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HomeMy WebLinkAbout02-22-11 1505610101 OFFICU4L USE ONLY REV-1500 °"°i'°' ~' PA Department of Revenue ~ County Code Year Fie. NMttr~ber Bureau of Individual Taxes INHERITANCE TAX RETURN PO Box 28°6°1 RESIDENT DECEDENT ,~' ` _ _ ~ 1 O ~~( . ~~_~.._ a ,.,.~Q„~.., I U Soaal Security Number Date a Death 177-26-1991. _ 11R8J2010 08/30/1922 Decedent's Last I~rrte Suffix _ Dent's First Nine MI Johns Lorraine (If Applkabis) Eater Swvivhg Spouse's irrtorrrratlon eetow Spouse's Last Name _ _ _ Suffix _ Spouse's First Name _ Mt spouse's Sor:iai ~"~ THIS RETURN MUST BE Fq.ED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. OrigfnaF Realm O 2• Suppferrterrtai Retum O 3. Remainder Return (date of death 13 82 12 - ) prior to - O 4. Umited Estate O ~. Future Irttereet Compromise (date a O 5. Federal Estate Tax Rshxn Required death after 12-12-62) O 6. DeCedeM Died Testate O Ma~nteuned; L~9 T~ 7. 8. Taal Number a Safe Deposit Boxes (attach Copy of tAliN) A ( Litigetlon Proceeds Received O 9 O 10. Spousal Poverty Credit (date of death O 11. Elecfion to tax under Sec. 9113(A) . befiveen 12-31-91 and 1-1-95) (Attach Sch. O) SPOND@R - THIS SEC't10N MUST BE WRRF COIAPLETED. ALL CDRRESPONDENCE AND CONFOENTIAL TAx ~~ TED T0: . Name _ _ _ Constance J. Lavoy (406) 323-4123 ~ _ _ n - ~-:~ ~ ,, ~g Y f f'TCC7'i 'TQ ~ f-*l _.I3 ~„ r' t~ C ~ ~ ; '~ 4 C_ J ~ First line ofi address ' ~ N ° ' r , 3284 US Highway 87 S d~~ --;, ~ c ' Second fine of address _ U~= -~ _- ~ ,~ ,. C'"j `~ ` DATE FILED City or Post Office _ State ZIP Code _ Roundup MT 59072.5816 Correspondent's e-rrwN address: lavoy midrivers tofrl under peneltles of perjrxy.l deaare theft I treire examined this return, trrdrxlM>e aooomperryirg actrecfuiss era sfaierrrsrgs. and to the bast of my krr°wledge and beief, it is true, correct and oomple/e. Declereaion of t>,everer other 1f ren the personal reP-eeerdaYve fs based °n ei i~f°rnmli°n of v~ pepaier ties arN imovrbdge• SIGNAL OF PERSO~RESPJ ONSIBLE FOR FILNrG DATE _7~ii ~1~e// 3284 US Highway 87 S, Roundup, MT 59072 SIGNATURE OF PREPARER OTFER TFUW REPRESENTATIVE DATE ADDRESS PLEASE UliE ORIGINAL FORM ONLY 1505610101 Side 1 1505610101 J J 1505610105 REV-1500 EX Decedents Social Security Number 1n-2s-1991 is Name: RECAPITULATION o.oo 1. Real Estate (Schedule A) .:.......................................... . ..... 0 2. Stocks and Bonds (Sd~edule B) .. .............................. 2. Partrrership or Sole-PnoprietorshiP (Schedule C) ..... 3. 0.00 on. 3. Closely Held Corpora D 4. Mortgaiges and Notes Receivable (Schedule ) .......................... . 4 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Sd~edule E)....... 5. 5,532.87 s. Jointly Owned Property (Schedule F) O Separate B~Nng Requested - ...... s. 0.00 7. Inter-Vivos Transte+'s & Mlis~laneous Non-Probete Y 7 0.00 (Schredule G) O Separate Biting ReQ........ . 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 5,532.87 9. Furl Expenses and Administrative Costs (Schedule H) ................... 9. 3,575.73.. 10. Debts of Decedent, Mortgage LiabiNties. and dens {Schedu~ q .............. 10. 743.87 11. Total Dew (~ lines 9 and 10) ................................. 1 L 4,319.60 12 Net Value of Estate (Line 8 mmus Line 11) .............................. 