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HomeMy WebLinkAbout08-17-10J 1505610101 REV-1500 Ex t°'-1°' PA Department of Revenue Pennsylvania Bureau of Individual Taxes nw„„E fc~pjNHERITANCE TAX RETURN PO BOX 2806ot RESIDENT DECEDENT Harrisburg PA i~i28-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth 096-52-2416 05/18/2010 10/08/1955 Decedent's Last Name Suffix Payne (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix MMDDYYYY Decedent's First Name MI Debra A Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OID 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Jacqueline M. Verney, E (717) 243-9190 First line of address 44 S. Hanover Street Second line of address City or Post Office Carlisle Correspondent's a-mail address: State ZIP Code PA 17013 REGISTER WILLS USE ANLY o ~ r ?. ", _.' ~ 7i "'J ~ - `~~ ~ cr ~ J ' <- :~ - ` ~ ~C7 ' ED D ~ , ..~ ...-- Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my xnowietlge antl Dauer, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS ~~~ I~ /4LC~~jjl/ ~C~ ~L+~T11/~!1-C((c4Y~ ~V~~ lu7/~~ SIGNATURE OF PREPARER OT ER THAt~t REPRESENTATIVE DATE A RESS ~J PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J OFFICIAL USE ONLY County Code Year File Number .r7 "7 f '. I , _t - T ~ ,~ ,~ .~_ 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: Debra A. Payne 096-52-2416 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 0.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 0.00 4. 9 9 ( ) ......................... Mort a es and Notes Receivable Schedule D 4. .. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 14,698.57 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 0 00 (Schedule G) O Separate Billing Requested...... .. 7. . 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 14,698.57 9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. 11,171.74 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .... 10. 8,336.24 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. 19,507.98 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. -4,809.41 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which . an election to tax has not been made (Schedule J) ................... ..... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. -4,809.41 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 00 (a)(1.2) X .0_ 15. . 16. Amount of Line 14 taxable 0 00 at lineal rate X .0 _ 16. . 17. Amount of Line 14 taxable 0 00 at sibling rate X .12 17. . 18. Amount of Line 14 taxable 0 00 at collateral rate X .15 18. . 0.00 19. TAX DUE .................................................... .....19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 REV-1500 EX Page 3 File Number Decedent's Complete Address: Debra A. Payne STREET ADDRESS 11 Heather Place CITY Carlisle STATE PA Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 0.00 2. CreditslPayments A. Prior Payments B. Discount Total Credits (A + B) (2) 0.00 3. Interest (3) 0.00 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 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 :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ 0 c. retain a reversionary interest; or .................................................................................................................... ...... ^ ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death 2 . without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable-upon-death 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? ................................................................................................................. ....... ^ 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 is 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) [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 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. REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Debra A. Payne 21-10-0534 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 1. Wachovia Bank checking acct. 666.60 2. Centurylink paychecks $721.16 + $1303.08= $ 2,024.24 3. Wachovia Bank acct 0.79 4. Centurylink final paycheck 348.12 5. Grape Certificate 284.00 6. Fidelity Investments refund of overpayment of loan 53.35 7. Fidelity Investments mutual fund 124.09 8. Rowe's Auction Service 2505 Ritner Highway Carlisle, PA 17015 household goods 4,197.38 9. Mobile home 7,000.00 TOTAL (Also enter on line 5, Recapitulation) 5 I 14,698.57 (If more space is needed, insert additional sheets of the same size) 07/21!2010 15:40 716-938-2780 w~ Q ti "~ . td --~ CATT CO JAIL PAGE 02166 ~ ~ . ~ ~; rL, .4 ~t- 4 ~ ~ C ~ ~ 4 "~'~ .... ey, ~ r". ~ .y ~ o- ~ . `.. ~, ~`"~ Q ~~ i7d "s ,~ ~ ~' ~ 4A cwt ~ w ~"'- ' ~ ,~ of ...~t~+. ~ CJt ,. "~l ~+, c+aW ^~ ~s b ~., ~~ o ~ c ~~ C9 ice. „~ ~~ ~ ,. ~ F., ~ ,, ro ,a --r ~.., ,~ ,,, a ,...~ ti.. ~ ~. ~ ~ ~ ~ . ~, ~ ' of ~ fQ to ~i oa b ~? '~i -~7 G ~a ~. y fp~~~'~ Q ~ '~ r -~ _~ ~ . . . 07/21/2010 15:40 716-938-2780 CATT CO JAIL PAGE 04106 WAC~~VTA, Deposit Account Clase Confirmation (Debi#) WACHOVIA BANK Date Customer Name(s) and Address 06/01/2010 DEBRA A PAYNE KATHLEEN M JOHNSON POA 11 HEATHER DR CARLISLE PA 17013-9629 ACCOUNT NUMBER: 1010118$92296 Available Balance $0.79 + Accrued Int : $I)AO -Fed W/Wd Due : $0.00 - Adrrtin Fee : X0.00 -Outstanding Db : $0,00 -Closing Fee : $0.00 Paid To Customer : $0.79 Taxpayer ID Number 5096522416 Wachovia Bank and Wachovia Bank of Delaware are divisions of Wells Fargo Bank, N.A., Member FDIC. 36596 {Rov 0 t) CUSTOMER COPY 05/26/2010 8Q United Tel-PA Name: RATHLBEN M. JOHNSON Pay Period: 05/16/2010 05/29/2010 Pay Date: 05/26/2010 Pers No: 00064830 Cost Center: T8569270 Pay Area: Bi-weekly Payroll Total Groan: 942.00 Pay Type: Regular Payroll Net Pay: 721.16 EARNINt3S AND OTHER PAYMENTS Hours Current YTD SALARY NON-EXEMPT 8,134.84 EVENING 9.78 STD 100 PAY 16.00 316.64 4,749.60 p,~ 1,068.20 GRANDFATHER VACATION 184.30 HOLIDAY 155.20 PTO PAYOUT 31.60 625.36 625.36 ADJUSTMBNT OVBRTIMB xA6ES 14.75 SHORT TBRM INCENTIVE 1,362.74 TIME AND ONS HALF(OT PAY) --- --------------- 421.95 ------------ ------------------------------ Total Gross: 942.00 16,726.72 Leave Hours Available: Balance: Paid Time Off (PTO) 0.00 l3randfathered Vacation 0.00 SUMMARY Totals: Current YTD Total gross 942.00 16,726.72 Total Taxes: 76.35 3,408.65 Net payments/Deductions 144.49- 1,766.13- Net Pay 721.16 11,551.94 Payment Details: Payroll Check 721.16 TAXES AND DEDUCTION3 Taxes: Current YTD Federal TX xithholding Tax 1,596.08 TX 8B Social Security Tax 54.23 991.16 TX 88 Medicare Tax 12.68 231.80 Pennsylvania TX xithholding Tax 416.95 TX SE IInemployment Tax 0.70 12.79 South Middlet TX xithholding Tax 8.74 159.87 Total Taxes: 76.35 3,408.65 Pre-Tax Deductions: Current YTD PR8-TAX MBDICAL INS 59.21 651.31 PRB-TAX DENTAL INS 6.71 73.81 PRE-TAX VISION INS 1.38 15.18 RSP DEDUCTION 16.84 325.61 Total Pre Tax Deductions: 86.14 1,065.91 Post-tax and Other Deductions: Current YTD LTD EMPLOYEB AFTER-TAX 38.82 RSP LOAN 1 27.14 307.69 Rqp I,O~ 2 26.21 298.71 UNITED xAY 5.00 55.00 ------------'---------- Post Tax ~ Other Deducts: 58.35 700.22 05/26/2010 8Q United Tel-PA Name: DBHRA PAYNE Pay Period: 05/02/2010 05/15/2010 Pay Date: 05/26/2010 Pers No: 00064830 Cost Center: T8569270 Pay Area: Bi-weekly Payroll Total Gross: 1,597.95 Pay Type: Regular Payroll Net Pay: 1,303.08 