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HomeMy WebLinkAbout06-08-10~~~_~~4~ ~(~5) 15056041154 PA l3dp•rtlnent d Revenuo ~' ~E QIE,.Y Bureau d Individual Taoas County Code Year Flle Number Po sax X0601 INHERITANCE TAX RETURN HsMiburg, PA 17128-0601 ~'~' ~~~ , l ~ ~ ~ ~S Social Security Number Date of Death Date of Birth 218-24-982.1 03312010 03101922 Decedent's Last Name Suffix Decedent's First Name M I DAWSON HARRY H (if ~plicable) Enttr Survhrir~y Spouse's IMormstion Below Spouse's Last Name Suffix Spouse's First Name M t Spouse's Social Security Number Fill IN APPROPRIATE BOXES BELt)W THIS RETURN BUST BE Fl1.ED MI DUPLICATE WITH THE REC~~R o~ vwus a 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (dam of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. ® 6. Decedent Died Testate ^ 7. (Attach Copy of Will) ^ 9. Litigation Proceeds Recx3iMed ^ 10. Future Interest Compromise (date of death after 12-12-82) Decedent Maintained a t.iving Trust (Attach Copy of Trust) Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Dspoait Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT • TFI~ SEC110N tiBUST BE COMPLETED. ALL CORRESPONt~NCE ANO CONFIOENTIAI~ TAX iNItCRMATION StiOUi.D tilS dRECT6r0 TO: Name Daytime Telephone Number CRAIG A• HATCH, E SQ• 717-?31-9600 Firm Name (If Applicable) GATES, HALBRUNER, First line of address 1013 MUMMA ROAD, HATCH 8 SUITE 100 GUISE, P • C • tiY1i.L.S USE ~Y C~ , m ; Second line of address ~ ~~ ... ...• City or Post Office State ZIP Code FILED .. r -- LEMOYNE PA 17043 ~'' Correapond~lt's e-m~1 address: _ C• H A T C H N G A T E Sl~A W F I R M• C 4 M Under penalties of perjury, I decians tfiat 1 haw examined thb rNum, including sccompanying schedules and statements, and to the best d m knows y edge and belielf, it is true, correct and oompN~le. C~ee~ration of preparer ocher than the personal representative is based on alt infomtation of which preparer hss any knowledge. ~~ "' J 15056042159 REV 1500 EX Decedent's Social Secx,rity Number 218-24-9821 D.c.a«~:Nam.~AWSON HARRY H RECAPITULATION 1. Real estate (Schsdwb A) 1. 0 • 0 0 2. stocks and Bonds (schedule B) . . . . . . . . . . . . ... . . . . . 2. 0 •0 0 3. Closely Held Corporation, Partnership or Sob-Proprietorship (Schedub C) • 3. 0 • 0 0 4. Mortgages 8 Notes Receivabb (Schedub D). . 4. 0 • 0 0 5. Cash, Bank Deposits s MisceNsneous Personal Property (Scnedub E) . 5. 6 3 9 2.10 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 8. 2 3 2 0.1 ~ 7. Inter-Vivos Transfers b MHscNlaneous Non-Probate Property (Schedub G) ~ Separate Billing Requested . .. 7. 4 2 4 5 5.2 D 8. Totsi aroes Asests (total Lines 1-7). 8. 51167 • 4 ~ 9. Funeral Expenses A Administrative Costs (Schedub H) . 9. 8 4 6 8.6 2 10. Debts of Decedent, Mortgage Liabilities, d~ Liens (Schedub I). 10. 18 • ?2 11. Total Deductbns (total Lines 9 810) . 11. 8 4 8 7.3 4 12. Nst value of Estate (Line 8 minus Line 11) ................... 12. 4 2 6 8 0.0 9 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an ebction to tax has not been made (Sc~edub J) . . . . . . . . . . . 13. 10 0 0 • 0 0 14. Nst Vslus Subject to Tax (line 12 minus Line 13) 14. y 16 8 0.0 9 TAX COMPUTATION -SEE IN>aTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabb at the spousal tax rate, or transfers ur~ Sec. 9118 1 2 x 0 (a)( . ) . 0.0 0 15• 0.0 0 16. Amount of Line 14 taxabb at lineal rate x .0~l.5 416 8 0.0 9 16• 18 7 5.6 D 17. Amount of Line 14 taxabb at sibling rate X .12 0. 0 0 17• 0. 0 0 18. Amount of Line 14 taxabb at collateral rate x .15 0.0 0 18• 0.0 0 19. TAX DUE 19. 1875.60 20. FILL iN THE BOX fF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Sid® 2 15056042159 15056042159 J 8M4648 2.000 I$1/-1800 EX Ppe 3 FIN I~hnnber DECEDENTS NAME STREET ADDRESS CITY STATE ZIP Tax Payml~nts wind Credit~es: 1. Tax Due (Pape 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 0 • 0 B. Prior Payments p • 0 ~ C. Discount 9 31.7 8 3. InteresVPenaity if appNcable D. Interest p • 0 0 E. Penalty ~ • 0 0 (1) 1875 • b0 Tdal Crodits (A + B + C) (2) 9 • 7 Total inter+salPenaky (D + E) 4. If Line 2 is greater than Line 1 + line 3, enter the difference. This is the OVERPAYMENT. Fill in twx on Page 2, Line ZO to nqueat s refund. 