HomeMy WebLinkAbout03-07-111505610105
ex (oz-11) (Fr) r
REV- ~ SOO OFFICIAL USE ONLY
PA Department of Revenue pennsylvania
DEV~RIMENT OF REVENUE County Code Year File Nurrlbe
Bureau of Individual Taxes
PO BOX 28o6oi ~
INWERITANCE TAX RETURN ~~ ~ ~ (JJ~d~~jj
C
Harrisburg, PA 1'7128-0601 ~
,,
RESIDENT DECEDENT
_
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
.192-70-3465 12/13/2009 02/03/1985
Decedent's Last Name
_.. _ . Suffix Decedent s First Name MI
WERT CODY E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name. MI
.Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONF{DENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
ROBERT WERT (717) 766-8718
First Line of Address
426 SPEEDWAY DRIVE
Second Line of Address
City or Post Office State ZIP Code
MECHANICSBURG PA 17055
REGISTER O~WILLS USE OMI,I/
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Correspondent's a-mail address:
ADDRE
1505610105
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INAL FORM ONLY
Side 1
1505610105
..~ ' "1{
Under penalties perjury, I declare that I have examined this return, includ'+ng accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, tort d complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU RSON F~ie6f'~ONSIBLE F R FILI RETURN ATE
1, 7 C~
ADD SS _ ~ n. .. _ ~ n
1505610205
REV-1500 EX (FI)
Decedent's Social Security Number
192-70-3465
Decedent's Name:
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. ' 9,243.88
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~- ~ ~~ _, . ,_ ~ ~ _ ~. _ ,., _,rF-_~,,,,,
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ' 9,243.88
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 5,761.51
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. 16,159.41
11. Total Deductions (total Lines 9 and 10) ................................. 11. 21,920.92
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ' 0.00
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. 0.00
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 _. _. _ _.v.. ......... .
(a)(1.2) X .Oi ' 15.
16. Amount of Line 14 taxable
at lineal rate X .0 _. 0.00 16, 0.00
17. Amount of Line 14 taxable °~ ~ ~., ~ ~~. .,,~ ~ ~_~ ~ , b .~ , _ , . ..,~_ - .~ ,~_ ,~.. nro~ ~.r~ ,..... ~ .W~ . a. _, ~ r~ » , _.~.,
at sibling rate X .12 17,
18. ~_.._w . ~_. ......,~. _. .. ....,:
Amount of Line 14 taxable :._. ..,~.. .,. .... .. . ...._~.... ,~...
at collateral rate X .15 18.
19. TAX DUE ......................................................... 19.' 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610205
1505610205
O
J
REV-1500 EX (FI) Page 3
Decedent's Complete Address:
File Number
DECEDENT'S NAME
CODY E. WERT
STREET ADDRESS _ ^^
426 SPEEDWAY DRIVE
CITY ~ ~
MECHANICSBURG STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments _...-__-....._..._..-.-____--
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Filt 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)
Total Credits (A + B) (2)
(3)
(4)
(5)
0.00
0.00
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 .............................................................................................................................. ^
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ........................................................................................................................ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent [72 P.S. §9116 (a) (1.1) (i)).
For dates of death on or after 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 for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [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,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-i5o8 EX+ (ii-io)
~.~ ~~~ pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
CODY E. WERT
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.
If more space is needed, use additional sheets of paper of the same size.
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1091, C y ./,tFor P OMB f1N60Y01 tOPi010, Cop B For NeeWtent. OMB f15AS-0117 :, i ~i ~~
Tax Statement for Forms 1098, 1099, 5498 for Year 2009 I~~ °~'P°~ "• °"~• •"~»t 7~Co~; B, F" T,O 9 ~ 6~f.4~079wi7 ~ s
lOM-INT, C B, F"~IIefIPNtu. OMB t1Ni-0114 10ie-sA, popy e, F" pt~~N, OMe nSfbtsl7 ~.'~ii~
tOtPMISC, Cop/ B, F" IMclpNnl, OMB IliN6-0/75 St91, C y 9; Fy" PtrtlolpN~ 6MB f16t607Q ~ ~? -
NAME, ADDRESS AND FEDERAL I.D. NO. CUSTOMER IVAME; ADDRESS `H'°P~~s~'~copYYB~orPerBel~`ml"yb~eMiius sie'S ~~ -
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VIST BANK CODY WERT DECD ~';
P. 0. BOX 741 HSA ACCOUNT ~?
LEESPORT PA 19533 C/0 ROBERT E WERT ;;1
426 5PEEDWAY DR ;~h
MECHANICSBURG PA 17055 ,:,:
Trustee's Federal ID# 23-0867965
Questions? (888) 238-3330
377D00016494-01 FORM 1 OF 1
2009 FORM 5498-SA: HSA, ARCHER MSA, OR MEDICARE ADVANTAGE':MSA fNFORMATION
Plan Reference Number IRS Descri b~'on IRS Box~t Amount'
000000056926950701
Total contributions made in 2009 2 1,18.14
Fair market value of HSA, Archer MSA, or MA MSA 5 1,270.66
HSA 6 X
TOTALS: Employee or self-employed person's Archer MSA contributions
made in 2009 and 2010. for .2009 1 0.00
Total contributions made in.2009 2 1,183.14
Total HSA or Archer MSA contributions. made in 2010 for 2009 ' 3' 0..00
Rollover contributions 4 - 0.00
Fair market value of HSA, Archer MSA, or MA MSA. 5 1,270.66
TAXPAYER I.D. NO. (keep for your records) DEPARTMENT OF THE TREASURY -INTERNAL REVENUE SERVICE
For Form 1089-DIV, INT, MISC, OID, and D: This u urtponant Ua inlormalbn and w bNnp tumished to the Internal Revenw Service. If you are required to fiN s alum, a nepligsrae penalty or other unction may be'wnpowd on you it this income
is uxabk and the IRS determines tMt h hu rat bwn reppoonsd.
