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Home My WebLink About01-18-11 (2) 1505610140 EX (01-10) REV-1500 OFFICIAL USE ONLY PA Department of Revenue ' County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 28oso1 2 1 1 0 0 7 2 3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW 2 0 5 0 9 2 0 7 0 0 6 2 8 2 0 1 0 1 0 1 4 1 9 1 3 Decedent's Last Name Suffix Decedent's First Name MI K Y L E R C ,A T H E R I N E A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spou~e's First Name MI Spouse's Social Security Number THIS RETURN MUST B FILED IN DUPLICATE WITH THE REGIST R OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ 4a. Future Interest Compromise (date death after 12-12-82) ® 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Tru (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of de between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number R O G E R B I R W I N 7 1 7 4 9 2~3 53~ First line of address 6 0 W E S T Second line of address City or Post Office C A R L I S L E Correspondent's a-mail address: State P A ZIP Code ~ 1 7 0 1 3 REGIST;E1~ ~ ~ WILLS USF ONLY '-;; l ~ 1._ ........ ( ~ ~ t I , ~ ~ l ,: . .. ~.~ ': _ 1 ~ .,_.... ~ .. E . ~ ~ __ _; ~_..> ..~ _ _ 3._~ ~.:r DATE FILED Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON SPONSIBLE F R ILIN RETURN DATE / l/ ADDRE S 60 BLACKSNAKE ROAD DUNCANNON PA 17020 SIGNATURE O EPARER OTHER THAN PRESENTATIVE DATE ADDRESS 60 WEST PO ET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY 1505610140 P O M F R E T S T R E E T Side 1 1505610140 J 1505610240 REV-1500 EX Decedent's Social Security Number ~ecedenYsName: CATHERINE A• KYLER 2 0 5 0 9 2 0 7 0 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 8 8 3 2 6. 0 0 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. 2 9 9 0. 0 0 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 6 6 5. 6 4 7. Inter-Vivos Transfers & Miscellaneous N Probate Property (Sched le G) ~ S Billi R t t d 7 u epara ng ....... e eques e . 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 9 1 9 8 1 . 6 4 9. Funeral Expenses and Administrative Costs (Schedule H) ........... ....... 9• 1 8 7 9 5 . 5 0 10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule ! 9 9 ( ) ...... ....... 10. 3 8 7 1 1 . 5 8 11. Total Deductions (total Lines 9 and 10) ........................ ....... 11. 5 ? 5 0 7 . 0 8 12. Net Value of Estate (Line 8 minus Line 11) ..................... ....... 12. 3 4 4 7 4 . 5 6 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. 3 4 4 7 4 . 5 6 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. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 3 4 4 7 4. 5 6 16. 1 5 5 1. 3 6 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. TAX DUE ............................................... ....... 19. 1 5 5 1• 3 6 20. FILL IN THE OVAL !F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT .~ Side 2 ~~ 1505610240 1505610240 J 1505610240 : REV-1500 EX Decedenrs Name: CATHERINE A• K Y L E R Decedent's Social Security Number 2 0 5 0 9 2 0 7 0 RECAPITULATION 1 8 8 3 2 6. 0 0 1. Real Estate (Schedule A) ........................................... . 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. • 2 9 9 0. 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 6 6 5. 6 4 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property uested Billi Re t ~ S 7 • ....... q ng epara e (Schedule G) . 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 9 1 9 8 1, 6 4 9. Funeral Expenses and Administrative Costs (Schedule H) ..... 9• 1 8 7 9 5. 5 0 10. 9 9 ( ) ............. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I 10. 3 8 7 1 1. 5 8 11. Total Deductions (total Lines 9 and 10) ............................... 11. 5 ~ 5 0 ? . 0 8 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12• 3 4 4 ? 4 . 