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HomeMy WebLinkAbout08-18-10r~ 15D56D5ZD4? PA ~e~ artment of Revenge Gountj~ C;~~e Year File I'~IUii!E;er Bttrea.~ of Individual Taxes P,~ ~~~ ~~~~, INHERITANCE TAX RETt1RN ENT ~ ~ ~ /-~ ~ L' ~ ~ ,~-~ ~ ~ ~"` €-iarris~ur~. PA 1.'-128-t~~1 RESIDENT DECED ..,. Ei~ITER DECEDENT INFC3RMATIt3N BELQW Social Secufit~~ lvurnher Date of Deat h Date of Bifth I ~~ 22 ~~7g~ ~~ U y201 v U2i ~ i~z7 Dececer,"s t_.ast Nar?~e SE~ffx Decedents Fifst Dame I4Rt M~y~.~. g~Tr Y ~ ~If Applicable} Enter Surviving Spouse's Information Etelow Spt)USe'S L~.~31 ~afl?e Sz..iffix '~~3Gi:Se'S Fifs1 dame ~I Spey;se's Soci<aI SecE.fit,r ~iEfft~her FILL. IN APPRQPRIATE C}VALS BEL4~tt~ 1 _ ~ri~inal ~?ettzsTt TH{S RETURN I~{UST BE FLED tN ©UPI.{CAFE W{TH THE 2. Suppier:~ental Return 3 Remainder Re'urr; (r#c~te of death prior to 12-~ 3-£3~ ~. Limi*ed estate 4a. s=u°ufe €nteres` C©r~~forr;ise gate of ;~, Fe~efal Estate T~ix RetE~m ~Zequireci death at~ter 1~-12-52;~ ~. Deceden# Died Testate 7. Decedent h~aintained a Livinc Trust ~ ~3, Total ~3umber cif `3.~fe Deposit Boxes Rit~Ch Copy or e~`itl; EAttach Copy of Trust; ~. Lititi:,ation Proceeds Received 1f}, Spousal Poverty Credit idate of death i =. Election to tax under Sec. 9'I13(A j hetvveen 12-31-~1 and 1-~-~t5) (Attach Sch. C?; .. coRR~sPa .. NDENT -- THIS SECTION MtlST 8E COMPLETED. ALL CORRESPONt}ENCERND CONFIDENTIAL TAX INFORMATION SH(7U1_L~ BE CtiRECTED TO: ~an-te Da`x in~e Telephone twurtther ~A ~~~y ~c ~~. ~ N~ ~ ~ ~ ~ ~ « ~ ~ ~3 Firrt~ t~~Iame rlf~ppiiralrte t°~_s ~ ,~~ ! Fife" Iifie of aC7C?fe~S '`1 c~ `} , _,~ '~ ~ Se~;ond Iine cf ac`cfe;~s - ~ ~~ -.. - -~ ~ State Z'IP Cede ~ CStj~ C?r PLSST: C~lffl.~e ~-... p ~) _~ Q / ~~ ~q /~ ~ ~ ~ i^.OrreS(?QflCief?t`'-3 e-(€tirtl addreSS: ~,~, ~~ ~ 1 ~` (~ (,~~10 or W"!~ ~ ~ statements. and tR the best of '?'+y' ~nc~4r~€Pdcie and be4iefi. Under ena'ties ~f r u:~. f d~eare that . gave exarn;ned th;s ret~trr~. ~-~uding acctn~~anying schedules aid , tt ~S tf'i<°„ :^,_~r" z,t a:`td CG!iit:~@tfi. I~ez^•$rBtiGi i t31 t~:r°i3~tre" fiitrler t, f8(i t^e vE.'CSOnis "ear G'Se')tcit'•,~e iS .`.~tS2Cl G~ i ar i, ~tC"'llcsttGn G~ br'!i<C!i N:'L' ~i £'.~ };<i,i a'tj` ~C~4o'e~'Iz CI'y`~. ~GNA C3 ERS FSF $LE Ft3R F€t_ff~ly RETtJR€~ JUTE O ~ ~ '' ADC?F,ES~ ._I1 ~' f~ur~tl~~,' ,~r. ~~~rr~ ~ bvr }~l-~ 1.7/~ Z ~i+:~N~TURE QF FREi'A.RER OT~R T HAtV REFEtESE1~#TAT'~lE ~ 3fitE' ~'.C}DRESS PLEASE USE QREGlNAL FQRIIA QNE.Y Side 7 ~,5D56D5I,D4? 15D56D51D~"~ ~ V ~J~ 155610105 REV-1500 EX Decedent`s Social ~3ecurity lumber G~ecedent's T3ame: RECAPITULAT#ON 1. Real Estate ~Sct?eduie A} ............................................. 1. ~ ~ Q U ~. Stacks and Bonds Schedule B) ...... . ............ . ................. .. 2. ~ . 3. Cit~sely field G.orporation, Partnership or Sole-Proprietorship (Schedule G; ... .. ~. ~ • ~~ ~. Ptlo~tgages anc Dotes Receivable (Schedule D, ............... ......... .. .~. ~~ . V ~. Gash, Sark i:3aposits and Miscellaneous Personal Property (,Schedule Ej..... .. 5. ~ ~ ~ l~' ~~ ~5 6. Jointly C;~vned Property l;Sched~!le Fj +'~ Separate Billing Recuested .... ~. ~ ~~ ~. !,~ ?. inter-Vivos Transfers ~ MiscellaneQUS Non-Probate Property 7 //~ ~;Sche~iule ~ O Separate Billing Repuestert...... .. . ~! 