HomeMy WebLinkAbout10-21-11
,a„ ,~.,.,. , .. - --- ---
ENTER DECEDENT INFORMATION BELOW MMDDYYYY
Social Security Number Date of Death MMDDYYYY Date of Birth
~. . _
179-44-9399 - 01/23/2011 04/10/1957.,....
_._
Suffix Decedent's First Name MI
_. - -.-
Decedent's Last Name ~ - - ~ ~ -- ~ ~ --~~, ~~-
__ .
_ .._.. _
Richards Beth A
(if Applicable) Enter Surviving Spouse's Information Below MI
Spouse's last Name Suffix Spouse's First Name
_._ ._._
_ i
N/A ..
spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return
O 4. Limited Estate
O 6. Decedent Died Testate
(Attach Copy of Will)
O 9. Litigation Proceeds Received
O 2. Supplemental Return
O 4a. Future Interest Compromise (date of
death after 12-12-82)
O 7. Decedent Maintained a Living Trust
(Attach Copy of Trust.)
O 10. Spousal Poverty Credit (Date of Death
Between 12-31-91 and 1-1-95)
O 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 5. Federal Estate Tax Return Required
0 8. Total Number of Safe Deposit Boxes
O 11. Election to Tax under Sec. 9113(A}
(Attach Schedule O)
CORRESPONDENT - THiS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD 13E olrter; I eu ~ v:
Name Daytime Telephone Number
Robert M. Walker, Esq. (171) 761-1200
First Line of Address
3906 Market Street
Second Line of Address
City or Post Office
Camp Hill
REGISTER OF WILLS USE ONLYr.,
{ i ....
<_ ~ ~:' _
DAiE FIL' ~D %="~
State ZIP Code
PA 17011
m
r~,.,
T7 ~~
r ,..~
~_ ~._.,
{ - ~..~
. ~ .
r"~_'`i
-~ ' `-::
r~
..~
__ j
--
_ ==r T
~' ~ C>
--r~
Correspondent's e-mail address: rmW rmwalkerlaw com
Under penalties of perjury, I dedare that I have examined this return, including accompanying schedules end statements, and to the beat of my knowledge and belief,
it is true, rrect and complete. Declaration of preparer other than the personal representative is based on all information of which preiparer has any knowledge.
SIGNAT OF PERSON R;SPONSIBLE FOR FILING RETURN DATE
131 o Circle, Enola, 025
SIGN U E O TH EPRESENTATIVE ATE
~~ -~v -`/
ADDRESS
3906 Market Street Camp Hill, PA 17011
PLEASE USE ORIGINAL FORM ONLY
1505610105
REV-1500 EX (oz-ii) (FI)
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
a~M.~~.~..~ __ _..
Bureau of Individual Taxes _
PO BOX 28o6oi INHERITANCE TAX RETURN " ^ I I' ~ I
__ _ __. IaFSInENT DECEDENT p(
Side 1
L 1505610105 1505610105
J 1505610205
REV-1500 EX (FI)
Decedent's Name: Beth Ann Richards Decedent's Social Security Number
179-44-9399
RECAPITULATION _ _ _. _.._ ..
1 160,300.00
1. Real Estate (Schedule A) ............................................. .
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. • Schedule E).......
Cash, Bank Deposits and Miscellaneous Personal Property ( 5. 44,260.97
,.,___ ,,,., ~...,,,,
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7 Inter-wos Transfers & Miscellaneous Non-Probate Property
. (Schedule G) O Separate Billing Requested........ 7.
8 204,560.97 :
8. Total Gross Assets (total Lines 1 through 7) ............................. .
9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 9,654.50
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 16,068.30
11. Total Deductions (total Lines 9 and 10) ............................. .... 11. 25,722 80
12.
..........................
Net Value of Estate (Line 8 minus Line 11)
....12. 178,838.17
~ ~,
13 Charitable and Governmental BequestslSec 9113 Trusts for which
. an election to tax has not been made (Schedule J) .................... .... 13. ',
14. Net Value Subject to Tax (Line 12 minus Line 13) ......... .... 14. 178,888.17
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or _. .
transfers under Sec. 9116
15
(a)(1.2) X .0_
~ .
~,_ ~ ~
~ ~
16. Amount of Line 14 taxable ~ ~ ' ~ ~~
at lineal rate X .0 ~ ~ 178,838.17
~ ~~~ ~ ~ ~ a ~ ~~
: 16. 8,047.72
17. Amount of Line 14 taxable ~~ m.~~~~~ 17
at sibling rate X .12
~ ~ ~~ ~~~ ~ ~ ~~~ ~
18. Amount of Line 14 taxable 18
at collateral rate X .15
~~ _ _. .
8,047.72
19. TAX DUE ..................................................... .... 19. _ _ ...
20. FILL IN THE OVAL IF YOU ARE RE4UESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610205 1505610205
O
REV-1500 EX (FI) Page 3
Decedent's Complete Address:
Beth Ann Richards
STREET ADDRESS
131 Tory Circle
CITY
Enola
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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
ZIP
PA 17025
(1) 8,047.72
(3}
(4)
(5) 8,047.72
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 ...................... .. .......... ^
b. retain the right to designate who shall use the property transferred or its income .......................................
.... .....
..... ^
c, retain a reversionary interest .....................................................................................................................
benefits or care? .................................................................
ments
life of either
a
f
i
h ..... ^
,
p
y
or
se
e prom
d. receive t
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
^
wiUlout receiving adequate consideration? .........................................................................................................
3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ......... .....
..... ^
4. Did decedent own an individual retirement account, annuity or other non-probate properly, which
^
contains a beneficiary designation? .................................................................................................................. ......
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers io 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(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent (72 P.S. §9116(a)(1.3)]. Asibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Flle Number
Total Cn;dits (A + B) (2)
REV-1502 EX+ (01-10)
~ , Pennsylvania SCHEDULE A
` DEPARTMENT OP REVENUE REAL ESTATE
INHERITANCE TAX RETURN
..~~...urr nrr-rncorr
ESTATE OF: FILE NUMBER:
Beth Ann Richards
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disdosad on Schedule F.
Attach a copy of the settlement sheet If the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1• Townshouse -131 Tory Circle, Enola, Cumberland County, Pennsylvania 160,300.00
TOTAL (Also enter on Line 1, Recapitulation.) ;' 160,300.00
If more space is needed, use additional sheets of paper of the same size.
REV-i$o8 EX+ (ii-SO)
~ ~,~ Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDt~LE E
CASH, BANK DEPOSITS & MISC.
PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Beth Ann Richards
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. Bank Accounts -Member's 1st Credit Union 25,541.50
2. :Automobile - 2008 Satum Aura Sedan 10,550.00
3. Househokl Items and Miscellaneous Personalty 1,000.00
4. `Final Wages and Annual Leave Payout 7,169.47
TOTAL (Also enter on Line 5, Recapitulation) ~ 44,260.97
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
~ . Pennsylvania
.~'' DEPARTMENT OF REVENUE
SCHEDULE H
FUNERAL EXPENSES AND
wnuTU*croerty~ rncrc
ESTATE OF FILE NUMBER
Reth Ann Richards
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A.
1 FUNERAL EXPENSES:
00
041
4
' Undertaker /Funeral Services .
,
2. Burial Plot 615.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2,500.00
2. Attorney Fees:
3. Family Exemption: (If decedent's address Is net the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
331.50
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
~• `Storage !Disposal of Personalty of Decedent 501.00
a Real Estate Utility Expenses -131 Tory Circle 1,666.00
TOTAL (Also enter on Line 9, Recapitulation) ; 9,654.50
If more space is needed, use additional sheets of paper of the same size.
