HomeMy WebLinkAbout08-01-111505610140
REV-1500 EX I°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN ~ ~ ~ ` V~~
Harrisburg, PA 17128-0601 RESIDENT DECEDENT l.~ ~7
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 7 4 0 5 3 5 8 1 1 2 2 7 2 0 1 0 0 8 2 3 1 9 1 7
Decedent's Last Name Suffix Decedent's First Name MI
H A I R S R R O B E R T 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
a 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
^X 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 0 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)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
R O G E R M O R G E N T H A L E S Q 7 1 7 2 3 4 2 4 0 1
First line of address
4 4 3 1 N F R O N T S T
Second line of address
3 R D F L O O R
City or Post Office State
H A R R I S B U R G P A
REGISTER OF WILLS USE ONLY
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Correspondent's a-mail address: RMORGENTHAL(u~SASLLP.COM
Under penalties of perjury, eclare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct a com te. Declaration of preparer oth than the personal representative is based on all information of which preparer has any knowledge.
SIG O E N I ILIN ETURN DATE
13 2 W •.~1~~ E D R
SIGNA RE F P PAF~R Otbl R~THAN R
CARLISLE
TE
ADDRESS ` ~''
4431 N• FRONT ST•, 3RD FLOOR HARRISBURG PA 17110
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140
1505610240
REV-1500 EX
Decedent's Name: ROBERT F • HAIR S R
Decedent's Social Security Number
1 7 4 0 5 3 5 8 1
RECAPITULATION
1. Real Estate (Schedule A) ......................................... .. 1.
2. Stocks and Bonds Schedule B 2. 2 1 0• 0 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3.
4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 8 5 3 . 0 9
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 1 5 9 0 . 3 0
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested ..... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 2 6 5 3 3 9
9. Funeral Expenses and Administrative Costs (Schedule H) ............ ...... 9. 1 6 7 6 3 7
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ...... 10. 8 8 0 2 8 9
11. Total Deductions (total Lines 9 and 10) ......................... ...... 11. 1 0 4 7 9 . 2 6
12. Net Value of Estate (Line 8 minus Line 11) ...................... ...... 12. - 7 8 2 5 . 8 7
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .......... ...... 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .............. ...... 14. - 7 8 2 5 • 8 7
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 _ 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .0 _ 0 0 0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 1 g.
19. TAX DUE ..................... .................. ... ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
1505610240
o. 0 0
0. 0 0
0. 0 0
0. 0 0
0. 0 0
REV-1500 EX Page 3
Decedent's Complete Address:
0.00
DECEDENT'S NAME
ROBERT F. HAIR, SR.
STREET ADDRESS
THORNWALD HOME ______
442 WALNUT BOTTOM R_D__.___
_
CITY
STATE Zli P
CARLISLE PA ~ 17013
Tax Payments and Credits:
~ ~ Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
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.
File Number
0 0
Total Credits (A + B) (2)
(3)
(4)
(5)
Make check payable to: REGISTER OF WILLS, AGENT
0.00
0.00
0.00
0.00
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 : ................................................................. ..... ^ ^X
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? .................................................. ..... ^ 0
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 death? .... ..... ^ Q
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ............................................................................................. ..... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory 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.
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
ROBERT F. HAIR, SR. 0 0
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CV STOCK -SOLD 210.00
TOTAL (Also enter on line 2, Recapitulation) I $ 210.00
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
ROBERT F. HAIR, SR. 0 0
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
1. REFUND - THORNWALD HOME 853.09
TOTAL (Also enter on line 5, Recapitulation) I $ 853.09
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
ROBERT F. HAIR, SR. 0 0
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) I ADDRESS (RELATIONSHIP TO DECEDENT
A. ROBERT F. HAIR, JR.
132 WEST LAKE DR
CARLISLE PA
SON
B.
C
JOINTLY-OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTERESI
1. A. SOVEREIGN BANK CHECKING ACCOUNT 3,180.60 50. 1,590.30
TOTAL (Also enter on Line 6, Recapitulation) I $ 1 590.30
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ROBERT F. HAIR, SR. 0 0
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. EWING BROTHERS 901.37
2. WESTMINSTER CEMETERY -OPENING GRAVE 210.00
B.
