Loading...
HomeMy WebLinkAbout11-12-10 (2) 15056101,40 REV-1500 ~ (01-10) PA Department of Revenue OFF{CIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 0 0 8 9 7 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYY 2 1 0 2 6 6 7 3 4 D 8 1 7 2 0 1 0 0 8 0 1 1 9 3 2 Decedent's Last Name Suffix Decedent's First Name Ml H E N R Y J O Y C E L (if Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder RE:turn (date of death prior to 12-13••82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ® 5. Federal EstatES Tax Return Required death after 12-12-82) QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit 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 Plumber R O G E R B I R W I N 7 1 7 ~,2 4 9 ' 3 5 3, - ~~ REGISTER y rV111LLS US~I~yNLY ..~ .' . Y' I , L t.7 "'~~ { ' First line of address `-,-.. ~~ t-z i~.3 --,; :--~~ - ... t: ~ . ~~: - ~_ . 6 0 W E S T P O M F R E T S T R E E T ''^~ -Q - Second fine of address `- ''=: ~ r~ I> •~ DATE FILED ~ City or Post Office State ZIP Code C A R L I S L E P A 1 7 0 1 3 Cocrespondent's a-mail address: 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. SI TURE OF PERSON 4~E ONSIBLE FOR FILING RETURN C-A~E ~i ~;~~ v AD RE S 100 FLINT TONE DRIVE NEWVILLE PA 17241, SIGNATURE ~ P~EP~ARER OTH sue, THAN PRESENTATIVE PATE ADDRESS 60 WEST PO RET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 15056101401 J J 1505610240 REV-1500 EX Decedent's Name: J 0 Y C E L• H E N R Y Decedent's Social S~scurity Number 2 1, 0 2 6 6 7 3 4 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 and Notes Receivable (Schedule D) .......................... 4. • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ 4 0 :3 4 8 . 1, 5 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 4 8 ~3 2 7 • 1 9 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 8 9 .L 7 5 . 3 4 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ..... 9. 1 2 E~ 8 9 . 9 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ ..... 10. 1 ~'3 9 6 . 9 2 11. Total Deductions (total Lines 9 and 10) .......................... ..... 11. 1 4 !5 8 6 . 8 2 12. Net Value of Estate (Line 8 minus Line 11) ....................... ..... 12. 1 7 4 5 8 8 . 5 2 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. 1 7 4 5 8 8 . 5 2 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 0 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 1? 4 5 8 8. 5 2 1 s. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 1 g. 19. TAX DUE ................. ........................... ... ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 150561024 0. 0 0 7 ~3 5 6. 4 8 0. 0 0 o. 0 0 7 ~3 5 6. 4 8 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0897 DECEDENT'S NAME JOYCE L. HENRY STREET ADDRESS - 100 FLINTSTONE DRIVE CITY NEVWILLE STATE PA ZIP 17241 Tax Payments and Credits: ~. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 8. Discount 3. Interest 392._82 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 7,856.48 Total Credits (A + B) (2) (3) (4} 392..82 (5) 7,463.66 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q ea occurre a er ecem er i ecedent trans er ro ert within one ear of y death • without receivm ade uate consideration? ........................... p.. p,,, Y.... 9 q ^ ^ 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death?_ ......... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. ~ ^ 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 3 percent [72 P.S. §9116 (a) (1.1} (i}]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to ar 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)]. A sibling 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-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER JOYCE L. HENRY 21 10 0897 Include the proceeds of litigation and the date the proceeds were received by the estate. Alf property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MOBILE HOME - 1999 SKYLINE 40,000.00 VIN #2N111030ABL 2. PERSONAL PROPERTY 200.00 3. SOVEREIGN BANK -CHECKING ACCOUNT #1691029602 7,564.47 4. SOVEREIGN BANK -SAVINGS ACCOUNT #1694002930 789.37 5. SOVEREIGN BANK-CERTIFICATE OF DEPOSIT#1695214245 1,665.74 6. SOVEREIGN BANK -CERTIFICATE OF DEPOSIT #1695214260 90,128.57 TOTAL (Also enter on line 5, Recapitulation) u $ 140, 348.15 (If more space is needed, insert additional sheets of the same size) 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 JOYCE L. HENRY 21 10 0897 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 NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST E=XCLUSION (IF APPLICABLE) TAXABLE VALUE 1. SOVEREIGN BANK -IRA #1698182407 9.84 100.00 9.84 BENEFICIARIES: MICHAEL HENRY, RANDY HENRY & KATHY LINE 2. WESTERN NATIONAL LIFE INSURANCE COMPANY 48,817.35 100.00 48,817.35 ANNUITY -CONTRACT #: XP223272 BENEFICIARY KATHY LINE TOTAL (Also enter on Line 7, Recapitulation) ~ $ 4$,827.19 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER JOYCE L. HENRY 21 10 0897 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOY'S GREENHOUSE -FLOWERS 95.40 2. CARLISLE BRETHREN IN CHRIST CHURCH -FUNERAL LUNCHEON 240.