192 - 70 - 34 65 ~F~ ; o~9e :°~:w o; Ths amount dawn may9nd De rtWly deduycdble by~you1 Limps baud on the Iwo amount arWklM cost and vat us of IM secured prWeM real aDWy ~~ you may oMy deduct interest a the erRant it was incurred by you,
aauahy paid Dy you, and not reimWrud Dy another person.
f' 1
Ths a nyorWV W reprrnaeon ara a peril h,rrteneo b Pte Irtgrr>a Revenue Berlin. M you are regtrad q lib a reran, a rrpGperoe pertaey «aetar aeraion may De inboaw on irtl«matbn in Dww t. 2, 3, ~ w hr~porlent lax rtbrtrwpon and ro DPPtp IurraPried o Pw 1nMnwl Revenue Sarvba. a you an required b file a rawm, a rieylpwoe perWty «drwr ' i
you 1 Pit IRS aetenttrtae dal an vaerpayrtrra d tax rosins peCiu6e ya orerofelW a dedCeon br aartlara ben stlarau A paroon (rcMrdrq a hrtartdal nsseAat, a gvnwrvnertal awtdion re+Y a imW aed on Ypu / Vn Ifi9 dalsrtrrrae If W an urgxpaymeM d lax rwrle DeCMN Wu overMMd +tladixtiori Ipr Itw morgape veered «lor eMN Odrps «beuute ~ 1
:rrL aria an a0ttalPOnW nsasrron) Ptal raoaivae raerW payrti+rae d 5600 «m«e t1Wtp Pta )YY m orw « mole quaifud alWaro low rrXad hntiert Pla aYMrrwa b you. Va rrwy r«+ 6d red report tltia raWra d sa.raal m Your ret«n.
pe dash 090rC1 sluoerP ban iP+reelPW nu+ci+W padb2006 on ywr nomwtu iearm.r+owwwr,ya,m.yra Da dole bdada tlr pll artovaditwslq rap«IW on art Aparean lhdrhgaktarcalwaNOn,ayovarrcwW d+4+rwawpwraPrarowgporpora5on)who senpepadinaaaa«lwavrta w.in woa.r.arrn Pan «a,wrs. -. `i
staternrt lb rot o«xad Pte recperwtertder br e>alwd«s d Ina requremarYC br lard row b here) arty abwaDla d+ra2eort br fr Peraat paid. Mrlaad, br ntoq'reorrrreon, recairW horn you a N+at 5800 d morpapa saaraat (htcsrdhtp attain pohtu) on arty «w narlpetta b tlw nlsrtdar year meal hrriah set alalamaru b you. ~
see Fb 370. Tu Bertha far EOUVepn, a!a Pte'SaowP Loan hParetl Dahx.9on W«kwtaet' b yov Form 1010 « t0/0A natruc0on. a you raoaMed fts Wlenu^l ea pw p+Yer d remd on a m«tgpe m wtlidl tlwe an filter Dormrwra, hxrtiN early d tM doer Oarrawere with iamnteon Wtout Pw prapw
Accpaa Rtnnar. Mar sraw an aaou+«arter iatwt rxa++0er rte ix,der actl7~ b d+»' war +~~ awi~ daortm. E'~'a~ c ,~ar~. Eaai tarrowv a «rsad a dada my er arrntw Ir «arr i»d aro l~,s lyid q rte aaw rem npnterii r.e «rw rwa a Pr ama,d ~ .. ~
Box 1. Sraws Pte raereQ rew.edq Px krtder duvtq eb yet an oro«more sodxabw made byou. FOr low madam«allarSepYrrlWrl, 1001, toil rtarY Ptl#rtla ben e1°~^o'4W+P+Y'n+ro+'^e'+eupaidiaed by a'wpowrnrrt yrwy, you my nq ba aDM bdeOrrlly rrourtdlr rOtiOy. See rtr baPUdbrr br F«m tOW. SdwdiaeA C.«E br .~,1
ortprwom lest ar0 caDRasxed rtlersa recenad n 2009. N yorr ban was male Osl«a Saplerrbar 1, 217(11, tau msy a ads b da0a ban mpna-ort kes aro npi.wd Paweal rot raw b reran Pr rratpaps Marna. Apo, br moro taorrnation, ew PuD. txi6, floor Morlpps lrttereal Daduclion, and pal. 535. Buarnaa E.xpenaw. ~: ~\'
reppned n pox t. Aocrlre rlYlrrber. May aaw an appoum «aew trtqu+ nunaar er kntlar Itaa '~ti
Bax 2 tl dtedfeo. rtdcates P1a1 ban origPrsm tees arri« cape+lireo nlenrt are not ytcllCed n tax t br bw made Debra SapMrribw t, 2001. See Hb. 970 br how b sox t. Snows Pr Mwea renhrad ar +++~9rrd b OaWtpaan y«r aapoUra.
any peo.<tbr ba orgrtanon lava « aaptalReO owed iGt++ loan. Tits antarP does red naafis ports, pwermwP suoaiCy paymwac, «, Pawed m dry obfpWOn waxed q real proP+rb, irdudrq a rarer eP~N• late d vatlt, « «eW card
Oey+nsnte m a ~vy4wxy malpepe. Such arriovta ara dadicaDb q you arty yt cerutt c>farrctenres.
