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Home My WebLink About11-18-111505611180 REV-1500 ~ (°2-"~ iFi, OFFICIAL USE ONLY Pennsylvania PA Department of Revenue OEPART6ENTOFREVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 260601 ~ Harrisburg PA 17126-0601 RESIDENT DECEDENT ~ ~ - ~ ~ - C.~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 172-46-4021 12202010 12221955 Decedent's Last Name Suffix Decedent's First Name MI MCKINSEY JULIE MAE. (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Retum 0 2. Supplemental Retum 0 3. Remainder Retum (Date of Death Prior to 12-13-82) 0 4. Limited Estate ~ 4a. Future Interest Compromise (date of 0 5. Federal Estate Tax Retum Required death after 12-12.82) ® 6. Decedent Died Testate 0 7. Decedent Maintained a Living Trust 0 - a. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy afTrust) 0 9. Litigation Proceeds Received Q 10. Spousal Poverty CredR (Date of Death Q 11. Election to Tax under Sec. 9113(A) Between 1231-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHW LD BE DIRECTED T0: Name Daytime Telephone Number ROBERT G. FREY 7172435838 First Line of Address 5 SOUTH HANOVER ST Second Line of Address City or Post Office State ZIP Code CARLISLE PA 17013 Correspondent's e-mail address: R F R E Y a F R E Y T I L E Y. C O M REGISTER 0~1lVILLS USE ONL'1' ~n ~ . `' `T,7 "_ rte' ~ " ~' ~`--ern ~~~~7 CO ~c~c3 -n ~. DA L~D ~7 -_r7 '--; is ~ - • -7 C -y ~ -, ~--~} ;; ~r ;.n Under penalties of perJury, I declare that I have examined this return, including accompanying schedules and statemerns, and to the best of my knowledge and belief, it is true correct and complete Declaration of preparor other than the personal ropreserrtative is based on all infonnation of which preparer has any knowledge. SIGNATURE OF P~SON RESPONSIBLE FOR FILING RETURN DATE ADDRESS DATE 5 SOUTH HANOVER STREET, C,l~~.ISLE, PA 17013 L 3E USE ORIGINAL FORM ONLY Side 1 L 1505611180 1505611180 J~ 1505611280 REV-1500 EX (FI) (Decedent's Social Security Number Decedent's Name: JULIE MAE MCKINSEY '172-46-4021 RECAPITULATION 1. Real Estate (Schedule A) ........................................ . 1. NONE 2 443.00 2. .................. Stocks and Bonds (Schedule B) .................. . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... 3. N 0 N E 4. . Mortgages and Notes Receivable (Schedule D) ....................... . a. NONE 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) .... 5. 36428.00 6. Jointly Owned Property (Schedule F) [Separate Billing Requested ....... 6. N 0 N E 7. Inter-vvos Transfers & Miscellaneous Non-Probate Property Separate Billing Requested ....... 7, N 0 N E (Schedule G) 8 3 6 8 71.0 0 8 ........................ Total Gross Assets (total Lines 1 throuoh 7) . 9. Funeral Expenses and Administrative Costs (Schedule H) ............... . 9 1129.00 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ 10. 61295.00 11. Total Deductions (total Lines 9 and 10) ............................. 11. 6 2 4 2 4 . 0 0 12. Net Value of Estate (Line 8 minus Line 11) ........................... 12. - 2 5 5 5 3.0 0 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which 0 . 0 0 . an election to tax has not been made (Schedule J) ...................... 13. 14. Net Value Sub ect to Tax Line 12 minus Line 13 .......... . 14. - 2 5 5 5 3.0 0 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 (ax1.2) X .0 0 15. . 