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09-13-11
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE BUREAII OF INDIVIDUAL TAXES REV-1162 EX(11-96) DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014955 LACKEY WILLIAM H 35 LONGVIEW DR MECHANICSBURG, PA 17050 ACN ASSESSMENT AMOUNT CONTROL -------- '°'d N U M B E R ESTATE INFORMATION: FILE NUMBER: DECEDENT NAME: DATE OF PAYMENT: POSTMARK DATE: COUNTY: DATE OF DEATH: REMARKS: SSN: 235-38-3815 2111-0771 LACKEY BETTY J 09/ 13/201 1 09/ 13/201 1 CUMBERLAND 07/05/201 1 TOTAL AMOUNT PAID: CHECK#109 INITIALS: HMW SEAL RECEIVED BY: $2,779.94 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS a ~ _ _ _ - 1 REV 15 1505610101 0o EX (oi-io) ~ PA Department of Revenue pennsy(vania Bureau OFFICIAL USE ONLY of Individual Taxes DEPAgTMENT OF REVENUE PO BOX 28o6oi INHERITANCE T County Code Year File Number Harrisburg, PA 1128-0601 RESIDENT D EDEN RN ENTER DECEDENT INFORMATION BELOW ~ + ~ ~ ( - Social Security Number ~~-~. Date of Death MMDDYYYY Date of Birth ,~ 3 S" 3 g ?~~ S o 7 o S~ o MMDDYYYY Decedent's Last Name r t ~ -~ ~ S I 9 ~ ~, Suffix Decedent's First Name ~. A c k~ ~ y MI (If Applicable) Enter Surviving Spouse's Informat' 8 E T ;r Y Spouse's Last Name ion Below ~ Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH T REGISTER OF WILLS HE FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 4. Limited Estate O 3. Remainder Return (date of death O 4a. Future Interest Compromise (date of prior to 12-13-82) ~ 6. Decedent Died Testate death after 12-12-82) O 5. Federal Estate Tax Return R equired (Attach Copy of Will) O 7. Decedent Maintained a Living Trust O 9. Litigation Proceeds Received (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes CORRESPONDENT- THI O 10. Spousal Poverty Credit (date of death 2-31-91 and 1-1-95) O 11. Election to tax under Sec. 9113(A) S SECTION MUST B Name E COMPLETED. ALLL CORRE SPONDENCE (Attach Sch. O) AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED ~ 1 ,~. ~, ! A ~ ~ ~ ~ C K ~ Lr T0: Daytime Telephone Number '7~ `7 6 ~ r 7a.~`~ ~- ~. First line of address REGIST (~jyytLLS UONLY ~-''" `{~~ ~`~ . ~ ~ '! Second line of address ~ ~ ~' ~ ~-~ '~ ~ ~ `,~ .~ ~-~ City or Post Office ~~ =-~ s ,~_,. //I L C N ~ N r c S 8 State ZIP Code t-,.- DATE FILED~`~'~ `~ 1 , v R~ ~ Correspondent's a-mail address: ,~ ~ i4 Ci~E Y Under enalties of er'u I declare that i ha„o e.,,,..,.:_ _ _, ... ~ e ~n2C A ST _ /J G ~ ~• •~ •~~~, ~~~rec[ and complete. Declaration of preparer other than the personal representative is based on all ~r,f.,rr,,,+;,.., _~ "_ , . urn, inc uding accompanying schedules and statements, and to the best of my knowledae anri hciioa SIGNATURE OF PERSON F~ESPONSIBI F Fno ~~~ ~.,,, ~__. ~- -- • ~' ~ ~ ~~~~~~ rct i URN ~~ """ "°"~~~ ~ ~~ wrncn preparer has any knowledge. y ADDRESS C DATE p ~ ~ 3 ~~ 3S' on/6v;~~„~ 13vj~G SIGNATURE OF PREPARER OTHER THAN REPRESEN ATIVEC ~~ 1 ~ O '~O ADDRESS DATE L 15056101py PLEASE USE ORIGINAL FORM ONLY Side 1 15056101,01 J ,Zt~r 1505610105 ' REV-1500 EX Decedent's Social Security Number Decedent's Name: S~`TT y ~ .~.A~ C I~E y d~ 3' S 3 8 3 8 I .'~ RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. .S 6 ~- ~ s ~ 3 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. ~ s ~ 3 ~ o 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ;Z ~ 3 `~ 8 / 9 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ` (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. '7 S ~ ~]' O ~ 3 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ O / g ~ ~, ~ p 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 02 ~ 6 ~"' ~/ 11. Total Deductions (total Lines 9 and 10) ................................. 11. / o c~i ~/ 3 „' o 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ,:; ( S o a 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. 6 ,~ D . ~- '7 ;* '7 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_ ~. 15. ~ 16. Amount of Line 14 taxable ~ F. x i ~ ,~+y~^ - t at lineal rate X .0 S ~' ~ ~~ 17. Amount of Line 14 taxable ~ ._ 4 ~ ~ +i~- f - 3 at sibling rate X .12 ~ ,~ ~ ` ~ ~~~` ~ 17 x ' ~• ~`{ 1 m ~ ~ 4 {'` ~ ~ ~ 18. _ ~ ; N _. {~ °`. Amount of Line 14 taxable ~ ~ ~ ~ ~ ~~r „ ~ »~~~ ~' '" ' ^ = ~M ~ at collateral rate X .15 ? 18 r ,;,~~~ , 19. TAX DUE ......................................................... 19. ` ~ ~.r 9 ` a-.=. (~ ?~ ~°;,5; 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT by L. ],505610105 Side 2 1505610105 O J REV-1500 EX Page 3 Decedent's Complete Address: STREET ~ '~~~_ ~--- ~ ~ C /{~ DDRESS File Numher a o/ t - a o '7'7'/ CITY !~'1 E c E-t,~ ~ ~ c s~ ~R G STATE -------~-ZIP ~~ I'7o~© (1) ~, 9a6. ~s Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount _ ~ ~ 6 , 3 ~ 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. Total Credits (A + B) (2) %56.3 ~ (3) (4) (5) a ~ ~ 9. 9 ~{ Make check payable to: REGISTER OF WILLS, AGENT. _r .... PLEASE ANSWER THE FOLLOWING QUESTIONS BY P LACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred :............... No ........................................................................... ~ Q b retain ahreversiona es 9 Bate who shall use the property transferred or its income : ............................................ ry est, or ............. ........................... Q 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? ... 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? ................................. t ~~ ~ ~ `~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCH .~ ._ ~, .. ~~ ~ Y ~.p..' EDULE 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 ra` ~~ ~ ~: ~^,~>,{~~~~~~~ _~~~®F~~~~ R~~~~~~~" 4 `~ 3 percent [72 P.S. §9116 (a) (1.1) (i)j. to Imposed on the net value of transfers to or for the use of the surviving spouse is For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or f [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the str the use of the surviving spouse is 0 percent filing a tax return are still applicable even if the surviving spouse is the only beneficiary. atutory requirements for disclosure of assets and 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 oun er at adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. Y 9 death to or for the use of a natural parent, an • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefi 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. curies is 4.5 percent, except as noted in • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 ercent 72 P Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or a ~S' §9116(a)(1.3)). Asibling is defined, under Y doption. ' REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT rnT.~~ .. SCHEDULE B STOCKS & BONDS ~.~ ~r~1 C Vr' Q ~•~-~-~, ~-- ~ ~ CKE y FMLE NUMBER All property jointly-owned with right of survivorship must be disclose ~ ~ /~ _ O 0 ~ ~ ! ITEM don Schedule F. NUMBER DESCRIPTION VALUE AT DATE 1. .~ r'.Z S NA ~Q E s ,/1/l ~c.~-~ + ~ E. a OF DEATH T.~ C . L D ,-~ ~ o.J S~~~a C 1C C ~.~ ~ P ~# .s9 SSG R t o /`: ~ ~ ~{. ~ 6 l~o~~+ ~S~.Ko '~/~ ~3' ~ 8 ?< ~ ,~ SNgRES' ~. I S;~R~ES ~~ ~~/i./~S ~~n»S ~,aZ37,~7 TOTAL (Also enter on line 2, RecaK~itulation (If more space is needed, insert additional sheets of the same size) ) $ ~ 6 ~ r ~ 3 REV-1508 EX + (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF 6 ITT y ~- ~,~ EKE FILE NUMBER r~~// -©077 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 NUMBER DESCRIPTION VALUE AT DATE ~ . OF DEATH rnaa~y ~K~ SA~,,~~s ACCT ~ I68yo~a~ goo Sti v ~R E-«,v Q ~a K '~o , 5l 3 i - © t 7 9 8 ~• Sfrn PSo,.~ S"-~-, n'1~cH4a,csdJR~ , P~ / ~oSe 79 g ~~ ~~i'rt/°So~.J .S7'~ ~'IECN~i~ ~CS'QtI~Q(r, ~f} /705-~ A6nv~ T~,~sF~RS F,e~~, /QEDFEME~D c''o's' ~ ~6fS~'so /~S /o, .