12. 1,213.27 Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 . ~ election to tax has rxx been made (Schedule J) ......... ...... 13• 14. Nat Yshie Subject to Tax (Line 12 minus Lure 13) ........................ 14. 1,213.27 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at tine spousal tax ram, or trar~fers under Sec. 9116 15. (ax1.2) X .0_ 16. Amount of Line 14 taxable 1,213.27 1s. 54.60 at lineal rate X .0 _ 17. Amount of Ur-e 14 taxable 17. at sibling rate X .12 18. Amount of Line 14 taxable 18. at collateral rate X .15 ti 19. TAX DUE ......................................................... 19. 20. FILL tN THE OVAL. IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 54.60 O Side 2 1505610105 1505610105 J REV 1500 EX Page 3 FNe Number Decedent's Complete Address: Lortaine Johns Messiah Yihage, Special Care 202 Messiah Circle STATE C Mechanicsburg PA Tax Payments and Credits: 1. Tax Due (Page 2, Lure 19) 2. CredifslPaYmer-ts A Prior Payments B. DrsoouM 3. Interest 4. ff Lure 2 is greater tlran t'ure 1 + tine 3. eater the difference. Ttus is the OVERPAI(tiENT. F~ M oval on Page 2, tine 20 to request a reflxrd. 5. If Lure 1 + Line 3 is greater ih~ Une 2, enter the difference. This ~ the TAX DUE (1) zIP 17055 54.so Total Crerrits (A + B) (2) (3} (4) (5) 54.60 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent malts a transfer and: Yes No a. retain the use a income of the property transferred :...................................•---................................................... ^ b. retain the rigfd b designate who shall use the property tanuferred a its ir-cane : ............................................ ^ c. retain a reversionary u a .......................................................................................................................... ^ ................................... ^ x d. receive the promt~e for bfe of eittrer paymarts, benefits or care? .................................. . 2. H death ocarred aNer Dec. 12, 1982, did decedent transfer property witlwr are Year of death wAhout receivurg adequate corrsidereti0r-? .............................................................................................................. ^ 3. Did dement own ~ "'m tnut tor' a Payatrle'uP°n-doh bank a security at tus a trer death? .............. ^ 0 4. Did decedent own an irxiittidtral rebuemerrt account, anraely a other ran-prot~abe property, wh~h oafs a bene~rery d? ........................................................................................................................ ^ If THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FlLE R AS PART OF .THE RE tURN. Fa dates of death on or after Juy 1,1994, and before Jan. 1, 1995, the tax rate on the net value of trar-sfers fp a for the use of the surviving spouse is 3 percent (72 P.S. §9116 (a) (1.1) (~]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the rret value of transfers to or for the use of the swvivirg spouse is 0 Percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does Trot exempt a transfer b a survrv~rg spouse from tax, and the statutory requirements for d'~sdosure of assets and fiNng a tax return are stiff appNrable even if the surviving spouse is the only benefidaiy. For dates of death on or