5. If line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interes# on the tax due. (3) 0.00 (4) 0.0 0 (5] 17 81.8 ~ (5A} 0.00 B. Enter the total of line 5 + 5A. This is the BALANCE DUE. (5B) ~ 81 ' 8 Make Check Payable to: IS'TER OF bVtit.LS, AC~EEIVT PLEASE ANSWER THE FOLLtyWNNG QUESTIONS BY PLACIN~3 AN "K" NV THE APPROPRIATE BLOCKS 1. Did decedent make a transfer snd: Y N a. retain the use or income of the property transferned; .. ... .. .. .. X b. retain the right to designate who shall use the property transferred or its fncxxne; x c. retain a reversionary interest; or . . . d. receive the promise for life of either payments, benefits or care? • 2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideration? .. 3. Did decedent own an "in trust for" or payable upon death bank amount or security at his or her death? . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which ® a contains a beneficiary des nation? iF THE AN8'WER TO ANY OF THE ABOVE C>;UESTION8 IS YEB, YOU MUST COMPLETE BCHEDU'LE G AND F><.E R AS PART OF Tt1E RETURN'. Far dates of death on or after Jury 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 t, 1995, the tax rate imposed on the net value of transfers to or for the uas of the surWving spouse is zero (0) percent [72 P.S. §9118 (a) (1.1) (ii)]. The statute does. not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the ony 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 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 ram imposed on the net value of transfers to or far the use of the decedent's lineal beneficiaries is four and one-hail {4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(s)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's sibifn~ is twehre (12) percent (72 P.S. ~9116(a)(1.3)]. A sibling N defined, under Section 9102, as an individual who hss at least one parent in common with the decedent, whether by blood or adoption. 8M4871 1.000 REV-150d EX; (&9a) ~~ CAMUONWEALTH of PENNSYLVANIA CASN, BANK L?EPK?SiT'3, d~ M'tSC. IN-ERITANCE TAI( RETURN ro~rr o~;~NT PERS~IAL PR~RTY ESTATE OF FILE 3W~16AD 1.000 (It moro space is needed, Msert addilionai aft dtf-s tame sise~ R~-~~ ~+ (~-~~ SCI~DULE F OONMOMMEALTti oi* Pe~sYLVAri~ JOiNTL`if•0'WNLD ~ROP~R~'Y 'ANCETAXRETURN Ri~D6~fT OBIT ESTATE OF FILE Nl _Hs~rrv H . Dawson Han asset was mach jt~int within one year of the deaeeMnt's date of cNath, R mist bs sported onikhech~N Q~ SURVNNG JONVt' TEtVAN1-(S) NAME ADDRESS RELA110NSFtiP TO DECEt7Erfi• A Dawson, Charles H 7 North Baltiaore Stroet, P.O. Box 122, Franklintown, PA 17323 Son B Zook, Hotte J 24 Gunpowder Road, Mechanicsburg, PA 17050 Daughter JOINTLY~O~WNLD PROPERTY: ~ f~i~ LETTER FOR JOMI TENANT OM1TE MRDE ~ nrCWDE NAME of FINANCNL INiTRUT10N ANO MNKACCOUNT NUMee+t ~ ~d~~ ' ATTACH DED FOR QATE Of D6~-~H VALUE OF ASSET 96 OF DECD'S NT DATE t3F DEATii VALUE OF OATS NTT 1 BA 1/1/2008 MST Bank checking account number 27623858 6,960.38 33.3300 2,320.13 ~T~L (tea ewer a, use S,g~a>~'te1l~tla I Y 2 , 32 0.1 ~ (M more spice is needed, insert eddNionai sheets of the same size) 3W18AE 1.000 REV 1510 EX + (08.09) psnnsyl~ana DEPARTUI~NT OF REVENUE ANC~~ RN SCHEDULE G tl~l1`ER-VIYOS YRANBI~~Rl~ ANa MISC. Nit-PR08147E PRE~P~RTY Harry H. Dawson This schedule must be completed and filed if the answer to any of questions 1 through 4 on pope three of the REV-1500 is yes. ITEM N(~E INCxwE TiE PWiAE of TPE TRAPI{FEREE, TtE1R REUTIOP~MP TC DECEOEPJT APO TIE PATE OF 1RAPaFp1. ATTALII A COPY OF THE QEED FOR REAL E6TATE. DATE OF DEATH VALUE OF ASSET % OF DEvv ~7 ~C+i-~~ TAXABLE V ~• Allstato Lif® Insurance Comapny -Annuity Contract Numb®r GA17246498 42,455.20 100.0000 0.00 42,455.20 TOTAL (Also enter on line 7, Recapitulation) S 42 , 455.20 if mars apace fs needed, use addidonsi sheets d paper of the same sfzs. 9W46AF 2.000 t . REV-1511 EX+ (10-09) ~~~~~ ~f1t1l~y~V1f11a oEPARTbIENroF REVeNUE FUNERAL~EXPENSES /~lND reaE~aTANC~E TrU( RETURN ADMINIS 11'1',1 EVE COSTS RE3~IENTOECEOENT ESTATE OF FILE tER Harry H DaMaon Decedent's debb must be reported on Sahsdule 1. ITEM NUMBER DESCRIPTION AMOUNT a. FUNERAL. EXPENSES: ~. Malg~zzi Ftsn~ral Hom® 6,248.62 Total from continuation acheidul®a . B. 1. ADIVIINI.STfiATIVE C©STS: Personal RepresentatiMe Commissions: Name(s) of Personal Represent~ive(s) Street Address CiN State ZIP 100.00 2. Attorney Fees: 2 , 000.00 3. Family Exemption: (It decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4. 5. 6. 7. 