~a/. a / ~ /6 SSSS~m 3~~ ~S ~oa•9 9 TOTAL (Also enter on line 5, Recapitulation) I $ ~j/,s' ~ 3 j , o / (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (i-97) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /J ~ TT ~/ ~ ~ ~ c KE y FILE NUMBER a~af l - as?7/ tf 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 •~S ~onlC+-vtEw ~R RELATIONSHIP TO DECEDENT .S'~ ,./ B. C JOINTLY-OWNED PROPERTY: ITEM LETTER FOR JOINT DATE M DESCRIPTION OF PROPERTY NUMBER TENANT ADE JOINT Include name of financial institution and bank account number or similar identifying number. Attach deed f i tl h DATE OF DEATH °~0 OF ' DATE OF DEATH orjo n y- eld real estate. DECD S VALUE OF \/ALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. f~R~oR ~'V(o~~'y ,~'ltcT ~S`RV,,~-~s ,~~~- ~ /c~81 '7a~ X93 To ~~ ~~R E«.,~ QA.~ K '~ ~3; ~ 9s 7 4~ So ~ !, '7 yc 7~ g 7 /~'lECNe4.J~CS'a'v~~ 1~i4 ~70~'0 ~. ~+. PR~~a ~~r~~K„~~ ,4~~r- ~ ~~sl~7a~a89 ~,,3do.~~ So ,~,6So.~a. To ~ c v ~6~El ~-~J ~~~ l<' (~` p p ~7 n~c~Na.~,~so~~e~ P~ ~?oSa 3tion) I $ ~ SF 3 9 S?. ~ 9 -- ---.._...,......... v~ a ~~. jai i i~ a1LC~ REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS cJIAIt OF Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION 1. l-{o ~ ~Q~ ~,1 DER Fv.~r ~=R~ c- f~o M ~' 1_Ra(-'ESSr6nIfiL SFRvrCES C~SCE-•T ~R~v~ nIQ~NI..~G- FILE NUMBER AMOUNT ~jr/OD.aO ~oo•cgO B. ADMINISTRATIVE COSTS: ~ . Personal Representative's Commissions Name of Personal Representative(s) ___ - __ _ ______ ---- --- Street Address City State Zip -- __ _ __ ear(s) Commission Paid: 2• Attorney Fees 3• 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 -- 4• Probate Fees ~ ~c.rr-~~ S. ~ Sq- //~~ a4ME.V'3'Ar2 ~I r Si+~,4?- IrEQTr tr=l CrR`7''E~S J' 86. Sa 5• Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ /' © / S6 •Sa (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF `" ~~ y ~ ~A cK~ ~/ FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death includi ~ o / ~ ' D ~ ~ ~ ITEM , ng unreimbursed medical expenses. NUMBER DESCRIPTION VALUE AT DATE 1. G° K~ ~ ~ ~ f M OF DE q~a~ C~R~ CARGl~fY'~E ATH °~ • ~ K 13- / o ~ - loo .L y SPr~ . r l~-~o s ~, ~A ~ Zf ,~. Sa 3 . Lk t~ /'0 3 - lac sP~~~ F~.FPN-o,~e ~~'D ~o. a o ~• cl< ~ / o c~ _ I,J Es'r S/fo R ~' ~~-, F2 /V(E-n S.r c ~ 0 8.7.5 TR .~..r S P~ 4 ~- - No < y SP, Q ~ ~ ~o s P 'Te /V(.f,J ®4 C A R ~- /~~~ A 8 ~ 1< 7~ / O S '- ~ o ,q ,~ y S : S C1 E ~ 'T ER S D F /4 nz ER i C A 13 8.7 9 PR ~s cR r f' -no .J ~ Es O v c`_'Ti (j ~ ~ G • /PE F~~o ~Qa~ ~{i G~ rtAR ~< -- N(ED ~C:A ~ `R~n1~ ~,,~ ~~ 6 /. Sµ `~• /1 ~-F'va• a ~2a.H ~A R~CiS~C~ ~--~aS Q -- c ~+/c~R PAY.~te~~v°i ~3 3 ~ o o, 8 • R~ F~,~A ~ieo,•1 MA~~ 2 CARE •- o v~R f'AYMF~ •r• , ~ ! a S• o a } ~. G 1< #- t o (~ -- ~ t~ L y S r S C €,.r •r~e S o r= ,q ~--~ E k t c Fr, ,~ 3• ~/ 8 P~ESetQ t Pica a D ~o uCTrB ~~ ~ ~ " C K ~- / 0 7 _ '~R u S~ ~ M 4 ~ L.~.~.s C ~ r1~ ~ ")' • ~ S T~An1.S.Pe,.R'T~ F2.a,+H DcA TO /~IbCY SPr~tT ~aS~~ ~~ (r C K ~- ~ (7 ~ ~- ~ ty ~'1 ~ ale I.4i~1O lrO G U bJ / L L FR E ~E~ C`• cS Cr ~rM S 3 G . t; d ~RA.~ .~~°b RT Fla M C A /'~.~ ~s~~ ~oS E' 'i n /vlA,~a Q C~ R ~- ~~• ~c< ~ /a 8 90 /6 - `7'-~~~- I°~--R~oT- NFw s l9©. 'T~3 s•T-~+ Tom- No-r-~ e ~ 8 ~i ~"~. , 8~ a a~ ~ ~ , g l ~. 9 l o , ~3 . GK f# 1 ~ ~ q o ~ '7 •- C ~ R ~Crs ~e /Q~G.. ~'l~o CTR So , Q a ~~ER RmaM ~ . rsu~e~c~ f ~' . CK ~ 1 a. ~' 9 a 18 ,_ C~rnbt;7e~~r~ ~oa w rc ~ ~R~- ~=Sever ~n~,s 1 o a . a aas;~~,~~-s Q~ ~ef~1 Nl,~.u~ R CARE ~~o CR~Q ~~s~c.~ ~s P ~R 1 S• e. t~ t,E l a Fl ~ a a o - ~ ~ Y c~P~ ~ ~,r ~ s P tfal•So ~~ ~-,~ rPo ~,,~ ~ . .~.~ s ~ ~~.~ e ~ TOTAL (Also enter on line 10. RPCani+~~~~+,,,.,~ ~ (If more space is needed, insert additional sheets of the same size) SCNEDVLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS as6.s6 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTeTF n~ SCHEDVLE J BENEFICIARIES ~_TT y ~ ~A c K~ y NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. W ~~ ~~.~~n ~ ~.i4cK~y 3 .~' .Co,.l G' vl ~w pR FILE NUMBER _ ~O~I - ~o~-TI RELA IT ON HS IP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE --- S~~ ~ ~aQ~o ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 II NON-TAXABLE DISTRIBUTIONS: COVER SHEET A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) $ ~7.~, ~ ~` ~~ ~K~ y ~~e.r~t~~~~ ~rF,~ 'lease Note: Your Sale Proceeds Check is Attached OMB NO. 1545-0715 BROKKIR'S Namtt, ~1ild-ess. ZIP Code. ~d ~ Zo ~ ~ Proceeds From Broker and Barter Exchange Tt ansactil~ns T ~ Form 1 Q99-B +~a ~r Re~,i«,~ Substitute COPY B FOR RECIPIENT Brr~lters and ttarta tinges r~ report a from harasactior~ to Ttta Bank of New York McNon "'IMPORTANT TAX INFORMATION""' ~ ~1d ~ ~ iii Revenue Service. Thajs form ~ used to rt~Ott N Blvd. ~, This is irrrportant tsar i~ att~ is being t~ . ,leraey ~tY . furrtistred to the Irdernal Revenue Service E 1a. Date of _.. 135160382 , ply mar o~ ~~ return, a negltgerwe ~y ~ ~ 07/25/2011 1b. CUSIP Number 59156210 Tebphone: 1-800.649-3593 you if this in~me is taxable ar~d the IRS deft~rrnirres that it has not basic re t d 2 ~ ~ 4. FEDERAL INCOME TAx wRHHEt,p - ro wHOM p por e . >~1,315.07 ~,~ Alb STd Crk' /~ ~ C6 S gross proceeds . P -7~S~it REPORTED D TO IRS [~ Oros Proceeds bss oanmission and rs~i ~f ~f. y ~ q premiums WILLIAM H LACKEY ~ .. J t~ ~ . ~ ~ 7. Description 35 LONGVIEW DR METLIFE, NBC. NE:t:HAN>CSBURG PA 17050-2722 3 Y j N AiR~fi Inve:br ~ VA ~.~ ~ r ~ ~ ~ _ Identification Number «- Fib 124925335®06 ~ ox 1a. -shows the trade date of the transaction. or entry vuill ecoc 4. -Shows badnlp with e _ a 2896 race if ~~ a P~ rra~t vvithtro~l at ox 1 b. -For broker transactions fly did not famish your' taxpayer icon number to the let~ific:ation Procedts+es) number ~ Iterrr~ CUSIP (Committee on Uniform SerxKily See Form W-9, Request for Tltncpayer ider>~Ition Number and Certi6taltion, for reported. iMc~rroatbn on bada~ wllhltolding,. Irrcptde this amount on your hrcotne tax auc 2. - Shows the proceeds from transadiorts involrirog . bow. other debt Tatum as tax withheld. bigaNorrs. oorrunodities, or forvlrard contracts. Losses on fonnlarr! oontrads are shown Boot 7. - Shows a brief descripiiorr of the i-errr or service far which the proceeds or i Wtrentileses. This box dress nvt iricfucle proceecJr tiara regulated tuhlres oortracts. gartering income is heir :short-4hisrerrrount-orrSchechrie p-(Fra~rf1040) CBipital Caains and Losses. -- _--_ _ 9 ~~ed.. Far rwgulated tutun3s contracts and fe-waM ,..-". cartraobs, "RFC' or otloer appropriate desrxlption ,nay be stwwn. or inquiries about your account, contact BNY Mellon Shar+eowner Services, MetLl-fe•s Transfer Agent: Telephone: 1-8UQ-649-3593 U.S. Mail: E-Mail: metiife~bnymellon.com MetLife Internet: vwvw.bnymelion.comishareowner/isd c/o BNY Mellon Shareowner Services PO Box 358447 Pittsburgh, PA 15252-8447 YOUR ACGOUNT HAS BEEN CLOSED. THE ATTACHED CHECK REPRESENTS THE FULL VALUE OF YOUR ACCOUNT. - _ _ - _ "IMPORTANT TAX RETURN DOCUMENT ATTACHED " NETLIFE, WC. • •••••••~•,a• ~ am un ~ t DESCRIPTION p 07/'252011 SHARES SOLD 001 928 59156810 I~IVEST124925335906 A ~.LH0000 CHECK 945824 CHECK OJ-TE CHECK AMOU VING TRUST ~ ~@/~ SHARES SOt.D 07/28120G1Ri~ PROC ;1 PRICE PER SHARE (~ 32'0000 41.09580D0 NITHHELD NEr PROCEEDS CLOSM~K3 TRUST INTEREST t3/1L.MICE ~i1.315.0 ~'~ 51,315.07 00.0000 v - - - - - - - - - - ...,,._._,~_.,~,~ _ ~r.,,.~„~",1, _ PLEASE DETACH BELOW - _ _ _ _ _ _ CHECK NUMBER: 945824 - ~-..,..r~ ._,..c ~ +4~.3i~ ~ -Q:65 (-1:59%~ ~ - -- _ _ u9 ' sty ~ _ .2 i z011 End: i a ~ j2 j ;2011 ~ ~ Nib tow qos~ 8/2/11 40.54 40.75 40.13 40.3 8/i/11 41.73 41.98 40.53 41.0 7/29/11 40.70 41.48 40.14 41.2 7/28,/11 39.93 40.45 39.53 39.8 7/27/11 40.80 40.92 39,51 39.5 7/26/11 41.19 41.5E 40.99 4i.1~ 7/25! 11 41.26 41.51 40,89 41.2 ?/?2Ji1 42.06 42.06 41.35 41.7 7/21/11 42.19 42.$6 41.66 42.0 7/ZO/ 11 40.70 41.13 40.43 40.$~ 7/19/11 •40.70 40.83 40.065 40.4 .7/18/11 41.25 -- ---~1.~9 -- --39.95 _ _ _...,90.4 ___ _.. _. - -- _ --- --- -- 7/15/11 42.02 42.12 41.25 41.5 7/14/11 41.96 42.28 41.51 41.? 7/13/11 41.83 42.48 41.405 41.8 7/12/11 41.78 42.56 41.46 41.5 7/ 11/ 11 42J6 43.19 41.87 42.0 7/8/11 43.