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HomeMy WebLinkAbout07-08-11 (2)r J 1505610140 REV-1500 ~ (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 8 8 1 2 5 9 4 8 0 4 1 1 2 0 1 1 1 2 1 0 1 9 2 2 Decedent's Last Name Sufi'ix Decedent's First Name MI F R Y S I N G E R S R D O N A L D Y (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^X 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ prior to 12-13-82) 5. Federal Estate Tax Return Required ^ 6 Decedent Died Testate ^ death after 12-12-82) 7 D . . ecedent 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) between 12-31-91 and 1-1-95) (Attach Sch. O) 6 0 W E S T P O M F R E T S T R ~- E E T ~` City or Post Office State ZIP Code DATE FILED C A R L I S L E P A 1 7 0 1 3 CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number F ,_, R O G E R B I R W I N 7 1 7 C~ 9 ~3 ~3~~ REGISTI~ LS U3EnNLY,-'.' '-C.1 ;;tom, f `r'! 1 ~-- t ~:::: First line of address ~~%~ ~ ~._ ~ ~-~ _~ CJ ..,,~ -, -ti-1 ~ ; ; :~-.:a I R W I N & M c K N I G H T P- C `~ ~ =~ ~'~' Second line of address ~ ~ ~ s~-- Correspondent's a-mail address: SIG TORE OF P R ON RESPO IBLE FOR FILING RET RN 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. ADDRESS V ~- 5 MOUNTAIN VIEW DRIVE CARLISLE PA 17013 SIGNA RE OF PR RER OTHER THAN REPRESENTATIVE ~'~~.~'i l~ 20 WAYNE AVENUE CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY L 1505610140 Side 1 1505610140 J J 1505610240 2. Stocks and Bonds (Schedule B) • • • • • • • ............................... 2• 3. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. • • REV-1500 EX Decedent's Social Security Number :L 8 8 1 2 5 9 4 8 Decedent's Name: DONALD Y - FRYSINGER ~ SR RECAPITULATION 1. • 1. Real Estate (Schedule A) .......................................... . 4. Mortgages and Notes Receivable (Schedule D) ..................... ..... 4. Bank Deposits and Miscellaneous Personal Property (Schedule E).. Cash 5 5. .... . • , . 5 0 3 4. 3 7 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .. ..... 6. 7. Inter-Vivos Transfers & Miscellaneous N-Probate Property ~ Separate Billing Requested .. ..... 7. 2 2 2 ], 8 7. 6 8 (Schedule G) 2 2 7 2 2 2.0 5 8 8. Total Gross Assets (total Lines 1 through 7) ......... 9 1 2 2 1 3. 4 8 Funeral Expenses and Administrative Costs (Schedule H) ............. 9 ..... • . 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .. • • 10. 1 1 1 2 8. 6 ? 11 2 3 3 4 2. 1 5 11. Total Deductions (totalLines9and10) ...•••••••••••••••••••••• . •'•"' 12. 2 0 3 8 7 9. 9 0 __•.••• 12. Net Value of Estate (Line 8 minus Line 11) .............. . .•.... 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 an election to tax has not been made (Schedule J) . • • • • • • • • • • • . 14 2 0 3 8 7 9. 9 0 .•.• ........ 14. Net Value Subject to Tax (Line 12 minus Line 13) . • • • ...... . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 D. D D 15 D. D O (a)(1.2) X •0 16. Amount of Line 14 taxable 2 0 3 8 7 9. 9 0 16. 9 1 7 4. 6 0 at lineal rate X •045 17. Amount of Line 14 taxable D D D 17 0 • D D at sibling rate X .12 18. Amount of Line 14 taxable D D D 18. D . 0 0 at collateral rate X .15 19 ...... 9 1? 4. 6 0 19. TAX DUE ............................................... . 20. FILL IN THE OVAL IF YOU ARE RE4UESTING A REFUND OF AN OVERPAYMENT Side 2 '~ 240 150561D240 . ~ 1505610 A t REV-1500 EX Page 3 . Decedent's Complete Address: . DECEDENTS NAME DONALD Y. FRYSINGER SR STREET ADDRESS 1020 WAYNE AVENUE CITY CARLISLE Tax Payments and Credits: 'I. Tax Due (Page 2, Line 19) ;?. Credits/Payments A. Prior Payments 458.73 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. (1) 9,174.60 458.73 (3) 0.00 (5) 8,715.87 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; ........... .... • • • • • • • • • • • • ~ • • • ^ X ............................................ ..................... ^ X 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? .......... ••••••••••••••••••••••••••••• ••••~•••~••~~~•••~ ^ 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her dE:ath? ......... ^ X 4. Did decedent own an individual retirement account annuit or other non- robate ro ert whi © ^ • ~ ~ ...........y .................p.........p..p...y.....ch 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 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 u:~e of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(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, undE Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. File Number 0 0 STATE ZIP pA 17013 Total Credits (A + B) (2) (4) REV-1509 EX+ (01-10) -~ Pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ~~~~~~~ ~ FILE NUMBER: ESTATE OF: CI 0 DONALD Y. FRYSINGER SR If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) A. DONALD Y. FRYSINGER, JR. 1020 WAYNE AVENUE CARLISLE, PA 17013 ADDRESS RELATIONSHIP TO DECEDENT SON B. c JOINTLY-OWNED PROPERTY: DESCRIPTION OF PROPERTY % OF DATE OF DEATH LETTER DATE ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL ATTACH DEED FOR JO NTLY HELD REABESTARE.IMILAR DAl UE OF A SET DENTEREST DECEDENT'S INTEREST NUMBER TENANT JOINT IDENTIFYING NUMBER. 1. A. PNC BANK -CHECKING ACCOUNT #5140427009 10,068.74 50. 5,034.37 TOTAL (Also enter on Lirne 6, Recapitulation) I $ 5,034.37 If more space is needed, use additional sheets of paper of the same ~~ize. REV-1510 EX+ (08-09) - ennsylvania SCHEDULE G ' DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT FILE NUMBER ESTATE OF 0 0 DONALD Y. FRYSINGER SR 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. DESCRIPTION OF PROPERTY DATE OF DEATH °~o OF DECD'S EXCLUSION TAXABLE ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST pF APPLICABLE VALUE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REALTATS. 