Loading...
HomeMy WebLinkAbout09-02-11COMMONWEALTH OF PENNSYLVANIA _ DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES REV-1 162 EX11 1-96) DEPT. 280601 HARRISBURG, PA 17128.0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014928 SEMANKO TONI A 818 SYCAMORE CIRCLE CAMP HILL, PA 1701 1 ACN ASSESSMENT AMOUNT CONTROL -------- f°'d N U M B E R ESTATE INFORMATION: SSN: 578-10-9378 FILE NUMBER: 211 1- 0661 DECEDENT NAME: ARMSTRONG TESSA A DATE OF PAYMENT: 09/02/201 1 POSTMARK DATE: 09/02/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 06/02/201 1 I UTAL AMOUNT PAID: REMARKS: TONI SEMANKO CHECK# 4441 INITIALS: ~/Z SEAL RECEIVED BY: S 1,953.87 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS r REV-•500 15p5610101 EX (oi-io) ~iiT A Department of Revenue PO Bau of Individual Taxes pennsy(vania OX 280601 OFFICIAL USE ENTER Harrisburg, pq 1 INHERITANCE T ONLY DECEDENT INFORM 7128'0601 ~ RETURN County Code Year Social Securit ATION BELOW RESIDENT pECEp ~ File Number Y Number ENT r '~ '~ Date of Death l ~' ~ ~% ~~ ~ ~ MMDD Decedent's 7 ~ C ~ C Y1'YY Date of Birth Last Name ~ Z o ~ ` MMDDYYYY ~ ~ ~ S T' 2 © Suffix ' ~ ~ ~ I ~ o ~ ' ~ ~ Decedent's First Name (If Applicable) Enter Su Spouse's Last Name rvw~ng Spouse's Information g -T' ~ S S ,,~ MI elow Suffix Spouse's Spouse's First Name Social Security Number MI THIS RETURN MUST BE FI FILL INAPPROPRIATE OVALS g LED IN DUPLIC ~ 1. Original Return ELOW REGIST ATE WITH THE ER OF WILLS O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Com O 3• Remainder Return O 6. Decedent Died Testate promise Prior to (date of death death after 12_ (date of 12-13-82) (Attach Copy of Will) 12-82) O 5. Federal O 9. Litigation Proceeds O ~' Decedent Maintained Estate Tax (Attach Co a Livin Return Required Received PY of Trust) g Trust O 10• Spousal Pove ~ 8. Total Number CORRESPONDENT- rtY Credit (date of death of Safe Deposit Boxes THIS SECTION MUST BE COMPLETED, be~een 12.31.91 Name and 1-1.95) O 1'.I. Election to tax under Sec. '~" (Attach Sch. p) ALL CORRESPONDENCE ANp CONFIDENTIAL 9113(A) 0 u' l ~ S ~ ~, ~ TAX INFORMATION SHOULD BE K C! Daytime Telephone DIRECTED TO: Number ~ (~ '' First line of address REGISTER OF WILLS 1 S S ~/ C, ~ USE ONLY Second line of address 1 ~ © 2 ~ e ~ 2, City or Post Off-ce C7 C.. ,_.. /~ ~ p •.` ~~ t~ l (__ L State .__,, ZIP Code ~ r ~ ~'? 4:,; r~:+ ~~; I 1 `t _I T^~ ~~- P a LED ""~ ,,.~~? Correspondent's e_ ~~t_ ~ ~ 4 ( f ~. t '~' mail address: 1 1" ~ Y ~ ~ t'~,~ Under penalties of T 5 ~ _ ~ it is true, correct andegury I declare that I have exa ~ ~ ~ ~ ~~ 4 complete. D mined this return, incl ~v ~ ~~ `"~ ~~ ~ SIGN TURF OF eclaration of preparer other than the udm ~ ~' PERSON RESPONSIBLE F g accompan in '~-~ y r---- 'E ' personal re y g schedules and statements, _ OR FILING RETURN Presentative is based and to the \+ .~~ ADD ESS on all infor best of ~'" J`r-~ mation of which preparer has a'ge an'ii' e 8 [ $ ~ `°knowledge. = r SIGNATURE OF P wl O fZ~' ~ i? DATE REPARER OTHER THAN REPRESENTA7'I p ADD A"~i° t `~ ` ~ (~ RESS I 1 DATE L 1 Side 505610101 1 ONLY 15056ypypy 15p561p1p5 Decedent's Social Securi ry Number J q ~ ~ ~. ~~~ ~~,, REV-1500 EX dent's Name a ~ ;,~~^ c~: ~.,~ • ~ 1 Dece 1. ~ ~ ~.~: ;~ , TION .. .. ~•••• RECAPITULA ..... ~'~~~~ Y;` Real Estate (Schedule A)• ~ • • ~ .... ~ • • .~~: ~ '.~. ~ ~,- 1. .•• .. ~ a,~~~, Schedule B) • .......... 3• ,_~ ;, ~,L. ~ ~a. ' " Schedule C) • • ~ • ' s .~.r ~ 2. Stocks and Bonds ( rietorship ( ~b.~; ; . t.~ , oration, Partnership or Sole-Prop 4 3, Closely Held Core • • . : ~ ,) ~ Y C]. `.1 le Schedule D) • • ' ' ' S. .,,.3-„~.'~" :~3~ ""~~""~ a es and Notes Receivab ( Schedule E)• • ~ ~ ' • ' ~ ~ `~ ~ 4. Mortg 9 ~ `~ 0 .Y x ~`,, i, ~.:` cellaneous Personal Prope~y ( 6 - Cash, Bank Deposits and Mis _ _ ~, 5. Separate Billing Requested . • • ~ ~ • • O t , ~.v~, E Schedule F) 7. ~., ~. ~ rt =' ` ~. Owned Property ( nested........ 