_ __
REV-1512 EX+ (12-~B)
~' Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Beth Ann Richards
Report debts incurred by the decedent prior to death that romained unpaid at the date of death, includlny unroimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1• I Ci6zens Automobile Finance 10,199.23
2. Bank of America Visa 251.19
3. Bananna Republic Visa 137.46
4. West Shore EMS 3,172.84
5. Heritage Medical Group 66.00
6. Holy Spirit Hospital 42.50
7. .2011 County /Township Real Estate Taxes -131 Tory Circle 471.58
8. Cumberland Goodwill EMS 1,727.50
TOTAL (Also enter on Line 10, Recapitulation) ~ 16,068.30
If more space is needed, insert additional sheets of the same size.
_ _
REV-1513 EX+ (O1-10)
Pennsylvania SCHEDULE ]
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Beth Ann Richards
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(:) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec, 9116 (a) (1.2).]
1• Jessica Miller Daughter 100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
L
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
L
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET. $
If more space 1s needed, use additional sheets of paper of the same size.
anit plilkll~
Z
v~
BETH ANN RICHARDS
t, Beth Ann Richards, of Enola, Cumberland County, Pennsylvania, being of
sound and disposing mind, memory and understanding, do make, publish and declare
this to be my Last Will and Testament, hereby revoking and making void all previous
Wills and Codicils heretofore made by me.
FIRST
I order and direct my personal representative hereinafter named to pay all of my
just debts, funeral expenses and expenses involved or connected with the
administration of my estate as soon after my death as is reasonably possible. However,
my persona! representative need not accelerate and pay those unmetured obligations
which, in his, her or its opinion, it might be proper and more advantageous to retain or
renew and pay as they become due and payable. If I do not own a burial plot or a grave
marker at the time of my death, I authorize my personal representative, in his, her or its
sole discretion, to purchase a burial plot and to erect a suitable marker at my grave, and
to expend sums from my estate for this purpose.
SECOND
I give, devise and bequeath my entire estate together with all insurance proceeds
thereon of whatsoever nature and wheresoever situated to my beloved daughter,
Jessica Richards Miller, providing that she survives me by sixty (60}days, per stirpes.
~t}h t.i~nv~ I``.cha,.d~
THIRD
Should my daughter, Jessica Richards Mllter, predecease me or die on or
before the sixtieth (60~') day following my death, leaving no children, then I give, devise
and bequeath my entire estate together with all insurance proceeds thereon of
whatsoever nature and wheresoever situated to my aunt Eleanor Slothour, of
Mechanicsburg, Cumberland County, Pennsylvania, provided she survives me by sixty
{60) days. Should my aunt Eleanor Slothour predecease me or die on or before the
sixtieth (fi0'") day following my death, then I give, devise and bequeath my entire estate
together with all insurance proceeds thereon of whatever nature and wheresoever
situated to my uncle. Frederick Slothour, provided he survives me by sixty {60) days.
Should my undo Frederick .Slothour predecease me or die on or before sixt®th (60~')
day following my death, then !give, devise and bequeath my entire estate together with
all insurance proceeds thereon of whatever nature and wheresoever situated to the
Humane Society of the Harrisburg Area Incorporated whose current address is
Sinclair and Eppley Roads, Mechanicsburg, Cumberland County, Pennsylvania.
FOURTH
My executor and trustee are authorized and empowered to exercise from time to
time in his, her or its sole discretion and without prior authority from any Court, in
respect of any property forming part of any trust hereby created or otherwise in its
possession hereunder all powers conferred by law upon trustees or executors and the
testator intends that such powers be construed in the broadest possible manner.
FIFTH
I nominate, constitute and appoint my daughter, Jessica Richards Mitier, of
New York, Executrix of this my East Will and Testament. In the event Jessica
Richards Miller is deceased, unable or unwilling to serve or shall cease to serve for
any reason whatsoever, then I nominate, constitute and appoint my undo. Frederick
Slothour, to serve instead.
d~~~~~
~~~r7Ll
I hereby declare it to be my expressed desire that my personal representative
employ Turo Law Offices of Cumberland County, Pennsylvania, for legal advise and
assistance regarding this my Last Wilt and Testament, they having considerable
knowledge of my affairs, views and wishes respecting any matters that may arise at the
probate of this instrument, the administration of my estate, and the execution of the
powers herein mentioned.
IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and
Testament this 26~' day of October, 2001.
ess Beth Ann Richards
Wit s
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
. SS
COUNTY OF CUMBERLAND
I, Beth Ann Richards, the Testatrix whose name is signed to the attached or
foregoing instrument, having been duly qualified according to the law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament;
that I signed it willingly, and that I signed it as my free and voluntary act for the
purposes therein expressed.
Ann
Swom or affirmed and acknowledged before me by Beth Ann Richards, the
Testatrix. this 26~' day of October, 2001.
~ ,„~
.. ,;
. ~~
Notary Pu c
Robert J. Mum g~! b ry PWbGc
CarNsle Boro. Cumberland C4un_ty
My Commission Expires Now. iS, 04
..
~ +
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
We, Galen R. Waltz, Esquire and Jacqueline G. Ege, the witnesses whose
names are attached to the foregoing document, being duly qualified according to the
law, do depose and say that we were present and saw Testatrix sign and execute the
instrument as her Last WIII and Testament; that she signed willingly and that she
executed it as her free and voluntary act for the purposes therein expressed; that each
subscribing witness in the hearing and sight of the Testatrix signed the Last IAlill and
Testament as witnesses and that to the best of our knowledge the Testatrixt was at the
time 18 or more years of age, of sound mind and under no constraint or undue
influence.
0
n R. Waltr, E ire
Ja eli .Ege
Swom or affirmed and subscribed before me by Galen R. Waltr, esquire and
Jacqueline G. Ege this 26~' day of October. 2001.
~~
Notary lic
Robert J. Mutde S~Notary
Carlisle Bolo, C~im~ ~iu~~jr_
My ComrrAselort Explre~ Nov 19,E ~oua
TaxDB Result Details
Detailed Results fo
DistrictNo r Parce109-14-083:
09
Parcel ID 09-14-0835-273.
MapSuffiz
HonseNo 131
Direction
Street TORY CIRCLE
Ownerl RICHARDS, BETH A
C/O
PropType R
PropDesc
LivArea 1652
CurLandVsl 43300
CurImpVal 117000
CurTotVal 160300
CurPrefVal
Acreage .21
CIGrnStat
TazEz 1
SaleAmt 124900
SaleMo 07
SaleDa 30
SaleCe 20
SaleYr O1
DeedBkPage 00247-03213
YearBlt 2000
HF Fyle Date 11/03/2004
HF Approval Statas A
s-273. in the 2010 Tax Assessment Database
Page 1 of 1
http://taxdb.ccpa.net/details.asp?id=09-14-0835-273.&dbselect=l 10/19/2011
REALTY TRANSFER TAB July 2011
Pennsylvania 201o cae~oN LEVEL RAT=o
QEPARTMENT OP REVENUE REAL $STATE VALUATION FACTORS
The following real estate valuation factors are based on sales
data compiled by the State Tax Equalization Board in 2010. These
factors are the mathematical reciprocals of the actual common
level ratio (CLR). For Pennsylvania Realty Transfer Tax purposes,
these factors are applicable for documents accepted from July 1,
2011 to Juan 30, 2012, oxa~pt as iadicat~d b~loM. The date of
acceptance of a document is rebuttably presumed to be its date of
execution, that is, the date specified in the body of the document
as the date of the instrument (61 Pa. Code ~ 91.102).
