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Home My WebLink About12-19-11J 1505610140 REV-1500 EX (°'-'°~ PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes PO BOX 2$0601 INHERITANCE TAX RETURN County Code Year File Number Harrisbu PA 17128-0601 RESIDENT DECEDENT 2' 1 1 1 1 1 0 7 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYY 2 0 8 1 4 8 9 9 0 0 4 0 6 2 0 0 7 1 0 1 9 1 9 2 5 Decedent's Last Name Suffix Decedent's First Name PET RASH GENE V'I EVE MI g (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 I N APPROPRIATE OVALS BELOW 0 1. Original Return ~ 2. Supplemental Return 3. Remainder Return (date of death 4. Limited Estate a prior to 12-13-82) 4a. Future Interest Compromise (date of ~ :i. Federal Estate Tax Return Required ® 6. Decedent Died Testate (Attach Copy of Will)' ~ death after 12-12-82) 7. Decedent Maintained a Living Trust ~ 8.. Total Number of Safe Deposit Boxes 9. Litigation Proceeds F~eceived ~ (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec 9113(A) b . etween 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED Na me T0: Daytime Telephone Number J I L L M WI NE K A ESQUI RE 7 1 7 2 34 4 1 7 8 REGISTER OF WILLS USE ONLY First line of address n `'-' ua 1 7 1 9 NORTH FRONT STREET ~~ Second line of address _ -I- r ,.~-_ r -r~ ._.. .. City or Post Office State ZIP Code D~T~,.TtLE't3 ~' HARRI SBURG PA 1 71 02 -~ _~ .. -> C. Correspondents a-mail addrelss: jwinekaCcapkh.cotn Under penalties of perjury, I deGare t at I have examined this return, including accompanying schedules and statements, and to the hest of my knowledge and belief, it is true, co and complete. Declatation of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATUR F PERSON RES~N IB FO ILING RETURN CCCC~~~ r DATE ADDRESS • ~ - ~' ~ ~ Cathleen E. Schmidt 330 ercu Drive Mechanic SIGNA E R ER TH THAN EPRESENTATIVE ADDRE Jill ineka Es 1'719 N. Front Street Harrisbur PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056101..40 ~u- r` PA 17050 PA 17102 1505610140 J ~, - r r_i w - rj ~. ~ ~~ .~., 1505610240 REV-1500 Ex G~NEVIEVE B. PETRASH Decedent's Social Security Number 2 0 8 1 4 8 9 9 0 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1 2. Stocks and Bonds (Schedule B) .................... . ............ ..... 2. . 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes f~eceivable (Schedule D) ..................... ..... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. 4 7 1 2 . 3 3 6. Jointly Owned Property'(Schedule F) ^ Separate Billing Requested .. . 6 7. Inter-Vivos Transfers &!Miscellaneous N -Probate Property (Schedule G) ~ Se t Bil .... . para e ling Requested .. ..... 7. 1 2 4 9 0 0, 0 0 8. Total Gross Assets (total Lines 1 through 7) ...................... ..... 8. 1 2 9 6 1 2 , 3 3 9. Funeral Expenses and !#dministrative Costs (Schedule H) .............. .... 9. 1 1 5 9 7. 2 5 10. Debts of Decedent, Morkgage Liabilities, and Liens (Schedule I) ......... ... . 10. 1 7 4 1 1 . $ 3 11. Total Deductions (total Lines 9 and 10) ........................... .... 11. 2 9 0 0 9. 0 $ 12. 13 Net Value of Estate (Line 8 minus Line 11) ........................ Charitable a d G .... 12. 1 0 0 6 0 3. 2 5 • ental Bequests/Sec 9113 Trusts for which an election to tax has nqt been made (Schedule J) ............... 13 14. Net Value Subject to T~x (Line 12 minus Line 13) 14. 1 0 0 6 0 3. 2 5 TAX CALCULATION -SEE IIN; 15. Amount of Line 14 taxabMe at the spousal tax rate, ar transfers under Sec. 9116 (a)(1.2) X .0 16. Amount of Line 14 taxable at lineal rate X .045 17. Amount of Line 14 taxabMe at sibling rate X .12 18. Amount of Line 14 taxabMe at collateral rate X .15 FOR APPLICABLE RATES 0 . 0 0 15. 1 0 0603.2 5 1s Q Q 0 17. Q Q Q 18 19. TAX DUE ...................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 0. 0 0 4 5 2 7. 1 5 0. 0 0 0. 0 0 4 5 2 7. 1 5 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: ~ENEVIEVE B. PETRASH STREET ADDRESS 1837 E. TRINDLE ROAD CITY MECHANICSBURG Tax Payments and Credits: 1~ Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments ._ B. Discount 3. Interest File Number 21 11 1107 STATE Zlp PA 17050 (1) 4 527.15 Total Credits (A + g) (2) 0.00 4. If Line 2 is greater than Line 1 + Line 3~ enter the difference. This is the OVERPAYMENT. (3) 848.39 FIII in oval on Page 2 Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 5 375.54 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THIS FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLoClcs 1. Did decedent make a transfer and: a. retain the use or in come of the property transferred : ....................... . . ......................... Yes ® No ^ .................. b. retain the ri ht to d g ~signate who shall use the property transferred or its income; c. retain a reversionary interest; or ............................................................................................ ^ .... d. receive the promisd for life of either payments, benefits or care? ....................................................... ^ 2. If death occurred after'December 12, 1982, did decedent transfer property within one year of death without receiving adeq uate consideration? ....................................................................... ^ ................ 3. Did decedent own an ~ in trust for' or payable-upon~ieath bank account or security at his or her death?' ......... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ....................................................................................... ........... ^ a IF THE ANSWER TO ANY OF THE ABgVE 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, 199, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (12 P.S. §9116 (a) (1.1) (ii)]. The statute dbes 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 it 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 tlf 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 dhild is 0 percent p2 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value r.#f 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 df transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, undo Section 9102, as an individual who has ~t least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (g_98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT =STATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ~ENEVIEVE B. PETRASH FILE NUMBER 21 11 1107 All propeRy join~Uy~ownfed wait~h ri9M of survNorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 7• Pennsylvania St to Employees Credit Union, Savings Acct. No. 7302188968593-S1 2. Pennsylvania State Employees Credit Union, Checking Acct. No. 7302188968593-S4 (See attached letter from PSECU documenting the date of death values on on the Decedent's accounts.) TOTAL (Also enter on line 5, Recapitulation) S (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 1,409.09 3,303.24 .33 REV-1510 EX+ (08-09) ESTATE GENE pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT P SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY FILE NUMBEF 21 11 11,,, This schedule must be completed and filedif the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DES RIPTION OF PROPERTY NUMBER INCWDETHENAMEOFTHETI~2AN$FEREE,THEIRRELATIONSHIPTODECEDENTAND DATE OF DEATH °k OFDECD'$ EXCLUSION THE DATE OF TRANSFER.' ATTACH A CDPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST oFA~ucne~E~ 1. 