$9 43.77 43.33 43.5 7/7/11 43.93 44,31 43.84 44.2 7/6/11 43.60 436774 43.06 43,3 7/5/11 44.40 44.40 43.36 43.7 ~ETT~/ ~ ~AC~'E ~/ S~~ ew~~ ~ Tra~ng Offers Spuds! n(Ren • ~ Invest in 1bletLife for $4 s Il~G DIRECT A.C1trI: Online Currency Trading Try a Free Practice Inve~tin~ _ account Toda~~, ~~ 2ofS 8/2/2411 11:22 A11- ,~~~ ~~ ~ i_ • overel n B ~~~~~~ INTEREST REPORTING FORM PZ # 00168-0718-102007 Date Redeemed 07/18/2011 Branch# 168 Processed Gloria Boot Teller # 001 b TRANSACTION DISBURSEMENT ^ Cash ^ Check TYPE(S) ^ Sovereign Acct Credited Account #: NUMBER OF #20 BONDS TOTAL REDEEMED $4237.47 Ensure that the following in#ormation applies to the NAME on 60ND/BOND OWNER. TOTAL 10991NTEREST TO BE REPORTED iS $3,487.47 SOCIAL SECURITY NUMBER OR EIN 456-37-5072 NAME on BOND/BOND OWNER ESTATE OF BETTY J LACKEY DATE OF BIRTH 03/05/26 STREET ADDRESS of NAME ON BOND/BOND 35 LONGVIEW DR OWNER cITY, STATE & ZIP CODE MECHANICSBURG PA 17050 COUNTRY OF CITIZENSHIP United States Complete the information below about the person cashing the bond(sj ~NLY'if NOT the NAME on BOND/BOND OWNER named above. NAME OF PERSON CASHING BOND(Sj RELATIONSHIP TO NAME on BOND/BOND ^ Parent/Guardian ^ Trustee OWNER: ^ Conservator ^ Executor/Administrator Certifications Instructions: You must cross out item 2 below if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends tin your tax return. 1 certify under penalties of perjury, that (1) tha# the number shown above is my Taxpayer Identification Number and is my correct TIN; (2) l am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the intemai Revenue Service has notified me that I am no longer subject to backup withholding; and (3)1 am a U.S. person Cnduding U.S. resident alien). Signature Legal Representative Title (if any) Date Important! By signing above, you certify that either 1) Your TIN is being used to report the interest earned on the savings bond(s) OR 2) You are authorized to sign on behalf of the registered hoiderlTlN reporter whose TIN is being used to report the interes# earned on the savings bond(s) (i.e., you are the parent/guardian, trustee, executor/administrator, or conservator) .._.__ Refer below for additional Federal Reserve Bank redemption resource mformatton. ~~~~~" ~' Via telephone: 1-800-Z45-2804 g Via the Internet: http://www.savingsbonds. ov/ 9 BRANCH USE ONLY Provide copy to customer. Retain copy in branch files. Forward original in Savings Bond Redemption Forms special use envelope the same processing div. 1099 PROCESSING TEAM USE ONLY UTJ SBR001 REPORT DATE PZ 250 REPORT DATE Effective 12/10/2008 Revised 07/15/2009 :atc~lated Value of Your Paper Savings Bondt~s :alculator Results for Redemp#ion Date 07/2011 ~ oral Nr~ce Total Value Total Interest 750.00 4 237.47 ~ 487,47 Bonds: i-20 of 20 YTD Interest X95.61 Serial # Series Denorr~ Issue Date Neat Accrual F"anal Maturity Issue Frice Interest Interest ~#e '~'aiue Note t25793693ee ; c25792968ee ,- _ EE EE' _ _- , .,_ $75 _{12/1982 $75 11/198 ,_ 12/2021 • 11%20 _ -12/2012 _. 11%2 1 ..._ ._$37.50 " 7 X160.62 4.0096 $198 12 _ k5645954ee . _._ -_ EE -. .__-- _ _ $75 . 2 11%1982_ _.. 1.1.' ;...11%201.1. , . 0. 2 _1120.12 -. $3 .50. _. ___ $37.50 ~ _-_$160.62 $16Q.62 : -- -4.OOg6 4.Ot196 -- _$198,12-- - _ $198 12 - c25792925ee _ _ _-- - c25792894ee. --- EE - _- EE - = --___$75 _-- $75 _09,~1982 .08~198z __09J2011_: _0$~2~i1 09/2012.` 08/2012 ~ __ $37.50._. $32.50: ____.$170,.13 $170 13 4 0096. 4 00 . __._ __ _ _..__. - .. _ . X201.63; 07 6 c25792861ee EE E $75 _ - 07/1982. 01/2012 07/2412 ._ ._ __. __ __ ._ 37 50 _ _... __..-.._ . _ . . .. 174.27 ~ ..._ . . 96„~. _ 4.00°16 _ $2 . 3 .. - $212.77 c25792827ee ...-. -- -_ ...._._ _.. -, _ _ 792795ee ; .._...~ _ EE .... _.$7S __ $75 ~6~1982 . _. 051982 -1?.~2011 _ 112011 ' 062012 - ' 05/2012 _ $37 50 - 37 50 ._ ~. $174 27 . $1 4 ______.__.....,_ ., 4.0096 ~ 0 ' ..._ _. .............~........,. $211.77 c25792762ee -_ - -_ EE _ _ ____ , 75 . __ - 04/1.982 . __ . ___10/2tJ11. _ 04/20.12 __ _ ._ ..._ ____. . ~_ . _ $37 50 ' . _ -_ _. ___ ___ 7 .27,', $174.27 _. 4. 096 _ 4,0096 $211.1? .._ _. _ . ' $211 17 c25792730ee ~ . k5645979ee :. , EE EE . ~_. __$75 _ $75 ~ 03,~1982~_ 09%2011 _ OZ/I982 082011 _03/2012 _., 022012 _ .._ $37.50 ;.-- - $37 0 ~ ..... - _ $174.27 - 7 27 _ ___4.0096 .____ ________ 4 ~ . _ $211.17 ____ ____ ---.-------___ ...._.... . k_ 5645925ee - -_ - - EE . _ - .__ ._, $75.. ._ 01/1982~ __ _ , 01~2012 _. -. .01,/2012: _ _._, .5 .- $37.50 ~ $1 4. $178.53: .0096 4.0096: $211 77 . $21S 03 _k5645890ee k56~5858ee _..:.._.._...,.,.w - - EE- EE _.- --_$75, 75 : ~ ..12/1981_~ 1 19 1/ 81 _12/201i . 11/2011 _12j~011-- 11/2011: _ . $37.50;,_... 7 $ ____ .___$178.53.:. ..__ ..._4.0096 ,~~_ . . $216 03: _._..._._._.__ ._._ _ .___ k5645823ee ................ . -_.._.. k56457 ~ - EE ...._..-_ . ... ..^__ .. . .............._._ 75 10 1981 ..... $.._ ~ / .... . ._....... ~- 1 0/2011 .. _.. ..._. 3..,SO . .. - 10/2011.:~ ... $397.50 ._.. _ .._. _ ._ ..... $178.53 .._.. _ . .. $178.53: 4.0 09~ ...:..---._... . 4.0096 16.03 __._._ ._ .. . ..... ........_ $21.03 90ee ................_-......:... k5645756ee EE ..... -. EE ._--.. $?5 ~ 09/1981 09;2011 ~ .._ 09/2011 ~ _ ............... . _...._.._._ .----- - .. $32.50.=. $178.53 :~ . .._.........._ _.,. _ ~ ~ ___._ _..._._.... 4.00 9b .. ... ,___, , _..~..._..__. _ ....._ $216.03 , _ .,---------_--- _._._._. . _ k5645722ee _ . _.. EE _ $?5 $75 Y 08/1981,„ 07/1981 08/2011 y_- .08/2011 -.... _..--- - - - j2 -~ -$37.50 ~ _._ _- $178.S3r.. . ._._.. _. . ..4.00~Xo - -. .......__........_....M.. -... . . $216.3.. --_... . k5645684ee - k5 _ .__. EE ..___ _ ., ... . _.__ $75. .,- 06/1981 - - ~----- -- ..._~_ . _._ ._. _ __ ..:-- 07 011._ - 06%2011 ' - _ $37;:50,:.----. $37.50 .._ __....._ ...$182.$5.;.... X182.85 = _.. ~ _. ----- ---- - $22.35 MA - - -- --__._ ._... .--.._.. X220 35 MA 645653 ee ~ . EE .- $75 05/1981 a- __ __ ... _ --_ - QS/2011... _ ..._ $37.St? . _-_-__-- __.$182. _ $5 __ _. ._. - __ _____ ______~ --- ---- --._ $220.35 MA Tatals for 20 Bonds ~ $ 750.00' $ -, . _. 3.487.47: .- ~ . _ ___.. _ ____ .._..._ _ . - _ __ ~ $4,237.47 Notes NI Not Issued .NE ,_Not_eiigibie. for_payment PS Includes 3 month interest na _ MA Matured and not earnin interest ..._. ~ }~~~- ~~ ~ - _.. , (` Gr •r ~ ~ ~ A C K~ y ~/4E p2o1/~ ~o°?'~/ ~overe~gn ~ . - ~ ~~ ~~ ~ ~ ~ ~ . ~ wr;.,. .. ~ .- .- ESTATE OF BE77Y J LACKEY Account # 7 684072700 WILLIAM H LACKEY ~DCEC Balances tnnin Balance $0.00 Current Balance $44,675.53. Deposits/Credits + $44,675.53 Avers a Daily Balance $42,902 87 Withdrawals/pebits ~..~ interest Paid this Period " $ 7.05 Annual. Percents a Yield F..amed 0.~0% Earned this Period $ 7.05 Paid Last Year $0.00 P2ti~I:Year-Tc~Ekate _ ': ~ 7.t?~. _ __r __ _ _,: ,:. ~.~ interest earned and the interest paid may differ depending on when interest is credited to your account. Account Activity Date Description 07-13 Beginning Balance 0~-13 [3EPOSIT $40,431:.0 07-18 DEPOSIT 54.237.47 Additions Subtractions Balance ti? 1 IrKCUt t oa~ance rr,v, vc~u 44,675.53 IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC TRANSFERS CALL YOUR CUSTOMER SERVICE CENTER AT THE NUMBER SHOWN ON THE TOP OF YO~1R_STATEMENT OR WRITE TO THE BANK _ __ __ FOR DEBIT CARD ISSUES: FOR ALL OTHER ISSUES: Sovereign Bank Sovereign Bank Attn: Card Dispputes Team Attn: Client Relations MA1 MB3 02 OS 10-421-CRI P.O. Box 831002 I.O. BOX 12646 Boston MA 02283-1002 READING, PA 19612-2646 Please contact us if you think your statement or receipt is wrong or if you need additional information about a transfer on the statement or receipt. We must hear from you no later than 60 days after we sent you the FIRST statement on which the error appeared. • Tell us your name and account number. • Describe the error or the transfer that you are unsure about and explain as clearly as you • Tell us the dollar amount of the suspected error. can why you believe there is an etYOr' or why you need further information. [f you tell us orally, we may require you to send your complaint or question in writing within I O business days.. We will promptly investigate the matter and call or write to you with an answer within 10 