EARNINGS AND OTHER PAYMENTS Hours Current YTD SALARY NON-EXEMPT 8,134.84 SVBNZNG 9'78 STD 1001r PAY 80.00 1,583.20 4,432.96 PTO 1,068.20 GRANDPATHER VACATION 184.30 HOLIDAY 155.20 ADJIISTMENT OVSRTIMB %AGBS 14.75 14.75 SHORT TERM INCENTIVE 1,362.74 TIME AND ON8 HALP(OT PAY) 421.95 Total Gross: 1,597.95 15,784.72 Leave Hours Available: Balance: Paid Time Off (PTO) 23.75 Grandfathered Vacation 0.00 ------------------------------------------------------------ SUMMARY Totals: Current YTD Total gross 1,597.95 15,784.72 Total Taxes: 133.63 3,332.30 Net payments/Deductions 161.24- 1,621.64- Net Pay ------------------------- 1,303.08 ----------------------- 10,830.78 ------------ Paymeat Details: Payroll Check 1,303.08 TAXES AND DBDIICTIONS Taxes: Current YTD Federal TX %ithholding Tax 1,596.08 TX 88 Social Security Tax 94.90 936.93 TX EE Medicare Tax 22.19 219.12 Pennsylvania TX %ithholdinq Tax 416.95 TX 88 Unemployment Tax 1.23 12.09 South Middlet TX %ithholding Tax 15.31 151.13 Total Taxes: 133.63 3,332.30 Pre-Tax Deductions: Current YTD YR8-TAX MEDICAL INS 59.21 592.10 PRE-TAX DSNTAL INS 6.71 67.10 PR8-TAX VISION INS 1.38 13.80 RSP DSDIICTION ------- 31.66 ---------------- 306.77 ------------ ------------------------- Total Pre Tax Deductions: 98.96 979.77 Bost-tax and Other Deductions: Current YTD LTD EMPLOYES AFTER-TAX 3.93 38.82 RSP LOAN 1 27.14 280.55 RSP LOAN 2 26.21 272.50 UNITED %AY 5.00 50.00 --'------'------------- Post Tax & Other Deducts: 62.28 641.87 07.(2112010 15:40 716-938-2780 CATT CO JAIL PAGE 03106 W~G~Q~A. Deposit Account Close Confirmation (Debit) WACHOVIA BANK date Customer Name(s) and Address Taxpayer tD Number 05/21/2010 DEBRA A PAYNE 5086522416 11 HEATHER DR CARLISLE PA 17013 ACCOUNT NUMBPR: 3000073298312 Available Balance $213.60 + Accrued Int : $0.00 - Fed W/Hd Due : $0.00 - Admin Fee : $0.00 -Outstanding Db : $0,00 Closing Fee : $0.00 Paid To Customer : $26.60 Wachovia Bank and Wachovia Bank of Delaware are divisions of Wells Fergo Bank, N.A., Member FDtC. 98596 (Rcv 07) CUSTOMER COPY cmvranv[ n~ ~ ~ncm~n ~ vr+r muo r~.r+n Taxable $~•o~ hlon-Taxable X53.35 ~1~ ..... 93234 MG DEBRA A PAYNE 10578 MOODY ROAD CATTARAUGUS, NY 14719 This check represents a refund of an excess loan overpayment. Since our records indicate that your ban is no longer outstanding, this amount is being returned to you. ~~- ~x,~. s J~~ I~ o ~~~ .~ ~~~ imm~nnnmm~n n`0243578i73n• ~:03LL00380~: 005903ii1~• 'CME ORIr31NAL pgCUN1ENT iiAS A REfLECTNE WATERMARK ON THE BACK. H06D AT AN ANGtI= T41ftEVV~ WHEt~1 GHEGKINGI'rHE ENdQ!RSENrENT ° O o, ~ ~ ~ o = ~ d l ~ A C ~ $ ' ~ O S ~ 3 S ~ o m~ -~ v f oe ~ s ; ~~ ~ ~ o ~ ~ =~ ~- ~. O $ n s ~ ~ ~ 0 ~ ~ ~, y o ~ '"~ - ~ t - ~ m o ~ p. ~. 3 ~ ~ o ~ ~ O ~' m 3 ~ W ~, Vi A ~ ~ ~ ~ V V y N ~. O a 0 A Op O ~ c e ~+ O O ~~ ~~ ~ .~' g o ~~ p o :o O 1 0. o_ A ~ s o N ~m ~ om ~D~ mc~--~-~ooa a ~' ~ ~ `°- No ~ n ~ ~ ~, aNi 3 O ~~ O 10 m m~ 7= ay ~~~o~a ~ ~ ~ m w m -. ~ N ~ n. n °, m ~ cn m o o_ ~ O 1CD ~ ~ N ~ ~ °- ~' ~ p ~ ~I N C ~ O .3. N o ~, W ~ 1 O pA ~ N ~ O N ~ 10 (Op O N O ~? ~' ~ o ~ ~ • ; ~ 3 `° ' m ~~ . .. m N o "` U n' 111 ~ N N Q 4l'm o o a a 1-1 ~ V M ~ "' 3I o g Ni ~ ~_'. Vl Q O a C m p ~ W e O P o A A O 3 .i V ~o~ ~ D ~ ~ o ~ _ ~ w ~~m ° DOm = ~ cOz 0 C v ~ ~ ~ ~ ~ ~ o ~ = 8 Z=_ s V Z ~ ~ - t=f ~ ~ r~ v C -_ ~ o '°o = A -_ ~ N N cD~ ~~= o -i ~ ~D n m ~ a m S 0 OOT1 in to n: m A ~ ~ U~1 n O rn1v'n3 ~W,: Z c` ~~ y ~~ y ~ ~1 ®` m ~ N w N ~ 0 3 C ~ ~ ~ m w ~ o ~ 0 0 O ROyVE'S AUCTION SERVICE (RH 79L) 2505 Ritner Highway Carlisle, PA 17015 Bill Rowe (AU 1538L) 249-1978 697-4794 249-2677 Dave Rowe (AU 2295L) Auction Is Action Call "Rowe" For Satisfaction , s s "1 .- t , ., ~ ~ , .w,. , .. ~~ ~ ~ , ,. , ~': ~`' ;~,. ~. r ~~. ~;~, DATE ! ~ i ~ . SELLERS NAME `~ xG,~,k ~` - s ~,... ti _~ -~~`. ,- - , ,:. ~ i `w s' r , . ADDRESS ~-~~ ~~--,~.~ ~._~.::„~, ~ ,~: ~~,~~,~ ~.,. x°~ tip, PHONE ! r`~::~.: ~'~ t ~ K.~.; 49_ OTHER ~ `"?; ~' ,t>t ,_, ~..r, h , x._~ ~~ } AUCTIONEER % ~4{ _ .. t_ _ e ~ AUCTION DA'Z'E/LOCATION s, ~, ; { E 6 ~„ b., J !4 ~ ?~ r .. ~C--~ s +:'~ ~~~~ ~t ~`~ ~»' s'' CLERK % ,~ 'r .. ~ e~e~ w m k } a v ~~ ~^ x~ :.... 3d4~`t t ~`s+° -\ 2:~ .,l~ ~ ~C.::~ {'~:Yyr . f t~'t k:. Y3.,..~,'"''_ x7 "r~ i! `, ~,~ I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- tative of the merchandise, goods and or property and have good title and the right to sell and that they are free from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title~,lo the purchaser. L-agree to hold harmless the Auctioneers against any claims of the nature referred to in w this agreement. `" .`.-SUCTION I~NATURE SELLERS~'SIGNATURE Total Sales (Clerking Tickets Attached) $ ~-~" ' * `'~~ r ' ~,. j... Less Sale Expense: .-> . ~~~ , , ,~ ~ ,.a.. tt % Commission Auctioneer $ ~~~ "°`' % Commission Clerks $ OTHER: TOTAL SALE EXPENSE DEDUCTED $ SELLERS NET $ ~ - ~: ~~ DESCR~~TION O~ MERCHANDISE 'F~.,. ~ qtr ~f~-d., 'C4`ti ~ ,~'~ *~ ~w., , ; ~,...„~ r r SALES AGREEMENT THIS AGREEMENT made t '~ ~~" his ~ day of u , offal C~ , by and between ~ 5~~~4~ hereinafter referred to as "B R," and "S L ~ ~~n ~ ~~`~~ go ~ ,, hereinafter referred to as LER WITNESSETH THAT the BUYER accepts the sum of $ 0 ~ as settlement in f~ll, to purchase ~c~ehl ~ ~2 iRS iS serial number a i ~5" ~I- ,located at } ~ Q8 a -~-~ P12 ~ within Country Manor West. g~ ~- /o Date o~, P~~~ ~~~~ova 1. COMMONWEALTH OF PENN3Yta/ANIA REV-151f EX+ (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debra A. Payne 21-10-0534 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' Hoffman-Roth Funeral Home 219 N. Hanover Street Carlisle, PA 17013 7,286.60 2. Murry Express transport body to NY 200.00 3. Middlesex Diner Carlisle, PA 17013 funeral lunch 256.00 a. New York memorial lunch Chivetta BBQ-$192.25; Luigi-$99.05; Walmart-$67.68 358.98 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _ _ __ _ __ __ _ _ State _ ZIP _ _ _ Year(s) Commission Paid: 2. Attorney Fees: 2,500.00 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: 150.00 5. Accountant Fees: 6. Tax Return Preparer Fees: 85.00 ~• Advertise letters: Sentinel-$176.92 Cumberland Law Journal-$75.00 251.92 s. Postage 65.24 s. Purchase estate checks 18.00 TOTAL (Also enter on Line 9, Recapitulation) I $ 11,171.74 If more space is needed, use additional sheets of paper of the same size. ;! FUNERAL HOME ~ CREMATORY, INC Kathy Johnson 10578 Moody Road Cattaraugus, NY 14719 219 North Hanover Street Carlisle, Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 wwwhoffmcuuoth.com info@hoffrria~rroth.com July 23, 2010 Statement of Funeral Expenses for: Debra Ann Payne Date of Death: May 18, 2010 Account Id: 15949-123 PACKAGE: Traditional Funeral Service TRADITIONALFUNERAL SERVICE PACKAGE $ 4,350.00 Sub Total: $ 4,350.00 FACILITIES AND PROFESSIONAL SERVICES: F/H in New York $ 100.00 Sub Total: $ 100.00 MERCHANDISE: Casket: Kinsey $ 990.00 Outer Container: Cave Proof Box $ 975.00 Sub Total: $ 1,965.00 TOTAL FUNERAL HOME CHARGES: $ 6,415.00 CASH ADVANCES: . Forestville Cemetery $ 400.00 20 Certified Death Certificates at $ 6.00 each $ 120.00 Newspaper Notice -Sentinel $ 117.42 Newspaper Notice -Dunkirk Evening $ 75.18 ~ pl Flowers $ 159.00 -`, 'O G" Sub Total: $ 871.60 ~ Total Funeral Expense: ,p 7,286.60 Y ~~~/~~ ~~ a~~ m m m N ~H m Q O N m W .. {{yy W ~ W 00 ~ww ~ W VSS ~"~ ~ ~ ,w^ Y/ xu-, ~. 