202, 078.66 1 ~~0.00 202, 078.66 1, PNC INVESTMENTS -ACCOUNT NUMBER 3.,769459 NEW YORK LIFE -ANNUITY #52148804 20,109.02 2. PNC INVESTMENTS -ACCOUNT NUMBER 33769459 20,109.02 100.00 TRANSAMERICA LIFE INSURANCE CO. ANNUITY #: 02CBT090384 BENEFICIARIES: DONALD Y. FRYSINGER, JR. DONNA LEE SEITH TOTAL (Also enter on Line 7, Recapitulation) ~ $ 222,187.68 If more space is needed, use additional sheets of paper of the same si;!e. REV-1511 EX+ (10-09) - Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER DONALD Y. FRYSINGER SR 0 0 Decedent's debts must be reported on Schedule I. ITEM AMOUNT NUMBER DESCRIPTION ,q, FUNERAL EXPENSES: 7,793.48 ~, HOFFMAN-ROTH FUNERAL HOME 1,720.00 2. WESTMINSTER CEMETERY -OPENING AND CLOSING GRAVE 185.00 3. WESTMINSTER CEMETERY B 1. 2. 3. 4 5. 6. 7 City State _ ZIP _ ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State _ ZIP _ Year(s) Commission Paid: Attorney Fees: IRWIN & McKNIGHT, P.C. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: REGISTER OF WILLS -FILING FEE 2,500.00 15.00 TOTAL (Also enter on line 9, Recapitulation) I $ 12,213.48 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) - Pennsylvania DEPARTMENT OF REVENUE _ INHERITANCE TAX RETURN RESIDENT DECEDENT SDHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER DONALD Y. FRYSINGER SR ~~ 0 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. - VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER ~. MILLENNIUM PHARMACY SYSTEM, INC. -MEDICAL 832.75 2. CHAPEL POINTE AT CARLISLE -NURSING 10,087.00 3. UGI UTILITIES, INC. -UTILITY 8797 4. (FAMILY HOME MEDICAL -MEDICAL I 120.95 TOTAL (Also enter on Line 10, Recapitulation) I $ 11,128.67 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) • ~ Pennsylvania DEPARTMENT OF REVENUE - INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: DONALD Y. FRYSINGER SR NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY j TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. DONALD Y. FRYSINGER, JR. 5 MOUNTAIN VIEW DRIVE CARLISLE, PA 17013 2. DONNA LEE SEITH 3 PFEIL AVENUE ALBANY, NY 12205 FILE, NUMBER: 0 0 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Lineal Lineal AMOUNT OR SHARE OF ESTATE 101,939.95 1/2 REMAINDER 101, 939.95 1/2 REMAINDER I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. jj, NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 MOVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. f Pl~lC ~ eeel~lG 7HE WAY May 10, 2011 Donald Frysinger 5 Mountainview Drive Carlisle, PA 17013 RE: Donald Y Frysinger SSN: 188-12-5948 DOD: 04/11/2011 Dear Mr.Frysinger: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checking Account Account # 5140427009 Established: 03/15/1985 DONALD Y FRYSINGER SR DONALD Y FRYSINGER JR DOD balance: $ 10,068.51 + 0.23 accrued interest Investment Account The decedent maintained Investment Account #33769459. For furthe;r information, you may call the Brokerage Department at 1-800-762-6111. Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and Savings}. We do not process any financial transactions or provide statements. If you need assistance with any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or sto~~ by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC Page 1 of 2 ' - .~ ' 'ntended or the use of the individual or entity to which it is addressed and cable law. This message as a .f tion that is rivileged, confidential and exempt from disclosure. under appslible or contain informa p the reader of this message is not the intended recipient or the employE~e hat ann dissemination, If deliverin this message to the intended recipient, you are hereby notifiedou have received this g distribution or copying of this communications is strictly prohabated. ~ ye hone at 800-762-1775 and communication in error, please notify me immediately by reply or by p immediately destroy this faxed document. 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N ~ -. c ~~ m ~ ~: ~ 3 ~ ~ ~ O .~i. tU m ~ O m O w c •~ N tp rt C ~ ~- N ~ ~, ~ .-. 3 ~` N m 0 c ~ ~ n ~' ~ 'o ~ m ~ 3. ~ ~ N ~ m ~ to ~, ~ a o c aN n ,..~ ~ ~ N N ~ O ~p ~ ~ Al a `G ~ ~~ ~ O Q' ~ a° c c ~ o m ~ ~ ~ `~ oa c w N ~ ~ m m .-- m m ~1 ~ ~ ~ C _~ ¢1 n 0 ~, o O C.1 O .-f ~ (p ! ~ ~ n - m a 0 c o' W ~ ~o o ~ W ~_ m ~ a ~ Q. w m d ~ N ~ m ~. N ~ ~ a n m ~ w ~ ~ n %-- m ~ ~- o ~ N a ~ ~ su N ~ m ~ c p1 m Q ~ ~ N ~ ~ < ~ ~ . ~ ? ~ m ~ N N N ~ h N ~ N ~ ~ ~,~o= ~t m ~ ~' ' O h ~ .-« 3 ~ m O = ~ a D~ ~ o c ~ i~ G ~ ~ _® ° 0;~~ ~ ~ ~ C ~ ~ ~ ~ "~ I / W~ r~ J~ ~O O ~ W N N "~ ~ ~ d ~ (p ~ ~ Q 3' j n m ~~~ ~ C~ 3 e-n ~ j ~ N 0 /`~V ~ J O j 1 y S ~ ~ _ ~ n A ~" A ~ ~ /~ ~ V ~ ~ ~ ~. A y 01 O C O A oq New York Life Annuity Service Cent ~r P.O. Box 9859 Providence, RI 02940 ~~ r, Winner of the ., DALBAR Servire Award :~ From 2000 •- 2009 MAY 4, 2011 I~~~III~~~III~~~~~~II~~II~~~~II~II~~~I~~I~~~IIII~~~~~I~I~I~~II MR DONALD Y. FRYSINGER ., 0 1020 WAYNE AVE APT 2 ° ° CARLISLE PA 17013-1641 Annuitant: MR DONALD Y. FRYSIN~;aER Policy No: 52148804 ~ ,. Policy Date: JUNE 22, 2007 Dear MR DONALD Y. FRYSINGER: ~~ Thank you for being a valued policyholc#erof the New York Life Fixed Annuity. As requested, this confirms that the bal ance of your New York Life Fixed Annuity as of 04/11 /2011 is $202,078.66. Your effective annual interest rate of 4..75% is guaranteed through 06/21/2013. If you have any questions, our Client `services Representatives are available Monday through Friday from 8:30 a.m. to 5:3() p.m. Eastern Time at 1-800-762-6212. We look forward to serving you for rr,any years to come. Sincerely, ~~r--- Stephen J. Abramo Vice President