HomeMy WebLinkAbout07-01-10 (2)
M c K N I G H T~ p C
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 1 0 0 3 7 9
Po sox 280601 RESIDENT DECEDENT
Harrisbu , PA 17128-0601
ENTER DECEDENT INFORMATION BELODate of Death Date of Birth
Social Security Number
1 6 2 2 2 2 4 9 9 0 4 0 3 2 0 1 0 0 1 2 4 1 9 2 9 MI
Suffix Decedent's First Name
Decedent's Last Name A R L E N E R
F E I S T E R
(If Applicable) Enter Surviving Spouse's Information Below Spouse's First Name MI
Suffix
Spouse's Last Name
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW ~
rn
t
l R 3. Remainder Return (date of death
1. Original Return ^ u
e
2. Supplementa prior to 12-13-82)
t ^ ~
4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required
e
4. Limited Esta
t
t
T
~ death after 12-12-82)
7. Decedent Maintained a Living Trust
8. Total Number of Safe Deposit Boxes
^
e
a
es
X 6. Decedent Died
(Attach Copy of Will)
d
i
~ (Attach Copy of Trust)
10. Spousal Poverty Credit (date of death ~
11. Election to tax under Sec. 9113(
O)
h Sch
A
ve
9. Litigation Proceeds Rece between 12-31-91 and 1-1-95) .
ttac
(
BE DIRECTED T0:
UST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIA
L ~ le
U
O
O
CORRESPONDENT -THIS SECTION M D
ber
ne Num
elepho
T
Name
I
R W
I N ~ E S Q U I R E
7 1 7 2 4 9 2 3 5
R O G E R B
Firm Name (If Applicable) REGISTER OF WILLS USE ONLY
I R W I N 13<
First line of address
6 0 W E S T
Second line of address
City or Post Office
C A R L I S L E
P O M F R E T S T R E E T
1505607121
State ZIP Code
r_,
;~ ~_
/'~ C:,~J
-- \,7 C,_
- _;~ r._
'-~- -
__ -~' ~,
r7 ___.
:,~~~ ~~c
~: -3 t~~'
"'Y1A7Ei~tLED
p q 1 7 0 1 3
cn
Correspondent's a-mail address:
Under ee~rrect andeoo pleteeCDe la lion of p sparer other thanuthe persolnal rep sentative scbased oon aldl nfotrmation of wh ch preparerfhas any know edge.belief,
it is tni , D~,TE`
SIGNATURE OF PF~2S SPONSIBI~R RET N -7,. / /
ADDRESS ~ /
18 RICHA D'~R~O~~AD
SIGNATURE OF PR,b:P(/ ~LO~-_ T N
CHANICSBURG PA 17050
D'ATEf
7; ~(~~
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505607121
1505607121
~~~
1505607221
REV-1500 EX Decedent's Social Security Number
Decedent's Name: ARLENE R• FEISTER 1 6 2 2 2 2 4 9 9
RECAPITULATION
........................................
1. Real estate (Schedule A) 1 • •
2. Stocks and Bonds (Schedule B) .................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ..................... ... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... ... 5. 1 1 2 6 7 5 . 1 1
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6.
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested .... ... 7.
8.
................
Total Gross Assets (total Lines 1-7) ........ ... 8. 1 1 2 6 7 5. 1 1
9. Funeral Expenses 8~ Administrative Costs (Schedule H) ............ .... 9. 1 5 9 6 7 . 9 4
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........ .... 10. 1 3 2 5 . D 3
11.
.......................
Total Deductions (total Lines 9 & 10)
.... 11. 1 7 2 `~ 2 • 9 7
f E t t L' 8 L~n 11) 12. 9 5 3 8 2. 1 4
12. Net Value o sae ( ine minus i e ............ .
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) .........
......... ..
.. .....
..... .. 13.
.. 14.
9 5 3 8 2 .
1
4
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
O
D
0
15
0.
0
0
(a)(1.2) x.o _ .
16. Amount of Line 14 taxable 9 5 3 8 2 1 4 4 2 9 2. 2 0
at lineal rate X .045 16.
17. Amount of Line 14 taxable
O
O
O
17
O.
O
O
at sibling rate X .12 .
18. Amount of Line 14 taxable 0 O 0 O • O O
at collateral rate X .15 18.
