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10-18-11
1505610140 REV 1500 ~` ~°'-'°' - OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO Box 280601 INHERITANCE TAX RETURN 2 1 0 9 0 0 4 7 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYW 1 8 7 4 2 6 5 6 7 1 2 2 2 2 0 0 8 0 6 1 3 1 9 5 2 Decedent's Last Name Suffix Decedent's Firs t Name MI S I M S H A R O L D T (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI S I M S A D E L E M Spouse's Social Security Number 2 0 8 3 6 4 7 5 7 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) State ZIP Code CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL GOKKESPONUENGt ANU GONhIUtN I IAL 1 AX INhOKMAI ION SFiOULU tat UIKEG t EU 1 O: Name Daytime Telephone Number R M A R K T H O M A S E S Q U I R E 7 1 7 7 9 6 2 1 0 0 First line of address 1 0 1 S O U T H M A R K E T S T R E E T Second line of address City or Post Office M E C H A N I C S B U R G 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) REGISTE3.PF WILLS US~ONLY ~t >> 7 i't ~ -'7 ~ ~~ C7 L - - r r-- ' 'T r-; ~' >~ - - j ~- -_ _._ I I~, -~fITL FILED ~ ~ ~ ~ ' T' _ J ~~ P A 1 7 0 5 5 Correspondent's a-mail address: rmarkthomas@gmail.com Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE~ERS/~ SPONSIBL F'~G RETURN DATE ((( ~ /O // 7 ~// ADDRESS 1007 BRIDGE STRE NEW CUMBERLAND PA 17070 SIGNATU OT AN _ PRESENTATIVE DATE,/ ~ . 101 SOUTH MARKET STREET MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 1505610140 J ~ REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0047 DECEDENT'S NAME HAROLD T. SIMS _ __ STREET ADDRESS 18 ROSS AVENUE, 2ND FLOOR CITY i STATE ,ZIP NEW CUMBERLAND PA 17070 Tax Payments and Credits: 1~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments - B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (1) o.oo Total Credits (A + g) (2) 0.00 (3) (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ................................................................ ...... ^ X^ b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^ Q c. retain a reversionary interest; or .......................................................................................... ...... ^ 0 d. receive the promise for life of either payments, benefits or care? ................................................. ...... ^ 0 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................. ...... ^ 0 3. Did decedent own an "intrust for" or payable-upon~ieath bank account or security at his or her death? ... ...... ^ X^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................ ...... ^ 0 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 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, undi Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 1505610240 REV-1500 EX Decedent's Name: H A R O L D T• S I M S Decedent's Social Security Number 1 8 7 4 2 6 5 6 7 RECAPITULATION 1. ...................................... Real Estate (Schedule A) 1 ..... 2. Stocks and Bonds (Schedule B) ................................. ..... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ..................... ..... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. 4 3 D 3 3 . 8 3 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .. ..... 6. 3 8 . 9 9 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested .. ..... 7. 8. Total Gross Assets (total Lines 1 through 7) ...................... ..... 8. 4 3 D ~ 2 • 8 2 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ..... 9• 3 4 3 0 8 . 9 3 10. Debts of Decedent, Mort a e Liabilities, and Liens Schedule I 9 9 ( ) ........ 10. ..... 2 8 5 2 D. 4 8 11. Total Deductions (total Lines 9 and 10) .......................... ..... 11. 6 2 8 2 9 . 4 1 12. Net Value of Estate (Line 8 minus Line 11) ....................... ..... 12. - 1 9 ~ 5 6 . 5 9 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................. ..... 13. D . 0 D 14. Net Value Subject to Tax (Line 12 minus Line 13) ................. ..... 14. - 1 9 ~ 5 6 . 5 9 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.o 1 0 D 0 0 15 16. Amount of Line 14 taxable at lineal rate X .0 16. 17. Amount of Line 14 taxable at sibling rate X .12 D D D 17. 18. Amount of Line 14 taxable at collateral rate X .15 D D D 18. 19. TAX DUE ......................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15D5610240 1505610240 0. 0 0 0. D 0 D. o D 0. D 0 0• D D REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER HAROLD T. SIMS 21 09 0047 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. roceeds from Litigation; Adele M. Sims, Administratrix, et al. vs. O'Donnell and Locke; Case No. 10-7816 40,000.00 ivil Term, Cumberland County, Pennsylvania. 2. New Cumberland Car Wash final paycheck ~ 183.65 3. embers 1st FCU, Checking Account No. 124969-11 2,679.18 . O. Box 40 echanicsburg, PA 17055 4. nited States Treasury (photocopy refund for form 4506) 171.00 TOTAL (Also enter on line 5, Recapitulation) I $ 43,033.83 (tf more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania ~ SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HAROLD T. SIMS 21 09 0047 If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS TIONSHIP TO DECEDENT A. Kristen Sims 09 Fifth Street aughter ew Cumberland, PA 17070 C. JOINTLY-OWNED PROPERTY: ITEM DUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST I. /1/1992 embers 1st FCU, Savings Account No. 124969-00 77.97 50. 38.99 . O. Box 40 echanicsburg, PA 17055 TOTAL (Also enter on Line 6, Recapitulation) I $ 38.99 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER HAROLD T. SIMS 21 09 0047 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Parthemore Funeral Home 7,924.92 2. Rolling Green Cemetery 9,645.00 3. Funeral luncheon buffet 1,410.08 B ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2 Attorney Fees: R. Mark Thomas, Esquire 3, Family Exemption: (If decedents address is not the same as claimant's, attach explanation.) claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. I Probate Fees: 5. I Accountant Fees: 6, ~ Tax Return Preparer Fees: 2,500.00 99.00 7. Parthemore Funeral Home (finance charge) 133.53 8. Healthport (medical records; 20% of $105.79) 21.16 9. R. Mark Thomas, Esquire (20% of contingent fee of the survival action) 12,000.00 10. The Patriot News (publication) 141.24 11. New Cumberland Police Department (accident report; 20% of $15.00) 3.00 12. Office of Coroner (coroner's report; 20% of $100.00) 20.00 13. Sheriff (service of complaint; 20% of $163.04) 32.60 14. Office of Prothonotary (Writ of Summons filing fee; 20% of $92.00) 18.40 15. United States Treasury (request for Form 4506) 285.00 16. Cumberland County Law Journal (publication) 75.00 TOTAL (Also enter on Line 9, Recapitulation) $ 34.308.93 If more space is needed, use additional sheets of paper of the same size REV-1512 EX+(12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER HAROLD T. SIMS 21 09 0047 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, embers 1st FCU, Loan No. 124969-13 3,000.00 . O. Box 40 echanicsburg, PA 17055 2. embers 1st FCU, Visa Account No. 4121449991249694 2,229.65 . O. Box 40 echanicsburg, PA 17055 3. nternal Revenue Service (back taxes for years 2005, 2007, and 2008) 4,867.16 4. immerman's Landscaping & Lawn Care 53.00 . O. Box 73 tters, PA 17319 5. omcast Cable 7.45 . O. Box 3006 outheastern, PA 19398 6. erizon 25.30 . O. Box 28000 ehigh Valley, PA 18002 7. orres Credit Services, Inc. (UGI Utilities) 426.60 . O. Box 189 arlisle, PA 17013 8. enn Credit Corp. (PP&L Electric Utilities) 204.74 . O. Box 988 arrisburg, PA 17108 9. SBC Card Services 1,600.23 . O. Box 88000 altimore, MD 21288 10. CM Services (Citibank, account no. ending in 6679) 7,834.47 150 Olson Memorial Highway, Suite 200 inneapolis, MN 55422 11. itifinancial, Loan No. 351510 8 271 88 401 Hartzdale Drive, #126 amp Hill, PA 17011 TOTAL (Also enter on Line 10, Recapitulation) I $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HAROLD T. SIMS 21 09 0047 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. Adele M. Sims Spousal 100.00 1007 Bridge Street New Cumberland, PA 17070 II. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. 0.00 Pennsylvania DEPARTMENT OF REVENUE January 28, 2011 R. Mark Thomas, Esquire Law Office 101 Market Street Mechanicsburg, PA 17055 Re: Estate of Harold T. Sims File Number 2109-0047 Court of Common Pleas Cumberland County Dear Mr. Thomas: The Department of Revenue has received the Petition for Approval of Settlement Claim to be _: filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has .' been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 56 year old decedent died as a result of a motor vehicle accident. Decedent is survived by his wife and one adult child. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action, $112,000.00 to the wrongful death claim and $ 28,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. sS8302; 72 P.S. §9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A?d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. . Siric~ rely, f ~ ~ ~ annon E. Baker Bureau of Individual Taxes ~ PO Box 280601 ~ Harrisburg, PA. 17128 ~ 717.783.5824 ~ snabaker@state.pa.us MEMBERS 1St FEDERAL CREDIT i7NION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established 124969-00 02/24/1992 $77.93 $.04 $77.97 Kristen Sims 04/01 /1992 CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner LOAN ACCOUNT: Account Number/Suffix Date Opened Principal Balance at Date of Death Loan Type Interest Rate Name of Co-Borrower 124969-11 11 /25/1994 $2,679.18 $0.00 $2,679.18 None 124969-13* 12/12/2008 $3,000.00 Unsecured 12.89% None ''Loan has death coverage. VISA ACCOUNT: Account Number/Suffix Date Opened Principal Balance at Date of Death Name of Joint Cardholder 4121449991249694* 07/15/2005 $2,229.65 None "Contractual Pledge of Shares. Estate of: HAROLD T. SIMS Date of Death: 12/2212008 Social Security Number: 187-42-6667 BERS 1ST FEDERAL CREDIT UNION ~~~ Danielle A. line Lending Insurance Support Specialist March 25, 2011 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsyhrania 17055 (800) 283-232 ~ti~titi:memberslst. erg _ _ ... a,~ _~.__ . _ _ _ . ._ ., _ __ _ ...._ ., _ _ 60-1878/313 _ _. ------_..._._~_.___~..__ __ _w..- - ~NC. _'_~ _ _ AMOUNT NEW CUMBERLAND CAR WASH, EXP6ANAT70N 669 FISHING CREEK ROAD ~ n ~ g NEW CUMBERLAND, PENNSYLVANIA 17070 G (71717740312 EIN 1125-1671438 ,~ inrr ~3:'1'~'°! ~~i ~ l '. ~ ~ ~ '»,t .,~'~ Ii s` CHECK AMOUNT a( ~ ~ .6 J/.~ 1I/~ t, ry ' INTEGRITY BANK ~C// wLRHORIZ® 3t6NA7URE ~~'~~>o. ___ _ -- - _ _ -- ~ 11'00 7.2 1911' i:0 3 L 3 L8 78 7~: 2 20 30000 0~~' a Empbyee~s ssN _ 187-42-65b7 b F.mpbyer identification number (EIM 25 1&71438 f. C EmpbYer's name. address. a~ ZIP code NEW CUMBERLAND CAR WASH INC 669 FISHING CREEK RD d Control number - @ FJnployee's name. address: and ZIP code HAROLD T SIMS 18 ROSS AVE D PA 17 D For Employer. 1 wages. tros. otlxr compensation 6240.00 3 social scarily wanes 6240.00 5 Med~re wages and tips 6240.OC 7 sociar searihl tips 2 Federal tax withheld 702.00 4 social sear+b tax withheld... _ 386.88 6 Medicare tax withheld 90.48 8 Allocated tips 9 advance ElC payment ~ ~ dependent care benefits _ _ _ - - Su(t. ~ 11 Nonquarified Plans ~ 12a - - 13 12b 14 other 12c PA 17070 PA-SUT 5.64 NEW CUMBERLAND 12d ~`:.:. - t.ocaliry 5 Stale Employer's stets ID number 6 Stata wages, tips. etc. 17 state income tax 8 local wages. tips. etc. 9 t.ocal some tax 20 name 6240.00 191_62 _ 6240.00 _____90•48WSFiORE_ PA_ 1795_6442________ ___- - ---- - ---- - - Department of the Treasury- Internal Revenue Service Wage and Tax 2007 For Privacy Act and Paperwork Reduction Form w'2 Statement Act Notice, see separate instructions. Fowaotos taotro~ ~~ I ~/ `` // a % A Family Tradltlon Of CanngR PARTHEIiiIORE Funeral Home & Cremation Services, Inc. Ms. Kristen Sims 509 Fifth Street New Cumberland, PA 17070 1303 Bridge Street P.O. Box 431 Nevv Cumberland. PA 17070 (717)774-771 (Fax)774-546 wvvw.parthemore.com Gilbert ~V. Parthemore. Founder Gilbert J. Parthemore, Supers isor Stephen K. Pat-thetr:ore. CFSP Bruce R. Parthemore, Pre-Need Coordinator. CPC Professional Memberships: NFDA • PFDA DCFDA•CCFDA ~~~~,u„~ ~» ~r« G~`»LD~N UL~; 77rc Buie }nu n;tu~, r. Tkr Pco/~Ic• ~%ni Ti~u;! -- _~= a _ ._. _ _. - ~ A--• -. `-~ i _ .~- _._ For the service of Harold T. Sims 12/2412008 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, facilities, automotive equipment and merchandise that you selected when making the funeral arrangements. Terms Due Date Account # Net 30 1/23/2009 2008111.4 Description ! Amount SERVICES & MERCHANDISE Traditional Funeral Service 5,595.00 Dove Stationery Set 165.00 Rosemont Cremation Casket ! 1,119.00 Navy Blue Marbleite Urn ' 203.00 Total Services and Merchandise I 7,082.00 CASH ADVANCE ITEMS Death Notice, Wilkes-Barre Citizen's Voice 75.00 Death Notice, Harrisburg Patriot I 307.92 25 Certified Copies of Death Certificate 150.00 Clergy Honorarium i 150.00 Cumberland County Coroner Fee, Cremation Authorization ~ 25.00 Total Cash Advances ( A 707.92 ADDITIONAL ITEMS i (15) Corrected Certified Copies of Death Certificate 135.00 Total Additional Items 135.00 Total $7,924.92 I ~! L ~, Payments/Credits $o•oo ~ ~'' J J Balance Due $7,924.92 - /~ 3j~ ~ - r-~ -/1 k 4 J-- Parthemore Funeral Lorne & Cremation Services, Inc. P.O. Box 431 1303 Bridge Street New Cumberland, PA 17070-0431 (717)774-7721 Ms. Kristen Sims 509 Fifth Street New Cumberland, PA 17070 Statement For the service of Harold T. Sims DATE 3/ 10/2009 AMOUNT DUE AMOUNT ENC. $8,058.45 DATE TRANSACTION AMOUNT BALANCE 12/31/Z003 Balance forward 0.00 12;24/2008 INV T1664. Due01i23/2009. 7,924.92 7,924.92 O~i0~/2009 [HIV =FC 424. Due 03/05/2009. Finance Charge I li3.~3 8,08.45 1-30 DAYS PAST 31-60 DAYS PAST 61-90 DAYS PAST GVER 90 DAYS -AMOUNT DUE CURRENT DUE DUE DUE PAST DUE 0.00 133.E 3 7.934.9? 0.00 0.00 $8.058.45 Pleasz don't hesitate to call our o~#ice if rve nay be of assistance. Thank you. f^HR-28-2©11 23~~2 ROLLING GREEN CEMETERY S~Q~7G GBE~Yd CEMETERY ~COD~ANY. N°_ 805007 1811 QNeiid+ Bad ~ GLt~ ~e P~ 17011 ~ 717/76].1066 CDmrad 544 ~Q /~~© ,METERYSNTERMENT File folder Name/Number AND SERVICES PURCHASE/SECURITY AGREEMENT THIS AfixECtyla+. a rba...-•-..