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Home My WebLink About05-05-11 (2)`~ 1505610101 REV_ ~ 500 EX (oi-io) j !,L OFFICIAL USE ONLI( PA Department of Revenue Pennsylvania ---- oEPARTMEN.oFRE~EN~E County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO Box z8o6o1 ~~ ~ ~ / °~ "' " Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT ~ ° t ~ !___=~`~ `~ °'~°°' '`' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI t ~ (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 4. Limited Estate ® 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82} O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 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 TO: Name Daytime Telephone Number <.•• , - .~.~ . _ ,A. REGISTBR:.(CrF7N111LLS USE"'ONLY-~ , ;a i .._ ;- , { -_• ~ ~ _-! 4 ~ ..'~~ ~ _ First line of address ~ '=_~ ~-n I ; ~__ -~-t (. - , ~ r°, - s }; ,,::_1~ _ . Second line of address t ~ - ~~ _. _ _, - .: ~ ! .. ., r.:.a ~1~ _ ..1-- ~-'~~ ~> D~~TE FILED ~~ ` ~ City or Post Office State ZIP Code -~-------- { ~ e /~ .w.,i ~ ~ I,^`` Correspondent's a-mail address: ~ ~ ~'. ~ ~- `~-', ~~ ~+'~ r , ,~..> ~ " " ~~-~ 1~'"w 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. SIGNATUIj~ OF PE~SON RE,SPOf~,SIBLE FaOj2 FILING RE RN DATE _ f'~ ~ '~ ADDRESS " ~ s ~.. ~ /" y ~._._._..~~.~.®.t~....~.,__.,~ ~_ t ~' !' .. ~ °~ r 9 L r.~.._r SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE T DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J J 1505610105 ' REV-1500 EX Decedent's Social Security Number Decedent's Name: ' ~ ~ ~, ~3 RECAPITULATION --- 1. Real Estate (Schedule A) ........................................ ..... 1. ,. ~ 2. Stocks and Bonds (Schedule B) .................................. ..... 2. , Q 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . .... 3. . ~ 4. Mortgages and Notes Receivable (Schedule D) ....................... .... 4. . Q 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)... .... 5. Z..Z ; ~ ~ ~ Q '7 ! 6. 7. Jointly Owned Property (Schedule F) O Separate Billing Requested ... Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested.... .... 6. .... 7. - . `, • Q 8. Total Gross Assets (total Lines 1 through 7) ......................... -- .... 8. ' ~ 2 `7~ ~ <z J___~ • 0~ (\\ 9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. ~ ~ ;~~ ~> -~ ~ g -~~ 10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I `~' °-~ 11. Total Deductions (total Lines 9 and 10) ............................. .... 11. °`> ~~ ~~--~ ~~ • ~: ~-r , 12. Net Value of Estate (Line 8 minus Line 11) ..... 12. -- --" , ~ - ~--' ~. . • 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. ~~ <~`" ~,:- "' ~ ~ ~ ~~ 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- . 15. 16. Amount of Line 14 taxable at lineal rate X .0 "~; ~ ~ ~ ~ . ~ ~ 16. ~` ~i ' 17. Amount of Line 14 taxable at sibling rate X .12 . 17 ~ 18. Amount of Line 14 taxable at collateral rate X .15 . 