8. Tota# Gross Assets (total Lines 1 thraugh 7i ..... .. . ........ ....... S ! ;,~, L ~~~ ~ ~=rsnera Expel?~~es and ~dministrat"sve Costs (Scl-fedule H~ ................ 0 t~ yy,,+~ ~ ) ~<~ Jam, ~/ 10. ©ebts cif Decelent. P~4ar*gage Liabilities, and Liens {Sched~ie i j ........... ... 10' (C' ! ~• -? 1. Tota# Deduotir~ns t"total Lines g and 'l0 .. , ...... ... , .... .... .. ... 11. L~` °~ ~ g. ~~ 12. Net Va#ue of Estate (Line 8 minus Line 11 j ........................... ... 12. I ~~ '1 :3. Charitable and Gr~vernmental BeauestsiSec ?113 Trusts for which ~ an elec~icsn to t~yx, has nct been made (Sched:,~ie J) ..... ... ... ' 3. ~. 1 ~ Net Va#ue Subject to Tax (Line 12 minus Line 13 ............... . .. . .. .. 14, r) N cvC "l ,+- TAX CALCU#_AT#ON s SEE #NSTRUCT#ONS FOR APP~.#CABL.E RATES 15. ~r-?QUnt of Line ~;4 taxai;le at the spousal tax rate; cr transfers under 5;c. '3110 `{6. Jtmflu~?t of L~r~e 14 t X_able r-~ ° ~ ~ ~ ~ ~'f~ ~~ //''~~ ~ ~ ~ ' at lineal rate ;{ .~; ~.~ . . ~ . / V 13. I~r??o~,~nt of L~n~~ 1~e taxable at sil~lin;~ rate r:.' 2 ? 7. 1~. xalee :rtt of E !~?~? 1<} ta t~mo~ .} V f at r~llc~terC~4 r:~-~° ~ 1 ~ ~ ~. ~ 3 ~ ~7~ 1~ TAx D1JE ... .. .............:...... ....... , ..... ~~. . 20. F#LL #N THE C1VAL iF YOU ARE REt~UEST#NG A REFUND OF AN OVERPAYMENT Side 2 ~5D561D1,D5 15D5E~~,DZDS File Number ~E4'-':50Q EX Fa~P .~ Decedent's Complete Address: Tax Payments and Creditsg ~ ,r ~j ] i~ 1. Tax ~iie G`Page 2 Line 1g'~ t f ,, __ / " ~ (V _„_ 2. vreditsEPayments ~-- ~. Spoasai Poverty ~rectt ---~_~._-.-------- _ -- -- ~. Prior Payt~er:ts G. discount -- ~ ~ 11 __ _ - - - __ -- -- --- Tcta' credits ~ :~ + ~ + ~ %2;i ~' ~3, interes~tPeralty if appzica~ie - _._.._.._ ~. irter~st '- E. Pena€t~ -- - __- -- -.--- --- " - Tcttai 4r~terest.`Pera?t}~ i ~ + E i ~~'_ ~ , ~ ~. if Lire ? ifi grea#er than.. Line 1 + Lute ~, en#er the dif#ererce: This is the 4VERRAYNtENT. -- __.__. _--~ Filt in Duet an Page 2, Line 2t1 to request; a refund. `.4~ _ ~~ 5. if Line 1 ~ Lire 3 is greater th<!~ i..irte 2, enter the cif`erenr~. This is tf ~e TAX Dt~E. ~,~.i ~-" / ~ ~ • 7 ~ ____~ A. Enter the in#er~s# en the t~,x ~~+~:~, ~~`i ~ r-~~' ~ ~ ._..._ mil' ~ ~' a~ ~. Enter the toter of Lire ~ ~- ~~. 'phis is the BALANCE DUE. ~~~~ ~ __ ~~ fake C~ec~ ~a~ab~e ~o: ~?;fG1Sl~R t~F V~lf>~,L~r AG~E1~~` PLEASE ANSWER THE FOLLOWING QUESTIONS Bl~ PLACING AN "X" IN THE APPR®PRIi~TE BL~GI(S 1. ~?id de~det't mike a transfer and: des Nc; a. retain! the ;.;4e, car income of the propert;~ transferrerl :.............................:.,,..............,..............,.................,., ..,... ~. retain the right tc~ designate ~~ho shall :se ~e property trans*erred cr its itc~:lrie, - ..,..:..,.:. ............... .. ...... c. retain a re3~ersicrary interest; cr ................................................................................................................... ...... ~~ ~. receive the prcrrtise for rife o? eiti~er payments, ?aene~ts or care? .............. ....................... ...... ........... ...... ~~ 2. !f death c~tx;~rre~~ after Decem~er 12, Z9~2: did decedent transfer property vithir oi~P year cf death "~~`Ethtitrt reCBPJr'g adet~:~at$ cons4derahcn? ............................. ... ~. L! 3. did c+ecedert c~~r ar "ire trust for" or payab4e aeon death nark accoart or secarity at Pis or her death? ....... ....... ~. did deceder`t !