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Home My WebLink About07-14-11,r 1505610101 REV-1500 Ex `01.1°' ~' PA Department of Revenue Pennsylvania OFFICIAL USE ONL~f_ DEPARTMENT OF REVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN °" ~ ~ ~'-y `~'~ PO BOX 280601 - Harrisburg, PA 1128-o6oi RESIDENT DECEDENT ~ _~ ~ ~) d ~_ U ~ ' ~` ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY .~ ~ ~; ,, . Decedents Last Name Suffix Decedent's First Name MI { r .- ~ ,. ;, », a ~, ~, _ ~ . - (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ~::: ;.. , ~ , ,., .., . -, . ~.R .~4. ,. m .:.: .. .. ..i~<~ r .> . ~ . it ~. '. .. ~_ Spouse's Social Security Nur7~ber ~~~ °~~~~~~~-~~~ ~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE u r ~ y ~ REGISTER OF WILLS ~~~„w .~ FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder F;eturn (date of death (~ 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received 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) prior to 12-13-8:?) O 5. Federal Estate l ax Return Required d 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 First line of address Second line of address City or Post Office State ZIP Code ~/}I2L1SL ~~ `~ `~'3 ;-~ C-'J C:7 ~: i. ~.._.., '~ ~.:, :; _.~.? ~`:~ :'r't O --rt l`7~~~" Correspondent's a-mail address: /~m C e v~ ~ ~ J ~ ~ C'_OYL.~ cxi.5 "~ ~ ~~ Q'f' SIGN9ILIR!< OF PERSON RESPONSIBLE FOR FILI TURN D TE ~ ~ ~ / 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. HUUT'CCJJ ` ~~ `~~ e ~Q~r ~ `3 ~ ~-- ~1~- 1 7 a i s -- SIGNATURE OF PREPARER OTHER TH REPRESENTATIVE DATE ADDRESS L 1505610101 PLEASE USE ORIGINAL FORM ONLY Side 1 150561011D1 J ~ R 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: l lr/ ~ l,:' ~~ RECAPITULATION ~~ 1. Real Estate (Schedule A) ............................................. 1. c~ . v ~.~ 2. Stocks and Bonds (Schedule B) ....................................... 2. (; v ~ * o ~-' 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. J . ~ v 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. c}+~ r~ ~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)... .... 5. ~., ~f S O + v ~-~' 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ... .... 6. C~ + ~ `~'' 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.... .... 7. '7 O ~ . ~ `~ 8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. ~ ~ 5 ?j + Z `-~ 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9..' ~~ -~ Z> Z + 'j~ v 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .... 10. ~ ~ ~ ` f ~ . ~~ 11. Total Deductions (total Lines 9 and 10) ............................. .... 11. ~ ;=, ~_ ~~ o 12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. ~-- ~ (t, ~~~~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................... .... 13. ----~s--- 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. 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. ~ s 0 ~~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C~ Side 2 1505610105 1505610105 `' REV-1500 EX Page 3 Decedent's Complete Address: Fiie Number DECEDENT'S NAME ._ -- ~~ ~ L~ i 1r-- _ ~ -~~~~ L= _ v~ --- -- --- __ _ __ _ __ __ _ - ----- -__ _ STREET ADDRESS ~_ ~ _ _ ~, ~.~ ~~~ - ~ ~ mow, ~ ~~e~,~ _ _ _ _ -- --- - ---- - -- - -- -- r --- --------- CITY .~ STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) ~~ . c:' ~' 2. Credits/Payments A. Prior Payments B. Discount ____ ___ _ _ _ _ _ Total Credits (A + B) (2) 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~1 . v c7 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 reversionary interest; or .......................................................................................................................... ^ 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? .............................................................................................................. ^ 0 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. -~,{~~i1^lJ ~'-~ i s ~ - - + ,y ~'r 3 KE~~ •~. ,~, f.., r ~ ~ •'r. ;..x .v nj. `~+ b< - 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, 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. RSV-1503 EX+ (6-98) F° .~ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) ~ ~ REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER 3 Include the proceeds of litigation and the date the proceeds were received by a estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH J - ~ ~J ~~- s ~~~ r_. TOTAL (Also enter on line 5, Recapitulation) $ `-~ ~ f ~~ . v ~= (If more space is needed, insert additional sheets of the same size) F'.EV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER _ ~ ~ ~ (~ ~ This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. ,~ ~-`' ~ ~ . ~ 3 3 1` ~1 L S ~ ~`' .~ ~ TOTAL (Also enter on line 7, Recapitulation) $ ~~ v1j r 2, (If more space is needed, insert additional sheets of the same size) The rzgl~t chore for the long terrn'~ Arr~erican Funds' PO Box 2560 Norfolk VA 23501-2560 MML INVESTORS SERVICES, INC. 100 CORPORATE CENTER DR STE 201 CAMP HILL PA 17011-1758 Best wishes for the New Year This statement shows your complete account activity for 2010. We recommend you keep it for your tax records. See our online Tax Center for tax forms, interactive worksheets, average cost information, and more. You can also go online to make your IRA contributions. Visit us at americanfunds. com/taxes. Guide to market recoveries A look back at several significant market declines -and their subsequent recoveries -can offer useful perspective for today. Visit americanfunds. com/recoveries to access our tools and resources. Year-end summary Dealer copy of Year-End Statement December 31, 2010 Shareholder CB&T CUST ROTH IRA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D 309 STONEHEDGE DR CARLISLE PA 17015-9134 Rep name GREENWOOD_LOGAN Phone number (717) 763-7365 Rep number S000338 Dealer branch number 255/037 Page 1 of 3 For more account information .................................................................................................. ^ Personal assistance - 8 a.m, to 8 p.m. Eastern time M-F Shareholder Services - 800/421-0180 ^ Sales and marketing information Adviser Marketing - 800/421-9900, ext.4 ^ Automated information and services Website -americanfunds. com American FundsLine ® - 800/325-3590 Reinvested Change in Value on dividends and account Value on Ending 12/31/09 + Additions + capital gains - Withdrawals +/- value = 12/31/10 share balance ..................................................... ........................................................................................ ............................................................................................................. CB&T CUST ROTH IItA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D Capital World„_Growth and Income Fund-A Account # 16655303D > $1,771.58 $0.00 $12.96 -$1,743.65 -$40.89 $0.00 0.000 Capital Income Builder-A Account # 66553Q30 _ , $2 , 516.38 $0.00 $22.09 -$2 , 511.54 -$26.93 $0.00 0.000 Tota Is $4,287.96 $0.00 $35.05 -$4,255.19 -$67.82 $0.00 The .right choice for the long terrn~' Dealer copy of Page 2 of 3 ~I71~riC~r1 FUr1t~S~~ Year-End Statement December 31, 2010 CB&T CUST ROTH IRA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D Year-to-date dividends and capital gains Short-term Long-term Account # Fund # Dividends capita! gains capital gains CB&T CUST ROTH IRA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D Capital World Growth and IncomE: Fund-A 66553030 33 $14.53 $0.00 $0.00 Capital Income Builder-A 66553030 12 $22.09 $0.00 $0.00 Totals $36.62 $0.00 $0.00 Beneficiary information .................................................................................................................................................................................................................... Account # Primary Contingent ............................................................................................................................................................................................................................................................................... . CB&T CUST ROTH IRA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D 66553030 PATRICIA L MCEVOY Not provided To update and read important legal information about your beneficiary designations, please go to americanfunds. com/beneficiary Year-to-date history CB&T CUST ROTH IRA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D Capital World Growth and Income Fund - ClassA Account # 66553030 Fund # 33 Symbol CWG IX Trade date Description Dollar amount Share price Shares transacted Share balance ...................... 01/01/10 ....................................................................... Beginning balance .................................................. $1 ,771 .58 ........................................ $34.08 .......................................................... .............................. 51 .983 03/19/10 Income Dividend 0.15 $7.80 $33.79 0.231 52.214 03/22/10 Early Distribution -$1, oao . 00 $33.82 -29.568 22.646 06/01/10 Early Distribution -$400.00 $30.06 -13.307 9.339 06/18/10 Income Dividend 0.40 $3.74 $31.33 0.119 9.458 09/17/10 Income Dividend 0.15 $1 .42 - ~~3.32 0.043 9.501 "` 11/08/10 Transfer To ~~~~~*~~150 -$343.65 $36.17 -9.50 0.000 `' {3/19/ oreign ax ai .14 ~-`--~- 0.000 06/18/10 Foreign Tax Paid $0.21 0.000 09/17/10 Foreign Tax Paid $0.22 0.000 12/31/10 Ending balance $0.00 $35.72 0.000 Special dividend. The fund's December payment included aone-time special dividend of 10.0 cents per share IRS reporting. CB&T is required to provide the value of your IRA(s) to the Internal Revenue Service. • The ri.gl~t choice for the long term i ,~~ Dealer copy of Page 3 of 3 Arnerlca.n Funds Year-End Statement December 31, 2010 CB&T CUST ROTH IRA PATRICIA L MCEVOY CUST FBO KEVIN T MCEVOY/DEC'D Capital Income Builder -Class A Account # 66553030 Fund # 12 Symbol CAIBX Trade date ...................... Description ...................................................................... Dollar amount .. .. .. . Share price Shares transacted Share balance 01/01/10 Beginning balance . .. .. ...................................... $2,516.38 ......................................... $47.89 ....................................................... ................................. 52.545 02/08/10 Early Distribution -$300.00 $45.59 -6.580 45.965 02/08/10 Early Distribution -$10.00 $45.59 -0.219 45.746 03/05/10 Early Distribution -$10.00 $47.66 -0.210 45.536 03/05/10 Early Distribution -$400.00 $47.66 -8.393 37.143 03/19/10 Income Dividend 0.42 $15.60 $47.82 0.326 37.469 03/22/10 Early. Distribution -$10.00 $47.89 -0.209 37.260 03/22/10 Early Distribution -$1,000.00 $47.89 -20.881 16.379 06/01/10 Early Distribution -$400.00 $44.52 -8.985 7.394 06/01/10 Early Distribution -$10.00 $44.52 -0.225 7.169 06/18/10 Income Dividend 0.45 $3.23 $45.77 0.071 7.240 09/17/10 Income 0.45 $3.26 $48.02 0.068 7.308 11/08/10 Transfer To **~*~~~~150 - 371.54 $50.84 - ~~ 0.000 12/31/10 Ending balance $0.00 49.91 0 , 000 Dividend change and special dividend. Beginning with the December payment, the fund increased its quarterly dividend from 45.0 cents per share to 45.5 cents per share. This payment also included cone-time special dividend of 23.5 cents per share. 00000000 REV-1512 EX+ (12-03) ~" ,, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETUF:N RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Rep -- -- ort debts incurred by the decedent prior to death which remained npaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DP,TE ~ OF DEATH __ _ _ `J ~ ~ a ~ ~ r - .