CLR CLR CLR
COOpTY FACTOR COONTY FACTOR COONTY ~1'OR
Adams (1) 1.00 Elk 2.36 Montour 1.23
Allegheny 1.17 Erie 1.18 Northampton 2.98
Armstrong 2.65 Fayette 1.21 Northumberland 3.62
Beaver 3.06 Forest 3.73 Perry (1) 1.00
Bedford 1.28 Franklin 7.63 Philadelphia 5.53
Berks 1.37 Fulton 2.85 Pike 4.67
Blair 6.67 Greene 1.20 Potter 3.21
Bradford 2.99 Huntingdon 7.19 Schuylkill 2.11
Bucks 8.85 Indiana 5.21 Snyder 5.56
Butler 5.24 Jefferson 1.85 Somerset 2.51
Cambria 2.99 Juniata 4.74 Sullivan 1.44
Cameron 2.44 Lackawanna 5.49 Susquehanna 2.82
Carbon 2.33 Lancaster 1.31 Tioga 1.36
Centre 3.56 Lawrence 1.05 Union 1.29
Chester 1.79 Lebanon 6.33 Venango 1.11
Clarion 3.38 Lehigh 2.80 Warren 2.89
Clearfield 4.95 Luzerne 1.00 Washington 4.69
Clinton 1.01 Lycoming 1.21 Wayne 1.25
Columbia 3.79 McKean 1.16 Westmoreland 4.20
Crawford 2.68 Mercer 2.89 Wyoming 5.08
Cumberland(1) 1.00 Mifflin 1.91 York 1.19
Dauphin 1.36 Monroe 5.95
Delaware 1.48 Montgomery 1.72
(1) Adjusted by the Department of Revenue to reflect an
assessment base change effective January 1, 2011
factor.not.doc
OCT-20-2011 12:39 From:M1ST LEND~INS SUPRT 7177955178 To:7177611201
Primary Owner: Bath Ann Richards
rm
MEMBERS 1'~
I~tr>ex~[.cruDUrr uNtun
SAVINGS ACCOUNT:
Account NumberlSuffix 81478.Ot1
Date Acwunt Estabbsited 08/14/1986
Principal Balance at Date of Death $5.18
ACrnied Intermit to C1 Ate of Death $.00
Total Principal and Accrued Interest $5.16
IVamo of Joint Owner None
SUPPLEMENTAL SAVINGS ACCOUNT:
Aocount Number/Suffix 81475-11
Date Account Established U(i/09l1989
Principal Balance at Date of Doath $1,866.43
llccrued Interest to Date of Death $.00
Tote! Prinrip81 enr! Ar;nrued Interest $1,866.43
Name of Joint Owner None
CERT1FItrATES OF DEPOSIT:
Arspunt NumherlSuffix 81478-D5
Dale Accoun[ Establlshod 04!1112006
Prtncipal Balance at Date of Death $23,t3G9.91
Accxued interest to Date of Dealh $5.19
Total Principal and Accrued Interest $23,875.10
Name of Joint C>'nrner Nnne
Primary Owner: Gordon Richards
SAVINGS ACCOUNT:
Account Number/Suffix
081e Account EslabliShed
Principal Balanco at Date of Death
Accrued Interest to Date of Death
Total PrlnGpal and Accxued Interest
Name of Joint Owner
Dato Joint pwnorshlp Established
7590-00
11/13/1964
$696.69
$.11
$696,80
Beth Ann Richards
11!13!1968
ME~MfB~E,RfS 1"T/FEDERAL CREDIT UNION
Leigh-~`utne Stallings
Lending Insurance Support Spocialist
October 20, 2011
Estato of: Beth Ann Riehards
Date of Death: 01/24!2011
Social Security Number: 179-44-9399
F.2~2
S00() ].etui:;c: l7rivc: P(7. Rr,x 40 M.echatucsburg, 1'et~nsyhr~nil '17055 (8011•} 283-2328 wwwit~etztberslst,c~rg
Saturn Aura 2008 -Car Standard Equipment - NADAguides.com Official Site
'leer Irr ~ ~tshick hrfan~nadan
NADAgvides.wns
2008 Saturn Aura
Sedan 4D XE
NADAguides.com Price Report
Rough
Trade-In
Base Price $9,075
Mileage: 50,000 miles $300
Options:
TOTAL PRICE $9,375
'Average
Trade-In
$10,250
$300
$10,550
Clean
Trade-In
$11,200
$300
$11,500
i
Page 1 of 3
®f'Inse Window
10/19/2011
Clean
Retail
$14,025
$300
Standard Equipment
Standard Equipment Details
Engine Specifications
Type: Gas I4
Size: 2.4L/145
Horsepower: 169 @ 6400 RPM
Torque: 160 @ 4500 RPM
Drive Train
Drive Train: Front Wheel Drive
Transmission: 6 speed Automatic
Safety
Air Bag-Frontal-Driver
Air Bag-Frontal-Passenger
Air Bag-Passenger Switch (On/Off)
Air Bag-Side Body-Front
Air Bag-Side Head-Front
Air Bag-Side Head-Rear
Brakes-ABS-4 Wheel
Brakes-Type-4 Wheel DISC
Child Safety Rear Door Locks
Daytime Running Lights
Engine Immobilizer/Vehicle Anti-Theft System
Headlights-Auto-Off
Headlights-Auto-On
Traction Control
Comfort ~ Convenience
Air Conditioning-Front
Auto-Dimming Rearview Mirror
Cruise Control
Keyless Entry
Max Seating Capacity: 5
Mirrors-Pwr Driver
Mirrors-Pwr Passenger
Mirrors-Vanity-Driver
Mirrors-Vanity-Driver Illumination
M irrors-Vanity-Passenger
Mirrors-Vanity-Passenger Illumination
Power Locks
$14,325
http://www.nadaguides.com/Cars/2008/Saturn/AURA-V6/Sedan-4D-XE/Standard-Equipment/Print 10/19/2011
Saturn Aura 2008 -Car Standard Equipment - NADAguides.com Official Site
Seat Trim-Cloth
Seat Trim-Leather
Seat-Adjustable Lumbar-Driver
Seat-Heated Driver
Seat-Heated Passenger
Seat-Power Driver
Seat-Power Passenger
Seat-Rear Pass-Through
Seats-Front Bucket
Steering Wheel-Adjustable
Steering Wheel-Audio Controls
Steering Wheel-Leather
Steering-Power
Trip Computer
Trunk-Release-Remote
Universal Garage Door Opener
Windows-Power
Music >5 Entertainment
Audio-AM/FM Stereo
Audio-CD Changer
Audio-CD Player
Audio-MP3 Player
Audio-Rear Seat Audio Controls
Audio-Satellite Radio
Interior
Auxiliary Pwr Outlet
Floor Mats-Front
Floor Mats-Rear
Exterior
Doors: 4
Fog Lamps
Mirror(s)-Heated
Mirrors-Heated Driver
Mirrors-Heated Passenger
Rear Window Defogger
Roof-Generic-Sun/Moon
Roof-Sun-Pwr Tilt/Sliding
Wipers-Intermittent
Tires
Front Tire Size: P215/50R17
Rear Tire Size: P215/50R17
Spare Tire Size: Compact
Wheels
Front Wheel Material: Steei
Rear Wheel Material: Steel
Back to too
Page 2 of 3
Rough Trade-In: #9,375
Rough Trade-in values reflect a vehicle in rough condition. Meaning a vehicle with significant mechanical defects requiring
repairs in order to restore reasonable running condition. Paint, body and wheel surfaces have considerable damage to their
finish, which may include dull or faded (oxidized) paint, small to medium size dents, frame damage, rust or obvious signs of
previous repairs. Interior reflects above average wear with inoperable equipment, damaged or missing trim and heavily
soiled /permanent imperfections on the headliner, carpet, and upholstery. Vehicle may have a branded title and un-true
mileage. Vehicle will need substantial reconditioning and repair to be made ready for resale. Some existing issues may be
difficult to restore. Because individual vehicle condition varies greatly, users of NADAguides.com may need to make
independent adjustments for actual vehicle condition.