`~~'r' crt il^di~fldtai Retirement t'1ise;CUnt, anr~Ety cr ether tort probate property r~rhic~h Coi'tr~inS a ~±?Patli:;iaf f ~eSi~n~fiLr~ .............................. e.....,.......,........... ......,.......... ....... .....,..... .....,, L~ ' ^1 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU DUST COMPLETE SCHEDULE G AND ~Ii.E IT AS PART OF THE RETURN. For dates of death on or after July ' , ~ 9g4 and before January ~ , 1985, the tax rate imposed on `he net tra!ue of transfers to or for }h:~ lase of the surviving spouse is three f.~) percent (72 P.S. ~~".~ (a (~ _' ~ #i~1 Far dates of death on or after January ' ; ~ 995, the tax rate imposed an the net valtae of transfers to or far the rase o' the s~arvi~ing spouse is zeta ~~; percent [72 P,S. §91"6 ia~ ~',~; iii;. The staute does net exempt a transfer to a surviving spouse {nom tax: and the statutory requirernerits fiat disclosure of assets and "ding a tax return are sail{ a,~plicabte even if the surviving spouse is the only berter~ciary. Far dates of death on or after Ju{~ A , ~~~ ~. The tax rate imposed on the net valtae of transfers from a deceased child t+~enty-one years of age or younger at death to ar for this use of a nature! parent, are adoptiue parent: or a stepparent. of the chid is zero f Gl percent (72 P.S. X911 G~~a,~12~. Ther}tax rateCimprose7dr~on the net value of transfers to or for the use of the decedent's lineal beneficiaries is faun and one-half +~:~ ~-ercent, except as noted in ~~. P.S. ~9~1F~1.2) ~1L l~.S. ~~~~il~i3j;~j, The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is tv~jel~fe f, 2} percent [72 P.S.. ~9'15~a,t1 3j~. A sibling is defined, under Section 9102, as an individual ~vho has at leas: one parent in common t+~ith the decedeni, whether by blood or adoption. LAST WILL AND TESTAMENT OF BETTY J. MOVER I, BETTY J. MOVER, now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article TT All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Artir.lP TTT I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed, located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. Artir.lP TV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath IN EQUAL SHARES to my children, KATHY J.:HERRING, of Dauphin County, Pennsylvania, and WILLIAM H. MOVER, JR., of Endwell, New York. However, if a beneficiary does not survive me by thirty (30) days, but leaves descendants who survive me by thirty (30) days, those descendants shall receive, per stirpes, the share the beneficiary would have received had he or she survived me by thirty (30) days. ArtinlP V I nominate, constitute, and appoint my daughter, KATHY J. HERRING, as Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, four any reason whatsoever of my Executrix, I nominate, constitute and appoint my son, WILLIAM H. MOVER, JR., as successor Executor of my Last Will and Testament. I direct that my Executrix or successor Executor be permitted to serve without bond and in addition to those powers granted by law, I grant them power to distribute in cash or in kind in like or in unlike shares and to file ;any qualified disclaimer I could have filed if living. My Executrix or successor Executor shall receive reasonable compensation