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HomeMy WebLinkAbout07-22-11 REV-15 0 0 Ex ennsylvania OFFICIAL. USE ONLY PA Department of Revenue P County Code Year File Number Bureau of Individual Taxes DEMIITNEMT OF IIEVENOE INHERITANCE TAX RETURN _ PO BOX 28o6oi ~ _ Harrisburg, PA RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ` Decedent's Last Name S~'~x Decedent's First Name MI Triplett ~ Lawrence ' A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name ~ Suffix Spouse's First Name MI Spouse's Social Security Number THlS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® Original Return O Supplemental Retum O Reir~ainder Return (Date of Death Prior to O Limited Estate O 4a. Future Interest Compromise (date of O Federal Estate Tax Return Required death after O Decedent Died Testate O Decedent Maintained a Living Trust Tonal Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O Litigation Proceeds Received O Spousal Poverty Credit (Date of Death O Election to Tax undF~r Sec. 9113(A) Between and (Att~3ch Schedule G) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ' ..Barbara Sumple-Sullivan ~ REGISTER OF WILLS USE ONLY ~ O -.V ~ First Line of Address ~ ~ ,ter Oj r Bridge Street c~~ ~ = f • ~ Second Line of Address U'y ~ ~ ~ r° r=-,, E. City or Post Office State ZIP Code DATE FIL~d~ ~ New Cumberland ~ PA ~ ~ ~ r-- „r~ C3 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI ATURE O PER N RESPONSI LE FOR FILING RE RN ~ Gary. L. Trlplei-t an~ATE ~ J~ f Rennie P . Tri _Lett / ADDRES Pine Tr rive, New Cumberland, PA Stonehedge Road, Mechanicsburg, PA SIGNAT E OF EPA OT REPRESENTATIVE A Barbara Sumple-~~ulli , Esq. DRE Bridge Street, New Cumberland, PA PLEASE USE ORIGINAL FORM ONLY Side 1 a ~ , ~ ~ •r REV-1500 EX (FI) Decedent's Social Security Number decedent's Name: Lawrence A. Triplett ';16Ei-12-7569 RECAPITULATION Real Estate (Schedule A) 1 _ . . . Stocks and Bonds (Schedule B) _ _ . . Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) Mortgages and Notes Receivable (Schedule D) Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... Jointly Owned Property (Schedule F) O Separate Billing Requested ' i Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ Total Gross Assets (total Lines 1 through Funeral Expenses and Administrative Costs (Schedule H) ' Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ' Total Deductions (total Lines 9 and Net Value of Estate (Line 8 minus Line Charitable and Governmental Bequests/Sec Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line minus Line TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES Amount of Line taxable at the spousal tax rate, or transfers under Sec. (a)(1.2) X Amount of Line taxable at lineal rate x Amount of Line taxable at sibling rate X Amount of Line taxable at collateral rate X TAX DUE _ _ _ _ _ _ FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 J r ~ ~ ~t REV EX (Fr) Page 3 Pile Number Decedent's Complete Address: DECEDENTS NAME Lawrence A. Triplett STREETADDRESS - . The Bridges at Bent Creek Bent Creek Boulevard CrTY STATE ZIP Mechancisburg PA Tax Payments and Credits: Tax Due (Page Line CreditslPayments A. Prior Pa ments _ y - - _ - _ _ - - - - - B. Discount Total Credits (A + B) Interest If Line 2 is greater than Line 1 + Line enter the difference. This is the OVERPAYMENT. Fill in oval on Page Line to request a refund. If Line 1 + Line 3 is greater than Line enter the difference. This is the TAX DUE. Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 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 ? d. receive the promise for life of either payments, benefits or care? ? If death occu?red after Dec. did decedent transfer property within one year of death without receiving adequate consideration? ? Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her dealh? ? Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July and before Jan. the tax rate imposed on the net value of transi~ers to or for the use of the surviving spouse is 3 percent P.S. (a) (i)]. For dates of death on or after Jan. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent P.S. (a) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July • The tax rate imposed on the net value of transfers from a deceased child years of age or younger at de~ith to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent P.S. §9116(a)(1.2)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is percent, except as noted in 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 percent P.S. §9116(a)(1.3)]. Asibling is defined, under Section as an individual who has at least one parent in common with the decedent, whether by blood or adoption. yl LAST WILL OF LAWRENCE A..TRIPLETT I, LAWRENCE A. TRIPLETT, of Jackson Township, York County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. FIRST: I direct that all my just debts and funeral expenses shall be paid from the assets of my estate as soon as practicable after my decease. SECOND: I devise and bequeath the residue oj: my estate of every nature and wherever situate to my wife, Louise B. Triplett, providing she shall survive me. Should my wife, Louise B. Triplett, predecease me,' I devise and bequeath the residue of my estate of every nature and wherever situate to my sons, Gary L. Triplett and ;Rennie P. Triplett, provided that the share of any son who predecfrases me shall be distributed to his issue per stirpes living at the time of my death, and I in default of any such then living issue such share shall be added to the share for my other son. THIRD : I direct that all taxes that may be asse~;sed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of t:he expense of the administration of my estate. LAWRENCE A. TRIPLETT FOURTH: I appoint my wife, Louise B~. Triplett, Executrix of this my last will. Should my wife, Louise B. Triplett, fail to qualify or cease to. act as Executrix, I appoint my son~~, Gary L. Triplett and Rennie P. Triplett, Executors of this my last will. FIFTH: I direct that my Executors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this ~3~ed day of December, LAWRENCE A . T1ZI PLE T The preceding instrument, consisting of this and one other typewritten page, each identified by the signature of the Testator, was on the day and date thereof signed, published and declared by LAWRENCE A. TRIPLETT, the Testator therein named, as and for his last will, in the presence of us, who, at his request, in his presence and in the presence of each other, all being present at t:he same time, have subscribed our names as witnesses hereto. ~ _ ~ r ~ j. ~ , . ' - r 2 ~I~ COMMONWEALTH OF PENNSYLVANIA - ss I COUNTY OF YORK TRIPLETT the Testator and 4 r~.: • ~ t ~.