5 6 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. 3 4 4 7 4 . 5 6 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 5 3 4 4 7 4 6 1 at lineal rate X .045 . g, 17. Amount of Line 14 taxable 0 0 0 17 at sibling rate X .12 . . 18. Amount of Line 14 taxable 0 0 0 1 g at collateral rate X .15 , 19. TAX DUE .................... ........................... ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0. 0 0 1 5 5 1. 3 6 o. 0 0 0. 0 0 1 5 5 1. 3 6 Side 2 1505610240 1505610240 a J REV-1500 EX Page 3 11ni+nrlonf~Q ~AMl1IAfQ Orlrlr~±cc~ File Number 21 10 0723 DECEDENTS NAME CATHERINE A. KYLER STREET ADDRESS 23~ HERMAN AVENUE CITY STATE ZIP LEMOYNE PA 17043 Tax Payments and Credits: 1 • Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount Total Credits (A + B) (2) 3. Interest (3) 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 1,551.36 10.91 0.00 (5) 1 540.45 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 : ................................................................. ..... ^ b. retain the right to designate who shall use the property transferred or its income; .......................... ..... ^ c. retain a reversionary interest; or ........................................................................................... ..... X d. receive the promise for life of either payments, benefits or care? 2. If death occurred after December 12,1982, did decedent transfer property within one year of death ^ X .................................................................................. without receiving adequate consideration? ..... ^ X ^ 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ... ...... Did decedent own an individual retirement account, annuity or other non-probate property, which 4 . 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 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 far 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. 10.91 REV-1502 EX+ (01-10) - Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CATHERINE A. KYLER 21 10 0723 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 230 HERMAN AVENUE, LEMOYNE, PENNSYLVANIA 88,326.00 TAX ASSESSMENT $70,100.00 X CLR = $88,326.00 TOTAL (Also enter on Line 1, Recapitulation.) I $ 88,326 00 If more space is needed, use additional sheets of paper of the same size. REV-1508 EX + (6-98) . SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RES DENTEDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER CATHERINE A. KYLER 21 10 0723 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 2 WOODLAWN BURIAL PLOTS 2,990.00 TOTAL (Also enter on line 5, Recapitulation) I $ 2, 990 00 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) Pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CATHERINE A. KYLER 21 10 0723 ff an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. ELIZABETH M. OVER 230 HERMAN AVENUE DAUGHTER LEMOYNE, PA 17043 B. EMMETT M. KYLER 60 BLACKSNAKE ROAD SON DUNCANNON, PA 17020 c 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 ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTERESI 1. A. M&T BANK 362.13 50. 181.07 CHECKING ACCOUNT #53153375 2. A/B MEMBERS 1ST FEDERAL CREDIT UNION 334.52 33.3 111.40 ACCOUNT #194993-00 3. A/B MEMBERS 1ST FEDERAL CREDIT UNION 1,120.62 33.3 373.17 ACCOUNT #194993-11 TOTAL (Also enter on Line 6, Recapitulation) I $ 665 64 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER CATHERINE A. KYLER 21 10 0723 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MYERS FUNERAL HOME, INC. 8,242.00 2. WOODLAWN MEMORIAL GARDENS 1,495.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2, Attorney Fees: IRWIN & McKNIGHT, P.C. 5,000.00 3, Family Exemption: (If decedents address is not the same as claimants, attach explanation.) 