for services rendered to my estate. e~-1~tP yr In addition to the powers conferred by law, I authorize my Executrix and successor Executor, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (fj to file any federal income tax return for any year for which I have not filed such return prior to my death, (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my -3- Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct alone or with others, any business in which I am engaged ire, or have an interest in at time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, BETTY J. MOVER, hereby set my hand to this :my Last Will and Testament, on ~` 2001, at Harrisburg, Pennsylvania. ~; BETTY ER In our presence, the above-named BETTY J. MOVER signed this and declared this to be her Last Will and Testament and now at her request, in her presence, and in the presence of each other, we sign as witnesses. Name Address _ ~ ~ ~, a ~;~ Y` ~ ~b ~, -4- I, BETTY J. MOVER, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by BETTY J. MOVER, the Testatrix on ~' ~ 1 ~ 2001. ~r ~~ , ~~~ Not Public Notarial Seal Marielle F. Hazen, Notary Public Lower Paxton Twp., Dauphin County My Commission Expires Sept. 23, 2002 ~~ ~ ~ BETTY OYER We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by ~ ~P~-~ i ~'~- l~~ . /~~~;:/~ and ~ t c' k,~ et , witnesses, on 1 ~ , 2001. l f I ~ V No ary Pub is Notarial Seal Marietie F. Hazen, Notary Public Lower Paxton Twp., Dauphin County My Commission Expires Sept. 23, 2002 -5- ~f ~~, SCHEDULE E -~ . •-` 'r `s ~C ~av}_f;L'~' .:- Y?=f`d!`J~'~, '%~~i!~ ~~~• ', BANK DEPOSITS, ~ 1NISC. l~~ PER54NAl. PRt~PE~TY J £Y~~~~ ~ ~;~t=~- ; ~.~ ~~~T~ _ ESTATE OF FILE NUMBER nciude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned wikh right of survivorship must be d'tscbsed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ~. ~ ~?CI'~. ~~t~~ C~. ~ ire' - ~~~ ~u.n~r~~ aC`C't~ ~~ ~~~.~. ~-l.. 1 ' " ~ V~ LL ~1 ~~y~ ~If~.t~~c~L~r~ I~l~~. ~~-~-r ~ ~u~ PA ICI IZ ~~5i~ ~~~~~tf ~.Cc~ ~ 5~~ ~~I I ~ ?r~ ~`~~ ~eslet, rive. i~~ c~`-~~.~~d c~ ~ ~~f P~ ~~v~~ r re. ru~~ ~ e C2i ~je~ ~~v~- 1~~~~-ern ~E Ili ~~ ~ ~7~~~ ~ TOTAL (Also enter on line 5, Recapitulation) $ ` ~ ~ , ~~ ~ .3, °~ (If more space is needed, insert additional sheets of the same size) 6Ci11 Lin~lestown Road Harrisburg, P.4 1711 (71i) 652-888 Wan-en R. Hoover. Jr., .S~rz~rr•vis_?r. i f~~ ~ i I ~~((~~-~ =;~ Kathy Herring 118 Huntley Drive Harrisburg, PA 17112 ~ver ru~-u rxomes t~ c..remawry, tnc. 'Oair Fa-rnily Sef~~if:~ Yc>tu~ Fan±ily for Five Get~tera-tioits" «~c«v.hooverfuneralhome.com Funeral Expenses for Betty J. Moyer Professional Services, Use of Facilities, Automotive Equipment aad Necessary Documents $ 3,795.00 Merchaadise Selected Route 42.2 c~: I:ucv avenue P.~~~. Boy 4?~ Hershey, P.A 1?B33 Sheldon ~~. Hoover, Stsf r .=-r~s~~=~ .