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Home My WebLink About08-31-101505610148 REV-1500 EX(°',°' OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 2806°1 21 0 9 0 617 Harrisburg, PA 17128-°601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 201-68-6705 04282009 04081987 Decedent's Last Name Suffix Decedent's First Name M I LYONS BENJA~1IN S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number FILL IN APPROPRIATE BOXES BELOW 1. Original Return ^ 4 . Limited Estate ^ 6. Decedent Died Testate (Attach Copy of Will) 0 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ 4a. Future Interest Compromise (date of death after 12-12-82) ^ 7. Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 5. Federal Estate Tax Return Required 0 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) --- CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number MARK E• HALBRUNER, ESQ• 717-731,-9600 First line of address 1,013 MUM~1A ROAD, SUITE Second line of address City or Post Office State ZIP Code LEMOYNE PA 1,7043 Correspondent'se-mail address: M • HALBRUNEROGATESLAWFIRM • COM .. ~ ' ,`-~ c.r~. Under penalties of perjury, 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 preparer other than the person esentative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ` DATE JUDITH I• SCROLL, ADMINISTRATRIX -~ S~M "-, ) ( Z~ !U ADDRESS ~` 1050 PINE ROAD C:AjRLISLE, PA 17015 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ±'- DATE MARK E • HALRUNER, ESQ • ~ -~,-Z_. , ,~ ~ - ~~~~-- =.~~ ,. ADDRESS 101,3 MUMMA ROAD, SUITE 100 LEMOYNE, PA 17043 PLEASE USE ORIGINAL FORM ONLY 1505610148 Side 1 9M4647 4.000 REGISTER OF WILLS USE ONLY !_~3 . ~~ ~ ~ -• ~ r:~ 3~ r ~} _-_. ~ ~'..~ f_ r , . -. :~ G.? ,_~t--~ %~-a ~ i i 1505610148 J ~m J 1505610248 REV-1500 EX Decedent's Social Security Number 201-68-6705 Decedent's Name LYONS BENJ AMI N S RECAPITULATION 1. Real Estate (Schedule A) 1. $ D . O O 2. Stocks and Bonds (Schedule B) . 2 $ O . O D 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3. $ O • O D 4. Mortgages and Notes Receivable (Schedule D) 4. $ O O D 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5. $ 6 2 ,16 5.3 6 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g, $ O • O D 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. $ D • O D 8. Total Gross Assets (total Lines 1 through 7) $. $ 6 2 ,1, 6 5.3 6 9. Funeral Expenses and Administrative Costs (Schedule H) , , g $ 3 2 , 5 5 6.7 7 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10. $ 4 , 0 5 6.9 0 1 1. Total Deductions (total Lines 9 and 10) , 11. $ 3 6 , 61, 3.6 7 12. Net Value of Estate (Line 8 minus Line 11) 12. $ 2 5 , 5 51.6 9 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , , 13. $ D • D D 14. Net Value Subject to Tax (Line 12 minus Line 13) , 14. $ 2 5 , 5 51.6 9 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 (a)(1.2) x .o _ $ 0.0 0 15. $ D • 0 0 16. Amount of Line 14 t xable O 4~ li l X nea rate . at $25,551.68 16. $1,149.83 17. Amount of Line 14 taxable at sibling rate X .12 $ D . D O 17. $ O • D O 18. Amount of Line 14 taxable at collateral rate X .15 $ D • D D 18. $ D • D D 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610248 1505610248 9M4648 4.000 $1,149.83 J REV-1500 EX Page 3 Decedent's Complete Address: File Number ~ 1, f19 fl I, 1, 7 DECEDENTS NAME LYONS BENJAMIN S STREET ADDRESS UM R AN CITY MECHANICSBURG STATE PA ZIP 17055- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments $ 0 • 0 0 B. Discount $ 0 . 0 0 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) (1) $1„ 1,49 •83 $0.00 (3> $0.00 $0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $ It , 1, 4 9 • 8 3 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: 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; c. retain a reversionary interest; or d. receive the promise for life of either payments, benefits or care? . Yes ^ ^ ^ ^ No 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ^ ^ 4. Did decedent own an individual retirement account, annuity, or other non-probate property, which contains a beneficiary designation? ® ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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. X9116 (a) (1.1) (i)J. 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. §91 16 (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. X9116(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)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + B) (2) 9M4671 2.000 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Beni amin S Lyons 21 0 9 0 617 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ~Dutys Lock Safe & Security Inc. reimbursement $30.00 2 Commonwealth of Pennsylvania 2008 income tax refund $18.86 3 Commerce Bank Checking Acct. No. 0536959323 $1,261.42 4 U. S. Treasury decedent's 2008 federal income tax refund $521.35 5 Dutys Lock Safe & Security, Inc. final paycheck $473.73 6 1993 Volkswagen Corrado VIN: WVWEE450XPK003302 (value per appraisal) $300.00 7 U. S. Treasury decedent's 2009 federal income tax refund $1,460.00 Total from continuation schedules $58,100.00 TOTAL Also enter on line 5, Reca itulation $ $ 62 ,165.3 6 3w46aD x.000 (If more space is needed, insert additional sheets of the same size) Estate of: Benjamin S. Lyons Schedule E (Page 2) Item No. Description 8 The decedent's estate received $100,000.00 as full and final settlement from Erie Insurance Policy #Q10-7906239, and $15,000.00 as full and final settlement from Erie Insurance Policy #QO1-2507984. Per letter from PA Department of Revenue dated April 23, 2010, the Department allocated the gross proceeds of the action as follows: 50~ or $57,500.00 to the wrongful death claim, and 50~ or $57,500.00 to the survival claim. The survival claim portion of $57,500.00 is being reported as a taxable asset of the estate per 42 Pa. C.S.A. Section 8302; 72 P.S. Section 9106, 9107. See attached copies of settlement checks, Order from Court approving settlement and letter from PA Department of Revenue dated April 23, 2010. 9 1986 Volkswagen Scirocco VIN: WVWCA0530GK013455 (value per appraisal) 21 09 0617 Value at Date of Death $57,500.00 $600.00 Total (Carry forward to main schedule) $58,100.00 REV-1510 EX + (08-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Ben-j amin S . Lyons 21 0 9 0 617 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBE DESCRIPTION OF PROPERTY INCLl1DETHENAMEOFTI-ETRANSFEREE.THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD~S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE ~~ Members 1st Investment Services CB&T Cust Simple IRA $899.44 100.0000 $899.44 $0.00 Owner: Benjamin S. Lyons Beneficiary: mother, Judith I. Scholl Any withdrawals by the decedent from this individual retirement account would hve been subject to a 10$ penalty under federal income tax law because he had not reached age 59.5. Therefore, this individual retirement account is not subject to Pennsylvania inheritance tax per 61 Pa. Code Section 93.131. TOTAL (Also enter on line 7, Recapitulation) $ 0.00 If more space is needed, use additional sheets of paper of the same size. 9W46AF 2.000 REV-1500 Schedule G (attachment) Benjamin S. Lyons, deceased SSN: 201-68-6705 Members 1st Investment Services IRA Any withdrawals by the decedent from this individual retirement account would have been subject to a 10% penalty under federal income tax law because he had not reached age 591/2. Therefore, this individual retirement account is not subject to Pennsylvania Inheritance Tax per 61 Pa. Code §93.131. REV-1511 EX+(10-09) SCHEDULE H pennsylvania DEPARTMENTOF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Benjamin S. Lions 21 090617 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESC~tIPTION AMOUNT A. FUNERAL EXPENSES: ~ Chestnut Hill Cemetery cemetery plot' $1,350.00 Total from continuation schedules ~ $12,637.10 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: $3, 729.92 Name(s) of Personal Representative(s) Judith I . Scholl Street Address 1050 Pine Road City Carlisle State PA ZIP 17015 Year(s) Commission Paid: 2010 2. Attorney Fees: $ 8 , 6 92 .5 6 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) $3 , 500.00 Claimant Judith I. Scholl Street Address 1050 Pine Road 4. 5. 6. 7. 