4 2 9 2. 2 0
19. Tax Due ........................... ........... ... ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505607221 1505607221 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 10 0379
DECEDENT'S NAME
ARLENE R. FEISTER
STREET ADDRESS
770 S. HANOVER STREET
CITY
CARLISLE STATE i ZIP
PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 214.61
3. Interest/Penalty if applicable
D. Interest
E. Penalty
(1) 4,292.20
Total Credits (A + B + C) (2) 214.61
Total InterestlPenalty (D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
(3)
(4)
0.00
(5) 4,077.59
(5A)
B. Enter the total of Line 5 +SA. This is the BALANCE DUE. (56) 4,077.59
Make Check Payable to: REGISTER OF W-LLS, 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 : ...................................................................... ^ ^X
b. retain the right to designate who shall use the property transferred or its income; ^ O
:::::::::::::::::::::::::::::::
c. retain a reversionary interest; or ......................................... .. . ^
d. receive the promise for life of either payments, benefits or care? ....................................................... ^
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ ^X
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... ^ ^Q
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................. ^ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
0.00
REV-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
ARLENE R. FEISTER 21 10 0379
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. AMERICHOICE FEDERAL CREDIT UNION -SAVINGS ACCOUNT 10.77
2. AMERICHOICE FEDERAL CREDIT UNION -DIVIDEND DRAFT 1,231.73
3. AMERICHOICE FEDERAL CREDIT UNION -MONEY MARKET 1,057.16
4. AMERICHOICE FEDERAL CREDIT UNION -PREMIER MONEY MARKET 110,375.45
TOTAL (Also enter on line 5, Recapitulation) I $ 112,675.11
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ARLENE R. FEISTER 21 10 0379
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MYERS FUNERAL HOME, INC. 8,420.00
2. FUNERAL LUNCHEON 368.90
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City State Zip
Year(s) Commission Paid:
2. AttomeyFees IRWIN & McKNIGHT, P.C. 6,250.00
3, Family Exemption: (If decedent's address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees REGISTER OF WILLS 261.50
5 Accountant's Fees
6. Tax Retum Preparers Fees PATRICIA A. ROSENDALE, CPA 350.00
7. REGISTER OF WILLS -FILING FEE 30.00
8. NOTARY FEES 25.00
9. THE SENTINEL -ESTATE NOTICE 187.54
10. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00
TOTAL (Also enter on line 9, Recapitulation) I $ 15.967.94
(If more space is needed, insert additional sheets of the same size)
r?EV-1512 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RFCIr1FNT nFC:FIIFNT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ARLENE R. FEISTER 21 10 0379
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CHAPEL POINTE AT CARLISLE -NURSING 530.00
2. IHARTZELL EYE MDS -MEDICAL
3. (PINKER & ASSOCIATES -MEDICAL
4. IJ L HARDESTY -MEDICAL
5. (CARLISLE HMA PHYSICIAN MANAGEMENT -MEDICAL
6. (CARLISLE REGIONAL MEDICAL CENTER -MEDICAL
7. GEORGE BRANSCUM, MD -MEDICAL
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
15.00
26.71
19.10
33.31
565.35
135.56
REV-1513 EX + (g-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
w~hi~vr
ARLENE R. FE
NUMBER
I.
1.
2.
3.
4.
II
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
JEFFREY G. FEISTER
18 RICHARD ROAD
MECHANICSBURG, PA 17050
DARLENE A. BEAR
168 MOUNTAINVIEW ROAD
MT. HOLLY SPRINGS, PA 17065
CYNTHIA D. MELLOTT
450 CUMBERLAND STREET
LEBANON, PA 17042
TERESA A. GINGRICH
6402 CANNON DRIVE
MECHANICSBURG, PA 17055
FILE NUMBER
21 10 0379
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Lineal
Lineal
Lineal
Lineal
AMOUNT OR SHARE
OF ESTATE
23, 845.54
1/4TH REMAINDER
23,845.54
1/4TH REMAINDER
23,845.53
1/4TH REMAINDER
23,845.53
1/4TH REMAINDER
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $
(If more space is needed, insert additional sheets of the same size)
LAST WILL AND TESTAMENT OF ARLIIVE R. FEISTER
I, ARLENE R. FEISTER, of the. Township of Hampden, County of
Cumberland and State of Pernzsylvania, being of sound and disposing mind,
memory and understanding, do make, publish and declare this my Last Will
and Testament, hereby revoking and r~.king void any and all former Wills
by me at any time heretofore made.
1.
I direct the payment of all my just debts and funeral expenses
as soon after my decease as the same may conveniently be done.
2.
I give, devise and bequeath all the rest, .residue and remainder
of my estate, real, personal and mixed, of whatsoever nature and whereso-
ever the same may be situate., to my husband, THEODORE G. FEiSTER, absolute-
ly and unconditionally.
3.
In the event that my said husband, THEODORE G. FEISTER, should
predecease me, or should he die. at about the same tune as I do, such as
in an accident common to both. of us, then in such event, I direct the set-
tlement and distribution of my estate to be made in the following manner,
to wit:
(A) I give and bequeath all my personal belongings and house-
-1-
hold furnishings to my children, share and share alike, or so much
thereof as they may. desire to have as theix own, and direct that
any items then rpmainin~u be disposed of and admiizi.stered according
to the provisions hereinafter set forth.
(B) I give and bequeath all the rest, residue and remainder
of my estate, of whatsoever nature and wheresoever situate, to my
four (4) children, to wit, TERRA A. GINGRICEi, CYNTHIA D. MF.iTCYr'i',
DARI,ENE A. BEAR., and JEF'.~'RL"Y G. FEISTER, share and share alike, per
stirpes.
4.
LASTLY, I nominate, constitute and appoint my husband, THEODORE
G. FEISTER, to be the. Executor of .this, my Last Will and Testament, and in
the event he should predecease me, or should he be unable or unwilling to
serve in such capacity for any reason, then I nominate, constitute and ap-
point my son, JEFk~tEY G. FEISTER, to be the. Executor of this, my Last Will
and Testament, in his place and stead.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of JLme, A. D. 1988..
~~~ ~ ~ ~~~ , (SEAL)
Arlene R. Feister
-2-
Signed,. sealed,. published and declared by the above-named
ART.F.NF' R. FEISTER, as and for her Last. Will and Testament, in the
presence of us, who, at her request .and in her presence, anal in the
presence of each other, have hereunto subscribed our..names as witnesses.