- _ ----- - t to rc r c aaa apPrwM of .d.rsl¢ud• referred fo w 'PUrebmw ~ hereby a¢rcn m purNao the Imrrmml RI¢Ma. MerWndiw and Swrket drurihed berate, sunjee nP m e ,owe nomad cemetery, aereaaer reRrredmu'Sdt•r•. (( Middle r,,t 1 1 1 1 L~ f 1 1 1 1 1 1 1 FirrL ~ I` r 1 11 1 I I I I t Irrl' I 11 1 I untuser: 4n Nanu: ~' &nas1: SSN: DOB: )__/ 121cpnone: , `= ,Wear s 1~f1r11~iC rl. ~/rl ~~~I I t I I L M,ddlc: - - -~ - ~ For: LI i l l l l l l l l l l l I I I I I 1 1 Ce•PUnaarer. Lrt Nana. LI ~ I I DDB: Gmait. ieiepimne: SSN: `_ JJ.J (~ ! Starr. 2fp. I I Clty` I l l l l l l l i l l~ l! t neeroer: 1 1 1 1 1 1 1 1 1 I I I J i' I I I I L~t_ fs First: 1~ ~- ~+•~. ~ yil 1 I I 11 I f I Middle: I I 1 I l I OeaasN: tau Name: ,~ •. ~ ~ I I l l l ! I I I f Ts ' /~ .~ a Vesunn. Q DOD: Hnnal Dare: r1 ,y2~[J~.U- DoH: f~ r !:~ r 4~ ~_ls~~-~- ~ lh r , 1 Mtmnrr.u,nunnat¢htr: pa«riptlon ar laurment RIgMa to bt arN: Issue Clrchcve of intermsm Righls:o: Swr Zip: Citr. deaeu: MERCHANDISE h SERVICES ~~ ••, Interment Rights 3 (In<ludex PorpomailHndowmcm Carc otS '-" ) ^_ • Imerment and Retarding Fem T- • purer Burial Comfiner snpvrrr 1 ModdlDmign MateriallColOr -- ~.~..~ • Oates Burial Container lnatailatloa - MEMORIALI7,ATION ^- ` Memorial i~ TyPe/Color _ _ PasigniSiu _ • Memorial Base $uppiitr Type/Color DesignlSiu ~_ • Memorial PerpetualfEodowment Care • Memorial htstatlaUoa Fee • Memorial Inspection F<e ~_ - • Namepl~telScroll • Lettcrtng --'- ~. • Flower Vane ~___.---------- "- Supplier - '-'- TY4eiCoio: Designi Siu ~_ • Vase Base --------~ -" $iZC/Matcrlal Nolm & 4aymem Terms (where appifable): .- Urn -.- ---.-- Supplier - ry4dCoim _. • Admla~raeas~~~e SL1_%•S tst~•rTi~ "~`~1~~ • Other GCS - R~ • Other _ • Other.. _ ____~ • Other _ _....-. --- .__ • Omer __,._-- --.'- -- Other _, - '- •TpTAES. AI.LOWANCE3kTA%ES ^- • Interment Riehu ........................... _.__...-...,..__....._..,... ( ) Reason _~ ---- • Mcnharsdiae/Service...._..........._._,......_..._......_.__....._ l _~- ) Reason ~--- APP)Y to ___ ..-~_ • MerrhnndlselServitt ............ ............__.........._._........._ ( ) Reason _ -° APP1Y to - '""' Suh Total ~!!L~ TMel Taxable _ • Stiles Tex(if ap4licxblel .............___. _,_.. __...,............._ _(y-~ TOTAL CA{S~H P''R~ItC~E/~S t.~~t1:.~ fxv: nown Paymenr~M~.~--_ -i-~"~ Other _ ~ ~- ,/ ~~ ~./~ TorulDownPnymem t`S..ILJ.r;.µl Unyaid Dafanct of Total Carb Price 3~ rnxrxw yon any The Total Cash Price is due and payable as of tyt dau of this Agreement. A delinquency Chnrgt uC _' _ pnretm will bt aswsscJ momht balance not paid wit: in ~ ?0 daYr of <he date of this AgICCment. It less than fail payment is reueivtd, Seller shall deduct the accmN delinquency charge from rht amount received and credit the remainder of the payment to the UnpaidHnlance. Saarrly IaleresR Seller (or is ass,gns) will hsvc a eecuri:y inters icnt~ ~n hr ^~ deli quency barges dmrtan! iveubeen paidsh ePurchhmnr~ Snller't• wrl! «tain tit c to said tmermcm Rights and Me[chandise anti) the `.'oral Cash Price.:og y gins gwing un i. NOTICE: BY aigniag this Agrtamene Puschaeer s agrenng mat any claim Pushnaet ma have a t the Seller shall be rnnlvcd by nrburauon and Pnrchaur+s blather right to a court orjury that az well as bather right oCappeal. !O -8'pi$YI.VANtA RINfR1•L SERVIClS¢ D'IC ~~ zo_iQ-- a~ 10LLilt(Ci cfiEei ~11AEi90f Signed this ~_- day ~~--~"- ' LL i- :Purch~~~ Rcdntianship: e;, --f AcctPted bY~ tn.nr.•n M....• n .«w ror.«.« JF,~ t I /1 ~--~ Relationship: Darr. ice./~ I l ) ~__ / seal Counselor. ~- NOTICE.: See Other Side for Additional Terms and Conditions which are Part of Thu Agreement Form 22D-PA (09107) Distrtbunon Schedule: `Mh~e ~ Cemrxty Copy Yellow a Cusmmec Copy ~1~~61a826 P.~~ TOTAL P.©4 MAR-28-2011 23 52 R~JLLING GREEN CEMETER`( ~ ~ ~ ~~ ~ ~ ~io~ No 804955 CDnuact 524 ~~ ~~ CEMETERY File Folder NamdNumbu AND SERVICES PURCH AGREEMENT The eMenigned• rWr*rd W ° •Wrehaeer•, beRby aanea m parehaae lla Interrt.<tn[ Rights. MerdraaWlu nut Servl<n dewfhed DerNn. suhien to aaeptanee e„d appronl of the [Hare lamed ten WS?. Dertatter reterrod toas'7ettrr'. fire: ~~ I 1_ I I I I 11 Middle ~ I 1 I I I ParcNw: Lau Nemr. I l ~' DOB. Finail: ry ~t Tclephoar i ~ SSH' C _ ~~ae! _J~1 ~ I~ IQ I 1 4 ay'' Ssse, Tin: Addmr Middle Ce•Pwcaaser: t~et None: ~ l l l l l l 11 l.~J Frst' I! 1 1 1 1 f V t 1 1 I 1 ~ I V I I l Telephone. ~~ _ -~ ---- ~ Slue t Zip: AdJttla: l I 11 1 I I L I 1 1 I I I I 1 1 6q. 1 1 1 V I I I I I I! I '~1 P c ~tlllf IA I\ ~' I f 1 1 I 11 Middle: ~ I I I DeteuM: last Namc: I 1 1 1 I I I rQ ,~ DOD ~~ /~_/~_ Aurial Dale: (7 /~'1 /~ Veienn: 009: ~ J_yLJ ~.~v-°' • !Memed•Drano° RIgIW: _1 ~ -- 1 Dtrtrtptian.rtm.rm«,tRlgnat.Den,w: n _N / - --- issue CeNacam of Inlermem RigD[s ra S 2i D late: City: ~ Address: MERCHANDISE & SBRV ICFS 1NTp.RNENT S .r- Urn T-- • Intemtent Righit (Incudts PerpduaUEndowmeat Carc o(S Supplier -___-__ ) ----- _ TypelColur -.--•- • interment acrd Retarding Pees DesignlSirs ~ --- • Outer &vial Container • AdmWProcesaing Pee 1•L •~~ SupPfier Other _j,yi~-,Y..-~4 ..+±gp~CO. . -- Modt1lDeugn Matclaa{/Color Othu - -- • Omer Boriai Container Installation _ ~ Other __. --- ----'"' MEMORSALIZA770N G(1n ,•~/~ Older. 7/w Other ..._- ~ ----~- - _-_. _ _._- - • Memorial _ _ _ L ~ ~'~ ~ S Other ___-- ----.__ - SupDlict i j ' 9 r L .'~.~ t > TOTALS. ALLUWANCFS R 7AXP.5 ^ . . e, f Type/Calarl y..,~ - r ' / ' ~~ ~`~ - Interment Rigbts ........................ ...._. _............__.......,...... (-. _- ) 1t 1 V• Dtaign/Sim C tt -- ~1~ ~/~ M ~s7S'-`>•U- Rtaaon _____.--_.. -- ~ • Nemarinl Anse • ~ ,,~. ~ i i Merehandiae/Servkt..... _-__.. . ) .........._...__._._.,.......__. (.. ~ ~ Supplier ~- ` •, .G,palz.- ' ~`~' t'~ 7ypetColor ~y S Reason "--- ~ a Devgn/Siu ~a T,Y `~ _ Apply to _. ~_ ) • Memorial Perpelarst/EssdowmtPt Care •._--- Merchandise/Strvlw........_ ...... ......._..._.__..._......_.,..._ (_. - • Memorial lrratallation Fec Reuon • httmorial Snspecnan Fee APPIy to Sub Total ~~~ • Nameplate/ScrNl Total taxable ____._ J • Lettering ~ • FlewerVaae~ - M Sales Tar litnppaeabiel...~......- -'-- _.., ^'- ..._-~......~~.~...._....__._._.. '1 i?RICF.SZlS~•Q~ 'OTAS.CASH SuPPlicr -- ~ C ~~~ Li^_S Lest: Down PaYmenl .Zr- e 'rypclCOlnc Other __. ._.-- -- DesgnrSire TanlDOwnPayment (atSA.rD) • Vax Bacc _._ -. _.~ Unpaid 8d ance o[Totel Cash Price S .. Siu/Matcra: __ Notes & Paymmt Terms (when apptkable): -- The Total Cash Price is due and payable en oE1he date of this Agreement. A delinquency ebatgt of _-- percent wilt be esccsaed monthly nn any betance not paid wirh;n 30 days of the date of this ~gr<ement. 1f less than full payment is rccetvcd, Setter shall deduct the accrued deiinduency charge Erom the am°um recuvcd and credit :hc :emainrY r oru4e paymentto the I!apg d Balance. g g pure Stxurit bneresC Seller (wits assi ns) wilt have a stcuriry inrtrut in the Interment Ri Ms and Marchandise bein Maed as descuhcJ anove. Sellec will retain title to sold Intermem Rights and Madmndise until tae Total Cash P1hce.angciFae'rm Purchaser may ha~r: againa m<ef a-er shall b<rcsolved q' arb uawn and Pomhnaer rs giving op NOTICE: ey signing tF.is Agreement, Purchaser is agredng Y his~her right m a caarl or jury tr 1 as well sa hislher:fight of appeal. 