7240 Jefferson Street, arrisbur Dau hin Coun PA g' p tY. 124,900.00100.00 Tax Parcel No.: 63-020108 (See attached Deed dated 7/21/87 and recorded 7/21/87 in Dauphin County Book' 978, Page 476, transferring ownership from the Decedent to her daughter, Cathleen E. Petrash n/k/a Cathleen ~. Schmidt, but reserving in herself a life estate. Alsp see attached HUD-1 Settlement Statement dated 8/17/111, documenting the value of the real estate when it was Fold by Cathleen B. Schmidt to a third party. It was nbt discovered until immediately prior to the 8/17/11 settlement date that the Decedent had reserved a life estate in the real estate, thus requiring the opening of flhe Estate.) TOTAL (Also enter on Line 7 If more space is needed, use additional sheets of paper of the same size. s TAXABLE VALUE 124,900.00 REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ATE OF H SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Decedent's debts must be reported on Schedule I. ITEM -- NUMBER DESCRIPTION A, FUNERAL EXPENSE ~• Neill Funeral Hokne, Inc. -funeral services 2. Lawton Americah Legion -post-funeral luncheon 11 1107 B• ADMINISTRATIVE CASTS: 1 ~ Personal Representative Commissions: Name(s) of Personal Representative(s) Cathleen E. Schmidt StreetAddresjs 6330 Mercury Drive city Mech~nicsburg state PA Zlp 17050 Year(s) Commission Paid: not Vet paid 2. Altomey Fees: PUr'C~II, Krug & Haller 3. Family Exemption: (If decedent's address is not the same as GaimanYs, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: Register of Wills 5. AcxountantFees: E. Ronald Hixon, P.C. 6• Tax Retum Preparer Fees: 7• Register of Willsi -Short Cert; JCS fee; Automation fee; fee to file Will 8• Register of Willsi-fee to file PA Inheritance Tax Return 9• Dirty Dog Hauling -fee to remove Decedent's personal property 10. Vital Records - fie to obtain Death Certificates 11. Postage - overnight mail, regular and certified mail 12. Mileage 13. Register of Wills ~~; additional Short Certificates 6,285.47 727.50 550.00 3,200.00 260.00 80.00 47.50 15.00 300.00 54.00 36.48 33.30 8.00 AMOUNT TOTAL (Also enter on Line 9, Recapitulation) ; If more space is needed, use additional sheets of paper of the same size. 597 REV-1512 EX+ (12.08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ATE ITEM NUMBER 2 Report debts incurred by SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS FILE NUMBER 21 11 1107 decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. DESCRIPTION VALUE AT DATE OF DEATH Cathleen E. Schrhidt -reimbursement for ancillary charges for hair, nails, medications and doctor's visit$ covering 10/31/02 through 4/30/07, related to Decedent's residence 10,273.51 at Country Meadows Nursing Home (See attached prt~tout from Country Meadows Nursing Home itemizing ancillary charges incurred'by the Decedent and paid by Cathleen E. Schmidt.) Cathleen E. Sch idt -reimbursement for purchase of Depends during Decedent's residence from 1/2002 through 4/2007 at Country Meadows Nursing Home. TOTAL (Also enter on Line 10, Recapitulation) 13 If more space ~s needed, insert add~6onal sheets of the same size. 7,138.32 17,411.83 I REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES W IHIC Vr: ~., GENEVIEVE B. PETRASH NUMBER NAME AND ADDRIESS OF PERSON(S) RECEIVING PROPERTY I, TAXABLE DISTRIBUTION [Indude outs' ht spousal distributions and transfers under Sec. 911"6 (a) (1.2).] 1. Cathleen E. Schmidt f/k/a Cathleen E. Petrash 6330 Mercury Drive Mechanicsburg, PA 17050 IUNT OR SH OF ESTATE 100% of residuary ENTER DOLLAR AMOUNTS OR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTI NS: A. SPOUSAL DISTRIBUTIONIS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. FILE NUMBER: 21 11 1107 RELATIONSHIP TO DECEDENT Do Not List Trusteefa) Lineal TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET I 5 If more space is needed, use additional sheets of paper of the same size, IN RE: ESTATE OF GEN~VIEVE B. PETRASH, DECEASED IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-11-1107 TABLE OF CONTENTS 1 2 3. 5. 6. Last Will ar~d Testament of Genevieve B. Petrash dated September 9, 2009. Deed date July 21, 1987, recorded July 21, 1987, in Book 978, Page 476 from Genevieve ..Petrash, Widow to Cathleen E. Petrash. HUD-1 Settlement Statement. Letter from ~SECU documenting date of death values on the Decedent's Accounts. Printout frorh Country Meadows Nursing Home itemizing ancillary charges incurred by the Decedent and paid by Cathleen Schmidt. LAST WILL AND TESTAMENT' OF GENEVIEVE B. PETRASH I, GENEVIEVE B. PETRASH, of Swatara Township, Dauphin (County, Pennsylvania , declare this to be my Last Will and Testament, and revoke any and all Wills and Codicils previously made by me. 'ITEIrt I: I direct that all my just debts, funeral expenses and last medical expenses shall be paid from the assets o,f my estate as soon as practicable after my decease. ITEM II: All federal, state and other death taxes payable because of my death with respect: to the property forming my gross estate for tax purposes, whether or not passing under this Will, including any interest or penalty imposed in connection with such tax, shall be considered a part of the expense of the administration of my estate and shall be paid out of the principal of my estate, without apportionment ~r right of reimbursement. IITEM III: I give, devise and bequeath all of my estate it ~ ~f every ,nature and wheresoever situate to my daughter, 'athleen E. Petrash, or to her issue, er stipres. In the event my said daughter, Cathleen E. Petras;h, predeceases me, I give, devise and bequeath all of my estate to my then living children, in equal shares. 'ITEM IV: I appoint my daughter, Cathleen E. Petrash, as the Exedutrix of this my Last Will and Testament. ITEM V: I direct that my Executrix shall not be required to give bond for the faithful performance of her duties in any jurisdiction. ~ 'ITEM VI: I direct my personal representative to employ John W. Purcell, Esquire, as attorney for my estate. This provisipn is made solely at my request anal without urging or suggestion by the said John W. Purcell. 'IN WITNESS WHER OF, I have hereunto set my hand and seal this "~ day of 1987. ~, ~;'- -sf ~ 1 9 Ck,ENEVIEVE B. SEAL) The preceding instrument, consisting of this and one ether typewritten pages was, on the date thereof, signed, published and declared by GENEVIEVE B. PETRASH, the testatrix Iltherein named, as and for her Last Will, in t:he 2 presen a of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. ,~~ Residing at /~ L ~ ~j i ~'~ '`''~- ~" r''~~ Residing at 3 COMMONWEALTH OF PENNSYLVANIA : COUNTY OF DAUPHIN ) SS: Carol A. Weber the testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the test<strix signed and executed the instrument as her last will, and that she had signed willingly and that she executed it a;s her free and voluntary act for the purposes therein exp~:essed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as witnesses and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. _ ; --~ ~ Testatrix Wi ne s ~' ~ f` Witness subscribed, sworn to and acknowledged before me, by GENEVIEVL B. pETRASH, the testatrix, and subscribed and sworn to 'before me by _ ,~A, paladino and Carol A. Weber aitnessesi, this 21st day of~ u Y 1987,E otary'publi~j y Comm i ss i orTa~~t Jobe, NOTARY PUBLIC My (;om is ~e$ptres Sept. 4, 1989 Nsrrsbvr^, PA Dauphin County WE, GENEVIEVE B. PETRASH, Amy A. paladino and 4 ,--~\ ' `i A. Settlement Statement (HUD-1) OMB Approval No. 25D2-0265 ~ 1= I NAL r.l.