New York Life Annuity Service Center • P.O. Box 9859 • Providence, RI 02940 • 1-800-762-6212 Annuities are issued by New York Life Insurrjnce and Annuity Corporation (NYLIAC) (A Delaware Corporation} Variable annuities are distributed by: NYLIFE Distributors LLC, Member FINRA/SIPC NYLIAC and NYLIFE Distributors LLC are K~holly owned subsidiaries of New York Life In,aurance Company 51 Madiscin Ave, New York, NY 10010 FL31 ` w iii ii \Y V` a ` • LIFE INSURANCE COMPANY Transamerica Life Insurance Compaay 4333 Edgewood Road NE PO Box 3183 Cedar Rapids, Iowa 52406-3183 April 20, 2011 Donald Y Frysinger Jr c/o Chuck Little 91 Cumberland Pkwy Machanicsburg PA 17055 RE: Aaauity Number(s) 02CBT090384 Dear Donald Y Frysinger Jr: We have received notification, Donald Frysinger, annuitant of the above listed non-qualified tax deferred annuity i.s deceased. Our office wishes to extend sincere condolences for your loss. The following is the current information on this aiznuity: Annuitant: Owner: Primary Beneficiary(ies): Annuity Policy Date: Full Value as of 04/20/2011: Taxable Portion: Full Value as of 04/11/2011: Donald Y Frysinc~er Donald Y Frysinc~er Donald Y Frysinc~er Jr 50~ November 12 , 2 0 I) 8 $20, 133 .23 $ 133.23 $20, 109.02 The attached document reflects the options availab:Le to the beneficiary. The full value as of the date of death is for tax ~~urposes only and is not a guaranteed death benefit amount. Operations performed on an automatic basis when applicable have been terminated, such as; Systematic Payouts or Automatic Billing. The attached document contains general tax information based on Transamerica Life Insurance Company's interpretati~~n and should not be relied upon for your personal tax planning. If yoga have questions concerning the direct tax consequences when selec:t:ing an option, you may wish to consult a tax advisor. Member of the AEGON. Group f' ~, ~ . , _ ~'"o A~~~ ~ Fier,^i~~,a~_ 4~, ,i~-, '~~ INT ~F. ~,Aa~ ~Sr? A. ~ ~~ ~ .._S~ ~E '~SE~. A~~°~anr- ~,~ zoos "~ zoo9 3 ._ _ , If you have any questions please contact your financial professional, ' or call us at 1-800-553-5957 Monday - Thursday, 7:00 a.m. - 5:30 p.m. or Friday, 7:00 a.m. - 4:30 p.m. Central time. We appreciate your business and look forward to serving you in the future. Sincerely, Katie Mozingo-Payne Transamerica Life Insurance Company Claims Enclosure(s): Annuity Claimant Statement Form Death Option Packet Postage Paid Return Envelope .