ '~ 1' PHONE ,~1`l f" !~~L~ .i~P ZIP CODE ~~_~~~ 1 c , ~/ r / ~r l ~ ~ ,', >',l , A ~ ti~~..r . 1, ~ 4 i ' ? ') SHEET # '-= ~ OF~-TOTAL SHEETS I (consignor) hereby rommiSSion you to sell the items listed above 8 on the attached sheets to the highest bidder by public auction. I certify that I am the owner of the above listed items and have good title and the right Ic sell them. I certify that the items listed are free from all incumbrances. I agree [o accept all resoonsibitity for providing good title antl for delivery of title (o the pumhaser.lt is agreed Ihat the consignee is not responsible for th(T~~'s of any item due to fire, theft, damage, etc. I understand that a _~ 9~ commission will be tleductetl from the gross sales of my ems "No Bid" items will be disposed of at fhe rliscrefion of the Aupt eer/Auction House. Payment will be made to the consignor within _. r ~ days iroyr5~late ldf sale- . .~ ' ~~-. Pvd,,.,.f Date f ~ .,,~ Consignor Signature ' ! ii tt 1 ~ ( ("~ C ,<. ,'.~i~ t~'~~~t ~~•1~ Date ~i~J If Auctioneer/Auction Staff Signature ILCONS9GNMENT CONTRACT AND SE`TTLEMENT~ 1,' / LVZ Vd. yf rj 1~,.. ~i SETTLEMENT EXPENSES: TOTAL CONSIGNOR SALES '' L'' % COMMISSION $ $ - $ l/Jr~}t~,~f(~/-/f1 TOTAL EXPENSES CMHCK NO. ~ NET PAYABLE TO CONSIGNOR J S~ ~~ MEMBERS 15` FEDER~IL CREDIT U~IOS PRIMARY OWNER: Mary C. Nelson REGULAR SAVINGS ACCOUNT: Account Number/Sutflx 196025-00 202066-00 Date Account Established 08!11/2000 02/16/2001 / Principal Balance at Date of Death $26.46 $5.66 / '„a ) Accrued Interest to Date of Death $.00 $.00 l ~~ '1 Total Principal and Accrued Interest to Date of Death $26.46 ` ~ $5.66 Name of Joint Owner Lynn Janes Judith Jones Date Joint Ownership Established 08/11!2000 02/16/2001 CHECKING ACCOUNT: Account NumberlSuffix 196025-11 Date Account Established 08/11/2000 Principal Balance at Date of Death Accrued Interest to Date of Death $328.75 $.00 ' Total Principal and Accrued Interest to Date of Death $328.75 Name of Joint Owner Lynn Jones Date Joint Ownership Established 08/11/2000 MBERS 1sT FEDERAL CR T UNION anielle A. ine Insurance Services Specialist May 14, 2009 Estate of: JUDITH A. JONES Date of Death: January 9, 2009 Social Security Number: 200-34-1501 50(11) Louise Drive P.O. Bos ~FU Mechanicsburg, Pennsylvania 17055 (8U(1) 283-2328 ww~umetaiberslst.org Sti MEMBERS 1st EEDER9L CREDIT OKIO\ REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest to Date of Death Name of Joint Owner Date Joint Ownership Established 130540-00 01 /06/1993 $2,045.96 $.45 $2,046.41 David Jones 11110!1993 INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix 130540-05 Date Account Established 01 /06/1993 /~ Principal Balance at Date of Death $58.68 Accrued Interest to Date of Death $.00 U Total Principal and Accrued Interest to Date of Death $58.68 Name of Joint Owner David Jonas Date Joint Ownership Established 11/10/1993 IRA ACCOUNT: Account Number/Suffix 1 3 0 540-1 0 Date Account Established 03/16/1994 Principal Balance at Date of Death $21.03 Accrued Interest to Date of Death $.01 Total Principal and Accrued Interest to Date of Death $21.04 Name of Beneficiary David Jones IRA CERTIFICATE: Account Number/Suffix 130540.16 Date Account Established 12/17!2008 Principal Balance at Date of Death $14,862.83 Accrued Interest to Date of Death $12.97 Total Principal and Accrued Interest to Date of Death $14,875.80 Name of Beneficiary David Jones M BERS 1sT FEDERAL CRF. IT UNION t~a.~.l ~ Dd. '~~--1~ Danielle A. Kline Insurance Services Specialist May 14, 2009 Estate of: JUDITH A. JONES Date of Death: January 9, 2009 Social Security Number: 200-34-1501 jClliO Louise llrive PO. Box -}0 Mechanicsburg, Pennsylvania 171155 (800) 283-2328 wwwutemberslst.org St MEMBERS 1s1 FEDERAL CR.FDI'r U~IOti REGULAR SAVINGS ACCOUNT: Account Number/Suffix 130540-00 Date Account Established 01/06/1993 Principal Balance at Date of Death $2,045.96 Accrued Interest to Date of Death $.45 Total Principal and Accrued Interest to Date of Death $2,046.41 Name of Joint Owner David Jones Date Joint Ownership Established 1 1 11 0/1 993 INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix 130540-OS Date Account Established 01/06/1993 Principal Balance at Date of Death $58.68 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest to Date of Death $58.68 Name of Joint Owner David Jones Date Joint Ownership Established 11/10/1993 IRA ACCOUNT: Account Number/Suffix 130640-10 Date Account Established 0 311 6/1 9 94 Principal Balance at Date of Death $21.03 Accrued Interest to Date of Death $.01 Total Principal and Accrued Interest to Date of Death $21.04 Name of Beneficiary David Jones IRA CERTIFICATE: Account Number/Suffix Date Acwunt Established 130540-16 12!17/2008 ~ Principal Balance at Date of Death $14,862.83 ` Accrued Interest to Date of Death $12.97 Total Principal and Accrued Interest to Date of Death $14,875.80 Name of Beneficiary David Jones M BERS 1sT FEDERAL CRF. IT UNION Danielle A. Kline