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Home My WebLink About12-03-10 (2)1505610143 REV-1500 EX (01-10) j i,~ [~FFIC_I~I 1 I!CF C)IJII Y PA Department of Revenue Pennsylvania County Code Year Bureau of Individual Taxes DEPARTMENT Of REVENUE PO 80X.280601 INHERITANCE TAX RETURN 21 0 9 Harrisburg, PA 17128-0601 RESIDENT DECEDENT File Number 0540 -- -- - - -- ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 201 18 3419 05 13 2009 Decedent's Last Name SOWERS (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Spouse's Social Security Number Date of Birth 03 19 1925 Suffix Decedent's First Name MI HELEN P Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ 4a. Future Interest Compromise (date of death after 12-12-82) ~~' L^- 6 Decedent Died Testate (Attach CORY of Will) ~ 7 (At acheCo a~of Trust a Living Trust PY ) 9. Litigation Proceeds Received ~ 1 p, Spousal Poverty Credit (date of death between 12-31 51 and 1-1-95) State ZIP Code PA 19606 CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ELIZABETH K MORELLI ESQ 610 370 9588 First line of address 5 HEARTHSTONE CT 201 Second line of address City or Post Office READING Correspondent's a-mail address: ekmorelli@msn.com Under penalties of perjury, I declare that I have examined this return including accompanying schedules and statements, and to the best cif my knowledge and belief, it is true, rect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT RE PERS SPONS FILIN RETURN DATE - Anita E Sowers 1 oZ- ~ ~ ~ ~ (,~ ADDRESS 903 East Kin Street Palm ra PA 17078 SIGN Rry OF PREPARER OTHE ;THAN REPRES, TATIVE j ` DATE '~ A ~ - j ~ Elizabeth K. Morelli Esq. ~~~? - ~ - iv ADDRESS 5 Hearthstone Ct 201, Reading, PA 19606 Side 1 1505610143 1505610143 J 3. Remainder Return (date of death prior to 12-13-8:2) C] 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes ~~ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) rti.-a REGISTER OF VitiQLS USE ONE C." t--~ .. . -a7 r.,:.~ %-_ .' ~ ~ ~ ,..i f - ~ 4 ~ y , Ir J L '!~ .. \ l C_.~ ,-w. ~• - ~ 7 .,,,. ~~ ryry DATE IFrL~E'd ~r-j ._;.-~ --}..: _._... ,, _,._, t ._~ :. --- ; :.•1~ ; .~j J 1505610243 REV-1500 EX Decedent's Name: Sowers, Helen P 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 & Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous I~q Probate Property (Schedule G) ^ Separate Billing Requested............ 7, g. Total Gross Assets (total Lines 1-7) ..................................................................... g. 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 13. Charitable and Governmental BequestslSec 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. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 (a)(1.2) X .00 . 16. Amount of Line 14 taxable 5 7 , 5 0 0.91 16. at lineal rate X .045 17. Amount of Line 14 taxable 0 0 0 17 . at sibling rate X .12 . 18. Amount of Line 14 taxable 0 0 0 18 • at collateral rate X .15 . 19. Tax Due .................................................................................................................. 19. 20. FILL IN THE OVAL 1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 13,599.04 7,849.84 21,448.88 57,500.91 57,500.91 0.00 2,587.54 0.00 0.00 2,587.54 Side 2 1505610243 1505610243 Decedent's Social Security Number 201 18 3419 76,000.00 916.32 95.00 1,938.47 78, 949.79 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-09-0540 DECEDENT'S NAME Sowers, Helen P STREET ADDRESS 100 East Butler Street _ ___ CITY Mount Holly Springs STATE PA ZIP 17065 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount (1) 2,587.54 0.00 83.40 2,670.94 3. Interest 0.00 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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. Total Credits (A + B) (2) (3) (~~) (•~) Make Check Payable to: REGISTER OF WILLS AGENT. ~r ~ ~ . 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 b. retain the right to designate who shall use the property transferred or its income :.................................. ^ Ox x c. retain a reversionary interest; or .............................................................................................................. 