~,r~`: and I We , LAWRENCE A , _ _=,Y~x~ ; ~ the witnesses, whose names ire signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned that the Testator signed voluntaril,~ and that each of the witnesses in the presence of the Testator, at ~iis request and in the presence of each other, signed the will as a witness and that to the best of the knowledge of each witness the Testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. Testator no.~ k / ss . / ~ / J / / ' • ' I ' Witness j SUBSCRIBED, SWORN TO AND ACKNOWLEDGED beforE~ me by LAWRENCE A. TRIPLETT, the Testator, and subscribed and sworn to before me by ~ , . r:.C•r~~ I . e C• ; ~ and ` f•-? ; ~ r c~ i i the 'witnesses, on the day of i~=~.~n~~c , C' ' ~ ~ 'T Not aryl 'Public ~ • - . ~ . My Commission Expires . - ~ -~r Yo~L~Yor~c Co 'f ~ ' N•~ Gomr~~ ~ ~~~~arvaJlssr~a'~ d 3 ` i REV-iso8 EX+ (li-io) ~~s«~~~ SCHEDULE E .:z pennsylvan~a DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Lawrence A. Triplett Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH New Cumberland Federal Credit Union Savings Account, Accnt. New Cumberland Federal Credit Union Check Account, Accnt. 5 New Cumberland Federal Credit Union CD New Cumberland Federal Credit Union CD New Cumberland Federal Credit Union CD New Cumberland Federal Credit Union CD M & T Bank Check Account, Accnt. #832537C2 1 g. Vanguard Mutual Funds Account g. Personal Property Prudental Rebate (No Receipt) Comcast Rebate Federal Tax Refund (No Receipt) Local Tax Refund (No Receipt) TOTAL (Also enter on Line Recapituilation) $ If more space is needed, use additional sheets of paper of the same size. ~ PAGE I STATEMENT OF ACCOUNT ~ 1 NEW CUMBEgtLAND ~'EDEIZAL CREDIT YTNI®N M ERR Y C H R I S T M A S ~~cr ~olntntcnit~ Credit ~Znion L O A N E L S E W H E R E I S B A C K.. NEW-USED CAR MO eo. Bns ass • !Yew Cumberland, 1'A wwN~.ncfcuunline.org 4 . % H O M E E QUIT Y T O O M O ; 7•~-~~o~ . (S00) 7 1 G-2325 . c~17~ 7~~t-~~~c W W W. N C F 0 0 0 N L I N E. 0 R G ACCOUIVT NUMBER 1 3 8 6 I A T 3 5 7 Joint Owners 0 "l 3 9 ~~~~~~~>I~~ili~~~~~~~~~~~~~~~~i~~~~~~~1~~~~~~~~uli~~~~~c~~ii~~ SOCIALSECURITY# LAWRENCE A TRIPLETT Stonehedge Lane STATEMENT PERIOD Mechanicsburg PA FROM To TRANSACTION EFFECTIVE DESCRIPTION AMOUNT FINANCE FEES/ DATE DATE CHARGE FINES BALANCE PREVIOUS BALANCE Sl-PRIMARY SHARES 4 ~ HOME BANKING TRANSFER TO S 4 4 DIVIDEND 7 THE ANNUAL PERCENTAGE YIELD EARNED IS . NEW BALANCE DIVIDEND IS CALCULATE 7 USING A DAILY BALANCE METHOD. PREVIOUS BALANCE S4-SHARE DRAFTS 8 SHARE DRAFT CLEARED 3 5 SHARE DRAFT CLEAREB 5 PAYMENT CHECK ~ 7 SNARE DRAFT CLEARED 5 2 SNARE DRAFT CLEARED 2 ~ HOME BANKING TRANSFER FROM S 1 2 SHARE DRAFT CLEARED 2 DIVIDEND THE ANNUAL. PERCENTAGE YIELD EARNED IS O.I . NE6V BALANCE DIVIDENI IS CALCULATE 4 USING AN AVERAGE DAILY BALANCE METRO SHARE DRAFT UMMARY - - - II03 PREVIOUS BALANCE CERTIFICATE 2 4 CERTIFICATE EARNINGS 3 THE A~~NUAL PERCENTAGE YIELD EARNED IS . NEW BALANCE (MATURES 3 Your current Member Rewards level is DIAMD PLUS wh ch entit es you to a increase over and above our base rate on fut re CD u chases. PREVIOUS BALANCE CERTIFICATE 8 9 CERTIFICATE EARNINGS 0 THE ANNUAL PERCENTAGE YIELD EARNED IS . NE4~ BALANCE (MATURES 9 1~our current Member Rewards level is DIAMD PLUS wh ch entit es you to ~ increase over and above our base rate on fut re CD u chases. L101 PREV:C.OUS BALANCE CERTIFICATE 9 4 TOTAL DIVIDEND YEAR-TO-DATE ~ ~ C 0 N T I N U E D ~ ~ TOTAL FINANCE CHARGE YEARR-TO-DATE for all savings except !RA savings. Dividends shown, if over ~ will be reported for all loans to the Internal Revenge Service: for this calendar year. tNDICATcS EFFECTIVE DATE NOTICE: See reverse side for important information ` PAGE STATEMENT OF ACCOUN-.~ 2 1o1EW ~UiVI~EIZLANI) ~EIDEI?.p:L C]ELEDI'I' L7RTION M ERR Y I~ H R I S T M A S dour Corn~nunit~ C'rec~it ZZnion LOAN ELSEWHERE IS BACK. . 2 . t~EW-USED CAR 6 0 MO I HOME EQUITY TO MO CO. lint GSts . Ncw Cumbcrlrnd, PA . ~~ww:ncfcuunlinc.org WWW . N C F= 0 0 0 N L I N E. 0 R G 7?4-77UG . 71G-2328. Faz: 774-7~9G ACCOUNT NUMBER Joint Owners 0 7 3 9 SOCIAL SECURITY # LAWRENCE A TRIPLETT STATEMENT PERIOD FROM TO TgANSACTION EFFECTIVE DESCRIPTION AMOUNT FINANCE FEES/ BALANCE DATE DATE CHARGE FINES CERTIFICATE EARNINGS 2 6 TFIE ANNUAL PERCENTAGE YIELD EARNED IS . h1EW BALANCE (MATURES 6 Your current Member Rewards level is DIAMD PLUS wh ch entit es you to a increase over and above our base rate on fut re CD u chases. PREVIOUS BALANCE CERTIFICATE 8 CERTIFICATE EARNINGS 5 TiiE,ANNUAL PERCENTAGE YIELD EARNED IS . NEW SAl..ANCE CL<~ATUl~ES 5 Your current Member Rear~ards level is DIAMD PLUS wh .ch eni:it es you to a increase aver aricd above our base rate on fut re CD u chases. OVERDRAFT AND RETURNED ITEM FE S SUMNI R ~ TOTAL FOR ~ TO AL ~ THIS PERIOD ~ YEAR-TO-DA E TOTAL-OVER RAFT FEES I S ~ s TOTAL RETURNED ITEM FEES ~ Y ~ $ TOTAL DIVIDEND YEAR-TO-DATE TOTAL FINANCE CHARGE YE~~R-TO-DATE for all savings except Ii3A savings. Dividends shown, if over will be reported for all loans to the Internal Revenue Service for this 5 3 0 0 0 calendar year. 'INDICATES EFFECTIVE DATC NOTiGE: See reverse side-far important information ACCOUNT N0. ACCOUNT TYPE STATEMENT PERIOD PAGE M&T CLASSIC CHECKING W/INTEREST NOV.20-DEC.20,2010 1 OF 1 0 06914M NM LAWRENCE A TRIPLETT STONEHEDGE LN MECHANICSBURG PA INTEREST PAID YEAR TO DATE ROUTE & PENNSYLVANIA AVE ACCOUNT SUMMARY BEGINNING.:: DEPOSITS::$ ::OTHER :CURRENT:..: ..:.ENDING BALANCE OTHER ADDITIONS CHECKS PAID _ ~SUBTRACTIONS~ ~ INTEREST PDBALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 0 0 1 ACCOUNT ACTIVITY POSTING:. _ - ~ DEPOSITS;INTEREST ::CHECKS g::OTHER::: DAIL:Y.. . DATE TRANSACTION DESCRIPTION :~:OTHER=ADDITIONS:<..:_SUBTRACTIONS BALANCE'_~ BEGINNING BALANCE CLOSEOUT ENDING BALANCE ANNUAL PERCENTAGE YIELD EARNED = **ANNOUNCING THREE CONVENIENT WAYS TO BANK ON YOUR MOBILE PHONE** 1-MOBILE TEXT BANKING: LOG ON TO WEB BANKING TO ENROLL NOW 2-MOBILE WEB BANKING: VISIT MTB.COM USING THE BROWSER ON YOUR MOBILE DEVICE 3-APP FOR IPHONE: DOWNLOAD IT FROM THE APP STORE TODAY M&T MOBILE BANKING IS FREE 8 SECURE. VISIT MTB.COM/MOBILE FOR MORE INFORMATION. (YOUR MOBILE CARRIER'S TEXT AND DATA CHARGES MAY APPLY) L006A DECEMBER t Vanguard LifeStrategy Income Fund RENNIE P TRIPLETT EX GARY L TRIPLETT EX ACCOUNT VALUE CHE~C~ EST ESTATE OF LAWRENCE A ~ ~ $ . C~~F~~~~'~~Q~~`~ TRIPLETT ~ - STONEHEDGE LN ~ M FUND NUMBER x'23 MECHANICSBURG PA ACCOUNT NUMBER CHECK NUMBER ACCOUNT SERVICE CALL Trade Transaction Dollar Share Share Shares Date Descri lion Amount Price Amount Owned BEGINNING BALANCE Transferfrorn x:,970.078 Check redemption -x:,970.078 PAID THIS Income + Short-term + Lony-term TOTAL CALENDAR Dividends Gains Gains DISTRIBUTIONS YEAR Detach this confirmation and retain for your records before cashing or depositincl check. - _.z _ , - _ , ; ~ _ _ ~ . 