3=.: - ~ ~~ ransfers & Miscellaneous Non-Probate Prope 6. Jointly ©Separate Billing Req ~ . ~ . ~ : w 7. Inter-Vivos T 8. ~~ +') (Schedule G) • , .. . • • Q c~ ~ ' ` 5 1 through 7) • • ~~`~`~' . ; `:, total tines ~ 9. . ; . ~ , .:.A, ;~'r.~` g. Total Gross Assets ( , ~.._._ - . ,.. - ~ \ a ~ . 5 ~ ~ . 5 Costs (Schedule H) . • • .. .... ~~".•:..:. d Administrative • 10. ~ '"'K `~' enses an , ~F,F_:,, n m-; ,,,, ~,:~~t ~ ~-- a .~ 9. Funeral Exp and Liens (Schedule I) ............. 2 ~ `,~ a ~ ~'~,,=., Mo~gage Liabilities, .. • 11. w ~~~' ¢ ~- edent, . ~~, ~ s 10. Debts of Dec .. , • . • . • • • ~ ~ ° ,,~.~~~, ~~.: ~ ~ :c ~ , 10 • • ,~~ ~ ~ c~, ~ #~ total Lines 9 and ) • ~ . 12. ~ , ~ ~ .~~ss ° . ~-~''~~ ~ '~ 11. Total Deductions ( .... , ... • _ • ' ,;~,.~.-1 - ~,., - .. Line 8 minus Line 11) ........... • . 13. .~ w <,~, ~~?~_~~~k~. ,.~:, .F . ~_ . ~. , ,~ 12. Net Value of Estate (~ uestslSec 9113 Trusts for whic . • a ~ ~ , ~ ~ ~ .~ Schedule J) • • ._ Charitable and Governs t beeB made ( 14. 13. an election to tax has • • t to Tax (Line 12 minus Line 13) ~ ~ ~ ~ LE RATES 14. Net Value Sublec FOR pppLICAB ,~„ -.: SEE INSTRUCTION ., ,~ .. y TAX CALCULATION - _. 15. Amount of Line 14 taxable 15. r i ousal tax rate, or « ~:. .,~' fi ~ ` G ~ 3~ s ~ ~ '~ ~ 1 at the p ~ ~ SeC. 91'16 ~ ~ ~:. transfers under r._ ~" ,-~~L :. _g 16. x } 14 taxable i ~, r,.,~.~<, ~~"~~° '~~~~ ~ ~ f~ mount of LinX 0 ~ ~~~ 17. A at lineal rate t e taxable ~r ~ ~~ 17 Amoun of Lin X •12 ~. ,.,~-~.~.•° ~ "''"' 18. at sibling rate ; r~. ~~, ,. ~~~ ~w.~~- ,.~~~, ' L~ O ~ "Z 14 taxable ~ ~ .;: ~-~.' 18. Amount of Line :~, ,. . 19• ~.~; ~ ~ . ~,~~--~ ~~ at collateral rate X .15 19. TAX DUE ............. . . TING A REFUND OF AN OVERPAYMENT FILL IN THE OVAL IF YOU ARE REaUES 20. n~ ~~3 Side 2 15~561p105 O 15p5610105 _.. „^.~ RFV_1~~~ ^v ~a ge 3 Decedent's Complete qd DECEDENT'S NAME dress; `~ -til ~ STREETADDRESS ---- -~ ~ s __ cirY ___- --__---- ---- M~~~,~a,cs$~t~~ Tax Payments and Credits: 1 • Tax Due (Page 2, Line 19) 2• Credits/Payments A. Prior Payments B. Discount --- F-le Numk~er srArE --------- PA- ~ ziP - (b $ ~ S ~ --_-----__ 3• Interest ---_ -- 4• If Line 2 is greater than Line 1 + Total Credits (q + B ) Line 3, enter the difference. This is the OVERPAYME Fifl in oval on Page 2, Line 20 to request a refund. NT. 5• If Line 1 + Line 3 is greater than Line 2, enter the ' difference. This is the TAX pUE. 2 (2) - l o (3) (4) (5) 3,~~ ~~ ..~~~~: ~;;~r ~~Make check payable to: R .~ EGISTER pF Will S b. retain the nght to designate who p rty transferred;....., Yes No use the ............................ shall ~••••"" c. retain ............................................ a reversionary interest• property transferred or its inco •• or.. ^ me : ............................................ ^ d. receive th ..................... e promise for life of either ~~~~~~~•~~~""""""•••••••••••• payments ..................... If death occurred after Dec. 12, 1982, did decedenbtranf is or care?........ • ~~'~~"'~~~~~•••~••••••~•~........ ...................................... rty within ....................... ^ without receiving adequate consideration? .,,•, sfer prope 3. Did dec one year of death edent own an "in trust for" •~•~~~~~•""""' 4. Did decede °f Payable-upon-dea ~ ................................................................................. ^ nt own an individual retirement account, anntuityaor othe~unt or security at his or her death?...., contains a beneficia d ^ . ~~, LEAs _~~.~ ~~~~~`.~.3 ~- GENT. SWER TH K ~ ~<<. ~ ~4 ~:~~~~ ~~..~ .. FOLLOWING ~ e ~~ ~, K_,h~~~ QUESTIONS BY P „ „ ~ ~ '`~~~~' ~~ 1. Did decedent make a transfer and: LACING AN X IN THE gppROPRIATE BLOC a. retain the use or income of the roe KS 9 ry esi nation? ....,..... non-probate property, which .............................. THE ANSWER TO ANY OF ................................ ~~ ~y z ~~..