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Home My WebLink About08-05-10 1505610140 t ~ REV-1500 ~` t°'-'°' PA Department Of RBVenUe OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po sox 2sosol INHERITANCE TAX RETURN Harrisburg. PA 17128-OS01 RESIDENT DECEDENT 2 1 1 0 0 0 9 6 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYW 1 9 2 3 0 1 8 9 6 1 0 2 7 2 0 0 9 1 1 0 6 1 9 3 7 Decedent's Last Name Suffuc Decedent's Fist Name MI R O B E R T S F R A N C E S R (If Applicable) Enter Surviving Spouse's Infortnatlon Below Spouse's Last Name Suifix Spouse's First Name MI Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW ® 1.Original Retum ^ 4. Limited Estate ^ B. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ ^ 4a. Future Interest Compromise (date of ^ death after 12-12-82) ^ 7. Decedent Maintained a Living Trust . (Attach Copy of Trust) ^ 10. Spousal Poverty Credk (date of death ^ between 12-31-91 and 1-1-95) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposk Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTU-L TAX INFORMATION SHOULD 8E DIRECTED TO: Name Daytime Telephone Number S T E P H E N L B L O O M 7 1 7 2 4 9 2 3 5 3 First Ilne of address 6 0 W E S T Second line of address City or Post Office State ZIP Code REGISTER OF WILLS USE ONLY C"~ rv ° - C ~ ~_,.: ~°~~ ~ "~ a c s ~~~ ' ~ .r] S r ~ ~:r:~ 7 . __~rn I r:,, - FILED D w `~ ~ ~- 3 C A R L I S L E P A 1 7 0 1 3 _, Correspondents e-mail address: Under penaHies of perjury, I declare that t have examined this return, indudirp axompanyinp schedules and statements, and to the Dent of my knaMadye and belief, k Is true, correct and compote. Dedaradon of preparerother than ttra personal representative is based on all information of whkh preparer has arty knowledge. S TIZRE OF-PER N S ONSIBLE FOR FILING RETURN SIGNATURE P O M F R E T S T R E E T THAN REPRESENTATNE 6D WEST POMFRET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 1505610140 J r Oh20'[9S05'[ Oh20'[9SOS2 Z aP!S D 0 '0 1N3WAtld213A0 Ntl dO 4Nnd3a tl ~JNI1S3nb321 321tl nOJI dl ltlAO 3Hl NI llld 'OZ .63 ...................................................... and Xtll '6l D D' 0 84 0 0' 0 Sl• X a;e~ lea;epoo;e n ' owy algexe3blaull;o;u gi D D' D ~L3 D O D n ' ourd algexe; q eu ~;o lu Ll 0 D' D 'gL D D D l ' O wtl L cull;o;uno algexelb gL 0 0 ~ 0 'St D D 0 - o'x(z'3)(e) • oag ~apun s~a;sue~i g; l.6 ~o 's;e~ xe; lesnods ay; le algexe; 4L cull to;unowy 'Sl S31tlM 3l8tlDllddtl 21Od SNOI1~n211SN133S - NOlltlln~ltl~ X1/1 D D ' Z D E 9 - .ql . ..... ................ (£ L Bull snulw ZL cull) xel o;;ae(gng enleA 3eN 'bL • £L • ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' (f alnPa4oS) spew uaeq;ou sey xe; o; uol~ala ue yolym ~o; sisn~l £ l L6 oag/s;sanbag le;uawwenoO pue algel!ig4~ '£ L 0 0 'Z O E 9 - ,ZL . ..... ...................... (l L cull snulw g cull) a;sls3 ~o anleq 3eN 'ZL Z. $ ~ $ 9 Q 2 9 ' L l . ..... ......................... (0 L Pue 6 Bawl 1e1o1) suoponpaO lelol ' L 6 '06 ~ ~ ~ ~ ~ ~ • ~ ~ (I alnPa4oS) suall pue 'sal3!I!gell a6e6yoW `luapeoaa;o s;qap •pi 0 'C ' 2 6 9 'C h 6 ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' (H alnPa4oS) s;sad an!;e~3slulwpy Pue sasuadx3 ~e~aund .6 G h 'E 2 2 0 2 ~ .g . ..... ..................... (L yBna43 L scull lelo;) s;asst' ssaO 1e3o1 '8 Z B S S S S S •L • • • • ~ ~ • pe;sanbaa 6ugllg a;eiedag n (O alnpayoS) Ryadad a;egad-'Qb'pI snoauellaoslW g SJa;sued sonlnaa;ul •L ~g ~ pa;sanbaa Buiplg a;e~edag ~ (d alnPa4oS) ~~adad paumO ~Rulof '9 .S • • ' • ~ ' ' (3 elnpayog) ~vadad leuosJad snoauellaoslW pue s~sodad ~lueg 'yse~ 'S Z S ~ Q S S 2 .b . ..... .................... (d alnPa4oS) algenlaaaa se;oN pue sa6eByoW '4 '£ ' ' ' ' ' (O alnpayoS) dlysJO;audad-slog ~o dlysiauped 'uol;wod~o0 PIBH 6lasolO '£ • ,Z . .... ................................. (8 alnpayoS) spuog pue sW~oiS 'Z . 