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HomeMy WebLinkAbout07-26-10' 150561014 REV-1500 ~` ~°'-'°' OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN 2 1 1 0 0 ], 0 6 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Np1ADDYYYY Date of Birth nau-DDY'mr 2 0 6 3 2 0 9 7 5 0 1 2 6 2 0 1 0 0 9 1 1 1 9 3? Decedent's Last Name Suffix Decedent's First Name MI B L A I N C A R O L Y N E (ff Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW a 1. Original Retum 4. Limited Estate Q 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Retum 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONF~NTUIL TAX SIfORMATION MOULD BE DIRECTED T0: Name Daytime TeHephone Number W I L L I A M A D U N C A N 7 1? 2 4 9 7 7 8 0 ~ _ - _ __- REGIST~ OF WILLS U NLY - -' ,~~ ~ '~ First line of address ~ Z ~~ ~ ~ ~ ~ ~~ -~~ ~~ 1 I R V I N E R 0 W _;;; ,,~. - ~~, Second fine of address I --~...-, , .-,~-- ' - ~ ''- - f . FZ`1 .... ~_ -- - - -- ._- _ _-__~.'a _ _. City or Post Office State ZIP Code ~ TE FILED , ~ ..J C A R L I S L E P A 1 7 0 1 3 CorrespondenCs a-mail address: B I L L D U N C A N c1 P A• N E T Under pen~ties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the hest of my knowledge and belief, it is true, correct and complete. Declaration of pneparer other than the personal representative is based on all information of which preparer has any knowledge. SIG TORE OF PERS~ RES LE FOR FILING RETURN DATE ~, ~' ~ . ADDR 84 MC ALLISTER CHURCH ROAD CARLISLE PA 17015 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 150561014D . ~. r J 1505610240 REV-1500 EX Decedent's Social Security Number Decedents Name: C A R O L Y N E- B L A I N 2 0 6 3 2 0 9 7 5 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 4 7 5 0 0 0. 0 0 2. Stocks and Bonds (Schedule B) ...................................... 2. 0 ' 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages and Notes Receivable (Schedule D) .......................... 4. • 4 1 ~ 4 6 . 3 9 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 8. Total Gross Assets (tots{ Lines 1 through 7) ........................... 8. 5 1 6 ? 4 6. 3 9 9. Funeral Expenses and Administrative Costs (Schedule H) ........... ....... 9. 1 4 1 1 8 . 2 9 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ...... ....... 10. 8 0 4 8 . 1 1 11. Total Deductions (total Lines 9 and 10) ........................ ....... 11. 2 2 1 6 6 . 4 0 12. Net Value of Estate (Line 8 minus Line 11) ..................... ....... 12. 4 9 4 5 ? 9. 9 9 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. 4 9 4 5 ? 9 . 9 9 TAX CALCULATION -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 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x• 0 4 5 4 9 4 5 7 9. 9 9 16. 2 2 2 5 6. 1 0 17. Amount of Line 14 taxable 0 0 0 17 0 0 0 at sibling rate X .12 . . 18. Amount of Line 14 taxable 0 0 0 0 0 0 . at collateral rate X .15 1 g. . 19. TAX DUE ............................................... ....... 19. 2 2 2 5 6• 1 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 10 010 6 DECEDENTS NAME CAROLYN E• BLAIN - - ------- - STREETADDRESS 74 MC ALLISTER CHURCH ROAD CITY STATE ZIP CARLISLE PA 17015 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2 2 , 2 5 6.10 2. CreditslPayments 2 0, 0 0 0.0 0 A. Prior Payments B. Discount 1, 0 5 2.0 0 Total Credits (A + B) (2) 21, 0 5 2.0 0 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.0 0 5. 1f Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1, 2 0 4 • 10 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 : ................................................................ ...... ^ 0 b. retain the right to designate who shall use the property transferred or its income; .......................... ...... ^ 0 c. retain a reversionary interest; or .......................................................................................... ...... ^ 0 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? ........................................................................