3, 500.00 Claimant ELIZABETH M. OVER Street Address 230 HERMAN AVENUE City LEMOYNE State PA zIP 17043 Relationship of Claimant to Decedent DAUGHTER 4. Probate Fees: REGISTER OF WILLS 178.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER OF WILLS -FILING FEE 30.00 TOTAL (Also enter on Line 9, Recapitulation) I $ 18, 795.50 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 I I ESTATE OF FILE NUMBER CATHERINE A. KYLER 21 10 0723 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. PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE -CLAIM ATTACHED 36,581.58 2. GOLDEN LIVING NURSING HOME -NURSING 1,930.00 3. BOSCOV'S -CREDIT CARD ~ 200.00 TOTAL (Also enter on Line!10, Recapitulation) I $ 38, 711.58 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) ,pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CATHER INE A. KYLER 21 10 0723 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. EMMETT M. KYLER, JR. Lineal 17,237.28 60 BLACKSNAKE ROAD 1/2 REAL ESTATE DUNCANNON, PA 17020 1/4TH REMAINDER 2. ELIZABETH M. OVER Lineal ', 17,237.28 230 HERMAN AVENUE ', 1/2 REAL ESTATE LEMOYNE, PA 17043 1/4TH REMAINDER 3. HARRY E. HORGAN Lineal 60 MEADOW RUN PLACE 1/4TH REMAINDER HARRISBURG, PA 17112-3369 4. DELORES JEAN TAYLOR Lineal 414 BRANDY LANE 1/4TH REMAINDER MECHANICSBURG, PA 17055 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES.15 T HROUGH 18 OF R V-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT T EN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 CCIVER SHEET. $ it more space is neeaea, use aaoltlonal sneers or paper of the same size. ~ ~ ~ t P L.~LS~INILL ~L.T~'D ~ES7.~lE~!'I" I, CATSERINE A. KYLER, of Lemoyne, 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 heretafore made by me. ONE. I direct my Executor or Executrix, 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 Executor or Executrix of my estate. TWO. My Executor or Executrix may, at his or her discretion, compromise claims, borrow money, retain property for such length of time as he or she may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as he or she may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder. I authorize and empower my Executor or Executrix 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 sufiYCient deeds and/or bills of sale therefor, in fee simple, as I could do if living. My Executor or Executrix is 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 Executor or Executrix. TffitEE. I hereby .give, devise and bequeath all of my estate of every nature and wherever situate to be distributed as follows: C.,4 .K r ,. t A. I hereby give, devise and bequeath my home at 230 Herman Avenue, Mechanicsburg, Cumberland County, Pennsylvania unto my daughter, ELIZABETH M. OVER, and my son, EM1V.~TT M. KYLER, JR., in equal shares, as tenants in~ common, per stirpes, which provides that the child or children of any deceased child shall take the share their parent would have taken if living. It is my desire that whichever party resides in the residence as they shall so agree, shall pay all real estate taxes, homeowners insurance premiums, utilities, maintenance costs to keep the property in its current state of repair, ordinary wear and tear expected during the time said party lives at the residence. All costs incurred without either party living at the property shall be shared equally. B. I give, devise and bequeath the following specific items to EIVIlVIETT M. KYLER, JR., per stirpes, which provides that the child or children of any deceased child shall take the share their parent would have taken if living: ~_. ~~~. (1) buffet table in living room; ~ p~ ~~ ~ .~ ~ (2) dining room table; ~~ (3) china closet in dining room; (4) organ; and (5) television ~~ ~'~ L~ C. I give, devise and bequeath one burial plot each at the Woodland Memorial ~' Gardens to EMMIETT M. KYLER, JR. and ELIZABETH M. OVER, per stirpes, which provides that the child or children of any deceased child shall take the share their parent would have taken if living. ~.,q. i<. 