HomeMy WebLinkAbout09-30-10 (3)1505610143
REV-1500 EX (01-10)
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year Fife Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 60X.280601 INHERITANCE TAX RETURN 21 10 0318
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
180 05 6823 O1 03 2010 12 25 1916
Decedent's Last Name Suffix Decedent's First Name MI
SHARK LESTER M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise
(date of death after 12-12-82) ^
5. Federal Estate Tax Return Required
g Decedent Died Testate
(Attach Copy of Will)
^ ~ Decedent Maintained a Living Trust
(Attach Copy of Trust) _ 0 8. Total Number of Safe De osit Boxes
p
9. Litigation Proceeds Received ^ 1 p. Spousal Povertyy Credit (date of death
between 12-31 ~J1 and 1-1-95)
~ 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
AMY M MOYA 717 652 7323
r~.~
~-
First line of address
5011 LOCUST LANE
Second line of address
City or Post Office
HARRISBURG
State ZIP Code
PA 17109
REGISTE~VILLS U$$ONL~f,i~.: ~. ,.
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DATE FILED ~
Correspondent's a-mail address: AI11y@LedererlaW.COm
1
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 personal representative Is based on all information of which preparer has any knowledge.
SIGNATURE OF,P..E SON RESPONSIBLE FOR FILING RETURN DATE
,--
.• ,..
,. -- ~' Ste hen M. Shaak ~ ~ .
802 Chippenha~rt Road, Mechanicsburg, PA 17050
SIG ATURE OF PR ARE HER THAN REPRESENTATIVE ~ DATE
~ Amy M. Moya _ ~~~~-%~
5011 Locust Lane, Harrisburg, PA 17109
Side 1
L 1505610143 1505610143
J 1505610243
REV-1500 EX
Decedent's Social Security Nurnber
Decedent's Name: Shaak, Lester M. 180 05 6823
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages 8 Notes Receivable (Schedule D) ........................................................ 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5.
23,850.67
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous Ian; Probate Property
(Schedule G) u Separate Billing Requested............
7. 1 O 4 8 7.51
~
8.
Total Gross Assets (total Lines 1-7) .....................................................................
g. 34 338.18
r
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
13,033.14
10. Debts of Decedent, Mortgage Liabilities, ~ Liens (Schedule I) .............................. 10.
713.54
11. Total Deductions (total Lines 9 & 10) ................................................................... 11. ~- 3 , 7 4 6 - 6 8
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 2 O , 5 91.5 0
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. 2 0 , 5 91.5 0
TAX COMPUTATION -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 .00 15. O . 0 0
16. Amount of Line 14 taxable 2 0 5 91.5 0
at lineal rate X .045 r 16. 92 6.62
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0. 0 0 18. O. O O
19. Tax Due .................................................................................................................. 19. 92 6.62
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3
rlarnr~lon•!c f_mm~lp+P OrItIrP_~S'
File Number 21-10-0318
DECEDENT'S NAME
Shaak, Lester M. _
STREET ADDRESS
Bethany Village _
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 926.62
2. Credits/Payments
A. Prior Payments 850.00
B. Discount 44.74
Total Credits (A + B) (2) 894.74
3. interest (3) -- --
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) __ -
Check box on Page 2 Line 20 to request a refund
5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) _ 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: Yes No
a. retain the use or income of the property transferred :............................................................................... x
e i Hate who shall use the roe transferred or its income :.................................. ^ ~]
b. retain the nght to d s g P p ftY
c. retain a reversionary interest; or ................................................~............................................................. x
d. receive the promise for life of either payments, benefits or care ............................................................. ^ ~]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^
receiving adequate consideration? .................................................................................................................... x
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. §9116 (a) (1.1) (i)].
For dates of death on or after January 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 ire
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)). 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.
Rev-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shaak, Lester M. 21-10-0318
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.
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-g8)
Rev-1510 EX+ (6-98!