~ -~.:.. THE ABOVE QUES E U M ............................................. ^ ~ .:~, ; h ,~ ~,,,.., TIONS IS Y S, YO UST COM ~r dates of death on or after July 1,1994 an ' ~ y. ~ ~'`~ " '°` ' pLETE SCHEDULE G AND FILE IT qS p percent [72 P.S. §9116 (a) (1.1) (i))• ~ d before Jan. 1, 1995, the tax rate im ,.: ~ ~ ~. ~~ ~ ~~ ~u "-~ ART OF THE RETURN. posed on the net value of transfers~tc~ ~ ~~~ ~_~ •~~{ ~~ r dates of death on or after Jan. 1 ~ ~ ~rw~~~. P S• ~ 1995, the tax rate imposed on the ne or for the use of the surviving spouse is §9116 (a) (1.1) (ii)). The statute does not exem t g a tax return are still applicable even if the survivin s o t value of transfers to or for the use of the p a transfer to a surviving spouse from tax, and the st dates of death on or after July 1, 2000: g p use is the only beneficiary, atutory requirements for-d9closurse is 0 e of assetsrand The tax rate imposed on the net value of transf adoptive parent or a ste pparent of the child is p ers from a deceased child 21 years of age or oun the tax rate imposed on the net value of tansfet [72 PS §9116(a)(1.2)). Y ger at death to or for the use of a 2 P.S. §9116(1.2) [72 I?S rs to or for the use of the natural parent, an §9116(a)(1)). decedent's lineal benef ' ' he tax rate imposed on the net value of transfers to -cianes is 4.5 ection 9102, as an individual who has at least one are percent, except as noted in or for the use of the decedent's siblings is 12 percent p nt in common with the decedent, whether by blood or2 P.S. §9116(a)(1.3)). gsibling is defined, under adoption. REV-1508 EX + (1-97) - COMMONWEALTH OF PENNSYLVANIA SCHEDULE E INHERITANCE TAX RETURN CASH, BANK DEPOSITS, & MISC. RESIDENT DECEDENT PERSONAL PROPER ESTATE OF TY ~~~~` ~ ~ ~ S~ rJ ~ FILE NUM BER Include the proceeds of litigation and the date the proceeds were received by the esta '~ l C ~ ~~° ~ ITEM te. All roe t NUMBER P P rty jointly-owned with the right of survivorship must be disclosed on Schedul DESCRIPTION e F. ~' 'P1~- S~}-a~(-~. ~~ VALUE AT DATE PI ~ ~ ~ ~ ~ ~-cL .~- U v, ~` ~ ~ _ OF DEATH ~ ~ ~o O v ~' ~~t.~- C V` t v t-.r 1 /~'1~ w ~ f~-tt `1 .~w~.2 1 ~ ~yI Soda.( S~~r;I' d ~ ~ S~-~ F ~ ~ ~ y C2~ ~. ~~ C~ ~ c~. (.~ c~ ~ v rn s~ 3 ~ Zc 11, l 1 ~ `~Q42,t"1 ~-$ 4~, $Z - Zit .oa ~ L a.r ~ ,~ ~ a ~ ~ 1 ~ l 2 ~ , e~-v P ~' 30 0 ,oc~ .. ._~, - TOTAL (Also enter on line 5, Recapitulation (If more space is needed, insert additional sheets of the same size) ) $ ~ ~ ~~~ ~~ =ia w1 y hops://homebank.ps~,u,com/Histo I"y/History.aspx?~SO Account History ~'~~-~- ~ ~ ~ ..- ~---~~ ~ ~1f - 60~~ Date ,~ Transaction Description DEPOSIT DIVIDEND 0.100% Amount Balance Check/Misc 05/31/2011 %% qpY EARNED 0.10% 05/01/11 TO o AVG DAILY gqL 4,460.23 05/31/11 /o%APYE DEPOSIT US TREASURY 312 $0.38 $324.35 06/01 /2011 TYPE: XXCIV SERV ID: 3121736156 CO: US TREA 2 DEPOSIT US TREASURY 303 SURY 312 $ .846.82 $3,171.17 06/03/2011 TYPE: XXSOC SEC ID: 3031036030 %% ACH Pqy SEMANKO FOR %% BENEF TESSA ARMSTRONGEE TONI CO: US TREASURY 303 578109378 $261.00 $3,432.17 06/16/2011 DEPOSIT AT ATM #00412688/350002 ATM 3500 TRINDLE ROAD CAMP HILL Pq 06/21/2011 CHECK 000226 TRACE: 0002750342 $1,560.00 $4,992 17 06/22/2011 CHECK 000227 TRACE: 0002870081 -$1, 731.96 $3,260.21 0 0226 06/30/2011 °/DoE APY qRN END 0.°100% -$106.71 $3,153.50 ED 0.10 /0 06/01/11 TO o 0 00~- AVG DAILY BAL 3,585.44 06/30/11 /o /o APYE 07/15/2011 CHECK 000229 TRACE: 000255 $0.29 $3153.79 07/18/2011 CHECK 000228 TRgCE: 0002452167 07/20/2011 CHECK 000230 7083 -$9'80 $3,143.99 00 229 TRACE: 0002935320 $4.52 $3,139.47 00 228 DEPOSIT DIVIDEND 0.100% -$60.16 $3,079.31 07/31/2011 %%APY EARNED 0.10% 07/01/11 TO 0 ° 00~ ~ AVG DAILY BAL 3,123.09 7/31/11 /o%APYE $0.27 $3,079.58 Social Securit • Re ' Y Administration tirement, Su Important Informati '~VOrs and Disabili on ty Insurance ~lil~ili~~iiiili~ii~~~~inli~~~~.ili~~il~l~i~ll~l~~~l~ ,i~ ~~, ~ ~ 001643 1 AB 0.368 0011 LTN T24 PC2 0621 i I I ~~k TONI SEMANKO FOR TESSA A ARMSTRONG 818 SYCAMORE CIR CAMF HILL PA 17011-1634 Mid-Atlantic Program