HomeMy WebLinkAbout10-18-10 (2)
J 1505610140
REV-1500 ~` t°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Buroau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 0 ~ ~ /~~
Hanisburg, PA 17126.0801 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
S°CIBI Security Number Date Of Death MNIDDYYYY .Date Of Birth A~ADDYYW
0 7 4 1 8 5 3 0 1 0 7 2 8 2 0 1 0 0 7 2 2 1 9 2 3
DscedeM's Last Name Suffix Decedents First Name MI
B I B B E N S A L B E R T H
(N Applkable) Enter Surviving Spouse's Irtfortnatton Below
Spouse's Last Neme Suffix Spouse's First Name MI
Spouse's Sociel Security Number
FILL IN APPROPRUITE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
® 1.Original Retum ^ 2. Suppbmental Retum ^ 3. Remainder Retum (date of death
pnor to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Retum Required
death after 12-12-82)
^ 8. Decedent Died Testate ^ 7. Decedent Maintained a living Trust 8. Total Number of Safe Deposk Boxes
(Attach Copy of Will) (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
S T E P H E N L B L O O M 7 1 7 c'~ 4 9 i 3 5~
REGIS'~FIt~ WILLS tI~ONLY;~;') :.
~ ~ ~ ~;-,
First line of address ~' ~ ^ ~ ~ -"
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6 0 W E S T P O M F R E T S T R E E T
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Second line of address GJ
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P ~
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Or POSt Office State ZIP Code
Cit DATE FILED
y
C A R L I S L E P A 1 7 0 1 3
Correspondent's s•msil address:
Under peneldaa of perjury, I dedare that I have examined thro return, induding accomparryinp sehedulss and statements, and to the best of my knowledge and belief,
h is hue, coned and campkta. Dedarefbn d` preparer other than the personal representative is based on all information or whk;h preparer has arty knowledge.
S~ TORE OF~ER30 S~ s~LE F_OR FILING RETURN DATE _
II /I nn i !I n i PT-~-/~ nM~IM--- /l)'l C ~/ c7
PA 17013
SIGNA ~ EPA OTHE HAN REPRESENTATNE 0 I~ / ( /~
60 WEST POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
1505610140
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Oh20'C95O5'C r
REV-1500 EX Pape 3
Ffle Number
DecAdent's Complete Address: z~ ~u u
DECEDENTS NAME
ALBERT H. BIBBENS
STREET ADDRESS
CITY STATE ZIP
Tax Payments and Credits:
~ • Tax Due (Page 2, L1ne 19)
2. Credits/Payments
A. Prior Payments
e. Discount 291.18
3. Interest
4. ff Line 2 is greater than Line 1 +Une 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to requoat a refund.
(1) 5,823.58
Total Credits (A + g) (2) 291.18
(3)
(4) 0.00
5. ff Line 1 + Une 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 5, 532.40
Make check payable to: REGISTER OF WILLS, AGENT
. `: j' ~ 9/8 ~` ~`~u .c~~ IR yd ~ 1'"~ ;.~ ~n i i Kia Avi`' ~{a 0 t t,. 1 ~y e €e ,,;
:: ~ r. ~.~r,s h..T.r.'~"`. ,.~~.:, ~ u... F;v~. aui2s. `v~5~''~`, 1, r.
a, . ,....~. , y"2~' .: Kflm~~C^t`v'~. ~~rciL,tw„ ±~ w #^ ik"'~ "' i K n 5~ :a t v ' c w r..~<n'.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ................................................................. ..... ^
b. retain the dght to designate who shall use the property transferred or its insane : .......................... ..... ^
c. retain a reversionary interest; or ........................................................................................... ..... ^
d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^
2. H death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideratian? .................................................................................. ..... ^
3. Did decedent own an 'in trust for' or payable-upon~ieath 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 benefiaary 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.
~~~
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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
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan.1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse ftom tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate Imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, unde
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1509 EX+ (01-10)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY•OWNED PROPERTY
ts7Are oF: FILE NUMBER:
ALBERT H. BIBBENS 21 10 0
H an aeaet was made jointly owned within one year of the decedents dam of dash, ft must be reported on Schedule G.
SURVMNO JOINT TENANT(S) NAME(S)
ADDRESS
TO DECEDENT
A.
s.
C.