07 0.'"'x N YF M ~ Wpm rI ~ =x yF ~ ~~~ . . X a v °~Q x Wmd X ~ W °o$~ X O ~ ~ ~ X ~ mU X .-»a mN X ~ J ~ a= my ~ a C.1 xz XW ~'o. XJz..m ~ Q F- ~~ XQ~~.. .:. O ~~! ~~Nmo~ a ~ ..._. ~ 'G: r~ h ~ .:. C :~'• ;~' 1, r-. .... ~~ ... _~I t^, ~ ~J .'~.J r+. a ,, ~ ~ ~ n ~ ~ C~ rT ~, =~ :.,; t~ ti :V Q W s r' ..., C V _~, v r~ r ~ ~; ~~ ys. e4r Te :rW x C/ .~. ~~. Ire ~ - `~ r. r. ~ t -J ~ G ~ g +r ~ ~~ : Z ..-. ,~~ _ ~ ~~ ._~r~ ~•A ..i-/ ~, ~~,~ ~.'.` ~. L~ ~_ N a ~ =i ~ L' ~. . . .u a ~: I.L ~ j THAN?i '/OU Waimart:°:.. Save money. Live better. Yelaart MANAGER MICHAEL MARLOR ( 716 ) 592 - 1460 ST8 2164 OP8 00006266 TE8 06 TR8 01054 CANNING JARS 001440060000 6.00 X CANNING JARS 001440060000 6.00 X( 1 CANNING JARS 001440060000 6.00 X' CANNING JARS 001440060000 6.00 X CANNING JARS 001440060000 6.00 X ** VOIDED ENTRY ** CANNING JARS 001440060000 6.00-X SC 15PK 1002 068113178113 F 2.00 NY DEP FEE 007874239424 F 0.60 0 SC 15PK 1002 068113178113 F 2.00 X NY DEP FEE 007874239424 F 0.60 0 SC 15PK 1002 068113178113 2.00 X EE 007874239424 ,60 0 12PK 00787421017 F .50 X FEE 06053885881 F ~ .60 0 STUP 0078742024 F ` .50 X 5L GOLR 00787424301 DEPOSIT FEE 060538858819 BUD LT BER 001820063030 NY30PKBLDEP 068113172226 F DOMINO SUGAR 004920004754 F OOMINO SUGAR 004920004754 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SJ PECTIN 004300029320 F SKS CHK LGHT 008000001660 F SUBTOTAL TAX 1 8.750 % TOTAL MCARD TEND ACCOUNT 11966 APPROVAL 8092160 PAYMENT SERVICE - A CHANGE DUE FEE 06063886881 F~Q .60 0 EE 0078742394 4 F 0 60 0 2PK 0078742209 7 F [~~ 2 50 X FEE 0605388588 6 F` \ 0 00 0 OLA 0078742209 F 2 50 X .98 X 1.20 0 19.97 T .5. ;i 1 5.4u 6.98 N 2.04 0 2.04 0 2.04 0 2.04 0 2.04 0 2.04 0 2.04 0 2.04 0 2.04 0 2.04 0 9.27 0, 112.48 5.60 118.08 118.08 0.00 # ITEMS SOLD 35 J~~ TC8 1934 1176 0110 9048 0834 1 IIIIINIIIIIIIIIIIIII~IIIIIIIINIIIIIINIIINIIIIIIIIbII~IIIIIi!!III!IIIIlIIIIIIIIIIIII We want aou to Paa the lowest Price: Ask about our Price catch Policy. 06/21/10 18:33:38 +~aaCt;STOMER COPY*** *****a+~aa***aa**e***aea**~r*****r~*~r*** ATTENTION CUSTOMERS **a*a*s*e*^****ee*ee*a**aae**sea**ee* Effective 03/20/08 All Cuato~era aPPearlns to be under the ace of 40 will be asked to Provide Proof of ase by ahowins Proper id. Custo~ers under lesal ace or without Proper id, will,not be, CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (71 ~ 249186 Fax: (717) 249-2683 June 11, 2010 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Jacqueline M. Verney, Esquire Debra Ann Payne Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: May 28, June 4, and June 11, 2010 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTI3 OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was. printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: May 28, June 4, & June 11, 2010 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. • _ ~ rt ~~ - 'isa arie Coyne, Ed~ r SWORN TO AND SUBSCRIBED before me this 11 day of June, 2010 Notary Payae, Debra Ann, deed. Late of North Middleton Town- ship. Executrix: Kathleen M. Johnson c/o Jacqueline M. Verney, Es- quire, 44 South Hanover Street, NOTARIAL SEAL Carlisle, PA 17013. DEBORAH A COLLINS Attorney: Jacqueline M. Verney, Notary Public Esquire, 44 South Hanover Street, Carlisle, PA 17013. CARLISLE BOROUGH, CUMBERLAND COUNTY My Commission Expiroa Apr 26, 2014 The. Sen#inel www.cvmb~rllak,co,m CI ~~.: cnruse ~ rr~xr coixnr JACQUELINE M. VERNEY 44 SOUTH HANOVER STREET CARLISLE, PA 17013 717-243-9190 AD NUMBER PAGE NO. 384307 1 of 1 BILL DATE SALESPERSON 06/07H 0 wolfs START DATE STOP DATE 05/24/10 06/07/10 AD NUWBER AD DESCRIPTION CLASS LINES 384307 EXECUTRIX NOTICE LETTERS TESTAMENT 10 PUBLIC NOTICES 32 * 2 cola Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $169.92 TOTAL AD CHARGE $169.92 3 PROOF OF PUBLICATION 01 PRF $7.00 Purchase Order Est.DebraPayne PAY THIS AMOUNT $176.92 $212.30* *AFTER 07/02110 Thank you for advertising with The Sentinel! Deadline for in-column legal ads is 4:00 p.m. two business days prior to date of insertion. For questions, call (717) 240-7130. THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 oooan ~ JACQUELINE M. VERNEY 44 SOUTH HANOVER STREET CARLISLE, PA 17013 rce[urn muc porcron wpm your paymenr Check # ~ Credit Card ^®^p^®o Acct #: Ems. Date: m m Name on credit card Signature Please make checks oavaWe to: THE SENTINEL clo LEE NEWSPAPERS PO BOX 540 WATERLOO IA 507040540 Legal THE SENTINEL c/o LEE NEWSPAPERS PO BOX 742548 CINCINNATI OH 45274-2548 ~i~n~~~r~ur~r~~nr~r~u~n~r~~~r~n~rr~~n~n~n~~n~~~n~~) 215402DD000003843D70D00000000000002123000000176926 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tames IQeinklaus, Director of Sales and Marketing, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): May 24, May 31 and Tune 7, 2010 COPY OF NOTICE OF PUBLICATION ~, EXECUTRIX N ICE Letters Testamentary on the Estate of DEBRA ANN PAYNE, late of the Township of North Middleton, Cumberland County, Pennsylvania, deceased,-have been granted to the undersigned. All persons knowing themselves to be indebted to said Estate will make payment Immediately, ahd those having,ciaims will present them for settlement. Jacqueline M. Vemey Attorney for Executrix Jecqueiine M. Verney, Attomey 44 South Hanover Street G'arlisle, PA 17013 Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. Sworn to and subscribed before me this I~~A~ ~' 111 ~(lA A ~,n~ n c~~k~A~- Notary Public My commission expires: NOTARIAL SEAL BAMBI ANN HECKENOORN Notuy Public CARLISLE BOROUGH, CUMBERLAND CNN My Commission Expires Jan 27. 2014 REV-1512 EX+ (12-48) ~ Pennsylvania SCHEDULE I DEPARTMENT DF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ___ ESTATE OF FILE NUMBER ebra A. Payne 21-10-0534 D _ 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~ 2008 taxes to Cumberland County Tax Claim Bureau 676.63 2. 2009 taxes to Cumberland County Tax Claim Bureau 685.05 3. 2010 taxes to Robin Sollenberger, North Middleton tax collector $108.38 + $454.17=$562.55 562.55 4. Northwest Consumer Discount 223 Penrose Place Carlisle, PA 17013 mobile home lien 1,119.05 5. Blue Mountain Anesthesia Assoc P.O. Box 947 Chambersburg, PA 17201 49.50 6. Health Network Lab 2024 Lehigh St Allentown, PA 40.75 7. Carlisle Regional Medical Center 45 Sprint Dr. Carlisle, PA 17013 1,472.38 8. Carlisle HMA Physician Mgt P.O. Box 281629 Atlanta GA 383.40 9. Carlisle HMA Physicain Mgt P.0 Box 281629 Atlanta GA 155.47 10. Carlisle HMA Physician Mgt P.O. Box 281629 Atlanta Ga 38.50 11. MCM P.O. Box 60578 Los Angeles CA 90060 1,151.83 12. Sprint cell phone 81.52 13. Centurylink home telephone 214.77 14. North Middleton Authority watelsewer 115.87 15. Dauphin Oil Co propane 68.61 16. PP&L electirc service $343.41 + $385.65 $729.06 729.06 17. Northview Manor Management LLC mobile home lot rent JuneJuly $445.00 + $390.00- $43.70(credit 791.30 TOTAL (Also enter on Line 10TOTAL (Also enter on Line l0, Recapitulation)~$ 8,336.248,336.24 If more space is needed, insert additional sheets of the same size. ~4 is ~. l ~` O ~ .tY~ ~~ c~ m k ~.~ 'I G M rY ~- j1° , I I' i i 1 4 t~s (~1 x .~ C.y 4;.~ '•' ~ ~ ° ; q ~ ~ ~~ ~Ow ~~' ~~ in ~ _ m =Q ~~ .: A i.n :: x. F~ ~ ~~ ... ~ J ~ ~- s ~; ~~ ~`" ~ ~~ , r ~`i ~y ,,+~ < h' ~v o -~% r ~`t 4.:. TJ: yr.. . '~"~lra5%.: tJ 2 ~ a.. ..