business days (I0 calendar days in Massachusetts). If we need more time, we may take up to 45 days to investigate your complaint or question. If we do we will credit your account within this 10-day period for the amount you think is in error, so you will have the use of the money during the time it ta~Ces us to complete our investigation. If we ask you to put your complaint or question in writing and we do not receive it within l0 business days, we may choose not to credit your account. For errors involving new accounts, point of sale purchases or foreign transactions, we may take up to 90 days to investigate your complaint or question. For new accounts, we may take up to 20 business days to credit your account for the amount you think is in error. We will tell you the results of our investigation within 3 business days after completing our investigation. If we decide there was no error, we will send you a written explanation. You may ask for copies of the documents we used m our investigation. Important information about your Sovereign Debit Card The networks through which some of ur Sovereign Debit Card purchases are processed have begun allowing merchants to process your purchases without either a signature or a PIN. lt~you are not reregqwired to enter your PIN when you make a purchase, your purohase may be~~pprocessed either through the Visa network or through the STAR or NYCE networks. If your purchase is processed through STAR or NYCE, ditTerent terms apply and you will not be eligible for the rights and protections available through Visa, Please see your Personal Deposit Account Agreement for more information. ~, ~ ` ~' .~ ,.. ~. ,. ~% ~'. page 3 of 3 7'21091342 ~~eHEGU:.~ ~.. .~r~ ,., .~.. WILLIAM H LACKEY EXEC Deposit Accounts Account Number Average Daily Balance Current Balance SOVEREIGN PREMIER CHECKING 721091342 PREMIER MONEY MARKET SAVINGS $5,.'!.32.02 $5,216.06 1684072700 $42 902.87 $44,675.53 Total Deposit _ $4a,sg~.59 Balances Beginning Balance $0 00 ` Current Balance Depos~ts/Cred~ts + $5,461.56 Average Daii Balance $5,216.06 Wifhdcavvals/Debits $2 .5 $5,132.02 -: 45 0 Interest Paid this Period * $ O.Q2 Annual Percents a Yield famed Earned this Period 0.0191; $ 0.02 Paid Last Year Paid Year To-Date $ 0:02..' $0 ~ 'The interest earned and the interest paid may differ depending on when int®reat is di cre ted to your account. Checks Posted Check # Date Paid Amount Reference ..101 07!20 5203 00 990974940 2 Check(s) Posted = $245.50 An asterisk (") indicates a skip in sequential check numbers. Account Activity Date Description Check # Date Paid Amount Reference 102 07/21 __ $42.50 977757050 An (E) indicates check was converted to an electronic item. Additions Subtractions Balance 07-13 Beginning Balance 07=13 DEPOSIT $0.00 07-19 DEPOSIT $5,000,00 $5,.000. 07-20 CHECK 101 $461.54 ~-'~'- $- 5' g1 07-21 CHECK 102 $203.00. ' $5258.x4 07-22 INTEREST CREDIT $42.50 $5,216.04 07-24 Ending Balance _ $0:02 $5,216.06 $5,216.06 pnge 2 0/'3 7Z 1 ~913,t2 WILLIAM H LACKEY EXEC ACCOUl7f # 727097342 ~~ .. w p~ ~~ ° . ~ ~` h ,j' l A.r o ~„ WILLIAM H LACKEY Deposit Accounts Account Number Average Daily Balance Current Balance SOVEREIGN PREMIER CHECKING MONEY MARKET 1681722089 $5,665.90- $5,300:69 1681727293 $42,321.55 $34 404.73 Total Deposit $39,705.42 Balances innin Baiar'tce $5,612:74 Current Balance DepositsfCredits + $2,129.34 Avera a Dai Balance $5 300:69 WithdrawalslDebits - $2,441 39 $5,665.90 . Interest Paid this Period Earned this Period $ .0.05 Annual Percenta a Yield Eamed 0 01 'Paid Year-To-Date $ 0.05 $ 0:31 Paid Last Year . $2.17 *The interest earned and the interest paid may differ depending on when interest i di s cre ted to your account. Checks Posted 2fi31 06/14 ~ 00 ~ (:17809240 2632 06120 50.00 / 627088500 E2633 06/21 ~:45 WAL-MART 2634 06/30 250.00 986314470 2635 07(07 $42 50 980199950" 10 Check(sj Posted = $1,691.39 An asterisk (*) indicates a skip in sequen#+al check numbers. Account Activity Date Description 06-10 Beginning Balance 06-14 :CASH CHK ' 2631 2636 07/05 83.00 ~ 987257395 2637 07108 103.50 98040 15' 2638 07/06 28 .11 987740450 263 07/07 71.83 996014140 2640 07/05 $334 00 986983715 An (Ej indicates check was converted to an etec;tronic item. Additions Subtractions Balance $5,612.74 $20.00 $5,592.74`, 06-21 WAL-MART STORES PURCHASE 110620 $50.00 $5,5'4'2.74 2633 MECHPA $47.45 $5,495.29 06-29 DEPOSIT 06-30 CHECK 2634 $129.77 $5,625.06 07-01 US TREASURY 303 XXSOC SEC 070111 $250.00 $5,375. A SSA $1,338 00 $6,713.06 07-01 BENEFIT PAYMENTS DEPOSIT 000009327724067 $fi61.52 $7,374.5$ 07-01 REC RETL )TNT Tt=R TO CKG #82471703739 07-05 CHECK 2636' $750.00 ~ $6,624.58 07-05 CHECK 2640 $483.00 $6,141.58.: 07-07 CHECK 2639 $289.1 $5,518.47 07-07 CHECK 2635 $71.83 $5.446.64 $42.50 $5,404.14. Check # Date Paid Amount Reference Check # Date Paid Amount Reference page 2 ojS 1681722()89 WILLIAM H LACKEY Account # 1681722089 .S"e ~ ~ ~ ~-~„ F 1 r,tE ~ S f A .~ ~ .'~~ i 00000 -o BETTY J LACKEY WILLIAM H LACKEY 35 LONGVIEW DR MECHANICSBURG PA 17050-2722 Protect your vaNuables and irr~partan~ documents anc~ ~~f ~t~~~ f~e~~e u f. rriir~c~ that comes from ki~ativing they ire ire ~ s~f~e p4~ce~. ~e~ ti<~e ~~nh~~cec~ se~urit~l caf ~~ Sot~ereit~n safe dep~asit bcrx. Keep yo~Ir impc~rt~nt d~~c~~ments, ~~ec~~re ,ask about spe~ia! di$counted safe depc~sft box I•~tes ~t yvt..lr ne~rc~st ~ar~ncl~. 18000?5033 ~^Ve kr~~~-~ yc~u c~~n't r~~~r~ thc~ Hassle ar~ci pratcntia) ~'rnta~:~rrassmcant crf Itavir~ ~ ral~it «rc~ ~urcl ease car ATt~~'.^~'Itl'iCi~c~~.~4's,! ~crrr~~ ~r~r~t~~~a~~th~fi~i~r3t fund, IV+r'w fer~erat re/ry'~ul~tions take ~rffe~t Auc u~ ~ f 1 ~ 7 ,~ 1 15, ~01t7, tf~at r~~uEr~~ us tt~ ri~ati~t~ ~•c~car F ' t y+ es~ t~aerr~raft5~ra ytaaar ~~craur~t ~r~d~f~arc~e fees. ~nrcall in SNover~+iclrt.~4c~taur~it Prc~tc~ttcar tc~.1~~~,, it ti,~r~r ~rv~ulci like us t~ tr.~~tilrtu~~ to f~Y ~vercir~ft5, anti potentialfy crat~rrJe ~:~ fE?+~.', tart ~4Tt~1 anal ~~a~~=.~tirr~e ~ic~it c;~rrl tr~~r7;~cti~arFs. Ire c~rci~.~r fc~r ~i5 tc~ c ~rttiriu~~ tra ~~ate~7t~ally f~~3~ tl~OSe c~+rrar~rafts., yr~u rr'rust e~lroll Icl a[7i1LrC.~I(~rl AC~~UU11t t?'r~t~r~~tryr. ~~~r r~~c~r~' ir-fc~rrnatiOr~, ~~e ti7~- nc~tite irl yr~ur N9~~r~f7 st~terrrent, C~~II 1-877-768,4721 car +~sit r~ !sovereign Branch ~.; .; ,M,.r sr0 '~~ ,~.L, ~.` ~ .,ir `~~ WILLIAM H LACKEY Deposit Accounts SOVEREIGN PREMIER CHECKING MONEY MARKET Total Deposit Account Number ~~~ 1'681722089. 1681727293 Sovereign is part of Santander, "Global Bank of thetYeagr."* Statement Period 05/10/10 TO 06/09/10 R For your convenience our Customer Contact Center is available from 7 am - 8 pm EST, 7 days a week. Call us at 1-877-768-1143. Hearing impaired may call 1-800-428-9121 (TTY/TDD). www. sovereignbank. com noon 70090 Average Daily Balance $6,729.00 $44.096.28 Current Balance $6,998.38 $44,108.66 x51,107.04 Time Deposit Accounts Account Number Maturity Date Interest Rate Current Balance 24-35 MONTH CD 1685210260 Total 06/05/12 0.99% $10,000.00 $10,000.00 page 1 Of 4 ~ Sovereign Bank is a Member FDIC and a wholly owned subsidiary of Banco Santander, S.A. ~ Sovereign and its logo and Santander and its logo are registered trademarks of Sovereign Bank and Santander, respectively, or their affiliates or subsidiaries in the United States and other ,,,~ countries. 'According to The Banker, December, zoos. 1681722089 (~A.:.N d mil(,. n^~7`7f r + .. ~ ~: i'J if .'~.. Balances Beginning Balance $44,096.28 Current Balance Deposits/Credits + $12.38 Average Daily Balance $44,108.66 withdrawals/Debits - $0 0 $44,096.28 . 