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shaak. Lester M. _ 21-10-0318
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
THE DATE OF RANSFER.SATTACIiTA COPY OF TIOHE DEED FOOREREAL ESTATE. DATE OF DEATH
VALUE OF ASSET °i° OF DECD'S
INTEREST ( EXCLUSION
IF APPLICABLE) TAXABLE
~JALUE
1 Monumental Life Insurance Company (Prepaid funeral 10.487.51 100.000°l0 10,487.51
contract -Jesse H. Geigle Funeral Home, beneficiary)
TOTAL (Also enter on Line 7, Recapitulation) I 10,487.51
(tf more space is needed, additional pages of the same size}
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98)
REV-1151 EX+ (10-06)
cnMMnNWFat TH nF PENNSYLVANIA
SCHEDULE H
FUNERAL EXPENSES &
ESTATE OF FILE NUMBER
Shaak, Lester M. 21-10-0318
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A, FUNERAL EXPENSES:
See continuation schedule(s) attached
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(sl Commission raid
10,745.64
2. Attorney's Fees Law Offices of Susan E. Lederer 2,000.00
3. Family Exemption: (1f decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Cumberland County Register of Wills 107.50
5. Accountant's Fees Accountant 150.00
6. Tax Return Preparer's Fees
7. Other Administrative Costs 30.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 13,033.14
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Shaak, Lester M. 21-10-0318
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Jesse H. Geigle Funeral Home 10,728.80
2 Thank you notes 16.84
H-A 10,745.64
Other Administrative Costs
3 Cumberland County Register of Wills - (filing fees -Inheritance Tax Return and Inventory) 30.00
H-B7 30.00
Copyright (c) 2002 form software only The Lackner Group, {nc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+ (12-08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Shaak, Lester M. 21-10-0318
Rpoort debts incurced by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+ (11-081
SCHEDULE J
CQM INHRESIDE T DECEDE ~RNA~IA BENEFICIARIES
ESTATE OF FILE NUMBER
Shaak, Lester M. 21-10-0318
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUN T OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT
Do of t T t (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 Graig M. Shaak Son 1/2 of residuary 10,295.75
3721 N.W. 38th Street estate
Gainesville, FL 32606
2 Stephen M. Shaak Son 1/2 of residuary 10,295.75
3802 Chippenham Road estate
Mechanicsburg, PA 17050
Total 20,591.50
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 15 00 cover sheet, as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF KEV-15UU c;UVtK ~r1tr= ~ I
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REV-1162 EX(11-961
No. c0 0~2~29
SHARK STEPHEN M
3802 CHIPPENHAM ROAD
MECHANICSBURG, PA 17050
-------- fold
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
---------- --------
ESTATE INFORMATION: ssN: 180-05-6823
FILE NUMBER: 2110-0318
DECEDENT NAME: SHARK LESTER M
DATE OF PAYMENT: 03/ 26/ 2010
POSTMARK DATE: 03/26/2010
cauNTY: CUMBERLAND
DATE OF DEATH: 01 / O3/ 2010
101 ~ $850.00
1
TOTAL AMOUNT PAID:
REMARKS:
CHECK# 8870
INITIALS: JN
SEAL RECEIVED BY:
$850.00
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
o~
BOO i~''
WILL OF LESTER M. SHARK
1, LESTER 1111. SHARK, of Harrisburg, Dauphin County, Pennsylvania, declare this
to be my last will and revoke any will previously made by me.
ITEM I. I give all my automobiles, and all other articles of personal and household
use, together with all insurance relating thereto, to my sons, STEPHEN M. SHARK and
CRAIG M. SHARK, share and share alike, per stirpes and not per capita, to be divided
among them as they may agree or, in the absence of agreement as my executor may
think appropriate; provided that articles which my executor considers unsuitable for any
minor children may be sold and the proceeds thereof added to my residuary estate. My
executor may, without further responsibility, distribute property passing to a minor under
this article to the minor or to any person to hold for the minor.
ITEM ll. 1 give all the residue of my estate, real and personal, to my son,
STEPHEN M. SHARK and GP,AIG M. SHARK, share and share alike, per stirpes and
not per capita, provided that the share of any child who predeceases me or dies on or
before the thirtieth day following my death shall be distributed to his issue per stirpes
living on the thirty-first day following my death and in defiault of any such then-living
issue such share shall be added to the share or shares for my other child.
Page 1 of 5 Pages.
ITEM III. No interest in income or principal shall be assignable by, or available to
anyone having a claim against, a beneficiary before actual payment to the beneficiary.
ITEM IV. All of my just debts and expenses owing at the time of my death and
any debts arising from my death and burial shall be paid out of the principa{ of my
residuary estate.
ITEM V. All federal, state, and other death taxes payable on the property forming
my gross estate for tax purposes, whether or not it passes under this will, shall be paid
out of the principal of my residuary estate just as if they were my debts, and none of
those taxes shall be charged against any beneficiary.