<d::q ,5.. .. } W .. ~t'.k i S I" ~' a a ~~ ~ ~'$ s r ~ rr ~~ d ~: ~. ~ ~~C ^:,, . ,' a, T ~.. n S D a m Z 7C r, , ~:'<;;; ~: /`'-[ ~~' O ,. ~,~ '',z ~. ".F-": ~" ~ w>a 1,~, ,aj~ Z,., ~~ ~ ~~ F_ ~ y ~~ / ~~ V ~6~ o J7 ~,~~s " ~ Y J~;; 3 ' , ti . , ~ ,..: v ~ N ~^ GARY EICHELBERGER CHAIRMAN RICHARD ROVEGNO VICE CHAIRMAN BARBARA B. CROSS SECRETARY Printed: 8/04/10 C 12:20:45 Control Number: 29-001643 PAYNE, DEBRA C/O KATHLEEN M JOHNSON 10578 MOODY ROAD CATTARAUGUS NY 14719 Map No: 29-15-1251-056 DENNIS MARION CHIEF OPERATIONS OFFICER EDWARD SCHORPP SOLICITOR STEPHEN D. TILEY ASSISTANT SOLICITOR Receipt No.: 76655 Receipt Date: 8/04/2010 **** RECEIPT **** Page: 1 Property Description: NORTH VIEW MANOR LOT 23 Mobile Home - No Land Situs Information: 11 HEATHER DRIVE & TOWER CIRCLE TR07947 NORTH MIDDLETON TOWNSHIP Tax Year Description 2009 CTY-NORTH MIDDLETON 2009 CLB-NORTH MIDDLETON 2009 MUN-NORTH MIDDLETON 2009 SCH-CARLISLE AREA 2009 BUREAU COSTS Penalty & Face Interest Costs 74.97 11.42 5.63 .84 27.78 4.25 447.81 68.30 15.00 29.05 Received For Year Of 2009 Tendered > CHECK Received By > JC Paid By > PAYNE, DEBRA ESTATE Remarks > 1403719219 TAX CLAIM BUREAU OF CUMBERLAND COUNTY One Courthouse Square, Room 106, Carlisle, PA 1 701 3-3 389 (717) 240-6366 Receipt Number: 76655 Total Received Total 86.39 6.47 32.03 516.11 29.05 $685.05 $685.05 Balance Due As Of 8/04/2010 Claim Balance: .00 Total Received: $685.05 Northwest Consumer Discount Company 223 Penrose Place Carlisle PA 17013 Payoff Receipt Customer Information PAYNE, DEBRA A. 11 HEATHER DRIVE CARLISLE PA 17013 Payment Information Date: 6/17/2010 Time: 13:31:26:236 User: Cindy L Hoover Workstation: QPADEVOOIN Type: 20 Payoff Cash Tendered 1,120.05 Payment Amount 1,119.05 Change Due Cash 1.00 Loan Information Loan Number 492-188708-3 Next Payment Due 11/06/2011 Old Balance 1,083.65 Principal Paid 1,083.65 Interest Paid 69.87 ~`' Current Balance .00 NORTHWEST CONSUMER DISCOUNT COMPANY AND SUBSIDIARIES RECEIVED FROM '^ ~+ DATE ~ ~ ~ 7 -~ D n v -S-u~ ~ Yom, a ~,C, DOLLARS$~ I Q. D$~ FOR LOAN # ~ - ~-3 AMOUNT RECEIVED $ 1 /~D .OS NEW BALANCE $ " ~ ' AMOUNT OF PAYMENT$ II l~1•D.~ CHANGE $ , Q(~ ~~Qn~ ~OU~ ~-zoz ~H D CHECK ^ M.O. BY~_~ ^r rw.~w o^ `wcv~• ~wwv~ r~cwac rRS.~vuR 4aca.vv~ BLUE MOUNTAIN ANESTHESIA ASSOC PO BOX 947 CHAMBERSBURG, PA 17201-0947 RETURN SERVICE REQUESTED (800)827-3458 8407 8AM-4PM CHAM-BMA ADDRESSEE: 15527 DEBRA A PAYNE 11 HEATHER DR CARLISLE, PA 17013-9629 1111""l~'IIIIt~Xl~~lll'I'~I'~1~11~1~111'~1~111111~1~1~111~1~111 ts2ts CHECK CARD USING FOR PAYMENT Mi.fMCi ~ t~A' ®MASTERCARD ®V13A GRD NUMBER SECURITY CODE SIGNITURE AMOUNT EXP. p1TE STATEMENT DATE PAY THIS AMOUNT ` ' ACCQUNT NQ 5/01/10 49.50 19243-G CHARGES AND CREDITS MADE AFTER STATEMENT DATE WILL APPEAR ON NEXT STATEMENT. SHOW AMOUNT PAID HERE MAKE CHECKS PAYABLE / REMIT TO: BLUE MOUNTAIN ANESTHESIA ASSOC PO BOX 947 CHAMBERSBURG, PA 17201-0947 IIIIIIIIIIIII'illllllllllllllllllllll'11I I111'Illlllllll'Il~il Please check box if above address is incorrect or insurance PLEASE DETACH AND RETURN TOP PORTION-WITH Information has changed, and indicate change(s) on reverse slde. ~ YOUR PAYMENT IN ENCLOSED ENVELOPE 04/i2/10 00912 DEBRA A ANES TRANSURETHRAL RESECTION OF BLAD 675.00 49.50 fit]WARO ALSTER 04/28/10 DEBRA A ,Payment HIGHMARK SS PREMIER BLU i98.00~ _ 364 ALEXANDER SPRING RD 04/28/10 dEBRA A BLUE SHIELD'AOJUSTMENT 427:50- .Please Pay 49.50 YOUR"CLAIM HAS BEEN SUBMITTED TO YOUR INSURANCE COMPANY. THE BLUE MOUNTAIN ANESTHESIA ASSOC PO BOX 947 REMAINING BALANCE IS YOUR RESPONSIBILITY. PAYMENT 15 DUE CHAMBER56URG, PA 17201-0947 WITHIN 30 DAYS. (800)827-3458 X407 8AM-4PM STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 15527 17216 01101 RR30-Ol) F02 L0034Bi4 STOCK • F-AA Health Network LABORATORIES 2024 LEHIGH STREET ALLENTOWN, PA 18103 Toll Free: 877-402-4221 Phone: 610-402-8170 Fax: 610-402-7661 Tax ID: 23-2948774 DOS: 04/07!10 Patient Name: DEBRA A PAYNE ADDRESSEE: DEBRA A PAYNE ~~ 11 HEATHER DR CARLISLE PA If PAYINGI~ By~,Y~~~V~I,,,SA OR NASTERCARD. FUl OUT BELOW ^VI6A ~ ^MnSTERCARD CnRD NDNBfA ANpIM 8~~ E%I. NOTE STATEMENT DATE PAY THIS AMOUNT ACCOUNT NO. 04/22/2010 540.75 208L49184-0 CHARGES AND CREDRS MADE AFTER STATEMENT DATE WILL APPEAR ON NEXT STATEMENT. SHOW AMOUNT PAID HERE ~~ MAKE CHECKS PAYABLE / REMIT TO: ~~ 0400-18 ~u~~~~i~nu~~~~ui~~u~1~~~u~~~~~~n~nu~~~~u~~~nuu~~~ HEALTH NETWORK LABORATORIES 17013-9629 PO BOX 8500,LOCKBOX # 9581 PHILADELPHIA, PA 19178-9581 00208L4918400000407500040710 7 ^ Please check box if above address is incorrect or insurance Information has changed, and indicate change(s) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE Physician: RYAN C CRIM Diagnosis Code: 780.79,783.21,626.2 Date Procedure Code Description Amount 04/07/10 36415 PHLEBOTOMY CHARGE 8 00 04/07/10 80053 COMP METB PANEL . 32 36 09/07/10 84443 TSH . 51 21 04/07/10 85025 COMPLETE BLOOD COUNT . 21 06 04/07/10 BSPA NOT APPROVED (04/20/2010, BSPA, 2, 5283, . _2 25 04/07/10 ~ BSPA-NOT APPROVED (04/20/2010, BSPA, 2, 5286, . -69.63 Current 31-60 Days 61-90 Da s 91-120 Da s 121-180 Days Over 180 Days Amount D $40 7 ue: . 5 $40 75 . _ $0.00 $0.00 $0.00 $0.00 $0.00 HEALTH NETWORK LABORATORIES PO BOX 8500,LOCKBOX # 9581 PHILADELPHIA, PA 19178-9581 If you have provided insurance information,these charges have Tax ID: 23-2948774 been submitted. This. balance represents the amount due from you Billing questions call: 610-402170 due to partial payment, orlack of response from your carrier. BSPA DEDUCTIBLE $40.75 Account Number: 208L49184-0 Patient Name: DEBRA A PAYNE STATEMENT ~IIIII~I~~~A~III~I SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 18 •~ ~ ~ ~ - ~ ~ T * ~~~ 007852 858HMA 000068R Rl~.f'11'CL,( 1 ~L..~~O~L 45 Sprint Drive IF PAYING BY CREDIT CARD, FlLL OUT BELOW AND SEE REVERSE SIDE - MEDICAL CENTER Carlisle, PA 17013 ADDRESS SERVICE REpUESTED '' ~ ~ UPON RECEIPT Debra A Payne 11 Heather Drive Carlisle PA 17013 ~n~~~~~n~~~unu~~n~~w~~~m~~~u~~i~~~~nm~~m~~~~n~~ ° ° ~ ^ MASTERCARD ®DISCOVER ~ VISA ~ ', '. AMERICAN EXPRESS ACCOUNT NO. 'STATEMENT DATE BALANCE DUE ~ , ~ 94b189b ~ 05/31/20101 $1,472.38 MAKE CHECKS PAYABLE TO: CARLISLE REGIONAL MEDICAL CENTER P.O. BOX 281442 ATLANTA GA 30384-1442 ~n~~~~~um~~~~u~n~n~m~~~~n~~~n~u~~~~~n~n~~~~~~~~~ 0000094618960000D147238DEBRA A PAYNE 6 ^ Please check if above address is incorrect and indicate change on reverse side. TO INSURE PROPER CREDIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. -- PATIENT NAM PATIENT ACCOUNT N0. QATE OF SERVICE TYPE OF SE VICE Debra A Payne 946189b 04/08/2010 INPATIENT DATE DESCRIPTION PAYMENT/ADJUSTMENTS. 