•.--.•.•- ..•... ^ 3. Did decedent own an "in trust for" or payable-upon-death bank arxount 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? ............................................................................................ ...... ^ 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 Jan. 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 21 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 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 4.5 percent, except as noted in 72 P.S. §9116(1.2) [T2 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 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, undE Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REY-1502 EX+ (01-10) Pennsylvania I SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RFSInFNT r)FCFnENT ESTATE OF: FILE NUMBER: CAROLYN E• BLAIN 21 10 0106 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 wiNing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disdosed 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 DESCRIPTION 1• ?4 MC ALLISTER CHURCH ROAD, CARLISLE, PA 17015 4?5,000.00 [SEE ATTACHED APPRAISAL] TOTAL (Also enter on Line 1, Recapitulation.) ~ S 4 7 5, 0 0 0- D O REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MASC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER CAROLYN E• BLAIN 21 10 0106 Indude the proceeds of litigation and the date the proceeds were n;ceived by the estate. AIt property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1- PROCEEDS OF ORRSTOWN BANK ACCOUNT # 106005028 [SEE DATE OF D EATH LETTER ATTACHED] 2- U-S- TREA SURY REFUN D 3- SEMI-ANNU AL RE NT ON FARM LAND 4- HMA PHYSI CIANS MANA GEMENT REFUND 5- PROCEEDS FROM SALE OF DIAMOND TRAILER 6- PROCEEDS FROM SALE OF UPRIGHT FREEZER 7- PROCEEDS FROM SALE OF PATIO FURNITURE 8- PROCEEDS FROM SALE OF COUCH 9• PROCEEDS FROM SALE OF COMPUTER DESK & CHAIR 10• PROCEEDS FROM SALE OF DOUBLE BED 11• PROCEEDS FROM SALE OF DINING ROOM TABLE&CHAIRS&HUTCH 12• PROCEEDS FROM SALE OF 42" SONY TV 13- PROCEEDS FROM YARD SALE OF PERSONAL PROPERTY 14• PROCEEDS FROM SALE OF 2000 CHEVY BLAZER 15• PROCEEDS FROM SALE OF PLANT STAND 16• PROCEEDS FROM SALE OF WASHER & DRYER VALUE AT DATE OF DEATH 29,924.52 722.00 640.00 30.00 1, 200.00 150.00 125.00 150.00 80.00 500.00 1, 000.00 250.00 j 2,096.10 '~ 3 , 700.00 ~, 65.00 500-00 TOTAL (Also enter on fine 5, Recapitulation) S 41, 7 4 6 • 3 9 Continuation of REV-15001nheritance Tax Return Resident Decedent CAROLYN E. BLAIN 21 10 0106 Decedent's Name Page 1 File Number Schedule E -Cash, Bank Deposits, ~ Misc. Personal Property ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1?• PROCEEDS FROM SALE OF PERSONAL PROPERTY 313.77 18• (COMMONWEALTH OF PA DEPT• OF TREASURY REBATE ~ 300.00 SUBTOTAL SCHEDULE E 613 • ? 7 GRAND TOTAL SCHEDULE E ~ 41, 746.39 REY-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER CAROLYN E- BLAIN 21 10 0106 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1• FUNERAL FLOWERS 344.45 2• WEST PENNSBORO FIRE HALL RENTAL 230.00 3- RONAN FUNERAL HOME - MEMORIAL MARKER 2,336.00 B. 1. 2- 3. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Repn~entative(s) Street Address City State ZIP Year(s) Commission Paid: AttomeyFees: DUNCAN & HARTMAN, PC Family Exemption: (If decedents address is not the same as daimanYs, attach explanation.) Claimant 10, 325.34 4• 5- 6- 7- 8- Street Address c;~y State Relationship of Claimant to Decedent Probate Fees: REGISTER OF WILLS Accountant Fees: TaxRetumPreparerFees: JOHN MC CREA 2009 TAX PREP REGISTER OF WILLS - FILING FEE HELD IN RESERVE 427.50 40.00 15.00 400-00 ZIP TOTAL (Also enter on Line 9, Recapitulation) S ], 4 ,118 • 2 9 REV-1512 EX+ (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER CAROLYN E- SLAIN _ 21 10 0106 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1- PPL - ELECTRIC BILL 72.33 2• EVERETT CASH MUTUAL INSURANCE CO- 313.00 3• KOUGH'S OIL - HEATING OIL 520•DD 4• PPL - ELECTRIC BILL 52.42 5- PPL - ELECTRIC BILL 71.9? 