ITEM VI. {authorize my executor:
A. to retain and to invest in all forms of real and personal property,
regardless of (i) any limitations imposed by law on investments by executors or trustees,
(ii) any principle of law concerning delegation of investment responsibility by executors
or trustees, or (iii) any principle of law conceming investment diversifcation;
B. to compromise claims and to abandon any property which, in my
executor's opinion, is of little or no value; to borrow from, and to sell property to others,
Page 2 of 5 Pages.
and to pledge property as security for repayment of any funds borrowed;
C. to sell at public or private sale, to exchange or to lease for any
period of time any real or personal property, and to give options for sales or teases;
D. to join in any merger, reorganization, voting-trust plan or other
concerted action of security holders, and to delegate discretionary duties with respect
thereto;
E. to use administrative or other expenses of my estate as income tax
or estate tax deductions and to value my estate for tax purposes by any optional method
permitted by the law in force when I die, without requiring adjustments between income
and principal for any resulting effect on income or estate taxes; and
F. to distribute IN KIND and to allocate specific assets among the
beneficiaries in such proportions as my executor may think best, so long as the total
market value of any beneficiary's share is not affected by such allocation.
These authorities shall extend to all real and personal property at any time
held by my executor and shall continue in full force until the actual distribution of all such
property.
Page 3 of 5 Pages.
All powers, authorities, and discretion granted by this will shall be in
addition to those granted bylaw and shall ~be exercisable without leave of court.
ITEM VII. I appoint my son, STEPHEN M. SHARK, executor under this will.
Should my son, STEPHEN M. SHARK, fail to qualify or cease to act as executor, I
appoint my son, GRAIG M. SHARK, executor under this will. No personal
representative appointed hereunder shall be required to give bond or furnish sureties in
any jurisdiction.
ITEM IX. The term "executor" and "trustee" or any pronoun used to indicate the
executor, trustee, any other fiduciary or any beneficiary shall be deemed to apply to one
or more than one person or corporation and to the masculine, feminine or neuter gender
as the case may be.
1N WITNESS WHEREOF, I have hereunto set my hand and seal to this, my last
will, this '~ day of July, 1999.
~~z 1~%' ~4-Gti~~-'~ (SEAL)
LESTER M.SHAAK
Page 4 of 5 Pages,
SIGNED, SEALED, PUBLISHED, and DECLARED by the above testator, as and
for his last will, in the presence of us, who thereupon at his request, in his presence and
in the presence of each other, have hereunto subscribed our names as witnesses.
/~ v/'
j ~~~
19273.1
Page 5 of 5 Pages.
STATE OF PENNSYLVANIA )
( ss:
COUNTY OF DAUPHIN }
We, LESTER M. SHARK, ~• and
. ~~i~ the testator and witnesses, respectively, w ose names are
signed to the attached or foregoing instnument, being first duty sworn do hereby declare
to the undersigned authority that the testator signed and executed the instrument as his
last will and that he had signed willingly and that he executed it as his free and voluntary
act for the purposes therein expressed, and that each of the witnesses, in the presence
and hearing of the testator, signed the will as witness and that to the best of our
knowledge, the testator was at that time eighteen years of age or older, of sound mind'
and under no constraint or undue influence.
D
SUBSCRIBED, sworn to or affirmed, and acknowledged before me by the
above-named testator and by the witnesses whose names appear above on
C.~ ~ , 1999.
Notarial ~Utary Fubtlc
Debprah S. BoDatiQhin County
Narcisburg. g, 2000
fVly Gommiss~on Expires May
ti4¢mber. Pennsylvania Association of Nota~ips
19273.1
~~// Prue"~~l~ial W SH Ba -, Jo. EW41 000000679
The Prudential insurance Company of America ~C' `'~-~`~~ ~° / ~ ~~~~
Customer Service pffice
PO f3ox 7390
Philadelphia, PA 19176
www.prudential.com F~eason for Check: Cash Surrender
Check Number: D 1201605851
Check Amount: $17,550.28
Date of Check: JAN 05 2010
Contract Number: 25 207 368
InsuredlAnnuitant: LESTER M SHARK
D 1201605851
LESTER M SHARK
3802 CHIPPENHAM RQ
MECHANICSBURG PA 17050-2198
YOUR CHECK .STATEMENT
Page 1 of 1
We have atta~:hed a check for $17,550.28 as a result of the cash surrender
of this contact. This amount is based on...