~ c:~~~~ -~ ~~~G~1~~G2 ~ FUNERAL HOME 67 CREMATORY, INC. Donald Y. Frysinger, Jr. 5 Mountain View Drive Carlisle, PA 17013 Statement of Funeral Expenses for: Donald Y. Frysinger, Sr. 219 North Hanover Street Carlisle, Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 vwvw.hoffmaxoth.com infoQhoffmarxoth.com May 11, 2011 Date of Death: April 11, 2011 Account Id: 16220-091 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,550.00 Sub Total: $ 4,550.00 MERCHANDISE: Casket: Carter Casket $ 2,050.00 Outer Container: Cave Proof Box $ 975.00 Sub Total: $ 3,025.00 TOTAL FUNERAL HOME CHARGES: $ 7,575.00 CASH ADVANCES: 5 Certified Death Certificates at $ 6.00 each $ 30.00 Newspaper Notice -Sentinel $ 182.12 Clergy $ 100.00 Flowers $ 6.36 Sub Total: $ 318.48 Total Funeral Expense: $ 7,893.48 Total Payments Made: $ 7,893.48 Payments Made: Donald Frysinger Check 687 May 2, 2011 7,793.48 Cumberland Cty VA Check 813320 May 11, 2011 100.00 Please return this portion with your Remittance. $ Amount Enclosed Donald Y. Frysinger, Sr. Service ID#: 16220-091 Balance: ~ 0.00 SERVING OUR COMMUNITY SINCE 1 907 Image Print Page 1 of 1 ~ _ _ ~~ ~~~ s. a~' R ~-tom ~ '~ ~~ ~ ~, n r.'~ c i Df~'~1a Y FRYS-I~iIQ~~~, ~~ ~~J ~.~ eQ ~h~ t~:der ~ ~' `~ ~ ~ ~' ' _C1r~lta~s ~ Frjc ~~~, r~A. a~u Ch~otce ~n~r r~~ ~'la~x ~~~ r t ~ ;~ Front ~ ~~ ,~ rf. ~!~ ` t"-k- r ` t , ~ , r ~' ~ ~ s:i'x~ ~ ka '~f '' ,_ , ..- . .. ;: _ ' _ _ _ ae '~ ~~~~~~ ~~~ ~~- ~ T ~ ~ +C9 '~ ~ ~ ~~~1~1~~~~~ ~ ~ ~ Banff c~' ~ orrs town ~ ~ ~ Sl~ipperts~~rg ~ P.A. 1?2~? phone : ?17`-532-~1~~ `~' .~ , ~z~ "~` Bus Date : Q~/~~,f 2 ~1~. ~` '~~~ ~''~ 8ra~nch,/T.ell~~ i~t?4fr/i~2~~ c~5,~a~,~2~ii ~~ : ~~ : - Back Y' - r t ~ _ ~. x - F v .. f ~ - f} 'r "sr a y 4~~''' ^ a'll - r } ~ it Y l i ~ € _ ~ ~ ~, ~s t i~ t '4. _ . s ,.. * F t ~ J t ~- 't 1 .t } '.fE { ; S~ r ~ 3 :J .t f f ~7 ~ C a M k_ r ~ .F 3 f ~. i. .~ <: t ~~ f (r ~ r1 ~ J 1 Y t/~ lt,~ i f ! 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Primary account number: 51-4042-7009 Page 3 of 4 Chsck Images DONALD Y FRYSINGER 135 1000 WAYNE AYE APT Z CANLI9LF PA 170H~ ~... /~~~ ~ QG ~-127ifJ11 in - pAY TO iFi6 aiasROORR ~n..~.~ i, e I ~~ $ .3 ~t~ °o ~PNCBANK MIC1f+nl NA Oa : GW.IrPA POII~~ 7 ~/~~ ~ r I:03i3i2?~81: 5a<4042'T009~t• Di35 135 $318.00 03/29/2011 ~ ~ ~ ~ ~1~ DoNAL" ~ tRYSIr1aF.fI, t;7T E'.83 DONALD t FRYSINGER. JR 10[O MfAY71E AVE Iy f - f/ 1D4itL3q CAIILOIIE PA 1701}tdlt ib4 171 Par a dw ~ q ~/ ~7f/ f .a ooa~, ~ ~a Q PNCBANK ~- M C1b0ICt ~aII Fu L~% ~ ~~'~r~=!col~ ~~~~YLa~~ r I:~3i31t73$i: 514042?OOq~' 0683 683 $278.54 04/05/2011 DONALD Y FRYSINGER SR DONALDYFRYSINGERJR :- -- . .. . 885 ~ ' 2j D07O-7 - ~ ~ _ ' tone wwrrte Ave , ~'- f f .. - ' •rtnaaiy . . _ .. - ~j/../ ~ WuJS4E,~ nof}7ss5 _ .-.tip; .. _ ._ . l?•t• to _ _.. - .. ... .. __. OYP m Nis ~ Qrder C $ `~~~•~ '~ 8 ~. D•aiR ~~ ~ ~ Qr<+I T/CPIA eN TIC ~~• ~ + Plan I 1I, ,~ ~D~/l may/ ~ --Y'--- - ' ' ~ a:D 3 i~38~: ~ 5 ph 2?OOqu• 068' 5 V 685 $1,720.00 04/21/2011 DONALD Y PRYSINOER, BR 882 DONALD Y PRYi1NOER, •JR oA~sAit~, Pw tm.eyey+ ,~, /~ - o.e. ~ -/~ _ ~~ ~~uanne yt CP P`N CBANK ~o~tl~e I:03i3i2?381: 5i~~042400g1r 068• 682 $87.67 03/24/2011 DONALD Y FRYSINGEq, SR 6$4 DONALD Y FRYSINGER. JR tOFO WAYN[ AV[ m•t,n=q G1RI.t9L,6. PA IhttlNt f lL.e{~_ ~ V~ Pay ro ohs y ~ ~_`7`_"7"'t. N _J h I ~ .