1 City Carlisle State PA ZIP 17015 Relationship of Claimant to Decedent MOTHER Probate Fees: Accountant Fees: Tax Return Preparer Fees: Roadside Auto Rescue auto salvage towing Total from continuation schedules . $85.00 $268.00 $2,294.19 TOTAL (Also enter on Line 9, Recapitulation) ~ $ $32 , 556.77 swasA~ z.ooo If more space is needed, use additional sheets of paper of the same size. REV-1500 Schedule H(B), Item 3 -Family Exemption (attachment) Benjamin S. Lyons, deceased SSN: 201-68-6705 Family Exemption The decedent resided with his mother, Judith I. Scholl, at 130 E. Locust Street, Mechanicsburg, PA 17055, at the time of his death. Judith I. Scholl moved to her current address as reported on Schedule H(B), Item 3, in July 2010. Estate of: Benjamin S. Lyons Schedule H Part 1 (Page 2) Item No. Description 2 Long's Flower Shop flowers for funeral 3 Lower Allen Township facility rental for luncheon 4 Myers-Harner Funeral Home, Inc. funeral goods & services 5 Gingrich Memorials monument & engraving 6 Rev. Michael Minnix funeral service 21 09 0617 Amount $249.10 $186.00 $9,302.00 $2,800.00 $100.00 Total (Carry forward to main schedule) $12,637.10 Estate of: Benjamin S. Lyons 21 09 0617 Schedule H Part 7 (Page 2) 2 Register of Wills filing fee for petition to appoint administrator $50.00 3 US Postal Service postage $29.42 4 Cumberland Law Journal publication fee $75.00 5 Patriot-News publication fee $245.57 6 Legal fees and costs associated with negotiation and settlement of insurance matter. One-half of the following total amounts are being deducted: Legal Fees: $3,739.50 Postage: $18.89 Filing Fees: $15.00 Medical Records: $15.00 Per PA Department of Revenue letter dated April 23, 2010, the fees and costs are being deducted in proportion to the amount of the settlement allocated to the survival action which was 50$. $1,894.20 Total (Carry forward to main schedule) $2,294.19 REV-1512 EX + (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ben-j amin S . Lyons 21 0 9 0 617 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• Holy Spirit Hospital medical bill $226.00 2 Camp Hill Emergency Physicians medical bill $449.00 3 Erie Insurance pro-rata auto insurance premium due $11.00 4 Hauser's Automotive Repair auto repair bill paid after date of death $257.47 5 AT&T phone bill $25.87 6 David C. Scholl personal loan from David C. Scholl to Benjamin S. Lyons made September 25, 2008. $2,500.00 7 Daniel Dunn, DNID dental bill $144.00 8 J&J Automotive auto repair bill paid after date of death $443.56 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS TOTAL (Also enter on Line 10, Recapitulation) ~$ $4 , 056.90 8W46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: Ben'amin S. L ons 21 09 0617 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Judith I. Scholl 1050 Pine Road Carlisle, PA 17015 One Half of Residue: $12,775.84 Mother $12,775.84 2 Michael Lyons 231 Callanan Avenue Bryn Mawr, PA 19010 One Half of Residue: $12,775.84 Father $12,775.84 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. yW4bA1 L.000 DEATH CERTIFICATE i;ll`, I<I'\' 1111/11/1 ~e.~C~ver`~~ ~Ir~~E.'~rJ'~@ }l~i~ Ry ~t f~~~~'R"'Q.~c~~ll ~(H ~~0~~4 t, tr1fQRNtt~~: {~ is Hlec~a{ tQ c~~}~sli ate this ro~a'~ ~~ ~-{~ioto tai or ~r~otog,~r~h. i~cyr this; certif-irate, S;(i.UU P ~.5~8~9°6 Ccrlification T`Juntl_TCr ^ . irjrr/~r~~ii.-,~.~.\ ] 1115 Iti t(1 C('I'tlf,1' tl7ill tl7e information I]ei~l: `,-'.l\~ell I ,it~i' ~~H Of p ~'==\ +,;tl' `ham --,file;-,~, cr)rrectl~r c(Thied irol» an irriririi_i) Certificate c)f~ Ueat /`~`~•~ - `J%- =\ d>ril~r filed v~rith me a5 Local Recistra.'. The ori~in~ tom` '' \~~1 certificate t~~ill lyL° l~e>r~~~arded tcT thL: 5tatc Vita x' Tl I-' I . ~'`.; ~r+'; ria,.,`,' T:L'~:(ii-(a:; ~ifll'L: f(ii 1-i~:i~liliiilCiir i ill~~ fly, ` , S'tv- _.. * ..' ' t , ~,/+ ~--.. , , . -- Lclctl }t(.~!~i~.trar Utttc 1ti5tred ,~ rOMMONWEALTH OF PENNSYLVANIA • QEPARTMEN7 OF HEALTH ~ VITAL Rt=CORDS CORONER'S CERTIFICATE OF dEATH 4~ '~ 2-DOG (See instructions and examples on reverse) STATE FILE NUMBER rte of Deoedont (p1R1, mk>dle, tacl, calla) 2. Sex 3. Soda! SectMty NtrttWer 4. Dale of Death IMoMh, dey, year) Benjamin S Lyons Male 201 - b8j 6705 April 28, 2D09 (Last &Mdeyl Under 1 war Under !dey B. Dera al elnn IMomh, Oay, year) 7, Btrtlttaaoe (GM end sure a IoMpn roranry Be. Wade of Deem (Cnsdc ony one) 22 ""'"e ue" "°"' ~` April 8, 1987 Harrisburg, pA Mapnal; Otrtar. Yro ^ Inpaucnl ^ ER / OulWlienl ^ DOA ^ Nuninp Home ^ Hacldenoe Olher • Bpodly rainy of UesUr Bc. Gq-, Fsoru, lwp, of Dulh led. Fatrary Name (lt ral eraUtutlon, glue stoat attd Herber) 8. Wa Uaadanl of Hwpade Odpln7 ~ No ~ Yse 10. Reed: Ameneen lndum, Burch. WNIe, etc. Cumberland Hampden Twp. Brandy Ln. @ Salem Church Rd. (Ilyea.apedtycuban, Maximo, Puena Rttlen, eld.) (spedry) >~~ cadertt't Uauel Oeetroalbn Khtd of vrod; d ate dtatra mast of wotYYa Mts. Do tai atata rowed! 12 Wu Gamdenl awr Yr the 13, iretladant'a Euaxtmn (Sxdty only hpneet prods eomn letadl 14. Madul 3utus: Memsd, Never Married, t 15. Sumvmg Spo ii Di d S W o use (It wile, grve meYien name! I hind of Wair .ksrruth iiera of iiuemete I trxar[try ock & Key Co. U . Armed FArLBSi DYee l~~ Elsmenury! Fieeondary (U-12) Cohepe (1-4 or eKl 12 iuorrrr vorm ( pec p , Never Ma .tied dadent'a MaWnp TAddreae (Strsel, dl~+/ wwn, aisle, zip mde) t t Deo~eM's Did Decedent Adwt Ralderoe t7a. Sole PA live Ina 17c. ^ Yes, Decadent Lived M Twp . J I EaS t LOCUS PA 17055 b r i h iowrunfp7 ,7b.cBUnry Cumberland ,7d.®~ ~^a;~Ned~'"^ Mechanicsburg G JU cs u g, 8n Iy om here Name (Ftrat, middo, !eel auihx) 19. Mnttra q a ( t. !den ) 3u it~l c~o~ rhea! Lyons , fonnenYa Name (Type / PrYtq 20U I o t'a Mel A (&raet, eJly / , atete, 1 PA 17055 Mechanicsburg 1~r°~Eas`~ ocust ~t. dith I. Scholl , , etttod of DlspalUon 1 ^ Crerreuon ^ Uorrellon lib. Date o1 DapaaUbn (Month. day, year) 21c. Piece of Dleomhron (Name of mmelery, aemetary dr other Wane) 21d. lor'aYon (Gry Mown, aisle, zrp otlde) g burial ^ RemovallromStele ~ weeCremetlonorponetlonAWlorized 2009 May 4 Chestnut Hill Cemetery Mechanisburg, PA her -Specify': oy Medlin! EtyAA54 GotoneYl ^ Yes D No , m p pe 22b. Ucenee Nlallwf 71c. Name andAdireeeol FadlUy Myers-Hamer Funeral Home 014819 L 1903 Market St. Hill PA 17011 to items 23a~ ady when mrtlyrng 2ra. To Ina Vest of my larowtedpe, deem occurred et the time, date and Wee! staled (&pnemre and tine! Tab, Ucense Number 23%. Dale Sipned (Muntl+, day, yam) n ~ not avallabla el Ume of deem ro sues d tlsem. 3-T6 rnuu be compleud W persm 24. Time dt Ueatn A rg , P Z5. Uate Prpraaroed Dead (Month, dey, year) 26. Was Case Relenetl to Medical Exemrrer! Coroner for a Reason Omer man Crernabon or Gonalan7 r,ourrdeedeam. 2:30 A. +~ April 28, 2009 Yea ^No CAUSE OF DEATH (See ineUvetlona atttl eaempies) , ApproxYnale muYVal: Ped II: Enter other erenthanl mndnxrr~. ranmbwno to tleath. 28. Did TMralso Use Contndrne Io Death? Part I: Flaer Ute drain di etrerrr< - dreeaaes, mNnes, or compeca6txrs - met dreetly reared the oeaUt DO NOT sine! umYnat events sudl es artec arras! + Onset to Death btn not rewUmp m Ins wdedying cause given ur Pan (. ~ Yes [~ Prooabty reapremry arrvet, or venmaaar Addaaoan without eMwmg me eUOlogy. Ust Dory ens reuse on sad, tea. ~ r ^ No ^ Unkrrotm ATE CAUSE (Flnnl deeesa a + nresraongndeem) Head Trauma ' ~Ir a T9. I! Femaa: ^ N i hi r DUB l0 10( BS a LUrOBQUerlt:e bfl; t 01 pregnant w n past year t ^ Premenl 61 tone of death deify Yq mntlAarl-s, h anY. b Motor V e h i c 1e Crash ~ . m ore reuse ested on Yne e. + i ^ Not prcgnenl, bUl pregnant rNttun 42 days (~ to la es a consequerroa o l: a UNDEgLYIN~ CAUSE + oI deem or inxay mat mittatetl ote c r ' erxdtmg n deem) LAST. Cue to (Or as a Wne00Uer,C6 DIJ: t r Na pregNnl, fArl prodnanl 43 days 10 1 year 0!10!8 deem d. + ^ Unarown II pregrrenl vMhrn Ure earl year s an Arnopsy 3nb. Were Autopsy FxWirrps 31. Manner of tlealn 32a. Dare d I++MY (tAarrln, day, year) 32b. Dasatae Flew tnnaY o~rned U nb e 1 t e d passenger , v e n 1 c 1 azc. Frees of IM+rrY Horne. Fenn, greet Fenory, fortned7 AveilslyePrartot:mrplalion of Cause of Deem? ^N~~al ~ Apr• 28, 2009 left roadway, struck trees °A"°B'~mr'D'~`~~~°'''~treet 5 ~ N° ^ Yea ^ Nu ~Arxideni [] Pendmo Invesdgalion 32d Trine of Irryry p rX . 328. Injury et WorK7 321. It i+ansPOrtat+dr+ mpuy (Srnoiy) 32g. tncatron of 1nNry (greet dty I torm, sratef ^Suidoe ^I:ouldrrotdeDerertmed 2.30 A ~y°6 ~"° ~Dr"°`/Dp°r'ror ~Pesaenger pPad.em.n Brandy Lane, Mechanicsburg, PA . M, D~- Uher IdtecY arvy one) 33b. 6rgneture and true df Lenihe / - - - Cartllymg Phyalolen (Prrvsiaan eerFihAtp came of deem when rutou,er wrveioen Ass Pn1 oeatrr and rnrtfpteled ham 23) oaamoaunedduetotneawe(alendmanneraaatau~--___-..