~ ~ I ~f ~ ~ ~ I .~ ~3 d'• 1 ~ _ _ S (yn. ~ ~t.(ti ~~-~~~ 1 1 v _ J / r"-sJ'~ 'cC,.-°_." ~ \C:Ly,,,~J \ "--a-_. :~ [.) ~ ~ ~ ~ ' ~ ~, 1 ~~ ~, _ ~ ~' ,~~; 3 G, _~ . ~~ __ TQTAi_ ~~is. ~ ~~er ~,r of ~, F:e~;~p~'-~a~;t ur, $ _ /Y~" J~(~J . ''J') 1 I riff' ~~ arc, 'S E.bi~E~:~, ,i'~Serl c~~dit-Cfla! ~ ~'e?S ~,f 'lf; ,d ., 5i _::7 ___ _ _..------- -___ ' Page: 1 Document Name: untitled ~DDHIST Acct 0981102832 Alpha key MCEVOKT.02 Demand Deposit Display History Request ALLTRANS_ Last stmt 10/22/10 S --Date-- ----Description----- -SERIAL NBR- -Reference- ------Amount------ * 10/18/10 #CHECK 332 09744208480 (50.00) * 10/18/10 INSUFFICIENT FUNDS 00000000000 (35.00) * 10/18/10 OVERDRAWN BALANCE -289.49 * 10/20/10 SUSTAINED OVERDRAFT 00000000000 (5.00) * 10/20/10 OVERDRAWN BALANCE -294.49 * 10/21/10 SUSTAINED OVERDRAFT 00000000000 (5.00) * 10/21/10 OVERDRAWN BALANCE -299.49 * 10/22/10 SUSTAINED OVERDRAFT 00000000000 (5.00) * 10/22/10 OVERDRAWN BALANCE -304.49 10/25/10 SUSTAINED OVERDRAFT 00000000000 (5.00) 10/25/10 OVERDRAWN BALANCE -309.49 10/26/10 SUSTAINED OVERDRAFT 00000000000 (5.00) 10/26/10 OVERDRAWN BALANCE -314.49 _ DDDHISTREQ _ DDDHISTBAL _ DDDMAIN _ DDDACCT DDDINT Requested function .ignored. (Not appropriate for this situation). _ GN25010E02 COMMAND =_ _> F2=Ret:rieve F3=Exit F4=CRFwindow F7=Backward -~ ~~~ r `~ ~ .~ ~~,~,,~- 1 ~- ~' ~- ~ S ` Crl 6017 10/26/10 Date: 10/27/2010 Time: 11:15:21 AM COMMONWEALTH OF PENNSYLVANIA ~: v~ul lly vl. LtiurnllY Mag. Dist. No.: 12 - 1 - 0 5 MDJ Name: Hon.: GEORGE A ZiO~iOS '" ;: . Address: 5 3 8 S 2 9TH ~`ST HARRISBIIRGPA 17104-0000 Telephone (717) 2 31- 3 5 0 0 BENCH WARRANT Commonwealth of Pennsylvania VS. NAME and ADDRESS r MCE'VOY, KEVIN T 533 SOIITH 19TH ST L HARRISBIIRG, PA 17104 - -- "~ asg l ~ 'M O• Citation .fro: ~ °01399458 "' ' Docket~No: TR--0002338 =10 Charging Officer: PROCTOR, EDWARD NCIC OFF: Date Filed: 9/27/10 OOC: OTN: WARRANT ID: MDJS23480336 Warrant Control No: 12 -1- 05 -BW- 0004632 - 2010 Issued For: MCEVOY, KEVIN T Reason for Warrant: Fail to Respond ,; _, E -~ ~ §3-131 §§3D~STR$ET CLEANING 2617024 08/09/..1'0 ;; ~~ `,, r ~. .; TO POLICE OFFICER: ti In the name of the Commonwealth of Pennsylvania, you are commanded to take the defendant, MCEVOY, KEVIN T F -- • ,into custody. When the defendant is taken into custody, either (a) accepf a signed gi~alty plea and the full amount of fines and costs, (b) accept a signed not guilty plea and the full amount of collateral, (c) accept the amount of restitution, fine and costs due following a guilty plea or conviction, or (d) if unable; to pay, promptly. take defendant for a hearing on the bench warrant as provided !n Pa.R.Crim.P. 431(C)(3):~' ~~~~~ .. ~ _ ._ _ .. `~~~lll l l l i lll~/ j j/ Witness the hand and official seal of theme! ~~ authority~f}t5~~~~'~~ 1,9t,,~%da -df October 2 O10 c • ~ ~ 0 7//~~~5~:'~ ;.:. ;~~` o it "i ~~. i Go, t ..~.,~~.:., . o ~~ (Signature) ~f ~ una•• •o• ~V ~~ . ~~ ~i~e~Q ~ ~ Y 4r "l``` uire o sa is y sen ence o Ines an cos s: -. •~ ~~ lul ~me: - ~;. ~H n ~~: Costs. ~~ (,~--U1NT~# others. ~~ Total: nt needed for collateral: y AOPC 417X-09 SHERIF °~~ I:.CONSTABLE/OFFICER . Page 1 ~of 2 ~,,,~, DATE PINTED : 10 19 10 2 :10:0 0 PM hw / / COMMONWEALTH OF PENNSYLVANIA County of: DAUPHIN BENCH WARRANT Commonwealth of Pennsylvania VS. . --..