~j- `~' ' ~" ~ LJ Kry~ 3. LJ Conv. Unins. ~'' ' """111Oef /~ Loan Number: SL11215 8. Mortgage Insurance Case Number 4. VA ~ ^ 5. Conv.lns. 1136558 . 4460857574703 C. Note: This form is furnished to give you a statertj'ent of actual settlement costs. Amounts paid to and by the settlement agents are shown. Items mart;ed "(p.o.c)" were paid outside the closing; thBy are shown here for informational purposes a d D. Name & Address of Borrower: n are not i ncluded in the totals. Maureen G. Pottinger E. Name & Address of Seller: Cathleen E. Schmidt F. Name & Address of Lender: 877 Dunkle Street, Harrisburg, PA 17113 724D Jefferson Street, Harisburg PA 17111 Susquehanna Bank , 3501 Concord Road, York, PA 17402 G. Property Location: H. Settlement Agent: 7240 Jefferson Street Select Land Transfers LLC I. Settlement Date: 08/17/2011 Harrisburg, PA 17111 Susquehanna Township , 4705 East Trindle Road, Mechanicsburg, PA 17050 Disbursement Date: 08/17/2011 Place of Settlement: 801 East Park Drive Suite 106 Harrisbur PA 17111 Title6cpress , , g, Printed 08/17/2011 at 10:00 am by KL 1D0. Gross Amount Due from Borrower 101. Contrail sales rice 400. Gross Amount Due to Seller -~ P 102. Personal ro 103. Settlement charges to borrower (line 1400) 1D4. 105. Ad'ustments for items aid b seller in advance ' 106. City/town fazes to 107. County taxes D8/172011 to 1 2131 2 01 1 108. Assessments to 109. School Taxes 08/172011 fo 061302D12 ' 110. Sewer (J1AlS) 08/17/2011 to 09/30/2011 ' 111. 112. 120. Gross Amount Due from Borrower 200. Amounts Paid by or in Behalf of Borrower ' 201. Deposit or earnest money 202. Prindpal amount of new loan(s) 203. Existing loarys) taken subject to 2D4. Appraisal fee POC 205. Credit Report Fee POC Ad'ustments for items unpaid b r seller 210. Cityltown taxes to 211. County taxes to 212. Assessments to 213. School Tax to 218. 219. 220. Total Paid b Ifor Borrower 300. Cash at Settlement fromko Borrower 301. Gross amount due from borower (line 120 302. Less amounts paid by/for borower (line 22 303. Cash 0 From ^ To Borrower ma Imm,'unless n e fgeYS a wlrreMly wliE oMe'wmro+,wmeec No coon Na ustments for items paid b seller in advance 406. Cityftown taxes to 335.59 407. Counfytaxes OB/1712011to 12/31/2011 408. Assessments to 110.57 409. Scholl Taxes 08/172011 to 06!302012 45.98 410. Sewer (J/A/S) 0 811 7120 1 1 to 09/302011 411. 412. 37.35 420. Gross Amount Due to Seller 500. Reductions In Amount Due to Seller 00.00 501. Excess deposit (see instructions) 34.00 502. Settlement charges to seller (line 14D0) 503. Existin loa s taken subject to ?5.00 504. Payoff of first mortgage loan ?5.84 505. Payoff of second mortgage loan 506. 507. Esaow-Inheritance Tax ~>>. county taxes to ' 512. Assessments to 513. School Tax to 514. ' 515. 516. 517. 518. 519. 115,484.84 520. Total Reduction Amount Due Seller ' 600. Cash at Settlement tolfrom Seller ' 132,937.35 g01, Gross amount due to seller (line 420) 115,484.84 602. Less reductions in amount due seller (line m 17,452.51 603. Cash X^ To ^ From Seller 102,787.17 See attached addendum for additional inf rmation Previous editions are obsolete Page 1 of 4 ' H 700. Total Real Estate Broker Fees $ 7,669.00 - Division of commission (line 700) as follows - Pa ~ d -rc m Paid From 701. $3,922.00 __ to Re/MaxRealryProfessionals Borrower's Seller's 702. $3,747.00 tp Remax Realty Select '-' Funds rat Funds at 703. Commission paid at settlement __ Settlement Settlement 704. Broker fee to Remax Realty Select ___ ',669.00 705. Deed Prep Fee to Re/Max Realty Professionals 1 X5.00 --- 800. Items Pa able in Connection with Loan ' -__ 100.00 801, Our origination charge (Includes Origination Poi t 0.000% or $0.00) $895 00 - . 802. Your credit or charge (points) for the specific foie est rate chosen $ (from GFE #1) 803. Your adjusted origination charges (from GFE #2) 604. Appraisal fee (from GFE A) fo ALS, Inc./A sisal Lo isfic Solutions (from GFE #3) 805. Credit report 85.00 325.00 to Kroll Factual Data Co 806. Tax service (from GFE #3) 15.10 to 807. Flood certification to CoreL is Flood Services 808. Appraisal Mgt Co fee from GFE #3 (from GFE #3) 12.00 900. Rems Re wired b Lender to be Paid in Advan to ALS, Inc. e (from GFE #3) 85.00 901. Daily interest charges from trom 08/17/201 to 09/01/2011 @ $12.05331da y 902. Mortgage Ins. Premium for 12 months o FHA (from GFE #10) 180.80 903. Homeowners insurance for 12 months USAA ifrom GFE #3) 1,124.10 904. months t (from GFE #11) 519.23 1000. Reserves De osked with Lender from GFE #11 1 DOt. Initial deposit for your esrrow account 1002. Homeowner's insurance 3 months ' $ 43 27/month $129 81 (from GFE #9) 643.23 1003. Mortgage Insurance months . . $ 22 88Imonth $ to Sus uehanna Bank 1004. City Property Tax months . $ 0.00/month $ to to 1005. County Property Tax 8 months 1006. School Property lax 3 74.51/month $596.08 to Sus uehanna Bank -I months 1007. Aggregate Adjustment 96.63/month $289.89 3 to Sus uehanna Bank J $- 72.55 to Sus uehanna Bank 1100. Title Char es -I 1101. Title services and lender's. title insurance 1102. Settlement or closing fee t from GFE #4 1,218.75 o $ 1103. Owner's title insurance -Fidelity National Title Insur nce Company 1104, Lender's title inswance -Fidelity National Title Insurance Com an P Y $1,153.75 from GFE #5 55.00 1105. Lender's title policy limit $113,534.00 .Lender's Poli 11 D6. Owner's title policy limit $124,900.00 Owner's Polic 1107. Agent's portion of the total title insurance premium $963.69 1108. Underwriter's portion of the total title insurance prem um $245.06 1109. E-Doc Delivery Fee to Came tone Land Transfer $25.00 1110. CourterlVJire Fee to Select and Transfers a en $15.00 1111. Notary Fee to Kandi ' enker $25.00 1112. Reimburse for Tax Certification to Select and Transfers a en $ 20.00 1200. Govemment Recordin and Transfer Char es 2(1.00 1201. Govemment recording charges $ 1202 Deed $65.00 Mort a e $83.00' Release $ 1203. Transfer taxes (from GFE #7) to Dau hin Count Recorder of D 148.00 $ 1204. CitylCounty taxlstamps Deed $1,249.00 Mort e $ (from GFE #8) 1,249.00 1205. State 7ax/stamps Deed $1,249.00 Mort a e $ to Dau hin Count Recorder of D 1206. Deed $ to Dau hin Count Recorder of D 1,249,00 1207. Recrord Sat of Judgment Mort a e $ to to Prothonotary 10.50 1300. Additional SetHement Char es 1301. Required services that you can shop for 1302. Sewer (JulylAuglSepf) to Swatara Town hi Munci al Authorit (from GFE #6) 1303. Satisfy Municipal Judgment to Swatara Town hi Munci al Authoril 94.00 1304. 2011 Cty/Twp Tax to Jose h L. Don to, III Treasurer 932' 72 , 1305. 2011-12 School Tax to Jose L. Don to III Treasurer 983"' , , 1306. 