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? .................................................................................................................... ~~ 0 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? .................................................................................................................. ^ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE 1T 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 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 under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1502 EX+ (11-08) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 ~~chedule A (Rev. 11-08) Rev-1503 EX+ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 744320102 24 shares of Prudential Financial Inc - Com; value is average 38.18 916.32 hillo for date of death TOTAL (Also enter on Line 2, Recapitulation) 916.32 ({f more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ (6-98) ,. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 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. 6-98) Rev-1509 EX+ (6-98) ,., COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Anita E Sowers B. C. 903 East King St. Daughter Palmyra, PA 17078 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSE % OF= DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 A 1/1/1978 PNC Bank -account #5140192078 held jointly 3,876.94 50.000% 1,938.47 with daughter TOTAL (Also enter on Line 6, Recapitulation) I 1,938.47 (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 F (Rev. 6-98) REV-1151 EX+ (10-06) ,~ COMMONWEALTCCH OF,,gqP~~ENNSUUYLVANIA IN RESIDEN7EDECEDENTRN ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N MBER q, FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Anita E Sowers Street Address 903 East King Street city Palmyra state PA Zia 17078 Year(s) Commission paid 2010 2. Attorney's Fees Elizabeth K. Morelli Esq. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 155.00 376.00 250.00 4. Probate Fees 177.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 12,641.04 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 13,599.04 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS 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 Sowers, Helen P 21-09-0540 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Anita Sowers -reimburse for memorial luncheon 155.00 H-A 155.00 Qther Administrative Costs 2 Anita Sowers -reimburse for fee for for sale signs for home 12.00 3 Borough of Mt. Holly -bills for water/sewer and trash while home for sale 356.40 4 Carlisle Area School District -real estate taxes during time of home for sale 602.71 5 Cumberland County Law Journal -estate advertising 75.00 6 Ebay -listing fee for sale of real estate 400.00 7 Harvey M. Shuler 11 -cost for tie downs for mobile home to be sold 900.00 8 Housecleaning -cleaning of decedent's home 126.00 9 Lawn care and maintenance -for home during time for sale 1,075.00 10 Met Ed -electric bills during period of time home for sale 269.49 11 Mt. Holly Borough -real estate taxes during time of home for sale 237.62 12 PA Real Estate Settlement Services, LLC -settlement costs 8,023.76 13 The Sentinel -estate advertising 138.06 14 The Virtus Group -fee to inspect home for FHA buyer 425.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 ITEM AMOUNT NUMBER DESCRIPTION H-B? 12,641.04 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-150Gt Schedule H (Rev. 6-98) Rev-1512 EX+ t12-o8) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 Resort debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. (1f 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+ (11-08) ~~ COMMNHEgIETANC,H~EOT~ERET~RN ANIA RE,,IDEN DEcc;;EDEN SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Sowers, Helen P 21-09-0540 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) D it tes I TAXABLE DISTRIBUTIONS [include outright spousal • distributions, and transfers under Sec. 9116(a)(1.2)] 1 Anita E Sowers 903 S. King Street Palmyra, PA 17078 Daughter 1100% Estate residue ~ Total ~ Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro i NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX I5 NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 57,500.91 57,500.91 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 2009- 00540 PA No . 