SEE REVERSE SIDE FOR OPENING INSTRUCTIONS IIIIII~II~III~'IJ~~IIIIIIIII'III'lll'IIIIIIIII'I'I'III'lllllll'IIIIII~IIII'IIII'I)
00016/94
FIRST-CLASS MAIL
VIST BANK - PRESORTED
P . 0 . BOX 741 -' ' ~'~'•-' '- -' Y - u.s. POSTAGE
~EESPORT PA 19533 PAID
TAMPA, FL
PERMIT NO. 1546
IMPORTANT TAX RETURN DOCUMENT ENCLOSED
377D00016494.1 FM YEDP7XDSA31728135002000946
••. CODY WERT DECD
HSA ACCOUNT
C/0 ROBERT E WERT
426 SPEEDWAY DR ~`~~~
MECHANICSBURG PA 17055 .r,,•,~
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St Send Inquires to: Statement of Accounts
5000 Louise Drive
PO Box 40
Mechanicsburg, PA 17055 Dec 01
www.memberslst.org , 2009 thru Dec 24, 2009
Main Switchboard: (800) 283-2328
EZ Call: (717) 697-4372 or (800) 283-4372 Account Number: 357482
TDD: (717) 697-5312 or (800) 283-2328 ext. 5312
® TeleBranch: (800) 237-7288
MEMBERS 1St
FEDERAL CREDIT UNION
3669 1 AV 0.335 7337-3669
*_ I~~~III~~~III~~~~~~II~~II~~~~II~II~~~~~III~~~II~~I~~I~~I~~~III
CODY E WERT
N~_ 1184 HARRISBURG PIKE
~' CARLISLE PA 17013
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Balances at a Glance:
Checking : 0.00
Savings : 5.00
Certificates : 0.00
Loans: 14,740.14
Money Management : 0.00
Swipe 5 YTD Reward : 0.20
Page : 1 of 2
Your current Member Loyalty Rewards level is Gold.
Your aggregate balance as of December 1st is $19,283.73.
An aggregate balance of $35,000 and having 3 products
will move you to the Platinum level.
1099-INT s are not included in this statement. If you earned at least $10 in
dividends on your account for 2009 you will receive your 1099-INT in a separate
mailing in early January 2010. 1099-INT information will also be available on
Members 1st Online early in January.
CHECKING ACCOUNTS
0011 -CHECKING
Date
Dec 0> Transaction ri tion ` , ~ ~
Ba/ance Forward itio btra bons Balance
Dec 06
Deposit Transfer From Lgan 0002
~
4
~6 - 45.63
4
Dec 06
Withdrawal Debit Card CHECkC CARD ~ ~~ - ~~~" ~~
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4
~ 9.79
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12/05 172243000.`187955~GIANT.:`~40D ~~#912'CARhf~l:~~ ~P 9.79- 0.00
Dec 07
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BELCO COMMUNITY 5344 CARLISI. ~~ Il~E'.~V1~~~AN1~$SURG PA
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AVINGS ACCOUNTS
0000 -REGULAR SAVINGS
Date Transaction tbn ,
S
Dec O1 Balance Forward coons Balance
Dec 24 Ending Balance 5.00
~'~~
rig. ~ 5':40
LOAN ACCOUNTS _ ~ ~ ;. ` ~xM~ ~
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Dec 23 Payments ;~,
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68:59- 10,018.59
9960.00
Dec 24 Ending Ba/anae ° ., ~ ~ ~ .00.
~~ ~ `'~ '0.00 ..133:88- 9,816.12
Annual Percentage Rate 7.894%
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paay Rate .021E 16%"A ~I.w ~=ti
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- - - Continued ~ on following page - - -
claim: 38-L824-07001 Autosource Valuation 2001 Audi A4 4WD AS Request: 26059565
~Audatex /4UtOSOUrCe VafUatfOn
a Snle~a tompany
t ~ ~ ~ a ~ ~
Claims Dept. Claimant
State Farm Insurance Insured Wert, Cody
Concordville CTLU Branch Claim 38-L824-07001
1 State Farm Drive Loss Date 12/13/2009
Concordville PA 19339 Loss Type Collision
Policy
Other
Appraiser License 149965
Owner Name WERT
Owner Address 1184 HARRISBURG PIKE AP
Owner City CARLISLE
Owner State PA
Owner Zip 17013-1617
Primary Impact 34
~ li ~ • t
See N.A.D.A See Valuation Autosource/
Value Section Detail Section N.A.D.A.