6- DIVERSIFIED APPRISAL SERVICES - 74 MCALLISTER CH•RD- 350.00 7- KEMPER INSURANCE - CAR INSURANCE 59.83 8- ROGER 8 TERRY SLAIN - REPAYMENT OF FUNDS ADVANCED 2,44D•DO 9- DEBORAH PIPER - TAX COLLECTOR - REAL ESTATE TAXES 450.65 10- DEBORAH PIPER - TAX COLLECTOR - PERSONAL TAXES 4.90 11• PPL - ELECTRIC BILL 56.55 12- PPL - ELECTRIC BILL 19.52 13- JOHN K- BIXLER III - LAND SURVEY 440.33 14- PPL - ELECTRIC BILL 19.52 15- PPL - ELECTRIC BILL 56.15 TOTAL (Also enter on Line 10, Recapitulation) I S 8 , 0 4 8.11 ~ If more space is needed, insert additional sheets of the same size. Continuation of REV-15001nheritance Tax Return Resident Decedent CAROLYN E. BLAIN 21 10 0106 Decedent's Name Page 2 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, ~ Liens ITEM NUMBER DESCRIPTION AMOUNT 16- S•W- BARRETT REAL ESTATE 8 APPRAISAL - 74 MCALL• CH- 500.00 17• PPL - ELECTRIC BILL 73.01 18- PPL - ELECTRIC BILL 19.48 19• HEALTH NETWORK LABORATORIES 128.07 20- DEBORAH W- PIPER, TAX COLLECTOR - REAL ESTATE TAXES 2,400.38 SUBTOTAL SCHEDULE I 3 ,12 0 •9 4 GRAND TOTAL SCHEDULE I ~ 8, 048.11 REV-1513 EX+ (01-10) Pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CAROLY N E• SLAIN ~y .LU uLUe RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pndude outright spousal distributions and transfers under . Sec. 9116 (a) (1.2).] 1• ROGER R• SLAIN Lineal 84 MC ALLISTER CHURCH RD 1/5 SHARE CARLISLE, PA 17015 2• LISA WILSON Lineal 635 MT ROCK RD 1/5 SHARE CARLISLE, PA 17015 3• STEVE SLAIN Lineal 68 MC ALLISTER CHURCH RD 1/5 SHARE CARLISLE, PA 17015 4• RANDY N• SLAIN Lineal 64 MC ALLISTER CHURCH RD 1/5 SHARE CARLISLE, PA 17015 5• MICHAEL D• SLAIN Lineal ?0 MC ALLISTER CHURCH RD 1/5 SHARE CARLISLE, PA 170],5 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. jj. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1• B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1• TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S If mnrP cnar~ is n~riw. i iicp arlrlitinnal chawtc of nan~r of tha cams ci~P ~...., _ .--.,. ~ o VJ' LAST WILL AND TESTAMENT ~.,~~ ~ 1.~:'-~ 4'.~ - ~ _:: r~ . OF ~-e © -~~ ~;~ ~ -x CAROLYN E. BLAIN I, CAROLYN E. BLAIN, of West Pennsborc 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 all other wills and codicils heretofore made by me. FIRST: I direct that all my just debts and funeral expenses, including my grave marker, shall be paid from the assets of my estate as soon as practicable after my decease. SECOND: I give, devise and bequeath the residue of my estate, of every nature and wherever situate, to five of my children, equally, namely ROGER R. BLAIN, MICHAEL D. BLAIN, RANDY N. BLAIN, STEVEN L. BLAIN, and LISA MAY WILSON. Should any of my five children. named herein predecease me then and in that event their share shall be distributed to their issue per stripes living at the time of my death and in default of such then living issue such ~ share shall be added to the share or shares for my other five children named herein and/ot• their issue. THIRD: I have specifically not made any provision in this my Last Will and Testament for my daughters, CAROLYN S. LINE and CONNIE R. LUCAS for reasons which 1~ they are aware of. FOURTH: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. FIFTH: I nominate, constitute and appoint, my son, ROGER R. BLAIN, Executcr cf this my Last Will and Testament. Should my son, ROGER R. BLAIN, fail to qualify or cease to act as Executor, I appoint my son, STEVEN L. BLAIN, Executor of this my Last Will and Testament. SIXTH: I direct my Executor and his successor to retain the services of Ronald E. Johnson, Esquire to act as attorney for the estate. SEVENTH: I direct my Executor and his successors shall not be required to give bond for the faithful performance of their duties in this or any other jurisdiction. . IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of two (2) typewritten pages, each identified by my signature, this ~ rt day of August 2009. .r-r-- (SEAL) Carolyn E. Blain Signed, sealed, published and declared by the above-named Testatrix, CAROLYN E. SLAIN, as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND I, CAROLYN E. BLAIN, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by CAROLYN E. BLAIN, thE; Testatrix, this ~ day of August 2009. COMMONWEAL?