Average Trade-In: X10,550
The Average Trade-In values on nadaguides.com are meant to reflect a vehicle in average condition. A vehicle that is
mechanically sound but may require some repairs/servicing to pass all necessary inspections; Paint, body and wheel surfaces
have moderate imperfections and an average finish and shine which can be improved with restorative repair; Interior reflects
some soiling and wear in relation to vehicle age, with all equipment operable or requiring minimal effort to make operable;
Clean title history; Vehicle will need a fair degree of reconditioning to be made ready for resale. Because individual vehicle
condition varies greatly, users of nadaguides.com may need to make independent adjustments for actual vehicle condition.
http://www.nadaguides.com/Cars/2008/Saturn/AURA-V6/Sedan-4D-XE/Standard-Equipment/Print 10/19/2011
~_ i
Saturn Aura 2008 -Car Standard Equipment - NADAguides.com Official Site
Page 3 of 3
Clean Trade-In: $11,500
Clean Trade-In values reflect a vehicle in clean condition. This means a vehicle with no mechanical defects and passes all
necessary inspections with ease. Paint, body and wheels have minor surface scratching with a high gloss finish and shine.
Interior reflects minimal soiling and wear with all equipment in complete working order. Vehicle has a clean title history.
Vehicle will need minimal reconditioning to be made ready for resale. Because individual vehicle condition varies greatly,
users of NADAguides.com may need to make independent adjustments for actual vehicle condition.
Clean Retail: $14,325
Clean Retail values reflect a vehicle in clean condition. This means a vehicle with no mechanical defects and passes all
necessary inspections with ease. Paint, body and wheels have minor surface scratching with a high gloss finish and shine.
Interior reflects minimal soiling and wear with all equipment in complete working order. Vehicle has a clean title history.
Because individual vehicle condition varies greatly, users of NADAguides.com may need to make independent adjustments
for actual vehicle condition. Note: Vehicles with low mileage that are in exceptionally good condition and/or include a
manufacturer certification can be worth a significantly higher value than the Clean Retail price shown.
The consumer values on NADAguides.com are based on the Consumer Edition of the NADA Official Used Car Guides and should not be
utilized for industry purposes. The consumer values may vary from the NADA Official Used Car Guide® values presented to you by
insurance companies, banks, credit unions, government agencies and car dealers due to vehicle condition, regional market differences and
F-.. ..F . ...i~4e
ncy ucna.r v. .. r..v w.~.
ADVERTISEMENT
IMIMI~IN!S
check out new ~r ~ric~es ~ info ~ ~~
~. i;J~IpOCB
C~~ Copyright 2011 National Appraisal Guides Inc. All Rights Reserved.
http://www.nadaguides.com/Cars/2008/Saturn/AURA-V6/Sedan-4D-XE/Standard-Equipment/Print 10/19/2011
BUREAU OF COMMONWEALTH PAYROLL OPERATIONS
DECEASED PAYMENT WORKSHEET
Date Submitted: 3/912011
Employee Name: Beth A. Richards
Personnel Number: 00131310
TIN Number: 27-7069167
Payee Name: Estate of Beth A. Richards
Payee Address: 1400 Bent Creek Blvd t 205 Mechanicsburg PA 17050
Taxable Non Taxable
PPE Hours Gross Totals PPE Hours Gross Totals
eery ver.U:,
Miscellaneous Paymenis
Salary 1!21/2011 75.00 $1,539.00
$0.00
$o.oo $o.oo
$o.oo $o.oo
$o.oo $o.oo
$o.oo $o.oo
$o.oo $o.oo
Total Sala Due $1,539.00 $0.00
Leave'Pa outs '
Annual 299.23 $6,140.20 $0.00
Personal $0.00 $0.00
Sick $0.00 $0.00
Holiday $0.00 $0.00
Comp $0.00 $0.00
$0.00 $0.00
0
00
Total Leave Pa outs $6,140.20 .
$
:Less Gross:Ove a nts '`°
Conversion Pay $0.00 $0.00
Salary/Overtime $0.00 $0.00
Pre Tax Medical $0.00 $0.00
Other $0.00 $0.00
Total Gross Ove ayments $0.00 $0.00
Deductions:-
Salary Overpayment-Net $0.00 $0.00
Medical Hospital Percentage $52.77 $0.00
Social Security/Medicare $433.87 $0.00
Union Dues $23.09 $0.00
Retirement $0.00 $0.00
Total Deductions Owed ($509.73) $0.00
Total Due Beneficiary/Estate $7,169:47 $0.00
21099 Ad'u~tment'AaiouM
Total Deductions Owed $509.73
Total Adjustment Amount $509.73
fi099~Amount $7,679.20 Non Taxable Amount $0.00
Revised 823A77
COMMONWEALTH OF PENNSYLVANIA
OFFICE OF THE BUDGET
COMPTROLLER OPERATIONS
333 Market Street, 19'" Floor
Harrisburg, PA 17101-2210
March 23,2011
Jessica R. Miller
1400 Bent Creek Blvd., Apt. 205
Mechanicsburg, PA 17050
Dear Ms. Miller:
The enclosed check represents payment to you on behalf of Beth A. Richards as the executrix of
her estate.
Please note that you, as the executrix, will receive a Form 1099-Misc in the amount of $7,679.20
in January of 2012. The form will be in the name of the Estate of Beth A. Richards and the Tax
Payer Identification number 27-7069167. This should be used for tax filing purposes.
The attached worksheet contains a detailed explanation of all payments made to you as the
executrix of the estate.
Should you have any questions regarding this letter, please contact Mr. Ed Brenner at telephone
number (717) 772-5368, email ebrennerna,state.pa.us or you may write to the above address.
Sincerely,
Margaret R. Keefer
Injury and Special Processing Division Chief
AttachmentsBnclosures
~ ~ I t 1 Z~ 115 yy ~ ~ ~,s~s~c~. +31~ INSTALLMENT LOAN STATEMENT
~11C Automobile Finance RJR ~S
P.O. Box 42002 ® ~ I`Scmber lrp~
Providenoo, RI 02940-2002
Wcr-w~ck. , ..~~... C7;Z~~
Cusoomc[ Service 1-877-265-327$
A-X - 1RS . C~e.,n~
Pa}mcnt Remittance Address:
~~.~" 3CQa - Co `ut-lgj . Citizens Automobile Finance, Inc.
IlJlllllll,lllllllllJllIIJ116JIIIIIIILJILIIIlN11„III P.O.Bos42113
B E T H A R I C H A R D S ~ Cj ~, ~ ~~,` P[ovidcnt:e, RI 0290-2113
131 TORY C I R ~ ^I~' `Q`vc7v
t: t0 0 L A, P A 17' 0 2 5- 2 6 4 2 r0 ACCOUNT' INFORMATION
1...111~~~111~~~~~61J~6~~LLIlllilllllll,LllllIlllllllJl ~'I'~ ~ -
PAYMENT DUE SUMMARY
Regular Mootlily T'aylnent Amount: 201.89
Past Dlx: Amount; 0.00
rte: o.oo
Total Payment Amount Due: 201.89
PAYMENT' DUE DATE: January 28, 2011
ACCOUNT ACTIVITY
Dste Description
12/27/t0 PAYMENT -THANK YOU
12/27/10 PRINCIPAL CREDIT
Account Nulnl~er:
Statement Date:
Current Interest Rate:
Current Principal Balance:
*Estiawtal PoyofT Amount Good
For Tanunry 28, 201 ]
2726093202
January 08, 2011
6.690%
10,139.75
10,199.23
• Pleose caU Customer Se,vka [vr an actual payoff amount
PriricIl,al lntcrest late Charge Other Amount
130.30 71.59 0.00 0.00 201.89
lo.oa o.oo a.oo o.oo lo.oo
SUo#tid yqu ~avc ~ltst~tis ceding ti'out bccf; Pk~e calf otrr Cils~lner`6crvtoe.pi~onc Ilut~ber listai do this statemcM. Our
Cusi~mtx SCli~ict Reptescnknlitirs-arc availabtz 2; Lauri, 7 d~~511 tQCCk Tlmlyk you ftx Banking v~ith Citizens.