16. Amount of Line 14 taxable at linealratex.o 45 -25553.00 1s. 0 . 0 D 17. Amount of Line 14 taxable at sibling rate X . 12 17 0 ~ 0 0 18. Amount of Line 14 taxable 0 0 0 at collateral rate X . 15 18. . 19. TAX DUE .......................................................19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 0.00 L 1505611280 1505611280 J R~y_t5pp EX (Fi) Page 3 File Number Decedent's Complete Address: STREET ADDRESS , ~~ 5 Z t.~ e s1- t ~~ ,.~ CITY Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest Z~_ 1 I -ooos STATE Total Credits (A + B ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box 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 172-46-4021 (1) o.oo (2) 0.00 (3) (q) 0.00 (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: • .................................................. a. retain the use or income of the property transferred ...................... .. ...... . Yes ...... NS fb-U'' n;tain the right to designate who shall use the property transferred or its income ..................................... b ..... ^ . ..................... ...... ^ c. retain a reversionary interest ............................................................................................... ? .... ^ ............................................................. d. receive the promise for life of either payments, benefits or care .. 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................... ...... ^ unt or security at his or her death? ...... k th b " " ...... ^ acco an orpayable-upon-dea in trust for 3. Did decedent own an 4. Did decedent own an individual retirement account, annuity or other non-probate property, which ......... ...... ^ contains a beneficiary designation? ..................................................................................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the 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 disGosure 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)j. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX+(6-98) SCHEDULE B COMp,,OpryyEALTHOFPENNSYLVANw STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT. DECEDENT ESTATE OF FILE NUMBER Julle Mae McKlnsev 7 I - l a Oo All property Jointly-owned with right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM NUMBER DESCRIPTION OF DEATH 1. 10 shares of Met Life, 44.30 ave. price per share 443 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (11-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY FILE NUMBER: ESTATE OF: Julie Mae McKinse 2. ~, '" l ~ ` C~t>O S 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 3cheduls F. VALUE AT DATE ITEM JMBE 1 2 3 4 5 6 2005 Ford Explorer, repossessed for balance owed 11,520 Pick up, repossessed for balance owed 7,392 2007 Honda Sabre 1100 motorcycle, see recent eBay sales prices attached, valued on payoff 7,881 300 Landscape trailer Household good and furnishings, see list attached 7,430 Federal Income Tax Refund 1,905 TOTAL (Also enter on line 5, Recapitulation) $ I 36,428 If more space is needed, use additional sheets of paper of the same size. REV-1511 Ex+(10-09) SCHEDULE H ' Pennsylvania DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT FILE NUMBER ESTATE OF Julie Mae McKinse 2 (- ~, l ^ y ocs ~ Decedent's debts must be reported on Schedule I. ITEM AMOUNT NUMBER DESCRIPTION A. FUNERAL EXPENSES: L B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 2. Attorney Fees: 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) e•.m• ea,~.e~~ __ 4. 