-3-
.. ~,
.
oce~NwFaLZx of ~vsYLV~xzA)
)ss:
oovrrrY of c~FRT ANA )
I, ARL.E~LVE R. FETSTER the testatrix ,whose name is signed
to the attached or foregoing instnment, havirb been duly qualified according to law,
do hereby aclax~wledge that I signed and executed the instn.ment as my Last Will and
Testaflnent; that I signed it willingly; and that I si,~ed it as my free and voluntary
act and deed for the purposes therein expressed.
Sworn and affirmed to and acla~owledged before me, the i tits, day of
June A. D., 19 88 .
OCi~2~i~]tr~ALZ~i OF PEI~ISYLUANIA)
)SS:
CQUNI'Y OF G'CINIBERLAND )
~~-~)
We, the undersigned, J. ROBERT STAUFFF~.t and JOHN M. EAKIN
the witnesses whose names are signed to the attached or
foregoing instr~mnent, being duly qualified according to law, do depose and say that
we were present and saw the testatrix ARLENE R. FEISTER ,
sign and execute the instrument as 3~s/her Last Will and Testaanent; that the said
testatrix ARLEI~ R. FEISTER ,, signed the same willingly and
that the said ARLIIVE R FEIS7~R executed it as /her free and
wluntary act for the purposes therein expressed; that each of us, in the hearing and
sight of the testatrix signed the Will as witnesses; and that to the best of our
~owledge the testatrix ,was, at the time, 18 or more years of age; of sound mind;
and under no constraint, duress or
Sworn and subscribed to before me
16th day of Time
_/._
Irfy Cccmission Expires; Septanber 21, 1991
My Commission F~.-pires : SeptelTlber Ll, lyyl.
~ AmeriChoice
F E D E R A L C R E D I T U N I O N
Building Relationships For Life
DECEIVED
April 15, 2010
~4PR l~'~ !(!~~'~
Irwin & McKnight, P.C. iRWIN ~ N~cKNIGHT
West Pomfret Professional Building iAW OFFICES
60 West Pomfret Street
Carlisle, Pa 17013
Re: Estate of Arlene R. Feister
Mr. Irwin,
The decedent had one member number 38391 titled Arlene R. Feister. Arlene was the sole owner
with a regular savings, (suffix Ol), a dividend draft (suffix 16), a money market (suffix 18), and a
premier money market (suffix 19). This regular savings account and sub-shares 16 and 18 were
opened September 27, 2005. Sub-share 19 was opened July 21, 2007.
Date of death balances were as follows:
Savings - $10.77
Dividend Draft - $1231.73
Money Market - $1057.16
Premier Money Market - $110,375.45
The above balances include any accrued interest.
No Accrued Interest
Accrued Interest - $0.96
No Accrued Interest
Accrued Interest - $336.14
An Estate account for Arlene has been established with AmeriChoice. All balances have been
transferred with the excepting of $5.00 in the regular savings and $526.70 in the draft account to
cover any outstanding checks.
Please feel free to contact me directly with any questions you may have.
Sincerely,
Bonnie R. Seagraves
Operations Specialist
Phone (717) 591-1282
Fax (717) 697-3713
Email bseaaraves(a,americhoice.org
Main Office: 2175 Bumble Bee Hollow Road • Mechanicsburg, PA 1 7055 • Phone: (717) 697-3474 • Fax: (717) 697-3713
Website: www.americhoice.org
Q NcuA ; E4~.,
Dual Nousir+o ~. J OppoAUniry
LENDER
LENDER
~~~
CREDIT UNIONS"
Myers Funeral Home, Inc.
Boyd L. Myers Jr., Supervisor
37 East Main Street
Mechanicsburg, Pennsylvania 17055
(717) 766-3421
A standard of excellence in Central Pennsylvania since 1910
Monday, April 5, 2010
Mr. Jeffrey Feister
18 Richard Rd
Mechanicsburg, PA 17050
Dear Jeffrey,
Fax (717) 795-7291
Thank you for selecting our funeral home to provide services for your family during your bereavement.
I hope that you found our services to be of the highest standards and that they met your needs and those
of your family and friends. The following is a summary of the service charges as previously explained and
provided in written form on the services for:
Arlene R: Feister
SUMMARY OF EXPENSES
TOTAL OF SERVICE RENDERED $90,025.00
LESS: Credits granted 1,605.00
LESS: Total Payments 8,420.00
CURRENT BALANCE $0.00
Credits Granted: $175.00 Early pay discount $1,430.00 Package Price Discount
Interest at the rate of 1.5 % per month (18 % per annum) will be added to balance after 30 days.
If there are any questions or concerns that remain unanswered, please call me.
Sincerely,
~~~~~~
~~ :- - -----_--r___~ __..__..~__._.~ r_..____._~ _.___ --.e_M~~__.._r _~. -~----- -__ _ _
I •. / TrackYnur Expenses ., rnx DeoucTlste IreM s C
{
^Mortgage /Rent ^Transpodation: -+ ^Entertainment & Travel D ~ NOT U $ E -
i~ ~ ~
~
'
^ Gas / ElecMc ^ Credit Card
'M
dical /D
t
l FOR REORDERING 3'~
;
e
en
a
S ^Telephgne ^Taxes ^Dependent Care ~
r
, Insurance
L..L' °0.~ ~~ ^(Life. Home, Autoj ^Savings & Investment
~~ ~
1
~` j ~ / v
Home Improvement
^Clothing ^(Maintenance Repairs) ^Othar
BAL.