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. AttomeyFees: IRWIN & McKNIGHT, P.C. 8,000.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) 3, 500.00 Claimant KATHY E. LI N E Street Address 100 FLINTSTONE DRIVE City NEWVILLE State PA zIP 17241 Relationship of Claimant to Decedent DAUGHTER 4. Probate Fees: REGISTER OF WILLS 137.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER OF WILLS -FILING FEE 30.00 8. REGISTER OF WILLS -SHORT CERTIFICATE 4.00 9. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00 10. THE SENTINEL -ESTATE NOTICE 166.30 11. SOVEREIGN BANK -DATE OF DEATH VALUATION 20.00 12. NOTARY 35.00 13. THE NEWS-CHRONICLE -ADVERTISING -MOBILE HOME 36.70 TOTAL (Also enter on Line 9, Recapitulation) $ 12 689.90 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER JOYCE L. HENRY 21 10 0897 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. FIA CARD SERVICES -CREDIT CARD 586.95 2. COUNTRY VIEW ESTATES -LOT RENT (3 MONTHS) 723.00 3. HOME INSTEAD SENIOR CARE -NURSING 396.00 4. DARRYL K. GUISTWITE -MEDICAL 114.78 5. ADAMS ELECTRIC COOPERATIVE -ELECTRIC 76.19 TOTAL (Also enter on Line 10, Recapitulation) f $ 1, 896.92 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) Y pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: .I[)YCF t HENRY 21 10 0897 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE j TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. MICHAEL D. HENRY Lineal 174,588.52 8 MARION DRIVE 'I/4TH REMAINDER LANDISBURG, PA 17040 2. RANDY J. HENRY Lineal 661 WILLOW GROVE ROAD 1/4TH REMAINDER CARLISLE, PA 17015 3. KATHY E. LINE Lineal 100 FLINTSTONE DRIVE 1/2 REMAINDER NEWVILLE, PA 17241 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. jj. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $~ If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT I, JOYCE L. HENRY, of North Middleton Township, Cumberland County, Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. 1. I direct my Executrix or Substitute Executors, as the case may be, to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore, I direct that all state, inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property composing of my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid by the Executrix or Substitute Executors of my estate. 2. My Executrix or Substitute Executors may, at her or their discretion, compromise claims, borrow money, retain property for such length of time as she or they may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as she or they may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder. 3. I authorize and empower my Executrix or Substitute Executors to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale; therefore, in fee simple, as I could do if living. My Executrix or Substitute Executors is/are authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said Executrix or Substitute Executors. 4. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: a. One-Fourth (1/4) to my son, MICHAEL D. HENRY, and if he not living, to his children, share and share alike; b. One-Fourth (1 /4) to my son, RANDY J. HENRY, and if he is not living, to his children, share and share alike; and c. One-Half (1 /2) to my daughter, KATHY E. LINE, and if she is not living, to her children, share and share alike. 5. I hereby direct that KATHY E. LINE and HARRY E. LINE shall be the Guardians of my son, ANDREW F. HENRY. 6. If ANDREW F. HENRY is not living at the time of my death, all of my estate shall be divided between MICHAEL D. HENRY, RANDY J. HENRY and KATHY' E. LINE, share and share alike. 7. I nominate and appoint KATHY E. LINE to be the Executrix of this my Last Will and Testament. In the event she has predeceased me, failed to qualify or is not able or does not serve for whatever reason, I then appoint MICHAEL D. HENRY and RANDY J. HENRY to be the Substitute Executors of this my Last Will and Testament, whereby the said Substitute Executors shall have the same powers as are given to the original Executrix hereunder. 2 8. No person(s) shall benefit hereunder unless such beneficiary shall suMvive me by sixty (60) days. 9. No Executrix or Substitute Executor acting hereunder shall be required to post bond or enter security in this or any other jurisdiction. 