5. 6. 7. Ciry State ZIP Relationship of Claimant to Decedent - Probate Fees: Accountant Fees: Tax Return Preparer Fees: ~ertisina costs to the Sentinel and Cumberland Law Journal 750 127 252 TOTAL (Also enter on Line 9, Re If more space is needed, use additional sheets of paper of the same size. REV-~ st z Ex+ (~ 2-oa> pennsylvania SCHEDULE 1 DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES 8c LIENS FILE NUMBER ESTATE OF 2 ~ _ ~ ( _ p OO-~/ Julie Mae McKinse Report debts incurred by the decedent prior to death that remained unpaid at the date of death, Including unreimbursed medkal expenses. VALUE AT DATE REM DESCRIPTION OF DEATH NUMBER 1. 980 Hershey Medical Center 2. Martin Army Community Hospital 18,252 14,294 3. Rent claimed due by Landlord 1,465 4. GE credit 11,520 5. Ford Explorer car loan 7'392 6. Pick up truck car loan 7'392 7. Honda Sabre loan TOTAL (Also enter on Line 10, Recapitulation) I S 61,295 If more space is needed, insert additional sheets of the same size. Register of Wills of County, Pennsylvania INVENTORY Estate of Julie Mae McKinsey No. 21-11-0005 also known as Date of Death 12/20/2010 ,Deceased Social Security No. 172-46-4021 Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/VNe verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unswom falsification to authorities. Attorney I.D. No.: Address: Dated - Telephone: Description Value `~ 'D ~~ R~~ m `~ ~ ~~ ~~-cam Y ~5O . . ~d~~ ~ ~ '4~a~~~ 50 .~ n bL~n. t~.a ~ c~5o .~ . . G.a~a~C. ~ t~ 35 ~°~ (Attach additional sheets if necessary) ~1 Total: -F NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. ~.~.., ~1 ~ ~~ ~d. _. _ Po~a...b1.e _~~.h ~_ _ _ _--_ __ __ _ -_ ~ ~ ~.~~. , ~6-~ po ~-, -1 ~,n ~ . s~vi v ~-r?_ _. --- -~~ ~ -_ .. _ __ Po-~ ar1c~ Ra-'~O o `~_ __ . ~ ~ _ _ __ -loo . c~__ __._ _ _ _ _ _ _ __ ~ ~ c~.~ /o . j S c..t...b ~o _ _ yet p-. 3. _D Ta~~ `~ ~~.. __ _ ,l x _ a _ __ _ __. _ - . 00 5 r~~~ C:ha.c~o .' 11 _ _ j o~o ~" ~ Cc.Q . _~_. C~1,Ct~.Qd--- _-- __---------------~---- 1 ~~--- _ ..__- v~~•~' 1 ~~~ _ _ __- .. --___.__ .5!S.!~-. ~_ - .. ~ _ -_ - _. 7 _ __ 7, honda sabre I eBay CATEGORIES Parts 8 Accessories 1015 / 11 4:24 PM __ _. Go l My eBay Self Community Customer Support Welcome! Sian in or register. ELECTRONICS FASHION MOTORS TICKETS DEALS CLASSIFIEDS Cars & Trucks. Motorcycles. Powersports, Boats 8 More. MY GARAGE TIRE CENTER LIGHT CENTER honda sabre _. ~AII Categories :~' Advanced Related Searches: gas station light, honda sabre 1100, honda sabre 2010, honda stateline ~ Include description 9,100 restaits found for honda sabre Save search ~ Tell Us What You Think? .. ~.. __._,__ ~ ..._ ._ _m ,...~._._.. _ .. Categories All items Auctions only . _ __ Buy tt Now Prooucts & reviewsBe~ Customize view eBay MOtOP3 ffi,859; View as: Sort by: Best Match ~~ Page 1 of 182 Parts 8 Accessories 8,£'s4(I i --~ CU'MFSt: 95-07 Honda Shadow VT 1100 o aids $19.95 3h 45m Motorcycles ; z>> i ' Aero Sabre Spirit ACE MANUAL buy it Now $22.95 Retums: Accepted within 7 days See ali categories l In Motorcycle Parts & ~ , NCiND_A' Accessories Model ~ ... ~,.._ ~_~ __.w ._ . Sabre &:188) _ ._. ...