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HomeMy WebLinkAbout08-20-10 1505610101 REV-1500 ~x (o~ -~o, _ ~. PA Department of Revenue OFFICIAL USE ONLY Pennsylvania Bureau of Individual Taxes DF •RTMEXTOFRfVExUE County Code Year File Number R INHERITANCE TAX RETURN PO BOX 28o6oi /~ t / ~ ` Harrisburg, PA 1'7128-o6oi D / RESIDENT DECEDENT o y ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY __ _ _ _. 162-07-9243 ' 05/20/2010 ~! 08/23/1917 Decedent's Last Name Suffix Decedent's First Name MI GARLING SR ,RAYMOND ~ ' (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/A ' Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t~ 1. Original Retum O 2. Supplemental Return O 3. Remainder Retum (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 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 ANDREW H. SHAW , (717) 243-7135 _ __ _ ra ~ . First line of address ' 200 S. Spring Garden St Second line of address Suite 11 City or Post Office "Carlisle Correspondent's a-mail address: andrewl~ashaWlaW.COm REGIST .. _'DF~IVILLS U99~NLY -': n rt~ rm~ C-7 ~~ .~- ~.,~ r, - ::3 ~ :. ,: , `_, _~~ ' - , , _. { DATE FILED -,-, _:; .:~ ,.,~ -1 ~, , --, Under penaRies of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of aver oth than the personal representative is based on all information of which preparer has any knowledge. SIG ATURE OF PER RES IBLE O FILIN R TURN ~DAjTE a-~ D S 41 one Leg a , Newville A 41 SIG ATURE PR P E THER THAN REPRESENTATIVE DATE ADDRESS 200 S. Spring Garden Street, Suite 11, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J J REV-1500 EX Decedent's Name: RAYMOND J. GARLING, SR. Decedent's Social Security Number 162-07-9243 10. Debts of Decedent, Mortgage Liabilities, and liens (Schedule I) .............. 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. r ,vav.cv 4,686.70 12,342.90 4,099.58 0.00 4,099.58 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 """" "" "°" (a)(1.2) x .0 0 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 ~ 4,099.58 17. Amount of Line 14 taxable ~~" " ~~ at sibling rate X .12 0.00 18. Amount of Line 14 taxable "~~ ~ ~~ ~ " ~ _ ~ "~~ ~~~~ at collateral rate X .15 0.00 f 15. '; 16. 17. 18. 19. TAX DUE ......................................................... 19.E 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610105 1505610105 1505610105 0.00 184.48 0.00 0.00 184.48 O s~ RECAPITULATION REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME Raymond J. Carling, Sr. STREET ADDRESS 41 Stone Ledge Road CITY Newville STATE PA ZIP 17241 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 184.48 2. Credits/Payments A. Prior Payments 0.00 B. Discount 9.22 Total Credits (A + g) (2) 9.22 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) 175.26 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 :.......................................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income :............................................ ^ ^X c. retain a reversionary interest; or .......................................................................................................................... ^ 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ x^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 0 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ ^Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ x^ 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. LAST WILL AND TESTAMENT OF RAYMOND J. GARLING I, RAYMOND J. GARLING, presently residing at 41 Stone Ledge Road, Newville, Pennsylvania, being of a sound and disposing mind, over the age of eighteen (18) years, and under no legal disability, and mindful of the brevity of this life, having placed my faith and confidence in Jesus Christ, my Saviour and Lord, Who redeemed my soul through His shed blood and death upon Calvary's Cross for my sins and Who, by His resurrection, thus assures me of eternal life, and knowing that the life which I