HomeMy WebLinkAbout08-17-11Ex (01-10>
~ REV-1500 1505610143
~} OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code rear File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 80X.280601 INHERITANCE TAX RETURN 21 ~A ?` ` (:;`~'3 ~r~
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
179 12 6326 08 31 2010 09 26 1913
Decedent's Last Name Suffix Decedent's First Name MI
ENGLE JOHN H
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return
^ 4. Limited Estate
® g Decedent Died Testate
(Attach Copy of Wilp
^ 9. Litigation Proceeds Received
Suffix Spouse's First Name
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
^ 2. Supplemental Return
^ 4a. Future Interest Compromise
(date of death after 12-12-82)
^ ~ Decedent Maintained a Living Trust
(Attach Copy of Trust)
^ 1 D Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
MI
^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
^ 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
GERALD J BRINSER 717 838 6348
First line of address
6 E MAIN STREET
Second line of address
PO BOX 323
City or Post Office State ZIP Code
PALMYRA PA 17078
Correspondent'se-mail address: JerryeQ bWZIaW.COm
REGISTER OF~IIII~S USE ONtY
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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.
SIGNATUI1RE~~OF~~ PERSON REcSPONSIBLE FDR FILING RETURN DATE 1
if7'vGG. 7r 71....Q~ John E. Engle /3 ~~t~c4~i7 ~~/
10 Lloyd Road, Waterville, ME 04901
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SIGNATU ~ F PREPARER OTHER N PRESENTATIVE bATf`
~~~~ ~~ - Gerald J Brinser
6 E. Main Street, Palmyra, PA 17078
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Side 1
1505610143 1505610143 J
J
15D5610243
REV-1500 EX
Decedent's Social Security Number
oecedent~s Name: E N G L E, JOHN H. 17 9 12 6 3 2 6
RECAPITULATION
1. Real Estate (Schedule A) ........................................................................................ .. 1.
2. Stocks and Bonds (Schedule B) .............................................................................. . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)........ .. 3.
4. Mortgages & Notes Receivable (Schedule D) ....................................................... .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... . 5. 3 , 4 2 3 3 9
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............ . 6. 4 2 , 2 0 3 3 8
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ............ . 7,
8. Total Gross Assets (total Lines 1-7) ...................................................................... . g, 4 5, 6 2 6 7 7
9. Funeral Expenses & Administrative Costs (Schedule H) ............................... ......... 9. 1 3 , 0 9 5 . 2 7
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ...................... .......... 10. 1 0 , 2 2 6 . 7 4
11. Total Deductions (total Lines 9& 10) ............................................................ .......... 11. 2 3, 3 2 2 0 1
12. Net Value of Estate (Line 8 minus Line 11) ................................................... .......... 12. 2 2 , 3 0 4 7 6
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. 2 2 , 3 0 4 7 6
TAX COMPUTATION -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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 2 2, 3 0 4. 7 6 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.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
1,003.71
1,003.71
Side 2
L 1505610243 15D561D243 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 10
DECEDENT' NAME
Engle, John H.
STREET ADDRESS
Messiah Village,
100 Mt. Allen Drive
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 1 ,003.71
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits (A + e> (z) 0.00
3. Interest
(3> 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box 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. (5) ~ , 0 Q 3 , 7 ~
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 :..................................... x
b. retain the right to designate who shall use the property transferred or its income :.................................. ~ C
c. retain a reversionary interest; or ................................................................................................................. ^ ^
d. receive the promise for life of either payments, benefits or care? ...............
......................... x
If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ........................... ^ ^
............................................... x
................................
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.
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. §9196 (a) (1.1) (i)].
For dates of death on or after January 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)1. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, w ether by blood or adoption.