3 .... ...................................... (tl alnpayoS) alais3 lean ' L 0 ^'0 0 0 E S NOlltllnlldtl~321 S 1213 8 0 ?J ' 21 S 3 J N V N~ :aweN s,3uapa~ao 9 6 9 2 O E 2 6 2 ~agwnN qunoaS leloog s,;uapeoap X3 OOS 6-n3a Dh2D29sos~ Continuation of REV-1500 Inheritance Tax Return Resident Decedent FRANCES R. ROBERTS 21 10 0096 Decedent's Name Page 7 File Number Correspondents Name S T E P H E N 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 L B L O O M P O M F R E T S T R E E T Daytime Telephone Number 7 1 7 2 4 9 2 3 5 3 State ZIP Code P A 1 7 0 1 3 Correspondent's e-mail address: Under penaltles of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the beat of my knowledge and belief, It is hue, oared and complete. Dedaradon of preparer other than the personal representative a based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIB~ FOR FILING RETURN _ DATEi _ ADDRESS ~ 249 WALNUT STREET MT. HOLLY SPRINGS PA 17065 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0096 DECEDENTS NAME FRANCES R. ROBERTS STREET ADDRESS 65 E. NORTH STREET CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: t• Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) o.oo Total Credits (A + B) (2) 0.00 (3) 0.00 (4) 0.00 (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT r 3SiL~ r n ra ,JP i W ~~ ea ~% icRnB S~UC~{B ~i2iEU'1 ~P~6+hl c+ i6 ~k~" t ~`! ~ P+~mi ~.a~4w n ,u to vusrN ~ ~ E i c :[;e, I €!; a„«56kl1=,c_.c,t .. .,,,_ a,c iu n,u ne.~~,~,99u 'ut~`a _d_~..ii e,,,"~.,, ,,, PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a Vansfer and: Yes No a. retain the use or inwme of the property transferred : ................................................................ ...... ^ b. retain the right to designate who shall use the property transferred or 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 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................. ...... ^ 3. Did decedent own an 'intrust for' or payable-upon~eath bank account 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. a.r~~~'i~i,f~.. ~~,€ r. .F;~~~(. ~~.~t)a ~'t~~)t ~,~; ~°` ~N[~rG°~.,~ ('~'~].14~'„,a~;r"~a,~(~~ `.~• ~~' 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 p2 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 benefiaary. 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 benefiaaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) p2 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(x)(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. REV-1502 FJ(+ (01-10) Pennsylvania I SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FRANCES R. ROBERTS 21 10 0096 All real property owned solely or as a tenarrt 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 orocerty that is Jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet ff 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. 65 E. NORTH STREET, CARLISLE, PENNSYLVANIA 53,000.00 SOLD -SETTLEMENT SHEET ATTACHED TOTAL (Also enter on Line 1, Recapitulation.) ~ E If more space ffi needed, use additional sheeffi of paper of the same size. REV-1509 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FRANCES R. ROBERTS 21 10 0096 Indude the s of litigation and the date the pproceeds were received by the esmte. All property intlyowned vriflr right of survhrorehip must be disobted on Schedub F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MEMBERS 1ST FEDERAL CREDIT UNION -SAVINGS ACCOUNT #30242-00 988.14 2. 3. EMBERS 1ST FEDERAL CREDIT UNION -CHECKING ACCOUNT #30242-11 PERSONAL PROPERTY TOTAL (Also enter on line 5, Recapitulation) ~ ; (If nrore space is needed, insert additlonal streets of the same size) 316.23 1,254.20 REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER FRANCES R. ROBERTS 21 10 0096 Decedent's debts must be reported on &hedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 2,400.34 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Staff Year(s) Commission Paid: ZIP y. AttomeyFees: IRWIN & McKNIGHT, P.C. 3. Family Exemption: (lf decedents address is not the same as claimants, attach explanation.) Claimant TRICIA P. ROBERTS SVeetAddress 65 E. NORTH STREET City CARLISLE srate PA Zlp Relationship of Claimantto Decedent DAUGHTER 4. Probate Fees: REGISTER OF WILLS 5. I Accountant Fees: 6. ~ Tax Retum PreparerFees: PATRICIA A. ROSENDALE, CPA 7. REGISTER OF WILLS -FILING FEE 8. CLOSING COSTS ON SALE OF REAL ESTATE 9. PUBLIC SALE COMMISSION 10. