HomeMy WebLinkAbout08-09-111505610101
REV-1500 I=_x t°1.1°'
PA Department of Revenue pennsylvania OFFICIAL USE ONL`f__
Bureau of Individual Taxes of>Aa.MEN,~f `~U` County Code Year File Number
PO BOX 28o6oi INHERITANCE TAX RETURN ~ ( ~ '`
Harrisburg, PA x'7128-o6oi RESIDENT DECEDENT l ___ ~f
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Decedent's Last Name Suffix Decedents First Name MI
(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
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
p 4. Limited Estate
O 6. Decedent Died Testate
(Attach Copy of Will)
O 9. Litigation Proceeds Received
O 4a. Future Interest Compromise (date of
death after 12-12-82)
O 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
O 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
prior to 12-13-82)
O 5. Federal Estates Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone tdumber
Q 2'~ f~ t'~ e s h -~- ~ r cx ~ 8 1 ~ G~ Y L~ ~ P~
REGISTE/IL.IS U:~NLY'-? ~=
,,
First line of address C~'_ r '~
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13~ ~~C,~+ ,f ,
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Second line of address ~ ~ ~ ::-
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City or Post Office State ZIP Code - DarE P_ICED-- -
~ e ,~/ ~- r e HQ r ~ ~° A ~ '~ K z r
Correspondent's a-mail address: ~(.:T
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
ers
nal
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b
.
p
o represen
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ased on all information of which preparer has any knowledge.
SIGN TURE OF PE SON ESPONSIBLE FOR FILING RETURN
~ ~~~~ DATE M~-r
~
_....___..~__ ~~.~ S~lL
-.~~•._-__-~_. _..-._ .._. ~_..
ADDRESS
~ /
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~ .~ __._ DATE ~ Mp
ADDRESS .--_-._~..._..____._.___ _.- ,.......____.._.._.~-a _,r
~A~-~~_~_~ ~-~ ~- PLEASE USE ORIGINAL FORM ONLY~~ ~`-`~""-`°~`_______~ ~__
Side 1
1505610101 1505610101
~~! `
15~561~1175
REV-1500 EX
Decedent's Social Security Number
Decedent's Name
RECAPITULATION
1. Real Estate (Schedule A) ........................................... .. 1. • v
2. Stocks and Bonds (Schedule B) ..................................... .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ~~
4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. • O
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ~ (~ I S • `~ Cp
6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. •
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) p Separate BiAing Requested...... .. 7. ~}
8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 3 ~ ~ ~ . y (~
9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. ~ ~ ~ I . J ~
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. ~ ,-~ 9 ~ .
11. Totai Deductions !total Lines 9 and 10) ............................... .. 11. ~ ~~ 7 `~ • 3 ~
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12 ~, :~ ~ 2 . 3 j
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~~ ,~
an election to tax has not been made (Schedule J) ............. ........ .. 13. ~---~--(n--;t-~. p
14. Net Value Subject to Tax (Line 12 minus Line 13) ............. . . 14. {~ `; rs ~ . 3 5
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
16. Amount of Line 14 taxable
at lineal rate X .0 _` . ~ 16.
17. Amount of Line 14 taxable
at sibling rate X .12 . 17.
18. Amount of Line 14 taxable
at collateral rate X .15 • 18. •
19. TAX DUE ....................................................... ..19. , ~,
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610105 1505610105
O
REV-1500 EX Page 3 File Number
Decedent's Complete Address:
__
STREET ADDRESS _ _ - _ - _ _ _ __
CITY ` ~ STATE ZIP
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) D
2. Credits/Payments ---
A. Prior Payments __ __ U __ _ _
B. Discount
_ C7 -
Total Credits (A + B) (2) ___ ~
3. Interest
(3) ___
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4}
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~~
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRI/ATE BLOCKS
1. Did decedent make a transfer and: 1'es No
. - i
a. retain the use or income of the property transferred :.........................................................................................
b. retain the right to designate who shall use the property transferred or its income : ........................................... ^ [~
c. retain a reversionary interest; or ......................................................................................................................... ^
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^ ~~
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^
4. Did decedent o~vn 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 suviving 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-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCI~IEDtILE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF ~ ~ ~ ~ ~r k~. FILE NUMBER
rn. ~ a~
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. f~~<iShers LEeac,,,i~) t-}ac~S.z Ac<;.~* (j .2ico~'.. ~Y4Tg _
~~~~ y'T
t Cµ,J, JY ,.