Insurance Services Specialist May 14, 2009 Estate of: JUDITH A..IONES Date of Death: January 9, 2009 Social Security Number: 200-34-1501 51.11111 Louise Drive PO. Box -4(1 Mechanicsburg, Peunsylvauia 17055 (800) 383-332R ~uwwmemberslst.org RECEI~IED JUN 2 6 ~CC9 C~~ee~~ee's ~e~ntee~~t~~e ~umena~ ~o~rne, ltd. 619 MAIN STREET BENTLEYVILLE, PA 15314 Barrett G. Greenlee, F. D., Supervisor 724-239-2191 Gordon B. Greenlee, F. D. FAX: 724-632-3320 Jason L. Schultz, F. D. June 24,2009 Acct #8371 Judy Jones Nathan C. Wolf Attorney At Law 10 West High Street Carlisle, PA 17012-2922 Basic Services $3,895.00 Basic Services F.D./Staff Embalming CREDIT -$660.00 Other Preparations of Remains Visitation Funeral Ceremony Transfer of Remains to Funeral Home Casket Coach Limousine Flower Car CREDIT -$75.00 Acknowledgement Cards Register Book Memorial Folders/Prayer Cards Total Our Service $3,160.00 Casket $2,425.00 Havenline 20ga. Silver Outer Burial Container $865.00 Unlined Concrete Top Seal Clothing $0.00 Cash Advance Items New Grave Space $0.00 1/2 of Vault Setting Fee Charged By Cemetery $0.00 Opening/Closing Grave $0.00 Cemetery Charge $0.00 Cemetery Equipment $160.00 Cemetery TentlEqu:rment $0.00 Receiving of Remains from Anoth;: -,neral Home $0.00 C~tcee~~ee's ~e~t~ey~ip~e ~u~nenaQ ~o~rne, ltd. 619 MAIN STREET BENTLEYVILLE. PA 15314 Barrett G. Greenlee, FD., Supervisor Gordon B. Greenlee, F. D. Jason L. Schultz, FD. Organist Clergy/Honorarium Soloist Valley Independent Herald Standard Observer Reporter Copies- Death Certificates Cremation Authorization Crematory Charges Hairdresser 10 copies @ $6.00 ea. Transportation 19 i.~ .,riles @ $2.75 mile Other Funeral Directors Charges Flowers Total Cash Advance Items Complete Total Amount Paid BALANCE DUE 724-239-21 g1 FAX: 724-632-3320 $0.00 $0.00 $0.00 $0.00 $0.00 $100.00 $60.00 $0.00 $0.00 $35.00 $526.62 $695.00 $0.00 $1,576.62 $8,026.62 $8,026.62 Terms: This is a cash transaction, due in 30 days, anti n ~ ,, events, becomes past due and delinquent upon expiration of due date. A charge of 12% per annum for unanticipated late payments will be charged effective after due date. QUINET MONUMENT COMPANY INTERSECTION OF 917 8r 170 (EXIT 12A) P.O. BOX 186 BENTLEYVILLE, PENNSYLVANIA 15314 AGREEMENT MAIN OFFICE: (724) 239-2886 FAX: (724)239-2896 SOLD TO ~ DATE (y ~) ~ ( ^ ~ i CEMETER I~C S ~ C SECTION G~o ~~t ON OR ABOUT CITY LOT BLOCK 7/~ 1 ~ ` ~ PHONE HOME ~ ,,,~ ~ WORK Gr. GRANITE -- SIZE BASE FINISHES OF GRANITE DESIGN NO. ^ D~pgcata or DESCRIPTION OF PANELS LITHOCHROME COLOR I DRAWING ~~~ ^ YES ^ NO NAME ON BACK ^ Need Rubbing FULL SIZE YES L1 NO Check Graves ^ YES ^ NO VASE ^ INGROUNb ^ SIDE MOUNT COLOR STYLE ~~~ L~. Foundation t_J Paid Ck No. ~~ ~$ ~~~ CEM~~T~Y $ ~ CFIA'RiE3 TOTAL S _ ~ DEPOSIT $ O ~ BALANCE $ ty~y ~ - i) The said memorial is guaranteed by Ouinet Monument Co. (QMC) against any defect in workmanship. The said memorial, wilt title thereto and right of possession thereof, shall remain OMC personal properly until I have paid for it in full. 2) A monthly interest charge of 1 1 /2%, which is en annual percentage rate of 18%, wilt be added to 811 aCCOUnffi not paid in full within 30 days after instagation. Reasonable collection cost will be home by the debtor. In default of any payment hereunder I license OMC to respossess and remove the said memorial withoi guilt of trespass of other wrong, and authorize and empower OMC, in my name and on my behalf, to apply to the management of said Cemetery or other premi for a permit for this removal; OMC may then retain said memorial or dispose of it at OMC's own discretion without being answerable to me for k or for any proceeds therefrom. 3) It is further agreed, tltat any lettering or other work done on this monument after it is erected in the cemetery is to be paid for extra. 4) This order is subject to any delay caused by any strike, lockout, fire or other condition beyond QMC's control. 5) There is no agreement regarding this order other than contained herein. 8) Any part of this agreement contrary to the laws of any State shall not invalidate any other part thereof. NOTICE TO BUYER: 1) Do not sign this contract before you read it. 2) You are entitled to exact copy of the contract you sign. ACKNOWLEDC3MENT: The Purchaser hereby acknowledges that he or she has carefully read and full understands the terms of this offer and hereby acknowledges receipt of an exact copy of this contract. BUYER'S FEt3HT TO CANCEL: If tftis agreement was soliated at your residence and you do not want the goods or services, you may cancel this agreement by meigng a nodca to the Seger. The notice must say that (1) you do not want the goods or services, (2) must be mailed before midnight of the third business day after you Si n this agreement and (3) must state that you are prepared to return any goods received in substantially the same condition as r ved. The no' m tied to Ouinet Monument Co. Customer's signature ~~ ~~ __ Representative .A-U~ ~~~ ~~~~ ~I;~-1U °l, and q T0: Nathan Wolf, Attorney 10 W. HIgh Street Carlisle, PA 17013 Greenlee Funeral Home P. O. Box 11 619 Main Street P. O. Box 395 Beallsville, PA 15313 Bentleyville, PA 15314 Fredericktown, PA 15333 724-632-5454 724-239-2191 724-377-2232 DATE DESCRIPTION TOTAL 5/4/09 6 Certified Death Certificates Judy Jone $ 9.00 $ 54.00 TOTAL DUE $ 54.00 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 JONES JUDITH A Estate File No.: 2009-00378 Paid By Remarks: WOLF & WOLF CJ ----------------- -- Receipt Distribution * DUPLICATE Receipt Date: 4/21/2009 Receipt Time: 08:51:54 Receipt No.: 1056528 Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260.00 CUMBERLAND COUNTY GENERAL FU SHORT CERTIFICATE 40.00 CUMBERLAND COUNTY GENERAL FU JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL . FU INVENTORY 15.00 CUMBERLAND COUNTY GENERAL FU RENUNCIATION 5.00 ------ CUMBERLAND COUNTY GENERAL FU Check# 2456 ---------- $335.00 Total Received......... $335.00 DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT THE SENTINEL -LEGAL Est J. Jones P.O. BOX 130. CARLISLE, PA 17013 AD NUMBER CLASSO START DATE STOP DATE 368215 PUBLIC NOTICES 05/03/09 05/17/09 AD DESCRIPTION BILLING DATE TELEPHONE NUMBER ADMINISTRATOR'S NOTICE LETTERS OF 05/18/09 717-241-4436 WOLF & WOLF ATTORNEYS 10 WEST HIGH STREET CARLISLE, PA 17013 I~~JII~~JIL~~„~II~~II~LJJ 20200000003682150000000000000002377900000198166 THE ESTATE OF JUDITH A. JONES 10 W HIGH SL CARLISLE, PA 17013 PAY TO THE ~ J~/1 S'~ Nei L" (~~(~y~L ORDER OF ~W $~' ~~ Y: ~~Sovereign ~anl~ FOR ,, ~~~~~-J u'00L00i11' ~:23i37269i~: ,~~ rr 074 i i64 II' GROSS AMOUNT OF 237.79 DUE AFTER 06/17/09 TOTAL AMOUNT DUE 198.16 ENTER AMOUNT ENCLOSED l~ ~/6 1001 DATE r 1!)N~ ~ S ~Jh eo-r~/za~a CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 fax: (717) 249-2683 May 22, 2009 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Nathan C. Wolf, Esquire RE: Judith A. Jones Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: May 8, May 15, and May 22, 2009 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by THE ESTATE OF JUDITH A. JONES 10 W HIGH ST. CARLISLE, PA 17013 PAY TO THE ORDER OF_ 1002 60-7269/2313 DATE _ ~S ~' DOLLARS 8 u„;." ~~Sovereign Bank' FOR ~~~' ~'J(~T't II'OOL00211• ~:23L372691~: 0741164 Expenses Desttnation:_ Carlisle, PA_ Travel Dates: aP~~i zoos & rune zoos zoo miller's ale house lunch in Sanford food i . J?~ dunkin donuts ~~ breakfast ~- ~~~~ ~~~ food_ i .o 20o Sun ass ..~__ tolls Gas Tolls zo.oo _ zoo~_ Shell _ __,_..._______~ __._ _ Gas __ _ _ __ _ Gas Tolls $ o.oo [zooQ Amtrak_ ___ _ ___~~_ _ R_o_und Tr____ip train fare _ _ Trans ortation _ $i 6 .60 8 20o hershe 's food court lunch food 2o.i2 8 aoo market cross ub dinner _ ~~ ~ food $2 . 8 zoo2_ fallen tree farm B & B ~~ hotel sta~for_i~ nights_ ~___~ ~ lodgings $i 6~i2 zoo Chilis __~__ lunch ~ food 20.0 io zoo Piatto dinner _ v food 6 . 2 io zoo hess as Gas Tolls $2 .i io 20o sta les su lies for or anizin Jud 's bill Misc. z io 20o wolf & wolf retainer & escrow acct Misc. i oo.oo ii zoo home de of arba a ba s for house Cleanin 2 .60 ii 20o a a 'ohns lunch for entire 'ones famil food 8 ii 20o anera bread dinner food 12.1 12 20o walmart food water etc food 2 i 20o market cross ub lunch food z . i 20o cracker barrel lunch food zo.z6 i 20o home de of new lock for house Misc. i8.z 4/i5/zoo9 wend 's lunch food $x.50 i 20o vinn 's dinner food zz. 8 i6 20o walmart water food etc. food i .6 i6 20o anera bread lunch food ii.8 i6 zoo anera bread drinks food .8i 16 zoo sta les folders etc. Misc. i i 20o wolf & wolf mone for escrow acct Misc. oo.oo i zoo fountain cafe lunch food 6i. i 20o unimart as Gas Tolls .20 20 20o walmart dinner food . 6 20 20o Chilis lunch food 2o.i6 21 200 to da s lunch in lorton food 2. o 22 20o uck's ex ress lunch in Sanford food i.io 22 20o Sun ass __ tolls Gas Tolls 20.00 2 20o sta les recei t book ba s for 'ewel etc. Misc. 2 .6 6 20o USPS mail re uests for credit re orts Misc. 22.21 6 i 200 boma's breakfast in Orlando sanford food 8 6 i 20o Sun ass __ _~ tolls Gas /Tolls 20.00 6 i 200 -eleven _~~~ Gas Gas Tolls o 6 i 20o Amtrak ~_ Round Tri train fare Trans ortation $i o .60 6 i 20o Chilis _ lunch food i .i6 6 i 20o walmart food & water food z6.8 6 i4/2oo9 ha erstown AC&T as Gas Tolls 8. o 6 i zoo fallen tree farm B & B hotel sta for i ni is iod,gi~ ~ 0.2 6 i zoo home de of ~ weedeater strin Cleanin .22 6 i zoo walmart ~~~ food water mist for house cleani ~~ Cleanin $i 2.80 6 i 20o marcellos ~~ ___ dinner _. food z6. 2 6 i6 20o walmart sneaker cleaner Cleanin i .ii 6 i6[2oo9 anera bread lunch food i6. 2 6 i6 20o manor care ~_~____ ~ co fees for medical records Medical i.28 6/i~/2oo9__ Chilis lunch food $26.oi Expenses 6 i 20o home de of ~~~ lanterns for house Misc. ~ ~ $ i ~ 6 18 20o fam~home medical w ~ oves to work in house Cleanin~~ $_8.g~. ____ 6 i8 20o coakle s lunch food 18.2 6 i8 20o turkey hill __~~_ as Gas Tolls _~ ~. $ i.