/~ ¢/y~~- ~F )J) I /j
~
~
~t
~
'
C FORD
' LIC.~ i~Ji
ft
%I ,>~3 if
1L
t
Y
• PAYMENT ~ j ~GI,
,~/- it 1~ ~ya---
,
lt..
~
' fir/~i
'
~'J'f
'~ ~ U' '" ~ ~~~
~~`
~
/~
~~
'
' f
,%Y, 1'r~ ' BALANCE
r
"r/G"'~,/
i
~
,~z
J
~t
//
.
J
%{
' _
7 ~
.~. Here's~How: ~ OTHER
• Carry B;ilance forward
~
• Check Pype of expense - BAL.
• Adtl details on memo line _- FORD
' d
• Retain duplicates in Deluxe Check box
Memo f vC 1 /- /~/,',i~`_, _ -,.r.y' ~~-.., r . \ .
iL`' ~
~1 r
\r ~ \ `
.. _ _.._ '~: `. ~ :.. ~.. ,- ~ _
_ ~. ~. t
~~OT NEGOTIABLE
~o o~P , ~:
-~''
u ;
~ _r ~
w `::
V _ . `.1
o 9
< ~ M
Z
o
m ~ ~ o
~
o ~ o
~ Q ~ ~;
N
, ,
o ,~
`
~ of ~
~ ~
t
`~ ~
~
Z
~ .
f `
Q ,
,
~, .
r E
_m ~
~ ~`\
''~_:
~
U 5
m
~ m '
'^.~...~
i~
~~=~ .r.~,.,
:
:m
~ W ~ O iq O ~
*
~ ~{
L
Q
k c o.
W m
~ '-
•
~ m¢
a
` ` '~
> m
o
c
Y o itl mE Em
V n U m2 ~
_m a_
F ~ U '~ a._ _~. ~ - "~
~ ~~
~..
- , ~ `~
1 ,...~
_
ul o m `~
U
m t m y
r w
~ ~
o
~ (7 H LL U Tom.. m~
-o = o
.~
...
h~ ' n
3 m a `
~._f ~
=a-
° .:
'
M ~
v~~
`,a ZUU¢¢
,.
te
'
a
~
W
J
OD
Q
~o
i~~,
`, w
~z ;
~,,
y,.
ti0'
``~:z
i
,~.1;
L,..Y
.~
:~
~.;
~~ ~ ti
~ ~ c~~v
'~ ~' Banquet ~ '
~~~;~ Mechanicsburg ~'~~
t/ 61 Gettysburg Pike
Mechanicsburg, PA 17055
(717}697-2214 '~~
wtuw,hasss.com ~ I ~~~
~t'
4/8/201 it 2 ; 20 : i)2 PM
Server; Laura A
Chick 40~~04 lab 1 ~ 64
Seat 1
1 Bison Bw'ger 5.aq
SuhTota1 254.96
Tax 15.30
ratuity
G 48.64
7
I~~~~ ~ j
I~~~ ~
TIP _._.- --
~JL~
TOTAL _
_
Visa 318.90
Acct:XXXXXXXX1133
AuthCode :087759 ~ ~,~,~
~~~~~~~~~~CUS~OMER COPY~~~~~ ~~~~~
Tell Us How We Oid:
You could Win $1,000
in cash!
Visit our website at:
4UwW , hoSSS , i:Om
for official rules anii
to complete the survey,
Enter the
survey code belaar
Survey Cade:O140--1822-5001-0457
_____-10 meals each under $10
limited time
$4,99 Salad Bar' Monday to Saturday
11:00 to 1;00
u~~u~inuw~i~~~u
°o o° °o, °o o° °o
~ O ~ N N ~ Ji
7
.
Q ~ ~
m
O
H
O ~ Aj
-
t~.> ~ `
O O O O
W .~ O~ C~ O
Q K^ ~~
2
V ~' ~
~ ~ ~ M
0
M
O
O 'et
C
~ ~
':0 C ~ o
M ~
d M O O
~ ~ N
W ~ ~ ~ ~ ~
~ -
~~~u ~~ ~o ~ ~
wH ~VW U U~ ~
~ ~' c ~ W
~ q p :~
+r +r
aH a a a
00 O
rl ri rl O
rl O
~
,!1
W
F- O O O
~ N N O
N O
N Q
.~. V
~_,
O
C~ ~
~
O ~+
Y~ ~
0 O O O ~ ~
0
~o
F-
Z
v
~\~\ 0
Q
J
O
H
O
N
`- O
~ O'
~ o
0
0
°~ O
~ o
w
> o
0
0
c
~ o
> o
O
a o
M
~
O
O
O
O
0
~ o
j M
,~ U ~
N
~i ~ L W O
N
N~ U
z
~ ~
~
. U nV
~ Q 2 ~ ~k
~
Q'
' Z ~
J i m
~ (..)
~ O F-
Z 00
-9
~.-
0 O O m
m
°
~
z J w ~
a
v
i ~ m ~ M
~ .-~
a
0
LL
M
O
a
a
U
F
Ww
a
F
a
w
0
0
r
W
a
~. U
~ ~
~~ W
W E..,
ao
°' a
~a
dam'
y
U
W
Q
Z
Z
1J
L
Y
000 00
~ o00 00 ~ o
v o~ o .-; a~ .-~
Q
~
~
~ ~ o
~
M O
O
0
0 F-
~
...i
Q n
^
r ~ ~O ~ ~ Fi4 i
m ~
Q
O O Q
H ~ ~ O
W ~ ~
.