.J G..Z c7L _~C S.¢~ J : ~ ~. .'!. N C~ ~ e ~ `I. ~1 t l ~t p
~ 1 2 °:
3 lid Q r- ~- a «.,t- R~r ~ •8' S_Cv .l 13 7 I v 2~ ;~' f `r f .~ z 7 ~ 3
`f. ~rilav.~r t'i~M~ A<-~~ l73-5-Y4 •Loc ~ `f !7
;5• V' . S ~t r= '-{ •i '1 '7 I (:, c:~ l 2 j C~ . ~ 1 Ir? <I ~.- ~ ~ 7. 't (. C:; C
~ ~,~ v ,z,,.; _~+-~ A .~ ~ ,g,~v d, Cr t. ,~r,~-r ~ r A ~~~~ s 3 '~t `t "=
,o. ~ ~L l~ - -~` w~ A << ~ `~. I1(eCe ~ z 9d 9,w
L2. t~wbi.3~ er,T C~~2Q{~,.r ~ ou, lz Ft ti~ ~ ~$ Rto 0001'{ 4 ? ~ 3 3 . ~ 3
t3: yl't ; `h ~,~y, Wal-4-er3 ~a, _ , Z ~ . v v
w tyro,,. S.S1 ~;a 'Gw.11~
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
Wells Fargo Combined Statement of Accounts
Primary account number: 1010018321401 ^ April 16, 2011 -April 26, 201 1 ^ Page 1 of 5
~•
MICHAEL CLARKE
1501 WILLIAMS GROVE RD #1
MECHANICSBURG PA 17055-0000
You and Wells Fargo
Welcome to Wells Fargo. We look forward to serving you as one company under
the Wells Fargo name and continuing the tradition of outstanding personal
service you've come to expect. We hope you will think of Wells Fargo as your
financial home with the people, resources and guidance to help you succeed now
and in the years ahead. For more information, speak to a banker or visit us at
wellsfargo.com.
D IMPORTANT ACCOUNT INFORMATION
Important Wells Fargo ExpressSend Service Information
Questions?
Available by phone 24 hours a day, 7 days a week:
1-800-"f0-WEi.LS (1-800-869-3557)
77Y: 1-800-877-4833
En espanol: 1-877-727-2932 1TY: 1-888-355-b052
aA 1-800-288-2288 (8 am to 7 pm PT, M-F)
Online: wellsfargo.com
Write; Wells Fargo Bank, IV.A. (345)
P.O. Box 6995
Portland, OR 97228-6995
Account options
A check mark in the box indicates you have these
convenient services with your account. Go to
wellsfargo.com or call the numberabove ifyou have
questions or if you would like to add new services.
Online Banking
Online Bill Pay
Online Statements
Mobile Banking
My Spending Report
Direct Deposit
Overdraft Protection ~/
Rewards Program
Auto Transfer/Payment
We would {ike -o inform you abe:~t several recant changes to your Weis Fargo Ex.pressSerd agreement(s) Terms and Cenditians
Section 10:
Effective immediately
-The maximum aggregate daily transfer limit for account and cash-based service agreements to all remittance network members in
Mexico, EI Salvador, Guatemala, Honduras, and Argentina is now $1,500 US dollars per day. The daily transfer limit for IFAMSA in Mexico
will continue at the Mexican peso equivalent for $1,000 US dollars per day.
-The maximum combined total daily amount that can be sent from all account and cash-based service agreements to all countries is
now $5,000 US dollars per day.
-The maximum combined total amount that can be sent during any rolling 30-day period from all account and cash-based service
agreements is now $12,500 US dollars.
0
N
w
N
ifyou have any questions please call 1-800-556-0605. Thank you for using the ExpressSend service when sending money home.