---------------------- ^ Tottwbeaotmylo'tovnedBa ~ ~ ' G o r on e r ~~ . Prorwunelnp end eerltMln9 physkrsn (Prrveiaen oath ororauxang Deem end eerufyna to !aura d death) D 33c. l~eartse Number dad. 6810 Srlned tMdrih, Oey, year) To Ins wet dt my krtotelsoge, tlsaih oeeurred n tits tln+e, tlele, and pees, and due ro the mrraNe) and rmrmer o elated- - - - - - - - - - - - - - - - - - Ap r i 1 3 0 , 2 0 0 9 Madill 6xaminer /Coroner On Ins basic of examinetlon and I or InwelrpaUon, In my opinion, deem oecumd at the tune, daLL, and Dlaee, end dw to the Wuee(a) aM manner o ateted_ ~ ~ N I F on W o{yg9 ype I pmt ~ - l~Vl 1"11L=CldC1 L. 1VULi1S~ ..Y.., ~,__.._ __r ,,,.,~,,, ... ,...e.... ., •~, 130. Dera F]ed,IMonttr/lx+v. !earl _ 6 3 7 5 B S s e h o r e RO a d,_ S u i t e 4~ 1 CERTIFICATE of GRANT of LETTERS ~^ ~i ESTATE OF BENJAMIN S. LYONS DECEASED BEFORE THE REGISTER OF WILLS OF CUMBERLAND COL'N~FY, PENNSYLVANIA NO 21-09-0617 DECREE OF THE REGISTER OF WILLS AND NOW, this 7th day of October, 2009, after a hearing on the matter, it is the decision of the Register of Wills that Letters of Administration shall be granted solely to Petitioner, Judith I. Scholl. Specifically, based upon testimony presented at the hearing, the Register hereby determines that Grant of Letters of Administration to Michael Lyons and Judith I. Scholl as co-administrators may not be in the best interest of the estate. The Register believes the acrimonious relationship existing between Michael Lyons and Judith I. Scholl will be a hindrance to the proper administration of the Estate, thereby causing undue delay and difficulties in its administration. Moreover, the Register believes that the Estate can best be administered by Judith I. Scholl, individually. Accordingly, IT IS HEREBY DECREED that upon the proper filing of a Petition for Letters of Administration by Judith I. Scholl, such letters shall be granted to her pursuant to 20 Pa.C.S.A. ~3155(b)(3). Judith I. Scholl shall then have all the rights and duties of a fiduciary under the laws of Pelulsylvania and shall proceed with the administration. ofthis Estate according to law. ,~ r r 1 r / ~~' . - ,~ = - ;~ Cienda Fanner Strasbaugh, Register of VW~lls ~.r - - -~ -_ ._J ~- ... ~` ~ .. ~. ! I..i _... i_ aw f._,__1 .. `_ ~ __ - ~: - ~~ - - t ., _. G.:_i ti ~`~ ~~.J ~ r V }~ :~ PA REV-1500 SCHEDULE E CASH, BANK DEPOSITS & MISCELLANEOUS PERSONAL PROPERTY Dutvs Lock Safe & Security Inc. 4301 Carlisle Pike Camp Hill, PA 17011 Benjamin S Lyons Employee Number Earnings Rate Hours Amount YTD Hrs YTD Amt Com 2228.51 Hol 31.00 310.00 OT 55.00 891.78 Reg 699.25 7480.00 Vag 8.00 80.00 Total Gross Pay 793.25 10990.29 Earnings Statement Check Date: August 28, 2009 Period Beginning: August 15, 2009 Period Ending: August 21, 2009 43 Dept 100 Check Number 7397 Net Pay 30.00 Check Amount 30.00 Taxes Status Taxable Amount YTD Amt Hampden T(Cumberland 19.00 Medicare 159.36 OASDI 681.40 PA SUI - EE 6.59 Hampden T. (Cumberla 186.85 Pennsylvania SITW 337.39 Federal Income Tax S!1 30.00 1070.75 Total Tax Withholding 2461.34 Deductions Amount Y7'D Amt Simple IRA -30.00 2SS.00 Total Deductions -30.00 2ss.oo Direct Deposits Account Amount No Direct Deposits Benefits Hours Amount YTD Hrs YTD Amt .._ ,. _ ,... _,: .. .., _ r µ,. ., K.._. ~ ~ s. Accruals Dollars a .. . .. . -.. a Comme_,~e Bank 60-184/313 Dutys Lock Safe & Security Inc. 4301 Carlisle Pike Camp Hill, PA 17011 Check Date Check Number August 28, 2009 7397 Pay this Amount: Thirty Dollars and No Cents ************************************************** ********* 30.00 -- 100 43 7397 ? Pay to Benjamin S Lyons ' - the order of: 130 E. Locust St. - ~ -- ~±~~ `i Mechanicsburg, PA 17055 , :~t_.~~ a_~._VC_ ~~~~ ~ ~--~. ~-) r .-_;~~- '~-~-,-_ ~_ '- Authorized Signature 11'000000 7 3 9 711' ~:0 3 1 30 L8 ~, 61': 0 3000 3 70 ~11' 9 8 8 ~ 0 0 0 O O O O Z L i ~i i :, o-o < .~ ' °~~ ~~~ -' ~ mo°rrn m y ~ ~ _~ m ~ o ~ x Z ~ ti~ ~ ~oZ _ ~ ' ~ D D D ~~ 1] ~ ~ C o ~-- ~ ~~;~ ~ C ~ car, 0 ~ -! r +D 1 ,- - N ~~ ~ -:~ - m _ o ~,.+ Q, ~ ~ -- ~. ~ ~ ~ _ ~, - m < ,,~, ~ .. - ~ -n = o C m ~ ~ = c~ii z - ~ C ~ W ca 00 ~ r W _ p ~ 0 D ~ ^ ~ " r' p. r ~ - m = o ,. ~~., - r,., .. 028273 r ru r ~ ~` 1 1~A 1 a ~° W 31 J _ ` W ; r J ~ r :;ra == ~ ~_ i '- T n S m T ~ / O * - n !~ ,~ D T -+ o v D * rn ~ m °~ 1 i 00 c 0 m~ ~ ~ D N N O ~ I T r v O n C s m -~ .~ -~ .n O N CO h i r , W li A i~ " w m T c ~ ai j m .p, Commerce CBank Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 1 71 1 1-0999 1-888-937-0004 ~~ ~~ ~ -- 0184021NY1 N00006188 .~,~ ~~ BENJAMIN SLYONS 130 E LOCUST STREET ~~ MECHANICSBURG PA 17055 "~"' ~~ ~~ We're here 7 days a week, 24 hours a day at 1-888-937-DODO. "- TOTALLY FREE CHECKING 0536959323 """" .____ ~. .~.yr~ _.__.....4. _ Statement Balance as of 04/09/09 $181.87 ~~~ Plus 3 Deposits and Other Credits $1,142.55 ~~ Less 1 Checks and Other Debits $63.00 '~'-~ Statement Balance. as of 05/11/09 $1,261.42 "== Transactions By Date Date Description Debit Credit Balance 04/10109 .DEPOSIT $638.26 $820.13 04/17/09 DEPOSIT $72.64 $892.77 04/27!09 DEPOSIT $431.65 $1,324.42_ 04/27/09 CKCD DEBIT 04126 APPALACHIAN $63.00 $1,261.42 BREWINHARRISBURG PA 013 Cycle Page 1 of 1 NOTE: SEE REVERSE SIDE FOR IMPORTANT iNFnRneeTinN - -- - THE YES BANK BENJAMIN S LYONS per 0000000536959323 From 5/11/2009 to 6/ 8/2009 Starting Balance: $1,261.42 0 Checks: $0.00 0 Withdrawals: $0.00 2 Deposits: $995.08 Ending Balance: $2,256.50 Date Description 5/19/2009 ACH Deposit - AC-US TREASURY 220 -TAX REFUND 5/26/2009 Deposit fi~ ~ ~ Y is ~-- U ~=. ~- ~ l~6? ~' r + C; ~~ ~' j:-,f' C;;(,t;~'( ,~~ Amount ,r-„~,/''' !~ .' .~~~.` ~,t;~.( $521.35 Gt ~( $473.73 Balance $1,7$2.77 $2,256.50 Page 1 '. , ~ II ly ~''~' 1.r!• ~yM'.1ri°~ vvr<<uru.l Y3• :..~. ~ ~R ~N,,tl-:r• >y1W~r'~'~'. 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L I... _ ~ i;~i, ! ~.'.fdrf-1 ~I'I 'i: rll f~C:' ! f --. f ```~"~~J;~ ~7DQMETER DIiCLQtiURE EXEMPT BY FEDERAL LAW r Er,,~' I~` ,~,° I~ ,EI,LI I_~"I!)r I-' -- I 1 ,171 _ t1Ll~i:;1 LRi-ir i~iJtdl-Fli>i ~ ;. i! l'~I IIi Lr ~ ` ~ i• p _ I .rl L7~~~~M11Y J L 1 ~IMr 1 pct Irlc rl I ~` ~.1. a , Ir r I_s I~ ~' ~~~,,~: ~~~~ E LVCU`~T t ~r3ruirt,r.ll ,.L,~~r;l„~~L,, r I r _. '. S ..l 11^I~ ILiI)7n'Iy ~ j',~ I I ,~-~,, •I. ~ I l ~ ;r Ir uLrrlnnL yr-lncr~ '~ '~ ~s~~~a(, M~E~CNANICSBURG RA 1755 ti rr,rrlrir 'LIIIILF r L.,;wrl ~. Nr n -I:~ litHn_,I ~, 'f }I~ ! ~ ~.1- IfIY nIJ ~TI;lK.T6D ~ ~~ ~ ~ 1~ r I -. rlf:r r l l f±CCr 7Flff-l- r1_Ftl Lr ( ~'~ - 1 I . Cl II t t ~ l ~rl I l lil F;I-I, I IF '.'I! I I~ ~,I, ~( r Lc, r r~.rncl_i_ I ~ ~ 1 ~ i ~r~~, H _ 1~,~1 _~_ ~ '1( It 4 .e f' clnc~- Lirr.i rn,Lrn" t?F. ; L. L:)IVfJ I.It.IJ 1-fl V!.11-! C!F. j.d,: I. . w .' ~' I'. _ "?tin ' a r er ~= I Cj I~Y~k~.ji., ~, I~ N a seccmrJ lieirl i~~ldt=1 Ir; llslerl uu(!n '~I3t~tif.lcll;;ri Ihr° lil~~'.t Irftt~, Ih.- flr,l r~ I Aw° W S ~{.}~-;,~~~ lianholcier mu:.i ir~rvvt~rcl Ilii~. Tilly; fo !Ilc: 5uledu nl Ivlutoi '~/tlli:le;; !vitl-i ;h~:: _ t ~Ipixollllatc I~rn11 unil ite. 1 '''1 I=IH`.;T LIEI~I RF_LC-A,;EU ._~.._.__ DATE ~ ~,~'I' . ,, ir~t~`~1 C;-t~____. - _-, t~;'..)plrl Lik_f, rll-I LH:,LL' --------.__... __' --'-~---"-_-_- .~I t 1~~ ~_~~_r11111-1!~111.tLr Hi_I'HE;~Lr~11NVF- I)falt. L. ~~ r' MAILIfJG ADURE:;S ~_ ~_ ;I n'%- E~ F.IITH~iRI _U HE('HI EI~lT/l1lVE ~` r. {. _ 1 I 1'~ ~ ' ~ I BENJAMIN S LYQ~4~ ~~``'! 1~3Q E LOCUST ST ;I `~~~~~~ MECHANICaBURG PA 1X155 ~~- ,,, .; ~. ~r-. ~::: ; r,; : - { ` , ~ ~~_. `a~ ~~ ~+D a~~~t :'. I FM~SI , tGk k ! p ~~ ~~~ ALLE~J D BIEHLER -~ :~{ I ~t~-~ • ~ I cc!riify a rri thy, i 11 - ~I ~_ I c-, thF -filrl;ll rac~rcJs Of the r'Pnrisvl r~ri.r I AEI .~rtmrnl i ~ ~ nl Trinspun itlm reiir.r! Ihn~ Ihr F~er;~nl_-.1 r~i r,omp~liy n~inr,c) herein I.~ rhF I~IV.rlul rnnn lNt I 1 = `'~ ~ n~~ F r, the ^,aid ieil,rlr~ :;1•cr~~tarR rrY ~i'ran:~ )irrlaliurr w _ Y r' I ~L ..~.0.•c::~F,~ee.R.St,......_ .. .. .. .. _ - _, _ ... _.. -..u~ -.n .~w~~'.uu.Y T':° ~ w: _'.~~ ~4fr..•eatY •~ - ,. J I 1 If r o-i (I ircha ;er other Iflar, nr :r.nu . I h ?nd an~~ vrili Vnll, !(lam. IIUF I:' ._ rl ESI.FIbED F,IdD ~NJ CHI __~.. h~ II:iE'r{ ;r I ,.r. 'j ~r.•'~':,' il;I. ,.. -. _ lr. _ _.1 I { ~~~~ ~-- -* ^•• OVJIICI. 1111c (]Ur :, 10 ~~UI VIVInCJ UWriCr.) r HL'.~i !T Y{f:=.~ iJlhEl'/vl~r. ~f•if Ir11~: well bE ,ssue.l ~. "Tr~ndnts in l:ommcr iOr, tl .a±r, d' one ovmcl Ir..~r- ,,i cieceas~d ou~Ii!=r uue:: ic- nhiher nelr ~, at:ae!_•I. ' ITT LIEFIHOLDER _. tr .~'. _ __ .. _. -_ ~Tr=,t~. IF fHl~ I`,; A' E ~~Ei:r H='1F ~ 1(I.~t!~~.t1~1. '~ _.`- _.,~.I~IrJ Sr=.. _IFi_'_' ..lUil.. il.~Ia,-. Lr~!D LIEti Ci<,7E: ~,,;_ 'r ; I~; L!cri ~Hi='.i< - I 2rIG UE+IHGLI~ER - -'--- ~. ;THr--~ T ,, .. ,~r__ ._,.. ~ , 1 r ~,,.;, ~ , ~ . ,~,~,~;, - --- --- ------.. u ~ !'F IF {.If t~~ i t I i _i _.r 1!FA ,y.. i F ~`:l : ~. I i~, ;, !~n„_ ~ -- r ~ I .I r ~, ,.l~l ~._1. .I~.;Ilrll I.IrTC Ali! r r Ulrtf-r~ I__: j 1 ,_ ~ '-!ii .i! tl':~ u :7titF31i17LSptL~tSL_t.LTSLLISir« 1LIS 1x2LLLS yl .1:*IL"L`Z3'_2:[~.!~1JS1===4r -1uJ-.f-Z•'.y='-~y1~f~-`.1-TL1L'+:•L'_Lpp'172!tTS64 11*'~T ~L~~! .f ~ r~ Ir,~~-`''~ v ~Yc 1=~ l~19~ 0 'tk'~^"P ,"_' 7. NI 7`y.~'3~'~N~~~ry~ ~i ~ bn ,ry s,.L r 1 - t- 1 ,,,`!~'~~l !.:~'~=~ ~±' 99y ; n „: I ~" 'fit O a ~~r~';G::,,! t,t;46~ t~ . '.