SOURCE OF FUNDS $7 536.00 CASH VALUE OF CONTRACT
~2 2.00 TERMINATION DIVIDEND
$9,72.28 ACCUMULATED DIVIDENDS
r ~ r r „ ~ r t ~ r . ~ • J. ~ r }rC - J iC }rC b iC }~C }rC }~C }rC }~ iC •'~ ~ }: }rC 'r' iC iC }rC
}. }C •C }C }C •• .C }C }C •C }C }C •• .C }C 3C •. .C }C }~ ••
-The company did not withhold income tax from the amount of your cash
surrender proceeds. However, the Internal Revenue Service requires us to
inform you that you may have to include all or part of this amount in your
gross income for tax purposes. If the amount previously paid to you under the
contract is greater than the amount you paid for the contract, the difference
is reportable as gross income.
- The amount of accumulated dividends withdrawn includes interest credited in
the amount of $10.02.
For insurance service, get in touch with your representative or this office.
PRUDENTIAL
150 CORPORATE CTR DR
CAMP HILL PA 17011
TEL 717-975-8150 STE 105
(OP993EW41 }
t 5231
a~~
499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12
Phone (888)502-4349
Fax (302)934-2955
May 13, 2010
Susan E Lederer
5011 Locust Lane
Harrisburg, PA 17109
Re: Estate of: Lester M Shaak.
Social Security: 180-OS-6823
Date of Death: January 3, 2010
Dear Sir or Madam:
Per your inquiry, please be advised that at the time of death, the above-named decedent had on deposit with this bank the
following:
1. 7~~pe of Account Checking Account
Account Number 76865010
Ownership (Names o, fl Lester M Shaak
Opening Date 0228/68 closed 04126/]0
Balance on Date of Death $ 5869.59
Accrued Interest $ 0.18
Total $ 5869.77
2. Type of Account
Account Number
Ownership (Names o~
Opening Date
Balance on Date of Death
Accrued Interest
Total
Savings Account
15004213584194
Lester M Shaak
0324/06 closed 0426/10
$ 430.62
$ 0.00
$ 430.62
Please be advised, there was no safe deposit box found for the above decedent.
* If upon reviewing the information above, you believe there are additional accounts not referenced, please provide
us with an account number and/or name of any possible joint account holder. For any additional information on the
above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact
our Hampton branch call#~»-2s5-22x3.
Sincerely,
,_ `~
(t~-caLdlL
c.
N rissa Sears,
Adjustment Services
S~
ISSUI' l?atC:
-VIOl1iUMEA1TAL LITE INSURANCE CfJ>1~ ('e17iticate No ~.~~_ `Y`~'
PANy, x E. CHASE ST., IiAL'F'IlVtt3R~;, MD Z 1242
~Rl)P(JSEI3 !,'VSL~RED CROUP iL[F~', (Nc URANCiF ENRULLM~;ryfi FOI~t,1!i
First T, `..._`
~amei A~Iiddle lriitiaU '~ _ --~- --------~~
Last Name: C~' Male
~CfiafB !Soria! Security i~lumaer:
Dzte of Birth. ___ .~_~______`_
Awe:
. { Ilp f 't'ele~7hi13iC':
( i
Felna}e ~ Sociat Security Num(~oI•;
Street Adclress
~`Y;~r'1t1'' t~
Sing}£ Premium
Premium ~;
Marc Am.c>unt $
REPI:ACE~~~~'~YI' .~._ _
V~'i11 this insctrancr replace any other insuranrc or annuiiies'?
If so. ~w-it}I tivhich cc~mpan~f'? _~__ _ _
State i 'T.ip -
-~ ~._...L~..~..._.
~ 3 1'av
Annual
}4~UIlt}1ly Iii
rJ Yes ~~',. _~io
Afier payment unl~er ally assi~ntllet~ts, I'cl~lait~in~ proceeds arc to lie paid to thrr estate ctf'th~ itlsctrctl Iltlletis anot}1s.~r i}eltef iciai~, is tI~11n~<.~~:1
below: -
F3eneFciary's I~ it'st Itian?~! Middle Initial.' Last 1~laIYle: _ `~
,Il '`t#t,~'fl ~'EK~',if'IC~TI'C~N
I represent s}~ecif rte}}y fQr the purpose cif obtaining t13is insurance thtlt:
a} I am not no~~ a I?rltien in a hospita}. and
h) l have I1ot been told l~}~a~}~sician that I now 11a.ve a terminal i}}ntr.ss ctr condiiiol3.