2~ D. I give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate to my children: HARRY E. HORGAN, DECOKES JEAN TAYLOR, EMIVV~TT M. KYLER, JR and ELIZABETH M. OVER, in equal shares, per stirpes, which provides that the child or children of any deceased child shall take the share their parent would have taken if living. F_ I nominate and appoint my son, EMIVIETT M. KYLER, JR. to be the Executor of this my Last Will and Testament. If he predeceases me, fails to qualify or is not able or does not serve for whatever reason, then I appoint my daughter, DECOKES JEAN TAYLOR, to be the Executrix of my estate. In the event that she has predeceased nte, failed to qualify or is not able or does not serve for whatever reason, then in her place I appoint my son, HARRY E. HORGAN to be the Executor of my estate, whereby all substitute persanal representatives shall have the same powers as the original Executor hereunder. I_VE. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty (60) days. SS X. No Executor, Executrix, or Trustee acting hereunder shall be required to post bond or enter security in this or any other jurisdiction. S_. No beneficiary may assign or anticipate his or her interest in any income or principal held or distributable hereunder; and no beneficiary's creditors may attach or otherwise reach any such interest. ~,t(. /f 3 • ~ IN WITNESS VV]EIEREOF, I have hereunto set my hand and seal this ~_~ day of October, 1995. ~~LZ~J~- /A • J~Dy ~rFAl.l CATHERINEA. SYLER Signed, sealed, published and declared by the above-named person as and for a Last Will and Testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. 4 ~ . ~ .• ~ ACKNON~LEDGMENT AND AFFIDA VIT WE, CATHERINE A. I~YL~I2, T~It~SA M. HENRY and CHERYL L. CLELAND, 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. CATHERINE %~'/, TERESA M. l L. COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by CATHERINE A. KYLER, the testatrix herein and subscribed and sworn to before me by TERESA M. HENRY and CHERYL L. CLELAND, witnesses, this 11TH day of October, 1995. Not~ary~ublic Noharial ~ 8etzi A AAerrisort, Notary Pubic Carlisle Boro, Curr~bertand My Commission Expires Dec.15,1 ember, PennsylvaniaAssodation of Note! LEMOYNE ~30ROUGH TAX OFFICE Faith A. Nicola, Tax Collector 510 Herman Avenue Lemoyne, PA 17043-'! 856 Phone: {717) 761-7785 Important Information • If your taxes are escrowed you must, send your bills to your mortgage company. • Failure to receive a tax notice is not an excuse for non-payment. Aself- addressed stamped envelope is required far returned tax receipts. • Non sufficient fund checks will be returned. A fee may be assessed. • Every resident 18 years of age or older must pay the per capita taxes levied under Section 679 of the Pennsylvania Public School Code and Act 511 Local Tax Enabling Act. Hours: Tuesday and Wednesday 9 am - 11 am Tax ~~ce will be Closed: ALL Holidays September 21-22, 2010 December 20, 2010 thru January 4, 2011 z 0 ~ _ O a N ~ O 2~ ~ f ~ Q a o ~ LU ~ X h iD w a 1 + O r m N w o Q tf~ o d" ~ Z F- u+ Q ~ ~ f- V ac 0 0 N Q ~ w ~ ~ ~ .J 1 J~ way _ ~ m F G J ~ 0 0 U W ~D Qf M .. ~ V ~ <Q M ~ o ,~ ~ ~ ~. o x Z ~ • . o -w- ~ v~ a ~' c .~ ~~ w ~ Q ~ ~Q°ooo C ` } F„ ~ N H ~ -aau F- N N N . O~ ~'" r r g 0 Q ~ j ut • ~m~QrT..~- ~u+ Q W K ~ = F ~ ~ ~ ~ o ~ ~~a m m Z a ~ ~ W c O ~ ti W ~ ~ ~ ~ y~ +~ ~ M i ~~^ O Imo. ~ ~ ~ oMO 'Z'' 2 d aQd O z f- sQ Q ~ ~ ~~~ ~" ~ ~gW ~ Z ~~a . Z~u! U ~ cflr- ~ W ~ W=o ~ o ~ w st; O Q d' Z @ } p ~G ~ Z N 4 N Q.