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05-09-11
1505610105 REV-1500 Ex `°2.11' `~' ~ nns lvania OFFICIAL USE ONLY PA Department of Revenue pe Y County Code Year File Number Bureau of Individual Taxes ~oMTMENT~aE~~E PO BOX 2$0601 INHERITANCE TAX RETURN ,~ ~ ~~~ Harrisbur , PA r71z8-o6o1 RESIDENT DECEDENT ~~, ~ I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYI' 201-16-4635 02/26/2011 02/28/1925 Decedent's Last Name Suffix Decedent's First Name MI Black Dorothy F (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum O 2. Supplemental Retum O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest. Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) ~ 6. Decedent Died Te:~tate O 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THiS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number r~ _ s ~ { ;: Steven Black (717) 528-8989 1. _ .-~ T _,~ ,_v .. , , _.... First Line of Address 225 Rupp Rd. Second Line of Address City or Post Office Gettysburg Correspondent's a-mail address: State ZIP Code PA 17325 REGISTER OF f S- NLY :$~ i .~ t ~, , _~ ~a =r7 _. _7 -... ` .- J "l>> .. `r 4 DATE FILED Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, rrect and complete. Declaration o reparer othe than the personal representative is based on all information of which preparer has any knowledge. SIGN OF PERSON ONSIB FILI RETURN DATE -' ~;, 05/08/2011 ADD ESS ` 225 Rupp Rd., Gettysburg, PA 17325 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE: ADDRESS PLEASE USE OR161NAL FORM ONLY Side 1 1505E~10105 1505610105 ~..., i;,,=_~~ (_ .~ ~_ i _ _.r --~ . _~_~ - __ .~ J W .~` ~~~ y Y 7 1505610205 ~~ REV-150() EX (FI) Decedent's Social Security Number Decedent's Name: glaCk, Dorothy 201-16-4635 RECAPITULATION 1. Real Estate (Schecule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) .................................... ... 2. 3. Closely Held Corpc-ration, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 4. Mortgages and Noises Receivable (Schedule D) ........................ ... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 17,282.31 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 681 101 33 (Schedule G) O Separate Billing Requested..... ... 7. . , 8. ( 9 ) .......................... Total Gross Assets total Lines 1 throw h 7 ... 8. 118,963.64 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 5,746.43 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 1,669.82 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 7,416.25 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 111,547.39 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subjeclt to Tax (Line 12 minus Line 13) ..................... ... 14. 1 ~ 1,547.39 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 45 111,547.39 16. 5,019.63 17. Amount of Line 14 taxable at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate }:.15 18. 19. TAX DUE ...... ............................................... ... 19. 5,019.63 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505E~10205 1505610205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: Dorothy F. Black _ _ __ _ _ - __ STREET ADDRESS 6969 Wertzville Rd. _ __ _ _ ______ _ __ _ _ CITY STATE. ZIP Enola PA 17325 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) _ _ 5,019.63 2. CreditslPayments A. Prior Payments ___ ___ __ B. Discount 250.98 Total Credits (A + B) (2) __ 250.98 3. Interest (3) _ _ 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. i Fill in oval on Page 2, Line 20 to request a refund. (4) _ ___ 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) _ _ 4,768.65 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 rew;rsionary 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 c-wn 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, ar 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 ar adoption. REV-1508 EX+ (ii-io} ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt~1LE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUM6ER: Black, Dorothy F. __ Include the proceeds of litigation and the date the proceeds were received by the estate. Ail 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. 1r.-~ , . ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Black, Dorothy F. __ _ 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 NUMBER DESCRIPTION OF PROPERTY INCL;IDE T^IE NAME of THE TRANSFEREE, THEIR REUTt0N5HfP T6 DECEDENT AND THE LATE (?F TRANSFER. ATTACH A COPY of THE DEED FDR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLU5ION (IF APPIICAt~tE~ TAXABLE VALUE 1. ANianz Lice Insurance I:o. of PI. America, PO Box 5'9064, Mtk-neapotis, trAN 92,277.05 100 92,217.05 55459-0060 pot~cy #70447943 2. Charter Schwab, 211 MAain Si~, San Franircv, CA 94105 account # 9,404.28 100 9;4(?4.28 7157-7614 i 1 1 I I { a I I ~ i, ~_..._ ~ ~ 101,681.33 TOTAL (Also enter on Line 7, Recapituiation~~_~ If more space is needed, use additional sheets of paper of the same size. ~ Pennsylvania DEPRRTMENT df REVENUE INH€RITANCE TAX RETURN RESIDENT DECEDENT sc~EDU~E H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS - -. ESTATE OF FILE NUMBER Black, Dorothy f. __ _ ---- Decedent's debts must be reported on Schedule I. ITEM ._... _.._..___.._._.____.._._.. ________~.__._._~__._. ____ PLUMBER DESCRIPTIQN P.MOUNT A. FUNERAL EXPENSES: i. Ricl-ardson Funsrat Hc>:ne trtc, 29 S. Er~ola Dr., Enda, PA 17025 4,041,77 2. R l~~ Gam, 6701,1~fr Rd, Frg, PA 17112 932.85 3. Fine Nbrmtain, 6476 Carte F~dce, M~a~tiscburg, PA 17050 (expense of wake) 255.40 B. ~! ADMINISTR.ATIVE CASTS: 1. I Personal Representative Commissions: Name(s) of Personal Representative(s) i 1 Street Address i City Slate Years; Commission Paid: 2• ~ Attarrtey Fees: 3. Family Exemption: (If decedent`s address is nat the same as claimant's, attach explanation.) Claimant Street Address City State ~ Relationship of Claimant to Decedent 4. ~ Probate Fees 5. ( Accountant Fees; 5, ~ Tax Return Preparer Fees: ?~ ~ Curd CauMy tsw.lOUrr~l, 32 S. Be~Ord St, Carlisle, PA 17013 s. I Paxtar>g Herald, 4910 Earl ik., Harrisburg, PA 17112 s. Materials to finals property ~a. Ccsts !