.r
I acknot~~lt:cl„e t31at the sfate-iaent:s liven are complete and. true to the best cif Iny Icnocufed~e atlcl t?chef: ~It~ti iha~ alto t,~,f~tl;ariy
~~ili act in re}iz7llce ttlt~rectll in thi; issttanrc~ of insurance, lf'l am they applicant roe insttrtlnce on the }if'c ot't}1e,• ~rc~},<:tsed ins~iret}, ! :.:ertify
thax 1 lave <<n inslaraE~It iraterEast in his or lace Iifo anti fu}} ,ut}lorit~- tit t:st: his nr l{cr ftsncls t~_, pretlltitll;s c711 the tt~sttl•ttncc; aj I;fi.~cl 1~~r. It ~,
agreed t};at (l) "I'l~e i1lsurarlce: a}?J~ficd for is e#lecti~°e. tt}ion receipt offil~c fir:~t. Jai~~t~tiu[7t p<I~+n~ent at~tl ti~~Ii~~+ar}=1~f the ~.:c~t-~il=cat.c~: c`?~ <~1}
J?r~ntittnl c}1ec;ks <Ire tc~ Lei naaclc Ira}~;tibli trt ~.•1urlilnlct~ta} I~ifc Insur<Irlcc C:onlparr~; (3} t ha~~:; paid S.__..__._.._.___._.. tivii}1 this c~t7rt~11rr;cy~,t
foam. } utulcrstattd a cr~py c7i'this tys~ro}}Ixlent fi7rtn w}}} seI-v~ as receipt for t}1e prcnliutll paid.
FRAIaD ~ARi~fING: A.n~~ Person wh+n knuwit~gly attcl with it~ierlt to defrauii any insuraltze cotnpan~• nr other pt.~-st7t~ ~lcs ~1I1
application for insurant=c or statement r~l"cF~im +~oniainiiig Tiny rnatea'iaily false inft~a•mz~tivn car rr~nccals fnr the I~u~-J~c~se csi'
misleaclin~, info~•nlatirzn citnserning any fact tna#eriat thereto commits (in TX, may b+e +~ommittalt~} a ft•attdttletlt iltsur~~nce :tct.
ti~hich is a crirlie<3ttc# sub~ecfS (iit K~, ~~'~hich may be determilted t>y a coact: of Inv cc- fit r{ cr++n~c whicfl s~tl>jects} s~ICtt pc>I-sr,s~ try
rrimina;l atld civic penalties.
I,
~i< t:~d ~st D~Iie: `. .:..._.~..._.._._ 1tlsurecl~' Applic~int. t7~.~net•: .....__._..~.._._..... _...` :__
,. t~,~nt's Statement: 134 t>> ~r si~1lattlre 1 ccrtity t}1At, fo the best of•n1y know}ed~e, a}1 inforrnatic~sl cvntainec} iat thi•, cnrt~I[rr~Lnt tc:)rtn ~:
" ~ ,
cc7rr+:.r?, teas rec~~rc}i;d ar.curat~:}y. alld col~frtzl this enro}lmcnt form was signed iI1 trlv.prescnce.
._
1
A`ent Sign ~ ~~` .
I'rlni ;a.gent Numc: .~...__.-._ - ~:::.~ . _ ,_ . _~- .,
• _C~7ies ~a: White -'~~Ec}n«metltal Yellow -_ I~~ac1~i1}' fink _ ?~~ctri _....._.. _._________-.......__-_----.~
s
Fr .
I.,irtlited Death I3encft 1'I:~II
Doti o#• F3irth: -_
Ar>e:
..~.__
'Te}e}Tone `~ _..---.._.__._..~.___.
Cl ~ F'ti~~ rC--~~ 1 U °av
J SEnlt-,A.IlIlilal ~ ~llilrtCr~~r
lril` Orat't ~ '',.~~nthli• Direct I3if;
A99200I~ ~~;
Client ~ Contract Number
Cliarg~~ are only for those items that you selected or that are required. if we are required by law or by a cemetery or crematory to use any items,
we will ext-lain the reasons in writing beloar. If you selected a fi~neral that may require embalming, such as a funeral with ~xewing, you may
have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as direct cremation
or immediate burial. If we charged for embalming we will explain why below.