after July 1,2000: at death to or for the use of a natural parent, an ~ ~ptive pa~r~ent~a a~steceppan~ent of tltie did is 0 percent (l2 P.S. §9116(ax1.2)I1 ~ ~ ~ a ~~ • The tax rate imposed on the net va~re of transfers to or for the use of the decedents bers3ficia<ies is 4.5 percent, except as noted in 72 P.S. §9116(12) (72 P.S. §9116(ax1)]. • The tax rate on the net value of transfers to a for fhe use of the decedents siblings is 12 percer~ [72 P.S. §9116(a}(1.3)]. A sr~ry is defined, urn Section 9102, as an individual who has at lanst one parent in comrtan v~ittr the decedart, yr by blood or . REV-i5o8 IX+ {li-lo) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDEPIf DES ESTATE OF: Lorraine Johns SCEIEpt~LE E CASH, BANK DEPOSITS~e yMISC. PERSONAL R~ i ~~ N~~: 2011-00082 .~~ ~~--~--~- ~.a..~r.~i.el'rinht d survivorship o m~ be diido~[d SCIN~dule F. If more SpBCe ~+ , use awrcRna~ ~rccu c. F,aNu w w....~....,.....~... 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 Lorraine Johns 2011-00082 Decedent's debts must be reported on Schedule I. NUM ER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' Myers Furteral Home, Mechanicsburg, PA cremation 2,325.00 2. Rev. Amy Banka, service offirtiant 150.00 3. Mary Jane Tanner, organist 75.00 a. United Methodist Women, Faith UMC, funeral luncheon 125.00 5. Elizabeth Gillman, flowers 44.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address Gty Year(s) Commission Paid: State ZIP 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) n~c~„~~r 4. 5. 6. ~. s. Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: Tax filing fee Travel expenses for executrix from Montana to PA 8~ return to file will 4as 3sa. ie' 'f'p ll5 (r,o rsu.~pfs ~ 33• ~S M.~Is a-fa. b S TOTAL (Also enter on Line 9, Recapitulation) I $ ZIP 81.50 15.00 760.23 3,575.73 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OS) Pennsylvania DEPARTMENT OF REtlENUE INH6tITANCE TAX RETtKW RESID9'IT OECEOENn' SCHEDULE I DEBTS OF DECEDENT, ~Gp~ 1 tgB_'R-TTiES ~ LIENS FILE NUMBER ESTATE OF 2011-00082 ~ ine Johns orta - - _ _ .__-. ~__ .~_ ._ - - W... -. a..a. Mut ~wnal~d unolid at the deE! OI desth, iflClu~lg UIIfe~IMblif'!!d 111e~g1 lX~IeltSEi. if ffiOfE 5{1x02 R neeuev~ p~,ql mw.u.n~a~ a..~...~ ......_ .._..._ _.~. REV-1513 EX+ (01-10) ~ pennsylvarria . _. pEpARTMENT QF pEYENUE mr+eerar~ TAX RFTURn n~oe~r oECEOe~r SCHEDULE ~ BENEFICIARIES ESTATE t)F: Lorraine Johns NUMBER NAME AND ADDRESS OF PERSON(S) ttECEIYING PROPBtTY I TAXABLE DISTRIBUTIONS [Include outrigd M ~ and is under 1.1 2. 3. 4. 5. 6. 7. 8. II Sec. 9116 (a] (1.2).] Cortshar-ce J. L.avoy, 3284 US Highway 87 S, Rorxtdtrp, MT 59072 David W. Johns, P 0'~ox 125, Croydon, PA 19021 Patricia O'DonrteN, 2728 Woodrow Ave., Harrisburg, PA 17112 Joseph Panrratio, P 0 Box 1817, Pitt Mountain, NC 27041 Maria ParRrorio, P 0 Box 242, Newport, PA 17024 'ittotnas Johns, 3567 SR 3011, tylesttopperl, PA 18630 Steven Jotms, RR 4, Box 4234, Wyalr>sing, PA 18853. Ryan Johns, RR 1, Box 114, Sugar Run, PA 18846 Do Not Ltd son 9M 9M b .grandchild 9 FILE NUMBER: 2011-00082 AMOUNT oR SH Of ESTATE 25% 25% 8.33% 8.33% 8.33% 8.33% 8.33% 8.33% ENTBt DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUgi 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNM9(TAL DLSTRIBUTIONS: 1. TOTAL pF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHff is I $ If more space is needed, use additional stM:ets of paper of the scene side. y . _ _.