~~ , e0 O.J.. d / pb J~'~~ +cP Cashad El lSGti.OQ PG ~, P~~rTi 7{~: f O~J~ ~l~t 532 F3QRR~G 11 n+t: NIIh:7aQ~a ww:~aF~'9'{'•[p~x,:,a Pa ' 73422 ti84 a0 ~ ~ f~ ~~~ - I:D 3 i 31 2? 981: 5 it.04 2?009~~' 06A4 ~~'00 OO SOOOOr' 684 $500.00 04/08/2011 With PNC online Banking, you can view, print and save up to the most recent 90 days of your canceled checks -front and back -FREE of charge. Please contact us for additional options. PNDMLT01-J0 668 1 09-140-NN N NNN-009-003RF4 Image Print Page 1 of 1 , . .-, ~ t. Cxt ~ T ~ 9 ~' ` ~ qiw ~ pt r'~ ~..~ ~ ~ N . ,.,t y .N' i ~ ~ 11pi~A~ ~ i$Y~ Y 7 ~ p~ wa r : ~; #;AF1~,!$L.~, Ply 1T'~i3•t~+t~ C}atc _., t16 F; y ' } _, ~~'-' ~ ~ ~f •,~~ ca cat '` ~ ,' - " xs~ .r:, , r~ `~ ~ ~~ ~ ~ ~. ~wrrr r.~ ~r ~~~ _ Q~C! . t~ 8.r~, M~ wo ~•.~ ~~- Fw _ _ ~` x.~ y Y I / i ~< y ~ t ~ F =~.fi r+r • 4 "i' ~ F r L ~ ~ is }tir sty `~+. l~n :s _ s~ .~ 3'r '` '~' `~ ~ ArA ~' s ~ > .+ r ~ i •~ ;~~, r ! _ ; . ~] ~. ~y- t ,r ~+ -ten 4 • L , ~n „ ,~_ =~ ~ -~~ i' , '1 F ` _ 1 ~f `S , ~'~ ~ 0 1 ,y,' ~ r~s/Y x i~rc ~v y S'+ f~r ,~ ~ ~r°~{K ' ~ Y .4 ki ~ { '}r ! try ~ t 1' ~iQ. ~~ £ ~. `- .a'.'a%f C~ r ''s d?`' ,~.4^ <a ~+ ' xCr~ ~ t''~ {1 :` i :? , 4 ' ,~ Please ~refer~~~o # .• r r' ,n r r t ~,'F`{~ r k'~ , t~ ~' a~' ,~ ~.~ ~ 4 .K~~y ~r #3 4 ~, ~,~ ~ H r ~-z Ft 3 f ~ a"f~:~'~ f~7E~ x ~~~ ~ t's'f~ ~•.i ~..r„i 4~f'y 1'.3.:~ - `.:1 14 ~ l ~ b 1 x ~oc~at~~r~s r acnor~~- ' ~ ct ~ ti G- a• ~I m cr:W~ ~ ~ th Ct . ~ ~ Yf/ F.r Yl W ' hi Cti ` Q m' ~` ~ ' .. as ro n .~ c~, m ~ f . Q. h~ cr . ~ ~ - . 'm m Rvc Q, ,~ z ~ ~,~ Back ~ ~ ~.'', ~ s y ~ ~x E ~~ ~ ~y:; 'fit ~ ~~~'~'l > ~ `F r'4 t 4 t 1 ' 1 m f',~r ~ iy 3.;. trY.a-F~;''`x << : t ~ f 'r 1 t f '}r,~s.~ y'Y a S 4 W 7~ ,. 7'~ 4 N hr .~ ~ ~ i 7 i M'. A~ Y ~ • •~ ~r. ~, c~~, ~>wrote~ or d~ ~ ~ ~~ Y ~aV ~ ~t~a~rtoSo~ ; x i ~y r ~ y Y °fi Y, f 'r :. ~ Y~'~.' " ' tj 1" t >` s ~i SirIS;.,.,. h.ity~ffr t ~ ~ ~ I g ~ ,, ~ a :-~ 3~ ~~ t5iy J ~ 'tf , tt~' .t' ~ ~. ~` ~ Fyn t!. ,,;~r~t v 'F:`i ~:o,C,yi i 4 F. ~ti _!' FI r c ,~::: w T x ~ r~ ~s, b% https://www.cct.pncbank.com/IMGPRINT.html 6/14/2011 Image Print Page 1 of 1 https://www.cct.pncbank.com/IMGPRINT.html 6/14/2011 e olnte ~, at Carlisle 770 S. NOVER STREET, CARLISLE, PA 17013 Mr. Donald F. Frysinger Donald Y. Frysinger, Jr. 5 Mountain View Dr. Carlisle, PA 17013 Form PB-01 ~UES~OhlS? CALL: ? 71 249-1363 :. ES1DEfJT #, UNIT STMT. QAT6 13355 M-1&A 05/02/2011 I~ES~#ENTfSi Mr. Donald F.:t± rysinger Td~AL aMO~JNT QUE $10 087.00 DATE ~3UE U on Recei t DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ AMOUNT REMITTED. _.._.._ .- --.~.. ~ .. ,...~....., a. ..._ `` r^A.`. y~.~j ~~:t~ . '. ~ j ' ~ .:: t. .. i .} x .i. . ... . . .... ... . _ -. _ :. ....... ,. .:~: ~: ...r..v.... .. ..... ..... ::....:1:::-:...i•~~:s~.