1 i t Ritner Highway Carlisle, PA Bill Rowe (AU 1538L) Dave Rowe (AU 2295L) .A~cction Is Action Call ``Rowe" For. Satisfaction . t ti _ DATE _ y; y,~` - SELLERS NAME ~ - ~ j ~ ~ ~ ~ PHONE Y, : ~ ~ f ADDRESS r - . a ~ t _ ~rst F~ OTHER ---a. ~ . ~,ti~ ` •Y- ~ AUCTIONEER % AUCTION DATE/LOCATION ' S;4'`' I'~ CLERK % DESCRIPTION OF MERCHANDISE 1 ~ `l i., i .i w,. P , t a ~.t •.i. 9 is ~,r' i ~ ` 1 - d ~ ~ r }i _ ~ ~ ?rte ' ( y.., ry> ' !~~~~'-!'v..~ r ~s,'~_"~,~ ~ n' - .-.r ~ F`~Y) , . . ~ .fib / Y~= ~ t'`.. ~ ~ ,,,irt:~ r~ of ~ f~ ~ r ..-..r 1 t :r1.. i1.;,,,.~ t~ f ~ r- _ t ti.'+. ,.r~ : _ _ ~ ~ b ~ .S 4.'\y 1 w ir'-..`_ } i S ~ S ~ ~ ..r_- ~'Z. •'_i '~-rr ~~f,,y: r~ty1 ' i•~i `~...i~tif"., yt, 'k„_`-s.. ti .ra"~ :~~o_,d "f ~e { ~ 1 t ' ± ''til-..~ ~ i~'j ,a.. t t ~'.-S~t"....r. 'vt E~ ~ , v'~'s~.:'b'°~.~ ~ c_ C~,~t.--- f.!'~, '~:F _ ter}.. ~ ,;..J - , f'h e. 4 ~ F, ~ I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise ~to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- tative of the merchandise, goods and or property and have good title and the right to sell and that they are free from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this -agreement. AUCTION SIGNATURE SELLERS SIGNATURE " Total Sales (Clerking Tickets Attached} ~ ~ t Less Sale Expense: _ .y - y...~ ~ -ti ~ ::r ,,...r„ ` % Commission Auctioneer $ ~A ~ % Commission Clerks ~ ~ - . _....r OTHER: • TOTAL SALE EXPENSE DEDUCTED ~ SELLERS NET ~ , Account Number 3 ' Billing Date Total Amount Due Payment DuE; by No Payment Due Page 1 of 2 1 Gontact us: Ott°F+~ www.comcast.com'~~'~~ LA1IV~ENGE T~IPLETT _ Previous Balance For service at: Payments -received by BENT CREEK BLVD RM MECHANICSBURG PA New Charges -see below .:Total ,A,mour~t due ~~WS ~rOt1'1 COi'1'1Gc~St Payment{Due by No Payment Due ` ~ - You have a credit balance of-22.99. Make no payment ! ~ - ~ ~ ~ ~ ~ ~ ~ - - ~ t ~ . , .r.._.._ _ Our records indicate that you have a credit balance. All Partial Month Charges & Credits credit balances of or more will automatically be Effective you made changes to your T refunded to you. If your credit balance is less then account. Seethe following pages for more details. T Q and you would like us to send you a refund, please Taxes, Surcharges Fees m contact our office by mail or phone with your forwarding - ° address. However, if you are still a customer, this Total~New,Charges ` balance will be transferred to your new account. _ - HearinglSpeech Impaired Call _ - _ _ - Detach and enclose this coupon with your payment. Please write your account number on your check or money order. Do not send cash. ~o~~~~~~ Account Number Payment Due by No Payment Due SUZY STREET' Total Amount Due LEBANON PA AV A**SDGT Amount Er1CIOSeC~ Ilit'III'~I~""~`III~"III"I.I~I~I1~1'~I~I~~~~~~I~I"~'~I~~II'~I Make checks payable to Comcast LAWRENCE TRIPLETT LAWRENCE TRIPLETT STONEHEDGE LN II'I~'~"~1'Illlll~ll'Il'III'~'II~II'Il~~ll~~~~~~1'~111'~"II~I~' MECH