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 11. THE SENTINEL -ESTATE NOTICE 3, 500.00 3, 500.00 198.50 350.00 30.00 6, 737.34 423.51 75.00 208.78 TOTAL (Also enter on Line 9, Recapitulation) I E H more space is needed, use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent FRANCES R. ROBERTS 21 10 0096 Decedent's Name Page 3 File Number Schedule H -Funeral Expenses 8~ Administrative Costs - B1 ITEM NUMBER DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s)otPersonalRepresentative(s) TRICIA P. ROBERTS 1,375.00 streetAddress 65 E. NORTH STREET City CARLISLE state PA ZIP 17013 Year(s) Commisson Paid: Name(s)ofPersonalRepresentative(s) STEPHANIE E. LEACH 1,375.00 Street Address 249 WALNUT STREET City MT. HOLLY SPRINGS state PA ZIP 17065 Year(s) Commission Paid: SUBTOTAL SCHEDULE H-B1 ~ 2,750.00 REV-1512 EX+ (12-09) Pennsylvania DEPARTMENT OP REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER FRANCES R. ROBERTS 21 10 0096 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbumed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH HOME -NURSING 2. UNITED CHURCH OF CHRIST HOMES, INC. D/B/A SARAH A. TODD MEMORIAL HOME TOTAL (Also enter on Line 10, Recapitulation) I S 10,895.41 30,796.69 If more space is needed, insert addldonal sheets of the sarrre size. REV-1513 EX+ (01-10) pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE I BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: FRANCES R. ROBERTS 21 10 0096 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 ought s usal dstribufbns and transfers under Sec. 91 i6 (a~(1.2).] 1. TRICIA P. ROBERTS Lineal 65 E. NORTH STREET 50% REMAINDER CARLISLE, PA 17013 50% REMAINDER 2. STEPHANIE E. LEACH Lineal 249 WALNUT STREET MT. HOLLY SPRINGS, PA 17065 3. JOSEPH S. LEACH Lineal 65 E. NORTH STREET CARLISLE, PA 17013 4. DANIEL R. LEACH Lineal 67 E. NORTH STREET CARLISLE, PA 17013 5. GARY R. LEACH Lineal 67 E. NORTH STREET CARLISLE, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ; If more space is needed, use additional sheets of paper of the same size. • '/ .j LAST WILL AND TeSTAMENT I, FRANCES R. ROBERTS, of 65 East North Street, Carlisle, Cumberland County, Pennsylvania 17013, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: ~~~. A. If at the time of my death Gary R. Leach is still residing in my real estate located at 67 East North Street, Carlisle, Pennsylvania and has not previously purchased it from me, I direct that my personal representative shall offer to him the right of first refusal to purchase said real estate for its then current market value. This right of first refusal must be exercised by Gary R. Leach within thirty days after receipt of vrritten notice from my personal representative or the attorney for my estate and settlement must be held on or before ninety days after receipt of said notice. If he does not notify the personal representative of his desire to purchase the property within thirty days or does not complete settlement within ninety days of receipt of said notice, then this right of first refusal shall terminate and the personal representative shall liquidate this asset and distribute the proceeds thereof in accordance with the remaining provisions of this will. n' B. All the rest, residue and remainder of my estate I give, devise and bequeath as follows: 1.) 50% to my daughter, Tricia P. Roberts, or if she is deceased, then to her children, share and share alike; and 2.) 50% to my grandchildren, Stephanie E. Leach, Joseph S. Leach, and Daniel R. Leach, share and share alike, the child or children of any deceased beneficiary taking the share their parent would have taken if living. 4. I nominate and appoint my daughter, Tricia P. Roberts, and my granddaughter, Stephanie E. Leach, to be the co-personal representatives of my estate, to serve without bond. N WITNESS WHEREOF, I have hereunto set my hand and seal this ~~day of April 2008. L) NC S .ROB R Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ~N~ -. ACKNOWLEDGMENT AND AFFIDAVIT WE, FRANCES R. ROBERTS, SARAH A. HARDESTY and KATHRYN M. MULLEN, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. FR,(NCESR: ROBERTS SA A. HAR KATHRYN ULLEN COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND :ss: Subscribed, sworn to and acknowledged before me by FRANCES R. ROBERTS, the testatrix herein, and subscribed and sworn to before me by SARAH A. HARDESTY and KATHRYN M. MULLEN, witnesses, this day of April 2008. COAp+IONWFAL7HOF PgNNSY4VANIA v `~ ~./(~ NOTARIALSF.AI. Notary Public Harold S. Irwin Ui, Gaq, Notmy Public ~G~ cam~oo 06, 2011 ~~ ols3 No. saozo2es 4P a B. TYPE of LOAN: 1. FHA 2 FmHA 9. CONY. UyBNB. 