2010 Taxes (63-020-108) fo Dau hin Count Tax Claim Bureau 1,136 ,,?7 2,435.:33 21 14,650.3: `Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nve$tor, Bro(K)er. ''Credit by lender show '" n on page 1. Credit by seller sho wn on page addendum for additional ii~rmation are obsolete Note: If ou have an 9 u ~•~~ Y y questions about the Settlement Char es and Loan Terms listed on this form, please contact your lender. See attached addendum for additional Previous editions are obsolete Comoarison of Good Faith Estimate (GFE) and HUD•1 Char es Charges That Cannot Increase 9 Good Faith Estimate HUD•1 uur origination chzrge HUD•1 Line Number Your credit or char e # 801 895.00 895.00 g (points; for the specific interest rate chosen # 802 Your adiusled origination charges 0.00 0.00 Transiertaxes # 803 895.00 # 1203 895.00 1,249.00 1,249.00 I have carefully reviewed the HUD-1 Settlement Stat meDnt endToFhe bestON O k B W edge a d bel ef, itEa true and accurate statement of all receipts and disbursements made on my account or by me in this transaction I further certify that I have received a copy of the HUD-1 Settlement Statement. i ~ I I Naure G Pottincer n I ~ ~ ~. - - i i The HUD-1 Settlement Statement which I have prepare is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement. ~ _~ ~~ ~J { , ,~ ~ ~ //~ SETTLEMENT AGENT / DATE WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALS STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONME .FOR DETAILS SEE TITLE 18: U. S. CODE SECTION 1001 AND SECTION 1010. See attached addendum for additional inf rmation Previous editions are obsolete Page 4 of 4 Name of Borrou,2c Name of Seller l,~aureen G Pottinger r=ile Number: Cathleen E. Schmid( SL11215 Prepared 08/17/2011 at 10:00 am addendum for additional information are obsolete Note: This page displa;y:; an itemization of the adjusted origination charges shown in section 800 of the HUD-1 Settlement Statemen This page accompanies but is not a part of the HUD-1 Settlement Statement. If a discrepancy exists, the information on the HUD Settlement Statement applies. FEE SnlPi.E - pENN.L DEED i~ Pl.ukm6orn (e., Waliam.po~ Pa. e~ r MADE tha ~j / '- day of .C ~~t.j to the year nineteen hundred and eighty-seven (1987) BETWEEN GENEVI~VE B. PETRASH, Widow, of Swatara Township,_Dauphin County, Pennsyl ania, Grantor, Party of the First Part, -A N D- CATHLEEN E. PET~tASH, of the same Place, Grantee, Party -v -.t ;T_ Ci7 2n 9.G ~'. of the second part, WITi~tESSETH, 'That said part Y of the first part, for end in oonsIderation of the sum of One ($1.Od) Dollar and other good and valuable consideration, Dollars, Iawful money of I'the i7nited States of America, well and tr„ ly paid by the said part y of the second pert to the said F~ y of the first pnrt, at and before the sealing and delivery of these presents, the receipt wher is hereby admowledged, has grantod, bargained, sold, aliened, enfeo$ed, r eased, conveyed and confirmed, and by these presents do grahnt, bargain, sell, elieq enfeoff, releasel convey and oonfum unto the said part Y ~. the second Pte. er heirs and assigns. ALL THAT CERTAIN tract or parcel of land situate in Swatara Township Dauphin County, ennsylvania, more particularly bounded and described according to sur~ey of D. P. Raffensperger, Registered Surveyor, date February 13, 19519, as follows:' W BEGINNING at a p 1nt on the Northern line of Jefferson Street, six hundred thirty (630) feet East of the Northeast corner of the inter- section of Jeffe~son Street and 71st Street, also being at the divid- ing line betweenlILots Nos. 109 and 110, Section "G" on hereinafter mentioned Plan off Lots thence North four (4) degrees no (00) minutes West along same,Ilat right angles to-Jefferson Street, one hundred forty .(140) feeti~to a point; thence North eighty-six (86) degrees no (00) minutes );ast along a line running parallel with Jefferson Street, seventy (70) feet to a point at the dividing line between Lots Nos. 110 an 111, Section "G" on said Plan; thence South four (4) degrees no ( 0) minutes East along same, and at right angles to Jefferson $treetl, one hundred forty (140)-feet to a point on the Northern line ofiJefferson Street; thence Westwardly along same, seventy (70) feed to a point, the place of BEGINNING. BEING Lot No. 11 , Section "G" on Plan.#of Lots known as Rutherford Manor, Section "~", recorded in Plan Book V, Page 89, Dauphin County. records. I doo~0978PaGE 476 HAVING thereon erected a one=story brick dwelling house known as No. 7240 Jefferson Street. Bt;ING the same pseinises which R. Dininni Construction Company, by deed dated April 1f1, 1959, 'recorded in Deed Book R, Vol. 44, Page 219; DaUgh;-?L~ounty recoYels, granted.and conveyed unto Ste hen E. Petrash and Genevieve B. ~etrasli, his wife. The said 5teptien E. Petrash died on the 1st day of February 19 63 , whereby title became vested in Genevieve B. Petrash by operation of law. Life Estate:' Grantor RESERVES unto herself a life estate in the subject premises, extinguishable only upon her death. Reversionary Interest: The Grantor further RESERVES unto herself a reversionary right in said premises in t:he event the Grantee pre- deceases the Grantor. In the event of the Grantee predeceasing the Grantor all legal and equitable title to s~sid premises shall revert to the Grantor. THIS is a tax exempt conveyance between mother and daughter. Mate of Pennsylvaniri l ~. ~' ~ ~'~"'~'~'`~iYl;~y~h Dauphin County, Recorded in fhe Office for ReL~1tYM$ F deeds, etC., In and for the County of Dau hin~ 14 .acord Booka7~ Page 'Witness my hand and seal of Office this o~ ~ ~ day ofd, L~ Anno Damini 19~ jl ~ Recorder BDi1nOc'3~~~jPnGE ~77 '~;u ~~i, rl ~I r~ ~. ~ ~ I I. ~ h ~ f ! i~ 1 ,; ,~ ,'i. '~ J r; '~ ~i ~,~ ;i ' r TOtGETI3ER with all and singular the tenements, hereditaments and appurtenances to the same be- longing, or in anywise appertoining, and the reversion and reversions, remainder and rem issues and profits thereof; AND ALSO all the estate, right, title, interest, ro ecf ~d~' rents, whatsoe both in law aad a uf. ~f the.snid p P y' ~°'m and demand ~, 9 ~ _ F~ Y `of the first art of, ' raises, au~3 every pa,~t and parcel thereof. 1? m; to or out'of the said pre- TO DAVE AND TO HOLD the said-premises, with all and singiilnr the nppurtennnces, Tinto P~ Y ~~ of the second part, her heirs and assigns, to and for the and ro ~ the said behoof of aid part y of the second art, her Y P P use and P heirs and assigns forcve% I AND the said party of the First Part, for herself, her heirs. execu~ors, and adminish-ators, do by these presents, covenant, grant and agree to and with the said p y of the second art, her P heirs and assigns, that the said Party ~f the First Part, her hg's, ~ an~i smgular the hereditaments and premises herein above described and granted, or mentioned and intended so to be, with the nppurtennnces unto the said part Y of the second part, her heirs and assigns. against fhe said pnr~r of the first art and every other arson or persons, whomsoever, ]awfully claiming oPto clunn the same or~nna'od against all and Y P~ thereof, shall and w' , by these presents, WAP.RANT AND IAf VVIT~I TESS 'vVIiEItEOF, the said part y of FOREVER DEFEND. hand thn first part hn s hcreunlo set find seal ,the day end year first written above. S; cr; a r m AND DEI.rVEnED . !~~!~~! ,,,,,,%%%%%%~~.~ ~ l.. IHIi Y$PSEfI(1/: OY ~y~/: ,_ f.~ _ . ,: ................................ (seer.) ~' r -......... GENEVIEVE B. PETRASH ~ '~ /, , ............. F....................................................... ........................ ...... (seer.) .................................... (seer.) ... ........................................................................................... (sE,-a ....... . ..................................................................... (sEer.) CERTIFICATE OF RESIDENCE I, hereby ee~hfy that the revise residence of the P grantee herein IS follows = . ~ 7240 Jef~Eerson Street, Ii~rrisburg, PA 17111 . `~ --- •: L _ ...r::~~ ...:....: - ~ Aaorner or A6enk for Craotw Ci wniMO 1'H OF PENN ~ exrA ) l ~, Coun of ...... AUPHIN } SS: h' ~ .................................. . On this, the ~/ ~ day of ~•-~G a Notary P~rblic l/ ~ , 19 87 ,before me the undersigned ~fficer, personally appeared GENEVIEVE B. PETRASH (mown to me (or atisfnetorily proven) to be the arson ~~ uutrument, and aelmowledged that she whose name is subscribed to the contained executed the same for the purpose therein ~TM'~T-`~~. ~ ~. ~:~ wave hereunto set my n d and off r.;:ti ~,: r:. icial ~ c: t seal. . • -- y I Y",t rr~ ................. .. ,. , r n: ~ ~V ~~ r ~ ~4r: i>6c~,,. P.1 Da::ph:a Cows;. d~~~ U ~8pa~~ g . --~+ ~ _- : ~. ._ I~ .g „_,.. ~ "'WSJ i'~ F_~iia~ttl~~~r~~r~~>c L _ ~ ~t tee ~ ~ a 0 LF ~ ~ il . ' ~' '~ ~ W w ~ trt . Q .~ YQi L - ; ', ,~ ; ~ i - -F •: r7 W N p _ a o .__i . . ~ i =`i . ~ V)~ J F\ eWI~ ~ a ~ • ~ J V .G . . tai f~' ( . ~ e . . . . . ~ lift? • a a a e c ,.V~ e ~ _ O a a ~ L z _ e . ` = I ~ ,~ e . ~ ~~I~ . .~7 i~ ~ e c [-- • L G~ s~G2L!~ ~ ~ ~~~ ~~~ ? ` ~ ~. .i~ ~ . ~2i=.tit-, ~tt1~i.1 ~ W ~I1i =°i- ; ~-Cts'~.~ i~iJI~EL ~ ~ ~ C~ ~ ~ ~ F--i Q W F--F ti- ~ W ~a ~~ 1 c~ ~ ~ ~ ;~~ ~:~~ i ~~ ~ ~U31?!~ -i-, i - i Q--i~,il3~~~ S~ECiQ i ~ ~ Z ~~ -rr ti ~: i.3. J 7 ~¢4sW~~~cW=-~ i ~ i~ i-• ~L ~.i ~ ~ t . Llis`i W ! ~.ft~ClQC3xx{.LI~;~~-tom Q ~ !~ i~i ~ ~ ~ ~ 1` ~ ~ cT~ kI7 tC i i i O ~ ~ r 1 i i ~ ~ ~ !•t ~ Q, r'd ~ t ~ l i /"~ Z ~~ fT iii ~ i i i i ~ i ~ ~ `:'~' u J (~ ~ ~/ t 'Cf ~ ~ =~ ~ ~ iC! ~ a . c ~ i ,~. ;,, W a W A . . . . ~ ~ ~ L. f ii ;2, i~ .~' ~ e e IIU~ WC~ ~ ::1C7 to ~ ~u ~ W;ri .i1 i W Z~~ W :: . ~ ~ } ~ ^II ;~ S . ~ ~ ~ ~ ~ + ~~ ~ ~.j it W tsi W W ~~ FL i!}r W . t~ i s !`_ ~ ' ~ . ~ ~ Ck3 >~:' 1-- Eft ' ~>-t J Efs¢~~Lrf;,i • :..i .. ~• rr• ~ 3 L SJWU?~ ULTC~CL~ ~ LL • ,...i U7 ~ i ~ ~ Wit3W WU?~n~WCt~L~! U _..i l ~ LJ ooso-sse toys) srnr~o~ caHmsno~a 3na.~ .~ F„i .... .. Q Z s U u! Q ~ i ~ CL, i~ Z Z ~ F-F ~ L? W ~ ~W PSEC~k November 22, 201;1 Re: Genevtieve Petrash Deceased. Refer~nce #: 7302188968593 Dear Ms. ~Vineka: The accou~Lt was opened on February 15, 1999. The Share accounts were held solel by Genevieve Petrash. Y The following are the Date of Death Balances for Ms. Petrash's account with PSECU Account Date of Death Balances Interest -April 1 - 6 Savings (S1) $ 1 408.80 Checking (S4) $ 3,303.13 $ 0.29 $ 0.11 If you have ,'any questions, please contact me at (717) 234-8484 or toll-free at (800) 237-7328, then press 6, extension 3120. Sincerely, ~(~ ~~ andra Fagley Service Advisor PSECU Pennsylvania State Employees Credit Union P.O. Box 6701, Harrisburg, PA 17106-7013 • 717.234.8484 • 800,237 7328 ~ „pSecu.com I Law Offi I es o f Purcell, Ig, Haller 1719 N. ront St. Harrisburg PA 17102-2392 Attn: Jill . Wineka i nu CREDIT UNION ISI FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION. EQUAL OPPORTUNITY LENDER. [P,g613] userid: sos60429 Summary Billing History Res#: 62312 Genevieve petrash Filter: Date Billed, From: Thru: Date Type Last of Due Financial charge Char e Fac_ i1it~ gilled Ch_ arge Fr m Class Date From DategThru Charge Amount Dateement --~- 9044 04/30/2007 ANC p 9044 04/30/2007 ANC p 9044 04/30/2007 ANC p 9044 04/01/2007 RB p 9044 04/01/2007 RB p 9044 04/01/2007 RB p 9044 04/01/2007 RB p 9044 03/31/2007 ANC p 9044 03/31/2007 ANC p 9044 03/31/2007 ANC p 9044 03/31/2007 ANC p 9044 03/31/2007 ANC p 9044 03/31/2007 ANC p 9044 03/01/2007 RB p 9044 02/28/2007 ANC p 9044 02/28/2007 ANC p 9044 02/28/2007 ANC p 9044 02/28/2007 ANC p 9044 02/28/2007 ANC p 9044 02/01/2007 RB p 9044 01/31/2007 ANC p 9044 01/31/2007 ANC p 9044 01/31/2007 ANC p 9044 01/31/2007 ANC p 9044 01/31/20(17 ANC p 9044 01/31/2007 ANC p 9044 01/01/2007 RB p 9044 12/31/2006 ANC p 9044 12/31/2006 ANC p 9044 12/31/2006 ANC p 9044 12/31/2006 ANC p 9044 12/31/2006 ANC p 9044 12/31/2006 ANC p 9044 12/01/2006 RB p 9044 11/30/2006 ANC p 9044 11/30/2006 ANC p 9044 11/30/2006 ANC p 9044 11/30/2006 ANC p 9044 11/30/2006 aNC p 9044 11/O1/2006 RB p p P p P P P P P ', P P I p P P p P P P ~' P 'p P 'p P 'p P IP 'P 'P ~p IP P P ~Ip SIP P P P P SIP p p 03/30/2007 03/30/2007 04/26/2007 04/26/2007 04/21/2007 04/21/2007 04/01/2007 04/30/2007 04/01/2007 04/05/2007 04/06/2007 04/06/2007 04/01/2007 04/30/2007 03/02/2007 03/02/2007 03/16/2007 03/16/2007 03/09/2007 03/09/2007 03/01/2007 03/01/2007 03/23/2007 03/23/2007 03/21/2007 03/21/2007 03/01/2007 03/31/2007 02/09/2007 02/09/2007 02/23/2007 02/23/Z007 02/16/2007 02/16/2007 02/21/2007 02/21/2007 02/02/2007 02/02/2007 02/01/2007 02/28/2007 01/05/2007 01/05/2007 01/11/2007 01/11/2007 01/19/2007 01/19/2007 01/26/2007 01/26/2007 12/29/2006 12/29/2006 of/zl/2oo7 of/zl/2oo7 01/01/2007 01/31/2007 12/12/2006 12/12/2006 12/21/2006 12/21/2006 11/22/2006 11/22/2006 12/01/2006 12/01/2006 12/08/2006 12/08/2006 12/15/2006 12/15/2006 12/01/2006 12/31/2006 11/17/2006 11/17/2006 11/10/2006 11/10/2006 10/27/2006 10/27/2006 11/03/2006 11/03/2006 11/21/2006 11/21/2006 11/01/2006 11/30/2006 14.00 05/01/0207 -10.00 05/01/2007 62.42 05/01/2007 -2411.00 05/01/2007 396.33 05/01/2007 46.75 05/01/21)07 2411.00 04/01/2007 14.00 04/01/2007 14.00 04/01/2007 14.00 04/01/2(107 4.72 04/01/2007 14.00 04/O1/20~07 126.15 04/01/2007 2411.00 03/01/2007 14.00 03/01/2007 14.00 03/01/2007 14.00 03/01/2007 155.87 03/01/2007 14.00 03/01/2007 2411.00 02/01/201)7 14.00 02/01/2007 14.00 02/01/2007 14.00 02/01/2007 14.00 02/01/20(17 14.00 02/01/20(17 l1a.86 oz/ol/zoo7 2411.00 O1/O1/200~7 4.24 01/01/2007 141.26 01/01/2007 14.00 01/01/2007 14.00 01/01/2007 14.00 01/01/2007 14.00 01/01/2007 2411.00 12/01/2006 la.oo 12/ol/zoo6 14.00 12/O1/2001i 14.00 12/01/2006 14.00 12/O1/200fi 117.19 12/O1/200f~ 2411.00 11/O1/200f~ Page 1 09/21/11 [PA613] Userid: sos60429 Summary Billing History Res#: 62312 Genevieve petrash Filter: Date Billed, From: Thru: Type Faci l Date of _ it~ Billed Cha o rge F e Financial Charge Char a om Class g D t fast Statement a e From Date Thru Charges gmpu~t Date 9044 9044 10/31/2006 ANC 10/31/2006 AN p p 10/10/2006 10/10/2006 5.30 11/01/2' 006 9044 C 10/31/2006 ANC p P p 09/29/2006 09/29/2006 . 