now live in this world is by faith in the Son of God Who gave Himself for me, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me at any other time. Article I: I direct that my Personal Representative, hereinafter named, pay all my just debts and funeral expenses as soon after my death as practicable, including all property, state and federal death taxes assessed against me, my estate, or my beneficiaries, without proration among my beneficiaries. However, all property bequeathed or devised hereunder, either outright or in trust, is bequeathed or devised subject to existing mortgages, liens or encumbrances thereon. Article II: I confer on my Personal Representative and/or any Trustee(s) appointed ul E ~ ' I Raymond J. Gar mg herein and their successors the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and on such terms and conditions as my Personal Representative shall determine, and to execute and deliver good and sufficient conveyances, assignments, and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, as permitted under Act 28 of 1999, the "Prudent Investor Act"; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and all other powers given under the statutory and common law of Pennsylvania available at the time of my death and the power to do all acts and things necessary or appropriate in the management, administration and distribution of my estate. Article III: At the time of execution of this Last Will and Testament I am a widower. Article IV: At the time of execution of my Last Will and Testament I have the following children: A. RAYMOND JACOB GARLING, JR.; B. RONALD L. GARLING. Article V: I hereby nominate and appoint my son, RAYMOND JACOB ~~~~ ~ ~~~ -1 V 2 Raymond J. Garling GARLING, JR., as Personal Representative of this my Last Will and Testament. In the event he predeceases me or is unable to serve as Personal Representative, then I nominate my son, RONALD L. GARLING, as Personal Representative of this my Last Will and Testament. My individual Personal Representatives shall not be required to furnish bond or surety. Article VI: I give, devise and bequeath all the rest and residue of my estate of whatever kind and description, wherever situate, absolutely and in fee simple, as follows: A. 5% of my estate to the CARLISLE BRETHREN IN CHRIST CHURCH of Carlisle, Pennsylvania, for use at its sole discretion. B. 95% of my estate to my children, in equal shares, per stirpes. [Remainder of Page Intentionally Left Blank] 3 Raymond J. Garling IN ~W~ITNESS WHEREOF, I have hereunto set my hand and seal thi, ~ day of ~) ;,,~r-eJ , 2008. ~.J ~ °"frn.c~~~ ~~~.~ (SEAL) Raymond J. Garling Signed, sealed, published and declared by the foregoing Testator as and for his Last Will and Testament, consisting of four (4) pages, in the presence of us, who at his request, and in his presence, and in the presence of each other,~ve hereunto set our hands as witraes es thereto. ~~l-%~o 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, RAYMOND J. GARLING, Testator, whose name is signed to the attached or foregoing instrument, being duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to or ~ffirmed and a knowledged before me by RAYMOND J. GARLING, the Testator, this c~~ day of ~ ~'1~k15~--~ , 2008. Raymond J. Garl>.ng ~~~~! , otary Public My COmm1SSlOn expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal 1<risti L. Monnett, Notary Public COMMONWEALTH OF PENNSYLVANIA Carlyle eoro, c~erland ~, MY Comnrfsston Expkes Jan. 30.20 2 Member, Pennsylvana Association of Notaries COUNTY OF CUMBERLAND We, ,, ~ ,..~ ~ and Gfil ~`i ~ ~~' ( Cl.~' the witnesses w ose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn toy r a~ ands bscribed before me b ~ r~~ ,. J ~ and r~'IL~6¢ f'~ , ` ~-,~ witnesses, this - day of - +-~-~~- , 2008. ~--- / ~~ ~.~.