JOINTLYAWNED PROPERTY:
SLE, PA 17013
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIFrION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FORJOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET !6 OF
DECEDENTS
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTERESI
1. A. M&T BANK -CHECKING ACCOUNT #9849419933 392.42 50. 196.21
TOTAL (Also enter on Line 6, Recapitulation) I S 196 21
If more apace is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERRANCE TAX RETURN
RESIDENTDE(~DENT
SCHEDULE G
INTER•VIVOS TRANSFERS AND
MISC. NON•PROBATE PROPERTY
ESTATE OF FILE NUMBER
ALBERT H. BIBBENS 21 10 0
This sdurdule 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
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NMff OFTHE TRANSF9tEE, THEIR RELA710NSFtlP TO DECEDENTAND
THE DATE OFTRAN,4FER.ATTACHACOPYOFTFEDEEDFORREALESTATE
DATE OF DEATH
VALUE OFASSEf
460E DECD'S
INTEREST
EXCLUSION
~F~wPUC~atT
TAXABLE
VALUE
t. VANGAURD - ACCOUNT #88036783261 8,245.37 100.00 8,245.37
SHARES SOLD ON DATE OF DEATH -NON-PROBATE
300.159 SHARES X $27.47 PER SHARE
2. VANGUARD -ACCOUNT #88036783261 3,118.06 100.00 3,118.06
SHARES SOLD ON DATE OF DEATH -NON-PROBATE
118.919 SHARES X $26.22 PER SHARE
3. VANGUARD - ACCOUNT #88036783261 12,641.12 100.00 12,641.12
SHARES SOLD ON DATE OF DEATH -NON-PROBATE
602.532 SHARES X $20.98 PER SHARE
4. VANGUARD -ACCOUNT #88036783261 3,171.47 100.00 3,171.47
SHARES SOLD ON DATE OF DEATH -NON-PROBATE '
293.440 SHARES X $10.78 PER SHARE/DIVIDEND
5. VANGAURD -ACCOUNT #88036783261 6,582.90 100.00 6,582.90
SHARES SOLD ON DATE OF DEATH -NON-PROBATE
648.775 SHARES X $10.11 PER SHARE/DIVIDEND
6. VANGUARD - ACCOUNT #88036783261 9,638.31 100.00 9,638.31
SHARES SOLD ON DATE OF DEATH -NON-PROBATE
310.142 SHARES X $5.51 PER SHARE/DIVIDEND
7. CASH GIFT TO DONA HEBBLETHWAITE 18,000.00 100.00 3,000.00 15,000.00
STEP-DAUGHTER
8. CASH GIFT TO JAMES KINNAMON 18,000.00 100.00 3,000.00 15,000.00
STEP-SON
9. CASH GIFT TO SUSAN CARLSON 18,000.00 100.00 3,000.00 15,000.00
STEP-DAUGHTER
10. CASH GIFT TO WAYNE BIBBENS 18,000.00 100.00 3,000.00 15,000.00
SON
11. CASH GIFT TO MARK BIBBENS 18,000.00 100.00 3,000.00 15,000.00
SON
12. CASH GIFT TO DENISE HILTERMAN 18,000.00 100.00 3,000.00 15,000.00
DAUGHTER
13. FIRST NIAGRA-ACCOUNT #9970104182 (TRUST) 7,217.68 100.00 7,217.68
TOTAL (Also enter on Line 7, Recapitulation) ~ E 140,614.91
If more space is needed, use additional sheets of paper of ttre same she.
REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENiDECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE pF FILE NUMBER
ALBERT H. BIBBENS 21 10 0
DecedeM'e dente moat be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOLLINGER FUNERAL HOME 550.00
2. WHITE CHAPEL FUNERAL HOME, INC. 7,049.00
3. SMILEY'S FLOWERS -CASKET SPRAY 210.55
4. TRANSPORTATION OF REMAINS 294.MI ~ 34.5C/MI 101.43
5. FUNERAL LUNCHEON - WEGMANS/STAN'S BEVERAGE/WINE 8~ SPIRITS 555.30
6. CD'S AND CASE 35.00
B.
1
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Canmissbn Peid:
y. AtOortleyFees: IRWIN & McKNIGHT, P.C.
3. Famiy Exemptlon: (If decedents address is not fhe same as dalmanYs, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant tD Decedent
4• Probate Fees:
5. ~ Accountant Fees:
6. ~ Tax Relum Preparer Fees: PATRICIA A. ROSENDALE, CPA
7. OFFICEMAX -COPIES
8. POSTAGE
9. OFFICEMAX -SUPPLIES
10. REGISTER OF WILLS -FILING FEE
1,000.00
350.00
23.68
27.26
16.33
15.00
TOTAL (Also enter on Line 9, Recapitulation) ~ S
If more space is needed, use additlonal sheets of paper of the same size.