10. No beneficiary may assign, anticipate or pledge his or her interest in arty income or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or otherwise reach any such interest. 11. I hereby suggest that my personal representative retain the services of Irwin & McKnight as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this _~8 day of May, 2007. I ~SE~.> YCE L. NRY Signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and Testament, in our presence, who, at her request, in her presence and in the presence of each other have hereunto set our names as subscribing witnesses. '~ I •~ 3 ACKNOWLEDGMENT AND AFFIDAVIT WE, JOYCE L. HENRY, I~:AREN S. NOEL and SHARON L. SCHWALM, the Testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to the best of their knowledge the Testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. ,~ L ~., ~ ~~OYCE L. HE Y 6£-~ N S. OEL n~ SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CiTMBERLAND Subscribed, sworn to and acknowledged before me by JOYCE ~ L. HENRY, the Testatrix herein, and subscribed and sworn to before me by I~'.AREN S. NOEL and SHARON L. SCHyVALM, witnesses, this t8 day of May, 2007. ~• N ary Public COMM NWEA H OF PENWSYLVANtA otariat Seal Roger B. Irwin, Notary Public Carlisle Boro, Cumberland County Member. Pennsylvania .Association Of Notaries LISTING CONTRACT XLS LXCLUSI`JE RIGI~T Tfl SELL REAL ]ESTATE This form recotmnended and approved for, but not restricted to use by, the members of the Pennsylvania Association of REALTO:~S~ (PARS. 3ROKER (Company) J~iLEX Real Estate Services LLC LICENSEE(S) ~;~~,,,, <~~1, ~,;,:~,, -- SELLER ~l/~ ~i( ~;~-~,- Does Seller have a Listing Contract with another Broker? ^ Yes ~ No z f yes, explain: - 1. PROPERTY . LISTED PRICE ~; L7; ~~C.~C% ;-, ,` ~ , Address ~ ~-~ ~ ~ ~~., ~.,.;~ ~ !~ ~:.~ (:~ `; ; ,_^, ~;~-~ <, NlunicipalitJ~ (cit;~~, borough, tow~iship) :'1;'~w ~' • ~! t' County (v ~,.`~,~% au ~~ u School District !~~ 5,~~.-, , ~~_ Zoning _ Present Use Identification (Tax ID =`; Parcel #; Lot, Block; Deed Book, Page, Recording Date) 1 J u i ~~ 11 l; i -t l~ 16 iJ 19 ~~ ~~ ~? 7 ~ J 7 S ~J ., - .~ 1 ~~ 31 32 ~3 ;rt J~ ~5 ~~ ,U a,~ rti 4J ~-'- ~J ~h ~i ;3 ~. ~. J. 7 ~~ ~ ~1 ~= J. ;~ J. STARTING & ENDING DATES OF LISTING C©NTRACT (ALSO CALLED "TERM") A. No Association of REALTORS has set or recommended the term of this contract. By law, the length or term of a listing con- tract may not exceed one year. Broker and Seller have discussed and agreed upon the length or term of this Contract. B. Startin Date: Th~s Contract starts when signed by Broker and Seller, unless otherwise stated here: _ • C. Ending Date: This Contract ends o _ 3~t7,~zG' 1 ~ DUAL AGENCY Seller agrees that Broker may also represent the buyer(s) of the Property. The Broker is a DUAL AGENT when representing both Seller and the buyer in the sale of a property. DESIGNATED AGENCY ^ riot Applicable ^ Applicable. Broker may designate licensees to represent the separate interests of Seller and the buyer. Licensee (identified above) is the Designated Agent, who will act exclusively as the Seller Agent. If Property is introduced to the buyer by a licensee in the Company who is not representing the buyer, then that licensee is authorized to work on behalf of Seller. If Licensee is also the Buyer's Agent, then Licensee is a DUAL AGEIv`T. BROI{ER'S FEE No Association of REALTORSC has set or recommended the Broker`s Fee. Broker and Seller have negotiated the fee that Seiler will pay Broker. Broker's Fee is ~L' °lo of the sales price AND $ , paid by Seller. COOPERATION WITH OTrIER BROKERS Licensee has explained Broker's company policies about cooperating with other brokers. Broker and Seller agree that Broker will pay from Broker's Fee a fee to another broker who procures the buyer, is a member of a vlultiple Listing Service (MLS}, and who: A. ^ represents Seller (SUBAGENT). Broker will pay of7from the sale price. B. ^ represents the buyer (BUYER'S AGENT). Broker will pay ~ of'from the sale price. A Buyer's Agent, even if compensated by Broker for Seller, will represent the interests of the buyer. C. ^ does not represent either Seller or a buyer (TRANSACTi0i1I LICENSEE). Broker will pay of/from the sale price. PAYiVIENT OF BROKER'S FEE A. Seller will pay Broker's Fee if Property, or any ownership interest in it, is sold or exchanged during the term of this Contract by Broker, Broker's salespersons, Seller, or by any other person or broker, at the listed price or any price accept- able to Seller. B. Seller will pay Broker's Fee ii a ready, willing, and able buyer is found by Broker or by anyone, including Seller. A willing buyer is ore who will pay the listed price or more far the Property, or one who has submitted an offer accepted by Seller. C. Seller will pay Broker's Fee