21- 09- 0540 Estate Of : HELEN P SO WERS (first, Midd/e, Lastl a/k/a : HELENA SOWERS Late Of : MT ROLL Y SPRINGS BOROUGH CUMBERLAND COUNTY Deceased Social Security No : 20 ~-18-3419 WHEREAS, on the 11th day of June 2009 an instrument dated July 16th 2008 was admitted to probate as the last will of HEL EN P SD WERS (First, Mrddle, Lastl a/k/a HELENA SOWERS late of MT ROLL Y SPR/NGS BOROUGH, CUMBERLAND County, , who died on the 13th day of May 2009 and, WHEREAS, a true copy of the wi 11 as probated i s annexed hereto . THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi 11 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: ANITA E SO WERS who has duly qualified as EXECUTOR(R/XJ and has agreed to administer the estate according to 1 aw, a1.I of which ful 1 y appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 11th day of June 2009. * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) LAST WILL AND TESTAMENT ~~ HELEN P. SOWERS ~-- ~~' ~ ~~=~ ~> C7 ~ ~---, ~--j I, HELEN P. SOWERS, of the Borough of Mt. Holly Springs, C ~Ianc ~:~.` ~;~ ~-~.. ,. . County, Pennsylvania, revoke my prior wills and codicils and declar ` . to beery ~,: Will: ~ - r.3 :.:~.~ I. Debts and Funeral Expenses: My debts and the expenses of my last illness, funeral and burial shall be paid out of my estate. Il. Personal and Household Effects: I give all my articles of personal or household use, including automobiles, together with all insurance relating thereto, to ANITA E. SOWERS, if she survives me. If she does not survive me, I give all said property to LYNN M. SCHMIDT. If she does not survive me, I give all said property to DOROTHY J. MYERS. Any items not selected by a beneficiary above or distributed by a memorandum are to be sold, abandoned or given to a charity or charities as determined by my executor. The proceeds of any sale shall be added to the residuary estate. My executor may make whatever arrangements my executor deems appropriate for storing and delivering articles of personal or household use to the beneficiaries and may pay the cost thereof and any related expenses, including insurance, from my residuary estate. I intend to leave a memorandum setting forth suggestions as to the distribution of certain items and I hope the suggestions in it will be carried out. III. Residuary Estate: All of the rest, residue, and remainder of the property that I own at the time of my death, both real and personal, and of every kind and description, wherever situated, to which I may be legally or equitably entitled at the time of my death (my "residuary estate"), I give to ANITA E. SOWERS, if she survives me. If ANITA E. SOWERS does not so survive me, the residue of my estate shall be given to LYNN M. SCHMIDT. If LYNN M. SCHMIDT does not so survive me, the residue of my estate shall be given to DOROTHY J. MYERS. If any beneficiary has not attained the age of twenty-one (21) years, his'her share shall be given to the guardian of the estate of such child, as custodian, to be placed in a Uniform Transfer to Minors Account (UTMA) until each named beneficiary has attained the age of twenty-one (21) years of age. IV. Adopted Persons: Persons adopted during minority shall be considered as children of their adoptive parents, and they and their descendants shall be considered as descendants of their adoptive parents. ADMINISTRATIVE PROVISIONS V. Protective Provisions: No beneficiary may sell, give or otherwise transfer his or her interest in income or principal hereunder. No person having a claim against a beneficiary may reach any such interest before actual payment to the beneficiary. VI. Death Taxes: All federal, state and other death taxes payable because of my death 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 probate estate so that t11e burden thereof falls on m~~ resicluar~T estate, and none of tllosc taxes shall be cI-~arged against any beneficiary or any outside fund. This provision shall not a~aply to generation-skipping transfer taxes. VII. Management Provisions: I authorize my executor: A. To retain and to invest in all forms of real and personal property (including common trust funds, mutual funds and money market deposit accounts operated by or offered by my corporate executor or any affiliate of it), without being required to diversify; B. To compromise claims and to abandon any property which, in my executor's opinion, is `of little or no value; C. To partition, subdivide or improve real estate and to enter into agreements concerning the partition, subdivision, improvement, zoning or management of any real estate in which my estate ox any trust hereunder has an interest and to impose or extinguish restrictions on any such real estate; D. 