~ p'e pity 1cr sale i'IP SIP TOTAL (Also enter on Line 9, Recapitulation) ~ If more space is needed, use additional sheets of paper of the same size. 9c~.50 75.00 48.00 x5.91 237.Oo 5,746.43 SCHEDULE I ~ pennsylvarna afPA~;~E~F ~~ fzE~.~~~4~~ DEBTS OF DECEDENT, ~~~;~at~rir~€ ,n;~ R~rc~^,~ MORTGAGE LIABILITIES 8c !TENS n€SLDE(ti i iJ~~~v~id ESTATE QF FILE NUMBER 61~dc, gamy F. ~ _.! Report det-ts incurred hlt the decedent prior to death that remained unpaid at the date of death, inchEding unreimbursed medical expenses. ITEM lialllE AT t1ATE ~lUMSE~i --...____._--- DE5~:RIPTf~N ~-- OF DEATH -- ~. €~ ~ Har~bu ~ I~T9(f Grayson Rci Hamsburg PA ~~~~~ ~ 200 a~ ~. 3. 4. ~. 6. T. 8. 9. t©. 11. ~ -, , lung, l~Ixrta ~ Sled , PC, 4497 S. fhreerf ~,, York, PA 174x3-3852 a~nt.# 3723a Try ~ Wash, 6465 Carte , ~-, ~~ 1705 Fug S NafwKxk, US Sfe~ Tower, 3ath t4r., 60a Grant St., Pittsburgh, PA aa~unt # 717-766.679a cwt (cabled, a~ot,rrt # a95472a7a~a1-7 Ka4hryr+ M. Franz: Nt.d., Susquehars~a l Me~cine, Cant ice, PA 17x11 PPI, 827 H~ Rd., ~t~, PA 'f81a4-9392 aorACmt # 5f~a-750x2 AA~t F~ Services, PC3 Box 45x49, Vlf~rorf, ©E 48886-5x49 accarrr4 # 5329a58Q245779a1 ~~ Auotive Inc., 522a E. Triru~e ~., AAecic~twrg, Pa ~ IQ55 QVC,12a(l Wilson t?r., Stucco Paslc, West Chester, PA 1938a r # 4646tI483 PEBTF,15a S. 4;ird St., Suite 1, Harrisburg, PA 17'[14-57aa oaf # 2a11fi4635 43.0 42.3 94.4 3 s.24 99.00 27.43 1,027.45 44.26 31.41 52.24 TaTAL ;Afs~ enter on Lsne 1~, Recapitu~atian'} ~ ~ '~ .06q.82 if mare space is needed, insert additianai sheets of the same size. ~'i= p~nns~~vania '~ REDUCE 3 DEPARTMENT ~']F REVEPtIJE ~~~E T~ ~,~~ ~ENE~~IARIES ~~~rr oaceae~rr ESTATE Qf: FIlE NUMBER: Btac~c, Doro#hy F. REIATi(~iSHiR Tb C3ECEbENT AM{~UM1' OR SHARE Nl~tBE#t DAME AND At~RE.SS OF P~SON(S} RbCEFViNG PROPERTY Do Nit L~ Tre~ee(s) OF ESTATE I TAXRSLE DISTRIBUTIONS (Intlt~e atttrigt~t s~ssa! distributions and transfers under Ste. 9116 {aJ (i.~).j 1. ~ Biat~t Sant ~ O~°1o ENTER €}O1.LAR ANQft~iTS FOR t1ISTitISUTIO~tS SNQi~F~t ABOVE ON LIDS 15 TiiRtRIGN I8 (3F REV-15U0 COVE€t SF{EET, AS ARRROPRIATE. II Nt3~1-TAXABLE t1iSTItiBUFIQ~tS A. SPOUSAL DISTRiIBUTIONS UNDER SECTION 9113 FtNt WHICH AN ELECTI(N~i TO TAX IS NOT TAitEN: 1. B. CHl4RITl49LE ANL~ GOV~tNMENTAL t?ISTRIBU'fIONS: 1. TOTAL t?F PART' II -ENTER TOTAL NON TAXABLE DISTRIQtITIONS ON LINE 13 OF REV-150Q COVER SHEET. ~ $ if msxe space is needed, use addRional sheets Qf pager oI the same size. ~~ ~~~~ f~ -ACCOUNT N0. ACCOUNT TYPE 10458530 RELATIONSHIP CHECKING WITH INTEREST STATEMENT.PERIOD PAGE FE8.12-MAR.11,2011 1 OF 2 00 0 06121M NM 017 44615 DOROTHY F BLACK STEVEN D BLACK 225 RUPP RD GETTYSBURG PA 17325 INTEREST EARNED FOR STATEMENT PERIOD 0.05 SUMMERDALE PLAZA INTEREST PAID YEAR TO DATE 0.27 A('f`f1i1NT CIIMMARV SEGZNNING BALANCE DEPpS~TS & OTHER ADDITIONS - - - - - CHECKS PAID OTHER SUBTRACTIONS CURRENT INTEREST PD ENpxNG BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 11,267.69 1 5,005.00 12 12,738.28 2 823.64 0.05 2,710.82 Ar`f`(IIIAIT of TT~ITTV PASTING DATE TRANSACTION DESCRIPTION` D~POSZTS,INTEREST ~ OTHER ADDITIONS :CHECKS $ OTHER" SUBTRACTIONS- DAILY BALANCE 02-12-11 BEGINNING BALANCE 511,267.69 02-14-11 CHECK. NUMBER 2567 331.98 02-14-11 CHECK NUMBER 2569 85.00 10,850.71. 02-15-11 CHECK NUMBER 2565 10.00 10,840.71 02-16-11 FIA CardServices CHECK PYMT 000000000002566 771.40 10,069.31. 02-25-11 DEPOSIT 5,005.00 15,074.31 02-28-11 CHECK NUMBER 2572: 7,026.00 02-28-11 CHECK NUMBER 2570 88.87 7,959.44 03-02-11 CHECK NUMBER 2571. 932.85 7,026.59 03-04-11 CHECK NUMBER 2574 4,041.77 03-04-11 CHECK NUMBER 2573 75.50 2,909.32 03-07-11 PEBTF RETIREE DEBITS 52.24 03-07-11 CHECK NUMBER 2575 44.26 2,812.82 03-11-11 INTEREST PAYMENT 0.05 03°11-11 CHECK NUMBER 257b~ 66.38 03-11-11 CHECK NUMBER 2577' 27.43 03-11-11 CHECK NUMBER 2578 8.24 2,710.82 ENDING BALANCE 52,710.82 _. CHECKS PAID SUMMARY 2565 02-15-11 10.00 2567* 02-14-11 331.98 2569 02-14-11 85.00 2570 02-28-11 88.87 2571 03-02-11 932.85 2572 02-28-11 7,026.00 2573 03-04-11 75.50 2574 03-04-11 4,041.77 2575 03-07-11 44.26 2576 03-11-11 66.38 2577 03-11-11 27.43 2578 03-11-11 8.24 ANNUAL PERCENTAGE YIELD EARNED = 0.00 L008A (6/07) ~_ :i i i ooooa 4oiooo„ a cEft ~ TE` I~iNIN'PVIP~I~I~d~1Pf~I~~PPVPPlnfAlil~Y~i~V~l~l~~~~%%Y1ae01 ~93,3gDL~~ SDD~~9~-DD1 1G~~~52~~XX~,~,~~~~ VEHICLE IDENTIFICATION NUMBER ~~~ BODV TYPE I DUP SEAT CAP p;4TE PA TITLED J DATE OF ISSUE ~~ ~ ~t~!~Y~t~~ YEAR .MAKE QJF VEHICLE ~! ~+~+J~~'9 PRIOR TITLE STATE I ODOM, PROCDlDATE UNLADEN WEIGHT I GVWR 5~3~~73~b],D~, ~L TITLE NUMBER ODOM. MILES ODOM. STATUS GCV'IR I "TITLE BRANDS ~~; ODOMETER STATUS. f 0 =ACTUAL MILEAGE ' ~ t =MIL'EAG'E EXCEEDS THE~,iefEGH.1NiCAL Z LIh11TS $ 2 =NOT THE ACTUAL'MII,EAGE ~ $ - ~ ~ 3 =NOT THE AC'iUAL MILEAGE-C~i~Ot,.4ETER TAMPERING vERIFIED 4 =EXEMPT FROM OpOPAETER DISCLOSl1RE 'j j 7 P, ~ I 1; -REGISTERED OWNE}a(S) ~ ,r ~ , _ ~ ~ TITLE BRAIVD5 A =ANTIQUEVEHICLE EHICLE C 1 ~': I~ ~ ~ ~' ~ i' ~ ~$~ ,~, ~ ~ ' ~ . - ~~~~„~ ~ V C =CLASSI D =COLLECTIBLE i~EhiIOLE F =OUT OF COUNTR ! - is kl , ~~~ ~~~~~~~~~~ ~~ q G =ORIGINALLYMFCD FORNON-US DISTAIBLIrION {: { >; ry N =AGRICULTURAL VEHICLE ti ~ ~ ~~ ~ ~ ~ ~~I~ ~ ~ L =LOGGING VEHICLE, ~~ I I' P = IS>tNAS PPOLICE VEHICLE r ~ R =RECONSTRUCTED ROD " EE k T' S = STR T =RECOVERED THEFT VEl-IkLE - V =VEHICLE CONTAINS REISSUED VIPJ « i ~.\ ' ! 1 -~.{ ia, qi"ar^^.~~~~{"t t:1-'~ 1 ~ i_i 'T w.e ,. 7°a El..+' i ~i > t _ t' ' i_'..+' !; 4V=FLOODVEj-IfCLE X =. ISlWAS A TAXI "~ # FIRST.LIEN FAV~f~„~; tr_~i~ ~ i p`y,',' ) t ;~~c tiL SEr'OND LIEN FAVOR OF' ~. i s, -`*~r"4 f=' 1;=~~-tiL , ~ *`~. er T~,i/`.~, ~i~,=~ 1~ ~'-~' ,~ - 1 ~+° ~°' ~I + ~~~ If a seGpnd lienholder is listed upon satisfaction 'oi the trst lien, the first penholder must forward this Title ?o the Bureau df Motor Vehicles with the ;. _ FIRST LIEN RELEASED DATE appropriate form and fee. l ; ~'- ~ ~ ~ ' IEN RELEASED ND I I ~ j..~f_,.z_..: /V 1. E_ BY ~ RIZED REPRESENTATIVE F AU L SECO - DATE S ~ ` L t~AA1LiNG ADDRESS BY 7 r' AUTHORIZED REPRESENTATIVE ,{r_ r. ~; .