Service C 300 Sprin Garden Street enter Philadelp~iia, Penns 1 Date: June 28, 2011 vania 19123.2992 Claim Number: 578-10-9378A we are sorry to learn of your to ss. Please accept our sincere s TESSA ARMSTRONG is not en ' 3~pathy. We cannot pay benefits for the titled to monthly benefits be ' month of death, or later, ginning June 2011. You may have saved some Social Any money that you have saved Security money for TESSA A her estate. ,plus any Interest on that mo RMSTRQNG. ney, belongs to You need to do one of these thin gs. • Give this money to the le al re g presentative of the estate, or • If there is no legal representati be able to tell you what to do ve, contact the state probate with the money, or court. They will • If there is no legal representativ contact the authorities who control'tand you live outside the Unit tell you what to do with the move he estate's move ed States, y. y• They will be able to jf You Disagree with The Dec ision If you disagree with this decisio review your case and consider an' y°U have the right to a make the first decision will decide new facts you have, ppeal. We w111 correct any mistakes. TESSA ARMSTRONG s pa son who did not believe are wron we w111 review those Se• We will g and will look at anarts of the decision which you review those parts which you belie y neW acts you have. unfavorable or less favorable to heVe are correct and ma we may also r, y make them • You have 60 days to ask for an a • The 60 da s st ppeal. this letter 5 a~ the day after you get this letter days after the date on It unless we assume not get it within the 5-da you show us that oy°u dot y period. y u dId C See Next Page 0 0 0 x 0 ;v b N z 0 H '~ n N N ~o a 0 g s 0 0 w 0 G REV-15pg EX + ry o7~ - SCHEDULE F COMMONWEALTH ~~~ PENNSYLVANIA JOINTLY-0 INHERITANCE ?AX RETURN WNED PROPERTY RESIDENT DECEDENT ESTATE OF T~ s <:: ~ ,~ ~,,,,~ s , e.Q, ~v ~ If an asset was made joint within one year of the decedent's date of death it m ust be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME B. C. JOINTLY-OWNED PROPERI LETTER DATE ITEM FOR JOINT MADE NUMBER TENANT JOINT 1. A, ~ 3 /~ 7 Z , ~ , a t f~4,~ FILE NUMBER _ ~ I (- OC~~,(,1 ADDRESS p ~~ I "? 011 RELATIONSHIP TO DECEDENT d~u~~~ ~Y: Include name of financial institutio Dand banklaccountnumPbeR orsimilar identifying number deed forjointly-held real estate. .Attach ~((S ~~qo /~cf.v~so rs fog3 6 ~0 53 DATE OF DEATH °~° OF DATE OF DEATH VALUE OF ASSET DECD'S VALUE OF INTEREST DECEDENT'S INTEREST Z.o ~'~ q . G,'7 I Sn ~~ ~ t c~ ~ 3 R - 8~ TOTAL. (Also enter on line 6, Recapitulation) $ (If more space is needed, insert additional sheets of the same size ~ `~ d ~' ~" ~-' w T~ s ~,~ ~ ~C ~ vk S,.i . ,~ , ..~ ~, ._. ~~, - I ~c>c~~t Tessa A. Armstrong & Toni A. Semanko Jt Ten WROS 5225 Wilson Ln # 3 Mechanicsburg, PA 17055-6663 .:. a Pa e > 9 1 of 1 a~gu~.d ~..~4~, re~::,~. :. _ i :: -.:y~~. . Voyager Services: 800-284-7245 Total repot value: (Total re `~---------____________~-._ $20,280,91 port value includes any accrued dividends.) '~ ~~ ~~tron~, To~ti A' S~n~nko ~' - A~!~~~ k U Y'I!~@ ~ l ~mar ~ , y, Name ~ _ ~~., . ,~. ~~,_ ` ~.~ ~' ~ t -A~~•.~,~ r,-;~. ~> Fund ~ A ~~ :~~~~ ~~~~ ~. ' a ~ Y punt ~ `' ~ ~ GNMA Fun d Investor Shares Numbe Date OP~ned ~ ~~ ° Fnce Per S ~,~ ,~ ~z .;,.:~ ,~ Asset Allocation F and Inv 0036-09911614531 04/08/2002 Shares Share Vaiue* i . Accrued Wellington Fund Inv 0078-0991614531 Q3/25/19Q$ 625.404 $10.98 $6, 866 94 Dividends Windsor I) Fund Inv 0021-09911614531 11/05/1997 0'00 $25.61 . $O Qp $1'24 0073.-09911614531 1.:7/05/1;997 414.101 $32.39 . $13,412 73 " Do se n mt elude accrued dividends. Q~000 Totals $X7,2$ . $0.00 - $20,279.67 $1.24 1149175561 07/11 /2011 12:36:15 v rn m a v f~ l v wI `aY J 3'' D'1 W ~' Y O O Y p L J X 00 V Q ~M M +-i N ^I I ~ ~ ` ~. J~ ~ ~ i ~ I ' ~ I f ~ ~~m i > ('~ ! ' I~ ~ ~ .~ f Q I ~ ,' Q! ~ m ~ f I i c m ~ I ., 'p~ ~~~ ~-q ~ O ! LL V ~ (NQ ~ ~~ ~ I:°~cp~'~~ °a~~ .