~o 6 i8 20o health south . ~~ _ r co fees for medical records Medical ._._-.~...___. $128. o 6 i8 20o ._. __ rw.__ sta les ~ _ _ ______ ~ co fees for medical records Medical __ __ $139.76_ 6 i8 20o ___ stales ~_~ envelopes & binder clips _ Medical _ _ t .8 6 i8 20o walmart ~ binder clips_~. Medical_~ $ .4~...__,.._._ 6 i8 20o __ ~___ wolf & wolf Nate's fees Misc. $ oo.oo 6 i9 200_ Nathan's ~ _ ~ lunch food_ $12.2 _ 6 20 20o waste mana ement dum ster Cleanin ~ .oo 6 21 20o Sunoco as Gas Tolls ~ $ .oo 6 2 zoo _ home de of ~ trash ba s bu s ra etc for hous Cleanin $ 6. i 6 2 20o Nathan's dinner food 12.2 6 2 20o _ waste mana ement dum ster Cleanin .oo 6 2 20o a s 'ohns dinner food i .26 6 2 20o cvs drinks & Cleanin wi es Cleanin i .i 6 2 20o cracker barrel dinner food 22. i 6 2 20o marcellos dinner food 21.10 6 2 20o anera bread lunch food 1 o 6 2 20o rutters as Gas Tolls .oo 6 28 20o home de of love re lacement Cleanin 2. 6 6 28 200 'n erbread man dinner food 20. 6 2 20o to o i lunch in lorton food i.i 6 2 20o Jeramiah Shaffer Lawn cuttin for June Misc. o.oo 6 0 20o dunkin donuts breakfast food io.o 6 0 20o b''s as Gas Tolls i.oo 6 0 20o shell Gas Gas Tolls 6. o 6/30/2009 Sun ass tolls Gas /Tolls $20.00 6 20o Member's 1st statement co ies Misc. o.oo 1 20o Hol S irit Hos ital Medical records co ies Medical 8.2 i 20o Sta les bank statement co ies Misc. .i8 1 20o UPS shi in statement co ies to Nate Misc. 2 i i6 20o Jeramiah Shaffer Lawn cuttin for Jul Misc. $ o.oo Total: St MEMBERS 151 FEDERAL CREDIT C'~'10~ REGULAR SAVINGS ACCOUNT: Account Number/Suffix 210975-00 Date Account Established 11/07/2001 Principal Balance at Date of Death $933.76 Accrued Interest to Date of Death $.t8 Total Principal and Accrued Interest to Date of Death $933.94 Name of Joint Owner None SUPPLEMENTAL SAVINGS ACCOUNT: Account NumberlSuffix 210975-01 Date Account Established 11/07/2001 Principal Balance at Date of Death $1.66 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest to Date of Death $1.66 Name of Joint Owner None CHECKING ACCOUNT: Account NumbeNSuffix 210975.11 Date Account Established 11/07/2001 Principal Balance at Date of Death $1,284.12 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest to Date of Death $1,284.12 Name of Joint Owner None LOAN ACCOUNT: Account Number/Suffix 210876-01• Date Account Established 0 1 /1 9120 05 I Principal Balance at Date of Death $14,224.39 Interest Rate 6.49% Collateral Held as Security 1004 Holly Pike Carlisle, PA 17013 Contractual Pledge of Shares Name of Co-Maker None "Loan does not have credit life coverage M BERS 1sT FEDERAL CREDI UNION ~,~ ~ - ~A~ Danielle A. Kline Insurance Services Specialist May 14, 2009 Estate oL JUDITH A. JONES Date of Death: January 9, 2009 Social Security Number: 200-34-1501 5(IU(1 Louise Drive [?O. Bos -}0 Medianicsburg, Pennsylvania 17055 (HUII) 3g3-333$ www.memberslst.or n O n b0 J a s ~' C ~ Y O ~ O 9 0 ~, ,,, ~ N w a°1C~ ~C~ L ~o E~ ~~ o~ d? a~~ 11 N c • ^L' O W ~ 11 t'~,' 3 .•W ,Q •• •• .. ..... .. 5z O ao ~ Q. ~ g~pO .~ 7 C ~ .0 ~ L ~ kJ~oN ~ N ~.~~ ~ ~Q~uO ~ ~ ~Q c .. 0 000 N `~ Y ` N` ro C"y ~0 ~ ~ ~ N O Q N~ r Q V ~ '~'~ U 7 ~ 7 ~ ` Q PO ~ v ~' C N .~+ N C ~ Z 7 ~ C f ~ v~~ ~~~rorow O~ O 0~" y T 0 ~ o v~ L ~ U.L ~~ pp ys ~ N~`~~ ~ V `On U~~~ ¢ M l 4 ~o N ~ ~- ~ _ M C°j tR O C r C O u d .~ L d w L W NC G Y L 0 N d .~ d Z ~~ ~~~ ~ ~ :So ("' sLa Q v~~TZ ~~ ~"` °' ~o M ti~ ~ ti ~ ~ ~ '~ o ~~ v O `-~ N O ~ 1~1 ~ ro~ v E v, c L W ~ Q fi: C ~ D O ~ ~ ~,, ~ C c Q.O ~' ro 0 > > ~ ~i v~ ~ O Q .Q ~~ N ~ r ro L d _~ ~ ~ r ~ b b ~'~ ~ ~ 7 0 -p 'O ~O N v '~ N N tt~~00 Q~ M 0 ~s,~~ N U U Q N ~Z ~~ ~ ~~v ~o ~~ i~° ~ Q ~° 2 w ~.~z ~ ~~ c o ~ ~~ ~z~z ap O ~o ~r ~ N appp ~o N N 8 ~ ~ a~ ~~ a~ ~~ `c`am' .ao ~rn U C vm u ~ o - ~ OO Q °Y~ ~ OO si in 7 W ~ w v g ~ ~ v ~ ~' N t7 N -~ C ~ ro 0 ~ ~ , ~ ~ ~~ ~ 00 ~ v'i W ~ ~ O '~„ V' r CU V ~ ~.~ OQZ C~'O N XO C RIO ~,~~ OA ~ v1 ~ N 2 a z roo ro OQ-g~ ~€ O ~ ~i,~~ O OA ~ CO ~ ~ ~ M Z ~@ 0o Y Q a, a` C 0 ~C m i W U O Rt~ O i~~,~ Z~~H° o a~ NNnn ~ 00 4 ~ . i O0p v~ Q_ NN s_ ~ tH - ~i ro.flNU> v ~°`~' . o o ~~Z 4 ~ ~ N O O O 4- ,.- ..- -o ro~~ c E ~ va~v ~ ` 7 NN V 0 7 ~ 7 O ~'O' v L t~ vv ~ b v ~ ~ N ~ ~~ C b ~ c ~ O_ a ~ Q ~ 'O I~ ~ ~ p C z ~, ~'~ TTT~ N ~n O L C N b ro ro TTT ~~ N N 'y' N N ~ ~ a4'O ~ ~ ~ .~ ~ 'O "'' O O .~ N . V L~s n NO QOM U m Q N B °~~'Z c m v~Q ~~ v6Z 2tfl a ~~ ~~ p ~~~~~z ~ v a o ~O OOE 3~ v vo.~~ ~o ~g Q' b, ~° ~ O ~ N ,~ ~ 0 ~ V ~ ro- >°~z~~N ~ ~ N umog"~o sn _ ~ ~ ~ ~ ~ PPL Electric Utilities Electric Service For: JUDITH A JONES 1004 HOLLY PIKE CARLISLE PA 17013 ' Questions about this bill? Please contact us by Feb 18 at1-800-347x5775 (1-S00-DIAIrPPL) ~. or write to: Customer Service 827 Hausman Rd. Allentown, PA ' 18104-9392 ~ www.pplelertric.com Electric Use ~`:•"''.