PA COMCAST CABLE P 0 BOX SOUTHEASTERN PA 3 7 REV-1511 EX+ Q:. ~.s::° SCHEDULE H ~y.::., . ~ ~ pennsylvan~a DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Lawrence A. Triplett Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: Keefer Funeral Home Funeral Luncheon (No Receipt) B. ADMINISTRATIVE COSTS: Personal Representative Commissions: - Name(s) of Personal Representative(s) - Street Address City - - State -.ZIP Year(s) Commission Paid: _ Attorney Fees: Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City _ - _ _ - - State -----ZIP Relationship of Claimant to Decedent _ Probate Fees: + - Accountant Fees: Tax Return Preparer Fees: West Shore EMS s. Cumberland Law Journal -Estate Notice -Legal Publication s. The Patriot News -Estate Notice -General Circulation Publication TOTAL (Also enter on Line Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. JOHN W, Mt. Rose Ave. W. Market St. York, PA York, PA ~ V N ~ ~ Fax: ~ O ~ ~ Fax: John W. Keffer, Supv. Joseph V. Keffer, Supv. Website: www.KefferFH.com AND CREMATORY INC. Email: KefferFH Cap aol.com December Mr. Rennie Triplett Stonehedge Lane Mechanicsburg, Pennsylvania For service for: Lawrence A. Triplett Our service including: Transfer from the Bridges at Bent Creek in Mechanicsburg Professional service Supervision of service and necessary office work A Monarch bronze finish steel sealed casket with a crepe interior and a blanket to match Funeral coach and service car for flowers and lead Register book, memorial folders, and acknowledgement cards Use of funeral home and equipment and service of assistants Total for services and merchandise: Items for which we advanced payment: Grave Opening Charge York Newspaper Obituary Harrisburg Newspaper Obituary Clergy Offering Certified Copies of Death Certificate Flowers Ordered Total advanced Total for service: ~ Balance due Thank you, Mr. Triplett. /~/~l~i~ Butler, Gin erich C:®. g Certified Public Accountants E. Market Street • P.O. Box York, PA Telephones: • Lawrence A. Triplett clo Rennie Triplett Stonehedge Lane Mechanicsburg, PA Terms: Payable within days from date of invoice. 1'/z`.% per month will be added on past due accounts. FOR PROFESSIONAL SERVICES RENDERED Preparation of personal income tax returns ~ ~ Balance D~ae _ <.!ur-tnc ~ i ~ Y Ut~IET PRICE (~t~fiOUt~IT STRETCHER One Way Transport T2005 Transport Van Mileage S0209 Totai Charges DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT d ~ - Total Credits RLE~SE ~~.Y.TE-~iS ~.ft~OE~t~T - EEe~06GE ~{.fE U'PO~~E F:EGE[PT ~ET~'F~~~Ef~ CE~EC~ FEE - ~31.QQ PATIENT NAME: TRIPLETT ESTATE, LAWRENCE ALL NUMBER: 2'11095W ,aMOUNr PAID: 6 3 [~~rP~~.T~,~~T {~~ESS~~ ES: THIS SERVICE IS NOT COVERED BY MEDICARE OR MIEDICAL ASSISTANCE. ~ 4 WEST SHORE EMS -BLS GRANDVIEW AVE SU{TE CAMP HILL, PA .I ~'~Rssocv~~`° CUMBERLAND LAW JOURNAL SOUTH BEDFORD STREET CARLISLE, PA Tele: Fax: December Cumberland Law Journal is published every Friday by the (;timberland 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: Barbara Sumple-Sullivan, Esquire Lawrence A. Triplett 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: December December and December Advertising Cost $ Proof of Publication $ Second Proof Request $ Payment received $ Total Amount Due $ Becky