. ~ - ~ ..-
Base Price $7,750 $7,457 $7,604
Engine
Transmission -325 -175 -250
Odometer
Equipment 300 -80 110
Value Before Adjustments $7,725 $7,202 $7,464
Value Before Condition Adjs. $7,202 $7,464
Suggested Total Condition Adj. 235
. • ~ . • . $7,699
General Sales Tax 6.000% $461.94
Title Fee
Transfer Fee'
~._
Deductible $ -500.00
Net Adjusted Value r'~j
-- ;f f- --- ~-
Salvage/Other ~-
~ ~~ ~ ~
VIN WAUDC68D71A005739
Decodes as 2001 Audi A4 Quatt ro Turbo 4WD 4D Sedan
Accuracy Decodes Correctly
Version: 1 Page: 1 12/23/09 07:55
REV-1511 EX+ (10-p9)
Pennsylvania
DEPARTMENT OF REVENUE
iNHERiTANC.E TAX RETURN
SCHEDULE H
FUNERAL EXPENSES AND
Af1MTNTCTReTTVIF [_ASTS
E5TATE OF FILE NUMBER
CODY E. WERT
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' EWING BROTHERS FUNERAL HOME INC. 4,421.27
2. EWING BROTHERS FUNERAL HOME INC. 100.00
3. THE MECHANICSBURG CLUB 1,153.74
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address _____
City ...___.,-.----..._..._.---.--.-_.~_____--
Year(s) Commission Paid: _ _.___
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant _~_ _ _ __~ -__ __~
Street Address
4.
5.
6.
~.
City , _. _ ____ State
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
CUMBERLAND COUNTY REGISTER OF WILLS
State ZIP
ZIP
86.50
TOTAL (Also enter on Line 9, Recapitulation) I $ 5,761.51
If more space is needed, use additional sheets of paper of the same size.
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
February 1, 2010
Robert E. Wert
426 Speedway Drive
Mechanicsburg, PA 17055
The Funeral Service for Cody E. Wert
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff , $1500.00
Embalming, $575.00
Dressing, Casketing Etc , $125.00
2. FACILITIES AND SERVICES
Viewing (Visitation/Wake) , $250.00
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home, $125.00
Service Vehicle for DC $125.00
C. SPECIAL CHARGES
Direct Cremation , $320.00
FUNERAL HOME SERVICE CHARGES $3020.00
SELECTED MERCHANDISE:
Rental Casket with Insert, $540.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED $3560.00
Cash Advances
Certified Copies of the Death Certificate , $30.00
Coroners Cremation Author-ization Fee $25.00
The Patriot with Small Photo $381.62
The Sentinel with photo , $214.11
The Patriot Reminder Obit $84.97
The Sentinel Reminder Obit, $25.57
2 Necklaces, $100.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES . $861.27
Total
Total Cost , $4421.27
~ ~~L ~~
SUB-TOTAL
INITIAL PAYMENT I DISCOUNT 1 CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 30 days is subjected to a 1.50 % service charge per month - 18.0000 % per annum.
$4421.27
4421.27
en nn
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www.Since1853.com
630 S. Hanover St., Carlisle, PA 17013
Phone: (717) 243-2421
Steven A. Ewing, FD, Supervisor
William M. Ewing, FD, (1926 ~ 2009) Seymour A. Ewing, FD, (1926 ~ 2009)
Jessie M. Ewing, FD, (1892 ~ 1988) William J. Ewing, FD, (1898 ~ 1934)
Hastings A. Ewing, FD, (1866 ~ 1924) Alexander B. Ewing, FD, (1831 ~ 1903)
January 5, 2010
Four Keepsake necklaces for Cody E. Wert: $100.00
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RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date: 1/13/2010
Cumberland County - Register Of Wills Receipt Time: 10:16:35
One Courthouse S uare Receipt No.: 1059624
Carlisle, PA 1713
WERT CODY E
Estate File No.: 2010-00038
Paid By Remarks: ROBERT WERT
WZ
------------------------ Receipt Distrib ution ----- -------- -------- ---
FeejTax Description Payment Amount Payee Name
PETITION LTRS ADM 45.00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 5.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 8.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
Cash $ 86.50
Total Received......... $ 86.50
REV-1512 EX+ (12-08)
~ pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CODY E. WERT
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
If more space is needed, insert additional sheets of the same size.
PNCBANK
i ~~t.
;;
30% Post Consumer
Previous Balance .. .............................
.. $831.38 Credit Line .. ...........................................
..... $800.00
Payments and Credits ......... $0.00 Available Credit ............... .......................... None
Purchases, Advances & Other Debits $0.00 Minimum Payment Due (Current Month)... $10.00
FINANCE CHARGES ........................ $0.00 Minimum Payment Due (Past Due} ........... $20.00
New Balance ....................................... $831.38 Total New Minimum Payment Due.......... $30.00
Payment Due Date .................................... Apr. 01, 2010
Minimum Payment Warning: If you make only the minimum payment each period, you will pay more in interest and it
will take you longer to pay off your balance. For example:
If;you make no additional You will pay off the.
charges usingg this card balance shown..on this And you wiH end up paying
and each month: ou a .... statement m about..:. an :estimated total of:..
Only the minimum 6 years $1,324
a ment
$30 3 years $1,085
Savin s= 239
If you would like information about credit counse{ing services, cafi 1-866-951-1391.
PNCBANK
Continued on Next Page
Please detach and send coupon with check payable to: PNC Bank
13408183000275171,10000030000000831386
To change your address or for
PNC Bank Cardmember Service please ca{I:
1-866-395-8294 Every Hour! Every Day!
000006163 1 AT 0.357 106481514068960 P
CODY E WERT
426 SPEEDWAY DR
MECHANICSBURG PA 17055-9740
i~~i~~~~l~i~ii~~lll~l~~~ll~li~~l~~~~l~l~~~~~ll~l~ili~~~l~l~ll~~~~
PNC Bank
P.O. Box 790350
St. Louis, MO 63179-0350
i~~~~lil~li~liiii~i~i~~ii~l~illlii~~~li~~~~ili~i~~lili~~~~i~~l~i~
Comcast.