__... ~ _._~_ _. _ Honda :Sabre VT1300 New _.. buy tt Now e _. $9,814.00 20d 21 h 23m VF750 t2.aa1) 2011 Honda VT13000S Sabre Shadow f1,52a) VTX ... VF700 1.40fli Retums: Not awepted VF1100 ;1,04 ~j _. __ _ _.. _ _ __.. _..... Honda VF 700 750 1100 V45 _ o aids _ $19.95 4h 37m VT11o0 X1.0351 V65 Magna Sabre REPAIR Buy It Now $22.95 Magna ('20} MANUAL Ace ("sa9j Expedded shipping available Choose more... Returns: Accepted within 7 days Part Type Body & Frame (2.'4?; Engines 8 Components '985} Antique, Vintage, Historic 1764) Brakes & Suspension (848} Accessories i632) ~~' Electrical Components (802? Lighting x4241 Cooling System (2431 Choose more... Condition New ~:s,287i Used i4 1 - t;l Not Specified 11,8251 Choose more... Honda :Shadow 1100 Sabre Black w/ HOT ROD FLAMES 2007 ... Retums: Not accepted Buy It Now $4,690.00 23h 6m Honda Shadow 750 1100 VTX 1300 1800 CHROME 7" RISERS Retums: Accepted within 7 days Price 1982-1988 Honda Magna Sabre g `to 3' V45 V65 VF 750 1100 MANUAL Returns: Accepted wthin 7 days Part By Region Asian 1'.3251 r Other Parts (448) . '~O' American 85; British 8 European (9) _.__. ~ ... _ .. .__._........ -- ' a r ~ P„~ - Honda :SABRE 1300 VT1300 - I Not Specified tfi10 ~ ~ ~ ' ~i ~ VTI3CSA New 2010 Honda V Choose more... SABR... o ales $39.95 euy It Now $44.95 . -12h 43m o Bids $17.95 1d 5h 43m euy It Now $19.95 suy xt Now $9,729.00 6d 22h 9m or Best Ofrei http:/Iwww.ebay.com/sch/i.html?_nkw=honda+sabre Page 1 of 7 honda sabre I eBay 1015111 4:24 PM ................_......... . .. ............ . ..................................__. .............. 0 Bids 534.95 1d 7h 41m Buy it Now $39.95 Show only Expedited shipping Returns accepted Free shipping Completed listings Choose more... _.... Location Honda .Shadow Sabre 1100 ... ~ 2007 Honda Shadow Sabre 1100 US Oniy ~ ty...' ... North America ~..: _ Returns: Not accepted Worldwide Choose more... Distance DuraShield Lined IiAotorcycle _, , . Cover Honda V45 Sabre 2C Customize preferences Returns: Accepted within 30 days Matching eBay Stores PinWall Cycle Parts Inc (4251 EC Cycle Parts Boneyard •,'295) WORLD WIDE MOTORCYCLE PARTS N ... 126j Generation Cycle (2t91 C D U TtA • S~ H ~i~l~.\ R Cotton lined C4vesr otton Lined Motorcycle Cover onda Magna Sabre 1100 2C etums: Accepted within 7 days _. ;, ~ Honda :Shadow Sabre 2007 ii ' ~ Honda Shadow Sabre 1100 VT2 Returns: Not accepted _. CHROME MOTORCYCLE LICENSE PLATE FRAME Returns: Accepted within 7 days DuraShield Lined Motorcycle Cover Honda V45 Sabre 2C Returns: Accepted wthin 30 days Honda V45 Sabre Cotton Motorcycle Cover EZ Pack Med 2M Returns: Accepted within 7 days http:llwyuw.ebay.comisch/i.html? nkw=honda+sabre __ _. _ ._ o Bids $31.99 1d 19h 44m suy It Now $36.99 Buy It Now $4,788.00 15d 3h 5m or Best Offer o Bids $31.99 2d 1 h 21 m Buy It Now $36.99 __.._. o aids $31.99 2d 2h im Buy It Now $36.99 . _..._........ Buy It Now $5,400.00 5d 19h 59m or Best Otter . _ ..................................... . ..............._..... . ._ ................. _..._ ......._... o Bias $8.95 2d Sh 8m Buy St Now $9.95 ... _........... . ......_ ................_.. . o Bids 518.99 2d 20h 11m Buy It Now $21'99 Page 2 of 7 See ali matching eBay Stores honda sabre I eBay I~ D U R A~SHIELD t. ~, f ~ a: ~~-.~~~- Colton UnQtl Gavsr t0/5/11 4:24 PM Cotton Lined Motorcycle Cover Honda Magna Sabre 1100 2C Returns: Accepted within 7 days O Bids $31.99 6d 20h 34m Buy tt Now $36.99 Honda Shadow Sabre Chrome Buy a Now $9.95 Zd 23h 42m or die^,i. offer Backrest Mount 08F75-MCK- 100P Realms: Accepted within 30 days ......__._......_ ........ ..............._..