1 Year(s) Commission Paid: City State ZIP Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Proparor Fees: Robert J. Emrich, Jr. - poraonal income tax gr~paration 120.00 TQTAL (Also enter On Line 9, Recap~uletion) ~ S 8 , 4 awaene 1.01o If more space is needed, add additional sheets of paper of the same sire. Estat® of: Harry H. Dawson 3ch®dul® H Part 1 (Pag® 2) Itom No. I3oscription 2 Immanuol Christian and Missionary Alliance Church - memorial lunch®on Amount 100.00 Total (Carry forward to main schsdul4) 100.00 REV-1512 EX+ (12-oe) SCHEDULE 1 p®nnsylvania OEPARTiYENT OF REVENUE DEBTS OF DECEDENT, STANCE TAX RETURN MORTGAGE LIABILITIES ~ ~~~~ R~sa~rR oEC~o~NT ESTATE OR RILE I~ItJfififiKR Harry H . Dawsion Report debts incurred by the decedent prtor to desth that nnnsfned unpsW at the dsb of dssth McludfnS unreNnbursed mpdksl expeeaes. ew4eAH a.oao if more space is needed, insert additional sheets of the same siae. REV-1513 EX+(11-OS) S~~IEDULE J Pennsylvania OEPAR'TMENTOF REVENUE QGI~Er1~~~~CS INHERITANCE TAX RETURN QG17G VI GG RESIDENTOECEUENT Li'rres W 11~vsnn FILE NU~ER RElATi01~ISH#f' TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ~ ~ PERSON(S) RECEMNG PROPERTY Do Nat Lfst TrwtN(s} OF ESTATE I TAXABLE DISTRIBUTIONS [include outtiNM spoussl distributions, and transfer under Sec. 2116 (a) (1.2).J 1. William C. Dawson 362 Valley Drive Fayetteville, PA 17222 13,119.97 Son 13,119.97 2 Bette J. Zook 24 Gunpowder Road Mechanicsburg, PA 17050 MST Bank checking account number 27623855 Inventory Value: 1,160.06 13,119.97 Daughter 14,280.0 ENTER DOLkAR AMOUNTS FOR OIS1!RIBlfF10N& SFIOWN ABOVE ON UI`ES 15 THROUGH 1 8 OF REV-15fl0 COVER SHEET, AS APP ROPRUITE. II NOhf-TAxA81.E t~fiRIBU'i10NS: A. SPOIiSAL OISTRIBlJf10N3 UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. t~iARl'fABLE AND GOVERNMENTAL DISTRIBUTIONS 1• See Attach®d 1 TOTAL OF 1sART N - ENTER TOTAL. NON-TAXABLE DISTRN3tJTiONS ON LNyE 13 OF REV-15110 COVER SHEET. i 1 000. 0 ~r more apace r nseaea, insert soap anee~s or me sine. ew4eni z.ooo Estat® of: Harry H. Dawson 3chodul® J Part 1 (Page 2) Item No. Dosaription 3 Charles H . Da~rson 7 North Baltimore Stmt P.O. Hex 122 Franklintown, PA 17323 MST Hank ch+~cking account number 27623858 Inventory Value: 1,160.06 13,120.01 Son 1~1:tion Amount 14,280.0 ,~ - Estat® of: Harry H. Daaaon 8ch~dule J Part 28 (Page 1) I twn No. ~acription 1 Immanuel Christian snd Missionary Alliance Church Amount Specific bequest per Will. 1,000.00 1,000.00 PHOTOCOPY OF THE CERTIFIED DEATH CERTIFICATE LOCAL REG1S~`RAR'S CERTIFICATlC3lV OF C}EATH WARNING: It is illegal to duplicate this copy by photostat or photograph. for this certificate, $6.00 P 1624~~.02 Certification Number This is to certify that the information here given i correctly copied from an original Certificate of Deat duly filed evith me as Local Registrar. The origin certificate will be forwarded to the State Vita Records Office for .p anent filing. ~- ~~~~ Local Registrar Date Issued ,++IS,u aEV ,aloof TYPE /PAINT M BLACK Da(N/l( COMMONWEALTH OF PENNSYLVANU • DEPARTMENT OF HEALTH • VITAL. RECORDS CERTfFtCATE OF DEATH- . (Stlta MslruCtbns and exflmDMs on reversal __ -- _ _ +. Mrr a Oaeadant (FYr. aldrk rK +do4 x Sae a Socr s.arry mob. - - ~. Lath d Deal, prbM,, Oaf, part h t~lws~n Male 218 -- 24 - 9821 March 31 2010 S Ape fur OYOdar) undtr+ t0+dtr, a oab d elnn >•. arorrer Be Prat a Oatlr reira a.r. lUre etarae . -~O;,r. ores 88 Yrs ~ ~ . rczh 10 1922 D~artvl l le PA D ws«e O f]i / orpal.a D DDA ®I-.rap rhea O naMdaa~. O Dwr • w•dr la Carty d Deah Ic. Cllr, Bob. Te;. d Drib tli faeiq Harr (Mrl iirObYen, (lire rieu rr naripar( 9. tetra Dlnrre d ttipr:c Orilh7 1b Yr ~ iree: Aaarlrp Udalt Bidc.lMfia. MG IO Yrr• ~ Cdrn. ~lalberlarbd Silver Bri At Bent Creek "'°~^• "~ ~• ~~ W,~ite n. Oeadrrs u.w daoA art alga a .Ilk Do na orb +2 wr Ordeat ewr b Or ,a Oaoadrars tit4caOon ISOror1 art ~r Wr ~Ob+a9 ,•. -bArr BrOrK raabO. Mryar Mr+rd, +i SrelAy 8paaa M dle, IMre eriean ~arM U An+rd Forma? S Mlide~4 0irard KMdW k K ~ i ' . . r f re J rddBurrr/Mrdurry ! ~ / - (O,2- f:drpe 01 a s.l Pi Steel: ®Yr ^ too 12 WidO~Wed ,6. osaaat: ~ ANrar tswr. cy / blr1, star, A• oolb) 2100 Bent Creek Boulevard Oaeadrfa Die Daeerlanl Silver A~ Rererrce +h SIMe _ Pennsylvania ,~~ CXJ Ysk Osesdrr Liwd in Sprlnq Mechanicsburg PA 17050 ~ T„p . ~~ ~r ~L1tm6e*-~ and. 