18 • 19. TAX DUE ...................................................... . 19 '-~ ~~ '~ h ~~ ~ .. . ... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 File Number Decedent's Complete Address: ~, ~ f ~ ,.._ ~ ~ u,. !~ ~~,. DECEDENT'S NAME "` . STREE DDRESS _ -- --- - -- ~.1..y,,.~ y , ,.. ti .. -- -- F 4 ,-...sue J `. ~ ~~ ~ ~ ~ t~ Y1~~ __..-_ _-__- -_ ~1.-.-.:_ _--_ _ _ __...-_ _.... _-_ -i _ -r.--__ _ _ __.. - -- _ _. _ CITY - ~- - --- -=„' _ __ -----__ _ - --- - '- t `' - _ _ _-- ------ - --- 'STATE ,`..,, ZIP 4,,, Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) ,~.~ ~M ~ ~ „„~ 2. Credits/Payments - ~^ ~ ""~ * ~`" - A. Prior Payments - - -_ - B. Discount 1.,~- -- _ Total Credits (A + B) (2) _~~ ~'.~, ~' ~Z 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. (q) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ 1,1L?. ~-~ --~w Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" !N THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: `(es 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 .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1932, 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 requiremenl~s for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. 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-150$ EX + (;-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ~ FILE NUMBER t ,,..... Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH .v ~. ti ~,~.. 1l C ~ '? ~' j` d ~ ~`~~ f1 eta ~ ~,,, ~, cal ~ r~,~(''c"~ ''~ ,f ~-i ~~ ~' ~' r~ , ~ ~ '~` ~ ' ~ ~ ~ , ,w] 1 1 l # ~ ,~. t~ ~ ~ ~ ~ ~ ~ °~ ., ~~ r .... ~ ,tF'r'~'" ~"`~ ".y`'Y. ,{.;fir °..,M~ ~ ! ~ ~.Q ~ ~ O ., TOTAL (Also enter on line 5, Recapitulation) $ .._?„ ~ ~ ~ , ~ ~' (If more space is needed, insert additional sheets of the same size) Dorothy Knowlton Page 1 of 2 Hel '~.>~e "" Wage ~~:counts Pa~'~glls Transfers Ser~ace Cenfer " ~nage Fee~tures ~~count Summary Alerts Center '.~"<;ssage Center Preferences Dorothy Knowlton ~ Shortcuts... Overdraft regulations have changed. It's not too late to set your ac,co~unt prefer Click on the - - - - :link below. INFORMATION CENTER 31 New Alerts • eStatement Notification Alert • Welcome to eStatements • Account has been inactivated • eStatement Notification Alert View Alerts ~ Manage Alerts DEPOSIT ACCOUNTS Account ~~. Circle Gold Checking w/ Interest Circle Gold Checking w! Interest Circle Gold Money Market Performance Money Market 0 New Messages No New Messages View Messages ~ Send Message Today's Date: Wednesday, 03130/: Last Log In: Wednesday, 03/30/20 View Session Receipt Open a Checking or Savings Ac Open a CD or Money Market Ac Apply for Home E ui iVlanage Overdrai Account Number ~oooooc5879 ~oooooc7752 x~ooooc2098 ~oooooc7698 Totals: Available Balance $14,808.23 $30.20 $119.71 $208,687.93 $223,646.07 MY GOALTRACK SAVINGS Already enrolled in GoalTrack Savings? View your plan and track your progress Not enrolled? Save regularly and eam a bonus. Enroll now PENDING PAYMENTS AND TRANSFERS PAYMENTS No Pending Payments Found TRANSFERS No Pending Transfers Found eStatements Go Paperless View e View ~, View ~ Leam More ~ ± ~ REV-1511 EX+ (10-06) pro,. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDIJLE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS i ~~~ ~ a rILG IY{JIYI~GI'S ~ ~ { *~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: S ~. ~. ~~-~ -~-, ,~ 1. ..~ ~~ ..,C`~ ,,.., ~, B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City __ State Zip 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 City __._ State -Zip Relationship of Claimant to Decedent 4. Probate Fees 5~ Accountant's Fees 6. Tax Return Preparer's Fees 7. ~.u,s ~~ i .~ ~- j / --` '' / TOTAL (Also enter on line 9, Recapitulation) I ~ ~ ~ (~' ~ "7 I,~. , (If more space is needed, insert additional sheets of the same size) .~, ~ j,~~ ..,~ _.. ,:~ ~. ... v.H~:.:< :u^'r ...~... ,"' .,.~.~ ~~~~t k, ~, °' G,.r"s.,. ,wax:. tv .-5'.~,~~:,N „3 _w .F FICTITIOUS NAM REGISTRATION Notice is hereby given that an Application for Registration of Fictitious Name was filed in the Commonwealth of Pennsylvania on October 29, 2010 for GEESE AT YOUR FEET OUTFITTERS located at 747 Ertord Road, Camp HiU, PA 1:7011. The name and address of each individual interested in the businesslsJustln Stewart, 747 Ertord Road, Camp Hill, PA f 7011. This was filed'u~ accordance with 54 Pa.C.S. 311. ESTATE NOTICE LETTERS TESTAMENTARY on the Estate of DOROTHY GRACE KNOWLTON, late of Upper Allen Township, County of Cumberland, Pennsylvania, deceased, were granted to Stephen P. Knowlton on April 4, 2011. Ali persons knowing themselves to be indebted to said Estate are requested to make immediate payment, and those having claims will present them, without delay, to the undersigned. Stephen P. Knowlton, 108 Deerfield ~ Road, Camp Hill, PA 17011. , x _, .. $ Market Plaza Way -- _ - _ ~ - (717) 697-4696 Mechanicsburg, PA 17055 www.malpezzifuneralhome.com Jeremy J. Shartzer, FD Michael J. Malpezzi, Owner, FD Kyle C. Knipe, FD Apri17, 2011 Stephen P. Knowlton 108 Deerfield Road Camp Hill, PA 17011 This is the final statement for the funeral services of Dorothy Grace Knowlton We sincerely appreciate the confidence you have placed in us and will continue to assist you :in every way. PROFESSIONAL SERVICES: Services of Funeral Director/Staff $4.,625.00 FUNERAL HOME SERVICE CHARGES $4,625.00 SELECTED MERCHANDISE: Poplar Casket $2,185.00 Guardian Burial Vault $1,125.00 Lord Register Package $75.