~ ~~ ~ , i otary Publi My Comm1SS1On EXp1reS: COMMONWEALTH OF PENNSYLVANIA Notarfai Seal Kristi L. Monnett, Notary public 5 Carlisle Boro, Cumberland Courriy MY Commissbn ExPkse Jan. 30, 2012 Member, Pennsylvania Assodatlon of Notaries REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYWANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER RAYMOND J. GARLING, SR. 21-10-0619 Indude the proceeds of litigation and the date the proceeds were received by the estate. All properly Jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) V z N W H Q V 0 N N Q F- Z w W Q Z a H J Q w D Q ~ N a ~ ~ z O Q F- Z d U ~_ I- Z w ~. O U Z O H a U W n m z ~ ~ U ~ I ~ ry N ~ ' Z O ri ' ~ O F- Q ~ O ~ 1 ~ ~ U r -1 O L\f1 O Z ~ ' ~ 7 i Z6' 6~T ~'dd2II110 OT9T966 OTOZ/SO/fi0 Qlbd LNfIOWd 1NflOOSlO' 1N3WiN00 ' NOI1d180S30 '' a38Wf1N 3010/~NI 31b'Q 3010/~Nt £9Z4ii0 OOLi 2IZJ Q3W J~2i 3'ISI'I2itiJ 'ONf 'S31tfI~OSSt~ 1N3W3Jt~Nt~W H1lt~3H U Z W H Q U O Q H Z W W a z a H J Q W 2 ~ _ Q r a N ~ 'O ~. Q H Z d U O z w ~' 'J~O `U z. 0 ~-. `U 'Z i ~ ~r iCJ N O ~ Z rl w: ~ Q o ~ N \ w. r~ U ~ z REV-iSog.EX+ (oi-io) jig pennsylvania ~7 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE. F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: RAYMOND J. GARLING, SR. 21-10-0619 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A• SALLIE C. GARLING ~ 41 Stone Ledge Road, Newville, PA 17241 ~ daughter-in-law B c. JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A• 11/19/08 PNC Bank checking account, #5004437106 32,203.10 50 16,101.55 TOTAL (Also enter on Line 6, Recapitulation) I # 16,101.55 If more space is needed, use additional sheets of paper of the same size. Rx Date/Time JUL-26-2010(MON) 13:05 d1270527d7 P. 001 Ju1.26. 2010 1:08PM PNC BANK 412-705-2747 No. 6458 P. 1/1 ~~~ LEARiNG THE WAY July 26, 2010 Andrew Shaw Attorney at Law 200 S Spring Garden St Ste 11 Cazlisle, PA 17013 RE: Raymond J Carling SSN: 162-07-9243 DOD; OS-20-2010 Dear IVIr. Shaw: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checking Account Account # 5004437106 RAYMOND J CABLING SR SALLIE C GARLIlVG Established: 11-19-2008 DOD balance: ~ 32,203.10 non interest bearing Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking aad Savings). We do not process any financial tran9actiona or provide statement9. if you need assistance with any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bask, N.A. FDIC Page 1 of 1 REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF RAYMOND J. GARLING, SR. Decedent's debts must be reported on Schedule I. FILE NUMBER 21-10-0619 (UMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' Harold M. Zimmerman & Son Funeral Home, Inc. 6,620.00 2. Greencastle Bronze & Granite 95.00 3. Fisher's Florist 206.70 B. 1. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: ~ _ 600.00 2. Attorney Fees: 0.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) ("laimant 4. 5. 6. 7. Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: State ZIP ZIP 134.50 0.00 0.00 TOTAL (Also enter on Line 9, Recapitulation) I ~ 7,656.20 If more space is needed, use additional sheets of paper of the same size. H~~rt~l~:~ ~~~, ~~~~i~~ ~~ ~C~l~ H. Martin Zimmerman Jr. er~l ~OtY'~[' ~~~ Supervisor 45 South Carlisle Street, Greencastle, Pa. 17225 • Phone 717-597-2828 www.zimmermanfh.com' Greencastle's Local Family Owned Funeral Home Since 1948 Andrew R. Everetts Director Mr. Raymond J. Carling Jr. June 1, 2010 41 Stone Ledge Rd Nevwille, PA 17241 Funeral Expenses for Raymond J Carling Sr.- Thank,you for electing our funeral hometo provide services for your family during your time of bereavement .. I hope that you found our services, so far, to. )e of the highest standards that we always try o acheive. The. following is a summary,of the service charges as previously explar-ed and'provided in written form below. ; PROFESSIONAL SERVICES Basic Services of Funeral Drector & Staff $ 1,995.00 "Embalming $ 945.00 OTHER STAFF AND RELATED FACILITIES -Use of Staff & Facilities for Funeral Ceremony at Funeral Home $ 320.00 'Use of Staff & Facilities for Viewing at Funeral Home $ 350.00 TRANSPORTATION. Traiisfer of Remains to Funeral Home- $ 295.00 Hearse $ 325.00 Lead Car $ 85.00 MERCHANDISE Alex Coppertone 20 Ga. Steel Casket $ 1,195:00 Regular Outer Burial Container $ 1,150:00 Visitors Register $ -45.00 'Memorial Folders - ` $ 80.00. CASH ADVANCES Cemetery Opening/Closing $ 350.00. Public Opinion Custom Obituary $ 135.00 Carlisle.Sentinel Custom Obituary $ 90.00 Harrisburg Patriot News Custom Obituary $ 152.00. 