REV-1512 EX+ (12-09)
- Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ALBERT H. BIBBENS 21 10 0
Repoli debt 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. VANGUARD -SELL ELECTRONIC BANK TRANSFER REDEMPTION FEE
2. VANGUARD -SELL ELECTRONIC BANK TRANSFER REDEMPTION FEE
3. GUARDIAN LONG-TERM CARE PHARMACY -MEDICAL
4. CUMBERLAND-GOODWILL EMS -AMBULANCE
5. WEST SHORE EMS -CARLISLE -AMBULANCE
6. ~CARLISIE REGIONAL MEDICAL CENTER -MEDICAL
6. ~M&T BANK - REIMBURSEMENT OF SSA DIRECT DEPOSIT
TOTAL (Also enter on Line 10, Rec~itulatlon) I f
H ~re space is needed, insert addM(onal sheets of the same size.
7.80
94.10
47.65
207.57
128.82
54.64
924.00
REV-1513 EXa (01-10)
Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ALBERT H. BIBBENS .,. .., ,.
~~ ~~
RELATIONSHIP TO DECEDENT
AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lbt Tmsfee(a) OF ESTATE
I TAXABLE DISTRIBUTIONS pndude M I disMbu6ons and Uansfers under
Sec. 91 f6 (a (1.2).]
1. WAYNE A. BIBBENS Lineal 129,412.99
3284 COTTLE ROAD 1/6TH REMAINDER
WEEDSPORT, NY 13166
2. MARK A. BIBBENS Lineal
6260 KNAPP ROAD 1/6TH REMAINDER
CANANDAIGUA, NY 14424
3. DENISE J. HILTERMAN Lineal
61 GREYSTONE ROAD 1/6TH REMAINDER
CARLISLE, PA 17013
4. SUSAN CARLSON Lineal
7797 MOSHER ROAD 1/6TH REMAINDER
HONEOYE, NY 14471
5. DONA HEBBLETHWAITE Lineal
170 ROWLEY DRIVE 1/6TH REMAINDER
ROCHESTER, NY 14624
6. JAMES KINNAMON Lineal
3928 NEW YORK DRIVE 1/6TH REMAINDER
ENON, NY 45323
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
~~ uiuie spaix is neeaea, use acamonai sneers m paper m me same size.
Q ~B~
September 16, 2010
Law Offices
Irnviri & McKnight, P.C.
West Pomfiet Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
499 Mitchell Street, Millsboro, D
'~~11ED'
_-
j ~SEP 18 1010
iRWIN & A4cItNiGHf
LAW OffICES
RE: Estate of Albert Bibbens
Date of Death: July 28, 2010
Social Security. Number: 07418-5301
Dear Mr. Bloom:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
1. Atxavt#Type ........................... Checking Account
Account Number ....................... 9849419933
Oumetship (Names off .............. Albert Bibbens. Denise Holterman
Opening Date ...........................06/ 19/09
Balance on Date of Death.........$392.42
Accrued Interest S 0.00
Total ......................................$392.42
The above named decedent did not have a safe deposit box.
If upon reviewing the information above, you believe there aze additional accounts not
referenced, please provide us with an account number and/or the 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, please contact
our Spring Garden branch at 100 South Spring Garden Street, Cazlisle, PA 17013 or #
717-240-4525.
Sincerely, , r
W
Charlene Warrington, Adjustment Services
1-888-502-4349
July 28, 2UlU Page 7 oC 7
- ~-`~'- Vanguard Total Stock Market Index Fund
Investor Shazes
ALBERT BIBBF,NS 800-662-2739 - Client Services
Fund number: 85
Account number: 88036783261
ACCOUNT VALUE On7/28l2010
$ 0.00
Trade date Trartsactgn Dollar amount Share rice Shares Var~sacted Total shares owned
Beginning balance 300.159
7/28 Sell electronic bank trensfer $ -8,245.37 $ 27.47 z -300.159 = ,000
Income dividends $ 88.90 ~' Zy S, 3 I
UNDER THE FREQUENT-TRADING POLICY. MOST PURCHASES AND EXCHANGES INTO
THIS FUND ACCOUNT BY PHONE OR ONLINE WILL BE RESTRICTED UNTIL 09/26/2010
PLEASE CONTACT A VANGUARD REPRESENTATNE WITH ANY QUESTIONS.