Primary account number: 1010078327401 ^ April 16, 2011 -April 26, 2011 ^ Page 2 of 5
Welcome to your new Wells Fargo statement. Your new statement is designed to help you quickly locate information that is important
to you. It includes an enhanced reader-friendly layout, new sections that allow key account information to be quickly reviewed, and
transaction information presented in chronological order. For additional details, visit wellsfargo.com/newstatement. If you have
questions about your new statement, speak to your Banker or call the number at the top of your statement. Our Phone Bankers are
available to assist you 24 hours a day, 7 days a week.
Summary of accounts
Checking and Savings
Account
Wells Fargo® Essential Checking
Wells Fargo Way2Savem Savings
Account number
1010018321401
3000168482004
Ending balance
last statement
2,080.91
79.10
Ending balance
this statement
2,080.91
79,10
Total deposit accounts
Wells Fargo° Essential Checking
$2,160.01 $2,160.01
Activity summary Account number: 1010018321401
Beginning balance on 4/16 $2,080.91 MICHAEL CLARKE
Deposits/Additions 0.00 Pennsylvania account terms and conditions apply
Withdrawals/Subtractions - 0.00 For Direct Deposit and Automatic Payments use
Ending balance on 4/26 $2,080.91 Routing Number (RTN): 031000503
Overdraft Protection
Your account is linked to the following for Overdraft Protection:
^ Savings - 003000168482004
When this account was converted From Wachovia to Wells Fargo, any previous Overdraft or Returned Item (Insufficient Funds -NSF)
fees did not carry over to this statement. Please refer to your last Wachovia account statement for information on Overdraft or
Returned item (Insufficient Funds -NSF) fees incurred prior to conversion.
With you when you want a place to call home
When you're ready to buy a home, we have the tools you'll need to help make a confident decision.
Our PriorityBuyer® preapproval helps you define your home price range so you can shop with
confidence. Speak with a home mortgage consultant for details or callus at >_-866-582-1253
to learn more today.
REV,1511 EX+ (10-06)
r ~ ,.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE N
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
ti'11; ~~r .r_l ~--~c~r~~
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: t ~ e3; "..~
1 a
f Z 5 cam..
~'. u ~:v 'J Q.~' .~ e~%t~'~e~.S-rt T''z 2.
to -t vv~ U.' i c.\ S<!v'uic~. - iA ~ts~" a 5c L c..f~2a ~,N ~'-`..w'cX.~, "7'S"._
B.
1. ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address t 34 ~~~-~,,,1 t-
City ~ 4.-vv~F-f•c ~ci t t
D
J~'t{~
Sf
_
r +
,1zS~C.Zd ~..k ~ G kec v:br , x,
_
State ~_ Zip jtl, ~ ~&`
Year(s) Commission Paitl: ` ~ - e s-F~-{~ .F; ~,~ ~" ~e~e- u~ ~ ~
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
__ _
Street Address
_ __
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
~li,av
TOTAL (Also enter on line 9, Recapitulation;1$ ~~ ~?f / -SQ
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX ~ (157)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8~ MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship rnust be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
<,~>
1. ~ COcr .,ti -~.t-l- re_ Vh:s s ~c~~~a~~i ~ `'~ 70 `'S ~ a~~ ~.
N • '~
2• 1't.{-~.~,e,.J •- C.i~'ts;.Cs 1-on-S~er Vv~~c:~~.rw~.~.~ c~;S~cS M~x.zc ~x;
c...i-F r~ 1, GU
3, ~~.
L, v-...,~ Cc~s rr. .- -7"V Pc~dS ~9~+d a-Nd3 -ic_k~1e~ <<l`?w`s "t5
y' S frz: ~'- ~3.r~ rw .~r. - T ~1 ~.~ w.
L C1c.52~' f G~~n Joo~'s L c
'~ ~ 4~~ ;l :c. J .1ca~4.