if negotiations that are pending at the Ending Date of this Contract result in a sale. D. Seller will pay Broker's Fee for a sale that occurs after the Ending Date of this Contract IF: (1) The sale occurs within of the Ending Date, AND (2) The buyer was shown or negotiated to buy the Property during the term of this contract, AND (3) The Property is not listed under an "exclusive right to sell contract" with another broker at the time of the sale. E. If a buyer signs an agreement of sale then refuses to buy the Property, or if a buyer is unable to buy t1e Property because of fail- ing to do ail the things required of the buyer in the agreement of sale (buyer default), Seller. will pay Broker of/from buyer's deposit monies, OR the Broker's Fee in Paragraph ~, whichever is less. F. If the Property or any part of it is taken by any government for public use (Eminent Domain), Seller will pay Broker's Fee from any money paid by the government. G. If a sale occurs, Broker's Fee will be paid upon delivery of the deed or other evidence of transfer of tittle or interest. If the Property is transferred by an installment contract, Broker's Fee will be paid upon the execution of the installment contract. ~ „ ~//~ Seller Initials: ~; ~'~~ XLS Page 1 of ~ Broker/Licensee Initials: LL (i~ r~ennsylvania Association of REALTORS° COPYRIGHT PE~iVSYLV,a~L~ ASSOCI:~TIOiv OF RE:~LTORS~ G~d7 _ - -- _ --. _ ,,.. -.. .....-., PhnnP~ (~1714'T7_93'_6 F~~~ Urtit;ed ANY CHANGES TO THIS PAGE MUST BE MADE AND INITIALED ON EACH DOPY ~6 8. DUTIES OF BROKER AND SELLER ~~ A. Broker is acting as a Seller's Agent, as described in the Consumer Notice, to market the Property and to negotiate with poten- g, tiai buyers. Broker will use reasonable efforts to find a buyer for the Property. B. Seller will cooperate with Brakes and assist in the sale of the Property as asked by Broker. '~'' C. All showings, negotiations and discussions about the sale of the Property will be done by Broker on Seller's behalf. All written 61 or oral inquiries that Seller receives or Iearns about regarding the Property, regardless of the source, v;ill be referred to Broker. ~=' D. if the Property, or any part of it, is rented, Seller will give any leases to Broker before signing this Contract. If any leases are ~ ~ oral, Seiler will provide a written summary of the terms, including amount of rent, ending date, and Tenant's responsibilities. ~~-~ E. Seller will not enter into or renew any leases during the term of this Contract without first giving notice to Broker. b~ 9. BROKER'S SERVICE T'0 BUYER c~ Broker may provide services to a buyer for which Broker may accept a fee. Such services may include, but are not limited to: 6 % deedldocument preparation; ordering certitlcations required for closing; financial services; title transfer and preparation services; 6~ ordering insurance, cor_struction, repair, or inspection services. Broker will disclose to Seller if any fees are to be paid by Buyer. 69 10. BROKER NOT RESPONSIBLE FOR DAMAGES %~ Seller agrees that Broker and Broker's salespersons are not responsible for any damage to the Property or any loss or theft of per- ~ ~ sonal goads from the Property unless such damage, loss or theft is directly caused by Broker or Broker's salespersons. %~ 11. DIEPOSIT MONEY %~ A. Brokzr, or any person Seller and the buyer name in the agreement of sale, will keep all deposit monies paid by or for the buyer 7~ in an escrow account until the sale is completed ar the agreement of sale is terminated. If held by Broker, this escrow account 7~ will be held as required by real estate licensing laws and regulations. Seller agrees that the person keeping the deposit monies %:~ may wait to deposit any uncashed check that is received as deposit money until Seller has accepted an offer. ?7 B. If Seller joins Broker or Licensee in a lawsuit for the return of deposit monies, Seller will pay Brol~;er's ar_d Licensee's attor- 73 nevs' fees and costs. 79 ?2.OTHER PROPERTIES 30 Seller agrees that Broker may list other properties for sale and that Broker may show other properties to prospective buyers. 31 13. CONFLICT OF INTEREST ~=' A conflict of interest is when Broke- or Licensee has a financial or personal interest where Broker or Licensee cannot put Seller's 8~ interests before any ot;'~er. If Broker, Licensee, or any of Broker's salespeople has a conflict of interest, Brokzr will notify Seller in 3Y a timely manner. 3~ 14. PUBLICATION OF SALE PRICE s5 Szller is aware that the Nlaltiple Listing Service (MLS), newspapers, and other media may publish the final sale price of the 3 % Property after settlement. 