~ , ~~, ~; ~, ~~ ~7? ~ ceniiy as of the date of issue, the official records of the Pennsylvania Department {~;'~ of Transpor'taHon reflect that theperson(s) or company named herein is the lawful owner ifs oi.the'said vehicle. a~ t ~' ~IIVh41 ~' ~ ~ If a co-purehaser'othe~ than your spouse is listed 'and you want the title tp xSUBSCRis1~u~, D SvllflRtJ ~ --~ ~ ~ be .listed as "Joint Tenants With PoghY of Survivorship ~(On death of one a: ~ ~T~"$EFOR~iIi El < ~~~I t ,~~~~~ ; , ~ 1 ~ Mo",~, 1 ~av / ' vEnR~ ~ nwner title ;goes to~surviving ownet.) GNECK HERE C7. Ofh~r^tise, the +itle .•• ' well be issued as "Tenants in Common" (On-death of one oN n r InterPSt C;f e ,'~ I ~~J ~ ~ ~ ~,~, 3 deceased owner goes to hislher heirs or estate)- :y~. e~ ~. ii ~ SIGNATURE OF N?.EFSON AbM1111tJ:I~RING~OAT~~"'' ~i ~ i A~ A A~~] ^C a i 1ST LIFN DATE: ~ IF NO LIEN. C,tiEGK ~ - i -~OT~~~A1 cr~ I 1ST LIENHOLDEP 1 ~ ' - ~d PAULA K. SMITI, NOTARY PUBLIC sTREET 5l1_~'ER ~!'AING 7WP, CUMB~RLANO coUMY ! CIfY ~', ~ sTA ! ., SIP i~9Y OOf~Ml5S10N EXPIAI=S FEBRUARY 3, 2Qt2 _ --- ~~ { FINANCIAL INSTI"1"UTION NUMBER 2ND LIEN DATE: -~ IF NO LIEN. G PECK ~J ~^ Thr- ~ iF-r Bred i~ergby makes application for Gertilicale of TIIIe to the vef,icia describes} !-- ,. /^°'~ eb~;-~ ~i,~r_i ?o !h~ oncumbrances and ~Iher lepalclnlmsset lonh here. l 2ND LIENHOLD6R ~~ f ' STREET --- ~~ --- --- ,~ ~.._ ~~2-~ ,NA'fU~~PLI ANTH'JFI tiN I P (dy_,*~~,! 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U 1 3ljr1lltld-._dIHSli3NM0 d0 Fi3dSNbFil 3Hl H11M N01103NN00 NI 3:7F/3HIW 3H1 31b1S nO/~ -1bHl~ 3dl(103H- SMb"1 ~ 31b1S ONb lbti3O3d 1 V I ICJ ! 1/ 1 (esaa ~o~ a~ofyan aye 6uip~oy ~a(eap paaa~sf6a,l e sf aaseyoand aye ssa(un `s~(ep 0z uiq~iM papiwgns aq ;snw a~7l1 {o ateoi~i}~a~ (1Nltid a0 3d.11) Erie®I nsu rance Group 100 Erie Ins. PI Erie, PA 16530 ESTATE OF DOROTHY F BLACK 6969 WERTZVILLE RD ENOLA PA 17025 NOTICE OF PREMIUM REFUND DP164G 1101 DATE MO. DAY YR. 04 18 11 REFUND AMOUNT $1 O8 . OO POLICY NUMBE R QO6 0502413 H AGENT NO. AA7605 AGENT'S NAME FARNHAM INSURANCE AGY REASON 1 REF. No. A584494 CHECK No. 01584494 AA7605 NON-NEGOTIABLE Allianz Life Insurance Company of North America PO Box 59060 Minneapolis, MN 55459-006() 800.950.1962 March 2, 2011 STEVEN BLACK 225 RUPP RD GETTYSBURG PA 17325 Re: Annuity Policy Number 70447943 Dear Beneficiary: Allianz ili We sent you this letter because you are the named beneficiary of Dorothy Black. Please accept our sincere sympathy on your loss. Listed below is information needed to file a claim for benefits on the fixed annuity contract(s). Refer to the enclosed brochure for answers to our most frequently asked questions. Payment Options Choose one of the options iri Section IV on the claim form. Contract Information Contract Number Annuitization Minimum Payout Cash Qualified or Value Period Value Nonqualified 70447943 $123,053.41 5 years $92,277.05 Non Qualified Policy values are affected by withdrawals, partial surrenders, loans, and market value adjustments; as a result, values quoted in this /efter may increase or decrease and are not guaranteed. Claim Requirements • Copy of the certified death certificate (only one copy is required for the deceased) • Fixed Annuity Claim Form Once we receive your claim requirements, allow 15 business days for processing. If you have any questions, feel free to call us at 800.950.1962. Annuity Claims Allianz Life Insurance Company of North America c: Cohen, Lawrence B _`\ LCL-1005 Rev. 7/26/10 R SCHWAB Account Statement Retain for Your Records Contributory IRA Statement Period: March 1, 2011 to March 31, 2011 Account Number: 7157-7614 Page 1 of 3 _ __ _ ., ___ _ _ _ __ Last Statement: February 28, 2011 Cui paper clutter. Switch to eStatements at schwab.com/paperless. Questions? Call i-800-435-4000 Banking Inquiries: Call 1-800-435-4000 31/03-PN3M2101-008797-SML-1 70251 03900 3364 1 '1-2 DOROTHY F BLACK CHARLES SCHWAB & CO INC CUST IRA CONTRIBUTORI' 6969 WERTZVILLE RD ENOLA PA 17025-1039 Account Value Summary ---- o ----- o ~~ ~ .~~ J c0 ~~~ v Cash & Sweep Money Market Funds $ 0.00 Total Investments Long $ 0.00 Total Investments Short $ 0.00 Total Account Value $ 0.00 Transaction Detail Change in Account Value Starting Account Value $ 9,507.75 Transactions 8 Income $ (9,404.28) Income Reinvested $ 0.00 Change in Value of Investments $ (103.47 Ending Account Value $ 0.00 Year-to-Date Change in Value Since 1/1/11 $ (15.,283.20) Rate Summary Dep- Accounts: Interest rate as of 03/31 Z 0.01 Value Adv Money Fd SWVXX 0.01 Sch Investor Money Fund 0.01% Settle Trade Date Date Transaction Description Quantity Price Total Cash, Money Market, and Deposit Accounts Activity 03/28 03/28 Journaled Funds JOTRANSFR 7088241687 (195.96) Investments Activity 03/28 03/28 Journaled Shares AMANA INCOME FUND: AMANX (39.1680) 32.$900 03/28 03/28 Journaled Shares MUTUAL BEACON FUND CL C: (627.0850) 12.6300 TEMEX Please see "Endnotes For Your Account" section for an explanation of the endnote codes and symbols on this statement. SIPC has taken the position that it will not cover the balances held in your deposit accounts maintained under programs like our Bank Deposit feature or Insured Bank Network feature. Please see your Cash Feature Disclosure Statement for more information on insurance coverage. wvi wi vv e,ao~vvvalo \ytSGV WVW GV'VVVG 4JJ Baia ady~dw !Id/\JdJdA J{ypl,l ~~V ~u~ uJ a+ ueM4~S sa~aey~ OGOZOO ;uauaa;e;s siy; uo s~ogcu.Ts pue sapoo a;oupua ay;;o uo~;eue/dxa ue ao; uor;oas „;uncooy ~no,~ ~o~ sa;oupu~„ aas as~a;d Jw}~J~uoJ;esuedwoo/nnaJn,rano~noge/woo~geauJosanoge//:d~~y o~ a6 `sania~;uasaada.r sai s~(ed geMyos nnoy uo uon~iu~o;iri ao~ ~poJ~ad ~uawa~e}S ..io~.id aya w paruooe ~eql ~saaa;uJ apnJauJ ~(ew pied ;sa~aluJ ayl pied si ;saaalui .!a~~e puJ.aad ~uawa~e~s aye 6uJ.rnp pan~ooe aney Sew ~~~;~ ~saaaiuJ ~(ue apnJouJ ~©u op seoueJeq ~Juefl ~a6ed r(~Ji.t~:;d s;unoooy 11soda. p aq~ uo paaeolpul se pled ~Jup-~t gennyos saJ~ey~ aer.J~ ~saaa~uJ ~(ue zpnpuJ saoueJ~;q ~ue~ ~poJaad aua!.va}ti~S auk wo.r; saaJJ:~p ~e~R poJaad U .roj pled sJ;saaaauJ auk fey} a;ou ase?Id 7 ~~IQ~ .aaqu!a!u `~{ue8 9eM4oS sa~.!ey~ le P1~31I saouc~s0 X --- __~. _~~ _.._.._., -^-. _._.__~._ ~~-------- __-_ pu~~ha~ aloupts3 /agcu~t ~uno~~~r .~noh ~o~ sa;oupu3 04"900`9 00'0 p0'9ZE 00'OLl` L 0(3'009`9 lelol area a~ aeaA 00"500`5 00"0 oo~5zs 00"OL l` G Oo~o~S`s ~ewaoN )unaurd )aN s u~e3 pla4y#!/Ii1 pla4y)-M )unowd ssoa~ xel a~e~S ~1 Isaapa~ ~aewwnS uoi~ngia3SiQ a~eu o~ aeaA ~. e{'~ r .ees~~ ! R.e 00'0 00'0 lelol abed o} aeaA 00 0 00"0 .