July 28, 2010
Pale 6 of 7
Vanguard Emerging Markets
Stock Index Fund Investor Shares
AI,BF.,RT BIBBF.NS 800-662-2739 - Client Services
Fund number: S33
Account number: 38036733261
ACCOUNT VALUE On7/28/2010
$ 0.00
Trade date Trensactbn Dollar amount Share ice Shares transactetl Total shares owned
Beginning balance 185.997
7/ 13 Exchange to HIYD CP IN $ -1,708.88 $ 25.54 -67.078 118.919
Redem fee -4.28
7/28 SeN electronic bank transfer 3,11 ~,~ 26.22 X -118.919 Y .000
Redem fee/~ ate) - ~ -
UNDER THE FRE(]UENT•TRADING POLICY, MOST PURCHASES ANO EXCHANGES INTO
THIS FUND ACCOUNT BY PHONE OR ONLINE WILL BE RESTRICTED UNTIL 09/28/2010
PLEASE CONTACT A VANGUARD REPRESENTATNE WITH ANY QUESTIONS.
~_ i--
.,
my 28, 2010 P.ige S of 7
Vanguard Wellesley Income Fund
Investor Shares
AI,BF,RT BIBBF..NS 800-662-2739 - Client Services
Fund number: 27
Account number: 38036783261
ACCOUNT VALUE On7/28/2010
$ 0.00
grade date Transactbn Dollar amount Share rice Shares transacted Total shares owned
Beginning balance 602 532
7/28 SeN electronic bank transfer $ -12.641.12 $ 20.98 X -602.532 'L .000
Incomedividertds $231.10 ~a/ ~, l~
UNDER THE FREQUENT-TRADING POLICY, MOST PURCHASES AND EXCHANGES INTO
THIS FUND ACCOUNT BY PHONE OR ONLINE WILL BE RESTRICTED UNTIL 09/26/2010.
PLEASE CONTACT A VANGUARD REPRESENTATNE WITH ANY QUESTIONS.
~'..
,i
ALBERT BIBBF.NS
Beginning balance
7/28 Sell electronic bank transfer
7/28 Income dividend check
Income dividends $ 61.79
iuly 28, 2010 Pale 4 of 7
Vanguard Short-Term Investment-Grade Fund
Investor Shares
800-662-2739 - Client Services
Iaund number: 39
Account number: 8803678326].
ACCOUNT YALUE On 7/28/2010
$ 0.00
Dollar arrwint Share price Shares Ransacted Total shares awned
$ -3,163.28 $ 10.78 X -293.440 L v.0pp
8.19 A00
3,1b3- z8
g~~9
t,
'~,
ALBERT BIBBENS
Trade date Transaction
Beginning balance
7/28 Sell electronic bank transfer
7/28 Income dividend check
Income dividends $149.87
Short-term gains 22.90
Total incomeyear-to-date ~ ;77
July 28, 2010 Page 3 of 7
Vanguard Intermediate-Term Investment-
Grade Fund Investor Shares
800-662-2739 - Client Services
Fund number: 71
Account number: 38036783261
AGGOUNT VALUE Onl/28/2010
$ 0.00
Doilar amount Share Price Shares transacted Total
$ -8( `~~-12~ $ 10.11 x -648.775 =
23.78 )
6, 5"59, l2
23~ ~~
UNDER THE FREQUENT-TRADING POLICY, MOST PURCHASES ANO EXCHANGES INTO 6 ~~ Z. 9O
THIS FUND ACCOUNT BY PHONE
saa.ns
.000
.000
OR ONLINE WILL BE RESTRICTED UNTIL09/26/2010. ~
PLEASE CONTACT A VANGUARD REPRESENTATNE WITH ANY QUESTIONS.
July 28, 2010 Paige 2 of 7
,_,',1 .,- Vanguard High-Yield Corporate Fund
Investor Shares
,4LBF..RT RIRBENS 800-662-2739 - Client Services
(800) 662-6273 - Tele-Account
Fund number: 29
Account number: 38036783261
ACCOUNT VALUE On 7/29/2010
$ 0.00
trade date Transactbn DOIW amount Share rice Shares transacted Total shares owned
Beginning balance
7/13
Exchangefrom EMERG MKTS
$ 1,708.88
$ 5.51
310.142 1,401.841
1
711
983
7/28 SeNelectronicbanktrerefer -9,4 5.60 ~C -1,711.983. ,
.
