HomeMy WebLinkAbout03-11-11' 1505610140
REV-1500 ~ (01-10)
OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601 2 1 1 0 0 1 7 6
Harrisbur PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY
2 0 6 3 2 2 1 1 6 0 1 2 7 2 0 1 0 0 1 3 1 1 9 1 9
Decedent's Last Name Suffix Decedent's First Name MI
H E N C H T H E E T A ~
(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 ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required
death after 12-12-82)
^ 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A)
O
between 12-31-91 and 1-1-95) )
(Attach Sch.
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 2 4 9 2 3 5 3
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
State
P A
ZIP Code
1 7 0 1 3
_; , --;
,~
.J ~-`
_'..,~
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
16 M -RON CT• CARLISLE PA 17
SIGNATU E F PREPARER OTHE HAN REPRESENTATIVE D TE
ADDRESS
t,n 61FC MFRET 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
150561014U
J
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: T H E E T A J• H E N C H 2 0 6 3 2 2 1 1 6
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. ? 1 8 3. 6 8
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested 6
7. ......
Inter-Vivos Transfers & Miscellaneous Nip-Probate Property
(Schedule G) .
.
a Separate Billing Requested ...... . 7. 3 5 8 5 5, 4 3
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 4 3 0 3 9. 1 1
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 4 8 4 5. 1 6
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 1 4 B 0 4 . ? 2
11. Total Deductions (total Lines 9 and 10) ............................... 11. 1 9 6 4 9 . 8 8
12.
13. Net Value of Estate (Line 8 minus Line 11) ............................
Charitable and Governmental Bequests/Sec 9113 Tr
t
f 12. 2 3 3 8 9 . 2 3
us
s
or which
an election to tax has not been made (Schedule J) ......................
13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... 14. 2 3 3 8 9. 2 3
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 2 3 3 E 9. 2 3 16, 1 0 5 2. 5 2
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 1 g, 0. 0 0
19. TAX DUE ...................................................... 19. 1 0 5 2. 5 2
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
150561,0240
1505610240 J
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
TI-=1EETA J. HENCH
STREET ADDRESS
33 W. WILLOW STREET
ciTY
CARLISLE
Tax Payments and Credits:
~ • 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.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
File Number
21 10 0176
STATE Zip
PA 17013
(1) 1 052.52
Total Credits (A + B) (2) 0.00
(3)
(4)
0.00
(5) 1 052.52
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE
APPR OP
RIA
TE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred; es
^
No
a
b. retain the right to designate who shall use the propert transferred or i
Y is income; ...........................
....
c. retain a reversionary interest; or .......
................................................
........................................
.
d. receive the promise for life of either payments, benefits or care? .....
........................................
^
..........
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........
.................................................
........... ^
X
...................
Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death?
^
Q
Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ......................................
............................................................
a
^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
or 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 s ouse
3 percent [72 P.S. §9116 (a) (1.1) (i)]. p
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)j. 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)J.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblin s is 12 ercent 2 P.S. 9116 a 1.3 . A siblin is defined, undE
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ()( )J g
REV-1508 EX + (6-98)
REV-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
THEETA J. HENCH FILE NUMBER
21 10 0176
Include the proceeds of litigation and the date the proceeds wen: received by the estate.
Ail property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
~. M&T BANK -CHECKING ACCOUNT NUMBER 42201829 OF DEATH
6,933.68
2. (PERSONAL PROPERTY I 250.00
TOTAL (Also enter on line 5, Recapitulation) I $ 7,183 68
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX+ (08-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
t5 i A ~ t OF FILE NUMBER
THEETA J. HENCH 21 10 0176
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1, THE HARTFORD -ANNUITY #711291471 35, 855.43 100.00 35, 855.43
TOTAL (Also enter on Line 7, Recapitulation) ~ $ 35, 855 43
If more space Is needed, use addltlonal sheets of paper of the same size.
REV-1511 EX+ (10-09)
• pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
FILE NUMBER
THEETA J. HENCH
21 10 0176
Decedents debts must be reported on Schedule I.