~ IIK/ 2S I, E. LORRAINE JOHNS, of Lakeville, Wayne County, Pennsylvania, declare this to be my Last Will and Testament, and hereby revoke all wills and codicils previously made by me. ITLM A - I direct my personal representative to pay my lawful .debts and funeral expenses from the assets of my estate as an expense of the administration of my estate. ITEM B.: I devise and bequeath my entire estate, of every nature and wherever situate, which I now own or later acquire or have the right to dispose of at my death, to my husband, WILLIAM T. JOHNS, provided he shall survive me by sixty (60) days. ITEM C.: In the event that my husband, WILLIAM T. JOHNS, does not survive me, or dies on or before the sixtieth (60th) day following my death, I devise and bequeath my entire estate, of every nature, wherever situated to my children then living. Should any of my children not be then living, I devise and bequeath his, her or their__share to..theirssuethen living, per stirpes. _ __ _.:__ _. ITEM D.: I direct that all taxes that may be levied in consequence of my death, by whatever jurisdiction, be paid from my .residuary estate as an expense of the administration of my estate. ITEM E.: I appoint my husband, WILLIAM T. JOHNS, to be the Executor of this my last will and testament. In the. event that my husband shall for any reason fail to qualify or cease to act as my executor, I appoint my daughter, CONSTANCE LAVOY, to be the ~~~~- .~ executrix of this, my last will and testament. ITS1K F I direct that my personal representative shall not be equred to post bond for the faithful performance of his or her duties in any jurisdiction. IN~~I~ESS WHEREOF, hav Hereunto set my hand and seal this ~,~t(~ day of ~ lggg . =" ~ { SEAL ) E. LORRAINE JOHN (SEAL) WILL Page 2 .. s The preceding instrument, consisting of this .and 3 additional pages, each identified by the signature of the Testatrix, was on the day and date thereof signed, published and declared by the said E. LORRAINE JOHNS as and for her last will and testament, in the presence of us, who in her presence and in the presence of each o have here signed our hands and seals as witnesses hereto. (SEAL) of 300 Keystone Street 'Hawley, Pennsylvania 18428-1322 (SEAL) of 1719 North Main Street, Honesdale, Pennsylvania 18431 WILL (SEAL) of Page 3 .» COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF WAYNE We, E. LORRAINE JOSNS, Victor A. Decker, III, Esq., and Kathryn J. Decker, The Testatrix and the Witnesses, respectively, whose names are signed on the foregoing will, being first duly sworn according to law, do depose and. say that the Testatrix signed and executed the foregoing instrument as her will, that she signed willingly, that she executed it as her free and voluntary act for the purposes therein expressed,-that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witnesses that to the best o~ the knowledge of each of them the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. SUBSCRIBED, SWORN AND ACKNOWLEDGED before me by E. LORRAINS JOANS, the Testatrix and subscribed and sworn before me by Victor A. Decker, III, Esq., and athryn J. Decker, witnesses, , this ~~~ day of ~, 1998. Notary Public Melissa V. Ciar::~ir:, l•lac:.y Public Hawley [3,;ro, L _a} na %~un1y My Commiesion Exp~ies i ;~;ni 22, 1999 Mgir>ber, Per~Ylv~sria Asso:~alion of Not::ti~ WILL ~ - - Page 4 _ . . E' . d5 w.. l r t2(- .s~~ t}fit . r. , j j °•! A t: •~~~Fitf~{+t$i+Elfllt w 1.