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 leases; E. To employ and to rely upon advice given by investment counsel, to delegate discretionary authority to make changes in investments to investment counsel (so long as my executor prescribes general investment guidelines, meets regularly with investment counsel, and evaluates periodically the overall performance of investment counsel}, and to pay investment counsel reasonable compensation in addition t~o any fees otherwise payable to my executor and my trustee; F. To employ a custodian, to hold property unregistered or in the name of a nominee (including the nominee of any institution employed as custodian), and to pay reasonable compensation to the custodian in addition to any fees otherwise payable to my executor. G. To borrow, and to pledge property as security for repayment of any funds borrowed; and H. To distribute in cash or in kind and to allocate property distributed in kind without any obligation either to distribute such property among the recipients proportionately or to distribute property having an equivalent income tax basis to all recipients, so long as the total market value of any beneficiary's share is not affected by such allocation. These authorities shall be in addition to those granted by law and shall be exei,cisable without court authorization. VIII. In Terrorem Clause: If any beneficiary or remainderman under this Will in any manner, directly or indirectly, contests or attacks this Will or any of its provisions, or objects to the accounts or actions of my fiduciaries, with probable cause, such beneficiary shall pay all costs, including but not limited to attorneys fees, arising in connection with such contest, attack or objection incurred by estate, such trust or such fiduciary personally. In the event that such beneficiary does not prevail in such action, any share or interest in my estate or such trust which would otherwise pass to such beneficiary or remainderman under this Will shall be revoked and the property consisting of such share shall be disposed of in the manner provided herein as if that contesting beneficiary or remainderman had predeceased me without surviving issue. IX. Renunciation of Executor Powers: An executox hereunder may by written instrument renounce in whole or in part any one or more powers, authorities or discretion given by this will or by law to that executor. Such renunciation shall be binding on successor executors if the renouncing executor so directs. EXECUTOR X. Executor: I appoint ANITA E. SOWERS executrix of this will. In the event that ANITA E. SOWERS shall predecease me or be unable or unwilling to so serve, I then appoint LYNN M. SCHMIDT executrix of this will in her place. In the event that LYNN M. SCHMIDT shall predecease me or be unable or unwilling to so serve, I then appoint DOROTHY j. MYERS executrix of this will in her place and I direct that: A. The ward "my executor" shall refer to all those from time to time acting as such; B. No executor shall be required to give bond. IN WITNESS WHEREOF, I, HELEN P. SOWERS, have set my hand and seal to this, m~ LAST WILL AND TESTAMENT, which consists of 3 previous pages, this day of (,t,( 2008. ~~}.~ ~ ~~ HELEN P. SOWERS Signed, sealed, puUlislled and declared by the within-named HELEN P. SOWERS, as and for his/her last will, in the presence of us, who, at his/her request and in his/ her presence, and in the presence of each other, have subscribed our names as witnesses thereto. ss / ~~ ,,; , Witnes 4 COMMONWEALTH OF PENNSYLVANIA . ss. COUNTY OF BERKS _ We, HELEN P. SOWERS, RICHARD A. FLORES, andFL/2~9~7f/ , the testatrix and the witnesses, respectively, whose names are signed to the foregoi g instrument, being duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as his/ her Last Will; that: the testatrix signed willingly and executed it as his/her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testatrix and of one another, signed t11e will as a witness; and that to the best of the tijitnesses' knowledge the testatrix was at that time eighteen or mor. e years of age, of sound mind, and under no constraint or undue influence. ~ ~ ~~~ HELEN P. SOWERS Witness ,~~ ~1 ~ ~ f Witness Subscribed, sworn to and acknowledged before me by HELEN l?. SOWERS, the testatrix, and subscribed and sworn to before me by RICHARD A. FLC>RES and ~2, 4CjE,Tr~ . ,~/D~E~.C/ ,the witnesses, this ~ day of , 2008. Z Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Catherine G. Bemsteel, Notary Public Exeter Twp., Berks County My Commission Expires Jan. 24, 2009 S ' Member, Pennsylvania Association of Notaries DECLARATION OF GIFTS This Declaration indicates my desire with respect to the disposition of certain items of personal property. It is my desire that my Executor and heirs recognize