~ ~
V
O
N
0 O r O
y p
p ~ O
--i O
~ ~
~ O
Q
2
V
G~ ~ O N ~
M ~ O
O
w
o
p
o
~
O
O N > O
M ~O O
O O
~ ~
O
a o0
~ UV M O
xx W o
__ ~;
~ 's. 't~
b ~ a~ a
.x
~
~"'
"
o
0
~ p
~
~
~ '
.~.°~oo
°E-{ ~Uf~W
~ ~ ~
z
~, 0
=~s~°~~ ?
~
~
~
'
~o°
i
e
~
s
,
o
aF as ~ o= w o
~~ z Y Q
0 0 0 0 W .Q U g w ~ ~*
00 00 z~~ m U O Z O
W N N N N
\ ~ ~ g o m gy m " W et
ri
Q
D rl ri ~
N O O O ~
p O
F O Q ~~
u- m Q m W
z =
F- Q
m p
v~ ~
~ ~ ~ ~ I ~
0 0 0 0
M
~--~
O
ti
a
W
U
F
WW
a
H
a,
W
O
x
~]
0
r
r
W
~.
U
Q
W
H
O
a
w
x
U
~.
.~
W
a~
a~
:T
u~
f •~~ _
{~~
~~'a
'~J ?, S';
•--! lL
ti l ~.
-•i
i [~~! !~~
~•,-~ : r -
+
:....~ ~ Iii e.{ . e-,~ -..` ] {
i
~.
W
~ 4, ky ~--i ~ ;µ
i.~ {_; roc Ca .a.t s=:.~.:.s.
1.. u.
``~
lm
{~.{
. ~:1
a
~t q
O 1` w
iJ'
J
J
t ~ ~
m
o m w p
~ Z Y Q
w aU ~ w ~
z~~ m U O
(0 ~ Qn~ N ~
~ ~ ~ m ~~~ Z F=-- [D
i,ia V
"r
;`3
.J . y
L.
.C ..
+~
.t,
l.ii
`ri
f~ ~
r,
~~~
,•.L V.
~ ~~
Q c
a~
(O '- QILL ~
W °i nao ~ oli ~~
rn p d' Cn C-~...~
LL = _ ~ ~ ~ ~ ~
G p ~ tl.
W p C ,~ ~p OJ ~ 'O C N
V o~~n.~a~'Y~~
~ O~SOw~cnz50
Q ~ N.--N M d'.-N ~-O~
*- N N N N M M e 0~
'~ C
'1" r~, (
6
.... ~
~
_ ~ >.
_~~ d
.... 3_, ...~, p7
? 3 {'• ~'
t' t.. _
'I'
N
U
~ ~
Cn
z O
N
L ~ C
O
U a a
PINKSF~ & ASSaCls41TES
PODIATRIC MEDICINE AND FOOT SURGERY
MARK E. PINKER, D.P.M., F.A.C. F.A.S.
MARK GOLEC, D.P.M.
ELISE J. NELSEN, D.P.M.
47 BROOKWOOD AVENUE
CARLISLE, PA 17015
(717) 243-2236
~~
0116
Date ,~ Zi
TO 'Pik, ~.~ ~D c,
FOR
BALANCE j R
ADD deposits or
SUBTRACT charges
NEW BALANCE STREET
THIS CHECK ~ ~ ~ 1 5
BAL FORWARD
STATEMENTDATE
05/06/10
~~
90421.0(1)
ARLENE R FE'15~rER (90421.0)
01/22/10 DEBRIDE MYCOTLC NAILS 6'0.00
0212`6/10 Ins.Pmt-MEDICARE 19.14
$14.29 was applied to your deductible
02/26/10 Adjustment 2'1.79
All or part of this service was applied to your deductible
03/26/10 DEBRIDE MYCOTIC NAILS 60..00
04/16/10 Ins Pmt-MEDICARE 30.57
04/16/10 Adjustment 21.79.
04/28/IO Reject-UNITED HEALTH CARE 0.00
TOTAL FOR.ARLENE R FEISTER',
~ ~ ~
~~'.'
C ~ l
~ ~ ~
~.
BA' NCE IS DUE 30 DAYS FROM YOUR FIRST STATEMENT DATE.
$ :00 PROC SSING FEE MAYBE ADDED EVERY 30 DAYS. WE ACCEP
• FFI E IF ANY QUESTIONS.
OTAL DUE URRENT 31 - 60 DAYS 61 - 90 DAYS 91 -120 DAYS OVER 120 DAYS
26.71 7.64 19.07 0.00 0.00 0.00".
r
0p M O
y r ~n o
~ M O
~ h ~
W
U
~ o
W
N
a
Q
x
V (~ .
5---
~ ~
~
-rr
" ~ ~`
J
^}~ i
~~ ~
v ~ M
~L Q
~ ~J~
~ `jF~
.~
V j
~
N /b ~ ~ .
N
Z ~ ~ m ~
Q Y N .C
~ N ~ V
a e w m ,t ~^
r ~ v
o~ ~~_
U
O E ~
N
j
~ ~~
M
g
v °
~ ~
°-
.