4. VA b. ^CONV. INS. UJ9.OePART10ENT pF ItO11BM0 i tMBAN 8. FILE NUMBER: 7. LOAN NUMBER SETTLEMENT 8TATEMENT SwAtz7-10 8. MORTGAGE INS CAGE NUMBER C. NOTE: Th/s Rrm Y ArNalad b pw you. uaMmerlt aachal asl6emsrlt eosL. Aneoalfs w+e b end hY me aemisment apart as ah5wn. rams marked (POCr wwe Pall oleslda 6a dodnat Bar eA shown hem her Mlltxmadond prposs+end en not kBYUdw In 8» oobla. to aN 1t7+te.P4010YM777-7 0. NAME AND ADDRESS OF BUYER: E. NAME AND ADDRE88 ~ SELLER: F. NAME AND ADDRE38 OF LENDER: JERRY W. SWARTL ESTATE OF FRANCES R ROBERTS CASH 17 LEBO ROAO 85 EAST NORTH STREET CJRLISLE, PA 17015 CARLISLE. PA 17013 G, PROPERiYLOCATION: H. ALiENT`. 26.7619B1t I. SETTLBrE14TDATE: 8B EAST NORTH STREET 11tF000NTY ABSTRACT SERVICE CARLISLE, PA 17013 Jun. 18, 2010 CtIAABERLANO Collelly, PemayNanta PLACE OF SETTLEMENT S3 80UTH PITT STREET CARLISLE, PA 17019 J. 8~S 100. surety: 400. BB AM Irr ale TO aeLJrle 101. conu.et 8a1w Prior 59 o00.ao 401. Colltrad Salve Pdw 53000.00 102 402. PeIwIW 109. 8a81eelrnt b 1400 1188.76 403. ta. 404. 105. +~• Fergana Pond 3elarN adwla FaBsma Paid 8 Se4wM sdwncs tae. ownTaxw oenen0 m Otrotnt 405. owoTaxw oenen0 b 01ro1H1 107. Thew b 407. Taxes b 105. BCHOOLTAX 08118110 b 07/01H0 28.20 405. SCNOOLTAx 05/18!10 b 07101/10 2810 108. 408. 110. 111. 411. 112. 4 2. 120. OR08S AMOUNTDII/E FROM BUYER ~ 54,987.85 420. GROSS AMOUNT DUE TO SFI l FR 53,219'.10 AMOUNTi P eY OR BI BEFIALF OF BUYER: 600. M TO SELLER 201. Ot 9000.00 501. Exews Bea YWfelfJtDw .. 202 Amowt a Naw 502. BatlMlar4 b BsMr 1 5737.94 209. Wan b 003. s taken b 2e4. 6a. atku 2a5. 20g, 508. 207. 607. dk4>, as 208. 208. ~. Farlbms Seller Forllsms SeBsr 210. own Taxes b 510. own Taxes b 211. Taxes b tit 1. Taws b 212. SCFi00LTAX b 512 BCHOOLTAX b 213. 613. 214. 614. 215. 515. 216. 518. 217. 617. 218. 518. 219. 818. 220. TOTAL PAID BYiFOR BUYER 9,000.00 820. TOTAL REDUC7/ONAMOUM DUE SELLER 8,737.94 900. CASH AT FROIYTO BAYER: T BeTTL91ENT 7'OIFROM 901. Gloss Da Fran 1 S4 987.85 801. Oran Amane Da To 8e6sr 59 18.10 971. Law Allxaent 220 000. 802. Lew ReeWdiaes Ow 8s0ar 8737 903. CASH{ X FROM) ( 717) BUYER 51.987.85 800. CASH (X TO) ( FROM) SELLER 48,481.78 TM unWaq~ red ~ rsalpt ofAµ I~d~iaz a this statement a aeryr dgdlmenls eararad b Ixaem. I HAVE CIUt.EBFT~J.~. EWED THE HUD-1 ST AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, R IS A TRUE AND ACCl1RA ATE ALL RECEIPTS MADE ON MY ACCOUNT OR BY ME Ill THE. i FURTHER CERTIF f TRANSACTION. HAVE PREPARED IS A TRUE AND ACCURATE ACCOUNT OF TH UNDERSKl14ED AS PART OF THE SETTLEMENT OF TFO6 WARNING: IT IS A CRIMh= TO KNOVNNGLY MAKE FALSE STATEMENTS TO THE UNRED STATES ON TNIS OR ANY 36NOAR FORM. PENALTIES UPO CONVICTIDN CAN INCW['>E A flNE AND BWPRISONMENT. FOR DETAILS SEE: TITLE 18 U.S. CODE SECTION 1001 8 SECTION 1010. ~.~., L SETTLEMENT CNARaE8 7 00. TOTAL COBNMSION Bawd on Pda 9 63000.00 5.0000 % 3 375.00 rNO rnarwAc a suvaxa asusRa 1. b RINDS AT iUWaAT BETTIENENr BETiL®1@IT e eo. TTB16 PAr w CONNECTION YYT711 LOAN 1. Loan Fw ro e ez. Loan DNoarN % m b Nw. . Fw b io REBN !pf LENOER7O BE PAW W ADVANCE 8 01. Mpnaat Fr'4rn b = % b 8 09. Hamd hrarrrarlCa PrwrlMrn 1W 1.0 m 8 04. 8 05. 1 000. O~OSRED Y1RF1 LENDER 1 001. Flawld months morph 1 1 002. MMI1aa11Ca morphs rrwnrh 009. own TawN morphs month 1 004. Taw moMM montlr 1 00b. SCHOOL TAX moMM f month 1 1 007. marohs ! month ADAI8TME1 moNhs morph 1 100. 1 101, ar Fw to 1 1 102 CLOSWO PROTECTION LETTER to FIRST AMERICAN TT17.E INSURANCE COMPANY 109. to 1 104. T2M 1 Bkldx b 1 1 1 1.06. n !o 100. Fsw to CASH 107. Faw to 8.00 abaro Nam rasnbera: 1 . 7 s .7 11 1 . 1 200. DOYERI~T RlCOIm1110 AND TRANSFER CHAROEB 1 201. Fws: Daad t 62.00: i Rskaws i 82.00 1 209. Shps T Rawnw 890.00: 530.00 1 204. 