14.00 11/01/2006 9044 10/31/2006 ANC p p 10/06/2006 10/06/2006 14.00 11/01/2006 9044 10/31/2006 ANC P P ~ 10/13/2006 10/13/2006 14.00 11/01/2006 9044 10/31/2006 ANC I p p ' 10/20/2006 10/20/2006 14.00 11/01/2006 9044 10/01/2006 RB , p P 10/21/2006 10/21/2006 120.25 11/01/2006 9044 09/30/2006 ANC P '' 10/01/2006 10/31/2006 2411.00 10/O1/2~006 9044 09/30/2006 ANC p p ' 09/01/2006 09/01/2006 14.00 10/01/2006 9044 09/30/2006 ANC P P ' 09/07/2006 09/07/2006 14.00 10/01/2006 9044 09/30/2006 ANC , p p 09/15/2006 09/15/2006 14.00 10/01/2006 9044 09/30/2006 ANC P P ' 09/22/2006 09/22/2006 14.00 10/01/2006 9044 09/30/2006 aNC , p p 09/21/2006 09/21/2006 158.70 10/01/2006 9044 09/01/2006 RB p p 09/12/2006 09/12/2006 4.24 10/01/2(106 9044 08/31/2(106 ANC p P 09/01/2006 09/30/2006 2411.00 09/01/2006 9044 08/31/2006 ANC p P ~ 08/11/2006 08/11/2006 14.00 09/01/2006 9044 08/31/2006 ANC p p ' 08/04/2006 08/04/2006 14.00 09/01/2006 9044 08/31/2006 ANC P P 08/21/2006 08/21/2006 154.69 09/01/2006 9044 08/31/2006 ANC p P ' 08/18/2006 08/18/2006 14.00 09/01/2006 9044 08/01/2006 RB , p P ~ 08/25/2006 08/25/2006 14.00 09/01/2006 9044 07/31/2006 ANC P P 08/01/2006 08/31/2006 2411.00 08/01/2006 9044 07/31/2006 ANC p P ' 06/23/2006 06/23/2006 14.00 08/01/2006 9044 07/31/2006 ANC , p p 06/30/2006 06/30/2006 14.00 08/01/2006 9044 07/31/201)6 ANC P P 07/07/2006 07/07/2006 14.00 08/01/2006 9044 07/31/2006 ANC p P ' 07/14/2006 07/14/2006 14.00 08/01/2006 9044 07/01/2006 RB p P 07/21/2006 07/21/2006 144.71 08/01/2006 9044 06/30/2006 ANC P p ' 07/01/2006 07/31/2006 2411.00 07/01/20(16 9044 06/30/20016 ANC p p ' 05/26/2006 05/26/2006 14.00 07/01/2006 9044 06/30/2006 ANC ,p p 06/02/2006 06/02/2006 14.00 07/01/2006 9044 06/30/2006 ANC 'P P 06/09/2006 06/09/2006 14.00 07/01/2006 9044 06/30/2006 ANC jP p 06/16/2006 06/16/2006 14.00 07/01/2006 9044 06/01/2006 RB p P 06/21/2006 06/21/2006 78.03 07/01/2006 9044 06/01/2006 RB P ~ 06/01/2006 06/30/2006 2294.00 06/01/2006 9044 06/01/2006 RB P P 06/01/2006 06/30/2006 2411.00 07/01/2006 9044 06/01/2006 RB P P 06/01/2006 06/30/2006 -2294.00 07/01/2006 9044 06/01/2006 RB P P ' 06/01/2006 06/30/2006 -2411.00 07/01/2006 9044 05/31/2006 ANC p P 06/01/2006 06/30/2006 2411.00 07/01/2006 9044 05/31/2006 ANC ~p p ' 04/28/2006 04/28/2006 14.00 06/O1/2001i 9044 05/31/2006 ANC P P ' 05/05/2006 05/05/2006 14.00 06/01/2006 9044 05/31/2006 ANC ,p p 05/10/2006 05/10/2006 14.00 06/01/2006 IP 05/19/2006 05/19/2006 14.00 06/O1/200Ei Page 2 09/21/11 [PA613] userid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Filter: Date Billed, From: Thru: Facil Date Type ity Billed cha n e p om Classcial p gF g Stateme t ate rom Date Thru n Char a Amount Date 9044 9044 05/31/2006 ANC 05/31/2006 ANC PI p 05/21/2006 05/21/2006 88'19 06/01/2006 9044 05/01/2006 RB P p P 05/26/2006 05/26/2006 9044 05/01/2006 RB P P 05/01/2006 05/31/2006 2294.00 05/01/2006 9044 05/01/2006 RB P p 05/01/2006 05/31/2006 -2294.00 07/01/2006 9044 05/01/2006 RB p p I 05/01/2006 05/08/2006 634.13 07/01/2006 9044 05/01/2006 RB P p 05/09/2006 05/09/2006 79.27 07/01/2006 9044 05/01/2006 RB P P ' 05/10/2006 05/31/2006 1743.85 07/01/21)06 9044 05/01/2006 RB P p 'i 05/01/2006 05/08/2006 -634.13 07/01/2006 9044 05/01/2006 RB P p ', 05/01/2006 05/08/2006 634.13 07/01/2006 9044 05/01/2006 RB P p ', 05/09/2006 05/09/2006 -79.27 07/01/2006 9044 05/01/2006 RB P P 05/10/2006 05/31/2006 -1783.85 07/01/2006 9044 05/01/2006 RB p p j 05/10/2006 05/31/2006 1743.85 07/01/2006 9044 04/30/2006 ANC p p ' 05/09/2006 05/09/2006 79.27 07/01/2006 9044 04/30/2006 ANC P P 03/31/2006 03/31/2006 12.00 05/O1/2006fJ0 9044 04/30/2006 ANC I p P 04/07/2006 04/07/2006 14.00 05/01/2006 9044 04/30/2006 ANC ~ p P ' 04/14/2006 04/14/2006 14.00 05/01/2006 9044 04/30/2006 ANC , p P 04/21/2006 04/21/2006 14.00 05/01/2006 9044 04/01/2006 RB p P ' 04/21/2006 04/21/2006 9044 03/31/201)6 ANC P P 04/01/2006 04/30/2006 2294.00 04/01/2006 9044 03/31/2006 ANC P P ' 03/03/2006 03/03/2006 12.00 04/01/2006 9044 03/31/2006 ANC ~ p P 03/10/2006 03/10/2006 12.00 04/01/2006 9044 03/31/20(16 ANC p P I 03/21/2006 03/21/2006 104.18 04/01/20(16 9044 03/31/2006 ANC p P 03/17/2006 03/17/2006 12.00 04/01/2006 9044 03/01/2006 RB P p 03/24/2006 03/24/2006 12.00 04/01/2006 9044 02/28/2006 ANC p p ' 03/01/2006 03/31/2006 2294.00 03/01/2006 9044 02/28/2006 ANC P P 02/03/2006 02/03/2006 12.00 03/01/2006 9044 02/28/2006 ANC p P ' 02/10/2006 02/10/2006 12.00 03/01/2006 9044 02/28/2006 ANC ,p p ' 02/21/2006 02/21/2006 90.73 03/01/2006 9044 02/28/2006 ANC ,P P 02/18/2006 02/18/2006 12.00 03/01/2006 9044 02/01/2006 RB ip p 02/24/2006 02/24/2006 12.00 03/01/2006 9044 O1/31/2001i ANC Ip P p 02/01/2006 02/28/2006 01 2294.00 02/01/2006 9044 O1/31/200Ei ANC p /06/2006 01/06/2006 12.00 02/01/2006 9044 O1/31/200Ei ANC jP P 01/13/2006 01/13/2006 12.00 02/01/2006 9044 O1/31/200Ei ANC p p 01/21/2006 01/21/2006 119.09 02/01/2006 9044 01/31/2006 ANC p P 01/20/2006 01/20/2006 12.00 02/01/2006 9044 01/01/2006 RB p h p 01/27/2006 01/27/2006 12.00 02/01/2006 9044 12/31/2005 ANC P ~ 01/01/2006 01/31/2006 12/02 2294.00 01/01/2006 9044 12/31/2005 ANC p /2005 12/02/2005 12.00 01/01/2006 9044 12/31/2005 ANC P ~ 11/25/2005 11/25/2005 1 12.00 01/01/2006 2/09/2005 12/09/2005 12.00 01/01/2006 Page 3 09/21/11 [PA613] Userid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Filter: Date Billed, From: Thru: Type Fac_ il Date of it~r gilled Cha D r~ce F e Financial Char a om Class D g g t-ast ement ate From Date Thru Charae Amount Date 9044 9044 12/31/2005 ANC 12/31/2005 AN P'' p 12/16/2005 12/16/2005 12.00 01/01/2006 9044 C 12/31/2005 ANC P p P' 12/28/2005 12/28/2005 2'88 01/01/; 006 9044 12/31/2005 ANC , p pl 12/21/2005 12/21/2005 ' 210.63 01/01/;.006 9044 12/01/2005 RB , P P' p 12/30/2005 12/30/2005 12 01 12.00 01/01/2006 9044 11/30/2005 ANC I PI / /2005 12/31/2005 2294.00 12/01/2'005 9044 11/30/2'005 ANC p p ' 10/28/2005 10/28/2005 12.00 12/01/2005 9044 11/30/2005 ANC , P P '' 11/04/2005 11/04/2005 12.00 12/01/2005 9044 11/30/2005 ANC , p p ' 11/11/2005 11/11/2005 12.00 12/01/2005 9044 11/30/2005 ANC P P ~! 11/18/2005 11/18/2005 12.00 12/01/2005 9044 11/01/2005 RB p p ', 11/21/2005 11/21/2005 155.59 12/01/2005 9044 10/31/2005 ANC p P 11/01/2005 11/30/2005 2294.00 11/01/2005 9044 10/31/2005 ANC ~ p p I 09/29/2005 09/29/2005 12.00 11/01/2005 9044 10/31/21)05 ANC ~ P P I 10/07/2005 10/07/2005 12.00 11/01/2005 9044 10/31/2005 ANC ~ p p 10/14/2005 10/14/2005 12.00 11/01/2005 9044 10/31/2005 ANC P P ~ 10/06/2005 10/06/2005 5.27 11/01/2005 9044 10/31/2005 ANC ~ p p I 10/21/2005 10/21/2005 140.68 11/01/2(105 9044 10/01/2005 RB P P I 10/21/2005 10/21/2005 12.00 11/01/2005 9044 09/30/2005 ANC P P 10/01/2005 10/31/2005 2294.00 10/01/2005 9044 09/30/2005 ANC I p p 09/09/2005 09/09/2005 12.00 10/01/2005 9044 09/30/2005 ANC P P I 09/02/2005 09/02/2005 12.00 10/01/2005 9044 09/30/2005 ANC p p 09/21/2005 09/21/2005 -459.48 10/01/2005 9044 09/30/2005 ANC P P I 09/16/2005 09/16/2005 12.00 10/01/2005 9044 09/30/2005 ANC , p p ~ 09/23/2005 09/23/2005 12.00 10/01/2005 9044 09/01/2005 RB j P P 09/13/2005 09/13/2005 5.00 10/01/2005 9044 08/31/2005 ANC ~ P P ' 09/01/2005 09/30/2005 2294.00 09/01/201)5 9044 08/31/2005 ANC , P p ~ 08/05/2005 08/05/2005 12.00 09/01/2005 9044 08/31/2005 ANC p P 08/12/2005 08/12/2005 12.00 09/01/2005 9044 08/31/2005 ANC p p '~ 08/18/2005 08/18/2005 693.04 09/01/2005 9044 08/31/20015 ANC P P ' 08/19/2005 08/19/2005 12.00 09/01/20(15 9044 08/01/2005 RB ,p p ' 08/26/2005 08/26/2005 12.00 09/01/2005 9044 07/31/2005 ANC ,p P ~I 08/01/2005 08/31/2005 2294.00 OS/O1/200~5 9044 07/31/2005 ANC IP p 07/01/2005 07/01/2005 12.00 08/01/2005 9044 07/31/2005 ANC P P 06/24/2005 06/24/2005 12.00 08/01/2005 9044 07/31/2005 ANC p p 07/08/2005 07/08/2005 12.00 08/01/2005 9044 07/31/2005 ANC IP P 07/15/2005 07/15/2005 12.00 08/01/2005 9044 07/31/2005 ANC p p 07/21/2005 07/21/2005 167.51 08/01/2005 9044 07/31/200:5 ANC P P ' 07/05/2005 07/05/2005 4.35 08/01/200:5 9044 07/31/200!i ANC ip P 07/21/2005 07/21/2005 3.55 08/O1/200!i 9044 07/31/200!i ANC P P p 07/22/2005 07/22/2005 07 29 12.00 08/O1/200!i / /2005 07/29/2005 12.00 08/01/200°i Page 4 09/21/11 [PA613] userid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Filter: Date Billed, From: Thru: Date Type