~,-- Q - ~ _ _ - January 9, 2010 Lumina 20 Ga. Steel Casket $ 1,895.00 Sentinal -Plastic-Lined Concrete Vault $ 1,285.00 Jesus of Nazareth Box Set $ 130.00 Clothing $ 110.00 Memorial Folders $ 45.00 TOTAL FUNERAL HOME CHARGES $7,260.00 Cash Advanced Items Flowers $ 280.00 Clergy $ 275.00 Organist $ 150.00 Newspaper Notices -Patriot $ 457.00 Mt. Calvary UMClBuilding Fee $ 125.00 Mt. Calvary UMC/Luncheon $ 150.00 3 Death Certificates @ $6 ea $ 18.00 TOTAL CASH ADVANCED CHARGES ~ i,4ss.oo TOTAL FUNERAL & CASH ADVANCED CHARGES $ s,7is.oo Payments and Adjustments $ 8,715.00 January 5, 2010 Evans Shade Vault Co. Discount $ 250.00 January 9, 2010 SecurChoice $ 8,436.95 January 9, 2010 Hoover Funeral Home Discount $ 28.05 BALANCE DUE: $ o.oo Run Report: Aug 03,201010:23 AM Bethany Skilled Nursing User: dcolon Balance Report Page 't of 1 Report Criteria Trust Account: BETHANY RESIDENT BANKING Print Zero Balance: No BAs O e: Q1104/20'l0 Balance Amt.Over: Unit: ALL Balance Amt.Under: MRN: 232 Include Residents with Status:.ALL Resident Name: Moyer, Betty J Sort Option: By Resident Name y e -- -- - Moyer, Betty ~ 232 CH ! 04 f A Inhouse $640.51 Total: $640.5'[ ~thany Village ~~~ 'llVesley Drive AAach~~;csbt~rg, t'A 17055 ,.~ U._...~ ~'i .rn -. `~' C2 9 ~ ~. ~ -s d' m -c T r ~i 0 m G m N Z 0 m n 0 Z ~~ zz pm T n ~~v mm~ ~ ~ Cy ~~_ yo7~ minC o x'~ ~<~ NmZ ~~i-t do7~ -amH r ..~ ZN o m in ~~~ m Z1 y ~o ~ `~-~ o I ~' ~ c~ ni z O o m C O y Z 3 N O C ,. I~1"'~E1~~ ; ~~CiC TAY ~7-C~ [ ~:~h RCSIt~t•,'~T ~iECEuE!'JT SCHEDI~LE F .IC~INTLY-AWNED PRfJPERTY ESTATE OF ~~ ~t ,, j ~ ~ (~ ~ FILE NUMBER J aJ _1 ff an asset was made joint within one year of the decedent's date of death, R must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. ~ ugh N~r+n ~~ ~I ~ Nun~l~~ ~lv~ C~a.~,~~ht~ y -~ 1-{ ~.rY i s~ ~,~ rc Pa I ~ ~ r 2 B C. aollvTLr-or~nlEl~ I~RO~~RT~: ~ ~~ i~iU~4$ER L~i~TER !'~~ }~i~; TFP,I?~N? ~)a.f ;: hdP,LC }(}4P2T i~~.~,~~ip~~ll}f'-~ L~F i~~J~~C PTl~ t~~t', Li1 L~,~ s~fi~~ `~ ~FF,ANrfl1L i~~S i 4Tf1F(~ Q.~tRi QA~~~ ?~~L~11`iT ~~EJ~t~ UM ~. i'yq iS_.~R l~t?S fEYik~?d.J~SE~ /I~ iAs~4 IIEE~ :=0~ .~~!Id?LY_~iEL€} ~EA~ Ev tA'E ~ 1~1 C "~!' f~.ttl~ V'A_UE OF ~SSt~ '?F fi ,.. ~7Fti; :~,ci ffx`iBt~' JUTE F ~E.aTH ~f~i=UE u~ uEt'tDEPiT'S iNTFP:Eu f ~. A. ~ c~o3 5~.,vC.~~i ~ n ~~ ch.~ uc, ~ a c c o~c.n f ~ ~ ~ r, Z2q. ~ 3 5~~ i - ~ - Z o ~ .~~ ~ ~ ~ fi O~~S1~332~5 ~ ~y.72 ~ CvD75 ~IICi~to~~~~ ~31V(,,~- l-Ni~-~ i s b ~,~ r~ P/~ I71 I Z TOTAL (Also enter on line 6, Recapitulation) $ ~p ~ Y ~ ~]~ (If more space is needed, insert additional sheets of the same size) BETTY J MOVER KATHY J HERRING ATTY IFF Balances Account # 581133285 Beginning Balance $1,326.65 Current Balance... $854.43 Deposits/Credits + $0.00 Average Daily Balance $1,066.02 WithdrawalslDebits - $372.22' Checks Posted Check # Date Paid Amount Reference 160 01 /05 $50.00 6236C115C?0 165' 12/31 $10.00 992029510 4 Check(s) Posted = $338.49 An asterisk (*) indicates a skip in sequential check numbers. Account Activity Date Description Check # Date Paid Amounnt Reference 166. 01 /06 $3:49 610944290 168'` 01/12 $275.C10 614000870 An (E) indicates check was converted to an electronic item. Additions Subtractions: Balance 12-31 Beginning Balance $1,326.65 12-31 ' KC)HLS DEPT STORE 6005645740 091231 $33.7;5 $1,292:92` 01.67 12-31 CHECK 165 $10.00 $1,282.92 01-05 ': CHECK 160 - $50.00 $1,232.92` 01-06 CHECK 166 $3.49 $1,229.43 01-12 CHECK 168 $Z75.Q0 $954.43 01-31 Ending Efalance $954.43 IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC TRANSFERS CALL YOUR CUS'T'OMER SERVICE CENTER AT THE NUMBER SHOWN ON THE 'TOP OF YOUR STATEMENT OR WRITE TO THE BANK FOR DEBIT CARD ISSUES: Sovereign Bank Attn: Debit Card Services MAl MB 301-06 P.O. BOX 