,000
Redemption fee 94.10
7/28 Income dividend check 51.2 n ~~ -~ / ^
`
/
U ,~0
Income dividends $ 225.05 , f ~~ ~/
~~
UNDER THEFREQUENT-TRADING POLICY, MOST PURCHASES AND EXCHANGES INTO 7 6~~ 3/
THIS FUND ACCOUNT BY PHONE OR ONLINE WILL BE RESTRICTED UNTIL 09/26/2010. /
PLEASE CONTACT A VANGUARD REPRESENTATNE WITH ANY QUESTIONS.
FIRST
NIAGARA
ACCOUNT STATBMSNT
Customer Service:
(718) 625-7800
t-boo-a2~-oooa
Page
1
Customer Connection Line:
(Automated Account Infonnetion)
(718) 825-7700
1-800-439-8230
* * * * * * * * * * * * * * * * * *AUTO* *ALL FOR AADC 170 CustomerserviceQfnfg.com
018436 0.3600 AB 00.360 57 2 13
I~~~Iil~~~lllr~~~~~ll~~ll~~~l~l~ll~„II~~II~~~~Ii~~~~~lll~~~ll
ALBERT H BIBBENS JR TRUST 251 Statement Date: 06/30/10
WHITE CHAPEL FUNERAL HOME INC
61 GREYSTONE RD Account Number: 9970104182
CARLISLE PA 17013-2660
***************************** Certificate 9970104182 ***********************
Date_Description Withdrawal Deposit Balance
03/31 Balance Forward -------------------------------------> 7,190.92
06/30 Interest Paid 26.76 7,217.68
Previous Statement Date: 03/31/10
Beginning Interest
Balance + Deposits + Paid
7,190.92 .00 26.76
Service Ending
Deductions - Charge = Balance
.00 .00 7,217.68
Statement from 04/01/10 thru 06/30/10
Interest Earned 26.78 *Annual Percentage Yield Earned 1.50
**************Summary of Deposit Accounts *************************************
AP ACCOUNT MAT DATE BALANCE INT-RATES YTD-INT YTD-PENALTY
-02 60 9970104182 08/15/11 7,217.68 1.490 53.13
On 8/15/10, the Non-Sufficient Funds/Uncollected Funds fee increases
to $35. To help manage your account, we recently limited overdraft
fees to 5 per day and allowed up to $5 in overdraws at no charge.
To view your account activity, including check images and statements, sign up for free Online Banking at www.fn, fg.com
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Hollinger Funeral Home & Crematory, Inc.
Eric L. Hollinger, Supervisor
501 North Baltimore Avenue
Mount Holly Springs, Pennsylvania l 7065
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Charges arc only for those items thaz you selected or [hat are requued. p are are required M' law a by a cemetery or crematory m use any i[emv. wr will
explain the reason N wdting below.
If you seeded a funeral that may require embalming, such as a funeral viewing, you may have m pay for embalning. You do not have m pay Fur ctnlzdm-
ing you did na approve if fw~ZnT~1~,Tw,~~,'i~°~.-,,~.~.zr-such ,7.~..Ca,~.w6i rt~mu-t~rv~~,~. immediate burial. If v12 c11¢rgGd for embalming, we will II~~n y~FhyY hrkm~.
For the Service of 17~.V~1'c/ ~'% .C//'r'~~J ])~ ~~~4~a~
~+•rBe ~~ ~~urs6 ~ ~Lf~g.~,bi/ /~/ ~?6ya~! ~ sly
A. CHARGR FOR 9~VI(84 91~II8CT®:
). PROFPSSIONAL SERVICIS
Services aF Funeral Dilector/StatF ...... S~
Fadukaing .....................f
nom' :its'.
.T.... f
9C~TOTAL of Feo~olvAi. s~vfc~s ......... AL s
2. PAt]LfI1E5 AND SERVICES
Use d IadFpea and arrvira far
vieaklg (Yitlrauon^^9PYake) ...... ... f
llse of (acaidea and swiora
for funeral memory ......... ... f
use of faciWies and service for
Memodal Scvice ............ ... S
Use of equipment and xrvices
for graveside service .......... ... f
Odser use of faWities
..............................f
SUBTOTAL OF FACQ111B4/HQURAI&tR' .......... A2 f
3. AUIUM07FVE EQ(RPaR'M'
Vehick to wander remains m Funeral Home
~
Local ....................... ..f
Hearne (Carpet Coach)
Lod ....................... ..f
Llnquakle
wd .......................