1
2.
3.
4.
5.
6.
7,
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State
Year(s) Commission Paid:
Attorney Fees: SMIGEL, ANDERSON & SACKS, L,LP
Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address
City State _
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
SOVEREIGN BANK -BANK FEE
550.00
15.00
TOTAL (Also enter on Line 9, Recapitulation) I $ 1 676.37
If more space is needed, use additional sheets of paper of the same size.
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ZIP
ZIP
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ROBERT F. HAIR, SR. 0 0
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. MILLENNIUM PHARMACY 63.91
2. (DEPARTMENT OF PUBLIC WELFARE -LIEN I 8,738.98
TOTAL (Also enter on Line 10, Recapitulation) I $ g,g02.89
If more space is needed, insert additional sheets of the same size.
I~EV-1513 EX+ (01-10)
pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ROBERT F. HAIR, SR. 0 0
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. ROBERT F. HAIR, JR. Lineal
132 W. LAKE DR.
CARLISLE PA
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A, SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN;
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
It more space is needed, use additional sheets of paper of the same size.
3514-01
LAST WILL AND TESTAMENT
OF
ROBERT F. HAIR SR.
I, ROBERT F. HAIR, SR., of 353 McAllister Church Road, Carlisle
(West Pennsboro Township), Cumberland County, Pennsylvania,
declare this instrument to be my Last Will and Testament, in manner
and form following:
1. I hereby expressly revoke all Wills and Codicils heretofore
made by me.
2. I hereby direct my Executor to pay all my just debts, funeral
and administrative expenses out of my estate, as soon as practicable
after my death.
3. I direct that all taxes which may be assessed in consequence
of my death of whatever nature and by whatever jurisdiction imposed
shall be paid out of my estate as a part of the administration of my
estate.
4. I give, devise and bequeath all the rest, residue and
remainder of my estate of every nature and wherever situated to my
son, Robert F. Hair, Jr. ; or if he is not then living, to his sons then
living in equal shares.
5. I nominate and appoint my son, Robert F. Hair, Jr., as
Executor of this my Last Will and Testament; and should rie fail to
qualify or cease to serve in that capacity, I nominate and appoint
Farmers Trust Company, Carlisle, Pennsylvania, as substitute Executor.
6. I direct that my personal representative shall not be required
to file any bond or other security in any jurisdiction to secure the
faithful performance of his duties nor be required to obtain any order
1
3514-01
or approval of any Court for the exercise of any power or discretion set
forth in this Will.
7. In addition to the powers conferred by case law, by statute
and by other provisions of this Last Will and Testament, my personal
representative shall have the following discretionary powers applicable
to all real and personal property held by him, which powers shall be
effective without Order of any Court and which shall exist and continue
until the time of actual distribution:
A. To retain any property of any nature re-
ceived by them for whatever period he shall deem
advisable;
B. To invest and reinvest all or any part of the
assets of my Estate without regard to statutes
limiting the property which a fiduciary may pur-
chase;
C. To sell, transfer, exchange or otherwise
dispose of, any part of the assets of my Estate, for
cash or on terms, publicly or privately, or to lease,
without liability on the purchasers to see to the
application of the proceeds, and to give options for
±rese purchases v }thout the obligation io repudiate
them in favor of a higher offer;
D. To execute and deliver any deeds, leases,
assignments or other instruments as may be neces-
sary to carry out the provisions of this Will;
E. To borrow money, if necessary to facilitate
the administration and closing of my Estate,
including the right to borrow money from any bank,
2
3514-01
and to mortgage or pledge any asset of the estate as
security;
F. To loan to, and to purchase assets from, my
estate, even if he is also acting as Executor thereof.