~ Mag. Dist. No.: 12 - 1 - 0 5 MDJ Name: Hon-: GEORGE A ZOZOS Address: 5 3 8 S 2 9TH ST HARRISBURG, PA 17104-0000 Telephone (~] 1~]) 2 31- 3 5 0 0 NAME and ADDRESS [- MCEVOY, KEVIN T 533 SOUTH 19TH ST L_HARRISBURG, PA 17104 n ~-:~~Q. ~ B 'r "'atM Citation No: 0119$969 Docket No: TR- 0002261-10 Charging Officer: GRANT, JAMES NCIC OFF: Date Filed: 9 / 13 / 10 OOC: OTN: WARRANT ID: MDJS23389799 Warrant Control No: 12 -1- 05 -BW- 0004907 -2010 Issued For: MCEVOY, KEVIN T Reason for Warrant: Fail to Respond Charge(s): Offense Date J ~3-131 ~~3D STREET CLEANING 2561832 07/26/10 TO POLICE- OFFICER: In the name of the Commonwealth of Pennsylvania, you are commanded to take the defendant, MCEVOY, KEVIN T ,into custody. When the defendant is taken into custody, either (a) accept a signed guilty plea and the full amount of fines and costs, (b) accept a signed not guilty plea and the full amount of collateral, (c) accept the amount of restitution, fine and costs due following a guilty plea or conviction, or (d) if unable to pay, promptly take defendant for a hearing on the bench warrant as provided in Pa.R.Crim.P. 431(C)(3). ,... Witness the hand and official seal of the issuing authority on this ~,,?~~b ~da'y October 2 O 10 t`. / `~~~~UNINtI~INi,~i SEAL ~: / . ``~~~~ 4~~PfjyNs~~i~~' ,(Signature) ~R .. , ~C /- ~ . ~~ - =c°~~' x . • ~c . _ . ~' : - :a ~, :, :- ~/ ;'~ 'C~~`~ ~~~ ~UNT1~ OF VP~~~~ I/tftE~ttt~ FR~N K t~U I NTANA SHERIF~,/CONSTABLE/OFFICER AOPC 417X-09 ~. - ~,,,,,~.,ti,_ ..DATE PRINTED : 10 / 2 6 / 10 moun :require o sa is y sen. ence o mes an cos s:_ -` .Fine: ~ - o~ .,. al ~~ Amount needed for collateral: 102 .9Q_ Page 1 of 2 4:11:13 PM Carlisle Regional Medical Center , P.O. Box 15618 Wilmington DE 19850 ~"~'~ ~'~II I~'~' ~~"~'~~II'I"~ ~~'I' ~~II~ I"') ~'ll ~"~ 82.2541678.8883 FOR RETURN MAIL ONLY SEP 20 2010 2541678 KEVIN T MCEVOY 533 S 1,9TH ST HARRISBURG PA 17104-2307 N Dear KEVIN T MCEV01', Thank you for choosing Carlisle Regional Medical Center for your healthcare needs. We value your use of our facilities. It is unfortunate that we have to inform you that your account is now past due! Please help us keep the healthcare costs down by paying your balance in full, promptly within the next ten (10) days. To ensure proper crediting of your account, please return your payment in the envelope enclosed along with the lower portion of this letter. For your convenience, we also accept Mastercard, Visa, Discover and American Express. If you have any questions regarding your bill or you have additional insuratlce information, which was not previously provided, please contact us at the telephone number listed above. If you have paid this account in full within f ve (5) days of the date of this letter,. please disregard this request.... and thank you. PAY ONLINE 7 DAYS A WEEK 24 HRS/DAY AT www.carlislermc.com PLEASE RETURN LOWER PORTION WITH YOUR PAYMENT IF PAYING BY CREDIT CARD COMPLETE BELOW CARDHOLDER'S NUM9ER VIN# EXPIRATION DATE CARDHOLDERS NAME AMOUNT CARDHOLDER ADDRESS ZIP CODE SIGNATURE OF CARDHOLDER KEVIN T MCEVOY 533 S 19TH ST HARRLSBURG PA 171 U4-23O7 Account: 1025800 Patient Name: KEVIN T MCEVOY Service Date: 07/06/10 Balance: $207.34 PLEASE UPDATE CHANGE OF ADDRESS OR INSURANCE INFORMATION ON REVERSE SIDE PLEASE MAIL PAYMENT TO Carlisle Regional Medical Center P.O. Box 281442 Atlanta GA 30384-1442 C CARLISLE F~EGIONAL MEDICAL CENTER Phone: 800-381-9160 Statement: 2541678 Account#: 1025800 PU Box 4100 Carlisle, PA, 17015-3661 2soo~-ss patient Name: 1VICEVOY Servi U6 alance: $207.34 EOS-8883-23007-99 00000102580000000020734KEVIN T MCEVOY 6 it ' Carlisle Regional 1~ledical nter P.O. Boy 15618 ~~ Wilmington DE 1)850 illilllllllllllllillllllillllll Ili] IIIIIIIIIIIIlII 82.37=16166.8802 FOR U N MA1L ONLY NOV 1 ~ 2010 3746166 ~~ KEVIN T MCEVOY 533 S 1,9TH ST HARRISBURG ESA 1,71,04-2307 Dear KEVIN T MCEVOY, CARLISLE REGIONAL MEDICAL CENTER Phone: 800-3 81-91 CO Statement: 374E 1.66 PO 13oa 4100 Carlisle, PA, 17015-3661 Account#: 1033070 23oo~-Z,s Patient Name: KEVIN T MCEVOY Ser<~ice Date: 08/U2I10 Balance: $261.90 You have ignored our previous requests for payment of your past due account. Your account is seriously DELINQUENT! If we do not receive the balance in full «-ithin ten (10) days, we swill recommend that your account be referred to a professional collection agency. This a FINAL NOTICE. The only sway to avoid this action is to pay in full or contact our office at the number above. You may pay with Mastercard, Visa, Discover or Amencan Etpress by filling out and signing the form below. ,~ ~ ~~-~ 1 , - S ~' .