..f
Family err
loral ....................... ..f
Hower err a floral dispaidal
Ind ....................... ..5
Lead nr/logy err
Lod ....................... ..f
Car far pallbeuers
Lod ....................... ..5
Our of mwn hampaulkan ........ .. f
f
SUBTOLII OF AUIOgWT1V8 RQURA!@IT .........A3
TOTAL ~ FROFF3~DNAL 9RRFI« S,
FACQIIIFS ANID AUrONOT1VE
BQOIPgffiYr .................. .................A
B. CHARGaB FOR 11
casket .........................f
(OeaMptlon)
Other RCCepmde ................. f
(Descdppon)
Outer burial container ............. f
(Descdpion)
Acknowkdgenent olds ...... ...... f
Register book(s) ............ ...... f
Memory (elders ............ ......5
Mayer stela .............. ...... S
temporary grave marker ...... ...... f
Budal Clothing ............. ...... f
SUAINARY OF CEARGE4
A. Plofeada151 Servkq Fadlltka and
Egdpmm, and Autaaotive
Equ)pment .....................5
F. kterchandtre .................... f
C. Special Charges .................. S
D. Cash Advalloo .................. f M
TOTAL OF ALL 9FG710NS ....................... ~ r
PAm AT TLS OP
ARRArff;~mlvrs C7FINr.~' ~!O ... f '7
parry law, ~ a aeantaY nquirmeaa hive retNkcd~ pm
d any of itans Feed above, the law or requiranea[ rs
1 agree tlu[ I have exaMned the Irmo of goods ant servlas sekxrcd above and fount dmm m be carted ant acmnding m the anangemelw I have requested. 1 acluwwlMge
receipt of a copy of due Smremna aF Pu11cd Goods and Services Selected. I «peeen[ tint 1 have sulfidela fads avaWhle fa pylaent of d1e ash prke for the pods
and aavias selected. t ako agree w nuke paymda off witlun Myer I agree m be johdy and eevaaFy False vdth allyme ehe who
siyro below. A bra Burge d per math amouaklg m per yar wtll be applkd m the unpaid bahace der
hmn dre due of thb agrmrc~a. I will abo pay m the Purrral Dkeaa aR reasaubie cwu pad by d1e Funeral Dueaor m oollea anwuna Ion W[dC tlds agrecnent
7LglG CoYa 1my hxllde aaorrleya~ fear 00111[ coots and otller Mats. Any addalarW servkn a merchudite ordered Di ([GIItlICd after die dale of drk agremleot will
be "~ p~~n gof~thin agreert77Kn and ear aN be refkRed on d1e fiml hill a autemem. O d
(Seafll~j~,Q[L~.'L 1` (Purcluser) ~~ ~~ ~ •u G~ /
(Purchaser) (Ucemee Direaar)
o r.aarivm n.~a oYv~a a.oratm .ra,z wmr norm rmml aRa« roe Cmnaw
sDfm - 60o nev;aea L/04
f
Gry
Od1er c)ahing
Sta[e
Cremation um ................... E
Gkiaiptbn)
onreF s
TorAL el~ca-Nnrss sFLECreu .................F s
G SPRCJAI. CfIAAGEk
Forwarding of remains m
5
(Furxd Hamel
Receiving of 1aluim ban
f
(Fullenl Home)
Immediate Fudal ................. f
Dkect Crcanpon ................. f
S
SUBTOTAL ~ SFgflAL ($ARfiffi ................C f
D. CASH ADVAN(BD
oPedng Grne ............... ... f
Y ~Pmmt ........... ... f
la aid Ihed ................ ... f
~PaPa Narim-Inul ........ ... f
Newspaper Nwom-autbF-mwn ... ... f
Telepbae A Telegrams ......... ... f
Akfale ..................... ... f
Clvgy/Haas Offering ........... ... S
Pallbearers .................. ... f
Cmmed Cogm d the Death ..... ... f
Catifinte ................... ... S
Pokoe Facet .... ..... ........ ...f
Flowers ..................... ... f
Vtdt Service Charge ............ ... f
f
S
f
f
S
SUBTOTAL OF AIFirANCF3 .......................D S
~Pe drrge you for ow service rn abmhling:
rnrb aa4mrar platen aurAadarp)
fa~4 p'
~Nkite C`iapel
FUNERAL HOME, INC.