ITEM
NUMBER nFSf'.RIPTI(1N
?• FUNERAL EXPENSES:
7 • HOFFMAN-ROTH FUNERAL HOME
2• WESTMINSTER CEMETERY
AMOUNT
2,179.66
985.00
B. ADMINISTRATIVE COSTS:
~ • Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State _ ZIP
Year(s) Commission Paid:
2. AttomeyFees: IRWIN & McKNIGHT 1,200.00
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address
City State _,_,_,_ ZIP
Relationship of Claimant to Decedent
4• Probate Fees: REGISTER OF WILLS 100.50
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 $
If more space is needed, use additional sheets of paper of the same size.
4,845.16
REV-1512 EX+ (12-08)
• pennsylvania
• DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
FILE NUMBER
THEETA J. HENCH 21 10 0176
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
7• OUTSTANDING CHECK #5488 FROM M&T CHECKING ACCOUNT 985.00
2. (GOODWILL AMBULANCE -MEDICAL I 75.25
3. (CONTINUING CARE RX -MEDICAL I 199.83
4. (CHURCH OF GOD HOME -NURSING I 13,544.64
TOTAL (Also enter on Line 10, Recapitulation) I $
14, 804 72
If more space is needed, insert add~onal sheets of the same size.
REV-1513 EX+ (01-10)
enns Iv
p y ania
DEPARTMENT OF REVENUE SCHEDULE J
INHERITANCE TAX RETURN EENEFICIARIES
RESIDENT DECEDENT
~~ i H i ~ ter:
THEETA J. HENCH
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [Include outtsn'ght s usal distributions and transfers under
Sec. 911"6 (a~1.2).)
1. TERRY L. HENCH
16 MEL-RON COURT
CARLISLE, PA 17013
FILE NUMBER:
21 10 017E
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Lineal
AMOUNT OR SHARE
OF ESTATE
23,389.23
REMAINDER
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:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $
If more space Is needed, use addltlonal sheets of paper of the same size.
s~
s
~~
~~~ t ~~ 1 .
~~~ 2~ .
~~.~ ! 0 FEQ 2 3 ~~ ! ! 0
I, THEETTA J. HENCH, of 33 West Willow Street, Carli CL~~C~"~
Cumberland Count pe ~~i~l ~ CG~1PT
y, nnsylvania 17013, declare this instrumen~~~~~~o f~`~:~if; ~'~~~ P~
be my Last Will and Testament, hereby expressl revoki
Y ng all
Wills .and Codicils heretofore made by me.
0~ I direct my Executor to pay all of my debts, funeral
and administrative expenses as soon as may be done convenien
tly
after my decease.
TWO: I authorize and empower my Executor to sell any realt
Y
and/or personalty owned by me at my death, at either public or
private sale or sales and to give good and sufficient deed
s
and/or bills of sale therefor, in fee simple, as I could do i
f
living. My Executor is authorized and empowered to cont'
. roue to
engage in any business in which I may be engaged at m de
Y ath, for
such period as seems expedient to said Executor.
THE I give, devise and bequeath all of my estate of
every nature and wherever situate to Terry L. Hench, providin he
9
shall .survive me by sixty (60) days. Should Terry L. Hen
ch
predecease me, I then give, devise and bequeath all of m estat
Y e
to Chris Jonathan Hench and Chad Oouglas Hench, share and sh
are
alike. Chris Jonathan Hench is hereby nominated to be t
he
trustee of the share bequeathed to Chad Douglas Hench s '
aid share
to be held in trust to provide for the proper su o
pp rt,
maintenance, education, medical care, etc, of Chad Douglas Hench.
'I
FOUR: I nominate and appoint Terry L. Nench to be the
i
1
Executor of this my Last Will and Testament without the filing of
any bond. Should he die before my death, renounce or refuse to
serve for any reason, or die leaving any of my estate
unadministered,. I nominate and appoint Chris Jonathan Hench as
substitute executor with the same powers as are given herein to
my Executor, and also without the filing of any bond.
FIVE: I direct my personal representative to retain the
services of Irwin, Irwin & McKnight, Carlisle, Pennsylvania, as
attorneys in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this 6~
3 day of August, 1990.
_yE95~~~~~F~~A""_~SEAL)
Signed, sealed, published and declared by Theetta J.
Hench, as and for her Last Will and Testament, in the presence of
us, who, at her request, in her presence and in the presence of
each other have hereunto set our names as subscribing witnesses.
s ~.
ACKNOWLEDGEMENT AND AFFIDAVIT
WE, THEETTA J. HENCH, KATHLEEN M. KENNEY and SHARON L.