> I W ~ti ~ a~ ~ o ~`Y -Ip 0 -~O ¢!,c! aim D~mj±~ ~~ _~ ~~~ ZT~ O Q ~, L- I ~C~ OI N1~ IQ ~ ~'IU ' "' ~Q H z ~ ~ I v ~ rl v~~m~ f ~~i O 1A I~ j ~.± ~ ~ D i N ~~p~p ~v ~~. iil ~~ ~~ `UI~ I'~tJl ;~: ~ ~~~iri Nl~~ c~ Ic.~i~,~l +M I' N O n n I ~ ;~ I O a ~i .~ ~j mI rn ZI ~~ p ~ I ~ I ~ ~ f t^MO !~I I ( ill + M C ~ ~' Q O ~I ~ O O ^ M ~ of OM ^ ~ i W + O Z ~ C Q a O M ti O Q~ M W~ J~ N ~~ •1~+ ~ I rv ~ ~ ~ ~I -r O m~ m*~ ~' ~~ ~7~ w~0 .C~O ~~v c; ~~ ~,r°, ~~ s O N #. f f j( ~~~ ~~ ...._.. 00 i __ . _ -i,....~ ......,......... ,....._. 3 .~..,..~_ N ~ tD I n ~ N v, ~; ~ ... _..~_. o . -.--.-,. o ~ ~~ o ~~ ' ~? i o M ~ ..~._ ,._._ _ O._..... i .', '-1 ~ .. { ~ ''` cv ~ € ~ ° ; ri i ~ ~ '-' ~ ~ - o ~r_....,...~..+.~ 6 ;~ ~ ... O O _~. O _,...__. O ~~..._._ 'O ~ °~ t O Io N i f\ . N t _ _ < ~ ... , _...._. . _~ . ~ ~, o s p ~O ~ O O ~ N ~ ~ #M ~~ o 0p J ~rj O ~ O ...~ ~., ~ - .,~o O ~ ~ } O 7 N ,...~.. N .-~ .--~ N ~ O t `"'~ \ ° N r ~ N ~ ~ 33t N ~ ~ O i O t0 O~ t ~' O <,_ : O __... X .. _ _ ~....~ .._..,~ _. Ar ~ ~~ g ~' ~ ,° € can ~ ~ a ..~_.~_~._.,~., ~..~__,._ _ ~' 4. r i a ~ d ^a i a ~ ~c~Oo00 Iz O W iUa ~ ~, ~ c ; Q 1z~g~F ~ ,Ja o~ ~ ~ ~ J ~ ~OQf~jsnl'~ ~a _.._.... ...1 LlJ Z~ J ,_c ~mu'~~vv~a ...... F............ ~ C O ~ ~ ~ . __..__... }._~. 0 0 ~~ ~rn M ~ ~ ~: ,--~ ' ` - a ! r y i O 01 ` lD ,-~ ~ , V ,~ ~ N w- O ~ ~ ~ ~ ~ ~ C ~ A 0 x Q c cII C "- cp ~ O ~'N ~ ` ~ C m rn~aw ° m ~ m ~ or. ~ .a ~c~o~n ~II ~« o ~ w o E o a~ ~ c ~c'cic~'vo~$ U C U Q. ~ ~ ~ N y pp ~ U p ~ ~ O O ~ • O Q ~ C - Q N= N ,O '`Q U ~~ J o c~ °~ E N O cII 0 C J ~c~'v~cmaNi c a ...... U C O O-C O Z N Nw. ~~.0 cB ~ ~Z7:0~~ C Q Ow O C Qw~ro ~ co r-~ ~ ~ ~ O C ~' U j U O _~ O O U O O ~ N ~ U c .., c .., ~ N C >, C O cII (~ O O f0 N N ~ N .n o~~a~o ~ O N O C N.C ~ .II ~ ` ~ ~ ~ N O t N ~p Q.O ~~ Ito N `O ~ U •C U ~ J fII Q •U L ~ cp ~ J .~ oc3a~c~ •~ ~c~..,co~ o :._, ~ c6 ~ U vi ~ w ~i ~c c ~ ~ ~~~~a N ~ co ~~> cV N O O Q ~' a> o ~' ~ rn ~ +a~. ~ _ ~.... c N~ _I ~ O ~j N ~ 0 0 (A ~~ ~ a ~ ~ O 0 N .~ ~ C O '~ ~ '~ Qp 0 J -p a p t tII ~' N U ~ ~~ ~F"~~ ~ ~ a~ ~ _ j ~ ~'~ N c~ ~'` ~ ~ t'(Y O ~ O a v~ c a o ~UO.., c o c a~ ~ ~ fII ° ~ ~ o i.n a - caicn~~w. ~ ~ C ~ ~:~ ~ '~ c U f 0 O N ~ ~ 'U ~ ~ ~ ~ ~ V C > fB U O -o~'v~ f°~occo~oa m v~ cB O ~ ~ C O x ~O ~~ 0 0 .tn Eo~ z x -' c ~ o ~v >rnc o:Q ~ v ~:.:.`~~ a°~~3~Y ~ v a ~~ 4-~ cL ;g ~ m ~ X ~` _>. O~~ C N ~ Q c~vr ~~ ~~ ~~ ~cv.a U oc~ ~~ ~v'vv s 0 ~ _ ~, O ` 0 ~ ~ .;j U ~ ~ ~ 0 N O ~ ~ '~-O ~ cII Rf N ~ ~ Z O oE ~ >~ in co;_~-c~~ `i m ' ~ ~ E c~ o o o c°°-' ~. a ~ °UV~oarn~ w ~ ~ ~ O `~~ N.tifn C O O L N O O ~ X cv ~, ::. O '0 'o ` ° Ux~ ~c`~~~~ ~ a V -~ lh w ~ ~.~.. ), t0 U ~ .~. C N Q F-o~ °a~coli~c cn o0 x ~~ N r ` ° Z~ ~ ; ~° ~ ~ ~g~~, .n was m ~ a~ a~ ~ = Q o 0~3~~ > c x Q ~~~a~~~~ ~ ~~ c w; o~ o ~ ti cu U Z ~ ~ p ~ U Y ~ ~ ~ ~ ~ ~ N C i Z, ~, ~ N O~ c O E O h N N ~ e > -~ F ~ r ~ E O - ~ v ~ O cp C ~ O REV-1511 EX+ (10-OFa) COMMONWEALTH OF PEN SCNEDUL~ INHERITANCE TAX RETURN ANIA FUNERAL EXPENSES & RESIDENT DECEDENT ADMINIST ESTATE OF RATIVE CASTS ITEM Debts of decedent must be reported on Schedule I. NUMBER A. FUNERAL EXPENSES: DESCRIPTION 1. ~' ~ ~n ~~ ~ ~ ~ n c~ ~' ~. ~ n r~ t ~'l C i 'a Flt C i~l ~wc~-~; i FILE NUMBER -~ _~~?ll-~~G,~i AMOUNT ZS.~~u S~~t , o ~ Sb , c' d S~ , o ~i 5~~~~ B. ADMINISTRATIVE COSTS: ~ ~ Personal Representative's Commissions Name of Personal Representative(s) Street Address - --- - City _ -----------------__----------- ------ Year(s) Commission Paid: State ___ Zip 2. Attorney Fees ----- --------------___------- 3' Family Exemption: (If decedent's address is not the sa me as claimant's, attach explanation) Claimant Street Address ---------- ---------------------- -- --- ---- -- -- City ----------- ----- --------- - -- Relationship of Claimant to Decedent State __ Zip _ - 4. Probate Fees -------------- -- ------ Accountant's Fees Tax Return Preparer's Fees K ~ i ~ kr' ~~ t 1,.c,' ~, II s ~ . P~~+~~ l~~~uS T~s~ ~ti' ', I I J ~- ti ~Z f 5 6. 7 Z+o.