~ 'iii , ~~, I .1~ ~...a J&~ AUTO SALES AND SERVICE Specializing in Volkswagen & Audi 3537 Hartzdale Drive Suite 1 Camp Hill, PA 17011 Phone: 717-737-7775 Fax: 717-737-7778 To whom it may concern, I John Smith looked over Ben Lyons 1993 Volkswagen Corrado. N.A.D.A suggests the book price on the vehicle" is around $1900.00. Due to body damage, electrical issues, no dashboard, mold damage on leather seats, and a non running motor, etc., I would value the car at $300.00. Thank You, John Smith ~~~ ~-____ } ~-- --_'_ ~_____--~'m~ J ~/ I DECEASEL~enjamin S Lyons 04/28/2009 • Department of the Treasury -Internal Revenue Service o4oA U.S. Individual Income Tax Return (99> 2~~9 Your In~st name and initial Last name (See Instructions.) Benjamin S Lyone LJSe the If a joint return, spouse's first name and initial Last name IRS label. Otherwise, please pant Home address lnumhPr and street). If ynu have a P.O. nnx, Gea instructions, ur type. - late of 130 E. Locust Street City, town or post office. If yot, have a foreign address, see instructions. Mechanicsbur Presidential Election IRS Use Unly - Uo not write or staple ul Illis slrlce- OMB No. 1545-C074 ~ Your social security number 201-68-6705 A,p~rtment no State ZIC' code PA 1?05~ . Ynu mujt enter your SSN(s) above Checking a box hei~w will not change your tax or refund Campaign ~ Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see instructions) .. ~ ~ ~ You ~ ~ Spouse Filing 1 X Single 4 ~ Head of household (with qualifying person). (See instructians.) StatUS 2 Marrietl filing jointly (even if only one had income) If the qualifying person Is a child but not your dependent, 3 Married filing separately. Enter spouse's SSN above and enter thl~ child's name here ~ Check only full name here ~ 5 (~ C~ualifying widow(er) with dependent child nna ],inv. (see instructions j Exemptions 6a X~ Yourself. If sorrleone can claim you as a dependent, do not check box 6a ... ....... Bores checked on 6a and 6b ..... 1 b n Spouse ........ - ^ If more than six dependents, see instructiois. c Dependents: 1) First name Last name (2) Dependent's social security I-I~n'1t1PY I (3) Dependent's relationship t~ y~t-: (4) ~ if quartylny child for ~ (,I llld lrlx ~1ert,t No. of children on 6c who: • lived urfth you • did not live with you due to divorce or separation (see instructions) .. . Dependents on 6c not entered above d Tota! number of exemptions claimed ................................ l.............. Add numbers I .......... on lines above ~ I 1 Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 ..................................... .... 7 10 , 73 5 . Attach Form(s) 8a Taxable interest. Attach Schedule B if required ........ ........................ .... 8a W-2 here. Also attach Form(s) bTax-exempt interest. Do not include on line 8a ......... . ~~~~~~ ~~~~~ 8b _ 1099-R if tax 9a Ordinary dividends. Attach Schedule B if required ............................... . .... 9a was withheld. b Qualified dividends St?P instructions ..... 9b 10 Capital gain distributions (see instructions) ..................`..................... .... 10 11 a iRA distributions ..... ........ 11 a 11 b Taxable amount . .... 11 b 12a Pensions and annuities ........ 12a 12bTaxable amount .. .... 12b If you did not yet a w-2, 13 Unem to p p p p yment coin ensation in excess of $2,400 er reci lent and Alaska see instructions. Permanent Fund dividends (see instructions) ....................................... .... 13 Enclose, bul do not attach, 14a Social security any payment. Also, please benefits ....................... 14a 14b Taxable amount .. .... 14b use Form loao-v. 15 Add lines 7 through 14b (far right column). This is your total income ........•......... . ~ 15 1Q , 73 5 , Adjusted 16 Educator expenses (see instructions) ....................... 16 gl'OSS 17 IRA deduction (see instructions) ........................... 17 ` income 18 Student loan interest deduction (see instructions) .. ......... 18 19 Tuition and fees deduction. Attach Form 8917 ............... 19 _ 20 Add lines 16 through 19. These are your total adjustments .......................... .... 20 21 Subtract line 20 from line 15. This is your adjusted gross income .......... . ........ ~ 21 10, 735 . BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. Form 1040A (2009) FC)IA1312 11/16/09 Spouse's social security number A (2009) Ben'amin S L one , 201-68-6705 Page 2 credits 22 Enter the amount from line 21 (adjusted gross incol~rle) ....................... .. 22 10 , 73 5 . -. , 23 _ a Check _~ You were born before January 2, 1945, Blind Total boxes ~ ayments If: Spouse was born before January 2, 1945, Blind _ checked . - 23a ~ Stan ad rd - b If you are married filing separately and your spouse itemizes deductions, see Instructions and check here .......................................... -~ 23b~ _ Deduction for - 24 a Enter our standard deduction see left mar In ... . , ......... y ( 9 ) ............... ...... , 24a 5 700 . • People who b If you are increasing your standard deduction by certain real estate taxes or checked any new motor vehicle taxes, attach Schedule L and check here (see instrs) . - 24b I box on line ~ 23a, 23b, or 25 Subtract line 24a from line 22. If line 24a is more than line 22, enter -O- .......... . ...... 25 5, 035 , 24b or who 26 Exemptions. If line 22 is over $125,100 or less and you ilid not provide housingco a wiidwestern displaced can be individual, multiply $3,650 by the number on line 6d. Otherwise, see instructions ......................... 26 3 , 650 . claimed as a dependent 27 Subtract line 26 fi~om line 25. If line 26 is more than line 25, enter -0 . This i; yor_tr , see instrs. taxable income ......................................... .............. - 27 1, 385 . • All others: 28 Tax, including any alternative minimum tax Single or (see instructions) .......... ............... ... ...... ... 28 13 9 . Married filing separately, 29 Credit for child and dependent care expenses. Attach Form 2441........ 29 $5,700 I 30 Credit for the elderly or the disabled. Attach Schedule R 30 .. Married filing 31 Education credits from Form 8863, line 29 .................. 31 jointly or i Qualifying 32 Relirernent savings contributions Credit. Attach Form SSSu 3[ 1lE! . widow(er), 33 Child tax credit (see Instructions) ........................ . 33 $11,400 34 Add lines 29 through 33. These are your total credits ....:.............................. 34 128 . Head of 35 Subtract line 34 from line 28. If line 34 is more than line 28, enter -0- .................... 35 11 . Household, 36 Advance earned income credit payments from Form(s) W-2, box 9 ....................... 36 $8,350 37 Add lines 35 and 36. This is your total tax .......................................... - 37 11 . 38 Federal income tax withheld from Forms W-2 and 1099 ...... 38 1, 071 . 39 2009 estimated tax payments and amount applied from 2008 return 39 If you have TI 40 Making work pay and government retiree credits. Attach Schedule M ....... 40 400 . a qualifying child, attach 41 a Earned income credit EIC 41 a ~ ) ................................ Schedule EIC. ~ b Nontaxable combat pay election. 41 b 42 Additional child tax credit. Attach Form 8812 ................ 42 43 Refundable education credit from ForrTl 8863, line 16 ........ 43 44 Add lines 38, 39, 40, 41 a, 42, and 43. These are your total payments ............................... - 44 1, 4 71 . Refund 45 If line 44 is more than line 37, subtract line 37 from line 44. This is the amount you overpaid ..................................................... 45 1, 460 . 46a Amount of line 45 you want refunded to you. If Form 8888 is attached, check here .. - ~ 46a 1, 460 . Direct deposit? - bRouting See instructions and fill in 46b, n number .......... xxxxxxxxx - c Type: I I Checking ~ Savings 46c, and 46d or - d Account Form 8888. number ......... XxxxxxxxxXxxxxxxx 47 Amount of line 45 you want applied to your 2010 estimated tax ............................................ 47 -- Amount 48 Amount you owe. Subtract line 44 from line 37. For details on how to pay, you OWe see instructions ...... ........ - 4,8 49 Estimated tax penalty (see instructions) .................... 49 Do you want to allow another person to discuss this return with the IRS (see instructions)? .......... Yes. Complete the following. X No Third party desi nee g Designee's - Phone dent f cation - name no. - number (PIN) Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and accurately list all amounts and sources of income I recewed during the tax year. DecJaraton of preparer (other Phan the taxpayer) is based on all here information of which the preparer has any knowledge. Your signature I Date I Your occupation ~ D2ytme phone number Joint return? See instructions. ' Keep a copy for your records. Spouse's signature. If a joint return, both must sign Paid preparer's use only Preparer's Date Check if signature / Mark E . Halbruner self- ~ 03~01~2010 employed Firm's name (or yours rfself- emptoyed), address. and ZIP code Gates, _Halbruner, Hatch_ & Guise, _PC _ _ _ _ _ _ - _ 101_3 Mum_m_a_R_d_._S_u_i_t_e_1_O_O_______ ________ EIN Lemo Phone Yoe PA 17043-1144 no. " FDIA':312 11/16/09 Locksmith Date Spouse's occupation Preparer's SSN or PTIN P00845421 20-4304745 717) 731-9600 Form 1040A (2009) ~ p~~r~s~~~~~~ DEPARTMENT OF REVENUE A rii 23 2010 P iVl:~rk F, H~tlhn_iner, ESC~ure Gates, Halbruner, Hatch & Guise, PC ] 013 Mumma Road, Suite 100 Lemoyne, PA 17043 Re: Estate of Benjamin S. Lyons File Number 2109-0617 Court of Common Pleas Cumberland Count~~ Dear Mr. Halbruner: The Department of Revenue has received the Petition for Approval of Settlement Claim to be tiled on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 22 year old decedent died as a result of a motor vehicle accident. Decedent is survived by his parents. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action. $57,500.00 to the wrongful death claim and $ 57,500.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Ya.C.S.A. 5 n302: 72 Y.S. ~91U6, 9 i 0 7. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth_ 1995). I trust that this letter is a sufficient representation of the Department's position. on this matter. As the Department has no objections to the Petition, a.n attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me it you or the Court has any questions or requires anything additiunal from this Bureau. ely, 5 nnon E. Balser Tnist Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes Bureau of Individual Taxes ~ PO Box 280601 ~ Harrisburg, PA 17128 (717.783.5824 ~ shabaker`~state.pa.us 1013 MUMMA ROAD SUITE 100 LEMOYNE PA Insurer: ERIE INSURANCE COMPANY Policy No.: Q10 7906239 Claim No.: 01 701 01 71 032704 Date of Loss: 04-28-2009 Check No.: 102047268 CMS No.: JT47268 Check Amt.: $100,000.00 For: PAYMENT OF BODILY INJURY LIABILITY Erie insurance offers home, auto, business and life insurance. Cal! your local ERIE Agent to learn what is available in your area. ~I ER{E fNSURANCE COMPANY ~1\ Home Office • 100 Erie Ins. PI. • Erie, PA 16530 ERIE® PAY ONE HUNDRED THOUSAND AND 00/)00 TO THE ESTATE OF BENJAMIN LYONS AND THE MARK HALBRUNER, THEiR ATTORNEY ORDER 1013 MUMA ROAD OF SUITE 100 LEMOYNE PA 17043 FOR PAYMENT OF 80DILY INJURY LIABILITY CLAIM NO.: 01 701 01 71 032704 DATE OF LOSS: 04-28-2009 cans No.: JT47268 Bank of America CustomerConnection 64-1278 ~ Bank of A.menca, N.A. -61~ -o Atlanta, Dekalb County, Georgia b CHECK NO.: 10204726$ ~ DATE ISSUED: 05-27-2010 ~ 0 m OPERATOR 683RITCH EY --~ TAX ID NO. """""***'` '~ '~ '~ '~ '~ i t I i i i i AUTHORIZED 51GNATURE Security featufca ENCL Y inc~ueetl. t Details on back. 11'Z0~04?6811' 1I:06~LL2788~: 329999949211' MARK HALBRUNER ESQUIRE 1013 MUMMA ROAD SUITE 100 LEMOYNE PA 17043 Insurer: ERIE INSURANCE EXCHANGE Policy No.: Q01 2507984 Claim No.: 01 701 01 71 065086 Date of Loss: 04-28-2009 Check No.: 102048575 CMS No_: JT48575 Check Arnt.: $15,000.00 For: F1NAL SETTLEMENT OF ANY AND ALL CLAIMS ARISING FROM BODILY INJURY UNDER THE UNDER- SERVICE DATE: 06-02-2010 TO 06-02-2010 Erie Insurance offers home, auto, business and life insurance. Call your local ERIE Agent to learn what is available in your area. H /~;~ ERIE INSURANCE EXCHANGE ~\ Home 0lfice • 100 Erie Ins. P!. • Erie, PA 16530 ERIE® PAY FIFTEEN THOUSAND AND 00/100 Tp JUDITH SCROLL AS ADMINISTRATOR OF THE THE ESTATE OF BENJAMIN S. LYONS & ORDER MARK HALBRUNER, ESQUIRE OF THEIR ATTORNEY FINAL SETTLEMENT OF ANY AND ALL CLAIMS FOR ARISING FROM BODILY INJURY UNDER THE UNDER- SERVICE DATE. 06-42-2010 TO 06-02-2010 bank of America CustomerConnection 64-1278 Bank of America, N.A. - -6i i- - Atlanta, Dekalb County, Georgia CHECK NO.: 102048575 DATE ISSUED: 06-02-2010 OPERATOR 2N4FRY AUTHORIZED SIGNATURE ' ,' - l ; r'~~. j ~' ~ ~1 s ~ clu Deta CLAIM No.: 01 701 01 71 065086 DATE OF LOSS: 04-28-2009 CMS No.: JT48575 TAX ID NO. ~' ~; '',i ENCL --' LO 20~,85751f' x:06 ~ ~ ~ 2788: 3 X9999949 CII' ,rwTr. ,, I~'IDu~); µTi' IP r µt to ,T; - - - '11!~n~rlir~"" ' i s 'll. illy ~ IYI:~,~ i3"~yl);~~ j't~~:`~~4Jtr 1~..~~. l ~ ~9 ' ~. ~ t ~~ t kv?w tM!. '~tlFMllht~'s~.~~f`1h ~Jr~'' r,~ ~!` ~~~ '1~~; ~~~ t Jr1.. c 'iN'~~ f 1i11T'{27TItIlTIT/IfIT[ITI:ITRI3TITfiITilIRt1T7TITY1'471TIr~'•IA'FiRT77'F77T11~tPTIi[TTY1T{T{'LS~Si'yYj$'jRT,L1ATI711TT'll:TtTl~ilTC:lTiiTItRTTiF17t'+7.i[iTlilil'tCJZ11~7377i*'T/IIIIif1711..f~Pln- ) ~~ ~IJP' ~ I ..I ,~, ~~`^ ~....~~~`iF'ICAT~ (JF TiTL~E ~'~I~ ~ Ei~i"CaL,~ ~ ~iij t `a f{ . ~'r ry it 0~3~1002~o0~s~~-oat 4~.;~_:}. I, ~J ~~'~ a1'~WCA053C1'J~:01,3455 I 1986 bl i3Lk':~'WAvEN 38.285218605 Lr ' .. ,l`v ~r VFHIf;I.F IOFrITIFIr`ATI()N NIIMRER YEAR MAKE OF t,'EHICLE I ri"ILE NIIPABFFt ~ ~~ 4 ••I I ~ ~ I d , i y~ I ` , ` ~' 0 ~-~ 1112710? E R EMFT 4 ~ ~~ [i()Ilt' TYPE ~ ()UI~ ~ SEAI I;AF' ! PRIUN TITLE 6'FATE j GDl)M. 1'RC1Cli. (igTE ~ C)L)UM. MILE ~ i_~UUh'I :CAT US ~ , :~~ 3S ~ , 5>F'Q9186 ~ :L1127I0? f ~ ~'~ ~ ~' t GATE NF. TI~LEL~ ( ifAlL vF IJSUE UNLAI~EIV WEIGHT I G\/1NFt fat;VvF 11TLt F+HAIVIJ , ~ if _.,I I r ~+ ~ ODOMETER ST--,~ITLJS ~ ~ - n!-rrl~i rv rnr~ , : I ~ sy ~ ~~~ ~„1~~ I MILEA.CF FXCEFUS THE INECikfJl(>i\L LIMIT;' 9G"^L0.~r . h1CJT THI ArTUr'~,l PdILEACEE tfc r .i I s MnT rHF ArruA! rnILEArf= f fcor.~~~TtH rAMPFriIfJCi'1/EHIFIEO ~~ ° ii }~ ~,~~ g D 4 M E T E R D I S C L C~ U R E E K E M P T B Y FEDE R A L LAW ~ ~XF~^~) FHt fnn r)L„)MF rEFI Ulti(:LUS[IHI __ ~ , xi I . H(-J1Sl EREC! U:^lrlEN(S) -- TITLL BHAfJfls . :, ~'f" ~ ,. /i AhJTIOl1F VEHIt.LF ~ig a ~ (~•~ T` t ~+~ ~ '~/ ~~ J ~ .. E N4 A M L N J 4 .. ~ C CLA SICVEFIIC,IE t L~r~ I r rtiNr-r ~u i.~ L~ ~ -~ ii~ * t . . r . ,. ~ F -Ollr OF COUNTRY ~ T w ~ `~^,,,.~ ~ ,.(~ ~ :L. 4 C ~ ~.T ~ T W V 1W 1 C' - ORIGIrIALL1' MFGD. FOR flr)rJ~LI.C. ' CtISTRIel1TION ~i~ > ~ xy ,I J , '~ X "1 '1 ~1 {~ C M E'CN A N I C ~' B U R ii p A 1 1 C,1 S J R= AiiRfCIILTURAL VEIiICLE L - LOGL~,ING VCIiICLE ~ j + pp~`~ r*,ii ,,yl ,~c'. ~ r ~ r' - IS/wCS A POLICE VFHICLt_ ~ I j s R -- REr r)NSTRUCTED t ~ .~ 5 ~ STREET NO(I yyj .J I ~ - 'f HE(,OVEHLD rl-IFFY VEIiICLE Yi kl +G --M - V VEHICLE C'OI-!1 AIMS REISLIIED VII~J [~ ° r W - FLUOU VFFIIGI :- :~I L1 r FIRST I IFN FAVC)Fi i)F r~E~ riti;n I~ nir.n~r jr' roc:. I~~IJN. n IAX.i ~ 4 ,il , ` . , - _ ; u~ ~ 4 >I I~ ~ ,I h ~ AI It a second lienhnlder is listed upon w'ItihftJCUnn cif the iirFt lien 'the flrsl lienhnlder must forward this Tillr, In Ihr;, Hnreau of I~AoIC+r V6;hicl'etr , ~rvith ltie, ~'6r~~~~'~ is *i '~.i Fift'iT Ltr=rJ RI=I_EASE[) DATE ~ appropriate loan and tee. }JjI.~ s ~~ (1 ~-7i: ; f;Y ^EC<INCJ LIEhJ REI LA9EU ~ ~, ~~~ - AUI[IUHI:'L-U riLi'fiES~LIIAIIVL - _ - DATE / _ ~i ~ I MAILING ACiDHESS BY I ~ ::I At1THURIZED REPRESEIJTATIVE BENJAMIN ~ LY4N~ 13^ E L~}CUaT ~~ T MECHANIC:~BURG f~A 1?05S I • t:r;rlify :~~, ~~r 111e dali/ ... ~ ;$nf?, rI~N nfhrlai records of ,he Pennsylvania Ue,laltmen, ALLEN D B I EH L E R of liansrrr,rlali~,i~ teflw~l Ilihf Ilir- Nelson(s) ur company named herein is the lawful ownai d ^ of the said vehlc:le. SlrreLlr~' of 7•r:lnsfwrt:llion ' i~ a ~,...~ a -. ~ '1'i3 i 4 i > r f l! ` g~4r f Fi K r 4~ I r~~ .iRt'+ • ,:H - '~ i i ~ i Ii R 1 Yr ~r -~ L~ ' .vfF a~1. ~.a.T~ tr ... .. Sa.is' ..`2. ~c,GnEG~i.i!•r• su©scRlFSErJ Ar•JO swoRn; TO BEFORE I~JE If a co-purchaser other than your spouse is listed anti you want the title tr, j1~_,;~~! .a~.-;.,.; , be listed as "Joint Tenants With Riaht of Survivorship" (On delah of one ' °" owner, title: goes to surviving owner.) CHECf°_ r-iEF~E O. Oiher+,vise, the title =~ y~~c; will be issued as "Tenants in Common" (On death of one owner, interest of fi~:~,o~:= _' deceased owner goes to hisitler heirs cr esta[ej. cif;' ~~;ij rl.,a.+4,... - •~Ir,fJA TI iHF C?F AF!'LI~.411T ~ iH :.I ITHJRI'~D ~I[31JFF ~. ~- ' 1ST LIEhJHOLDER ._ a .~i +, r .,r;...„ , __.-;.! STREET R!.. CITY STATE ZIF E ;; ~ i i . ..