of D e Financial Charge Char a fast Facility Billed Charge F om Class g statement Date From Date Thru Charge Amount Date ------ _- 9044 9044 07/01/2005 RB P p 07/01/2005 07/31/2005 9044 06/30/2005 ANC 06/30/2005 AN P p 05/27/2005 05/27/2005 9044 C 06/30/2005 ANC P p ' 06/03/2005 06/03/2005 9044 06/30/2'005 ANC P p j 06/10/2005 06/10/2005 9044 06/30/2005 ANC p p P ' 06/16/2005 06/16/2005 9044 06/01/2005 RB p ' 06/21/2005 06/21/2005 9044 05/31/2005 ANC P , P ' 06/01/2005 06/30/2005 9044 05/31/2005 ANC P , p I 04/29/2005 04/29/2005 9044 05/31/2005 ANC P p ' 05/06/2005 05/06/2005 9044 05/31/2005 ANC P I p ' 05/12/2005 05/12/2005 9044 05/31/2005 ANC P , p P ' 05/20/2005 05/20/2005 9044 05/01/2005 RB p P ' 05/21/2005 05/21/2005 9044 04/30/2005 ANC , P P I 05/01/2005 05/31/2005 9044 04/30/2005 ANC p P '' 04/01/2005 04/01/2005 9044 04/30/2(105 ANC , p P 04/08/2005 04/08/2005 9044 04/30/2005 ANC p 04/21/2005 04/21/2005 9044 04/30/2005 ANC P p 04/15/2005 04/15/2005 9044 04/01/2005 RB P p 04/22/2005 04/22/2005 9044 03/31/2005 ANC P P P ' 04/01/2005 04/30/2005 9044 03/31/2005 ANC , p P ~ 03/04/2005 03/04/2005 9044 03/31/2005 ANC p P ' 03/11/2005 03/11/2005 9044 03/31/2005 ANC p P 03/21/2005 03/21/2005 9044 03/31/2005 ANC p P 03/18/2005 03/18/2005 9044 03/01/2005 RB p 03/25/2005 03/25/2005 9044 02/28/2005 ANC P p 03/01/2005 03/31/2005 9044 02/28/2005 ANC P p ~ 02/21/2005 02/21/2005 9044 02/28/20(15 ANC P p 02/04/2005 02/04/2005 9044 02/28/20015 ANC p p 02/11/2005 02/11/2005 9044 02/28/2005 ANC P P P y p 02/17/2005 02/17/2005 02/25 9044 02/O1/200~5 RB i p ' /2005 02/25/2005 9044 01/31/2005 ANC p ' 02/01/2005 02/28/2005 9044 01/31/2005 ANC P ,p p ' 12/24/2004 12/24/2004 9044 01/31/2005 ANC ~P 12/31/2004 12/31/2004 9044 01/31/2005 ANC P p P ~ 01/07/2005 01/07/2005 9044 01/31/2005 ANC p P 01/14/2005 01/14/2005 9044 01/31/2005 ANC p P ' 01/21/2005 01/21/2005 9044 01/31/200:5 ANC ,P p 01/21/2005 01/21/2005 9044 O1/O1/200!i RB p ' 01/28/2005 01/28/2005 9044 12/31/2004 ANC P ~P P p 01/01/2005 01/31/2005 11/27/2004 11/27/2004 2294.00 07/01/2005 12.00 07/01/2005 12.00 07/01/2005 12.00 07/01/2005 12.00 07/01/2005 106.57 07/01/2005 2294.00 06/01/2005 12.00 06/01/2005 12.00 06/01/2005 12.00 06/01/2005 12.00 06/01/2005 169.10 06/01/2()05 2294.00 05/01/2005 12.00 05/01/2005 12.00 05/01/2(105 224.92 05/01/2(105 12.00 05/01/2005 12.00 05/01/2005 2165.00 04/01/2005 12.00 04/01/2005 12.00 04/01/2005 135.12 04/01/2005 12.00 04/01/2005 12.00 04/01/2005 2165.00 03/01/2005 134.87 03/01/2005 12.00 03/01/2005 12.00 03/01/20(15 12.00 03/01/20(15 12.00 03/01/2005 2165.00 02/01/2005 12.00 02/01/2005 12.00 02/01/2005 12.00 02/01/2005 12.00 02/01/2005 152.41 02/01/2005 12.00 02/01/2005 12.00 02/01/2005 2165.00 O1/O1/200!i 12.00 O1/O1/200!i Page 5 09/21/11 [PA613] userid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Filter: Date ei'iled, From: Thru: Date Type of D e Financial Char a Char a fast Facility gilled Charge F om Class Date9From DategThru Charge Amount ~ateement 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 12/31/2004 ANC 12/31/2004 ANC 12/31/2004 ANC 12/31/2004 ANC 12/31/2004 RB 11/30/2004 ANC 11/30/2004 ANC 11/30/2004 ANC 11/30/2004 ANC 11/30/2004 ANC 11/01/2004 RB 10/31/2004 ANC 10/31/2004 ANC 10/31/2004 ANC 10/31/2(104 ANC 10/31/2004 ANC 10/01/2004 RB 09/30/2004 ANC 09/30/2004 ANC 09/30/2004 ANC 09/30/2004 ANC 09/30/2004 ANC 09/01/2004 RB 08/31/2004 ANC 08/31/2004 ANC 08/31/2004 ANC 08/31/20(14 ANC 08/31/20(14 ANC 08/01/2004 RB 07/31/2004 ANC 07/31/2004 ANC 07/31/2004 ANC 07/31/2004 ANC 07/31/2004 ANC 07/31/2004 ANC 07/31/2004 ANC 07/ol/zoo4 RB 06/30/2004 ANC 06/30/2004 ANC 06/30/2004 ANC P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P I P I P P p '~ p I P P P P P p P p P II P ~' P P P P ~, P I P P iilP P Ip IP ~P 'P P Ip P P IP ~P P p P 12/03/2004 12/03/2004 12/10/2004 12/10/2004 12/17/2004 12/17/2004 12/21/2004 12/21/2004 12/01/2004 12/31/2004 10/29/2004 10/29/2004 11/05/2004 11/05/2004 11/12/2004 11/12/2004 11/19/2004 11/19/2004 11/21/2004 11/21/2004 11/01/2004 11/30/2004 10/01/2004 10/01/2004 10/08/2004 10/08/2004 10/15/2004 10/15/2004 10/22/2004 10/22/2004 10/21/2004 10/21/2004 10/01/2004 10/31/2004 09/17/2004 09/17/2004 09/24/2004 09/24/2004 09/10/2004 09/10/2004 09/21/2004 09/21/2004 09/03/2004 09/03/2004 09/01/2004 09/30/2004 08/06/2004 08/06/2004 08/13/2004 08/13/2004 08/20/2004 08/20/2004 08/20/2004 08/20/2004 08/27/2004 08/27/2004 08/01/2004 08/31/2004 07/02/2004 07/02/2004 06/25/2004 06/25/2004 07/09/2004 07/09/2004 07/16/2004 07/16/2004 07/21/2004 07/21/2004 07/23/2004 07/23/2004 07/30/2004 07/30/2004 07/01/2004 07/31/2004 06/18/2004 06/18/2004 06/11/2004 06/11/2004 05/28/2004 05/28/2004 12.00 O1/O1/"e.'005 12.00 O1/O1/~'005 12.00 01/01/2005 138.37 01/01/2005 2165.00 12/01/2004 12.00 12/01/2004 12.00 12/01/2004 12.00 12/01/2004 12.00 12/01/2004 176.66 12/01/2004 2165.00 11/01/2004 12.00 11/01/2004 12.00 11/01/2004 12.00 11/01/2004 12.00 11/01/2004 130.75 11/01/2004 2165.00 10/01/2004 12.00 10/01/2004 12.00 10/01/2004 12.00 10/01/2004 121.38 10/01/2004 12.00 10/01/2004 2165.00 09/01/2004 12.00 09/01/2004 12.00 09/01/2004 121.08 09/01/2004 12.00 09/01/2004 12.00 09/01/20(14 2165.00 08/01/2004 12.00 08/01/2004 12.00 08/01/2004 12.00 08/01/2004 12.00 08/01/2004 107.08 08/01/2004 12.00 08/01/2004 12.00 08/01/2004 2165.00 07/01/2004 12.00 07/O1/200~F 12.00 07/O1/200~4 12.00 07/01/2004 Page 6 09/21/11 LPA613] use rid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Filter: Date Billed, From: Thru: Date Type of Due Financial Charge Char a Last Facility Billed Char~ce. Fr m Class Date From DategThru Char a Amount DateemHnt 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 9044 06/30/2004 ANC 06/30/2004 aNc 06/01/2004 RB 05/31/2004 ANC 05/31/2004 ANC 05/31/2004 ANC 05/31/2~D04 ANC 05/31/2004 ANC 05/01/2004 RB 04/30/2004 ANC 04/30/2004 ANC 04/30/Z004 ANC 04/30/2(104 ANC 04/30/20104 ANC 04/01/2004 RB 03/31/2004 ANC 03/31/2004 ANC 03/31/2004 ANC 03/31/2004 ANC 03/31/2004 ANC 03/01/2004 RB 02/29/2004 ANC 02/29/2004 ANC 02/29/2004 ANC 02/29/2004 ANC 02/29/20(14 ANC 02/29/2004 ANC 02/01/2004 RB 01/31/2004 ANC 01/31/2004 ANC 01/31/2004 ANC 01/31/2004 ANC 01/31/2004 ANC 01/31/2004 ANC 01/01/2004 RB 12/31/200:3 ANC 12/31/200:3 ANC 12/31/2003 ANC 12/31/2003 ANC 12/31/2003 ANC P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P p P '~ p ~I P II P ~ P P II P ~, P ~I P p P P ', P p ~ P P P Ip p 'P P ilp P ~'P ~P P P p 'p 06/04/2004 06/04/2004 06/21/2004 06/21/2004 06/01/2004 06/30/2004 05/07/2004 05/07/2004 04/30/2004 04/30/2004 05/21/2004 05/21/2004 05/14/2004 05/14/2004 05/21/2004 05/21/2004 05/01/2004 05/31/2004 04/09/2004 04/09/2004 04/02/2004 04/02/2004 04/20/2004 04/20/2004 04/16/2004 04/16/2004 04/23/2004 04/23/2004 04/01/2004 04/30/2004 03/05/2004 03/05/2004 03/12/2004 03/12/2004 03/21/2004 03/21/2004 03/19/2004 03/19/2004 03/26/2004 03/26/2004 03/01/2004 03/31/2004 02/06/2004 02/06/2004 02/13/2004 02/13/2004 02/21/2004 02/21/2004 02/25/2004 02/25/2004 02/20/2004 02/20/2004 02/26/2004 02/26/2004 02/01/2004 02/29/2004 01/02/2004 01/02/2004 01/09/2004 01/09/2004 01/16/2004 01/16/2004 01/21/2004 01/21/2004 01/23/2004 01/23/2004 01/30/2004 01/30/2004 01/01/2004 01/31/2004 11/28/2003 11/28/2003 12/05/2003 12/05/2003 12/12/2003 12/12/2003 12/19/2003 12/19/2003 12/21/2003 12/21/2003 12.00 