G. To assume continuance of the status of any
beneficiary with regard to death, marriage, divorce,
illness, incapacity and similar incidents or matters
in the absence of information deemed reliable
without liability for disbursements made on such
assumption;
H. To make any distribution hereunder either
in kind or in money, or partially in kind and partially
in money, considering of course the reasonable
wishes of the beneficiary. Distribution in kind shall
be made at the appraised value of the property
distributed, as it is set forth in the inheritance tax
return filed in my Estate;
I. To exercise any subscription right in con-
nection with any security held hereunder, to consent
to or participate in any recapitalization, reor-
g2.:Zization, consolidation or merger of any corpo-
ration, company or association, the securities of
which may be held hereunder; and to delegate au-
thority with respect thereto, to deposit investments
under agreements, to pay assessments, and generally
to exercise all rights of investors;
3
351 4-01
J. To continue in any partnership, joint ven-
ture, joint ownership or other business enterprise of
which I am a part at the time of my death;
K. To compromise claims;
L. To continue for whatever period of time my
personal representative shall deem necessary any
ownership as a tenant in common or as a partner, in
real estate or other property and to act as I would
have done had I been living;
M. To do all other acts in his judgment
necessary or desirable for the proper management,
investment and distribution of the assets of my
Estate.
8. All income or principal held for the use and benefit of the
beneficiaries of this Estate shall not be in any way or manner subject to
anticipation, assignment, pledge, sale or transfer, no shall any such
interest, while in the possession of my personal representative, be
liable for or subject to the debts, contracts, obligations, liabilities or
torts of any beneficiary, or to attachments, executions or seques-
trations ~.Ander process of la~v.
If any beneficiary of the Estate shall, in the sole opinion of my
personal representative, be or become mentally or physically inca-
pacitated, by reason of illness, accident, minority or other circum-
stance, my personal representative may apply either income or
principal for the support and welfare of such beneficiary directly or to
4
3514-01
the person who has the care and control of such beneficiary, without
the intervention of any Guardian and without obligation to supervise
application of said amounts in any way.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this ~ ~,-~ day of December, 1991.
,; ,._ ~ (SEAL)
ROBERT F. HAIR, SR.
~- • r •.
5
3514-01
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
I, ROBERT F. HAIR, SR. , Testator, whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law, do hereby acknowledge that I signed and executed the in-
strument as my Last Will; that I signed it willingly; and that I signed it
as my free and voluntary act for the purposes therein expressed.
Sworn or affirmed to and acknowledged before me, by ROBERT
F. HAIR, SR. , Testator, this I ~~~ day of December, 1991.
1 J i
Testator
r_
w„.,,~ ..
SCE+'~t...~Nc;tA'1s~ ;~16;.1~ ..
~ aANICE E. a~bCl ~ ;~ ~...I ~;~.~~~.E. ~~
~N GOMN6lSStLh ~f:: ~ ...,
6
3514-01
COMMONWEALTH OF PENNSYLVANIA
. SS.
COUNTY OF CUMBERLAND
We, Roger M. Morgenthal and Debbie D. Nelson ,the
witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and say
that we were present and saw Testator, ROBERT F. HAIR, SR. , sign
and execute the instrument as his/her Last Will; that he/she signed
willingly and that he/she executed it as his/her free and voluntary act
for the purposes therein expressed; that each of us in the sight of the
Testator signed the Will as witnesses; and that to the best of our
knowledge the Testator was at that time 18 or more years of age, of
sound mind and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me by Roger M.
Morgenthal and Debbie D. Nelson ,witnesses, this ~ ZfL. day
of December, 1991.
Roger M. '1`.Zor~en+hal
b
tJpTAR1Al SFAt.. , ~'~
N{3T . ~ a
J1~NICE E. NERt2LER. r ~ ~~~ ~¢
CUM6F1iiJtND WUNYY
FAY.WMMlSSiON EXPIRES Ft •P.G~~ r ~, 1Q95
7
:.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
January 31, 2011
SMIGEL ANDERSON & SACKS LLP
ROGER M MORGENTHAL ESQUIRE
4431 NORTH FRONT STREET 3RD FLOOR
HARRISBURG PA 17110-1778
Re: Robert Hair
CIS #: 860293252
SSN: ###-##-3581
Date of Death: 12/27/2010
Dear Attorney Morgenthal:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $8,738.98 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse t=he
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $8,738.98, was incurred during
the last six months of the decedent's life; therefore, it is a Class 3 claim
pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20
Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered
as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
. ~' .. _~,,tt
~,r ~ JG{~
Terri M. Smith
Claims Investigation Agerit
717-772-6961
717-772-6553 FAX
Enclosure
COMMONWEALTH OF PENNSYlVAN1A
pEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
January 24, 2011
STATEMENT OF CLAIM SUMMARY
NAME Estate of HAIR, ROBERT
IQ 880 293 252
MEDICAL CLASS 3 CLASS 5.T TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 7,977.98 .00 7,977.98
DRUG 761.00 .00 761.00
REIMBURSEMENT TO DPW 8,738.98 .00 8,738.98
COMMpNWEALTH OF PENNSYLVANIA'
DEPARTMENT .OF PUBLIC WELFARE
EIN - 23-6003113 '.