SCHl-f~t~L.E E
CASH, BANK nEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA ; PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Engle, John H. 21 -10
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 MMA -Refund 545.15
2 PNC Bank -Checking Account #5004708746 2.878.24
TOTAL (Also enter on Line 5, Recapitulation) ~ 3,423.39
SCHED LE
U F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Engle, John H. 21 - 10
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
John E. Engle 10 Lloyd Road Son
A Waterville, ME 04901
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
Include name of financial institution and bank account number
similar identifying number. Attach deed for jointly-held real estat DATE OF DEATH
r1/ALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
1 A 07/18/2006 PNC Bank -Checking Account #5000000388 sa,aos.~5 50% 42.203.38
(Includes accrued interest of $2.36)
All expenses on Schedules H and I that were in
excess of the probate assets were paid by the
joint owner from these funds.
TOTAL (Also enter on line 6, Recapitulation) I 42,203.38
SCHEDULE H
FUNERAL D~ENSES &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN A rMAwK~Tp AT1~ /C /~~1C1Y~
RESIDENT DECEDENT /~1LJI~~~~7 ~ f\/'\ ~ ~YG N\./v7 ~ ~7
ESTATE OF Engle, John H. FILE NUMBER
___ 21 - 10
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A• 1 Cocklin Funeral Home 9,281.67
2 Funeral Luncheon i 1,783.60
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
2.
3.
4.
5.
6.
7.
1
City State Zip
Year(s) Commission paid
Attorney's Fees Brinser, Wagner & Zimmerman -- Gerald J. Brinser
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's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Register of Wills -Inheritance Tax Filing Fee (No Letters)
2,000.00
15.00
TOTAL (Also enter on line 9, Recapitulation) 13,095.27
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Schedule H
Funeral F~er~ses 8~
Administrativle Costs continued
Page 2 of Schedule H
SCHEDULEi
DEBTS OF DECEDENT, MORTGAGE
COM NHERITANCEOTAX RENURNANIA LIABILITIES, & LIENS
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Engle, John H. 21 - 10
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Messiah Village 8,127.44
2 Alert Pharmacy 121.42
3 Personal Tax 30.50
4 AXA Equitable -Reimbursement of Overpayment 177.22
TOTAL (Also enter on Line 10, Recapitulation) I 8,456.58
REV-1513 EX+ (~ 1-08)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Engle, John H.
21 - 10
NUMBER
NAME AND ADDRESS OF PERSON(S)
RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s) SHARE OF ESTATE
(Words) AMOUNT OF ESTATE
($$$)
I, TAXABLE DISTRIBUTIONS[include outright spousal
dlstnbutlons, and transfers
under Sec. 9116 (a) (1.2)]
1 John E. Engle Son Schedule F (less 24,074.9;
10 Lloyd Road "excess expenses on
Waterville, ME 04901 Schedule H & I); 1/6
Residue
2 James R. Engle Son 1/6 Residue 0.0[
510 Rockingham Drive
Harrisonburg, VA 22801
3 Marilyn G. Wolgemuth Daughter 1/6 Residue 0.0(
1108 Centerville Road
Lancaster, PA 17601
Enter dollar amounts for distributions shown above on lines 15 t hrough 18 on Rev 1500 cover she et, as appropriate.
III NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI 0.00
REV-1513 EX+(g-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES continued
ESTATE OF I FILE NUMBER
Engle, John H. 21 - 10
NUMBER
NAME AND ADDRESS OF PERSON(S)
RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s) SHARE OF ESTATE
(Words) AMOUNT OF ESTATE
($$$)
I. TAXABLE DISTRIBUTIONS[include outright spousal
dlstrlbutlons, and transfers
under Sec. 9116 (a) (1.2)]
4 Joanne M. Miller Daughter 1/6 Residue 0.01
340 Holyridge Drive
Roswell, GA 30076
5 Eugene K. Engle Son 1/6 Residue 0.01
310 Hossler Road
Manheim, PA 17545
6 Richard L. Engle Son 1/6 Residue 0.01
3 Albert Road
Poughkeepsie, NY 12603
Page 2 of Schedule J
WILL
OF
JOHN H. ENGLE
I, JOHN H. ENGLE, currently of South Londonderry Township,
Lebanon County, Pennsylvania, realizing the uncertainty of this
life, but with confidence in God and trust in His Son, my Lord
and Savior, Jesus Christ, who died for my sins upon the cross and
rose again to redeem me and give me eternal life, do hereby make,
publish and declare this to be my Last Will and Testament, hereby
revoking any and all prior Wills and Codicils made by me.