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $8,010.00 CASH ADVANCES: At the time funeral arrangements were made, we advanced certain payments to others as an accomodation. The following is an accounting of those charges. Opening Grave $845.00 Cemetery Equipment $170.00 Certified Death Certificates '60.00 Newspaper Notices -Patriot - $368.19 Flowers TOTAL CASH ADVANCES AND SPECIAL CHARGES SUB-TOTAL INITIAL PAYMENT /DISCOUNT /CREDITS TOTAL AMOUNT DUE BY Apri129, 2011 $.185.50 $1,628.69 $9,638.69 $0.00 $9,1138.69 If you have any questions or concerns regarding this bill, please call our office at (717) 697 - 4696. i t ~ z rzc MEMOA~IALS Since 1921 5243 Simpson Ferry Road, Mechanicsburg, PA 17050 (717) 766-5622 • Fax (717) 766-800? www. gingrichmemorials. com SOLD TO: ~ ~ _ ~ . ;.g, ~, ~,. ' , ~ ~~;. 2_ ~,~ ~ ~ ~.~u. S Drawing Drawing Sent to Cust. ,_ Approved Found. By Vendor Grave Position Verified 1- Date of Order ~ . f=ound.Ordered Ack. # Cremation f `~ ~ `~~ ~ ~ Cemetery ~ ~ ~ ~:. g ,~ ~, ~- „ Cemetery Location fd '~ e ~ . ~ ~: ; yn. -~ Phone ~ F~. ' '~ ``' ~ ~ Cell Center Over Graves Sec. /Lot # Email Approx. Date of Completion ~~"~~~ ~ ,~~ ~ ~~ ~ .~~s = ~~ 3~ Lettering ~~ >. S ~ yyy ;Y t ~ Y % 1 n dA ~ fy::. s !{ Type ~ ;`4~~, ~~"°, ° ` Material ~`,^~,,- ~~:_ 's~.~.~:A ~~ ~~ ~. ~ ~ ~~ Additional Lettering: ~. Size t~ X ~ ~ X _ Finish ~ ~. ~ ` ~~ ~: ^ Back ^ Base ~~'~'~ "~~'°"' Finish Description Location on Cemetery ^ Vase ^ Photo ^ Other Agreement: A 50°6 deposit is required to of work. Agree to pay stated balance upon erection regardless of labor troubles or shipments or any other good reasons. This order or contract cannot be canoetled ny customer unless agreed by both parties. The article herein mentioned shall remain the property of James R. Gingrich Memorials until paid in full and they reserve the right to remove the same is not paid as stated. I agree to carefuNy proofread aN names and dates for accuracy and accept full responsibility for any errors or omissions. THERE WILL BE AN ADDITIONAL CHARGE FOR ANY LETTERING ADDED TO THIS MEMORIAL AFTER ERECTED ON THE CEAAE EERY. 1 further agree to pay the balance stated for the work pertormed under this contract within thirty (30) days of receipt of the final invoice and further agree that interest shall accrue at the rate of one and one-half percent (1'/i%) per month on the unpaid balance owed to James R. Gingrich Memorials not paid within thirty (soj days of the invoice date. In addition thereto, 1 agree if it becomes necessary for James R. Gingrich to institute legal proceeding to collect any funds due from me for my account being past due thirty (30) days, to pay all~rourt costs and attorneys fees incurred by James R. Gingrich Memorials to collect the same. Dealer ~°~~"_ `~~„~h ^~ Customer (l further agree that the above names, spelling, and dates are correct) COSTS: Memorial $ ) ~~y ~ ; Foundation $ '~ "~~ §~g Cemetery Fees $ $ - -- $ $ TOTAL °~ $ ~ ~ ~, ~. DEPOSIT ~., ~.. `m° ~$ , ~~ ,,...~ F Balance Due $ Upon Completion ~~ t , ~, _ . RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Receipt Date: 4/04/2011 Cumberland County - Register Of Wills Receipt Time: 11:57:13 One Courthouse Square Receipt No.: 1065033 Carlisle, PA 17613 KNOWLTON DOROTHY G Estate File No.: 2011-00427 Paid By Remarks: STEPHEN KNOWLTON HMW ------------------- ----- Receipt Distribution ----- ---- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL 310.