3C1 PB'1N511VANIA RJ41BtAl 56tVIQS, WG '~`~ 'B_5.1,~ pba 0.0U,Il~Gt GAFl31 Signed this ~~day of _ . - ~ an~h;p.. ri ~ -- Accepted by~ nte.w^. al a«vmrn~mr><a,..r•••a:ra~^ NPvrchaser: ff~~f~ )y'7~` Co-Purchas Rtlationshlp Date: }-mil '~' L '~li _. Counsel '- NO 1CE: See Other Side for Additiufwl Terms and Cotditioac which me Part DCL'bis Agreement DIRSIDUdw Schedule, W bite = Ccmony C.,py: Yellow = Cusromer Copy Form: Z20-PA (05107) ?17614826 F.03 MAR-21-2011 00 13 ROLLING GREEN CE"?ETERY 7177614826 P.02 yei a~ut. soya : ~c~ s~t~Pa ~cni ~ ~~ -eo6a N ~ 8 0 4 4 9 6 ~cntract 6R4- `c, 4 ~ ~a Fill Folder Neme/Number CEMETERY INTERMENT RIGHTS, MERCHANDISE, AND SERVICES PURCHASEISECURITY AGREEMENT ne Olan DDODCTi t A ( IL`NMW11lCNT /• A Q ri The undenietwd, rekrrtd to w'Purehaaer', hertay agree b purchase the Iatnmu RlghUr Merenaadl•e aM aerrko described hertm• ao}ecr to aaeptanee sad approval ar rho above named cemetery, hexafur rtkrred to ts'Seikr'. e ~' • a u t PureMaer. Last Nam I , 1~ '+ - - a ~ I I I{ I I I Firc' ~~{'I\ {t1t ~I t11 I! 1( l Middle: ~1 1 J I 1 I ~~ -~ Nr yyyyr/ 5 ? •~.~ ~ t t ~ ~ Tctephaw: t t\ i r 1aLLr~ ~4~] S1LE: ~ •~Ti~ DOB:.~~_--_~ F,m•it. Adarese: I k 11. I I i 1 cuy: s.re: rp: Co-Purcha•er: Vu Name. I 1 1 4 1 1 1 [ 1 1 ! 1 1 1 1 ~rsr' I V V i l l t I 1 1 1 1 Middle: I I I ! I I I SSN: hone: T l J FinaVi: DOH: 1 ~_) __ e ep _ , ' Addrc"` I l l! '~ 1 1 1 1 1 1 1 4 1 1 1' 1 1 1 1 1 1 4 1 1 Cay' { 1 1 1 1 1 1 1 i~ 1! {gate. ~ ~ Z.ID: Dettared: Case Name: ~l ~. i 41 I I I I I t ! { 1 I 1 I I Puss: t Middk: 1` I { I i 1 ~_Q~ aarialDart: (1 !~~_ ~<~rmn:p OOe: (~ /1~5~... DOD'~>~ DeMrlptton oflmarmeut RiBhL to he wed: {~. ~~ • a n / ~ Memor/•IWlioa Ri8a4: 1. r' tame Cn:ifcam of lnwnnem Righa io: _~T .tddrecc: City: State: Zip: INTERMENT MERCHANDISE & SERV ICES • ]nterment RighLS S Urn (includes Perpetual/Endowment Care o(S ^~ ) t•~~ 00 Supplier • Interment amt Recording hers Tn~ . TypefCnlor • Outer Buriul Container _ ~_ Desiga/Siu - Supplier Adminlpromsfng Fce ._ ~_ Mcd<1lDesign Oihtr Maerial/Color Other • Outtr Burial Camninv hastnllntion ~- ._ O[Acr MEd10R1ALI'LATION Other • Memorial -^ O[her Sapplia Other _._.-..._.._._ Type2oWr TOTALS. ALLOWANCES&TAXES Design/Siu _ Interment RIgh4 ..............................__....__...........,........ ( ) -^ • Memories{ Base Rw°an .-_ Supplier Mercharidtx/Servke._..._._.__ ......................................_ ( ) TypUColor Resaon IksigniSiZe APDIY t° ~~ • Memorial PerpetuailBndowment Gtr ) Mttthandise/Serviee__._...__..__......_____......._........_ ( • Memurial Installation Fee Rcaaon • Memorial lnapection Fee - •SPply tO Q~ • NameplmrBcrWi _ -~ Sub TtNal if-+~.Y---- • Lettering ~_-. ~• Totsl Tnaahlt - • Flower Vau ., _ .. .... _....._....._._._ ^"- • Salts Taa (If applkahk) ~ Suppiirr C F~ n,I n,(TnOTAL CASII_ PRI S ~Q 1 C w Type/Cnbr Less: Down Paymrn_ ~, } `'>- - Design/Site ._.- Other ~"-- ~ • Vase Bas< Totei Down payment ( ) Size/Material Unpaid Htdanee of Total Caah Prke S N•Hes & Yaymem Terms (where appifeshle): ~ TERMS i ) TF.< 1'ornl Cash Price is due and payable as of the da ;e of :Ais Agree ant. A del ltquency charge of _ percem will be asaessed monthly on any bilantt ant paid whhin n 3U Jnys of Ilia dam of ln~s Agremeut. If leas roan full paymemt is r<cencd, Selkr shall deduct the accrued delinquency charge rrom Ilia amount recmved and credit the rcmainJer of [hc payment to the Unpaid Balance. Security Interest: Seller (or i[s ossigns) will have a sccuray imerest in the lmerment Rights and Merchandise being Dun;hased as descriheJ above. Seller will retain title to aid Interment Rights and Mcronandisc anvil the Tota (Cash Price, tngethtr with any delinquency chargts thereon, have been paid by Purchaur to Setter. ` NOTICE: Ay signing this Agreement. Purchaser is a greeing that any claim Pumhaur may have against fie Shier snail be rendvcd by nroivation and Purchacer is giving up I pis/hrr:ieht toxcourt or iury vial as well as his/hu rightof appaal. Signed this a-~'~- day o ~ ` , 20~t 1~.L_ sa re•INSVCVrd•11k Furleaa.L seRVl~se 1NIC. dlro ROILING G3tffi'! CE~AEIBIY ~ ~ ~~'~"''R~tl ationshi Accepted by. ~ ` ~P~uchascr. ~~ P i5'A+-~?U'GS i A ~n„~•m~a, t«.nv~r ~ Cn-Purchas • • RelatiomsfilP: - Date1~ ~ `!•aJr '~~ Catnue _~~ O'T1C .See Other Side for Additional Terms and Conditions which art Part of This Agreement Fur:n: 3.U-PA ;US/U7) n~.vhvunn scneamr-what = ecmera•r'=aDr: veunw. cusmmer copy TOTAL P.O T;,KE GnDER _ _ - _ _ - - - - - ICFTTLJ RIGiiT- ~^2 ~~\` 2 3' - s a 5- _ _ CLGCKWiSE seavEa v ~~ ' ~' ~ < ZOO ® Qs 6 5 OS ~ O 8 S aer"•ef ~~~~ Guests Date ~ APPT - SOUP/SAl -ENTREE - VE~/P07 - DESSELiT - BEV 1 l f ~ f ~.., ~ i~ ;.t-~ 2 5 ~ U~c?C,~,L.: ~ ±;,~ /"~~u...,i~ tom, '~-~ _, :.~.. ~. „ . ~ 6' L~ ~ ~~CL~•'. Y .L ~ L.G...ni lit, `'~ ~.1 •-'r 7 ' ~ ~ ~ Ss o^~~ ~,.a,J 9 ~ ^•`~~, ('~ ~ ',~ . J~~~k~ t~~ ~i'1 ft .1.,- . xZ,/[': V 11 I 12 ~ 13 14 I ~ f i `-`75I ~ Coffee Tee Miik i I Lr~ J~ ~~~C,~,~ ~ / Faod . ' ~~ ; t~3 Beverage I J, S- ~? t t 0 ~ ~ L~ ` ~ ~-~ ~ j'_ ~~Zr~ (r7 J - - - T - - -- Cate ---- Amount __ - - ' - QC V~~~~s /~'~`- ~~ ~ G~ ect ,,/~~ / Page 1 of 1 ~:: -HealthPort_ Notice Date 02/03/11 SEND CORRESPONDENCE ONLY TO: P.G. Box 1812 Customer No. 1417980 Alpharetta GA 30023-1812 IIIIII'I II ~'lll III'I III~I IIII I'II 515 Federal Tax ID: 58-2659941 R MARK THOMAS 101 S MARKET ST REMIT TO: HEALTHPORT MECHANICSBURG PA 17055-6328 PO BOX 409740 ATLANTA, GA 30384 DELINQUENT NOTICE AGED BALANCES . ~ .. • ~ .. ~ • . - ~ • . Total Due USD 105.79 .00 105.79 .00 .00 Please be advised that your account is now past due. You are receiving this letter because our records indicate that you have failed to pay for requested medical records. " after invoice indicates a prebill invoice. Records are being held until payment is received. ,. .~ • ~ ~ ~ SIMS HAROLD 0083270748 12/11/10 84 HMG-CONNER RICH ASSOCIATES 105.79 105.79 ^ DOB 061352; SSN *"y'**6567 TOTAL AMOUNT 105.79 ' ~ • ' ' , TOTAL REMITTANCEUSD Fast. Secure. Free. HealthPortPay is a free, online payment processing service that provides you a fast and convenient way to pay your HealthPort invoice. You can now pay your HealthPort invoice by visiting www.HealthPortPay.com which provides options to pay by ECheck or your major credit card. For questions, please contact The Collection Group at 800-303-8049 or 770-360-1767 aaoaoo.zo~?ozo2aiaoi oos~s The Fatrio±-News Co. 812 Market St. Harrisburg, PA 17101 Inquiries - 717-255-8213 ~,he ~latriotDews Now you know R. MARK THOMAS ATTN: JOETTE L. MCGOWEN 101 SOUTH MARKET STREET MECHANICSBURG PA 17055 THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin} ss Joseph A. Dennison, being duly sworn according to law, deposes and says: That he is the Assistant Controller of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market Street, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, 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 daily and/or Sunday/ Metro editions which appeared on the date(s) indicated below. That neither he nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book "M", Volume 14, Page 317. PUBLICATION COPY This ad # 0001946198 ran on the dates shown below: February 11, 2009 February 18, 2009 ESTATE.NOTICE ~ ~` ` February 25, 2009 Letters of Administration on theEs - tate of Harold Thomas Sims,. late of New Cumberland, Fairview Township, York {/ ~--~, County, Pennsylvania, deceased, have - /Gl~ ter. -~~-yy . • ~ , been granted to the undersigned, all Per = ~' ~,J sons knowlny lhemseNes to be Indebted /// to said estate will make Payment imme - diatelyand ttwse having claims will present them for settlement to: SWUfn to and subscribed before me this 26 da~i of E'ebruary, 2009 A. D. Adele M.Slms,Adminlstratrix !, ~ c/o R. Mark Thomas, Esquire ' r, ~ ~ 1O15outh Market Street ~ ~--" Mechanicsburg, PA 17055 ~ ~`.