COMMONWEALTH OF"PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
NAME'- HAIR, ROBERT
ID ''.. " 860 293 252
THORNWALD HOME
442 WALNUT BOTTOM RD
:ARLISLE PA 17013
DATE OF, SERVICE PAYMENT DATE ORIGINAL CRN
10/01/10 - 10/31/10 12/20/10 20103374030340001
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
11/01/10 - 11!30/10 12/20/10 20103374030330001
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
12/01/10 - 12/27/10 01/20/11 27110204021850001
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
ADJUSTED CRN ' I USUAL CHARGES (.AMOUNT APPROVED
20103374030340001 5,861.17 3,235.91
20103374030330001 5,672.10 3,050.58
27110204021850001 5,199.67 7,691.49
PROVIDER SUB TOTAL THORNWALD HOME 18,732.94 7,977.98
03 100755529 0006
COMMONWEALTH OF PENNSYLVANIA
.DEPARTMENT OF PUBLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
NAME HAIR, ROBERT
ID 860 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
VIECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10/01/10 - 10/01/10 01/03/11 25103405542590001 25103405542590001 52.11 7.48
DIAGNOSIS 1 : 0
NDC CODE : 00228266550 GABAPENTIN 100 MG CAPSULE - ANTICONVULSANTS
10/04/10 - 10/04/10 12/27/10 25103375724440001 25103375724440001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
10/05/10 - 10/05/10 01/03!11 25103405542460001 25103405542460001 211.50 56.66
DIAGNOSIS 1 : 0
NDC CODE : 00065026005 TRAVATAN Z 0.004% EYE DROP - OPHTHALMIC PREPARATIONS
10/09/10 - 10/09/10 12127!10 25103375724350001 25103375724350001 2.78 2.78
DIAGNOSIS 1 : 0
NDC CODE : 00472034356 HYDROCORTISONE 1% CREAM - GLUCOCORTICOIDS
10/11/10 - 10/11/10 12/27/10 25103375724630001 25103375724630001 238.81 36.47
DIAGNOSIS 1 : 0
NDC CODE : 00597007541 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS
10!13/10 - 10!13/10 12/27/10 25103375724680001 25103375724680001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
10/18!10 - tOH8l10 1?/27f10 25103375724780001 25103375724780001 152.30 31.06
DIAGNOSIS 1 : 0
NDC CODE : 00023916330 RESTASIS 0.05% EYE EMULSION - OPHTHALMIC PREPARATIONS
10/20/10 - 10/20/10 12/27!10 25103375729520001 25103375729520001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
COMMONWEALTH OFPENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
NAME HAIR, ROBERT
!D 660 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
ECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN : USUAL CHARGES AMOUNT APPROVED
10!20110 - 10/20/10 12/27/10 25103375729630001 25103375729630001 6.69 5.09
DIAGNOSIS 1 : 0
NDC CODE : 50111099001 VIT D2 1.25 MG (50,000 UNIT) - FAT SOLUBLE VITAMINS
10/21/10 - 10/21!10 12/27/10 25103375729760001 25103375729760001 20.08 17.06
DIAGNOSIS 1 : 0
NDC CODE : 61314063705 PREDNISOLONE AC 1% EYE DROP - OPHTHALMIC PREPARATIONS
10/22/10 - 10/22/10 12/27/10 25103375729860001 25103375729860001 24.00 17.25
DIAGNOSIS 1 : 0
NDC CODE : 24208091055 ERYTHROMYCIN EYE OINTMENT - OPHTHALMIC PREPARATIONS
10/25/10 - 10/25/10 12/27110 25103375730280001 25103375730280001 34.05 7.75
DIAGNOSIS 1 : 0
NDC CODE : 00168000480 TRIAMCINOLONE 0.1% CREAM - GLUCOCORTICOIDS
10/28/10 - 10/28/10 12/27/10 25103375730050001 25103375730050001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