5 ~; '_
4. oCidS ~Lu Z4 ~ 5 ~'', c~+-~-J e S n.l. ~t~ :~r.c_k~ ; ~ ~ ~.. ~ ~:
~ ~.. -~ f i.1 /h . r 1.; !- !~u.cl (pct
'1• T'('c~ t rc C' - L ~.t-Y'- l ~ `1y ,~. ~ 7 '7 p(z }r~~. 12a ('c:..i. L. ~.. ~ ~'C< ~._
Uu
~ ,p "=+ L~
>~ . .N :iV ¢ So'f~c `. ~¢ - lei ~~ ~ - Su~~ W I ~N ~.~ '~~ ~ to 1T~vr~
~--•--
f 4~
pp ((ll d. t~ ~
~. `j Wee .c1 Sf r k .iS ~ v c~~,/v~ hOtts..z Y\:e ~J cS....1 cE~.u~
11 ~ . - `~`~ ~`1 ~=
A.K. Sca,V ~N S ~•~lls0,
9 , ~ h t ~k.rr• ~ ~
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
RE~,t1513 EX+ (9-00)
mm
.. SCl~IEDI~LE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ~><~ ~ ~
~~~~~t~.~~ ~~
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under _
Sec. 9116 (a) (1.2)]
1.
G ~~ G l a. ,c- k ~
f3 ~ 4~ ~ r-
3
tl~ j SKJJ /'Jr9 ~ 6.p 1~.~
\
~~~ k /'_4
iZ4~Y
~' S i-ew«r~'
Crr~ h:
r
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~f 5 f %
Z /+ ~C3~. i'Y13~ J v` ~ ~YL` p r" .3
`
~ ~;c~ , PC f,otis
3. C-- ~~~ k~
~ 6'
~
.
~
Ci ~~ t~-. ~.; t
'~3
y l~.. x t Lo
~Z rZ
~?vim `~
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON RE:V-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
1 A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
- ~a _'
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)
e
V ~/'~~~
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NOTICE Or ~L~.IM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
CUMBERLAND COLTNT~, PENNS~'LVANIA
ORPHANS' COURT DIVISION
ESTATE OF MICHAEL CLARKE , DECEI~SFD
No. 21-2011-0518
To the Cle~-x of the Orphans' Court Division:
Enter the claim of AscensionPoint Recovery Set-~~ices, LLC on behalf of Alliance Data X~~XXX6602
(Claimmzt)
in the amount of 8$897.23 ,against the above entitled Estate.
The Decedent. u~ho resided at 1501 WILLIA~'vIS GROVE RD. MECHAhTICSBURG. PA
(Street Address)
170559760 died on_04/03r20ll. Written notice of said claim «~as given to
(Date of Death)
BETTY NESHTERUK. _~ __
(Personal Representative or hisilzer counsel)
at 136 FRONT STKEL-T. CENTRE I-3ALL 16828,
(Address)
on 7!2112011.
/Date)
~~ii~ ~~ v
i ''J APRS Reureser_t_a~ive
(Claimant)
200 Coon Rapids B{vd. Suite 200
(Street iidd~ essj
Coon Rapids, MN 55433-5876
(City, State, ZipJ
Robin LeDonne - IL Bar # 6294763
(Claimant's Counsel)
200 Coon Rapids Blvd. Suite 200
(Address)
Coon Rapids, MN 55433-5876
(7631235-4260
(Telephone)
c~
Ascension '
r~ec~rr:~~ _~ F,vi-t,, --
AscensionPoint Recovery Services, LLC
200 Coon Rapids Blvd. Suite 200
Coon Rapids, MN 55433-5876
(888) 420-2510 Phone - (763) 235-4055 Fax
Hours: Monday -Friday 8:OOAM to S:OOPM CST
Creditor: Alliance Data Assignee of INTERNATIONAL MALE
Account No.: XX~O~XXXXX~~~XX2941
Reference No.: 503180
Balance: $327.13 July 7, 2011
Dear estate of MICHAEL CLARKS,
We would like to offer our deepest condolences during this time of loss for you and your family. Thank you in
advance for attending to this important matter in the life of MICHAEL CLARKS.
The Alliance Data Assignee of INTERNATIONAL MALE account in the amount of $327.13 for MICHAEL
CLARKS has been placed with our office for collection. Please contact our office toll-free at 1-888-420-2510
to discuss your options. Payments and/or the estate information coupon on the reverse side can be mailed to the
address listed above.