~ - ", ~ ~il __ .L ' ' R. Mark Thomas ~\ 1 ~ ~V` ( ~ ~--~~- , ~ ~ ~~ ,offs utnl~vlaketstreer '- Notary Public Mechanicsburg, PA 17055 CL'AAMOSVWI:ALTH t~F P~~{NSYLV/1i~1iG Notarial Sea! Stlerrs L itisrter, ~9otary s~ubli;, l Cry t:7f ~rti~bcN*a; iJaupMn County 1Ay Cornrrti>~ton moires Nov. 26, 2011 Memt)er, Pennspl+~attia Asaa~.l~tl~n of Notaries The Petriot-News Co. 812 Market St. Harrisburg, PA 17101 Inquiries - 717-255-8213 R. MARK THOMAS ATTN: JOETTE L. MCGOWEN 101 SOUTH MARKET STREET MECHANICSBURG ACCT # NAME 35242 R. MARK THOMAS 35242 R. MARK THOMAS 35242 R. MARK THOMAS 35242 R. MARK THOMAS c~he~latriot•News NOw you know PA 17055 INVOICE ALL CHARGES ARE NET AD ORDER # DATE EDITION ADDTL. INFO. 0001946198 02/11/09 METRO WEST Harold Sims Estate 0001946198 02/11/09 METRO WEST Harold Sims Estate 0001946198 02/18/09 METRO WEST Harold Sims Estate 0001946198 02/25/09 METRO WEST Harold Sims Estate TYPE OF CHARGE AMOUNT BOLD TEXT CHARGE 84.00 BASIC AD CHARGE 544.08 BASIC AD CHARGE 844.08 BASIC AD CHARGE 544.08 AFFIDAVIT CHARGE 55.00 TOTAL: REMITTANCE ADDRESS The Patriot-News Co. 23794 Network PL Chicago, IL 60673-1237 Please include the Accoun# # or Ad Order # (above) with your remittance--Thank You $141.24 NOTE: This Invoice replaces the Order Confirmation which we previously sent with Proofs of Publication PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: Februar~l3 February 20 and February 27 2009 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Lis Marie Coyne, Edito SWORN TO AND SUBSCRIBED before me this 27 day of February, 2009 Notary / Sims, Harold Thomas, decd. Late of Vew Cumberland, Fairview Township, York County. Administratri_x: Adele M. Sims c/o R.:~~Iark Thomas, Esquire, 101 South Market Street, iVlechanics- burg, PA 17055. Attorney: R. Mark Thomas, Es- quire, Attorney at Law, 101 South Market Street, Mechanicsburg, PA 17055. ~:., 10?AR AL SQL CE30RAH A COLLiNS Nctan,~ Public CARLISI~ BCRO, CUMSERL.AND COON?`! "i1`,~ C~rr:nission G;<pir~s Apr 28, 2010 1 _..~.._ .,.,.,a..,~,.._, .~, CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249166 Fax: (717) 249-2663 February 27, 2009 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: R. Mark Thomas, Esquire Harold Thomas Sims Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: February 13, February 20. and February 27, 2009 Advertising Cost Proof of Publication Second Proof Request Payment received Total Amount Due $ 75.00 $ 0.00 $ 0.00 $ 75.00 $ 0.00 Becky H. Morgenthal, Executive Director R. MARK THOMAS Attorney at Law 101 South Market Street Mechanicsburg, Pennsylvania 17055-3851 Telephone: (717) 796-2100 Telefax: (717) 796-3600 January 20, 2009 New Cumberland Police Department 1120 Market Street P. O. Box 220 New Cumberland. PA 17070 Re: Estate of Harold Sims Accident Report -Incident Number 2008-94 Dear New Cumberland Police Department: Please be advised that I represent the Estate of Harold T. Sims, deceased, who died as a result of being struck by a car on December 22, 2008. As counsel for the estate, I need a copy of the police accident report which would have been prepared following this accident. Enclosed is a check in the amount of $15.00 to cover the cost of this accident report along with aself-addressed, stamped envelope. Would you kindly forward to me a copy of this accident report? If you need additional information, please contact me at ~~our convenience. Very truly yours, R. Mark Thomas RMT/jlm Enclosures cc: Adele M. Sims, Administratrix OFFICE OF THE CORONER MICHAEL L.• MORRIS CORONER TODD G. ECKENRODE CHIEF DEPUTY CORONER Cwnhrrland County. PA C~ Y Coroner's Office RICHARD C. MIDDLEKAUFF DEPUTY CORONER MATTHEW S. STONER DEPUTY CORONER MARLIN R. MCCALEB SOLICITOR CUMBERLAND COUNTY 6875 BASEHORE ROAD, SUITE 1 MECHANICSBURG, PA 17050 PHONE 717-766-641 8 FAx 717-766-641 9 27 January 2009 R. Mark Thomas, Esquire Attorney at Law 101 S. Market Street Nlechanicsburg, Pa. 17055-3851 RE: Harold T. Sims Coroner's Case #31-418 Dear Mr. Thomas: Enclosed, per your request, are certified copies of the Coroner's View and the Toxicology Report for the above-captioned case. Your firm's Check #2199 in the amount of $100.00 has been received and has been recorded as payment-in- full for the information contained in these reports. If you have any questions, or if you require any additional information with regards to this case, please don't hesitate to contact me. Respectfully, Michael L. Norris Cumberland County Coroner N1LN/mmn Enclosures RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland County Prothonotary's Office Receipt Date 12/21/2010 Carlisle, a 17013 Receipt Time 12:17:22 Receipt No. 252676 SIMS ADELE M ADMINISTRATRIX (VS) O'DONNELL MARY C ET AL Case Number 2010-07816 Received of PD ATTY THOMAS RL Total Non-Cash..... + Total Cash......... + Change ............. - Receipt total...... _ 92.00 Check# 3060 .00 .00 $92.00 ------------------------ Distribution Of Payment -------- -------------------- Transaction Description Payment Amount WRIT CF SUMMONS 55.00 CUMBERLAND CO GENERAL FUND TAX ON WRIT .50 BUREAU OF RECEIPTS AND CONTROL SETTLEMENT 8.00 CUMBERLAND CO GENERAL FUND AUTOMATION FEE 5.00 CUMBERLAND CO AUTOMATION FUND uCP FEE 23.50 BUREAU OF RECEIPTS PND CONTROL $92.00 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 8/11/2011 Cumberland County - Orphans Court Receipt Time: 09:36:49 One Courthouse Sgware Receipt No.: 1046323 Carlisle, PA 17613-3387 SIMS HAROLD THOMAS File Number: 2009-00047 Paid By Remarks: R MARK THOMAS HMW ------------------------ Receipt Distribution ------------____________ Fee/Tax Description Payment Amount Payee Name SATISFCTN OF CLAIM 10.00 CUMBERLAND COUNTY GENERAL FUN Cash $10.00 Total Received......... $10.00 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 2/18/2010 Cumberland County - Register Of Wills Receipt Time: 11:22:59 One Courthouse S~uare Receipt No. 1060030 Carlisle, PA 17 13 SIMS HAROLD THOMAS Estate File No.: 2009-00047 Paid By Remarks: R MARK THOMAS JN ________________________ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 4.00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash $4.00 Total Received......... $4.00 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 1/15/2009 Cun;berla.nd County - Register Of Wills Receipt Time: 09:33:31 One Courthouse S uare Receipt No.: 1055382 Carlisle, PA 1713 SIMS HAROLD THOMAS Estate File No.: 2009-00047 Paid By Remarks: cJMS/THOMAS ________________________ Receipt Distrib ution ----- -------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20.00 00 16 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN SHORT CERTIFICATE . 