1 206. OVERNIOHflCOURIERFEES 1 900. ADDITIDNAL SETIIEAWNT CHAR028 1 901. ro 1 1 1 1 902. Pwt I b 909. TRASH AL ro G. SCOTT RAMSEY 904. 2010 /fOVYNSHIP TAXES Eo SOROIIfiIi.OF CARLISLE TAX COLLECTOR BILL MB47 905. 8w add21 asfilMt to 1000.00 361.86 1,472:48 1 400. TOTAL SlTTLEAIDR CHARGES on.Lhrw 1 Baetlon J and 8aetlon 1,180.75 8,737.34 3[TTLEME ti,oR~~ ~, 1 ~ CsrtlOed m bs a Nrs copy. SetllarrwttN Aysnl ~ srwlano/avwrn-m/s ~ St MEMBERS is prmnn~~.CRBDIT UNION 3AVINl33 ACCOUNT: Account Number/Sufflx Date Account Establkhed Prindpal Balance at Date of Death Accrued Interest to Date of Death Total Prindpal and Axrued Interost Accrued Interest from 01/0112009-10127/2009 Name of Joint Owner CHECKIlKi ACCOUNT: Axount NumbeHSuBbc Date Account Established Prtndpal 8elanee at Date of Death Accrued Ir-tsrsst to Date of Death Total PAndpal ant Aaxued interest Accrued Interest from 01/01/2009-10/27/2009 Name of Joint Owner LOAN ACCOUNT: Account Number/Suffix Date Loan Established Prtndpal Balance at Date of Death Loan Type Collateral Held Name of CaBorrowar soul-oo 05/21/1982 5987.58 5.56 5988.14 535.43 None 30242-11 05/21H982 5318.23 So.oo $316.23 x2.94 None 30242A2 ' 10/19/2005 50.00 HELOC-Noma Equity Une of CredR 65 E. North Street, Carlisle, PA 17013 None MEMBERS 1~ FEDERAL CREDIT UNION Leip~- n-11rr,ne sta landing Insurance Support Spedalist April 18, 2010 Estab of: Frances R. Roberts Dab of Death: Odxrbar 27, 2009 Sodal Security Numbar.182J0-1896 RECEIVE® APR 1,7 2010 IRWIN & MdQVIGHT LAW OFFICES 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvarria 17055 (800) 283-2328 wwwmemberslst.org ~vcrrar ~1eam or.-- i _~anr;r ~r Numbel - L(e.2 l ~a ., ~t ~m~+' „ tam or .ot Number fY~... *- RKa: ~ ~, ~..~,~, i~cs: j 1 . 7h1B'rac~j~. lee a ` ' Th~_at verln,~s aarmer~t sr~. ael- ~ ptthe anrnre ...' ,Sgk#Te, where Is 'hlGealea fidal x~ te ~` "',~"'r+'^' 0 ' 0 ' , , ~pdordx Ferrm CT Nlheauri Awaon aG14oI N+f•(w~rrber t_-~ ~ g (~S ~ - - . u' ~ . ' ~.-_. ._ ~ Or mj~ 3.4 0 + y { . : _~.: 2 ._ Buyer's Name.. ~_ -r ... hem;br -_.,~~' 1 7.20 + LotNumbe ~~ 7 Number .:_ r,a ~-` ~_ ? 5.10 + ~ j em or _ ~ of Number -----~~~, -Ttt~aa.~+.~ rt~-- ~ $-s-.~~ 2 0.2 0 + ~ y ,-, ~ .~:.$ . iv -__ $. y' ':~. 86.00 + I ;~ _ Thra ~pt This rec~fpt veAHes'PaYrnent'and delivery of~tfie~above: = "^""'-~dq!'~O^ s~ 3 9 • 6 0 + . sad as.is, whsle ~s: a-~salea,flnel::,fienk.,,a,: aeoref« Form.CT MWorri Aueitbn.8e•J1wd www.Ap~cnwhnokoom _ Buy&.•s I 3 1 4 ' 2 0 9a m I _ -- _,~ ~ _ 3-•- ryer's Name, . '- x Or Num 1' e . Item .o~ =~i 3 5• X L f rNumber ~ .~ Lot Number 1 0 9. 9 7 m ~ rm or -t Number . „~t~'~ ~ '~^~wres: ~ . $~ I ~ .c g ~. 204.23-x ~ ' Thrs recap ~~"'~ This rQcerpt v:psprmenfand delivery of the. abgye. s • .r~RsorW, Fam Chi' ~ ~~~ I~ s ajt ~ fl of tk~ ~ ~ U ~ y- '~' ~ ~ a old ae ~;.wliere rs .All final ?tienlc you.;. ~mCr.MhsauiAuibn m ~i41N ` "~ rou. , . ~ .rr,l:3 r«~pz ~w~".p~..~~,~,. °"° ~ ~~ ( _. , oan -_...'.... •-,-°:..,-._ ; y ~ ,,_ ~ Y - +~ ` m -~ I AF Sold ea is; where is. All ealee~tiii8r rnrnm,~ ~ ~ Reordex Fonn.GT Mbeairi~Auctbn 9dwol.www.auotloii~ohgp6~ri. I ~ - ~ ~;~ , i z ~ d , "r $ Name r yer' ~ i .. . --.~._ _.~~ T _ . . _. _._ ..._ _ ~ ~~ . ~ 4 ~~'. Number ~ to e ~ TI or ,:, _• :Number , : ' ' br N bar um ~ "~ r ~ r ~. $=-r-.Lci _.. $ - ~0 ~ 1 ' - Item or - Lot, Number ' , I ~ RernAdres: Th~ ~~ verifies Paynrant:arxl delrvery:vf the above I ~ ~ - 3oid es la, where la Allsal~a flnatt Thank your , _ } Raorda Fam.CrMYwuA Auotlon 3ehpa.wvny. ~~ .. __ __ _, --~«~oa~ com _ ~ - • ' Thls receipt verifies pa enddeli of the yment '' ve. • < Sold as Is where 1s::All s lsa firiel p ~ - n or ~ . a k y u . ~ .: fam cr M~,a axnar saaw www~.ucdon~nooi.cw• _ .:_ Number. -_;~- - _.._.._ - - .. ' _ ~~ - ~ $-~•'~- = ~ I - __ ~t Buyer's Name Or Number . :. eAFxs: I i 14em or- -- -- ` - it Lot Number (~ - ' rnis taeeipt verifies Payment-and d~ivery of the a-iova. (~ ~ $r~a . , .Sold as Js, where`is. NI sales:flnal.:Thenk yai• ~ F~wKa: ° ~.,•,~ ~_ Reordrft rroren CT:MI•sourl AiroUon school vniw wctioneerwd earn -'-' ~ - ryer~ Name 3" ;~ Number an or ( .J Thte.