~: ' Page 1 ., - pp~ :.:_ •-- .. .,' Summary Page Balance as of Jan 28, 2009 Char es: Tota~PL ELECTRIC ITTILITIES Charges 37201 22013 ~:~ $598.28 $184.47 Total Charges $782.75 Account Balance $782.75 84 70 56 42 28 14 0 KWH -Average Per Day Meter Reading Inforuration This graph shows your electric use over the last ] 3 months. Types of Meter Readings: Actual . Adjusted Estimated Customer Q FMAMJJASONDJF 2008 Months 2009 Meter #42837542 Jan 28 Actual 97845 Dec 30 Actual 95746 29 Da s KWH Billed 2099 a g Ave r e -Jan 2008 2009 ~ p e t 369 ~ a 26F K WH P er Day Yearly Use: Total Average Use Monthly Feb 2007-Jan 2008 18388 1532 Feb 2008-Jan 2009 19733 1644 Other important information on back ~ Return this part to address below with a check payable to PPL Electric Utilities Corporation . 41bC . r,3tute:3~i~tWst 37201-22013 SP 01 066196 82746E 355 ASNGLP JUDITH A JONES 1004 HOLLY PIKE CARLISLE PA 17013 .; Feb 18, 2009 $782.75 ^cl~ ^ ^ ^. PPL ELECTRIC UTII.TTIIiS 2 NORTH 9TH STREET RPC~'rENNl ALLENTOWN PA 1 8101-1 1 75 II~~~1'~'I~'1111'I'~Il~~~l~~lh~l'I~'II~IIIII~J~~'~~11~1~~~I~~~1 1 13171700782753000782756 3720122013 a ~~~~101BARQ Pegs 1 of 3 Monthly Statement Account Number March 4, 2009 717-268-8144093 (pN P Payment Options & Contact Info Current Charges At-A-Glance Retail Store in Your Arsa a CARLISLE 202 Westminster Drive in The Carlisle Crossings Center Pay Online EM BARD. comlmyaccount Pay by Phone 1-877-813-7604 Customer Service 1-800-829-8009 Repair Ssrviee 1-800-788-3600 Internet Address EM BARQ.comlresidenti al EMBARO Services Total - ®_ Total Current Charges Total Amount Dus .00 ~ a483.B7 Curreni Charges Due By: 03/29/09 Previous Balance Payments & Adjustments Past Due, Please Pay Now 483.67 ~ .00 ~ 483.67 I 6 EMBARQ" Please return this portion with payment ' Customer Service Internet Address 1-800.829-6009 EMBARO.eom/residerttial Please pay past due amount of 6483.5 lmmedlately Total Amount Due: 3P O1 064194 96184E 264 ABNGLP 'I'1111111'llllllllll~llllll~~lllllll~~lll"I'Illlll'll'll'llllll JUDITH JONES 1004 HOLLY PIKE CARLISLE PA 17013 Amount Enclosed: Write your 13-digk account number on check Make checks payable to: Embarq PO Box 96064 Charlotte NC 28296-0064 I'IIIIIIIIIIIIrI11LLllllli'1111111'I'I'I"III'lllll'lll'1'llll~ ® Plaaw R~eycl~ Account Number 717-268-8144093 ~4ss.s7 12 71725881440935 00000000000000 000483577 0909302 Borough of Carlisle ~ ~ Account 53 W South Street Statement Carlisle, PA 17013 •~ www.carlislepa.org JUDITH JONES 1004 S Hanover St Carlisle, PA 17013 717-249-4422 7:30AM - 4:30PM Please be advised that your account number has changed. If you utilize an autopsy service you need to notify the provider of this change. Please note the meter usage history displayed on the graph below is the history of your personal account. •- B Payment Coupon .- PLEASE RETiJRN THIS PORTION ALONG WITH YOUR PAYMENT PLEASE MAKE CHECK PAYABLE TO: BOROUGH OF CARLISLE ACCOUNT: 011999-000 SERVICE ADDRESS: 1004 S Hanover St SERVICE PERIOD: 10/27/2008 to 1/26/2009 (91 days) BILLING DATE: 2/13/2009 DUE DATE: 3/29/2009 ACCOUNT: 011999-000 SERVICE ADDRESS: 1004 S Hanover 5t SERVICE PERIOD: 10/27/2008 to 1/26/2009 (91 days) BILLING DATE: 2/13/2009 DUE DATE: 3!2912009 ., Previous Reading Current Reading Serial No Date Reading Date Reading Cons 03323418 10/27/08 830 1/26!09 835 5 5/8" Meter -Water 36.45 5/8" Sewer 25.80 TOTAL CURRENT CHARGES 62.25 DUE IMMEDIATELY 47.67 PAYMENTS RECEIVED ..47,87 ADJUSTMENTS 0.00 CURRENT CHARGES 62.25 TOTAL AMOUNT DUE 62.25 TOTAL AMOUNT DUE BY 3129/2009 62.25 REMIT PAYMENT TO: Borough of Carlisle PO Box 340 Carlisle, PA 17013 JUDITH JONES 1004 S Hanover St Carlisle, PA 17013 MAR APR MAV JUN JUL AUG 9EP OCT NOV CEC JAN FEB ~~~,,,_~ ?~6r„~~,-,,~ C~ ! URGENT ®L, ~r'~ 7~m~~ rL5 u~~rc018 March 5. 2009 Judith Jones 1004 Holly Pike Carlisle, PA 17013 I~~~III~~~lll~~~~~~ll~~ll~l~~l~l Account Number: 0993201076 Account Holder's Name: Judith Jones By now, your AOL account access has been suspended due to non-payment. The oustanding balance you owe is $18.99 AOL wants you back as a customer in good standing! So, if it's your intent to reactivate your account ... • Contact an AOL Member Services rep today @ 1-866-859-0176 Or • Check the reinstate box on the tear-off coupon. • Insert the coupon in the return envelope along with your payment in full and mail it today. We request that payment in full be made today. Payment Due Date: IMMEDIATELY All delinquent accounts are subject to collection agency referral. So act today in order to resolve this urgent and important billing matter! CB1 q,~ INVIOICE Account No. 0993201076 PAST DUE Pay This Amt: $18.99 Judith Jones U To reinstate your membership check here and provide your. billing information below. If you had previously registered with the method of payment via electronic debit from your checking account, we can reactivate the account only if you provide a credit card number for reactivation. Once your account has been reactivated, ynu may select KW Billing and select electronic debits as an alternative method of payment. "' Membership closed due to Tenns of Service violations will be reviewed before reactivation