~ ~~/~ c~ ~ ~- ~~ rv~ - S ~ S ~ `~- , `~ ~~~ PAY ONLINE 7 DAYS A «EEK 24 HRS/DAY AT www.carlislermc.coni PLEASE RETITRN LOWER PORTION ~~IITH YOUR PAYMENT IF PAYING BY CREDIT CARD COMPLETE BELOW 0 CARDHOLDER'S NUMBER VIN# EXPIRATION DATE CARDHOLDER`S NAME AMOUNT CARDHOLDER ADDRESS ZIP CODE SIGNATURE OF CARDHOLDER KEVIN T MCEVOY 533 S 19TH ST HARRISBURG PA ] 7104-2307 Account#: 1033070 Patient Name: KEVIN T MCEVOY Ser<-'ice Date: 08/02/10 Balance: $261.90 PLEASE UPDATE CHANGE OF ADDRESS OR INSURANCE INFORMATION ON REVERSE SIDE PLEASE MAIL PAYMENT TO Carlisle Regional Medical Center P.O. Box 281442 Atlanta GA 30384-1442 8802-23007-213 ^0000103307000000026190KEVIN T MCEV4Y 2 __ IF PAYING BY VISA_ MASTERCAUn nR AMFR1rAN FXPR FCC FTi ! (1TTT RFi /lll~ ~ Y. PO Box 823 Fort Mill, SC 29716-0823 ,~~I `1~+Iffi4~1~ ~~~ October 22, 2010 'I'lllllllllll'llll"1111'1'111111'll~llllll'll"'1111'1"1'11'1 27754582-7001 - 1 KEVIN T MCEVOY 309 STONEHEDGE DR CARLISLE PA 17015-9134 7 ]0 00001366 776046 --- CHECK CARD USING FOR PAYMENTv o ~....~ o uv vv ~ vyvv.. CARD NUMBER AMOUNT CARD HOLDER NAME EXP. DATE SIGNATURE CURRENT BALANCE $89.99 .III,III.,Il~lll~l~~lllill,,,III,III,lllllllllllli,ll,~ll,l,l,i,l FMS INC. PO BOX 707600 TULSA, OK 74170-7600 CJ FMS INC. • 4915 South Union Avenue • Tulsa • Oklahoma • 74107 • 866-530-3790 """ PLEASE DETACH AND RETURN IN THE ENCLOSED ENVELOPE WITH YOUR PAYMENT "" CREDITOR -TRS RECOVERY SERVICES INC. CUSTOMER NO. - 35100263525068 ACCOUNT OF - KEVIN T MCEVOY ACCOUNT NO. - 27754582 TOTAL BALANCE DUE - $89.99 October 22, 2010 This is to inform you that the above mentioned creditor has placed your account with this agency with the full intention of settling this debt. You may not have intentionally neglected this obligation, but it is seriously past due and demands your attention! We would like your cooperation. We ask that you: 1. Remit payment to this office or, 2. Contact this office in person or by telephone and arrange settlement. * Any returned payment will be represented electronically. Your payment should be made payable to TRS RECOVERY SERVICES INC. and mailed to the address on the tear-off portion of this letter. IMPORTANT NOTIFICATION PER FEDERAL LAW THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. THIS COMMUNICATION IS FROM A DEBT COLLECTOR. UNLESS YOU NOTIFY THIS OFFICE WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT YOU DISPUTE THE VALIDITY OF THIS DEBT OR ANY PORTION THEREOF, THIS OFFICE WILL ASSUME THIS DEBT IS VALID. IF YOU NOTIFY THIS OFFICE IN WRITING WITHIN 30 DAYS FROM RECEIVING THIS NOTICE THAT YOU DISPUTE THE VALIDITY OF THIS DEBT OR ANY PORTION THEREOF, THIS OFFICE WILL OBTAIN VERIFICATION OF THE DEBT OR OBTAIN A COPY OF A JUDGMENT AND MAIL YOU A COPY OF SUCH JUDGMENT OR VERIFICATION. IF YOU REQUEST THIS OFFICE IN WRITING WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE, THIS OFFICE WILL PROVIDE YOU WITH THE NAME AND ADDRESS OF THE ORIGINAL CREDITOR, IF DIFFERENT FROM THE CURRENT CREDITOR. We also accept payment by Western Union, MoneyGram, Visa, Mastercard and American Express. Call us at 866-530-3790 for information on these easy methods of payment. Street Address: FMS INC. • 4915 South Union Avenue • Tulsa • Oklahoma • 74107 Office Hours: Monday through Thursday, 7:00 a.m. - 9:00 p.m. CST, Friday, 7:00 a.m. - 5:00 p. m. CST, Saturday, 9:00 a. m. - 1:00 p. m. CST FMS001 776046 ~'~~~~T~TE i~'~: 'The Miltnn S. Hers~he~ ( 1~~Pdcal Center August 13, 2010 Kevin McEvoy 533 S 19~' Street Harrisburg, PA 17104 Account #482913 Patient Name: vin Physician Bal ce: $3146.64 Hospital Bal ce: $8,666.69 Dear Mr. McEvoy: Patient Financial Services P.O. Box 853 Hershey, PA 17033-0853 