10/31/10 - 10/31!10 12/27/10 25103375730440001 25103375730440001 .74 .74
DIAGNOSIS 1 : 0
NDC CODE : 00904546080 OYSTER SHELL CALCIUM-VIT DTAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
10!31/10 - 10/31!10 12/27/10 25103375730490001 25103375730490001 58.61 4.80
DIAGNOSIS 1 : 0
NDC CODE : 68382012205 AMLODIPINE BESYLATE 5 MG TAB - OTHER CARDIOVASCULAR PREPS
10!31/10 - 10/31!10 12/27/10 25103375730670001 25103375730670001 29.57 4.87
DIAGNOSIS 1 : 0
NDC CODE : 00781150610 ATENOIOL 50 MG TABLET - OTHER CARDIOVASCULAR PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF RUBLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
NAME HAIR, ROBERT
ID s 860 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
ECHANICSBURG PA 17055
.`.DATE OF SERVICE PAYMENT DATE ORIGINALCRN : ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10/31/10 - 10131!10 12/27/10 25103375730710001 25103375730710001 16.19 4.90
DIAGNOSIS 1 : 0
NDC CODE : 00378262501 AMITRIPTYLINE HCL 25 MG TAB - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
10/31/10 - 10/31/10 12/27!10 25103375730880001 25103375730880001 266.24 29.19
DIAGNOSIS 1 : 0
NDC CODE : 00228299611 TAMSULOSIN HCl 0.4 MG CAPSUL E - MISCELLANEOUS
10/31!10 - 10/31/10 12l27N 0 25103375730970001 25103375730970001 30.03 20.37
DIAGNOSIS 1 : 0
NDC CODE : 62175011837 OMEPRAZOLE DR 20 MG CAPSULE - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
11/01/10 - 11/01/10 12/27/10 25103375302550001 25103375302550001 50.59 7.37
DIAGNOSIS 1 : 0
NDC CODE : 00228266550 GABAPENTIN 100 MG CAPSULE - ANTICONVULSANTS
11/04/10 - 11104!10 12/27/10 25103375303530001 25103375303530001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
11108/10 - 11/08/10 12127N0 251033753D3940001 25103375303940001 152.30 31.06
DIAGNOSIS 1 : 0
NDC CODE : 00023916330 RESTASIS 0.05% EYE EMULSION - OPHTHALMIC PREPARATIONS
11/11110 - 11/11H0 12/27/10 25103375304250001 25103375304250001 34,05 7,75
DIAGNOSIS 1 : 0
NDC CODE : 00168000480 TRIAMCINOLONE 0.1% CREAM - GLUCOCORTICOIDS
11/11/10 - 11!11/10 12/27/10 25103375304560001 25103375304560001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1 % OINTMENT - GLUCOCORTICOIDS
'' COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF Pl3BLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
NAME HAIR, ROBERT
ID 860 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
ECHANICSBURG PA 17055
DATE OF SERVICE `PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11/11!10 - 11/11/10 12/27/10 25103375305120001 25103375305120001 238.81 197.03
DIAGNOSIS 1 : 0
NDC CODE : 00597007541 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS
11/17/10 - 11/17/10 12/27/10 25103375305890001 25103375305890001 6.69 5.09
DIAGNOSIS 1 : 0
NDC CODE : 50111099001 VIT D2 1.25 MG (50,000 UNIT) - FAT SOLUBLE VITAMINS
11/18/10 - 11118/10 12127H0 25103375306050001 25103375306050001 2.78 2.78
DIAGNOSIS 1 : 0
NDC CODE : 00472034356 HYDROCORTISONE 1% CREAM - GLUCOCORTICOIDS
11!19/10 - 11/19/10 12/27/10 25103375306140001 25103375306140001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
11/26/10 - 11/26/10 12127/10 25103375306330001 25103375306330001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS
11/28!10 - 11/28/10 12/27H0 25103375306610001 25103375306610001 152.30 32.85