`~~f ~' ; :'; W achovi`a thiline Services ~ Account Activity WACxov~ ACCOUNT ACTIVITY Account CRWN CLASSIC "2619 1 want to... View Recent Activity Transfer Funds Pay Bills View Paper Aation Stat_. _ Order Checks Check Seam View Check Card Rewanis Go to Customer Senrice P~ Find Transactions Yage 1 of'l Save the easy way: Set up automatic transfers to Premium Savings. L.eam_More `O' Date All Available - OR - ~ to Range: Sort By: All Transaction Types - (MMiDD/YYYI~ (MMIDD/YYYY) Note: You have aa~unt history ava'labls from:11/12/2010 To view up to 7 years, go to Yiew P ear Sfia~ements Posted Balance as of 02/0312011: $787.92' Available Balance ~ of 0?J048011 : $787.92 " (View Holds Transactions for: CRWN CLASSIC *2619 Date . ~ Description Withdrawals De~sits Balance 01848011 Check View CHECK 3341 $150.00 .._ -____ ~_.~__._-___~ $787.92 ____._._____~ ~__._.__- -_- INTEREST FROM .01/188011 Deposit 12/158010 THROUGH $0.06 $937.92 01/188011 _ __.------- ---.__..__ _ ~~~ .._- __ ___~_ _._ ._ ___-------~_-__-_.. 12888010 a_-_____---.---__~ Check Ytevv _- - .._.___~.__ _. ___ CHECK 3338 . _ $743.87 -_ - _ .~ _ $937.86 12808010 Deposit ^ TRNSFR 3000007021186 $300.00 $1 681.73 ______ 12/19 ~^__ ^__ . _ _- - ~- , 12208010 Deposit DEPOSIT ~ $700.26 ~ $1,381.73 12/178010 ~ ~ Check Yiew CHECK 3337 -~ $2,325.00 -- i -- - - $681.47 . _.-_~ ~__ i INTEREST FROM .12/148010 Deposit 11/138010 THROUGH $0.06 $3,006.47 12/142010 4 12/138010 Deposit ~ TRNSFR 1010009729423 $2.300.00 $3,006.41 12/12 . . - - _.--.___~___.____ 12/078010 _ _~____- Other __.~__~__ _.._.__ ACH RETURN _ __._n. $1,139.00 __~___._ - ----_-- - -___.-~_.____ $706.41 12/03/2010 DeP~t AUTOMATED CREDIT US 139.00 $1 845.41 $1 TREASURY 303 SOC SEC .- , i'i__- ~ , `~ ~ 12/028010 _ Check View CHECK 3336 $743.87 a706.41 ` 11/128010 Deposit INTEREST FROM H O $0.07 / $1,450.28 ~ '~ 10/168010 THR UG hops://onlinebanking2.wachovia.com/AccountActivity.aspx?Index=l 2/4/2011 Wachov><a unime services ~ Account Activity ~ACHOVIA ACCOUNT ACTIVITY Page 1 of 1 1 want to... neat Recent A~ Account REGULAR SAV *1186 - ®Action Transfer Funds View Paper Save the ea wa . sy y Set up automatic transfers to Premium Savings. Leam More VieMrlnterest Paid Go to Customer Service Page Find Transactions `~' Datie All Availat~le - OR - ~ ,i to Range: Sort By: All Transaction Types ~ (MMroammr> ~MMmom~YY> Note: You have account history available from: 11 /128010 To vfew up to 7 years, go b V Statements Posted Balance as of 0?/031Z011 :1351.68 * Available Balance as of 02!04/2011 ::351.68 *" Transactions for: REGULAR SAV *1186 Date ~ Type ___.___._____, ___.______~_ Descxiption VVithdrawals Deposits Balance ~ w ._~_~ INTEREST FROM ~" "' --------°-.._- . 01/1812011 Deposit 12/152010 THROUGH x0.02 3351.68 _._.~_~__._._. ~.__ ____~.____-~_. 01/182011 _._._.____.___.___e~.__ ___..~._ .12/20/2010 Other TRNSFR 1000008942619 ____--------_-______ _____._._______ ~ S~0 ~ 3351 ---____~----._-_--- 12/19 _ INTEREST FROM ~___ _.