and abide by my wishes contained herein. Below is a brief description of certain personal property which is owned by me and to which this Declaration applies anal the name of the person I would like to have such property. If any beneficiary of any bequest listed below does not survive me, then the gift shall lapse. If, at the time of my death, the property is not in existence, or if I do not own or have an interest in this property, the said gift shall fail. Brief Description of Personal PropertX Dated this day of WITNESS Donee to Whom I Give the Prope_r~ 2008. HELEN P. SOWERS ~~'~ ~ A. Settlement Statement (HUD-1) . ~Iilll~ ;. v OMB Approval No. 2502-0265 FINAL XQ FHA 2 ^Conv. Unins. ^ RHS 3 1 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: . . . 2010-1074 1015301 4460419595 4. ^ VA 5. ^Conv. Ins. C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown Items marked "(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not Included in the totals. D. Name & Address of Borrower: E. Name & Address of Seiler: F. Name & Address of Lender: David A. Heinbaugh, Sr. The Estate of Helen P. Sowers alk/a Helen A. Sowers American Financial Resources, Inc. P,O. Box 1441, Carlisle, PA 17013 9 Sylvan Way, Parsippany, NJ 07054 G. Property Location: H. Settlement Agent: I. Settlement Date: 1 V17/2010 100 East Butler Street PA Real Estate Settlement Services LLC Disbursement Date: 1 V17/2010 Mount Holly Springs, PA 17065 Telephone: 717-249-6333 Fax: 717-249-7334 Mount Holly Springs Borough Place of Settlement: TitieExpress 354 Alexander Spring Road, Carlisle, PA 17015 Printed 1 V18/2010 at 2:1'7 pm by KSC ':100. Gross.AmounfDue from Borrower 4011. Gross AhSOUntt)ueto Seller 101. Contract sales price 76,000.00 401. Contract sales price 76,000.00 102. Personal ro rt 402. Personal ro ert 103. Settlement charges to borrower (line 1400) 7,466.70 403. 104. 404. 105. 405. Ad'ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance 106. City/town taxes to 406. City/town taxes to 107. County taxes 11/17/2010 to 12/31/2010 29.30 407. County taxes 11/17/2010 to 12/31/2010 29.30 108. Assessments 11/17/2010 to 06/30/2011 480.05 408. Assessments 11/17/2010 to 06/30/2011 480.05 109. 409. 110. 410. 111. 411. 112. 412. 120. Gross Amount Due from Borrower 83,9711.05 420. Gross Amount Due to Seller 76,509.35 200. `Amounts Pal'db or,ih' Behalfof-Borrower 500. Reductlons in.Amount Due to Seller 201. Deposit or earnest money 1,000.00 501. Excess deposit (see instructions) 202. Principal amount of new loan(s) 74,990.00 502. Settlement charges to seller (line 1400) E,023.76 203. Existin loa s taken sub'ect to 503. Existin loa s taken sub'ect to 204. 504. Pa off of first mort a e loan 205. 505. Payoff of second mortgage loan 206. 506. 207• 507. Escrow for Inheritance taxes 10,272.84 208. 508. 209, 509. Ad ustments for items un aid b seller Ad'ustments for Items un aid b seller 210. City/town taxes to 510. Cityltown taxes to 211. County taxes to 511. County taxes to 212. Assessments to 512. Assessments to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218• 518. 219• 519. 220• Total Paid b /for Borrower 75,990.00 520. Total Reduction Amount Due Seller 18,296.60 300.- Gash at=Settlement fromito Borrower ;` ' : - 600. Cash,at'Setflementitolfrom Seller 301. Gross amount due from borrower (line 120) 83,976.05 601, Gross amount due to seller (line 420) 76,509.35 302. Less amounts paid by/for borrower (line 220) 75,990.00 602. Less reductions in amount due seller (line 520) 18 296.60 303. Cash ^X From ~ To Borrower 7,986.05 w epo en or u co ron o morns an ma s rtunu a per rssponw or m urp, revrerrnp, this lorrrt unisee i1 d eplsys a currently valid OMB control number. No conOdanllellly b a-ureQ tMs dledosure b mendalory. TM esttlemenl procsu 6 r s k 03. Cash QX To ~ From Seller a .pency mey no s r orm ior< you us no rsgre o dealpned to provide the psrlies to a RESPA covered Inn-dbn wllh Information durirq th , 58,212.75 comp e e e Previous editions are obsolete Page 1 of 4 HUD-1 700. Total Real Estate Broker Fees $ 4,755.00 Paid From Paid From Division of commission Tine 700 as follows: Borrower's Seller's 701. $4,755.00 to Prudential Homesale Services Group Funds at Funds at 702• 80.00 to Settlement Settlement 703. Commission paid at settlement 4,755.00 704, to 800. Items Pa able in Connection with Loan 801. Our origination charge (Includes Origination Point % or $0.00) $2,828.50 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $ (from GFE #2) 803. Your