83 15. SELLER. WILL REVEAL DEFECTS & ENVIRONNIEIti`TAL HAZARDS 89 A. Szller (including Sellers exempt from the Real Estate Seller Disclosure Law) will disclose all known material defects and/or 9u environmental hazards on a separate disclosure statement. A material defect is a problem or condition that: 91 (1) is a possible dancer to those living on the Property, or 9~ (2) has a significant, adverse effect on the value of the Property. `~~ The fact that a structural element, system or subsystem is near, at or beyond the end of the normal useful life of such a struc- 9~ tural element, system or subsystem is not by itself a material defect. 9~ B. If Seller fails to disclose known material defects and/or environmental hazards: `~ ~ (i) Seller will not hold Broker or Licensee responsible in any way; 97 (~) Seller will protect Broker and Licensee from any claims, lawsuits, and actions that result; 93 (3) Se1_ler will pay all of Broker's and Licensee's costs that result. This includes attorneys' fees and. court-ordered payments ~~ or settlements (money Brakes ar Licensee pays to end a lawsuit or claim). 10i~ 16. IF PROPERTY WAS BUILT BEFORE 1978 101 The Residential Lead-Based Paint Hazard Reduction Act says that any seller of property built before 1978 must give the buyer an 10~ EPA pamphlet titled Protect Yoarr Family From Lecr~l in Yoirr Home .The seller also must tell the buyer and the broker what the sell- I ~~ er knows about lead-based paint and lead-based paint hazards teat are in or on the property being sold. Seller must tell the buyer ii~~ how the seller knows that lead-based paint and lead-based paint hazards are an the property, where the lead-based paint and lead- 10} based paint hazards are, the condition of the painted surfaces, and any other information seller knows about lead-based paint and 1Gb lead-based paint hazards on the properly. Amy seller of a pre-1978 structure must also give the buyer an;~ records and reports that I07 the seller has or can get about lead-based paint or lead-baszd paint hazards in or around the property being sold, the common areas, IOS or other dwellings in multi-family housing. According to the Act, a seller must give a buyer 10 days (unless seller and the buyer 109 agree to a different period of time} from the time an agreement of sale is signed to have a "risk-assessment" or inspection for pos- 1 1 ~ sible lead-based paint hazards done or. the property. Buyers may choose not to have the risk assessment or inspection for lead paint 11 i hazards done. If the buyer chooses not to have the assessment or inspection, the buyer must inform the seller in writing of the 1 ~=' choice. The Act does not require the seller to inspect for lead paint hazards or to correct lead paint hazards on the property. The Act i I ~ does not apply to ho in,g built in 1978 or later. , ~ Seller Initials: ~~~ ~r XLS Page 2 of a Broker/Licensee Initials: -(1 AN'I<' CI-iANCiES TO THIS PAGE MUST BE MADE AND INITIALED ON EACH. COPY l I =i ilk 116 ~ 1.,, ilk 11 ~? 12U 12i 122 1~3 1?-1 12 12fi 12', 1?_S 1 ~ ~~ l~U 131 132 13? 13~ i 3; inn ~~. 13~ 139 1 -fir ~J 1~1 ;~? 1~~ 1=1~ 1Y1 1~0 14% 1~S 1.1G 1~0 i~l 1~2 1~3 i 5 -1 1~~ 1~6 1ST 1~8 1~9 15+~ 15': 1c2 l0~ l0~' i5 150 i5~ 108 i0; 17i_ 1?? i 7. RECCDVERY FUND Pennsylvania Izas a Real Estate Recovery Fund (the Fund) to repay any person who has received a final court ruling (civil judgment) against a Pennsylvania real estate licensee because of fraud, misrepresentation, or deceit in a real estate transac- tion. The Fund repays persons who have not been able to collect the judgment after trying all lawful tivays to do so. For com- plete details about the Fund, call {717) 783-368, or (800) 822-2113 (within Pennsylvania) and (717) 783-484 (outside Pennsylvania). I`~'. ?~rOTICE T O PEI.SOIV'S O}~ FERINO TO SELL OR RENT FJ[OUSII~IG IN PENNSYLVANIA Federal and state laws make it illegal for a seller, a broker, or anyone to use RACE, COLOR, RELIGION or RELIGIOU S CREED, SEX, DISABILITY {physical or mental), FAMILIAL STATUS (children under 18 years of age), AGE (40 or elder), NATIONAL ORIGIN, USE OR HA~iDLING,~TRAINING OF SUPPORT OR GUIDE ANIMALS, or the FACT OF RELA- TIONSHIP OR ASSOCIATION TO AN INDIVIDUAL KNO'vV?v" TO HAVE A DISABILITY as reasons for refusing to sell, shotiv, or rent properties, loan money, or set deposit amounts, or as reasons for any decision relating to the sale of propemy. 