~ ~ del Ieruoi~ip~;al llnZ OLOZ _ __ _ _.. ,~,~eu~wrS uos~ngi.i~uo~ ,~ ~61/5l/60 - ll.i9l/ZO snm pouad;saia;ur,rnvra '%10~p seen ;~;~~p;o se a;~~;sa.~a;u~ .s;un~~ooy;!sod~p 00'0 = ~,xaaueleS fiwpu3 00'0 96'966 Ailnl;ad lelol 96"56l ~Jba~~IU~B Gl a~~SNdal ~iNdB as;sueal o~ny 6Z/~0 ~!sodaa !ennerpy~!M ~.. ~ uo!;d!aosa~ uo!~oesuaal a~~q sue,~l 96'96L ~ Z,Xaauele9 Guiuadp g ~o Z afied 6lOZ `6£ yaaew o~ 660Z `6 yaaey~ :polaad 6uawa6e6S spaooa~ ano,~ ao; uie~ad ~.uauaa~.a~.s ~uno~~y F~Ihi~~d s~viio~ab ~Isodaa ~~uee ge~lyaS salaeq~ t~69L-L961 :aagwnN aunoaa~r dal ~aoinglaluo~ g~MH~S ~w 29 SOUTH ENOLA DRIVE ~tiC~Qr(,I~On ~u~eYQ~ ~01~e~ ~ N,C. ENOLA, PA^17025 (717) r32-0581 AlICHAEL G. MURRAY RVISOR STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED SUPS Charges arc cnly for those items that you selected or that are required. If we arc required by law or by a cemetery or crematory to use any items, we will explain in writing below. ' If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you elected arran ements such as a direct crema~Jon or immediate burial. If we chuged for embalming, we ll ex.~la`in w blow. For the Service of ~~ ~'~~~ 7 t[~`4~~ Date of Death ~n-'~`" ~~ b~~ Charge to: -c~~-~-'-~ d!t [.L , ~'~ c~ ' /' N.d.-1 Name Ad ress City A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES L Services of Funeral DirectorlStaff .... ~`~ ; Embalming ...................... E f ~G~ Other preparation of body ' ~ t G 4 i ' : ~ ~ ~ )) r'. %~ ` ~ [ Jf': , ~r 1, SUB-TOTAL OF PROFESSIONAL SERVICES......... Al i 2. FACILITIES AND SERVICES Use of facilities and services for viewing (Visitation/Wake)......... Use of facilities and services ~~. ~~ for funeral ceremony ............ f.~L_[.~ Use of facilities and services for Memorial Service ............... f Use of equipment and services for graveside service ............. f Other use of facilities ............................... f SUB-TOTAL OF FACILITIES/EQUIPMENT ........... A2 i AUTOMOTIVE EQUIPMENT Vehicle [o transfer remains to Funeral Ho~m '• ~ U Local ..................... ...... f' i Hearse (Casket Coach) ' v ~ . Local ........... .......... . ...... Limousine Local ........... .......... ...... f Family car Local ........... ......... ...... f Flower car or floral disposition Local ........... ......... ...... f Lead carlclergy car ~, /v Local ........... ............... Tf~ Car for pallbearers Local ....... ................... f Out of town transportuion ......... f Other clothing Cremation urn .................. . (Description) OTHER f ` TOTAL MERCHANDISE SELECTED .................. B f ` ~ ' ~~ C. SPECIAL CHARGES: Forwuding of remains to f (Funeral Home) Receiving of remains from f (Funeral Home) Immediate Burial ................. f Direct Cremation ................. f SUB-TOTAL OF SPECIAL CHARGES . ............... C f D. CASH ADVANCED Opening Grave ................. ,~~~ . f~~"-w Cemetery Equipment ............. . f Lot and Deed ................... . f~ Newspaper Notices-Local ........ . f Newspaper Notices-Out-of-town ... . f/ ~.~i , Telephone & Telegrams .......... . f Airfare ........................ . f - _ Clergy/Mass Offering ............. ~ . f --L ~ `~ Pallbeuers ..................... . f Certified Copies of the Death Certificate ..................... . f~i?/L Police Escort ................... . f Flowers ...................... f Vault Scrvicc Charge ............. . ~'~ f ~ ~/v .sI -~ 't f f f f ~} 7 SUB-TOTAL OF ADVANCES ....................... D f~` / J SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 f We charge you for our services in obtaining: TOTAL OF PROFESSIONAL SERVICES (specfjy cash advances that are marked-up) FACILITIES AND AUTOMOTIVE 7 EQUIPMENT ................................... A , ~.• SUMMARY OF CHARGES B. CHARGE FOR MERCHANDISE SELECTED: A . Professional Services, Facilities and Casket .......................... f Equipment, and Automotive (Description) Equipment .................... 7 4"~ .. ~ i n B. Merchandise ..................... f ~ Other Receptacle ................. f C . Special Charges .................. f (Description) D. Cash Advances ................... f ~ 7 ~ TOTAL OF ALL SECTIONS ........................ f Outer burial container ............. f PAID AT TIME OF OR PRIOR TO f /S J ~ ~, ARRANGEMENTS (Description) ................................ -+ BALANCE DUE........ ~..d`~:%.c.-~. !Y.~ ~~....... f_~ o~~ Acknowledgement cards ........... f ~~ ~ `' REASON FOR EMBALMING ~ ~ "~ ~•~' ~'7 v Register book(s) .................. f =~ ~ G `'~ -----'G~~ y~~y(7 } Memor • folders .................. fv ~ If any law, ceme , or crem ry requirements ave required the purchase Prayer cards ..................... f of any of the 't s listed above the law or, requirement is explained below. Temporary grave marker ........... f Burial clothing ......... f `" I agree that 1 have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I acknowledge ~~ receipt of a cop} of this Starement of Funeral Goods and Services Selected. 1 represent that I have sufficient funds available for payment of the cash price for the goods and sen•ices selected I also agree to ake payment off ~ within e e days. I agree to be jointly and severally liable with anyone else who I ~ 1 signs below. A late charge of ' ` per month amounting to _ per year will be applied to the unpaid balance beginning days3 " from the date of this agreement. I will also pay to the Funeral Director all reaso ab a costs paid by the Funeral Director to collect amounts I owe under t is agreement. 6 Those costs may i dude attorne s' fees, court costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreement will he consider tt 'this aet and a cost thereof will be reflected on the final bill or statement. /_ ~ ~ ~ ~ ~ (Seal). 