'Td D ~ ~~+~^ , ay/Bhro ,fL foes: tsaab ~*r. a,idde, asc,wid +a ltrrr: Mama lFrr. riddle, naidrr surrwey William F. Dawson E, titterer 2Da Idornsnfs Moab R~ / Prinq xlb. Wowrrr't Miq Aearra t51eaL W / biMt rte, rIP ~+q Bette Zook 24Gunpcxader Road Mechanic PA 17050 ztk llee,m d D4porilon r ^ CraaOm ^ Oamisr Ili ~rw D g 9rt ~ ?ta oab d Oispaetlioa (Nett,, dslr, rsr( 2,c Prce d oiaorxar O+oere d c«rrwp. ci.rrbry a art ab'+i Ltd uawan Qglyd bra rte. aP ardN ear e rrs ararrs r oonrbr, AeNrred D ol,r• ' IlffledfaiEOaaiar/Cararrrt D reD No ril 2 1 ROlii Green Cemetery Hill PA ~ la ~+~ r sad~- - ~ .. rm. t;oan. MoarAar as Msar spa Agates d Faoigr 8 Market P13Za Wrl Y a+r etaa onyss+.p r pa bslsor r wn d daeln b d xlk 7a sn aw raOba gabs. (5grrara aad,rN i ~' ~ ~ ~ /y 23b. Licare tAraer / '~' ~ ~ Oeb SfOiM lr+epN. dN. rwl ae~rore sarn. a- , L i ~,~ 71 G U, l .~1 ~r7D/v hepr 21.26 air b oengbbd by peraan 21. Tar d Oeb Pp,nrrred Oro ~. deY. rw1 26. Wr Cap Iiarlwd b Nedcr Esriw / Career for a Ilan OOer Iarr CranrYar or DorfanT M d rn a r P ~ . U..r' .~ YLI- ~~ Ot~f~ ^ Yr ~ No GU6E OF DEATH ($~ inaenrrkrns and a:arrrplaa) ~ ApOroriwb ireervd Part M: EreM drr 2l DN ToYaoee lie CrrrR,Ir b Deafer her 27. PaR t frr,ar Or td6f6.at/elslli- dYeraa, lpl~rrk r arapto/as -Oat draeOy aerrd M drO,. DO MDT aer rrairi amore asA r ardae artrt ~ Drwt b Daaln Eat not 0 b Or uadlrlrip oar rwpb HR L ^ Yr ^ PaOrOq rO frr O ~ E i O rY resat r grO erOar I MOaa rrw slrorwra Or aOobfN. lit a+y one aara m eadr irr. Ib ^ lirtrrew n !~ r s°' "~'u~fi"~i ~i-°~'~° ~ ('t ~ l ~ ~+ t YYt.~ ~iw U ~ Szsi~.Z ~ 7 tai l~t.~ G~n l.~c~ 1 m. r ream ~ , ^ lit Ike rYtir Oar Yaer Des b (r r • aweQrroe dr ~ ~ 2 PwPw r Ire d dsrr .:r'Y-~ ~~L• ( 4/YL n r ~ ~ ~ ~ r . , ~eq}uMr lle I k fJOr LMIER.YMB CAUSE Duo b (or r a orwgrrra d-: ~ ^ Nr prtyart InA peyWO eAOirr 12 dare ~ .~°IIM.Mpo`*"1n""dwr~e~T" ' ~ ~ ~ t ~1/' T dart ,:.c,;.yt ~~, . . , . Due b trr r a rrrr4rr~ dk ~ D Not pe0rit ed pr6rbnt q dNs b / roar Ogler dealt Q r . r ^ tltOarr I pre6nrO rtNq Or Oar rrr aok tlLa rr Arbgr Plrbrnred7 ages,. VWr Aubpr Avalara Pdr b Crpb6rn ~,. Nenw a DaalA ~2k Oar a N"'tr Plrpst M. rrrl ~ Dnoee lbw bjiry ooorrr ue ~ ~,. ~ a s ~ j d Cane d Dard ® Mrral D lbmiade D r l i , ^ Yr ~ lb ~ ^ Yr ^ tb ^ Aoddrl ^ Pendrq Ywrlleion ~d TYrr d MrY 72a bjury Y NbaT ni I.O Taraporaron bjtry ISPrrI'1 ~ tauten d bjugr (6qr, dN / beq rrd ^ Sriride ^ CaAd Na be 0arrnined N ^ YK ^ 14 ^ Oriwr/ OOratrr D Parrrpr ^ Padrarn DOw • SPre+Y1' xn Griar taredr r+r ry ~Mi~M1~l~leMirarOylMarrdtlnMWruanoOirpMrbrnArP~ounoeddeaOraadoaapbbdlWn?9( xle. sgraw. aro TIS. d i ~ i1'C Tstlr6ardw.r~b4-dreMreurdruecalenrrys)rdwwirasrred__---_- --- (~ --------------------- 1 ~ ~. i~ a P+~~B~a+rO6pOeyafeMPAreldrOaOrOreaarrrigdaartand b roar d deelq T.astar.Imltawrb4t~ear,ocarraOrlR.raa,orb.mow.r.rrrusaa.c.w.(alrww.rrrr.bs------------------ ^ • l6eaertsuerrrr/Ce,rrsr 7IcLJrrreMrrM h t~ J'a-"~ ~j 4 .Z ~ 3d ar. rasa ~ ~ 110 Oa Ode Erb al rrnbrfaa oar/ r YarMyeYerS b M aObbn, darA oeerrred r tiretbre, rbta. and Oboe, arr0 des b Mearrae(el aM rrrwae e,+cerl. ^ H. Mare and Adber d Prato Yler Cara d OaaOr (Mm 7>) Tppe / PMee o ' c ~ DiaYlr m , t ~0~ 11~~f1 j a i a .~ -~ ~i.DmP4s6~!arstdar. I I ( 1 I 1 ~ ~ l~ ~o • ~~ ~ - , . , i T 1 t ~ ~ 1 iO;~.S ,~,,~ 0479622 LA5T WILL AND TESTA1vIENT ~Y H DA~,gON Iit~ LAST WILL AND TESTAMENT OF HARRY H. DAWSON r i L I, HARRY H. DAWSON, of Hampden Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all wills by me at any time heretofore made. 1. I direct that all my debts and funeral expenses be paid as soon as practical after my death by my Executrix hereinafter named. I direct that all taxes that may be assessed as a consequence of my death shall be paid from my residuary estate as part of the expenses of the administration of my estate. 2. All the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be situate, I give, devise and bequeath to my wife, VIVIAN R. DAWSON, her heirs and assigns, provided my said wife, VIVIAN R. DAWSON, shall survive me by a period of sixty (60} days. 3. Should my said wife, VIVIAN R. DAWSON, predecease me or fail to survive me by the aforesaid period of sixty (60} days, then in such event, I give, devise and bequeath my estate as (follows: (A) I give to the Immanuel Church of The Christian and Missionary Alliance the sum of One Thousand Dollars ($1,000.00). (B) All the rest, residue and remainder of my estate, real personal and mixed, I give, devise and uw o=Faces SNELBAKER. BRENNEMAN At SP0.RE bequeath in equal shares to my children, WILLIAM C. DAWSON, BETTE J. ZOOK and CHARLES H. DAWSON. Should any of my children herein predecease me, I direct the share such deceased child would have received __ _~.._____-.Y ~~ hereunder shall be given to his or her issue surviving me, per stirpes. 