Very truly yours,
Christina Mallen
AscensionPoint Recovery Services, LLC
Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt
or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30
days from receiving this notice that you dispute the validity of this debt or any portion thereof; this office will
obtain verification of the debt or obtain a copy of a jud ment and mail you a copy of such judggment or
verification. If you request of this office in wrttmg within 30 days after receiving this notice 1:his office will
provide you with the name and address of the original creditor, if different from the current creditor.
This communication is from a debt collector. This is an attempt to collect a debt and any information
obtained will be used for that purpose.
* * * PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION
ABOUT YOUR RIGHTS AND THE PROBATE COUPON.
ACA
1NI'ERNATIONAL
The Ilssoeiation of Credit
and Collection Professionals
PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT :blernher
DEPT 303 1469419411078
PO BOX 4115 Amount Enclosed:
CONCORD CA 94524 Creditor: Alliance Data Assignee of INTE=RNATIONAL MALE
Account No.: XXXXXXXXX gXXX2941
(~~~~~~~ ~~~~ ~~~~~~ ~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~ ~~~~ Balancec $327.1303180
ADDRESS SERVICE REQUESTED
#BWNFTZF #TAM146941 941 1 078#
~Illttl~~i~lti~~~tt~~~~It~Itit~~Itlllli~ll~litll~lll~iltiitii~itl
503180
ESTATE OF MICHAEL CLARKS
1501 WILLIAMS GROVE RD
MECHANICSBURG, PA 17055-9760
All payments should be made payable to the creditor listed above.
PLEASE SEND PAYMENTS & CORRESPONDENCE TO:
ASCENSIONPOINT RECOVEFIY SERVICES, LLC
200 COON RAPIDS BLVD. SUITE 200
COON RAPIDS, MN 55433-5876
TAIv11ST-0706-166854458-00098-98
We are required under state law to notify consumers of the following rights. This list does not contain a
complete list of the rights consumers have under state and federal law.
California
The state Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Practices Act
require that, except under unusual circumstances, collectors may not contact you before 8 a.m. or after 9 p.m.
They may not harass you by using threats of violence or arrest or by using obscene language. Collectors may not
use false or misleading statements or call you at work if they know or have reason to know that you may not
receive personal calls at work. For the most part, collectors may not tell another person, other than your attorney
or spouse, about your debt. Collectors may contact another person to confirm your location or enforce a
judgment. For more information about debt collection activities, you may contact the Federal Trade
Commission at 1-877-FTC-HELP or www.ftc.gov.
Colorado
FOR INFORMATION ABOUT THE COLORADO FAIR DEBT COLLECTION PRACTICE5 ACT, SEE
WWW.COLORADOATTORNEYGENERAL.GOV/CA. A consumer has the right to request in writing that a
debt collector or collection agency cease further communication with the consumer. A written request to cease
communication will not prohibit the debt collector or collection agency from taking any other action authorized
by law to collect the debt. Colorado Office: 3025 South Parker Road, Suite 705, Aurora, Colorado 80013, (720)
343-1993
Minnesota
This collection agency is licensed by the Minnesota Department of Commerce.
New York
New York City Department of Consumer Affairs License number: 1280393
North Carolina
North Carolina Permit Number: 102865
Tennessee
AscensionPoint Recovery Services, LLC is a collection agency licensed by the collection service board of the
TN Department of Commerce and Insurance.
PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT
Answer the following if a probate has or will be filed:
Attorney Name & Phone:
Executor & Phone:
County and State filed in:
TAMIST-0706-166854458-00098-98
J. CHAD MOORE
Attorney at Law, LLC
E-mail: JCMEsquire@aol.com
270 Market Street
Millersburg, PA 17061
Ph: (7I7) 692-5533
Fax: (717} 692-5111
July 20, 2011
Michael R. Clark
1501 Williams Gro:~e Rd. #1
Mechanicsburg, PA 17055
Re: WQLV-FM
Acct # 1166
Balance: $3290.90
Post. Office Box 220
Hughesville, PA 17737
Ph: (570) 584-5000
Fax: (570) 584-2009
Dear Mr. Clarke:
You previously expressed an intention to make payments on the above
referenced account. Kindly contact me within 10 days to make arrangements or I will
pursue accordingly.