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 15.00 20.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN JCS FEE AUTOMATION FEE 23.50 5.00 -- BUREAU OF RECEIPTS CUMBERLAND COUNT~i' & CNTR GENERAL M.D FUN Check# 1934 -------------- $373.50 Total Received..... .... $373.50 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS wiril~ yr ~I ~ ~ ~ FILE NUMBER Report debts incurred by the decedent prior to death which remainprl unnairl ~c of 4he a~+....i.l....a~. :__i..~:___ ___ .. ~•• ••~~~~ ~r~~.. ~~ iiccucu, niacii auuRlUl181 Sfl@@IS Oi ill@ S8Ci12 SIZ@~ 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 STEPHEN KNOWLTON 108 DEERFIELD ROAD CAMP HILL, PA 17011 QATE DESCRIPTION _ _ ~Baance Forwa~- - - __-- _ 03/29/2011 PAYMENT RECEIVED -THANK YOU!!! * * * Enhanced Living * * * 03/02/2011 ELPS -DELAWARE SINGLE 03/01-03/02 03/09/2011 BARBER/BEAUTY SHOP SHAMPOO/SET ..03117/2011 BAR.BER/BEAUTY SHOP SI~[AMPOO/SET 03/24/2011 BARBER/BEAUTY SHOP SHAMPOO/SET 03/29/2011 ELHS -DELAWARE SINGLE 03/03-03/29 03/31/2011 ELHS -DELAWARE SINGLE 03/30-03/31 03/31/2011 MISC. MED SUPPLY - AL 1 PACK PULLUPS Form PB-01 RESIDENT # UNIT STMT. DATE..: 49905 333 03/31/2011 RESIDENTS '~~ Mrs. DOROTHY G. KNOWLTON .TOTAL AMOUNT DUE $5 155.00 DATE DUE 04/30/2011 RATE Days/ Urnts CHARGES- CREDITS _ , _BALANCE 3,640.00 3,640.00 0.00! 128.00 2.00 256.00 256.00' 14.00 1.00 14.00 ~ 270.00 14.00 1.00 14.00 284.00 14.00 1.00 14.00 298.00 167.00 27.00 4,509.00 4,807.00 167.00 2.00 334.00 5,141.00 14.00 1.00 14.00 5,155.00 r r~. ~! ~~ rj3 .. ............. .....:. RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOT~C.'AMOUNT DUE 49905 5,155.00 0.00 0.00 0.00 0.00 °, $5,155.00 RESIDENT NAME Mrs. DOROTHY G. KNOWLTON FormPB-o, Please make check payable to Messiah Village. A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! 11/~~ssic~h Village ~~:. _.: .~.~ ~.. ~ ..~~ Form PB-07 H~~~~ ~A~E, t,Lc 100 MT. ALLEN DR., MECFiANICSBURG, PA 17055 STEPHEN KNOWLTON 108 DEERFIELD ROAD CAMP HILL, PA 17011 QUESTIONS? CALL: 717 697-4666 RESIDENT #' UNIT :STMT. DATE 49905 333 03/31/2011 RESLDENT S Mrs. DOROTHY G. KNOWLTON TOTAL AMOUNT DUE $966.75 DATE DUE 04/30/2011 ___ .DATE _ DESCRIPTION RATE ~ay~ CHARGES _ CREDITS BALA__N_C_E - ._. _- _ __ _ __ ._ _ _ Una __ ._ _ Balance Forward r~~ ~ 0.00 * * * Enhanced Living * * 03/27/11 Home Care Asstnt - Wknd (Campus) 03/28/11 Home Care Assistant (Campus) 03/28/11 Home Care Assistant (Campus) 03/28/11 Home Care Assistant (Campus) 03/28/11 Home Care Assistant (Campus) 03/28/11 Home Care Assistant (Campus) 03/28/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/29/11 Home Care Assistant (Campus) 03/30/11 Home Care Assistant (Campus) - 33/36f3~-- ~ormre~~ai-~ 03/30/11 .Home Care Assistant (Campus) 19.00 1.00 19.00 17.00 7.00 119.00 17.00 3.00 51.00 17.00 3.00 51.00 17.00 1.25 21.25 17.00 6.75 114.75 17.00 1.00 17.00 17.00 7.00 119.00 17.00 2.00 34.00 17.00 1.50 25.50 17.00 1.25 21.25 17.00 1.75 29.75 17.00 0.50 8.50 17.00 2.00 34.00 17.00 4.00 68.00 17.00 3.00 51.00 17.00 1.00 17.001 17.00 5.00 85.00 r ~ ~ nn _- ----_- ---- _.