Contact us: www.comcast.com
717-243-4918
Account Number 09547~381139-042 ~~ ' TM
Billing Date 03/14/10 . ~ `,
Unpaid Balance $250.42 -Due Now
New Charges $133.59 -Due 04/07/10
Total Amount Due $384,01
., , Page 1 of 2
CODY WERT
For service at:
1184 HARRISBURG PIKE
CARLISLE PA 17013-1617
News from Comcast
Disconnect Warning: Payment for services received is
now seriously past due. Ali past due charges must be
paid immediately. Failure to comply may result in
disconnection of services without further notice. Thank
you for your prompt payment.
Introducing XFINITY: More HD, more On Demand, more
speed, more choice and more control than ever before. ~ TV,
Phone and Internet -- reinvented. There; nothing youll need to
do. Learn more about your XFINITY service from Comcast by
visiting XFIN11l'.com
Hearing/Speech Impaired Call 711
You are receiving a paper bill this month due to a legally
required insert for specific customers. If you qualify for
the insert, it is enclosed. Your electronic bill is available
at comcast.oom/eoobili.
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pon with our a ment Please write our account number on our check or money order. Do not send cash.
comcast~ Account Number, 09547 381139 -
-04 2
Payment Due by Due Now
1555 SUZY STREET
LEBANON PA 17046-8317 TOtal AmOUnt Due v~'J
$384.01 /
AV 01 014515 636446 49 A**5DGT Amount Enclosed $ 12
III~~I"111111'1"'I'llillllll'I'III'lllllll'll'1'llllllllll~ll~~
CODY WERT Make checks payable to Comcast l~ ~ (,C
1184 HARRISBURG PIKE
CARLISLE PA 17013-1617
II~I~~I111~1~~11,II,IIIIIIII'i'IIIlilllll'I'IIII1~111~~i1111~1"I
COMCAST CABLE
P 0 BOX 3006
SOUTHEASTERN PA 19398-3006
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09547 381139 04 2 6 038401,
PENNSYIYANIA
NOTORYE!iICLE'NSTAELYENiSA!ECDNTRACT, Oaud
07/06/200°
JUL '0 b qty
ANNUAL FINANCE Amount Financed ~ Total of Payments I Total $ale Price
PERCENTAGE RATE CHARGE ThcamounfotcreditDrovlded IheamoudYwwilNrepaidsfttryou TAesdalcostolyaxpwcMxm
Tree cost ai ro„r utau es Tree ddur amount the to you a on your txNll have made all schdukd paymenS, cr/di, inr~i di t~uut dowtsDaytned
a yearly race Citdn wlll COST y)L d S
6.99 % t 980.10 I { 5127.90 s 61~oB.oMEMBE
- ..3 o T,
'armrm Schedule ed de: - - r......~....
o~ a ' '"0n`n'y °is^" - - - - - - - W : II you wY oR cant. You win red have ro wY a penalty.
N A 010
fiing Fees:1 ' C rL~, R
tau LAxgr: If a payment is laic you rd be cMrged 214 d the Dortwn d the D,Ymenl wrticn is late ex th, a paA `a rtaMh,R7D des , that it remairtf un
Sa oebw and any dNr CartraQ documents for any addinttrd inbrnuAm about nalpayrntnt rWwrd repyrteM n IuA Mart Ute sUxdukd desk
relunds and perukirs
mmisCartracl8 SMITH FORD L[NCOLN MERCURY 1NC
tN SERER. 1100 MARKET ST LEMOYNE, PA ~3
Name Addfen CUMBERLAND Iip~t
CODY uERl County
reuarc 'I184 HARRISBURG PK Carlisle PA 17013 _
flee BUYERtSI: ~ Tip Cde(sl
NamNs) Mtlfesslesl
County
If there a more Nan one BuYa, each Drdntses, xpuatdy and topiner: ro pay ap vent due us and b perldrm all apeemerRs n this CoRUSCt
TRADE•IN:
Yew I4K Uaded in N/A
the toio+ing vehicle:
Yur and Wke Descnpfpn
Y a tuWsce u sul even{ on tAt rMick You lure treed n ate Sr!Ia aiR wy eN fhb anwd w your txhdl. You warrant atd reaesai b us Nal
My bsde•in b free from kM, ckim, atatnbrarKt a SetuMy rAeru~ eueq u sltdrrrr in pe'IWnitalion d Aetaufi Finanud' u Ik'litn hydl.'
IROPERTY INSURANCE: You may elms. the Dawn mrargn rhttm inwnncs u obbirtd agAimt ides a chap b tM Veh4de arM apimt
hsbtkry ariptrq oW d ex n OwMerfAiD d ttx Vebicia In Ihit WrWact yw xaprankin{ b lover. Rte Ytkiclt rod Ypp it revered.