adjusted origination charges (from GFE A) 2,828.50 804. Appraisal fee to Minnici A raisal Services $500.00 P.O.C. B' (from GFE #3) 805. Credit report to American Financial Resources, Inc. (from GFE #3) 21.83 806. Tax service to from GFE #3 807. Flood certification to Corelo is Flood Services (from GFE #3) 12.00 808. to 900. Items Re wired b Lender to be Paid in Advance 901. Daily interest charges from from 11/17/2010 to 12/01/2010 @ $11.2999/day (from GFE #10) 158.20 902. Mortgage Ins. Premium for months to HUD (from GFE #3) 1,650.15 903. Homeowner's insurance for months to (from GFE #11) 904. months to from GFE #11 1000. Reserves De osited with Lender 1001. Initial deposit for your escrow account (from GFE #9) 697.29 1002. Homeowner's insurance 4 months $ 55.92/month $223.68 1003. Mortgage Insurance months $ 33.41/month $0.00 1004. Flood Insurance 4 months $ 34.00/month $136.00 1005. County Property Tax 11 months $ 19.80/month $217.80 1006. Assessments 6 months $ 64.61/month $387.66 1007. Aggregate Adjustment $-267.85 1100. Title Char es 1101. Title services and lender's title insurance (from GFE #4) 1,085.25 1102. Settlement or closing fee to $ 1103. Owner's title insurance (from GFE #5) 77.48 1104. Lender's title insurance $983.75 1105. Lender's title policy limit $74,990.00 Lender's Policy 1106. Owner's title policy limit $76,000.00 Owner's Policy 1107. Agent's portion of the total title insurance premium $868.30 1108. Underwriter's portion of the total title insurance premium $192.93 1109. 1200. Government Recordin and Transfer Char es 1201, Government recording charges (from GFE #7} 146.00 1202• Deed $62.00 Mort a e $84.00 Release $0.00 1203. Transfer taxes (from GFE #8) 760.00 1204. City/County tax/stamps Deed $760.00 Mort a e $0.00 1205. State Tax/stamps Deed $760.00 Mort a e $0.00 760.00 1206. Deed $0.00 Mort a e $0.00 1207. 1300. Additional Settlement Char es 1301. Required services that you can shop for (from GFE #6) 30.00 1302. 2010-11 School Taxes to Mable Satterson, Tax Collector $ 852.84 1303. Final WtdSwr Bill to Mount Holl Borou h $ 5.00 1304. Deed Prep to Salzmann Hu hes, P.C. $ 125.00 1305. Pest Control/Inspection to Per Pest $30.00 775.92 1306. Engineering Services to Carl Bert & Associates, Inc. $ 750.00 'Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K)er. Previous editions are obsolete Page 2 of 4 HUD-1 Com arison of Gond Faith Estimate GF and HUD•1 Char es Char es That Cannot.Increase HUD•1 Line Number Ourorigination charge # 801 Your credit or charge.(points) for the specific interest rate chosen # 802 Your adjusted origination.charges. # 803 Transfer taxes # 1203 Char. es That in Total Cannot-Increase.More Than 1D% Government recording charges # 1201 Appraisal fee to # 804 Credit report to # 805 Flood Certification # 807 Mortgage insurance premium # 902 Title services and lender's title insurance # 1101 Owner's title insurance # 1103 ~• ~ ~ ~• Char es That;Can Chan e Initial deposit. for your escrow.account # 1001 Daily interest charge # .901 $11.2999/da. Homeowner's insurance # 903 . 2010-11 School Taxes # 1302 Final Wtr/Swr Bill # 1303 Deed Prep # 1304 Pest Control # 1305 En ineerin Services # 1306 Loan Terms Good Faith Estimate HUD-1 2,828.50 2,828.50 0.00 0.00 2,828.50 2,828.50 1,520.00 760.00 Good. Faith Estimate HUD=1 188,00 146.00 500.00 500.00 49.00 21.83 13.00 12.00 1,650.15 1,650.15 935.00 1,085.25 0.00 77.48 3,335.15 3,492.71 $ 157.56 or 4.7242% Good Faith Estimate HUD-1 726.00 697.29 339.00 158.20 0.00 0.00 0.00 0.00 0.00 0.00 0.00 30.00 0.00 0.00 Your initial loan amount is $74,990.00 Your loan term is 30. years Your initial interest rate is 5.5000% Your initial monthly amount owed for principal, interest, and any mortgage $459.19 includes insurance is X^ Principal ^X Interest ^X Mortgage Insurance Can your interest rate rise? ^X No. ^ Yes, it can rise to a maximum of %. The first change will be on / I and can change again every years after / / .Every change date, your interest rate can increase or decrease by %. Over the life of the loan, your interest rate is guaranteed to never be lower than % or higher than %. Even if you make payments on time, can your loan balance rise? X^ No. ^ Yes, it can rise to a maximum of $ Even if you make payments on time, can your monthly amonntowed for X^ No. ^ Yes, the first increase can be on / / and the monthly principal, interest, and mortgage insurance rise? amount owed can rise to $ The maximum it can ever rise to is $ Does your loan have a prepayment