~ t IF THIS IS AN ELT. CHECY, HERE ~ I FINANCIAL t!M•'e ' ro,..;, ' tJGTE: FIN REOUIREL IrJSTiTIJTlOh1 fJ[i t',•e~y'' -t~ »..:.: _i~4 .,. ~ 2ND LIEN DATE: IF h10 LIEfJ, CHECK t-~ I ` - , ,. ~ ,F~:r,i ~_~ ~~,f;;'i 2ND LIEfJHOLDER _ Y `. , , . STREET , ., I±~° I ~ . ! i :' ~ ~° ~r&''- i , CIT / - - STATE: _'IF' ~:1':e °i ~ i ~ ...,.. ,. IF I HIS I;; AN tLi C;HEC:K f-IERE I-_~I F~IJANC;IAL ':,ICfir.r~lr,~, I ~: ~ r,r~i'i i ,~.;JT Rit t ,,r <;~!iFir~Hrz[~~ slr;rJEn NOTE: FIN NEUt11RFD u IN~.TITIJTION Nf~ !"; :I _ _` J&,J AUTO SALES AND SERVICE Specializing in Volkswagen & Audi 3537 Hartzdale Drive Suite 1 Camp Hill, PA 17011 Phone: 717-737-7775 Fax: 717-737-7778 To whom it may concern, I John Smith looked over the 1986 Volkswagen Scirocco. N.A.D.A suggests the book price on the car is around $1500.00. As it sits now I would value the car at $600.00. It needs many new parts ~ be able to sell for any more. Thank You, ~ ,, ,~hn Smith i~ PA REV-1500 SCHEDULE G INTER-VIVOS TRANSFERS and MISCELLANEOUS NON-PROBATE PROPERTY St Members 1st Investment Services January 21, 2010 Located at Members 1st FCU 5000 Louise llrive Mechanicsburg, PA 17055 0 71.7-795-605] X00 ?37-4054 MEMBERS 1st 717-795-5176 fay FEDERAL CREDIT UNION Traci Sepkovic Gates, Halbruner, Hatch & Guise, P.C. 1013 Mumma Road/Suite 100 Lemoyne, PA l 7013 Dear Traci, Andrew Steele S%~t~i~~r Im~estrru~ttt Cnrlst~ltant You requested the following information for Benjamin Lyons: Account title: CB&T CUST SIMPLE IRA Benjamin S. Lyons Beneficiary: Judith IScholl -Mother - 100% Date Established: 4/25/2008 Interest from Jan 09 to DOD: Starting Value: 1 /09 - $406.73 Ending Value -DOD - $899.44 Contributions added between 1/1 and 4/28 - $502.95 If there is anything I can help you with, please call me at 717-697- 1161 x 5719. Sincerely, Michele A Jones Investment Assistant II Registered Representative of, securities and certain insurance products are offered through INVEST Financial Corporation (INVEST), member FINRA, SIPC and affiliated insurance agencies. INVEST is not affiliated with Members 1st Investment Services. Products and services offered through INVEST are: • Not NCUA Insured • Not a deposit of or guaranteed by any credit union • May lose value PA REV-1500 SCHEDULE H FUNERAL EXPENSES and ADMINISTRATIVE COSTS 1I~-eI•s-Harney Funeral Hone, Inc. 1Q03 MARKET STREET ~~~(:~D HILL, PENNSYLVANIA 1701 _-~-- - -~ ~.,-- -_~ ?one: (71-1737-9961 Dustin R. 8ake~r, F~unera! Director ~T>.-rF~±F=~T ~~F Ft\ER~L GOODS Al`D SERVICES SELECTED - ._ ,~ 'a:; or he .t cemet:n or acnuo~rr n us. ~ n .cn'~, ,~:e hill e~plair :n ~,~ririn~~ hel:tts _ __ I„ ~e ;a C~.+c .~ ;ntl~ahtsin~. '~nu di, •t+,; h.nc to rte f tr er,balmi~t~ t,:~c did r ~ ~! appr~rr .:: 'o- anha-m +. . ,: il! r 4~!am h•, !~elmc `~ ~^ ~-: 1-i l C - - - ---- - .^ Y r -,~ ~ . ------- Date ~tti DcathS~ -~~ t l tira[~ ~,~ ~tnG l- SLB-TOT.aL OF PROFS~~IO\,1L ~FR~"IC:\FS ?. FACILITIES ,1ND SER\7CES l~a• of t t~ilfri~ t ~ :, . : 6,, t funrr.tl ~: i n~~ in l ce of I:+ciliti~~. and yen i~ct fn• ~ t (~~ . \knnxia~ ~cnicc .. ' I ~c ~t r~t~.tii~mrnr and per: ici~ ! ~. _ -- (lthrr n~c ~~(t~cihrics hthcr .1t ca I'nh.+rttinn IL~iuu ~ l-^~~~ ~ ~~„~~ +~I-t1 E P TOTAL MERCHANDISE SELECTED .. \I ~ ~~ n~ C. SPECL~I. CFL~RGES: F_•rnardin~ of remains r:. SI'B-TOT_1l. OF F9CILITIFS,'EQi TP\IIitiT .... :1? S,yr~~.~ 3. AL"TOntOTIV-G EQUIP\IE\T Vehicle in reu,~fer remains tc. Fune!al Ilcmn~ L<ual .. < 1 n ~. Ncarc ~,l,a.,.;°[ Coachl 1_Pl;i~ .. ' r ~- '~-G~ r .arclcr~r~ gar SiB-TOT:\L OF _\l-TOt\IOTI\-E~L=QI IP\II~ti"I' ~i 5j.~~ ..... R S c _ +Funeral Home. Rr~c: ir,~ rat rcnaim fmr.t F.n„raf f' ,_.. SL A-TO-aL OF SPECLII C H_\RGf S C S D. C_15H .~D~ ANCED: il~ ,. .. ~~.',<<hap;r Anri~c'-!~'^[-rf_i~ ;~'I1 `-- 1itt.trc ~ l'.rr~.-',ins, ,, 1th_nns ~ ~.~~ Cerud~ (_r,hiu o! the C~ctu;t ~ hettiticnte~ -7~ (a' C~ ~ - ~ each ~ K~L_-- l t•~~anir ........ .. ... ti Jol~>ist ~ \lr.,r ti:ni:e~ S _-~ Cnr~~ne+ Fry C \lingc ~ SL'B-TOTAL OF .1D\ L~ C~ ~ .. D S ~~ _ ~ ~C~. :hark c~u tar uur s:r~ices in ohtainfne. TOTAL OF PROFESSIONAL. SERVICES, ~ch~r-r ,~,r~ ,cdrr!;~r. ti~.rt ~r-~: v:.r~::rt-r-;~ FACILITIES :1ND :\UTOI`IOTI~~ EQi'IPnIENT~~1,~ C~fY,~ ~ T~CG~~•~ S-k~~-~"~ ,-_ ---- -_ --- B. CHARGE FOR ilIERCHANDISE SELECTED: SttJibi\Rl~ OF CHARGES Gtskct -....-.- - >`~ ____ ~ ~- Pmfessi,nal ~rn.ce Ftcii;ti:~ trd T +I.,~,crit~ti~,n~ carrw~l.c~~.l~;c~._-- L,~,,;~,,,~•+,t. ~:,~~ ,t n,~,ti,~ s. ~. Iqu+t,n~rnr ;~ S~JO L~~ t lthcr h,r~chncir ~ ~~~ _ _ ,,`,Irreha t ai ,. ~ O'L7 ~ I~CSI I'I I~Cft~fl~ _ `r~____ (-. ~~tll,t ~ it 1-~e5 - - ~ l ~utcr burin! atn[aim r ~ _ _ TOT:~1[, OF :1LL SECTIONS ....... ............. S--f'~-~`'"• iUescrihri~m' __________ `__~_ PAID AT T1DIE OF OR PRIOR TO ARRANGERILNTS .......... . . .......... .. s - ~ ,_,., .,... ~ 1~~ --- BALAi~CE DlE ~ ~ . ,i~-~- . ` lL6G~ ---- - , - `'~cnt r ~J~i.'~ >)_f1~~ Q RL.~ \FOREIIB. S 1L \fING I race tn~. > --- , ( ~ ( ~ -.-J`Lc~M L I ~-J.LJt C~/~~1 I~'O Icntp~ran ~r.n r n,.u6:rr ~ -- - 13uri.tl ~lothine ~ -_ _-- 1` ,n,. late: ,etnexr.: ~,r a~em,u,•rs reyu~rcment~ i~a':e requitrd the pur;hasc ,f t )they darhir~ -- • -`- -- am' ct the ~'c•n15 IisreJ a:~rn~. r6~ I„t or reyuucr°:~nt i~ _~riainrd bc!t~t~: a~nr that I hate e~~an:ined thr itrnt> :d ~or~ds ,red .eni~~~..~,{~cttd ahrn'e and t~~un~i rhe ~ m ~~• br correct an~1 ac,ordin~ rn rhr uranren•:c°nr~ ~ 'tat~e reyuestcrl. 1 .rl :ott'ed.,r re -eihr t,f .t a~pc ~~(th+.- ``t.nemrnt ~,I Fun r 1 + r ,ds t '. ~~~ic~ ~~_ted. I rrpre-,rnt rh ~ at i + ,:-r •utii;ient fund: i:~ail.thl - 1 ,r p.~t n -n. r she cash Fnc< fir r'.~c• ~nn~l:; .utc cerncr srlectrd. I .tht, a,rer a, mai,r !~" i, .nr ~ < _--•,lnain _C ,/ : /~ {' :., > I a~,;-ee tr I•e u+nd, an::e ~eralk I .thlc ~~ci-..u,;onr eltt ~chr ~i~ns i eln:•;. \ I:nr Thar<~e ~t1 `; fD her n,n~,th .t~tr~~~uttin~ +~~ ~ ~~ ~~~ per-.rtr:s ill f•e .t~~F[ird to the unpaid h.tlan:r I °_innutF____(ZQ dacs f;~r~m the d;tte ~,f th,~ :+~recmrnr 1 t~.ill ,tlsn i•,tt ro .ire F.+„rr.tl .~itector all r~'asnna!~le msrs pair ht~ dx F ~.meral Dirrc ~u m rolls anr~unts I ~~:ce und;r tlti. agreement. Th~,:r a,sts n, tt include annrnrt ~ Irr•- ~tu+rt .usr=and •~'h, r , > ;1~tt~ addi~mnal ~ertice, ~r me-~La,tdisc ~-diced w reyue~ted etier nc~ ~i, re u1 this aer:r;r:nr •:cill he atnsidereti hart n- rF is a~rccma, + thr coot tLr~rul hill ~ tehlrtai ~ r e f~n.;l bi!I ~.r st:urment. i~cali ~~ ~ - ~( /~ i Ct " i Puri!,; ,i~! -- +ticai? _ ~:t C~.-h ~.~ ' tl.+lr nerd FIIiCrif ~'. r[l"~r~ Page 1 of 2 3~ 7~ JUt~17~i 1. SCH4LL ` 130 E. LAC U S T ST. 6~- i 841313 MECHANlCSBUAQr~ PA ti055 Date ~ ~~_ t~~ ~ / °~ Pay to the ~ ~ )~ Order of ~ ~ ~ ~ ~ ~ 1 `~ ~~(J~-~ ~Jallars ~ « ~w Camrr~er~e ,,,,,,.~, ~~ ~~,,..,k„f ~~~- ~ank r-~.-s~~.~ I~ ~:a3~3C~L8~+~~: 5~ 2L06~,i. D 3L?6 Acct# 512106410 - For $249.10 - Chk# 3176- 06/03/2009 ~ • . • a • . r . ~ ~: ~ - a ~.--~ ~--„err-T~~ . ~ 4 r ~- j w ~-~ V ~o t" G V. ~• ~_ ` .~ ~ r~i ~.~ G-7 ~ ~'~ ~ ~~~~ .....i...:..~ _ - Cn ~ ~ ~ 3 ~'~.~ ~ ~ i~•}~ ~ i..~ ~~ L~ Q L!~ rt~i Acct# 512106410 - For $249.10 - Chk# 3176- 06/03/2009 rTi T 1,1 ~' /j\ ~~' ~~ ~ ~~~~~ ~~~~~~ ~~~' 1~~~~~~~ 4~ ~/~/!'.,, r`/~= .~py1~[ry ~y/~y} rt1/~yn, ~®\ .~ry{~.~~'F/ (}jj~~{Fq (~(~( /I'~~5 PLEASE LIST REPRESENTkT1VE'S NAIdtE Af~D TO WHOM SEGUR(TY DEPOSIT GHEGK SHOULD SE MAILED: Representative's fume (Must Attend the Event) Security Deposit Gheck - Maif To: {v1~~~, ~i~...,~ ~~.-~ c~c.~~ Name ~~~t- ~r~'~~" ~ ~Lr 2~ -'~iiA ,~ Address Address '~-~ C3 ~'j C ~ !~`~ ~ ~ c~L- rt~ 1..~i~~~ Cam= ~-~- ~. ~ L ~ ~ ~. ~ ~~ ~ 1 ~ c~ i Phone # ~ C~ - "?2~ ) fume and Address of Organization, if any 3~5-y~75 ~_ ` r t3~ ~„ . DATE RE(~UESTED: ~ EVENT TIME: ~' _~'~ ~ ~- CSO TIME: E ~ Cass ~~ FEES: RENTAL FEE {Upper, Lower oth $ ,~ ~~~ ~ ~~ $100.00 SECURI POSIT $ - ~' Serving Atcoho{? es No $ i p0. .~-._ Additional $100.00 deposit ,,/• ~~ ~~ TOTAL AMOUNT DUE ~ W'tt b t t7 Y /(~~ TYPE of EvENT: r you a using a en . es Wiff you be using a Disc Jockey? Yes /~ Other sound system? Yes / No Vlli{[ you be providing any Large games where proof of insurance is required? Yes lease include) R~i'U~~ GOMPLEi'ED APPLlCAT101~ WITH PAYMENT NQ LATER THAI: f have read and understand the rules and regulations governing the use of the °8arn" at the LowerAlten Community Park and i agree to comply wiin ail i~he requirements as stated. !agree to assume a/I responsibility for any damages Incurred beyond normal wear and tear and also assume all lta6111ty for personal damages or injuries incurred fhrough use of the facility and relieve Lower Allen Township and its officials of any responsibility for such activities. AUTHORtZEf? SIGNATURE ~ DATE G><>~?G>G><><>~>G><><>G>G><><><><>~><><?<><>C>C><?<><><><?~><>C><><><><><><? FoR oFf=ictAL usE ONLY: Date Application Receiv /Fee Paid: ~ ~ ~ / ~teei"t~# `r ~~~~ 1~.`~ t ~- ~• r- APPROVED DISAPPROVED Securi De osEt Returned ~ + '1 ~ p ~~ ~t ~~i~~ 4~,~ . i ,. ~ 04 10 10:09a Gingrich Memorials 717-266-8007 P,2 Y zn ~rzc ~~6 -o~.5u MEMf~ RIAIL,S Since 1921 ~ ~ # t p 5243 Simpson Ferry Rc~~d, tilechanicsburg, PA 17050 (717) 766-5622 • Fax (717} 756-007 • cvu.~,v.gingrichmemorials.corn ~eh~aw~t'~ ~....y or s vn~r i a~~ ~ ~~n 1rQ.v~z~ ~- ~ p~,~, ~ d~ ~ s ~ e. ~e ~ ~ P `' u r ~ ~° tr rr ~ ~ 3 ~ ~~ ~ 5 a~ ~ ~ a~~~~t~ ~ -~~ c~~~}~a~ C y ~ra~C t„ ~ ~ ou,~ c ~~ ~ C~ ,~ ~~~ ~ ~c~~ ~~5~~~~~~~- 1 ,- ~, w ~ c`~u-~ ~- (' ~~~ ~ a,~a°' J ~ ~o Y ~ a ~~o ~Z C~ owl v~ ~ ~ ~ ~ ~-T~-e r' P ~ ace(M_cn.~" :~ t., o c~ 1.~ (.~ `° ~J r b •,~ et ~~ ~~. N e r''`v ~~a .u~ N ~ W Z 4 w t11 O V ~ Z o Q r ~ ~ Z °' -L r' r~ o r z a o Q N Q s~; c a= ~ ~Q ,'.. U ----..s `'-~-. i~ ~+ { ~, ;} ti ,F i ""C ~ ~~ ._ r ,.a cD T ti ..+r .# tP .. r N T •~ ~ ;~ o i ... ~ d r ~d V ~ o. W `° ~ ~ ~ a~ O ~a 'HETRO BANK ~, ~ ~~~~ 1 ~~/~ ~~ ~" JUDITH I. SCROLL 3177 G~ Ciry 730 C. LUCUCT ^,T. ~} ~ uriauJl,l ~ 4 NCCFfANICS6UfiO. NA 1705.