05/05/10 BLUE CROSS CONTRACTUAL DISCOUNT 05/05/10 BLUE CROSS PAYMENT 47,522.09- 05/17l10.: PATIENT PAYMENT 1I,305.b2- 125.00- PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT. ~ ~ '' ~ S1, 472.38 MESSAGES The amount shown on this statement is outstanding at FOR BILLING GIUESTIONS, PLEASE LL: this time. Your prompt paymenfiwii be greatiy (717) 960-1680 appreciated. Bills can be paid online at our hospital Internet web site www.carlislermc.com ~' ~ PON RECEIPT ° 758872 STATEMENT PAYMENT 'OPTIONS 'C'ARLISLE F3MA PHYSICIAN MANAGE>v1 Check #__ Amt $-_ PO BOX 281629 - ATLANTA, GA 303891629 RETURN SERVICE REQUESTED vlaola o71 539aD THaa Please Include Securit Code From Back Of Card CHECK CARD USING FOR PAYMENT MASTERCARD VISA OSA ® OSCOVER CARD NUMBER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT REMIT TO: CARLISLE HMA PHYSICIAN MANAGEM >00259 7653672 001 092096 PO BOX 281629 DEBRA A PAYNE i••~•: ATLANTA GA 30384-1629 10578 MOODY RD CATTARAUGUS NY 14719-9760 ~„~~,~~,,,,,~~,~„~„~„~,~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PLEASE RETURRI THIS PORTION WITH PAYMENI Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT ~ Q~ 717 519-0753 07/22/10 758872 1 CONTINUED PAID HERE 1J ' ------------------------------------------------------------------------------------------------------------------- CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT ~~ 040810HAGGAG MD HOSPITAL CARE INV#:1 ~zPAYNE,DEBRA AMOUNT APPLIED TO DEDUCTIBLE $130,:00 '_042110 ~ BLIIE SHIELD PAYMENT 0 9 2110 ,' BLIIE SHIELD ADJUSTMENT , . ' Insurance Balancer 0.00 - Patient 041010-IiAGGAG 11dII HOSPITAL CARE INV#:2 PAYNE,DEBRA AMOUNT TO BE PAID BY CO INS -$15:-00 ' 042110 BLUE SHIELD PAY119ENT -'0421.10 BLUE SHIELD ADJUSTMENT Insurance Balance: 0.00 Patient 040910'HAGGAG MD HOSPITAL CARE INV#:3 .:PAYNE,DEBRA ' AMOUNT APPLIEb TO DEDUCTIBLE $75.,Q0 :042110 BLUE SHIELD-PAYMENT. 260.00 0.00- - -130.00" Balance: 130.00 129 .'00 -60.00'. 54.00 Balance: ' 15.00 129.00 ;042110 BLUE. SHIELD ADJUSTMENT Insurance Balance: 0.00 ~ Patient Balaflce: 041110HAGGAG,MD"_" HOSPITAL CARE INV#:4 ~.FAYNE,DEBRA=: 129.00 _ AMOUNT APPLIED TO DEDUCTIBLE $54:25 AMOUNT TO $E PAID BY CO INS $4:~5;: ~z042110 BLUE SHIELD PAYMENT. :;042110 ~ BLUE SHIELD ADJUSTMENT Insurance Balance: 0:00` Patient Balance: 041210.ACRI D0 HOSPITAL CARE INV#:5 ~PI~YNE,DEBRA 129.fl0 \ AMOUNT TO $E PAID BY CO INS $15.'00 " 0.00 -54.00' -16.60 54.00" 75.80 58.40 Statement Date: 07 / 22 / 10 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 7 5 8 872 .; PATIENT BALANCE PAY THIS AMOUNT _ CONTINUED SE~f~INZ~cftF~l~SfPI~YYvIFNiS-'f0: }~~'~ s n a ', ry ~ ° AC r ~. PO"~..BO~C `,? ~$ j:fi`'? k. ~ ~ ~_ ~ I '~ All i~npaic'1 b~aricaa~ vrill }~ ATLIINTA„ ~©1~ $038~t~.G~29 ~ _ i' °~ ~ sett: ;to a .col:teCtion-.a.gency 727-,~1.5° .~7.',~~ ~ '~` ~" ° `` - ~ _ a ~-"- and a1~~~~olle~taon7-leg~~.~`feea - will'be-your =esponsib2ity. 00259 7653672 Q00776 000776 00001!00003 90966902 759258 I PAYMENT OPTIONS STATEMENT Check # Amt s CARLISLE HINA PHYSICIAN MANAGEM FO BOX 281629 ATLANTA, GA 303841629 V1aoaD 080 539aD Please Include Securit Code From Bac wEa 3 CHECK CARD USING FOR PAYMENT ^ yam; ~ RETURN SERVICE Fit;, QUESTED ~ MASTERCARD ~ VISA CARD NUMBER CARDHOLDER NAME DEBRA A PAYNE ® ^DISCOVER EXP. DATE SECURITY CODE REMIT TO: CARLISLE HMA PHYSICIAN MANAGEM PO BOX 281629 ~rrY~•L ATLANTA GA 30384-1629 • I~~II~II~~~~~II~I~~Ir~l~~l~~~llrll~~~~l~ll~l~~~~l~li~l~~~~ll~i PLEASE RETURN THIS PORTION WITH PAYMENT Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT 717 519-0753 06/23/10 759258 2 155.47 PAID HERE ~ ___ --------------------------------------------------------------------------------------------------- CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT ~~ 042110 BLIIE SHIELD PAY~QENT -•345.87 042110 BLIIE SHIELD ADJIISTMENT -344.66 052610 BLIIE. SHIELD PAYMENT 345.87 ' 052610 INTEREST PAY -0.55 ' 052610 BLIIE SHIELD PAYMENT -470.87 052610 BLIIE SHIELD ADJOSTBSENT 344.6.6 052610 BLIIE SHIELD ADJIISTMENT -344.66 05261b ~ INTEREST ADJ. 0.55 IF%surance Balances. 0.00 Patient Balance: 8.6.47 t Statement PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 759258 Date: 0 6 / 2 3 / 10 „_ ,., Current 31-60 `Days 61-90 .Days >90 Days - PATIENT BALANC Total Ins Pending PAVTHISAMOUr° :86.4_. Sfl.00 51.Otf 0.00 155..47 0.00 - -.155.47 SENF3 i'~~'~E?AYFr~tsFLS`Tb f ;. ~ ~ r~. c'ART,x§LE HISA:,,FHYSICIAN 1l~AI~P,GEM ~ .'_ - - F Pb'.~o~C281~~29 ~~ s ATLAN~b,, .dA~~a3,~,4.~629 717 52g=075'3 ' °~ . 00007 7627343 000015 000015 p0002n00002 -. ... ... - -- - - - - -' --... ----- -- --...._,....~ ...............e.,. 92096= 759573 STATEMENT PAY'!l4ENT OPTIONS CARLISLE HMA PHYSICIAN MANAC,~t Check # pmt $ PO BOX 281629 ATLANTA, GA 303841629 RETURN SERVICE REQUESTED >21533 7636D29 DD1 D92D96 DEBRA A PAYNE 10578 MOODY RD CATTARAUGUS NY 14719-9760 Current 31-60 Bays 61-90 Days Q:00 0.00 ?38.50 CaRF~2SLL •H>lSJi ~ t ~, PO ~'B~>]C'' ~ 9 ~'~~ ~ 1.TL1~tNg~i, `~¢ti 3 ~3 s z tsar 7s~ozs a2tsaa o2~s3a oovb viaoiz o7a 539aD 3A03 REMIT TO: Please Include Securit Code From Back Of Card CHECK CARD USfNG FOR PAYMENT M^ASTERCARD YlSA OgA ®O SCOVER CARD NUMBER E%P.DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT CARLISLE HMA PHYSICIAN MANAGEM PO BOX 281629 ATLANTA GA 30384-1629 I~~II~II~~~~~II~I~~I~~I~~I~~~Ii~il~~~~l~ll~l~~~~l~ll~l~~~~ll~l `>50 -Days Total 0.00 .~ .°~ . ~..~ .- ~.r . i.Y~ ~ ._ ~~: 154.OU -a30.OfF Ins Pending] 759573 38.50 .50. :. 0.00 38.50 ;'t `cif I I .-be ~-your '~es'pQ>i ~.; .: D01 ,8266902 NOTE: Charges and Haul„>.,*~ .,..f ~ .............. __ .~._ _._.___ _. ... PLEASE RETURN THIS PORTION WITH PAYMEN-~ Office Phone Number Statement Date Your Account Number Page No. Patient Balance 717 519-0753 07/Oa/10 759573 1 SHOW AMOUNT 38.50 PAID HERE -------------------------------------------- ______ CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT ~ --- -- ~~ Dept. 12421 C m PO Box 603 ~"~~" Oaks, PA 19456 11111111 NNIIAIIIIIl II IIIIIH IIIHIIIIIIIIIIIIIIIIIIIIIIII IIIIIIH IIIIIIII IIII I III 05-21-2010 #BWNHLTH #0000 0853 4125 3681 # DEBRA A PAYNE ~~ 11 HEATHER DR CARLISLE, PA 17013-9629 r1ca~ r7F_BRA. Hours of Operation: ~"' eezs M-Th 6am - 7pm; Fri Gam - 5pm; Sat Gam -Noon PST ~a ~. ~,~ !°rd .Option 3: To hear more options, call one of our Account Managers. your credit report will be ,updated as `Paid in Full'!* CALL US TODAY! (800) 282-2644 Sincerely, Midland Credit Management (800) 282-2644 PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION * Your credit report will not be updated if the federal reporting period has expired. Please tear off and return lower portion with payment in the envelope provided ~~ ~ ~~ MCM Account No.: 8534125368 Original Account No.: 5440455038952142 Current Balance: $1,151.83 Payment Due Date: 06-20-2010 Amount Enclosed: Payment Options: 1) Mail in this coupon with your payment 2) Pay by phone (800) 282-2644 Make Check Payable to: Midland Credit Management, Inc. 111CI11Midland Credit Management, Inc. P.O. Box 60578 Los Angeles, CA 90060-0578 PO BOX 3827 ENGLEWOOD CO 80155-3827 #BWNKCTX #0000 0570977110 B 2# 0610 Sprint~- AB 01 059797 21024 H 194 A Your Account Information DEBRA PAYNE 11 HEATHER DR Account Number: 570977110 CARLISLE PA 17013-9629 Date: June 15, 2010 Amourrt Dua: $81.52 'I'FIIIIIIII'IIIII'IIIIIIIJI'lllllll'I"I"IIIIIII111111"II YOUR REQUEST IS COMPLETE On behalf of Sprint, please accept our condolences for your loss. Per your request, account . 