DEBT CAMCElUT10N (GUAIUMTFED AUTO PROTECTION) AGREEMENT IS YOIUMTARY ANO NOT REQUIRED AS A CONDITION OE 1NE
CREDIT. Tks apeemerR di red be Drarided Mkss You sign Oebw, apw m wY Ute addidend chxp, and sips lie sepenb elSCbsWe orb
a{reernent page. whiU u pan d this Camact This sgreenen wip ,{N>fY derive{ lAe retire tam d the CoMrad lAU sptwaenl may rbl roves
Yosa mire indebadness, see tae IaARIMIJM PROTECTION account sirid 4n IAe sepanh disrdowrt rota apeeetent
i ypt d Debt Cartceeanon A{rrxmem Chirp Sgnriun
~Guararneed sum Dnrtttben (GaPI S BY signing, You xka iwranbd aub protrrUia
Sipulure d Duya
SERYKE CONTRACT OR WARRANT! AGREEMENT IS VpIUMTARY AND MOT REQUIRED AS A CONOlT10N Of TH[ CREDIT. The xrvice codrad
a +u,amy speemeni wit red be provided unkss yeu'si{n IAe sepank apeemai trilb the thud WKY provides, wht u red IAC Sdkr nsned
above, and sgtee b pay dM ad0iliond tNarp. TAk xGiien dos not apply b any runnty tf W you Huy rtotiva br wAith IAtre it not seDxad
chxge.
CREDIT INSURAMCF ISROT RF t)IIIRED: Gedl Uk InsurMCS +nd Gedd Accident i NWth loitadiryl Ittwnna sre nest rpuird b obtain
rlediE aad .ill od be provided evicts yw sip bebr ad apw b D+Y tM atMibnal tbstpl. PNast read Ule NOTICE OF PROPOSED CREDIT
INSURANCE m trk recess. side. Your rnunru urtiEcah or DdKY ra tell you tM MAXIMUM amount d irwunnce mihhk. Ai itnwsnu
purcAasd rote o< la the hrm d the aedA We rosy recent a SNrtpd bend'd tram your Wrciau q udR inwrsrta
BT sdP+ti you select Sdpe Gail Uh liaurarsee, What is your BY siMbi You iWtt Sink Gdi Raided i >~lA, yaw
weicl t:bsU S ogee _ Tun FkaAA Inwneee, +hcl ctaU S yet _ Yun
SRrtahrs d Buys b 4 iNwd for Smile Gede Elk laswraau Siptaen d Ruyr Y W +aud b Sttys Credi AdtidMl i /kaM IRStwsrsu
a1 u0uni feu bteh select hero WNI ul 6Y siOwr/.1re beYt stiNA Jdrt C170i1 WW1 an PKMbp
Gems Lik Instarsnet whet tssU S you ages! AtaidM A NeaRk Isrtusra>t, thici melt S ~ Yue alsss b d
iRwrd
1 ~ 2. _%
SgNtura d bare Baym b tx iawrd M lam Gedl 54gnahsra d bah Buyas b d .wed hr lad
tree faswarce Crttdi Acddatt i fksRh lamrrsntx
YFNICEE: Tw lure aptx0 b purdax. undo the taw d Utb CoAVad the tdbwin{ tRda veAidt and its aUa egdaealk whkh u caged
tAe'YtAick' ill lku ConfraU.
NLlI TLf iDd L+yks Ssaef E9dX SDdR f~. l.XL ilYLh Im TdOlSltli SItiY NulaOtE
USED 2001AUD[ A~ YAUOC68D71A005739
Equipped _ AT . P.S _ AMiM Stereo _ S Spa. qha i
wish _ A.C.. P.W. _ AdiM Tsa _ Yinyt ToD
ASSIGNEE: we may asvgn Ibis Cavaa and SeuarityApeetxM.b a sales finaRCt company trAicA.b UM 'Anignte.' II Ik Auipre asst{ns
tree Conuxt u s wbseGUem usigrtee, the term also relas~le wca tubserautnt wiplw. Alfa the sssignrtenl +R rights and bmelis d DK
Setkr in Utis Convxt and n the Security Apetnal sNt Mon{ to and be Mkrteabk by IAt4 Ass4gRae The Assgnee riq roUty yw when
rod it 5dkr rmkts an asvgrtnmt MEMBERS 1ST FEDERAL GREDIT'UNION
P.O. BOX 40, MECHANICSBURG. PA 17055 '
CO-SIGMEt: My Derson n{nag iM Co-Sigror's Apeemeat Oebw pralwses.sepanuy area bgetha tritll d Co-Siplerts) arW Buya(sl, m per
,A wets tlue xd b paean aY a{reernerats n tree CmUxt Co-Sipla role Rot a ea Or+ra el 1N vaMiek.
CO-DINNER: My person si{root iM Co-0.nels Sxurdy /,{rtemtmt franc {ices us a security intaesl n tAa Yelick and apes sepanlNy and
bgAha .tiro as Co-Oraupq and Buyer(U, b perform aY apeeraaah in the SecurAy Agnenenl aetl all oUa pens of Thu Convxl eaceq tAe
•Prtrriix to P,f serYion.
TERMS: The tuw strewn n iN hoses strove are part of Ihs CaMnd Rk wy reLin a poAion of arROUtus rltxkd•
Pt0Y1SE f0 PAT: Yw apes b Oaf u ert TuW Ak h4ce b Uw YdritY b/ makry eke CuA iAswnp,ymed and atsiinirq UM trade-In, i slbwn aheve, on a hdae Yx Mk d ihs foNract and
P+YW us Yte Arwwi Frurcd Oka iVerut Yos premix b rose. prytRMls n a¢twdana riq Ile Payreetrt Sthdsk Yw atrttise b auks payments w a btkre lie sane day d ucl menM as
tAe hrsl p,ynent due date You agree b pay dl d1Nr amounts Mich tuy~benme~dsN undo. eu brrrc d lies tmusct YW apt. b WY the Sekr x Axiplee vests d suit You also spec to pay
rustnade suorneYS' toes ii Seger a Atsrgnte Ares an stbretY b cdkct smartb due ua0er UtuLotswscl a b aatd a id posssssim d the YrthiWt. Yeu apse b Hake Daymmb d the pbce a b
nerd Da1wmU b Vw ddresi waiCA the Assi{nw mast recMtly SDxliea N the rrilm noitrb You. .