+eee1 v scld~as. erlfies Payment and delivery of the atwve. ilnel Tn ~ ~. d Numbet` r 1 : er,k:you. • R.aeler Form cr M n,; g~ wree°^.chaw earn,- :. - -..: - -- -- . (' , - Buyer's Name _ _._ _._ -. r e ~ y.AAFl c : ~ Item qr I . Lot. Number <~,:. Thla receipt verifies payment and delivery of the above.. • ' Sold ~ is, where is. i4lLsales final.-Thank you. I ,, ~ ~ $.~~_ _ $ ~ I . neord•r Form CT Mhaouri Auction 9daol www.auatiorrcrrod:cam ~ ~ ~ -This receipt-Yariflee Payment d .. _.._.. _. ......,a~.ura: r rrerlK yOU:. _ an S.~ ~ilMry Of the~abOVe. •. I sa is. where Is. All sales final. Thank you: E .. - -- . sA~E rw. ~ oq DATE. ~ T~ _ Tor s /'7 Ira Tricia P Roberts 65 East North Street Carlisle, PA 17013 219 Ngih Fl~~er Sfreef Car~sle, penruyNania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 www,ho~nc~roih.cbrri infa®I~narcom.oon, January 7, 2010 Statement of Funeral Expenses for: Frances R. Roberts Date of Death: October 27, 2009 Account Id: 15768-245 PACKAGE: Immediate Cremation, Memorial Service at Funeral Home OPTION 3 -Cremation $ 2,090.00 Sub Total: $ 2,090.00 MERCHANDISE: Urn: Other - Misc Um $ 300.00 Sub Total: $ 300.00 TOTAL FUNERAL HOME CHAR(3E3: ; y~390,00 CASH ADVANCES: 5 Certified Deattt Certificates at $ 8.00 each $ 30.00 Newspaper Notice -Sentinel $ 80.34 Clergy $ 75.00 Coroner's Fee $ 25.00 Sub Total: $ 210.34 Total Funeral Expense: $ 2,600.34 Total Payments Made: $ 200.00 Payments made: Jeffrey 8 Diane Snider Check 4864 Nov 6, 2008 100.00 Margaret "Peggy" Morrow Check 468 Nov 6, 2008 100.00 Total Balance Due: Please return thb portion with your Remittance E Amount Encl~ed Frances R. Roberts Service ID #:15768-245 FUNERAL HOME 8t CREMATORY, INC. SERVING OUR COMMUNITY SINCE 1 907 NOTICE OF CI:AIM COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF FRANCES R. ROBERTS, DECEASED No. 21-2010-0096 To the Clerk of the Orphans' Court Division: Kindly enter the claim of Thornwald Home in the amount of $10,895.41 against the above-captioned Estate. This claim is a priority claim under 20 Pa.C.S.A. §3392(3) for the value of nursing facility services performed for the Decedent within six (6) months of the date of death. The Decedent, who resided at Thornwald Home, died on November 8, 2009. Written notice of said claim was given to Tricia P. Roberts at 65 East North Street, Cazlisle, PA 17013 and Stephanie E. Leach at 427 North Walnut Street, Mt. Holly Springs, PA 17065 on March 5, 2010. Claimant: Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 Date: 3' s• d OIO By: Steven M. Montresor Attorney No. 74244 Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Boulevazd, Suite 140 Mechanicsburg, PA 17050 (717)620-2424 C7 a C p o :_~, .~ n ~ ~ ma r _~-: 'P._ r - `:~z~ 1 c.%; 7 ~tf mi=x ~ ~ -, , :... ;. a c-~ ~~ 'v . ~_'~ c' '~ L 3-' r O ~: ~ ~ ~ --~ 136288 1 $tatBlge2lt United Church of Christ Fames Sarah A. Todd memorial Home 10D0 mist South atrmet Carlisle, PA 17013 Trisha Roberts 63 E. ]>lorth st Carlisle, PA 17013 Statement Date: 10/10/20t~r~ Due Date: 1D/2S/2008 Re: Fraacas R Roberts Account Nr; 101955 Date Deseziption Bays Rate Char err` $ pa ~~ y~ yments BalancE Quant 09/02/08 BAAA,NCE EOR4~ARD Heauty & Barber 1 00 20 00 15, 717 , 00 15,717.Oa 09/08/08 09/08/08 Thera . . 2 0.00 1 15,737.0 15 09/08/08 Therapeutic Activit Therapeutic Aetivit 1.00 27.40 5.98 ,747.41 15,7'52.9 09/08/08 Therapeutic Exercis }„ 00 2.00 27.4D 26.Oq 10 42 15,758.3.9 09/08/p8 Neuromusculaz R®edu 1.00 27.08 . 5 q2 15,768.86 09/09/08 09/09/08 Self Caxe Mngemcnt Therapeuti A i 1.00 27.78 . 15,779.2:? 779 15 713 09/09/06 c ct vit Therapeutic Activit 2.00 1 D0 27.40 27 40 10.96 , . 15,790.74 09/09/08 Th®rapeutic Exercis . 2.00 . 26.04 5.48 10 42 15,796.22 09/09/08 Th®rapeutic Exercis 1.00 26.09 , g 21 -5.806.64 09/D9/08 Beauty & Barber 1.00 20.00 , 20 00 15,811.85 09/10/08 Self Care mngement 1.00 .27.78 . 5 56 15,831.8;; 09/iD/0$ Therapeutic Exercis 1.00 26.pq . 15,837.4_ 09/10/08 Therapeutic Activit 2.00 27.40 10.96 15,842.6:: 09/10/08 Therapeutic Activit 1.OD 27,40 5 q8 I5,853.5f3 09/10/08 Therapeutic Exercis 2.00 26.04 10 42 15,859.06 09/11/08 Therapeutic Exercis 2.OD 26.04 . 10 42 15,869.gFi 09/11/p8 Therapeutic Exercis 1.00 26.04 . S Z1 15, 879.9ca 09/11/08 09/11/08 Se]P. Care magsment Therapeutic Activit 1.00 27.78 . 