1~ _ ~/ s o (Purchaser) (Seal) ' (Purchaser) (Licensed Funeral hector) C Pcnnsylv~ni~ Funeral Directors ~ssocistian WHITE Funeral Director YELLOW Funeral Dire or form - 600 Revised 4/94 Customer Statement Blue Ridge Mem'1 Garden;> 6701 Jonestown Road Harrisburg, PA 17112 ~~i~~~~~i~~~~~~~~i~~~~~~~~ n i~~~~i~n~~~~~~~~~~~~~i~~i~i~~~~~~~ DOROTHY BLACK 6 6969 Wentzville Rd Enola PA 17025-1039 Account # Statement Date: Balance: Last Payment Date Payment Amount: Past Due Amount: Due Date: 498 2600314 02/ 11 /2011 1313.41 O 1 /20/2011 69.21 0.00 03/01/2011 ~ ~~~~~ Credit Office Toll Free: (877)857-8892 Location Office (717)545-5382 wv,~w. BlueRidgeMemorial.com Thanl~ You for handling your account in a professional manner. You've already pre-arranged your cemetery space, so why not complete the planning process by pre-arranging your Vault Opening and Closing. ? ~~~ ~~ Respond by March 15, 2011 and you'll receive 12 months interest free financing. ~_G-~ )/ ~. 'q ~~ ~Y~ ~ ~ 1 ~ M z (/' 7- i "To help families memorialize every life with dignity" Retain this portion for your records 1 LN BEVERAGE 2.09 1 COKE 1 LN BEVER'AGE 2.09 1 COKE 1 LN BEVER'AGE 2.09 1 LUKE 1 LN BEVERAGE 2.U9 1 COKE 1 LN BEVERAGE 2.09 1 coKE 1 WATER N 1 WATER N 1 WATER N 1 WATER N 1 WATER N 1 WATER N 1 WATER N SUB `>U3.21 Sales fax 12.19 TOTAL :~' ~I ~ . ~~ CREDIT CRC) 215.40 CHANGE DUE 0.00 Items; (~ ~ ENTER 1=0~~ A CHANCE ~f0 WIN ~1U00 ~ ~ I_LAME 1' NODRIA GANAR X1000 CALL OUR SURVEY ~ ~ 1 -H00--936-51 53 Jo i r~ our eC 1 uk~ at ryai7s , cony ~ AND ~ Follov~ us are Facebook C * facek~ook.com/RyansBuffet 15;35 r03 3/03/11 NOW 5ERUl:NG BREAKFAST ON SAT & SUN FROM B TU 10;30 FOR ~~$$~~~~~~~ 4.99 ~$$~$$~$~~~~$ THANK YOU FOR CANING AT f~IRE MOUNTAIN. -~~_ raRC nn+ ~z,u~ 000e02465 6476 CARLISLE PIKE MECNANICSBURG, PA 17050 717-591-1791 Salt Clerk ID: 6499 ID: 002 Merchant IU: 000000080'L00 Bank ID: 1340 15:35:00 03~03i11 Batchp: 062001 Retrie~~al Ref u: 88901442 VISA Entry Method; S~iaed XXXXXXXXXXXX462Z Apar Code; 003368 Inu ~; 000050 dotal; ~ ~ 215.40 Customer Copy THANK YOU _~. ..~. ti~~ry~:IL 1 COKE 1 LN BEUERAGE 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEUERAGE 1 COKE 1 LN BEUERAGE 1 CCiKE 1 LN BEVERAGE 1 COKE 1 LN BEVERAGE 1 COI(E 1 LN BEUERAGE 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEUERA(E 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEVERAGE 1 COKE 1 LN BEVERAGE 1 COKE ~f~I:~': .90 90 52 1.09 2.09 2,09 2.09 2.09 2.09 2.09 2,09 1.09 2.09 2.09 2.09 . CI `) 2.09 1.09 2.09 ~\ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 2/28/2011 Cumberland County - Register~Of Wills Receipt Time: 09:32:19 One Courthouse Square Receipt No.: 1664628 Carlisle, PA 17613 BLACK DOROTHY F Estate File No.: 2011-00283 Paid By Remarks: STEVEN BLACK CJ Receipt Distrib ution ------ ------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20.00 00 15 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN WILL JCS FEE . 23..50 00 5 BUREAU OF RECEIPTS ~ CNTR CUMBERLAND COUNTY GENERAL M.D FUN AUTOMATION FEE SHORT CERTIFICATE . 12.00 CUMBERLAND COUNTY GENERAL FUN Check# 2573 $ 75.50 Total Received......... $ 75.50 ,~ ~~ ~~ , -' ~ ~ ~,J~ ~~./ V .~ ~' ~ ~~ ., ~l , '~ .. ,~ \, CUMBERLAND LAW JOURNAL .32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2663 April 15, 2011 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Steven D. Black Dorothy F. Black Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: April 1, April 8, and April 15, 2011 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director \, PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH. OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and. State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly t11e same as was printed in the regular editions and issues of the said Cumberland Law Jounlal on tl7e following dates, viz~~ April 1, April 8, and Aril 15, 2011 Affiant fiirther deposes that he is authorized to verify this statement by the Cumberland Law Jounlal., a legal periodical of general circulation, and that he is not interested in the subject matter of t:he aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. _.-~ Li Marie Coyne, Edi r SWORN TO AND SUBSCRIBED before me this 15 of April, 2011 Black, Dorothy F., deed. Late of the Township of Silver Spring. Executor: Steven D. Black, 225 Rupp Rd., Gettysburg, PA 17325. Attorney: None. Notary I`dO7ARIAl_ SFFtiI_ DEfiDRAH A (;OLLlNS Notary Public CARLISLC BORO1.lGH, CUMBERLAND COl1NTY tJly Commission Expires Apr .?.i:?, 7Q14 ^:.m!R4~~4^.n?~xn+i*.+++ s veers .~Id~eLL' - ,. 'ffiR..:.:. ~ ne rMw ~ ~n ne~cw~~a Fax (717) G57-3523 STATE OF PENNSYLVANIA COUNTY OF DAUPHIN Tha Pa~lon Herald • 4910 Eorl Drivn, Flarrishurg, FA 17112 • .5Jb~95aJ Office & Plant - (PO Box 6310) 101 Lincoln Street Harrisburg, PA 17112 PROOF OF PUBLICATION Before me, the subscriber, a Notary Public in and for the said County, personally came Lisa M~ Carnes who, being duly sworn, doth depose and say that she is CLERK of THE PAXTON HERALD, a newspaper of general circulation published in Harrisburg, Pzniisylvania; That THE PAXTON HERALD was established on the 28th day of June, 1960, and has been published continuously since that date; That the advertisement, of which a copy is attached hereto, was published in the advertising columns of THE PAXTON HERALll in all respects as ordered in the issue(s) of `';~ j ~°~,, ~-~ ~ F~;~ Affiant further deposes that she is not interested in the subject matter of the aforesaid notice or advertisement, and that the allegations in the foregoing statement as to the time, place and character of publication are hue. East Shore (717) 545-9540 (717) 545-8762 ESTATE NOTICE NOTICE IS HEREBY GIVEN that Letters of Testamentary in the estate of Dorothy F: Black, late of the Tov-inship of Silver Spring, County of Cumber- land, Commonwealth of Penn- sylvania (died on February 26, 2011), haying been granted to the undersigned, afl persons indebted to the said estate -are requested to make immediate payment and those having clams will present them with- out delay to: Steven D. Black Executor 225 Rupp Rd. Gettysburg, PA 17325 3-30, 4-6, 4-13 I (Signatu ~ of the Af pant) Sworn and subscribed before me this day of ~~ ~ r~ A.D. -----°°`' NO~'ARIAL SEAL DAVID P~t.