0 Interest Paid this Period * $ 12.38 Earned this Period Annual Percentage Yield Earned o 0 33 /o $ 12.38 Paid Year-To-Date $ 104.89 Paid Last Year . $289.31 *The interest earned and the interest paid may differ depending on when interest i di s cre ted to your account. Account Activity Date Description Additions Subtractions Balance 05-10 Beginning Balance OB-09 INTEREST CREDIT $44,096.28 06-09 Ending Balance $12'38' $44,108.66 $44,108.66 IN CASE OF ERRORS OR QUESTION S ABOUT YOUR ELECT CALL YOUR CUSTOMER SERVICE CENTER AT THE NUMBER RONIC TRANSFERS SHOWN ON THE TOP OF YOUR STATEMENT OR WRITE TO FOR DEBIT CARD ISSUES: THE BANK Sovereign Bank FOR ALL OTHER ISSUES: Attn: Debit Card Services Soverei n Bank g MAI MB 301-06 Attn: Client Relations P.O. BOX 841003 10-421-CR1 Boston, MA 02284-1003 P.O. BOX 12646 READING, PE, 19612-2646 Please contact us if you think your statement or receipt is wrong or if you need additional information about a transfer on the statement or receipt. We must hear from you no later than 60 days after we sent you the FIRST statement on which the error appeared. ~ Tell us your name and account number. • Describe the error or the transfer that you are unsure about and explain as clearly as you can why ~ Tell us the dollar amount of the suspected error. you believe there is an error or why you need further information. If you tell us orally, we may require you to send your complaint or question in writing within 10 business days. We will promptly investigate the matter and call or write to you with an answer within 10 business days (10 calendar days in Massachusetts). If we need more time, we may take up to 45 days to investigate your complaint or question. If we do, we will credit your account within this 10-day period for the amount you think is in error, so you will have the use of the money during the time ~t takes us to complete our invest~gatton. If we ask you to put your complaint or question in writing and we do not receive it within ] 0 business days, we may choose not to credit your account. For errors involvingg new accounts, point of sale purchases or foreign transactions, we may take up to 90 days to investigate your complaint or question. For new accounts, we may take up to 20 business days to credit your account for the amount you think is in error. We will tell you the results of our investigation within 3 business days after completing our investigation. If we decide there was no error, eve will send you a written explanation. You may ask for copies of the documents we used in our investigation. Important information about your Sovereign Debit Card The networks through which some of your Sovereign Debit Card purchases are processed have begun allowing merchants to process y our purchases without either a signature or a PIN. If you are not required to enter your PIN when you make a purchase, your purchase may be processed either through the Visa network or through the STAR or NYCE networks. If your purchase is processed through STAR or NYCE, different terms apply and }~ou will not be eligible for the rights and protections available through Visa. Please see your Personal Deposit Account Agreement for more information. ' Mir ~~.~~ 21:58 xwc.aca~, w "~,m~ / •s•ss i•~ ~- _. .r. r { r -r - ._A n26F.._.. ran - l!1rn'e~'~o. Ban) w.r._1t~f ant i - - - ...~-t~~Py,,,',,;,,,y ~: ? ~ i ~~g 9 7 X69 ~~, 166 1 ~ 2 2i]a9r ~~ 58 ,,,, O~t7i¢q~61dO.P 1681722089 # 2458 05/13/10 $50.00 eEtfy ~ Llrfil~[Y _----•.•--.~-._ r'11-1A1N N. ~`KRY °u-RS r ra 2 A 5 ~ IKti1*M1Y1':iNW1l. ~4.y, wig. .C~f,. ~.:C ._.. f MAN 1Mt p~ 7 . a~~ika....,. ~Ll°.~f~~eh(. Si :4'~°aa Ot~ 1~~ ~ _ ~, rt231~F~~,gi~: i6rii9~2~1~i'i~r°2454 Df~OOf _ r -- 1681722089 # 2459 05/11/10 $18.00 page 3 of 4 1681722089 WILLIAM H LACKEY .Account # 1681727293 ~ETT Y' ..~ l,,f~ Cl~E; S'C~t ~l)~~,~ ~rF~4 Statement Date 06/30/2011 Account Number 000372-99394 Inpatient Amount Due Outpatient Amount Due Total Amount Due Balance Due Upon Receip $878.00 $0.00 Skilled Nursing Center Monthly Statement ~, • • • . • We thank you for your prompt attention to this statement. Please notify the business office of any changes to your benefits or insurance. ~afi, 1 t ~.. ` ~ l~ ~ /~ a ±wK~ c ~J~ °v"~r~~r~sp, r. ~ tf z-S~ N7 T ~ ~. a • ~'~ Questions? Please calf 717-249-0085 to reach the business office during our regular business hours Please confirm that the information is correct for: Patient Name Medical Record No. A/R Representative Primary Payer: Secondary Payer: BETTY LACKEY 000372-99394 WILLIAM LACKEY HIGHMARK BC BS Insurance information and payment activity on individual accounts are included in the attached detail. i~m~ilium Mail Check Payable and Remit To: MCHS CARLISLE 940 WALNUT BOTTOM RD CARLISLE PA 17015-fi926 91194-47941 -980074 r-'~~E abr<_ ~®'~r .TT E ~ a~ • • ~ * . ~~ We have r~eived the explanation of benefits -~~ from your insurance company(s) and have applied whatever payments andlor adjustments ._._._.. are appropriate. Please make payment for the A balance due $50.00 QR take advantage of a The Spirit of Cnrtr~g 1596 prompt payment discourrt and remit $42.50 ~~ on or before 08/09/2011. ~..~.. 39801386 Here are two canve~nient ways to make BETTY J LACKEY payment: 35 LONGVIEW DR MECHANICSBURG PA 17050-2722 1. Call Customer Service at 71?-763-2138 to make payment by cn3dit catrd. 2. Maif tear-off coupon below with payment using the enelosed self~addressed --- - -- _-- vel Patient Name: Lackey ,Betty J Statement Date: 07!10/11 Service Dates): 05/22/11 Account Number. 39801386 Medical Recorcl Number: 433552 Insurance Information Ins. 1: HIGHMARK SECU Ins. 2: Ins. 3: Ins. 4: .- Previous Balance: 0.00 Total New Charges: 02, 415.00 Payments/Adjustmenis: #2, 425.00- Acxount Balance: 050.00 Please Pay This Amoy X50.00 OR I?iscounted Amau of $42.54 if pa d on rar before 08/©9/2411 ~ ~ i S /( Please call Customer Service at 717-763-2138 ~? to add or make conecc~ions to your insurance ~ ~ information, or to make arrangements far a ~ ~ payment plan. If you are unable to make ~ payment, please contact the Financial Counselor's Offrce at (717) 763-2885 to discuss finanaai assistance options. _ _ Please Note_ Your physicians w-7l bill separately for profiessiona/ services _ _ _ _ _-- _ -- _ _ _ _ _ 1~'T'7' Y .~ ~A C/(~ ~' ~/ 1. ~° ~ C- / ~ .. to 0 '~- ;r SG u ~ ~ ~ ~ ~ ,`~ ~~ TFM 3 ••~• . •~ ~~ HTT HOSPITAL Tl~LEPHONE AND TEL,COM, LTD. P.O. Box 39127 Cleveland, OH 44139 BETTY LACKEY 35 LONGVIEW DR MECHANICSBURG , PA 17050 INVOICE Patient Name: BETTY LACKEY Invoice #: PH1107-55277 Date: 7/19/2011 Balance Due: $40.00 a~~ ~ 13°j `t ~~ f o~ Admission Date Discharge Date Service Days Description of Service e; 5 / 24 / 2011 6 / 10 / 2011 17 N/PHONE $40,00 These charges are for the convenience of having use of #elephone and / or #elevision services during your hospital stay. at Pinnacle. These services are not 'covered byany-insurance plan. Please contact us with any questions at our toll free number,l-866-362-3880, between the hours of 8:00 AM and 5:00 PM' Monday through Friday. Thank you. Pay Online at paypatientbiil.com Customer Service: 866-362-3880 8AM-SPM, M-F 0 _____ ~~w" ~ CAMP HILL, PA 17011-1708 ----- -- ---- --- --- - ~~~~~' ~~~~~ Phone #: (800) 367-0512 Federal Tax ID: 23-24~i3002 ON REVERSE SIDE PATIENT NAME: BETTY LACKEY ~I ~G ~o B! .. o o ~ 7 / INSURANCE: HIGHMARK -FREEDOM BLU S`cli ~n~~. ~ ~N IggL CALL NUMBER: 21947'1 W ~,~.. E ~ ~ ' OF CALL: 7~ 1/20'11 '1BAL FROM: HOLY SPIRIT HOSPITAL TO= MANORCARE HEALTH SVCS - CARLI: BETTY LACKEY ACCOUINT SUMMARY 35 LONGVIEW DR MECHANICSBURG PA 17050 TOTAL CHARGES: 185.05 , PAYMENTS/ADJUSTMENTS: 7g~p PLEASE PAY THIS AMOUNT: 108.75 _ DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT DESCRIPTION OF CHARGE QUANTITY UNIT PRICE STRETCHER One Way Transport T2005 1.0 Transport Van Mileage S0209 108.75 20.4 3.74 }y[n ~+ t( ~~ _ ~, ~„~~ DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE Medicare Assignment Adjustment 07/28/2011 Insurance Payment - HIGHMARK -FREEDOM Bl 13302224 07/28/2011 PLEASE PAY `THIS AMOUNT -INVOICE DUE UPON RECEIPT --~- RETURNED CHECK FEE - $31.00 AMOUNT 108.75 76.30 Total Charges 185.05 AMOUNT 25.30 51.00 Total Credits 76.30 $108.75 PATIENT NAME: ---~~~~'`' LACKEY, BETTY J CALL NUMBER: 219471 W AMOUNT PAI : f d $ •7.S' 08/01/2011 IMPORTANT MESSAGES: This is the amount due after your Insurance Carrier's payment. ~~ S~~`~. ~~ ~~ ~ WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUfTE 211 CAMP HILL, PA 17011-1708 ~~ y ~~ ~ "~ ~ KE Y r ~' c N Env t~ ,~. rE ~ ~ x~ FROM THRU CLAIM AND DESCRIPTION - 04/O1/11 04/06/11 175012 - HEMODTALYSIS TREATMENT 04/18/11 04/20/11 177885 - HEMODIALYSIS TREATMENT 04/06/11 04/29/11 185341 - FTEMODIALYSIS TREATMEN'T' CHARGES PAYMENTS 518,680.64 510 $9,057.68 5510.8 ~.