SCHWALM, the testatrix and witnesses, respectfully, 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 this instrument as her Last Will
and that she had signed willingly, and that she executed it as
her free and voluntary act for the purposes therein expressed,
and that each of the tivitnesses, 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.
r E :NCH ~'~
~~~~ ~
'"3A1~b~T` H
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
.-
Subscribed, sworn to and acknowledged before me by THEETTA
J. HENCH, the testatrix, and subscribed and sworn to before
me b THLEEN M. KENNEY and SHARON L, SCHWALM, witnesses,
this day of August, 1990.
i/~ Tj~;~.ra,~:a ~~~~, ~o7~n`rPUl~1.4C
. ,.,
,"~i~,~;5-_~ :?.~1Ri~, i:~.!~,Ri~f i-~:.f~•<t, G;~L~NTY
~1,Y'~•~_~;~~!f~~S~•..~1 F?CP;:~.S ~?Lv. 15,1392
M•.~~l~er, ?o~ins~~arua kssaaation of 1~eiarias
On~rsa~,k
42201829 DIRECT DEPOSIT CHECKING
.......:......................:.:...::.........:.
JAN.09-FEB.10,2010 1 OF 1
00 0 04345M M2 077
.~~ ~~
,_ THEETTA J HENCH
33 W WILLOW ST APT 4
CARLISLE PA 17013-3880
STONEHEDGE
'~EG~NNING'
.~~CE: ?i
N0.
6,933.68
02-09-10 CHECK NUMBER 5488
02-10-10 SERVICE CHARGE
02-10-10 DIRECT DEPOSIT REBATE
ACCOUNT SUMMARY
... ..
OUNT NO. AMOUNT N0:
1,469.47 1 985.00 1
,~,'.,.,_,T„ ,,, ' „ACCOUNT ACTIVITY
_ SENDING BALANCE
5488 02-09-10 985.00
AMOUNT - ----~ ..
10.00 0.00 7,408.15
~,.$ 933.68
423.47 7,357.15
~l 1'' h ~ 1, 036.00
8,393.15
985.00 7,408.15
10.00
10.0 0 7 ,, 4 Q.8 ..].5.
$7,408.15
A
~~ _7 y~ ~ ; ~S~
/j ~ j /, G G
G' _ .__ ... .. _...
,~ - j -~.,1 , ~~._.-- ._
C i
. ~~5
' March 27, 2009 ~ ~ ~~ ~~ ~;
f1~
~ ~
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HEETT
33 W WILLOW ST #4 THE
CARLISLE, PA 17013
~~ART F
ORD
Re: Hartford Life Annuity 711291471
Dear THEETTA J_HENCH: S
This letter is to confirm direct deposit information on the annuity contract referenced above.
Please note that our records have been updated for your scheduled payments to be
electronically transferred to your financial institution with the following information:
Transit Routing Number: 031302955
Bank Account Number: 42201829
Bank Account Type: CHECKING
Please notify us immediately if any of the information changes.
If you ,please contact our Annuity Client Service Center at
-800-862-6668, Mond hrough Thursday 8:00 a.m. to 7:00 p.m., and Friday 9:15 a.m. to
6:00 p.m. as ern time).
We appreciate the opportunity to service your needs.
Hartford Life Insurance Company
Investment Products Services
Individual Annuitization Service Team
P.O. Box 5085
Hartford, CT 06102-5085
V519R0
~ ~ o
., `~-
TERRY HENCH
16 MEL-RON COURT
CARLISLE, PA 17015
TRUSTED
20U
YEARS
THE HARTFORD
Type of Contract: Non-Qualified
Contract Number: 711291471
Your Saver Plus Annuity Confarmation For Your Survivor Benefit
Transaction Details
Trade Date Fund Name
Value
03/ 10/2010 FIIXED
$35,855.43
Withdrawal Amount: ** $3 5, 855.43
Non-Taxable Amount: $35,855.43
* * Due to rounding the totals may not equal 100%
The amount of the lump sum paid for the commutation is equal to the present value of the remaining guaranteed Anrlui
Payments. The present value is calculated by discounting each future, remainin a ~
calculating the present value is intended to account for any costs related to commuta on. t by a factor. The factor used in
Has your name or address changed?