__._.____ _ __._.___T- 12/142010 Deposit 11/13/2010 THROUGH 30.03 3651.66 ----_____.__ _ _.___.~______.__.r~ 12/142010 _ 11/122010 Deposit INTEREST FROM ~ 10/162010 THROUGH i ' v 30.02 % 5651.63_ 11/12/2010 ~____. __ - _ ____ 1 - 4 of 4 _ _ _ _ __ __ • Includes trarrsac~ions that have cleared your acoouM as of the dose of the pr+erious business day. See help with this page for more details. *' Transactions that have been authorized but not yet posted are ir~luded. See help with the page for more details. customer Agreement P~ Securi~ L~gai O 2011 WeNs Fargo. AJI rights reservad_ Wadtovia Bank and Wachovia Bank of Delaware, division of Wells Fargo Bank, NA Member FDIC https://onlinebanlcing2.wachovia.com/AccountActivity.aspx?Index=l 2/4/'2011 W achovta Vnline ~ervtces ~ ACCOtmt Acttvriy WA~xCi-viA ACCOUNT ACrM'i'Y 1 want to... View Recent Arty Transfer Funds Pay Bills Yage 1 of 1 View Paper Save the easy way: Set up automatic transfers Account HIGH PERF MMA *9423 ~ Action ----- Statements to Premium Savings. Leam More Orcler Checks Check Search View Check Card Rewards Go to Customer Service Pane Find Transactiora ~' Dats All Available - OR - ~^} to Range: _ Sort By: All Transactlon Types ~ (MM/DD/YYYI~ (MM/DD/YYYY} Nola: You have arxotxrt history available from: 11/122010 To view up to 7 y~rs, go to Yew P~ ear Sfatemertts ~_ Posted Balance as Of 02/032011 ::1.03' AvaNsbie Balance ~ of 02/04/2011 : Z9R'1.03 " (View Holds) Transactions for. HIGH PERF MMA'~9423 Date . Type Des t ecaiptin Wdhdrawals Deposits Balance 01/182011 _~ Dept INTEREST FROM 12/15/2010 ~~~ -`_"60.02 $981.03 THROUGH 01/1812011 INTEREST FROM 11/132010 .12/142010 THROUGH 12/142010 ~•~ 3981.01 12/13/2010 ~ Other ____ TRNSFR 100000894261912/12 __~~_~ 32.300.00 -_` 1980 9l3 11/12/2010 ~ INTEREST FROM 10/162010 _-.- ~~~ -_.__ ~•~ __ ~ ~•~~ THROUGH 11/122010 1-4of4 Irtdudes trargadiorrs that have dared your acxotrrt as of the dose of the previous business day. See help with this page for more detaNs. '"Transactions that have been authorbed but rat yet posted are induded. See trelp wqh tt~is page for more details. Cu$t9rner A~eemard Pmt Secxxr~'t t Lam O 2011 VJeps Fargo. Ail rights reserved. Wadtovia Bank and VUadavia Bank of Delaware, division of VJeVs Fargo Bank, NA Member FDIC https:!/onlinebanking2.wachoviacom/AccountActivity.aspx?Index=l 2/4/2011 Myers :.Funeral Home, Inc. Boyd L. Myers Jr., Supervisor 37 East Main Street Mechanicsburg, Pennsylvania 11055 (717) 766-3421 Fax (717)795-7291 A standard of excellence in Central Pennsylvania since 1910 Monday, December 6, 2010 Constance J. LaVoy 3284 US Highway # 87S Roundup, MT 59072 Dear Constance, Thank you for selecting our funeral home to provide services for your family during your bereavement I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form on the services for. E. Lorraine Johns SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED ;2,970.00 LESS: Credits granted 1,045.00 LESS: Total Payments PLUS: Items ordered later 400.00 CURRENT BALANCE ;2,325.00 Credits Granted: 51,045.00 Package Price Discount PLUS: Items ordered Iater Newspapers Bucks County 185.00 Citizens Voice 75.00 Times Leader 60.00 Pocono Times 80.00 Interest at the rate of 1.5 % per month (18 °~ per annum) will be added to balance after 30 days. If there are any questions or concerns that remain unanswered, please call me. 