___ .. _._ _. Honda : VF1100S V65 1984 ........_ _. ......................... . .. ......._... t> Bids $1,025.00 m Honda Sabre VF1100S V65 " NO . R... w '~ Returns: Not accepted ~~~~~~y~~~"~"ti"%~': ,.~ ~~~" _.... _ ............... . 82 Honda VF 750 S Sabre V45 Gauges Meters K23 ........... __ . > Btds $65.00 d 4h 11 m Iy~ ~ -- < Returns: Accepted wthin 7 days , , ~,, ,~, t- ~-.. .._ . _._. 1N!'°~ .. Honda VT1100C2 Shadow Buy it Now $11.00 29d 6h 35m Sabre Nighthawk 750 Chrome Trim Returns: Accepted within 14 days _ Honda :Shadow 1100 Sabre 5 Bids $2,500.00 5d Oh 1 m CLEAN SPOTLESS 2007 Honda Sha... Returns: Not accepted `, " Honda:Shadow Honda 1100 sabre Returns: Not accepted .,...._....~.~~.. ~ ...v..,.~, ......_...._. ~ , .... _.. ,..__.v., .. HONDA MAGNA SABRE CX500 CBX CUSTOM CHROME TANK TRIM Returns: Accepted within 14 days .. ,. x T _.. t; Honda :Shadow Sabre 1100 Returns: Not accepted , http:/Iwww•ebay.com/sch/i.html? nkw=honda+sabre 3 aids $1,026.02 2d 4h 53m ._._. r..,._.__ __, ~, Buy it Now $11.00 29d 7h 33m .~ z Bids $1.00 6d 6h 52m Page 4 of 7 1015/11 4:24 PM honda sabre I eBay _. ..._... ......_.... ;w:N.. =' Honda: Shadow 2007 HONDA Buy Tt Now $5,999.00 7d 18h 27m VT1100 SHADOW SABRE Retums: Not accepted _ _ __ Honda Magna Sabre 1100 o Bids $18.99 2d 21h 46m Motorcycle Cover EZ Pack 2M Buy Tt Now $21.99 Retums: Accepted wthin 7 days HONDA VF700 SABRE o Blds ORIGINAL OWNERS MANUAL Retums: Accepted within 7 days honda ~aore Toms Retums: Accepted within 7 days $9.95 3d 4h 5m ............................. Buy It Now $2.20 25d 9h 45m _,.. _.. _. . ~"' KURYAKYN ISO GRIPS HONDA o Bids $69.99 4d 5h 52m SHADOW SABRE SPIRIT AERO guy it Now $76'99 Retums: Not accepted _ _.._ _ __ __. ` ~ `~- W o Bias $7.00 4d 19h 9m Honda V45 Magna, Honda V45 Sabre, Suzuki GS450T motorcy... Retums: Accepted within 7 days Honda Shadow Sabre Chrome Backrest Mount OSF75-MCK- 100P Returns: Accepted within 30 days 1985-2007 Honda Shadow VT 1100 Spirit Aero Sabre MANUAL L , Retums: Accepted within 7 days ! E~onda !. xr~ http:/Ivvyyw.ebay.com/sch/i.html? nkw=honda+sabre Buy Tt Now $9.95 2d 23h 42m pr Best Offer o Bids $22.50 5d Sh 12m Buy It Now $24.95 Page 3 of 7 MARTIN ACH FT BENNING GA 25 Jan 2011 1334 Personal Data - Privacy Act of 1974 (PL 93-579) Page: 1 ',MARTIN ARMY COMMUNITY HOSP MEDDAC, 7950 MARTIN LOOP DEPARTMENT OF THE ARMY FT BENNING GA 31905-5637 HOSPITAL INVOICE AND RECEIPT ----------- -------------------------------- SERVICE: BRANCH OF SV SPONSOR NAME: MCKINSEY,JULIE GRADE: DUTY ADDRESS: BILLING NAME: MCKINSEY,JULIE FMP/SSN: 98/1222 BILL ADDRESS: 1952 WEST TRINDLE RD CARLISLE PA 17013 PATIENT NAME: MCKINSEY,JULIE ACCOUPIT NO: 1130516 ADM: -24 Dec 201~~.2325 ~ DISCH: 20 Dec 2410n~2325 TOTAL CHARGES: .~'~=8251. - 99 ONE TIME CHARGES: CHG CAT QTY CHARGE DATE DESCRIPTION VR 1 18251.99 20 Dec 2010 INPATIENT FEE ----------------------------- INVOICES & RECEIPTS ------------------------------ DATE PAYMENT TYPE PAY CHECK NO. CTRL NO. BALANCE 25 Jan 2011 0.00 11-1113 18251.99 ----------------------------------- l. Payment of this bill is due upon receipt. ~'ou may inspect and copy government records related to this debt to the United States. and question its validity or accuracy. If payment is not received for this debt within 30 days of hospital discharge or outpatient date of service, your account is subject to referral to higher authority for collectian action, involuntary pay checkage (if you or your spouse is_a federa~..employee), and referral to your employer. 