5.56 15,885.1]. X5,890.6^ 1.00 27.40 5.48 15,896.1; Statement t7nited Church o7: Christ NpTpeg Sarah A. 'odd Memor:lal Home 1000 West South Street Carlisle, PA 17013 Trisha Roberts 63 E. North 5t Carlisle, BA 17013 Statement Date: 10/10/2008 Due Date: 1D/25/2008 Re: FranceB R Roberts Account Nr: 101955 Date Description Days Rate ~Y`Charges "payinentsr~ Balance Quint 09/12/08 09/12/08 Se].f Care Mngement Thera eutic E 1.00 27.78 5.56 09/-7:2fOB p Therapeutic xercis Exercis 7..00 2,Op 26.04 26 04 5'2.1 09/12/08 09/12/08 Neuromuscular Reedu 1.00 . 27.08 1D,42 5.42 09/12/08 Therapeutic .Therapeutic Activit Acti it 1.00 27,90 5.48 09/15/08 Therapeutic v Activit ~,pp 27 40 10.96 09/15/08 Therapeutic Exercis 1.00 . 26 04 10.96 09/15/08 09/15/08 Therapeutic Th Activit 2.00 . 27.40 5.21 10.96 09/16/08 erapeutic Therapeutic Exercis Activit 1.00 00 3 26.09 2 5.21 09/16/06 Therapeutic Activit .. 2.00 7,40 27.40 10 96 D9/16/08 09/16/08 Therapeutic Therapeutic Ex®rcis E 1.00 26.04 . 5.21 09/16/08 xercis Beauty & saxber 1.00 1 00 26,04 20 00 5.21 09/16/08 Self Care Mngement . 1.00 , 27,78 20.00. 5 56 09/17/08 09/17/08 Therapeutic Th Activ7,t 1.00 27,90 . 5.4A 09/17/08 erapeutic Th®rapeuti c Activit Exercis 1.00 D0 2 27,40 5.48 09/17/08 . Therapeutic Exercis . 2.00 26.04 26.04 10,42 09/18/08 09/18/08 Therapeutic Th Exercis Z.00 26.04 7.0.42 09/18/D8 erapeutic Therapeutic Actirri.t Exercis 1,00 2 00 27.40 26 0 5.48 . . 4 10.42 15, 901.7:1 15,906,92 15,917.34 7,5, 922.76 15,928.2! 15,939.20 15,9SO.lE's 15,955.3; 15,966.33 15,971.54 15,977.0< 15,987.9E 15,993,1 15,998,40 16,018,40 16,023.96 16,029.44 16,034.92 16,045.34 16,055.76 16,066.18 16,071.66 16,082.08 Stat~nent t7u.ited Church of Christ Homes Sarnh A. Todd fiGamori8l Hoene 1oD0 West South Street Carli,s],e, PA 17013 Statement Di~te: 10/10/20()8 Trisha Rabert9 63 E. Narth St Cazlisie, PA 17013 Due Date: 1D/25/2008 Re; Frances R Robezts Account Nr: 101955 Date Description Da s y Rate - Charges ------------~-``---" Payment ____,~____ -- Quant s Baianca 09/18/08 09/19/U$ Therapeutic Therapeutic Activit Exerci 1,00 27,40 5'48 --- ., - - - 16 087 5E 09./19./.08 Therapeutic s Activit 2.00 40 27 10.42 , . 16, 097.98 09/19/0@ 09/19/08 Therapeutic Exercis 1.00 . 26.g4 10.96 5.21 16,106.94 09/22/08 Therapeutic Therapeutic Activit Activit 1.00 27.4p 5.48 16,1],4.15 16 119 6 3 09/22/08 0 Therapeutic Ex®rcis 1.00 2.Op 27,90 26.D4 10 42 , . . 16,125.11 9/22/08 09/22/08 Therapeutic Exeraia 2.00 26.04 . 10.42 16,135.83 09/23/08 Therapeutic Therapeutic A,ctiviL• Aoti vit 1.00 1 00 27,40 5.48 16.145.95 16, 151.9: 09/23/08 , geaut & Barber y . 1.00 27.90 20.00 5'48 20 00 16,156.91 09/23/08 09/23/08 Beauty & Barber T 1.00 16,00 . 16,00 16,176.91 09/23/08 herapeutic Th Exazcis 2.00 26.04 10.42 16,192.9:. 09/24/08 erapeutic Exercis 2.00 26,04 10.42 16,203.3;3 09/24/08 Therape:~tic Th Exercis 1.00 26.04 5.21 16, 213.7;; 09/24/08 erapeutic Th Activit 1.00 27.40 5.48 16, 218.9E 09/24/08 erapeutic Therapeutic Activit Exercis 1,00 00 2 27.40 2 16,224.44• 16'228'8` 09/24/08 Self Care Mngement . 1.00 6.04 27.78 10,42 5 6 16,240.34 09/25/08 09/25/08 Therapeutic Activit 2.00 27.40 c 10,6 16,245.9G 09/26/08 Therapeutic Th®rapeutic Exercis Exerci 1.00 26.04 5.21 16,256.8E• 16,262 07 09/26/08 ThQrapeuta,c s Activit 2.00 1.OD 26.04 27,40 10.42 5,99 . 16,272.98 16,277.97 i I~ J ~l i 11 Stat®ment Unite 4hurch of Christ Hvtaes Saxa Todd Memor3,a1 Fiume 10(10 ~est south Street ~a isle, PA 1,7013 Trisha Robext$ 63 E. North 3t Carlisle, PA 17013 statement Date; 10/10/2008 Due Date: 10/25/2008 France~9 R Roberts =ount Nr: 101955 Date Description 09/26/08 Thera}~eutic Exercis 09/29/08 Thaxapautic Activit .Q9./.30/.08 Med.~,cal supplies 09/30/08 Medical Equipment R 09/30/08 Oxygen 09/30/06 Cable Tel®vision 09/30/UB Personal J.auadry se 09/30/08 C02N8URANCB STLLED 09/30/08 Finence Charge 09/30/08 Beauty & Barber 10/01/08 Room K Board - gem, NOTE; ***** PAYMENT 13 DUE THE 25TH OF THE MONTH ***** your statement. Include the . of your cheek. Payments a~Gte NOTE: ** LATE FAYD~NTS AAL 9 A $10,00 FEE WILL BE CHARGED aY 811 Rate Charges Payments-_--Ha.lanab •0 .0 26,04 27 40 10.92 16,288.33 . 0 . '151.47' 10.96 151.47 ].6, 299.35... . 