00 10 BUREAU OF RECEIPTS & CNTR M.D JCP FEE FEE ~ . AL FUN r AUTOMATION 00 15 CUMBERLAND COUNTY GENER BOND ~~d --------- . ------- Check# 809/2184 66.00 00 66 Total Received......... . ,,,p ~ ~~- ~a u~/~'`O~`~ GEC ay ~~~~ s~~~ . ~~ c~~ Cam. C~ r1 ~ ~ ~~ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 SIMS HAROLD THOMAS Estate File No.: Paid By Remarks: 2009-00047 R. MARK THOMAS HMW ------------------------ Fee/Tax Description SHORT CERTIFICATE Cash Total Received......... Receipt Date: 3/22/2011 Receipt Time: 14:11:33 Receipt No.: 1064878 Receipt Distribution ------------------------ Payment Amount Payee Name 4.00 CUMBERLAND COUNTY GENERAL FUN ---------------- $4.00 $4.00 v " V RI 1'f1 [1.t !"~ ^^ O O O t.I7 r :^ W ,7 r L.fl l.Ti .L7 r Q~ r 01 X97 i \ \\ ~ ~ ."i M1, JrryL• ~. 1 ~ ~ ~,' R ~ ~ ~~ n p , ~ -p O .A O ~ ~~ i l7~ -f c°, n 3~~ N O c m O N o• m j n~ 3 N ~+ 2 D ~ O ~ c Dtn~ ~ z ~ ~o _ ~-r 3 W ~ r ~ o nD~ ~1 O ~ m t/1~S ~ 07 7C O v7 ~+ ~~ Cm3 V7 N -~ ~ ~ D O 0~ ~ ONN ~ o~~ ni "II-~ N o i~ ' D O ~ O D V ~ O 1.11 L 0 69 X- O O ~o c O N ~ "'{ O H OZ 3 3 .-~ m x H D ~ ~ N n C7 ~ N O N o O N n v W a T' ,~ ~ or -+ ~ w z ~ ~ •° o -o r Z C'1 1.17 m ~ O ,~~ D a •ikt ..~.i Ti Adele M. Sims, Administratrix 1007 Bridge Street New Cumberland, PA 17070 May 24, 2011 Internal Revenue Service Atlanta Service Center Atlanta, GA 39901-0025 Re: Harold T. Sims, Deceased SS No. 187-42-667 Form 1040 Years 2005, 2007, and 2008 Dear Internal Revenue Service: As Administratrix of the Estate of Harold T. Sims, deceased, enclosed please find a check in the amount of ~4,863.3~ as payment in full for years 2005, 2007, and 2008. I know that he was audited for 2004 and owed for taxes for 2004, but this notice does riot address 2004. Although he had been making pa,~ments for some time at $250.00 a month, it is unknown to me if 2004 was paid in full. Please advise. Additionally, I received two notices on May 14, 2011, one stated this needed to be paid by'~Iay 8, 201 1, and the other stated it needed to be paid by May 9, 201 1. As Administratrix of the estate, I would like to make sure all the taxes are paid, so that I can close the estate in the near future. Very truly yours, C~ Adele M. Sims A_'VIS/jlm Enclosures cc: IRS -Andover Service Center Account Transcript 187-42-6567 1040 Dec. 31, 2007 SIMS FORM NUMBER: 1040 TAXPAYER IDENTIFICATION NUMBER: 187-42-6567 HAROLD T SIMS ~~ Pagelof2 ~iv~ , ~~' x'13 S~ ~ -~=' ~ ~ Request Date: OS-18-2011 Response Date: 08-18-2011 Tracking Number: 100107475390 TAX PERIOD: Dec. 31, 2007 --- ANY MINUS SIGN SHOWN BELOW SIGNIFIES A CREDIT AMOUNT --- ACCOUNT BALANCE: 0.00 ACCRUED INTEREST: 3.81 AS OF: Jun. 20, 2011 ACCRUED PENALTY: 0.00 AS OF: Jun. 20, 2011 ACCOUNT BALANCE PLUS ACCRUALS (this is not a payoff amount): 3.81 ** INFORMATION FROM THE RETURN OR AS ADJUSTED ** EXEMPTIONS: O1 FILING STATUS: Single 36,352.00 ADJUSTED GROSS INCOME: TAXABLE INCOME: 27,602.00 TAX PER RETURN: 2,583.00 0.00 SE TAXABLE INCOME TAXPAYER: 0.00 SE TAXABLE INCOME SPOUSE: 0.00 TOTAL SELF EMPLOYMENT TAX: RETURN DUE DATE OR RETURN RECEIVED DATE (WHICHEVER IS LATER) Apr. 15, 2008 Jun. 16, 2008 PROCESSING DATE TRANSACTIONS CODE EXPLANATION OF TRANSACTION CYCLE DATE AMOUNT 150 Tax return filed 20082308 06-16-2008 $2,583.00 09222-113-17123-8 04-15-2008 -$2,100'.00 806 W-2 or 1099 withholding https://eup.eps.irs.gov/PORTAL-PRODi psc/CRM/EMPLOYEE/CRM/c/TDS _MENU_IR... 8/ 18/2011 Account Transcript z x 3 z v 7 s s U 4 E-~ E-~ 00 ~, 0 0 ~ ~ N N A O Gil ~ n ~-+ '~' C C C O v'i ~i N N ~ ~ m a Hz d LLI c ._ .~ ~ a y 4 . ~~ ~~~ o ~~ ° 3 3 o *-+ r ~+ '" 4 ~' ' '~ ~~ ~ ~ ~ ~ ~ Q o00 0 0 '~ , : o ~ a~ o ~i ~ z ,~~ oo °o, o °c, ~ ~ ~ ~ ~ ~ 8 8 ~ `" ~ U ~ ~ ~ A v ~ ~n ~ H a q ~~ ~~ v ~Q ~~ U z oA ~~ c~ ~ ~ ~~ p0 ~~ w ~~ ~ ~ ~ N W ~ FFF111 ~M! }ptp~ C"' ~ t ACCOUNT DATE TOTAL ~ ~ ~ ^ ~Om~jas l® NUMBER DUE AMOUNT DUE ~ ^ 09547 234203-01-9 ON RECPT $7.45 / Indicates the Oomcast Visit us on the web at services you subscribe to www.~~omcast.com How to reach us... HAROLD SIMS For service at 18 ROSS AVE APT B NEW CUMBERLAND PA 17070-2610 News from Comcast We regret losing you as one of ourcable subscribers. Our records indicate that the final balance shown above is now due. Your prompt payment is appreciated. Any outstanding equipment must be returned to our office within 7 days. Please call us at any time should you wish to reconnect your service. Hearing ! Speechimpaired Call 711 How to reach us: 4830 Carlisle Pike, Suite D-14 Mechanicsburg, Pa 17055 (717)540-8900 Telephone Customer Service 24 hours a day, seven days a weak Summary Of Charges Statement Prepared02l07l09 Billed from 02/18/09 114.82 Previous Balance 1Q0.94 cr Comcast Cable Television - 6.43 cr Taxes, Surchar es & Fees Total Due $7.45 Detail of Charges ort back COMCAST CABLE Please detach and enclose this coupon with your payment. 1555 SUZY STREET Do not send cash. Make checks payable to: ~omcas~~ LEBANON PA 17046-8317 COMCAST CABLE Date Due Total Amount Due AMOUNT ENCLOSED ADDRESS SERVICE REQUESTED ON RECPT $7.45 ~ #BWNMZNH #PIEDGBCDBPCPA7# ____- manifest line -------- I„lilll„i,1,i,il,llllllllllll~lli,nlil„Ilinl,llrlllnrlil~ HP,ROLD SIMS R. MARK THOMAS 101 S MARKET ST MECHANICSBUR6 PA 17055- 030-02-09-C-D Account Number 0957 234203-01-9 I.,lilllrri,I.i.ll,Illllllillll~ui,Inil„Ilinl~lirlllnrlil~ COP~ICAST CABLE P 0 BOX 3006 SOUTHEASTERN PA 19398-3006 09547 264203 61 9 2 600745 PO BOX 189 CARLISLE, PA 17013-0189 Return Service Requested ~wU ~s~ __ m-~~- i ~~ ~ ~ ~~ -c~ c~~c~` ~~ TORRES CREDIT SERVICES, INC. 27 Fair~~ie~~~ Stree PO ox 89 - ~; PA 17tH ~-31 (~ 1' ; ?~,-8424 ~, 86617 ~ 6-680 Client Name: UGI UTILITIES INC For: Client ID : 21 ~ 14~8~7060 1 ?980 % 10 Acct. #: 220486 TOTAL DUE: $426.60 May 29, 2009 {u~~~~n~~~~nn~~~n~~~n~~un~~ni~i~~n~i~{nnu~~n~~~~ Harold Sirns-2204851 101 S MARKET ST MECHANICSBURG PA 17055-6328 Prone Hrs: Sam- l Opm EST M-Th 8arn-rpm EST Fr Sam-noon EST Sat Office I-h-s: B:OOam-rpm EST M-Fr ~~ T C~f~ "l- u.~ -~ L bear Harold Suns. ~~~~ ~' Your account has been listed with us for collection. Please remit your check or money order in the amount of $436.60. For ~~our con~~eiuence «-e ha~~e enclosed a return en~-elope. All pa}'menu must be made directly to this office for prompt credit to your account or call toll free at 866-7~6-680 ~ u~ make arransements. Unlcas ~_ ou notifr this office within 30 days after recei~-ing tl>;s notice that you dispute the ralidit:~ of this debt or any portion thereof. this office «~ill assume this debt is ealid. If you notif~~ this office in ~tiriting ~ti~ithin 30 days from recei~~mg this nonce; this office «ill obtain ~-erification of the debt or obtain a copy of a judgment and mail you a cope of such judgment or ~~erification. If ~~ou request this office in ~~-riting «~ithin 30 days after recen-mg this notice. this office «~ill pro~-ide you ~~•ith the name and address of the original creditor, if different from the cun-ent creditor. This is an attempt to collect a debt. Any information obtained will be used for that purpose. This conununication is from a collection agenc~~. Sincerel~~- Torres Credit Services, Inc. TO PAY" BY PHONE USING YOUR CREDIT CARD OR CHECKING ACCOt?NT ~ PLEASE CALL 1-866-7~6-6803 0 To assure proper credit to your account, return this coupon ~~•ith ~-our payment. If requesting a receipt, please enclose aself-addressed stamped en~~elope. IF YOU WISH TO PAY BY CREDIT CARD, FILL IN THE INFORMATION BELOW. (CIRCLE ONE) VISA .