___-__- 17.00 2.75 _ X6.75 ~- V ., ,~ -- i ~_ - ~~, -, RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AM6~1NT DUE 49905 966.75 0.00 0.00 0.00 0.00 $966.75 RESIDENT NAME Mrs. DOROTHY G. KNOWLTON Form PB-01 Please make check payable to Messiah Village Home Care, LLC. A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! PHARMACY SERVICES INC. 2I 9 North Baltimore Ave Mt Holly Springs, PA 17065 800-266-9954 (717)486-8606 www.alertpharmacy com iTATEMENT OF ACCOUNT IF YOU RECEIVE A NBW INSURANCE CARD FOR YOUR PRESCRIPTIONS BE SURE TO SUPPLY US WITFi.A COPY. Date 03/31/2011 PMT DIIE..04/29/11 ---~~ ~ KNOWLTON, DOROTHY 'E KATC}WD _ STEPHEN RNOWLTON ' GRIP-47 '~ 108 DEERFIELD ROAD ! PAGE 1 iw CAMP HILL PA 17011 ~ . { Amount Paic PLEASE DETACH AND RETURN TOP PORTION 1MTH YOUR PAYMENT ALERT P'1ntARMACY SBRV. INC.219 NORTH BALTIMORE AVS. MT.HOLLY~SPRINGS,PA 17065 f' ii ~ ~ f r* ACTIVITY FOR KNOWLTON, DOROTHY -RNOWD - -049905 _ ._~ ~03 jDI J'~TI " ~ -772 $151 52 7 _ - POLYET]Ei'YLBNE GLYC O l 7.0 0 _ - . 0 0 7.00 C 03/D2/11 7810391 14 DILTIAZEM XT 360 O1 7.00 .00 ?.OOc 03/08./11 7812757 8 FUROSBMIDL 80 MG O1 2.03 .00 2.03c 03°/0.9/11- 7813290 7 METOPROLOL XL 25M O1 7.00 .00 7.OOc 03/10/11 2042439 30 MORPHINE SIILFATE 01 7.00 _00 7.OOc 03/11/11 Payment-Thank You 146.92- .00 146.92- 03/14/11. 7814681 3 WARFARIN 2MG Ol 2.03 .00 2.03c 03/16/11 7659710 60 Mi7CINEX 600 MG Ol * 26.07 .00 - 26.07 03/16/11 7801613 10 MIRTAZAPINE 30 MG O1 7.00 .00 7.OOc 03,/16/11 7801614 10 RISPSRIDONE 0.25 O1 7.00 _00 7.OOC 03/16/11 7801615 21 POTASSIUM CL 10 M 01 7.00 .00 7.OOc 03/16/11 7766922 21 GABAPENTIN 300 MG O1 7.00 .00 7.OOc 03/16/11 7748927 21 PANTOPRAZOLE 40MG O1 7.00 .00 7:OOc 0.3/16/-11 7730532 15 LEVOTHYROXINE 125 Ol 4.21 .00 4.21c 03/16/11` 7812757 11 FUROSEMIDE 80 MG Ol 4.87 .00 4.87c 03/16/11 7814681 7 WARFARIN 2MG O1 7.00 _00 7._000 03./16/11 7813190 11 METOPROLOL XL 25M Ol 7.00 .00 7.OOc 03/16f 11 7810391 11 DILTIAZEM XT 350 Ol 7.00 .00 7.000 03/16/11 7789698 60 SUCRALFATE 1 GM O1 ?.00 .00 7.000 03/17/21 2042497 60 MORPHINE *ER* 30M O1 7.00 .00 ?.-0Oc 03/25/11 7819312 28.4.0 BACITRACIN ZINC O O1 * 2.89 .DO 2:89 03/26/11 7819519 1 WARFARIN 1 MG 01 1.34 .00 1.34c 03/29/,.11 ____._. 7659710 . - - 39 _ - ._ _ ___ MLTCINEX-_600 MG______ Ol * _ ._ __._~. ;o- ____ __._ - 00- ,... 15:.__3-9- - .00 ~3 ~ STS ~ LEGEND NON-LEGEND ? ~ TOTAL TAX FOR MONTH FOR MONTH ~evlous Balance charges thus tnonffi Finance Clmrge TOTAL CHARGES row t a c~ea~cs~ ; AMOUNT DUE 146.92 T 141.44 _ .00 - 288.36 162.31 - 126.05 •'~, I _ _~ - - ~` _ + ~~ `. (AN P.