~-02 51.043.5 517, Your clalrrr has beat processed by your In~rarance pr+ovlder; r~tralnir~{g Js .1'~' Pay~rteat oa this accountls crow dellnquerrt You have been two prfor and oas oftlG~s hls !s year last oppontrraity to resolve this accoua~ We Hurst elvs paynrera !n w&hht t/rlrtj- (3 d ays UP°n P~~your caacdled chec~Y or cnedlt enrart !s your rtce~ ~' l~~i( ~ n.~~ d ~~~ _ ~ - ~~ ' ~ ~ A~ v .~ ~ ~ '', `~~~_~-~_r_~ .~~, t ~ ~ll~„E_. .. rf/` ~ ~~ as"• i ~ ~ • r ' QUESTIONS: (214)'136-2781 ACCOUNT NUMBER: 7286 FACE ~1SRENAL3-0282624-0000000-2074978-001-001021-*004463.7p73 BALANCE $29.31 $13.36 529.16 BALANCED $71.83 DCA of Mechanicsburg, LLC . F.,t,~ ~a s r _ 0 0-~7~ ~T~ ~ ~. iF'ROM THRU CLAIM AND DESCRIPTION 05/02/11 05/06/11 186913 - HEMODIALYSIS TREATMENT 05/04/11 05/13/11 188125 - HEMODIALYSIS TREATMENT 05/16/11 05/20/11 193994 - HEMODIALYSIS TREATMENT CHARGES 1 PAYMENTS IADdUSTMENTS~ BALANCE $15,764.58 $924.2 $14,818.1 x,32 $17,102.58 $786.8 $16,293.53 $22.32 $13,972.08 $786.8 $13,163.0 $22.32 Your claim has been processed by your Insurance Provider; th remaining Bala a is your respa aymem on this account is now past due. Your prompt remitta ce of the balance frtU upon rec notice is appreciated. Upon payment your cancelled check or credit card statem mt is your paid ~~t~~~i ,(- l/~ ry ~ ~ o G-~- QUESTIONS: (214) 736-2781 ACCOUNT NUMBER: 7286 FA USRE~tAL2-0282711-0000000_2074977-001-000289-11003336_7075 BALANCED $66.96 DCA of Mechanicsburg, LLC 13~~r-~7 ~ ~ ~h ~+~ ~j {-~i ~. ~~ ~ a t t ~ ~ o"~ ~- ~ ."~~~ C. ~GNI~MRK. Date: 07/12/2011 This Month Gross payment amount 461.54 Net payment amount 461.54 ~L~~~~ ~ ~ ~ ~ ~ ~ ~ *~; " ~v 0359445 ~-~' n ,s- ~CAR.LISLE REG MED C"I'R N! ~: 06 26/2011 9499476 ~~- . C 334.00 ;heck Dater 07-27-2011 ~ ~ . , , ivoice Number invoice Date . \ ~ Check No. 0005801228 . e . ' • .Gross AmtJUnt : Discount Avaii~ble , F~aid Amount 994` 07-05-2011 Manor Care.~•of CarZi 125,.00 ati Refund In Dice: 99394 .00 125.00 !it r &` 2. S' ~`~Spf~rC c ~~T'~~ +11S (3 ~ Y ,~"` ~ ~ c~tr ~/ ~ of any ~'r 4 E` ~ o l/ .~ 0 0'7'7 ! Sck~r~~~.rE ~T~ ~ Name Tots nectc tyumber Date X005801228 07-27-2011 125.00 REMOVE DOCUMENT ALONG THIS PERFORATION .~~. . Y ~ '`~ t,. ~~ _,~~ .gam ~..~ "-~.~^kY,,~ ~--&.c ,;w~`~~ v`~'~• ,~ ~.p.<. ~ ~~r~e„~r .T Y* ~ .era sp"'x~r t"~ e'~~~~ ~ y': 5~~4 a ' '~b~ ~"' <C~ ~-~ as +t''~` 4 ~ ~". ~ f ~ r 1 ° , y. a ~s _ fir, ~' s , ~~ ~,@y' .» ~ ~ ~~ yak b~~ `~' ~~~7. ~ ~ ~ > g ', s~" _ r ~~'. ~ ~ ,,.~~y ~ 'i kti~~ `'~ - ~ °~Z.° v9z»,w~ z 41. `t•d.t~'~~ :~ r .+ _°1 ~~~~'""i~~,% ,~ 'r~Y~ ~ ~ ~ ~~¢ stir s.-2 ~~ 4r F - t ~ `~ ~~ .`..~ ,}~~*. y~` p~ .. , ~ ~'fy ~ ~ ~ °; ~~ Est' A~*:~ a5+ _ '. •''~~cJ` .'t~ rt~ta~~yi ~ '~ >. i'T '~~°' ~ ryY sa' -- _...._.~~..__~~~~_._._.__ _ ..~,..e,.. .....e:.~s. a~. ....y~".'da,,. •'t;?.x'r Yv`~°R+~Z'i ~,'~'`~ ~ Bess ~„ °- ' ,, ,. `~ ..y. Y~o~s~ *".~~t~itik.~~113~~'S6~~i~a'Y~e~e.:'. n.,~t~~'.auSa.'~!'.cr"+sti.~Ae' ~p,~r~.... ..~,~ - - ~ .. ~r. ... _ ._ .__ . ~ii-.A vt 1.i..aR...a.....~a,au ~, . ,s ,a. I20 S. Filbert Street Mechanicsburg PA 17055 ~~ y ~;~,~ ~.~~" .~ ~-~~ M 9 t~uestians: (214) 736-2781 Ob58S ~lnl~l~i~lirimilitlililli~r~i~illlll~illlirll~llllJirl"Ililll Lackey, Betty M hani~csburg PA 17050-2722 3 ~-s~cH~s~c ~~ ~ a~avE 7 7q FROM THRU CLAIM AND DE.SC7tl!"I'ION 06/2?JI 1 I 06/24/1 1 1210089 - HF.1bi0INALYSIS TREATMENT' q iit 8~z 1 ~`~ ~~ ~ ~~ ----.~ - StatementDate: 08/19/2011 ~~ Dne Date: °09/18/2011 Account Number ; 7286 Amount Due: $23.48 AMOUNTI X23-~f~ MAKE CHECK PAYABLE & REMIT TO: l~lili!''lil'illiili'!lllliill'ill!illllllll'iilllliit'Iriririrr! : , DCA of Mechanicsburg, LLC PO Boa 713158 Cincinnati OH 452'1-315$ -~rac~+ ,..~A(V_R~1~ 7Hts rc~ ~^-ar ~a:~tH YQ1~R PAY~IEN ~~ USI+IG THE RETURN ENVELOPE ENCLOSED CHARGES PAXMEN'I5 ADJUSTMENT'S BALANCE S11,811.b9 S?3?.1 511,051.!2 523,48 ~ BALANCE $23.48 QUESTIONS: (214) T36-2?al ACCOUNT N[TiVIBFg: 7286 FACiL,TTy: DCA of Mechanicsburg, LLC usRl~-~~-aza3a~~-ooaoooo-ao~zezs-oo~-oooa~s~eioo4as~aors ,;~,, ~~' ~ d _ ~ ~ ~ tD m --~ m ~ -~ ~ gyp- is `~- ~•.. SU ~ ~ ~ ~ ~ r- ~ ~ ~ ~ ~ o m ~ m o ~ ~ m ~. in ~• ~ ? ." ~ .. "~ Q m Q m~ ~ a --- - ---- --- - p _. ~' -' ~ c ~----- ---- -- --- - - - .._ _--r.--- _ ..___ __.~.__.__ _ __ _ _ _._._~ .,... .~a. -~ -- ~ N Ql ~ w ~ _ ~ ~ ~ ~ ~ ~ ~ w y ~ ~ 3 V~ '' '`~ O to ~ ~ '~ m ~ '~ o ~~ ~ ~ ~~ ~ o = ~ ~ ~ -" .. ~ N O ~ ~ ~ •~~• J ~T r y ~ ~ N N ._. 04 -~ < V Q w _O j O p ~ ~' .a _ __- _ tea. O ~, ~ ~' N ~ ~. w V y v ~, }'` ~. O W pQ o~~rna~ ooww ~ o ~ N o o ~ ~ .~ ~ ~ o ~ ~ ~ ~ ~, ~~~ ... ~'d o3m~s', 1 4 ~ ~~~~ ~ O ~ ~ _ ~ ~ o Q - .~ 7 C! ~ w~, ° ! ~ ~ iQ m w ~ c o ~ m 3 a~ ~ ~ ~ ~ r m A a + ~ t p !C n !A ~- -- O ~ (') m N ~ -~ Q ~ ~. m ~ ~ ~ rn o -~ ~ ~, „r A ,, ~~ ;~ ~ ~o ~ ~ ~ ~ o s:.5` ` .... 0 ~ -~ ~, w m ~ x~ <~ , n ~ ~ a¢ a ,~ `~ 'Y o ° ~ ~ c O ~ b o c ~ ~, ~ ~ ~ O +. . ,ti, ~i ~ , ~ rr :+t~y. ~ tip, ~ ~'F ~. ~ ~ C ~ ~~ ~ +r. ~ ~ ~ 3 ~ ;. ~: ~ ~ O Q- "' m O ~ o~ Q' ~ ~ r ~ O ~ ~ ~ ~ ~ n ~ O ~~ A ~ ~ ~ m ?r '~ `° ~.,, rr O A K '~ ~ ~, 3 ,~, ~ ~ A ~ ~ O n m ~ ~ 3 i ~- . GJ w 1 ~ ~ ~ rt (p ~ 3 Q i ~ ~ ~ Q. 1 (,,,~ .' ~ ~ P" ~ -R ~ °~„ a C tit o ~ ., ~ ~- ~ ~ ` ~ ~ ~ i ~ ~ ~ ~ ~ ,~t //VV~ ~~//' ~~JJ 1 ~ VI ~ ~ ~w ~3`~'. 1~ q^ ~~~ ~~' ~ ~ ~~; a ~' D ~ ~~ , 0 ~, ~ O =- ~ fD /~ N ~ ~` ~~z s as H r 0 m V V N F+ A ri a~ m w ~a '!~ a' ~~ ,~ W w Q quite X00 Mechanicsburg, PA 17050 Inquiries - 717-255-8213 LACKEY 35 LONGVIEW DR MECHANICSBURG F'i~E ~.oi~ -ao7?1 ~'~T E M ~ ~--~ PA 17050 INVOICE `~rr~)r ~ ~. ~rr-~rr f `- ~ ~r •~ war Now you know SAME AD ORDER # DATE EDITION ~QQ~, INFO TYPE OF C,_,~HAR~ a X6678 LACKEY 0002162870 08/15/11 REGULAR BASIC AD CHARGE ~ {6678 LACKEY 0002162870 08122h 1 REGULAR 561.91 78 LACKEY BASIC AD CHARGE 561.91 ~- ~ 0002162870 08/29/11 REGULAR BASIC AO CHARGE 561.91 AFFIDAVIT CHARGE 55.00 TOTAL; 5't 90.73 /~~~ ~ ~~ BL'Mii"TAI~I~E ADDRE~-~ ~ l z 8 g ~/ ,6 ~~ The Patriot News Co. ` 23794 Neiwork PL Ch~ago, tL 60673-1237 Please include the Account # or Ad Order # (above) with yourremittance--Thank You NOTE: This Invoice replaces the Omer Confirmation which we previously sent with Proofs of Publication ~` ~~ ~'~ ! ~L.Jil1t Vt`1L 415 Drina ~~~, ` ~~~~~°M £ D 1 C A L C £ N 'TER Car~sie PA 17013 ADDRESS SERVICE REQUESTED '' ~ UPON RECEIPT Betty Lackey 35 Longview Drive Mechanicsburg PA 17060 r... r r r.,. r r r. ~„r, r. r r.,... r, r r... r„i, r,. r, r,. r r.. r. r. ~ r r.. r CHECK CARD USING Fri PAYMENT MASTE~p ~ ~ ~ ~ v~sA 4 a, ~.~ AA~HIf,~W EXPRESS AC,COINtT NO. STAT'EMEM' QATE BALANCE DUE 9500083 08/31/2011 X50.00 ,S o,a o MAKE CHECKS PAYABLE TO: ~ rETr y ~ ~q ~ K~ y ~i~r ao~J.po77/ SCHEDJrCE CARLISLE REGIONAL MEDICAL CENTER STEM -~3 P.O, BOX 281442 ATLANTA GA 30384-1442 I~~Il~ll~~~~~tl~l~~i~~l~~l~~~ll~l~~l~l~~I~~I~I~I~~i.