`r j'j;~~ yl.Q..O` ~ ~-\`W C~ ~V ~o ~~ Yaytothl~ ~C_47(2:t~-S' ~~--~~Q,~3-~- ~:~1p~. 1 U,r~uuc~of___Y ~L I'- - S ~~T~ SI y'~~(L Y ~~ ~I~.LQ~ +w Dullur:, ~ ,_,.. " Commerce ,r ,~ ,~„~„„,,,,, ~ L~ I'o r~l .'1;~.~(1~,1v._\C ~Y i31.7"14~c1~~j _ .. ~ :1 q I:Oii3Qi846s1: Si 210641 Ou 3177 #3177 20090615 $268.00 .~~~~-+~ ~- 3180 JUDITH 1. SCROLL 130 t. tDCUST 5T. /n ~ ~ ,~ ` ~ 60-iMr313 ML~CINNIC89URG, PA I]OS5 //~~ ,, a DAEe V W~~ O~/V W P:+y to l.hl+' ~ ~/S'a nA-v R t~~ l _Q rn~x+.t $ (_ ~ <.t2 ~~j~h 1 .SLEu 9 ~ ~~ I For__ t:^ 3 i 30 i846~: S i 2 1064 l Oil' 3 180 #3180 20090702 $650.00 JuotrH I. scNOLL ` 3179 130 E. LOCUST Ft. MECFNNIC68UHl±, YA 170!3 q ~w~ N-In..au U1tf ~~ 07w~ B6 1'ay tnthe ~~ -Clfl ; (~ I1Y1,«i'~(4,~.~,~~ :-4.4tCfp-.~l__~ ~ ~~J.~p ~~ Unllars 6 w` C ..,...~ .~.,~,,..,.......,..~ ~ ~ Fnr-.~IlY1~Catt~ttt y ~-1 UYI() 1, ( J' ~ `~ ------ I:03L30i846t: 5i 2i~64i i 3i?9 - - .>!r~~ #3179 20090702 $1,350.00 ~~ ~ ~ ,\ ,\ ,\ ,\ ~~ ;~ `,~ ~, I~..~~~1 ~~r' ~, lug,,,, X1»1 ----~... ,r - - ~ i I ~~ ~. CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2663 November 13, 2009 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: Mark E. Halbruner, Esquire Benjamin S. Lyons 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: October 30, November 6, and November 13, 2009 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 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date: 7/01/2009 Cumberland County - Register Of Wills Receipt Time: 12:43:30 One Courthouse Square Receipt No.: 1057340 Carlisle, PA 17613 LYONS BENJAMIN S Estate File No.: 2009-00617 Paid By Remarks: GATES ET AL JN ------------------------ Receipt Distribution ----- Fee/Tax Description Payment Amount Payee Name PETITIONS 15.00 CUMBERLAND COUNTY GENERAL FUN CITATION 20.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN ---- Check# 12507 ------------ $50.00 Total Received......... $50.00 J PA REV-1500 SCHEDULE I DEBTS OF DECEDENT MORTGAGE LIABILITIES and LIENS Holy Spirit Hospital 503 North 218' Street • Camp Hill, PA 17011 • (8001 596-9997 Your Account With: Holy Spirit Hospital Account #: 338779?9 For: Benjamin S Lyons Admission Date: U?/04/09 Total I)ue: X226.00 Dear Benjamin S Lyons: June 1, 2009 Perhaps you overlooked our recent correspondence in which we notified you that the above referenced account is still outstanding. W`e are wiiiiti~ to work with you t. resolve this account. Payment in full is preferred but if you are unable to remit the entire balance due, our representatives are prepared to work with you to reach a mutually acceptable payment schedule. If you have any questions regarding this account, please feel free to call this office at 1-800-596-9997 and speak with oi~r~ of our representatives. Once again, thank you for choosing 1-~oly Spirit Hospital for your family's health care and for resolving this outstanding balance. To assure proper application of your payment, please attach the bottom portion of this letter to it. If you wish to pay by credit card, please complete the required information on the reverse side of this letter. If you have insurance that may pay all or a portion of ti~is debt, please complete the information on the reverse side of this letter and return the entire letter. Sincerely, Holy Spirit Hospital ***Uetach Lower Portion And Relum With Payment*** Account # Total Due: OM~IRI10 PO E3ox 1 UL Wixom MI 48393-1(122 .lone 1, 20U9 33877929-192 173636607 ~1~1~~!'~~~I~~illllllll"~IIIIII~11111~1~~'ll~ll~i~l~~lll~ll~~~l~ 13cnjatni 5 Lyons 130 E Locust St Mc;chanicsburg PA 1705-3H40 33877929 $22(1.00 Holy Spirit Ilospital PU E3ox 822183 Philadelphia PA 19182-2183 I.~~III~I~~~~~lll~~l,~~1~L~1~1~~~111~~1~~~11~1~~1~~~11~~1~~11 IONFIR110192 000033877929001000DD022600001,00735000000D1],300 C;l',Mf' i-IILL ~=NI:I:~GENCY PHYSICIA ~'CJ BC~X 13U9:~ PI-IILArJcLPHIA, PA 19101-3693 tit{~~r>r~~~~>frl~~l~~~i~~,~t~~~~~w~~~>t~ u « ~~i~~t~,~~~ n u {~i 08251,6-00000338?7929-06 #BWNJFDB #OOQOOOHYP23211 ~5# BENJAMIN S LYONS 1:30 E LrJCUST ST MECHANICSBURG PA 17055-3840 STATEMENT OF ACCOUNT (~} Statelttent Date: May 29, 200J - _ _ - - -~ ACCOtDNT NUMBER: HYP33877929 ~- __Pat~ent Narrie BENJAMIN S LYONS J lax ID #l ?0-4667340 Account Balance: g',g49.00 Amount Pending Insurance: $0.00 Amount Due From Patient (Current}: $4~r9.00 Amount Due From P_atie_nt (Past Due): $0.00_ Pay 71ris Amount: $449.00 C------------ - - 1 PLEASE F1EM1T PAYMENT l3Y "PAYMENT DUE 8Y" DATE. THANK YOU. Please refer f:o coupon below fur payment instructions. - ------- Date -- - # I DescnpUon } Chorge Paid 6y P~ud By F'vd ~fy Amount Due Frorn F'A fIENT I Fast Ins Other Ins Patient Adjusted insurance E~AI AIdC:E ~ - _---~ -~ ~ - - U'.'Jl)41t)J 1 99283 t_IV{f_RC,EPdCY C VAI_ t; MC3M i $4U1 OU (LVL 3) G>Y 462 DR FI~JARDCllI IC,LY `,PIhfT HO.~F'ITAL ~ nqr r~lncr ~ rt f .t rPAr a c= r,ir, rat ~Pr,r r~F cROP.A l'Ar•rik g-n nn ~ ~ y nn, 001 )l`l Ir1C,i 0 4. I _ !11 ~!'/i 7~ _. rJ~~rJ ! 1 nc-I,.,` ~~.~L:.L I ~_ _ _L I.J.~,~, ` 4:1 t'.:iQ i W i I ~ ~ rrTIME.IKY f>X Aci? r)~ f A.IARni~rM(71 Y SPIRfT yIOSPiTAI_ I 04/22/09 ~ j I IrJ~URAI~JCF_. f~ICr KLSI'~~PJSL FRONT I'AYOR ~ I SCI (]0 i ~ 548 00 4 ----- I L-- _-_----------- - T4TALS. -- b44y 00 --- ~~ ~U -- 5~~ tttr ~o ou ~o ao ~r~ oo ~44y oo~ Important Messages: Tlds statern~_nt is for the duect trcatrnerd and/ur supervrsron of care you recently received from an Emergency Physician at Holy Spirit Hospital. The fees for this pnvate pl ~ysician are billed separately frum any hospital charges ur other professional fees for which you may also be responsible Therefore, should you reserve a bill from the Iwspdal i,r other p4rs~aans fur charges rn connectrun vwth this visit, it will not hn:;lude the dems listad on this stalerrrcnt "Payment Plans" Accepted Questions about this statement? / L1ame de Lunes a Viernes? Call 1-800-355-2470 Monday thraugh Friday 9:30AM - 4:OOPM. Your automated system access code is 0801-3387799, or you can send email to billing_questions~emcare.com. ~'~ Please detach and return bottom portion with your rentittance. ''J~ QENJAMiN S LYONS 130 E LOCUST ST MECHANICSQURG PA 17055-3810 YOU MAl' PAY THIS BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE. Make Check/Money Order payable to: 1~~~~11~i~r~..III{~-~r~~~~~~fi~~if~~l~ir~~rlf~f~~~li CAfy1P HILL Eiv1ERvENCY PHYSICiA PO BOX 13693 PHILADELPHIA, PA 1910 i-3693 STATEMENT OF ACCOUNT Statement Date: May 29, '?U09 ~ ACCOUNT NUMBER:HYP33877929 _ ___ Patient Nam_ _e: BENJ_AM_IN S LYONS _ _ __ ~__ Payment Due By: 06/19/U9 Amount Due: $449.00 ~rn3rtnt Fn~incnrl; ~--~_-~~ __~~ L------- - --~ ThP insurance intonn~lllGil in our file aprears beiovi Please make any sorrectn~ns and/or adchtrons on file reverse side of this form and return d to us i-Hank you rf IASL>1 HF NI THAIVIE=flICA 80Ui51545601 17221380001 2b1_'tj ATTfJ GRCrUP HEALTr-I CLP.IMS LGhJD~:~PJ K'! 4 074 ^ If your address has changed, check this box and complete the reverse side of this for~rn 08251,6000D0338??`i290004~9D00d00000000005 ETR4 BAN K C c:2'r' Transactions By Date Date Description Debit Credit ~~" ' ~~"° ' `' ' `' ""'1^^ POS RF#945739 06/14 MECHANICSBURG,PA $112.49 $6,929.30 06/1.5/09 BOB EVANS REST # $22 95 POS RF#030078 06/14 MECHANICSBURG,PA . $6,906.35 06/15/09 CHECK $268 00 06/16/09. 5032 SIMPSON FERRY . $60 00 $6,638.35 WTH RF#001815 06/16 MECHANICSBURG,PA . $6,578.35 06/16/09 COMMERCE BANK $~ 92 ,- _::' POS RF#001814 06/16 MECHANICSBURG,PA $6,570.43 06/46/09. SALVATION ARMY # $19.56 POS RF#001028 06/15 MECHANICSBURG,Pq ', $6,550.87 06/16/09 CHECK $140 27 ~' 06/1'6/09 CHECK . 8 09 $ $6,410.60 06/17/09 POS CNS JOANN STORES . °` $112 65 $6,405.51 RF#553855 06/17 LEMOYNE,PA 121443 . $6,292.86 06/18/09 WTH 2 WEST MAIN &TREET $62 75 RF#422232 06/78 MECHANICSBUFtG,PA' 170638 . $6,230 11 06/19/09 HIGHMARK INC DEPOSIT '' U, _ ~ 0018300 SCHOLL,JUDITH 1 ~ $1,405.39 $7,635.50 06/19/09 POS` GIANT FOOD.#331 ~ ~ $115 84 RF#605713 t)6/4.9 MECHANICSBURG,PA 131405 . $7,519 66 06/19/09 POS CVS 1626 5305 SI $70 00 - ` ~~'~ :~:<: RF#864045 06/19 MECHANICSBURG,PA 134415 . $7,449.66 06/19/09 CHECK $15.75 ' • 06/22/09 WTH 1745 BROADWAY $162 00 ; _ $7,433.91; RF#768782 06/20 NEW YORK,NY 115421 . $7,271.91 06/22/09 VISA SALYATION,ARMY # $33.43 RF#001040 06/19 MECHANIC5BURG,PA 223746 $7238'48 06/22/09 VISA BOB EVANS REST # $8 26 ,. -. RF#018002 06/20 ALLENTOWN,PA 191354 . $7,230.22 06!22/09 POS CVS 1626 5305 SI $143:43 RF#24D993 06/21 MECHANICSBURG,PA 432812 $7,086.79 06/22/09 VISA ASHCOMBE FARM 8~ $44 47 RF#001196 06/19 MECHANICSBURG,PA 211734 . $7 04 2'32 06/23/09 CUSTOMER DEPOSIT 06/23/09 POS GIANT FUEL #331 $37 46 ` $500.00 : $7,542.32 83 06/23 MECH . $7,504.86 06/23/09 SU ,. SERIAL MBER:' 3184 Q1079062 0 ~ $7,49 8 .; RF#988760 06/24 CAMP HILL,PA 112411 7' 06/24/09 POS BON-TON CAMP HI $50 35 RF#332714 06/24 CAMP HILL,PA 114136 . . $7,427.61 06/25/09 POS OLD NAVY USA RF#542003 06/25 CAMP HILL,PA 142603 $19.50 $7,447.11 06/25/09 POS GIANT FOOD #331 $48.95 RF#836977 06f24 MECHANICSBURG,PA 18014D $7,398.16 06/26/09 WTH 742 WERTZVILLE ROAD $100 00 RF#004318 06/26 ENOLA,PA 165255 . $7,298.16 06/26/09 VISA. ALLENBERRY THEAT $220 00 RF#091470 06/24 999-9999999,PA 040915 . $7,078.16 06/26/09 VISA INTERNAL MEDICIN $20 00 RF#050004 06/25 MECHANICSBURG,PA 055718 . $7,058.16 06/26/09 CHECK $700 00 06/26/09 CHECK . $756 00 _ $6,358.16 06/26/09 CHECK . $5,602.16 06/29/09 VISA NISSLEY WINE SHO $150.00 $5,452.16 RF#033039 06/25 CAMP HILL,PA 234959 $27.99 $5,424.17 06/29/09 VISA VI'S NAILS $35 00 RF#000004 06/25 MECHANICSBURG,PA 211512 . $5,389.17. 