570977110 has been cancelled. We have applied the appropriate adjustments and waived all associated early termination fees. An unpaid balance remains on the account. Please mail your payment today to the address below, referencing the account number on your payment to ensure proper credit. If you prefer, you may call us at (800) 456-6070 to discuss your payment options with a Finance Services Representative. Sprint utilizes NCOg"" as an outside collection agency that specializes in estate and probate matters. They may contact you if further correspondence is required. Please g/w this matter your promFt attention. Make your check payable to Sprint and mail it wlUt the Coupon below in the enCk~sed ernrek~pe. Amount Duo: 3$1.52 Sincerely, Pat R. Sprint Credit Compliance Note: This letter is an attempt to collect a debt owed to Sprint Any information obtained will be used for that purpose only. Credit Compllanca Hours of Operation Monday-Friday: 8 a.m. to 5 p.m. Central Tim IMPORTANT: TO INSURE PROPER CREDIT, PLEASE RETURN THIS LOWER PORTION TOGETHER WITH YOUR REMITTANCE. DEBRA PAYNE 11 HEATHER DR CARLISLE PA 17013 Your Account Information Account Number: 570977110 Amount Dua: $81.52 PO BOX 54977 LOS ANGELES CA 90054-0977 III~~III1111"'II"11'11111"11"'I"111'1111"II'III'IIIII11~1~1 m x 0 w __...,.,.,, , ~ nnnnflt 1 44 nnnnnL9San fl^OD081528 .~~- ~--~-~ CenturyLink° Page 1 of 6 Monthly Statement Account Number June 13, 2010 717-249-4857-260 Payment Options & Contact Info Current Charges At-A-Glance Retail Store in Your Area a See Centurylink Website CenturyLink Services Total Pay Online ~ Local and Optional Services -Page 3 CENTURYLINK.com/myaccount -7.12 Pay by Phone ~ Internet -Page 3 1-877-813-7604 -7.49 Customer Service Long Distance -Page 3 1-800-829-8009 3.50 Repair Service ~~ Entertainment -Page 4 -26.00 1-800-788-3600 Internet Address Taxes and Surcharges -Page 5 2.30 CENTURYLINK.com/residential _:::::::: - :::_:..:_,::::::::.___,:.:::: _ .................... r :: ::_ : - ~ :_:::,:::::__::::_.::::::_::::::-:..__._.... _._._.......:....... ~.:: __: _::..:. _.._ s. _ ::::::....:::._:_ Total Current Ch ~--::.::.::.:.-_..:.: _-_ .........: - -T-== - - g ;:::: _._ ....._-.:_....:.-:a._........_._:::-_.......__.... ~__......~.._...... ~.._..a _._.......__.:___-._._:.. ...... _.__............_.:. c:u::::::......_._... _....._ ..__....__-...._......__.. __..... _.-...Y.-::-.:::-:ac_s_-::_:c_-:::::.-....___~.x-.::... _...__......._._...._......:.....___- _.._~-:e:a:-_:_:::u:_....__.__:u......_.... - ..... ......... _... .._......A.___-...-__...._..::n::::.____:::-:v..e..vs~~:5ie:_._...._._..s......_....:.._......_._.._........_.-=:_a:_i _._:ie _.ue:i:i-. Previous Balance Payments & Adjustments Past Due, Please Pay Now Total Current Charges Total Amount Due 249.58 I .00 I 249.58 I -34.81 ~ ~2 7 4.77 Current Charges Due By: 07/07/10 If received after July 13: $217.37 6 ® Please Recycle `„~ Please return this portion with payment Customer Service Internet Address Account Number ~11~ 1-800-829-8009 CENTURYLINK.com/residential 717-249-4857.260 ^ Please pay past.due amount of CenturyL~nkTM $214.77 immediately Total Amount Due: $214 77 $217.37 if received after July 13 Amount Enclosed: MB 01 057920 88130 B 236 A "1111'11"'1111"I11'Il'1111111'I'1'1111111""11111111'1111"11 Mrake checks payable to beroncheck ESTATE OF DEBRA PAYNE 10578 MOODY RD CenturyLink CATTARAU G U S, NY 14719-9760 PO Box 96064 Charlotte NC 28296-0064 ~IIIIIIIIII~I1i1~111„~111~nllllnl'In'I'lllll'n11111~~11 M n °~ 12 71724948572606 00000000003481 000214777 0000005 NORTH MIDDLETON AUTHORITY 240 CLEARWATER DRIVE CARLISLE, PA 17013-1100 (717) 243-8269 ' 11 HEA HER DR 7/1/2010 .[ ~*- 12000810 0 04/16/2010 ;06/15/2010 . ; ~~, ~7` 1 1051000 1060000 9000 Actual Previous Balance 250.15 Payments -205.39 Adjustments -44.76 Penalty 0.00 Sewer Service 71.58 Water Service 44.29 Pay Before 07/30/10 115.87 Pay After Due Date 121.66 Office will be Gosed on Monday, July 5, ' 2010. ~ur~~~ni ~ ~/,~/~~ ccrr r 30 O DAY 90 & O o :~a' ~`• 6 4~.- .4 NCE CHARGE ON ACCOUNTS OVER 30 DAYS. THLS RATE AppLIES TO I DAUPHIN OIL CO., INC. • DEBBIE PAYME 11 HEATHER DR CARLISLE PA 17013 CURRENT ~ BUDGET ; ~ PAYME , . 0 0 _ ,, LANCES OVER 30 DAYS FROM INVOICE DE LE, PA 17013 • (717) 243-5515 NON-BUDGET '~~J DEBBIE PAYME 11 HEATHER DR CARLISLE PA 17013 AMOUNT ENCLOSED $ .~.wo~ce o•.ossirb~n cA.cRmrc.+uMO aee.~uyce.toa~wurorpArMeHr usoax.~urcr.~.wwpn rcvn~uNCSCiuecs P7:EASEDETAGHANDRET[JRNTHZSTUPSTUB~VFTHYOURPAYMEN7 Beginning Balance 68.61 a ~ t~ ~~ u r~ ~~ / 9, = f~-, ,t- ~ , i ~~ 1VT 30 DAYS 60 DAYS 90 DAYS & OVIIt 0.0 0.00 1.0 67.6 CE CHARGE ON ACCOUNTS OVER 30 DAYS. THIS RATE APPLIES TO F DAUPHIN OIL CO., INC. • BUDGET • NON-BUDGET PAYMENTS CHARGES 0.00 0.0 0.0 LANCES OVER 30 DAYS FROM INVOICE DATE. ANNUAL PEf LE, PA 17013 • (717j 243-5515 68.61 PPL Electric Utilities Electric Service For: DEBRAPAYNE 11 HEATHER DR CARLISLE PA 17013 Questions aboat this bill? Please contact us by Jun 9 at 1-800-342-5775 (1-800-DIAL.-PPL) or write to: Customer Service 827 Hausman Rd Allentown, PA 18104-9392 www.pplelechic.com Electric Use This graph shows your electric use over the last 13 months. Types of Meter Readings: Actual - Adjusted Estimated Customer 0 1 ~ ~, , I ^ ._ .,., .;., pp~ ~~~- ,, Page 1 15530-70000 Summary Page Balance as of May 19, 2010 $171.26 Char es: Tota~PL ELECTRIC UTILITIES Charges $172.15 Total Charges $343.41 Account Balance ~4 70 56 42 28 14 0 KWH -Average Per Day MJJASONDJFMAM 2009 Months 2010 $343:41 ~i~llo ~~Q~ll~ Meter Reading Information Meter #96206570 Aay 20 Actual Pr 86370 29 Da s KWH Billed _ 1211 Average -May 2009 ZO10 T tore KWPer Da 60F 22 58F y 42 Yearly Use: Total Avera e Use Mon Jun 2008 -May 2009 16347 13 Jun 2009 -May 2010 15201 1267 Other important information on back ~ Return this part to address below with a check payable to PPL Electric Utilities Corporation ;;; .~ ~~~ ~.~....,~; - Page 1 ." PPL Electric : , pp ~~`~~` '"~~~ ~~~° Utilities , ,; '~~ TM 15530 70000 ~~ ~~. Electric Summary Page Service Balance as of Ju12O, 2010 $170.00 For: Charges: DEBRA PAYNE Total-PPL ELECTRIC UTILITIES Charges $215 65 1 I HEATI~R DR . CARLISLE PA 17013 Total Charges $385.65 ,_ .. .. Account Balance $385.65 Questions about this bill? Please contact us by Aug 10 at 1-800-342-5775 (1-800-DIAL,-PPL) or write to• Statement of Account __~_____ North View Manor Management LLC Statement Date :Jul 12. 2010 Debra Payne North View Manor Lot No. Q23 11 Heather Drive Carlisle PA 17013 Account No. - ~i 9349 Eviction Letter Issued: Security Deposit: Date Paid Re: Starting Account Balance = .~~> Payments Date Check/M.O. No. Amount Monthly har Jan 8, '10 1411 $~ 00 Fixed Chrgs Utilities Late Fee/Dsct Feb 11, '10 1420 Mar 10, '10 1422 ~ ~ January $38315 $0 ~ Apr 14, '10 1429 $~.~ February $383.15 $O.Op May 12, '10 1440 $380.0p March $383.15 $O.Op Jun 8, '10 994 $445.00 April $383.15 $O.Op $~.~ Jul 12, '10 997 $390.00 May $383.15 $p.Op $40.00 June ~~ ~. July ;.$363:15 7 F-$Q00 August September ,g .rte .~'o ~ ~/ T fib ~ October / November ~ December Yf'E ~id v,~ ~f~i,-i ~'~,~~~-r Total ;~ X80.00 7`i~f ``'s,~.a~,~' .f~°?d. as EXTi~.t _®_ they Chras & Crdts Rem Amourst ~°` ~~~s. +~/t fly, ~,r -~~i`°sP! s~ old ~ .~ ~` .~7d ~jP~'G~% (~ ~ Total Other Chrgs &Crdts Account Summary Starting Balance <$25.75> Total Fixed Charges $2,642.05 Total Utilities $0.00 Total Late Fees $80.00 Total Other Charges & Credits 740.00 ~~s Total Payments < $2,740.00 > Total Balance Due °' x$43 70 ;' I Statement of Account North View Manor Management LLC Statement Date :May 19. 