Very truly yours,
J. Chad Moore
JCM/bsf
~' .
WILL OF
MICHAEL R. CLARKE
I, Michael R. Clarke of Cumberland County, Mechanicsburg,
Pennsylvania, declare this to be my last Will and hereby revoke all
prior Wills and Codicils.
I direct that all my just debts, funeral expenses,
gravemarker and administrative expenses shall k>e paid
from my residuary estate as soon as practicable after my
death.
2. I direct that all inheritance, estate, transfer, succE~ssion
and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out ~of my
residuary estate.
3. I direct that my entire estate be distributed as follows:
A. I direct that my entire estate go to Guy Clarke,
Carl D. Stewart and Roy B. Clarke in equal
shares.
B. Should Guy Clarke, Carl D. Stewart or Roy B.
Clarke predecease me their share shall lapse and
be divided into equal shares between the
survivors.
4. I appoint Betty Neshteruk Executrix of this my last Will. If
Betty Neshteruk should predecease me or cease to act in
such capacity, I appoint Guy Clarke as alternate.
5. The Executrix of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. I direct that no Executrix acting under this Will shall be
required to enter bond in any jurisdiction.
i_:~n oFric~a of
STEPHEN J. HOGG
19 S. HANO~~ER STREET
SUITE i01
CaRLISLL. PA 17013
IN WITNESS WHEREOF, I have hereunto set my hand this
_~ ::~' ~ -day of r', -.~~~.y ~~ ~~z~.?O ;,,..2011.
-Ta c
M hael~~R. Clarke
~~~~
A
~_~~~ ~~rF~~~~~s ~~F
STEPHEN J. NOGG
19 S. IIA\OVER STREET
SU[TE 101
C~~RLISLE. PA 17013
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Michael R. Clarke as and for his last Will in the presence of us, who at
his request, in his presence and in the presence of each other have
subscribed our names as ~Nitnesses hereto.
~ ~ ~ _ ~:- ~
WITNESS
s
~tJ ~~ ~ ~! \ ~ , ,~ l.. t
1NITNESS u
~ r
ACKNOWLEDGMENT
State of Pennsylvania
County of Cumberland
ss
I, Michael R. Clarke, the 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
instrument as my last Will; that I signed it willingly and as my free and
voluntary act for the purposes therein expressed.
,,-.
Michael R. Clarke
LaVC Clf~f'ICL S OF
STEPHEN J. HOGG
~~~ s. riA~;~ovErz srxE~~r
SUITE 101
CARLISLE. P-A 17013
Sworn to or affirmed an. cknowledg ~.efore me by P~lichael
R. Clarke the Testator, this =:='- day of <~ ~l ~ ~~ ~~ - ,
2011 ,, ., .. ., -- .
C ~dT,Si~r -'IC.~ c~ ~. ai, dP 4r',yr eSWibH'~ ~-_.1^yn `--9~+{ .
,~~ ~,~„~~„~y~ g ~, ,. ~ 4, ~ Notary Public/Attorney
._._.~-. _ .__,.._.. -~ ...o--mot. i,~,~y~;'r~~~Ea$ i
.. ~..
AFFIDAVIT
State of Pennsylvania
ss
County of Cumberland
` and ~ ~ ,k,Y
We, ~-~r ~ ~, t_ ~ ~:`- ~~~ ~ t r-~ .~ i -~ ,the
witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose ar~d say
that we were present and saw the Testator sign and execute the
instrument as his last Will; that the Testator signed willingly anti
executed it as his free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the Testator signed the Will as a witness; 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 of undu ~ nflu " nce. ti
worn to or aff
this __day of ~'
and subscribed to
__-~_-___--~'~~~~ ~~'~t.~ Notary
fore me by witnesses,
~2 111.