~- OLDSTEI;~t, Notary Public City of Harrisburg, Dauphin County My Commission ExpirQS May 26, 2014 WE VALUE YOUR t1PTNION! WE WANT TO KNOW ABOUT YOUR SHOPPING EXPERIENCE TODAY AT WAL-MART. Please complete a survey about today's stare visit at: http~//www.survey.walmart,com You will need ttr eater the followins online: ID #, 7CNQOJNF6N3 ~~ IN RETURN FOR YOUR TIME YOU COULD RECEIVE ONE OF FIVE X1000 WALMART SNOPPING CARDS Must be 18 or older artid a lesal resident of the 50 US ar DC to enter. No purchase necessary to enter or win. To enter without purchase and for complete official rules vtsit www.entry.survey.walmart.com. Sweepstakes period ends on the data shown in the official rules. Survr~y must be taken within TWO weeks of today. Esta encuesta tambt$n se encuentra en espanol en la P$sina del lnternr~t THANK YOU .,~,~• W Save money. Live better. MANAGER STEVEN MYERS ( 717 ) 691 - 3150 ST# 1886 OP# 00000678 TE# 11 TR# 0(092 55G CONTR 008999402058 9.ii6 X PCKG TAPE 007535307841 1.U8 X BUBBLE WRAP 007535311832 17 . ~i4 X BUBBLE WRAP 00'7535311832 17 . ~(4 X SUBTOTAL 45 . t~2 TAX 1 6.000 x 2.'.5 TOTAL 48 .' ~7 VISA TEND X8.!,7 ACCOUNT ~ 9627 APPROVAL # 008788 TRANS ID - 0081067766424235 UALIDRTION - 5C9C PAYMENT SERUICE -- E CNANGE DUE # ITEM'S SOLD 4 WE VALUE YOUR OPINION! WE WRN•C TO KNOW ABOUT YOUR SHOPPING EXPERIENCE TODAY AT WAL-MART. Please corrrplete a survey about today's store visit at; httP://www.survey.walmart.com You will need to enter the followins online: TD #: 7CNPXNNF5BN IN RETURN FOR YOUR TIME YOU COULD RECEIVE ONE OF FIVE X1000 WALMART SHOPPING CARDS Must be 18 or older and a lesal resident of the 50 US or DC to enter. No purchase necessary to enter or win. To enter without purchase and for complete offictal rules visit www.entry.survey.walmart.com. Sweepstakes period ends on the date shown in the offictal rules. Survey must be taken wtthin TWO weeks of today. Esta encuesta tambl$n se encuentra en espanol en la p$stna del Internet THANK YOU ~ t ~ Save money. Live better. MANAGER STEVEN MYERS ~,~ (717)691-3150 ` ST# i886 OP# 00006123 TE# 22 TR# 02833 i}i~BBI_E WRAP 007535311832 17.44 X 55G CONTR 008999402058 9.86 X CNOC CANDY 004000040265 F 0.50 N DONUT 002056973780 F 2.50 0 1002 BENEFUL 0017$0010967 1.56 X 1002 BENEFUL 001780010764 1.56 X BPM RST TKY 001780010968 1.56 X BPM RST TKY 001780010968 1.56 X BPM CKN STEW 001780012861 1.56 X BPM CKN STEW 001780012861 1.56 X 1002 BENEFUL 001780010764 1.56 X 1002 BENEFUL 001780010967 1.56 X SUBTOTAL 42.78 TAX 1 6.000 x 2.39 T VT5A TEND 45.17 ACCOUNT # 9627 APPROVAL # 007988 TRANS ID -- 0281066563260019 O.uO pAYMENTTSERVTCE6P E CHANGE DUE 0.00 VIIINMI~IM~IIN~IW~I~I~I~MIIINI~V~NI~III~WI as*CUSTOMER COPYa** # ITEMS SOLD ~2 IIIIIIIIIVI~N~II~I~IIIIIIIIIIVIIIIIIWIIIIIIIIIIIIG~I~III *e*CUSTOMER COPYee* )ATE DESCRIPTION -ucher: 181540 118/11 Critical Care, First Ho X19/11 Subsequent Hospital Car X06/ 11 Commercial Insurance Pa 106/ 11 Commercial Insurance Ad X06/ 11 Commercial Insurance Tr is amount represents your deductible. Please alit payment. Ending Balance: cur prompt payment is greatly appreciated. l :~ ~~ ~~ .~. CHARGE PAYMENT/ADJ BALANCE $407.00 $210.00 $290.00 $284.00 $43.00 $43.00 BALANCE DUE: $43.00 Account Number: 37230 ** Due Upon Receipt ** Lung Asthma & Sleep Associates, PC 1497 S. Queen Street York PA 17403-3852 LASAPC01-0270321-0001 331-1 91 1 632-001-00000 7-#001362-0006 phone: 717/335-2021 IRS# 20-3192731 BASIC 0006 _~ m~c~hrai~Ii.~~hal_rr~y, F'fl ~~i z r-.. ~-~ ~ ~-~ a~r~ i iW~a~~~~ :~ U((~''•:~~~{{fi l y l~ /i~ yam/ c~ Y -- ~; Y ~ } {~1a tr' i ~~ i I~IC; 4~ Y ~;~ ~~ ~t~ 1 f r~e~ t ~~~ ~rl~a i 1. ±a l"r° i ~rlr~ 1 ~c~r•~w~~1~ii~ Y ~~ F~~ ~~ ~ ~~~ . c:: ~w~ rri tw ~ :I. ~~~ ~~~ ~t ~F ~ _~ r~ ~r a r, r.~ •l: ~~~ h~ e~-rY~ i rI r~ f r~~M~rri y~~~ I_~ [.:~ ~:.Y .~ ~~ a. Y I r ...~ MJ 1 Your Full Service Network Statement February 26, 2011 DOROTHY BLACK 6969 WERTZVILLE RD 225 RUPP RD GEi-1YSBURGH, PA 1;7325 I~~~III~~~I~~II~~~I~I~I~I~~~I~II Previous Balance ........................................................ 59.78 Payments ................................................................... 59.78 New Charges .............................................................. 66.38 Total Anent Due Datie Due $66.38 Mard~t 22, 2011 ~~. Fug ~ SERV/CrE Bill (Number: 8 Services provided by Full Service Network L. P. Customer Service: 1-888-347-6000 Repair Service: 1-888-327-9115 w~nnN. fullservioenetvwrk Dorn Got Friends? Refer your friends and family and receive $40! Call or visit our website for details Payment must be received on or before the indicated due date to avoid a 1.25% finance charge plus late fees. Far your records: .'f ~~,~~ ~ date Paid: _ ~% / ,; ~ ~' Check Number: _ ,/ ~~ ~ ~~ L ~ t` ~~' Amount: _ - ~~r ~~ ~ ~%~ _~ ~, Your Full Service Network Statement Apri126, 2011 DOROTHY BLACK 225 RUPP RD GETTYSBURG, PA 17325 I~~~III~~~I~~II~~~I~I~I~I~~~I~II Account Summary Previous Balance ........................................................ 72.72 Payments .................................................................... 0.00 Due Immediately,. ....................................................... 72.72 New Charges ............................................................ -44.67 Total Amount Due Datie Due $28.05 May 18, 2011 Payment must be received on or before the indicated due date to avoid a 1.25% finance charge plus late fees. For your records: Date Paid: ,~" s '<. ~~~'~~ Check Number: :~~,~-~~ Amount: ~"~~'~>~~' '~~ C,E FULL SERV/ n ~- r Bill Number: 10 Services provided by Full Service Network L.P. Customer Service: 1-888-34;7-6000 Repair Service: 1-888-327-9115 w~nn-.fullservic~networic com A Subsequent bill will be rendered if needed to collect charges, such as additional tolls or lost equipment. Got Friends? Refer your friends and family and receive $40! Call or visit our website far details t~c:asa, ComCast3 ~~,.:.r. Account Number Billing Date Total Amount Due Payment Due by 09547 20703fi-01-7 02/28/11 $8.24 03/25/ 11 Page 1 o f 2 ~, ~ ,~, Contact us L~~ www.comcast.com ,~~` 717-540-8900 ~~ ' .:_ . _ 1.:._ .. _4 ._ ~~.._ ~~~_._ . ~__ .~..~ ._. MS DOROTHY BLACK _... ~ ;; {~~~~~+~ ~~°~~~,~~~~_~~~~ ~~~~~~,~ ~ ~ .s,. ~~~4~~,~ ~~ ~. } n i ~ 1 ~~~ ~ i i .+.,a;d+~„1u3u;~„h y,~'. rff-~N'at~~,.~kwa~,~t~ti4~7+~~rk,~uL~e~ntuct..r,.u~.si~o4a.;~1~':~:;w~~~s~i.-;. ~E4' a~•-, ~,~~:'~'.-+:±!