Did yon ktsuw#iut ywt ~aa tq~lt~c ygpr I-uya~t b}r'~I~Ie, ar aMilnc'#a~ It s<rttull eoavcnleact tee? Plc><sc CuTI Iwr slutc,ralttetl
PaY ~ P~ sv3~c~ri ~t I:-88~8o5~U21I0.o+~ V}~it tr~vvv:c311~~r~altcix~oae~imcp,t}~.
PLEASE DETACEi AND RLr117AN THE PORTION BELOW \vITIi YOVR CHECK PAYABLE TO C1T17.EPi3.1UTOS10BILE FINe1NCE, li\C
Pleue a0°w 7 dais Ibr msNlnp to Basuto 'meal k ikarercd by the due dalr.
i1+TSTALLMENT LOAN STATEIKENT Acrnunt Number. 2726093202
Due Date: Jsousry 28, 2011
Total Amount Due: 201.89
BL'TH A RICtTA1tUS Additloesl Principal: S
131 TORY CIR '
I:NOL.A, PA 17025-2692
Check this box if your add,+aa a personal iafortaatioa
has chonBed aa~d oomploto the foam oa tho rovcnw side.
~~! Citizens
t^i Automobile Finance
P.O. Box 42002
Providenoo, RI 02940-2002
Late Fees: S
Totsl Psymcnt: S ,
II,I,I~llll,~Illlllll,Illllllllllll~l111lllillllllllllllllll,l
Citizens Automobile Finance, Inc.
P.O. Box 42113
Providence, RI 02940*2I 13
Illl,,,llllllilllll~llll~lill 111,lllllllllllll,l,ll„Illlll~ll
54450015 271 02726093202 0000020189
QO OO
~~ ~~
N N
w
N
n
W t i
U
~
Q N N Y
i
y
~
`
N
N ,,,
~
N
N
if t
ii
6 7t
if t
t
n ~ _ ~
N ~ a
~T~~
~ C'? C7 ~
~~ a
~~
A'
N
W
O O
$8
~~yY1~
A ~ ? A
~t~~a
_ _ ~ n
~~{~
a a c a
a ~ ~i
~~
m m
~~
L L
A W
b~~
wa~
A
N
f!1
V
~~
fI
O
~ ~ {
~ ~..
~q r
~ ~ ti':
! L''
~:
~~~„ ,
~~I
~R'
~ I
~y+r 1
r;~
^~= ~~
w. .
c ° 3
9 ~~.i~.
7
~ K
~i. ~ 3
s F
~-
3 ~ ,
~.pC ~, ~
~ r'1
,
~
C 3 N N y~y~. N ,
i
rr \ <JI ffl Y
m ~
•
~ ~ ~
~:
~ s
n
r. R"
~ to p
~
~
ac
~~~~
m m
a ~'
z~
m
~
~
$ ~ $ ~~ ~
.~
'
p ~ 8
y
ep = f ~
~^p s i
E
~
1
,
~f
` 00
O t~+ 4l O
o ~ ~ ~~ i`
i
p
4~YNHS ~ p
p
~O $ .
V.N ,~~ ,
ZS~ ~°~~ ~~~3 ~>
' _ ~ ~
p g ~ y p c ~
~ a+ S ~ ~ ~
~ ~ o ~ ' ~.
- q i
~~~i s '~ ~ ~ ~ 3?x
0~3~~ ~_~ ~~ ~_~
A
~~y ~~ ~'n ~~ m~N
m A ,z v
$. 3 ~ ~ ~ ~
a~ _ ~« NN
~~m ~~ g °~
33 -~ m
m a~ ~ ~ _ o
BANANA REPUBLIC
DfD YOU KNOW...
YOU CAN REDEEM YOUR REWARD CARDS+
AT ANY OF OUR BRANDS:
® ~ ~ ~ ~ PIPERLIII+C~ ~• ~~
aAriAria a>rrueuc
'Pk+ase see your Revnrd Program Terms and Condttlons far dNeAs.
BANANA REPUBLIC aETH RIOHARDS
YO` s.•.w,wr N, wnl.er Id70 fa3~ a 4560 7577
NCO
VISA`CARD
Prevkxls f3alancs
-Payments
+ Fees Charged
+ interest Charged 5165.08
~•~
i~0.00
5~•~
e~ir aalance 1 7.46
Credit umtt ~~~•~
Available Credit 53.082.00
Cash L.(mit ~•~
Available Cash ~•~
Slatemant Closing Date 01!21!2011
Days M Bimng Cyde ~
V!ki! us st esetvice.banenatapllbliacom
Cusbolrler Service:1-666.460.2330
peyrtterit•Intortruf
New Haisnca $t37,d6
Total MlNmum Payment sue ~•~
Payment Dua Date 02M4/2011
Late Payment Warning: ilt we do not roceive your miNmum
payment by the date Ikted above, you may have to pay a lat8
fee up to 536.00.
MMinalm Pi~-ment Warning: It you matte only tlw r~~um°'
payment ee~ch period. You will pay mate In tn6erest alai K witl
take you lodger to pay oft, your balance, For exampie:
i~ you make ntt; `i~ou i*y n~.' 'i~ ka~iw~l «,a
~
additional chargill; trtw~elsarce. ~P i?eY~?It ~'
. usln~q,ttiis card rtl(;Prl t6g1: aatirixtpd~totnl
and~aaCh`monitl ~ ~' : ~ :..
you.pay ,::. iibioul:.=
Only rl9 MinMum 8 5148.00
payment mar101s
It you would Ilke Inrarrnedbn aboat cnedlt coan=allnp
services, sell 1.877-302~8775.
Rewllyd~~,Symm'aty!,~~'.' Account News
Beginning Poirris Balance 780 Thankyou for shopping with us. Each purchase feeds to
Points Earned in Our Stores' 0 Rewards. Enjoy a 110 ~tawarcl Card for awry 1,000 points
Total Points T88 ~ earned. You're 214 polrris awayfrom your next Reward
POINTS TO NEXT REWARD 214 Crrd. Happy shopping!
w _E ___._
Transactlotz Sumrrxlry,
Tran Date Poet Gate Raferonce Number Deecriptlon of Transaction or Credit Arnaurat
"Purchases in Our stores (Oep, Old Navy, Banana Republic, PipsMrfine and Alhlehet)
Otft~er Transactions {yes, etooorias, etc.)
01/17 01117 7447984oH00Y90MM6 PAYMENT - THAN K YOU (~•~}
(Contlnued on nextpage)
PA~GM.I<d.7~~E~C~_~M. r Tf oN TH~Q.41E.j29I~:
NOTICE: We may corwert your payment Into en electronic debit 80o reverse for deWle, BlMing Rights and other fmportent
intormatlon.