`H OF PENNSYLVANIA NOTARIAL SEAL SHELLY SEXTON, Notary Public Carlisle 6oro, Cumberland County My Commission Expires April 26, 2011 t 13/ l (SEAL) _. _ _ K r AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) We, RONALD E. JOHNSON and ~ ~r 1", ~~+rrw-s ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will and Testament; that Carolyn E. Blain, signed willingly and that she executed it as her free and voluntary act for the purpose 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 knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. t,,~-two of armed to and subscribed to before me by RONALD E. JOHNSON and ~~ ~r ~• ,~,5 ,witnesses, this ~ ~ day o August 2Q49. ~_ ri/%~.~~~' _ -(SEAL) COMMONWEALTH OF PENNSYLVANIA ~ onald E. J NOTARIAL SEAL SHELLY SEXTON, Notary public ~ Carlisle Boro, Cumberland County 1VIy Commission Expires Apn126, 2011 ~; Witness ,(SEAL) Notary Public OxxsTOwrrBa~ A Tradition of Excellence ~. ~ . 77 East King Street Shippensburg, PA 17257 February 24, 2010 Duncan & Hartman, P.C. 1 Irvine Row Carlisle PA 17013 Attention: William Duncan ,Esquire Shirley Wescott Orrstown Bank PO Box 250 Shippensburg, Pa 17257 Phone 717.530.2515 Re: Estate of Carolyn E Blain Date of Death: 1!26!10 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT, ON THE ABOVE DATE, HAD THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK.• CHECKING A CCO UNT Account # Title of Account 106005028 Carolyn E Blain Date opened Principal 2/14/09 29,924.39 Accrued Interest DOD Bal .13 $29,924.52 Best re rds, .~ ~~~~~ hirley Wescott Receptionist St - MEMBERS 1st • FEDERAL CREDIT iJNION v-sa Statement Closing Date: February 24, 2010 ~u~as~r O~ Account ~4~tivit~ ~~ ~~ Previous Balance ~~~~~ ~' Payments - 344.99 - Oiher Credits - 0.00 Other Debits + 0.00 Purchases + 1,116.11 Cash Advances 0.00 Fees Charged 0.00 Interest Char ed + NEW BALANCE S 1,116.11 r V y .,r~di Limit ~~ Available Credit Available Cash Amount Disputed 0.00 Statement Closing Date 02/24/10 Days in Billing Cycle 29 ©nltact Inf~fmation Customer Service: (800) 283-2328 Ext: 6035 ~i. Report Lost or Stolen Card: (866) 839 - 3485 Ptease send Billing Inquiries and Correspondence to: ~~ CUSTOMER SERVICE PO BOX 30495 TAMPA , FL 33630-3495 Visit us on the web at: vvvvw. members1 st. org Please Mail Your Payments to: PO BOX 4517 CAROL STREAM IL 60197-4517 PaytTlent }itfOfmation New Balance Total Minimum Payment Due S 0.00 Payment Due Date 03/21/10 Late Payment Warning: If we do not receive your minimum payment by the date listed above. vnu may have to ecru a $30 late fee. Minimum Payment Warning: If you make only the minimum payment each period, you will pay more in interest and it will take you longer to pay off your balance. For example: T.. ~ _^~ You witl pay off the And you wilt etld up 1f you make no additional oharges balance. shown sin this Iraytng an estisrr~ted using this card aril statement in about ... >tfltal of..: each month y©u' pay..,. Only the minimum 6 year(s) $1,440.00 payment 35.00 3 years $1,277.00 (Savings= $163.00) If you would like information about credit counseling services, call (866) 791-4360. Q~~ K~~ l5 C ~C°~_~D F_ ., _ tmpor n ews .. ._.. .. TO REPORT A LOST OR STOLEN CARD PLEASE CALL MEMBERS 1ST FCU AT 800-283-2328 ~OR 866-260-0868 AFTER HOURS. TO- OBTAIN ACCOUNT INFORMATION 24 HOURS A DAY CALL 500-288 2 QR..~G~$S ONLINE AT EZCARDINFO.COM. .. Trans Date Post Date Plan Name Reference Number Description Amount 01/26 01/28 PPNR02 24388940027038310274814 FTD'PEALER'S FLOWER SH CAMP HILL PA $ 344.45 NOTICE: CONTINUED ON PAGE 3 Page 1 of 3 -'