4. I hereby nominate, constitute and appoint my said wife, VIVIAN R. DAWSON, as Executrix of this my Last Will and Testament. In the event she should predecease me or fail to qualify, I nominate, constitute and appoint my daughter, BETTS J. ZOOK., as Executrix of this my Last Will anti Testament. I further direct that no person serving as Executrix hereunder shall be required to post any bond to secure the faithful performance of her duties in the Commonwealth of Pennsylvania or in any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament written on Two (2) pages this 29th day of September, 1999. i --,/ -~ i~~4''-~'ls'~ l_--~~~~cr. {SEAL) Harry ~~'Dawson Signed, sealed, published and declared by HARRY H. DAWSON, the Testator above named, as and for his Last Will and Testament, in our presence, who, in his presence, at his request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. '. - ~ r ,~.~ ~>-r_ a=-- 1~ ;. '~-/(SEAL ) -. LAW OFFICE6 SNELBAKER. BRENNEMAN & SPARE i~-~~ (SEAL) -2- COMMONWEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND) We, HARRY H. DAWSON, KEITH O. BRENNEMAN, ESQUIRE and SUSAN L. ZYCH, the Testator and the witnesses, respectively,. whose names .are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament and that he had signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and that to the best of his or her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~; ~ .--- ; .. ~: T tator Witn~ !~ /7 (:' Witness ~~Subscribed, sworn to and acknowledged before me by HARRY H. DAWSON, Testator, and subscribed and sworn to before me by KEITH O. BRENNEMAN, ESQUIRE and SUSAN L. ZYCH, witnesses, this 29th dayf of September, 1999. !' ` . 1 . i ^E 1 .~ Notary ublic LAW OFFICES SNELBAKER. BRENNEMAN & SPARE r7~ ~t~p . ~: N My Ctymm~iaNS~on Fx~e~ $1.17 Z00 P'&tYfi3~fl113111~ A55(tiF.faCil;is ft1 YA RE~'-150U SCKEDU EPOSITS & r ASH, B~KD~C YERS~NAL MISCELLpgOYERTY Q McTBank 499 Mitchell Road, Millsboro, DE 199b6 Mail Code DE-MB-12 Gates, Halbruner, Hatch & Guise, PC Traci L Sheridan 1013 Mumma Road Suite 100 Lemoyne, PA 17043 Dear Sir or Madam: Re: Estate of: H H Dawson Social Security: 218-24-9821 Date of Death: March 31.2410 Phone (888)502-4349 Fax (302)934-2955 May 5, 2010 Per your inquiry, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: l . Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total 2. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 27623858 Charles H Dawson, joint sec~r~dary Harry H Dawson, joint primary Vivian R Dawson, joint-secondary Berle J Zook joint-secondary o8~s~~a / $ 6960.38 ~ $ 0.00 $ 6960.38 Checking Account 9847063568 Harry H Dawson, principal Bette J Zoo1~ Rep Payee 12/118 $ 0.00 $ 0.00 $ 0.00 3. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Checking Account 9850596108 Harry H Dawson, principal Bette J Zoo1~ custodian 04112/09 closed 04/!10/10 $ 453.99 ~/ $ 0.00 Total $ 453.99 please be advised, there was no safe deposit box found for the above decedent * If upon reviewing the iufonor~ation above, you believe there are additional acoou~s not refed, P Pi''o~ us with an account nua~er and/or name of any possible joint account holder. Fbr any ' ' iamfo~stion on the above accounts, Ong ownership and any changes, closures and/or reimb~irse~nent of fa~nds, eta, please contact our Hampden branch at#717-255-22s~. sincerely, N rissa Sears, Adjustment Services operty Account robe 20100-000 _ -. . _ . Invoice Description Amount :Refund Move out refund 4,389.00 ~~ 4,389.00 ~,a~-~~ ~ ~~ac~~ ~-~~ e~nQ c~ i vi ~o ~~~~'S ~~~'t` i~`--ti ~~~~~ 1 ~~.~ ~(~ S s E t Carlisle Pike i i 6280 Carlisle Pike Mechanicsburg PA 17050 Inquiries Call: 717-697-4432 Acct XXXXXXX361 ZOOK,DEDTNIS E Eff: 04J21/10 Date: 04/21/10 Tlr: 0781 Time: lZ:llpm Deposit to CiiECKING 0011 Prev Bal: 9,315.12 Amq.uutt.-.,,r__,..__...._.~..._.-~ .._..~_.._.------ .4-,384.,Q0 ~ -New Bal. } ___,., .,.-13.704.12 _.___ _ -_~ a'eq - -- - ..- ~ • . -----._.._ #29105 Cki~-hld,. ~.