°-W I Y N J ~^ J g tt1 L N '~ ~ ~ ~ ~ H Q ~ ~ m x a ~ U " ~ w~Z ~ Q ti w NQ~ d a ~ ~ ~ ~ D 0~ ~ 1 - ~ J J ~ ma VV iV iV 11~ VV LJ.JVLJ LJL J./ V'2 ~JVIZ a99 Mitchell Road a Millsboro, DE 19966 Mall Dods DE-M8-12 Phone: 888-502-4349 Fax: 302.934-2966 - _ J@JLJJ`3LU1YJ 1 JJJ 1 YJ IU YJLJ YJ YJ YJJ L 11"3 Fax To: Roger B Irwin Fnor~ Sue Kimble F'uc 717-249-8354 Date. August 10, 2010 Rs: Estate of Catherine A Kyler Paws: 2 •Gonrnenb: Attached, please find the information you requested for the Estate of Catherine A Kyler, es of June 28, 2010. ff I can be of further assistance, please do not hesitate to call me at 888-502-439. Thank you and have a great day! Sue Kimble @ M ~ T Bank This oommunlcadon oontalns IniermeMon which may be confldentfal and proprietary. You may not use, dlsseminete, dlsMtwte or copy al or any pert of this oonvnunlcation without the express consent oaf M ~ T Bank, AIIArst Fhsmclal Inc. or their r+espectlve sut~sidtaries or aAlllates. In addition, ff you are not the addressee (or are authoMzed to receive this Ir~fonnatlon by the addnessee), you are not authoHzed to receMe or review the conte~rts of this communication. If you have received this communication in error, please return it to M $ T Bank at~ P.O.~ Box 1596, Baltimore, MD 21203 arul delete arty copy of this oomrnunication from your systems. Thank you. ILI ~,J 1 V 1 V 1 1 V ~/ i 1 JvL J l JL L V ~.I V 1 Z l 1. Type of Aacrnmt Ac+t:vunt Number Chvrlers~hip (Nctrn~t vf) C~riing 1~atF Balance on Dale vjDeacth Ac~uNJlntc~•cti~t Tukil _ __ _ _ JPJLJJZLUIYJ 1 u.J.J 1 IuVUUf cruu~ + Checking A~acrnmt .5~1,533~.5 Grxt~u~ine A kyl~• Elth M (hoer 02/ZR/71 $162.13 ~ U.UU $362.13 N'or farther accoaM information, closuree'ndlor reimbnraement affando pkaee call the Highland ParklOpice at #717 737 3322 We were orr:hle to locate any safe deposit box for the above-meationed decedent. Sutcerely, Suzanne M Kimble Adjustment Services ____ _ _ __ _. 1 rCl\1\JiLrAI\lA 11\i7CR1IAI\lrC INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D PO BQX 280601 TAXPAYER RESPONSE •'HARRISBURG PA 17128-0601 REV-1543 EX AFP <OB-06) IAA FILE N0. 21 ACN 10140761 DATE 07-15-2010 ELIZABETH M OVER 230 HERMAN AVE LEMOYNE PA 17043 EST. OF CATHERINE A KYLER SSN 2051-09-2070 DATE OF DEATH 06-28-2010 COUNTY CUMJBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WIL S 1 COURTHOUSE SQ ARE CARLISLE PA 1 013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. MEMBERS 1ST F CU provided the Department with the infonoation below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a ]o~nt owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tex laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 194993-11 Date 08-22-2000 To ensure proper credit to the account, two Established copies of 'this notice must accompany Account Balance $ 1 120 62 payment tm the Register of Wills. Make check , . payable tm "Register of Wills, Agent". Percent Taxable X 1b.667 Amount Subject to Tax $ 18b 77 NOTE: If tax payments are made within three . months of ';.the decedent's date of death, Tax Rate X . 045 deduct a $ percent discount on the tax due. Potential Tax Due $ 8.40 Any Inheritance Tax due will become delinquent nine monthhs after the date of death. P T TAXPAYER RESPONSE ~ 1 A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of CHECK Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3~ below. PART If indicating a different tax rate, please state a relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 $ PART DEBTS AND DEDUCTIONS CLAIMED ^S DATE PAID PAYEE DESCRIPTION AMOUNT PAID 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. HOME C WORK C TAXPAYER SIGNATURE TELEPHONE NUMBER DATE i i-CPIPIJiLYAPIlA 1P11'ItKl IAPII.t INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D PO BOX 280601 TAXPAYER RESPONSE #IARRISBUR6 PA 17128-Ob01 REV-1543 E% AFP (00-08> IAR FILE N0. 