197 SOUTH STREET • AUBURN. NEW YORK 13021 • TELEPHONE: (315) 258-9101 • FAX: (315) 258-8322
P.O. BOX 192 • 2719 ERIE DRIVE • WEEDSPORT, NEW YORK 13166 • TELEPHONE: (315) 834-9312
DIRECTORS: MARK FARRELG KEVIN FARREL4 MICHELLE FARRELL
Mrs. Denise Hillerman
61 Greystone Road
Carlisle, PA 17013
Statement of Funeral Expenses for: Albert Hamilton Bibbens Jr.
Date of Death: July 28, 2010
August 4, 2010
All Professional Services and Facilities Charges: $2,545.00
(See statement of goods and services for detailed itemization)
Casket: Gemini Copper $1,375.00
Outer Burial Container: Monticello $1,410.00
Stationery Items and Other Merchandise: $195.00
Automotive Equipment: $335.00
Cash Advances Items:
Weedsport Rural Cemetery
3 Certified Death Certificates at $ 6.00 each
The Citizen
Post Standard
Veteran Marker Installed
Engraving Monument
Overtime Cemetery Fee
American Legion Donation
Television Rental
Total Cash Advance Items:
$ 535.00
$ 18.00
$ 108.00
$ 73.00
$ 80.00
$ 75.00
$ 150.00
$ 100.00
$ 50.00
Total Funeral Charges:
Less Payments Received by:
Refund:
$5,880.00
$1.189.00
57,049.00
Jul 30, 2010 $-7,225.93
5-176.93
Funeral Home Charges:
Family Owned and Operated
*** This is an Advice ***
ALBERT H BIBBENS
DENISE J HILTERMAN
61 GREYSTONE RD
CARLISLE PA 17013
Subject: Notification of Death /Reclamation
Case Number: 29185
Funds Deposited to Account: ******9933
Funds Deducted from Account(s): ******9933 $924.00
P.O. Box 4650
ACH/EDI Services
Buffalo, NY 14240-9975
(800)724-2240
Date: Thursday, August O5, 2010
This is to advise you that on 8/5/2010 we deducted from the account(s) shown above the amount of $924, for
the SSA Direct Deposit of 8/3/2010.
Due to the fact that ALBERT H BIBBENS has passed away prior to the issuance of the credit, the Treasury of
the United States is requesting reimbursement. In accordance with Federal Regulations, direct deposits may not
be retained by the beneficiary unless the beneficiary lived through the entire month prior to the date of issuance.
If the number of the 'account deducted from' is different from the account into which the funds were originally
deposited, the deduction is authorized under the bank's rules for right of offset because one or more of the
owners on both accounts are the same.
Should you have any further questions about this charge, please call and refer to the case number above.
This advice is provided to facilitate the reconcilement of your monthly account statement.
Respectfully,
ACH/EDI Services
M&T
STgI~ ° S L3EVERgGE
75 ASHLAND RD.
CARLISLE, Pq 17013
717-24s-1D1o
Store #1 - Station #2
0721512 07/29/2010. 8:49 PM
1. 1651, `_..._ @27 36 ---_. -__.~. __
SARANAC VARIETY 24/12 NR 36 ,
1 iteHl(5) SO~d `
Sub Total==-~--27.36
To t a ~i'ax 8.00% 1 64
Master Card ~'3 ' ~~
xxxxxxxXxxxx9125 09/12 29.00
Auth # 345.198
`.