2. Per the Debt Collection Act of 1982, interest and/or administrative .charges will be assessed on accounts not paid within 30 days of initial billing. If payment in full is not possible at this time, installment payment arrangements may be made by contacting the TREASURER OFFICE (MCXB-PT at (706)544-5724. k . Please make checks payable to: DFAS-IN and mail to: TREASURER OF-ICE (MCXB-PT MEDDAC, MARTIN LOOP FT BE GA 31905-5637 Prepared by: Received by: AF FORM 1127/DA FORM 3154/NAVMED FORM .7270/1 (CG-CHCS/SAIL) PENNSTAT~ ___ __ The Mikan S. Hers ey 11+1edical Center Patient Financial Services P.O. Box 853 Hershey, PA 17033-0853 Email: HMCBillina(a~hmc.asu.edu Telephone: 1-800-254-2619 717-531-5069 January 13, 2011 Julie McKinsey 1952 W Trindle Road Carlisle, PA 17013 Account #713668 Patient Name: Julie Dear Ms. McKinsey: The Hershey Medical Center has attempted to contact you regarding the above account. There are balances of $957.32 and $22.63 on your Hospital account and if you would like to include it with your existing Budget Plan please contact our office to make those arrangements. Please contact us directly if you have any questions. You can reach us at 1-800-254-2619 ext 5070 or 531-5070 Monday through Friday 8:00 am ti114:30 pm. You can also reach us Wednesday ti115:30 pm. Your help and cooperation in getting this matter resolved is greatly appreciated. Sincerely, r. Brenda Gruber Financial Counselor LAST W/LL AND TESTAINENT of Eugene Mcwnsey Julie Mae McKinsey (Identification /Social Security Number/s) Eugene McKnsey -170-44-5422 Julie Mae McKinsey 1726-4021 1952 West Trindle Road Carlisle, PA 17013 1. Declarat~n We hereby declare that thbi is our last will and testament and that we hereby revoke, cancel and annul aq wipe and codicils previously made by us either jointly of severely. We declare float We are of legal age to make this wiq and of sound mind and that this last wrq and testament expresses our wishes with~t undue influence or duress. 7. Family Details •We have the folbwing children: Name: Eric Eugene McKinsey Date of B'uth 08J28/1974 Name: Michael Shawn McKtnsgy Da6e of Birth 09102M975 3. Appoirrpr+eM of Executors 3.1. 1, Eugene M{cK~seY, hereby nominate. erorurtdute and appoint my spouse, Juge McKinsey, as Execxrtor or if this Executor is tmabie or urnNiging to serve then i appoint Eric McKinsey as alternate Execttor. 3.2. I, Julie McKinsey, hereby nominate. constitute and appoint my spouse, Eugene McKinsey, as Executor o< if this Executor is unable or urnaiging to serve then I appoint Eric McKinsey as atlemate Executor 3.3. I hereby give and grant the Executor aq powers and authortly as are required or agowed in law, and especially that of assumption. 3.4. 1 hereby direct that our Executors shag not be required to famish security and shall serve without arty bond. 3.5. Pending the dishibution of our estate our Executors shall have authority to carry on any business, venture or partnership in which 1 may have any interest at the lime of our death. 3.6. air Executors shall have fuq and absolute power in hisTher discretion ip insure, repair, improve or ~ sell aq or any assets of our estate. whether by pubec auction o< private sale and shag be entitled to let arty property in our estaM on such temps and conditlons as wiq be in the best interest of our beneficiaries. 