is considered. NEW BILLING INFORMATION Select Payment Method: ~ PAasterCard ^ Visa U American Express Card Number: Exp. Date: Name as it appears on card: _ ___ Discover ^ Diners Club ---- /~10 `. ~i~ Card Holder Signature: ._ ____ _ _- _ _-- --- - _ __ _ -- - ate: 099320107600000018990305^9000100^^00010007 ~~ CAMP HILL EMERGENCY PHYSICIA PO BOX 13693 PHILADELPHIA, PA 19101-3693 0 ~ Iffflllftflllffrflllfflflfftllffltliflltffflfllffflfltlfflttll b 082516-OD00033596354-06 #BWNJFDB #OOOOOOHYP2206690# JUDITH A JONES 175 LANCASTER BLVD MECHANICSBURG PA 17055-3562 STATEMENT OF ACCOUNT (1) Statement Date: February 6, 2009 ACCOUNT NUMBER: HYP33596354 Patient Name: JUDITH A JONES Tax tD #: 20-4667340 Account Balance: $22.90 Amount Pending Insurance: $0.00 Amount Due From Patient (Current): $22.90 Amount Due From Patient (Past Due): $0.00 Pay This Amount: ;22.90 PLEASE REMIT PAYMENT BY "PAYMENT DUE BY" DATE. THANK YOt Please refer to coupon below for paymef instructions. ACCOL/ ni Ueiafl Date A Description Charge Paid By Paid y aid By Amount Due From PATIENT Firs[Ins. Other Iris. Patient Ad-usted Insurance BALANCE 12/22/08 1 99284 EMERGENCY EVAL & MGMT $598.00 (LVL 4) DX:995.91 DR. ARORAMOLY SPIRIT HOSPITAL 01/30109 MEDICARE CONTRACTUAL ALLOWANCE $-490.94 01/30/09 MEDICARE PAYMENT $-85.85 $21.41 'I1Y[2/08 2 93042 RHYTHM STRIP INTERr'RETA'rIGIJ $42.00 DX:995.91 OR. ARORAIHOLY SPIRIT HOSPITAL 01/30/09 MEDICARE CONTRACTUAL ALLOWANCE $34.57 01/30109 MEDICARE PAYMENT $-5.94 $1.49 TOTALS: $~~ $-91.59 $0.00 $0.00 $-525.51 50.00 522.90 Important Messages: This statement is for the direct VeatmerR and/or supervision of care you recendy receivetl from an Emergency Physkian at Hdy Spirit Hospital. The fees for this private physician are billed separately from any hocpihal charges or other professgnal fee6 for which you may also be responsible. Thereforo, should you receive a bill from the hospital or other physicians for charges in connection with this visit, it will not include the Rams listed on this statement. "Payment Plans" Accepted Questions about this statement? /Llama de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM -4:OOPM. Your automated system access code is 801-33596354, or you can send email to bi I li ng_questi ons~emcare.com. Please detach and return bottom portion with your remittance. ~ y JUDITH A JONES 175 LANCASTER BLVD MECHANICSBURG PA 17055-3562 YOU MAY PAY THIS-BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE. Make Check/Money Order payable to: LtJILLnffI111ffffffllffllnl6tlJrfrflldfrfll CAMP HILL EMERGENCY PHYSICIA PO BOX 13693 PHILADELPHIA, PA 19101-3693 STATEMENT OF ACCOUNT Statement Date: February 6, 2009 ACCOUNT NUMBER:HYP33596354 Patient Name: JUDITH A JONES Payment Due By: 02!27108 Amount Due: ;22.80 Amount Enclosed: The insurance mformaWn in our rile appears below. Please make any correctbns and/or addi[wns on [he reverse side of this form and return R to us. Thank you. MED HGS ADMIN MEDICARE PART B 200341501A ^ If your address has changed, check this box and complete the reverse side of this form 0825160000033596354000022900000000000001 HERSHEY KIDNEYSPECIALISTS INC PO BOX 517 HAZLETON PA 18201 0517 HKSI MC oioi JUDITH A JONES 1004 HOLLY PIKE CARLISLE PA 17013 IF PAYING BY CREDIT CARD, FlLL OUT BELOW CHECK CAHG TYPE USING FOP PAYMENT CARD NUMBER EXP. DATE Security Code SIGNATURE AMOUNT GROUP NUMBER ACCOUNT NUMBER K I 1 STATEMENT DATE PAY THI AMOUNT SHOW AMOUNT PAID Make check payable and send to: cxsTM 'll'IIIIIN~lllllllll HERSHEY KIDNEYSPECIALISTS INC PO BOX 517 HAZLETON PA 18201 0517 ^ Please check box of above address la Incorrect or if insurance information has changed and indicate change(s) on reverse side. Please detach and return the top portion with your payment. If you have any questions please contact us at (800) 450-6208 EXT 212 1 of 1 c o~ .O O 0 a "'D b aoi o a a''i .C >.~ b y a~ o~ O \O " ~ Q~ ~~ ~v c W ~a ~ ~ V O R O ~ ~O ~ ~G ~~ a ~~ z ~~ ,~~ O ao a a ~ ., N A o ~ ~ ~'p W~.~ I.n ~~,~ O' ~ ~ ~0~~ "~~ O.Y es F•~n ..* Y ~re+ O ~ U`r v~I1b b ~ abi ~ ~~~? ~ 3 °, q p Afnocfl s9 o ~ ~3 ~ ~, o U `~ «. v ~ ~, o J ~ p, [• ~ Y.~ v ~ A ~[ _o a ~ ~ ~,•~ y ~ ~ 0 0 C C F. ~o tt..~,... 'py'Q.p~. o e o cxi p V1 i~l F. 1-r f~C. ~ ~ ?.~ 00 ~ = UUAd ~ ~ 3 ~, ">¢ ~ c o "~ a e, 3 o c ~" ~ °>, 0 0~ e 33 ,,, ~ v .C.C G ~ `~ .a Q ~" r .~ A 5~' ~~ ~ b A ~ ~ ~,, ~v~C.Qa~ ~O ,N ~'~'D^". O w,oo~~ ~. oM~~C ~'' ~ 5 '~ o '~> U ~ ~• d N C~JOO~ at 3~ ~~ o a.~ ~ a 3 u >.OC 00 y rnO>,~ G ~~ ~0..+ O a R y ~`~ o.o o y~,...,, a~ bq C p, q ~ [.G O ~y~ ~' .~ ~~ ~•nq ~ y O ~ ~~ ~A'O'd O ~ L v,y~m~„ ~~~ ^~~ ~~~~a~ aL •~,_,,,v. ,~ ea ., -r~~~o a~ w w0"A~~p ~"O ~~a.°~'b.a•a o °~ e~'~ O ~ t°i'C u 6> p`'"' yw~i7 ~ .~a O'er CD~~ O Ho'S~t,~ °w~ ~.....r N ~..+ '~ tp"'~~ O .+ ~O~> ed ~O i i i i .~ 6~ z yi a ' ~ ~i Tye ~'S ~ 3 ~~ ~ Ti i V ~ d ~~ ~~ ~ Ci &~~', a~ g "~ 2~ a. 8 ~' ~~ a ~$ ~~ ~% ~~ 0 '" a o a, ~ M O ~ ~ O ~ ~ ~ N 6`? c'~ ~D : oo ~ N ~O CO C~ F: ~~,. ~!1 :CN 00 ~ U .. ~ A~ Ay,~ ~ ~ o-$ ~ ~ ~ _ a zw ~~~Q A° ~p O 00 O~ r ~n .ti ~ 3 f~ 0. H A rn .