19. ADDITIONAL OFFERS Unless prohibited by Seller, if Broker is asked by a buyer or cooperating broker about the existence of other offers on the Property, Broker will reveal the existence of other offers and whether they were obtained by the Licensee identified in this Contract, by another Licensee working with Broker, or by a cooperating Broker. ONCE SELLER ENTERS I~1T0 AN AGREEViENT OF SALE, BROKER IS NOT REQUIRED TO PRESENT OTHER OFFERS. ~'1). TRA:~ISFER OF THIS CONTRACT A. Broker will notify Seller immediately in writing ii Broker transfers this Contract to another broker when: (1) Broker stops doing business, OR (2) Broker forms a netiv real estate business, OR (3) Broker joins his business with another. Seller agrees that Broker may transfer this Contract to another broker. Broker will notify Seller immediately in writing when a transfer occurs or Broker will lose the right to transfer this Contract. Seller will follo~h~ all requirements of this Contract with the new broker. B. Should Seller give or transfer the Property, or an ownership interest in it, to anyone during the term of this Contract, all owners tivill follow the requirements of this Contract. ?1. NO OTHER CONTRACTS Seller will not e Ater into another listing contract with another broker that begins before the Ending Date of this Contract. ??.ENTIRE CONTRACT This Contract is the entire agreement between Broker and Seller. Any verbal or written agreements that were made before are not part of this Contract. '3. CHANCrES TCD THIS CONTRACT All chances to this Contract must be in tivriting ai.d signed by Broker and Seller. 24. SPECIAL INSTRI;CTIONS The Office of the Attorney General has not pre-approved any special conditions or additional terms added by any parties. Any special conditions or additional tzi-ms in this Contract must comply with the Pennsylvania Plain Language Consumer Contract Act. ?~. COPYRIGHT In consideration of Broker's efforts to market Seller's Property as stated in this Contract, Seller grants Broker anon-exclu- sive, world-wide license (the "License") io use any potentially copyrightable materials (the ";/laterials") which are related to the Property and provided by Seller to Broker or Broker`s representative(s). The Materials may include, but are not limited to: photographs, images, video recordings, vil~tual tours, drawings, written descriptions, remarks, and pricing information related to Seller's Property. This License permits Broker to submit the Materials to one or more multiple listing services, to include the Materials in compilations of property listings, and to otherwise distribute, publicly display, reproduce, publish and produce derivative works from the Materials for any purpose that does not conflict with the express terms of this Contract. The License may not be revoked by Seller and shall survive the ending of this Contract. Seller also grant:> Broker the right to sub- license to others anti of these rights Qranted to Broker by Seller. Seller represents and warrants to Broker that the License granted to Broker for the 1Viaterials does not violate or infringe upon the rights, including any copyrights, of any person or entit~l. Seller understands that the terms of the License do not grant Seller any legal right to any works that Broker may pro- duce using the Materials. ,~~ '\ Seller Initials: ~- ~ ;" XLS Page 3 of ~d ~~ Broker/i.,icensee Initials: l''J,% '_ 72 26. l~'IARKETIi~TG OF PRtflPERTY 173 A. Where permitted, Brokel-, at Broker's option, may use: ~~ For sale sign ^ Sold sign ^ Key in office ,~ Lock box 17~ ~ Print /electronic advel rising, including photographs ^ Property address in print/electronic advertising. 17~ B. Broker ~] ~viili ^ ~vi11 not use a ivlultiple Listing Service (VIES) to advertise the Property to other real estate brokers and salespersons. 17~ Seller agrees that Broker, Licensee, and the MILS are not responsible for mistakes in the MLS and/or advertising of the Property. ' "'? ?7. ITE1nIS I'*1CLUDED/NOT INCLLT~ED IN THE PRICE OE TIRE PRt7PERTY 1 ~ 3 w A. INCLUDED in the sale are all existing items permanently installed in the Property, free of liens, including plumbing; heating; 179 lighting flXtlll'e5 (lI7Clliding chandeliers and ceiling fans); water treatment systems; pool and spa equipment; garage door openers i3~~~ and transmitters; television antennas; unpotted shrubbery, plantings, and trees; any remaining heating and cooking fuels stored ! 3 on the Property at the time of settlement; sump pumps; storage sheds; mailboxes; wall to wall carpeting; existing window t 32 screens; storm tivindows and screerL'storm doors; window covering hardware shades and blinds; built-in air conditioners; built- 133 in at,nliances; and the rar~ae/oven, unless otherwise stated. Also iicluded: ~}. S ~, ~~~~s~`='=' ~`~~4~.~. ~~'~~ ~'f 18-+ • - 13~ B. LEASED items (not owned by seller): 1sF 137 C. E~C~.LUDED fixtures and items: 133 139 190 191 192 193 19~ 19 i 9~6 i9% 193 i99 ,;-,, ~. _,,.