07/01/2004 95.73 07/01/2004 2165.00 06/01/2004 12.00 06/01/2004 12.00 06/O1/2~004 12.00 06/01/2004 12.00 06/01/21)04 126.02 06/01/2004 2165.00 05/01/2004 12.00 05/01/2004 12.00 05/01/2004 126.51 05/01/2(104 12.00 05/01/2004 12.00 05/01/2004 2073.00 04/01/2004 12.00 04/01/2004 12.00 04/01/2004 115.21 04/01/2004 12.00 04/01/2004 12.00 04/01/2004 2073.00 03/01/201)4 12.00 03/01/2004 12.00 03/01/2004 109.90 03/01/2004 3.18 03/01/2004 12.00 03/01/2004 12.00 03/01/2004 2073.00 02/01/200'4 12.00 01/01/2004 12.00 02/01/2004 12.00 02/01/2004 100.25 02/01/2004 12.00 02/01/2004 12.00 02/O1/200~4 2073.00 O1/O1/200~4 lz.oo of/0l/2ooa 12.00 01/01/2004 12.00 O1/O1/200~) 12.00 01/01/2004 104.88 01/01/2004 Page 7 09/21/11 [pA613] Userid: sos60429 Summary Billing History Res#: 62312 Genevieve petrash Filter: Date Bi11ed, From: Thhu: Date Type Last statement Facility Billed Char~ce Fr m Classcial pategFrom DategThru Charge Amount Date 9044 12/31/2003 ANC P I p 12/03/2003 12/03/2003 9044 12/31/2003 ANC p 2.92 01/01/2004 P 12/26/2003 12/26/2003 12 00 O1/O1 2 904 4 12/01/2003 RB p 9044 11/30/2003 ANC p 9044 11/30/2003 ANC p 9044 11/30/2003 ANC p 9044 11/30/2003 ANC p 9044 11/30/2003 ANC P 9044 11/30/2003 ANC p 9044 11/01/2003 RB p 9044 10/31/2003 ANC p 9044 10/31/2003 ANC p 9044 10/31/2003 ANC p 9044 10/31/2003 ANC p 9044 10/31/2003 ANC P 9044 10/01/2003 RB p 9044 09/30/2003 ANC p 9044 09/30/2003 ANC p 9044 09/30/2003 ANC p 9044 09/30/2003 ANC p 9044 09/30/2003 ANC p 9044 09/30/2003 ANC p 9044 09/30/2003 ANC p 9044 09/01/2003 RB p 9044 08/31/2003 ANC p 9044 08/31/2003 ANC p 9044 08/31/2003 ANC p 9044 08/31/2003 ANC p 9044 08/31/2003 ANC p 9044 08/31/200.3 ANC p 9044 08/31/200:3 ANC p 9044 08/31/200:3 ANC p 9044 08/01/2003 RB p 9044 07/31/2003 ANC p 9044 07/31/2003 ANC p 9044 07/31/2003 ANC P 9044 07/31/2003' ANC P 9044 07/31/2003 ANC p 9044 07/31/2003 ANC p 9044 07/01/2003 RB p p I P li, P P P P P P P P I p SIP ~p ~I P IP P I~p P 0 12/01/2003 12/31/2003 10/31/2003 10/31/2003 11/07/2003 11/07/2003 11/14/2003 11/14/2003 11/21/2003 11/21/2003 11/21/2003 11/21/2003 10/28/2003 10/28/2003 11/01/2003 11/30/2003 10/03/2003 10/03/2003 10/10/2003 10/10/2003 10/21/2003 10/21/2003 10/17/2003 10/17/2003 10/24/200310/24/2003 10/01/2003 10/31/2003 09/05/2003 09/05/2003 09/12/2003 09/12/2003 09/21/2003 09/21/2003 09/19/2003 09/19/2003 09/26/2003 09/26/2003 08/27/2003 08/27/2003 09/24/2003 09/24/2003 09/01/2003 09/30/2003 07/25/2003 07/25/2003 08/01/2003 08/01/2003 08/08/2003 08/08/2003 08/15/2003 08/15/2003 08/21/2003 08/21/2003 08/29/2003 08/29/2003 08/22/2003 08/22/2003 08/20/2003 08/20/2003 08/01/2003 08/31/2003 07/23/2003 07/23/2003 06/27/2003 06/27/2003 07/04/2003 07/04/2003 07/11/2003 07/11/2003 07/18/2003 07/18/2003 07/21/2003 07/21/2003 07/01/2003 07/31/2003 • / 004 2073.00 12/01/2003 12.00 12/01/2(103 12.00 12/01/2003 12.00 12/01/2003 12.00 12/01/2003 106.95 12/01/2003 3.23 12/01/2003 2073.00 11/01/2003 12.00 11/01/2003 12.00 11/01/2003 106.95 11/01/2003 12.00 11/01/201)3 12.00 11/01/2003 2073.00 10/01/2003 12.00 10/01/2003 12.00 10/01/2003 118.32 10/01/20(13 12.00 10/01/2003 12.00 10/01/2003 3.76 10/01/2003 3.23 10/01/2003 2073.00 09/01/2003 12.00 09/01/2003 12.00 09/01/2003 12.00 09/01/2003 12.00 09/01/200.3 91.15 09/01/200:3 12.00 09/01/200:3 12.00 09/01/200:3 4.24 09/01/2003 2073.00 08/01/2003 4.77 08/01/2003 12.00 OS/O1/2003~ 12.00 08/01/2003 12.00 08/01/2003 12.00 08/01/2003 110.06 08/01/2003 2073.00 07/01/2003 page 8 09/21/11 [PA613] userid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Filter: Date Billed, From: Thru: Date Type Facilit Billed °f o e Financial Charge Charge past -Y CharcZe F om class Date From Date Thru Charoe Amount Dateement 9044 9044 06/30/2003 ANC 06/30/2003 AN P p 06/06/2003 06/06/2003 9044 C 06/30/2003 ANC P p ' 05/30/2003 05/30/2003 9044 06/30/2003 ANC P , p PI' 06/13/2003 06/13/2003 9044 06/30/"1.003 ANC ' p P'' 06/20/2003 06/20/2003 9044 06/01/2003 RB ~ p P~ P 06/21/2003 06/21/2003 9044 05/31/2003 ANC , p', 06/01/2003 06/30/2003 9044 05/31/2'.003 ANC P P ~ 05/02/2003 05/02/2003 9044 05/31/2003 ANC , p P '' 05/09/2003 05/09/2003 9044 05/31/2003 ANC , p P ' 05/21/2003 05/21/2003 9044 05/31/2003 ANC , p P ' 05/16/2003 05/16/2003 9044 05/31/2003 ANC p P ' 05/23/2003 05/23/2003 9044 05/31/2003 ANC p P I 04/15/2003 04/15/2003 9044 05/31/2003 ANC p P ' 05/07/2003 05/07/2003 9044 05/01/2003 RB , p '' 05/21/2003 05/21/2003 9044 04/30/2003 ANC P , P p ! 05/01/2003 05/31/2003 9044 04/30/2003 ANC P P 04/03/2003 04/03/2003 9044 04/30/2003 ANC i p P i 04/21/2003 04/21/2003 9044 04/30/2003 ANC i p P 04/18/2003 04/18/2003 9044 04/30/2003 ANC p P 04/25/2003 04/25/2003 9044 04/30/2003 ANC ~ p P i 03/26/2003 03/26/2003 9044 04/01/2003 RB t p 04/15/2003 04/15/2003 9044 03/31/2003 ANC p p p 04/01/2003 04/30/2003 9044 03/31/2003 ANC P P ' 02/20/2003 02/20/2003 9044 03/31/2003 ANC i p P ~ 02/28/2003 02/28/2003 9044 03/31/2003 ANC p P 03/07/2003 03/07/2003 9044 03/31/2003 ANC I p P 03/14/2003 03/14/2003 9044 03/31/2003 ANC I p P '~ p 03/21/2003 03/21/2003 03/21 2 9044 03/31/2003 ANC P / 003 03/21/2003 9044 03/O1/20C13 RB ~p ' 03/2g/2003 03/28/2003 9044 02/28/2003 ANC p , p p 03/01/2003 03/31/2003 9044 02/28/2003 ANC p 'P I 01/31/2003 01/31/2003 9044 02/28/2003 ANC P P 02/07/2003 02/07/2003 9044 02/28/2003 ANC p P 02/14/2003 02/14/2003 9044 02/01/2003 RB p P ' 02/21/2003 02/21/2003 9044 01/31/2003 ANC P p 02/01/2003 02/28/2003 9044 01/31/200:3 ANC IP P I 01/21/2003 01/21/2003 9044 01/31/200:3 ANC P P ~ 01/17/2003 01/17/2003 9044 01/01/2003 RB !p p ' p 01/24/2003 01/24/2003 9044 12/31/2001 ANC , p 01/01/2003 01/31/2003 IP 12/05/2002 12/05/2002 12.00 07/01/2003 12.00 07/01/:2003 12.00 07/01%2003 12.00 07/01/;?003 117.50 07/01/;!003 2073.00 06/01/2003 12.00 06/01/2003 12.00 06/01/2'003 138.00 06/01/2003 12.00 06/01/2003 12.00 06/01/2003 3.92 06/01/2003 3.98 06/O1/2~003 3.76 06/01/2003 2073.00 05/01/2003 12.00 05/01/2003 121.32 05/01/2003 12.00 05/01/2003 12.00 05/01/2003 5.57 05/01/2003 3.92 05/01/2003 2073.00 04/01/2003 38.00 04/01/2003 12.00 04/01/2003 12.00 04/01/2003 12.00 04/01/2003 127.71 04/01/2003 38.00 04/01/2003 12.00 04/01/2003 2073.00 03/01/20(13 12.00 03/01/2003 12.00 03/01/2003 12.00 03/01/2003 109.12 03/01/2003 2073.00 02/01/2003 71.43 02/01/2003 22.00 02/01/2003 28.00 02/01/200:3 2073.00 01/01/200:3 12.00 01/01/2003 Page 9 09/21/11 [PA613] userid: sos60429 Summary Billing History Res#: 62312 Genevieve Petrash Page 10 Filter: Date Billed, From: Thru: 09/21/11 Date Type Facility Billed °f D e Ch arge F o Financial m Class Charge D char a 9 fast ement ,_, ate From Date Thru Charge Amount Date 9044 9044 12/31/2002 ANC 12/31/2002 ANC P' ' p 12/12/2002 12/12/2002 12.00 O1/O1/;?003 9044 12/01/2002 RB P , PI p 12/21/2002 12/21/2002 9044 11/30/2002 ANC I Pi P 12/01/2002 12/31/2002 2073.00 12/01/2002 9044 11/30/2002 ANC , P ' p 11/15/2002 11/15/2002 28.00 12/01/2002 9044 11/30/2002 ANC , p ' p 11/21/2002 11/21/2002 133.33 12/01/2002 9044 11/30/2002 ANC I P ~ p 11/21/2002 11/21/2002 12.00 12/01/2002 9044 11/30/2002 ANC ~ p p 11/27/2002 11/27/2002 12.00 12/01/2002 9044 11/01/2002 RB p II 11/14/2002 11/14/2002 9.04 12/01/2002 9044 10/31/2002 ANC P I P 11/01/2002 11/30/2002 2073.00 11/01/2002 9044 10/01/2002 RB P ~ p 10/21/2002 10/21/2002 107.18 11/01/2002 I P 10/01/2002 10/31/2002 2073.00 11/01/2002