DIAGNOSIS 1 : 0
NDC CODE : 00023916330 RESTASIS 0.05% EYE EMULSION - OPHTHALMIC PREPARATIONS
11/30/10 - 11130/10 12!27!10 25103375306780001 25103375300780001 28,78 4,84
DIAGNOSIS 1 : 0
NDC CODE : 00781150610 ATENOLOL 50 MG TABLET - OTHER CARDIOVASCULAR PREPS
11/30/10 - 11!30110 12/27/10 25103375307240001 25103375307240001 29.23 19.84
DIAGNOSIS 1 : 0
NDC CODE : 62175011837 OMEPRAZOLE DR 20 MG CAPSULE - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE -
January 24, 2011
STATEMENT OF CLAIM
NAME HAIR, ROBERT
I D 860 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
NECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE- ORIGINAL CRN ' ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11/30/10 - 11/30!10 12!27/10 25103375307410001 25103375307410001 .72 .72
DIAGNOSIS 1 : 0
NDC CODE : 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
11/30/10 - 11/30/10 12/27/10 25103375307760001 25103375307760001 56.88 4.77
DIAGNOSIS 1 : 0
NDC CODE : 68382012205 AMLODIPINE BESYLATE 5 MG TAB - OTHER CARDIOVASCULAR PREPS
11130!10 - 11/30/10 12/27/10 25103375308490001 25103375308490001 238.81 32.47
DIAGNOSIS 1 : 0
NDC CODE : 00597007541 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS
11/30/10 - 11/30110 12/27/10 25103375308900001 25103375308900001 257.82 28.80
DIAGNOSIS 1 : 0
NDC CODE : 00228299611 TAMSULOSIN HCL 0.4 MG CAPSUL E - MISCELLANEOUS
11/30/10 - 11!30/10 12127!10 25103375309170001 25103375309170001 15.83 4.87
DIAGNOSIS 1 : 0
NDC CODE : 00378262501 AMITRIPTYLINE HCL 25 MG TAB - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
12/01/10 - 12/01/10 01/17/11 25103585224150001 25103585224150001 44.51 6.92
DIAGNOSIS 1 : 0
NDC CODE : 00228266550 GABAPENTIN 100 MG CAPSULE - ANTICONVULSANTS
12/03/10 - 12/03/i0 i2/27l10 25103375593930001 25103375593930001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1 % OINTMENT - GLUCOCORTICOIDS
12/07/10 - 12/07/10 01/03/11 25103415247390001 25103415247390001 211.50 43.89
DIAGNOSIS 1 : 0
NDC CODE : 00065026005 TRAVATAN Z 0.004% EYE DROP - OPHTHALMIC PREPARATIONS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
NAME HAIR, ROBERT
ID 860 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
VIECHANICSBURG PA 17055
DATE OF SERVICE I PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/07/10 - 12107/10 01h7/11 25103585224180001 25103585224180001 52.39 6.39
DIAGNOSIS 1 : 0
NDC CODE : 50111030701 HYDROXYZINE HCL 10 MG TABLET - ANTIHISTAMINES
12!09110 - 12/09/10 01103111 25103435493600001 25103435493600001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
12!14/10 - 12!14/10 01/10/11 25103485259470001 25103485259470001 152.30 36.85
DIAGNOSIS 1 0
NDC CODE : 00023916330 RESTASIS 0.05% EYE EMULSION - OPHTHALMIC PREPARATIONS
12/15/10 - 12/15/10 01N7l11 25103585224160001 25103585224160001 6.69 5.09
DIAGNOSIS 1 : 0
NDC CODE : 50111099001 VIT D2 1.25 MG (50,000 UNIT) - FAT SOLUBLE VITAMINS
12/18/10 - 12/18/10 01/17/11 25103525370620001 25103525370620001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
12(22110 - 12122/10 01/17/11 25103565519220001 25103565519220001 2.60 2.60
DIAGNOSIS 1 : 0
NDC CODE : 51672201802 HYDROCORTISONE 1% OINTMENT - GLUCOCORTICOIDS