~ z ~ i i~ u
C E
O
C E~
v ~ N E
m
Y
N
~
~ ~
I
O
y
~ ~ ~ ~ C 7
a n
w o a
, o
r
O
~ fl~
W
_
~ O
a c M
L ~
a ~ '~..
rn
~ ~ ~ OL W O
O
.~
.N ~ U
Z Y Q
°
W
o 0 0 0
\\\
~
v
¢ ¢ ~
m
O
Q ao 00 o
\ ~ cr
~Clm U
~ O
~ F- O ¢o~
I w ~ -~
=
M .} ~t ~T t CO ¢ fn Z F
- m
0 0 0 0
E
U
0
0
v
a
U
C
R
7
C
a
U
C
a
N
m
N
7
'O
N
U
C
f0
m
.n
N
_t
C
N
U
N
~ U
~ .c
N y0
~ C
Ct N
N `'
~ fU
i~ C
fU
V N
O C
N ~
~ ++
°' 3
~. ~
y C
O C
n a
7 +~..
6 C
O
'm ~
U Q
0 O O
~ O O
N
W
0
fA O O
Q O O
~ O O
N
0
p O
~ 0 0
D O O
O
0
m
0 0
} 0 0
Q O O
(p
O
ch
~" ~ 61
Z N
W ~ ~
~ ~
V
O
O
~ W
U
a
~ Z Z
o g m
~ m W
U
Q Z a
w ~
~ N ~
w ~' ~
~~
a
O
~t
N
_ti
O
w °~
~_~
~ O
>-w~
N~a
z
~ J W
CCF-~
= W J
~~
J
~~nU
O
O
O
U
LL
Z
0
O
F
J
c~
a
M
,~.
~.,
„ ~
m ~ 'o
~ N ; ~+ o
~ ~
~
~
in <r o
i
W rt v~
H N
~ i i
~ ~ ~ O
~ O
i p ~ M ~i
~_
'
m
. ~ -bg- ~ ~, M
a
~
~ ~ -~ `~-
a w
ro
-~ ~
~
i O
,_ ~ R+ '~-- ` ~
~
Z ~ ~
CL ~ b'
i
Q
Q a
~ ~ ,;
;
H'
Ca ~ l ~ ~
_ ~
' J
Z c
l
M. ~-- _
~ O rn ~
Z
~W ~ ~
a ~
~ ~ E
-
H
a ~
z E _ t~
' ~
U E ~ ~ o
•
~~ ~ W N U o
~, x
~N ~ A ~ A H
a ~ ~ r
i H ~ Y
.Z aw
w
x _ _. _ _ _ Q.
'
~ ~
+
W ~ A'
6~
,
R
v
iZ i
O ~ H H
.E t
d ~
~
i Q
W~ t
O M ~
~ o M
w
C7 ~
~
O ~ 3 ~"
i ~
i
O O O
°J o=
W
O
'`
i ~ W t*1 M c•f
a o o .-~ V m~
w o v Z
~ U ~
w
~ H to to ul Z~~ m U O
1 U~ O O O ~ Q~ H LL
~
~ ~ ~ ~ ~ m Q~ Z I=- m
i CY1
~
o _.
,~ ~
o
r
~a
L.' O
qj ~
o
~
U H
0
~ ~ '
O m
~
Z M
c7
J ~...~
J
Q ~
U ~
~
Z E
W O
m O
~ •
~ O
Z N ;
~ A
z
~
o ~,
~ ~
a
~ ~
} ~ o
O E
U Q O
c
D
Z O
~ ~ ~
W ~
c-1
C9 G
c
W ~ ~ ~'
~ C
~
J
R ~ F
c
~ c~ C
~
b N ~
A O
H H, o
0
,~ °
~
O m ~'
y~ ~
~ .~ ~ a O ~,
~'
`
O 'd
d ~
.~ cp
N
wN -. 1
m ~, a ~ o~' g
L.'
~
~ ~
a~ ~
° ~w
u a
~ ~; N
W
~ ~
r1 ~
W
V
y
I 1
~
n.. ~
~p 'y a
T N rw
~
~
~
~ ~
d1
W
V
y ~
1=
t0 ~ ,.,~
V
~
J r W
oe
~
O W W
~ rl O CC
ul t0 ~1
~
~
., _
V N
~
Z
~ a °D V ~
oo N .= O
m
a c
W M ~ ~, ~ t
O C ~ ~ ~ ~ Q O
~
y N M ~.,
u1
d E
\ ,
u. N ~\ W C O
a ~
~ '
~ ~
~`
~
~
~ _ ~
°
~
o E _
o
o
~ :
p o _ ~
Z ~ z.
d
.- ,Q,
.:.~ o
J CO d =
~ .y _
~ m v
z ---~ '_
W ~ n
~
O ~
C 0 r
~ v NI
.~ 3
~. y m 3
Q N
J (~ ~
}' ~
1~
{L ~ ~
i ~
m Q -
-t~!~~
V/ \
J
3 ~
._, ~
~ ~ ~•
~
F- ~' z
~ H Z
o a w
~
,"` ~
W
W W N +..
~ a~
)
Q C N ~ Q)
z
f- a a ~
H H ~ : 4 ~ v
a i •.-~
'~ wwi
~E =. ~~ ~ - 6' ~Z ~
~ H 1~ ~ ~ ~ ~ A>
~ ~
01 O c r J- ~'°
.al N N N O ~ ~ y
~,
.~N. U
'
t
_ O. O O o U
W
a (~ ~
= ,...? i
Q
~~a
Z -o tr m ~
O O
I f°
~
I O
I- O Qom
~ mam w
z = Q
F- ~ -__'
O
,~ 1
z
~
IJJ
~
' I t 1 ~.. ('/~
-
Imo N
"
~ o ~
~ W t2u N ~ G1 ~ ~ `
W
~ C
~
a
~
G~ ~
~ d
e. ,
~ ~ v
O ~
r ~ r0
W ~
o
~
~ ~ ~
o
~ ~
W-
o ~
L ~.