~l~i~i~l~r r O000095D00$300~f1D0050~08ETTY LACKEY 9 ^ Please check if above address is incorrect and indicate-change on reverse side. TO INSURE PROPER CREDIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. _.. PaT1CYT itM~ _ _... Betty Lackey 9500083 DATE DESCRIPTION 08/29/11 ADJUSTMENT 08/29/11 BLUE CROSS PAYMENT 07/03/2011 EMERGENCY ROOM ______ PAYMENT/AD.IUSTMEtITS 3,536.20- 453.40- ~/~~-- 8~°l~ ~ 12 ~~ ~, rAY1161TS ANO pIAR~S AFTER THE STATEAN+NT OATS WN1. BE OM THE NEXT STAT~IR. ~ ._ ___ . _._ __._ , _ ~ ' X50.00 ES The amount shown on this statement is outstanding at FOR 61WNG ~UES71~, p'1-EASE CA '~ this time. Your rom t a appreciated. p P p yment wilt tie greatly (717) 960-1680 Bips can be paid onpne at our hospital Internet web :it• www.caHisle~mccan 'i PON RECEIPT ~~- . . ~.:~ ~.: t ~,a$~ i';€~mit ?ayment 'ra: C:~ umberiand Gac~dwiii Fire Rescue EMS EYi-ling office F' CJ. Box 72fi slaw Cumberland, PA 17070 (-IJESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espan"ol: 866-724-4114 Fax: 717-214-60:10 Email: infof~ambulancebiilingoffice.com Date of Service: 7/3!2011 14:13 Patient Name: LACKEY, BETTY J. From: MANORCARE HLTH SVC-CARLISLE To: Carlisle Regional Medical Center Please visit our website to provide insurance or make payment, and for additional payment options and frequently asked questions: ww'w.ambulancebiliingoffice.com 14fedicare paid their pvrtiort of these ~'harge~ ~ balan~~ a~tre ~Y" re„~~~,. ,P~~:rernit payment for the ri~ai~tfng balance. ~'"hurnk yva~ _ ~: = 7/03/11 ALS Emergency Transport Lei A0427 1.0 1,335.00 1,335.00 7/03/11 Mileage A0425 0.9 11.50 10.35 7!03/11 Adjustment -Insurance 6102/11 Payment 6/04/11 Adjustment -Insurance Tots! 1,345.35 ~~~`Yry ~' ~R eKE y ~-~~,s,,~ a,o~(_ X0771 ..ScN~t~u,t4 ,~ ~'T ~`~M -939.51 2.33 -937.18 -358,17 -358.17 ~ ~/ g~°~~ r J2~~'o/~ b ~~ ~ ~ DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. ~,.....„,~,.-,._,..-..--------------,.ate.-....-_.~...,.,.~.... (,~.~ ~ _.. - ~ s is y ~' Pleas Iflc3ieate yc,ur p~Yffiltilt chotc~e beipW and flll In required information. If otfier arrangements, are Cumberlarnd Gc~vdwill Fire necessary, please call us at 877-214-6018. Rescue EMS r ...... ~ 11-139515 Credit Card: D MASTERCARD C7 VISA D AMERICAN EXPRESS ^ DISCOVER Amount Paid : Card Number Name on Card Expiration Electronic Check bedudion -_ _. Please send a voided check OR provide information below: - ' Bank Routing Number - ~ Checking Account Number $ 50.00 Please make any corrections to address below. To the Estate of BETTY J. LACKEY 35 LINGVIEW DR MECHANICSBURG, PA 17055 "'ease '~em;~: ?payment To: ~a:umberfand Goodwill .Fire Rescue EMS E}filling C}ffice F~ Q. Box 726 Pdew Cumberland, PA 17070 ()UESTI'ONS ABOUT T1iIS BILL? Phone: 877-214-6018 Espan"oi: 866-724-4114 Fax: 717-214-6020 Email: info~Dambuiancebiilingoffice.com Date of Service: 6/26/2011 18:03 Patient Name: LACKEY, BETTY J. From: MANORCARE HLTH SVC-CARLISLE To: Cartisle Regional Medical Center Please visit our website to pr+~vide insurance or make payment, and for additional payment options and frequently asked questions: www.ambulancebiliingoffice.com ?l~ledlccrre bars paid their~ro>~`c~ ~„~'~e ~c~iarge,~ 7~ie bcr/ar~rce d`ue is yt~ur respansb/lid. ~` ~ ' hove lenient I i w~Z~h covers than ca- f .~.~' supp a nsurance ,~~+~~~ plecr.~e ccr fete the back t~ the invoice ar contact our bi~i>~g a,~frce ~~ct~ 1126/11 ALS Emergency Transport-t_e~ A0427 1.0 1/26/11 Mileage A0425 1.0 1/26/11 Adjustment -Insurance 3/26/11 Adjustment -Insurance 3/26111 Payment 3/26/11 Payment Total ~~°rr y ~ ~,AC rk'~~ ~rt,~ doll - oc77~ .~`TE ~ ~ DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. R.R RRR RR,! R R R 1!. - - }I ,lam f.....f. J~.w.il~~~- ~ . ~ y'!„~FiRlf.w+w.w+A+AF-+'+I+ ~ ~ ~ RIa ft~: by dt~c,* ate" r,# ~' ~~ check declucfion. Please Hndicate your paym~t dya~~~ ~- `' ~ ~'' ~.~ and hill in required information. If other arrahg~r~~tts arm ~tlrl`1d t~ood~# 1=ire necessary, please call us at 877-214-6018. RP~GU~' FMS '11-138472 ~ ~ __ DISCOVER' .nswo.. Credlit Carol: [~ MASTERCARD +J VISA CiAMERICAN EXPRESS ^ DISCOVER Amount Paid: ~ -r- ---~---~---~----~---~- - 1, 335.00 1, 335.00 11.50 11.50 -939.97 1.69 -347.82 -10.40 w~..~.. ~..~ ice. 1, 346.50 -938.28 -358.22 ~ gar l ~ ~ z~~°~~ . ~ ~l ~~ -~ Card Number ------~.~._ ,_.~ ___~.~x~_~_,r~.-~_-___.~_.._~___1 Name on Card Expiration Electronic Check Deduction -~ __--: - Please send a voided check OR - _ _ _ _ ,. Provide Information below: :y.,.~.~--...:~._. Bank Routing Number wr~ Checking Account Number ~ so.oo Please make any corrections to address below. To the Estate of BETTY J. LACKEY 35 LINGVIEW DR MECHANICSBURG, PA 17055 ~~ErrY ~ .~ R C k'~ ~ ~~i~~ ~of~- oo??/ N E.A U C. ~ ~ ~TE M / ~ s s a +,, ,Y. W@ have n~ #~@ explanation of benefits from our' a7s y uranae aorr~pany(s) and have applied whatever payments and/or adjustments ....... ane appropriate. Please make payment for the L balance due X50.00 QR take advantage of a T7~ Sp~e,it of Caris~ 1596 prmnpt p~0yrnerit dlsoount and remit X42.50 art or before 1 Ql0+IJ2011. .,..,,.,,,. 40093833 l~lere are two com-enient ways to make BETTY J LACKEY payment: 35 LOtVGV1EW DR MECHANICSBURG PA 17050-2722 1. Cali Custorrarr Service at 717-763-213a tia- rrraiae payment by credit cacti. 2. Mail tear•~o1f coupon below with payment _ - using the enclosed self-addr~ed - - - - _ _ ~ __ -- envelope. Patient Name: Lackey ,Bettyy J ~ ~: 0~0~4J11 Service Date(s): 07/01/11 Account Number: 4048gg~ Medical Record Number: 433552 Insurance Information Ins. 1: HIGHMARK SECU Ins, 2: Ins. 3: Ins. 4: Previous Balance: 4.00 Pa~yrrre~C~~ 43, 449 , 00 moo: 43,399.00- A~rrK ~~~: 450.00 Please Pay This Amount: iRQ.Oa OR Discounted Amount of $42.60 if paid ora or before 1Olt)4I2011 Please call Customer Service at 717.763-2138 to add or make com~tions to your insurance information, or to make arrangements for a Payment plan. If you arse unable to make Payment, please contact the Financial Counselor's Office at (717) 763-2885 to di5~ss financial assistance options. Please lU~+e: Your° Pbl~slblans wi~- bfll separai~ely ~' Icxo~-ssiortal servk~es Make Checks Paya~e-`ro: 77o y~pir~ HIo- _ _.. 40093833 S03 N 118T ST~B,ST GAl[t HIIZ!!I~ 1'1x111 7f~!i+.~c~s ADDRESS SERVICE REQUESTED "~ ai.Rt ~aoc a yar awns or i~.ra~o. i~w.r+.. ~J 1a~t etw~~- PUw ~4 elr~~ a~ l~ci~. OOD01903 d01 0.53 40093833 BETTY J LAGKEY 35 LONGVIEW DR MECHANiCSBURG PA 17050-2722 ~: 0 ;~px.: Q '"~ Pay only $42.50 If aid b 1UIQ4/2p' Q_ ^ '~} a~ - ~Q "rlr~ ~•'VN2 No, is ~d b pocaios ~ per, R k the fit on ors bade ct~r credit,~d, ~1~' mss. I~Mraec card hoids~s, it is rie 48~it rW.neer an the trnnt cr~ar cargl, ~ ~ c~ro nrwnbrr: ~~ p~g~f- Irrrlllrl~rrrrlll~rlrrrlrl! HOLY SPIRIT HOSPITAL ~ v c!~ ~ l~~ 9o a-o P.O. BOX 822183 PHILADELPHIA,P,A 19182 2i$3 DOOD4009383300ZOOpOQ005000001D0?35Dppppppyy3pppp00750QD000 D4250~0042DZ14 r ~~~ ` ~ rte, ~' ='`''sue` ..~~v'S~~ ="< :~': ~j ~ ~ 7 L~.` OF .. r,,,, ,;.~, F ' ~ • (~.~ {..r~ ` ~_ BETTY J. LACKEY _~~~ ?~' ~_~ ~~ ~` ~-' =- I , Betty J. Lackey, of 166 laurelwood Court, Empori urn, Cameron Count, ~~ ~ Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Wi1T •and Testament, hereby revoling and making null and void all former Wills and Codicils by me at any time heretofore made. As to such estate as it hath pleased my Creator to endow me with at the time of my demise, I dispose of the same as follows, via: I. I direct my Executor to pay all ~ just debts and funeral expenses as soon after my demise as conveniently may pe, II. All the rest, residue and remainder of my estate, be it real, personal or mixed, of whatsoever kind and wheresoever situate of which I may die, seized and possessed or to which I may become entitled, I give, devise and bequeath unto my beloved fiusband, Hubert B. Lackey, absolutely and in fee si mete. III. I nominate, constitute and appoint my beloved husband, Hubert 8. lacke , as Executor under the Pr'ecedin y g paragraph of this my last Wi11 and Testament;, IV, In the event my beloved wife should predecease me or our deaths occur simultaneously or approximately so or under circumstances leaving doubt .as to which survived the other, then and in that event, I give, devise and bequeath the rest, residue and remainder of my estate, ,real, personal or mixed, of whatsoever kind and wheresoever situate, of which I may die seized and possessed unto my beloved son, William H. Lackey, absolutely and in fee simple. under the terms hereinafter set forth. Page One -~. "~- {SEAL ~etty J. cke,~, ~ ) ~- I t a : i ;, ~~ _~ , ~ ~„~.:,~ s r{:~~ ~ d era ion ~~~edeCeaSe ~n:~ ~ r x death, 1~-~ r , ~ . ~;~~~~ , , ~,~~ + ~..,.~~d~~}~r~~; ~sha~~~ .,ta.ke t~P share that th~'~''" tart ~r~~• ~,g `~ ~Y~`~'r ~:,r~~~,sat`~-1`~ ~ "'3;b'.rl, S~js~k~~ ~Rd shave ~~'16!(~, crnde'r this my ~..