841003 Boston, MA 02284-1003 FOR ALL OTHER ISSUES: Sovereign Bank: Attn: Client Relations 10-421-CR 1 P.O. BOX 12646 READING, PA 19612-2646 Please contact us if you think your statement or receipt is wrong or if you need additional information about a transfer on the statement: or receipt. We must hear from you no later than 60 days after we sent you the FIRST statement on which the error appeared. • "Tell us your name and account number. • Describe the error or the transfer that you are unsure about and explain as clearly as you can why • Tell us the dollar amount of the suspected error. you believe there is an error or wl~y you need further information. If you tell us orally, we may require you to send your complaint or question in writing within 10 business days. We will promptly investigate the matter and call or write to you with an answer within 10 business days (10 calendar days in Massachusetts). If we need more time, we may take up to 45 days to investigate your complaint or c(uestion. If we do, we will credit your account within this 10-day period for the amount you think is in error, so you wrll have the use of the money during the time it takes us to complete our investrgation. If we ask you to put your complaiint or question m writing and we do not receive it within IO business days, we may choose not to credit your account. For errors involving new accounts, point of sale purchases or foreign transactions, we may take up to 90 days to investigate your complaint or question. For new accounts, we may take up to ZO business days to credit your account for the amount you think is in error. We will tell you the results of our investigation within 3 business days after completing our investigation. If we decide there was no error, we will send you a written explanation. You may ask for copies of the documents we used in our investigation. Important information about your Sovereign Debit Card The networks through which some of your Sovereign Debit Card purchases are processed have begun allowing merchants to process your purchases without either a signature or a PIN. If you are not required to enter your PIN when you make a purchase, your purchase may be processed eityE;r through the Visa network or through the STAR or NYCE networks. If your purchase is processed through STAR or NYCE, different terms apply and you will not be eligible for the rights and protections available through Visa. Please see your Personal Deposit Account Agreement for more information. page 2 of 3 S8 J 133285 REv-151 i. EX+ i1G-+iG! ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBE~t 1~e~~ y ~ , n~ ~ u ~~ Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~a~~e~~ ~~~~.i' ~~me ~G~t Lin l~sr~w~r~ ~c~. l~~~e ~~ i71~ G ~' g, `~~~~~~ _~ ~ B. I ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Names} of Personal Representative(s) _ Street Address City ---- --__ State -------- ZIP - __ __ Years} Commission Paid: ___ ______ 2. Attorney Fees: ~~ ~{ ~, ~ ~ ~ ~ ~~ L~.l~ ~ ~ ~~ 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.