I. I direct that all my just debts and funeral expenses be
paid from the assets of my estate as soon as practicable after my
demise.
II. I direct that all estate and inherit
be assessed in consequence of my death, shall
principal of my general estate to the same
taxes were expenses of administration
includable in my taxable estate whether or
this Will shall be free and clear thereof.
once taxes that may
be paid out of the
effect as if said
and all property
not passing under
III. I bequeath unto my wife, Anna K. Engle, all tangible
personal property which I own at my death.
IV. All the rest, residue and remainder of my estate, of
whatever nature and wherever situate, including property over
which I hold a power of appointment, I devise and bequeath unto
my wife, Anna K. Engle.
V. In the event that my wife, Anna K. Engle, does not
survive me, I devise and bequeath my entire estate that would
have otherwise passed under Paragraphs III and IV above as
follows:
A. I intend to keep with this my Will a separate
set of instructions concerning disposition of certain
items of tangible personal property. I bequeath the
items on said list to the persons designated.
B. All the rest, residue and remainder of my
estate I devise and bequeath equally unto my children,
namely, John E. Engle, James R. Engle, Marilyn G.
Wolgemuth, Joanne M. Miller, Eugene K. Engle and
~~ a
J'~ ~ ~
~ ~-
Richard L. Engle. If any child predeceases me, his or
her share shall pass unto his or her issue per stirpes.
If said child leaves no issue, said share shall lapse
and be added to the shares passing to my other children
or their issue per stirpes.
VI. I appoint my wife, Anna K. Engle, Executrix of this my
Will. In the event that she fails to qualify or ceases to act
as Executrix, I appoint my son, John E. Engle, and my daughter,
Marilyn G. Wolgemuth, Executors, or the survivor of them as sole
Executor, of this my Will.
VII. I direct that no bond be required of my fiduciaries for
the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I, JOHN H. ENGLE, herewith set my hand
to this my Last Will, typewritten on two (2) sheets of paper
including the attestation clause and signatures of witnesses,
this 18th day of May, 1994.
c ~ ~ -~~.~
SEAL
JO N H. ENGLE 1
Signed by JOHN H. ENGLE, by him declared to be his Will in
our presence, who have hereunto subscribed our names as witnesses
in his prese~ e and at his request, this 18th day of May, 1994.
~; ,~
-c.-tf' ,~"c~--~~,...~-. residing at L" ~~~ ~~.:.~.~~- rr
~ ~ --~.~G-G~ 'X.,~- i - ' residing at -~.~~CC~' ~.~: ~ 'r ~ ~ ,, ~ ~f'~
-~
-2-
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LEBANON
WE, JOHN H. ENGLE, Gerald J. Brinser and ~,L' 1~,-,~.,j.- ~
j.~>.. ~-{~~~ ~.;;, the testator and the witnesses, respectively, whose
names a~ signed to the attached or foregoing instrument, being
first duly affirmed, do hereby declare to the undersigned
authority that the testator signed and executed the instrument as
his Last Will and that he signed willingly (or willingly
directed another to sign for him), and that he executed it as
his free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of
the testator, signed the Will as witnesses and that to the best
of our knowledge the testator was at that time eighteen years of
age or older, of sound mind and under no constraint or undue
influence.