0512106410 Page 3 of 8 Page 1 of 1 Hauser's Automotive Repair invoice Po Box 144 3507 East Main Street ~ 6867 Morgantown, PA 19543 Estimate Ref #5,456 Shop Phone: (610) 286-6116 Date Printed: 07/24!2009 Fax: (610) 913-7713 Printed Time: 4:27 pm Email: fhauto@dejazzd.com Hat/Ref: SPECIALIZING IN V1/V & AUDI REPAIRS Time Promised: LYONS, BENJAMIN S. 1986 VOLKSWAGEN SCIROCGO DLX L4 1.8L 1780CC FI GAS N A JH 130 E. LOCUST ST. V1N: WVWCA0530GK013455 MECHANICSBURG, PA 17055 License: GWE4632 Mileage In: 0 Date Written: 7/24/2009 12 OO:OOAM Home: (717) 395-7049 -Matt unit #: Mileage Out: 103,148 Written By: cell: DoM: Save Old Parts: No Job Name Description Technican Qty List Extended Job #1 Labor per hour Work Requested -Dr ain cooling system and replace radiator/ Refill co~liny ~- 80 75.90 z31 9 system and rc~:heck ~ -~~hicle operation Part FZadiator 1.00 155.00 155.00 Part Radiator fan switch 1.00 19.90 19.90 Part Glo Ant Global antifreeze 0.50 16.00 8.00 Job Total: 242.90 Payment Date Type Method Amount Payment Totals: Thank you for your business Parts: $182.90 Labor: $60.00 Sublet: $0.00 Misc: $0.00 Hazmat: $0.00 Supplies: $0.00 Tax: $14.57 Invoice Total: $257:.47 I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission to operate the car or truck herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto. Authorized By Date Time .~. at&t How 'I'o C'ontact Us: . I -8(N)-331-05{){) ar b1 1 tram yen r cell phone • F~~~r U~a~I'iHar~l ~~i•T-1e~tirin~ ('ustt~n~iers (TT1'/TllI)} 1-8Gf~-?41-G567 Wireless Number with Rollover 717-?15-74?U - 4~~y Minutes Page: I c~i ~ • ti Billing cycle Date: 114/06/U9 - OS/OS/U9 Account Number: 4tu1t112fi42025 ~~...~~ Previous Balance 125.87 , Pavrr~erit Posted _ ~ n-10t~;4~(J >1'A~T nT)F. IiAI~~NCE 75.87 IS~,ya>al~ lmn,~d>i~-t~ly Monthly Service Charges ~1T:59 Usage Charges 1.79 Credits/Adjustments/Other Charges 9.84 Government Fees & Taxes 4.12 'TOTAL;. ['III2lZEN`l' CI11t-I2~'E5 5f .34' Dnc 'lay 28, 2[109 I~sttctees ~-ssosged after ,htn tIS Total AmounlF Dine ~~~.21 ***This Bill Includes A Past Due Balance*** lf'payment has already been made, thank you, please disregard. If not, payment n-lust he made irnlnedtately. Please send your payment, Including current charges, in the enclosed envelope. You may also pay 24 hours a-day, by major credit card or electronic check at 1-800-3> 1-0500, or att.com/MyV4'ireless. If your service is suspet7ded, a reconnection fee will a~ply. If yolt have yuestlons regarding your account, contact us at 1-800-947-SU~6. ~~ C .m ~ °~~ ;: ~; -~~ ,:,~ j,~ `4..A3 J ~ '.• ,.: `~'" o ~ ~ „ „,~ .-.~ ~' " "rte; ~t,, ~ w ~'~~f.% : _~. ~ ~ ,. ~... ti,,~ ,. ' ,~ #BWNJSZT #054640126920254# AV 01 021009 23311H105 A**5DGT BENJAMIN S. LYONS 130 E LOCUST ST MECHANICSBURG, PA 17055-3840 I~I~~~~~Iil~~l~~~~lllll~~ii~~lll~ll~il~l~l'~~~~~I~I~I~~~I~"~IIII Return the portion below with .,~. ; '` ~----- payment only to A'FScT Mobility. ~ r "~k ~ ~` Account Number: 464012692t]25 ~ • Total Amount Due: $82.21 Amount. Pafd: ~- ~, ,, ~., r~ ease c o nol sear corresponr ence mil r },c{~~nrenl. ,~ f~ f .~ ~, Yes, enroll me in AutoI'ay ,; .~ . ~.: Signature required on reverse " ~~•~ Please Mail Check Payable To: AT&T Mobility PO BOX 537104 ATLANTA, GA 30353-7104 I~~~III~~~I~I'I~Ilii~lllll~~'I~~I~II~i~~~~~~~~~llilll~~l~~~li~'ll 921,00464D1,26920250000000000563400000D08221,D08 ~~ . ~ . ~.,. ~ ,~, ~~ ~,~ ~-°~ .~ ~~ ',. a.. ~~ 06/24/2009 "1 smith Barney David C. Scholl Dorothy J. Scholl Jtwros 920 W oodley Dr Mechanicsburg PA 17055-9175 Account # 1010646846 Dear FMA Client, Enclosed you will find the Financial Management Account (FMA) check copy(s) that you requested on 06/22/09. Please note that a check copy is certified and valid proof of payment to any merchant, including the Internal Revenue Service. If you have any questions, you may call the FMA Client Service Center at 1-800-634-9855, Monday through Friday from 8:00 a.m. to 11:00 p.m. and Saturday from 8:00 a.m. to 5:00 p.m. EST. If you would like to request additional check copies, you can go to our website at smithbarney.com or contact the FMA Client Service Center. Thank you for doing business with Smith Barney. Sincerely, FMA Client Services 800-E34-9855 Financial Management Account is a service mark of Citigroup Global Markets Inc. FMA is a registered service mark of Citigroup Global Markets Inc. *03b000Dg0~ - - U9/29/2008 0 _ ._ - ~ - r--- - ------~ 6 316 4 5 4 5 7 5 O DAVID C 5CHO1L CltIQCOl1~ 1976 ~ ~ ~ DOR07t1Y~SCHOLL S~II~'~r This i s a LEGAL. COPY o f your check . You can u s e i ..a m t ti m g40w0001EY DRIVE ~ .~. 2~ 7~~ ~ er7zesn~z , , MECHANICSBURG, PA 17050.9775 the same way you wou I d ~ ~ / ~ llr. use the or 1 g i na 1 check . C ~ ~totlx C~J ~~+, c~ ao $ 25Lo oaf . R ~ ~ ~ ~ C ~ ~. ~ L'~ O O '0 ° m O SFI.F,cr Cc ~ Rnn.ara.n~a - FZ1iA AccoWr ~ r ~(t ''a O i CuiEint Ys t. E~ilt~ool gQfi, kJ. J O O c -nr-; - 7~ - r3'~' m Far ~ ~:02i272S55~: LDL06468~+60~ 1976 41:0212726551: 10 10 6 4 68 4 611'1976 ~I'0000250000~i' i._ .. -- ,~ a ~ W N W ~ N CD p 4 °Q' D o fh wn Q. ~ ~ ~ r~ a "U r 0^ • ~ r p ~. • ~r U2 ! 2 ~N 55 ~,;, w N i 19 4 ~i~tUE~6a~'~i '~lR~ttf_iF~ ~ ~ ~ N VIN - - -Q - - ~ ~ ~ a ' y0a not endoae a writs below this ifnsi Posted 09/29/2008 Bank 0030 R/T 002127265 Account 1010646846 Check 1976 Amount 2500.00 DIN 614156006842300000 '~ UNITED CONCURDIA DENTAL www . uccl . coM EXPLANATION OF BENEFITS DENTAL CUSTOMER SERVICE P.O. BOX 69420 KEEP FOR YOUR TAX RECORDS HARRISBURG PA 17106-9420 Subscriber: BENJAMIN S LYONS ID Number: XXXXXXXXX Page : 1 of Patient: BENJAMIN S LYONS Provider: DANIEL F DUNN JR DMD PC (1720180292) Claim Number: 09091275768 Date: 04/02/09 PROCEDURE DESCRIPTION PROCEDURE CODE (NUMBER OF SERVICES) *TOOTH DESCRIPTION SERVICE DATE(Sl PROVIDER'S CHARGE ALLOWANCE AMOUNT PAID AMOUNT NOT PAID REMARKS 1 SURF RESIN POSTERIOR (001) 03/28109 96.00 .00 .00 .00 J1020A D2391 *15/0* ONE SURF AMALGAM (001) 03/28/09 96.00 49.00 .00 49.00 DEDUCTIBLE D2140 47.00* Q1050 *15/0* X5018 J9490 1 SURF RESIN POSTERIOR (OOlI 03/28/09 96.00 .00 .00 .00 J1020A D2391 *21/F* ONE SURF AMALGAM (001) 03/28/09 96.00 49.00 48.00 1.00* DEDUCTIBLE D2140 47.00* Q1050 *21/F* J9490 TOTALS 192.00 48.00 48.00 144.00 ~ ~~~ L~l..,l~'L'~'L~ r You can view or print a copy of our Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice of Privacy Practices by visiting our website at www.ucci.com and clicking on the HlPAA Privacy Notice button or by calling 1-866-295-2352 (toll free) to request a paper copy. [f you are covered by more than one health benefit plan, you should file al! your claims with each plan. UNITED C+~NCORDIA PO Box 69407 HARRISBURG, PA 17106-9407 BENJAMIN S LYONS 130 EAST LOCUST STREET MECNANICSBURG PA 17055 HAVE A QUESTION? PLEASE CALL 1-800-332- 0366 Business Hours: Sam-8pm E.T. Service for the Deaf via TDD Equipment is available at 1-800-345-3837. THIS !S NOT A BILL DN130869 1105-S Current Dental Terminology © American Dental Association J&.J Auto Sales and Ser~jice :537 Hartzdale D>f~. S><><itel Camp Hill, PA 17011 717-737-7775 www.jandjautos.com Bill To Matth~:~~ I,v~~n~ 1301: I,~~rust St ~rl~~rl~:z~~i~~h~:rr l~n l~t~; 717-3~)~-7U~~) Invoice 4 Date Invoice # :"` lip , I%I1!?U1O 7R1 Vehicle fnfo l~)K(, VVV ~cirr~~c~~ LIC#(iVl~l~:~t63? Brakes & Tires Inspection Sticker Emission Sticker Description qty Rate Amount Il~;~~ic~vc and R~,hlacr. I)rivcrs r~~lc 1 h~.OU r,S.UO ~ L3uaclt ltcbuill ~lltcrnatur i I ~~1.U~1 I l~.t--t kem~~~e and Rchiacc nltcrnat~~r O.i b~.OU i~.?(i ~i ,~,4,~i~~~ I ~ 1 l f I i f 1 dJ.UO ~15.U+~ ~ w 1 1 ,, I, ~ I I I l l ( I 1 s I ' Sales Tax (6.0 0) ~ I ~.~~ Total ~ ~~-~~~.~ -~ ; ~- . ,,~ ~, J~J A.uto Sales and Se~•vice ~a 3537 I-lartzdale Dr. Suitel '~`~~- ~ ~ ~ ±~ Camp Hill, PA 17011 717-737-7775 www.jandjautos.com Bill To i Matth~~~ I,~uu~ 1301: I,s~cutit ~t n~lcrhanic~;h;sr~~ I~:~ 1-~~~:~ ~i 717-3')~-7i1=t~) Invoice Date Invoice # I,'1 ~!?(t I n 7~~4 Vehicle Into I~)R(~ VW' tiC'(RR(K'O Brakes & Tires ~ Inspection Sticker ~ Emission Sticker Description Qty Rate Amount f)(z Fr~~nt rule I (.y,~~9 r.<> t><> I I i I Sales Tax (6.0 0) `~-~~~~~ Tota I ~7~ I ~~ *** END OF ATTACHMENTS ***