~ :{~~~''~,,~'+,: r; Previous Balance 77.25 For service at: Payments -received by 02/28/11 0.00 6969 WERTZVILLE RD ENQLA PA 17025-1039 New Charges -see below ~ -69.01. Total Amount Due $g,24 MOWS fC'OI'1'1 ~OI'YICaSt Payment Due b Y Q3/25/11 We regret losing you as one of our subscribers. Our records indicate that the final balance shown above is now due. Your prompt payment is appreciated. Any outstanding equipment must be returned to our office within 7 days. Please calf us at 1-800-COMCAST any time should you wish to reconnect your service. Hearing/Speech Impaired Call 711 ~~~~ f1 ;~~ aY xn K~ r w Jfi '~°~~ ' Zz+1u1 ~ia~'r~ i%r " ~ ~~ "~ ~ ,. rail :~. r~ 1t("hn .~~wT»k~r:~~i;ls~e~~+t~t~,~nad~~.fti ~. t~~.,r ~; > ~ :) ,: rY ~ i ~~ ~ 4~~iV?. sLr~mi~:.. l~i+~ :'~ ~~~~ Partial Month Charges & Credits -64.89 ' Effective 02/ 16/ 7 y, you made changes to your account. See the following pages for more details. ~ ~ ~-~ Taxes, Surcharges & Fees -4.12. o 4 Total New Charges -$69.01 ') ~ ' ~~~~.-~ ~ ~. ~~, ~~, .~ =- fig O O ~ ~ C c ~ O ~ ~ v o m N ~ o a ~~ o° ~~ rn cfl O bg O O ~ c ~ ~ ~ o O ~ N a C ~-. 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O O O ~- O O O O 518£-t-9L (LPL) ~ ~ ~OLt- dd 'll!H dwe~ ~ 805 a~!nS peon y~any~ aeldod 068 ~ au!~!paw leu~a}ul euueyanbsns 00'66$ 00'0$ 00'66$ (00'06$) 000$ 000$ 00'0$ 00601$ 000' 3~~~'z~~~'r~ 6 ;, ~,h 00'604$ 00'0$ 00'606$ (00601$) 00'0$ (~5"L$) (00'01$) 00'0$ 00'0$ 00'L$ 00' 1 00'0$ 00"L$ 00' 1 oo'ol$ 00'5£1$ 00'1 100'04$) 00'0$ (oo'ol$) oo'ol$ 00'0$ (0001$) (00'01$) 00'0$ 00'01$ (00'01$) 00'0$ (00' 15$) 00'0$ (00'6£6$) 00'0$ 00'OOZ$ 00' 1 r r",+ '~6!I!ge1l 3~811~f1Cl~Cl ano s;oa!~a~ }uawa;e~s'`s!yl ~ao!;ou s!y; ~o a;ep ay; woa} s~(ep pg u!y;!nn nog( ~(q pled a~ s;unowe ~,~l~f1Cl3Cl Ile pap!nad 'saoin~as ;uaoaa ~no~( ao; ;uawu6!sse ;daooe o paa~6e a y ann 'sueio!s~(yd 6u!}ed!o!}~ed sy 80b16Z# f~ aoue~nsu! wad Ja;sueal 80ti16Z# o!paw eu;ay wad }uaw~(ed aoue~nsu! 80b16Z# a~eo!paw eu}a wa};uaw;snfpy }uaw;snipe !e!o~awwo~ ~ ~(y;o~oa '~{oe18 wa} ;uaw~(ed ;ua!;ed 00'L$ a~n}oundiuan 00'L$ haw 006 0} do uiuaelegoooue~(~ Z6-8 o0'9b1$ n lanai Iles ao!~O aui ipayy ~eu~a;u~ euueyanbsng :uoi;e~o-7 8ZZ66b/aW z~uea~ u/V4~e~/1505£b)~loel9 ~ ~4;o~op 11C 11C 11C 11C 11C 11C 11C 8b189Z# aoue~nsu! wad as}sued OLC 8bL89Z# a~eo!pa eu;ay wo~~;uaw~(ed aaeo!paw O1C 6LbZ# ~ ~y;a '~{oe1e wo~~;uaw~(ed }ua!;ed O1C ~tedoo }ua!}ed o} anp ~a}sueal ~Lb016L# aouemsu! woad ~a~sueal O1C Lb016L# aaeo!paw a ay woa} }uaw~(ed a~eo!paW O1C ~L~016L a~eoipaW eu;ay woa} }uaw nfpy }uaw}snipe a~eo!paW O1C 00'OOZ$ ~}isuaQ auo8 O1C au!~!paw ~eu~a u! euueyanbsng :uo!;e~o~ ti9898£laW z~ue~~ W u/VUle~/ 05£ 4)~loel9 ~ l~y~oaoa ~~ PPL Electric Utilities Electric Service For: DOROTHY F BLACK 6969 WERTZVILLE RD ENOLA PA 17015 Final Bill Questions about this bill? Please contact us by Mar 23 at 1-500-342-5775 (1,800-DIA.L~PPL) or write to: ~~ Customer Service 827 Hausman Rd. Allentown, PA 18104-9392 www. ppl el ecti-i c. com Electric Use This graph shows your electric use over the last 13 months. Types of Meter Readings: Actual . Adjusted Estimated Customer L~ :, ~~ v .:, ~ d ~`~~~~~ ~ ~ Page 1 ~~ pp ~~~~._ ~~ 50890-75002 TM ... .:::. .:.. . Summary Page Balance as of Mar 2, 2011 $0.00 Char es: Tota~PL Electric Utilities Charges $27.43 Total Charges $27.43 . --::::: Account Balance $27.43 Meter Reading Information KWH -Average Per Day 36 Meter #59043504 Mar 2 Actual 40647 30 Feb 10 Actual 40475 20 Da s KWH Billed 172 24 Average -Mar 2010 . - 2011 18 Temperature 37F 35F KWH Per Day 14 9 12 Yearly Use: Total Average 6 Use Monthly Apr 2009 -Mar 2010 5095 425 0 Apr 2010 -Mar 2011 4491 374 MAMJ J A50ND J FM ,,.~ ~~~~~~ 2010 Months 2011 ~ ~ ~~ , ~~~, ~,7 . ~ 1 ~ r ,/ / V i ~ ,~,, Other important information on back ~ ~\ ,~vw.aaanetaccess.com IVAN DALE: BLACK / DOROTHY F BLACK Account Number: 5329 0580 2457 7901 February 8 -March 8, 2011 `count Information: ~w.aaaneta~cces s.com ail billing inquiries to: ~A Financial Services J. Box lE^2G :ilmiugt.on, DE 19850-5026 ail payments to: ~A Financial Services J. Box 15019 ilmingtou, DE 19886-5019 istomer Service: 100.807.3068 ,800.346.3178 TTY) New Balance Total .....................................................................$1,027.45 Current Payrnent Due ......................................................................$15.00 Total Minimum Payment Due ............................................................$15.00 Payment Due Date ..........................................................................4/5/11 Total Minimum Payment Warning: If you make only the Total Minimum Payment each period, you will pay more in interest and it will take you longer to pay off your balance. For example: Previous Balance ...........................$771.4() Payments and Other Credits ..............-771.4() Purchases and Adjustments .............1,027.45 Fees Charged ....................................................O.OU Interest Charged ...............................................O.OU - __. New Balance Total ........................$1,027.4'. Credit Line ..................................$19,000.00 Statement Closing Date .....................3/8/1:1 Days in Billing Cycle ` v Transaction x Posting Reference Account Date Dafe Description Number Number Aruount Total Payments and Other Credits 02 15 PAYMENT -THANK YOU ~ ,.~~f -771.40 / ~;~ - °/~~ ~ ~~ ~ y --> 771.40 Purchases and Adjustments 02/06 02/08 PIZZA HUT #23084430115 MECHANICSBURGPA 0619 7901 8.48 02/08 02/09 WAL-MART #1886 MECHANICSBUR PA 8588 7901 40.40 02/08 02/09 QVC 374113467101 800-367-9444 PA 2433 7901 24.58 02/08 02/09 QVC 374113467102 800-367-9444 PA 2425 7901 22.22 G2/09 02/10 QVC 374149697701 800-367-9444 PA 1650 7901 45.87 02/10 02/11 HOLLINGER FUNERAL & CR MOUNT HOLLY SPA 0019 7901 836.52 continued on next page... If you woHld like information about credit counseling services, call 1-866-300-5238. l~amp~ien Automotive Ins X220 E. Trindle Road Mechanicsburg, PA 17050 9 t -{ i y ~ L~ ka ~ . , _~ a .~...i ~ ., _.. - ~ ~ ., .. . -'S'~ a. Steve/Gloria D Black 225 Rupp Rd Gettysburg, Pa. 17325 Year/Make/Model: 1999 Chevy Impala License PIa#e: Vin No.: 1G1ND52TXXY168019 Mileage: 20,693 .~ s.. .-0 Services: General check over brakes suspension belts hoses and fluid Parts: Wiper blades Y~ i ~~ ~ ~, ,, i ti j... ~ J YYYYYY ~ ~ y . ~/ ~~~. ~, ~ , r ~l ~~J .