Please tell us if your name or mailing address has changed so we can update our records.
For assistance:
For investment-related questions, please contact your Investment Professional.
~ For specific questions about your contract:
a_^_ Call 1-800-862-6668 Monday through Thursday 8:00 a.m. to 7:00 p.m., and Friday 9:15 a.m. to 6:00
~~, Eastern time or write to Hartford Life Insurance Com an Investmen p.m.'
~g Hartford, CT 06102-5085. p y' t Products Services, P.O. Box 5085,
z For general information on The Hartford products or services:
Visit www. hartfordinvestor. com
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711291471
PAGE 1 OF 1
FUNERAL HOME dt CREMATORY, INC.
Terry Hench
16 Mel-Ron Ct.
Carlisle, PA 17013
Urn: Centurian (without Lip) Roman
$ 180.00
TOTAL FUNERAL HOME CHARGES: Sub Total: $ 180.00
CASH ADVANCES: $ 1,870.00
12 Certified Death Certificates at $ 6
00 each
.
Newspaper Notice -Sentinel $ 72.00
Clergy $ 43.76
Flowers $ 100.00
Coroner's Fee $ 68.90
Statement of Funeral Expenses for: Theetta Jane Hench
Date of Death: January 27, 2010
Account Id: 15840-23
PACKAGE:
Immediate Cremation
OPTION 5 -Cremation $ 1,690.00
MERCHANDISE: Sub Total: ~ 1,690.00
$ 25.00
Cu1~ T..~~1.
- - _~...
G t uneral Expense:
Total Payments Made:
219 North Hanover Street
Carlisle, Pennsylvania 17013
717.243.4511
toll free 1.866.451.4511
fax 717.243.3723
www.hoffmanroth.com
info@hoftma-voth.com
March 1, 2010
S 309.66
S 2,179.66
$ 2,179.66
Terry Hench a ~~'"'"°-----
Check 5490 Mar 1, 2010 -~
2,179.66
Total Balance Due: $ o_oe
SERVING OUR COMMUNITY SINCE 1 907
Osiris Holding of Pennsylvania, Inc,
Retail Installment Contract and Security Agreement
^ Tti-County Memorial Gardens LLC ("LLC") k7 ~'-testtninster Cemetery LLC ("LLC„) Contract #
("Company") Tri-County Memorial Gardens Subsidiary LLC ("Company") Westminster Cetetery Subsidiary LLC ("Company")
'rY") Tri-County Memorial Gardens ("Cemetery") Westminster Cemetery ("Come
' 740 Wyndamere Road, Lewisbeny, PA 17339 1159 Newville Road, Carlisle PA 17013
717-938-3435 717-249-2029
vely~n this A ement as "Seller") are owners an operators of the Cemetery. THIS AGREEMENT is made by and between Seller and
~-
LLC and Ctm~ny a~ ro sell t• rtrchaser, or his designated bene5 ' ~ hereinaRer caller the "Purchaser'.
Burial Ri is covered b the A ~5' utatxwtdance Huth the tents heteof, the folbwing items ro be provided or used at the above checked location.
~ Y gteement are shown by the map of such gardert/bttilding on file in the office of the CEMETERY, and are more particularly described below.
I +Mausoleum: ^ Chapel ^ Garden ^ Tandem ^ Side-by-Side ^ Single ^ Devveloped ^Preconstruction
] Double Depth ^ Side-by-Side Niche: ~ ^ Chapel ^ Garden ^ Single ^ Companion ^ Developed ^Preconstruction
] Single ^ Developed ^Preconstruction
+Marimrrm cosket dimensions are: length 85 ", width ?9 ", height 26"
2nd Choice 1st Choice
Garden Building 2nd Choice
Section Building
Section Section
Lot No.(s) No.(s)
Space(s) Level
Level
3. ITEMIZATION OF CHARGES LLC* Company*
red for use at another cemetery. (A) Burial Rights (u desrn'bed is P,r,. t ,bore) $
(B) Perpetual Care $
(C) Less Certificate Discount g
(D) Second Right of Interment ~ S ~~~-
(E) Vault(s) S
(F) Um(s) S
(G) Mausoleum Lettering/Crypt Plate ~
(H) MemoriaUMonument S
(I) Granite Base(s) S
(J) Installation Charge S S
(K) Caskets S
(L) Initial Fce for Interments""` ';~ . ~ 1
Vase: Y/N .. .~`~tn.t S (r, 7.~r..r
_ Granite Size X (M)Fwinal Interment/Entombment/Inurnment Fee S ~ i,, ~ , "'
(N) Permanent Records 8t Processing F`-'ee ~' a 145.00 a
(O) Other ~
(P) Sales Tax S S
d_ TATAr rev niini.r^.~....