-NNUAL PERCENTAGE RATE OF 18.0 ~) OR A MINIMUM SERVICE CHARGE OF $ 1.00 WILL BB CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST DUPS REV-1513 E~C+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE J BENEFICIARIES ESTATE OF ~ -'~ ..~- r~r^, ... ~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 1. y; ~ ~~ k t e 1! ~~ ~ ~~ ~__ ~r, -,'` ~`~ ~` j~~4: r r ` ~ °1~ v r~~ ~ ~'~` ,~ ~a ..~. 4 FILE NUMBER ~. ~~~ ,~ r ~' ~' r 1•"'° RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE ... ~ - r ~.,~ , ~ } ~ - ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 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, insert additional sheets of the same size) W x w ~ z ~ ~ o ~ ~'' w ° ~ ~. 3 ~ ~'" ¢ ° ~ ~ ~ Ey ~ a~ ao a ~~ ~ ~o~M ~ z Wp~Aj~ ~ c°.~ ~ ~% ~~~~0 ~ W "¢wzzaQ c~~a¢v~,W ° a~~~~~ ~ ~ Wa oo'~ z ¢ W Z A _ ~ a Q N ~ b~ ti ~ W ~.,, ~ aka ~+~pp~ ~V ~ ~ ~, ~ ~U '~ ~V A~ W '~ o p A .. W z ~ ~ U b ~~ ~' ~ w ~ ~ w REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA .:- - -_- -- ~' ~~ --°- ~ , CERTIFICATE OF GRANT OF LETTERS No . 2011- 0042 7 PA No . 21 ~- 11- 042 7 Estate Of: DOROTHY GRACE KNnw~ Toni (First, Middle, Last/ Late Of : UPPER ALLEN TO WNSH/P CUMBERLAND COUNTY Deceased Social Security No : 149-01-6906 WHEREAS, on the 4th day of April 2 011 an instrument da ~ted May 22nd 2008 was admitted to probate as the last will of DOROTHY GRACE KNO WL TON (First, Midd/e, Last/ 1 a t e of UPPER ALLEN TO WNSH/P, CUMBERLAND County, who died on the 3 0th day of March 2 011 and, WHEREAS, a true copy of the wi I1 as probated i s annexed hereto . THEREFORE, I, GLENDA EARNER STRASBAUGH Register o.f~ Wi 11 s in and for ;,, CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: S TEPHEN P KNO WL TON who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARL/SLE, PENNSYL VAN/A. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 4th day of April 201 ~. d ,, i `~ ~ ~ .~ egister o~s r ~ ~ '~ ~~~~° -_ .y eivury ~a C7 -^ M .~-~ :-, ~ ~ ~ c T! r, ~ ~ C7 -- ~ f ~7 _ _ .., -- ` -n D r- ` _- t t - _ _ ., , _ ~.~ _... rt't LAST WILL ~~ • ;.~. _..: ~'~ a R. SCOTT CRAMER Attorney at Law 5. S. Market St P.O. Box 159 Duncannon, PA 17020 I, DOROTHY G. HrTOWLTON, of Cumberland County, Pennsylvania, decla~'e this to be my Last Will, hereby revoking all prior Wills and Codicils. FIRST: I direct that the expenses of my last-. illness and t~uneral be paid ~.;~t of my estate as soon after rriy death is ~ 1 .~ (~ _! 1 L `/ `~ 1 1 - . i 1 ~_ :,i ! i t..e t_.. i i/ ~ ~-- .. i_ ~, ! . - ... _ ~ y a ~„ -• _.. r ~ ~ . w+ rl r 1- .F -r• . ~ ' _ c i'~ _ _. .. 1~ Executor, hereinaf=ter Warned. J SECOND: I give, devise and bequeath my entire eSt3te t0 my three (3) children, Kathleen Logue, Nand,- Knowlton and Stephen P. Knowlton, or the survivor/survivors cf the t:l.r~e, in equal shares, share and share alike. THIRD: All estate, inheritance and other deat'r~ Lazes, t~og•ether '~-ith any interest and penai_ties pa~~abie wis_~; resp_ ect }o pro~~erty chi interests t~;erein sub;ect t.i taXat:lUn by Y'E'.ci;:;~:)n Gi :~:?y ~`7E'ciC~'1 ~11C~ wf':et~ler ~.