~,~. tS' , (~ c~ ~C3 , C C: L3.5`~u S .0~3 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size ~ ~ ~~ ~~ 1 1 _ _ - __ uER ~ .M~ATIQN 4100 Jonestown Ro ~~~~~~~ ad, Harrisb urg, PA 17109 1-8 - ~~~~~ TQ Charges are only for it ~ OO 720-$221 j+ ' " ems that you selected or that ax 1'717-541-9943 ~ ~~• writing below. 1t >'ou h~;`e selected services that mayrrequ9 ei embalmµn Shawn E. Car required for direct cremation or immediate burial. Embahnin + are acquired by taw orb per 'S11pervisor g, you may have to Y a cemetery or cremato b is not required b pay for embalmi^ n' to use any items you have not selected, we will explain the reasons in y law, except in certain special oa eSU df not have to pay fo-- embalming that STATEMENT You are charged }or embalmin YOq did not approve. Embalmiu • ' .i. ` /~ Deceased. -~ ~x, + ~ OF GOODS AND SERVICES g, we will explain why below. b is not ~~ s ~ t~ ?'" t° C x~ :~~-~~;:. t~..c~i"iz., SELE T E Charge to: - - ~ _~ . ~.~~~;, g. ± ~- .. Date Qf+D,eath `~ tl~ ~ =` ,as ~ :t. i, D ~~ ~. ~ t .s . Name -. ;, l,~ ~r ~-~~"t~,, ~, ,: .; ,~ _ ate of Arrangements `.~ ut~. -:. .~ ~; j, Address ~, i .~ • f ""s~ti r, .. A• SPECIAL SERVICES: { ~' ~` City f 7 _ _. State Zip Code ~~ ~ , ,~ `~ Direct Cremation.. D, Phone Number 4 AUTO Iy . qj _t r .~, ~ ~ , E NT: Worldwide Tra~antee Program .............. ~ `, y ~ . ~ ~ RemolvalOVen E ,~. QUIPME .. TOTAL SPECI ~ AProtection .................. Lead Car and/ ,C.................................. - .~: ~ .acf {4i AL CH RGES ..................... ~.~ ~. , ~ _ Family Car ors lergY Car...................., w (Sedan or Limo). Service Vehicle.. _ ~"""""•••••••• B• PROFESSIONAL SERVICES: TOTAL OF A UTOMOTIVE E ' ~ ~ • ' ~ ' ~ " ' ' .. QUIPMENT........ . ervices of Funeral Director and Staff......... ~.ir~ ~ ~ •. - _: w E• CASH ADVANCE ITEMS: Dressing and/or ~ s .c. ~~c_a Facilities and Cosmetizing... •.. • .. Grave Opening. , Staff for Memori • Crematory Chi-ge. • al Service.... Cemetery Equipment.... ~ • • • " ~ • •" • • • • " " "' " "' Staff and Equipment for' ..................... .~ tzc: t ~~: Newspaper .......................... Memorial Service.. Ne~'spaper `" -- ~3 Private ID Viewing, ••• ''` --_.- . ' '••••••• Newspap er Witnessin ............... ... g the Cremation.. ' ~ ~ • ~ ~ Clergy. , -- Packaging and Foi•v.'arding Cremated Chur .........:................. ... Remains by Registered Mail:.. Flo ch/Sexton/Organist/Soloist.. ~•~• Personal Delivery of Cre d .............. veers............... .............. . mate Remai Co ' ~"~' ' • • • • Scattering of Remains over Land or Seas , .. Ce unty Coroner Fee..~4,..~.,s"~• ,~ (•~» ~'• ~• ~,~`~ ..~(-~, rtified Copies of the Death Certificate.. ~,~ ~ ~ ~ , ~,~ TOTAI:, OF PROFESSIONAL SERVICE 5..... S U . ~t;U C- MERCHANDISE: TOTAL OF CASH "' Re aster ADVANCES,,,, `~ ~- g~ Book. SU ....... a 1 t~ ~ Sit Memorial Folders/Pra ' ' • '. • ~ ~ ' • ~ ~ ~ ~ ' ~ ~ • • • "" ' MMARY OF CHARGES: •• • • • • • • • • • • yer Cards.. Thank You Cards ................................ A• Special Charges.. , .... , .• ememberance Package.......... •...... B• Professio ....................... ~ ~ ` ~ ~~¢ . ~~~~ Urn(s)......... ............ ~ ~ ~ •'~ w nal Services...... (Descr ~ "~' y'~ 4.•• .... ~ ...... C. Merchandis .................... ____ ~ ~ , ~~v.z iption ~-st :.~~t:~~~c'W' '' ~ e.......... 1..Ui3.~, ` •, ~.~, , t . '11 , ~'1 Urn Burial Vault Container.. D• Automotive Equipment. (D scription .................... E• C ......................... .% ~. ,.. , ~~ ~~ ash Advanced Items. ;4. Veteran Flag Case.......... . .................. ~~ 1, r, , .... ~ . ~} Grave Mai- ....................... SUBTOTAL.... er/Monument....... CRED ....,,........ - . ~~ ~~i ............... ITS.... .................... t~ "~-~~i • C, , ...... TOTAL DUE ...............................................: ~'= ; a ~,`~# :..,. ~ -• ~ ~ ~:, a ~~ .i ci p, .... PAID......... .......................... -- -~ • '`~ ~ TOTAL MERCHANDISE ....... BALANCE DUE ........................................... if ~Y 1e~a1, cemetery, or cremato • i;..t.