The Annual Percerlta;e Rafe fray be neaodabk wlth'tht Seller. ' ADDITfONAI DISCLOSURES, TERMS AND CONDITIQM4 ~ .
The Seller may asstjrt this contract and reUin its rigTht l0 Oiscburu: &fae siptiei Ihk Cenind. bt rove Ibaf yeu recene and cud tAe Gscloulre b
receive a part oy the Finance l~large. ~~
Serves sod Cwduions: Edon si{Rutg fhb CPntnct be sure you receive and cud Dte
lollewing, R narked {, which ue additional MRs b and part d fAis CoRUtIU
m TNS Caslnd catlilwq oR Dtt revere si4.
' ~ ^ DeY CurceWtbn (gwrxdetd odes adectiord sap»le disclosure xd apeement
8y sigmn{ tadnw..e a{tee b seV the Vetticfe b yw under tot lens d tAis Contrxt NOTICE TO BUYE OT IGN HIS CONTRACT IN 8[ANK. YOU ARE
ENTITLED TO A C COP ONTRACT YOU SIGN. KEEP Ii TO
PROTECT YO E
stuERlB SMITH FORD LINCOLN MERCURY I ~ gip ~ IsuU 07/06)09
D,b
BY: y~~~ ~ 07/06/09 BUYER HEW O7/O5IO9
Dau O,k
CO-SIGNER: YOU SNUUED READ THE NOT3CE TO CO-SECNF.R. WHICH HAS BEEN GIVEN TO YOU ON A SEPARATE DOCUMENT, •EFORE
SIGNING THE CO-SIGNER5 AGAE.EM ENT.
CO-SICNENI AGREEM 6,NT: You, the person (ur persons) seining below at `Co-Si{Her; promise so pay so us all sums dtte o0 this Canlraet and to perform eel
agreemenu is tAis Contract. You interd to be lcga4y bound by aU tic terms of tree Contras, aepunacly and tnptAer, with the Ruyor. You an making tAu promise in
endue. us to make this Contras witA the 3Wyet, cvea though rve will ux tAr pruoceds only roc the Buyer! benefit. Ybu ogre. to pay .sere though +re may not haK
made anY Poor demand far paymrnr on the Buya nr eacrcisW our xerrily inreresl. Yuu alw stcaouwledge reeairiog a compkteJ coPY of this Contreet.
_ (SERI.)
Co-Signer's Signaturc•~ Addrtsa Dui
(SEAL) ___
Co-Signcr's Signature Aderess Dote
CPO N'NERS SECURITY ACREEATENT: You, the pcnun signing below u `Co-OwMt." together wph she 9uyer w olACrwise being all of the fhvners of rAc Vehick,
give us a retunty rmcrntin the VeMck idcrnifird above. You agree to be bound Dy IAr terms of llK Security Apeement and all other puts of tie Convect eaCCpl the
"Frame. To Pay' sresion. You err giving u. the security imrrest to laden. us to make Thu Contract with toe Buyer, end to secure she paymem by IM Ruyer of dl sums due
nn she Con,ru~,. Yuu nll not be rpponsihk (or any d<frorncy which might Dt due after «posxssion and sak of the Vehide. ~ '
(SEAL] 07!06/09
Co-0+rrr's Sigaawrr Address Date
BUYER, CO• fR AND CO-OWNER, IF APPLICABLE, ACKNOWLEDGE RECEIPT OF A COMPLETED COPY OF THIS
CONTRACT T T INIE OF SIGNING, INCLUDING THE ADDITIONAL DISCIOSURES.AND PAGES LISTED iN THE SECTION
CAiIED D 0 AL OSURES, TERM AND CONDITIONS.
C
BUYER BUYFR C6SIGNER CO•SICNER DR Ct}OSYNER
NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION
oet7lYa ~ rrwr • pftt(a CD•'r Caarr • ,onawvvco-sraalrs crier ~ Ml • WPt • 6sasrM
1M,R'W YATTASE THE MOTOR
NICEE AND /ROPERTT TNAT YOU
BOUCHI'WIiH TNIS CONTRACT, AND/OR
AEONET ON DEPOSIT WITH THE ASSIGNEE.
lh'a Cortbait u bdreen saes and &ryd. Ai
dedosura teN beM aide by SeW. Se4r
inM+dt b m{n Ois Corrtred b the Anipet
S~ Sendlnquires to:
5000 Louise Drive
PO Box 40
Mechanicsburg, PA 17055
www.memberslst.org
Statement of Accounts
Dec 01, 2009 thru Dec 24, 2009
Main Switchboard: (800) 283-2328
Ez calf: (717) 697-4372 or (800) 283-4372 Account Number : 357482
TDD: (717) 697-5312 or (800) 283-2328 ext. 5312
® TeleBranch: (800) 237-7288 -
MEMBERS 1St Balances at a Glance:
FEDERAL CREDIT UNION Checking : 0.00 -
3669 1 AV 0.335 7337-3669 Savings : 5.00
I~~~III~~~III~~~~~~II~~II~~~~II~II~~~~~III~~~II~~I~~I~~I~~~III Certificates: 0.00
'- CODY E WERT
N _'~ 1184 HARRISBURG PIKE Loans : 14, 740.14
CARLISLE PA 17013 Money Management : 0.00
.-- Swipe 5 YTD Reward: 0.20
_ Page : 1 of 2
Your current Member Loyalty Rewards level is Gold.