Email: HMCBilling(a~hmc.psu.edu Telephone: 1-800-254-2619 717-531-5069 The Hershey Medical Center has tried to reach you regarding your account. Enclosed is a Financial Statement for our Financial Assistance program. If you complete the form and return with proof of income and a copy of 2009 tax return then we can review for our Financial Assistance program. We could possible assist you with the balances on your account. Enclosed is an envelope for you to return this information. Please contact us directly if you have any questions. You can reach us at 1-800-254-2619 ext 5070 or 531-5070 Monday through Friday 8:00 am till 4:30 pm. You can also reach us Wednesday till 5:30 pm. Your help and cooperation in getting this matter resolved is greatly appreciated. Sincerely, `l .,~ Brenda Gruber Financial Counselor GEORGETOWN UNIVERSITY HOSPITAL 12/10/10 KEVIN T MCEVOY 309 STONEHEDGE DR CARLISLE PA 17015 PATIENT NAME: KEVIN MCEVOY ACCOUNT NUMBER: 7718941052 BALANCE DUE: ~ 1100.00 DATE OF SERVICE: 09/25/10 DEAR KEVIN T MCEVOY ~~~ MedStar Health Financial Services THIS IS YOUR FINAL NOTIFICATION Your account is seriously past due. Failure to send full payment immediately may result in your account being referred to our collection agency. Contact our office to make payment arrangements or mail payment in full of $ 1100.00 within 10 days from the date of this letter. If you have made a partial payment toward your balance but your account will not be paid in full within the next ten days you must still contact our office to make definite payment arrangements. For your convenience, free of charge, you may pay by check or CREDIT CARD OVER THE TELEPHONE BY CALLING (703)558-1400 Or (888) 896--1400. To mail your payment, make check or money order payable to the hospital and return it in the enclosed envelope. Please include your account number with your payment. To discuss your account, please call: (703) 558-1400 MONDAY - THURSDAY 8:00 A.M.- 4:30 P.M. (888) 896-1400 FRIDAY 8:00 A.M.-- 1:00 P.M. To pay by credit card, please complete the following and return it to us in the enclosed envelope. Circle credit card type: Credit Card Number: AMEX VISA DISCOVER MASTER CARD Please print Cardholder's Name: Cardholder's Signature: Account Number: 7718941052 Charge Amount 4969 Mercantile Road Baltimore, Maryland 21236 Exp Date .:~ ~~ MedStar Heaulth yj~"((G1 ''~i1~1{~i~l III GEORGETOWN PHYSICIANS GROUP PHYSICIANS' UNIFIED BILLING SERVICES P.O. BOX 631856 BALTIMORE, MD 2 1 263-1 856 COLLECTION NOTICE THIS IS A VERY IMPORTANT NOTICE. HAVE SOMEONE TRANSLATE IMMEDIATELY. ESTE ES UN AVISO IMPORTANTE. PIDA DUE ALGUIEN SE LO TRADUZCA INMEDIATAMENTE. DAY LA MQT THONG BAO RAT QIJAN TRONG. HAY CF{O NGUO'I ~DICH NGAY. AVI SA A~ENPOTAN ANPIL. FE YON MOl1N TRADWI Li IMEOYATMAN. 6S:ta'lull.{1~616r;t5€LS'1 6`L~'435Fi6~iU~i6LUA'1tSS1S'1 ESTE E UM AVISO MUITO IMPORTANTE. PEA OUE ALGUEM 0 TRADUZA IMEDIATAMENTE PARA VOCE. ATTN EINAI MIA IIOAT EHMANTIKH EHMGIS2EH. ZHTHE"1'E Af10 K,41lOlON NA SAE TII META<hPAEEI. • ~.!-°-{ I L>~ EA-.,~~ y --~ I ~ j.~ "J~ I . I ..tom ~ Lm a1~-~ Sl..e a .i.m BILL DATE: 10/28/2010 Estate Of Kevin Mcevoy 533 S 19TH ST HARRISBURG,PA 17104 10 ACCOUNT NO.: 6532301 Dear Estate Mcevoy: The balance due on your account has not yet been resolved. We would like to offer you a final opportunity to make payment on your account. Please complete the payment portion of this letter and mail your payment upon receipt of this letter. Your balance due is: $1387.57 If we do not receive payment or hear from you within 10 days, your account may be subject to further collection action. If you dispute this bill please contact our office immediately. Thank you, Unified Billing Services Collection Department A $30 service fee will be charged for checks returned for any reason. GEORGETOWN PHYSICIANS GROUP PHYSICIANS' UNIFIED BILLING SERVICES MedStar Health ~v~~ P.O. BOX 631856 gl~~~~~i~~~~~~~1 BALTIMORE, MD 21263-1856 BILLING QUESTIONS METRO AR EA: 703-558-1400 (OUTSIDE D.C.): 888-896-1400 PATIENT NAME ACCOUNT NUMBER Mcevoy,Revin T 6532301 BILL DATE AMOUNT DUE AMOUNT ENCLOSED 10/28/2010 1387.57 PLEASE SEE h;~~ r ~, ~ ~ ~ REVERSE SIDE WE ACCEPT: ~ .