~. '
o .. ~
D
Z
z
0
w
Q M
Z
~
O' `^ ~~
u
i ~ W
~
G Z ~
~ W~ ~
3 ~ ~-- ~~ ~'9--
v~
__._ l ~
}
~-
-~. 1
Z
Z !-
O W
E
z F" 1 Q C.
A d
W W W U
L Q
Q G
I Q
Q
y_ ,}, UU~
~ H H ~
~~
~ f ~ H
0 ~ Q
C ~ 1"'t
~ h
a ~p ~p O
~ .1 M
a , ° ~ ~ ~
O d O
O~
fl1
N
Z
O
F=
N
w
~~ o
V ~
Z ~
J p
J ~p
m ~
~ n
O ~'
u. C
d
y
3
N
C
N
.R
'a
N
0
s
0
m
c o
o v
v E
Q
~ •L
C ~
v V
N
'm 3
"~
C
+~,, ~,
N +, ,
O ~
~ ~
n +~~' C
rn
o (~'
~
q J
~
V)
~ N
N
~^ ~
O ~0
L W ~
~
Z
Y
Q [L
1~
~J W o U ~ W
n
Z
a
=
~ N (
j O
~
~ O ~ J ~ CD
O ~ ~ J
m Q (n Z F- CO
Q ~.
y
_
W ~
N
W
V = 1 I '.{
p N o
~
~ I~ D O
d1 Q
L~ W W M ~
C
fi
~ r-a
I- '
o ~
-
F-
~ -
O
W
V
:a
~ ~..~
o
y ~ ,
ti ~ ^
H
G ~t
o
O ~
Z z
W
,.. ~
Z W
F
y
a ~ ~
,
~..,
W .-,
~
~
O~.
d W
~
o
a ^
~ V
W A w
D Z W
2
O W
3 m
3
a
0
~ H z
Z ~ _ g v
W
e
O W E ¢
c
Z N Q C. ~ s
A ~
~
W ~ ~
d C
-
•.
d ~ aaa W
.#., v v ~
N H ~ u~
~ A A !n uva
~ W W Z ~
~ ~ ~ N W
~ C7
4
p p V
c rl '-, .-1
_
~,~~~
W W
F" p p'~ Q
r-1 M M '..1 F
a ° ~~~
~
0 0 0
nQ.
N
F
W O.
.Q W
3 ~
W
J ~ m
Q C
~ ~
V
*~ O
a
W .c
W '
a
.J
a O
vi
o
°~
~ 10
O
N
W c
v
'
~ O v
O 'O F
Z ~ i
C ~
..1
O N
.~Q
i -
,J ~
m ~ R V
~ ^ ° 3
O m
C 3
ftS
C
C
(~ A
~_
y (~
O L
N ~
C ~
„_ N
N +..
7 +.. s-
i ~ t _. _..
~ N
> .tn
1
~+ '
~
N
v ~
~
`` ~ ~~
~ U~
E ~
(CS'
~ ,~
$ =
w p
N
~ ' ~
.NF
W o ~ O ~
Z Y Q
~ ~
g
1--'
I""' ' U ~ ~
z _
Q ~ rV
'-' ~
~ ~ O m m v o
3 ~ tL rG
i
X 0 0 Qom
_._a4 Q ~ W= a
Z F- m
~--
W O~
~
:~ F-'
~ i i ~ ~
~
^
o ~
'v-
c
b
a
IJ F- F N
~ W ~++ M ~p
N
L ~
a
a
O
u
7 N.
i dD
C M
~ o
~
z
.r
M
M p
O~ tl.1
~ d ~+
n a
v U
y
W A
O Z
O
3
Z
F- Z
W O W ~'
g N ~ Q
Z N.Q G
a' a
W iL W (~ '
~ IY Z
d ~ V V ~
~
i
UI ' ~ ~ ~
'~ W W Z
GI
LL ~ ~ H
CI ~~~
G
~ ~ \ ~
H ~ ~O ~ O „
L
p ~ ` ~
.
~
` ~. ~.
d Q Q
w
'
w a
~ w
3 U
W
J a- ~
Q =
U w °
w
.__ a
a
J
w
a _
ui
Z o.
O
_
~ W E
~
W _' O
-
v _
~ o fJ
~ v ~
Z co ,~ d
J '' ~ H -
O
CO .II
m ~ R V
~ ~ " 3
'
O ~ ~ 3
u. C 'm 3
~ ~
O ~
a~
yam,, Q
~~
._ ~
~ .=
N S
~,
cC
~.. N
"~
N'
W '>
t9 ~'
Q U
ti ~
a \
H ' N 41
g O o ct '~'
_'
~> ~
J ~ ii~
~ ~
~, ~ y ~
~:. .~ ~ ~
RS; m
' J o L ~ ~
0
++ "'~~' Y v U
Z Y Q
W o
U ~ w
Q ~
`
(q'
Q
~ Za~
2 J >m U
~ O \
;
0 ~ Om__>
~ m
~ J
Q (n Z {-- m
F-
F-
~:;
W
G~t_'I ~
~~~`d
_1
`Z
U
Z
m
W
C~
O
W
C.7
~,
`
~,,
~v ~ cc o~no~no
~
d ~ DONO~NO
a
m ~ ~o.-oo
~, ~ ~.~ CO M .•- M .-1~
. I r ~
' ~
^
C
~ ! r r-
jNN
,
~ ~ rr
a O~
i" ~ 1
,.