12123710 - 12/23/10 01/17111 25103585224120001 25103585224120001 .62 .50
DIAGNOSIS 1 : 0
NDC CODE : 00904546080 OYSTER SHELL CALCIUM-VIT DTAB - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS
12/23!10 - 12/23/10 01/17/11 25103585224130001 25103585224130001 49.96 .74
DIAGNOSIS 1 : 0
NDC CODE : 68382012205 AMLODIPINE BESYLATE 5 MG TAB - OTHER CARDIOVASCULAR PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 24, 2011
STATEMENT OF CLAIM
.NAME HAIR, ROBERT
ID 860 293 252
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
ECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DRTE ORIGINAL' CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12123/10 - 12/23/10 01117!11 25103585224140001 25103585224140001 224.11 7.33
DIAGNOSIS 1 : 0
NDC CODE : 00228299611 TAMSULOSIN HCL 0.4 MG CAPSULE - MISCELLANEOUS
12/23/10 12/23/10 01/17!11 25103585224170001 25103585224170001 25.61 .62
DIAGNOSIS 1 : 0
NDC CODE : 00781150610 ATENOLOL 50 MG TABLET - OTHER CARDIOVASCULAR PREPS
12123/10 - 12123!10 01117/11 25103585224190001 25103585224190001 14.39 .76
DIAGNOSIS 1 : 0
NDC CODE : 00378262501 AMITRIPTYLINE HCL 25 MG TAB - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
PROVIDER SUB. TOTAL MILLENNIUM PHARMACY SYSTEMS INC 3,222.57 761.00
24 001887261 0008
Ewing Brothers Funeral Home, Inc. Steven A. Ewing, Supervisor
630 South Hanover St.; Carlisle, ''A 17013 Since 1853 Seymour A. Ewing, Deceased
Phone: (717)243-2421 Fax (7'T243-7553 E-N dmin@since1853.com William M. Ewing, D sed
STATEMENT OF FUNERAL GOODS AND SERVI(,L,, SELECTED
Charges are only Cur those items drat you elected or that are required. If we are required by law or by a cemetery or a crematory to use any items,
we will explain the reasons 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 no,-have to )gay Fer embalminl~ you did no[ approve ifyou selected arrangements such a; cremation or immediate burial If we charged for
~~ ~ua~„~~ng we w... e:ipi a... wli} uucw. -
I=orthe Service of: Robert F. Hair _ _ Date of Death December 27, 2010
I:harge to : Robert F. Hair 132 Westlake Drive Carlisle PA
Name ------ n~,~.o~~ ,..._ ...-
A. CHARGE FOR SERVICES SELECTED: Traditional Package Itemized Services
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff - $ 1,840.00
Embalming .. 5. 875.00
Other preparation. of body
Dressing Casketinq Cosmo etc.
................................. 5` 290.00
SUB-TOTAL OF PROFESSIONAL SERVICES..... .. Al $ 3,005.00
FACILITIES AND SERVICES
Use of facilities and services for
Other Clathina
$_ -0-
$_ -0-
Cremation Urn ..... ...... .... .. $ _p-
(Description)_
$ -0-
$_ -0-
$ -0-
TOTAL MERCHANDISE SELECTED ....... ... B $ -1,345.00
C. SPECIAL CHARGES
Forwarding of remains to
Viewing (Visitation/Wake)~ ~ .. ........$_ -0-
Use of facilities and services for
Funeral Ceremony,,,,,,,,,,,,,,,, .g _0-
Use of facilities and services for
Memorial Service .... , . , , , , . , , .. g , _p-
Use of equipment and services for
GravesideSen,~ice,,,,,,,,,,,,,,,,,,,, g.. _p_
Other use of facilities
Same day services al facility usage
....................................$._ 890.00
SUB-TOTAL OF FACILITIESIEQUIPMENT ......... A2 $ 890.00
3. AUTOMOTIVE EQUIPMENT
V ;hide to transfer remains to Funara!