6514 e0M el#N 1 7 19 110IZ1 pA6E 1 of 3 3179 1000 E40i DIFA6544 101730
_ _ _ ~ _
- -- -__
'"~~' WEST SHORE EMS -ALS ~~ orscove~ v _~
~`~ 205 GRANDVIEW AVE SUITE 211 Ira "'"'~
4n I
~~~ CAMP HILL, PA 17011 oN REVERSE sIDE
~~~~ ~~~ Phone ~: (800) 367-0512 Federal Tax ID: 23-2463002
31
PATIENT NAME BETH ANN RICHARDS INSURANCE: HIGHMARK pp
PP1
CALL NUMBER: ~ 100071A DATE OF CALL: 01/01!2011
FROM: 131 TORY CIRCLE
TO: HOLY SPIRIT HOSPItAL
ACCOUNT SUMIIAARY
BETH ANN RICHARDS
131 TORY CIR TOTAL CHARGES: 996.74
ENOLA, PA 17025 PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 996.74
DETACH ALONKi PIRF•ORATIdN ANA RET'lIFiN 37'U8 WfTH PAYMENT
DESCRIPTION OF CHARGE DUANTITIC UNiT PRICE AMOUNT
ALS EMERGENCY LEVEL 1 A0999 1.0 967.62 967.62
ANGIOCATH (14-24) A0394 1.0 6.72 6.72
EKG ELECTRODES (1) A0396 4.0 0.80 3.20
EXTENSION SET 8" NEEDLELESS A0394 1.0 12.52 12.52
GAUZE PADS A0382 1.0 0.20 0.20
INF CONTROL GLOVES (PR) A0382 2.0 1.00 2.00
OP SITE A0394 1.0 1.92 1.92
SALINE PREFILLED SYRINGE A0394 1.0 2.56 2.56
Total Charges 996.74
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~- =986,74
RETURNED CHECK FEE - X31 _bD
PATIENT NAME: RICHARDS, BETH ANN CAU NUMBER: 1100071 A AMOUNT PAID:
03/03/2011
IMPORTANT MESSAGES: This account is now PAST DUEII Payment must be n3ceived
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS -ALS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
WEST SHORE EMS -CARLISLE
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
{800) 367-0512
Federal Tax ID: 23-2463002
Credit Statement
As Of 07!11!2011
Patient Name: BETH ANN RICHARDS
Guarantor Name: BETH ANN RICHARDS
131 TORY CIR
ENOIA, PA 17025
f>escriction of Payment! Credit
Private Payment 1 Check
Patient Number: 97223
Call Number: 212960W
Date Of Call: 01/15/2011
Receipt Number Crodit Date Amount
1042 06/13/2011 176.10
Total Payments l Credits As Of 07/11/2011 176.10
Total Charges As Of 07/11/2011 176.10
Current Balance 0.00
__ _ _ _ _ T
WEST SHORE EMS -BLS
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
(800) 367-0512
Federal Tax ID: 23-2463002
Credit Statement
As Of 07111!2011
Patient Name: BETH ANN RICHARDS
Guarantor Name: BETH ANN RICHARDS
131 TORY CIR
ENOLA, PA 17025
Descriction of Pavment /Credit
Write Off- No Estate
Private Payment /Check
Patient Number: 97223
Call Number. 1100902R
Date Of Cail: 01/14/2011
Receict Number Credit Date Am un
07/11/2011 858.93
1052 07/11/2011 400.00
Total Payments /Credits As Of 07/11/2011 1258.93
Total Charges As Of 07!11!2011 1258.93
Current Balsnce 0.00
1
WEST SHORE EMS -BLS
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
(800) 367-0512
Federal Tax ID: 23-2463002
Credit Statement
As Of 07111!2011
Patient Name:. BETH ANN RICHARDS
Guarantor Name: BETH ANN RICHARDS
131 TORY CIR
ENOLA, PA 17025
Description of Pavment !Credit
Write Off - No Estate
Private Payment /Check
Patierrt Number: 97223
Call Number: 1100752
Date Of Call: 01/12/2011
Receipt Number Credit Date Amount
07/1112011 856.19
1052 07/11/2011 400.00
Total Paymerrts i Crodits As Of 07H1/2011 1256.19
Total Charges As Of 07/11/2011 1256.19
Current Balance 0.00
_ _ ,
WEST SHORE EMS -BLS
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
(800) 367-0512
Federal Tax ID: 23-2463002
Credit Statement
As of 07/11/2011
Patient Name: BETH ANN RICHARDS
Guarantor Name: BETH ANN RICHARDS
131 TORY CIR
ENOLA, PA 17025
Desolation of Payment /Credit
Write Off - No Estate
Private Payment /Check
Patient Number. 97223
Call Number: f 100446R
Date Of Call: 01/07/2011
Recefot Number Credit Dad Amount
07/11/2011 734.41
1052 07/11!2011 400.00
Total Payments /Credits As Of 07H 1/2011 1134.41
Total Charges As Of 07111!2011 1134.41
Current: Balance 0.00
WEST SHORE EMS -BLS
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
(800) 367-0512
Federal Tax ID: 23-2463002
Credit Statement
As Of 07111 /2011
Patient Name: BETH ANN RICHARDS
Guarantor Name: BETH ANN RICHARDS
131 TORY CIR
ENOI.A, PA 17025
Description of Pavmerrt I Credit
Write Off - No Estate
Private Payment /Check
Patlerrt Number: 97223
Call Number: 1100386R
Date Of Call: 01/06/2011
Recelot Number dit Amount
07!11/2011 801.29
1052 07/1112011 400.00
Total Payments /Credits As Of 07N1/2011 1201.29
Total Charges As Of 07/11/2011 1201.29
.Current Balance A.00
~ c~Sa-..
WEST SHORE EMS -BLS
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
(800) 367-0512
Federal Tax ID: 23-2463002
Credit Statement
As Of 07/11/2011
Patient Name: BETH ANN RICHARDS
Guarantor Name: BETH ANN RICHARDS
131 TORY CIR
ENOLA, PA 17025
Description of Payment 1 Credit
Write Off - No Estate
Private Payment /Check
Patient Number: 97223
Call Number: 1100253R
Date Of Call: 01/04/201 i
Receipt Number Credit Date Amount
O7N 1/2011 858.19
1052 07/11/2011 400.00
Total Payments / Crediffi As Of 07/11/2011 1258.19
Total Charges As Of 07/11/2011 1258.19
Current. Balance 0.00
~`
U
tfJ
31.'
~,
LJ.. p
ti
r
C '
~
-~
~ ~
C
~ ~
a t[Y
~ ~ ~. ~
~xE
~,
~' ~ `
~ ~ U
d
~ O
(, Q
~,.,
C
~ N
+; C
G ~
d
E d
~ ~
a
u ~-
E i6
L.~.
o ~
c ~
® d
C
C
d r0
~ c
~ o
a a
O
y ~.r
C
u N
~ ~.
Q
~. b
d ~
O
M
h
>~O
e
s
0
C
E
N
0
~O
a
h
h
N ''
.~
N
n
a
ie
~.
m
d
tD
.a
n
m
m
J
M
u
r
A
7
+~
d
o.
J
J
U
N
J
r ~ = d.
N m ~ O
r ~ V '' C
r
O
~UQ-~,
~ r~~=
I
.~~~~
m Z ~
u
~,
~a
Qi
o ~
oya ~-.
_~
L
h~
i} ,~
C
- a_
'~,~
~. ,,
ti
4;' ~
~. a.~
~V
41Y'ii~~S
~;C
~ ~C
~,~
~~
~o
E
~~
~ ~
b'
w
~ -..
~.
,~_
~~
`~
~,, 4i
~' ~.,
v
„p
0
0
O U 1~C
eO 1'~ h
st N hN-,
r ~"
Q l~f!
~ r
oa
r to
N
OQ QQ
~n
N
C
V
m
W .,,,,
~~_w
,~ ~ }•-
r r_
c i NN
i'
`~
l~
~.••~
i
t
i
~ ~
Zi ~
UJ ~
~~
nj
~~
~~
1]
Y~
.~. ~
~` i
i
Z ~
Qr
t
d
ai
Z~
O~
H~
O;
m,
z'
~~
~~
F- ~
~~
~~
O~
Z~
Qj
s'
i
~~
o~
i
t
t
i
1
1
i
r
t
1
t
t
t
t
r
t
1
f
~~ ~ ~ ~
N
m«~~ ~
c ,~ ~,, m ti ~ 'v
mgE~o~~ z ~ $.