STATEMEi~TT OF FiTNERAL G04DS AND SERVICES SELECTED
PROFES5IUNAt. SERVICES '`~~~~
Basic Services of Funeral Director and Staff and Overhead $~` . - ~~'~' ~ ': f
Embalming $
Other Preparation of the Deceased $
Subtotal Professional Services $
FACILITIES
Ilse of Facilities and Stafffor Viewing~sitation
Use of Facilities and Staff for Funeral Ceremony
tJse of Equipment and Staff for Off Premise Ceremony
Use of Facilities and Staff for lwiemorial Service
L'se of Equipment and Staff for Graveside Service
Subtotal Facilltics
'i'RAI~ISPORTATItDN
Transfer of Deceased to Funeral Home (____ miles}
I3earse
Limousine
Escort
Other Automotive Equipment
Additional mileage ~_ miles r~ $ per mile)
Subtotal Transportation
0-THER SERVICES
Direct Cremation
Immediate Burial
Forwarding of Remains to AnotherTuneral Hrnne
Receiving of Remains from Another Fur-eral Home
Other
$
$
$
$~
$
$
MERCHANDISE
Casket ~-.'
TA`TAL MERCHANDISE
CASH ADVAiYCE5
Cemetery Fees
Crematory Fees
Medical Examiner or Coroner
Newspaper Notices and Obituaries
Clergy Honorarium
Music
Certified,Copies of Death Certificate
~_ ~ $ ~ each)
Other
Sales Tax
V4'e Charge You for Our Services i.n
Obtaining:
$ ..
~,
$_
$
$~
$~
$ ''
$~
$~
$~
$~
$:
$..__
$ __
$
TQTAL CASH ADVANCES $
T+DTAL SERVICES $ ..,,., TO'T'AL t?F SILL SELECTIONS $ ,
PRICE GUARANTEE : At time c,f death the above selections maybe guaranteed under the Funeral Planning Agreeiment:.:
Services ~~ ,yes no Merchandise ;: yes ____, no Cash .Advances yes n~a
xclcnfificatian of'Re+quired P+urehaaea and EXplana#i~n at Embalm~tng Charge: We have identified and described any legal, cemetery or
crc~natory req~xirement compelling the purchase of any items listed above and we have explained our charge for embalming below:
~Vlute -Fungal Firm Yellow -Family Pink - Monumental
Jcs~e H. Gcigl.e Funeral. Home
Mailing Address
3125 Walnut St.
Ha~crisbur , PA. 17109
Phone # 717-G5z-7701
BiN To
Stephen M. Shaak
3802 Chippcnham Rd.
Mechanicsburg, PA 1705Q
~~,+~1
Due Data
2/26/2010
Quantity Description
i'rof~sional Scrvicca of ataff ar-d dircctars. '
Satidhur~t Ca9kcc
Sentinel Vault
H~rclwood Rcgi~ter Book Package
{ ..
,~ ~:,
~~~ ;:
'~.~ ...: ~ .v .,
ri~rNF.r. f'AMt1,Y .FtlNF'.k/~.t. t-lc~M.~~;
1nvo~~~
Date Invoice #
.~
ux7~2o1 o x94
Perms Client
Net 30 LcsGcr M. S~r.~.-ak
Rate Amaunt
4,44'1.44 4,44,44
2,(177.18 2,077.1$
1,253.SG i,x53.5G
181.30 181.31
Total $7,gsc.4s
____.~~
Pa~rrl~~its/~red~ts ~-7,~sG.~s
----.-_
Balance l~ue ~o.ao
Jesse H. Geigle Funeral Home
_ Mailing Address
3125 Walnut St.
Harrisburg, PA 17109
Phone # 717-652-7701
Bill To
Stephen M. Shack
3802 Chippenham Rd.
Mechanicsburg, PA 17050
Invoice
Date Invoice #
1 /27!2010 295
Due Date Terms Client
2/26!2010 Net 30 Lester Shack
Quantity Description Rate amount
4 Weekend Equipment Renta!
Opening and Closing of Grave
Clergy offering
Flowers
Death Certificates
Obituary 495.00
1,565.00
200.00
159.00
6.00
329.32 495.00
1,565.00
200.00
ll 59.00
24.00
329.32
Total $2,77z.32
- ~ PaymentSiCreditS $-2,531.03
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you Balance Due ~24~..29