16 Laminated Obituaries $ 48.00 10 Death Certificates @ $6 ea $ 60.00 TOTAL CHARGES $ 7,620.00 PAYMENTS & ADJUSTMENTS -$ 6 ,H9O.OO May 29, 2010 ' SecurChoce $ 6;890:00 BALANCE DITE: 6/25/2010 $ 730.00.. BALANCE DUE AFTER:. 6/25/2010 $ 740.95 If there are any questions or concerns. that remain unanswered, please, call me. Sincerely, H. Marfin Zimmerman, Jr. .I--1~~1-t~~t:~ ~,~~. ~~~~ __ ~~ ~~?ta H. Martin Zimmerman Jr. ~~~~~ ~~('~[~ ~('~~~ Supervisor 45 South Carlisle Street, Greencastle, Pa. 17225 • Phone 71.7-597-2828 www.zimmermanth.com Greencastle 's Local Family Owned Funeral Home Since 1948 Local Monument Dealers Gilland Memorial Works 14902 Buchanan Trail East Blue Ridge Summit, PA 717-794-2981 Gordon's Memorials 924 Lincoln Way West Chambersburg, PA 717-264-8443 Andrew R. Everetts Director Greencastle Bronze & Granite J~; %'1 ~'~ 500 Buchanan Trail West ~~ . C` l? ~-'~- ~ ~ ~~ ~~ ~ ~~ ~ Greencastle, PA ~ ~ ~ .t'~`7 ~'~ l -~~' f ~~' 717-597-4580 Hammaker & arner Monument & Bronze 523 South Potomac St. Hagerstown, MD 301-733-1792 Shull-Koontz Cemetery Memorials 130 East Queen St. Chambersburg, PA 717-264-6916 Wagoner's Memorials 5851 Manheim Rd. Waynesboro, PA 717-749-7157 Heoraer ri um: e ne John henry Co j Lansing, Michigan g ~~ riearoer rrom: i ne ~oiu~ Henry moo. - ~~. Lansing, Michigan ~ii 1-866-448-8300 '. ,I FISHER ~ TRpL EAST 782 8~~ GREENCA PA. 17225 ` ~ T 7I7-s 4a88 ~1.J ~~.IL~~~ Trrw ID: TV25634745081 Sale „f~~?r~ VISA Entrv I~thod: Swiped .~~-'~~`t~~, 1 4 ~ ~ 206,10 '~ ~ .._ ~ .~ ,, 1 c~ ~ .~ =4 '_h ^ CASH. ^ CHECK ^ C.O.D. ^ CREDIT CARD ^ CHARGE ^ NEW ACCOUNT ©v'~a91 ND0162 Opt.; VD0163;.3pt. tal~ WRI N tSY _ (~[ ry~ _, ~ J L J U 13• D LIVERY DATE -- [ ~ 1 qq J/21~10 HON nv a; lNWar+ )+ ) gr r ~ p L i ~ ~~ 4LOLL O' P.M. s M T w t F s pp BLDG PT, 1 ~arud; Online 0 Batcha. 0 ~eT Nr ~•~~~~ N 4 I ZIP. SPECIALINSTRUGTIONS ~~ -;C f~F fJ l_1 P.1 E'ER Customzr COPY i f - ~.- PI IOhJE THANK YDU! {~-~ ~'` ~ \~~~- ~ ~ T~PJ1 ^,~,T PERSON 3 ARRANGEM' qr I ~ E~4T~ ~ T ~-~;C RSAGL ~;U FL r?\^JERS T ER QUANTITY ^ __ ~- ~)E ~~'FiIPT10fJ ~ - J a ~ h~ +l '.,. ^ BIRTHDAY ^ NO SENTIMENT ^ BABY B G ^ GET WELL OTAL ~ ^ SYMPATHY ~ ANNIVERSARY ~ HOLIDAY ~ OTHER REtav CHARGE CAy{ 1~ESSAGE j ~y/ ^ ~+ Q ~ r;..{ I O. PHONE - d LIVERY n r~ ~ . +- CHARGE TO 'HOMe Teo i ~ ~ WORK TEl ADDRESS ORDERED BY CITY, STATE ~ ZIP CODE MC V AX DC OTHER CREDIT CARD NUMBER EXP. DATE ~ ~ CJ AUTH. # REV-1512 F.X+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER RAYMOND J. GARLING, SR. 21-10-0619 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. Shippensburg Health Care Center 121WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 (717) 530-8300 RAYMOND GARLING 01642 SR„ RAYMOND J. GARLING 41 STONE LEDGE RD NEWVILLE, PA 1?241 06/01/10 Balance Forward 05/13/10 ROOM AND BOARD SEMI PT 05/13/10-05/19/10 06/OI/10 Patient Liability Balance Due: Charges 0.00 1,434.00 700.00 2,134.00 Payments/ Credits 0.00 RAYMOND GARLING 01642 Please Remit: 2,134.00 1dI3~3b NOd 1 ~. 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GARLING, SR. SCHEDULE ~ BENEFICIARIES FILE NUMBER: 21-10-0619 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Do Not List Trustee(s) OF ESTATE Sec. 9116 (a) (1.2).] 1• ~ SALLIE C. GARLING daughter-in-law ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II 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 3924.32 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET If more space is needed, use additional sheets of paper of the same size. $