~n :~. Ott i riLJ ~ ~ t'c~ re uire~l7enl h ~~J-t i Y ~~rec~i~e~ tt}h,e ,arch ~ of .. ~tl~~: ~ v4C;rhe`.lt~~t~~t~~~.~"" I agree that I have examined the items of - ~~ ~~» explain the requirement below. acknowledge receipt of a co g°Ods and Services selected above and found them to be correct goods and services selected.pl of this statement of Goods and Se below. A late charge of - ~s4.~gree to mane lected. 1 re and according to the arrangements 1 have requested. L •~ Paymegt of $ , ~ ~ p= t ays I have suifuient funds available for a agreement. I will also =----pef month arnountin to *~- within 1 pay to the Funeral Director all reasonable cost-per Year will be agree to be jointl p Yment of the cash price for the attorneys' fees, court costs Y and severally li le with agreement and the cost thereof w 11~be eflecte on the fin paid by the Funeral Directopltoc ollect unpaid balance be i ~ anyone else who signs Y additional services or merchandise ordered or requested after the d g nntng _~- days from the date of this ~; a! bill or statement. amounts I owe under this agreement. Those costs may include (Seal) ~'`. ' ,~. : ;'' ate of this a reement will be considered g <:. - Part of this (Seal) ~~,~ 1 ~ (Purchaser) :~~'t"ti"i ? ~'~ .~ . :..- s f ~w .. :! 1 -% (Licensed Fwieral Director) Gate) r' ' . ~, (Date) ~~ Hui=n ~:kEI~iATIUiV SEkviCt 4100 JONESTOWN RD HARRISBURG, PA 17109 06/072011 Merchant ID: 11:00:+6 Terminal ID: 0000 00001669375 23517757099; 02508749 CREDIT CARD VISA SALE CARD # INVOICE XXX~,~,k„ ;~,~,~t~X9369 Batch #: 0001 Approval Cudr: 000188 Entry Method: 010592 Approved: Manual Online SALE A~YlOU~~T , $449.07 Mrs. Toni A. Semanko 818 Sycamore Circle Camp Hill, PA 17011 SPECIAL CHARGES X Direct Cremation X Nationwide Worldwide Travelntee Program TOTAL SPECIAL protection CHARGES TOTAL PROFESSIONAL SERVICES PROFESSIONAL SERVICES X Services of F Other pre uneral Director & Staff Facilit1eparation of the god & Staff for y Staff & Equipment for Memorial Service Witnessin Memorial Service g the Cremation Private Famil Packa in y Viewing/Witnessin g g And Forwardin g Cremation Personal Deliver g Cremated Remains Scatterin y °f Cremated Remains Medical g °f Cremated Remains Documents/Courier Fee AUTOMOTIVE EQUIPMENT X Removal Vehicle Lead Car/Clergy Car Family Car Service Vehicle TOTAL AUTOMOTIVE EQUIPMENT EMATION SE RVICES OF j~ • Harrisburg, pA 1 ~ ENNSYLYANIA 71 ~~, .1.800- , INC. 720-8221 • Fax 717-541-9943 . Shawn E. Carper, Su ervi • p SOI Jun 2, 20T1 Tessa Allene Armstrong - Decea sed $1,595.00 $295,00 Included Included 110634 LL5 $1,890.00 $0.00 $0.00 REV-1512 EX+ (12.03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ----_ SCNEDI,ILE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~FSSq ~ /4~rns~~ 'r~lG Report debts incurred by the decedent prior to death which remained u FILE NUMBER ITEM ~-t~~r.. c.~G~G>I NUMBER npaid as of the date of death, including unreimbursed medical expenses. 1. ~~ ,~, ~ ~ ~ ~ : l ~ DESCRIPTION y + ~ ~~ ~ 5 ~..~ ~ (~~~ ~ ~ t'~ ~ r, ~ VALUE AT DATE 2 , OF DEATH CI ° ~ ~ }'l i'1 ~ 1 ~ c~ SG C ,,~- ~ x 3 ~ l~ t~,~z ~,~~J ~L.S~ TOTAL (Also enter on line 10, Recapitulation) $ (~.~5 ~ (If more space is needed, insert additional sheets of the same size) T ~ Bethany ~r~1lage X25 Wesle .D . ~'le~:hanicsbur ~ nve g~ PA 17055 ,~ ~ ~, ,~ J ~ ,Gi ~' ~k. _12~, S TgTEM N P Invoice ~ ~ ~ ~ T age: 1 of 4 Account ~ , 182166 t3at 23411 06/06/2011 D~te~ date Ar~~~nt >3ue 06/13/2011 Amount pfd $1,731.96 Toni Semanko 818 Sycamore Circle Camp Hill, PA 17011 Resident Name Armstrong, Tessa A PLEASE DETACH AND RETURN Armstrong, Tessa A UPPER P ORTION WITH YOUR _,_a ~ Bethany Village _ The Oaks REMITTANCE ----~_ Payment Received (5/26/2011) X6/30/2011 Room and Board )5/01/2011 Incontinence Care- )5/01/2011 Mobility Alarms Mod/Heavy X5/01 /2011 5/31/2011 