2010 Debra Payne North yew Manor, Lot No. ~ 11 Heather prive Account No. - vl 9349 Carlisle PA 17013 Eviction Letter Issued: Security Deposit: Date Paid Re: Starting Account Balance = ~2s.75> Payments Monthly Charges Date Check/M.O. No. Amount Jan 8,'10 1411 $385.Op Fixed Chrgs Utilities Late FeelDsct Feb 11,'10 1420 ' ~•~ January $383.15 $0 00 Mar 10, 10 1422 $380.00 . Apr 14,'10 1429 $38000 February $383.15 $0.00 May 12, '10 1440 $380.00 March $383.15 $0.00 April $383.15 $0.00 $40.00 May $383.15 $0.00 $40.00 June July August September October November December Total 1 1 7 ~0 X0.00 Other Chrgs & Crdts ttem Amount Total Other Chrgs &Crdts Account Summary i Starting Balance <$25.75> Total Fixed Charges $1,915.75 Total Utilities $0.00 Total Late Fees $80.00 Total Other Charges & Credits Less Total, Payments ~ $1,905.00 > ~ Total Payments .~ i ~ Total Balance Due ~d $65.0 7'T` ~ ~_ ~ ~ New York State Higher Education Services Corporation 99 Washington Avenue -Dept. 736 Albany, New York 12255 866-991-HESC (4372) Fax: 518-402-3697 www.hesc.com May 26, 2010 DEBRA A PAYNE 11 HEATHER DR CARLISLE PA 17013-9629 001082 Account No: 90001661694 Balance: $5,484.88 As of the date of this letter, you owe the balance reflected. Because of interest and other charges that may vary from day to day, the amount due on the day you pay may be greater. Therefore, if you pay the amount shown above, an adjustment may be necessary after we receive your check, in which event we will inform you. For further information, contact NYSHESC at 1-866-991-HESC (43'2). Dear DEBRA A PAYNE: This letter serves as formal notice that your above-referenced default account belongs to New York State Higher Education Services Corporation (NYSHESC) for collection purposes. This is a reminder that your loan(s) is in default. If this loan(s) is not paid in full within 60 days of default, we will report the default status of the loan(s) to all national credit bureaus. Your balance owed will increase as a result of the application of federally mandated collection charges. If you wish to avoid further collection procedures, you may remit the entire balance of your aC~Ct:t t: ~::,~: Yo:k tat:. Is~her EdLicatioTi .~'iBrvlCcS CIIrpGrutii~ri at ~i> `v`v'a~'iuiigicii t-~Y@11ii6 - Dept. 736 Albany, NY 12255, or contact NYSHESC at 1-866-991-HESC (4372), to make arrangements to retire your obligation. To Ensure Quality Service Your Call Will Be Recorded and May Be Monitored. N~ Tu New York State Hi~her Education Services Corporation 99 Washington venue Albany, New York 12255 (866) 944-4372 Fax (518) 402-1347 www.hesc.org Date: 05/24/2010 *Total Balance Owed: 55, 479.93 #BWNKHSL #BLXP JJGR XRBB PAYNE, DEBRA A. 11 HEATHER DR CARLISLE, PA HE1231 Acct #: 2416 PJGS# Amount Past Due: 55, 479.93 Payment Due to Bring Current: 55,479.93 17013-9629 Our records show that your account is past due by the amount indicated above as of the date of this letter. The Higher Education Services Corporation (HESC) and the New York State Department of Taxation and Finance are authorized by the New York State Tax Law section 171-F, to credit any New York State, New York City or City of Yonkers tax refund against the balance on any HESC past due defaulted guaranteed student loan. Your account will be reported to the New York State Department of Taxation and Finance for interception of your refund, unless your account is brought current within thirty (30) days of the date of this letter. If you file a joint return with your spouse, or separate returns on a single form, your spouse may attach a statement to your State/City tax return requesting that his/her share of any refund not be offset against this liability. In such cases, the Department of Taxation and Finance shall refund the part of the refund attributable to that person. You have the right to a review of HESC's determination to certify your name to the Department of Taxation and Finance. HESC will also provide you with records on your account by written request. If you do not request a review within 30 days of the date of this letter, your state tax refund may be seized. Requests for a review must be sent to: HESC, Collections Appeals Unit 99 Washington Avenue Albany, New York 12255 A partial list of defenses you may raise is as follows: 1. Death of Borrower 4. Mistaken Identity 2. Permanent and Total Disability of Borrower 5. Account Paid-in-Full 3. Loan Discharged or Currently in Bankruptcy 6. Balance Discrepancy HESC will base its decision on its records and the records and arguments you submit. Include copies of all records and information supporting your claim. An oral review will be provided upon request. All certification determinations may be challenged by the commencement of a proceeding in the Supreme Court against HESC pursuant to Article 78 of the Civil Practice Law and Rules for New York State. Total Balance Owed includes principal, interest and collection costs. Collections To Ensure Cluality Service Your Call Will Be Recorded and May Be Monitored. HE1231 (Rev. 07/2008) REV-1513 EX+ (01-10) j`-'i Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES ESTATE OF: FILE NUMBER: Debra A. Payne 21-10-0534 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 [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Kathleen M. Johnson 10578 Moody Road Cattaraugus, NY 14719 friend 40% 2. Terry Lee Payne 150 S.E. 81st Place Ocala, FL 34480 brother 10% 3. Jeremiah Payne 150 S.E. 81st Place Ocala, FL 34480 nephew 20% 4. Gracie Payne 150 S.E. 81st Place Ocala, FL 34480 great niece 10% 5. Christian Payne 150 S.E. 81st Place Ocala, FL 34480 great nephew 10% 6. Dominique Payne 150 S.E. 81st Place Ocala, FL 34480 great niece 10% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. 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. I $ If more space is needed, use additional sheets of paper of the same size. 07/21/2010 15:31 716-938-2780 CATT CO JAIL PAGE 03108 r a ~T wzL.L ~n ~ES~AI~EN~ .~ ~_ o ~ _ ,. ..1., ~ 1 ~~~' •~11 AEBRA .ANN PA~'NE ~' ~> :~' .~: -.-, ~ ~ r} :; ~ C~ ~..' .,._~ C:j , - ""~ Y, DEBRA ANN PAYNE, of 11 Heather Place, Carlisle, Cumberland County `c' T , Pennsylvania, being of sound and disposing ~naind, men-oxy, and understanding, do hereby analce, publish and declare Ibis as and fox my Last Will and. Testament, hereby revoking and making void any and a1I former Wills, Codicils, or writings in the nature thereof, by me at any time heretofore made. k'JtItST: I hereby direct my Personal Representative to pay all my just debts, funeral and admin~isbrative expenses out of ztay estate, as soon as practicable after my death. SECOIVA: I direct that a.11 taxes which may ~ assessed in eonsequexace of my death, of whatever nature and by whatever juxisdictiaa~ imposed, shall be paid out of xx~y estate as a part of tl~e administration of nny estate. 