~~. .'01 ~,,., _~~ ~~: ZC~Y 20~ 20b 20~ Zos 209 210 211 ']~' 21.3 21=t ADDITIONAL INFORMATION (OPTIONAL) TITLE c°x POSSESSION A. Seller will give possession of Property to a buyer at settlement, or on B. At settlement, Seller will give full rights of ownership (fee simple) to a buyer except as follows: (1 } Mineral Rights Agreements: (?} Other: C. Seller has: ^ Mortgage with: Amount of balance Address: Phone: Acct. #: ^ Equity Loan with: Amount of balance $ Address: Phone: Acct. ~: ^ Seller authorizes Broker to receive mortgage payoff and~`or equity loan payoff information from lender(s). D. Seller has: ^ Judgments ^ Municipal Assessment ^ Past Due Taxes ^ Other: S $ $ $. E. If Seller, at any time on or since January 1,1998, has been obligated to pay support under arl order on record in any Pennsylvania county, list the county and the Domestic Relations Number or Docket Number: TAXES, UTILITIES, & ASSOCIATION FEES A. Az settlement, Seller will pay one-half of the total Real Estate Transfer Taxes, unless otherwise stated here: B. Real Estate Property Tax Assessment $ Wage!Income Tax $ C. Estirr~ated Utilities (trash, tivater, setiver, electric, gas, oil, etc.): Yearly Taxes $ _ Per Capita Tax $ ^ VA mortgage D. Association Fees $ Include: BUYER FINANCING Seller will accept the follo~,ving arrangements for buyer to pay for the Property: ~ ^ Cash ^ Cor~ventienal mortgage ^ FI~iA mortgage ^ Seller's help to buyer {if any}: 1 ~ Seller has read the Consumer Notice as adopted by the State Real Estate Commission at 49 Pa. Code §35.336. 15 Seller gives permission for Broker to send information about this transaction to the fas number(s) and/or a-mail address(es) listed below. i ~ Seller has read the entire Contract before signing. All Sellers must sign this Contract. 21 Q Return by facsimile (FAY) constitutes acceptance of this Contract. ?? 9 itiOTICE BEFORE SIGNING: IF SELLER H.4S LEGAL QUESTIONS, SELLER IS ADVISED TO CONSULT AN ATTORNEY. 2?O SELLER'S tiIAILING ADDRESS: (r.L:.' !!~~~ ~~~~~;,~ .~ ~;~ 22^ PHONE: { 7! ~) J !;; -~d ~ {; ~ FAX: E-MAIL: 223 SELLER it;`~~;'•, ~. ~ ,,,~-.~- _ DATE o~ 1 + L1~_~~__1~`~ 1 '2-~ SELLER _ Da-TE 22~ BROKER (Company Name) J~.LEX Real Estate Services , LLC ZZb ACCEPTED BY" DATE XLS Page ~# of =1 -,- ~°~ ~ -~ ~ t ~~`` ~ a e ~ ~~ i ~ ~~ ~--- -=;~ . ~ -:,: 2~~ ~~ ~: ~- ~' ~ ~~_.- '~`,~` ! - "~' 4' ~ r-- _ 1-l~~`-:4 ~. /~ i (. 1 t~ 1t, --_'_` 's j ~ ~ ~ ~~ ~~f V" l E: ~~f ` S G ~- ~ ~'': • ` ~ `~ ~ _ ~,~ "~, Y ~ ' sovereign Court Ordered Processing \ Decedents - MA 1-MB3-02-10 - P. O. Box 84 ] 005 -Boston, MA 02284 '~~ September 22, 2010 CEP ~'7 2~~t~ Irwin & McKnight, PC ~RWIN & McKN'1GHT 60 West Pomfret Street SAW OFFlCE:S Carlisle, PA 17013-3222 RE: Estate of Joyce L. Henry Date of Death: 06/17/2010 Dear Mr. Irwin: Per your request, enclosed please find the account information as of the da~,te of death for the above-named decedent. For your information, accrued interest is not included in the date of death balance. Please feel free to contact me if I can be of any further assistance. Very truly yours, ~~~„~~- Helen Alboth Lead Specialist 617-533-1789 D Sovereign Bank ESTATE OF Joyce L. Henry SOCIAL SECURITY #: 210-26-6734 DATE OF DEATH: August 17, 2010 Account #: 1691029602 Type: Checking Open date: 7'18/2003 In the name of: Joyce LHenry - (Kathy ELine - POA) Date of Death Balance: $7,563.45 Int.(YTD) from 1 /1 /2010 to 7/22/2010 $13.11 Accrued interest to date of death: $1.02 Other Info: Account closed 9/1/10 - $6,034.33 Account #: 1694002930 Type: Savings Open date: 3!5/1996 In the name of: Joyce LHenry - (Kathy ELine - POA) Date of Death Balance: $789.25 Int.(YTD) from 1/1/2010 to 7/22/2010 $0.58 Accrued interest to date of death: $0.12 Other Info: Account closed 9/1/10 - $789.25 Account #: 1695214245 Type: CD Open date: 11/:23/1987 In the name of: Joyce LHenry - (Kathy ELine - POA) Date of Death Balance: $1,659.44 Int.(YTD) from 1 /1 /2010 to 5/23!2010 $13.03 Accrued interest to date of death: $6.30 Other Info: Account closed 9/1/10 - $6,034.33 Account #: 1695214260 T e: ,~ i' ~ CD YP , ~ O en date: 2120/19 p 88 In the name of: Joyce L Henry or Kenneth AHenry - (Kathy ELine - POA) Date of Death Balance: $89,946.97 Int.(YTD) from 1/1/2010 to 7/31/201x. $2,111.45 Accrued interest to date of death: $181.60 Other Info: Account #: 1698182407 Type: IRA CD Open date: 4/5/1995 In the name of: Joyce L Henry Date of Death Balance: $9.84 Int.