Sold by JAH
Thanks for shopping at Stan's
i
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i WINE & SPIRITS. STORE 2101
281 S SPRING GARDEN ST
CARLISLE PHONE 11249-8159
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2101 002 B 00657804 1156
5813 DeKypr Peachtr
1 AT 17.99 SALE 17.99
SUBTOTAL 17,99
6.Ox SALES TAX 1.08
TOTAL 19.07
INVOICE NUMBER 21083227
Credit Card 19 07
MasterCard Card Number
*e*a*rs**~a~9125
Autit S: 218358
TOTAL UNITS SOLD 1
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CUSTOMER COPY
7/29/10 20:42
345 EASTERN BOULEVRRD
CRNANDAIGUR, NY 14424
(585) 394-4820
07/31/10 OP>< 99725
`CRTERING ORDER 257.46 B
CONTRRCT NUMBER 010191
:9X 19.48
**~* BALANCE 276.99
UISA PURCHASE
RCCT: **r^********3686
RUTH: 056510
RCPT: 76435
CODE: 0000
CREDIT CARD 276.94
CHRNGE 0.00
07/31/10 04:59pm 11 76 25 99725
~~~i,~arrks -~ ~rlarrs
345 ERSTERN BOULEVARD
CRNpNDAIGUA, NY 14424 345 ERSTERN BOULEVRRD
(585) 394-4820 CRNRNORIGUR, NY 19424
(585) 394-4820
07/30/10 OPi 70009
07/31/10 OPi 310117
3@2.99
SC RRND MG SRNDYICH T 8.97 F 2 @ 7.gg
7 ! 0.49 ~ WG YHERT HAMBP.G RL 3.9B F
SC AgND SRNDYICH THIN 1.47-F 2 @ 0.99
SC YEG MILK 2 % L/F 2.99 F yEG LRRGE EGGS 1.98 F
SC YE! MILK 2 1c L/F 1.01-F 3 @ 2.49
STNYFLD FF FR VRN 3.79 ~F yEfi PREM UR JUICE 7.47 F
YEG SH CHED SHREDS 3.99 F yEG SH CHED SHREDS 3.99 F
2 @ 3.99 TRIBE RD PEP HUMUS 3.99 F
YEG SYISS CHEESE. 7.98 F ; @ 2.qg
DAN RCTIVIA PERCH 2.49 F SC WEG VRNILLR ICE CR 7.47 F
6 Q 0.39 3 ! 0.50
YG GREEN BEANS-CUT 2.34 F ~ yEG ICE CREfV1 1.60-F
4 @ 2/5.00 3 @ 1.49
YEG MULTITORT CHP 10.00 F UEGMRNS ICE 4.47 R
TOSTITOS RST STYL 3.49 F SPRI"E 2 LITER 1.29 8
2 ! 3.49 SC 7-•UP REG 2 LITER 1,29 B
DOVE DC BONUS BAG 6.96 B pP CON?RINER DEPOSIT 0.05 F
NAB TRISCUIT YRFER 2.69 F ~ T UP REG 2 LITER 0.04-8
DIRMONO PECRNS 5.99 F H)IZ COCKTAIL SRUCE 1.99 F
4 @ 2.29 HI.NNS RED FRT MRYO 2.69 F
NE VEGGIE B CHKN 9.16 F KRRFT MIRACLE WHIP 3.59 F
YEG BNLS• BRST 14.29 F NLMNS EO RERL MRYO 3.99 F
SM TKY.BST PLRINVL 9.80 F SNYD THIN PRETZELS 2.69 F
SM TKY BST PLRINVL 9.71 F SC OORITOS NRCHO CHIP 2.99 F
SC PRESIDENT BRIE 80Z 6.99 F ~ OOgIT~ NpG10 CHIP 1.00-F
SC PRESIDENT IRIE 102 1.00-F ERSY GRIP CUP i80Z 3.29 T
GROWERS CHOICE BOT 11.99 T pIi( PLRTE LIME 3.99 T
2 ! 4.25 ULT CHOC CRKE 14.00 F
ROSEMARY LORF 8.50 F OP CONTRINER DEPOSIT 0.05 F
MULTIGRN Y/CNT(27) 4.75 F 7p;{ 1.08
3 ! 14.00
~- ULT CHOC CRKE 42.00 F ~**. BRLANCE 73.29
YEG REO SDLS GRRPE 2.99 F
2.99 lb ! 0.49 /lb ~dISR PURCHASE
YT BRNRNRS T.47 F RCCT: rrrr***rrrrr3686
BLUEBERRIES 2i 7.99 F RUTH 022202
1 ! 2/5.00 RCP1~ 6271
STRRYBERRIES ti 2.50 F CODE 0000
1.93 !b ! 1.99 /Ib
WT BEANS YR% 3.84 F
8 ! 0.39 CREDIT CRRO 73.29
1 GRL YRTER REFILL 3.72 B CHRNGE 0.00
TAK 1.67
rrrr BRLANCE 198.99 _--._-__-_ $RVINDS SUNMRItY ----------
--y2•~' SHOPPERS CLUB SRVINSS _._~f~._2 54 :-_-
DISCOVER PURCHASE
ACCT: rrrrrrrrrrrr2710 ~ ' ,~
pl1TH: 03085R
RCPT: 17858 ~'~