} Claimant Street Address City - - State ---__ ZIP _- _ ____ Relationship of Claimant to Decedent 4. Probate Fees; 5. Accountant Fees: 6. Tax Return Preparer Fees: ~. J ~c,~. ~~}~ ~+,c)l ~ ~ b ~ q F~e~rr~ #~x r ~.fi~-~ n ~ I Z~`. U U TOTAL (Also enter on Line 9, Recapitulation) $ D ~ ~ J ~ - ~ -~ If more space is needed, use additional sheets of paper of the same size. 61111 Linglestown Road Harrisburg, P.4 17112 (717) 652-8888 Wan-en R. Hoover, Jr., ~~`r.~peri~isc~t• -_ - ~- ~. ~-- R -~-:; ~. .. - _,_.,. Kathy Herring 118 Huntley Drive Harrisburg, PA 17112 Fua~ Homes d+ Crematory, Inc. "Ot.tr Fa-mily Sen~ir~g Your ~~-nu~ly for ~'iF~e Geraer~a-tions° v~~v~v.hooverfuneralhome.com Funeral Expenses for Betty J. Moyer Professional Services, Use of Facilities, Automotive Equipment and Necessary Documents $ 3,795.00 Merchandise Selected Lumina 20 Ga. Steel Casket $ 1,895.00 Sentinal -Plastic-Lined Concrete Vault $ 1,285.00 Jesus of Nazareth Box Set $ 130.00 Clothing $ 110.00 Memorial Folders $ 45.00 TOTAL FUNERAL HOME CHARGES Cash Advanced Items Flowers $ 280.00 Clergy $ 275.00 Organist $ 150.00 Newspaper Notices -Patriot $ 457.00 Mt. Calvary UMC/Building Fee $ 125.00 Mt. Calvary UMC/Luncheon $ 150.00 3 Death Certificates @ $6 ea $ 18.00 TOTAL CASH ADVANCED CHARGES TOTAL FUNERAL & CASH ADVANCED CHARGES Payments and Adjustments January 5, 2010 Evans Shade Vault Co. Discount $ 250.00 January 9, 2010 SecurChoice $ 8,436.95 January 9, 2010 Hoover Funeral Home Discount $ 28.05 BALANCE DUE: Route 422. ~ Lucv venue 1?t~. Boy 475 Hershey, P.4 17033 (717) 533-7700 Sheldon K. Hoover, Stti~et~~ir~rj• -~ '~ - ~ January 9, 2010 $7,2fi0.00 $ 1,455.00 $ g,~is.oo $ 8,71 _`i.00 $ o.oo ~.. i~~ ~~ ~ `i ~ ~~-1 ~~ Hazen Elder Law 2000 Linglestown Road, Suite 202 Harrisburg, PA 17110 Ph:(717) 540-4332 www.HazenElderLaw.com Fax:(717) 540-4313 Mrs. Kathy J. Herring 118 Huntley Drive Harrisburg, PA 17112 Attention: File #: Inv #: RE: Asset Protection Planning DATE DESCRIPTION Jun-07-10 Telephone call with Kathy Herring Totals Total Fee & Disbursements Balance Now Due July 16, 2010 Herring,Kath 11571 HOURS AMOUNT LAWYER 0.20 37.00 MSM 0.20 $37.00 $37.00 $37.00 If no payment is received within 30 days, there will be a $10.00 rebillin,g fee charged to your account, and interest will accrue at 18% annually. If you have any questions, please contact our office at 540-4332. Thank you for your payment. Hazen Elder Law 2000 Linglestown Road, Suite 202 Harrisburg, P A 17110 Ph:(717) 540-4332 www.HazenElderLaw.com Fax:(717) 540-4313 Mrs. Kathy J. Herring 118 Huntley Drive Harrisburg, PA 17112 Attention: RE: Asset Protection Planning DATE DESCRIPTION Jan-06-10 Phone conference with client regarding Medical Assistance recovery issues Totals Total Fee & Disbursements Balance Now Due February 16, 2010 File #: Herring,Kath Inv #: 10712 HOURS AMOUNT LAWYER 0.30 52.50 MSM 0.30 $52.50 $52.50 $52.50 Beginning January 1, 2010, our new hourly rates will be as follows: Attorney Hazen, X295 per hour; Associate Attorneys, $185 per hour; Paralegals, $140 per hour. In order to provide our existing clients witlc advance notice of the new rates, existing clients will not be charged the new rates until February 1, 2010. If you have any questions, please let` us know Thank you. If no payment is received within 30 days, there will be a $10. DD rebelling fee charged to your account, and interest tivill accrue at 18% annually. If you have any questions, please contact our off ce at 540-4332. Thank you for your payment. ~^ O rLl ~, ~ W r C W ~. -ti7 rTu u _ 7~ .