~' ~ `- ~ I ~~ 1 FOR DETAILS MAKE CHECKS PAYABLE TO: MGMC PROVIDERS GROUP 7 Estate Of Kevin Mcevoy 533 S 19TH ST HARRISBURG,PA 17104 REMIT TO: MGMC Providers Group 7 P. O. Box 631856 Baltimore, MD 21263-1856 I~~I~I~~~II~~I~I~II~~~~II~~~~III~~I~~I~I~~II~~~I~I~~II~~~I~I~I Please check here if your address has changed. If so, please list new address on the back of this stub. ' GEORGETOWN UNIVERSITY PHYSICIANS i PHYSICIANS' UNIFIED BILLING SERVICES M~ dS-r Health K~ P.O. BOX 631872 q~~ll~lll~p BALTIMORE, MD 2 1 263-1 872 I ESTATE OF KEVIN MCEVOY 533 S 19TH ST HARRISBURG PA 17104-2307 C~LLECTIQN NOTICE THIS IS A VERY IMPORTANT NOTICE. HAVE SOMEONE TRANSLATE IMMEDIATELY. ESTE ES UN AVISO IMPORTANTE. PIDA (]UE ALGUIEN SE. LO TRADUZCA INMEDIATAMENTE. DAY LA MQT THONG BAO RAT QIJAN THONG. HAY CHO NGUC7I DICI-I NGAY. AVI SA AaENPOTAN ANPIL. FE YON MOUN TRADINI LI IMEDYATMAN. 6s:L'1u6111~616€tf6i..f'1 EiS~ii~i6~it5~i6LSStri`1tSSlsa`1 ESTE E UM AVISO MUITO IMPORTANTE. PE(;A OUE ALGUEM 0 TRADUZA IMEDIATAMENTE PARA VOCE. AT'1-H EINAI MIA fIOAT £HMAN I'IF:H £HMEI12£H. ZHTH£TE AflO KAIIOION NA £A£ TH META4~PA£EI. . ~ ~g.aJ I ~ L~~ y .i.~ i ~ , , I t, I . I .~ a~ Lie aJd.~ ~ , ,i,e BILL DATE: 10/28/2010 2101 ACCOUNT NO.: 6532301 Dear Estate Mcevoy: The balance due on your account has not yet been resolved. We would like to offer you a final opportunity to make payment on your account. Please complete the payment portion of this letter and mail your payment upon receipt of this letter. Your balance due is: $303.65 If we do not receive payment or hear from you within 10 days, your account may be subject to further collection action. If you dispute this bill please contact our office immediately. Thank you, Unified Billing Services Collection Department A $30 service fee will be charged for checks returned for any reason. _ ............._.._._......._......-....-....-...-...-_....-............._.--..-.-....._..._..._...-........- ......._............-.-.......-.....__..._--........-._..........-_..__................_..._-._.........._-..-..--..........._.......-........._-..._......-......__..__.........-...-........._.._-..-....-----~~~c-c~oo.~..{~ios~..... ~ GEORGETOWN UNIVERSITY PHYSICIANS ~~.~ I='HYSIGiANS' i:EVIFIED BILL!tiCa SERVICES MedStar Health '~~~` P.O. BOX 631872 II~III ~I~IIIII BALTIMORE, MD 21263-1872 BILLING QUESTIONS M ETR O AR EA: 703-558-1400 (OUTSIDE D.C.): 888-896-1400 Estate Of Kevin Mcevoy 533 S 19TH ST HARRISBURG,PA 17104 PATIENT NAME ACCOUNT NUMBER Mcevoy,Revin T 6532301 BILL DATE AMOUNT DUE AMOUNT ENCLOSED 10/28/2010 303.65 PLEASE SEE ~~ I~~ ~ r ~, ~~ ~~ REVERSE SIDE WE ACCEPT: H A I '~ 1T0. FOR DETAILS MGMC RESEARCH PROVIDERS GROUP 5 REMIT TO: MGMC Research Providers Group 5 P. O. Box 631872 Baltimore, MD 21263-1872 I~~I~I~~~II„I~I~II~~~~II~~~~III~~I~I~~~I~I~I~I~~~I~~I~II~I~~I Please check here if your address has changed. If so, please list new address on the back of this stub. REV-1511 EX+ (10-06) .~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER `.. ~--,. Debts of decedent must be reported on Schedule I. ~4 (If more space is needed, insert additional sheets of the same size) ~iEV-1513 EX+ (9-00) ~. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE i TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. `~~~~ r . ~ ~.- -- ri' ~' \ C fC' V ~:~ ~' C ~ C., Y~i'l O ~~, Y`~'~'v ~ ~ C> ~o v' ~ ~ S ~ ~ ~/~' 1 ~ c~ I .5 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: 1. 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 $ fir more space is needed, insert additional sheets of the same size)