~ / MASTERCARD ~ ,DIGIT SECURITY CODE (BACK OF CARD) ACCOUNT # ~ - ~ EXP. DATE CARDHOLDER NAME BILLING ADDRESS- PHONF_ NUMBER (_ SIGNATURE Client ID #: 21 ~ 14~8~7060 19980710 TORRES CREDIT SERVICES. INC. PO Box 189 ,' ~~ Carlisle, PA 17013-0189 ~~~ (~~ Harold Sims-2.204861 May 29, 2009 1 ENCLOSED IS MY PAYMENT IN FULL. TOTAL DUE: 5+426.60 ~ ~~~~~ ///qr(//~D ~Q~ r HOD0010C-0529D300256N-J X03-2 2047 `, ,15 :-E:R~ ICE RE(Z~-ESTER _ #BWNDVFW U1 s '~ ~#2~0908-409636# HAROLD SIMS-ESTATE ATT -RMARK THOMAS 101 S MARKET STREET MECHANICSBURG, PA 17U»-6328 Client Name: Pp&I Electric Utilities Client Account: 72810820(13 1~ ~~ ~. ~~~ a, ss - ^_saa March 30. 2009 Amount Due: 5204.7~t Account Balance: $2114.74 Your past due account has been placed with this office for pa}~ment. Unless you notify this office within 30 days after receiving this notice that you dispute the vulitlity oI'this debt or um portion thereof, this office will assume this debt is valid. If you notify this office in ~~ ruing ~~'ithin 30 days tYom receiving this notice that you dispute the validity of this debtou h}ud intent or ~~erif'ication.`~Ifl~outreque.tlof thrsnofi'ice in writ ng obtain a copy of a judgment and mail ,you a cop. o J b within 30 days after receiving this not ~s commun catilontfro tin a debt collector iss an attempt to c~llect atdebt and un~~r, if different from the current creditor. Th information obtained will be used for that purpose. ACCOUNT REPRESENTATIVE (412)03-9230 SF`E F_F'E'EFWE SIDS' FOR IMPORTANT IN~'O~!"!=~'fIQN 01 RETURN THIS PORTION WITH YOUR PAYMENT HAROLD SIMS-ESTATE ATT -R.MARK THOMAS 101 S MARKET STREET MECHANICSBURG, PA 170»-6328 Pp&1 Electric Utilities Account # : 24-0908.10963 Balance: $20-4.74 ~) ~0 ~~ ~~ - ~~ s g6G _ boo IF PAYINO BY PISA OR MASTERCARD, FILL OUT BELOW ~ ,~~ ^wsa !~~ ^MasrEacaao !~!~!~ ~. ~~ ~~ ~~ HONEI+'~ area coEe) 6H3NATUi1E CBCS 24 P.O. Box 164U~9 Columbus. OH 43216-409 I~I~~LJ{~~~LL~~II~II~~~l~~III~~~~{~LLL~I ..~.~o~ -,nnn~nu74 Billing Date: 01/25!09 Page 1 of 6 Telephone Number : 717 774-8547 V@~''~/'~ Account Number: 717 774-8547 148 33Y ~Tr'~~ HAROLD T SIMS ' Account Summary FIOS DVR Free for First 6 Months! Previous Charges $ 46.55 Get a HD DVR or HD multi-room DVR FREE No Payment Received .00 when you sign up for FiOS ®TV, 46.55 Internet & phone by 2/21/09 (install Past Due Charges (please pay now) $ by 4/21/09). 245+ digital channels, up to 10/2 Mbps speeds. & unlimited calls New Charges - $99.99/mo plus taxes & fees with a 1 Verizon (page 3) $ 23.54 year agreement. Call 1-877-424-1883. Subj. to availability & restrictions. Total New Charges Due Feb 19, 2009 $ 23.54 Total Due $ 70'09 FiOS The Most Amazing Picture. Period. Verizon FiOS TV. Only $47.99/mo Enjoy the most amazing picture quality at a great value from Verizon FiOS ®. Gef over 245 digital channels and - crystal-clear Hi-Def channels for only $47.99/mo (plus taxes & fees). Order at 1-877-424-1871.Offerends 2/28/09. Subj. fo availability & restrictions. FiOS For More Speed and More Capability Get Verizon FiOS at a Great Value Switch to Verizon FiOS ®Internet for fast download and upload speeds. Get Internet speeds of up fo 10/2 Mbps for only $44.99/mo plus faxes and fees with a 1-year agreement. Order at Questions about your bill? 1-877-896-1377. Offer ends 2/28/09. Visit verizon.com or call 1-800-VERIZON (1-800-837-4966) Subj. to availability & rest»ctions. Change of billing address? Go to verizon.comibillingaddress or call us. ~ Detach & return payment s6p with your check_ payable to Verizon. _________~_______________________ 210"HBRDAI Account: 717 774-8547 148 33Y ono3otol ITOOOO19a3as 33-PA P160 New Charges Due: Feb 19, 2009 n%%%aasa% zoo%o~o~ veiri-Zn 012 5 0 9 Total Dus: $ 70.09 Yesl f want to be a Literacy Champion. ^ Sign me up fora $1 monthly donation Amount Paid fo Verizon Reads. 00030101 01 AV 0.324 ECP02711 0145 HAROLD T SIMS 18 ROSS AV FIR 2 NW CMBRLND PA 1 i 070-2610 19'1'I~aininlllllll~I~lilnllllili~~11l~'ll'I~~nnlll'~il~III~ ~ ^o~^ Verizon PO BOX 28000 LEHIGH VALLEY PA 18002-8000 L,~IIi,~l~ll,~,~~nn~~~~~u~~~~~n~~in~~nnn~~~ ],0971707748547148802802164000006000000465570000007009400000 WEINBERG & REIS CO., L.P.A. DETROIT, biI BROOhLY~ HTS, OH ELTMAN, 248362.6100 216.739.5100 Attorneys at Law CHICAGO, IL 323 W. Lakeside Avenue, Suite 200 GROVE CITY', OH 312.782.9676 Cleveland, OH 44113 ~ (216) 685-1001 (800) 807-7796 ' 614.801.2600 CINCL~" SATI, OH (216) 363-4086 (fax) PHILADELPHLY, PA 5li.7232200 - _pm ST Ion=Tf~urs 8a"'~~ m-6Pm~ r ~ 215.599.1500 CLEVELA\"D, OH www.weltman.com _ PITTSBC~tGH, PA 216.685.1000 412.434.7955 CoLImlBtis, off 2009 March 12 614228.7272 , To The Estate of: HAROLD T SIMS 18 ROSS AVE NEW CUNiBERLND, PA 17070 ~: The Estate of: HAROLD T SIMS ~ ~'u/J ~~~" ~ _~. Creditor: HSBC CARD SERVICES 1530 ~/Q~ ~ l~~ ~~ •' Client Account No. t/` ~ Balance: $1,600.23 ~ ,9 ' ~~ Our File No.: 7346302 t l~~,l~ (/ Dear Personal Representative of the Estate: /~ ~j f /,~,~C~ ~ ff ~ ,~L` ~~`' V I ~ ~.'1/+~ "V Please be advised that this law firm representEs VICES was curredlby HAROLD T SIMS.e above-referenced 1 account. This account with HSBC CARD S In an effort to encourag'a prom nt o be ore OS/10/20091as settlement m fu1L In oBder tto onfirm yourEaccept nce of to accept the sum of $1,_80.00 0 this offer, please contact our office. If the amount of $1,280.00 is received on or before 05/10/2009, then my client's claim against the Estate of HAROLD T SIMS will be deemed satisfied in full. Enclosed for your convenience is a postage-paid envelope to remit your payment in should this offer be acceptable. Should you have any additional questions, please feel free to contact us by using our toll-free number: 1-800-807-7796, ext. 1017. The Estate may be required by law to reportces this manthavenoroany roeport~requirements hat mlay be impo don make no representation about tax consequen y our client. You should consult independent tax counsel of your own choosing if you desire advice about any tax consequences, which may result from this payment. me ely, a a ~~~~~v Probate Specialist Ext. 1017 This law firm is a debt collector attempting to/ /collect thi ~ebt for our client and any information obtained will be used for that purpose. ~ g ~ _ (e 9' 7 ~Q ~ ~ 6>1 / 8564562 ~ ~ ~ ~~X/(~" ~~~ ~~ G~~~'~`G~ ~~ ~ ~ ~~lD a 1 aSS- D©o/ ~~ ~~ services 4150 OLSUN MEMORIAL HIGHWAY, SUITE 200 MINNEAPOLIS MINNESOTA 55422-4811 TELEPHONE 763-852-8620 Fax 877-326-8784 TOLL-FREE 877-326-5681 July 28, 2009 Account No ************6679 Dear Sir or Madam: t)npaid Balance $7834.47 Hours (CST) 7:OOam-9:OOpmM-TH 7:OOam-S:OOpmF S:OOam-12:OOpmS Reference No 5552679 Our company represents Citibank (South Dakota) N`A. CITI AT&T UNIVERSAL MASTERCARD. This letter is in regard to the claim filed by our client against the Estate of HAROLD SIMS. Our company has been asked to monitor the status of this Estate and to seek payment. It would be appreciated if you would advise us on the status of the Estate. Please contact our office toll-free at 