•_:.?:~~:?::?r.3 :.~: :u...;v.__~...7-... ... _. :. - .. ... ... u _ ...~... .:wJrr~s. ~. .. ._. ..i:•.:...:::'`n~ lr, . . .-Balance.Forward •.., 15,143.00` 04/Ol/201~1 Rooni~~and Board Private.-HC~ 04/01-04/30 30 _ 7,650:.00 : 7.;493.40 <04/Q6/201'1 Room-and Board~Private;-HC 04/01-04/06 6 1,530.00 9;023:00 ~ 04%07/201] Resident Escort Service 2 44.00 .9.:,0.67.0:0 ~CRMC ER 10::30-1'2:30 04/10/2011 Room and,Board Private-HC04/07-04/10 4 1,020.00. 10;087.00 RESIDENT # CURRENT ..._ OVER 30 OVER 60 OVER 90 OVER 120. TOTAL AMOUNT DUE _' .13355 0.00 10,087.00 0.00 0.00 0.00 $10;087.00 .. .. _ ., _. Form PB-01. RESIDENT NAME Mr. Donald F. Frysinger CHAPEL POINTE AT CARLISLE, 770 S. HANOVER STREET, CARLLSLE, PA 17013 ~H ~si~irrrs. pie. June 16, 2011 DONALD V FRYSINGER 5 MOUNTAINVIEW DR CARLISLE, PA 17013 Customer Account Number: 221780335134 19980710 Service Address: 1020 WAYNE AVE APT 2 CARLISLE, PA 17013 FINAL NOTICE BEFORE INITIATION OF CREDIT AND /OR LEGAL ACTION You have a past due UGI balance of $87.97 that is due immediately. Please pay this amount to avoid further collection action. You can mail your payment to: UGI Utilities, Inc. P.O. Box 15523 Wilmington, DE 19886-5523 If you have any questions or need additional information about this bill, please contact UGI at 1-800-276-2722. Our representatives are available Monday through Friday, 8 a.m. to 5 p.m. If we don't hear from you or the above amount remains unpaid after five (5) days, UGI Utilities, Inc. will refer your account to an outside collection agency. This can have a damaging effect on your credit rating and may prevent you from receiving credit in the future. If necessary, our attorneys may file a lawsuit against you in order to collect on this account. You may be required to appear in court and may have t:o hire an attorney to represent you. If you have paid this bill within the last three (3) days, we thank you and ask that you please disregard this letter. Sincerely, UGI Utilities, Inc. Credit & Collections Department • .. Family Home Medical Invohce No. .a .,.: 1 Sprint Drive Carlisle, Pa 17015 717.249.8051 fax 717.243.9423 INVOICE - n.........,..._ ~ VY.7LV111~i1 Name Donald Frysinger Address 1020 Wayne Ave City Carlisle State PA Zip 17013 Phone Date (p~~ ~ / Order No. 93735 / Rep rdr FOB Tax Qty Description Unit Price TOTAL 1 wheeled walker supplied 2/8/11 $1'20.95 $120.95 ~ I ~ Medicare has denied payment for the walker . , `~ a stating that you are in a skilled nursing facility. Medicare will not pay. Payment of this invoice is your responsibility. 1_ l lP ~ \ O SubTotal $120.95 Payment Details Shipping & Handling $0.00 O Cash Taxes State $0.00 O Check _ O Credit Card TOTAL $120.95 Name _ CC # Office Use Only Expires We specialize in making home care easier Thank you for your business