~- ~
~~~ao~~ c ~~ ~u
~~~~aQ ~ ~~ ~m~
.~ a~~o ~ ~,~ ~
~~.~~~~~ ~ ~~ we
mE~-mc~o~o` ~~ t~E ~~m
'~ ~ t0 ~ ~G rte- Q ~ fig r N
~~
~~
~, ~ ;,
~~
~ ~~
~~a
~~~
_3~
°°~°Q
e°+ ~1`~ U
o:
o
~~og o
.~-1 ~ 1ft ~ O
OO~N
as
c E m
m a C
~ ~.~ ~o
~ ~-
m,-,c~C +N
~~~,, ~?
..~ c~
~~~~
~ a •ac a o ~
d ~ ~ r
~~~e+a~
oo~io
ea
~~::~Z
m ~ w
Z E ~ ,~ ~
~m._~~
a ~ ~ d ~
~ W
ch~o~ v
"- a_w
~- L m c ~ 00
~~~•5~+
o~WW~
o ~ ~~~o
u~~ ,~ mt3C~.
`m~~~$~~
o g~_
~~o~~
~ N
~o~m~°~
~~~~~a~
a~ ~ ~~.~~
a
W
W
J
m
:= iii rri ;r
~`~c~
11470
. Heritage Medical Group®
Listening, caring, leading.
PATIENT REFUND
DATE: March 16, 2011
FROM: HERITAGE DIAGNOSTIC CENTER
PAYABLE TO: BETH RICHARDS
ADDRESS: 131 TORY CIRCLE
ENOLA, PA 17025
RE: Patient: BETH RICHARDS
Date of Service: 12/202010
Ticket #: HDC166790
AMOUNT OF REFUND: $66.00
Check Number: ll" v 1.~( ~-
Reason for Patient Refund:
^ Duplicate Payment
• Paid By Your Insurance Company
°.'• No Copayment Necessary for Services Rendered
^ Overpayment
~' Others, Please Explain:
If questions, please contact us at (717) 909-7118 ext.14
Thank you,
Julie LewislBilling Specialist
Please deposit or cash the enclosed check within the next 90 days. We realize this may be a small dollar
balance, but we are required to refund this to you. If you do not cash this check, it is consider+~d unclaimed
property and after the required waiting period, must be tamed over to the PennsyNan/a Treaswry Department In
accordance of Pennsylvania Unclaimed Properly rules.
Unclaimed balances as small as;.01 must be turned over to the state fund, so please assist us in our
compliance efforts by depositfng or cashing this check. If you should have any questions regarding this
matter, please telephone our accounts payable department at 717-761-0208.
Lust Revised: 8/30/10
107
Myers Funeral Home, Inc.
l3ovd L. trMera Jr.. Suparvhar
37 Eaal t#In Sfnet
AAechsntcabtrrq. PennavNanla 17055 Far (7171795.7291
(71717a63I21
STATEMENT OF FUNERAL GOODS AND SERVICEoryS SELECTED
fhy u~saiected etyfunreral tl,atamay~requireatemb m g, such as~trtfuner i wItL vie viur~g, yoyu may iu a to paytfaoryr rnbautlm g• You do a Navat° pay for embalming yougdldt aot
approve if you selected arrangements such as direct cremation or immediate burinl. If we charge you form embalming. we wilt explain why below.
For 5ervitxs of Beth Ann Richards Date Of Death ~ 13 Z o ~t Date of Contract / 2 Z v r. {
Charge to Jcssica Miller y zro
A. CHARGE FOR SERVICES SELECTED: C. 3PECIAL CHARGES
1, PROFESSIONAL SERVICES Forwarding Remains to other Funeral Home S
Services of Funtral Director and Staff $ 2093.00 Receiving Remains form other Funeral Home S
Embalming $ Immediate Burial r S
g Direct Cremation S
Casketing, dressing, cosmetolo~_. 95.00 S
Other Preparation of bodv S~_
S SUB-TOTAL OF SPECU.L CHARGES C S
S
S
SUB-TOTAL PROFESSIONAL SERVICES Al S 2,190.00
Z. USE OF FACILITIES AND SERVICES
For visitation / wake service $ 287.06
For funerel cereanon~ $
For memorial service $ 525.00
Equipment do services Cor graveside service $
SUB-TOTAL FACILITIES AND EQUIPMENT A2 $ 812.00
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Homc $ 350.00
Hearse (Casket Coach) ~ $
Flower Car 1 Floral Distribution _ $ Incl
Family Car S
Lead Car / Clerg}• Car $ 195.00
Utility Car ~
Out of town transportation $
a
SUB-TOTAL AUTOMOTIVE EQUIPMENT A3 $ 543.00
TOTAL SERVICES, FACi0L1TIES, AUTOMOBILE A S 3,547.04
B. CHARGES FOR MERCHANDISE SELECTED ,
Casket S
Other Receptacle Cardboard Cremation S 100.00
Outer Burial Container S
Acknowledgrrtent Cards _ S!'rfncl
Register Book ~ S
Memorial Folders a^~~
Prayer Cards 5.~.---
Temporary Grave Markers
Burial Clothi 5.---
Other Clothing $
Cremation um $
Shcet Bronze Urn $ 50.00
pg e o so t rott2e S~
TOTAL MERCH SELF D B S 445.00
D. CASH ADVANCED
Opening GravelCrypt $
Newspaper $ 200'00
Newspaper $
Clergy !Mass Offering $
Certified Copies of Death Certificate S 90.00
Family Flowers Flowers Ordered $ 1 ~•~
Coronet's Au orization Fa S 25.00
Cretnatory Fee S 225.00
Nombe' Bud Vase $ 175.00
$
SUB-TOTAL OF CASH ADVANCED! St Dae Date Calc S 821.00
We charge you for our serviexa is obtaining the following:
....~.,~
TOTAL ABOVE ITEMS (A,B.C.D) S 4,813.00
Sales Tax (if App) Q 0 % S
TOTAL OF ALL SECTIONS $ 4,813.00
LESS: Payment Made S
LESS: Credits Paneling $
LESS: Otltu Credita/Paymenls Packa^___ge_PrEce Discount S 772.00
BALANCE DUE _ "~ Z'~~. $ 4,041.00
A late charge of 1.SaYe per month on the out landing balance (ani °I a of 189~G)
will be added to the balance.
REASON FOR REQUIRED SERVICES OR MERCHAtYDISE
DISCLAIMER OF WARRANTIES
Our hut~M home makss rto reprasentagqons or warranties regardi~ castcets
or outer bural container. The Doty rwiarr~ttties, expressed or implied, granted
In oonnerdlon with goods sold wkh the funeral service are the expross written
warranti~as, B any, extended byy the manultaGunr theroof. No other warrsrttle:
1rtcludMg the implied warrantks of metchantsbUity or titnesa for particular
purpose are extended by the seller.
requested. I acknowledge rece+p~ yr u wMr ~~ .•~~~
payment of the cash price for,the yodels tend servii
liable with anyone else who signs below. A U#7E+
the data of thisayconiraci. (will also pay the Funerz
beoi'selelecect~ on the foal bifltt I aeluiceow that a
General Price L+sl was given to me poor o my ma
(Seal)
Purchaser
(Seal
Pure aser
3% er annum} vvill'E>e applied to the uttpatp oalance oegatnm ,~+ ~pr~ a„a~
alr~b the Funegral Dire or to coksct'anwuntspp love undaegr is agreement.
Burdlsl~C n~ rear Pr~'ice List wersromade atvail~abtet o mehand That a copy of t ~a
~/~r z dry
Go tc
yens tcense unera Directo
_ _~
~ ~ N
r
} ~ ~ O
~ ~~r a~i
V ~ ~ ~ O
~~~-' ~
u
V ~ C
v=a~~~
wctN~~~
O o ~p ~
.~ 1-
~ ~ T ~_ U
~ ~
0 ~
oI
t
{
1
rJn
V
m~
~i
~~
o
f
1
J
> rJ/
N
?- ~ f
a`¢~{
~j ~ >I
~+ 1 ~
V ,,. j I I
~ ~ ~'~ ~
Z ,~ °'
~ ~~ Z ~ tyo~ i
?~ ,.