~, ~. _; ~~~ 717-620-8817 OR 717-315-6978 www.HampdenAutomotive.com Thank you for your business! inv©ice sot 3/1/2011 Tel;zn~ An annua118% (1 ll2`Yo monthlvl finance fee will be applied t+~ past due invoices. A minimum $5.00 will be applicable. NSF chi rk~ will milt in a 4~'i0 (i(1 renr~c~P~+:inu ie `~'r~ee Lai A.,~u~tt 1 ~~ 19.99 ~ 19.99T 2 ~ 10.88 ~ 21.7bT Sub#o#al $41.75 Sales Tax (6.0°fo} $2.51 Tots I $44.26 ~o ~ ~ ~~~: ~~~ ~ ~ :~~~ ~ ~~ \~ ro ~~ N~ Accounf;.Ending In 4627 Cabela's CLUB Points Previous Balance = $1,498.33 Purchases This Year: $5,868.27 $137.45 Payments/Credits - $1,498.33 Credit Limit: $12,000.00 FREE Gear at Cabela's! Purchases/Cash Advances + $2071.45 Available Credit: $9,883.00 Interest Charges/Fees + $0.00 Days in Billing Cycle: 31 Previous Points Balance = 11,67 New Balance $2,071.45 Statement Date: 03/18/2011 Points Earned at Cabela's + Payment Information ~ Points Earned at Cenex + ~_ New Balance $2,071.45 Points Earned Elsewhere + 2,07 Amount Over Credit Limit $0.00 ( t_a a Payment Wamina: If we do not receive your Other Points Added + oo minimum payment by the payment due date, you $o t P t D A Points Redeemed - ~ . ue moun as may have to pay a late fee of up to $35. CLUB Points Available = 13,74' Minimum Payment Due $41.00 Payment Due Date 04/12/2011 Minimum Payment Wamina: If you make only the minimum payment each period, you will pay more in interest a~~d ~t ~v~iil take you foiige~ to Nay off your balance. ~ or exa~~~ple: ` ~~/"~~ ~;;~~.~ ' If you make no additional charges You will pay o1'f the balance And you will end up paying an ~ • on your card & each month you pay:. shown on this statement in about:- __~ estimated total ofd ` _ Earn 2% back In CHUB polntS only the minimum payment 7 years $3,171.00 for all purchases at Cabela's $72.00 3 years $2,594.00 (Savings = $577.00) &Cenex®Convenience stores! 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BLACK I, DOROTHY F. BLACK, now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other wills and codicils that I may have previously made. My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out c-f and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which becorzle payable as the result of any property over which I have the power of appointment. \~ Article III I give, devise and bequeath my tangible personal ro ert ' p p y 111 accordance with an y memorandum I have handwritten or signed, located with my will or with my valuable papers anca found within 30 days of the probate of my will. Gifts ma o y my be to persons who survive me o~~ to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. To the extent no such memo random is found, or all of my tangible personal property is not disposed of pursuant thereto, m tan i bl y g e personal property shall be added to m~~ residuary estate and pass under Article IV hereof. Article IV All the rest, residue and remainder of my estate, of whatsoeve r nature and wheresoever situate, I give, devise and bequeath to my son, STEVEN D. BLACK, of Adams County, Pennsylvania, PeY Sti~pes. A~-tl-= Except as otherwise provided in this Will, I have intentiona lly failed to provide for any other persons or relatives, whether claiming to be an heir and/o - i relative of mine or not. Insofar as I have failed to provide in this Will fo1- any of my relatives a nd/or Issue now living or later bo1~1 or adopted, such failure is intentional and not occas' toned by accident or mistake. Specifically, my sons, DAVIDSON M. BLACK and JEFFRE ' ~ L. BLACK, are not to inherit any monies or property, personal or real, under the terms of this Wil 1. Article VI I nominate, constitute and appoint my son, STEVEN D. BLACK, of Adams County, s lvania as Executor of my Last Will and Testament. I direct that my Executor be Penn y ermitted to serve without bond. In addition to those powers granted by law, I grant my P Executor the power to distribute in cash or in kind, in like or in unlike shares. and to file any ualified disclaimer I could have filed if living. My Executor shall receive reasonable q compensation for services rendered to my estate. Article VII In addition to the powers conferred by law, I authorize my Executor, in his absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, ' vest and reinvest in all forms of property without being confined to legal (c) to in investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and. without consent of any benef ciar:y, (~ to file any federal income tax return for any year for which I have not filed such return prior to my death, to make distributions in cash or in kind, or in both., and to determine the value G~f ~g any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor and to pay from my estate reasonable compensation. for all their services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death., and (j) to receive reasonable compensation in accordance with his standard schedule of fees in effect while his services are performed. IN WITNESS WHEREOF, I, DOROTHY F. BLACK, hereby set my hand to this my A _ Last Will. and Testament, on ~~ ~ , 2007, at Harrisburg, Pennsylvania. DOROTH .BLACK In our presence, the above-named DOROTHY F. BLACK signed this and declared this to be her Last Will and Testament and now at her request, in her presence, and in the presence of each other, we sign as witnesses. Name Address 2000 Lin~lestown Rd., Suite 202, Harrisburg, PA 17110 '~Q--j ~ ~~C.SL;~~ 2000 Lin~lestown Rd., Suite 202, Hai-risbur~, PA 17110 ~~ 4 I, DOROTHY F. BLACK, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and Acknowledged before me by DOROTHY F. BLACK, the Testatrix on ~: a~ C~ , 2007. ~~ Notary ublic DOROTHY F. LACK COMMONWEALTH OF PENNSYLVANIA Notarial Seal Melissa M. Kain, Notary Public Susquehanna Twp., Dauphin County -- My Commission Expires Auc~.11, 2Q19 We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (1 S) years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and Subscribed to before me by 1'Vl,~~',l 5~ l~l l~ L~ and = ~ ~-~?a~ ~~,-., ~, witnesses, on ~T,~. ~ / ~ ~ , 2007. `~'~ Notary Public COMMONWEALTH OF ~'ENNSYLVANIA Notarial Seal Melissa M. Kain, Notary Pubifc Susquehanna Twp., Dauphin County My Commission Expire AWq.11, 2010 ~- Witness Witne s 5