(YTD) from 1/1/2010 to 7/31/2010 ; $0.06 Accrued interest to date of death: $0.01 Other Info: Beneficiaries: Equally to: Michael Henry-Son, Randy Henry-Son, Kathy Line-Daughter Page 1 of 1 WESTERN ~ I~1ATI~NAL Life I n s u r a n c e C o m p a n y Western National Life Insurance Company P. O. Box 871 Amarillo, Texas 79105 Telephone: 800.424.4990 September 20, 2010 ROGER B IRWIN 60 W POMFRET ST CARLISLE PA 17013 Re: Name of Deceased: Joyce Henry IRWIN & NicKNIt~H~' Contract Number: XP223272 ~W OFFICES; Beneficiary: Kathy E Line Dear Sir or Madam: We have received notification of the death of Joyce Henry, the owner/annuitant of the referenced contract. On behalf of Western National Life Insurance Company, we wish to express our sincerest condolences for your loss. The following items are enclosed: 1) Claims Checklist - A list of items required to initiate a claim for this contract. 2) Beneficiary options page - A list of claim options available to the referenced beneficiary. 3) Applicable documents for completion. The value of policy on the date of death was $48,817.35. We appreciate your prompt attention to this matter. Should you have any questions or require further assistance, please contact our Client Care Center by using our toll free number of 1-800-424-4990. Sincerely, ~~ . ~~~ ~- B.M. Graves Annuity Claims Manager Enclosures WNL Cvr Lcr DOD ~. ct" tai tG t--' 0 -~G ~• ~C tD cY ttl C1' n ~ ~ G ~ ~ 4 F,,,... ~ z ,~ x c~ ~ ~' ° ~ N ~ ~~ r• ~ ~ ~ ~ ~ ~ ~~ ro m ~ ~' ~ ~' rt ro ~ R7 ~ .a d t't' Ct N N N• ~p ~,~,. ~ ~*' ~ 0 rn r~ 0 K to x c~ n K ~~ ~ rn ~ ~ o ~ g,, ~ ~ ~ ~ ~ n^n'~'^x ~ ~''~ t31CT~'vV+~V~U~y ~ -0- rd ~ ~ Q O '~, ~~ ~ ,,.,,, ~ +.1~ tG o ~~ ~ ~ N N x a °~~x .. cr w "~ ~ r ~~~~ o a °• !-s two X251 . . uq ~ qnl (IIL,dAw~ ~ i'f nulA ~ ~ipn~ I ini4, A ~~~~~~ a The News-Chr~r~ic:le Co. 22 East King Street P.O. Box 100 Shippensburg, PA 17257 Phone: (717) 532-101 KATHY L{NE 100 SLINTON DR NEWVILLE, PA 17241 Customer : 01108475-000 Phone : (717)776-4165 Date : 09/30/10 Page : 1 Date Reference # (Type ~ Description 09110/10 01578049-001 i FOR SALE: Double Wide Mobi! Remarks PLEASE RETURN A COPY WITH PAYMENT .---- Current ,36.70 1-:Z~7 Runs Lines Inches Total 3 20 2.39 36.70 Sub Tota{: 36.70 Discounts: 0.00 Total Due: 36.7 U.UU 31 -6U ~ ~ UO 61-90 O.OU 91-E O.0O f l „= mo°O O1 ... "' ~T-G c ~ ~~~ a o .~ r-zr w pp. - ~ mai= = Z H ~ zQ~ ~~17 _ DQ ~ ~ ~ z Pt1 Z ,,,, Tl " < v l ~ - O ~° ._ v - . ? ~ c p _= $ - mci ~ m -"" V ~ r:.. t p U1 . ~. O W ..: i CD _ - ....~ = - O ~ ~- "'- ... ~ ~ O - ~ f • '~' F+ : . ~ :.. ~ ~ - - ~~ r ~r ~~- ~~ j. --- _ -- _ O = ro ,,,,, ~,,, = - - o ru - - w - n., ~+ O m ^ ~ ~ z a ~ z 4' ~ sc°o~~` c ~ ~ o ~ Oa ~ m m 3 ~ y, s ~ ~ ~, ~ ~ L!1 0 ~' ~ = ~ cWp x' ~ a v W ~ ~ ~ a W ~ m ~ q o~ ~ y - W 0 ~ O ~ ti - m ~ 0 a ro o e ~ `~ a c n .tn F~.• 0 0° ~ ~~ 0" O O ..~ L!'1 ~ ~ I.!'{ 0 v a a v 0 a Ll1 a n ZJ'1 W W : DETAILED INVOICE Service For :Joyce Henry Billed To : Mrs. Joyce Henry Invoice #: 1316-0710-2 Invoice Date : 7/31/2010 Service Period c Jul 16, 2010 - Ju131, 2010 ~ ~ ome n~tea 0 5002 Lenker Street Mechanicsburg, PA 1705(1 (717) 731-9984 www.HomeInstead.com 7/30 9:OOam 3:OOpm Normal Crout, Barbara Hourly Service, Leve12 6.00 $20.95 $125.70 3:OOpm b:00pm Schlusser, Marlene Hourly Service, Level 2 3.00 $20.95 $62.85 7/31 9:OOam 12:OOpm Weekend Goshom, Bethany Hourly Service, Leve12 3.00 $23.05 $69.15 12:OOpm 6:OOpm Parris, Colby Hourly Service, Leve12 6.00 $23.05 $138.30 Miles: 0.00 @ $0.58• _ $0.00 Miscellaneous Charges: _ $0.00 Additional Charges/Credits: _ $0.00 Service Deposit Applied: _ $0.00 Current Invoice Total: ~_ $396.00 Total Amount Due: $396.00 Due Date : Due upon Receipt *All Overdue Invoices are Subject to an 1 S% Annual Service Charge Please Retain For Your Records C ®arryf K. Guistwite, ®.®., fnc. 56 Ashton Street Carlisle, PA 17015-6914 (717) 609-2639 ~l JOYCE L. HENRY C/0 KATHY LINE 100 FLINTSTONE DRIVE NEWVILLE PA 17241 Date Description Charge Credit JOYCE L. HENRY ( 180.0} O1/06j10 NURSING HOME EST. P ATIENT 75.00 01/26j10 Ins Pmt-MEDICARE _ 0.00 $61.21 was applied to your de uctible - O1j26j10 Adjustment 13.79 ~ O1j26/10 Ins Pmt-MENNONITE MUTUAL AID ASS. 0.00 $61.21 was applied to your de uctible Olj12j10 NURSING HOME EST. P ATIENT 105.00 02j05j10 Tns Pmt-MEDICARE 21.92 $53.57 was applied to your de uctible 02j05j10 Adjustment 24.03 02j11j10 Ins Pmt-MENNONITE MUTUAL AID ASS. 5.48 $53.57 was applied to your de uctible TO AL FOR JOY E L. HENRY Total Due Current 31 - 60 Days 69 - 90 Days 99 -120 Days Over 920 Days 114.78 0.00 0.00 0.00 0.00 114.78 i -__ __ _ __ ______ _ __ _ Al'71_J~1'll.~ Z, vl • Carlisle Brethren In Christ Church 1155 Walnut Bottom Road Phone: 717-243-1863 Carlisle, PA 17015 Invoice 8/24/2010 Bill To: Cathy Line Funeral Services Please make check payable to: Joyce Henry Carlisle 8IC Kitchen Fund pate Description # of people Payment Balance 8/24!2010 Luncheon 80 $3.00lPerson $240.00 Haen $ Cheese Sandwiches Chicken Salad Sandwiches Pasta/Potato Salad Chips Pickles CoffeelIce Tea/Wnter Cookies Total $240.00 Carlisle BIC Kitchen Committee