3.7. our Executors shop have authority to borrow money for any Purpose connected with the liquidation and administration of our estate and to that end may encumber any of the assets of our estate. 3.8. our Exewtocs st~aq have authority tD engage the services of attorneys, accountants and other advisors as he/she may deem necessary to assist with the execution of this last vuiil and testament and to pay reasonable carripensation for their services from our estate. 4. B~neticiary l bequeaifi the whole of my estate, ProP~Y and effects, whether mav~Ie or immovable, wheresoever situated and of whatsoever nature b my spouse. whichever or whoever should outlive the other. 5. Alternate 8eneficiarits not survive me by thirty {30) days 1 direct that the whole of my estate. property and effects, whether 5.1. Should my spouse mp~raete or irrmiovable, wheresoever situated and of whatsoever nature be divided amongst my children named in 2. above n equal shares. 5.2. 1 direct that the inheritance devoMng upon any of my children under my last wiN and testament as weN as the proceeds, the reinvesbrrent of such pn~ceeds ark the income thereon shall be free from the legal effects of arry present or suture marriage of an of my chNdren, whether in or out of community of property including any accrual system and with or without the presence of any pre-manta! agreement. 5.3. If any of my children are proved to be indebted to me by means of a legal instrument, then his !her share of my estate shah be reduced by the amount of such debt 5.4. Should any of my children not survive me and my spouse by 30 (thirty) days I direct that the non-surviving chNd's share goer to his /her natural, adopted or step chNdren in equal shares. 5.5. If my chNdren cannot reach agreement within one year of this wNl coming into effect on how to divide the property bequeathed to them, the Executor shall liquidate aN the property and d'wide the pt~oceeds acx~rding to the shares as directed by me. & Special Requests i direct Ihat on my death my remains shah be cremated and aN cremation expenses shall be paid out of my estate. T. General 7.1. Wonis signiying arts ger><ier shah include the ethers and words signifying the singular shall include the plural and vice versa where appropriate. 7.2. Should arty Provision of this wiN be judged by an appropriate court of !aw as invalid it shah not affect any of the remaining ptrnrisions whatsoever. `` .-~~ ~ day of ~ 0 v e rnb~ Q. 20i at IN WITNESS WHEREOF I hereby set my hand on this ~ the pr~~ of the undersigned witr-esses. SIGNED: ~ , ~/ ~~-~-~•~E~~ McKinsey) SIGNED: G (Julie McKinsey) WITNESSES as witnesses we declare that we are of sound mind and of legal age to witness be of sound mi and signed this w ~ging{Y ands McKMsey and JuNe Mae McKhseY are of legal age to make a will, appea ncx3 ~ we signed as widnesses in the free of undue rnfkrence or duress. We declare that he /she signed this wiN in our presedeciare these statements to be true and presence of each otter, all ~t at the rqe tome u~d~r 2_ pt P trj'rry correct on this .~ ~ -day Iv u ~" wrmess ~. Name: Eric McKinsey Address: 8225 Monroe Court, Fort 8enning, GA 31905 Signature: ~~~'~'"~ `` Mess 2 Name: ,rl -CN~~ • sey address: 4273 Cary t?rdve, SnellviNe, GA 30038 COMMONWEAL ~ ~S~'VANV- ~ndra A.1Cat~tz. NohaN cots<tb S~lwx SP~9 T~•• 10.?A11 rv~y ~ °t ~ires May :~sso:~auon of Notaries M~mb~~. p,:..,., ,