«~S1.iZ~ i1nd~.`:: ~:'y Y~'~L~ ! C1~ cis:}% `:~dicii thereto, ~~r otherwise incu~~i.na jointly hl~d an _?. :~thez non-testamer_taY y property shall be paid out of t ~r principal of my residuary estate without apportionment.., FOURTH: I hereby nominate, constitute aizd appoint: my son, Stephen P. Knowlton, Executor of this my Last Will. I further direct that he shall not be required to post any bond to secure the faithful performarc,e of his duties in the ::ommonwealth -->f Penn~:ylvania or r~ any :~the~~ j urisdict ic~r~ . IN G~~iI'?'~~E- ~S WHEk~OF, I Piave ~,ereunto se, my hand ani:+ se:~l to this ->^~f- i:.~._;t:. Will, which L.ons:ists of ~~r~e ' i sheet: a paper, pater this -~~., day cf ,''~I~~ 20U~ . .~ ._~ Dorothy G. I~Cnowlton The writing contained on the one (1) preceding page was signed and sealed by Dorothy G. Knowlton, and by her published and declared as her Last Will, in the presence of us, who have hereunto subscribed our names as witnesses at her request, in her presence, and in the presence of each Other. ~~G`~ COMMONWEALTH OF PENNSYLVANIA) )SS COUNTY O F ~'~'~Y C c~M'~2irFt~SJ) I, Dorothy G. Knowlton, testatrix, whose name is si.grled to the attached or foregoing instrument, having been duly qualified acc~~rding to law, do hereby ackr.owledgz t:~at I signed and executed the instrument as rriy Last Will; that 1 signed it willingly; and that I signed it as my free and voluntary act or the purposes therein expressed. ~- ~-- Do othy G. Knowlton R. SCOTT CRAMER Attorney at Law 5. S. Market St P.O. Box 159 Duncannon,PA 17020 SWORN or affirmed to and acknowledged before me by Dorothy G. Knowlton, testatrix, this ~a. day of ~`~lc~~ 2008 ~~ y~~~s~ COMt+AONViIEAI.TN OF PFJVNSYLVANIA Notarial Seal BB>sy Beunhart, Notary Pt~ic North Cornwal Twp.. t_ebanon County My Commission Expires Jan. 27, 2010 COMMONWEALTH OF PENNSYLVANIA) Cv-M~2,t-~O ) SS COUNTY OF P£~Y ) We , ~~~ ~ ~ ~ S'"'~0 ~l`~ and ~t l~~l ~~ ~'i~~~ , the witnesses whose names are signed to the attached! or foregoing instrument, being duly qualified according to law, ~c depose an~~ say tha:.~ we were preser:t and saw testatrix =-igr~ Slid C-X~;..:1:~= _ L:~ i_. .:j:' _~iT~I:~. ~i~; i ~ _. ~G:.~.. .,~_..i; t~t::.t;' ~G'i4~i~ ~~. Knowlton signed willingly and tt~~at she executed i` as h.er free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the will as witnesses; and~that to the best of our knowledge the testatrix was at the time 18 or more years of age, of sound mind and ender no constraint or undue influence. _~,,c~. c~dah,,~--_ R. SCOTT CRAMER Attorney at Law 5. S. Market St. P.O. Box 159 Duncannon,PA 17020 SWORN or affirmed to and subscribed t o before me b y ~~~ (~ S-~-p~,`-~ _ th~.s a~ da ~ of (~-~~~ - 2008 . '\ COMMONWEALTH OF PENNSYLVANIA Notarial Seal ~7/ Barnhart, Notary Public North CorrwvaN Twp.. Lebanon Cotrriy NIA/ Oorm>ission Expires ,lan. 27, 2010 Member, Pennsyivz~ta Hssaaiatton of Notaries