21 ACN 10140762 DATE 07-15-2010 TYPE OF ACCOUNT EST. OF CATHERINE A KYLER ~ SAVINGS $$r( 205-09-2070 ® CHECKING DATE OF DEATH b6-28-2010 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: EMETT M KYLER REGISTER OF WILDS b0 BLACK SNOEK ROAD 1 COURTHOUSE SQUARE ., ' DUNCANNON PA 17020 CARLISLE PA 17013 ~ ~~ .~~ ,~J\~ V MEMBERS 1ST F CU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a ~oiint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No . 194993 -11 Date 08 - 22 - 20 0 0 To ensure .proper credit to the account, two Established copies of his notice must accompany payment to the Register of Wills. Make check Account Balance $ 1 ~ 120 • 62 payable td "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If 'tax payments are made within three Amount Subject to Tax $ 18b . 77 months of 'the decedent's date of death, Tax Rate X .045 deduct a ~ Percent discount on the tax due. Any Inherijtance Tax due will become delinquent Potential Tax Due $ 8 • 40 nine months after the date of death. PART TAXPAYER RESPONSE A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A'• and return this .notice to the Register of C H E C K Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informa ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 ~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID 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. HOME C WORK C ? TAXPAYER SIGNATURE TELEPHONE NUMBER DATE I r~~~~~~ t ~xr-nir- inncRi ~Nn~.~ ~r+n INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I LE NO. 21 Po Box 280601 • HARRISBURG PA 17128-0601 REY-)543 EX AFP (00-0 ) TAXPAYER RESPONSE ACN DATE 10140760 07-15-2010 - TYPE OF ACCOUNT EST. OF CATHERINE A KYLER ® SAVINGS SSN 205-09-2070 ~ CHECKING DATE OF DEATH IO 6 - 28 - 2 010 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FlORMS T0: \ EMETT M KYLER 60 BLACK SNOEK ROA G `~ REGISTER OF WIL S 1'~ D 1 COURTHOUSE SQ ARE DUNCANNON PA 17020 n, `` ~ CARLISLE PA 1013 MEMBERS 1ST F CU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a io~nt owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Ttn( laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 194993-00 Date 07-07-2000 To ensure proper credit to the account, two Established copies of ^this notice must accompany Account Balance $ 3 3 4 5 2 payment t¢ the Register of Wills. Make check . payable tb "Register of Wills, Agent". Percent Taxable X 16.667 Amount Subject to Tax $ 5 5 7 5 NOTE: If~tax payments are made within three . months of 'the decedent's date of death, Tax Rate X . 045 deduct a ~ percent discount on the tax due. Potential Tax Due $ 2.51 Any Inheritance Tax due will become delinquent nine montN~s after the date of death. P T TAXPAYER RESPONSE ~ 1 A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of thisanotice to obtain a discount or avoid interest, or check box "A" and return thisnotice to the Register of CHECK Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the. Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions werR paid. Complete PART 1=.J and/or PART 3~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X 8. Tax Due 8 $ PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above ire true, correct and complete to the best' of my knowledge and belief. H 0 M E C ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE _. _ _ _ i _ rGl\1\J i L. •NI\iN il\17CR1 1 NI\~.C 1 NA INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES _ .~ ,..r .. ,.-~~.,~.. AND PO BOX 280601 ~.'~.I ~ !,.•':`~'.~C'~(PAYER RESPONSE .HARRISBURG PA 17128-0601 ._ , k :1 . i ~ `i ~ . `J ~ ;.. ~. REV-1543 EX A P (06-06) FILE N0. 