~,s_,Q4/23/10 4,139 :QO~ Check Received 4,389.QO ~t-~i-i C ~ ii Authorized by Li ~E 1C .. . Z?J ^aourc:e Drv Lic SigCard iii Known r j Other Got 3.99=~ APR on your VISA Credit Card? Here's how you can: Get our VISA Platinum Choice Rewards Card. Ask for details. DENNIS E F.OOK ROBC Limited Partnership statement 202 Black Matt Road Douglassville, PA 19518 Account: horobc - 0152 - hodawha1 Date: 04/19/10 Harry Dawson Payment: c/o Bite Zook 24 Gunpowder Rd Mechanicsburg, PA 17050 Description Charges Payments Balance Balance Forward 0.00 Rent 4,139.'00 4,139.00 chk# 1003 2,000.00 2,139.00 chk# 1577 1,111.10 1,027.90 chk# 1008 1,027.90 0.00 Beauty Shop -Cut oMy 1 /5 16.00 16.00 Personal Care Items 12/16-1/15 2.85 18.85 chk# 1004 2,5(}0.00 -2,481.15 chk# 1009 1,004.80 -3,485.95 chk# 1580 779.05 -4,265.00 Rent 4,265.00 0.~ Personal Care Items 1 /16-2/15 0.108 0.08 Rent 4,265.00 4,265.08 chk# 1005 1,000.00 3,265.08 chk# 1010 1,004.80 2,260.28 chk# 1582 2,260.28 0:00 Personal Care Items 2/16-3/15 7.42 7.42 Credit Personal Concumables -7.42 p.Op chk# 1006 2,000.00 -2,000.00 chk# 1011 1,004.80 -3,004.80 chk# 1584 1,260.20 -4,265.00 Credit Rent 03/31 /10 -140.00 -4,405.00 Rent 4,265.00 -140.00 Credit April Rent -4,265.00 -4,405.00 Beauty Shop -Cut only 3/17 .16.00 -4,389.00 Amount to be refunded 4,389.p0 0.00 P 117414} Move out ~ x,389.00 Check # paid out _ f -4,389.0 0.00 30 Days 60 Days 90 Days Amount Due 0.00 0.00 0.00 0.00 8 Market Plaza Way Mechanicsburg, PA 17055 3. Shartzer, ~: 1 ~~ ~~~~~~~~ ~~~1~~I~~~ ~ ~~I~~~ "~ -~ . -`. t~ .'_~~ -.~. (717) 697-4696 www.mal zzifuneralhome.com ~Iicbael J. Malpezzi, Owner, FD April 12, 2010 Bette J. Zook 24 Gunpowder Road Mechanicsburg, PA 17055 The Funeral Service for Harry Hugh Dawson Kyle C, Knipe, FD V4'e sincerely appredate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES: Viewing (Visitation/Wake) $500.00 Funeral Ceremony $540.00 Graveside Service $475.00 Vehicle to transfer remains to Funeral Home $325.00 Hearse (Casket Coach) $425.00 Flower car or floral disposition $185.00 Lead car/Clergy $18S 00 Services of Funeral Director/Staff - $1,895.00 Embalming $785.00 Other Preparation of Body $ 185.00 FUNERAL HOME SERVICE CHARGES $5,500.00 SELECTED MERCHANDISE: 100 Flag Memorial Folders $45.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $5,545.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCGLiVTING F4P THuSE CHARGES. CASH ADVANCES: Certified Death Certificates $60.00 Newspaper Notices -Patriot $356.62 Military Honor Guard $75.00 Flowers $212.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES $703.62 CONTRACT PRICE $6,248.62 HISTORY: 04/12/2010 Forethought $3,825.52 04/1?/20I0 Forethought (Vivian) 53,779.11 04/ 12!2010 Overpayment ~R~f~un~l Ch'~.G ~ % G~S"7,5' ~ _ ~ ~ $ l ,3S5.OI TOTAL AMOUNT DUE 50.00 ^S AD-Automatic Deposit ! AP-Automatic Payment E ATM Teller Machine 1E DC-Debit Card i T Tax Deductible E TT Telephone Transfer F NUMBER OR DATE ~ '~~:~'~`' TRAt+Ld4CTIdN ~SCR~i,...' ~! 1~ {:P ME~1v.!:_ / FEE DEPOSIT S n_~ ~ ~' _ L` I 4 ~ . , t ,~t~<:. t~,. ~-` 3 ~ .., - .fA~' 1 f i I ~ ( ~ ~ t ' ~ _ ~ ~,... ,.,.,., ~. PROTECT TOUR ACCOUlET -USE (HUGS IN SEQUENTI AL OtDEA. RECO N(IEE ST ATEMEN TS PRO MPTIT. PA ~tEV-150a SCHEDULE F JOINTLY OWNED PROPERTY M~i'Bank 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-]2 Gates, Halbruner, Hatch & Guise, PC Traci L Sheridan 1013 Mumma Road Suite 100 Lemoyne, PA 17043 Dear Sir or Madam: Re: Estate of: Harry H Dawson Social Security: 218-24-9821 Date of Death: March 31, 2010 Phone (888) 502-4349 Fax (302)934-2955 May S, 2010 Per your inquiry, please be advised that at the time of death, the above-named decedent had on deposit wig this bank the following: 1. Type of Account Checking Account Account Number Ownership (Names o, f } Opening Date Balance on Date of Death Accrued Interest Total 2. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total 27623858 Charles H Dawson, joint-secondary Harry H Dawson, joint primary Vvian R Dawson, joint-secondary Bette J Zook joint-secondary 0828/64 $ 6960.38 $ 0.00 $ 6960.38 Checking Account 9847063568 Harry H Dawson, principal Bette J Zook Rep Payee 12/11/(78 $ 0.00 $ 0.00 $ 0.00 3. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 9850596108 Harry H Dawson, principal Bette J Zool~ custodian 04/22~t79 closed 04/ZO/10 $ 453.99 $ 0.00 $ 453.99 Please be advised, there was no safe deposit box found for the above decedent. * If npon reviewing the it~ormation above, you believe there are additional not re.ferenoed, please provide us with an acooa~nt number and/or Home of any P joint aocxxnt holder. For ~ additional in~otmtion on the above acooimts, o~-ners~ip and any changes, closures and/or reimbursement ~rf , etG, pie contact our Hampden branch at #~i~-2~-22s~. sincerely, N rissa Sears, Adjustment Services PA REV-1 SCHEDULE G INTER-VIVOS TRANSFERS and MISCELLANEOUS NON-PROBATE PROPERTY Allstate Life Insurance Company P.O. Boy; 94212 Palatine, IL 60094-4212 Telephone: (877j 499-6418 Facsimile: (866) 635-4523 May 7, 2010 Traci L. Sheridan Gates, Halbruner, Hatch ~ Guise, P.C. Via Facsimile 717-731-9627 Re: Harry H. Dawson Contract No: GA 17246498 Dear Ms. Sheridan: Yau're in good hands. Thank you for your correspondence to our department dated Apri127, 2010. The following is a breakdown of the information you had requested on the above closed annuity claim: lZ Title of Annuity: Harry H. Dawson 2Z Date of Issue: 1 l/03/2003 Ownership Changes contraM: Contract was original issued with both Harry H. Dawson & Vivian Dawson. On 05/1512009 Harry H. Dawson continued contract as sole owner on death of Vivian Dawson 4Z Value of the Annuity on the Date of Death: $42,455.20 Initial Investment: X35,000.00 Cost Basis: $35,000.00 Value as of January 1, 2010: X42,250.70 _5~ Beneficiaries: William C. Dawson, Bette J. Zook & Charles H. Dawson Chan a of beneficiary form: Submitted on 03/08/2010: Changing percentages to equaIly_ 7.~ No Loans or credits. 8~ Annuity payable to: William C. Dawson, Bette J. Zook & Charles H. Dawson Should you have any questions. or require further assistance, please contact our Customer Care Unit at 1- 877-499-641$. Sincerely, Wendy Navarro Sr. Claim Processor PA REV-1500 SCHEDULE H FUNERAL EXPENSES and ADMINISTRATIVE COSTS .- .. ~: •Meiket,ttsza W.tar~-Mteltsrttesljrer ~ Pit J•7~SS. •, • • ~~ ~~~~~~ r'` ~~' t ~. ~: ' . `lNtchacl J:.MnCpe;;u, EJlwner : - '' . ' Pbowet tff7-Kf6 : FUNERAL HOME • Jeremy J. Shareztr, Funerat Director. STATEMENT OF FC2JERAI, (',ODDS AND SERVICES SELECTED Charge., :ter only for those items that you selected or that are rt~quiretl. It we are requirrcl by law tx by a crme[ery ~r crem:t[un• to tt.r atn• item,. t~'r wilt explain the reason in writing below. if you selected a fitnrral that may require embalming, such as a funeral viewing, you m:,y ha~•r to Pity for rmbctlmirtg. You elo not h:t~•r to p:ry l'or emhalnr ing you did not approve J you selected arrtngemerus such as direct cremation or immediate tx-rial. It we ctrargrcl for rmlralming, wr will rxl>tain why I~rkn~. For the Service of __!-f.,_-. i. N ~r ~ ,.,__ Datc of Death /~. r, ;.. •'r ?c,~: ~. Charge to: %1 :lr ~~,.Y Ly ~ ~.~.r b~ k /Zb~~- ~ -- Name Address ~ •1 ~ ! * . ! r c' ~, .. . • City .. .State A. CHARGE FOR SERVICES SELECTED: 1. PROFESaIOTvA1)ERtiICES Srrv-ices of Funeral DuectaiStaff ...... 5 ~' ` ` Other prep:rra[iort of hotly ............................. S1i5- SUB-TOTAL OF PROFESSIONAL SERVI(~ ..........Al S ~ !G r 2. FACiLCiIESS AND SERVICES • Use of facilittes and.servicrs for :~ • ' ..viewing.(Yisitatio4,~,t1:e)~ ......... S :n~ :. Usti of facilities arMi services .. . for htrieral ceremtxty _'............ f a/U UsC of facilities and services fair Memorial Service ................ S Use of equipment and services for graveside service ............. S `-~ ; r Other use of facilities ..............................5 _ .. _ SUB-TOTAL OF FACIIITIFS/EQUIpJl~r ...........A2 S t Sim 3. AUTOMOTIVE EQUIPMENT Vehicle to trar~fer. rrrrtitins to Funeral Horne Loral .................. ....... S Hearse (Casket Coachj Loral .................. ....... 5 t ! ,: r Limowine Local .... ... .. ........ ....... S Family car Local ......... ........ .......5 Flower car or Ilurrl dispacitiun Local .................. ....... S f;~~ Lead car/dertry• car Ixxal .................. ....... f i ;"~ Car for pallhearers Ltxal .................. .......S Out d town trarupnnation ... ....... S 5 SUB-TOTAL OF AUTOMOTIVE EQ .........A3 S 1 l ~n TOTAL OF PROFESSIONAL SERVICES, FACILtTff$ AND AUTOMOTfVE EQUIPItlF1VT ...................................ASS .cx~ Cghrr dtxhing Crrntation um ................... S (Description) OTHER S 5 TOTAL MERCHANDLSE S)E1ECfED ... ........... ...B S tr'- GSPECIAL CHARGES: Ftxwartling of remains to 5 (Funeral lioune) Receiving tN remains from S (Funeral Htxne) Inunediate Burial ................. S Direct Cremation ................. S S SUB-TOTAL OF SPECIAL CHARGES . ............ ..:C S •- ~' D C,ASIi ADVANCED . Ctpening Grave .................. S f_;~.,~„•, Cemetery Equipment .............. S Lot aril Deed ................... 5 Newspaper Notices-Cart! ........... 5~ Newspaper Naticec-Ottt-o[-ttnvn ...... S Telephone A Telegrams ............ S Airfare ........................ 5 Uergy/Mass OFfrring ............... S r .,.. •., ~- Pallbearers ..................... 5 Certitied Copies of the Dc`ath ........ S Certificate .l.c .crt.,t.,, .;s . d.,..ou ..... S !; ; - ,! Pdice Ecccxt 5 '~: Flowers ........................ Vault Service Charge ............... S ' t 2 5 ~ ~ 4r/ ~ r f ~~ S : , • 5 S SUB-TOTAL OF ADVANCES ......... ........... ...D 5 ~ ~ ~-- Vlk charge you for otu services in obtaining: (sprctJy cash aduarrrxs rtwt are nwrkrhtFup) B. CHARGE FOR MERCHANDLSE SELECTED: SUMMARY OF CHARGES Casket .....................:... S t•->!.: A. Professional Servict~s, Facilities anti lDrscriptionl t'~ Y._..:~~ ut and Automotive ~ fit' c. Equipmeru ..................... S - B. Mercharxlise - ~, . ....................a ~•. Ctther Receptacle ................. S C. Special Charges 5 - ,. - ....... ........... (Drscriptiun) D. Cash Advances .................. 5 i . Z Outer huri:rl container ............. S .z TOTAL OF ALL SECTIONS ..................:.... 5 ~~ ~ l' .' t Description) ` , .=i.. = t -:: ,. •, `•,. ~ PAID AT TIifE OF OR PRIOR TO ARRANG • tTS ... ............. c Acknowledgemrnt card; ............ S VCE DUE ................................ S .- ~. •' Register book(s) .................. S REASON FOR EMBAIMIIVG blemoryfolders .................. i < < _ F;..,~l.. /lt .t, (.' ~` r - Prayer carcLs ....- .................:S -- -•--,~~.~-;:-..:...~, ..:- --i tcrvt~yr,the.pm.~x.,.~__.._.. ;_ Temporary grave ngrker ............ S ~ of any of the items listed above, the law or requirement Lc explained below. Burial clahing .................. S _ [ `~:J ~ %, •. ( CL.. -t . / ~ , ,'1 ~:.., f 1 agree that 1 have eaam;nrd the items of goods and services selected above arm found them to be ccxrttt and according to the arrangrmrnts 1 have requested. 1 ackrowkdgc receipt of a copy of this Sta[ement of Funeral Goods and Services Sekxted [represent that 1 have sufficient Funds available for paymrm of the crsh prier for the goods and services selected. 1 also agree m rnakt payment d S ,(: ~s l within s U days. 1 agree to be jointly and severally -iablr with alone else who signs bekrn. A late charge of / `f_ per rttotuh atnotttRing to / .? i.. per year will be applied to the unpaid balance beginning .' i drys from the dart of this agreement. I will also pay to the Porten! Director all rtasornble casts paid by the Eurirral Director to cdlect amouriu 1 owe tuidrr this agreement. Those costs may include attorneys' fees, court casts and other costs. Any additiona l services or rt~rchandise txtferrd or rrytirstrd after the (late of thLc almrment will br consitkrrd of this agreement and the thereof will be refkctted on the final bill or statement. (Seal) ~ .~ t1J. ..} ~ ~ r~ ~:. ,11 ~ 1 71 ~ i r . (Itirocltaser) . -IDa[r) (Seal) (Purchaser) i~ Iknrt~~k~nia Funmr D'urnae Aawru~ion ' form -600 Revised l /04 " ~/ " / .. C y ~f.i ~L'_r'~.'', icrnsed Ft~iEral.Directa) rr'NttE Furcnl Dirnwr~ YELLtn- Funerd Uirrcar Pl~'1: ruv:+mn ' (~f+~ u,rt1 e i AD-Automatic Dep NUMBER OR "r CO~d ~E ~~ `_, -.. - -t ^ AD-Aucpmatic pep ^ /1p.~lutomacic Payment ^ ATM Ttger Machine ^ DC-petit Card ^ T Tax Deductible ^ TT-TekpMane Transfer NUMBER OR .., t,. {i ~ PAYMENT ./ FEE ©EPOStT s ,.= ,, ~rnee~t et•T~nw, AKf•fltffTAt4 . .,; .. ~.. ., ..... . '~'.Y/ill ~~ ~[• 1'~ 1~8~ `~ ~~ 4 . r ~~,t . ~'` r t; ~.~~ ~- i-, ~_~ PA REV-150p SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES and LIENS * * ACTIVITY FOR DAWSO~f , %iA:R.RY H 03/12/10 7653408 24 HCTZ 25MG 03/17/10 7653407 24 AMLUDIPINE 5MG 03/17/10 7653409 47 ENALAPRIL 20 MG 03/29/10 Payment-Thank You -DAWSH - -58 O1 3.62 .00 3.62c O1 7.10 .00 7.lOc OI 8.00 .00 8.OOc 65.96- ~ .00 65.96- y a~-~o ~~..~ LEGEND FOR MONTH •evious~ Balance Charges this month Finance Char TOTAL CWAR6ES Totem Payment ~ fr~dita 65.96 + 18.72 + .00 84.68 65.96 ` FOR ALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services, Inc at 1-800-266-9954 Stgtement Terminology on reverse , . o r~ ! TOTAL TAX AMO~~,INT UE 18.72 *** END OF ATTACHMENTS *** 'f.; :1