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Aao~ aa~ucusn~ ~ f ~- >. ~' H a ~° u i ~ ~ ~~,~ \ '1.' _ ~~~ - ~~ .. ~ ~. ~•' APPLEE3EE' S NEIGNB~HOOD GRILL & BAR 791 Indian Boundry Rd Chesterton, IN 46304 ; ~ta-t7O1 (219)-921-0070 1,a3}~~{g HS3~1~ 1SER: JEFFREY G VISA 3WOS 3WOH 3>It/1 LATE: 01-24-11 TIME: 17:34 CTRL: 20196 ---------------------------------------- Wd0£~90 ------------ «,~aaE~------------ ;ARD NUMBER: ************2192 _____________pasoL3 ~ay'J 81------------ :XR DATE; **/~* ~•6Z 1N3WAtld APPROVAL CODE: 024388 ~•~ dIl a392i~ Xtll AMOUNT : 24 .59 ~•£Z 1tl1019(1S TIP : ~ 99'6Z tlSIfl/OW T ~~ .__. XX/XX Z6lZXXXXXXXXXXXX 00•y dIl a3921tlH3 86'£Z 66'll a tl1Stld (10Atl9 -W3 Z ------------------------------- Wd5ti~50 Lt,SZuEI' ;ardae grew to pay total in Z }sg Z6tr6 X143 ~/~ lql is ce with agreeaent governing - -------------------- INNOS 8~ use of such card. ** GUEST COPY ** 6661-566 (509) l0£LS DS ` l l~l~}~W --- - - - ---- _ - sans ' S l0£ l 958£# aao}S 1-a3Xtl9 ~ 1Ntl2~1tl1S3a SNIX213d }Y - ~ ~~ ~s- - _ ._ a .~- . ~_-~ •~ ` ,~ ,, .~ .- :,,~ :' .-~ ~a r~ ~~ ~ . ~ 711 L'3 -..1 _ r 7 .. 1 ~_, :EC t, ~ '. ;,,-; 1. !..'_ ~ ice' - -.. ~ X:.7 s ~_ ~ 7 - ,._ ; h -~ .3 - a- ' ~>. iii ~~~ -. C_. 7 . ~: _ _ e_` HACIENDA .1pLISCO MEXICAN RESTAURANT 2185 EAST MEIN STREET GALESBURf. IL 61981 (388) 344-2957 Merchant ID: 2itifdB'i1F;155681 Sale 1l~1llfJi%%%XX%2192 VISA Entrr Method; Saiaed Rramt; S 29.94 Tiv; _~~~~, Total; ~~ 81~11i11 11;39;19 Inv: 869998 Rear Code: 011868 Raarud:Online BatchM:881523 cuata.e.~ Ca+r T-wx mu! PLEASE CDME AGRIN! Ad03 1S3(19 •~uawaaaBe aanssi p~eo ~w oT 6uipaoooe leToT anoge ayT fed o~ aarBe I ----------- - - - le~ol U~"'~ d l 1 8 L E 2; ~ leTo~gnS bONII LL :aan.~aS l/l9 ~algel 6 l L ~ ~1oa43 910020 :apop uTnd XX/XX :aTeO dx3 8ZL£ilSLtrtr0033d :AaX sue.~l Z6lZXXXXXXXXXXXX ~# Tootl '~SIA13W : ad~tl p.~ea WHO£~80 II,OZuer :aTeO OS9S-StrS (Lll) Z6£6-ZllLl bd `Bangs~~.~eH •pa umoTsalButl ££8L l£trZ# aaoTS Aa3Xd8 '8~1Nba(1V1S3H SNIXb3d Dew Dine In Restaurant #1584 68296 Red Roof Lane St Clairsville, OH 43950 (740) 695-2036 1/18/2011 6:24:36 PM Order: 651899 Server: HEATHER F Table: 7 .Guests: 2 SEAT: 1 1 Hot Tea 1.75 1 No 6evera~e 0.00 1 Half AppleCran Chk Salad 5.99 1 Chicken/Prime Skillet 8.99 1 Refill Tortilla 0,00 SubTotal 16.73 Tax 1,17 Gratuity 3.00 1ata1 _ 70,1 Visa 20.90 Acct:XXXXXXXX2192 AuthCode:01886B *****:t**~:~*~*******************#******* Contact us at www.Dennys.com ~ to .d~ys,ca~ and jain , Davy s R~ards to r~~Ve e~clus~de offers ark tha latast nays del ivarad right to your ~r~ox, I~6 5 1 8 9 9 C~tr Capy r~~~~~ ~r/~~ ___t3/~li*- __ _ ,- _-- -- - DESON- > > _. _ - -- - -- Rp'=E , .. ~~ AGES-- CREOITS"V :,'CE_ Balaace Forward 743.87 11/30/201 PAYMENT RECEIVED - THANKYOU~3i 743.87 0.00 *** Nnrsiu8 Care *** 11730/201 PATIENT LIABILITY 27.00 743.87 743.87 i~~ ~~ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL /WOUNT DUE 60809 743.87 0.00 0.00 0.00 0.00 $743.87 RESI<3ENT NAME Mrs. LOIitRAINE JOHNS ~""~'01 Please maloe check payable to Messiah Village. A 1% 5nance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If yon have any gneattons or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You!