1 / f :~
~~
Public/Attorney
Cumberland County Pennsylvania
TAX COLLECTOR COPY -RETURN WITH PAYMENT FOR PROPER CREDIT
MICHAEL R. CLARKE
LOT1
1501 WILLIAMS GROVE RD
MECHANICSBURG, PA 17055-9760
Payable To:
MARY A MURRAY, TAX COLLECTOR
t375 CREEK ROAD
BOILING SPRINGS, PA 17007-9656
Phone: (717) 258-6420
Bill No: 605
Bill (Date: 3/1/11
Control No: 22-7047
OCC
COUNTY OF CUMBERLAPD
~ Discount Face Penalty
COUNTY PC $4.9U $5.00 $5.50
TWP OF MONROE
MUN PC
$4.90
$5.00 -
$5.50
MUN OCC 0.000 $0.00 $0.00 $0.00
TAX AMOUNT DUE
If Date Of Payment Is On $9.80
3!1111 thru 4/30/11 :610.00
5/1/11 thru 6/30/11 $11.00
7/1/11 or Later
2011 STATEMENT OF PER CAPITA TAXES FOR CUMBERLANd COUNTY AND TWP OF MONROE
Payable To: MARY A MURRAY, TAX COLLECTOR
1375 CREEK ROAD
BOILING SPRINGS, PA 17007-9656
Phone: (717)258-6420
$1.00 FEE FOR ADDITIONAL RECEIPTS
Tax Payer:
MICHAEL R. CLARKE
LOT 1
1501 WILLIAMS GROVE RD
MECHANICSBURG, PA 17055-9760
Office Hours: MAR-JUNE; MON 8 WED 5PM-7PM Bill No: 605
SPEC HRS: APRIL 19 & 26 5PM-7PM Bill Date: 311/11
JULY-DEC; SEE SCHOOL BILL;AFTER '12/5 Control No:22-7047
CASH ONLY
PHONE (717) 258-6420
OCC
COUNTY OF CUMBERLAND- Discount Face Penalty
COUNTY PC $4.90 $5.00 $5.50
TWP OF MONROE
MUN PC _
$4.90
$5.00
$5.50
MUN OCC 0.000 $0.00 $0.00 $0.00
TAX AMOUNT DUE
If Date Of Payment Is On $9.80
3/1/11 thru 4130/11 $10.00
5/1111 thru 6130/11 $11.00
711/11 or Later
TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS
MARY A MURRAY, TAX COLLECTOR
1375 CREEK ROAD
BOILING SPRINGS, PA 17007-9656
TEMP - RETURN SERVICE REQUESTED
OFFICIAL COUNTY MUNICIPAL TAX,BILL'
II II~~~II~~II~IL111~11111111111" 'I~IIL~I'~I11'1~11111~11~1~~~~ s~ir~- 2a~n
e Ig,~+; MICHAEL R. CLARKE
:, } LOT 1
1501 WILLIAMS GROVE RD
MECHANICSBURG, PA 17055-9760
87110-P-29717
Hetrick Cremation Services of Central Pennsylvania, Inc.
3125 Walnut Street
Harrisburg, PA 17109
Bill To
Guy Clark
I ] 15 Sunnyside Rd.
York, PA 1740x
Invoice
Date Invoice #
aixizo 1 ~i
626
Client Terms Due Date
William Clark COD 4/8/2011
Qty Description Rate Amount
Direct Cremation 1,595.00 1,595.00
TSA Urn 75.00 75.00
12 Death Certificates 6.00 72.00
Coroner's Release Fee 25.00 25.00
v~~\
`1
~~~ ,,\_/
Total S I ,767.00
Payments/Credits ~o.oo
It's been a pleasure working with youl
767
00
Balance Due $1
.
,
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17613
CLARKE MICHAEL R
Estate File No.: 2011-00518
Paid By Remarks: BETTY NESHTERUK
HMW
-------------------
Fee/Tax Description
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
JCS FEE
AUTOMATION FEE
Check# 6721
Total Received.........
Receipt Date: 4/27/2011
Receipt Time: 12:18:58
Receipt No.: 1065383
Receipt Distribution ----- -------- -------- ---
Payment Amount Payee Name
20.00 CUMBERLAND COUNTY GENERAL FUN
15.00 CUMBERLAND COUNTY GENERAL FUN
48.00 CUMBERLAND COUNTY GENERAL FUN
23.50 BUREAU OF RECEIPT~3 & CNTR M.D
5.00 CUMBERLAND COUNTY GENERAL FUN
----------------
5111.50
$111.50