E
~~JJ S
k j~' ~
!J
i
~ 4 ~ b'
. (~
a
~.i~ I i
i
o I~
i
Z
y
~i
V
~ ~~
C~
~ I I~~c~~a~~ ~Qe~ad~
RECEIPT FOR PAYMENT
GLENDA FARMER STRASBAUGH Receipt Date: 2/07/2011
Cumberland County - Register Of Wills Receipt Time: 09:22:52
Receipt No.: 1064299
One Courthouse S uare
Carlisle, PA 1713
RICHARDS BETH ANN
Estate File No.: 2011-00150
Paid By Remarks: SICA MILLER
HMW
__________________ ______ Receipt Distrib ution ----- -------- '-" ---- --
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 260.00
00
15 CUMBERLAND
CUMBERLAND COUNTY
COUNTY GENERAL
GENERAL FUN
FUN
WILL
SHORT CERTIFICATE .
28.00
2 CUMBERLAND COUNTY GENERAL
S
R FUN
JCS FEE 00
5 BUMBERLAND COUNTY GENERAL FUN
AUTOMATION FEE .
----------------
Cash
Total Received.... $331.50
..... $331.50
__ - i _ _I
TaxDB Result Details
r)Ptailecl Results for Parcel 09-14-0835-273. in the 2010 Tax Assessment Database
C1GrnStst
TazEz 1
SaleAmt 124900
SaleMo 07
SaleDa 30
SaleCe 20
SaleYr O1
D~ggpage 00247-03213
YearBlt 2000
HF File Date 11/03/2004
~ Approval Status A
CouK~ rk.lla.ye._
R~ 0.002045 x
~yP.sjo~,Q J~lue,160 ~ 300 • _
tot 1 f,GUw{~')Zk~ 327.81
0. C
'ry~,,~. (M~ V~~ 00095700 X
~ 160300• -
153.40
Zotl i~•'~'w
0• ~
327.81 +
CDu~3 ~ 153.40 +
~p~L`///~~~lp~ /r~/_e 481.21 0
~~^r ~_ ~,^~ i r8 i • L1 X
_- ~ 0.98 =
~; Zg ~'~ 1;71.58 ~
~_""~
http://taxdb.ccpa.netldetails.asp?id=09-14-083 5-273.&dbselect=l
Page 1 of 1
9/28/201.
c
0
a
0
0
N
0
a
O
a
m
rrrrsx vaaa v_
Appr ~~CCCwNNNV,NN~zzzzz;~~~000mOD~-ODDS u,
v~~000pxxsm00 ~ -iovm 3'0;~0~,9
aD>D Om~~~ccc~~v~z7oz~ zva~~f ~ 7Ck
CCC= ;~~~7m0~~~ix,jmm~~~r~c~pmZ7mo7mo7mo~mmm ~~_ ~
t/~WtA r~ D zzOz3r ~rmN-3"DmrzZO mr
rrrz mm~~ra-z3;~ztnv~~ m;C7.~.i~A-~r r zz~ r
mmmm ~z- rg~ v W "+~ ra -~ a
z~+t~n ai~'~zmlv"i~~ccN vrO~ov~-IOD~zz~OOOO 70700
vv~x cmz~~omzczioc~0i~=o ~ ~8z°7c0Z~-~o ~~~~oo
aD>~ ~~-~oo~o~-+~-,ao~~ocz°c~iz~ao~~~=o~ ~c
zzzm av°o~ozpOOOoo ozc~v~_u,~o=_~~b~xx_.~-~s x=
lmCXk ~p~-IN=p~Z~~O ~O~ O 0 ~7ow0= ~ ~~
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ _ ~ fA C C A ~ N ~ S
22 N 2 S = A A = 2 ~
n
0000 00000000000000000000000000000000o O
°o°o$o °ogg~oo°oo°o°o$°oo$$o$°oog°o$~$o°oo$°oo$$o°o
N N N N oNo N N o No Noo N N N N N N N N N N N N N N N N N N N N N N N N N N N N
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O O ~ ~
p C O C O 0 0 Z
oo pQ, p op~j$~pp$°~°ppo_o~$~~$~~g$~ssssWW ~ m
W~O WQO~OQ~ O~ON ~Of WNp ~I W ~ tNT N~.O ~tO0A00 'p ~"I
OOi COT VOi W ON OtN0 t0 V OWD CJ1O~ C71O ~l OfO OD OD W OOG7~C71 p~ppO C11N
W p~ OD A O O 0001 CIA ODN ~
sss~ s~ ~oo~ ~~sso~~s~~s~s~~a~sssss~ss m
0000 00000000000000000000000000000000o N
oooc ccooooocooocoo_cc_ooooo0p0~p0~00p0000_pp0~00 =
~~~ ~p-~'~pa~~p1~~~~~~~~p~1 p1 A~p1pW ACCA OOSOI CTN OD'O ~N
AAA 01000A0~ W OA W W OOOo00f Of 0ONN~l
ppp 0o W v~1 pOO ~gaiO 0~t07ba~N~Caal fpT f7p~pppp p8S8p pp p pp81Qy8
S S ~ 00 0 0 0 0 0 0 0 0 0 0 00 00 0 0 0 0 0 0 0 0 0 00 O O 00 O O O v v V O O
O O O O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O
O C O C C C C C C C C C C C G O O O O O O C G O O O C C O O O O O O O C C a
J J~ J J J ~ j
~~~~ ~~~~'~•+~~~~~ J~~ V OlA tp iO fON
m SQOi~ vW+pp~NON V Vii ~~Nppp~~N~~(07f~A p~l tNppON~pp <O OO Oppi tpp0 f7~0pp 01 jpp Wpp Cppl r
O O O O S O O S O O O S O p O O~ 0 0 0 0 0 0 0 0 S 0 0 0 0 0 0 0 0 p 0 0 N
C A
fT U1 fT U7 Cp71 01 01 01 01 01 CT (T CpT CT 01 01 W Vt Vpt Vt W CppT CT Vt f)1 01 Vt 0p1 O Vt V7 N U flppn 01 Cpp71 tll C
O O O O S O S S O O S S S S S O S O O O O O O O O O O O S O O O O p O O S
3
c
z
ZzZS" ~'ZC1iy+ZZZY'v~cnZZ~yly,ocnZrnyicnrncny+aicnZcl,cngcl,zz
o c~oo~~~ o~~ O°o$Do$og$°o °ooDooDoDD ,A-o
DDDo oDooDDD$$oDD$ooo D
r
N
C'1
ZZZZ rntntnrnZcnZ~+ZZa~cnt>ttnZcnvtcnZZZZtrcl+v+cncn ZZZ~v'Z~' SO
O O C O~ O~~ C O Q O 0 0 0 0 0~~ O H O
DDDD ooooD$DoDDc$$ooDgo$DDDDoooooDDDoDo O
r
3
c
o z
DDDD DDDDDDD`DDDD~DDDo`D$DDDDDo2~SDDDDDDD
r
zzzz zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz s
DDDD DDD`DDDDDDDDDDDDDDDDDDDDDDDDDDDDDD C
N
cna~cliv,Za+ZcnZ orna~cnZa+vta+ZZZZ~cncncna~a+ZZZU'ZO =
z zz ~~' oo~oo$DDDD$ooo°oT+DD$D$ O
DDDD ~°oo°oD$D°oDD$$ooDoo O
r
m
n
D
n
A
C
a
0
z
70
m
N
v
m
Z