penalty? ^X No. ^ Yes, your maximum prepayment penalty is $ Does your loan haven .balloon payment? X^ No. ^ Yes, you have a balloon payment of $ due in years on I I Total monthly amount owed including escrow account payments ^ You do not have a monthly escrow payment for items, such as property taxes and homeowner's insurance. You must pay these items directly yourself. ^X You have an additional monthly escrow payment of $174.33 that results in a total initial monthly amount owed of $633.52. This includes prinncipal, interest, any mortgage insurance and any items checked below: Q Property taxes 0 Homeowner's insurance ^X Flood insurance ^ School Taxes ^ Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Previous editions are obsolete Page 3 of 4 HUD-1 HUD CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my account or by mein this transaction. I further certify that i have received a copy of the HUD-1 Settlement Statement 1 .~ avid A. Heinba gh, r. ~~~:~-~ e-~- two -a~-o ° .__~, SQ,N~._. /.j ~ ~ /` ~ ~~ ~'-~, ~ J ~~... The Estate of Helen P. Sowers a/k/a Helen A. Sowers ,, The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement SETTLEMENT AGE T DATE WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 101 C1. Previous editions are obsolete Page 4 of 4 HUD-1 ~+omi~satinn rif ~ inPS 1101. 1103 and 1104 l Name of Borrower: David A. Heinbaugh, Sr. Name of Seller: The Estate of Helen P. Sowers a/k/a Helen A. Sowers File Number 2010-1074 TitleExpress Prepared 11/17/2010 at 2:32 pm Note: This page is furnished to give you an itemization of the amounts shown on Lines 1101, 1103 and 1104 of the Settlement Statement (HUD-1 ). This page accompanies but is not a part of the settlement statement. If a discrepancy exists, the information shown on the Settlement Statement (HUD-1) applies. Paid-F>•~rn Bb 'rower's F~~nds~at ~ett4ernent Paid Frflm. ~el~er`s Funds at S~ettlemer~t Aihount~?fircl,t~fetl 1100: ~'itle Charges - In Lti1e ~'Q'f~~ 1101. Title services and lender's title insurance 1,085.25 a. Wire Fee $ 12.00 b. Ovemi ht Mail 20.50 c. Processin Fee 29•~ d. Notary Fee -Est. 40.00 101.50 1102, Settlement or closin fee -- 1103. Owner's title insurance lic $ 77.48 77.48 1104. Lender's title insurance olic 708.75 $ 983.75 -- a. Endorsement 400 Manufactured Housing 50.00 b. Endorsement 900 EPL-Residential 50.00 c. Endorsement 100 (No Violation 50.00 d. Endorsement 300 Surve 50.00 -- e. Closing Service Letter 75.00 -- (Total 1103 + 1104) 1:105: lenders itle polic limit'~74`,990?-Or3 110:6. Owner'sailte policy limit S7li,Q00i00+.. 1107.:A ~ent's portion of#Me totallitleinsuance retiiium : _ . $ 86g~30: 1108. Underwflteras portion of the;tatal title insurance prim. 7!2'93: (Tofa1~1107 +.11.08).,. _- 1109. 1110. -- 1111. -- 1112 - 'Additional Information for Line 1104 )terns - 1.100. title~ChaF es;vrith,Fa Vie, .. T"o1`at~ Ghar `~ Bp1ro.Hrer; PO`~'o'rC>?edit; 'B'orvawer' Gige 114?; Selli;~ -Pa{d 1101. Title services and lender's title Insurance $ a. Wire Fee to Salzmann Hughes, P.C. 12.00 12.00 b. Overnight Mail to Salzmann Hughes, P.C. 20.50 20.50 c. Processing Fee to Salzmann Hughes, P.C. 29.00 29.00 d. Notary Fee -Est. to Notary Clerk 40.00 40.00 -- 1104. Lender's title insurance to Stewart Title Guaranty/PA RE SS 983.75 983.75 .. _ ,. THE ESTATE OFa HELEN P. SOWERS A/K/A HELEN A. S ~W E~ R~~C~I~~ _ ,.,,t~,P-'~"•u' ~ ~ ~ ~G.a t ~ ~-,`"'75 ~ f , S~WZ.~ ~~k~~~ Date _11/17,110 By ~~' ~`-'~~ ~~ ~~ Date 11/17/10 David A. Heinbaugh, Sr. Prudential 000027 'III"II~~~I~~III~~I~~llll~~~~l~lll~l~l~~llll'~~'~'ll'~III~I~I'I HELEN P SOWERS 903 S KING ST ~omputershare '~' Computershare Trust Company, N.A. PO Box 43033 Providence, Rhode Island 02940-3033 Within the US, Canada ~ Puerto Rico 800 305 9404 Outside the US, Canada 8 Puerto Rico 732 512 3782 ww~v.computershare.com/investor Prudential Financial, Inc. is organized under the laws of the State of NJ. PALMYRA PA 17078-3527 Holder Account Number 00001326252 Company ID PRU SSNITIN Certifed Yes Prudential Financial, Inc. -Direct Registration (DRS) Advice Transaction{s) Date Transaction Description ShareslUn is CUSIP I Descr ption 01 Jul 2009 Non-Routine Transfer -24.000000 744320102, Common Stock Account Information: Date: 01 Jul 2009 (Excludes transactions pending settlement) - Certificate Balance Current Direct it I lU l S CUSIP Class s hares n Held by You Registration Balance I Tota Descri tion p 0.00 0.000000 0.000000 744320102 Common Stock IMPORTANT INFORMATION RETAIN FOR YOUR RECORDS. This