Local . ..... ............ ... .....$_ 275.00
Hearse (Casket Coach)
Local ....................... ..- $ 250.00
Limousine (No Charge) _
Local ........................... .....$_ -0-
Family Car
Local ........................... .....$_ -0-
Flower car or floral disposition
Local ........................... .....$ _p_
Lead car/Clergy
Local ........ ... .... $_ 125.00
Car (or pallbearers
Out of town transportation ......... .....$_ -0-
Utility \'enicle for DC retrieval/filinc
-- $ 125.00
__ $ -0-
SUB-TOTAL OF AUTOMOTIVE EOUIPMENT...........A3 $ 775.00
$ -0-
(Funeral Home)
Receiving of remains from
$
-0-
(Funeral Home) _
Immediate Burial ....... . ...... .. . . . $ _0_
Direct Cremation .. ............ ... $ -0-
$ -0-
SUB-TOTAL OF SPECIAL CHARGES ... ... C $_ -0-
D. CASH ADVANCED:
Opening Gave . . . . . . . ... . . . ...$_ 1,595.00
Cemetery Equipment ............ . .$ -0-
Lot and Deed ............... $ -0-,
Newspaper Notices -Out-of-town... ...$ -0-
Telephone 8 Telegrams . .... . . . .. . . .$ -0-
Airfare ........................ ...$ -0-
Clergy/Mass Offering (Estimate), $ 75.00
Pallbearers ................. $ -0-
Certified Copies of the Death CertiTcate.$ 24.00
Police Escort
................... $
... -0-
Flowers,,...,,,,,. 159.00
Vault Service Charge ........... . ...$ -0-
The Sentinel Obit w/photo (Est) ... ... $ 150.00
$ -0-
$ -0-
$ -0-
$ -0-
$ -0-
$ -0-
SUB-TOTAL OF ADVANCES.......... D $_~_p03 00
e char a ou {or our ;;ervi4es in obtaining
specify L~as~i advance items/.
1"OTAL OF PROFESSIONAL SERVICES,
FACILITIES AND AUTOMOTIVE SUMMARY OF CHARGES:
E:QUIPMENT ................... ................ A $ 4,670.00 A. Professional Services, Facilities and
CHARGES FOR MERCHANDISE Equipment and Automotive
Casket ............................. $_ 2,625.00 Equipment...... - ........... $. 4,670.00
(Description) 18G Brushed Cooper Cashmere B. Merchandise ......................$ 4,345.00
C. Special Charges........ _ . S -0-
D. Cash Advances ............. .....$ 2 003.00
Outer Receptacle .... . ..... ...........$_ 1,595.00
(Description) American Chief OBC
TOTAL OF ALL SELECTIONS . - .......... $ 11 01 B 00
Outer burial container ............ .... $_ -0- PAID AT TIME OF OR PRIOR TO
(Description) Alternate Container ARRANGEMENTS ............. .... ... .... $ 0.00
Acknowledgement cards , , . $._ 10.00 BALANCE DUE ...................... ...... $ 11 018.00
Register Book(s)........ $_ 40.OD REASON FOR EMBALMING
Memorial folders ..................... $_ 75.00 Required for traditional funeral with viewinc
Prayer cards ~ ~ ........................$ _0- If any law, cemetery or crematory requirements have required the purchase of
- any of the items listed above [he law or requirement is explained below.
Temporary grave marker ................ $._ _0-
Bvrial clothing ...... ............. $~ _0_ OBC by cemetery
I agree that I have examined the terms of goods and services selected above and found them to be correct and according to the arrangements I have
-equested and I acknowledge a copy of this Statement of Funeral Goods and Services selected. I represent that I have sufficient funds available for
payment of total price for goods and services selected. I also agree to make payment of $ 11,018.00 within 30 days. I agree to be jointly and
severally liable with anyone who signs below. A late charge of 1.5 % per month amounting to 18 % per year will be applied to the unpaid balance
Beginning 30 days from the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts
I owe under this agreement. T se sts may in Jude attain 's fees, court costs and other costs. Any additional services or merchandise ordered or
requested a e dat t agr nsider art of this agreement and the/cost thereof~willQbe r lected on the final bill or statement.
(Seal / -.Z/~,yJ ~~C7/ G
( urchaser' ~ Da
(Seal)
(Purchaser) (Licensed Fu irector)