Specialty Mattresses 5/02/2011 Nutritional Supplements 5/02/2011 Incontinence Care- Mod/Heavy i/02/2011 Mobility Alarms i/03/2011 Specialty Mattresses Incontinence Care- Mod/Heavy /03/2011 Beauty/Barber s/s /03/2011 Mobility Alarms '03/2011 Specialt '04/2011 Incontinence Care es 04/2011 Mobility Alarms Mod/Heavy X4/2011 Specialt )5/2011 Incontinence Care es 15/2011 Mobility Alarms Mod/Heavy '5/2011 Specialt 6/2011 Y Mattresses Incontinence Care- Mod/Heavy 5/2011 Mobilit 3/2011 Y Alarms '/2011 Specialty Mattresses Incontinence Care- Mod/Heavy '/2011 Mobility Alarms '/2011 Specialty Mattresses /2011 Incontinence Care- ~2011 Mobility Alarms MOd/Heavy '2011 Specialty Mattresses Dhi#$ 06/06/2011 ,,U~it . SIDENT QE~~ .; =host r_ . Ne# 2.00 Day 1.00 Day 347.0 694.0 -11,084.29 $11,084.29 0.00 1.00 Each 11'5 6 0 11.5 $69 4.00 1.00 Each ' 11 5 6.0 $705.50 31.00 Each ' 2 1 11.5 $711.50 1.00 Day ' 11 5 66.9 $723.00 1.00 Each ' 6 0 11.5 $789.96 1.00 Each ' 11 5 6.0 $801.46 1.00 Day . 11 5 11.5 $807.46 1.00 Each ' 18 0 11.5 $818.96 1.00 Each ' 6 0 18.0 $830.46 1.00 Each ' 11 5 6.0 $848.46 1.00 Day ' 11 S 11.5 $854.46 1.00 Each ' 6 0 11.5 $865.96 1.00 Each ' 11 5 6.0 $877.46 1.00 Day ' 11 5 11.5 $883.46 1.00 Each ' 6 0 11 5 $894.96 1.00 Each ' 11 5 6.0 $906.46 1.00 Day ' 11 5 11.5 $912.46 1.00 Each ' 6 0 11.5 $923.96 1.00 Each ' 11 5 6.0 $935.46 1.00 Day . 11 5 11.5 $941.46 1.00 Each ' 6 0 11.5 $952.96 1.00 Each ' 11 5 6.0 $964.46 1.00 Day ' 11 5 11.5 $970.46 1.00 Each ' 6 0 11.5 $981.96 1.00 Each . 11 5 6.0 $993.46 . 11.5 $999.46 $1,010.96 Fro Date Bethany Village -The Oaks ~ ' ~ . -- ~ ~ ~ ~ ~ ~ ~~ ~ ` - m rou Desgription 5/31/2011 Balance Fo-ward Units Unit RESIDENT RESP © , _~1 5/01/2011 3/01/2011 06/01/2011 06/ Payment Received (6/20/20 Nutritional Su 11) l O-ySIBIL( TY 1/01/2011 >/01/2011 01/2011 6/01/2011 0 PP ements Incontinence Care- Mod/Heavy Mobilit Y Alar 1.00 Each 2 1 /02/2011 /02/2011 6/01/2011 06/02/2011 ms Specialty Mattresses Incontinenc 1.00 Day 1.00 Each . 11'5 0 6 2.1 11.5 /02/2011 06/02/2011 06/02/2011 e Care- Mod/Heavy Mobility Alarms Specialt Y M tt 1.00 Each 1.00 Day 0 ' 11.5 11 6.Oi 11.51 a resses 1.00 Each .5 b 00 11.5( 1.00 Each . 1 1 5 6.OC . 11.50 ~~I~ ~~f ~0~~~ ~' Z~'~ Please contact Donna Colon at (717) 591-8029 . with any questions regarding this bill. 07/08/2011 t Balance . C d• -1 73 $1, 731.96 1.96 $0.00 $2.16 $13.66 $19.66 $31.16 $42.66 $48.66 $60.16 TOTq~ RESIDENT RESPpNSIBILITY TOTAL:. $60,16 ., .,,.- .i, ~_ F .... J.1:, t_i J:. ~ ~~,, ~ .. .. _ ~ ~ t~ti _.:. , ~-' 7 ~.., ~i~ ~ °1 - t j ~C7,~ r ~~ Z Z~ ~.:.... .; r' ' ~7 -` - ~ s. _ _ s ...r , ) . , t .i i i , s } ~ f ~ t ~ ~ 1.: ~ i ~ .... .~ ~t` f .,. l:..f ~.... L.f 1 ~f l ~ . ' -. ~-}~"' • .1. ~`... •. .. . i ~, } . ... t __ . .. ... i. i...t '~~ ~y , ~ .~ f s f t '• t..~ ~'~. ~.C. ~..'7 I~ L'' 5 +t t:t ~..~ ~i r~,j r ` . ~~ Lat ~ . 1 ,~ H...~.~. ~,.' L,~N t5 ~' j ~~l~~X: ~~ s 1 t . ~ r f.~ »-x i ~ i. . i ~ i1 ... y ~ ~ t e ' i ;: i `~ .. L. 5.`J ~ -1 '1:l ~ 1f~_ ff"~ tl "'t ~... {J i- t~'1 7 , is L i jet... ~~ ! .. ~ ~ ...} ~.-{',f~•~ . ~E;,1t.?~'`;4:r .J ''~..C ~,:('~~..} -.:, .. F .. ;., .. ,.. ~ :.._ .. ~ ~ :~~ .. :.. .~ . . r.:, f,. ~ ~ : ' ~ 1 ~. co~rTlrvulnr~ caR~ Rx ~8 s s~co~rD sT lVEWPpRT Pa i 7p?4 ~ .~. 8 T A r E M E ~ ~- ~~ Statement pate: 6I3U/11 p age: ~ Account #: ipa(74?iq~, TESSA A ARt`'1STRpMG TSh! I SEhfAH~t7 8113 SYCahlt3RE L IRt'LE DAMP MILL, PA i7g1i ~ -`~, ~~, `pate___ Description Prevzous'~al ~`~~~~~'~ ''~`__"~'_--_ Qty Amount 11 _`---------._ __ 6/~1 / DC7C#993Q9II68aPAy "_~_ -..._._ _ __ 6/p i / 11 R X# 8493651 MEMT _ THAhIK YUU 1 D~ ,?~, 6/C71/11 RX# g~.g36?1 1~i0RPHIhlE SULF '~ 1~?6. ?i- ~`LORa z e ~4lMG/ML 88L Pam Q• 51"IGIML QEL ~' ~'. 13 ~BPAY 8 • 34 CC7PAY Endiny balance - Pay this a mount --__.~__- .~. _"~ #• ~2 Current Fast Due past pue -______-_-- 31-b4 days 61 fast Due __.~ ~-9Q days 94+ d a s PLEASE BALL BETH i -8??-~37,~ QQ~ QQ -`"".~.._~. ~.~.?9 EXT. 33Q • 4n ~. z~,.- .