advice is your record of the share transaction affecting your account on the books of the Company as part of the Direct Registration System. It is neither a negotiable instrument nor a security, and delivery of this advice does not of itself confer any rights on the recipient. It should be kept with your important documents as a record of your ownership of these shares. No action on your part is required, unless you wish to deposit your existing oatificates, sell or request a certificate, or transfer your book-entry shares. Upon request, the Company will furnish to any shareholder, without charge, a full statement of the designations, rights (including rights under any Company's Rights Agreement, if any), preferences and limitations of the shares of each class and series authorized to be issued, and the authority of the Board of Directors to divide the shares into series and to determine and change rights, preferences and lirritations of any class or series. Assets are not deposits of Computershare and are not insured by the Federal Deposit Insurance Corporation, the Securities Investor Protection Corporation, or any other federal or state agency. 4 O U D R P R U '~" 001 CS0092.G.D.EQS.B_891/000027/000037/i oo~coaoo2o nf1FI5AR-PRI I Please see imnertant PRIVACY NOTICE on reverse side of statement BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 EX AFP (OB-OB) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND TAXPAYER RESPONSE ANITA E SOWERS 903 S KING ST PALMYRA PA 17078-3527 FILE N0. 21 09-0540 ACN 09148121 DATE 07-27-2009 EST. OF HELEN P SOWERS SSN 201-18-3419 DATE OF DEATH 05-13-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 M E C ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER nnrF TOTAL CEnter on Line 5 of Tax Computation) 8 ,/" COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 January 13, 2010 ANITA SOWERS 903 S KING ST PALMYRA PA 17078 Dear Ms Sowers: Re: HELEN SOWERS CIS #: 290259211 SSN: 201-18-3419 Date of Death: 5/13/2009 Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of $5,712.44 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $5,712.44, was incurred during the last six months of the decedent's Life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment and a current appraisal, if available. Sincerely, ~~ ~~' ° Marianne Meckley TPL Program Investigator 717-772-6246 717-772-6553 FAX Enclosure i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 January 13, 2010 STATEMENT OF CLAIM SUMMARY NAME Estate of SOWERS, HELEN {D_ 290 259 211 MEDICAL: CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 5,667.22 .00 5,667.22 DRUG 45.22 .00 45.22 REIMBURSEMENT TO DPW 5,712.44 .00 5,712.44 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 COMMONWEALTH OF :PENNSYLVANIA DEI~ARTMENT OF PUBLIC WELFARE January 13, 2010 STATEMENT OF CLAIM NAME SOWERS, HELEN I D 290 259 211 MANORCARE HEALTH SERVICES-CARLISLE 940 WALNUT BOTTOM RD ARLISLE PA 17015 DATE OF SERVICE PAYMENT DATE.: ORIGINAL_CRN ADJUSTED CRN USUAL CHARGES: AMOUNT APPROVED' 04/01/09 - 04/30/09 08/31/09 20092234032080001 20092234032080001 5,052.30 4,349.30 DIAGNOSIS 1 : 4149 CHR ISCHEMIC HRT DIS NOS DIAGNOSIS 2 : 496 CHR AIRWAY OBSTRUCT NEC PROC CODE : 000000 05/01 /09 - 05/13/09 08131 /09 20092234032090001 20092234032090001 2,020.92 1,317.92 DIAGNOSIS 1 : 4149 CHR ISCHEMIC HRT DIS NOS DIAGNOSIS 2 : 496 CHR AIRWAY OBSTRUCT NEC PROC CODE : 000000 PROVIDER SUB TOTAL ` MANORCARE HEALTH SERVICES-CARLISLE 7,073.22 5,667.22 03 102063521 0001 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE January 13, 2010 STATEMENT OF CLAIM NAME': SOWERS, HELEN `ID 290 259 211 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD LLENTOWN PA 18106 DATE OF SERVICE PAYMENT' DATE: ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED' 04/07/09 - 04/07/09 08/24/09 25092115604130001 25092115604130001 127.54 43.35 DIAGNOSIS 1 : 0 NDC CODE : 00781632079 CALCITONIN-SALMON 200 UNITS SP - OTHER HORMONES 04/07/09 - 04/07/09 08/24/09 25092115604140001 25092115604140001 DIAGNOSIS 1 : 0 NDC CODE : 00378181310 LEVOTHYROXINE 125 MCG TABLET - THYROID PREPS 04/20/09 - 04/20/09 08/24/09 25092115604210001 25092115604210001 DIAGNOSIS 1 : 0 NDC CODE : 00168001531 HYDROCORTISONE 1% CREAM - GLUCOCORTICOIDS 05/06/09 - 05/06/09 08/24/09 25092115604120001 25092115604120001 DIAGNOSIS 1 : 0 NDC CODE : 00378181310 LEVOTHYROXINE 125 MCG TABLET - THYROID PREPS 22.37 .65 10.88 .57 22.37 .65 PROVIDER SUB TOTAL HEARTLAND PHARMACY PA LLC 183.16 45.22 24 101710595 0001