-, S S - N N N c%~ O ~~ ~ ona. ~--, ~ ai pOU fU S .~ rl 0 0 7 ...~ Q" 0 0 0 m N O 0 fLl 04/27/2009 14:41 3303725805 In the Estate of Judith 11. Tones /~, /.' 1- LMS SEF.~/ICES CLAIM AGAINST ESTATE PAGE 02 Landstar Investments II, Inc., claimant, states that there i.s due from the above captioned estate, the sum of $43052.58 on account of Judith A. Jones as evidenced by: Truth In Lending Disclosure dated 9/23/99 The claimant holds security for said clam as follows: None ?iffiant states affiant is claimant and that tine claizxiant has given credit to the estate for payments anal offsets to which it i.s entitled and that the balance claimed as above stated is justly due. The undersigned swears that the matters set forth in the foregoing pleading axe true and correct according to the und.ersigned's best knowledge and belief and subject to penalty for making a False off davit or declaration. Dated: 2/23/09 Affiant: Robert L. Delisio -President Landstar Investments II, Inc 1265 N Rivcr Rd. NE, Ste 1 Warren, OH 44483 Our Loan Fi].e ~ 20L50129 ~\ J ~74/27/2PJ09 14:41 3363726865 LMS SEP.tiIIrES NAHE 67939 JONES, JUDITH COLLECT COB DN~G --OWING-- 09 25 744 APDRESS 808 SHDR7 5T hIlAH INT . 17,3D8.49 ApDRE552 TY-ST-ZIP CJ4NOh15BURG Pn. 15317 r GANCELLEp 0.04 00 0 _ CLIENT 20L5 L,gNDSTAR IN~rESTMENTS II IhIC ATTORNEY . 00 0 TOT INT 17948.49 COURT . PHONE# DT p•SGN: 01-28-05 DESK.# DEP. Mlsc ,~~rxxx TOTAL o.oa 43. D52.58 LST PAY: D6-D6-D2 REF # 20L5d12g PP LAN $ PKt # CL IC/LP 06-06-02 ST .T US ..,NET*"* DEP , ...,. COMM - . MI55ING DATA `'. .. ~...~ TRANSACTION # 150342X1 AMOUNT (?} 7RAN5 CODE L?) TRANS DATE STATUSlDESK COMM RATElP.MOUNT HDLDOV SOURCE tx.D) REC' D FROM ; (". D} PAGE B3 -RECEIVED- O.dO 0.0~ 0.00 0.00 a.ao 0,00 43,052.58 ~~ MICHAELS, LOUIS & ASSOCIATES, INC. P.O. BOX 1062 MOON TOWNSHIP, PA 15108 412-604-5395 DATE: 1/12/2009 JUDITH JONES 1004 S HANOVER ST CARLISLE PA 17013 RE: HSBC/DIR. MERCH. MC CUSTOMER NO: 5458002211301769-40 ACCOUNT NO: JUDITH JONES AGENCY NO: 5545 BALANCE: 975.67 Please be advised that the above referenced account has been purchased by MICHAELS, LOUIS & ASSOCIATES. Therefore, payments or correspondence concerning this account must be directed to MICHAELS, LOUIS & ASSOCIATES at the address above or by calling 412-604-5395 between the hours of 9:OOam - 7:OOpm Monday through Friday and allow our courteous staff to assist you in resolving this issue. IMPORTANT NOTIFICATION: Unless you notify our office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt to be valid. If you notify us within 30 days from receiving this notice, we will obtain and send to you verification of the debt or a copy of any judgment against you arising from this debt. Also, upon request, within 30 days after receipt of this notice, we will provide the name and address of the original creditor if different from the creditor named above. Further action can be avoided by paying the total amount due or by making monthly payment arrangements. If we do not receive the total amount due or payment arrangements are not made, we reserve the right to take legal action within the 30 day verification period. Sincerely, L.M. Ciccone MICHAELS, LOUIS & ASSOCIATES This is an attempt to collect a debt and any information obtained will be used for that purpose. 1 YAb1Et3Ub1 -I~II~IIIIIIIIINNNIIIIIIIIIIIIIIIIflIgIIIIIBIIIIII ~~ PO Box 129 Linden AQI 48451-0129 ADDRESS SERVICE REQUESTED #BWNKGZZ #TYA61EB061# 6039705-00037 Judith Jones 1004 HOLLY PIKE CARLISLE PA 17013 I~t~II1~~Jll~~~~t111~~11~1 L.BADING EI3GE ~' ~t~~~~.~t_r:~ ~~Lt1'i~rONS LEADING EDGE RECOVERY SOLUTIONS, LLC 5440 N CUMBERLAND AVE STE 300 CHICAGO, IL 60656-1490 Account #: Client~Reference #: Balance: January 20, 2009 6039705 """""""0888 ;585.28 ngina Creditor: CITIBANK •'• Detach Upper Portion and Return wMh Payment ••` usLCwcw+rxns~nwsi Account #: lent a erence Balance: 6039705 """"'"""""`0888 ;595.28 Creditor: LVNV Funding LLC $$$$ Save Big Money $$$$ Settle your bill using .your tax return and SAVE, SAVE, SAVE! Dear Judith Jones, That's right! If you pay Just $476.22 of the $595.28 you currently owe our client, we will consider the account SETTLED IN FULL! In return, we will then notify our client that the account has been settled in full and that your credit bureau should be updated accordingly. Interested in the deal but don't have that kind of cash available ri ht nov/? Haven't gotten your refund check back yet? No problem! Please call us immediately at (800 663-4707 to make arrangements! Our representatives are happy to work with you on time and terms. This is a special offer specificallyy solicited to you to help you clear up this account with your forthcomingg tax return. Please disregard this notice if you have already made arrangements to pay your account.lNe are not obligated to renew this offer. Sincerely, Collections Department (800) 663-4707 Hours of Operation: Monday-Thursday 8:OOam - 9:00 pm CST /Friday 8:00 am - 5:00 pm CST /Saturday 8:00 am - 12 Noon CST .This is an attempt to collect a debt. Any infomtation obtained will be used for that purpose. This information is from a debt collector. PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION HEALTHSOUTH Rehabilitation Hospital Of Mechanicsburg 175 Lancaster Blvd. Mechanicsburg, PA 17055 (717) 691-3700 PATIENT NAME: Judith A Jones PATIENT NUMBER: 732812 BILL TO: Judith A Jones 1004 Holly Pike Carlisle, Pa. 17013 BILLING DATE: January 31,2009 DESCRIPTION AMOUNT TELEVISION: ($1.00 PER DAY) DATE: $ PAST DUE AMOUNT: $11.00 DATE: Original bill sent on 12/29/09 DATE: $ 11.00 PREVIOUS PAYMENTS RECEIVED: TOTAL: (PLEASE PAY THIS AMOUNT) $11.00 (For proper credit, please return the bottom portion with your remittance) PATIENT NAME: Judith A Jones PATIENT NUMBER:732812 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 13 ~ ~ ~ ~,. ";t°' - "~„a~~ COMPLETED BY: RMB TV BILL ACCGUrJT NUMBER U,ati OF STAT~.dlt~i~~ 26'33598285 02/16/2009 ?P,TIcfiT PJA"A~ JUDITH A JONES OU8852 ~~ a n .~ `_ rP ii-~.c fi i F. 7~i- ~~ c DaTF `,^,I ~,..F~FAa c~,'~ 1'l ._._. $7.31 __ ''!vUR b:ci'S ~T.4.Tcft^,cv' INSURANCE PAID THEIR PORTION ON THIS ACCOUNT. YOU ARE RESPONSIBLE FOR THE BALANCE. PLEASE MAIL PAYMENT IN FULL TODAY. BILLING HOURS ARE lOAM TO 4PM A $25.00 FEE INILL 8E CHARGED FOR ALL RETURNED CHECKS. Place of Service: HOLY SPIRIT HOSP IP Referring Doctor: DANIEL RELY MAKE CHECKS PAYABLE TO: WEST SHORE PATHOLOGY PO BOX 750 SCRANTON PA 18501-0750 800/238-3614 SEE REVERSE :SIDE FUF~ IMPG'RTG~O`~I'T BILLiI'vG Ii~1F~Jl~MATiC?iV Date Doctor Code Description 01!07/2009 THOMAS GRIFONE,MD 88305 SURG PATH SINGLE COMP 02/13/2009 1199 MEDICARE CONTRACTUAL ADJUSTMEN 02/13/2009 1100 MEDICARE PAYMENT Page 1 of 1 Amount 130.00 -93.44 -29.25 For questions call, 8001238-3614 and when prompted enter your identification number as follows 2129'33598285 THESE SERVICES WERE PERFORMED BY THE PATHOLOGIST AT HOLY SPIRIT HOSPITAL. PLEA`,E- ~~I~T,acr-~ .~;vr,> NF~ru~,nl i-~~ r~or-; ,~,,, vijFi~ ~, nr~ ~ ~. , arr,OUPIT a~a~~Hr N '=n.nrrn~ ivv.i:aF WEST SHORE PATHOLOGY 26'33598285 JUDITH A JONES PO BOX 750 ;rn'reinei~i n~~rE nnou~aroi,e 4i~oi.~~;rF ~~~~::e SCRANTON PA 18507 Return Service Requested 02/16!2009 $7.31 Place of Service: HOLY SPIRIT HOSP IP PHL4'26`33598285 l~D571.A2vw65o01229. J02CL5.008852 008808 2129 I I~Ii~ I~~II..III..III II~~I ..III.III.II~~I I~II~ ~I~II ~II~I.III.II~~I I~~II 1 JUDITH A JONES 175 LANCASTER BLVD m MECHANICSBURG PA 17055 0 I„~III~,~III~~~~IJ,J~L~JI,~I~I~~II,,,J~II~„I~LI~~I,~II II~I~I~II~iII,~IIi~~llll~~~ll~ll~~lll~~lllll~~~l~ll~,III~~III,II~I WEST SHORE PATHOLOGY PO BOX 750 SCRANTON PA 18501-0750 I~nlllnl~~l~ltll~u~nlllln~l~nl~l~itll~~ul~l~ll~nl~~l~l (IINI IIIII IINI IIIII IIIII IIIII I IIII Intl IIIN INII IINI IIIII INI IIIN IBII IIIN IIIN IIIN IIIII Ills IIIII Ilia IIIII IIIII III INN IIIII ilk IIIN IIIN IIN IINI NN NCI IN III is~ ® Nationwide On Your Side 00073 Michael C Ferster 155 W High St Carlisle, PA 17013-2916 April 7, 2009 RE: Policy Number 58370 503731 Automobile Insurance Policy Customer From: October 05, 2008 To: March 31, 2009 Balance Due: $5.60 Judith Jones 1004 Holly Pike Carlisle PA 17013 " This bill represents the balance due on your policy that has been cancelled. Any premium paid did not fully o cover the actual time that you were insured. If you have already submitted the balance due -thank you! If you ti have not paid the remaining balance, please do so immediately to prevent your account from being referred to o an agency for collections. °°o Your balance may be reduced or eliminated if you obtained other insurance coverage prior to March 31, 2009. ,,, To determine if you qualify for a reduction, please send us a copy of your new policy Declarations page, which ~ contains the following: ° Name of the insuring company • Policy Number • Vehicle(s)/Property Insured Effective date of coverage To avoid collections, please return the bottom portion of this letter with your payment or new policy Declarations page in the enclosed return envelope. Note: This is the onlx notic~ou will receive regarding your balance due. If you have any questions, please contact our Customer Service Department at 1.877.669.6877. Si usted desea hablar con un representante bilingiie, por favor comuniquese con nuestro Departamento de Servicio al Cliente al 1.877.669.6877. _____ •PleasedetachandmailthissliPwithYou~ayment.________________________________________________, Judith Jones y . P 1004 Holly Pike Pa ment S1~ Carlisle PA 17013 Total Due $5.60 Due By April 7, 2009 Make payable to: Nationwide Insurance Amount Enclosed Account Number 5801655727 Poliq Number 58370503731 In~lll~lun~llllnunllull~l~lml~l~lnlnl~l~lnl,Ilu,l Nationwide Mutual Insurance Company Your Nationwide Agent PO Box 13958 Michael C Ferster Philadelphia, PA 19101-3958 1.877.669.6877 13 ^101^^^^^^ 37 ^3 ^^ ^^^^5^3731 4 ^^^^^^^5hn MMMn.Si,n 5R 1,