H. Morgenthal, Executive Director a Thy Patriot-dews Co. , 202J Technology Pk~Ny ~ ~ Suite ~ ~ti~echanicsburg, PA ~l101r~/ ~fOLI ~CP10W Inquiries - ' BARBARA SUMPLE-SULLIVAN BRIDGE STREET NEW CUMBERLAND PA ALL CHARGES ARE NEl ACCT # NAME AD ORDER # DATE EDITION ADDTL. INFO. TYPE OF CHARGE AMOUNT BARBARA SUMPLE-SULLIVAN REGULAR BOLD TEXT CHARGE BARBARA SUMPLE-SULLIVAN REGULAR BASIC AD CHARGE BARBARA SUMPLE-SULLIVAN REGULAR BASIC AD CHARGE BARBARA SUMPLE-SULLIVAN REGULAR BASIC AD CHARGE AFFIDAVIT CHARGE TOTAL: REMITTANCE ADDRESS The Patriot-News Co. Network PL Chicago, IL Please include the Account # or Ad Order # (above) with your rerrlittance--Thank You NOTE: This Invoice replaces the Order Confirmation which we previously sent with Proofs of Publication REV-1512 EX+ (12-OS) r pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Lawrence A. Triplett Report debts incurred by the decedent prior to death that remained unpaid at the date of death, includin51 unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Rosa Lucidor -Round the Clock Care Bridges at Bent Creek Albert Pharmacy + TOTAL (Also enter on Line Recapitulation) $ If more space is needed, insert additional sheets of the same size. . ~ U' / ~ ~ ~ rt ~ ~~r. , r ~ ,J ' it { r G V f r ~ ~ 1 ~ ~ ~ ~ r G'~~ ~G v ~r ! ~ ~ 3 ~ . ~ ~ ~ . ~i ~ ~ ~ ~ ~yV / t ~~~/~~V~ li ii ~ l ~ ~ ' y-'f" L v ~ ~ ~ - r~. ~ L,L ~ i `j ~ ~ F ~ . ~ y F, ~ ~ v.vv ~,v ~ v Kent , , Cr Rent ..rte ~ Y v~.r Current Days Days Days Amount Due - czv.u. a-+.~ .11VL.LJ1 a7Y1C11V17.7 ~ i'H 1 ~ Vb~ D' P D 0 rD ° . ~ ACTIVITY FOR TRIPLETT, LAWRENCE -TRIPE - THERA TABLET O1 * TAMSULOSIN 0.4MG O1 PROPRANOLOL ER O1 SERTRALINE 100MG O1 SIMVASTATIN MG O1 4 ACTONEL MG O1 FUROSEMIDE 40MG SENNA PLUS TABLET O1 * PLAVIX MG O1 ISOSORBIDE *MN* 3 O1 CALCIUM 600MG W/D O1 * OMEPRAZOLE MG Payment-Thank You 1 OMEPRAZOLE MG O1 2 ELASTIC BANDAGE 6 O1 * GAUZE PAD STER 3X O1 1 TRAZODONE MG Ol • . 0 LEGEND NON-LEGf;N g FOR MONTH FOR MONT revious Balance Charges this month Fanan~e Charge 4®'FAL C6~/'~FZ~aES Total Payment & Credits bs ~'~~~~g + + - ~ / J~~ ~ FOR ALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services, Inc at Statement Terminology on reverse ~ ~ w e ~ ~ ~ ~ ~ ~ ® e ACTIVITY FOR TRIPLETT, LAWRENCE -TRIPE - it/1Uj10 THERA TABLET Ol * TAMSULOSIN 0.4MG Ol 18.11c PROPRANOLOL ER O1 24.87c SERTRALINE 100MG O1 11.90c SIMVASTATIN MG O1 13.82c 3 ACTONEL MG O1 86.82c SENNA PLUS TABLET O1 * PLAVIX MG Ol 110.14c FUROSEMIDE MG Ol 8.40c ISOSORBIDE *MN* 3 O1 11.71c CALCIUM 600MG W/D O1 * OMEPR.AZOLE MG Ol 17.92c 9 TRAZODONE MG Ol 7.29c Payment-Thank You . o o LEGEND NON-LEG~;ND TO~'AL YAX FOR MONTH FOR MONTH 'revious Balance Charges this month Finance Charge T®T'AL CFl/ARGES Total Payment 8 f;redits ~M®~~ . ~ E + + - - - FOR ALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services, Inc at 1-800-266-9'x54 Statement Terminology on reverse I ' ! , ' RE1~'-151:1 EX+ (Ui-lU) Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Lawrence A. Triplett 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. (a) Mr. Gary L. Triplett Pine Tree Drive, New Cumberland, PA Son Mr. Rennie P. Triplett - Stonehedge Road, Mechanicsburg, PA Son ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES THROUGH OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size.