~ ~i r =O'tn 0 ~~~ ~~m wry ~zm DzZ r ~~'D N ~Z L.J1 ~~.. # -~f._ f;...s; .;F~ r ;; W ~ • w ®,. ru ~ -. LJl ~ c ~ \~~~ ~pp ~ ~, ~ ~, A ~ ~ '"' ^e ~` Cti,, ~~ ~ ~ r `_ ~ ~ ~ ~~ '~~. ~: ~~ V a ~` ~ ~ N i i~ ~ r O ~~ .......:... ...:. .... f ~ ~ . .. 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O r O r O r O r r O O r O r r N r r N `' N r N r N r N r r O r O ~- O r O ~- O ~-. O r- O r O r O r r O O r O m I ~> O O O r O O W O O c^ O O O ~-- O O W O O r O r O r O r O r O r O ~- O O - O O O eV ~I .m Q.;i N N N N N N N N N O N O N O N O N O N O N O N r O N r O N r r O O N N r O N ~ ~ ~ O N O ~ C7 N (r7 ~ ~ N O N O r Cr7 N M O Or N N N r O O ~ M M O ~ m -~ ~ r O r ( r 0 r O r N r r O N O N O N O N O ~ O r O (~ O N 0 ems- r 0 O O • L II T~ ~.I L Q ~ X10, TI Y / N Z ~ c?= ~ ! a a a ~ cr ~ a Q. o.. a ~ ~ ~ ~ r d ~ ~ o ~ ~ Y N A L~'% d M C C ~ ~ t t .. j ~ ~ ~' ~` ~ ~ ~"' L. ~ ~ Q ~ m - . ~ ~ ~+ ~ u e'_o C e 0 ~ a N ~ N ~ ~ ~ c N o o o ~- ~ tt3 ~~ LU ° ~ m ~ ~ ~ ~ V m ~ ~ ~ a . N ` ~ ~ ~ C ~ m - m ~ n~ .o ~ ~ m ~ m .o ~ ~ a' m v V ~ ~;_;` ~ ~ m m ~ m ~ a ~ C T ~~ Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 Statement Date Due Date 02/28/2010 Upon Receipt $75.35 232 AMOUNT PAID $ MRS. BETTY J MOYER c/o MRS. KATHY HERRING 118 HUNTLEY DRIVE HARRISBURG, PA 17112 Please make check payable to BETHANY SKILLED NURSING Remit To: BETHANY VILLAGE 325 WESLEY DRIVE MECHANICSBURG, PA 17055' Please detach and return this portion with your remittancE; to the address above. Comments Please contact Donna Colon at 717-591-8029 with any billing questions. ____ __ ___ --- ~ ~ • ____ ~ (, ~ ~ ~ Y - - ~i - Date Descri ton ~I, Da sl ~~ Rate ~ CMat~ est Pa menu ~Batance ~___-- ,~ Units I Credit ~~ _ - - -- __: Balance Forward $614.91 02/18/10 - 02/18/10 xfer frm resident banking res respon Check # $558.33 02/18/10 - 02/18/10 xfer frm resident banking phone/bb chgs Chec $56.58 01 /04/10 - 01 /04/10 Nebulizer Treatment 3 $7.25 $21.75 01/04/10 - 01/04/10 BOOST PLUS CHOCOLATE 6 $1.60 $9.60 01/04/10 - 01/04/10 Incontinence Care -Mod/Heavy 4 $11.00 $44.00 TOTAL BALANCE DUE: $75.35 ,ACCOUNT NUMBER FACILITY NAME RESIDENT NAME ACCOUPJT NUMBER BETHANY SKILLED NURSING MRS. BETTY J MOYER 232 .~k i~z 31~ziio ~ ~ ! ~~ - • ~ ' ! . '~7•): •~~l-G1=~~:»_lt•IaZK•1~1-~rr'f_1-~ a1~-1-1:tli~•]9-la:r_~A~a-~>• Payable To: BONNIE K MILLER, TREASURER Office Hours: MON,TUES 8 THURS 9-4 OR BY APPT Bill No: 6889 2233 GETTYSBURG ROAD CLOSED WED, FRI AND HOLIDAYS Bill Date: 3/1/10 CAMP HILL, PA 17011-7302 BONNIE M{LLER~LOWER-ALLEN.PA.US Control No: 13-023308 Phone: (717) 975-7575 EXT 1701 PHONE (717)975-7575 EXT 1701 $1.00 FEE FOR ADDITIONAL RECEIPTS Tax Payer: BETTY MOYER 5225 WILSON LN MECHANICSBURG, PA 17055-6663 OCC COUNTY OF CUMBERLAND Discount f=ace Penalty COUNTY PC $4.90 $5.00 $5.50 T'WP OF LOWER ALLEN MUN PC $4.90 $5.00 $5.50 MUN OCC $0.00 $0.00 $0.00 TAX AMOUNT DUE If Date Of Payment Is On $9.80 3/1 /10 thru 4/30/10 $1 ~D.00 5/1 !10 thru 6/30/10 $11.00 7/1 /10 or Later TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS BONNIE K MILLER, TREASURER 2233 GETTYSBURG ROAD CAMP HILL, PA 17011-7302 RETURN SERVICE REQUESTED 0 Q N BETTY MOYER 0 5225 WILSON LN N~ MECHANICSBURG, PA 17055-6663 87110 - 9921 d d 87110-P-9921