21 ACN 10140759 DATE 07-15-2010 z~ r o ~~~ ; 9 ~~ ~o: 3 ~ o~~ K c~ T S CQU~ cU~e~~~~~n+o 00 , Pa, ELIZABETH M OVER 230 HERMAN AVE LEMOYNE PA 17043 EST. OF CATHERINE A KYLER SSN 2059-09-2070 DATE OF DEATH '06-28-2010 COUNTY CUMIBERLAND REMIT PAYMENT AND F?ORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 1'..7013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST F CU provided the Department with the information below, whidh has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, Please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is. taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 194993-00 Date 07-0 7-2000 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance $ 3 3 4 5 2 payment tp the Register of Wills. Make check . payable td "Register of Wills, Agent". Percent Taxable X 16 .667 Amount Subject to Tax $ 5 5 7 5 NOTE: If tax payments are made within three months of; the decedent's date of death, Tax Rate X ,.045 deduct a ~ percent discount on the tax due. Potential TaX Due ,~` 2 .5 1 Any Inheritance Tax due will become delinquent nine months after the date of death. RT P TAXPAYER RESPONSE A 1 A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of thisr notice to obtain a discount or avoid interest, or check box "A" and return this notice to the Register of CHECK Wills and an official assessment will be issued by the PA Depalrtment of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 5. Debts and Deductions 5 - 6. Amount Taxable 6 $ 7. Tax Rate 7 X 8. Tax Due 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE P AID PAYEE DESCRIPTION AMOUNT PAID 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 DATE _ _._ T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE - BUREAU OF PROGRAM INTEGRITY DMSION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 August 14, 2010 ~~~~~~~~ IRWIN & MCKNIGHT PCWEST POMFRET PROFESSIONAL BLDG ROGER B IRWIN ESQ ~AUCj 1 $ 2~1~ 60 WEST POMFRET STREET CARLISLE PA 17013-3222 I~wlly & r~CIwlcHt LAW OFFICES Re: Catherine Kyler CIS #: 220206313 SSN: ###-##-2070 Date of Death: 06/28/2010 Dear Attorney Irwin: Please be advised that the Department of Public We1fa~Ce maintains a claim in the amount of $36,581.58 against the above-mentioned estate. This claim is for restitution of medical assistance granted on }behalf of the decedent for which the Probate Estate is now responsible tc~ reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed i$ the Department's itemized statement of claim. A portion of this medical expense, namely $5,191.70, cuas incurred during the last six months of the decedent's life; therefore, it ~.s 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 $31 ,89.88, is to be entered as a priority Class 5.1 claim against the estate. " Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and 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, Judy E. Deaven Claims Investigation Agent 717-214-1284 717 -fi72 ='6'g~3" FAX ~~~`~ ~~ Enclosure Four Generations... Ceiehmting Lfje, Hoemring Traditions BOYD L. MYERS, JR, Supervisor J~~~ 37 & MAW STRfiET ~ J~~ ~~ ,.~,^~ 7 MF.CHANICSBURG, PBIVNSYLVAAIIA 17055 • llnti°/~~ (.;~'l./OlTi'B, `7rn(i. (717? 766-3421 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or t°remuory to use any items, we will explain in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. Y~ott do not have to pay for embalming you did not approve u selected en 1 direct oa r immediate burial. If we chuged for , we _ whl~ l O For the Servicgof ~,.. ~ ~ ~ ~ ~. ~ e ~- mate f Death . 1 Charge to: A. CHARGE FOR SERVICES SELECTED: I . PROFESSIONAL SERVICES Services of Funeral Director/Staff .... ~8~~. ,L- Embalming ...................... 5~~.. Other preparation of body ............................... . SUB-TOTAL OF PROFESSIONAL SERVICES......... Al 2. FAC[LITIES AND SERVICES Use of facilities and services for ~ viewing (VisitationlWake)......... S Use of facilities and services C for funeral ceremony ............ S ~.