~~
~I~GLE
WITNF~S ~" , '
WITNESS
Subscribed, sworn or affirmed and acknowledged before me by
JOHN H. ENGLE, the testator, Gerald J. Brinser and L ~, ~ ;~_~~ L ,
1;~~_ ~r~~-~,~.~ , witnesses, this 18th day of May, 1994. ~-r
(S F'AL l
NOTARY PUBLIC
Notarial Seal
Carla A. Gadd ,Notary Public
Palmyra Boro, Lebanon Courriy
MY Commissian E~ires June 23,1997
-3-
MMA°
2at/~ao
1110 North M1tain Street _ >- - -_ NOS 288 _!~ `~ __ -_
Post Office Boz 483 -` __- - - __= _ =~ -_
Goshen, IN 46527 __ _ _ __ _ -
__ `= = ' - _ Jl'MotgttChaseBank,NA
DATE DOLLARS CENTS
EXactty ******545 dollars and 15 cents: - --9/14/2010 $545.15
==Pay
TO THE 1-
ORDER
OF
John H Engle= Est~~.e , = __=
C/0 JOHN E l~Ii€GF~ IrID ___-
I 0 LLOYD RD_ - _ _ _-- - __°
WATERVI LLE ME =~34 9 0-~ = --
Mennonite Mutual Aid Association
~- _{'~`'
~~ 6~z~
Authorized si9~sWre
DETACH AND RETAM THIS STATEMENT. A,
Mennonite Mutual Aid Association 7HEATTACHEDCHECKISINPAYMENTOFITEMSDESCRIBEDBELOW 'vO 2881 13
Post Office Box 483. Goshen, IN 46527 IF NOT CORRECT. PLEASE NOTIFV US PROMPTLY. ~
DATE DESCRIPTION AMOUNT
9/14/2010 Refund due to death of John H Engle A# 5153685 $545.15
rar
;NRLMTBILL
'~ ;~ t n ,n JA'w ~ •) ,n r
~~
~FJlD1Nt3 TH E ~VAY
September 23, 201 U
Gerald J 13rinser
Attorney at Law
P O Box 323
Palmyra, PA 17078
RE: John H Engle
SSN: 179-12-6326
DOD: 08-31-2010
Dear Mr. Brinser:
~,; o , ; ~ '~ ~ ~~, I / i
In response to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
CLeckiwg Account
Account # 5000000388 Established: 07-18-2006
JOHN H ENGLE
JOHN E ENGLE
DOD balance: $ 84,404.39 + 2.36 accrued interest
Interest paid O 1-01-2010 thru 08-31-2010 $ 27.00 YTD
Account # 5004708746 Established: 07-06-2005
JOHN H ENGLE
JOHN E ENGLE REP PAYEE
DOD balance: $ 2,878.24 non interest bearing
Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and
Savings). We do not process any financial transactions or provide statements. if you need assistance with
any of these items, please call 1-888-PNC-SANK (1-888-762-2265) or stop by yow local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank, N.A.
Membez FDIC
Page 1 of 1
Cocklin Funeral Home, Inc.
30 N. Chestnut St.
Dillsburg, PA 17019
(717)432-5312
September 7, 2010
Mrs. Marilyn G. Wolgemuth
1108 Centerville Road
Lancaster, PA 17601
The Funeral Service for John H. Engle
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTNE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
Professional Services
Funeral Director & Staff 3,725.00
Total Professional Services ~;7~~ilD
Merchandise
Libra 1,995.00
Graveliner 800.00
Total Merchandise Selected --- ------ - -~;7~3~iSb
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTA IN PAYMENTS TO
OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
Cash Advances
Cemetery Charges 650.00
Newspaper Notice Lancaster 441.60
Newspaper Notice Harrisburg 397.57
Newspaper Notice Lebanon 229.32
Death Certificates 72.00
Flowers 321.18
Cutting date on Stone 175.00
Tent Rental 250.00
Organist 75.00
Clergy Honorarium 1 SO.tiu
Total Cash Advances -----------------2;761.67---
SALES TAX 0.00
SUB-TOTAL 9,281.67
INITIAL PAYMENT /DISCOUNT /CREDITS 9,281.67
TOTAL AMOUNT DUE 0.00
The unpaid balance over 1 days is subjected to a 0 % service charge per month - 0 % per annum.