COlor:
x p
x p
x p
Gauge:
Gauge:
i secondarily liable to the other for the sal f 't
-- - ~- -•......-.~^. , vaa.nrwrv riu~,~ (A r riKU Y) $
' ~ .--
~ '1 .
ITEMIZATION OF THE AMOUNT FINANCED
(1) Total Cash Price ...........
.......................5 ~( ;:; '; . "'~
(2) A: Down Payment O Cash O Check O Credit Card ` ' };.}
B. Trade In: ,~(~ .
Old A ..~ y.. S
greement No. '
C. Total Down Pa ment 2A + 2B ~~
Y ( ) ........ .....
k ~..;
` - ~ ~ '~
(3) Unpaid Balance of Cash Price (1 - 2C) ................ J
(4) Finance Charge ...................................5 ,~ _.
(5) Total Unpaid Balance (3 + 4) ........................ S ~~ -
es o t ems and servtces provtaea oy one another pursuant to this Agreement; however, Purchaser shall not be required to exhaust
before proceeding against the other. `
ElNANCE CNAINiE AMOUNT FINANCED ~ TOTAL OF PAYMENTS TOTAL SALE PRICE
The cost of your txedt as a yearly rate. The dollar amount the credit will cost you. T~ amount of credit provided to you The amount you wip have paid after you The total cost of purchase on credit, includ-
on your own behaB. have made all payments as scheduled, ing down payment of S
-~-- -
,.....,.. , ar„,Q~~w
~•
Amount of Payments Fir ~t Payment Due Date ThereaRer, Payments Are Due
- y on ttie~ .~~^~,,~~~ .
to goods or property being purchased or in paR of the funds paid under this Agreement held in a Merchandise Trust Fund.
have to pay a penalty and you may be entitled to a refund of part of the Finance Charge.
eluding General Provisions on the reverse side hereof) for additional information about nonpayment. default, delinquency charge, security interests, any required payment in full before the
and penalties.
~r w ~~1v~ulvlr:R CREDIT SALE AND IS SUBJECT TO THE ADDITIONAL GENERAL PROVISIONS CONTAINED ON THE REVERSE SIDE
:APART OF THIS AGREEMENT.
he heirs, executors, administrators, successors and assigns of the parties hereto.
RILY PROTECTION CERTIFICATE, IF APPLICABLE, CONTAIN ALL THE COVENANTS AND PROMISES BETWEEN THE PARTIES, AND
'THER REPRESENTATIVE OF EITI~R PARTY HAS AUTHORITY TO MODIFY, ADD TO OR CHANGE ANY OF THE TERMS AND
AGREEMENT AND/OR THE FAMII,Y PROTECTION CERTIFICATE.
NOTICE TO A4.41IC'NFF OF i LER
mtract is subject to all claims and defenses which the debtor (Purchaser) could assert against the Seller of goods or services obtained pursuant hereto
Hereunder by the debtor (Purchaser) shall not exceed the amount paid by the debtor (Purchaser) hereunder.
NOTICE TO PURCHASER
iyou read it or if it contains any blank spaces.
led in copy of this Agreement at the time you sign it.
o pay off in advance the full amount due and under certain conditions to obtain a partial refund of the finance charge; to redeem the property if repossessed for
conditions, a resale of the property if repossessed.
PURCHA ER'S >rt^H TO CANCFI
~ur residence and you do not want the goods or services, you, the Purchaser, may cancel this Agreement at any time prior to midnight of the third
~ment. (For an explanation of this right, see the attached Notice of Cancellation form. )
i Fund exists to reimburse persons who have suffered monetary loss and have obtained an uncollectible judgement due to fraud, misrepresentation, or deceit in a
icensee. For complete details call (717) 783-3658 or 1-800-822-2113.
SEE REVS 4F ~1nE FOR ADDITinNAr 'r~R,IyIS Ate CONDITIONS
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