0 113„ 90 1 131.90 ~ 16r 450. B.ti. .0 156.$0 156.3C 17,582.72 •0 17.00 17 00 17,739.0;: •0 30,00 . 30.00 ].7,756.0."", 128.00 640.D0 17,786,02 72.11 18,426.OG .0 20.00 20.00 18,498.1; 3 235.00 7,285.00 18r518.1;~ 25,803.1: I 'I N RECEIPT ***** g~ Np LATER TFIAN ease remit the LAST AMOUNT printed on # ~xom the statement on the N1EM0 LINE /OBy08 da npt .reflect on statement. CT $O A 1.25$ LATE CHARGE PER MONTH ** RETIIRNED CHECKg ** !I II ~I r 8tateement Unitad Churoh of Christ homes Sarah A. Todd Memorial Home 1000 Weat South str.®et Carlisle, PA 17013 6tatement Date: 11/19/2008 Trisha Roberts 63 E. North St Carlisle, PA 17013 Due Date: 11/25/2008 Re: Frances R Roberts Account Nr: 101955 Date Descript~,on Days Rate Charges Payments- "Halancae Quant 10/-07-/•08• BALANCE FORWARD Beat~•ty ~ Barber 1.00 20.00 25,803.13 20 00 25,803.1:; 10/10/OB Wheelchair Mgmt Tra 2.00 25.34 , 10.14 25, 823.1; 25 833 2; 10/10/08 PT Evaluation 1.00 66.53 13.31 , . 25 896 5E 10/10/08 Therapeut~.c Activit 9.00 27.40 21,92 , . 25 868 SG 10/14/08 Beauty & Sarbex 1.00 20.00 20.00 , . 25 888 5 C• 10/21/D8 Beauty 6 Barber 1.00 20.00 20.00 , . 25 908 50 10/31/08 Personal Laundry 5e 1.00 3D.D0 30.00 , . 25 938 50 10/31/08 Cable Televis3~on 1.00 17.00 17.00 , . 25 955 50 10/31/D8 Beauty & Barber 1.00 16.00 16.00 , . 25 971 50 10/31/08 Finance Chazge 197,36 , , 26 168 8E 10/31/08 Earsonal Supplies 1.00 1.25 1.23 , . 26 170 11 10/31/06 Medical Supplies 1.00 224.33 224.33 , . 26 394 49 10/31/08 Oxygen 1.00 31.26 31.26 , . 26 925 70 10/31/08 Medical Equipment R 1.00 1483,62 1,483.62 , . 27 909 32 10/31/08 Beauty & Barber 1.00 10.00 10.00 , . 27 919 32 10/31/08 ' Beauty & Rarber 1.00 5.00 5.00 , . 27 924 32 1 1/01/08 Room S Surd - Semi 7 235.00 1,645.00 , . 29,569.32 NOTE: ***** PAXMENT TS DUE UPON €tECEIPx ***** BQT NO LATER THAN THE 25TH OF THE MONTH ***** Please remit the L1l6T AMDl7NT printsd on your statement. Include the ACCT# from the statement on the MEMO LxNE of your check. Fayments attar 11/06/08 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE 9USJ'ECfi TO A 1.25$ LATE CHARGE PER MONTH ** A 510.00 FEE WILL BE GNARGED !or RETURNED CIiECRS ** r 8tatament United Church of Christ Homes sazah A. Todd Memorial 1~ome 1000 hest Bouth Street Carlisle, pA 17013 Statement Date: 12/12/20C8 Trisha Roberts 63 E. North St Carlisle, PA 170.13 Due Dat®; 12/26/2008 R®: Frances R Roberts Account Nx: 101955 -Date -~--Descriptiion--------------Da_s--~----------------------------~-------~__ y Rate Charges Payments Balance --------- --------------- Quant 11/0'4/06 BALANCE FORWARA Beauty & Barber 1.00 20 00 29,559.32 29,569.3'? 11/07/06 11/07/p$ Medical Equipment R p 1.00 . 405.10 20.00 903.10 29,589.3:2 11/07/0$ ex$onal Laundry Se Cable Tei evision 1,00 1 30.00 30.00 29~ggg $.~ 30 024 4'? 11/07/08 , Oxygen .00 1'00 17.00 15 63 17.OC , . . 30,041.4? 11/07/08 11/30/08 Medical Bu lies FP 1.00 . 90.95 15.63 40,95 30,057.p~ Finance Charge 325,01 30,09$.00 30,923.01 NOTE; +**** pAYMEN4' IS DUE UPON RECEIPT "+~**w BUT NO LATER THAN THE 25TH OF THE MONTW ***** Please remit the LAST AMOUNT painted on your statement. TncludG the ACCT# from the statement on the MEMO L=NE of your check. Payments after 12/11/08 do not xeflect on statement. NOTE: ** 7aATE PAYMENTS ARE 3UEJECT TO A 1,25$ LATE CHARGE PER MONTH ** A $10.00 FE F,, WILL SE CHARGED fqr RETURNED CFIECTCS ** Statement C,~lited Church of Christ tioA:ea Sarah A. Todd Memori,a~. Homme 1000 West South Street Cazli.sle, PA 17013 Statement Date: 01/14/20{79 Tri,Bha Roberts 63 E. North St Carlisle, PA 17C'i3 Due Date; 01/25/2009 Re: granceg R Roberts Account Nr: 101955 Date Desaript~,on Days Rate Chargas Paym®nts T^Balancg 4uant BALANCE FORWARD 12/31/08 Finanee Charge 30423.01 373.68 30,423.0. 30,796.69 NOTE: ***** EAYMENT T:= bUL" UPpN RECEIPT *w*** BUT NO LATER T$A,I~ xHE 25TH OF THE MONTH w*r•w* Please xamit the LAST AMOUNT printed on your statement. Tnclude the ACCT$ prom the statame~nt on the M6H0 LINE oT your check. Payments after 01/09/09 do not raPlect on atntwrtent. NOTE; ** LATF PAYMENTS .FIRE SUBJECT TO A 1.259 LATE CHARGE PER MONTH ** A 510.00 FEE WILL SE CHAY,GED for RETtTRNED CHECKS ww