'T)(~R,D: It is my desixe to have my ren~ins buried. F~LTRTH: I hereby give, devise and bequeath items of personal property that I may own at the time of my death, in accordau,ce with a memorandum, signed and dated by Debra PaynE, 07/21/2010 15:31 716-938-2780 CATT CO JAIL PAGE 04/0$ attached to or iz~.cluded with this my Vast Will and Testament, if there is na memorandum that can be located at the time of my death, and ome cannot be identified or located within thirty days of the date of zn.y death, then it shall be presumed that no such document exists and I give devise and bequeath all sucks property to ~athlee~ M. Johnson, Ok' 205781V2oody Raad, Catarangus, NY 14719. >H'1<FT'H: X hereby give, devise aad bequeath all the rest and residue of zny entire estate, of whatever nature to ,l~athlee~u M. Johnson. SI.XTI~: 2 namauate and appoint zny lC.athleen Johnson, as Executrix of this my Last Will attd Testament. I diroct that my personal representative shall not be required to give bond or security for the perfornaa~ace of their duties in azty jurisdiction. k')(FTH: T:n ad.ditivn to the powers confezxed by case law, by statute and by other provisions of this Last Will and Testament, my persoztal representative, and any successors an that capacity sb.all have the following discretionary powers applicable to all real estate and personal property held by thezzt, which powers shall be effective without drder of any Court and wkuch shall exist and contisaue until the time of actual, distribution: A. To retain any property of any nature received by th.enrt for whatever period it shall be deemed advisable; B. T'o invest and reinvest al. ~~c ~~«y p~ of the assets of my Estate without regard to statutes limiting the prol~ax•ty whic).t a fiduciary may purchase; C. To sell, transfer, exchange or otherwise dispose of, arty part of the assets of my Estate, for cash or on tez~s, publicly or privately, or to lease, without liability on the purchasers to see to the application of the proceeds, arxd to purchases without the obli~:~tion to repudiate them in favor of a high ~offertbese @7/21/2@1@ 15:31 716-938-278@ CATT CO JAIL PAGE @5/08 A. To execute and deliver any deeds, leases, assigztxt~.en.ts or other instruments as may be necessary to carry otrt the provisions of this Wiil; E. To bozxow money, if necessary to facilitate the administration and closing of my Estate, including the right to borrow money from any baz~lC, anal to mortgage or pledge any asset of the estate ,~ security; F. To loan to, and to purchase assets from, my Estate, even if also acting as Executor tlxereo£; G. To assume continuance of the status of arty beneficiary 'with regard to death, marriage, divorce, illness, incapacity and similar incidents or matters in the absence of information deemed reliable without liability for disbursements made on such assumption; I~. To make any distributiozt hereunder either in kind or in money, or partially in bind or partially in money, considering of course the reasonable wishes of the beneficiary. Distribution in kind shall be made at the appraised. value of the property distributed, as it is set forth in the.Inbez~tance Tax Return filed in my Estate; I. To exercise any subscription right in connection with any security held hereunder, to consent to or participate ~ ~y recapitalization, reorganization, consolidation ox merger of any corporation cotxapany or association, the securities of which may be }geld hereunder; and to delegate authority with respect tl~ereta, to deposit investrneats wader agreements, to pay asscssrt~ents, and generally to exercise all rights of investors; J. To continue in arty partriexship, joizlt venture, joint ownership or other business enterprise of which I am a part at the time of my death; I~. To compromise cleans; L• 'Z'o continue for whatever period of time my personal representative shall deem necessary any ownership as a tertazat in common or as a partner, in real estate or ots~er property and tb act as Z would have done had T been living; M. To do all other acts in thezr judgmeztt accessary or desirable for. the proper malaagement, investment and distribution of the assets of my Estate; 1\t. I direct that my persortal representative may be compensated for the services they render as Executor under this my Last WiII ar~d Testament; O. Should at7y changes occur in the Internal Revenue Code or Pennsylvania statutes after the date of the execution of this Will which affect tlxe tax liability of my estate a 07/21/2010 15:31 716-938-2780 CATT CO JAIL PAGE 06/08 tltezl to the extent possible and as may be permitted by law, nn.y personal representative sh~l.I have the power and discretion to interpret this Will and to administer my l~state in a manner wluch results in the lowest tax inability possible; IN'VVITNI~SS WH.E~EO~', I hereunto set my hand and seal this ~~`~ day a£ M "-y , 2010 ~ ~. DT~]lLPi, A, N PA SIGNER, SEALED, PUEtLISHLD and DECLARED in tkie presence o~ ~,1, U~ V ~/ 07/21/2010 15:31 716-938-2780 CATT CO JAIL PAGE 07108 A.CE~TOWLEIaGEMENT 1, AEBRA, ANN PAYNE, the Testatrix whose name is signed to the attached or foregoing instxwbe~t, having been. duly qualified according to the law, do ktez~eby acknowledge that I signed and executed the ~ins~ument as zny Last Will and 7estanaent; that I signed it willingly, and tkiat I signed it as my free and volun~y act for the purposes therein Expressed. s~ nE~RA ANN ~, v Sworn ar affirm and acknowl ged before me by AEB~A, ANN pA'YNE, the ~'es 'x, this day of , 2010. otaty public GOMMONW~gL'fli OF P£PlNSYLVAp11q NOTARIAL SEAL VALERIE F. GSEI.L, Notary WubAo C2disle Boro., Cumt~ertand Coun Cgrrsmisslon ices October 9, ~t)10 07!21/2010_15:31 716-938-2780 CATT CO JAIL PAGE 08/08 AT+'F~l]AVIT We, DEBIZA A,N1~T 1~1~YNE, ~`'~u.4-4."'~~ 1~V~~ ~4,,iti~a k -~ ~~~y ,the Testatrix and the r~ritnesses, respectively, whose names are signed to the attached ar Foregoing izi,strument, being £ust duly swornn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrurrtent as her Last Will and Testau~eztt and. that she had signed willingly, and that she executed it as her free anal voluntary act fox the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the Last Will arxd Testament as witness and that to the best of their knowledge the Testatrix was at that tinne eighteen (18) years of age or older, of sound mind and under no cortstxai,nt or undue influence. T~STA.'iCi<71~i~ , residuag ax ~~ L~ ~",i~.- W~TN~SS, ~sid.ing at '~ ~- ~-- VI~'I'N~SS, z~esiding at ~~~~. 7,~ Subscribed, sworn to at~.d acknowledged before me by DEBR.p- A.NI`11'.A.XNE, Testatrix, and subscribed and sworn to before me by~~~~-~~ ~- ~-~ and ~~~~ ~~„„y ,,the witnesses, this ~ day of 2010. V Notary Public COMMOFZWEAL'1'H OF PENNSYLVANIA NQTARIAL SEAL VALERIE F. G^,ELL, Notary PubAc CarGsie Boro., Cumberiend County Camrnissian Expires October r ~ 0 Personal Property Memorandum of Debra Ann Payne 1. Black Cabinet to Sta,~ia Reisinger 2. Love Seat to Sta~ia Reisinger 3. Lieutenant Moses Chicken Light to Stadia Reisinger 4. Brown Crock with Lid to Sta~ia Reisinger 5. Kitchen Cabinet to Kathy Johnson 6. Plate & Platter with Deer Print and Hoover to Mary Lu Hughes 7. 1 Cypress Coffee Table to Mary Lu Hughes 8. Large Wooden Salad Bowl to Kelly Jo Defoe 9. Grandmother Clock and Safe to Dolores Herbert 10. Genealogy & Pictures to Aunt Sis & Mary Lu Hughes (both agree on_ what they want) 11. Rocker Horse Balance Victorian Toy to Kylee Johnson 12. Computer Desk, grill and bathroom Cabinet to Robin Merrick 13. 1990 Ford Taurus to Sam Johnson -~ 2 ~~ 14. - b Marble Top Coffee Table to Father Jeremiah Payne 15. Angel Jewels to Stactie (Mary Lu's daughter) 16. Antique Dresser to Ruth's daughters Rae Elle or Dixie Johnson 17. Long Coffee Table (computer on it) to Kathy Johnson 18. Computer to Tyler Defoe 19. Mom's Hope Chest for Miranda (niece) 20. 21. Armoire to Kathy Johnson Terry Payne, brother $ /a 22. Oak Rocker to Dolores Herbert 23. Sewing machine to Kathy Johnson 24. Tools to Sam Johnson ~ 25. ~ s l~ Dominique, Christian & Gracie $ ~ ~ ~ ~ ~ ~a~ Y 1 ~~ < L/ r~~~e.~s ~ ~' ~ ~~~~~ J '- ~ ~S`, ~~ ~~ ~~e s-~~ -~n Date Debra Ann Payne ~. M.~~~ ~!~~. `a