Page
PNCBANK `tour account was DEBITED for the following reason:
Check # -posted on 1 / encoding error -posted to incorrect account
Closed account _ -
^Branch adjustment (branch name)
^ Service charge error
^ Other:
Account Number File ID
a a ~t~o .b ~~o
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Address
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AMOUNT $ ~ ~ 4 '") 8. ~ t~
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PNC Bank, National Aissociation
FOR BANK USE ONLY
~~ 10:x#4 ~°SEF~t~1U - ~-~~
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CASHIER'S CHECK southcentrel, PA '` EF•TEC4DElr: ~'I ? , ~i i 14
DATE
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PAY TO THE f•t1('~~LI~'~ f `~~iEP~F~I~ F1f~~tG ~ ~ ~ r~~^~~ /{
ORDER OF •
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100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055
JOHN E. ENGLE
10 LLOYD ROAD
WATERVILLE, ME 04901
Form PB-Ot
RESIDENT # UNIT STMT. DATE
89509 002 D 08/31/2010
RESIDENT S
Mr. JOHN H. ENGLE
TOTAL AMOUNT DUE $8 127.44
DATE DUE 09/30/2010
DATE
DESCRIPTION
RATE Days/
Unlts
CHARGES
CREDITS
BALANCE
Balance Forward 16,553.44
08/26/2010 PAYMENT RECEIVED -THANK YOU!!! 7,960.70 8,592.74
08/26/2010 PAYMENT RECEIVED -THANK YOU!!! 8,592.74 0.00
*** Nursing Care ***
08/01/2010 MOTION MONITOR 08/01-08/30 4.84 1.00 4.84 4.84
08/04/2010 OXYGEN 17.50 1.00 17.50 22.34
08/29/2010 PREVAIL PROTECTIVE UNDERWEAR 1.30 27.00 35.10 57.44
08/30/2010 RM/ BRD -NURSING -SEMI-PVT 269.00 30.00 8,070.00 8,127.44
08/01-08/30
JOHN H. ENGLE 417
JOHN E. ENGLE, POA
10 LLOYD ROAD J~ ~C
Date l - so-t273/3~1~3
WATERVILLE, ME 04901
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RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE
89509 8,127.44 0.00 0.00 0.00 0.00 $8,127.44
RESIDENT NAME Mr. JOHN H. ENGLE FormPB-01
N!A
Please make check payable to Messiah Village.
A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you!
If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You!
John E. Engle, M.D.
10 Lloyd Road
Waterville, Maine 04901
PHONE: 207 873-2880
Pennsylvania Department of Revenue
1 Revenue Place
Harrisburg, Pennsylvania 17129-0001
Dear Sir or Madam,
I am enclosing Pennsylvania Personal Income Tax Returns for my father, John H. Engle
(SSN 179126325) for years 2006 through 2010. He had a stroke in January 2005, and it
was my responsibility as his Power of Attorney to file his Pennsylvania Tax Returns. I
failed to do this. He died on August 31, 2010.
I used the interest and penalty calculator on the Pennsylvania Personal Income Tax
e-Services Center and came up with the following amounts.
Tax Year Tax Interest Penalty Total
2006 479 112.79 119.75 711.54
2007 391 61.85 97.75 550.60
2008 237 22.25 59.25 318.50
2009 113 5.27 28.25 146.52
2010 36 0.34 7.20 43.54
Along with the returns, I am enclosing one check for the amount of $1770.70 from my
late father's account. Please let me know if the there are concerns or questions about
these returns.
V'
John E. Engle, M.
Cc: Gerald J. Brinser