1-877-326- 5681. Thank you for your cooperation. Cordially, DCM Services, LLC *IMPORTANT NOTICE* 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 after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will obtain verification of the debt or a copy of a judgment and mail you a copy of such judgment or verification. If you request of this office in writing within 30 days after receiving this notice this office will provide you with the name and address of the original creditor, if different from the current creditor. This company is a debt collector. We are attempting to collect a debt and any information obtained will be used for that purpose. Calls may be monitored or recorded for quality assurance purposes. NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION -Side 1 of 2- """Detach Lower Portion and Retum with Payment"` DCM Services, LLC 4150 OLSON MEMORIAL HWY STE 200 Reference #: 5552679 Client ID: CITI31 ~ ~ ~ MINNEAPOLIS MN 55422-4811 Unpaid Balance: $7834.47 Checks Payable to: ADDRESS SERVICE REQUESTED Citibank (South Dakota) N.A. CITI AT&T UNIVERSAL IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIillllllllllllllllllllllllllllllllllllllllll MASTERCARD Amount Enclosed: $ July 28, 2009 5552679-~ n00 16517 - 9 #SV'JT~'JGZF DC;1 Services/Citibark #1'851720°554836# PO box 1.568 The Estate of HAROLD SIMS I"inneapolis MN 55440-1568 ADELE r^ SIMS LI~I~J~1,~1„ICI„lII~~~~~~II~I~t~~If~~I~~1~~IL~I~J~1„L1 1,pp7 i3RIDGE ST NEW CJt18ERLAND PA 1707-1631 5552675 6671 ~~..'-~'s.,a-s Disclosure .Statement ,grower(s) (Name and mailing addcess) .~-° HAROLD T SIMS 18 ROSS A IE 2F . NEW CUMBERLAND PA 17070 ANNUAL PERCENTAGE RATE The cost of Borrower's credit as a yearly rate: 27.14 % Payment Schedule: Number of Amount of 168.24 59 ~$ 158.92 Note and Securi Lender (Name, address, city and state) CITIFINANCIA~rERVICES , INC. '~ ti~ 3401 HAR I SUITE 126 CAMP ~~'L~ .~ FINANCE CHARGE:" The dollar amQinC'•tli~ cost Borrower ~ ''' ,,~~ ~' $ 4,-354.7 u .................--- The~~minount of credit provided to B~i~oci%er or on Borrower's beha } When Payments ,,~'" Are Due 05/05/2008 MONTHLY BEGINNING 06/05/2008 Account No. 351510 Date of Loan 04/01/2008 Total of Payments . The amount Borrower will have paid after Borrower has made all payments as scheduled. $ 9,544.52 Securi If checked, Borrower is giving a security interest in: ^ Motor Vehicle ^ Mobile Home ^ Real Property ^ Other: Late Charge: If a payment is late, Borrower will be charged a late charge equal to 1.5 % per month on the past due amount until paid in full, minunum charge $ 1.00 . Prepa ment: If Borrower pays off early, Borrower may See the contract documents for any additional information about nonpayment, default, be entitled to a refund of part of the finance charge. any required repayment in full before the scheduled date, and prepayment refunds and penalties. additional Information: PRECOMPUTED INTEREST SERVICE CHARGE DATE CHARGES BEGIN First Payment Due 4 , 19 5 . 4 7 $ 15 0 . 0 0 0 4 / 01 / 2 0 0 8 Date Extension Charge: $ 9 .3 2 (included in Finance Charge.) INSURANCE DISCLOSURE Required Insurance: If Borrower obtains credit that is secured by Borrower's interest in improved real property (including a mobile or manufactured home that is part of real property), then Lender requires Borrower to provide fire .and extended coverage for the replacement value of the improvements. If the collateral securing the credit is a motor vehicle (including a recreational vehicle, boat, or movable mobile home), Borrower must provide collision and comprehensive casualty insurance in an amount sufficient to satisfy the unpaid balance of the loan or equal to the value of the collateral, whichever is less. All such policies and renewals thereof must name Lender as loss payee and must be maintained by Borrower, until the credit is repaid in full. Borrower may obtain a new insurance policy or provide an existing policy from any insurer that is acceptable to Lender. If Borrower obtains the collateral protection coverage or Automobile Physical Damage Insurance at Lender's office, Borrower acknowledges that such insurance (1) may cost more than insurance that is available from another insurer, (2) will only protect Lender's interest in the collateral and does not protect Borrower's interest, and (3) does not protect Borrower from claims by other persons. Optional Insurance: Credit life insurance, credit disability insurance, credit personal property insurance, involuntary unemployment insurance, and any other insurance products that are not required per the above paragraph are optional to Borrower and are not required in order to obtain credit. If Borrower desires voluntarily to purchase any of these optional insurance products, Borrower mrist sign below and in other required documents and will receive an insurance certificate or policy detailing the coverage terms and conditions that apply to the insurance. Borrower should refer to the terms and conditions contained in the applicable insurance certificate or policy issued for the exact description of benefits and exclusions. Borrower is encouraged to inquire about coverage,and refund provisions. If the initial amount of coverage for credit life insurance and/or credit personal property insurance set forth in Borrower'sinsurance certificate or policy is equal to the Total of Payments stated above, it may exceed the amount necessary to pay off Borrower'sloan at any given time. Any excess insurance coverage amount that may become payable will be paid to the appropriate party as designated in the insurance certificate or policy. Borrower acknowledges that if optional credit personal property insurance is purchased, Borrower'sproperty coverage under other policies such as homeowner's or renter's insurance may be adversely affected. Borrower's regular monthly loan payment if Borrower elects not to purchase insurance will be $ 153 .27 Termination of Optional Insurance: Borrower may cancel any of the optional insurance products obtained at Lender's office at any time upon Borrower's written request for cancellation to Lender. If Borrower is in default under the terms of this agreement, Borrower authorizes the insurer to terminate any and/or all optional insurance products. upon Lender's request. Upon termination of any insurance for any reason, Borrower authorizes and directs that the insurer deliver the premium refund, if any, to Lender, which will apply it to Borrower's outstanding loan balance. Borrower hereby irrevocably and unconditionally assigns to Lender any right, title or interest which Borrower may have in any premium refund ("Refund"). Such assigrunent is absolute and not intended as security. Borrower acknowledges and agrees that the Refund shall be the sole property of Lender and that Borrower shall have no interest in the Refund. Lender agrees to pay to Borrower any amount by which the Refund received by Lender exceeds the outstanding loan balance. Iiwe request the following insurance: ~, Cost/Premium: Insurance Type: Insurance Term (in mos.): / _ ~ l l U $ 189 , 75 SINGLE CREDIT LIFE 60 Fi st Borrower's Signature Date $ NONE $ NONE S NONE Second Borrower's Signature Date NGNE _ _ _