•~ - Use of facilities and services for --~ ~ "" Memorial Service ............... E ~-^ Use of equipment and urvices ~~ for graveside service ............. S - Other use of facilities city state ~ rf p 20 Other clothing a S 1 CfematiOn urn .............. ' ... S (Description) i i OTHER S S TOTAL MERCHANDISE SELECTEIE .... s ............. B 8~~ ~~ C. SPECIAL CHARGES: Forwarding of remains to S (Funeral Home) Receiving of remains fmm S (Funeral Home) Immediate Burial .............'.... S Direct Cremation .............'',.... 5 S ~- SUB-TOTAL OF SPECIAL CHARG ................ C S D. CASH ADVANCED ...... f O ~' FA P .... S Cemet m went ......... . SUB TOTAL OF FACILITIES/EQUIPMENT ........... A2 S 1~ g .................. S S 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral H l L ................... oca ........ Hearse (Casket Coach) ~~ Loral ................... ........ S Limousine S~~ Local ................... ....... Fatuity car Loral .................. ......... S -. Flower car or floral disposition ..~, ~.. r+~ S Local .. . ............... Lead c e car Local . ..~y ~,lr^ .~ - .. . ...... . ~ .~~~. S~ Car for p ers ~ Local .................. Out of town transportation ......... S ~" ......... 8~ 8 _~_ Lot and Deed.. V` °~ Newspaper Notices-Local .... ... S Newspaper Notices-Out-of-towal.... S Telephone & Telegrams .......'.... S AlffarC ..................... L ... S Clergy/Mass Offering ..........',.... S~`~ Pallbearers .................. j.... 3 Certified Copies of the th rte '' 1 ~ ~ Certificate ....Zf " ~. .... .. - i~ S Police Escort ................ .... 8 Flowers ........................ S Z,~'j,~, Vault Service Chuge .............. S S S S S S ~ 2 3UB-TOTAL OF ADVANCES ..... ... .............. D 5 i + SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 We thuge you for our services in ob g TOTAL OF PROFESSIONAL SERVICES, PACILITIES AND AUTOMOTIVE EQUIPMENT ................................... A B. CHARGE FOR MERCHANDISE SBLBCTBD: Casket .......................... 3 (Description) Other Receptacle ................. S (Description) Outer burial container ............. S~S r" (Description) Acknowledgement cods ......... t Register book(s) .................. S Memory folders ................. . Prayer cods ..................... S Temporary grave marker ........... S Burial clothing ................... S SUMMARY OF CHARGES A . Professional Services, Facilities and Equipment, and Automotive i E ~ ~ ~ r pment ...................... qu B . Merchandise ................. '.... 5~,~~t,'fQ C . Special Charges .............. '.... S ----~ D. Cash Advances . r ... . •.. ~ S 7(Z. t~ .• .............. ~ vp + PAID AT TIME O OR PRIOR O ~ ~ Z ARRANGEMBNTS........... .. ... ................ • . BALANCE DUE .............. ' QN F G ... ................ S • ,~ ~. any law, c tery, or crematory requ' is have required the p e qty of the it listed above daw r uiremettt is explained below. / ' ~ ~ ~-L~( ~O/ 1 agree that 1 have examined the items of goods and services selected above and found them to be correct and acrncding to the acrang is I have requesud. i aclmowledge receipt of a copy of this Statement of Funeraly~ and Serv ~ . I reptese~ t~ I have sufficirnt funds available for eat of the cash price for the goods acrd services sekaed. I also to t days. I agree to be jointly an severally liable with aan~+~~ggee else who signs below. A late charge o per month amounting to per yeu will be applied to the un balance beginning _L- days From the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to wllec amounts I owe under this agreement. Thou costs may include attorneys' fees, court costs and other costs. Atry additional services or merchandise ordered or req after the date of this agreement will be considered part of this agreanrnt and the cost thereof will be reflected oa the final bill or statemen~ ~ ~ ~ ~! (si~lY crib adrtances that are markal up) 'ems ~z- 5~4 (~ ( r) tensed uneralt Director) WH17'E - Formal oiixwr YELIAW -Cuxromer a .Cl _ r1 /^- . r.