~O
~ ~ r-
~ ' O
a i ~
~ ~
0
Q ~ M
0Y
! F U F- F- I-
r.•; uzi X 0 2 W W l!l
` ; ~ ; OF-~1-EH
~ } fn ZF-ZF-~
0 ~Q ~WInWCq
in ~ oF-}•~>-~z
h;°? ~ ~ ~EQoQo
•;
< _ ~awwwww
~'° U OI-[Y[Y~~O
Li-ZQQQQ~J'
[L~_~~ I WUUUUW
"~ ! •HHHHH(n
C ~`~ I JF-00000
~~ massssc=n
_~:i I..... ___ ._....
~, _._ _
_ -- - -
o
~o, ~
T_ M
W
z i
z
i
I
,.. ..
__... _ __. ..
CCU
~ W' ~ p ~i
~l ~
iO
~ W ~ O
CA
"~'
~~
ni
o
_ C
0 0 0 0 0 0
cD
Q op oO <p fp .- .
U N00000
I `~~~~~
d: 000000 w °
' Z Y ~
c'- ~
p i.__
...__ ._._.__ ~--• _...__-__
. m 1-
W oU ~ W
'~ to ~ 0 U ~ ~ Q = ~
r-a to W!
O
p 4?
ca Q '~ F m
~ U
to O
~: Q U i N ~ ~_,z
~ ;i
Z
w
s
}
__ --a--_
_ _.. __ ._ .
-- __.
Z
W
U
W
~'
OC
O
}
O
LL
O
}
_5C. ___
Z
-
. _
H
cc ~ v' s N
~ ~~
.~ m
n_ ' c ~ u .ci
i ~ i s °~ ~ o
M i [_n ~ ~ ~~ ~ ~
r ~ <n ~ c -c
i a~ .n o
~ °'~
-_. 't ~ ~:
~, .r ,~ c
c =~=
r E ~ ai
j, -o ~ -s ca
~ ~_ r o as c
_~~5
~ i Lij I ~_.- ~ _:
U~
~ i IT ~`a _c_ i_v .c
~ ~ n, ~ o'i c °m .n
m m
U) U F-- ~-
-- r~
_G] [ •_ O
f i (t$ (_
~.
G ~~ U) Q`
~_`A U~ ~ u1 .- f-
e c R ~ 4
+~ J cl> L
i'~ M1'41 f ~ f' L ~- '°' a ~;
R r. _._. u v L m ~.
'' r~ 4AJ t~l ~ ~ w v ~ n~
~' ~ ~ c's, c ~ L
~s
I ~ ~~- ~.i n? ~ c° ~> c-
'i L9~ ~`J "I ~: ~ o a~ r
~~ .co--c°i~ n
!'~ !r iQ~r'~
i' a ~ ~ 6 O
S o ~ a£_
<, . _
to - n ~, ~°
N ~
~iI-~. ~~
! v;'~r~-n~o
~~ .~~~a~
-~_
i~-. 2=
rr
i L41
~ j I
~..._
O . ~~~ ~
I
0 ~ ~ ~ ! cr_
w~
U i m
C_ ; z
i ~~~ '„
' O i
~--
0 ~ \n' ~~
i L7 j
w W.
N
~. ~ ~ e} W
T
N a
1~,i~}~~
i O I 'r.
0 ' ~ ! w i
~ ;¢I
O R
Cl
~',
i ,~ F
;~ ~
~~ i }_Jc
~ ~~
~ I
E
O ~ G ~u
O , O ~ o~z
~ i r j j~
~ ~ : ~ !m
;ai`' wI~
I ~ ! ~ I- IK
O ~ ~ l7
I I
z
a
a_
U
W
l...
W
Q
a
oc
W
Q
•
r
L
a
L
fQ
U N
•r ~
-Q ~ v
~ •r L
~ > ~a
c. u
~L N L
L fn i•~ f6
J V
E Ql IQ t
L L. Q} +'
{••, LA lQ = J
•r •r V (6
N S •r ~ dl
•r '~ N =
~• i a +~
E •r ~
~ r L •r
' ~
.~ ~ ~
-~ O` L O ~
.a M O O ~
(0 00 •r O (6
~ ~
N O
w i-+ f +~ v
N ~ ~ ~
•r C E C E J
O v ?, N ~. ~
V •r iQ ~ ~ •r
~ ~ ~ ~ ~
r fQ to U
00 Q C O ~ 7
• ~-+ ~ •~--, f0 -Q
3 J '•~ J
Efl O a. ¢ a. ~
m
c
v
L
a
s
.J,
O O O O
~ ~ r• ~
~~~~
r M M N
O O O O
~~~~
~ ~ ~ ~D
0 0 0 0
N
O
}--
....~ ~~
I
~
J
`os w ~
'-' v
• Z Y Q
~ F-
Q
~
U ~ Q =
Z~~ m U O
~ w ~
O O Q0~
~ ~ ~ m~tcn
~ .~
m
z
.~
v
1
•~
V
m
U
C
N
C
O
m
U
C
O
m
.O
.~
•3
O
m
m
V
C
_~
m
L
.~
C
N U
~ C
r.+
N p
~ C
m
J ~
U
C
N
C ~
C
v •-
L
ca ._
~ ~
i ~
~• c
c ~
o ~
~" a
~ C
Q ~
co Q
U