Your aggregate balance as of December 1st is $19,283.73.
An aggregate balance of $35,000 and having 3 products
will move you to .the Platinum level.
1099-INT s are not included in this statement. If you earned at least $10 in
dividends on your account for 2009 you will receive your 1099-INT in a separate
mailing in early January 2010. 1099-INT information will also be available on
Members 1st Online early. in. January.
CHECKING ACCOUNTS ~~
„~ . r
0011 -CHECKING ~ +, ~ "* ~3++ , _
' tt~ \ ~;~i4Vr
~~ ~ ,: ~ '
r ;r ;,~Y ~ o- ,
,;'. ~s ~~~~~~+atns~
Date Transaction Dt3sc ' do ~ ~ ' ^r,,x, ,.~~w~ `J,•~`,~ .~~~ "t~-r .,
Doc 0 > Balance Forrva~+d ~ ~ `~ ns ~ ~ Balance ~~
Dec 06 Deposit Transfer From .Loan 0002~~~ ~ ~~~ f. ~ ~`~~~~~`^' ~ ' ~ ~~~~'~ ° " ,' ~~~~~'' ' `~.~ `:
.: z '~ r 4 ~g ~;~,~~'~'~;'~ 49.79
06 ` ~ ,
Dec Withdrawal Debit Card CH~.CK ~~A ~ _;~'~ ~~~ _ ~~~ ~r ' ` ~~~~~ ''~~~ ~ ~ ~ <49:79
"~ ~ ~ r I '~ ' ' t~ it
Dec 07 12/05 ~172243Q00167955~:GI~N '^~~~~ G:~~r '~ ~.~ ~ ~.~°~~ ~4;; ,~,~,~~~~ a~~t~~~~~~~ ~ ~ ~ 0.00
Deposit Transfer, From.~Loa ~ - ~ ~~'~' w, ~~° ~~ ~'~~~~.`~~
n ~~ ~~ .~
Dec 07 ~ ,:, ' " ~ ,,:.~'~~ ~~ `r°y~~,~' ' ~ ~' ~ ~~ ~ - 40.00
Withdrawal at ATM #103887~.x ' ~ ~' ~ '~~
BELCO COMMUNITY -5304 CAR~I$,= ~:~ I, ,~.' RG' RA`k~~=T:::;~~,. ~ ~- ~ ~ 0.00 ,
Dec 23 Deposit_ ~ ~ ,,~ ~~ ~ 1 ~~~- < -fir _..~,
Dec 23 Withdrawal. ~ ~ f ~'~ ~~~"~ !~~ ~ ~~ , ~~ ~ ti` .~ ~ ~ .,~r
1 252.28
~u ~wtr ;:~- ~ Ali' b~ ~~~ ,~~yS
Dec 23 Withdrawal.. µ`,,~.~,~,a~~`~,y: r~, '~~' ~,z~~,~` ~,f~~ 133.88
Dec 24 Ending QQ,,..,, ~ ,~ ~'~~~'~ n ~~ .00
~Q~n 1. +~ eY f.d. ~ ~ r• ~'} k .0
.~,. ,.~.`,~y,~, ,,~yyam ~ ~ .0.00
~ `
SAVINGS ACCOUNTS = -f'`z`'~-. , .~. *~, .,. , ~'~'k~t~'~ s~ ~ =~"~ti~` -~ ~~ ~~
~L-.
0000 REGULAR SAVINGS.
ar ~ ~''~ -r't ,.it;ry~ r c' Z } .~{~ t~ y~,'. N ~t6'~+`~2.tI j ,' ~,.
Date Transaction '.~ ~~ ,~`,~ ~ ~~'`~ ~ -
Dec 0> Balance Fon~vam~ ; ,~- jn ~, r Rl.~° Balance
Dec 24 Ending Ba/anc~ ~ "~.r~ `' ~ _ ~ 5.00...
~~ 5~ ~
,. ~ ~z~ ~`~ ~i,' ~ ~ 5 : 00 .
Q~, ~„x ,~., :.
~_ .
.~
r
A.
+~~Y
'!
Date Transaction Descn lion :.~. ,'~ "; ~ . Y ~ ~, .
Dec 0 > Balance Forward
~ r Balance
Dec 23 Payments ~ ~ ~-~ rt ,';~rr~h~ r, a~,-~~«~ ~ r ~ :~~~~< <:~, , ' 10;01.8.59
Dec 23 Payments ~ ~ ~' i ~ ~11~~•40 ~ :~ 49:$1 ; 0 p0 '„~ f$ ~59 9 950.00
Dec 24 Ending Ba/an ,. .;~~~ ~" ~~ `~`' p-'" , ~0 40~'r t ,~;~1~,,~R0,$16.12
Annual Percenta Rate 7 Q '~
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REV-1513 EX+ (01-10)
~`~ ~ ~~~ Pennsylvania SCHEDULE ~
DEPARTMENT UFREVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
CODY E. WERT
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).J
1. ROBERT WERT 426 SPEEDWAY DR. MECHANICSBURG PA 17055 FATHER 0.00
2. SUSAN WERT 426 SPEEDWAY DR. MECHANICSBURG PA 17055 MOTHER 0.00
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ 0.00
If more space is needed, use additional sheets of paper of the same size.