~r t; ~ i R . ,~ $::t t;?rr,~f~ t. , ~: .r ~ j _ m my r~te~~ t: ghat i ~ arty grand- child di~~;~~~~ ~~r~~~~c.vi>~d.a ~~~ ~~~~~> ~lr-~~~~~~tC~, ~:,r m~y s~~rviwing ara~nd~children shall take undc~r• 1;I•~ ~~~;, t:~a ~ ,;.~ ~~~~ ~ ~ih ~:; ~:" ~~ _~ ~~ ..:~ r, t ~ i l ] aro~~~ ]'~~s~tament . ~,. In i;l•u~~~ c~~~~r:rr.~ ~~, .~r.ti~~7nr;.~a ar~i> ~~~ :,~ entam~r°ated in the preceding paragraph, arr~u:~ ~~i' ~~~~. °6 ~~,t: ~ M,r~ mmy >~~~ -:.per the age of ~5 years {o~r my grandchi 1 c~~re~n h•~ rv~~ .r ~ ~.~ ~~ti~ y~a~ agr~ ~~+~ ,~' ~ years , as the case maybe) , then and in tha~.i:. cahd~~~rt,„ t°~~~::~r~rina~~„ ~w~r°.sti?..r:~ and apci°rt rtry helaved son, William H. Lackey,. E~c~~~,rc:.rt.~c-a~ ~,•~'~ P.}-~~i°s r~}~ ~~_,3~s~. ~i~~ !1 :~~nd Test.a~ent. }:n the ewent William H. Lackey ~~~ho~~~rl i C:rr~~~lt~r::«~a5e m~=, %n d~~a~", ~,~ for and, reason be unable to act, then I norm Hate,,, c~t~~ri~~.,i.~~,t~ ar~u a.F~a~i r; ~~;~cktail bank & Trust Company as Executofi Crp= thri :~ mw ~~ ~-~c. h: Wi 3 ~ arrct Tes t ~;r~ e~•: t. !~ ] In the eve°r t: t~°rca r::~„gin ti r~g~;; i;,y srlc U ~ ~ ,,r rise a5 enumerated i n paragraph IV and if +~rt that: t~mr~ r~n~,, helave~ scan ~~as not attained the age of 45 years, or, in the altern~~at,~~w~~~,,, i l'~ ~r~,y ~el~orre~ds ~a~d~rr should predecease me leaving chil- dren survi~tiring ~',;rtry ~~tr~~,a•~~~r~~i')dr~rr ~ whoa ~aa~i~:. not yet reached the age of 21f years, then and ir, that: event:,, I: girra, devise an{:N bequeath all my property, re~rl, personal or mixed, . of~ r~-trats,aever kind ~~rrd wheresoewer situate, of which I may die, seized and pc~ ~~ess ed, uar-to ani,~ T rE,Astee, hereinafter named, IN ~TF~UST, nevertheless, fc~r the i~ra~]o~ing ~r~~>r•p~os~:.s. I direct a1y Trustee, herei r~~after .ra~~.~d, to pay then income from sale! Trust unto my Guardian„ here•i naf't~er r~anred, aG~r ~~;he use of my beloved son or grand- children in equal s.:har~;r~~. The pr•incipmrl ~f' said Trust Fund shall be di;~tributed to said children when •f:h~y re~ac~~ t:he a~~e ~:~f 21 or 45,respectively, or 1 f any chi 1d dies before age of 2l car 4'S, respecti~rk~l;y, leaving heirs surviving, then said heirs shall take said. chi 1 cg's share urr ale r this rtry Last Will and testament. In ,~. ~~: Rage Two ,,~~''~ "~,~~. ~ u,-~" ~(SFAL) fl~'tt:~~ J. Lac y ~ ~ j ~,,., t r i ~,- a i r. - ->~ b~ ~~ ~~ L~ ~S`t` fir.-~i..'h.Y y ~~J'."'' . ~. r..:, ti ,=1 J~,. - +~" r~} LAST WILL NAD TESTAIHEIVT OF BETTY J. LACKEY the event, however, no heirs are surviving, then the residuary of his or her share shall be distributed to my surviving grandchildren, VII. In the event the contingency arises as enumerated in paragraphs IV and VI, then and in that even t, I nominate, constitute and appoint Buck tail Bank ~ Trust Company as Guardian/Trustee under this my Last Will and Testament. VIII. In the event the contingency arises as enumerated in paragraphs TV and VI, then and in that event, I direct my Trustee and/or Executor, after discussion with the Gua rdian, hereinbefare named, to pay to the Guardian for the benefit of my chi i d or grandchi 1 dren, either from principal or from income, such amounts as may be necessary for their adequate maintenance and education. IX. Without undertaking to distinguish between the duties and powers o~f my Executor or Trustee/Guardian, and by way of illustration and not of limitation of their powers, I hereby authorize alY Executor and Trustee/ Guardian: a~ To sell any property, real or personal, publicly or privately, for cash or on time without an order of Court, upon such terms and conditions as they shall deem best without liability on the part of the purchaser to see to the application of the purchase price. b) To retain any, or the original investnent, or other property constituting my estate at the time of my death, regardless of the character of said investments or other property or whether they be such as are authorized by law for investment by fiduciaries for such time as to them shall deem best, and t4 dispose of any such property by sale or exchange or otherwise as and when they shall deem advisable, and to invest and reinvest funds only in such stacks, bonds, notes, securities or mortgages as they see fit, even though they are not of the character expressly approved by law for investment by fiduciaries. k Page Three ` . ' ' ~. ` a ~'` ` ~ ~ ~~ ~ '(SEAL ) e"t y .~ ac ey ~.~.~ _ ., ~: ~~~ t.. `~ LAST WILL AMD TESTAN~NT OF BETTY J. LACKEY c) To charge the premiums of securities purchased at a premium ei ther against principal or income or partly against income as they shall deem advisable. To apply stock dividends and other extraordinary dividends to income or principal or to apportion such dividends between income and principal in their absolute discretion and their decision with respect thereto shall be conclusive and binding upon all parties in interest. d) To hoid any or ail securities or other property in the name of aduly appointed nominee with or without disciosing their fiduciary relations. e) To make distribution of principal in cash or in kind, or partly in cash and partly in kind, not necessarily ratable but upon the basis of equal vaiue according to their own judgment. X. I request that my Executor or Trustee/6uardian, hereinbefore named, not be required to give any band, and that if notwithstanding this request, arty bond is required by any law, statute or rule of Court, then no sureties be required thereon. IN WITNESS WHEREOF, I, betty J. Lackey, set ~ hand and seal to thi;~ my Last Will and Testament this " r_____ day of 5~~~p. 1984. ~ i l etty J. ack ~ ~ . The foregoing instrument, consisting of this and three preceding pages, was signed, published and declared by the testatrix to be her Last Wiil ahd Testament in the presence of us, who at her request, in.~her presence and in k `` the presence of each other all bein ~ 9 present at the same time, have hereunto stdscribed our names as witnesses. ~ ~^ . ~~ ~ Addres ~.~ W, s _ ` f yf_ eS S 't '~~` ~° Addy I~ i tneS S "~ ~'-; ~ .f ddre~s ~ Wi tness~ ~r.~ ""'"`"' V - - Suite X00 Mechanicsburg, PA 1 T050 Inquiries - 717-255-8213 LACKEY 35 LONGVIEW DR MECHANICSBURG PA 17050 vy~ ~~~sv~ ~~~w~• Now you know _ _ _ _ _ _ THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Public~„4,~ Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin} ss Holly Blain, being duty sworn according to law, deposes and says: That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the ;ommonwealth of Pennsylvania, with its principal office and place of business at 2020 Technology Pkwy, Suite 300, in the 'ownship of Hampden, County of Cumberland, State of Pennsylvania, owner and publisher of The Patriot News and The Sunday 'atriot-News newspapers of general circulation, printed and published at 1900 Patriot Drive, in the City, County and State foresail; that The Patriot-News and The Sunday Patriot News were established March 4th., 1854, and September 18th, 1949, 3spectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular ally and/or Sunday/ Community Weekly editions which appeared on the date(s) indicated below. That neither she nor said :ompany is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as ~ the time, place and character of publication are true; and ,. That she has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on ehaff of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the tiockhotders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds ~ and for said County of Dauphin in Miscellaneous Book "M°, Volume 14, Page 317. ~UBLiCATlON COPY This ad # 0002162870 ran on the dates shown below: ,~ ,N, August 15, 2011 ~,~ °r, s~ August 22, 2011 ~'~"'~` f ~ ~ ~ August 29, 2011 doln~s wilt ares~nt tlMm without dNeiy 1 ._.._-~ ,tor setflernent ~o .. • • .... .. .... . -W111iam~N Ladter r,~~ .' Exec,~~ <.: ~,,~ -, __ ___ °r, pA ~~- S1MOm to.. s ~ before ~ thi of September, 2011 A.D. --~------~_.._ r,. _ Notary Public ~MMON~j~TN OF VAhilq ~e ssa LoMner ~x~on ~' MernbK, ~~ 201! of NaEa~